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Suicide and Related-Behavior Among Youth Involved
in the Juvenile Justice System
Michelle Scott
1,2
•Maureen Underwood
2
•Dorian A. Lamis
3
Springer Science+Business Media New York 2015
Abstract Youth in the juvenile justice system are at
significant risk for suicidal thoughts, behaviors and deaths.
Approximately 70 % of youth in the juvenile justice sys-
tem have at least one mental health diagnosis which in-
creases their risk for suicide. Over the past 20 years, the
juvenile justice system has made extensive efforts to
identify and address the mental health needs of these youth.
This paper reviews risk factors for suicidal behavior, de-
scribes the current approaches and recommendations for
programs (i.e., mental health and suicide screening and risk
assessment) and policies throughout the juvenile justice
system to reduce the risk for suicide and related-behavior
among youth.
Keywords Suicide Prevention Intervention
Juvenile justice
Introduction
The suicide rate among the general population of
10–18 years olds began increasing in 2008 breaking the
10 % mark—rising to 11.2 % (n=1337 suicide deaths) of
all deaths among this age group (Center for Disease Con-
trol and Prevention [CDC] 2015). Deaths by suicide in this
age group have continued to rise becoming the second
leading cause of death in 2010; currently (2013 data), ac-
counting for 17.2 % (n=1636 suicide deaths) of deaths
(CDC 2015). Suicide is three times as prevalent in juvenile
justice residential placements compared to the general
population (Gallagher and Dobrin 2006a). Specifically,
suicides accounted for more than a third (35 %) of the
deaths of juveniles in confinement (Hockenberry et al.
2015). Moreover, these estimates may be conservative
given that the deaths from all institutions such as private
settings may not be included in the count (Hayes 2009).
Furthermore, studies of both incarcerated youths (e.g.,
Penn et al. 2003) and youth on probation (Langhinrichsen-
Rohling and Lamis 2008) found a higher prevalence of
suicide attempts than those reported in the general
population (Moskos et al. 2005; Putnins 2005). Among
youth ages 10–18 in the Cook County Juvenile Detention
Center, 27 % of females and 10 % of males entered de-
tention with a prior suicide attempt with 19 % of female
and 10 % of male detainees thinking about death or dying
in the 6 months prior to detention (Abram et al. 2008).
On any 1 day, there is a census of approximately 86,000
adolescents who are confined (Sickmund 2010); however,
there are many more youths involved in probation and an
even greater number who have had contact with a police
officer but were diverted away from the justice system at
this initial point of contact. Youth in these systems have
significantly more risk factors found to be associated with
suicide (National Action Alliance for Suicide Prevention,
[NAASP] 2013a). Detention centers and residential fa-
cilities where youth involved with the juvenile justice
system are confined have the custodial obligation to protect
their wards; therefore, when a youth dies under the su-
pervision of public or private settings, litigation may result
(Hanson 2010). Fortunately, youth are supervised in
&Michelle Scott
mscott@monmouth.edu
1
Monmouth University, 400 Cedar Ave, West Long Branch,
NJ 07764, USA
2
Society for the Prevention of Teen Suicide, Freehold, NJ,
USA
3
Emory University School of Medicine, Atlanta, GA, USA
123
Child Adolesc Soc Work J
DOI 10.1007/s10560-015-0390-8
confinement and have limited access to the means and
opportunity for suicide. Nonetheless, deaths still occur,
making it important for the juvenile justice system to de-
velop, implement and maintain a comprehensive suicide
prevention program (NAASP 2013a). In this paper, we
review the characteristics and risk factors of suicide and
related-behavior among youth in juvenile justice, and de-
scribe prevention and intervention programs that can be
implemented.
Suicide in Confinement
In 1999, the U.S. Justice Department’s Office of Juvenile
Justice and Delinquency Prevention in conjunction with the
National Center on Institutions and Alternatives’ identified
101 suicide incidents in juvenile justice settings during the
years 1995–1999 (Hayes 2009). By analyzing 79 of these
101 deaths they provided important information regarding
how and when youth killed themselves. Similar to general
population (CDC 2015), the majority of youth who died by
suicide while in confinement were white males, with 70 %
between the ages of 15 and 17 years (Hayes 2009). Results
from this survey suggest an increased risk for completion
during periods of time where the youth is lacking super-
vision or is isolated. Although most youth died waking
hours (7am to 9 pm), approximately half of all suicides
occurred during 6 pm to midnight (50 %). Three-quarters
of the youth who died by suicide were housed in single
occupancy rooms and 50 % of the deaths occurred among
youth who were currently confined to their rooms (Hayes
2009). Similar to national suicide incidents which indicate
that suffocation is the most common means (47.9 %) of
suicide death among 10–18 years olds (CDC 2015b), the
rate of death by suffocation is doubled among youth in
juvenile justice. Hayes (2009) report indicated that 98.7 %
of youth died by hanging (all but 1 youth) with ap-
proximately three-quarters of youth using their bedding to
facilitate their death.
