Keywords

International migration is a worldwide phenomenon, and the United States (US) is the main country of destination since the 1970s (United Nations, 2020). Indeed, the foreign-born population has more than quadrupled since the 1970s, with an estimated 51 million foreign-born migrants in the US in 2010 (United Nations, Department of Economic and Social Affairs, 2019). The majority of foreign-born individuals in the US largely originate from the global south (i.e., Latin America and Asia; United Nations, 2020), and typically hold collectivist-based beliefs that emphasize a focus on the well-being of the family, clan, nation, or religion. In contrast, the US is one of the most highly individualistic countries, placing a great deal of emphasis on autonomy and self-sufficiency (Hofstede, 2019). As a result of the increasing flow of international migrants coupled by these cultural divides, scholarly interest in acculturation has substantially increased over the last few decades (Schwartz et al., 2010a).

Acculturation refers to the psychological change that occurs as a result of contact between two cultural groups (Berry, 1980). Although this may occur across a variety of contexts (e.g., vacation, international students), the majority of the acculturation literature has focused on international migration (Schwartz et al., 2010a). When applied to immigrants, acculturation specifically focuses on the extent to which an individual retains their cultural heritage and/or adopts the new host culture (Berry, 1980). Indeed, immigrants need to be sufficiently facile in the language and customs of the host society to make friends, find work, and otherwise “fit in” with members of the dominant culture (Schwartz et al., 2010a). It should be noted however that acculturation not only affects foreign-born individuals but also impacts US-born individuals from immigrant families who grow up in an immigrant home and are exposed to multiple cultural influences (Berry, 2006; Portes & Rumbaut, 2014; Rudmin, 2010). For this reason, throughout this chapter, we use the term “immigrants” to refer to both first-generation (born abroad) and second-generation (born in the destination society but raised by at least one foreign-born parent) individuals.

Over the last few decades, there has been a growing interest in the relation between acculturation and a wide range of positive and negative indicators of psychosocial functioning (for a comprehensive review, see Schwartz & Unger, 2017). This chapter serves as a review of contemporary models of acculturation and the role of acculturation in suicide-related risk among adolescents from immigrant families. Our focus on adolescence is driven by our motivation to understand the role of acculturation in the early stages of vulnerability and the acknowledgment that the links between acculturation and suicide-related risk among adults are likely to be confounded by situational (i.e., length of residency) and contextual (i.e., economic) factors (Meca et al., 2019). In addition, this chapter focuses on identifying potential explanatory mechanisms behind the association between acculturation and suicide-related risk and on identifying conceptual and methodological limitations that have been prominent in the field of acculturation. Finally, we conclude with clinical implications and discuss the benefits of integrating acculturation into suicide prevention strategies to reduce suicide-related risk among immigrant and racial/ethnic minority adolescents.

Contemporary Models of Acculturation

Traditional conceptualizations of acculturation have largely drawn on what is viewed as a “unidimensional” model of acculturation (Schwartz et al., 2010a). Within this framework, acculturation is conceptualized along a single continuum ranging from “completely unacculturated” to “completely acculturated.” This framework is not only problematic because it assumes “successful” acculturation involves loss of ones’ cultural heritage (Gordon, 1964), but also because there is no “middle” ground where the individual can reconcile their heritage culture when cast in the context of the host culture. In recent decades, more contemporary views of acculturation have increasingly drawn on a bidimensional framework (Berry et al., 2006), which views host-culture acquisition and heritage culture retention as independent dimensions. Within this bidimensional conceptualization, acquiring the culture of the host society does not imply that an individual will discard their own cultural heritage. Indeed, as proposed by Berry (1997), immigrants may take on one of four acculturation approaches: marginalization (rejects/discards host and heritage culture), assimilation (acquires host culture and discards heritage culture), separation (rejects host culture and retains heritage culture), and integration (acquires host and retains heritage culture). Integration, or biculturalism ,Footnote 1 allows youth to judiciously straddle a fence between two cultural worlds, where different cultural streams will be expressed depending on the situation at hand (Benet-Martínez & Haritatos, 2005).

More recently, several scholars have extended Berry’s (1980) original conceptualization by suggesting that acculturation is not only bidimensional (i.e., heritage culture versus host culture), but also varies across at least three relevant components: practices, identifications, and values (Castillo & Caver, 2009; Schwartz et al., 2010a). The vast majority of studies and measures have focused on cultural practices , which refer to behaviors such as language use, choice of friends, and cultural customs and traditions (e.g., Stephenson, 2000). Extending beyond cultural practices, contemporary conceptualizations of acculturation emphasize the importance of cultural identification , or the strength of commitment and attachment a person feels toward their cultural heritage and/or the host culture (Meca et al., 2020a). Finally, cultural values represent belief systems associated with a specific context or group. Research focused on cultural values has focused on broad cross-ethnic group values such as collectivism and individualism and/or group-specific values such as familism (strength of family ties; Galanti, 2003) and filial piety (bestowing honor upon one’s family; Yeh & Bedford, 2004). Together, acculturation can be conceptualized across six facets: host practices, heritage practices, host identification, and heritage identification, heritage values, and host values (Schwartz et al., 2010a).

Acculturation and Suicide

In the subsequent section, we review the literature examining the links between acculturation and suicide-related risk across the prevailing conceptualizations. We begin with a review of studies that have drawn on demographic proxies of acculturation (i.e., nativity and years in the US) and proceed to review studies that have utilized a unidimensional conceptualization across cultural practices, identification, and values. Given the dearth of findings, we also include studies with adult populations or studies that examine the association between acculturation and internalizing symptoms, namely depression and hopelessness—well-known predictors of suicidal behavior (Cha et al., 2018).

