Study Finds Adolescent Suicidal Behavior Is Significantly Associated with Externalizing Behaviors and Violence Exposure

Suicide remains a leading cause of death among adolescents. A new study among US high school students has found that suicidal behavior is significantly associated with externalizing behaviors and violence exposure. The new study, appearing in the American Journal of Preventive Medicine, published by Elsevier, is the first to assess this association at the state level.

Although access to firearms and other weapon use contribute to suicide risk, the underlying risk for, and correlates of, firearm use among US adolescents is understudied. A cross-sectional study using data from 1991 to 2021 on 234,588 adolescents from the Youth Risk Behavior Survey examined the associations between externalizing behaviors, violence exposure, firearm carrying, and suicidal behavior to provide an assessment of the ways in which broader violence risk factors may increase the risk for injurious self-harm.

Externalizing behaviors are characterized by aggressive and disruptive behaviors that can be harmful to others or the social environment. Examples of externalizing behaviors and violence expression are threatening others with a weapon, starting a physical fight, and committing sexual violence.

First author Victoria A. Joseph, MPH, Department of Epidemiology, Columbia University Mailman School of Public Health, says, "We found significant associations between suicidal behavior and externalizing behaviors and violence exposure, with higher magnitudes of associations among those with a suicide attempt requiring medical treatment. The association between externalizing behaviors and violence exposure and injurious suicide attempt also varied over time and by sex."

Firearm-based suicide rates have increased among adolescents in recent years, suggesting a growing urgency to examine dynamics surrounding firearms and their role pertaining to suicidal behavior. Access to firearms and suicide rates in the US vary by state.

Ms. Joseph explains, "Suicide deaths are more prevalent among individuals who live in rural areas due in part to firearm access, isolation, and limited access to mental health services. State-level variations of suicide rates are heavily driven by suicide deaths involving firearms."

The study's researchers evaluated trends from data available from 16 states (ID, IL, IA, LA, MI, MS, MT, NE, NH, NM, NY, OK, PA, UT, VA, and WV) on carrying a gun or other weapon. They found that among adolescents with an injurious suicide attempt in 2021, state-level differences in weapon access emerged.

Ms. Joseph notes, “Although the prevalence of suicide involving firearms is higher in the West, surprising trends emerged such as low prevalence of weapon access among those with an injurious suicide attempt in gun ownership states such as Montana and high prevalence in states with low gun ownership such as New York. It should be noted that sparse data at the state level hindered the assessment of trends over time in every state. Due to variations in suicide rates, gun laws and weapon access in the US, state-level assessments of suicide risk and interventions are essential.”

Lead investigator of the study Katherine M. Keyes, MPH, PhD, Department of Epidemiology, Columbia University Mailman School of Public Health, concludes, “Firearm injury is a leading cause of morbidity and mortality among young people in the United States, including through suicidal behavior. Youth who carry weapons and have higher risks of engaging in physical violence also have a higher risk of self-inflicted violence, underscoring the need for stronger firearm protections to protect youth health.”

Notes for editors

The article is “Externalizing Behaviors/Violence Exposure and Suicide Among US Adolescents,” by Victoria A. Joseph, MPH, Noah T. Kreski, MPH, and Katherine M. Keyes, MPH, PhD (https://doi.org/10.1016/j.amepre.2024.08.014). It appears online in advance of the American Journal of Preventive Medicine, Volume 68, Issue 1 (January 2025), published by Elsevier.

The article is openly available for 30 days at https://www.ajpmonline.org/article/S0749-3797(24)00292-7/fulltext.

Full text of this article is also available to credentialed journalists upon request; contact Astrid Engelen at +31 6 14395474 or [email protected]. Journalists wishing to interview the authors should contact Stephanie Berger at [email protected].

All phases of this study were supported by NIH grant R01-DA048853.

About the American Journal of Preventive Medicine

The American Journal of Preventive Medicine is the official journal of the American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials. https://www.ajpmonline.org/

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