N EW R E S E A R C H

Characteristics and Precipitating Circumstances of

Suicide Among Incarcerated Youth
Donna A. Ruch, PhD, Arielle H. Sheftall, PhD, Paige Schlagbaum, BS, Cynthia A. Fontanella, PhD,
John V. Campo, MD, Jeffrey A. Bridge, PhD

Objective: Studies show incarcerated youth are at increased risk for suicidal behavior, yet little is known about factors associated with suicide for this
population. Using a nationally representative sample, this study examined characteristics and precipitating circumstances of suicide in incarcerated youth
decedents compared with youth suicide decedents in the general population.
Method: Data were analyzed for suicide decedents 10- to 24-years-old (N ¼ 10,126) in the United States from 2003 through 2012 from the National
Violent Death Reporting System. Logistic regression compared precipitating circumstances of suicide for incarcerated youth decedents and those not in
custody. Details on suicide deaths in detained youth were captured from coroner/medical examiner and law enforcement reports associated with each
incident.
Results: Most youth suicide decedents were older, white, and male regardless of incarceration status. Incarcerated youth suicide decedents were more
likely to die by hanging, strangulation, or suffocation and less likely to disclose suicide intent, leave a suicide note, or exhibit depressive symptoms
compared with those not in custody. Additional risk factors for suicide were not significantly different between youth decedents in custody and those not
in custody, suggesting that unique aspects of the incarceration environment could be associated with an increased risk of suicide.
Conclusion: Study findings highlight the need for early suicide risk detection and developmentally relevant interventions tailored for youth in
correctional settings. Future efforts should include evaluation studies to support suicide prevention programs designed for incarcerated youth and
research that examines distinctive factors associated with suicidal behavior in youth in custody.
Key words: adolescent suicide, incarcerated youth, suicide risks, adolescent mental health, prevention/early detection
J Am Acad Child Adolesc Psychiatry 2019;58(5):514–524.

uicide is the second leading cause of death in
S youth 10- to 24-years-old in the United States,
with a rate of 9.6 per 100,000.1 In 2016, more
youth died of suicide than of cancer, heart disease,
congenital anomalies, influenza, pneumonia, diabetes mel-
litus, and stroke combined, with suicide accounting for
17.3% of all deaths in this age group.2 In an effort to
decrease suicide, the National Action Alliance for Suicide
Prevention (NAASP) established a strategic goal focusing on
suicidal subpopulations in select boundaried settings.3
These subpopulations refer to persons defined by an orga-
nizational service or system at an increased risk for suicide
who might benefit significantly from preventative efforts.3
One such boundaried subpopulation in which rates of
suicide are particularly concerning is composed of incar-
cerated youth.3-9
More youth in confinement die of suicide than of any
other reported cause of death.10,11 In a biennial national
survey of juvenile correctional facilities from 2000 to 2014,
suicide rates were consistently 2 to 3 times higher for youth in
custody than for those in the general population.10 Mortality
statistics for young offenders younger than 25 years in adult
facilities show even more alarming results, with suicide ac-
counting for 53% of all deaths in that age group and rates up
to 5 times higher than those not in custody.11 Despite such
dramatic risk differences, little attention has been directed to
understanding determinants of suicidal behavior in detained
youth, with existing research focused primarily on individual
characteristics of youth at risk for suicide and only secondarily
on the impact of incarceration.
Research has identified multiple risk factors for youth
suicide, including major mood disorders, impulsive-aggressive
behavior, and prior suicide attempts.12-15 The literature further
suggests delinquency is associated with a larger number of
suicidal risks, with higher rates of suicide for those involved
with the juvenile and adult justice systems.8,12,16-18 Studies
indicate approximately two-thirds of youth in the criminal
justice systems meet criteria for at least 1 psychiatric condition

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Volume 58 / Number 5 / May 2019

