Relationship violence is a common problem faced by adolescents in the United States. In general, adolescents are at higher risk for relationship victimization than adults (Silverman, Raj, Mucci, & Hathaway, 2001), and females between the ages of 16 and 24 years are at the highest risk of relationship victimization (Rennison, 2001). This study uses data from the 2007 Youth Risk Behavior Surveillance (YRBSS) System (or referred to as Youth Risk Behavior Survey [YRBS]; N = 11,781) of adolescents between the ages of 14 and 17 years to estimate two logistic regression models on the association between relationship violence and suicidal behaviors controlling for variables such as sexual assault and drug use. The findings indicated that victimized adolescents are at higher risk for planning and/or attempting suicide compared to nonvictimized adolescents. Implications for research and practice are explored.
Keywords: juvenile behavior; suicide; sexual assault; adolescent dating violence; suicidal ideation
Suicide is the third leading cause of death among adolescents and young adults in the United States (The National Adolescent Health Information Center [NAHIC], 2006). Statistics indicate that suicidal behavior increases dramatically between early adolescence (10-14 years old) and young adulthood (20-24 years old; NAHIC, 2006). Furthermore, for every successful adolescent suicide, there are approximately 100-200 unsuccessful attempts (Centers for Disease Control and Prevention [CDC], 2009). On average, males are more likely to be successful in their suicide attempts, whereas females tend to engage in much higher rates of nonfatal suicidal behavior (Brockington, 2001). In fact, research indicates that 1 in 10 adolescent girls are estimated to have attempted suicide in her lifetime as compared to 1 in 25 adolescent boys (Lewinsohn, Rohde, & Seeley, 1996). Clearly, adolescent suicidal behavior is a major public health concern.
Given the alarming prevalence of suicidal behavior among adolescents in the United States, more research on the causal factors of suicidal ideation and actions will be influential in developing appropriate prevention strategies targeting adolescent populations. Research on risk factors of suicidal behavior among adolescents and young adults indicate that substance abuse, sexual assault, family violence, psychological disorders such as depression and posttraumatic stress disorder (PTSD) and family history of substance abuse or psychological disorders predict suicidal behavior (Deykin & Buka, 1994; Epstein & Spirito, 2009; Flisher et al., 2000; Wilcox & Anthony, 2004; Wu et al., 2004). A number of studies have suggested a relationship between both physical and sexual violence and suicidal behavior; however, few studies have specifically explored the association between relationship violence and subsequent suicidal ideation or actions. Fewer still have examined the relationship of these variables among adolescent samples.
The adolescent stage in development corresponds with initiation into dating relationships. In adolescence, teenagers begin to experiment with various romantic and sexual experiences as well as some of the negative outcomes of those experiences, including violence. Because teenagers are relatively inexperienced with relationships, they are often more vulnerable to victimization. Adolescent dating relationships often involve physical or sexual violence, or both. In fact, teenagers are at higher risk for intimate partner violence than adults (Silverman, Raj, Mucci, & Hathaway, 2001). At the same time, females are more likely than males to be a victim of physical or sexual violence by an intimate partner or known perpetrator. Survey data indicates that about 20% of female high school students report being physically or sexually assaulted by a date (Silverman et al, 2001). In fact, females between the ages of 16 and 24 years are at the highest risk for IPV, three times higher than the national average (Rennison, 2001).
In an effort to add to the literature on factors associated with adolescent suicidal behavior and to encourage policy discussions on prevention, this study will examine the association between relationship violence and suicidal behaviors among a nationally representative sample of U.S. high school students. To accomplish this, suicidal behaviors was broken down into two categories: suicide ideation (thoughts of suicide) and suicidal action (taking overt action to commit suicide but failed to complete the act). This study uses data from the 2007 Youth Risk Behavior Survey (YRBS) of adolescents in high school between the ages of 14 and 17 years to estimate two logistic regression models on the association between relationship violence and suicidal behaviors (suicidal ideation and suicidal actions). Because adolescent dating behavior often involves violence and much of that violence is often directed at females, establishing relationship violence as a predictor of suicidal behavior may be particularly useful in explaining the gender gap in suicidal behavior. Further research and policy recommendations will also be discussed.
