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Suicide is the second leading cause of death for youth aged 11 to 15, taking over 5,500 lives from 2003 to 2014. Suicide among this age group is linked to risk factors such as mental health problems, family history of suicidal behavior, biological factors, family problems, and peer victimization and bullying. However, few studies have examined the frequency with which such problems occur among youth suicide decedents or the context in which decedents experience these risk factors and the complex interplay of risk that results in a decedent’s decision to take his/her own life. Data from a random sample of 482 youth (ages 11–15) suicide cases captured in the National Violent Death Reporting System from 2003 to 2014 were analyzed. The sample had fewer girls than boys (31 vs. 69 %) and comprised primarily White youth (79 %), but also African Americans (13 %), Asians (4 %), and youth of other races (4 %). Narrative data from coroner/medical examiner and law enforcement investigative reports were coded and analyzed to identify common behavioral patterns that preceded suicide. Emergent themes were quantified and examined using content and constant comparative analysis. Themes regarding antecedents across multiple levels of the social ecology emerged. Relationship problems, particularly with parents, were the most common suicide antecedent. Also, a pattern demonstrating a consistent progression toward suicidal behavior emerged from the data. Narratives indicated that youth were commonly exposed to one or more problems, often resulting in feelings of loneliness and burdensomeness, which progressed toward thoughts and sometimes plans for or attempts at suicide. Continued exposure to negative experiences and thoughts/plans about suicide, and/or self-injurious acts resulted in an acquired capacity to self-harm, eventually leading to suicide. These findings provide support for theories of suicidal behavior and highlight the importance of multi-level, comprehensive interventions that address individual cognitions and build social connectedness and support, as well as prevention strategies that increase awareness of the warning signs and symptoms of suicide, particularly among family members of at-risk youth.
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J Youth Adolescence
DOI 10.1007/s10964-016-0610-3
Antecedents of Suicide among Youth Aged 1115: A Multistate
Mixed Methods Analysis
Kristin M. Holland
Alana M. Vivolo-Kantor
Joseph E. Logan
Ruth W. Leemis
Received: 9 August 2016 / Accepted: 1 November 2016
© Springer Science+Business Media New York 2016
Abstract Suicide is the second leading cause of death for
youth aged 11 to 15, taking over 5,500 lives from 2003 to
2014. Suicide among this age group is linked to risk factors
such as mental health problems, family history of suicidal
behavior, biological factors, family problems, and peer
victimization and bullying. However, few studies have
examined the frequency with which such problems occur
among youth suicide decedents or the context in which
decedents experience these risk factors and the complex
interplay of risk that results in a decedents decision to take
his/her own life. Data from a random sample of 482 youth
(ages 1115) suicide cases captured in the National Violent
Death Reporting System from 2003 to 2014 were analyzed.
The sample had fewer girls than boys (31 vs. 69 %) and
comprised primarily White youth (79 %), but also African
Americans (13 %), Asians (4 %), and youth of other races
(4 %). Narrative data from coroner/medical examiner and
law enforcement investigative reports were coded and
analyzed to identify common behavioral patterns that pre-
ceded suicide. Emergent themes were quantied and
examined using content and constant comparative analysis.
Themes regarding antecedents across multiple levels of the
social ecology emerged. Relationship problems, particularly
with parents, were the most common suicide antecedent.
Also, a pattern demonstrating a consistent progression
toward suicidal behavior emerged from the data. Narratives
indicated that youth were commonly exposed to one or
more problems, often resulting in feelings of loneliness and
burdensomeness, which progressed toward thoughts and
sometimes plans for or attempts at suicide. Continued
exposure to negative experiences and thoughts/plans about
suicide, and/or self-injurious acts resulted in an acquired
capacity to self-harm, eventually leading to suicide. These
ndings provide support for theories of suicidal behavior
and highlight the importance of multi-level, comprehensive
interventions that address individual cognitions and build
social connectedness and support, as well as prevention
strategies that increase awareness of the warning signs and
symptoms of suicide, particularly among family members
of at-risk youth.
Keywords Youth suicide Precipitating factors
Qualitative analysis
Suicide is the second leading cause of death among youth
and young adults 11 to 15 years old according to 2014 data
from the Centers for Disease Control and Prevention (CDC
2016). The suicide rate among this age group has doubled
since its decade low in 2007, from 1.6 to 3.2 deaths per
100,000 population (CDC 2016). Suicidal ideation is even
more common among this group of youth and adolescents.
According to CDCs2015 national Youth Risk Behavior
Survey, 17.7 % of high school students reported seriously
considering suicide in the past year, and 14.6 % made plans
to carry out suicide (Kann et al. 2016). Research suggests
that early adolescence in particular is a time period marked
by important school-age and biological transitions, such as a
move from elementary to middle and middle to high school,
*Kristin M. Holland
Division of Violence Prevention, National Center for Injury
Prevention and Control, Centers for Disease Control and
Prevention, Atlanta, GA, USA
along with the onset of puberty. This time period can be
associated with increased stress, depressive and internaliz-
ing symptoms, suicide, and other negative health outcomes
(Bolger et al. 1989; Robinson et al. 1995; Windle et al.
2008). While only a small proportion of individuals die by
suicide during this time period, in light of the increasing
trends in suicide among youth and adolescents, and with the
goal set forth by the National Action Alliance for Suicide
Prevention to reduce suicides by 20 % by 2020, the need to
identify modiable factors that may help prevent youth
suicide has never been as imperative as it is now.
A review by Gould et al. (2003) identied numerous risk
factors for youth suicide related to characteristics of youth
and their social environments. These factors involved
individual-level and relationship-level problems, with very
few community/environmental-level factors identied. Risk
factors that span this social ecology (Dahlberg and Krug
2002) include psychopathology, family history of suicidal
behavior, biological factors, parental divorce, poor parent-
child communication habits, and contagion or imitation of
suicidal behavior sometimes fueled by media coverage
sensationalizing these violent acts. More recent studies have
also linked peer victimization, bullying victimization and
perpetration, cyberbullying, and sexual minority status to
suicidal ideation and behaviors among youth (Holt et al.
2015; Stone et al. 2014; Van Geel et al. 2014).
Identifying the imminent and critical antecedents of
suicidal behavior and placing them within the context of
theories may help researchers to better understand and
prevent lethal self-harm. For example, Sabbaths(1969)
family systems theory of adolescent suicidal behavior posits
that suicidal youth may perceive themselves as non-
essential, burdensome family members. The interpersonal
theory of suicidal behavior expands upon Sabbaths theory
and suggests that individuals at risk for suicide may suffer
from three inter-related symptoms: thwarted belongingness,
or a feeling of not belonging to a family or peer group;
perceptions of burdensomeness; and an acquired capability
to engage in harmful behavior or an acquired tolerance of
pain, which can be physical or mental (Van Orden et al.
Youth suicide prevention programs have been developed
to impact modiable risk factors, some of which address
constructs included in these theories, such as reducing
thwarted belongingness by enhancing connectedness.
However, these programs have been associated mostly with
reductions in suicidal ideation, with limited evidence of
effects on suicidal behavior (see Aseltine et al. 2007; Gould
et al. 2003; Katz et al. 2013). To develop more effective
interventions, it is critical that the causal pathways leading
to suicide are better understood, especially those that take
into account the dynamic interplay of individual-, relation-
ship-, and community-level factors (Magnusson and Stattin
2006). In addition, more research is needed on imminent
warning signs (Rudd et al. 2006) for suicide and how such
signs may play a role in impacting a youths decision to die
by suicide. As these pathways become clearer, theories of
suicidal behavior can be honed or expanded to inform future
prevention strategies.
