Suicidal Behavior Among Adolescents: Correlates, Confounds, and (The Search For) Causal Mechanisms

EDITORIAL
Suicidal Behavior Among Adolescents: Correlates,

Confounds, and (the Search for) Causal Mechanisms
MATTHEW K. NOCK, PH.D.
The death of a child is a tragedy. When a child commits

suicide, the loss is particularly devastating. Unfortunately,
such deaths are common because suicide is a leading cause
of death worldwide and the third leading cause of death
among children and adolescents in the United States.1 Preventing suicide in these age groups requires that we develop
a better understanding of why children and adolescents
kill themselves.
Explanatory models in clinical science typically develop
by identifying correlates of the outcome of interest and
conducting well-controlled, prospective, experimental studies to identify causal relations among variables, followed
by more fine-grained studies aimed at delineating causal
mechanisms (i.e., the pathways or processes through which
the correlate influences the outcome).2,3 The development
and testing of explanatory models is more challenging in
the case of suicidal behavior, given the clinical, ethical/legal,
and methodological challenges that characterize this work.
For instance, although suicide is a leading cause of death,
suicidal behaviors have a relatively low base rate in the
population, thus studies of suicidal behaviors typically require large sample sizes to test the complex models that
will be needed to understand and predict suicidal behavior.
In addition, concerns about failing to adequately monitor
or treat suicidal behavior, or about increasing suicidal behavior in response to an experimental manipulation, often
preclude the use of experimental designs. Furthermore, the
stigma associated with suicidal behaviors can lead to underreporting or to avoidance of research studies altogether.
As a result, although studies of suicidal behavior have
Accepted November 7, 2008.

Dr. Nock is with the Department of Psychology, Harvard University.
Correspondence to Matthew Nock, Ph.D., Department of Psychology, Harvard
University, 33 Kirkland Street, Cambridge, MA 02138; e-mail: nock@wjh.
harvard.edu.
0890-8567/09/4803-02372009 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/CHI.0b013e318196b944
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:3, MARCH 2 009
provided valuable information about the correlates of these

outcomes, many questions remain about the nature of
these correlations (e.g., what are the mediators and moderators?) and about the causal mechanisms through which
these relations exist. For instance, dozens of research studies
have shown that suicidal behavior occurs at higher rates
among those who are female, are adolescents, have a history of violence (or victimization), have a family history of
mental disorders, and have a mental or alcohol/substance
use disorder.1 However, little is known about how or why
each of these factors is correlated with suicidal behavior.
Why do girls make more suicide attempts than boys? Why
are there such enormous racial/ethnic differences in suicide rates? How or why are mental disorders like depression and alcohol abuse/dependence associated with suicidal
behavior?
Three articles in this issue of the Journal overcome many
of the limitations of previous work in this area and, in
doing so, move us further along the path from knowledge
of correlation to understanding of causality.4Y6 Notably,
each study uses a large (N 9 1,000) and representative
sample of adolescents, and each goes beyond simple tests of
bivariate correlations to provide fine-grained information
about the nature of the relations between previously identified correlates and suicidal behaviors.
The prevalence of suicidal behaviors varies significantly
across countries, cultures, and racial/ethnic groups around
the world.1,7 In the United States, although 90.5% of suicides occur among European Americans,8 the suicide rate
for black adolescent male subjects has risen significantly
during the past several decades and now approximates
that of European Americans.8 The article by Joe and colleagues,6 which examines the prevalence and correlates of
suicidal ideation and attempts among a nationally representative sample (N = 1,170) of black adolescents in the
United States, is especially important, given this context.
The authors document that 7.5% of black adolescents
report seriously thinking about killing themselves at some
point in their lifetime, and 2.7% report a past suicide
attempt, underscoring the broad scope of this problem. The
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237
Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
NOCK
fact that female sex, older adolescent age, and the presence and accumulation of mental disorders again emerge
as correlates of suicidal ideation and attemptsVa finding
consistent with studies conducted across many different
countries7Vconfirms that there is strong consistency in the
correlates of suicidal behaviors across diverse groups. Interestingly, only 52.7% of black adolescent suicide attempters
report ever having met criteria for a mental disorderVa
rate much lower than those observed in previous studies
of adolescents more generally.9 Thus, in addition to raising
questions about what causal mechanisms can explain why
mental disorders are associated with suicidal behavior, this
study highlights the importance of moving beyond the
study of mental disorders to better understand how a
broader range of factors might help to explain the development of this behavior.
Previous studies have revealed that bullying is correlated
with suicidal behavior. However, it is not known whether
bullying somehow causes suicidal behavior in the perpetrator (or victim) or if this correlation is simply the result
of confounding by other variables. Klomek and colleagues4
shed light on this issue using data from a large (N = 5,302)
population-based birth cohort in Finland assessed at 8 years
of age for the presence of bullying and victimization (i.e.,
being the victim of bullying) and followed until age 25
years. The author shows that bullying and victimization
during childhood are associated with increased odds of a
subsequent suicide attempt. Importantly, their study advances understanding of this relation by showing that these
effects differ for boys and girls and after adjusting for
conduct disorder and major depression (i.e., potential confounds). Among boys, bullying (but not victimization) is
associated with increased odds of suicide attempts when
examined alone; however, the association is no longer significant after adjusting for conduct disorder and depression.
This suggests that bullying is not causally related to suicidal behavior but instead correlated because both are consequences of conduct disorderVa known risk factor for
suicidal behavior (especially among boys).10,11 Results are
the opposite for girlsVvictimization (but not bullying) is
associated with suicide attempts, even after adjusting for
conduct disorder and depression. This study provides more
detail about the nature of the associations between bullying
and suicidal behavior and sets the stage for future studies
that address key remaining questions. Most importantly,
why is conduct disorder associated with suicidal behavior?
Perhaps it is not conduct disorder per se that is important
but the presence of impulsive-aggressive tendencies, which
itself increases the likelihood of conduct disorder and suicidal behavior (e.g., by increasing the likelihood of acting
on suicidal thoughts). For girls, how, why, and for whom
does being victimized lead to suicidal behavior?
238
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Studies also have shown that alcohol use disorders are

