In this paper, we will offer a hypothesis as to why some Indigenous communities have much higher rates of youth suicide than other Indigenous communities. In order to understand these differences in suicide rates, particularly so we can build on the strengths and resilience of lower-rate communities, and provide targeted, effective interventions for higher-rate communities, we need to understand more about the risk and protective factors that contribute to this discrepancy.
We propose that early childhood adversity is a key risk factor for later suicidal behaviour over the life course. Further, early childhood adversity may be understood as a key mechanism by which disruption and loss related to colonization is mediated into suicidal behaviour. See Figure 1, which will be examined in more detail throughout. We then offer suggestions for future interventions that target optimizing childhood development and decreasing adversity.
Models of suicide risk and suicide prevention have tended to focus primarily on risk factors encountered close in time to the suicidal behaviour. In turn, suicide prevention efforts largely focus on reducing these risks through measures that reduce access to lethal means (gun storage campaigns, barriers at bridges used for suicide, etc.), training to help others recognize someone at risk of suicide (e.g., ASIST- Applied Suicide Intervention Skills Training), and treatments and interventions for at-risk individuals to decrease the likelihood of future suicide attempts. These comprise much of the evidence for suicide prevention (World Health Organization, 2014), and are important in Indigenous communities as in the general population, and can also be adapted to be more culturally relevant to Indigenous communities.
However, few models of suicide risk adequately address the complexity of more distal (background) life events as risk factors for later suicidal behaviour, and even fewer propose early-life interventions as a key to decreasing elevated rates of suicide. Similarly, few models for suicide risk explain elevated rates of suicidal behaviour within Indigenous contexts and communities and fail to provide a satisfactory explanation of these higher rates, or the ways in which patterns by age and sex differ from those of the mainstream population. These models also do not take into account larger scale social and community factors such as the legacies of colonialism, intergenerational trauma, and persistent socioeconomic inequities. This lack of valid models of suicidal behaviour within Indigenous communities is not only abstract – it has real world consequences. If a solid conceptual understanding is missing, then strategies for prevention and intervention will fail to address important risk and resilience factors. We focus here on how colonization, related trauma and loss, socioeconomic inequity, and childhood adversity can contribute to later suicidal behaviour.
Colonization and increased risk for suicide
A growing area of research is aimed towards understanding how colonization, particularly recent colonization, contributes in an ongoing way to social distress and to systemic socioeconomic inequities for some Indigenous communities (see, for example, Kirmayer, Gone, Moses, 2014; Bombay, Matheson, Anisman, 2014). Although much remains to be understood about how colonization is mediated into current social distress, one of the most often-cited mechanisms is through intergenerational trauma. One legacy of colonial disruption is elevated levels of traumatic stress in many Indigenous households, which may manifest in biological dysregulation as well as disrupted relationships, including caregiving relationships. We suggest that related traumatic stress and loss is linked to increased risk for suicide, and that this risk is transmitted through generations by disrupting parenting relationships, which exposes children to higher levels of stress throughout childhood while also impairing their optimal development. Capacity for parenting is impacted by parental substance misuse, mental and physical disorder, being the perpetrator or victim of domestic violence, and having been through foster care (Canada, Public Health Agency, 2008).
This current family-level distress can be further compounded by social and economic factors such as inadequate housing, food insecurity, and unemployment. As a recent report from the Samaritans, a UK-based suicide-prevention organization, has documented, socioeconomic disadvantage is a key risk factor for suicidal behaviour (Samaritans, 2017). The spectrum of colonial experiences that different Indigenous peoples have endured have left varying degrees of colonialism-related stress in those groups, contributing to higher rates of suicidal behaviour in subsequent generations.
