Suicide Attempts and Self-Mutilative Behavior in a Juvenile Correctional Facility

Suicide Attempts and Self-Mutilative Behavior in a Juvenile Correctional Facility JOSEPH V. PENN, M.D., CHRISTIANNE L. ESPOSITO, PH.D., LEAH E. SCHAEFFER, B.A., GREGORY K. FRITZ, M.D., AND ANTHONY SPIRITO, PH.D.

ABSTRACT Objective: To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration. Method: A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation. Results: Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non–self-mutilative adolescents. Conclusions: Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non–self-mutilative counterparts, suggesting a need for mental health treatment. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(7):762–769. Key Words: adolescent, suicide, self-mutilation, incarcerated.

Research suggests that incarcerated juveniles are at elevated risk for suicidal behavior. In the only published national survey of completed suicide among incarcerated juveniles, which included all juvenile detention facilities and 20% of jails (with a population of 250 or more) in the United States, the juvenile suicide rate was estimated at 2,041 per 100,000 in adult jails (165 times higher than youths in the general population) and 57 per 100,000 in detention facilities (4.6 times higher than youths in the general population) (Memory, 1989). The Department of Justice estimates that more than 11,000 juveniles engage in more than 17,000 Accepted February 4, 2003. All authors except Ms. Schaeffer are with Brown University Medical School, Providence; Drs. Penn and Fritz are with Rhode Island Hospital; Drs. Esposito and Spirito are with the Center for Alcohol and Addiction Studies at Brown University; and Ms. Schaeffer is with Baylor University, Waco, TX. This study was funded by an American Academy of Child and Adolescent Psychiatry Eli Lilly Pilot Research Award. The authors acknowledge Warren Hurlbut and Charles Golembeske, Ph.D., for their support in making this study possible. Correspondence to Dr. Penn, Rhode Island Hospital, Child and Family Psychiatry, 593 Eddy Street, Providence, RI 02903; e-mail: [email protected]. 0890-8567/03/4207–0762䉷2003 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.CHI.0000046869.56865.46

incidents of suicidal behavior while incarcerated in juvenile facilities each year (Parent et al., 1994). Rates of current suicidal ideation among incarcerated youths are similarly high, with up to 51% reporting suicidal ideation in one study (Esposito and Clum, 1999). Incarcerated youths also report high rates of lifetime suicide attempts and ideation. Rates of lifetime suicide attempts range from 19.4% (Rohde et al., 1997a) to as high as 61% (Alessi et al., 1984) among incarcerated youths. Rates of suicidal behavior are similarly high when the time period examined is within the last year. Morris et al. (1995) administered a modified version of the Youth Risk Behavior Surveillance Survey (YRBSS) to 1,801 adolescents incarcerated across 39 facilities in the United States. Approximately 22% of incarcerated youths reported seriously considering suicide, 20% made a suicide plan, 16% made a suicide attempt, and 8% were injured in a suicide attempt within the last year. Despite the high rates of suicidal ideation and behavior found among incarcerated youths, affective and behavioral contributors to suicidality in this population have been understudied. A few studies found lifetime diagnosis and/or severity of symptoms of mood and anxiety

