Suicide and Life-Threatening Behavior 39(2) April 2009 137

2009 The American Association of Suicidology

The Impact of Parental Suicide on Child

and Adolescent Offspring
S. Janet Kuramoto, MHS, David A. Brent, MD, and Holly C. Wilcox, PhD

Child and adolescent survivors of parental suicide experience two stressful

events simultaneously: (1) the loss of a primary caregiver, and (2) suicidal death of
a significant person. These youths are thought to be at increased risk for mental
health problems, but a systematic review of studies on these survivors has not yet
been conducted. A comprehensive search for published literature identified nine
studies. The existent studies provided modest yet inconsistent evidence on the
impact of parental suicide on offspring psychiatric and psychosocial outcomes.
More methodologically rigorous research is needed to inform and guide postven-
tion efforts for these survivors.

Approximately 32,637 Americans died from participants, risk of retraumatization, lack of

suicide in 2005, which is equivalent to 89 sui-
cides per day (Kung, Hoyert, Xu, & Murphy,
2008). One study found that an estimated 4.6
million Americans had known someone who
died by suicide in the past 25 years, a figure
equivalent to 1 out of every 65 individuals
(McIntosh, 2008). Studies of child and ado-
lescent survivors of suicide are rare, primarily
due to practical issues and the sensitivity of
this research area (e.g., difficulty in recruiting
S. Janet Kuramoto is with the Depart-
ment of Mental Health, Bloomberg School of
Public Health at Johns Hopkins University in Bal-
timore; David A. Brent is with the Department
of Psychiatry, Pediatrics and Epidemiology,
Western Psychiatric Institute & Clinic, University
of Pittsburgh School of Medicine; and Holly C.
Wilcox is with the Department of Mental Health
and the Division of Child and Adolescent Psychia-
try at Johns Hopkins University.
The authors wish to acknowledge NARSAD
for a Young Investigator Award to Holly C. Wil-
cox and an anonymous SLTB reviewer for his/her
helpful comments.
Address correspondence to Holly C. Wil-
cox, PhD, The Johns Hopkins University School of
Medicine, 550 North Broadway, Room 203C, Bal-
timore, MD 21205; E-mail: hwilcox1@jhmi.edu.
validated assessment tools, etc.). Adequately
assessing the magnitude to which child and
adolescent survivors of parental suicide are at
risk for psychosocial problems and psychiat-
ric disorders, as well as identifying modifiable
risk factors, could inform and strengthen
postvention efforts for this population. The
few empirical studies available on child and
adolescent survivors of a first degree family
members suicide suggest that survivors are at
increased risk for psychosocial problems such
as depressive symptoms, posttraumatic stress
disorder, and social maladjustment (Brent,
Perper, Moritz, & Liotus, 1993; Pfeffer et al.,
1997; Sethi & Bhargava, 2003).
Children and adolescents who have
lost a parent to suicide may need special at-
tention for several reasons. Death by suicide
is often followed by stigma and guilt, factors
that have not been reported for many other
types of parental death (Cvinar, 2005; Jordan,
2001). Child and adolescent survivors of pa-
rental suicide may have increased familial risk
for mental disorders, suicidal behavior, and
impulsive aggressive behavior (Brent & Mann,
2005; Hawton, Haw, Houston, & Townsend,
2002; Qin, Agerbo, & Mortensen, 2002;
138
Schulsinger et al., 1979; Wender et al., 1986).
Furthermore, contextual factors such as dis-
rupted family functioning prior to and/or
after parental suicide (e.g., parental psychiat-
ric status, legal problems, and marriage prob-
lems), negative life events following the death
(e.g., financial problems, geographic reloca-
tion, and inadequate childcare), and the qual-
ity of parenting by the surviving parent and
their mental health status may influence the
psychosocial functioning of the offspring
(Cerel, Fristad, Weller, & Weller, 2000;
Cerel, Fristad, Verducci, Weller, & Weller,
2006; Garmezy & Rutter, 1983; Jordan,
2001; Pfeffer et al., 1997; Tennant, 1988).
