Intersecting Identities and the Association Between Bullying and Suicide Attempt Among New York City Youths: Results From the 2009 New York City Youth Risk Behavior Survey

Objectives. We examined the intersections of sexual minority, gender, and Hispanic ethnic identities and their interaction with experiences of bullying in predicting suicide attempt among New York City youths.Methods. We performed secondary data analysis of the 2009 New York City Youth Risk Behavior Survey, using logistic regression to examine the association of sexual identity, gender, ethnicity, and bullying with suicide attempt. We stratified results on these measures and reported adjusted odds ratios.Results. Compared with non–sexual minority youths, sexual minority youths had 4.39 and 1.96 times higher odds, respectively, of attempting suicide and reporting bullying. Identity variables did not interact with bullying in predicting suicide attempt individually; however, a four-way interaction term was significant. The effect of bullying on suicide attempt was strongest among non-Hispanic sexual minority male youths (odds ratio = 21.39 vs 1.65–3.38 for other groups).Conclusions. Sexual minority, gender, and ethnic identities interact with bullying in predicting suicide attempt among New York City youths. Interventions to limit both the prevalence and the effect of bullying among minority youths should consider an intersectional approach that considers ethnic, gender, and sexual identities.In 2010, several high-profile suicides of lesbian, gay, and bisexual (LGB) youths shed new light on bullying in schools in the United States. Nationally, suicide is the third leading cause of death among 12- to 19-year-old youths and fourth in New York State.1 Estimates from the 2011 Youth Risk Behavior Survey (YRBS) indicate that 7.8% of US youths reported attempting suicide in the past year.2 According to the New York City (NYC) Department of Health and Mental Hygiene, suicide attempts among NYC teens had remained constant at 7% until 1999 when suicide attempts increased to 10%.3In 2011, an estimated 20% of US youths reported bully victimization in the past year.2 Research into understanding the effect of bullying on health outcomes among youths has focused on those who perpetrate bullying, those who are victims of bullying, and those who are both perpetrators and victims.4 Youths who are involved in bullying as either victims or perpetrators experience higher levels of psychosocial harm,5,6 depression,7 and substance use8 than those who are not involved in bullying, but those who are victims of bullying are more likely to experience depressive symptoms than are perpetrators.4Bullying is a significant risk factor for suicide ideation independent of other suicide risk factors.9,10 Youths who report any involvement in bullying are more likely to report seriously considering or attempting suicide than those who report no involvement.11 A survey of the literature on bullying and suicide has suggested that the relationship between bullying and suicide may have different effects among different minority groups, including racial, gender, and sexual minorities.Both the US Surgeon General and the Institute of Medicine have listed LGB youths as a high-risk group for suicide, and the Institute of Medicine and the Centers for Disease Control and Prevention (CDC) recommended increasing national surveillance on the health of LGB people to better assess the health disparities of sexual minorities in the United States.12–15 As many as one third of youth suicide deaths have been estimated to occur among sexual minorities.16 A 2011 Morbidity and Mortality Weekly Report showed that the prevalence of suicide attempt was higher among sexual minority youths than among heterosexual youths,14 and in a 2007 report, 1 in 3 sexual minority youths in NYC reported attempting suicide compared with 1 in 12 heterosexual youths.3LGB youths are also at increased risk for peer victimization compared with heterosexual youths.17,18 In 2005, a survey of school safety among a national sample of students found that LGB students were 3 times more likely to feel unsafe at school than heterosexual peers, and 90% of LGB students reported having been verbally or physically harassed.19 Among New York state students, 61.1% felt unsafe in school because of their sexual orientation, and 84.6% of LGB students reported verbal harassment, 40.1%, physical harassment, and 18.8%, physical assault.20Abelson et al. 21 suggested that suicidality among LGB youths is not the result of individual pathologies but rather a direct result of peer victimization. Hunter22 reported that 34% of gay male youths and 41% of lesbian female youths who sought services at the Hetrick-Martin Institute in NYC reported attempting suicide because of the antigay violence they experienced.Although female youths are twice as likely as male youths to report suicide attempt,23 male youths are 3 to 5 times more likely than female youths to successfully commit suicide.12 Brent et al.24 suggested that this may be because female adolescents are more likely to attempt suicide using reversible methods, such as pill overdose, and are also less likely to attempt suicide under the influence of alcohol, which may increase the likelihood of death during a suicide attempt. According to the 2011 YRBS, female youths were more likely than male youths to report attempted suicide both nationally and in NYC.2 However, male adolescents are 6 times more likely to successfully commit suicide than female adolescents.25Studies have suggested that male youths are more likely to perpetrate bullying than are female youths.26–28 Nationally, female youths are more likely to report bullying than are male youths, but in NYC, no difference was found in reported bullying by gender.2 Some studies have suggested that gender may be an effect modifier of the relationship between bullying and suicide attempt and that female youths who experience peer victimization have higher odds of suicide attempt than male youths, but these associations are inconsistent across studies.9–11,29–33A 2002 report from the Institute of Medicine showed that suicide rates vary significantly across race/ethnicity. The global burden of suicide falls disproportionately on Whites.12 According to the CDC’s WONDER mortality database, the crude rate of suicide death per 100 000 of those aged 10 to 19 years from 1999 to 2008 was 5.0 for non-Hispanic Whites, 2.9 for non-Hispanic Blacks, and 3.2 for Hispanics.25 A study exploring self-harm and suicide attempt among high-risk urban youths in the United States suggested that Hispanics have higher rates of suicide attempt and self-harm than do non-Hispanic Whites or non-Hispanic Blacks.23 Despite lower rates of completed suicide, results of the 2011 YRBS suggested that Hispanic youths were more likely to report a suicide attempt than were White or Black youths.2 Taken together, these 2 results suggest that Hispanics are more likely to attempt but less likely to be successful at suicide than are Whites and Blacks. With respect to bullying, a nationally representative study of US youths has suggested that Blacks report lower rates of bully victimization than do Whites or Hispanics.34The literature on minority identity development is becoming populated with new perspectives on the development of intersectionality specifically related to race and sexual identity formation.35–38 A relatively new paradigm in the literature, intersectionality suggests that as with many social constructs such as race, gender, and class, sexuality can serve as a basis for social power and oppression. Theorists have argued that without acknowledging the cross-construction of several conflicting identities, it is impossible to understand the effects of victimization on varying groups of sexual minority youths.39 The acknowledgment of these often complex identity development trajectories served as the theoretical framework for this study.Theorists have hypothesized that youths who are both sexual and racial minorities may experience different identity development trajectories as a result of heterosexism, homonegativity, and homophobia often present in ethnic minority communities.40 Studies exploring the relationship between racial and sexual identities have suggested that sexual identity developmental milestones, such as age of same-sex attraction and same-sex sexual debut, do not differ by race/ethnicity.41 Nonetheless, the literature has revealed that racial minority families often attempt to socialize their children to cope with the realities of covert and overt racism experienced within the context of White heterosexual communities.42 Although systematic attention is increasingly being paid to White LGB youths, little attention has been paid to racially diverse same-sex–attracted youths. Therefore, these youths confront many interpersonal issues simultaneously: their racial and sexual identity developmental changes, heterosexism within their respective ethnic and cultural communities, heterosexism within the White cultural community, racism within the LGB community, and racial disparities associated with the HIV epidemic.42A study exploring psychiatric disorders among racial minority LGB individuals found that Black and Latino LGB individuals were more likely to report serious suicide attempts despite having a lower prevalence of psychiatric disorders than Whites.43 With respect to gender and sexual identity, D’Augelli et al.44 assessed suicide attempts that were specifically associated with sexual identity. Although female youths were more likely to report suicide attempt than were male youths, male youths were more likely to report that their suicide attempt was related to their sexual identity. The association between peer victimization and suicide attempt may be further modified by the intersections between race and gender. In a study of young Black and Hispanic students in Texas, male students reported a higher prevalence of both verbal and physical bullying than did female students. Black students of both genders had a higher prevalence of verbal and physical bullying than did Hispanic students.45 In a study exploring the correlates of adolescent bullying, Carlyle and Steinman4 reported that gender differences in reported bullying were only significant among Whites and Native Americans.The literature has suggested a complex relationship among sexual identity, gender, race/ethnicity, and bullying in the probability of suicide outcomes that has not yet been explored in previous research. In this research, we used data from the 2009 NYC Youth Risk Behavior Survey to explore the associations among these 4 factors—sexual identity, gender, Hispanic ethnicity, and bullying—on suicide attempt in a sample of 9th- through 12th-grade students in NYC.     