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disorders (Biggam and Power, 1999; Rohde et al., 1997a,b) to be linked to a history of suicide attempts in incarcerated adolescents. A relation between conduct disorder and history of suicide attempts has been found only for males (Rohde et al., 1997b). Frequency of hallucinogen, sedative/hypnotic, narcotic, stimulant, inhalant, and alcohol use (Morris et al., 1995; Putnins, 1995; Rohde et al., 1997a) but not cannabis use (Putnins, 1995; Rohde et al., 1997b) prior to incarceration has been associated with a history of suicide attempts among juvenile detainees. Other correlates of suicide attempts among incarcerated youths include anger, suicide by a friend, and poor coping skills (Rohde et al., 1997a). As is evident, much of the aforementioned research examined factors associated with a lifetime history of suicide attempts. Less is known about affective and behavioral contributors to suicidality experienced by juveniles during incarceration. A related yet distinct high-risk behavior engaged in by adolescents is self-mutilation. Suicidal and self-mutilative behaviors (i.e., purposeful nonlethal injuries such as selfbiting, skin-cutting, and burning) have been differentiated on the basis of three characteristics: lethality, repetition, and intent or ideation. First, methods of self-mutilation tend to be of low lethality, with physical damage ranging from superficial to moderate (Favazza and Conterio, 1989). Second, self-mutilation tends to be a more repetitive behavior than suicide attempts. Pattison and Kahan (1983) found that 63% of subjects had multiple episodes of self-mutilative behavior, ranging from 2 to more than 100 episodes, with an average of 21 per subject. Finally, only a small minority of individuals report suicidal intent or ideation at the time of self-mutilative behaviors (Lloyd et al., 1997; Walsh and Rosen, 1988). In comparison with suicidal behavior, even less research has been conducted to examine self-mutilative behaviors among incarcerated juveniles. Chowanec et al. (1991) published the only study documenting prevalence of selfmutilative behaviors among incarcerated youths. They found that 10.4% of male juveniles engaged in at least one act of self-mutilation during their incarceration, which is substantially higher than the prevalence rate of self-mutilative behaviors found in the general adolescent population (1.2%–2.8%; Garrison et al., 1993; Suyemoto, 1998). Affective and behavioral factors found to be associated with self-mutilative behaviors in adolescent community and psychiatric inpatient samples include depressed mood, substance use, anxiety, and anger (Garrison et al., 1993; Guertin et al., 2001; Walsh and Rosen, 1988). Relief and escape

from such emotional upset are commonly offered as reasons for self-mutilative behaviors by these youths. Research has not been conducted to examine whether the same affective and behavioral factors are associated with selfmutilative behaviors among incarcerated juveniles. The purpose of this study was to document the lifetime history of suicidal behavior/ideation among incarcerated youths and to obtain rates of current suicidal and self-mutilative behaviors during incarceration at a state juvenile correctional facility. A second goal was to examine risk factors associated with current suicidal and selfmutilative behaviors. It was hypothesized that juveniles who reported suicidal and self-mutilative behavior during incarceration would exhibit more severe affective symptoms, greater levels of behavioral dysfunction, and more substance use than those without suicidal behavior or self-mutilative behaviors, respectively.

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METHOD PARTICIPANTS Two hundred eighty-nine adolescents (234 males and 55 females) who were admitted to a juvenile correctional facility in southern New England comprised the “general” study sample. Their mean age was 15.8 years (range = 12–18, SD = 1.5). These 289 youths were selected from a 25% systematic random sample (all cases every fourth week) of newly incarcerated youths from 2000–2001. There were 129 (44.6%) white, 82 (28.4%) African American, 51 (17.6%) Hispanic, 5 (1.7%) Native American, 7 (2.4%) Asian, and 9 (3.1%) youths of other ethnicity. Ethnicity was not recorded for 6 (2.1%) of the youths. Seventy-eight (27%) of the 289 adolescents from the “general” study sample were included in the “referred” study sample. These youths were clinically referred for additional psychiatric assessment upon admission and/or during incarceration by social workers and correctional staff because of a variety of problems including evidence of suicidal behavior, self-mutilative behavior, sleep problems, maintenance of psychotropic medication, disruptive behaviors, and/or by the youth’s request. The referred sample included 56 males and 22 females with a mean age of 15.6 years (range = 12–18, SD = 1.4). The racial composition of this subsample was as follows: 42 (53.8%) white, 19 (24.4%) African American, 11 (14.1%) Hispanic, 3 (3.8%) Asian, and 3 (3.8%) youths of other ethnicity. The medium-security correctional facility from which the youths were recruited was located in the Northeast and serves as the state’s sole juvenile correctional facility. Approximately 1,100 youths are admitted per year (some recidivists). All youths are sent to the facility by the state family court. The average time served is approximately 6.1 months. Youths are incarcerated for a variety of violent and nonviolent offenses including, but not limited to, arson, robbery, drug-related crimes, murder, manslaughter, sexual assault, child molestation, burglary, and stolen motor vehicle. On average, approximately 20% of youths housed at the facility are preadjudicated (pretrial) and 80% are adjudicated (sentenced). Medical and mental health services are provided on site. A board-certified child and adolescent psychiatrist is available to provide diagnostic evaluations and pharmacotherapy. Adjudicated youths may also receive individual, family, and/or group therapy, as well as offense-

