SERIOUS SUICIDE ATTEMPTS AMONG ADOLESCENTS IN CUSTODY D. Lawlor, R.Kosky
The Royal Commission into Aboriginal Deaths in Custody has focused attention on people who are held in custody in police cells, prisons, remand centres and detention centres. A series of research papers has been released by the Royal Commission which delineates some important aspects of the needs of these people. Nearly half of the deaths which occur in these custodial settings appear to be self-inflicted. Suicide seems to be particularly common among younger age groups of those in custody [1,2]. This pattern parallels suicide levels among young people in the Australian community generally, so that suicide is now a leading cause of death among young Australians [3,4]. Australian and New Zealand Journal of Psychiatry 1992; 26:474-478 Recent research has demonstrated that young people held in a remand centre report high levels of symptoms of emotional disorder, particularly of depression, which are commonly associated with suicidal behaviour [ 51. While completed suicide in youth remand centres is relatively rare [I], anecdotal reports from clinicians working with adolescents in custody indicate that serious suicidal attempts are not uncommon. This survey was undertaken to determine the incidence and nature of serious suicide attempts among adolescents in a youth remand centre in Perth. West Australia. The paper is primarily descriptive, but where possible comparative data with non-suicidal adolescents held at the centre is provided. It was hoped that the findings would be helpful to staff and might lead to better management of troubled adolescents held in custody and decrease the potential for suicide among them.
Formerly Longmore Remand Centre, Perth, West Australia
D. Lawlor BA. MPsych (Clin). Dip Ed, Clinical Psychologist University of Adelaide, Department of Psychiatry, Adelaide Children’s Hospital, North Adelaide, South Australia R. Kosky BSc. MD, FRANZCP Correspond with Prof Kosky
Methods Longmore Remand Centre is a detention centre for juveniles (aged less than 18 years) in Perth, Western Australia. Juveniles who have been arrested or charged are held there for custody prior to their trial or while they await sentencing. Cases of life-threatening suicide attempts occurring at the Remand Centre between July 1987 and June 1989 (24 months) were identified. A life-threatening suicidal attempt was defined as a suicide attempt which could have led to death if the individual had not been discovered and if intervention had not been successful. Data on identified cases was obtained from file entries. These included incident reports, demographic data, assessment and conference reports, court records, medical/psychological reports and reports from other institutions. Information relating to previous behaviour as well as information about the suicidal incident was obtained from staff reports of “unusual occurrences”. In addition, the senior author (DL) was able to interview staff members. In order to provide comparative data on non-suicidal adolescents held in the remand centre, files of 30 non-suicidal adolescents consecutively admitted to
D.LAWLOR, R.KOSKY
Table I. Comparisons (fsuicidal and nonsuicidal reviatided adolescents
Characteristics
Suicide Non-suicidal attempters adolescents (n=l2) (n=30)
Yo
n
47s
attempts (66.7%) occurred between 7 and 35 days after admission. In the non-suicidal sample of 30 residents, 24 (80.0%) were out of the centre and before the courts within 1 week of admission; only 6 (20%) were at the centre for longer than 1 week. Therefore, the suicide attempters were in custody for longer periods than was usual.
Yo
Family background From 2 parent family From 1 parent family From institution/foster care Living on streets, with friends or relatives prior to admission Previous suicide attempt Previous psychiatric assessment Violent offence In custody >7days
8.3 50.0 41.7
1 6 5
26.7 66.7 6.7
8 20 2
75.0 75.0
9 9
56.7 6.7
17 2
58.3 91.7 66.7
7 11 8
0.0 26.7 20.0
0 8 6
Longmore were examined. Less information was available on these non-suicidal adolescents since few were associated with any incidents while in the centre.
Results During the 24 months of the survey there were 12 cases of life-threatening suicide at the Remand Centre. In this time there were 5,s 16 admissions to Longmore.
