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Journal of the American Academy of Child and Adolescent Psychiatry
Separation/divorce and child and adolescent completed suicide.
Author/s: Madelyn S. Gould
The suicide rate among teenagers has increased approximately 200% since 1960, moving suicide from the fifth leading cause of death among 15- to 19-year-olds to the third leading cause of death in 1993 (National Center for Health Statistics, 1993). A considerable number of causal explanations, involving diagnostic, social, or familial factors, has been posited for this dramatic secular trend in suicidal behavior (Berman and Jobes, 1995; Diekstra et al., 1995). A social condition highlighted as a cause for the secular increase in suicide has been the change in the nuclear family due to increased divorce rates during the past few decades (Berman and Jobes, 1995; Diekstra et al., 1995). Findings from ecological studies (Stack, 1980, 1981; Trovato, 1986, 1987)are consistent with the link between divorce and suicide. Time-series analyses (Stack, 1981; Trovato, 1987) and area analyses (Stack, 1980; Trovato, 1986) report increased rates of suicide with high levels of divorce. The main limitation of these studies is their inability to draw individual-level inferences from aggregate data (the "ecological fallacy") (Kelsey et al., 1986). Furthermore, youth suicide has not been their focus. Studies involving individual-level examinations of the association of divorce and youth suicide have largely involved clinical populations of suicide attempters (Beautrais et al., 1996; Spirito et al., 1989). Most studies have shown higher rates of parental divorce or separation among adolescents who have attempted suicide compared with nonsuicidal community control groups (Spirito et al., 1989); however, some studies have found no differences between suicide attempters and nonsuicidal psychiatric control subjects (Spirito et al., 1989).
Few psychological autopsy studies of representative samples of children and adolescents who have committed suicide have examined the relationship between divorce and suicide (Brent et al., 1993a, 1994; Dizmang et al., 1974; Gould et al., 1996; Shafii et al., 1985). Two large-scale controlled studies (Brent et al., 1993a, 1994; Gould et al., 1996) found that suicide victims were more likely to come from a nonintact family of origin. Another study, based on a small sample of 20 suicide victims, found no significant difference between suicide victims and controls (Shafii et al., 1985). The nature of the relationship between divorce and suicide and the examination of possible modifying and explanatory factors has not been explored in the psychological autopsy literature.
Divorce may have an effect on increasing suicide risk by increasing the youths vulnerability to psychopathology, such as depression (Amato and Keith, 1991; Aro and Palosaari, 1992; Aseltine, 1996), an established risk factor for suicide (Brent et al., 1988a, 1993a; Marttunen et al., 1991; Rich et al., 1986; Runeson, 1989; Shaffer et al., 1996; Shafii et al., 1985). Alternatively, the association may arise from social and environmental factors which are associated with both increased risk of divorce and increased risk of suicidal behavior, e.g., parental psychopathology (Beautrais et al., 1996; Brent et al., 1994). Potential modifiers of the impact of a divorce on the child's subsequent mental health include the age of the child at the time of the dissolution (Allison and Furstenberg, 1989; Amato, 1994; Chase-Lansdale et al., 1995; Palosaari and Aro, 1994), remarriage of the custodial parent (Allison and Furstenberg, 1989; Chase-Lansdale et al., 1995), frequency of contact with the nonresident parent (Amato, 1994) and the parent-child relationship (Amato, 1994; Black and Pedro-Carroll, 1993). The aim of this report is to examine whether such situational and familial psychosocial factors underlie, amplify, or dampen the association between divorce and teenage suicide.
A detailed description of the methods of this study has been provided by Shaffer et al. (1996). With the exception of social and familial variables that are unique to this article, only a brief description of the sample and methods is given. Several reports describe the robustness of the psychological autopsy method (Beskow et al., 1990; Brent et al., 1988b; Shaffer et al., 1996). The project was approved by the New York State Psychiatric Institute/Columbia University Institutional Review Board.