Unfortunately, few data sources exist that permit ana-
lyses of the interplay of risk factors and other proximal
circumstances that inuence suicidal behavior. The National
Violent Death Reporting System (NVDRS) is one such
system and is a valuable source of information because it is
designed to identify and characterize risk factors from
multiple sources, including coroners/medical examiners and
law enforcement ofcials. Other studies have used these
sources to identify common precipitators of suicide deaths
among middle-aged men and women and to examine the
frequency and characteristics of intimate partner homicide
and homicides-followed-by-suicide (Logan et al. 2008;
Schiff et al. 2015; Smith et al. 2014; Stone et al. 2016).
However, to date, NVDRS data have only been used to
quantify or tally descriptive characteristics of circumstances
related to youth suicide (Karch et al. 2013), but not to
qualitatively examine how these circumstances collide.
Karch and colleagues (2013) used three years of law
enforcement and coroner/medical examiner report data from
the NVDRS and quantied the common precipitators of
suicide among youth 10 to 14 years old, nding that suicide
decedents often experienced a recent crisis, mental health
problems, and/or dating partner problems. While this study
provided an overview of youth suicide cases; more rigorous
qualitative analytic methodologies involving thorough
review and coding of law enforcement and coroner/medical
examiner narrative data are still needed to investigate other
possible precipitators such as the specic types dating
partner problems and school problems (e.g., ghts, break-
ups, bullying and teasing at school, sports-related
Psychological autopsies, which involve synthesizing
relevant information on decedentslives through medical
records and postmortem interviews with family members
and acquaintances, are helpful in describing the proximal
precipitators and psychological circumstances of suicide in
great detail (Isometsä 2001). For example, Houston et al.
(2001) conducted a psychological autopsy study of 27
youth aged 15 to 24 who had died by either suicide or an
undetermined cause. Through informant interview and
medical and coroner records, they found that 70 % of their
sample had a diagnosed mental illness, 50 % of whom
suffered from depression. Decedents also suffered from
relationship and legal problems that contributed to their
suicide. Another psychological autopsy study of 120 youth
who died by suicide in New York indicated that 59 % of its
sample had a diagnosable mental illness, and almost half
J Youth Adolescence
had symptoms lasting more than three years and had
received mental health treatment (Shaffer et al. 1996).
Finally, a psychological autopsy study of youth who died
by suicide in Utah quantied the frequency with which
parents, siblings, friends, distant relatives, and other infor-
mants reported problems experienced by the decedent after
his/her death, nding that 65 % of the sample had a psy-
chiatric diagnosis and demonstrating that parents and
friends observe the warning signs of suicide more fre-
quently than other informants (Moskos et al. 2005).
Although most psychological autopsy studies like those
described here collect qualitative data, the majority still
simply tally informant survey responses in an attempt to
provide a frequency with which certain characteristics (e.g.,
mental health problems) occurred among their sample of
decedents. Thus, these studies typically do not describe the
complex interaction of risk experienced by suicide dece-
dents. Moreover, psychological autopsy studies, which are
conducted seemingly sparingly, involve labor- and time-
intensive data collection and analysis efforts, often resulting
in small, localized samples, thereby limiting the general-
izability of their ndings.
The Current Study
In the present study, we built upon research that has used
quantitative NVDRS data to characterize suicides of youth
aged 11 to 15 years olda group that theoretically
experiences distinct stressors related to adolescent devel-
opment compared to older adolescents (Bolger et al. 1989;
Robinson et al. 1995). Additionally, similar to psychologi-
cal autopsy studies, we reviewed summaries of data col-
lected on suicides among 11 to 15 year olds through
interviews conducted by law enforcement and coroner/
medical examiners with decedentsfamily, friends, and
acquaintances and conducted qualitative analyses to provide
a rich illustration of all known circumstances surrounding
youth suicides. The purpose of this study was to identify
common characteristics and antecedents of suicides among
youth across the U.S. using narrative data from law enfor-
cement and coroner/medical examiner suicide investigations
in 17 states participating in the NVDRS. A goal of this
research was to place the identied suicide antecedents
within the context of a theoretical model that explains sui-
cidal behavior to inform targeted and universal prevention
programming. Drawing from two existing theories regard-
ing suicide and suicidal behavior, we hypothesized that
antecedents in three domains would emerge during our
content analysis of law enforcement and coroner/medical
examiner narratives of youth suicides: feelings of loneliness
or burdensomeness, which we presumed may be family- or
peer group-related; familial tension or problems with
parents; and a build-up of tolerance for engaging in self-
harm, exhibited through non-suicidal self-harm, suicidal
ideation, and previous suicide attempts.
Data Source and Study Population
A total of 1,606 suicides among youth aged 1115 were
recorded in 17 of the 18 U.S. states that participated in the
NVDRS from 2003 to 2014
. The NVDRS collects quan-
titative and qualitative details on violent death incidents,
including suicide. Data sources for the NVDRS include
death certicates, coroner/medical examiner reports, law
enforcement reports, and toxicology reports (CDC 2014).
Much of the information regarding the circumstances pre-
ceding suicide events is collected from next-of-kin inter-
viewed by law enforcement and coroner/medical examiner
death scene investigators. The NVDRS records an extensive
amount of information on each incident based on multiple
reports as well as law enforcement and coroner/medical
examiner reports. NVDRS data abstractors develop brief
summaries containing details regarding known circum-
stances, or precipitating factors, that preceded the death.
Data abstractors are trained to include only factors from the
law enforcement and coroner/medical examiner reports that
seemingly contributed to the suicide (CDC 2015).
A random selection of 30 % (n=482) of NVDRS suicide
cases among 11 to 15 year oldsall with known circum-
stanceswere included in this study. This sample size was
deemed small enough to conduct thorough content analysis
of case narratives, which requires extensive time and labor,
yet large enough to reach qualitative saturation (i.e., the
point at which no new themes emerge from the data; Strauss
and Corbin 1998) and to obtain descriptive data regarding
prevalent suicide precipitators.
Sample characteristics
Sample characteristics including decedent sex, race, age,
and means of suicide are provided in Table 1. Using
chi-square tests of independence, we did not nd any sig-
nicant differences between our selected sample (n=482)
and the remaining youth decedent population of these ages
(n=1,124; data not shown) contained in the NVDRS.
Data included from Alaska, Colorado, Georgia, Kentucky,
Maryland, Massachusetts, New Jersey, New Mexico, North Carolina,
Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
Virginia, and Wisconsin. California collected data from 20052008;
however, these data were excluded because collection was not
J Youth Adolescence
Content Analysis
Content analysis of law enforcement and coroner/medical
examiner data took place in three phases. In phase one, a
combination of conventional content analysis and directed
approaches to content analysis (Hsieh and Shannon 2005)
were used to develop a comprehensive coding guide; the
coding guide was created based on theoretical under-
standing of suicidal behavior and was then modied using
an iterative process that involved narrative review and open
coding (i.e., creating overarching code categories after
reviewing narratives; Strauss and Corbin 2007). This pro-
cess resulted in a coding guide that included detailed codes
for the following: the suicide decedents emotional state,
precipitating health circumstances (e.g., physical and mental
health problems experienced by decedent), family medical
history, history of adverse childhood experiences, pre-
cipitating stress-related circumstances (e.g., school and/or
bullying-related problems, dating partner problems, family-
related stressors), evidence of premeditation, prevention
opportunities, and toxicology results. Within each of these
overarching categories, detailed codes were developed for
more nuanced narrative data (e.g., whether bullying was
conrmed vs. perceived, type of mental health problem
experienced, type of dating partner problem). The nal
coding guide (Table 2) and law enforcement and coroner/
medical examiner narrative data for each case were entered
into NVivo 10.0 qualitative data analysis software.