Age, sex, race The youngest suicide attempter was 1 I . 1 1 years old; the oldest was 17.10 years. Most of the suicide attempters were over 16 years old (average age 16.9 years); range 1 I . 1 1 to 17.10 years. The average age of the 5,516 adolescents admitted to custody at Longmore during the survey period was 15.0 years (range 11.0 - 18.10 years). The majority of adolescents in the Remand Centre were males (84%). All the suicide attempters were male. Although 45% residents at the Remand Centre during the survey were aboriginal. only 4 of the 12 suicide attempters (33.3%) were aboriginal.
Time of attempt One suicide attempt was made on the day of admission; one was made 120 days after admission. Eight
Table 1 shows that most adolescents at Longmore came from broken homes. Commonly, suicide attempters had been in foster care or institutions. More detail was available about the family experiences of the suicide attempters. In each case, family breakdown had been chronically stressful and bitter. Overall, seven (58.3%) had experienced excessive physical violence from care givers. There were no reports of sexual abuse from suicide attempters.
Current living The living circumstances of adolescents immediately prior to their admission to Longmore was characterised by lack of stability. In the non-suicidal sample, 17 (56.7%) were living with relatives or “friends” or were on the streets, while among the suicide attempters, 9 (75.0%) were living in these circumstances (see Table I). Staff informed us that only a few adolescents in custody received visits from family or friends while they were in the remand centre. The youngest suicidal child received no visits from his family, even though they lived nearby.
Past medical history. Nine (75%) suicide attempters had made a previous suicide attempt compared to only 2 (6.7%) of the 30 non-suicidal adolescents. Seven (58.3%) suicide attempters had been assessed by a psychiatrist or a psychologist at some time in their lives, but these assessments were unconnected with their admission to the remand centre. These assessments were not available to the staff of the remand centre. None of the non-suicidal comparative group were known to have had such assessments. None of the suicide attempters had physical illness.
SERIOUS SUICIDE ATTEMPTS AMONG ADOLESCENTS IN CUSTODY
476
quiet and they were compliant and responsive to staff directions, although in retrospect the staff noted that they did not seem to interact well with their peers.
Table 2 . Method offirst suicide attempt
Number (n=12) Self-strangulation Hanging Cutting Fire
7 3
1 1
The suicide attempts YO 58.3 25.0 8.3 8.3
School record Non-attendance, or poor attendance, in late primary school years (grades 6 and 7) onwards was common among all the adolescents in custody. Exemptions from school had been granted from grade 8 (i.e. from around age 14 years) for 11 of the 12 suicide attempters.
Alcohol and drug use Eleven of the 12 suicide attempters (91.7%) had histories of significant use of alcohol (4 cases) or mixtures of alcohol, solvent and pharmaceutical drugs (7 cases). A similar pattern was noted by staff among other adolescents in custody, but precise details of their drug use were not available.
Offences The offence pattern among individual adolescents who were in custody at Longmore was varied and multiple. The vast majority had been admitted to the remand centre on numerous occasions previously, some as many as 30 times. In the cases of non-suicidal adolescents only 8 (26.7%) had involved a violent offence and one other case was of a sex offender. However, nearly all the suicide attempters (1 1 cases, 9 1.7%) had been charged with a violent offence: these included violence or robbery with violence, indecent assault, assaults, deprivation of liberty, arson and dangerous driving.
