The perceived relationship adolescents have with their parents and its effect on adolescent suicidality (ideation and attempts) in Ireland

AbstractBackground: A significant negative association between suicidality in adolescents and a

perceived positive relationship/bond with parents as been illustrated in a number of studies.

However causality and the direction of association are still rather unclear. This relationship

has also never been studied in Ireland where adolescent suicide is unusually high.

Aim: To test the association between adolescent’s (13-16 years) relationship with their

parents and their suicidality, in Ireland and try to establish the direction of this relationship.

Methods: Using data collected in the baseline questionnaire of the 2009 SEYLE Programme

to create cross-tabulations, chi-square significance tests and logistic regression incorporating

main confounders (smoking, binge drinking, recent loss, gender, age) and also anxiety. Also

examined possible gender differences and used one year follow-up data to try and establish

the direction of the relationship.

Results: A strong association was found between positive parent relationships and reduced

suicidal ideology as well as suicide attempts, even after allowing for main confounders. This

association was the same for both sexes. Inclusion of anxiety weakened associations: for

suicidal thoughts only good to poor relationship comparison remained significant, OR = 2.69

(95% CI: 1.21, 5.99), and none were significant for suicide attempts. Parental relationship at

baseline was not significantly associated with the development of suicidal ideology at 1 year

follow-up but suicidal ideology at baseline was significantly associated with decreased parent

adolescent relationship at follow-up.

Conclusion: Ireland exhibits a strong positive association between poor parent relationships

and higher adolescent suicidality, as found in other countries. However it is probably not

causal. Suicidal thought and associated mental health difficulties appear to cause

relationships between adolescents and their parents to deteriorate (at least in adolescent’s

views), not the other way around as most previous literature has speculated.

Introduction

Suicide is an extremely important public health concern today causing about 800,000 deaths

worldwide each year and ranked as the 15th leading cause of death in 2012, the second largest

for both 10-19 and 15-29 year olds (WHO, 2016; Hawton et al., 2012). Millions of people are

affected by these losses every year with actual suicidal thoughts and attempts being far

higher. In America nearly 43,000 die from suicide each year and it is estimated that for every

suicide death there are 25 attempts (American Foundation for Suicide Prevention, 2016).

Overall suicide rates are varied within the European region with a few countries such as

Lithuania being exceptionally high (31 per 100,000 people) and others such as Turkey

exceptionally low (2 per 100,000 people) (EuroStat, 2012a). Ireland is around the middle

with (12 per 100,000 people) just over the EU average but far higher than our nearest

neighbour the United Kingdom (7 per 100,000 people) (see Figure 1 (EuroStat, 2012a)).

However when we look at different age groups, Ireland has a huge problem with adolescent

suicide (15-19 years) ranking third in Europe with nearly 10 cases per 100,000 people. By

contrast the United Kingdom is only 3 cases per 100,000 (see Figure 2 (EuroStat, 2012b)).

Lithuania

HungaryLatvi

a

Slovenia

BelgiumEsto

nia

CroatiaSerbia

Poland

Finland

Czech

Republic

France

Austria

Switzerla

nd

Romania

Sweden

Denmark

Ireland

Bulgaria

EU (28 co

untries)

Germany

Slovakia

Luxembourg

Netherlands

Norway

Portugal

Liech

tenstein

Spain

United Kingdom

Italy

Malta

GreeceCyp

rusTurke

y0

5

10

15

20

25

30

3530.69

24.11

21.82 21.53

18.76 18.4 18.2317.28 16.71 16.14 15.97 15.71 15.2

13.2 12.67 12.39 12.22 12.18 12.11 11.72 11.52 11.1 10.69 10.66 10.62 9.98 9.64

7.43 7.22 6.68 6.44.41 3.82

2.12

Figure 1: 2012 Suicide mortality

European countries(2012 data unavailable for Iceland, Montenegro, and Albania)

Suici

de d

eath

s per

100

,000

per

sons

One would suspect that Ireland should be similar to the United Kingdom and we need to

consider if we are overlooking any risk factors. Individual factors such as gender, drug use

and mental health have been well explored but less attention has been payed to broader social

issues and relationships and these can still pose risks (King and Merchant, 2008; Gould et al.,

1996). Theoretically it is easy to assume that relationships with family or friends could play a

role. This connection has been suspected in some high risk groups such as Latinas in the

United States for some time (Kuhlberg et al., 2010; De Luca et al., 2012).

Previous research suggests parental and school supports are the most important social aspects

(Miller et al., 2015) and that parental warmth is the most important of the family influences

(Sheftall et al., 2013). Thus the purpose of this paper is to examine whether the relationship

between adolescents (13-16 years) and their parents affects adolescent suicidality (ideology

and attempts) in Ireland. This relationship to the best of my knowledge has never been

examined in an Irish context and only once within Europe (Donath et al., 2014). Firstly I will

review the existing literature on the topic, then using study data obtained in the 2009 SEYLE

Study (Wasserman et al., 2010) I will examine if the same relationship is evident for

adolescents in Ireland.