In phase two of data analysis, three study team members
(KH, AV, and RL) coded 30 identical case narratives. A
coding comparison query was run in NVivo, and a kappa
coefcient of 0.90 was obtained, indicating an excellent rate
of inter-coder agreement. An additional 452 cases were split
among the three team members and coded using the nal
coding guide.
In the third and nal phase of analysis, overarching code
categories were reviewed in NVivo. Categories that were
frequently coded in the narrative data were closely analyzed
for repetitive themes using the constant comparative method
(Glaser and Strauss 1967). Further, excerpts of text led in
the most frequently coded categories were quantied as well
as identied as either a school-, relationship-, or individual-
level factor in order to provide detail regarding the sample-
specic prevalence of key precipitators of suicide.
Suicides were precipitated by a range of problems repre-
senting multiple levels of the social ecology, with the most
common types of problems precipitating suicide being
family, peer, and dating partner relationship problems, fol-
lowed by individual-level factors such as mental health and
substance abuse problems, and school-related struggles,
respectively. It was also common for youth to simulta-
neously experience multiple types of problems spanning the
social ecology. Overall, the narrative data reviewed pro-
vided insight regarding the process of suicide, with exten-
uating circumstances, including relationship, individual,
and school problems (often in combination) resulting in
non-suicidal self-harm, thoughts, and/or plans about death.
In many of the cases reviewed, such exposure to stressful
stimuli and maladaptive coping behaviors likely resulted in
the decedentsacquired capacity to act on suicidal ideation
using lethal means. Excerpts from law enforcement and
coroner/medical examiner narratives illustrating the themes
and suicidal processes that emerged during qualitative
analysis are provided in Table 3.
School or School-Related Social Problems
School or social problems were reported in 40 % (n=193)
of suicide cases. Among these cases, school disciplinary
problems (n=43, 22 %) and non-specic school problems
(n=50, 26 %) contributed to more suicides than any other
type of school-related problem. Non-specic school pro-
blems were characterized by law enforcement and coroner/
medical examiner narratives through broad statements such
Table 1 Sample characteristics of youth who died by suicide,
17 states, 20032014
Male 335 69.5
Female 147 30.5
White 380 78.8
African American 61 12.7
Asian 17 3.5
Other 22 4.5
Unknown 2 0.4
Age (Mean, SD) 13.99 1.16
11 23 4.8
12 35 7.3
13 84 17.4
14 123 25.5
15 217 3
Means of suicide
Suffocation 285 59.1
Firearm 163 33.8
Poisoning 18 3.7
Other 15 3.1
Missing 1 0.2
J Youth Adolescence
as problems at schoolwith no specic details noted.
School disciplinary problems that were specied, such as
suspension, occurred in conjunction with other possible
contributors of suicide, such as arguments with parents,
punishment, or feelings of hopelessness or depression, in 30
(70 %) of 43 cases. For instance, one decedent left suicide
notes stating he thought he would be a failure in life and
therefore he was going to end his life to not disappoint
anybody. The victim was a good student and did not display
signs of suicide. However, he had recently been disciplined
at school because of an academic problem. The parents had
disciplined the victim the evening prior to his death.
Bullying or teasing at school was apparent in 22 %
(n=43) of the 193 cases that involved school or social
problems and in 9 % of total cases included in this study.
Thus, bullying alone was not a leading contributor to the
Table 2 Qualitative topic codes assigned to law enforcement and
coroner/medical examiner narrative text on youth suicide decedents in
the national violent death reporting system
Overarching code Subcode
Precipitating mental
health circumstances
Current depressed mood
Untreated/undiagnosed mental health
Diagnosed mental health problems
Treatment for mental health problems
Prescribed medication
Prescribed medication by a physician, but
did not take it according to directions
Received counseling/therapy
By medical professional
By school counselor
Alcohol abuse/Substance abuse
At time of death
Family history of mental health problems
Engaged in non-suicidal self-injury
History of suicidal
ideation and behaviors
Family history of suicidal ideation or
Family history of suicide
Decedents history of suicide attempts
Decedents history of suicidal ideation
Physical health
Other physical problems
Relationship problems Family problems
Argument with parents
Punishment by parents (or threatened
Argument with siblings
Recent move
Living in blended family
Thwarted belongingness
Non-specic problems with friends
(not school-related)
Dating partner problems
Indelity or accused indelity
Table 2 continued
Overarching code Subcode
Dating partner violence victimization or
Recent break-up
Other un-specied relationship problems
Conrmed bullying
Perceived bullying (e.g., bullying assumed
by parents/friends/schoolmates, but not
conrmed by school authorities)
Disciplinary problems at school
Pressure from parents, teachers, or
coaches to perform well in school
Sports-related problems
Problems at school, no specics provided
Thwarted belongingess
Physical ghting at school
Other relevant stressors Recent crisis (occurred within 2 weeks of
death or was impending)
Death/illness of friend or family member
History of adverse
childhood experiences
Child physical abuse
Child neglect
Child sexual abuse
Foster home development
Evidence of
Left a note
Disclosed intent
Posted suicidal intent on social media
Texted friends/family about suicide
J Youth Adolescence
broader group of suicides related to school problems.
Instead, when bullying was noted, it often overlapped with
other precipitators of suicide; for example, one case indi-
cated that the victims mother was reported to have a pro-
blem with alcohol, which often led to poor parenting. She
also had abusive relationships, which the victim witnessed.
The victim suffered from physical health problems, physical
and psychological abuse from her family, and was socially
excluded by other youth. Still, bullying was reported more
frequently than general problems with friends, which were
reported in approximately 6 % (n=5) of cases with school-
or social-related problems.
Academic problems were noted in 29 cases (6 %) that
involved school problems. In 15 (52 %) of these 29 cases,
academic problems were experienced in conjunction with
another problem, such as an argument with parents. For
instance, one decedent had received a bad school report
card and was yelled at by his parents.Another victim had
been experiencing difculty at school with grades and had
been acting outlately.
Additionally, informants interviewed during the death
investigation and/or the suicide decedents themselves
sometimes disclosed to others or through journal entries a
sense of thwarted belongingness (Van Orden et al. 2010), or
a perception of difculty tting in,either in general social
contexts or at school. For example, one victim reportedly
did not have many friends and had been in counseling due
to problems at school. The victim was reportedly happy at
home, but very unhappy at school and had difculty making
friends. Another victims health records indicated that she
continued to have problems with her primary support group,
at school, and in social relationships.
Relationship Problems
Relationship-level problems were common among this
sample of youth. Family problems were most frequently
noted in this category, with 56 % (n=267) of youth
demonstrating a problem with a relative. Frequently, family
stress resulted in arguments with parents, followed by a
punishment, which was often immediately (i.e., the same
day) followed by suicide. Other family-related stressors
included living within blended families (e.g., with step-
parents or step-siblings; n=44, 9 %), parental divorce
(n=33, 7 %), and a recent move (n=29, 6 %). For
instance, one case narrative indicated that the victims
mother had been having problems with the victim being
argumentative and acting out. The family had recently
moved to a new house. On the evening of the suicide, the
victim was upset and argued with his mothers partner. The
arguing continued until the partner disciplined the boy.
