Assessing Traumatic Experiences of Justice-Involved Latinx Youth A Systematic Review

Background: Traumatic experiences have been linked to the unmet behavioral health needs of justice-involved youth. Unmet behavioral health needs are some of the most salient predictors of initial justice involvement and recidivism. Latinx youth are one of the most overrepresented ethnic and racial minority groups in the Juvenile Justice System in the United States. The primary aim of this systematic review was focused on justice-involved, Latinx youth in order to compare traumatic experiences and PTSD rates by race/ethnicity and gender. Methods: To ensure methodological rigor and reduce bias, a protocol was developed to outline criteria for study inclusion and to identify relevant data for extraction. For inclusion in this systematic review, studies had to be (a) observational or randomized controlled trials, (b) assess either trauma exposure or symptoms of justice-involved Latinx youth 13 to 18 years of age, (c) sample detained youth in the juvenile justice system, and (d) compare Latinx trauma experience or symptoms by gender and/or by ethnicity/race. A librarian at the University of California, San Francisco assisted to identify seminal articles in the �eld of juvenile justice and to identify subject headings and keyword terms from titles and abstracts. Results: Seven peer-reviewed articles were collected from PsycINFO, PubMed, and EMBASE, analyzed, and summarized. Themes from the literature were organized into the following sections: (a) participant characteristics, (b) measurement of trauma experience and PTSD, (c) types of studies, (d) trauma rates, (e) trauma exposure by race/ethnicity and Latinx gender, and (f) PTSD by race/ethnicity and gender. There were differences in the number and types of traumatic experiences that the youth were asked about, which precluded allowing direct data comparisons across studies. Most of the studies varied in their measurement of PTSD. Trauma exposure rates by race/ethnicity and Latinx gender was mixed. Latinx youth disclosed PTSD symptoms at a statistically signi�cant higher rate than did White and Black youth. Conclusion: Trauma rate differences varied by study, presumably related to a lack of construct equivalence and variability in the number and types of traumatic experiences assessed by the measures. Further research is needed to inform appropriate assessment and treatment of justice-involved Latinx youth.

earlier onset of drug use and more polysubstance use (Racz et al., 2015) than for White and Black males.Justice-involved Latinx females have been shown to have more severe psychiatric symptoms than their White and Black counterparts (Lopez & Nuño, 2016) and heavier substance use than their Black and White counterparts (Abram et al., 2015).
The existence of gender differences among justice-involved youth is well understood (Lopez & Nuño, 2016).Latinx males and females have been documented to differ in terms of their arrest rates, offense types, psychiatric symptoms, and substance use (Lopez & Nuño, 2016).
Arrest data collected from 5,400 law enforcement agencies throughout the United States showed that females make up 30% of Latinx juvenile arrests (O ce of Juvenile Justice and Delinquency Prevention, 2012).However, among Latinx youth who were arrested, females were arrested for 13.8% of violent crimes (i.e., murder, violent sex offense, robbery, and assault), 39.2% of larceny arrests, and 57.5% of runaway arrests (O ce of Juvenile Justice and Delinquency Prevention, 2012).Research has also shown that justice-involved Latinx females have more severe internalizing disorders (Hoskins et al., 2019) and lower rates of substance detected by urinalysis than Latinx males (46.1% versus 58.9%; McClelland et al., 2004).What still needs investigation is the underlying cause of these differences in the incarcerated Latinx youth population and how these underlying causes are related to their behavioral health needs (e.g., traumatic experiences).Griner and Smith (2006), in their seminal meta-analytic review, showed that culturally adapted mental health interventions were 4 times more effective when tailored to one cultural group versus to clients from a variety of cultural backgrounds.It has been documented that White youth prior to and upon contact with the justice system receive psychiatric services at much higher rates than do Latinx youth (White, 2016), even when the behavioral health needs are equivalent to those of other ethnicities and races (Winkelman et al., 2017).Rather than basing all services on the needs of White youth, research that provides a nuanced understanding of trauma exposure as it relates to the Latinx community, and by gender in particular, is warranted.

Study Aim
In addition to Latinx youth being overrepresented at every intercept of the justice system (Winkelman et al., 2017), they have been shown to have unmet behavioral health needs (Hoskins et al., 2019).Trauma has also been shown to be an environmental condition that disproportionately affects Latinx youth (Hinton et al., 2013).I address published research on trauma and PTSD in the juvenile justice system in this systematic review.Speci cally, I asked this research question: Among justice-involved, detained youth in the United States, how do rates of trauma exposure and trauma symptoms differ by race, ethnicity, and gender?I hypothesized that detained Latinx youth in the United States will have higher rates of trauma exposure and trauma symptoms than both their White and Black peers.I also hypothesized that Latinx females will have higher rates of trauma exposure and trauma symptoms than Latinx males.
[1] Latinx is used throughout this paper to avoid gender binaries and to be inclusive of gender-uid Latinx youth.The term encompasses a heterogenous population that differs in terms of race, social class, country of origin, and gender identity, to name a few (Vélez, 2016).

