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Predicting Suicide Risk in Incarcerated Adolescent Females Utilizing the MAYSI-2

Adolescent suicide is on the rise in the United States and a significant number of suicides among youth occur within juvenile justice facilities. In the five-year time period from 2002 through 2007, 7,822 adolescents took their own lives and many of those were youth housed in correctional facilities (Centers for Disease Control and Prevention, 2007). While it is deeply concerning that the suicide rate in young people ages 15 to 24 tripled between 1950 and 2001 (Arias, Anderson, Kung, Murphy, & Kochanek, 2003), it is more alarming that adolescents in confinement have an even greater risk of suicide than the general population (Gallagher & Dobrin, 2005; Gallousis & Francek, 2002; Penn, Esposito, Schaeffer, Fritz, & Spirito, 2003; Suk et al., 2009). It is estimated that up to 60% of juvenile offenders in custody attempt suicide (Penn, et al., 2003). Statistics such as these indicate the vital need for research that examines factors associated with suicides among youth in custody.

In 2004, The National Center on Institutions and Alternatives (NCIA), in conjunction with the United States Justice Department, completed the first national survey on juvenile suicide in confinement (Office of Juvenile Justice and Delinquency Prevention, 2004).Researchers investigated the extent, characteristics, and distribution of adolescent suicide in confinement (Hayes, 2005).  This study examined cases (n = 79) of male and female adolescent suicides in secure facilities, detention centers, residential treatment centers, and diagnostic or reception centers (Hayes, 2009b).  Results of the study indicated that 90 percent of the victims were housed in facilities that had suicide precaution protocol in place (Hayes, 2009a). Seventy percent of those with successful suicide attempts were detained in facilities that had intake screening to identify suicide risk (Hayes, 2009a). Almost half of the youth who committed suicide had been assessed by a qualified mental health professional within the six days preceding their deaths, and precipitating factors were identified for only one-third of those youth who died by their own hand (Hayes, 2009a). The results of this survey indicate that current suicide prevention measures in juvenile justice facilities are inadequate and more research focusing on the factors associated with suicide risk among youth in custody is needed to prevent further senseless death.

Researchers have explored several risk factors linked to adolescent suicide and found issues of mental health to be prevalent among suicidal youth. Sevecke, Lehmkuhl, and Krischer (2009) observed that Psychopathology and delinquency in adolescents appear to overlap. More than half of all criminal adolescents are thought to have comorbid mental health disorders (Sevecke et al., 2009), and studies have demonstrated that rates of mental disorders among youth in juvenile justice settings are higher than in the general population (Odgers, Burnette, Chauhan, Moretti, & Reppucci, 2005). It is estimated that 70 percent of detained youth have at least one psychiatric disorder (Teplin, Abram, McClelland, Washburn, & Pikus, 2005) “with at least 20 percent experiencing disorders so severe that their ability to function is significantly impaired ” (Skowyra & Cocozza, 2007, p.vii). Some of the most common mental health disorders among incarcerated adolescents include depression, anxiety, posttraumatic stress disorder, attention deficit hyperactivity, conduct disorder, and substance abuse (Odgers et al., 2005; Sevecke et al., 2009), and many of these have been shown to increase the likelihood of suicide attempts (Grewal & Porter, 2007; Stewart & Trupin, 2003).

Sadly, adolescents who have a history of suicide attempts are at higher risk for an eventual completed suicide (Penn et al., 2003). The completed suicide rates for youth in custody are two to four times higher than among youth in the general population (Abram et al., 2008; Gallagher & Dobrin, 2005). In fact, Gallagher and Dobrin (2006) found that suicide was the leading cause of death among youth in juvenile facilities over a recent two-year span, whereas in the general population, suicide is the third leading cause of death among youth (Centers for Disease Control and Prevention, 2007). This is particularly tragic considering that suicide attempts in correctional facilities are highly preventable if a youth’s suicide risk is determined upon admission (Chapman & Ford, 2008). Clearly, assessing for factors that influence suicide risk is paramount to ensuring the safety of detained youth.

