Disaggregating Adversity: Differential Effects of ACE Subtypes on Adolescent Suicidality In the United States

Background: Suicidal thoughts and behaviors (STBs) among adolescents remain a critical public health concern in the United States, with persistent increases observed over the past decade. Adverse childhood experiences (ACEs) are well-established determinants of poor mental health outcomes; however, much of the existing literature relies on cumulative ACE scores, potentially obscuring the distinct and differential effects of specific adversity types. Understanding how individual ACE subtypes relate to STBs is essential for identifying targeted intervention points and advancing equity-focused prevention strategies.

Objectives: This study examined the associations between nine ACE domains and suicidal ideation, suicide planning, and suicide attempts among U.S. adolescents. Additionally, the study assessed racial/ethnic differences in ACE exposure and evaluated the independent contributions of key psychosocial factors, including bullying victimization and persistent sadness or hopelessness.

Methods: Data were drawn from the 2023 Youth Risk Behavior Survey (YRBS), a nationally representative, school-based survey of U.S. high school students. The analytic sample included 19,928 adolescents aged 14–18 years. Weighted binary logistic regression models were used to estimate the associations between individual ACE subtypes and STBs, adjusting for demographic characteristics and psychosocial covariates. Prevalence estimates and adjusted odds ratios (AORs) with 95% confidence intervals were reported, accounting for the complex survey design.

Results: Overall, 21.5% of adolescents reported suicidal ideation, 17.5% reported suicide planning, and 10.4% reported suicide attempts. Significant racial and ethnic disparities in ACE exposure were observed, highlighting inequities in the distribution of early-life adversity. Specific ACE subtypes—including emotional abuse, sexual abuse, physical neglect, and exposure to neighborhood violence—were consistently associated with higher odds of all STB outcomes. Sexual abuse demonstrated the strongest association with suicide attempts (AOR = 2.23, 95% CI = 1.72–2.90). Household poor mental health and substance use were associated with increased odds of suicidal ideation and planning. Among psychosocial factors, persistent sadness or hopelessness emerged as the most robust correlate across all STBs, underscoring its central role in pathways from adversity to suicidality.

Conclusions: Findings demonstrate that not all adversities confer equal risk; rather, interpersonal and community-level ACEs exert particularly strong and consistent effects on adolescent suicidality. For social work practice, these results underscore the importance of routine, developmentally appropriate screening for specific ACE subtypes and psychosocial distress across schools, healthcare settings, and community-based organizations. Trauma-informed and culturally responsive interventions that address both emotional distress and environmental risk factors are critical. At the policy level, results highlight the need to address structural determinants of adversity, including neighborhood violence, family instability, and inequitable access to mental health resources, particularly in marginalized communities. For social work research, this study advances the field by demonstrating the value of disaggregating ACEs to better understand mechanisms of risk and by incorporating population-based, equity-focused analyses. Future research should continue to examine intersectional and longitudinal pathways linking adversity to suicidality and evaluate multilevel interventions that target both individual and structural drivers. By centering the differential impact of adversity, this work contributes to rigorous, policy-relevant social work research aimed at reducing disparities and promoting adolescent well-being for the common good.