Lithuania

Finland

Ireland

Luxembourg

Poland

BelgiumLatvi

a

Switzerla

nd

Norway

Bulgaria

Czech

Republic

Romania

Sweden

HungaryCyp

rus

Croatia

Denmark

Netherlands

EU (28 co

untries)

Estonia

Germany

France

Austria

Slovakia

United Kingdom

SerbiaSpain

Turkey

Italy

Portugal

Greece

Slovenia

Liech

tenstein

0

2

4

6

8

10

12

14

16

1815.4

13.57

9.79 9.428.96

8.127.61 7.41

6.766.34 6.09 5.84 5.53 5.19 4.97 4.89 4.74 4.62 4.52 4.52 4.51 4.34 4.33 4.32

2.78 2.5 2.29 2.12 1.97 1.8 1.451.01

0

Figure 2: 2012 Suicide mortality for 15-19 year olds

European countries(2012 data unavailable for Malta and Iceland)

Suici

de d

eath

s per

100

,000

per

sons

Literature Review

The purpose of this literature review is to locate good quality studies that have been

published on the topic of whether the relationship between adolescents (13-16 years) and

their parents plays any role in increasing or decreasing their likelihood of either suicidal

thoughts or attempts. Table 1 shows chosen inclusion and exclusion criteria.

Table 1: Inclusion and Exclusion criteria

Inclusion criteria Exclusion criteria

Language English only Non-English studies

Literature type Published only Unpublished

Time Published Within last 16 years Previous to last 16 years

Population Adolescents aged 13-16 years

(slight deviation accepted)

All age groups well outside the

age category 13-16 years

Subject area: Primary and secondary research

directly related to the topic:

adolescent suicidality (ideology

and attempts) and perceived

relationship with parents

Primary or secondary research not

directly related to the topic:

adolescent suicidality (ideology

and attempts) and perceived

relationship with parents

Since only published peer reviewed material is going to be included I decided to search

online electronic data bases. Google Scholar was used since it is the largest and most diverse

data base available, and the question is hard to specify to a specific subject area or journal. It

could be categorised under social science, psychiatry or broader public health depending

upon the researchers. PubMed was also searched to locate papers more specifically intended

for medical professionals.

Table 2: Electronic databases searched

Electronic database searched Search terms used Limits used Number of results yielded

Google Scholar (1)

(sorted by relevance)

suicide AND adolescent

AND parent

Since 2000 43,800

(25/02/16)

PubMed

(sorted by relevance)

suicide AND adolescent

AND parent

Since 01/01/2000

Humans only

English only

771

(25/02/16)

Google Scholar (2)

(sorted by relevance)

allintitle: suicide AND

parent OR parental OR

parenting

Since 2000 96

(25/02/16)

Initially a total of about 43,800 results (articles, books etc.) were identified on Google

Scholar on the broad subjects of adolescents, suicide and parents since the year 2000.

Google Scholar identified 96 results (mainly articles and citations) with the words

suicide and one of the following: parent, parental or parenting in its title, since the

year 2000.

PubMed identified 771 results on the broad subjects of adolescents, suicide and

parents since the year 2000.

The titles, abstracts and full texts of each were examined where necessary to determine

relevance to the topic. This was carried out for the first 100 results under the broad

Google Scholar and PubMed searches (in order of relevance) and all 96 of the more

specific Google Scholar search. These 296 studies lead to a total of 17 relevant studies

(after excluding 2 duplicates and 1 with Korean full text). Out of these remaining 17

studies the 3 “most relevant” were chosen for further analysis based on the number of

participants, more recent findings and a preference for cross-sectional surveys (more

comparable to SEYLE Data).

Figure 3: Summary of electronic database search

Table 3: Overview of 3 chosen studies

Study Design Sampling Strengths Limitations Results(Li et al., 2015) Cross-

sectional

Schoolsurveys in 2014

1529 Chinese adolescents

52 % male48% female

Age (years):11-19Mean = 14.74 SD = 1.48Thus 95% of participants between 11.78 and 17.7 years

Large sample size, over 95% participation, and less than 1% missing data

Same study design as SEYLE data thus highly comparable with this study

Recent data – April 2014

Examined both

Sample still not large enough for analysing gender sub-groups

Cross-sectional study so cannot establish causality

Age range was slightly wider than the intended age group (13-16 year olds)

Only includes 4

Hopelessnesssuicidal ideationOR = 1.82, p<0.001 suicide attemptsOR = 1.67, p<0.001

Parental warmthsuicidal ideationOR = 0.49, p<0.001 suicide attemptsOR = 0.43, p<0.001hopelessnessβ = -0.21, p<0.001

Behavioural control

Google Scholar (1)

No of results = 43,800

296

17

3 most relevant studies chosen

for inclusion

Considered the first 100 results for each (ordered by relevance)

Results relevant to topic after reading titles, abstracts, and full

texts where necessary

Google Scholar (2)

No of results = 96

PubMed

No of results = 771

suicidal ideology and attempts

Analysed parent relationship in 3 parts (warmth, behavioural and psychological control) using well considered valid psychological measures

Also examined the effect of parenting style on feelings of helplessness as a possible reason for link with suicidality

confounders (gender, age, family structure, socioeconomic status). No other known risk factors e.g. death of loved one, alcohol or drug use etc.

