Health Care Use and Health Behaviors

Among Young Adults With History

of Parental Incarceration
Nia Heard-Garris, MD, MSc,​a,​b,​c,​d Tyler N.A. Winkelman, MD, MSc,​a,​e,​f,​g Hwajung Choi, PhD,​h Alex K. Miller, BS,​a,​i
Kristin Kan, MD, MPH, MSc,​b,​c,​d Rebecca Shlafer, PhD, MPH,​j Matthew M. Davis, MD, MPPb,​c,​d,​k ,​l,​m

OBJECTIVES: To determine if longitudinal associations exist between parental incarceration abstract

(PI) and health care use or health behaviors among a national sample of young adults.
METHODS: We used the National Longitudinal Survey of Adolescent to Adult Health to examine
associations between history of mother incarceration (MI) and father incarceration (FI),
health care use, and 3 dimensions of health behaviors (eg, general health behaviors,
substance use, and other risky behaviors) (N = 13 084). Multivariable logistic regression
models accounted for individual, family, and geographic factors and generated adjusted
odds ratios (aORs).
RESULTS: Over 10% of the sample had a history of PI before the age of 18. History of MI and
FI were both associated with forgone health care (aOR = 1.65 [95% confidence interval
(CI), 1.20–2.27], aOR = 1.22 [95% CI, 1.02–1.47], respectively), prescription drug abuse (MI
aOR = 1.61 [95% CI, 1.02–2.55], FI aOR = 1.46 [95% CI, 1.20–1.79]), and 10 or more lifetime
sexual partners (MI aOR = 1.55 [95% CI, 1.08–2.22], FI aOR = 1.19 [95% CI, 1.01–1.41]).
MI was associated with higher likelihood of emergency department use (aOR = 2.36 [95%
CI, 1.51–3.68]), and FI was associated with illicit injection drug use (aOR = 2.54 [95% CI,
1.27–5.12]).
CONCLUSIONS: The effects of incarceration extend beyond incarcerated individuals. PI histories
are associated with lower health care use and unhealthy behaviors in young adulthood. By
addressing barriers to health care and health-harming behaviors, health care providers and
policy makers may reduce health disparities among this population.

aRobert Wood Johnson Foundation Clinical Scholars Program, University of Michigan Medical School, Ann WHAT’S KNOWN ON THIS SUBJECT: A history of
Arbor, Michigan; bDivision of Academic General Pediatrics and cMary Ann & J. Milburn Smith Child Health parental incarceration (PI) is associated with poor
Research, Outreach, and Advocacy Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie physical and mental health outcomes into adulthood.
Children’s Hospital of Chicago, Chicago, Illinois; Departments of eMedicine and fPediatrics, Hennepin Healthcare,
However, the relationship between PI and health
Minneapolis, Minnesota; gCenter for Patient and Provider Experience, Minneapolis Medical Research
Foundation, Hennepin Healthcare, Minneapolis, Minnesota; hDepartment of Internal Medicine, University of care use and multidimensional health behaviors has
Michigan Medical School, University of Michigan, Ann Arbor, Michigan; iUniversity of Michigan Medical School, been understudied.
University of Michigan, Ann Arbor, Michigan; jDivision of General Pediatrics and Adolescent Health, Department
of Pediatrics, University of Minnesota, Minneapolis, Minnesota; and Departments of dPediatrics, kMedicine, WHAT THIS STUDY ADDS: Young adults with PI
lMedical Social Sciences, and mPreventive Medicine, Feinberg School of Medicine, Northwestern University, histories are less likely to use health care and more
Chicago, Illinois likely to engage in unhealthy behaviors compared
with peers without PI.
Dr Heard-Garris conceived and designed the study, acquired data, conducted data analysis and
interpretation, and drafted the initial manuscript; Dr Winkelman conceived and designed the
study, acquired data, conducted data analysis and interpretation, and provided critical revisions
to the manuscript; Dr Choi assisted in data analysis and interpretation and provided critical
revisions to the manuscript; Mr Miller conducted the literature review for the study and provided
critical revisions to the manuscript; Dr Kan conceived and designed the study, acquired and
interpreted data, and provided critical revisions to the manuscript; Dr Shlafer interpreted data To cite: Heard-Garris N, Winkelman T.N.A., Choi H, et al.
and provided critical revisions to the manuscript; Dr Davis interpreted data, provided critical Health Care Use and Health Behaviors Among Young Adults
With History of Parental Incarceration. Pediatrics. 2018;
142(2):e20174314

