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. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: J Forensic Psychol Res Pract. 2022 Mar 30;24(1):48–65. doi: 10.1080/24732850.2022.2057268

Suicide Risk, Self-Injury, and Sleep: An Exploration of the Associations in a Sample of Juvenile Justice Involved Adolescents

Selby M Conrad 1,2,3,4, Margaret Webb 1,3, Katelyn Affleck 2,3, Erik Hood 1, Kathleen Kemp 1,3,5
PMCID: PMC10959508  NIHMSID: NIHMS1794811  PMID: 38525195

Abstract

Court-involved youth living in the community represent a vulnerable, yet understudied, group that is at risk for a variety of concerning outcomes including increased suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI). Additionally, sleep disruption, which has been associated with an increase in impulsive decision making, appears to be disproportionately high in this population. However, little is known about any connection between poor sleep and increased suicide risk and NSSI in a group of youth. This study explores the associations between sleep disruption, suicidal ideation, suicide attempts, and NSSI in a sample of court-involved youth in the community referred for mental health evaluation at a court based mental health clinic. Findings suggest that sleep disruption is related to NSSI in this population but not suicidal ideation and suicide attempts. Additional relationships were found between NSSI and being female, as well as having a lifetime history of trauma and marijuana use. Findings suggest that court clinics may wish to screen for sleep disruption as a risk factor for NSSI, and future studies may wish to explore improved sleep as a protective factor for CINI youth.

Keywords: Court-involved youth, non-suicidal self-injury, suicide, sleep

Over the past 20 years, the suicide rate among those aged 10–24 has been steadily increasing (1999: 7.0 per 100,000, 2018: 10.7 per 100,000; CDC WONDER, 2020). According to the most recent National Vital Statistics Reports suicide remains the second leading cause of death for this age group, constituting 19.2% of all deaths in 2017 (NCHS, National Vital Statistics System, Mortality, 2019). Antecedents to suicide have increased at similarly concerning rates. Among a nation-wide sample of high-school students (9th through 12th grade), self-reported suicidal ideation increased significantly from 2007 to 2017 (2007: 14.5% versus 2017: 17.2% seriously considered attempting suicide in the 12 months before the survey; Kann et al., 2017). Rates of self-reported suicide plans saw a similarly significant increase from 2009 to 2017 (2009: 10.9% versus 2017: 13.6%; Kann et al., 2017).

For juvenile-justice involved youth, these rates are amplified. A 2015 review examined rates of suicidal ideation and behaviors at varying levels of justice involvement (Stokes et al., 2015): lifetime suicidal ideation rates were consistently elevated, ranging from 13.9% to 36.4% (Abrantes et al., 2005; Archer et al., 2004; Bhatta et al., 2014; Rohde et al., 1997), as were lifetime suicide attempts – ranging from 11% to 26.8%. As youth progress through the justice-system, suicide risk increases (Wasserman et al., 2010). Further, risk among this population is heavily compounded. Justice-involved youth who endorse suicidal thoughts and behaviors are more likely to suffer from multiple comorbid mental health disorders including disproportionally high rates of trauma and substance use (Nolen et al., 2009; Kemp et al., 2020). Furthermore, they often lack access to mental health resources (Skowyra & Cocozza, 2007).

Growing levels of suicide risk among youth calls for serious public concern and for increased efforts to understand the underlying mechanisms behind these thoughts and behaviors. The elevated risk observed in justice-involved youth represents an important apex of this public health concern. Given the unique context of the justice-system, risk factors for suicidality cannot be assumed to associate in the same way as in the broader population. Risk factors assessed for youth in the community should be subsequently examined among justice-involved youth.

Sleep Problems and Mental Health

Sleep quality has long been considered an important pillar of good physical and mental health. Yet, concerningly, the majority of adolescents in the United States get insufficient sleep. According to the Center for Disease Control, an estimated 74.6% of youth get less than the suggested eight hours of sleep each night and trend analyses indicates a significant decrease in prevalence of youth getting enough sleep from 2007 to 2017. Of note, these sleep deficiencies also increase with age: 65.4% of 9th graders to 82.4% of 12th graders (Kann et al., 2017). Across all ages, sleep deficiencies have been found to significantly impact aspects of physical and mental health (Fitzgerald et al., 2011; Lowry et al., 2012; Owens et al., 2014; Paruthi et al., 2016)

Epidemiological studies of mental health problems in adolescents have begun to consider the effect of sleep on impaired thoughts and behaviors. Sleep problems in early childhood and early adolescence have been shown to predict mental health concerns in later adolescence (Armstrong et al., 2014; Wong et al., 2011). Specifically, links between persistent childhood sleep problems and anxiety, externalizing behaviors, and ADHD in adolescence have been found (Armstrong, et al., 2014).