VIOLENT VICTIMIZATION AND SUICIDAL BEHAVIOR
Numerous studies have examined the association between violent victimization and suicidal ideation and/or actions using different sampling strategies and research designs. Whereas some studies have used probability samples from the general population, others have used nonprobability samples of students or clinical patients. Most studies have used cross-sectional data and relied on single-item measures, whereas few studies have used longitudinal data and multi-item measures. Furthermore, many studies have used adult samples, whereas others have used children and adolescents. Despite the variance in research strategies, on average, research findings indicate an association between violent victimization, either physical or sexual, and suicidal behavior.
Borowsky, Ireland, and Resnick (2001) used longitudinal data from the National Longitudinal Study of Adolescent Health (Add Health) from 1995 to 1996 to study risk factors for suicidal behavior in 7th to 12th graders in the United States (N 5 13,110). Consistent with previous cross-sectional studies on the risk factors of suicidal behavior (Garrison, McKeown, Valois, & Vincent, 1993; Resnick et al., 1997; Woods et al., 1997) as well as smaller longitudinal studies (McKeown et al., 1998), their findings indicate that the main predictors of suicidal behavior include involvement in interpersonal violence (as perpetrator, victim, or both) and substance abuse. In fact, interpersonal violence was one of the strongest predictors of self-injurious behavior.
Bossarte, Simon, and Swahn (2008) used cross-sectional data from a sample of dating adolescents from a high school district in a high crime area in the United States (N 5 1,653) and found that individuals exposed to or involved in more frequent incidents of interpersonal violence are also likely to be at higher risk for self-inflicted violence. Earlier studies on the association between violent behavior and suicidal behavior have found similar results (Orpinas, Basen-Engquist, Grunbaum, & Parcel, 1995; Sosin, Koepsell, Rivara, & Mercy, 1995). In a study of public high school students in New York state (N 5 1,569), 11% of respondents reported to have experienced both violent and suicidal behavior in the past year (Cleary, 2000). Similarly, Swahn, Lubell, and Simon (2004) used national YRBS data (N = 11,815) from 2001 and found that both male and female high school students who reported to have attempted suicide in the last year were also five times more likely to have been involved in a physical altercation during the same time period.
Research findings, however, have been consistent in suggesting strong relationships between sexual assaults and suicidal behavior. Davidson, Hughes, George, and Blazer (1996) used data from an epidemiological study (N 5 2,851) and found that sexual assault was related to a higher risk of suicide attempts and that a history of sexual assault prior to the age of 16 was a particularly strong correlate of suicidal behavior for females. Nelson, Higgingson, and Grant-Worley (1994) used cross-sectional data from high school students in Oregon (N 5 2,332) to study the effects of sexual abuse or assault and found that students that had been sexually assaulted in the past year reported more suicide ideation in the past year as well. Subsequent studies have found similar results. These studies suggest that sexual assault may predict suicidal behavior, especially in the short term. Furthermore, these studies suggest higher rates of sexual victimization and suicidal behavior among females and a stronger relationship between the variables for female participants (Ullman, 2004).
RELATIONSHIP VIOLENCE AND SUICIDAL BEHAVIOR
Previous research indicates that physical and sexual victimization may be a significant predictor of adolescent suicidal behavior; however, few studies have examined the relationship between violent victimization within the context of adolescent dating relationships and risk of suicidal behavior. Most research on relationship violence and its physical and psychological consequences have focused on adult couples; however, it is well known that relationship violence frequently begins during adolescence. Nevertheless, only few studies have addressed its effects on high school students. Swahn et al. (2008) used crosssectional data from the Youth Violence Survey from 2004 (N = 4,131) and found that both peer violence and relationship violence were associated with suicidal behavior among the sample of public school students. Kreiter et al. (1999) used data from students in 8th to 12th grades in Vermont (N 5 20,724) to study the correlates of relationship violence and found relationship violence to be correlated with suicidal behavior in both girls and boys, although the relationship was stronger for girls. Similarly, Howard and Wang (2003) used national YRBS data (N = 7, 824) from 1999 and found a clustering of dating violence and suicide attempts among adolescent girls.