In light of these findings, the impact of
parental suicide on psychiatric disorders and
psychosocial outcomes among child and ado-
lescent offspring warrants further attention.
The aim of this study was to evaluate the ex-
istent research on the association between
parental suicide during childhood and ado-
lescence and offspring psychiatric and psy-
chosocial outcomes.
METHODS
A literature search was conducted us-
ing the following electronic databases:
MEDLINE, PsycARTICLES, PsycINFO, Cu-
mulative Index to Nursing & Allied Health
Literature (CINAHL), Educational Resources
Information Center (ERIC), and EMBASE.
Search terms were generated using free text
and medical subject headings (MeSH) for
MEDLINE and the thesaurus for other data-
bases. The following phrases were used to
identify the literature: ((parent OR mother
OR father OR maternal OR paternal) AND
suicide) OR (suicide AND survivors) for
MEDLINE, psycINFO, psycARTICLES,
EMBASE, and CINAHL; and (parent OR
mother OR father OR maternal OR pater-
nal) AND suicide for the ERIC database.
The search terms found 3,755 unique docu-
ments from databases with coverage as far
back as 1887 (psycINFO), 1953 (MEDLINE),
1985 (psycARTICLES), 1982 (CINAHL),
Impact of Parental Suicide
1966 (ERIC), or 1974 (EMBASE) through
July 2007.
Full text articles were obtained if ei-
ther the abstract or the title (for those with-
out abstracts) included terms representing
parental suicide. The studies were included
in this review if they (1) specified parental
death from suicide as an independent vari-
able, (2) examined psychiatric and/or psycho-
social outcomes of surviving offspring as the
dependent variable, (3) assessed the impact of
parental suicide that occurred during the off-
springs childhood or adolescence, and (4)
were available in the English language. Case
reports were excluded from this review. Ref-
erence sections of articles that met inclusion
criteria were carefully reviewed to identify
articles that may have been missed by the ini-
tial search strategy. Applying these selection
criteria, a total of nine unique articles were
identified.
RESULTS
Formal empirical research in this area
appears to have commenced in the 1960s
when Cain and Fast (1966) published a case
series suggesting pathogenic consequences of
parental suicide on surviving offspring. Since
then, several observational studies have been
conducted either to assess the impact of pa-
rental suicide on offspring psychosocial out-
comes using cross-sectional, qualitative, or
longitudinal study designs (six studies) or to
examine the association between parental
suicide and risk for psychiatric disorders in
offspring using the nested case-control
method (three studies). Each study will be re-
viewed individually and all are summarized in
Table 1.
A quantitative meta-analysis was not
feasible given the heterogeneity in methods
used by the nine studies. The studies pre-
dominantly employed case-control (n = 3)
and cross-sectional designs (n = 2), whereas
two longitudinal, one qualitative study and
one randomized intervention were identified.
The study populations also varied from clini-
Kuramoto, Brent, and Wilcox
cal (n = 2), to community (n = 6), to a combi-
nation of both (n = 1). Two studies lacked
control groups. Those with controls either
compared the survivors of suicide with off-
spring of living parents or offspring bereaved
by other types of parental death. All studies
were conducted in developed countries
(USA, Demark, UK, Canada, and Israel). The
offsprings age at assessment ranged from two
years to adulthood (for retrospective studies)
and the assessment occurred anywhere from
within a few weeks to several years after pa-
rental death. The offspring or surviving par-
ents served as informants in many of the
studies. Taken together, these studies re-
ported findings from a total of 730 child and
adolescent survivors of parental suicide.