Behaviour in remand centre Six of the suicide attempters (50%) were noted by staff to have exhibited labile moods with irritability and aggressive outbursts in the days prior to their attempts. However, the behaviour of the others was
The suicide attempts were made when the adolescent was alone. In 5 cases (41.7%) the suicide attempt occurred after an angry confrontation with staff, following which the adolescent was isolated in his own cell or in a single room. In two other cases, the adolescent was placed in his cell, alone, because of especially high numbers requiring supervision in day activity programs. In another 5 cases, the adolescents were alone in their cells for routine procedures. No clear reasons were given by any of the adolescents for their suicide attempts. One said that he was “mentally ill”, another said he had been “depressed for weeks” and one said he feared being sexually attacked if he was sentenced to jail. Table 2 shows the methods used by the adolescents. These included self strangulation, hanging, cutting and fire. Self-strangulation and hanging involved using sheeting, blanket strips, mattress fabrics, pyjamas, shirts, and socks. Commonly, fabrics were wound around the neck, then attached to taps or other fixtures, while the subject rolled off the bed on the floor. Those who attempted to hang themselves used similar materials attaching fabric to ceiling ventilators, window grilles or window latches. One adolescent cut his wrists with glass from a broken light globe; another set fire to his mattress. In nine cases (75%) the suicide attempt was discovered during routine checks. In three cases, the subjects attracted attention by pressing their call buttons or noises were heard by staff on the cell intercommunication system. After discovery, 9 suicide attempters were unconscious. When resuscitated, they were tearful, miserable, depressed and crying. Most were still actively suicidal. Four made further attempts; one within minutes, another later that day, and two after being transferred to other settings. Staff were injured while trying to restrain one of the adolescents who was intent on making a further suicidal attempt.
Management afterwards Table 3 shows the medical and nursing care provided following the discovery of the suicide at-
D. LAWLOR, R. KOSKY
Table 3. MatiaRement folloMiing fir-st suicide attempt
Management
Seen by remand centre nurse Seen by remand centre GP Seen by a psychiatrist Admitted to hospital (initially)
Number (n=12)
%
12 7 4 3
100 58.3 33.3 25.0
tempt. All attempters were seen by the remand centre nurse. A general practitioner was called to see 7 (58.3%), referring one to the mental health service’s Psychiatric Emergency Team and another to a psychiatric hospital. Two others were admitted by the staff directly to psychiatric care in hospital. Three were seen by the remand centre nurse only. Following second attempts, three more were then admitted to hospital, while a fourth was seen by a psychiatrist at the remand centre. In all, only just over half of these serious suicide attempters were assessed by a psychiatrist at the remand centre or in hospital following their attempts. A quarter were not seen by any doctor following their attempt.
Discussion Serious, life-threatening suicide attempts in a juvenile remand centre in Perth, West Australia, occurred at the rate of about one every 500 admissions. More significantly for juvenile justice authorities, one in every 100residents remaining longer than 7 days in the Remand Centre seriously attempted suicide. All the attempts had features of failed suicides, rather than of attention-seeking suicidal gestures [6]. The methods employed were planned and lethal and death could have resulted if staff intervention had not occurred. Without the vigilance, the constant checking and the quick responses by the staff at the remand centre, there would have been a disturbingly high level of completed suicide among these adolescents in custody. Although research associated with the Royal Commission into Aboriginal Deaths in Custody has, for the first time, explored the incidence and nature of self-inflicted harm occurring in prison and police custody [2], that occurring in juvenile detention centres has so
477
far not been scrutinised. We feel that the findings from this survey point to a serious deficiency in our current knowledge about attempted suicide in these settings. Adolescents who identified themselves as aboriginal made up nearly half of the admissions to the remand centre. This is a huge (x 15) over-representation, because aboriginal people make up less than 3% of the West Australian population. We found that aboriginal adolescents were not more likely than nonaboriginal adolescents in custody to attempt suicide. However because of their over-representation in the detention centre as a group, and the distressing effects of suicidal attempts by such young people, there must be considerable impact from them among the relatively small aboriginal community in Western Australia. When compared to non-suicidal adolescents on remand in custody, suicide attempters were more likely to be male and older (over 16 years). They were more likely to have had a history of foster (or institutional) care. They were more likely to have committed