PEDIATRICS Volume 142, number 2, August 2018:e20174314 ARTICLE

The United States has the highest interventions to improve the health with wave 4 self-reported health care
incarceration rate in the world, and of individuals with a history of PI. use, health behaviors, and PI history.
nearly 60% of incarcerated adults We used a large, nationally
are parents to minor children.‍1–‍ 3‍ At Measures
representative sample of young
least 5 million children in the United adults to evaluate the relationship PI
States have had a parent who lived between PI before the age of 18 and
with them go to jail or prison.‍1 Black, In wave 4, respondents were asked
health care use and health behaviors. if their biological mother or father
low-income, and rural children We hypothesized a priori that PI
experience disproportionately high ever spent time in jail or prison.
would be associated with lower Respondents were also asked their
rates of parental incarceration levels of health care use and a higher
(PI).2,​4‍ Most children experience age at the first and most recent time
prevalence of unhealthy behaviors their biological mother or father
the incarceration of a father; compared with individuals without
however, maternal incarceration is went to jail or prison. We included
PI.‍19,​20
‍ individuals who reported any history
increasingly more common because
of rising incarceration rates among of mother incarceration (MI) or
women.‍2 Mothers tend to have METHODS father incarceration (FI) after birth
slightly more children than fathers and before the age of 18.
at the time of incarceration.‍2,​5,​
‍6 Data
Health Care Use
Although incarceration may have a We used data from the National
marked impact on an incarcerated Longitudinal Study of Adolescent Data on health care use were
individual’s life, it also disrupts the Health to Adult Health (Add Health), collected in wave 4. Respondents
family unit and thereby negatively a nationally representative cohort were asked about forgone care,
affects his or her children.‍7 study following adolescents into worsening health problems because
adulthood in the United States. Add of lack of health care, the timing of
PI has been identified as 1 of several Health is a multisurvey, multiwave annual dental examinations, the
adverse childhood experiences study in which systematic sampling receipt of mental health counseling,
(ACEs), a group of traumatic or methods with implicit stratification the timing of physical examinations,
persistent childhood experiences are used. High schools serve as and the usual source of care
associated with poor physical the primary sampling unit for the (‍Table 1). Time since last physical
and mental health across the life clustered design. The sample design examination was categorized into
course.‍8–‍‍ 11
‍ PI is associated with ensures adequate representation 2 categories: <1 year and >1 year
learning delays and behavioral by region, urbanicity, school size, or never. Location of care was
problems,​12–‍‍ 15
‍ perhaps because of school type, and ethnicity.‍21 During categorized as a primary care setting
the traumatic separation from a wave 1 (1994–1995 school year), (ie, hospital-based clinic; community
parent, the loss of parental resources, 18 924 adolescents (12–19 years health clinic; health maintenance
and the lack of social support.‍7,​12 old) completed in-home interviews, organization; private medical
The authors of a growing body were assigned a sample weight, and office; school, college, or work
of literature indicate that PI is were invited to continue in follow-up clinic; military hospital or clinic; or
detrimental to health in childhood waves. In wave 4 (2008), 13 861 respondent “never gets sick”) and
and adulthood. The prevalence of respondents (24–32 years old) who emergency department (ED) or non–
asthma, HIV and AIDS, depression, were in wave 1 completed follow-up primary care site.
anxiety, and posttraumatic stress surveys and were assigned a sample
weight. Written informed consent Health Behaviors
disorder is higher among individuals
with a history of PI.‍16,​17
‍ was obtained from the participants. In wave 4, respondents were asked
Additional information on the questions regarding their general
In contrast to what is known about sampling procedures and study health behaviors, substance use, and
the health of individuals who design is documented elsewhere.‍21 other high-risk behaviors (‍Table 1).
experience PI, little is known about Respondents were asked about
their health care use and health Study Population television screen time, fast food and
behaviors in young adulthood, Among eligible participants with sugary drink consumption, frequency
which are strong determinants of wave 1 and wave 4 sample weights, of physical fitness center use, and
health.‍18 The impact of PI on health- 13 084 (94.4%) had complete data sunblock use. We defined excessive
related behavior is important to and were included in our analytic screen time as >50 hours per week
examine because understanding sample. Sociodemographic data were (3.5 times higher than the national
these relationships can inform drawn from wave 1 and combined average for ages 25–34 and 1.5 times