Cross-sectional, Longitudinal,
and Qualitative Studies
A longitudinal study by Shepherd and
Barraclough (1976) in Great Britain exam-
ined via parental report 36 child and adoles-
cent offspring (aged 217 years) of suicide
decedents and 150 control offspring of par-
ents who died from other causes. Surviving
parents of the children and adolescents who
lost the other parent to suicide reported a
significant increase in psychiatric referrals for
their children, as compared to parents of con-
trol children. In addition, suicide surviving
parents reported more delinquency (e.g., re-
ceiving warnings from the police for their be-
havior) and prolonged anxiety in their off-
spring. The authors stressed the importance
of considering the family environment of the
children before the suicide, as surviving chil-
dren with worse psychosocial functioning at
follow-up (57 years later) were more likely
to have had a disruptive family setting, such
as marital separation and parental involve-
ment with the legal system, prior to parental
suicide. However, the authors noted a gen-
eral lack of adverse impact among the chil-
dren. The inability of children to communi-
cate their feelings, the limitation of parental
report as the only source of assessment, and
a sense of relief from the long-term exposure
139
to family stress were suggested as possible ex-
planations for this finding (Shepherd & Bar-
raclough, 1976). Important points regarding
the context of suicidal death of a parent were
first raised in this study. However, the lack of
well-defined constructs and exclusive reliance
on self report of the surviving parent sug-
gested the need for more methodologically
rigorous studies.
Grossman, Clark, Gross, Halstead,
and Pennington (1995) conducted a descrip-
tive study based on interviews with 16 chil-
dren (6 to 12 years old) from ten families,
within three years of their fathers suicide, in
the United States. These children were
drawn from a child bereavement program
and their psychosocial functioning was as-
sessed using parent or caregiver report on the
Child Behavior Checklist (CBCL). No sig-
nificant differences in emotional and behav-
ioral functioning were found between child
offspring of suicide decedents and the nor-
mative sample from the CBCL, which was
used for comparison since a control group
was not recruited. The child and parent or
caretaker also completed the Child Posttrau-
amtic Stress Reactions Index Scale, a struc-
tured interview to assess DSM-IV criteria
symptoms of posttraumatic stress disorder
(PTSD). Although relatively low rates of
PTSD symptoms were found among the
children, the posttraumatic stress reaction
scores differed significantly by whether a par-
ent had threatened divorce or the children
had discovered their parents body. The
authors suggested that good mental health
outcomes of the surviving children could be
attributed to the absence of childrens psy-
chopathology prior to parental suicide, as
well as the availability of strong social and
family support after the suicide (Grossman et
al., 1995). Additionally, mothers who sought
help and enrolled in this study may have had
higher psychosocial functioning compared to
mothers who did not seek help. This poten-
tial selection bias may have contributed to
the lack of findings. Although structured as-
sessments were available in this study, the
small sample size and the lack of a compara-
TABLE 1
Summary of Articles Examining the Impact of Parental Suicide
Gender
Age at of
Author (Year) Design Country Cases Control assessment parent Informant Relevant Finding

Longitudinal and Cross-Sectional Studies

Shepherd & longitudinal UK 36 commu- 150 of parental 217 years old Both parent increased psychiatric re-
Barraclough nity cases of death matched (few weeks after ferral
(1976) parental the parent for death; 2nd as- possible increase in risk
suicide age, sex, marital sessment 57 of delinquency
identified status, and geo- years later) anxiety common and
through graphic location long lasting in some chil-
relatives, of case parent, dren
physicians, drawn ran- psychosocial functioning
or medical domly from gen- worse among children
records eral practice re- who had the following
gister before the suicide: par-
ent who separated, legal
trouble, attended two or
more schools after sui-
cide
Grossman et cross- USA 16 commu- none (CBCL nor- 612 years old Father self, posttraumatic stress re-