A systematic review conducted by Kearns et al. (2020) focused on studies of sleep disturbance in youth and subsequent suicidality. The review for literature prior to December 2017 highlighted both the dearth of literature (only 10 studies met inclusion criteria) and the growing, though mixed, evidence that sleep problems may be a unique risk factor for suicidal thoughts and behaviors in youth. Of the 10 studies included, three studies found a significant relationship between some aspect of sleep and suicidal ideation over the broad follow-up range of one week to five years. Four studies found a significant relationship between sleep and suicide attempts over the follow-up periods of 5 to 10 years, and that general sleep problems and insomnia predicted suicide attempts over the following 6–7 years. The authors note, importantly, that due to the follow-up period used in nine of the ten studies, suicidal thoughts and behaviors were assessed in participants’ adulthood. Therefore, while findings suggest sleep disturbance in childhood may be uniquely predictive of suicide risk in adulthood, they do not allow broad conclusions to be drawn about the impact of immediate sleep disturbance on suicide risk in childhood and adolescence (Kearns et al., 2020).

The single study in the Kearns et al. (2020) review assessing immediate sleep disturbances was conducted by Bernert et al. (2017). This study examined the association between sleep and suicidal thoughts and behaviors over a one to three-week follow-up period. The authors concluded that self-reported sleep problems including difficulty falling asleep, remaining asleep, and sleep-onset variability were predictive of changes in suicidal ideation, even after controlling for baseline suicidal ideation and depressive symptoms (Bernert, et al., 2017).

The domain of immediate sleep disturbance and suicide risk has been more thoroughly assessed among adults. A systematic review conducted by Porras-Segovia et al. (2019) looked across 65 studies of various sample types including community-based adolescents and elaborated upon the mechanisms of risk. In the context of the motivational-volitional model of suicidal ideation (O’Connor & Kirtley, 2018), findings reflect that sleep disturbance may play a role in the final volitional stage of suicidal behavior, differentiating those who engage in suicidal behavior versus those who do not (Porras-Segovia et al., 2019). Specifically, the influence of poor sleep on suicidal behavior may be due to the effect of poor sleep on neurocognitive performance and subsequent decision-making as impacted by the risk/reward discrimination systems. Looking at specific types of sleep disturbances the review found insomnia to be associated with suicidal behavior in all the reviewed studies. Additionally, reductions in sleep quantity/quality, nightmares, hypersomnia, and sleep-related breathing problems were all found to be associated with suicidal behavior across various studies in the review (Porras-Segovia et al., 2019).

The effects of both distal and immediate sleep problems on mental health – in particular related to suicidal thoughts and behaviors – as well as the presence of effect across differing types of sleep problems (i.e., insomnia, sleep disturbance), suggest that sleep as a risk factor for suicide is complex. Given this, the dearth of research on distal and – even more so – immediate sleep disturbances in youth represents a significant and critical gap in the literature. Research focused understanding the associations between sleep disruption, mental health, suicidal thoughts, suicide attempts and non-suicidal self-injury (NSSI) may reveal an underutilized intervention point to help promote improved mental health in young offenders.

Sleep Problems in Juvenile-Justice Involved Youth

Studies linking sleep problems to delinquent behavior have noted the co-occurring effect of sleep deprivation on mental health symptoms such as depression and suicidality (Clinkinbeard et al., 2010; Meldrum et al., 2015); however, the association between sleep and these specific mental health concerns does not appear to have been explicitly studied among justice-involved youth. In fact, research explicitly considering sleep problems as a risk factor for any mental health concern among this group seems nonexistent. Despite this absence in the literature, one study of incarcerated adolescents (IIreland & Culpin, 2006) has examined the association between aggression and the quantity/quality of their sleep. However, the analysis focused on the ability of aggression to predict sleep problems rather than the impact of sleep problems on aggressive behaviors with findings reflecting that hostility was predictive of sleep problems and such problems increased during incarceration (Ireland & Culpin, 2006).

Impulse Control, Self-Regulation and Sleep.

