A domain-based cumulative risk framework for suicidal behaviors in adolescents: the 4-domain risk index (4D-RI)
- 1Pediatrics 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
- 2Pediatric Intensive Care Unit, Affiliated Children’s Hospital of Xiangya School of Medicine, Central South University (Hunan Children’s Hospital), Changsha, China
- 3Hunan 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
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.
Methods: 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.
Results: 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.
Conclusions: 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.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28952-3.
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BibTeX
@article{li2026domainbased,
title = {{A domain-based cumulative risk framework for suicidal behaviors in adolescents: the 4-domain risk index (4D-RI)}},
author = {Xun Li and Shi-Ting Xiang and Jie Dong},
journal = {BMC Public Health},
year = {2026},
month = aug,
doi = {10.1186/s12889-026-28952-3},
url = {https://doi.org/10.1186/s12889-026-28952-3},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - A domain-based cumulative risk framework for suicidal behaviors in adolescents: the 4-domain risk index (4D-RI)
AU - Xun Li
AU - Shi-Ting Xiang
AU - Jie Dong
PY - 2026
DA - 2026/08/07
JO - BMC Public Health
DO - 10.1186/s12889-026-28952-3
UR - https://doi.org/10.1186/s12889-026-28952-3
AB - 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. Methods: 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. Results: 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. Conclusions: 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. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28952-3.
SN - 1471-2458
ER -