Applicability - students in China may differ from students in Ireland

suicidal ideationOR = 0.94, p = 0.579 suicide attemptsOR = 0.98, p = 0.907hopelessnessβ = -0.12, p<0.001

Psychological controlsuicidal ideationOR = 1.53, p<0.001 suicide attemptsOR = 2.00, p<0.001hopelessnessβ = 0.24, p<0.001

(Donath et al., 2014) Cross-sectional

Schoolsurveys over 2007 and 2008

44,610 German adolescents

51.3% male48.7% female

Age (years):Mean = 15.3SD = 0.7Thus 95% of participants between 13.9 and 16.7 years

Huge sample size

The first (only?) paper to address the research topic in a European country

Very similar age group and same study design as SEYLE Data thus highly comparable with this study

Analysed parent relationship using Baumrind’s 4parenting styles: Authoritative, Permissive,Authoritarian, and Rejecting-Neglecting

Only 62% of total drawn students participated however it was 88% not counting director refusal. Numbers are so large it is not a huge concern. 5% missing data but was imputed except for gender (1.1%)

Cross-sectional study so cannot establish causality

For suicidal attempts:

Permissive parenting was not statistically significant (p = 0.482)

AuthoritarianOR = 1.30, p = 0.005(95%CI: 1.08, 1.56)

AuthoritativeOR = 0.789, p<0.001(95%CI: 0.71, 0.88)

Rejecting-NeglectingOR = 1.629, p<0.001(95%CI: 1.50, 1.78)

Figure 4 summarises all significant results for suicidal attempts

For suicidal thoughts:

AuthoritarianOR = 1.59, p<0.001andSchool grades not significant (p = 0.083)(Rest were similar)

(Kidd et al., 2006) Longitudinal Using the Add Longitudinal Sample got very Found the parent

study

Using Carolina’s Add Health data from 1995 and 1996

Health nationally representative sample of 12,105 adolescents a subset of students in grades 7 to 11 (at start 1995) was selected

9,142 American adolescents

48% male52% female

Age (years):median = 16

design so causality (rather than association) can be inferred

Large sample size

small when only dealing with males who had attempted suicide the year before N=96

How the social relationships were defined in the original questionnaire seriously restricted breadth of study

Old data (1995/96) and may not be applicable to adolescents today in Ireland

Slightly older than intended age group (13-16 year olds)

relationships had a protective effect for one specific group (males who had attempted suicide before and had poor peer relationships).

The protective effect of parent support was stronger if school relations were also good.

Supportive social relations with peers, parents, and school appeared to have no impact on suicide prevention for all other groups i.e. males without attempt history, males with attempt history but good peer relations, and all females

Figure 4: Significant results for suicide attempts (Donath et al., 2014)

PS = Parenting style

Migration background II = Islamic imprinted countries

Migration background III = All other countries

Findings/Conclusions of literature review

Key findings: High parental warmth had an odds of both suicide attempts and ideology over 50% less than those with poor parental warmth. Psychological control (shame, guilt) increased to odds of suicidal thought by 50% and attempts by 100%. Behavioural control (rules, structure, active monitoring) had no effect on suicidality but was negatively associated with feelings of helplessness. Authoritative relationships reduced the odds of suicide by about 20% whereas authoritarian increased it by about 30%, and neglect by about 63%. However mental health states were not accounted for. Longitudinal findings suggest the likelihood of suicide attempts is reduced by good parent relationships for males with poor peer relationships who have already attempted suicide; this effect was even stronger when school relations were also good. It did not appear to benefit any other adolescent groups.

Strength of evidence: All three studies use very large sample sizes 1529, 44,610 and 9,142 people respectively and there do not appear to be any major problems with participation or missing data. Thus type 1 and type 2 errors should be low, providing statistically sound results. Also the measures used for parent relationship are well considered and based on previously approved psychology. All of them manage to locate statistically significant relationships with very low p-values (<0.001) which means these observed relationships are extremely unlikely to be due to chance.

Applicability of evidence: The data is all very recent and considering that similar findings were found for both German and Chinese adolescents it seems reasonable to assume they are applicable to Ireland too. Kidd et al., 2006 could be less applicable as it was of American adolescents in 1994, and the lives of present day Irish adolescents differ in many respects.

Limitations of this review: Reporting bias of adolescents in questionnaires, no Irish studies, mental health measures not included, only one could show causation (rather than just association) and its applicability is questionable.

Overall conclusion: Adolescents who have poor parent relationships (psychologically controlling, cold or neglectful) have a significantly increased odds of suicidality compared with adolescents who have positive parent relationships (structurally controlled, involved, warm) in China and Germany and probably elsewhere. Causation however is unclear and in America it only appears causal for males with poor peer relations who have already attempted suicide; and this protective effect is strengthened by school support.

Research MethodologyAim:

To test the association between adolescent’s (13-16 years) relationship with their parents and

their suicidality (ideation and attempts), in Ireland and try to establish the direction of this

relationship.

Objectives:

To gain a basic understanding of factors associated with adolescent suicide globally and in Ireland, and look into parent relationship as a possible overlooked social/environmental cause of adolescent suicidality.

To examine if the negative association between good parent relationships and adolescent suicidality observed in the literature review occurs in Ireland.

To see if gender has an influence on this association.

To examine if the association is temporal i.e. the poor parental relationships come before suicidality. If so this would be strong evidence for causality.

