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Cited by 235Suicide and Self-Harm StudiesHomicide, Infanticide, and Child AbuseChild and Adolescent Psychosocial and Emotional Development

Adolescent Suicide as a Failure of Acute Stress-Response Systems.

Open access
Miller, Adam Bryant, Prinstein, Mitchell J.·2019·Annual Review of Clinical Psychology
DOI 10.1146/annurev-clinpsy-050718-095625PMC PMC6953613
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Abstract

Suicide is the second leading cause of death worldwide for adolescents. Despite decades of research on correlates and risk factors for adolescent suicide, we know little about why suicidal ideation and behavior frequently emerge in adolescence and how to predict, and ultimately prevent, suicidal behavior among youths. In this review, we first discuss knowledge regarding correlates, risk factors, and theories of suicide. We then review why adolescence is a period of unique vulnerability, given changing biology and social network reorganization. Next, we present a conceptual model through which to interpret emerging findings in adolescent suicide research. We suggest that a promising area for future research is to examine adolescent suicide as a failure of biological responses to acute stress in the proximal moments of a suicidal crisis. After reviewing initial evidence for this conceptualization, we review future directions for studies on adolescent suicide.

AI snapshot

Written from the paper’s full text.

TL;DR

This review proposes that adolescent suicidal crises may be usefully understood as failures or dysregulation of biological acute stress-response systems during a developmentally sensitive period. It synthesizes prior suicide risk-factor research and preliminary biological findings to offer a heuristic model centered on proximal stress responses, stress thresholds, and suicide propinquity.

Key findings

  • Suicide ranks as the second leading cause of death globally among people aged 10–24; suicidal ideation affects roughly 19.8–24% of youths and suicide attempts roughly 3.1–8.8%, yet prediction remains weak.
  • Distal risk factors are limited: internalizing predictors show meta-analytic odds ratios of about 1.17–1.71, and even prior suicidal ideation/behavior weakly predicts later suicidal behavior; only childhood maltreatment, peer victimization, worthlessness, and low self-esteem prospectively predict beyond depression and prior suicidality in one review.
  • Preliminary biological correlates include lower resting respiratory sinus arrhythmia or excessive withdrawal, mixed prospective RSA findings, both hyper- and hypocortisol responses, elevated proinflammatory cytokines in some suicide samples, and altered prefrontal–subcortical activation or connectivity.
  • The authors propose two moderators: a stress-threshold process, where risk rises when stress exceeds a person’s usual or perceived coping capacity, and suicide propinquity, where prior self-injury, exposure to others’ suicide, or peer socialization makes suicide a more available option.

Methods

  • Narrative/integrative review, not a primary empirical study; it synthesizes prior reviews, meta-analyses, theories, and emerging biological literature.
  • Scope focuses on suicidal self-injurious thoughts and behaviors, excluding nonsuicidal self-injury, and covers adolescence, four acute stress-response systems, and a conceptual model.
  • Main analysis is qualitative synthesis and heuristic model-building; the authors note that adolescent biological data are sparse and much cited evidence is cross-sectional or from adults.

Limitations

  • The paper states that it excludes NSSI, cautions against treating suicide constructs as equivalent, notes more research on ideation and attempts than other outcomes, and acknowledges limited adolescent biological data and mostly cross-sectional/adult studies.
  • The authors state the model cannot yet explain why some distressed adolescents develop suicidal outcomes rather than other psychopathology, and they note omitted topics including biological sex, culture, race/ethnicity, religiosity, protective factors, and macrosystem influences.
  • Evident from the text: the proposed acute stress-response framework is heuristic and not directly tested in this review, and many cited biological associations are preliminary, mixed, or based on small samples.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1146/annurev-clinpsy-050718-095625

Cites

160 of 160 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

58 of 109 cited sources checked · 22 supported · 1 flagged · accuracy not yet measured

  • Premisecitation

    Adults with a history of suicide attempts have more blunted cortisol reactivity to a Trier Social Stress Test than those with only suicidal ideation history or healthy controls.