One factor that may have been overlooked as a determinant for suicide risk is gender. Findings suggest that suicide risk manifests differently in males and females (Abram et al., 2008). A thorough review of published research on suicide in juvenile justice facilities reveals that studies have concentrated primarily on incarcerated males. Very little research exists that focuses on suicide risk in females confined to juvenile justice facilities (Gallousis & Francek, 2002; Sevecke et al., 2009). The few research studies that have explored suicidal behavior in adolescent females discovered that females have a higher risk for suicide than male adolescents and are more often referred for mental health services than males (Abram et al., 2008; Eltz et al., 2007; Sevecke et al., 2009; Wasserman & McReynolds, 2006). Some investigators have also found that incarcerated adolescent females had higher incidences of suicidal ideation, suicide plans, and attempted suicides than males (Abram et al., 2008; Stathis et al., 2008). Therefore, gender differences should be taken into account when assessing suicide risk among adolescents in confinement.

Knowledge of risk factors, however, may not be enough to lower suicide risk and increase safety of incarcerated youth. The frequency of adolescent suicides in confinement indicates that there is an immediate need for juvenile justice facilities to institute an action plan to ensure the safety of detained youth. The National Commission on Correctional Health Care (NCCHC) recommends that “all juvenile facilities, regardless of size or type, develop and implement a comprehensive suicide prevention program...” (National Commission on Correctional Health Care, 2009, p. 228). To actively address NCCHC concerns, all juvenile facilities must have a suicide prevention policy that includes seven critical components: a detailed written policy, intake screening, training, CPR certification, observation, safe housing, and mortality review (National Commission on Correctional Health Care, 2009). The NCCHC further recommended that current suicide prevention procedures should be followed closely and modifications to increase effectiveness should be based on new research findings (National Commission on Correctional Health Care, 2009).

In spite of these recommendations, the adolescent suicide rates in juvenile justice facilities remain high.  Hayes’ (2009a) report on the NCIA National Survey discusses factors that may be linked to high suicide rates in detained youth. One important factor was the fact that only 17 percent (n = 13) of the adolescents (n = 79) that committed suicide were on suicide precaution status at the time of death (Hayes, 2009b).  Of those that were on suicide watch, almost half (n = 6) had not been observed during the 15 minutes prior to their deaths (Hayes, 2009a).  These findings indicate that supervision of adolescents at highest risk for suicide has been insufficient. The importance of adequate supervision in preventing suicides led Hayes (2009a) to publicize the NCIA recommendations for specific levels of supervision as part of a comprehensive suicide prevention program. Two levels of supervision were recommended for suicidal youth:  close observation and constant observation.  In close observation, youth who are not actively suicidal but have risk factors such as suicidal ideation, history of suicidal attempts, or other characteristics of concern are supervised at staggered intervals every 15 minutes (Hayes, 2009a).  In constant observation, youth who are actively suicidal are supervised on a continuous uninterrupted basis (Hayes, 2009a).  These levels of supervision must be assigned upon entrance into a juvenile facility in order to provide a safe environment for those youth at risk for a suicide attempt.  In order to assign appropriate levels of supervision, facilities have a duty to utilize effective assessments to evaluate an individual’s potential for suicidal behavior.

Effective assessment for suicide risk, including screening for current and previous suicidal thoughts and behaviors, is acknowledged to be a critical tool in preventing suicides among incarcerated adolescents (Abram et al., 2008; Gallagher & Dobrin, 2005; Gallousis & Francek, 2002). The utility of the assessment in reducing suicides, however, is affected by the point in time when the assessment is administered. Systematic screening for suicide risk at the onset of incarceration reduces the likelihood of suicide attempts more than screening after warning signs occur (Gallagher & Dobrin, 2005). Furthermore, facilities that screen youth within 24 hours after arrival have a lower incidence of suicide attempts than facilities that delay screening (Gallagher & Dobrin, 2005). Therefore, successful screening for suicide risk involves other factors in addition to completing the assessment.

Variability of screening procedures among detention centers is another factor that determines success of predicting suicide risk in incarcerated adolescents. The quality and range of content assessed fluctuates across facilities (Gallousis & Francek, 2002). Methods for determining which youth should be screened, the timing of the screening, and the training of screeners differ dramatically from facility to facility (Gallagher & Dobrin, 2005). As a result, predicting an incarcerated youth’s risk of suicide is still a challenge due to the lack of research focused on the efficacy and administration of suicide risk instruments, as well as the lack of standardized procedures among correctional facilities (Gallousis & Francek, 2002; Grewal & Porter, 2007). Consequently, it is essential that researchers study the specific tools of assessment in order to make recommendations for standardization of suicide risk assessment for incarcerated youth.

