Cyber Bullying and Physical Bullying in Adolescent Suicide: The Role of Violent Behavior and Substance Use

This study examines the relationship between victimization from both physical and cyber bullying and adolescent suicidal behavior. Substance use, violent behavior, and unsafe sexual behavior were tested as mediators between two forms of bullying, cyber and physical, and suicidal behavior.

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Cyber Bullying and Physical Bullying in Adolescent Suicide: The Role of
Violent Behavior and Substance Use
Article in Journal of Youth and Adolescence · February 2013
DOI: 10.1007/s10964-013-9925-5 · Source: PubMed
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EMPIRICAL RESEARCH
Cyber Bullying and Physical Bullying in Adolescent Suicide:
The Role of Violent Behavior and Substance Use
Brett J. Litwiller • Amy M. Brausch
Received: 6 November 2012 / Accepted: 29 January 2013 / Published online: 5 February 2013
Ó Springer Science+Business Media New York 2013
Abstract The impactof bullying in allformson the
mentalhealth and safety ofadolescentsis of particular
interest, especially in the wake of new methods of bullying
thatvictimizeyouthsthrough technology.The current
study examined therelationship between victimization
from both physicaland cyberbullying and adolescent
suicidalbehavior.Violentbehavior,substance use,and
unsafe sexualbehavior were tested as mediators between
two forms ofbullying,cyberand physical,and suicidal
behavior.Data were taken from alargerisk-behavior
screening study with a sample of 4,693 public high school
students (mean age = 16.11,47 % female).The study’sfindingsshowed thatboth physicalbullying and cyber
bullying associated with substance use,violentbehavior,
unsafe sexualbehavior,and suicidalbehavior.Substance
use,violentbehavior,and unsafe sexualbehavior also all
associated with suicidalbehavior.Substance use and vio-
lentbehavior partially mediated the relationship between
both forms ofbullying and suicidalbehavior.The com-
parable amount of variance in suicidal behavior accounted
for by both cyberbullying and physicalbullying under-
scores the important of further cyber bullying research. The
directassociation ofeachrisk behaviorwith suicidal
behavior also underscores the importance of reducing risk
behaviors.Moreover,the role ofviolence and substance
use as mediating behaviors offers an explanation of how
risk behaviors can increase an adolescent’s likelihood of
suicidal behavior through habituation to physical pain and
psychological anxiety.
Keywords Adolescence Suicide Bullying Cyber
bullying Substance abuse Violence
Introduction
For American youth between the ages of 10 and 24, suicid
ranks as the third leading cause of death (Murphy etal.
2012).Recentincreases in adolescentsuicide rates have
motivated attempts to identify and understand the causes
adolescentsuicide(Cash and Bridge 2009).Researchfindings (e.g.,Klomek etal. 2010) and media reports of
adolescentsuicides(e.g., Cloud 2010)have identified
bullyingas an environmentalstressthat substantially
increases an adolescent’s suicide risk.A large amountof
theoreticaland empiricalevidence supports this relation-
ship between bullying and adolescentsuicide.Bullying
consistsof intentionaland repeatedaggressionthat
involves a disparity of power between the victim and the
perpetrator(Olweus1993).Recentstudiesof bullying
prevalence show thatapproximately 20–35 % ofadoles-
cents report involvement in bullying as a bully,victim,or
both (Levy etal. 2012).Given the high prevalence of
bullying in adolescence and its association with suicide
risk,it is crucial to further study this relationship.
Bullying in adolescence has been identified as occurring
in differentforms,with differentprevalence rates for the
various forms.Bullying behaviorgenerally takes one of
four forms:physical(i.e.,assault),verbal(i.e.,threats or
insults),relational(exclusion orrumorspreading),and
cyber (i.e., aggressive texts or social network posts) (Wan
et al. 2009). Previous findings from longitudinal and cross-
B. J. Litwiller
Industrial/Organizational Psychology,University of Oklahoma,
455 West Lindsey Street,Norman,OK 73019,USA
A. M. Brausch (&)
Department of Psychology,Western Kentucky University,
1906 College Heights Blvd.,Bowling Green,KY 42101,USA
e-mail: [e-mail]
123
J Youth Adolescence (2013) 42:675–684
DOI 10.1007/s10964-013-9925-5

sectional research have shown that each of these types of
bullying can increase the risk of a victimized adolescent
experiencing suicidalthoughtsand behaviors(Klomek
et al. 2010).Severaldifferences between cyberbullying
and more traditional forms of bullying have been identified.
Specifically,cyber bullying is perceived as different from
other types of bullying by victims (Slonje and Smith 2008)
more likely to occur outside of school (Smith et al. 2008).
Unlike victims of the other three types of bullying, victims
of cyberbullying are more likely to reportdepressive
symptoms than cyber bullies or bully-victims (Wang et al.
2011). Current research suggests that cyber bullying occurs
with less prevalence than the other types of bullying,but
still affects around 10–20 % percentof adolescents who
reportbeing bullied or bullying otherselectronically
(Ybarra,Boyd,et al.2012; Ybarra,Mitchell,et al.2012).
