Responding to the Alarm: Addressing Black Youth Suicide

Transcript

Operator:  Hello and thank you for joining the Office for Disparities Research and Workforce Diversity 2020 Webinar Series titled Responding to the Alarm: Addressing Black Youth Suicide.  At this time, all participants are in a listen-only mode. Questions can be submitted at any time via the Q&A pod in the lower righthand corner of your screen. Please note this call may be recorded.  I will be standing by should you need any assistance.  It is now my pleasure to turn today’s conference over to Crystal Barksdale, Chief of Minority Mental Health. Please go ahead.

Crystal Barksdale:  Thank you.  Good morning all. On behalf of the National Institute of Mental Health, I want to welcome you to the 2020 Office for Disparities Research and Workforce Diversity Webinar Series. This is the first of four webinars for the 2020 series. We offer the webinar series as an opportunity for staff and the public to learn about recent scientific advances and sponsored research in key areas that our office is focused on, which includes minority mental health, the mental health of sexual and gender minorities, women’s mental health, and the mental health of people living in rural communities. 

The details for all webinars, including registration for this year’s series, can be found at www.nimhodwdwebinars.com, where you accessed information about today’s roundtable.  In addition, following the live presentations, all webinars will be archived and accessible on the NIMH ODWD website. This typically takes a little bit of time, but please use this option if you’re unable to attend the presentation in real time.  Please note that the second webinar in the series will be held on Wednesday, May 20th at 12:30 PM Eastern Time, entitled Women’s Decision-Making around Pre-Exposure Prophylaxis for HIV Prevention featuring Dr. Laurie Bauman and Dr. Siobhan M. Dolan. Today, I’m pleased to introduce Dr. Joshua Gordon, the Director of the National Institute of Mental Health, who will provide a few opening remarks for our first webinar on Black youth suicide. Following Dr. Gordon, you will hear from my co-moderator, Roslyn Holliday Moore from the Substance Abuse and Mental Health Services Administration, who will introduce our esteemed panelists for today.
One note regarding our panelists.  Due to extenuating circumstances, unfortunately Jason Wilson from The Yunion, Inc. will be unable to join us today.

As the Director of the National Institute of Mental Health, Dr. Gordon oversees an extensive research portfolio of basic and clinical research that seeks to transform the understanding and treatment of mental illnesses paving the way for prevention, recovery, and cure.  Dr. Gordon pursued a combined MD-PhD degree at the University of California San Francisco, where medical school coursework and psychiatric and neuroscience convinced him that the greatest need and greatest promise for biomedical science was in these areas. 
Upon completion of his dual degree program, residency, and research fellowship, he joined the faculty at Columbia University in 2004 as an assistant professor in the Department of Psychiatry.  Dr. Gordon’s own research focuses on the analysis of neural activity in mice carrying mutations with relevance to psychiatric diseases including schizophrenia, anxiety disorders, and depression. 

In addition to pursuing research, Dr. Gordon was an associate director of the Columbia University/New York State Psychiatry Institute Adult Psychiatric Residency Program, where he directed the neuroscience curriculum and administered research training programs for residents. Dr. Gordon also maintained a general psychiatric practice, caring for patients.

Dr. Gordon’s work has been recognized by several prestigious awards, including the Brain and Behavior Research Foundation – NARSAD Young Investigator Award, the Rising Star Award from the International Mental Health Research Organization, the A.E. Bennett Research Award from the Society of Biological Psychiatry, and the Daniel H. Efron Research Award from the American College of Neuropsychopharmacology.

I warmly welcome and thank Dr. Gordon for his remarks.  Dr. Gordon.

Joshua Gordon:  Hi.  Thank you for that perhaps overly long introduction, but I guess we had to let people get time to make sure that their setups are working.  Welcome everyone.

I’m frankly ambivalent about being here to be honest, and the reasons why I’m ambivalent is what I’m showing here on this graph. I’m ambivalent because of the need to be here, the need to have this webinar, which is tremendous, and one might say overdue but nonetheless crucial. Why am I ambivalent?  I’m ambivalent because on the one hand we have to have this for a negative reason, which is shown here the increasing rates of suicide amongst Black youth in the United States, and we’ll come back to that in a moment.

I’m excited to be here because it’s about time we began to address this from a science perspective. There’s a thousand people or nearly a thousand attendees, and although I’m reading the comments that some of you can’t hear me, I’m hoping that most of you can and particularly excited that this will be archived so that people can listen in, can watch, can hear from these experts on the web for a good long time.

So, let’s come back to this problem. As many of you know, perhaps all of you know, for the past 20 years in the United States, the rates of death by suicide have been increasing across virtually all demographic groups. There are very few pieces of good news in health for minorities particular underserved minorities.  They typically have worst access to care and often worst outcomes as well, but in mental health one of the exceptions to that rule has been suicide rates, particularly for African Americans but across the board for many minorities. 

However, we have noticed now over the last two or three years a startling increase in the suicide rates amongst Black youth, and we must recognize that we do not understand the reasons for it fully, nor have we figured out what we need to do to try to counter this disturbing trend. 

I’m really looking forward to the presentations today by our guest speakers to begin the process of trying to understand where and how we can intervene and try to reduce these disturbing trends. With that, I’ll turn it back over to Crystal, and I’m really looking forward to listening in with you all as we hear from our esteemed speakers.

Crystal:  Thank you, Dr. Gordon.  Roslyn.

Roslyn Moore:  So, Dr. Gordon, this is Roslyn Moore from SAMHSA.  I’m going to jump in at this point and move us forward in the conversation.

Thank you very much for your framing remarks. I think your ambivalence as you framed it is one that we share, and while we recognize that there are a number of negative reasons that bring us to this afternoon’s event, we also see the opportunity with the expertise that we will be hearing from shortly.