al. (1995) sectional nity cases mative sample) (w/in 3 years only mother, or actions index scores dif-
from child post death) caretaker fered significantly by
bereave- whether the parents
ment pro- threatened divorce or
gram par- the child discovered the
ticipants body
no significant difference
in emotional and behav-
ioral functioning
Cerel et al. longitudinal USA 26 commu- 332 community 517 years old Both self; parent; no differences in PTSD,
(1999) (cross- nity cases controls of non- (approx 1 month teacher suicidal behavior, and
sectional recruited suicide parental post-death) psychosocial functioning
analysis) from no- death recruited increase in anxiety,
tice in daily from notice in anger, shame, and be-
obituaries daily obituaries havioral dysregulation
or local fu- or local funeral among the suicide-be-
neral homes homes reaved children
Pfeffer et al. cross- USA 11 families 57 families of pa- 512 years old (w/ Both self and suicide-bereaved chil-
(2000) sectional (16 cases) rental death in 1.5 years parent dren had higher depres-
from medi- from cancer (64 post-death) sive symptoms than can-
cal exam- controls) of hos- cer-bereaved children
iner re- pital records rates of depressive symp-
cords, as toms was similar to nor-
well as com- mative community
munity and sample
clinical re- no significant difference
sources in suicidal ideation, so-
cial competence, and be-
havioral problems be-
tween groups
Avrami (2005) qualitative Israel 10 commu- none 2252 years old Both self sharing of feelings
nity cases (950 years among family members
since parental was discouraged
suicide that oc- long-lasting impact of
curred between parental suicide such as
1322 years old) feeling of social stigma,
anger, guilt, need to suc-
ceed in adult lives
exhibited fear that they
will also die from sui-
cide
(continued)
TABLE 1
Continued

Gender
Age at of
Author (Year) Design Country Cases Control assessment parent Informant Relevant Finding

Brown et al. randomized USA 24 commu- 302 community 816 years old Not avail- Self, parent, no differences in inter-
(2007) interven- nity cases controls of non- (within 30 able teacher nalizing, externalizing,
tion from fam- suicide parental months post- grief, and rumination be-
(cross- ily bereave- death from fam- death) tween the suicide be-
sectional ment pro- ily bereavement reaved and nonsuicide
analysis of gram program bereaved children
pre- no significant differ-
interven- ences in risk and protec-
tion tive factors and family
groups) functioning between the
two groups
Nested Case-Control Studies
Roy (1983) case-control Canada 16 clinical 22 clinical cases of adulthood Both self early parental loss by
cases of pa- parental suicide (31.7 mean age) suicide (<11 years old)
rental sui- after 20 years had increased risk for
cide before old subsequent suicide at-
11 years old tempt, as compared to
those whose parent took
their lives after they
were age 20
Agerbo et al. nested case- Den- 496 suicide 24,800 controls 1021 years old Mother population- both paternal and mater-
(2002) control mark cases from matched for sex, (before suicide vs. based reg- nal suicide increased the
population- age, and time of child off- Father istries risk of offspring suicide
based regis- from popula- spring) after controlling for in-
tries tion-based regis- dividual and family his-
tries tory of psychiatric diag-
nosis
higher risk in offspring
whose mother died from
suicide than offspring of
paternal suicide
Tsuchiya et al. nested case- Den- 947 clinical 47,350 age- over 10 (before Mother population- both paternal and mater-
(2005) control mark bipolar dis- matched con- the 1st admis- vs. based reg- nal suicide increased the
order cases trols from popu- sion to psychiat- Father istries risk of bipolar disorder,
from popu- lation-based reg- ric or outpatient as compared to other
lation- istries facility) types of death after con-
based re- trolling for individual
gistries and family history of
psychiatric diagnosis
increased risk of bipolar
disorder among children
of maternal suicide
7 times more likely to
develop bipolar disorder
among those who expe-
rienced maternal suicide
between 09 years old
144
ble control group were major limitations.
Additionally, this finding was limited to pa-
ternal loss, which may be less generalizable
to children who lost a mother to suicide.