The experience of bullying in childhood and adolescence is
importantto study as research has shown thatchildhood
bullying predictsadultsuicide attempts(Meltzeret al.
2011) as well as suicide deaths by the age of 25 (Klomek
et al.2009).
Although each form of bullying has been shown to relate
to adolescentsuicide, significantuncertaintyexists
regardingthe relationshipbetweenvictimizationfrom
bullying and suicidalbehavior.Currently,there are no
empirically supported answers to questions ofwhy vic-
timization increases the risk for suicidalbehavior or how
the effectsof cyberbullying compare to the effectsof
specific traditional forms of bullying (e.g., physical, verbal,
and relational).A widely supported theory of suicide eti-
ology, called the interpersonal theory of suicide, appears to
have tremendous value for explaining the effects of bul-
lying on suicidal behavior (Joiner 2005). The interpersonal
theory ofsuicide posits thatthwarted belongingness and
perceived burdensomeness cause suicidaldesire.The the-
ory furtherstates thatindividuals with high amounts of
suicidal desire only become capable of engaging in suicidal
behavior through habituation to the physically painful and
anxiety provoking nature of self-harming behaviors (Van
Orden et al.2010).
Bullying and Suicidal Behavior
In the contextof the interpersonaltheory of suicide,vic-
timization from bullying would represent an environmental
cause ofthwarted belongingness,perceived burdensome-
ness,and ultimately suicidaldesire.Victimization from
bullying has been shown to associate with low self-esteem
(Juvonen et al.2000),anxiety (Kumpulainen et al.1998),
and depression (Fekkes etal. 2004;Klomek etal. 2007).
Low self-esteem,anxiety,and depression also have all
been identified as correlates of thwarted belongingness and
perceived burdensomeness (Van Orden etal. 2008;Van
Orden et al.2012).To result in suicidal behavior,victim-
ized adolescents who are habituated to the physicaland
psychologicalpain associated with suicidalbehavior may
then develop suicidal desire and capability.Consequently,
one attemptto explain how bullying resultsin suicidal
behavioris to examine risk behaviors thatco-vary with
both bullying and suicidalbehaviorand may habituate
adolescentsto physicalpain and psychologicalanxiety.
Joiner (2005)proposedthat painful and provocative
behaviors,such as drug use,prostitution,and violent
behavior may provide pathways to an acquired capability
for suicidal behavior.In adults,these painful and provoc-
ative behaviors have been shown to increase an individ-
ual’s capability for self-harm (Van Orden et al. 2008). The
currentstudy attempted to examine some behaviors that
may resultin habituation to physicalpain and emotional
distress that also relate to bullying in an adolescent sampl
Risk Behaviors
Several painful and provocative behaviors have been iden
tified consistently as behaviors that relate to both bullying
and adolescent suicidal behavior. Of all such risk behavior
alcoholand/orillicit drug use has mostfrequently been
shown to relate to bullying and suicidal behavior.Victim-
ization from bullying generally has been shown to associat
with or predict adolescent alcohol/drug use (Mitchell et al.
2007; Windle 1994). Findings from these studies of bullyin
victimization and alcoholuse suggestthatexperiences of
bullying produce negative psychological states that increa
the probability than an adolescent will engage in substanc
use. This view of alcohol use as a means to cope with neg-
ative affectis consistentwith pastresearch related to the
etiology ofadolescentsubstance use (Sher,Grekin,and
Williams2005).Findingsfrom otherstudiesalso have
shown substance use to increase an adolescent’s risk of
performing suicidal behaviors (Bolognini et al. 2003; Dey-
kin and Buka 1994; Fombonne 1998; Spirito et al.2003).
These findings suggest that substance use may contribute
habituation ofphysicalpain and psychologicalanxiety
associated with self-harm. Specifically, substance use may
enableadolescentsalready experiencing suicidaldesire
to perform suicidalbehaviorsby decreasing inhibition,
encouraging self-harming behaviors, and exacerbating pre
existing negative moods (Gould et al. 1998).
Like substance use, the amount of violent or physically
aggressive behavior exhibited by adolescents also relates
positivelyto victimizationfrom bullyingand suicidal
behavior.In particular,adolescents who experience phys-
ically violentvictimization have been shown to be more
likely to actviolently towards others (Cleary 2000;Ma
2001;Nickerson and Slater2009).Klomek etal. (2007)
found that adolescents who reported being both a bully an
676 J Youth Adolescence (2013) 42:675–684
123

a victim ofbullying were mostat risk. Taken together,
these findings related to bullying and the performance of
violentbehaviorsuggesta possible cyclicalrelationship
between being a victim of violentbullying and violently
bullying others.Additionalstudies also have shown that
engaging in violent behavior increases the probability that
an adolescentwill perform suicidalbehavior(Borowsky
et al. 2001;Evanset al. 2001).The findingsregarding
bullying,violentbehavior,and suicidalbehaviorsupport
theoreticalviews thatphysicalpain and psychological
anxiety provoked by violentbehavior may habituate ado-
lescents to the physical and psychological pain associated
with suicidal behavior (Joiner 2005).