One screening instrument utilized in many secure care facilities is the Massachusetts Youth Screening Instrument, Version Two or MAYSI-2 (Grisso, Barnum, Fletcher, Cauffman, & Peuschold, 2001). This assessment is a 52 item self-report inventory commonly used in juvenile justice facilities to screen adolescents for suicide risk as well as for potential emotional and behavioral problems (Archer, Simonds-Bisbee, Spiegel, Handel, & Elkins, 2010; Grisso et al., 2001; Wasserman et al., 2004). Research studies demonstrate that the MAYSI-2 has utility in identifying adolescents with a high level of mental health symptoms (Archer et al., 2010; Stewart & Trupin, 2003). According to Archer et al. (2010), the MAYSI-2 also shows promise for identifying youth at risk for suicidal ideation or behaviors; however, as of the date of this article, the MAYSI-2 has not been verified as an accurate assessment of suicide risk in incarcerated adolescent females. For this reason, researchers in the current study chose the MAYSI-2 to evaluate its efficacy as a screening instrument for suicide risk among female adolescents housed in correctional facilities.

The purpose of this study was to determine the accuracy of the MAYSI-2 assessment instrument in predicting suicidal behavior among incarcerated female adolescents. Researchers hypothesized that the six subscale scores from the MAYSI-2 would correlate with incidences of suicidal behavior reported by the juvenile justice facility staff.

It was theorized that accurate assessment measures could identify those female adolescents most at risk for suicidal behavior, therefore enabling the facilities to immediately place the juveniles on an elevated watch status, and ultimately reduce the number incidents of suicidal behavior within correctional facilities.

METHOD

Sample

Data regarding 553 female adolescents was obtained from archival records dated between 2005 and 2010 at a secure care juvenile justice facility in a southwestern state. All of the female juvenile participants have been adjudicated delinquent and committed to the jurisdiction of the Department of Juvenile Corrections. Juveniles committed to this facility can range in age from 12 to 21 years old; however, ages were not available for participants of this study. The sample consisted of Hispanics (n=216)(39%), Caucasians (n=214)(38%), African Americans (n=74)(13%), Native Americans (n=38)(7%), Mexican Nationals (n=8)(1%), and Asians (n=3)(1%).

As outlined by the Department of Juvenile Corrections’ guidelines and procedures, upon arrival to the secure care facility, all juveniles are provided a structured intake screening by a Qualified Health Care Professional (QHCP).  The screening serves to identify incarcerated juveniles who are at risk for suicidal behavior.  As part of the initial screening process, a standard assessment instrument, the MAYSI-2, is administered within one hour of the juvenile’s arrival to the facility by a Youth Program Officer III (YPO III). All 553 participants in this study were given the MAYSI-2 upon entry to the facility.

Instrument

This study examined the MAYSI-2 subscale scores collected from the participants in the sample upon admittance to the juvenile justice facility. The MAYSI-2 is a brief 52 item screening instrument developed to identify mental health needs of youth (12-17 years) entering the juvenile justice system (Grisso et al., 2001). This instrument helps to identify detained youth who require immediate intervention for suicidal behaviors (Archer et al., 2010; Ford et al., 2008). The MAYSI-2 includes a combination of mental, emotional, and behavioral items and requires no more than ten minutes to administer (Grisso et al., 2001). Individuals answer “yes” or “no” to the items on the assessment which is composed of the following 6 subscales for females:  Alcohol/Drug Use, Angry-Irritable, Depressed-Anxious, Somatic Complaints, Suicide Ideation and Traumatic Experiences. The objective of the MAYSI-2 is to assist juvenile justice facilities in identifying those who need immediate care for mental or emotional problems (Grisso et al., 2001). The MAYSI-2 was determined to be reliable (.61-.86 range of internal consistency) and significantly valid through the use of a sample size of 1,279 youth (Grisso et al., 2001). The MAYSI-2 is also reported to have test-retest reliability (median intraclass correlation=0.74), concurrent validity, and interscale correlations comparable to other measurements scales (Ford et al., 2008; Grisso et al., 2001). Some participants of this study received multiple MAYSI-2 assessments; however, for the purposes of this study only initial assessments were used for data analysis.