Risk Factors for Death by Suicide
General Population of Adolescents
Mental Health Risk Factors
In non-committed population suicides, 90 % of youth had a
psychiatric disorder (Fleischmann et al. 2005). Psycho-
logical autopsies of suicide deaths and suicide attempters
have identified several risk factors, such as psychiatric
disorders including depression, substance abuse, conduct
disorder/antisocial behavior, and anxiety including post-
traumatic stress disorder, and prior suicide attempt (see
Bridge et al. 2006; Gould et al. 2003 for reviews). Youth
with multiple diagnoses such as comorbid depression with
conduct disorder and/or substance abuse are at increased
risk for suicide; in some studies, 70 % of individuals who
died by suicide had multiple diagnoses with risk for suicide
increasing with each diagnosis (Brent et al. 1999; Fleis-
chmann et al. 2005). Although most individuals who die by
suicide have a diagnosable disorder, a small number of
adolescents who killed themselves were found not to have
a psychiatric disorder.
Prior Attempts and Situational Risk Factors
Youth with a mental health diagnosis were more likely to
have a prior attempt, disciplinary or legal problems (Brent
et al. 1993), factors which often describe those who present
to the justice system. In fact, in a study of suicides in Utah,
80 % of youth had juvenile justice contact within the
12 months prior to their death (Gray et al. 2002).
Juvenile Justice Population
Youth engaged in the juvenile justice system at multiple
points that range from first contact with the police to arrest,
probation, detention, community-based intervention, and
incarceration present with many of these risk factors.
Among studies conducted in a variety of these settings,
juveniles demonstrated several major suicide risk factors in
higher prevalence compared to the general community
population (Hayes 2005,2009—see NAASP 2013b for a
thorough review of risk factors for suicide and related
behavior in the juvenile justice system).
Mental Health Risk Factors
Using large, representative samples and standardized
measurements, studies have shown that approximately
60–70 % of youth in residential placements within the ju-
venile justice system meet criteria for at least one psychi-
atric disorder (Shufelt and Cocozza 2006; Skowyra and
Cocozza 2007a; Teplin et al. 2002; Wasserman et al. 2002,
2004,2010). Forty to fifty percent had two or more diag-
noses (Abram et al. 2003; Wasserman et al. 2010) and one
multi-site study including youth from several points of
contact reported rates of comorbidity as high as 79 %
(Shufelt and Cocozza 2006; Skowyra and Cocozza 2007b).
Many of these youth are experiencing severe mental health
issues, with 27 % needing mental health treatment (Shufelt
and Cocozza 2006). Athough the highest rates of death by
suicide were among males, females have higher rates of
mental health problems (66–81 %) than males (ap-
proximately 66 %; Shufelt and Cocozza 2006; Skowyra
M. Scott, D. A. Lamis
123
and Cocozza 2007b; Teplin et al. 2002). Accordingly, at-
tention must be paid to the mental health needs of ado-
lescents of both genders and communication and
collaboration with local mental health partners is essential.
Among non-committed but juvenile justice involved
populations, the rates of mental health problems are also
substantial and higher than the general population. Ap-
proximately one-third of youth presenting to a juvenile
assessment center (JAC; a centralized, short-term, 24 h a
day location where law enforcement officers take youth
who are arrested for receiving, processing and intervention;
Nolan et al. 2008) reported at least one mental health
disorder (McReynolds et al. 2008; Wasserman et al. 2010).
Anxiety disorders (17 %) were the most prevalent, fol-
lowed by substance use disorders and disruptive disorders
(each approximately 10 %), and only 5 % meeting criteria
for affective disorders (McReynolds et al. 2008). Similar to
youth in commitment, girls had significantly higher rates of
each of these disorders, except substance use, compared to
boys (anxiety disorder—25.8 vs. 14.1 % for males; dis-
ruptive disorders—14.9 vs. 8.8; and affective disorders 9.7
vs. 3.4 % for males; McReynolds et al. 2008). Although
anxiety is prevalent, only a small proportion (2.5 %) of
youth at intake to a JAC met criteria for posttraumatic
stress disorder (PTSD), with rates of PTSD significantly
higher for girls (5 %) than boys (1.5 %).