Unsafe sexualbehavior,such as unprotectedsex,
anonymous sex,or coerced sex,constitutes a third painful
and provocative behavior that co-varies with both bullying
and adolescent suicidal behavior.Specifically,adolescents
who reported being victims of relational or verbal bullying
have been found to be more likely to engage in unsafe
sexual behavior (Zweig et al. 2002). These findings suggest
that sexual behavior may represent a means of coping with
negativepsychologicalconsequencesof victimization.
Investigations of these behaviors demonstrate thatunsafe
sexualbehaviormay have consequencescomparable to
victimization.Severalstudieshave shownthat unsafe
sexual behavior increased the likelihood that an adolescent
would engage in suicidalbehavior(Houck etal. 2008;
Silverman et al. 2001). Like violent behavior and substance
use,repeated experiences of unsafe sexualbehavior may
habituate adolescents to the physicalpain and psycholog-
ical anxieties associated with suicidalbehavior and exac-
erbate any suicidaldesire caused by being a victim of
bullying.
Rationale and Hypotheses
The presentstudyattemptedto examinethe role of
painful and provocativerisk behaviorsas potential
explanations for how adolescents who are bullied acquire
the ability to perform suicidalbehaviors.This study also
attempted to determine if a novel form of bullying,cyber
bullying,had a similar relationship with suicidal behavior
as a physicalbullying.To examine these research ques-
tions,the study tested two different models that predicted
adolescent suicidal behavior.Each model used a different
form of bullying,cyberor physical,to predictsuicidal
behavior.Both models hypothesized thatthe amountof
bullying experienced by an adolescentwould positively
predictsubstanceuse, violentbehavior,unsafesexual
behavior,and ultimately suicidalbehavior.Additionally,
hypothesespresented by themodelsposited thatsub-
stance use,violentbehavior,and unsafe sexualbehavior
would each uniquelypredict suicidal behaviorand
mediate the relationship between both forms ofbullying
and suicidalbehavior.If supported asmediators,sub-
stance use,violentbehavior,and unsafe sexualbehavior
would provide three related explanationsfor how ado-
lescents who experienced bullying acquired the capability
to perform suicidalbehavior.
Method
Participants and Procedure
Data for the current study were accessed from an existing
databaseof a large-scalecommunitymentalhealth
screening in a rural area of a Midwestern state in the US
The data collection occurred in the spring of 2008 and was
collected from 27 high schools in a seven-county region.
All high schools in the region received the opportunity
to participate in the survey.Regionalenrollmentfor all
high schools for the academic year was 7,232 and 4,693
students completed the survey,for a participation rate of
65 %. A local coalition, sponsored by the community hos-
pital, conducts biennial screenings of area high schools for
prevalence and prevention purposes, and received approv
from the hospital’s Human Subjects Review Board.Simi-
larly, the authors consulted with the university Institutiona
Review Board with whom both authors were previously
affiliated,and received approval for analyzing an archival
data set.The coalition utilized passive parentalconsent,
and students were notasked to sign assentdocuments to
protectconfidentiality ofstudentsat schoolswith low
enrollment (e.g.,total student body \100).
Adolescents were between the ages of 14 and 19 years
old (M = 16.11,SD = 1.20)and were allhigh school
students.The ethnic distribution of the sample was 89 %
White,1.5 % Black,1.5 % Hispanic,1.0 % Asian,2.0 %
American Indian,1.0 % Native Hawaiian or other Pacific
Islander,and 3.6 % multi-racial.The sample had a near
equaldistribution of participants in the freshmen,sopho-
more,junior,and senior grade levels.Participantsex was
equally distributed with 47 % percent of the sample male,
47 % female, and 6 % of participants not identifying a sex
Data collection took place atschools attended by the
adolescents during schooldays.Generally,data was col-
lected from large groups of students who sat at individual
desks in classrooms. Before beginning the survey, researc
assistants and stafffrom the coalition instructed adoles-
cents that their participation was completely voluntary an
thatthey could stop atany time for any reason.Students
were told to mark their responses on a bubble sheetand
avoid marking any identifying information on the response
sheet or survey packet. Throughout the survey, project sta
J Youth Adolescence (2013) 42:675–684 677
123

memberswere presentto collect responsesheetsand
answer any participant questions.
Measures
During the study, adolescents completed a packet of survey
questions which mainly included items from the Youth Risk
BehaviorSurvey (YRBS;CDC 2008),butalso included
items written by coalition members orconsulting board
membersto furtherassesshealth and risk behaviorsof
interest to the region. The Youth Risk Behavior Survey is a
scale created by the Centers for Disease Control and Pre-
vention (CDC) to assess the prevalence of risk behaviors that
contribute to the leading causes ofdeath,disability,and
social problems among youth and adults in the United States.