serious offences involving violence, and to have been held in custody for a longer period (greater than 7 days). They were more likely than non-suicidal adolescents in custody to have made a previous attempt at suicide, and to have seen a psychiatrist previously. Adolescents in custody in Australia generally appear to come from social backgrounds characterised by unstable, sometimes violent, and unsupportive families. Most have poor school records and are unemployed [ 5 ] . Adolescents in custody who were suicidal were more likely to come from foster care or welfare institutions than non-suicidal adolescents. A history of alcohol and drug use seems particularly common among adolescents in custody and was typical of the suicidal attempters. These results emphasise the marginalised social circumstances of the suicidal youths. The use of hanging and self strangulation as a method of attempting suicide emphasises the seriousness of the attempt since, among adults in prison or police custody, hanging accounts for the vast majority of completed suicides [2]. As with adults in prison or police custody, the attempts were made when the detainee was alone, usually in a single cell. This raises a dilemma for correctional staff since it is hard to imagine any humane system of custodial management which does not allow the prisoner some privacy and time alone. In the youth remand centre, routine checks were valuable in discovering suicide attempts but, of
478
SERIOUS SUICIDE ATTEMPTS AMONG ADOLESCENTS IN CUSTODY
course, too frequent checks may lead to increasing frustration and irritation on the part of the detainee which may possibly lead to a heightened propensity to self-harm. There seems to be some evidence from staff reports that those who attempted suicide were showing some behavioural disturbances in the days prior to their suicide attempts. Some were excessively moody and irritable, others were quiet and withdrawn. It seems particularly likely that any disturbance in mood might be heightened by the experience of being in a cell alone, especially when this was a form of punishment following a conflict with the staff. The practice of so called “time out” when detainees are placed alone in a cell following an altercation needs to be reviewed. (For critical observations on this issue see Commissioner E. Johnston’s report [ 71.) Most of the adolescent suicide attempts occurred among those who were held in custody for between 1 week and 1 month, periods which were longer than was generally customary for most adolescents to be held in remand centres. This finding is in significant contrast with adults in police custody, where suicide attempts were more likely in the first few hours, but is consistent with figures for suicide attempts among adult prisoners which were most common during the period between 1 and 3 months of imprisonment [ 2 ] . As a result of this study, new procedures have been introduced to reduce suicide risk factors. These include early scheduling of court appearances to minimise the length of stay in custody. Closer links have been established with the emergency psychiatric team, and more ready psychiatric referral has been established for adolescents when staff note mood disturbances. More work programmes have been introduced along with a range of procedural measures to reduce the time individuals can spend alone in cells. (However, at times of crowding, staff surveillance can be greatly reduced.) A psychologist has been employed full time and as a result there has been greater use of counselling of adolescents who seem disturbed by lock-up. These procedural changes may be useful in helping calm disturbed young people in the custodial system. However, one pre-attempt measure might be useful in addition to staff assessments. Self-report symptom screening questionnaires could be filled in by new arrivals in order to assist staff in identifying adolescents who are depressed or who may benefit from an
early referral for a psychiatric assessment. Questionnaires such as the General Health Questionnaire and the Youth Self Report are well known and can be fairly easily administered. Generally, adolescents cooperate in reporting their symptoms on these questionnaires [ 5 ] . Since this survey. provision has been made for the President of the Children’s Court to hear cases more quickly in an attempt to reduce the time people spend in custody on remand. However we found that suicidal adolescents’ offences were likely to be more serious than non-suicidal adolescents, and ones for which remand in custody for a period of assessment may be appropriate. Yet the current custodial environment could precipitate the serious suicide attempts. This is a dilemma for justice, welfare and mental health authorities. Despite the seriousness of the offences questions must still be raised about the necessity for custodial care in each and every case, and whether the environment is appropriate for potentially disturbed young people. This is an issue which deserves urgent analysis.
Acknowledgements We are especially grateful to the Superintendent and staff of Longmore Remand Centre who kindly helped in the study, and to the Director General, Department for Community Services, Perth, West Australia, for permission to publish this paper.