They found the boy deceased in his room later that evening.
In this case, the victim also had a history of suicidal ideation
Table 3 Narrative examples of overarching themes regarding antecedents of youth suicide by ecological level
Ecological level Overarching theme Example quotes in support of overarching theme [qualitative codes appear in brackets]
School or social problems Non-specic school problems Victim was crying previous day [emotional statedepressed mood] and told her mother it was
something at school [non-specic school problem].
School disciplinary problems Victim had gotten into trouble at school because of an academic issue and received a phone call home
concerning it [school disciplinary problem].
Bullying victimization Victim had been bullied for the last two years [bullying victimization]. The parents reported frequent
bullying [bullying victimization].
Relationship problems Family problems (e.g., arguments with parents, recent move,
parental divorce)
Victims mother had yelled at the victim and threatened punishment [argument with parent].
Dating partner problems (e.g., break-up, argument) Victim and her boyfriend fought and threatened to break up with each other frequently [ongoing
arguing with dating partner].
Individual problems Mental health problems (e.g., depression, alcohol/substance
Victim had reportedly consumed an excessive amount of alcohol [recent alcohol abuse] on the day of
the fatal event. Victim had received treatment for her depression [mental health problemdepression.
Victim had had a history of alcohol and marijuana abuse [history of substance abuse].
History of suicidal ideation and/or self-harm Cut marks were found on victims wrists, but it is unknown if they were suicidal [history of self-harm].
Note: The quotes are presented as originally written in the National Violent Death Reporting System narratives to ensure preservation of the original framing and character of the content. Narrative
details have been modied non-substantively only to reduce risk of victim identication
J Youth Adolescence
and engaged in self-harm during arguments with his par-
ents. Finally, thwarted belongingness also emerged as a
theme that co-occurred with family problems. For instance,
some cases describing arguments with parents or living
within blended families were accompanied by victim dis-
closures indicating that they thought their family or parents
didnt careabout them.
Problems with dating partners were another relatively
frequent precipitator of youth suicide with 20 % (n=95) of
cases involving some sort of dating dispute. Many cases
cited an argument, a break-up, or both. For example, one
case involving a female noted that the victim was at a
school social activity where she saw her ex-boyfriend with
another girl. She left the activity and was later found
deceased. In another case, while the victim and his girl-
friend were breaking up, he told her he was going to kill
himself. Several hours later, he was found deceased.
Individual Problems
Many of the case narratives included in our study docu-
mented individual-level problems, including mental health
problems, alcohol or substance abuse, prior exposure to a
friend or family members suicide, and experience with non-
suicidal self-injury, prior suicidal ideation and/or attempts.
Mental health problems were documented in 249 cases
(52 %) included in our sample. Over half (n=149, 60 %) of
the mental health problems documented included a
diagnosis of depression. Other mental health problems
included Attention Hyperactivity Decit Disorder (ADHD;
n=37, 8 %) and other mental illnesses (n=62, 12 %), such
as bipolar disorder (n=17) obsessive compulsive disorder
(n=4), anxiety (n=8), schizophrenia (n=2), and other
non-specied mental health problems (n=31). Addition-
ally, indication of mental health problems was typically
accompanied by a reported recent crisis or other stressful
incident. Alcohol and/or substance abuse or misuse was
involved in a total of 37 cases (8 %). Nine victims were
reportedly drinking immediately prior to their suicide, eight
were using drugs, and three were both drinking and using
drugs immediately before dying. Twenty-one victims (4 %)
regularly abused drugs, ten (2 %) regularly abused alcohol,
and eight (2 %) regularly abused both alcohol and drugs
prior to dying by suicide.
Evidence of non-suicidal self-injury was documented in
43 cases (9 %) and typically included cutting, but other
forms of self-mutilation (e.g., burning) were also noted. For
instance, one case indicated that a victim had scars on his
wrists that appeared to be from cutting.His mother con-
rmed that he had a history of cutting himself. Also of note
in this case is that other risk factors for suicide were iden-
tied, including peer suicides, an argument with family, and
tensions with friends.
Twenty-ve youth (5 %) in this sample had either a
family history of suicide or had been exposed to a friend or
acquaintances death by suicide. One case narrative indi-
cated that the victim made statements about wanting to be
with a parent who died years ago. The records indicated that
the victim used the same method that other family members
who had died by suicide had used. Four decedents who had
been exposed to a friends suicide were suspected to have
been involved in a suicide pact. In two of these cases, the
suicide occurred immediately following the rst victims
suicide, using the same rearm. In another case, the victim
died without anyone nearby, but his death was preceded by
two other youth suicides in the same county within a 24
hour period. Four cases indicated the presence of a potential
suicide cluster, marked by two or more seemingly related
other youth suicides in the school or surrounding commu-
nity. One case involved the railway suicide of a boy whose
death followed nine other suicides of students from his high
school over a four-year period. Additionally, according to
law enforcement reports, two victims out of the entire
sample had allegedly entered a suicide pact with another
friend or dating partner, but the other party involved in the
pact did not ultimately die by suicide.
Finally, evidence of suicidal ideation was not uncommon
among this sample of youth. In fact, 54 % (n=262) of
youth demonstrated at least one kind of premeditative
activity. The most common form of premeditation was
leaving a suicide note (n=150, 31 %). Twenty-seven per-
cent (n=131) of the sample had a history of suicidal
ideation, while only 16 % (n=77) had a history of suicide
attempts. Most youth who disclosed intent to die by suicide
(n=125, 26 %) did so to a family member, friend, or dating
partner, and this was often done during or following an
argument. For instance, one victim had an argument with
his parents before his death, and records indicated that the
punishment made him angrier, and during the argument the
victim threatened to kill himself.Ten percent of youth
(n=48) used social media or text messages to disclose their
intent to die by suicide or to talk about suicide in general.
Another 7 % (n=33) of youth expressed thoughts about
suicide through journal writings that detailed different types
of problems the decedents experienced (e.g., Police found a
journal in victims bedroom that stated how unhappy she
was and made numerous references to ending her life).
Co-Occurrence of Risk Factors
Almost 60 % (n=281) of youth experienced multiple types
of problems spanning the social ecology. The most com-
mon, co-occurring problems involved relationship and
school problems (n=191, 40 %), often characterized by a
disciplinary or academic problem at school in combination
with an argument with a parent. The combination of
J Youth Adolescence
individual and relationship problems (n=184, 38 %)
was almost equally as prevalent as school plus relationship
problems; these comorbid problems were often character-
ized by the decedent experiencing an individual-level
problem such as mental illness in combination with a
relationship problem, such as a break-up or an argument
with parents. Over one-third (n=173) of decedents
experienced both an individual problem and a school or
social problem. For example, one decedent had ADHD and
major depressive disorder. This youth had made several
suicide attempts in the past, and had recently been expelled
from school. Finally, almost one out of every ve decedents
in this sample (n=88, 18 %) experienced all three types of
problemsindividual, relationship, and school/social pro-
blems. For instance, one victim had a history of bipolar
disorder, was suspended from school, and had been recently
punished by his parents for criminal behavior.
