Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices
Abstract
Suicide is the second leading cause of death among adolescents and young adults. Historically, Black youths have experienced lower rates of suicide; however, recent data point to significant racial disparities. In this article, the authors review current suicide rates, including alarming new data suggesting that suicide rates are two times higher among Black children ages 5–12 compared with White children in that age range. A clinically focused summary of socioecological risk and protective factors associated with suicide among Black youths, with particular attention on structural drivers and culturally relevant factors, is provided. Current evidence-based reviews suggest that dialectical behavior therapy is the only well-established treatment against self-harm and suicide among youths. However, it is unknown whether current established treatments work for Black youths, because Black youths are rarely included in randomized controlled trials. The authors conclude by reviewing emerging treatments developed and tested specifically for Black youths.
In this article, the authors review current suicide rates, including alarming new data suggesting that suicide rates are two times higher among Black children ages 5–12 compared with White children in the same age range. A clinically focused summary of socioecological risk and protective factors associated with suicide among Black youths is provided, and emerging treatments developed and tested specifically for Black youths are discussed.
Clinical Context
Rates of Suicide by Demographic Characteristics
Suicide is the second leading cause of death among U.S. adolescents and young adults (1). Historically, Black youths have experienced lower rates of suicide and suicide attempts; however, recent data indicate racial disparities in rates of suicide across different developmental epochs. Data from the Youth Risk Behavior Surveillance System (2), which include input from 14,765 high school students across the nation (53.5% non-Hispanic White, 22.8% Hispanic/Latinx, 13.4% Black, and 10.3% Other) indicate that 6.1% of non-Hispanic White adolescents reported a previous suicide attempt in the 12 months before the survey, compared with 8.2% of Hispanic/Latinx youths and 9.8% of Black youths. In addition, the COVID-19 pandemic increased many of the associated risk factors associated with self-harm and suicide, and primarily affected Black and Latinx youths compared with youths of other racial-ethnic groups. In fact, recent data from the National Center for Health Statistics (3) on death from suicide (from 2019 to 2020) show that, although rates of suicide declined for White and Asian groups, they increased for Black, Latinx, and American Indian/Alaska Native groups. Changes in rates of suicide from 2019 to 2020 are not available by race-ethnicity and gender, however, suggesting that intersectional data are urgently needed to better understand how the COVID-19 pandemic has affected youths of color.
In addition to racial disparities, significant gender differences exist for suicide attempts and deaths. Black adolescent females lead prevalence rates of suicide attempts compared with adolescent females of other racial-ethnic groups. Data from the 2019 Youth Risk Behavior Survey (4) indicate that 15.2% of Black adolescent females reported a previous suicide attempt in the 12 months prior to the survey, compared with 11.9% of Latinx females and 9.4% of non-Hispanic White females. An examination of (5) suicide death trends found that Latinx and Black females experienced the greatest increases in deaths by suicide (133% [from 1.8% to 4.2%] and 125% [from 2.0% to 4.5%], respectively), compared with an 88% increase (from 3.4% to 6.4%) among non-Hispanic White and a 61% increase (from 4.1% to 6.6%) among Asian and Asian American females of the same age range. Additional data (6) also support that rates of suicide increased from 2001 to 2017 for Black adolescents; however, Black adolescent females experienced a 182% increase (from 1.18% to 3.33%), whereas Black adolescent males experienced a 60% increase (from 5.71% to 9.15%). The above findings reflect “intersectionality,” a term coined by legal scholar Kimberle Crenshaw to highlight the ways in which marginalized identities intersect to amplify risk.
Rates of suicide among Black youths demonstrate striking differences in differing age groups. Although Black youths (ages 5–11) made up 15% of the population, they accounted for 37% of all youth suicides between 2003 and 2011 and thus were overrepresented in deaths by suicide during that time (7). Other recent studies of Black youths ages 5–17 (8) indicate an increase in deaths by suicide, with Black youths ages 15–17 experiencing the greatest increase (4.9%) within the 2003–2017 time frame. Similar data (9) examining trends in suicide among adolescents ages 15–19 found that the most dramatic increase was among girls, with rates rising from 1.2 suicides per 100,000 per year in 2007 to 4.0 per 100,000 per year in 2017. However, for Black youths ages 10–14, there has been a drastic increase of 131.5% in deaths by suicide over the last 20 years (9). Even more concerning, recent articles (10) report that very young Black youths, ages 5–12, are twice as likely to die by suicide compared with White children of the same age range. These alarming rates indicate that Black children and adolescents are experiencing significant increases in suicide and suicide attempts, whereas children and adolescents of other racial-ethnic groups, with the exception of Latinx adolescents, have had no significant change or have even experienced decreases in suicide and suicide attempts (11). Given the fact that suicide is the second leading cause of death for adolescents and a major public health concern, if these gaps are not addressed or prioritized, these disparities will continue to widen.