Methods Inclusion/Exclusion Criteria
To ensure methodological rigor and reduce bias, I developed a protocol to outline criteria for study inclusion and to identify relevant data for extraction.For inclusion in this systematic review, studies had to be (a) observational or randomized controlled trials, (b) assess either trauma exposure or symptoms of justice-involved Latinx youth 13 to 18 years of age, (c) sample detained youth in the juvenile justice system, and (d) compare Latinx trauma experience or symptoms by gender and/or by ethnicity/race.Assessment measure types included structured or semistructured measures of trauma exposure or symptoms.Exclusions included adult samples, case studies with a small sample size (N < 10), nondetained and non-juvenile-justice population, Latinx not included in the analysis, non-U.S.population, and not able to compare either trauma exposure or severity of trauma symptoms.

Search Strategy
Initially, I consulted seminal articles in the eld of juvenile justice to identify subject headings and keyword terms from titles and abstracts.A librarian at the University of California-San Francisco was consulted to identify additional subject headings and keywords and assemble search strings.Three databases-PsycINFO, PubMed, and EMBASE-were selected because of their scope, breadth, and expansive access for the topic's related disciplines.Search strings were run in the these databases using the selected subject headings and keywords to identify the broadest set of relevant terms used for studies of Latinx youth and the juvenile justice population.
The following search strings were used in the three selected databases: PubMed: (justice-involved OR detained OR incarcerated OR rst contact OR "justice-involved youth") AND (trauma OR psychotrauma OR "traumatic stress" OR "traumatic disorder" OR "traumatic exposure" OR "posttraumatic stress" OR "trauma symptoms" OR "stress disorders, post-traumatic"[MeSH]) AND (Latino OR Latina OR Hispanic OR Mexican OR immigrant) AND (youth OR "young adult" OR teen Or teens OR teenager OR teenagers OR adolescent OR adolescents OR adolescence).This search returned 58 results.In EMBASE, I used the following search strings: ('justice involved' OR detained OR incarcerated OR ' rst contact' OR ( rst AND ('contact'/exp OR contact)) OR 'justice-involved youth') AND ('Hispanic'/exp OR Hispanic) AND ('PTSD'/exp OR PTSD OR 'traumatic experience'/exp OR 'traumatic experience').This search returned 11 results.In PsycINFO, I used (justice-involved OR detained OR incarcerated OR rst contact OR "justice-involved youth") AND (trauma OR psychotrauma OR "traumatic stress" OR "traumatic disorder" OR "traumatic exposure" OR "posttraumatic stress" OR "trauma symptoms" OR PTSD) AND (Latino OR Latina OR Hispanic OR Mexican OR immigrant).This search returned 20 results.Data Abstraction, Quality Assessment, and Analysis Plan I independently abstracted the study data and assessed the quality of the identi ed studies.I undertook a narrative synthesis of the ndings.
Of the 89 references screened, 17 were duplicates, leaving a total of 72 unique papers.I then reviewed titles, abstracts, and full articles for study inclusion.I excluded the following: 23 studies that were not restricted to justice-involved youth, 15 studies that used adult samples, nine studies that did not involve comparisons to Latinx youth, seven studies on non-U.S.populations, six studies in which trauma rates were not discernable by race/ethnicity and/or PTSD rates were not discernable by race/ethnicity or gender, and ve case studies with small sample sizes (i.e., N < 5).This left seven studies that t the study criteria:

Participant Characteristics
Participants in all seven studies were enrolled after 1995.Combined, the study authors observed 94,103 detained youth in the juvenile justice system.Sample size in individual studies ranged from 264 to 64,329.Latinx youth represented 9% to 30% of the samples.Of the seven studies that met inclusion criteria, youth represented three different intercepts of the juvenile justice system: (a) pretrial detention (n = 5), incarcerated (n = 1), and repeat offenders (n = 1).All studies included a mix of ethnicities/races (i.e., Black, White, and Latinx) and genders; males were a majority in each study.Table 1 is a summary of all seven studies.(Insert Table 1).

