Handbook of Youth Suicide Prevention: Integrating Research into Practice 3030824640, 9783030824648

Table of contents :
Handbook of Youth Suicide Prevention
Acknowledgments
Contents
About the Editors
Contributors
Untitled
1: Introduction to the Handbook of Youth Suicide Prevention: Integrating Research into Practice
References
Part I: Research and Theory
2: Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth Suicide Research
Sociology: Theories of Societal Change and of Imitation
Social Integration and Regulation (Durkheim, 1951)
Social Imitation Theory (De Tarde, 1903)
Biology: Stress–Diathesis Model (Mann, 1998)
Psychology: Theories of the Suicidal Mind
Psychache Theory, Cubic Model of Suicide (Shneidman, 1993, 1998)
Escape Theory of Suicide (Baumeister, 1990)
Cry of Pain Model of Suicide (Pollock & Williams, 2001; Williams, 1997, 2001)
Hopelessness Theory (Beck et al., 1985, 1990) and Cognitive Model of Suicide (Wenzel & Beck, 2008)
Integrated Psychological Theories: Ideation-to-Action Frameworks
Interpersonal Theory of Suicide (Joiner, 2005)
Integrated Motivational-Volitional Model of Suicidal Behavior (O’Connor, 2011; O’Connor & Kirtley, 2018)
Three-Step Theory (Klonsky & May, 2015)
Sociocultural Perspectives: Ecological Theories of Suicidal Behaviors
Ecodevelopmental Model of Latina Suicide Attempts (Zayas et al., 2005)
Cultural Theory and Model of Suicide (Chu et al., 2010)
Relevant Developmental Models and Perspectives
Discussion
Lack of Developmental Focus
Lack of Cultural Context
Lack of Specificity and Temporal Resolution
Lack of Understanding about Chronic Course of Suicidal Thoughts and Behaviors
Future Directions
References
3: Early Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk
Childhood Maltreatment and Suicidal Behavior
Theoretical Frameworks for the Study of Maltreatment and Suicidal Behavior
Mechanisms Linking Childhood Maltreatment to Suicidal Behavior
Childhood Maltreatment, Genetics, Epigenetics, and Other Biological Systems
Child Maltreatment, Brain Structure, and Function
Childhood Maltreatment and Stress Reactivity
Childhood Maltreatment and Emotion Regulation
Childhood Maltreatment and Executive Functioning
Maltreatment and Pubertal Timing
Reproductive Considerations
Conclusion
References
4: Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework
Introduction
Cognitive Systems and Youth Suicide
Positive Valence Systems and Youth Suicide
Negative Valence Systems in Youth Suicide
Conclusion
References
5: Parental and Family History of Suicidal Behaviors and Psychopathology and Suicide-Related Risk in Youth Offspring
Parental and Family History of Suicide and Youth Suicide-Related Outcomes
Parental and Family History of Suicidal Behaviors and Youth Suicide-Related Outcomes
Parental Psychopathology and Youth Suicide-Related Outcomes
Transmission of Parental Psychopathology
Clinical Implications
Limitations and Future Directions
Conclusion
References
6: Examining the Relationship Between Suicide and Nonsuicidal Self-Injury Among Adolescents and Young Adults
Classifying and Defining Nonsuicidal Self-Injury
Prevalence, Methods, Frequency, and Functions of NSSI
NSSI as a Risk Factor for Suicide
Proposed Mechanism of Association between NSSI and Suicide
General Risk Factors for Youth NSSI
Individual Risk Factors
Demographic Factors
Previous Self-Injury
Emotion Dysregulation
Cognitive Factors
Psychopathology
Aggression
Environmental Risk Factors
Social Support and Peer NSSI
Abuse and Family Factors
Peer Victimization
Summary
Risk Factors for Underserved Populations of Youth
Black, Indigenous, and Youth of Color
Prevalence
Systemic Factors Affecting Risk
Summary
Gender and Sexual Minority Youth
Prevalence
Systemic Correlates and Risks for GSM Youth
Summary
Conclusion
References
7: Suicidal behavior and the media
History and Definitions of Terms Used to Describe Media Influences on Suicidal Behavior
Suicide Behavior, Suicide-Related Outcomes, and “13 Reasons Why”
Factors Impacting the Likelihood of Suicide Clustering and Contagion with Media Exposure to Suicide
Exposure to Suicide on Social Media and Suicidal Behavior in Youth
Implications for Media Reporting and Consuming of Suicide Stories
Future Directions for Research to Inform Suicide Prevention in Youth Given Media Depictions of Suicide
Conclusion
References
8: Understanding Suicide-Related Risk in Immigrant and Ethnic and Racial Minority Youth Through an Ecological and Developmental Context
Contemporary Models of Acculturation
Acculturation and Suicide
Demographic Proxies
Cultural Practices
Cultural Identification
Cultural Values
Findings from Studies Employing a Bidimensional Perspective
Cultural Practices
Cultural Identification
Cultural Values
Summary Remarks
Potential Mechanisms Underlying the Relationship between Acculturation and Suicide
Cultural Stress
Family Functioning and the Parent-Child Acculturation Gap
Suicide Models Compatible with an Acculturation Framework
The Way Forward: Addressing Gaps and Methodological Concerns
Mechanisms and Conceptual Concerns
Bidimensional Conceptualizations of Acculturation
Acculturation as a Developmental Process
Acculturation Within the Family Context
Acculturation, Cultural Stress, or Both?
Methodological Concerns
Effects of the Host Context and Ethnic and Racial Density
Intersectionality and Within-Group Differences
Clinical Implications
Conclusion
References
Part II: Assessment
9: Understanding Patterns of Adolescent Suicide Ideation: Implications for Risk Assessment
Introduction
What Some Theories of Suicide Suggest About Suicide Ideation
Role of Attention Bias and Engagement/Disengagement
Limitations of Current Measurement of Suicide Ideation
Suicide-Related Imagery
Suicide Ideation Trajectories
Moment-to-Moment Variability in Suicide Ideation: Data from Ecological Momentary Assessment Studies
Suicide Ideation Subtypes
Limits of Direct Inquiries About Adolescent Suicide Ideation
Clinical Implications
Conclusion
References
10: Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents
Introduction
Suicide Prediction Tools
Self-Reported Suicidal Thoughts and Behaviors
Self-Reported Risk and Protective Factors
Composite Self-Report Measures
Behavioral Measures of Suicidal Thoughts and Behaviors
Additional Considerations when Applying Explicit and Implicit Measures
Safety of Suicide Prediction Tools
The Role of Disclosure in Suicide Prediction Tools
The Cultural Context around Suicide Prediction Tools
Future Directions in Youth Suicide Risk Assessment
Conclusion
References
Part III: Specific Populations
11: Understanding Risk and Protective Factors to Improve Well-Being and Prevent Suicide Among LGBTQ Youth
Introduction
Core Theoretical Frameworks
Within-Group Differences
Risk Factors
Internalized Stigma
Coming-Out Distress
Family Rejection
LGBTQ-Based Discrimination and Victimization
LGBTQ Conversion Efforts
Community-Level Factors
Protective Factors
Positive Identity
Coping Skills
Family Support
Peer Support
Teacher Support
Positive Mentors and Connections to Non-Parental Adults
Supportive and Inclusive Schools
Supportive Policies
Evidence-Informed Efforts to Reduce LGBTQ Youth Suicide
Incorporation of LGBTQ-Affirming Principles
Gender-Affirming Care
LGBTQ-Specific Crisis Lines
Family-Based Interventions
Strategies for Safe and Supportive Schools
Conclusion and Future Directions
References
12: Suicide Among Justice-Involved Youth
Overview
Prevalence
Risk Factors
Custodial Settings
Mental Health
History of Trauma
Peer Relationships
History of Suicidal Behavior
Diversity and Risk for Suicide
LGBTQIA Youth
Female Youth
Racial and Ethnic Minority Youth
Assessment
Treatment
Prevention
Conclusion
References
13: Suicide Among American Indian/Alaska Native Populations
Who Are American Indians/Alaska Natives?
Brief History of AI/AN Peoples in the US
Cultural Worldviews, Values, and Strengths in AI/AN Populations
Coronavirus Global Pandemic
Suicide in Indian Country
Historical Trends of Suicidality Among AI/AN Peoples
Current Trends of Suicidality Among AI/AN Peoples
Social Determinants of Suicide Risk in AI/AN Populations
Socio-Historical Risk Factors for Suicide
Community Risk Factors for Suicide
Family Risk Factors for Suicide
Individual Risk Factors for Suicide
Theoretical Models and Frameworks to Understand Suicide in AI/AN Populations
Evidence-Based Treatments for Suicide Prevention and Intervention with AI/ANs
Considerations and Limitations of Evidence-Based Treatments for Suicide
Resilience and Protective Factors against Suicide Risk in AI/AN Populations
References
14: Asian American Youth Suicide: Research and Intervention
The Importance of Understanding Asian American Youth Suicide
Barriers to Mental Health Care for Asian American Youth
Risk Factors for Asian American Youth Suicide
Protective Factors against Asian American Youth Suicide
Prevention and Treatment of Asian American Youth Suicide
Conclusion
References
15: Suicidal Behaviors in Youth with Foster Care Experience
Introduction
Suicidal Behaviors of Child Welfare-Involved Youth
Transition-Age Youth
Potential Reasons for Enhanced Risk
Child Maltreatment
Mental Illness
Mental Illness and Suicidal Behavior
Mental Illness in Youth in Care
Social Support
Social Support and Suicidal Behavior
Inadequate Social Support in Youth in Care
Interpersonal-Psychological Theory of Suicidal Behavior and Youth in Foster Care
IPTS Described
IPTS Applied
Critiques
Assessment and Intervention
Conclusion
References
16: Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and Risk Factors
The Epidemiology of Latina Adolescents Suicide Attempts
Conceptual Models of Latina Adolescent Suicide Attempts
Zayas’ Ecodevelopmental Model of Latina Suicide Attempts
Gulbas’ System Dynamics Approach to Charting Suicide Risk in Latina Adolescents
Joiner’s Interpersonal–Psychological Theory of Suicide
Familial, Cultural, and Community Protective and Risk Factors for Suicide Attempts Among Latina Teens
Familial Protective and Risk Factors for Suicide Attempts Among Latinas
Cultural Protective and Risk Factors for Suicide Attempts Among Latinas
Community Protective and Risk Factors for Suicide Attempts among Latinas
Conclusion and Future Directions
References
17: Risk and Protective Factors for Suicide in Black Youth
Definition of Terms
Risk and Protective Factors
Depression
Anxiety
Trauma
Racism
Protective Factors
Hope
Ethnic Identity
Social Support
Family Support
Peer Support
Religiosity/Spirituality
Conclusion
References
Part IV: Treatment and Prevention
18: Suicide Prevention Through Community Capacity Building in Resource-Poor Areas and Low- and Middle-Income Countries (LMICs)
Introduction
Defining Terms and Chapter Focus
How Do We Define Persons at Risk for Suicide in Low-Resourced Settings?
What Role Does Poverty Play in Capacity Building Suicide Prevention for Both LMIC and Indigenous Populations?
What Suicide Risks Are Better Understood with a Cultural-Specific CBPR Approach?
What CBPR Research Methods Have Been Used to Build Capacity in Resource-Poor and LMIC Settings?
How Do CBPR Suicide Prevention Studies, to Date, Compare Between LMIC Samples and Indigenous Samples?
How Are LMIC and Indigenous Communities Empowered Through Capacity Building Suicide Prevention CBPR?
Conclusion
References
19: Psychosocial Treatments for Ethnoculturally Diverse Youth with Suicidal Thoughts and Behaviors
Psychosocial Treatments for Ethnoculturally Diverse Youth with Suicidal Thoughts and Behaviors
Top-Down: An Evidence-Based Treatment Approach
Bottom-Up: An Evidence-Based Practice Approach
State of Intervention Approaches for STBs and NSSI by Minoritized Ethnocultural Group
Hispanic/Latinx Youth
Demographics and Epidemiology of Suicidal Behavior
Evidence
Black/African American Youth
Demographics and Epidemiology of Suicidal Behavior
Evidence
Multisystemic Therapy (MST)
Attachment-Based Family Therapy (ABFT)
American Indian/Alaska Native/Indigenous Youth
Demographic Characteristics and Epidemiology
Evidence
New Hope Brief Intervention for AI Teens
Restoring the Native American Spirit
American Indian Life Skills Development Curriculum
Asian American Youth
Demographic and Epidemiology of Suicide
Evidence
Middle Eastern/North African Youth
Demographic Characteristics and Epidemiology
Discussion
Defining Cultural Adaptation and Treatment Development in Suicide Intervention Research
Envisioning the Future of Suicide Intervention Research with Minoritized Ethnocultural Groups
References
20: Training Mental Health Providers to Prevent Teen Suicide Using Evidence-Based Approaches
Risk Assessment and Safety Interventions for Suicidal Youth
Suicide Risk Assessment
Navigating Privacy with Teen Clients and Their Parents
Direct Questioning About Suicidal Ideation, Intent, and Plans
History of and Current Engagement in Self-Harming and Suicidal Behavior
Assessment of Additional Risk Factors and the Presence or Likelihood of Potential Stressors or Triggering Events
Access to Lethal Means
Youth’s Willingness and Ability to Commit to Use of a Safety Plan
Safety of the Youth’s Environment
Structured Clinical Interviews and Self-Report Measures
Safety Interventions
Critical Considerations
Training Requirements
Existing Training Initiatives
Universal Approaches to Suicide Prevention
Gatekeeper Training (GKT) Programs
Targeted Training for Behavioral Health Providers
Training in Evidence-Based Psychotherapies for Suicidal Youth
Future Directions
References
21: Preventing Youth Suicide in the School Community: Strategies for Postvention, Intervention, and Prevention
Suicide Ideation, Attempt, and Death
Preparing for the Worst, Post-Suicide Intervention (i.e., Postvention)
Purpose
Evidence
Suicide Intervention in a School-Based Setting
Suicide Risk Assessment
Responding to Students at Risk for Suicide
Suicide Safety Planning Intervention (SSPI)
How to Make a Referral from Talking to Parents/Caregivers to Connecting a Youth to Services
Reintegration to School After Hospitalization or Extended Absence
School-based Prevention Approaches to Suicide
Purpose
Structure/Programs
Suicide Awareness Curricula
General Skills Training
Screening
Gatekeeper Trainings
Peer Training
Combined Programs
Evidence
Putting It All Together
References
22: Technology-Enhanced Interventions for Youth Suicide Prevention: Implications for Research and Practice
Introduction
State of Research Literature on Technology-Enhanced Interventions
Type of Technology
Tiers of Interventions
Impact on Youth Suicidality
Limitations of Current Interventions
Social Media
Benefits: Improving Social Connection
Benefits: Improving Detection and Prevention
Increasing Suicide Risk: Normalizing Suicide
Increasing Suicide Risk: Peer Victimization
Increasing Suicide Risk: Mental Health Symptoms
Limitations of Social Media Research
Practice Elements/Considerations
Youth Access to Technology
Privacy and Confidentiality
Text Messaging
Mobile Apps and Online Interventions
Practice Considerations
Discussion
References
23: Incorporating a Trauma-Informed Approach in Youth Suicide Research
Incorporating a Trauma-Informed Approach in Youth Suicide Research
What Is Trauma?
The Trauma-Informed Approach
Our Experiences Integrating a TI Approach into Research
Bringing the Trauma-Informed Model into Youth Suicide Research
Realization of the Widespread Impact of Trauma and Awareness of the Paths for Recovery
Recognition of the Signs and Symptoms of Trauma
Integration of Knowledge about Trauma in All Procedures and Practices
Active Prevention of Re-Traumatization
Conclusion
References
24: Conclusion: The Future of Youth Suicide Prevention
Introduction
Next Steps
Concluding Remarks
References
Index

Citation preview

Regina Miranda Elizabeth L. Jeglic Editors

Handbook of Youth Suicide Prevention Integrating Research into Practice

Handbook of Youth Suicide Prevention

Regina Miranda  •  Elizabeth L. Jeglic Editors

Handbook of Youth Suicide Prevention Integrating Research into Practice

Editors Regina Miranda Hunter College City University of New York New York, NY, USA

Elizabeth L. Jeglic John Jay College of Criminal Justice City University of New York New York, NY, USA

The Graduate Center City University of New York New York, NY, USA

ISBN 978-3-030-82464-8    ISBN 978-3-030-82465-5 (eBook) https://doi.org/10.1007/978-3-030-82465-5 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to our families, whose life histories, sacrifices, and support enabled us to pursue careers as youth suicide researchers; to our children, who inspire us to pursue research that opens up opportunities for future generations; to our students, who motivate us to work to break down barriers faced by communities that have not been centered in suicidology research; and to the scholars, researchers, clinicians, and organizations working to understand, assess, and prevent suicide among youth from diverse backgrounds.

Acknowledgments

We would like to thank Kseniya Katsman for her incredible dedication and assistance in the publication of this Handbook.

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Contents

1 Introduction  to the Handbook of Youth Suicide Prevention: Integrating Research into Practice������������������������������������������������   1 Regina Miranda and Elizabeth L. Jeglic Part I Research and Theory 2 Theories  of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth Suicide Research������������   9 Carolina Hausmann-Stabile, Catherine R. Glenn, and Raksha Kandlur 3 Early  Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk����������������������������������������������������������������  31 Ana Ortin-Peralta, Sarah Myruski, Beverlin Rosario-Williams, and Mariah Xu 4 Perspectives  on the Neurobiology of Youth Suicide Within an RDoC Framework����������������������������������������������������������  59 Richard T. Liu, Anastacia Y. Kudinova, Aliona Tsypes, and Shayna M. Cheek 5 Parental  and Family History of Suicidal Behaviors and Psychopathology and Suicide-­Related Risk in Youth Offspring������������������������������������������������������������������������������������������  75 Rhonda C. Boyd, Lillian Polanco-Roman, and Michelle Hernandez 6 Examining  the Relationship Between Suicide and Nonsuicidal Self-Injury Among Adolescents and Young Adults ����������������������������������������������������������������������������  87 Joshua J. DeSon, Nathan J. Lowry, Colleen M. Jacobson, and Margaret S. Andover 7 Suicidal  behavior and the media���������������������������������������������������� 105 Megan Chesin, Elisheva Adler, and Michelle Feinberg 8 Understanding  Suicide-Related Risk in Immigrant and Ethnic and Racial Minority Youth Through an Ecological and Developmental Context������������������������������������ 115 Alan Meca, Lillian Polanco-Roman, Isis Cowan, and Audris Jimenez ix

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Part II Assessment 9 Understanding  Patterns of Adolescent Suicide Ideation: Implications for Risk Assessment �������������������������������������������������� 139 Regina Miranda, Ana Ortin-Peralta, Beverlin Rosario-Williams, Tara Flynn Kelly, Natalia Macrynikola, and Sarah Sullivan 10 Using  Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents ������������������������������������������ 159 Katherine M. Tezanos, Kerri-Anne Bell, and Christine B. Cha Part III  Specific Populations 11 Understanding  Risk and Protective Factors to Improve Well-Being and Prevent Suicide Among LGBTQ Youth�������������� 177 Amy E. Green, Lindsay A. Taliaferro, and Myeshia N. Price 12 Suicide Among Justice-Involved Youth������������������������������������������ 195 Kseniya Katsman and Elizabeth L. Jeglic 13 Suicide  Among American Indian/Alaska Native Populations������ 207 Ashley B. Cole, Cassidy M. Armstrong, Sarah RhoadesKerswill, Susanna V. Lopez, and Jessica Elm 14 Asian  American Youth Suicide: Research and Intervention�������� 229 Elizabeth A. Yu and Edward C. Chang 15 Suicidal  Behaviors in Youth with Foster Care Experience���������� 241 Colleen C. Katz, Danielle R. Busby, and Eden V. Wall 16 Latina  Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and Risk Factors�������������� 261 Carolina Hausmann-Stabile and Lauren E. Gulbas 17 Risk  and Protective Factors for Suicide in Black Youth�������������� 279 Sherry Davis Molock, Makiko Watanabe, Ariel P. Smith, Amrisha Prakash, and David W. Hollingsworth Part IV Treatment and Prevention 18 Suicide  Prevention Through Community Capacity Building in Resource-Poor Areas and Lowand Middle-Income Countries (LMICs)���������������������������������������� 297 Henry C. Peterson and Ellen-ge Denton 19 Psychosocial  Treatments for Ethnoculturally Diverse Youth with Suicidal Thoughts and Behaviors ������������������������������ 315 Yovanska Duarté-Vélez, Carolina Vélez-Grau, and Kiara Álvarez

Contents

Contents

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20 Training  Mental Health Providers to Prevent Teen Suicide Using Evidence-Based Approaches ���������������������������������� 349 Stephanie Clarke, Abigail Ross, Claudia Avina, Lauren Allerhand, and Michele Berk 21 Preventing  Youth Suicide in the School Community: Strategies for Postvention, Intervention, and Prevention������������ 371 Michelle Scott, Jonathan B. Singer, and Jennifer Hughes 22 Technology-Enhanced  Interventions for Youth Suicide Prevention: Implications for Research and Practice�������������������� 391 Hannah S. Szlyk, Tanya Singh, and Jazmin A. Reyes-Portillo 23 I ncorporating a Trauma-Informed Approach in Youth Suicide Research �������������������������������������������������������������� 409 Yanet Quijada Inostroza and Carolina Hausmann-Stabile 24 Conclusion:  The Future of Youth Suicide Prevention������������������ 423 Elizabeth L. Jeglic and Regina Miranda Index��������������������������������������������������������������������������������������������������������  431

About the Editors

Regina  Miranda, Ph.D.  is a Professor of Psychology at Hunter College and The Graduate Center, City University of New York, and Director and founding member of the Youth Suicide Research Consortium. She received her doctorate in Clinical Psychology from New York University and completed a postdoctoral fellowship at Columbia University Medical Center under the mentorship of Dr. David Shaffer, where she specialized in the study of youth suicide ideation. Dr. Miranda’s research focuses on understanding why young people think about and attempt suicide, characteristics of adolescent suicide ideation that may inform risk of future suicide attempts, the interplay between culture and cognition in conferring and/or protecting against suicide risk, and how to modify the cognitions that give rise to suicidal thoughts and behavior. She has received grants from the National Institutes of Health and the Substance Abuse and Mental Health Services Administration. She has published more than 70 peer-reviewed articles and book chapters focused on youth suicidal behavior. Elizabeth  L.  Jeglic, Ph.D.  is a Professor of Psychology at John Jay College in New  York and a founding member of the Youth Suicide Research Consortium. She received her doctorate in clinical psychology from Binghamton University and completed a postdoctoral fellowship at the University of Pennsylvania under the mentorship of Dr. Aaron T. Beck where she specialized in the assessment and treatment of suicidal behavior. Dr. Jeglic’s research interests are primarily focused on issues broadly related to forensic populations and suicide risk assessment. She has received grants from the National Institute of Justice and the American Foundation for Suicide Prevention to fund her research. Dr. Jeglic

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has published more than 125 peer-reviewed articles and book chapters focused on suicidal behavior, culture, and individuals involved in the criminal justice system. She is the co-editor of Sexual Abuse Evidence Based Policy and Prevention (Springer, 2016) and New Frontiers in Offender Treatment (Springer, 2018), and co-­author of Protecting your Child from Sexual Abuse (Skyhorse, 2018).

About the Editors

Contributors

Elisheva  Adler Department of Psychology, William Paterson University, Wayne, NJ, USA Lauren Allerhand  Child Mind Institute, New York, NY, USA Kiara  Álvarez Disparities Research Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Margaret  S.  Andover Department of Psychology, Fordham University, Bronx, NY, USA Cassidy  M.  Armstrong Department of Psychology, College of Arts and Sciences, Oklahoma State University, Stillwater, OK, USA Claudia Avina  David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA Kerri-Anne  Bell Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA Michele Berk  Stanford University, Stanford, CA, USA Rhonda  C.  Boyd Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, USA Danielle R. Busby  Baylor College of Medicine, Houston, TX, USA Christine  B.  Cha Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA Edward C. Chang  University of Michigan, Ann Arbor, MI, USA Shayna  M.  Cheek Department of Psychology and Neuroscience, Duke University, Durham, NC, USA Megan  Chesin Department of Psychology, William Paterson University, Wayne, NJ, USA Stephanie Clarke  Stanford University School of Medicine, Stanford, CA, USA

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Ashley  B.  Cole  Department of Psychology, College of Arts and Sciences, Oklahoma State University, Stillwater, OK, USA Isis Cowan  Old Dominion University, Norfolk, VA, USA Ellen-ge  Denton College of Staten Island, City University of New York, Staten Island, NY, USA Joshua  J.  DeSon  Department of Psychology, Fordham University, Bronx, NY, USA Yovanska  Duarté-Vélez Department of Psychiatry and Human Behavior, Emma Pendleton Bradley Hospital and Brown University, Providence, RI, USA Jessica  Elm Bloomberg School of Public Health, Center for American Indian Health, Johns Hopkins University, Baltimore, MD, USA Michelle Feinberg  Department of Psychology, William Paterson University, Wayne, NJ, USA Catherine R. Glenn  Department of Psychology, Old Dominion University, Norfolk, VA, USA Amy E. Green  The Trevor Project, West Hollywood, CA, USA Lauren E. Gulbas  Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA Carolina  Hausmann-Stabile  Graduate School of Social Work and Social Research, Bryn Mawr College, Bryn Mawr, PA, USA Michelle Hernandez  Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, NY, USA David  W.  Hollingsworth Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL, USA Jennifer Hughes  UT Southwestern Medical Center, Center for Depression Research and Clinical Care, Dallas, TX, USA Yanet  Quijada  Inostroza Facultad de Psicología, Universidad San Sebastián, Concepción, Chile Colleen  M.  Jacobson Department of Psychology, Iona College, New Rochelle, NY, USA Elizabeth L. Jeglic  John Jay College of Criminal Justice, City University of New York, New York, NY, USA Audris  Jimenez  John Jay College of Criminal Justice, City University of New York, New York, NY, USA Raksha  Kandlur Department of Psychology, Old Dominion University, Norfolk, VA, USA Kseniya Katsman  Fordham University, New York, NY, USA

Contributors

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Contributors

Colleen C. Katz  Silberman School of Social Work, Hunter College, CUNY, New York, NY, USA Tara Flynn Kelly  Hunter College, City University of New York, New York City, NY, USA Harvard University, Cambridge, MA, USA Anastacia  Y.  Kudinova Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA Richard T. Liu  Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA Susanna V. Lopez  Department of Psychology, College of Arts and Sciences, Oklahoma State University, Stillwater, OK, USA Nathan J. Lowry  Department of Psychology, Iona College, New Rochelle, NY, USA Natalia  Macrynikola  Hunter College, City University of New York, New York City, NY, USA The Graduate Center of the City University of New York, New York City, NY, USA Alan Meca  The University of Texas at San Antonio, San Antonio, TX, USA Regina Miranda  Hunter College, City University of New York, New York City, NY, USA The Graduate Center of the City University of New York, New York City, NY, USA Sherry  Davis  Molock Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA Sarah  Myruski Department of Psychology, The Pennsylvania State University, State College, PA, USA Ana  Ortin-Peralta Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA Department of Psychology, Hunter College, City University of New York, New York City, NY, USA Henry C. Peterson  City College, City University of New York, New York City, NY, USA Lillian  Polanco-Roman  Department of Psychology, The New School for Social Research, New York, NY, USA Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, NY, USA Amrisha  Prakash Counseling and Psychological Services, University of San Francisco, San Francisco, CA, USA Myeshia N. Price  The Trevor Project, West Hollywood, CA, USA

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Jazmin  A.  Reyes-Portillo Psychology Department, Montclair State University, Montclair, NJ, USA Sarah  Rhoades-Kerswill A Tribal Mental Health Clinic, Norman, OK, USA Beverlin  Rosario-Williams Department of Psychology, Hunter College, City University of New York, New York City, NY, USA The Graduate Center of the City University of New York, New York City, NY, USA Abigail Ross  Fordham University School of Social Service, New York, NY, USA Michelle  Scott SRF Suicide Prevention Research and Training Project, School of Social Work, Monmouth University, West Long Branch, NJ, USA Jonathan B. Singer  Loyola University Chicago, Chicago, IL, USA Tanya Singh  Psychology Department, Montclair State University, Montclair, NJ, USA Ariel  P.  Smith Department of Psychology, Lone Star Circle of Care at University of Houston, University of Houston, Houston, TX, USA Sarah Sullivan  The Graduate Center of the City University of New York, New York City, NY, USA Icahn School of Medicine at Mount Sinai, New York City, NY, USA Hannah S. Szlyk  Rutgers, School of Social Work, The State University of New Jersey, New Brunswick, NJ, USA Lindsay A. Taliaferro  University of Central Florida, Orlando, FL, USA Katherine M. Tezanos  Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA Aliona  Tsypes Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA Carolina Vélez-Grau  Silver School of Social Work and McSilver Institute for Poverty Policy and Research, New York University, New York, NY, USA Eden  V.  Wall  Silberman School of Social Work, Hunter College, CUNY, New York, NY, USA Makiko  Watanabe Massachusetts General Hospital/Harvard Medical, Boston, MA, USA Mariah Xu  School of Nursing, Columbia University, New York, NY, USA Elizabeth A. Yu  University of Michigan, Ann Arbor, MI, USA

Contributors

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Introduction to the Handbook of Youth Suicide Prevention: Integrating Research into Practice Regina Miranda and Elizabeth L. Jeglic

Suicide is among the top three leading causes of death among 15–29-year olds in the United States (US) and around the world (Centers for Disease Control and Prevention, 2019; World Health Organization, 2019). Around the time that we were beginning our postdoctoral careers, youth suicides had just begun to show substantial increases in the US after some years of decline. For instance, between 2003 and 2004, suicide rates among 10–24-year olds had increased by about 8%, following an overall decrease of about 28.5% that had occurred between 1990 and 2003 (Bossarte & Caine, 2008; Lubell et  al., 2007). The US Food and Drug Administration had issued a “black box” warning against the use of antidepressants in children following controversy over whether they might lead to increased risk of suicidal thoughts and behaviors (Hamad et  al., 2006; U.S. Food and Drug Administration, 2004). At the same time, national efforts to implement universal screening (Hogan, 2003) encountered resistance due to concerns that over-identification R. Miranda () Hunter College, City University of New York, New York, NY, USA The Graduate Center, City University of New York, New York, NY, USA e-mail: [email protected] E. L. Jeglic John Jay College of Criminal Justice, City University of New York, New York, NY, USA e-mail: [email protected]

and labeling of children as at-risk would also lead to their overmedication (Vedantam, 2006). Until about 20  years ago, youth suicide research had primarily been focusing on studying sociodemographic, psychosocial, and clinical risk factors (Bridge et al., 2006). However, findings that one of the highest risk periods for suicide tended to be during the weeks following discharge from clinical care (Qin & Nordentoft, 2005) led to concerns that those at highest risk of suicide death would be unlikely to disclose their suicidal thoughts (Busch et al., 2003; Horesh & Apter, 2006). Thus, the field began to move in the direction of looking for alternative ways to identify youth at risk without the need for direct inquiries about suicide ideation and attempts. This included the development and testing of indirect measures, such as the Implicit Association Test (Nock & Banaji, 2007), and a focus on genetic and neurobiological markers (Jollant et al., 2011; Lin & Tsai, 2004), with the hope that these would improve suicide risk assessments. The last 15 years also saw the advent of new psychological models of suicide (e.g., Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011; O’Connor & Kirtley, 2018; Van Orden et  al., 2010) that led to more research seeking to understand the transition from suicidal thoughts to suicidal behaviors (May & Klonsky, 2016; Nock et al., 2016). We have known for many years that suicidal thoughts and behaviors tend to peak during

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_1

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a­dolescence (Nock et  al., 2008). We have also known that in adulthood, more people think about and attempt suicide between the ages of 18 and 25 than they do in older adulthood (Substance Abuse and Mental Health Services Administration, 2020). What has received less attention is that the period of risk of suicide death is different for non-Hispanic White compared to Asian, Black, Hispanic/Latinx, and Indigenous/ American Indian/Alaska Native communities in the United States. For non-Hispanic White individuals, the highest risk period for suicide death has tended to be in older age, and within the past decade, between the ages of 45 and 54-years old. However, for other racial and ethnic groups for which data are available, risk of suicide tends to be highest in youth, particularly during the early-­ to-­mid-twenties (Centers for Disease Control and Prevention, 2020). Stated differently, Black, Indigenous, and People of Color (BIPOC) groups in the US (which include American Indian/ Alaska Native, Asian American/Pacific Islander, Black, and Hispanic/Latinx individuals) who think about, attempt, and die by suicide more often do so when they are young than when they are older. In contrast, non-Hispanic White individuals more often think about and attempt suicide when they are young but tend to more often die by suicide when they are older. Recent studies have also highlighted racial disparities in suicide risk among children, with Black youth, ages 5–12, having higher suicide rates than non-­ Hispanic White youth in the same age group (Bridge et  al., 2018), and with increases in suicide attempts among Black high school students between 1991 and 2017 (Lindsey et  al., 2019). Furthermore, Indigenous youth consistently have the highest suicide rates of all racial and ethnic groups in the US (Centers for Disease Control and Prevention, 2020). In 2019, the first year that saw a decrease in the overall youth suicide rate since the continued upward trend that began in 2004, further analysis of the data by race and ethnicity suggested that among 15–24-year olds, that decrease in suicide rates was among non-Hispanic White and American Indian/Alaska Native youth, with increases occurring for Black and Asian or Pacific

R. Miranda and E. L. Jeglic

Islander youth. Despite the observed decrease, the highest youth suicide rate remains among American Indian/Alaska Native youth, followed by non-Hispanic White youth (Ramchand et al., 2021). Until recently, rates of suicide ideation and attempts were found to be higher among Hispanic/Latina high school students than among their White and Black counterparts, prompting the development of conceptual models (e.g., Zayas et  al., 2005) and research to understand why Latina youth attempt suicide (see Chap. 16 in this handbook, for a review). However, historically, there has been a dearth of research that has focused on understanding culturally specific risk factors for suicidal behavior. Youth is also a period of particularly high risk of suicide ideation, suicide attempts, and suicide deaths among sexual and gender minorities, with national surveys suggesting even higher risk of suicide ideation and attempts among BIPOC sexual and gender minoritized youth (The Trevor Project, 2020, 2021). A recent estimate suggests that the 12-month prevalence of suicide ideation is about 47% among lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) 13–18-­ year olds, while the 12-month prevalence of suicide attempts is about 19–23% in this age group (The Trevor Project, 2021; Ivey-­ Stephenson et al., 2020), both of which are about three times higher than their straight cisgender peers (15% and 6%, respectively). Despite these disparities, along with the increasing diversity of the US youth population (Frey, 2019), some of the most popular theories of suicide, such as the Interpersonal Theory (Joiner, 2005), and accompanying research on those theories (Chu et al., 2017), have tended to give focus primarily on White cisgender adults. Even conceptual models focusing on intersectionality have used such theories as a starting framework (Opara et al., 2020). (This latter point is made as an observation, rather than a criticism). It should be noted that there are models that consider sociocultural context and development (see Chap. 2 of this handbook, for a review). Nevertheless, a meta-analysis by Cha and colleagues noted not only a limited reporting of demographic characteristics such as race,

1  Introduction to the Handbook of Youth Suicide Prevention: Integrating Research into Practice

e­thnicity, and sexual orientation in suiciderelated studies, but that over 70% of longitudinal studies in which data on race and/or ethnicity were available were conducted with primarily White populations (Cha et al., 2018). In a recent letter to the editor of a major suicide journal, Polanco-Roman and Miranda (2021) outlined systemic barriers that have impeded suicide research with BIPOC youth, including difficulties related to sampling, lack of available resources, an undervaluing of research designs and topics, and limited opportunities for publication, which affect opportunities for funding. The launch of the Youth Suicide Research Consortium in January of 2019 was an attempt to address and begin to break down these barriers that limit the study of and funding for youth suicide research with diverse populations and by diverse groups of researchers. As per our mission statement, “We are an interdisciplinary network of researchers dedicated to the study of youth suicidal behavior among diverse populations (i.e., diversity based on race, ethnicity, socioeconomic status, gender, sexual orientation, and ability), with an emphasis on understanding and decreasing disparities.” Using our collective expertise, our aim was to improve research on the understanding, assessment, treatment, and prevention of youth suicidal behavior, increase research on youth suicidal behavior in underrepresented populations, and advance the careers of researchers from a variety of backgrounds and disciplines. This Handbook is a part of a larger effort to carry out this mission by helping to increase the diversity of research on youth suicide and the diversity of the investigators conducting that research. Each chapter in this handbook is written by members of the Youth Suicide Research Consortium or our external advisory committee, many of whom were writing together for the first time, along with their colleagues. The first section of the Handbook provides an overview of existing theories of suicidal behavior, developmental and neurobiological pathways, familial risk for suicidal behavior, the relationship between suicide and non-suicidal selfinjury, media influences on youth suicide risk,

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and the unique risks faced by members of racial and ethnic minoritized groups. The second section of the Handbook focuses on the assessment of adolescent suicide risk, including the importance of understanding suicide ideation, and the use of explicit and implicit measures to predict adolescent suicidal behavior. The third section of the Handbook focuses on suicidal behavior among specific populations, including lesbian, gay, bisexual, and transgender youth, justiceinvolved youth, American Indian/Alaska Native/Indigenous populations, Asian American youth, youth in the foster care system, Latina adolescents, and Black/African-American youth. The final section of the Handbook focuses on treatment and prevention. It includes an overview of suicide prevention through community capacity building in low- and middleincome counties, which account for over three-fourths of worldwide suicides (World Health Organization, 2019) but are underrepresented in suicide research, overall. The section proceeds with chapters on tailoring interventions for diverse ethnocultural youth at risk for suicidal behavior, how to train mental health providers using evidence-based approaches, and suicide prevention in schools. This section concludes with a chapter on technology-­ enhanced interventions for youth suicidal behavior. This Handbook is a starting point for bringing together researchers and research on diverse populations of youth into one text, but it is by no means comprehensive. There are populations (e.g., rural youth, youth of differing abilities) and methods (e.g., computational, network analysis) not represented in this text and that will hopefully be included in future editions of this handbook. However, our hope is that by putting together this handbook, we are starting to change the conversation and challenge the traditional way that we have looked at the problem of youth suicide. We believe that by bringing together researchers from so many diverse backgrounds, that this Handbook represents a resource and springboard for the future of youth suicide research and treatment.

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References Bossarte, R. M., & Caine, E. D. (2008). Increase in youth suicide rates 2004. Injury Prevention, 14(1), 2–3. https://doi.org/10.1136/ip.2007.017772 Bridge, J.  A., Goldstein, T.  R., & Brent, D.  A. (2006). Adolescent suicide and suicidal behavior. The Journal of Child Psychology and Psychiatry, 47(3–4), 372–394. https://doi.org/10.1111/j.1469-­7610.2006.01615.x Bridge, J. A., Horowitz, L. M., Fontanella, C. A., Sheftall, A. H., Greenhouse, J., Kelleher, K. J., & Campo, J. V. (2018). Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatrics, 172(7), 697–699. https://doi.org/10.1001/ jamapediatrics.2018.0399 Busch, K. A., Fawcett, J., & Jacobs, D. G. (2003). Clinical correlates of inpatient suicide. Journal of Clinical Psychiatry, 64(1), 14–19. https://doi.org/10.4088/jcp. v64n0105 Centers for Disease Control and Prevention. (2019). 10 leading causes of death, United States, 2001–2019, both sexes, ages 15–29, all races. Retrieved from https://www.cdc.gov/injury/wisqars/LeadingCauses. html Centers for Disease Control and Prevention. (2020). WISQARS fatal injury reports, National, Regional, and State, 1981–2019. Retrieved from http://www. cdc.gov/injury/wisqars/fatal_injury_reports.html Cha, C.  B., Tezanos, K.  M., Peros, O.  M., Ng, M.  Y., Ribeiro, J. D., Nock, M. K., & Franklin, J. C. (2018). Accounting for diversity in suicide research: Sampling and sample reporting practices in the United States. Suicide and Life-threatening Behavior, 48(2), 131– 139. https://doi.org/10.1111/sltb.12344 Chu, C., Buchanan-Schmidt, J. M., Stanley, I. H., Hom, M. A., Hagan, C. R., Rogers, M. L., Podlogar, M. C., Chiurliza, B., Ringer, F. B., Michaels, M. S., Patros, C. H. G., & Joiner, J. E. (2017). The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. Psychological Bulletin, 143(12), 1313–1345. https://doi.org/10.1037/ bul0000123 Frey, W. H. (2019). Less than half of US children under 15 are white, census shows. Brookings Institution. Retrieved from https://www.brookings.edu/research/ less-­t han-­h alf-­o f-­u s-­c hildren-­u nder-­1 5-­a re-­w hite-­ census-­shows/ Hamad, T.  A., Laughren, T., & Racoosin, J. (2006). Suicidality in pediatric patients treated with antidepressant drugs. Archives of General Psychiatry, 63(3), 332–339. https://doi.org/10.1001/archpsyc.63.3.332 Hogan, M.  F. (2003). The President’s New Freedom Commission: Recommendations to transform mental health care in America. Psychiatric Services, 54(11), 1467–1474. https://doi.org/10.1176/appi. ps.54.11.1467 Horesh, N., & Apter, A. (2006). Self-disclosure, depression, anxiety, and suicidal behavior in adolescent psy-

R. Miranda and E. L. Jeglic chiatric inpatients. Crisis, 27(2), 66–71. https://doi. org/10.1027/0227-­5910.27.2.66 Ivey-Stephenson, A. Z., Demisse, Z., Crosby, A. E., Stone, D. M., Gaylor, E., Wilkins, N., Lowry, R., & Brown, M. (2020). Suicidal ideation and behaviors among high school students—Youth Risk Behavior Survey, United States, 2019. MMWR Supplements, 69(1), 47–55. https://doi.org/10.15585/mmwr.su6901a6 Joiner, T. (2005). Why people die by suicide. Harvard University Press. Jollant, F., Lawrence, N.  L., Olie, E., Guillaume, S., & Courtet, P. (2011). The suicidal mind and brain: A review of neuropsychological and neuroimaging studies. World Journal of Biological Psychiatry, 12(5), 319–339. https://doi.org/10.3109/15622975.2011.55 6200 Klonsky, E.  D., & May, A. (2015). The Three-Step Theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114–129. https://doi. org/10.1521/ijct.2015.8.2.114 Lin, P.-Y., & Tsai, G. (2004). Association between serotonin transporter gene promoter polymorphism and suicide: Results of a meta-analysis. Biological Psychiatry, 55(10), 1023–1030. https://doi. org/10.1016/j.biopsych.2004.02.006 Lindsey, M. A., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of suicidal behaviors among high school students in the United States: 1991–2017. Pediatrics, 144(5), Article e20191187. https://doi.org/10.1542/ peds.2019-­1187 Lubell, K. M., Kegler, S. R., Crosby, A. E., & Karch, D. (2007). Suicide trends among youths and young adult aged 10-24 years – United States, 1990–2004. MMWR Weekly, 56(35), 905–908. Retrieved from https://www. cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm May, A. M., & Klonsky, E. D. (2016). What distinguishes suicide attempters from suicide ideators? A meta-­ analysis of potential factors. Clinical Psychology: Science and Practice, 23(1), 5–20. https://doi. org/10.1111/cpsp.12136 Nock, M. K., & Banaji, M. R. (2007). Prediction of suicide ideation and attempts among adolescents using a brief performance-based test. Journal of Consulting and Clinical Psychology, 75(5), 707–715. https://doi. org/10.1037/0022-­006X.75.5.707 Nock, M.  K., Borges, G., Bromet, E.  J., Cha, C.  B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133–154. https://doi.org/10.1093/epirev/mxn002 Nock, M. K., Kessler, R. C., & Franklin, J. C. (2016). Risk factors for suicide ideation differ from those for the transition to suicide attempt: The importance of creativity, rigor, and urgency in suicide research. Clinical Psychology: Science and Practice, 23(1), 31–34. https://doi.org/10.1111/cpsp.12133 O’Connor, R.  C. (2011). The integrated motivational-­ volitional model of suicidal behavior. Crisis: The Journal of Crisis Intervention and Suicide Prevention,

1  Introduction to the Handbook of Youth Suicide Prevention: Integrating Research into Practice 32(6), 295–298. https://doi.org/10.1027/0227-­5910/ a000120 O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational-volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B, 373(1754), Article 20170268. https://doi.org/10.1098/ rstb.2017.0268 Opara, I., Assan, M. A., Pierre, K., Gunn, J. F., Metzger, I., Hamilton, J., & Arugu, E. (2020). Suicide among black children: An integrated model of the interpersonal-­ psychological theory of suicide and intersectionality theory for researchers and clinicians. Journal of Black Studies, 51(6), 611–631. https://doi. org/10.1177/0021934720935641 Polanco-Roman, L., & Miranda, R. (2021). A cycle of exclusion that impedes suicide research among racial and ethnic minority youth. Suicide and Life-­ Threatening Behavior. https://doi.org/10.1111/ sltb.12752 Qin, P., & Nordentoft, M. (2005). Suicide risk in relation to psychiatric hospitalization: Evidence based on longitudinal registers. Archives of General Psychiatry, 62(4), 427–432. https://doi.org/10.1001/ archpsyc.62.4.427 Ramchand, R., Gordon, J.  A., & Pearson, J.  L. (2021). Trends in suicide rates by race and ethnicity in the United States. JAMA Network Open, 4(5), Article e2111563. https://doi.org/10.1001/ jamanetworkopen.2021.11563 Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services

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Administration. Retrieved from https://store.samhsa. gov/sites/default/files/SAMHSA_Digital_Download/ PEP20-­07-­01-­001-­PDF.pdf The Trevor Project. (2020September 24). The Trevor Project research brief: Latinx LGBTQ youth suicide risk. Retrieved from https:// w w w. t h e t r e v o r p r o j e c t . o r g / 2 0 2 0 / 0 9 / 2 4 / research-­brief-­latinx-­lgbtq-­youth-­suicide-­risk/ The Trevor Project. (2021). National Survey on LGBTQ Youth Mental Health 2021. Retrieved from https:// www.thetrevorproject.org/survey-­2021/ U.S.  Food and Drug Administration. (2004). Suicidality in children and adolescents being treated with antidepressant medications. Retrieved from https://www. fda.gov/drugs/postmarket-­drug-­safety-­information-­ patients-­a nd-­p roviders/suicidality-­c hildren-­a nd-­ adolescents-­being-­treated-­antidepressant-­medications Van Orden, K.  A., Witte, T.  K., Cukrowicz, K.  C., Braithwaite, S., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Bulletin, 117(2), 575–600. https://doi.org/10.1037/ a0018697 Vedantam, S. (2006). Suicide-risk tests for teens debated. The Washington Post. Retrieved from https:// www.washingtonpost.com/wp-­d yn/content/article/2006/06/15/AR2006061501984.html World Health Organization. (2019). Suicide in the world: Global health estimates. Retrieved from https://www. who.int/publications/i/item/suicide-­in-­the-­world Zayas, L. H., Lester, R., Cabassa, L. J., & Fortuna, L. R. (2005). Why do so many Latina teens attempt suicide? A conceptual model for research. American Journal of Orthopsychiatry, 75(2), 275–287. https://doi. org/10.1037/0002-­9432.75.2.275

Part I Research and Theory

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Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth Suicide Research Carolina Hausmann-Stabile, Catherine R. Glenn, and Raksha Kandlur

Why people think about, plan, attempt, and kill themselves remains an enduring and largely unanswered question. For over a century, scholars who study suicide have tried to answer this question through the development of theories1 that inform research, public policy, and clinical practice. Theories guide research by suggesting which approaches, variables, and explanations should be tested in a study. Research, in turn, informs the development and revision of theories; research evaluates the explanatory power of theories. In this chapter, we examine the major theories and models that seek to explain suicidal thoughts and behaviors from sociological, psychological, and sociocultural perspectives, and briefly discuss the dominant biological approach. These disciplines have dominated the suicide field since its inception, with sociocultural perspectives emerging as an approach to combine and enrich In this chapter, we use the terms “theory” and “model” interchangeably, as done often by some of the authors referenced in the text. We acknowledge however that in the general literature, the meaning of these works are different. 1 

C. Hausmann-Stabile () Graduate School of Social Work and Social Research, Bryn Mawr College, Bryn Mawr, PA, USA e-mail: [email protected] C. R. Glenn · R. Kandlur Department of Psychology, Old Dominion University, Norfolk, VA, USA e-mail: [email protected]; [email protected]

elements of all predecessors. Although this chapter presents these models as nested within disciplines, this classification is somewhat arbitrary. The ideas promoted by each one of these approaches have influenced theorization and research beyond the borders of their disciplines, resulting in “cross-pollination” across theories and disciplines. What all these theories have in common is that they see suicide as a product of a disturbed society, a disordered mind, a dysfunctional family, or a combination of some or all. All theories discussed in this chapter were developed to specifically explain suicidal thoughts and behaviors (i.e., suicide attempts and deaths). This chapter will highlight the most prominent theories and those that have received the most research, but it is by no means comprehensive of all suicide theories and models.2 We exclude suicide models embedded within theories of personality (for example, Erikson, 1993); clinical models focused on a specific diagnostic group (e.g., psychosis; Johnson et  al., 2008), severe psychiatric sample (Schotte & Clum, 1987), or treatment modality (e.g., Dialectical Behavior Therapy; Linehan, 1987); or theories that have been applied to suicidal behavior but were developed to understand other phenomena (e.g., Intergenerational Economic and genetic theories and models are excluded because of space limitations. These theories have been reviewed extensively elsewhere: for economic theories of suicide see, for example, Hamermesh and Soss (1974), and for genetic and epigenetic theories of suicide see, for example, Cheung et al. (2020). 2 

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Acculturation Conflict Model, Phinney et  al., 2000). Moreover, we exclude the epidemiological and public health literature that has examined a wide range of risk and protective factors. Although these factors may be tied to major suicide theories and/or conceptualized within a socio-ecological model (Caine, 2020), this research is largely datadriven, a-theoretical, and is more of an approach than a testable model. Finally, we include theories that are supported by research, even when their empirical support is limited, and thus have intentionally excluded psychoanalytic/psychodynamic perspectives that have not been tested (e.g., Freud, 1957). Our inclusion and exclusion criteria are based mostly on identifying theories that, from our perspective, have impacted youth suicide research. For those theories and models that are included, we outline the theories’ conceptual premises, briefly discuss their empirical support, and describe their strengths and weaknesses (see Table 2.1). One major limitation of this chapter is that most theories we review have been developed by scholars in the United States, and, thus, privilege a Western perspective. This is a notable limitation of the field; most current research about suicidal thoughts and behaviors is dominated by American and European scholars grounded in a positivist epistemology. In addition, although this chapter is included in a book about youth suicide, most theories and models have not been developed to explain the suicidal thoughts and behaviors in this population. When available, we highlight the models’ developmental considerations and the empirical testing of theoretical constructs as they apply to youth. Another evident limitation of this chapter is that it presents a summary description of each of the theories. Due to space limitations, we describe the major theories with greater detail than what we allocate to models that propose iterations from seminal work. For example, we describe Beck’s Cognitive Model of Suicide (Beck et al., 1975, 1985; Wenzel & Beck, 2008) with greater detail than Rudd’s Fluid Vulnerability Theory (Rudd, 2006). We hope the reader will use this chapter as a springboard to further explore this topic.3 Interested readers can review Gunn and Lester (2015).

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C. Hausmann-Stabile et al. Table 2.1  Theories of suicidal thoughts and behaviors Theory Main constructs Sociology: Theories of Societal Change and of Imitation Social Integration and Social integration Regulation (Durkheim, 1951) Moral regulation Status Integration Theory Stability of social (Gibbs & Martin, 1964) relations Durability of social relations Cultural-Structural Theory of Sociocultural places Suicide (Abrutyn & Mueller, Cultural regulation 2018) The Strain Theory of Suicide Conflict (Zhang, 2019) Psychological strains Social Imitation Theory (De Imitation Tarde, 1903) Clustering Biology Stress–Diathesis Model Trait-like diathesis/ (Mann, 1998) predisposition State-like stressors Interaction Psychology: Theories of the Suicidal Mind Psychache Theory, Cubic Psychache Model of Suicide (psychological pain) (Shneidman, 1993, 1998) Stress Perturbation Escape Theory of Suicide Distorted beliefs (Baumeister, 1990) about falling short of expectations Negative self-attributions Negative self-awareness Negative affect Cognitive deconstructions Hopelessness Escape Cry of Pain Model of Suicide Arrested flight and (Pollock & Williams, 2001; entrapment Williams, 1997, 2001) Defeat Innate helplessness schema Over-general autobiographical memory Hopelessness Theory (Beck Overwhelming et al., 1985, 1990) and hopelessness Cognitive Model of Suicide Modal processing (Wenzel & Beck, 2008) Dispositional vulnerability Cognitive processes Suicidal schemas (continued)

2  Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth… Table 2.1 (continued)

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Table 2.1 (continued)

Theory Fluid Vulnerability Theory (Rudd, 2006, Rudd, 2000)

Main constructs Suicidal mode Suicidal-relevant beliefs Aggravating events Integrated Psychological Theories: Ideation-to-action frameworks Thwarted Interpersonal Theory of belongingness Suicide (Joiner, 2005; Van Perceived Orden et al., 2010) burdensomeness Hopelessness Acquired capability High pain tolerance Low fear of death Pre-motivational Integrated Motivational-­ phase Volitional Model of Suicide Motivational phase Behavior (O’Connor, 2011; Defeat O’Connor & Kirtley, 2018) Entrapment Volitional phase Access to means Suicide exposure Impulsiveness Three-Step Theory (Klonsky Pain & May, 2015) Hopelessness Connectedness Dispositional or inherited contributors Learned acquired capacity Practical factors such as access to means Sociocultural perspectives: Ecological theories of suicidal behaviors Acculturation Ecodevelopmental Model of Cultural norms Suicide Attempts (Zayas (female rearing et al., 2005) norms) Adolescent development (independence and autonomy) Family conflict Cultural Theory and Model of Life stressors Suicide (Chu et al., 2010) Cultural meanings Idioms of distress Cultural sanctions Minority stress Social discord Relevant developmental models and perspectives (continued)

Theory Developmental psychopathology perspective (Crowell et al., 2008, 2013, 2014)

Developmental-transactional model (Bridge et al., 2006)

Developmentally informed heuristic model (Miller & Prinstein, 2019)

Main constructs Transactional nature of risk Impulse control deficits (inherited vulnerability) High-risk environments Difficulties with emotion regulation Intrapersonal and interpersonal deficits Multifinality Inherited vulnerability Depression Impulsive aggressive Environmental stressors Pubertal transition Stressful life events Suicidal behavior facilitators Failure of biological stress-response systems Interpersonal stressors Pubertal changes Stress threshold Exposure to suicide

We conclude this chapter by summarizing the main limitations of these theories, as a whole, as they apply to research on youth suicidal thoughts and behaviors, and propose some approaches to address these shortcomings. We suggest that given the complexity and heterogeneity of suicidal thoughts and behaviors and their determinants across the lifespan, it may not be possible to explain them using a unified theoretical approach. We call for interdisciplinary theorization that can capture the developmental nuances of suicidal thoughts and behaviors, advance a cross-cultural informed understanding of suicide, and identify both universal and context-specific causal paths that explain these behaviors.

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Sociology: Theories of Societal Change and of Imitation In the late 1800s, sociology secularized the study of suicide by detaching it from moral considerations and treating suicide rates as indicators of social forces that shape individual actions. There are two seminal theories about suicide in sociology, both aimed at explaining the increase in suicide rates observed in rapidly industrializing European countries. Durkheim’s (1951) theory focused on societal mechanisms leading to suicidal behavior. De Tarde (1903) focused on processes of imitation and contagion leading to suicidal behavior. Although Durkheim’s and De Tarde’s theories were developed more than a century ago, their seminal insights remain very relevant to current suicide theories.

 ocial Integration and Regulation S (Durkheim, 1951) Emile Durkheim inaugurated the modern study of suicidology in 1897 with his book “Suicide.” In this book, he sought to provide a scientific explanation for the increased suicide rates observed in the late 1800s. The focus of Durkheim’s work was on the societal mechanisms that lead to suicide. Specifically, he explained that increased suicide rates were due to societal changes brought about with the industrial revolution, which differentially impacted individuals who were both vulnerable because of their psychological makeup and their place in society. Durkheim postulated a four-group typology of social conditions emerging from the interaction of two dimensions: social integration and moral regulation. Integration refers to the sense of social belonging and inclusion flowing from social ties; regulation is the guidance and monitoring provided by these social ties. Contexts where integration and regulation are unbalanced, such that individuals feel a discrepancy between their own needs and those of their social environment, may lead to suicide. This could result from contexts with excessive/high integration and regulation or in contexts where there is an imbalance between levels of integration and regulation.

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Durkheim’s suicide theory has held up well in the broader sociological literature (Wray et  al., 2011), and its influence extends beyond sociology. In particular, the theory’s focus on human connection and belonging remains central to current psychological explanations of suicidal thoughts and behaviors. Status Integration Theory (Gibbs & Martin, 1964). Building on Durkheim’s work, Gibbs and Martin developed the Status Integration Theory (1964). They postulated that suicide rates were inversely proportional to the stability and durability of social relations, which are defined by role expectations constructed around an individual’s social status. This theory received some empirical support (Cutright et  al., 2007; Gibbs, 1982; Gibbs & Martin, 1964), but, for the most part, has been forgotten. Cultural-Structural Theory of Suicide (Abrutyn & Mueller, 2018). Building on Durkheim’s theory, Abrutyn and Mueller (2018) developed the Cultural-Structural Theory of Suicide. They call for bringing culture into the understanding of the social roots of suicide. For that, they incorporate recent cultural sociology scholarship and research focused on places and local cultures. They posit that high levels of cultural regulation in culturally coherent contexts that prescribe suicide translate into an increased vulnerability to suicide. They applied their model to explain suicide clusters in high schools, the military, and among white middle-­ aged men. This theory shows promise for understanding how to mitigate risk for suicide within and between systems that have high risk for suicidal behaviors. The Strain Theory of Suicide (Zhang, 2019). The Strain Theory of Suicide (STS), influenced by sociological theories such as Durkheim’s theory (1951), Merton’s strain theory of crime (Merton, 1957), and Agnew’s strain theory of deviance (Agnew, 2006), posits that unique ­conflicting psychological strains drive individuals toward suicide (Zhang, 2019). Unlike daily stressors, psychological strains result in intense frustration and suffering that could result in mental disorders, and extreme response to escape these unresolved strains could result in suicide

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(Zhang et  al., 2017). Four primary sources of strain lead to suicide: (1) value strain—two opposing values or beliefs that are in conflict within an individual (e.g., an immigrant adolescent who has to follow cultural norms enforced by parents while navigating conflicting values of the host country); (2) aspiration strain—aspirations of the individual do not match reality; the larger the discrepancy, the greater the strain (e.g., a young adult might aspire to establish a successful business right after graduating college, but, in reality, this is not possible due to school debt); (3) deprivation strain—resulting from a comparison of their (lower) status with another, including poverty (e.g., a student fails a course while their classmate excels); and (4) coping strain—lack of coping skills to navigate a crisis; a lower capacity to cope leads to higher strain (e.g., a child is unable to navigate the sudden divorce of their parents). The presence of the strain results in a strained mentality, which subsequently leads to suicidal behavior through a range of social and psychological factors (e.g., disconnection, impulsiveness; Zhang, 2019). The STS shares components of prior sociological theories (e.g., Durkheim), aimed at highlighting the social and environmental reasons for suicidal behaviors rather than the individual-level motives. To date, it has been tested primarily in the US and China (Lew et al., 2020; Zhang et al., 2009, 2011, 2013). The STS focuses on how suicidal ideation develops but provides less detail about the pathway to suicidal behavior. Moreover, like most suicide theories, the theory pays less attention to how strains might change over the course of development and those that might be most relevant for adolescents.

 ocial Imitation Theory (De Tarde, S 1903) Gabriel De Tarde’s (1903) theory stresses the role of imitative behavior to explain suicide clusters. He postulated that humans tend to imitate the behaviors and ideas of people in their social environment, especially those of individuals who are highly regarded in the community or by the imi-

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tator. Building on De Tarde, Phillips (1974; Phillips & Carstensen, 1986) showed that suicide deaths tended to increase in the aftermath of a celebrity death publicized in the media. In 2014, Abrutyn and Mueller wrote a comprehensive review of De Tarde’s thesis, outlining a promising sociological theory of suicide contagion bridging social psychology and sociology of emotions, and highlighting mechanisms to test. Although for the most part forgotten by the field, De Tarde’s insights underpin the scholarship dealing with the spread of behaviors, emotions, and attitudes (Abrutyn & Mueller, 2014), including work in suicide contagion among youth (Insel & Gould, 2008), and the application of social learning theory (Bandura, 1977) to the study of attitudes about suicide (Stack & Kposowa, 2008).

 iology: Stress–Diathesis Model B (Mann, 1998) Biological models of suicide have been around for decades (Mann, 1998), and a detailed overview of this literature is beyond the scope of this review (see, for example, Pandey, 2013; Sudol & Mann, 2017; Sunnqvist et  al., 2008). Here, we briefly review the stress–diathesis model, which shaped other biological theories and models and has particular relevance for developmental perspectives (which we turn to later in this chapter). The crux of the model emphasizes that suicidal acts are not only influenced by a psychological disorder but also through a diathesis (Mann et al., 1999). Specifically, the stress–diathesis model of suicidal behavior posits that suicide risk results from an interaction between state-like stressors (environmental, psychiatric illness) and a trait-­ like diathesis (impulsivity, aggression) that increases suicide risk. For example, childhood abuse could elicit a trait-like diathesis of aggression and impulsivity, which, in turn, could increase an individual’s risk of acting on suicidal thoughts (Brodsky et al., 2001). Alternatively, an individual could have a trait-like predisposition influenced by genetic or other biological underpinnings (e.g., HPA axis hyperactivity, limited development of prefrontal cortex during adoles-

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cence) that could result in lower ability to regulate suicidal thoughts; with this diathesis, exposure to a stressful life event could increase an individual’s risk of acting on suicidal thoughts (Boldrini & Mann, 2015; Miller & Prinstein, 2019). One strength of this model is that it takes into account person-environment-biological interactions to explain the risk for suicide. However, additional research would be important to delineate specific variables that result in ideation-­to-action mechanisms. It would also be helpful to examine the stress–diathesis interactions across time to more clearly explain the onset and increased prevalence of suicidal behavior during adolescence (see Miller & Prinstein, 2019).

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To date, the majority of suicide theories have been developed by psychologists. Psychological theories primarily view suicidal thoughts and behaviors as resulting from dysfunction within the individual (intrapersonal processes). Initially, psychological theories focused on disordered thinking patterns, negative appraisals of life experiences, unbearable negative emotional states, and dysfunctional coping strategies. Over time, increased attention was paid to the social and experiential conditions that shape cognitions, emotions, and behaviors. Recent integrated theories have focused on explaining the progression from suicidal thoughts to suicidal actions. Overall, what distinguishes psychological theories is that, even when external events or stressors are included, the major focus is how the individual perceives, processes, adapts, and copes with these experiences.

Suicidology in 1968, as well as its flagship journal, Suicide and Life-Threatening Behavior. Shneidman and Farberow (1956) introduced the study of suicide notes in the United States. In 1993, Shneidman published his theory of suicide. He posited that suicide is caused by psychache, a “hurt, anguish, soreness, aching, psychological pain” (Shneidman, 1993, p.  145), a feeling that he differentiated from depression and hopelessness. Psychache is an overwhelming state of suffering that emerges when individuals experience frustrated psychological needs critical for their well-being, including love, belongingness, and connection, among others. Moreover, it is the simultaneous presence of pain (psychache), press (stress), and perturbation (agitation) that makes this state intolerable and most likely to lead to lethal suicidal behavior (cubic model of suicide; Shneidman, 1987, 1998). With his theory, Shneidman wanted to apply a neo-­ introspectionism approach in suicide studies, which emphasizes the mental, phenomenological aspects of suicidal and self-destructive behaviors (Shneidman, 1998). Empirical work testing this theory depends on the measurement of psychache, assessed most commonly with Shneidman’s Psychological Pain Assessment Scale (1999), an instrument combining unstructured and structured questions, and projective techniques. Empirical support for this theory is limited, and often involves underpowered cross-sectional studies, or studies with large samples of college students (see, for example, Troister & Holden, 2010). This may be due, in part, to the lack of consensus on the definition of psychache—specifically, which emotions are unique to it, and what differentiates this form of psychological pain from other forms of human suffering that are prevalent but do not lead to suicidal behaviors.

 sychache Theory, Cubic Model P of Suicide (Shneidman, 1993, 1998)

Escape Theory of Suicide (Baumeister, 1990)

Edwin S. Shneidman, a clinical psychologist, cofounded the Los Angeles Suicide Prevention Center in 1958, and the American Association of

In the Escape Theory of Suicide, Baumeister was influenced by Shneidman’s earlier work integrating psychological pain and suicide, Baechler’s

Psychology: Theories of the Suicidal Mind

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taxonomy of suicides (1980), and developments in social and personality psychology. From Baechler (1980), Baumeister (1990) took the idea that all suicidal behavior seeks to solve a problem. He argued that suicide attempts represent the last step in a chain of failed attempts to escape psychological suffering. In his theory, Baumeister outlined a six-step causal chain that connects negative experiences leading to distorted and painful self-blaming, and emotional suffering. These steps are: (1) the individual falls below their own standards; (2) negatively attributes this failure to themselves; (3) has heightened awareness of their own inadequacies; (4) experiences aversive and negative affect; (5) withdraws into a state of cognitive deconstruction; and develops (6) a state of disinhibition, irrationality, lack of emotion, and passivity. The acute state of emotional distress and behavioral disinhibition culminates in suicide attempts as a means to alleviate psychological suffering. One of the strengths of this theory is that it breaks away from previous scholarship suggesting that suicidal tendencies occur primarily in the context of psychopathology, and more specifically from depression. Instead, it enables understanding of suicidal thoughts and behaviors experienced in adverse contexts and integrates individual responses to these conditions. However, there is little empirical support for this theory (Cornette et al., 2002), in part because the theory outlines a series of steps that are challenging to test, as a whole. And, because steps in the process may unfold quickly, it becomes more challenging to test parts of the theory. Moreover, the theory lacks specificity regarding the emergence of suicidal thoughts, as well as individuals’ predispositions, such as coping and/or cognitive style, that contribute to escape responses to distress.

 ry of Pain Model of Suicide (Pollock C & Williams, 2001; Williams, 1997, 2001) Building upon Baumeister’s ideas of suicidal behaviors as an escape from pain (1990), and

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Gilbert and Allan’s “arrested flight” animal behavior model developed to understand depression (1998), the Cry of Pain model outlines the conditions that increase one’s propensity to die by suicide. Specifically, suicidal behavior is a response to situations of arrested flight and entrapment, characterized by a sense of defeat, an impossibility of escape, and no hope of rescue. Responses to such situations are driven by a combination of individual and innate characteristics. The assessment of a situation as entrapping depends on an individual’s psychological characteristics (e.g., problem-solving ability, generality of autobiographical memory). For instance, over-­ general autobiographical memory restricts the ability to consider different options in the future and effective problem-solving. Once an individual perceives being entrapped, an innate helplessness schema is activated, leading to suicidal thoughts. The drive toward suicide is then dependent on contextual and learned factors, such as the availability of lethal means and the modeling of suicidal behaviors, among others. The “cry” is the suicidal act in reaction to these painful and inescapable circumstances. There is some empirical support for the role of entrapment (see, for example, O'Connor, 2003), overly general autobiographical memory (Williams & Broadbent, 1986), and difficulties with problem-solving (Pollock & Williams, 2001) in relation to suicidal behavior. The inclusion of an animal behavior model in the theory carries multiple challenges. First, the arrested flight model was originally developed by Gilbert and Allan to explain depression among humans, but Williams does not provide a clear application of this model to suicide. Furthermore, the arrested flight model, an evolutionary model developed with nonhumans may be irrelevant to explain suicide—a behavior only observed among humans. As with other psychological theories reviewed here, the theory neither provides clear distinctions between constructs (e.g., hopelessness and depression) nor does it define a clear, testable pathway.

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 opelessness Theory (Beck et al., H 1985, 1990) and Cognitive Model of Suicide (Wenzel & Beck, 2008) Aaron Beck is one of the most influential suicide theorists of the last half-century. As early as 1973, Beck started to integrate his theory of depression and suicidal behaviors (see, for example, Minkoff et al., 1973). He proposed that overwhelming hopelessness (i.e., unchangeable negative situation) leads to suicidal ideation and ultimately suicide death (Beck et al., 1985, 1990). Furthermore, Beck enhanced his theory of hopelessness with the concept of modal processing in suicidal behavior through five schema modes— cognitive, behavioral, affective, physiological, and conscious control—that increase the vulnerability for negative responses to internal and external stimuli (see Beck, 1996). In 2008, Wenzel and Beck formulated a heuristic cognitive model of suicidal behavior that builds on research on cognitive processes and the finding that most individuals who die by suicide have a diagnosable psychiatric disorder. The key components of Wenzel and Beck’s model are (a) dispositional vulnerability (trait-like variables that carry nonspecific risk for psychiatric diagnoses and suicidal behaviors), (b) cognitive processes associated with psychiatric disturbances (maladaptive cognitive contents and information processing biases associated with psychiatric disorders and symptoms), and (c) suicidal schemas (hypothesized maladaptive cognitive contents and information processes at work in a suicidal crisis). During a suicidal crisis (when the suicidal schema becomes activated), an individual becomes hopeless; attends to, has difficulty disengaging from, and exhibits narrowed attention toward suicide-related information; and acute suicidal ideation develops. When these cognitive processes cross the critical threshold of tolerance, the individual will attempt suicide. Taken together, these concepts explain how cognitive misperceptions and misrepresentations about past, present, and future life experiences lead to vulnerabilities for suicide.

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The strengths and weaknesses of this theory have common underpinnings. Conceptually, the cognitive theory has been criticized for the reductionist assessment of cognitions as causal entities, to the detriment of a more nuanced and precise description of complex psychological processes and person-environment interactions (see, for example, Coyne, 1982; Coyne & Gotlib, 1983, 1986). Methodologically, the vast empirical support for the theory emerges mostly from data informed by the theory (e.g., using the developers’ measures), using cross-sectional designs or underpowered longitudinal studies (see, for example, Beck et  al., 1985), with samples that exclude comparison groups and do not test alternative hypotheses, and use correlation-based techniques that cannot infer causation to support causal inferences. Although there is considerable empirical support for cognitive-based approaches to suicide (see, for example, Cha et  al., 2010, 2019; Wenzel et  al., 2009), little research has examined the complete cognitive model proposed by Wenzel and Beck (2008). Fluid Vulnerability Theory (Rudd, 2006). M.  David Rudd built on Beck’s mode (Beck et  al., 1985, 1990) to understand the temporal dynamics of suicide risk. Rudd (2006) posited that there is a “suicidal mode” composed of cognitive, emotional, behavioral, and physiological risk and protective factors. With a basis in cognitive theory, the cognitive components of the suicidal mode are, in turn, formed by suicide-relevant beliefs consisting of core negative presuppositions: unlovability, helplessness, and poor stress tolerance. The suicidal mode forms a baseline, chronic, and stable risk level that can be activated by external, time-dependent triggers (aggravating events), leading to an acute state of risk. This theory is one of the few to make predictions about who may be at risk for repeated suicide attempts (i.e., those with higher baseline risk levels; e.g., Joiner & Rudd, 2000). Although cognitive components of this theory are well studied, little research has examined the interwoven components of the suicidal mode (i.e., cognitive, affective, and behavioral).

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Integrated Psychological Theories: Ideation-to-Action Frameworks A cluster of contemporary suicide theories aim to explain how people transition from suicidal thinking to suicidal action.

Interpersonal Theory of Suicide (Joiner, 2005) The most prominent contemporary theory of suicide is Joiner and colleagues’ Interpersonal Theory of Suicide (Joiner, 2005; Van Orden et al., 2010). This theory was the first to provide specific processes that lead individuals down the pathway to suicide—from suicidal thinking to suicidal action. In this theory, potentially lethal suicidal behavior will only occur if a person has both the wish to die by suicide and the ability to carry out that wish (Joiner, 2005). The desire to die emerges from two psychological states: perceived burdensomeness (to others) and thwarted belongingness (from others). Hopelessness that these states will never change leads to active suicide desire (Van Orden et al., 2010). In order to act on this suicide desire, the theory suggests that individuals must also have the capability to hurt themselves, specifically a high tolerance for pain and low fear of death. A large number of studies have examined components of the interpersonal theory of suicide. However, not all of these studies have tested the specific hypotheses delineated by the theory (Van Orden et  al., 2010). A recent review and meta-analysis (Chu et  al., 2017a) found mixed support for the interpersonal theory. Specifically, interactions between the main interpersonal theory constructs modestly predicted suicide-related outcomes. They found that different pathways of the theory variables, for example, by reversing the order of the theory’s main predictors, were equally useful for predicting suicidal behaviors as theory-consistent pathways. In addition, the majority of studies testing this theory have relied on cross-sectional samples from the United States and Canada, enrolling a majority of white adult participants. Although the interpersonal

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theory is not developmentally informed, there is an emerging body of literature testing it with adolescents (see, for instance, Barzilay et al., 2015; Stewart et  al., 2017) and Latina adolescent suicide attempters (see Gulbas et al., 2019). Despite its strengths, there are several limitations to the interpersonal theory. For example, the theory fails to explain how individuals can simultaneously experience themselves as a burden to others while feeling disconnected from others. Furthermore, one proposed pathway to capability for suicide is through exposure to painful and provocative experiences (e.g., trauma and violence). However, little is known about the specific timing and dose of exposure to trauma and violence that leads to increased capability. As with risk models, the theory fails to effectively predict how and when suicidal people move from wanting to die by suicide to acting on their thoughts. Overall, this theory describes a set of preconditions, such as the desire to die and capability to die, that may be found among many individuals—most of whom will never die by suicide. As such, the interpersonal theory may be more useful in identifying individuals who are at risk for suicide than it is in actually predicting suicide.

Integrated Motivational-Volitional Model of Suicidal Behavior (O’Connor, 2011; O’Connor & Kirtley, 2018) The Integrated Motivational-Volitional (IMV) Model of Suicidal Behavior (O’Connor, 2011; O’Connor & Kirtley, 2018) integrates components of the theory of planned behavior (Ajzen, 1991), the diathesis-stress model of suicidal behavior (Schotte & Clum, 1987), and the arrested flight model of suicidal behavior (Pollock & Williams, 2001; Williams, 2001). O’Connor and colleagues propose a three-step model to explain the development of suicide risk, consisting of a pre-motivational, a motivational, and a volitional phase. The pre-motivational phase refers to the psychological, experiential, and contextual factors that underlie vulnerability

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to suicidal thoughts and behaviors. The motivational phase refers to the emergence of suicidal ideation during challenging situations in which individuals feel defeated and entrapped, and because of their baseline vulnerabilities, cannot respond in an adaptive way. The transition from suicidal ideation to suicidal behavior is driven by “volitional moderators.” These include access to means for suicide, previous exposure to suicidal behaviors, impulsivity, and capability for suicide. A strength of this theory, like others in this section, is that it distinguishes factors associated with suicidal ideation from those related to suicidal acts, which is consistent with current understanding of the differential risk associated with each of these domains (see, for example, Klonsky et al., 2017). Studies using this framework have produced mixed results. Most studies have supported the motivational phase of the theory in which defeat either mediated or was associated with entrapment, which in turn was related to suicidal ideation (Branley-Bell et al., 2019; Dhingra et al., 2015; Owen et al., 2018; Wetherall et al., 2019). However, a few studies also highlight inconsistencies in the theory. For example, a cross-sectional study with university students in the United States (Tucker et  al., 2016) did not confirm the role of entrapment in the emergence of suicidal ideation. Similarly, a prospective study by Taylor et  al. (2011) found that only defeat was associated with suicidal ideation over time; Gooding et al. (2017) also could not confirm the role of entrapment but supported the role of defeat in suicide probability among a prison sample at high risk for suicide. A strength of the IMV is that it has been tested across countries, including among Chinese adolescents (Li et al., 2020), German psychiatric inpatients (Lucht et  al., 2020), and Iranian students (Chelmardi et al., 2019). Finally, IMV is one of the few theories that has been tested using intensive longitudinal methods. Stenzel et  al. (2020) found that while defeat was positively associated with entrapment at one time point, defeat did not significantly predict entrapment at the next time point—thus, highlighting the need to evaluate the theory using studies with greater temporal reso-

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lution. Considering the theory is fairly new, additional research delineating various phases of IMV using intensive longitudinal designs and across age groups would be beneficial.

 hree-Step Theory (Klonsky & May, T 2015) The Three-Step Theory (3ST; Klonsky & May, 2015) outlines a sequential process that aims at explaining how individuals move from suicidal thinking to suicidal action. Step one of this process posits that the emergence of passive suicidal ideation results from a combination of an experience of pain (emotional or otherwise) and feelings of hopelessness about the prospect of the pain ending. Step two involves an escalation of suicidal ideation, from passive to active, due to deteriorating connectedness in one or various dimensions of a person’s life, such as relationships, job, or sense of purpose. Step three describes the progression from intense suicidal ideation to suicidal acts. This progression depends on three elements: dispositional, or inherited, contributors (e.g., tolerance to pain); a learned acquired capacity; and practical factors (e.g., access to lethal means). There is some emerging empirical support for this theory (see, for example, Dhingra et  al., 2019; Klonsky & May, 2015) and notably, from a study in China (Yang et al., 2019). However, this theory is relatively new, and there is less empirical work supporting the model at this time, particularly in youth.

Sociocultural Perspectives: Ecological Theories of Suicidal Behaviors Sociocultural theories build upon contributions from sociology, cultural and medical anthropology, cross-cultural psychiatry, and developmental and social psychology to describe the impact of social systems and culture on human development, well-being, and behaviors. These models aim to address two major gaps in sociological

2  Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth…

and psychological theories and research on suicide: (a) the failure to recognize the importance of cultural reasons for suicidal thoughts and behaviors and (b) their exclusion of, or lack of attention to, ethnic, racial, and other minority and underrepresented groups. Sociocultural models delineate an ecological context that accounts for the dynamic interrelations between various individual and environmental factors. In general, sociocultural models aim to highlight minority-­ specific characteristics within specific contexts (see Stevenson, 2014) while avoiding explanations rooted in psychopathology or cognition. Their overall goal is to delineate the influence of sociocultural processes on suicidal behaviors and to disentangle context-specific from universal factors associated with suicidal thoughts and behaviors among minority groups. As such, these models have been primarily used to explain the suicidal behaviors of ethnocultural minorities (e.g., Latina teens) and marginalized communities (e.g., ethnic and sexual minorities). These theoretical perspectives remain somewhat at the margins of suicidology, as most contemporary suicide theories aim for universal explanations and most often relegate the consideration of culture to models interested in “exotic,” non-­Western behaviors. By doing so, suicide researchers have neglected understanding and exploring cultural variabilities in the assessment of distress, patterns of tolerance and coping, the expression of emotional distress and mental illness, and their treatment models, as well as of suicidal behaviors and the theories about them.4 The main challenge with sociocultural approaches is that they can only be tested through ex post facto designs, in which the investigation starts after the ecological effects have occurred without interference from the researcher. Thus, when testing these models, the variables cannot be manipulated, eliminating the possibility of understanding causality. Furthermore, sociocultural models are seldom tested using comparative studies with diverse For the influence of culture on the experience, expression, and treatment of distress, see for example, Kleinman (2008), Guarnaccia et  al. (1996), and Takeuchi et  al. (2002). 4 

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populations, focusing instead on specific groups, such as Latinas or sexual minorities, without comparing them with nonminorities. Although the focus on minorities may allow understanding of group-specific dynamics, the lack of comparison limits our ability to discriminate universal from group-specific mechanisms in youth suicidal behaviors, as well as their specific effects within groups.

 codevelopmental Model of Latina E Suicide Attempts (Zayas et al., 2005) Luis Zayas, a developmental psychologist and social worker, along with an interdisciplinary and multicultural team of anthropologists, psychiatrists, and social workers, developed the Ecodevelopmental Model of Latina Suicide Attempts (2005).5 This model suggests that the suicidal behaviors of Latina adolescents emerge at the intersection of sociocultural (e.g., female rearing norms), familial (e.g., conflict), and developmental (e.g., adolescent autonomy) dynamics within the larger context of multiculturalism and Latino immigration in the United States. The theory characterizes these dimensions through a cultural lens, in which culture organizes psychological representations of the world, interpersonal relations, family structure, and interactions, as well as expression and management of distress. Family dynamics and parent–adolescent conflict are seen as key factors explaining the prevalence of suicide attempts among adoles­ cents, in general, and among Latina teens, in particular. Support for Zayas’ model confirmed the role of female rearing and family functioning cultural norms (Baumann et  al., 2010), adolescent developmental processes issues, and cultural change (Zayas et al., 2010) in the suicidal behaviors of Latina adolescents. Specifically, the adolescent’s developmentally appropriate increasing autonomy and independence result in clashes with her parents as they attempt to reinforce traDisclaimer: The first author has been involved in research applying this model. 5 

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ditional Latino expectations about adolescent females’ dating, household chores, and peer choices (Zayas et al., 2010). Suicidal Latina adolescents report stressed mother-daughter relationships characterized by low levels of mutuality and communication (Zayas et  al., 2009), and family dynamics characterized by conflict and dysfunctionality (Gulbas et  al., 2011; Kuhlberg et al., 2010; Peña et al., 2011). Suicide attempts have been identified as an iteration of the “ataque de nervios” (Zayas & Gulbas, 2012), a cultural idiom of distress described by Lewis-Fernandez et  al. (2005). This has led Zayas and Gulbas to propose that the suicide attempts observed among Latina teens in the United States might be a developmental or cultural variation of the ataque de nervios recorded among adult women in the Caribbean, constituting a gendered response to social and relational crises impacting the family. Although richly developmentally informed when compared to the other theories presented in this chapter, Zayas’ model lacks conceptual specificity to predict suicide attempts among adolescents. That is, the model cannot answer why certain individuals growing up in similar contexts (for example, urban Latino enclaves) attempt suicide while most of their peers do not. Furthermore, the model lacks the precision in defining mechanisms unique to Latina adolescents who attempt suicide, as it mostly focuses on the role played by variables that are universally associated with adolescents’ suicide attempts, such as conflicts with parents. Its focus on parental responses to normative and universal developmental challenges needs further refining, as it only provides clues to understanding the responses of parents who endorse Latino traditional values, but is in contradiction with research that suggests that third-generation Latino youth are at greater risk for suicidal and other risk behaviors than children of recent immigrants or immigrant children (Peña et al., 2008). The understanding of suicidal behaviors as a language of distress however may offer a rich area of interdisciplinary research in youth suicidal behaviors, as their prevalence and presentation are gendered phenomena. Further testing of the model comparing Latina and non-Latina ado-

lescents may help pinpoint culture-specific risk and protective factors among Latinas, and understand the role of culture in shaping the expression of distress through suicidal behaviors among youth.

 ultural Theory and Model of Suicide C (Chu et al., 2010) Joyce Chu and a group of psychologists at Palo Alto University developed the Cultural Theory and Model of Suicide (2010), an inductive and empirically grounded approach based on culturally specific risk factors associated with suicidal behaviors among African Americans, Asian Americans, Latinos, and sexual and gender minorities (LGBTQ).6 One of the advantages of this work is that it provides a framework to factor in and evaluate the role of culture in suicide risk across diverse minority groups, while at the same time integrating work from nontheoretical risk models into a theoretical framework. The Cultural Theory and Model of Suicide encompasses three theoretical principles. First, cultural scripts shape the expression of suicidal thoughts, plans, and attempts (idioms of distress). Second, culture affects the types of stressors that result in suicide (minority stress, social discord, and cultural sanctions) and how they interplay with other risk and protective factors. Third, cultural meanings about stressors and suicide impact the development of suicide dispositions. Chu and colleagues propose a cultural suicide pathway that begins with life stressors, assessed and experienced by the individual based on cultural scripts, which, in turn, burdens a person’s coping and increases their risk for suicidal behaviors. In response to these stressors, cultural scripts ascribe a meaning to suicide as a mode of coping with life stressors, as well as to the thresholds of tolerance for distress. Cultural scripts provide the mode of thinking about suicide and guide the manifestation of suicidal behaviors (e.g., planned or impulsive). Culture then shapes the aftermath We follow the Chu et al. (2010) categories as labeled in their text. 6 

2  Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth…

of suicidal behaviors, including familial reactions and perceptions of the suicidal act. Based on their theory and model, Chu and colleagues developed the Cultural Assessment of Risk for Suicide (CARS; Chu et al., 2013, 2018a), a tool that can identify cultural suicide risk factors that are not captured by other suicide ratings. There is emerging evidence of the theory’s usefulness. For example, empirical evidence supports the central role of life stressors and culture in the pathway to suicidal thoughts and behaviors (Chu et al., 2020), and its usefulness in guiding clinical decision-making in suicide risk management (Chu et  al., 2017b). The model has also been applied to understand differential risk across cultural groups (see, for example, Chu et  al., 2018b; Hollingsworth et al., 2017). This model challenges the central role of mental illness as a primary driver of suicide risk and instead advances our understanding of the roles of culturally scripted life stressors and responses leading to suicidal thoughts and behaviors.

 elevant Developmental Models R and Perspectives As already discussed, few theories of suicidal thoughts and behaviors have been developed with children and adolescents in mind. Those that are youth-focused have been developed for specific adolescent populations (e.g., Latina adolescents). Given the focus of this handbook, we think it is important to highlight other models and perspectives that have relevance to youth suicide. Family systems and familial risk factors have been implicated in the development of youth suicidal behavior for decades (for reviews of this literature: see Berman et  al., 2006; Wagner, 1997). However, evidence for many purported familial mechanisms is weak, and earlier literature did not provide a comprehensive, or testable, model suggesting how these factors interact to lead to suicidal behavior in youth (Wagner, 1997). Three examples of more integrated developmental models or perspectives are described below.