Demographic Proxies

In one of the few studies to examine youth suicide trends by immigration status in the US, Sorenson and Shen (1996) compared suicide death rates between foreign-born and US-born youth, ages 15–34 years, between 1970 and 1992 in California. They found that the relation between immigration status and suicide death varied across racial/ethnic group. Specifically, non-HispanicFootnote 2 White youth born outside of the US were at greater risk of dying by suicide compared to non-Hispanic White youth born in the US. The authors thus concluded that relocation stress and limited social capital contributed to this elevated risk among immigrant youth. This was not consistent with their observations among Hispanic youth, however, as Hispanic youth born outside of the US were at lower risk of dying by suicide compared to Hispanic US-born youth. No significant immigrant group differences were observed in Black and Asian youth, though this may have been due to low cases. Further, the immigrant group differences in youth suicide rates within non-Hispanic White and within Hispanic groups decreased over time from 1970 to 1992.

In contrast , in a larger sample of suicide deaths among Hispanic individuals from various metropolitan areas across the US, Wadsworth and Kubrin (2007) found that, overall, immigrants had higher rates of suicide than US-born Hispanics individuals, but not among immigrants who lived in ethnic enclaves. This finding highlights the critical influence of contextual factors in the relation between acculturation and suicide. For instance, areas with a larger Cuban immigrant population (relative to Mexican immigrants) had higher suicide rates, whereas areas with larger immigrant populations born in Puerto Rico or Dominican Republic (relative to Mexican-born) had lower suicide rates. Thus, the migration experience does not entirely explain the differences in suicide between immigrant and US-born people, suggesting acculturative processes may play a more important role in suicide risk.

As observed in some of these early studies on suicide deaths, similar patterns indicating greater suicide-related risk in US-born (versus immigrant) youth were also detected in nonfatal manifestations of suicide (i.e., suicide ideation, suicide attempts) in Hispanic (Peña et al., 2008), Asian (Wong & Maffini, 2011), and Black adolescents (Joe et al., 2009). For instance, using a nationally representative sample of Hispanic adolescents in the US, Peña et al. (2008) found that immigrant Hispanic teens had lower rates of suicide ideation and attempts than US-born Hispanic teens with immigrant parents, who had lower rates compared to US-born Hispanic teens with US-born parents. The graded increase in suicide ideation and attempts with each subsequent generation supported earlier claims that acculturation may impact youth suicide-related risk.

To further explore this line of inquiry , researchers used various proxies for acculturation beyond immigration status, such as English language acquisition or Spanish language retention, age of migration, and length of residency in the US, to assess greater exposure to the dominant US culture. Using this approach, albeit in adults, findings have overwhelmingly indicated that greater exposure to US culture is associated with elevated suicide-related risk (Borges et al., 2012; Brown et al., 2015; Duldulao et al., 2009; Fortuna et al., 2007; Pérez-Rodriguez et al., 2014). This is in contrast, however, to findings from an earlier study of Mexican American adolescents presenting to an inpatient clinic, which indicated that frequency of lifetime suicide attempts was negatively associated with length of residency in the US (Ng, 1996). As expected considering the findings from suicide deaths, acculturation may better explain the risk for suicidal behaviors than migration.

Despite the nearly exclusive focus on adults, these studies served as important steps toward understanding the impact of acculturation on suicide-related risk. They have prompted further inquiries to identify factors that protect against suicide-related risk in Hispanic immigrant youth and increase risk in US-born Hispanic youth. It is important to note however that the utilization of demographic proxies masks important variability in the degree to which individuals retain their cultural heritage and/or adopt the new host culture.

Cultural Practices

Moving beyond demographic proxies , researchers have also utilized a unidimensional assessment of acculturation via cultural practices such as language use, selection of friends, and engagement in cultural customs and traditions. For example, in a school-based sample of Hispanic adolescents in California (Hovey & King, 1996), a clinical sample of largely Hispanic adolescents presenting at an Emergency Department in a hospital in NYC (Ortin et al., 2018), and a community sample of Hispanic adolescent girls also in NYC (Zayas et al., 2009), researchers found that greater level of acculturation, assessed as greater acquisition of US practices, was not associated with suicide ideation or attempts. Similarly, in a school-based group of Korean high school students with varying migration backgrounds (i.e., permanent migration from Korea to US, temporary migration as Korean international student), Cho and Haslam (2010) found no direct association between suicide ideation and acculturation assessed as language use, friendships, behaviors, and attitudes. However, in a school-based sample of Mexican American adolescents in Texas, Rasmussen et al. (1997) found that increased acculturation was not directly associated with suicide ideation, though the association was significant in the presence of increased depressive symptoms and decreased self-esteem. In sum, a substantive number of studies have indicated no significant association between acquisition of US practices and suicide .

That being said , other studies have reported a negative association between acculturation and suicide-related risk. For instance, in an ethnically diverse (predominantly Mexican American) group of middle school students in Texas, Olvera (2001) found that lower level of acculturation, assessed via language practices, was associated with suicide ideation. This finding, however, was trending and did not reach statistical significance. When they assessed acculturation by generation status, they found that children whose mothers were born in the US, compared to mothers born outside of the US, were at lower risk for suicide ideation. Similarly, in a clinical sample of Asian American children and adolescents from an outpatient clinic in California, Lau et al. (2002) reported that high level of acculturation (assessed as language practices along with demographic proxies such as length of residency in the US) was associated with lower risk of suicidal behaviors, though ethnic and SES differences were found in acculturation levels, which may confound these findings. Taken together, findings have produced mixed results, with some studies showing that increased engagement in US cultural practices was not associated with suicide ideation or suicide attempts in ethnic and racial minority youth (Cho & Haslam, 2010; Hovey & King, 1996; Ortin et al., 2018; Rasmussen et al., 1997; Zayas et al., 2009), whereas others indicated a negative association (Lau et al., 2002; Olvera, 2001).

