Article
Attempted Suicide, Self-Harm, and Psychological Disorder Among Young Offenders in Custody
Journal of Correctional Health Care 2015, Vol. 21(3) 243-254 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345815584849 jcx.sagepub.com
Elizabeth Moore, PhD1,2, Claire Gaskin, MBBS, MRCPsych, FRANZCP3,4, and Devon Indig, PhD, MPH1,5
Abstract This study aims to identify risk factors for suicide and self-harm among young offenders. The data are from the 2009 New South Wales Young People in Custody Health Survey. The sample (N ¼ 313) were 88% male and 48% Aboriginal. Sixteen percent reported ever having suicidal thoughts and 10% reported a suicide attempt. Twenty-one percent reported thoughts of self-harm and 16% reported actual self-harm. Female young offenders reported higher rates of suicidal behavior and self-harm compared to males. Significant correlates of attempted suicide and self-harm included childhood adversity and psychiatric disorder. This study finds that young offenders are at high risk of suicidal and self-harm behaviors. Early identification and support among this vulnerable group are critical. Keywords attempted suicide, self-harm, young offender, Australia, psychological disorder
Introduction Attempted suicide is an important public health concern, particularly among young people. Many developed countries have witnessed rapid increases in reports of suicidal behavior among adolescents and young adults (i.e., those aged 15 to 24 years) over the last three decades (Beautrais, 2003; Graham et al., 2000). While suicide is relatively rare, estimates among youth suggest 100 to 200 suicide attempts occur for every completed suicide (Centers for Disease Control and Prevention [CDC], 2010).
1
Centre for Health Research in Criminal Justice, Justice Health and the Forensic Mental Health Network, Sydney, Australia National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia 3 Justice Health and the Forensic Mental Health Network, Sydney, Australia 4 University of New South Wales, Sydney, Australia 5 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia 2
Corresponding Author: Elizabeth Moore, PhD, Suite 302, Level 2, 152 Bunnerong Road, Pagewood NSW 2035, Australia. Email: [email protected]
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Research in Australia and internationally has documented rates of suicidal behaviors to be substantially elevated (up to threefold higher) among incarcerated young people compared to the general youth population. Estimates suggest around a third of those surveyed reported suicidal thoughts, and around a quarter report at least one suicide attempt over their lifetime (Howard, Lennings, & Copeland, 2003; Putnins, 2005; Sedlak & McPherson, 2010). A large U.S. sample of 1,801 juveniles detained in 39 correctional facilities found that 22% had considered suicide, 20% had planned it, and 16% had made a prior attempt (Morris et al., 1995). An Australian study of young offenders on remand documented significantly elevated rates of all forms of recent suicidal behavior compared with a community sample: suicidal ideation (21% vs. 12%), making a suicide plan (16% vs. 9%), attempting suicide (19% vs. 4%), and needing medical treatment following a suicide attempt (5% vs. 1%; Sawyer et al., 2010). While research has identified a complex mix of factors that are thought to increase vulnerability to suicide, efforts to predict suicide from a given set of factors are generally inaccurate (Kenny, Lennings, & Munn, 2008). More work is needed to improve identification of those most at risk and explore protective factors that may work to increase resilience to suicidal behavior. A family history of suicide and a range of sociodemographic factors (e.g., gender, educational achievement, ethnicity) have been linked to suicide attempts (Beautrais, 2003). Additionally, recent research (Turner, Finkelhor, Shattuck, & Hamby, 2012) has identified that young people who have experienced any form of victimization are significantly more likely to experience suicidal ideation, and the more types of victimization they experience, the more likely the suicidal ideation. Other types of childhood adversity (e.g., parental psychopathology; parental loss, separation, or divorce; neglectful parenting) have been found to be prominent among those with a history of suicidal behavior (Beautrais, 