    “adults with a history of suicide attempts have more blunted cortisol reactivity to a Trier Social Stress Test (TSST) than those with only suicidal ideation history or than healthy controls (Melhem et al. 2016, O’Connor et al. 2017)”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites Melhem et al. 2016 source

      The Results section reports no significant group differences in cortisol reactivity to the TSST, contrary to the claim. The Abstract and Discussion instead report lower total cortisol output and lower pre-task cortisol in suicide attempters than in the comparison groups; those measures are distinct from reactivity. (LLM, conf=0.94)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites O’Connor et al. 2017 source

      The Results (§3.1; page unavailable) report lower cortisol output in attempters than in healthy controls, but no significant difference between attempters and ideators. The Methods (§2.2; page unavailable) identify this study’s stress task as the Maastricht Acute Stress Test, not the TSST. The Introduction (§1; page unavailable) says the TSST study it discusses found no significant between-group difference in cortisol reactivity. (LLM, conf=0.92)

      Experimental — accuracy not yet measured
  • Premisecitation

    Most suicidal behavior among youths occurs in response to a discrete stressful precipitant.

    “Last, most suicidal behavior among youths occurs in response to a discrete stressful precipitant (King & Merchant 2008).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites King & Merchant 2008 source

      The Community-Based Epidemiologic Studies section reports that stressful life events were associated with suicidal behavior in a longitudinal cohort. It does not say that most suicidal behavior among youths follows a discrete stressful precipitant; the review also states that research on life stress was outside its scope. Page numbers are unavailable in our copy. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
  • Premisecitation

    Beyond demographic characteristics, only childhood maltreatment, peer victimization, feelings of worthlessness, and low self-esteem increase risk for suicidal ideation or behaviors over time after accounting for depression and prior suicidal ideation or behaviors.

    “Results from this review suggest that beyond demographic characteristics, only childhood maltreatment, peer victimization, feelings of worthlessness, and low self-esteem increase the risk for suicidal ideation or behaviors over time, after accounting for depression and prior suicidal ideation or behaviors as predictors (Cha et al. 2018).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Cha et al. 2018 source

      The Psychological risk factors section reports that worthlessness and low self-esteem predict later suicidal thoughts or attempts after adjustment for depressive symptoms and baseline suicidality. The Environmental risk factors section supports childhood maltreatment and peer victimization as longitudinal risk factors, but does not establish that every form was assessed after both adjustments. The review also describes similar findings for neuroticism, so it does not support the claim that *only* the four listed factors increase risk. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Throughout puberty, changes in social and mentalizing neural networks allow more sophisticated social comparisons and reflected appraisals, enabling a more stable self-concept heavily dependent on perceived peer appraisals.

    “Throughout puberty, changes in social and mentalizing neural networks allow for more sophisticated social comparisons and reflected appraisals, allowing adolescents to form a more stable sense of self-concept that is heavily dependent on perceived peer appraisals (Casey et al. 2008, Harter et al. 1996, Somerville 2013).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Casey et al. 2008 source

      The Introduction (page unavailable) links puberty to changes in brain function and describes adolescents spending more time with peers. The Conclusions (page unavailable) describe developmental changes in frontolimbic regions, but relate them to cognitive control and self-regulation. Our copy does not connect changes in social or mentalizing networks to social comparisons, reflected appraisals, or a more stable self-concept dependent on perceived peer appraisals. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites Harter et al. 1996

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Somerville 2013 source

      The sections “Thinking about the thoughts of others” and “Vigilance to social evaluation” describe developing mentalizing abilities, heightened sensitivity to peers’ impressions, and adolescent changes in socioaffective neural activity. They do not establish that these changes enable more sophisticated social comparisons or reflected appraisals, or that they produce a more stable self-concept heavily dependent on perceived peer appraisals. Our copy provides no page numbers for these passages. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    Depressive symptoms are associated with the development of hyporeactive HPA axis responses to stress.

    “depressive symptoms are associated with the development of hyporeactive responses to stress in the HPA axis (see Guerry & Hastings 2011 for a review)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Guerry & Hastings 2011 source

      The Psychological Challenge Studies section reports relatively hyporesponsive cortisol reactions to stress in prepubertal children with subclinical depressive symptoms. But it reports hyper-reactivity in post-pubertal dysphoric youths and does not establish that depressive symptoms cause hyporeactive responses to develop. Page numbers are unavailable in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • May combine two claims. 32
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Premisecitation

    Recent reviews show that little is known about the etiology of adolescent suicidal ideation and behaviors and that predictors of suicidal ideation, suicidal behavior, and death by suicide are surprisingly weak.