Cultural Identification

Unidimensional studies focused on cultural identification have largely drawn on an entirely distinct body of research rooted in ethnic and racial identity (ERI) development. Broadly, ERI is a multidimensional psychological construct that reflects individuals’ beliefs and attitudes about their ethnic or racial group membership, as well as the process by which these beliefs and attitudes develop over time (Umaña-Taylor et al., 2014). Many studies on ERI have largely drawn on Phinney’s (1989) developmental perspective that proposed three key dimensions: exploration or search (i.e., the process by which one considers what it means to belong to a cultural group), commitment (i.e., an understanding of what ones’ cultural group membership means to them), and affirmation (i.e., positive attitudes toward the social groups to which they belong).

Research examining the links between ERI and suicide-related risk in youth has been extremely limited, has largely ignored the multidimensionality of ERI, and has produced mixed findings. For example, Polanco-Roman and Miranda (2013) found ERI was negatively associated with hopelessness, depressive symptoms, and suicide ideation within an ethnically and racially diverse sample of emerging adults from a diverse public college in a Northeastern metropolitan area of the US. Most recently, Cheref et al. (2019) found ERI was negatively associated with suicide ideation in an ethnically and racially diverse sample of emerging adults and mitigated the potential role of discrimination and anxiety, but only for Hispanic emerging adults. In contrast to these studies, O’Donnell et al. (2004) found ERI was not related to suicide ideation in a cross-sectional ethnically diverse sample. Similarly, ERI was not significantly associated with suicidal behaviors among Latina undergraduate students attending an urban public college in New York City (Chesin & Jeglic, 2012). As a whole, the findings note an inconsistent association between ERI and suicide, potentially due to the utilization of composite measures of ERI.

Seeking to expand beyond composite measures of ERI, Chang et al. (2017) found ERI commitmentFootnote 3 was negatively associated with hopelessness but not suicidal behaviors in a sample of Latinx college students attending a large public college on the East Coast. More recently, Forster et al. (2019) examined the links between ERI exploration and belonging (i.e., composite of affirmation and commitment)Footnote 4 on both suicide ideation and attempt among a large longitudinal sample of Hispanic youth. Although ERI exploration was not significantly associated with either suicide ideation or attempt, ERI belonging was negatively associated with suicide attempts and attenuated the effect of parental incarceration on suicide ideation and attempt. Finally, in a sample of Hispanic/Latinx college students, Oakey-Frost et al. (2019) found ethnic ERI belonging (i.e., composite of affirmation and commitment) was negatively and directly associated with suicide-related risk (i.e., composite of history of suicide ideation and attempts). As a whole, these findings seem to indicate that the establishment of a commitment and sense of belonging to one’s ethnic and racial group is protective against suicide.

Additionally, studies have also found ERI processes are significantly associated with symptoms of depression. For example, Juang et al. (2006) found ERI was associated with lower symptoms of depression among Asian American college students. Similarly, Tummala-Narra (2015) found ERI was associated with fewer depressive symptoms among ethnic and racial minority high school students. In contrast, Hovey et al. (2006) found no significant association between ERI and symptoms of depression among Korean college students. Looking beyond composite measures, Umaña-Taylor and Updegraff (2007) found that ERI exploration and commitment were negatively associated with symptoms of depression vis-à-vis its impact on self-esteem in a sample of Latinx adolescents. Mahalingam et al. (2008) also found a negative association between ERI affirmation and symptoms of depression among Asian American youth.

Moreover, within the adult literature, studies have found ERI to be negatively associated with suicide ideation and attempts in Latinx and Asian samples (Cheng et al., 2010; Perez-Rodriguez et al., 2014). For example, utilizing data collected as part of the National Epidemiologic Survey of Alcohol and Related Conditions, Perez-Rodriguez et al. (2014) found that ERI was negatively associated with lifetime risk for suicide ideation and attempts among Hispanic adults. Similarly, utilizing data from the National Latino and Asian American Study (NLAAS), Cheng et al. (2010) found a high ERI was associated with lower rates of suicide attempts among Asian American adults .

Like ERI, US identity represents a multidimensional psychological construct that reflects individuals’ beliefs and attitudes about their national group membership, as well as the process by which these beliefs and attitudes develop over time (Meca et al., 2020a). Moreover, US identity research has similarly drawn on Phinney’s ERI model proposing three key US identity processes: exploration (i.e., process by which one considers what it means to be American), commitment (i.e., understanding of what being American means), and affirmation (i.e., whether an individual feels positively or negatively about their national group membership). In our review, no study to date has examined the link between US identity and suicide-related risk. However, Kiang and Witkov (2018) found US identity was negatively associated with symptoms of depression, a strong predictor of suicide-related risk, among Asian American adolescents.

Cultural Values

Studies utilizing a unidimensional conceptualization of acculturation as assessed by cultural values have been fairly limited. In our review, solely four studies have examined the links between cultural values and suicide (Baumann et al., 2010; Kuhlberg et al., 2010; Peña et al., 2011; Zayas et al., 2009). All of these studies have focused on familism, which encompasses a cultural value in which individuals place a greater emphasis on the family unit in terms of respect, support, obligation, and reference (Calzada et al., 2012). Although studies have found that familismo is not unique or group-specific to Hispanic/Latinx individuals (Keller et al., 2006; Schwartz et al., 2010b), it has been characterized as a central tenet of Latinx culture (Zinn, 1982). Consistently, all four of these studies were conducted with Hispanic/Latinx youth in the New York City area.

Zayas et al. (2009) found no significant differences in familistic attitudes between adolescent Latinas who attempted suicide and those who did not. In contrast, Baumann et al. (2010) found familism was positively related to mutuality (i.e., how attuned adolescents were with their mothers) and negatively related to externalizing behaviors, which in turn, predicted history of a suicide attempt. Similarly, Peña et al. (2011) found that familism was associated with a greater likelihood for Latinas to be in a tight-knit family, which was negatively associated with history of a suicide attempt, compared to being intermediate- and loose-knit families. At the same time, whereas Kuhlberg et al. (2010) found familism was negatively and indirectly associated with suicide attempt vis-à-vis parent-adolescent conflict, their findings also indicated an indirect positive effect through internalizing symptoms .

