Juvenile Suicide in Confinement: A National Perspective

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Juvenile Suicide in Confinement A National
Perspective

• May 1, 2006
• Presented by
• Lindsay M. Hayes
• National Center on Institutions and Alternatives

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Juvenile Suicide Research

• The National Center on Institutions and
  Alternatives recently (2004) completed the first
  national survey on juvenile suicide in
  confinement
• The study was funded by the Office of Juvenile
  Justice and Delinquency Prevention, U.S. Justice
  Department
• The study identified 110 juvenile suicides
  occurring between 1995 and 1999. Data was
  analyzed on 79 cases

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Juvenile Suicide Research

• 42 occurred in Training School/Secure Facilities
• 37 in Detention Centers
• 15 in Residential Treatment Centers
• 6 in Reception/Diagnostic Centers

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Juvenile Suicide Research

• Almost half (48) of the suicides occurred in
  facilities administered by state agencies, while
  39 took place in county facilities and 13 in
  private programs.

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Juvenile Suicide Research

• 68 of the victims were White
• 80 of victims were male
• Average (mean) age of victims was 15.7, with over
  70 between the ages of 15 and 17
• Most (40) of victims were living with one parent
  of time of confinement

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Juvenile Suicide Research

• 70 of victims were confined on non-violent
  offenses
• None of the victims were under the influence of
  alcohol and/or drugs at the time of the suicide.
• 79 of victims had a history of prior offenses,
  most (76) were of a non-violent nature

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Juvenile Suicide Research

• Approximately two-thirds (67) of all victims
  were held on commitment status at time of death
• 33 on detained status
• Not surprisingly, however, the vast majority
  (89) of victims held in Detention Centers were
  on detained status

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Juvenile Suicide Research

• Deaths were evenly distributed during a more than
  12-month period, with the same number of suicides
  occurring within the initial 1 to 3 days of
  confinement as occurring in more than 12 months
  of confinement
• Only 4 of all suicides occurred within the first
  24 hours of confinement

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Juvenile Suicide Research

• However, all Detention Center suicides occurred
  within the first four months of confinement, with
  over 40 occurring within the first 72 hours

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Juvenile Suicide Research

• 88 of victims had a substance abuse history
• 23 of victims had a history of medical problems
• 58 of victims had emotional abuse history
• 44 had physical abuse history
• 39 had sexual abuse history

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Juvenile Suicide Research

• 74 of victims had a history of mental illness
  (and most thought to be suffering from depression
  at the time of death), with 54 of victims taking
  psychotropic medication

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Juvenile Suicide Research

• 71 of victims had a history of suicidal
  behavior, with suicide attempt(s) being the most
  frequent type of suicidal behavior (46),
  followed by suicidal ideation and/or threat
  (31), and suicidal gesture and/or
  self-mutilation (24)

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Juvenile Suicide Research

• Approximately half (51) of victims were found
  during a six-hour period of 601pm and midnight,
  with almost a third (29) of all suicides
  occurring between 601pm and 900pm
• 71 of suicides occurred during traditional
  waking hours (701am to 900pm)

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Juvenile Suicide Research

• 75 of victims were assigned to single-occupancy
  rooms
• 98 of suicides were by hanging
• 72 of victims utilized their bedding (e.g.,
  sheet, blanket, etc.) as the instrument
• A variety of anchoring devices were utilized in
  the hangings, including door hinge/knob (21),
  air vent (20), and window frame (15)

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Juvenile Suicide Research

• For purposes of this study, Room Confinement was
  defined as
• a behavioral sanction imposed on youth that
  restricted movement for varying amounts of time.
  It included, but was not limited to, isolation,
  segregation, time-out, or a quiet room. Room
  confinement did not include a youth assigned to
  their room during traditional sleeping hours.

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Juvenile Suicide Research

• 50 of victims were on room confinement status at
  the time of death (and 62 of victims had a
  history of room confinement)
• The circumstances that lead to room confinement
  at the time of death included failure to follow
  program rules/inappropriate behavior (47),
  threat/actual physical abuse of staff or peers
  (42), and other (11)

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Juvenile Suicide Research

• 85 of victims who committed suicide on room
  confinement status died during waking hours
  (701am to 900pm), a percentage found to be
  higher than those victims who committed suicide
  during waking hours but not on room confinement
  status (71)
• Only 17 of Residential Treatment Center victims
  were on room confinement status at the time of
  death

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Juvenile Suicide Research

• 41 of victims were found in less than 15 minutes
  following the last observation of the youth,
  however, 15 of victims were found after more
  than one hour of last being seen alive
• 17 of victims were on suicide precautions at the
  time of their deaths (most of whom were required
  to be observed at 15-minute intervals)

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Juvenile Suicide Research

• 70 of victims were assessed by a qualified
  mental health professional (QMHP) prior to their
  death (although only 35 of Detention Center
  victims received such assessments)
• Slightly less than half (44) of all victims
  either had never seen a QMHP or had not seen a
  clinician within 30 days of their deaths

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Juvenile Suicide Research

• Although the vast majority (79) of respondents
  reported that their facilities maintained a
  written suicide prevention policy at the time of
  the suicide, only 20 of facilities had all seven
  suicide prevention components (written policy,
  intake screening, training, CPR certification,
  observation, safe housing, and mortality review)
  at the time of the suicide

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Juvenile Suicide Research

• The degree to which facilities had all seven
  suicide prevention components varied considerably
  by facility type
• Detention Centers (10)
• Training Schools/Secure Facilities (24)
• Reception/Diagnostic Centers (40)
• Residential Treatment Centers (25).