I’d like to use your comments to create a momentum for the dialogue. We will be asking the panelists a series of questions today. Most of them have emerged from a broad spectrum of subject matter experts but also from canvasing the literature and ways in which we can also hear voices from community members rise up and help us understand some of the core elements that we need to explore, so thank you for all of those comments and suggestions that help feed the dialogue for today.

And with that, I also want to encourage all participants to submit questions in the Q&A box on your screen, and as time permits, we will address as many as possible towards the end of this event.

At this point, I’d like to move forward with introducing today’s speakers. Dr. Rhonda C. Boyd is an Associate Professor in Psychiatry in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine.

Next, we have Dr. Michael Lindsey, who is the Executive Director of New York University’s Silver’s McSilver Institute for Poverty Policy and Research and is the School’s Constance and Martin Silver Professor of Poverty Studies.

Following him, we have Dr. Arielle Sheftall, who’s the Principal Investigator at the Center for Suicide Prevention and Research and the Center for Innovation in Pediatric Practice at Nationwide Children’s Hospital.

As you heard earlier our fourth panelist, Mr. Jason Wilson, is not able to join us today, but we do believe he’s joining us in the audience and doing good work in Detroit. Details about his work and all of the panelists can be found on the event page if you’re interested in following up with them directly and learning more about their particular expertise. So, welcome to all of the panelists.

I would like to open the conversation as we are about to hear from each of you.  With a focus on understanding, what makes the topic of Black child and youth suicide so important to discuss at this point in time? I’m sure the audience is interested in knowing why the Congressional Black Caucus Taskforce Report—well the taskforce was convened and the report Ring the Alarm: The Crisis of Black Youth Suicide in America was developed. So, with that, maybe Dr. Lindsey, would you like to kick us off?

Michael Lindsey:  Sure. I just want to make sure you can hear me. First of all, I want to thank Roslyn and Crystal for convening us, definitely Dr. Gordon for making all of this possible as well through NIMH.

Dr. Gordon mentioned that he was ambivalent or experiences ambivalence, and quite frankly I’m alarmed and scared for a lot of Black kids and their families because suicide has somehow become an option for how they reconcile their emotional and psychological pain. I want to thank Congresswoman Bonnie Watson Coleman. I’ve often referred to her as an angel because as an elected official, she at the federal level was very concerned and took this concern to the Congressional Black Caucus and really championed the importance of bringing a federal response, a federal lens to this issue. And so, I just want to thank Congresswoman Bonnie Watson Coleman for her courageous leadership in this space.

You know I’ve talked to a number of families and moms in particular who have had a child die by suicide, and the one thing that they have expressed to me is that they saw no warning sign that their child was in that deep of pain.  They didn’t know that their child was pained in that way and didn’t know what could be done or should be done. And so, this is a ring the alarm moment, and I think that through this conversation we hope to illuminate what we think are some plausible next steps and things that we can do to address this crisis.

Roslyn:  Did anyone else want to chime in on that particular question or did Michael cover it for us?

Rhonda Boyd:  I think he covered it.

Roslyn:  Okay then.  So, with that, I noticed Michael when you talked about some of your observations and I’m wondering with others if there’s an idea or a growing understanding of just how common are suicide and suicidal behaviors in Black children and youth and if we can learn a little bit about changes over time.  I was wondering Arielle if you maybe wanted to start with that.

Arielle Sheftall:  Yeah, sure.  So, my research within this topic area has really focused in on the epidemiology and looking at how changes over time have actually occurred in Black youth. So, the first paper that we conducted looked at young children 5- to 12-years-old, and what we—excuse me, 11-years-old. And what we found is when you compared the rates of suicide in this younger age group, Black youth actually were more likely to die by suicide than White youth, and that got myself and colleagues very much interested in the what’s going on question.

So, after that came about, we looked at precipitating circumstances, so basically what are the factors that may differ in this younger group compared to older youth—early adolescents specifically, so we looked at kids 5- to 11-years-old compared to kids that were 12- to 14-years-old and tried to figure out what were those factors that were actually related to suicide deaths specifically.  And what we found is that, again in this young age group, kids were more likely to be Black, more likely to be male. They were also more likely to have a problem or a conflict with a family member or friend prior to death, and if they did actually have a mental health concern, they were more likely to be diagnosed with ADD or ADHD. Whereas with the 12- to 14-year-olds, they were more likely to be diagnosed with depression or dysthymia, have a boyfriend or girlfriend problem, so we did find differences within these two groups.

And then the last paper that we actually wrote looked at the disparity within age as well as race, and what we found is that kids 5- to 12-year-old that were Black were two times more likely to die by suicide compared to White youth in that age range, and then it actually flipped once you hit that 13-year mark, when they were about half as likely to die by suicide.

So, what the research is showing is that suicide deaths specifically are more likely to occur in Black youth that are younger, 5- to 12-years- old, compared to White youth, and then also there’s been some other research that’s come out talking about how there’s been significant increases in hospitalization among Black youth for suicidal ideation and suicide attempts. So, things are definitely changing within the community and unfortunately not for the better.

Roslyn:  It’s interesting that you note those changes in the increases in terms of how treatment is dispensed and some of the early alerts, the factors that you identified as contributing to our understanding. So, I’m wondering Rhonda if maybe in your experiences in the work that you’re doing in Philadelphia if you’re seeing some of the same factors play out in your community in the work that you’re doing?

Rhonda:  So, yes, I am. I’m Associate Director of the Child and Adolescent Mood Program, and we initially started that program with the focus on extensive evaluations of youth presenting with mood problems. And what we quickly became aware of is that most of the youth particularly had significant suicidal ideations, suicidal behaviors, and that became a focus of what we were evaluating treating in our clinic, and with the work that came out with Arielle’s group, we decided that we needed to start focusing on understanding youth suicide and what is happening in urban communities and particularly with Black youth.