Adverse childhood events and increased risk for suicide
Adverse childhood experiences are strongly linked to later suicidal behaviour in the general population, particularly among teenagers and young adults. The Adverse Childhood Experiences (ACEs) Study in the United States examined abuse (emotional, physical and sexual) during childhood, witnessing domestic violence, parental separation or divorce, and living with substance-abusing, mentally ill, or criminal household members (Anda et al., 2006; Stevens, 2012). The ACEs study revealed that 80% of suicide attempts during childhood and adolescence are attributable to ACEs – as are a majority of suicide attempts among adults. The impact of ACEs on suicidal behaviour over the life course is “of an order of magnitude rarely observed in epidemiology and public health data” (Dube et al., 2001).
Higher rates of early childhood adversity put people at greater risk for stress and negative health outcomes – including psychological distress, suicidal thoughts and suicide attempts – over their entire life course. Further, people with early onset mental health disorders are at risk for chronic problems throughout their lives. Similar findings have resulted from the Christchurch Human Development Study in New Zealand (Fergusson and Lynskey 1995). In line with this research, the suicide follow-back study conducted in Nunavut found that those who died by suicide were significantly more likely to have experienced childhood abuse, compared with age-matched controls (Chachamovich et al., 2014).
We have limited data on whether Indigenous children are likely to suffer higher rates of early childhood adversity than non-Indigenous children, in large part because provincial and territorial governments in Canada do not collect data on early childhood adversity in the same manner that state governments in the U.S. do. In Alaska, for example, the state government recently published data showing that Alaska Native children are more likely to experience adverse childhood experiences than are non-Native children. We suspect that if similar data were collected in Canada, the differences in the rates of early childhood adversity between Indigenous and non-Indigenous children would be similar to (if not greater than) those in Alaska and New Zealand.
An indication of adversity is found in the data on Inuit preschool children from the Nunavut Child Health Study, which identified high rates of food insecurity and crowded housing, suggesting socioeconomic disadvantage (Egeland et al., 2010), while among adults interviewed in the Inuit Health Survey (2007-2008), 52% of women and 22% of men reported a history of severe sexual abuse during childhood. In contrast, a 1997 survey of adults in Ontario found that 11.1% of women and 3.1% of men reported a childhood history of severe sexual abuse (Macmillan et al., 1997). National data on reported child abuse and neglect also shows that across Canada the rate of substantiated child maltreatment investigations was four times higher in Aboriginal child investigations than non-Aboriginal child investigations (49.69 per 1,000 Aboriginal children versus 11.85 per 1,000 non-Aboriginal children; Canada, Public Health Agency, 2008). Critical analyses have highlighted the multiple factors contributing to this higher rate, including socioeconomic disadvantage, the misapplication of Western values to judge Indigenous parenting, and lack of access to intervention programs (Blackstock, Trocmé, Bennett, 2004; Trocmé, Knoke, Blackstock 2004). However, given the evidence that childhood adversity, including physical, emotional and sexual maltreatment and neglect, are linked to suicide behavior among youth, this is an area where public health policy, research, and interventions are urgently needed.
Suicide prevention and intervention targeted towards improving childhood development and decreasing adversity
There is a body of knowledge regarding evidence-informed interventions to treat early childhood adversity in the general population, but it is not known whether interventions that address early childhood adversity decrease the known link with later suicide behavior. There are very few intervention studies in Indigenous communities to address early childhood adversity, and none that we are aware of that look at outcomes relevant for suicide prevention. This is a critical area for research, intervention and evaluation.
The 2014 World Health Organization (WHO) report on suicide prevention does highlight the link between childhood adversity and later morbidity and mortality, including suicide. Conversely, protective factors (e.g., social connectedness) acquired in childhood may reduce later suicide risk. While effective upstream strategies exist, they remain largely unevaluated with regard to their impact on suicide and attempted suicide; however, they are theoretically valid and provide promising directions for future suicide prevention and evaluation. Examples of upstream strategies include:
- Early childhood home visits to provide education and screening by trained staff (e.g., nurses) to low-income expectant/new mothers.
- Early child development and parenting programs.
- Interventions to treat children and families who have experienced trauma and loss, including childhood maltreatment.
