When Stress Accumulates: Interacting Effects of Childhood Adversity, Multidimensional Victimization, and Protective...

Adolescent suicide is a leading cause of death globally and remains a major public health concern in the United States. Chronic stress perspectives suggest that suicidal behaviors emerge from cumulative and interacting stress exposures that become biologically and psychologically embedded across development. This study applies an integrated chronic stress framework to examine how adverse childhood experiences (ACEs), victimization, and protective relational resources jointly shape suicide-related behaviors among U.S. high school students.

We conducted a cross-sectional analysis of the 2023 combined National Youth Risk Behavior Surveillance System dataset (N = 254,675). National-level proportional outcomes included serious suicidal ideation, suicide planning, suicide attempts, and medically treated suicide attempts. Standardized composite indices were constructed for ACEs, victimization, and protective resources (school connectedness and parental monitoring). Fractional logistic regression models estimated average marginal effects (AMEs), adjusting for persistent sadness/hopelessness, poor mental health, sleep duration, unstable housing, and demographic characteristics. Interaction terms tested cumulative and conditional stress processes.

Higher ACE and victimization indices were independently associated with greater prevalence of all suicide-related outcomes. A one-unit increase in the ACE index was associated with increased ideation (AME = 0.0534, 95%CI [0.0411, 0.0656]) and attempts (AME = 0.0240, 95%CI [0.0148, 0.0332]). Victimization demonstrated comparable or stronger associations, particularly for planning (AME = 0.0723, 95% CI [0.0605, 0.0841]) and attempts (AME = 0.0571, 95%CI [0.0472, 0.0670]). Protective resources were inversely associated with planning (AME = -0.0130, 95%CI [-0.0192, -0.0067]) and attempts (AME = -0.0110, 95%CI [-0.0159, -0.0060]). Interaction analyses revealed diminishing marginal effects at higher combined levels of ACEs and victimization (eg, ACE × victimization for ideation AME = -0.0395, 95% CI [-0.0567, -0.0223]), indicating nonlinear accumulation of stress burden. A significant three-way interaction for ideation (AME = 0.0193, 95%CI [0.0045, 0.0342]) suggested conditional buffering by protective resources. Persistent sadness/hopelessness remained the strongest correlate across outcomes.

Adolescent suicidality reflects cumulative and interacting stress processes rather than isolated risk factors. Early adversity establishes foundational stress load, ongoing victimization compounds risk, and protective relational assets provide partial-but not complete-buffering. These findings support multilevel prevention strategies that reduce chronic stress exposure while strengthening relational protection across developmental contexts.