linked to suicidal behavior, including anxiety, depression,
substance use, and conduct disorders.19-25 A meta-analysis on
the prevalence of mental health disorders in confined youth 10-
to 19-years-old found substantially higher rates in youth in
custody compared with youth in the general population.26
Conduct disorder was 10 to 20 times more common for
incarcerated youth than for other youth, and the prevalence of
psychotic disorders was 5 to 10 times higher.26 Engagement in
high-risk behaviors at a young age (eg, sexual activity, alcohol
and illicit drug use),27-30 experiences of trauma, neglect, or
abuse,27,28,31-34 and familial environments characterized by
poor parental discipline/supervision, conflict, violence, and
criminality are additional risk factors for suicide and involve-
ment in unlawful behavior.12,34-36
Conditions of confinement also are associated with higher
rates of suicide in incarcerated youth.4,6,7,37,38 Characteristics of
the incarceration environment, such as separation from family
and friends, crowded living arrangements, strict disciplinary
actions, and extended periods in locked rooms, are associated
with youth suicide in correctional institutions.37,38 Other
harmful conditions, including the use of force and physical re-
straint, abuse, and solitary confinement practices, are further
noted as risk factors predisposing incarcerated youth to suicidal
behavior.7,37,38 The lack of appropriate mental health screening
and treatment in facilities also has been strongly linked to
increased risks of suicide for youth in custody.23,25,39,40
Youth confined in adult jails and prisons are at partic-
ular risk for suicidal behavior.7,41,42 Young offenders in
these facilities are exposed to increased violence and are
highly vulnerable to adverse situations, such as physical and
sexual victimization.7,41-43 Youth also are more likely to be
placed in isolation for long periods as a protective measure
from the adult population.7,41-43 These conditions can
severely exacerbate the risk for suicidal behavior. Higher
rates of mental health problems also have been reported by
youth in adult confinement, with 1 study showing that
youth in adult prisons were 20 times more likely to be
depressed than offenders in juvenile facilities.24 Research
further suggests the adult prison environment can aggravate
existing mental health problems in youth, leading to an
increased risk for suicide.23-25 Adult facilities also might lack
age-appropriate mental health treatment services, including
professionals specialized in youth care.7,23-25
Although independent lines of inquiry have elucidated
some commonalities between risks for suicide and justice
system involvement, only a small number of studies have
explored these factors in youth suicide decedents under
custodial authority, with the few available studies being
limited to descriptive reporting of demographic and facility-
related statistics.5,6,37,38,41 Using the National Violent
Death Reporting System (NVDRS), a state-based
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SUICIDE AMONG INCARCERATED YOUTH
surveillance system that collects data on all violent deaths, the
present study addressed this gap by examining associations
between characteristics and precipitating circumstances of
suicide in decedents in custody compared with youth suicide
decedents in the general population. Additional details on
suicide deaths in detained youth were captured through a
narrative analysis of coroner/medical examiner and law
enforcement reports related to each suicidal incident.
METHOD
Data Source
This retrospective study analyzed data on youth suicide de-
cedents in the United States from 2003 through 2012 from
the NVDRS, which captures and links violent death data
from multiple reports by coroners, medical examiners, and
law enforcement.44 Forty-two states currently participate in
the NVDRS; however, restricted-use detailed data are avail-
able from only 17 states: Alaska, Maryland, Massachusetts,
New Jersey, Oregon, South Carolina, and Virginia (2003–
2004); Colorado, Georgia, Oklahoma, North Carolina,
Rhode Island, and Wisconsin (2004–2012); Kentucky, New
Mexico, and Utah (2005–2012); and Ohio (2010–2012).45
Participants
Decedents were selected if the underlying cause of death was
coded as suicide based on the International Statistical Clas-
sification of Diseases and Related Health Problems, Tenth
Revision (X60–X84, Y87.0, and U03) and were 10- to 24-
years-old (N ¼ 11,399).1 The 10- to 24-year age group is
consistent with previous research and focuses on a critical
age group at risk for suicide.1,46-48 Incidents were excluded
if circumstances precipitating suicide were unreported,
leaving 10,126 cases (n ¼ 213 for youth suicide decedents
in custody and n ¼ 9,913 for youth suicide decedents not
in custody). Analyses comparing included and excluded
cases found no difference in decedent characteristics for age,
sex, race/ethnicity, or suicide method and time of suicidal
injury. Narrative data from coroner/medical examiner and
law enforcement reports pertaining to youth suicide de-
cedents in custody were analyzed to further interpret the
quantitative findings and provide additional context. This
study was considered exempt according to the review policy
of the institutional review board of The Research Institute
at Nationwide Children’s Hospital (Columbus, OH).
Measures
A single variable in the NVDRS indicates whether the
decedent was in custody at the time of the suicide. Custody
was defined as confinement in a juvenile detention center or
adult jail, where youth were detained while awaiting trial, or