Progression toward Suicidal Behavior
Narrative data demonstrated a common progression toward
suicidal behavior among the decedents in our sample. First,
narratives indicated that victims most often experienced
multiple problemseither within one level of the social
ecology (e.g., an argument with a parent, plus an argument
with a boyfriend, plus punishment by a parent) or across
levels (e.g., depression, plus a recent move from one resi-
dence to another, plus bullying at school). Second, exposure
to these problems often resulted in feelings of loneliness
and burdensomeness, which progressed toward thoughts,
disclosure, and sometimes plans for or attempts at suicide.
For example, one decedents friend advised law enforce-
ment during an interview that the victim had told her the
previous week that he felt like no one cared about him and
that he wanted to kill himself.Another victim suffered
from depression, had excessive school absences, resulting
in failing grades which added to her depression,did not
have many friends, did not have a boyfriend, was a cutter,
and had been hospitalized recently for a suicide attempt.
Another victim had recently argued with her parents; she
was upset when this resulted in her cell phone being taken
away. The family had relocated several months before, and
as a result the victim was seen as an outsider [at school].
[The day of the incident], she voiced possible suicidal
ideations to a family member.
Further evidence in support of this progression toward
suicidal behavior came directly from victimssuicide notes,
which often indicated a build-up of pain and suffering and
an inability to cope in another way. For instance, one vic-
tims note stated that he was in so much pain and tried to
deal with it, but he just couldnt do it anymore and wanted
to die.Another victim indicated that he had tried to cope
with his pain for so long, but that he had nally decided to
take his own life, stating, I just want the pain to go away.
In a small number of cases (n=27, 6 %), suicides were
identied as impulsive in nature. Impulsivity was char-
acterized by an immediate, unplanned response to an acute
or recent negative experience or situation, such as a break-
up, argument, or punishment. In these cases, the progression
toward suicide described above was not entirely supported.
Instead, these impulsive suicides, which were precipitated
by one or more problems, were not known to be precipitated
by premeditation and usually did not demonstrate the gra-
dual acquired capacity to inict self-harm in response to
long-term ideation or exposure to problems. In some cases,
however, victims did disclose suicidal intent; unfortunately,
they did so providing little, if any, time in which to effec-
tively intervene or respond to prevent the suicide. For
instance, one case narrative stated the 15 year old victim
and her mother had an argument, and victim became upset
and ed. During this argument she told her mother she was
going to kill herself.In another case, a 13 year old was
having disciplinary problems at school and became upset
when confronted by his mother, running to his room and
shutting the door. Ten minutes later, the victim was found
deceased. In another case, upon nding her boyfriend
deceased from a self-inicted gunshot wound after they had
an argument, a 15 year old girl used the same rearm to
immediately kill herself. Finally, one narrative described a
victim as quick to become emotional,indicating that he
had problems managing his anger and that he would
mention his wishes not to live, but these statements were
considered to be spur-of-the-moment and anger-driven
rather than disclosures of intent.
Little research has been conducted to identify the proximal
events leading to suicide among youth, barring small,
localized psychological autopsy studies and quantitative
studies that fail to examine the dynamic interplay of specic
experiences and the context in which they occur (Houston
et al. 2001; Karch et al. 2013; Moskos et al. 2005; Shaffer
et al. 1996). Given that youths coping skills are not fully
developed (Dumont and Provost 1999; Zimmer-Gembeck
and Skinner 2008), it is necessary to gain an understanding
of the imminent warning signs and precipitators of suicide
among youth. Building the evidence around such warning
signs, identifying common antecedents of suicide, and
understanding similarities between youths progression
toward suicidal behavior can help to inform theories
regarding suicidal behavior and suicide prevention strate-
gies specically targeting youth and adolescents.
J Youth Adolescence
Our results indicate that youth suicide is a result of a
constellation of risk factors, as opposed to only one specic
type of problem. Multiple problems spanning the social
ecology are often described in death investigation narra-
tives. The problems these youth experienced piled up
(e.g., parental ghting accompanied parental divorce, which
preceded a family move, which accompanied arguing
between parent and child), potentially making it seem as if
one particular negative experience was the nal straw that
resulted in suicide. However, our results demonstrate that
youth experienced many problems simultaneously and over
time, thus making it impossible to pinpoint one specic
event that led them to take their life.
Three main types of problemsschool-, relationship-,
and individual-level problemsemerged from the qualita-
tive data we examined, with relationship-level problems
being the most frequently noted, and conict within parent-
child relationships related to arguments, punishment, and
blended families being the most common of these problems.
However, individual-level problems, particularly mental
health problems, were the second most commonly noted
contributor to suicide. Other individual-level problems
included alcohol and substance abuse and a history of self-
harm ideation or behavior among a minority of youth.
Finally, while school-related problems were noted fairly
often as precipitators of youth suicide, bullying or teasing at
school was only apparent in 43 of the 193 cases that
involved school or social problems, and often, parents and
school ofcials were seemingly unaware of the problem.
Thus, bullying alone was not a prevalent contributor to the
broader group of suicides related to school problemsa
nding consistent with emerging literature (CDC 2014).
The results from this study are in line with other studies
identifying risk factors for youth suicide at multiple levels
of the social ecology. Many studies have indicated that
individual-level factors, particularly mental illness, are risk
factors for suicidal ideation and suicide (Gould et al. 1998;
Shaffer et al. 1996; Shai et al. 1988). At the relationship
level, family discord in the forms of parental divorce, child
maltreatment, and poor parent-child relationships have been
associated with an increased risk of suicide among youth
(Bridge et al. 2006), as have other family-related stressors,
such as a recent change or multiple changes in residence
(Cash and Bridge 2009; Qin et al. 2009). These factors were
frequently noted in case narratives included in the present
study (Cash and Bridge 2009).
Additionally, our results provide evidence in support of
both Sabbaths family systems theory of adolescent suicide
(1969) and Joiners interpersonal theory of suicide (2010) in
that this sample of youth demonstrated a consistent pattern
toward suicide. For instance, conict with parents and
feelings of unimportance, thwarted belongingness, and
perceived burdensomeness as a family member were
prevalent among our sample and described particularly in
relation to the victimspremeditative thoughts about sui-
cide. Several case narratives included quotes from parents
such as he didnt want to be around anymore,and the
family would be better offwithout the victim. Addition-
ally, Joiners theory extends beyond the family into social
circles where victims are described to be lacking con-
nectedness with their peers and with the school environment
in generalboth risk factors that were prevalent among this
sample. Further, Van Orden et al. (2010) described per-
ceived burdensomeness not only as perceived liability, but
also as affective thoughts of self-hatred, which were
apparent among our samplenarratives frequently indi-
cated that youth were angry with themselves and had low
self-esteem. Finally, the interpersonal theory of suicide also
delineates an acquired capacity to act on suicidal ideation
through the cumulative exposure to painful or threatening
experiences. Youth who previously engaged in non-suicidal
self-injury and/or attempted suicide lend support to this
component of the theory, as their continued non-suicidal
and/or suicidal behaviors may have served as an accumu-
lation of exposure to painful stimuli, allowing youth to
build up the required capacity to act on their suicidal
thoughts and plans.
Suicides identied as impulsive during our analyses
represent one exception to the standard progression toward
suicide theme which emerged from our data and do not
align well with Sabbaths and Joiners explicit theories of
suicidal behavior. However, Joiners theory implies an
indirect pathway toward suicide for impulsive individuals,
indicating that a decit in impulse control is an indicator of
other disorders, such as conduct disorder and intermittent
explosive disorder, and these disorders are associated with
an increased chance of acting on suicidal thoughts. In fact,
Van Orden and colleagues (2010) argue that the tendency to
be impulsive, in and of itself, may increase risk for lethal
self-harm because impulsivity is inherently a painful, fear-
inducing characteristic.