2 HEARD-GARRIS et al
TABLE 1 Health Care Use and Health Behaviors Survey Questions, National Longitudinal Study of Adolescent Health, 2007–2008
Health care use
  Forgone care: has there been any time in the past 12 mo when you thought you should get medical care, but you did not?
  Worsening health problems: in the past 12 mo, did a health problem get worse because you did not get care when you thought you should?
  Annual dental examination: in the past 12 mo, have you had a dental examination by a dentist or dental hygienist?
  Mental health counseling: in the past 12 mo, have you received psychological or emotional counseling?
  Annual physical examinationa: how long ago did you last have a routine checkup?
  Usual source of careb: where do you usually go when you are sick or need health care?
General health behaviors
  Television: in the past 7 d, how many h did you watch television or videos, including VHS, DVDs, or music videos?
  Fast food: how many times in the past 7 d did you eat food from a fast food restaurant, such as McDonald’s, Burger King, Wendy’s, Arby’s, Pizza Hut, Taco
Bell, Kentucky Fried Chicken, or a local fast food restaurant?
  Sugary drinks: in the past 7 d, how many regular (nondiet) sweetened drinks did you have? Include regular soda, juice drinks, sweetened tea or coffee,
energy drinks, flavored water, or other sweetened drinks.
  Fitness center use: on average, how many times per wk do you use a physical fitness or recreation center in your neighborhood?
  Sunblock: when you go outside on a sunny day for >1 h, how likely are you to use sunscreen or sunblock?
Substance use
  Cigarettes: during the past 30 d, on how many days did you smoke cigarettes?
  Prescription drugs: have you ever taken any prescription drugs that were not prescribed for you, taken prescription drugs in larger amounts than
prescribed, more often than prescribed, for longer periods than prescribed, or taken prescription drugs that you took only for the feeling or experience
they caused?
  IV drug use: have you ever injected (shot up with a needle) any illegal drug, such as heroin or cocaine?
  Problem drinking
  1. How often have you been under the influence of alcohol when you could have gotten yourself or others hurt, or put yourself or others at risk, including
unprotected sex?
  2. How often have you had legal problems because of your drinking, like being arrested for disturbing the peace or driving under the influence of alcohol
or anything else?
  3. How often have you had problems with your family, friends, or people at work or school because of your drinking?
  4. Have you ever continued to drink after you realized drinking was causing you any emotional problems (such as feeling irritable, depressed, or
uninterested in things or having strange ideas) or causing you any health problems (such as ulcers, numbness in your hands and/or feet, or memory
problems)?
  5. Have you ever given up or cut down on important activities that would interfere with drinking, like getting together with friends or relatives, going to
work or school, participating in sports, or anything else?
  Problem drug use
  1. How often have you been under the influence of (favorite drug) when you could have gotten yourself or others hurt, or put yourself or others at risk,
including unprotected sex?
  2. How often have you had legal problems because of your (favorite drug) use, like being arrested for disturbing the peace or anything else?
Other risky behaviors
  Lifetime sexual partners: with how many partners have you ever had vaginal intercourse, even if only once?
  Sex in exchange for money: in the past 12 mo, how many times have you paid someone to have sex with you or has someone paid you to have sex with them?
  Gambling problems: has your gambling ever caused serious financial problems or problems in your relationships with any of your family members or
friends?
DVD, digital video disc; VHS, Video Home System.
a Categorized into <1 y and >1 y or never.
b Categorized as a primary care setting (ie, hospital-based clinic; community health clinic; health maintenance organization; private medical office; school, college, or work clinic; military

hospital or clinic; or respondent never gets sick) and ED or non–primary care site.