Toward Understanding Suicide Among Youths: Results From the White Mountain Apache Tribally Mandated Suicide Surveillance System, 2001�C2006

Objectives. We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions.Methods. Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations.Results. Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict.Conclusions. An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.Suicide is the third leading cause of death among US youths aged 10 to 24 years,¹ and suicide attempts are a major source of adolescent morbidity in the United States. As behavioral scientists have increasingly recognized youths'' suicide behavior as an important and preventable public health problem, Healthy People 2010 has set specific objectives to reduce suicide and suicide attempt rates among youths. Past evidence supports the premise that youth suicide can be prevented by addressing risk factors and promoting early identification, referral, and treatment of mental and substance use disorders. However, risk factors vary across races, ethnic groups, and regions, necessitating targeted formative research and community-specific prevention approaches.²It is well-documented that American Indians and Alaska Natives have the highest rates of suicide of all US races.³ American Indian and Alaska Native (AIAN) suicides occur predominantly among youths ( < 25 years), in contrast to the US general population, in which deaths from suicide are concentrated among the elderly ( ≥ 65 years).⁴ Further, there is significant variability in suicide rates among youths across tribes and rural versus urban AIAN populations. Among the 1.3 million American Indians and Alaska Natives residing on or near rural reservation lands tracked by the Indian Health Service, the average rate of suicide per 100 000 is 20.2, with a range of 7.7 (Nashville area) to 45.9 (Alaska area).⁵ In comparison, for all 4.1 million American Indians and Alaska Natives identified by the US Census, the suicide rate is 11.7.⁶ Because urban AIAN residents compose approximately 60% of the US Census AIAN population,⁷ the lower overall census suicide rate indicates that rural reservation suicide rates are higher than urban AIAN suicide rates.To date, little reservation-specific information on suicide behavior or related risk factors exists to explain differences in rates across AIAN communities and in comparison with other US populations. Developing the means to collect and analyze local tribal data is key to discerning unique risk factors that are driving local and national disparities in suicide among AIAN youths, and to the public health mission of reducing suicide among youths across the United States and the world.There are approximately 15 500 White Mountain Apache (Apache) tribal members who reside on the 1.6 million acre Fort Apache Reservation in east-central Arizona. More than half (54%) of the tribal members are younger than 25 years, compared with approximately 35% of the US all-races population.⁸ In 2001, a cluster of suicides among youths on the Apache reservation led the Tribal Council to enact a resolution to mandate tribal members and community providers to report all suicidal behavior (ideation, attempts, and deaths) to a central data registry. The resulting surveillance system is the first of its kind, gathering data from both community-based and clinical settings.In 2004, as part of the Johns Hopkins Center for American Indian Health, we partnered with the Apaches to conduct a community-based participatory research (CBPR) project that included formalizing the mandated reporting process, transferring the registry system to an electronic format, analyzing quarterly trends, and engaging community leaders in interpreting surveillance data to inform prevention strategies. Because of the contentious history of research in tribal communities, CBPR methodologies are essential to ensuring a culturally sensitive interpretation of findings and culturally relevant interventions.⁹ A CBPR approach is particularly important in the complex area of mental health because explanatory models for cause and treatment of mental illness can vary widely across tribal and nontribal cultures.¹⁰We describe the Apache suicide behavior surveillance system, report patterns of Apache youths'' suicide and suicide attempts between 2001 and 2006, and compare those rates with those of other tribal and North American populations. We discuss the relevance of the paraprofessional-administered surveillance system and its findings to public health prevention of suicide behavior among youths.     

Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population

Objectives. We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample.Methods. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004–2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder.Results. Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0).Conclusions. Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.With almost 1 million deaths worldwide every year and a rate increase of 60% over the past 45 years, suicide is clearly a major public health problem.¹ Although the US Surgeon General has prioritized suicide prevention,² suicidal behavior has not significantly decreased in the United States.³ Suicide attempts are strong risk factors for eventual suicide completion^4–6; therefore, understanding and modifying risk factors for suicide attempts remain a promising approach to reducing suicide rates.Unfortunately, our understanding of the risk factors for suicide attempts is plagued by poor specificity. Vigorous study efforts have identified multiple risk factors, including several sociodemographic factors and mental disorders.^3,7–10 However, significant associations between candidate risk factors and suicide attempts are tempered by low positive predictive values.¹¹ The population-attributable fraction (PAF; also known as the population-attributable risk) has emerged as a promising statistical tool to better quantify the effect of risk factors on a given outcome at the population level. The PAF describes the reduction in incidence of a particular outcome if the entire population was not exposed to the examined risk factor.¹²The PAF has been underused in the study of suicide risk factors.^13,14 A recent review of the PAF in suicide research¹⁵ showed that existing studies examining the PAFs of risk factors for suicide attempts have focused primarily on depression and mood disorders, with PAFs ranging from 28% to 74%.^14,16–21 A small number of studies have investigated the PAFs of substance use disorders and anxiety disorders for suicide attempts, also with mixed findings.^14,18,22 Other findings suggest that the risk of suicide attempts attributable to mental disorders is largely explained by the association between mental disorders and suicidal ideation.⁹ A major limitation in the literature is that relatively few mental disorders have been examined by using PAFs for suicide attempts. Despite substantial evidence for the causative role of personality disorders in suicidal behavior,^23–25 the PAF of personality disorders has been examined in only 1 study to date, and that study was unable to examine the effects of individual personality disorders.¹⁸ Borderline personality disorder is a strong risk factor for suicide attempts,²⁵ yet the PAF of borderline personality disorder for suicide attempts is unknown. Posttraumatic stress disorder (PTSD) is another disorder associated with suicide attempts,^26,27 yet the proportion of suicide attempts attributable to PTSD has not been examined. Furthermore, many previous studies included limited adjustment for confounding factors. Even though several mental disorders have been labeled as risk factors for suicidal behavior,⁷ many studies using the PAF do not adjust for mental disorders other than the disorder of interest. The PAF is based on the assumption that the examined risk factor is causally related to the outcome,¹² and given the high rates of comorbidity of mental disorders,²⁸ multivariate models examining a comprehensive range of mental disorders are needed to provide a more realistic assessment of the PAF for a specific mental illness.Our primary objective was to examine the proportion of suicide attempts attributable to specific mental disorders. To address the limitations of the existing literature, we used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),²⁹ wave 2, as the data set. This data set features a very large sample size (N = 34 653), includes a comprehensive assessment of Axis I disorders and all 10 Axis II personality disorders, and is representative of the US population. On the basis of existing literature showing high PAF values for major depressive disorder and other mood disorders, we hypothesized that whereas several mental disorders would be independently associated with suicide attempts, major depressive disorder and other mood disorders would account for the highest proportion of suicide attempts.^16,21 We further hypothesized that anxiety and substance use disorders would have lower PAF values for suicide attempts, on the basis of previous studies that often showed lower PAF values.^14,18,22 The limited literature on the PAFs of personality disorders for suicide attempts suggested that we would find low PAF values; however, because of its consistently demonstrated association with suicide attempts, we anticipated that borderline personality disorder would have a relatively high PAF value.     

Correlates of Suicidality: Investigation of a Representative Sample of Manitoba First Nations Adolescents

Objectives. We examined individual, friend or family, and community or tribe correlates of suicidality in a representative on-reserve sample of First Nations adolescents.Methods. Data came from the 2002–2003 Manitoba First Nations Regional Longitudinal Health Survey of Youth. Interviews were conducted with adolescents aged 12 to 17 years (n = 1125) from 23 First Nations communities in Manitoba. We used bivariate logistic regression analyses to examine the relationships between a range of factors and lifetime suicidality. We conducted sex-by-correlate interactions for each significant correlate at the bivariate level. A multivariate logistic regression analysis identified those correlates most strongly related to suicidality.Results. We found several variables to be associated with an increased likelihood of suicidality in the multivariate model, including being female, depressed mood, abuse or fear of abuse, a hospital stay, and substance use (adjusted odds ratio range = 2.43–11.73). Perceived community caring was protective against suicidality (adjusted odds ratio = 0.93; 95% confidence interval = 0.88, 0.97) in the same model.Conclusions. Results of this study may be important in informing First Nations and government policy related to the implementation of suicide prevention strategies in First Nations communities.Indigenous adolescents worldwide engage in more suicidal behavior and suicide completion than do other adolescent groups.^1–4 Examining the correlates of suicidality in these youths, which includes suicidal ideation and attempts but excludes completion, could help target interventions to improve the well-being of indigenous communities. Many risk and resiliency factors in indigenous youths are similar to those in other adolescents; however, several unique factors may apply.⁵ Furthermore, factors from several levels (e.g., community, family, individual) likely influence suicidality in this population.^6–9With regard to individual-level correlates, males in indigenous samples of varied age ranges show higher rates of suicide completion than females,^10,11 but a higher frequency of suicidality is typically reported in females (although sex is rarely significant in multivariate models).^7,12–15 Meanwhile, mixed results have been found for the association between age and suicidality in indigenous youths.^{6,8,13,16–19} Other variables found to be associated with increased suicidality in indigenous youths include depressive symptoms, substance use (including smoking), abuse, and traumatic or stressful life events.^{6,7,13–15,19–22} Finally, cultural variables have been investigated in relation to suicidality. In studies from British Columbia, adolescent suicide was low in those First Nations communities with higher levels of cultural continuity^23–25 and where 50% or more of individuals knew a First Nations language.²⁶ However, studies examining relationships between suicidality and cultural variables have reported mixed findings,^{12,13,15,20,27} which are likely attributable to the use of different measures, samples, and constructs across studies.An association between less suicidality and aspects of family or friend unity and support has been found in studies of indigenous adolescents in bivariate and multivariate models.^6,7,17,28 Conversely, several studies have examined different forms of family or friend dysfunction in relation to increased suicidality. Potential correlates include family conflict, little family care, parental absenteeism, deviant friends, familial substance use, suicidality or completion by family or friends, and interpersonal difficulties.^{6,7,12,14,16,18–20,29–31} Economic disparity may also be associated with suicidality^32–34; however, not all research has shown this association in samples of youths.^13,18,22 Finally, from the late 1800s until 1973, many aboriginal children in Canada were taken from their communities and housed in residential schools managed by the government and churches, with the intent of assimilating these children into mainstream Canadian society.^1,35,36 Indigenous cultural practices and the use of traditional languages were prohibited, and abuse was prevalent.^1,35–37 Although several researchers have discussed the intergenerational impact of the residential school experience,^35,37 no study to date has examined the relationship between having had a parent or grandparent in residential schools and suicidality in youths.Aspects of perceived community caring and suicidality in indigenous youths have been examined, with mixed findings. Less community safety and isolation from one''s community and family have been found to be associated with suicide attempts in American Indian/Alaska Native youths,^6,14 whereas perceived care from community members has been protective for attempts in bivariate models.^6,7 Other studies have found no association between suicide attempts in American Indian youths and related factors such as gang involvement¹¹ or perceived connection to others.³⁸ Geographical location may also be related to suicidality and suicide,^20,23,30 but more research is needed.Most previous studies examining correlates of suicidal behavior in indigenous youths have been conducted on American Indians/Alaska Natives and native Hawaiians. None of these studies have used representative samples, and most have been limited by small samples or convenience samples. Furthermore, several potential correlates of suicidality have been underinvestigated.We aimed to examine associations of individual, friend or family, and community or tribe factors with suicidality in a representative on-reserve sample of more than 1100 First Nations adolescents.     

