{
  "abstract": "Background: Suicide remains a leading cause of death among adolescents worldwide. This study investigated whether a domain-based framework, termed the 4-Domain Risk Index (4D-RI), could characterize adolescent suicide-related vulnerability by quantifying cumulative risk across four domains: substance use, aggressive behaviors, victimization, and low support.\n\nMethods: Data from the 2023 Youth Risk Behavior Survey (YRBS) were used as the primary analytic dataset, and data from the 2021 YRBS were used for temporal validation of the 4D-RI framework. Relevant YRBS items were mapped to four risk domains, and the number of domains with positive responses was calculated for each participant. A reduced-item version excluding items related to illicit drug use, firearm-related behaviors, and sexual violence was also evaluated. Associations between the number of risk domains and suicidal ideation and suicide attempts were examined.\n\nResults: The prevalence of suicidal behaviors increased progressively with the number of risk domains. For suicidal ideation, adjusted prevalence ratios (aPRs) ranged from 2.54 (95% CI: 1.89, 3.41) for one domain to 9.65 (95% CI: 7.45, 12.51) for four domains (reference group: zero risk domains). For suicide attempts, aPRs ranged from 4.32 (95% CI: 2.53, 7.37) to 32.51 (95% CI: 19.74, 53.55). The AUC was 0.76 (95% CI: 0.75, 0.77) for suicidal ideation and 0.79 (95% CI: 0.78, 0.80) for suicide attempts. Similar discriminative performance was observed for the reduced-item version and temporal validation analyses, and was comparable to that of models incorporating domain-specific coefficients. Similar discriminative performance was observed for the reduced-domain versions and temporal validation analyses, and was comparable to that of models incorporating domain-specific coefficients. Sensitivity analyses addressing missing data and subgroup analyses stratified by age, sex, and race further demonstrated consistent risk gradients and comparable discriminative performance.\n\nConclusions: Co-occurring vulnerability across the four domains was associated with progressively higher prevalence of suicidal behaviors. The 4D-RI provides a simple and interpretable framework for characterizing cumulative psychosocial vulnerability related to suicidal behaviors in adolescents.\n\nSupplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28952-3.",
  "abstract_shown": true,
  "affiliations": [
    "Pediatrics Research Institute of Hunan Province, Affiliated Children’s Hospital of Xiangya School of Medicine, Central South University (Hunan Children’s Hospital), 86 Ziyuan Road, Changsha, 410007 China",
    "Pediatric Intensive Care Unit, Affiliated Children’s Hospital of Xiangya School of Medicine, Central South University (Hunan Children’s Hospital), Changsha, China",
    "Hunan Provincial Key Laboratory of Emergency Medicine for Children, Affiliated Children’s Hospital of Xiangya School of Medicine, Central South University (Hunan Children’s Hospital), Changsha, China"
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 3,
  "authors": [
    {
      "affs": [
        0,
        1,
        2
      ],
      "name": "Xun Li"
    },
    {
      "affs": [
        0
      ],
      "name": "Shi-Ting Xiang"
    },
    {
      "affs": [
        0
      ],
      "name": "Jie Dong"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/11vr461x648fq.bib",
  "cited_by": 0,
  "doi": "10.1186/s12889-026-28952-3",
  "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13732846/",
  "id": "11vr461x648fq",
  "issns": [
    "1471-2458"
  ],
  "landing_url": "https://doi.org/10.1186/s12889-026-28952-3",
  "language": "en",
  "licence": "CC-BY-NC-ND-4.0",
  "licence_label": "CC BY-NC-ND 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "heading",
      "Research"
    ],
    [
      "openalex",
      "3203|Suicide and Self-Harm Studies"
    ]
  ],
  "openalex": "W7201877740",
  "pdf_url": null,
  "pmcid": "PMC13732846",
  "pmid": "42983384",
  "published": "2026-08-07",
  "publisher": "BMC",
  "ris": "https://research.draconitic.com/paper/11vr461x648fq.ris",
  "sources": [
    {
      "first_seen": "2026-11-08T12:22:45Z",
      "native_id": "PMC13732846",
      "source": "pmc",
      "url": "https://doi.org/10.1186/s12889-026-28952-3"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:3203|Suicide and Self-Harm Studies",
      "subfield": "psychiatry"
    }
  ],
  "title": "A domain-based cumulative risk framework for suicidal behaviors in adolescents: the 4-domain risk index (4D-RI)",
  "title_text": "A domain-based cumulative risk framework for suicidal behaviors in adolescents: the 4-domain risk index (4D-RI)",
  "type": "peer-reviewed",
  "updated_at": "2026-11-08T12:22:45Z",
  "url": "https://research.draconitic.com/paper/11vr461x648fq",
  "venue": "BMC Public Health",
  "versions": []
}