To discuss whether my findings are consistent with past research.

Study Design/Participants:

A secondary analysis using two cross-sectional surveys done in Ireland as part of a school-based health promotion and suicide prevention programme “Saving and empowering young lives in Europe” (SEYLE). This programme was implemented in 11 European countries and funded by the European Union under the Seventh Framework Health Program (Wasserman et al., 2010). In Ireland, 17 randomly-selected, mainstream, mixed-gender secondary schools in Cork and Kerry participated. The parent(s)/guardian(s) of 1722 adolescents mostly in second year were asked to consent to their child participating in the project (Cotter et al., 2014).

Sampling:

A total of 1112 adolescents participated at baseline, representing a response rate of 65%. Students were aged 13-16 years and most were 14 years of age (Cotter et al., 2014). 973 completed the follow-up questionnaire one year later, representing a drop-out rate of 12.5%.

Questionnaire Procedures:

All data collected was part of a self-reported questionnaire filled in by participants in a classroom setting (Cotter et al., 2014). The baseline data was collected in 2009 and a follow-up questionnaire was completed 12 months later in 2010 (Wasserman et al., 2010).

Statistical Methods:

SPSS™ was used to generate tables and graphics to demonstrate if there is an association between parent relationships and adolescent suicidality for Irish adolescents. Microsoft Excel and Microsoft Word were used to make improved tables and bar charts. A range of statistical methods were used to conduct this analysis:

Phase 1: Descriptive statistics - A frequency table including all the variables of interest was used to gain an overall picture of the study with the numbers and percentages of participants in each group being displayed.

Phase 2: Association – Cross-tabulation with the aid of a Pearson’s Chi Square Test was used to demonstrate the unadjusted relationship between parent relationships and adolescent suicidality, and see if it is statistically significant. With significance observed a Binary Logistic Regression Model was used to include adjustments for the following previously identified risks: gender, smoking, binge drinking, and recent loss of family/friend (Hallfors et al., 2004; Donath et al., 2014). The adjusted Odds Ratios, 95% Confidence Intervals and p-values were included to measure the strength, direction and significance of associations. The model was also run a second time with the addition of anxiety since mental health was not included in most previous studies. The risk factor difficulties with gender orientation (Marshal et al., 2011; Cotter et al., 2014) was not included in the data set I was provided and the risk factor socioeconomic status (Donath et al., 2014) was very difficult to define given the studies questions.

Phase 3: Gender differences – Cross-tab of gender and parent relationship, with Pearson’s Chi Square Test. Binary Logistic Regression was also used to see if the effect differed between genders for crude odds ratio.

Phase 4: Temporality and causation - Cross-tab of parent relationship at start and suicide ideology in follow-up, with Pearson’s Chi Square Test. Binary Logistic Regression was also used to see if suicide ideology at start was associated with worse parent relationship one year later.

Data Analysis and Coding:

The data was analysed using SPSS™ and to carry out the statistical methods described above a number of variables had to be created and/or re-coded. All missing data was excluded from analysis.

Variables from baseline:

Parental relationship (3 groups): I created the variable parental relationship from question 99. There were 4 parts to this question asking how often do your parents: “Help you make important decisions”, “Take time to talk with you about things that happened to you”, “Come to see you when you do some special activity like being in a play, a sport, or you giving some sort of a performance”, “Pay attention to your opinion or what you say”. Each of these could be answered 1 (never or almost never), 2 (sometimes), or 3 (often). Computed a new variable by adding these 4 questions together getting values between 4 and 12 and coded scores of 10,11,12 as “Good” (0 = reference group), 7,8,9 as “Okay” (1), and 4,5,6 as “Poor” (3).

Suicide ideology: Suicide ideology or suicidal thoughts (I use these interchangeably) was obtained from question 65 part 3 – “Thought of taking own life during past 2 weeks”.

Suicide attempts: Question 66 – “Ever tried to take own life”. This could have been anytime.

Gender: Question 2 – “Gender: male[] female[]”

Smoking: Question 103 – “Have you ever smoked cigarettes?”

Binge drinking: Used Question 71 – “How many drinks containing alcohol do you have on a typical day when you are drinking? There were five possible answers to this question: “I never drink alcohol”, “1 or 2”, “3 or 4”, “5 or 6”, “7 or more”. According to the NIAAA definition of binge drinking it usually occurs after 4 drinks on one occasion for adult women (National Institute on Alcohol Abuse and Alcoholism, 2016) and while this is possibly a little high for adolescents I decided to apply that cut-off point here, coding the answers “5 or 6” and “7 or more” as “Yes” and the rest as “No”.

Loss of a close friend and/or family member: Added together question 126 part 25 – “Death of a close friend in last 6 months” and question 126 part 26 – “Death of a close family member in last 6 months”. 2 was no and 1 yes for both of these, so combined got values 2, 3, 4. Coded 4 as “No” (as this was no for both parts) and 2 and 3 as “Yes”.

Age: Question 1 – “How old are you?”. Did not recode or change this variable in any way.