The study by Cerel, Fristad, Weller,
and Weller (1999) in the United States pro-
spectively followed children who were ascer-
tained from a community through notices in
daily obituaries or funeral homes following
the death of a parent. Although this study
collected information longitudinally, the
analysis was conducted cross-sectionally. They
compared 26 child and adolescent survivors,
517 years old, of parental suicide with 332
child and adolescent survivors of parental
death from causes other than suicide or ho-
micide at 1, 6, 13, and 25 months after paren-
tal death. A structured interview from the
Diagnostic Interview for Children and Ado-
lescents-Revised (DICA-R) was used to as-
sess DSM-III-R criteria symptoms among
children. The authors found a higher degree
of anxiety, shame, and anger at the 6 month
and one year assessment among the offspring
of suicide decedents, as compared to youth
offspring of parents who had died from other
causes. Less significant differences were
found for depressive symptoms. No differences
were found between the suicide-bereaved and
non-suicide bereaved offspring for PTSD,
suicidal behavior, and psychosocial function-
ing such as behavioral problems in school
and difficulties with peer relationships. The
authors noted, however, that offspring of sui-
cide decedents had more behavioral prob-
lems that started to occur one month before
the suicide. Differences in self-esteem and
internalizing behavior between the groups
were observed at the six-month assessment,
although initially not observed after parental
suicide. This finding highlights the impor-
tance of longitudinal studies to examine indi-
vidual change over time, as the death of a
parent by suicide may affect the short-term
and/or long-term adjustment of the offspring
(Cerel et al., 1999). A follow-up study of this
sample (Cerel et al., 2000) examined family
functioning and surviving parents psycho-
pathology. This study found no difference in
the surviving parents mental health out-
Impact of Parental Suicide
comes between the suicide-bereaved and
non-suicide bereaved families. Although the
authors reported that families of suicide de-
cedents were functioning worse than the
other bereaved families prior to death, no
significant differences in family functioning
between the groups were found at follow-up.
This finding suggested some improvement in
functioning among the suicide-bereaved fam-
ilies following the death (Cerel et al., 2000).
A study by Pfeffer, Karus, Siegel, and
Jiang (2000) in the United States investigated
whether childrens depressive symptoms, so-
cial competence, and behavioral problems re-
ported on the CBCL differed by cause of pa-
rental death. The researchers compared 16
child offspring (512 years old) of suicide
decedents from 11 families with 64 age-
matched offspring of cancer decedents from
57 families, two to eighteen months after
death. This was primarily a referred sample
identified from records of local medical ex-
aminers offices and other community re-
sources. Although no statistically significant
differences in behavioral and social compe-
tence on the CBCL were found between the
cancer and suicide groups, the authors found
a higher prevalence of depressive symptoms
(specifically negative mood, anhedonia, and
interpersonal problems) in the offspring of
suicide decedents. Additionally, depressive
symptoms were directly assessed in children
using the child report of the Childrens De-
pression Inventory (CDI). The authors noted
that the rates of depressive symptoms re-
ported in this study were similar to a pre-
viously reported normative community sam-
ple. They attributed their findings to resiliency
among child survivors of suicide or the short
duration of follow-up (Pfeffer et al., 2000).
Although the small sample size may have af-
fected statistical power, this study and the
aforementioned study by Cerel and col-
leagues significantly strengthened this body
of research by their use of structured assess-
ments to examine the impact of parental sui-
cide on multiple psychosocial domains.
Avrami (2005) conducted ten in-depth
retrospective qualitative interviews of child-
hood parental suicide survivors, aged 2252
Kuramoto, Brent, and Wilcox
years old. The snowball sampling method
was used to recruit participants in Israel. The
study reported a long-lasting impact of sui-
cide on the offspring such as the inability to
share their feelings with other family mem-
bers, feelings of stigma, anger, and guilt. Ad-
ditionally, participants reported a strong need
to succeed in their adult lives to regain the
control that was lost after parental suicide.
The survivors in this study also reported
fears that they too will die from suicide
(Avrami, 2005). The qualitative method em-
ployed in this study was able to elucidate the
thoughts and feelings of these child survivors.
However, these findings may have also been
influenced by the specific culture in which
this study was conducted, and its generalia-
bility to other cultures may be questionable.