    “Remarkably, all of these reviews demonstrate that we know surprisingly little about the etiology of adolescent suicidal ideation and behaviors and that predictors of suicidal ideation, suicidal behavior, and death by suicide are surprisingly weak.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Cha et al. 2018 source
    • cites Franklin et al. 2017 source
    • cites Glenn et al. 2017a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Early chronic stress is linked with increased amygdala reactivity and reduced prefrontal regulation to acute stressors.

    “early chronic stress is linked with increased amygdala reactivity and with a lack of prefrontal regulation to acute stressors (Tottenham & Galván 2016)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Tottenham & Galván 2016 source

      In the section on amygdala–PFC circuitry and developmental stress (page unavailable), the review links stress exposure to increased amygdala reactivity and reports that trauma-exposed youths failed to dampen that reactivity during an emotional-conflict task. It does not establish a general lack of prefrontal regulation in response to acute stressors: the evidence concerns emotional tasks, and it also describes increased prefrontal recruitment or adult-like regulatory connectivity in some stress-exposed youths. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Little is known about processes immediately preceding suicide, and few effective strategies exist to intervene in the hours or minutes before suicidal behavior, perhaps particularly among youths.

    “Consequently, little is known regarding the processes that may immediately precede suicide, and few effective strategies designed to intervene in the hours or minutes before individuals engage in suicidal behavior are available (Asarnow et al. 2017, Cha et al. 2018, Miller et al. 2017a), perhaps particularly among youths.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Asarnow et al. 2017 source

      The Introduction says that treatments with replicated efficacy for youth suicide attempts and self-harm are lacking, supporting the claim that effective strategies are limited among youths. It does not address what is known about processes immediately preceding suicide or whether effective interventions are available in the hours or minutes before suicidal behavior; the Method describes a safety plan but does not establish its effectiveness on that timescale. Page numbers are unavailable in our copy. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites Cha et al. 2018 source

      The Potential etiology section says the pathways by which young people develop suicidal thoughts and act on them are not well understood, and Future directions calls for more short-term, real-time research. The Prevention section says crisis lines address immediate needs but have not been studied for reducing suicidal behaviour in youth. These passages support the broad knowledge and intervention gaps, but do not specifically establish a lack of effective interventions in the hours or minutes before suicidal behaviour across individuals generally. Page numbers are unavailable in our copy. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites Miller et al. 2017a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Across rodent and human studies, adolescents show changes in ANS responses, including increased SNS reactivity and PNS withdrawal to acute stressors, suggesting greater physiological reactivity and less flexible regulation.

    “For example, across rodent and human studies, adolescents demonstrate changes in ANS responses, including increased SNS reactivity and PNS withdrawal to acute stressors (Allen & Matthews 1997, Choi & Kellogg 1996, Kurtz & Campbell 1994, Stroud et al. 2009), suggesting that adolescents are more physiologically reactive to stressors and less able to flexibly regulate these increased signals.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Allen & Matthews 1997 source
    • cites Choi & Kellogg 1996 source

      The Results (section 3.2) and Discussion report age-dependent responses to restraint in male rats, supporting the general point that stress responses change during adolescence. But the study measures hypothalamic norepinephrine, not SNS reactivity or PNS withdrawal, and describes this system’s stressor-responsiveness as blunted at mid-adolescence rather than increased. It does not study humans or establish less flexible regulation. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites Kurtz & Campbell 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationcitation

    Accumulating evidence suggests pubertal adaptations in acute stress-response systems contribute to a protracted period of increased stress reactivity and prolonged stress responses in adolescence, during the same period as greater exposure to interpersonal stress.

    “Although data from studies in developmental affective neuroscience are still emerging, accumulating evidence suggests that pubertal adaptations in acute stress-response systems likely contribute to a protracted period of increased stress reactivity and prolonged stress responses (i.e., a slower return to baseline) in adolescence, which is during the same developmental period associated with”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Dahl & Gunnar 2009 source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Lower resting RSA is associated with suicidal ideation in adults and distinguishes individuals with and without a history of suicide attempt.

    “a lower resting RSA is associated with suicidal ideation (Rottenberg et al. 2002) and distinguishes individuals with and without a history of suicide attempt (Tsypes et al. 2018)”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Rottenberg et al. 2002 source
    • cites Tsypes et al. 2018 source

      The Results report significantly lower resting RSA in women with a history of suicide attempt than in women without one. The citing sentence attributes only this attempt-history finding to Tsypes et al.; its suicidal-ideation clause cites a different source. The Discussion cautions that the women-only finding has not been shown to generalize to men, so the unqualified reference to individuals is broader than this study supports. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Early in puberty, limbic system changes include synaptic pruning, increased myelinization, and proliferation of dopamine and oxytocin receptors that facilitate rapid and dramatic responses to social rewards and avoidance of social punishment.