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Rooted in the developmental psychopathology perspective (Cicchetti & Rogosch, 2002; Rutter & Sroufe, 2000), Crowell et  al. (2008, 2013, 2014) note that a theory of suicidal behavior must consider normative developmental challenges, the ability to successfully navigate these challenges, and the transactional nature of risk across the lifespan (between individuals and their environments). They propose a potential pathway through which vulnerable youth interact with high-risk environments to lead to a range of negative mental health outcomes in adolescence, including suicidal behavior. Specifically, youth with impulse control deficits (an inherited vulnerability) interact with high-risk familial and peer environments (e.g., rejection, invalidation, conflict) to develop extreme difficulties with emotion regulation. Over time, transactions between youth and their environment lead to significant intrapersonal (e.g., maladaptive cognitions, emotion dysregulation) and interpersonal deficits (e.g., social withdrawal, rejection sensitivity, problems with conflict resolution). As the authors note, this pathway is nonspecific to suicide, as it may result in a number of negative outcomes in adolescence (i.e., multifinality). Bridge et al. (2006) proposed a developmental-­ transactional model with some additional specificity to suicidal behavior. In this model, suicidal behavior develops through the interaction of two key vulnerabilities—major psychiatric disorder (primarily depression) and impulsive aggression. Familial risk factors, including family history of psychiatric disorders, impulsive aggression, and suicide attempts, confer an inherited vulnerability. After puberty, these vulnerabilities manifest as depression and impulsive aggression, significant environmental stressors (i.e., family abuse and discord) can increase depression, and suicidal ideation develops. The model also suggests potential mechanisms leading from suicidal ideation to attempts (impulsive aggression; risk factors: interpersonal and legal stressors; protective factors: family and school connectedness, religious/cultural beliefs) and suicide death (availability of lethal means; facilitators: intoxication and exposure to suicidal behavior). This model offers two promising upstream pathways to

C. Hausmann-Stabile et al.

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reduce suicidal behaviors: addressing psychiatric disorders and impulsive aggression. By targeting these vulnerabilities prior to the emergence of suicidal behaviors, this model implies a public health strategy that could potentially reduce youth suicides. Most recently, Miller and Prinstein (2019) provided a developmentally informed heuristic model focused on the transition to adolescence. The significant cross-national rise in suicidal thoughts and behaviors during adolescence coincides with key biological changes and increased salience of interpersonal stressors. Integrating research across multiple biological stress-­ response systems, the model proposes that youth with certain distal risk factors (e.g., childhood adversity, early chronic stress, depression) may exhibit a failure of biological responses to acute stress. As a result, these adolescents may be less equipped to manage the significant interpersonal stress that occurs during this developmental period. Moreover, suicidal behavior is likely to result, specifically, when stress is severe (most critically, when it exceeds an individual’s own threshold to cope) or when an individual is exposed to suicide as a means to alleviate distress (i.e., either through their own engagement in non-suicidal selfinjury or suicidal behavior, or by exposure to others’ suicidal behavior). A strength of this model is that it seeks to explain not only why suicide risk increases during adolescence but why an adolescent might be drawn to suicide, specifically. Taken together, existing developmental models are rooted in the developmental psychopathology perspective and focus on the key challenges and changes that occur during adolescence. This approach is a significant departure from most existing suicide theories, which were developed to understand suicidal behavior in adults. However, as their authors recognize, these developmental models are broad. Although they may help to explain risk mechanisms generally among youth, they may not adequately account for societal and cultural factors that increase risk among marginalized groups of young people.

Discussion Theorization about suicidal thoughts and behaviors has grown exponentially since Durkheim’s seminal publication in 1897. However, the ideas remain centrally relevant to the ancient Western tradition of thinking of suicide as a response to contextual circumstances.7 Breaking away from this tradition, current psychological theories emphasize individual characteristics largely to the exclusion of contextual factors that may impact individuals with differential levels of vulnerability. Below, we group the main limitations of this body of theorization and propose some approaches to address these shortcomings.

Lack of Developmental Focus Suicide theorists have, for the most part, neglected building developmental explanations of suicidal behaviors. So far, what we have instead of developmental explanations are descriptions of patterns of emergence and of prevalence across the lifespan. Moreover, most theories reviewed in this chapter have either assumed that suicidal behavior is an adult phenomenon or have treated it as such. This leaves researchers interested in youth suicidal behaviors without a theoretical framework, often applying models that have kept developmental characteristics of children and adolescents out of the picture. We reviewed existing developmental models and developmental psychopathology perspectives. These models consider the changes and challenges unique to adolescents (e.g., puberty, salience of interpersonal stressors, role of parental relationships). However, to date, these models have not garnered widespread adoption or testing by the field. Future research would benefit from focusing on these developmentally informed models and perspectives to identify why adolescents, compared to children and to adults, may be at increased risk for suicidal thoughts and behaviors. For more on the ancients’ thinking about suicide, see Garrison (1991). 7 

2  Theories of Suicidal Thoughts and Behaviors: What Exists and What Is Needed to Advance Youth…

Lack of Cultural Context

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that the majority of theories of suicide focus on distal predictors that are not specific to suicide Most suicide theories, and particularly the most (e.g., depression, etc.) while neglecting the proprominent ones, lack inclusion of cultural context cesses and their timing in relation to suicidal and an understanding of the role of cultural fac- thoughts and behaviors. Theories need to identify tors that shape the expression of distress through direct causes that mediate the relationship suicidal behaviors. The implicit assumption of between distal predictors and suicidal thoughts most theories is that what applies to predomi- and behaviors, as well as distinguishing condinantly white individuals and high-income coun- tioning factors that due to lasting exposure influtries will apply to most, leading to the ence and/or determine suicidal behaviors (e.g., homogenization and thinning out of the diversity racial discrimination), and precipitating factors and richness of the human experience. (e.g., access to guns) that result in suicide. Furthermore, there is little reason to believe that Conditioning must distinguish condition sine qua a one-size-fits-all theory will apply across diverse non from those predictors that may only contribgroups and countries. Even within one country, ute to suicidal thoughts and behaviors under spethe United States, suicide trends vary widely at cific cases. The theoretical inclusion of the intersection of age, gender, class, and race nonspecific and sometimes unchangeable (e.g., (see, for example, Bridge et  al., 2015; Ivey-­ gender) predictors requires precision in the Stephenson et  al., 2017). Cross-cultural suicide description of when they lead to suicide risk. research needs to take into consideration that Furthermore, theories must help explain the role culture is associated with contextual factors, of individual- and aggregate-level predictors to including socioeconomic conditions. understand their accumulated effect on suicide. Socioeconomically vulnerable youth tend to present greater levels of suicidal thoughts and behaviors than their better-­ off peers (see, for Lack of Understanding about Chronic example, Valdivia et al., 2015). Nuanced suicide Course of Suicidal Thoughts theorization should consider the intrinsic diver- and Behaviors sity of minority and majority groups within contexts. For example, the mechanisms leading to Most suicide theories and models suggest how suicide death among Black children (Bridge individuals may first progress down the pathway et  al., 2015), Native American young men to suicide (i.e., first escalation to suicidal think(Leavitt et  al., 2018), and older White men ing and from suicidal thinking to suicidal action). (Hedegaard et al., 2020) are likely as diverse as However, these theories tell us less about how these groups. The field’s understanding of suicide these suicidal thoughts and behaviors become risk among diverse and underrepresented popula- repetitive, more lethal, and are more likely to tions, particularly young people, is lacking and a result in death (for exception, see the suicidal crucial direction for the field. mode in the Fluid Vulnerability Theory; Rudd, 2006). This is particularly relevant for understanding risk among adolescents, as this is the Lack of Specificity and Temporal time period during which suicidal thoughts and Resolution behaviors have their first onset (Nock et al., 2008) and individuals first transition from thoughts to After 122 years of research, current theories lack action (Nock et al., 2013). Notably, the suicide-­ specificity to predict who will die by suicide, and attempt-­to-death ratio is also higher among adowhen individuals identified as “at risk” will think lescents than adults, meaning that most suicide about or engage in suicidal behavior (i.e., lack attempts in youth are low in medical lethality temporal resolution). The lack of progress in (Safer, 1997). Thus, it is imperative to identify these areas can be attributed, in part, to the fact which youth are likely to engage in repetitive sui-

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cidal behaviors that increase in lethality (e.g., due to age; Goldston et al., 2015) and are more likely to result in death. This is an important direction for future developmental theories and models of youth suicide.

Future Directions We conclude this chapter by suggesting that given the complexity and heterogeneity of suicidal thoughts and behaviors and their determinants, it may not be possible to explain them using a unified theoretical approach. We propose that innovative theorization could draw on developmental, biological, psychological, sociological, and cultural theories (among others), to bridge distinct bodies of knowledge that have historically been siloed, resulting in a broader and deeper understanding of the complex nature of suicide, its emergence, course, and prevention. Such approaches could capture the complex, multifactorial, and dynamic pathways at all levels of individuals’ ecological context, and lead to a complex and rich understanding of why some youth attempt suicide while the majority do not, and why some progress from suicidal thinking to action (and in some cases death), while others stop this path in time to reduce suicidal behaviors and deaths.

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Early Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk Ana Ortin-Peralta, Sarah Myruski, Beverlin Rosario-Williams, and Mariah Xu

The prevalence rates of suicidal behavior, including suicide ideation and attempts, and suicide vary across the life span and follow different developmental trajectories. In childhood, suicidal behavior and suicide are rare. In early adolescence, suicide ideation sharply increases around the age of 10–12, followed by a surge in suicide attempts, placing early adolescence as a critical time for suicide prevention (Nock et  al., 2013; Wyman, 2014). The prevalence of suicidal behavior peaks around middle-late adolescence, remains elevated throughout young adulthood, A. Ortin-Peralta () Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA Department of Psychology, Hunter College, City University of New York, New York, NY, USA e-mail: [email protected] S. Myruski Department of Psychology, The Pennsylvania State University, State College, PA, USA e-mail: [email protected] B. Rosario-Williams Department of Psychology, Hunter College, City University of New York, New York, NY, USA The Graduate Center of the City University of New York, New York, NY, USA e-mail: [email protected] M. Xu School of Nursing, Columbia University, New York, NY, USA e-mail: [email protected]; [email protected]

and decreases in adulthood (Boeninger et  al., 2010; Lipari et  al., 2015). In adolescence, most transitions from suicide ideation to suicide attempts occur within 1 year from the onset of the suicidal thoughts (Nock et  al., 2013) and over half of the adolescents and young adults who die by suicide do so on the first attempt (McKean et al., 2018). Suicide rates, however, increase steadily from early adolescence to late adulthood. In the US, 47,511 people (13.9% of the population) died by suicide in 2019, and the highest prevalence was at the age range of 55–59 years old. Although suicide is more frequent in late adulthood, it is not among the three leading causes of death for those age 35 and older. However, it is the second leading cause of death among the age groups of 10–14, 15–24, and 25–34 (WISQARS, 2019). In 2019, the youth age-adjusted death rates were 0.06 (5–9 years old), 2.6 (10–14 years old), 10.5 (15–19  years old), and 17.3 (20–24  years old) (WISQARS, 2019). In the 2019 Youth Risk Behavior Survey (YRBS)—a biannual survey conducted by the Centers for Disease Control and Prevention (CDC) among a representative sample of 9th–12th-grade students in the US, the prevalence of having seriously considered attempting suicide, having made a suicide plan, and having attempted suicide in the previous 12 months was 18.8%, 15.7%, and 8.9%, respectively. Two and a half percent of students reported having made a

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_3

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suicide attempt requiring medical treatment (YRBS, 2019). Overall, across several YRBS reports, there has been an increase in suicide ideation between 2007 and 2019, in plans between 2009 and 2019, and in suicide attempts between 1991 and 2019. The most frequent methods for suicide have been linked to accessibility, acceptability, and sociocultural norms; as such, these methods vary by country and age (Ajdacic-Gross et al., 2008). While hanging is the predominant method of suicide in most countries, firearms are the most common method in the US after the age of 15. Before that age, suffocation is the most frequent method used by children ages 10–14, and, across all age groups, poisoning is the third leading method, except for older adults (65+), where the percentage of people who die by poisoning surpasses suffocation (WISQARS, 2019). As a comparison, in a group of European countries, hanging was the most prevalent suicide method (49.5%), followed by poisoning by drugs (12.7%) and jumping from a high place (9.5%). Firearms were the fourth most common method, with a prevalence of 7.6% (Värnik et  al., 2008). In other areas, such as rural Latin American countries (e.g., El Salvador, Nicaragua, and Peru), Asian countries (e.g., the Republic of Korea and Thailand), and Portugal, poisoning with pesticides is among the most frequent method used, especially among women (World Health Organization, 2019). Striking sex differences exist in the prevalence of suicidal behavior and suicide in many countries. In the US, suicidal behavior is higher among girls than boys, whereas suicide is more frequent among boys than girls, and this tendency is observed in older ages, as well (YRBS, 2019). This phenomenon has been called the gender paradox (Schrijvers et  al., 2012). The methods for suicide used by adolescents and young adults (10–24 years old) differ by sex. In 2019, the most common method for boys was firearms (51.6%), followed by suffocation (35.3%), and for girls, the most common methods were suffocation (48.7%) and firearms (23.9%) (WISQARS, 2019).

The prevalence of suicidal behavior varies by racial/ethnic groups in the US. In the last YRBS (2019), American Indian or Alaska Native adolescents reported the highest prevalence of suicide ideation (34.7%) and attempts (25.5%).1 By sex, multiple race girls (33.1%) reported the highest prevalence of suicide ideation, followed by White (24.3%), Black (23.7%), Hispanic (22.7%), and Asian girls (22.0%). Of note, this is the first time since the 1990s that White girls reported a higher prevalence of suicide ideation than Hispanic girls, although the difference was not statistically significant. Multiple race boys also reported the highest prevalence of past-year suicide ideation (17.5%), and they were followed by Asian (17.3%), White (13.8%), Hispanic (11.4%), and Black (10.7%) boys. For past-year suicide attempts, multiple race girls (17.8%) were followed by Black (15.2%), Hispanic (11.9%), White (9.4%), and Asian (8.4%) girls. Among boys, Black boys (8.5%) were followed by multiple race (7.3%), Asian (7.1%), White (6.4%), and Hispanic (5.5%) boys. Across YRBS reports from 1991 to 2017, there has been a significant linear increase in the prevalence of suicide attempts among Black girls and boys, but not among other racial/ethnic groups (Lindsey et al., 2019). Noticeably, Black boys have consistently reported the lowest prevalence of serious thoughts about suicide in subsequent YRBS, but they have been among the top three racial/ethnic groups with the highest prevalence of suicide attempts, and the leading group in the 2017 and 2019 reports. For suicide, American Indian and Alaska Natives have the highest rates of suicide across all age groups (10–19, 20–24, 25–29, 30–49, and 50–85+). While the highest risk period for dying by suicide among White individuals is 30 years old and up, for racial and ethnic minority groups, the highest risk period is between the ages of 20 and 24 years old (WISQARS, 2019). There are also dramatic differences in the prevalence of suicidal behavior by sexual orientation. In the last YRBS (2019), Lesbian-Gay-­ Data on suicidal behavior among American Indian or Alaska Native adolescents by sex was not provided. 1 

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Bisexual adolescents reported an alarming past-year prevalence as high as 46.8% for serious suicide ideation and 23.4% for suicide attempts. They were followed by adolescents self-­identified as “not sure,” with a prevalence of 30.4% and 16.1% for suicide ideation and attempts, respectively. Finally, heterosexual adolescents ­ reported the lowest prevalence for suicide ideation (14.5%) and attempts (6.4%). Recent findings on changes in the prevalence of suicide by age and racial/ethnic groups are worth mentioning. In the past 15 years, the highest increase in suicide rates has been observed among early adolescents, ages 10–14, especially among girls (200% increase among girls and 37% among boys) (Curtin et al., 2016). Although the prevalence of suicide in childhood is low and has remained stable since the 1990s (WISQARS, 2019), suicide rates have increased among Black children (5–11  years old), decreased among White children, and remained stable for the other race/ethnic groups (Bridge et  al., 2015). Specifically, between 2001 and 2015, the suicide rate for Black children (5–12  years old) was approximately two times higher than for White children. However, among adolescents (13– 17 years old), the suicide rate was approximately 50% higher among White adolescents than Black adolescents (Bridge et  al., 2018). A study comparing suicide rates between children (5–11 years) and early adolescents (12–14  years) (Sheftall et al., 2016), found that between 2008 and 2012, the suicide rate among Black children was higher than among Black early adolescents (36.8% vs. 11.6%, respectively), with the reverse tendency found among children and early adolescents classified as non-Black (63.2% vs. 88.4%, respectively). Additional noticeable differences between children and early adolescents were found regarding suicide methods, with children more often dying by hanging, strangulation, or suffocation, versus early adolescents dying most commonly by firearms. Children died more frequently at home than did early adolescents. Finally, while children who died by suicide were more likely to be diagnosed with Attention Deficit/Hyperactivity Disorder (ADD/ADHD), early adolescents were more likely to be diagnosed with a depression/

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dysthymic disorder. They did not differ in the prevalence of other diagnoses examined (e.g., bipolar, anxiety, OCD, and others).

Childhood Maltreatment and Suicidal Behavior Exposure to adversity in childhood has severe psychological consequences later in life. Childhood maltreatment, broadly defined as sexual abuse, physical and emotional abuse, and neglect, has been associated with a range of psychopathological symptoms (Agnew-Blais & Danese, 2016; Carvalho et  al., 2020), including suicide ideation and attempts (Hoertel et  al., 2015). Still, the specific mechanisms that explain why children who have experienced maltreatment fare worse than children with no abuse history remain poorly understood. The next sections describe different theoretical frameworks for the study of maltreatment and suicidal behavior and propose potential mechanisms that may link childhood maltreatment and suicide ideation and attempts, such as deficits in neurocognitive and executive functioning.

 heoretical Frameworks for the Study T of Maltreatment and Suicidal Behavior The empirical research on maltreatment can be integrated into a number of theoretical frameworks, each contributing differentially to our understanding of the association between childhood maltreatment and suicide risk. Three theoretical frameworks are described in the following paragraphs. The Adverse Childhood Experiences (ACE) framework is the most well-known and widely studied of the three frameworks. The ACE Study, conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente from 1995 to 1997, provides a foundational body of research linking early adversity, especially cumulative adversity, to negative physical and mental health outcomes. It includes data from

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over 17,000 adult participants interviewed in two waves, with 8708 participants interviewed in Wave 1 and additional 8629  in Wave 2. Participants retrospectively reported on experiences from the first 18 years of life, as well as on current health and behaviors. ACEs include different forms of maltreatment (physical, sexual, or psychological abuse and neglect), parental mental health (substance use and mental illness), and other experiences (i.e., witnessing violence, parental separation or divorce, and family member incarceration). Nearly two-thirds of the full sample reported having experienced at least one ACE; 36.1% of participants reported no adverse childhood experiences (ACEs), 26.0% reported one ACE, 15.9% reported two, 8.5% reported three, and 12.5% reported four or more ACEs (CDC & Kaiser Permanente, 2016). A study using data from Wave 1 cohort of the ACE sample found a graded relationship between ACE score (a sum of how many different forms of adverse experiences were endorsed cumulatively) and most leading causes of death in adults. For example, compared to those who experienced no ACEs, individuals who experienced four or more ACEs had 4.6 times higher odds of endorsing depression symptoms, 7.4 times higher odds of self-reported alcoholism, and 2.5 times higher odds of having a sexually transmitted disease. Their odds of experiencing heart disease, cancer, stroke, and diabetes were also 1.5–3.9-fold higher. Moreover, individuals who endorsed four or more ACEs had 12.2-fold higher odds of having ever attempted suicide (Felitti et al., 1998). Analysis of the full sample of 17,000+ individuals also found a graded relationship between number of cumulative ACEs and lifetime suicide attempts (Dube et  al., 2001). After adjusting for other suicide risk factors, individuals who reported one ACE had 1.7 higher odds of ever attempting suicide; those with four ACEs had 3.9 times higher odds; and those with seven or more had 17.0 times higher odds. Proponents of the ACE framework posit that ACEs contribute to poorer psychosocial, emotional, and cognitive adjustment, which then lead to risky behaviors and illness, disability, and problems with social functioning throughout the lifespan. In turn, these factors contribute to an early death.

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The original ACE study examined the effect of early life experiences on outcomes in adulthood, but more recent research using the same framework indicates that early adversity is also related to suicide ideation and attempts in children and adolescents. Cumulative ACEs are associated with both suicide ideation and attempts in adolescence cross-culturally among American (Thompson et  al., 2012), Chinese (Wan et  al., 2019), Finnish (Isohookana et  al., 2013), and South African teens (Cluver et  al., 2015). The timing of adverse experiences can also impact suicidal behaviors among youth: Thompson et al. (2012) found that more recent experiences of adversity in adolescence, rather than more distal adverse experiences in childhood, more strongly predicted suicide ideation among adolescents. Further, childhood and adolescent adversities interacted, such that childhood adversities had a stronger effect on adolescent suicide ideation in the presence of lower levels of adolescent adversity, and vice versa. Other research has examined the relationship between specific ACEs and youth suicide ideation and attempts. For reviews of the relationship between childhood maltreatment and suicide attempts, see Angelakis et al. (2020) and Miller et al. (2013). The critical work from the ACE Study and related research provide ample evidence for a cumulative risk framework of early adversity and health. That is, the greater the number of adverse experiences in childhood, the greater the risk of negative health outcomes. Crucially, the effects of multiple ACEs are cumulative, amounting to more severe negative outcomes when experienced together than individually; in other words, cumulative risk posits that the overall risk of each additional ACE is greater than the sum of its parts. As a theory, cumulative risk has its benefits as well as its drawbacks. Its conceptualization of adversity, centered around the simple sum of different types of adversity experienced, is parsimonious and easy to model statistically, and thus provides higher power for a wide range of complex analyses. However, it does not consider important theoretical factors, such as frequency or severity of adversity; and as an additive model,

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interactions between adversity variables cannot be examined (for a comprehensive review of statistical and theoretical strengths and weaknesses of cumulative risk, see Evans et  al., 2013). Cumulative risk is helpful in understanding how systems across the geopolitical, national, community, and family levels interact to create a deep and lasting impact on individual health, and as such, its contributions to policy are innumerable and substantial. However, it lacks specificity in nature and provides little insight on why certain experiences may cause certain conditions and through which mechanisms each adverse experience leads to negative outcomes. As a result, a cumulative risk approach falls short in contributing to the development of effective interventions. To address the shortcomings of cumulative risk, a growing area of research points to a deprivation and threat model, also known as the Dimensional Model of Adversity and Psychopathology (DMAP; see McLaughlin et al., 2014a; McLaughlin & Sheridan, 2016). This model distills a continuum of early adversities onto two core dimensions: deprivation (a lack of expected stimuli from the environment) and threat (harm or threat of harm). Physical abuse, for example, is high on threat and low on deprivation, while neglect is high on deprivation and low on threat. While these two dimensions of adversity can and often do occur simultaneously, threat and deprivation can be measured independently and seem to have a unique impact on learning and fear conditioning (McLaughlin et al., 2016), neural and biological systems (Busso et  al., 2017), cognitive and affective functioning (Lambert et al., 2017), and mental health problems (Miller et al., 2020). For example, threat, but not deprivation, impacts areas of emotional reactivity and automatic regulation (Lambert et al., 2017; Miller et al., 2020; Sheridan et al., 2019) and it is associated with blunted sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis reactivity to a social stress test (Busso et  al., 2017). Deprivation, but not threat, is associated with impaired cognitive functioning, including verbal abilities and executive functioning (Miller et  al., 2020; Sheridan et  al., 2017; Vogel et  al.,

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2021). While deprivation is associated with externalizing problems, threat is associated with both externalizing and internalizing problems (Miller et al., 2020). Despite the rapidly growing body of research using DMAP, the two proposed dimensions and associated impairments have not been examined in relation to suicide ideation and attempts. Nonetheless, DMAP provides a valuable framework that researchers can utilize to classify the experiences of maltreatment and test specific mechanisms to explain the relationship between early adversity and suicide among children and adolescents, with the hope of developing more effective, tailored interventions for those at risk. Suicide-specific theories provide another lens through which to understand how maltreatment and adverse experiences might contribute to suicide risk. The Interpersonal Theory of Suicide (Van Orden et al., 2010) specifies that perceived burdensomeness and thwarted belonging both contribute to desire for suicide, but individuals only proceed to act on that desire if they also develop acquired capability. Acquired capability refers to the habituation to pain and fear that would allow a person to perform the physically painful or intimidating acts required to attempt suicide. The Interpersonal Theory suggests that physically painful or threatening forms of maltreatment, such as physical or violent sexual abuse, may contribute to acquired capability, and thus suicidal behavior, whereas less invasive forms of maltreatment, such as verbal abuse or molestation, may only contribute to suicide ideation (Joiner et al., 2007).

 echanisms Linking Childhood M Maltreatment to Suicidal Behavior There is a thread in research on the potential mechanisms or underlying processes through which experiences of maltreatment may lead to the development of suicidal behavior. In this section, we describe several biological underpinnings (i.e., epigenetic, brain structure) and key areas of functional impairment (i.e., emotional regulation, executive function) that have been

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associated with maltreatment and/or suicidal behavior and could potentially serve as mechanisms that explain the maltreatment-suicide association.

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largely informed by studies with adults (e.g., Brent & Mann, 2006; Sarchiapone et al., 2016). Fewer studies have confirmed this link in adolescents. Pandey et al. (2002) showed that serotonin receptor levels in brain regions involved in emoChildhood Maltreatment, Genetics, tional reactivity and regulation (PFC, limbic sysEpigenetics, and Other Biological tem) were greater among teenagers who died by Systems suicide compared to controls. Tyano et al. (2006) Family and adoption studies (Petersen et  al., found that serotonin levels in depressed teens 2014; Tidemalm et al., 2011), as well as genome-­ were significantly higher among those exhibiting wide association studies (Erlangsen et al. 2020; suicidal behavior, including suicide ideation and/ Levey et  al., 2019; Mullins et  al., 2019), have or suicide attempts, versus controls. However, indicated a genetic component for suicide risk. other attempts at replicating adult findings in These genetic vulnerabilities coincide with those adolescents have yielded inconsistent results implicated in other psychopathologies (Levey (Picouto et al., 2015), suggesting that more taret al., 2019; Voracek & Loibl, 2007), suggesting geted developmental studies are needed that conthat the link between genes and suicidal behavior sider the specific biological processes during this is mediated by maladaptive cognitive and affec- period of life (i.e., pubertal change, gender tive traits (Hoehne et  al., 2015; McGirr et  al., differences). 2009) shared by multiple psychopathologies. Environmentally driven variations in gene Critically, early life adversity, including mal- expression, or epigenetics, have been shown to treatment, has been linked with alterations in contribute to dysregulation of the stress response genetic expression and associated biological sys- system, the hypothalamic-pituitary-adrenal tem functioning, inducing long-term maladaptive (HPA) axis. The HPA axis has also been linked to biobehavioral consequences that increase the risk both childhood maltreatment and suicidal behavfor suicidal behavior (Brodsky, 2016, review; ior (e.g., Heim et al., 2008; Turecki & Meaney, Lengvenyte et al., 2019; Ludwig et al., 2017; Roy 2016). Building on a large body of animal & Dwivedi, 2017). While exposure to abuse at research (e.g., Liu et  al., 1997; Weaver et  al., any age has been shown to increase the likelihood 2004), human studies (Labonte et  al., 2012; of suicide ideation and attempts, depressive McGowan et  al., 2009) showed that individuals symptoms and suicide ideation are particularly who died by suicide and also had a history of elevated if abuse is first experienced in early childhood abuse or neglect exhibited epigenetic childhood (Dunn et  al., 2013), suggesting a changes in glucocorticoid receptor gene expresheightened vulnerability during the foundational sion in the hippocampus, the neural regulator of development of biological systems. Key biologi- the HPA axis. Reduced glucocorticoid receptor cal systems and processes identified to poten- density in this region disrupts the negative feedtially explain the link between adversity and back loop of the HPA axis, resulting in exacersuicidal behavior include serotonergic mood bated stress reactivity and dysregulation, which, regulation (Underwood et  al., 2018), HPA axis in turn, may contribute to suicidal behavior. stress reactivity (e.g., Oquendo et  al., 2014; Other studies (Perroud et  al., 2011, 2014) have Teicher & Samson, 2016), immune system func- demonstrated that the severity and frequency of tion (e.g., Baumeister et  al., 2016), and neuro- childhood maltreatment predicted the degree of plasticity (e.g., Dwivedi, 2009; Salas-Magaña epigenetic glucocorticoid receptor changes, suget al., 2017). gesting that the nuances of early life adversity are Dysfunctions of the serotonergic system, critical to consider when determining biological including abnormalities in receptors, transport- suicide risk. ers, and metabolite concentration, have been sugHPA axis dysregulation, in turn, disrupts the gested as biomarkers for suicidal behavior, immune system function, which has also been

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implicated as a mechanistic link between stress- et  al., 2018) suggests that childhood abuse, ful life events and suicide (Postolache et  al., coupled with genetic variants impacting neuro2016). In a healthy immune system, cytokine plasticity and monoamine receptors involved in messenger molecules coordinate pro- and anti-­ mood regulation, contribute to increased risk of inflammatory responses to defend against suicidal behavior. For example, a BDNF gene ­pathogens and maintain homeostasis. Extreme or functional polymorphism (Val66Met) has been chronic stress, like that induced by maltreatment, investigated in terms of genetic vulnerability to can disrupt this adaptive feedback loop, resulting stress and subsequent suicidal behavior. In parin disordered immune response and chronic ticular, the presence of the Met allele has been inflammation, which has detrimental long-term linked with lower BDNF activity (e.g., Egan effects on neuronal function (e.g., Coelho et al., et  al., 2003), suicide attempts (e.g., Schenkel 2014). Indeed, abnormal levels of pro-­ et al., 2010), and childhood maltreatment (e.g., inflammatory cytokines have been shown to dis- Pregelj et al., 2011). Further, the proportion of tinguish between control psychiatric patients as Met allele carriers was shown to be greater compared to those with active suicide ideation, a among suicide victims versus controls, and history of a suicide attempt, and/or who died by within suicide victims, the Met allele was more suicide (Black & Miller, 2015), and measured common among those who experienced childfrom postmortem brain samples from adolescents hood adversity versus those who did not (Pandey et  al., 2012) and adults (Pandey et  al., (Pregelj et al., 2011). One recent study (Youssef 2018) who died by suicide. A variety of other et  al., 2018) demonstrated that postmortem adversity-related epigenetic changes disrupting BDNF levels were decreased among those who basic neuronal functions, including signaling experienced maltreatment, died by suicide, or cascades (e.g., Pandey et  al., 2004; Dwivedi both. However, this study did not replicate the et al., 2004) and gene transcription (e.g., Pandey finding that possessing the Met allele, itself, et al., 2007), have also been shown to be associ- was more common among suicide victims. ated with death by suicide and a history of a sui- Further, another study demonstrated the oppocide attempt (Sarchiapone et  al., 2016), site pattern, with childhood maltreatment assosuggesting that there are wide-spread cellular-­ ciated with suicide attempts only among those level aberrations that could contribute to broad without the Met allele (Perroud et al., 2008). In cognitive consequences, yet the complexities of addition, several studies (Cicchetti et al., 2007; these causal relations necessitate further research. Gibb et al., 2006; Shinozaki et al., 2013) have Another potential biological mechanism link- shown that exposure to childhood maltreatment ing childhood maltreatment and suicide risk is is associated with greater suicide ideation for neuroplasticity driven by brain-derived neuro- those carrying the short polymorphism of the trophic factor (BDNF), which plays a particularly 5HTTLPR gene, a major regulator of serotonercritical role in the development of serotonergic gic function. However, other studies have failed pathways (e.g., Dwivedi, 2009; Lessmann et al., to replicate this finding (Coventry et al., 2010; 2003). BDNF synthesis has been shown to be Zalsman et al., 2006). Thus, further research is inhibited by stress (e.g., Murakami et al., 2005) needed to clarify the particular mechanism and levels of BDNF are depleted in postmortem through which gene expression may be modubrains of suicide victims (Dwivedi et  al., 2003; lated by maltreatment among those with these Karege et al., 2005). Since BDNF plays a critical genetic vulnerabilities. role in neurodevelopment and plasticity, it has been suggested to be particularly significant as an Child Maltreatment, Brain Structure, indicator of suicidal behavior (Sher, 2011) and and Function death by suicide (Pandey et al., 2008) in youth. Long-term cellular and system changes may, in Research on gene–environment interactions turn, shape maladaptive neurodevelopment. (e.g., Ben-Efraim et  al., 2013; Underwood Although results have been somewhat incon-

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sistent and implicated many alterations in brain regions associated with suicide, the most consistent findings point to reduced brain volume in frontal lobe structures, including the orbitofrontal cortex, prefrontal cortex, and anterior cingulate cortex, as well as subcortical structures, including striatal and limbic regions (Gosnell et al., 2018; Jollant et al., 2011; Zhang et  al., 2014). These brain areas govern cognitive and affective functions, including planning, decision-­making, impulse control, reward processing, emotional reactivity, and regulation. Reduced volume of the corpus callosum, a critical structure involved in connectivity between brain regions, has also been associated with suicidal behavior (Cyprien et  al., 2011). Neuroimaging studies focused on youth with a history of suicidal behavior (Martin et  al., 2015) have shown aberrations in the right superior temporal gyrus (Pan et al., 2015), a region dedicated to emotion and facial processing, and white matter hyper-intensities (Ehrlich et  al., 2004), indicating abnormality in the myelinated tracts connecting brain regions. Further, reduced white matter in fronto-striatal circuitry (e.g., Jia et  al., 2010, 2014) and reduced resting-state functional connectivity between frontal and subcortical regions involved in cognitive control of emotion (Gosnell et  al., 2019; Pan et  al., 2013a, 2013b) differentiate suicidal and nonsuicidal patients. The structure and function of these critical brain regions and pathways underlying cognitive and affective functioning also differentiate those who have experienced childhood maltreatment from those who have not (McCrory et al., 2010). Underwood et al. (2019) showed that structural abnormalities, namely reduced gray matter in postmortem prefrontal and anterior cingulate cortex samples of adults, were linked to a history of maltreatment. However, these brain differences did not differentiate those who experienced maltreatment and later died by suicide, suggesting further research is needed to clarify the neural foundations that link maltreatment and risk for suicidal behavior.

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 hildhood Maltreatment and Stress C Reactivity Exposure to childhood maltreatment has been associated with dysregulated stress reactivity in youth (MacMillan et  al., 2009; McLaughlin et al., 2014b; Trickett et al., 2014). One potential explanation is that over time, childhood maltreatment may sensitize individuals to adversity and increase the risk for suicidal behavior and other psychopathological symptoms. We note that many studies examining the association between maltreatment and stress reactivity have often referred to childhood sexual and physical abuse as “traumatic experiences.” Other studies have collapsed childhood maltreatment with natural disasters, exposure to interpersonal violence, and domestic violence and have also referred to these experiences as traumatic. This section synthesizes findings on childhood maltreatment (and traumatic experiences) in adolescence and young adulthood suicide ideation and attempts by focusing on the neurobiological underpinnings that influence stress reactivity after childhood adversity. Childhood maltreatment and traumatic experiences have been related to the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Briefly, the HPA axis is implicated in the stress response—a response to a perceived threat, whether real or imaginary (Lupien et al., 2009). When people encounter stressful events, the HPA axis is activated, ultimately leading to the secretion of cortisol, which prepares the body to respond to a stressor (see Lupien et al., 2007 for a review). Cortisol is a glucocorticoid stress hormone implicated in the homeostasis of the HPA axis—when enough cortisol is released, negative feedback loops transmit signals from the adrenal glands to the hypothalamus to return the system back to homeostasis (Lupien et  al., 2009). Although HPA axis activation is beneficial to combat stress, prolonged activation of the HPA axis (i.e., hypersecretion of cortisol) can result in deleterious health effects (Lupien et  al., 2007; McEwen, 2012). The timing of maltreatment exposure seems to have a unique impact on the HPA axis. Kuhlman et al. (2015a) found that while abuse or traumatic

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experiences before age 1 were associated with a delayed recovery from physiological stressors that may extend to adolescence, these experiences after age 1 were associated with deviating diurnal cortisol cycles (Kuhlman et  al., 2015a). Timing of these experiences was also found to affect the cortisol diurnal cycle in a community sample of children and adolescents (ages 7–14). Specifically, children who reported traumatic experiences proximal to the time of completing the study (within a year) exhibited increased cortisol levels at bedtime compared to children who reported distal (over a year) traumatic experiences (Weems & Carrion, 2007). Furthermore, there is also evidence that the type of childhood trauma/maltreatment experienced differentially affects HPA axis dysregulation. In another study conducted by Kuhlman et  al. (2015b), physical abuse was associated with HPA activation (cortisol hypersecretion), while emotional abuse was implicated in HPA recovery, and other traumatic experiences such as witnessing a natural disaster were implicated in dysregulated bedtime cortisol levels (Kuhlman et  al., 2015b). Together, these findings show strong evidence suggesting that early traumatic experiences influence children and adolescents’ physiological response to stressors; however, most studies use cross-sectional designs and rely on retrospective recall of childhood maltreatment and traumatic experiences, limiting causal inferences. Thus, current measures of cortisol levels and retrospective assessments of childhood trauma may only provide indices of current HPA axis functioning without causally demonstrating changes in the HPA axis as a function of childhood trauma and maltreatment. Dysregulation of the HPA axis is implicated in suicide ideation and attempts (e.g., Ghaziuddin et al., 2014; McGirr et al., 2011). Both hypersecretion and hyposecretion of cortisol are associated with an increased risk for suicide ideation and attempts. One line of research shows that children and adolescents who display hyperresponsivity to cortisol are at increased risk for suicide ideation and attempts at follow-up, independent of psychiatric diagnosis and puberty level (Giletta et  al., 2015; Mathew et  al., 2003;

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Pfeffer et  al., 1991), suggesting that cortisol hyperreactivity may be closely associated with emotional stress (Pfeffer et  al., 1991). For instance, Mathew et al. (2003) followed a group of adolescents into young adulthood to identify whether abnormal cortisol activity during sleep onset in adolescence predicted suicidal behaviors in adulthood. Participants who attempted suicide at 10-year follow-up exhibited higher levels of plasma cortisol prior to sleep onset compared to participants with a suicide attempt history at baseline, no suicide attempts with a diagnosis of major depressive disorder, and healthy controls. Other research suggests that adolescents and adults who have made suicide attempts exhibit blunted levels of salivary cortisol (hyposecretion of cortisol) following a psychophysiological stressor (Melhem et  al., 2016, 2017; O’Connor et al., 2018). In fact, findings indicate that recency of suicide attempts is inversely associated with salivary cortisol levels, such that suicide attempts within the preceding year are associated with lower cortisol levels (O’Connor et  al., 2017). Moreover, lower cortisol at baseline also predicts higher suicide ideation at 1  month follow-up, accounting for an additional 5% of the variance among individuals with suicide attempts only. These findings suggest differential pathways of cortisol activity between youth who have attempted suicide relative to those who have considered suicide. Both lines of research point to an impact of dysregulated HPA axis in increasing risk for suicide ideation and attempts. A recent meta-analysis indicates that age moderates the relation between cortisol reactivity and suicide attempt history, such that individuals over age 40 who have made suicide attempts exhibit lower cortisol levels, while younger individuals who have made suicide attempts exhibit higher cortisol levels (O’Connor et al., 2016). However, this meta-­analysis included only one sample in which the average age was 17, limiting generalizability of these findings to adult populations. Given that individuals with previous suicide ideation and attempts typically exhibit different neuroendocrine responses, it is plausible that they have developed distinct pathways that respond differently to stress. A developmental

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framework may elucidate how these different pathways mature over time, and how different cortisol measurements can better capture these nuances. Moreover, considering that childhood maltreatment and traumatic experiences alter biological systems, including HPA axis functioning, further work is needed to elucidate how HPA axis functioning may mediate the relation between childhood adversity and suicide ideation and attempts in later life. Evidence indicates that the timing and type of traumatic experience differentially affect HPA axis functioning among children and adolescents (Kuhlman et al., 2015a, 2015b). Traumatic experiences may explain blunted cortisol among individuals with suicide attempts, while emotion dysregulation may explain cortisol hypersecretion. Prospective longitudinal studies are needed to elucidate how cortisol measurements capture distinct trajectories of HPA axis functioning among individuals with suicide ideation and attempts. Further, developmental and longitudinal designs are needed to identify the mediating role of HPA axis dysregulation in trauma-exposed, suicidal individuals throughout their lifespan.

 hildhood Maltreatment and Emotion C Regulation Biological vulnerabilities manifest as behavioral and subjective impairments regarding emotional experiences. Emotional reactivity, which captures the intensity and duration of negative emotional experiences, has been shown to be heightened among those with suicide ideation (e.g., Nock et  al., 2008). In contrast, one study (Weinberg et al., 2017) showed that, when controlling for current suicide ideation, those with a prior suicide attempt showed a blunted neural response to threatening stimuli. Further, among young adults, difficulty expressing emotions partially mediated the link between greater emotional reactivity and suicide ideation (Polanco-Roman et  al., 2018). Heightened or blunted emotional reactivity has been documented among individuals with a history of childhood maltreatment (e.g., Heleniak et  al., 2016; Harkness et al., 2011). This suggests that disruptions in emotional reactivity to negative

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stimuli or events, a pattern of responding forged by aversive childhood experiences, may interfere with adaptive cognitive and behavioral processes. Indeed, high self-reported emotional reactivity predicts suicide ideation and attempts among young adults, and this link is particularly strong among those who also experienced childhood maltreatment (Shapero et al., 2019). Abnormalities in neurocognitive emotion regulation have also been examined among youth with suicide ideation and a past suicide attempt (e.g., Hatkevich et  al., 2019). Specifically, decreased functional connectivity between attentional control (dorsal anterior cingulate gyrus) and emotion processing (insular cortex) regions was observed among adolescents with a history of suicide attempt when they viewed angry, but not happy, faces, suggesting a disruption specific to unpleasant emotional stimuli (Pan et al., 2013a, 2013b). Research has further shown that emotion dysregulation, or impaired ability to adaptively manage negative emotions, may explain the link between childhood maltreatment and psychopathologies (e.g., Cloitre et  al., 2019; Dvir et  al., 2014). Dysfunction in neurocognitive regulatory capacity mediates the association between early life maltreatment and suicide ideation and attempts in adults, particularly among those lacking social support and/or socioeconomic stability (Lemaigre & Taylor, 2019).

 hildhood Maltreatment and Executive C Functioning Extensive evidence demonstrates an association between childhood maltreatment and impaired cognitive and executive functioning (e.g., Carvalho et  al., 2020). Executive functioning refers to a series of cognitive processes that are responsible for goal-directed behavior such a decision-making, working memory, and self-­ regulation (Anderson, 2002; Wade et al., 2018). Maltreated children perform worse than their peers on reading and academic functioning, and these cognitive disadvantages may affect their development in adulthood (Mills et  al., 2011). For instance, previously and currently maltreated children perform worse on tasks assessing verbal cognitive functioning (i.e., knowledge, compre-

3  Early Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk

hension/understanding, analysis) than their peers at risk for maltreatment but who have not experienced maltreatment yet (Hong et  al., 2018). Adolescents who have experienced maltreatment display more impairments in tests of processing speed, working memory, and both verbal and non-verbal skills, independent of their performance on general intelligence tests (Kirke-Smith et al., 2014, 2016; Mothes et al., 2015). Although evidence supports the association between ­maltreatment and executive functioning, several open questions remain. For instance, the specific impairments in executive functioning may be a function of the number and type of maltreatment experienced (Mothes et  al., 2015). Specifically, adolescents who have experienced neglect display more disruptions to their inner speech than adolescents who have experienced abuse (Kirke-­ Smith et  al., 2016). These differences are often missed when researchers compare broad categories of maltreatment to youth who have not been maltreated and align with the findings proposed by the Dimensional Model of Adversity and Psychopathology (DMAP). The direction of causality between maltreatment and impairment also warrants further examination, as a large study including two cohorts suggested that lower cognitive performance may be preexisting individual differences that increase the risk for maltreatment (Danese et  al., 2017). Further, much variability exists between studies on how researchers conceptualize and measure both maltreatment and executive functioning (Irigara et  al., 2013). Despite significant strides in advancing our understanding of how maltreatment and performance in executive functioning are related, most studies have relied on small sample sizes, consisting primarily of girls, and focusing mostly on physical and sexual abuse rather than emotional abuse and neglect (Irigara et al., 2013). Maltreated children also exhibit more social-­ emotional problems than their non-maltreated peers (Mastorakos & Scott, 2019) and unique patterns in attentional bias that may contribute to the emergence of trauma symptoms (Briggs-­ Gowan et  al., 2016), but this relation may be a function of age. For instance, maltreated preschool children display an attentional bias away

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from threatening and sad faces (Briggs-Gowan et al., 2016; Mastorakos & Scott, 2019), whereas school-aged children display a bias toward sad faces and away from angry faces (Bertó et  al., 2017). The mechanisms explaining these developmental differences ought to be further assessed with longitudinal studies. Nevertheless, attentional bias is associated with poor psychosocial development and symptoms of mood disorders (Bertó et al., 2017; Humphreys et al., 2016). In fact, maltreated children and adolescents appear to interpret neutral stimuli as threatening, relative to their non-maltreated peers (van Hoof et  al., 2017). Focusing on attentional bias in abused children is important because recent findings suggest that school-aged children with suicide ideation exhibit an attentional bias toward fearful faces, suggesting that social threat may be salient for children who have thought about suicide (Tsypes et al., 2017a). Understanding how basic cognitive mechanisms underlie the relationship between childhood maltreatment and suicide ideation and attempts may facilitate intervention efforts to reduce the risk for future suicidal thoughts and behavior. Besides maltreatment, poor performance in cognitive control and executive functioning have also been linked to suicide ideation and attempts. A systematic qualitative review found that lower performance in executive functioning was related to suicidal behaviors primarily among individuals with a mood disorder, followed by individuals with heterogenous diagnosis (Bredemeier & Miller, 2015); however, the findings were inconclusive, given that while many studies found significant relationships between executive functioning and suicidal thoughts and behaviors, other studies found no association, and most studies used cross-sectional designs that limit causal inferences. Nevertheless, findings from a meta-analysis indicated that adult patients who had attempted suicide generally scored lower on neuropsychological tests than patients without suicidal behaviors or nonclinical adults, and this gap is especially pronounced in decision-making processes (Richard-Devantoy et al., 2014); individuals who have made a suicide attempt display more difficulty making decisions in uncertain

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situations (Richard-Devantoy et  al., 2014) and blunted neural activation for high versus low-risk engage in more risk-taking behaviors (Ackerman decisions during a gambling task (Pan et  al., et al., 2015). We note, however, that samples in 2013a, 2013b). However, these studies did identhe qualitative review and the meta-analyses were tify differences among depressed youth, such that predominantly from adult populations, and these those with a history of a suicide attempt showed findings may not generalize to youth in different differential activation of response inhibition and developmental stages. Compared to adolescents decision-making circuitry, suggesting that future with psychiatric symptoms and no history of sui- research should focus on functional abnormalicidal behavior, adolescents with a suicide attempt ties within clinical samples. display more difficulty in decision-making, Impaired executive functioning related to sui­independent of affective disorders, medication, cidal behavior has also been examined using neuand impulsivity (Bridge et  al., 2012). Further, ral oscillations measured via even though both youth who have considered sui- electroencephalography (EEG), which capture cide and those who have attempted suicide per- neural coherence or functional connectivity form similarly on tests of overall cognitive between cortical regions. Neural coherence was functioning, those with a suicide attempt appear exaggerated among youth categorized as high to have more difficulty with both inhibition and versus low suicide risk during a working memory decision-­making (Saffer & Klonsky, 2018). The task, indicating an overcompensation for prespecific mechanisms that explain these differ- sumptive cognitive impairment (Kim et  al., ences are unclear, but deficits in inhibition and 2019). Gamma wave activity, an indicator of decision-­making are more strongly related to sui- broad cognitive functioning, including attention, cide attempts than to suicidal thoughts (Sheftall memory, perception, and awareness, was greater et al., 2015). However, we note that a large study among participants with suicide ideation and of community children and adolescents found attempts versus controls (Arikan et  al., 2019), that although suicidal youth reported higher potentially indicating inefficient or exaggerated severity of psychological symptoms, they per- cognitive effort and disrupted awareness of cogformed better on neurocognitive tasks, after nitive difficulties. Moreover, Benschop et  al. adjusting for depression and psychopathology (2019) showed that suicide ideation and attempts (Barzilay et al., 2019). were associated with reduced frontal resting-state In studies using neuroimaging techniques, EEG activity, indicating disruptions in regions impaired decision-making among adults with a critical for executive functioning, and consistent history of a suicide attempt has been found to be with neuroimaging literature. associated with decreased activity in orbitofronChildhood maltreatment increases the odds of tal and prefrontal brain regions (Richard-­ suicidal behaviors, irrespective of neuropsychoDevantoy et al., 2014). Further, a neuroimaging logical functioning (Zelazny et  al., 2019). study of cognitive control showed that adults who Specifically, although some areas of neurocognilater died by suicide showed widespread brain tive functioning (e.g., working memory, language activation differences compared to those who did fluency, impulse control) may have protective not die by suicide, indicating overactivation and/ effects against suicidal behaviors, these protecor inefficient neural activation during a cogni- tive effects are lessened among maltreated chiltively challenging task (Willeumier et al., 2011). dren. The stressors and abuse that youth face Few studies have attempted to replicate these throughout critical developmental periods may findings in youth samples, and results have been severely affect their neurocognitive functioning, inconsistent. For instance, contrary to predic- overall, which may increase the risk for subsetions, when compared to healthy controls, ado- quent suicidal behaviors by impairing key execulescents with a past suicide attempt did neither tive functioning domains like inhibition and demonstrate differential neural activity during a decision-making. It is also possible that maltreatresponse inhibition task (Pan et  al., 2011), nor ment only affects specific areas of executive

3  Early Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk

functioning, and, therefore, youth with suicide ideation and attempts may perform poorly on some tasks but perform just as well or better than their peers on other tasks. Alternatively, the methodologies that researchers use to assess both executive functioning and socio-emotional functioning (e.g., parental report vs basic measures) vary widely by study, and this may yield different findings (Fay-Stammbach & Hawes, 2019). Finally, several studies have examined neurocognitive functioning among relatives of those with a history of suicidal behavior. Tsypes et al. (2017b) showed that children of parents with past suicide attempts showed greater psychophysiological responses to losses during a reward processing task. McGirr et  al. (2013) provided evidence for neurocognitive dysfunction, measured as performance of executive functioning and flexibility via the Wisconsin card sorting test, among non-suicidal first-degree relatives of individuals who died by suicide. This suggests that neurocognitive impairment may be transmitted in families through genetic inheritance and/or shared environment. It is imperative for future research to shed light on these knowledge gaps.

Maltreatment and Pubertal Timing Puberty is a universal transition that results in unique social experiences for adolescents as they interact with parents and peers. At the same time, this transition is characterized by physiological changes, adjustment in self-perception, and mood swings (Greenspan & Deardorff, 2014). Most adolescents navigate these changes successfully, whereas others develop emotional and behavioral problems. Pubertal timing—being earlier, about the same, or later in development compared to same-sex peers—is one of the aspects of puberty considered a salient precursor of psychopathology (Graber, 2013; Kaltiala-Heino et al., 2003). Sex differences in the onset of secondary characteristics (i.e., earlier among girls than boys), underlying hormonal changes, as well as social implications of maturing, place girls at a higher risk of psychopathology than boys. The early timing hypothesis posits that adolescents, espe-

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cially girls, who mature too early have less time to acquire and assimilate the necessary skills to successfully adapt to social pressure and experiences associated with sexual maturity (Peskin, 1973). The off-time or deviance hypothesis proposes that adolescents who mature earlier or later than expected have more adjustment difficulties because they face milestones at an atypical developmental age (Ge & Natsuaki, 2009; Petersen & Crockett, 1985; Petersen & Taylor, 1980). Both hypotheses have received empirical support. Early pubertal timing has been associated with depressive and anxiety symptoms, and behavioral problems and high-risk behaviors such as early onset of substance use (Kaltiala-Heino et  al., 2011; Mendle et  al., 2010). Moreover, among boys, late pubertal timing has been also associated with psychopathology in (mostly) cross-sectional studies (Graber et  al., 1997; Rudolph, 2014). Early-maturing girls are at a higher risk for depressive symptoms than are on-­ time or late-maturing girls (Ge et  al., 2001). Among boys, some studies have found that both early and late pubertal timing are related to depressive symptoms (Benoit et al., 2013; Conley & Rudolph, 2009). Growing evidence suggests that early or late pubertal timing may predict suicide ideation and attempts. A study with a large national representative sample of adolescents, the National Longitudinal Study of Adolescent to Adult Health or Add Health, found a cross-sectional link between pubertal timing and suicide attempts among ninth graders but not among 11th graders (Fried et al., 2013). In another sample, perceived early pubertal development predicted suicide attempts more strongly among girls than among boys (Wichstrøm, 2000). In a clinical sample, Ortin and Miranda (2020) found that girls with younger age at menarche started thinking about suicide earlier than did girls with later menarche. In cross-sectional studies, girls with a younger age at menarche report more past-year suicide ideation (Lee et al., 2020), more lifetime suicide ideation, but not more suicide attempts (Chen et al., 2017), and lifetime self-harm with suicidal intent (Roberts et al., 2020) than girls with normative or older age at menarche.

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Several factors seem to affect the onset of pubertal changes. One is early exposure to adversity, especially sexual abuse (Mendle et al., 2011, 2016; Ryan et  al., 2015). A recent study using self-report and biological measures of pubertal development found that experiences of threat, but not neglect, were associated with advanced pubertal age, which, in turn, was associated with greater depressive symptoms. Furthermore, exposure to deprivation was associated with delayed pubertal age (Sumner et al., 2019). These findings support the Dimensional Model of Adversity and Psychopathology (DMAP), suggesting different mechanisms through which experiences of threat and deprivation may increase the risk for suicide. Another study has provided support for the cumulative adversity model. Gur et al. (2019) found that a higher load of traumatic stress, including lifetime exposure to natural disasters; witnessing someone getting killed, badly beaten, or die; and/or ever experiencing a sexual assault, was associated with completing puberty at an earlier chronological age and with higher mood/anxiety symptoms. Taken together, these findings suggest that exposure to specific forms of early adversity may increase the risk for developing mental health problems through the acceleration of the onset of pubertal development. This hypothesis has been tested with age at first intercourse. In the Add Health sample, early pubertal timing was identified as a mediator of the association between exposure to sexual abuse before age 6 and younger age at first intercourse; however, it did not mediate the physical abuse-age at first intercourse association (Ryan et  al., 2015). Future studies should test whether exposure to different types of maltreatment early in life leads to suicidal behavior through an accelerated onset of pubertal changes.

Reproductive Considerations In the last section of this chapter, we provide a description of studies conducted on suicide risk and the menstrual cycle, which has been considered as a relevant factor in clarifying the gender

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paradox in suicide, mentioned earlier in this chapter. We note that most studies examining the relation between the menstrual cycle and suicide ideation and attempts have primarily focused on women older than 18 years of age. Few studies have focused on adolescents, and some studies combine samples with adolescents, young adults, and middle-aged women. Thus, distinguishing risk by age group is not feasible, given the current state of the field. Nevertheless, these findings are informative in demonstrating how changes throughout the menstrual cycle may be related to suicidal behaviors and open a promising area of research on youth suicide risk. Before reporting research on menstrual phases and suicidal behavior, a brief discussion of the menstrual cycle is warranted. The menstrual cycle is conventionally studied using a 28-day  cycle, but there is variability in cycle length (usually between 23 and 32 days; Cole et al., 2009). The first day of menstruation (menses) marks the beginning of a new menstrual cycle. Each cycle is divided into the follicular and luteal phase, and each phase is subdivided into early-, mid-, and late-follicular/luteal phases. Menstruation denotes the beginning of the follicular phase, while ovulation marks the beginning of the luteal phase. Levels of progesterone, estradiol, and luteinizing hormones are low during the first (early and mid) stages of the follicular phase. However, levels of estradiol and luteinizing hormones peak around day 13 and decrease immediately prior to ovulation, marking the onset of the luteal phase. Progesterone and estradiol peak during the earlyand mid-stages of the luteal phase. Given the fluctuation of reproductive hormones throughout the menstrual cycle, suicide research in reproductive-age women has primarily focused on the association between phases of the menstrual cycle and suicidal behavior. Women report greater suicide intent and suicide attempts during menstruation (early-follicular phase) relative to other phases of the menstrual cycle (Baca-Garcia et  al., 2009) and are more likely to attempt suicide when estrogen and progesterone levels are low; suicide attempts during this time are often more severe than suicide attempts when levels of estrogen and progester-

3  Early Childhood Adversity, Stress, and Developmental Pathways of Suicide Risk

one are high (Baca-Garcia et al., 2009). A recent meta-analysis indicates that women are 27% more likely to die by suicide, 17% more likely to attempt suicide, and 20% more likely to be hospitalized for a psychiatric admission during menstruation compared to other phases of the menstrual cycle (Jang & Elfenbein, 2018). Although this research is compelling and ­provides the field with an understanding of which menstrual cycle phase places reproductive-age women at increased risk for suicidal behaviors, the mechanisms that explain these associations are poorly understood. Synthesizing knowledge from menstrual cycle phases and reproductive hormones as predictors of suicidal behaviors, other studies have examined menstrual-cycle-related conditions as suicide risk factors. Premenstrual syndrome, commonly known as PMS, is characterized by cognitive, physiological, and affective changes that may sometimes interfere with occupational, educational, and interpersonal domains of women’s lives (Lee et al., 2006; Quintana-Zinn et al., 2017). PMS occurs in the late-luteal phase of the menstrual cycle (prior to menstruation), and the symptoms experienced in this phase affect multiple domains of women’s health, including emotional, behavioral, and interpersonal domains (Schmelzer et al., 2015). Unlike PMS, premenstrual dysphoric disorder (PMDD) is a clinical diagnosis conceptualized as a more severe form of PMS.  Approximately 2–6% of women are diagnosed with PMDD and women who meet the criteria for this diagnosis report significant impairment and disability (American Psychiatric Association, 2013; Halbreich et  al., 2003). PMDD is characterized by severe physiological, cognitive, and affective symptoms that begin prior to menstruation and subside within a few days of menstruation (American Psychiatric Association, 2013). In a nationally representative study, women with PMDD reported a higher prevalence of suicidal thoughts (37%), plans (19%), and attempts (16%) than women with no symptoms or with moderate/ severe PMS (Pilver et  al., 2013). Moreover, PMDD is highly comorbid with many psychiatric conditions, including depression, anxiety, sub-

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stance abuse, somatoform disorder, and suicidal behaviors (Hong et al., 2012). Menstrual pain is a unique type of pain that girls and women of reproductive-age experience. Menstrual pain can be conceptualized as an intermittent, reoccurring type of pain, because most women may experience it before or during their menstrual cycle (approximately once a month). Because menstrual pain is reoccurring, women may perceive it as unbearable and inescapable. Given that severe menstrual pain can interfere with occupational responsibilities, it can become a burden and increase the risk of suicidal behavior. Girls who experience menstrual pain are more likely to seriously consider, plan, and attempt suicide than their peers without menstrual pain (Lee et  al., 2006). Still, all women who experience menstrual pain do not engage in suicidal plans and attempts. Therefore, other factors may explain this relation. Pain catastrophizing has emerged as a cognitive risk factor in chronic pain (Racine, 2018). Evidence indicates that girls with a chronic pain diagnosis report higher levels of menstrual pain catastrophizing and anxiety sensitivity than girls without chronic pain (Payne et al., 2016). In fact, pain catastrophizing predicts menstrual pain ratings in girls with chronic pain. However, girls with a chronic pain diagnosis have been found to report similar acute pain ratings during a cold pressor task (requires placing the forearm into cold water to generate mild to moderate pain), highlighting the pivotal role that pain catastrophizing plays in perceptions and experiences of menstrual pain (Payne et al., 2016). These findings are in line with previous work highlighting the comorbidity between chronic pain and menstrual pain (Olafsdottir et  al., 2012; Zondervan et al., 2001). Pain catastrophizing is also associated with suicide ideation and suicide attempts (Legarreta et  al., 2018). In fact, among patients who experience chronic pain, pain catastrophizing is associated with suicide ideation severity after adjusting for symptoms of anxiety and depression (Edwards et  al., 2006). This highlights the unique contribution of chronic pain in suicide risk. Recent work demonstrates that pain catastrophizing prospectively predicts suicide

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ideation after adjusting for depression, perceived burdensomeness, and thwarted belongingness, among other variables (Noyman-Veksler et  al., 2017). Relatedly, pain catastrophizing also predicts pain severity, sensory pain, affective pain, and depression among patients with chronic pain (Noyman-Veksler et  al., 2017). Understanding the cognitive underpinnings of pain ­catastrophizing and its relation to suicide ideation and attempts among adolescent girls is a critical step in identifying the unique risk among adolescent girls. The literature reviewed above contains many limitations. First, most studies rely on cross-­ sectional designs, retrospective assessments, and descriptive data. Causal inferences are limited, and the mechanisms underlying differences in suicidal behaviors are poorly understood. Moreover, although pain catastrophizing is associated with suicide attempts, most studies have measured lifetime suicide ideation or attempts; therefore, our understanding of the predictive effects of pain catastrophizing on suicidal behavior is limited. Second, future research should distinguish between state and trait pain catastrophizing when assessing suicide risk in girls and women. Next, the temporal context in which pain catastrophizing takes place must be clearly delineated. Do girls and women engage in pain catastrophizing during the late-luteal phase of the menstrual cycle? Do they continue to catastrophize their pain during the early-follicular phase? Is pain catastrophizing specific to menstrual pain or does it translate to other somatosensory symptoms? Finally, the conundrum that women report severe symptoms of PMS or PMDD during the late-luteal phase but report higher rates of suicidal behaviors during the early-follicular phase while on menstruation should be addressed. One viable avenue to assess this question is by using daily diaries or ecological momentary assessments (EMA) to measure different aspects of pain in vivo as well as suicide ideation and attempts and cognitive risk factors such as pain catastrophizing. By using EMA assessments, health researchers can capture nuances in cognitive-affective changes and pain severity fluctuations throughout the day. EMA

also allows researchers to obtain qualitative information that may explain the specific thoughts a girl or woman has while she is experiencing menstrual pain. Combining EMA assessments with short-term longitudinal studies can allow researchers to understand how pain catastrophizing increases suicide risk.

Conclusion The biological consequences of childhood adversity that predict suicidal behavior span multiple bodily systems and levels of analysis, demonstrating the complexity of the mechanistic pathway from maltreatment to suicide. While this body of literature is promising, a meta-analysis (Chang et al., 2016) showed that biological risk factors identified thus far only predict suicide attempts weakly, and many of these effects become non-significant when adjusting for publication bias. Several challenges can be addressed to inform future research on mechanisms linking maltreatment and suicide. First, while many studies have examined the biological vulnerabilities associated with either maltreatment or suicide, more research concurrently targeting both constructs is needed. Further, a greater focus on key developmental periods and milestones linked to heightened suicide risk, namely early adolescence and puberty, is warranted. In sum, early experiences of maltreatment are well-established risk factors for suicide and suicidal behavior. Information about the mechanisms through which maltreatment increases suicide risk is key to identify targets of intervention. Treatments tailored to address these mechanisms have the potential to curb the emergence of suicidal behavior in youth.

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4

Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework Richard T. Liu, Anastacia Y. Kudinova, Aliona Tsypes, and Shayna M. Cheek

Introduction Whereas much of the prior literature has examined the relations between sociodemographic and psychiatric factors associated with suicide risk among youth, the neurobiology of youth suicidal thoughts and behaviors (STBs) is a relatively new but rapidly growing area of research focused on brain-behavior mechanisms involved in STBs. Given the demonstrated difficulty predicting suicide (Franklin et al., 2017) and limited efficacy of interventions targeting suicidal youth (Ougrin et al., 2015), advancing what is known about neurobiological factors related to STBs among youth is a key direction for research focused on youth R. T. Liu () Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA e-mail: [email protected] A. Y. Kudinova Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA e-mail: [email protected] A. Tsypes Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA e-mail: [email protected] S. M. Cheek Department of Psychology and Neuroscience, Duke University, Durham, NC, USA e-mail: [email protected]

suicide risk. An increased understanding of the neurocircuitry underlying STBs could inform the development of novel interventions that target specific neurobiological mechanisms. First introduced in 2009, the Research Domain Criteria (RDoC) initiative provides a useful dimensional framework for psychopathology research focused on transdiagnostic understanding of mental health (Cuthbert, 2014). Particularly well-suited for suicide risk research, the RDoC framework captures the full spectrum of mental disorders while also addressing the co-­occurrence and heterogeneity limitations of categorical approaches to psychopathology research (Glenn et al., 2018). As such, the continuously evolving RDoC framework organizes psychopathological mechanisms according to seven units of analysis (genes, molecules, cells, circuits, physiology, behavior, self-report) among five transdiagnostic domains (Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Social Processes, Arousal, and Regulatory Systems) at present. This chapter mainly focuses on the relevant neurobiological research within the domains of Cognitive Systems, Positive Valence Systems, and Negative Valence Systems due to these domains having particular conceptual relevance to suicide risk in youth. Furthermore, for this chapter, we focused primarily on task-based measures of neurocognitive functioning in relation to youth suicide, complementing an excellent recent review on this topic (Stewart et  al.,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_4

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2019a; for a comprehensive recent review of relevant neuroimaging literature, see Auerbach et al., 2021).

 ognitive Systems and Youth C Suicide Falling within the RDoC domain of Cognitive Systems, neurocognitive function may hold particular interest, as it has been recognized as a promising candidate for short-term risk for suicidal behavior (Glenn & Nock, 2014; Homaifar et al., 2012; National Action Alliance for Suicide Prevention, 2014). Neurocognitive function is an umbrella term that encompasses multiple distinct processes. Of the various neurocognitive functions that have been subject to empirical study, executive function may be of special relevance from a developmental perspective to adolescent suicide. This is because the prefrontal cortex, responsible for executive function, is the brain region that experiences the most pronounced development during adolescence (Lupien et  al., 2009). The slower development of the prefrontal cortex relative to other brain regions (e.g., amygdala) in adolescence may in part explain increases in risky behaviors, such as suicide attempts, at this age (Casey et  al., 2008, 2011; Steinberg, 2007, 2010; Windle et al., 2018). According to one prominent model of executive function (Diamond, 2013; Miyake et  al., 2000; Shields et  al., 2016), it involves: (i) the ability to switch between tasks or mental “sets” (i.e., cognitive flexibility); (ii) the ability to avoid or suppress pre-potent responses (i.e., inhibition of impulsive action); and (iii) the ability to monitor and control the contents of working memory. Of these, inhibition of impulsive action, along with inhibition of impulsive choice,1 is commonly conceptualized as part of the broader construct of impulsivity (Hamilton et  al., 2015a,

Impulsive choice (e.g., as indexed with delay discounting paradigms) is represented in the RDoC matrix under the Positive Valence Systems construct of reward valuation, and so will be discussed below in our coverage of positive valence. 1 

R. T. Liu et al.

2015b; Winstanley et al., 2006). Executive function is therefore encompassed by the Cognitive Systems constructs of cognitive control and working memory, with (i) cognitive flexibility captured by the cognitive control subconstructs of goal selection, updating, representation, and maintenance; (ii) inhibition of impulsive action falling under the cognitive control subconstructs of response selection and inhibition/suppression; and (iii) working memory being its own Cognitive Systems construct. Although cognitive inflexibility has long been viewed as characterizing suicidal individuals (Neuringer, 1964; Patsiokas et al., 1979), this is a relatively emergent area of research, and all studies to date have been conducted exclusively with adult samples (Bredemeier & Miller, 2015). There is some support for greater cognitive inflexibility in suicidal individuals relative to clinical and healthy controls, but with most of this support coming from performance on the Stroop test (Richard-Devantoy et  al., 2014). Additionally, only two longitudinal studies, based on the same sample of young adults, have been conducted in this area. In these studies, cognitive inflexibility, as indexed by the Wisconsin Card Sort Test, prospectively predicted suicidal ideation 6 and 2–3  years later (Miranda et  al., 2012, 2013). Thus, despite the importance of prefrontal cortical development in adolescence, to what degree cognitive inflexibility is related to risk for suicidal ideation or behavior in youth is currently unclear. The second component of executive function, inhibition of impulsive action, may also be of particular relevance to risk for adolescent suicide from a developmental perspective. In particular, not only is impulsivity more pronounced during this developmental period than in adulthood (Galvan et  al., 2007; Harden & Tucker-Drob, 2011; Steinberg et al., 2008, 2009), but it is also more strongly linked, albeit at the trait level, with suicide attempts (Kasen et al., 2011) and deaths (McGirr et al., 2008) in adolescence than later in life. With regards to neurocognitive indices of impulsive action, according to a recent meta-­ analysis (Liu et al., 2017), 23 studies have been conducted to date examining its relation with sui-

4  Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework

cidal ideation and behavior, four specifically with adolescent samples, and a fifth has been published since this meta-analysis (Zelazny et  al., 2019). Across these studies, there was an overall relation between impulsive action and suicidal behavior. It is interesting to note that functioning of the ventrolateral prefrontal cortex, particularly the right inferior frontal gyrus, has been implicated in impulsive action (Aron et  al., 2003; Winstanley et al., 2006) and that prior reviews of brain imaging studies of suicidal individuals also found the greatest structural and functional differences in some relevant parts of the prefrontal cortex (Auerbach et  al., 2021; van Heeringen et  al., 2011; van Heeringen & Mann, 2014). Nonetheless, none of the aforementioned studies were longitudinal, leaving unclear whether state differences in impulsivity are concomitants or risk factors for suicidal behavior. The third component of executive function is working memory, which involves actively holding and manipulating multiple pieces of information in mind, and thus differs from other forms of memory, such as short-term memory, which involves serial reproduction of encoded and transitory information (Conway & Engle, 1996; Goldman-Rakic, 1996). The association between working memory and suicidal behavior was found to have a small effect size in a meta-­ analysis of 10 studies (Richard-Devantoy et  al., 2015). None of the included studies, however, were longitudinal or featured adolescent samples. Indeed, to our knowledge, no studies have been conducted examining working memory deficits in suicidal adolescents, despite the potential for working memory to advance short-term suicide risk prediction (Glenn & Nock, 2014). Overall, there appears to be substantial evidence implicating executive function deficits in suicide risk, but with existing support for this association coming almost exclusively from research with adult samples. Thus, the relevance of aberrant executive functioning to suicidal ideation and behavior in adolescence remains largely undetermined. Even in the adult literature, relying almost entirely on cross-sectional findings, the issue of whether executive function is a concomitant or risk factor for these outcomes cannot

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be answered in the absence of longitudinal research. This is important because beyond the question of whether executive function is a risk factor for suicidal ideation and behavior in youth is the issue of what such an association offers in terms of translational potential. That is, although establishing the temporal precedence of executive function aberrations in relation to suicidal ideation and behavior in youth may be beneficial for identifying at-risk individuals, it leaves uncertain whether, or perhaps how, these executive function processes may be meaningful targets for clinical intervention in these individuals. Indeed, a recent meta-analysis of executive function training studies in children (Kassai et al., 2019) found that although near-transfer effects were obtained (i.e., training on a task measuring an executive function led to improved performance on other tasks measuring the same executive function), there was no compelling evidence in support of far-transfer effects to other components of executive function (i.e., training on a task measuring one component of executive function leading to improvement on another untrained component). Although far-transfer effects from one component of executive function to others is not the same as far-transfer to clinical outcomes influenced by the targeted component, the findings of this meta-analysis indicate that experimental research investigating the clinical effects of modulating executive function on suicide-related outcomes is an important next step after a temporal association between executive function and adolescent suicide risk is established.

 ositive Valence Systems and Youth P Suicide The Positive Valence Systems (PVS) of the RDoC encompasses multiple aspects of reward-­ related processes, represented via the constructs of reward responsiveness, reward learning, and reward valuation. Reward-related processes are of high relevance for the understanding of adolescent suicidal behavior because of the promi-

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nent changes in these processes during adolescence. Indeed, ample empirical evidence supports the dual systems model of adolescent development, according to which it is the interaction between rapidly developing heightened reward sensitivity and much slower development of cognitive control that predisposes middle and late adolescents to dangerous behaviors, including suicide attempts (Shulman et al., 2016). The RDoC construct of reward responsiveness (i.e., hedonic responses to anticipated and obtained rewards) includes the subconstructs of reward anticipation, initial response to reward, and reward satiation, with the former two being most relevant to adolescent suicidal behavior. Most studies that have specifically examined initial response to reward in relation to STBs have done so by using the Doors task (Carlson et al., 2011)—a version of the Simple Guessing Task paradigm recommended by the RDoC for the assessment of this subconstruct—during which continuous electroencephalography (EEG) is recorded to elicit the Reward Positivity (RewP) event-related potential (ERP). Quantified as the difference between neural responses to monetary gains and neural responses to monetary losses and associated with reward-related activation in the ventral striatum and medial prefrontal cortex (Carlson et al., 2011), this component is thought to represent an objective quantifier of initial response to reward. Growing evidence indicates the presence of alterations in initial response to reward across different age groups and forms of STBs, including children with recent (i.e., past 2 weeks) suicidal ideation (Tsypes et al., 2019), children with a parental history of suicide attempts (Tsypes et  al., 2017), children with a history of nonsuicidal self-injury (NSSI; Tsypes et  al., 2018), depressed adolescents with active STBs (i.e., at least subthreshold active suicidal ideation or suicidal acts; Pegg et al., 2020), and adults with suicide attempt history (Tsypes et al., 2020). Although overall indicative of suicide risk-related impairments in initial response to reward, the results are mixed with regard to the direction of these impairments. Specifically, whereas depressed adolescents with active STBs (Pegg et al., 2020) and children with a parental

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history of suicide attempt (Tsypes et  al., 2017) and personal history of NSSI (Tsypes et  al., 2018) exhibited an enhanced RewP to rewards versus losses, children with recent suicidal ideation exhibited the opposite pattern of responsiveness (i.e., blunted RewP; Tsypes et al., 2019). Further, although adult suicide attempters did not differ from adult non-attempters in their RewP magnitude, they also exhibited abnormalities in initial response to reward, as evidenced by reduced gain-related delta power (Tsypes et al., 2020). Taken together, current evidence supports a link between engagement in different forms of STBs and altered initial response to reward, but further research is needed to clarify the nature of these abnormalities, particularly in youth. The RDoC has recommended the Monetary Incentive Delay task (Knutson et al., 2001) as the experimental paradigm best-suited to assess the subconstruct of reward anticipation. Although reward anticipation deficits are understudied in relation to adolescent STBs, there is growing converging evidence from the studies that used this task suggesting that STBs are also linked with blunted responding to reward-predictive cues. For example, an fMRI study that focused on self-injury (including both suicide attempts and NSSI) uncovered lower neural reactivity to reward-predictive cues in the striatum (putamen), orbitofrontal cortex, and bilateral amygdala in adolescent self-injuring girls, compared to those without a history of self-injury (Sauder et  al., 2015). Further, a study that used reward anticipation-­related ERPs found blunted cue-P3 ERP component thought to capture the allocation of attention toward reward-predicting stimuli that motivates subsequent reward-seeking behavior (Glazer et al., 2018; Novak et al., 2016; Novak & Foti, 2015) in adult suicide attempters, compared to non-attempters (Tsypes et al., 2020). Overall, there is some evidence for blunted reward anticipation in those who engage in suicidal and nonsuicidal self-injury, but significantly more empirical work is needed in this area of inquiry. The RDoC construct of reward learning (i.e., processes involved in obtaining and using reward-­ related information to guide behavior) includes the subconstructs of probabilistic and reinforce-

4  Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework

ment learning, reward prediction error, and habit-­ PVS. Although the former two subconstructs are likely highly relevant for suicidal behavior across the lifespan, most studies to date have focused on elucidating the mechanisms of disrupted reward learning in suicidal behavior in samples of older adults. A recent study that included two samples of adults between ages 42 and 82 uncovered a pattern of findings indicative of reward learning and value-based choice impairments in suicide attempters during a three-armed bandit task (Dombrovski et  al., 2019). Specifically, suicide attempters exhibited deficits in learning based on the outcomes of their choices as well as impairments in the ability to compare the values of available options in order to make an optimal choice (Dombrovski et al., 2019). The pattern of these learning deficits is similar to the one demonstrated in a prior study, with older (i.e., aged 60 and older) suicide attempters displaying a tendency to make decisions based on the consequences (i.e., reward or punishment) of the last trial, rather than on learning history throughout the entire task (Dombrovski et al., 2010). Further, in line with the evidence for impaired value comparisons, there is growing converging evidence from fMRI and reinforcement learning models demonstrating blunted expected value signals (i.e., the signals updated through a discrepancy between the anticipated versus actually obtained outcome—prediction error—on each trial) in the ventromedial prefrontal cortex (vmPFC) in older adult suicide attempters (Brown et  al., 2020; Dombrovski et  al., 2013). Taken together, substantial evidence points at disruptions in reward learning in suicide attempters, which appear to be largely driven by impairments in value comparisons. However, it will be important to examine the generalizability of these findings to younger samples. The RDoC construct of reward valuation (i.e., processes involved in computing the probability and benefits of a prospective outcome) includes the subconstructs of reward (probability), delay, and effort. Empirical evidence is suggestive of the relevance of reward valuation to adolescent suicidal behavior, with most research attention dedicated to the latter two subconstructs. Delay

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discounting (subconstruct: delay) refers to the degree to which future rewards are devalued as a function of the delay to the receipt of these rewards. In delay discounting paradigms, individuals are asked to choose between a smaller amount of reward available sooner and a larger amount of reward available after a longer delay. Discount rates are high if there is exaggerated preference for immediate over delayed rewards and low if delayed rewards have high value. Delay discounting is highly relevant for suicidal behavior because it assesses the mental processes that an individual undergoes in order to compare the choices they can make at a given time point. For example, they could decide to make a suicide attempt to escape from a seemingly hopeless situation, or they could choose to tolerate their current distress in order to come up with a different solution that does not involve a suicide attempt. There is some evidence that high delay discounting has been linked with certain forms of suicidal behavior in adolescents, including multiple suicide attempts in adolescent girls (Mathias et al., 2011) and suicide attempts in adolescents who engage in nonsuicidal self-injury (Dougherty et  al., 2009). Notably, however, there are also studies that failed to find a link between altered delay discounting and suicidal behavior across several age groups, including adolescents (e.g., Bridge et al., 2015). Effort-cost computation processes (subconstruct: Effort) refer to the value computations in relation to a reinforcer as a function of the magnitude of this reinforcer and the perceived costs of the actions required to obtain it. In effort-cost computation paradigms, participants are required to choose between an easier option that would yield a smaller reward or a more difficult option for a larger reward. A study that compared depressed adolescent suicide ideators with attempters found lower preference for the difficult higher valued option in the attempters, compared to ideators (Auerbach et  al., 2015). Interestingly, this difference between the ideators and attempters emerged only on the trials when rewards were uncertain, with suicide attempters’ future decision-making not being influenced by the reward receipts (Auerbach et al., 2015).

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In summary, although all of the PVS constructs of the RDoC are relatively understudied in relation to suicide risk, particularly in adolescents, there is strong growing evidence suggestive of deficits in reward responsiveness, reward learning, and reward valuation in individuals with STBs. It may be that the reward-related deficits identified by prior research contribute to the decision-making processes that ultimately lead to a suicide attempt. Specifically, convergent evidence across the PVS constructs of the RDoC suggests that deficient initial responses to reward disrupt the ability to accurately anticipate future rewards and learn from experience. In suicidal crisis, these deficits might hinder the ability to generate and evaluate alternatives to suicide. It will be important for future studies to examine whether the effects uncovered in primarily adult samples replicate in adolescent samples. Further, to clarify the mixed findings, future research will need to examine numerous important moderators that likely contribute to the mixed findings in the literature, including the recency and severity of STBs. In addition, a recent review of the pathways through which reduced PVS activation might emerge across development (Kujawa et al., 2020) suggests the presence of three possibilities for these atypical trajectories (i.e., chronically low PVS function, accelerated development of PVS function, and stress reactive PVS function), which might also contribute to inconsistencies in prior research on PVS in STBs and thus requires further empirical investigation.

 egative Valence Systems in Youth N Suicide In the RDoC matrix, negative valence systems manage our responses to aversive or challenging circumstances (e.g., loss). These processes are key risk factors for suicidal ideation, suicide attempts, and death by suicide (Glenn et  al., 2018). Here, we focus on responses to loss (grief, rumination, depressed mood), as well as acute and potential threats (fear and anxiety, respectively), as they are among the central components of the negative valence system identified by the

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RDoC committee (National Institute of Mental Health, 2011) and are particularly relevant to STBs. Loss implies being deprived of a range of social and nonsocial factors, such as relationships, loved ones, personal health, behavioral control, or shelter (National Institute of Mental Health, 2011). Responses to loss can be transient or sustained and vary on how well they respond to treatment depending on a range of factors, including the timing and type of loss and a multitude of individual characteristics (Gollier-Briant et al., 2016; Klass et al., 2009; Łosiak et al., 2019; Nishikawa et al., 2018; Yue et al., 2016). Indeed, specific types of loss have a uniquely strong impact on suicidal behavior. Specifically, adults who attempted suicide had experienced a greater number of major interpersonal negative life events (e.g., divorce) versus non-interpersonal life events (e.g., physical injury) during the 3 months preceding their attempt. (Conner et al., 2012). Interpersonal negative life events also served as triggers for suicide attempts in adults, as they occurred more often on the day of an attempt compared to the days leading up to attempts (Bagge et al., 2013; Conner et al., 2012). Consistently, negative life events that belong to two specific categories, love–marriage and crime–legal, prospectively predicted a suicide attempt within the following 1–2  months (Yen et al., 2005). Similarly, negative interpersonal life events of a forensic and interpersonal nature had occurred more often among young adults who died by suicide in the week leading up to the suicide compared to those with no history of attempts (Cooper et  al., 2002). Together, these findings suggest that experiencing a severe negative life event, specifically within an interpersonal domain, is a robust proximal risk factor and a trigger for suicide attempts in adults. Research in adolescents to date has mainly focused on the link between negative life events and suicidal ideation rather than behavior. As interpersonal relationships are of paramount significance in adolescence (Somerville, 2013), a robust positive link between interpersonal life stress and suicidal ideation in the community as well as clinical settings is not surprising (Arnett,

4  Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework

2014; Collins et  al., 2009; Glenn et  al., 2018; Hardt & Johnson, 2010; King et al., 2001; Liu & Miller, 2014; Mackin et  al., 2017; Steinberg, 2001; Tang et  al., 2015; Whitlock et  al., 2014). Psychiatrically hospitalized adolescents who had gone through a major loss event experienced increased STBs, mainly suicidal ideation, in the 3 months following the loss (Daniel et al., 2017). A loss of a romantic relationship (i.e., a break­up) was also linked to increased suicidal ideation and risk in Australian, South African, and US youth (George & van den Berg, 2012; Price et al., 2016). Limited research that examined negative life events and suicidal behavior found that, among psychiatrically hospitalized adolescents, the number of recent (i.e., 3–12 months prior to hospitalization) interpersonal negative life events differentiated adolescents who attempted suicide from those who experienced suicide ideation only and psychiatric controls (Stewart et  al., 2019b). Exposure to negative life events also served as a mediator in the relation between childhood adversity and suicidal behaviors later in life, highlighting the potential for negative life events to exacerbate childhood vulnerabilities to STBs (Fergusson et al., 2000). Given the particular relevance of interpersonal negative life events for adolescence, longitudinal research that examines their predictive power and underlying neurobiological mechanisms in relation to suicidal behavior and pinpoints the time period of increased risk in youth is warranted. The ventral and dorsal striatum, insula, orbitofrontal cortex, prefrontal cortex, and anterior cingulate cortex are brain areas involved in a response to or an anticipation of loss that have been identified via the use of laboratory paradigms among individuals with no mental illness history (Delgado et  al., 2000, 2003; Oldham et  al., 2018; Tom et  al., 2007). Increased functional connectivity during loss trials was observed between the ventral striatum and orbitofrontal cortex, as was a greater involvement of amygdala in the network (Camara et al., 2008). Intriguingly, depressed adults with a history of suicide attempts evidenced greater aversion to loss compared to both nonsuicidal depressed individuals and individuals with no history of depression or suicidal

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behavior, and that aversion was linked to differential insula reactivity to loss (Baek et al., 2017). These findings suggest that individuals with a history of suicidal behavior may have differential neural processing of loss. However, future research examining the neural responses to different types of loss, including interpersonal loss in the context of STBs, is needed to identify potential neural markers of suicide risk and treatment targets. One of the key underlying molecular mechanisms for the association between interpersonal loss and STBs may be dysregulation of the immune system responses. Indeed, interpersonal loss and social rejection have been linked to increased peripheral levels of increased inflammatory markers in adolescents and adults (Fagundes et  al., 2019; Murphy et  al., 2013; Schultze-Florey et  al., 2012). In turn, immunotherapy used to treat health conditions such as hepatitis C or multiple sclerosis has been shown to lead to increased STBs in adults who had no suicidal ideation prior to starting immunotherapy (Brundin et  al., 2017; Fragoso et  al., 2010). However, studies that specifically examine whether immune processes are among the molecular mediators of the association between interpersonal loss and STBs in youth are needed to inform their use as risk markers or the potential of targeting these mechanisms in treatment. Responses to a sustained threat constitute another significant construct of the negative valence systems that play a key role in the etiology and pathology of STBs. Several convergent lines of research have examined the association between STBs and responses to sustained early life stressors, including childhood abuse and neglect, peer victimization, and bullying (Glenn et al., 2018). The findings in this area suggest that experiences of childhood abuse and neglect are linked to suicide attempts in youth and adults (Björkenstam et  al., 2017; Joiner et  al., 2007; Thompson et  al., 2019; Ystgaard et  al., 2004). Recent meta-analytical findings show that individuals who experience any type of childhood abuse, including physical, emotional, or sexual abuse, had two to three greater odds of attempting suicide during their lifetime, and having a

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history of sexual and complex forms of abuse was linked to a five-fold higher odds in attempting suicide (Angelakis et al., 2019). This association seems to traverse different countries and cultures (Adeyemo et  al., 2020; Bruwer et  al., 2014; Fergusson et  al., 2013). The odds of attempting suicide seemed to increase proportionally to the number of adverse childhood experiences (Raleva, 2018). Similarly, peer victimization and traditional bullying and cyberbullying are well-­established robust predictors of STBs (John et  al., 2018; Koyanagi et  al., 2019; Nesi et  al., 2020; van Geel et  al., 2014). Being bullied prospectively predicted STBs 2  years later in youth, and those who were still being bullied 2  years later showed a fivefold increase in suicide attempts (Geoffroy et al., 2016). Bullying appears to negatively affect adolescents on both sides of peer victimization, as self-harm and suicidal behavior were increased not just among youth who were being cyberbullied, but also the perpetrators, themselves (John et  al., 2018). Additionally, peer experiences involving social rejection have been found to prospectively predict suicidal ideation and suicide attempts in adolescents (Cheek et  al., 2020). Overall, experiencing sustained threat types of events early in life, including childhood abuse, peer victimization, and bullying, robustly increases lifelong suicide risk. Findings from neuroimaging studies show that the brain areas that are consistently structurally and functionally affected by childhood abuse are the lateral and ventromedial fronto-limbic regions involved in behavioral and affect control (Hart et al., 2017; Hart & Rubia, 2012). Similar areas were shown to be sensitized in chronically peer-victimized adolescents during a risk-taking paradigm (Telzer et al., 2018). Stimuli related to cyberbullying elicited greater activation in the middle temporal gyrus and posterior cerebellum clusters, brain areas that are involved in social cognition and processing of emotions, compared to neutral stimuli, among adolescents with a history of cybervictimization (McLoughlin et  al., 2020; Schienle & Scharmuller, 2013; Zahn et al., 2007). Adolescent girls with a history of peer victimization evidenced differential activation in the

anterior cingulate cortex and insula, areas that comprise the social pain network, during a social exclusion paradigm (Rudolph et  al., 2016). Critically, structural and functional alterations in fronto-limbic circuitry were noted in relation to STBs in both adolescents and adults, highlighting the need to examine whether these structural/ functional differences mediate the link between childhood adversity and later suicide risk in youth (Balcioglu & Kose, 2018; Ding et  al., 2015; Johnston et al., 2017; Monkul et al., 2007; Pan et al., 2015). Collectively, separate lines of evidence exist in support of the position that: (i) loss-related stressors, particularly within interpersonal domains, are related to risk for STBs; (ii) suicidal individuals may have increased neural sensitivity to loss; (iii) loss-related experiences may affect suicide risk through eliciting immune activation; (iv) threat-related experiences, especially in the form of adverse childhood experiences, such as abuse and neglect, may confer risk for STBs; and (v) this risk may be produced through structural and functional differences in processing emotion and behavioral control.