Culturally Responsive Suicide Prevention in Indigenous Communities: Unexamined Assumptions and New Possibilities

Indigenous communities have significantly higher rates of suicide than non-Native communities in North America. Prevention and intervention efforts have failed to redress this disparity. One explanation is that these efforts are culturally incongruent for Native communities. Four prevalent assumptions that underpin professional suicide prevention may conflict with local indigenous understandings about suicide. Our experiences in indigenous communities led us to question assumptions that are routinely endorsed and promoted in suicide prevention programs and interventions. By raising questions about the universal relevance of these assumptions, we hope to stimulate exchange and inquiry into the character of this devastating public health challenge and to aid the development of culturally appropriate interventions in cross-cultural contexts.Suicide is a significant public health problem that accounts for approximately 30 000 deaths each year in the United States alone.1 Striking cross-cultural variability, however, is found in prevalence of suicidal behavior.1–7 For example, suicide disproportionately affects Native Americans, and young indigenous men have the greatest risk.8–14 In some locales, these youths complete suicide at a rate of 17 times the US average.13,15 This stands in marked contrast to the patterns of nonindigenous suicide in the United States, in which older men are at highest risk,1 and in China, where suicide disproportionately afflicts young rural women.16 These disparities suggest diverse motivations and meanings for suicidal behavior across cultural and demographic divides, underscoring the need for culturally specific interventions.17,18American Indian/Alaska Native (AI/AN) communities display a striking association between suicide and community-level factors, indicating a need for a broader approach to prevention. Indigenous suicide is associated with cultural and community disruptions,12,19–21 namely, social disorganization, culture loss, and a collective suffering.10,22–24 Conversely, lower suicide rates and increased well-being have been associated with community empowerment, connectedness, family cohesion, and cultural affinity among Native people.25–27 Yet despite the connection between personal and community health in AI/AN communities, suicide prevention interventions are often individually focused and clinically based. Thus, mental health services in tribal communities are not always structured to be culturally meaningful28,29 and are frequently underutilized.13,30–32Here we explore potential cultural misalignment by contrasting 4 normative assumptions that underpin standard suicide prevention interventions with indigenous understandings common in North America: (1) suicide expresses underlying psychological problems versus suicide expresses historical, cultural, community, and family disruptions; (2) suicide is primarily an agentic expression of personal volition versus suicide is primarily an enacted consequence of social obligation; (3) suicide prevention is best achieved by mental health professionals versus suicide prevention is best achieved by nonprofessional community members; and (4) suicide prevention most properly falls within the purview of formal mental health service delivery systems versus suicide prevention most properly falls within the purview of locally designed decolonization projects.Drawing on more than 30 years of combined experiences in clinical, administrative, and research settings in AI/AN communities, we examine the relevant meaning systems of both dominant prevention–intervention models as well as AI/AN perspectives concerning suicide because greater understanding of the cultural meanings of mental health problems such as suicide may help public health and mental health professionals improve access and remove barriers to treatment, develop culturally responsive practices, and improve the quality of care for vulnerable populations.33 Although diverse indigenous beliefs and practices are necessarily conflated here, our comparison is intended to offer innovative ways to understand and effectively prevent suicide in indigenous communities in North America. Moreover, because different understandings of emotional expression and self-representation are associated with other issues, such as alcohol misuse,34,35 our perspective may be similarly useful for promoting many culturally appropriate behavioral health interventions in tribal communities.     

Smoking behavior of US youths: a comparison between child welfare system and community populations

Objectives. We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group.Methods. We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking.Results. CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior.Conclusions. Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population.Cigarette smoking among US youths persists as a critical public health problem. Notably, 80% to 90% of adult smokers initiate smoking by age 18 years.^1–3 Trends in smoking behavior among youths have not paralleled the steady decline evident among adult smokers.² Tobacco use is related to more than 400 000 US deaths per year, and direct medical costs attributable to smoking total more than $50 billion in the United States annually.^1,4 The public health importance of tobacco use is underscored by the Obama administration''s prioritization of smoking prevention and cessation.⁵Youths involved with the child welfare system (CW) face unique experiences that may put them at elevated risk for smoking compared with youths without similar experiences.^6,7 Youths enter the CW system as a result of case investigations conducted by local child protective services agencies. This population includes both youths receiving services in their homes and those in out-of-home care. The lives of CW-involved youths are characterized by problems such as child abuse, neglect, poverty, domestic violence, and parental substance abuse.⁸ Although CW cases are typically referred on the basis of parent behavior, these youths are also at high risk for mental health disorders, substance use, and other psychosocial problems.^6,8–10 However, we are unaware of any studies examining cigarette smoking among CW youths in comparison with community samples to determine whether a difference in smoking-prevalence risk exists for these youths. It is important to determine whether CW-involved youths are at higher risk for smoking so that targeted prevention and intervention strategies can be developed.Among community youths, studies have demonstrated that some subgroups (e.g., age, gender, race/ethnicity, region) are at higher risk for both lifetime and current smoking.² Boys are more likely to initiate smoking, but they smoke more infrequently than girls do.^2,11,12 Racial/ethnic minority youths smoke less than do their White peers.^11–13 Parent education and family structure are associated with lifetime, current, and regular smoking, with youths from households of lower socioeconomic status smoking at higher rates.^14–17Smoking is also linked to emotional well-being, including internalizing and externalizing behaviors and parent–child closeness. Depression is related to increased smoking behavior.^18–23 Engaging in delinquent acts is associated with increased youth smoking.^11,15,24 Youths who report having a close relationship with their parents are less likely to be regular smokers.²⁵Several longitudinal studies have connected youth smoking with behavioral outcomes in adolescence and adulthood. Early-onset smokers are 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and engage in stealing and other delinquent behaviors.²⁶ In addition, long-term emotional and physical health—such as reduced adult life satisfaction, more severe nicotine dependence, and higher smoking quantities—are associated with youth smoking.^27,28Our purpose in the current study was to investigate whether CW-involved youths were at greater risk for smoking than were community youths and to determine whether factors associated with smoking behavior were similar among both populations. We focused explicitly on early adolescence because smoking initiation occurs most often between the ages of 12 and 14 years,^29,30 and early smokers face greater risk of later negative outcomes. We examined 3 distinct measures of smoking behavior: lifetime, current, and regular smoking. Each of these outcomes has a unique public health impact, and investigating them together provides a comprehensive picture of smoking across the 2 youth populations. We expected smoking rates to be higher for CW-involved youths than for community youths. Although there is a dearth of previous research on factors related to smoking behavior in the CW population, we expected some similarities between the groups, with demographic characteristics, family structure, and emotional and behavioral health being associated with smoking among CW-involved youths.     