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specific treatments (e.g., substance abuse). Both preadjudicated and adjudicated youths were included in this study. MEASURES General Sample Juvenile Risk Assessment Adjudicated Form. The Juvenile Risk Assessment Adjudicated Form is an institutional rating scale, completed by a social worker, which lists the number and severity of the juvenile’s present offense and prior adjudication, probation history, prior escapes, foster placements, and other related data. A total security risk score is calculated from these data. Suicide Risk Assessment. The Suicide Risk Assessment is an institutional semistructured interview that was administered by a registered nurse as part of the admission process. Youths were asked about current suicidal ideation, suicide plans, past suicide attempts, family history of suicide attempts, past mental health treatment, recent losses, and psychosocial stressors. Referred Sample

Spectrum of Suicidal Behavior Scale. The Spectrum of Suicidal Behavior Scale (SSBS) (Pfeffer, 1986) is a five-item clinician-rated scale used to assess suicidal behavior on a continuum from no suicidal thoughts or behaviors to serious suicide attempts. Each participant’s score on this scale is determined by the highest degree of documented suicidal tendency. The SSBS has been shown to have high interrater reliability (Pfeffer et al., 1988). The SSBS was completed with reference to suicidality exhibited during the current incarceration. Functional Assessment of Self-Mutilation. The Functional Assessment of Self-Mutilation (FASM) (Lloyd et al., 1997) was used to assess selfmutilative behavior. It assesses the presence of the following selfmutilative behaviors: cutting/carving, burning, self-tattooing, scraping skin to draw blood, erasing skin to draw blood, hitting self on purpose, pulling out hair, biting self, inserting objects under nails or skin, picking at wounds, and picking skin to draw blood. The FASM has fair internal consistency (Lloyd et al., 1997). A list of 22 potential reasons for self-harm (e.g., to get attention, to stop bad feelings) is also rated. Incarcerated youths were asked to complete this measure in reference to self-mutilative behavior engaged in both in the year prior to and during incarceration. In this study, the internal consistency estimate for the FASM in the year prior to and during incarceration was acceptable (coefficient α = .86 for both time periods). Adolescent Drinking Questionnaire. The Adolescent Drinking Questionnaire (Donovan et al., 1999) was used to assess alcohol use. It contains four items that measure average drinking quantity, frequency of drinking, high-volume drinking, and drunkenness, using 8-point Likert scales. Construct validity has been well established for this measure (Donovan et al., 1999). In this study, youths were classified into one of two groups (users, nonusers) depending on whether or not they reported alcohol use prior to incarceration on any of the items. Scores were collapsed because they were not normally distributed. Drug Use Questionnaire. The Drug Use Questionnaire (Spirito, 1999) contains 12 items that assess number of days adolescents used different types of drugs over the past 6 months including marijuana, cocaine, LSD, PCP, inhalants, etc. The Drug Use Questionnaire has adequate internal consistency (coefficient α = .75) and test-retest reliability (r = 0.83–0.94) (Spirito, 1999). Incarcerated youths were asked to indicate frequency of drug use over the 6 months prior to incarceration. Drug use was categorized as either occurring or not occurring (users, nonusers). Scores were collapsed because they were not normally distributed.