Conclusion In conclusion, promising empirical evidence has recently emerged relative to the neurobiology of STBs among youth. This research fits well within the RDoC perspective, which takes a transdiagnostic approach toward the understanding of psychopathology. Because STBs are multi-determined and do not occur exclusively within the context of a single psychiatric diagnosis, the RDoC framework, with its emphasis on the integration across levels of analysis, including observable behavior and neurobiological measurement, provides a lens through which the neurobiology of STBs can be more effectively studied. The domains of Cognitive Systems, Positive Valence Systems, and Negative Valence Systems explored in the current chapter are of particular relevance to the neurobiology of STBs among youth.

4  Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework

Within the domain of Cognitive Systems, neurocognitive function, and in particular, executive function, may be of specific interest to the neurobiology of STBs. As it stands, there appears to be some cross-sectional evidence primarily among adults that implicates executive functioning deficits, such as cognitive flexibility and inhibition of impulsive action, in suicide risk. Future work in this area is especially needed with adolescents and featuring longitudinal designs that would allow for evaluations of what executive control features may be temporally predictive of STBs in youth. Additionally, an important next step for research in this area is to determine whether cognitive control systems identified to be aberrant and to predict STBs in youth may be modifiable, and thereby risk for STBs be potentially reduced. In terms of Positive Valence Systems, encompassing multiple aspects of reward-related processes, recent emerging evidence has begun to suggest deficits in reward responsiveness, reward learning, and reward valuation among individuals engaging in STBs. Specifically, deficiencies in initial responses to reward may disrupt the ability to effectively anticipate future rewards and learn from that experience. Thus, in a suicidal crisis, these deficits may be highly relevant to generating and valuing alternative options to suicide attempts. As with research on Cognitive Systems, the research in this area has primarily focused on adults. Although generally supportive of an association with STBs, the findings in this area have been somewhat mixed. Therefore, in addition to the need for greater empirical focus on association with STBs in youth, future work is required to elucidate potential moderators that may account for these mixed findings, and recent work (Kujawa et al., 2020) suggests that longitudinal investigations may be justified for evaluating whether aberrant trajectories in PVS may be relevant to suicide risk. Lastly, neurobiological processes implicated in Negative Valence Systems, comprised of an individual’s response to aversive circumstances and conditions, are of direct empirical and theoretical importance to the understanding of STB risk among youth. Specifically, neural sensitivity and immune activation in response to loss (spe-

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cifically of an interpersonal nature), and threat-­ related experiences, including childhood abuse and neglect and peer victimization, potentially confer risk for STBs. However, research directly evaluating these possibilities with neuroimaging and inflammatory markers, especially in the context of interpersonal loss, is required to confirm involvement and prediction of STBs in youth. Overall, promising evidence exists suggesting neurobiological deficits conferring risk for STBs, which could mechanistically underlie the decision-­making processes relevant to suicide risk. However, this research is in its nascent stages, particularly among samples of adolescents and young adults. Given normative neurodevelopment throughout adolescence and young adulthood, particularly within these domains of functioning, this gap in the literature is of considerable importance. Further, even more work is needed to integrate our understanding of the neurobiology of suicide risk in youth with broader cultural neuroscience literature. Indeed, a recent review that synthesized the foundations in cultural neuroscience within the RDoC framework provides a useful overview of how cultural variation meaningfully affects several processes within the three RDoC domains reviewed in this chapter, including positive and negative emotional experiences and a range of cognitive processes (Chiao et al., 2020). Related to this point, despite the utility of the RDoC as an organizing framework, it is important to acknowledge its limitations, such as potential creation of artificial divides between domains, constructs, and subconstructs that in real-world settings likely operate together and interact dynamically to affect acute and chronic suicide risk. Further, due to the paucity of longitudinal studies examining neurobiological factors related to STBs, the temporality of these relationships has yet to be well-established. Thus, future research on the neurobiology of youth suicide should focus on neural and immune response to threat and loss, as well as deficits in neurocognitive and reward-­ related processes, particularly among adolescents, over time. Increasing understanding of neurobiological processes related to STBs among youth may

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provide novel intervention targets to aid in suicide prevention efforts.

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R. T. Liu et al. Psychiatry, 16(8), 544–566. https://doi.org/10.3109/1 5622975.2014.925584 Rudolph, K.  D., Miernicki, M.  E., Troop-Gordon, W., Davis, M. M., & Telzer, E. H. (2016). Adding insult to injury: Neural sensitivity to social exclusion is associated with internalizing symptoms in chronically peer-victimized girls. Social Cognitive and Affective Neuroscience, 11(5), 829–842. https://doi. org/10.1093/scan/nsw021 Sauder, C.  L., Derbidge, C.  M., & Beauchaine, T.  P. (2015). Neural responses to monetary incentives among self-injuring adolescent girls. Development and Psychopathology, 28(1), 277–291. https://doi. org/10.1017/S0954579415000449 Schienle, A., & Scharmuller, W. (2013). Cerebellar activity and connectivity during the experience of disgust and happiness. Neuroscience, 246, 375–381. https:// doi.org/10.1016/j.neuroscience.2013.04.048 Schultze-Florey, C.  R., Martinez-Maza, O., Magpantay, L., Breen, E.  C., Irwin, M.  R., Gundel, H., & O’Connor, M.-F. (2012). When grief makes you sick: Bereavement induced systemic inflammation is a question of genotype. Brain, Behavior, and Immunity, 26(7), 1066–1071. https://doi.org/10.1016/j. bbi.2012.06.009 Shields, G.  S., Sazma, M.  A., & Yonelinas, A.  P. (2016). The effects of acute stress on core executive functions: A meta-analysis and comparison with cortisol. Neuroscience & Biobehavioral Reviews, 68, 651–668. https://doi.org/10.1016/j. neubiorev.2016.06.038 Shulman, E.  P., Smith, A.  R., Silva, K., Icenogle, G., Duell, N., Chein, J., & Steinberg, L. (2016). The dual systems model: Review, reappraisal, and reaffirmation. Developmental Cognitive Neuroscience, 17, 103–117. https://doi.org/10.1016/j.dcn.2015.12.010 Somerville, L. H. (2013). The teenage brain: Sensitivity to social evaluation. Current Directions in Psychological Science, 22(2), 121–127. https://doi. org/10.1177/0963721413476512 Steinberg, L. (2001). We know some things: Parent– adolescent relationships in retrospect and prospect. Journal of Research on Adolescence, 11(1), 1–19. https://doi.org/10.1111/1532-­7795.00001 Steinberg, L. (2007). Risk taking in adolescence: New perspectives from brain and behavioral science. Current Directions in Psychological Science, 16(2), 55–59. https://doi.org/10.1111/j.1467-­8721.2007.00475.x Steinberg, L. (2010). A dual systems model of adolescent risk-taking. Developmental Psychobiology, 52(3), 216–224. https://doi.org/10.1002/dev.20445 Steinberg, L., Albert, D., Cauffman, E., Banich, M., Graham, S., & Woolard, J. (2008). Age differences in sensation seeking and impulsivity as indexed by behavior and self-report: Evidence for a dual systems model. Developmental Psychology, 44(6), 1764–1778. https://doi.org/10.1037/a0012955 Steinberg, L., Graham, S., O’Brien, L., Woolard, J., Cauffman, E., & Banich, M. (2009). Age differences in future orientation and delay discount-

4  Perspectives on the Neurobiology of Youth Suicide Within an RDoC Framework ing. Child Development, 80(1), 28–44. https://doi. org/10.1111/j.1467-­8624.2008.01244.x Stewart, J.  G., Polanco-Roman, L., Duarte, C.  S., & Auerbach, R.  P. (2019a). Neurocognitive processes implicated in adolescent suicidal thoughts and behaviors: Applying an RDoC framework for conceptualizing risk. Current Behavioral Neuroscience Reports, 6(4), 188–196. https://doi.org/10.1007/ s40473-­019-­00194-­1 Stewart, J.  G., Shields, G.  S., Esposito, E.  C., Cosby, E.  A., Allen, N.  B., Slavich, G.  M., & Auerbach, R. P. (2019b). Life stress and suicide in adolescents. Journal of Abnormal Child Psychology, 47(10), 1707– 1722. https://doi.org/10.1007/s10802-­019-­00534-­5 Tang, F., Xue, F., & Qin, P. (2015). The interplay of stressful life events and coping skills on risk for suicidal behavior among youth students in contemporary China: A large scale cross-sectional study. BMC Psychiatry, 15, Article 182. https://doi.org/10.1186/ s12888-­015-­0575-­x Telzer, E.  H., Miernicki, M.  E., & Rudolph, K.  D. (2018). Chronic peer victimization heightens neural sensitivity to risk taking. Development and Psychopathology, 30(1), 13–26. https://doi. org/10.1017/S0954579417000438 Thompson, M.  P., Kingree, J.  B., & Lamis, D. (2019). Associations of adverse childhood experiences and suicidal behaviors in adulthood in a U.S. nationally representative sample. Child: Care, Health and Development, 45(1), 121–128. https://doi.org/10.1111/ cch.12617 Tom, S.  M., Fox, C.  R., Trepel, C., & Poldrack, R.  A. (2007). The neural basis of loss aversion in decision-­ making under risk. Science, 315(5811), 515–518. https://doi.org/10.1126/science.1134239 Tsypes, A., Owens, M., & Gibb, B.  E. (2019). Blunted neural reward responsiveness in children with recent suicidal ideation. Clinical Psychological Science, 7(5), 958–968. https://doi.org/10.1177/2167702619856341 Tsypes, A., Owens, M., & Gibb, B.  E. (2020). Reward responsiveness in suicide attempters: An EEG/ERP study. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. Advance online publication. https://doi.org/10.1016/j.bpsc.2020.04.003 Tsypes, A., Owens, M., Hajcak, G., & Gibb, B.  E. (2017). Neural responses to gains and losses in children of suicide attempters. Journal of Abnormal Psychology, 126(2), 237–243. https://doi. org/10.1037/abn0000237 Tsypes, A., Owens, M., Hajcak, G., & Gibb, B.  E. (2018). Neural reward responsiveness in children who engage in nonsuicidal self-injury: An ERP study. Journal of Child Psychology and Psychiatry and Allied Disciplines, 59(12), 1289–1297. https://doi. org/10.1111/jcpp.12919 van Geel, M., Vedder, P., & Tanilon, J. (2014). Relationship between peer victimization, cyberbullying, and suicide in children and adolescents: A meta-analysis. JAMA

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5

Parental and Family History of Suicidal Behaviors and Psychopathology and Suicide-­Related Risk in Youth Offspring Rhonda C. Boyd, Lillian Polanco-Roman, and Michelle Hernandez

There is a critical need for clarifying early markers of suicide to improve detection and prevention prior to the onset of suicidal behaviors in youth, considering that 50–75% of youth suicide deaths are initial attempts (McKean et al., 2018). This is particularly concerning among Black, Indigenous, and People of Color (BIPOC), for whom suicide deaths are most prevalent before the age of 30. The onset of suicidal behaviors generally occurs about a year or two following the onset of suicidal thoughts (Nock et al., 2013), leaving a narrow window for the transition from suicidal ideation to attempts. A well-supported early indicator of youth suicide risk is a family history of suicide or suicidal behaviors (Tidemalm et  al., 2011), particularly parental history R. C. Boyd () Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, USA e-mail: [email protected] L. Polanco-Roman Department of Psychology, The New School for Social Research, New York, NY, USA Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, NY, USA e-mail: [email protected] M. Hernandez Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, NY, USA e-mail: [email protected]

(Geulayov et  al., 2012; Goodday et  al., 2019a). Nevertheless, little remains known about the mechanisms underlying this shared parent-child risk for suicidal behaviors. This information could provide important knowledge about the etiology of suicide-related risk to yield novel targets as well as greater opportunities for preventive strategies to reduce youth suicide-related risk. This chapter will provide an overview of the literature on familial and parental history of suicide, suicidal behaviors, and psychopathology in relation to youth offspring suicide-related risk. We will summarize emerging evidence identifying potential pathways through which familial and parental risk for suicidal behaviors and psychiatric disorders may impact suicide-related risk in their youth offspring. The theoretical frameworks that have guided these investigations will be described. This chapter will close with clinical implications to promote bridging the gap between research and practice.

 arental and Family History P of Suicide and Youth Suicide-­ Related Outcomes Converging evidence from multiple lines of inquiry, including studies of childhood risk factors for suicide and suicidal behaviors, genetic

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underpinnings of suicide risk, and the developmental consequences of parental loss as an adverse childhood experience, suggests that a family history of suicide may increase suicide-­ related risk among youth. A meta-analytic review of 28 studies from 1976 to 2011 examined parental history of fatal and nonfatal suicidal behaviors in relation to offspring suicide and suicidal behaviors (Geulayov et  al., 2012). This review reported that offspring with a parent who died by suicide had two-fold greater odds of dying by suicide than children without a parental history of suicide. Overall, this review indicated that a family history of suicide, particularly parental history of suicide, increased odds of suicide in their youth offspring by two- to four-fold. Further, this elevated risk was independent of youth and parental psychopathology. The association was stronger at younger age of youth offspring, and maternal suicide, in particular, was a stronger risk factor than paternal suicide. The findings suggest a unique pathway from parental suicide to youth suicide that involves both genetic and environmental factors. Population-based registry studies have been instrumental in highlighting genetic influences in familial aggregation of suicide. For instance, a Swedish study found that full-siblings shared higher risk of suicide than half-siblings, monozygotic twins shared higher risk than dizygotic twins, and cousins shared higher risk than individuals with no family history of suicide (Tidemalm et  al., 2011). They also found that genetic predisposition does not fully explain the familial aggregation of suicide risk, suggesting environmental influences also play a critical role in the development of suicide risk. Specifically, the odds of siblings of a suicide decedent were three-fold higher than matched controls (i.e., individuals with no relation to a suicide decedent), whereas odds for the offspring of a suicide decedent were two-fold higher than matched controls, and maternal half-siblings shared greater risk than paternal-half siblings. A family history of suicide is also associated with an increased risk for nonfatal suicidal behaviors in youth offspring (Christiansen et al., 2011). Studies on bereaved children have significantly

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contributed to our understanding of the impact of parental suicide on youth suicide-related risk. By combining population-based registries from three Scandinavian countries (Denmark, Sweden, Finland), researchers found that children with parental suicide, particularly maternal suicide, were at greater risk for attempting suicide compared to children whose parent died of other causes (Guldin et al., 2015). This suggests that maternal loss, specifically by suicide, may uniquely impact risk for suicidal behaviors in youth offspring. This finding also further alludes to the environmental influences that may play a critical role in the development of suicide-related risk. There is also emerging evidence that a family history of suicide may impact risk for other poor mental health outcomes in youth offspring, including psychiatric disorders, personality traits, stress reactivity, and cognitive functioning— though these outcomes are less well-investigated than suicidal behaviors. For instance, Brent et al. (2009) found that youth ages 7–25  years old whose parent died by suicide were at elevated risk for depression and alcohol/substance abuse compared to non-bereaved youth. Further, youth with parental history of suicide were at elevated risk for depression compared to youth whose parent died of sudden natural causes (e.g., myocardial infarction). These mental health outcomes may serve as potential pathways through which suicide risk aggregates within families. In a similar vein, compared to first-degree relatives of decedents with no personal or family history of suicidal behaviors or psychiatric disorders, first-degree relatives of suicide decedents exhibited more blunted stress reactivity (McGirr et al., 2010), Cluster B personality traits (McGirr et  al., 2009), and alterations in neurocognitive functioning, including inhibitory control and decision-making processes (Hoehne et al., 2015; McGirr et al., 2010, 2013). The first-degree relatives in these studies are not exclusively parents, as siblings and offspring are included. Additionally, these studies rely largely on small, predominantly White, clinical samples of adults from Canada. Thus, the generalizability of the findings to the larger youth population remains unclear.

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Parental history of nonfatal suicidal behaviors is also associated with youth offspring nonfatal suicidal behaviors. Specifically, children whose parent attempted suicide had two-fold greater The familial aggregation of fatal suicidal behav- odds of attempting suicide, and those with a iors (i.e., suicide deaths) is also evident in nonfa- maternal history specifically had three-fold tal suicidal behaviors, such as the impact of a greater odds, compared to children without family history of suicide attempts on youth parental history of suicide behaviors (Geulayov ­offspring. Specifically, a family history of suicide et al., 2012). Parental suicidal behaviors are also attempt was associated with earlier age of onset associated with earlier onset age of youth offof suicide attempt in clinical (Hawton et  al., spring suicidal behaviors. This increased risk is 2002; Roy, 2004) and community-based samples not fully explained by youth or parent psychopa(Ballard et al., 2019), and increased frequency in thology, though it is attenuated slightly. In a lifetime suicide attempts (Lizardi et al., 2009). A nested case-­control study of adults in treatment cumulative effect was further detected, as an for mood disorder and their offspring, Brent et al. increase in the number of relatives with a suicide (2015) found offspring whose parent attempted attempt history was associated with a greater risk suicide had a five-fold increased odds of attemptfor attempting suicide (Brent et  al., 2009; Roy, ing suicide than children whose parent did not 2004). For instance, individuals with a parent and attempt suicide, even after controlling for parent a sibling who attempted suicide were at greater and offspring psychiatric disorders. Using risk of attempting suicide themselves, compared population-­ based registry data from Denmark, to individuals with a parent but no sibling history Mok et  al. (2016) found a three-fold increased of suicide attempt (Brent et  al., 2009). Further risk of suicide attempts in offspring with a pareninquiries about the impact of a family history of tal history of a suicide attempt, and the risk suicidal behaviors on an individuals’ risk for sui- increased four-­fold with parental history of suicidal behaviors have largely focused on parental cide attempt and parental history of any psychiathistory. Unfortunately, less is known about the ric disorders. Thus, there is a unique link between impact of a sibling history of suicidal behaviors, parental suicidal behaviors and offspring youth despite evidence suggesting a strong influence. suicidal behaviors that may be exacerbated by Such studies would broaden our understanding of parental psychiatric problems. shared environmental influences on suicide-­ Further supporting the critical role of both related risk. genetic and environmental influence, one study As observed with parental suicide, meta-­ examined suicide-related risk in adopted children analyses by Geulayov et al. (2012) and Goodday and compared risk in relation to biological parent et al. (2019a) similarly found the odds of suicide and adoptive parent factors (Wilcox et al., 2012). deaths was increased nearly three-fold in chil- Using population-based registry data from dren whose parent attempted suicide compared to Sweden, Wilcox et al. (2012) found that neither children without a parental history of suicidal biological parent history of suicidal behaviors behaviors. This risk is detected even when (reflecting genetic influences) nor adoptive paraccounting for other risk factors such as youth ent history of psychiatric hospitalization (reflectand parental psychopathology. Despite the retro- ing environmental influences) were independently spective nature of the majority of these studies, associated with adoptee suicidal behaviors. findings consistently showed that a parental his- Instead, they found an increased risk for suicidal tory of suicidal behaviors may confer risk for sui- behaviors in adopted children with biological cide in youth offspring. Thus, the impact of parent history of suicidal behaviors and adoptive family, namely maternal history of suicide, on parent history of psychiatric hospitalization. youth offspring suicide risk is not entirely The risk conferred by parental suicidal behavexplained by the death of a parent by suicide. iors may even extend beyond offspring suicidal

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behaviors to include suicidal thoughts. In a prospective, population-based birth cohort study of parents and children in the United Kingdom (UK), researchers found that children whose mother attempted suicide had three-fold increased odds of suicidal behaviors and thoughts than those with no maternal history of suicide attempts (Geulayov et  al., 2014). Similarly, in a large, racially and ethnically diverse sample of children ages 9–10-years old in the United States (US), family history of suicide and suicidal behaviors was associated with elevated risk for suicidal thoughts and behaviors (Deville et al., 2020). Parental suicidal behaviors in childhood are also linked to disruptions in other areas of functioning, including psychiatric disorders, behavioral problems, life stress, and cognitive functioning. For instance, using the National Epidemiologic Survey on Alcohol and Related Conditions, a cross-sectional, nationally representative sample in the US, youth exposed to parental suicide attempts in childhood were at increased risk for a lifetime prevalence of substance use disorders in adulthood when compared to individuals in the general population (O’Brien et  al., 2015). Using population-based registry data from Denmark, Mok et al. (2016) found that a parental history of a suicide attempt was associated with a three-fold increased risk for violent offending. Additionally, using a population-based community cohort of Puerto Rican children in two contexts, Jennings et  al. (2010) found that children whose parent attempted or died by suicide were at increased risk for delinquency, even after accounting for other relevant risk factors such as parental mental health problems, coercive discipline, and exposure to community violence. Taken together, these findings indicate that children whose parents attempt suicide may be at elevated risk for externalizing problems. There is also evidence that children with a maternal history of suicidal behaviors are at elevated risk for experiencing life stress. For instance, Sheftall et al. (2020) found that children from the community, ages 6–9-years old and 50% Black, whose mother attempted suicide were more likely to experience negative life events and greater negative affect (i.e., sadness,

discomfort, difficulty to soothe) compared to children without a maternal history of suicidal behaviors. Group differences were detected at baseline but not during a follow-up assessment 6 months and a year later. This discrepant finding may reflect the proximal, though not distal impact, of parental suicidal behaviors on life stress. It is also possible that the sample was underpowered, given that it was a pilot study. Nevertheless, there is early evidence to suggest that maternal history of suicidal behaviors may increase risk for offspring suicidal behaviors through increases in negative affect and increased stress exposure. Children whose parents attempt suicide may also be at elevated risk for disruptions in cognitive functioning. Using a population-based birth cohort in the UK, one study found that maternal history of a suicide attempt was associated with poor academic performance at age 14 (Geulayov et  al., 2016). Similarly, in a community-based sample of youth (52% BIPOC), ages 8–21-years old in the US, one study found that family history (80% parent) of fatal (7%) and nonfatal suicidal behaviors were associated with lower performance on cognitive tasks, including language reasoning and attention (Jones et al., 2021). There is also early neural evidence suggesting that a parental history of suicidal behaviors may impact youth offspring cognitive processes. Using Event-Related Potential (ERP) data, one study reported that children from the community, ages 7–11, with a parental history of a suicide attempt had a blunted response to rewards, independent of child and parent psychopathology (Tsypes et al., 2017). Across these studies, disruptions in cognitive functioning involving attention and rewards have been identified in these at-risk youth.

Parental Psychopathology and Youth Suicide-Related Outcomes As mentioned, parental psychopathology, in general, has been identified as a risk factor for youth suicide-related outcomes. Youth exposure to

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parental psychopathology can occur at various periods during their development. There is extensive research examining the impact of parental depression (mostly maternal depression) on offspring outcomes (Goodman et  al., 2011). Some of these studies have also examined suicidal ideation and behaviors in these youth. Overall, there appears to be an increased risk for youth o­ ffspring of parents with depressive and mood disorders; nonetheless, there is some complexity in the findings. In a systematic review of the association of parental psychopathology and suicide-­ related outcomes in youth, most of the studies reviewed found a positive association between parental mood disorders and youth suicidal ideation and attempts (Goodday et  al., 2019a). In particular, the review noted two studies (Klimes-­Dougan et al., 1999; Weissman et al., 1986) that utilized diagnostic interviews to determine parental psychopathology, compared to a nonpsychiatric control group, demonstrating that adolescents of mothers with mood disorders reported higher rates of suicidal ideation and attempts than psychiatrically well mothers. In a study of adolescents in the US, paternal Major Depressive Disorder (MDD) was associated with increased risk for suicide attempts, but not maternal depression or other parental psychiatric disorders (Lewinsohn et al., 2005). However, not all studies have indicated an association between parental depression and suicide risk. For example, a large prospective study of parents with depression from a data registry in Germany found that adolescent and young adult offspring who had one or both parents with a depression diagnosis did not differ in suicide ideation or attempt history from those without a parent with depression (Lieb et al., 2002). A large birth cohort study of parents and children in the UK found that the odds of adolescent past-year suicidal ideation at age 16 increased with greater maternal depression symptom severity (Hammerton et  al., 2015, 2016). Mediation analysis among this sample suggested that maternal depression may impact adolescent suicidal ideation through multiple pathways, such as maternal suicide attempt, adolescent psychiatric history, and parent–child relationship

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(Hammerton et al., 2016). Additionally, for mothers with the most severe chronic depression symptoms, there was a direct effect on offspring suicide attempts (Hammerton et  al., 2015). Nonetheless, there were indirect effects through adolescent psychopathology, with MDD, Disruptive Behavior Disorder, Generalized Anxiety Disorder, and Attention-Deficit Hyperactivity Disorder (ADHD) being the most highly associated with suicide attempt history (Hammerton et al., 2016). In another large birth cohort study in Canada, offspring exposure to elevated maternal depression symptoms during the first 10 years of life was associated with an increased risk of suicidal ideation and attempts between ages of 11 and 25 years (Goodday et al., 2019b). This pattern was also evident with recurrent suicidal ideation and attempts. Studies looking at parental depression among selected samples of youth have yielded further information regarding the risk conferred. In a small cross-sectional study of African American mothers with a past-year diagnosis of a depressive disorder, approximately a third of their children ages 8–14 endorsed suicidal ideation within the previous 2  weeks, although only 6.5% had high levels of depression symptoms (Boyd et al., 2011). Furthermore, a study examining risk for substance use initiation in a sample of 12–15-­ year olds and their parents in Puerto Rico found a 4.4% prevalence of suicide attempts 12  months after study entry. The percentage of the sample that had a suicide attempt was higher for adolescents with a mother with a depression diagnosis than mothers without a depression diagnosis; the association between maternal depression diagnosis and suicide attempts became marginally significant when all demographic risk factors were examined together in the same statistical model (Reyes et al., 2011). A prospective study of young children with ADHD, ages 4–6  years (40% BIPOC), assessed suicidal ideation with a plan and suicide attempts longitudinally (Chronis-­ Tuscano et  al., 2010). The study found that among youth ages 9–18 years with ADHD, lifetime maternal depression diagnosis significantly predicted future suicidal ideation with a plan. Finally, Weissman et al. (2016) found that grand-

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children, interviewed at ages 12 and 18, who had both a grandparent and parent with MDD had a higher risk of suicidal ideation or behaviors than those with only a grandparent with MDD or only a parent with MDD.  These studies provide further evidence of increased suicidal behavior among the youth of parents with depression. Other parental psychiatric disorders have similarly been linked with offspring suiciderelated risk. In a recent systematic review, Goodday et  al. (2019a) demonstrated that 55% of studies examining the impact of parental substance use disorders showed a positive association with suicidal ideation and/or attempts. In the study of national registries in Sweden, nested case-control methods were utilized to examine offspring suicide attempts and deaths in offspring 10 years of age and older. One investigation showed that parental disability receipt for psychiatric disorders was associated with increased suicide attempts and deaths and that this association was more pronounced when the offspring was exposed at a younger age (Niederkrotenthaler et  al. 2012). Similarly, parental inpatient hospitalization as a result of a psychiatric disorder was associated with 2.6 and 3.0 higher odds of suicide deaths and attempts, respectively. Suicide risk was highest among offspring exposed under 3 years of age. An earlier investigation examined adolescents and young adults with a suicide attempt and found increased risk with all paternal and maternal psychiatric disorders (Mittendorfer-Rutz et  al., 2008). The two most highly associated psychiatric disorders were parental personality disorders and substance use disorders. A population-based cohort study in Denmark that followed youth from the age of 15 years also showed that psychiatric disorders in any parent were associated with an increased risk of a suicide attempt in offspring. However, Cannabis use disorder and Antisocial Personality Disorder were the parental psychiatric disorders that showed the most risk for a suicide attempt (Mok et  al., 2016). These studies show further support for the association between parental psychopathology and offspring suicide risk and suggest that early exposure is particularly harmful.

Most of the studies in this field have been conducted in the US or Europe (Goodday et  al., 2019a). Nonetheless, some studies have been conducted in Latin America. A household survey of adults in a major city in Brazil inquired about their lifetime suicide ideation and attempt history, including timing during childhood and adolescence and family history of parental psychopathology. This survey found significant associations between parental symptoms of depression, generalized anxiety, and panic disorder with adolescent suicide attempts. The study also showed an association between report of adolescent suicidal ideation and parental depression and Antisocial Personality Disorder (Santana et  al., 2015). A limitation of this study is that adults were reporting on their childhood experiences and their parents’ psychiatric symptoms, which are both subject to retrospective report bias; however, it is one of a few studies in a Middle-Income country. Another study of a nationally representative survey of adults in Mexico found that parental disorders during childhood were positively associated with both lifetime suicidal ideation and attempts (Borges et  al., 2013). Although this study focused on adults and has a similar bias in reporting of parental psychiatric history, its findings mirror Santana and colleagues’ results. After controlling for each psychiatric disorder, only Panic Disorder and Antisocial Personality Disorder remained associated with suicidal ideation and attempts. These two studies conducted in Latin American Middle-Income countries provide further support that the association between parental psychopathology and offspring suicide risk occurs cross-culturally.

Transmission of Parental Psychopathology There have been several processes proposed by which offspring negative psychological outcomes, such as suicide risk, are transmitted from a parent. One comprehensive model that can be used flexibly is Goodman and Gotlib’s theoretical model of the transmission of depression from

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a mother to her children (Goodman, 2007; Goodman & Gotlib, 1999). Although this theoretical model was initially proposed for a mother with depression to her children, the mechanisms, moderators, and vulnerabilities described in the model are applicable to other parental psychiatric disorders. The model includes four mechanisms of the transmission process. The first is a genetic predisposition toward psychopathology. Children may inherit genes that predispose them to specific psychopathology or lead to temperamental and personality traits that increase their vulnerability to psychiatric distress and disorders. The second proposed mechanism is a dysfunctional neuroregulatory system. This is the result of an abnormal environment for fetal development due to the possible impact of maternal psychopathology on the neuroendocrine system, blood flow, or prenatal care. The third mechanism is the child’s exposure to the mother’s negative cognitions, behaviors, and affect, which interfere with the mother’s ability to meet the child’s emotional and developmental needs. Additionally, the child may acquire similar maladaptive cognitive and coping skills through a social learning process. The third mechanism captures parenting and parent–child interactions. The fourth mechanism is an increase in children’s exposure to negative life events and stressors that accompany parental psychopathology. Any of these mechanisms may increase children’s vulnerabilities in multiple domains of functioning, including biological, social, and behavioral domains. Children’s vulnerabilities, which include dysfunctional cognitions, hopelessness, difficulties in emotional regulation, poor impulse control, and impaired social skills, have been linked to an increased risk of psychiatric symptoms and disorders. The Goodman and Gotlib model (Goodman, 2007; Goodman & Gotlib, 1999) presents several moderators that are relevant in the transmission of psychopathology. First, fathers may increase a child’s risk if they are absent or exhibit psychopathology. It is common for a mother with a psychiatric disorder to partner with someone who also has psychopathology. Second, the timing and course of a mother’s psychopathology may influence the

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child’s functioning capabilities. Specifically, psychopathology occurring earlier in a child’s life and with a chronic course may be more deleterious to the child. Furthermore, severe psychiatric symptoms may also have a stronger impact on child outcomes. Finally, child characteristics that serve as moderators include easy temperament, higher intelligence, and better social–cognitive skills. These mechanisms, moderators, and vulnerabilities lead to child internalizing and externalizing behaviors and dysfunction.

Clinical Implications The current research on the impact of parental suicidal behaviors and psychopathology clearly documents suicide risk for offspring, and thus indicates that clinical interventions are needed. Suicidal thoughts and behaviors may not be immediately evident in this high-risk group; however, opportunities exist for prevention efforts. Two points of clinical intervention delivery occur when parents are identified with suicidal behavior or psychopathology and when youth present with suicide-related risk. Within the adult mental health system, family assessment and early supportive intervention can occur when a parent dies by or attempts suicide. This is also applicable to parents being treated for mental health problems. It is critical to identify mental health needs of children as early as possible and to intervene accordingly. Additionally, brief interventions can be delivered, such as psychoeducation about parental mental illness. A systematic review of evidence-based intervention strategies for psychoeducation about parental psychopathology delivered across settings showed support for positive changes in youths’ internalizing and externalizing symptoms (Oja et  al., 2020). Other outcomes were increased knowledge and understanding of parental mental health, improved communication, and relieving guilt and blame for both parents and children and parental improved understanding of their children’s perspectives. One such example of an intervention is Let’s Talk about Children, which consists of 2–3 sessions that aimed to empower

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parents with psychopathology in their roles as parents and to strengthen resilience and coping within families (Maybery et al., 2017). Such clinical interventions could be administered universally for identified families. Parental history of suicidal behaviors and psychopathology increase risk of youth presentation of psychopathology. Thus, these youth may ­present in mental health settings for treatment. This entry becomes another point for clinical intervention. As part of initial evaluation for mental health treatment, it is critical to ask routinely about fatal and nonfatal suicide attempts, psychopathology, and hospitalizations among relatives, as their presence confers an additional risk for suicidal ideation and behavior. Understanding this risk will help with the treatment formulation for the presenting youth and can be addressed and monitored in the course of treatment.

Limitations and Future Directions Despite the growing evidence described in this chapter, there are several limitations of the existing literature to note. Unlike the literature with parental suicide where birth of offspring cannot precede parental suicide, the timing of exposure to parental suicidal behaviors is not clear. In other words, previous studies examined direct exposure (i.e., witnessed) in childhood (Burke et al., 2010). To date however no study has examined distinctions between the impact of parental suicidal behaviors pre and postconception. This would further clarify environmental influences on suicide-related risk and potential mechanisms underlying shared parentchild risk. Similarly, as research has largely focused on parental, namely maternal, suicidal behaviors, examining shared risk between siblings, as well as the impact of paternal suicidal behaviors, is further warranted. Gender differences in this relation should also be examined, as research has largely focused on the maternal history of suicidal behaviors, and has rarely examined gender differences in outcomes of their youth offspring.

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Many of the studies described used the same samples, resulting in moderate to high risk of bias (Goodday et al., 2019a). Furthermore, the samples were also largely racially and ethnically homogenous, limiting the generalizability of the findings. Indeed, there is a critical need for studies with more heterogenous groups, including from Lowand Middle-Income countries, where suicide rates among youth are appreciably high (McLoughlin et al., 2015). More generally, inclusion of racially and ethnically diverse youth and families within this research is critical, especially as increased suicide risk has been identified for certain groups, such as younger Black youth (Bridge et al., 2018). Considering the strong relation between parental mental health problems and parental suicidal behaviors, the role of adverse childhood experiences in children whose parents attempt suicide remains relatively understudied. Research has only begun to examine the impact of parental suicidal behaviors on suicide-related risk beyond suicidal thoughts and behaviors in offspring youth. Outcomes also linked to suicide-related risks, such as problems with cognitive functioning, emotion regulation, and elevated life stressors, are garnering more attention in understanding the  familial aggregation of suicide-related risk. Information about contextual influences in this association would address the gap in this knowledge. Similarly, the current evidence generally supports that parental psychopathology places youth at risk for maladjustment and suicide-related risk. However, the current research is limited by retrospective reporting, cross-sectional designs, and variability in assessments of parental psychopathology and offspring suicide-related outcomes. In particular, there is not a wealth of research examining suicidal behavior as an outcome of parental psychopathology as compared to research examining the general functioning of these offspring. Use of prospective research designs that do not rely on lengthy retrospective recall would strengthen the current methodology. Additionally, our understanding of the mechanisms by which suicide risk is transmitted and whether suicidal ideation and behaviors are a byproduct of the psychopathology the offspring are exhibiting warrants further examination.

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Conclusion

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5  Parental and Family History of Suicidal Behaviors and Psychopathology and Suicide-Related Risk… QJM: An International Journal of Medicine, 108(10), 765–780. https://doi.org/10.1093/qjmed/hcv026 Mittendorfer-Rutz, E., Rasmussen, F., & Wasserman, D. (2008). Familial clustering of suicidal behaviour and psychopathology in young suicide attempters. Social Psychiatry and Psychiatric Epidemiology, 43(1), 28–36. https://doi.org/10.1007/s00127-­007-­0266-­0 Mok, P.  L., Pedersen, C.  B., Springate, D., Astrup, A., Kapur, N., Antonsen, S., Mors, O., & Webb, R.  T. (2016). Parental psychiatric disease and risks of attempted suicide and violent criminal offending in offspring: A population-based cohort study. JAMA Psychiatry, 73(10), 1015–1022. https://doi. org/10.1001/jamapsychiatry.2016.1728 Niederkrotenthaler, T., Floderus, B., Alexanderson, K., Rasmussen, F., & Mittendorfer-Rutz, E. (2012). Exposure to parental mortality and markers of morbidity, and the risks of attempted and completed suicide in offspring: An analysis of sensitive life periods. Journal of Epidemiology and Community Health, 66(3), 233– 239. https://doi.org/10.1136/jech.2010.109595 Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N.  A., Zaslavsky, A.  M., & Kessler, R.  C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70(3), 300– 310. https://doi.org/10.1001/2013.jamapsychiatry.55 O'Brien, K.  H. M., Salas-Wright, C.  P., Vaughn, M.  G., & LeCloux, M. (2015). Childhood exposure to a parental suicide attempt and risk for substance use disorders. Addictive Behaviors, 46, 70–76. https://doi. org/10.1016/j.addbeh.2015.03.008 Oja, C., Edbom, T., Nager, A., Månsson, J., & Ekblad, S. (2020). Informing children of their parent's illness: A systematic review of intervention programs with child outcomes in all health care settings globally from inception to 2019. PLoS One, 15(5), Article e0233696. https://doi.org/10.1371/journal.pone.0233696 Reyes, J. C., Robles, R. R., Colón, H. M., Negrón, J. L., Matos, T. D., & Calderón, J. M. (2011). Polydrug use and attempted suicide among Hispanic adolescents in Puerto Rico. Archives of Suicide Research, 15(2), 151–159. https://doi.org/10.1080/13811118.2011.56 5274

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Roy, A. (2004). Family history of suicidal behavior and earlier onset of suicidal behavior. Psychiatry Research, 129(2), 217–219. https://doi.org/10.1016/j. psychres.2004.08.002 Santana, G. L., Coelho, B. M., Borges, G., Viana, M. C., Wang, Y.  P., & Andrade, L.  H. (2015). The influence of parental psychopathology on offspring suicidal behavior across the lifespan. PLoS One, 10(7), Article e0134970. https://doi.org/10.1371/journal. pone.0134970 Sheftall, A.  H., Bergdoll, E.  E., James, M., Bauer, C., Spector, E., Vakil, F., Armstrong, E., Allen, J., & Bridge, J.  A. (2020). Emotion regulation in elementary school-aged children with a maternal history of suicidal behavior: A pilot study. Child Psychiatry and Human Development, 51(5), 792–800. https://doi. org/10.1007/s10578-­020-­01010-­8 Tidemalm, D., Runeson, B., Waern, M., Frisell, T., Carlström, E., Lichtenstein, P., & Långström, N. (2011). Familial clustering of suicide risk: A total population study of 11.4 million individuals. Psychological Medicine, 41(12), 2527–2534. https:// doi.org/10.1017/S0033291711000833 Tsypes, A., Owens, M., Hajcak, G., & Gibb, B. E. (2017). Neural responses to gains and losses in children of suicide attempters. Journal of Abnormal Psychology, 126(2), 237–243. https://doi.org/10.1037/abn0000237 Weissman, M. M., John, K., Merikangas, K. R., Prusoff, B.  A., Wickramaratne, P., Gammon, G.  D., Angold, A., & Warner, V. (1986). Depressed parents and their children. General health, social, and psychiatric problems. American Journal of Diseases of Children, 140(8), 801–805. https://doi.org/10.1001/ archpedi.1986.02140220083038 Weissman, M.  M., Berry, O.  O., Warner, V., Gameroff, M.  J., Skipper, J., Talati, A., Pilowsky, D.  J., & Wickramaratne, P. (2016). A 30-year study of 3 generations at high risk and low risk for depression. JAMA Psychiatry, 73(9), 970–977. https://doi.org/10.1001/ jamapsychiatry.2016.1586 Wilcox, H. C., Kuramoto, S. J., Brent, D., & Runeson, B. (2012). The interaction of parental history of suicidal behavior and exposure to adoptive parents' psychiatric disorders on adoptee suicide attempt hospitalizations. American Journal of Psychiatry, 169(3), 309–315. https://doi.org/10.1176/appi.ajp.2011.11060890

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Examining the Relationship Between Suicide and Nonsuicidal Self-Injury Among Adolescents and Young Adults Joshua J. DeSon, Nathan J. Lowry, Colleen M. Jacobson, and Margaret S. Andover

Suicide is the second leading cause of death among youth in the United States and worldwide (WHO, 2020). To better inform suicide prevention and intervention efforts, a greater understanding of the risk factors associated with suicide is needed. Nonsuicidal self-injury (NSSI) has emerged as a potent risk factor for suicide among adolescents and young adults. NSSI is a phenomenon that is fairly prevalent among adolescents and young adults; however, there is still limited research on the risk factors associated with NSSI and the mechanism of association between NSSI and suicide. This chapter has three primary goals: (1) to classify and provide an overview of NSSI, (2) to highlight research examining NSSI as a risk factor for suicide and its proposed mechanism of association, and (3) to discuss risk factors associated with NSSI among youth and young adults, specifically Black, Indigenous, and people of color (BIPOC) and gender and sexual minority (GSM) youth and young adults.

J. J. DeSon · M. S. Andover () Department of Psychology, Fordham University, Bronx, NY, USA e-mail: [email protected]; [email protected] N. J. Lowry · C. M. Jacobson Department of Psychology, Iona College, New Rochelle, NY, USA e-mail: [email protected]; [email protected]

Classifying and Defining Nonsuicidal Self-Injury Previously, the study of self-injurious behavior was limited by inconsistent terminology, thus impeding research on the topic, as definitions of NSSI varied considerably across research  studies. To address this inconsistency, researchers and clinicians arrived at the following definition of NSSI; NSSI is defined as intentional, self-­ inflicted destruction of body tissue without suicidal intent and for purposes not socially or culturally sanctioned (International Society for the Study of Self-Injury, 2018). This definition clearly distinguishes NSSI from thoughts or behaviors with suicidal intent and accounts for culturally sanctioned traditions. Nonetheless, it is still a common misconception that NSSI indicates the presence of suicidal ideation or a suicide attempt. Therefore, it is important to emphasize that NSSI differs significantly from suicidal thoughts and behaviors in intent always and severity, methods, and frequency often (Butler & Malone, 2013; Muehlenkamp & Gutierrerz, 2004). Notably, NSSI as a unique psychological disorder has only recently been acknowledged. NSSI has traditionally been considered a symptom of borderline personality disorder (BPD) or eating disorders. However, growing empirical research has shown that NSSI is not unique to these illnesses and in fact may co-occur with

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many different mental illnesses, as well as in the absence of another mental illness (Jacobson et  al., 2008). Additionally, repetitive NSSI is associated with frequent thoughts about and urges to engage in NSSI behaviors and may impair one’s ability to function. For these reasons, NSSI Disorder (NSSID)  was included in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5; American Psychiatric Association, 2013; Gratz et al., 2015). While NSSID is a new diagnosis that requires further evaluation by research, its recognition by the DSM-5 is instrumental in the advancement of our understanding of NSSI and its association with suicide and other mental health disorders.

 revalence, Methods, Frequency, P and Functions of NSSI The age of onset for NSSI typically occurs between the ages of 12 and 14; however, NSSI behavior has been reported in children even younger (Cipriano et al., 2017). Reported prevalence rates of NSSI vary greatly from study to study due to inconsistent definitions, assessment approaches, and sampling techniques. For example, some studies assess previous NSSI behavior using a dichotomous yes/no response question, while others utilize a multi-item behavior checklist. Research has found this discrepancy to influence prevalence rates considerably; studies using a yes/no response question typically yield a lower prevalence rate than studies using a behavior checklist (Swannell et al., 2014). The most comprehensive assessment of prevalence among adolescents is a recent meta-analysis that included over 27 studies conducted internationally (Lim et al., 2019). Results found that 22.5% (95% CI: 16.9–28.4%) of adolescents have a lifetime history of NSSI with a 12-month prevalence rate of 19.5% (95% CI: 13.3–27.6%; Lim et al., 2019). Of note, one large-scale study of a representative sample of high school students in the US found a much higher 12-month prevalence rate of NSSI in females (23.8%) than males (11.3%).

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Prevalence of NSSI among young adults is similar to adolescents. Results from a large-scale assessment of NSSI among a representative sample of 11,529 college students in the northeast indicated a lifetime prevalence rate of 15.3%, while data from a smaller sample of college students by the same group of researchers found a rate of 19.7% (Whitlock et al., 2013; Whitlock & Rodham, 2013). Similar to adolescents, female young adults (18.9%) reported a higher rate of engagement than males (10.9%; Whitlock et al., 2013). NSSI methods reported across studies are relatively consistent. Cutting, hitting, scratching, and burning oneself are the most commonly reported methods, with many individuals engaging in more than one form of NSSI (e.g., Cipriano et al., 2017). Individuals engaging in NSSI typically act on the arms, legs, wrists, and stomach. Additionally, gender differences in NSSI methods exist; men are more likely to engage in hitting or burning while women are more likely to self-cut (e.g., Cipriano et al., 2017). In contrast, frequency of NSSI can vary greatly, ranging from daily engagement to one-­ time isolated incidents (Jacobson & Gould, 2007). It is unclear why this disparity exists, though some of the variability between individuals may be due to existing psychopathology, how studies operationalize and measure NSSI, or the individual’s early experiences with NSSI. Individuals who engage in NSSI often do so for intrapersonal functions with the goal of emotion regulation (Taylor et  al., 2018). Individuals cite wanting to escape an unwanted internal state or inducing positive affect as common reasons for engaging in NSSI.  Individuals also engage in NSSI for interpersonal reasons, hoping to communicate the pain they are in to others or to effect a change in their environment  (Taylor et  al., 2018). Importantly, these findings directly dispute a common misconception that individuals engage in NSSI to gain attention or manipulate others, a misconception that has contributed to the stigma surrounding NSSI.

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NSSI as a Risk Factor for Suicide Research has identified NSSI as a potent risk factor for suicide among adolescents and young adults in both clinical and nonclinical samples. While controlling for common mental disorders, youth who engage in NSSI are significantly more likely to have suicidal thoughts and behaviors than those who do not engage in NSSI (Kiekens et al., 2018). Moreover, research has found that individuals who report current suicidal ideation are more likely to have a subsequent suicide attempt if they had previously engaged in NSSI (Nock et  al., 2018), a notable finding that has important clinical implications. The majority of research examining NSSI and suicidal thoughts and behaviors has been cross-­ sectional. However, longitudinal studies have also provided evidence to support NSSI as a risk factor for subsequent suicidal thoughts and behaviors. A study conducted by Whitlock et al. (2013) followed 1466 college-aged students for 3 years and found a history of NSSI significantly predicted future suicidal thoughts and behaviors. Interestingly, this study found a dose-dependent relationship between NSSI and suicide, with increased frequency of NSSI being associated with greater risk of future suicidal thoughts and behaviors. A separate longitudinal study examining mental health, coping and academic achievement among college students found that, while controlling for baseline suicidal ideation and previous suicide attempts, NSSI significantly predicted subsequent suicidal ideation and attempts over a 5-year period (Hamza & Willoughby, 2016). Lastly, during a 24-week trial for adolescents with treatment-resistant depression, a baseline history of NSSI was found to be a significant predictor of suicide attempts through week 24 (Asarnow et al., 2011). Moreover, a baseline history of NSSI was a stronger predictor of a suicide attempt than a baseline suicide attempt history. While NSSI has been identified as an important risk factor for suicide, there are gaps that future research should address. Notably, different methods, frequency, and the severity of NSSI seem to influence the risk of an individual having future suicidal thoughts and behaviors (Victor &

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Klonsky, 2014). Additionally, it is unclear how NSSI interacts with other factors, such as mental illness, to influence the risk for suicide. This is especially relevant for clinical contexts, and variation among those who engage in NSSI should be considered.

 roposed Mechanism of Association P between NSSI and Suicide A growing body of research has demonstrated NSSI to be a risk factor for suicide; however, the mechanism of link between the two remains unclear. One theory, the interpersonal theory of suicide (Van Orden et al., 2010) provides a theoretical framework for suicide that may explain their relation. The interpersonal theory of suicide posits that individuals die by suicide partly because they have the capability to attempt suicide. The theory also posits that an individual must acquire the capability to overcome self-­ preservation instincts. Building this capability may involve having an increased pain tolerance or lack of fear about pain, injury, or death. While an individual may be born with a biological vulnerability that allows them to acquire the capability for suicide, an individual may also experience painful or provocative events, such as NSSI, that allow them to acquire the capability for suicide (Joiner et  al., 2012). Interestingly, research has found that those who engage in NSSI have an increased pain tolerance (Tuna & Gençöz, 2020), providing the basis for research to examine NSSI and the acquired capability for suicide in greater detail. A limited amount of research has examined the relation between NSSI and acquired capability for suicide. A longitudinal study conducted by Willoughby et al. (2015) found that a higher frequency of past year engagement in NSSI predicted higher capability for suicide over time. Moreover, this association was found after statistically controlling for other suicide risk factors such as age and anxiety. This study was also able to identify this relationship as unidirectional, meaning that only an increased frequency in NSSI led to an acquired capability for suicide.

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This study and others (e.g., Franklin et al., 2011) offer initial evidence of the association between NSSI and the acquired capability of suicide; however, there are still gaps that research must address. Notably, it is still unclear why engagement in NSSI would lead to an increased pain tolerance. Additionally, other research finds no association between NSSI and acquired capability for suicide (Gratz et al., 2020), suggesting that other moderating variables may influence the relationship between NSSI and suicide. NSSI, itself, is a destructive behavior, and its association with increased risk for suicide confirms its importance as a clinical target and topic of research. By understanding risk factors for NSSI, we may be able to intervene with those at highest risk for NSSI, also reducing the risk for suicidal behavior. In the following sections, we review risk factors for NSSI among youth and young adults, including risk factors for BIPOC and GSM youth, specifically.

General Risk Factors for Youth NSSI Across all ages, NSSI has been conceptualized psychologically as a method of regulating emotions, expressing distress, avoiding psychological pain and negative affect, and distracting from negative stimuli (e.g., Klonsky, 2007; Walsh, 2007). Several models have been developed to explain the development and maintenance of NSSI (e.g., Chapman et al., 2006; Hasking et al., 2017; Nock, 2010; Selby & Joiner, 2009), and researchers have investigated individual and environmental factors proposed to confer risk for NSSI among youth and adults through longitudinal studies. In the following sections, we review the current literature on factors that increase the risk of NSSI among youth, differentiating between risk factors and correlates. Because of the dearth of literature on risk factors for NSSI among underserved youth and young adults, we first review research on individual and environmental factors that are associated with increased risk for NSSI among youth and young adults in general. We then focus specifically on risk factors among Black, Indigenous, and people of color

(BIPOC) youth and young adults and gender and sexual minority (GSM) youth and young adults.

Individual Risk Factors Demographic Factors As noted above, being female has been associated with NSSI engagement and onset (Andrews et  al., 2013; Fox et  al., 2015; Wilkinson et  al., 2011), as has being younger (Wilkinson et  al., 2011). Specific factors related to race, ethnicity, and gender and sexual identity will be discussed later in this chapter. Previous Self-Injury One of the strongest predictors of future NSSI behavior is past engagement in NSSI.  Additionally, distinguishing features of NSSI, such as the number of methods used, influence the likelihood of future NSSI (e.g., Fox et  al., 2015; Wilkinson et  al., 2011). Although NSSI and suicide are distinct behaviors that differ in intent to die, previous suicidal thoughts and behaviors also predict future NSSI (e.g., Fox et  al., 2015). Further research is necessary to determine if the predictive associations between the different types of self-injury are due to the co-occurrence of the behavior, or if engagement in one type of self-­injury does, in fact, confer unique risk for the other type (Fox et al., 2015). Emotion Dysregulation Research has supported emotion dysregulation, or difficulties regulating emotional experiences, as a significant risk factor for NSSI among male and female adolescents and adults (Wolff et al., 2019). Moreover, the most common function of NSSI is affect regulation (Klonsky, 2011; Sadeh et al., 2014), suggesting that while emotion dysregulation confers risk for NSSI, the behavior also serves to address and temporarily resolve the experience of emotion dysregulation. Several interventions that demonstrate efficacy in decreasing NSSI behaviors, such as dialectical behavior therapy and emotion regulation group therapy (Gratz et  al., 2014; McCauley et  al., 2018), focus on emotion dysregulation, again

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highlighting the contribution of emotion dysregulation to NSSI behavior.

Cognitive Factors Research has also identified the important role cognitions play in risk for NSSI.  Hopelessness, for example, is associated with increased NSSI risk among adolescents (e.g., Fox et  al., 2015; Hankin & Abela, 2011; Wilkinson et al., 2011). Negative attributional style and depressogenic cognitions, especially in the context of negative life events, and anxiety-related cognitions have also been found to increase the risk for NSSI (Guerry & Prinstein, 2010; Hughes et al., 2019; Lin et al., 2018). The interaction between cognitions and emotional experiences is also important in understanding NSSI risk; NSSI-related cognitions, such as NSSI outcome expectancies and perceived self-efficacy to resist NSSI, interact with emotional reactivity to predict NSSI behavior (Dawkins et al., 2019; Hasking et al., 2017). Psychopathology NSSI is not uniquely associated with any one psychiatric disorder (Nock et  al., 2006), and NSSI is reported among youth without psychiatric diagnoses (Zetterqvist, 2017). However, both internalizing and externalizing disorders are risk factors for NSSI (e.g., Fox et al., 2015), and psychological distress is also associated with increased risk of NSSI (Andrews et al., 2013; Fox et  al., 2015). Specifically, depressive disorders and symptoms have been identified as a risk factor for NSSI in youth (e.g., Asarnow et al., 2011; Fox et  al., 2015; Hankin & Abela, 2011). Additionally, anxiety disorders are associated with increased risk for NSSI (Jacobson & Gould, 2007; Wilkinson et al., 2011). Insomnia and sleep disturbance have also been implicated as risk factors for suicidal thoughts and behaviors, and poor sleep is associated with increased risk for NSSI among adolescents (Asarnow et al., 2020; Lundh et al., 2013). Eating and body-related concerns are also associated with NSSI. There is robust support for the associations between NSSI and body dissatisfaction, body image concerns, and disordered eating (Cucchi et  al., 2016; Pérez et  al., 2018),

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and eating disorders have been supported as factors that increase risk (Fox et  al., 2015). Polysubstance use is associated with increased NSSI, and substance use disorders are associated with both occasional and repetitive NSSI in clinical and community youth samples (Doksat et al., 2017; Lüdtke et al., 2018). However, disordered eating behavior and substance use may reflect an indirect form of NSSI, as the behaviors can result in direct harm to the body, even though the intent may not be self-injury itself (e.g., Schatten et al., 2013; St. Germain & Hooley, 2012). Although cluster B personality disorders, such as borderline personality disorder and characteristics, are associated with increased risk for NSSI (e.g., Fox et al., 2015), NSSI itself is not indicative of a BPD diagnosis. It is important to remain cognizant of this to avoid overpathologizing NSSI behaviors (Bracken-Minor & McDevitt-­ Murphy, 2014; Muehlenkamp et al., 2017; Turner et al., 2015).

Aggression Trait levels of aggression have been implicated by multiple studies as a risk factor for NSSI and may be one of the strongest proximal risk factors for NSSI (Fliege et  al., 2009). For example, parent-­reported levels of aggression at age 12 were found to predict NSSI engagement at age 15 (Sourander et al., 2006). Additionally, increased trait-level aggression has been associated with engagement of more frequent and more aggressive forms of NSSI (i.e., self-hitting; Kleiman et al., 2015). Despite evidence for a direct effect of aggression on NSSI, research suggests that negative cognitive style and perceived social support may mediate the relationship (Wolff et  al., 2014).

Environmental Risk Factors  ocial Support and Peer NSSI S Overall, perceived support from family, friends, and other sources are low among youth who engage in NSSI (Rotolone & Martin, 2012; Trepal et  al., 2015), and poor family support is associated with increased NSSI risk (Andrews

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et al., 2013). Poor relationship quality, defined by lack of social support and negative interactions within close relationships with peers and family, was found to differentiate adolescent youth aged 11–14 who did and did not engage in NSSI over a 2-year follow-up period (Hankin & Abela, 2011). Another study using a daily diary methodology found that young adults with NSSI had significantly less contact with family and friends, perceived less support from their friends, and were less likely to use support seeking as a coping strategy (Turner et  al., 2017). Peer engagement in NSSI can also influence an individual’s NSSI behavior; research has shown that peer NSSI increases the risk for NSSI among girls (Prinstein et al., 2010).

 buse and Family Factors A Adverse childhood events, such as childhood maltreatment and its subtypes (sexual abuse, physical abuse, emotional abuse, and neglect), have been associated with youth NSSI (Kaess et al., 2013; Liu et al., 2018). Childhood physical and sexual abuse is a risk factor for youth NSSI (Tatnell et  al., 2017), and meta-analyses have found effects ranging from small to medium for the associations (Klonsky & Moyer, 2008; Liu et al., 2018). Some research suggests that parental antipathy, emotional abuse, and witnessing domestic violence may be stronger contributors to NSSI risk than childhood physical or sexual abuse (Armiento et al., 2016; Kaess et al., 2013; Liu et  al., 2018; Thomassin et  al., 2016). The relationship between childhood maltreatment and NSSI may be mediated by other factors, such as psychopathology, distress, self-blame, emotion dysregulation, self-efficacy, and dissociation (Klonsky & Moyer, 2008; Liu et al., 2018). Poor parental mental health, family functioning, and parent–child relationship quality and attachment have also been associated with youth NSSI (e.g., Fox et  al., 2015; Kelada et  al., 2018; Morgan et al., 2013). Peer Victimization Researchers have identified peer victimization as an important risk factor for NSSI among youth (Claes et  al., 2015; Jiang et  al., 2016; Vergara

et  al., 2019), as it is associated with increased intensity of NSSI thoughts and behaviors (Ammerman et  al., 2018; Giletta et  al., 2012, 2015; Vergara et al., 2019). Some studies, however, suggest that depression may mediate this relationship (Jiang et  al., 2016; Stewart et  al., 2018). Cross-sectional research suggests that specific types of peer victimization may be differentially associated with NSSI by gender. For example, weight- and socioeconomic status-­ based harassment were associated with NSSI among adolescent girls, and race-based harassment was associated with NSSI among adolescent boys; sexual harassment was associated with NSSI among both girls and boys (Bucchianeri et al., 2014).

Summary Research continues to identify risk factors for NSSI—and potential candidates for risk factors—among youth and young adults. These individual and environmental factors, including self-injury history, sex, emotion dysregulation, psychopathology and psychological distress, low social support, and peer victimization, have been shown to increase the risk for NSSI specifically among youth. However, much of the research on NSSI utilizes samples that are predominantly White, cisgender, and heterosexual. To better understand the heterogeneity of NSSI and to provide equitable care across all youth populations, it is necessary to investigate whether identified risk factors function similarly among BIPOC and GSM youth and to identify risk factors for NSSI that are specific to these populations.

 isk Factors for Underserved R Populations of Youth Risk factors are determined through longitudinal studies, which evaluate the association between a factor and NSSI at two or more time points. Potential risk factors (i.e., correlates) for NSSI can be identified through cross-sectional studies. Because cross-sectional studies only include one

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time point, researchers are unable to determine if a factor increases the risk for future NSSI (i.e., risk factor), varies along with NSSI, or is an outcome of another factor that also influences NSSI.  However, correlates identified through cross-sectional studies may be candidates for risk factors to be evaluated through longitudinal research. Because of the limited longitudinal research on risk factors among underserved youth, this section will also consider correlates that may be investigated as risk factors in future longitudinal research.

Black, Indigenous, and Youth of Color There is a dearth of research on risk factors for NSSI among BIPOC youth, due to previous research utilizing predominantly homogenous, White samples. However, existing studies of BIPOC youth suggest risk factors for and correlates of NSSI that are systemic, social, and institutional in nature.

Prevalence Nationwide data suggest overall increasing suicidal behavior within BIPOC youth (Bridge et al., 2015). Though Black and Latinx individuals experience elevated rates of suicidal behavior and make up the largest racial and ethnic groups in the US, there is a limited amount of research on NSSI incidence and risk among youth in these populations and other racial and ethnic minorities (Rojas-Velasquez et  al., 2020). As such, prevalence estimates of NSSI in BIPOC youth are varied. BIPOC youth were previously perceived as not likely to engage in NSSI however recent literature suggests otherwise (Muehlenkamp & Gutierrez, 2004; Rojas-Velasquez et  al., 2020; Sansone et al., 2012). Lifetime prevalence rates of NSSI range from 9.2%–43.0% for Black youth, 10.4% for Hispanic youth, 21.4% for Asian youth, and 21.7%–37.0% for White youth (Chesin et al., 2013; Gratz et al., 2012). However, evidence suggests that rates of NSSI among BIPOC youth may be underreported due to mental health stigma within these communities (Kaminski et  al., 2010; Rojas-Velasquez et  al.,

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2020; Sansone et  al., 2012). Methods of NSSI may differ among BIPOC and White youth. For example, cutting and carving are more commonly reported among Latina and White youth compared with Black youth (Croyle, 2007; Gratz et al., 2012; Gulbas et al., 2015; Rojas-Velasquez et al., 2020), who are more likely to report methods such as hitting, biting, scab-picking, and hair-pulling (Lloyd-Richardson et  al., 2007). Additionally, BIPOC youth may be at risk for engaging in NSSI at younger ages than their White counterparts (Gratz et al., 2012). In sum, NSSI is a heterogenous behavior that may take different forms across racial minorities, but accurate prevalence rates remain difficult to ascertain due to underreporting.

 ystemic Factors Affecting Risk S Some research has focused specifically on racial and ethnic minority youth in the US, identifying risk factors that may be more likely to affect BIPOC youth. There are well-documented barriers to mental healthcare among racial and ethnic minorities in the US, namely for Hispanic and Black youth (Marrast et  al., 2016; Rojas-­ Velasquez et al., 2020); although research has not yet investigated barriers to NSSI treatment specifically, barriers to mental health care, in general, may prevent other risk factors for NSSI, such as depression, anxiety, and psychological distress, from being effectively addressed. In addition, BIPOC youth face more stressors than their White counterparts, including discrimination, barriers to healthcare, socioeconomic disparities, and increased risk of exposure to adverse environments (Jones & Neblett, 2017; Madubata et al., 2019; Rojas-Velasquez et al., 2020). Racial and ethnic identity-specific stressors faced by some BIPOC youth, such as acculturative stress, anti-immigrant attitudes, and language barriers in Hispanic, Latinx, and Asian youth (Hatzenbuehler et  al., 2017; Rojas-Velasquez et  al., 2020; Sirin et  al., 2019), may also place youth at risk for higher levels of psychological distress and potential for NSSI.  Acculturation gaps, immigration stresses, and minority-specific fragmented family structure, such as changes in family structure due to migration, are correlated with NSSI in Latinx

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youth—particularly among low-income Latina women (Cervantes et al., 2014; Rojas-Velasquez et  al., 2020). In a study of Black and White female youth in the juvenile justice system, negative familial experiences were more strongly related to NSSI among Black youth than among White youth (Holsinger & Holsinger, 2005). More longitudinal studies are needed to further understand the relationship between NSSI and experiences of anti-immigrant sentiment, acculturation and immigration stress, language barriers, and fragmented family structures experienced by BIPOC youth. Perceived racism and microaggressions have been associated with negative mental health outcomes in BIPOC adults and youth; however, few studies have investigated discrimination and racism as a potential risk factor for NSSI (Brondolo et  al., 2011; Jones & Neblett, 2017; Rojas-­ Velasquez et al., 2020), and those that have report mixed results. Although Chesin et  al. (2013) found that experiences of targeted discrimination and racism were not associated with NSSI, Bucchianeri et  al. (2014) found that race-based harassment was associated with NSSI in both boys and girls of various racial minority identities. Microaggressions have not yet been investigated in relation to NSSI, but they are associated with a wide range of negative outcomes, including decreased well-being and increased depression and negative affect (Gattis & Larson, 2017; Hernandez & Villodas, 2020; Kim et  al., 2017; Nadal et al., 2014, 2015). Further research is necessary to investigate microaggressions as a contributing factor for NSSI among BIPOC youth.

Summary Although traditional conceptualizations have largely regarded NSSI as a problem among White youth, current research demonstrates that BIPOC youth do engage in NSSI at rates potentially comparable to White youth. Prevalence rates of NSSI in BIPOC youth however are difficult to ascertain due to underreporting. The literature on NSSI in BIPOC youth, though limited, demonstrates distinct risks for NSSI that are experienced in minority populations. The ways in which systemic inequity affects family composi-

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tion, acculturation, immigration stress, stress involved in language barriers, and experiences of race-based harassment may also lead to increased risk for NSSI. Stressors such as immigration and acculturation stress, instances of microaggressions and discrimination, and language barriers are environment-level risks not inherent to BIPOC identities, but rather imposed upon BIPOC individuals. However, little research on NSSI among BIPOC youth exists. Opportunities for growth in this research involve exploring the effects of racial discrimination and prejudice on BIPOC youth NSSI, as well as research looking at differential sources and effects of ethnic belongingness across ethnicities. More research examining traditional NSSI risk factors in BIPOC samples is necessary, in addition to research investigating unique risk and protective factors within these populations of youth.

Gender and Sexual Minority Youth Research has demonstrated a clear association between GSM identity and increased risk for NSSI. However, many identified risk factors for NSSI among GSM youth can be considered as systemic, social, and institutional risks experienced in a predominantly cisgender, heterosexual society.

Prevalence In the last decade, an increasing amount of research has investigated risk for increased self-­ injurious thoughts and behaviors among GSM individuals. Although scarce, lifetime prevalence of NSSI among GSM individuals across all ages has been estimated at nearly 30% for LGB (lesbian, gay, bisexual) individuals, over 40% for bisexual individuals, and over 45% for transgender individuals; these rates are greater than those for heterosexual, cisgender individuals (14.6%; Liu et al., 2019). Greater 12-month NSSI prevalence is also reported for LGB, bisexual, and transgender individuals, compared to those who are heterosexual and cisgender (Liu et al., 2019). Of note, transgender and gender nonconforming (TGNC) youth report high rates of NSSI

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(Connolly et  al., 2016; Eisenberg et  al., 2017; Taliaferro et  al., 2019), with 12-month prevalence rates estimated between 45.5% and 54.8% (Clark et  al., 2014; Eisenberg et  al., 2017; Taliaferro et al., 2018). Additionally, individuals who are female assigned at birth, regardless of current binary transgender or nonbinary identification, report higher rates of NSSI than those who are male assigned at birth (Arcelus et  al., 2016; Rimes et al., 2019; Taliaferro et al., 2018).

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development process was difficult, have been shown to be predictive of NSSI among GSM youth (Liu et  al., 2019; Pereira, 2015; Smith et al., 2020; Taliaferro et al., 2019). Internalized stigma is a complex constellation of emotions involving shame, fear, and discomfort regarding one’s sexual or gender identity; studies examining internalized stigma have identified its importance in the development of psychological distress in sexual minority individuals (McLaren, 2016; Newcomb & Mustanski, 2010). Perceived Systemic Correlates and Risks for GSM burdensomeness, implicated in theories of suiYouth cide (Van Orden et al., 2010), has been found to Minority Stress. GSM youth face risk for NSSI mediate the association between minority stress conferred from general risk factors, as well as and NSSI (Muehlenkamp et  al., 2015). Further, risk factors specifically associated with their gen- Muehlenkamp et al. (2015) suggest that minority der and sexual identity (Liu et al., 2019). In this stress may overwhelm individual coping skills, way, LGB and TGNC youth appear to experience leading to feelings of burdensomeness, which multiplied risk. The minority stress model, a individuals may attempt to regulate by engaging prominent etiological model, posits that higher in NSSI. In support of this idea, other researchers risk for a variety of negative mental health out- posit that sexual minority stressors may undercomes, including NSSI, in GSM can be attributed mine the development of adaptive emotion reguto minority stress, defined as the direct and indi- lation strategies, which contributes to greater use rect effects of systemic and direct stigma experi- of NSSI in order to regulate emotional experienced by marginalized communities (Meyer, ences (Fraser et al., 2018; Smithee et al., 2019). 2003; Plöderl et  al., 2014; Testa et  al., 2017). Minority-specific environmental factors, such Experiences of discrimination, victimization, as daily experiences of discrimination and microinternalized sexual stigma and internalized trans- aggressions, are also risk factors for NSSI (Smith phobia, less social support, more isolation, and et  al., 2020). Gender minority-specific environdifficulties with family—all experiences of mental experiences of identity-based interperminority stress—have all been evidenced as sonal stigma, discrimination, gender-based either correlates or risk factors for suicidal behav- physical bullying, and sexual violence victimizaior among GSM youth and adults (e.g., Plöderl tion are associated with increased NSSI (Arcelus et al., 2014; Testa et al., 2017). Similarly, many et  al., 2016; Liu et  al., 2019; Ross-Reed et  al., GSM-specific correlates and risk factors for 2019; Taliaferro et  al., 2018). Unstable housing NSSI align with concepts found in minority and running away from home have also emerged stress models. as correlates to NSSI (Ross-Reed et  al., 2019; GSM-Related Risk Factors. While research Taliaferro et al., 2019), potentially indicating the among sexual minority youth has supported gen- role of family rejection or the unsafe household eral risk factors, such as self-criticism, depres- environment in NSSI risk for TGNC youth. sion, low self-esteem, and body image concerns Gender and Sexual Minority BIPOC Youth. (Liu et  al., 2019; Smith et  al., 2020), GSM-­ Though the minority stress model was originally specific or -related risk factors have also been developed for LGB populations, its assertion that identified. Minority-specific factors, such as everyday experiences of discrimination, microinternalized stigma (known as internalized sexual aggressions, harassment, and victimization constigma in sexual minority populations and inter- fer risk for negative mental health outcomes nalized transphobia in TGNC populations) and apply to BIPOC populations, as well (Meyer, perceptions that one’s sexual and gender identity 2003). GSM BIPOC faces multiple minority

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stresses within a predominantly White, cisgender, heterosexual society (McConnell et  al., 2018). GSM BIPOC may even face multiple minority stressors from within their own communities, as they encounter racism within the GSM community and homophobia, transphobia, and heterosexism within their racial and ethnic communities (Cyrus, 2017). Currently, there is limited research demonstrating an additive effect of multiple minority status on negative health outcomes, more broadly (Cyrus, 2017; Kertzner et al., 2009). Although this has not been studied in relation to NSSI risk, belonging to a racial minority group is associated with NSSI among GSM youth and adults (Liu et al., 2019). In addition, research clearly demonstrates the widespread rates of violence and victimization that GSM—and especially TGNC—BIPOC individuals face (McCown & Platt, 2020). Given the associations between NSSI and discrimination and victimization among GSM youth, youth experiencing multiple minority stressors may be at risk for a variety of negative mental health outcomes, including NSSI. Further research is necessary to understand how increased victimization experienced as a result of multiple marginalization can influence NSSI within GSM BIPOC youth, specifically.

Summary Recent research has highlighted the heightened prevalence of NSSI in GSM youth and young adults. Bisexual and TGNC communities, in particular, have reported the highest prevalence estimates for NSSI.  This may reflect the unique challenges faced by bisexual and TGNC youth due to their GSM identities. Bisexual youth may experience anti-bisexual prejudice from lesbian and gay youth and resulting feelings of community invisibility (Shearer et al., 2016; Taliaferro & Muehlenkamp, 2017). TGNC youth experience fewer legal protections, more medical discrimination, and other sources of systemic oppression that are experienced less by non-TGNC youth, even those who have sexual minority identities. This difference may explain the higher prevalence of NSSI among TGNC youth, but more research is needed.

Several risk factors for NSSI that are related to systemic oppression have been identified in GSM youth. Internalized stigma, microaggressions, discrimination, and victimization have been identified as associated with increased NSSI. Of note, unstable housing among TGNC youth is an NSSI correlate, representing a critical need for systems-­ based support to protect the mental health and safety of youth in these communities. Additionally, further research on GSM BIPOC youth and NSSI risk is necessary, as being multiply marginalized presents risk for a wide range of negative mental health outcomes, potentially including NSSI risk. Research specifically focused on GSM BIPOC youth is critically needed to better identify risk factors for NSSI in this population in order to develop appropriate integrative, social justice-informed clinical interventions.

Conclusion Youth suicide is preventable. Research demonstrates that suicide results from the intersection of many individual and environmental factors, one very significant one being engagement in NSSI. Increased awareness and understanding of the extent of, causes, and interventions for NSSI therefore have the potential to significantly reduce suicide. Research indicates a high prevalence of NSSI in both community and clinical adolescent and young adult populations. Prevalence of NSSI is notably elevated in GSM youth and therefore demands attention, understanding, and interventions. Risks for engagement in NSSI broadly include prior NSSI engagement, cognitive factors, emotion dysregulation, psychopathology and psychological distress, low social support, and peer victimization. Tailored longitudinal research on NSSI in underserved and underrepresented populations of youth, including BIPOC and GSM youth, is needed to further our understanding of the phenomenon within these communities. Studies of NSSI in BIPOC youth show varied prevalence rates due to underreporting and unique correlates such as acculturation stress and racial h­ arassment.

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Suicidal behavior and the media Megan Chesin, Elisheva Adler, and Michelle Feinberg

Traditional mass media (e.g., print media, television, films, and material online where content is not user-generated) and social media (i.e., platforms that are comprised of user-generated content, including networking and blog sites) are powerful platforms for the transmission of ideas and information among youth, or adolescents and emerging adults aged 15–24  years (Gottfried & Shearer, 2017; Perrin & Anderson, 2019). Similarly, much of what youth know about suicide is learned from the media (Beautrais et al., 2004; Biddle et  al., 2018; Dunlop et  al., 2011; Mars et al., 2015). Thus, responsible reporting of suicide in the media is important and has implications for suicide knowledge, beliefs about people who die by suicide, and suicide-related behaviors in youth (O’Connor & Portzky, 2018). Suicide stories in the media, for instance, have been associated with increased suicide behavior rates and risk in youth (see Dunlop et  al., 2011; Memon et al., 2018; Niederkrotenthaler et al., 2012, for a review). However, others have found exposure to suicide stories in the media may reduce suicidal behavior risk, including among high suicide-risk youth (e.g., Dodemaide et  al., 2019; Niederkrotenthaler & Till, 2020). Multiple factors explain inconsistent results, including, for M. Chesin () · E. Adler · M. Feinberg Department of Psychology, William Paterson University, Wayne, NJ, USA e-mail: [email protected]; [email protected]; [email protected]

example, characteristics of the suicide story, e.g., whether the suicide story was fictional, portrayed suicide-related coping, and was not sensationalized, and the group studied, e.g., age and similarity of the media consumer to the suicidal individual in the story (Gould, 2001; Niederkrotenthaler et  al., 2012; Stack, 2005). The purpose of this chapter is to review what is known about the relationships between suicidal behavior and the media, with a focus on what is known in youth. Implications and directions for future research to inform youth suicide prevention are then presented.

 istory and Definitions of Terms H Used to Describe Media Influences on Suicidal Behavior Interest in testing associations between media depictions of suicide and suicidal behavior began in the 1970s. By the close of the twentieth century, interest in testing such associations had dwindled, with a few studies of such phenomena continuing into the early 2000s (see Ferguson, 2019; Gould, 2001, for reviews). Nonetheless, by the end of this era, there was evidence, albeit not completely consistent (see Stack, 2005, for a review), for an increase in the rates of youth suicide attempts and suicides following a nonfiction story about suicide in the traditional media (see Gould, 2001; Gould et al., 1990; Hawton et al.,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_7

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2019; Niederkrotenthaler et al., 2012; Niedzwiedz et al., 2014; Sisask & Värnik, 2012, for reviews). This phenomenon is referred to as suicide behavior clustering in the scholarly literature (Cheng et al., 2014); however, no such positive association for fictional depictions of suicide in the media and suicide attempt and suicide rates was consistently found (see Ferguson, 2019, for reviews; Gould, 2001; Pirkis & Blood, 2001). Suicide behavior clustering subsequent to a suicide story in the media is sometimes referred to as the Werther Effect after the eighteenth-century novel, The Sorrows of Werther, which was one of the first reported instances of suicide clustering subsequent to a suicide story in print (Phillips, 1974). In fewer studies, evidence of suicide behavior contagion, i.e., increased suicide and suicide attempt risk among individuals who were exposed to the suicide story, emerged from survey studies of patients and emerging adult community members who self-reported whether they had seen a  specific television show or movie where a suicide was portrayed (Hawton et  al., 1999; Stack et al., 2014). Findings from randomized controlled studies, however, are inconsistent, and show no specific effect on risk of suicidal behavior for exposure to fictional or nonfictional depictions of suicide in traditional media among non-suicidal adult and emerging adult community members (Till et al., 2010; Williams et al., 2020; Williams & Witte, 2018). Inconsistent findings regarding the existence of suicide behavior contagion with exposure to suicide stories in traditional media may be explained by the use of non-suicidal samples in the studies where evidence for suicidal behavior contagion was not found. There is evidence that suicide stories in film resonate more with adult viewers who have a history of suicidal behavior (Till et al., 2013), and that such viewers show increased risk of suicidal behavior after viewing films depicting suicide (Till et  al., 2015). It could also be that earlier findings from studies using cross-sectional survey methods detected an interest in suicide stories among those with a history of suicidal behavior, as opposed to a causal relationship whereby exposure to suicide in the media resulted in increased risk of suicidal behavior. The defini-

tions of suicidal behavior, suicide behavior clustering, and suicide behavior contagion are provided in Table 7.1. Interestingly, the positive effects of exposure to suicide stories in the media featuring coping and resilience with respect to decreasing suicidal behavior have also been acknowledged for the past two decades. This phenomenon is sometimes called the Papageno effect, after the opera, The Magic Flute, in which the main character successfully manages a suicidal crisis (Niederkrotenthaler et  al., 2010a). Consistent with this idea, a handful of recent randomized controlled studies in adult community members show reduced suicide ideation with exposure to media depictions of suicide-related coping, when compared to medical education or information unrelated to health or suicide (see Niederkrotenthaler & Till, 2019b, for a review). Notably, this finding has been replicated in emerging adults (Arendt et al., 2016), including emerging adults at risk for suicidal behavior given past year suicide attempt or ideation (Niederkrotenthaler & Till, 2020). Thus, when suicide-related coping is depicted, suicide in the media can have protective effects on suicidal behavior in youth.

Table 7.1  Chapter terms, defined Suicidal behavior

Suicide behavior clustering

Suicide behavior contagion

Self-inflicted injury perpetrated with at least some intent to die. This category of behavior includes suicide deaths as well as nonfatal suicide attempts and suicide ideation Increased suicide behavior rates near to an incident suicide behavior, or for the purposes of this chapter, near to a media depiction of suicide. Uses aggregate, epidemiological data Increased suicide behavior risk among individuals who were definitely exposed to suicide. In its cleanest form, an experimental design is used and individuals are randomly assigned to view or read the suicide story. In many cases and to increase ecological validity, longitudinal or cross-sectional survey data is collected and used and exposure is self-reported. Regardless, individual-­ level data is used

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In addition to the observed protective effects on suicide ideation in youth that are shown with suicide-related coping stories in the media, improvements in suicide knowledge and beliefs are also observed among adult community members exposed to suicide-related coping stories in the media and when media depictions of suicide include psychoeducation. For instance, decreased suicide stigma, defined as negative beliefs about people who die by suicide, and increased suicide knowledge resulted among high suicide-risk adults who were exposed to a story of suicide-­ related coping (Niederkrotenthaler & Till, 2019a). Taken together, there is evidence for positive effects on suicide knowledge and beliefs as well as reductions in suicide ideation with exposure to suicide stories in the traditional mass media where suicide-related coping is shown. This includes emerging adults. Whether results would hold in youth with a history of suicidal behavior is unclear.

 uicide Behavior, Suicide-Related S Outcomes, and “13 Reasons Why” In March 2017, a fictional television series about the suicide of a high-school student, 13 Reasons Why (13RW), was released on Netflix, a streaming, on-demand broadcast service. The first season of 13RW was the second most in-demand digital series in the United States in 2017 (Parrot Analytics, 2018), and it significantly engaged public interest (Ayers et al., 2017; Niederkrotenthaler et al., 2019). Almost immediately upon its release, faculty and staff of professional organizations released statements of concern that 13RW portrayed suicide irresponsibly (e.g., in a glorified, glamorized, and romanticized way) and increased suicidal behavior, particularly among vulnerable youth (American Association of Suicidology, 2017; American Foundation for Suicide Prevention, 2019; International Association for Suicide Prevention, 2017; National Association of School Psychologists, 2017; The JED Foundation, 2017). In line with these concerns, evidence for suicidal behavior, including suicide, clustering with

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13RW was found among adolescents (Niederkrotenthaler et al., 2019). Crisis Text Line conversations, which are predominately initiated by youth, along with suicide ideation content also consistently, albeit very transiently, rose following the release of the first two seasons of 13RW (Sugg et al., 2019; Thompson et al., 2019). Fewer available studies tested suicidal behavior in viewers who were definitely exposed to the suicide story in 13RW, i.e., suicidal contagion with 13RW, and results did not show an association between viewing 13RW and suicidal behavior in emerging adults (Chesin et al., 2019). In fact, a protective effect on suicide ideation among emerging adults who watched the entirely of season 2 versus none of season 2 was found (Arendt et al., 2019). Nonsignificant findings here may be explained by the older age of the youth participants. The suicide clustering with 13RW was observed in adolescents, and, here, emerging adults were studied. Taken together, there is concerning evidence for suicide behavior clustering among adolescents with 13RW. Older youth, i.e., emerging adults, seem less affected by the suicide story in 13RW with regard to risk of suicidal behavior. 13RW was also associated with positive changes to suicide-related outcomes, including increased help-seeking behavior, and improved suicide knowledge and beliefs. After the release of 13RW seasons 1 and 2, increased suicide crisis help-seeking behavior, as indicated by Crisis Text Line use and Internet research into suicide hotlines, was observed among youth (Ayers et al., 2017; Sugg et al., 2019). Exposure to the suicide story in 13RW was also associated with decreased suicide stigma and increased suicide knowledge among youth (Chesin et  al., 2019; Lauricella et al., 2018).

 actors Impacting the Likelihood F of Suicide Clustering and Contagion with Media Exposure to Suicide Because both protective and deleterious effects are associated with suicide stories in the media, a focus of research has been on determining for

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whom media depictions of suicide may be harmful as well as how to safely present suicide in the media. In an analysis of print media reports of suicide, for example, Niederkrotenhtaler et  al. (2010b) found sensational language (e.g., referring to a suicide epidemic) and repetitive reporting of suicide were associated with suicide clustering. In a later study, sensational, as opposed to neutral language, also predicted acceptance of suicide as a solution in adult community members (Arendt et al., 2018). In traditional online media, the number of suicide prevention resources provided (i.e., suicide prevention hotline notices) is positively associated with suicide-related coping and specifically further searching for suicide prevention information (Cheng & Yom-Tov, 2019). Consistent with Social-Learning Theory (Bandura & Walters, 1977), the likability or popularity of the character or individual who dies by suicide in the story matters. When the suicide model in the media is not portrayed favorably, the Papageno effect may be stronger (Arendt et  al., 2016; Sinyor et  al., 2018; Stack, 2005). Meanwhile, censoring the suicide scene (e.g., not depicting the suicide in detail) in a fictional film is not associated with a reduction in suicide ideation among adult community members (Till et  al., 2010). Taken together, suicide stories in traditional media are safer for youth when they are portrayed in a non-­ sensationalized manner, the suicide is not repetitively reported, and the suicide model is not attractive. Provision of suicide prevention resources is also associated with help-seeking behavior, which, in turn, can prevent suicidal behavior. A poignant example of how reporting on suicide matters comes from the suicide of Kurt Cobain, the very popular front man of the band Nirvana, in 1994. Suicide contagion was not observed following his suicide. The lack of suicide contagion  was attributed to the media reporting. His suicide was not romanticized, and suicide prevention resources were provided in media reports (Jobes et al., 1996). Factors unique to the viewer or reader, i.e., the consumer, that impact risk of suicidal behavior after media exposure to suicide include consumer similarity to the character or individual whose

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suicidal behavior is portrayed in the media. Similarity between the consumer and the character or individual suicide model is positively linked to suicide clustering and contagion (see Notredame et  al., 2017, for a review). Again, these ideas align with some fundamental tenets of Social-­ Learning Theory whereby factors unique to the learner, in this case the media consumer, influence the likelihood that the observed behavior will be replicated (Bandura & Walters, 1977). A personal history of suicidal behavior, as well as other risk factors for suicidal behavior (e.g., a history of depression), are also proposed and to a certain extent shown to increase the risk of negative outcomes with media exposure to suicidal behavior in adults (Till et al., 2015). Taken together, suicidal in the media is more strongly linked to suicidal behavior risk and suicide rates among those who are more similar to, and thus may more greatly identify with, the suicide model in the media. Those who are vulnerable to suicidal behavior given their personal history may also be more likely to engage in suicidal behavior when suicide is portrayed in the media.

 xposure to Suicide on Social Media E and Suicidal Behavior in Youth Social media is a relatively new medium. It first became prominent in 1999 with Blogger (van Dijck, 2013). Since then, youth have readily adopted this platform for communication, connection, and edification (Anderson & Jiang, 2018), including on  suicidal behavior (Dunlop et al., 2011). Nine percent of youth admit to discussing self-harm, suicide intent unknown, on social media (Mars et  al., 2015), and 26% of youth presenting to the emergency department for self-harm, suicide intent unknown, reported that they read self-harm-related content on the Internet prior to the event (Padmanathan et  al., 2018). As with suicide stories in traditional media, there are both positive and negative effects on youth from exposure to suicide-related content on social media (see Luxton et  al., 2012; Marchant et  al., 2017; Memon et  al. 2018, for

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reviews). In a systematic review, Mok et  al. (2015) found that social media use to discuss and learn about how to die by suicide and connect with other suicidal individuals was positively related to suicide attempts. In a reinterpretation of Niederkrotenthaler et  al. (2019)’s findings regarding suicide clustering among adolescents with exposure to 13RW, Hawton et  al. (2019) suggested increased discussion of the show on social media explained or at least contributed to the observed suicide clustering with 13RW. Others, however, have found little to no evidence of suicide contagion among support group members on social media (Dodemaide et  al., 2019; Hsiung, 2007). In fact, in a meta-synthesis on the effects of social media use on suicidal youth, reductions in suicide ideation among emerging adult youth with a history of suicidal behavior were noted in the majority of studies, and identified mechanisms of safety gains included decreased loneliness among the social media users as well as increased identification of help-seeking resources (Dodemaide et  al., 2019). Inconsistent findings regarding the safety of social media use among youth may reflect differences in the suicide risk among those studied. Biddle et  al. (2018), for instance, found emerging adults at lower risk for suicide were more likely to report positive effects with social media use when distressed, e.g., finding connection and resources, than those at higher suicide risk. In fact, whether exposure to suicide on social media is associated with suicide contagion is not well tested (Krysinska et  al., 2017). Few large-scale, rigorous tests exist. Instead, case studies or small qualitative analyses are more often conducted. Moreover, targeting the effect of social media, versus traditional media, is arduous. Studies and participants often consider Internet media use broadly (Krysinska et  al., 2017), and the two media platforms are often used simultaneously. For instance, there may be content on social media directing users to traditional media for more information or vice versa (Scherr & Steinleitner, 2017b). Thus, emerging evidence shows that this medium presents similar concerns and opportunities with respect to suicide-­related outcomes in youth as traditional media. Given content may also be generated by

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the user, additional considerations are warranted. For instance, identification of individual suicide risk by mining user content on social media is possible (see Ortiz & Khin Khin, 2018, for a review). While the feasibility of using social media data, natural language processing, and machine learning to detect those at risk for suicide on social media has been demonstrated, the ethics of such an approach to suicide prevention is still debated (Coppersmith et al., 2018).