2003). Exposure to further stress and adversity (e.g., unemployment, sexual orientation) as well as a history of psychiatric illness (e.g., mood, anxiety, personality, and substance use disorders; comorbidity) or previous suicide attempts have each been found to increase the risk for subsequent suicide attempts (Beautrais, 2003). Research suggests that among young offenders, similar (to the general population) individual, family, school, and neighborhood factors contribute to an increased risk for suicide attempts (Kenny et al., 2008). An elevated prevalence of suicidal behaviors among young offenders is not surprising, given that many of the identified risk factors exist at higher rates among this population when compared to the general youth population (Putnins, 2005). Moreover, cumulative exposure to multiple risk factors is also likely among youth in custody, further increasing the risk of suicidal behaviors. Direct comparisons with regard to the prevalence of deliberate self-harm across studies are particularly difficult due to the different populations studied, methods of data collection used, and varying definitions. Studies using consistent definitions in Australia and the United Kingdom have documented a lifetime prevalence of deliberate self-harm among adolescents to be 12% and a past year rate of 6% (De Leo & Heller, 2004; Hawton, Rodham, Evans, & Weatherall, 2002). Additionally, research has identified differences in risk and protective factors for adolescents who only engage in self-harm compared to those with a history of self-harm and attempted suicide (Brausch & Gutierrez, 2010). This suggests they could be distinct phenomena or behaviors that operate along a continuum. Although limited, studies documenting self-harming behaviors among young offenders have reported a lifetime prevalence of 14% and a 12-month prevalence estimate of 9% (Gunter, Chibnall, Antoniak, 2011; Kenny et al., 2008). While self-harm has been identified as a strong predictor of suicide in general population studies (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), the relationship between the two behaviors has rarely been examined specifically in juvenile offender populations. This study will provide prevalence estimates of suicide attempts and self-harm among young people in custody in New South Wales (NSW), Australia. The study aims to identify correlates
Downloaded from jcx.sagepub.com at UNIVERSITE LAVAL on October 31, 2015
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associated with a history of attempted suicide and self-harm and explore the potential relationship between suicide attempts and self-harm in young offenders.
Method Study Design The data for this study were derived from the 2009 Young People in Custody Health Survey (YPICHS). YPICHS was conducted between August and October 2009 in NSW at eight juvenile justice centers and one juvenile correctional center. The study comprised a number of components (administered face-to-face) as part of the baseline assessment including a health questionnaire, psychometric testing for psychological and intelligence quotient (IQ), a childhood trauma questionnaire, and a physical health exam. Full methodological details for this study are reported elsewhere (Indig et al., 2011). The study received ethics approval from the following committees: Justice Health Human Research and Ethics Committee, the Juvenile Justice Research Committee, the Corrective Services NSW Ethics Committee, and the Aboriginal Health and Medical Research Council Ethics Committee.
Sample All young people who were in custody on the first day the study team visited a center were eligible for participation. Those who were unable to speak sufficient English, had a mental illness that prevented them from providing informed consent, or were unavailable (due to work or court commitments) at the time the survey was conducted were excluded from participation. Informed consent was obtained for all participants, including parental/guardian consent for those aged less than 14 years and those unable to give their own informed consent. The study yielded a 95% response rate and the total sample (N ¼ 361) represented 80% of all young people in custody. The current article used data from 313 young people who responded to each of the questions assessing suicidal behavior and self-harm.