In my particular clinical practice, the patients that  I see are typically Black teenagers and mostly are girls, and I’ve noticed over the years of seeing these youth that the severity of their depression, suicidal ideation is becoming a main focus of the work that I do in treating them. And the research literature is not there to sort of help guide it, and so that’s been a struggle of these youth are presenting. They need to be treated, but we still need to figure out sort of how to get them the best empirically supported treatment, and that’s where these disparities and sort of thirst —in knowledge comes up.

Roslyn:  What’s also interesting in listening to the three of you talk there is a circular pathway now almost moving back to where Michael started with people who—from family members talking about they didn’t see warning signs. And I’m also hearing you, Rhonda, talk about the need for additional information, research, literature, that helps us better understand it on a practice end as well, so going across the gamut looking at how data is informing the policy drivers that are informing the research and practice, and then ultimately the experiences of children and families in communities. 

And so, when we get to that, maybe this is the opportunity to drill down a little further and perhaps each of you could comment on what you think we can identify as a core element or a key factor that we now understand as contributing to patterns of suicide and suicidal behaviors.  Looking at historical context, are there ways in which we can leverage what we’re learning to link with historical factors as well as contemporary factors because while it hasn’t come up today, we do know many individuals are dealing with increased anxiety and stress because of our current struggles with COVID-19?  And if you want to address some of that in your remarks that would be helpful to hear as we think about context and background as a way to move forward into thinking a little bit more and talking in a few minutes about protection and risk factors and ways in which we can start to apply this to work that we do.  So, for now, looking at what are we learning about historical contemporary factors in the context of both how we’re living but also the data that you’ve already extracted.

Michael, you can start us off.

Michael:  Yeah great. So, Arielle mentioned that work that she and her colleagues have done with the 5- to 12-year-olds, and Arielle and I also along with some other colleagues completed a study that appeared in the Journal of Pediatrics last fall looking at high school aged youth and I know has some data from the CDC Youth Risk Behavior Survey and looking at four indices of suicide behavior: ideation, plans, attempts, and injury by attempt from 1991 to 2017.  I just want to highlight that that study also found—we found that 73%--there was a 73% increase in suicide attempts among Black youth.

Now, let me put that in context.  A 73% increase by comparison it fell 7.5% for White adolescents, 11.4% for Latinx adolescents, 56% for Asian teens, and it fell about 4.8% for American Indian and Alaska Native teens. And so, I think when you historically look at trends, what we know is that Black youth have historically been disconnected from treatment, you know, for the most part. There’s the experience of having mental health challenges that may be precursor to a suicide attempt, yet those kids are disconnected from treatment. Oftentimes, what we’ve seen in schools because I’m going to target schools as a key setting that Black and brown kids are often over-suspended and expelled from school. We know and have had voluminous research around implicit biases that disconnect kids from schools in meaningful ways, and oftentimes I believe that those problems that they present with are treatable problems from the context of providing mental health support to those kids and their families.  And oftentimes that is not the case for kids.

I think also from a historical context, you can look at environmental stressors like discrimination and community violence, which tend to be sort of over-experienced, if you will by Black kids. Community violence is associated with suicidal ideation for example. And so I think some of those issues are really, really key in terms of understanding why these trends have continued to increase over time and really point to some key areas that we could really hone in on like school-based mental health service delivery and proportionate to the number of kids in the schools, not just one provider for 100 kids or 200 kids but proportioned to the number of kids in the school.

And that’s one of the things that we’ve been talking with our elected officials about—the key members in Congress that supported this taskforce. We’ve been compelling them to really consider how can we support school mental health services and ensure that in communities of color that there’s not just one provider but there’s many providers proportioned to the needs and the number of kids in that school.

Roslyn:  Well, you know Michael, your answer was so comprehensive I’m going to give a bye to Arielle and Rhonda in the sake of time so we can move on to the next section, but I’m sure the thoughts that would be relevant here will also cascade over as I pass the mic to Crystal and we focus more on the risk and protective factors.  So, don’t lose your thoughts, but we’re just going to transition a little bit faster here in the conversation to make sure that we everything in. Crystal, I’m turning it over to you.

Crystal:  Thank you.  Yeah, I think this is really important and certainly helpful in terms of establishing some of the context.
As you all started to talk about the context and started to allude to some of the risk and protective factors, I want to ask a few more questions specifically about risk and protective factors for suicide and suicidal behaviors in Black youth. And so, I want to start with hearing from you about what are the risk and protective factors for suicide and suicidal behaviors in Black youth. And what are the aspects of the unique cultural experiences that contribute to these factors?

Rhonda:  I guess I could start doing that, and Arielle, you can finish if that’s fine.

One of the things that typically that we look at overall for risk factors as had been mentioned in the intro and what Arielle mentioned is sort of psychopathology and sort of, you know, depression, anxiety, ADHD are risk factors for having suicidal ideation and behaviors as well as things like family conflict. There’s gender issues that come up, in which Arielle had talked about, and also with sexual identity with kids who are sexual and gender minority youth are at particularly high risk of having suicidal ideation. And so, there’s a range of variables and substance abuse and impulsivity, family conflict, and also parent psychopathology. A lot of my research focused on maternal depression and the children of parents who have psychopathology are at risk for suicidal ideation and other range of negative behaviors. 

And so, when you look at some of the things that focus on Black youth in particular, we try to figure out sort of are there things that are different that may make risk factors. So, as Michael had mentioned, there are sort of certain things that are more common in African American/Black communities such as sort of dealing with racism, community violence, some of the economic stressors, and we talk about how COVID-19 comes into play. With this pandemic, these things are coming to light as we see what losing your job being sort of frontline workers and how these affect people of color more, and so these families are under more stress. And these things have been existing prior to the pandemic, and so these are things that sort of affect youth.