I mplications for Media Reporting and Consuming of Suicide Stories In line with current knowledge, e.g., that depictions of suicide-related coping decrease suicide ideation, and conversely, sensationalist portrayals of suicide are more likely to result in suicide clustering, evidence-informed guidelines for mass media depictions of suicide have been published by groups and organizations such as the World Health Organization (2017, 2019). Guidelines specific to social media producers and platforms also exist and include Suicide Awareness Voices of Education (2013, 2017). There is also evidence that journalists and reporters appreciate and apply guidelines to their suicide stories (Markiewitz et  al., 2020; Scherr et al., 2019; Thienel et al., 2019). Less is known about the uptake and impact of social media guidelines for suicide stories. Unlike traditional media, terms of use for social media platforms may allow for censoring or banning of users who post suicidal content. How often material or users are removed and to what effect, however, is unknown. Further, particular evidence-based guidelines for media depictions of suicide may function differently in mass and social media, and thus future studies of the uptake and impact of adherence to social media guidelines or platform terms of use on suicide content are warranted. In addition to the aforementioned guidelines and terms of use for media content generators, there are guidelines and psychoeducational resources for media consumers of suicide stories, and specifically consumers of the suicide story in

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13RW. Multimedia resources for youth and adults who are interested in learning more about s­ uicide, suicide risk factors, and how to discuss mental illness and suicide in the context of 13RW are available (see https://www.13reasonswhytoolkit. org). Netflix now provides a content warning ahead of each episode of 13RW, a companion episode titled, “Beyond the Reasons,” and a webpage with suicide crisis management resources (https://13reasonswhy.info/). Providing such resources may increase the safety of youth who view 13RW. Firm conclusions here, however, await further study in youth, and particularly vulnerable youth, as no study has tested the impact of adhering to the guidelines or using the psychoeducation resources on suicide-­related outcomes in youth viewers. With respect to social media and suicidal behavior in youth, the consensus is that social media use should be assessed among suicidal or otherwise distressed youth (Marchant et  al., 2017), given the high rates of social media use among youth and the benefits and consequences of social media use in high suicide-risk youth (Dodemaide et al., 2019; Marchant et al., 2017; Padmanathan et al., 2018).

 uture Directions for Research F to Inform Suicide Prevention in Youth Given Media Depictions of Suicide While many strides have been made towards understanding the link between suicidal behavior and the media and leveraging such information to increase youth safety in the context of media depictions of suicide, additional study is warranted to inform suicide prevention in youth. Specifically, 1. Additional experimental studies are needed to test whether media exposure to suicide increases suicide risk in youth. For ethical reasons, experimental study of suiciderelated outcomes using potentially triggering or conversely safety-promoting content is difficult. Despite these difficulties, some experimental tests of outcomes associated

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with suicide stories in the media have been done on adults and emerging adults (e.g., Niederkrotenthaler & Till, 2020). Experimentally studying suicide outcomes in adolescents presents even more challenges given the vulnerable nature of this population. Thus, studies are particularly limited, though needed, here. 2. Additional studies of characteristics of youth viewers that are associated with increased risk of suicidal behavior or suicide rates are needed so that suicide prevention efforts can be better targeted to those who are most likely to be triggered by suicide stories in the media. There are already indications that adolescents, even compared to emerging adults, as well as those who share similarities with the suicide model and those with personal vulnerabilities to suicide, are more likely to be negatively affected by suicide in the media (see Gould, 2001, for a review). 3. More studies of social media exposure to suicide and suicide-related outcomes are needed. Youth often use and create social media, yet little is known about the impact of suicide-­ related content in this medium on suicide-­related outcomes in youth. Analysis of Crisis Text Line use for suicide-related concerns following 13RW (e.g., Thompson et al., 2019) may provide a model for how to track and test changes in suicidal content among social media users following a particular incident. Given indications that youth search the Internet for suicide information prior to suicidal behavior, further study of how to ethically and effectively leverage social media content data to identify individuals at suicide risk is also warranted. Finally, the impact of aggregate exposures across multiple social and traditional media is not well studied (Scherr & Steinleitner, 2017a)  but needed, as there are indications that repeated reporting of suicide in traditional media is positively linked to suicide contagion (Niederkrotenthaler et al., 2010b). 4. More implementation science studies to understand uptake, as well as how to increase uptake of guidelines for depicting suicide in

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the media, are needed. Particularly little is known about the extent and impact on suicide clustering and contagion in youth of adherence to social media guidelines or terms of use for depicting suicidal content.

Conclusion Renewed interest in studying suicidal behavior and the media emerged after the release of 13RW, a popular television show that depicted the suicide of an adolescent. There is now significant evidence for suicide clustering among adolescents in the wake of the show (Niederkrotenthaler et al., 2019). In the broader literature, there is evidence of suicide clustering and contagion in youth, particularly with nonfiction, as compared to fictional, suicide stories in the media (Hawton et al., 2019). Limited literature also suggests that those who have intraindividual risk factors for suicide, including mental illness and a history of suicidal behavior, may be particularly affected by consuming suicide stories in the media (Till et  al., 2015). Given the evolving content and delivery of suicide stories in the media and evidence of the impact of suicide stories in the media on suicide risk and rates in youth, the review provided in this chapter is timely and important. The provided implications, and associated resources, for suicide prevention in youth who view suicide stories in the media can be immediately leveraged, and the identified directions for future research highlight areas where additional study could aid in refining youth suicide prevention efforts.

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111 the-­american-­foundation-­for-­suicide-­prevention-­on-­ netflix-­s-­13-­rea Anderson, M., & Jiang, J. (2018, May 31). Teens, social media & technology 2018. Pew Research Center. Retrieved from https:// w w w. p ew r e s e a r c h . o rg / i n t e r n e t / 2 0 1 8 / 0 5 / 3 1 / teens-­social-­media-­technology-­2018/ Arendt, F., Scherr, S., Niederkrotenthaler, T., & Till, B. (2018). The role of language in suicide reporting: Investigating the influence of problematic suicide referents. Social Science and Medicine, 208, 165–171. https://doi.org/10.1016/j.socscimed.2018.02.008 Arendt, F., Scherr, S., Pasek, J., Jamieson, P. E., & Romer, D. (2019). Investigating harmful and helpful effects of watching season 2 of 13 Reasons Why: Results of a two-wave US panel survey. Social Science and Medicine, 232, 489–498. https://doi.org/10.1016/j. socscimed.2019.04.007 Arendt, F., Till, B., & Niederkrotenthaler, T. (2016). Effects of suicide awareness material on implicit suicide cognition: A laboratory experiment. Health Communication, 31(6), 718–726. https://doi.org/10.1 080/10410236.2014.993495 Ayers, J.  W., Althouse, B.  M., Leas, E.  C., Dredze, M., & Allem, J.-P. (2017). Internet searches for suicide following the release of 13 Reasons Why. JAMA Internal Medicine, 177(10), 1527–1529. https://doi. org/10.1001/jamainternmed.2017.3333 Bandura, A., & Walters, R.  H. (1977). Social learning theory (Vol. 1). Prentice-Hall. Beautrais, A.  L., John Horwood, L., & Fergusson, D.  M. (2004). Knowledge and attitudes about suicide in 25-year-olds. Australian and New Zealand Journal of Psychiatry, 38(4), 260–265. https://doi. org/10.1080/j.1440-­1614.2004.01334.x Biddle, L., Derges, J., Goldsmith, C., Donovan, J. L., & Gunnell, D. (2018). Using the internet for suicide-­ related purposes: Contrasting findings from young people in the community and self-harm patients admitted to hospital. PLoS One, 13(5), e0197712. https:// doi.org/10.1371/journal.pone.0197712 Cheng, Q., Li, H., Silenzio, V., & Caine, E.  D. (2014). Suicide contagion: A systematic review of definitions and research utility. PLoS One, 9(9), e108724. https:// doi.org/10.1371/journal.pone.0108724 Cheng, Q., & Yom-Tov, E. (2019). Do search engine helpline notices aid in preventing suicide? Analysis of archival data. Journal of Medical Internet Research, 21(3), e12235. https://doi.org/10.2196/12235 Chesin, M., Cascardi, M., Rosselli, M., Tsang, W., & Jeglic, E. (2019). Knowledge of suicide risk factors, but not suicide risk, is greater among college students who viewed 13 Reasons Why. Journal of American College Health.. Advance online publication. https:// doi.org/10.1080/07448481.2019.1586713 Coppersmith, G., Leary, R., Crutchley, P., & Fine, A. (2018). Natural language processing of social media as screening for suicide risk. Biomedical Informatics Insights, 10, 1–11. https://doi. org/10.1177/1178222618792860

112 Dodemaide, P., Joubert, L., Merolli, M., & Hill, N. (2019). Exploring the therapeutic and nontherapeutic affordances of social media use by young adults with lived experience of self-harm or suicidal ideation: A scoping review. Cyberpsychology, Behavior and Social Networking, 22(10), 622–633. https://doi. org/10.1089/cyber.2018.0678 Dunlop, S.  M., More, E., & Romer, D. (2011). Where do youth learn about suicides on the Internet, and what influence does this have on suicidal ideation? The Journal of Child Psychology and Psychiatry, 52(10), 1073–1080. https://doi. org/10.1111/j.1469-­7610.2011.02416.x Ferguson, C. J. (2019). 13 Reasons Why not: A methodological and meta-analytic review of evidence regarding suicide contagion by fictional media. Suicide and Life-threatening Behavior, 49(4), 1178–1186. https:// doi.org/10.1111/sltb.12517 Gottfried, J., & Shearer, E. (2017, September 7). Americans’ online news use is closing in on TV news use. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-­tank/2017/09/07/ americans-­online-­news-­use-­vs-­tv-­news-­use/ Gould, M.  S. (2001). Suicide and the media. Annals of the New York Academy of Sciences, 932(1), 200–224. https://doi.org/10.1111/j.1749-­6632.2001.tb05807.x Gould, M.  S., Wallenstein, S., Kleinman, M.  H., O'Carroll, P., & Mercy, J. (1990). Suicide clusters: An examination of age-specific effects. American Journal of Public Health, 80(2), 211–212. https://doi. org/10.2105/AJPH.80.2.211 Hawton, K., Hill, N., Gould, M., John, A., Lascelles, K., & Robinson, J. (2019). Clustering of suicides in children and adolescents. The Lancet Child & Adolescent Health, 4(1), 58–67. https://doi.org/10.1016/ S2352-­4642(19)30335-­9 Hawton, K., Simkin, S., Deeks, J. J., O'Connor, S., Keen, A., Altman, D. G., Philo, G., & Bulstrode, C. (1999). Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: Time series and questionnaire study. BMJ, 318, 972–977. https://doi.org/10.1136/bmj.318.7189.972 Hsiung, R.  C. (2007). A suicide in an online mental health support group: Reactions of the group members, administrative responses, and recommendations. Cyberpsychology & Behavior, 10(4), 495–500. https:// doi.org/10.1089/cpb.2007.9999 International Association for Suicide Prevention. (2017, May 2). Briefing in connection with the netflix series '13 Reasons Why'. Retrieved from https://www.iasp. info/pdf/2017_iasp_statement_13_reasons_why.pdf Jobes, D. A., Berman, A. L., O'Carroll, P. W., Eastgard, S., & Knickmeyer, S. (1996). The Kurt Cobain suicide crisis: Perspectives from research, public health, and the news media. Suicide and Life-threatening Behavior, 26(3), 260–271. https://doi.org/10.1111/ j.1943-­278X.1996.tb00611.x Krysinska, K., Westerlund, M., Niederkrotenthaler, T., Andriessen, K., Carli, V., Hadlaczky, G., Till, B., & Wasserman, D. (2017). A mapping study on the

M. Chesin et al. internet and suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 38(4), 217–226. https://doi.org/10.1027/0227-­5910/a000444 Lauricella, A.  R., Cingel, D.  P., & Wartella, E. (2018). Exploring how teens and parents responded to 13 Reasons Why: United States. Center on Media and Human Development, Northwestern University. Retrieved from https://13reasonsresearch.soc.northwestern.edu/netflix_global-­report_-­final-­print.pdf Luxton, D.  D., June, J.  D., & Fairall, J.  M. (2012). Social media and suicide: A public health perspective. American Journal of Public Health, 102(Suppl. 2), S195–S200. https://doi.org/10.2105/ AJPH.2011.300608 Marchant, A., Hawton, K., Stewart, A., Montgomery, P., Singaravelu, V., Lloyd, K., Purdy, N., Daine, K., & John, A. (2017). A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS One, 12(8), e0181722. https://doi. org/10.1371/journal.pone.0181722 Markiewitz, A., Arendt, F., & Scherr, S. (2020). Increasing adherence to media guidelines on responsible reporting on suicide: Suggestions from qualitative interviews with German journalists. Journalism Studies, 21(4), 494–511. https://doi.org/10.1080/1461 670X.2019.1686412 Mars, B., Heron, J., Biddle, L., Donovan, J.  L., Holley, R., Piper, M., Potokar, J., Wyllie, C., & Gunnell, D. (2015). Exposure to, and searching for, information about suicide and self-harm on the Internet: Prevalence and predictors in a population based cohort of young adults. Journal of Affective Disorders, 185, 239–245. https://doi.org/10.1016/j.jad.2015.06.001 Memon, A.  M., Sharma, S.  G., Mohite, S.  S., & Jain, S. (2018). The role of online social networking on deliberate self-harm and suicidality in adolescents: A systematized review of literature. Indian Journal of Psychiatry, 60(4), 384–392. https://doi.org/10.4103/ psychiatry.IndianJPsychiatry_414_17 Mok, K., Jorm, A. F., & Pirkis, J. (2015). Suicide-related internet use: A review. Australian and New Zealand Journal of Psychiatry, 49(8), 697–705. https://doi. org/10.1177/0004867415569797 National Association of School Psychologists. (2017). 13 Reasons Why Netflix series: Considerations for educators. Retrieved from https://www.nasponline.org/resources-­a nd-­p ublications/resources-­ and-­p odcasts/school-­c limate-­s afety-­a nd-­c risis/ mental-­health-­resources/preventing-­youth-­suicide/13-­ reasons-­why-­netflix-­series/13-­reasons-­why-­netflix-­ series-­considerations-­for-­educators Niederkrotenthaler, T., Fu, K.-W., Yip, P. S. F., Fong, D. Y. T., Stack, S., Cheng, Q., & Pirkis, J. (2012). Changes in suicide rates following media reports on celebrity suicide: A meta-analysis. Journal of Epidemiology and Community Health, 66(11), 1037–1042. https:// doi.org/10.1136/jech-­2011-­200707 Niederkrotenthaler, T., Stack, S., Till, B., Sinyor, M., Pirkis, J., Garcia, D., Rockett, I. R. H., & Tran, U. S.

7  Suicidal behavior and the media (2019). Association of increased youth suicides in the United States with the release of 13 Reasons Why. JAMA Psychiatry, 76(9), 933–940. https://doi. org/10.1001/jamapsychiatry.2019.0922 Niederkrotenthaler, T., & Till, B. (2019a). Effects of suicide awareness materials on individuals with recent suicidal ideation or attempt: Online randomised controlled trial. The British Journal of Psychiatry. Advance online publication. https://doi.org/10.1192/ bjp.2019.259 Niederkrotenthaler, T., & Till, B. (2019b). Suicide and the media: From Werther to Papageno effects  – A selective literature review. Suicidologi, 24(2), 4–12. Retrieved from https://journals.uio.no/suicidologi/ article/view/7398/6916 Niederkrotenthaler, T., & Till, B. (2020). Effects of awareness material featuring individuals with experience of depression and suicidal thoughts on an audience with depressive symptoms: Randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 66, 101515. https://doi.org/10.1016/j. jbtep.2019.101515 Niederkrotenthaler, T., Voracek, M., Herberth, A., Till, B., Strauss, M., Etzersdorfer, E., Eisenwort, B., & Sonneck, G. (2010a). Papageno v Werther effect. BMJ: British Medical Journal (Online), 341, c5841. https://doi.org/10.1136/bmj.c5841 Niederkrotenthaler, T., Voracek, M., Herberth, A., Till, B., Strauss, M., Etzersdorfer, E., Eisenwort, B., & Sonneck, G. (2010b). Role of media reports in completed and prevented suicide: Werther v. Papageno effects. The British Journal of Psychiatry, 197(3), 234–243. https://doi.org/10.1192/bjp.bp.109.074633 Niedzwiedz, C., Haw, C., Hawton, K., & Platt, S. (2014). The definition and epidemiology of clusters of suicidal behavior: A systematic review. Suicide and Life-­ threatening Behavior, 44(5), 569–581. https://doi. org/10.1111/sltb.12091 Notredame, C.-E., Pauwels, N., Walter, M., Danel, T., Nandrino, J.-L., & Vaiva, G. (2017). Why media coverage of suicide may increase suicide rates: An epistemological review. In T. Niederkrotenthaler & S. Stack (Eds.), Media and suicide: International perspectives on research, theory and policy (pp.  159–170). Transaction Publishers. O'Connor, R.  C., & Portzky, G. (2018). Looking to the future: A synthesis of new developments and challenges in suicide research and prevention. Frontiers in Psychology, 9, Article 2139. https://doi.org/10.3389/ fpsyg.2018.02139 Ortiz, P., & Khin Khin, E. (2018). Traditional and new media's influence on suicidal behavior and contagion. Behavioral Sciences & the Law, 36(2), 245–256. https://doi.org/10.1002/bsl.2338 Padmanathan, P., Biddle, L., Carroll, R., Derges, J., Potokar, J., & Gunnell, D. (2018). Suicide and self-­ harm related internet use: A cross-sectional study and clinician focus groups. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 469–478. https://doi.org/10.1027/0227-­5910/a000522

113 Parrot Analytics. (2018). The global television demand report. Retrieved from https://insights.parrotanalytics.com/hubfs/Resources/whitepapers/Parrot%20 Analytics%20-­% 20The%20Global%20TV%20 Demand%20Report%202018.pdf Perrin, A., & Anderson, M. (2019, April 10). Share of U.S. adults using social media, including facebook, is mostly unchanged since 2018. Pew Research Center. Retrieved from https://www.pewresearch. org/fact-­t ank/2019/04/10/share-­o f-­u -­s -­a dults-­ using-­s ocial-­m edia-­i ncluding-­facebook-­i s-­m ostly-­ unchanged-­since-­2018/ Phillips, D. P. (1974). The influence of suggestion on suicide: Substantive and theroretical implications of the Werther effect. American Sociological Review, 39(3), 340–354. https://doi.org/10.2307/2094294 Pirkis, J., & Blood, R.  W. (2001). Suicide and the media: Part II: Portrayal in fictional media. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 22(4), 155–162. https://doi. org/10.1027//0227-­5910.22.4.155 Scherr, S., Markiewitz, A., & Arendt, F. (2019). Effectiveness of a workshop intervention on responsible reporting on suicide among Swiss media professionals. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(6), 446–450. https://doi. org/10.1027/0227-­5910/a000584 Scherr, S., & Steinleitner, A. (2017a). Between Werther and Papageno effects: A propositional meta-analysis of ambiguous findings for helpful and harmful media effects on suicide contagion. In T. Niederkrotenthaler & S.  Stack (Eds.), Media and suicide: International perspectives on research, theory and policy (pp. 159– 170). Transaction Publishers. Scherr, S., & Steinleitner, A. (2017b). Media and suicide: International perspectives on research, theory, and policy. In T. Niederkrotenthaler (Ed.), Media and suicide: International perspectives on research, theory, and policy (pp. 183–195). Transaction Publishers. Sinyor, M., Schaffer, A., Nishikawa, Y., Redelmeier, D.  A., Niederkrotenthaler, T., Sareen, J., Levitt, A.  J., Kiss, A., & Pirkis, J. (2018). The association between suicide deaths and putatively harmful and protective factors in media reports. Canadian Medical Association Journal, 190(30), E900–E907. https://doi. org/10.1503/cmaj.170698 Sisask, M., & Värnik, A. (2012). Media roles in suicide prevention: A systematic review. International Journal of Environmental Research and Public Health, 9(1), 123–138. https://doi.org/10.3390/ijerph9010123 Stack, S. (2005). Suicide in the media: A quantitative review of studies based on nonfictional stories. Suicide and Life-threatening Behavior, 35(2), 121–133. https://doi.org/10.1521/suli.35.2.121.62877 Stack, S., Kral, M., & Borowski, T. (2014). Exposure to suicide movies and suicide attempts: A research note. Sociological Focus, 47(1), 61–70. https://doi.org/10.1 080/00380237.2014.856707 Sugg, M. M., Michael, K. D., Stevens, S. E., Filbin, R., Weiser, J., & Runkle, J. D. (2019). Crisis text patterns

114 in youth following the release of 13 Reasons Why Season 2 and celebrity suicides: A case study of summer 2018. Preventive Medicine Reports, 16, 100999. https://doi.org/10.1016/j.pmedr.2019.100999 Suicide Awareness Voices of Education. (2013). Responding to a cry for help: Best practices for online technologies. Retrieved from http://topreventtheattempt.com/ Suicide Awareness Voices of Education. (2017). Recommendations for blogging on suicide. Retrieved from https://www.bloggingonsuicide.org/ The JED Foundation. (2017, April 24). Netflix 13 Reasons Why: What viewers should consider. Retrieved from https://www.jedfoundation. org/13-­reasons-­jed-­point-­view/ Thienel, R., Bryant, M., Hazel, G., Skehan, J., & Tynan, R. (2019). Do Australian media apply recommendations when covering a suicide prevention campaign? Journal of Public Mental Health, 18(2), 135–147. https://doi.org/10.1108/JPMH-­10-­2018-­0071 Thompson, L.  K., Michael, K.  D., Runkle, J., & Sugg, M.  M. (2019). Crisis Text Line use following the release of Netflix series 13 Reasons Why Season 1: Time-series analysis of help-seeking behavior in youth. Preventive Medicine Reports, 14, 100825. https://doi.org/10.1016/j.pmedr.2019.100825 Till, B., Niederkrotenthaler, T., Herberth, A., Vitouch, P., & Sonneck, G. (2010). Suicide in films: The impact of suicide portrayals on nonsuicidal viewers' well-­ being and the effectiveness of censorship. Suicide and Life-threatening Behavior, 40(4), 319–327. https://doi. org/10.1521/suli.2010.40.4.319 Till, B., Strauss, M., Sonneck, G., & Niederkrotenthaler, T. (2015). Determining the effects of films with sui-

M. Chesin et al. cidal content: A laboratory experiment. The British Journal of Psychiatry, 207(1), 72–78. https://doi. org/10.1192/bjp.bp.114.152827 Till, B., Vitouch, P., Herberth, A., Sonneck, G., & Niederkrotenthaler, T. (2013). Personal suicidality in reception and identification with suicidal film characters. Death Studies, 37(4), 383–392. https://doi.org/10 .1080/07481187.2012.673531 van Dijck, J. (2013). The culture of connectivity: A critical history of social media (1st ed.). Oxford University Press. Williams, C.  L., Gauthier, J.  M., & Witte, T.  K. (2020). Effects of exposure to multiple, graphic suicide news articles on explicit and implicit measures of suicide risk. Archives of Suicide Research. Advance online publication. https://doi.org/10.1080/13811118.2020.1 715905 Williams, C. L., & Witte, T. K. (2018). Media reporting on suicide: Evaluating the effects of including preventative resources and psychoeducational information on suicide risk, attitudes, knowledge, and help-seeking behaviors. Suicide and Life-threatening Behavior, 48(3), 253–270. https://doi.org/10.1111/sltb.12355 World Health Organization. (2017). Preventing suicide: A resource for media professionals, Update 2017. Retrieved from https://apps.who.int/iris/bitstream/ handle/10665/258814/WHO-­MSD-­MER-­17.5-­eng. pdf World Health Organization. (2019). Preventing suicide: A resource for filmmakers and others working on stage and screen. Retrieved from https://www. who.int/publications/i/item/preventing-­s uicide-­a -­ resource-­f or-­filmmakers-­a nd-­o thers-­w orking-­o n-­ stage-­and-­screen

8

Understanding Suicide-Related Risk in Immigrant and Ethnic and Racial Minority Youth Through an Ecological and Developmental Context Alan Meca, Lillian Polanco-Roman, Isis Cowan, and Audris Jimenez

International migration is a worldwide phenomenon, and the United States (US) is the main country of destination since the 1970s (United Nations, 2020). Indeed, the foreign-born population has more than quadrupled since the 1970s, with an estimated 51 million foreign-born migrants in the US in 2010 (United Nations, Department of Economic and Social Affairs, 2019). The majority of foreign-born individuals in the US largely originate from the global south (i.e., Latin America and Asia; United Nations, 2020), and typically hold collectivist-based beliefs that emphasize a focus on the well-being of the family, clan, nation, or religion. In contrast,

A. Meca () The University of Texas at San Antonio, San Antonio, TX, USA e-mail: [email protected] L. Polanco-Roman The New School for Social Research, New York, NY, USA e-mail: [email protected] I. Cowan Old Dominion University, Norfolk, VA, USA e-mail:[email protected] A. Jimenez John Jay College of Criminal Justice, City University of New York, New York, NY, USA e-mail: [email protected]

the US is one of the most highly individualistic countries, placing a great deal of emphasis on autonomy and self-sufficiency (Hofstede, 2019). As a result of the increasing flow of international migrants coupled by these cultural divides, scholarly interest in acculturation has substantially increased over the last few decades (Schwartz et al., 2010a). Acculturation refers to the psychological change that occurs as a result of contact between two cultural groups (Berry, 1980). Although this may occur across a variety of contexts (e.g., vacation, international students), the majority of the acculturation literature has focused on international migration (Schwartz et al., 2010a). When applied to immigrants, acculturation specifically focuses on the extent to which an individual retains their cultural heritage and/or adopts the new host culture (Berry, 1980). Indeed, immigrants need to be sufficiently facile in the language and customs of the host society to make friends, find work, and otherwise “fit in” with members of the dominant culture (Schwartz et  al., 2010a). It should be noted however that acculturation not only affects foreign-born individuals but also impacts US-born individuals from immigrant families who grow up in an immigrant home and are exposed to multiple cultural influences (Berry, 2006; Portes & Rumbaut, 2014; Rudmin, 2010). For this reason, through-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_8

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out this chapter, we use the term “immigrants” to refer to both first-generation (born abroad) and second-generation (born in the destination society but raised by at least one foreign-born parent) individuals. Over the last few decades, there has been a growing interest in the relation between acculturation and a wide range of positive and negative indicators of psychosocial functioning (for a comprehensive review, see Schwartz & Unger, 2017). This chapter serves as a review of contemporary models of acculturation and the role of acculturation in suicide-related risk among adolescents from immigrant families. Our focus on adolescence is driven by our motivation to understand the role of acculturation in the early stages of vulnerability and the acknowledgment that the links between acculturation and suicide-related risk among adults are likely to be confounded by situational (i.e., length of residency) and contextual (i.e., economic) factors (Meca et al., 2019). In addition, this chapter focuses on identifying potential explanatory mechanisms behind the association between acculturation and suicide-­ related risk and on identifying conceptual and methodological limitations that have been prominent in the field of acculturation. Finally, we conclude with clinical implications and discuss the benefits of integrating acculturation into suicide prevention strategies to reduce suicide-related risk among immigrant and racial/ethnic minority adolescents.

Contemporary Models of Acculturation Traditional conceptualizations of acculturation have largely drawn on what is viewed as a “unidimensional” model of acculturation (Schwartz et al., 2010a). Within this framework, acculturation is conceptualized along a single continuum ranging from “completely unacculturated” to “completely acculturated.” This framework is not only problematic because it assumes “successful” acculturation involves loss of ones’ cultural heritage (Gordon, 1964), but also because there is no “middle” ground where the individual can rec-

oncile their heritage culture when cast in the context of the host culture. In recent decades, more contemporary views of acculturation have increasingly drawn on a bidimensional framework (Berry et  al., 2006), which views host-­ culture acquisition and heritage culture retention as independent dimensions. Within this bidimensional conceptualization, acquiring the culture of the host society does not imply that an individual will discard their own cultural heritage. Indeed, as proposed by Berry (1997), immigrants may take on one of four acculturation approaches: marginalization (rejects/discards host and heritage culture), assimilation (acquires host culture and discards heritage culture), separation (rejects host culture and retains heritage culture), and integration (acquires host and retains heritage culture). Integration, or biculturalism,1 allows youth to judiciously straddle a fence between two cultural worlds, where different cultural streams will be expressed depending on the situation at hand (Benet-Martínez & Haritatos, 2005). More recently, several scholars have extended Berry’s (1980) original conceptualization by suggesting that acculturation is not only bidimensional (i.e., heritage culture versus host culture), but also varies across at least three relevant components: practices, identifications, and values (Castillo & Caver, 2009; Schwartz et al., 2010a). The vast majority of studies and measures have focused on cultural practices, which refer to behaviors such as language use, choice of friends, and cultural customs and traditions (e.g., Stephenson, 2000). Extending beyond cultural practices, contemporary conceptualizations of acculturation emphasize the importance of cultural identification, or the strength of commitment and attachment a person feels toward their cultural heritage and/or the host culture (Meca et  al., 2020a). Finally, cultural values represent belief systems associated with a specific context or group. Research focused on cultural values has focused on broad cross-ethnic group values such as collectivism and individualism and/or group-­ specific values such as familism (strength of famIntegration or biculturalism will be utilized interchangeably in the remainder of this article. 1 

8  Understanding Suicide-Related Risk in Immigrant and Ethnic and Racial Minority Youth…

ily ties; Galanti, 2003) and filial piety (bestowing honor upon one’s family; Yeh & Bedford, 2004). Together, acculturation can be conceptualized across six facets: host practices, heritage practices, host identification, and heritage ­identification, heritage values, and host values (Schwartz et al., 2010a).

Acculturation and Suicide In the subsequent section, we review the literature examining the links between acculturation and suicide-related risk across the prevailing conceptualizations. We begin with a review of studies that have drawn on demographic proxies of acculturation (i.e., nativity and years in the US) and proceed to review studies that have utilized a unidimensional conceptualization across cultural practices, identification, and values. Given the dearth of findings, we also include studies with adult populations or studies that examine the association between acculturation and internalizing symptoms, namely depression and hopelessness—well-known predictors of suicidal behavior (Cha et al., 2018).

Demographic Proxies In one of the few studies to examine youth suicide trends by immigration status in the US, Sorenson and Shen (1996) compared suicide death rates between foreign-born and US-born youth, ages 15–34  years, between 1970 and 1992 in California. They found that the relation between immigration status and suicide death varied across racial/ethnic group. Specifically, non-Hispanic2 White youth born outside of the US were at greater risk of dying by suicide compared to non-Hispanic White youth born in the US.  The authors thus concluded that relocation stress and limited social capital contributed to this elevated risk among immigrant youth. This Throughout this chapter, the terms Hispanic and Latinx are used interchangeably to refer to direct descendants of Latin American and Spanish speaking Caribbean countries. 2 

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was not consistent with their observations among Hispanic youth, however, as Hispanic youth born outside of the US were at lower risk of dying by suicide compared to Hispanic US-born youth. No significant immigrant group differences were observed in Black and Asian youth, though this may have been due to low cases. Further, the immigrant group differences in youth suicide rates within non-Hispanic White and within Hispanic groups decreased over time from 1970 to 1992. In contrast, in a larger sample of suicide deaths among Hispanic individuals from various metropolitan areas across the US, Wadsworth and Kubrin (2007) found that, overall, immigrants had higher rates of suicide than US-born Hispanics individuals, but not among immigrants who lived in ethnic enclaves. This finding highlights the critical influence of contextual factors in the relation between acculturation and suicide. For instance, areas with a larger Cuban immigrant population (relative to Mexican immigrants) had higher suicide rates, whereas areas with larger immigrant populations born in Puerto Rico or Dominican Republic (relative to Mexican-born) had lower suicide rates. Thus, the migration experience does not entirely explain the differences in suicide between immigrant and US-born people, suggesting acculturative processes may play a more important role in suicide risk. As observed in some of these early studies on suicide deaths, similar patterns indicating greater suicide-related risk in US-born (versus immigrant) youth were also detected in nonfatal manifestations of suicide (i.e., suicide ideation, suicide attempts) in Hispanic (Peña et al., 2008), Asian (Wong & Maffini, 2011), and Black adolescents (Joe et al., 2009). For instance, using a nationally representative sample of Hispanic adolescents in the US, Peña et al. (2008) found that immigrant Hispanic teens had lower rates of suicide ideation and attempts than US-born Hispanic teens with immigrant parents, who had lower rates compared to US-born Hispanic teens with US-born parents. The graded increase in suicide ideation and attempts with each subsequent generation

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supported earlier claims that acculturation may impact youth suicide-related risk. To further explore this line of inquiry, researchers used various proxies for acculturation beyond immigration status, such as English language acquisition or Spanish language ­retention, age of migration, and length of residency in the US, to assess greater exposure to the dominant US culture. Using this approach, albeit in adults, findings have overwhelmingly indicated that greater exposure to US culture is associated with elevated suicide-related risk (Borges et al., 2012; Brown et al., 2015; Duldulao et al., 2009; Fortuna et  al., 2007; Pérez-Rodriguez et al., 2014). This is in contrast, however, to findings from an earlier study of Mexican American adolescents presenting to an inpatient clinic, which indicated that frequency of lifetime suicide attempts was negatively associated with length of residency in the US (Ng, 1996). As expected considering the findings from suicide deaths, acculturation may better explain the risk for suicidal behaviors than migration. Despite the nearly exclusive focus on adults, these studies served as important steps toward understanding the impact of acculturation on suicide-­related risk. They have prompted further inquiries to identify factors that protect against suicide-related risk in Hispanic immigrant youth and increase risk in US-born Hispanic youth. It is important to note however that the utilization of demographic proxies masks important variability in the degree to which individuals retain their cultural heritage and/or adopt the new host culture.

Cultural Practices Moving beyond demographic proxies, researchers have also utilized a unidimensional assessment of acculturation via cultural practices such as language use, selection of friends, and engagement in cultural customs and traditions. For example, in a school-based sample of Hispanic adolescents in California (Hovey & King, 1996), a clinical sample of largely Hispanic adolescents presenting at an Emergency Department in a hospital in NYC (Ortin et al., 2018), and a community sample of Hispanic adolescent girls also in

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NYC (Zayas et al., 2009), researchers found that greater level of acculturation, assessed as greater acquisition of US practices, was not associated with suicide ideation or attempts. Similarly, in a school-based group of Korean high school students with varying migration backgrounds (i.e., permanent migration from Korea to US, temporary migration as Korean international student), Cho and Haslam (2010) found no direct association between suicide ideation and acculturation assessed as language use, friendships, behaviors, and attitudes. However, in a school-based sample of Mexican American adolescents in Texas, Rasmussen et  al. (1997) found that increased acculturation was not directly associated with suicide ideation, though the association was significant in the presence of increased depressive symptoms and decreased self-esteem. In sum, a substantive number of studies have indicated no significant association between acquisition of US practices and suicide. That being said, other studies have reported a negative association between acculturation and suicide-related risk. For instance, in an ethnically diverse (predominantly Mexican American) group of middle school students in Texas, Olvera (2001) found that lower level of acculturation, assessed via language practices, was associated with suicide ideation. This finding, however, was trending and did not reach statistical significance. When they assessed acculturation by generation status, they found that children whose mothers were born in the US, compared to mothers born outside of the US, were at lower risk for suicide ideation. Similarly, in a clinical sample of Asian American children and adolescents from an outpatient clinic in California, Lau et  al. (2002) reported that high level of acculturation (assessed as language practices along with demographic proxies such as length of residency in the US) was associated with lower risk of suicidal behaviors, though ethnic and SES differences were found in acculturation levels, which may confound these findings. Taken together, findings have produced mixed results, with some studies showing that increased engagement in US cultural practices was not associated with suicide ideation or suicide attempts in ethnic and racial minority youth (Cho & Haslam, 2010; Hovey &

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King, 1996; Ortin et al., 2018; Rasmussen et al., 1997; Zayas et  al., 2009), whereas others indicated a negative association (Lau et  al., 2002; Olvera, 2001).

Cultural Identification

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New  York City (Chesin & Jeglic, 2012). As a whole, the findings note an inconsistent association between ERI and suicide, potentially due to the utilization of composite measures of ERI. Seeking to expand beyond composite measures of ERI, Chang et al. (2017) found ERI commitment3 was negatively associated with hopelessness but not suicidal behaviors in a sample of Latinx college students attending a large public college on the East Coast. More recently, Forster et al. (2019) examined the links between ERI exploration and belonging (i.e., composite of affirmation and commitment)4 on both suicide ideation and attempt among a large longitudinal sample of Hispanic youth. Although ERI exploration was not significantly associated with either suicide ideation or attempt, ERI belonging was negatively associated with suicide attempts and attenuated the effect of parental incarceration on suicide ideation and attempt. Finally, in a sample of Hispanic/Latinx college students, Oakey-Frost et  al. (2019) found ethnic ERI belonging (i.e., composite of affirmation and commitment) was negatively and directly associated with suicide-­ related risk (i.e., composite of history of suicide ideation and attempts). As a whole, these findings seem to indicate that the establishment of a commitment and sense of belonging to one’s ethnic and racial group is protective against suicide. Additionally, studies have also found ERI processes are significantly associated with symptoms of depression. For example, Juang et  al. (2006) found ERI was associated with lower symptoms of depression among Asian American college students. Similarly, Tummala-Narra (2015) found ERI was associated with fewer depressive symptoms among ethnic and racial minority high school students. In contrast, Hovey et  al. (2006) found no significant association between ERI and symptoms of depression among Korean college students. Looking beyond composite measures, Umaña-Taylor and Updegraff (2007) found that ERI exploration and commit-

Unidimensional studies focused on cultural identification have largely drawn on an entirely distinct body of research rooted in ethnic and racial identity (ERI) development. Broadly, ERI is a multidimensional psychological construct that reflects individuals’ beliefs and attitudes about their ethnic or racial group membership, as well as the process by which these beliefs and attitudes develop over time (Umaña-Taylor et  al., 2014). Many studies on ERI have largely drawn on Phinney’s (1989) developmental perspective that proposed three key dimensions: exploration or search (i.e., the process by which one considers what it means to belong to a cultural group), commitment (i.e., an understanding of what ones’ cultural group membership means to them), and affirmation (i.e., positive attitudes toward the social groups to which they belong). Research examining the links between ERI and suicide-related risk in youth has been extremely limited, has largely ignored the multidimensionality of ERI, and has produced mixed findings. For example, Polanco-Roman and Miranda (2013) found ERI was negatively associated with hopelessness, depressive symptoms, and suicide ideation within an ethnically and racially diverse sample of emerging adults from a diverse public college in a Northeastern metropolitan area of the US.  Most recently, Cheref et al. (2019) found ERI was negatively associated with suicide ideation in an ethnically and racially diverse sample of emerging adults and mitigated the potential role of discrimination and anxiety, but only for Hispanic emerging adults. In contrast to these studies, O’Donnell et  al. (2004) found ERI was not related to suicide ideation in a cross-­ sectional ethnically diverse sample. Similarly, 3 Referred by Chang et  al. (2017) as “ethnic identity ERI was not significantly associated with sui- achievement”. 4  cidal behaviors among Latina undergraduate stu- Referred by Forster et al. (2019) as cognitive ERI (i.e., exploration) and affective ERI (i.e., commitment/ dents attending an urban public college in belonging).

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ment were negatively associated with symptoms ues have been fairly limited. In our review, solely of depression vis-à-vis its impact on self-esteem four studies have examined the links between in a sample of Latinx adolescents. Mahalingam cultural values and suicide (Baumann et  al., et  al. (2008) also found a negative association 2010; Kuhlberg et  al., 2010; Peña et  al., 2011; between ERI affirmation and symptoms of Zayas et  al., 2009). All of these studies have depression among Asian American youth. focused on familism, which encompasses a culMoreover, within the adult literature, studies tural value in which individuals place a greater have found ERI to be negatively associated with emphasis on the family unit in terms of respect, suicide ideation and attempts in Latinx and Asian support, obligation, and reference (Calzada et al., samples (Cheng et  al., 2010; Perez-Rodriguez 2012). Although studies have found that et al., 2014). For example, utilizing data collected familismo is not unique or group-specific to as part of the National Epidemiologic Survey of Hispanic/Latinx individuals (Keller et al., 2006; Alcohol and Related Conditions, Perez-­Schwartz et al., 2010b), it has been characterized Rodriguez et al. (2014) found that ERI was nega- as a central tenet of Latinx culture (Zinn, 1982). tively associated with lifetime risk for suicide Consistently, all four of these studies were conideation and attempts among Hispanic adults. ducted with Hispanic/Latinx youth in the Similarly, utilizing data from the National Latino New York City area. and Asian American Study (NLAAS), Cheng Zayas et al. (2009) found no significant differet  al. (2010) found a high ERI was associated ences in familistic attitudes between adolescent with lower rates of suicide attempts among Asian Latinas who attempted suicide and those who did American adults. not. In contrast, Baumann et  al. (2010) found Like ERI, US identity represents a multidi- familism was positively related to mutuality (i.e., mensional psychological construct that reflects how attuned adolescents were with their mothindividuals’ beliefs and attitudes about their ers) and negatively related to externalizing national group membership, as well as the pro- behaviors, which in turn, predicted history of a cess by which these beliefs and attitudes develop suicide attempt. Similarly, Peña et  al. (2011) over time (Meca et  al., 2020a). Moreover, US found that familism was associated with a greater identity research has similarly drawn on likelihood for Latinas to be in a tight-knit family, Phinney’s ERI model proposing three key US which was negatively associated with history of a identity processes: exploration (i.e., process by suicide attempt, compared to being intermediatewhich one considers what it means to be and loose-knit families. At the same time, American), commitment (i.e., understanding of whereas Kuhlberg et  al. (2010) found familism what being American means), and affirmation was negatively and indirectly associated with sui(i.e., whether an individual feels positively or cide attempt vis-à-vis parent-adolescent conflict, negatively about their national group member- their findings also indicated an indirect positive ship). In our review, no study to date has exam- effect through internalizing symptoms. ined the link between US identity and Summarizing these findings in a meta-­ suicide-related risk. However, Kiang and Witkov analysis, Valdivieso-Mora et  al. (2016) found a (2018) found US identity was negatively associ- relatively small effect size between familism and ated with symptoms of depression, a strong pre- suicide, depression, and internalizing behaviors. dictor of suicide-related risk, among Asian More recently, in a large longitudinal study of American adolescents. Latinx youth in Southern California, Lorenzo-­ Blanco et  al. (2012) found that familism was negatively associated with symptoms of depresCultural Values sion vis-à-vis its impact on family conflict and family cohesion. Drawing on a multidimensional Studies utilizing a unidimensional conceptualiza- conceptualization, Corona et  al. (2017) found tion of acculturation as assessed by cultural val- that familism support (i.e., a desire to maintain

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close relationships) was significantly and inversely associated with symptoms of depression, whereas familism obligation (i.e., providing tangible support to family members) was ­significantly and positively associated with psychological stress but not symptoms of depression among Latinx college students in the Southeast. Finally, most recently, Piña-Watson et al. (2019) found that familism was associated with lower symptoms of depression among adolescents of Mexican descent in South Texas. Taken together, these findings indicate that adherence to heritage cultural values such as familism is protective against suicide for Latinx youth. However, although Hovey et al. (2006) did find that greater endorsement of heritage cultural value (i.e., as indicated by the Asian Value Scale; Kim et  al., 1999) was associated with increased state anxiety, trait anxiety, and symptoms of depression, we could not find any study examining the links between filial piety (bestowing honor upon one’s family; Yeh & Bedford, 2004), a cultural value group-specific to several Asian countries, and suicide-related risk.

 indings from Studies Employing F a Bidimensional Perspective As a whole, findings utilizing demographic proxies and unidimensional conceptualization of cultural practices, identification, and values have produced mixed results. The discrepancy may be due to an overly simplistic approach to acculturation that obscures important elements of the acculturative process. Toward this end, we now turn our attention to the handful of studies that have utilized a bidimensional conceptualization in exploring the associations between acculturation and suicide-related risk.

Cultural Practices In terms of cultural practices, our review indicated solely one study that utilized a bidimensional perspective toward understanding links between acculturation and suicide. Specifically, Zayas et al. (2009) compared Latina adolescents who attempted suicide and those who did not to

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find no significant differences in either heritage or host cultural practices. However, it should be noted that several bidimensional studies have looked at the association between cultural practices and symptoms of depression. For example, Smokowski et al. (2007) found heritage cultural practices were positively associated with internalizing symptoms (i.e., anxiety and depression) in a community sample of first-generation Latinx adolescents. In contrast, utilizing data from the Latino Acculturation and Health Project, Smokowski et al. (2009) found that heritage cultural practices negatively predicted hopelessness a year later. Furthermore, Smokowski et  al. (2010) found that US cultural practices were negatively associated with internalizing symptoms in a sample of Latinx adolescents in North Carolina and Arizona. Most recently, Driscoll and Torres (2020) found heritage cultural practices, but not host cultural practices, were significantly and negatively associated with subsequent symptoms of depression through its impact on acculturative stress in a sample of Latinx college students. Despite these promising findings, García et  al. (2014) found no significant associations between heritage or US cultural practices and symptoms of depression in a sample of Mexican American adolescents from a large immigrant enclave in the Midwest. As a whole, these findings point to contradictory associations between heritage and host cultural practices with depressive symptoms and prompt the necessity for future research to further explore these associations.

Cultural Identification Although in our review, no bidimensional study examined the association between cultural identification and suicide-related risk, it is worth noting recent bidimensional studies have found important links between cultural identification and symptoms of depression. For example, Meca et  al. (2017) found that US identity belonging (i.e., composite of affirmation and commitment) negatively predicted symptoms of depression six months later in a sample of recently immigrated Hispanic adolescents in Miami and Los Angeles. Similarly, in an ethnically and racially diverse sample of college students, Tikhonov et al. (2019)

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reported that US identity, but not ethnic identity, was negatively related to symptoms of depression. Looking beyond composite measures, Meca et al. (2020a) found both US and ethnic identity affirmation were the only identity processes negatively associated with symptoms of depression among a sample of Latinx college students. As a whole, the findings seem to indicate that the establishment of a sense of belonging to ones’ host culture seems to be particularly protective against internalizing symptoms. That being said, future research is clearly necessary to explore the associations between heritage and host identification with suicide.

Smokowski et  al., 2010; Tikhonov et  al., 2019), and both heritage retention and US acquisition/ retention (Meca et  al., 2020a) are protective against symptoms of depression and internalizing problems.

 otential Mechanisms Underlying P the Relationship between Acculturation and Suicide

Cultural Values In our review, we could not find a single study exploring how the cultural values of both ones’ heritage and of the host culture influence suicide or symptoms of depression and other related constructs.

Beyond these direct associations, several studies have identified indirect associations between acculturation and suicide-related risk, indicating potential mechanisms underlying this relation. In the subsequent section, we will focus on two key mechanisms: a) cultural stress and b) family functioning. Finally, we describe contemporary suicide models that lend themselves to understanding suicide-related risk through an acculturation framework.

Summary Remarks

Cultural Stress

To summarize, whereas unidimensional models of cultural practices largely indicate no association between acculturation and suicide-related risk (Cho & Haslam, 2010; Hovey & King, 1996; Ortin et al., 2018; Rasmussen et al., 1997; Zayas et al., 2009), findings from cultural identification indicate heritage retention may be protective against suicide-related risk (Cheref et  al., 2019; Forster et  al., 2019; Polanco-Roman & Miranda, 2013) and risk factors (e.g., symptoms of depression; Juang et  al., 2006; Mahalingam et  al., 2008; Tummala-Narra, 2015; Umaña-Taylor & Updegraff, 2007). Similarly, although limited, findings seem to indicate familism is protective against suicide risk (Baumann et  al., 2010; Peña et al., 2011; Valdivieso-Mora et al., 2016) and risk factors (Corona et al., 2017; Lorenzo-Blanco et al., 2012; Piña-Watson et al., 2019; Valdivieso-­Mora et al., 2016). In contrast, studies from a bidimensional perspective looking at risk factors for suicide have indicated that heritage retention (Driscoll & Torres, 2020; Smokowski et  al., 2009), US acquisition/retention (Meca et  al., 2017;

Within the broader acculturation literature, several theoretical frameworks have proposed that it is the stress associated with the process of immigration and acculturation, versus migration or acculturation itself, that compromises mental health. Acculturation Strain Theory (Vega et al., 1993), Segmented Assimilation Theory (Portes & Zhou, 1993), Bicultural Stress Theory (Romero & Roberts, 2003), Stress, Coping, and Adaption Theory (Berry, 2006), and the integrative model (García Coll et al., 1996) have all emphasized the role various stressors associated with acculturation may have on health. The conceptualization of cultural stress has focused on a variety of different stressors, including ethnic and race discrimination (Carter et al., 2017), negative context of reception (Schwartz et al., 2014), acculturative stress (Vega et  al., 1993), immigration-related and acculturation-gap stress (Cervantes et  al., 2012), and bicultural stress (Romero & Van Campen, 2011). There is growing evidence to suggest that ethnic and race discrimination may influence the

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well-being of ethnic and racial minority and immigrant youth (Benner et al., 2018), including suicide-related risk. Using cross-sectional data in a nationally representative sample of Black, Hispanic, and Asian adults in the US, researchers found that racial/ethnic discrimination was associated with suicidal thoughts and behaviors (Oh et al., 2018). Similar findings were also reported in a racially and ethnically diverse group of college students (Gomez et  al., 2011), as well as Black and Latinx adolescents using prospective data (Assari et al., 2017; Madubata et al., 2018). Some studies, however, found no direct association between racial/ethnic discrimination and suicidal thoughts and behaviors in Latinx (Chesin & Jeglic, 2016) and Black college students Castle et al., 2011). These mixed findings suggest that the association between ethnic and race discrimination and suicide-related risk may be more nuanced and indirect, potentially influenced by other mediating factors. Early studies have focused on ethnic and race discrimination as an interpersonal-level race-based stressor (i.e., overt displays of racial/ ethnic discrimination in the form of discrete major events or as daily hassles). Recent research, however, indicates other forms of race-based stressors, such as microaggressions (i.e., covert displays of interpersonal discrimination; O'Keefe et al., 2014; Madubata et al., 2019) and institutional forms of discrimination (i.e., racial/ethnic biases in policies and practices), may similarly impact suicide-related risk (Wang et al., 2018). Acculturative stress is another form of cultural stress characterized by a more broadly defined experience of navigating different cultural environments (Berry, 2006). Acculturative stress may involve not only novel encounters of ethnic and race discrimination, but also pressures to assimilate to the dominant culture, language and other culture-specific barriers, and intra-familial conflict arising from differing expectations. Though scarce, research shows that increases in acculturative stress are associated with increases in suicide ideation and attempts in racially and ethnically diverse groups of adolescents and young adults (Gomez et al., 2011; Hovey & King, 1996; Polanco-Roman & Miranda, 2013; Walker

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et al., 2008). That being said, some studies have reported no association (Cho & Haslam 2010; Chesin & Jeglic, 2016). A few studies have also examined different cultural stressors together, with findings alluding to a potential additive effect, as each source of cultural stress may uniquely contribute to suicide-­ related risk. For instance, Gomez et  al. (2011) examined cultural stress across various contexts (i.e., environmental, social, familial, attitudinal, discrimination) in a racially and ethnically diverse sample of young adults and reported that familial stress (i.e., stress resulting from intra-­ familial conflict) and discrimination stress were most strongly associated with a suicide attempt history. Meanwhile, in a sample of Mexican American adolescents, Piña-Watson et al. (2015) reported that acculturative stress in the context of family, but not discrimination or peers, was most strongly associated with suicide ideation. Additionally, cultural stressors such as ethnic and race discrimination and acculturative stress may be more distal risk factors for suicidal thoughts and behaviors, and impact suicide-­ related risk through more proximal risk factors. Indeed, early findings have identified potential pathways through which ethnic and race discrimination may confer suicide-related risk, including cognitive factors such as hopelessness (Lane & Miranda, 2018; Polanco-Roman & Miranda, 2013), emotion dysregulation (Mayorga et al., 2018), and rumination (Cheref et al., 2015); interpersonal factors such as perceived burdensomeness (Hollingsworth et  al., 2017), and psychiatric symptoms, including depression (Goodwill et  al., 2019; O'Keefe et al., 2014; Polanco-Roman & Miranda, 2013; Walker et  al., 2017), anxiety (Kwon & Han, 2019), and post-­ traumatic stress (PolancoRoman et al., 2019). Despite growing evidence to suggest cultural stress may impact suicide-related risk, this research has largely relied on cross-sectional data, adult samples, nearly exclusive focus on suicide ideation (versus attempts) as an outcome, and independently examined varied forms of cultural stress. Thus, more refined research from a developmental perspective with larger samples

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and longitudinal designs is warranted. This information would provide a better understanding of the mechanisms through which experiences of cultural stress such as ethnic and race discrimination and acculturative stress may ­ impact suicide-­related risk, particularly in ethnic and racial minority and immigrant adolescents.

 amily Functioning and the Parent-­ F Child Acculturation Gap Although acculturation has typically been examined as an individual developmental process, it is important to note that both caregivers and adolescents are faced with the challenge of retaining their heritage culture and/or acquiring aspects of the dominant US culture (Berry, 1997; Schwartz et  al., 2010a). However, whereas school attendance encourages adoption of US cultural practices, values, and norms (Padilla, 2006), immigrant parents are more likely to settle into ethnic enclaves where they can maintain their own cultural practices and adapt to US culture (Schwartz et al., 2006). As youth and parents further distance themselves in terms of the cultural orientations, there is a greater likelihood for dissonance that, if not addressed, may produce turmoil and conflict that compromises family functioning (Lau et al., 2005; Portes & Rumbaut, 2001; Szapocznik & Kurtines, 1993). Consistently, several researchers have proposed that discrepancies between the adolescents’ and parents’ acculturation disrupt family functioning. For example, the acculturation discrepancy hypothesis (Szapocznik & Kurtines, 1993) posits that gaps in acculturation between parents and their adolescents may compromise family functioning (e.g., poor communication, lack of involvement). Similarly, Portes and Rumbaut’s Segmented Assimilation theory (1996) identified three patterns of acculturation rates between parents and children: consonant (i.e., both acculturate quickly), dissonant (i.e., youth acculturates more quickly than parents), and selective acculturation (i.e., pattern of assimilation where children maintain values related to their family’s culture of origin while also accul-

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turating into select aspects of their US cultural context). It should be noted, consistent with a bidimensional and multicomponent conceptualization of acculturation, that discrepancies between children and their parents may emerge either in relation to heritage retention (acquisition in the case of second-generation immigrants) and US acquisition across practices, identification, and values. Building on these broader theoretical frameworks, research focused on the relationship between acculturation and suicide-related risk has increasingly turned to examining the role that family functioning plays as a key mediator. Through a series of studies with a sample of Latina adolescents in New  York, findings from Zayas and colleagues (Baumann et  al., 2010; Kuhlberg et al., 2010; Zayas et al., 2009) support the acculturation gap theory. For example, although Zayas et al. (2009) found no significant differences in acculturation and familistic attitudes between Latina adolescents who attempted suicide and those who did not, mothers of those who attempted reported lower mutuality and communication. Subsequently, Kuhlberg et  al. (2010) not only found parent-adolescent conflict indirectly predicted suicide attempt vis-à-vis self-esteem and internalizing behaviors, but familism or cultural value retention was negatively associated with parent-adolescent conflict. Further expanding on this line of inquiry, Baumann et al. (2010) found that gaps in familism (i.e., mothers scoring higher than their daughters on the scale) was positively associated with suicide attempts via its negative association with mother-daughter mutuality, which, in turn, was positively associated with internalizing and externalizing symptoms (i.e., familism gap - > mother-daughter mutuality - > internalizing and externalizing symptoms -  >  suicide attempt). Similarly, Cervantes et  al. (2014) found that stress associated with gaps in acculturation (as measured by the Hispanic Stress Inventory) was positively associated with suicide ideation among Hispanic adolescent boys and with self-harm behavior among girls. In contrast, Ortin et  al. (2018) found no direct links between acculturation gap and suicide ideation in a racially diverse

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group of adolescents presenting to an Emergency Department for suicide-related risk utilizing a unidimensional scale of cultural practices. However, they did find that emotion reactivity was more negatively associated with suicide ideation when acculturation gaps were greater, whereas hopelessness was more strongly associated with suicide ideation the smaller the gap. Despite these preliminary studies, in our review, no study to date has examined the associations between parent-youth acculturation discrepancies and suicide-related risk utilizing a bidimensional conceptualization of acculturation. That being said, studies focused on symptoms of depression may provide important information for the field moving forward. For example, in a longitudinal study with Chinese American families in Northern California, Kim et al. (2009) found that discrepancies in parent-­ adolescent US orientation were associated with greater symptoms of depression vis-à-vis its impact on parents’ use of unsupportive parenting practices, which in turn, led to an increased sense of alienation between parents and children. However, discrepancy in parent-adolescent Chinese orientation was not directly or indirectly related to symptoms of depression. These findings are consistent with previous frameworks that differential adoption of US cultural norms results in disruptive family functioning. In contrast, Cano et  al. (2016) found that adolescents with higher levels of US identity relative to their caregiver reported lower levels of depressive symptoms in a longitudinal study of recently immigrated Hispanic families in Miami and Los Angeles. At the same time, higher collectivism among adolescents relative to their parents was associated with greater family functioning, which in turn, led to lower symptoms of depression. Extending these findings and utilizing the same data as Cano et al. (2016), Schwartz et al. (2015) plotted trajectories of acculturation discrepancies and found that an increasing discrepancy between adolescents and their parents on individualistic values (i.e., higher scores indicating adolescent higher than parent) was negatively associated with symptoms of depression. In contrast, greater discrepancy between collectivistic

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values and ethnic identity (i.e., higher scores indicating parent higher than adolescent) was positively associated with symptoms of depression vis-à-vis its impact on family functioning. In other words, as parents’ collectivistic values and ethnic identity are increasingly higher than their parents, family functioning is compromised, resulting in increased symptoms of depression. Taken together, findings by Cano et  al. (2016) and Schwartz et al. (2015) indicate that it is the loss of one’s heritage values and identity that disrupt family functioning.

 uicide Models Compatible S with an Acculturation Framework Few contemporary suicide models lend themselves well to understanding suicide-related risk within an acculturation framework. One of the few existing models to do so is the Cultural Model and Theory of Suicide (Chu et al., 2010). The model highlights the influence of cultural experiences along the spectrum of suicide-related risk, particularly in ethnic and racial minority groups. This model proposes that cultural experiences impact suicide-related risk through three distinct avenues: (1) culture-specific stressors such as ethnic and race discrimination stress and acculturative stress; (2) manifestations, expressions, and management of distress; and (3) attitudes toward and expressions of suicidal thoughts and behaviors. Indeed, the select studies reviewed in this section of the chapter offer empirical support for this model, though with a greater emphasis on examining the relation between cultural stressors and suicide-related risk. The Interpersonal Theory of Suicide (IPTS; Van Orden et al., 2010) is another contemporary suicide model that intersects with the acculturation framework to provide critical insight into suicide-related risk in immigrant youth. The IPTS model describes the development of suicide-­related risk in terms of interpersonal processes, specifically thwarted belongingness and perceived burdensomeness. These interpersonal processes may reflect family functioning, which play a critical role in suicide-related risk in immi-

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grant youth. Indeed, Oakey-Frost et  al. (2019) found that ethnic identity, as a composite of affirmation and commitment, was directly and negatively associated with suicide ideation and thwarted belongingness. Further, they also found that ethnic identity was negatively and indirectly associated with suicide ideation through increases in perceived burdensomeness, but only when thwarted belongingness was high. In using the IPTS model within an acculturation framework, we can identify ways through which cultural experiences may compromise interpersonal functioning to confer risk for suicide.

 he Way Forward: Addressing Gaps T and Methodological Concerns Although these studies have represented an important step forward, there are several important limitations. In this final section of our review chapter, we outline recommendations for future research necessary for understanding the complex association between acculturation, cultural stressors, and suicide-related risk among immigrant youth.

Mechanisms and Conceptual Concerns Bidimensional Conceptualizations of Acculturation Despite contemporary views of acculturation, only one study in our review utilized a bidimensional conceptualization of acculturation in exploring the association between acculturation and suicide-related risk. In doing so, research exploring suicide-related risk among immigrants has been limited by its operationalization of acculturation as a “zero-sum game,” making it impossible to determine whether it is the loss of (or failure to acquire) heritage culture or the acquisition of US culture that places youth at risk for suicide. Indeed, as we have noted in our review of research on symptoms of depression, internalizing symptoms, and/or hopelessness, studies utilizing a bidimensional framework have

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shown differential effects not only between heritage retention/acquisition and US acquisition, but also across domains of acculturation (i.e., practices, identification, and values). As such, there is a critical need for research to draw on contemporary models of acculturation to better understand how these cultural processes may impact the risk for suicide.

Acculturation as a Developmental Process It is also critical to acknowledge that acculturation is inherently a developmental process (Schwartz et  al., 2020). Indeed, as proposed by the Relational Model of Bicultural Systems (RMBS; Meca et al., 2019), acculturation can be conceptualized as a change in overall sense of self and identity in response to contact between two cultural groups. Within an RMBS framework, identity development occurs both (a) within people as they make choices about goals, roles, and beliefs about the world and (b) within the person’s cultural context as the communal group recognizes and affirms these choices. An individual’s sense of self and identity regulates the actions individuals use to adapt to changing developmental contexts, thereby serving as a “steering mechanism” for decisions and actions throughout the life course (Meca et al., 2019). As such, not only is identity development, and by extension acculturation, a developmental process, but it also emerges from the ongoing dynamic relation between self and society, and thus serves to actively shape how individuals navigate two or more cultural streams. Thus, it is critical for acculturation research and research specifically focused on the links between acculturation and suicide-related risk to conceptualize acculturation as a developmental process and attend to the processes involved in managing cultural identities. Acculturation Within the Family Context Acculturation is also embedded within a specific social, cultural, and historical context (García Coll et al., 1996; Meca et al., 2019). Indeed, as we have noted in our review of the existing litera-

8  Understanding Suicide-Related Risk in Immigrant and Ethnic and Racial Minority Youth…

ture, several studies have emphasized that acculturation unfolds within the family context. However, research examining the impact of acculturation gap on suicide-related risk has also been limited by its current conceptualization and operationalization of acculturation. By drawing on largely unidimensional conceptualizations, research has been unable to determine if it is the loss of youths’ heritage culture or the greater acquisition of US culture relative to their parents that disrupt family functioning. Another overlooked avenue of future research is the need to understand how family dynamics unfold over time. Indeed, the family is best understood as a holistic and constantly evolving system (Meca et  al., 2019). Consistently, in the past decade, sociologists and psychologists have clarified the specific ways in which parents actively and passively encourage children to gravitate toward specific aspects of their cultural heritage and to avoid specific aspects of the host cultural context (Portes & Rumbaut, 2006). The term, familial ethnic socialization, has been utilized to describe this phenomenon (Umaña-Taylor et  al., 2006). However, it is important to note that not only do parents socialize their children to retain (or reject) their heritage culture and/or acquire (or reject) US culture, adolescents also impact their parents’ cultural orientation. As such, and consistent with contemporary developmental theory (see Causadias & Cicchetti, 2018), a critical step for future research requires conceptualizing the family as a holistic, interacting, constantly evolving system with culture integrated across every level of this system. This requires taking into account the personality, psychosocial functioning, and ongoing acculturation processes in youths and their caregivers, as well as taking into account the various contextual levels in which both agents (i.e., youth and caregivers) are embedded (e.g., peer, school, work, etc.).

 cculturation, Cultural Stress, or Both? A As we have reviewed, research has documented interactive effects between acculturation and cultural stressors on suicide-related risk (e.g., Cheref et al., 2019; Gomez et al., 2011; Polanco-Roman

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& Miranda, 2013). Although studies have explored the direct association between cultural stress and suicide-related risk, paralleling the need for more comprehensive operationalization of acculturation, no study, to date, has sought to comprehensibly assess the impact various cultural stressors have on suicide-related risk. As such, a critical next step in developing a comprehensive model that articulates the relationships between acculturation and suicide-related risk is to separate the “process of acculturation” from the underlying “process of cultural stress” (Gilbert & Cervantes, 1987). Indeed, studies have not only indicated complex interactive effects between acculturation and cultural stressors and various mental health outcomes but have also found complex longitudinal patterns in the relationship between acculturation and cultural stressors (Gonzales-Backen et  al., 2019; Meca et  al., 2020b). In sum, future research is necessary to disentangle the process of acculturation from the experience of stress and determine how they impact each other and contribute independently and interdependently to suicide risk among immigrant youth.

Methodological Concerns Over and above these future directions, it is important to draw on key methodological limitations observed in the broader acculturation literature (Meca et al., 2017; Schwartz et al., 2010a), as they not only potentially play a role in the contradictory findings above, but will likely continue to hinder understanding of the relationship between acculturation and suicide-related risk.

 ffects of the Host Context and Ethnic E and Racial Density Acculturation is not only inherently a developmental process (Schwartz et al., 2020), but immigration and acculturation can also be conceptualized as the interaction between a specific immigrant group and the perceived context in which they are received (Schwartz et  al., 2010a). At the broadest level, the views and expectations of members in a given society, as

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they relate to multiculturalism (i.e., joint value placed on cultural diversity and equitable participation), play a role in shaping youths’ acculturation (Berry, 2013). However, as emphasized by Meca et al. (2019), the presence (or absence) of “multiculturalism may present in the immediate neighborhood (e.g., Little Havana in Florida), the receiving city (e.g., Miami), and/or at the broader level of receiving society (e.g., the United States)” (p. 50). Within contexts marked by multiculturalism, youth are afforded the capacity to interact with people from the larger society and from the heritage cultural community to draw social support, as needed (Schwartz & Zamboanga, 2008). In contrast, in more monocultural, culturally disjointed, or conflicted societies, individuals would likely be expected to restrict their heritage cultural activities to their homes and other private contexts (Arends-Tóth & Van de Vijver, 2007). Regardless of the views a particular society has toward multiculturalism, though, discrimination and foreigner objectification (i.e., perceptions of being treated as a foreigner) can serve as barriers, challenges, and threats toward immigrant youth. Indeed, at a more fine-grained level of analysis, there are important differences across immediate neighborhoods and host cities. Research has consistently highlighted differences in the degree to which receptions in a particular society vary in how welcoming and inviting they are perceived to be (Schwartz et  al., 2014). Moreover, youths’ perception of their context plays an instrumental role in how much they experience acculturative stress (Smokowski & Bacallao, 2011). In sum, given the variability of reception in the US likely encountered by immigrants, it is critical that future research move beyond large ethnic enclaves and utilize multisite research designs to more fully understand the impact that an immigrants’ perception of their context of reception has on acculturation, cultural stress, and suicide risk.

Intersectionality and Within-Group Differences Beyond conceptualizing acculturation within a specific social and cultural context, it is impor-

tant to acknowledge the high degree of intersectionality and within-group diversity in acculturation (Schwartz et al., 2010a). Although research has typically focused on immigrants from large pan-ethnic/racial groups (e.g., Hispanic, Asian, etc.), there are drastic differences within each of these pan-ethnic/racial groups across national origin in terms of socioeconomic status, culture, dialect, history with the US, skin tone, and ability to fit into the dominant US culture (Chu & Sue, 2011; Ennis et al., 2011). Collectively, these factors can result in very different experiences that may influence the acculturation process across a variety of direct and indirect ways. We acknowledge that the decision to combine immigrants across national origin into larger pan-ethnic groups is partially due to the difficulty associated with obtaining a large enough sample to examine these within-group differences (Sue et  al., 1999). However, the aggregation of immigrants within larger pan-­ ethnic groups often masks differences among subgroups and prevents understanding of withinand between-group differences in acculturation and its association with suicide.

Clinical Implications Although limited, the knowledge obtained about the impact of acculturation on suicide-related risk has important clinical implications in the prevention of suicidal behaviors in immigrant youth. This is especially the case in ethnic and racial minority youth, who are less likely than their White peers to seek mental health services (King et al., 2019), and thus are particularly vulnerable to suicidal thoughts and behaviors. Indeed, several existing interventions have incorporated culture-specific strategies, specifically in addressing the appreciably high rates of suicidal behaviors in Latinx youth, in particular. For instance, Life Is Precious is an after-­ school, community-based program throughout New York City that directly addresses acculturation to reduce suicidal behaviors in Latina adolescents by providing support in the areas of academic, peer, and family relations, and pro-

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moting coping skills targeting cultural stressors and family conflict (Humensky et  al., 2017). Familias Unidas, a culturally specific intervention originally developed to reduce substance misuse and sexual risk behaviors in Latinx youth, may also help reduce the risk for suicidal behaviors (Vidot et al., 2016). This family-based intervention targets communication between parents and adolescents to reduce family conflict that may arise from acculturation gaps. Despite a lack of suicide-specific targets, the intervention was associated with decreases in suicide-related risk among a group of Latinx youth, but only among those with compromised parent-youth communication. Alternatively, Socio-Cognitive Behavior Therapy for Suicidal Behaviors (SCBT-SB; Duarté-Vélez et al., 2016) is a cultural adaptation of an existing evidence-based treatment widely used for suicidal behaviors, Cognitive Behavior Therapy (CBT). In addition to traditional targets of CBT such as thinking traps and behavioral activation, SCBT-SB also targets family conflict and cohesion, culture-specific stressors (e.g., minority and discrimination stress), and identity development. Together, these prevention and intervention strategies provide early evidence demonstrating the importance of addressing acculturation in suicide prevention among immigrant and ethnic and race minority youth.

turation, explore the unique and interactive effects between acculturation and cultural stressors, further contextualize acculturation within the family system and context of reception, and, finally, identify potential withingroup differences across immigrant and ethnic and race groups. By addressing these gaps, we will not only develop a better understanding of the role acculturation plays in suiciderelated risk, but may potentially improve screening for youth at greatest risk for suicidal behaviors, provide novel targets for intervention, improve the cultural sensitivity of existing strategies, and promote the development of new culturally centered strategies. While there is considerable work to be done, we hope that this chapter will serve to stimulate innovative and informative work that further illuminates the relationship between acculturation and suicide-­r elated risk.

Conclusion

Arends-Tóth, J., & Van de Vijver, F.  J. R. (2007). Acculturation attitudes: A comparison of measurement methods. Journal of Applied Social Psychology, 37(7), 1462–1488. https://doi. org/10.1111/j.1559-­1816.2007.00222.x Assari, S., Lankarani, M. M., & Caldwell, C. H. (2017). Discrimination increases suicidal ideation in black adolescents regardless of ethnicity and gender. Behavioral Sciences, 7(4), Article 75. https://doi. org/10.3390/bs7040075 Baumann, A. A., Kuhlberg, J. A., & Zayas, L. H. (2010). Familism, mother-daughter mutuality, and suicide attempts of adolescent Latinas. Journal of Family Psychology, 24(5), 616–624. https://doi.org/10.1037/ a0020584 Benet-Martínez, V., & Haritatos, J. (2005). Bicultural identity integration (BII): Components and psychosocial antecedents. Journal of Personality, 73(4), 1015–1050. https://doi. org/10.1111/j.1467-­6494.2005.00337.x

As a whole, our review of the literature emphasizes the importance of acculturation in understanding suicide-related risk among immigrants and ethnic and racial minority youth. However, the scarcity of empirical studies, coupled with several conceptual and methodological problems, hampers our understanding of the developmental processes linking acculturation with suicide-­related risk. As we have outlined above, and consistent with contemporary models of acculturation (Meca et  al., 2019; Schwartz et  al., 2010a), future studies should utilize a bidimensional and multicomponent conceptualization of accul-

Acknowledgments  Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number T34GM118259. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Matching funds from Old Dominion University are also acknowledged.

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Part II Assessment

9

Understanding Patterns of Adolescent Suicide Ideation: Implications for Risk Assessment Regina Miranda, Ana Ortin-Peralta, Beverlin Rosario-Williams, Tara Flynn Kelly, Natalia Macrynikola, and Sarah Sullivan

Introduction Adolescence is a time of life during which suicidal thoughts and behaviors tend to emerge and have their highest prevalence, relative to adulthood. In the United States, the 12-month preva-

R. Miranda () · B. Rosario-Williams · N. Macrynikola Hunter College, City University of New York, New York City, NY, USA The Graduate Center of the City University of New York, New York City, NY, USA e-mail: [email protected]; [email protected]; [email protected] A. Ortin-Peralta Hunter College, City University of New York, New York City, NY, USA Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA e-mail: [email protected] T. F. Kelly Hunter College, City University of New York, New York City, NY, USA Harvard University, Cambridge, MA, USA e-mail: [email protected] S. Sullivan The Graduate Center of the City University of New York, New York City, NY, USA Icahn School of Medicine at Mount Sinai, New York City, NY, USA e-mail: [email protected]

lence of suicide attempts among high-school students rose from about 6% in 2009 to about 9% in 2019 (Ivey-Stephenson et al., 2020). This compares to a 12-month prevalence of 1–2% among 18–25-year-olds and 0.3–0.4% among adults ages 26 and older within the same time period (Substance Abuse and Mental Health Services Administration, 2020). However, because many more adolescents attempt suicide than die by suicide, suicide deaths are difficult to predict in this age group. Psychological autopsy studies of adolescent suicides are limited and were conducted decades ago. However, evidence from these studies suggests that over half of adolescents who die by suicide may do so at their first attempt (Brent et al., 1999; Shaffer et al., 1996), making prediction of suicide deaths from previous suicide attempts difficult in adolescence. Difficulty predicting short-term risk of suicide with traditional clinical predictors has prompted researchers to develop alternative methods of predicting suicide risk, including the development of implicit measures (Cha et al., 2010; Nock et al., 2010; Tello et  al., 2020), real-time and passive monitoring methods (Allen et  al., 2019; Kleiman et  al., 2019a), and the use of machine learning algorithms (Linthicum et  al., 2019; Walsh et  al., 2018). While these are promising research avenues, we would like to suggest that one critical gap in knowledge that has prevented researchers and clinicians from being able to predict adolescent

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_9

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suicidal behavior is having a limited understanding of suicide ideation, defined as “thinking about, considering, or planning for suicide” (Crosby et al., 2011, p. 11). In a recent editorial, Jobes and Joiner (2019) argued that “...In our singular pursuit to prevent suicide deaths, we need to stop trivializing the obvious and vital importance of attending to suicidal ideation” (p. 229). Gaining a better understanding of suicide ideation, whose 12-month prevalence among US high-school students was about 19% in 2019 (Ivey-Stephenson et  al., 2020), is an important step in assessing risk among adolescents. This is especially important, given research suggesting that first-time suicide attempts occur within 1 year after the onset of suicide ideation (Nock et  al., 2013). Contemporary theories of suicide focus on factors that lead to the development of suicide ideation, and there has been a push over the last decade to move beyond predicting suicide ideation to understanding the transition to suicide attempts (Glenn & Nock, 2014). Furthermore, the proposed Suicidal Behavior Disorder in the DSM-5 focuses exclusively on suicide attempts and does not include suicide ideation among its diagnostic criteria (American Psychiatric Association, 2013), missing a potential opportunity to understand the phenomenology of the thoughts preceding suicidal behavior. Other proposed syndromes aimed at capturing imminent risk, such as Suicide Crisis Syndrome and Acute Suicidal Affective Disturbance (Galynker, 2017; Rogers et  al., 2017; Stanley et  al., 2016), focus primarily on other criteria (e.g., entrapment, arousal, social alienation), and while they do consider increases in suicidal intent, they do not elaborate on the features of suicide ideation that might be informative about risk. There is no theory, of which we are aware, that has sought to tackle understanding suicide ideation, itself, nor how suicide ideation might change the nature of risk for suicide attempts. Furthermore, many prevailing psychological models of suicide focus on adults and ignore adolescence, the time of life when rates of suicide ideation increase (Boeninger et al., 2010; Bolger et al., 1989; Borges et al., 2008b; Kessler et al.,

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1999; Nock et al., 2013). In this chapter, we present a case for the importance of understanding the form and patterns of suicide ideation. We begin with a review of what some contemporary theories of suicide suggest about suicide ideation and address their limitations. We follow with research that is informative about the characteristics of suicide ideation, in terms of its form and patterns. Next, we describe evidence of different suicide ideation trajectories from prospective and ecological momentary assessment studies. Finally, we conclude with a proposed model of classification of subtypes of suicide ideation that can inform and guide clinical assessment, and we discuss clinical implications of these suicide ideation subtypes.

 hat Some Theories of Suicide W Suggest About Suicide Ideation Some contemporary psychological theories of suicide suggest that understanding the form that suicide ideation takes is important. For instance, the Interpersonal Theory of Suicide suggests that suicide risk is a function of both capability for suicide and suicidal desire (Joiner, 2005; Van Orden et  al., 2010). While suicidal desire—i.e., how much a person wishes to die—depends on whether people perceive themselves as a burden to others (perceived burdensomeness) and whether they do not feel that they belong to a group (thwarted belongingness), whether people have the ability to engage in lethal self-harm depends on their lowered fear of death and elevated tolerance for physical pain. The model suggests that people lower their fear of death through experiences, such as previous self-harm or suicide attempts, that habituate them to the idea of lethal self-harm. This can include detailed suicide-­ related mental simulation. Thus, the Interpersonal Theory would suggest that it is not only whether people think about suicide that matters, but how they think about suicide that might also contribute to the capability for suicide (Joiner, 2005; Van Orden et al., 2010). Much of the research testing the Interpersonal Theory of Suicide either focuses on the circumstances that

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lead to suicide ideation (e.g., examining perceived burdensomeness and thwarted belonging as predictors of suicide ideation) or on the relationship between capability for suicide and suicidal behavior (see Chu et  al., 2017, for a systematic review and meta-analysis). However, the ways in which the form that suicide ideation takes (e.g., how often people think about killing themselves, how vivid their thoughts are, how long they last, and how much difficulty they have disengaging from their thoughts) might also give rise to the capability for suicide has been neglected. Like the Interpersonal Theory, Rudd’s Fluid Vulnerability Theory distinguishes between acute and chronic suicide risk. Acute risk lasts only as long as a particular suicidal episode. However, chronic risk is underlying and is influenced by such factors as previous suicide attempt history, with individuals who have engaged in multiple previous suicide attempts having higher chronic risk of engaging in future suicidal behavior than individuals with no previous suicide attempt history or compared to individuals with only one previous suicide attempt. Drawing upon Beck’s theory of modes (Beck, 1996), which suggests a connection in memory between suicide-related thoughts, feelings, behaviors, and motives, the fluid vulnerability theory suggests that each suicidal episode lowers the threshold for triggering future episodes, because it strengthens the connections between the thoughts, feelings, and behaviors that surrounded previous suicidal episodes (Rudd, 2000, 2006). Thus, repeated suicide ideation would continually strengthen the connections in memory between aspects of the suicidal mode, ultimately increasing chronic risk of making a suicide attempt. The cognitive model of suicide (Wenzel & Beck, 2008) centers on the role of maladaptive cognition in facilitating the transition to suicidal behavior. Like the fluid vulnerability theory, the cognitive model suggests that trait-like vulnerability factors contribute to chronic risk for psychiatric disturbance, in general. Then in the presence of elevated life stress, these general cognitive processes may activate suicide-specific cognitive processes. Cognitive processes in this

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theory refer to both the content and form, or process, of thinking—that is, what people think about and how they think about it (e.g., information processing biases). Specifically, the theory proposes that the greater the frequency, intensity, or duration of cognitive processes associated with psychiatric disturbance, the greater the likelihood of activating a suicide schema. A schema is defined as a mode of thinking that helps people organize information in a meaningful way (Clark & Beck, 1999). When a suicide schema is activated, according to the theory, it facilitates biased information processing in such a way that suicide-­ specific cognitions and cognitive processes are given preference. Two such processes are attentional biases toward suicide-relevant cues and attentional fixation, a narrowing of attention and preoccupation with suicide as the only solution. These processes together, along with state hopelessness, exacerbate suicide ideation and culminate into suicidal behavior at the point when the individual cannot tolerate distress any longer (Wenzel & Beck, 2008). Taken together, these theories suggest that repeated suicide ideation, over time, would increase a person’s underlying risk for engaging in future suicidal behavior by biasing attention to suicide-related stimuli, and perhaps fixating attention on suicide-related stimuli, reinforcing suicide-related schemas, lowering the threshold for triggering future suicidal episodes, and ultimately increasing the capability for suicide.

 ole of Attention Bias R and Engagement/Disengagement The cognitive model of suicidal behavior suggests an important role of attention bias toward suicide-related stimuli and attentional fixation on suicide in conferring vulnerability to making a suicide attempt (Wenzel & Beck, 2008). Past and recent research has provided some support for this idea, mainly in research that has made use of an adapted form of the Stroop Task to measure attention bias toward suicide-related stimuli among adults with differing histories of suicidal behavior. The classic Stroop task (Stroop, 1935)

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is a color-naming task in which there is either congruence or incongruence between the ­semantic content of a word and the color in which the word is printed (e.g., the word “green” printed in green ink vs. the word “green” printed in blue ink). The speed and accuracy with which people perform the color-naming task are used as a measure of people’s ability to inhibit the cognitive interference from the semantic content of the words in the incongruent trials, but it is also used as a measure of attention. The Emotional Stroop Task (Cisler et  al., 2011; Dobson & Dozois, 2004; Epp et  al., 2012) and the Suicide Stroop task (Cha et al., 2010) are modified versions of the classic Stroop task. Instead of using names of colors as word stimuli, the emotional Stroop task uses different categories of valenced stimuli to detect “attentional biases” specific to relevant psychopathologies (e.g., depression-related or anxiety-related words). The Suicide Stroop task is a modified version of the Emotional Stroop task and uses suicide- and death-relevant stimuli to detect suicide-specific attentional biases, rather than a general attentional bias toward negative stimuli. Attention bias is indicated by a person’s average response latency to respond to suicide-related words relative to neutral words (see Cha et al., 2010, for details). A meta-analysis of four studies examining suicide-specific attentional processing using the Suicide Stroop found a small effect for suicide-­ specific interference for adults with suicide attempt histories (Richard-Devantoy et al., 2016). In contrast, there was no interference effect for negative stimuli, suggesting specificity to suicide-­ related cognitions. We highlight that none of the studies examined these relationships in children or adolescents, and only one of the studies in the meta-analysis focused on emerging adults (Chung & Jeglic, 2016). The findings using the Suicide Stroop have been generally consistent, though the methodologies and analyses have varied between studies. For instance, Cha et  al. (2010) found that adults with a suicide attempt history exhibited greater suicide-specific interference than interference from negative stimuli (relative to neutral); further, adults with recent suicide attempts demonstrated greater suicide-­

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specific interference than adults with more distal suicide attempts. Importantly, this attentional interference predicted suicide attempts within 6  months. Two other studies found that adults with a suicide attempt history exhibited longer latencies in responding to suicide-specific stimuli (see Becker et al., 1999; Williams & Broadbent, 1986). A more recent study of adult patients used both a classic Stroop and an Emotional Stroop Task to identify differences in Stroop interference between patients with high and low risk for suicide ideation and attempts (Thompson & Ong, 2018). Findings revealed a strong Stroop effect for the classic Stroop task, such that the high-risk group was less accurate and responded more slowly. In contrast, participants responded more quickly to all emotional stimuli when engaging in the Emotional Stroop task, with no Stroop effect occurring. Still, the high-risk group took longer to respond to the word “suicide,” replicating previous findings from a college-student sample (Chung & Jeglic, 2016). Although the Suicide Stroop has been used as a proxy for attentional processing and thereby attentional bias relevant to suicidal cognitions, a recent psychometric study that analyzed data from seven separate studies, with participants ranging in age from 12 to 81 years, found that the most common scoring approach for the Suicide Stroop had low internal consistency reliability. In addition, it performed no better than chance in classifying individuals with versus without a suicide attempt history (Wilson et al., 2019) thus not replicating one of the previous Suicide Stroop findings (Cha et  al., 2010). This low reliability potentially undermines conclusions drawn from previous work and recent attempts to develop interventions to shift suicide-specific attention bias. For instance, a study that used an attention bias modification task to reduce severity of suicide ideation and suicide-specific attentional bias among a community and clinical sample found no effect in shifting these cognitive processes. The authors suggested that the duration and implementation of the bias modification task may not have been adequate to obtain the desired effects (Cha et al., 2017). However, another pos-

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sibility is that the task was targeting the wrong attentional process. A major limitation with the Suicide Stroop is that it is unclear whether it measures how long it takes to focus attention on suicide-related stimuli (engagement) versus how long it takes to remove attention after the person has attended to a stimulus (disengagement), or whether it does, in fact, measure attention bias at all (versus cognitive/semantic interference). Prior to developing suicide-related attention bias modification interventions, it is important to understand which suicide-specific attentional processes are associated with suicide ideation and confer risk of suicide attempts. Recent work has begun to distinguish between these attentional processes in relation to suicide-­ specific biases. One study used Posner’s spatial cueing paradigm (Posner, 1980) to measure both attention engagement and disengagement. In this spatial cuing task, participants view a cueing word (e.g., suicide-related, negatively valenced) followed by a cueing probe. Congruent trials present both the cueing word and the cueing probe in the same visual field, whereas incongruent trials present them in opposite visual fields. Congruent trials measure attention engagement, while incongruent trials measure attention disengagement. The results indicated that depressed patients high in suicidal behavior (determined via median split of scores on a measure assessing suicide ideation and attempt history) more easily disengaged from suicide-related stimuli, relative to neutral stimuli, even when taking into account their symptoms of anxiety and depression (Baik et al., 2018). It is possible that adults with more experiences of suicide ideation and attempts have developed greater automaticity in processing suicide-­specific content. There is limited work examining suicide-­ related attention bias among children and adolescents. One study examining attentional bias toward fearful, sad, and happy faces found that children with previous suicide ideation sustained (i.e., focused) their attention on fearful faces longer than on sad or happy faces, relative to children without a history of suicide ideation (Tsypes et al., 2017). However, there was no difference in attention orienting (i.e., how long it took the chil-

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dren to initially focus their attention) on fearful, sad, or happy faces. Importantly, these findings were only captured through eye-tracking techniques, because there were no differences in attention orienting and sustained attention using reaction time methods, highlighting the need for sensitivity in multimethod approaches. Further work is needed to better disentangle specific attentional processing underlying the development and maintenance of suicide ideation, particularly among children and adolescents.

