• Include self-harm ideation, and self-harm with suicidal intent
• Increased risks associated with self-harm don’t attenuate upon discharge; The period of greatest risk is after release 

A high prevalence of self-harm, self-harm ideation, and self-harm with suicidal intent, has been identified among young people detained in the youth justice system in Sri Lanka.

These findings were made in an article on "Self-harm among young people detained in the youth justice system in Sri Lanka" which was authored by L.V. Hettiarachchi (attached to the National Institute of Mental Health's Forensic Psychiatric Unit), S.A. Kinner (attached to Australia's Murdoch Children’s Research Institute's Centre for Adolescent Health, the Melbourne University's Melbourne School of Population of Global Health's Centre for Mental Health, the Queensland University's Mater Research Institute, the Griffith University's Griffith Criminology Institute, and the Monash University's School of Public Health and Preventive Medicine), H. Tibble (attached to the Melbourne School of Population of Global Health's Centre for Mental Health) and R. Borschmann (attached to the Murdoch Children’s Research Institute's Centre for Adolescent Health, the Melbourne School of Population of Global Health's the Centre for Mental Health, England's King's College London's Institute of Psychiatry, Psychology and Neuroscience's Health Service and Population Research Department, and the Melbourne University's Psychiatry Department), and published in the International Journal of Environmental Research and Public Health, in January 2018.

Self-harm and suicidal behaviours are common in adolescence in low- and middle-income countries (LMICs) including Sri Lanka (J. Marecek's "Charting a path from data to action: A culturally sensitive intervention for adolescent self-harm in Sri Lanka", and J. Marecek and C. Senadheera's "‘I drank it to put an end to me’: Narrating girls’ suicide and self-harm in Sri Lanka"). Risk factors for self-harm include a history of adversity in childhood, mental illness (such as anxiety, depression, schizophrenia), and substance use, all of which are disproportionately prevalent in young people who come into contact with the youth justice system. Young people who cycle through the youth justice system often have life trajectories characterised by multiple disadvantage, instability, parental incarceration, abuse and neglect. Many have grown up in circumstances of socio-economic deprivation or have been placed in out-of-home care. They are a vulnerable group who, when compared to their peers with no justice contact, have elevated rates of self-harm, mental disorders, substance use, poor physical and oral health, and myriad social risk factors including academic disengagement, violent victimisation, sexually transmitted infections, and human immunodeficiency virus-acquired immunodeficiency syndrome risk-taking behaviours. As such, justice-involved young people are a vulnerable group with unique and significant psychosocial needs.

Materials and methods

Setting and participants

In the youth justice system in Sri Lanka, one option available to judges when sentencing young people (aged 12–16) convicted of any offence is to recommend rehabilitation at a certified school for a set period of three years (although many young people remain in such schools for considerably longer than this period). There are four fully functioning certified schools in Sri Lanka: two in the Western Province (Makola and Ranmuthugala), one in the Southern Province (Hikkaduwa), and one in the Central Province (Keppetipola). All certified schools are administered by the Probation and Child Care Services Department under the Social Services Ministry (V. Samaraweera's "Report on the abused child and the legal practice of Sri Lanka", and the National Monitoring Committee on the Children Charter). Young people detained in certified schools continue their formal education during this time, with many undertaking various forms of vocational training such as welding, woodwork, or sewing.

Certified schools also house young people in need of special care with no justice system involvement, such as those in need of protective custody, and victims of abuse, trafficking or other exploitation; these young people were excluded from the study. All eligible young people in these four certified schools were invited to participate in the study.

Data collection

Outcome measures

The definition of self-harm used was an act with a non-fatal outcome in which an individual deliberately initiates behaviour (such as self-cutting), or ingests an illicit drug or non-ingestible substance or object, with the intention of causing harm to themselves. Hettiarachchi et al. also included poisoning with any legal substance. The definition of suicidal ideation is passive thoughts about wanting to be dead or active thoughts about killing oneself, not accompanied by preparatory behaviour.

Procedure

All study data were collected between 1 July 2016 and 30 September 2016. 

Results

Profile of cohort members

A total of 181 young people (92.3 per cent of the 196 eligible residents at the four certified schools) participated in the study. Most participants were male, Sinhalese, and aged 16 or above (reflecting the fact that many people remain in detention for considerably longer than the recommended three months). A total of 77/43% reported a lifetime history of self-harm. More than half of all the participants had substance use histories and two thirds reported being the victim of verbal bullying. One-in-six reported childhood sexual abuse victimisation, more than one quarter reported a family history of suicide, and more than half reported experiencing self-harm ideation at some point in their lives (107/59%). The offences that cohort members were convicted of included theft (38%), truancy from school (19%), eloping (13%), selling drugs (8%) and sexual offences (4%). 