    “Early in this process, beginning before physical manifestations of puberty are evident, changes within the limbic system include synaptic pruning, increased myelinization, and a proliferation of dopamine and oxytocin receptors that facilitate more rapid and dramatic responses to social rewards and avoidance of social punishment (Casey et al. 2008, Chein et al. 2011).”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites Casey et al. 2008 source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites Chein et al. 2011 source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    Adolescents experience several years during pubertal transition with robust responses to social environment and sophisticated capacity to let social experiences shape self-concept, but without mature abilities to regulate emotions or inhibit impulsive responses.

    “In sum, findings from developmental affective neuroscience suggest that adolescents experience several years during the pubertal transition with newly developed and robust responses to their social environment and a more sophisticated capacity to allow these social experiences to shape their self-concept, but without mature abilities to regulate their emotions or inhibit impulsive responses (Casey”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Casey et al. 2008 source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Prior suicidal ideation and behaviors are relatively weak predictors of future suicidal behavior; in most studies only a minority of those who attempt suicide are likely to do so again.

    “Even the effects of prior suicidal ideation and behaviors are relatively weak in predicting future suicidal behavior (Ribeiro et al. 2016), reflecting that in most studies, only a minority of those who attempt suicide are likely do so again.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Ribeiro et al. 2016 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Less is known about adolescent-specific changes in peripheral stress-response systems, although research has begun examining typical adolescent levels of immune markers such as cytokines.

    “Less is known regarding adolescent-specific changes in peripheral stress-response systems, although research has begun examining typical adolescent levels of immune system markers, such as cytokines (Riis et al. 2014).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Riis et al. 2014 source

  • May combine two claims.

    Premisecitation

    Adolescents show increased physiological responses to stressors, increased prefrontal brain activation during social evaluation, and increased difficulty implementing cognitive control in emotionally evocative events.

    “Research confirms that adolescents experience increased physiological responses to stressors (Stroud et al. 2009), increased prefrontal brain activation during social evaluation (Somerville 2013), and increased difficulty implementing cognitive control skills in the context of emotionally evocative events (Cohen et al. 2016, Somerville et al. 2011).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Stroud et al. 2009 source
    • cites Somerville 2013 source
    • cites Cohen et al. 2016 source

  • May combine two claims.

    Findingcitation

    In our research, cortisol hyperreactivity to the TSST had a significant effect on risk for suicidal ideation 3 months later, with a marginal trend for hyporeactivity, controlling for lifetime suicidal ideation and other distal risk factors.

    “Initial findings revealed a significant effect for cortisol hyperreactivity (and a marginal trend for hyporeactivity) to the TSST on the risk for suicidal ideation 3 months later, even after controlling for the lifetime history of suicidal ideation and other distal risk factors (e.g., impulsivity) (Giletta et al. 2015)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Giletta et al. 2015 source

  • May combine two claims.

    Premisecitation

    Compared with nonsuicidal controls, youths with a history of suicidal behavior had decreased gray matter volumes in the hippocampus and cerebellum and decreased amygdala-prefrontal functional connectivity when viewing emotional faces.

    “compared with nonsuicidal controls, youths with a history of suicidal behavior had decreased gray matter volumes in the hippocampus and cerebellum and decreased functional connectivity between the amygdala and the left ventral and right rostral PFC when viewing emotional faces (Johnston et al. 2017)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Johnston et al. 2017 source

  • May combine two claims.

    Premisecitation

    DNA methylation systematically alters gene expression, increasing risk for psychopathology and specifically suicide.

    “DNA methylation systematically alters gene expression, resulting in an increased risk for psychopathology and, specifically, suicide (Haghighi et al. 2014)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Haghighi et al. 2014 source

      The Introduction links methylation at specific sites to decreased gene expression, and the Abstract says increased methylation may contribute to psychopathology and suicide risk. But the Discussion explicitly says the study cannot establish a causal relationship between increased DNA methylation and suicide risk, so the citing sentence overstates the evidence by saying methylation results in increased risk. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    We replicated a similar pattern of results in a separate sample of adolescents and in a sample of emerging adults.