Youth presenting to probation, further along in the
system compared to a JAC but not detained or committed
to a residential placement, also had higher rates of mental
health disorders. Forty-six percent of youth met DSM-IV
criteria for at least one mental health disorder (Wasserman
et al. 2005); with the highest rates being found for sub-
stance use disorder (25.4 %). The gender differences in
probation reflect differences similar to those observed in
confinement, with more females meeting criteria for anxi-
ety disorder (29 vs. 17.4 % for males); affective disorders
(13.0 vs. 5.9 % for males; specifically, major depression
11.4 vs. 5.1 %); and oppositional defiant disorder (10.5 vs.
5.3 % for males; Wasserman et al. 2005). Four percent of
youth, with no gender difference, met criteria for PTSD;
however, Wasserman et al. (2005) found that girls were
more likely to report sexual abuse, another risk factor for
suicide (Bebbington et al. 2009; Bridge et al. 2006; Sulli-
van et al. 2006; Waldrop et al. 2007).
Although most of the studies reviewed examined only
one point of contact or represented one state or county, it is
important to note that rates of mental health diagnoses and
suicidal behavior increases as one moves to more restric-
tive environments. Wasserman et al. (2010) merged studies
‘‘with uniform measures and protocols’’, accumulating data
for nearly 10,000 youth (N=9,818) across multiple points
of juvenile justice contact including intake, detention and
post adjudication correctional facilities. Rates of affective,
anxiety, disruptive and substance use disorder, recent and
lifetime suicidal attempts as well as rates of comorbidity
increased as a youth moved from intake to detention to post
adjudication commitment.
Prior Suicide Attempts
One of the most significant risk factors for death by suicide is
a prior suicide attempt (Abram et al. 2008; Brent et al. 1999;
Bridge et al. 2006), increasing the risk for suicide by 10–60
fold (Brent et al. 1999). In Hayes (2009) review of suicide
deaths in confinement, almost 70 % of youth who died by
suicide in the juvenile justice system had a history of suicidal
behavior, with 45.5 % having made a prior suicide attempt.
Regardless of point of contact, youth involved at all levels of
the juvenile justice system have significant rates of prior
suicide attempts. Nolan et al. (2008) evaluated history and
predictors of lifetime suicide attempts among 1148 youth in a
JAC and found that 10 % of youth reported prior suicide
attempts. It is interesting to note; however, that youth with
severe suicidal ideation were excluded from the sample as
they were diverted away from the JAC (Nolan et al. 2008),
which may account for the lower reported percentage of prior
attempts. Moreover, Wasserman and McReynolds (2006)
assessed suicidal behavior among 991 youth at probation
intake and found that 12.7 % reported suicidal ideation in the
past month and 13.2 % reported having made a suicide at-
tempt in their lifetime. Even among youth in detention and
secure commitment where access to means and opportunity
is limited, the rates of recent attempts are 3.8 and 2.5 %,
respectively, and 17.7 and 16.3, respectively, for lifetime
attempts (Wasserman et al. 2010). In the Survey of Youth in
Residential Placement, SYRP (Sedlak and McPherson
2010), an investigation of a random sample of more than
7000 youth in secure placement, 15–26 % of youth reported
some thoughts of killing oneself and 22 % reported prior
suicide attempts, a rate that is slightly higher than the one
reported in Wasserman et al. (2010). Youth in residential
placement reported the highest rates of ideation (33 %) and
prior attempts (26 %; Sedlak and McPherson 2010). The
SYRP also found that youth in detention had the highest rate
of lifetime suicide attempts. The differences between the
Wasserman et al. (2010) and Sedlak and McPherson (2010)
studies may reflect the differences in the ways in which the
questions were asked.
Characteristics Predicting Suicidal Behavior Among
Juvenile Justice Involved Youth
It is clear that youth at all points of contact with the ju-
venile justice system have a high prevalence of risk factors
Suicide and Related-Behavior Among Youth…
123
found to be predictive of suicide attempts and deaths
among the general population. Research has been con-
ducted to predict which demographic and juvenile justice
factors predict prior attempts among youth involved in
various points of contact within the juvenile justice system
(Nolan et al. 2008; Wasserman and McReynolds 2006;
Wasserman et al. 2010). Youth who had made a suicide
attempt were more likely to have committed a violent of-
fense (Nolan et al. 2008; Wasserman et al. 2005)ortobea
repeat offender (McReynolds et al. 2008; Wasserman et al.
2010). Demographically, attempters (i.e., recent or life-
time) across all points of contact were more likely to be
female (Buttar et al. 2013; Nolan et al. 2008; Wasserman
et al. 2005,2010) and less likely to be African American or
Hispanic compared to White youth (Wasserman et al.
2010). Among youth in probation, those who met criteria
for major depression (excluding the suicide items) or a
current substance use disorder were more likely to have
made a recent suicide attempt; however, major depression
was a stronger predictor of prior attempts. Moreover, re-
cent suicide risk increased almost 12-fold for boys who
were depressed compared to non-depressed boys, equaliz-
ing the risk between depressed boys and girls (Wasserman
et al. 2005); however, this gender-depression relation did
not hold for lifetime attempts.