Sexual Orientation and Suicide Ideation,Plans, Attempts,and Medically Serious Attempts: Evidence From Local Youth Risk Behavior Surveys, 2001–2009

Objectives. We examined the associations between 2 measures of sexual orientation and 4 suicide risk outcomes (SROs) from pooled local Youth Risk Behavior Surveys.Methods. We aggregated data from 5 local Youth Risk Behavior Surveys from 2001 to 2009. We defined sexual minority youths (SMYs) by sexual identity (lesbian, gay, bisexual) and sex of sexual contacts (same- or both-sex contacts). Survey logistic regression analyses controlled for a wide range of suicide risk factors and sample design effects.Results. Compared with non-SMYs, all SMYs had increased odds of suicide ideation; bisexual youths, gay males, and both-sex contact females had greater odds of suicide planning; all SMYs, except same-sex contact males, had increased odds of suicide attempts; and lesbians, bisexuals, and both-sex contact youths had increased odds of medically serious attempts. Unsure males had increased odds of suicide ideation compared with heterosexual males. Not having sexual contact was protective of most SROs among females and of medically serious attempts among males.Conclusions. Regardless of sexual orientation measure used, most SMY subgroups had increased odds of all SROs. However, many factors are associated with SROs.Suicide is the 10th leading cause of death overall and the 3rd leading cause of death among youths aged 10 to 24 years. In 2010, more than 157 000 people in this age group visited US emergency departments because of attempted suicide or other self-harm injuries.1 Media reports convey the message that sexual minority youths (SMYs) have much greater rates of suicide (i.e., self-inflicted death) than do non-SMYs; however, the unavailability of sexual orientation information on death certificates makes this impossible to confirm or refute using archival data. What is known is that studies document large disparities in key indicators of suicide risk among SMYs, including suicidal ideation (i.e., considering suicide) and suicide attempts (i.e., nonfatal self-directed potentially injurious behavior with the intent to die).2–5 In early studies, often using small convenience samples without comparison groups, 20% to 40% of SMYs reported suicidal ideation and attempts.6–8 Later population-based surveys confirmed these reports and found odds of suicidal ideation and attempts up to 5 to 6 times greater among SMYs than among non-SMYs.9–16 Researchers understand this increased risk for suicide ideation and attempts in the context of minority stress,17,18 whereby a hostile social environment characterized by stigma, prejudice, and discrimination may be associated with increases in individual risk factors for suicide, including depression, substance abuse, social isolation, peer conflict, and victimization4,5,11,19–32 and decreases in protective factors such as supportive relationships with peers and family.33–35We sought to expand what is known about the risk of suicide among SMYs by addressing gaps in the research related to the measurement of both sexual orientation and suicide risk outcomes (SROs). That is, most studies on the topic measure only suicide ideation or attempts.11–15,36,37 Less is known about the full range of suicidal behaviors, including suicide planning and medically serious attempts (MSAs). These outcomes are important, as they indicate sustained injury and may indicate increased risk for future suicide, suicide attempt, or repeat attempts.38–41 Indeed, some research suggests that SMYs not only make more medically serious attempts but also have greater intent to die.10,42,43 Other research contests these findings.44 The Youth Risk Behavior Survey (YRBS) is a population-based study of high school students administered nationally, statewide, and locally that measures ideation, plans, attempts, and MSAs. Four state or local sites have published studies examining sexual orientation and SROs.9,16,37,45–48 All studies examined suicide attempts, 3 measured ideation,37,46,47 4 measured plans,37,45–47 4 measured MSAs,16,37,46,47 and 1 measured all.37 In this last study, the sample size precluded conducting adjusted analyses. A recent Centers for Disease Control and Prevention study reported prevalence rates of all SROs by sexual orientation for each of the selected state and local sites that collected sexual orientation information.49 We aggregated data across local sites providing adequate power to test the associations between sexual orientation and SROs while accounting for a range of risk factors and demographic variables. The use of data across local sites that are also urban areas adds a unique aspect to this study, as little is known about the associations between sexual orientation and SROs among urban populations.In addition to expanded measurement of SROs and a unique sample, we have provided multiple measures of sexual orientation. Most studies measure a single dimension of sexual orientation, typically sexual identity (e.g., lesbian, gay, bisexual [LGB]) or sexual behavior (sexual contact with opposite, same, or both sexes).29,32,50 This assumes that dimensions of sexual orientation are interchangeable and that 1 measure correctly identifies all SMYs. Sexual orientation, however, is multidimensional and dimensions may not overlap.9,49,51 For example, SMYs of color may engage in sexual contact with same-sex partners but not identify as sexual minorities because of social stigma.52 We have added to the research base and examined the associations between sexual orientation and SROs using 2 of 3 recommended dimensions of sexual orientation—sexual identity and sexual behavior53—with sexual attraction being the third and currently unavailable recommended measure. Finally, to avoid obscuring important within-group differences imposed by dichotomous measures of sexual orientation (e.g., LGB vs heterosexual),9,10,12,15,16,45,54 we analyzed subgroups of males and females on the basis of sexual identity and sex of sexual contacts, including the less studied population of youths who are unsure of their sexual identity.15,42 Using data from a unique urban sample and with expanded measures of sexual orientation and SROs, we asked the following questions:

1. On average, do youths who report their sexual identity as LGB or unsure have increased odds of suicide ideation, plans, suicide attempts, and medically serious attempts compared with heterosexual youths, controlling for a range of individual-level risk factors and demographic variables?
2. On average, do youths who report same- or both-sex sexual contact have increased odds of suicide ideation, plans, suicide attempts, and medically serious attempts compared with youths who have sexual contact with opposite-sex partners only, controlling for all other factors?

     

The Contribution of National Disparities to International Differences in Mortality Between the United States and 7 European Countries

Objectives. This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries.Methods. Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries.Results. If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%.Conclusions. Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.The United States has lower life expectancy at birth than most Western European countries. In 2009, life expectancy in the United States was 76 years for men and 81 years for women, between 2 and 4 years less than in several European countries.1 The disadvantage is greater for women than for men and originated in the 1980s.2 The US health disadvantage is found not only for life expectancy, but also for self-reported health measures,3,4 biomarkers,3 and many specific causes of death5,6 across the entire life course.3–5,7A recent report by the National Research Council suggests that smoking and obesity explain an important part of the US mortality disadvantage.2,8,9 However, an approach that solely emphasizes behavioral differences is impoverished by ignoring the role of socioeconomic and environmental determinants.10 A substantial body of research suggests that most behavioral risk factors are socially patterned; lower education or income are associated with a higher prevalence of smoking, excessive alcohol consumption, obesity, and poor dietary patterns.11–19 In addition, European countries and the United States differ in many aspects of the physical and social environment that can affect population health and that are in turn socially patterned within each country. For example, the socioeconomic distribution of access to healthy food differs between countries.20 Social environmental factors related to safety, violence, social connections, social participation, social cohesion, social capital, and collective efficacy have also been shown to influence health and in turn differ between countries and socioeconomic groups.21 Indeed, differences in mortality between the United States and Europe are larger among those with a lower educational level,6 suggesting that larger educational disparities in mortality, which partly coincide with differences in behavior, partly explain why Americans have higher mortality than Europeans.The United States is characterized by relatively higher levels of income inequalities,22 residential and racial segregation,23–25 and financial barriers to health care access2,26 than any European country. Social protection policies and benefits are also less comprehensive in the United States than in Europe, including policies on early education and childcare programs,27 access to high-quality education,28 employment protection and support programs,29,30 and housing29,31 and income transfer programs.31,32 A plausible hypothesis is that the more unequal distribution of resources and less comprehensive policies contribute to the more unfavorable risk factor profile and poorer health of lower-educated Americans as compared with corresponding Europeans.4,33,34 A follow-up report by the National Research Council and the Institute of Medicine published in 2013 concluded that there is a lack of evidence on how these factors explain the US health disadvantage.21 The aim of this article is to assess to what extent larger educational disparities in mortality explain why Americans have higher mortality than Europeans.     