Limitations of Current Measurement of Suicide Ideation Suicide ideation measures tend to either include a few items that screen for the presence of suicidal thoughts or scales that generate total scores indicating increasing degree or severity of ideation. However, there is no established cutoff score that indicates whether an adolescent is at risk of making a suicide attempt, nor does a total score provide specific information about the nature of the adolescent’s suicide ideation. Further, the ability of suicide ideation measures to predict whether adolescents will make a suicide attempt is mixed (Gipson et  al., 2015; King et  al., 1997, 2014; Prinstein et al., 2008), with research with clinical samples of adolescents suggesting that change in suicide ideation scores predict future suicide attempts (Prinstein et  al., 2008), others finding this to be the case among adolescent girls but not among boys (King et al., 2014), and still others finding that scores on a measure of suicide ideation intensity do not predict future suicide attempts among adolescents presenting to an emergency department with suicide ideation (Gipson et al., 2015). Developing ways of classifying suicide ideation to provide information to clinicians about an adolescent’s risk of making a future suicide attempt may improve clinical care of adolescents who disclose suicide ideation or report thoughts about suicide on a screening questionnaire. There is a dearth of research on characteristics of suicide ideation that predict future suicide attempts, overall, but particularly among adoles-

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cents. Established ways of assessing suicide ideation tend to focus on how strongly people wish to die, whether they have considered a method, and whether they engage in planning (Beck et al., 1997; Harriss & Hawton, 2005; Harriss et  al., 2005; Joiner et al., 1997, 2003; Suominen et al., 2004; Witte et al., 2006). There is little information on whether such characteristics predict suicide attempts and suicide deaths among adolescents. No measure of suicide ideation of which we are aware focuses on the form that suicide ideation takes—in terms of its frequency (i.e., the actual number of times it occurs on a given day or in a given week), duration (i.e., the actual number of minutes or hours it lasts), and pattern (i.e., the actual number of subsequent days it happens). Those that do inquire about these characteristics do so as part of summary scales not meant to focus on these elements of ideation. For example, the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008) includes questions about frequency, duration, and controllability of ideation under a five-item suicide ideation “intensity” subscale that also includes reasons for ideation and the presence of deterrents to making a suicide attempt. The Scale for Suicidal Ideation (SSI; Beck et al., 1979) captures frequency and duration of ideation under its “suicidal desire” subscale that also includes ratings of wish to die. The Suicide Ideation Questionnaire (SIQ-Jr.) (Reynolds, 1987) assesses how frequently adolescents have thoughts about being better off dead, wishing they were dead, of killing themselves, or of communicating their suicidal intent in the previous month on a scale ranging from “never” to “almost every day.” However, the measure does not inquire about how many times per day individuals think about suicide nor about how long the thoughts last. This is a limitation of current measures, because there is emerging evidence that the form of suicide ideation might be informative about an individual’s risk profile. A study of adolescents with a previous suicide attempt history found that in addition to having a serious wish to die, suicide planning lasting an hour or longer (vs. less than an hour) preceding the adolescent’s most recent suicide attempt (as

assessed at baseline) predicted a reattempt during a 4–6-year follow-up period (Miranda et  al., 2014a). Miranda et al. (2014b) found that among adolescents who endorsed suicide ideation in the previous 3–6 months, length of their most recent ideation predicted whether they went on to make a suicide attempt during a 4–6-year follow-up period, independently of wish to die, even adjusting for depressive symptoms and for history of a previous suicide attempt. Further, among those who attempted suicide within a follow-up period, length of a suicide ideation episode greater than an hour predicted earlier onset of a future attempt (within 1 year), relative to ideation length of less than an hour (within 3–4  years). Gipson et  al. (2015) found that one question on the C-SSRS that inquired about duration of suicide ideation predicted a future suicide attempt among adolescents who presented to an emergency department with suicide ideation. However, other questions about frequency, controllability, deterrents, and reason for ideation were not associated with attempting suicide during a 12-month follow-up (Gipson et al., 2015). These findings suggest that knowing not only whether adolescents think about suicide but also how they do so—i.e., the form of their suicide ideation—is informative about their vulnerability to future suicidal behavior.

Suicide-Related Imagery One understudied but potentially important characteristic of adolescent suicide ideation is the degree to which adolescents think about suicide in the form of verbal thoughts versus visual imagery. Research conducted with adolescents and young adults has examined the role of suicide-­ related imagery in distinguishing individuals with and without a history of a suicide attempt and in thus potentially conferring risk for future suicidal behavior. Building upon theories of mental imagery proposed by Beck (1971) and Lang (1979), Holmes and colleagues proposed that suicide-related imagery occurs in the form of “flash-forwards”—defined as “suicide-related mental images experienced during a crisis,

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including acting out future suicidal plans or being dead” (Holmes et al., 2007, p. 431; Hales et al., 2015). These images were considered akin to flashbacks experienced due to past trauma—but focused on the future rather than the past. In a study of 15 adults from the United Kingdom (UK) with a history of major depression and suicide ideation, Holmes and colleagues found that 13 out of 15 participants who were asked to describe their suicide-related cognitions during their “worst point” suicide ideation reported suicide-­related images about the future, and two participants reported suicide-related images about the past. These images tended to be rich in detail. Two out of nine categories of thoughts— planning for a suicide attempt and thinking about what might happen if they died—were more often endorsed as containing imagery than verbal thoughts, while other categories (e.g., what might happen to other people if the person died) were equally reported as verbal thoughts versus imagery (Holmes et  al., 2007). Other studies with small samples of adults from the UK with depression or bipolar disorder found similar results (Crane et al., 2012; Hales et al., 2011). In addition, Crane and colleagues found that severity of worst-point suicide ideation was associated with lower levels of distress and higher levels of comfort from the suicidal imagery (Crane et  al., 2012), supporting the idea that suicidal imagery might lead to habituation to the idea of suicide, as would be predicted by the Interpersonal Theory of Suicide (Joiner, 2005; Van Orden et al., 2010). Additional research with adults has found differences in suicide-related imagery depending on the recency of suicide ideation or lifetime suicide attempt history in nonclinical samples. For instance, a study of 82 adults in Hong Kong with current suicide ideation, identified from an epidemiological sample, found that over one-third of these individuals reported imagery that was assessed by independent raters as being suicide-­ related, and over half of these images were about what would happen after the suicide. Individuals who reported suicide-related imagery had more severe suicide ideation than those without imagery at baseline but not at a 7-week follow-up (Ng et al., 2016). A study of 237 college undergradu-

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ates from the South-Central United States found that total score on a measure of overall frequency and severity of lifetime self-harm behavior, as assessed by the Self-Harm Behavior Questionnaire (Gutierrez et al., 2001), was associated with greater suicide-related imagery. Furthermore, among 84 participants with a history of suicide ideation or attempts, 85% reported suicide-related imagery, and self-reported vividness of suicide-related imagery was associated with overall frequency and severity of self-harm (Holaday & Brausch, 2015). Finally, a study of 39 college undergraduates from the Northeastern United States who reported a lifetime history of suicide ideation found that reporting a higher degree of suicide-related mental imagery was associated with over two-and-a-half times higher odds of reporting a lifetime history of a suicidal plan or a suicide attempt (Lawrence et al., 2021b). Thus, studies with nonclinical samples of adults suggest that the presence of lifetime suicide-­ related imagery is relatively common among individuals with a history of suicide ideation or behavior and is associated with greater severity of their lifetime suicidal thoughts or behavior. Thus far, there is only one published study of which we are aware that examined suicide-related imagery among adolescents. A study of 159 racially and gender-diverse adolescent inpatients from the Northeastern United States, 102 of whom had a lifetime history of suicidal thoughts, found that about 64% of adolescents with a history of suicidal thoughts reported a lifetime history of suicidal mental imagery. Furthermore, adolescents who reported suicidal mental imagery had 2.4 times higher odds of reporting that they had previously made a suicide attempt, compared to those without suicidal mental imagery, adjusting for demographic variables, history of non-suicidal self-injury, and history of suicidal verbal thoughts (Lawrence et al., 2021a). This is consistent with findings from our recent studies examining the process and content of suicide ideation among predominantly Hispanic/Latinx samples of adolescents from New York City presenting with recent suicide ideation or a suicide attempt and who were interviewed about their most recent suicide ideation (Miranda et  al.,

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2021a, 2021b). About three-quarters of adolescents reported that their suicide ideation occurred in the form of mental imagery. In contrast to Lawrence et al.’s study, there was no difference between adolescents with and without a suicide attempt history in whether they reported mental imagery during their most recent suicide ideation. Our study differed demographically, clinically, and methodologically from that of Lawrence et al. (2021a). One difference was that we interviewed adolescents—all of whom presented with either suicide ideation or an attempt— about their recent suicide ideation/attempt, while about two-thirds of Lawrence et  al.’s (2021a) sample had a lifetime history of suicide-related cognitions, and the researchers inquired about lifetime (rather than recent) suicide-related imagery. Collectively, however, research with both adults and adolescents seems to suggest that suicide-­related imagery is common among clinical samples of individuals with a history of suicide ideation and that it should be studied further as a potential marker of risk for suicidal behavior.

Suicide Ideation Trajectories Traditionally, studies have defined different patterns of suicide ideation based on instances in which an individual reported the presence of suicide ideation over different times of assessment. These trajectories include no suicide ideation, one-time ideation, and persistent ideation, in which suicide ideation is reported during more than one assessment point (Borges et al., 2008a; Have et al., 2009; Kerr et al., 2008; Ortin et al., 2019; Steinhausen & Winkler Metzke, 2004). The persistent pattern of ideation has been found to be associated with a higher risk of attempting suicide, compared to one-time suicide ideation or no ideation, in adult (Wilcox et  al., 2010) and adolescent samples (Vander Stoep et  al., 2011). One limitation of this traditional approach is that it does not capture change in the nature or severity of suicidal thoughts. More recent studies with community and clinical samples of adolescents that have measured

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suicide ideation as a continuous variable over at least three time periods of assessment have identified three trajectories of suicide ideation. These trajectories include (1) persistently high; (2) persistently low; and (3) declining (suicide ideation that begins high and then decreases) or persistently moderate suicide ideation (Adrian et  al., 2016; Czyz & King, 2015; Rueter et  al., 2008; Wolff et al., 2018; Zhu et al., 2019), with trajectory names varying by study and with some studies finding sex differences in trajectories (Adrian et al., 2016; Reuter et al., 2008). A few of these studies have further examined how different suicide ideation trajectories predict risk of future suicide attempts and found that those adolescents whose suicide ideation was classified in the persistently high trajectory were more likely to attempt suicide in the future than those classified in the persistently low (Czyz & King, 2015; Rueter et al., 2008) or declining suicide ideation trajectory (Wolff et al., 2018). Thus, understanding how adolescents’ suicide ideation changes over time may help predict the risk of future suicidal behavior. Research that has examined trajectories of suicide ideation from adolescence to adulthood or suicide ideation trajectories among adults have yielded slightly different findings. Erasquin et al. (2019) examined trajectories from adolescence to adulthood (ages 12–31  years) with a dichotomous measure of suicide ideation (i.e., presence/ absence of suicide ideation in the previous year) and identified three trajectories of suicide ideation: sustained higher risk (i.e., suicide ideation consistently present from adolescence to adulthood), sustained lower risk (i.e., few suicidal thoughts from adolescence to adulthood), and adolescent-limited risk (i.e., presence of suicidal thoughts limited to ages 12–19) (Erausquin et al., 2019). Studies examining suicide ideation trajectories with adults, primarily among inpatient or military samples, have usually identified four trajectories of suicide ideation (Allan et  al., 2019; Kasckow et  al., 2016; Köhler-Forsberg et  al., 2017; Madsen et al., 2016). Three of these trajectories are low-stable, moderate-stable, and high-­ stable suicide ideation, with the fourth trajectory varying across studies (e.g., high-declining,

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moderate-­ unstable, high-increasing). This discrepancy between studies with adolescents and adults suggests that suicide ideation profiles may vary by developmental period. In sum, data from longitudinal studies suggest that temporal patterns of suicide ideation matter, in terms of predicting risk for future suicide attempts. These findings support the value of conceptualizing suicide ideation as a complex dynamic phenomenon.

Moment-to-Moment Variability in Suicide Ideation: Data from Ecological Momentary Assessment Studies Studies examining change in suicide ideation over time have tended to rely on retrospective self-report measures and lengthy gaps between assessment follow-ups in longitudinal designs, with an average time between assessments of about 7 years (Ribeiro et al., 2016). Such gaps in measurement time points make it difficult to understand moment-to-moment variability in suicidal thoughts and behaviors (Glenn & Nock, 2014). To overcome these limitations, ecological momentary assessment (EMA) methods use smartphones, tablets, computers, and/or wearable devices to measure day-to-day changes in suicide ideation and risk of suicide attempts (Glenn & Nock, 2014; Nock et  al., 2009; Shiffman et  al., 2008). EMA involves frequent and repeated measurement of people’s experiences, feelings, and physiological responses as they naturally occur outside of a clinical or laboratory setting, to decrease recall bias and to increase reliability and ecological validity (Kleiman & Nock, 2018; Shiffman et al., 2008). EMA studies of clinical samples of suicidal adults have found fluctuation of suicide ideation within very short time intervals (Forkmann et al., 2018; Hallensleben et  al., 2019; Husky et  al., 2017; Kleiman et  al., 2017, 2018; Nock et  al., 2009; Peters et  al., 2020; Spangenberg et  al., 2019; Wang et al., 2021). For example, Kleiman et al. (2017) queried participants about their suicidal desire, suicidal intent, and ability to resist

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their suicidal urges every 4–8 h over a period of 28 days and found that 94–100% of participants displayed high variability (change of more than one standard deviation over previous responses) in suicide ideation on most days. Furthermore, factors such as hopelessness, burdensomeness, and loneliness, which also showed high variability, were correlated with suicide ideation but did not predict short-term change (i.e., within 4–8 h) in suicide ideation (Kleiman et al., 2017). Other studies have found similar results within clinical samples of adults (Forkmann et  al., 2018; Hallensleben et  al., 2019; Husky et  al., 2017; Peters et  al., 2020; Spangenberg et  al., 2019; Wang et al., 2021). In a 28-day EMA study of 51 adults with recent suicide ideation or attempts, Kleiman et al. (2018) used a latent profile analysis approach to identify five distinct phenotypes, or subtypes, of suicide ideation and found that those with a higher mean and lower variability around the mean (i.e., more severe and persistent suicide ideation) were more likely to have made a recent suicide attempt (Kleiman et  al., 2018). Furthermore, one study of 83 adults found that variability in suicide ideation, assessed via EMA, improved prediction of short-term risk of a suicide attempt within a month of discharge from a hospital, beyond baseline admission data (Wang et al., 2021). Several studies have suggested that EMA monitoring of suicidal thoughts and behavior is feasible and acceptable among adolescents (Czyz et  al., 2018; Glenn et  al., 2020; Kleiman et  al., 2019b). Of the few existing studies examining short-term variability and prediction of suicide ideation and attempts among high-risk adolescents, most have produced similar findings to those conducted with clinical adult samples (Czyz et al., 2019, 2020). For example, a study of 34 adolescents hospitalized with recent suicide ideation or a suicide attempt (N = 34), assessed once per day over 28 days post-discharge, found that suicide ideation, as well as known correlates of suicide ideation (i.e., hopelessness, burdensomeness, and connectedness), varied considerably from day-to-day (Czyz et  al., 2019). This research suggests that EMA can capture changes in suicide ideation potentially missed by longitu-

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dinal studies that conduct assessments over longer periods of time. Furthermore, a recent proof-of-concept study of 32 adolescents discharged from a hospital found that the combination of mean and variance of hopelessness, self-efficacy, and duration of suicide ideation, assessed via daily diary over an initial 2 weeks, predicted the occurrence of a suicide-related event (either rehospitalization or a suicide attempt) 2  weeks later (Czyz et  al., 2020). It remains to be seen whether different profiles of suicide ideation, assessed via EMA, predict future suicidal behavior among adolescents. Despite the feasibility and potential for fine-­ grained measurement of variability in suicide ideation, there are limitations to EMA approaches. One of these is compliance. Two recent studies found compliance rates to be approximately 65% for each momentary assessment among samples of adults presenting with suicide ideation (Kleiman et  al., 2017; Porras-Segovia et  al., 2020). A recent study of 53 adolescents found an EMA adherence rate of about 63%, with significantly lower adherence among racial and ethnic minoritized adolescents (40%), compared to White adolescents (69%) (Glenn et  al., 2020). Factors that impact EMA compliance/adherence include study duration, number of assessments per day, compensation/incentives, and participant fatigue or burden (Ballard et al., 2021; Kleiman et  al., 2017; Porras-Segovia et  al., 2020). Furthermore, in studies using real-time monitoring, a standing issue that remains is how to keep participants at imminent risk of suicidal behavior safe (Kleiman et al., 2019a). Even while considering these limitations, EMA and real-time monitoring might help researchers better understand fluctuations in suicidal thoughts and behaviors, protective factors, and risk factors that might be missed by traditional approaches and measures (Ballard et al., 2021).

Suicide Ideation Subtypes Collectively, longitudinal and EMA studies suggest that suicide ideation varies over the longand short-term, with different risk profiles

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depending on a person’s pattern of suicide ideation. This research has highlighted the importance of tracking change in suicide ideation to potentially identify subgroups of individuals at risk of making a suicide attempt. However, some adolescents who come to the attention of a clinician may only be seen on one occasion, and there may not be opportunities to conduct multiple assessments of their ideation to identify a specific suicide ideation pattern. In those cases, it would be useful to develop ways of classifying adolescents’ suicide ideation during an initial assessment to inform decision-making, and perhaps supplement those classifications with information from subsequently available assessments. One profile or subtype of adolescent suicide ideation suggested by both longitudinal and EMA studies is persistently elevated suicide ideation. Several studies involving follow-up of adolescents over 6  months to 1  year suggest that suicide ideation that remains persistently elevated is associated with increased risk of a suicide attempt during follow-up, compared to ideation that starts off elevated but declines or ideation that remains at subclinical levels (Czyz & King, 2015; Wolff et al., 2018). Furthermore, of the five suicide ideation subtypes identified in Kleiman et al.’s (2018) EMA study of adults, suicide ideation that was more persistently elevated was most strongly associated with having made a recent suicide attempt. There have been no comparable published studies, of which we are aware, identifying subtypes of adolescent suicide ideation via EMA, nor whether these subtypes prospectively predict future suicidal behavior. However, the limited evidence suggests a stronger association between a pattern of persistently elevated suicide ideation and suicide attempt risk. Additional cross-sectional research with adults has also suggested different patterns of suicide ideation among adults who attempt suicide. A study of individuals, ages 18–64, who presented to a hospital within 24  h of a suicide attempt, found that suicide attempts that were preceded by 3 or more hours of suicide planning were less often triggered by a negative life event, compared to adults whose suicide attempts were

9  Understanding Patterns of Adolescent Suicide Ideation: Implications for Risk Assessment

preceded by less than 3  h of planning (Bagge et al., 2013). This finding suggests that whether negative life events precipitate an attempt depends on the nature of the suicide ideation preceding an attempt. In a related vein, researchers have suggested two potential pathways of suicide risk involving differences in response to precipitating events, based on research with adolescents and adults. A study of a racially and ethnically diverse sample of 130 adolescents admitted to a hospital for a self-injurious threat, suicide ideation, or a suicide attempt found that adolescents whose suicidal crises were not preceded by a precipitating event had higher depressive symptoms, lower perceived problem solving, higher suicidal intent, and were more likely to have a history of a previous suicide attempt, compared to those whose suicidal crises were preceded by a precipitating event in the week before the crisis. The authors suggested that these findings reflected two potential pathways of risk: a non-stress-reactive pathway that might occur in the context of a depressive episode and a prior history of a suicide attempt and reflecting a longer, more gradual accumulation of risk; and a stress-reactive pathway involving brief escalation of a suicidal crisis and involving fewer suicidal plans and preparations (Hill et  al., 2012). Bernanke et  al. (2017) also proposed two subtypes of suicide attempts in adults—one involving acute responsiveness to stress and another involving non-stress-reactive suicide attempts. They propose that the former is associated with a history of trauma and involves suicide ideation that fluctuates in response to stressors, while the latter is associated with serotonergic dysfunction and depressive symptoms and involves persistent suicide ideation that does not fluctuate. A study of 35 adults with Major Depressive Disorder found that those classified as having brief suicide ideation, based on an item on the Beck Scale for Suicide Ideation (Beck et al., 1979; Beck & Steer, 1991) assessing duration of ideation, showed greater cortisol response to a social-evaluative stressor (the Trier Social Stress Test; Kirschbaum et al., 1993), compared to healthy volunteers and also compared to those classified as having “long/continuous” ideation,

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suggesting greater stress reactivity among those with brief suicide ideation (Rizk et  al., 2018). This classification was based on a single item characterizing suicide ideation over the previous week, rather than examining a more extended pattern of day-to-day ideation. Furthermore, this model focuses on suicide ideation in the context of a suicide attempt. It is unclear whether the model, developed with adults, would apply to adolescents with suicide ideation, or to adolescents without major depression and/or with suicide ideation but no history of suicide attempts. However, these findings suggest that different types or patterns of suicide ideation might have different profiles of risk, and supports the importance of going beyond examining the presence of suicide ideation or total scores on a suicide ideation measure in the assessment of suicide risk. Current adolescent suicide risk assessments do not classify suicide ideation based on characteristics that might be informative about the risk of future suicide attempts. In order to fill this knowledge gap and encourage future research, we suggest, as a starting point, three broad categories of adolescent suicide ideation subtypes that we have observed in our ongoing research and that might be supported by previous studies—brief suicide ideation, intermittent suicide ideation, and persistent suicide ideation. We classify these adolescents using a semi-structured interview we developed that makes detailed inquiries about adolescents’ most recent suicide ideation (Miranda et al., 2021b). We theorize that persistent suicide ideation, which we classify as involving uninterrupted suicide ideation over at least a 2-week period, is associated with increased risk of a suicide attempt and with a shorter time-­ to-­an-attempt, based on research suggesting that ideating for a longer period of time is associated with increased risk of a suicide attempt and with shorter time-to-an-attempt (Miranda et  al., 2014b). This is the type of suicide ideation that might be precipitated by a sustained dysphoric mood, rather than a specific triggering event. It might be described by adolescents as always being present in the back of their minds (e.g., They might start thinking about wanting to die or about killing themselves as soon as they wake up

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in the morning, and these thoughts might continue at different points throughout the day). In contrast, we classify brief suicide ideation as lasting less than 2  weeks, whether interrupted or uninterrupted. Brief suicide ideation is the type of suicide ideation that tends to be precipitated by a particular event, such as an interpersonal conflict (e.g., argument with a parent, friend, or romantic partner), rather than being longer standing and not arising in response to an external precipitant. This type of suicide ideation might last from several minutes to several hours or days. Intermittent suicide ideation is similar to persistent suicide ideation, in that it is longer standing suicide ideation (lasting 2  weeks or more) but might be described as occurring “on and off.” See Table  9.1 for working definitions and descriptions of these proposed suicide ideation subtypes. Based on contemporary models of suicide, we would expect that a persistent form of suicide ideation would be associated with increased accessibility of suicide-related cognitions (reflecting persistent activation of a suicide-­ related schema) and thus a lower threshold necessary to trigger a suicidal episode. The more adolescents think about suicide, the more that memories of previous suicide attempts might be activated, and the more that environmental cues available while an adolescent is thinking about suicide might become associated, in memory, with making a suicide attempt. In other words, persistent suicide ideation might continually trigger the suiciderelated schemas used to organize the circumstances surrounding previous suicide attempts or suicidal thoughts in memory, in the same way that having a history of repeated previous suicide attempts is thought to lower the threshold for triggering future suicidal episodes by making the activation of a suicidal mode more likely (Rudd, 2000, 2006). If this is the case, adolescents with persistent suicide ideation may be more likely to consider suicide when faced with even minor stressors (e.g., perceived social slights) than adolescents with brief suicide ideation. Additional research is needed to examine these possibilities.

Table 9.1  Proposed suicide ideation subtypes (adapted from Miranda et al., 2021b) Suicide ideation subtype Brief suicide ideation episode

Persistent suicide ideation episode

Intermittent suicide ideation episode

Definition An instance of suicide ideation that occurs on a given day and is not preceded by previous instances of suicide ideation; or a period during which one or more instances of suicide ideation occur for less than 2 weeks prior to the day of assessment. The ideation typically occurs in response to a precipitating event A period during which one or more instances of suicide ideation occur every day for 2 weeks or longer. During that period of time, no more than 24 h go by without suicide ideation

A period during which one or more instances of suicide ideation occur, on and off (with interruptions lasting 24 h or more) for 2 weeks or longer

Adolescent has argument with their parent, which makes them sad and angry. They start to wonder why they were born and think their family would be better off without them. They had one other instance of suicide ideation within the previous 2 weeks

Adolescent wakes up thinking about killing themselves. The thoughts come and go throughout the day. As they walk home, they see a drug store and think about buying pills to take an overdose. They also either thought about killing themselves or wished they were dead every day during the previous 2 weeks Adolescent thinks about killing themselves in school in response to bullying. They think about suicide on days that they go to school but not on weekends or days when they do not have to go to school

9  Understanding Patterns of Adolescent Suicide Ideation: Implications for Risk Assessment

 imits of Direct Inquiries About L Adolescent Suicide Ideation Before discussing the implications of considering the form and pattern of suicide ideation in assessments of adolescents presenting for clinical care, we should note that despite efforts to better understand suicide ideation, and potentially use that information to improve risk assessments, there are limits to asking direct questions about suicide ideation. Some youth experiencing suicide ideation may not disclose their thoughts, and there is evidence that those with higher risk profiles are less likely to disclose their suicide ideation. One study of 990 adolescents, ages 14–17  years, found that among 74 adolescents who reported past suicidal behavior, 27 of these adolescents did not disclose their suicide attempt to parents or significant others, and those who did not disclose their ideation were characterized by higher levels of suicide ideation and perceived victimization, along with a lower willingness to talk to others about their problems (Levi-Belz et al., 2018). Another study of 527 young adults experiencing homelessness found that less than one-third of young adults disclosed their suicide ideation (Fulginiti et  al., 2020). Similarly, a cross-national study in Europe found that adolescents who had previously disclosed their suicide ideation reported lower current ideation than those who had never disclosed (Eskin, 2003). In addition, research on self-disclosure has previously suggested that low self-disclosure is associated with higher suicide-related risk (Apter et al., 2001; Horesh & Apter, 2006). Finally, research with college students has suggested that racial and ethnic minority young adults are less likely to selfdisclose their suicide ideation when seeking treatment, compared to White young adults (Morrison & Downey, 2000). Whether this translates to an unwillingness to disclose during a suicide risk assessment is unknown.

Clinical Implications Existing interventions for suicidal youth focus primarily on reducing suicidal behavior. Little research exists on whether such interventions

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have the potential to reduce suicide ideation. For example, Dialectical Behavior Therapy (DBT) is a leading evidence-based treatment for suicidal individuals, with evidence of efficacy in adolescents (McCauley et  al., 2018). A recent metaanalysis, however, showed that while DBT significantly reduced suicidal behavior across studies, there was no statistically significant pooled effect of DBT on suicide ideation (see DeCou et al., 2019). Although these results may appear to suggest that DBT is less effective at reducing suicide ideation, perhaps the problem is that too few research studies assess suicide ideation, as even DBT prioritizes focus on suicidal behaviors rather than suicidal thoughts (Linehan, 1993). How can a greater focus on suicide ideation influence prevention and intervention efforts? First, it can help us understand the scope of the problem and influence clinical assessment. A growing body of research suggests that different forms of suicide ideation differentially impact suicide risk. Persistent suicide ideation, in particular, may predict both greater risk of an attempt and shorter time to an attempt. Better documenting and understanding this link can lead to change in the practice of clinical assessment. Clinicians can start to classify adolescents who present with a brief, intermittent, or persistent profile of ideation—and each classification will then call for a different intervention. Second, to arrive at more precise and effective interventions for suicide ideation, several questions need to be answered regarding the nature and function of specific types of suicide ideation. At what point does each subtype arise? What precipitates it? What function does it serve for the adolescent at the moment? Answering these questions will influence treatment of suicide ideation. For example, evidence suggests that brief ideation may be an outcome of stress reactivity, whereas persistent ideation may occur in the context of a sustained negative mood. If this is the case, clinical intervention for brief ideation might prioritize a focus on adaptive coping with stressful events ahead of time. In contrast, for persistent ideation, a mindfulness approach to strengthen the individual’s awareness of and abil-

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ity to exit negative thought spirals as they arise may be more effective. The question regarding function of specific types of suicide ideation is also important. For example, if as some evidence suggests, suicide ideation that takes the form of imagery provides comfort during a suicidal crisis (Crane et  al., 2012), alternatives can be found that provide similar benefits without conferring risk for suicidal behavior. Equally importantly, understanding how form and characteristics of suicide ideation confer risk can improve treatment by leading to interventions that directly target those underlying mechanisms. For example, how might persistent ideation confer increased risk for an attempt? What is it, specifically, about persistent ideation that increases risk? The cognitive model of suicide, which serves as the conceptual framework for cognitive therapy for suicide attempts (Brown et  al., 2005; Wenzel & Jager-Hyman, 2012), emphasizes the role of attentional biases in facilitating the transition to an attempt once a suicide-­ related schema has been activated (Wenzel & Beck, 2008). Persistent ideation may have different underlying mechanisms (e.g., attentional fixation) than other forms of ideation, in which case treatment might then prioritize strategies to ease disengagement from suicide ideation. Importantly, increasing adolescents’ own awareness of how exactly their thoughts function to perpetuate their own distress can motivate them to engage in the process of learning alternative strategies that reduce harm and provide relief— an endeavor that can only be achieved with greater research focus on the nature and consequences of different forms of suicide ideation.

Conclusion In this chapter, we have made a case for why a detailed assessment of suicide ideation is an important and understudied area of research. We have argued that addressing this gap in knowledge has the potential to improve prediction of adolescent suicidal behavior. We join other voices in the field who have called for a great focus on understanding and preventing suicide ideation

just as much as we, as a field, have focused on understanding and preventing suicidal behavior (Jobes & Joiner, 2019). Meta-analytic evidence suggests that suicide ideation is the third strongest predictor of future suicide (Franklin et  al., 2017); understanding the nature of suicide ideation and how its form and characteristics may confer risk for suicidal behavior can pave the way for improved prevention and interventions efforts.

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158 Journal of Child Psychology and Psychiatry, 59(12), 1261–1270. https://doi.org/10.1111/jcpp.12916 Wang, S.  B., Coppersmith, D.  D. L., Kleiman, E.  M., Bentley, K.  H., Millner, A.  J., Fortgang, R., Mair, P., Dempsey, W., Huffman, J.  C., & Nock, M.  K. (2021). A pilot study using frequent inpatient assessments of suicidal thinking to predict short-term postdischarge suicidal behavior. JAMA Network Open, 4(3), Article e210591. https://doi.org/10.1001/ jamanetworkopen.2021.0591 Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12(4), 189–201. https://doi. org/10.1016/j.appsy.2008.05.001 Wenzel, A., & Jager-Hyman, S. (2012). Cognitive therapy for suicidal patients: Current status. The Behavior Therapist, 35(7), 121–130. Wilcox, H.  C., Arria, A.  M., Caldeira, K.  M., Vincent, K.  B., Pinchevsky, G.  M., & O'Grady, K.  E. (2010). Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. Journal of Affective Disorders, 127(1–3), 287–294. https://doi. org/10.1016/j.jad.2010.04.017 Williams, J. M., & Broadbent, K. (1986). Distraction by emotional stimuli: Use of a Stroop task with suicide attempters. British Journal of Clinical Psychology,

R. Miranda et al. 25(2), 101–110. https://doi.org/10.1111/j.2044­8260.1986.tb00678.x Wilson, K.  M., Millner, A.  J., Auerbach, R.  P., Glenn, C. R., Kearns, J. C., Kirtley, O. J., Najmi, S., O’Connor, R. C., Stewart, J. G., & Cha, C. B. (2019). Investigating the psychometric properties of the Suicide Stroop Task. Psychological Assessment, 31(8), 1052–1061. https://doi.org/10.1037/pas0000723 Witte, T. K., Joiner, T. E., Jr., Brown, G. K., Beck, A. T., Beckman, A., Duberstein, P., & Conwell, Y. (2006). Factors of suicide ideation and their relation to clinical and other indicators in older adults. Journal of Affective Disorders, 94(1–3), 165–172. https://doi. org/10.1016/j.jad.2006.04.005 Wolff, J.  C., Davis, S., Liu, R.  T., Cha, C.  B., Cheek, S.  M., Nestor, B.  A., Frazier, E.  A., Schaffer, M.  M., & Spirito, A. (2018). Trajectories of suicidal ideation among adolescents following psychiatric hospitalization. Journal of Abnormal Child Psychology, 46(2), 355–363. https://doi.org/10.1007/ s10802-­017-­0293-­6 Zhu, X., Tian, L., & Huebner, E. S. (2019). Trajectories of suicidal ideation from middle childhood to early adolescence: Risk and protective factors. Journal of Youth and Adolescence, 48(9), 1818–1834. https://doi. org/10.1007/s10964-­019-­01087-­y

Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

10

Katherine M. Tezanos, Kerri-Anne Bell, and Christine B. Cha

Introduction Suicidal thoughts and behaviors most commonly emerge during adolescence. Most suicidal adults report first experiencing suicidal thoughts and behaviors before the age of 18 (Brezo et  al., 2007). Alarmingly, rates of suicidal thoughts and behaviors among adolescents have increased in recent years, especially among racial, ethnic, and sexual minority groups (Kann et  al., 2018; Lindsey et al., 2019). Determining exactly who is at greatest risk for suicide across diverse populations could be especially consequential during this developmental period. How do we determine who is most likely to consider, attempt, or die by suicide? The answer to this question is not immediately obvious. Not all adolescents, who are depressed or suicidal, for instance, proceed to kill themselves. And hospitalizing anyone who is at least remotely at-risk would be both impractical and potentially harmful (Coyle et  al., 2018). Clinicians, despite perceived confidence in their clinical judgments, are in need of standardized tools to aid clinical decision-­ making in order to provide the most efficacious treatment follow-up as possible

(Airey & Iqbal, 2020). Early risk detection using suicide prediction tools may help triage youth to appropriate levels of care and mark a necessary step toward reducing suicide rates. To that end, in this chapter, we discuss psychological measures that have previously been used to help predict suicidal thoughts and behaviors among adolescents—hereafter referred to as suicide prediction tools.1 Here we place particular emphasis, whenever possible, on underrepresented demographic groups. Throughout this chapter we refer to suicidal thoughts and behaviors, which include suicidal ideation, suicide plan, suicide attempt, and death by suicide. This chapter begins with an overview of suicide prediction tools; we outline common individual measures, summarize their corresponding evidence, and evaluate their known generalizability to underrepresented populations. We then introduce several factors to consider when using these tools, including their safety, respondents’ tendency to disclose suicidal thoughts and behaviors, and their application to diverse populations. This chapter concludes with suggested directions for future research. Recent innovations in suicide prediction research have featured the application of risk prediction algorithms to routinely collected clinical data (e.g., electronic medical health records; Walsh et al., 2018; Gordon et al., 2020). Since the scope of this chapter is limited to individual psychological measures, we do not review risk prediction algorithms in detail. However, we reference this scalable and highly promising line of work under Future Directions. 1 

K. M. Tezanos · K.-A. Bell · C. B. Cha (*) Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA e-mail: [email protected]; [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_10

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Nock et  al., 2007; Posner et  al., 2011). The C-SSRS and SITBI are optimal assessments to A myriad of psychological measures has been use when delving into many features of past suiused to predict suicidal thoughts and behaviors cidal thoughts and behaviors. For time-limited among adolescents. These tools tend to come in administrations, shortened versions of these the form of self-report and behavioral mea- interviews have been adapted, along with other sures—some that assess psychological constructs interviews that are deliberately brief (e.g., 4-item directly related to suicide, and some that do not. Ask Suicide-Screening Questions; Horowitz Bearing in mind that adolescents’ experience of et al., 2012). Alternatively, suicidal thoughts and undergoing these assessments may vary by behaviors could be assessed within a comprehendegree of face validity, we review suicide predic- sive diagnostic interview, such as the Kiddie tion tools starting from explicit measures (i.e., Schedule for Affective Disorders and high face validity) to implicit measures (i.e., low Schizophrenia for School-Aged Children-Present face validity). and Lifetime Version (K-SADS-PL; Kaufman et  al., 1997) and the Mini International Neuropsychiatric Interview for Children and Self-Reported Suicidal Thoughts Adolescents (MINI-KID; Sheehan et al., 2010)— and Behaviors with each examining prior engagement in suicidal thoughts and behaviors across distant and Explicit measures most often involve asking an more recent time frames (e.g., lifetime, past individual directly whether they are thinking month). Finally, self-report measures such as the about killing themselves (e.g., Bryan & Rudd, Beck Scale for Suicide Ideation (SSI; Beck & 2006). These tools are typically administered Steer, 1991) and the Suicidal Ideation through interviews and questionnaires and rely Questionnaire (Reynolds, 1987) have been tested heavily on the assessment of current and past sui- in adolescents and examine multiple aspects of cidal thoughts and behaviors. Indeed, assessing recent suicidal ideation (e.g., wish to live, wish to past and current properties of suicidal ideation is die, reasons to live/die, active suicidal ideation, encouraged and recommended at all levels of passive suicidal ideation, reasons for living, suicare (e.g., Bryan & Rudd, 2006; Horowitz et al., cide plan, preparatory actions; Steer et al., 1993). 2014). We outline some of the most common Prior research with adolescents suggests that explicit measures below and summarize their these interviews and questionnaires have some existing empirical support. predictive value. This is the case for predicting One of the most common explicit measure- adolescents’ future suicide attempt, for instance ment approaches is to ask adolescents to recall (e.g., C-SSRS; K-SADS-PL; SIQ; Gipson et al., their past suicidal thoughts and behaviors. 2015; King et  al., 2015; Posner et  al., 2011; Starting with questions about past  suicidal Tuisku et  al., 2014). Some gender effects have thoughts and behaviors may not be met with as been reported, with the SIQ more strongly premuch reluctance or resistance from the respon- dicting future suicide attempt among girls than dent as starting with questions about current sui- boys (i.e., King et  al., 2014). Moreover, very cidal intent (Bryan & Rudd, 2006). Both the brief measures such as the ASQ have been Columbia Suicide Severity Rating Scale reported to predict adolescents’ follow-up emer(C-SSRS; Posner et  al., 2011) and the Self-­ gency department visits for suicide-related chief Injurious Thoughts and Behaviors Interview complaints (Ballard et al., 2017). Of note, other (SITBI; Nock et al., 2007) measure the presence, prominent questionnaires such as the SSI have severity, intensity and frequency of suicidal shown to predict future suicidal ideation, attempt, thoughts and behaviors, and have been validated and death among adults but are not yet tested in for use in adolescent psychiatric populations adolescents (Beck et  al., 1999, Posner et  al., (Conway et  al., 2017; Gratch et  al., in press; 2011). Finally, single-item measures of suicidal

10  Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

ideation can predict future suicide attempt and death in both adult and adolescent samples (Lewinsohn et al., 1994; Simon et al., 2013), but have revealed weaker specificity and may lead to misclassification compared to multi-item assessments (Millner et al., 2015). Few if any studies have tested the predictive validity of these explicit measures among demographically diverse samples. The C-SSRS, for instance, has been tested in predominantly white samples, with limited information on predictive utility for use in racial, ethnic, and sexual minority youth. One notable exception is the SIQ, which was specifically found to predict future suicide attempt among Native American youth (Keane et al., 1996). And very recently, the SITBI has been tested in more racially and ethnically diverse samples, with there being greater parent-­ child discrepancies in the reporting of adolescents’ suicidal ideation and nonsuicidal self-injury among racial minority groups (Bell et  al., in press; Gratch et  al., in press). Taken together, there is a clear need to validate the utility of these measures in diverse samples in order to ensure we are effectively capturing risk among vulnerable populations (for more on this, please refer to the Future Directions section in this chapter).

 elf-Reported Risk and Protective S Factors Directly assessing suicidal thoughts and behaviors is not the only way to identify at-risk adolescents. An alternative approach is to measure non-suicide-related risk and protective factors which are often captured through questionnaires. Among many individual risk and protective factors, several commonly used instruments tested among youth are described below. Risk factors most commonly examined among adolescents include negative internal states such as hopelessness and depressive symptoms (Gould et al., 2003). Hopelessness has been conceptualized as a set of negative perceptions about the self, the world, and the future (Beck et al., 1974), and is most often measured using the Beck

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Hopelessness Scale (BHS; Beck et  al., 1988). Depressive symptoms include sadness, anhedonia, and worthlessness, and are often measured using the Beck Depression Inventory (BDI; Steer & Beck, 1988) and the brief Patient Health Questionnaire (PHQ-9). Prior studies have demonstrated that depressive symptoms and hopelessness can predict future suicidal ideation and attempt in youth (Horwitz et  al., 2017; Huth-­ Bocks et  al., 2007; Soto-Sanz et  al., 2019). Among depression measures, the predictive utility of the full-scale PHQ-9 has been more mixed than the BDI, with some studies showing that the PHQ-9 is predictive of suicide ideation and attempt 3 months after hospital discharge (King et al., 2019), and other studies demonstrating that the PHQ-9 is not predictive of future suicide ideation (Horwitz et  al., 2017). Importantly, the PHQ-9 is one of the most widely used depression measures globally and has demonstrated strong validity and reliability among various racial, ethnic, and sexual minority populations (e.g., Arthurs et  al., 2012; Keum et  al., 2018; Tsai et al., 2014). An alternative approach is to assess for protective factors. Perceived social support is a prominent protective factor assessed among adolescents, most often measured using the Child and Adolescent Social Support Scale (CASSS; Malecki & Demary, 2002) which covers social support across multiple sources—parents, friends, teachers, and classmates. High levels of social support, particularly from family and peers, have been shown to buffer against the effects of depression on suicide ideation (Brausch & Decker, 2014), while low levels of perceived social support are predictive of future suicide attempt among adolescents (Tuisku et al., 2014). Adolescents’ reasons for living (vs. dying by suicide) is another common protective factor and captured using the Reasons for Living Inventory (RFL; Linehan et al., 1983). The RFL has demonstrated predictive utility among psychiatrically hospitalized adolescents, specifically adolescents who self-reported more positive reasons for living were less likely to attempt suicide following discharge, suggesting a buffering effect (Goldston et  al., 2001). Of note, the RFL has been used

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p­ rimarily in white and female samples, and thus generalizability to other client populations is limited at this time.

Composite Self-Report Measures Some risk assessments include a combination of questions about suicidal thoughts and behaviors and non-suicide-related risk and protective factors. They are designed with the intention to directly guide decision-making and connect risk level with subsequent steps. For instance, the Linehan Risk Assessment & Management Protocol (LRAMP; Linehan et  al., 2012) is organized into four steps that take a clinician through the process of identifying and assessing risk through the process of disposition planning and documentation. Embedded into the second step are questions assessing history of suicide attempt, current suicidal ideation, as well as non-suicide-­related risk and protective factors (i.e., hopelessness, high social support, reasons for living). As another example, the Suicide Risk Assessment and Management Decision Tree (DT; Chu et  al., 2015; Gallyer et al., 2020; Joiner et al., 1999) offers a similar approach to risk assessment and management. The DT is a semi-structured, clinician administered interview that assesses past history of suicidal thoughts and behaviors, aspects of current suicidal ideation (such as intent, plan, and desire resolve to act on suicidal thoughts), and empirically validated risk factors (e.g., hopelessness, thwarted belongingness). Through completion of the DT, risk is assessed and categorized into seven categories (i.e., low, low-to-moderate, moderate, moderate-tosevere, severe-to-extreme, or extreme), and based on these categories, appropriate treatment recommendations are offered. These measures offer examples of how to combine elements to create comprehensive risk assessments and have been featured in numerous treatment studies (e.g., Linehan et  al., 2012); however, it is important to note that their prospective predictive validity has not been empirically tested.

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 ehavioral Measures of Suicidal B Thoughts and Behaviors Thus far, we have described and discussed commonly utilized adolescent risk assessment tools that depend on explicit self-report of risk. The accuracy of these tools relies on several assumptions, such that: (1) the respondent is fully and consciously aware of their risk and (2) the respondent is able, willing, and/or motivated to accurately disclose their risk. There are a number of reasons why adolescents may willingly or unwillingly conceal or deny their suicide risk such as fear of being hospitalized as a result of disclosure or simply not being aware of their cognitive and emotional vulnerabilities. Thus, measures that do not rely on explicit self-report may increase the effectiveness of suicide risk assessment. We now turn our attention to risk assessment tools that do not rely on self-report. These tools aim to uncover implicit cognitive processes that place an individual at increased risk for suicidal thoughts and behaviors that are not automatically available to conscious awareness. Implicit cognitive processes are argued to be activated by “traces of past experience [that] affect some performance, even though the influential earlier experience is not remembered in the usual sense—that is, it is unavailable to self-report or introspection” (Greenwald & Banaji, 1995, p. 4). There have been several promising advances in this field of research demonstrating that implicit measures may augment traditional risk assessment procedures. We explain several examples and corresponding evidence below. Implicit suicide prediction tools come in the form of reaction-time tasks that are generally quick to administer (~3–5 min) and can be taken via computer, tablet, or other portable device. The implicit suicide prediction tool that has received the greatest empirical support is the Death Implicit Association Test (IAT; Nock et al., 2010). Respondents are instructed to sort words into categories based on concepts related to their identity (e.g., Me/Not me) and concepts related to suicide and self-injury (e.g., death, suicide). Reaction times on trials when participants are asked to sort words with the pairing of “Me” with

10  Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

“Death” are compared to trials with the pairing “Not me” with “Death.” It is expected that suicidal individuals would have stronger implicit associations with death, and as such their performance when “Me” is paired with “Death” is expected to be faster than when “Not me” is paired with “Death.” Thus far, death- and self-­ injury-­adapted IATs have been shown to prospectively predict suicide ideation in community-based and psychiatric adolescent samples (Glenn et al., 2017a, 2019; Nock & Banaji, 2007). With some exceptions (Glenn et al., 2017a), the IAT remains significantly predictive after controlling for common risk factors (e.g., history of suicidal thoughts and behaviors). It demonstrates fairly high specificity (82–87%) but low sensitivity (23–57%; Glenn et al., 2017b). Studies testing the prediction of suicide attempt suggest that the IAT may be more predictive with community-based adolescents (Glenn et al., 2019), with mixed results among more clinically severe adolescents in hospital and emergency department settings (Millner et al., 2019; Brent et al., 2021; Shin et al., 2021). Finally, the IAT has shown sensitivity to change over time in both adolescent and adult samples (Ellis et  al., 2016; Glenn et  al., 2017b; Millner et  al., 2019; Price et  al., 2009). This finding is important as it suggests that implicit identification with death may vary and be a marker for periods of increased risk in addition to being a potentially malleable marker to target in treatment. Other reaction-time tasks pertaining to suicide have also been developed, though less frequently tested among adolescents. Attentional bias measures assess speed of response to suicide-related vs. -unrelated (e.g., negative, positive, neutral) words, and include the Suicide Stroop Task (Cha et  al., 2010; Williams & Broadbent, 1986) and the Modified Spatial Cuing Task (Baik et  al., 2018). Preliminary evidence points to a possible ability for these tasks to distinguish suicidal ideation and suicide attempt (e.g., Stewart et  al., 2017), but investigations thus far remain cross-­ sectional and more often tested in adults (Baik et  al., 2018; Cha et  al., 2010; Chung & Jeglic, 2017). These same caveats apply to an alternative reaction-time measure that is similar to the IAT,

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known as the Suicide-Affect Misattribution Procedure (S-AMP; Franklin et al., 2016; Tucker et al., 2018; Wells et al., 2020). While implicit measures offer a promising and novel approach to suicide risk assessment, these measures are not currently used in everyday practice for several reasons. First, most studies examining predictive utility of these tools have been conducted with small samples (Nock & Banaji, 2007), studied in specific psychiatric (Glenn et al., 2017a; Stewart et al., 2017) or community settings (Glenn et  al., 2019), and have included primarily white female participants (Glenn et al., 2017a, 2019; Nock & Banaji, 2007; Stewart et  al., 2017). Thus, replication in larger more diverse samples is necessary to enhance generalizability and identify which populations these tools most effectively serve. Second, there is a need to strengthen the psychometric properties of implicit measures. While the IAT demonstrates adequate reliability (e.g., Millner et  al., 2019), the Suicide Stroop task does not (Wilson et  al., 2019). This may help explain the modest sensitivity and specificity that the Suicide Stroop task demonstrates when distinguishing individuals with and without suicidal thoughts and behaviors (Wilson et  al., 2019). Third, it remains unclear what to do should implicit and explicit measures contradict one another. Further testing of these implicit measures is needed to enhance their accuracy, generalizability, reliability, and usability in real-world settings.

 dditional Considerations when A Applying Explicit and Implicit Measures There are an increasing number  of suicide prediction tools, raising the question of which tool is best? There is no single answer to this since studies comparing implicit and explicit measures have revealed mixed findings (e.g., Cha et  al., 2010, 2016a; Nock et  al., 2010). At minimum, the use of each measure has its optimal time and place, leading toward a more timely and practical question: Which factors determine each tool’s optimal “fit” for use? To this end, we discuss

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three considerations when administering the aforementioned assessments: safety, disclosure, and cultural context. Below, we expand on each consideration.

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increase urges to self-injure, do not increase desire to die, and do not decrease mood (Cha et al., 2016b). This was the case across multiple samples and settings, including psychiatrically hospitalized adolescents, in-person college student participants, and web-based adult particiSafety of Suicide Prediction Tools pants. There was a slight, consistent shift from positive to more neutral mood among females but First, a common concern around using suicide pre- not males. Overall however all effect sizes were diction tools is respondent safety and potential risk small, pointing to the conclusion that there are of harm. Directly asking an adolescent about sui- little to no concerns warranted around short-term cide can feel like a delicate endeavor for clinicians iatrogenic effects. and researchers alike. Concerns range from the While iatrogenic effects from explicit and fear of “implanting” thoughts of suicide in adoles- implicit suicide risk assessments are low, adolescents by merely asking about it to the uncertainty cents are a vulnerable population, and safeguards around how to manage disclosed risk (e.g., should be in place for assessing change in suiFeldman et al., 2007; Meerwijk et al., 2010). cidal ideation and intent pre- and post-­ Fortunately, research demonstrates that administration. This could be done efficiently explicitly assessing teens for suicide risk does and safely by monitoring responses to questions neither increase distress nor suicidal thoughts administered both before and after assessment and behaviors (Gould et al., 2005); in fact, high-­ (e.g., Cha et al., 2018). risk youth who completed a suicide risk assessment were less distressed and less suicidal following assessment compared to high-risk The Role of Disclosure in Suicide youth who were not assessed. Similar findings Prediction Tools have emerged among young adults being asked about nonsuicidal self-injury, such that these Explicit suicide prediction tools rely on direct questions do not increase immediate or future disclosure of suicidal thoughts and behaviors to self-injury risk (Muehlenkamp et  al., 2014). others. Although individuals may have thoughts Finally, repeatedly asking adolescents about their about suicide, they might choose not to disclose ongoing suicidal thoughts and behaviors via eco- these thoughts (Blanchard & Farber, 2020; Busch logical momentary assessment (EMA) has been et  al., 2003; Mérelle et  al., 2018; Morrison & shown to not correspond to participation-related Downey, 2000). Indeed, as many as 78% of adverse events or iatrogenic effects during the patients have been found to deny suicidal ide28-day monitoring period (e.g., Glenn et  al., ation before later dying by suicide (Busch et al., 2020). Glenn and colleagues’ recent findings are 2003). Similarly, another study found that only especially notable given that evaluation took 2.8% of ethnic minority youth who were in fact place immediately after acute psychiatric care. experiencing suicidal ideation willingly disSimilar work in adult populations has also dem- closed these thoughts to a mental health profesonstrated that repeated assessment of suicidal sional (Morrison & Downey, 2000). Taken thoughts through EMA, sometimes multiple together, it can be concluded that there is a subset times per day, was not associated with increased of people who could be at risk for suicide, but do severity of suicidal ideation (Coppersmith et al., not self-disclose and therefore  their risk is left 2020). undetected. When specifically considering implicit meaThose suicidal youth who choose not to dissures of risk, where adolescents are shown close their suicidal thoughts may be the very ones images or words pertaining to suicide and death, in need of greater clinical attention (Apter et al., research has indicated that these stimuli do not 2001). Specifically, nondisclosure has been asso-

10  Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

ciated with more severe forms of suicidal behavior, in that people with lower levels of overall self-disclosure report more severe suicidal thoughts and behaviors (Horesh et  al., 2004). Specifically, low levels of overall self-disclosure, and self-disclosure to family and older adults corresponded with increased levels of suicidal ideation and more severe forms of suicidal behavior among adolescents. Additionally, lower self-­ disclosure also correlated with other psychological constructs related to suicide such as repulsion by life and attraction to death (Horesh et  al., 2004). Moreover, nondisclosure has been found to be associated with decreased help-seeking, increased loneliness and withdrawal, increased distress, and increased likelihood of suicide attempt (Apter et  al., 1993, 2001; Levi et  al., 2008, Mérelle et al., 2018). Adolescents may choose to conceal their thoughts of suicide for various reasons. First, stigma has been identified as an impetus for concealing suicidal thoughts and behaviors. Research has found that mental health stigma is a commonly reported factor in nondisclosure of suicidal thoughts and behaviors (Denmark et  al., 2012; Sheehan et  al., 2017, 2019). Previously experienced stigma, anticipated stigma, internalized stigma, and fear of stigma have all been found to affect one’s decision to reveal their presence, and history, of suicidal ideation (Blanchard & Farber, 2020; Sheehan et  al., 2019). Second, youth may perceive themselves as being at  low risk for attempting suicide. Low-risk perception is another deterrent of youth nondisclosure of suicidal thoughts and behaviors (e.g., “I hoped that they would just go away on their own as they have in the past”; Denmark et al., 2012). Third, adolescents may fear the consequences of self-­ disclosure. These consequences, namely involuntary hospitalization and leave of absence from school, could be extremely disruptive and have academic and social repercussions (Denmark et al., 2012; Sheehan et al., 2019). Indeed, many individuals who deliberately concealed suicidal thoughts from their therapist report that they would have been more inclined to self-disclose had the threat of hospitalization been reduced (Blanchard & Farber, 2020).

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Adolescents’ disclosure of suicidal thoughts and behaviors to their caregivers may be especially critical, as parents/guardians are key gatekeepers to treatment access (Goldston et  al., 2008). However, evidence thus far suggests that caregiver-youth agreement on suicidal thoughts and behaviors ranges from poor to fair (Gratch et al., in press; Jones et al., 2019; Klaus et al., 2009). Specifically, youth-reported history of suicidal thoughts and behaviors are often unknown or unreported by their caregivers (Deville et al., 2020; Gratch et al., in press; Jones et  al., 2019; Klaus et  al., 2009). Alarmingly, youth belonging to ethnic and racial minority groups may be even less likely to share their suicidal thoughts and behaviors with their caregivers. Recent work has shown that youth belonging to ethnic and racial minority groups may be especially less likely to selfdisclose their history of suicidal thoughts or behaviors (Anderson et al., 2015; Bell et al., in press; Chu et  al., 2018; Morrison & Downey, 2000). Consistent with the aforementioned research on correlates of self-disclosure, racial/ ethnic minority youth who choose to conceal their suicidal thoughts and behaviors have higher levels of reported suicidal thoughts and behaviors than youth who disclose to family, older adults, and friends (Apter et  al., 2001; Chu et  al., 2018; Morrison & Downey, 2000). Furthermore, caregiver-­youth dyads belonging to racial minority groups tend  to display a greater degree of disagreement on the child’s thoughts of suicide when compared to white caregiver-youth dyads (Bell et  al., in press; Jones et al., 2019; Kim et al., 2016). These findings highlight potential disparities in suicidal self-disclosure among youth as a function of race and ethnicity. Although there is great value in directly asking questions about suicide, there remain questions around what information might be missed. Additional steps may be required to adapt explicit suicide prediction tools. Achieving more comprehensive batteries of suicide prediction tools, such as the use of validated composite measures or integrating implicit measures, may also augment explicit self-report.

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The Cultural Context around Suicide Prediction Tools

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role of moral disapproval of suicide; Bender, 2000; Morrison & Downey, 2000; Neeleman et al., 1998), Asian American and Latinx (e.g., Considering that the most common suicide pre- family conflict as a relatively heightened diction tools are explicit measures, there is a need stressor; Cheng et al., 2010; Garcia et al., 2008; to ensure that this assessment approach is useful Queralt, 1993), and LGBTQ+ (e.g., bullying, for all. Culture plays an integral role in not only loss of friends as a result of disclosing sexual the manifestation but also the expression of sui- orientation; Bontempo & D’Augelli, 2002; cidal thoughts and behaviors (Chu et al., 2010). D’Augelli, 2002; Friedman et al., 2006). Considering this, and especially relevant to The Cultural Assessment of Risk for Suicide explicit suicide prediction tools, it remains Scale (CARS; Chu et al., 2013) is a correspondimperative to understand how best to  assess ing instrument that channels cultural compeyouth from diverse backgrounds. Indeed, the sui- tence and humility into practice. The CARS, cide risk literature has been shown to insuffi- meant to be used to supplement existing explicit ciently account for sociodemographic diversity suicide prediction tools, captures cultural varia(Cha et al., 2018). And few, if any, culturally sen- tion in the expression of suicide risk and sitive measures of suicide- and non-suicide-­ assesses the aforementioned four cultural risk related risk and protective factors exist. In the categories (Chu et  al., 2013). This self-report absence of sufficient cultural sensitivity, here we measure was developed to guide providers in discuss aspirational models that may help inform integrating cultural factors into risk assessment. the design and implementation of explicit suicide The scale consists of eight subscales: family prediction tools in the future. conflict, social support, sexual minority stress, The Cultural Theory and Model of Suicide is acculturative stress, nonspecific minority stress, a framework that adopts cultural competence emotional/somatic idioms of distress, suicidal and humility to improve understanding and action idioms of distress, and cultural sancinclusiveness in assessing the risk of suicide tions. Interpretation of scores is somewhat (Chu et  al., 2010). The model was informed nuanced in that although higher total scores sigusing four prevalent cultural categories of sui- nify greater suicide risk, providers are encourcide risk that differ as a function of race, ethnic- aged to attend to elevated subscale  scores and ity, sexual orientation, gender expression, etc. determine culturally specific indicators of sui(Chu et al., 2010). The four categories include: cide risk (Chu et al., 2013). (1) cultural sanctions, which refer to the attiThe CARS has preliminary evidence based on tudes and beliefs held by a community about adult samples. Such studies have demonstrated suicide (e.g., moral disapproval of suicide); (2) both internal consistency and convergent validity idioms of distress, which refer to how suicide when compared with explicit measures of suisymptoms manifest and are expressed among cidal ideation and non-suicide-related risk factors group members (e.g., expression of suicidal (e.g., BDI, BHS, SSI; Chu et al., 2013). The identhoughts, or lack thereof); (3) minority stress, tification of the aforementioned risk factors which refers to unique stress experienced by resulted in the curation of a culturally informed minority group members that are directly related approach to a risk management plan (Chu et al., to their identity (e.g., discrimination); and (4) 2017). Recent work suggests that the CARS capsocial discord, which refers to potential conflict tures unique cultural correlates of suicidal or ostracization from other minority group thoughts and behaviors such as minority stress members (e.g., lack of connectedness with and family conflict, as well as cultural idioms of group members). These could be highly relevant distress which can mediate such associations to suicidal thoughts and behaviors among ado- (Chu et  al., 2020). Future steps, as encouraged lescents belonging to minority groups identify- further below, would help inform the use of such ing as Black/African American (e.g., protective a measure with younger populations.

10  Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

 uture Directions in Youth Suicide F Risk Assessment In the previous sections, we have reviewed some of the most widely utilized tools in the assessment and prediction of suicide risk among youth; we outlined their strengths along with their limitations. We now pause to remind readers of the alarming fact that the rate of death by suicide continues to rise in this age group, along with rates of crisis service utilization (CDC, 2018). This tells us that the current methods for assessing and predicting risk are in need of further attunement and refinement. There are several critical steps that must be taken to strengthen current risk assessment practices to improve our ability to identify and help at-risk youth. Here we propose five key approaches that may help increase the predictive utility of risk assessments among youth. First, we recommend testing the predictive validity of suicide prediction tools with more demographically diverse samples. Recent systematic reviews have observed that key demographic characteristics, including those that have been shown to mark increased risk, are disproportionately underaccounted for in the suicide risk literature (e.g., race, ethnicity, sexual orientation; Cha et  al., 2018). Commonly used risk assessments have been formulated and validated with homogenous, mostly white, samples. Considering the increasing rates of suicide among racial minority groups, namely Black youth (Bridge et al., 2015; Sheftall et al., in press, future work on suicide risk and suicide prediction tools with adolescents are encouraged to more deliberately consider representativeness of samples. It is imperative to validate suicide risk assessments for use with diverse populations. Second, culturally sensitive measures should be further tested and adapted to youth whenever appropriate. The aforementioned CARS measure, for instance, shows promise for formulating and using a suicide risk assessment made specifically for culturally diverse populations (Chu et al., 2013, 2017). This has yet to be adapted for and tested with adolescents. Future work is also  encouraged to compare culturally sensitive

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assessments with traditional suicide prediction tools to test incremental predictive validity. Finally, it is not enough to solely design culturally competent suicide risk assessments; cultural competence extends to persons administering the measures as well. Training clinicians to practice cultural humility is an essential component to not only treating, but also assessing patients of diverse backgrounds. Third, multiple informants should be taken into account when assessing suicide risk among youth. A multi-informant approach may increase the usability and predictive utility of risk assessments among youth. While parent-child agreement for suicidal thoughts and behaviors tend to be low-to-moderate (Gratch et al., in press; Jones et al., 2019; Klaus et al., 2009), parent-child discrepancies could potentially be utilized to improve the validity of risk assessments (De Los Reyes & Kazdin, 2005; Kazdin, 1994; Kraemer et  al., 2003). Specifically, recent work supports the notion that a systematic integration of multiple informants, discrepant reports, via a trait-­ score approach, improves the predictive validity of clinical outcomes above and beyond single-­ informant reports (Makol et al., 2020). Similarly, different informant reports could be predictive of future suicidal thoughts and behaviors. Indeed, parent-reported internalizing and externalizing risk factors have been found to be related to future adolescent suicidal ideation, suicide planning, and suicide attempts (Connor & Rueter, 2009). Therefore, it may be beneficial for suicide risk assessments to incorporate parent/caregiver reports as well, regardless of concordance with self-reports from the youth. Fourth, more interpretable and standardized scoring systems are needed to improve the utility of explicit and implicit suicide prediction tools. With some exceptions (e.g., SIQ; C-SSRS; Reynolds, 1987; Posner et al., 2007), explicit and implicit measures do not offer standardized scoring and interpretation procedures (e.g., SSI; K-SADS-PL; Beck & Steer, 1991; Kaufman et al., 1997). For example, to date implicit suicide prediction tools use a variety of scoring methods for the suicide-related IATs and the Suicide Stroop Task (Millner et al., 2019; Wilson et al.,

K. M. Tezanos et al.

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2019). By establishing standardized scoring, interpretation, and risk management procedures, clinicians may be better equipped to identify, triage, and administer life-saving interventions to at-risk suicidal adolescents. To achieve this, studies with large and diverse samples will be needed in order to determine clinical cut-offs and to test the most appropriate and effective risk management procedures. The field can look to successes outside of psychology, in which standardized scoring systems have helped clinicians identify and triage high-risk patients more consistently and efficiently with corresponding guidelines established for follow-up care (e.g., Apgar scores for birth outcomes; the Glasgow Coma Scale for profundity of loss of consciousness). On a separate but related note, the overwhelming majority of risk assessments do not offer guidelines for managing risk identified through completion of the assessment. Some exceptions exist (e.g., LRAMP, DT; Gallyer et al., 2020; Linehan et al., 2012), but they require further validation. Fifth, greater integration of suicide prediction tools is strongly encouraged. Prior work has been comprised of focused examinations of one or very few suicide prediction tools. This has yielded modest predictive strength of suicidal thoughts and behaviors among adolescents and adults alike (Franklin et al., 2017). Suicide death and suicide attempts are complex, multidetermined outcomes whose predictions may be optimally achieved through the consideration of many more risk factors and assessments than previously examined (Ribeiro et  al., 2016). Computational approaches such as machine learning make possible the pursuit of such prediction models among adolescents (Just et  al., 2017; Walsh et  al., 2018). Thus far, research in this area has been promising and may complement traditional risk assessment protocols in handling the most possible data to determine risk profiles and assist in disposition planning for suicidal individuals. Finally, building on the previous points, we as a field are in need of person-specific, shorter-­ term prediction models that assess the various explicit and implicit factors that contribute to risk. While we know that there are certain win-

dows of heightened risk (e.g., first month following hospital discharge; Meehan et  al., 2006), more precisely identifying when individuals will seriously consider or attempt suicide eludes current risk models. This has largely been due to constraints of traditional data collection methods (e.g., retrospective data collected in laboratory or hospital settings) and a focus on between-person differences. This could be achieved through ecological momentary assessment (EMA), which repeatedly assesses individuals’ current experiences and behaviors, as they occur in real-time and in their environment. Data are generally collected and pooled through survey applications on smartphones, physiological monitoring, and/or through the phones’ background processing systems (e.g., geolocation, biometric data, and passive data monitoring). Consequently, the presence of explicit (e.g., EMA survey responses) and implicit (e.g., actigraphy data) risk factors could be assessed simultaneously and in real-time. A compelling example of integrating explicit and implicit inputs to generate short-term risk models comes from a study conducted in the United Kingdom in which authors paired implicit data collected from actigraphs (i.e., noninvasive devices, worn like a wristwatch, that monitor physiological activity such as skin conductance and heart rate) with sleep assessments administered via daily EMA surveys (Littlewood et  al., 2019). Authors were able to generate short-term risk models based on within-person variances of sleep-related implicit and explicit assessments in predicting next day suicide ideation severity (Littlewood et al., 2019). This type of work offers exciting hope about being able to improve our ability to detect not only who is at risk, but also when they are imminently at risk.

Conclusion Suicide prediction tools are intended to efficiently and accurately inform triage and follow­up care. As detailed throughout this chapter, there are benefits to both explicit and implicit measurement of risk. We do not suggest that one or the other risk assessment method is superior, but

10  Using Implicit and Explicit Measures to Predict Suicidal Behavior Among Adolescents

rather encourage future research to test both the fit of individual measures and the combination of multiple measures. This approach is bound to yield a more rich and complete picture of suicide risk thus enhancing triage and treatment recommendations for diverse adolescent populations.

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Journal of Consulting and Clinical Letter to the Editor: Suicide as a complex classificaPsychology, 61(6), 1096–1099. https://doi. tion problem: Machine learning and related techniques org/10.1037/0022-­006X.61.6.1096 can advance suicide prediction – A reply to Roaldset Stewart, J. G., Glenn, C. R., Esposito, E. C., Cha, C. B., (2016). Psychological Medicine, 46(9), 2009–2010. Nock, M.  K., & Auerbach, R.  P. (2017). Cognitive https://doi.org/10.1017/S0033291716000611 control deficits differentiate adolescent suicide Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., ideators from attempters. The Journal of Clinical Bannon, Y., Rogers, J. E., Milo, K. M., Stock, S. L., Psychiatry, 78(6), 614–621. https://doi.org/10.4088/ & Wilkinson, B. (2010). Reliability and validity of JCP.16m10647 the Mini Internaitonal Neuropsychiatric Interview Tsai, F.-J., Huang, Y.-H., Liu, H.-C., Huang, K.-Y., for Children and Adolescents (MINI-KID). Journal Huang, Y.-H., & Liu, S.-I. (2014). 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Part III Specific Populations

Understanding Risk and Protective Factors to Improve Well-Being and Prevent Suicide Among LGBTQ Youth

11

Amy E. Green, Lindsay A. Taliaferro, and Myeshia N. Price

Introduction Lesbian, gay, bisexual, transgender and nonbinary, queer, and questioning (LGBTQ1) youth face disparities in suicide risk compared to their non-LGBTQ peers. Research has documented that LGBTQ youth report significantly higher rates of seriously considering suicide, planning to attempt suicide, and attempting suicide compared to straight and/or cisgender youth (Johns et  al., 2020; Marshal et al., 2013; Toomey et al., 2018b). These disparities in suicidal thoughts and behaviors are linked to stressors and discrimination associated with being in a socially stigmatized position in society (Meyer, 2003), as opposed to being LGBTQ in and of itself. National prevalence studies have only recently begun to include items on sexual orientation and gender identity. In 2015, the Centers for Disease Control and Prevention (CDC) included a question in the Youth Risk Behavior Survey (YRBS) The term LGBTQ is used as an umbrella term in this chapter to describe individuals who identify with a diverse range of sexual and gender identities, including those who use labels beyond those captured by this acronym.

1 

A. E. Green () · M. N. Price The Trevor Project, West Hollywood, CA, USA e-mail: [email protected]; [email protected] L. A. Taliaferro University of Central Florida, Orlando, FL, USA e-mail: [email protected]

to ascertain sexual identity in the standard questionnaire used by states and large urban school districts. Based on data from 2019, 2.5% of high school students identified as gay or lesbian, 8.7% identified as bisexual, and 4.5% were not sure of their sexual identity (Underwood et  al., 2020). The inclusion of sexual identity measures was crucial for documenting adverse mental health indicators among lesbian, gay, and bisexual high school students. For example, researchers found that lesbian, gay, and bisexual high school students attempted suicide during the previous 12  months at more than four times the rate of their straight peers (Johns et al., 2020). In 2017, ten states and nine large urban school districts included a question in their YRBS to measure the proportion of high school students who identify as transgender. Results showed that 1.8% of students identified as transgender and 1.6% were not sure whether they were transgender (Johns et al., 2019). Further, transgender students who completed the YRBS were nearly five times more likely to report attempting suicide in the past 12 months compared to cisgender students. Research on LGBTQ youth suicide risk focuses on cognitive (e.g., suicidal thoughts) and behavioral (e.g., suicide attempts) indicators, but not on suicide deaths. Although efforts are in place to promote valid and reliable data collection on sexual orientation and gender identity as part of violent death reporting, these data are not yet available (Haas et  al., 2019). As such, this

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_11

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review excludes data on factors specific to death by suicide among LGBTQ youth. Using the Minority Stress Model as a framework, this chapter reviews existing research on factors that are associated with suicidal thoughts and behaviors among LGBTQ youth, focusing on risk and protective factors at the individual, relational, and community levels. Given the intersectional nature of LGBTQ identities, this review also highlights within-group differences in suicidal thoughts and behaviors among members of the LGBTQ community. Finally, although there remains a lack of evidence-based interventions to address suicide risk among LGBTQ youth, promising practices are reviewed, with recommendations for future research and practice.

Core Theoretical Frameworks During adolescence, a number of developmental challenges occur as individuals struggle to understand their identities (Steinberg, 2008). These challenges are compounded for LGBTQ youth who must also navigate their sexuality and gender identities, including disclosure and fears of rejection and victimization. The Minority Stress Model suggests processes that occur along a continuum of distal stressors (i.e., external stressful events and conditions) to proximal stressors (i.e., the internalization of negative messages and experiences) impact the mental health of LGBTQ individuals (Meyer, 2003). The Minority Stress Model was originally conceptualized to explain minority stress in relation to sexual orientation, but the model has been adapted to reflect minority stress processes in relation to gender identity as well (Hendricks & Testa, 2012). For LGBTQ youth, distal stressors include experiences of rejection, victimization, and discrimination relating to their LGBTQ identity (Bradford et  al., 2013; Kosciw et al., 2018), while proximal stressors include internalized LGBTQ stigma, expectations of rejection, and concealment of their LGBTQ identity. Facing these stigmatizing stressors, in combination with more typical daily adolescent stressors, leads to diminished psychological well-being and increased risk for suicide.

However, the model also allows for a resilience framework (Meyer, 2015), highlighting the role of social support, coping, and identity strengths in buffering the impact of stressors on mental health outcomes. Processes highlighted in the Minority Stress Model can also be applied to explain how thwarted belongingness (i.e., loneliness resulting from a lack of caring connections with others) and perceived burdensomeness (i.e., the belief that one is a burden to society or others in their life), core elements of the Interpersonal Theory of Suicide, may operate among LGBTQ youth (Joiner, 2005). For LGBTQ youth, the distal stressors of rejection and victimization may lead to ostracism and feelings of loneliness that are core to thwarted belongingness. Additionally, the proximal stressors of internalized stigma and fears related to concealment and coming out may result in LGBTQ youth’s experiences of perceived burdensomeness to others. A recent study of LGBTQ youth found that minority stress was significantly associated with both perceived burdensomeness and thwarted belongingness, with a significant direct path between minority stress and attempting suicide, as well as a significant indirect path mediated by perceived burdensomeness and thwarted belongingness (Fulginiti et al., 2020). Together, the Minority Stress Model and Interpersonal Theory of Suicide provide useful frameworks to understand risk and protective factors at individual, relational, and community levels specific to LGBTQ youth, as well as how intersectional identities within the LGBTQ community can impact risk for experiencing suicidal thoughts and behaviors.

Within-Group Differences In thinking about LGBTQ youth suicide, there are important within-group differences to consider (O’Brien et al., 2016). LGBTQ youth represent an array of diverse sexual and gender identities, who come from every racial and ethnic group. A review of LGBTQ youth mental health and suicide research noted that the current knowledge base needs to be expanded to better understand how

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LGBTQ identity is intersectionally situated across racial and ethnic identities (Russell & Fish, 2016). Intersectionality is a framework for understanding how interdependent and multidimensional social identities at the individual level, such as race/ethnicity, gender, and sexuality, are shaped by interlocking systems of privilege and oppression at the societal level, such as heterosexism, cisgenderism, and racism (Crenshaw, 1991). This intersection of identities may, in turn, present distinct stressors for some LGBTQ youth compared to others, and minority stress may be most persistent and problematic for youth who occupy multiple marginalized social positions (Cyrus, 2017). That said, largely due to sample size limitations, researchers often fail to examine within-group differences among LGBTQ youth, limiting our understanding of within-group disparities in suicidal thoughts and behaviors. However, existing research points to increased disparities for bisexual youth, transgender and nonbinary youth, and LGBTQ youth of color. Bisexual youth make up a substantial proportion of youth who are part of the LGBTQ community, with prevalence data suggesting almost twice as many LGBTQ youth identify as bisexual compared to lesbian or gay (Underwood et  al., 2020). Bisexual youth may experience stigma from both the majority population, for having an identity that is not heterosexual, and from within the LGBTQ community, for not having exclusive same-gender relationships and attractions (Callis, 2013). Youth who are bisexual may also have less access to protective factors, such as family and school connectedness, even when compared to gay or lesbian youth (Saewyc et al., 2009). While there are few studies examining suicidal behavior specific to bisexual youth, existing studies find that bisexual youth often experience more risk factors for suicide such as sexual abuse, intimate partner violence, and bullying victimization (Pathela & Schillinger, 2010; Phillips et  al., 2017). Bisexual youth also report higher rates of depressive mood, seriously considering suicide, and attempted suicide (Johns et  al., 2020; The Trevor Project, 2019b), compared to their gay and lesbian peers. Future research should focus on examining within-group differences in sexual

orientation among LGBTQ youth to fully capture the unique risks and protective factors for suicide, particularly among bisexual youth. Transgender and nonbinary youth also face unique challenges and elevated risk of suicidal thoughts and behaviors compared to their cisgender peers. Given that transgender and nonbinary youth may occupy marginalized identities for both their sexual and gender identities, among other identities, they may be more susceptible to increased risk factors, and, therefore, increased rates of suicidal thoughts and behaviors (Testa et  al., 2017). For example, identification with a non-heterosexual identity may further exacerbate the risk of attempted suicide for transgender youth (Toomey et  al., 2018b). Indeed, transgender and nonbinary youth report increased mental health disparities compared to cisgender youth (Johns et al., 2019) and even compared to their cisgender LGBQ peers (Price-Feeney et  al., 2020). Transgender and nonbinary youth may also experience gender dysphoria when a person experiences discomfort and distress between their assigned gender and their gender identity, which increases the risk for attempting suicide (Peterson et al., 2017). Important differences in suicide risk also exist within transgender and nonbinary identities, with two recent studies both finding that youth who identified as transgender men reported the highest rates of attempting suicide compared to other gender identities within the LGBTQ community (Price-Feeney et al., 2020; Toomey et al., 2018b). More research should examine specific outcomes for transgender and nonbinary youth as well as the heterogeneity within this population. LGBTQ youth also come from every racial and ethnic background, including those that may place them at increased risk due to their stigmatized location in society. Just as with transgender and nonbinary youth, LGBTQ youth who are racial or ethnic minorities may experience challenges that are even more striking than LGBTQ youth who are not. Stressors faced by racial and ethnic minorities in the United States have long been documented in the literature and include, but are not limited to, higher rates of discrimination (Seaton et al., 2008) and victimization (Kilpatrick et  al., 2003), and a higher likelihood of referral to the juvenile justice

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system rather than mental health treatment (Voisin et  al., 2017). These stressors may then combine with those related to being LGBTQ, placing these youth at higher risk for poor mental health outcomes than youth without multiple marginalized identities. Indeed, researchers found that Black and Latinx youth subjected to multiple forms of discrimination, such as race, class, and gender discrimination, have mental and physical health outcomes above the effect of one form of discrimination (Grollman, 2012). In a recent report, Latinx LGBTQ youth had 30% greater odds of reporting a suicide attempt in the past year compared to nonLatinx LGBTQ youth. Nearly half of these Latinx LGBTQ youth reported worrying about themselves or a family member being detained or deported due to immigration policies, and these worries accounted for the greater odds of attempting suicide compared to non-Latinx youth (The Trevor Project, 2020b). In addition to Latinx LGBTQ youth, Black LGBTQ youth and American Indian/ Alaskan Native LGBTQ youth also report higher rates of attempted suicide (The Trevor Project, 2019c). Future examinations of suicidal behavior among LGBTQ youth must do better to understand the experiences of LGBTQ youth of color and how to best address their unique needs in suicide prevention.

Risk Factors The existing literature on LGBTQ youth focuses primarily on factors that are associated with greater risk for suicide. Although general risk factors for suicide, such as intimate partner violence and sexual assault, also apply to LGBTQ youth (Hatchel et al., 2019), this review focuses on LGBTQ-specific risk factors at the individual (internalized stigma and coming-out distress), relational (negative experiences with family and peers), and community levels.

Internalized Stigma LGBTQ youth generally develop in a heteronormative and cisgender-normative environment in

which individuals are assumed to be straight or heterosexual by default, with their gender completely aligning with the sex they were assigned at birth. As such, they often receive messages of invalidation and rejection for their LGBTQ identity. These experiences can result in a negative internalized view of one’s own or others’ sexual or gender identities. Youth who experience internalized stigma, guilt, or shame about their LGBTQ identity show increased risk for psychological distress and suicide attempts (Puckett et  al., 2017). For example, in one study of LGBTQ youth, a higher rate of internalized LGBTQ stigma was associated with both greater odds of reporting suicidal thoughts in the past month and reporting more chronic suicidal thoughts compared to fleeting thoughts about suicide (Gibbs & Goldbach, 2015). Internalized stigma may be particularly problematic for youth who are exposed to environments that are more rejecting of LGBTQ identities, such as more conservative geographic regions (Puckett et  al., 2017) and non-LGBTQ-affirming religious communities (Gibbs & Goldbach, 2015). Although few studies have specifically examined internalized LGBTQ stigma among youth, in line with the Minority Stress Model, it has been consistently associated with greater suicidal thoughts and behaviors.

Coming-Out Distress The process of disclosing one’s LGBTQ identity to others and facing potential judgment and rejection represents another form of minority stress (Meyer, 2003). Actual and anticipated negative reactions to disclosing one’s LGBTQ identity are related to greater levels of perceived burdensomeness among LGBTQ youth (Baams et  al., 2015). Additionally, among LGBTQ adults, the stress of LGBTQ identity concealment has been related to increases in anxiety and depression, as measured through ecological momentary ­assessment (Livingston et al., 2020). In one study of lesbian, gay, and bisexual youth, the relationship between coming-out stress and suicidal thoughts was partially mediated by perceived

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burdensomeness. However, this significant relationship was only found among lesbian, gay, and bisexual girls, despite gay and bisexual boys being more likely to report coming-out stress (Baams et  al., 2015). As boys also reported the highest rates of victimization, the study’s authors hypothesized that victimization experiences may overpower the role of coming-out stress for boys, whereas girls may be more sensitive to how their coming out may impact others, increasing the saliences of perceived burdensomeness for LGB girls. To date, there remains a lack of research on relationships between coming-out distress and suicidal thoughts and behaviors among transgender and nonbinary youth, who may experience unique risks around disclosing their gender identity. Given the stressors associated with identity concealment and fears of rejection, there is a need for future research on how the coming-out process impacts suicidal thoughts and behaviors among diverse subgroups of LGBTQ youth.

Family Rejection A review of literature examining sexual identity development among lesbian, gay, and bisexual adolescents found that one-third of youth experience parental rejection when disclosing their sexual orientation, another one-third experience parental acceptance, and the remaining third do not disclose their sexual orientation until later in life (Rosario & Schrimshaw, 2013). In a study of transgender individuals, nearly 40% of transgender young adults ages 18–24 experienced rejection from their families as a result of their gender identity or expression (Klein & Golub, 2016). Studies have shown that parental rejection of LGBTQ youths’ identities predicted suicidal thoughts and behaviors (Klein & Golub, 2016; Ryan et  al., 2009). One study found that those who experienced frequent rejecting behaviors by their parents during adolescence had over eight times greater odds of reporting a suicide attempt than those with accepting parents (Ryan et  al., 2009). Researchers found that early openness about sexual orientation with their families, being considered gender atypical in childhood by par-

ents, and parental efforts to discourage gender atypical behavior were associated with sexual orientation-related suicide attempts among lesbian, gay, and bisexual youth (D’Augelli et  al., 2005). Although parental rejection has been strongly associated with suicidal thoughts and behaviors among transgender and nonbinary adults (Klein & Golub, 2016), there is a need for additional youth-specific research. The literature suggests robust relationships between parental rejection and suicidal thoughts and behaviors among LGBTQ youth; however, further attention to intersectionality within this body of research is warranted to better inform prevention and intervention strategies.

LGBTQ-Based Discrimination and Victimization Discrimination and victimization are among the most empirically supported correlates of suicidal thoughts and behaviors among youth (Hatchel et  al., 2019). LGBTQ youth experience greater rates of bullying and victimization compared to their heterosexual and cisgender peers (Toomey & Russell, 2016), including biased-based bullying and victimization focused on their LGBTQ identity (Russell et al., 2012). Results from The Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health found that one in three LGBTQ youth were physically threatened or harmed due to their LGBTQ identity, and 60% experienced discrimination due to their LGBTQ identity (The Trevor Project, 2020a). These experiences of LGBTQ-based discrimination and victimization contribute to minority stress. For LGBTQ youth, peer victimization based on their LGBTQ identity may have stronger associations with suicidal thoughts and attempts than non-­ biased-­ based victimization experiences (Poteat et  al., 2011; Russell et  al., 2012). In examining mediators of relationships between LGBTQ-­ based discrimination and victimization and ­suicidal thoughts and behaviors, strong support has been found for the role of perceived burdensomeness, with thwarted belongingness playing less of a role when both variables are examined

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together (Baams et  al., 2015; Mitchell et  al., 2018). These findings indicate that conversations around peer victimization of LGBTQ youth need to include not only how it relates to social isolation, but also how these experiences may contribute to LGBTQ youth’s perceptions that they are a burden on others in their lives, and in turn, risk for suicide.

LGBTQ Conversion Efforts Efforts to convince LGBTQ youth to change so they are cisgender and/or straight constitute a particularly harmful form of rejection based on one’s LGBTQ identity. Recent research has highlighted strong associations between exposure to conversion efforts and attempting suicide. For example, Ryan and colleagues’ study of LGBT young adults found that those who reported parent-­initiated efforts to change their sexual orientation during adolescence had more than three times higher odds of reporting a suicide attempt than those who did not experience this type of conversion effort (Ryan et al., 2018). Further, LGBT youth who reported both parentinitiated and formal conversion efforts conducted by therapists or religious leaders had over five times higher odds of attempting suicide than those who had not experienced conversion or change efforts. The findings of another study involving data from more than 27,000 transgender adults found that undergoing gender identity conversion efforts before age 10 resulted in a more than four-fold adjusted odds of a suicide attempt (Turban et al., 2020a). Finally, a recent study of LGBTQ youth ages 13–24 found that those who reported undergoing sexual orientation or gender identity-based conversion efforts had more than two times greater odds of attempting suicide and having multiple suicide attempts, even after adjusting for other known risk factors, including LGBTQ-­ based victimization and discrimination (Green et al., 2020). When taken together, these studies establish a significant positive association between exposure to conversion efforts and suicide attempts among LGBTQ youth.

Community-Level Factors Events and policies that restrict LGBTQ rights are also associated with suicidal thoughts and behaviors among LGBTQ youth. For example, one study found that lesbian, gay, and bisexual youth who resided in a neighborhood with higher recent LGBTQ hate crime rates reported greater rates of considering or attempting suicide, a trend not found for heterosexual youth residing in the same neighborhood, compared to those who lived in a different neighborhood (Duncan & Hatzenbuehler, 2014). Further, suicidal thoughts and suicide attempts among lesbian, gay, and bisexual youth were not found to increase in neighborhoods with greater overall violent and property crimes, suggesting that the results were specific to LGBTQ hate crimes. Another study found that lesbian and gay youth who lived in counties with fewer LGBTQ-specific anti-­ bullying policies had double the odds of attempting suicide compared to those who lived in counties with more LGBTQ-specific anti-­ bullying policies (Hatzenbuehler & Keyes, 2013). For transgender and nonbinary youth, denial of access to gender-affirming resources and spaces presents an additional community-level concern. For example, transgender and nonbinary youth report challenges using public bathrooms and feeling unsafe in public bathrooms (Porta et al., 2017). Although there remains a dearth of research on the association between these experiences and suicidal thoughts and behaviors among transgender and nonbinary youth, researchers found that denial of transgender college students’ access to bathrooms or housing was significantly related to attempting suicide, even after controlling for interpersonal victimization (Seelman, 2016). Such findings highlight ways the broader ecological environment may be associated with LGBTQ youth suicide risk.

Protective Factors Although much of the research to date on LGBTQ youth suicide has focused on negative factors associated with greater suicide risk, compared to

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positive factors related to lower suicide risk (Hatchel et al., 2019), a number of studies have explored aspects of social support and coping skills. This review focuses on positive factors at the individual (positive identity attitudes and coping skills), relational (supportive and accepting relationships with others), and community (supportive spaces and policies) levels.

Positive Identity Possessing positive attitudes about one’s sexual and gender identity enhances resilience and protects against suicidal thoughts and behaviors among LGBTQ youth, even in the context of minority stressors, given that having a positive view of oneself facilitates well-being (Gilman & Huebner, 2006; Keyes, 1998; Mann et al., 2004). Facets of a positive sexual identity, such as identity authenticity, affirmation, and centrality, are related to increased satisfaction with life and lower depression symptoms (Riggle et al., 2014, 2017; Riggle & Rostosky, 2012). Studies show the ability to authentically express one’s identity is important to mental well-being in heterogeneous LGBTQ samples (Harter, 2005; Lehavot & Simoni, 2011; Riggle & Rostosky, 2012). Further, researchers found that positive identity was related to improvements in mental health and reductions in internalized stigma among LGBTQ young people (Mohr & Sarno, 2016). As suggested by the Minority Stress Model, this research indicates that identity strengths should be examined in efforts to address suicide risk among LGBTQ youth.

focused groups or organizations and inclusive spaces (Jones & Hillier, 2013; Kosciw et  al., 2018), as well as LGBTQ adult mentors (Asakura, 2016; Bird et al., 2012). Researchers have shown the LGBTQ-specific coping strategies that facilitate belongingness and access to LGBTQ community support systems may be especially important for improving resilience and health outcomes, including reduced depression, among LGBTQ youth (Singh, 2013; Toomey et  al., 2018a). Although coping skills are an important part of resilience among all youth, existing research suggests that LGBTQ-specific strategies may be warranted to best protect these youth. Thus, there is a need for ongoing research into the effectiveness of LGBTQ-specific coping skills as well as ways to help LGBTQ youth increase their use of effective coping skills.

