Self-harm and early mortality in justice-involved young people: a global systematic review Rohan Borschmann – Murdoch Childrens Research Institute Australasian Juvenile Justice Administrators (AJJA): 2nd Australasian Youth Justice Conference Brisbane; 13 September 2016

Justice-involved youth in Australia >65% of deaths in young people are due to preventable, behaviourally-driven causes => gen pop. Youth Justice System (YJS) => vulnerable +++ In 2013 on any given day, 6,300 young Australians were under YJS supervision (1/420 young people) Disproportionately male (83%) and from disadvantaged or remote locations (Indigenous youth x 17)

Health and social problems in justice-involved youth: what does the (limited) evidence tell us? Population is characterised by complex health and social problems: Self-harm, injecting drug use, mental ill-health, physical and oral health problems, externalising behaviours, HIV/AIDS risk behaviours and STIs Many of these are risk factors for early mortality (*self-harm) Despite this => very little is known about the mortality outcomes for the growing number of marginalised young people who come into contact with the YJS ever year (few rigorous studies to date)

Synthesising the evidence To inform targeted prevention strategies, it is necessary to first understand the epidemiology of mortality in specific high-risk groups (within this already high-risk cohort) On that basis: “Self-harm and early mortality in justice-involved young people: A global systematic review”

+ terms relating to rates/risk & protective factors: Search strategy Search terms relating to the population and outcome + terms relating to rates/risk & protective factors: Population terms ((e.g., (prison* or offend* or detain* or inmate*) and (juvenile* or adolescent or youth* or boy* or girl*)) AND Outcomes terms (e.g., self-harm, self-mutilat* or cutting or suicid* or mortalit* or death* or early mortality) Incidence and risk and protective factor terms (e.g., incidenc* or crude or rate* or epidemiolog* or protect* or risk*)

Inclusion & exclusion criteria To be included in the current review, each study had to satisfy the following criteria: The study had to report at least one of the following in a sample of young people (aged <25 years) with current/prior contact with the YJS: 1.) Rates of mortality (all cause); or 2.) Risk factor/s for mortality; or 3.)  Protective factor/s for mortality

Inclusion & exclusion criteria Existing systematic reviews/meta-analyses were eligible for inclusion Excluded: Narrative reviews, commentaries, purely qualitative studies book chapters, conference papers or proceedings, dissertations, magazine/newspaper articles, pamphlets, lectures and web pages Medline, PUBMED, PsycINFO, Embase, Global Health, CINCH, Applied Social Sciences Index and Abstracts (ASSIA) and SciELO Citation Index

Findings

Findings Scope too big for one review!

Findings Scope too big for one review!

Findings As such, we split it into two reviews:

Findings As such, we split it into two reviews: 1.) Self-harm in the YJS (prevalence/risk & protective factors) and 2.) Early mortality in the YJS (prevalence/risk & protective factors)

Progress to date Literature searched Full text of articles screened Eligible papers identified Data extraction complete Preliminary data only presented this morning

Risk factors (32/44 studies): Results: Self-harm 44 studies – only 12 prospective cohorts; N=45–27,000 USA (18), Australia (12), UK (4), Japan (3), Sweden, Iran, Austria, Spain, Turkey, Russia, Taiwan (1) Detention centres, justice registry data, youth probation databases Risk factors (32/44 studies): Demographic / temperament: Female, LGBT, homelessness, impulsive, ↓self- esteem, ↓coping skills, bad temper, anger management Family-based: Family drug/alcohol abuse, social worker involvement, family suicide attempts, parental mental health problems, not living with a relative Behavioural: High-risk sexual behaviour (females), other risk-taking behaviour

Protective factors (2 / 44 studies): Risk factors (cont.): Health: ADHD, personality disorder, depression/anxiety, past suicide attempt, substance use disorder, physical health problems Social: Exposure to delinquency, exposure to attempted suicide, school expulsion Criminogenic: Violent offence(s) Victimisation: Sexual abuse (childhood or adolescent), dating violence, bullied in custody (9x more likely to have suicide attempt), childhood victimisation/trauma Protective factors (2 / 44 studies): Temperament: Good coping skills, positive beliefs

Risk factors (11/15 studies): Results: Mortality 15 studies – only 4 prospective cohorts; N=118 - 380,000 USA (10), Australia (3), Canada (1), Germany (1) Detention centres, justice registry data, youth probation databases Risk factors (11/15 studies): Demographic / temperament: Male, African American (US studies), impulsive, aggressive behaviour Family-based: Low parental education, parental mental health problems, evidence of caregiver neglect

Protective factors (3/15 studies): Risk factors (cont.): Health: Evidence of cognitive deficit, mental health problems, substance use problems, injecting drug use, past suicide attempt(s) Social: Exposure to violence, gang membership (>10x hazard of homicide) Criminogenic: Greater involvement with YJS, early involvement with YJS, drug-related offences Justice system: Use of restraints and being locked into sleeping cells increased rate of suicide attempts Protective factors (3/15 studies): 1) Positive attitude; 2) ‘Partnered / completed school / working or training / stable housing; 3) Screening within 24hrs of reception: ↓suicide attempts

Many risk factors. Some are modifiable: Summary of findings Many risk factors. Some are modifiable: Substance use, gang membership, drug dealing, early detention, early screening upon reception …others are not: Gender, ethnicity, parental education / mental health

What has not been evaluated/reported? Communication impairments / verbal ability / comprehension & expression (x 0) 75% => language skills and literacy below national average Cognitive impairment / disability (x 1) Support received on transition into the community (x 0) For each of these => strong narrative about policy and practice responses Missed opportunities for screening & intervention? What support should be provided to young people? The dire consequences of custody for most

Current research 2016-19: Prof. Stuart Kinner (Griffith Uni.); NHMRC funding “Deaths in young people involved in the youth justice system: Towards evidence-based prevention” (QLD-based study) Data linkage to examine mortality outcomes of all young people who had contact with the youth justice system from 1 July 1993 to 30 June 2014 N~50,000; 622,000 person-years of observation; approx. 2,600 - 4,500 deaths.

Aims of current study: To rigorously and comprehensively examine long-term mortality outcomes in this group of vulnerable young people. To document the incidence, timing, causes, context and risk factors for preventable death in young people who have had contact with the YJS . Inform targeted prevention and policy reform by identifying key psychosocial risk factors, health morbidities, precipitating factors and health/social service contacts in those who have died.

Contact: rohan.borschmann@mcri.edu.au Thank you! Contact: rohan.borschmann@mcri.edu.au