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RUCH et al.
incarceration in a longer-term juvenile correctional facility or
adult prison after conviction. Comparisons were made based
on custody status for sex, age, race/ethnicity, suicide method,
and estimated time of the injury. Additional comparison
variables included precipitating circumstances related to job,
school, and relationship problems; toxicology findings; and
suicide-related circumstances, such as history of suicide
attempt and whether youth disclosed suicide intent.
Youth suicide decedents were identified as having a
current mental health problem if the coroner/medical
examiner report indicated that the decedent was diagnosed
with a disorder listed in the DSM-IV. Alcohol and other
substance abuse problems were noted in the coroner/med-
ical examiner report if the youth was perceived by others to
have a problem or if youth participated in a rehabilitation or
treatment program within the past 5 years leading up to the
incident. Categories identified in the narrative data provide
further details about method and means of suicide, type of
correctional facility, and time in custody leading up to the
suicide incident.
Statistical Analyses
The number and percentage of suicide decedents in custody
versus suicide decedents not in custody were determined
overall and stratified by the characteristics listed earlier. For
each variable of interest, logistic regression was used to
calculate odds ratios (ORs) for youth in custody who died of
suicide compared with youth not in custody who died of
suicide. Subsequent logistic regression analyses investigated
whether associations retained statistical significance when
adjusting for age, sex, and race/ethnicity. To account for
multiple comparisons, results are presented as ORs with
corresponding 99% CIs. Suicide method was excluded from
the regression analyses given the disproportionate number
of youth in custody who died of hanging, strangulation, or
suffocation (n ¼ 206, 96.7%). This resulted in numbers too
small for calculating meaningful comparisons across other
suicide method subgroups. Similarly, time of injury was
excluded given the large proportion of missing data (n ¼
4,730, 47%). Statistical analyses were performed with
STATA/IC Statistical Software 14.1 (StataCorp Inc., Col-
lege Station, TX).
Two authors (D.R. and P.S.) completed a review of
coroner/medical examiner and law enforcement narratives
corresponding to each suicide decedent in custody. Using
qualitative methods, open coding procedures were applied
to identify and define situational themes explaining or
describing the suicide incident. A constant comparative
method was used to refine the codes into more succinct
categories.49,50 A high interrater agreement was achieved
(192 of 216, 89.0%, Cohen k 0.69). Discrepancies in
516 www.jaacap.org
coding were resolved by reaching a mutual consensus after
discussion between researchers.
RESULTS
Most youth suicide decedents were male, white, and 20- to
24-years-old regardless of custody status (Table 1). In the
multivariate analyses, older youth suicide decedents were
significantly more likely to be in custody than younger
decedents, and black youth who died of suicide were
significantly more likely than their white counterparts to be
in custody. Hanging, suffocation, or strangulation was the
predominant method of suicide for decedents in custody
(96.7%). Suicide by firearms was the most common
method of suicide for decedents not in custody (47.2%)
followed by hanging, suffocation, or strangulation (38.3%)
and poisoning (8.1%). Approximately 70% of youth died of
suicide during waking hours from 6:00 AM to midnight for
youth in custody and those not in custody. Youth suicide
decedents in custody were significantly less likely to expe-
rience job, school, or intimate partner problems compared
with suicide decedents not in custody. Decedents in custody
also were significantly less likely to disclose suicide intent to
another person before their death (adjusted OR 0.57, 99%
CI 0.36–0.89).
A current mental health problem was present in slightly
more than 37% of all youth suicide decedents (Table 2).
Rates of current mental health treatment and a history of
mental health treatment did not differ significantly between
groups, but youth suicide decedents in custody were
significantly less likely to exhibit depressive symptoms
leading up to the suicide incident (adjusted OR 0.54, 99%
CI 0.36–0.82). Of all youth suicide decedents with a cur-
rent mental health problem, depression/dysthymia was the
most common diagnosis, with higher rates for youth not in
custody who died of suicide (68.9%) compared with youth
in custody who died of suicide (48.7%). The presence of
alcohol and marijuana at time of death also was greater for
youth suicide decedents not in custody (30.9% and 20%)
compared with those in custody (7.4% and 10.7%); no
group differences emerged for the presence of other illicit
drugs at time of death.
Results from the narrative analysis showed additional
details regarding method, location, and timing of suicide for
youth in custody (Table 3). For method, 188 cases (88%)
were identified with detailed information. Most youth used
a bedsheet (56.4%) or type of clothing (13.8%) as the
means of suicide by hanging, strangulation, or suffocation.
The most common clothing articles were shirts, shoelaces,
and pants. Other means of suicide by hanging, strangula-
tion, or suffocation (4.8%) included some type of cord or
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 SUICIDE AMONG INCARCERATED YOUTH