Family Support

Research suggests that social support and acceptance of one’s sexual orientation and gender identity are particularly beneficial for LGBTQ youth’s mental health and emotional well-being, compared to general social support, and can buffer against the negative effects of minority stressors (Doty et  al., 2010; Russell & Fish, 2016; Ryan et al., 2010). Having at least one accepting adult in one’s life was associated with 40% reduced odds of a suicide attempt among LGBTQ youth (The Trevor Project, 2019d). Researchers found that family accepting behaviors and support, in particular, in response to LGBTQ adolescents’ sexual orientation and gender expression are associated with lower levels of suicidal thoughts and behaviors, as well as depression and subCoping Skills stance use, and predicted greater self-esteem, social support, general health status, and quality LGBTQ youth may need to cultivate distinct of life (Ryan et  al., 2010; Simons et  al., 2013). strategies to effectively cope with minority stress- For LGBTQ young people, sexuality-related ors related to their LGBTQ identity, as opposed social support from parents during adolescence to similar coping strategies used by their hetero- has also been found to be associated with positive sexual and cisgender peers for dealing with nor- well-being in young adulthood (Snapp et  al., mative adolescent stressors (Toomey et  al., 2015). Examples of family acceptance include 2018a). For example, LGBTQ adolescents may how often parents talked openly about their seek and glean social support from LGBTQ-­ child’s sexual orientation, a child’s openly

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LGBTQ friends were invited to join family activities, parents brought their sexual or gender minority child to an LGBTQ youth organization or event, and parents appreciated their sexual or gender minority child’s clothing or hairstyle, even though it might not have been typical for the child’s gender (Ryan et  al., 2010). Youth who reported greater parental acceptance were more likely than those with more rejecting parents to report identity affirmation and fewer struggles with their identities (Bregman et al., 2013), suggesting that the level of parental acceptance may affect adolescents’ acceptance of their own sexual and gender minority identities (Katz-Wise et  al., 2016). Researchers have also shown that general family support and connectedness are associated with reduced risk of suicidal thoughts and behaviors among LGBTQ youth (Reisner et al., 2014; Taliaferro et al., 2019; Taliaferro & Muehlenkamp, 2017). Family support and acceptance have consistently been found to be among the strongest associations with lower suicide risk among LGBTQ youth; however, research has also pointed to the role of support from peers, teachers, and other adults in LGBTQ youth suicide prevention.

Peer Support Having supportive, accepting peers, particularly LGBTQ peers, is also very important for LGBTQ adolescents’ self-esteem, positive identity, and mental health (Russell & Fish, 2016; Singh, 2013). Online friends can represent an important source of social support for LGBTQ youth because these young people are more likely than non-LGBTQ youth to face stigma and social marginalization in face-to-face settings (Gay, Lesbian & Straight Education Network, 2013). LGBTQ youth view online spaces as safe places to receive support from friends and sometimes describe the Internet as a safer place for them to socialize than in-person (Hillier & Harrison, 2007). One study found that sexual minority youth were significantly more likely than heterosexual youth to indicate their online friends were better than their in-person friends at providing

support (Ybarra et al., 2015). Although much of the research on peer relationships among LGBTQ youth has focused on bullying and victimization, there is also a need to focus on how these positive relationships may be leveraged to reduce LGBTQ youth suicide risk.

Teacher Support Attending a school where staff are supportive and accepting of LGBTQ students is related to feeling safer, missing fewer days of school, greater educational achievements and career aspirations, enhanced school connectedness, higher levels of self-esteem, and lower levels of depression among LGBTQ youth (Kosciw et  al., 2018). Research with transgender and nonbinary youth, in particular, has shown that relationships with supportive teachers were associated with improved school outcomes, including less absenteeism, greater feelings of safety at school, and improved academic experiences (Johns et  al., 2018), which are factors associated with lower suicide risk among LGBTQ youth (Burton et al., 2014; Taliaferro et  al., 2018; Whitaker et  al., 2016). These findings suggest that school staff can play a role in reducing suicide risk among LGBTQ students as well as in contributing to enhanced well-being. Future research should examine ways to increase the availability of supportive school staff for LGBTQ youth.

 ositive Mentors and Connections P to Non-Parental Adults Researchers have found that positive portrayals of LGBTQ characters in popular media, and LGBTQ politicians, comic book characters, and maybe even athletes can positively influence LGBTQ identity formation among adolescents (Gomillion & Giuliano, 2011). Readily a­ ccessible role models have also been found to be important for influencing health outcomes among LGBTQ youth (Bird et  al., 2012). Thus, formal mechanisms for connecting LGBTQ youth with caring adults who can serve as role models, such as

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mentoring programs, remain critical (Bird et al., 2012). For some LGBTQ youth, their families of origin are not sources of support, so these youth may create families of choice that provide greater support, connectedness, and acceptance than their families of origin. Researchers found that stronger connections to non-parental adults (i.e., other adult relatives, adults in the community) moderated the relationship between depressive symptoms and suicidal ideation among bisexual youth (Taliaferro & Muehlenkamp, 2017). Among bisexual youth who reported depressive symptoms, those who had higher connectedness to non-parental adults were less likely to report suicidal thoughts. Connectedness to non-parental adults also emerged as an important protective factor that distinguished transgender and nonbinary adolescents without any history of non-­ suicidal self-injury or suicide attempts from those who engaged in non-suicidal self-injury and attempted suicide during the preceding year (Taliaferro et al., 2019). Thus, existing research suggests that in addition to parents, supportive non-parental adults can play an important role in suicide prevention among LGBTQ youth.

Supportive and Inclusive Schools Supportive and inclusive school climates, in which youth feel a sense of connection, acceptance, and belonging, are associated with reduced risk of suicidal thoughts and behaviors among LGBTQ young people (Hatchel et  al., 2019; Poteat et al., 2013). One recent study examined six practices related to creating a supportive LGBTQ school climate (i.e., having a point person for LGBTQ student issues, displaying sexual orientation-specific content, having a gender and sexualities alliance, discussing bullying based on sexual orientation, and providing professional development around LGBTQ inclusion and LGBTQ student issues) and found that students attending schools with more supportive LGBTQ climates reported lower odds of relational bullying victimization, physical bullying perpetration, and sexual orientation-based harassment, compared to students in schools with less supportive

LGBTQ climates (Gower et  al., 2018). Further, sexual orientation did not moderate these relationships, indicating LGBTQ-supportive practices may be protective for all students, regardless of their sexual orientation (Gower et  al., 2018). Other researchers examined effects of gender and sexualities alliances in schools and found that the presence of these organizations was associated with lower psychological distress, including reduced risk of suicide attempts, as well as other health-risk behaviors, and more favorable school experiences (greater school belonging and less at-school victimization), especially among LGBTQ youth (Heck et  al., 2011; Poteat et  al., 2013). The presence of gender and sexualities alliances can positively affect school climates by reducing homophobic and transphobic remarks and victimization related to sexual orientation and gender expression, and increasing responsiveness of school staff when hearing negative LGBTQ remarks, a sense of belonging to the school community among LGBTQ students, and the number of supportive staff and accepting peers at the school (Kosciw et  al., 2018). Researchers have also demonstrated that LGBTQ-inclusive curricula, in which positive representations of LGBTQ events, people, and topics are taught, are associated with lower levels of victimization, less absenteeism, and better mental health among LGBTQ adolescents (Greytak et  al., 2013; Russell & Fish, 2016). LGBTQ students who attend schools with an LGBTQ-inclusive curriculum report greater acceptance of LGBTQ people among their classmates, higher levels of school belonging and self-­ esteem, and lower levels of depression than LGBTQ students in schools without an inclusive curriculum (Kosciw et al., 2018). Supportive and inclusive school policies and climates are protective for all LGBTQ youth but may be especially beneficial for transgender and nonbinary students (Greytak et al., 2013).

Supportive Policies Policies that protect LGBTQ youth from harm have also been associated with lower victimiza-

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tion and suicide risk. For example, anti-bullying laws are associated with less bullying victimization and fear-based absenteeism among LGBTQ youth, especially males (Seelman & Walker, 2018). Additionally, state same-sex marriage policies were associated with a 7% reduction in the proportion of adolescents who attempted suicide in states with those policies (Raifman et  al., 2017). Researchers also found that LGBTQ youth residing in more supportive regional environments, that include a greater proportion of same-sex couples within the region, showed a 20% reduced risk of suicide, compared to those living in unsupportive environments (Hatzenbuehler, 2011). The availability of LGBTQ-friendly, gender-affirming healthcare and social services in communities is also imperative for reducing mental health disparities among LGBTQ youth (Hadland et  al., 2016). These studies highlight the powerful role that LGBTQ-inclusive policies may play in reducing suicide risk and point to the need for suicide prevention efforts that address change at systemic and policy levels.

Evidence-Informed Efforts to Reduce LGBTQ Youth Suicide Despite a growing body of evidence indicating that LGBTQ youth are at increased risk for experiencing suicidal thoughts and suicide attempts, there remains a dearth of evidence-based interventions to inform suicide prevention efforts among LGBTQ youth. For example, the Suicide Prevention Resource Center’s repository on Programs with Evidence of Effectiveness has no suicide prevention interventions listed for LGBTQ populations (Suicide Prevention Resource Center, 2020). Further, a review of LGBTQ youth mental health research found no published studies on the efficacy of suicide prevention interventions for LGBTQ youth (Russell & Fish, 2016). Despite the lack of efficacy trials focused on LGBTQ youth, existing research evidence points to practices and programs at the individual, relational, and community levels that may reduce the risk for suicide.

Incorporation of LGBTQ-Affirming Principles One promising approach toward addressing LGBTQ youth suicide risk is the incorporation of LGBTQ-affirming practices into existing evidence-­based treatments targeting depression and suicide prevention. Such practices aim to equip LGBTQ youth with coping skills to address experiences of stigma-related stress, while also providing opportunities for cognitive restructuring related to identity affirmation aimed at reducing internalized stigma (Craig & Austin, 2016). Additionally, LGBTQ-affirming treatments aim to leverage LGBTQ pride and community building to buffer stigma-related stress (Pachankis, 2018). Although no efficacy trials have been published to date with LGBTQ youth populations, LGBTQ-affirming principles have been integrated into a number of existing evidence-based practices to reduce suicide, including cognitive-­ behavioral therapy (Pachankis et  al., 2020) and dialectical-behavior therapy (Pantalone et  al., 2019). Future studies should investigate the effectiveness of such interventions in reducing suicide risk among LGBTQ youth as well as ways to ensure access to affirming care is equitable across intersectional identities.

Gender-Affirming Care For transgender and nonbinary youth, there is also existing evidence that social and medical transition processes are associated with a reduction in suicide risk. Social transition is the primary gender-affirmative intervention for prepubertal transgender and nonbinary youth and involves encouraging them to present in the way that feels most genuine to them. This intervention may also include the use of a different name or pronouns. Transgender and nonbinary youth who have socially transitioned demonstrate comparable levels of self-worth and depression as youth who are not transgender and nonbinary. These findings have been demonstrated in research that asks parents to report on their child’s mental health (Olson et al., 2016) as well as asking the youth themselves

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(Durwood et  al., 2017). Medical affirming care can include treatments that postpone physical changes as well as treatments that lead to changes that affirm one’s gender identity. Pubertal suppression, commonly known as “puberty blockers,” is used to delay the onset of puberty, while hormone therapy is used to promote gender-affirming physical changes. Among adolescents, pubertal suppression has been shown to significantly improve overall psychological functioning after only 6 months of care (Costa et al., 2015). Additionally, adult transgender individuals who desired and received pubertal suppression as adolescents reported significantly lower lifetime suicidal ideation compared to those who desired the treatment but did not receive it (Turban et  al., 2020b). Further, recent research has shown that genderaffirming hormone therapy is associated with decreases in suicidal thoughts, with one study of transgender youth demonstrating that after approximately 1 year of treatment, the average scores on a measure of suicidal ideation were 25% lower than before treatment (Allen et al., 2019). Given the findings in existing research studies and the high rates of suicidal thoughts and behaviors experienced by transgender and nonbinary youth, there is a need for increased research on ways gender-­ affirming care can reduce suicide risk among these youth, as well as ways to increase access to gender-affirming care.

Additionally, nearly half of youth (42%) indicated they reached out specifically because of the opportunity to speak with an LGBTQ-affirming counselor, with higher rates of endorsement among transgender and nonbinary youth compared to cisgender youth (Goldbach et al., 2019). Thus, the existence of free LGBTQ-specific crisis lines provides a valuable resource for LGBTQ youth.

Family-Based Interventions

Given the powerful role that both family rejection and family acceptance can play in LGBTQ youth mental health and suicide risk, it is imperative to address the role of the family in approaching suicide prevention among LGBTQ youth. One of the longest running family-based interventions is the Family Acceptance Project (Ryan, 2010). The Family Acceptance Project is a psychoeducation-­ based program designed to help ethnically and religiously diverse families learn to recognize how rejection impacts LGBTQ youth, and how to best support their LGBTQ children in ways that improve mental health and well-being. The program is based on research regarding reasons parents engage in rejecting behaviors and provides families with tools and resources to learn how to accept and support their child. Another intervention that integrates acceptance principles is an adaption of attachment-based family therapy for LGBTQ-Specific Crisis Lines suicide risk among LGBTQ youth (Diamond & Shpigel, 2014). The intervention was adapted to Within the United States, The Trevor Project help parents process their disappointment and operates the nation’s only 24 h crisis intervention fears related to their child’s LGBTQ identity, suicide prevention helplines for LGBTQ youth. increase awareness of ways they might be invaliAn independent evaluation of The Trevor dating their child’s identity, and address the Project’s crisis services found that over 90% of meaning and process of enacting acceptance. youth who were assessed by a crisis counselor as Preliminary research indicated significant being at low to high risk of attempting suicide decreases in youth thoughts of suicide and during their initial contact were assessed as being depressive symptoms over the course of the interat no-risk for suicide during a 1 month follow-up vention (Diamond et al., 2013). Due to the powcontact (The Trevor Project, 2019a). Further, erful role families can play in LGBTQ youth most youth indicated they either would not have suicide risk, it is imperative that evidence-based contacted another helpline (26%) or were not interventions aimed at increasing support from sure (48%) if they would have contacted a non-­ families continue to be developed, evaluated, and LGBTQ helpline if they were in crisis. disseminated.

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protect LGBTQ youth and support LGBTQ equality are related to lower suicide risk. Research also highlights ways that minority stress factors A supportive and safe school environment is part are associated with core elements of the of a comprehensive public health strategy to pre- Interpersonal Theory of Suicide, with particular vent LGBTQ youth suicide. Based on existing emphasis on the mediating role of perceived burevidence, the CDC suggests the following prac- densomeness on the relationship between tices to meet the needs of LGBTQ youth: (1) LGBTQ-based minority stress and suicide risk. existence of LGBTQ groups in schools, such as Despite the progress being made in understandof genders and sexualities alliance networks, (2) ing how to improve well-being and prevent suiidentification of safe spaces for LGBTQ students, cide among LGBTQ youth, major gaps in (3) policies that prohibit harassment and bullying research and clinical applications remain. based on sexual orientation and gender identity, Research on LGBTQ youth has been ham(4) provision of and referrals to health and mental pered by a lack of data collection on both sexual health service providers with experience serving orientation and gender identity. Although national LGBTQ students, (5) professional development prevalence studies are increasingly including for all school personnel regarding the needs of items to assess sexual orientation, there remain LGBTQ students, and (6) LGBTQ-inclusive sex large gaps in the collection of gender identity education curricula (Centers for Disease Control data. Robust collection of sexual orientation and and Prevention, 2017). Each strategy is based on gender identity data are needed in population-­ existing evidence regarding the relationship based studies to track trends and obtain addibetween school climate and LGBTQ suicide. A tional data on factors associated with suicide risk. randomized study investigating the implementa- Additionally, given the documented disparities in tion of these strategies in school settings on suicidal thoughts and behaviors among LGBTQ LGBTQ youth suicide risk is currently being youth, suicide intervention and prevention trials conducted (Willging et  al., 2016). Given the need to include measures of sexual orientation amount of time LGBTQ youth spend in school and gender identity. Individual study sample and the research supporting the role of non-­ sizes may not allow for segmented analyses by parental connectedness and supportive policies in sexual orientation and gender identity; however, reducing suicide risk, there is a need for greater results from individual prevention and interveninvestment in school-level changes that can better tion studies can be synthesized to create datasets support LGBTQ youth. powerful enough to detect intervention effects among LGBTQ youth (Schrager et  al., 2019). There is also an urgent need to expand valid and Conclusion and Future Directions reliable sexual orientation and gender identity data collection as part of violent death reporting. Evidence has consistently demonstrated elevated Such data are essential to understanding the rates of suicidal thoughts and behavior among extent to which LGBTQ youth die by suicide and LGBTQ youth compared to their straight and cis- the factors that precipitate their deaths. gender peers. Framed by the Minority Stress Clinically, there is a need to develop and test Model, a growing body of research has begun to interventions aimed at reducing minority stress highlight factors, such as LGBTQ-based discrim- and enhancing resilience among LGBTQ youth. ination and victimization, family rejection, and Interventions must go beyond simply focusing on internalized LGBTQ stigma, associated with individual-level change to address the broader greater risk of suicidal thoughts and behavior sociocultural environment in which LGBTQ among LGBTQ youth. However, factors such as youth develop, including the family, school, and a positive LGBTQ identity, support from others, community levels. Studies focusing on adaptaLGBTQ role models, and policies designed to tions to existing evidence-based suicide preven-

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tion interventions that incorporate concerns related to LGBTQ-based minority stress, as well as studies focusing specifically on family, school, and community interventions designed to dismantle distal experiences of minority stress, are needed. There is also a need to ensure that professionals charged with supporting LGBTQ youth well-being, including healthcare professionals, mental healthcare providers, and school staff, are provided with ongoing training to promote high levels of LGBTQ competency. Further, given the challenges in creating positive changes for a stigmatized population, there is a need to integrate dissemination and implementation strategies to promote uptake of effective interventions (Green et al., 2018). Finally, the LGBTQ community is incredibly diverse with respect to intersecting identities and experiences. Suicide prevention efforts need to account for the unique lived experiences of LGBTQ youth, particularly those with multiple marginalized identities. Doing so will require the involvement of community stakeholders, including LGBTQ youth themselves, in the development, testing, and implementation of strategies to reduce suicide and improve well-being. Such efforts are required to begin reducing suicide-­ related disparities for LGBTQ youth in ways that are effective and equitable.

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Suicide Among Justice-Involved Youth

12

Kseniya Katsman and Elizabeth L. Jeglic

Overview

2017). Considering that youth, in general, are at increased risk for suicidal behavior, stressors Suicide is a leading cause of death for justice-­ associated with being involved in the justice sysinvolved individuals (Webb, 2017). This concern tem and incarceration further enhance the risk for is particularly salient among justice-involved suicidal behavior among justice-involved youth. young people due to the presence of multiple Consequently, it is estimated that detained youth stressors and risk factors, both within and outside have suicide rates between two to four times of the criminal justice system (American higher than those in the general population Academy of Child and Adolescent Psychiatry, (Gallagher & Dobrin, 2006a; Memory, 1989). 2001; Casiano et  al., 2013; Kang et  al., 2015; This chapter provides an overview of suicidal National Action Alliance for Suicide Prevention, behavior among justice-involved youth. First, we 2013a). When the juvenile justice system was ini- look at the prevalence of suicidal behavior among tially established, it was understood that youth youth involved in the justice system. Then we were distinct from adults and had different needs; explore the possible risk factors. Next, we examthus, the focus was on treatment and rehabilita- ine diversity issues, such as gender, race, culture, tion and not punishment (Cox et  al., 2017). and ethnicity, followed by assessment and treatHowever, in the 1980s and 1990s, there was the ment options. Finally, we look at promising prepublic perception that youth crime was increas- vention directions and provide recommendations ing, and in line with the “get tough on crime” for practice. zeitgeist of the era, changes were made to the juvenile justice system that allowed for custodial sentences for even minor crimes, mandatory sen- Prevalence tences, and transfer to adult court for certain crimes (Cocozza & Skowyra, 2000; Cox et  al., Youth, in general, are at a heightened risk for suicide. While suicide is the tenth leading cause of death in the United States’ general population, it K. Katsman (*) is the second leading cause of death for individuFordham University, New York, NY, USA als 10–24  years of age (Centers for Disease e-mail: [email protected] Control and Prevention [CDC], 2018b; Drapeau & E. L. Jeglic McIntosh, 2020). However, justice-involved John Jay College of Criminal Justice, New York, NY, youth may be at particular risk for suicide. While USA there are methodological challenges in determine-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_12

195

K. Katsman and E. L. Jeglic

196

ing suicide rates among justice-involved youth, it is clear that young people involved in the justice system are at a higher risk for suicidal behavior compared to their non-justice-involved peers (Fazel et  al., 2008; Gallagher & Dobrin, 2007; Joshi & Billick, 2017; Radeloff et  al., 2015). Specifically, court-involved, non-incarcerated young people and detained youth have suicide rates up to three times higher than that of a general population of youth (Gallagher & Dobrin, 2006a; Kemp et  al., 2016). For the 12-month prevalence rates, youth involved in the juvenile justice system reported rates of past-year suicidal ideation ranging from 19–32% and rates between 12 and 15.5% for past-year suicide attempts, as compared to non-justice-involved youth, of whom 15.8% reported past-year suicidal ideation and 7.4% of whom reported at least one past-year suicide attempt (CDC, 2018a; Stokes et  al., 2015). Additionally, suicidal behavior is more prevalent among youth who are more significantly involved in the criminal justice system and is, on average, more prevalent among post-­adjudicated adolescents as compared to pre-­ adjudicated youth (Hayes, 2009; Stokes et al., 2015). These findings highlight that risk for suicide and suicidal thoughts and behaviors are elevated among youth involved in the juvenile justice system.

Risk Factors Research on suicidal behavior has identified several common risk factors. These include a history of mental health disorders, particularly those related to depression and substance use, a history of aggression, a history of trauma or abuse, past suicidal behavior, feelings of hopelessness and isolation, family factors, and psychosocial stressors (Bilsen, 2018; CDC, 2019). For justice-­ involved young individuals, some of the risk factors are similar to those youth in the general population, but there are several environmental (e.g., related to being in a correctional setting) and individual characteristics (e.g., mental health disorders that are more prevalent among justice-­ involved youth) that present unique risks for suicidal behavior among justice-involved youth.

Custodial Settings The settings that young justice-involved people find themselves in can have an impact on suicidal thoughts and behaviors. It is estimated that each year, approximately 250,000 youth are involved in the adult criminal justice system, with 10,000 minors in adult prisons and jails in the United States (Griffin, 2010; West, 2010). By the most recent estimates, 4535 young individuals are residing in adult jails and prisons—representing almost 9.5% of the 48,000 youth in custodial sentences on any given day (Prison Policy Initiative, 2019). Young people housed in adult jails and prisons experience higher rates of distress and are at increased risk for suicidal behavior compared to those housed in juvenile detention centers (Beyer, 2002; Flaherty, 1980; Murrie et  al., 2009). This is related to a variety of reasons, including the higher occurrence of psychiatric disorders (Washburn et al., 2008), increased isolation, physical and sexual victimization, and inadequate staff training in preventing adolescent suicide (Beyer, 2002). Further, certain facility characteristics and housing practices have been found to increase the risk for suicide among detained youth. These include being detained in a large facility that utilizes mechanical restraints, sleeping in rooms that are locked, and being sent to solitary confinement (Hayes, 2009; Joshi & Billick, 2017).

Mental Health A history of mental health diagnosis and treatment are among the important risk factors for suicidal behavior. Mental health disorders are more common in justice-involved youth compared to their general population peers (Fazel et al., 2008; Ryan & Redding, 2004). For young people in the justice system, the risk for suicidal behavior is associated with a history of mental health disorders, a history of psychiatric hospitalization, and a history of substance use (Abram et al., 2008; Kemp et al., 2016; Mallett et al., 2012). Interestingly, hopelessness, a common precursor to suicide, is not related to suicidal behavior among justice-involved youth;

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however, the fear of peer social disapproval as a result of engaging in an unpopular behavior (i.e., suicidal behavior) is a strong deterrent for this population (Joshi & Billick, 2017). Criteria for at least one psychiatric disorder are met by approximately 60–70% of young people in residential placements, with 40–50% having been diagnosed with two or more disorders (Scott et  al., 2015; Teplin et al., 2010). A history of substance abuse was reported among 73% of juveniles who died by suicide in the US and South Australia thus making it an additional significant risk factor (Hayes, 2009; Putninš, 2005). Psychiatric diagnoses related to increased risk of suicidal behavior fall into two categories: externalizing (e.g., oppositional defiant disorder, conduct disorder) and internalizing (e.g., depression, anxiety). For internalizing disorders, a particular concern is high rates of depression and persistent depressive disorders among detained youth, as these are known risk factors for suicidal behavior (Abram et  al., 2008; Wasserman & McReynolds, 2006). These rates are higher than in the general population: Major depression is four to five times more common among detained females and twice as common among detained males compared to rates of depression in the general youth population (Fazel et al., 2008; Beaudry et al., 2020). Bipolar disorder is also more prevalent among justiceinvolved youth compared to their community peers (Harzke et  al., 2012; Ryan & Redding, 2004). Internalizing disorders, such as mood disorders, may also exacerbate delinquency through impaired social functioning, and distorted processing of information that may lead to higher peer pressure susceptibility (Ryan & Redding, 2004). For externalizing disorders, higher levels of aggression and loneliness are related to higher suicidal behavior among detained youth (Carrizales, 2007). Conduct disorder is 10–20 times higher among detained females and 5–10 times higher among detained males when compared to community youth samples (Fazel et al., 2008). Severe conduct disorder is related to suicidal behavior among justice-involved adolescent males (Aebi et  al., 2019). Additionally, the irritable subtype of oppositional defiant disorder was found to be related to suicidal behavior

among detained male youth, as well as persistent criminal behaviors (Aebi et  al., 2016). Considering that over half of detained male youth have conduct disorder or oppositional defiant disorder (Aebi et al., 2016, 2019), it is vital to consider these diagnoses when assessing the overall risk for suicidal behavior in this population.

History of Trauma The population of youth involved in the justice system is at high risk for traumatic events. A substantial number of justice-involved youth have experienced multiple and significant traumatic events—about one in five young people involved in the justice system has experienced multiple traumatic events (Charak et  al., 2019). Specifically, three-quarters of females and two-­ thirds of males have experienced physical abuse, and more than 40% of females and 10% of males reported a history of sexual abuse (Charak et al., 2019; King et al., 2011). Among trauma-related factors, physical abuse, domestic violence, and traumatic neglect are related to suicidal ideation in detained youth (Ford et al., 2008). A history of abuse may be particularly salient among youth who died by suicide. A national survey on juvenile suicide in confinement that examined 79 suicides that occurred over a 4-year period of time in public and private juvenile facilities across the United States found that a little more than one-­ third (34%) of all detained youth who died by suicide had a history of physical abuse, mostly by immediate family members (Hayes, 2009). Emotional abuse was present in 44% of these youth, and 28% had a history of sexual abuse, where the perpetrator was also mainly an immediate family member (Hayes, 2009). Specifically, a history of sexual abuse has been found to be a significant risk factor for both suicidal ideation and suicide attempts among detained young people (Bhatta et al., 2014; Johnson, 2017). In addition to history of traumatic events, current family discord and stressful life events such as suicide by a friend are considered as contributing to elevated suicide risk—this is particularly salient in justice-involved adolescents who may lack

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appropriate coping skills and social support (Joshi & Billick, 2017).

Peer Relationships From a social standpoint, association with delinquent peers and gang membership are associated with increased risk for suicidal ideation and ­suicide attempts, respectively (Joshi & Billick, 2017; Petering, 2016). Bullying may present an additional risk factor for males in custody. Kiriakidis (2008) found that for detained adolescents, being bullied while incarcerated was the largest significant predictor of a suicide attempt, emphasizing the institutions housing justice-­ involved youth should actively work on anti-­ bullying interventions to prevent future suicide attempts, as being bullied may represent a particularly salient suicide risk factor for justice-­ involved youth.

higher rates of suicidal ideation and behavior (CDC, 2018a; Nock et  al., 2013). For justice-­ involved youth, factors pertaining to the intersectionality between having a diverse identity and being justice-involved amplifies the risk for suicide.

LGBTQIA Youth

Sexual and gender identity is related to the risk for suicidal behavior among youth both in and out of the juvenile justice system. A higher percentage of high school students who identified as lesbian, gay, or bisexual reported experiencing a persistent feeling of sadness and hopelessness, seriously considering attempting suicide, making a suicide plan, attempting suicide, and getting injured in a suicide attempt than heterosexual high school students (CDC, 2018a). Sexual minority youth who identify as lesbian, gay, or bisexual (LGB) are reportedly more likely to have seriously considered attempting suicide History of Suicidal Behavior (heterosexual 14.5%, LGB 46.8%), made a suicide plan (heterosexual 12.1%, LGB 40.2%), and Similar to the general population, past suicide attempted suicide (heterosexual 6.4%, LGB attempts and recent suicidal ideation are signifi- 23.4%) in the past 12 months (Ivey-Stephenson cant risk factors for suicide among detained et  al., 2020). In juvenile facilities, lesbian, gay, youth (Abram et  al., 2008; Langhinrichsen-­ bisexual, and transgender youth often face Rohling & Lamis, 2008; Putninš, 2005). Justice-­ stigma, abuse, and hostility, which increases their involved young people in residential settings risk for suicide (Estrada & Marksamer, 2006; reported particularly high rates of lifetime sui- Majd et al., 2009). Thus, staff in youth detention cidal ideation and past suicide attempts—15–26% facilities needs to be aware of such harassment or and 22%, respectively (Sedlak & McPherson, abuse and ensure that lesbian, gay, bisexual, and 2010). Among youth in custody who died by sui- transgender youth receive adequate mental health cide, 25.8% had a past suicide attempt and 19.2% services if suicidal (Estrada & Marksamer, 2006). previously disclosed their intent to die by suicide Research on nonbinary and binary transgender (Ruch et al., 2019). young people is still in its infancy; however, existing findings show that these youth have a higher rate of suicidal ideation and behavior Diversity and Risk for Suicide when compared to binary non-transgender youth (Rimes et al., 2019). Diverse backgrounds and their associated struggles are related to the risk for suicidal behavior among young people. In the general population, Female Youth adolescents whose identity falls out of the majority spectrum (including sexual orientation, gen- On average, female detainees have been found to der, and racial and ethnic background) experience experience higher rates of psychiatric disorders,

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including depression, anxiety, and substance use disorders (other than alcohol and marijuana), compared to male detainees (Teplin et al., 2010). Female justice-involved youth also report higher rates of physical and sexual abuse as compared to their male counterparts and non-justice-involved female adolescents (Sedlak & McPherson, 2010; Tossone et al., 2018). This may help explain why female youth involved with the justice system have a higher risk for suicidal behavior than male justice-involved youth (Abram et  al., 2008; Sedlak & McPherson, 2010; Wasserman & McReynolds, 2006), a finding that is comparable to the general adolescent population (CDC, 2018a). Detained female adolescents experience more suicidal ideation and attempt compared to detained males (Bhatta et  al., 2014): For every one suicide attempt by a male detainee, female detainees make three suicide attempts (Howard et al., 2003). However, despite making fewer suicide attempts overall, males in the juvenile justice system comprise a majority of individuals who die by suicide, possibly because males use more lethal means, on average, than do females (Hayes, 2009; Lewinsohn et al., 2001; Radeloff et  al., 2015). Additionally, lack of parental care and supervision seem to be more prominent risk factors for suicide among justice-involved adolescent girls than among their male peers (Joshi & Billick, 2017).

Racial and Ethnic Minority Youth Suicidal behavior among justice-involved youth varies by racial and ethnic background. Although racial and ethnic minority youth are overrepresented in the juvenile justice system (Robles-­ Ramamurthy & Watson, 2019), non-Hispanic White and Native American detained adolescents generally exhibit a higher risk for suicide (Ford et al., 2008; Hayes, 2009). This finding is similar to non-justice-involved youth, where Native American and non-Hispanic White adolescents have higher rates of death by suicide (Nock et al., 2013), although past data have also suggested that Black and Latinx youth may be thinking about and making suicide attempts at higher rates

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than White youth (CDC, 2017). It is unclear if this trend is also being observed among youth who are justice-involved. In terms of risk factors for suicide, Black justice-­involved youth are less likely to report disruptive behavior disorder or substance use disorders, while Hispanic and Native American youth are significantly more likely to report substance use disorders compared to their white counterparts (Wasserman et  al., 2010). Native American and Alaska Native court-involved youth were reported to have the highest rates of substance use, a known risk factor for suicide (Heaton, 2018), although suicidal behavior rates are still the highest among White youth (Heaton, 2018; Wasserman et  al., 2010). Similar to findings among non-incarcerated youth (CDC, 2018a; Chesin & Jeglic, 2012; Ford-Paz et  al., 2013), Hispanic girls involved in the justice system experience higher suicidal ideation as compared to their White justice-involved peers (Abram et  al., 2008). Given the overrepresentation of racial and ethnic minority youth within the juvenile justice system and recent trends showing high rates of suicide or suicidal behavior by Native American, Black, and Latinx youth, more research assessing the prevalence and risk for suicide among justice-involved racial and ethnic minority youth is critical.

Assessment Suicide is a preventable cause of death, making an accurate assessment of suicide risk crucial. Further, given the high rates of suicidal behavior among justice-involved youth, timely suicide assessment is imperative. However, screening for suicide risk in residential placements is not homogeneous. Twenty-six percent of detained young people are in facilities that do not screen all youth for suicide risk, and 45% of young people are in facilities that fail to screen all youth within 24 h of admission to the facility (Sedlak & McPherson, 2010). As most youth who offended are managed in their communities, and not incarcerated, it is imperative to assess suicide risk in non-secure settings as well as in secure ones

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(Wasserman & McReynolds, 2006). Additionally, justice-involved youth may not present with all the criteria needed for the diagnosis of any one mental disorder, a known risk factor for suicide. Rather, they may present with subclinical levels of depression and a history of suicidal behavior, both of which are related to future suicidal behavior (Kang et  al., 2015). Thus, screening for suicidal ideation and behavior should be per­ formed for all adolescents involved in the justice system, regardless of the presence or absence of a diagnosis. While screening youth within 24 h of arrival to the juvenile justice facility is associated with decreased risk of suicide death (Gallagher & Dobrin, 2006b), this is not always possible due to staffing shortages (Winters et al., 2017). Given that assessing all youth upon intake should be the goal, the next best strategy would be to assess suicide risk among high-risk individuals such as individuals who exhibit suicidal thoughts or behaviors during intake or at any other point in time and those who experience clinically significant changes in their psychological status, such as an increase in depression or self-harm (Centre for Addiction and Mental Health, 2011). To successfully implement suicide screening at any point of a juvenile’s contact with the criminal justice system, three criteria should be met: (1) clear facility-wide policies on an assessment tool’s administration and scoring; (2) assessment-­specific staff training; and (3) periodic monitoring of the quality of assessment administration (National Action Alliance for Suicide Prevention, 2013b). In addition, general guidelines for assessing suicide should include determining access to lethal means and an assessment of the level of intent to die by suicide (Blasko et al., 2008). Suicidal intent can be assessed using the youth’s expressed desire to die, the presence of a specific and detailed plan, the presence of a past suicide attempt, and presence of risk factors for suicide (Blasko et al., 2008), with the risk of suicidal behavior increasing with the number of intent elements present. It is recommended that any suicide screening tools that are developed should be brief, easily administered by a staff member without specialized clinical training, and should be able to iden-

tify adolescents who require a more comprehensive examination (Cocozza & Skowyra, 2000; National Action Alliance for Suicide Prevention, 2013b). Proposed guidelines suggest that screening for suicide risk should occur before housing arrangements have been made to identify and accommodate those at a higher risk level with increased monitoring; and that the screening should include questions about current suicidal ideation, current and past suicidal behavior, past and current mental health treatment, recent significant life change or loss, and suicide by anyone close to them (Hayes, 2010). The screening procedure should also take into consideration suicide risk during any previous contact with criminal justice and transporting officers’ opinions regarding the youth’s current risk for suicide (Hayes, 2010). Several assessment instruments specific to justice-involved youth have been developed (e.g., Juvenile Suicide Assessment, Galloucis & Francek, 2001; Suicide Screening Inventory, Kaczmarek et  al., 2006). Kang et  al. (2015) proposed the Massachusetts Youth Screening Inventory-Second Version (MAYSI-2; Grisso & Barnum, 2006) as a useful and brief self-report assessment measure to assess suicide risk and mental health symptoms, although other reports did not support this suggestion for justice-involved females (Collins, 2012). There is currently no one standardized suicide risk assessment instrument for young people who have offended.

Treatment Suicidal behavior is often treated in the context of related factors, such as mood disorders and substance use (American Foundation for Suicide Prevention, n.d.). Evidence-based interventions, such as cognitive-behavioral therapy, are efficacious in reducing suicidal behavior among individuals, in general, regardless of justice involvement (Jobes et  al., 2015)—however, justice-­involved youth in juvenile justice facilities face many barriers to treatment of related factors and suicidal behavior. An effective approach to mental health treatment would include ade-

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quate monitoring of individuals who expressed a ment options that address the family and comdesire to die (e.g., observation cells, closed-­ munity should be considered (Ford et al., 2008). circuit monitoring), psychiatric evaluation, conOne such treatment is multisystemic therapy tinuous treatment efforts, monitoring of treatment (MST), which is a comprehensive, evidence-­ effectiveness, consistent case management, crisis based intervention geared at helping at-risk youth intervention services, and a variety of supple- and their families in the natural environment— mental services, such as educational, vocational, this includes home, school, and/or general comand social competency programs—juvenile facil- munity (Henggeler & Borduin, 1990). For ities may find it difficult to meet all of these crite- justice-involved youth, MST is an alternative to ria due to limited funding and lack of specialized incarceration and is associated with larger programs in the community (Ryan & Redding, decreases in criminal behavior and increases in 2004). While there is no one evidence-based interpersonal functioning and prosocial behavior treatment for justice-involved youth who engage compared to other methods of intervention (e.g., in suicidal behavior, several evidence-based probation services, family court, individual thertreatment options for the general population, apy) (Borduin et al., 2018). Another treatment that such as Collaborative Assessment and involves family members and is comparable in Management of Suicidality (CAMS) and treatment effects to MST is Functional Family Dialectical Behavior Therapy (DBT), are cur- Therapy (FFT; Baglivio et  al., 2014). This brief rently in the process of being evaluated for this (about 3 months) intervention works to improve population and adapted to juvenile facilities family members’ self-efficacy in handling their (Banks & Gibbons, 2016; Jobes et al., 2019). problems—it has also been associated with Although more research, specifically random- decreases in recidivism and improvement in interized controlled trials, is needed to evaluate the personal communication (Celinska et  al., 2019). efficacy and effectiveness of treatment options Considering previously discussed risks of associfor suicidal behavior and factors associated with ating with delinquent peers and the protective role increased risk for suicide among justice-involved of social supports for suicide risk, MST and FFT young people, group-based cognitive-behavioral may be used as promising treatments for reducing interventions have been shown to be the most suicide risk among justice-involved youth. effective in addressing challenges associated with depression, anxiety disorders, and/or self-­ harm in detained youth (Townsend et al., 2010). Prevention Considering the high levels of trauma experienced by justice-involved youth, trauma-­ Focus on prevention is paramount when dealing informed care (TIC) may be a particularly good with suicidal behavior. One of the best prevention fit for this population (Espinosa et al., 2013). TIC practices for court-involved youth is the adminisaddresses the effect the traumatic life experiences tration of routine screening tools at the time of have had on offenders, and system response (e.g., intake and then periodically throughout their judges, probation officers) that is trauma-­ detention/court involvement—these should informed includes this important context in addi- include questions about current physical and tion to a strictly legal one. In a juvenile justice mental well-being and history of adverse life system that is trauma-informed, youth are experiences, paying particular attention to those screened for trauma exposure and offered who experienced multiple types of victimization evidence-­based treatment, as needed, and judges (Joshi & Billick, 2017; Suárez-Soto et al., 2018). and probation officers are cognizant of the impact As violent victimization and substance use are that the history of trauma has on adolescents’ strongly related to suicidal behavior among involved youth, prevention strategies behavior and well-being (Espinosa et al., 2013). justice-­ Additionally, as these traumatic events often should also be applied to these areas (Joshi & include family members, comprehensive treat- Billick, 2017). Screening for suicidal thoughts

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and behaviors should be performed for both detained and non-incarcerated court-involved youth (Kemp & Poindexter, 2016). When needed, this should be followed by a detailed safety planning intervention that lists useful coping strategies, advanced planning on when and how to seek treatment and care, and identification of resources and social supports (Kemp & Poindexter, 2016). Staff training is integral to suicide prevention among justice-involved youth. Prior research found that 27% of youth were in residential facilities where the staff who conducts suicide screening is untrained (Sedlak & McPherson, 2010). Comprehensive suicide prevention policies should be provided in all juvenile facilities. These policies should address several crucial components, such as training, screening, levels of supervision, intervention, reporting, and follow-up (Hayes, 2010). There is evidence that the staff in both residential placements and in probation services is interested in and receptive to training related to screening for mental health needs and suicide risk. Correctional staff views mental health interventions positively and agrees that more mental health services are needed for youth in the justice system, although knowledge of suicide risk factors is not consistent across staff members (Penn et al., 2005). Facility-wide training has been found to increase awareness and knowledge of mental health needs and treatment, as well as suicide risk factors, even after one session (Penn et al., 2005). One study of a training and referral intervention for probation officers (“Project Connect”) showed promising results in terms of increased recommendations for mental health consultations and referrals for young justice-­involved people (Wasserman et al., 2009). To enhance the effectiveness of suicide prevention programming, training tailored to justice-­ involved youth, as well as annual instruction in suicide prevention and in recognition of risk factors pertaining to suicidal behavior (including correlates of subclinical disorders), should be provided to personnel at juvenile facilities (Joshi & Billick, 2017; Kang et al., 2015). Additionally, staff members at juvenile facilities should all be trained in first-aid, including CPR, and instructed

to initiate any life-saving measures after alerting medical personnel and until their arrival (Hayes, 2010). The rehabilitative rather than punitive approach should be strongly considered, particularly for adolescents with histories of physical and sexual abuse and childhood maltreatment—this approach would ideally involve several agencies, in addition to the juvenile justice system such as child welfare systems (for example, as is in place in New York City, Illinois, and Los Angeles county), mental health services, and prevention of unnecessary institutionalization through the decriminalization of minor delinquent behaviors (King et al., 2011). Reducing and rethinking institutionalization of justice-­involved youth and shifting to a community-­based service model while creating system transparency and investing in a successful reentry process has been recommended as the best action plan in a juvenile justice system (Governor David Paterson’s Task Force on Transforming Juvenile Justice, 2009). Additionally, prevention and treatment efforts need to be culturally relevant, and methods should be adapted, including utilizing a multifaceted approach, promoting social connection and cultural enrichment, and raising awareness in culturally meaningful ways (Ford-Paz et al., 2013).

Conclusion By the time justice-involved youth come in contact with the criminal justice system, they have often already faced many stressors, traumas, and hardships that can then be exacerbated by the correctional environment, leading to an increased risk for suicidal behavior compared to their non-­ justice-­ involved peers. This chapter briefly reviewed the important topics pertaining to suicide among young people involved in the justice system. Several important risk factors have been identified, and treatments specific to suicide prevention are being continuously developed and adapted to juvenile justice facilities and resources. One of the most important components in suicide prevention among justice-involved youth is a timely and accurate assessment of suicide risk

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analysis: Mental disorders among adolescents in juvethat requires staff training and institutional supnile detention and correctional facilities. Journal of the port. On a larger scale, rehabilitative policies that American Academy of Child & Adolescent Psychiatry. involve multiagency collaborations keeping Advance online publication. https://doi.org/10.1016/j. jaac.2020.01.015 youth within the community, as well as family-­ based intervention strategies, may help to reduce Beyer, M. (2002). Experts for juveniles at risk of adult sentences. In P.  Puritz, A.  Capozello, & W.  Shang suicide risk. Thus, suicide prevention among (Eds.), More than meets the eye: Rethinking assessjustice-involved youth requires systemic change ment, competency and sentencing for a harsher era of juvenile justice (pp. 1–22). American Bar Association both in terms of how suicide risk is assessed and Juvenile Justice Center. treated within facilities but also more broadly in Bhatta, M. P., Jefferis, E., Kavadas, A., Alemagno, S. A., terms of examining policies, such as sentencing & Shaffer-King, P. (2014). Suicidal behaviors among youth as adults, which significantly increase their adolescents in juvenile detention: Role of adverse life experiences. PLoS One, 9(2), e89408. https://doi. risk for suicide.

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204 August 12, 2020, from https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html Centre for Addiction and Mental Health. (2011). CAMH suicide prevention and assessment handbook. Author. Charak, R., Ford, J. D., Modrowski, C. A., & Kerig, P. K. (2019). Polyvictimization, emotional dysregulation, symptoms of posttraumatic stress disorder, and behavioral health problems among justice-involved youth: A latent class analysis. Journal of Abnormal Child Psychology, 47(2), 287–298. https://doi.org/10.1007/ s10802-­018-­0431-­9 Chesin, M.  S., & Jeglic, E.  L. (2012). Suicidal behavior among Latina college students. Hispanic Journal of Behavioral Sciences, 34(3), 421–436. https://doi. org/10.1177/0739986312445271 Cocozza, J. J., & Skowyra, K. R. (2000). Youth with mental health disorders: Issues and emerging responses. Juvenile Justice, 7(1), 3–13. Retrieved from https:// www.ncjrs.gov/html/ojjdp/jjjnl_2000_4/contents.html Collins, K.  M. (2012). Predicting suicidal behavior of juvenile females in secure care (Publication No. 3528141) [Doctoral dissertation, Regent University]. ProQuest Dissertations Publishing. Cox, S. M., Allen, J. M., & Hanser, R. D. (2017). Juvenile justice: A guide to theory, policy, and practice. Sage Publications. Drapeau, C.  W., & McIntosh, J.  L. (for the American Association of Suicidology). (2020). U.S.A. suicide: 2018 Official final data. American Association of Suicidology. Retrieved from https://suicidology.org/ wp-­content/uploads/2020/02/2018datapgsv2_Final. pdf Espinosa, E. M., Sorensen, J. R., & Lopez, M. A. (2013). Youth pathways to placement: The influence of gender, mental health need and trauma on confinement in the juvenile justice system. Journal of Youth and Adolescence, 42(12), 1824–1836. https://doi. org/10.1007/s10964-­013-­9981-­x Estrada, R., & Marksamer, J. (2006). The legal rights of LGBT youth in state custody: What child welfare and juvenile justice professionals need to know. Child Welfare, 85(2), 171–194. Fazel, S., Doll, H., & Långström, N. (2008). Mental disorders among adolescents in juvenile detention and correctional facilities: A systematic review and metaregression analysis of 25 surveys. Journal of the American Academy of Child & Adolescent Psychiatry, 47(9), 1010–1019. https://doi.org/10.1097/ CHI.0b013e31817eecf3 Flaherty, M.  G. (1980). An assessment of the national incidence of juvenile suicide in adult jails, lockups, and juvenile detention centers. Community Research Forum, University of Illinois at Urbana-Champaign. Department of Justice. Ford, J. D., Hartman, J. K., Hawke, J., & Chapman, J. F. (2008). Traumatic victimization, posttraumatic stress disorder, suicidal ideation, and substance abuse risk among juvenile justice-involved youth. Journal of Child & Adolescent Trauma, 1(1), 75–92. https://doi. org/10.1080/19361520801934456

K. Katsman and E. L. Jeglic Ford-Paz, R. E., Reinhard, C., Kuebbeler, A., Contreras, R., & Sánchez, B. (2013). Culturally tailored depression/suicide prevention in Latino youth: Community perspectives. Journal of Behavioral Health Services & Research, 42(4), 519–533. https://doi.org/10.1007/ s11414-­013-­9368-­5 Gallagher, C. A., & Dobrin, A. (2006a). Deaths in juvenile justice residential facilities. Journal of Adolescent Health, 38(6), 662–668. https://doi.org/10.1016/j. jadohealth.2005.01.002 Gallagher, C.  A., & Dobrin, A. (2006b). Facility-level characteristics associated with serious suicide attempts and deaths from suicide in juvenile justice residential facilities. Suicide and Life-threatening Behavior, 36(3), 363–375. https://doi.org/10.1521/ suli.2006.36.3.363 Gallagher, C.  A., & Dobrin, A. (2007). Risk of suicide in juvenile justice facilities: The problem of rate calculations in high-turnover populations. Criminal Justice and Behavior, 34(10), 1362–1376. https://doi. org/10.1177/0093854807302177 Galloucis, M., & Francek, H. (2001). The Juvenile Suicide Assessment: An instrument for the assessment and management of suicide risk with incarcerated juveniles. International Journal of Emergency Mental Health, 4(3), 181–199. Retrieved from https://europepmc.org/article/med/12387191 Governor David Paterson’s Task Force on Transforming Juvenile Justice. (2009, December). Charting a new course: A blueprint for transforming juvenile justice in New York State. https://www.vera.org/publications/ charting-­a-­new-­course-­a-­blueprint-­for-­transforming-­ juvenile-­justice-­in-­new-­york-­state Griffin, P. (2010, June 18). National Institute of Corrections convening on youthful offenders in the adult criminal justice system. National Center for Juvenile Justice. Grisso, T., & Barnum, R. (2006). Massachusetts Youth Screening Instrument-Version 2: User’s manual and technical report. Professional Resource Press. Harzke, A. J., Baillargeon, J., Baillargeon, G., Henry, J., Olvera, R.  L., Torrealday, O., Penn, J.  V., & Parikh, R. (2012). Prevalence of psychiatric disorders in the Texas juvenile correctional system. Journal of Correctional Health Care, 18(2), 143–157. ­https://doi. org/10.1177/1078345811436000 Hayes, L.  M. (2009). Juvenile suicide in confinement— Findings from the first national survey. Suicide and Life-threatening Behavior, 39(4), 353–363. https://doi. org/10.1521/suli.2009.39.4.353 Hayes, L.  M. (2010). Characteristics of juvenile suicide in confinement. In O.  B. Hahn (Ed.), Perspectives on juvenile offenders (pp.  1–35). Nova Science Publishers. Heaton, L. L. (2018). Racial/ethnic differences of justice-­ involved youth in substance-related problems and services received. American Journal of Orthopsychiatry, 88(3), 363–375. https://doi.org/10.1037/ort0000312 Henggeler, S. W., & Borduin, C. M. (1990). Family therapy and beyond: A multisystemic approach to treating

12  Suicide Among Justice-Involved Youth the behavior problems of children and adolescents. Brooks/Cole. Howard, J., Lennings, C.  J., & Copeland, J. (2003). Suicidal behavior in a young offender population. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 24(3), 98–104. https://doi. org/10.1027//0227-­5910.24.3.98 Ivey-Stephenson, A.  Z., Demissie, Z., Crosby, A.  E., Stone, D.  M., Gaylor, E., Wilkins, N., Lowry, R., & Brown, M. (2020). Suicidal ideation and behaviors among high school students—Youth Risk Behavioral Survey, United States, 2019. Morbidity and Mortality Weekly Report, 69(1), 47–55. https://doi.org/10.15585/ mmwr.su6901a6 Jobes, D.  A., Au, J.  S., & Siegelman, A. (2015). Psychological approaches to suicide treatment and prevention. Current Treatment Options in Psychiatry, 2(4), 363–370. https://doi.org/10.1007/ s40501-­015-­0064-­3 Jobes, D.  A., Vergara, G.  A., Lanzillo, E.  C., & Ridge-­ Anderson, A. (2019). The potential use of CAMS for suicidal youth: Building on epidemiology and clinical interventions. Children’s Health Care, 48(4), 444– 468. https://doi.org/10.1080/02739615.2019.1630279 Johnson, M.  E. (2017). Childhood trauma and risk for suicidal distress in justice-involved children. Children and Youth Services Review, 83, 80–84. https://doi. org/10.1016/j.childyouth.2017.10.034 Joshi, K., & Billick, S. B. (2017). Biopsychosocial causes of suicide and suicide prevention outcome studies in juvenile detention facilities: A review. Psychiatric Quarterly, 88(1), 141–153. https://doi.org/10.1007/ s11126-­016-­9434-­2 Kaczmarek, T. L., Hagan, M. P., & Kettler, R. J. (2006). Screening for suicide among juvenile delinquents: Reliability and validity evidence for the Suicide Screening Inventory (SSI). International Journal of Offender Therapy and Comparative Criminology, 50(2), 204–217. https://doi.org/10.1177/03066 24X05278520 Kang, T., Eno Louden, J., Ricks, E.  P., & Jones, R.  L. (2015). Aggression, substance use disorder, and presence of a prior suicide attempt among juvenile offenders with subclinical depression. Law and Human Behavior, 39(6), 593–601. https://doi.org/10.1037/ lhb0000145 Kemp, K., & Poindexter, B. (2016). Preventing suicide among justice-involved youth using public health partnerships. The Brown University Child and Adolescent Behavior Letter, 32(9), 1–7. https://doi.org/10.1002/ cbl.30149 Kemp, K., Tolou-Shams, M., Conrad, S., Dauria, E., Neel, K., & Brown, L. (2016). Suicidal ideation and attempts among court-involved, nonincarcerated youth. Journal of Forensic Psychology Practice, 16(3), 169–181. https://doi.org/10.1080/15228932.2016.1172424 King, D.  C., Abram, K.  M., Romero, E.  G., Washburn, J. J., Welty, L. J., & Teplin, L. A. (2011). Childhood maltreatment and psychiatric disorders among

205 detained youths. Psychiatric Services, 62(12), 1430– 1438. https://doi.org/10.1176/appi.ps.004412010 Kiriakidis, S.  P. (2008). Bullying and suicide attempts among adolescents kept in custody. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 29(4), 216–218. https://doi.org/10.1027/0227-­5910.29.4.216 Langhinrichsen-Rohling, J., & Lamis, D.  A. (2008). Current suicide proneness and past suicidal behavior in adjudicated adolescents. Suicide and Life-Threatening Behavior, 38(4), 415–426. https://doi.org/10.1521/ suli.2008.38.4.415 Lewinsohn, P.  M., Rohde, P., Seeley, J.  R., & Baldwin, C.  L. (2001). Gender differences in suicide attempts from adolescence to young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 40(4), 427–434. https://doi. org/10.1097/00004583-­200104000-­00011 Majd, K., Marksamer, J., & Reyes, C. (2009). Hidden injustice: Lesbian, gay, bisexual, and transgender youth in juvenile courts. Legal Services for Children, National Juvenile Defender Center, National Center for Lesbian Rights. Retrieved from https://www.nclrights.org/wp-­content/uploads/2014/06/hidden_injustice.pdf. Mallett, C., DeRigne, L.  A., Quinn, L., & Stoddard-­ Dare, P. (2012). Discerning reported suicide attempts within a youthful offender population. Suicide and Life-threatening Behavior, 42(1), 67–77. https://doi. org/10.1111/j.1943-­278X.2011.00071.x Memory, J.  M. (1989). Juvenile suicides in secure detention facilities: Correction of published rates. Death Studies, 13(5), 455–463. https://doi. org/10.1080/07481188908252324 Murrie, D.  C., Henderson, C.  E., Vincent, G.  M., Rockett, J. L., & Mundt, C. (2009). Psychiatric symptoms among juveniles incarcerated in adult prison. Psychiatric Services, 60(8), 1092–1097. https://doi. org/10.1176/ps.2009.60.8.1092 National Action Alliance for Suicide Prevention. Youth in Contact with the Juvenile Justice System Task Force. (2013a). Suicidal ideation and behavior among youth in the juvenile justice system: A review of the literature. Author. Retrieved from https://theactionalliance. org/resource/suicide-­ideation-­and-­behavior-­among-­ youth-­juvenile-­justice-­system-­review-­literature National Action Alliance for Suicide Prevention. Youth in Contact with the Juvenile Justice System Task Force. (2013b). Screening and assessment for suicide prevention: Tools and procedures for risk identification among juvenile justice youth. Author. Retrieved from https://theactionalliance.org/resource/screening-­and-­ assessment-­suicide-­prevention-­tools-­and-­procedures-­ risk-­identification-­and Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N.  A., Zaslavsky, A.  M., & Kessler, R.  C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70(3), 300– 310. https://doi.org/10.1001/2013.jamapsychiatry.55

206 Penn, J.  V., Esposito, C., Lacher-Katz, M., & Spirito, A. (2005). Juvenile correctional workers’ perceptions of suicide risk factors and mental health issues of incarcerated juveniles. Journal of Correctional Health Care, 11(4), 333–346. https://doi. org/10.1177/107834580401100403 Petering, R. (2016). Sexual risk, substance use, mental health, and trauma experiences of gang-involved homeless youth. Journal of Adolescence, 48, 73–81. https://doi.org/10.1016/j.adolescence.2016.01.009 Prison Policy Initiative. (2019). Youth confinement: The whole pie 2019. Author. Retrieved from https://www. prisonpolicy.org/reports/youth2019.html Putninš, A.  L. (2005). Correlates and predictors of self-­ reported suicide attempts among incarcerated youths. International Journal of Offender Therapy and Comparative Criminology, 49(2), 143–157. https:// doi.org/10.1177/0306624X04269412 Radeloff, D., Lempp, T., Herrmann, E., Kettner, M., Bennefeld-Kersten, K., & Freitag, C.  M. (2015). National total survey of German adolescent suicide in prison. European Child & Adolescent Psychiatry, 24(2), 219–225. https://doi.org/10.1007/ s00787-­014-­0568-­1 Rimes, K.  A., Goodship, N., Ussher, G., Baker, D., & West, E. (2019). Non-binary and binary transgender youth: Comparison of mental health, self-harm, suicidality, substance use and victimization experiences. International Journal of Transgenderism, 20(2–3), 230–240. https://doi.org/10.1080/15532739.2017.13 70627 Robles-Ramamurthy, B., & Watson, C. (2019). Examining racial disparities in juvenile justice. The Journal of the American Academy of Psychiatry and the Law, 47(1), 1–5. https://doi.org/10.29158/JAAPL.003828-­19 Ruch, D. A., Sheftall, A. H., Schlagbaum, P., Fontanella, C.  A., Campo, J.  V., & Bridge, J.  A. (2019). Characteristics and precipitating circumstances of suicide among incarcerated youth. The Journal of the American Academy of Child & Adolescent Psychiatry, 58(5), 514–524.e1. https://doi.org/10.1016/j. jaac.2018.07.911 Ryan, E. P., & Redding, R. E. (2004). A review of mood disorders among juvenile offenders. Psychiatric Services, 55(12), 1397–1407. https://doi.org/10.1176/ appi.ps.55.12.1397 Scott, M., Underwood, M., & Lamis, D.  A. (2015). Suicide and related-behavior among youth involved in the juvenile justice system. Child & Adolescent Social Work Journal, 32(6), 517–527. https://doi. org/10.1007/s10560-­015-­0390-­8 Sedlak, A. J., & McPherson, K. (2010). Youth’s needs and services: Findings from Survey of Youth in Residential Placement. Juvenile Justice Bulletin, April 2010, NCJ 227728. https://www.ojjdp.gov/ojstatbb/publications/ StatBBAbstract.asp?BibID=249735 Stokes, M. L., McCoy, K. P., Abram, K. M., Byck, G. R., & Teplin, L. A. (2015). Suicidal ideation and behavior in youth in the juvenile justice system: A review of

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Suicide Among American Indian/ Alaska Native Populations

13

Ashley B. Cole, Cassidy M. Armstrong, Sarah Rhoades-Kerswill, Susanna V. Lopez, and Jessica Elm

“I think the most important issue we have as a people is what we started, and that is to begin to trust our own thinking again and believe in ourselves enough to think that we can articulate our own vision of the future and then work to make sure that that vision becomes a reality.”—Wilma Mankiller (First Female Chief of the Cherokee Nation of Oklahoma).

 ho Are American Indians/Alaska W Natives? To understand suicidality in Indian country, it is imperative to define American Indians/Alaska Native peoples as distinct populations and to discuss social and health inequities within historical and contemporary contexts. Many different names are used to describe the original inhabitants of the North American continent, also known A. B. Cole () · C. M. Armstrong · S. V. Lopez Department of Psychology, College of Arts and Sciences, Oklahoma State University, Stillwater, OK, USA e-mail: [email protected]; [email protected]; [email protected] S. Rhoades-Kerswill A Tribal Mental Health Clinic, Norman, OK, USA J. Elm Bloomberg School of Public Health, Center for American Indian Health, Johns Hopkins University, Baltimore, MD, USA

as Turtle Island (Elm & Antone, 2000), including American Indian, Native American, Alaska Native, First Nations, Native Peoples, Aboriginal, Métis, Inuit, and Indigenous peoples. We use American Indian and Alaska Natives (AI/ANs) throughout this chapter, which is the term that was selected by the National Congress of American Indians in 1944 (NCAI, 2019). There are currently 4.2 million individuals (1.3% of the US population) in the United States (US) who exclusively identify as AI/AN (Census, 2020). When allowing for multiracial identification, this number increases to 6.9 million individuals (2.1% of the US population) (Census, 2020). However, these numbers can vary when accounting for tribal citizenship or when considering who is eligible for federal health services (NCAI, 2020). For example, 2.6 million AI/ANs are currently eligible for health services through the Indian Health Service (IHS) (Heisler, 2021). To date, there are 574 federally recognized tribes, or tribal nations, in the US (NCAI, 2020; NCSL, 2020). Federally recognized tribes are sovereign nations recognized by the federal government through treaties and federal policies (Villegas et  al., 2016), and as such, each tribe determines its own citizenship edibility criteria as an exercise of tribal sovereignty. Federal recognition is a form of political status, which indicates that tribes are recognized as pre-US constitutional sovereign nations who have, in some form or another, formed treaties with the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_13

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US government at least once; thus, signifying a government-to-government relationship (Villegas et  al., 2016). AI/AN peoples are citizens or descendants of tribal nations, including federally recognized tribes, tribes recognized by state governments yet not recognized by the federal government, and other tribes that exist as cultural entities without federal or state recognition.

A. B. Cole et al.

the US needed an estimate of the number of AI/ AN peoples. Thus, the Indian rolls were the first to employ the fractional blood quantum in the enumeration of Indian peoples (Villegas et  al., 2016). In 1978, the Bureau of Indian Affairs (BIA), within the Department of Interior, published regulations about the criteria that unacknowledged or unrecognized tribal groups had to meet to be formally recognized (Villegas et  al., 2016). As Brief History of AI/AN Peoples previously mentioned, some tribes are recogin the US nized by state governments yet not recognized by the federal government, and other tribes exist as AI/ANs peoples are currently the only ethnic/ cultural entities without federal or state recogniracial group in the US that necessitates, largely tion. Thus, AI/AN peoples represent both a disdue to sociocultural and political reasons, having tinct ethnic/racial group and citizens of sovereign to prove one’s heritage through documentation of tribal nations (NCAI, 2020). Further, AI/AN tribal citizenship/enrollment, which is generally populations are heterogeneous, representing traced through ancestral Indian blood quantum many different cultures, languages, traditions, and is documented as fractions. The estimated practices, and histories. AI/AN peoples have disquantity of Indian blood, a metonym for self-­ tinct, rich cultures with unique perspectives on identified race and political status, was initially the human experience and ways of relating with employed through the 1887 Dawes Act to revoke the world. political status through intergenerational invisibility and erasure of AI/AN peoples (Jaimes, 1992; Villegas et al., 2016). The 1887 Dawes Act Cultural Worldviews, Values, declared that AI/ANs were required to prove ½ or and Strengths in AI/AN Populations greater degree of Indian blood to qualify for an allotment of their tribal estate (Jaimes, 1992; While AI/ANs are heterogeneous, certain comVillegas et al., 2016). monly shared cultural values and a similar tradiColonization and tactics for the genocide of tional worldview span many tribal communities AI/AN peoples changed over time and included and differentiate AI/ANs from other ethnic/racial the establishment of land allotment policies and groups, particularly from non-Hispanic White Indian blood quantum. For many AI/AN peoples, (NHW) populations (Gone & Kirmayer, 2020). the creation of, and forced relocation to, rural res- For example, Indigenous epistemology, also ervations in the 1800s resulted in a loss of cul- known as indigeneity, entails an ecological sense ture, traditions, and familiar ways of life. This of self that is rooted in the land and interconexperience left many AI/AN peoples isolated in nected with nonhuman agencies or persons (e.g., unfamiliar, remote places that were far removed nature); this worldview is commonly associated from the resources available in urban areas with health and well-being (Gone & Kirmayer, (Roubideaux, 2005). Years of poor educational 2020). Similarly, Indigenous scholars have dissystems and lack of opportunities have resulted cussed health as tied to a holistic worldview in in poor socioeconomic conditions in many reser- which people are interconnected to self, others, vations (Roubideaux, 2005). As colonizers’ and all things in the universe (Hill, 2006; Lowe, expansions reached the pacific coast and US 2002). Subcomponents of this holistic worldview Indian policy shifted from removal to forced include community connectedness (Ullrich, allotment, narrower racial criteria served to fulfill 2019) and working together toward harmonious US land ownership goals. To achieve these goals, common goals (Lowe, 2002). Additional

13  Suicide Among American Indian/Alaska Native Populations

e­xamples that span AI/AN traditional ways include having a reticular (vs. linear) frame of reference, in which all places, people, and things are interconnected across time (Cajete & Bear, 2000); having place (vs. time) orientation, in which events and memories are traced back to where they occurred rather than when (Walters et al., 2011); matrilineal/matriarchal organization or equity in gender roles (Maracle et al., 2020); the use of storytelling as learning (Lawrence & Paige, 2016); respect, which encapsulates characteristics of relationships, honor, identity, and strength (Lowe & Struthers, 2001); cooperation/ collectivism (e.g., one’s tribe and family take precedence over the individual; competition may be looked down upon if viewed as an expression of individuality (Brant, 1990); and noninterference (e.g., AI/ANs are often taught not to interfere with others and to observe rather than reacting impulsively; this is sometimes perceived as being “permissive” in child rearing) (Brant, 1990). While we discuss suicide and associated risk factors in this chapter, it is equally important to impart knowledge of AI/AN peoples’ strengths and resilience. Each AI/AN individual living today has survived despite generations of violence, trauma, and governmental policies aimed at ending the AI/ AN way of life (i.e., settler colonialism). Hence, the intergenerational transmission of resilience among AI/AN peoples is strong. This chapter concludes with discussions about strengths, resilience, positive mental health among AI/AN peoples, future directions for research, and a call to end the systemic oppression of AI/AN peoples with the authors’ outline of a strategic plan.

Coronavirus Global Pandemic Before discussing suicide statistics among AI/ AN peoples, we wish to acknowledge that this chapter was written during the ongoing SARS-­ CoV-­2 coronavirus disease (COVID-19) global pandemic, which has disproportionately affected AI/AN communities. According to the most recent national statistics, AI/AN persons are 1.7 times more likely to contract COVID-19, 3.7 times more likely to be hospitalized due to

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COVID-19, and 2.4 times more likely to die from COVID-19 compared to non-Hispanic White (NHW) persons (CDC, 2021). While research on the long-term impacts of the widespread losses in Indian Country due to COVID-19 is not yet available, we acknowledge that Indian Country has experienced disproportionately greater losses than the general public while simultaneously receiving less funding and supplies. Tribal community leaders have expressed continued concern for the health of their constituents given their propensity for worse physical health outcomes if infected with COVID-19 and generally worse mental health outcomes, including high rates of substance use to cope with COVID-19 impacts (Sandoiu, 2020; Urbatsch & Robledo, 2020). In keeping with our strengths focus, we wish to acknowledge tribal nations who have enacted guidelines and shared resources to protect their communities in ways that have been missing in other communities. For example, many tribal, urban Indian, and IHS healthcare organizations have demonstrated leadership by providing some of the highest rates of vaccinations in the US, with many tribes (e.g., tribes in Arizona, New Mexico, and Oklahoma) opening their vaccination services to all community members regardless of tribal enrollment status, which is an exercise of tribal sovereignty that has benefitted communities. Throughout this chapter, we have attempted to integrate other ways we can look to AI/AN communities for examples of incorporating strengths and resilience-based knowledge in the context of suicide prevention.

Suicide in Indian Country

Historical Trends of Suicidality Among AI/AN Peoples Prior to European contact (i.e., settler colonization), suicide was rare in AI/AN communities, and some Indigenous populations in the US and Canada held explicitly negative attitudes about suicide (Kirmayer, 1994). According to certain

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AI/AN communities’ religious beliefs, those who died by suicide were denied funeral and burial services, and their spirits were thought to go to a separate realm from those who died from other causes (Hultkrantz, 1979). Drawing from Durkheim’s Sociological Theory of Suicide that proposed four forms of suicide: egoistic, altruistic, anomic, and fatalistic (Durkheim, 1951; Niezen, 2015), altruistic suicides were theorized to have occurred historically among some AI/ AN populations through self-sacrifice (e.g., during battles; self-sacrifice among Elders, those with incurable illnesses, and those with disabilities) to help their community by reducing burden (Davenport & Davenport, 1987). However, the actual prevalence of historical altruistic suicides that occurred among AI/AN populations remains unknown (Vogel, 2013). Suicide continued to be relatively rare in AI/ AN communities until the 1930s–1950s, with some variability depending on particular tribes and geographical regions (Levy & Kunitz, 1987; NASM, 2019). According to Indian Health Service (IHS) records, the age-adjusted (also adjusted for racial misclassification) rate for suicide deaths among AI/ANs across age and sex was 11.9 per 100,000 in 1955; 21 per 100,000  in 1972–1974; 19 per 100,000  in 1980; 19.2 per 100,000  in 1993 (IHS, 1997); and 20.4 per 100,000 from 2009 to 2011 (IHS, 2019). The increases in suicide rates across AI/ AN tribes in the US during this period were believed to be due, in part, to increased rates of alcohol use and alcohol-related health problems (e.g., cirrhosis) (Levy & Kunitz, 1987). Among AI/AN youth, in particular, some estimates indicate that suicide rates began to spike in the 1980s and have continued to increase over time (NASM, 2019). Epidemiological data revealed that suicide mortality rates increased among AI/AN young and middleaged populations across sexes from 1999 to 2014, with AI/ANs exhibiting the highest premature mortality rates, defined as deaths of individuals aged 25–64 years, across all ethnic/ racial groups during 2011–2014 (Shiels et al., 2017).

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 urrent Trends of Suicidality Among C AI/AN Peoples According to the most recent nationally available suicide statistics, the crude rate for suicide deaths among AI/ANs across age is 22.1 per 100,000 (NCHS, 2019). A closer examination reveals that AI/AN young adults are disproportionately affected by suicide, and the crude rate for suicide deaths is 24.28 per 100,000 among AI/AN young adults ages 15–34 years (CDC, 2020). Using the National Violent Death Reporting System (NVDRS) data, approximately 10% of AI/AN suicide deaths occur among those between the ages 10–17 and 26% occur among those between the ages 18–24 (Leavitt et al., 2018). AI/ANs are nearly twice as likely to die by suicide compared to their NHW counterparts (Leavitt et al., 2018). To synthesize prior literature and the most current nationally available statistics, the general trajectory of suicide risk across the lifespan indicates that AI/AN populations are at greatest risk for suicide between the ages of 10–24 years old, with 36% of suicide deaths among AI/AN youth and young adults occurring within this age range, which is more than two times higher when compared to same-age peers from other ethnic/racial backgrounds (Leavitt et al., 2018). These alarming rates of suicide deaths and increased suicide risk among AI/AN youth populations may be attributed to a number of risk factors, further detailed below, that are present in some AI/AN communities, including underemployment, rural location, lack of belonging, historical trauma, adverse childhood experiences, and mental health and substance use problems (Cunningham et al., 2016; O’Keefe et al., 2019). Importantly, elevated suicide risk among AI/AN young adults is followed by a drastic decrease after age 44, resulting in significantly lower suicide rates for AI/AN older adults, including Elders, when compared to all other ethnic/racial groups (SPRC, 2018). The term “Elder” refers to an older (e.g., age 60 or 65 and above) individual who possesses cultural knowledge and wisdom and is typically well-­ respected and highly revered in AI/AN communities. Taken together, these data provide

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preliminary evidence that AI/ANs in middle- to older-adulthood (e.g., age 40 years and beyond) are at lower risk for suicide and are less likely to die by suicide compared to their same-age peers from other ethnic/racial backgrounds. In general, deaths by suicide among AI/AN populations in the US are projected to continue rising through 2030 unless substantial interventions or sociopolitical changes are implemented. Best et al. (2018) published a modeling study to project estimated, age-adjusted premature mortality rates, defined as deaths of individuals aged 25–64  years, across age, sex, and race/ethnicity from 2017 to 2030. While results demonstrated that suicide rates were projected to increase across all ethnic/racial groups, AI/AN women aged 25–64 were estimated to experience some of the most pronounced increases in suicide deaths. Specifically, the observed crude rate of suicide deaths among AI/AN women aged 25–64 was 20.6 per 100,000 in 2015, and the crude rate of suicide deaths among AI/AN women is projected to be 27.7 per 100,000 in 2030 (Best et al., 2018). Notably, it can be difficult to obtain accurate estimates of suicide rates among AI/AN populations because they are often misclassified as other ethnic/racial groups (Arias et al., 2016) or entirely excluded from studies and datasets (Villegas et al., 2016). This may indicate an underestimation of suicide deaths among AI/AN populations. Therefore, the aforementioned suicide statistics should be interpreted with caution.

 ocial Determinants of Suicide Risk S in AI/AN Populations  ocio-Historical Risk Factors S for Suicide Reasons why some AI/AN communities, particularly AI/AN youth and young adults, are disproportionately affected by suicidality, and related emotional suffering, involve an understanding of historical and contemporary risk factors. AI/AN peoples have endured centuries of stressful and traumatic events. A vast literature exists detailing

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stressful and traumatic events that occurred historically throughout the geographical US and resulted from federal expansionist and assimilation policies, including genocides; community massacres; pandemics resulting from the introduction of new diseases; forced relocation; forced removal of children into Indian boarding schools; forced assimilation into Westernized practices; and losses of traditional cultural and spiritual practices, including losses of land, language, identity, and kinship (Bear et al., 2018; Stannard, 1993; Thornton, 1987). Intergenerational trauma among AI/AN peoples has manifested as psychological symptomology and increased suicide risk (Evans-Campbell, 2008; McQuaid et al., 2017; Wexler et al., 2016). Colonization carries a historical and ongoing burden for AI/ANs that sets the stage for many potent societal factors and stressors thought to contribute to (e.g., correlates of) AI/AN youth suicide (Elm et al., 2019). For example, AI/ANs have the highest rates of poverty compared to all other racial/ethnic groups in the US (KFF, 2019). Poverty has been found to be a risk factor for suicide among AI/ANs, along with living on rural reservations in geographically isolated areas (Goldston et  al., 2008). Unfortunately, the current poverty rates are maintained by limited access to quality education and few opportunities for gainful employment. Some statistics have indicated that the high school dropout rate is higher for AI/ANs compared to other ethnic/ racial groups. For example, the national high school dropout rate for AI/ANs, averaged across males and females ages 16–24  years old, was 11% in 2016, which was higher compared to all other same-age ethnic/racial groups (9.1% for Hispanic/Latino(a)s, 7.0% for Black/African Americans, 6.9% for Pacific Islanders, 4.8% for those who identified with two or more races, 4.5% for NHWs, and 2.0% for Asian/Asian Americans) (NCES, 2018). Data from 2016 also indicated that college enrollment rates were lowest among AI/ANs (19%) compared to all other ethnic/racial groups (i.e., 58% for Asian/Asian Americans, 42% among those who identified with two or more races, 42% for NHWs, 39% for Hispanic/Latino(a)s, 36% for Black/African

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Americans, and 21% for Pacific Islanders) (NCES, 2018). As a result, the unemployment rate for AI/ANs was higher (11%) compared to all other ethnic/racial groups (8% for Black/ African Americans, 5% for Hispanic/Latino(a)s, 4% for Asian/Asian Americans, and 4% for NHWs) in 2016 (NCES, 2018). In addition to increased stress surrounding poverty, AI/ANs often experience systemic discrimination which is further confounded by unique and individual experiences of acculturation stress (e.g., pressure to conform to the dominant culture). These experiences of discrimination and acculturation stress often may occur simultaneously, manifesting at the individual level and have been found to be potent stressors that are consistently linked with suicide ideation (e.g., Wexler et  al., 2015). Drawing on Wheaton’s (1994, 1999) conceptualization of stressors and Evans-Campbell’s (2008) multilevel classification of historical trauma, Walls et al. (2014) proffered a multilevel framework (e.g., individual/ interpersonal microlevel factors; family and community meso-level factors; and broader macro-­ level factors, including government, economics, and environment) for understanding suicide in Canadian First Nations youth. Similarly, we present social determinants of suicide risk among AI/ AN populations by sociohistorical, community, family, and individual contexts below. Walls et al. (2014) conducted six focus groups with Elders and service providers (e.g., counselors/mental health providers, crisis response team members, youth and family welfare/child safety employees, youth educators, and substance use counselors) across three Canadian First Nations reserves to better understand community needs and strengths surrounding Canadian First Nations youth suicide. Thematic analysis of focus group transcripts revealed that youth suicidal behaviors were largely viewed as a problem with historical and contemporary structural roots (Walls et  al., 2014). Specifically, macro-level factors identified as influencing rates of suicide among Aboriginal youth included government influence (e.g., inability to discipline children and effects of the welfare system), economics (e.g., unemployment and dependence on the welfare system), and

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environment (e.g., creation of the reserves by federal systems) (Walls et al., 2014). Contemporary impacts of historical losses, and the link between historical loss thinking and suicidality, have also been empirically studied in AI/AN young adults. In a sample of AI/AN college students, two components of ethnic experience, social affiliation (e.g., one’s preference for social interactions with other AI/AN members), and ethnic identity (e.g., one’s attitudes about their AI/AN identity and about participation in traditional activities) each demonstrated indirect relations to depression symptoms through the frequency of thinking about historically traumatic events and losses (Tucker et al., 2016). In a follow-up study, the frequency that AI/AN young adults thought about historically traumatic events and losses was associated with suicidal ideation through brooding rumination (Tucker et al. 2016).

Community Risk Factors for Suicide Similar to topics discussed previously, community-­level risk factors are rooted in history, connected to societal level risk factors, and influence local tribal systems. While there are few empirical studies that directly link historical trauma to community-level suicide risk, AI/AN scholars have speculated that historically traumatic events have led to community-level responses, including weakened social structures, social malaise, and high suicide rates (Duran & Duran, 1995). Thus, it has been previously articulated that AI/AN communities affected by historical trauma may be more susceptible to these negative “second-order effects” (Evans-­ Campbell, 2008, p. 328). In addition to historical trauma, AI/ANs have long been underserved in healthcare due to systemic barriers, including insufficient healthcare access and healthcare funding, inability to afford medical or psychological care, a shortage of health care providers, and high staff turnover rates (Gray & McCullagh, 2014). As early as 1914, Warren Moorehead, the commissioner for the Bureau of Indian Affairs at the time, described funding for AI/AN healthcare

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as “meager” while describing the funds for education as “lavish” (Moorehead, 1914). These descriptions may reflect the US government’s priorities at the time to assimilate AI/AN peoples rather than provide life-sustaining healthcare. Access to medical care has been identified as an important contributor to health inequities in general among AI/AN populations (Call et  al., 2006). Geographic barriers may further compound difficulties accessing care, particularly when the nearest clinic is located far away, such as outside the city on a reservation (Marrone, 2007; Wille et  al., 2017). While approximately 70% of AIs reside in urban areas (U.S. Department of Health and Human Services, 2017), primary care services through IHS Urban health programs are only funded at 22% of the level of need (IHS, 2021a). The underfunding of healthcare for AI/ AN populations is a trend that continues to this day despite several legislative attempts to secure greater funding (Warne & Frizzell, 2014). For example, the projected budget needed to fully fund IHS for the 2021 fiscal year was $37.6 billion (NTBFW, 2019); however, IHS only received a total budget of $6.4 billion for the 2021 fiscal year (IHS, 2021b). Moreover, even those who can physically access IHS may continue to experience unmet treatment needs due to the significant underfunding of IHS facilities (Wille et al., 2017). The chronic underfunding of IHS impacts the quality of healthcare and contributes to ongoing health inequities among AI/AN populations (Wille et  al., 2017), as the IHS budget has not kept pace with increases in AI/AN populations nor medical cost inflation rates (Warne & Frizzell, 2014). In fact, the Office of the Inspector General has found that while many IHS workers believe passionately in the mission of IHS, they also doubt the ability of the agency to make the lasting and necessary changes to well serve AI/AN peoples (U.S.  Department of Health and Human Services, 2019). The historical underserving and mistreatment of AI/AN communities by medical and research communities alike may further compound community-­level difficulties related to historical trauma and access to quality healthcare. It may be argued that these difficulties interact to con-

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tribute to community-level stigma and mistrust surrounding seeking mental healthcare, particularly for suicidal thoughts and behaviors, in AI/ AN communities. For example, some AI/AN communities may be less likely to report suicidal thoughts and behaviors or seek treatment for mental healthcare when needed. One study compared risk factors of suicide between AI/AN and non-AI/AN adolescents, and findings demonstrated that AI/ANs were less likely to report suicide ideation compared to non-AI/ANs. Moreover, AI/ANs had, on average, two more risk factors (e.g., depression and substance use) stacked against them than non-AI/ANs before they reported suicidal thoughts or attempts (Mackin et al., 2012). Gray and McCullagh (2014) discussed reasons AI/ANs are more reluctant to seek mental health care services than their non-AI/AN counterparts. For example, it is difficult to seek confidential services within tight-knit, rural communities if living on a reservation, indicating stigma against mental health problems is a barrier. In addition, AI/ANs often prefer AI/AN counselors and providers as well as traditional models of treatment (O’Keefe et  al., 2019; Rieckmann et al., 2016). Nevertheless, there is a lack of evidence-based, culturally appropriate services for AI/ANs, and many services available are often run by a majority of staff and providers who are not AI/AN.  This creates a Westernized model of care that is ill-equipped to serve a population whose cultural values and needs fall outside of what Western medicine can offer.

Family Risk Factors for Suicide The role of family relationships and ties to kinship appear to be a significant factor for suicide risk. Family relationships is an important factor to consider, as one of the strongest predictors of suicide among AI/ANs is having a family member or friend who attempted or died by suicide (Langhinrichsen-Rohling et  al., 2009). Other family disruptions, such as child abuse or neglect, divorce, intimate partner violence, and substance abuse in the family, also place AI/AN youth at

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greater risk for suicidality (Brockie et al., 2015; Olson & Wahab, 2006; Warne et al., 2017). Importantly, loss of ethnic identity (defined as the strength of one’s ties to and engagement with one’s culture) and acculturation (defined as the change of identification or engagement from one’s heritage culture to the mainstream American culture) (LaFromboise et  al., 2007) have been found to lead to the dismantling of family structure, further heightening risk for suicide (Gray & McCullagh, 2014). Researchers have speculated that, while ethnic identity is often a protective factor against negative outcomes, its positive effects may not be salient enough if ethnic identity is also tied to ruminative and negative thinking styles in general (Tucker et al., 2016). In fact, Tucker et al. (2016) demonstrated stronger ethnic identity was indirectly associated with depressive symptoms through rumination of historical trauma (Tucker et  al., 2016). In a follow-up study, having a ruminative thinking style was positively associated with suicide ideation in a sample of AI/AN college students (Tucker et al., 2016). These results speak to the importance of strong family connections in mitigating ruminative thinking styles among AI/ AN populations and suggest that prevention efforts should focus on increasing support and promoting cultural and individual strengths.

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level risk factors for suicide that are somewhat unique to AI/AN populations, but are present in other marginalized groups, include discrimination, racism, racialized mascots, racial microaggressions, and thinking about historical losses (Chaney et al., 2011; O’Keefe et al., 2015; Tucker et al. 2016; Tucker et al., 2016). Much of the literature on individual-level suicide risk factors among AI/AN populations, particularly youth and young adults, identifies substance use (i.e., alcohol and drugs) as a strong correlate of suicidality. A population-based study compared AI/AN youth with the youth of other ethnic/racial backgrounds and demonstrated higher prevalence rates of alcohol, cigarette, and marijuana use among AI/ANs compared to their counterparts from other ethnic/racial backgrounds (Subica & Wu, 2018). Further, this study revealed that alcohol, cigarette, and marijuana use each positively predicted suicide attempts among AI/ANs (Subica & Wu, 2018). In another study with reservation-based Apache youth, 91% of those who attempted suicide reported lifetime alcohol use, 88% reported marijuana use, and 48.5% reported illicit drug use; the most frequently reported method of suicide attempts in this study was alcohol or drug overdose (31%), most commonly by prescription drugs (Cwik et al., 2015). Moreover, alcohol is twice as likely or more to be detected in AI/ANs decedents who have died by suicide compared to the general Individual Risk Factors for Suicide population (Caetano et  al., 2020; May et  al., 2002). In line with the majority of the literature, Individual-level risk factors for suicide among the aforementioned studies indicate that alcohol AI/AN populations must be taken into context and drugs play an important role in suicide with familial, environmental, and societal factors among AI/AN youth. However, it is important to to fully understand suicide and suicide preven- further contextualize the role of alcohol and tion from a culturally appropriate perspective drugs in AI/AN communities and to acknowl(Alcántara & Gone, 2007). Many of the same edge the wide variation in use of alcohol and individual risk factors for suicide in the general drugs, including abstinence, that exists across AI/ population are present and more severe among AN communities. For example, prior research AI/AN youth, including substance use, anxiety indicates that AI/ANs do not have a greater and mood disorders, interpersonal factors, and genetic predisposition to develop alcohol use disprevious suicide attempts (Cole et  al., 2020; orders (AUDs) (Enoch & Albaugh, 2017), which Cwik et  al., 2015; Gray & McCullagh, 2014; suggests the importance of social, cultural, and Kelley et al., 2018; Mackin et al., 2012; O’Keefe environmental factors. While the majority of data et al., 2014; Olson & Wahab, 2006; Tingey et al., indicates that AI/ANs have some of the highest 2014; Zamora-Kapoor et  al., 2016). Individual-­ rates of smoking compared to other ethnic/racial

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groups (Jamal et al., 2016), recent work has suggested lower rates of commercial tobacco use among AIs in the Southwest, particularly if they are involved with their tribe (Greenfield et  al., 2018). Identified individual-level risk factors that have been shown to place AI/AN youth at higher risk for suicide than the general population are previous suicide attempts and anxiety/mood disorders (Kelley et al., 2018; Mackin et al., 2012; Olson & Wahab, 2006). A study comparing AI/ AN youth who attempted multiple times to those who attempted once found that youth who attempted multiple times had their first attempt at an earlier age than those who attempted once (Cwik et al., 2015). The authors also found higher depression scores as well as lower social and adaptive functioning among those who attempted multiple times versus those who attempted once (Cwik et al., 2015). Research has indicated that interpersonal risk factors (e.g., perceptions of not belonging and social isolation) are associated with suicidal behaviors and attempts among AI/AN youth. Several studies have demonstrated that lack of belonging predicted suicide ideation, attempts, and deaths (Hill, 2009; Zamora-Kapoor et  al., 2016). A qualitative study with AI/ANs who attempted suicide identified that many participants expressed statements such as “I feel like no one needed me around anymore” (Tingey et al., 2014). Though evidence suggests lack of belonging is a significant risk factor, some studies suggest otherwise. For example, research linking the Interpersonal Theory of Suicide (e.g., Joiner, 2007; Van Orden et al., 2010) with AI/AN populations indicated that thwarted belongingness (i.e., the belief that one is socially inadequate or isolated) was a nonsignificant risk factor for suicide ideation or attempts (Cole et  al., 2020). Perceived burdensomeness (i.e., the belief that one is a burden on others), on the other hand, was linked to suicide ideation among AI/AN populations (Cole et  al., 2020; O’Keefe et  al., 2014). Researchers believe there are several possible explanations of this. One is that there may be a difference between a lack of belonging with one’s culture and community versus lack of belonging

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with one’s immediate social circle (Cole et  al., 2020). Based on measurement methods for thwarted belongingness, it is possible AI/ANs in these studies may not feel a lack of belonging from their culture or community. Rather, suicide ideation may stem from isolation from their immediate friends and family. Studies have identified serious arguments with friends and family members as a trigger for suicide attempts (Cwik et al., 2015), indicating a need for future research to better define the level of social isolation felt by AI/AN youth.