Procedure

Archival data was obtained from the juvenile justice facility’s electronic intake records. Data was acquired from intakes administered from May 18, 2005 to September 7, 2010. The MAYSI-2 was used to screen for a variety of factors including suicidal ideation and behaviors. Many of the juveniles in our study had multiple MAYSI-2 scores due to re-admittance to the facility as a result of recidivism. For the purposes of this study only the scores from the first administration of the MAYSI-2 were included in the analysis. Of the 7 subscale scores from the MAYSI-2, the researchers utilized the six subscale scores that were applicable to females as the independent variables. The reported incidents of suicidal behavior were the dependent variables for the study (Table 1). A standard multiple regression was conducted to determine the accuracy of the independent variables from the subscales on the MAYSI - II (Alcohol/Drug Use; Angry-Irritable; Depressed-Anxious; Somatic Complaints; Suicide Ideation; and Traumatic Experiences) predicting suicide incident reports.

Results

A preliminary analysis found the Angry-Irritable subscale to be highly correlated with the Depressed-Anxious subscale (r = .631, n = 553, p <.001); therefore the Angry-Irritable subscale was dropped from the final regression analysis. All other assumptions for AllAllostatistical multiple regression were met. A stepwise regression was then conducted by entering the remaining five variables resulting in the Suicide Ideation subscale as the only remaining subscale in the model showing significance, R2 = .012, R2adj = .010, F(1,551) = 6.764, p = .01. However, this model accounts for only 1.2% of the variance in suicide incident reports. The subscales Depressed-Anxious, Somatic Complaints, and Traumatic Experiences were excluded as having any significance.

Table 1. Suicidal Incidents Reported by Secure Care Facility Listed by Category

Incident# of reported cases
Self-Injurious Behavior 462
Suicidal Behavior with Injury 363
Suicidal Behavior with No Injury 1552
Suicide Threat 273

Table 2. The unstandardized and standardized regression coefficients for the variable included in the model.

VariableBSE Bßp
Suicide Ideation 3.93 1.51 .11 .01

The rise in adolescent suicides in juvenile justice facilities presents an urgent need for effective methods of identifying those juveniles most at risk for suicidal behavior. Juvenile justice facilities are responsible for at-risk juveniles who engage in suicidal behavior, attempt suicide or commit suicide. Often facilities rely on standard policies and procedures to screen juveniles who are at risk. Commonly, these procedures consist of administering a battery of screening assessments in order to determine special needs that would warrant increased observation of the juvenile. The goal of these procedures is to adequately screen juveniles for suicidal thoughts and behaviors so that effective interventions can be implemented to prevent suicides. Given the life or death potential, the importance of using effective screening instruments is imperative. As the MAYSI-2 is the initial screening assessment administered by many residential facilities and may determine safety precautions as well as whether or not additional screening measures are utilized, there is much dependence placed on this assessment to accurately assess suicide risk.

Analysis of the MAYSI-2 subscale scores used in this study did not find any significant results that the subscale scores accurately predicted suicidal incidents. The MAYSI-2 was designed to identify juveniles upon admission who may have special mental health needs such as suicidal ideation and who therefore may need immediate intervention. Through this study, the researchers sought to determine if the assessment could accurately predict those who would engage in suicidal behavior during incarceration. It was determined that none of the subscale scores from the MAYSI-2 were accurate predictors of suicidal behavior. While the MAYSI-2 may be utilized to determine other mental health needs of juveniles, the results of this study suggest that it could not be used to accurately determine suicide risk as part of the identification of special mental health needs.

Current protocol for this facility requires staff to administer the Suicide Probability Scale as a follow-up measure when a juvenile has elevated scores on the Suicide Ideation subscale of the MAYSI-2. However, since the Suicide Ideation scale only accounted for 1.2% of the variance, it is possible that other variables may account for variance and should be considered. Given these findings, researchers do not believe that the MAYSI-2 is effective in predicting suicidal behaviors and, therefore, suggest that facilities adopt a more effective protocol for screening juveniles for suicidal behavior. Furthermore, researchers for this study suggest that the facilities are unable to provide effective suicide prevention measures in part because the MAYSI-2 is not accurately predicting suicidal behaviors as the facilities are assuming. Facilities may need to consider other screening instruments to ensure the safety of those who are incarcerated.

