Structural Adversity and Suicide: The Mental Health Field is Asking the Wrong Questions

A new study published in Suicide and Life-Threatening Behavior finds that structural adversity—such as food insecurity, housing instability, and parental incarceration—is strongly linked to suicide attempts, suicidal thoughts, and repeated self-injury among racially and ethnically minoritized youth. Led by Patricia I. Jewett of the University of Minnesota, the research shows that youth experiencing two or more of these structural adverse childhood experiences (ACEs) face a particularly high risk.

These findings challenge dominant psychiatric models that attribute suicide risk primarily to individual mental illness. Instead, the study underscores how systemic inequality, economic precarity, and state violence shape psychological suffering. The authors write:

“We found that SI, SA, and repetitive NSSI were strongly associated with having experienced structural ACEs (parental incarceration, housing instability, food insecurity, and recent foster care involvement). SI, SA, and repetitive NSSI rates were alarmingly high across all ethnoracially minoritized groups when two or more of these structural ACEs were reported, and were highest among Black Latino, AIAN, NHPI, and multiracial youth. Further, these same ethnoracially minoritized groups reported the highest structural ACE exposure levels.”

The study analyzed data from the Minnesota Student Survey, a statewide school-based survey that collects information on youth risk behaviors, mental health, and family circumstances. Researchers examined data from 93,573 students across three survey years (2013, 2016, and 2019), focusing on questions related to suicidal ideation (SI), suicide attempts (SA), and repeated nonsuicidal self-injury (NSSI).

They found that students who had experienced structural adversity had significantly higher rates of suicidal thoughts and behaviors. When young people faced multiple structural ACEs, their risk increased dramatically.

The study also highlighted significant racial and ethnic disparities. Black Latino, American Indian/Alaskan Native (AIAN), Native Hawaiian/Pacific Islander (NHPI), and multiracial youth reported the highest rates of structural adversity and, in turn, the highest levels of suicidal behavior and self-injury.

Rather than treating suicide and self-injury as personal medical conditions, the study suggests that addressing food security, housing access, and mass incarceration would be far more effective at reducing suicide risk. While mainstream mental health interventions focus on therapy and medication, they cannot provide the basic necessities needed for young people to survive and thrive.

The current research aimed to examine connections between structural ACEs and SA, SI, and NSSI in minority youth. The authors used data from the 2013, 2016, and 2019 Minnesota Student Survey. This survey is administered to 5th, 8th, 9th, and 11th graders in Minnesota public schools once every three years. The survey asks questions about risk behaviors (like alcohol use and suicidal behavior), violence, sexual activity, and connections to family, school, and community.

To be included in the current research, survey respondents had to provide data on SA, SI, NSSI, and race/ethnicity. 5th grade students were excluded from the analysis because they were not asked about SA, SI, or NSSI. Twenty-six thousand nine hundred seven students from the 2013 survey, 34,973 from 2016, and 31,693 from 2019 were included in the present analysis. In total, the authors analyzed 93,573 survey responses.

Measures

SI was measured by asking students “Have you ever seriously considered attempting suicide?” If students responded yes, they were further asked if they had these thoughts in the past year. SA was measured by asking “Have you ever actually attempted suicide?” Students that responded yes were further asked if they had attempted suicide in the past 12 months. Repeated NSSI was measured by asking “During the last 12 months, how many times did you do something to purposely hurt or injure yourself without wanting to die, such as cutting, burning, or bruising yourself on purpose?” Values of 10 or higher were counted as repeated NSSI.

Housing instability was measured by asking “During the past 12 months, have you stayed in a shelter, somewhere not intended as a place to live, or someone else’s home because you had no other place to stay?” Parental incarceration was measured by asking “Have any of your parents or guardians ever been in jail or prison?” Food insecurity was measured by asking “During the last 30 days, have you had to skip meals because your family did not have enough money to buy food?” In the 2013 and 2016 surveys, foster care involvement was measured by asking “Which adults do you live with?” In the 2019 survey this question was changed to “Have you ever been in foster care?” Students answering yes to this question were further asked if they had been in foster care in the past 12 months.