Summarizing these findings in a meta-analysis, Valdivieso-Mora et al. (2016) found a relatively small effect size between familism and suicide, depression, and internalizing behaviors. More recently, in a large longitudinal study of Latinx youth in Southern California, Lorenzo-Blanco et al. (2012) found that familism was negatively associated with symptoms of depression vis-à-vis its impact on family conflict and family cohesion. Drawing on a multidimensional conceptualization, Corona et al. (2017) found that familism support (i.e., a desire to maintain close relationships) was significantly and inversely associated with symptoms of depression, whereas familism obligation (i.e., providing tangible support to family members) was significantly and positively associated with psychological stress but not symptoms of depression among Latinx college students in the Southeast. Finally, most recently, Piña-Watson et al. (2019) found that familism was associated with lower symptoms of depression among adolescents of Mexican descent in South Texas. Taken together, these findings indicate that adherence to heritage cultural values such as familism is protective against suicide for Latinx youth. However, although Hovey et al. (2006) did find that greater endorsement of heritage cultural value (i.e., as indicated by the Asian Value Scale; Kim et al., 1999) was associated with increased state anxiety, trait anxiety, and symptoms of depression, we could not find any study examining the links between filial piety (bestowing honor upon one’s family; Yeh & Bedford, 2004), a cultural value group-specific to several Asian countries, and suicide-related risk .

Findings from Studies Employing a Bidimensional Perspective

As a whole, findings utilizing demographic proxies and unidimensional conceptualization of cultural practices, identification, and values have produced mixed results. The discrepancy may be due to an overly simplistic approach to acculturation that obscures important elements of the acculturative process. Toward this end, we now turn our attention to the handful of studies that have utilized a bidimensional conceptualization in exploring the associations between acculturation and suicide-related risk.

Cultural Practices

In terms of cultural practices , our review indicated solely one study that utilized a bidimensional perspective toward understanding links between acculturation and suicide. Specifically, Zayas et al. (2009) compared Latina adolescents who attempted suicide and those who did not to find no significant differences in either heritage or host cultural practices. However, it should be noted that several bidimensional studies have looked at the association between cultural practices and symptoms of depression. For example, Smokowski et al. (2007) found heritage cultural practices were positively associated with internalizing symptoms (i.e., anxiety and depression) in a community sample of first-generation Latinx adolescents. In contrast, utilizing data from the Latino Acculturation and Health Project, Smokowski et al. (2009) found that heritage cultural practices negatively predicted hopelessness a year later. Furthermore, Smokowski et al. (2010) found that US cultural practices were negatively associated with internalizing symptoms in a sample of Latinx adolescents in North Carolina and Arizona. Most recently, Driscoll and Torres (2020) found heritage cultural practices, but not host cultural practices, were significantly and negatively associated with subsequent symptoms of depression through its impact on acculturative stress in a sample of Latinx college students. Despite these promising findings, García et al. (2014) found no significant associations between heritage or US cultural practices and symptoms of depression in a sample of Mexican American adolescents from a large immigrant enclave in the Midwest. As a whole, these findings point to contradictory associations between heritage and host cultural practices with depressive symptoms and prompt the necessity for future research to further explore these associations .

Cultural Identification

Although in our review, no bidimensional study examined the association between cultural identification and suicide-related risk, it is worth noting recent bidimensional studies have found important links between cultural identification and symptoms of depression. For example, Meca et al. (2017) found that US identity belonging (i.e., composite of affirmation and commitment) negatively predicted symptoms of depression six months later in a sample of recently immigrated Hispanic adolescents in Miami and Los Angeles. Similarly, in an ethnically and racially diverse sample of college students, Tikhonov et al. (2019) reported that US identity, but not ethnic identity, was negatively related to symptoms of depression. Looking beyond composite measures, Meca et al. (2020a) found both US and ethnic identity affirmation were the only identity processes negatively associated with symptoms of depression among a sample of Latinx college students. As a whole, the findings seem to indicate that the establishment of a sense of belonging to ones’ host culture seems to be particularly protective against internalizing symptoms. That being said, future research is clearly necessary to explore the associations between heritage and host identification with suicide .

Cultural Values

In our review, we could not find a single study exploring how the cultural values of both ones’ heritage and of the host culture influence suicide or symptoms of depression and other related constructs.

Summary Remarks

To summarize, whereas unidimensional models of cultural practices largely indicate no association between acculturation and suicide-related risk (Cho & Haslam, 2010; Hovey & King, 1996; Ortin et al., 2018; Rasmussen et al., 1997; Zayas et al., 2009), findings from cultural identification indicate heritage retention may be protective against suicide-related risk (Cheref et al., 2019; Forster et al., 2019; Polanco-Roman & Miranda, 2013) and risk factors (e.g., symptoms of depression; Juang et al., 2006; Mahalingam et al., 2008; Tummala-Narra, 2015; Umaña-Taylor & Updegraff, 2007). Similarly, although limited, findings seem to indicate familism is protective against suicide risk (Baumann et al., 2010; Peña et al., 2011; Valdivieso-Mora et al., 2016) and risk factors (Corona et al., 2017; Lorenzo-Blanco et al., 2012; Piña-Watson et al., 2019; Valdivieso-Mora et al., 2016). In contrast, studies from a bidimensional perspective looking at risk factors for suicide have indicated that heritage retention (Driscoll & Torres, 2020; Smokowski et al., 2009), US acquisition/retention (Meca et al., 2017; Smokowski et al., 2010; Tikhonov et al., 2019), and both heritage retention and US acquisition/retention (Meca et al., 2020a) are protective against symptoms of depression and internalizing problems.