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Juvenile Suicide Research

• Although the majority (65) of respondents
  reported that a mortality review was conducted
  following the suicide, only 38 identified
  possible precipitating factors to the deaths.
  These factors included
• Fear of waiver to adult system, transfer to a
  more secure juvenile facility, and/or pending
  undesirable placement (including home)

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Juvenile Suicide Research

• Recent death of a family member
• Failure in the program
• Contagion (from another suicide in the facility)
• Parent(s) threat of/failure to visit
• Other (loss of relationship, close proximity to
  birthday, suicide pact with peer, ridicule from
  peers)

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Study Recommendations

• Consistent with national correctional standards
  and practices, all juvenile facilities,
  regardless of size and type, must have a detailed
  written suicide prevention policy that addresses
  each of the following critical components
  training, identification/screening,
  communication, housing, levels of supervision,
  intervention, reporting, and mortality review.

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Study Recommendations

• Young lives will continue to be lost and
  jurisdictions will incur unnecessary liability
  from these tragic deaths unless juvenile
  administrators create and maintain effective
  training programs, as well as ensure that all
  direct care, medical and mental health personnel
  receive both pre-service and annual instruction
  in suicide prevention.

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Study Recommendations

• Suicide prevention training curricula utilized in
  juvenile facilities has historically relied on
  information gathered from adult inmate suicide,
  as well as youth suicide in the community. Given
  the findings from this study demonstrating
  differences between adult inmate suicide and
  juvenile suicide, development of separate
  training curricula targeted to suicide prevention
  within juvenile facilities appears warranted.

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Study Recommendations

• Significant deficiencies in intake screening, as
  well as overall suicide prevention programming
  within Detention Centers experiencing suicides,
  warrants immediate attention. Resources need to
  be channeled to all juvenile facilities
  throughout the country, particularly detention
  centers, to ensure that any agency housing a
  juvenile provides basic, yet comprehensive
  suicide prevention programming.

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Study Recommendations

• More than one-third of the suicides identified in
  this study were unknown to many agencies
  responsible for the care and advocacy of confined
  youth. The fact that any suicide occurring within
  a juvenile facility throughout the United States
  could remain outside the purview of a regulatory
  agency should be cause for great concern within
  the juvenile justice community. At a minimum, we
  must ensure that each death is accounted for,
  comprehensively reviewed, and provisions made for
  appropriate corrective action.

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Study Recommendations

• Future research efforts should be directed at
  determining the possible precipitating factors to
  juvenile suicide, the perceived relationship
  between suicide and room confinement, and the
  effect, if any, of prolonged confinement on
  suicidal behavior.

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Conclusion

• Findings from this study create a formidable
  challenge for both juvenile correctional and
  health care officials, as well as their
  respective staffs. For example, although room
  confinement remains a staple in most juvenile
  facilities, it is a sanction that can have deadly
  consequences and will need to be closely
  scrutinized and utilized judiciously.

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Conclusion

• In addition, because data also showed that
  suicides can occur at any time during a youths
  confinement, with the same number of deaths
  occurring within the first few days of custody as
  in more than a year of confinement, intake
  screening for the identification of suicide risk
  upon entry into a facility should be viewed as
  time-limited.

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Conclusion

• Instead, because youth can be at risk at any
  point during confinement, the challenge for those
  who work in the area of juvenile detention and
  corrections will be to conceptualize the issue as
  requiring a continuum of comprehensive suicide
  prevention services aimed at the collaborative
  identification, continued assessment, and safe
  management of youth at risk for self-harm.

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Further Information

• Juvenile Suicide in Confinement A National
  Survey will appear as an OJJDP publication in the
  near future. The full report, however, can be be
  accessed through the NCIA website
• http//www.ncianet.org/cjjsl.cfm

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Toward a Better Understanding of Suicide
Prevention

• We do an admirable job of managing juveniles
  identified as suicidal and placed on precautions.
  
• Very few juveniles successfully commit suicide
  while on suicide watch.
• PRIMARY CHALLENGE How do we prevent suicide of a
  youth who is not easily identifiable as being at
  risk for self harm?

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Toward a Better Understandingof Suicide
Prevention

• If suicidal individuals were either willing or
  able to articulate the severity of their suicidal
  thoughts and plans, little risk would exist.
• Kay Redfield Jamison, a prominent psychologist
  and author of Night Falls Fast Understanding
  Suicide (1999)

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Guiding Principles forSuicide Prevention

• The assessment of suicide risk should not be
  viewed as a single event, but as an on-going
  process.
• Intake screening should be viewed as something
  similar to taking ones temperature it can
  identify a current fever, but not a future cold.