Black youth also have a lot more loss, grief issues, and I think these things will come out much more with the COVID-19 and sort of how it’s affecting the Black community losing relatives, and this happened before because of some of the chronic health conditions that are more common, sort of the structural racism and discrimination that exists in our country.  And so, these are things that come into play.
When you think about protective factors, there are things that have been identified about having cohesion within families, community cohesion, involvement in religious activities and things like that, which have shown to be helpful in the past.  One of the things we were wondering is sort of are these protective factors being less so now and why the rates are increasing, and there’s a lot we don’t know.

Arielle, you had something to add to it?

Arielle: Yes. Sure. So, the other thing I would like to add to that is the thoughts concerning double stigma. So, double stigma is a combination of stigma surrounding mental health specifically but also when you pair that with prejudices concerning ethnic minority membership. 

So, unfortunately as many of you know that are on this call today, there is a ton of stigma concerning mental health just in general. And then when you add on the prejudices that are faced by Black youth and just being here in this world unfortunately, we have this combination of these risks that could potentially limit access to care, limit the ability to get to care, limit the thought that care is even necessary unfortunately.

The other thing that I would like to note is something that’s known as John Henry-ism, which is the fact that we should be able to handle—and I say we because I am an ethnic minority—we should be able to handle these things on our own and by ourselves or within the family. Unfortunately, this is something that has been seen to be very detrimental to getting care for mental health concerns as well as even just physical health concerns. So, that is something that I do know has been researched within the Black community. We are supposed to be strong. We are supposed to handle things on our own. We’re supposed to handle these things together as a family and not, unfortunately, let outsiders in, and because of that I think that does lead to a lot of these problems that we may be facing as a community. And because of that the beliefs about treatment being necessary may not be present. 

And then also confidentiality is another concern as well. If we feel as if we need to handle that within the family, within our own family not let others in, not let the secret, so to speak, of my child having a mental health concern being let out so to speak, that could also exacerbate the problem as well. So, those are just some other limitations that may be playing a role as risks. Also, the cost of care as well could also be a potential risk.

Crystal:  Absolutely. And you’ve both spoken about—and definitely spoken about some of the culturally salient risks. I’m curious about whether those risks that are more pertinent to or relevant to Black youth of particular ages that are more relevant to younger youth, for example, or older youth. Can you speak a little bit to that? Michael, you as well, are there other risks that we should be looking out for, for older youth or for younger youth?

Michael:  Yeah, there’s an emerging body of research looking at social media and the role that it plays. Adolescents, you know, tend to have more time interacting with social media and there’s been some research suggesting that the more involvement you have with it the likely you are to experience stress related to it, and so there’s work being done related to that. I think it’s more sort of acute for adolescents, so that’s one thing I’m seeing in terms of an age differential so the risk factor.

Crystal:  Okay.  What about for younger youth, especially given the rise, Arielle, and some of the patterns you’ve seen for younger youth? What about risk factors for younger youth?

Arielle:  Yeah, so with the research that we conducted looking at younger youth versus the early adolescents, what we found is that the younger children who died by suicide were more likely to actually have a conflict with a family member or a friend prior to death.  They were also more likely to, again if they were diagnosed with a mental health problem, be diagnosed with ADHD or ADD, which as many of you know that are on this call is associated with impulsive behavior, hyperactivity, inattention, in ability to focus, so those are some of the risk factors that I would say potentially are related to younger children.

In my own research that I am currently conducting, I look at kids 6- to 9-years-old that have a parental history of suicidal behavior, and what we’re finding in that research is that kids who have a parental history are more likely to have emotion dysregulation concerns, and that is also something that can be intervened upon at an earlier age, so that is something that I am seeing in my own research is that emotion dysregulation is present in these youth. Having a parental history of suicidal behavior is also a major concern not only just for Black youth but for youth in general, so we do know that that is something else to be concerned about with these younger kids, unfortunately is also associated with an earlier onset of suicidal behavior as well.

Michael:  Can I add something real quick. I’m sorry Rhonda. Go ahead.

Rhonda:  No, I just want to kind of hone in on sort of the importance of which I assume we’re getting to sort of identifying sort of risk behaviors early on in particular (in light of) the risk factors may be different for younger youth and Black youth than the older Black youth. And so, this is an important thing that I hope we talk about a little later. So, go ahead Michael.

Crystal:  Yes. Yes, absolutely. Absolutely. Michael.

Michael:  I was just going to quickly mention that in the study we published in Pediatrics, we also saw 122% increase in injury by attempt among Black adolescent males suggesting that they perhaps may be engaging in more lethal means by which to attempt suicide. And so, I think that access to lethal means and weapons certainly is something that you see more so among adolescents. And there’s a gender difference too whereby females tend to engage in suicide attempts by hanging or suffocation, and you know weapons and things like that for the males.

Crystal:  Yeah. This was actually something that was kind of the next question in talking about some of the patterns among Black children and youth and suicide behaviors. Can you all speak to that? What are some of these patterns and how have they changed over time? What are you all seeing?

Arielle:  I can speak to that. So, what we’ve noticed in general is that the method of suicide has actually changed over time. Unfortunately, it’s become more lethal and actually we have seen increases in female suicide because of that.

So originally, when suicide research was being conducted, males were more likely to die by suicide than females and that is still the case. However, there has been a significant increase in female suicide because of the method that they are using. In the past, females would use prescription medications or overdosing specifically, whereas now the leading method, so to speak, in youth suicide is hanging suffocation. And that is considered a very lethal means of dying by suicide. Unfortunately, because of that, we have seen these increases happening and it’s not necessary that they are dying by overdoses. They still are, but unfortunately the shift has actually occurred to more lethal means as Michael has indicated.

Crystal:  And these are among Black youth Arielle that you’re seeing these trends?