the amount of television associated of lifetime sexual partners (≤9 vs parental education (no resident
with adverse health outcomes).‍22‍–‍24 ≥10 lifetime partners),​25,​‍26 sex in parent, less than high school, high
Substance use behaviors included exchange for money in the past 12 school, and college or higher), and
cigarette smoking, prescription drug months, and any gambling problems. receipt of public assistance; and (3)
abuse, illicit intravenous (IV) drug geography, such as the geographical
use, and alcohol use. Respondents Covariates classification of the respondent’s
were determined to have problem We controlled for wave 1 residence (urban, suburban, rural,
drinking or problem drug use if their sociodemographic factors associated or other).‍16,​27
‍
substance use–related behavior with health care use and health
endangered the respondent or behaviors in our analysis, including
others, caused legal problems,
Statistical Analysis
(1) individual factors, such as sex,
caused problems with family and race and/or ethnicity, and age; (2) We summarized sociodemographic
friends, or interfered with school or family characteristics, such as family characteristics of our study
work. Questions about other risky structure (2 parents, 1 parent, or no population by PI history. We created
behaviors included the number biological parents in the household), 3 categorical variables for no PI

PEDIATRICS Volume 142, number 2, August 2018 3

TABLE 2 Analysis Sample Characteristics, National Longitudinal Study of Adolescent Health, 2007–2008
No PI (Lifetime) (95% CI) MI (<18 y) (95% CI) FI (<18 y) (95% CI)
Weighted %a, n = 10 908 Weighted %a,​b, n = 269 Weighted %a,​b, n = 1230
Sex, female, % 49.7 (48.2–51.1) 54.3 (46.2–62.2) 51.0 (47.1–55.0)
Race and/or ethnicity, %
  Non-Hispanic white 68.6 (62.6–74.0) 47.2 (36.2–58.5) 57.4 (50.1–64.4)
  Non-Hispanic Black 13.1 (9.9–17.2) 34.3 (25.2–44.8) 23.0 (17.1–30.3)
  Hispanic 11.3 (8.2–15.3) 11.4 (6.7–18.6) 14.2 (10.5–19.1)
  Non-Hispanic, other race and/or ethnicity 7.0 (5.4–9.1) 7.1 (2.9–16.3) 5.4 (3.6–7.9)
Age, meanc 15.3 (15.0–15.6) 15.5 (15.2–15.7) 15.5 (15.2–15.7)
Family structure, %
  2-parent household 65.5 (63.4–67.5) 13.5 (8.8–20.3) 27.3 (23.5–31.4)
  1-parent household 31.8 (30.0–33.6) 63.7 (54.8–71.8) 65.7 (61.9–69.3)
  No biological parents in household 2.8 (2.2–3.4) 22.7 (15.5–32.1) 7.0 (5.2–9.4)
Mother’s education, %
  No resident mother 3.5 (3.1–4.0) 10.4 (6.4–16.4) 5.4 (3.9–7.3)
  Less than high school 16.2 (13.9–18.7) 27.8. (21.1–35.7) 25.6 (21.7–29.8)
  High school, trade school, or GED education 41.4 (38.7–44.2) 42.7 (35.2–50.5) 44.5 (39.8–49.3)
  College education or higher 38.9 (35.6–42.3) 19.1 (12.5–25.7) 24.6 (20.6–29.1)
Father’s education, %
  No resident father 21.3 (19.4–23.3) 49.9 (41.3–58.4) 48.7 (44.7–52.7)
  Less than high school 13.5 (11.5–15.7) 14.7 (10.1–21.0) 18.5 (15.2–22.3)
  High school, trade school, or GED education 30.5 (28.0–33.1) 23.2 (17.0–30.8) 23.8 (20.2–27.9)
  College education or higher 34.7 (31.4–38.2) 12.2 (7.0–20.2) 9.0 (7.0–11.3)
Received public assistance, % 7.4 (6.1–8.9) 28.3 (21.2–36.6) 25.3 (21.7–29.4)
Geography, %
  Suburban 40.7 (35.4–46.1) 25.4 (18.3–34.1) 28.8 (23.6–34.6)
  Urban 27.5 (23.1–32.4) 47.9 (38.2–57.8) 38.8 (31.9–46.1)
  Rural 28.8 (24.1–33.9) 21.3 (14.8–29.7) 28.7 (22.2–36.1)
  Other 3.1 (2.3–4.1) 5.4 (2.6–10.9) 3.8 (2.6–5.5)
CI, confidence interval; GED, General Equivalency Development.
a Reflects the representative proportion in the target US population. Percentages may not total 100% because of rounding.
b Columns may not sum to the total number of participants (N = 13 084) because 0.7% (n = 95) of individuals experienced both MI and FI before the age of 18 and are reflected in both

categories; 5.9% (n = 772) of individuals had MI or FI after the age of 18.