Theoretical Models and Frameworks to Understand Suicide in AI/AN Populations In conceptualizing and understanding suicidality among AI/AN populations, it is vital to first have a solid foundation of knowledge regarding existing theoretical frameworks and how they may be applied to AI/AN suicide. While much of the harm perpetrated by the development of nonrepresentative theoretical models is likely unintentional, it is nonetheless harmful to develop these frameworks without keeping AI/ANs, as well as other marginalized groups, at the forefront of their conception. One conceptual model developed with AI/AN populations is the Indigenist-Stress Coping Model (Walters et  al., 2002). Various interpersonal and environmental factors specific to AI/ ANs such as historical trauma, psychological functioning, and familial or community conflict may contribute to experiencing significant stress. The Indigenist-Stress Coping Model suggests that these chronic stressors often serve as predictors for negative health outcomes such as suicide ideation or substance abuse (Walters et al., 2002). As this model was developed specifically for AI/ ANs, numerous cultural protective factors (e.g., spirituality, involvement in community, family support) have been identified as buffers against these chronic stressors and their associated negative health outcomes (Walters et al., 2002). Another model focused on AI/AN communities is the Cultural Continuity model (Chandler &

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Lalonde, 1998). This model posits that individuals have an inner need to connect their culture across time, carry on traditions, and pass on their own culture to subsequent generations. Cultural continuity is often displayed through factors such as various tribal languages, self-government, and land control (Chandler & Lalonde, 1998). In AI/ AN communities, this model has been examined in the context of suicide. For example, in a sample of Canadian First Nations individuals who had previously attempted suicide, participants’ cited reasons for their suicide attempts related to personal and cultural continuity, including family shame and chronic life stress with relative isolation. These themes are investigated in-depth within the Indigenist-Stress Coping Model described previously (Mehl-Madrona, 2016; Walters et al., 2002). The Cuqyn Model of Protective Factors for Alaska Native (AN) youth (Allen et  al., 2014) was developed to serve as a preventative measure against alcohol abuse and suicide-related outcomes for AN youth. This model suggests that five factors (individual, family, community, social, cultural) interact with each other to result in either the development or the prevention of alcohol abuse and suicide risk (Allen et al., 2014). Many of the measures of this framework are culturally based, including family cohesion, self-­ mastery, peer influences, and support among the community (Allen et al., 2014). The large focus on culture aids to improve cultural relevance and acceptability among the community, potentially improving suicide-related outcomes and alcohol abuse for entire AI/AN communities. Lastly, the Transactional-Ecological Approach to Suicide introduced by Alcántara and Gone (2007) acknowledges intersectionality among individuals by embracing and understanding the systemic and communal factors that can play a role in suicide risks, especially for those who identify as AI/AN persons. Considering environmental stressors and sociological conditions, such as interpersonal influences on personal affect and socioeconomic status, this framework posits that pathology is a communal experience. In other words, various negative outcomes such as suicide deaths or substance misuse impact

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entire communities, rather than simply the individual and their closest relationships (Alcántara & Gone, 2007). Ultimately, this approach aims to address issues at the community level (i.e., widespread substance abuse, suicide-related outcomes) as a preventative measure rather than waiting until crisis and treating negative outcomes on the individual level. The Racial-Cultural Framework (RCF) is a theoretical suicide model that was developed for People of Color broadly by Wong et al. (2014). The RCF is composed of three primary principles that serve as a guide in conceptualizing and preventing suicide-related outcomes among people of color, including 1) culturally relevant constructs to consider when conceptualizing suicide, 2) identifying underserved populations to increase research and clinical practice efforts, 3) suicide prevention efforts among communities of color (Wong et  al., 2014). This framework serves to directly inform suicide research among people of color and should be extended to include AI/AN communities in order to reduce suicide deaths among these communities. The RCF was developed for suicide prevention among People of Color broadly but has yet to be tailored specifically to an AI/AN population (O’Keefe et al., 2018). Most theoretical and empirical suicide models and frameworks were not developed specifically with AI/AN communities, but several have received preliminary empirical support when applied to AI/AN populations. One example is the Interpersonal Theory of Suicide (ITS), which describes the process that leads to death by suicide as composed of three separate constructs— perceived burdensomeness, thwarted belongingness, and acquired capability (Joiner, 2007; Van Orden et al., 2010). It was previously theorized that these constructs may be applicable to AI/AN populations given the theory’s interpersonal emphasis coupled with the collectivistic nature of AI/AN populations (Elliott-Groves, 2018). In fact, these constructs have been empirically examined with AI/AN populations (Chiurliza et  al., 2016; Cole et  al., 2020; Cole et  al., 2013; O’Keefe et  al., 2014). The studies that included the two interpersonal constructs

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from the ITS, perceived burdensomeness and thwarted belongingness, indicated that thwarted belongingness did not predict and/or was not associated with suicidal ideation across AI/AN samples (Cole et  al., 2020; Cole et  al., 2013; O’Keefe et al., 2014). These differential findings, particularly with thwarted belongingness, when examined with AI/AN samples compared to predominantly NHW samples with which the theory was derived (Joiner, 2007; Van Orden et  al., 2010), suggest that the ITS theory may not be culturally relevant for AI/AN populations. The Sociological Theory of Suicide explains that suicide is not the result of solely psychological factors, environmental factors, and sociocultural factors. Durkheim (1951) identified four primary forms of suicide: egoistic, altruistic, anomic, and fatalistic suicide. Empirical support has been found for altruistic and anomic forms of suicide among AI/AN populations, with suicide as a result of cultural changes and historical trauma as an example of anomic suicide in AI/ AN populations (Niezen, 2015; Zitzow & Desjarlait, 1994). While the most recent aforementioned theoretical models and frameworks may inform our understanding of suicide among AI/AN populations, researchers have cautioned that culturally sensitive frameworks should take priority over more broadly focused models such as the Interpersonal and Sociological Theories of Suicide (Parker et al., 2019).

Evidence-Based Treatments for Suicide Prevention and Intervention with AI/ANs While suicide rates in AI/ANs have increased over time, few evidence-based suicide interventions and treatments exist. The disadvantages and adversity AI/ANs face on a daily basis contribute to a decrease in hope and optimism within AI/AN communities, which are important to strengthen when aiming to prevent suicide (Gray & McCullagh, 2014; O’Keefe & Wingate, 2013). Lowering suicide risk among AI/AN populations takes community involvement as well given that community-level risk factors are rooted in his-

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tory, connected to societal level risk factors, and influence local tribal systems. Below, we discuss three culturally focused interventions/treatments to address suicide in AI/AN communities. We encourage individual and tribal-wide providers, researchers, and public health professionals to continue furthering culturally relevant suicide intervention efforts with AI/AN communities. The American Indian Life Skills (AILS) curriculum is a widely known suicide prevention program for AIs (LaFromboise & Howard-Pitney, 1995). This curriculum uses a social-cognitive and stress coping model to address avoidant styles of coping. The program is school-based and includes versions for middle school and high school students (LaFromboise & Howard-Pitney, 1995). Originally developed with Zuni youth, AILS has been expanded to 56 lessons that can be tailored to each tribe and/or school. AILS focuses on seven core elements: building self-esteem, emotions and stress, effective communication and problem-solving, recognition and elimination of self-destructive behavior, understanding why people attempt suicide, how to help a friend who is thinking about suicide, and planning for the future. Outcomes of the AILS include decreased hopelessness, suicidal behavior, and suicide. Participating in the AILS has also been associated with increased confidence in anger control, peer suicide intervention, problem-­ solving skills, public collective esteem, stress coping skills, community support, social resources, self-efficacy, and self-awareness (LaFromboise & Howard-Pitney, 1995; LaFromboise & Malik, 2016; May et al., 2005). While the AILS shows promise for addressing suicide prevention in AI/AN populations, it is not directly a clinical intervention. Dialectical Behavior Therapy (DBT) is one of the few evidence-based interventions for targeting suicidality in youth (MacPherson et  al., 2013; McCauley et al., 2018). Beckstead et al. (2015) adapted DBT for AI/AN youth at an inpatient substance use program. The mindfulness activities central to DBT were culturally adapted to include attending a weekly sweat lodge, smudging ceremonies, and talking circles. A spiritual counselor who attended DBT

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and mindfulness implementation training also explained traditional practices and activities as they related to core DBT and mindfulness skills. Results of this study demonstrated that the majority of participants had clinically significant improvements in both internalizing (e.g., depression and anxiety) and externalizing (e.g., substance misuse, truancy, school performance, and aggression) symptoms (Beckstead et  al., 2015). While this study did not exclusively focus on treating suicidal behavior, it provided initial utility for blending an evidence-based treatment with cultural practices to produce positive outcomes among AI/AN youth. The White Mountain Apache Surveillance Model (WMASM; (Cwik et al., 2014, 2016)) was developed in partnership with researchers at Johns Hopkins University and has demonstrated effectiveness for AI/AN suicide prevention. This model uses community-based surveillance of suicide and suicide-related behavior, as well as case management, to identify individuals at high risk for suicide. A trained team of White Mountain Apache tribal members collects reports of suicidal ideation, suicide attempts, and non-suicidal self-injury, and then follows up with treatment referrals. In the first 5 years of surveillance, the suicide death rate was 40 per 100,000  in this community; however, suicide death rates have been reduced by nearly half in recent years (Cwik et al., 2014, 2016). The WMASM highlights the large impact of community-driven suicide prevention programs by identifying those at risk and making treatment referrals, as well as highlighting the importance of collaborative partnerships between researchers and community members for AI/AN suicide prevention.

Considerations and Limitations of Evidence-Based Treatments for Suicide Increasing help-seeking for suicidal thoughts and behaviors, as well as for addressing other mental health and substance use problems, may help to cultivate resilience and improve mental health outcomes for AI/AN peoples. It is important to

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recognize that many AI/AN communities have existing, designated “natural helpers” who serve as a resource for those in need of help or advice for various topics. These individuals are often sought out prior to seeking help from mental health or medical providers, which may be attributed to strong shared cultural values (Kirmayer et al., 2009), as well as to the historical maltreatment of many AI/AN communities by medical providers and researchers (e.g., Hodge, 2012). It is important to note the key differences in treatment responses among AI/ANs when working with AI/AN versus non-AI/AN medical providers—AI/AN providers are more likely to elicit a positive response from AI/AN patients, resulting in improved treatment responses and overall health outcomes (O’Keefe et  al., 2019). These results may be influenced by an understanding of Native history, AI/AN perspectives surrounding health and wellness, and/or improved rapport, among many other factors. It is imperative that mental health professionals understand the cultural context of AI/AN communities to integrate their cultural values into intervention and treatment approaches, further underscoring the imminent need to increase the number of AI/AN mental health providers in tribal communities in efforts to reclaim collective strength, reduce mental health inequities, and improve overall quality of life for AI/ANs (O’Keefe et al., 2019). Importantly, given historical and ongoing racism, discrimination, and federal tactics aimed to differentially treat AI/AN populations, there may be instances wherein evidence-based treatments will not fit for AI/AN clients. For example, many evidence-based, gold standard treatments for posttraumatic stress disorder (PTSD) center on treating a single index traumatic event (e.g., prolonged exposure therapy; PE) (e.g., Foa et  al., 2005). However, these treatments are limited in scope to explore the additive effects of multiple traumatic events, which span generations for AI/ AN populations (Evans-Campbell, 2008). Further, these diagnostic categories (e.g., PTSD) and evidence-based treatments for such categories (e.g., PE) do not consider the intergenerational transmission of trauma from person to person or within communities (Evans-Campbell,

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2008). Additionally, most psychological evidence-­based treatments and randomized clinical trials (RCTs) were conducted with predominantly NHW populations; thus, rendering many of these evidence-based treatments inapplicable (Brave Heart et al., 2016; Gone, 2009), or offering limited applicability at best. Recently, the Iwankapiya study (Brave Heart et al., 2020) compared a historical trauma and unresolved grief intervention (HTUG) combined with group interpersonal psychotherapy (HTUG+IPT) versus IPT-only to reduce symptoms of depression and related trauma and grief in a sample of American Indian adults. Results of this pilot study indicated that depression symptoms significantly decreased in both treatment groups without a significant difference in depression scores between the two groups; however, HTUG+IPT participants demonstrated greater group engagement, and clinicians preferred administering HTUG+IPT (Brave Heart et  al., 2020). These results are promising and suggest the potential clinical utility of incorporating historical trauma and unresolved grief into interventions for AI/AN populations, which may have implications for suicide interventions with AI/AN populations as well. We recommend that clinicians working with AI/AN clients incorporate the client’s strengths and resilience into therapy, from a holistic, or full spectrum of health, approach. We believe that it is imperative for providers and researchers alike to understand that racism, discrimination, and historical trauma are direct results of larger societal and systemic problems, and the onus should not lie on individual AI/ANs to learn to cope with these cumulative experiences and any potentially resulting psychological problems. Rather, changes to public policy and public education should occur to reduce these harmful practices; thereby, reducing the emotional and physical burden on AI/ANs, as well as those experienced by other underrepresented ethnic/racial groups, to ultimately achieve health equity, social justice, and liberation. Additionally, many AI/AN populations have been disillusioned by the abundant research that has, arguably, overemphasized pathology and negative outcomes in their communities (Stiffman

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et al., 2007). While suicide prevention and intervention efforts with AI/AN populations are critically important public health foci, pathology and negative outcomes are not the complete picture of AI/AN peoples’ way of life, in which many lives are filled with unique cultural strengths and resilience. Moreover, we wish to conclude this chapter with, and impart to the reader, a positive take-away message: strengths and resilience factors have existed in AI/AN communities for centuries despite the lack of empirical published studies and national data on this topic. Moreover, every single AI/AN person living today has persisted and thrived through strengths and resilience despite threats to their very existence.

 esilience and Protective Factors R against Suicide Risk in AI/AN Populations Resilience is a multifaceted construct that transcends societal, community, familial, and individual levels, and resilience can be understood as positive adaptation in the face of adversity (Luthar, 2006). Researchers have studied suicide resilience by identifying protective factors that can reduce suicidal thoughts and behaviors (e.g., Cole & Wingate, 2018). While somewhat limited compared to the vast amount of work on suicide risk in AI/AN populations, researchers have emphasized the importance of identifying and studying protective factors that mitigate suicidal thoughts and behaviors in AI/AN communities (Alcántara & Gone, 2007). Moreover, researchers have begun examining suicide resilience by identifying protective factors in AI/AN populations. Hope, defined as having a positive motivational state based on goal-directed energy (i.e., agency) and planning to meet one’s goals (i.e., pathways) (Snyder et  al., 1991), and optimism, defined as having an expectation that positive events will occur (Scheier & Carver, 1985), have been studied in relation to suicidal ideation among AI/AN peoples. Specifically, O’Keefe and Wingate (2013) demonstrated that hope and optimism were each independently shown to be

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n­ egatively associated with suicidal ideation in a sample of AI/AN college students. Social support is an important protective factor that may mitigate suicide risk at individual, family, and community levels. Strickland et  al. (2006) conducted interviews about youth suicide with AI/AN parents of adolescents and tribal Elders from the Pacific Northwest region. Parents and Elders made similar comments that some of the most important actions to prevent suicide are to hold the family together and maintain cultural values. Notably, participants explained that “holding the family together” did not only mean immediate family members living in the same house. For many parents and Elders, the whole community was considered family. It entailed maintaining healthy communication, passing down traditions, and providing spiritual, emotional, physical, and economic support for those in need (Strickland et al., 2006). Flourishing mental health is the most positive state of emotional, psychological, and social well-being (e.g., Keyes, 2009). Flourishing mental health has been observed in Black and Latinx communities and described as a “unique paradox” given heightened adversity and psychological distress that is also experienced by these communities (e.g., Keyes, 2009). This paradox has also been observed in AI/AN communities (Kading et al., 2015; Walls et al., 2016). This paradox likely contributes to an increased sense of cultural identity, social support, and cultural connectedness encompassing beliefs, values, and practices (Walls et  al., 2016). The combination of these coping mechanisms seems to create a buffering effect to the unique vulnerabilities marginalized communities are exposed to, resulting in the flourishing mental health paradox, which is otherwise interpreted as greater resilience (Keyes, 2009). Spirituality is another important component of AI/AN resiliency and mental flourishing. For example, among AI women with cancer, spirituality was found to be a key factor in buffering against the stress related to cancer (Roh et  al., 2018). In particular, faith served as a source of strength, fostered meaningful connections among friends and family, and allowed these women to

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find meaning in their battle with cancer (Roh et al., 2018). Similar effects have been observed in AI/AN youth populations, wherein many adolescents are exposed to substance abuse and violence at frequent rates and at younger ages when compared to their non-Native White counterparts (Kulis et al., 2017). A strong desire to uphold and live by AI/AN spiritual beliefs was determined to delay substance use, as well as uphold antidrug attitudes and norms. Culture plays a particularly important protective role among AI/ANs, often enhancing the effectiveness of medical treatment and facilitating healing. This effect can likely be attributed to the sense of identity found in collective culture, providing a basis of long-held tradition and establishing a sense of belonging or purpose in the world (Bassett et al., 2012). A study with AI/ AN college students in the Southwest demonstrated that they engage in low rates of alcohol use and cigarette smoking compared to the general student population, and this effect was stronger for AI/AN students who were involved with traditional cultural activities (Greenfield et  al., 2018). In fact, contrary to stereotypical depictions, empirical studies have demonstrated that some AI/ANs abstain from alcohol at greater rates when compared to NHWs, with 60% of AI/ AN individuals and 43% of NHWs choosing to abstain from alcohol (Cunningham et al., 2016). These lowered rates are indicative of flourishing behavioral health in the face of historical, societal, and economic disadvantages faced by AI/ ANs and are likely bolstered by AI/AN culture. As previously mentioned, rates of suicide among AI/ANs over the age of 40 are significantly lower compared to their NHW counterparts (SPRC, 2018). As such, these data provide preliminary evidence that AI/ANs in middle-age to older-adulthood (i.e., age 40 and beyond) are less likely to attempt suicide. This finding highlights the importance of studying AI/AN Elders to better understand their low risk for suicide compared to their same-age counterparts from other ethnic/racial groups, particularly NHW middle-age and older adults. Several previous empirical studies have involved community Elders in suicide prevention and other mental

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health treatment efforts with AI/AN youth (Rasmus et  al., 2014; Strickland et  al., 2006; Walls et al., 2014) given their respected cultural status as caregivers, storytellers, and wisdom-keepers. Engagement in traditional cultural activities in AI/AN communities has also demonstrated a protective role in suicide prevention. For one Yup’ik village in Alaska, community members place an emphasis on interconnectedness, the concept that one is connected to all things—the animals and land, community Elders, and the past, present, and future. This cultural network has a positive effect on the village, fostering resilience on both the individual and community levels. This is especially imperative for youth in the Yup’ik Alaskan village who may be more at risk than their ancestors ever were for trauma and crisis (Rasmus et  al., 2014). One promising approach to enhance resilience in AI/AN communities involves culture/community as treatment or medicine. For example, AI/AN Elders may play an important role in developing suicide interventions for their communities, according to one empirical study involving the White Mountain Apache Tribe. By delivering cultural education to AI/AN youth through storytelling, emphasizing the value of respect and sacredness of life, and Apache culture/traditions, AI/AN communities could greatly benefit from reduced suicide rates for their youth and adolescents (O’Keefe et al., 2019). This cultural approach has the capacity to enhance resilience and overall quality of life in AI/AN communities. The literature thus far has significantly strengthened suicide prevention, intervention, and research efforts in AI/AN communities. To continue furthering these efforts, we recommend that individuals and systems actively attempt to increase the number of Indigenous scholars conducting research in AI/AN communities. This may include increasing opportunities for Indigenous high school students to engage and participate in college preparation. It may mean increasing opportunities for undergraduate students to be competitive for graduate school and means greater support for graduate students to engage with, participate in, and cre-

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ate culturally relevant research. It is recommended that systems provide increased training and support to early career investigators advancing research in AI/AN communities. This may mean accommodations on the tenure timeline for the time taken to build relationships with AI/ AN communities and may also include, for example, increasing the number of applications for Research Supplements to Promote Diversity in Health-Related Research through the National Institutes of Health (NIH) among other funding opportunities for research. To increase the cultural relevance of research conducted in AI/AN communities, we recommend increasing cultural knowledge in grant review criteria and among grant reviewers as grant reviews and reviewers are gatekeepers to which studies ultimately receive funding. It is also recommended that efforts are made to ensure that AI/AN populations are sufficiently represented in grantfunded projects and priorities. For individual researchers, we recommend building and strengthening connections with the tribal communities in your area. Relationships are crucial in AI/AN communities and trust often has to be earned. We suggest contacting local tribes to build collaborative partnerships. Researchers may also wish to contact local tribal or area health boards, which often serve as liaisons between tribes and researchers. The National Indian Health Board (NIHB) maintains a list of area health boards and contact information. It is imperative that researchers review existing guidelines for research among AI/AN communities in order to better understand best practices and gain competence in working with AI/AN communities. Some resources include the American Psychological Association (APA) ethics code commentary on culturally appropriate recommendations for research and practice within AI/AN communities by the Society of Indian Psychologists (Morse & Blume, 2013). Guidelines for research with tribal youth by the National Congress of the American Indian, and Principles for engaging in research with Native American communities by the University of New Mexico and several tribal communities (Straits et al., 2012).

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Lastly, for individuals and institutions (e.g., universities) alike, we recommend increasing programs and supports to encourage AI/AN students, as early as middle or high school age, to pursue college and advanced degree programs in health and mental health-related fields. We believe that increased intuitional supports, in particular, that provide opportunities to train AI/AN students will strengthen what has previously been referred to as a “leaky pipeline” by facilitating sustainable recruitment and retention efforts for AI/AN students. These efforts will help to address the call for increased numbers of AI/AN researchers, providers, and practitioners (O’Keefe et al., 2019), and will likely further help to positively impact the health of AI/AN communities and their members. In closing, we have outlined the unique historical, societal, cultural, and political aspects that impact suicidality among AI/AN communities. We also provided an overview of the historical and current suicide rates in AI/AN communities by summarizing past literature and recent national statistics. Further, we outlined both theoretical and empirical frameworks that have been applied to understanding suicidality among AI/AN communities. We also reviewed suicide prevention and intervention efforts that have demonstrated effectiveness, efficacy, or promise with AI/AN communities. We highlighted some of the unique cultural strengths and resilience factors among AI/AN communities, which are often overlooked in suicidology. While AI/AN communities continue to experience significant stressors ranging from racism and chronic underfunding of health services to individual experiences that are connected to suicidality, AI/AN communities also have key strengths that should be leveraged to address suicidality in their communities. Lastly, we provided recommendations on suicide prevention and intervention efforts for AI/AN communities, with the hope that these recommendations will help guide and improve future work among suicide researchers, providers, and practitioners. Finally, we conclude by calling on systems and individuals to help address suicidality in Indian country by centering culturally relevant understandings while

not overemphasizing pathology and negative outcomes when working with AI/AN communities. Land Acknowledgment  Much of the preparation and writing of this chapter occurred near Oklahoma State University (OSU) located in Stillwater, Oklahoma. OSU sits on lands promised to the Muscogee (Creek) Nation in exchange for their ancestral homelands during the 1830s removal period. Originating in the Great Lakes area and migrating south and west, the Iowa was placed by an 1883 Executive Order in the area just south of present-day Stillwater, which was established illegally by “boomers” in 1884. Just prior to the April 22, 1889, land run, the first of seven official land runs, President Harrison proclaimed the lands “unassigned” and open for settlement. Funding: The preparation of this work was supported by R01CA221819-01A1S1.

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Asian American Youth Suicide: Research and Intervention

14

Elizabeth A. Yu and Edward C. Chang

Suicide is the second leading cause of death among individuals ages 10–24  in the United States (US) (Centers for Disease Control and Prevention [CDC], 2011/2013; World Health Organization [WHO], 2014). Kann et al. (2014) identified that an astonishing one out of five high school students has considered suicide. Further, among adolescents with suicidal thoughts, fewer than 17% receive mental health services, indicating a stark gap between mental health care need and mental health care utilization (Cummings et al., 2010). While these findings help to highlight the prevalence of suicide risk in this age group, they also point to the continued need for research to identify specific risk factors and protective factors, and the development of prevention programs, interventions, and treatments. Although suicide is an important mental health concern among all age groups, including adolescent youths and young adults, it may be especially important among ethnic and racial minority groups. Most research on suicide has focused on non-Hispanic White samples (Goldston et  al., 2008), and it is possible that these findings do not generalize to, or capture the nuanced cultural experiences of individuals from other ethnic and racial groups. Furthermore, adolescents experiencing suicide ideation have low

E. A. Yu (*) · E. C. Chang University of Michigan, Ann Arbor, MI, USA e-mail: [email protected]; [email protected]

rates of mental health utilization and racial and ethnic minority youths are even less likely than White peers to seek and receive mental health treatment in outpatient and inpatient settings (Cummings & Druss, 2011; Nestor et al., 2016). Indeed, Wong et  al. (2014) have argued for the importance of reducing barriers to mental health treatment for youths of color who experience suicide ideation and behaviors. The goal of this chapter is to outline our current understanding of factors (both risk and protective) that affect suicide among Asian American youths. We start by elucidating the importance of understanding suicide risk among Asian American youths. We then discuss important unique cultural factors and considerations that may serve as a risk for suicide or protective against suicide among Asian American youths as well as more nuanced understanding of how these cultural factors may function. Finally, we will highlight some important considerations for the development of prevention programs and interventions for Asian American youth suicide.

 he Importance of Understanding T Asian American Youth Suicide Asian Americans are one of the fastest growing populations in the US, growing by over 45% from 2000 to 2010 (US Census Bureau, 2015). Despite this growth, Asian Americans continue to

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_14

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have unmet mental health needs related to intervention and treatment (Cheng et al., 2017; Hall & Yee, 2012; López et  al., 2017). Compared with other racial and ethnic groups, research on Asian American adolescent mental health is especially sparse (Goldston et  al., 2008), and researchers have emphasized the important problem of mental health concerns being under-identified and underserved among Asian American adolescents (Garland et  al., 2005; Kataoka et  al., 2007). Several factors may contribute to this problem. First, the “Model Minority” stereotype wrongly shapes the perception that Asian American youths are less likely to have mental health problems, leading to the disconcerting level of unmet needs in this population (Miller et  al., 2011). Second, Asian Americans tend to underutilize mental health services, with mental health stigmatization likely playing a large role in hindering Asian American youths and families from seek services. For example, in a study by Walker et  al. (2008) Asian American youths were found to have the highest level of stigmatization after reading vignettes about depression compared with non-Asian counterparts. Third, and relatedly, Asian American youths are also more likely to be hidden ideators, not disclosing their suicidal thoughts and feelings (e.g., on assessment forms, clinician prompting; Morrison & Downey, 2000). This means that individuals in this group are less likely to spontaneously disclose struggles with suicide ideation without being prompted, and even sometimes may continue to hide struggles when explicitly asked about suicide ideation and behaviors. Although there are no large epidemiological estimates for Asian American youth suicide, some findings have indicated that Asian American adolescents report higher rates of suicide ideation than European American adolescents (Vander Stoep et  al., 2009). Indeed, in a study of Asian American middle schoolers, La Salle et al. (2017) found that Asian American students were at increased risk of suicidal thoughts and behaviors compared to their non-Hispanic White peers. Taken together, it is especially important to continue building greater understanding of, and interventions for Asian American youth suicide.

E. A. Yu and E. C. Chang

 arriers to Mental Health Care B for Asian American Youth It is important to acknowledge the many barriers to Asian American youth suicide detection and intervention. First, logistical hindrances such as language and transportation may impact Asian American youth and/or their families’ access to mental health services. It is important to continue efforts to reduce these logistical barriers through increasing accessibility of mental health interventions through schools, virtual services, and translators. Furthermore, factors such as stigma, low mental health literacy among guardians or caregivers, and lack of evidence-based and culturally competent interventions for Asian American youths also obstruct Asian American youths’ access to mental health care (Gudiño et al., 2008; Leong & Lau, 2001). Cultural values that promote saving face or not bringing shame to the family may function in ways that exacerbate or maintain stigma and reduce willingness to seek help (Cauce et  al., 2002). In a study of Vietnamese-American youths, Guo et al. (2015) found that stronger family obligation related values suppresses the association between mental health need and help seeking. Relatedly, immigrant parents of Asian American youths that adhere more strongly to these cultural values that contribute to mental health stigmatization may be less likely to perceive a need for mental health care, consent to mental health care, and interact with mental health care providers as part of treatment for their child (Cauce et al., 2002; Kataoka et al., 2007). Assessment tools and interventions to target mental health needs, including suicide ideation and experiences, have predominantly been developed with non-Hispanic White populations. Given the unique cultural experiences of Asian American youths, the absence of culturally informed assessment tools and interventions bring to question the cultural competency available to provide risk assessment, prevention, and treatment for Asian American youths. As previously noted, the “Model Minority” myth also perpetuates obstacles to mental health care for Asian American youths. Researchers have found

14  Asian American Youth Suicide: Research and Intervention

that compared with non-Asian American youths, Asian American youths are less likely to exhibit disruptive behaviors and typically have less involvement with school disciplinary action, factors that typically prompt the identification of mental health needs and lead to referrals (Guo et al., 2014; Nguyen et al., 2004). Increased culturally competent psychoeducation is needed to help parents, teachers, and health care providers identify factors related to increased suicide risk for this population group, a topic we will discuss in the next section.

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impulsivity, antisocial behaviors, and under-­ controlled behaviors) were not supported as a risk factor for suicidality for Asian American youths. Similar to majority groups, past suicide attempt is one of the strongest predictors of future suicide attempts (Hishinuma et al., 2018; WHO, 2014). In their 6  months longitudinal study of over 2000 high schoolers who identify as Native Hawaiian, Pacific peoples, and Asian American, Hishinuma et  al. (2018) found that youth who self-reported a suicide attempt at Time 1 had an approximate suicide attempt rate of 29% at Time 2 compared to the rate of 1.4% for the youth who did not report a suicide attempt at Time 1. Risk Factors for Asian American Youth Interestingly, with regard to gender differSuicide ences, while some findings are consistent with that from the majority group indicating that In this section, we will focus on risk factors that female adolescents report more suicide ideation have been found to be especially important and behaviors compared to male adolescents among Asian American youths. Bronfrenbrenner’s (Else et al., 2009), there is support that a smaller (1979) Ecological Model, which works to under- gender gap in suicidal behaviors and risk exists stand how behaviors are influenced by the inter- among Asian American groups compared to actions between individual, interpersonal, social, majority groups (Hishinuma et  al., 2018; Lau and cultural levels has been shown to be a useful et  al., 2002; Shiang et  al., 1997). This further guide for the study of suicide among racial and highlights the need to develop more cultural ethnic minority groups, including Asian competency in understanding Asian American Americans (Cheng et  al., 2010). This model is youth suicide. One possible problem without this helpful in recognizing that there are several lay- competency may be that suicide risk among ers of influences, beyond the individual factors Asian American male youths is disproportionthat are typically the focus, that contribute  to ately under-identified. Indeed, some findings understanding Asian American youth suicide. have shown that Asian American males are at At the individual level, Asian American youths heightened risk for suicide compared to males share some risk factors for suicide with their from other racial and ethnic groups at the elemajority counterparts (Lau et  al., 2002). With mentary and middle school levels (Kim et  al., regard to age, older Asian American adolescents 2018). have increased risk of suicidal behaviors. In a With regard to specific ethnic group, there study of Asian American children and adoles- may be specific ethnic group differences in Asian cents, Lau et  al. (2002) found that about three-­ American youth suicide. However, more research quarters of the suicidal youths in their study were is needed, as studies typically examine Asian adolescents between the ages of 15- and 17-years Americans as a homogeneous group or do not old. Individual psychopathology is also an impor- have large enough sample sizes of specific Asian tant risk factor, similar to findings from White American ethnic subgroups to conduct meaningAmerican youth samples. In the same study, the ful statistical analyses. Differences in immigrasuicidal Asian American youths were also more tion history, generational trauma experiences, likely to have a depression-related diagnosis and refugee experiences, and socioeconomic and higher internalizing symptoms compared to the acculturative stress may contribute to different non-suicidal group (Lau et  al., 2002). rates of suicide among specific Asian American Externalizing symptoms and behaviors (e.g., ethnic groups. As such, it is also possible and

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likely that there is an even bigger dearth in the field’s understanding of the unique predictors of suicide risk, assessments, and interventions to more specific Asian American ethnic groups. It is also helpful to understand the risk factors of Asian American youth suicide beyond the individual level. Indeed, there are unique cultural considerations that suggest that the interplay of interpersonal, social, and cultural levels may be especially important to take into account when conceptualizing Asian American youth suicide risk factors. Most salient perhaps is the greater cultural emphasis on interdependence, relational harmony, and family cohesion. Joiner Jr.’s (2005) Interpersonal-Psychological theory of suicide (Joiner Jr., 2005; Van Orden et al., 2010) which suggests that thwarted belongingness and perceived burdensomeness to others are key factors that lead to suicidality may be especially salient for understanding suicidal risk among more interdependent and collectivist cultural groups, including Asian Americans. Tang and Masicampo (2018) found that Asian American college students reported higher levels of perceived burdensomeness and thwarted belongingness compared to White students. They also identified that Asian American students self-reported less willingness to seek help from mental health professionals compared to White American students. Interestingly, these researchers found that for Asian Americans, perceived burdensomeness works to increase suicidality but also decrease willingness to seek help with fear of bringing shame to their family being an additional motivating factor for not seeking help. Family relationships, school relationships, and peer relationships can serve as important risk or protective factors for Asian American youth however differences exist based on factors such as acculturation level and gender (Wong & Maffini, 2011). The parent-child relationship, especially parental stability, warmth, support, and conflict is a major suicide risk factor for all adolescents, but perhaps especially for Asian American youths. Asian American youths have unique challenges related to needing to develop bicultural competency and effectively navigating potential

E. A. Yu and E. C. Chang

intergenerational differences in acculturation and cultural values. Difficulties in these areas can lead to increased experiences of conflict especially between Asian American youths and parents who have different acculturation levels, which in turn can result in mental health concerns, including suicide risk (e.g., Berry et al., 1987; Cheng et al., 2010; Cho & Haslam, 2010; Liu et  al., 1990; Phinney et  al., 1990). Parent-­ child conflicts around topics such as clothing choices, relationships with peers, dating, and communication styles may lead to increases in stress and adjustment difficulties. Lau et  al. (2002) found that Asian American youth who experience a high level of parentchild conflict had a 30-fold increase in risk for suicide behaviors compared to Asian American youth who had low levels of parent-child conflict. The link between parent-child conflict and increased risk for suicide behaviors appears to be complicated by varying acculturation levels. Specifically, mixed messages around acculturation such as parents’ disapproval of their Asian American children adopting the norms of the majority culture while also encouraging Asian American children to acculturate in order to aid them as interpreters or negotiators within the majority culture may also contribute to adjustment stress and identity confusion for the Asian American youth. Indeed, Asian American youth with higher levels of acculturation experience higher levels of parent-child conflict. However, the link between higher parent-child conflict and increased risk for suicide behaviors is especially strong for Asian American youth with lower levels of acculturation (Lau et al., 2002). Asian American youths with lower levels of acculturation may adhere more strongly to cultural values that encourage deference to parents and elders and family cohesion. When there is greater conflict between parent and child, this may be especially distressing to this group. For Asian American youths with higher levels of acculturation, they may not hold to the same cultural values as strongly and may also have a wider range of social supports (e.g., peers) they can turn to when there is conflict in

14  Asian American Youth Suicide: Research and Intervention

the parent-child relationship. Relatedly however suicide attempts made by a friend is also an important risk factor for Asian American youth suicide (Hishinuma et al., 2018). Interpersonal violence is another area of concern related to suicide risk. In a study of Hawaiian high school students, Else et al. (2009) identified that experiences of both victimization and perpetration of domains of teen power and control (e.g., physical violence, emotional abuse, peer pressure, sexual coercion) were related to seriously considering suicide, making a suicide plan, and suicide attempt. However, associations were stronger for victims of interpersonal violence compared to perpetrators. Wang et  al. (2018) found that face-to-face victimization, cyber victimization, and perceived negative school climate predict higher suicidal thoughts and behaviors among Asian American middle schoolers. The harmful impact of cyber and face-to-face victimization on suicidal ideation and behaviors was stronger for girls than for boys. These findings support the need to understand social and interpersonal factors that increase the risk for Asian American youth suicide.

 rotective Factors against Asian P American Youth Suicide Just as there are many different risk factors for Asian American youth suicide, it is also important to understand how individual, social, and cultural factors may serve as protective factors. Similar to findings from majority groups, social support is one of the most important protective factors against youth suicide for Asian Americans. Although support from peers, school, and other relationships is important, parental and family support is the most important source of social support to protect against suicide risk (Cho & Haslam, 2010; Hishinuma et al., 2018; Wong & Maffini, 2011). Relatedly, parental involvement with education has been found to be inversely related to suicidal ideation and behaviors among Asian American middle school youths (Wang et  al., 2018). Parental involvement may work to improve

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academic achievement as well as provide parental support that helps to foster mental health and well-being (Wang & Sheikh-Khalil, 2014). Furthermore, strong ethnic identity can also be an important protective factor (Cheng et al., 2010) however findings can be mixed as some suggest that stronger ethnic identity is associated with higher self-esteem whereas others may suggest that higher ethnic identity may also be related to adjustment difficulties to the mainstream culture and a sense of dissonance between the adolescent’s sense of self and their peers. This highlights the importance of understanding the nuances of how and when different cultural factors may serve as risk or protective factors. Similarly, perceived burdensomeness often is shown to function as a factor that increases the risk for suicide. However, in a qualitative study of Asian American college students, Tran et  al. (2015) found that the desire to not hurt or burden others as an important reason for living and for not acting on their suicidal ideation. Other protective factors identified from this study were: self-reliance, where individuals cited their willpower, self-control, including restraint and a belief in their ability to independently resolve emotional distress; social support from family, friends, romantic partners, and mentors; insight and meaning, where individuals cited a realization for a purpose in life, being future-oriented, and humility and gratitude for their lives; and fear, including fear of physical pain, the unknown, and fear of an unsuccessful attempt resulting in further distress. Finally, high academic achievement has been noted as an important protective factor for Asian American youths. Hishinuma et al. (2018) found that higher selfreported grade-point average predicted lower levels of suicide attempt rates. At the broader school level, Wang et  al. (2018) found that a positive school climate, which indicates a supportive school environment that students view as a safe place, can protect against suicidal ideation and behaviors and buffer the negative associations between cyber and face-to-face victimization and suicide ideation and behaviors.

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 revention and Treatment of Asian P American Youth Suicide There remains a lot unknown in suicide prevention and therapeutic intervention for youth suicide in general, and that dearth in knowledge is even larger among specific racial/ethnic groups including Asian Americans. One of the first and most important steps toward prevention and treatment is having effective means for assessment and identifying high-risk Asian American youth. Schools are on the frontline for identifying and preventing adolescent suicide risk. Efforts have been taken at many schools to implement gatekeeping models which focus on providing student suicide detection and assessment training to school personnel (i.e., gatekeepers) and crisis intervention training to aid in the referral processes (Kim et al., 2018). The goal of such programs is to help gatekeepers increase knowledge, increase confidence in their ability to intervene with a high-risk individual, and promote supportive attitudes of suicide prevention (Chagnon et  al., 2007). However, the efficacy in reducing suicidal behavior, referring to mental health services, and receiving mental health services is not as strong as was hoped for these programs (Condron et al., 2015; Foster et al., 2016). Some findings indicate that programs that have longer periods of training show stronger results. The barriers described earlier in this chapter are also important barriers to consider when designing gatekeeper training programs to reduce Asian American youth suicide. The authors offer the following recommendations to possibly increase the efficacy of gatekeeping efforts to reduce suicide risk among Asian American youth: 1. Gatekeepers need to be trained in understanding cultural differences in the presentation of suicide risk factors for Asian American youth (e.g., hidden ideators, experiences of internalizing symptoms, signs of family conflict, acculturative stress). 2. Gatekeepers also need to be comfortable and ready to explicitly assess for suicide ideation and behaviors, possibly asking in multiple ways or multiple times in order to provide

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many opportunities for Asian American youth who have hidden ideator tendencies to disclose their struggles with suicide ideation, plans, or attempts. 3. While training gatekeepers, programs may be improved with the inclusion of diversity training to encourage gatekeepers to be mindfully aware of their own cultural biases. Gatekeepers need to continually check whether they may be subscribing to the “model minority” myth which contributes to under-­identification of at-risk Asian American youths. 4. Although referring at-risk youth to community mental health services is a goal of the gatekeeping programs, we know that ethnic minority adolescents, including Asian American adolescents, are less likely to be referred for mental health services. Gatekeepers should also be provided with resources for identifying culturally competent referrals available in the community. Psychiatric emergency departments are also important catchment sites and efforts to intervene in reducing suicide risk following hospitalization is imperative. Studies have shown that adolescents have an increased risk for mortality following hospitalization for a suicide attempt (Goldston et al., 1999). A few notes may be important for emergency department detection of and interventions for suicide risk for Asian American youth: 1. When assessing for past and present suicide ideation, it is important to note that hanging is the most common suicide method among Asian Americans, occurring at higher rates than for White Americans (Wong et al., 2018). This is especially problematic as means for hanging are widespread (e.g., rope, belts, and anchor points such as closets, stair rails, and doorknobs). Typical efforts to reduce access to means are not as simple and less effective for suicide by hanging. Prevention strategies may include encouraging families to install break-away closet bars, lower the  height of anchor points, increase monitoring, reduce access to ligatures such as rope, belts, and loose cords, and reduce the misconception

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that suicide by hanging is a “clean” lethal method that involves little pain (Baker et al., 2013; Wong et al., 2018). 2. Asian American youth who died by suicide are also more likely to leave a suicide note compared to other ethnic groups (Lee & Wong, 2020). This may be helpful to identify Asian American adolescents who are at higher risk and need higher level of care. 3. Clinicians working with the parents of the Asian American adolescents who present to the psychiatric emergency departments will also need to work to build rapport with parents who may hold more mistrust of mental health services, deny the severity of the suicide risk for their child, and who may hold more stigma around mental health concerns including suicide. As parental involvement and support is especially important in the treatment and prevention of suicide for Asian American youth, this is an especially important part of the emergency and inpatient interventions.

health stigma and reduce early treatment dropout. Psychoeducation for both the at-risk youth as well as for their parents would be important. 3. If there are logistical barriers in the way, such as transportation, time, and language, continued efforts to reduce barriers may include increased teletherapy options and services where translators are available. 4. Clinicians also need to continue building cultural competency in working with Asian American youth and families. This can be aided through better understanding the cultural values of their client and client’s family. Reading about commonly held Asian American values can also help supplement their knowledge. Finally, as the research on Asian American mental health continues to grow, it is important for clinicians to keep up with evidence-supported best practices for working with Asian Americans as well as more nuanced considerations for specific Asian American ethnic subgroups.

Within outpatient treatment settings, continued efforts to reduce barriers to mental health service utilization among Asian Americans is needed.

According to a 2015 meta-analysis of randomized clinical trials (RCTs) for treatment of suicidal thoughts and behaviors among adolescents, there are no interventions that meet the criteria to be considered a “well-established treatment” and only six interventions that are identified as “probably efficacious” for reducing suicidal ideation and behavior (Glenn et  al., 2015). At this time there are no interventions that have been developed or tested to target reducing suicidal ideation and behavior among Asian American adolescents. Given this dearth, we would recommend following protocols for the “probably efficacious,” and when available, “well-established treatment” interventions developed for general adolescent populations while being mindful of, and making adaptations for cultural considerations. According to the meta-­ analysis, common elements found in the promising treatments include family skills training, parent education and training, and individual skills training. Heavier emphasis on family skills training and parent education and training may be especially important in interventions adapted

1. When working with Asian American youth, parents, and families, one of the key factors to assess for is parent support, including their support of treatment. Earlier discussion in this chapter on the importance of parental support showed that this is one of the most salient risk-protective factors for Asian American youth therefore this should also be an important part of treatment and intervention. Rapport building with parents and encouragement of their active supportive involvement in treatment may be especially beneficial for Asian American youth. 2. Researchers on Asian American mental health treatments have identified that more thorough psychoeducation early in the treatment process is especially important when working with Asian American populations (Hwang et al., 2018). This may help to reduce mental

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for working with Asian American youth. Skill-­ building-­based interventions such as individual, family, or group Cognitive Behavioral Therapy or Dialectical Behavioral Therapy are more effective compared to supportive therapy (Glenn et al., 2015; McCauley et al., 2018). Additionally, “skill building” may be less stigmatizing than “therapy” for some individuals and families and may increase treatment adherence. The Youth-Nominated Support Team (YST) Intervention has shown some promising results (King et al., 2019) and may be especially useful for reducing mortality by suicide for Asian American youth. In this intervention, adolescents nominate, with permission from parents and guardians, “caring adults” to involve in their intervention plan. These nominated individuals meet with YST specialists to learn about the adolescent’s mental health concerns, treatment plans, and ways they can support the at-risk youth. The nominated “caring adults” will meet with the at-­ risk adolescent with support from a YST specialist over the course of 3  months. YST may be effective for Asian American youth due to its interpersonal approach and efforts to increase social support for the at-risk youth. It is also possible that parents of the Asian American at-risk youth may also benefit from this broader support and this collective approach to help their child struggling with suicidal ideation and/or behaviors. Shame and stigma are potential barriers to implementing YST with an Asian American youth or family. The individual or family may not wish to disclose mental health struggles with others. Continued efforts to identify appropriate cultural adaptions for programs such as YST or other interventions are needed.

Conclusion There remains a lot of room to grow as a field in understanding risk and protective factors of Asian American youth suicide and efforts to reduce risk and mortality by suicide in this population. Suicide is a serious concern among Asian American youth and this concern is even more greatly exacerbated by the dearth in research and

interventions. Several key takeaways from this chapter will be highlighted here. First, suicide as a concern among Asian American youth is minimized as a result of false beliefs in the “model minority” myth. This reduces the likelihood of at-risk Asian American youths from being identified and assessed for suicide ideation and behaviors. Second, Asian American youth are more likely to present as “hidden ideators” compared to peers from other racial and ethnic groups. This also reduces the likelihood of effective risk assessment and identification of at-risk individuals. Third, while family and parents can be a strong source of support and an especially strong protective factor, when this is absent, it can serve as an especially detrimental risk factor for Asian American youth. Factors to consider and intervene on include: parental support, parent-child conflict, stigma of mental health concerns, suicide, and treatment, the youth’s fear of bringing shame to their families, acculturation differences between parent and child, and other logistical barriers (e.g., language and mental health service accessibility). While no well-established evidence-­ based treatment for Asian American youth suicide exists yet, cultural adaptations to currently available interventions developed for general or majority group adolescent populations may be helpful.

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Suicidal Behaviors in Youth with Foster Care Experience

15

Colleen C. Katz, Danielle R. Busby, and Eden V. Wall

Introduction There are currently over 430,000 youth in the United States (US) Foster Care System (U.  S. Department of Health and Human Services, 2020). The majority of these youth have been placed in foster care as a result of parental maltreatment, with neglect being cited as the most common reason for entry (U.S.  Department of Health and Human Services, 2020). Youth entering foster care may also have experienced physical abuse (about 13% of youth entering foster care) or sexual abuse (4% of youth entering foster care) and may have a parent or primary caregiver who was engaging in substance abuse (36% of youth entering foster care). Risks associated with child maltreatment and foster care entry are well documented (Doyle Jr, 2007; Jonson-Reid et al., 2012). Youth with maltreatment experiences are more likely than their peers without them to experience psychiatric illness (Oswald et  al., 2010), to engage in substance use and abuse (Moran et  al., 2004; Tonmyr et  al., 2010), to engage in violent and delinquent behaviors C. C. Katz (*) · E. V. Wall Silberman School of Social Work, Hunter College, CUNY New York, NY, USA e-mail: [email protected]; [email protected] D. R. Busby Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]

(Stouthamer-Loeber et al., 2001; Topitzes et al., 2011), and to report limited social support (Sperry & Widom, 2013). Youth in foster care are also significantly more likely than their peers outside of the system to engage in suicidal behaviors (Anderson, 2011; Brown, 2020; Evans et  al., 2017; Hjern et  al., 2004; Katz et al., 2011). In this chapter, we will explore the suicidal behaviors of youth with foster care experience, including how often these youth tend to engage in suicidal behaviors and which youth may be at highest risk. We will then discuss three potential reasons for this enhanced risk: a history of maltreatment (specifically physical and sexual abuse), high rates of mental illness (both psychiatric illness and substance use), and inadequate social support (both familial and peer). We will also explore how these risk factors map on to the Interpersonal-Psychological Theory of Suicidal Behavior (Joiner, 2005) and conclude with a discussion of promising assessments and interventions that could be used for youth with foster care experience.

 uicidal Behaviors of Child Welfare-­ S Involved Youth In a recent review, Evans et al. (2017) found that youth in foster care are about twice as likely to experience suicidal ideation and three times as likely to attempt suicide as those in the general or

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comparison populations (Evans et al., 2017). The prevalence of suicidal ideation in child welfare-­ involved youth ranges between 10% and 27% in the majority of studies (Anderson, 2011; Gabrielli et  al., 2015; Harkess-Murphy et  al., 2013; Johnson et  al., 2002; Sigfusdottir et  al., 2013; Taussig et al., 2014; Zapata et al., 2013). Pilowsky & Wu (2006) found that about 26.8% of the child welfare-involved youth in their study reported suicidal ideation and 15.3% reported suicide attempts, compared to 11.4% (ideation) and 4.2% (attempts) of same-age youth who were not child welfare-involved. Some studies report even higher rates of suicidal behavior in child welfare populations. Hukkanen et  al. (2003) found that 32% of child welfare participants in their sample in Sweden engaged in self-destructive and suicidal behavior. Similarly, Harkess-Murphy et  al. (2013) found that 32% of child welfare participants in their sample in Scotland had engaged in suicidal behavior (ideation or attempt). In a sample of child welfareinvolved adolescents in Spain (ages 14–17), Suarez-Soto et al. (2018) found that 39.4% were engaging in suicidal behavior (ideation or attempt). That said, Katz et  al. (2011) found that rates of attempted suicide dropped after entry into foster care, which could imply that circumstances improved for some youth after formal entrance into the foster care system, including the possibility that some youth acquired mental health services that they did not have before. Foster care placement type may influence the suicidal behavior of youth in care, as youth in group home settings appear to be at enhanced risk for suicidal behaviors. Anderson (2011) found that youth who lived in group homes were 7.25 times more likely to engage in suicidal ideation than youth who lived with relatives in kinship care. Similarly, Gabrielli et al. (2015) found that youth in group care engaged in more suicidal ideation than youth in family foster care (and also found that rates varied depending on whether the care provider or youth reported this behavior). In a clinical sample, Stewart et al. (2001) found that youth with a prior suicide attempt were significantly more likely to return to the Emergency Department and engage in future attempts when

they had a past group home placement while in out-of-home care. These findings may be related to the fact that youth who reside in group homes may have experienced greater foster care placement instability and tend to have higher rates of psychiatric illness than youth who live in family foster care or kinship foster care settings (Baker & Calderon, 2004; Curtis et al., 2001). In their qualitative study of youth in care in England who engaged in self-harm and suicidal behavior, Wadman et al. (2017) found that transitions (into care, back into care, or between placements) were particularly relevant for self-harm behaviors (which they define as “intentional self-­ injury or self-poisoning regardless of suicidal attempt” (p.3). Youth in their study described transitions as catalysts for self-harm and self-­harm as a catalyst for transitions. These youth also reported not being able to talk with foster care staff about their self-injurious and suicidal behaviors for fear of the consequences (such as staff and administrators needing to “get involved”), and in light of the fact that they did not always trust foster care providers, caseworkers, or administrators.

Transition-Age Youth Transition-age youth who are preparing to emancipate from foster care may be at higher risk of suicidal behavior than their younger counterparts. Each year, approximately 20,000 youth “age out” of the foster care system between the ages of 18 and 21, depending on the state in which they reside (U.S.  Department of Health and Human Services, 2018). These youth are expected to provide for themselves (and, in some cases, their own children) as independent adults despite often compromised resources, skills, and social support networks (Negriff et  al., 2015; Samuels & Pryce, 2008). While many transition-­ age youth demonstrate resilience and tenacity in the midst of this challenging transition (Hass & Graydon, 2009; Strolin-Goltzman et  al., 2016), others struggle in numerous domains. Their struggles in the areas of housing, employment, health, substance use, delinquency, and incarceration have been well documented in the literature

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(Courtney et  al., 2014; Dworsky et  al., 2013; Geenen & Powers, 2007; Pecora et al., 2006). In a recent study of youth preparing to emancipate from the foster care system in California, Courtney et  al. (2014) found that over 40% of 17-year-old youth in their sample reported having contemplated suicide in the past, and 23.5% reported having attempted suicide in the past. Rates were higher for female-identified ­participants: 51% reported having contemplated suicide in the past, and 29.9% reported having attempted suicide in the past. The rates of suicidal ideation/attempt declined among youth when asked at age 19 and 21 (Courtney et  al., 2016; Courtney et al., 2018); however, it is important to note that at those interviews youth were asked about ideation/attempt since the time of the last interview (approximately 2 years prior) as opposed to over course of their lifetime. At age 21, 17% of participants reported suicidal ideation and 6% reported suicide attempt at some point since the last interview (when they were 19). For comparison purposes, approximately 1.9% of same-age youth outside of the foster care system reported suicide attempt in the past year (U.S. Department of Health and Human Services, 2018). Exposure to both the juvenile justice and foster care systems may put some transition-age youth at particularly heightened risk (Berlin et al., 2011). Additionally, male-identified youth with exposure to both systems may be more likely than their female counterparts to die by suicide (Berlin et al., 2011). Renaud et al. (2005) found a ratio of 3.8 males to 1 female for suicide. They noted that the most frequent method of suicide was hanging (used by 73.6% of youth in their sample) and that approximately half of those youth who died as a result of suicide attempt had at least one past suicide attempt. Half of those who died by suicide had used drugs or alcohol prior to their attempts.

Potential Reasons for Enhanced Risk Youth in foster care (and those with a history of foster care involvement) are often at the center of a constellation of risk factors that may increase

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their likelihood of engaging in suicidal behavior. They are more likely than their peers outside of the foster care system to have experienced child maltreatment, mental illness, and inadequate social support. All three of these risk factors are empirically linked with suicidal behavior and are detailed below.

Child Maltreatment Child maltreatment is a well-researched risk factor for suicidal behavior (Miller et al., 2013). The CDC defines child maltreatment as “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child” (Leeb et  al., 2008). There are multiple types of child maltreatment, including sexual abuse, physical abuse, emotional abuse, and neglect (U.S. Department of Health and Human Services, 2018). Given that child maltreatment often precipitates entrance into the foster care system (Bruskas, 2008; Katz et al., 2016), it follows that youth in the foster care system experience or have experienced maltreatment at uniquely high rates. A report on child maltreatment by the U.S. Department of Health and Human Services paints a stark picture, revealing that 678,000 children experienced maltreatment in the US during federal fiscal year 2018 (U.S.  Department of Health and Human Services, 2018). Of these children, 60.8% were neglected, 10.7% were physically abused, and 7.0% were sexually abused. In the same year, 1,770 children died from neglect or abuse, with children who were younger, male, and/or African American dying at higher rates (U.S. Department of Health and Human Services, 2018). These statistics include both children who experienced maltreatment before entering the foster care system, as well as children who were maltreated during their time in care. While the majority of youth in foster care only experience one type of maltreatment, a growing body of research suggests that various types of childhood maltreatment can and do co-occur (Edwards et  al., 2003; Katz et  al., 2016; Pears

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et al., 2008). In fact, the 2018 DHHS report found that 84.5% of children experienced one type of maltreatment, while 15.5% experienced two or more (U.S.  Department of Health and Human Services, 2018). Although comorbidity may make it difficult to examine unique consequences of specific types of maltreatment, it is an important consideration as research has revealed an association between multiple maltreatment (i.e., the experience of more than one form of maltreatment) maltreatment and problematic behaviors, such as substance use and risky sexual behavior (Berzenski & Yates, 2011; Smith & Thornberry, 1995). These conduct-related behaviors can lead to further abuse and maltreatment while in care (McFadden & Ryan, 1986). Children with experiences of multiple maltreatment may also be at heightened risk for psychiatric illnesses, such as depression and ADHD (Ackerman et  al., 1998; Chapman et  al., 2004; McMillen et al., 2005). An established body of research in the US and abroad reveals a relationship between maltreatment and suicidal behavior (Garnfeski & Arends, 1998; Miller et  al., 2013; Sigfusdottir et  al., 2013; Zapata et  al., 2013). All types of maltreatment—sexual, physical, emotional, and neglect—have been linked to suicidal ideation among adolescents and young adults (Davidson et  al., 1996; Miller et  al., 2013; Ullman & Brecklin, 2002). Perhaps in part due to the increased impulsivity associated with the developmental stage, adolescence may be a particularly vulnerable time for youth who have experienced abuse (Brown et al., 1999). In their sample of adolescents and young adults with childhood maltreatment experiences, Brown et al. (1999) found that the adolescents with histories of maltreatment were more likely to attempt suicide repeatedly than the adults with histories of maltreatment, ultimately increasing their risk of fatality. Some studies have explored the relationship between maltreatment and suicidal behavior among youth in foster care specifically, revealing unexpectedly high rates of suicidal behavior in youth who had experienced

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maltreatment (Rhodes et  al., 2012; Rhodes et al., 2013; Taussig et al., 2014; Thompson & Newman, 1995). It is worth noting that youth with maltreatment experiences are at increased risk of developing mental illness (Infurna et al., 2016; Trickett et al., 2011), which is also empirically linked with suicidal behavior (Bachmann, 2018; see following section); However, maltreatment can act as a risk factor for suicidal behavior even among children who have no indication of mental illnesses such as depression (Martin et al., 2016). There are a number of factors that seem to increase the risk of suicidal behavior among children who have experienced maltreatment. Studies found that suicidal ideation increased as maltreatment became more severe and chronic (Thompson et  al., 2005). There is some variation across studies regarding which types of abuse are most closely linked to suicidal behavior. For example, some studies found that physical, sexual, and emotional abuse were more strongly linked to suicidal behavior than neglect (Suarez-­ Soto et  al., 2018; Taussig et al., 2014). Of these forms of abuse, Taussig et  al. (2014) found physical abuse to be the most predictive. By contrast, in a systematic review of research in this area, Miller et  al. (2013) point to sexual and emotional abuse, rather than physical abuse or neglect, as being particularly important in predicting suicidal behavior. Finally, other studies point to sexual abuse as the strongest risk factor (Brown et al., 1999; Palmer et al., 2020; Zapata et al., 2013). There may also be gender differences to take into consideration with regards to which form of abuse poses the most significant risk. For example, several studies reveal that sexual abuse may carry heightened risk for suicidal ideation among male-identified youth (Garnfeski & Arends, 1998; Martin et  al., 2016; Zapata et  al., 2013). Ultimately, children who experienced multiple types of maltreatment had the highest risk of suicidal behavior (Miller et  al., 2013; Suarez-Soto et al., 2018; Taussig et al., 2014).

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Mental Illness  ental Illness and Suicidal Behavior M One of the most empirically supported risk factors for suicidal behavior in childhood and adolescence is mental illness (Bridge et  al., 2006; Steele & Doey, 2007). Most of the youth who engage in suicidal behaviors (ideation, attempt, and suicide) have a history of psychiatric illness. A study by Bridge et al. (2006) asserts that approximately 90% of adolescents who engage in suicidal behaviors have one or more known psychiatric disorders. Rates of mental illness may be lower for younger adolescents and children (around 60%; Beautrais, 2001; Brent et al., 1999). Depressive disorders (specifically major depressive disorder and bipolar disorder) appear to pose the greatest risk for suicide (Cash & Bridge, 2009; Ferrari et  al., 2014). In their review of the literature, Steele & Doey (2007) found that approximately 49–64% of adolescents who died by suicide had been diagnosed with a depressive disorder, with major depression as the most significant risk factor for female-identified adolescents. Conduct disorders and post-traumatic stress are also robust predictors of suicidal behaviors in youth (Ford et  al., 2008; Mustanski & Liu, 2013; Waldrop et al., 2007; Wei et al., 2016). Substance use is also a known risk factor for suicidal behavior. Substance use, and in many cases alcohol abuse, has been determined to play a role in between 19% and 63% of suicides (for a review, see Schneider, 2009). Schilling et  al. (2009) found that adolescents who drank when they felt down were at significantly greater risk of attempting suicide than those who did not and that heavy episodic drinking increased the likelihood of suicide attempt in youth who did and did not report prior ideation. Some studies highlight the interaction between comorbidity of psychiatric illness (specifically, depression) and substance use/abuse as they related to suicidal behavior (Aharonovich et al., 2002; Pompili et al., 2010; Sublette et  al., 2009; Tuisku et  al., 2014). For example, Oquendo et  al. (2000) found that participants with bipolar disorder who reported alcohol use were at significantly greater risk of

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attempting suicide than patients with bipolar disorder who did not use alcohol. Some studies have identified a link between parental mental illness (both psychiatric illness and substance abuse) and risk of suicidal behavior in youth (Brent et al., 1994; Joffe et al., 1988; Mittendorfer-Rutz et al., 2008). King et al. (2001) found that youth who had parents with mental illness were at increased risk for suicidal ideation and attempt. This increased risk may be correlated with inconsistent parenting, discord in the home, and lack of social support (which will be described in detail later in this chapter). Johnson et al. (2002) found that poor parental role fulfillment was linked with interpersonal challenges (such as arguments) between adolescents and their parents; youth with these interpersonal challenges were more likely than their peers to engage in suicidal behavior. Further, youth who have parents that have attempted suicide or died by suicide may be at increased risk for major depression, substance use, and their own suicidal behavior (Brent et al., 2009; Mittendorfer-Rutz et al., 2008; Wilcox et  al., 2010). Brent et  al. (2002) found that youth who had a parent that had attempted suicide were six times as likely to attempt it themselves.

 ental Illness in Youth in Care M Youth in the foster care system are significantly more likely than their peers outside of the system to be diagnosed with a mental illness (Braciszewski & Stout, 2012; Burns et al., 2004; Clausen et al., 1998; Harman et al., 2000; Leslie et al., 2000; Oswald et al., 2010) and to have parents who have been diagnosed with mental illness (both psychiatric illness and substance abuse; U.S.  Department of Health and Human Services, 2020). Numerous studies point to the link between child maltreatment (e.g., neglect, emotional abuse, physical abuse, sexual abuse) and mental illness, with both immediate and delayed onset of symptomatology (De Bellis, 2001; Dubowitz et  al., 2002; Heneghan et  al., 2013; Scott et  al., 2010; Widom et  al., 2007; ). Foster care factors can also play a role in the development and onset of mental illness, as foster care placement instability and maltreatment

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while in care are both distinctly linked with mental illness (Benedict et al., 1996; McGuire et al., 2018). Both maltreatment and foster care experiences are linked with substance use and abuse in adolescence (Braciszewski & Stout, 2012). It comes as little surprise that between 39% and 80% of youth in foster care have known mental health disorders (Leslie et  al., 2000; McMillen et al., 2005; Shin, 2005). Rates of mental illness in older youth in foster care may be particularly high. In their systematic review, Havlicek et al. (2013) found that 17- and 18-year-old youth in the foster care system are two to four times as likely as their peers outside of the system to have a current, or to have had a past psychiatric disorder. McMillen et al. (2005) found that about one-third of their Missouri-­ based sample of adolescents in foster care reported having had one or more psychiatric disorders in their lifetime. In a more recent study of older youth in foster care, Courtney et al. (2016) found that over 50% of 19-year-old participants had at least one mental or behavioral health disorder, with major depression, psychotic disorders, mania, alcohol abuse, and substance abuse being the most prevalent. Females in this sample were more likely than males to report symptoms of depression and PTSD (Courtney & Charles, 2015). Other studies of older youth in foster care show high rates of PTSD (approximately 15%; Keller et  al., 2010) and conduct disorder (40– 47%; McMillen et al., 2005; Shin, 2005). Some researchers have found rates of alcohol use in child welfare-involved youth to be comparable with same-age youth in the general population (Keller et al., 2010; Merikangas et al., 2010). Others however have found rates of alcohol use and alcohol dependence in child welfare-involved youth to be higher than rates in the general population, with rates of use 1.5 times higher and rates of alcohol dependency 3.8 times higher in child welfare-involved youth than their peers (Pilowsky & Wu, 2006). Rates of drug use and substance use disorders in youth with foster care experience tend to be consistently higher than their same-age peers in the general population (McDonald et al., 2014; Narendorf & McMillen, 2010; Pilowsky & Wu, 2006; Thompson & Hasin, 2011; White

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et  al., 2008). Courtney et  al. (2014) found that rates of substance abuse (non-alcohol) were 10.8% and rates of substance dependence (non-­ alcohol) were at 10.5% when youth were 17 years of age. Havlicek et al. (2013) point out that substance use disorders may occur later in life (mid-twenties) for youth with foster care experience than for same-age young adults in the population who show peak rates of substance use and abuse between the ages 18 and 20. While these youth are in care, some may be participating in mental health treatment (in-­patient hospitalization, drug treatment, psychotherapy and psychotropic medication; Courtney et  al., 2004; Leslie et al., 2010; McMillen et al., 2005; Munson et  al., 2020; Park et  al., 2017; Pecora et  al., 2009). However, studies have shown that this mental health treatment may decline after youth have formally emancipated from the system (at approximately age 18 or 21, depending on their state of residence; Brown et  al., 2015; Havlicek et al., 2013). This may have to do with youth feeling overwhelmed as they transition to independent living and may also have to do with access to mental health services (Iglehart & Becerra, 2002; Pecora et  al., 2009). Some youth preparing to emancipate from foster care have expressed that they do not feel adequately prepared to address their own mental health needs (Munson et  al., 2020). Ultimately, this reduction in mental health service provision may exacerbate symptoms of mental illness and may be linked with a greater likelihood to engage in suicidal behaviors. Lastly, youth in care who identify as sexual and gender minorities (SGM) may be at enhanced risk of both mental illness and suicidal behavior. Marshal et al. (2011) found that sexual minority youth in the general population were significantly more likely than their peers to experience symptoms of depression and to report higher rates of suicidal behavior. Mustanski & Liu (2013) found that SGM youth who reported hopelessness, depression, conduct disorder, and impulsivity to be at highest risk. These are important findings, as Fish et  al. (2019) found that sexual minority youth were 2.5 times as likely than their peers who do not identify as sexual minorities to have foster care experience.

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Social Support  ocial Support and Suicidal Behavior S A lack of social support is also an empirically supported risk factor for suicidal behavior (Kleiman & Liu, 2013; Compton et  al., 2005). Studies have commonly evaluated social support in two primary domains: (1) family connection and social support and (2) peer connection and support. Inadequate support in either of these areas has been found to increase the likelihood that youth will engage in suicidal behaviors (King & Merchant, 2008). This may be related to the finding that inadequate social support is linked with depression in youth (Rueger et  al., 2014). It may also be related to the finding that social support can be especially protective in moments of stress and adversity (Kotler et  al., 2001; Nie et al., 2020). The relationships that youth have with their parents or primary caregivers may play a role in the likelihood that they will engage in suicidal ideation. Presence of caretakers and the quality of parent/child relationship both appear to be important predictors of suicidal behavior (Kidd, 2006). King et  al. (1993, 1995) found that perceived family support is an important predictor of suicidal behavior and that adolescents who engaged in suicidal behaviors perceive lower levels of family support than adolescents who do not. Flouri & Buchanan (2002) found that youth who reported lower levels of parental interest and academic motivation may be more likely to attempt suicide than their peers with higher levels. Relatedly, Fotti et al. (2006) found that lower levels of parental nurturance and higher levels of parental rejection were linked with suicidal behavior in early adolescence. Some studies have also found that living with only one parent may increase the risk of suicide in adolescence (Flouri & Buchanan, 2002; Kuramoto-Crawford et  al., 2017). However, Kuramoto-Crawford et  al. (2017) found that high rates of parent/child connectedness protected youth against suicidal ideation in mother-only households. A perceived lack of social support in the peer domain may also place youth at heightened risk for suicidal behavior. This lack of support may

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come in the form of having very few or no friends or being bullied by other youth. Roland (2002) found that youth in Norway who reported being bullied, as well as youth who reported bullying others, were more likely than their peers to report suicidal ideation. A number of other studies have also found an association between bullying and suicidal behaviors (Baldry & Winkel, 2003; Klomek et al., 2007; Delfabbro et al., 2006; Park et al., 2006; Russell & Joyner, 2001). Bonanno & Hymel (2010) evaluated “social hopelessness” (or “negative expectations in the social domain,” p.426) in adolescence, finding that it partially mediated bullying victimization and suicidal ideation in a sample of early adolescents. Peer connectedness also appears to be an important predictor of suicidal behavior in clinical samples of youth with prior attempts. Czyz et al. (2012) found that reported peer connectedness was a protective factor against suicide attempt in a sample of adolescents with a history of suicidal behavior in the 12 months after they were discharged from the hospital. Gender may also play a role in perceived peer support as female-­ identified youth tend to report more peer support than male-identified youth (Kerr et al., 2006). Alternatively, peer support and affiliation may also work to enhance the risk of suicidal behavior in adolescents. Some studies have found that peer connection may increase some youth’s likelihood to engage in delinquent, risky, and impulsive behaviors (e.g., substance use and violence; Dishion & Owen, 2002). These behaviors are empirically linked with suicidal behavior and may exacerbate risk in youth with existing risk factors (Prinstein et al., 2000). Some youth may also be more likely to engage in suicidal behaviors if their friends engage in these behaviors (Prinstein et al., 2000). While rare, suicide “contagion” or clustering has been reported in the literature (see Niedzwiedz et al., 2014 for review) and is more likely to affect adolescents than adults (Gould, 1990).

I nadequate Social Support in Youth in Care Youth in foster care are less likely than their peers to report adequate social support in both family

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and peer domains (Negriff et al., 2015; Samuels & Pryce, 2008; Singstad et al., 2020). Caregiver connection and support may be negatively impacted by episodes of maltreatment and by the removal of children from their homes of origin after such episodes (Negriff et  al., 2015). Placement in the foster care system most often reduces the frequency of interaction between youth and their primary caregivers and may also reduce the likelihood that these caregivers are available to offer their support on a day-to-day basis. Further, parents who have lost temporary custody of their children to the foster care system may have a history of substance use and mental illness, both of which could further compromise their ability to offer consistent support to the youth in their care (Brook & McDonald, 2009; Kohl et al., 2011). Youth in foster care may therefore receive and benefit from support from relatives in their extended families (Singstad et  al., 2020). Youth in foster care may also have fewer peer connections and supportive relationships than same-age youth outside of the system (Wolanin, 2005). Youth who come into the foster care system may be forced to leave their communities of origin and the schools they were attending in those communities (Fawley-King et  al., 2017). Such youth may struggle to make new friends after they have moved, especially if they are experiencing symptoms of traumatic stress, if they are engaging in problematic or delinquent behaviors, or if they are held back/older than other youth in their classes (Pecora, 2012). These effects may be compounded if youth experience high rates of placement instability; such youth are repeatedly asked to adapt to new school and community environments (Chimange & Bond, 2020; James, 2004; Pecora & Huston, 2008; Vacca, 2008). Youth transitioning to new schools may also experience administrative delays in starting at these schools and may struggle to adapt academically (Pecora, 2012). All of these factors may contribute to the fact that youth in foster care are more likely than their peers to experience bullying (Mazzone et  al., 2018; Mohapatra et  al., 2010; Vacca & Kramer-Vida, 2012).

An important body of literature is devoted to evaluating the interacting effects of social support in different domains, and specifically how the presence of social support in one domain may protect against a lack of social support in others. This is an important line of inquiry given that youth in foster care are less likely to retain strong connections with their parents of origin (Negriff et  al., 2015). For example, Gauze et  al. (1996) found that, in some cases, peer support may protect against or compensate for lack of connection and support in the family domain. Kidd (2006) also found interactive effects of social support in different domains in their evaluation of suicidal behaviors in boys with a history of suicide attempt. The protective effects of parental support were enhanced by peer support. Miller et al. (2015) were also committed to evaluating the interactions between and among social support provided by parents, friends, and adults at school; they found that suicidal ideation was highest among youth who perceived low school and low peer support.

Interpersonal-Psychological Theory of Suicidal Behavior and Youth in Foster Care IPTS Described While factors that precipitate suicide risk among youth in foster care continue to be explored (Brown, 2020), the three risks discussed—maltreatment, mental illness, and inadequate social support—have been well established in the literature. The application of theories specific to suicide risk may provide a greater structural understanding of the experiences and behaviors of youth in foster care, as well as possible areas for intervention. Specifically, the Interpersonal-­ Psychological Theory of Suicidal Behavior (IPTS), developed by Thomas Joiner, has contributed to advances in the understanding and prevention of suicidal behavior and has undergone significant empirical examination (Joiner, 2005). The theory provides an appropriate frame-

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work through which to consider suicidal behaviors among youth with foster care experience. The IPTS proposes that the desire to die, or suicidal ideation, is the result of two interpersonal-­ psychological factors that often co-occur for suicidal youth. The first factor is thwarted belongingness, defined as the feeling that one is disconnected or does not belong, which is a fundamental human need (e.g., “I am alone.”; Van Orden et al., 2010). The second is perceived burdensomeness, which is defined as the perception that one is a burden to all others in their life (e.g., “Others would be better off without me.”; Van Orden et  al., 2010). According to the IPTS, the transition from having suicidal thoughts or desires to attempting suicide occurs through a third component, termed acquired capability (Van Orden et al., 2010). Acquired capability is generally attributed to reduced fear surrounding death and increased tolerance to physical pain (Van Orden et al., 2010). In the presence of suicidal desire, increased acquired capability for suicide leads to suicide attempt (Joiner, 2005).

IPTS Applied The IPTS’ three main interpersonal-­psychological components clearly relate to the three risk factors for suicidal behavior discussed earlier in this chapter: social support, mental illness, and child maltreatment. Given that youth in care often have limited social support from family and friends (Singstad et al., 2020), the feeling of being alone or not belonging may be especially persistent. Opperman et al. (2015) examined suicidal desire (i.e., suicidal ideation) in a sample of adolescents in the general population who screened positive for low social connectedness. The researchers found that a combination of high perceived burdensomeness and low family connectedness significantly predicted suicidal ideation. Chimange & Bond (2020) found that placement instability also contributed to a feeling of disconnection and a lack of belongingness among children. The connection between limited social support and thwarted belongingness is critical to consider when working with youth in foster care as

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research shows that these children often have limited peer connections (Wolanin, 2005) and may be particularly vulnerable to and impacted by bullying (Vacca & Kramer-Vida, 2012). The link between mental illness, a significant risk factor for suicidal behavior, and the IPTS’ components is also clear. Mental illnesses, such as depressive and bipolar disorders, borderline personality disorder, and schizophrenia, have been linked with perceived burdensomeness and thwarted belongingness (Silva et  al., 2015). While Silva et al.’s (2015) study was conducted with an adult outpatient population, it can provide insight into the experience and perspectives of youth in foster care who struggle with mental illness. Furthermore, this relationship might be particularly relevant in the consideration of older youth in foster care who may be especially reliant upon others after they have emancipated from care. Finally, maltreatment is an important and well-researched risk factor for suicidal behavior. The IPTS suggests that painful and provocative experiences can increase an individual’s acquired capability (Van Orden et al., 2010), which aligns with the finding that youth who have experienced maltreatment are likely to exhibit higher acquired capability (Van Orden et al., 2010). Research has also demonstrated that physical pain tolerance is higher among suicidal youth than youth who have experienced accidental injuries (Orbach et  al., 1997). These findings hold a particular importance for youth in care as they experience physical maltreatment at high rates (U.S. Department of Health and Human Services, 2020).

Critiques While the IPTS may be a particularly relevant theory for youth in foster care with suicidal risk characteristics, the theory is not absent from critique. The IPTS examines thwarted belongingness, perceived burdensomeness, and acquired capability from a solely individual context, neglecting the multitude of ways in which one’s immediate environment (e.g., home) and context

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(e.g., poverty, oppressive institutional systems) may influence and impact the development of each component of the IPTS. This theory would be enhanced by incorporating an ecological perspective, more explicitly taking into consideration contextual factors at multiple levels, including access to care and structural inequalities, that may influence an individual’s experience and risk for suicidal behavior (Bronfenbrenner, 1992). A second critique of this theory is that it may not accurately reflect the racial and ethnic diversity represented among youth in foster care as it has most commonly been tested in predominantly White samples (Chu et al., 2017; Czyz et al., 2015; Opara et al., 2020). Further research might study the relevance of the IPTS among more racially and ethnically diverse samples. This research could elucidate ways in which the IPTS could be broadened or adapted to better reflect the experience of these children and youth.

Assessment and Intervention When examining suicidal behavior among youth in foster care, it is important for the adults in their lives to be able to assess for the aforementioned risk factors (i.e., child maltreatment, mental illness, and limited social support) and their clear link to the primary components of the IPTS. Examples of utilizing the IPTS with youth in foster care include providing opportunities for youth to be assessed for feelings or thoughts around burdensomeness, social support/belonging, and acquired capability. Carefully examining the intensity of both perceived burdensomeness and thwarted belongingness will provide greater understanding of their risk for suicidal thoughts. Regarding acquired capability, the assessment of history of abuse and trauma, exposure to violence, high pain tolerance, and fearlessness of death give insight into risk for future suicide attempts. Under ideal circumstances, mental health providers would assess the mental health of youth with foster care experiences. As this is not always possible, it is important to provide educational opportunities and trainings for foster

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care providers and other caretaking adults so they can recognize troubling signs and symptoms of mental illness and suicidal behavior. Additionally, of note, prior research indicates that transition periods (e.g., coming in or out of care and changing placements) are particularly stressful for youth in foster care (Wadman et  al., 2017) and may work to exacerbate the risk for suicidal behavior. Thus, additional monitoring and safeguards should be put into place around these times, while simultaneously providing child welfare service providers with training and systems that are sensitive to concerns related to mistrust of foster care providers, caseworkers, and administrators. While there are a range of suicide risk assessments and interventions, the discussion that follows outlines a non-exhaustive list of assessment measures and interventions that may be particularly beneficial for youth with foster care experience. While there are currently no suicide risk screening measures that are specifically intended to meet the needs of these youth, certain indicated suicide risk screening tools can aid the service providers serving youth in foster care. Specifically, suicide risk screening tools that are brief and can be used by a range of professionals are ideal. Future research assessing the unique needs of youth in foster care, and the many systems in which suicide risk can be assessed, will provide additional insight into the best possible screening tools and strategies for youth with foster care experience. Two suicide risk screening measures that assess current thoughts of suicide are the Columbia Suicide Severity Rating Scale (CSSRS; Posner et  al., 2011) and the Self-Injurious Thoughts and Behavior Interview (SITBI; Nock et al., 2007). While the CSSRS is not absent from critique (Giddens et al., 2014), the primary benefits of these measures are centered on their availability in the public domain, their ability to be administered quickly when time is limited, and their fair support regarding reliability and validity (Posner et  al., 2011). Additionally, when assessing for suicide risk, prior research has found that it is most beneficial to use open-ended questions and to directly name what actions one

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is seeking to assess (Goldston, 2003). For exam- self-harm behavior. A significant review highple, a clinician or foster care provider may ask, lighted that most interventions with positive “Sometimes youth think about hurting them- effects included family involvement or nonfamilselves or ending their own lives. How many times ial support (Ougrin et al., 2015). have you tried to hurt yourself? How many times Of note, the Youth-Nominated Support Team– have you tried to end your own life?” The Suicidal Version II (YST; King et al., 2019) is a psychoIdeation Questionnaire—Junior Version (15 educational, social support intervention for items; Reynolds, 1987) is a brief suicide risk suicidal adolescents during the 3-month period screen for youth 11–18 years that examines the following psychiatric hospitalization. In this frequency and severity of suicidal thoughts in intervention, adolescents nominate “caring youth. An even briefer measure for adolescents adults,” whose support they believe will be helpand adults is the Suicide Behaviors Questionnaire-­ ful to them following hospitalization, to be a part Revised (4 items; Osman et  al., 2001). This of their personal support team. While youth in assessment measure asks questions specific to foster care may have more limited supports than lifetime suicide ideation and attempt, the fre- youth who are not in foster care, YST allows quency of ideation over the past 12 months, the youth to nominate adults who have a range of potential for suicide attempt, and self-reported roles in their lives (e.g., foster care providers, likelihood of future suicidal behaviors. caseworkers, athletic coaches). With the permisAfter assessing for suicide risk, it is important sion of caregivers, these support persons meet to provide a plan for intervention when needed. with intervention specialists from the YST team. As an initial response to assessment, safety plan- In these meetings, nominated support persons ning is a useful approach that clinicians can learn about the youth and their psychopathology, embed within larger treatment plans and that can their treatment plan, and a range of related be shared with the foster care caregiver/s to help resources. The first RCT conducted for YST manage times of possible crisis. Safety plans are found that participating in the YST intervention distinct from “safety contracts,” which ask youth was associated with a significant, positive main to agree not to harm themselves and have been effect for suicidal ideation. Specifically, youth found to be ineffective in managing suicide risk who were in the YST plus Treatment as Usual (Rudd et  al., 2006; Stanley & Brown, 2012). (TAU) group, compared to youth in the usual Instead, safety plans outline a clear plan for iden- treatment group, indicated a greater reduction in tifying the triggers of suicidal thoughts and the severity of suicidal thoughts at 6-week folbehaviors and the steps that can be taken to keep low-­up. However, the difference that was indiyouth safe (Rudd et al., 2006). cated was not maintained at additional follow-ups. There are very few evidence-based interven- That said, secondary analysis using National tions intended specifically for adolescents who Death Index 11–14 year mortality outcome data make suicide attempts and engage in self-harm. indicated that the YST intervention for suicidal One meta-analysis of randomized control trials adolescents is associated with reduced mortality (RCTs) found a total of nine studies with a total (King et al., 2019). of 2,176 adolescents that examined psychosocial Mobile- or web-based interventions may hold interventions (Ougrin et al., 2015). Overall, find- specific promise for older youth in foster care, ings indicated there was an overall intervention especially those youth who experience housing effect for self-harm (suicidal or non-suicidal self-­ instability and homelessness after foster care harm). However, this meta-analysis did not find emancipation (Bender et  al., 2015; Katz et  al., an overall effect for suicide attempts examined 2020). Research has indicated that the majority independently. Cognitive-behavioral, family-­ of US citizens have access to smartphones and based, and psychodynamic therapies with family/ the Internet, including individuals with low parent components were named as “probably socioeconomic status (Tsetsi & Rains, 2017). A efficacious” in their ability to reduce suicidal and review by Christensen et al. (2014), suggests the

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importance of having suicide prevention programs intentionally target suicidal risk content. This outlines the distinct difference in the intentional target of suicidal risk content compared to targeting a risk factor, like depression (Cole et al., 2017). Relatedly, Witt et al. (2017) conducted a review to assess the effectiveness of mobile and web-based interventions for suicide prevention and found that these types of interventions decrease suicidal ideation. One intervention, the LEAP intervention, is a web-based intervention that reduces suicidal ideation by targeting perceived burdensomeness (Buitron et al., 2016), an important component of the IPTS that is particularly relevant for youth in foster care

Conclusion Youth with foster care experience are more likely than their peers outside of the system to report child maltreatment, mental illness, and inadequate social support. The interaction of these experiences very likely contributes to the fact that these youth are twice as likely to engage in suicidal ideation and three times as likely to attempt suicide than their same-age peers in comparison populations (Evans et  al., 2017). Each of these adverse experiences maps onto the Interpersonal-­ Psychological Theory of Suicidal Behavior (IPTS; Joiner, 2005), enabling greater insight into the potential mechanisms at work and targets of assessment and intervention. Youth in foster care, especially those who do not demonstrate problematic externalizing behaviors, may not be routinely assessed for mental illness and suicidal behaviors. Brief, widely available and evidence-supported assessment protocols may work to reduce this critical oversight, increasing the likelihood of all youth in care being assessed and receiving the mental health treatment they require in a timely manner. Interventions that integrate a core social support component may be especially protective in light of the diminished social support reported by many youth with foster care experience. Online and mobile interventions may also hold promise, especially for older youth in care or youth who

have emancipated from the system and have not secured in-person mental health service provision. The need to investigate the effectiveness of promising interventions specifically with youth in foster care is clear and immediate. Further research in this area would help us to cultivate a better understanding of protection for these youth and, more importantly, reduce the likelihood that youth with foster care experience will feel the need to end their lives.

