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


Several limitations of this study should be considered when interpreting the findings. First, the findings are based on high school students and therefore the findings do not reflect experiences of those who have dropped out of school. Second, the findings are based on self-reported data and have not been corroborated with other sources. Third, the findings are based on cross-sectional survey data, which do not permit determination of the temporal ordering of the risk factors relative to the outcome. Fourth, the assessment of co-occurring suicidal and violent behaviors only indicates the presence of both suicidal and violent behaviors within the past 12 months. Based on how the survey questions were asked, more specific timing of the presence of suicidal or violent behavior cannot be provided or inferred. Fifth, the survey is limited in the number and types of correlates that were examined, and it is possible that other potential confounders, if available, and included in the analyses, could have impacted our findings. Sixth, the confidence intervals for the odds ratios for some of the risk factors were relatively wide, indicating that some associations, while strong, were possibly unstable. Finally, it is possible that bias associated with social desirability may have contributed to an underreporting of high risk and violent behaviors.

Previous research has suggested that there is a significant overlap among both suicidal behavior and violent behaviors among youth.[8,10,11] However, because of our relatively limited understanding of how different types of violent behavior overlap, efforts to design prevention programs that can address multiple types of violence, such as fighting and suicidal behaviors, have been limited.[8,10] Findings from this study and others underscore how important it may be to develop programs that may be relevant across multiple forms of violent behaviors that span across self-directed and interpersonal violence.[8,10,11] The current study is one of very few that seeks to better understand the potentially shared and modifiable risk factors between involvement in violent and suicidal behaviors.

In future studies of shared risk factors for co-occurring suicidal and violent behaviors, it is particularly important to assess modifiable factors that can be addressed by current evidence-based strategies and intervention. Meanwhile, the findings from our study indicate that early alcohol use initiation is an important predictor of suicidal and violent behaviors among both boys and girls. The specific mechanism linking suicidal and violent behavior is not well known nor is the role of early alcohol use initiation among these youth. Therefore, longitudinal research that can better assess the temporal ordering between early alcohol use initiation, suicidal and violent behavior is needed.

In terms of clinical practice and implications, these findings combined with earlier research calls for screening of early alcohol use initiation in pediatric populations prior to their teen years, by healthcare providers, because of the high incidence of alcohol use initiation among youth.[8] However, prevention efforts are also needed to further delay the initiation of use and many of the associated adverse health linked to early alcohol use. Pediatricians as well as emergency physicians and other healthcare providers are in a unique and very important position to discuss alcohol use and its potential hazards with their pediatric patients and parents, particularly when patients are seen for injuries or risk for self-harm.[32–34]

Finally, based on the findings, it is clear that youth who report co-occurring suicidal and violent behaviors appear to experience a range of negative experiences including low academic grades, weapon carrying, binge drinking and drug use exposure that may further exacerbate the severity of their current health problems. While they are a small percentage of the youth population overall, they appear to be particularly vulnerable and in need of services.