References I . Biles D. McDonald D, Fleming J. Australian deaths in custody 1980-1988: an analysis of aboriginal and non-aboriginal deaths in prison and police custody. Research Paper No 7. Royal Commission into Aboriginal Deaths in Custody, July 1989. 2. Fleming J. McDonald D, Biles D. Self inflicted harm in custody. Research Paper No 16. Royal Commission into Aboriginal Deaths in Custody. July 1990. uicidal behaviour increasing among Australian cal Journal of Australia 1987: 147:164-166. 4. Hassan R, Carr J. Changing patterns of suicide in Australia. Australian and New Zealand Journal of Psychiatry 1989: 23:226234. 5. Koaky R. Sawyer M, Gowland J. Adolescents in custody: hidden psychological morbidity? Medical Journal of Australia 1990; 1.53124-27. 6. Kosky R . Childhood suicidal behaviour. Journal of Child Psychology and Psychiatry 19x3; 24:457-468. 7. Johnston E. Report of the Inquiry into the Death of Michael Leslie Gollan. Royal Commission into Aboriginal Deaths in Custody, Canberra AGPS, 1990.
The Royal Commission into Aboriginal Deaths in Custody has focused attention on people who are held in custody in police cells, prisons, remand centres and detention centres. A series of research papers has been released by the Royal Commission which delineates some important aspects of the needs of these people. Nearly half of the deaths which occur in these custodial settings appear to be self-inflicted. Suicide seems to be particularly common among younger age groups of those in custody [1,2]. This pattern parallels suicide levels among young people in the Australian community generally, so that suicide is now a leading cause of death among young Australians [3,4]. Australian and New Zealand Journal of Psychiatry 1992; 26:474-478 Recent research has demonstrated that young people held in a remand centre report high levels of symptoms of emotional disorder, particularly of depression, which are commonly associated with suicidal behaviour [ 51. While completed suicide in youth remand centres is relatively rare [I], anecdotal reports from clinicians working with adolescents in custody indicate that serious suicidal attempts are not uncommon. This survey was undertaken to determine the incidence and nature of serious suicide attempts among adolescents in a youth remand centre in Perth. West Australia. The paper is primarily descriptive, but where possible comparative data with non-suicidal adolescents held at the centre is provided. It was hoped that the findings would be helpful to staff and might lead to better management of troubled adolescents held in custody and decrease the potential for suicide among them.
Formerly Longmore Remand Centre, Perth, West Australia
D. Lawlor BA. MPsych (Clin). Dip Ed, Clinical Psychologist University of Adelaide, Department of Psychiatry, Adelaide Children’s Hospital, North Adelaide, South Australia R. Kosky BSc. MD, FRANZCP Correspond with Prof Kosky
Methods Longmore Remand Centre is a detention centre for juveniles (aged less than 18 years) in Perth, Western Australia. Juveniles who have been arrested or charged are held there for custody prior to their trial or while they await sentencing. Cases of life-threatening suicide attempts occurring at the Remand Centre between July 1987 and June 1989 (24 months) were identified. A life-threatening suicidal attempt was defined as a suicide attempt which could have led to death if the individual had not been discovered and if intervention had not been successful. Data on identified cases was obtained from file entries. These included incident reports, demographic data, assessment and conference reports, court records, medical/psychological reports and reports from other institutions. Information relating to previous behaviour as well as information about the suicidal incident was obtained from staff reports of “unusual occurrences”. In addition, the senior author (DL) was able to interview staff members. In order to provide comparative data on non-suicidal adolescents held in the remand centre, files of 30 non-suicidal adolescents consecutively admitted to
D.LAWLOR, R.KOSKY
Table I. Comparisons (fsuicidal and nonsuicidal reviatided adolescents
Characteristics
Suicide Non-suicidal attempters adolescents (n=l2) (n=30)
Yo
n
47s
attempts (66.7%) occurred between 7 and 35 days after admission. In the non-suicidal sample of 30 residents, 24 (80.0%) were out of the centre and before the courts within 1 week of admission; only 6 (20%) were at the centre for longer than 1 week. Therefore, the suicide attempters were in custody for longer periods than was usual.
Yo
Family background From 2 parent family From 1 parent family From institution/foster care Living on streets, with friends or relatives prior to admission Previous suicide attempt Previous psychiatric assessment Violent offence In custody >7days
8.3 50.0 41.7
1 6 5
26.7 66.7 6.7
8 20 2
75.0 75.0
9 9
56.7 6.7
17 2
58.3 91.7 66.7
7 11 8
0.0 26.7 20.0
0 8 6
Longmore were examined. Less information was available on these non-suicidal adolescents since few were associated with any incidents while in the centre.