TABLE 1 Individual Characteristics and Precipitating Circumstances of Suicide in Youth 10- to 24-Years-Old Not in Custody
Compared With Youth 10- to 24-Years-Old in Custody for 17 US States: 2003–2012

Youth Not in Youth in

Custody Custody
(n ¼ 9,913) (n ¼ 213) Unadjusted Adjusted
a a,b
n % n % OR 99% CI OR 99% CI
Individual characteristics
Sex
Female 1,883 19.0 24 11.3 1.00
Male 8,030 81.0 189 88.7 1.85c 1.05e3.24c 1.65 0.94e2.90
Age (y)
20e24 5,900 59.5 168 78.9 1.00
15e19 3,453 34.8 44 20.7 0.45c 0.29e0.69c 0.46c 0.30e0.71c
10e14 560 5.6 1 0.5 0.06c 0.00e0.83c 0.06c 0.00e0.81c
Race
White 7,950 80.2 144 67.6 1.00
Black 1,049 10.6 48 22.5 2.53c 1.63e3.91c 2.66c 1.71e4.16c
American Indian/Native 375 3.8 9 4.2 1.33 0.54e3.24 1.50 0.61e3.70
American
Other 539 5.4 12 5.6 1.23 0.56e2.69 1.47 0.53e2.58
Ethnicity
Non-Hispanic 9,024 91.0 186 87.3 1.00
Hispanic 889 9.0 27 12.7 1.47 0.86e2.52 1.78 1.02e3.10
Suicide method
Firearm 4,675 47.2 0 0.0
Hanging, strangulation, 3,797 38.3 206 96.7
or suffocation
Poisoning 804 8.1 2 0.9
Otherd 637 6.4 5 2.3
Time of injury leading to
deathe
12:00e5:59 am 91 1.7 2 1.5
6:00e11:59 am 1,983 37.7 44 32.8
12:00e5:59 pm 1,595 30.3 46 34.3
6:00e11:59 pm 1,594 30.3 42 31.3
Precipitating circumstances
Intimate partner problem 3,647 36.8 34 16.0 0.33c 0.20e0.53c 0.29c 0.18e0.47c
Other relationship problemf 1,990 20.1 26 12.2 0.55c 0.32e0.95c 0.75 0.43e1.30
Perpetrator of interpersonal 419 4.2 20 9.4 2.35c 1.26e4.36c 1.67 0.89e3.13
violence
Victim of interpersonal 102 1.0 3 1.4 1.37 0.30e6.27 1.93 0.41e9.00
violence
Job problem 879 8.9 3 1.4 0.15c 0.03e0.66c 0.12c 0.03e0.54c
School problem 883 8.9 2 0.9 0.10c 0.02e0.61c 0.16c 0.03e0.98c
Physical health problem 403 4.1 1 0.5 0.11 0.01e1.48 0.12 0.01e1.56
Recent crisis 3,211 32.4 86 40.4 1.41 0.98e2.03 1.44 0.99e2.08
Death of friend, family, 511 5.2 13 6.1 1.20 0.57e2.52 1.21 0.57e2.56
other
Suicide-related
circumstances
History of suicide 2,122 21.4 55 25.8 1.28 0.85e1.93 1.40 0.92e2.12
attempt
Suicide intent disclosed 3,026 30.5 41 19.2 0.54c 0.35e0.85c 0.56c 0.35e0.88c
(continued)

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RUCH et al.
TABLE 1 Continued
Youth Not in
Custody
(n ¼ 9,913)
n %
Presence of suicide note 3,069 31.0
Recent suicide of friend 365 3.7
or family member
Note: OR ¼ odds ratio.
a
Youth not in custody is the reference group for all analyses.
b
Adjusted for age, sex, race, and ethnicity.
c
Statistically significant.
d
Other suicide methods include fall, transportation-related, drowning, cut/pierce, fire/burn, and unspecified methods.
e
Time of injury leading to death was known in 5,263 cases for youth not in custody and 134 cases for youth in custody.
f
Suicide deaths related to friction or conflict with friends or family.
cloth ligature. Supplement 1 (available online) presents
accompanying brief case descriptions on suicide deaths in
which hanging, strangulation, or suffocation was the
method of suicide.
Details for location reflect the type of facility youth were
confined to at the time of the suicide incident. For 123 cases
(57.7%) with location information, 72.4% were confined in
a juvenile detention center or adult jail and 27.6% were in a
juvenile correctional facility or adult prison. Of the 57 cases
(26.8%) with information regarding time in confinement
before the suicide incident, approximately 75% were in
custody less than a week, with 33.3% in custody less than 24
hours and 43.9% in custody for 1 to 7 days (Figure 1). All
told, more than 90% of youth suicides in custodial facilities
occurred within the first 30 days, with most taking place in
pretrial juvenile detention centers or adult jails.
DISCUSSION
This study extends what is currently known about the
characteristics and precipitating circumstances of suicide in
incarcerated youth. Consistent with prior research, youth
who died of suicide were more likely to be older, white, and
male, irrespective of incarceration status.5,6,10 Youth in
custody who died of suicide were less likely to disclose their
suicide intent or leave a suicide note compared with de-
cedents not in custody. However, the percentage of youth
decedents with a history of suicide attempts did not vary
significantly between groups. Youth suicide decedents in
custody were more likely to die of hanging, suffocation, or
strangulation and less likely to report job, school, or rela-
tionship problems than decedents not incarcerated. Most
suicide deaths occurred during waking hours for all youth.
Although previous research has shown higher rates of
mental health problems in incarcerated youth compared
518 www.jaacap.org
Youth in
Custody
(n ¼ 213) Unadjusted Adjusted
a a,b
n % OR 99% CI OR 99% CI
48 22.5 0.65c 0.42e0.99c 0.74 0.48e1.15
5 2.3 0.63 0.19e2.03 0.71 0.22e2.30
with youth in the general population, findings from this
study suggest few group differences in rates of mental health
problems and mental health treatment.18-20,23,25 Of de-
cedents with a current mental health problem, a diagnosis of
depression/dysthymia was most prevalent, but incarcerated
decedents were less likely to be recognized as having been
depressed than nonincarcerated decedents. The percentage
of youth with alcohol or substance abuse problems,
including the presence of alcohol or illicit drugs at the time
of death, was smaller for youth suicide decedents in custody
compared with decedents not in custody, likely a conse-
quence of less access to alcohol and illicit substances in
custodial facilities.
Previous studies have demonstrated that suicide rates for
incarcerated youth in juvenile and adult facilities are
considerably higher than those observed in the general pop-
ulation.10,11 Results from this study show that key risk factors
for suicide—including history of suicide attempts, rates of
psychopathology, and alcohol/drug use—were not signifi-
cantly different between youth suicide decedents in custody
and those not in custody. These findings suggest that unique
aspects of these environments might be associated with an
increased risk of suicide and that the experience of incarcer-
ation deserves greater examination as a suicidal risk factor in
this boundaried population. Relevant to this latter point,
results from a select number of cases showed that most
incarcerated youth died of suicide within the first few days of
confinement and were more likely to be detained in a tem-
porary juvenile detention center or adult jail.
Researchers have proffered different explanations for
higher suicide rates in these facilities. Confinement in pre-
trial detention centers and jails could be the first incarcer-
ation experience for many young offenders.5,7 The
immediate shock of confinement and disruption to one’s
Journal of the American Academy of Child & Adolescent Psychiatry
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 SUICIDE AMONG INCARCERATED YOUTH