Measurements Suicidal behavior and self-harm. The questionnaire assessed suicidal thoughts, suicide plans, attempted suicide, and self-harming behaviors over the respondents’ lifetime and in the previous 12 months. A distinction was made between self-harm and attempted suicide in order to elicit consistent responses from participants. Self-harm was defined as the act of deliberately hurting or injuring oneself, but not trying to kill oneself. Thoughts or self-harm behaviors were measured by asking participants ‘‘Have you ever considered hurting or injuring yourself?’’ and ‘‘Have you ever intentionally or deliberately hurt or injured yourself?’’ Suicidal thoughts and attempts were measured by asking participants ‘‘Have you ever considered attempting suicide?’’ and ‘‘Have you ever attempted suicide?’’ A number of additional questions were included if these questions were affirmative, including frequency, methods, location, medical treatment, and disclosure of intentions. Psychological functioning. Psychiatric disorders including major depressive episode, posttraumatic stress disorder, attention-deficit/hyperactivity disorder (ADHD), and conduct disorder were assessed using the Kiddie Schedule for Affective Disorders for Children–Present and Lifetime Version (K-SADS-PL) 2009 Draft (Axelson, Birmaher, Zelazny, Kaufman, & Gill, 2009). The K-SADS-PL determines whether the young person meets criteria for the full disorder or subthreshold levels of symptomatology. Alcohol consumption prior to entering custody was measured using the Alcohol Use Disorder Identification Test, with a score of 8 or more indicating
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alcohol-related harm (Saunders, Aasland, & Babor, 1993). Cannabis use at the time of incarceration was measured by the Severity of Dependence Scale, with a score of 4 or more indicating problematic use (Martin, Copeland, & Gilmour, 2006). Psychological distress was measured using the Kessler Psychological Distress Scale with a score of 22 or more indicating high or very high psychological distress (Kessler et al., 2002). Comorbidity was defined as the presence of at least two psychiatric (including substance abuse) diagnoses. The Childhood Trauma Questionnaire was used to measure childhood maltreatment including physical, sexual, and emotional abuse/neglect (Bernstein & Fink, 1998). Juvenile offending. Offending behavior was measured through data linkage to the Juvenile Justice (Department of Attorney General and Justice) database for information related to previous and baseline incarcerations. Intellectual functioning. Cognitive functioning (intelligence testing) was determined using the Wechsler Adult Intelligence Scale–Fourth Edition (WAIS-IV) Australian and New Zealand Language Adaptation for young people aged 17 years and over (Wechsler, 2008). All participants aged 15 years or younger received the Wechsler Intelligence Scale for Children–Fourth Edition (WISC-IV) Australian Standardised Edition (Wechsler, 2003). Participants who were 16 years old were able to complete either test (on the advice of the research psychologist) due to the overlap in the age bracket for the tests. An IQ test result of less than 80 was used to determine a possible borderline intellectual disability or possible intellectual disability. Social determinants. Sociodemographic variables included age (
Attempted Suicide, Self-Harm, and Psychological Disorder Among Young Offenders in Custody
Journal of Correctional Health Care 2015, Vol. 21(3) 243-254 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345815584849 jcx.sagepub.com
Elizabeth Moore, PhD1,2, Claire Gaskin, MBBS, MRCPsych, FRANZCP3,4, and Devon Indig, PhD, MPH1,5
Abstract This study aims to identify risk factors for suicide and self-harm among young offenders. The data are from the 2009 New South Wales Young People in Custody Health Survey. The sample (N ¼ 313) were 88% male and 48% Aboriginal. Sixteen percent reported ever having suicidal thoughts and 10% reported a suicide attempt. Twenty-one percent reported thoughts of self-harm and 16% reported actual self-harm. Female young offenders reported higher rates of suicidal behavior and self-harm compared to males. Significant correlates of attempted suicide and self-harm included childhood adversity and psychiatric disorder. This study finds that young offenders are at high risk of suicidal and self-harm behaviors. Early identification and support among this vulnerable group are critical. Keywords attempted suicide, self-harm, young offender, Australia, psychological disorder
Introduction Attempted suicide is an important public health concern, particularly among young people. Many developed countries have witnessed rapid increases in reports of suicidal behavior among adolescents and young adults (i.e., those aged 15 to 24 years) over the last three decades (Beautrais, 2003; Graham et al., 2000). While suicide is relatively rare, estimates among youth suggest 100 to 200 suicide attempts occur for every completed suicide (Centers for Disease Control and Prevention [CDC], 2010).