Potential Mechanisms Underlying the Relationship between Acculturation and Suicide

Beyond these direct associations, several studies have identified indirect associations between acculturation and suicide-related risk, indicating potential mechanisms underlying this relation. In the subsequent section, we will focus on two key mechanisms: a) cultural stress and b) family functioning. Finally, we describe contemporary suicide models that lend themselves to understanding suicide-related risk through an acculturation framework.

Cultural Stress

Within the broader acculturation literature , several theoretical frameworks have proposed that it is the stress associated with the process of immigration and acculturation, versus migration or acculturation itself, that compromises mental health. Acculturation Strain Theory (Vega et al., 1993), Segmented Assimilation Theory (Portes & Zhou, 1993), Bicultural Stress Theory (Romero & Roberts, 2003), Stress, Coping, and Adaption Theory (Berry, 2006), and the integrative model (García Coll et al., 1996) have all emphasized the role various stressors associated with acculturation may have on health. The conceptualization of cultural stress has focused on a variety of different stressors, including ethnic and race discrimination (Carter et al., 2017), negative context of reception (Schwartz et al., 2014), acculturative stress (Vega et al., 1993), immigration-related and acculturation-gap stress (Cervantes et al., 2012), and bicultural stress (Romero & Van Campen, 2011).

There is growing evidence to suggest that ethnic and race discrimination may influence the well-being of ethnic and racial minority and immigrant youth (Benner et al., 2018), including suicide-related risk. Using cross-sectional data in a nationally representative sample of Black, Hispanic, and Asian adults in the US, researchers found that racial/ethnic discrimination was associated with suicidal thoughts and behaviors (Oh et al., 2018). Similar findings were also reported in a racially and ethnically diverse group of college students (Gomez et al., 2011), as well as Black and Latinx adolescents using prospective data (Assari et al., 2017; Madubata et al., 2018). Some studies, however, found no direct association between racial/ethnic discrimination and suicidal thoughts and behaviors in Latinx (Chesin & Jeglic, 2016) and Black college students Castle et al., 2011).

These mixed findings suggest that the association between ethnic and race discrimination and suicide-related risk may be more nuanced and indirect, potentially influenced by other mediating factors. Early studies have focused on ethnic and race discrimination as an interpersonal-level race-based stressor (i.e., overt displays of racial/ethnic discrimination in the form of discrete major events or as daily hassles). Recent research, however, indicates other forms of race-based stressors, such as microaggressions (i.e., covert displays of interpersonal discrimination; O'Keefe et al., 2014; Madubata et al., 2019) and institutional forms of discrimination (i.e., racial/ethnic biases in policies and practices), may similarly impact suicide-related risk (Wang et al., 2018).

Acculturative stress is another form of cultural stress characterized by a more broadly defined experience of navigating different cultural environments (Berry, 2006). Acculturative stress may involve not only novel encounters of ethnic and race discrimination, but also pressures to assimilate to the dominant culture, language and other culture-specific barriers, and intra-familial conflict arising from differing expectations. Though scarce, research shows that increases in acculturative stress are associated with increases in suicide ideation and attempts in racially and ethnically diverse groups of adolescents and young adults (Gomez et al., 2011; Hovey & King, 1996; Polanco-Roman & Miranda, 2013; Walker et al., 2008). That being said, some studies have reported no association (Cho & Haslam 2010; Chesin & Jeglic, 2016).

A few studies have also examined different cultural stressors together, with findings alluding to a potential additive effect, as each source of cultural stress may uniquely contribute to suicide-related risk. For instance, Gomez et al. (2011) examined cultural stress across various contexts (i.e., environmental, social, familial, attitudinal, discrimination) in a racially and ethnically diverse sample of young adults and reported that familial stress (i.e., stress resulting from intra-familial conflict) and discrimination stress were most strongly associated with a suicide attempt history. Meanwhile, in a sample of Mexican American adolescents, Piña-Watson et al. (2015) reported that acculturative stress in the context of family, but not discrimination or peers, was most strongly associated with suicide ideation.

Additionally, cultural stressors such as ethnic and race discrimination and acculturative stress may be more distal risk factors for suicidal thoughts and behaviors, and impact suicide-related risk through more proximal risk factors. Indeed, early findings have identified potential pathways through which ethnic and race discrimination may confer suicide-related risk, including cognitive factors such as hopelessness (Lane & Miranda, 2018; Polanco-Roman & Miranda, 2013), emotion dysregulation (Mayorga et al., 2018), and rumination (Cheref et al., 2015); interpersonal factors such as perceived burdensomeness (Hollingsworth et al., 2017), and psychiatric symptoms, including depression (Goodwill et al., 2019; O'Keefe et al., 2014; Polanco-Roman & Miranda, 2013; Walker et al., 2017), anxiety (Kwon & Han, 2019), and post-traumatic stress (Polanco-Roman et al., 2019).

Despite growing evidence to suggest cultural stress may impact suicide-related risk, this research has largely relied on cross-sectional data, adult samples, nearly exclusive focus on suicide ideation (versus attempts) as an outcome, and independently examined varied forms of cultural stress. Thus, more refined research from a developmental perspective with larger samples and longitudinal designs is warranted. This information would provide a better understanding of the mechanisms through which experiences of cultural stress such as ethnic and race discrimination and acculturative stress may impact suicide-related risk, particularly in ethnic and racial minority and immigrant adolescents .

Family Functioning and the Parent-Child Acculturation Gap

Although acculturation has typically been examined as an individual developmental process, it is important to note that both caregivers and adolescents are faced with the challenge of retaining their heritage culture and/or acquiring aspects of the dominant US culture (Berry, 1997; Schwartz et al., 2010a). However, whereas school attendance encourages adoption of US cultural practices, values, and norms (Padilla, 2006), immigrant parents are more likely to settle into ethnic enclaves where they can maintain their own cultural practices and adapt to US culture (Schwartz et al., 2006). As youth and parents further distance themselves in terms of the cultural orientations, there is a greater likelihood for dissonance that, if not addressed, may produce turmoil and conflict that compromises family functioning (Lau et al., 2005; Portes & Rumbaut, 2001; Szapocznik & Kurtines, 1993).

