Thank you for joining us today for a call to action addressing the Black youth suicide crisis. We are fortunate to have Dr. Tammy Benton with us today to discuss the significant increase in the number of deaths by suicide among African American youth. In addition, she will address this emerging crisis and share existing evidence for prevention and interventions for African American youth. But first, a few housekeeping items. Funding for the Striving for Excellence series is made possible by a grant from SAMHSA of the U.S. Department of Health and Human Services. The contents of those are the authors and do not necessarily represent the official views nor an endorsement by SAMHSA, HHS, or the U.S. government. Next slide. Know that by being here today, you are eligible to receive CME credit. The American Psychiatric Association is accredited by the Accreditation Council for Continuing Medical Education. As such, this course will be available for a maximum of one AMA PRA category one credit. At the end of the presentation, there'll be more information on how to claim the credit. Next slide. In addition, if you'd like to download the handouts, please note, if you're using the desktop, please look on the left side. There is an arrow pointing to where you would find it to download. If you're joining through the viewer, click the page symbol to display the handouts area and also download. Next slide, please. Also, we would love for you to participate in the Q&A. Here's a visual on how you can actually access the Q&A function on both desktop and via the instant join webinar. Next slide. Dr. Benton has provided us the following disclosures. And so as you can see, here's one from the National Institute of Mental Health, the Juvenile Law Center, Friends Central School and AFSP. Next slide. And now about our amazing speaker. Dr. Tammy Benton has extensive clinical and research experience and assessment of children and adolescents with mood disorders and suicidality and development of clinical programs to support children and families in healthcare setting. She has established a reputation as a leader in the development of integrated mental health and medical care. Further, her expertise extends to health disparities and healthcare education and care focused upon clinicians and services for families. To that end, she serves as a diversity recruitment officer for an institutional K-12 fellowship. She is a psychiatrist in chief and chair of psychiatry at the Children's Hospital of Philadelphia and the holder of the Frederick Allen Endowed Professorship in Psychiatry. She is a member of the National Institutes of Mental Health, National Advisory Mental Health Council. Her research expertise is in the areas of mood disorders, medical conditions in children, adolescents and adults, specifically HIV and sickle cell disease. She has trained pediatrics, psychiatry, sorry, she has trained in pediatrics, psychiatry, child and adolescent psychiatry and psychosomatic medicine. She has received funding from numerous sources such as NIH, HRSA, private foundations and clinical trial support. In addition, she is a site director for the Lifespan Brain Institute at CHOP Penn and she mentors clinical and research physician fellows and post-doctoral trainings. So again, it is my pleasure to introduce Dr. Benton and from here she will take it on and provide a wonderful presentation and we'll follow with Q&A. Dr. Benton. Thank you so much and thank you for that generous introduction and I'm really pleased to be here with you today. So I'm going to share with you what we know about these emerging trends in Black youth suicide and suicide-related behaviors. We're going to talk about minoritized youth broadly initially and then we'll focus on what's happening with Black youth. We're also going to talk about clinical experience with suicidal minoritized populations and factors that we need to consider when engaging in care. And we're also going to talk about the disparity in suicide care and treatment that has been identified for Black youth. So I just want to start by sharing with you this very busy diagram but I'm only going to highlight for you a few key points. So this is the data that's been collected by the Centers for Disease Control. Many of you may be familiar with the Youth Risk Behavior Survey that happens every two years where children and adolescents across the United States, non-clinical samples, just high school students, are surveyed every couple of years focusing specifically on health and health behaviors that place them at risk. And suicide and suicidal behavior is one of the categories of questions that's asked every couple of years. This particular diagram just reflects the data between 1991 and 2017 and specifically focuses on suicidal thoughts and behavior trends by race and ethnicity. And this is actually one of the most comprehensive representations of all ethnic groups and how we've seen trends in suicidal behavior between 1991 and 2017. And I want to call your attention to a few things because it's hard to parse out a lot of details in these slides because they're busy. But if you look at suicide attempts in the past year and injury by suicide attempts in the past year, you'll notice that almost every group between 2019 and 2017, every ethnic group had higher rates or increasing rates of suicidal attempts or injury by suicide for all ethnic groups when compared with white youth. So, in this diagram, white youth is the dark orangish line. And if you'll see, just focusing on injury by suicide attempt, you'll notice that that line has the lowest rates of injury by suicide attempt. You'll also notice that Native Americans and Alaskan Islanders have the highest rates. And even though they have declined over time, the reality is that for every other ethnic group, including multiracial youth, the rates of suicide attempts in the past year and injury by suicide attempts in the past year are higher for every ethnic group than they are for Caucasian youth. And this is consistent with trends that we've seen nationally. And looking at this other representation of the same dataset from 2009 to 2019, this is a diagram reflecting high school students who made the suicide attempt by race and ethnicity, focusing specifically on Latino, Black, and white youth. And what you'll observe is the dotted line reflects suicide rates for white youth in that time period. You'll notice that they've risen slowly, dipped in 2019 and started to increase again. You'll notice for Hispanic youth, the rates are higher, but they've seemed to level off between 2017 and 2019. But there's been a consistent upward trend of suicide attempts for Black youth. And basically, the suicide rates have been declining for white youth, but they continue to be higher or increased for every other ethnic group. This is an interesting diagram, and I couldn't find a lot of them, that really reflects suicide rates among Native Americans and Alaska Natives. And this diagram actually reflects suicide rates across the lifespan. So looking at the youngest age of 10 and the oldest