Measurement of Trauma Experience
There were differences in the number and types of traumatic experiences that the youth were asked about, which precluded allowing direct data comparisons across studies.At the lower end, four studies queried for eight or fewer traumatic experiences (Abram et al., 2004;Ford et al., 2008;Lau et al., 2015;Rawal et al., 2004) versus three that queried for 10 or more (Baglivio & Epps, 2016;Ford et al., 2013;King et al., 2011; min = 3 [Rawal et al., 2004], max = 21 [Ford et al., 2013]).Even when two articles (Ford et al., 2008;Ford et al., 2013) used the same measure (i.e., the Traumatic Events Screening Inventory) to query trauma exposure, the difference between the number of traumatic exposures queried was 14.A traumatic exposure that was not commonly assessed for was traumatic separation or loss due to immigration (Abram et al., 2004;Baglivio & Epps, 2016;Ford et al., 2008;Lau et al., 2015;Rawal et al., 2004).

Measurement of PTSD
Most of the studies varied in their measurement of PTSD.Only two studies compared PTSD symptom severity across races/ethnicities (Abram et al., 2004;Ford et al., 2008), and only one study compared PTSD severity by Latinx gender (Abram et al., 2004).Both studies used a standardized and highly accepted measure of PTSD that elicited Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria.

Assessing Trauma
The responses to trauma were collected in three ways.In all but one study (Rawal et al., 2004), interviewers were used to elicit self-report from youth; unfortunately, there is a reporting bias inherent in self-report, In four studies (Abram et al., 2004;Ford et al., 2008;Ford et al., 2013;King et al., 2011), measures were delivered by individuals with counseling degrees, who presumably would be more sensitive to assessing traumatic experiences from youth than the o cers from the court used to assess trauma exposure in two other studies (Baglivio & Epps, 2016;Lau et al., 2015).Baglivio and Epps (2016) used trauma screening as part of a risk assessment done by an o cer of the court to predict the likelihood that the youth would reoffend, and there was no mention of whether the youth were blinded to this, which would further create response bias because youth are less likely to report traumatic history when doing so puts them at risk to reoffend in the rater's perspective (van Batenburg-Eddes et al., 2012).Lastly, two studies reviewed prior court documentation on the youth (e.g., Child Protective Services reports) to assess past abuse/maltreatment; King et al. ( 2011) used this as a supplement to court documentation, and Rawal et al.
(2004) used it by itself.King et al. (2011) noted that if there was a discrepancy between the court report and the self-report, they would keep the response that indicated trauma exposure.Allowing the researcher to choose the desired response is also highly problematic.

Type of Studies
I evaluated the studies in this systematic review to determine the strength of the ndings.The quality of the study designs was mixed.Of the seven studies, three (Abram et al., 2004;Lau et al., 2015;Rawal et al., 2004) strati ed their samples to be representative of the state's juvenile justice sample where the research took place in terms of age, sex, race/ethnicity, and legal status.Baglivio and Epps (2016) and Lau et al.
(2015) used secondary databases containing samples of youth in detention throughout the entire state, allowing for much larger sample sizes.However, these studies are problematic in that Latinx youth were consistently underrepresented in the study samples.In the same two studies, the authors also reported attrition; 22% in Baglivio and Epps and 5% in Lau et al.King et al. (2011) reported that after reviewing the characteristics of the participants they lost, they determined that these participants were more likely to be male or Latinx than the participants who were sampled.Trauma Rates I seven studies that assessed either the number of traumatic experiences or PTSD severity by ethnicity/race or Latinx gender.I also investigated traumatic loss by ethnicity/race and sex abuse by Latinx gender.The studies varied in that not all allowed comparisons by trauma experience and PTSD severity.Table 2 shows the effect sizes of traumatic exposure, PTSD severity, traumatic loss, and sex abuse with odds ratios and 95% con dence intervals.(Insert Table 2).

Trauma Exposure by Race/Ethnicity
There were mixed ndings in terms of rates of trauma exposure by race/ethnicity.In Abram et al. (2004), Latinx youth reported a mean number of traumatic experiences that was higher than that of White youth and comparable to that of Black youth.In Ford et al. (2013), polyvictimization and subsequent PTSD were combined using exploratory latent class analysis, which created a high polyvictimization class (M = 11.37,SD = 1.11; trauma types), relatively moderate adversity (M = 8.9, SD = 0.34; trauma types), and low (M = 7.39, SD = 0.42; trauma types).Latinx youth (n = 18, 3%) were the lowest proportion of youth in the highest polyvictimization class (White = 5.9%, Black = 5.4%); however, in the same study, the proportion of Latinx youth that made up the other two subcategories was similar to White and Black youth at the moderate and low categories of polyvictimization.Baglivio and Epps (2016) and Lau et al. (2015) found that Latinx youth reported the lowest number of cumulative trauma exposures.King et al. (2011) reported that Latinx youth had trauma rates similar to those of Black youth but less than those of White youth.One study with a low N was inconclusive (Rawal et al., 2004).Lastly, Ford et al. (2008) indicated that Latinx youth, when compared to Black and White youth, were more likely to report both traumatic loss and community violence.