TABLE 2 Mental Health and Alcohol/Substance Use Characteristics in Youth 10- to 24-Years-Old Not in Custody Compared
With Youth 10- to 24-Year-Olds in Custody Who Died by Suicide in 17 US States: 2003–2012

Youth Not in Youth in

Custody Custody
(n ¼ 9,913) (n ¼ 213) Unadjusted Adjusted
a a,b
n % n % OR 99% CI OR 99% CI
Individual characteristics
Mental health characteristic
Current mental health 3,752 37.8 78 36.6 0.95 0.66e1.37 1.06 0.72e1.54
problem
Current mental health 2,689 27.1 60 28.2 1.05 0.71e1.57 1.27 0.85e1.90
treatment
History mental health 3,396 34.3 78 36.6 1.11 0.77e1.61 1.27 0.87e1.86
treatment
Current depressed mood 3,827 38.6 53 24.9 0.53c 0.35e0.80c 0.54c 0.36e0.82c
Mental health diagnoses
present in those with current
mental health problemd
Depression/dysthymia 2,585 68.9 38 48.7 0.43c 0.24e0.77c 0.43c 0.24e0.77c
Bipolar disorder 360 9.6 10 12.8 1.38 0.57e3.35 1.39 0.58e3.38
Schizophrenia 109 2.9 4 5.1 1.81 0.47e6.94 1.49 0.38e4.81
Anxiety disorder 51 1.4 3 3.8 2.91 0.61e13.23 2.92 0.60e14.13
Obsessive compulsive 16 0.4 0 0.0 — —
disorder
ADD/ADHD 138 3.7 0 0.0 — —
Other 493 13.1 23 29.5 1.38 0.30e6.40 1.41 0.33e7.11
Alcohol/drug-related
precipitating circumstances
Alcohol problem 1,141 11.5 21 9.9 0.83 0.46e1.50 0.78 0.43e1.43
Other substance abuse 1,905 19.2 36 16.9 0.84 0.52e1.35 0.86 0.53e1.40
problem
Presence of alcohol or drugs at
time of death
Alcohol
Tested 7,415 74.8 175 82.2 — —
Present (among those 2,291 30.9 13 7.4 0.18c 0.09e0.38c 0.13c 0.07e0.29c
tested)
Amphetamine
Tested 4,965 50.1 134 62.9 — —
Present (among those 226 4.6 5 3.7 0.81 0.25e2.66 0.76 0.23e2.50
tested)
Opiate
Tested 5,292 53.4 146 68.5 — —
Present (among those 555 10.5 10 6.8 0.63 0.27e1.47 0.63 0.27e1.48
tested)
Marijuana
Tested 4,089 41.2 103 48.4 — —
Present (among those 817 20.0 11 10.7 0.48 0.21e1.10 0.44 0.19e1.01
tested)
Cocaine
Tested 5,307 53.5 148 69.5 — —
Present (among those 350 6.6 4 2.7 0.39 0.11e1.46 0.33 0.09e1.23
tested)
(continued)

