Adverse Childhood Experiences and Suicide Attempts Among High School Students: The Mediating Effects of Peer Victimization and Depression By Sex

Background
Adolescents in the U.S. are at the highest risk of suicide. Peer victimization and depression have been identified as significant contributors to suicide attempts. Adolescents exposed to adverse childhood experiences (ACEs), such as abuse, neglect, or household dysfunction, are at even greater risk. Although research has established an association between ACEs and suicide attempts among adolescents, few studies have examined indirect influences of peer victimization and depression or whether the pathways from ACEs to suicide attempts differ by sex, although sex differences in ACEs, victimization, and mental health outcomes have been well-documented. Guided by the ecological systems perspective, this study examined the direct and indirect effects of ACEs on suicide attempts through four types of peer victimization and depression. The study also tested sex differences in these associations.

Methods
Data were drawn from the 2023 Youth Risk Behavior Survey. The final sample included 9,325 high school students in grades 9–12, after excluding cases with missing values (female 48.9%, male 51.1%; White 44.4%, Multiracial 26.2%, Black 11.5%, other 12.8%, Hispanic/Latino 5.1%). In the mediation path model, the exogenous variable was a composite score of eight binary ACE items: sexual abuse, emotional abuse, physical abuse, witnessing intimate partner violence, physical neglect, household substance abuse, household mental illness, and parental incarceration or detention. Mediators include four types of peer victimization (school bullying, cyberbullying, physical dating violence, and sexual dating violence) and depression. The endogenous variable was suicide attempts. Path analysis was conducted using Mplus 8.0 to examine both direct and indirect associations in the model. A group invariance test was also performed to compare these associations by sex. The path model demonstrated good fit (χ² = 468.48, p < .001, CFI = .95, TLI = .92, RMSEA = .04).

Results
Overall, females (M = 2.77) had significantly higher average ACE scores than males (M = 2.03), and a higher percentage of females experienced four or more ACEs (31% vs. 15.7%). Path analysis revealed a direct effect of ACEs on suicide attempts among high school students, with a stronger influence observed in females. Additionally, all four types of peer victimization and depression significantly mediated the relationship between ACEs and suicide attempts for both sexes. Notably, the indirect effects of ACEs on suicide attempts through sexual dating violence victimization and depression were stronger for males.

Implication/Conclusions
The findings highlight that ACEs are a serious public health concern given their impact on adolescent mental health problems through peer victimization. A key starting point is to advance ACE-related research using robust measures and rigorous methodologies to provide a foundation for effective prevention and intervention efforts. These results also underscore the need for gender-specific, trauma-informed interventions in school and community settings. Prevention strategies should prioritize the early identification of ACEs and address peer victimization and mental health, particularly depression. For males, targeted support addressing dating violence and its psychological impact is essential.