Sex-Specific Patterns of Adolescent Suicidal Behaviors: Roles of Adverse and Positive Childhood Experiences

Background and Purpose
Suicide remains a major public health concern among adolescents, but suicidal behaviors do not occur uniformly. Some adolescents experience emotional distress without progressing to suicidal thoughts, whereas others move across ideation, planning and attempts. Adverse childhood experiences (ACEs) are well established predictors of adolescent suicidality. However, not all adolescents exposed to adversity engage in suicidal behavior, suggesting the importance of protective factors such as positive childhood experiences (PCEs). Most prior studies use variable-centered approaches, potentially overlooking heterogeneity in suicide patterns. Additionally, sex differences in emotional expression and suicide outcomes are often treated as covariates rather than a focal analytic dimension. Guided by a person-centered and ecological systems perspectives, the study aimed to (a) identify sex-specific suicide behavior patterns, (b) examine the association between ACEs and pattern membership, and (c) test whether PCEs moderate these associations.

Methods
Data were drawn from the 2023 Youth Risk Behavior Survey, including high school students in grades 9-12 (females: N=4,865; males: N=5,027). Latent class analysis (LCA) was conducted in Jamovi Version 2.3 to identify patterns of suicide behaviors based on four indicators: feeling sad or hopeless, suicidal ideation, suicide planning, and suicide attempts. Model fit and class enumeration were evaluated using AIC, BIC, and entropy to determine the optimal number of classes. Class membership served as the dependent variable. The independent variable was ACEs (an eight-item composite), including abuse, neglect, household dysfunction, and violence exposure. Three PCEs (parental monitoring, school safety, and school connectedness) were used as moderators. Analyses were conducted separately by sex. Multinomial logistic regression models (SPSS Version 29) were estimated to examine associations between ACEs and class membership and to test moderation by PCEs, with the low-risk group as the reference group.

Results
Among females, three classes were identified: High Suicide Risk (18.2%), Distress/Ideation without Attempt (23.8%), and Low Risk (57.9%). Each additional ACE increased the odds of High Suicide Risk (OR=1.91, 95% CI=1.53–2.37) and Distress/Ideation (OR=1.40, 95% CI=1.09–1.81) relative to the Low Risk group. All three PCEs showed significant protective main effects (ORs=0.59–0.81), but none significantly moderated the associations.
Among males, three classes were identified: High Suicide Risk (13.8%), Psychological Distress with Minimal Suicidality (24.2%), and Low Risk (61.7%). Greater ACE exposure was associated with increased odds of High Suicide Risk (OR=1.67, 95% CI=1.31–2.13). School safety (OR=0.58) and school connectedness (OR=0.67) were significant protective factors for High Risk membership, but parental monitoring was not. School connectedness significantly moderated the relationship between ACEs and the High Suicide Risk group (OR=1.06, 95% CI=1.02–1.10). Decomposition of the interaction indicated that ACEs were not associated with increased high-risk membership at higher levels of school connectedness, but the association strengthened at lower levels.

Conclusions and Implications
ACEs were strongly associated with elevated suicide risk, while PCEs showed protective effects but limited moderation. Suicide risk patterns varied by sex, highlighting heterogeneity. Findings suggest the need for trauma-informed, sex-responsive interventions, with school-based supports, such as connectedness and safety, playing a key role, particularly among male students exposed to adversity.