    “We have replicated a similar pattern of results in a separate sample of adolescents and in a sample of emerging adults (Miller et al. 2018).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Miller et al. 2018 source

      The Methods (Participants; page unavailable) describe one sample of 49 adolescents, and the Discussion reports differences in neural activation associated with suicidal ideation in that sample. This supports the reference to a similar pattern in adolescents, but the paper does not report a separate sample of emerging adults. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Adolescents who engage in NSSI or make suicide attempts are significantly more likely to engage in future suicidal behavior, especially within the first few months after an attempt.

    “Adolescents who engage in NSSI or make suicide attempts are significantly more likely to engage in future suicidal behavior (Ribeiro et al. 2016), especially within the first few months following an attempt (Goldston et al. 2001)”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Ribeiro et al. 2016 source
    • cites Goldston et al. 2001 source

  • May combine two claims.

    Premisecitation

    Adverse social experiences characterized by loss or threat activate proinflammatory cytokine activity and trigger alterations in genes regulating proinflammatory cytokine production.

    “adverse social experiences characterized by loss or threat activate proinflammatory cytokine activity (Giletta et al. 2018, Slavich & Cole 2013) and trigger alterations in the genes regulating proinflammatory cytokine production (Slavich et al. 2010)”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites Giletta et al. 2018 source

      The Peer Victimization and Adolescent Inflammatory Responses to Social Stress section (page unavailable) says threats to the social self may increase acute inflammatory responses. The Results (page unavailable) find greater IL-6 and IL-1β reactivity among girls with more peer victimization, but no significant average cytokine increase after the stressor. Thus, the citation supports a narrower, qualified link than the claim’s general statement that loss- or threat-related experiences activate cytokine activity. The separate claim about gene alterations is attributed to Slavich et al. (2010), not this source. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites Slavich & Cole 2013 source
    • cites Slavich et al. 2010 source

  • May combine two claims.

    Premisecitation

    Individuals with a history of suicidal ideation or behavior show altered neural activation and neural network connectivity in prefrontal cortex regions.

    “An emerging line of research points to altered neural activation (Just et al. 2017, Miller et al. 2018, Pan et al. 2013, Quevedo et al. 2016) and neural network connectivity (Chase et al. 2017; Ordaz et al. 2018; Zhang et al. 2014, 2016) in PFC regions among individuals with a history of suicidal ideation or behavior.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Just et al. 2017 source

      Not checked in the free run.

    • cites Miller et al. 2018 source
    • cites Pan et al. 2013 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Following acute stress, proinflammatory cytokines signal the brain to engage in sickness behaviors that mimic depression and can lead to clinical depression in physically ill people.

    “Following acute stress, proinflammatory cytokines signal the brain to engage in sickness behaviors closely mimicking depression and, in some cases, leading to clinical depression among physically ill people (Dantzer et al. 2008)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Dantzer et al. 2008 source

      The Abstract says that pro-inflammatory cytokines act on the brain to cause sickness behaviour, that its symptoms resemble depression, and that sustained immune activation may contribute to depression in vulnerable physically ill people. It describes infection and ongoing inflammation, however, not acute stress as the trigger; it also says the similarity between sickness and depression is only partial. No page number is provided in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    Predicting which adolescents become suicidal may require understanding whether they have recently been exposed to suicide and possess less-aversive attitudes toward it.

    “those who become suicidal might be predicted by understanding whether adolescents have recently been exposed to and, perhaps, consequently possess less-aversive attitudes toward suicide (Nock et al. 2010)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Nock et al. 2010 source

      The Results (page not provided) show that an implicit association between death/suicide and self predicted subsequent suicide attempts in psychiatric emergency-department patients. The paper does not establish that these patients had less-aversive attitudes toward suicide, or assess recent exposure to suicide as a predictor. It does not establish the proposed prediction specifically for adolescents. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Higher-than-usual peer stress predicted suicidal ideation over 18 months regardless of HPA axis function, but predicted suicidal behavior only among girls with blunted cortisol responses to the TSST at baseline.

    “higher-than-usual peer stress predicted suicidal ideation over 18 months, regardless of HPA axis function, but it predicted suicidal behavior only among girls with blunted cortisol responses to the TSST at baseline (Eisenlohr-Moul et al. 2018a)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Eisenlohr-Moul et al. 2018a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Prior work has not clarified the biological or psychological processes that immediately follow stressful experiences and occur within hours, minutes, or seconds before suicidal behavior.