Some studies have found that dating violence involving sexual assaults may also be positively correlated with suicidal behavior. Silverman et al. (2001) found that physical and sexual dating violence are associated with many negative outcomes, including suicidality. In a study of 9th and 12th grade students in Minnesota (N 5 81,247), Ackard and Neumark-Sztainer (2002) found that girls had greater odds of suicide ideation and attempts if they had experienced date rape than nonsexually assaulted girls. They also found that more than 50% of youths reporting both physical violence and rape also reported attempting suicide. Molidor, Tolman, and Kober (2000) found that relationship violence is associated with many negative outcomes, including substance abuse, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicide.
This research will add to the literature on the risk factors of suicidal behavior focusing on the association between relationship violence and adolescent risk of suicide, particularly ideation and action. This study is based on the hypothesis that relationship victimization will predict suicidal behavior and that this association is likely to be stronger for females than males. Many studies have considered the effects of relationship violence on females exclusively because it is assumed that girls are more likely than boys to suffer injury from partner violence (Gelles, 1981; Lane & Gwartney-Gibbs, 1985); however, there are strong indications that violence in adolescent dating relationships involves the reciprocal use of violence by both partners (Foshee, 1996; Gaertner & Foshee, 1999; Gray & Foshee, 1997; O'Keefe, Brockopp, & Chew, 1986). It is important to assess the effects of relationship violence on male suicidal behavior as well and, therefore, this study takes a more gender-neutral approach.
Sample and Data
The sample for this study consisted of a nationally representative sample of public and private high school students in the United States who participated in the 2007 Youth Risk Behavior Surveillance (YRBSS) System (or referred to as Youth Risk Behavior Survey [YRBS]; N 5 14,028). The YRBS is an 87-question survey conducted by the CDC between February and May of each odd-numbered year (CDC, 2007). The rationale of the YRBS is to monitor six types of health risk behaviors among adolescents, including tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, physical activity, and behaviors that increase risk for intentional and unintentional injuries (CDC, 2007). Schools with relatively high numbers of minority students were oversampled to ensure adequate representation of these groups. Participation in the survey was voluntary and the parents of the participants were required to consent to their child's participation in the survey. Survey responses were anonymous (CDC, 2007).
The school response rate was 81%, and the student response rate was 84% (CDC, 2007). The 14,041 students completed the national survey in 2007, and the overall response rate was 68% (CDC, 2007). For the purposes of this research, only adolescents aged 14-17 years were included in this study. Adolescents younger than 14 years old were excluded because the sample represented a small percentage of the entire population (, .01%). The final sample size used is 11,781. Data from the 2007 YRBS indicates that approximately 14.5% of high school students in the United States-18.7% of females and 10.3% of males-have seriously considered suicide in the last 12 months preceding the survey (CDC, 2007).
