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Juvenile detention. The roles and competences for doctors associated with the European NPMs Warsaw, December 2011 Hans Draminsky Petersen, MD. Vulnerabilities As a juvenile in detention < 18 years of age. Being deprived of one’s social network Being young Being female
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Juvenile detention The roles and competences for doctors associated with the European NPMs Warsaw, December 2011 Hans Draminsky Petersen, MD
VulnerabilitiesAs a juvenile in detention < 18 years of age • Being deprived of one’s social network • Being young • Being female • Difficult family background • Broken family. Lack of appropriate role model • Lack of social skills and educational maladjustment • Substance abuse • Psychic condition or illness • First time offender in custody: • New discipline with restrictions and rules – official ones • Unofficial rules set by hard core criminals • Cohabitation with hard core criminals and violent fellow detainees lacking positive social skills • To clarify vulnerabilities and their consequences, talk with inmates
Basic considerations • Legislation: age, detention as last resort shortest appropriate period of time • Specialised juvenile justice system, no unnecessary delay • Upon arrest, basic rights: • notification of parents, information about rights • presence of a parent /guardian and a lawyer at interrogations • Separation from adults and by gender, • Pre-trial detainees separated from convicted, Justified allocatio to cell /block • Appropriate facilities • Multidisciplinary approach in the institution and at ministerial level • Staffing of the institution: • Selection; training in dealing with juveniles • Multidisciplinary: e.g. teachers, social workers, psychologists, etc • Appropriate gender balanced • Support and supervision
Basic considerations • Material conditions, incl. personal items • Hygiene, female juveniles • Activities, incl. females: • School, education, vocational training, • Sport, recreation, library • Health care, incl. psychological, e.g. psycho-education • Discipline • Complaints • Maintaining of contact with the outside world
The outside world: • Maintaining contact with the family from the outset of detention. Visits once a week and unrestricted communication with family and phone calls twice a week • Involving the family /guardian in • all procedural steps and • in the project for the life and • important health events • Creating a new social network if the family is the problem • Preparation for release: • Continuation /commencement of education /training • Follow-up on any treatment – psychic or somatic – if needed
The institution holding juveniles • Designed to hold juveniles, ensuring: • Privacy, unobtrusive supervision of sleeping areas, personal effects and clothes • Sensory stimuli, • Opportunities to associate with peers, • Participation in sports and physical activities, • Leisure activities, library • Safe /fire-safe with alarm systems • No known health risks • Appropriate staffing, trained and committed /selected, • Multidisciplinary staff • Facilitating continuation of education and vocational training
Arriving to the institution • Careful assessment of the juvenile by the doctor, psychologist, teacher, social worker as to health, personality, social needs, potential for education and training, criminal record, • Protection against harmful influence and risk situations from being detained and from fellow-inmates - First time offenders not together with recidivists • Allocation to a particular block and cell, with reasons for this entered into the personal record • Drafting a plan for treatment, education and work with a view to rehabilitation in the best interest of juvenile • Discussing possibilities with the juvenile • Jointly with the juvenile taking a decision for a plan
Building of a post-detentionproject for the life of the juvenilewith a view to reintegration into the society • Drawing a realistic role model and a goal in life • Strengthening social skills and network • Relations of mutual understanding and support • A family of one’s own • Spouse and children • Education and professional competences • Recreational interests and activities, physical /intellectual • Serving a sentence should be more than mere punishment
The staff • Selection, • Interest, experience and training in dealing with juveniles • Education, in-service training and refresher courses • The objectives of the detention, rules and discipline, using force and restraints • Basic legal aspects and human rights • Basic psychology of the young, conflicts and models for resolution • Basic knowledge of common health conditions, first aid • Gender issues • Dynamics in working in multidisciplinary teams, competencies /limitations. Instruction not to filter health requests from inmates • Using registers • Issues to report to superior • Supervision in daily practice • Gender representation
Organisation of the medical staff • Independence from the ministry of interior or justice • Ministry of Health responsibility: • Set standard for health services in places of detention, incl. • health promotion and treatment programmes, • Implement standards and ensure compliance in institutions: • Instructions for conduct, treatment /examin. guidelines & protocols • Guidelines for supervision of staffs • Instructions for handling gender aspects, persons with disabilities, • Monitoring, incl. addressing reports from visiting bodies • Allocate resources, incl. equipment and medicine • Staff • criteria for employment • curriculum for training programmes
The medical staff, training • Basic legal aspects and the rights of the detainee • Basic psychiatry, incl legal aspects • Psychology of juveniles in conflict, suicide and self-harm • Handling conflicts • The doctors role in using restraints, incl. legal issues • Forcible administration of treatment /medicine • Security issues in dealing with violent inmates • Forensic medicine, description and assessment of lesions • Substance abuse • Preventive medicine, hygiene, transmissible diseases, • Using registers, examination protocols and keeping records • Maintenance of confidentiality, • Issues to report to superior • Medical ethics, difficult situations, dual loyalties, ref. points, Med Asso
Health services • The routine interview and examination upon arrival: • “Immediate” • A doctor - or a nurse with necessary back-up by a doctor • Easy access to the clinic whenever needed • No filtering by non-health professionals • Equivalent to the services of all citizens. Free of charge. • Guidelines for prevention: • Substance abuse and related conditions • Risk behavior related to health: drugs, sex, violence • Transmissible diseases • Suicide and self harm • Health promotion