being 65 plus, what you'll notice and what I want to call your attention to is the yellow line. This reflects the rates of suicide for American Indians and Alaska Natives. What you'll notice is that the suicide rates start to increase at a much younger age than you will see in other ethnic groups. And so the suicide rates start to increase for this population at around 10 to 14 years of age. And that's a striking difference in trends that we've seen in other populations, with the exception of emerging trends in a similar direction among Black youth. And we're going to talk about that a little bit more later. This particular study by Julia Raifman and her colleagues really looked at youth who identify as sexual minority youth, and then youth who identify as sexual minority youth who have had same-sex contact. And the reason I'm highlighting this group is when we look at disparities in suicide care and treatment, sexual minority youth are another group who have higher rates of suicide attempts and completed suicides than other populations. What was interesting about this study by Raifman and her colleagues is they also looked at changes in trends of identification as sexual minority between 2009 and 2017. And what they discovered is the number of young people identifying as sexual minorities in that time period have more than doubled. And if we look at the top diagram, what we're looking at is the number of young people who identify as sexual minorities who has made one or more suicide attempts over time during this time period. And this too is data from the Youth Risk Behavior Survey as well. And what you'll see is that for the populations, if you look at the green line, you'll see that there was a decrease and a bump in the rates of suicides attempts by sexual orientation in 2013, and the rates started to decline again. That's the good news. The rates are declining. The bad news is the blue lines are for those youth who do not identify as sexual minorities. As you can see, the number of attempts are still high compared with those who identify themselves as heteronormative populations. If you look at the lower diagram, this was an interesting finding. The green line, again, reflects individuals who identify as sexual minorities who have had same-sex contact compared with those who identify as heteronormative and have had only opposite-sex contact. And what you'll see is that the rates of suicide attempts for those who are sexual minorities engaged who haven't had same-sex contact are still significantly higher than for those youth who identify as typically heterosexual youth. So what is all of the data telling us about youth suicide? Well, what's been reflected for us that's actually different than what the traditional thinking has been about suicide and youth is that Black, Indigenous, and people of color are at increased risk for suicide and that the suicide trends look different. They're different age trends than what we find in the general population. What we've also learned, and we're going to take a deeper dive into this because this is vitally important, that our whole population data for suicide risk do not reflect the trends for minoritized youth, meaning that we have to take a deeper dive into our data when we're analyzing suicide rates for minoritized populations. We also know that for LGBTQIA plus youth, suicide attempts occur at a much higher rate than they do for the heterosexual peers. And then we also know that those who experience intersectionality, identification as a member of more than one minoritized group are at higher rates of suicidality than white youth who may also be gender non-conforming or identify as a sexual minority. And so that group, for a variety of reasons, appears to be at increased risk for suicide when compared to other minoritized populations. So I want to talk a little bit about what we're learning about disparities in suicide care and treatment. So when we went back to look at the data between 1991 and 2017, there's some interesting things that we learned about what was happening to Black youth specifically. So traditionally, our clinical guidance suggests that Black students are actually at lower risk for suicide than other populations, and we practice from that perspective. And we identify white youth at higher risk, and we typically make our assessments and treatment recommendations based on that traditional knowledge. But what we're learning is that our traditional knowledge was misleading. So what we learned that between 1991 and 2017, that Black students actually had the highest prevalence of attempts, and that Black adolescents had higher rates of suicide attempts, while at the same time, the rates were declining for other racial and ethnic groups. Another curious finding is that, and this continues to be true, that Black male students reported the lowest levels of suicidal ideation. But when Black youth made suicide attempts, their rates of serious injury resulting from the suicide attempt was much higher. We also observed between 1991 and 2017 that Black adolescent girls experienced a significant increase in suicide attempts, while girls in every other racial and ethnic group showed rates of decline in suicide attempts. So I want to talk a little bit about Black children, and the reason I'm separating out these age groups is, for most of you, if someone asked you how common is suicide or suicide attempts among this age group, you'd probably say almost non-existent. And I would have said the same thing not all that long ago. But we're learning some new things from our data looking at young Black children. So here's a diagram from between 1999 and 2017, same data, looking at data from our samples of Black youth who present with suicidal ideation or attempts. And what you'll notice is that when we look at the age groups, we see vast differences. So from 1999 to 2017, when we look at the 5 to 11-year-old group, which is the dark line at the bottom, as expected, the rates would be low, and we shouldn't see changes. That's what I would have predicted. And based on this description, that would be true. And then as expected, we start to see the suicide rates increase as children become older. So in the early adolescent group, 12 to 15, you see that the rates start to increase around 2017, and they're higher than the 5 to 11-year-olds, which we expect. And then when you look at the 16 to 18-year-olds, you see higher rates. And we would expect that as well, because we know that the suicide trends tend to trend towards older adolescents. And so I looked at this data like everybody else, and I thought, this is about what we'd expect. But of course, the devil's in the details, because when we took a deeper dive into the 5 to 11-year-old group, we found some curious findings that were quite disturbing. So when we took a deeper dive and looked at the data for the 5 to 11-year-olds, and we observed the flat line, when we broke down the data, it actually revealed something quite different. So between 1993 to 1997, with the dark line being black boys, you'll notice that the