c Age at wave 1 mean age (2007–2008).

history, MI history, and FI history. unless otherwise noted.‍28 This study were from 1-parent households and
We also used descriptive statistics was approved by the University of urban areas.
to describe the prevalence of PI and Michigan Medical School Institutional
For individuals with PI histories, the
the mean age at first episode of PI in Review Board.
mean age at first PI episode was 10.7
our sample. We used unadjusted and
years (8.8–12.6) for those with MI
adjusted logistic regression models
and 10.8 years (9.2–12.3) for those
to examine associations between
with FI (data not shown).
PI and our outcome variables. RESULTS
We modeled PI as 2 independent
Unadjusted Analyses
variables indicating history of MI or ‍ able 2 illustrates the weighted
T
history of FI. This approach allowed sociodemographic characteristics In ‍Table 3, we display the unadjusted
us to isolate the impact of MI and of our sample by history of PI. odds ratios (ORs) of health care use
FI for individuals who experienced Of the 13 084 individuals in the patterns and health behaviors among
incarceration of 1 or both parents. analysis sample, 10.7% experienced individuals with a history of MI or FI
In unadjusted analyses, only MI and any PI (2.1% experienced MI and compared with individuals without
FI were included in the model. In 9.4% experienced FI before 18 a history of PI. Young adults with MI
adjusted analyses, we controlled for years of age). Non-Hispanic Black and FI had significantly higher odds
all previously described covariates. individuals had a disproportionally of forgone health care. Individuals
In all analyses, we conducted them high prevalence of PI, accounting for with FI only had higher odds of
using Stata 14.0 (Stata Corp, College 34.3% of individuals reporting MI having a health problem worsen
Station, TX); accounted for the and 23.0% of individuals reporting because of lack of care. Dental
clustered, stratified survey design; FI, while representing only 14.8% of health care use was significantly less
and used survey weights to generate our sample (data not shown). A large common among individuals with an
national population estimates proportion of individuals with PI MI or FI history. Individuals with

4 HEARD-GARRIS et al
FI had significantly higher odds of TABLE 3 Unadjusted ORs of Health Care Use and Health Behaviors by PI
having had counseling within the MI FI
past year. Although neither MI nor FI Unadjusted OR (95% CI) Unadjusted OR (95% CI)
was associated with delayed annual
Health care use
physical examinations, young adults   Forgone health care 1.95*** (1.42–2.68) 1.44*** (1.20–1.72)
with a history of PI were significantly   Worsening health problem(s) 1.50 (0.89–2.52) 1.70*** (1.35–2.14)
more likely to report using the ED or   Annual dental examination 0.58*** (0.43–0.78) 0.74*** (0.62–0.88)
a non–primary care site as their usual   Mental health counseling 1.13 (0.70–1.83) 1.47** (1.15–1.87)
source of care.   Annual physical examination 1.25 (0.84–1.85) 1.04 (0.86–1.25)
  Usual source of care in ED or non– 3.31*** (2.31–4.73) 1.76*** (1.39–2.23)
primary care setting
Individuals with PI were more likely General health behaviors
to engage in several unhealthy   >50 h of television watched per wk 0.82 (0.30–2.21) 2.14*** (1.37–3.34)
behaviors. Any history of MI or FI   Fast food ≥4× per wk 1.31 (0.87–2.00) 1.39*** (1.14–1.70)
was associated with drinking sugary   Sugary drinks ≥4 per wk 1.49* (1.05–2.11) 1.63*** (1.34–1.98)
  Fitness center use ≥4× per wk 0.67 (0.37–1.19) 0.65** (0.47–0.89)
drinks, smoking cigarettes, and
  Sunblock use 0.87 (0.56–1.34) 0.55*** (0.45–0.67)
having 10 or more lifetime sexual Substance use
partners. Whereas MI history was   Cigarette smoking (within 30 d) 1.86*** (1.34–2.59) 1.71*** (1.45–2.00)
positively associated with high-   Problem drinkinga 1.21 (0.85–1.72) 1.18 (0.97–1.42)
risk behaviors, including having   Prescription drug abuse 1.38 (0.88–2.15) 1.41*** (1.16–1.71)
  Illicit IV drug use 0.91 (0.22–3.79) 2.51* (1.22–5.19)
sex in exchange for money, FI was
  Problem drug useb 1.23 (0.55–2.76) 1.80*** (1.34–2.40)
associated with obesogenic behaviors Other high-risk behaviors
(ie, related to fast food consumption   10+ lifetime sexual partnersc 1.77** (1.25–2.50) 1.30*** (1.11–1.51)
and sedentary behaviors), lower   Sex in exchange for money 2.75** (1.40–5.37) 1.24 (0.69–2.23)
sunblock use, and higher substance   Gambling problems 1.38 (0.58–3.32) 1.67 (0.95–2.3)
use (ie, prescription drug abuse, illicit CI, confidence interval.
a Drinking that put yourself or others at risk, including unprotected sex, drinking that led to legal problems, or drinking
IV drug use, and problem drug use). that caused problems with family, friends, work, or school.
Neither MI nor FI was associated b Using drugs that put yourself or others at risk, including unprotected sex or drinking that led to legal problems.