The scalecontainsapproximately 98 self-reportitems
designed to measure the frequency and severity of behaviors
within six categories:violentand self-injurious behavior,
tobacco use,alcoholand other drug use,sexualbehavior,
unhealthy dietary behaviors,and physical inactivity (CDC
2008).Severalstudieshave examined the psychometric
properties of the YRBS. The results of these examinations
indicate thatthe YRBS has sufficientlevels of test–retest
reliability and that adolescents accurately report behaviors
on the measure (Brener et al. 1995, 2002, 2003). No formal
subscales or scoring procedure exists for the YRBS. In the
present study, subscales were created by grouping items by
content,and also through the use of internalconsistency
analyses.Any item thatlowered a subscale’s alpha value
below .70 wasdiscarded.Through internalconsistency
analyses, six subscales were derived. These subscales mea-
sured physical bullying,cyber bullying,suicidal behavior,
drug use, violence, and sexual behavior.
Physical Bullying
The physicalbullying subscale consisted of 3 items from
the Youth Risk BehaviorSurvey (YRBS; CDC 2008)
intended to measurehow frequently adolescentswere
victims ofbullying atschool.All items were presented
with Likertscales thatasked adolescents to rate how fre-
quently they experienced physicalbullying orfearsof
physicalbullying victimization during the past30 days
(e.g., ‘‘On how many days did you not go to school because
you feltyou would be unsafe on yourway to orfrom
school?’’,‘‘During the past30 days,how many times has
someone threatened or injured you with a weapon, such as
gun,knife,or club on school property?’’,and ‘‘During the
past 30 days, how often has someone threatened or injured
you on school property?’’). The 3 items were summed with
higher scores corresponding to more experiences of being
physically bullied.The subscale demonstrated a satisfac-
tory level of internal consistency (a = .77).
Cyber Bullying
The cyber bullying subscale consisted of 3 items written b
coalition membersintended to measure how frequently
adolescentswere bullied by peersthroughelectronic
communication mediums(i.e., textmessage,socialnet-
working).All itemswere presented with dichotomous
scales that asked participants to respond ‘‘Yes’’ or ‘‘No’’ to
questions about cyber bullying (e.g., ‘‘Has someone sprea
a rumor about you online, in a chat room, through a social
networking website,in emails,or through a textmes-
sage?’’,‘‘Has there even been an inappropriate photo post
of you online (illegal activity or sexually compromising)?’’,
and ‘‘Hasanyone sentyou a threatening oraggressive,
e-mail,instant message,or text message?’’).The format of
these itemswas consistentwith the recommended item
format for studying cyber bullying (Wang et al. 2009). The
items were summed with higherscores corresponding to
more experiences ofbeing victimized by cyberbullying.
The subscale demonstrated a satisfactory levelof internal
consistency (a = .71).
Suicidal Behavior
The suicidalbehavior subscale contained four items from
the Youth Risk BehaviorSurvey (YRBS;CDC 2008),
which were used to assess how many suicidalthoughts
and behaviors adolescents experienced during the past ye
The items asked adolescents to respond ‘‘no’’ or ‘‘yes’’ to
items measuring suicidalideation (e.g.,‘‘During the past
12 months, did you ever seriously consider attempting sui
cide?’’), suicide planning (e.g., ‘‘During the past 12 month
did you make a plan abouthow you would attemptsui-
cide?’’), self-injury and suicide attempts (e.g., ‘‘During the
past 12 months,how many times did you actually attempt
suicide?’’). The suicidal behavior subscale had good intern
consistency (a = .88).
Substance Use
The substance use subscale consisted of17 items from
Monitoring the Future survey (MTF; Johnston et al. 2009)
and 7 coalition-authored items designed to assess adoles-
cent’s history of using alcohol, marijuana, inhalants, LSD,
ecstasy,cocaine,crack,heroine,methamphetamine,tran-
quilizers,cigarettes,and smokeless tobacco.Adolescents
rated their responses on Likertscales which assessed fre-
quency ofuse.Higherratingsindicated more frequent,
reckless, or earlier use of a specific substance (e.g., ‘‘Durin
yourlife how many times have you used methampheta-
mines?’’).The substance use subscale demonstrated suffi-
cient internal consistency (a =.87).
678 J Youth Adolescence (2013) 42:675–684
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Violent Behavior
The violent behavior subscale contained 4 items from the
Youth Risk Behavior Survey (YRBS;CDC 2008) which
measured the violent or threatening behavior exhibited by
adolescents.The items asked adolescents to rate how fre-
quently they hurtanother student,threatened another stu-
dent,and carried a weapon during the last30 days (e.g.,
‘‘During the past 30 days, on how many days did you carry
a gun?’’ or ‘‘During the past 30 days, how many times were
you in a physical fight on school property?’’). Adolescents
rated theirresponses to each item on Likertscales.The
violentbehaviorsubscale had good internalconsistency
(a = .81).