All youths referred for a psychiatric evaluation were administered the following self-report and clinician-rated assessment instruments in addition to the aforementioned measures. All assessment instruments were administered by the first author (J.V.P.). Children’s Depression Rating Scale. The Children’s Depression Rating Scale (Poznanski et al., 1979), administered in an interview format, covers 15 symptom areas relevant to childhood depression. Items are rated on Likert scales, with higher scores indicating greater depression severity. Adequate reliability and validity have been established for this measure (Poznanski et al., 1979, 1983). In this study, the internal consistency estimate was excellent (coefficient α = .90). Multidimensional Anxiety Scale for Children-10. The Multidimensional Anxiety Scale for Children-10 (MASC-10) (March et al., 1999) is an abbreviated version of the Multidimensional Anxiety Scale for Children (MASC) (March et al., 1997). The MASC-10 is a unidimensional measure that combines the four anxiety factors offered in the MASC (Physical Symptoms, Harm Avoidance, Social Anxiety, and Separation Anxiety) and has demonstrated satisfactory test-retest reliability in adolescents (March et al., 1999). Items are rated on a 4-point Likert scale with higher scores reflecting more severe anxiety. In this study, the internal consistency estimate for the MASC-10 was adequate (coefficient α = .72). State-Trait Anger Expression Inventory. The State Anger subscale of the State-Trait Anger Expression Inventory (STAXI) (Spielberger, 1988) was used to measure adolescent experience of anger as an emotional state during incarceration. Items are rated on a 4-point Likert scale, with higher scores indicating greater intensity and frequency of experienced and expressed anger. The STAXI has adequate internal consistency and construct validity (Spielberger, 1988). In this study, the internal consistency estimate for the State Anger subscale was excellent (coefficient α = .91). Youth Risk Behavior Surveillance Survey. The YRBSS (Kolbe et al., 1993) is a survey designed to monitor health-risk behaviors among youths and young adults. Four suicide items from the YRBSS were used to assess suicidal ideation and suicide attempts (whether the adolescent seriously considered suicide, made a suicide plan, actually attempted suicide, or received medical treatment for the suicide attempt) experienced over the past year. The items from the YRBSS have been shown to have adequate test-retest reliability (Brener et al., 1995). The internal consistency estimate for the four suicide items in the current study was acceptable (coefficient α = .82). Responses to these items were compared to national norms.

Preliminary analyses were conducted to examine differences on demographic and psychosocial characteristics between clinically referred (n = 78) and nonreferred ado-

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PROCEDURES All adolescents in the general study sample (n = 289) were interviewed by a correctional worker, nursing staff, and a social worker within 2 days of their incarceration. The Juvenile Risk Assessment Adjudicated Form and the Suicide Risk Assessment were completed at this time and then placed in each youth’s record. Juveniles in the clinically referred study sample (n = 78) received an additional psychiatric assessment. These youths were administered standardized self-report and clinician-rated assessment instruments as part of standard care to assess depression, anxiety, anger, suicidal behavior, self-mutilative behavior, alcohol, and drug use. Approval to use these archival data was obtained from the institutional review boards at the first author’s hospital and correctional facility. RESULTS Preliminary Analyses

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TABLE 1 Psychiatric and Psychosocial Differences by Suicide Status in the General Sample Previous Suicide Attempt

Total Variable Living situation Relative Nonrelative History of psychiatric treatment Yes No Type of crime Violent Non-violent Suicidal ideation at admission Yes No Family/friend suicide attempt Yes No