Arielle:  These are among youth in general in terms of—yes.  So, in terms of Black youth, when we did our paper looking at young children versus early adolescents—our study, excuse me—we did find that the younger youth did die more likely by hanging suffocation. And they were more likely to be Black and more likely to be male.

Crystal:  Great. Rhonda, what about you? Have you seen some of these patterns or any changes over time in your practice?

Rhonda:  Well, part of it is I think there’s this sort of more increase and sort of kids endorsing suicidal ideation and behaviors, and I know we haven’t talked about non-suicidal self-injurious behaviors, but they have increased also, which they could also lead to youth ending up sort of progressing to suicidal ideation and actually attempts. So, those things have increased over time in the patients that I’ve seen.

Also, what comes up, which I guess we know in society has changed is the issue and the role of social media and all of this and the potential of cyberbullying. And those things are just more commonly discussed in treatment that we see. Youth are on many social media platforms. They are influenced by it, and they also are becoming aware of other people having suicidal behaviors, ideation that are put out on social media and that impacts multiple youth because they are seeing these things in this platform at all times, and so that’s a new thing that we grapple with.

When you talk about sort of having the more lethal means, youth have talked to me about going on the internet and researching how to kill yourself, and so these things are available and that is more common and that we have to kind of grapple with that.  All of this is at the access of youth, and we have to kind of be able to intervene in those parts oftentimes when we’re not there. They can access that anywhere on their—at school, at home, on their phones, so these are the things that we’re dealing with that may have been different ten years ago or so.

Michael:  Yeah, I would just add to that that I think we’ve also experienced and heard in our clinical practice and our research the experiences of kids who are worried about their vulnerability with respect to interactions with the police particularly if they live in highly stressed communities. And so, I think along with the sort of overconsumption of social media and that sort of thing, I think seeing the continuous loops of police and Blacks in terms of shootings and that sort of things have sort of built up a sense of hopelessness and perceived vulnerability, which is traumatic.

And so, I think what we’ve come to see more and more and appreciate in our clinical work and we need to do more research on this is the role of trauma in terms of the lived experiences, whether that’s your struggle with food insecurities or housing instability or community violence. Those factors do play a role in the sense of perhaps building up this notion that life is hopeless for a lot of kids.

Crystal:  Good point. And we’re going to move to in a moment kind of what can we do because I get the sense both from some of the questions that are coming in from the audience but also from the panelists about the urgency around not only recognizing the risks and maximizing on the protective factors, building on the protective factors but trying to understand so how do we use this information to act, to move, to intervene. 

So, with that, I want to ask you all what is needed to better understand the increase in suicide among Black children and youth? What do we need to do? What is needed?

Michael:  Well, I’ll start. I think we need to--

Crystal:  It’s a big question.

Michael:  Yeah, it is a big question.  You know there’s been a popular myth that Black people don’t commit suicide and so not so much attention has been paid to the growing crisis, and I think that you know convenings like this and we need to be having more that are community based that perhaps partners with important institutions within Black communities, like the church, to really raise the importance of this issue so that kids and their families are understanding sort of what things might trigger their sense of hopelessness and their sense that suicide is an option.  And so, we need to be paying more attention to the issue for certain.  And I think that there’s a lot that we can do in schools.

And earlier, I mentioned the proportionate issue around school providers and kids.  I’m saying that we need more providers in schools to deliver mental health services that 1 provider to 100 or 200 kids is not enough, and so I think that those are things that really resonate with me as being incredibly important. 

Crystal:  Excellent. Rhonda? Arielle?

Rhonda:  One of the things, which I guess we need to discuss is really how to identify the youth early on and that is an area in which I think there needs to be sort of ways to identify screen across a variety of settings. I work at a children’s hospital, so it’s important as we think about sort of how can we screen most kids go to the pediatrician. They go to well child visits. And so, can we begin to screen youth who will be at risk for suicide completions or even ideation or identify it earlier.

I also think it’s important to reach out to the community and have key people knowing sort of knowledge about sort of what puts kids at risk and sort of how to have those conversations with youth about these issues. We found in our research that most parents were unaware that their children were having suicidal ideations and that’s (a part) because the parents are usually the gatekeepers who get kids into treatment, and so if they’re not aware that their youth are struggling, then the youth are not getting the services that they need.  And so, we need sort of more widespread education to multiple community settings and be able to identify these youth early on and so that we won’t get to death by suicide. Go ahead Arielle.

Arielle:  So, I think the other thing that need to be addressed is the actual risk factors that may be significantly different in Black youth compared to youth of other races. We have a couple of research studies here and there that have looked at those things, but I think we definitely need to know more about the risk factors and not only that we need to know more about the perspectives of the community. I think in order for us to change anything, in order for us to understand the problem, we need to get some more information about how the community itself understands the problem.

And that I think goes back to Rhonda’s point as well as Michael’s point that education is absolutely necessary. Mental health literacy programs are available. Gatekeeper training programs are available.

So, I think that is something that should definitely be incorporated within the community and may look very different from what we would consider to be currently what’s being conducted in terms of gatekeeping programs. So, it may not be done in an auditorium forum.  It may be done in an afterschool program. It may be done at a Boys & Girls Club. It may be done somewhere at a church you know where we can actually disseminate information to the community itself but also gain some insight from the community as well about how they understand the issue of youth suicide in their own communities so that we can figure out ways of how to intervene.

Also, there are interventions that are present, but we don’t know if those interventions actually will work within our community. So, we have to figure out okay what are the interventions that are considered best practice and then also do those work within the Black community specifically. And if they don’t, what are the changes that are going to be needed in order to actually have success?

Michael:  Can I add something to that? 

Crystal:  Yes.

Michael:  Or do we need to get to another question?

Crystal:  We will.  But, yes, please. 

Michael:  Yeah, this is really rich conversation, and I just want to build on what Rhonda and Arielle have laid out.