Psychological autopsies were conducted on 120 of a consecutive series of 170 suicides completed by persons younger than age 20 within a 2-year period in New York City and 28 surrounding counties in New York State, New Jersey, and Connecticut. The study area represents rural, suburban, and urban areas, with diverse ethnic and socioeconomic characteristics. The percentage of victims living in urban, suburban, or rural communities at the time of their death was 28.5%, 57.6%, and 13.9%, respectively. A random comparison sample, stratified on the age, ethnic, and sex distribution of the completed suicide cases, was identified from the study region (N = 147 participants from a potential pool of 196 eligible community children and adolescents) by means of a random-digit dialing procedure. The rural/urban status of the controls' communities was not significantly different from that of the victims. Participants in both groups did not differ from nonparticipants on demographic variables (Gould et al., 1996; Shaffer et al., 1996). A detailed demographic description of the sample is presented by Shaffer et al. (1996) and Gould et al. (1996).
The age and sex of the subsample of 58 suicide victims and 49 community controls from nonintact families of origin did not differ significantly from those of the subjects from intact families (Table 1). However, the nonintact families of suicide victims and community controls were less affluent and consisted of a significantly higher percentage of African-Americans and Hispanics than the intact families. The socioeconomic and ethnic differences are accounted for in the analyses.
Information on completed suicides was obtained from a parent or another adult member of the household in which the victim was living at the time of death, either a sibling or a friend, and one to three schoolteachers. Information on community controls was obtained from the adolescents themselves, a parent or caretaker, and up to three schoolteachers. Only the parent/guardian reports alone were used in this report because case-control comparisons are not clearly interpretable without a comparable informant base. The length of each assessment ranged from 4 to 8 hours. Only the community control informants were paid $50. The informants were interviewed by 1 of 11 master's- or doctoral-level psychologists or certified social workers. The interval between suicide and assessment ranged from 28 days to 976 days (median of 159 days). Fifty-four percent of the sample were assessed within 6 months and 81% within 1 year of the suicide.
Demographic Variables. The interview with the informants assessed the household and family constellation during the 3 months preceding the death (or assessment for the controls) and parental education, occupation, and marital status. Nonintact families of origin consisted of those families in which the biological parents had permanently separated or divorced during the youths lifetime, regardless of the current family structure at the time of the youth's death (or assessment for controls). The separation had to have been of at least 3 months' duration and have led to the permanent dissolution of the parents' marriage. The socioeconomic status (SES) of each participant family was derived using Hollingshead's Four Factor Index of Social Status (Hollingshead, 1975).
Parent-Child Relationships. A measure of poor parent-child communication is included in this study because it was significantly associated with suicide risk in an earlier report (Gould et al., 1996). The measure was derived from principal-components factor analyses conducted separately for the mothers' and fathers' relationship items (Gould et al., 1996). The poor communication measure included frequency with which each parent had conversations with the child or adolescent, the extent to which the youth confided in the parent, and the parent's satisfaction with the quality of conversations with the adolescent. The scale scores were dichotomized using what we [TABULAR DATA FOR TABLE 1 OMITTED] considered to be clinically relevant cutoff points. Only relationships with the biological parents were available in this article. The parent's self-report of his or her relationship with the youth took precedence when available (85% for mothers, 42% for fathers).
Parental Psychopathology. For each parent, a lifetime history (before the suicide) of mood symptoms (depression and dysthymia), psychotic symptoms, alcohol or substance abuse problems, psychiatric treatment, and trouble with the police (other than minor traffic violations or warnings) was ascertained (Gould et al., 1996). The symptoms had to meet the duration criterion as specified in DSM-III and had to result in some dysfunction to be scored positive. Only assessments about the biological parents were used in this article. A self-report took precedence when available (78% for mothers, 43% for fathers).