Mental Health and Suicidality Among Racially/Ethnically Diverse Sexual Minority Youths

Objectives. We examined the relationships among sexual minority status, sex, and mental health and suicidality, in a racially/ethnically diverse sample of adolescents.Methods. Using pooled data from 2005 and 2007 Youth Risk Behavior Surveys within 14 jurisdictions, we used hierarchical linear modeling to examine 6 mental health outcomes across 6 racial/ethnic groups, intersecting with sexual minority status and sex. Based on an omnibus measure of sexual minority status, there were 6245 sexual minority adolescents in the current study. The total sample was n = 72 691.Results. Compared with heterosexual peers, sexual minorities reported higher odds of feeling sad; suicidal ideation, planning and attempts; suicide attempt treated by a doctor or nurse, and self-harm. Among sexual minorities, compared with White youths, Asian and Black youths had lower odds of many outcomes, whereas American Native/Pacific Islander, Latino, and Multiracial youths had higher odds.Conclusions. Although in general, sexual minority youths were at heightened risk for suicidal outcomes, risk varied based on sex and on race/ethnicity. More research is needed to better understand the manner in which sex and race/ethnicity intersect among sexual minorities to influence risk and protective factors, and ultimately, mental health outcomes.Over the past 20 years, research has documented elevated suicidality1—defined as behavior related to contemplating, attempting, or completing suicide2—among sexual minority youths (an umbrella term, generally including those who identify as lesbian, gay, bisexual, or transgender [LGBT]; engage in same-sex sexual behavior; or have same-sex attractions). This research has consistently demonstrated substantial sexual orientation disparities in suicidality, with sexual minority youths having higher prevalence of suicidality than their heterosexual peers.3–6 A recent review of the literature indicated that sexual minority youths are at least twice as likely as heterosexual youths to contemplate suicide, and 2 to 7 times as likely to attempt suicide.7 A meta-analysis found that 28% of sexual minority youths had a history of suicidality, compared with 12% of their heterosexual peers.8Despite the development of knowledge about suicidality among sexual minority youths, little is known about suicidality in sexual minority youths of color. To the extent that existing researchers have explored racial/ethnic differences, analyses have rarely gone beyond dichotomous (White vs “youths of color”) or trichotomous (White vs Black vs Latino) comparisons. As a result, there exists scant literature exploring the full spectrum of racial/ethnic differences in suicidality among sexual minority youths.The literature on suicide in the general adolescent population demonstrates racial/ethnic differences in suicide ideation and attempts. For example, prevalence of suicide among Native American and Alaska Native youths is twice that of other youths,9 and Latino youths are more likely than either Black or White youths to have considered and attempted suicide.10 Differences are further moderated by participants’ gender: girls are more likely to consider suicide and attempt suicide than boys,10 although boys are more likely to complete suicide.11Studies that have considered racial/ethnic differences in suicidality among sexual minority youths have found differences, though the patterns have been inconsistent. A study based on Youth Risk Behavior Survey (YRBS) data from Massachusetts, reported that among self-identified lesbian, gay, or bisexual (LGB) youths3 Latinos were significantly more likely than Whites to report past-year suicide attempt. Another study found that same-sex–attracted Black and White youths were more likely than their other-sex–attracted peers to report suicidal ideation, whereas same-sex–attracted Latino and Asian/Pacific Islander youths did not differ from other-sex–attracted peers.12 In a nonprobability sample of urban LGBT youths,13 Black and White youths were more likely to report suicidal ideation than Latinos; however, Latinos reported the highest frequency of suicide attempts. A study of New York City adults found that Latino and Black LGB participants were more likely to report serious suicide attempts than were White LGB participants, with most reported attempts occurring during adolescence and young adulthood.14 These conflicting results suggest that there are important differences in suicidality at the intersections of sexual minority status and race/ethnicity, yet further study requires data of sufficient scale and scope to enable analyses of low-prevalence behaviors across small subgroups of youths.To address the need for information about suicidality among racially/ethnically diverse sexual minority populations, we assess suicidality patterns among youths based on sexual orientation, race/ethnicity, and sex. With this, we respond to calls for public health to utilize minority stress and intersectional frameworks as potential lenses through which to understand health and health disparities among sexual minority populations.15,16 Rather than treating social identities as separate and discrete phenomena, our inquiry allows that co-occurring minority identities operate together. An intersectional approach suggests that sexual identity–race–sex intersections are informed by unique cultural, historical, social, and political factors that differentially influence life experiences, including discrimination based on such identities.17–19 In turn, minority stress theory posits that discriminatory experiences predispose populations to stress and adverse mental health outcomes, including suicidality.20The focus on health differences among sexual minority youths across race/ethnicity and sex is vital to creating effective health interventions and programs. Such a focus is particularly relevant within the context of youth suicide, as risk and protective factors associated with suicidality vary across both racial/ethnic and sexual minority groups, and there is a need to better integrate these bodies of research.21     

Suicide,Guns, and Public Policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means.In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions.Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”1a

—Johann Wolfgang von Goethe

Suicide is a complex behavior involving the intentional termination of one’s own life. The prevalence, causes, means, and prevention of suicide have been extensively studied and widely reported.1b–4 The World Health Organization (WHO) has identified suicide as a serious public health concern that is responsible for more deaths worldwide each year than homicide and war combined,5 with almost 1 million suicides now occurring annually. In 2007, the Centers for Disease Control and Prevention (CDC) reported that 34 598 Americans died by suicide, far more than the 18 361 murders during the same period.6 Among Americans younger than 40 years, suicide claimed more lives (n = 13 315) than any other single cause except motor vehicle accidents (n = 23 471).6Psychiatric disorders are present in at least 90% of suicide victims, but untreated in more than 80% of these at the time of death.7 Treatment of depression and other mood disorders is therefore a central component of suicide prevention. Other factors associated with suicidal behavior include physical illness, alcohol and drug abuse, access to lethal means, and impulsivity. All of these are potentially amenable to modification or treatment if recognized and addressed. It is important to distinguish between impulsivity as a personality trait and the impulsivity of the act of suicide itself. It is not generally appreciated that suicide is often an impulsive final act by a vulnerable individual8 who may or may not exhibit the features of an impulsive personality.9The impulsivity of suicide provides opportunities to reduce suicide risk by restriction of access to lethal means of suicide (“means restriction”). Numerous medical organizations and governmental agencies, including the WHO,5 the European Union,10 the Department of Health in England,11 the American College of Physicians,12 the CDC,4,13 and the Institute of Medicine,14 have recommended that means restriction be included in suicide prevention strategies. In the United States, firearms are the most common means of suicide,15 with a suicide attempt with a firearm more likely to be fatal than most other means.16 In a study of case fatality rates in the northeastern United States, it was found that 91% of suicide attempts by firearms resulted in death.17 By comparison, the mortality rate was 84% by drowning and 82% by hanging; poisoning with drugs accounted for 74% of acts but only 14% of fatalities. Many studies have shown that the vast majority of those who survive a suicide attempt do not go on to die by suicide. A systematic review of 90 studies following patients after an event of self-harm found that only two pecent went on to die by suicide in the following year and that seven percent had died by suicide after more than nine years.18The availability of guns in the community is an important determinate of suicide attempts by gun.19 Given the public health importance of suicide and what is known about the role of guns in suicide, strategies that keep guns out of the hands of individuals who intend self-harm are worthy of careful scrutiny. Since a handgun (revolver or pistol) is far more likely to be used for suicide than a long gun (shotgun or rifle),20 it may be particularly beneficial to focus suicide prevention efforts on this type of weapon. Only a small minority of states restrict access to handguns by methods such a waiting period, a permit requiring gun safety training, or safe storage of guns in the home. In 2010, US Department of Justice reported that only 15 states had a waiting period for purchasing a handgun.21 Although federal law prohibits the sale of handguns to persons younger than 21 years, in the absence of federal preemption (i.e., the removal of legislative authority from a lower level of government), some states and municipalities allow the sale of handguns to younger individuals.21     

Variations in Health and Health Behaviors by Nativity Among Pregnant Black Women in Philadelphia

Objectives. We compared health behaviors and health outcomes among US-born, African-born, and Caribbean-born pregnant Black women and examined whether sociodemographic and psychosocial characteristics explained differences among these population subgroups.Methods. We analyzed data from a prospective cohort study conducted in Philadelphia, Pennsylvania, with a series of nested logistic regression models predicting tobacco, alcohol, and marijuana use and measures of physical and mental health.Results. Foreign-born Black women were significantly less likely to engage in substance use and had better self-rated physical and mental health than did native-born Black women. These findings were largely unchanged by adjustment for sociodemographic and psychosocial characteristics. The foreign-born advantage varied by place of birth: it was somewhat stronger for African-born women than for Caribbean-born women.Conclusions. Further studies are needed to gain a better understanding of the role of immigrant selectivity and other characteristics that contribute to more favorable health behaviors and health outcomes among foreign-born Blacks than among native-born Blacks in the United States.Studies examining health differences among immigrant subgroups and their native-born counterparts have largely focused on Hispanics. This literature consistently shows that Hispanics born outside the United States have lower mortality rates and better health and reproductive outcomes than do US-born Hispanics.^1–3 These studies also reveal that the protective effect of foreign-born status varies by country of origin.^4,5 For example, Cho et al. found that Mexican immigrants had better self-reported health status, fewer activity limitations, and fewer sick days confined to bed than did persons from Cuba and Central America,⁴ and Hummer et al. reported a similar variation for infant mortality rates.³Far less is known about the health of foreign-born Black immigrants, who make up an expanding proportion of US immigrants. For example, in 1960 fewer than 1% of Black US residents were foreign born; by 2005 this figure increased to 8%.^6,7 Studying health differentials among native-born and foreign-born Blacks may shed light on factors that contribute to racial health disparities in the United States.Previous studies showed that health behaviors, health status, and reproductive outcomes were more favorable among foreign-born Blacks than among native-born Blacks.^3,8–10 However, only a handful of studies have examined health status¹¹ or birth outcomes^12–15 among foreign-born Blacks by region of birth. These studies found that foreign-born Black women, whether from the Caribbean¹⁴ or Africa,¹² were less likely than US-born Black women to have low-birth-weight infants. A recent study of 2000 vital records for New York, New York, observed that although the risk of low birth weight was lower among infants of foreign-born Black mothers than among infants of native-born Black mothers, that risk varied by the foreign-born mothers'' place of birth: infants born to women from the Dominican Republic had the lowest risk, and infants born to women from Haiti had the highest risk.¹⁵ Proposed explanations for more favorable birth outcomes and better health status among the foreign-born include selective migration, greater social support, and fewer adverse health behaviors.^{4,5,9,13,14,16–18}We examined the role of nativity in health behaviors and health status among pregnant Black women in Philadelphia, Pennsylvania. We compared health behaviors and status among Black women born in the United States, the Caribbean, and Africa. Our data, collected through extensive face-to-face interviews, allowed us to examine whether individual-level sociodemographic and psychosocial characteristics explained differences in behavior and health among Black women by region of birth.     