No Previous Suicide Attempt

%

n

%

n

%

n

χ2

83.3 16.7

224 45

68.8 31.3

22 10

85.2 14.8

202 35

5.50*

33.5 66.6

92 183

70.6 29.4

24 10

28.2 71.8

68 173

24.03**

41.7 58.3

78 109

50.0 50.0

10 10

40.7 59.3

68 99

0.63

5.5 94.5

15 260

23.5 76.5

8 26

2.9 97.1

7 234

24.58**

12.0 88.0

33 242

26.5 73.5

9 25

10.0 90.0

24 217

7.69**

Note: Total Ns vary across variables due to missing data. df = 1 for all analyses. * p < .05; ** p < .01.

lescents (n = 211). Using χ2 analyses, we found that the referred sample compared with the nonreferred sample was more likely to be female (28.2% versus 15.6%), χ2(1, N = 289) = 5.84, p < .05; to be living with a nonrelative (26% versus 13.1%), χ2(1, N = 283) = 6.70, p < .05; to have a psychiatric treatment history (57.8% versus 26.1%), χ2(1, N = 275) = 22.20, p < .01; to be incarcerated for a violent crime (57.1% versus 39.3%), χ2(1, N = 199) = 4.76, p < .05; to report suicidal ideation at admission (12.5% versus 3.3%), χ2(1, N = 275) = 8.03, p < .01; and to have a prior history of a suicide attempt (32.8% versus 6.2%), χ2(1, N = 275) = 32.19, p < .01. There were no differences between groups in age, race, or whether a family/friend attempted suicide. Because one of the aims of this study was to examine psychosocial differences among adolescents with and without a history of suicidal behavior in the incarcerated sample as a whole, the two groups were collapsed in the general sample when analyses related to this aim were conducted.

and those without a history of a suicide attempt (NSA) prior to incarceration as per the Suicide Risk Assessment. The SA and NSA groups were statistically equivalent across gender and age. However, youths in the SA group were more likely to be white than those in the NSA group (61.8% versus 42.7%), χ2(1, N = 273) = 4.38, p < .05. We conducted χ2 analyses to determine whether the SA and NSA groups differed in psychosocial characteristics. Results are presented in Table 1. Adolescents in the SA group were less likely to be living with a relative, more likely to have a history of psychiatric treatment, more likely to report suicidal ideation at the time of admission into the juvenile correctional facility, and more likely to have a family member or friend who attempted suicide than adolescents in the NSA group. No differences were evident across groups on type of crime committed (violent versus nonviolent) that led to incarceration. Referred Sample

Of the 289 charts reviewed, 12.4% of youths reported a lifetime history of a suicide attempt prior to incarceration. More than half of those attempts were by violent means: 40.6% by cutting/stabbing self and 18.8% by hanging/choking self. Preliminary analyses examined whether there were any demographic differences between adolescents in the general sample with a lifetime history of a suicide attempt (SA)

Among the 78 youths who comprised the clinically referred sample, responses on the YBRS indicated that 28.2% seriously considered attempting suicide, 21.8% made a suicide plan, 32% made at least one suicide attempt, and 12.8% made a suicide attempt that required medical attention in the prior year. Responses on the SSBS indicated that 30% of adolescents reported experiencing suicidality (15.4% reported suicidal ideation, 8% made a suicide threat, and 6% made a mild suicide attempt) during their current incarceration.

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Responses on the FASM indicated that 30% of clinically referred adolescents engaged in one or more types of self-mutilative behavior (12.8% carved/cut skin, 10.3% hit self on purpose, 6.4% pulled hair out, 6.4% tattooed self, 14.1% picked at wounds, 2.6% burned self, 3.8% inserted objects under nails or skin, 20.5% bit self, 9% picked areas of body to the point of drawing blood, 7.7% purposely scraped skin to draw blood, and 2.6% used an eraser on skin to draw blood) during their incarceration. Of those who endorsed self-mutilative behavior, 45% reported engaging in one type of self-mutilative behavior, 32% reported engaging in two or three behaviors, 14% reported engaging in four or five behaviors, and 9% reported six or more self-mutilative behaviors. The most frequently cited reasons for self-mutilation were to stop bad feelings (65%); feel something, even if it is pain (60%); and punish self (60%).