Variables from follow-up:

Parental relationship reduced: The same 3 category parental relationship variable was made from question 99 in the follow-up data question but recoded with 0 (good), 10 (okay) and 20 (poor). This way when added with 3 category baseline parental relationship (giving values 0, 1, 2, 10, 11, 12, 20, 21, 22) distinctions could be made between what participants reported at the start and in the follow-up i.e. 0 if good in both baseline and follow-up, 1 if okay in baseline and good in follow-up, 2 if poor in baseline and good in follow-up, 10 if good at baseline and okay at follow-up etc. Then coded numbers where there is a lower relationship at follow-up than at baseline as “Yes” (i.e. 10, 20 and 21) and all the rest as “No” (0, 1, 3, 11, 12, 22).

The two following variables were created using the same method as above:

New suicidal ideology in follow-up: Using question 65 in follow-up, same as baseline question.

New suicide attempts in follow-up: Using question 66 in follow-up, same as baseline question.

Results and Analysis

Phase 1: Descriptive statistics

Table 4: Descriptive statistics of baseline variables used in analysis

Variable (percentage answered) Categories Number Valid percentages

Baseline data Total 1112 100.0%

Age (98.1%) 13 years 409 37.5%

14 years 598 54.8%

15 years 55 5.0%

16 years 29 2.7%

Gender (98.6%) Male 600 54.7%

Female 496 45.3%

Parental Relationship (94.2%) Good 640 61.1%

Okay 331 31.7%

Poor 76 7.3%

Suicide ideology (96.8%) No 939 87.3%

Yes 137 12.7%

Suicide attempt (85.6 %) No 923 97.0%

Yes 29 3.1%

Smoking (97.5%) No 862 79.5%

Yes 222 20.5%

Binge drinking (96.3%) No 1032 96.4%

Yes 39 3.6%

Loss of close friend or family member (85.0%) No 774 81.9%

Yes 171 18.1%

Shown here the participant’s ages range between 13 and 16 years, the majority 13 (37.5%) and 14 (54.8%) years, about 54.7% are male, 61.1% had a good parental relationship, 31.7% okay and 7.3% poor, 12.7% had suicidal thoughts in the last 2 weeks, 3.1% had attempted suicide before, 20.5% smoked, 3.6% binge drink, and 18.1% had lost a close friend and/or family member in the last 6 months.

Phase 2: Association

Table 5: Cross-tabulation of parent relationship with suicidal thoughts

From tables 5 we can see that the unadjusted association between suicide ideology and relationship with parents is highly statistically significant (p-value <0.001). 7.3% of those with a good parent relationship had suicidal thoughts in the last 2 weeks, 17% of those with an okay parent relationship had suicidal thoughts in the last 2 weeks and 38.4% of those with a poor parent relationship had suicidal thoughts in the last 2 weeks.

Table 6: Cross-tabulation of parent relationship with suicide attempts

Table 6 shows similar for suicide attempts with the unadjusted association between suicide attempts and relationship with parents being highly statistically significant (p-value <0.001). 1.3% of those with a good parent relationship had previously attempted suicide, 4.9% of those with an okay parent relationship had previously attempted suicide and 14.7% of those with a poor parent relationship had previously attempted suicide.

Table 7: Logistic Regression of parent relationship and possible confounders for suicidal thoughts (with and without inclusion of anxiety)

Suicidal thoughts No Suicidal thoughts

Good parental relationship 46 (7.3%) 582 (92.7%)

Okay parental relationship 56 (17%) 273 (83%)

Poor parental relationship 28 (38.4%) 45 (61.6%)

Pearson Chi-Square p-value <0.001

Suicide attempts No Suicide attempts

Good parental relationship 8 (1.3%) 626 (98.7%)

Okay parental relationship 16 (4.9%) 313 (95.1%)

Poor parental relationship 11 (14.7%) 64 (85.3%)

Pearson Chi-Square p-value <0.001

Variable p-value Odds Ratio

95% CI for Odds Ratio

Variable p-value Odds Ratio

95% CI for Odds Ratio

[72.7% included] Lower Upper [75.5% included] Lower Upper

Parent Relationship (overall) <0.001

Parent Relationship (overall) .052

Parent Relationship (Okay/Good) 0.002 2.220 1.330 3.706

Parent Relationship (Okay/Good) .271 1.380 .777 2.450

Parent Relationship (Poor/Good) <0.001 6.614 3.275

13.358

Parent Relationship (Poor/Good) .015 2.692 1.210 5.993

Zung Anxiety score - - - - Zung Anxiety score .000 1.147 1.108 1.187

Smoking (Yes/No) <0.001 3.427 2.059 5.705 Smoking .001 2.539 1.449 4.451

Loss of family and/or friend (Yes/No)

.001 2.423 1.445 4.061Loss of family and/or

friend (Yes/No).003 2.416 1.357 4.301

Gender (Females/Males)

.015 1.807 1.121 2.914Age (for each 1 year

increase).281 1.217 .852 1.741

Age (for each 1 year increase)

.320 1.180 .851 1.636Gender

(Females/Males).552 1.178 .687 2.018

Binge Drinking (Yes/No)

.494 1.392 .539 3.597Binge Drinking

(Yes/No).997 1.002 .318 3.154

Constant .012 .003 Constant .000 .000

Table 7 shows that when adjusted for other factors (smoking, binge drinking, recent loss, gender, and age) those with lower parental relationships still have a significantly higher odds of suicidal thoughts. This odds of suicidal thought is 6.6 times higher for those with a poor relationship compared to a good relationship. We can be 95% certain the true value for the Irish adolescent population is between 3.3 and 13.4 times.