You know you’ve asked the question what is unique and perhaps more nuanced about suicide expression among Black youth. One of the things that is sort of emerging from the literature, and the research that’s been done is that you know Black youth in terms of how they engage in suicide may be incredibly nuanced. And what I mean by that is for example Sean Joe and some colleagues did a study in 2019 that showed that Black youth attempting suicide did not have a mental health disorder. And then Lavome Robinson a few years ago with some colleagues did a study that showed the Black adolescent girls, who had higher levels of suicide ideation, did not have elevated depression.

And so we often look at mental disorders as perhaps a precursor, and it in fact is, but I think more research is necessary to really tease out all of these sort of collection of factors whether it’s precursor mental health issues or whether suicide, you know, attempts for example may be more of an impulsive behavior that Black youth engage in. 

And so, I think it’s really important for us to call these issues out and really highlight them in a sense of really illuminating the light on—the research that needs to be done to really tease out these factors in terms of what’s driving these increasing rates among Black youth.

Rhonda:  Can I add something quickly?

Crystal:  Yes, and then it’ll be a perfect segue into what do we do and how do we address these suicides.

Rhonda:  Yes, that’ll be great. I mean part of I think Michael mentioned sort of the different research found. I think what we—which sometimes we don’t really talk about is there is diversity amongst Black youth, and they’re not all the same. There’s difference in socioeconomic status and religion, and so we’re talking about the church, but there’s the mosque.

And so, we also—there may be a lot of expressions that we don’t discuss, and so I think that’s the piece between rural, suburban, urban, and so we really need to kind of understand these things and how this intersectionality between race and other factors come into play.  That is the segue.

Crystal:  Yes, brilliant. No, absolutely brilliant, and I think I’m going to turn it over to Roslyn to ask a few questions in our last section about addressing Black youth suicide and asking you all—our esteemed panelists for your thoughts about how do we start to address this problem—this very concerning problem. So, Roslyn, please. 

Roslyn:  Thank Crystal and for all the panelists who are setting the stage so nicely to move into what can we do, the action framework so really pulling together this rich knowledge base to inform those next steps. And so, with that, I ask the question what interventions have been shown to be most effective for Black children and youth who are suicidal? Which interventions work best for younger children?  Which interventions might work better for older children? So that we can really give people information that’s actionable once they leave this discussion. Rhonda, you look like you want to start.

Rhonda:  So, this is a very difficult question.

Roslyn:  It is. It is.

Rhonda:  We don’t have a lot of research to kind of know for sure or that is evidence based. There was a review that Sean Joe and his colleagues did looking Black female youth, and they showed that multisystemic therapy and attachment-based family therapy has the most evidence so far in possibly supporting.

But I think one of the big issues is that a lot of the RCTs do now have enough Black youth for us to really look at it. People haven’t looked at the differentials among their samples, researchers to say how does my intervention work with Black youth, and I think that’s the area that we don’t know. So, we’re taking research that’s been done kind of in the general population and saying I guess this is the best that we have to use in clinical practice. And so, we don’t know. I mean we have things that are suggestive, but we don’t know if they many times actually work with Black youth.

So, Michael, you’re shaking your head, so I’ll turn it over to you.

Michael:  No, no I think you nailed it. I mean I agree with that. I mean if you’re talking about a precursor issue like depression, anxiety, you know we know a lot of interventions that are out there at least at the adolescent level for depression, CBT, IPT-A (Laura Mufson’s intervention) certainly has some evidence and support in terms of use for Black youth, but, yeah, I think Rhonda nailed it in terms of the fact that we need more in terms of the variety and range of the types of interventions.

But I would also just end on this point which is that any intervention that is done around suicide with Black adolescents and youth in particular you know needs to incorporate the family and really ensure that it’s a family-based intervention and not sort of exclusively working with the youth.

Roslyn:  So, Arielle, we can’t see you, but I would imagine you have some thoughts on that particular question.

Arielle:  Yeah, no I agree with Rhonda and Michael 100% that family definitely needs to be involved especially with younger youth. I would say as you all know we have this shift in development where come adolescence parents or legal guardians aren’t as important supposedly even though we really still are. Towards adolescence, they consider their friends to be more supportive at that point in time.
But at the younger age, parents and legal guardians play a really big role in that child’s physical health, mental health, emotional health, etc., so having a family intervention is definitely one that I would really want to see if works in our community. 

There have been a number—well not a number I shouldn’t say. There have been some interventions that have used churches specifically that have shown some positive findings so to speak, but again, these are more broad I would say in terms of looking at mental health specifically, not so much looking at suicide specifically. And of course, once you have an intervention that looks at depression or hopelessness and you incorporate that into the community, that does decrease the likelihood of suicidal behavior occurring because those are strong correlates of suicidal behavior. However, when looking at mental health—excuse me, suicide behavior intervention specifically in African American communities, those research studies are very limited.

Michael:  I mean I think also… Go ahead Rhonda.

Rhonda:  I just want to kind of piggyback off of Arielle talking about including the family. I do think also and as Michael had mentioned, it’s important in adolescence in particular when we talk about the youth who are most at risk for having suicide attempts, those who had suicide attempts before and who may be at risk and once they get out the hospital, we have to do what we call safety planning and that’s been used widespread.  And parents need to be involved in that. They’re the ones that are going to restrict the means of youth being able to have access. They’re the ones that have to be make sure that there’s no gun in the home, to make sure the knives are put up, that there’s nothing to hang—the child can hang themselves with, and these are things that we have to use as a community approach.
And so, safety planning is a possibility of an intervention that needs more evidence-base to kind of see how it works with Black youth. Go ahead Michael.

Michael:  No, I just was going to mention—I mean we talked about this earlier about partnership and work with pediatricians.  I think Rhonda you mentioned that in terms of well visits and how, you know, they might be trained on and understand these sort of symptom expressions or behavioral expressions and how to sort of triage those kids into the requisite care.