The qualitative ndings from this study underline results
from previous research and have important implications.
For instance, the nding that youth suicide is precipitated
by myriad social and individual-level factors highlights the
importance of multi-level, comprehensive interventions that
address individual beliefs and cognitions while also build-
ing and maintaining important community, family, and peer
relationships through strong social engagement, con-
nectedness, and support.
Further, given our nding that many youth suffered from
mental health problems, targeted approaches to combat
suicidal behavior among those at high risk, particularly
J Youth Adolescence
those who have expressed premeditative symptoms, may
help to prevent these tragic deaths. Many of the problems
experienced by our sample of youth decedents were known
to school or medical personnel who previously treated them.
Gatekeeper training (e.g., Walrath et al. 2015) to increase
the awareness of salient risk factors among youth may help
to effectively prevent destructive self-harm.
Finally, many of the youth in our sample disclosed sui-
cidal intent or had suicidal thoughts prior to their suicide.
As was the case for several deaths, one victims mother
attributed the victims behavior to attention seeking;and
one victims boyfriend indicated that the victim often
talked about killing herself, but he did not take her threats
seriously that day.This nding demonstrates the impor-
tance of heeding disclosures of suicidal intent and ideation,
taking them seriously, and seeking help from service pro-
viders when necessary. In addition to implementing cross-
cutting violence prevention programs and gatekeeper
training, linking youth to other services through research-
and evidence-based screening programs at school, in pri-
mary care settings, or emergency departments, and inte-
grating wrap-around services into a comprehensive care
system within these settings may also be a promising
practice for reducing suicidal ideation and behavior
(VanDenBerg 1993).
Limitations and Strengths
Though NVDRS narrative data can provide rich detail
regarding the stressful events experienced by youth who
have died by suicide, data quality varies by state and inci-
dent, and the law enforcement and coroner/medical exam-
iner reports are limited to information provided by next-of-
kin, parents, friends, and others familiar with the decedent,
who may not know all of the details regarding the victims
life or his/her decision to die by suicide. Additionally, those
interviewed during the suicide investigation process may
not feel comfortable sharing intimate details of their loved
ones life. Suicide and its contributors are often stigmatized
(Sudak et al. 2008), which may prevent people from fully
disclosing what they know. In some cases, few details are
provided because informants may not have been aware of
problems the decedents experienced, or information from
suicide notes and other data sources was not available. For
instance, given ndings from several studies demonstrating
a signicant association between sexual minority status and
suicidal ideation and suicide risk (Kann et al. 2016; Russell
and Joyner 2001; Stone et al. 2014), it is important to note
the limitation that data on decedentssexual orientation may
not be accurately captured through informantsreports.
Further, the small sample size used in this study and the
lack of data from every state, limit our ability to generalize
these ndings.
Notwithstanding these limitations, this study has several
strengths. It is the rst thorough qualitative analysis of
NVDRS data on youth suicide. Although psychological
autopsy studies use interview data from deceased indivi-
dualsfriends and family similar to that obtained through
the NVDRS to acquire information on suicide antecedents,
such studies are expensive and time-consuming because of
the primary data collection involved. The data for the cur-
rent study were abstracted directly from the NVDRS,
thereby providing an efcient manner through which to
study common precipitators of youth suicide. Further,
although the sample size for this study was small by
quantitative standards, using NVDRS data allowed for the
study of a relatively large sample of individuals for a qua-
litative study and resulted in the emergence of themes that
provide further evidence in support of quantitative studies
previously conducted. Finally, this study identied several
practical points of intervention and prevention.
This study reveals that the circumstances preceding suicide
among youth typically involve an interplay of multiple
individual, social, familial/parental, and school related
problems, which often compile and result in a progression
toward suicide. These ndings highlight the importance of
multi-level, comprehensive interventions that address indi-
vidual cognitions and build social connectedness and sup-
port (CDC 2009). Prevention strategies with demonstrated
impact on child abuse and neglect, sexual violence, dating
violence, youth violence and suicide are highlighted in
technical packages developed by CDC in an effort to guide
communities toward implementation of evidence-based
programs (Basile et al. 2016; David-Ferdon et al. 2016;
Fortson et al. 2016; Niolon et al. Forthcoming 2017; Stone
et al. Forthcoming 2017). The overlap in risk and protective
factors among these multiple types of violence is clearly
documented (Wilkins et al. 2014). Comprehensive violence
prevention programs with demonstrated impact on multiple
types of violence that have shared risk and protective factors
with suicide may hold promise for reducing youth suicide
downstream by preventing other types of violence asso-
ciated with suicidal behavior (e.g., dating violence, peer
violence) and helping youth to improve coping skills, build
healthy relationships, and enhance social connectedness
(e.g., Kellam et al. 2012; Wilcox et al. 2008; Wyman et al.
2010). Additionally, prevention strategies that increase
awareness of the warning signs and symptoms of suicide,
particularly among friends of at-risk youth, such as Signs of
Suicide (Schilling et al. 2016), may also be effective at
preventing youth suicide given that so many of the cases
included in this study involved disclosure of suicidal
J Youth Adolescence
ideation to friends. Finally, programs that enhance parenting
and family skills and reduce risk factors for suicide, such as
anxiety and depression (e.g., the Incredible Years; Webster
Stratton et al. 2008; WebsterStratton et al. 2011), or
address family problems, particularly arguments with and
punishment by parents may also help to prevent youth
suicide. Interventions that can interrupt the interaction of
these types of problems before they snowball might prevent
youth from falling into a state of hopelessness and help-
lessness to where they believe suicide is their only option.
Disclaimer The ndings and conclusions in this report are those of
the authors and do not necessarily represent the ofcial position of the
Centers for Disease Control and Prevention.
Funding This study received no ofcial funding and was conducted
by staff at the Centers for Disease Control and Preventions Division of
Violence Prevention using data from the National Violent Death
Reporting System, which is publicly available. Data collection through
the National Violent Death Reporting System is funded through state
health departments by the Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control, Division of Vio-
lence Prevention.
AuthorsContributions KMH conceptualized and drafted the
initial manuscript, coded narrative data and conducted analyses,
reviewed and revised the manuscript, and approved the nal manu-
script as submitted. AVK contributed to the conceptualization and the
design of the study, conceptualization and drafting the initial manu-
script, and approved the nal manuscript as submitted. JEL con-
tributed to the conceptualization and the design of the study,
conceptualization and drafting the manuscript, and approved the nal
manuscript as submitted. RWL contributed to the coding and analysis
of data, drafting the initial manuscript, reviewed and revised the
manuscript, and approved the nal manuscript as submitted. All
authors read and approved the nal manuscript.
Compliance with Ethical Standards
Conict of Interest The authors declare that they have no com-
peting interests.
Ethical Approval This article does not contain any studies with
living human participants or animals performed by any of the authors.
Informed Consent Data used in this study involved circumstances
surrounding the suicide deaths of de-identied deceased individuals.
Thus, for this type of study informed consent is not required.
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Kristin M. Holland is a behavioral scientist in the CDCs Division of
Violence Prevention Surveillance Branch. Her research interests
include the etiology and epidemiology of youth violence, homicide,
and suicide. She also has an interest in evaluating programs to prevent
youth violence, dating and sexual violence, and suicide.