The authors corrected the data for several variables outside of structural ACEs that could have contributed to SA, SI, and NSSI. These variables included household ACEs (e.g. verbal abuse, physical abuse, sexual abuse, domestic violence, and drug abuse in the household), sex, grade, treatment for mental health issues, and perceived safety of the environment. The authors also wanted to avoid grouping minorities together in such a way that vulnerabilities of some subgroups may be hidden. This led to nine racial/ethnic groupings: Hmong, Asian, Latino, Black Latino, Somali, Black/AA, Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, and multiracial (three or more races).

Structural ACEs by Race/Ethnicity

The most common structural ACE for every racial/ethnic group except Somali was parental incarceration. Black Latinos had the highest rates of parental incarceration at 42.1% and Somalis the lowest as 6.7%. Overall parental incarceration rates were relatively high in the current research:

• Latino – 24.7%
• Black Latino – 42.1%
• Black/African American – 30.3%
• Somali – 6.7%
• Multiracial – 35.9%
• Hmong – 14.5%
• Asian – 9.3%
• Native Hawaiian/Pacific Islander – 22.5%
• American Indian/Alaskan Native – 40.6%

The most common structural ACE for Somalis was having ever been homeless at 7.5%. Multiracial students reported the highest rates of having ever been homeless at 12% and Asians the lowest at 5.8%. Homelessness was the second most common structural ACE for minority students behind parental incarceration:

• Latino – 7.4%
• Black Latino – 10.6%
• Black/African American – 7.9%
• Somali – 7.5%
• Multiracial – 12%
• Hmong – 11%
• Asian – 5.8%
• Native Hawaiian/Pacific Islander – 9.9%
• American Indian/Alaskan Native – 10.2%

Multiracial students reported the highest rates of food insecurity within the past 30 days at 11.6% and Asians the lowest at 3.8%. Food insecurity was the third most common structural ACE reported by minority students in the current research:

• Latino – 6.8%
• Black Latino – 10%
• Black/African American – 8%
• Somali – 6%
• Multiracial – 11.6%
• Hmong – 9.2%
• Asian – 3.8%
• Native Hawaiian/Pacific Islander – 9.1%
• American Indian/Alaskan Native – 9.1%

Black Latinos reported the highest rates of foster care involvement at 2.7% and Hmong the lowest at 0.2%. Foster care involvement was the least common ACE reported by every racial/ethnic group in the current analysis:

• Latino – 0.6%
• Black Latino – 2.7%
• Black/African American – 1.1%
• Somali – 0.9%
• Multiracial – 2%
• Hmong – 0.2%
• Asian – 0.4%
• Native Hawaiian/Pacific Islander – 1%
• American Indian/Alaskan Native – 2.3%

Parental Incarceration

Parental incarceration was associated with greater risk of suicidal ideation and suicide attempts in all ethnic/racial groups in the model adjusted to account for other possible causes of SI (e.g. neglect, abuse, etc). Parental incarceration was associated with increased risk of repeated NSSI in all groups except Native Hawaiian/Pacific Islander and multiracial in the adjusted model.

The increased risk of SI ranged from 7% in Hmong students to 108% in Somali students. The increased risk of SA ranged from 2% in Asian students to 95% in Native Hawaiian/Pacific Islander students. The increased risk of repeated NSSI ranged from 11% in American Indian/Alaskan Native students to 186% in Somali and Hmong students.

Housing Instability

Housing instability was associated with greater risk of suicidal ideation and suicide attempts in all ethnic/racial groups in the adjusted model. Housing instability was associated with an increased risk of repeated NSSI in all groups except the multiracial group in the adjusted model.

The increased risk of SI ranged from 16% in Asian students to 91% in Black Latino students. The increased risk of SA ranged from 38% in Black Latino students to 189% in Somali students. The increased risk of repeated NSSI ranged from 3% in Native Hawaiian/Pacific Islander students to 98% in Somali and Hmong students.