with gambling problems. c Vaginal sex only.

* P < .05.
** P < .01.
*** P < .001.
Multivariable Analyses

Multivariable results of the Individuals with FI were significantly DISCUSSION

association between MI or FI and more likely to watch 50 hours or
In this nationally representative
health care use and health behavior more of television per week, consume
study of young adults, we found
outcomes are presented in ‍Table 4. sugary drinks, and less likely to use
a consistent association between
sunblock than individuals without
the incarceration of a mother or
In adjusted analyses, MI and FI FI. MI history was not significantly
father and suboptimal health care
remained significantly associated associated with these general health
use and unhealthy behaviors. Our
with forgone health care. FI history behaviors in adjusted analyses.
findings suggest a history of MI or
remained statistically significantly
Young adults with MI or FI history FI is independently associated with
associated with worsening health
had significantly higher adjusted activities detrimental to health,
problems because of lack of health
odds of smoking cigarettes, drinking including higher levels of ED use,
care. Individuals with MI were
problems, and prescription drug obesogenic behaviors, substance
significantly less likely to receive
abuse compared with peers without use, and other high-risk behaviors.
annual dental examinations
a PI history. For individuals with FI, Adverse health care use patterns and
compared with peers; however, this
adjusted odds of using illicit IV drug more health-harming behaviors may
association was no longer significant
use and problem drug use were also ultimately contribute to poor health
for individuals with FI. Adjusted
significantly higher. outcomes throughout the life course
odds of having recent psychological
for young adults with a history of PI.
counseling were significantly higher MI and FI were associated with
for young adults with FI compared significantly higher odds of having Authors of previous studies have
with those without FI. The ED as ≥10 sexual partners. MI remained demonstrated that children with PI
a usual source of care remained significantly associated with having histories and young adults with a
significant for individuals with MI sex in exchange for money in history of MI, exclusively, experience
only. adjusted analyses. barriers to health care.‍29,​30
‍ Our