Alana M. Vivolo-Kantor is a behavioral scientist in the CDCs
Division of Violence Prevention Research and Evaluation Branch. Her
research interests include evaluating teen dating violence and youth
violence prevention programs.
J. E. Logan is an epidemiologist in the CDCs Division of Violence
Prevention Research and Evaluation Branch. His research interests
include examining the etiology and epidemiology of suicide,
particularly in military populations.
Ruth W. Leemis is a behavioral scientist in the CDCs Division of
Violence Prevention Research and Evaluation Branch. Her research
interests include evaluating sexual violence prevention programs and
examining the epidemiology of homicide-suicide incidents.
J Youth Adolescence
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In the USA, crisis hotlines, such as the National Suicide Prevention Lifeline, have become a valued resource for individuals experiencing a suicidal crisis. Often staffed by trained counselors, crisis hotlines can provide immediate support and can help to identify a caller’s problem and potential solutions, ensure the caller’s safety, and connect them with appropriate resources. Notably, with the introduction of the 988 crisis system in the USA, it is important that crisis hotlines continue to improve their systems of care as their services will be used with increased frequency. This chapter highlights Behavioral Health Response (BHR), a regional crisis hotline located in St. Louis, Missouri, and details methods they have employed to address gaps in youth crisis response with the creation of the Youth Connection Helpline system. This chapter emphasizes the importance of integrating crisis hotlines with other community resources and the value of tracking outcomes to achieve intended goals. Guidance on how to implement and evaluate a youth-focused crisis system is provided.
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Although the last several years have been marked by significant advances in intervention efforts for youth suicide prevention, suicide remains the second leading cause of death among this age group in the United States. We discuss promising results from intervention research with the goal of informing policies for enhancing suicide prevention care for youth. Additionally, we review findings that denote the critical role of the media and civil legislation on youth suicide prevention.KeywordsSuicide preventionYouthFamilyInterventionCare linkageTherapeutic assessmentCBTDBTCare process model
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Lethal means counseling and safety planning (i.e., a written list of individualized coping strategies and sources of support) are empirically supported strategies to prevent suicidal behavior. Both approaches are often prescribed as ways to manage clients’ risk of suicide. However, there is limited guidance on how to effectively implement these strategies with youth. In this chapter, we review current literature on safety planning and lethal means counseling and highlight adaptations for working with youth. We further recommend areas for future research in training and implementation of safety planning and lethal means counseling.
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This chapter describes the role of machine learning in youth suicide prevention. Following a brief history of suicide prediction, research is reviewed demonstrating that machine learning can enhance suicide prediction beyond traditional clinical and statistical approaches. Strategies for internal and external model evaluation, methods for integrating model results into clinical decision-making processes, and ethical issues raised by building and implementing suicide prediction models are discussed. Finally, future directions for this work are highlighted, including the need for collaborative science and the importance of both data- and theory-driven computational methods.
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Preventing suicide in youth with autism spectrum disorder (ASD) and other intellectual and neurodevelopmental disorders (INDs) is a critical issue. In the USA, the overall number of individuals living with ASD and other developmental disabilities has been increasing in prevalence; in 2014 the prevalence of children ever diagnosed with any developmental disability was 5.76%, and this increased to 6.99% by 2016 (Zablotsky et al., 2017). Concurrent with the rise in IND prevalence is a troubling rise in the rates of suicide, with suicide now being the second leading cause of death among those between the ages of 10 and 24 in the USA (CDC, 2020). Due to gaps in our existing knowledge including a lack of validated assessment tools and suicide-specific treatments for these youth, researchers and clinicians alike grapple with how to prevent suicide in individuals with INDs. This chapter explores the evidence regarding the prevalence of suicidal ideation and behavior in this population and discusses lessons learned during the implementation of suicide prevention policies within programs serving patients with INDs at a large pediatric hospital setting.
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Suicide is the second leading cause of death among youth aged 10–19 years in the United States. Numerous risk factors are associated with suicide and suicidal behavior including individual, family, and social characteristics. Knowledge of the complex interplay of factors contributing to youth suicide is highly relevant to the development of effective prevention strategies.
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Youth who are lesbian, gay, bisexual, queer, and questioning (LGBQ PLUS_SPI ) and youth who are a gender distinct from their birth-assigned sex (i.e., transgender and gender diverse), collectively LGBTQIA PLUS_SPI , show nearly triple the risk for self-injurious thoughts and behaviors (SITBs). Research to date highlights that minority stressors across structural, interpersonal, and intrapersonal levels may help to explain this heightened risk. This chapter reviews the research linking stress across each of these levels on LGBTQIA PLUS_SPI SITBs. Moreover, this chapter reviews evidence-based treatments to reduce SITBs in LGBTQIA PLUS_SPI youth, highlighting that interventions that reduce minority stressors and increase coping skills in the context of minority stress appear most effective. In addition to inter- and intrapersonal-level interventions, we argue that major structural changes are needed to meaningfully reduce elevated risk for SITBs in LGBTQIA PLUS_SPI youth.
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Research concerning Black youth suicide and suicidal behavior is limited, yet the rates of these behaviors continue to rise in this population of youth. In children, 5–12 years, Black youth are two times more likely to die by suicide than their White peers, and suicide attempts among Black adolescents have increased by 73%. Understanding the risk factors associated with suicidal behavior in Black youth is imperative to create prevention efforts for Black youth. This chapter will discuss what is known concerning the topic of Black youth suicidal behavior and provide research, practice, and policy recommendations.
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Suicide risk screening for youth in medical settings, especially in primary care, is supported and encouraged by The Joint Commission, the American Academy of Pediatrics, and the National Action Alliance for Suicide Prevention. Implementing suicide risk screening and assessment with evidence-based tools can enhance feasibility of screening programs without overburdening busy systems of care. This chapter will highlight existing research on suicide risk screening and assessment in medical settings, discuss the importance of utilizing clinical pathways to effectively manage youth who screen positive for suicide risk, and provide recommendations on best practices for implementing suicide risk screening in medical settings.
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The rising rates of youth suicide in the USA demand thoughtful evidence-based strategies to help schools and communities recover after a suicide loss has occurred. With this chapter, we review research on the experience of suicide bereavement in adolescence, outline what is known about the potential for suicide to spread through social networks and for singleton suicides to escalate into suicide clusters, and discuss best practices for thoughtful postvention in schools and communities.KeywordsSuicide bereavementSuicide lossSuicideSchoolsGriefContagionClustersPostvention
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Introduction: Between 1999 and 2013, rates of suicide in mid-life increased more than 30%. The purpose of this study is to examine life stressors impacting middle-aged suicide, to determine whether these stressors vary by sex, and to explore their co-occurrence. Methods: A random sample of 315 men and 315 women aged 35-64 years was selected from 17 states implementing the National Violent Death Reporting System from its inception in 2003 to 2011. Data collection took place between 2003 and 2011 and analysis occurred in 2015. Analysis included coding circumstances of death noted in the law enforcement and coroner/medical examiner reports using an investigator-designed coding instrument. Using the most commonly cited life stressors as a basis, thematic analyses were conducted for cases. Quantitative comparisons of the most common circumstances by sex were calculated via multivariable logistic regression. Results: The five most common life stressors of suicide included intimate partner, job/financial, health, family, and criminal/legal problems. In adjusted analyses, job/financial problems and criminal/legal problems were more common among men, whereas health and family problems were more common among women. Men and women had similar rates of intimate partner problems. Life stressors also co-occurred, as found per qualitative and quantitative analyses. Conclusions: Men and women in mid-life have both common and unique circumstances preceding suicide. Prevention strategies that consider these circumstances and co-occurring circumstances are warranted.
