Antecedents of Suicide among Youth Aged 11–15: A Multistate Mixed Methods Analysis

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 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.

Full text

J Youth Adolescence
DOI 10.1007/s10964-016-0610-3
EMPIRICAL RESEARCH
Antecedents of Suicide among Youth Aged 11–15: A Multistate
Mixed Methods Analysis
Kristin M. Holland
1
●Alana M. Vivolo-Kantor
1
●Joseph E. Logan
1
●Ruth W. Leemis
1
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 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 pre-
ceded 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.
Keywords Youth suicide ●Precipitating factors ●
Qualitative analysis
Introduction
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 CDC’s2015 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
KHolland@cdc.gov
1
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 modifiable factors that may help prevent youth
suicide has never been as imperative as it is now.
A review by Gould et al. (2003) identified 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 identified. 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, Sabbath’s(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 Sabbath’s 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.
2010,2008).
Youth suicide prevention programs have been developed
to impact modifiable 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 youth’s 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 influence 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 officials. 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 quantified the common precipitators of
suicide among youth 10 to 14 years old, finding 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 specific types dating
partner problems and school problems (e.g., fights, break-
ups, bullying and teasing at school, sports-related
problems).
Psychological autopsies, which involve synthesizing
relevant information on decedents’lives 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 quantified the frequency with which
parents, siblings, friends, distant relatives, and other infor-
mants reported problems experienced by the decedent after
his/her death, finding 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 findings.
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 old—a 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 decedents’family, 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 identified 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.
Method
Data Source and Study Population
A total of 1,606 suicides among youth aged 11–15 were
recorded in 17 of the 18 U.S. states that participated in the
NVDRS from 2003 to 2014
1
. The NVDRS collects quan-
titative and qualitative details on violent death incidents,
including suicide. Data sources for the NVDRS include
death certificates, 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 olds—all with known circum-
stances—were 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 find any sig-
nificant 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.
1
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 2005–2008;
however, these data were excluded because collection was not
statewide.
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 modified 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 decedent’s 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
confirmed vs. perceived, type of mental health problem
experienced, type of dating partner problem). The final
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
coefficient 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 final
coding guide.
In the third and final 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 filed in
the most frequently coded categories were quantified as well
as identified as either a school-, relationship-, or individual-
level factor in order to provide detail regarding the sample-
specific prevalence of key precipitators of suicide.
Results
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 decedents’acquired 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-specific school problems
(n=50, 26 %) contributed to more suicides than any other
type of school-related problem. Non-specific 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, 2003–2014
n%
Sex
Male 335 69.5
Female 147 30.5
Race
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 school”with no specific details noted.
School disciplinary problems that were specified, 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
problems
Depression
Anxiety
PTSD
Other
Diagnosed mental health problems
Depression
Anxiety
PTSD
ADHD
Other
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
Recent
History
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
attempts
Family history of suicide
Decedent’s history of suicide attempts
Decedent’s history of suicidal ideation
Physical health
problems
Disability
Other physical problems
Relationship problems Family problems
Argument with parents
Punishment by parents (or threatened
punishment)
Argument with siblings
Recent move
Living in blended family
Thwarted belongingness
Non-specific problems with friends
(not school-related)
Dating partner problems
Infidelity or accused infidelity
Table 2 continued
Overarching code Subcode
Jealousy
Dating partner violence victimization or
perpetration
Recent break-up
Other un-specified relationship problems
School-related
circumstances
Confirmed bullying
Perceived bullying (e.g., bullying assumed
by parents/friends/schoolmates, but not
confirmed 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 specifics provided
Thwarted belongingess
Physical fighting 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
premeditation
Left a note
Disclosed intent
Posted suicidal intent on social media
websites
Texted friends/family about suicide
intentions
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 victim’s 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 difficulty at school with grades and had
been ‘acting out’lately.”
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 difficulty “fitting 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 difficulty making
friends. Another victim’s 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 victim’s
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 mother’s 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-specific school problems Victim was crying previous day [emotional state—depressed mood] and told her mother it was
something at school [non-specific 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)
Victim’s 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
abuse)
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 problem—depression.
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 victim’s 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 modified non-substantively only to reduce risk of victim identification
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