Addressing Mental Health and Suicide Risk
in the Juvenile Justice System
Given that the risk for suicide and related-behavior is
present among youth at all entry points to the juvenile
justice system, effective suicide prevention must occur at
each possible point of contact. A consensus has been
reached (see NAASP 2013a; Wasserman et al. 2003;
National Commission on Correctional Health Care
[NCCHC] 2004; Skowyra and Cocozza 2007b) on the
approaches necessary to prevent suicide, which include
training, screening/assessment, and interventions. Fur-
thermore the National Strategy for Suicide Prevention
(U.S. Department of Health and Human Services (HHS)
Office of the Surgeon General and NAASP 2012) en-
courages the integration and coordination of suicide pre-
vention activities in juvenile justice by ensuring
individuals are aware of risk factors, warning signs, pro-
tective factors, as well as are able to identify individuals
at-risk for suicide via screening assessment and inter-
vention. To go even further, it would be a prudent ap-
proach for all points of the juvenile justice system to
incorporate more upstream approaches for suicide pre-
vention by increasing awareness, identification and re-
ferral for mental health risk factors rather than just
intervening at the time of suicidal thoughts or behavior.
Training
Those who work in the juvenile justice system have a legal
responsibility to keep youth safe. One way to accomplish this
goal is to recognize the importance of being aware of the risk
factors for mental health problems and suicide as well as what
to do when they identify these factors among juveniles
(Wasserman et al. 2003). For adolescents whose contact with
the justice system is in a community setting, probation officers
are usually responsible for obtaining information about the
mental health needs of the youth in their caseloads (Vilhauer
et al. 2004). However, some studies (Vilhauer et al. 2004;
Wasserman et al. 2009) suggest that25 and 40 % of probation
officers were uncomfortable with their knowledge of suicide
risk and assessment, respectively. Because the non-clinical
probation officer staff are often responsible for completing
suicide risk assessments and making decisions regarding the
severity of the suicide risk among youth and their subsequent
referral to mental health services, this lack of confidence is of
great concern (Wasserman et al. 2005,2008).
Although most probation officers (70 %) do report at-
tending conferences and workshops in mental health, most
would like more training, specifically in-house training and
case conferences (Vilhauer et al. 2004). For example, in a
study of probation cases in New York State, Wasserman
et al. (2008) found that probation officers rated their mental
health knowledge and efficacy at 70–74 %, respectively.
As expected, probation officers with higher ratings of
previous mental health experience, knowledge, and com-
petency scores were more likely to identify youth in need
of mental health services. Although the exact reason for
identification of at-risk youth was not provided in many of
the cases because standardized screening was not con-
ducted, among referred-youth where a reason was indi-
cated, most were identified and referred for disruptive
disorders and/or substance abuse; whereas, less than 5 %
were referred for internalizing problems including suicide
risk (Wasserman et al. 2008). In a follow-up study where
standardized diagnostic assessments were administered
(described in Wasserman et al. 2008), probation officers
identified 50 % of youth with disruptive disorders (12 %
without standardized instrument vs. 22 % with standard-
ized instrument) or a substance problem (7.5 vs. 13 %).
However, only 20 % (5 vs. 20.4 %) of youth with anxiety
or depression were identified. Given the high rates of sui-
cide attempts in this population and the importance of
depression as a risk factor, these findings raise the question
of whether probation officers and other juvenile justice
gatekeepers are knowledgeable regarding suicide risk. It
also highlights the need for training on risk factors and
standardized risk assessment among this population of
providers.
M. Scott, D. A. Lamis
123
Sample Training Interventions
There are a variety of gatekeeper trainings listed in the
Suicide Prevention Resource Center’s Best Practice Reg-
istry (www.sprc.org), including Question Persuade Refer,
ASIST, and SafeTalk. However, there have been no ran-
domized trials of gatekeeper trainings with juvenile justice
personnel. There are two non-randomized studies (correc-
tions: Penn et al. 2005; probation: Wasserman et al. 2009)
that have examined the impact of training gatekeepers in
correctional and probation settings. Project Connect
(Keating 2009) is a four pronged approach to improve the
identification, referral, and access of at-risk youth in pro-
bation to community mental health providers (see
Wasserman et al. 2009 for a full description of the project
and procedures). The four steps of the program include: (1)
creating collaborations between the probation officers and
the mental health authorities; (2) developing program
materials to facilitate referral; (3) providing training for
probation officers; and (4) screening for mental health and
substance abuse problems. Support materials including
definitions of risk, a decision tree to facilitate appropriate
case response and management, and a resource guide were
created. Probation officers attend a 2-day training that
covers suicidal behavior and its associated risks, such as
specific mental health and substance use disorders, and
evidence-based treatments for these disorders. In addition,
the training addresses screening, how to facilitate a referral
with parents including potential barriers and motivational
interviewing techniques, as well as the importance of en-
gaging and debriefing the families (Wasserman et al.