Dependent Variable(s)-Suicidal Behaviors. We included two measures of suicidal behavior. Our first measure is suicidal ideation-a phrase used in the medical and psychological community to describe a person's thoughts of suicide. Our second measure is suicidal action, a phrase that represents suicide attempts (i.e., overdosed on pills, cut wrist with intent to die, etc.). Suicidal ideation was measured by two questions: (a) if the respondent reported having seriously considered suicide during the past 12 months (1 5 yes) and (b) if the respondent had made a plan about how he or she would attempt suicide during the past 12 months (1 5 yes). Similarly, suicidal action was measured by asking two questions: (a) how many times the respondent actually attempted suicide during the past 12 months (1 5 one or more times) and (b) if any attempt resulted in an injury, poisoning, or overdose that had been treated by a nurse or doctor (1 5 yes). For the purposes of this research, we are defining a suicide attempt as any overt action made to take one's own life but does not result in taking of one's life. An injured suicide attempt is when a person is physically harmed from the attempt to take one's life but is not successful at it. An example of this would be overdosing on pills that resulted in medical assistance or the cutting of ones wrists that required medical intervention. For the purposes of this research, considering suicide or suicide ideation is when a person thinks about killing oneself but fails to follow through with this. The person only contemplates killing oneself but does not go beyond just thinking about it. In suicide plan, this is when a person has made an overt act to plan to commit suicide but has failed to fully complete it. For example, writing a suicide note or purchasing a firearm with the intent to take one's life. These measures of suicidal behaviors have been shown to be reliable indicators assessed in the YRBS and by Cohen's kappa statistics.
Independent Variable-Relationship Violence. The primary independent variable in this study is a measure of relationship victimization. The measure for relationship victimization is based on the following question from the YRBS survey: In the last 12 months, have you ever been hit, slapped, or physically hurt on purpose by a boyfriend or girlfriend? The variable was coded 0 = no and 1 = yes.
Control Variables. Various demographic control variables were used. These control variables were used based on their relevance in previous suicide research and are consistent with the control variables used in previous studies (Woods et al., 1997). The demographic control variables used for this research are age, race, and gender. The age variables were coded 0 5 14 and 15 year olds and 1 5 16 and 17 year olds. The race variable was coded 0 5 White and 1 5 non-White or minority. The gender variable was coded 0 5 male and 1 5 female. Two other control variables were also used due to their relevance to earlier research on the predictors of suicidal behavior. These variables are drug use and sexual abuse history. The adolescents were asked in the YRBS: (a) How many times did they use cocaine? (b) How many times did they use marijuana? (c) How many times did you use heroin? Responses were coded as 0 5 never used and 1 5 used at least once. Sexual assault history was measured based on the following question from the YRBS survey: Have you been forced to have sexual intercourse when you did not want to? This variable was coded 0 5 no and 1 5 yes. It was expected that gender, drug use, and sexual assault history would be statistically significant predictors of suicidal behavior and that relationship victimization would also be a statistically significant predictor of suicidal ideation and action, controlling for the other predictors.
Model Estimation and Analytic Strategy
To examine the relationship between suicidal behaviors and victimization, we estimated a logistic regression model in SPSS version 17.0. Logistic regression may be used solely with two types of variables: a categorical variable that has exactly two categories (dichotomous variable) and a continuous target variable that has values in the range of 0-1 (Fox, 2008). Logistic regression is a statistical technique using predictive modeling procedures that may be used when the predictor and outcome variables are categorical with two binary categories. For the purposes of this research, the dependent variables are recoded. For example, 0 5 no suicide ideation/action and 15 suicide ideation/action.
The interpretation of the aj parameter estimates is as the additive effect on the log odds ratio for a unit change in the jth explanatory variable. The rationale of a binary dichotomous explanatory variable, for example, is the time of the suicide ideation and action (no suicidal ideation 5 0 or presence of suicidal ideation 5 1; no suicidal action 5 0 or presence of suicidal action 5 1), ea is the estimate of the odds ratio of having the outcome for suicide behavior.
The variance inflation factor (VIF) was also used as a separate multicollinearity diagnostic test to determine if multicollinearity truly existed in the regression analysis. The VIF measures how much variance that a regression coefficient has increased due to the presence of correlated variables (Gujarati, 2003). According to Gujarati (2003), multicollinearity might exist if the VIF factor is around 10. The VIF results averaged 1.26 across all models. This concludes that the likelihood of multicollinearity within the confines of this research is well below the accepted threshold.