Consistently, several researchers have proposed that discrepancies between the adolescents’ and parents’ acculturation disrupt family functioning. For example, the acculturation discrepancy hypothesis (Szapocznik & Kurtines, 1993) posits that gaps in acculturation between parents and their adolescents may compromise family functioning (e.g., poor communication, lack of involvement). Similarly, Portes and Rumbaut’s Segmented Assimilation theory (1996) identified three patterns of acculturation rates between parents and children: consonant (i.e., both acculturate quickly), dissonant (i.e., youth acculturates more quickly than parents), and selective acculturation (i.e., pattern of assimilation where children maintain values related to their family’s culture of origin while also acculturating into select aspects of their US cultural context). It should be noted, consistent with a bidimensional and multicomponent conceptualization of acculturation, that discrepancies between children and their parents may emerge either in relation to heritage retention (acquisition in the case of second-generation immigrants) and US acquisition across practices, identification, and values.

Building on these broader theoretical frameworks , research focused on the relationship between acculturation and suicide-related risk has increasingly turned to examining the role that family functioning plays as a key mediator. Through a series of studies with a sample of Latina adolescents in New York, findings from Zayas and colleagues (Baumann et al., 2010; Kuhlberg et al., 2010; Zayas et al., 2009) support the acculturation gap theory. For example, although Zayas et al. (2009) found no significant differences in acculturation and familistic attitudes between Latina adolescents who attempted suicide and those who did not, mothers of those who attempted reported lower mutuality and communication. Subsequently, Kuhlberg et al. (2010) not only found parent-adolescent conflict indirectly predicted suicide attempt vis-à-vis self-esteem and internalizing behaviors, but familism or cultural value retention was negatively associated with parent-adolescent conflict. Further expanding on this line of inquiry, Baumann et al. (2010) found that gaps in familism (i.e., mothers scoring higher than their daughters on the scale) was positively associated with suicide attempts via its negative association with mother-daughter mutuality, which, in turn, was positively associated with internalizing and externalizing symptoms (i.e., familism gap - > mother-daughter mutuality - > internalizing and externalizing symptoms - > suicide attempt). Similarly, Cervantes et al. (2014) found that stress associated with gaps in acculturation (as measured by the Hispanic Stress Inventory) was positively associated with suicide ideation among Hispanic adolescent boys and with self-harm behavior among girls. In contrast, Ortin et al. (2018) found no direct links between acculturation gap and suicide ideation in a racially diverse group of adolescents presenting to an Emergency Department for suicide-related risk utilizing a unidimensional scale of cultural practices. However, they did find that emotion reactivity was more negatively associated with suicide ideation when acculturation gaps were greater, whereas hopelessness was more strongly associated with suicide ideation the smaller the gap.

Despite these preliminary studies , in our review, no study to date has examined the associations between parent-youth acculturation discrepancies and suicide-related risk utilizing a bidimensional conceptualization of acculturation. That being said, studies focused on symptoms of depression may provide important information for the field moving forward. For example, in a longitudinal study with Chinese American families in Northern California, Kim et al. (2009) found that discrepancies in parent-adolescent US orientation were associated with greater symptoms of depression vis-à-vis its impact on parents’ use of unsupportive parenting practices, which in turn, led to an increased sense of alienation between parents and children. However, discrepancy in parent-adolescent Chinese orientation was not directly or indirectly related to symptoms of depression. These findings are consistent with previous frameworks that differential adoption of US cultural norms results in disruptive family functioning. In contrast, Cano et al. (2016) found that adolescents with higher levels of US identity relative to their caregiver reported lower levels of depressive symptoms in a longitudinal study of recently immigrated Hispanic families in Miami and Los Angeles. At the same time, higher collectivism among adolescents relative to their parents was associated with greater family functioning, which in turn, led to lower symptoms of depression.

Extending these findings and utilizing the same data as Cano et al. (2016), Schwartz et al. (2015) plotted trajectories of acculturation discrepancies and found that an increasing discrepancy between adolescents and their parents on individualistic values (i.e., higher scores indicating adolescent higher than parent) was negatively associated with symptoms of depression. In contrast, greater discrepancy between collectivistic values and ethnic identity (i.e., higher scores indicating parent higher than adolescent) was positively associated with symptoms of depression vis-à-vis its impact on family functioning. In other words, as parents’ collectivistic values and ethnic identity are increasingly higher than their parents, family functioning is compromised, resulting in increased symptoms of depression. Taken together, findings by Cano et al. (2016) and Schwartz et al. (2015) indicate that it is the loss of one’s heritage values and identity that disrupt family functioning.

Suicide Models Compatible with an Acculturation Framework

Few contemporary suicide models lend themselves well to understanding suicide-related risk within an acculturation framework . One of the few existing models to do so is the Cultural Model and Theory of Suicide (Chu et al., 2010). The model highlights the influence of cultural experiences along the spectrum of suicide-related risk, particularly in ethnic and racial minority groups. This model proposes that cultural experiences impact suicide-related risk through three distinct avenues: (1) culture-specific stressors such as ethnic and race discrimination stress and acculturative stress; (2) manifestations, expressions, and management of distress; and (3) attitudes toward and expressions of suicidal thoughts and behaviors. Indeed, the select studies reviewed in this section of the chapter offer empirical support for this model, though with a greater emphasis on examining the relation between cultural stressors and suicide-related risk.