Associations of Adolescent Hopelessness and Self-Worth With Pregnancy Attempts and Pregnancy Desire

Objectives. We examined the associations of pregnancy desire (ambivalence or happiness about a pregnancy in the next year) and recent pregnancy attempts with hopelessness and self-worth among low-income adolescents.Methods. To evaluate independent associations among the study variables, we conducted gender-stratified multivariable logistic regression analyses with data derived from 2285 sexually experienced 9- to 18-year-old participants in the Mobile Youth Survey between 2006 and 2009.Results. Fifty-seven percent of youths reported a desire for pregnancy and 9% reported pregnancy attempts. In multivariable analyses, hopelessness was positively associated and self-worth was negatively associated with pregnancy attempts among both female and male youths. Hopelessness was weakly associated (P = .05) with pregnancy desire among female youths.Conclusions. The negative association of self-worth and the positive association of hopelessness with pregnancy attempts among young men as well as young women and the association of hopelessness with pregnancy desire among young women raise questions about why pregnancy is apparently valued by youths who rate their social and cognitive competence as low and who live in an environment with few options for material success.Rates of adolescent pregnancy and childbearing in the United States are among the highest in the developed world.1 Each year, approximately 750 000 women younger than 20 years become pregnant,2 and about 400 000 give birth.3 In the United States, adolescent pregnancy rates are about two thirds higher among non-White young women than among White young women, and childbearing rates are approximately one third higher2; 57% of births to adolescents in 2010 were to African American or Hispanic/Latino mothers.3 Surveillance data for 9th- to 12th-grade US students show that Blacks and Hispanics are more likely than Whites to engage in risk behaviors associated with pregnancy (e.g., vaginal intercourse at an early age, nonuse of hormonal contraceptives).4Race and ethnicity do not, in themselves, explain adolescent pregnancy risk. Kirby identified more than 100 antecedents of adolescent pregnancy, primarily related to the types of physical and social environments in which minority youths in the United States are disproportionately represented.5 He concluded that most risk factors, including poor school performance6 and residence in a socioeconomically disadvantaged neighborhood,7–9 reflected dysfunction, disadvantage, or disorganization. Offspring of adolescent parents or sisters of women who began childbearing in adolescence are at high risk for adolescent parenthood, suggesting a cultural or intergenerational component.8–10 Family quality, especially parent characteristics and relationships9,11–16; the quality of relationships with one’s school, residential community, and peers6,7,9,12,14; and substance use and mental health,9,17–22 are associated with pregnancy or pregnancy risk behaviors among both female and male adolescents.Youths who live in challenging social and physical environments typically have negative psychological and cognitive responses to their surroundings (e.g., low self-worth and hopelessness).23,24 Although the evidence is mixed,20–22,25,26 it is generally assumed that poor self-image, poor self-worth, and poor self-esteem in girls are associated with pregnancy or pregnancy risk markers, including early age at first vaginal intercourse and an inability to negotiate condom use. Hopelessness reflects negative expectations about future desired or valued outcomes and helplessness with respect to one’s ability to change the odds that negative outcomes will occur.27 Hopelessness has been identified as a risk marker for youth violence and self-harm and poor adult social trajectories.24,28–31 In industrialized countries, adolescent pregnancy (and the decision to continue a pregnancy) may be a consequence of a lack of hope and the perception of too few positive life options,32,33 although only a limited number of studies have directly examined hopelessness and pregnancy risk.Kogan et al. examined a related phenomenon, conventional future orientation, and found associations with decreased sexual risk taking at age 16 and avoidance of pregnancy at age 19 years.34 A 2013 study of Mobile Youth Survey (MYS) participants showed that having a positive feeling about the future was marginally associated with older age at first intercourse, a risk factor for adolescent pregnancy.35 Neither study examined female and male youths separately. Despite the health, social, and economic burdens associated with pregnancy involvement among boys,9,36,37 little is known about the psychological or cognitive correlates of adolescent paternity risk.Adolescent pregnancy and childbearing disproportionately occur among historically marginalized youths and present significant, and often lifelong, social and health risks to parents and their offspring.37 Many known antecedents, including poverty, neighborhood quality, and quality of the parental relationship, may be intractable. However, learned cognitive factors such as hopelessness and low self-worth may be modifiable.27Because of our overarching interest in identifying potentially intervenable correlates of pregnancy involvement among high-risk youths, we examined the hypotheses that hopelessness is positively associated and self-worth is negatively associated with 2 known risk markers of adolescent pregnancy: pregnancy attempts and pregnancy desire.15,26,38–42 Our analyses involved a cross-sectional sample of adolescent female and male participants in the MYS,43 a study of primarily African American and impoverished young people with little variation in their social risk for pregnancy. Because there may be gendered cultural meanings or consequences associated with early pregnancy and parenting (especially in communities where rates of adolescent pregnancy are disproportionately high) and because the psychological or cognitive correlates of pregnancy risk may vary according to gender,21,22 we examined female and male youths separately.     

Protective School Climates and Reduced Risk for Suicide Ideation in Sexual Minority Youths

Objectives. We examined whether sexual minority students living in states and cities with more protective school climates were at lower risk of suicidal thoughts, plans, and attempts.Methods. Data on sexual orientation and past-year suicidal thoughts, plans, and attempts were from the pooled 2005 and 2007 Youth Risk Behavior Surveillance Surveys from 8 states and cities. We derived data on school climates that protected sexual minority students (e.g., percentage of schools with safe spaces and Gay–Straight Alliances) from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention.Results. Lesbian, gay, and bisexual students living in states and cities with more protective school climates reported fewer past-year suicidal thoughts than those living in states and cities with less protective climates (lesbians and gays: odds ratio [OR] = 0.68; 95% confidence interval [CI] = 0.47, 0.99; bisexuals: OR = 0.81; 95% CI = 0.66, 0.99). Results were robust to adjustment for potential state-level confounders. Sexual orientation disparities in suicidal thoughts were nearly eliminated in states and cities with the most protective school climates.Conclusions. School climates that protect sexual minority students may reduce their risk of suicidal thoughts.Suicide is the third leading cause of death among youths aged 15 to 24 years.1 Decades of research have identified multiple risk factors for adolescent suicide ideation and attempts.2 One of the most consistent findings is that lesbian, gay, and bisexual (LGB, or sexual minority) adolescents are more likely than heterosexual adolescents to endorse suicidal thoughts3,4 and to report having a suicide plan.5 Additionally, a recent review of the epidemiological literature found that LGB youths are between 2 and 7 times more likely to attempt suicide than their heterosexual peers.6Given the elevated risk of suicidal ideation, plans, and attempts among sexual minority youths, researchers have focused on identifying factors that explain these marked disparities. Theories of minority stress7 and stigma8 have highlighted the important roles that social-structural contexts as well as institutional practices and policies play in contributing to mental health disparities. Consistent with these theories, LGB adults who live in states with fewer protective social policies have higher rates of psychiatric and substance use disorders than LGB adults living in states with more protective policies.9,10 For instance, LGB adults in states that passed constitutional amendments banning same-sex marriage experienced a 37% increase in mood disorders, a 40% increase in alcohol use disorders, and nearly a 250% increase in generalized anxiety disorders in the year following the enactment of the amendments.10 These and other studies11 have shown that the broader social contexts surrounding LGB adults shape their mental health.Among adolescents, schools are an important social context that contributes to developmental and health outcomes.12 For sexual and gender minority youths in particular, the social context of schools can promote both vulnerability and resilience.13–16 A variety of methodological approaches have been used to evaluate the mental health consequences of school climates for LGB students. The predominant approach is to ask LGB adolescents to report on the supportiveness of their schools.17–19 Studies using this approach have indicated that LGB youths who report greater school connectedness and school safety also report lower suicidal ideation and fewer suicide attempts.18 Although informative, this research may introduce bias because information is self-reported for both the exposure and the outcome.20 Studies using alternative methodologies may therefore improve the validity of the inferences on the relationship between the social environment and individual health outcomes.An alternative methodological approach has been to develop indicators of school climate that do not rely on self-report, such as geographic location of the school (i.e., urban vs rural)21 and the presence of Gay–Straight Alliances in the school.22 Although this approach has received comparatively less attention in the literature, recent studies have documented associations between these more objective measures of school climate and sexual minority mental health. For example, lesbian and gay adolescents are at lower risk for attempting suicide if they live in counties where a greater proportion of school districts have antibullying policies that include sexual orientation.23 Although they provide important initial insights, existing studies have been limited by examining only 1 aspect of school climate (e.g., antibullying policies or presence of Gay–Straight Alliances),16,22,23 relying on nonprobability samples,16,22 and using a single location,16,22,23 all of which can restrict generalizability.We built on this previous research by using data on multiple school climate variables relevant to LGB students that we obtained from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention (CDC).24 We then linked this information on school climate to population-based data of adolescents living in 8 states and cities across the United States. We hypothesized that LGB adolescents living in states and cities with school climates that are more protective of sexual minority youths would be less likely to report past-year suicidal thoughts, plans, and attempts than LGB youths living in areas with less protective school climates.     