Factors Driving Disparity
Several factors have been hypothesized to further our understanding of the aforementioned disparities. First, there is some evidence that Black adolescent males engage in more lethal methods of suicide, ultimately leading to higher medical needs and more suicides (11). Second, cultural differences regarding symptom presentation and manifestation, such as public stigma, courtesy stigma (i.e., the stigma experienced by close family members, including parents), and internalized stigma, may prevent Black youths from seeking care in times of distress. In fact, aggregated data from 2007 to 2019 from the Healthy Minds Study (N=153,635 college students) (12) have indicated that Black students endorse the highest rates of public stigma related to receiving mental health treatment, and that ratings of public stigma (even with analyses controlled for symptoms of depression) are significantly associated with greater odds of past-year suicide attempts. Stigma relating to receiving mental health treatment has been documented (13) as a significant barrier that increases the gaps between effective prevention and treatment interventions. Identification of barriers to treatment can help inform providers of the disparities in mental health treatment experienced by Black youths and may help increase service access and use. Mental health stigma is a prominent, known barrier to treatment that can hinder prompt interventions for psychiatric problems (14). Medical mistrust, in combination with stigma within the Black community, may amplify the mental health disparities that are significantly affecting Black youths (15, 16). The history of unethical medical experiments (e.g., Tuskegee syphilis study) has unsurprisingly contributed to the Black community’s distrust of the health care system. The extended record of structural racism, discrimination, institutional inequities, and structural disparities continues to be an obstacle to seeking mental health services (17).
Stigma, in particular, often leads to silencing, shame, and fear, and several studies (18–21) have found that Black youths are more likely than their White peers to not endorse suicide ideation before a suicide attempt. Black adolescents also report fearing that their friends may tease them for seeking mental health support and worry that their family members may feel ashamed. Relatedly, researchers have found that Black adolescents report a lack of family support as another barrier to seeking mental health services (22). Because mental health access is a socially embedded process, other social networks, including the religious or spiritual community, also play an important role in the seeking of mental health treatment. In particular, religion and spirituality have a noteworthy impact among some Black communities. Faith-based community settings are trusted by many within communities of color, and the ideals and values presented during services may influence members to seek culturally acceptable services (e.g., faith or spiritual-based healing, consulting with clergy), instead of psychiatric and psychological services (23). Other studies (14) have also noted that some Black parents may rely on spirituality instead of mental health treatment for their children. Yet, other social support, including teachers and social workers, may facilitate treatment seeking among Black youths (15).
Because youths may lack autonomy in determining their mental health treatment, decision making regarding mental health services often falls to caregivers, guardians, and educators. Several studies (16, 24–26) have found that youths, caregivers, and primary care providers often do not believe there is a presenting mental health issue or believe that the problems are not severe enough to warrant treatment, thereby creating gatekeeping barriers to accessing care. Furthermore, self-reliance and refusal to attend treatment have also been found to prevent youths from seeking and receiving mental health services (15, 25). Black caregivers with children at risk for developing a psychiatric disorder are less likely to report that their adolescents need psychological services than are White caregivers (27). This finding may be related to mental health stigma, medical mistrust, lack of information on problem recognition or how and where to seek services, or preferences for culturally focused services (e.g., church). Black parents have also described the challenges of navigating the school system and lack of resources as systematic barriers to youth mental health service use (14, 28).
Socioecological Risk and Protective Factors
Historical risk factors associated with youth suicide may not be inclusive, representative, or relevant to youths from different racial-ethnic backgrounds, factors that have negatively thwarted advancement of our understanding of the current suicide crisis among Black and other non-White youths. For example, the “common” risk factors associated with suicidal behaviors recently have been found to not be associated with suicidal behaviors among Black youths (8, 21, 28), therefore challenging the notion of what is considered common, given what has been observed epidemiologically in terms of trends. Typically, queries on suicidal ideation are one of the most used indicators for detecting suicide risk, yet this symptom indicator is a less reliable predictor among Black youths. These findings indicate that historic warning signs may not be applicable for detecting suicide risk among Black youths. Moreover, unique risks are associated with suicide among Black youths. Although hopelessness and depression symptoms are considered traditional risk factors, researchers have not found similar associations for these symptoms among Black youths (20, 29). Data from a high-risk group of 6–9-year-old children, with and without parental history of suicidal behavior (7), indicated differences in parenting style and social anxiety among Black and non-Black youths. Specifically, the sample of Black youths reported more psychological control by their parents, a factor that has been associated with adolescent suicidal behavior (30). Furthermore, Black youths were more likely to report symptoms of social anxiety. Taken together, these findings indicate that reported social anxiety symptomatology and parenting style are important factors to consider in the development of suicide intervention strategies specific to Black youths.