rates of suicide are lower than they are for white boys between 93 and 97. If you look at 1998 to 2002, you start to see a change in trends, and you start to see a slight increase in the rates for black boys compared with white boys. But by the time you get to 2003, 2007, there's a significant difference that holds true for 2008 to 2012. So what we were seeing was not a flat line. What we were seeing is rates of suicide heading in opposite directions that appeared to be a flat line, so that the data was misleading in how it was presented. When we started to look at these age groups, the disparities became very clear. So if you look at the 5 to 9-year-old age group, the differences between black and white youth are quite significant, and they start to decline over time. So that by the time you get to the 13 to 14-year-old age group, they're very similar in terms of suicide trends for black and white youth. But the disparity is noted among the younger age groups, somewhat similar to what we noticed among Native American populations. And then other authors tried to characterize the differences between the 5 to 11-year-olds with the early adolescents, which are more similar to the 5 to 11-year-olds than the 15 to 18-year-olds. And what we learned is that for young black boys specifically, the youth who die by suicide in that age range tend to be male. They tend to be black. They tend to die by means that are difficult to manage at home, like hanging, strangulation, suffocation. And then they're most likely to have the precipitance of relationship problems with family members and friends as precipitants that were closely proximally related to the time of the suicide. And what we also learned is that for most youth, particularly early adolescents and children, about 30 percent have actually told someone that they were thinking about suicide prior to their deaths. In looking at trends in suicide data over time, what we observed is that these trends have been in the making for quite a number of years. So, if you look at the CDC data from 1980 to 1985 for black youth 10 to 19 years of age, there was 114 percent increase in suicide rates for black youth. And every other study since that time focused on this population has shown similar trends, positive trends, towards increasing suicide rates among black youth. And the question is, why didn't we notice this? And I have to say, unfortunately, it wasn't the mental health professionals who did ultimately notice this. It was the Congressional Black Caucus. So, a couple of years ago, Representative Bonnie Watson Coleman learned of this data back in 2015, 2016, and pulled together a task force made up of mental health professionals, legislators, administrators, and individuals affected by suicide. They pulled together to create an emergency task force on black youth suicide and mental health and generated a report that has really prompted increased research and focus on risk and protective factors associated with suicidal thoughts and behaviors for black youth. So, what are some of the risk and protective factors specific for black children and adolescents? And we want to share what we know, but I have to tell you upfront that what we're finding is that there's actually not been a tremendous amount of study on what the factors are that might be protective and what the factors are that might increase risk for suicidal behavior among black youth. So, what do we know? Well, we know that neighborhood violence and poverty are strongly associated with poor outcomes and suicidal behavior for black youth. Factors that disproportionately impact minoritized youth populations, such as neighborhood violence, economic insecurity, adverse childhood experiences, historical trauma, and intergenerational trauma. And we also know that many minoritized populations experience trauma, but trauma is disproportionately experienced in Black communities when compared with other communities. And in addition to that, the traumas that are experienced are much more likely to be severe traumas, and they're much more likely to be more than one. Other findings that have been specific for Black adolescents are the association of suicidality with depression and externalizing behavior. And I put an asterisk by externalizing behavior because what you'll discover is that Black youth are much more likely to be identified as having an externalizing behavior disorder rather than a mood disorder. And there definitely are well-documented disparities in diagnosis. Poor family support is a risk factor, substance abuse in the individual or within their family, and the presence of a diagnosed mental health disorder for the family or for the youth. Family victimization, racism, and discrimination has been associated with suicidal ideation for Black and Latino youth. And then sexual and gender minority status have been risk factors. And when coupled with racial minority status, increases risk even further. So racism and discrimination, there have been lots of studies, particularly recently, looking at the impact of discrimination on suicidal ideation in Black and Latino adolescents. And there's a plethora of data that confirms that perceived discrimination, increased suicidal ideation, and impairs psychological health in the populations who are impacted. We also know, based on all the studies, that Black youth are much more likely to have experience of discrimination than any other youth population. That's not to say that Black youth are the only youth to experience discrimination. They absolutely are not. But the literature documents pretty clearly that racial discrimination against Black adolescents is more pervasive than among other groups. On average, for your average Black teen, they experience over five racial discrimination experiences each day in the form of macroaggressions and microaggressions. We also know that in studies looking at exposure to traumatic videos online, that they have actually been associated with depression and post-traumatic stress symptoms in Black and Latino adolescents. And both of these factors are associated with suicide risk. We also know that for Latino adolescents, there are greater odds than other LGBTQIA adolescents for suicide. And that discrimination is associated with increased suicidality among Latino adolescents as well. And it's much more significant among Latina girls than it is for boys. For sexual and gender minority Black youth, they have higher rates of suicidality than White youth, recognizing that intersectionality increases risk. And interestingly, the Trevor Foundation just completed a survey of LGBTQIA youth, and they looked at the increased suicide rates that were identified during the COVID pandemic. And what they discovered is that suicide attempt rates increased across the LGBTQIA population. But for those who identified as minoritized members of our society, the rates were actually higher for those who identified with dual minority identities. And that's really significant. And that's persistent, and that was worsened during the COVID pandemic. So I want to talk a