Child and Adolescent Psychiatric Diagnoses. Details about the method of diagnostic assessments are presented by Shaffer et al. (1996). Briefly, the symptom-based interview was derived in part from the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer, 1978), the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Chambers et al., 1985), and the Present State Examination (Wing et al., 1974), supplemented by questions for diagnostic criteria listed in DSM-III. The presence of symptoms during the 3 months before death (or assessment) was ascertained. Lifetime assessments were made for some low-frequency events (e.g., arrests) and for previous manifestations of suicide-related behavior. Diagnoses were assigned by computer algorithms, derived from DSM-III criteria, using a comparable informant base (parents/caretakers only) for suicides and controls. Superordinate diagnostic categories of mood, disruptive, substance and alcohol, anxiety, and miscellaneous disorders were created because the prevalence of many individual diagnoses was low. The best-estimate clinical diagnoses, incorporating nonblind information from all available informants, were not used in these analyses because decipherable case/control comparisons need a comparable informant base and blind assessment. Sensitivities for the superordinate diagnoses using best-estimate clinical diagnoses are given in an earlier report (Shaffer et al., 1996).
Whether the association between separation/divorce and suicide could be accounted for or modified by their significant associations with the contextual or familial measures was examined in the total sample of suicide victims and community controls using maximum-likelihood logistic regression analyses (Hosmer and Lemeshow, 1989). Separate analyses were conducted for each of the familial measures with divorce status as predictors of completed suicide. The matching variables of age, gender, and ethnicity were included as covariates in the analyses because the cases and controls were frequency-matched rather than individually matched (Kelsey et al., 1986) and to account for the ethnic difference between nonintact and intact families of origin. SES was included as an additional covariate because the community controls had a significantly higher SES than the completed suicides (Gould et al., 1996). The analyses also examined interactions between divorce and the familial psychosocial risk factors.
TABLE 2 Living Arrangements of Suicide Victims and Community Controls From Nonintact Families of Origin Suicide Community Victims Controls (n = 58) (n = 48)(a) No. % No. % Mother only 27 46.6 24 50.0 Father only 4 6.9 5 10.4 Mother and other male 10 17.2 12 25.0 Father and other female 4 6.9 3 6.2 Neither 13 22.4 4 8.3(*) a One community control was missing data on living arrangements. * p [less than] .05 by [[Xi].sup.2] test.
Factors that were meaningful only within the context of a separation/divorce (e.g., current family situation, age at separation, and years since separation) were examined within the subsample of 58 suicide victims and 49 community controls from nonintact families of origin.
As reported by Gould et al. (1996), suicide victims were significantly more likely to come from a nonintact [TABULAR DATA FOR TABLE 3 OMITTED] family of origin (48.3%) than community controls (33.3%) (odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.1 to 3.3).
Current Family Structure and Living Situation
Among suicides and controls from nonintact families of origin, there was no significant difference in the percent living in two-caretaker households - "reconstituted" families with one natural parent and one stepparent - at the time of the suicide (or assessment, for controls) (Table 2). Nearly half of the suicides and community controls from nonintact families of origin were currently living with the mother alone. During their lifetime, the number of parenting figures that the suicide victims and community controls had did not significantly differ. Suicide victims were more apt than the community controls to be living with neither parent at the time of their death (assessment) ([[Xi].sup.2] = 4.0, p [less than] .05). Most of these victims were living with another relative; three were living with a girlfriend at the time of their death.
Age at Separation
The age of the victims and community controls at the time of the parental separation is presented in Table 3. The distribution of the years since the separation is also presented, despite being highly correlated with age at separation (r = -.87), because it more clearly portrays the timing of the separation in relation to the death (or assessment). There was a tendency for the suicide victims to have experienced the parental separation/divorce [TABULAR DATA FOR TABLE 4 OMITTED] more recently than the community controls and, as would follow, to be slightly older at the time of the dissolution.