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RUCH et al.
TABLE 2 Continued
Youth Not in
Custody
(n ¼ 9,913)
n %
Antidepressants
Tested 4,353 43.9
Present (among those 601 13.8
tested)
Note: ADD ¼ attention-deficit disorder; ADHD ¼ attention-deficit/hyperactivity disorder; OR ¼ odds ratio.
a
Youth not in custody is the reference group for all analyses.
b
Adjusted for age, sex, race, and ethnicity.
c
Statistically significant.
d
A current mental health problem was present in 3,752 youth suicide decedents not in custody and 78 youth suicide decedents in custody.
regular life can be traumatic and increase the risk for suicidal
behavior.5-7 This might be especially true for incarcerated
youth with existing suicidal risk factors. Local detention
centers and jails also might be less likely to have intake
procedures or staff trained to identify mental health issues or
risks associated with youth suicide.5,7,21,25 The primacy of
hanging/suffocation as a means of suicide for incarcerated
youth also highlights the potential impact of successful
means restriction and argues for greater innovation and
attention to restricting access to ligatures and ligature points
in all correctional facilities.
Results from this study appear to have practical im-
plications for prevention of suicide in incarcerated youth,
most notably timely and ongoing suicide risk assessment,
the development and implementation of targeted suicide
prevention programs, and greater attention to means re-
striction and the safety of the correctional environment.
Although reported in only a limited number of cases, the
finding that more than 75% of youth decedents in cus-
tody died of suicide during the first 7 days of incarcera-
tion, compared with approximately 50% of suicide deaths
in incarcerated adults, does raise an important issue of
clinical concern.38,41 These results underscore the signif-
icance of prevention strategies that promote effective
suicide risk screening during the initial admissions process
with an emphasis on the first few hours and days of
confinement. Increased staff awareness and safety pre-
cautions concentrating on this highest-risk period for
suicide also is justified, as are efforts to minimize isolation
for incarcerated youth. Studies also have advocated for
ongoing suicide risk assessment as part of a continuum of
care until incarcerated youth are reintegrated into their
communities.39,40
Despite these reports, existing data show that 93% of
juvenile correctional facilities screen youth for suicide
520 www.jaacap.org
Youth in
Custody
(n ¼ 213) Unadjusted Adjusted
a a,b
n % OR 99% CI OR 99% CI
113 53.1 — —
16 14.2 1.03 0.51e2.08 1.27 0.62e2.62
solely at intake, with rescreening conducted only as
deemed necessary.10 Less than half (44%) of these facilities
conduct screening and assessment using mental health
professionals with at least master’s degree level education
and licensing.10 Responding to the mental health needs of
young offenders in adult facilities is even more challenging
because many adult facilities are ill-equipped to address
these concerns and lack the necessary screening and
assessment tools to identify youth mental health prob-
lems.23,25 Greater investment in comprehensive suicide
risk screening and assessment administered by qualified
mental health professionals might be justified given the
potential to better identify those at risk and decrease sui-
cide in incarcerated youth.
Findings also support the development and imple-
mentation of proactive suicide prevention programs
tailored to correctional facilities. The present study
showed fewer than 20% of youth suicide decedents in
custody shared their suicide intent with someone else.
Youth in custody also were less likely to exhibit depres-
sive symptoms before suicide, suggesting a more impor-
tant role for impulsivity in suicide in incarcerated youth
and greater difficulties in accurately assessing risk. In light
of other studies showing higher rates of mental health
issues in incarcerated youth, these findings further raise
awareness of potential screening deficiencies for mental
health conditions in this population.25,26 The ability to
express suicidal feelings also might be compromised in
correctional settings given a potentially impersonal and
threatening environment where access to mental health
services is limited. Furthermore, only 25.9% of youth
who died of suicide in custody had a history of suicide
attempts. In tandem with existing research, these findings
suggest that reactive approaches alone are likely insuffi-
cient and that correctional facilities cannot rely solely on
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 58 / Number 5 / May 2019
 SUICIDE AMONG INCARCERATED YOUTH