School Environment and the Mental Health of Sexual Minority Youths: A Study Among Dutch Young Adolescents

Objectives. We examined whether structural elements of the school environment, in particular cultural pluralism and consistency and clarity of school rules and expectations of students, could mitigate the risk for mental health problems among young sexual minority adolescents.Methods. Data were collected in 2008 by means of a computer-based questionnaire completed at school by 513 young Dutch adolescents (12–15 years old) during regular class times. Eleven percent of these students, who were enrolled in 8 different schools, reported having at least some feelings of same-sex attraction.Results. Adolescents with same-sex attractions in schools where rules and expectations were experienced as less consistent and clear reported significantly more mental health problems than their peers with no same-sex attractions in the same schools. Such differences were absent in schools where rules and expectations were experienced as more consistent and clear. There were no such effects of cultural pluralism.Conclusions. Our results suggest that schools with consistent and clear rules and expectations mitigate the risk for mental health problems among students with same-sex attractions and underscore the importance of structural measures for the health of sexual minority youth.Shocking reports appear in the press with some regularity about the bullying of adolescents who are gay or lesbian or who are perceived as such, sometimes resulting in suicide attempts and even actual suicides.^1–3 Such reports draw attention to the role of schools: what can schools do to protect sexual minority youths?Studies conducted in various countries have shown that sexual minority youths are at disproportionate risk for several negative health outcomes, including victimization, witnessing and perpetrating violence, substance use, sexual risk behaviors, and suicide ideation and attempts.^4–9 A recent Dutch study of younger adolescents (13- to 15-year-olds) showed that those experiencing same-sex attractions had significantly higher levels of depression and lower self-esteem than did their peers not experiencing same-sex attractions.¹⁰Sexual minority youths come of age in a society that is often hostile to their interests and needs. Increased health problems in these youths are usually understood as a consequence of discrimination by peers and family. Victimization in high school has been shown to be positively associated with mental health and traumatic stress symptoms in sexual minority youths.¹¹ In a survey of Illinois middle school students, being the target of homophobic verbal harassment was associated with higher levels of anxiety and depression, personal distress, and a lower sense of school belonging among boys and higher levels of withdrawal among girls.¹²Homophobic bullying by classmates can start at an early age, as suggested by the April 2009 suicides of 2 boys, both 11 years old, in Massachusetts and Georgia, each bullied at school for being perceived as gay.^1,2 In a study involving a community-based sample of self-identified lesbian, gay, and bisexual youths (aged 15–19 years) who were interviewed about their lifetime experiences of sexual orientation victimization, the mean ages at which verbal victimization began were 11.4 years for male participants and 14.4 years for female participants.¹³ The corresponding mean ages at which physical victimization began were 13.1 years and 14.2 years.¹³ School was reported as the setting for 72% of first experiences with verbal victimization and 56% of first experiences with physical victimization.¹³A few studies suggest that structural factors may affect how young people feel at school. In one investigation, students who reported having a Gay–Straight Alliance (GSA) at school, knowing where to go for information and support related to sexual orientation and gender identity, and having lesbian, gay, bisexual, and transgender (LGBT) issues included in their school curriculum were more likely to report feeling safe at school than were those who did not have these resources.¹⁴Another study showed that sexual minority students in schools that have a comprehensive harassment policy (i.e., specifying sexual orientation or gender identity and expression) are less frequently verbally harassed and hear fewer homophobic remarks than students in schools with no policy or a policy not specifically inclusive of LGBT people; students reported that school personnel were also more likely to intervene upon hearing homophobic remarks in these schools.¹⁵ Feeling safe at school seems to be a protective factor for sexual minority youths. In one study, feeling safe at school attenuated the association between sexual orientation and suicidal ideation and attempts.¹⁶Further support for the importance of structural factors comes from a cross-sectional study that compared rates of victimization and suicidality among sexual minority adolescents in schools with and without GSAs and other school programs.¹⁷ Using data from the Massachusetts Youth Risk Behavior Survey and controlling for student demographic characteristics and school characteristics, Goodenow et al. showed that sexual minority youths in Massachusetts schools with GSAs were less than half as likely as those in other schools to report dating violence, being threatened or injured at school, or skipping school as a result of fear; in addition, they were less than one third as likely to report multiple suicide attempts in the past year.Goodenow et al. also found that peer support groups other than GSAs, nonacademic counseling, school antibullying policies, a student judiciary, staff training on sexual harassment, and peer tutoring systems were associated with lower rates of victimization and suicidality among sexual minority students. Sexual minority youths from schools where there was a perception that school staff could be approached about a problem were less likely to report multiple suicide attempts, and those from schools where antibullying policies were in place were less likely to report single or multiple suicide attempts.Building on existing knowledge, we explored whether a protective school climate offsets negative health outcomes among young adolescents. In particular, we hypothesized that when schools support cultural pluralism and have consistent and clear rules and expectations, the relationship between same-sex attraction and mental health will be attenuated.     

Lesbian,Gay, Bisexual,and Transgender Hate Crimes and Suicidality Among a Population-Based Sample of Sexual-Minority Adolescents in Boston

Objectives. We examined whether past-year suicidality among sexual-minority adolescents was more common in neighborhoods with a higher prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT) individuals.Methods. Participants’ data came from a racially/ethnically diverse population-based sample of 9th- through 12th-grade public school students in Boston, Massachusetts (n = 1292). Of these, 108 (8.36%) reported a minority sexual orientation. We obtained data on LGBT hate crimes involving assaults or assaults with battery between 2005 and 2008 from the Boston Police Department and linked the data to the adolescent’s residential address.Results. Sexual-minority youths residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation (P = .013) and suicide attempts (P = .006), than were those residing in neighborhoods with lower LGBT assault hate crime rates. We observed no relationships between overall neighborhood-level violent and property crimes and suicidality among sexual-minority adolescents (P > .05), providing evidence for specificity of the results to LGBT assault hate crimes.Conclusions. Neighborhood context (i.e., LGBT hate crimes) may contribute to sexual-orientation disparities in adolescent suicidality, highlighting potential targets for community-level suicide-prevention programs.Suicide is the second-leading cause of death among all youths worldwide and is the third-leading cause of death among all youths in the United States,1 making the topic of adolescent suicidality a global public health and medical priority.2 One of the most consistent findings in psychiatric epidemiology is the existence of marked sexual orientation disparities in adolescent suicidality (e.g., suicidal ideation and suicide attempts).3 Lesbian, gay, bisexual, and transgender (LGBT, or sexual minority) adolescents are more likely to contemplate,4–6 plan,7 and attempt4,5,8 suicide than their heterosexual peers, and these disparities have been documented across multiple countries.4,5,8Despite the increased attention devoted to eliminating sexual orientation disparities in adolescent suicide, a 2011 report from the Institute of Medicine on LGBT health disparities noted the dearth of research into determinants of adverse health outcomes, including suicidality, within this population.9 To date, research has focused predominantly on individual (e.g., hopelessness, depressed mood),5,8,10–13 peer (e.g., recent suicide attempts by a peer, peer victimization),5,8,14,15 family (e.g., family rejection, family abuse),5,8,13,16–18 and school (e.g., presence of gay–straight alliances in schools, school safety)14,18,19 factors that are associated with suicidality among sexual-minority adolescents, which mirrors research on adolescent suicidality more broadly.20 This research has offered key insights into determinants of suicide risk, but sexual orientation–related disparities in suicidality remain after control for these established risk factors.4,5,8 The persistence of these disparities indicates the importance of considering additional risk factors, including at the social-ecological level, which we define as influences that occur above individuals, peers, families, and schools, including neighborhoods as well as institutional practices and policies (e.g., state policies that ban same-sex marriage).21,22Decades of research in medical sociology and social epidemiology have provided substantial evidence for the role that broad social-ecological factors play in shaping population health,23,24 and Healthy People 2020 recognizes that such factors may be implicated in LGBT health.25 Yet there is a paucity of research into the social-ecological risk factors for suicide among sexual-minority adolescents. In one of the few studies to address this topic, Hatzenbuehler26 created an ecological measure of the social environment surrounding lesbian, gay, and bisexual youths living in counties across the state of Oregon. Compared with lesbian, gay, and bisexual youths living in counties with supportive environments, the risk of attempting suicide was 20% higher among sexual-minority youths in less-supportive environments,26 suggesting that ecological measures can reveal previously unrecognized social determinants of suicide risk among sexual-minority adolescents. However, additional research on other social-ecological factors that may influence suicide risk within this population is warranted.Therefore, in the current study, we used a novel measure of the social environment: neighborhood-level hate crimes targeting LGBT persons. Hate crimes refer to “unlawful, violent, destructive or threatening conduct in which the perpetrator is motivated by prejudice toward the victim’s putative social group.”27^(p480) Evidence demonstrates that many sexual minorities experience hate crimes28; data from the Federal Bureau of Investigation demonstrated that 17.4% of the 88 463 hate crimes between the years of 1995 and 2008 targeted sexual minorities,29 a rate that was more than 8 times what would be expected when one considers the relatively low percentage of sexual minorities in the general population.30The objective of the present study was to examine whether suicidal ideation and suicide attempts among sexual-minority adolescents are more common in neighborhoods with a higher prevalence of hate crimes targeting LGBT individuals. Although there is limited research on the relationship between neighborhood-level LGBT hate crimes and suicidality among sexual-minority populations, existing research suggests strong associations between neighborhood-level exposure to violence and suicide in general (i.e., non-LGBT) populations.31,32 On the basis of this literature, we hypothesized higher rates of suicidal ideation and attempts among sexual minority adolescents residing in neighborhoods with more LGBT hate crimes. To test this hypothesis, we obtained LGBT hate crimes data from the Boston Police Department Community Disorders Unit and linked this information to individual-level data on suicidality (i.e., ideation and attempts) and sexual orientation from a population-based sample of Boston, Massachusetts, adolescents. This study therefore capitalizes on a rare opportunity to examine a potentially salient social-ecological risk factor for suicidality among sexual-minority adolescents.     