Table 1 presents a brief descriptive analysis of the adolescents that participated in the 2007 YRBS. Most of the sample (60.9%) consisted of older youth who were 16 and 17 years old. The sample was fairly evenly divided by gender. Males represented 50.7% of the sample, whereas females represented 49.2%. A slight majority of the adolescents in this sample were members of a racial/ethnic minority group (58.2%). Consistent with the previous literature, most youths in this sample had never used drugs. The most common drug used was marijuana (38.1%), followed by cocaine (7%) and heroin (2%). Most youths in this sample did not report being a victim of relationship violence-the main predictor variable examined in this research.
The logistic regression estimates [Exp (b)] for each model are presented in Table 2. Model 1 examines the association between relationship violence and suicide action, whereas Model 2 examines the association between relationship violence and suicide ideation. The results of these models are consistent with the literature. Results indicate that adolescents who experience relationship violence are at a higher risk for engaging in suicidal behaviors than youth who are not victimized. Relationship violence is a statistically significant (p < .001) predictor of all four measures of suicidal behavior (suicide attempt, injured from suicide attempt, considered suicide, made a suicide plan).
Regarding race, the only significant relationship between the predictor variables is between race and attempting suicide (Exp (b) = .375, p < .001). Age was negatively related to all four of the outcome variables indicating that younger adolescents were more likely to report suicide ideation and action. However, age was only significantly related to considering suicide (Exp (b) = 2.186, p , .01) and attempting suicide (Exp (b) 5 2.275, p < .01). Gender was positively and significantly related to each dependent variable. Female adolescents were more likely than males to report having suicidal ideation or taking suicidal action.
All three of the used substance variables (marijuana, cocaine, and heroin) are significantly and positively related to all four of the outcome variables, indicating that the use of any of these substances increases an adolescents' odds of engaging in any of the suicide outcome measures included in this study. Of the three substances measured in this study, heroin consistently increases the odds of suicide ideation (Exp (b) for considered suicide = 2.01, Exp (b) for suicide plan = 2.11, p < .001, respectively) or suicide action (Exp (b) for attempt suicide = 2.56, Exp (b) for injured from suicide attempt 5 3.94, p , .001) more than two times.
Youth who reported being victims of relationship violence were almost twice as likely to consider and to actually attempt suicide (Exp (b)'s = 1.85 and 1.86, p , .001, respectively) than youth who did not report being assaulted by a boyfriend or girlfriend. The variable of physical assault by boyfriend or girlfriend is statistically significant in predicting suicide attempt and making a suicide plan after controlling for both drug use and sexual assault. Regarding making a suicide plan, the only two variables that are more predictive than physical assault are sexual assault and heroin use (odds ratios of 2.24, 3.61, and 3.94, respectively). Adolescents who report being physically assaulted by a boyfriend or girlfriend are almost 62% (Exp (b) = .619, p < .001, respectively) more likely to attempt suicide than adolescents who had not been physically assaulted. Clearly, adolescent relationship violence is a serious problem that may increase vulnerability to self-inflicted injury.
DISCUSSION AND LIMITATIONS
Suicide is one of the most common causes of death among teenagers and young adults between the ages of 15 and 24 years (CDC, 2002). Annually between 2,000 and 2,500 adolescents under the age of 20 commit suicide in the United States (CDC, 2002). Much of the research that examines adolescent suicidal behavior fails to give specific reasons for the behavior (Rutter & Behrendt, 2004). Research suggests that adolescents, who face other problems such as substance abuse, medical or psychiatric problems, prior history of abuse, or a history of suicide in the family are at increased risk for becoming suicidal (Grholt, Ekeberg, & Wichstrom, 2000; Rutter & Behrendt, 2004). This study was conducted to examine the association between relationship victimization and suicidal behavior among high school students.