TABLE 3 Circumstances of Suicide in Youth 10- to 24-Years- consider distinctive risks for suicide in juvenile correc-
Old in Custody for 17 US States: 2003–2012 tional facilities and racially/culturally relevant in-
terventions for effective suicide prevention efforts in this
Suicide Methoda n %
Hanging, strangulation, or
setting. In addition, more than 90% of suicide decedents
suffocationb in custody were over the age of majority at 18 to 24 years,
Bedsheet 106 56.4 implying likely confinement in adult facilities. Suicide
Clothing 26 13.8 prevention programs in adult corrections that are appro-
Shirt 8 4.3 priate for this vulnerable transition-aged population also
Pants 6 3.2 are warranted.
Shoelaces 5 2.7 Consistent with prior research,5-7,38,41 the vast ma-
Belt 3 1.6 jority of incarcerated youth suicide deaths occurred by
Sock 2 1.1 hanging, strangulation, or suffocation using bedsheets or
Waistband underwear 2 1.1 clothing attached to different anchoring devices, such as
Jacket 1 0.5
air vents, bedposts, and window frames in youths’ cells.
Necklace 1 0.5
This raises important questions about the need for
Other 9 4.8
Cord 3 1.6
uniform safety standards that focus on suicide preven-
Cloth ligature 3 1.6 tion in correctional facilities. At a minimum, there ap-
Rope 1 0.5 pears to be wisdom in expanding the availability of
Fabric pieces 1 0.5 protected physical environments that include suicide-
Shower curtain 1 0.5 resistant cells equipped with safety bedding and
Plastic bag over head 3 1.6 clothing. Findings also validate the importance of
Poisoning enforcing safety protocols and observational policies for
Overdose of prescription drugs 2 1.1 youth on suicide precautions to lower the risk of suicide
Other for confined youth, even in the most environmentally
Leap/fall 2 1.1 sound facilities.
Razor blade 3 1.6
Minimal research exists on suicidal behavior in incar-
Locationc
cerated youth. Future studies that examine the risks and
Juvenile detention/adult jail 89 72.4
Juvenile correctional facility/ 34 27.6
precipitating circumstances associated with suicide in
adult prison confinement should be a priority. Providing empirical
Time incarcerated before injuryd support for suicide prevention programs developed specif-
0e24 h 19 33.3 ically for juvenile correctional settings is another important
1e7 d 25 43.9 area for study. One such program recognized by the NAASP
8e30 d 8 14.0 is Shield of Care.3,52 This educational intervention teaches
31e90 d 4 7.0 correctional staff specific steps of effective suicide preven-
91 de1 y 1 1.8 tion, including policy implications.52 The program further
Note: aDetails for suicide method were identified in 188 narrative
stresses communication between law enforcement personnel
reports. and staff connectedness to youth as essential elements of
b
Details for hanging, strangulation, or suffocation were identified in 181 suicide prevention for youth in custody.52 Opportunities
narrative reports of 206 designated cases.
c
Location of confinement at the time of the suicide incident was iden-
also exist to encourage studies on the adaptability of suicide
tified in 123 narrative reports. prevention programs found effective with other youth
d
Time incarcerated before suicidal injury was identified in 57 narrative populations. Sources of Strength is a school-based inter-
reports. vention supported by the National Institute of Justice (NIJ)
for youth involved with the juvenile justice system that uses
peer leaders to leverage protective factors and promote
prior suicide attempts or disclosure of suicidal intent to help-seeking behavior for decreasing youth suicide.53,54
identify youth at risk for suicide and prevent suicidal Identified by the NIJ as a promising program, further
behavior.3,5,12,13 evaluation of its effectiveness in a correctional environment
A larger proportion of black youth who died of suicide is recommended.53
were in custody, which is most likely indicative of the Additional evaluation of screening tools to detect
overall disproportionate rates of confinement for black suicide risk in youth in the criminal justice system also is
youth.51 Collectively, findings support the need to an opportunity for future research. Although many tools
Journal of the American Academy of Child & Adolescent Psychiatry www.jaacap.org 521
Volume 58 / Number 5 / May 2019
RUCH et al.
FIGURE 1 Time Incarcerated Before Suicide Incident in Youth in Custody 10- to 24-Years-Old in 17 US States: 2003–2012
30
25
32.8%
Number of Suicide Deaths
20
15
10
5
0
0-24 Hours
Note: Please note color figures are available online.
are available to screen for youth suicide risk, few have
been validated for incarcerated populations.39,40 Re-
searchers also must determine the most effective way to
administer these assessments. Sentencing youth to adult
correctional facilities raises concerns as to what specific
effect this environment might have on suicidal behavior
and merits further inquiry.
This study is not without limitations. First, NVDRS
restricted-use data are available from a limited number of states
and cannot be interpreted as nationally representative. Second,
data on precipitating circumstances of suicide were unknown
for approximately 10% of youth and these decedents were
excluded from the analyses. In addition, toxicology results for
alcohol and drugs at time of death are reported only for youth
decedents who were tested for these substances and therefore
are not generalizable to all suicide decedents. Third, we did
not have sufficient data to examine precipitating circumstances
by race/ethnicity and in important clinical subgroups.
Fourth, incident narratives from coroner/medical exam-
iner and law enforcement reports were not consistently
available. Method of suicide was unreported in approximately
12% of youth suicide decedent cases, and location was
captured in only roughly 60% of cases. The duration of
confinement leading up to the suicidal incident was found in
approximately 27% of cases, which could limit the interpre-
tation of this finding for direct clinical practice. This study
also found similar rates of psychopathology for youth in
522 www.jaacap.org
43.1%
15.5%
6.9%
1.7%
1-7 Days 8-30 Days 31-90 Days 91 Days-1 Year
custody and those not in custody; however, common di-
agnoses for incarcerated youth, such as conduct disorder and
antisocial personality disorder, were not identified, which
could contradict these results.23,25 In addition, data were not
available for potentially relevant suicidal risk factors such as
type of offense and criminal history leading up to incarcera-
tion. Fifth, although the study design included a comparison
group of youth suicide decedents not in custody, the analyses
are uncontrolled; future studies are needed to shed light on
whether specific precipitating circumstances are causal risk
factors and to identify specific characteristics of the incarcera-
tion environment that increase risk for suicide.
Study results showed similarities and differences in
characteristics and precipitating circumstances of suicide
between youth decedents in custody and decedents in the
general population, suggesting suicide prevention efforts
for incarcerated youth might require a comprehensive
array of programming that addresses the unique condi-
tions of confinement. Safety protocols for confined youth
on suicide precaution are critical, but findings also
emphasize the need for improved early suicidal risk
detection and upstream developmentally relevant preven-
tative interventions that have the potential to decrease
suicide rates for incarcerated youth. Important next steps
should include evaluation studies to support suicide pre-
vention programs designed for youth in correctional set-
tings and research that further examines the risk,
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 58 / Number 5 / May 2019