There was some overlap between the suicidal and selfmutilative groups. Approximately 18% of adolescents in the clinically referred sample reported engaging in both suicidal and self-injurious behavior during their incarceration. Suicidal Versus Nonsuicidal Groups. Preliminary analyses examined whether there were any demographic differences between referred adolescents who reported experiencing suicidal ideation/behavior during their current incarceration (SB) and those who did not report suicidal ideation/ behavior during incarceration (NSB) as per the SSBS. The SB and NSB groups were statistically equivalent across gender, age, and race. We conducted χ2 analyses to determine whether the SB and NSB groups differed in background characteristics, substance use, or behavioral functioning. Results are presented in Table 2. The SB and NSB groups did not

TABLE 2 Psychosocial and Psychiatric Differences by Suicide Status and Self-Mutilatory Status in Clinically Referred Adolescents Variable

Living situation Relative Nonrelative History of psychiatric treatment Yes No Type of crime Violent crime Nonviolent crime Family/friend suicide Yes No History of suicide attempt Yes No FASM-P Yes No FASM-W Yes No Alcohol use Yes No Cannabis use Yes No Illicit drug use Yes No

Suicidal

Nonsuicidal

Self-Mutilative

%

n

%

n

χ2

77.3 22.7

17 5

72.7 27.3

40 15

60.0 40.0

12 8

56.8 43.2

38.5 61.5

5 8

20.0 80.0

Non–Self-Mutilative

%

n

%

n

χ2

0.17

81.0 19.0

17 4

73.1 26.9

1 14

0.50

25 19

0.06

52.9 47.1

9 8

60.5 39.5

26 17

0.28

63.9 36.1

23 13

2.52

71.4 28.6

10 4

54.8 45.2

17 14

1.11

4 16

11.4 88.6

5 39

0.85

17.6 82.4

3 14

11.6 88.4

5 38

0.38

69.6 30.4

16 7

16.4 83.6

9 46

21.08**

50.0 50.0

11 11

23.1 76.9

12 40

5.23*

83.3 16.7

15 3

40.4 59.6

21 31

9.87**

90.9 10.0

18 2

36.0 64.0

18 32

16.70**

61.9 38.1

13 8

17.0 83.0

9 44

14.53**

—

—

78.3 21.7

18 5

55.1 44.9

27 22

3.58

70.0 30.0

14 6

57.1 42.9

28 21

0.99

78.3 21.7

18 5

62.0 38.0

31 19

1.89

75.0 25.0

15 5

62.0 38.0

31 19

1.07

47.8 52.2

11 12

27.3 72.7

15 40

3.08

59.1 40.9

13 9

19.2 80.8

10 42

11.50**

Note: FASM-P = Functional Assessment of Self-Mutilation, prior to incarceration; FASM-W = Functional Assessment of Self-Mutilation, while incarcerated. df = 1 for all analyses. Total Ns vary across variables because of missing data. * p < .05; ** p < .01.

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TABLE 3 Differences in Affective Symptoms by Suicide Status and Self-Mutilatory Status in Clinically Referred Adolescents Suicidal

Nonsuicidal

Self-Mutilative

Non–Self-Mutilative

Variable

n

Mean

(SD)

n

Mean

(SD)

df

t

n

Mean

(SD)

n

Mean

(SD)

df

t

CDRS STAXI MASC-10

23 21 23

31.4 26.1 15.1

(8.5) (8.0) (6.4)

55 52 55

23.4 19.4 10.8

(8.0) (6.7) (5.1)

76 71 76

3.95** 3.70** 3.18**

22 21 22

28.5 24.4 15.0

(9.9) (8.2) (5.3)

52 48 52

24.5 19.5 10.4

(8.4) (7.0) (5.2)