2009). After the training, the rate of youths receiving a
referral to mental health from a probation officer increased
from 35 to 61 %; with more probation officers confirming
the initiation of services (44 % at baseline vs. 61 % after
training). These actions by the probation officers led to
more youth receiving services (76 %) after the training
compared to before (52 %; Wasserman et al. 2009).
As a youth becomes further involved in the juvenile jus-
tice system, studies have shown (see above) that rates of
mental health problems and suicide risk increase. In response
to these unfortunate realities, post-adjudication correctional
staff needs to be aware of how to identify youth at risk for
suicide. The most efficacious manner to successfully identify
at risk youth may require staff to receive specific training in
order to improve mental health knowledge. An example of
this type of training was conducted in Rhode Island and
evaluated by Penn et al. (2005). The one-time training was
presented by the authors and based on the NCCHC recom-
mendations and strategies proposed experts in the literature.
The content of the training included information on preva-
lence and indicators of mental and substance use disorders
among incarcerated juveniles, suicide attempts and risk
factors in these youths, and identification and prevention
approaches for correctional staff. Further details of the
training (i.e., duration of the training, etc.) were not indicated
in the evaluation, nevertheless, the evaluation improved
knowledge. Although correctional officers with prior clinical
training and those who worked for mental health or social
services in the past had higher baseline levels of knowledge
and positive attitudes towards mental health, knowledge and
attitudes improved for all participants who completed the
training. After the training, correctional officers were more
likely to understand that youth in the juvenile justice
population have significant mental health problems and to
effectively identify the specific confinement risk factors that
increased suicide risk (e.g., a recent court appearance, new
legal charges or sanctions, isolation and segregation; Penn
et al. 2005). Unfortunately, there was no control group nor
were the trainees followed to determine the impact of the
training on the identification and referral patterns of the post-
adjudicated youth in confinement. Additional trainings and
rigorous evaluations are encouraged to help further under-
stand the impact of correctional officer trainings.
Screening and Assessment
Screening is a brief (30 min or less) approach to identify
individuals who may be at risk for suicide. It can be
computerized or in a paper–pencil format, but has typically
been self-report and not administered by clinical staff; with
that said, standardized screening at all transition points and
as needed should also be utilized. Information from the
screen is not used to diagnose or to plan treatment ap-
proaches, but to identify youth who need further evaluation
or attention (NAASP 2013c). Suicide rates have decreased
over time as the use of routine screening instruments has
increased in settings across the juvenile justice system
(Skowyra and Cocozza 2007a). In the early 1990’s, mental
health and suicide screening were nearly non-existent, and
those instruments that did exist were flawed through the
use of superficial non-standardized measures employed at
inappropriate points of contact with the juvenile offenders
(Skowyra and Cocozza 2007a). In 2009, Hayes reported
that 44 % of youth who killed themselves had either never
been assessed, or had not been assessed within 30 days of
their death for suicide risk or mental health problems by a
mental health professional. Fortunately, the rates of
screening for suicide risk among youth in confinement
have significantly increased from 62 % of facilities in 2000
screening all youth (Sickmund 2006) to 84 % screening all
youth in 2008 (Hockenberry et al. 2015). Rates of
screening for all youth in confinement for mental health
problems have also increased (41 and 62 %, public/private
respectively in 2000; Sickmund 2006) to 44 and 74 %,
public/private in 2008 (Hockenberry et al. 2015) among
Suicide and Related-Behavior Among Youth…
123
youth in confinement. It is important to note that screening
for suicide risk is still more frequent than screening for
mental health problems. The majority of youth (87 %) are
screened within 24 h for suicide risk; whereas, only 32 %
of youth are screened for mental health problems within the
same timeframe (Hockenberry et al. 2015). Although this is
a great improvement, screening for suicide risk and mental
health issues is often not conducted on a regular basis or in
timely manner among juvenile-justice-involved youth in
community settings or on probation where they have
greater access to means and opportunity (Wasserman et al.
2003). Although most probation officers believed that
assessing for suicide risk was appropriate, 70 % reported
that screening for suicide risk is rarely assessed and less
than half identified the individual in their agency who was
responsible for assessing suicide risk (Vilhauer et al. 2004).