Parental divorce significantly increased suicide risk, even after adjusting for poor mother-child communication (OR = 1.96, 95% CI = 1.06 to 3.62) (Table 4). Similarly, poor mother-child communication maintained its significance after adjusting for divorce (OR = 3.95, 95% CI = 1.46 to 10.70). Suicide victims were more likely to have a poor relationship with their fathers regardless of whether the parents were separated/divorced, whereas the community controls had less frequent and less satisfying communication with their fathers only when the parents were separated/divorced. Thus, poor communication with the father significantly increased suicide risk only for intact families (OR = 17.21, 95% CI = 4.36 to 67.88). Conversely, separation/divorce increased the risk of suicide only in the absence of poor communication (OR = 3.76, 95% CI = 1.61 to 8.75). The amount of actual contact with the nonresident father did not significantly differ between the victims and community controls.
When parental psychopathology was accounted for, the association between separation/divorce and suicide was somewhat diminished (Table 4). The impact of separation/divorce was no longer significant when adjusting for any type of mother's psychopathology. The impact of divorce remained a significant risk factor in the presence of father's mood symptoms, alcohol and substance problems, and history of psychiatric treatment, but it was no longer significantly related to youth suicide in analyses adjusted for the father's history of trouble with the police. No significant interactions between parental psychopathology and divorce emerged.
Indirect Effects of Divorce
Divorce may have an indirect effect on suicide through increasing the risk of disruptive, substance, and mood disorders, established risk factors for suicide (Brent et al., 1988a, 1993a; Marttunen et al., 1991; Rich et al., 1986; Runeson, 1989; Shaffer et al., 1996; Shafii et al., 1985). Divorce significantly increased the risk of substance disorder (OR = 2.82, 95% CI = 1.16 to 6.84) but not disruptive disorders (OR = 1.47, 95% CI = 0.88 to 2.59) or mood disorders (OR = 1.36, 95% CI = 0.67 to 2.75) in the total sample of suicide victims and community controls. The effect of separation/divorce on increasing the risk of substance disorder was no longer significant after adjusting for the father's history of trouble with the police.
The dramatic secular increase in teenage suicide is unlikely to be explained by separation/divorce since the overall impact of separation/divorce on suicide risk was small, including its indirect effects of increasing the youth's vulnerability to psychopathology. In this article the association between separation/divorce and suicide was somewhat explained by parental psychopathology. This is consistent with the reported association of divorce and parental depression (Weissman et al., 1992). Brent et al. (1994) also showed a trend toward higher rates of mental disorder in the parents of both suicide victims and community controls from nonintact families of origin. This family constellation was not associated with increased suicide risk when parental mental disorders were examined simultaneously (Brent et al., 1994). In the present study, other contextual family factors did little to amplify or dampen the association between separation and teenage suicide.
Children and adolescents of divorced parents tend to have poorer parental communication (Hetherington et al., 1982). Poor mother-child communication, however, does not explain the association, albeit a small association, between divorce and suicide in the present study. Both mother's poor communication with the child and divorce independently contributed to increasing the risk of suicide. Poor father-child communication had an interactive effect with divorce on suicide risk. If the father is not residing in the home as a result of a divorce, then poor communication may be somewhat normative and not particularly disruptive; however, when the father is living with the youngster, the "failure to communicate" may reflect a more dysfunctional relationship.
The remarriage of the resident parent did not modify the impact of the separation/divorce on suicide. The effects of remarriage remain inconsistent in the divorce literature. Remarriage has often been found to have a negative effect on children and adolescents (Chase-Lansdale, 1994; Cherlin and Furstenberg, 1994; Garnefski and Diekstra, 1997; Hetherington and Clingempeel, 1992), while other studies report no differences due to remarriage (Allison and Furstenberg, 1989) or an even better outcome among those youngsters whose parents remarried (Chase-Lansdale et al., 1995). The number of subjects in most studies, as in this study, does not allow an examination of the impact of the timing of the remarriage in relation to the timing of the divorce.