Trauma Exposure by Latinx Gender
Trauma exposure Latinx gender was also mixed.Abram et al. (2004) found that a higher proportion of Latinx males than females reported experiencing trauma.King et al. (2011) found that, on every construct of types of abuse (i.e., physical and sexual abuse), a higher proportion of Latinx females disclosed every type compared to Latinx males.Abram et al. allowed analysis by trauma type and reported that a higher proportion of Latinx males than Latinx females disclosed two items: "witnessing or experiencing someone get hurt badly or killed" and "being threatened by a weapon."Abram et al. also found that a higher proportion of Latinx females than males disclosed "forced to do something sexual." PTSD by Race/Ethnicity PTSD by Latinx Gender Abram et al. (2004) were the only researchers to compare PTSD symptoms by Latinx gender.They found that a higher proportion of Latinx males were diagnosed with clinically signi cant PTSD than were Latinx females.

Discussion
My study aim was to assess trauma exposure and severity of PTSD symptoms by race/ethnicity and Latinx gender.I had mixed ndings.
Latinx youth did report high rates of cumulative trauma, particularly when assessed for traumatic loss and community violence.Only two studies (Abram et al., 2007;Ford et al., 2008) t the criteria to analyze PTSD symptoms by race/ethnicity; both reported Latinx youth having greater of PTSD symptoms than youth of other backgrounds.Latinx females reported higher rates of sexual abuse whereas males reported more witnessing or experiencing violence.Treatment of juvenile justice-involved youth should take these differences into account.
Possible Distortions for Latinx Youth's Lower Trauma Rates That Latinx youth, in comparison to White and Black detained youth, showed lower rates of trauma experiences but more PTSD severity warrants further exploration.A primary reason for this seeming discrepancy is the narrow focus of the elicited trauma exposure of the justiceinvolved youth.King

Trauma in Home Country
Phipps Degges-White (2014) identi ed another distinct type of trauma related to Latinx youth, showing that they are also at risk for poor health outcomes due to traumatic events in their country of origin stemming from political warfare, gang violence, and drug cartels with minimal protection by police and during the migration process.In Ford et al. (2008) study that elicited traumatic separation/loss, Latinx youth were substantially higher compared to both Black and White youth.In addition, in a community sample of 1,004 school-aged youth, Jaycox et al. (2002) noted that 76% reported exposure to violence in their home countries.However, none of the studies reviewed here elicited trauma experience related to traumatic events in the home country or during migration.In addition, a serious methodological complaint is that every study analyzed Latinx youth as a monolithic ethnic group rather than considering them by country of origin.Trauma measures should be relevant to the lived experiences of Latinx youth.

Traumatic Separation and Loss
One last methodological speci c to Latinx individuals is the measurement of traumatic separation and loss.Traumatic separation and loss was not a construct consistently assessed in studies on traumatic exposure reviewed for this study.Given the propensity to immigration in comparison to White and Black youth, this is a construct that should be routinely assessed.

Gender Differences
Gender differences of justice-involved youth has been a research focus (Lopez & Nuño, 2016).Latinx girls involved in the justice system are on the rise as one fourth of all Latinx arrests are female (Hockenberry & Puzzanchera, 2016).However, there has been limited research on justice-involved Latinx females (Lopez & Nuño, 2016).Many justice-involved girls have trauma histories with resulting unmet behavioral health needs (Belenko et al., 2004).My ndings are consistent with the literature in that there was limited attention given to gender differences in the studies reviewed, particularly related to Latinx youth and gender.However, when sexual abuse was taken into account and assessed by both gender and race/ethnicity, Latinx girls consistently demonstrated higher rates.Further research is needed to appropriately assess and intervene for justice-involved Latinx girls.