Poverty has been found to be associated with suicidality, along with witnessing violence, both of which are prevalent among Black youths. Nearly 40% of Black adolescents are living in poverty— twice the rate of their White counterparts (31, 32). Furthermore, many Black families are disproportionately overrepresented as low income compared with White families (33). Indeed, research has indicated that areas of concentrated poverty are linked to higher rates of suicide among youths. The experience of numerous interrelated stressors (e.g., financial burden and exposure to community violence, gang activity, and drug use) places poverty as a risk factor for mental health difficulties (34–36).
In addition, most research has largely neglected to consider the direct and indirect effects that race-related oppressive experiences, such as racial discrimination and racial trauma, have on suicidal behaviors. To address this gap, new theoretical frameworks highlight the importance of examining interpersonal stress factors and culturally relevant risk factors, such as racism, to better understand suicide risk among Black youths (37). This topic is a critical area of focus, because some of the most fundamental causes of adverse outcomes among racial-ethnic groups, including suicide, are related to factors associated with racism and discrimination. Unfortunately, racial discrimination is a far too common experience for Black youths across various developmental periods (i.e., childhood, adolescence, and young adulthood). For example, studies (38) examining the longitudinal association between racial discrimination and suicide among 10-year-old Black children have found that perceived racism predicts later suicide. The link between racial discrimination and suicide ideation has also been noted among Black adolescents (39). In recent studies, perceived racial discrimination predicted depression symptoms (40) and suicide ideation (41) among both Black and Latinx youths. In a sample of college students (42), discrimination (not specific to racial-ethnic discrimination) was significantly associated with increased capability for suicide (defined as one’s physical capacity to inflict lethal injury on oneself) among Black but not White college students. Across studies and developmental stages (39, 43, 44), racial discrimination has been significantly associated with suicidal ideation. However, the mechanisms underlying this association remain understudied.
The extensive history and experience of racism and discrimination that affect the Black community considerably influence stress levels in the community, and as noted previously, have become barriers to seeking mental health services (17). Low-income Black youths are more likely to report elevated exposure to racial discrimination, indicating an urgent need to provide resources to Black children experiencing poverty. Furthermore, recent research has highlighted an association between stress, trauma, and racial discrimination, which can lead to severe mental health outcomes. For example, the effect of traumatic stress from racial discrimination may increase risk for suicidal behavior (45). Therefore, race-related trauma and stress also require significant attention in mental health treatment. In addition to overt racism, the experience of microaggressions (defined as commonplace verbal, behavioral, or environmental insults that suggest hostile or negative racial slights toward people of different races), whether intentional or not, have been found to increase levels of poor mental health consequences and psychological distress (46).
Although there has been a recent focus on risk factors related to suicide among Black youths, the evidence focusing on protective factors continues to be sparse. A systematic review (36) of protective factors against suicide among Black adolescents indicated that religious, social, familial, and personal factors may mitigate risk for suicidal behaviors. Religiosity is often a focal part of the lives of Black families; therefore, several religious factors, such as intrinsic religiosity, religious awareness, perceived membership in a spiritual community, and collaborative religious problem solving, have been found to protect against youth suicidality (47–50). Familial protective factors that are strongly supported are parent-family connectedness and family support, but familial factors have been found to be less protective among low-income youths (36, 50, 51). Additionally, several social factors, such as dense school social networks, school climate, popularity, and perceived social support have been found to be protective against suicide among Black adolescents. However, several of the factors, including popularity, teacher bonding, and perceived support have been found to be nonprotective among urban Black youths (47, 50, 51). The mixed findings of past studies suggest there may be protective factors unique to Black youths of different socioeconomic backgrounds. Additionally, several individual characteristics, including age, high self-esteem, emotional well-being, hope, academic success, reasons for living, purpose in life, and life satisfaction, have been found to protect against suicidal behavior (36, 51–57). Other protective factors, such as racial socialization, racial pride, and racial-ethnic connectedness have shown promise in terms of promoting resiliency and, therefore, warrant further exploration.
Treatment Strategies and Evidence
Understanding culturally relevant risk and protective factors for suicide among Black youths is key to advancing the development of culturally informed, evidence-based treatments for suicide prevention, because principles guiding prevention work include both reducing risk factors and enhancing protective factors. A recent review by Glenn and colleagues (58) of evidence-based treatments for suicidal thoughts and behaviors among youths reviewed all available randomized control trials (RCTs) and found only 26 trials. Examination of the available 26 RCTs suggested that only dialectical behavior therapy for adolescents (DBT-A) is a well-established treatment for suicide among youths, given that it was the only treatment modality with significant evidence for reducing self-harm across two independent trials. DBT-A treatment typically lasts about 6 months and includes multiple components, including individual therapy, family therapy, and multifamily skills groups to learn a wide range of behavioral, cognitive, and distress tolerance skills. Few clinicians of color are trained in DBT; consequently, there is low availability of Black DBT-trained clinicians. Furthermore, limited progress has been made in testing DBT (or other evidence-based treatments) among non-White youths, because current RCTs have included a majority of White participants or participants outside the United States (59).