protective, and precipitating factors associated with sui-
cidal behavior in youth in custody.
Accepted August 15, 2018.
Drs. Ruch, Sheftall, Fontanella, and Bridge and Ms. Schlagbaum are with the
Research Institute at Nationwide Children’s Hospital Center for Innovation of
Pediatric Practice, Wexner Medical Center, The Ohio State University, Co-
lumbus. Dr. Campo is with the Rockefeller Neuroscience Institute, West Vir-
ginia University School of Medicine, Morgantown.
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SUICIDE AMONG INCARCERATED YOUTH
Disclosure: Drs. Ruch, Sheftall, Fontanella, Campo, Bridge, and Ms.
Schlagbaum report no biomedical financial interests or potential conflicts
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Correspondence to Donna A. Ruch, PhD, Nationwide Children’s Hospital,
Center for Innovation of Pediatric Practice, 700 Children’s Drive, 3rd Floor
FOB, Columbus, OH 43205; e-mail: Donna.Ruch@nationwidechildrens.org
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SUPPLEMENT 1
Youth Suicide Decedents in Custody—Case Examples
Victim is a 16-year-old white boy who was found inside his
jail cell hanging by a bedsheet around his neck. The victim
tied a bedsheet over bars above the door. The victim had
been arrested 2 days previously for assault. The victim had
been placed in isolation. There was no evidence of a mental
health diagnosis or treatment. The victim had never
attempted or threatened suicide.
A 19-year-old black man had been arrested the previous
evening on court remand. A deputy found the victim
hanging from a bunk bed with a bedsheet wrapped around
his neck. He was transported to the hospital, where he was
pronounced dead. The victim left several suicide notes in his
cell indicating that he was sorry for past mistakes, infor-
mation for his funeral, and that he was depressed.
The victim, a 20-year-old white woman, was incarcer-
ated in county jail for failure to appear at a hearing. She was
on a “behavior watch” because of mental health issues.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 58 / Number 5 / May 2019
SUICIDE AMONG INCARCERATED YOUTH
Another inmate saw the victim hanging in her cell with a
bedsheet threaded through the ceiling vent cover and
notified jail staff. The victim was cut down and transported
to the hospital for treatment.
A 21-year-old American Indian woman was found
hanging from a metal screen on her window, with the
waistband from her pants, approximately 12 hours after
being placed in a cell. The victim had been arrested and
booked for public intoxication and resisting arrest. The
victim was placed on a suicide watch and checked every few
minutes and found quickly.
A 20-year-old Hispanic man was found hanging and
deceased in his cell. The ligature was made from the 2
shoelaces on his tennis shoes. He had been incarcerated after
his court hearing the previous day. He was ordered to be in
a segregated jail cell and monitored every 15 to 30 minutes;
however, there was a 48-minute lapse when he hanged
himself. He was supposed to be wearing prison-issued
clothing and was not; therefore, he still had the shoelaces.
www.jaacap.org 524.e1