Also when anxiety is also allowed for, differences between those with okay and good parent relationships are no longer significant (p-value = 0.271) but significant differences do remain between those with good and poor parent relationships (p-value = 0.015). This is a lower odds ratio of 2.7 (95% CI: 1.21, 5.99). Other significant factors are Anxiety (p-value < 0.001), Smoking (p-value = 0.001), and Loss of family and/or friend in last 6 months (p-value = 0.003). Smoking appears to have the largest effect raising the odds of suicidal thought by 7.6 times compared to those who do not smoke. We can be 95% certain the true value for the Irish adolescent population is between 1.5 and 4.5 times.

Table 8: Logistic Regression of parent relationship and possible confounders for previous suicide attempts (with and without addition of anxiety)

Variable p-value Odds Ratio

95% CI for Odds Ratio

Variable p-value Odds Ratio

95% CI for Odds Ratio

[77.8% included] Lower Upper [76.2% included] Lower Upper

Parent Relationship (overall) .003

Parent Relationship (overall) .215

Parent Relationship (Okay/Good) .027 3.439 1.151 10.276

Parent Relationship (Okay/Good) .592 1.411 .400 4.978

Parent Relationship (Poor/Good) .001 8.651 2.486 30.107

Parent Relationship (Poor/Good) .094 3.176 .821 12.288

Zung Anxiety score - - - - Zung Anxiety score .000 1.132 1.077 1.190

Smoking (Yes/No) .000 6.739 2.403 18.903 Smoking .001 7.599 2.262 25.531

Binge Drinking (Yes/No) .008 4.831 1.521 15.346

Binge Drinking (Yes/No) .039 3.947 1.072 14.534

Gender (Females/Males)

.383 1.485 .612 3.604Age (for each 1 year

increase).505 1.230 .670 2.256

Loss of family and/or friend (Yes/No)

.758 1.169 .434 3.147Gender

(Females/Males).888 1.077 .380 3.052

Age (for each 1 year increase)

.995 1.002 .596 1.684Loss of family and/or

friend (Yes/No).920 .941 .285 3.108

Constant .121 .003 Constant .006 .000

Table 8 shows the same analysis as in Table 7 but for suicide attempts. Parent relationship is significant before the addition of anxiety which makes it lose all statistical significance as a predictor of suicide attempts. The only significant factors are anxiety (p-value < 0.001), smoking (p-value = 0.001) and binge drinking (p-value = 0.039). Smoking again appears to be the largest influencer with an odds ratio of 7.6 (95% CI: 2.3, 25.5).

It is interesting how loss of close family and/or friend in the last 6 months is associated with an increase in suicide ideology but not attempts and how binge drinking is associated with suicide attempts but not suicidal thought.

Phase 3: Gender differences

Table 9: Cross-tabulation of differences between parent relationships and gender

Table 9 shows that female adolescents tend to have a better relationship with their parents with about 67% of females in the top category compared to only 56% of males and 7.7% of males in the lowest category compared to 6.7% of females. This difference is statistically significant (p-value = 0.002).

Table 10: Logistic Regression for differences in the association between gender and suicide ideology

Variable p-value Odds Ratio 95% CI for Odds Ratio

Lower Upper

Parent Relationship (overall) <0.001

Parent Relationship (Okay/Good) <0.001 2.673 1.565 4.564

Parent Relationship (Poor/Good) <0.001 8.07 3.562 18.283

Gender (Females/Males) 0.078 1.682 0.943 3

Gender X Parent Relationship 0.81 1.07 0.617 1.855

Constant 0 0.058

Table 10 shows that the association between parent relationship and suicide ideology is the same for both genders (p-value = 0.81). This remains so when my other confounders are included, and also for suicide attempts. Thus the association between parent relationship and suicidality (shown in Tables 7 and 8) is not altered by gender and is applicable to both genders alike.

Phase 4: Temporality and causation

Male Female

Good Parent Relationship

313 (56.4%) 319 (66.9%)

Okay Parent Relationship

199 (35.9%) 126 (26.4%)

Poor Parent Relationship

43 (7.7%) 32 (6.7%)

Total (males/females) 555 (100%) 477 (100%)

Pearson Chi-Square p-value = 0.002

First lets assume that a poor parent relationships lead to suicide ideology in adolescents. If that is the case we would suspect that out of all those without suicide ideology at the start a greater proportion of those with poorer parent relationships should developed suicidal thoughts by the follow-up than those with good parent relationships at the start.

Table 11: Parent relationship at the start and suicidal ideology in follow-up only

Developed suicidal thoughts 1 year later

Did not develop suicidal thoughts 1 year later

Total (parent relationship)

Good Parent Relationship at

start19 (3.5%) 530 (96.5%) 549 (100%)

Okay Parent Relationship at

start13 (4.6%) 272 (95.4%) 285 (100%)

Poor Parent Relationship at

start5 (8.8%) 52 (91.2%) 57 (100%)

Pearson Chi-Square p-value = 0.147

The results in Table 11 appear to confirm this. However they are not statistically significant (p-value = 0.147).