72 67 72

1.75 2.50* 3.40**

Note: CDRS = Children’s Depression Rating Scale; STAXI = State-Trait Anger Expression Inventory, State Anger subscale; MASC-10 = Multidimensional Anxiety Scale for Children-10. Total Ns vary across variables because of missing data. * p < .05; ** p < .01.

differ across living situation, history of psychiatric treatment, type of crime committed that led to incarceration, number of family/friends who attempted suicide, or history of substance use. However, the SB group was more likely than the NSB group to report a lifetime history of suicide attempts, and both a prior history of selfmutilative behavior and engaging in self-mutilative behavior while incarcerated. A series of t tests was conducted to examine whether the SB and NSB groups differed in severity of affective symptoms while incarcerated. Results are presented in Table 3. The SB group evidenced higher levels of depression, state anger, and anxiety than the NSB group. Self-Mutilative Versus Non–Self-Mutilative Groups. Preliminary analyses examined whether there were any demographic differences between referred adolescents who reported engaging in self-mutilation while incarcerated (SM) and those who did not report engaging in selfmutilation (NSM). The SM and NSM groups were statistically equivalent across gender, age, and race. We conducted χ2 analyses to determine whether the SM and NSM groups differed in background characteristics, substance use, or behavioral functioning. Results are presented in Table 2. The SM and NSM groups did not differ across living situation, history of psychiatric treatment, type of crime committed that led to incarceration, number of family/friends who attempted suicide, history of alcohol use, or history of cannabis use. However, the SM group was more likely than the NSM group to report a history of suicide attempts, engaging in suicidal ideation/behavior while incarcerated, a history of selfmutilative behavior, and a history of illicit drug use. A series of t tests was conducted to examine whether the SM and NSM groups differed in severity of affective symptoms while incarcerated. Results are presented in Table 3. The SM group evidenced more severe state anger and anxiety than the NSM group but not depression.

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DISCUSSION

The first goal of this study was to examine the lifetime history of suicidal behavior reported by adolescents incarcerated in a state juvenile correctional facility. Approximately 12% of the adolescents in the all-inclusive general incarcerated sample reported a prior suicide attempt. This rate is somewhat lower than other published data on incarcerated youths (Morris et al., 1995; Rohde et al., 1997a) but is slightly higher than the 7% to 10% rates typically found in community samples (Safer, 1997). More striking is that almost two thirds of incarcerated adolescents attempted suicide by violent means (e.g., cutting, hanging) in comparison with psychiatric samples of adolescent suicide attempters, of whom 75% to 85% attempt suicide by overdose (Beautrais et al., 1996; Nakamura et al., 1994). Use of violent suicide methods has been linked to eventual completed suicide (Otto, 1972). Thus incarcerated youths with a lifetime history of suicidal behavior may be at risk for eventual completed suicide. Adolescents who reported a lifetime history of a suicide attempt, in comparison with those without such a history, also reported higher rates of prior psychiatric treatment, suicidal ideation at admission, and exposure to friend/family suicidal behavior, suggesting significant psychiatric difficulties in this group. A second goal of the study was to examine rates of prior and current suicidal behavior among clinically referred incarcerated youths, as well as affective and behavioral characteristics associated with suicidality experienced during incarceration. Of the 27% of incarcerated youths who were referred for psychiatric evaluation from the general population, responses to the YRBSS questions indicated a level of suicidal ideation and behavior in the prior year that was comparable with if not greater than that found in a survey of adolescents incarcerated across 39 facilities in the United States (Morris et al., 1995), but much higher than rates from the 1999 national 767