- Mentoring programmes to enhance connectedness between vulnerable young people and supportive, stable and nurturing adults.
- School-based skill-building programs to engage teachers/staff, students and parents in fostering social responsibility and social-emotional skills-building (e.g., coping, problem-solving skills, help-seeking).
There are significant challenges and ethical concerns with early childhood as a point of intervention in Indigenous communities. Communities that have experienced high rates of removal of children from homes may well be apprehensive about government strategies focused on children. There may be concerns that parents will be blamed for larger social factors, and that Indigenous parenting practices will be pathologized (see the undeniable arguments forwarded by Maxwell, 2014). More generally, there may be concerns that an approach that focuses on risk factors as much as on protective factors is too negative in tone, and not strength-based. One possible reply to this concern is that, in some Indigenous communities, risk factors are so numerous and strong that suicide prevention is unlikely to succeed without targeted efforts to reduce their intensity. For example, a suicide prevention strategy limited to investing in youth in high school may be too late in development to ameliorate risk and build resilience.
Suicide prevention strategies developed by Indigenous peoples can play an important role in orienting public health and community development policy towards meeting the developmental needs of children. Taking action on early childhood has been a central pillar of both the 2010 Nunavut Suicide Prevention Strategy (NSPS) and the 2016 National Inuit Suicide Prevention Strategy (NISPS). The NSPS presents a compelling hypothesis regarding the roots of the level of social suffering seen in Nunavut communities today – and the role that early childhood adversity plays in mediating colonialism into suicidal behaviour. One of the commitments contained in the NSPS is that “The [Government of Nunavut] will invest in the next generation by fostering opportunities for healthy development in early childhood.”
Another Indigenous-specific suicide prevention strategy placing emphasis on “upstream” approaches is Australia’s National Aboriginal and Torres Strait Islander Suicide Prevention Strategy. It cites the growing evidence that “in order to reduce rates of suicidal behaviour and suicide over the longer term, measures should also be put in place to address the developmental precursors of suicide and suicidal behaviour.” It identifies the need for “a shift towards collaborative, cross-sectoral approaches to treatment and prevention to treat both current risk and its developmental precursors” (Australia, Department of Health and Ageing, 2013).
The growing attention being paid to the link between early childhood adversity and later suicide is urgent and overdue. If we want to decrease the rates of suicidal behaviour among youth, particularly Indigenous youth, then we need to better understand the full range of risk and protective factors. We have further hypothesized a connection between colonization and increased childhood adversity. We must appreciate relevant early life risk and protective factors, and find novel and efficacious ways of intervening. We need to address upstream risk factors by promoting optimal early childhood development and reducing socioeconomic and early life disadvantage. Interventions should be developed by and in collaboration with Indigenous communities. The future of Indigenous communities will reflect the research undertaken and the investments made in the coming years. ◉
Allison Crawford is Director of the Northern Psychiatric Outreach Program at the Center for Addiction and Mental Health, and Assistant Professor in the Department of Psychiatry, University of Toronto.
Jack Hicks is Adjunct Professor of Community Health and Epidemiology, College of Medicine, University of Saskatchewan; and, Suicide Prevention Advisor, Federation of Sovereign Indigenous Nations.
1 Parenting risk factors for childhood maltreatment have been identified in the general population in the Canadian Incidence Study of Reported Child Abuse and Neglect, 2008. The multifaceted factors that lead to the overrepresentation of child maltreatment among Indigenous children have also been explored (Trocmé, Knoke, Blackstock, 2004).
2 Upstream interventions and strategies focus on improving fundamental social and economic structures to decrease barriers and improve supports that allow people to achieve their full health potential. Downstream interventions and strategies focus on providing equitable access to care and services to mitigate the negative impacts of disadvantage on health. See: http://nccdh.ca/glossary/entry/upstream-downstream
3 A recent review of such interventions is provided by Lechner, Cavanaugh, Blyler, 2016.
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