The same was true (p-value = 0.701) for new suicide attempts (those who reported a previous suicide attempt in the follow-up but not at the baseline). But small numbers are a problem here.

When regression was used instead of just cross-tabulation including the following baseline confounders (smoking, binge drinking, recent loss, gender, age), with and without anxiety, parental relationship at baseline was still insignificant for both new suicide ideology and new suicide attempts.

Since statistical significance was not reached we will now look at it from the other point of view that suicidal thoughts lead to poor parent relationships.

When binary regression was used to test the crude unadjusted odds ratio between suicide

ideology at baseline and the reporting of reduced parent relationship at follow-up it was

highly statistically significant |(p-value <0.001). When the following confounders (smoking,

binge drinking, recent loss, gender, age) were included it was still significant (p-value =

0.001). Having suicide ideology at the start increased the odds of reporting a poorer parent

relationship 1 year later by 2.9 times compared to those without suicide ideology at the start

(95% CI: 1.580, 5.296). Smoking (p-value = <0.001) and gender (p-value = 0.029) were also

significant influences.

I think from the above findings it is most likely that parent relationships and adolescent

suicidality are associated because suicidality causes poor parent adolescent relationships not

the other way around. However as seen in Table 12 when anxiety was also included it lost

statistical significance (p-value = 0.219). Gender and smoking remained significant alongside

anxiety. This shows that it is probably mental health difficulties that are concurrent with

suicide ideology that really cause parent relationships to deteriorate, and thus poor parent

relationships are associated with suicidal thoughts since they occur together.

Table 12: Conditions at baseline and reporting lower parent relationships at follow-up

Variable p-value Odds Ratio 95% CI for Odds Ratio

63.8% included Lower Upper

Suicide Ideology .219 1.518 .781 2.950

Zung Anxiety score .000 1.101 1.070 1.134

Gender (females/males) .001 .588 .425 .814

Smoking .003 2.098 1.286 3.423

Binge Drinking .225 .525 .185 1.487

Age .600 .934 .723 1.206

Loss of close family or friend .678 1.096 .712 1.687

Constant .305 .155

Discussion

Almost all previous studies in Australia (Martin and Waite, 1994), Germany (Donath et al., 2014), United States (Connor and Rueter, 2006; Flouri and Buchanan, 2002; Ackard et al., 2006), China (Li et al., 2015), and Korea (Oh et al., 2008) have shown statistically significant associations between various aspects of parent’s relationship and adolescent suicidality. One in the US failed to reach statistical significance for high school students (Saffer et al., 2015). This report has found an expected statistically significant association between parent relationships and suicidality for adolescents in Ireland allowing for similar confounders.

Previous studies examining the relationship tend to look at possible broader social and environmental causes of adolescent depression and perhaps some life choices, they do not however appear to include the effects of mental health states such as depression or anxiety. One study which included these found the relationship between parental care and adolescent suicidality lost its statistical significance (Fergusson et al., 2000). I did analysis both with and without anxiety here for this reason and found that it removed all statistical significance for suicide attempts but not fully for suicidal thoughts where good compared to poor parental relationships still maintained a significant but weakened relationship with an Odds Ratio of 2.69 (95%CI: 1.21, 5.99). This may have changed if depression was also included.{Fergusson, 2000 #39}

While not many studies have looked at gender differences there is some previous evidence that the association between parental relationship and adolescent suicidality is the same for both males and females (Flouri and Buchanan, 2002). I also found there to be no gender differences in this association.

Finally another huge gap in this area of research is if the relationship is causal and its direction. From the results of this analysis it appears very likely that suicidal thoughts come before a reduction in parent adolescent relationships. It also seems likely that this change is mainly caused by anxiety accompanying suicidal ideology. It does not appear to be the other way i.e. poor parent relationships do not appear to cause suicidality in a one year follow-up. However it is worth noting that this study could not address possible longer term effects or poor parent relationships at earlier ages.

Other l{Kidd, 2006 #4}ongitudinal studies also appear to have difficulty finding a strong parent relationship to suicidality causal pathway in adolescents once allowing for mental health. As mentioned in the literature review Kidd et al., 2006 using 1990s Add Health data in the US did not find this relationship for the majority of the adolescent population after accounting for mental health.

Another study, which used Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) data to examine child maltreatment before age 12 and suicide ideology at age 18, found a concurrent association between depression severity and parent-relationship quality at age 16. However parent-relationship quality at age 16 did not predict subsequent depression or suicide ideology at age 18 (Miller et al., 2014).

A study using Christchurch Health and Development Study (CHDS) data from New Zealand found that parental changes, attachment to parents, and childhood sexual abuse all did not predict suicidal behaviour once adolescent mental health and life events were included in the models (Fergusson et al., 2000).However one study using Project EAT-I and Project EAT-II data found that over a 5 year period parent–child connectedness was associated with an increased body satisfaction for

females, increased self-esteem for males, and decreased depressive symptoms for both males and females (Boutelle et al., 2009). All of which would be expected to reduce the likelihood of suicidal thought.