PEDIATRICS Volume 142, number 1, August 2018 5

TABLE 4 Adjusted ORs of Health Care Use and Health Behaviors by PI with other systems, such as the
MI FI health care system, because of fear
Unadjusted OR (95% CI) Unadjusted OR (95% CI) of surveillance and formal record-
keeping.‍32 Caregivers are also more
Health care use
  Forgone health care 1.65** (1.20–2.27) 1.22* (1.02–1.47)
likely to be financially stressed and
  Worsening health problem(s) 1.29 (0.76–2.22) 1.51** (1.18–1.95) may have access to fewer resources
  Annual dental examination 0.67** (0.50–0.90) 0.89 (0.75–1.07) that allow them to model good health
  Mental health counseling 1.14 (0.71–1.85) 1.60*** (1.23–2.08) behavior for children. Additionally, PI
  Annual physical examination 1.47 (0.96–2.25) 1.13 (0.94–1.36) has been associated with a truncated
  Usual source of care in ED or non– 2.36*** (1.51–3.68) 1.22 (0.98–1.53)
primary care setting
transition from adolescence to
General health behaviors adulthood,​‍33 which may result in the
  >50 h of television watched per wk 0.66 (0.27–1.58) 1.63* (1.03–2.56) failure to acquire knowledge of how
  Fast food ≥4× per wk 1.10 (0.69–1.75) 1.15 (0.94–1.43) to access or use preventive health
  Sugary drinks ≥4 per wk 1.29 (0.90–1.87) 1.37** (1.10–1.69)
care. Together, these behaviors may
  Fitness center use ≥4× per wk 0.71 (0.39–1.31) 0.75 (0.54–1.04)
  Sunblock use 1.14 (0.71–1.83) 0.67*** (0.54–0.82) be mirrored in the future as the child
Substance use ages and begins to independently
  Cigarette smoking (within 30 d) 1.77*** (1.26–2.50) 1.53*** (1.28–1.82) engage with the health care system.
  Problem drinkinga 1.70** (1.17–2.49) 1.46*** (1.21–1.75)
  Prescription drug abuse 1.61* (1.02–2.55) 1.46*** (1.20–1.79)
Individuals with PI histories also
  Illicit IV drug use 0.96 (0.19–4.77) 2.54** (1.27–5.12)
  Problem drug useb 1.38 (0.59–3.23) 1.74*** (1.25–2.41) reported more unhealthy behaviors
Other high-risk behaviors compared with their peers without
  10+ lifetime sexual partnersc 1.55* (1.08–2.22) 1.19* (1.01–1.41) PI. For example, we found that
  Sex in exchange for money 2.16* (1.05–4.45) 1.03 (0.0.57–1.85) young adults with a history of FI,
  Gambling problems 1.34 (0.56–3.20) 1.77 (0.98–3.20)
but not MI, were more likely to
CI, confidence interval. engage in obesogenic behaviors, such
a Drinking that put yourself or others at risk, including unprotected sex, drinking that led to legal problems, or drinking

that caused problems with family, friends, work, or school. as excessive television watching.
b Using drugs that put yourself or others at risk, including unprotected sex or drinking that led to legal problems.
Researchers of previous work have
c Vaginal sex only.
* P < 05.
shown that children with PI histories
** P < .01. are more likely to eat unhealthy
*** P < .001.
foods, such as fast food and salty,
starchy, and sweet snacks, suggesting
findings related to the association to the numerous social and economic the health behaviors we observed
of PI with forgone care and FI with barriers to primary care and may among young adults may also have
worsening health problems because experience unmet health care their origins in childhood.‍34 We
of no health care suggest there is needs.‍14,​29,​
‍ 30‍ found that a history of MI or FI was
underutilization of needed health associated with significantly higher
care. The higher use of mental Although we examined young adults rates of smoking, problem drinking,
health counseling among individuals in this study, drivers of health prescription drug abuse, and ≥10
with a history of FI likely reflects a care being underused may begin lifetime sexual partners than peers
in childhood for individuals with without a history of PI. The results
greater mental health burden in this
PI. PI often leads to disruptions in presented in previous studies have
population but does not necessarily
the family unit, including possible been mixed regarding substance use
indicate adequate mental health
transitions in the adults who serve as among children and youth with PI
treatment.‍16,​31
‍ Additionally, young
the primary caregiver, as well as the histories.‍14,​35
‍ However, researchers
adults with MI are more likely to
child’s residence.‍7 Such disruptions of previous studies used small sample
use the ED as their usual source of may make it more difficult for sizes, whereas we employed a large,
health care. These young adults may caregivers to take children to the nationally representative data set in
seek care after their health problems doctor or dentist for preventive our study.‍36 Our results aligned with
have worsened, propagating existing health care, which may normalize studies in which population-based
health disparities experienced by forgoing medical care. Additionally, samples were also used.35,​37‍ Other
individuals with exposure to MI.16 parents and children who have high-risk behaviors varied by MI or
Higher frequencies of ED use is experienced a history of negative FI history. Individuals with a history
not unexpected given the multiple interaction with institutions, such as of MI had twice the odds of having
health conditions that ACE-exposed the criminal justice and child welfare sex in exchange for money, whereas
populations experience in addition systems, may be less likely to interact a history of FI was associated with