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15  Suicidal Behaviors in Youth with Foster Care Experience Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., Van Orden, K., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-­ Threatening Behavior, 36(3), 255–262. https://doi. org/10.1521/suli.2006.36.3.255 Rueger, S.  Y., Chen, P., Jenkins, L.  N., & Choe, H.  J. (2014). Effects of perceived support from mothers, fathers, and teachers on depressive symptoms during the transition to middle school. Journal of Youth and Adolescence, 43(4), 655–670. https://doi.org/10.1007/ s10964-­013-­0039-­x Russell, S.  T., & Joyner, K. (2001). Adolescent sexual orientation and suicide risk: Evidence from a national study. American Journal of Public Health, 91(8), 1276–1281. https://doi.org/10.2105/ajph.91.8.1276 Samuels, G.  M., & Pryce, J.  M. (2008). “What doesn’t kill you makes you stronger”: Survivalist self-­ reliance as resilience and risk among young adults aging out of foster care. Children and Youth Services Review, 30(10), 1198–1210. https://doi.org/10.1016/j. childyouth.2008.03.005 Schilling, E.  A., Aseltine, R.  H., Jr., Glanovsky, J.  L., James, A., & Jacobs, D. (2009). Adolescent alcohol use, suicidal ideation, and suicide attempts. Journal of Adolescent Health, 44(4), 335–341. https://doi. org/10.1016/j.jadohealth.2008.08.006 Schneider, B. (2009). Substance use disorders and risk for completed suicide. Archives of Suicide Research, 13(4), 303–316. https://doi. org/10.1080/13811110903263191 Scott, K.  M., Smith, D.  R., & Ellis, P.  M. (2010). Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Archives of General Psychiatry, 67(7), 712–719. https://doi.org/10.1001/archgenpsychiatry.2010.71 Shin, S.  H. (2005). Need for and actual use of mental health service by adolescents in the child welfare system. Children and Youth Services Review, 27(10), 1071–1083. https://doi.org/10.1016/j. childyouth.2004.12.027 Sigfusdottir, I.  D., Asgeirsdottir, B.  B., Gudjonsson, G. H., & Sigurdsson, J. F. (2013). Suicidal ideations and attempts among adolescents subjected to childhood sexual abuse and family conflict/violence: The mediating role of anger and depressed mood. Journal of Adolescence, 36(6), 1227–1236. https://doi. org/10.1016/j.adolescence.2013.10.001 Singstad, M. T., Wallander, J. L., Lydersen, S., Wichstrøm, L., & Kayed, N.  S. (2020). Perceived social support among adolescents in residential youth care. Child & Family Social Work, 25(2), 384–393. https://doi. org/10.1111/cfs.12694 Silva, C., Ribeiro, J.  D., & Joiner, T.  E. (2015). Mental disorders and thwarted belongingness, perceived burdensomeness, and acquired capability for suicide. Psychiatry Research, 226(1), 316–327. https://doi. org/10.1016/j.psychres.2015.01.008 Smith, C., & Thornberry, T.  P. (1995). The relationship between childhood maltreatment and adolescent

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260 and Alcohol Dependence, 117(1), 66–69. https://doi. org/10.1016/j.drugalcdep.2010.12.020 Tonmyr, L., Thornton, T., Draca, J., & Wekerle, C. (2010). A review of childhood maltreatment and adolescent substance use relationship. Current Psychiatry Reviews, 6(3), 223–234. https://doi. org/10.2174/157340010791792581 Topitzes, J., Mersky, J.  P., & Reynolds, A.  J. (2011). Child maltreatment and offending behavior: Gender-specific effects and pathways. Criminal Justice and Behavior, 38(5), 492–510. https://doi. org/10.1177/0093854811398578 Trickett, P.  K., Negriff, S., Ji, J., & Peckins, M. (2011). Child maltreatment and adolescent development. Journal of Research on Adolescence, 21(1), 3–20. https://doi.org/10.1111/j.1532-­7795.2010.00711.x Tsetsi, E., & Rains, S.  A. (2017). Smartphone Internet access and use: Extending the digital divide and usage gap. Mobile Media & Communication, 5(3), 239–255. https://doi.org/10.1177/2050157917708329 Tuisku, V., Kiviruusu, O., Pelkonen, M., Karlsson, L., Strandholm, T., & Marttunen, M. (2014). Depressed adolescents as young adults–predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up. Journal of Affective Disorders, 152–154, 313–319. https://doi.org/10.1016/j.jad.2013.09.031 Ullman, S.  E., & Brecklin, L.  R. (2002). Sexual assault history and suicidal behavior in a national sample of women. Suicide and Life-Threatening Behavior, 32(2), 117–130. https://doi.org/10.1521/suli.32.2.117.24398 U.  S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018. Washington, DC: Author. Retrieved from https://www. acf.hhs.gov/sites/default/files/cb/cm2018.pdf U.S. Department of Health & Human Services,Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2018). Child Maltreatment 2016. Retrieved from https://www.acf. hhs.gov/cb/research-­data-­technology/statistics-­research/ child-­maltreatment Vacca, J. S. (2008). Breaking the cycle of academic failure for foster children—What can the schools do to help? Children and Youth Services Review, 30(9), 1081–1087. https://doi.org/10.1016/j.childyouth.2008.02.003 Vacca, J.  S., & Kramer-Vida, L. (2012). Preventing the bullying of foster children in our schools. Children and Youth Services Review, 34(9), 1805–1809. https:// doi.org/10.1016/j.childyouth.2012.05.014 Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. https://doi.org/10.1037/a0018697

C. C. Katz et al. Wadman, R., Clarke, D., Sayal, K., Armstrong, M., Harroe, C., Majumder, P., Vostanis, P., & Townsend, E. (2017). A sequence analysis of patterns in self-­harm in young people with and without experience of being looked after in care. British Journal of Clinical Psychology, 56(4), 388–407. https://doi.org/10.1111/bjc.12145 Waldrop, A. E., Hanson, R. F., Resnick, H. S., Kilpatrick, D. G., Naugle, A. E., & Saunders, B. E. (2007). Risk factors for suicidal behavior among a national sample of adolescents: Implications for prevention. Journal of Traumatic Stress, 20(5), 869–879. https://doi. org/10.1002/jts.20291 Wei, H.  T., Lan, W.  H., Hsu, J.  W., Bai, Y.  M., Huang, K. L., Su, T. P., Li, C. T., Lin, W. C., Chen, T. J., & Chen, M.  H. (2016). Risk of suicide attempt among adolescents with conduct disorder: A longitudinal follow-up study. The Journal of Pediatrics, 177, 292– 296. https://doi.org/10.1016/j.jpeds.2016.06.057 White, C.  R., O’Brien, K., White, J., Pecora, P.  J., & Phillips, C.  M. (2008). Alcohol and drug use among alumni of foster care: Decreasing dependency through improvement of foster care experiences. The Journal of Behavioral Health Services & Research, 35(4), 419–434. https://doi.org/10.1007/s11414-­007-­9075-­1 Widom, C. S., DuMont, K., & Czaja, S. J. (2007). A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Archives of General Psychiatry, 64(1), 49–56. https://doi.org/10.1001/archpsyc.64.1.49 Wilcox, H.  C., Kuramoto, S.  J., Lichtenstein, P., Långström, N., Brent, D. A., & Runeson, B. (2010). Psychiatric morbidity, violent crime, and suicide among children and adolescents exposed to parental death. Journal of the American Academy of Child & Adolescent Psychiatry, 49(5), 514–523. https://doi. org/10.1097/00004583-­201005000-­00012 Witt, K., Spittal, M.  J., Carter, G., Pirkis, J., Hetrick, S., Currier, D., Robinson, J., & Milner, A. (2017). Effectiveness of online and mobile telephone applications (‘apps’) for the self-management of suicidal ideation and self-harm: A systematic review and meta-­ analysis. BMC Psychiatry, 17(1), 297–315. https://doi. org/10.1186/s12888-­017-­1458-­0 Wolanin, T. (2005). Higher education opportunities for foster youth: A primer for policymakers. The Institute for Higher Education Policy. Retrieved from http:// www.ihep.org/sites/default/files/uploads/docs/pubs/ opportunitiesfosteryouth.pdf Zapata, L.  B., Kissin, D.  M., Bogoliubova, O., Yorick, R. V., Kraft, J. M., Jamieson, D. J., Marchbanks, P. A., & Hillis, S. D. (2013). Orphaned and abused youth are vulnerable to pregnancy and suicide risk. Child Abuse & Neglect, 37(5), 310–319. https://doi.org/10.1016/j. chiabu.2012.10.005

Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and Risk Factors

16

Carolina Hausmann-Stabile and Lauren E. Gulbas

In the early 1960s, clinicians sounded the alarm that many Latina1 teens were presenting in emergency rooms for care after a suicide attempt. Trautman (1961), a clinician at Lincoln Hospital in the South Bronx of New York City, published the first reports about the suicide attempts of Puerto Rican adolescent patients. He hypothesized that these behaviors resulted from the process of adjustment to the new culture that the teens were undergoing because of their immigration to the United States. Although clinicians serving Latino families continued to share anecdotal data about this phenomenon, the issue remained for the most part understudied until the early 1990s, when the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance Survey (CDC, 1996) provided confirmation of the scope of disparities in suicidal behaviors between Latinas and their White and Black counterparts, both male and female. Subsequent CDC YRBS reports confirmed this health disparity (2000, 2002, 2004) and triggered efforts to explain why so many Latina adolesLatinas are defined as females of Latin American origin living in the United States (Merriam-Webster.com, n.d.) 1 

C. Hausmann-Stabile () Graduate School of Social Work and Social Research, Bryn Mawr College, Bryn Mawr, PA, USA e-mail: [email protected] L. E. Gulbas Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA e-mail: [email protected]

cents living in the United States presented with suicidal ideation, planning, and attempts. The new research sought to identify avenues to reduce the prevalence of these high-risk behaviors. Epidemiological findings such as those in the CDC YRBS are central to the initial description of health disparities in the population. After health disparities have been identified in these studies, researchers often explore which phenomena are related to the disparity, generating hypotheses that will be tested through explanatory studies designed to test causality. There are two traditions informing the approach to explore and explain health disparities: one seeks to identify contextual factors relevant to the difference and the other involves an intragroup approach. Examples of the former approach seek to identify contextual factors (e.g., social, environmental) that affect a subgroup of the population more intensely, contributing to its higher levels of disease or injury. The intragroup approach involves identifying elements within the subgroup experiencing higher rates of disease or injury (e.g., culture) that can account for the disparity. In the United States, research on mental health disparities affecting ethnocultural minorities tends to privilege the intragroup approach (see, for example, Feldman et  al., 2010) because of the well-­ established relationship between culture and mental health (see, for example, Kleinman, 2008). Thus, the choice to apply an intragroup approach to explain health disparities is not arbitrary, but rather one that emerges from theoretical

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_16

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and methodological practices that carry implications for how research questions are formulated and answered. In this chapter, we review the scholarship that addresses intragroup dimensions of Latina adolescent suicide attempts.2 We focus specifically on the familial, cultural, and community protective and risk factors linked with the suicide attempts of Latina adolescents growing up in the United States. We begin with a review of the epidemiological data about Latina suicide attempts, describe the conceptual models that frame this research, briefly introduce some cultural dimensions suggested to be relevant to understand Latinos, and thus their behaviors and health outcomes, and then discuss research findings. We review two types of studies addressing protective and risk factors for suicide attempts among Latina teens: research that describes the role of protections and risks without quantification (e.g., qualitative studies), and studies that model protections and risks to quantify their effect on suicide attempts (e.g., quantitative and system dynamics research). We conclude this chapter with a reflection on the state of this area of research and provide suggestions to advance our understanding of this health disparity.

 he Epidemiology of Latina T Adolescents Suicide Attempts Almost four decades of epidemiological research has shown that Latina adolescents in the United States are at elevated risk for suicide attempts (Centers for Disease Control and Prevention [CDC], 1996, 2000, 2004, 2006, 2008, 2010, 2012, 2014, 2016, 2018, 2020; Razin et al., 1991; Roberts & Chen, 1995). In this research, a suicide attempt is defined as a nonfatal, self-inflicted destructive act with the explicit or implied intent to die (Goldsmith et  al., 2002). Fortunately, while still higher than

In the selection of what to include in this chapter, we identified peer-reviewed texts published in English since 2000 that deal exclusively with adolescents of Latina descent or that report data on Latina adolescent suicide attempters. 2 

C. Hausmann-Stabile and L. E. Gulbas

White teens, in recent years there has been a decrease in the prevalence of suicide attempts among Latinas. Today, nearly one in 10 Latina teens attempts suicide, compared with one in 14 White, and 1  in 10 Black teenage girls (CDC, 2020). Yet, despite declines in suicide attempts, Latina teens have been found to present high reattempt rates. One study has found that up to 62% of Latina attempters make a second attempt, a rate that is an order of magnitude higher than that for adolescents in other racial and ethnic groups (Hausmann-Stabile et al., 2012). In addition, compared to their male counterparts, Latina teens report higher rates of suicidal ideation (21% vs. 12.6%), suicide planning (17.6% vs. 11.1%), and suicide attempts (13.5% vs. 6.9%, CDC, 2020). The elevated rates of suicide attempts equally affect Latinas of different national origin (Fortuna et al., 2007; Garcia et  al., 2008; Tortolero & Roberts, 2001).

 onceptual Models of Latina C Adolescent Suicide Attempts Starting in the 1990s, theorists and researchers developed new or tested existing theories to explain why Latina adolescents were vulnerable to attempting suicide. With the support of federal agencies, a group of researchers embarked on developing approaches that were attentive to unique dimensions of Latina adolescents’ experiences and culture, with the goal of identifying intragroup, ethnic-specific mechanisms at play in their suicidal behaviors. The best-known conceptual model for Latina adolescent suicide attempts is Zayas’ Ecodevelopmental Model (2005). More recently, Gulbas led two teams focusing on advancing theory in this area. In 2018, Gulbas and colleagues developed a system dynamics model to understand the onset of suicidal ­behaviors among Latina adolescents. Then in 2019, Gulbas and colleagues tested the cultural and developmental appropriateness of Joiner’s Interpersonal–Psychological Theory of Suicide (IPTS) to explain the suicide attempt risk of Latinas. These theoretical

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and…

developments share a common perspective that acknowledges that an understanding of suicidal behaviors could not focus solely on disproportionate risk, but rather should consider the role and interactions of broader ecological factors—including familial, cultural, and community dimensions—in shaping protections and risk. Furthermore, by incorporating culture as an important dimension to understand the suicidal behaviors of Latinas, these models propose a significant move forward to untangle the complexity of these behaviors.

 ayas’ Ecodevelopmental Model Z of Latina Suicide Attempts In 2005, Zayas and colleagues developed a theoretical model suggesting that at the core of the suicidal crisis of Latina teens are sociocultural processes (e.g., acculturation, gender socialization), family dynamics (e.g., conflict, mutuality), and adolescent developmental issues (e.g., autonomy and independence). The model proposes that the suicide attempts of Latina adolescents emerge as the result of a linear trajectory involving increasing conflict between the teen and her caregivers related to the normative developmental processes of increasing autonomy and independence. Cultural elements can exacerbate the potential for conflict due to differential understandings of gender socialization practices and expectations. These conflicts aggravate the girl’s emotional vulnerability and can shape the potential for suicidal behaviors. Zayas’ model advances the theoretical conceptualization of Latina suicide attempts in multiple ways. It recognizes that explanations based solely on individual-level processes are insufficient to account for suicidal behaviors disparities among ethno-racial groups. It draws attention to ethnocultural dynamics as they shape normative developmental transitions and relationships among families of immigrant backgrounds. Finally, it emphasizes an ecological consideration of protections and risks for suicidal behaviors.

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 ulbas’ System Dynamics Approach G to Charting Suicide Risk in Latina Adolescents More recently, Gulbas et  al. (2018, n.d.) developed an empirically supported system dynamics model charting suicide risk among Latina adolescents. A key tenet of system dynamics research is that complex human behaviors emerge via multiple, mutual, and continuous interactions between individuals and their ecological contexts (see Richardson, 2011; Sterman, 2000). Gulbas’ feedback theory is organized around seven constructs identified as salient by Latina teens related to psychological functioning (e.g., including emotional vulnerabilities, avoidant coping, experiences of high-risk behaviors), familial and social dimensions (e.g., family conflict, social support), cultural socialization and ethnic identity. Additionally, these authors identified several exogenous stressors to the system that were important to the perceived onset of emotional vulnerabilities among adolescents. These included migration of a parent or close family member and experiences of physical or sexual assault. Specifically, these stressful experiences can trigger a reinforcing loop that shapes psychosocial risk through emotional vulnerabilities, avoidant coping, high-risk behaviors, and family conflict. Over time, the reinforcing loop shapes a trajectory toward suicidal thoughts and behaviors. Among the innovations of this model are the use of system dynamics to identify mechanisms that could be altered through interventions at various levels of the model; and the confirmation that suicide feedback trajectory among Latinas is not deterministic, despite the presence of salient risk factors.

Joiner’s Interpersonal–Psychological Theory of Suicide In 2019, Gulbas and colleagues evaluated the cultural and developmental appropriateness of Joiner’s Interpersonal–Psychological Theory of Suicide (IPTS; Joiner, 2005; Van Orden et  al., 2010) to explain Latina teen suicide attempts.

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Although Joiner’s model attends primarily to psychological processes, the ecological context appears in the theory through direct or indirect experiences of violence (e.g., at home or in the community) that desensitize individuals and increase their threshold of pain tolerance, reinforcing the trajectory from suicidal feelings and thoughts to attempts. Despite being developed with adults in mind, Joiner’s model has emerged as an empirically supported theory of suicide risk among adolescents (see, for example, Barzilay et al., 2015; Stewart et al., 2017). Gulbas’ team compared the IPTS core constructs (perceived burdensomeness, thwarted belongingness, and acquired capability) and then evaluated how these were linked with the occurrence of a suicide attempt. Although their findings suggest predominantly positive support for the application of IPTS to explain suicide attempt risk among Latinas, there are some variations between the lineal trajectory of risk proposed by Joiner and those identified among Latina teens. Specifically, Gulbas and colleagues observed that the adolescents’ developmental tensions are exacerbated by broader sociocultural dynamics (e.g., immigration, cultural conflict) unique to adolescent Latinas. Gulbas’ testing of Joiner’s IPTS contributes to a broader understanding of suicide risk among Latina adolescents that incorporates developmental and cultural dimensions.

 amilial, Cultural, and Community F Protective and Risk Factors for Suicide Attempts Among Latina Teens Research on the suicide attempts of Latina adolescents has prioritized ecological, intra-ethnic approaches that highlight the role of psychosocial and cultural attributes. Rather than comparing Latinas to their White or Black counterparts to identify universal and culturally specific targets of intervention, this scholarship has focused on disentangling what distinctive features of this group protect from or increase risk for suicidal behaviors. To do so, researchers have built a body of scholarship using a variety of methods and

C. Hausmann-Stabile and L. E. Gulbas

approaches. These include quantitative (see, for example, Kuhlberg et  al., 2010 and Peña et  al., 2011) and qualitative (see, for example, Gulbas et al., 2019 and Nolle et al., 2012) methods, using primary (see, for instance, Zayas et al., 2010) and secondary-data analysis (see, for example, Boyas et  al., 2019). More recently, researchers have applied system dynamics, a mathematical computer simulation feedback model combining assessing the role of standard variables associated with suicide attempts and culturally specific dimensions (see Gulbas et al., 2018; unpublished manuscript). This body of knowledge was built using data collected among clinical (see, for example, Zayas & Gulbas, 2012) and nonclinical samples collected in schools (see, for example, Price & Khubchandani, 2017) and in community settings (see, for example, Gulbas et  al., 2019). Furthermore, some researchers compared clinical and nonclinical samples of Latina teens and included in their analysis data collected from their caregivers (see Baumann et al., 2010). These approaches have created a deeper understanding of the experiences of Latina teens with or without suicide attempts, and how it is for them to grow up within their families, along with their peers, and in their communities. In this section, we review the literature to address protective or risk factors across three main topics: family dynamics, cultural dimensions (including cultural values about gender, family expectations, idioms of distress, migration, acculturation, and generational status), and community (schools).

 amilial Protective and Risk Factors F for Suicide Attempts Among Latinas Most of the research on Latina suicide attempts has focused on familial processes and ­parent-­daughter dynamics that protect or increase the risk for suicidal behaviors among teens (see Table  16.1). Several factors contribute to the choice to foreground familial factors over universal psychological processes or macro ecological dynamics. First, independently of race or ethnicity, the association between parent-child relationships—including conflicts—for youth suicidal

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and… Table 16.1  Familial protective and risk factors for suicide attempts among Latinas. Protective factors Mutuality (bidirectional interpersonal responsiveness) between adolescent Latinas and their mothers negatively related to attempts Maternal affection protected against suicidal behavior in Mexican female students Mother-daughter mutual empathy and engagement protects against suicide attempts through reducing internalizing and externalizing behaviors Families with predominantly reciprocal relationship patterns had adolescents who did not attempt suicide Tight-knit families (with high cohesion and low conflict) are more likely to have non-suicide attempter daughters Risk factors Family conflicts trigger suicide attempts Many teens decide to attempt suicide following and experience of violent family trauma Families with predominantly asymmetrical or detached relationship patterns had adolescents who did attempt suicide Family conflict is frequent among teens who attempt suicide Suicide attempts reported feeling unloved and unsupported with their families Fragmented family structures due to parental divorce or separation, death, or migration were common among suicide attempters The teens are often met with parental criticism ranging from negative parental judgments to verbal assaults, leading to feelings of worthlessness and alienation Adolescents reported experiences of violence in the home, including physical abuse, sexual abuse, and witnessing domestic violence Exposure to violence in the home is related to the attempter’s “acquired capability” to self-harm

References Turner et al. (2002)

Unikel et al. (2006) Baumann et al. (2010)

Gulbas et al. (2011)

Peña et al. (2011)

Zayas et al. (2010)

Gulbas et al. (2011)

Gulbas and Zayas (2015)

Gulbas et al. (2019) (continued)

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Table 16.1 (continued) Protective factors Lower mutuality and communication between mother/daughter more common in Latina adolescent attempters than non-attempters One-third of suicide attempters reported a history of sexual abuse Paternal emotional mistreatment increased the risk for attempts There was an incongruence of academic aspirations between suicidal adolescent and their parents, with parents reporting lower aspirations than the teens Suicide attempters felt unloved and unsupported by their families Interpersonal discord within families and subjective distress shape the teens’ experiences of emotional isolation that lead to suicidal behaviors Family conflict around issues related to immigration, acculturation to the US society, and over gender roles Unaddressed (silenced or kept secret) family and sexual violence may intensify parent–daughter conflicts and contribute to the teen’s suicide attempts Lack of family support increases the likelihood of suicide attempts among Mexican-American teens Latina suicide attempters report significantly less mutuality and communication with their mothers than non-attempters. Mothers of Latina suicide attempters report significantly less mutuality and communication with their daughters than the mothers of non-attempters The trigger for suicide attempts is often a fight with a parent, usually the mother, but it can also come about as the result of a fight or conflict with siblings and/or other family members. The fights leading to attempts were related to changes in family structure (e.g., death of a family member, emigration), or to the teen expressing greater autonomy

References Zayas et al. (2009)

Unikel et al. (2006)

Hausmann-­ Stabile et al. (2013)

Gulbas et al. (2015) Gulbas and Zayas (2015) Humensky et al. (2017) Szlyk et al. (2019)

Winterrowd et al. (2011) Zayas et al. (2009)

Zayas et al. (2010)

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behaviors is well-established (see, for example, Adams et  al., 1994; Bilgin et  al., 2007; Chang et al., 2020). Furthermore, as a child enters adolescence, their behavior, socialization, and expectations change, often resulting in stressful adjustment for caregivers and changes in family life. Regardless of ethnicity and race, adolescence is a time in which parent-child conflicts are more frequent and intense than in any other age (Laursen et  al., 1998; Montemayor, 1983), with conflicts peaking at middle adolescence (Greydanus & Bashe, 2003; Santrock, 2015). In addition to these reasons for the focus on family dynamics, research on Latinos in the United States has stressed the importance of the cultural value of family and family connectedness, also referred to as familismo,3 as a factor in a variety of Latino child outcomes (see, for example, Stein et  al., 2015; Toyokawa & Toyokawa, 2019). Lastly, families offer an analytical microcosm of the relational and dynamic qualities in which, through interactions with others, culture organizes adolescents’ emotions, perceptions, behaviors, and experiences (see, for example, Canino & Guarnaccia, 1997). Thus, analyzing family dynamics has the potential to offer an understanding of intra-ethnic dynamics that could help explain why so many Latina adolescents attempt suicide. Most of the research on familial protective and risk factors for suicide attempts among Latinas has focused on describing relational and experiential dimensions, such as the quality of the relationships (see, for example, Gulbas et al., 2011) and communication between caregivers and teens (see, for example, Zayas et al., 2011). Overall, this literature has confirmed the protective role of caring, empathic, affectionate, and engaged relationships between caregivers and Latina adolescents. Relevant risk factors for suicide attempts include lack of parental care for the teen, poor communication and engagement, and support, and increased conflicts, incongruent expectations and/or aspirations between caregivers and teens. Conflicts among adolescents and caregivers are elevated among families with suicide attempters compared to those without (Gulbas et al., 2015) and often precede the For a discussion on familism, please refer to the next section. 3 

C. Hausmann-Stabile and L. E. Gulbas

onset of suicide attempts (Zayas et al., 2010). Latina suicide attempters have been found to report greater levels of emotional and physical neglect and/or maltreatment than their non-attempter peers (see, for example, Unikel et al., 2006). Unaddressed family and sexual violence increase parent-adolescent conflicts (Szlyk et al., 2019). Suicidal teens often report feeling unloved and isolated (Gulbas et al., 2015). Furthermore, Unikel et al. (2006) found that about one-third of Mexican-American teens that were interviewed for their study and reported a history of suicide attempts had experienced sexual abuse compared to about one-tenth of their peers who did not self-harm. Not surprisingly, the picture emerging from this research is that loving, functional, and supportive Latino families are more effective at navigating conflicts with adolescent members through communication and support, and that the quality of the communication between the teens and their caregivers, particularly their mothers, is important for the girls’ well-being. Communication and support, in turn, protect the girls from the normative emotional vulnerabilities experienced during adolescence and reduce the risk for suicidal behaviors.

 ultural Protective and Risk Factors C for Suicide Attempts Among Latinas The research on the cultural protective and risk factors for suicide attempts among Latina adolescents has relied on different views of culture. While some researchers have conceptualized culture as material and value orientations, such as the use of language or endorsement of values (see, for example, Peña et  al., 2011), others advance a view of culture that integrates value orientations and material conditions into social interactions that shape and manifest a person’s emotions, perceptions, and experiences (see, for example, Zayas & Gulbas, 2012). The former view of culture has dominated the research on the suicide attempts of Latina teens, focusing ­primarily on exploring two broad areas: acculturation and associated phenomena (e.g., generational status, migration), and cultural values (e.g., gender socialization, familism).

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and…

Acculturation refers to the process of cultural change that takes place in the context of cultural exchanges that result in new cultural formations (Guarnaccia & Hausmann-Stabile, 2016). Initially, anthropologists used groups as the unit of analysis of acculturation processes. Later, as the study of acculturation expanded from anthropology to sociology and—more importantly— psychology, the unit of analysis shifted from groups to individuals (Guarnaccia & Hausmann-­ Stabile, 2016). As described by Berry (2015), at the group level, acculturation involves changes in social structures and institutions, and in cultural practices; and at the individual level, it is about changes in a person’s behaviors and psychology. Another important change that took place as psychologists began to contribute actively to the study of acculturation is that the focus of study moved from the processes of acculturation to the outcomes of acculturation (Guarnaccia & Hausmann-Stabile, 2016). To assess the outcomes of acculturation, researchers mainly focus on either assimilation or biculturalism (Guarnaccia & Hausmann-Stabile, 2016). Assimilation perspectives are based on the sociological conceptualization of acculturation (see, for example, Shaull & Gramann, 1998), which assumes a unidirectional movement from the culture of origin to the host culture. Assessments of acculturation as assimilation ask about the dominant culture acquisition (e.g., English proficiency). The bicultural view of acculturation is based on Berry’s work (2006) and aims at assessing the simultaneous and distinct involvement in the culture of origin and the host culture (see, for example, language of origin use at home and English proficiency at school). Scholars interested in the study of cultural change following immigration have also used generational status (see, for example, Peña et al., 2008) as a proxy for acculturation, as it captures dimensions central to the acculturation process, such as cultural change. It is not surprising that acculturation and its proxies have been a focus of attention in the study of Latina suicide attempters. Among the reasons given for this interest is that the majority of immigrant Latinos living in the United States arrived

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in the country since 1990 (see, for example, Flores, 2017), suggesting that this group is adapting to the dominant culture. Furthermore, the literature has suggested that both developmental and acculturation changes are at the core of adaptation problems experienced by this population (see, for example, Cervantes & Cordova, 2011). Acculturation requires that Latina teens learn and adapt to sociocultural contexts that have different cultural scripts (Smokowski & Bacallao, 2011) that sometimes offer contradictory definitions of the self, interpersonal dynamics, and gender roles. The experience of navigating different cultural worlds—the one at home and that of the “outside”—can be challenging for some teens. Furthermore, it has been theorized that cultural conflicts between Latina adolescents and their less acculturated parents may play a central role in destabilizing the teen-parent relationship (see, for example, Zayas et  al., 2005). For example, conflict might arise between caregivers endorsing familismo and their children socialized to American cultural values that stress individuality and independence (see, for example, Fortuna et  al., 2007; Marsiglia et  al., 2009). Conflicts between the teen and her caregivers may be experienced as culturally dissonant because of the importance of the Latino cultural value of familismo. Although the value for family closeness is not unique to Latino families (Schwartz, 2007), familismo has been hypothesized as a central cultural value for Latinos (see, for example, Calzada et  al., 2013). This cultural value emphasizes interpersonal harmony among family members (Gulbas et  al., 2015). Sabogal et  al. (1987) describe three interconnected dimensions of familismo. The first aspect of this cultural value refers to familial obligations, described as the belief that family members are responsible for providing economic and emotional support to their kin. The second dimension, family as perceived support and emotional closeness, refers to the notion that members are steadfast resources of help during crises and should have close relationships supported (and conducive) to a sense of family unity. The last dimension, family as referent, is the idea that the behaviors displayed by

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family members should meet the expectations set by others within the family. The prioritization of family needs over personal interests—sometimes including sacrifice for the benefit of the family— and the responsibility that family members have to provide emotional support to one another (Ferrari, 2002; Hill & Torres, 2010) may cause acute distress in Latina teens when they find themselves in conflicts with their parents around their personal needs or autonomy. Gender is another dimension that has received the attention of researchers interested in the cultural protective and risk factors associated with suicide attempts among Latinas. This is because it is often assumed that Latino parents’ expectations for their teen daughters embrace parenting and gendered cultural values that value obedience (see, for example, Calzada et  al., 2010; Delgado-Gaitan, 1994; Harwood et  al., 1995; Lara-Cantú et  al., 1990), and that these are in conflict or are incompatible with American cultural values that stress adolescent autonomy, independence, and gender equality (see, for example, Zayas, 2011). Lastly, researchers have considered whether Latina adolescents’ suicide attempts can be conceptualized as a cultural idiom of distress. Idioms of distress represent a broad spectrum of emotional, physical, and cultural responses to suffering (Hollan, 2004). Rather than classifying these responses as illness or syndromes, understanding them as cultural languages allows researchers to attend to the cultural elements that shape these responses to distress, and to uncover what they might highlight about the broader worldview in which the idiom of distress is embedded (Kirmayer & Sartorius, 2007). In its presentation, an idiom of distress can overlap with international syndromic classifications, as it is the case for panic attacks and ataques de nervios (see, for example, Lewis-Fernández et al., 2002), but they are different in that they develop from distinct cultural frameworks. A culturally informed analytical approach of suicide attempts as idioms of distress is directed to understand how the experiential nature of suffering and distress is interpreted through the lens of culture, and thus becomes interpreted as illness or dysfunctional

C. Hausmann-Stabile and L. E. Gulbas

behaviors in the first place (Zayas & Gulbas, 2012). Research findings of the role of cultural protective and risk factors in the suicide attempts of Latinas offer a complex picture (see Table 16.2). Although acculturation and related phenomena have received significant attention from investigators, their role in adolescent suicide attempts is still unclear. For example, in studies that rely on quantitative metrics of acculturation and that conceptualize it as a process leading to biculturalism (see, for example, Turner et  al., 2002; Zayas et al., 2009), suicide attempters and non-­ attempter Latina adolescents reported equal acculturation levels and acculturation gaps with their caregivers. This suggests that the impact of acculturation on suicide attempts may be either mediated or moderated by other factors, or it might not be as significant as suggested in the Zayas et al. (2005) model. Alternatively, it might be a problem inherent to the way that some quantitative metrics register acculturation. For example, the Bidimensional Acculturation Scale for Hispanics (BAS; Marin & Gamba, 1996) relies only on language-based items to create an acculturation score that does not capture acculturation processes across different dimensions, such as changes in attitudes and values (Cabassa, 2003). Thus, instead of acculturation, these studies may be comparing the level of linguistic proficiency among attempters and non-attempters, as well as the linguistic proficiency disparities between the teens and their caregivers. Furthermore, studies that have relied on qualitative analysis, compared to those using quantitative methods, have produced a more nuanced description of adolescent acculturation in terms of changes in cultural attitudes and values, as well as about how Latina teens and their parents experience and resolve their cultural tensions. For example, when researchers found that Latina teens and their caregivers differed in their endorsement of cultural values (e.g., about family, roles, and expectations), they also ­ reported that these differences resulted in conflicts and discord among family members (see, for example, Gulbas et al., 2015). As described in the previous section, conflicts between the teens

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and… Table 16.2  Cultural protective and risk factors for suicide attempts among Latinas Acculturation Latina adolescents with and without history of attempts did not differ in acculturation levels Latina teen attempters and non-­ attempters were similar in acculturation levels, and similar acculturation disparities with their parents Higher adolescent Hispanic cultural involvement was associated with greater mother-daughter mutuality and thus led to reduction in the likelihood of suicide attempts Acculturation gap stress and immigration stress are significantly associated with suicide attempts among adolescent Latinas Family conflicts related to suicide attempts emerge, among other issues, around issues of acculturation to the US society Latina teens and their parents express conflicting and often contradictory culturally shaped conceptions of the family, roles, and expectations that lead to family discord, subjective distress, and emotional isolation among the teens Latina attempters are not only between cultural worlds but between cultural subjectivities. These cultural contradictions generate experienced within the self and the relational world Familism Familism (understood as families with high cohesion and low conflicts) protects teens from suicide attempts Familism reduces conflicts with parents but increases internalizing behaviors and reduces self-esteem, which in turn are related to suicide attempts The relationship between familism and suicide attempts is complex and nuanced, depending on individual factors. Familism can be both a protective and risk factor for suicide attempts. Familism can lead some girls to feel that they are a burden to their families, who can then decide to make the ultimate sacrifice for the Well-being of their families by attempting suicide. The idea of sacrifice for the family is part of the familism constellation of expectations

References Turner et al. (2002) Zayas et al. (2009)

Zayas et al. (2011)

Cervantes et al. (2014)

Humensky et al. (2017)

Gulbas and Zayas (2015)

Peña et al. (2011) Kuhlberg et al. (2010)

Nolle et al. (2012)

(continued)

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Table 16.2 (continued) Acculturation Familism does not appear to play a major role in the suicide attempts of Latina teens Gender Latina teens and their parents express conflicting and often contradictory culturally shaped conceptions of roles Family conflicts related to suicide attempts emerge, among other issues, around issues of differential gender expectations for teen girls and boys Teens increasing autonomy and violation of gender expectations, such as completing chores in the house, lead to conflicts with parents that triggered suicide attempts Generational status Second-generation more likely than first to attempt suicide Risk higher among early immigrant and US-born Mexican-Americans than Mexicans Second generation and third+ generation more likely than first generation Latino youth to have a suicide attempt history Being born outside the US increases the risk for suicide attempts Idioms of distress Latina suicide attempts may be a developmental or cultural variant of ataque de nervios Migration Girls who attempted suicide reported transnational stress

References Zayas et al. (2009)

Gulbas and Zayas (2015) Humensky et al. (2017)

Zayas et al. (2010)

Baumann et al. (2010) Borges et al. (2009) Peña et al. (2008)

Hall et al. (2018) Zayas and Gulbas (2012) Gulbas and Zayas (2015)

and their caregivers are a significant risk factor for suicidal behaviors among Latinas. The picture that emerges from the studies on generational status and suicide attempts is puzzling. Two studies found that having been an immigrant increases the likelihood of attempting suicide among Latina teens (see, for example, Hall et al., 2018), while two other studies reported the opposite, that belonging to second or later generations increases this risk when compared to new arrivals (see, for example, Peña et al., 2008). The latter findings on generational status might carry implications for understanding the role of acculturation in the suicide attempts of Latinas.

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This is because later-generation teens are raised in the United States by parents who are themselves presumably socialized to American culture because they were US-born. There is a robust body of literature demonstrating that first-­ generation immigrants generally have many initial health and mental health advantages over their US-born counterparts and that these advantages erode the longer immigrant groups reside in the United States (see, for example, Alegría et al., 2008). This phenomenon has been labeled the acculturation hypothesis (Scribner, 1996). Research on Latina suicide attempters has not been able to provide concrete answers about the role played by value orientations, specifically the teens and their caregivers’ endorsement of familismo, on the teens’ self-harm behaviors. Some investigators have suggested that familismo operates as a protective factor, reducing conflict between the teen and her parents (see, for example, Peña et al., 2011), but others have found that the suppression of conflicts with parents due to familismo increases the teen’s internalizing behaviors and reduces her self-esteem, which in turn, increases her likelihood of reporting suicidal behaviors (Kuhlberg et al., 2010). Zayas et al. (2009) go as far as to suggest that familismo may not play a major role in the adolescents’ suicide attempts. The dissonance in research findings about acculturation, generational status, and familismo is not found in the research about value orientations around gender roles and expectations. In this area, all the studies we reviewed confirm that the teens and their parents express conflicting and often contradictory expectations about the girls’ roles and behaviors (Gulbas et  al., 2015), especially when compared to boys (Humensky et al., 2017). These differential perspectives lead to conflicts between caregivers and teens, which in turn can trigger the suicidal crisis (Humensky et al., 2017; Zayas et al., 2010). Finally, the exploration of the cultural roots of Latina adolescent suicide attempts suggests that these represent an idiom of distress and posits that they may be a developmental or cultural variant of ataque de nervios (Zayas & Gulbas, 2012). Ataques de nervios are a well-established idiom of distress experienced by Caribbean, Mexican,

C. Hausmann-Stabile and L. E. Gulbas

and Central American women (Davis & Low, 1989). As described by Zayas and Gulbas (2012), the adolescents’ suicide attempts share many phenomenological, contextual, and historical characteristics with ataques de nervios, even though suicide attempts seem to manifest at a higher rate among Latina adolescents, whereas ataques are usually experienced by adult women.

 ommunity Protective and Risk C Factors for Suicide Attempts among Latinas The research on community protective and risk factors for suicide attempts among Latinas has focused mostly on schools (see Table  16.3). Among Latinas, Hall et al. (2018) found that a positive relationship with and encouragement from adults at school protected teens from suicidal behaviors. Bullying, cyber-bullying, and threats at school increased the odds of suicide attempts among adolescent Latinas (Boyas et  al., 2019; Price & Khubchandani, 2017; Romero et al., 2018). Academic experiences and aspirations have been a focus of attention, too. We include them here because, even though they refer to the teens’ internal processes and not directly to what happens at school, they are related to the teens’ experience of being in school and can inform targets of suicide attempt prevention for Latinas in educational settings. Qualitative researchers have observed that Latina adolescents who attempt suicide tend to interpret academic failures as proof of their perceived inadequacy (Gulbas et  al., 2015), and that, when compared to their non-suicidal peers, they describe fewer personal, academic, and professional expectations (Hausmann-Stabile et al., 2013). While most often Latina teens who attempt suicide report experiencing detachment or ­alienation within family relationships (see, for example, Zayas et al., 2009), and even violence and abuse at home (see, for example, Unikel et  al., 2006), some adolescents also describe experiences of discrimination and violence in their broader social spheres (see, for example, Gulbas et  al., 2019; Prince &

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and… Table 16.3  Community protective and risk factors for suicide attempts among Latinas School Being bullied and threatened at school increases the risk for suicide attempts Adolescents who attempted suicide were more likely to interpret academic shortcomings as evidence of their perceived worthlessness Exposure to violence at schools is related to the attempter’s “acquired capability” to self-harm Adolescent suicide attempters described few personal, educational, and professional aspirations compared to their non-suicidal peers There was incongruence of academic aspirations between suicidal adolescent and their parents Being bullied and threatened at school increases the risk for suicide attempts for LGB youth (including females) Positive relationships with adults at school are strongly correlated with reduced odds of suicide attempt A school adult believing they would be successful was protective for Latina girls Being bullied and cyberbullied increases the likelihood of suicide attempts among Latina teens Neighborhood Avoiding social connection with others, or experiencing marginalization or discrimination, is related to the attempter’s “thwarted belongingness” Exposure to violence in the community is related to the attempter’s “acquired capability” to self-harm

References Price and Khubchandani (2017) Gulbas et al. (2015)

Gulbas et al. (2019) Hausmann-­ Stabile et al. (2013)

Boyas et al. (2019)

Hall et al. (2018)

Romero et al. (2018)

Gulbas et al. (2019)

Khubchandani, 2017). Experiences of discrimination and/or violence in the community may, according to the IPTS (Joiner, 2005; Van Orden et  al., 2010) increase an adolescent’s sense of alienation and her tolerance of pain, increasing, in turn, the risk for suicide attempts (Brooks et al., 2020).

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Conclusion and Future Directions Research on the familial, cultural, and community protective and risk factors for Latina adolescents suicide attempts has built a substantial body of scholarship using a variety of methods (qualitative, quantitative) and approaches (including primary and secondary data analysis, system dynamics, etc.) to understand what can promote the girls’ well-being and reduce their self-harm. Among the strengths of this scholarship is that— for the most part—it is informed by theory. The models applied in this scholarship were either developed exclusively to explain the suicide attempts of Latinas (see Gulbas et  al., 2018; Gulbas et al., n.d.; Zayas et al., 2005), or developed for other groups (for example, IPTS, Joiner, 2005) and tested with data collected among Latina suicide attempters (see Gulbas et  al., 2019). The richness of this interdisciplinary body of scholarship is enhanced by its use of data collected among clinical and nonclinical samples, bringing to light a deeper understanding of the lives and experiences of Latina teens with or without suicide attempts. Overall, this research has confirmed the importance of nurturing and caring relationships for the well-being of Latina adolescents and has provided further support for the role of universal (i.e., independent of ethnicity) protective and risk factors for adolescent suicidal behaviors, located at the familial and community levels. Important universal protective factors are the role of functional and caring caregivers at home (see, for example, Adams et al., 1994; Brent et al., 1993; Summerville et al., 1994) and caring adults and safe peer relationships at school (see, for example, Kutsyuruba et  al., 2015). Many of the risk factors identified in this research, such as family conflict, are also noted as risks for suicide attempts in non-Latino adolescents (see, for example, Brent & Mann, 2003; Bridge et  al., 2006), and in suicidal youth in Latin America. For example, research conducted by Herrera et  al. (2006) in Nicaragua, and by Hausmann-­ Stabile and her team (in press) in Colombia, indicated that the relationship between teens who attempted suicide and their parents were often

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conflictive, and that attempters reported poor communication with their caregivers and a lack of mentoring and support. Although the studies reviewed here have advanced our understanding of the familial risk and protective factors for suicide attempts, we still do not have definitive reasons as to why so many Latina teens attempt suicide. This is in part because, rather than implicating each one of these protective and risk dimensions as a causal factor for suicide attempts among Latinas, this scholarship has examined them as a starting point to understand what is associated with these behaviors. From this foundation, researchers studying Latina adolescents suicide attempts could advance the field by testing causal explanations for the behaviors, an issue that has been extremely challenging across suicide scholarship on other populations (see Cha et al., 2018). We lack definitive answers about the cultural protections and risks for suicide attempts among Latinas beyond the agreement that the differential endorsement of gender values reported by Latina parents and adolescents leads to conflicts between them, which in turn are associated with the girls’ self-harm. More importantly, the scholarship is not in agreement about the role of acculturation in the teens’ suicide attempts. The lack of definitive answers in this area may be in part because of the overall challenges posed by the study of acculturation (see Guarnaccia & Hausmann-Stabile, 2016) or because of acculturation measurement issues (see Cabassa, 2003). There are several underlying conceptual and methodological issues that need to be addressed before this scholarship can move forward. First, although there is a general understanding that the cultural incorporation of Latino youth in the United States is kaleidoscopically complex, this perspective has—for the most part—not been embraced by researchers. This may be in part because understanding diverse experiences of acculturation, especially in ways that attend to within-group heterogeneity (e.g., immigration histories, national heritage, geographical context), requires complex longitudinal research designs. Second, the difficulty in straddling different cultures hypothesized for Latina teens has

C. Hausmann-Stabile and L. E. Gulbas

been observed among non-Latino adolescents from other groups with high rates of suicidal behaviors. For instance, indigenous youth in Canada and in the United States have high rates of attempted suicide and suicide death (see Harder et  al., 2012). Perhaps the underlying mechanism in the relationship between acculturation and suicidal behaviors among Latinas has to do less with the teens’ process of cultural change, and more with the contexts in which it takes place. The central limitation of the research on cultural protective and risk factors for suicidal behaviors among Latinas may be that this scholarship relies on a conceptualization of culture that is decontextualized. For example, a decontextualized approach of culture assumes that the acculturation of a teen in a predominantly White rural area would be similar to that of an adolescent growing up in an urban Latino ethnic enclave. Furthermore, this research attributes a homogeneity to Latino and American cultures that contradicts their diversity. Despite being labeled under one demographic category, Latinos in the United States are a heterogenous group in terms of immigration experiences and language use (Guarnaccia et  al., 2007), income (Semega et al., 2019), and citizen status (Neo-Bustamante et  al., 2020) among others. Similarly, research has identified distinct subcultures in the United States based on racial origin, ethnic ancestry, religious affiliation, and social structures (see, for example, Lieske, 1993, 2010), that in turn have been linked with, for example, regional patterns of individualism and collectivism (Vandello & Cohen, 1999), and policy variation of support for low-income families (Meyers et  al., 2001). Developmentally informed ethnographic research about Latino and dominant cultures across multiple settings, attuned to class, gender, and their diversity, among others, might generate evidence of the dynamic nature of cultural processes, and a more nuanced understanding of the role of contexts in shaping acculturation and well-being trajectories among youth of immigrant backgrounds. This body of research has confirmed other universal protective and risk factors for suicidal

16  Latina Adolescent Suicide Attempts: A Review of Familial, Cultural, and Community Protective and…

behaviors. Not surprisingly, safe schools and neighborhoods are important for the well-being of Latina adolescents, and, therefore, the protection from suicidal behaviors. The role of bullying and cyber-bullying as risk factors for suicide attempts among Latinas (see, for example, Romero et  al., 2018) is in line with previous research on non-Latino adolescents (see, for example, Van Geel et  al., 2014). What may be unique to Latinas is that among the risks that they experience in the community are discrimination and marginalization because of their ethnicity and/or immigrant status. As stated in the introduction to this chapter, the choice of focus on extra- or intra-ethnic protective and risk dimensions to explain suicidal behavior disparities among adolescents is not arbitrary. It emerges from theoretical lenses and methodological practices that carry implications for how questions are formulated, approached, and answered. Furthermore, these approaches are nested within professional traditions that are not always in conversation with other scientific disciplines concerned with similar issues. In the case of Latina suicide research, investigators have embraced an intra-ethnic perspective as a starting point to explain a health disparity between this group and their non-Latino counterparts. This may have led to neglecting the dynamic nature of the relationship between the extra and intragroup dimensions, an understanding that places the disparity as situated within complex and dynamic sociocultural contexts in which the “extra” and the “intra” shape each other. Rather than approaching Latina suicide attempt disparities as an either/or project, future research in this area could conceptualize the disparity as both/and, as simultaneously extra- and intra-ethnic. This would make it possible to conceptualize the suicide disparity as emerging from structural factors contextualizing and shaping ethnic minority suicidal behaviors, as well as intragroup dynamics of response to these structures that contribute to this outcome. The first step toward a shift in the approach could engage researchers focusing on Latinas in dialog with scholars who study adolescent suicidal behaviors in other disciplines (e.g., public health, anthropology, psychiatry, and soci-

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ology), and those who focus on other populations. This could help build up a common understanding of the universal and group-specific dynamics that shape adolescent suicidal behaviors, test explanatory models, and identify universal and group-specific targets of prevention and treatment. Future research needs to look for innovative research methods and engage the intersectional dynamics that shape the lives of Latina adolescents, with variation by race, ethnicity, gender, sexual orientation, and other dimensions of diversity. Several promising areas include syndemic (see Singer, 2000, 2009) and resilience approaches. Syndemic theory proposes a conceptual and methodological approach that allows researchers to test how the accumulative effects of risk results in health vulnerabilities at the population level such as suicidal behavior disparities (see, for example, Mustanski et al., 2014). In contrast, a resilience approach highlights what prevents suicide attempts among Latina teens growing up in contexts of similar risk. Given current demographic trends in the United States, specifically the predicted increase in the percentage of racial and ethnic minority adolescents to about 60% in 2050 (Office of Population Affairs, 2019), it is critical that suicide researchers understand the role of diverse experiences in shaping and protecting adolescents to ensure Latina adolescents live to reach their fullest potential. To this end, the next steps in this area should aim to apply the knowledge gained into effective real-world prevention and treatment interventions. To date, most suicide interventions apply evidencebased models that target micro-level risk factors in isolation, such as cognitive deficits or poor family functioning (see, for example, Ougrin et al., 2015). Although salient, interventions must also be able to address the dynamic interplay of multiple risk factors across individual, interpersonal, and cultural domains to promote the development of more effective prevention strategies across diverse populations. Given the persistent nature of disparities of suicidal behaviors among Latina adolescents, our

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Risk and Protective Factors for Suicide in Black Youth

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Sherry Davis Molock, Makiko Watanabe, Ariel P. Smith, Amrisha Prakash, and David W. Hollingsworth

Suicide is the second leading cause of death in youth ages 10–19. Historically the suicide rates for Black youth have been lower than the rates for White youth, but that picture is beginning to change. As of 2018, suicide became the second leading cause of death in Black children aged 10–14, and the third leading cause of death in Black adolescents aged 15–19, (Center for Disease Control and Prevention [CDC], 2020). Suicide rates for Black children aged 5–12 are approximately double than that for White children of similar ages (Bridge et al., 2015). Suicide S. D. Molock (*) Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA e-mail: [email protected] M. Watanabe Massachusetts General Hospital/Harvard Medical, Boston, MA, USA e-mail: [email protected] A. P. Smith Department of Psychology, Lone Star Circle of Care at University of Houston, University of Houston, Houston, TX, USA A. Prakash Counseling and Psychological Services, University of San Francisco, San Francisco, CA, USA e-mail: [email protected] D. W. Hollingsworth Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL, USA e-mail: [email protected]

attempts rose by 73% between 1991 and 2017 for Black adolescents (boys and girls), while injury by attempt rose by 122% for adolescent Black boys during that same time period (Lindsey et al., 2019). While there is a paucity of data on suicide rates among sexual minority youth from communities of color, in general, research suggests that youth who endorse one or more marginalized statuses have higher rates of depressive and suicidal symptoms (Gore & Aseltine, 2003; Hatzenbuehler et al., 2008). In one study, sexual minority adolescents comprised less than 10% of the overall sample but accounted for 79.6% of the total youth suicide attempts (Reisner et  al., 2014). In this chapter, we discuss the risk and protective factors for suicide in Black youth at multiple levels (e.g., individual, familial, community).

Definition of Terms The term African American is often used to describe people of African descent who were born in the United States. In this chapter, we will use the term Black as opposed to African American or black in describing research samples because the term “Black” refers to people of African descent from the African diaspora who may live both within or outside of the African continent. While many studies describe their samples as African American, most researchers do not include information on the ethnic diversity

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of study participants who represent the African diaspora. Most researchers use the terms Black/ African American interchangeably without giving participants the option to identify with their racial and ethnic group (e.g., Afro-Latinx; Afro-­ Caribbean). The term Black will be capitalized because it refers to a race of people; black refers to a color. The term suicide is often used synonymously with suicide completion and involves intentional self-injurious behavior that results in a fatality (Silverman et al., 2007). In this chapter, suicidal behavior is a generic term that will be used to describe suicide ideation, suicide-related communications, suicide attempts, and suicide deaths. Suicidal ideation refers to having thoughts about or an unusual preoccupation with suicide. These thoughts can include both passive thoughts about one’s own demise as well as more direct thoughts about taking one’s life. Suicide-related communications can involve a person making a suicide threat or in some way conveying the person’s thoughts, wishes, or intent, either implicitly or explicitly, to engage in suicidal behaviors. A suicide attempt is often characterized as self-­ injurious but nonlethal behavior that has some degree of intent to end one’s life.

Risk and Protective Factors Risk factors are characteristics that increase the likelihood that individuals will develop problematic behaviors; it is important to note that risk factors are not static and can change over time. Key risk factors for suicidal behaviors in youth, in general, include: (1) the presence of a psychiatric disorder, (2) gender (with females being more likely to attempt suicide and males being more likely to die from suicide), (3) prior attempts, (4) being a victim or perpetrator of bullying, (5) socioeconomic factors, (6) family functioning, (7) exposure to suicide, and (8) access to means (Matlin et  al., 2011). The few studies that have examined suicide risk specifically in Black adolescents suggest that depression, poor family sup-

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port, trauma, and racism are risk factors for suicidal thoughts, attempts, and/or suicide deaths (CBC Emergency Task Force on Suicide and Mental Health, 2020). Even fewer studies have examined protective factors against suicide in Black youth. Protective factors are characteristics in the individual’s world that mitigate against the development of psychopathology or problem behaviors, often by interacting with the risk factor to moderate risk (Tebes et  al., 2001). Protective factors against youth suicide can be broadly categorized into five groups: personal factors (e.g., positive racial/ethnic identity), strong family support, peer/community support, stable environment (i.e., stable family housing, income, and employment), and religious and spiritual engagement (CDC, 2020). In a systematic review of the literature in this area, Droege et  al. (2017) found that what the protective factors for suicidality for Black youth had in common was that they promoted social integration through a variety of mechanisms, including family, relational, and religious connections. While risk and protective factors are often studied independently, it is important to examine their relative importance in either exacerbating or diminishing suicide risk together because risk and protective factors often act in tandem. As a result, utilizing an ecodevelopmental framework (Szapocznik & Coatsworth, 1999) is helpful with understanding risk and protective factors for maladaptive behaviors in the context of the social systems in which they occur. This framework has been successfully applied to other risk/protective mechanisms related to other problematic behaviors in youth, including substance use, risky sexual behaviors, and suicide attempts (Cordova et al., 2016; Li et al., 2017; Zayas et al., 2005). This framework is useful to frame our discussion of several suicide risk and protective factors that operate at multiple levels (individual, family, community) through a developmental lens. This chapter will review the risk and protective factors for suicidal behaviors in Black youth at the individual, familial, and societal levels.

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17  Risk and Protective Factors for Suicide in Black Youth

Depression Depression has been found to be one of the best predictors of suicide in both youth and adults (Nanayakkara et  al., 2013). Depressive symptoms are an important risk factor to target in ­suicide prevention for Black youth since depressive symptoms tend to increase during adolescence and thus increase the likelihood of suicidal behavior (Varley, 2002). Epidemiological data suggests that the greatest risk period for the onset of major depressive disorder occurs from mid- to late adolescence to early 40s across all countries (Yalin & Young, 2019). Although some risk factors for suicide seem to differ across racial and ethnic groups in different developmental periods, depression is consistently identified as one of the most significant risk factors associated with adolescent suicidal behavior (Gattis & Larson, 2016). Findings on the prevalence of racial and ethnic group differences in depression and depressive symptoms have been somewhat inconsistent in the literature, with some studies suggesting Black youth have higher rates of depressive symptomatology (Franko et al., 2005; Merikangas et al., 2010) while others suggest lower rates of depression in Black youth, compared to their Caucasian peers (CDC, 2020). Some of the differences in these findings may be due to how Black youth understand and express depressive symptoms. It is important to note that not all Black youth who exhibit suicidal behaviors report depressive symptoms (Joe et al., 2009; Lewinsohn et al., 1998). For example, in a confirmatory factor analysis of the widely used Center for Epidemiologic Studies Depression Scale (CES-D), Lu et al. (2017) found that a two-­ factor rather than the original four-factor model was a better fit in a sample of Black adolescents. The results found that the first factor was a combination of the Depressed Affect, Somatic Symptoms, and Interpersonal Problems factors in the original model; the second factor corresponded to the Positive Affect factor in the original model. They also found that compared to Black females, Black males were less likely to endorse positive affect items. Lindsey et  al. (2017) note that depression may be misdiagnosed

in Black adolescent males because antisocial behaviors may “mask” depressive symptoms. Unfortunately, Black youth are less likely to receive treatment for depression thereby increasing their risk for suicide (Breland-Noble et  al., 2013). Barriers to treatment are complex, multi-­ scalar (individual-, interpersonal-, and structural-­ level), and socially embedded. Some examples of barriers include stigma, religion/spirituality, treatment affordability/availability/accessibility, the paucity of referrals from the school system, and social networks and can also include child-­ related factors and clinician/therapeutic factors (Planey et al., 2019).

Anxiety Research examining associations between anxiety and suicidality has speculated that somatic concerns, catastrophic cognitions (e.g., fears of dying or losing control), and rumination interact with the stress response to trigger suicidal behavior (Sareen, 2011). Further, a systematic review of the literature posits that increased anxious distress is linked with the perceptions of defeat, entrapment, and loss of autonomy, which have been associated with both suicidal ideation and behavior (Taylor et al., 2011). There is also evidence suggesting an independent relationship between anxiety symptoms and suicidal ideation among youth, in particular, beyond what can be accounted for by depression (O’Neil Rodriguez & Kendall, 2014). However, these findings have been documented using primarily White samples, despite evidence that Blacks with anxiety disorders are more likely to experience severe mental illness and more functional impairment (Himle et  al., 2009). Thus, examining the specific features of anxiety among Black youth is important in providing a culturally and racially informed perspective on suicide prevention in this population. Black youth have been more likely to report somatic or physical complaints of anxiety such as physiological hyperarousal, which may reflect a more culturally acceptable way of expressing anxious distress than affective symp-

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toms (Gaylord-Harden et  al., 2011; Newman Trauma Kingery et al., 2007). In addition, physiological hyperarousal has been associated with increased Exposure to traumatic stressors has been well-­ exposure to violence for Black youth living in understood to be associated with significantly low-income, urban communities (Gaylord-­ increased risk of depression, hopelessness, overt Harden et  al., 2011), consistent with findings aggression, and future suicidal ideation and that negative life events are more common and attempts (Bernard et  al., 2020; Graves et  al., more significantly linked with anxiety for Black 2010; Kaplow et  al., 2014; Thornton, 2020). youth than their White counterparts (Lewis Further, the development of PTSD from this et al., 2012). exposure, particularly to experiences of assaulThe cognitive component of anxiety may tive violence, is an independent predictor of suialso be particularly relevant for Black youth cide attempts among urban youth, controlling for and their risk for suicide, particularly concern- the effects of depression and alcohol and drug ing judgments they may make about situations abuse (Wilcox et al. 2009). There is also evidence or events they might experience. Black youth for emotional suppression to function as a mediahave demonstrated significantly increased tor of this association between adverse or trauappraisals of threat or harm and more cata- matic life events and suicidal ideation and strophic (exaggeratedly negative) thinking behavior among youth (Kaplow et  al., 2014). about stressors, compared to White youth, both However, these factors have particular relevance of which are robust predictors of emotional dis- for suicide prevention among Black youth, a poptress and the effectiveness of coping efforts ulation that is overrepresented in high-risk con(Forsythe et al., 2011). In addition, rumination texts for trauma exposure such as low-income, or perseverative thoughts about negative expe- urban communities, juvenile detention centers, riences appear to be causally linked with emo- and foster care placements (Bernard et al., 2020). tional and behavioral distress for Black but not Blacks experience violence that is more severe White youth (Borders & Liang, 2011) thus than other races, and PTSD has been shown to be effectively functioning as a maladaptive form more prevalent among Black adults than White of passive coping. adults (Graves et al., 2010; Himle et al., 2009). Research examining the comorbid presenta- Further, Black youth are more likely to experition of anxiety and depression among Black ence trauma, have the highest rates of victimizayouth has elucidated overlap in symptoms of tion, are more likely to report multiple adverse negative affect and described physiological childhood experiences than their White counterhyperarousal as a distinct fear of anxiety for parts, and have more mental health concerns and African American youth (Gaylord-Harden et al., evidence of health risk behaviors following expo2011). Since hyperarousal, specifically, has been sure to traumatic events (Bernard et  al., 2020; associated with suicidality independent of other Graves et al., 2010). They also are at greater risk symptoms of stress or anxiety (Briere et al., 2015; for experiencing more severe forms of maltreatMorabito et  al., 2020; Newman Kingery et  al., ment, specifically interpersonal trauma (physical 2007), relaxation and mindfulness-based clinical abuse, sexual abuse, community violence, and interventions may be especially indicated for domestic violence) that has been associated with Black youth reporting significant somatic com- significantly more clinical symptoms of PTSD plaints and at increased risk for suicide. Further, (Hunt et  al., 2011). Additionally, Black youth cognitive-behavioral therapy providing Black reporting multiple adverse childhood experiences youth with skills for more active coping and have been more likely to report suicidal ideation restructuring of initial fear-based judgments may and behavior than those reporting primarily be protective against triggers of suicidal neglect or fewer adverse experiences (Thornton, behavior. 2020).

17  Risk and Protective Factors for Suicide in Black Youth

Among the clusters of PTSD symptoms, hyperarousal appears to be particularly relevant in examining the impact of post-traumatic stress on suicidality among Black youth, including evidence of hyperarousal symptoms fully mediating the relationship between the severity of trauma and the extent of suicidal thinking and behavior (Briere et al., 2015). This finding is particularly relevant for Black youth whose increased hyperarousal may function as a physiological response to community violence exposure that protects them from future victimization, while also being related to more reactive forms of overt aggression associated with juvenile detention and incarceration (Graves et  al., 2010; Phan et  al., 2020). Further, this hyperarousal has been linked to increased impulsive forms of aggression among Black youth, including suicide attempts, due to its role in sensation seeking and lack of premeditation (Gaylord-Harden et al., 2017; Graves et al., 2010; Salami et al., 2015). Positively, reasons for living can buffer the impact of hyperarousal and impulsivity resulting from PTSD, and reasons for living have been found to be higher among Black youth compared to their White peers (Salami et al., 2015).

Racism Several studies have suggested that racism is a common experience for many Black youth and can contribute to various negative outcomes (Walker et al., 2017). However, research studies that focus on the relationship between experiences of racism and suicide risk among Black youth have only recently emerged in the literature. One of the first studies that examined the relationship between racism and suicide risk found that there was a direct effect of perceived racial discrimination on suicide ideation and morbid thoughts about death in general or about their own death and that depression and anxiety symptoms also mediated that relationship (Walker et  al., 2017). Madubata et  al. (2019) also conducted a longitudinal study to examine the relationship between different forms of racism and

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suicidal ideation among a sample of Black youth between the ages of 14 and 17 from a rural, low-­ income school district. They found that (1) Black youth experienced subtle forms of racism (also sometimes referred to as “microaggressions”) more often than overt racism and that (2) experiencing more racial microaggressions predicted current suicidal ideation as well as ideation 1 year later (Madubata et  al., 2019). The researchers also noted that these relationships were even stronger than the relationship they found between depression and suicidal ideation, suggesting that compared to depression, assessing for experiences of racism (especially subtle forms of racism) may be a better way to predict suicidal ideation among some Black youth. Relatedly, racial microaggressions were associated with higher levels of perceived burdensomeness, which were then associated with higher levels of suicidal thoughts in Black young adults (Hollingsworth et al., 2017). Arshanapally et  al. (2018) also explored the relationship between racial discrimination and suicidality (i.e., ideation, plan, and attempts) among Black youth and young adults between the ages of 13–32 from primarily low-income families, some of whom were struggling with alcoholism. The researchers found that there was a significant relationship between racial discrimination and suicidality for the participants, as a whole, but that this relationship became nonsignificant for male participants when also accounting for their mothers’ experiences of racial discrimination. These findings suggest that mothers’ experience with racial discrimination may explain the relationship between racial discrimination and suicidality among Black male youth. Future research should explore both maternal and youth experiences with racism because maternal experience with racism may influence how these mothers socialize their children about racism. Research suggests that boys tend to receive more negative racial socialization (e.g., messages about stereotypes and racial barriers) and report more sadness and hopelessness, whereas girls tend to receive more positive racial socialization (e.g., messages about racial pride) and report less sadness and hopelessness (Arshanapally et  al.,

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2018). Therefore, caregivers becoming more aware of this gender bias and making efforts to provide more positive racial socialization may help reduce the link between their own experiences of racism and their child’s level of suicidality when their child experiences racism. Ford et  al. (2013) also found a similar negative relationship between caregivers’ experiences of racial discrimination and Black youth’s psychological well-being over time. Overall, it appears that experiencing racial discrimination (including racial microaggressions) can be associated with depression and anxiety, as well as higher suicide risk among Black youth. There also appears to sometimes be a multigenerational effect where the youth’s primary caregiver’s experiences with racism may have some indirect influence on the youth’s psychological well-being and suicidal risk, potentially because of the way they were racially socialized by their caregiver.

Protective Factors Hope While hope has been found to be a protective factor against suicidal thoughts and behaviors in adults (Grewal & Porter, 2007; Tucker et  al., 2016), very few studies have examined the role of hope in preventing suicide in youth, in general, and in Black youth, in particular. In a recent systematic review of the literature on protective factors for suicide in Black youth (Droege et  al., 2017), only one of the 26 articles reviewed examined hope as a possible protective factor for suicidal behaviors. One of the reasons for this paucity of research in hope as a protective factor for suicide is the overwhelming focus on risk factors in suicide research, with most of the research looking at depression and/or hopelessness as risk factors for suicidality. But according to Snyder’s hope theory, which derives from positive psychology (Grewal & Porter, 2007), hope is the ability to have a plan (i.e., pathways) and the motivation (i.e., agency) to successfully achieve the desired

goal (Snyder, 2002; Snyder et  al., 1991). The importance of hope in Black culture can be seen historically through overcoming slavery, the civil rights movement, Jessie Jackson’s “Keep Hope Alive” mantra, and President Obama’s 2008 presidential campaign. In fact, research suggests that Blacks have higher levels of hope than their White counterparts (Davidson & Wingate, 2011). In one of the few studies that examined whether hope was a protective factor against suicidality in Black youth, Davidson et al. (2010) found that high levels of hope were predictive of lower levels of suicidal thoughts among Black college students. In addition, for Black young adults who had low levels of hope, as their feelings of being a burden and not belonging (i.e., perceived burdensomeness and thwarted belongingness) increased, so did their thoughts of suicide. In a similar study, Hollingsworth and colleagues found that among Black young adults who had high levels of hope, the relationship between perceived burdensomeness, thwarted belongingness, and suicidal thoughts was no longer significant (Hollingsworth et  al., 2016). These studies indicate that having goals and the motivation to achieve said goals (i.e., hope) can be protective against the development of suicidal thoughts in Black young adults. However, further work is needed to examine other suicide risk factors that hope may mitigate against and to see if these findings can be replicated in other subgroups that may have higher risk for suicide (e.g., clinical sample).

Ethnic Identity Ethnic identity is a multidimensional and dynamic construct that refers to one’s identity as a part of an ethnic group. It involves various dimensions such as attitudes toward one’s own ethnic group, practice, values, and beliefs, as well as belongingness to one’s cultural heritage. It develops over time through exploration and commitment and fluctuates with time and context (Phinney & Chavira, 1992; Phinney & Ong, 2007). Literature suggests that ethnic exploration usually starts during early adolescence and is

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often triggered by exposure to discrimination and racism (Cross, 1995; Helms, 1995; Phinney & Chavira, 1992; Quintana, 2007). Positive ethnic identity is known to be associated with better psychosocial outcomes among youth such as positive emotional adjustments among Black and White adolescents (Yasui et al., 2004) and self-esteem among ethnic minority youth (i.e., Asian American, Black, and Hispanic) (Phinney & Chavira, 1992). Polanco-Roman and Miranda (2013) reported that ethnically diverse college students with higher levels of ethnic identity reported lower levels of hopelessness, depressive symptoms, and suicidal ideation. Notably, hopelessness only mediated the association between acculturative stress and depressive symptoms among students who reported lower levels of ethnic identity, suggesting a buffering effect of ethnic identity on depression and suicidal ideation. Ethnic identity may be important for Black youth, in particular. Aries and Moorehead (1989) interviewed Black high schoolers and found the significant role of ethnic identity in forming one’s overall identity. Given the centrality of ethnic identity for these youth, it is not surprising that positive ethnic identity is associated with positive well-being and protective against psychological distress among Black adolescents and young adults. For instance, strong ethnic identity was associated with higher academic achievement among low-income Black adolescents (Adelabu, 2008) and lower depressive symptoms among Black, male adolescents (Gaylord-Harden et al., 2017). It also buffered the detrimental effects of racial discrimination on anxiety among Black adolescents (Tynes et al., 2012). Despite the dearth of research examining the ethnic identity-suicidality relationship in Black youth, one study explored how ethnic identity impacts suicidality among Black college students. Walker et al. (2008) found that Black college students with low levels of ethnic identity were more likely to endorse higher levels of suicidal ideation. Moreover, stronger associations between depression and suicidal ideation were found among students who reported lower

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attachment to their ethnic group, compared to those who reported higher attachment to their group. Interestingly, these moderation effects of ethnic group attachment were not found among European American college students, highlighting the unique significance of ethnic identity in Black youth. Walker et al. (2008)‘s findings are consistent with what we know about the relationship between ethnic identity and suicidal behaviors in Black adults. For instance, Kaslow et al. (2002) found that Black adults with a history of suicide attempts reported lower levels of ethnic identity (i.e., feeling less connected and affirmed by their own ethnic group) compared to those that did not make suicide attempts. Perry et  al. (2013) also found that having high levels of ethnic affirmation and belonging was proactive against negative effects of gendered racism on suicidal ideation and behaviors. The researchers posited that ethnic affirmation might help youth externalize racist or sexist events, preventing their self-­ concepts from being negatively influenced. They noted that individuals who put in time and cognitive effort in solidifying their own identities might be negligibly affected by occasional negative messages from others. They also pointed out that those with a strong sense of collective identity developed a sense of belongingness and acceptance—factors that might mitigate the negative effects of racism and oppression. Overall, the literature suggests that strong ethnic identity is associated with positive mental health outcomes, and ethnic identity protects against depressive symptoms and suicidality among minority youth including Black youth. Despite the limited research on the role of ethnic identity in relation to suicidal behavior among Black youth, there are a handful of suicide studies suggesting the importance of promoting ethnic identity in preventing suicide in Black adults. While further research is warranted to better understand the protective mechanisms of ethnic identity against suicide among Black youth, positive ethnic identity is likely to be protective and imperative in promoting wellbeing in this group.

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Social Support

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tent with the communal values promoted in Black culture, in that communalism emphasizes the There is a more robust literature that has exam- extended self, the fundamental interdependence ined the role that social support can play as a pro- of people, and the importance of social bonds tective factor for suicidal thoughts and behavior (Harris & Molock, 2000). in Black youth (Droege et al., 2017). Social supIndeed, family support has been found to port typically involves the availability of inter- function as a protective factor for suicidality personal social resources; implicit in the concept among Black adolescents. Kandel et  al. (1991) of social support is that it provides stability for showed that closeness to parents has a direct human relationships (Turner & Turner, 1999). effect in reducing suicidal ideation in high school Social support provides people with a sense of students, independent of depressive symptoms. connectedness with others, and its importance as Longitudinal studies of economically disadvana protective factor against suicidality dates back taged Black adolescents (O’Donnell et al., 2004) to Durkheim’s seminal theory on suicide found that the level of family closeness and (1897/1951), which posited that suicide reflected parental support predicts depression and suicidala person’s level of social integration. ity over time. In addition, studies have shown that Previous research has indicated that different family support and cohesive families protect types of social support, namely family and peer Black college students from depression and suisupport, are important protective factors against cidal ideation (Kimbrough et al., 1996; Marion & suicide for youth and adults (Barrera & Garrison-­ Range, 2003), and perceived parent-family conJones, 1992). Little research has focused on com- nectedness (feeling loved, wanted, and cared for) munity connectedness as a type of social support; has also been protective against suicide attempts however, available studies suggest it may play an among Black adolescents (Borowsky et  al., important role in suicide prevention because it 2001). can provide a sense of belonging or mattering to a group, a sense of personal value or worth, and Peer Support access to a larger network of support (CDC, Adolescence is a developmental period that is 2008). In addition, there is evidence of strong typically marked by an increase in the amount of school connectedness reducing the probability of time individuals spend with peers, rather than Black youth’s suicidal ideations and attempts with their families (Cole & Cole, 1996). over time, in part due to the amount of time that Furthermore, adolescents who perceive their Black children and adolescents spend at school friends as supportive report fewer school-related fostering a sense of belonging (Tomek et  al., and psychological problems, greater confidence 2018). in their social acceptance by peers, and less loneliness (Cole & Cole, 1996; Lagana, 2004). Peer Family Support support has been shown to be influential in many Although adolescence is a time when family rela- mental health outcomes, including suicidal tions often change, there is considerable evidence behavior. Suicidal adolescents have been found that family support is important to adolescent to be more socially isolated than non-suicidal psychological adjustment. Cauce et  al. (1982) adolescents (Berman & Schwartz, 1990; Hawton found family support to be the single most impor- et al., 1996) and to perceive themselves as more tant type of social support among lower income rejected by peers (Prinstein et al., 2000). Others adolescents. Among Blacks, family support is have found that peer social support can promote considered a culturally salient variable because positive outcomes even for youth living in stressconnectedness to family is historically important ful family conditions and that the protective in coping with a society that is often experienced effects of social support increase as the number as hostile to the Black community (Billingsley, of sources of support expands (Forster et  al., 1992). Further, family connectedness is consis- 2020). In a nationally representative sample of

17  Risk and Protective Factors for Suicide in Black Youth

adolescents from diverse backgrounds, Winfree and Jiang (2010) found that feeling safe at school was one of the most consistent protective factors for teens. Very few studies however have examined the relationship of peer support and suicidality among ethnic minority adolescents. Studies that do exist have contradictory findings: Kimbrough et al. (1996) found family and peer support to be protective for suicidal ideation in Black college students, but O’Donnell et al. (2004) found that peer support was not protective against suicidality among urban Black adolescents. Matlin et al. (2011) found that increased family support and peer support are associated with decreased suicidal thoughts and behaviors in a Black adolescent sample and found that peer support and community connectedness moderated the relationship between depressive symptoms and suicidal ideation and behaviors. Thus, although the relationship of peer support to suicide among Black adolescents is less well-understood than that of family support, it remains an important possible protective factor.

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Pescosolido, 1990). van Tubergen et  al. (2005) argue that religion protects against suicide because religious communities not only provide support, but they also often have prohibitions against suicide. Several researchers have noted that cultural/religious prohibitions against suicide may actually serve as a buffer against suicide for Blacks (Anglin et al. 2005; Barnes, 2006; Early & Akers, 1993). Several studies have empirically looked at the relationship between suicidality and religiosity in Black people, in part, because of the central role that religion plays in Black culture (Lincoln & Mamiya, 1990; Taylor & Chatters, 2010). In multiple national samples examining different aspects of Black American life, Blacks have consistently engaged in more public (e.g., church attendance) and private religious devotion (e.g., reading religious material) than other racial/ethnic groups (Chatters et  al., 2009; Taylor et  al., 2000). In general, research suggests that religiosity is associated with both positive and negative mental health outcomes (Chatters, 2000; Larson & Larson, 2003). For example, religiosity is inversely related to delinquent behavior (Stark et  al., 1983), substance use (Robertson et  al., Religiosity/Spirituality 2010), PTSD in women experiencing family violence (Watlington & Murphy, 2006), and depresAnother factor that has been found to be protec- sion (Lesniak et  al., 2006; Jang & Johnson, tive against suicide in the general population is 2004). But churches can simultaneously present religiosity. Durkheim’s (1897/1951) seminal barriers to help seeking. In general, clergy are work on the role of religion in suicide posited more likely to underestimate the severity of psythat religion acts as a deterrent against suicide chotic symptoms (Larson, 1968), make fewer because it enhances social integration and nor- referrals to mental health professionals (Blank malizes submission or adherence to regulation. et al., 2002), and are less likely to recognize suiMore contemporary researchers have challenged cidal lethality (Domino & Swain, 1985/1986). Durkheim on both theoretical and methodologi- Theological perspectives and church doctrine can cal grounds. They have suggested using a micro-­ also influence the church community’s receptivemacro level approach that looks at the relationship ness to community-based interventions (Gray & between individuals and the societies in which Molock, 1999; Swanson et al., 2004). they are embedded. In the case of suicide, this Some of the equivocal findings in the literasuggests that religious contexts affect the rela- ture on the relationship between religion and suitionship between religion and suicide at the indi- cide can be attributed to the failure to differentiate vidual level. For example, several researchers among different aspects of religious behaviors. have argued that higher levels of religious Taylor and his colleagues (2000) have validated a involvement reduce suicide risk because reli- three-dimensional model of religious involvegious institutions provide important community ment, consisting of organizational, non-­ support to individuals (Ellison & Taylor, 1996; organizational, and subjective religiosity in Black

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adults (Chatters et al., 1992; Levin et al., 1995). Public religious participation refers to behaviors that occur within the context of a church, mosque, or other religious setting (e.g., church attendance). Private religious participation refers to behaviors that may occur outside of a religious setting (e.g., private prayer, reading religious materials), while subjective religiosity refers to perceptions and attitudes regarding religion, such as the role of religious beliefs in daily life (Chatters et al., 1992). Most of the research that has looked at the relationship between religion and mental health has focused on public or organizationally based religious behaviors (e.g., church membership, church attendance, involvement in church activities), which may not fully capture the role of religion in psychological well-­ being. The research that has examined the relationship between public religious participation and mental health outcomes has found the two variables to be inversely related (Mason & Windle, 2002; Steinman & Zimmerman, 2004). More recently, some researchers have begun to focus on the relationships between mental health outcomes and religious coping. Religious coping refers to strategies that are activated in an effort to manage illness (Pargament et al., 2000). Nooney and Woodrum (2002) found that religious coping was strongly predicted by public religious activity and that it more strongly predicted depression relative to church-based social support. Gray and Molock (1999) found that among Black college students, collaborative religious coping styles were associated with lower levels of hopelessness and suicide ideation. Molock and her colleagues (2006) found that self-directed religious coping style was significantly related to suicidal behaviors in a community-­ based Black adolescent sample. Specifically, self-directed coping (God empowers me to solve my own problems) was related to increased hopelessness, depression, and suicide attempts, while collaborative coping (God and I solve problems together) was related to increased reasons for living. Greening and Stoppelbein (2002) found that holding strong core beliefs in Christian orthodoxy (e.g., belief that suicide is

incompatible with Christian teachings) mitigates suicide risk in Black adolescents. In addition, Fitzpatrick et al. (2008) found that belonging to a spiritual community was protective against suicidal ideation, though not attempts, for Black youth who lived in low-income communities. These findings on the role of religion on mental health suggest the need to use more complex models to understand the role of religiosity and mental health outcomes and give credence to the use of more integrative approaches that encompasses a wide array of mechanisms by which religion might affect suicide risk.

Conclusion Suicide is a serious concern among Black children and adolescents, being the second and third leading cause of death in Black youth aged 10–14 and aged 15–19, respectively (CDC, 2020). The rate of reported suicide attempts by Black youth has significantly increased between 1991 and 2017, while they have remained the same among White youth (Shain, 2019). The drastic rise in suicide attempts among Black youth indicates an urgent need to better understand suicidality in Black youth. Goldston et al. (2008) posited that suicide risk and protective factors vary among different ethnic youth groups due to unique cultural contexts in which suicidal behaviors take place. Thus, identifying culturally relevant risk and protective factors is necessary to better detect youth with a high suicide risk and help them reduce vulnerability to suicide. In this chapter, we used an ecodevelopmental framework to discuss the risk and protective factors for suicide in Black youth at multiple levels (e.g., individual, familial, community). While there is a great value in examining the independent effects of either risk or protective factors, researchers are encouraged to further investigate associations between risk and protective factors to recognize their joint effects on suicidal behaviors among Black youth. That way, clinicians can accurately assess overall risk and foster protective factors with an aim to reduce suicide in Black youth.

17  Risk and Protective Factors for Suicide in Black Youth

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Part IV Treatment and Prevention

Suicide Prevention Through Community Capacity Building in Resource-Poor Areas and Lowand Middle-Income Countries (LMICs)

18

Henry C. Peterson and Ellen-ge Denton

Introduction

nity the skills to conduct their own data collection, identify relevant interventions, and Defining Terms and Chapter Focus implement tools that contribute to building health infrastructure. In practice, capacity building Community-Based Participatory Research involves a cycle of developing, training, and sup(CBPR) is an increasingly popular research ori- porting. It engages community members as partentation for use among historically oppressed ners. Researchers provide feedback mentoring populations. CBPR is a research design where and support for communities that collect inforresearcher and participant roles are mutually mation and gather data. The following review integrative, and both share project decision-­ includes 41 studies that focus on suicide prevenmaking and directioning (Skerrett et  al., 2018). tion and capacity building in low-resourced comTrue CBPR places equal value on the respective munities through culture-specific approaches, contributions, strengths, and perspectives of both diverse methodologies, community-health academicians and community members (Israel empowerment, and research implementation. et  al., 1998). The cultural relevance of a CBPR To highlight CBPR scholarship and service, design is to provide results that readily translate this chapter summarizes capacity building efforts into action with immediate and direct benefit to that have broadly influenced policy, practice, participants (Skerrett et  al., 2018; Viswanathan and/or curriculum changes using study samples et al., 2004). that contributed as research partners, consultants, CBPR can be limited to mutually integrative or beneficiaries. For example, a previous CBPR academic and community partnerships but may literature review of studies that included youth as extend to include clinical-research collaborations partners in the research process found that 26 out that provide an overall benefit to community of 40 manuscripts had designs where community organizations. Capacity building maximizes partnerships were formed with a community-­ CBPR efficacy as it offers members of a commu- based organization directly related to youth issues or with a specific population of youth, though youth were not contributing partners in H. C. Peterson the research process (Jacquez et  al., 2012). For City College, City University of New York, New York, NY, USA the purposes of this chapter, we will include community partnership-based suicide research studE-ge Denton () College of Staten Island, City University of ies such as these to be inclusive of all CBPR New York, Staten Island, NY, USA research. e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. Miranda, E. L. Jeglic (eds.), Handbook of Youth Suicide Prevention, https://doi.org/10.1007/978-3-030-82465-5_18

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This chapter focuses on community-based sample showed heightened risk to suicide ideapproaches tailored to build capacity in settings ation for Caribbean Blacks relative to African with little mental health infrastructure, undevel- Americans, but the reverse for suicide attempt oped suicide prevention-intervention protocols, risk; elevated suicide attempt risk for African and among populations that remain largely American relative to Caribbean Black individuals underrepresented (and thus misunderstood) in the (Joe et al., 2009). Therefore, an open mind to the scientific literature. Suicide risk in low- and diversity of suicide risk within LMIC and middle-­ income countries (LMIC’s) and Indigenous samples will prepare the reader for Indigenous contexts are related to historic and interpretation of this chapter discussion. Second, systemic oppression, insufficient health surveil- suicide risk is not explicable by cultural norms lance, and/or limited resources. Thus, LMIC and and values. Observational data that reports sigIndigenous youth study samples are prime candi- nificantly higher suicide deaths among Indigenous dates for suicide prevention through capacity youth when compared to non-­Indigenous youth building CBPR. does not mean that “being” Indigenous causes Forming participatory research designs in pre- suicide (Yuen et al., 1999). This chapter aims to dominantly low-income communities and/or disaggregate the complex behavioral predictors communities of color, CBPR bridges the historic associated with cultural group identification and gap between researchers and community mem- directs the readers’ focus to intervenable or modbers (Israel et al., 2010). Capacity building CBPR ifiable targets that prevent death by suicide offers opportunities to develop skill sets in low-­ among youth in LMIC and Indigenous settings. income communities and/or communities of color that address concomitant, systemic disparities in mental health infrastructure (Israel et al., How Do We Define Persons at Risk 2010). Capacity building suicide prevention for Suicide in Low-Resourced uniquely benefits resource-poor communities Settings? where isolation and stigma distinctly contribute to suicide risk for individuals who have survived We define those most at risk for suicide as those family member and friend suicides, have made a who are least represented in the suicide literature, previous attempt, and/or have suicide ideation. namely LMIC and Indigenous youth populations. We highlight a diverse array of CBPR approaches Given that suicide risk peaks along the lifespan in within the suicide literature that improves under- adolescence, we restrict our definition of at-risk standing, prevention, treatment, and rehabilita- study samples to youth in LMIC and Indigenous tion of youth affected by suicide in low- and samples. Suicide is the second leading cause of middle-income countries (LMIC’s), under-­ death among youth, ages 15–24, and 7.4% of resourced settings, and historically disadvan- youth in grades 9–12 reported that they had made at least one suicide attempt in the past 12 months taged communities (Indigenous samples). Related misconceptions about suicide in com- (World Health Organization [WHO], 2014; Kann munities of color are formally presented in other et al., 2018). Although youth are capable of parsections of the Handbook (See Chap. 17). Yet, we ticipating in the research process, data from a emphasize two misconceptions that are particu- comprehensive review of 385 studies showed that larly important to understanding suicide preven- only a few studies, 56/385 (14.5%), directly parttion capacity building among LMIC and nered with youth in the research process. The Indigenous youth samples. First, communities of majority of research studies (159 out of 385) uticolor are neither monolithic, nor do they present lized a research process broadly consistent with with uniform suicide risk. Collective conscious- community placements, partners, and pairings ness and featured community life do not protect with adults that target benefits for youth in their LMIC and Indigenous populations from suicide age designated organizations (Jacquez et  al., (Durkheim, 1951). In fact, epidemiological 2012). The following studies review research observation of suicide risk within a Black youth findings that demonstrate underrepresentation

18  Suicide Prevention Through Community Capacity Building in Resource-Poor Areas and Low…

and support our emphasis on LMIC and Indigenous youth. Indigenous people represent one of the world’s most vulnerable suicide demographics. In a systematic review of manuscripts comparing rates of Indigenous suicide to non-Indigenous suicide by country (N = 99), 21 studies showed lower suicide rates among non-Indigenous compared to Indigenous populations (Pollock et  al., 2018). While Indigenous suicide rates were consistently elevated relative to non-Indigenous suicide rates, this pattern was not universal across countries (e.g., In Brazil, Indigenous people of Sao Gabriel de Cachoeira, Amazones Rate Ratio (RR) = 9.98 per 100,000, In Taiwan, Atayal RR  =  5.69, In America, American Indian and Alaska Native RR  =  2.45, In Israel, Bedouin  =  0.4 and In Australia, Aboriginal and Torres Strait Islanders RR = 0.9; Pollock et al., 2018). The majority of studies examined Indigenous populations (e.g., Alaska native, Aboriginal and Torres Strait Islander, and Inuit) in high-income countries (N  =  76; United States, Australia, or Canada). LMICs represented n = 22 studies from countries such as Brazil, China/Taiwan, and Fiji. Within LMICs, Palawan communities in the Philippines had the highest suicide rates (134 per 100,000), while Indigenous peoples in Malaysia and some Pacific small island states such as Fiji had rates under 7 per 100,000 population. Further, of studies that provided age-specific rates, youth ages 15–24 had the highest suicide rates of any age group (in 89% of studies, n = 34; Pollock et al., 2018). We consider young, ethnic, and limited resource demographics to be most underrepresented in the suicide literature and those who benefit most from suicide prevention through community capacity building.

 hat Role Does Poverty Play W in Capacity Building Suicide Prevention for Both LMIC and Indigenous Populations? Poverty takes on many forms in the surveyed resource-poor settings and complexly undergirds a lack of mental health capacity. Without clinical and research mental health capacity, the effects of

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poverty on suicide outcomes become systematic. For example, risk factors for suicide are linked to the material needs of disadvantaged communities and communal “comorbidities” like epidemic alcohol abuse, inadequate housing, utilities, transportation, and other public services. Such contextual conditions are inextricably interwoven into individuals’ lives and sometimes hopeless realities. Below we explore the multifaceted associations of poverty on suicide outcomes among LMIC and Indigenous youth. A systematic review of 37 studies classified individual or national level poverty indicators correlated with suicide deaths in LMICs like Ghana, Uganda, Iran, Turkey, and Brazil. Individual poverty was measured by absolute and relative poverty, economic status and wealth assets, unemployment, debt, and/or financial problems. National poverty was coded as an economic crisis, low national income, and/or national inequalities. In adjusted and unadjusted analyses, there was an observed significant positive correlation between poverty and suicides. In the review, LMICs identified as having increased national (n = 9 studies) and individual-­level poverty (n  =  5 studies) had more suicides (Iemmi et al., 2016). Baseline data was gathered from three village clusters of the Millennium Villages Project (MVP), which was an integrated, community-­ led, rural-development program that included Ruhiira, Uganda, Pampaida, Nigeria, and Bonsaaso, Ghana to determine poverty-related risk factors to suicide. In Nigeria, the only risk factor for suicidal ideation (SI) was food insecurity (β  =  −0.255, p