I also think that churches—now Arielle mentioned churches and examples of churches. I’m thinking about Sherry Molock’s work around the importance of the church and addressing suicide. So, I think that strategic partnerships that are really focused on making the community aware about these issues and helping to train parents and also school personnel on the signs and symptoms of suicide behavior and particularly the nuanced expressions of those behaviors might be important. 

So, what I mean by that is I once had a kid in a study tell me that when he’s sad and depressed about something that he wants to go and knock somebody’s head off. And so that kid might be suspended obviously for those behaviors, but he had underlying depression that may have you know prompted that behavior. And so, I think that we really have to understand that and address it accordingly.

Roslyn: I think you all brought out very important points in the role of community, other partners across systems and industries. What do you see as a challenge in addressing some of the cultural differences in ways in which we want to ensure culturally responsive interventions? Is that a part of your current research or ways in which we think we could expand what we're doing in learning so that we're more aligned with the needs of Black youth?

Michael: I'll start. I think if you're talking about treatment, one of the things that we've been doing, and thanks for the support from NIMH, is looking at engagement interventions that really focus on stigma reduction, increasing the perceived relevance of treatment because it's usually in the context of treatment where we can identify that a kid is struggling with depression–I’m sorry suicide and might be at risk for engaging in the behavior.

I think to get that kid into treatment by virtue of addressing the stigma and perceived irrelevance of treatment that the kid and the family might have is really important. We found in our research that when we are sort of intentional about addressing those issues precursor to the kid's involvement in the treatment, that they have an impact for how the kid and the family not only engages with the treatment but also on outcomes. I think from a cultural perspective, that's really important.

Rhonda: I'm going to add the importance of actually training mental health providers, therapists on how to assess and treat Black youth is a critical part of the disparities that we see, that even when Black youth get the treatment that they're often not receiving adequate treatment or empirically supported treatment. We need to have our frontline staff be able to culturally engage with those families and to be able to provide care in a culturally competent way.

The percentage of Black mental health providers, psychologists, social workers is pretty low across the fields, and they don't equal the population. We need to develop a pipeline to get more Black providers into the field. The training, it should start as early as possible I believe.

Roslyn: I appreciate you bringing up the issue of the workforce because I think it's something that we don't often have the opportunity to focus on. As we are coming to the end of this particular segment of the conversation, I thought I'd introduce a lightning round question, one that everyone will have a chance to respond to quickly. Here it is. How can communities work with mental health systems and engage with Black children and youth and their families to implement prevention strategies? Arielle, we'll start with you the lightning round. Short, one-minute response. Prevention partnership with communities, mental health systems, and families.

Arielle: Okay. I would say, the first thing that comes to my mind is the work that we're doing with the Boys & Girls Club. We are currently engaged with the Boys & Girls Clubs of Columbus, and we are going to be implementing gatekeeper training for their staff members as well as the students themselves in the summer. Basically, what that will include is educating everyone on what the signs of suicide are and what to do if a sign is seen. That would be one of the things that I would recommend, and we're doing that again in conjunction with the Boys & Girls Club of Columbus.

Roslyn: Thank you very much. That was a great way of pulling all that together. Rhonda?

Arielle: Thank you.

Rhonda: I think one of the things that's important is educating and developing partnerships with the community. In Philadelphia, we have a child youth consortium in which a chair in my department, Dr. Benton leads. We've held different town halls to bring people from the community providers, different non-profit organizations to sort of shed light on these issues and so focus on different topics that sort of educate the community. This has to be a tiered approach.

In some of my work, we work with one agency, but it's nice to be able to partner with different agencies with the city, the Department of Behavioral Health, and building those partnerships which take time and trust, but really having a common agenda to be able to educate and also come up with a project to probably be able to pilot and see if it works, because I think people have to be invested for the long haul. This focusing on Black youth suicide, and that we need to develop these partnerships–of friendship–and partnerships for long term.

Roslyn: Thank you for that. Absolutely underscore the partnership component as we move to Michael, last minute of this round.

Michael: Yes, I have two examples. One is I think that there's an opportunity to partner with churches. One example that comes to mind is First Corinthian Baptist Church here in New York City in Harlem, which has a free-standing mental health clinic, free to parishioners, free to the community. It's all funded and supported by the church. I think that's a wonderful example. I think that bringing more content around how do you understand suicide and suicide behaviors can happen in the context of churches.

Then also in New York City, there's Connections to Care which is providing mental health supports and community-based organizations that may deal with domestic violence or reentry programs where you're training front-line staff on mental health issues or how to triage people into treatment. They're being trained on– it’s task-shifting approach. They're been trained on motivational interviewing, psychoeducation and all those kinds of things that really helped to get populations who need treatment connected to care.

Roslyn: Thank you for that. Fabulous lightning round. Great way to transition over to the broader set of questions. Crystal is going to kick us off with questions that have come from participants. I know the dialogue will continue but thank you so much for your comments. Crystal.

Crystal: Thank you. We are now about to open it up. Thank you, panelists, for this very enlightening round of moderated questions and answers. We're now going to open it up to the audience and ask you for your questions. Please do submit your questions. We'll take your questions as they come in and ask the panel to answer them. You may type your questions in the Q&A box, and we will field your questions, although we won't have a chance obviously to ask all of the questions. We will go through them as we can.

We do have our first question with regards to a point that Rhonda made very recently with regard to attracting Black practitioners into the pipeline. The question is, how do we best attract Black practitioners into the pipeline? Rhonda, actually all the panelists, please, if you could share your responses to that, what are your thoughts about that? Again, please, just submit your questions into the Q&A box, and we'll go through them. While we're doing that, Rhonda, and panelists, please give your thoughts about that. How do we best attract Black practitioners into the pipeline?