Epidemiology of Tuberculosis Among US- and Foreign-Born Children and Adolescents in the United States, 1994–2007

Objectives. We examined trends in tuberculosis (TB) cases and case rates among US- and foreign-born children and adolescents and analyzed the potential effect of changes to overseas screening of applicants for immigration to the United States.Methods. We analyzed TB case data from the National Tuberculosis Surveillance System for 1994 to 2007.Results. Foreign-born children and adolescents accounted for 31% of 18 659 reported TB cases in persons younger than age 18 years from 1994 to 2007. TB rates declined 44% among foreign-born children and adolescents (20.3 per 100 00 to 11.4 per 100 000 population) and 48% (2.1 per 100 000 to 1.1 per 100 000) among those who were born in the United States. Rates were nearly 20 times as high among foreign-born as among US-born adolescents. Among foreign-born children and adolescents with known month of US entry (88%), more than 20% were diagnosed with TB within 3 months of entry.Conclusions. Marked disparities in TB morbidity persist between foreign- and US-born children and adolescents. These disparities and the high proportion of TB cases diagnosed shortly after US entry suggest a need for enhanced pre- and postimmigration screening.Tuberculosis (TB) case rates continue to decline in the United States and were recently recorded at their lowest level since national recording began in 1953.¹ Although annual TB incidence among US-born persons is declining, the number of new cases reported each year among foreign-born persons has been relatively stable over the past decade; foreign-born persons accounted for almost 60% of TB cases reported in the United States in 2008.¹ TB in foreign-born persons in the United States is largely attributable to acquisition of latent TB infection (LTBI) in TB-endemic countries of origin and subsequent activation of disease after US arrival.² The large burden of TB among foreign-born persons in the United States likely reflects the persistently large burden of TB in many other countries.³An estimated 11% of all TB cases worldwide occur in children younger than age 15 years.⁴ In TB-endemic settings, acquisition of TB infection often occurs in childhood because children are more likely to have frequent and close contact with adults with infectious TB.^5,6 Compared with adult rates of progression from infection to disease (historically 5%–10% progress to disease), rates are higher for children of all ages and highest for infants younger than 1 year (43%) and children aged 1 to 5 years (24%).^4,7,8 Furthermore, children who become infected with TB but do not progress to disease in childhood represent a potential pool for disease in adulthood.^4,7 Elucidating the epidemiology of TB in foreign-born children could therefore facilitate efforts to improve children''s health and control TB by preventing future disease.TB cases are generally reported in the broad age categories of children (defined as < 15 years) and adults (≥ 15 years).^2,9,10 However, adolescents are an important group to study because TB rates rise in adolescence following the decline seen in the elementary school years.¹¹ In addition, adolescents are more likely to present with adult-type pulmonary TB (characterized by disease in the lung apices and a tendency to form cavitary lesions).¹¹ As a result, adolescents are more likely than are younger children to transmit TB to others.^8,11As part of an effort to limit importation of TB disease, the Centers for Disease Control and Prevention in 2007 published revised requirements for overseas medical screening of applicants for US immigration.¹² All persons aged 15 years or older continue to be screened with chest radiographs. Revised technical instructions now require a tuberculin skin test (TST) for all applicants aged 2 to 14 years who live in countries with a large TB burden. Chest radiographs are performed for those whose TST is positive.¹² The potential effect of these changes is not known.We sought to describe the epidemiology of TB among foreign- and US-born children and adolescents in terms of demographic and clinical characteristics and to analyze the potential effect of the 2007 changes to the instructions for overseas screening of applicants for immigration to the United States.     

Lifting boats without closing gaps: child health outcomes in distressed US cities from 1992-2002

Objectives. We compared cause-specific mortality and birth rates for children and youths aged younger than 18 years in 100 US cities from 1992 through 2002.Methods. We used 5 census indicators to categorize the 100 most populous US cities in 1990 as economically distressed or nondistressed. We used Poisson regression to calculate rate ratios for cause-specific mortality and birth rates, comparing distressed cities to nondistressed cities overall and by race/ethnicity from 1992 through 2002. We also calculated rates of change in these variables within each city over this period.Results. Despite improvements in health for the study population in all cities, disparities between city groups held steady or widened over the study period. Gaps in outcomes between Whites and Blacks persisted across all cities. Living in a distressed city compounded the disparities in poor outcomes for Black children and youths.Conclusions. A strong national economy during the study period may have facilitated improvements in health outcomes for children and youths in US cities, but these benefits did not close gaps between distressed and nondistressed cities.Substantial evidence has demonstrated that city residence in the late 19th and early to mid-20th centuries was associated with high rates of injury and infectious diseases.^1–6 Researchers have noted that cities have continued to impose a health penalty on their residents, with poorer outcomes among children and youth in cities than in the rest of the United States.^7–11Some have argued that this penalty was associated with the period of urban decline after 1970, during which physical infrastructures deteriorated and city government services shrank. Yet a number of scholars have noted that the decline from 1970 to 1990 set cities on different demographic and economic trajectories.^12–17 In this formulation, some cities suffered substantively different qualities of economic distress. One group of cities endured ongoing “White flight,” increasing crime rates, poorly performing schools, shrinking populations, an eroding tax base, and greater demand for health and social services.^18–22 A second group of cities experienced the same ills but less severely, and they were buoyed by new immigration.^23,24 These trajectories may have positioned cities differently to benefit from the economic prosperity that the United States experienced from 1992 through 2001.Surprisingly, even within the field of urban health, little attention has been paid to the ways in which economic and population differences among cities may be associated with poorer health outcomes and racial/ethnic health disparities among cities. To be sure, investigators have extensively studied the racial/ethnic disparities that persist despite overall gains in life expectancy and in specific health indicators in the last 15 years.^25–29 However, to our knowledge, health scholars have not investigated the different trajectories of city distress as a factor explaining health disparities and urban health. Several influential studies have demonstrated that health disparities exist between Blacks and Whites within cities,^30–32 and that the health of Blacks in cities is worse than that of Blacks in rural areas.^33,34 Much recent scholarship has demonstrated that neighborhoods of concentrated poverty in cities impose an additional health disadvantage beyond that explained by a resident''s individual poverty level.^35–39 The independent effects of neighborhood residence in urban areas have been documented across educational and social outcomes as well.^40–44We investigated the impact of different patterns of urban distress on selected mortality and birth outcomes for children and youths from 1992 through 2002. First, we assessed whether there were differences in health outcomes for children and youths in economically distressed versus nondistressed cities at the beginning of this period and whether there were racial disparities for these outcomes between different groups of cities in 1992. Next we asked whether, as the period of economic prosperity ended, all boats had risen to the same degree. That is, did improvements in health over this period narrow differences between economically distressed and nondistressed cities? Further, did disparities in health outcomes between Black and White children and youths residing in these 2 groups of cities decrease during this period? To address these questions, we investigated selected causes of mortality and birth rates for children and youths in 1992 and 2002 in 100 US cities. We also compared mortality and birth rates for Whites and Blacks in economically distressed cities versus nondistressed cities, to assess differences across this time period.