    “Yet prior work has not elucidated the biological or psychological processes that immediately follow stressful experiences and occur within the hours, minutes, or seconds prior to suicidal behavior.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Adolescent suicide can be understood as a failure of biological responses to acute stress during the proximal moments of a suicidal crisis.

    “We suggest that a promising area for future research is to examine adolescent suicide as a failure of biological responses to acute stress in the proximal moments of a suicidal crisis.”
    • Also stated in: § INTRODUCTION · hedged
      “Specifically, we suggest that failures in biological responses to acute stress may underlie acute suicidal crises in youth.”
    • Also stated in: § Organization of Review · hedged
      “We suggest that adolescent suicidal crises may result from failures of biological responses to acute stress.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    It is not clear how these risk factors confer risk in the proximal moments of a suicidal crisis.

    “Further, it is not clear how these factors confer risk in the proximal moments of a suicidal crisis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Adolescents enter a world of novel, complex, unfamiliar social interactions with increased stakes, but with immature biological resources to regulate social stress.

    “Biologically equipped with an increased investment in social interactions and enhanced social sensitivity, adolescents enter a world involving novel, complex, and unfamiliar social interactions with increased stakes for success, but with immature biological resources to adequately regulate social stress.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    These risk factors are nonspecific: they do not indicate which youths are more vulnerable or when a given youth will experience suicidal ideation or engage in suicidal behavior.

    “While these risk factors provide information about global risk for any suicidal ideation or behaviors in the future, they are nonspecific. In other words, they do not provide information about which youths are more vulnerable to these risk factors or when a given youth will experience suicidal ideation or engage in suicidal behavior.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Internalizing risk factors accounted for nearly 66% of all predictors examined but were not strongly related to future risk for suicidal ideation or behaviors, with odds ratios between 1.17 and 1.71.

    “For example, they note that while internalizing risk factors accounted for nearly 66% of all predictors examined in the literature, they were not strongly related to future risk for suicidal ideation or behaviors when omnibus effect sizes are considered in meta-analyses (odds ratios between 1.17 and 1.71; Franklin et al. 2017).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Franklin et al. 2017 source

  • May combine two claims.

    Premisecitation

    Compared with children and adults, adolescents report higher levels of peer-related interpersonal stressors and greater emotional reactivity to these stressors.

    “As compared with children and adults, adolescents report higher levels of peer-related interpersonal stressors and greater emotional reactivity to these types of stressors (Rudolph 2014).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Rudolph 2014 source

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Markers of central stress-response systems may be promising predictors of proximal suicide risk in adolescents.

    “Markers of central stress-response systems may be promising predictors of proximal suicide risk in adolescents.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The pubertal transition is associated with marked increases in peer interactions, decreases in parental supervision, and more severe parent-child conflict.

    “Indeed, research suggests that the pubertal transition is associated with marked increases in adolescents’ interactions with peers, concomitant decreases in parental supervision, and more severe parent–child conflict (Prinstein & Giletta 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Prinstein & Giletta 2016 source

  • May combine two claims.

    Interpretationreasoning

    Adolescence is marked by biological and social changes that simultaneously increase acute stress-response system reactivity and orientation toward social stimuli, creating a uniquely vulnerable period for emergence of suicidal ideation and behavior.

    “Adolescence is marked by dramatic changes in biological and social systems that simultaneously increase acute stress-response system reactivity and adolescents’ orientation toward social stimuli, thus creating a uniquely vulnerable time frame for the emergence of suicidal ideation and behavior.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    For healthy individuals, stress thresholds may be quite high.

    “For healthy individuals, stress thresholds may be quite high.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Several factors may increase the likelihood that adolescents will readily consider suicide: prior self-injury or suicide experiences, knowledge of others' suicidal behavior, and peer socialization toward self-injurious thoughts and behaviors.

    “there are several factors that may increase the likelihood that adolescents will readily consider suicide, including (a) their own prior experiences with self-injury and suicide, such as prior NSSI, ideation, or attempts; (b) their knowledge of others’ (a relative’s or celebrity’s) suicidal behavior; and (c) peer socialization toward self-injurious thoughts and behaviors”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Suicide is most likely to occur when at least one of two conditions is met.

    “suicide is most likely to occur when at least one of two conditions is met”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Almost all prior theories of suicide have not addressed the adolescent increase in suicidal ideation and behavior.