little bit about community violence, because I am sure that we all work in communities where community violence may be high, but every youth's not at risk for suicide. But we talk a lot about the potential impact on adverse childhood experiences with community violence being one of them. But there have been very few studies that have really looked at the impact of community violence as a moderator for suicidal behavior. But in this particular study, it was very interesting, it had a pretty large sample. And they actually, in this study, the investigators, Lambers and their colleagues, looked at the association between community violence exposure and suicidal ideation and attempts in a large sample of middle schoolers who were in sixth, seventh, and eighth grade. So in this sample of 473 middle school Black youth, they looked at whether depressive symptoms and aggressive behaviors identified in this sample were a variable that may be a moderator for suicidal behavior within this group. The variables in this study were community violence exposure, depressive symptoms, aggressive behavior, suicidal ideation, and attempts. And they followed these youngsters through sixth, seventh, and eighth grade. What the authors found is that when they looked at community violence exposure, and this is specifically for boys, they observed that community violence exposure was associated with suicidal ideation and suicide attempts. So if you look at the box in the center of community violence exposure, you'll see there's an association with depressive symptoms and then an association with aggressive behavior. And you see that the depressive symptoms are associated with suicidal ideation and that aggressive behavior is associated with a suicide attempt. So aggressive behavior was not necessarily associated with suicidal ideation, but it was associated with an attempt. So the take-home message being community violence exposure in the sixth grade was associated with depressive and aggressive behavior in the seventh grade and was associated with suicidal ideation and a suicide attempt in eighth grade. If you look at girls, what you'll see is that there's somewhat of a different pattern. So community violence in the sixth grade was associated with depressive symptoms in the seventh grade and aggressive behavior in the seventh grade, but only the depressive symptoms in the seventh grade was associated with suicidal ideation in the eighth grade, not aggressive behavior. And then, of course, suicidal ideation was linked with a suicide attempt. And so what did the study tell us? And that this study, actually, I think the investigators are continuing this particular study as we speak. But the study identified longitudinal associations between community violence exposure and suicidal ideation. The authors concluded that the moderator was actually the presence of depressive symptoms. So it wasn't community violence itself. It was actually the presence of depression that seemed to be the most consistent predictor of the suicidal ideation and behaviors. But of course, the suicidal ideation and suicidal behaviors were actually linked to community violence. And then what do we know about depressive symptoms in Black adolescents? Because if in fact, as with other populations, the presence of depression is one of the more consistent predictors of suicidal ideation and behavior, what do we know about depression among Black youth? And interestingly, it is very difficult to find data reflecting consistent representations of the prevalence of depression among Black youth. The study's samples reflect rates of somewhere between 13% and other studies have reflected over 20%. And so those studies are ongoing, but we actually don't really know. What we do know is that, as I mentioned, depression is one of the most well-established risk factors for suicide. And so in studies looking at Black adolescents, they found that about half of Black adolescent suicide attempters had actually never met criteria for a psychiatric disorder. And this is commonly true. So the question is, are there differences in how Black youth express depressive symptoms? What we do know is that most of the screening tools that we use have not been validated for Black youth. So we actually don't know how effective they are in identifying which Black youth actually meet criteria for depression. And so I want to share this study, which I thought was really interesting, and areas for further exploration. So in this study, Lou and colleagues and Mike Lindsay examined commonly used screening tools, the 20 items CESD in a sample of Black adolescents, to determine whether the CESD, which is, as we all know, a very commonly used screening tool, actually captures depressive symptoms in Black youth. And so when we use the CESD, just for overview for those who are unfamiliar, we actually measure the presence of depression based on four symptom profiles, depressed affect, positive affect, somatic complaints, and interpersonal relationships. And then the authors looked at this, they used this instrument in a large group of Black youth. And what they found was that the four-factor model, the four factors I just described, do not actually capture depressive symptoms for Black youth. For Black youth, there was a lack of distinction between the depressed affect scale, somatic complaints, and interpersonal relationship items among Black youth. And then the authors actually found that those factors actually grouped into one factor in the study, not four. So for example, when they broke it down and looked at symptoms that were consistent with depression for Black youth, they recommended a two-factor scale. So that factor one, depressed affect, somatic complaints, and interpersonal relationships should be one factor. And that recommendation, that finding resulted from the fact that for Black youth, they frequently had difficulties disentangling those three symptom complexes. So that many times what the interpersonal relations stressor and the somatic symptoms, the depressed affect, were experienced as one symptom for Black youth, with the second factor being positive affect, suggesting that maybe the tools that we are using and the way that we're using them may be missing Black youth. The other things we do know about Black youth, based on the data that we've collected, is that Black children are much more likely than any other population to have adverse childhood experiences at a rate of about 61% compared to about 40% of White youth. And then most Black kids are at higher risk for experiencing two or more adverse childhood experiences and economic hardship, parental separation, parental incarceration, or violence in the home. So what are some of the protective factors? And this is an area that deserves a lot more focus because these are things that we can do at the community level to support resilience and help families support their children. What we do know are protective factors for Black youth are strong family support and strong family relationships. We also know that high positive levels of ethnic