Fortunately, new research is emerging on the treatment of suicidal behavior among Black youths. The Adapted Coping with Stress Course (A-CWS) is a group-based, 15-session cognitive-behavioral intervention that teaches Black adolescents how to cope with stress associated with racism (28). A recent study of the A-CWS intervention (28) found promising results, suggesting high feasibility and acceptability of the intervention curriculum and that Black student participants overwhelmingly liked the program. An RCT (60) of the A-CWS found that the culturally adapted intervention was efficacious in reducing relative suicide risk among Black adolescents.
Other noteworthy advances have included Joe and colleagues’ review (61) of what works to prevent suicide among Black adolescent males. Of the six interventions included in the Joe et al. review, however, only three included a majority of Black adolescents; enrollment of Black youths in these three studies ranged from 65% to 89%. These interventions included two trials of attachment-based family therapy (62, 63), which targets repair of family attachment relationships and promotion of autonomy among youths. Both trials of attachment-based family therapy had significant effects on reducing suicidal ideation; however, effects on suicide attempts were not examined. The third intervention was a trial of multisystemic therapy (MST), a family-centered, home-based intervention (64) that helps youths and their families solve problem behaviors through a socioecological framework. The MST trial (64) reported significant reductions in suicidal behaviors, such that participants enrolled in the MST arm reported a 27% reduction in suicide attempts at the 1-year follow-up and a 41% reduction in suicidal ideation. Nevertheless, the review by Joe and colleagues (61) concluded that the empirical treatment literature on suicide among Black youths remains severely underdeveloped and grossly insufficient for guiding clinical practice protocols regarding what is effective for preventing suicide among Black youths. Finally, Joe et al. did not find a single study that focused on gender differences. An additional intervention, developed specifically for Black families but not specifically focused on suicide, is the Strong African American Families–Teen (SAAF–T) program. This intervention integrates parenting skills centered on communication and skills for coping with discrimination for rural Black teens. Research on this intervention (65) found significant reduction in conduct problems, substance use problems, and depressive symptoms compared with adolescents in the control condition. Despite recent advances in culturally adapted treatments for Black youths, very little is known about what works for the prevention of suicide among Black youths.
Questions and Controversies
Suicide among youths is a relatively new field, and many clinical questions remain. Evidenced-based treatments for youth suicide ideation and attempts include DBT-A and multisystemic therapy, yet these evidence-based treatments remain largely understudied among Black youths. Culturally adapted treatments for suicide that target socioecological factors that have an impact on suicide risk among Black youths (i.e., racial trauma, racial discrimination, racism) are urgently needed. In addition to the current gaps in research that limit progress in suicide interventions for Black youths, other biases affect suicide intervention among Black youths. For example, research findings (66) indicate that physicians and other health care workers are less likely to screen for suicide risk among Black youths, a situation that can be combated with racial bias training in medical settings to improve detection. In addition, studies (67) indicate higher suicide misclassification among Hispanic or Latinx and Black adolescents ages 10–19 compared with White adolescents in the United States. Greater sustained effort is needed to course-correct misclassification bias and failed identification of suicide among racial-ethnic minority youth populations to better understand rates and trends of suicide reported in surveillance studies, which ultimately inform important suicide prevention efforts.
Recommendations
Current intervention strategies against suicide are grounded in risk factors that have been established with White adolescents (68). However, in order to truly address the current suicide crisis among Black youths, interventions need to address the socioecological context in which Black youths are embedded. Similarly, most research to date has largely used quantitative methods to examine risk and protective factors, which affects our ability to capture the narrative of the how and why of suicide among Black youths. Important future work can focus on mixed-methods strategies that integrate both quantitative and qualitative methods. In addition to mixed-methods approaches, it is important to incorporate intersectionality frameworks, given that Black girls have multiple oppressed identities that may be associated with factors related to self-injurious thoughts and behaviors. Finally, although many theories of suicide exist, none integrate a focus on race-related experiences unique to Black youths, with the exception of that of Opara and colleagues (37). The lack of theories aimed at improving our understanding of suicide among Black youths impedes the necessary advances in culturally relevant assessments and treatments aimed at detecting and preventing suicide among Black youths. Future directions should not only elucidate important risk and protective factors associated with suicide among Black youths but should also prioritize development of treatments that specifically target mechanisms of change.
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Published in print: Spring 2022
Published online: 22 April 2022
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