Another consideration when determining effective suicide prevention protocols is education. At this time juveniles who are incarcerated are at a greater risk of suicidal behavior than their teen counterparts; yet there are few suicide prevention curriculums available for juvenile justice facilities. Development of prevention measurements such as these may increase the accuracy of identifying those juveniles who are at risk for suicidal behavior and potentially save lives. Utilizing other suicide assessments as prevention measures may also benefit facilities.

The facility that participated in this study does administer the SPS as a follow-up to the MAYSI-2 assessment; however, there is limited archived data for juveniles’ scores on the SPS assessment (n=63) and so the data was not analyzed in this study. Future research should consider the predictability of suicidal behavior using the SPS as a standard screening instrument of juveniles upon intake to the facility. Currently, the assessment is only used when an elevation is reported on the Suicide Ideation scale of the MAYSI-2. The results of this study indicate that it may prove beneficial for facilities to consider utilizing the SPS as an additional initial intake screener. Another consideration for future research would be to examine the effectiveness of a combination of assessments such as the MAYSI-2 and the SPS to determine if the effectiveness of suicide prediction is increased when two assessments are used together. While results of this study indicated that the MAYSI-2 alone was not a strong predictor of suicidal behavior, it is important to note possible limitations of using the archival data.

Archival data provided some limitations to the study. Data was confounded by the fact that some juveniles in this study were discharged and re-admitted to the facility on multiple occasions over a short period of time. Each time a juvenile re-entered the facility, a new assessment was administered. At times the scores indicated in the archived data during these times of re-entry are identical to the scores obtained during their initial entry. These re-entry scores reported were not included in this study, but should be noted as a possible limitation.

Another limitation from the archived data included the inability to manipulate the dependent variable or account for extraneous variables which may have impacted the results. Some juveniles reported trauma and substance use prior to being committed to the facility. However, these variables were not taken into consideration nor were they studied in relation to the predictability of suicidal behavior. As mentioned, the facilities’ current policy states that the juvenile is administered the Suicide Probability Scale (SPS) if the Suicide Ideation subscale of the MAYSI-2 is elevated. Our data revealed that this policy was not followed closely; the archived data used in this study demonstrated that only 63 participants were administered SPS assessments. The strength of this study could have been increased if the SPS data had been usable and the researchers could have analyzed the predictive strength of the MAYSI-2 and SPS scores combined. Analyzing the combination of MAYSI-2 scores and SPS scores and their predictive ability combined could increase the ability of the facility to more effectively prevent suicidal behavior.

Since many juveniles in this study reported that they had experienced some form of trauma prior to incarceration, future research could explore the extent to which prior trauma affects suicidal behavior. There are many other variables that could contribute to a juvenile’s suicidal behavior as well including drug use, depression, confinement, and variability of screening procedures. Juvenile justice facilities could benefit from research examining the effect of these as well as other factors that may play a role in adolescent suicidal behavior.

Incarcerated female juveniles engage in suicidal behaviors at an alarming rate, yet there are few research or prevention tools to address these concerns. Facilities that house these individuals could benefit from screening assessments that best assess those who are in need of immediate attention. Not only are screening assessments needed, it is critical to the safety of at-risk juveniles that appropriate levels of watch are in place. Juveniles tend to commit suicide while in isolation and within the immediate days following onset of incarceration which suggests that accurate initial screening measures are essential to safeguarding at-risk adolescents. The data examined in this study did not yield results that would indicate that the MAYSI-2 is an effective initial screener to identify juveniles at risk for suicidal behavior. Facilities should consider other initial intake assessments as well as protocols that require immediate assessments upon a juvenile’s admittance to the facility.

References

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Archer, R. P., Simonds-Bisbee, E., Spiegel, D. R., Handel, R. W., & Elkins, D. E. (2010). Validity of the massachusetts youth screening instrument-2 (MAYSI-2) scales in juvenile justice settings. Journal of Personality Assessment, 92(4), 337-348. doi:10.1080/00223891.2010.482009.</p>

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