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Pathways to suicide or collections of vicious cycles? Understanding the complexity of suicide through causal mapping

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Abstract

Suicide is the second leading cause of death among youth ages 10–19 in the USA. While suicide has long been recognized as a multifactorial issue, there is limited understanding regarding the complexities linking adverse childhood experiences (ACEs) to suicide ideation, attempt, and fatality among youth. In this paper, we develop a map of these complex linkages to provide a decision support tool regarding key issues in policymaking and intervention design, such as identifying multiple feedback loops (e.g., involving intergenerational effects) or comprehensively examining the rippling effects of an intervention. We use the methodology of systems mapping to structure the complex interrelationships of suicide and ACEs based on the perceptions of fifteen subject matter experts. Specifically, systems mapping allows us to gain insight into the feedback loops and potential emergent properties of ACEs and youth suicide. We describe our methodology and the results of fifteen one-on-one interviews, which are transformed into individual maps that are then aggregated and simplified to produce our final causal map. Our map is the largest to date on ACEs and suicide among youth, totaling 361 concepts and 946 interrelationships. Using a previously developed open-source software to navigate the map, we are able to explore how trauma may be perpetuated through familial, social, and historical concepts. In particular, we identify connections and pathways between ACEs and youth suicide that have not been identified in prior research, and which are of particular interest for youth suicide prevention efforts.

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Availability of data and materials

Our data are provided on a third-party repository by the Open Science Framework (OSF), which can be publicly accessed without registration at https://osf.io/7nxp4/In particular, the online repository includes the individual map from each SME, the questionnaires used to assign weights to causal relationships, the overall map, and the software used to visualize the map.

Notes

  1. ACEs are preventable, potentially traumatic events that occur in childhood such as neglect, experiencing or witnessing violence, and having a family member attempt or die by suicide. This also includes aspects of a child’s environment that can undermine their sense of safety, stability, and bonding, such as growing up in a household with substance use, mental health problems, or instability due to parental separation or incarceration of a parent, sibling or other member of the household. ACEs have complex and negative influences on individual health outcomes throughout the life course, including increased risk of suicidal behaviors (World Health Organization 2014).

  2. Fuzzy Cognitive Mapping (FCM) is “a powerful means to represent knowledge domains that are characterized by high complexity, by widespread knowledge sources that usually only have partial knowledge, by qualitative information that frequently changes, and by a lack of a commonly accepted ‘theory’ or ‘truth’” (Jetter 2006).

  3. Fuzzy Logic can produce highly accurate estimates, as demonstrated by the use of FCMs in settings highly sensitive to errors such as radiotherapy treatment, diagnostics of brain tumor (where the system was above 90% accurate) (Amirkhani et al. 2017), or drug therapy management (Bevilacqua et al. 2018).

  4. For the mathematical foundations of Fuzzy Logic and standard operations involved (Mamdani, Algebraic Sum, Center of Gravity), we refer the reader to (Xu and Da 2003; Kruse et al. 2016; Mamdani 1977).

Abbreviations

ACEs:

Adverse childhood experiences

CDC:

Centers for disease control and prevention

FCM:

Fuzzy cognitive map

SME:

Subject matter expert

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Acknowledgements

We are indebted to all fifteen subject-matter experts for engaging in this process and sharing their perspectives: Sarah Bacon, Margaret Brown, Eric Caine, Monica Chambers, Alexander Crosby, Beverly Fortson, Christopher Harper, Kristin Holland, Asha Ivey-Stephenson, Cheryl King, Melissa Merrick, Marilyn Metzler, Kelly Quinn, Deb Stone, and Elizabeth Swedo. The complete list including affiliations and fields of expertise is provided in Appendix A.

Funding

This publication was supported by the Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Intergovernmental Personnel Act (IPA) Assignment Agreement 20IPA2009427.

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Authors and Affiliations

  1. Department of Computer Science and Software Engineering, Miami University, Oxford, OH, USA

    Philippe J. Giabbanelli, Michael C. Galgoczy & Minh Duc Nguyen

  2. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA

    Ketra L. Rice, Nisha Nataraj, Margaret M. Brown & Christopher R. Harper

  3. Ecole Nationale Supérieure Des Mines d’Ales (IMT Ales), Ales, France

    Romain Foy

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Contributions

KLR managed and coordinated responsibilities for the research activity planning and execution. KLR and PJG conceptualized and designed the study. PJG designed the methods. KLR recruited participants. PJG and KLR acquired data. DMN visualized the data for analysis. MCG, PJG, KLR, MMB combined individual datasets into one map. KLR, PJG, NN, MMB, CRH analyzed and interpreted the data. PJG and KLR directed the first draft. KLR, PJG, NN, MMB, CRH reviewed and edited the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Philippe J. Giabbanelli.

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Conflict of interest

The authors declare that they have no competing interests.

Consent for publication

The manuscript received clearance from publication from relevant divisions within the Centers for Disease Control and Prevention (CDC): the National Center for Injury Prevention and Control (NCIPC) Division of Injury Prevention (DIP)—Data Analytics Branch (DAB), and the National Center for Injury Prevention and Control (NCIPC) Office of Strategy and Innovation (OSI). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Ethics approval and consent to participate

The study protocol was examined given the CDC guidelines to determine the need for approval by the Institutional Review Board (IRB) and Office of Management and Budget (OMB). The study received exemption from both as it does not involve clinical investigations (e.g., drugs, biologics, devices) and the number of non-federal interviewees included in the study is under the threshold requiring a review by the Human Research Protection Office. Each interview was conducted and recorded using WebEx video conferencing after receiving informed consent from the SME.

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Appendix A: Affiliations of the subject matter experts (SMEs) who were interviewed

Appendix A: Affiliations of the subject matter experts (SMEs) who were interviewed

Sarah Bacon, PhD.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Office of the Director.

Margaret Brown, DrPH.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team.

Eric Caine, MD.

Psychiatrist.

University of Rochester Medical Center.

Monica Chambers, MS.

Mental Health Counselor.

Odyssey Family Counseling Center.

Alexander Crosby, MD, MPH.

Medical Epidemiologist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Office of the Director.

Beverly Fortson, PhD.

Behavioral Scientist.

U.S. Department of Defense, Sexual Assault Prevention and Response Office.

Christopher Harper, PhD.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, Child Abuse Neglect and Adversity Team.

Kristin Holland, PhD, MPH.

Health Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Overdose Prevention, Office of the Director.

Asha Ivey-Stephenson, PhD.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team.

Cheryl King, PhD.

Professor.

University of Michigan, Youth and Young Adult Depression and Suicide Prevention Research Program.

Melissa Merrick, PhD.

President and CEO.

Prevent Child Abuse America.

Marilyn Metzler, MPH.

Public Health Analyst.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, Office of the Director.

Kelly Quinn, PhD, MPH.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, Child Abuse Neglect and Adversity Team.

Deb Stone, ScD, MSW, MPH.

Behavioral Scientist.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Suicide Prevention Team.

Elizabeth Swedo, MD, MPH.

Physician.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, Morbidity and Behavioral Surveillance Team.

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Giabbanelli, P.J., Rice, K.L., Galgoczy, M.C. et al. Pathways to suicide or collections of vicious cycles? Understanding the complexity of suicide through causal mapping. Soc. Netw. Anal. Min. 12, 60 (2022). https://doi.org/10.1007/s13278-022-00886-9

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