Juvenile justice involved youth in the community have disproportionally high rates of impulsive behavior and difficulties with self-regulation that appear to be associated with high-risk decision-making including increase suicidal ideation, suicide attempts and NSSI (Abrams, et al., 2003; Kemp, et al., 2010; Wasserman et, 2010). In his 2014 article, Hagger describes a model of impulse control and health behavior that can provide a foundation for the current study. Based on a wealth of research related to health behaviors, the proposed a model of impulse-control states that self-control is an active and thoughtful process in which an individual can engage with the aim of resisting impulses (Baumeister, et al., 1998; Baumeister, et. al. 2007). According to this model, self-control is a finite resource. It can be stored in reserve for future situations, it can be developed overtime with practice and it can be restored through relaxation (Gailliot, et al., 2007; Mauraven, et al., 1999; Haggar, 2014). Sleep has been suggested to be one process by which the reserve of self-regulation or impulse control can be renewed (Barber, 2010).

Though untested in juvenile justice populations, this model appears applicable to the current population as it promotes development self-control and suggests that learning skills, such as how to improve quality of sleep, can support improved mood and decision making. Both factors are part of adolescent development and seem relevant to an adolescent brain which is developing the circuity to support the suppression of impulses that may lead to high-risk behaviors and mood dysregulation (Casey, 2015). Furthermore, these factors are particularly relevant to community-based court involved youth who have higher rates of behavior health concerns and suicide. However, it is unknown how sleep is associated with these factors in these youth.

Despite sparse research on the associations between sleep problems and suicidality in juvenile-justice youth, prior research indicates issues with sleeping could mediate associations between comorbid disorders. Anger and irritability have been found at enormously elevated levels among suicidal youth coming in contact with the justice system for the first time (28.3% of non-suicidal youth reported clinically significant levels of anger-irritability versus 75.9% of suicidal youth; Kemp et al., 2020). In the context of Ireland and Cuplin’s findings, the importance of assessing the connection between sleep and suicidality in the juvenile justice system is therefore underscored. Considered in tandem with associations found at the community level between suicide and sleep problems in adolescents, it seems critical that this avenue be explored.

The present study aims to illuminate associations between sleep problems, NSSI and suicidality in a justice-involved population. Data from a sample of court-involved community-based youth collected during their intake to a court-ordered mental health evaluation are examined.

Materials and Methods

Participants and Procedures

A retrospective chart review of 200 youth referred to a Northeast juvenile court mental health clinic for a non-emergency, court-ordered forensic mental health evaluation was conducted. All mental health evaluations occurred between 2014 to 2016 and were conducted by licensed mental health professionals employed by the court clinic. Evaluations included the completion of standard intake forms, standardized measures, formal interviews with youth and parents, and review of collateral materials. Evaluations resulted in formal assessment reports which were reviewed and coded for the current study. This chart review study was completed in a manner consistent with ethical guidelines and with the consent of the court clinic. The hospital’s institutional review board approved all study procedures and authorized a waiver of informed consent given the retrospective nature of the study.

Three doctoral student coders read and coded the assessment reports using a formalized coding system created for this study. Prior to coding reports independently, 20% of documents were double coded to ensure appropriate inter-rater reliability. Disagreements within the double-coding were resolved using a third coder until a consensus was reached. Final inter-rater reliability of the double-coded reports was excellent (κ =.89).

Measures

Demographics

Demographic information was collected from standard intake forms completed by a legal guardian prior to evaluation and included: child age, sex, race, and ethnicity. Additional demographic information about offense type (i.e., status or delinquent) was also collected through the chart review based on information collected from court records.

History of Suicidality and Non-Suicidal Self-Injury

History of suicidal ideation, suicide attempt, and non-suicidal self-injury (NSSI) were also formally assessed as part of the mental health evaluation. Assessment reports were reviewed and coded for the presence or absence of lifetime history of suicidal ideation, lifetime history of suicide attempt, and lifetime history of engagement in NSSI. Each category was separately coded as Yes or No.

Trauma Exposure

History of trauma exposure was determined by the presence of any of the following reported in the evaluation report: sexual abuse, emotional abuse, physical abuse, neglect, witness to domestic violence, witness to violent crime/neighborhood violence, experienced natural disaster, death of family member, other death, accident, and removal from home/group home placement. History of trauma exposure was coded Yes or No if the youth experienced at least one event.

Substance Use

Substance use information was coded from parents and youth separately. Four codes for substance use were utilized: youth report of lifetime marijuana use, youth report of lifetime alcohol use, parent report of youth lifetime marijuana use, and parent report of youth lifetime alcohol use. All categories were coded as Yes or No. Youth were coded as engaging in alcohol or marijuana use during their lifetime if at least one reporter identified use.

