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JAMA Pediatr. 2020 Jan 27. doi: 10.1001/jamapediatrics.2019.5678. [Epub ahead of print]

Association of Pediatric Suicide With County-Level Poverty in the United States, 2007-2016.

Author information

Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.



Suicide is the second leading cause of death among youths aged 10 to 19 years in the United States, with rates nearly doubling during the past decade. Youths in impoverished communities are at increased risk for negative health outcomes; however, the association between pediatric suicide and poverty is not well understood.


To assess the association between pediatric suicide rates and county-level poverty concentration.

Design, Setting, and Participants:

This retrospective, cross-sectional study examined suicides among US youths aged 5 to 19 years from January 1, 2007, to December 31, 2016. Suicides were identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes from the Centers for Disease Control and Prevention's Compressed Mortality File. Data analysis was performed from February 1, 2019, to September 10, 2019.


County poverty concentration and the percentage of the population living below the federal poverty level. Counties were divided into 5 poverty concentration categories: 0% to 4.9%, 5.0% to 9.9%, 10.0% to 14.9%, 15.0% to 19.9%, and 20.0% or more of the population living below the federal poverty level.

Main Outcomes and Measures:

The study used a multivariable negative binomial regression model to analyze the association between pediatric suicide rates and county poverty concentration, reporting adjusted incidence rate ratios (aIRRs) with 95% CIs. The study controlled for year, demographic characteristics of the children who died (age, sex, and race/ethnicity), county urbanicity, and county demographic features (age, sex, and racial composition). Subgroup analyses were stratified by method.


From 2007 to 2016, a total of 20 982 youths aged 5 to 19 years died by suicide (17 760 [84.6%] were aged 15-19 years, 15 982 [76.2%] male, and 14 387 [68.6%] white non-Hispanic). The annual suicide rate was 3.35 per 100 000 youths aged 5 to 19 years. In the multivariable model, compared with counties with the lowest poverty concentration (0%-4.9%), counties with poverty concentrations of 10% or greater had higher suicide rates in a stepwise manner (10.0%-14.9%: aIRR, 1.25 [95% CI, 1.06-1.47]; 15.0%-19.9%: aIRR, 1.30 [95% CI, 1.10-1.54]; and 20.0% or more: aIRR, 1.37 [95% CI, 1.15-1.64]). When stratified by method, firearm suicides had the strongest association with county poverty concentration (aIRR, 1.87; 95% CI, 1.41-2.49) in counties with 20% or higher poverty concentration compared with counties with 0% to 4.9% poverty concentration.

Conclusions and Relevance:

The findings suggest that higher county-level poverty concentration is associated with increased suicide rates among youths aged 5 to 19 years. These findings may guide research into upstream risk factors associated with pediatric suicide to inform suicide prevention efforts.

[Available on 2021-01-27]

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