identification are also protective. So we know that a positive racial self-esteem and connection is supportive of mental health for Black youth. Interest in spiritual engagement has been a cornerstone for the Black community, community and social support. And then for each individual child, there are personal factors that have been associated with resilience, such as positive self-esteem, strong academic performance, and overall emotional well-being and security within their families. And then of course, financial factors. So stable housing, income, and employment are also supportive and necessary, but not sufficient. When we look at family factors for Black youth that support their mental health and decreased levels of depression and anxiety, we know that family functioning is one of the areas that's been most strongly studied or most extensively studied, but also one of the factors that's most extensively associated with reductions in mental health and psychological impairments in youth and mental health conditions. We know that parental mental health is a factor that impacts outcomes for Black youth and conflict and family violence is negatively associated with mental health for positive or healthy psychological functioning for Black youth. But strong family functioning is most consistently associated with good psychological health. We also know that parental monitoring is associated with decreased depression and anxiety and positive parenting. Psychological and behavioral control has not necessarily been associated with better mental health for Black youth, but positive parenting and appropriate parental monitoring has been effective in protecting Black youth mental health. So I want to talk a little bit about the protective effects of ethnic racial identity and how we can actually use racial identity as a factor in supporting youth mental health preventatively, but also in the treatment context. So when we talk about ethnic and racial identity, just so that we're all talking about the same thing, we're talking about a psychological construct that's multidimensional and that reflects the beliefs and attitudes perspective that individuals have about themselves and their ethnic racial groups and their membership in those groups. But it also reflects the processes by which these beliefs and attitudes develop over time. So those are impacted by our families of origin. They're impacted by the environments in which we're in. All of those things help shape and promote or impair healthy ethnic identification. This concept is really important for understanding the impacts of racial discrimination for Black Americans and for Black youth. And it's important to understand that in the context of the impact of racial discrimination on the development of racial trauma. And so what is racial trauma? So racial trauma is defined as a form of race-based stress that refers to Black and indigenous people of color's reactions to dangerous events and real or perceived experience of racial discrimination. And these experiences might be direct threats of harm or injury. They might be humiliating and shaming events that occur with microaggressions. It also occurs in witnessing racial discrimination towards other Black and indigenous people of color. So for those who are watching the videos of Mr. Floyd's murder, for people who are working in a setting where you're witnessing your colleagues experiencing discrimination, those are all recurrent episodes of trauma. And what's different about racial trauma than when we think about post-traumatic stress disorder is that racial trauma is somewhat unique in that it involves ongoing individual and collective injuries due to exposure and re-exposure to race-based stress. And we know that cumulative racial trauma leaves scars so that the day-to-day microaggressions that people might perceive as hassles that shouldn't be that big a deal are cumulative with these other experiences that happen in the environment. And so that concept is important to understand because it also provides us with an opportunity to think about intervention. And so we have interventions that are helpful in addressing trauma. But most of those interventions are not tailored to addressing racial trauma for those individuals that experience them. And so I just want to talk to you about a couple of the interventions that have been identified that actually can support racial healing. And one of those is racial socialization. And racial socialization just basically describes how we think about and how we make meaning of race for ourselves. And the goal of understanding that and making meaning of race is to boost our own self-efficacy. And so we see racial socialization as a moderator for more positive outcomes. So racial socialization is associated with developing appraisal and coping skills for race-related specific events of well-being. And so, for example, when we think about race-related events for which many of us have to be prepared for, I think one of the most common ones that we can all relate to is being, what does it mean when you're a black driver stopped by white police officers? And how do you teach an individual to manage themselves in those situations? So some of the aspects of the skills that we can provide for young people to help them manage themselves is pride messaging to foster pride about race, positive statements about who you are, positive experiences with your peers. Pride messaging is really an important strategy in trauma-based racial interventions, racially focused interventions. We prepare people for bias recognition and ways to prepare for it. So we teach our children that when the police stops you, if you're driving, you put your hands up, put them on the dashboard, and you are responsive and polite. Other mechanisms are promotion of distrust. And there's a downside of promotion of distrust. That distrust can be appropriate, but sometimes it's not. And then egalitarianism, teaching young people that we're all equal despite race and helping them develop that as a persistent attitude and perspective over time. One intervention in which we integrate these interventions is called RECAS, racial encounter coping appraisal and socialization theory, developed by Howard Stevenson. And it was really an intervention designed to describe the complexities of the racial socialization process for Black Americans. And so racial socialization and racial coping processing is used to understand experiences of discriminatory racial encounters. And it's also used to change health outcomes for Black Americans. It integrates a cognitive and behavioral approach to managing physical and emotional responses to racially charged situations. So for example, it is in fact the case that when these situations happen, where people are experiencing microaggressions or macroaggressions, that our heart rates become elevated, they're upsetting. It's important that in this particular paradigm, that one learns to recognize their physiological states of arousal when these things happen and use some cognitive and behavioral strategies