A study by Brown, Sandler, Tein, Liu,
and Haine (2007) in the United States exam-
ined mental health problems and grief reac-
tions of 24 suicide-bereaved children and ad-
olescents, 816 years old, compared to 302
children and adolescents bereaved by other
causes of parental death. The participants
were enrolled in the Family Bereavement Pro-
gram (FBP), a randomized group interven-
tion for parentally bereaved children re-
cruited from the community within 30 months
post parental death (Sandler et al., 2003).
Childrens reports of internalizing and exter-
nalizing symptoms were assessed using the
CDI, Childrens Manifest Anxiety Scale-
Revised, and the Youth Self-Report external-
izing problems subscale. Additional informa-
tion on the children was obtained from the
surviving parent using the CBCL. Cross-
sectional analyses using the pre-intervention
assessments found no significant differences
in family functioning, internalizing, external-
izing, grief, and rumination between the sui-
cide and non-suicide bereaved children. The
cause of death did not appear to interact with
risk and protective factors such as negative
life events, parental depression, self-esteem,
and parenting. The authors concluded that
suicide bereaved children should also benefit
from the intervention targeted for children
bereaved by other types of parental death.
The authors acknowledged the importance
145
of adding a component to the intervention
that addresses issues unique to children be-
reaved by suicide, but they suggested that
cause of death should not dictate who should
receive and will benefit from an intervention
(Brown et al., 2007). Similar to other studies
that examined the aftermath of parental sui-
cide, small sample size and cross-sectional
analysis were the major limitations of this
study.
Nested Case-Control Studies
Three studies examined parental sui-
cide as a risk factor for offspring subsequent
mental health outcomes using a nested case-
control study design. In 1983, Roy employed
a case-control design comparing records of
243 psychiatric inpatients with a family his-
tory of suicide with records of 5,602 psychi-
atric inpatients in Canada without a family
history of suicide. Of the 243 cases with a
family history of suicide, 42 patients were
survivors of parental suicide. There were
more suicide attempts (as recorded in medi-
cal charts) among those whose parent died
from suicide before the offspring reached 11
years of age (n = 16), as compared to those
with a parent who died from suicide after the
offspring reached the age of 20 (n = 22) (Roy,
1983). This study was one of the first that
examined the relationship between suicide of
a parent and offspring suicide attempt. How-
ever, the study focused on a clinical sample
(psychiatric inpatients) and relied exclusively
on chart reports.
Two population-based studies in Den-
mark examined risk for suicide and bipolar
disorder among suicide decedents using
methodologically rigorous study designs to
examine the long-term impact of parental
suicide. Agerbo, Nordentoft, and Mortensen
(2002) found a significantly higher number of
parental suicides among 496 youths, ages 10
21, who died from suicide in 19811997, as
compared to 24,800 demographically matched
control subjects with living parents. Young
people who died from suicide were more
likely to have a history of psychiatric hospi-
talization and parental history of suicide than
146
controls. These histories were recorded using
the International Classification of Diseases
(ICD) and were obtained from the Danish
medical registries. After adjusting for demo-
graphic variables as well as individual and
family history of admission for mental illness,
paternal suicide was found to increase the
risk of offspring suicide two-fold, while ma-
ternal suicide increased the risk approxi-
mately five-fold. The risk for suicide did not
significantly differ between child offspring of
fathers who died from causes other than sui-
cide and those with fathers who were alive.
Child offspring of mothers who died from
other causes, however, showed a two-fold in-
crease in risk for suicide, as compared to chil-
dren of living mothers. Additionally, they es-
timated that 30% of the risk for suicide was
attributable to individual mental illness,
mental illness of a parent, and suicide of a
parent. The authors inferred that an increase
in suicide risk among these youths may be
due to unidentified and/or untreated mental
illness in the family, as well as genetic factors
(Agerbo et al., 2002).
