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Original Investigation
January 27, 2020

Association of Pediatric Suicide With County-Level Poverty in the United States, 2007-2016

Author Affiliations
  • 1Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
  • 2Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
JAMA Pediatr. Published online January 27, 2020. doi:10.1001/jamapediatrics.2019.5678
Key Points

Question  What is the association between pediatric suicide and county-level poverty in the United States?

Findings  In this cross-sectional study of 20 982 US youths aged 5 to 19 years who died by suicide from 2007 to 2016, the adjusted pediatric suicide rate increased with increasing county poverty concentration, defined as the percentage of the county population living below the federal poverty level.

Meaning  The findings suggest that higher county-level poverty concentration is associated with increased suicide rates among persons aged 5 to 19 years, which may have implications for suicide prevention efforts.

Abstract

Importance  Suicide is the second leading cause of death among youths aged 10 to 19 years in the United States, with rates nearly doubling during the past decade. Youths in impoverished communities are at increased risk for negative health outcomes; however, the association between pediatric suicide and poverty is not well understood.

Objective  To assess the association between pediatric suicide rates and county-level poverty concentration.

Design, Setting, and Participants  This retrospective, cross-sectional study examined suicides among US youths aged 5 to 19 years from January 1, 2007, to December 31, 2016. Suicides were identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes from the Centers for Disease Control and Prevention’s Compressed Mortality File. Data analysis was performed from February 1, 2019, to September 10, 2019.

Exposures  County poverty concentration and the percentage of the population living below the federal poverty level. Counties were divided into 5 poverty concentration categories: 0% to 4.9%, 5.0% to 9.9%, 10.0% to 14.9%, 15.0% to 19.9%, and 20.0% or more of the population living below the federal poverty level.

Main Outcomes and Measures  The study used a multivariable negative binomial regression model to analyze the association between pediatric suicide rates and county poverty concentration, reporting adjusted incidence rate ratios (aIRRs) with 95% CIs. The study controlled for year, demographic characteristics of the children who died (age, sex, and race/ethnicity), county urbanicity, and county demographic features (age, sex, and racial composition). Subgroup analyses were stratified by method.

Results  From 2007 to 2016, a total of 20 982 youths aged 5 to 19 years died by suicide (17 760 [84.6%] were aged 15-19 years, 15 982 [76.2%] male, and 14 387 [68.6%] white non-Hispanic). The annual suicide rate was 3.35 per 100 000 youths aged 5 to 19 years. In the multivariable model, compared with counties with the lowest poverty concentration (0%-4.9%), counties with poverty concentrations of 10% or greater had higher suicide rates in a stepwise manner (10.0%-14.9%: aIRR, 1.25 [95% CI, 1.06-1.47]; 15.0%-19.9%: aIRR, 1.30 [95% CI, 1.10-1.54]; and 20.0% or more: aIRR, 1.37 [95% CI, 1.15-1.64]). When stratified by method, firearm suicides had the strongest association with county poverty concentration (aIRR, 1.87; 95% CI, 1.41-2.49) in counties with 20% or higher poverty concentration compared with counties with 0% to 4.9% poverty concentration.

Conclusions and Relevance  The findings suggest that higher county-level poverty concentration is associated with increased suicide rates among youths aged 5 to 19 years. These findings may guide research into upstream risk factors associated with pediatric suicide to inform suicide prevention efforts.

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