Hospital-presenting self-harm and suicide among justice-involved adolescents on community-based orders: A...

To estimate the incidence and identify risk factors for hospital-presenting self-harm and suicide among justice-involved adolescents serving community-based orders in New South Wales, Australia.

We conducted a population-based retrospective cohort study of 44,887 adolescents aged 10-17 years at first proven offence who received community-based orders between 1994 and 2020. Hospital and emergency department records were linked with mortality, child protection, and justice data. Cox regression estimated hazard ratios (HRs) for self-harm, and Fine-Gray models estimated subdistribution HRs for suicide, accounting for competing risks.

Over 163,676 person-years, 1901 adolescents had a first self-harm episode (11.6 per 1000 person-years), with higher rates in females than males. Rates were higher among those with psychiatric disorders and with ≥3 types of childhood adversity. Over 168,425 person-years, 61 adolescents died by suicide (0.4 per 1000 person-years). Prior self-harm was associated with suicide (adjusted sHR 11.95, 95% CI 5.58-25.58), however, most suicides (75.4%) occurred without prior hospital-presenting self-harm.

Findings highlight the need for proactive, developmentally informed mental health screening and intervention within youth justice settings, with referral pathways that do not solely rely on prior hospital or emergency presentations for self-harm.