The Interpersonal Theory of Suicide (IPTS; Van Orden et al., 2010) is another contemporary suicide model that intersects with the acculturation framework to provide critical insight into suicide-related risk in immigrant youth. The IPTS model describes the development of suicide-related risk in terms of interpersonal processes, specifically thwarted belongingness and perceived burdensomeness. These interpersonal processes may reflect family functioning, which play a critical role in suicide-related risk in immigrant youth. Indeed, Oakey-Frost et al. (2019) found that ethnic identity, as a composite of affirmation and commitment, was directly and negatively associated with suicide ideation and thwarted belongingness. Further, they also found that ethnic identity was negatively and indirectly associated with suicide ideation through increases in perceived burdensomeness, but only when thwarted belongingness was high. In using the IPTS model within an acculturation framework, we can identify ways through which cultural experiences may compromise interpersonal functioning to confer risk for suicide.

The Way Forward: Addressing Gaps and Methodological Concerns

Although these studies have represented an important step forward, there are several important limitations. In this final section of our review chapter, we outline recommendations for future research necessary for understanding the complex association between acculturation, cultural stressors, and suicide-related risk among immigrant youth.

Mechanisms and Conceptual Concerns

Bidimensional Conceptualizations of Acculturation

Despite contemporary views of acculturation , only one study in our review utilized a bidimensional conceptualization of acculturation in exploring the association between acculturation and suicide-related risk. In doing so, research exploring suicide-related risk among immigrants has been limited by its operationalization of acculturation as a “zero-sum game,” making it impossible to determine whether it is the loss of (or failure to acquire) heritage culture or the acquisition of US culture that places youth at risk for suicide. Indeed, as we have noted in our review of research on symptoms of depression, internalizing symptoms, and/or hopelessness, studies utilizing a bidimensional framework have shown differential effects not only between heritage retention/acquisition and US acquisition, but also across domains of acculturation (i.e., practices, identification, and values). As such, there is a critical need for research to draw on contemporary models of acculturation to better understand how these cultural processes may impact the risk for suicide .

Acculturation as a Developmental Process

It is also critical to acknowledge that acculturation is inherently a developmental process (Schwartz et al., 2020). Indeed, as proposed by the Relational Model of Bicultural Systems (RMBS; Meca et al., 2019), acculturation can be conceptualized as a change in overall sense of self and identity in response to contact between two cultural groups. Within an RMBS framework, identity development occurs both (a) within people as they make choices about goals, roles, and beliefs about the world and (b) within the person’s cultural context as the communal group recognizes and affirms these choices. An individual’s sense of self and identity regulates the actions individuals use to adapt to changing developmental contexts, thereby serving as a “steering mechanism” for decisions and actions throughout the life course (Meca et al., 2019). As such, not only is identity development, and by extension acculturation, a developmental process, but it also emerges from the ongoing dynamic relation between self and society, and thus serves to actively shape how individuals navigate two or more cultural streams. Thus, it is critical for acculturation research and research specifically focused on the links between acculturation and suicide-related risk to conceptualize acculturation as a developmental process and attend to the processes involved in managing cultural identities.

Acculturation Within the Family Context

Acculturation is also embedded within a specific social , cultural, and historical context (García Coll et al., 1996; Meca et al., 2019). Indeed, as we have noted in our review of the existing literature, several studies have emphasized that acculturation unfolds within the family context. However, research examining the impact of acculturation gap on suicide-related risk has also been limited by its current conceptualization and operationalization of acculturation. By drawing on largely unidimensional conceptualizations, research has been unable to determine if it is the loss of youths’ heritage culture or the greater acquisition of US culture relative to their parents that disrupt family functioning. Another overlooked avenue of future research is the need to understand how family dynamics unfold over time. Indeed, the family is best understood as a holistic and constantly evolving system (Meca et al., 2019). Consistently, in the past decade, sociologists and psychologists have clarified the specific ways in which parents actively and passively encourage children to gravitate toward specific aspects of their cultural heritage and to avoid specific aspects of the host cultural context (Portes & Rumbaut, 2006).

The term, familial ethnic socialization, has been utilized to describe this phenomenon (Umaña-Taylor et al., 2006). However, it is important to note that not only do parents socialize their children to retain (or reject) their heritage culture and/or acquire (or reject) US culture, adolescents also impact their parents’ cultural orientation. As such, and consistent with contemporary developmental theory (see Causadias & Cicchetti, 2018), a critical step for future research requires conceptualizing the family as a holistic, interacting, constantly evolving system with culture integrated across every level of this system. This requires taking into account the personality, psychosocial functioning, and ongoing acculturation processes in youths and their caregivers, as well as taking into account the various contextual levels in which both agents (i.e., youth and caregivers) are embedded (e.g., peer, school, work, etc.).

Acculturation, Cultural Stress, or Both?

As we have reviewed , research has documented interactive effects between acculturation and cultural stressors on suicide-related risk (e.g., Cheref et al., 2019; Gomez et al., 2011; Polanco-Roman & Miranda, 2013). Although studies have explored the direct association between cultural stress and suicide-related risk, paralleling the need for more comprehensive operationalization of acculturation, no study, to date, has sought to comprehensibly assess the impact various cultural stressors have on suicide-related risk. As such, a critical next step in developing a comprehensive model that articulates the relationships between acculturation and suicide-related risk is to separate the “process of acculturation” from the underlying “process of cultural stress” (Gilbert & Cervantes, 1987). Indeed, studies have not only indicated complex interactive effects between acculturation and cultural stressors and various mental health outcomes but have also found complex longitudinal patterns in the relationship between acculturation and cultural stressors (Gonzales-Backen et al., 2019; Meca et al., 2020b). In sum, future research is necessary to disentangle the process of acculturation from the experience of stress and determine how they impact each other and contribute independently and interdependently to suicide risk among immigrant youth .

Methodological Concerns

Over and above these future directions, it is important to draw on key methodological limitations observed in the broader acculturation literature (Meca et al., 2017; Schwartz et al., 2010a), as they not only potentially play a role in the contradictory findings above, but will likely continue to hinder understanding of the relationship between acculturation and suicide-related risk.