Factors associated with self-harm

Participants who had self-harmed were more likely to be female, to have been the victim of sexual abuse, to have been exposed to self-harm by one or more friends, or to be detained in the Ranmuthugala certified school (compared to Hikkaduwa). 

The most common method of self-harm reported was cutting (84%) (other methods were banging the head, poisoning, strangling, other) and the mean number of reported lifetime self-harm episodes was 10.1 (standard deviation 16, median five). More than one third of the participants who had self-harmed reported doing so for the first time since being detained in their certified school. In relation to their most recent self-harm episode, one quarter of the participants stated that they believed that they would die (19/77; 25%) and almost two thirds reported engaging in self-harm impulsively, without any prior planning (50/77; 65%). Of the 77 who reported self-harm, females were more likely than males to report cutting, poisoning, and to report that the expected outcome from their most recent self-harm episode was death (the other expected outcomes of the most recent self-harm episode included might die, and will not die). Males were more likely than females to report banging their head. The most commonly reported reasons for self-harm included anger, sadness, family problems, and frustration. Other reasons including to threaten others, to solve problems, in response to scolding, experimenting, and self-harming due to intoxication from illicit substances, were reported less frequently.

Discussion

More than two-in-five of the young people detained in certified schools had engaged in self-harm at some point in their lives (43%), and, of these, more than one third did so for the first time since being detained in a certified school. A lifetime history of self-harm was associated with being female, prior sexual abuse victimisation, prior exposure to self-harm by friends, and a lifetime history of self-harm ideation. Young people detained in the Ranmuthugala certified school were more likely than their peers in other schools to have self-harmed, likely reflecting that Ranmuthugala was the only school of the four which detained females at the time of the data collection. Of the young people with a history of self-harm, two thirds reported cutting themselves as the method of self-harm and one quarter reported self-harming with suicidal intent in relation to their most recent episode (10% of the entire sample). The orders of magnitude were higher than that observed in community samples, in which the lifetime prevalence of self-harm with suicidal intent is approximately 1%. The prevalence of self-harm was almost twice as high in females as in males (64% versus 33%). This finding may also possibly reflect the fact that females in this setting represent a particularly vulnerable subset of females from the wider community.

More than half of the participants reported experiencing self-harm ideation at some point in their lives (59%).

Almost two thirds of the participants with a history of self-harm reported having self-harmed prior to their current detention in a certified school. This finding highlights the importance of screening young people for a history of self-harm upon reception into detention. The risk of suicide deaths in juvenile detention is the lowest when young people are screened for a history of self-harm and current suicidal ideation within 24 hours of reception into detention. The finding that a history of self-harm is associated with prior exposure to self-harm by friends underscores the importance of engaging peers and exploring peer-support options in interventions designed to reduce self-harm. The high degree of impulsive self-harm reported by the participants in the sample (65% reported no planning at all and 85% reported less than three hours’ of planning) suggests that systematic preventive interventions may have more impact than targeted, clinical responses to emergent risk.

Participants reported a high prevalence of sexual abuse, bullying (physical, psychological, verbal) victimisation, and a range of parental risk factors including incarceration, substance use history, parental self-harm, family conflict, and parental abuse, highlighting the complex adversity that characterises many young people in detention. Many of these have previously been identified as adverse childhood experiences which are associated with an increased risk of self-harm and suicide in psychiatric populations and the general population of other LMICs. Adverse childhood experiences are more prevalent in justice-involved young people than in the general population, and are associated with both self-harm and violence perpetration in the general population. As such, in addition to proximal prevention efforts, there is a need for upstream efforts to reduce exposure to adversity and increase resilience, to reduce the impact of self-harm in this vulnerable population of young people. One avoidable consequence of employing a narrow conceptualisation of criminal offending in this population is that it fails to contextualise what is often a lifetime of disadvantage, trauma and neglect.

Given that self-harm in young people may be a conspicuous marker of emotional and behavioural problems that are often associated with adverse life outcomes, it seems that the increased risks associated with self-harm do not attenuate upon discharge from the youth justice system. The period of greatest risk for this population is likely to be after release from detention. There is a strong association between self-harm and reduced life expectancy.

The estimates of self-harm - in terms of both the prevalence and the strength of the associations with other variables — are likely to be conservative, as most self-harm occurs in private and is never reported. It is likely that there is a considerable under-ascertainment of mental disorder in the sample.

Conclusions

The prevalence of these behaviours was higher. Young people who were female, who had been the victim of sexual abuse, and who had been exposed to self-harm by friends were more likely to report self-harm.