6 HEARD-GARRIS et al
IV drug use and problem drug use. with FI but not MI. Although this to identifying patients who may
These findings add to the broader aligns with previous research and benefit from further assessment
ACE literature by explicating the could be interpreted as FI being and health behavior counseling.
differential association between MI a stronger driver for many health Additionally, group medical visits
or FI and health behaviors. behaviors compared with those with for children impacted by PI may be
MI,​‍6,​38
‍ the sample of individuals another strategy to improve health
The differential impact of
reporting MI was small and may have behaviors and decrease ED visits.‍43
incarceration by parent has been
lacked the power to detect significant At those group visits, providers
described in the literature, with a
associations. Additionally, we did can discuss healthy behaviors
specific focus on the influence of
not report the primary caregiver and link children with effective
maternal incarceration.‍6,​30,​
‍ 38
‍ The
before PI, the type of offenses leading interventions to encourage healthy
evidence regarding the effect of MI
to PI, or measure the length of each behaviors. These group visits could
on child outcomes is mixed, but some
episode of PI in our study because foster a patient-provider trust, a
scholars have suggested FI may have
these data were not collected in Add sense of community, and support
a greater influence on children’s
Health. Moreover, incarceration can among individuals experiencing
long-term outcomes.‍6,​38,​39
‍ For
be a sensitive subject and a source of PI.‍44 Finally, policy makers should
example, Miller and Barnes‍39 found
stigma or shame,​‍41,​42
‍ and respondents support policies that (1) reduce
that FI exclusively was associated
could have underreported their PI incarceration rates by addressing
with physical (ie, asthma, bronchitis,
history, which may have led to more aggressive incarceration policies
emphysema, and physical injury)
conservative estimates. that lead to mass incarceration,
and mental health (ie, depression
disproportionately affecting
and anxiety) conditions. In our study,
minority and poor individuals,
we found that FI was more strongly
CONCLUSIONS and (2) maintain a child’s contact
associated with general health
with an incarcerated parent, when
behaviors and drug use than MI. The
A history of PI is associated with appropriate. Addressing PI is critical
mechanisms for these differential
health care use patterns and because the long-term consequences
relationships are unclear. The impact
health behaviors into adulthood. may impact future generations to
of FI may be related to a father’s role
Barriers to health care and health- come.
as the primary wage-earner in the
harming behaviors may contribute
household and the loss of income and
to overall poorer health for this
economic strain after incarceration. ACKNOWLEDGMENT
population. Research that focuses
This strain may place children at risk
both on the identification of specific We thank Jessica Haefner, BS, of the
for living in lower socioeconomic
barriers to health care, targeting University of Michigan, for providing
families and neighborhoods.‍40 In
this population’s under-utilization detailed literature reviews during the
addition, financial challenges during
of care, and the development of initial stages of this study.
and after FI may impede a family’s
unhealthy behaviors for PI-exposed
ability to afford health care, healthy
individuals is needed. Also,
food options, and activities that
determining if existing interventions
promote physical fitness. Fewer
that increase preventive health ABBREVIATIONS
opportunities for healthy experiences
care use and improve unhealthy
may increase screen time and ACE: adverse childhood
behaviors for children exposed to PI
other unhealthy behaviors.‍34 These experience
should be prioritized. For example,
findings reveal that interventions Add Health: National
partnerships between government
aimed at improving the health among Longitudinal Study
organizations, community
this population may need to be of Adolescent Health
organizations, and health care
tailored according to which parent to Adult Health
organizations that provide services to
was incarcerated. ED: emergency department
children with PI could communicate
FI: father incarceration
Although this study has many about children that need to establish
IV: intravenous
strengths, the results of this study care within a medical home and
MI: mother incarceration
must be interpreted in the context help them gain access to care. Also,
OR: odds ratio
of specific limitations. Several of the pediatric providers could consider
PI: parental incarceration
findings were significantly associated ACE screening as an initial approach

PEDIATRICS Volume 142, number 1, August 2018 7

revisions to the manuscript, and supervised the study; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of
the work.
DOI: https://​doi.​org/​10.​1542/​peds.​2017-​4314
Accepted for publication Apr 19, 2018
Address correspondence to Nia Heard-Garris, MD, MSc, Division of Academic General Pediatrics, Department of Pediatrics, Ann and Robert H. Lurie Children’s
Hospital, 225 E Chicago Ave, Box 162, Chicago, IL 60611. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Drs Heard-Garris, Winkelman, and Kan completed some portions of this study during their tenure as Robert Wood Johnson Clinical Scholars at the
University of Michigan and acknowledge funding from the Robert Wood Johnson Foundation during that time. Dr Winkelman also acknowledges funding from the
US Department of Veterans Affairs. The funders were not involved in the study design, collection, analysis, interpretation of data, writing of the report, or in the
decision to submit the manuscript and they accept no responsibility for the content.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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