Youth Self-Report

The Youth Self-Report (YSR; Achenbach, 1991) is a 112 item self-report measure of current mental health and psychological functioning. The YSR has been used extensively with adolescent populations and has been used in juvenile justice settings. The YSR provides scaled scores that indicate risk or clinical significance in a variety of diagnostic areas including anxiety, depression, ADHD and oppositional behaviors.

As part of routine intake, youth were asked to complete the YSR for mental health symptoms. From this measure, depression and anxiety scores were collected. Scores on the YSR above 60 indicate at risk and those above 70 indicate clinically significant symptoms. Two dichotomous variables were created using this data: (1) depression and (2) anxiety. Scales were coded as yes (1), if a youth scored above a 60 on the scale.

Sleep Disturbance

Sleep disturbance was formally assessed as part of the mental health evaluation and included difficulty falling asleep (n=84, 74% of those with sleep disturbance), difficulty staying asleep (n=35, 35% of those with sleep disturbance), difficulty waking (n=18, 19% of those with sleep disturbance) and oversleeping (n=24, 25% of those with sleep disturbance). These variables were all included in a single variable related to sleep disturbance which was coded as Yes or No.

Statistical Analysis

Prior to conducting group comparisons, descriptive statistics were calculated for all the main study variables. For continuous demographic variables, such as age, median splits were used to create dichotomous variables to be consistent with other dichotomous or categorical demographic data. A series of independent logistic regression models were then conducted to explore bivariate associations between study variables and to compute effect size in the form on an odds ratio (OR). Bivariate analyses compared three different outcome variables [lifetime history of suicidal ideation (1 yes, n=68), lifetime history of suicide attempt (1 yes, n=10), and lifetime history of NSSI (1 yes, n= 51)] on (a) demographics (gender, age and race/ethnicity), (b) self-reported lifetime trauma, (c) self-reported lifetime marijuana use, (d) self-reported lifetime alcohol use, (e) YSR scores for depression and anxiety, (f) NSSI (for the models exploring suicidal ideation and suicide attempts) and (g) sleep disruption. Variables were simultaneously entered into SPSS version 26 and independent models for each outcome variable were run. Results of the bivariate analyses and any additional variables known in the literature to contribute to risk of each behavior (e.g., depression) were included in the models to determine prospective associations between juvenile demographics, psychiatric and substance use factors and suicidal ideation, suicide attempts and NSSI. Odds ratios were reviewed to determine the association between sleep disturbance and each outcome while controlling for alcohol use, marijuana use, and trauma exposure.

Results

Sample Characteristics

The demographic characteristics of the sample are presented in Table 1. Adolescents in our sample were primarily young (M = 14.6, SD = 1.6) and male (55%). Most adolescents self-identified as White/Non-Hispanic (51.7%), while approximately one-fifth (20.5%) self-identified as Minority/Hispanic. A large proportion of the sample (87.5%) were referred for a forensic mental health evaluation following a wayward offense (e.g., truancy, disobedient child). There were no significant differences found between these demographic variables.

Table 1.

Characteristics of the sample (N = 200)

Demographic Variables n (%) n (%) female n (%) male χ2 or t
Youth biological sex Male 230 (55)
Female 188 (45)
Age 14.58 (1.55) 14.57 (1.54) 14.58 (1.56) .04
Youth race/ethnicity White/Non-Hispanic 209 (52) 89 (49) 120 (54) 1.01
Minority/Non-Hispanic 50 (14) 27 (17) 22 (12) 1.49
Minority/Hispanic 83 (21) 42 (23) 41 (18) 0.67
Other/Did not respond 55 (14) 20 (11) 35 (16) 1.91
Original Legal Charges Wayward offense 175 (88) 83 (95) 92 (89) 3.08
Delinquent offense 16 (8) 4 (5) 12 (12) 1.81
Risk Variables
History of marijuana use 62 (15) 29 (33) 33 (31) 0.07
History of alcohol use 40 (10) 22 (25) 18 (17) 1.84
Anxiety 43 (17) 21 (23) 13 (11) 4.32*
Depression 60 (30) 34 (37) 26 (23) 4.31*
Lifetime history of trauma 131 (67) 59 (66) 72 (67) 0.02
Lifetime history of SI 68 (34) 40 (46) 28 (27) 7.60**
Lifetime history of SA 20 (10) 17 (20) 3 (3) 13.77**
Lifetime history of NSSI 51 (26) 37 (43) 14 (14) 19.72**
Lifetime history of sleep disturbance 113 (57) 80 (94) 97 (86) 3.21*
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*

p < .05;

**

p < .01

A small minority endorsed a history of marijuana (14.8%) and alcohol (9.6%) use. Within the sample, 34% had a lifetime history of suicidal ideation, 10% had a lifetime history of at least one suicide attempt, and 25.5% endorsed a lifetime history of NSSI. More than half (56.6%) reported a lifetime history of sleep disturbance. Gender differences were found between several of these variables including: anxiety (χ2=4.32, p<.05), depression (χ2=4.31, p<.05), lifetime history of suicidal ideation (χ2=7.60, p<.01), lifetime history of suicide attempts (χ2=13.77, p<.01), lifetime history of NSSI (χ2=19.72, p<.01), and lifetime history of sleep disturbance (χ2=3.21, p<.05). Girls reported significantly higher rates on all significant variables.