Youth involved in the juvenile justice system should be
screened for both mental health well-being and suicide risk
at each point of contact, preferably within the first hour or
at least within the first 24 h of arrival to a facility. Con-
tinued screening is also recommended on a regular basis as
long as the youth remains involved in the juvenile justice
system, as needed or during transition such as when
placements change or prior to re-entry into the community
to facilitate continuity of care (NCCHC 2004; Skowyra and
Cocozza 2007b; Wasserman et al. 2003). Screening can be
helpful in identifying the youth’s immediate mental health
needs and should include assessment for suicide risk fac-
tors including depression, anxiety, substance abuse, and
aggression as well as current suicidal ideation and prior
suicide attempts (Grisso and Underwood 2004).
When considering screening, it is critical to be aware of
both the potential risks and benefits of screening. The
benefit of screening is in identifying individuals who may
be at risk for a specific outcome such as suicide in a quick
and efficient way; however, it has its risk of identifying
individuals who are not really at risk (i.e., false positives)
and missing individuals who are truly at risk (i.e., false
negatives; Scott et al. 2010). However, the potential ben-
efits of preventing youth suicide outweigh the possible
risks.
Several instruments that have been demonstrated to be
reliable and valid measures have been suggested as
screening tools (see Grisso and Underwood 2004 and
NAASP 2013c for a full review and guide). Currently, the
majority of the sites that report screening all youth at intake
use the Massachusetts Youth Screening Instrument—Ver-
sion 2 (MAYSI-2; Grisso and Barnum 2000). The MAYSI-
2 is a 52-item self-report instrument that assesses indi-
viduals for alcohol and drug use, anger and irritability,
depression and anxiety, somatic complaints, suicidal idea-
tion and attempts, thought disturbances and traumatic ex-
periences (Grisso and Underwood 2004). Another suicide
screening instrument that has been recently validated in
adjudicated youth (Langhinrichsen-Rohling et al. 2012)is
the life-attitudes schedule-short form (LAS:S). The LAS:S
is a 24-item risk assessment for suicide proneness, which is
broadly defined to include overtly suicidal behavior, subtle
self-destructive behaviors, risk-taking behaviors, and the
absence of life-affirming and safety behaviors (Lewinsohn
et al. 2004). Other multiple domain screening measures
that include items about suicidal behavior include the Child
and Adolescent Functional Assessment Scale (Hodges and
Wong 1996) and Global Appraisal of Individual Need-
Short Screen (GAIN-SS; Dennis et al. 2006; Ramchand
et al. 2009).
A suicide risk assessment tool, The Columbia Suicide
Severity Rating Scale (C-SSRS; Posner et al. 2011) that
assesses for suicidal ideation, and attempts based on the
consensus definitions of suicidal behaviors (O’Carroll and
Berman 1996) was recently validated among girls involved
with the juvenile justice system (Kerr et al. 2014). Kerr
et al. (2014) demonstrated for long-term validity of the
C-SSRS and did not assess for current risk assessment. The
C-SSRS was developed originally for use in clinical trials;
however, it has been adapted, validated and used in a va-
riety of clinical and non-clinical settings by non-clinical
gatekeepers (Mundt et al. 2013; Posner et al. 2011). The
C-SSRS is now being used in juvenile justice settings at
intake and transition times (personal communication K.
Posner).
Follow-Up to Positive Screens
Individuals who are identified to be at risk for suicide need to
be formally assessed further with a standardized clinical
measure (see Wasserman et al. 2003; Grisso and Underwood
2004; or NAASP 2013c, for a review). Clinical assessments
provide information on diagnosis and inform the need for
referral to specialized treatment or disposition planning (i.e.,
diversion or specialized residential treatment; Grisso and
Underwood 2004; Skowyra and Cocozza 2007a, 2007b;
Wasserman et al. 2003). Some clinical assessment measures
which provide DSM diagnoses such as the Diagnostic In-
terview Schedule for Children (DISC, Shaffer et al. 2000)
can be also used as a secondary screening tool as it can be
computer-administered without the need for clinical training
(Wasserman et al. 2003). As part of the Project Connect
(described above, Wasserman et al. 2010), probation officers
were more likely to make a referral after screening with the
Voice DISC (83 % were referred) compared to youth iden-
tified by means other than screening (21.4 %;Wasserman
et al. 2009). Regardless of whether screening or assessments
take place in the juvenile justice system, there must be pro-
tocols and procedures in place to address when a youth is
identified. Screening and assessment alone do not comprise a
M. Scott, D. A. Lamis
123
comprehensive strategy for suicide prevention; rather are
one component. Once a youth is identified proper referral and
intervention must occur.
Interventions
Juvenile justice personnel may not be equipped to provide
treatment for the mental health problems which can lead to
suicide attempts and deaths; however, there are important
steps they can take to intervene and protect youth. Some of
the suggested procedures include direct service interven-
tions in juvenile justice placements, coordination of ser-
vices and communications with mental health providers,
creation of a protective environment via supervision, re-
moval of environmental risk factors, and implementation of
policies and procedures that address suicide attempts
(NAASP 2013a; Hayes 2009; NCCHC 2007; Skowyra and
Cocozza 2007b).