Sexual Behavior
The sexual behavior subscale consisted of 5 items from the
Youth Risk Behavior Survey (YRBS;CDC 2008).These
items measured how early adolescents began having sex,
their number of sexualpartners,their history of sexually
transmitted disease,pregnancy,and the amount of protec-
tion they used while having sex.Adolescents rated their
history of sexual behavior on Likert scales.A lower score
indicated a lower amountof potentially dangerous sexual
behavior (e.g.,‘‘The last time you had sexual intercourse,
whatone method did you or your partner use to prevent
pregnancy?’’ or ‘‘During the pastthree months,with how
many peopledid you havesexualintercourse?’’).The
sexual behavior subscale had a sufficient levelof internal
consistency (a = .87).
Missing Data
As a result of the large scale nature of data collection and
the limited amountof time availableto completethe
questionnaire,a number of participants failed to complete
the survey or skipped survey items.Of the original 4,693
participants,only 3838 participants completed allitems.
Missing datawere replaced by multipleimputation,a
procedure forgenerating multiple simulated valuesfor
each missing data point (Schafer 1997) to create an analy
sample of 4,376. Complete data sets were created from th
original data sets using the SPSS Missing Values 20 pro-
gram.One thousand Monte Carlo Marko Chain imputa-
tions were calculated,with every 200 imputations used to
create a total of 5 data sets.Statistical analyses were con-
ducted on each data set and then combined to yield a sing
setof results applying ‘‘Rubin’s rules’’ for combining the
results of an analysis of multiple imputed data sets (Rubin
1987).
Results
Descriptive statistics and intercorrelations amongststudy
variablesappearin Table 1.Prevalence ratesof cyber
bullying, physical bullying were comparable to prevalence
rates from previously reviewed studies (e.g.,Levy etal.
2012; Ybarra, Mitchell, et al. 2012) and the prevalence rat
of suicidal ideation and suicidal behavior was higher than
in previous studies. Subscale responses indicated that 33
of adolescents reported being a victim of physical bullying
23 % of adolescentreported being a victim of cyber bul-
lying,and 30 % of adolescents reported experiencing sui-
cidalideation or performing suicidalbehavior in the past
year. All study variables were significantly correlated with
each other.The observed correlations supported the two
hypothesizedmultiplemediatormodels.To test both
mediationalmodels,a bootstrapping approach was used.
The bootstrapping (or resampling) approach to mediationa
analysis enables the inclusion of multiple mediators in a
single model that does not impose the assumption of nor-
mality ofthe sampling distribution (Preacherand Hayes
2008). This analytic approach provides more accurate Typ
1 errorrates and greaterpowerfor detecting mediating
effects (Preacher and Hayes 2008). In models with multipl
mediators,bootstrapping entails repeatedly sampling from
the data setand estimating the totalindirecteffectand
specific indirect effects in each resampled data set.These
Table 1 Subscale,Cronbach’s alpha values,descriptive statistics and zero-order correlations between bullying,risk behaviors,and suicidal
behavior
Scale a M SD Skew 1 2 3 4 5 6
1 Physical bullying .77 4.72 2.86 2.01 –
2 Cyber bulling .71 5.38 1.60 .60 .55* –
3 Substance use .87 40.72 18.96 1.29 .70* .57* –
4 Violence .81 6.62 3.71 2.09 .79* .53* .63* –
5 Sexual behavior .87 12.20 7.03 .48 .42* .29* .65* .44* –
6 Suicidal behavior .88 6.72 2.28 1.17 .73* .68* .74* .67* .45* –
* p \ .001
J Youth Adolescence (2013) 42:675–684 679
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estimates are used to construct confidence intervals for the
total and specific indirect effects.The total indirect effect
describes cumulatively how all of the mediators transmits
the effect of the predictor variable on the outcome variable
and the specific indirecteffects describe how each indi-
vidual mediator transmit the effect of the predictor variable
on the outcome variable.
The analytic diagram (see Fig.1) presents the concep-
tual meaning of each coefficient in both multiple mediator
models.The ‘‘a’’coefficients representthe effectof the
predictor variable on each mediator,the ‘‘b’’ coefficients
represent the effect of each mediator on suicidal behavior
when controlling for the effect of the predictor variable, the
‘‘c’’ represents the total effect of the predictor on the out-
come,and the ‘‘c0
’’ coefficientrepresents the direct effect
of the predictor variable on suicidal behavior. In addition to
the variables featured in the analytic diagram,both multi-
ple mediation models controlled for the effects of gender,
age, and ethnicity. An SPSS Macro for multiple mediation
was used to examine the hypotheses (Preacher and Hayes
2008). The analyses used 1000 bootstrap samples to create
a population of indirect effects. This population of indirect
effects enabled the creation ofninety-five percentconfi-
dence intervals that evaluated the significance and magni-
tude of indirect effects generated through the bootstrapping
technique.A significant effect does not have a confidence
intervalthatincludeszero. The regression coefficients
generated by both multiple mediation models are unstan-
dardized.The scale of unstandardizedcoefficientsis
determined by thescaleof measurementof variables
included in the analysis Unstandardized metrics are the
preferred metric in causalmodeling because standardized
effect sizes provide no additional meaning and can actually
obscure interpretation ofthe effectsof some predictors
(Hayes 2009).