associated with an increased risk for suicidal behavior and
suicide death among adolescents.10,11 It is not clear, however, if this association varies across developmental periods.
Aseltine and colleagues5 examine the relation between heavy
episodic drinking (HED) and the presence of a recent suicide
attempt among adolescents participating in a large, crosssectional, school-based suicide screening program (N =
32,217). The authors find that HED is associated with
suicide attempts, even after controlling for depression. They
also take the next step of decomposing their overall
findingVin this case, testing whether the relation between
HED and suicide attempts differs by age. They report
that the association is strongest in those aged 13 years or
younger and decreases monotonically with increasing age.
One possible interpretation of this finding is that the
influence of HED on suicidal behavior (if there is one)
decreases over time. A more parsimonious explanation is
that HED is not causally related to suicidal behavior, but
instead, early HED is a marker for some other factor (e.g.,
poor behavioral inhibition, poor decision making, cognitive
precociousness) that is causally related to suicide attempts.
Clarifying the nature of these relations is not merely an
academic exercise. Prevention and intervention programs
targeting correlates that are not causally related to suicidal
behavior are unlikely to be effective. For instance, if bullying, HED, and suicidal behaviors are correlated because
they are all consequences of impulse-aggressive traits, clinical
attention should not focus on the former but on the latter.
Once revealed, information about causal mechanisms not
only will enhance scientific understanding of suicidal behaviors12 but also will guide the development of more
effective methods of preventing these tragic outcomes.
Disclosure: The author reports no conflicts of interest.
REFERENCES
1. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide
and suicidal behavior. Epidemiol Rev. 2008;30:133Y154.
2. Kazdin AE, Nock MK. Delineating mechanisms of change in child and
adolescent therapy: methodological issues and research recommendations. J Child Psychol Psychiatry. 2003;44:1116Y1129.
3. Hill AB. The environment and disease: association or causation? Proc R
Soc Med. 1965;58:295Y300.
4. Klomek AB, Sourander A, Niemela S et al. Childhood bullying behaviors
as a risk for suicide attempts and completed suicides: a population-based
birth cohort study. J Am Acad Child Adolesc Psychiatry. 2009;48:
254Y261.
5. Aseltine RH, Schilling EA, James A, Glanovsky JL, Jacobs D. Age
J. AM. ACAD. CHILD ADOLESC. P SYCHIATRY, 48:3, MARCH 2009
EDITORIAL
variability in the association between heavy episodic drinking and
adolescent suicide attempts: findings from a large-scale school-based
screening. J Am Acad Child Adolesc Psychiatry. 2009;48:262Y270.
6. Joe S, Baser RS, Neighbors HW, Caldwell CH, Jackson JS. 12-month
and lifetime prevalence of suicide attempts among black adolescents in
the National Survey of American Life. J Am Acad Child Adolesc Psychiatry.
2009;48:271Y282.
7. Nock MK, Borges G, Bromet EJ et al. Cross-national prevalence and risk
factors for suicidal ideation, plans, and attempts in the WHO World
Mental Health Surveys. Br J Psychiatry. 2008;192:98Y105.
8. CDC. Web-based Injury Statistics Query and Reporting System
(WISQARS) Fatal Injuries: Mortality Reports. National Center for
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Injury Prevention and Control, Centers for Disease Control and Prevention (producer) [http://www.cdc.gov/nipc/wisqars]. http://www.cdc.gov/
nipc/wisqars. Accessed November 5, 2008.
Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal
behavior. J Child Psychol Psychiatry. 2006;47:372Y394.
Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L. Age- and sexrelated risk factors for adolescent suicide. J Am Acad Child Adolesc
Psychiatry. 1999;38:1497Y1505.
Shaffer D, Gould MS, Fisher P et al. Psychiatric diagnosis in child and
adolescent suicide. Arch Gen Psychiatry. 1996;53:339Y348.
Kendler KS. Explanatory models for psychiatric illness. Am J Psychiatry.
2008;165:695Y702.
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EDITORIAL

Suicidal Behavior Among Adolescents: Correlates,

The death of a child is a tragedy. When a child commits

Accepted November 7, 2008.

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:3, MARCH 2 009

provided valuable information about the correlates of these

Studies also have shown that alcohol use disorders are

Disclosure: The author reports no conflicts of interest.

J. AM. ACAD. CHILD ADOLESC. P SYCHIATRY, 48:3, MARCH 2009

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:3, MARCH 2 009

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