1
Centre for Health Research in Criminal Justice, Justice Health and the Forensic Mental Health Network, Sydney, Australia National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia 3 Justice Health and the Forensic Mental Health Network, Sydney, Australia 4 University of New South Wales, Sydney, Australia 5 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia 2
Corresponding Author: Elizabeth Moore, PhD, Suite 302, Level 2, 152 Bunnerong Road, Pagewood NSW 2035, Australia. Email: [email protected]
Downloaded from jcx.sagepub.com at UNIVERSITE LAVAL on October 31, 2015
244
Journal of Correctional Health Care 21(3)
Research in Australia and internationally has documented rates of suicidal behaviors to be substantially elevated (up to threefold higher) among incarcerated young people compared to the general youth population. Estimates suggest around a third of those surveyed reported suicidal thoughts, and around a quarter report at least one suicide attempt over their lifetime (Howard, Lennings, & Copeland, 2003; Putnins, 2005; Sedlak & McPherson, 2010). A large U.S. sample of 1,801 juveniles detained in 39 correctional facilities found that 22% had considered suicide, 20% had planned it, and 16% had made a prior attempt (Morris et al., 1995). An Australian study of young offenders on remand documented significantly elevated rates of all forms of recent suicidal behavior compared with a community sample: suicidal ideation (21% vs. 12%), making a suicide plan (16% vs. 9%), attempting suicide (19% vs. 4%), and needing medical treatment following a suicide attempt (5% vs. 1%; Sawyer et al., 2010). While research has identified a complex mix of factors that are thought to increase vulnerability to suicide, efforts to predict suicide from a given set of factors are generally inaccurate (Kenny, Lennings, & Munn, 2008). More work is needed to improve identification of those most at risk and explore protective factors that may work to increase resilience to suicidal behavior. A family history of suicide and a range of sociodemographic factors (e.g., gender, educational achievement, ethnicity) have been linked to suicide attempts (Beautrais, 2003). Additionally, recent research (Turner, Finkelhor, Shattuck, & Hamby, 2012) has identified that young people who have experienced any form of victimization are significantly more likely to experience suicidal ideation, and the more types of victimization they experience, the more likely the suicidal ideation. Other types of childhood adversity (e.g., parental psychopathology; parental loss, separation, or divorce; neglectful parenting) have been found to be prominent among those with a history of suicidal behavior (Beautrais, 2003). Exposure to further stress and adversity (e.g., unemployment, sexual orientation) as well as a history of psychiatric illness (e.g., mood, anxiety, personality, and substance use disorders; comorbidity) or previous suicide attempts have each been found to increase the risk for subsequent suicide attempts (Beautrais, 2003). Research suggests that among young offenders, similar (to the general population) individual, family, school, and neighborhood factors contribute to an increased risk for suicide attempts (Kenny et al., 2008). An elevated prevalence of suicidal behaviors among young offenders is not surprising, given that many of the identified risk factors exist at higher rates among this population when compared to the general youth population (Putnins, 2005). Moreover, cumulative exposure to multiple risk factors is also likely among youth in custody, further increasing the risk of suicidal behaviors. Direct comparisons with regard to the prevalence of deliberate self-harm across studies are particularly difficult due to the different populations studied, methods of data collection used, and varying definitions. Studies using consistent definitions in Australia and the United Kingdom have documented a lifetime prevalence of deliberate self-harm among adolescents to be 12% and a past year rate of 6% (De Leo & Heller, 2004; Hawton, Rodham, Evans, & Weatherall, 2002). Additionally, research has identified differences in risk and protective factors for adolescents who only engage in self-harm compared to those with a history of self-harm and attempted suicide (Brausch & Gutierrez, 2010). This suggests they could be distinct phenomena or behaviors that operate along a continuum. Although limited, studies documenting self-harming behaviors among young offenders have reported a lifetime prevalence of 14% and a 12-month prevalence estimate of 9% (Gunter, Chibnall, Antoniak, 2011; Kenny et al., 2008). While self-harm has been identified as a strong predictor of suicide in general population studies (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), the relationship between the two behaviors has rarely been examined specifically in juvenile offender populations. This study will provide prevalence estimates of suicide attempts and self-harm among young people in custody in New South Wales (NSW), Australia. The study aims to identify correlates
Downloaded from jcx.sagepub.com at UNIVERSITE LAVAL on October 31, 2015
Moore et al.
245
associated with a history of attempted suicide and self-harm and explore the potential relationship between suicide attempts and self-harm in young offenders.