Descriptive Analyses

Table 2 presents the univariate risk predictors of suicidal ideation, suicide attempts, and NSSI. Significant findings are described below.

Table 2.

Univariate analyses for risk predictors of suicidality and NSSI (N = 200)

SI SA NSSI
Yes No χ 2 Yes No χ 2 Yes No χ 2
Gender (female) Yes 46.5% 53.5% 7.60** 20.0% 80.0% 13.77** 43.5% 56.5% 19.17**
No 27.2% 72.8% 3.0% 97.0% 14.1% 85.9%
Marijuana Use Yes 45.9% 54.1% 3.99* 20% 80% 7.52** 43.1% 56.9% 10.34**
No 30.9% 69.1% 6.5% 93.5% 20.2% 79.8%
Alcohol Use Yes 42.1% 57.9% 1.02 26.3% 73.7% 11.02** 41.7% 58.3% 4.89**
No 33.3% 66.7% 7.1% 92.8% 23.4% 76.6%
Trauma Exposure Yes 42.9% 57.1% 7.40** 13.7% 86.3% 3.16 31.1 % 68.9% 1.96
No 22.6% 77.4% 5.0% 95.0% 21.3% 78.7%
Anxious/Depressed Yes 66.7% 33.3% 16.35** 18.2% 81.8% 2.26 59.4% 40.7% 19.38**
No 29.5% 70.5% 9.2% 90.8% 21.1% 78.9%
Withdrawn/Depressed Yes 35.1% 64.9% 29.66** 21.4% 76.6% 9.39* 51.8% 48.2% 23.28**
No 23.5% 76.5% 6.2% 93.8% 17.2% 82.8%
NSSI Yes 76.5% 23.5% 54.54** 30.0% 70.0% 27.72** - - -
No 18.3% 81.7% 3.1% 96.9% - -
Sleep Disturbance Yes 42.2% 57.8% 3.548 22.9% 77.1% 3.412 35.8% 64.2% 14.11**
No 26.5% 73.5% 4.0% 96% 8.0% 92.0%
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*

p < .05;

**

p < .01

Gender

Being female was associated with significant increased risk of all outcomes: suicidal ideation (χ2=7.60, p<.01), suicide attempts (χ2=13.77, p<.01) and NSSI (χ2=19.17, p<.01).

Substance Use. When considering substance use, marijuana use was significantly associated with the three variables: suicidal ideation (χ2=3.99, p<.05), suicide attempts (χ2=7.52, p<.05) and NSSI (χ2=10.34, p<.05). Additionally, alcohol use was significantly associated with suicide attempts (χ2=11.02, p<.01) and NSSI (χ2=4.89, p<.01) but not suicidal ideation.

Trauma Exposure

Trauma exposure was associated with suicidal ideation (χ2=7.40, p<.01) but not suicide attempts or NSSI.

Depression

Scales related to anxious depression were associated with suicidal ideation (χ2=16.35, p<.01) and NSSI (χ2=19.38, p<.01) and scales for withdrawn depression were associated with all three outcomes: suicidal ideation (χ2=29.66, p<.01), suicide attempts (χ2=9.39, p<.05) and NSSI (χ2=23.28, p<.01).

Non-suicidal Self-Injury

NSSI was significantly associated with both suicidal ideation (χ2=54.54, p<.01) and suicide attempts (χ2=27.72, p<.01).

Sleep Disturbance

Report of sleep disturbance was associated with NSSI (χ2=14.11, p<.01) but not suicidal ideation or suicide attempts.

Logistic Regression Analyses

Logistic regression analysis was used to examine sleep disruption as a predictor of suicidal ideation, suicide attempts, and NSSI. Three models were run to explore these associations and results are presented in Table 3. All models included gender, trauma exposure, anxiety, depression, alcohol use, marijuana use, NSSI and sleep disturbance.

Table 3.