Using the Danish registries as well,
Tsuchiya, Agerbo, and Mortensen (2005)
compared 947 bipolar disorder cases and
47,350 age-matched controls from the gen-
eral population. Adjusting for sex, family his-
tory of psychiatric diagnosis, and parental
age, offspring of maternal suicide had at least
a three-fold increased risk for bipolar disor-
der, while offspring of paternal suicide had a
two-fold increased risk, as compared to off-
spring of parents who were alive. However,
the children and adolescents who experi-
enced other types of paternal or maternal
death did not show an increased risk of bipo-
lar disorder. A more compelling association
was found when the authors stratified by age
of offspring at the time of parental suicide,
although the small sample size should be
noted in these stratified analyses. Children
whose mother died from suicide when they
were between 09 years old had a seven-fold
increased risk of developing bipolar disorder,
while this risk was three-fold for children and
adolescents whose mother died from suicide
when they were 1019 years old. Maternal
Impact of Parental Suicide
death by other causes showed no significant
increase in risk for either age group. Simi-
larly, offspring who experienced their fathers
death from suicide or other causes were not
at increased risk for bipolar disorder at either
age group. Early loss of a primary caregiver
and parent-of-origin effects were suggested
as possible explanations for the differences in
bipolar risk by parents gender (Tsuchiya et
al., 2005).
COMMENT
Despite a systematic and extensive lit-
erature search, we found only nine uniquely
published studies on psychiatric and psycho-
social outcomes in offspring of suicide dece-
dents that fit our selection criteria. Research
in this area has been limited for several rea-
sons: (1) difficulty in finding a large number
of participants since completed suicide is a
rare event (Grossman et al., 1995), constitut-
ing approximately 1.3% of all deaths in the
United States in 2005 (Kung et al., 2008),
and (2) the sensitivity of this area of investi-
gation and the surviving parents effort to
protect their children, either from research-
ers who may exacerbate stress in these fami-
lies or by not disclosing the true cause of
death to their children (Cain, 2002).
This review focused on empirical stud-
ies published in peer-reviewed journals,
which also restricted the number of studies
to be identified. The limitation of using ab-
stracts and titles as guidance in selecting the
literature for this review should be noted as
well. This search methodology is subject to
publication bias and may not have captured
some studies that have examined parental
suicide but did not have significant findings.
For example, at least one study examined
childhood parental suicide as a predictor for
suicide attempt with and without co-morbid
disorders, but this was not indicated in the
abstract since they could not fully explore the
association due to the rarity of this event in
the study population (Hawton, Houston,
Haw, Townsend, & Harriss, 2003).
The cross-sectional, qualitative, and
Kuramoto, Brent, and Wilcox
longitudinal studies that examined the after-
math of parental suicide had the ability to en-
sure that the children were aware that their
parent died from suicide. This may be im-
portant since hiding the true cause of death
from offspring occurs especially among child
survivors, and this has been hypothesized to
lead to later psychosocial problems among
offspring (Cain, 2002). Additionally, these
studies allowed assessment of relatively short-
term psychosocial outcomes up to two years
post suicide, using one or multiple infor-
mants and various psychosocial measure-
ments. The major limitation noted in these
studies was small sample size, which de-
creased the power to detect any possible dif-
ferences between the groups. Second, many
were cross-sectional in study analysis and re-
lied on retrospective reports, which cannot
assess causality and is subject to recall bias.
Third, the samples were drawn from rela-
tively homogenous populations or clinical
samples that are susceptible to selection bias.
Fourth, the absence of or vast differences
among the control groups made comparisons
across studies difficult. Fifth, the long-term
impact of parental suicide was not observable
within the timeframe of many of these stud-
ies. The longest follow-up for these studies
was fifty years in the qualitative study by
Avrami (retrospective reports), but many
only followed their samples for up to two
years or less. And lastly, most studies did not
take into account or control for family his-
tory of mental illness, which is more com-
mon among suicide survivors.