Limitations And Future Research
This systematic review should be considered with some limitations.First, I found only a small number of studies that t the criteria for this review.Second, given the lack of construct equivalence in measuring traumatic experiences, the generalizability of this study related to traumatic experiences and potential race/ethnic differences and gender differences is limited.Lastly, only two studies compared traumatic experiences by Latinx gender (Abram et al., 2007;King al., 2011).Although the lack of construct equivalence and Latinx gender comparisons are problematic, public health o cials and policy makers can use these ndings to further inform proper assessment of Latinx youth, which will provide proper referral strategies for early prevention and intervention efforts.
Future research would bene t from the aforementioned study limitations.Speci cally, comparing traumatic experiences of justice-involved youth by race/ethnicity and gender, taking into account Latinx youth's speci c traumas endured in the home country and during migration, traumatic separation and loss due to migration, and community violence.Furthermore, comparing traumatic experiences by Latinx gender would further assist practitioners seeking to properly refer justice-involved youth to the appropriate services.Lastly, assessing whether proper intake of traumatic experiences bene ts treatment outcomes is recommended.

Conclusions
Latinx youth involved in the justice system have been shown to endorse high rates of trauma exposure (Hoskins et al., 2019).Trauma exposure has been linked to unmet behavioral health needs (i.e., psychiatric symptoms, substance use, and sexual risk behaviors), and unmet behavioral health needs have been linked to recidivism.I set out to compare traumatic experiences of justice-involved youth by race/ethnicity and gender.I found that the lack of construct equivalence when eliciting traumatic experiences led to variability in trauma rates and ultimately resulted in misclassi cation of trauma rates.In order to provide proper assessment and intervention to offset further justice involvement and to treat the unmet behavioral health needs of justice-involved Latinx youth, clinicians are urged to use measures of trauma experience and to take these ndings from these measures into consideration.

Declarations
Role of Funding Source: This study was funded by National Institute of Drug Abuse under grant number RO1DA034538-05S1 and the National Institute of Health Loan Repayment Program, NIMHD (Hoskins, L60 MD009257).
Competing Interest: The author certi es that he has NO a liations with or involvement in any organization or entity with any nancial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-nancial interest (such as personal or professional relationships, a liations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Tables
Abram et al. (2004), Baglivio and Epps (2016), Ford et al. (2008), Ford et al. (2013), King et al. (2011), Lau et al. (2015), and Rawal et al. (2004).I calculated odds ratios and standard deviations for each study.When the study authors provided the proportion and sample sizes, I used the Corn eld approximation in Stata 15.2 to calculate odds ratios and the 95% con dence intervals.When the mean and standard deviation were provided, I used the Practical Effect Size Calculator(Wilson, n.d.).
Most of the studies used count data to summarize cumulative traumatic responses.The number of possible count outcomes ranged from 0 to 19; only Abram et al. (2004) used a count regression model to analyze count data.Ford et al. (2013) used an exploratory latent class analysis to determine the number of latent classes of polyvictimization and subsequent PTSD, while two studies used logistic regression to compare rates of abuse by demographic characteristics (Ford et al., 2008; King et al., 2011).Rawal et al. (2004) used analysis of variance to detect and report differences chi-square tests to report differences, and Baglivio and Epps used prevalence rates.
et al. (2011), Rawal et al. (2004), and Baglivio and Epps (2016) solely focused on traumatic experiences from physical or sexual abuse, with Baglivio and Epps also focusing on traumatic experiences endured in the family system.Lau et al. (2015) elicited a limited number of trauma types, and Ford et al. (2013) combined trauma symptoms and PTSD severity, thereby not allowing for a detailed examination of trauma exposure.Lau et al. is also problematic in that the researchers categorized individuals of Caribbean descent as Black.Many Latinx youth hail from Caribbean countries.Community Violence Researchers have documented that Latinx youth endure unique and distinct types of trauma compared to White and Black youth.For example, Finkelhor et al. (2014) noted that Latinx youth are more likely to live in disadvantaged neighborhoods and experience community violence compared with youth of other racial/ethnic groups in the United States.Of the six studies that provided comparisons by trauma experience, only Abram et al. (2004), Ford et al. (2008), and Ford et al. (2013) elicited traumatic experience related to community violence.In these three studies, Latinx youth showed a trend toward a higher mean number of traumatic experiences than White youth, with Abram et al. also showing a comparable number to Black youth.Latinx youth in Abram et al. and Ford et al. (2008) also showed more severe PTSD symptoms than White and Black youth.
Ford et al. (2008)Ford et al. (2008)reported PTSD symptoms by ethnicity/race.Abram et al. found that Latinx youth disclosed clinically signi cant PTSD symptoms at a statistically signi cantly higher rate than did White and Black youth.Ford et al. reported a similar trend, while not statistically signi cant, with Latinx youth reporting more severe PTSD symptoms.

Table 2 Trauma
Exposure, Posttraumatic Stress Disorder (PTSD) Symptoms, Traumatic Loss, and Sex Abuse Differences by Ethnicity/Race and