In summary longitudinal research so far suggests that self-reported poor parent relationships during adolescence often occurs alongside mental health difficulties but on its own it is not a risk factor for future suicidal thoughts or attempts. However it may have a small impact on mental health over longer time periods. This paper is the first to actually look at the parent relationship to suicidality pathway in reverse and has found that parent relationships are probably reduced as a result of the mental health difficulties, which are themselves indicative of suicidality.

Overall findings suggest that a poor parent relationship at adolescence on its own is probably not a concern in relation to suicidality for the majority of adolescents. Parent relationships however may be more important for certain high risk groups or the conversion from suicide ideology to suicide attempts (Kidd et al., 2006; Saffer et al., 2015). Further research should focus on longitudinal study designs since association is already very well established.

References

Ackard DM, Neumark-Sztainer D, Story M, et al. (2006) Parent–child connectedness and behavioral and emotional health among adolescents. American journal of preventive medicine 30: 59-66.

American Foundation for Suicide Prevention. (2016) Suicide Statistics. Available at: https://afsp.org/about-suicide/suicide-statistics/.

Boutelle K, Eisenberg ME, Gregory ML, et al. (2009) The reciprocal relationship between parent–child connectedness and adolescent emotional functioning over 5 years. Journal of Psychosomatic Research 66: 309-316.

Connor JJ and Rueter MA. (2006) Parent-child relationships as systems of support or risk for adolescent suicidality. Journal of Family Psychology 20: 143.

Cotter P, Corcoran P, McCarthy J, et al. (2014) Victimisation and psychosocial difficulties associated with sexual orientation concerns: a school-based study of adolescents. Irish medical journal.

De Luca SM, Wyman P and Warren K. (2012) Latina adolescent suicide ideations and attempts: associations with connectedness to parents, peers, and teachers. Suicide Life Threat Behav 42: 672-683.

Donath C, Graessel E, Baier D, et al. (2014) Is parenting style a predictor of suicide attempts in a representative sample of adolescents? BMC Pediatr 14: 113.

EuroStat. (2012a) Death due to suicide, by sex (tps00122). In: EuroStat (ed).

EuroStat. (2012b) Suicide death rate, by age group (tsdph240). In: EuroStat (ed).

Fergusson DM, Woodward LJ and Horwood LJ. (2000) Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychol Med 30: 23-39.

Flouri E and Buchanan A. (2002) The protective role of parental involvement in adolescent suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention 23: 17.

Gould MS, Fisher P, Parides M, et al. (1996) Psychosocial risk factors of child and adolescent completed suicide. Archives of general psychiatry 53: 1155-1162.

Hallfors DD, Waller MW, Ford CA, et al. (2004) Adolescent depression and suicide risk: association with sex and drug behavior. American journal of preventive medicine 27: 224-231.

Hawton K, Saunders KE and O'Connor RC. (2012) Self-harm and suicide in adolescents. The Lancet 379: 2373-2382.

Kidd S, Henrich CC, Brookmeyer KA, et al. (2006) The social context of adolescent suicide attempts: Interactive effects of parent, peer, and school social relations. Suicide and Life-Threatening Behavior 36: 386-395.

King CA and Merchant CR. (2008) Social and interpersonal factors relating to adolescent suicidality: A review of the literature. Archives of Suicide Research 12: 181-196.

Kuhlberg JA, Peña JB and Zayas LH. (2010) Familism, parent-adolescent conflict, self-esteem, internalizing behaviors and suicide attempts among adolescent Latinas. Child Psychiatry & Human Development 41: 425-440.

Li D, Li X, Wang Y, et al. (2015) Parenting and Chinese Adolescent Suicidal Ideation and Suicide Attempts: The Mediating Role of Hopelessness. Journal of Child and Family Studies: 1-11.

Marshal MP, Dietz LJ, Friedman MS, et al. (2011) Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health 49: 115-123.

Martin G and Waite S. (1994) Parental bonding and vulnerability to adolescent suicide. Acta Psychiatr Scand 89: 246-254.

Miller AB, Adams LM, Esposito-Smythers C, et al. (2014) Parents and friendships: a longitudinal examination of interpersonal mediators of the relationship between child maltreatment and suicidal ideation. Psychiatry Res 220: 998-1006.

Miller AB, Esposito-Smythers C and Leichtweis RN. (2015) Role of social support in adolescent suicidal ideation and suicide attempts. J Adolesc Health 56: 286-292.

National Institute on Alcohol Abuse and Alcoholism. (2016) Drinking Levels Defined. Available at: http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking.

Oh HA, Park YR and Choi MH. (2008) The effects of parent-adolescent communication and depression on suicide ideation. Journal of Korean Academy of Child Health Nursing 14: 35-43.

Saffer BY, Glenn CR and David Klonsky E. (2015) Clarifying the relationship of parental bonding to suicide ideation and attempts. Suicide and Life-Threatening Behavior 45: 518-528.

Sheftall AH, Mathias CW, Furr RM, et al. (2013) Adolescent attachment security, family functioning, and suicide attempts. Attach Hum Dev 15: 368-383.

Wasserman D, Carli V, Wasserman C, et al. (2010) Saving and empowering young lives in Europe (SEYLE): a randomized controlled trial. BMC public health 10: 1.

WHO. (2016) Mental Helath - Suicide data. Available at: http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.