Direct Service Interventions
There are opportunities for direct service intervention at
various points of the juvenile justice continuum. In non-
secure settings, the probation officer, social worker or case
worker may be in a position to provide a brief intervention
such as a safety plan (Stanley and Brown 2008,2012). The
safety planning intervention has been identified as a best
practice for caring for suicidal individuals (www.sprc.org)
as a single session intervention that is now widely used in
the U.S. in a variety of settings. The safety planning in-
tervention is a prioritized list of steps that individuals can
employ should they become suicidal. The plan begins with
the identification of personal warning signs that a crisis is
impending, followed by young adult-clinician jointly de-
veloped list of internal coping strategies (often distracting
tactics), external strategies (supportive people, healthy so-
cial settings), those who can be relied on to provide
guidance including clinicians, and emergency settings and
contacts. Problem solving obstacles to implementing the
safety plan is a key component of the intervention (Stanley
and Brown 2008,2012). Currently there is no evaluation of
using the safety planning intervention in the juvenile jus-
tice system; however it has been widely used in the
Department of Defense with active military and veterans
(Stanley and Brown 2008).
Interventions may also occur at the time when a ju-
venile is found to be attempting suicide. Given that the
individual who identifies a youth who attempts suicide
may not be medically trained, facility staff should be
certified in life saving interventions, such as Cardio
Pulmonary Resuscitation (CPR), and have a clear un-
derstanding of the protocol of what to do in this
situation, including how to contact medical support and
the importance of not stopping CPR until medical sup-
port has arrived (Hayes 2009).
Coordination and Communication with Mental Health
Coordination with mental health and compliance with
mental health recommendations should begin early in the
youth’s engagement with the juvenile justice system;
however, it is an often over-looked step in the process.
Although probation officers are more effectively identify-
ing and referring youth to mental health services, atten-
dance at these mental health sessions is infrequently
incorporated into probation supervision and court orders,
and, rarely, is case management or support for mental
health linkages for the youth and family provided. Instead,
it is the family’s decision to pursue or not pursue the rec-
ommendation (Wasserman et al. 2008) without conse-
quence. It is imperative that the juvenile justice system
works to provide coordination across service sectors (i.e.
mental health), by developing relationships and protocols
prior to a suicidal crisis so youth who are identified can
easily access the services they need. Although the majority
of residential facilities have on site mental health coun-
seling and treatment (Hockenberry et al. 2015), the extent
of treatment services is unknown. Coordination and link-
ages between systems are essential to ensure that the
comprehensive range of services necessary for effectively
preventing youth suicide is offered.
The Collaborative Assessment and Management of
Suicidality (CAMS; Jobes 2006), a process for assessment,
monitoring and management of suicidality, has proven to
be successful in reducing depression, hopelessness, suicidal
ideation, suicidal-relevant cognitions, and factors driving
suicidality in various populations (Ellis et al. 2012; Jobes
et al. 2005). A large scale investigation of the CAMS
framework within a juvenile offender population is cur-
rently underway (O’Conner et al. 2014). Specifically,
clinicians are using CAMS to guide assessment and treat-
ment of suicidal youth across 28 different forensic facilities
within the Department of Juvenile Justice in the state of
Georgia Preliminary results have indicated that clinicians
using CAMS in this setting have reported finding the ap-
proach highly effective in clarifying suicidal thinking while
providing valuable structure to managing genuine suicidal
risk and self-harm behaviors (O’Conner et al. 2014).
After the training on suicide risk factors is complete, the
facility staff needs to know the protocol for reporting their
observations and be confident that the appropriate officials
will act to protect the youth. Enhanced communications
through the form of written policies, procedures and pro-
tocols that are widely disseminated and reviewed annually
in staff meetings should assure the facility staff that there is
Suicide and Related-Behavior Among Youth…
123
an administrative commitment to suicide prevention
(Hayes 2009; NCCHC 2007).
Protective environment via supervision
One of the most effective suicide prevention measures in
secure settings is the close supervision of at-risk youth. In a
report describing 79 deaths by suicide within confinement,
Hayes (2009) demonstrated that most deaths occurred
when youth were isolated. Moreover, 85 % of those youth
who were on room confinement killed themselves during
waking hours when there is the assumption of closer su-
pervision and/or less opportunities for isolation. This sug-
gests that youths in isolation may be at an increased risk for
ruminating about their problems and depression as well as
ways to die by suicide. Although increased supervision
may not completely eliminate the risk of death, it may help
to deter a suicidal youth from acting on his/her impulses.