The effects of the timing of the divorce are not clearcut or easily interpretable (Emery, 1988). Many previous studies have reported that a marital dissolution has the most deleterious effects on the psychological well-being of children when they are very young at the time of separation (Allison and Furstenberg, 1989; Emery, 1988; Hetherington, 1981). Other studies (Chase-Lansdale et al., 1995) have reported that divorces during adolescence may be more deleterious. In this study, there was a tendency for the parental separation/divorce to have been a more recent event among the suicide victims, consistent with the reports of an association of life stressors, such as interpersonal losses, with suicide (Brent et al., 1993b; Gould et al., 1996; Marttunen et al., 1993; Rich et al., 1988). Unfortunately, because age at separation and years since separation are confounded in this study - a common problem in most studies (Amato, 1994) - it is difficult to disentangle the alternative interpretations of the findings on age at separation.
Our study has several limitations. First, because there is no psychiatric control group, the specificity of the associations cannot be determined. The association between separation/divorce and suicide would probably be smaller if a psychiatric control group had been included in this study, since parental divorce is more prevalent among psychiatric outpatients than among community controls. We could have controlled for the youth's psychiatric disorder in the analyses (Gould et al., 1996); however, we wanted to allow for the possible indirect effects of divorce. Adjusting for the youth's disorder (a more proximal cause of suicide than the parent's separation/divorce) may remove the link between the parental separation/divorce and the youth's suicide, resulting in "overcontrol" in the analysis (Gould et al., 1996). Second, given the small number of girls who complete suicide, we were unable to examine the possible differential impact of divorce on suicide for boys and girls. The gender effect of divorce on emotional distress is still controversial (Zaslow, 1989); however, gender interactions are likely. For example, parental remarriage has been reported to be more detrimental for boys than girls (Garnefski and Diekstra, 1997). Third, adequate information was not available on the relationship of the youth and the stepparent(s) or on the divorce or separation of nonbiological or stepparents, possible modifiers of the impact of a separation/divorce of the biological parents. Fourth, there was a substantial proportion of missing data in our assessment of fatherchild (27%) and mother-child (15%) relationships (Gould et al., 1996). The primary reason for these missing data was that the questions that assessed these domains were added later in the study or changed during the course of the study so that the final set of constructs was not available for the full sample. No systematic bias was evident in the available data, since there were no diagnostic, demographic, or psychosocial differences between those with and those without the assessments (Gould et al., 1996). Fifth, our reliance on mothers' reports of father-child relationships could reflect the mothers' perception of paternal nonavailability, rather than a real problem between father and child. However, the rate of self-reports from fathers was not significantly different between the suicide (44.3%) and the control group (38.3%), nor did it differ for nonintact families (32.7%) and intact families (43.9%). When we limited the examination of poor paternal communication to the subsample with fathers' self-reports (Gould et al., 1996), its significance remained. Finally, a prospective, longitudinal design would ordinarily be considered the optimal strategy to determine the effects of separation/divorce. However, given the rarity of completed suicide among children and adolescents, a case-control retrospective design is the only strategy to ensure an adequate number of cases.
Our findings are not supportive of the popular notion that the increase in youth suicide is due to increased divorce rates during the past few decades. There is still much work to be done to explain the upward secular trend in teenage suicide.
This work was made possible by William T. Grant Foundation Faculty Scholars Award 84-0954-84, NIMH Research Training Grant T32 MH16434, NIMH Research Grant MH 38198-05A2, and NIMH Center Grant MH 43878-A1. The authors acknowledge the assistance of the following medical examiners: Drs. C Galvin, R. Goode, E. Gross, C.S. Hirsh, M.J. Hyland, L. Lukash, S.M. Menchel, J.M. Zarcone, and F. Zugibe.
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From the Division of Child and Adolescent Psychiatry, Columbia University, New York, and the New York State Psychiatric Institute.
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