to address them in order to more effectively manage those situations without them having an adverse psychological or physical impact on us. And it's actually a great intervention in working with young Black youth. Other interventions that have been helpful, more in adult populations than kids, has been social support, religious practices, and other health-promoting behaviors that can happen in a group context. So some people use emotional emancipation circles. And they actually are support groups where Black Americans get together on a regular basis to share stories about their experiences of discrimination. Resistance methods, young people protesting is a great way to address race-related stress and advocate for yourself. And then mindfulness. There have been some studies looking at mindfulness, which allows you to place nonjudgmental attention and awareness on the present moment. It's been demonstrated to have some efficacy in protecting your emotional health in situations of racial discriminations. And it's had some positive impact on depression symptoms. So there have been other studies looking at racial identity as a protective factor. And a more recent study looked at what's the impact of racial identity with online bullying and online discrimination. And as we know, that's much more common and much more pervasive. In this particular study, with a fairly large sample, these investigators looked at anxiety specifically because online discrimination has been associated with worsening mental health. And so they looked at a group of adolescents who had experienced online racial discrimination and they measured ethnic identity. So they had two groups, a group that had high ethnic identity, one with low ethnic identity. What they discovered is that for youth who had high ethnic identity, that episodes of bullying online did not increase their levels of anxiety, but rather decreased their level of anxiety over time. So those kids were not impacted by the online bullying. While those youth who described low levels of ethnic identity had higher rates of anxiety in response to online racial bullying. One of the other questions that comes up often really has related to, are we actually seeing the impact of racial discrimination or is what we're seeing really the impact of poverty? And so there've been a few studies looking at that specific question. And these two studies, one was the National Survey of American Life. The investigators in a fairly large sample identified that higher income is protective for Caribbean blacks, but it was associated with greater depression for African-American boys. In a follow-up study by the same authors, what they learned is that it wasn't the income that made the difference, it was where the children lived and who were their social groups. And so higher income was associated with less depression for black boys who were living in neighborhoods that had more black people and were more diverse. So I wanna shift gears a little bit to talk about what's actually happening in clinical settings. And what we're finding is increasing number of black and Latino youth presenting in emergency settings. So in this particular study, which I think captures a lot of what we're saying prior to the pandemic and now, looked at a national database of six to 24-year-olds between 2011 and 2015. And what they observed was an overall 30% increase in psychiatric emergency department visits. But when they looked at the ethnic composition of the youth who were presenting, the largest increase occurred among African-American or black youth and Latino youth. While white youth's presentation in the emergency department remained relatively flat, and you can see that here, the divisions by race with the dotted lines being the African, this being the African-American youth. They also noticed that the reasons for the visits had shifted and that visits related to suicidal ideation and adolescence increased by more than two, two and a half percent. So that there was a significant increase in the number of youth who were presenting for suicide visits. And you can actually see this here in the 12 to 17-year-old age group between 2011 and 2015. And then interestingly, although psychiatric visits, as you know, typically tend to be long, so all the visits were greater than three hours, that it was only a minority of youth who were seen by a mental health professional, 16%. And we're talking about three hours in the ED and access to mental health professionals. And what they noticed is that when they looked at the disposition for these youth, that the African-American youth were much more likely to be identified as not having an urgent problem, more likely to have public insurance and more likely to be identified as having a behavior disorder as opposed to an internalizing disorder like depression. In a more recent study that was completed in 2020, and this study was actually quite profound. You know, Fontanelle and their colleagues looked at about 140,000 youth who were covered by Medicaid between the ages of 10 to 18, who had been psychiatrically hospitalized. And then they looked at attendance at a follow-up mental health appointment within one week after discharge. And this was pretty impressive. They found that for the youth who had a follow-up mental health appointment within a week of discharge, that there was a 50% decrease in the risk of a subsequent suicide attempt within the six months after discharge. Now, I don't know anything that decreases suicide risk by 50%. And so this finding is actually important. But more concerning is that only about half of the youth, right, about 56% in the study had attended any follow-up mental health appointment within seven days. When they took a deeper dive and a closer look at who was most likely to have an appointment, what they discovered is that black youth, individuals receiving Medicaid because of low income, those with chronic illnesses or self-harm or substance abuse were least likely to have a mental health appointment within a week of discharge. And, you know, that's the highest risk group for completed suicide, suggesting that access to care may be one of the major factors impacting black youth. In this study, which I thought was really, really quite revealing, this is an analysis of a subsample of a population of a large ongoing study called ED-STARS. That Cheryl King and her colleagues have been leading across the United States, it's a multi-site study. And this subsample of youth, these investigators wanted to understand what were the risk profiles for this group of adolescents that may place them at greater risk for a suicide attempt, but also they wanted to look at these risk profiles as they related to follow-up care. Like did these people utilize services? And so they basically created five risk profiles. And if you look at the X-axis at the top, suicidal thoughts and behavior, past, current, current, severe. On the Y-axis, it's aggression, low or high. And they generated five risk profiles based on that. Past suicidal thoughts, behavior, low aggression, severe