Reports have suggested three levels of supervision
(Hayes 2009; NCCHC 2007) for youth in residential
placements:
•‘‘Close observation’’ requires supervision at staggered
intervals not to exceed 15 min for youth who are not
actively suicidal, but express suicidal ideation and/or
have recent histories of self-destructive behavior as
well as youth who do not indicate ideation but
demonstrate concerning behavior.
•‘‘Intermediate observation’’ is for youth at moderate
risk for suicide and requires supervision at staggered
intervals not to exceed 5 min.
•‘‘Constant observation’’ is necessary for actively suici-
dal youth and requires supervision on a continuous, 1:1
monitoring, on an uninterrupted basis. NCCHC (2007)
also suggests assessment of these individuals for
psychiatric hospitalization with constant observation
maintained until transfer to the hospital. One method to
improve supervision is to reduce isolation and use of
solitary confinement by requiring individuals at risk for
suicide to have a roommate. Anecdotal evidence in the
state of New Jersey suggests that requiring a roommate
in adult populations has significantly reduced the
number of suicides by reducing the isolation of the
individual.
Cleansing the Environment
Additional precautions such as cleansing the environment
of potential suicide methods should be taken to protect
youth from dying by suicide (Gallagher and Dobrin 2006b;
Hayes 2009; NCCHC 2007), given that research (e.g.,
Beautrais et al. 2006; Beautrais et al. 2009) has shown that
the risk for suicide can be reduced if access to lethal means
is eliminated. Evidence suggests that youth who died by
suicide in residential placement most often died by hanging
using bed sheets suspended from protrusions, such as door
hinges, bed frames, air vents in their room (Hayes 2009).
Although the removal of many of these items may be im-
possible, efforts should be made to make ‘‘rooms suicide
resistant’’; furthermore, policy suggests that officers have
cutting tools readily available to remove the ligature within
seconds of discovering suicidal youth (NCCHC 2007).
Appropriate Policies and Procedures
Ensuring organizations are implementing appropriate
policies and procedures that address suicide attempts is one
of the first steps to increase awareness that suicide pre-
vention is a priority. The Suicide Prevention Resource
Center (SPRC) and the Council of Juvenile Correctional
Administrators (CJCA) recently developed a two-part we-
binar series titled Suicide Prevention in Juvenile Detention
and Correctional Facilities (http://www.sprc.org/training-
institute/juvenile-correctional-curriculum), which is for
administrators and staff who are responsible for developing
and implementing suicide prevention policies among youth
in detention facilities, including state juvenile correctional
administrators, facility and mental health directors. The
webinar teaches eight critical components of sound suicide
prevention policy, including staff training, intake screening
and ongoing assessment, communication, housing, levels
of supervision, intervention, reporting, and mortality
review.
Summary
The knowledge base regarding the mental health needs and
the risk for suicide among youth in the juvenile justice
system has evolved over the last 20 years. Is it now clearly
recognized that youth who become involved with the ju-
venile justice system have significant mental health needs,
and that many recidivists have the highest rates of mental
health problems and suicidality (McReynolds et al. 2008,
2010; Wasserman et al. 2010). In light of this, there has
been a growth in attention, response and promising pro-
grams that address mental health needs and suicide risk
throughout the juvenile justice system. In this paper, we
have highlighted some of the current approaches; however
the implementation of this work is far from ubiquitous.
Individuals, such as social workers, working in the juvenile
justice system must be aware of these approaches and ad-
vocate for universal adoption and implementation of sui-
cide prevention efforts across the juvenile justice system.
Although the primary role of the juvenile justice system
is not to offer mental health treatment, it has an important
M. Scott, D. A. Lamis
123
role in the system of care of youth and building youth
capacities; therefore, the partnership between juvenile
justice and mental health is imperative. The juvenile justice
system should provide a safe environment for youth across
the multiple points of contact, which includes protecting
them from suicide risk by increasing awareness and inter-
ventions at each phase of involvement. Social workers can
help to advocate for this change.
Many of the policies and procedures that encourage
collaboration between the juvenile justice and mental
health systems, training of juvenile justice staff, screening
for mental health and suicide risk and diversion and/or
interventions of at-risk youth have been encouraged and
outlined in this paper as well as other National white papers
(NAASP 2013a). If society is going to move forward with
the goal of reducing juvenile offending by building youth
capacities (and ultimately reducing the risk of death by
suicide), the youth-serving providers from initial police
contact to confinement must be knowledgeable about the
risk factors for suicide and mental health problems, and be
willing to collaborate and communicate across service
sectors in order to identify those who need assistance and
refer them to appropriate treatment and services.
Conflict of interest The authors declare that they have no conflict
of interest.
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