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Guiding Principles forSuicide Prevention

• Prior risk of suicide is strongly related to
  future risk.
• Do not rely exclusively on the direct statements
  of a youth who denied that they are suicidal
  and/or have a prior history of suicidal behavior,
  particularly when their behavior, actions and/or
  history speak louder than their words.

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Example

• In Washington State, a youth was booked into a
  local juvenile detention center and informed the
  intake officer that she had a history of mental
  illness, had attempted suicide two weeks earlier,
  but will not hurt herself in the facility.
  Juvenile records indicated that the youth
  threatened suicide during a recent prior
  confinement in the facility. The juvenile
  attended a court two days later and the probation
  officer noticed that she appeared despondent, was
  crying, and appeared scared. She was not
  referred to mental health staff, nor placed on
  suicide precautions. The juvenile committed
  suicide the following day.

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Example

• In Virginia, police were involved in a high-speed
  pursuit of a juvenile who had fired a gun in a
  convenience store. The youths vehicle was
  eventually stopped after ramming into several
  police cars. When officers approached the
  juvenile, he placed a handgun to his head a
  threatened suicide. An officer talked with the
  youth for several hours and was eventually able
  to convince him to surrender. He was transported
  to a juvenile detention center, refused medical
  treatment, and placed in a cell. The juvenile was
  not referred to mental health staff, nor placed
  on suicide precautions. He committed suicide
  several hours later.

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Guiding Principles forSuicide Prevention

• We must provide meaningful suicide prevention
  training to our staff. Training should not be
  scheduled simply to comply with an accreditation
  standard. A workshop limited to an antiquated
  videotape, or recitation of the current policy
  might demonstrate compliance (albeit wrongly)
  with accreditation, but it is not meaningful.

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Guiding Principles forSuicide Prevention

• Many preventable suicides result from poor
  communication amongst direct care, medical and
  mental health staff. Facilities that maintain a
  multidisciplinary approach to suicide prevention
  avoid preventable suicides.

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Guiding Principles forSuicide Prevention

• One size does not fit all and basic decisions
  regarding the management of a suicidal youth
  should be based upon their individual needs, not
  simply on the resources that are said to be
  available.

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Example

• If an acutely suicidal youth requires continuous,
  uninterrupted observation from staff, they should
  not be monitored via CCTV simply because that is
  the only option the system chooses to offer.

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Example

• A clinician should never feel pressured, however
  subtle that pressure may be, to downgrade or
  discharge a youth from suicide precautions
  because additional staff resources (e.g.,
  overtime) will be necessary to maintain the
  desire observation level.

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Guiding Principles forSuicide Prevention

• We must avoid creating barriers that discourage
  youth from accessing mental health staff should
  they feel suicidal. If a youth believes suicidal
  precautions are punitive, i.e. automatic
  removal of clothing , issuance of a safety smock,
  limited movement (for showers, visiting,
  recreation, telephone, etc.), loss of desired
  housing unit placement, they may very well be
  reluctant to seek out mental health staff.

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Guiding Principles forSuicide Prevention

• Few issues challenge us more than youth who
  threaten suicide for a perceived secondary gain.
  Yet we should not assume that youth who appear
  manipulative are not also suicidal. The
  critical issue is not how we label the behavior,
  but how we react to it. The reaction must
  include a multidisciplinary approach.

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Guiding Principles forSuicide Prevention

• A disproportionate numbers of suicides take place
  on room confinement. We must create more
  interaction between youth and direct care,
  medical, and mental health staff in these units,
  including more frequent rounds by staff and
  admission screening.

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Guiding Principles forSuicide Prevention

• Lack of youth on suicide precautions should not
  be interpreted to mean that there are no
  currently suicidal youth in your facility, nor a
  barometer of sound suicide prevention practices.
  You cant make the argument that your facility is
  housing more mentally ill and/or other high risk
  individuals and then state there are not any
  suicidal youth in our facility today.

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Guiding Principles forSuicide Prevention

• Continued.
• Juvenile facilities contain suicidal youth every
  day the challenge is to find them. The goal
  should not be zero number of youth on suicide
  precautions rather the goal should be to
  identify, manage and stabilize suicidal youth in
  our custody.

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Guiding Principles forSuicide Prevention

• We must avoid the obstacles to prevention.
  Experience has shown that negative attitudes
  often impede meaningful suicide prevention
  efforts. These attitudes often embody a state of
  mind (even before the inquiry begins) that
  juvenile suicides cannot be prevented.

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Guiding Principles forSuicide Prevention

• Create and maintain a comprehensive suicide
  prevention program that includes the following
  essential components
• Staff Training
• Intake Screening/Assessment
• Communication
• Housing
• Levels of Observation
• Intervention
• Reporting
• Follow-up/Mortality Review

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Juvenile Suicide Prevention Resources

• For more information, contact
• Lindsay M. Hayes
• Project Director
• National Center on Institutions and Alternatives
• 40 Lantern Lane, Mansfield, Massachusetts 02048
• [phone]-office, [phone]-fax
• e-mail Lhayesta_at_msn.com
• www.ncianet.org/cjjsl.cfm