The association between violent victimization and suicidal behavior has been examined in previous research (Orpinas et al., 1995; Sosin et al., 1995). The findings of this study are consistent with earlier research and indicate a moderate association between violent victimization and suicidal behavior among adolescents. In other words, adolescents who experience relationship victimization are more likely than nonvictims to engage in self-inflicted violence. Considering adolescents' limited experience with romantic relationships, adolescents are likely to find it particularly challenging to deal with some of the challenges of intimate relationships. Some may respond to relationship difficulties with violence. Others may find themselves without adequate coping strategies to manage these violent conflicts and may turn toward self-inflicted violence to cope with the physical and psychological pain.
Relationship violence may, in fact, have an even stronger effect on suicidal behavior than what this study suggests. The control variable of sexual assault history is based on a question that asked respondents about whether or not they had ever experienced forced sex. Although some adolescents may have responded in the affirmative to this question based on prior abuse history in which a parent, family member, neighbor, or stranger was involved, many others are likely to have considered situations in which a boyfriend or girlfriend acted forcefully or coercively to compel the respondent when he or she did not really want to have sex. Considering the prevalence of sexual attacks by perpetrators known to victims (intimates or acquaintances), it is highly likely that many sexual attacks are, in fact, relationship violence. Future research with more specific measures may be able to shed light on the effects of both physical and sexual relationship victimization on subsequent suicidal behavior among adolescents.
Before addressing the implications of this study, it is important to mention certain limitations. The YRBS has been used in many previous studies and is a recognized source of data on adolescents in the United States; however, it is important to note that the study is limited by the YRBS screening instrument, and the measures used are limited by the questions asked in the survey. Furthermore, the self-reporting nature of the data also presents some limitations. Self-report data may be susceptible to sampling errors, inaccurate reporting, telescoping, untruthfulness, and social desirability. It is always possible that the adolescents participating in the survey might be exaggerating or telling the researchers what they think the researchers want to hear. Another limitation of this study is that we cannot control for the presence of depression among adolescents. Depression would be confounding because suicidal behavior and depression are strongly correlated. A final limitation is the lack of a more comprehensive set of control variables. A study that could include more control variables would be optimum.
These limitations aside, we believe the findings provide important policy implications for secondary education institutions. It is true that parents are often on the front line of spotting this problem and intervening in the child's life; however, children often spend most of their day interacting with peers and teachers in an academic environment. This research proposes that the schools are also in a position to observe these children and spot potentially harmful behavior. Secondary school teachers receive a lot of education of understanding teenage relationships and providing support to these kids outside the academic curriculum. This research proposes that the culture of secondary education must change its line of thinking that suicidal ideation is a short-term behavioral issue. Although adolescents have been known to threaten or attempt suicide as a cry for attention, many adolescents use suicide as a last means to get rid of the physical and psychological pain of violent victimization. Schools, along with parents, are also on the front line when dealing with these victimized adolescents. Schools should take on a more active role in engaging youth on matters of relationship socialization, relationship violence, sexual coercion, and coping strategies to manage various problem situations. To accomplish this, the schools must increase the presence of qualified mental health professionals to assist the students with relationship issues and socialization. Furthermore, more training is needed to educate secondary teachers and staffabout the danger signs so that they are able to intervene and provide assistance to adolescents before situations escalate to suicide. This includes referring them to a mental health specialist that is available at the school to intervene in a timely manner. Early interventions are essential for prevention. Furthermore, more research is needed to examine the precise causes and effects of suicidal behavior, not just from a risk factor perspective.
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Scott H. Belshaw, PhD
University of North Texas
Julie Ahmad Siddique
John Jay College of Criminal Justice, New York
University of Cincinnati, Ohio
G. Solomon Osho, PhD
Prairie View A & M University, Texas
Correspondence regarding this article should be directed to Scott H. Belshaw, PhD, University of North Texas, Department of Criminal Justice, 1155 Union Circle #305130, Denton, TX 76203. E-mail: email@example.com…