Resultsfrom the firstmediation modelshowed that
physical bullying had significant and positive direct effects
on substance use,violentbehavior,sexualbehavior,and
suicidalbehavior.Tests of the directeffects of the medi-
ators on the outcome showed that substance use and viol
behavior had significant direct positive effects on suicidal
behavior.Sexualbehavior,however,did nothave a sig-
nificant direct effect on suicidal behavior in the presence o
other mediators.The totaleffectof physicalbullying on
suicidal behavior was also significant and positive. Overall
the modelthat usedphysicalbullyingas a predictor
explained 64 % of the variance in suicidalbehavior (see
Fig. 2).
The hypothesizedmediatorsof physicalbullying’s
effects on suicidal behavior had a significant total indirect
effect on suicidal behavior and several significant specific
indirecteffectson suicidalbehavior.The totalindirect
effectwas significant(CI.95= .26, .32) (see Table 2).
Examination of the proportion of effects mediated shows
that 50 % of the total effect of physical bullying on suicida
behaviorwas mediatedby substanceuse and violent
behavior. The specific indirect effects derived by the mode
indicatesubstanceuse (CI.95= .22, .27) and violent
behavior(CI.95= .02, .08) both uniquely mediated the
effectsof physicalbullying on suicidalbehavior(see
Table 2).
Resultsfrom the multiple mediatormodelthatused
cyber bullying as the predictor showed direct effects sim-
ilar to the onesfound by the physicalbullying model.
Specifically,results showed thatcyberbullying had sig-
nificant and positive direct effects on substance use, viole
Substance Use
Bullying
(Cyber & Physical) Suicidal Behavior
Violent Behavior
Sexual Behavior
Bullying Suicidal Behavior
c
b1
b2
b3
a1
a2
a3
c’
Fig. 1 Analytic diagram for the multiple mediation model proposed
Substance Use
Physical Bullying Suicidal Behavior
R2 adj = .64
Violent Behavior
Sexual Behavior
Physical Bullying Suicidal Behavior
.58*
.29*
.05*
.001
.046*
4.60*
1.04*
1.06*
Fig. 2 Physical bullying, risk behaviors and suicidal behavior. * p\.001
Table 2 Total and specific
mediated effects and their
corresponding bootstrap
confidence intervals for physical
bullying and cyber bullying
Indirect Effects Physical bullying Cyber bullying
Estimate SE 95 % CIs Estimate SE 95 % CIs
Substance use .25 .011 (.22,.27) .32 .012 (.28,.35)
Physical violence .048 .02 (.02,.08) .16 .01 (.14,.19)
Sexual behavior \.001 .01 (.00,.001) .003 .005 (.00,.015)
Total .29 .01 (.26,.32) .48 .013 (.45,.51)
680 J Youth Adolescence (2013) 42:675–684
123

behavior,sexual behavior,and suicidalbehavior.Tests of
the direct effects of the mediators on the outcome showed
thatsubstance use and violentbehaviorhad significant
directpositive effects on suicidalbehavior.Additionally,
sexual behavior did not have a significant direct on suicidal
behaviorin the presence ofothermediators.The total
effectof cyberbullying on suicidalbehaviorwas also
significant and positive. Overall, the model that used cyber
bullying as a predictor explained 67 % of the variance in
suicidal behavior (see Fig.3).
The hypothesized mediators of cyber bullying’s effects
on suicidal behavior had a significant total indirect effect on
suicidalbehaviorand severalsignificantspecific indirect
effects on suicidalbehavior.The totalindirecteffectwas
significant (CI.95= .45, .51) (see Table 2). Examination of
the proportion of effects mediated showed that 48 % of the
totaleffectof cyberbullying on suicidalbehaviorwas
partially mediated by substance use and violentbehavior.
The proportion ofeffectmediated in the cyberbullying
modelis substantially larger than the proportion of effect
mediated in thephysicalbullying model.The specific
indirect effects derived by the cyber bullying model indi-
cated thatsubstance use (CI.95= .28, .35) and violent
behavior(CI.95= .14, .19) both uniquely mediated the
effects of cyber bullying on suicidal behavior (see Table 2).
Discussion
With suicide remaining one of the leading causes of death
for adolescents,recentresearch has emphasized the iden-
tification of factors in adolescent suicide risk (Brausch and
Gutierrez2010).Bullying victimization repeatedly has
been found to associate with or predict adolescent suicide
risk (Kim and Leventhal2008).Although clear evidence
for links between bullying victimization and suicide exists,
no previous research has attempted to determine empiri-
cally why bullying might increase an adolescent’s risk for
suicidalbehavior.Behavioraloutcomesassociated with
being a victim ofbullying may increase an adolescent’s
suicide risk (e.g.,Wang et al.2011).
