Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Epidemiology and Population Health

Degree Program

Public Health Sciences with a specialization in Epidemiology, PhD

Committee Chair

Peiper, Nicholas

Committee Co-Chair (if applicable)

Baumgartner, Richard

Committee Member

Baumgartner, Richard

Committee Member

DuPre, Natalie

Committee Member

Wallis, Anne

Committee Member

Creel, Liza

Author's Keywords

Maltreatment; suicidal behavior; mortality


Suicide has proven to be difficult to predict and prevent at the individual level,1–3 so much so that a recent analysis of individual risk assessments found a maximal positive predictive value of 5.5% for suicide death,2 and suicide continues to be a leading cause of death among adolescents age 10-19 years.4 By targeting modifiable risk factors at the population level, policy has the potential to extend our reach to people and subgroups that are missed by individual level interventions. This ecological study of adolescent suicide rates, state policies, and child maltreatment in US states from 2005-2019 and Kentucky counties from 2010-2019, combines secondary data from multiple databases to implement a mediation analysis and investigate whether the incidence rate of child maltreatment is a mediator between state policies promoting socioeconomic stability and rates of suicidal behavior among youth. No evidence of mediation is found in this analysis to support our primary hypothesis that child maltreatment rates acted as a mediator between state policy and suicidal mortality rates at the national level, nor is there evidence of mediation when investigating access to these programs at the county-level in Kentucky. At the national

level, a generous state minimum wage and an increase in TANF access are associated with decreases in adolescent suicide mortality rates. However, despite previous work implicating child maltreatment as a significant risk factor for suicide mortality, the rate of child maltreatment is not significantly associated with the adolescent suicide rate. The results of this study also indicate a significant role for a refundable state EITC in the decrease of the child maltreatment rate. Shifting the focus to a population level decrease in suicidal behavior and mortality among children and adolescents in addition to effective individual level supports may be a positive strategy toward overall population health. State governments aiming to decrease expenditures by reducing economic benefits and weakening policies that support socioeconomic stability in the population may be failing to take advantage of the upstream prevention benefits for many well-established public health risks of economic insecurity.