Effects of the Host Context and Ethnic and Racial Density

Acculturation is not only inherently a developmental process (Schwartz et al., 2020), but immigration and acculturation can also be conceptualized as the interaction between a specific immigrant group and the perceived context in which they are received (Schwartz et al., 2010a). At the broadest level, the views and expectations of members in a given society, as they relate to multiculturalism (i.e., joint value placed on cultural diversity and equitable participation), play a role in shaping youths’ acculturation (Berry, 2013). However, as emphasized by Meca et al. (2019), the presence (or absence) of “multiculturalism may present in the immediate neighborhood (e.g., Little Havana in Florida), the receiving city (e.g., Miami), and/or at the broader level of receiving society (e.g., the United States)” (p. 50). Within contexts marked by multiculturalism, youth are afforded the capacity to interact with people from the larger society and from the heritage cultural community to draw social support, as needed (Schwartz & Zamboanga, 2008). In contrast, in more monocultural, culturally disjointed, or conflicted societies, individuals would likely be expected to restrict their heritage cultural activities to their homes and other private contexts (Arends-Tóth & Van de Vijver, 2007).

Regardless of the views a particular society has toward multiculturalism, though, discrimination and foreigner objectification (i.e., perceptions of being treated as a foreigner) can serve as barriers, challenges, and threats toward immigrant youth. Indeed, at a more fine-grained level of analysis, there are important differences across immediate neighborhoods and host cities. Research has consistently highlighted differences in the degree to which receptions in a particular society vary in how welcoming and inviting they are perceived to be (Schwartz et al., 2014). Moreover, youths’ perception of their context plays an instrumental role in how much they experience acculturative stress (Smokowski & Bacallao, 2011). In sum, given the variability of reception in the US likely encountered by immigrants, it is critical that future research move beyond large ethnic enclaves and utilize multisite research designs to more fully understand the impact that an immigrants’ perception of their context of reception has on acculturation, cultural stress, and suicide risk.

Intersectionality and Within-Group Differences

Beyond conceptualizing acculturation within a specific social and cultural context, it is important to acknowledge the high degree of intersectionality and within-group diversity in acculturation (Schwartz et al., 2010a). Although research has typically focused on immigrants from large pan-ethnic/racial groups (e.g., Hispanic, Asian, etc.), there are drastic differences within each of these pan-ethnic/racial groups across national origin in terms of socioeconomic status, culture, dialect, history with the US, skin tone, and ability to fit into the dominant US culture (Chu & Sue, 2011; Ennis et al., 2011). Collectively, these factors can result in very different experiences that may influence the acculturation process across a variety of direct and indirect ways. We acknowledge that the decision to combine immigrants across national origin into larger pan-ethnic groups is partially due to the difficulty associated with obtaining a large enough sample to examine these within-group differences (Sue et al., 1999). However, the aggregation of immigrants within larger pan-ethnic groups often masks differences among subgroups and prevents understanding of within- and between-group differences in acculturation and its association with suicide .

Clinical Implications

Although limited, the knowledge obtained about the impact of acculturation on suicide-related risk has important clinical implications in the prevention of suicidal behaviors in immigrant youth. This is especially the case in ethnic and racial minority youth, who are less likely than their White peers to seek mental health services (King et al., 2019), and thus are particularly vulnerable to suicidal thoughts and behaviors. Indeed, several existing interventions have incorporated culture-specific strategies, specifically in addressing the appreciably high rates of suicidal behaviors in Latinx youth, in particular.

For instance, Life Is Precious is an after-school, community-based program throughout New York City that directly addresses acculturation to reduce suicidal behaviors in Latina adolescents by providing support in the areas of academic, peer, and family relations, and promoting coping skills targeting cultural stressors and family conflict (Humensky et al., 2017). Familias Unidas, a culturally specific intervention originally developed to reduce substance misuse and sexual risk behaviors in Latinx youth, may also help reduce the risk for suicidal behaviors (Vidot et al., 2016). This family-based intervention targets communication between parents and adolescents to reduce family conflict that may arise from acculturation gaps. Despite a lack of suicide-specific targets, the intervention was associated with decreases in suicide-related risk among a group of Latinx youth, but only among those with compromised parent-youth communication .

Alternatively, Socio-Cognitive Behavior Therapy for Suicidal Behaviors (SCBT-SB; Duarté-Vélez et al., 2016) is a cultural adaptation of an existing evidence-based treatment widely used for suicidal behaviors, Cognitive Behavior Therapy (CBT). In addition to traditional targets of CBT such as thinking traps and behavioral activation, SCBT-SB also targets family conflict and cohesion, culture-specific stressors (e.g., minority and discrimination stress), and identity development. Together, these prevention and intervention strategies provide early evidence demonstrating the importance of addressing acculturation in suicide prevention among immigrant and ethnic and race minority youth .

Conclusion

As a whole, our review of the literature emphasizes the importance of acculturation in understanding suicide-related risk among immigrants and ethnic and racial minority youth. However, the scarcity of empirical studies, coupled with several conceptual and methodological problems, hampers our understanding of the developmental processes linking acculturation with suicide-related risk. As we have outlined above, and consistent with contemporary models of acculturation (Meca et al., 2019; Schwartz et al., 2010a), future studies should utilize a bidimensional and multicomponent conceptualization of acculturation, explore the unique and interactive effects between acculturation and cultural stressors, further contextualize acculturation within the family system and context of reception, and, finally, identify potential within-group differences across immigrant and ethnic and race groups. By addressing these gaps, we will not only develop a better understanding of the role acculturation plays in suicide-related risk, but may potentially improve screening for youth at greatest risk for suicidal behaviors, provide novel targets for intervention, improve the cultural sensitivity of existing strategies, and promote the development of new culturally centered strategies. While there is considerable work to be done, we hope that this chapter will serve to stimulate innovative and informative work that further illuminates the relationship between acculturation and suicide-related risk.