suicidal thoughts and behavior, low aggression. And you can see these laid out in the five boxes. What they found is that for the black youth, their profiles were more likely to be characterized by a history of suicidal thoughts and behaviors and aggression at about 15%. And at about 49% had a history of suicidal thoughts and behaviors. And so essentially, when they broke these, I wanna mention this study, interestingly, had a fair representation of minoritized youth, which is not common. What they identified was that youth who were meeting the profiles most commonly identified among black youth were the ones who were least likely to be evaluated for suicide in the emergency department. So adolescents who had a history of suicidal thoughts and behaviors or suicidal thoughts and behavior and aggression were least likely to present to the emergency department with a mental health chief complaint, although they had reported a previous suicide attempt. And then they also noticed that mental health service utilization paralleled the distribution of these latent class profiles. So that African-American youth had lower mental health service utilization as well. The study suggests that the risk profile for black youth may increase their risk for under-identification of suicide. So in emergency departments, we typically ask about suicidality now, suicidality in the past few weeks. If you say no, even though you had a suicide attempt a year ago, there may be no further suicide assessment. So in settings where there's a go, no-go triage algorithm, the risk for discharging these kids is much greater. We also know there's significant literature confirming bias in diagnosis for black and Latino youth. And so there've been several studies demonstrating that white youth were much more likely to be given a diagnosis of attention deficit or internalizing disorders, while black and Latino youth were much more likely to be given a diagnosis of conduct disorder. In large national samples, black and Latino children were much less likely to receive a diagnosis of ADHD and much less likely to receive treatment. We also, in long-term studies, we know that even in schools that black and Latino kids are much less likely to be referred for treatment and much more likely to be referred for expulsion or detention. And then for black and Latino youth in juvenile detention, most of the kids have a diagnosis of conduct disorder alone, but on further assessment in some of the larger scale studies, we found that the majority met criteria for major depression, generalized anxiety or PTSD, or another access one disorder. And that most of them, 66% met criteria for at least two mental health conditions that have been undiagnosed. And so what do we know and what do we need to know? Well, I can tell you that the report by the Congressional Black Caucus prompted the NIMH and other organizations to issue requests for applications for studies focusing on black youth. What we do know is very few studies have focused on black youth and no studies have been shown to reduce risk for suicide. There've been a couple of studies, older studies, that report on suicide behavior reduction. And then a few studies that mention some reduction in suicidal ideation. So Guy Diamond's attachment-based family therapy has been one of the ones that's more commonly used. There has been one study looking at black youth and it was a study completed in the South, I can't remember the state, that was designed to determine whether an intensive family and community-focused intervention could be a safe and effective alternative to inpatient hospitalizations for youth presenting with psychiatric emergencies. It happens that in this sample, the sample was predominantly black, predominantly low SES, which was about 66%. And in that study, they assigned kids to multisystemic therapy inpatient treatment with community follow-up. And what they discovered is that for the youth in the MST group, they showed more progress and it was more effective than psychiatric hospitalization in reducing suicide attempts over about a year and a half. They also identified the intervention as providing increased parental control for the youth and for the parents. But that only lasted for about a year. And then there was no long-term effects on suicidal ideation, depression, parental control, or hopelessness. And so what we do know is that, as I mentioned from the prior study, that not all patients at risk for suicide receive resources in the ED after discharge or following a psychiatric crisis. And this is especially true for minoritized youth. We know that there's some demonstrated early benefits for treatment, engagement, and retention. Utilizing motivational interviewing principles with a focus on attention to family stress and coping. Using care navigators to facilitate connection, particularly culturally competent or culturally humble care navigators. And matching race and ethnicity of clinical providers and families demonstrates some effectiveness, but there aren't really large-scale studies examining that particular phenomenon. What we do know is true for everyone and it should be in place for black youth when we evaluate them, is that everybody should be screened to identify those who are at elevated risk and to reduce disparities in care. And even though that's not currently recommended by the U.S. Services Preventive Task Force, we're recommending that we do screening for all youth. And then when positive, proceeding with a suicide risk assessment and risk formulation. Collaborative safety planning has been highly effective for adults and adolescents. And there are ongoing studies focusing on collaborative safety planning with patient and families for adolescents. And this is true for those that are gonna be discharged to the outpatient setting. That's all the outpatient settings. You know, intensive outpatient, partial hospital, and kids discharged from inpatient psychiatric units. When I talk about safety planning, I mean Stanley Brown safety planning. So a structured safety planning intervention like Stanley Brown, which includes elements of evidence-based therapy. So the Stanley Brown safety planning intervention, it includes elements of CBT, dialectical behavioral therapy, problem solving skills therapy, and family crisis management. And that is the intervention that we should all be using. And then we should review that safety plan regularly and update it and maintain contact between visits, particularly missed visits. And ongoing safety assessments at every visit is essential. It will also be important in treatment what we know. And the studies, we're seeing more intervention and treatment studies is that individual treatments for suicidal youth or depressed youth exhibiting suicidal ideation and suicidal behaviors actually requires targeted focused intervention. So it's not just CBT, it's CBT for suicide prevention. It's DBT, which is one of the best evidence-based treatments, but and family crisis intervention, such as the safety intervention. But the intervention should be