Consequently,this study examinedwhetherthree
behavioraloutcomes frequently associated with bullying
and suicidal behavior, substance use, violent behavior, an
unsafe sexualbehavior,mediated the frequently observed
relationshipbetweenvictimizationfrom bullying and
adolescentsuicidalbehavior.Two types of bullying were
examined in thisstudy,cyberbullying and physically
violentbullying.Generally,the results revealed thatboth
types of bullying,cyber and physical,positively predicted
suicidalbehavior,substanceuse, violentbehavior,and
unsafesexualbehavior.Cyber bullyingaccountedfor
slightly more variance in allfour of these behaviors than
physical bullying. Findings from the two models tested als
showed that two risk behaviors,substance use and violent
behavior, positively predicted adolescent suicidal behavio
and partially mediated the relationship between both form
of bullying and suicidal behavior.
The role of physicalbullying asa factorthatmay
increase the risk of adolescentsuicidalbehavior supports
previous cross-sectional and longitudinal research that ha
shown a relationship between the two variables (Klomek
et al.2010).The relationship between cyber bullying and
suicidalbehaviorin the currentstudy,however,extendsfindings from limited previous research on cyber bullying
which used measures thatwere less behaviorally specific
and did notinclude assessmentof communication with
social networks (Klomek et al.2008; Hinduja and Patchin
2010).The currentstudy also showed thatcyber bullying
had a similar sized effecton suicidalbehavior,substance
use, violent behavior, and unsafe sexual behavior as phys
ical bullying. This finding provides further evidence of the
potentialconsequences ofcyberbullying.In contrastto
physical bullying, cyber bullying has been found to be mor
difficult to avoid,anonymous,and likely to coincide with
other forms of bullying (Li 2005). Although not specifically
examined in this study, victims of cyber bullying may mor
be likely to experience negative psychological states,thus
contributing to feelingsof thwarted belongingnessand
perceivedburdensomeness.If cyberbullyingactivates
feeling like one does not belong or is a burden to others, a
adolescent’s risk of suicidalbehavior may increase,espe-
cially if adolescents are also engaging in risk behaviors tha
may habituate them to pain and fear of death.
Bullying,Risk Behaviors and Suicide
The two models tested in this study supported this possibl
effect of cyber bullying by showing that substance use and
violent behavior could explain how both physical bullying
and cyber bullying increase suicidal behavior risk for ado-
lescents. Correlates of victimization, such as low self-estee
(Juvonen et al.2000),anxiety (Kumpulainen et al.1998),
and depression(Fekkeset al. 2004),could motivate
Cyber Bullying Suicidal Behavior
.97*
Substance Use
Cyber Bullying Suicidal Behavior
R2 adj = .67
Violent Behavior
Sexual Behavior
.05*
.13*
.02
5.42*
1.22*
.1.33*
.49*
Fig. 3 Cyber bullying, risk behaviors and suicidal behavior. * p \ .001
J Youth Adolescence (2013) 42:675–684 681
123

adolescents to use substances to cope with negative feelings.
If an adolescent’s substance use resulted in painful or pro-
vocative behaviors, such as self-injection, then the adoles-
centmay acquire the capability to overcome the physical
pain and psychological stress that prevents many people with
suicidal desire from actually performing suicidal behavior
(Joiner 2005). This possibility that substance use could help
adolescents become more capable of performing suicidal
behavior draws support from previous research that shows
adolescent substance use to be one of the more frequently
identified predictors ofsuicidalbehaviorfor adolescents
(e.g., Bolognini et al. 2003; Spirito et al. 2003).
Findings from both multiple mediatormodels suggest
that violent behavior has a similar role as substance use in
inoculating adolescents to physical pain and psychological
fearsthatpreventsuicidalbehavior.Certain behaviors
related to violent behavior, such as participating in physicalfights,havebeen shown to increasesuicidalbehavior
capability in adults (Van Orden et al.2008).Many of the
injury and pain outcomes associated with physicalfights
could slowly habituate adolescentsto suicidalbehavior.
Moreover,the well-established presence of a victim-bully
cycle (Ma 2000; Pellegrini and Bartini 2001) suggests that
violentbehaviormay mediate the relationship between
bullying victimization and suicidal behavior because ado-
lescents who are bullied are more likely to bully others.
This bullying ofothers could resultin the same type of
violent behavior that has been shown many time to increase
an adolescent’s risk of suicidal behavior (Borowsky et al.
2001; Evans et al.2001; Swahn et al.2008).