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YRBSS high school survey (Kann et al., 2000). Incarcerated adolescents referred for psychiatric evaluation were more likely than the national YRBSS school-based sample to have seriously considered attempting suicide (28.2% versus 19.3%), made a plan for attempting suicide (21.8% versus 14.5%), made at least one suicide attempt (32% versus 8.3%), and made a suicide attempt that required medical attention (12.8% versus 2.6%) in the prior year. Of the adolescents referred for psychiatric evaluation during their incarceration, those who were suicidal (ideation and/or behavior) while incarcerated, in comparison with nonsuicidal clinically referred youths, reported higher rates of prior suicide attempts, as well as self-mutilative behavior, both prior to and during incarceration. Thus, similar to that found in the general incarcerated population, current suicidality was strongly associated with prior suicidal behavior. In addition, affective disturbance was more evident in referred suicidal incarcerated youths than referred nonsuicidal youths. These adolescents were more depressed, angry, and anxious than their nonsuicidal counterparts. Suicidality among clinically referred incarcerated adolescents appears to be associated with significant psychiatric difficulty, suggesting that these youths likely require intensive clinical monitoring and care. Another goal of the study was to examine self-mutilative behavior in this population. Among adolescents referred for a clinical evaluation, those who engaged in self-mutilative behavior during incarceration also evidenced a high prevalence of suicidal behavior. Half of these adolescents had a history of a suicide attempt and close to two thirds reported current suicidality (ideation and/or behavior). Illicit drug use also distinguished the self-mutilative group from those without self-mutilative behavior, as did higher levels of state anger and anxiety. Deserving of mention is the nature of the self-mutilative behavior examined in this study. It ranged from minor self-mutilative behaviors such picking wounds to more severe behaviors such as carving or cutting on skin. More than half of youths endorsing self-mutilative behavior reported engaging in two or more of these behaviors. Furthermore, most adolescents reported engaging in these behaviors to address negative affective and/or cognitive states (e.g., stop bad feelings, feel something even if it was pain, punish self ), suggesting that even relatively minor forms of self-mutilation may be reflective of significant distress in these clinically referred youths. Despite the high degree of overlap between suicidal and self-mutilative youths, a few factors differentiated

these groups, namely depressive symptoms and illicit drug use. Higher levels of depressive symptoms differentiated suicidal from nonsuicidal youths, but were not significantly associated with self-mutilative behaviors. In contrast, illicit drug use differentiated youths with from those without self-mutilative behaviors, but was not associated with suicidal behavior. These findings may reflect that suicidality among incarcerated youths is more strongly associated with feelings of hopelessness and worthlessness. Esposito and Clum (1999) found hopelessness and low self-esteem to be the depressive symptoms most strongly associated with suicidal ideation among incarcerated youths. In contrast, anxiety and state anger appear to act as the primary precursors to self-mutilative behavior. Illicit drug use and self-mutilative behavior may provide a “temporary” as opposed to a “permanent” escape from intense emotion and frustration associated with current life circumstances (Suyemoto, 1998).

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Limitations

There are several limitations to this study. First, the sample was limited to one juvenile correctional facility. While this facility comprises the state’s entire population of incarcerated youths, the relatively small sample size and racial composition of the study population limits generalizability to other juvenile correctional facilities nationwide. An additional concern is the validity of the youth’s self-report on questionnaires and interviews. The results were not cross-validated with reports from corroborating sources. Furthermore, the instruments completed by clinically referred youths have been used with psychiatric samples but not validated in incarcerated juvenile populations. However, reliability estimates on all instruments used in this study were acceptable. Finally, the first author (J.V.P.) administered all of the assessment instruments but was not blind to reason for referral. Clinical Implications

This study has implications for the evaluation and management of incarcerated youths. First, adolescents who report a history of suicidal behavior upon admission to a juvenile correctional facility are at risk for suicidal and self-mutilative behavior during incarceration. Thus these adolescents may require close monitoring throughout the span of their incarceration. Second, clinically referred suicidal and self-mutilative incarcerated youths report greater affective disturbance than their nonsuicidal and non–self-mutilative counterparts, respec-

SUICIDE AND SELF-MUTILATIVE BEHAVIOR

tively, suggesting the need for more intensive mental health evaluation and treatment among these subgroups of incarcerated youths.

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