Logistic regressions (N = 200)

Predictors of Suicidal Ideation β SE β Wald χ2 p AORa 95% CI OR
Gender −0.13 0.49 0.01 0.98 0.99 0.37–2.57
Age −0.19 0.48 0.17 0.68 0.82 0.32–2.08
Race −0.21 0.48 0.02 0.96 0.98 0.21–2.55
Trauma Exposure −0.93 0.54 2.89 0.05* 0.39 0.34–1.15
Anxiety 0.18 0.74 0.06 0.81 0.84 0.19–3.61
Depression −1.36 0.58 5.37 0.02* 0.26 0.08–0.81
Alcohol Use 0.24 0.71 0.12 0.73 1.27 0.32–5.11
Marijuana Use −0.90 0.63 0.02 0.88 0.91 0.26–3.16
NSSI −2.65 0.57 20.99 0.01** 0.07 0.02–0.22
Sleep disturbance 0.70 0.54 1.65 0.19 2.01 0.69–5.85
Predictors of Suicidal Attempts
Gender 1.01 0.79 1.63 0.20 2.75 0.58–13.04
Age 0.21 0.71 0.08 0.77 1.22 0.31–4.89
Race 0.76 0.68 1.24 0.25 2.14 0.56–9.23
Trauma Exposure −1.12 0.97 1.32 0.25 0.32 0.04–2.19
Anxiety 0.23 0.90 0.06 0.79 1.25 0.21–7.33
Depression −1.13 0.86 1.97 0.16 0.32 0.06–1.56
Alcohol Use −1.11 0.83 1.76 0.18 0.33 0.65–1.69
Marijuana Use −0.53 0.78 0.46 0.49 0.59 0.12–2.72
NSSI −1.81 0.78 5.85 0.01** 0.15 0.03–0.69
Sleep disturbance −0.66 0.90 0.54 0.46 0.52 0.09–3.01
Predictors of NSSI
Gender 1.91 0.52 13.75 0.01** 6.77 2.46–18.62
Age 0.22 0.50 0.19 0.66 1.24 0.46–3.31
Race −0.81 0.45 2.98 0.08 0.42 0.16–1.12
Trauma exposure −1.01 0.59 2.90 0.50* 0.36 0.11–1.16
Anxiety −0.13 0.68 0.04 0.83 0.87 0.22–3.31
Depression −1.51 0.58 6.69 0.01** 0.22 0.07–0.69
Alcohol Use 0.81 0.68 1.42 0.23 2.25 0.59–8.60
Marijuana Use −1.41 0.62 5.04 0.02* 0.24 0.07–0.83
Sleep −1.66 0,69 7.71 0.01** 0.19 0.04–0.74
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a

AOR = adjusted odds ratio

*

p < .05;

**

p < .01

Lifetime history of suicidal ideation

The overall model fit the data well: Model χ2=58.64 (10), p<.01 and 84% of the cases were correctly classified. There was not a statistically significant effect of sleep disruption on lifetimes suicidal ideation; however, the model demonstrated a significant association between lifetime trauma exposure (AOR = 0.39; 95%CI = 0.34, 1.15; p = 0.05) depression (AOR = 0.26; 95%CI = 0.08, 0.81; p = 0.02) and NSSI (AOR = 0.07; 95%CI = 0.02, 0.22; p = 0.01) on lifetime history of suicidal ideation. No other variables in this model were significant predictors of lifetime history of suicidal ideation.

Lifetime history of suicide attempts

Overall, this model was also a good fit for the data: Model χ2=34.77 (10), p<.01 and 92% of the cases were correctly classified. This model for predicting lifetime history of suicide attempts did not have a main effect for sleep disruption. The sole predictor for lifetime suicide attempts was NSSI (AOR = 0.15; 95%CI = 0.03, 0.69; p = 0.01).

Lifetime history of Non-Suicidal Self-Injury (NSSI)

The final model run in this analysis included the same variables as the previous models with the aim of predicting lifetime history of NSSI. This model was a good fit for the data: Model χ2=52.14 (9), p<.01 and 89% of the cases were correctly classified. There was a main effect for sleep disruption in this model (AOR = 0.19; 95%CI = 0.04, 0.74; p = 0.01). Additionally, being female (AOR = 6.77; 95%CI = 2.46, 18.62; p = 0.01) having a history of lifetime trauma (AOR = 0.36; 95%CI = 0.11, 0.69; p = 0.01), endorsing a history of marijuana use (AOR = 0.24; 95%CI = 0.07, 0.83; p = 0.01) and having symptoms of depression (AOR = 0.22; 95%CI = 0.07, 0.83; p = 0.02) were all associated with increased risk for lifetime NSSI. No other variables in the model were predictive for NSSI.