    “a fact that, unfortunately, has been unaddressed in almost all prior theories regarding suicide”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Markers of several peripheral response systems may be relevant correlates of adolescent suicide.

    “Markers of several peripheral response systems also may be relevant correlates of adolescent suicide.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Both higher and lower levels of cortisol have been associated with suicide.

    “both higher and lower levels of cortisol have been associated with suicide”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Each of four biological systems implicated in acute stress responses is associated with relevant suicidal outcomes, at least preliminarily, based on limited empirical studies.

    “is associated with relevant suicidal outcomes, at least preliminarily, based on limited empirical studies”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Many other domains of psychopathology may also be predicted by the same distal factors, pubertal social-biological adaptations, and atypical stress-response systems.

    “many other domains of psychopathology also may be predicted by these same distal factors, the onset of social–biological adaptations to puberty, and atypical stress-response systems”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In a community sample of early adolescents, resting RSA and greater RSA withdrawal to a noninterpersonal frustration task did not predict self-injurious thoughts and behavior over the following 6 months.

    “resting RSA and greater RSA withdrawal to a noninterpersonal frustration task did not predict engagement in self-injurious thoughts and behavior (defined as a composite of NSSI, suicidal ideation, and suicidal behavior) during the following 6 months”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wielgus et al. 2016 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Suicide propinquity may moderate the association between adolescents' acute stress response and suicidal ideation or behavior.

    “Thus, suicide propinquity may moderate the association between adolescents’ acute stress response and suicidal ideation or behavior.”
    Quote in the paperNot a substantial claim
41 of 41

  • The paper relies on this without support.

    The acute stress-response systems are the proximal mechanisms linking stress to suicidal ideation and behavior.

    “we have suggested that our understanding and, ultimately, the successful treatment of suicidal thoughts and behaviors and the prevention of suicide would be aided by addressing one of the central facts about this perplexing and troubling clinical phenomenon”

  • The authors state this as an assumption.

    Individuals have a stress threshold that can be exceeded by severe distress.

    “we posit that suicide may become more likely when individuals experience distress that is unusual, severe, and exceeds their actual or perceived capacity to activate cognitive and social coping resources”

  • The authors state this as an assumption.

    Suicide propinquity is a meaningful factor that moderates the association between acute stress response and suicidal ideation or behavior.

    “A second factor that may increase the likelihood that vulnerable (i.e., stress-exposed) adolescents might exhibit suicidal ideation or suicidal behavior reflects the extent to which they have been exposed to suicide as an option for ameliorating distress.”

  • The paper relies on this without support.

    The prefrontal cortex modulates subcortical activation during acute stress responses.

    “The PFC serves a critical role in leveraging higher-order cognitive skills in the service of modulating subcortical activation.”

  • The paper relies on this without support.

    Subcortical structures monitor the environment for reward or threat and signal the body to enact stress responses.

    “Subcortical brain regions, including the amygdala and hippocampus, are primitive brain structures that monitor the environment for salient cues for reward or threat.”

  • The paper relies on this without support.

    The biological measures used in the reviewed studies validly index the acute stress-response systems.

    “Although data on adolescents is sorely lacking, research suggests that each of these biological stress-response systems may be linked with suicidal ideation and behaviors.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • A failure of biological responses to acute stressors increases proximal risk for STBs.

    “This can be attributed to a failure of biological responses to acute stressors, increasing proximal risk for STBs (for a comprehensive review, see Miller & Prinstein, 2019).”

    From Toward objective characterizations of suicide risk: A narrative review of laboratory-based cognitive and behavioral tasks (2023) · cites this paper as Miller & Prinstein, 2019

    The Introduction (Organization of Review; page unavailable) proposes that adolescent suicidal crises may result from failures of biological responses to acute stress. The review thus supports the proposed link to proximal risk, but the citing sentence presents it as an established causal effect; the Synthesis and Future Directions section describes the evidence as preliminary and limited. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • During adolescence, the HPA axis is more reactive to stress and more sensitive to social threat, peer rejection, and early trauma.