Method Study Design The data for this study were derived from the 2009 Young People in Custody Health Survey (YPICHS). YPICHS was conducted between August and October 2009 in NSW at eight juvenile justice centers and one juvenile correctional center. The study comprised a number of components (administered face-to-face) as part of the baseline assessment including a health questionnaire, psychometric testing for psychological and intelligence quotient (IQ), a childhood trauma questionnaire, and a physical health exam. Full methodological details for this study are reported elsewhere (Indig et al., 2011). The study received ethics approval from the following committees: Justice Health Human Research and Ethics Committee, the Juvenile Justice Research Committee, the Corrective Services NSW Ethics Committee, and the Aboriginal Health and Medical Research Council Ethics Committee.
Sample All young people who were in custody on the first day the study team visited a center were eligible for participation. Those who were unable to speak sufficient English, had a mental illness that prevented them from providing informed consent, or were unavailable (due to work or court commitments) at the time the survey was conducted were excluded from participation. Informed consent was obtained for all participants, including parental/guardian consent for those aged less than 14 years and those unable to give their own informed consent. The study yielded a 95% response rate and the total sample (N ¼ 361) represented 80% of all young people in custody. The current article used data from 313 young people who responded to each of the questions assessing suicidal behavior and self-harm.
Measurements Suicidal behavior and self-harm. The questionnaire assessed suicidal thoughts, suicide plans, attempted suicide, and self-harming behaviors over the respondents’ lifetime and in the previous 12 months. A distinction was made between self-harm and attempted suicide in order to elicit consistent responses from participants. Self-harm was defined as the act of deliberately hurting or injuring oneself, but not trying to kill oneself. Thoughts or self-harm behaviors were measured by asking participants ‘‘Have you ever considered hurting or injuring yourself?’’ and ‘‘Have you ever intentionally or deliberately hurt or injured yourself?’’ Suicidal thoughts and attempts were measured by asking participants ‘‘Have you ever considered attempting suicide?’’ and ‘‘Have you ever attempted suicide?’’ A number of additional questions were included if these questions were affirmative, including frequency, methods, location, medical treatment, and disclosure of intentions. Psychological functioning. Psychiatric disorders including major depressive episode, posttraumatic stress disorder, attention-deficit/hyperactivity disorder (ADHD), and conduct disorder were assessed using the Kiddie Schedule for Affective Disorders for Children–Present and Lifetime Version (K-SADS-PL) 2009 Draft (Axelson, Birmaher, Zelazny, Kaufman, & Gill, 2009). The K-SADS-PL determines whether the young person meets criteria for the full disorder or subthreshold levels of symptomatology. Alcohol consumption prior to entering custody was measured using the Alcohol Use Disorder Identification Test, with a score of 8 or more indicating
Downloaded from jcx.sagepub.com at UNIVERSITE LAVAL on October 31, 2015
246
Journal of Correctional Health Care 21(3)
alcohol-related harm (Saunders, Aasland, & Babor, 1993). Cannabis use at the time of incarceration was measured by the Severity of Dependence Scale, with a score of 4 or more indicating problematic use (Martin, Copeland, & Gilmour, 2006). Psychological distress was measured using the Kessler Psychological Distress Scale with a score of 22 or more indicating high or very high psychological distress (Kessler et al., 2002). Comorbidity was defined as the presence of at least two psychiatric (including substance abuse) diagnoses. The Childhood Trauma Questionnaire was used to measure childhood maltreatment including physical, sexual, and emotional abuse/neglect (Bernstein & Fink, 1998). Juvenile offending. Offending behavior was measured through data linkage to the Juvenile Justice (Department of Attorney General and Justice) database for information related to previous and baseline incarcerations. Intellectual functioning. Cognitive functioning (intelligence testing) was determined using the Wechsler Adult Intelligence Scale–Fourth Edition (WAIS-IV) Australian and New Zealand Language Adaptation for young people aged 17 years and over (Wechsler, 2008). All participants aged 15 years or younger received the Wechsler Intelligence Scale for Children–Fourth Edition (WISC-IV) Australian Standardised Edition (Wechsler, 2003). Participants who were 16 years old were able to complete either test (on the advice of the research psychologist) due to the overlap in the age bracket for the tests. An IQ test result of less than 80 was used to determine a possible borderline intellectual disability or possible intellectual disability. Social determinants. Sociodemographic variables included age (