focused on suicidal behavior. And if ethnic matching is possible, that's a plus in most situation and minimally culturally competent care or a clinician trained in the use of cultural humility is essential. It's also important that we identify stressors that increase risk for suicidal behavior and that we address those things. So if it's substance use, family problems, we should intervene. And then we need to talk about racism in our assessments and perceived experiences of racism, and we have to address them. So you don't have to be an expert in what it's like to be black and experience racism, but you do need to be an expert in demonstrating cultural humility with a willingness to ask questions and the ability to be able to listen to the answers and understand how they impact a young person's development. And then it's extraordinarily important, and I think this is where we lose young people, is the continuity of care between the family, the treatment providers, the school and communities. For black youth, we have to be proactive in assuring these transitions of care, use care navigators, use case managers, motivational interviewing, partnerships with community supports. It's essential that we do this in order to protect these youth. And so just to kind of summarize the big takeaway points, that suicidality in minoritized youth is increasing, and we don't yet know how to intervene because there's limited evidence. Few studies have focused on risk factors. No studies have been shown to reduce risk. Few studies have focused on resilience factors and protective factors. Few studies have examined racism, discrimination, historical trauma, although we're starting to see more of those specifically as they relate to suicidality. And we also know that we're missing the boat on some of our assessments and interventions with our current practices. It's important to remember that when kids leave the emergency department, they need to have resources and follow-up, especially for minoritized youth who tend to be less engaged in treatment. And then a proactive approach, as I mentioned, motivational interviewing, care navigators, all of those other things, is really essential to protect youth. And high attention to youth who are intersectional who are BIPOC and LGBTQ youth. And so I'll stop on that note. I think we have a few minutes, just a couple of minutes for questions. So thank you for your time and attention. Thank you so much, Dr. Benton. I mean, this presentation, I know it was called a call to action, but literally what you've given people is an action plan. So thank you so much for the thorough presentation. If anyone in the audience has a question, we can probably take one or two questions. As you're thinking about posing a question, I will ask Dr. Benton a question. What can families proactively do to prevent black youth suicide? Yeah, that's an excellent question. So what we're recommending for families, because this is an area of fairly intensive study right now, is really focused on developing and supporting the resilience that exists within families by mobilizing and supporting the protective factors. So things like pride messaging, positive cultural identification, supportive family spending time together, being able to talk to your kids about emotional issues and modeling how to talk about your feelings appropriately, being open to hearing what your children are experiencing, families that are supportive, supportive friend networks, like all the things that help kids feel better about themselves. And if they're dealing with issues around racism or racial discrimination, how do you bolster their ability to be in control of those situations? And families can do that by creating a sense of a supportive community. And therapists can do the same thing. We can ask kids, what do they feel good about in terms of their own ethnic and racial identification? What do they enjoy about their culture? How are they engaged with their culture? I mean, those are preventive strategies that are simple, they don't cost any money, but they actually work. No, I appreciate that. And those are all great strategies. Is there anything when you add intersectionality of LGBTQ, anything additional? Because those are all great strategies that should also apply to our LGBTQ youth. But given the startling statistics that you gave, is there anything else you would add? Yes, most definitely. And that's an excellent question. And so those are, you're correct. Those are the same things that we would recommend for LGBTQ plus youth. But we also have to recognize that there are many families who are not ready for the acceptance of who their children actually are. And the same for many communities. And so we strongly recommend that, and this is true for all youth who are minoritized youth, that if you don't have a natural community in your family, then you create a community, or you find a community. Or as a therapist or a family member, you find a community of support because that's really important. And that we find ways to maintain those connections no matter what. So during the pandemic, we had an issue with a lot of LGBTQIA youth not having access to their support groups, but we're able to do that online. And so that's a very, very important protective factor. On a more broad preventive scale, we've been partnering with communities that have typically marginalized LGBTQ plus youth. So the American Foundation for Suicide Prevention has a new program called Soul Shop. And we started to partner with churches, black churches, in supporting their opening themselves up to their members who identify as LGBTQ. And embracing those individuals with a sense of community. So I would recommend that for those youth, they find a community and as a provider, if they can't find one, we should help them find one. Because that's really important. Thank you, Dr. Benton. And we are out of time and no additional questions have came in. So on that note, on behalf of the American Psychiatric Association, thank you so much for giving up your time and sharing your talent with us today. I very much enjoyed the presentation and you definitely have given us a lot to think about and a lot for us to be able to implement and move forward. So if we go to the next slide, I can let everyone know how they can actually receive their CME credit. Thank you. Thank you, Dr. Benton. Oh. So you'll be receiving, if you have any questions, definitely send an email to the learning center at psych.org with any questions for how to claim the credit. You attended this virtual event, you'll submit an evaluation, you'll select the claim credits tab, and then you'll choose the number of credits from the dropdown menu. Today's session was for one CME and then you'll click the claim button. And once again, thank you to everyone for attending. Thank you so much, Dr. Benton and wishing everyone a wonderful day. Thank you.

suicides

African-American youth

risk factors

protective factors

interventions

racial discrimination

trauma

resilience

mental health services

culturally competent care