Discussion

Court-involved youth in the community youth appear to be vulnerable to a variety of risk factors including increased mental health symptoms, trauma exposure, suicide risk, NSSI and substance use. Each of these trajectories have the potential to have significant negative outcomes for youth as they age. As such, early interaction, screening and intervention within the court system may represent a unique and timely moment in a youth’s trajectory that could support diversion from increased risk behaviors, including suicide.

A decrease in quality and quantity of sleep has been associated with a variety of negative outcomes including behavioral issues, mood concerns and increases in suicide and self-injury in populations across the lifespan but research related to these ideas in justice involved youth remains scant. This study adds to the literature focused on juvenile justice involved youth and documents rates of sleep disruption, suicidal ideation/suicide attempts and NSSI in a sample of youth referred for forensic mental health evaluations. Published studies have suggested that improving sleep quality for adolescents is associated with a variety of positive outcomes related to mental and physical health. For example, improved sleep has been shown to support reduction of trauma symptoms for those in trauma focused treatment (Skawinski, et al, 2019). Additionally, studies have found that targeting sleep though short-term interventions such as CBT-I have help support substance use reduction in adolescent samples (Hogue, 2014. However, few of these studies have focused on youth in the justice system. Additionally, there have been few studies that have explicitly explored the associations between disrupted sleep and engagement in risky behaviors suicide and NSSI in court involved youth in the community making this study’s findings novel and an important first step in a possibility fruitful area of intervention.

The third model in the study yielded the most novel findings that suggest that being female, having a history of trauma, having symptoms of depression, lifetime history of marijuana and a self-report of poor sleep increase risk of engagement in NSSI. This suggests that in samples of court-involved youth with identified mental health needs sleep may be an important factor to consider when assessing and treating. There is a growing body of literature related to adolescent’s quality of sleep, emotional dysregulation and increased risk of self-injury. For example, Liu, et al. (2017) found a strong association between poor quality of sleep and NSSI in a sample of high school students. Wong, et al., (2011) found that adolescents from high-risk families with parental substance use also had increased NSSI when reporting poor sleep, even when controlling for suicidal ideation and suicide attempts. Both of these studies suggest that poor sleep may be impacting emotion regulation and impulse control leading to increased events of NSSI. Studies documenting these findings in court-involved youth are limited.

Our study provides evidence that poor sleep quality is a potential risk factor for NSSI in juvenile justice populations with historically higher rates of impulsivity. This finding is especially relevant given that it persisted while controlling for previously researched risk factors for NSSI including depression, gender (being female), trauma history and substance use. Community based youth involved in the court system have been shown to have increased risk for impulsive behaviors including NSSI. Our findings suggest that sleep may be a clinically significant co-occurring factor to assess when screening youth for mental health risk factors. Of note, our study did not specifically focus on impulse control as a mediating or moderating the relationship between sleep and NSSI which may be an important factor to consider in future research. Despite this limitation, findings suggest that screening for sleep disturbance and, possibly treating poor sleep, may support improved mental health outcomes including reduced NSSI. This, in turn, may also support reductions in suicidal ideation and suicide attempts, as risk of these factors seems to be increased by engagement in NSSI.

Additionally, the model focused on NSSI yielded several other significant findings in this sample. Specifically, gender (being female), lifetime history of trauma, depression and lifetime history of marijuana use appear to be associated with increased risk for NSSI. These findings appear to echo current literature in this area: court involved youth have higher rates of trauma than non-court involved adolescents, and this appears to be especially true for girls who report even higher rates that boys (e.g., between 70–90% of court involved girls report trauma) (Zahn, et al, 2010). NSSI has been consistently reported as a behavioral symptom of trauma and may be linked to over modulation of trauma symptoms (Modrowski, et al., 2019). Additionally, symptoms of depression are often associated with NSSI for youth both in and out of the court system (Koposov, et al., 2021). Finally, substance use, specifically marijuana use, has been linked with a variety of increased risk behaviors including NSSI and risky sexual behavior, increased psychiatric symptoms, and other externalizing behaviors in court involved youth (Abram, Teplin, McClelland, & Dulcan, 2003; Wasserman, McReynold, Schwalbe, Keating, &Jones, 2010). All of the factors above have been linked with sleep disturbance. In addition to increased impulsivity, sleep disruption may therefore also place youth at increased risk for a variety of behaviors associated with negative consequences including NSSI.