Unlike substance use and violent behavior, unsafe sexual
behavior was not found to mediate the relationship between
victimization from eitherform of bullying and suicidal
behavior in this study. It was also not a significant predictor
of suicidal behavior in either model. This lack of prediction
indicatesthatunsafe sexualbehaviorby itselfdoes not
enable suicidal behavior. Especially painful and dangerous
sexual behaviors that were not measured in this study, such
as prostitution orsexualassault,may representthe only
sexual behaviors that can habituate people to the physical
and psychological pain associated with self-harm. Although
unsafe sexualbehavior did notpredictsuicidalbehavior,
both forms of bullying did predictsexualbehavior.Thisfinding provides the first known evidence of a link between
bullying and sexualbehaviorand suggests thatnegative
emotional states associated with bullying may still have life
altering consequences for adolescents apartfrom suicidal
behavior, substance use, and violent behavior.
Limitations
A number of limitations existed in this study as a result of
the sample size,measures used,and cross-sectionalstudy
design.The large size ofthe sample likely inflated the
statistical significance of several regression model finding
Although statistically significant, several findings from the
study may possess lesser clinical significance than similarfindingsobtained from a smallersample (Odgaard and
Fowler 2010). The use of a cross-sectional design prevents
the testing ofdirectionality ofthe relationship between
victimization and suicidal behavior.The use of self-report
measures to assess victimization from bullying also may
limit the findings because it excluded other frequently use
methods of collecting victimization data,such as reports
from parents,teachers,and peers,which could have
improved the victimization measure and introducesthe
possibility of shared method variance.The bullying mea-
suresalso contain severallimitations.Specifically,dis-
crepanciesin the lengthassessedbetweenthe cyber
bullying and physical bullying measures limit comparisons
of the two forms of bullying in this study.Also,the com-
bination of threats and actual experiences measured in bo
of the bullying measures reduce their construct validity an
introduce a need for more precise measurementin future
studies.As another measurementlimitation,the measures
of sexualbehavior and substance used in this study were
widely used measuresof those constructsthatdid not
specifically assess the pain and fear habituating aspects o
substance use and sexual behavior.
Future Directions
Despite the above limitations,results from this study do
provide the first empirically supported explanation for how
bullying may increase suicide risk.Future research could
extend the findings from this study by further examining
the value ofthe InterpersonalTheory ofSuicide (Joiner
2005) as an explanation for the relationship between bul-
lying and suicidalbehavior.Specifically,future studies
related to bullying and suicide should measure constructs
such asperceived burdensomeness,thwarted belonging-
ness,suicidalbehavior,and otherpainfulor provocative
behavior that could be included in a model to explain how
bullying ultimately increases an adolescent’s risk for sui-
cidal behavior. With sufficient measurement of the various
types ofbullying,future research could also attemptto
determine if relational, physical, verbal, and cyber bullying
differentially affect suicidal behavior.
Conclusion
Models of adolescentrisk behavior often examine how a
sequence of events that lead to a risk behavior can occur
result of exposure to certain risk factors (Compas et al. 19
This cross-sectional study provides the firstindication for
682 J Youth Adolescence (2013) 42:675–684
123

how bullying victimization may trigger a sequence of events
thatresults in suicidalbehavior.Rejection by peers and
bullying specifically has been found to trigger psychological
processesthatresultin externalizing behavior(Deater-
Deckard 2001).Key findings from this study show that
harmfulexternalizing behaviors thatcan develop during
adolescence,such as substance use and violentbehavior,
mediate the effects between ofboth cyberand physical
bullying on suicidalbehavior.This finding draws support
from theory regarding the importance of habituation to pain
to acquiring the ability to perform self-injury (Joiner 2005)
and providesmodifiablebehaviorsthat should receive
attention in interventions aimed atpreventing adolescent
suicide. Professionals who aid adolescent victims of bullying
should encourage healthy coping behaviorsand support
interventions that diminish the probability of an adolescent
engaging in substance use or violent behavior.
AcknowledgmentsThe authors would like to thank and acknowl-
edge Gaye Harrison and the I Sing the Body Electric (888-550-7464;
www.isbe.org)coalitionfor their supportof theseanalysesby
granting access to their existing data.
Author Contributions BL conceived of the study,participated in
its design and coordination,performed the statisticalanalyses,par-
ticipated in the interpretation of the data, and drafted the manuscript;
AB participated in the design and coordination of the study,partici-
pated in the interpretation of the data,and helped to draftthe man-
uscript; All authors read and approved the final manuscript.
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Author Biographies
Brett Litwiller is a Ph.D. candidate in Industrial/Organizational
Psychology at the University of Oklahoma. He earned his Master’s in
Clinical Psychology from Eastern IllinoisUniversity.His major
research interests include risk-taking behaviors in adolescents, as we
as individualdifferencesand organizationalcharacteristicsthat
influencephysicaland mentalhealthoutcomesexperiencedby
employees in the workplace.
Amy Brausch is an AssistantProfessor of Psychology atWestern
Kentucky University.She received her Ph.D.in Clinical Psychology
from NorthernIllinois University.Her major researchinterests
encompassadolescentsuicideand non-suicidalself-injury,risk-
taking behaviors,body image,and disordered eating.
684 J Youth Adolescence (2013) 42:675–684
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