The initial examination upon arrival • Confidentiality /privacy, only medical staffs present • Safe confidential archive for medical records • Relaxed atmosphere, more than running through a check-list • The content /protocol • Informed consent • History of previous and present illnesses, somatic and mental • Exposure to violence, previous and present, incl. by police • Present somatic health problems, needs for treatment • Present psychic condition, incl. depression, anxiety; risk of suicide, i.e. urgent psych. assessment, placement in “safe” area • Substance abuse, injection • Other risk behavior, incl. sexual
The physical examination: • Informed consent • Patient and doctor same gender • Assessment of general health, nutritional status • Body function, locomotion, organs • Body surface, lesions, injection marks? • Preliminary psychological assessment
The conclusion of the routine medical examination: • Needs • Immediate / long-term treatment • Follow-up in the clinic • Special arrangements, e.g. referral to specialized wards, persons with disabilities • Referral to specialist doctors or hospital • Urgent referral to psychologist /psychiatrist • Treatment or prevention of withdrawal symptoms • Treatment of substance abuse • Assessment of signs of violence • Assessment of history of ill-treatment • Health promotion: • Risk behavior: Drugs, sex, tobacco • Transmissible diseases • Nutrition
Obligation of the doctor to report findings • General issues: • Health risks: Hygiene, food, • Transmissible diseases • situations implying risks of violence • Individual issues, • to the director, • independent authority responsible for safeguarding well-being of juveniles • A central register* • Injuries, • *Possible ill-treatment, with consent or anonymised • Any observation that indicates the physical or mental health of the juvenile has been or will be injuriously affected by continuous detention
Supervision and inspection of medical services • Supervision by a director of prison medical services • Links to the medical community, e.g.: • Clinics for treatment of TB and HIV • Institute for forensic medicine • Psychiatric institutions • Community health care, incl. psychological • + • Authorised inspectors of places of detention for juvenile , incl. doctors, with a mandate to visit unannounced and speak in private with juveniles, with obligation to report and have dialogue on findings • Obliged to report violation of legal provisions to bodies vested with powers for investigation and prosecution
Record keepingAny contact apart from the initial examination: • The reason for the contact, • Health complaints, sypmtoms • Clinical observations, consent to examination • The diagnosis /conclusion, • The recommendations /treatment • If injuries: • Patients account of origin and circumstances • Symptoms present • Clinical findings • Opinion of origin and recommendation for treatment • ! Note on reporting of incident and injuries • If other persons present, who and why?
Record keepingForcible examinations, if relevant • The authority who requested the examination • The nature of the procedure • The legal fundament • Identity of other persons present • Any force or restraint used by officers • Procedures undertaken by the doctor • The result of the medical examination • Any undesired effects
RegistersDetails to be entered into the individual record • A log for the activities of the day. • Name, age, sex, block, reason for contact, diagnosis • Referrals to specialist treatment, incl. psychiatrist, psychologist • Referrals to hospital • Injuries, Alleged origin, two-word description, action taken • Self-harm and suicides • Transmissible diseases • Treatment in substance dependence schemes • Health professionals’ participation in means of restraint and forcible procedures • Death in custody • Log of health promotion activities • Log of inspections of dormitories, kitchen etc., if relevant
HIV and STD prevention • Information: written material, individual and group education • Easy access to counselling and HIV testing • Access to clean syringes • Access to condoms and lubricants • Drug free units • Maintenance of confidentiality • Avoidance of discrimination
Substance abuse • Health promotion Prevention • general and • individual, identification of individuals at particular risk • Any treatment with consent and on medical ground only • Guidelines for detoxification • A specialised unit with trained staffs • Guidelines for tapering /stopping or commencing maintenance therapy • Drug administration under supervision • Social, behavioural, educational programmes
Suicide prevention • Training of staffs to be vigilant • Early detection, The initial interview with the doctor • Immediate evaluation by psychiatrist /psychologist, evt. transfer to psychiatric institution • Allocation to a quiet cell /block without known inter-prisoner conflicts • Regular surveillance by staffs and health professionals • Regulated access to items that could be used to self-harm
Before release • Placement in open detention with minimal security facilitation contact with other juveniles and with family • Early release • Semi-institutional arrangements facilitating integration into the social and cultural environment of the community: • Educational homes • Daytime training centres • Placement in support family • Plan for follow-up on to ensure: • Medical /psychological treatment, • Education, Contact with school • Social arrangements, • family support, • Support groups • A suitable residence, employment, clothing and sufficient means
Competencies of the doctor in the visiting team • Skills in working in multidisciplinary groups, • Basic knowledge of: • National and international legislation on the rights of the child /juvenile • The juvenile justice system – from arrest to release / follow-up • National regulations on protection of the child /juvenile. • The social system; educational system; the health care system, incl. community • Psychology of the child /juvenile • Common somatic and psychiatric conditions in children and juveniles • Standards for prison health care, incl. nutrition • Medical ethics • Prevention and treatment of substance related conditions • Prevention and treatment of transmissible diseases, HIV, TB, STD, hep • Forensic medicine
Suggestion for the discussion Concrete challenges experienced by NPMs in their work in institutions for juveniles Thank you for your attention