Suicide Prevention Program

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Because suicide is a leading cause of death in juvenile facilities nationwide, NCCHC recommends an active approach to the management of suicidal juveniles. The implementation of the 2011 Standards for Health Services in Juvenile Detention and Confinement Facilities brought noteworthy changes to the Suicide Prevention Program standard through a number of new compliance indicators.

Prevention Program Details
The compliance indicators for standard Y-G-05 go into more detail on what a suicide prevention program should entail. For instance, the responsible health authority should approve the facility’s suicide prevention plan; the training curriculum for staff, including development of intake screening for suicide potential and referral protocols; and the training for staff conducting the suicide screening at intake (CI #5).


Other compliance indicators specify that facility staff should identify suicidal juveniles and immediately initiate precautions, and that suicidal juveniles should be evaluated promptly by the designated health professional who directs the intervention and assures follow-up as needed (CI #1a, 1b). Treatment plans addressing suicidal ideation and its reoccurrence should be developed, and patient follow-up should occur as clinically indicated (CI #4).

The 11 key components of a suicide prevention program are outlined in compliance indicators #2a-k. Of note, the need to provide treatment is now explicit. Qualified mental health professionals should consider strategies and services to address the underlying reasons (e.g., depression, auditory commands) for the juvenile’s suicide ideation. The strategies should include treatment needs when the patient is at heightened risk to suicide as well as follow-up treatment interventions and monitoring strategies to reduce the likelihood of relapse.

Housing and Monitoring
Housing and monitoring are now combined into one component. Child care workers and health staff alike will need to be aware of and receive training in the major changes to this piece, which center on the monitoring of actively and potentially suicidal juveniles.

Actively suicidal juveniles express a state of acute thought of completing suicide associated with imminent risk. They should be placed on constant observation (CI #1c).

Potentially suicidal juveniles are not actively suicidal, but express suicidal ideation and/or have a recent history of self-destructive behavior. They should be observed at staggered intervals not to exceed every 15 minutes, for example, 5, 10 and 7 minutes (CI #1d). In other words, potentially suicidal juveniles should be monitored on an irregular schedule with no more than 15 minutes between two checks. Note that precise 15-minute observation periods are not in compliance with the standard, nor are consistently recurring intervals (even “q1 checks” do not meet the intent of this standard). The idea is that the youth under watch cannot predict when the next check will occur.

If, however, the potentially suicidal juvenile is placed in isolation, constant observation is required. Unless constant supervision is maintained, a suicidal juvenile should not be isolated but should be housed in the general population, mental health unit or medical infirmary and located in close proximity to staff. All cells or rooms housing suicidal juveniles should be as suicide-resistant as possible (e.g., without protrusions that would enable hanging). Other supervision aids, such as a closed circuit television, can be used as a supplement to, but never as a substitute for, staff monitoring. The use of other juveniles in any way, including as companions or suicide-prevention aides, is not a substitute for staff supervision (CI #3).

Risk Factors
Recent research points out that adolescent suicides in correctional settings have different high-risk periods compared to adults. Although juveniles may become suicidal at any point during their stay, high-risk periods include immediately upon admission, after adjudication, after return to a facility from court, after the receipt of bad news regarding self or family (e.g., serious illness, the loss of a loved one), prolonged stays in juvenile detention facilities and after suffering humiliation (e.g., sexual assault) or rejection. In addition, high risk of suicide has been identified for juveniles entering or unable to cope with segregation, other specialized single-room housing assignments or room confinements (e.g., time-out, quiet time, separation). Juveniles who are in the early stages of recovery from severe depression also may be at risk.


Signs of Prevention Success
Despite the differences in adult and juvenile populations, data from a recent study examining jail suicide underscore the importance of appropriate monitoring. In 2010, the National Center on Institutions and Alternatives released a major study called the National Study of Jail Suicide: 20 Years Later. Commissioned by the U.S. Justice Department’s National Institute of Corrections, the study found a dramatic decrease in the rate of suicide in county jails during the past 20 years.

In 1986, NCIA released a Justice Department commissioned study that reported 107 suicides per 100,000 inmates; strikingly, the 2010 study calculated the suicide rate in county jails to be 38 deaths per 100,000 inmates, which is a threefold decrease from 20 years earlier. This rate is still three times greater than that of the general U.S. population (11 deaths per 100,000 people), but as Lindsay Hayes, NCIA project director and author of the study, has said, “The recent decrease is extraordinary.”

The 2010 study identified 696 jail suicides in 2005 and 2006 combined, with 612 deaths occurring in detention facilities (housing individuals for more than 72 hours) and 84 in holding facilities (housing individuals for less than 72 hours). Various characteristics of the jail facilities were summarized in the findings. Notably, 93% provided a protocol for suicide watch, but less than 2% had the option for constant observation; most (87%) used 15-minute observation periods. It should be noted that precise 15-minute observation periods would not be in compliance with NCCHC’s standards on suicide prevention for juvenile facilities, jails or prisons.

Corrective Action
It is clear that much progress has been made with regard to suicide prevention in correctional facilities in the last 20 years, and NCCHC has been at the forefront of this movement in setting standards for suicide prevention. The Y-G-05 standard is intended to ensure that suicides are prevented if at all possible. When suicides do occur, appropriate corrective action should be identified and implemented to prevent future suicides.

To that end, in the event of a youth’s suicide, a psychological autopsy should be completed within 30 days. A psychological autopsy, sometimes referred to as a psychological reconstruction and usually conducted by a psychologist or other qualified mental health professional, is a written reconstruction of an individual’s life with an emphasis on factors that may have contributed to the death. The typical psychological autopsy is based on a detailed review of all file information on the juvenile, a careful examination of the suicide site and interviews with staff, juveniles and family members familiar with the deceased. (See Y-A-10 Procedure in the Event of a Juvenile Death.)

A continuous quality improvement root cause analysis should be conducted for all suicides and suicide attempts. Remedial action should be taken on identified policy, staff performance, environment or other system failures that allowed the event to occur. The remedial change(s) should be successful in preventing opportunities for future suicide attempts.

[This article first appeared in the Winter 2012 issue of CorrectCare.]

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