    “the adolescent HPA axis is hyper-reactive to stressors, particularly social threat and peer rejection (95)”

    From Exploring the neurobiological markers of suicidal behaviors in pediatric population: a narrative review (2026) · cites this paper as [95]

    In “Typical Biological Responses to Acute Stress,” the review says adolescents have heightened HPA-axis cortisol reactivity to acute stressors relative to children and adults. “The Adolescent Transition” also describes greater sensitivity to social experiences and emotional reactivity to peer stressors, but it does not establish that the HPA axis is particularly reactive to social threat or peer rejection. The review links early chronic stress to altered stress responses, not specifically to heightened HPA reactivity. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The age-dependent reversal in cortisol reflects a real developmental progression: the adolescent HPA axis is hyper-reactive to stressors, particularly social threat and peer rejection, and only later transitions to the blunted, exhausted profile characteristic of chronic adult HPA dysregulation.

    “Rather than a quirk of age stratification, this reversal likely reflects a real developmental progression: the adolescent HPA axis is hyper-reactive to stressors, particularly social threat and peer rejection (95), and only later transitions to the blunted, exhausted profile characteristic of chronic adult HPA dysregulation.”

    From Exploring the neurobiological markers of suicidal behaviors in pediatric population: a narrative review (2026) · cites this paper as [95]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • Several current theoretical perspectives hold that acute suicide risk occurs during relatively short-lived periods of heightened arousal or agitation.

    “several current theoretical perspectives hold that acute suicide risk occurs during relatively short-lived periods of heightened arousal or agitation (Deisenhammer et al., 2009; Miller & Prinstein, 2019; Tucker et al., 2016; Wolfe-Clark & Bryan, 2017)”

    From Sleep and suicide: A systematic review and meta-analysis of longitudinal studies (2020) · cites this paper as Miller & Prinstein, 2019

  • Adolescence is a developmental window of unique biological vulnerability, characterized by ongoing maturation of stress-response systems, prefrontal-limbic circuits, and reward processing pathways that are still calibrating their adult set-points.

    “Adolescence is a developmental window of unique biological vulnerability, characterized by ongoing maturation of stress-response systems, prefrontal-limbic circuits, and reward processing pathways that are still calibrating their adult set-points (95).”

    From Exploring the neurobiological markers of suicidal behaviors in pediatric population: a narrative review (2026) · cites this paper as [95]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Self-check results appear here once an independent check has confirmed them.

Cited works that were retracted

Works this paper cites that were later retracted, from the retraction notices publishers deposit. Major when the notice came out before this paper was published.

  • Cites a retracted work: 10.1038/s41562-017-0234-y

    Info

    The cited work was retracted on 2023-04-06 (notice 10.1038/s41562-023-01581-1), not before this paper was published (2019-05-07).

    Cited work 10.1038/s41562-017-0234-y · retracted 2023-04-06 · notice 10.1038/s41562-023-01581-1 · this paper published 2019-05-07

1 of 1

Cites

1 retracted

Flagged first, then by citations

Research works printed but not linked: 5

  1. Beck AT, 1987, J. Cogn. Psychother., 1, 5
  2. Curtin S, 2016, NCHS Data Brief, 241, 1
  3. Harter S, 1996, J. Res. Adolesc., 6, 285
  4. Menninger KA, 1933, Int. J. Psychoanal., 14, 376
  5. Spirito A, 2012, Child and Adolescent Therapy: Cognitive-Behavioral Procedures, 234

Cited by

Sorted by citations

Related

Authors
Miller, A. B., & Prinstein, M. J.
Affiliations
University of North Carolina at Chapel Hill (US)
ORCID
Venue
Annual Review of Clinical Psychology
Publisher
Annual Reviews
Published
2019-05-07
Volume
15
Issue
1
Pages
425-450
ISSN
  • 1548-5943 (ISSN-L)
  • 1548-5951
DOI
10.1146/annurev-clinpsy-050718-095625
PMC
PMC6953613
OpenAlex
W2915425527
Semantic Scholar
9d46ab775c12bc217f7dafb0ebcc8a71740f065b
Cited by
235
References
158
Citations by year
2026: 26 · 2025: 34 · 2024: 66 · 2023: 35 · 2022: 23 · 2021: 24 · 2020: 17 · 2019: 9 · 2016: 1
FWCI
2.88
Type
journal article
Language
en
Open access
Locations
  • Annual Review of Clinical Psychology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (F32MH108238, R01MH107479, K01MH116325)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
adolescent suicide, suicidal ideation, acute stress response, stress system, suicide risk factors, suicide prevention, adolescent vulnerability
MeSH terms
Adolescent, Adolescent Behavior, Humans, Models, Biological, Stress, Psychological, Suicide

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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