Results During the 24 months of the survey there were 12 cases of life-threatening suicide at the Remand Centre. In this time there were 5,s 16 admissions to Longmore.
Age, sex, race The youngest suicide attempter was 1 I . 1 1 years old; the oldest was 17.10 years. Most of the suicide attempters were over 16 years old (average age 16.9 years); range 1 I . 1 1 to 17.10 years. The average age of the 5,516 adolescents admitted to custody at Longmore during the survey period was 15.0 years (range 11.0 - 18.10 years). The majority of adolescents in the Remand Centre were males (84%). All the suicide attempters were male. Although 45% residents at the Remand Centre during the survey were aboriginal. only 4 of the 12 suicide attempters (33.3%) were aboriginal.
Time of attempt One suicide attempt was made on the day of admission; one was made 120 days after admission. Eight
Table 1 shows that most adolescents at Longmore came from broken homes. Commonly, suicide attempters had been in foster care or institutions. More detail was available about the family experiences of the suicide attempters. In each case, family breakdown had been chronically stressful and bitter. Overall, seven (58.3%) had experienced excessive physical violence from care givers. There were no reports of sexual abuse from suicide attempters.
Current living The living circumstances of adolescents immediately prior to their admission to Longmore was characterised by lack of stability. In the non-suicidal sample, 17 (56.7%) were living with relatives or “friends” or were on the streets, while among the suicide attempters, 9 (75.0%) were living in these circumstances (see Table I). Staff informed us that only a few adolescents in custody received visits from family or friends while they were in the remand centre. The youngest suicidal child received no visits from his family, even though they lived nearby.
Past medical history. Nine (75%) suicide attempters had made a previous suicide attempt compared to only 2 (6.7%) of the 30 non-suicidal adolescents. Seven (58.3%) suicide attempters had been assessed by a psychiatrist or a psychologist at some time in their lives, but these assessments were unconnected with their admission to the remand centre. These assessments were not available to the staff of the remand centre. None of the non-suicidal comparative group were known to have had such assessments. None of the suicide attempters had physical illness.
SERIOUS SUICIDE ATTEMPTS AMONG ADOLESCENTS IN CUSTODY
476
quiet and they were compliant and responsive to staff directions, although in retrospect the staff noted that they did not seem to interact well with their peers.
Table 2 . Method offirst suicide attempt
Number (n=12) Self-strangulation Hanging Cutting Fire
7 3
1 1
The suicide attempts YO 58.3 25.0 8.3 8.3
School record Non-attendance, or poor attendance, in late primary school years (grades 6 and 7) onwards was common among all the adolescents in custody. Exemptions from school had been granted from grade 8 (i.e. from around age 14 years) for 11 of the 12 suicide attempters.
Alcohol and drug use Eleven of the 12 suicide attempters (91.7%) had histories of significant use of alcohol (4 cases) or mixtures of alcohol, solvent and pharmaceutical drugs (7 cases). A similar pattern was noted by staff among other adolescents in custody, but precise details of their drug use were not available.
Offences The offence pattern among individual adolescents who were in custody at Longmore was varied and multiple. The vast majority had been admitted to the remand centre on numerous occasions previously, some as many as 30 times. In the cases of non-suicidal adolescents only 8 (26.7%) had involved a violent offence and one other case was of a sex offender. However, nearly all the suicide attempters (1 1 cases, 9 1.7%) had been charged with a violent offence: these included violence or robbery with violence, indecent assault, assaults, deprivation of liberty, arson and dangerous driving.
