Co-occurring Physical Fighting and Suicide Attempts Among U.S. High School Students

Examining Patterns of Early Alcohol Use Initiation and Current Binge Drinking

Monica H. Swahn, PhD, MPH; Robert M. Bossarte, PhD; Jane B. Palmier, JD, MPH; Huang Yao, MA


Western J Emerg Med. 2013;14(4):341-346. 

In This Article

Abstract and Introduction


Introduction: A growing body of empirical research documents a significant co-occurrence of suicide attempts and interpersonal violence among youth. However, the potential role of early alcohol use initiation and current heavy alcohol use as correlates of this comorbidity has not been examined in a nationally representative sample of high school students.

Methods: We based our analyses on cross-sectional data from the 2009 Youth Risk Behavior Survey, which includes a nationally representative sample (n = 16,410) of high school students in grades 9 through 12 in the United States. Multinomial logistic regression analyses were conducted to test the associations between measures of alcohol use (early alcohol use initiation and heavy drinking) and comorbid suicidal and violent behavior while controlling for potential confounders.

Results: Among high school students, 3.6% reported comorbid physical fighting and suicide attempt in the past year. Early alcohol use (prior to age 13) and heavy drinking (5 or more drinks in a row) were strongly associated with comorbid reports of physical fighting and suicide attempts (Adj. odds ratio [OR] = 3.12; 95% confidence interval [CI]:2.49–3.89) and (Adj. OR = 3.45; 95%CI:2.63–4.52).

Conclusion: These findings underscore the importance of both early alcohol use initiation and heavy drinking as statistically significant correlates of comorbid fighting and suicide attempts among youth. While future research is needed to determine the temporal ordering between problem drinking and violent or suicidal behaviors, existing prevention programs may benefit from including components aimed at reducing and delaying alcohol use.


Recent research on adolescents suggests a strong link between violence involving other persons and self-directed violence.[1–10] Previous studies have reported a comparatively high prevalence of comorbid self-directed and interpersonal violence among youth in the United States (U.S.) and in Africa.[2–4,8,9,11–12] While the overlap appears significant and of great concern to the general public health community, few studies have examined specific and potentially modifiable risk factors associated with co-occurring interpersonal and selfdirected violence.

Early alcohol use initiation has been identified as a strong risk factor for a number of adverse health outcomes including self-directed and interpersonal violence.[8,13–23] Recent research has documented that early alcohol use initiation is associated with both self-directed violence[8,13,14,21–23] and interpersonal violence.[8,17] However, there is a scarcity of research that has examined specific alcohol factors that may contribute to involvement in co-occurring violent and suicidal behaviors. The extent to which early alcohol use initiation is specifically associated with the overlap of self-directed and interpersonal violence has not been previously reported.

Reviews of prior research indicate that both suicidal and violent behaviors may share several characteristics associated with increased risk for both forms of violence.[10] In particular, it is clear that aggressiveness, impulsivity, and correlates of poor mental health, such as substance abuse, depressive symptomology and hopelessness, can increase risk of both suicidal and violent behaviors.[10,24,25] Moreover, research also shows that youth who perform poorly in school have reported higher levels of suicidal ideation, interpersonal violence and substance use.[26,27] However, there is little existing literature on the extent to which co-occurring violent and suicidal behavior actually share common risk factors identified with either suicidal behavior or interpersonal violence.[11,12] Among youth, early alcohol use initiation is of particular importance because of the existing research linking early alcohol use to different forms of violence and evidence that early alcohol use may be reduced by existing prevention strategies.

The purpose of the current study is to examine early alcohol use initiation, prior to age 13, as a specific risk factor associated with co-occurring suicidal and violent behaviors among a nationally representative sample of boys and girls in the U.S. Other factors that have been associated with violence or suicidal behaviors, either empirically or theoretically, in earlier studies and that are available within the Youth Risk Behavior Survey were included as potential confounders (ie, sadness, low academic grades, binge drinking, weapon carrying, and drug use.[1,10,27,28] The current study will determine the role of early alcohol use initiation in the comorbidity of self-directed and interpersonal violence and findings can be used to guide prevention and intervention programs.