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Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances. We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed. Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010. Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only. Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.
Introduction: The Centers for Disease Control and Prevention (CDC) developed the Web-based Injury Statistics Query and Reporting System (WISQARS(TM)) to meet the data needs of injury practitioners. In 2015, CDC completed a Portfolio Review of this system to inform its future development. Methods: Evaluation questions addressed utilization, technology and innovation, data sources, and tools and training. Data were collected through environmental scans, a review of peer-reviewed and grey literature, a web search, and stakeholder interviews. Results: Review findings led to specific recommendations for each evaluation question. Response: CDC reviewed each recommendation and initiated several enhancements that will improve the ability of injury prevention practitioners to leverage these data, better make sense of query results, and incorporate findings and key messages into prevention practices.
Background WISQARS is an interactive, web-based data query system (WBDQS) that is accessible from the internet. It includes modules for fatal and non-fatal injuries, a separate module on violent deaths, and injury costs and maps. Data come from a variety of trusted sources, including national health surveys and health data repositories. CDC created WISQARS in 1999 to meet the data needs of injury practitioners in the United States. Since that time, the audience has expanded to include researchers, policy makers, media, and the general public. Objective The purpose of this evaluation was to assess the focus, quality, usefulness, impact, and outcomes of WISQARS; and to identify gaps and areas for improvement. Data were collected through peer-reviewed and grey literature searches, google searches, an environmental scan of internal and external WBDQS, and a series of stakeholder interviews. Results WISQARS is used as a data source by NGOs, academic institutions, other U.S. federal agencies, and social media websites. Stakeholders most frequently used the fatal and non-fatal modules. The most frequently accessed data were on suicides, poisonings, homicides, motor vehicle crashes, and falls. WISQARS is most often used to respond to data requests, educate decision makers, conduct basic analyses, and teach and plan. Areas for improvement included building more capacity for data visualisations and for users to export both data and graphics, allowing for full mobile responsiveness when accessing, expanding by incrementally including additional data, and developing better support information and guidance on use. Conclusions While WISQARS has been largely a success in expanding access to U.S. injury and violence surveillance data, there are several opportunities to enhance the functionality of the system for the end user. CDC is planning to use innovations in data science to enhance WISQARS’s capacity.
Problem: Priority health-risk behaviors contribute to the leading causes of morbidity and mortality among youth and adults. Population-based data on these behaviors at the national, state, and local levels can help monitor the effectiveness of public health interventions designed to protect and promote the health of youth nationwide. Reporting period covered: September 2014-December 2015. Description of the system: The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors related to unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of obesity and asthma and other priority health behaviors. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and large urban school district school-based YRBSs conducted by state and local education and health agencies. This report summarizes results for 118 health behaviors plus obesity, overweight, and asthma from the 2015 national survey, 37 state surveys, and 19 large urban school district surveys conducted among students in grades 9-12. Results: Results from the 2015 national YRBS indicated that many high school students are engaged in priority health-risk behaviors associated with the leading causes of death among persons aged 10-24 years in the United States. During the 30 days before the survey, 41.5% of high school students nationwide among the 61.3% who drove a car or other vehicle during the 30 days before the survey had texted or e-mailed while driving, 32.8% had drunk alcohol, and 21.7% had used marijuana. During the 12 months before the survey, 15.5% had been electronically bullied, 20.2% had been bullied on school property, and 8.6% had attempted suicide. Many high school students are engaged in sexual risk behaviors that relate to unintended pregnancies and STIs, including HIV infection. Nationwide, 41.2% of students had ever had sexual intercourse, 30.1% had had sexual intercourse during the 3 months before the survey (i.e., currently sexually active), and 11.5% had had sexual intercourse with four or more persons during their life. Among currently sexually active students, 56.9% had used a condom during their last sexual intercourse. Results from the 2015 national YRBS also indicated many high school students are engaged in behaviors associated with chronic diseases, such as cardiovascular disease, cancer, and diabetes. During the 30 days before the survey, 10.8% of high school students had smoked cigarettes and 7.3% had used smokeless tobacco. During the 7 days before the survey, 5.2% of high school students had not eaten fruit or drunk 100% fruit juices and 6.7% had not eaten vegetables. More than one third (41.7%) had played video or computer games or used a computer for something that was not school work for 3 or more hours per day on an average school day and 14.3% had not participated in at least 60 minutes of any kind of physical activity that increased their heart rate and made them breathe hard on at least 1 day during the 7 days before the survey. Further, 13.9% had obesity and 16.0% were overweight. Interpretation: Many high school students engage in behaviors that place them at risk for the leading causes of morbidity and mortality. The prevalence of most health behaviors varies by sex, race/ethnicity, and grade and across states and large urban school districts. Long-term temporal changes also have occurred. Since the earliest year of data collection, the prevalence of most health-risk behaviors has decreased (e.g., riding with a driver who had been drinking alcohol, physical fighting, current cigarette use, current alcohol use, and current sexual activity), but the prevalence of other behaviors and health outcomes has not changed (e.g., suicide attempts treated by a doctor or nurse, smokeless tobacco use, having ever used marijuana, and attending physical education classes) or has increased (e.g., having not gone to school because of safety concerns, obesity, overweight, not eating vegetables, and not drinking milk). Monitoring emerging risk behaviors (e.g., texting and driving, bullying, and electronic vapor product use) is important to understand how they might vary over time. Public health action: YRBSS data are used widely to compare the prevalence of health behaviors among subpopulations of students; assess trends in health behaviors over time; monitor progress toward achieving 21 national health objectives for Healthy People 2020 and one of the 26 leading health indicators; provide comparable state and large urban school district data; and help develop and evaluate school and community policies, programs, and practices designed to decrease health-risk behaviors and improve health outcomes among youth.
This study replicated and extended previous evaluations of the Signs of Suicide (SOS) prevention program in a high school population using a more rigorous pre-test post-test randomized control design than used in previous SOS evaluations in high schools (Aseltine and DeMartino 2004; Aseltine et al. 2007). SOS was presented to an ethnically diverse group of ninth grade students in technical high schools in Connecticut. After controlling for the pre-test reports of suicide behaviors, exposure to the SOS program was associated with significantly fewer self-reported suicide attempts in the 3 months following the program. Ninth grade students in the intervention group were approximately 64 % less likely to report a suicide attempt in the past 3 months compared with students in the control group. Similarly, exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (1) intervening with friends who may be exhibiting signs of suicidal intent and (2) getting help for themselves if they were depressed or suicidal. In addition, high-risk SOS participants, defined as those with a lifetime history of suicide attempt, were significantly less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants. Differential attrition is the most serious limitation of the study; participants in the intervention group who reported a suicide attempt in the previous 3 months at baseline were more likely to be missing at post-test than their counterparts in the control group.
We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to Garrett Lee Smith (GLS) program efforts. We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score-based techniques. We also analyzed closely related outcomes that we did not expect to be affected by GLS as control outcomes. Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation. These results support the existence of an important reduction in youth suicide rates resulting from the implementation of GLS suicide prevention programming. (Am J Public Health. Published online ahead of print March 19, 2015: e1-e8. doi:10.2105/AJPH.2014.302496).