Behaviour in remand centre Six of the suicide attempters (50%) were noted by staff to have exhibited labile moods with irritability and aggressive outbursts in the days prior to their attempts. However, the behaviour of the others was
The suicide attempts were made when the adolescent was alone. In 5 cases (41.7%) the suicide attempt occurred after an angry confrontation with staff, following which the adolescent was isolated in his own cell or in a single room. In two other cases, the adolescent was placed in his cell, alone, because of especially high numbers requiring supervision in day activity programs. In another 5 cases, the adolescents were alone in their cells for routine procedures. No clear reasons were given by any of the adolescents for their suicide attempts. One said that he was “mentally ill”, another said he had been “depressed for weeks” and one said he feared being sexually attacked if he was sentenced to jail. Table 2 shows the methods used by the adolescents. These included self strangulation, hanging, cutting and fire. Self-strangulation and hanging involved using sheeting, blanket strips, mattress fabrics, pyjamas, shirts, and socks. Commonly, fabrics were wound around the neck, then attached to taps or other fixtures, while the subject rolled off the bed on the floor. Those who attempted to hang themselves used similar materials attaching fabric to ceiling ventilators, window grilles or window latches. One adolescent cut his wrists with glass from a broken light globe; another set fire to his mattress. In nine cases (75%) the suicide attempt was discovered during routine checks. In three cases, the subjects attracted attention by pressing their call buttons or noises were heard by staff on the cell intercommunication system. After discovery, 9 suicide attempters were unconscious. When resuscitated, they were tearful, miserable, depressed and crying. Most were still actively suicidal. Four made further attempts; one within minutes, another later that day, and two after being transferred to other settings. Staff were injured while trying to restrain one of the adolescents who was intent on making a further suicidal attempt.
Management afterwards Table 3 shows the medical and nursing care provided following the discovery of the suicide at-
D. LAWLOR, R. KOSKY
Table 3. MatiaRement folloMiing fir-st suicide attempt
Management
Seen by remand centre nurse Seen by remand centre GP Seen by a psychiatrist Admitted to hospital (initially)
Number (n=12)
%
12 7 4 3
100 58.3 33.3 25.0
tempt. All attempters were seen by the remand centre nurse. A general practitioner was called to see 7 (58.3%), referring one to the mental health service’s Psychiatric Emergency Team and another to a psychiatric hospital. Two others were admitted by the staff directly to psychiatric care in hospital. Three were seen by the remand centre nurse only. Following second attempts, three more were then admitted to hospital, while a fourth was seen by a psychiatrist at the remand centre. In all, only just over half of these serious suicide attempters were assessed by a psychiatrist at the remand centre or in hospital following their attempts. A quarter were not seen by any doctor following their attempt.
Discussion Serious, life-threatening suicide attempts in a juvenile remand centre in Perth, West Australia, occurred at the rate of about one every 500 admissions. More significantly for juvenile justice authorities, one in every 100residents remaining longer than 7 days in the Remand Centre seriously attempted suicide. All the attempts had features of failed suicides, rather than of attention-seeking suicidal gestures [6]. The methods employed were planned and lethal and death could have resulted if staff intervention had not occurred. Without the vigilance, the constant checking and the quick responses by the staff at the remand centre, there would have been a disturbingly high level of completed suicide among these adolescents in custody. Although research associated with the Royal Commission into Aboriginal Deaths in Custody has, for the first time, explored the incidence and nature of self-inflicted harm occurring in prison and police custody [2], that occurring in juvenile detention centres has so
477
far not been scrutinised. We feel that the findings from this survey point to a serious deficiency in our current knowledge about attempted suicide in these settings. Adolescents who identified themselves as aboriginal made up nearly half of the admissions to the remand centre. This is a huge (x 15) over-representation, because aboriginal people make up less than 3% of the West Australian population. We found that aboriginal adolescents were not more likely than nonaboriginal adolescents in custody to attempt suicide. However because of their over-representation in the detention centre as a group, and the distressing effects of suicidal attempts by such young people, there must be considerable impact from them among the relatively small aboriginal community in Western Australia. When compared to non-suicidal adolescents on remand in custody, suicide attempters were more likely to be male and older (over 16 years). They were more likely to have had a history of foster (or institutional) care. They were more likely to have committed serious offences involving