“didn’t care”about 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 member’s 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 Deficit 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-specified 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-
firmed that he had a history of cutting himself. Also of note
in this case is that other risk factors for suicide were iden-
tified, including peer suicides, an argument with family, and
tensions with friends.
Twenty-five youth (5 %) in this sample had either a
family history of suicide or had been exposed to a friend or
acquaintance’s 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 friend’s suicide were suspected to have
been involved in a suicide pact. In two of these cases, the
suicide occurred immediately following the first victim’s
suicide, using the same firearm. 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 victim’s 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 five decedents
in this sample (n=88, 18 %) experienced all three types of
problems—individual, 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 problems—either 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 decedent’s 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 victims’suicide notes,
which often indicated a build-up of pain and suffering and
an inability to cope in another way. For instance, one vic-
tim’s note stated that “he was in so much pain and tried to
deal with it, but he just couldn’t 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 finally 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
identified 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 inflict 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 fled. 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 finding her boyfriend
deceased from a self-inflicted gunshot wound after they had
an argument, a 15 year old girl used the same firearm 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.”
Discussion
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 specific
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 youth’s 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 youth’s progression
toward suicidal behavior can help to inform theories
regarding suicidal behavior and suicide prevention strate-
gies specifically 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 specific
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 fighting 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 final 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 specific
event that led them to take their life.
Three main types of problems—school-, relationship-,
and individual-level problems—emerged from the qualita-
tive data we examined, with relationship-level problems
being the most frequently noted, and conflict 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 officials were seemingly unaware of the problem.
Thus, bullying alone was not a prevalent contributor to the
broader group of suicides related to school problems—a
finding 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; Shafii 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 Sabbath’s family systems theory of adolescent suicide
(1969) and Joiner’s interpersonal theory of suicide (2010) in
that this sample of youth demonstrated a consistent pattern
toward suicide. For instance, conflict 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 victims’premeditative thoughts about sui-
cide. Several case narratives included quotes from parents
such as “he didn’t want to be around anymore,”and the
family “would be better off”without the victim. Addition-
ally, Joiner’s 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 general—both 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 sample—narratives 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 identified 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 Sabbath’s and Joiner’s explicit theories of
suicidal behavior. However, Joiner’s theory implies an
indirect pathway toward suicide for impulsive individuals,
indicating that a deficit 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.
Implications
The qualitative findings from this study underline results
from previous research and have important implications.
For instance, the finding 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 finding 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 victim’s mother
attributed the victim’s behavior to “attention seeking;”and
one victim’s boyfriend indicated that the “victim often
talked about killing herself, but he did not take her threats
seriously that day.”This finding 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 victim’s
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
one’s 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 findings from several studies demonstrating
a significant 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 decedents’sexual orientation may
not be accurately captured through informants’reports.
Further, the small sample size used in this study and the
lack of data from every state, limit our ability to generalize
these findings.
Notwithstanding these limitations, this study has several
strengths. It is the first thorough qualitative analysis of
NVDRS data on youth suicide. Although psychological
autopsy studies use interview data from deceased indivi-
duals’friends 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 efficient 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 identified several
practical points of intervention and prevention.
Conclusions
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 findings 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; Webster‐Stratton 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 findings and conclusions in this report are those of
the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Funding This study received no official funding and was conducted
by staff at the Centers for Disease Control and Prevention’s 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.
Authors’Contributions KMH conceptualized and drafted the
initial manuscript, coded narrative data and conducted analyses,
reviewed and revised the manuscript, and approved the final 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 final manuscript as submitted. JEL con-
tributed to the conceptualization and the design of the study,
conceptualization and drafting the manuscript, and approved the final
manuscript as submitted. RWL contributed to the coding and analysis
of data, drafting the initial manuscript, reviewed and revised the
manuscript, and approved the final manuscript as submitted. All
authors read and approved the final manuscript.
Compliance with Ethical Standards
Conflict 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-identified 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 CDC’s 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 CDC’s
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 CDC’s 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 CDC’s 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