Food Insecurity

Food insecurity was associated with greater risk of suicidal ideation in all ethnic/racial groups except Black Latino, Native Hawaiian/Pacific Islander, and multiracial in the adjusted model. Food insecurity was associated with increased risk of suicide attempt in all groups except multiracial in the adjusted model. All ethnic/racial groups exposed to food insecurity saw increased odds of repeated NSSI.

The increased risk of SI ranged from 13% in Latino students to 62% in Hmong students. The increased risk of SA ranged from 11% in Native Hawaiian/Pacific Islander students to 114% in Somali students. The increased risk of repeated NSSI ranged from 6% in multiracial students to 222% in Somali and Hmong students.

Foster Care Involvement

Foster care involvement was associated with greater risk of suicidal ideation in all ethnic/racial groups except Black Latino, Native Hawaiian/Pacific Islander, and Somali in the adjusted model. Foster care involvement was associated with increased risk of suicide attempt in all groups except Native Hawaiian/Pacific Islander and multiracial in the adjusted model. All ethnic/racial groups exposed to food insecurity saw increased odds of repeated NSSI except Black/African American, Asian, and American Indian/Alaskan Native.

The increased risk of SI ranged from 1% in Black/African American students to 180% in Hmong students. The increased risk of SA ranged from 26% in Black Latino students to 298% in Asian students. The increased risk of repeated NSSI ranged from 16% in Latino students to 114% in Black Latino students.

Multiple Structural ACEs

The link between structural ACEs to SI, SA, and repeated NSSI was much stronger for students with two or more structural ACEs. Rates of SI, SA, and repeated NSSI commonly doubled and in some cases quadrupled when comparing students with one structural ACE to those with two or more. The authors also found that rates of SI, SA, and repeated NSSI were higher for females compared to males in every ethnic/racial group:

• SI – 1 ACE – Female (16.4% – 32.7%) — Male (6.5% – 15%)
• SI – 2+ ACEs – Female (30.7% – 49.5%) — Male (19.8% – 32.4%)
• SA – 1 ACE – Female (5.7% – 18%) — Male (1.8% – 8%)
• SA – 2+ ACEs – Female (12.6% – 34.6%) — Male (9.8% – 22.2%)
• NSSI – 1 ACE – Female (3.5% – 11.9%) — Male (2.1% – 5.9%)
• NSSI – 2+ ACEs – Female (6.5% – 29%) — Male (8.4% – 20.2%)

Limitations

The authors acknowledge several limitations to the current research. The data collection method did not report precisely when students were exposed to structural ACEs or when they had SI, SA, and repeated NSSI. This means in some cases, suicidal thoughts, behaviors, and self-injury could have come before exposure to structural ACEs. The self-report nature of the survey means the data was subject to problems with memory. The data was also subject to social desirability bias, when participants reported what was most socially desirable rather than what was true.

SI, SA, and NSSI data were collected using a single question. This limits validity and reliability compared to validated measurement tools. The survey only asked about students living in foster care in the past year. This means students who had lived in foster care more than a year ago were not counted in the ‘exposed to foster care’ category. The adjusted model corrected for students receiving mental health treatment, but was not able to correct for any untreated mental health issues. Additionally, the data was collected from public schools in the US state of Minnesota, limiting generalizability to other populations. The authors conclude:

“Our findings confirm that overarching ethnoracial categorizations commonly used in public health research hide subgroup variability in youth SI, SA,and repetitive NSSI rates. Addressing structural ACEs is possible, for example, through policies, without having to intervene at the individual or family level and may reduce youth SI, SA, and repetitive NSSI. This would especially benefit ethnoracially minoritized youth who experience structural ACEs disproportionately often.”

Past research has found that children who experience housing instability report worse physical and mental health later in life. Food insecurity in young adults has been linked to poor mental health. Racial discrimination has also been linked to poor mental health in young people. Suicide rates among black youth have increased compared to other groups in recent years.

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Jewett, P. I., Taliaferro, L. A., Borowsky, I. W., Mathiason, M. A., & Areba, E. M. (2024). Structural adverse childhood experiences associated with suicidal ideation, suicide attempts, and repetitive nonsuicidal self‐injury among racially and ethnically minoritized youth. Suicide and Life-Threatening Behavior. (Link)