Given the existing literature in this area, and the vulnerability of this population, it is surprising that an association between sleep disruption and increased suicide thoughts and behaviors was not found. In a recent study of community-based youth ages 12–18, Asarnow, et al., (2020) found that poor sleep was associated with increased risk of NSSI, suicidality and depression and the authors suggest that address sleep as a contributing factor may help reduce NSSI and suicidality. Court involved youth in the community have been demonstrated to have increased number suicide attempts versus their non-court involved counterparts and this is true for this sample as well (Abram et al., 2008; Kemp et al., 2016). Despite, the null finding related to sleep disruption and suicide attempts in this study’s sample, the literature emerging from community-based youth suggests sleep disruption may be an important area to continue to explore.

Limitations

There are some limits to this study’s findings that are worth noting. First, this is a chart review study and data were limited to what was included in each evaluation. The way in which clinicians assessed for sleep disruption may not have provided the detail needed to support the hypothesis. For example, sleep disruption may have been noted when severe or associated with other findings in the evaluation, but evaluations did not include detailed specifics of sleep disruption including initial versus episodic insomnia, difficulty staying asleep, early morning waking and number of hours of sleep per night. Future studies may wish to collect these details in a more consistent manner which may provide future research with needed specifics to determine if there are more nuanced associations between type of disrupted sleep and increase risk of suicidal thoughts and attempts.

The nature of the chart review may also limit the report of suicide thoughts and behaviors. The amount of detail that CINI youth were willing to disclose within this context is unknown and, additionally, it is possible that the way in which the reports were written may also limit information about these thoughts. Collecting this data in other ways (e.g., computer-based survey, measures) in the future may yield different results in studies of this nature.

Furthermore, it is worth noting that this sample is a mental health sample. Youth were identified by the court as needing additional mental health evaluation and support. This is a sub-set of CINI youth with increased vulnerability, impulsivity and clinical need. As such, the rates of mental health need, NSSI and sleep disruption may have been higher than in a CINI youth sample that was not flagged for mental health concerns. That said, despite the high rates of suicidal ideation, suicide attempts and NSSI in this population, this study was still able to detect differences and illustrate that sleep disruption is associated with NSSI (especially for girls) which can be useful to court clinic clinicians to make targeted recommendations to improve quality of sleep for these court-involved youths.

Future Directions

The literature on adolescent sleep patterns clearly suggests that poor quality, insufficient sleep-wake schedules are associated with increased risk for physical and mental health consequences (Adornetti, et. al. 2020). Additionally, studies suggest that re-aligning sleep-wake cycles in youth can yield a reduction in mental health symptoms including impulsivity. Studies of incarcerated adults have found that even one-session of cognitive behavior therapy focused on improving sleep has been associated with improved sleep and reductions in anxiety and depression (Randall, et. al. 2019). Future studies may wish to explore improved screening and brief-intervention with court-involved youth in the community with the aim of providing an additional tool in helping mitigate some of the risk inherent to this population related to increased impulsive decision making and specific to NSSI.

Although sleep disturbance was not a risk factor for suicidal ideation or suicide attempts in the current study, these findings may highlight the importance of assessing sleep as a potential treatment target to reduce self-harm behaviors with court-involved youth. It is unclear the extent to which court clinics are currently screening youth for sleep disruption; however, this study’s finding suggest that a structured sleep assessment and possible brief intervention may be an important factor for future studies to explore with the aim of improving mental health symptoms and reducing risk behaviors such as NSSI.

Additionally, this study supports previous literature that suggests that girls in the juvenile justice system with history of trauma may have different intervention needs that their male counterparts. The call for gender response intervention in the juvenile justice system has been on-going related to trauma and psychiatric symptoms (Zahn, et al. 2010). Future studies may wish to explore any gender differences in sleep, trauma, substance use, and self-harm with the aim of developing the most appropriate intervention for youth.

Finally, this study suggests that sleep may be an important factor to explore and treat in community-based samples of court involved youth. The literature focused on court-involved youth and sleep is scant; however, the community-based literature related to sleep is clear. Improved quality of sleep is associated with improved decision making, reduced impulsivity, improved health and well-being and may be protective against NSSI, and possibly suicidal ideation and attempts. This study is one of the first to suggest that sleep may be an important variable to study and potentially develop specific intervention around for court-involved youth. The associations between sleep disruption and NSSI behavior for court involved youth in the community may lay the groundwork for future research focused on sleep screening and targeted intervention that could potentially improve the quality of life for these youths.

Funding:

K23 MH111606 (PI: Kemp)

Footnotes

We have no conflict of interests to disclose.

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