violence, and to have been held in custody for a longer period (greater than 7 days). They were more likely than non-suicidal adolescents in custody to have made a previous attempt at suicide, and to have seen a psychiatrist previously. Adolescents in custody in Australia generally appear to come from social backgrounds characterised by unstable, sometimes violent, and unsupportive families. Most have poor school records and are unemployed [ 5 ] . Adolescents in custody who were suicidal were more likely to come from foster care or welfare institutions than non-suicidal adolescents. A history of alcohol and drug use seems particularly common among adolescents in custody and was typical of the suicidal attempters. These results emphasise the marginalised social circumstances of the suicidal youths. The use of hanging and self strangulation as a method of attempting suicide emphasises the seriousness of the attempt since, among adults in prison or police custody, hanging accounts for the vast majority of completed suicides [2]. As with adults in prison or police custody, the attempts were made when the detainee was alone, usually in a single cell. This raises a dilemma for correctional staff since it is hard to imagine any humane system of custodial management which does not allow the prisoner some privacy and time alone. In the youth remand centre, routine checks were valuable in discovering suicide attempts but, of
478
SERIOUS SUICIDE ATTEMPTS AMONG ADOLESCENTS IN CUSTODY
course, too frequent checks may lead to increasing frustration and irritation on the part of the detainee which may possibly lead to a heightened propensity to self-harm. There seems to be some evidence from staff reports that those who attempted suicide were showing some behavioural disturbances in the days prior to their suicide attempts. Some were excessively moody and irritable, others were quiet and withdrawn. It seems particularly likely that any disturbance in mood might be heightened by the experience of being in a cell alone, especially when this was a form of punishment following a conflict with the staff. The practice of so called “time out” when detainees are placed alone in a cell following an altercation needs to be reviewed. (For critical observations on this issue see Commissioner E. Johnston’s report [ 71.) Most of the adolescent suicide attempts occurred among those who were held in custody for between 1 week and 1 month, periods which were longer than was generally customary for most adolescents to be held in remand centres. This finding is in significant contrast with adults in police custody, where suicide attempts were more likely in the first few hours, but is consistent with figures for suicide attempts among adult prisoners which were most common during the period between 1 and 3 months of imprisonment [ 2 ] . As a result of this study, new procedures have been introduced to reduce suicide risk factors. These include early scheduling of court appearances to minimise the length of stay in custody. Closer links have been established with the emergency psychiatric team, and more ready psychiatric referral has been established for adolescents when staff note mood disturbances. More work programmes have been introduced along with a range of procedural measures to reduce the time individuals can spend alone in cells. (However, at times of crowding, staff surveillance can be greatly reduced.) A psychologist has been employed full time and as a result there has been greater use of counselling of adolescents who seem disturbed by lock-up. These procedural changes may be useful in helping calm disturbed young people in the custodial system. However, one pre-attempt measure might be useful in addition to staff assessments. Self-report symptom screening questionnaires could be filled in by new arrivals in order to assist staff in identifying adolescents who are depressed or who may benefit from an
early referral for a psychiatric assessment. Questionnaires such as the General Health Questionnaire and the Youth Self Report are well known and can be fairly easily administered. Generally, adolescents cooperate in reporting their symptoms on these questionnaires [ 5 ] . Since this survey. provision has been made for the President of the Children’s Court to hear cases more quickly in an attempt to reduce the time people spend in custody on remand. However we found that suicidal adolescents’ offences were likely to be more serious than non-suicidal adolescents, and ones for which remand in custody for a period of assessment may be appropriate. Yet the current custodial environment could precipitate the serious suicide attempts. This is a dilemma for justice, welfare and mental health authorities. Despite the seriousness of the offences questions must still be raised about the necessity for custodial care in each and every case, and whether the environment is appropriate for potentially disturbed young people. This is an issue which deserves urgent analysis.
Acknowledgements We are especially grateful to the Superintendent and staff of Longmore Remand Centre who kindly helped in the study, and to the Director General, Department for Community Services, Perth, West Australia, for permission to publish this paper.
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