Rhonda: I think training programs, in particular, I've been involved with summer training programs with undergraduate students. I think mechanisms like those could be utilized as well as with high school students. We have those kind of programs also. Also being able to identify Black high school students, undergraduates that have an interest and really fostering their evolution career wise, so they are in a good place to be able to move on to graduate school and really build up the excitement and experience in this area. That is a mechanism by which we can increase the pipeline. I don't know if Arielle--

Michael: I was just going to add that this question makes me think about why I came into this area of work and it was through mentorship. It was through mentorship around research. I think not only do we need practitioners, but we need scholars, folks who are trained to do this work. I was involved in a pre-doctoral program that was funded by NIMH, funded by SAMHSA as well. I think those kinds of programs are really important and are essential to establishing a pipeline for even scholars to move into these fields.

Arielle: I would agree with all that has been stated. I think encouraging youth at a very young age, letting them know about the problem of mental health within the Black community, letting them know about the problems concerning Black youth suicide may get them excited to actually do the work that's necessary and to get the support through summer programs.

I know our institution, we do a summer research program not only for high school students but for med students as well, to give them an understanding of what the current problems are within the field. Just having them involved in those problems, excuse me, programs at a young age and getting them excited about the topic can really drive their desire to be in the field.

Crystal: Great. Thank you. We have several questions coming in. Let's see. I think there was a great question with regard to engagement and treatment engagement that I saw, with regards to, once you identify the risk factors and starting engagement that's one thing, but how do you maintain individual’s engagement in treatment, especially youth. If you could maybe speak to that, how do you keep people, and especially youth, how do you keep youth engaged in treatment?

Michael: Well, in the engagement work that we do, we delineate the few types of engagement. There's behavioral engagement and then there's attitudinal motivational engagement. I think that when you are addressing issues that are germane to the experience of kids and their families that is practical to them, that helps them to address things and matters that are happening in their lives, that is motivating them to be involved in treatment.

We also have to deal with, as I mentioned earlier from a motivational perspective, the stigma related to treatment because most of the literature suggests that among those two factors related to engagement, that the motivational aspects of engagement actually explain most of the variance in terms of outcomes with respect to treatment. I think that you have to address it really early on and be really clear about those challenges that might get in the way.

They are afraid of what family members might think. What happens if they're in treatment for some time and it's not seeming to work? How do they explain that to their families and that sort of thing? These are the things that we hear from kids and caregivers about their challenges related to continuing to be motivated to stay in treatment. I think addressing those issues, being clear about what the evidence is for the intervention, how it's presumed to work and then helping them to troubleshoot any challenges related to their engagement in terms of giving them strategies to address family members or peers that might give them a hard time for being involved in treatment are really, really important.

Rhonda: I just wanted to add, part of when someone comes in for treatment, there's this therapeutic alliance, this relationship. I think that gets back to this issue of cultural competence. Part of it is connecting with the youth and the families in a way that they feel that they're in a trusting relationship with you as a provider and also being able to deliver the best intervention that fits their needs, as Michael is saying, if you have to adapt it, but also being clear about the communication expectations.

What I do in my practice is, I'm fairly flexible. I work late so kids can get out of school, I think it's important for kids to be in school and allowing those kinds of flexibility with the intervention so that it can be delivered and that you can address the family's needs. Those are the things that many times just had to be done, this many sessions at this time may not work with families that may be going through a lot of economic or transportation issues. We have to be able to address that.

I think with this COVID-19 providing telehealth now shows the way that we always thought that we could provide treatment was not necessarily the case. I think we have to be creative in delivery of services and meeting people where they are. We have services in primary care, integrated behavioral health at our institution. That is a way that takes away from the stigma, kids can just go to their pediatrician office and see a therapist.

Crystal: Great. We're getting great questions and again, unfortunately, I am mindful of our time. How can we help parents and particularly use research and translate research to help parents and caregivers understand mental health risk factors for their children?

Arielle: I think it all goes back to meeting parents where they are and then also allowing them to know what those signs are and what are those risks. It really goes back to education. Being able to sit down with a parent, sit down with a bunch of parents, whatever way you see fit, and getting their perspective, getting how they understand the problem. Then also providing education so that they do understand what are those risks. Another risk factor that is different in young children versus older children is that young children, unfortunately when they have decided they want to die by suicide, are more likely to give away possessions. Children will start to give away toys to other children. Whereas with older youth, they're more likely to write a suicide note or to say goodbye.

That is something different that you would see in a younger child versus an older child. As a parent, if you don't know that information, you may just think that, “Oh, that's just my child giving away a toy to somebody else.” Again, I think it really goes back to meeting that parent where they are and then also educating them on those risk factors that we do know exist within children when it comes to suicide.

Crystal: Would you say, or would the panel say, would that be, education—would that be one of the ways that we could also use to help change some of the myths that I think Michael and others mentioned, especially among maybe African Americans, that Black youth don't commit suicide?

Michael: Absolutely. I think that's really key.

Rhonda: I think it's important to maybe provide this information, a way that people can access it through the internet. Most people on the internet have smartphones that we have had this information available for all people to be able to look for when they're in need.

Crystal: Perfect. Great point. We have one-minute left, so I'm not going to force the question, but again, this has been an excellent panel. Panelists, thank you so much. Rhonda, Michael, Arielle, thank you so much. We have resources listed. If we could put that slide up. We have resources available for our audience and they are downloadable. You are able to download them and use them at your disposal.

Again, thank you all so much for your time with this wonderful information and just the willingness to share all of your research findings, all of your knowledge on this incredibly important topic. We appreciate you. We hope that you're staying safe and staying well. Again, this information, this webinar will be archived as soon as possible. As soon as we can transcribe it and get it available. It will be archived and available on the NIMH ODWD website. Again, the resources are downloadable on this PDF under resources.

Thank you. Thank you to my co-moderator Roslyn Holliday-Moore. Again, thank you to our panelists.