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From the Centers for Disease Control and Prevention
July 28, 2004

Suicide Attempts and Physical Fighting Among High School Students—United States, 2001

JAMA. 2004;292(4):428-430. doi:10.1001/jama.292.4.428

MMWR. 2004;53:474-476

1 table omitted

Violence is a major cause of morbidity and mortality, particularly among youths. In the United States, homicide and suicide are the second and third leading causes of death, respectively, for persons aged 13-19 years.1 Although suicide commonly is associated with anxiety, depression, and social withdrawal, research suggests a link between violent behaviors directed at oneself (i.e., suicidal behaviors) and violent behaviors directed at others among adolescents.26 Certain students who engage in extreme forms of violence, such as school shootings, exhibit suicidal ideation or behavior before or during the attack.2,3 However, suicidal behavior also might be associated with involvement in less extreme forms of violent behaviors, such as physical fighting, which might be a risk factor for more severe forms of violence.3 To characterize any potential association between suicide attempts and fighting, CDC analyzed self-reported 2001 data from a nationally representative sample of high school students in the United States. The results of that analysis indicated that students who reported attempting suicide during the preceding 12 months were nearly four times more likely also to have reported fighting than those who reported not attempting suicide. Prevention programs that seek to reduce both suicidal and violent behaviors are needed. Because prevalence of this association was determined to be highest in the 9th grade, these efforts might be most effective if implemented before students reach high school.

Analyses were based on data from 11,815 (out of 13,601) nationally representative high school students in grades 9-12 who participated in the 2001 Youth Risk Behavior Survey (YRBS) and responded to questions about whether they had attempted suicide and whether they had participated in physical fighting in the preceding 12 months.7 Participation in YRBS was voluntary, anonymous, and required parental permission. Students completed a self-administered booklet consisting of 95 items and recorded responses directly on a computer-scannable answer sheet. The data were weighted to be representative of students in grades 9-12 in public and private schools in the United States.

The prevalence of reporting a suicide attempt among all students was 8.9% and the prevalence of involvement in any physical fight was 33.2%. Overall, 5.3% of the students reported both attempting suicide and participating in a fight (females, 6.0%; males, 4.5%). Logistic regression analyses were used to test whether the prevalence of fighting differed by suicide attempt status within each demographic population. Students who reported attempting suicide were more likely to have been in a physical fight than students who reported not attempting suicide (61.5% versus 30.3%). Results from the stratified models indicated an association between attempting suicide and fighting for each demographic population (Table). Higher proportions of both male and female suicide attempters (77.8% and 54.0%, respectively) reported fighting than males and females who had not attempted suicide (41.2% and 19.8%, respectively). Among those who reported attempting suicide, the proportion who reported fighting was highest among 9th graders (64.5%) and decreased with each subsequent grade.

Reported by:

MH Swahn, PhD, KM Lubell, PhD, TR Simon, PhD, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

CDC Editorial Note:

The findings of this analysis indicate that one in 20 high school students reported both suicide attempts and participation in physical fighting in the preceding year. Moreover, the majority (61.5%) of those students who attempted suicide also reported physical fighting, compared with less than one third (30.3%) of those who had not attempted suicide. This analysis extends earlier study26 of the link between suicidal behavior and interpersonal violence by documenting the strength of the association across demographic populations. The findings indicate that suicide attempt status was associated with involvement in physical fighting for both males and females; students in grades 9-12; four racial/ethnic populations; and youths living in urban, suburban, and rural areas.

The observed association between suicide attempts and fighting across demographic populations suggests that violence prevention programs directed at reducing both suicide and fighting are likely to be relevant for youths. However, the mechanisms linking suicidal behavior and interpersonal violence are unclear; these results do not permit an assessment of the extent to which suicidal and fighting behaviors are directly associated or the direction of the association. The two behaviors might be linked because they share common risk factors. Aggressiveness, impulsivity, substance abuse, depression, and hopelessness can increase the risk for both suicidal and violent behaviors.8,9 Additional research is needed to examine these and other factors to better determine the underlying mechanisms that link suicidal and violent behaviors as well as the overlap between multiple types of violent behavior.

The findings in this report are subject to at least three limitations. First, all participants were high school students and do not reflect the experiences of youths who have dropped out of school. Second, suicide attempts and fights were self-reported and therefore subject to reporting bias. Finally, the data do not permit either an assessment of the temporal ordering between suicide attempts and physical fights or a determination of whether the two behaviors occurred within a narrower period during the preceding 12 months.

Prevention strategies to reduce both suicide attempts and fighting might be possible and advantageous to design. Strategies determined effective in reducing youth problem behaviors (e.g., skill and competence-building programs, positive youth development, and parent training)10 might reduce underlying risks and provide the skills and support students need to avoid fighting and suicidal behavior. Additional research is needed to determine whether strategies that reduce youth risk for interpersonal violence also can be implemented to prevent suicidal behavior.

References
1.
CDC.  Web-based Injury Statistics Query and Reporting System (WISQARS™). Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control, 2004. Available at http://www.cdc.gov/ncipc/wisqars.
2.
Vossekuil B, Fein R, Reddy M, Borum R, Modzeleski W. Final report and findings of the safe school initiative: implications for the prevention of school attacks in the United States. Washington, DC: U.S. Department of Education, Office of Elementary and Secondary Education, Safe and Drug-Free Schools Program, and U.S. Secret Service, National Threat Assessment Center, 2002.
3.
Anderson M, Kaufman J, Simon TR.  et al.  School associated violent deaths in the United States, 1994-1999.  JAMA.2001;286:2695-702.
4.
Flannery DJ, Singer MI, Wester K. Violence exposure, psychological trauma, and suicide risk in a community sample of dangerously violent adolescents.  J Am Acad Child Adolesc Psychiatry.2001;40: 435-42.
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Borowsky IW, Ireland M, Resnick MD. Adolescent suicide attempts: risks and protectors.  Pediatrics.2001;107:485-93.
6.
Cleary SD. Adolescent victimization and associated suicidal and violent behaviors.  Adolescence.2000;35:671-82.
7.
Grunbaum JA, Kann L, Kinchen SA. Youth risk behavior surveillance—United States, 2001. In: CDC Surveillance Summaries (June 28).  MMWR.2002;51(No. SS-4):340-6.
8.
Plutchik R. Outward and inward directed aggressiveness: the interaction between violence and suicidality.  Pharmacopsychiatry.1995;28(suppl 2):47-57.
9.
Trezza GR, Popp SM. The substance user at risk of harm to self or others: assessment and treatment issues.  J Clin Psychol.2000;56: 1193-205.
10.
U.S. Department of Health and Human Services, et al.  Youth Violence: A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control, 2001.
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