Youth involved with the juvenile justice system die by suicide at a rate two to three times higher than youth in the general population. The risk for suicide is greatest overall for young people on probation, which is the segment of the justice system that allows youth to remain in their community (versus being in residential facilities, such as correctional institutions) while under justice supervision. Although screening for suicide risk and provision of behavioral health services is standard for youth in locked facilities, there is a lack of behavioral health screening and related services for youth on probation.
Despite the fact that eight times as many youths are under community supervision than in detention facilities, and validated tools to identify suicide behavior in these youth, many states lack standard procedures for identifying suicide risk for this subset of youth and when treatment needs are identified, few youth actually make it to treatment. Recent data from 32 counties in six states indicate that among probation youth identified with behavioral health needs, only one in five receive service referrals and fewer than one in 10 get treatment.
Katherine Elkington, PhD, Director of the Center for Behavioral Health and Youth Justice at Columbia University, is working to develop interventions to increase access to behavioral health services for young people on probation by building connections between the justice system and community-based systems of care. Dr. Elkington recently received an award of $5.5M from the National Institute of Mental Health to support the expansion of her and longtime mentor Dr. Wasserman's research, and the implementation of e-Connect-a digital clinical decision-support system to help identify and reduce risk for suicide among youth by linking at-risk young people to appropriate care.
We spoke with Dr. Elkington, Professor of Medical Clinical Psychology (in Psychiatry) at Columbia and a research scientist at the New York State Psychiatric Institute, to learn more about e-Connect and her long-term goals for the program.
What was the inspiration for e-Connect?
Historically, there have been scant resources and little training for probation officers to address the elevated suicide risk of teens in the juvenile justice system and to help them tap into behavioral health services to get the support these youth need. We drew on modern, web-based technologies, our behavioral health expertise, and decades of experience working within the justice system to develop e-Connect as a solution to help both probation officers and the at-risk teens they serve.
What are some of the reasons the suicide risk is so high among youth on probation?
Young people within the juvenile justice system are at greater risk for suicidal behavior than other youth because of increased prevalence of mood and substance use disorders, adverse childhood experiences, trauma and PTSD, and access to firearms. These factors, combined with a higher number of suicide deaths in youth involved in the justice system and greater rates of attempts, suggest that identifying and addressing suicidal behavior and related behavioral health problems is an important priority for both juvenile justice and public health sectors.
Your early work shows e-Connect to be a promising model for identifying and responding to youth at risk for suicide. How does e-Connect reduce suicide risk?
e-Connect employs digital decision support technology to assist probation officers in identifying suicide behavior and behavioral health risk, referring youth to appropriate services, and achieving cross-system linkage to community-based behavioral health system. To put it succinctly, e-Connect identifies youth in one system (juvenile justice) and gets them to treatment in another system (community-based behavioral health). To do this, it employs a systematic approach to develop local referral decisions (pathways) in partnership with local probation and behavioral health system leadership. The pathways reflect different levels of severity of suicide risk within three clinical need classifications (crisis/imminent risk; crisis/non-imminent risk; non-crisis). Based on their level of clinical/suicide risk, youth are directed to appropriate care, within pre-determined specific time frames. This means that limited behavioral health resources are deployed appropriately to help the youth who need them the most.
What increases suicide risk, and why aren't community supervision agencies consistently screening for it? Why is it important to look at youth under community supervision?
Before the COVID-19 pandemic, 18% of youth in the US juvenile justice system reported a lifetime suicide attempt, compared to 3%-9% of general population youth. Unfortunately, during the pandemic, rates of adolescent suicide have spiked among all young people. Although protocols for suicide behavior screening are provided for youth in secure juvenile justice settings, youth who remain in their homes under community supervision are frequently overlooked. This is a significant missed opportunity and is concerning given that there are almost eight times as many youth under community supervision, compared to in secure juvenile justice facilities.
The Center recently received a grant to expand e-Connect, in collaboration with University of Indiana. Why is Indiana an ideal location for e-Connect? How will the program be rolled out?
The e-Connect program proved to be a success in New York and because of that is well-positioned to be scaled-up in new geographic areas such as Indiana, where there has been a 71% increase in youth suicide deaths between 2008 and 2017. This grant will allow us to understand how to best implement e-Connect to serve more youth. Each Indiana county has a coordinator who will serve as a facilitator for e-Connect. If the scale-up strategies deployed in the proposed study result in e-Connect successfully leveraging an existing countywide network like JDAI, it will allow us to expand the program to other counties and states where suicide risk in probation youth has been overlooked.
What is the long-term vision for e-Connect?
Simply put, our big-picture goal is to save youths' lives. We hope to do this by improving partnerships between justice agencies and behavioral health providers so that they can better recognize risk for suicide and get youth the care they need to thrive. By cultivating partnerships between justice and behavioral health, we can create more collaborative, communicative approaches to better serve young people, their families, and the communities in which they live. Given the spike in youth suicide deaths, particularly among high-risk groups such as youth on probation, it is critical that e-Connect continues to expand.