The case-control studies overcame
several of these limitations. These popula-
tion-based studies had more study power in
comparison to the small-scale studies, which
also allowed researchers to examine the dif-
ferential impact of maternal and paternal sui-
cide. These studies assessed the long-term
psychiatric status of offspring (via psychiatric
hospitalization data) and controlled for fam-
ily history of psychiatric hospitalization and
psychiatric hospitalization of the offspring
prior to parental death. Major limitations of
these study designs are the assumption that
offspring were aware that their parent died
147
from suicide, and only psychiatric illnesses
severe enough to be represented in the inpa-
tient hospital registries were examined. The
analyses were limited to constructs recorded
in the population-based registries so direct
measures of important constructs such as
psychosocial or adjustment problems, quality
of parenting, stressful life events, and coping
strategies were not available. Additionally,
the population-based studies were conducted
in Denmark, which may limit generalizability
to other populations.
The impact of parental suicide on off-
spring mental health and psychosocial func-
tioning is a complex process driven by multi-
ple factors. Hence, parental suicide should
not be thought of as an isolated event that
increases the risk of psychiatric disturbances
in offspring (Shepherd & Barraclough, 1976;
Brown et al., 2007). Family functioning prior
to and after suicide may be equally or more
important to the psychological well-being of
these survivors ( Jordan, 2001), as well as how
their parents death was communicated to the
child and adolescent offspring (Cain, 2002;
Mitchell et al., 2006).
The context in which suicide of the
parent occurred is also important in under-
standing if psychiatric and psychosocial risk
of the surviving offspring is due to conse-
quences of suicide, genetic predisposition to
mental disorders that may have caused paren-
tal suicide, or the interaction of both. Child
survivors of suicide may be more vulnerable
to mental disorders and suicidal behavior.
The potential genetic contribution of depres-
sion (Weismann et al., 2005) and suicide, in-
dependent of depression, has been suggested
in a number of studies that have used behav-
ioral genetic methods (Brent et al., 2002;
Goodwin, Beautrais, & Fergusson, 2004;
Roy, 2004; Runeson & Asberg, 2003; Schul-
singer et al., 1979). According to the stress-
diathesis theory adapted to suicide (Mann,
Waternaux, Haas, & Malone, 1999), parental
suicide may serve as an indicator for the di-
athesis, and characteristics such as impulsiv-
ity, suicidal ideation, and hopelessness may
precipitate suicide attempt among the survi-
vors. The study by Tsuchiya and colleagues
148
suggested that differential vulnerability to
stress, depending on the age in which the
child experienced parental suicide, may pos-
sibly explain the stronger association of bipo-
lar risk among younger children. However,
the more robust impact of parental suicide in
early childhood than later may also in fact
be due to stronger genetic predisposition to
mental disorders. Melhem and colleagues
found that bipolar disorder was the single
largest cause of early parental death, espe-
cially due to suicide (Melhem, Walker, Mo-
ritz, & Brent, 2008). This finding suggests
that those who experienced early parental
suicide may have greater genetic risk for bi-
polar disorder, independent of parental sui-
cide.
In addition, these offspring may have
undergone considerable emotional distress
prior to parental suicide compared to indi-
viduals who experienced other type of paren-
tal loss. Such cumulative risk may be predic-
tive of future psychosocial functioning among
these individuals. Several studies have high-
lighted this possibility, as more family disrup-
tion and stress were noted among families of
suicide survivors compared to non-suicide
bereaved families prior to parental death
(Cerel et al., 2000; Shepherd & Barraclough,
1976).
Parental suicide during childhood or
adolescence could cause disruption in multi-
ple important social fields (such as school,
peers, family). According to the life course/
social field theory (Kellam, Branch, Agrawal,
& Ensminger, 1975), whether development
follows a normal or pathological trajectory
depends upon the adaptive capacity of the in-
dividual to respond adequately to the social
task demands of the social fields relevant to
each stage of life. An inability to adequately
master the demands placed by these social
fields could increase risk for maladaptive out-
comes. Harris, Brown, and Bifulco (1986)
suggest that family dysfunction (e.g. inade-
quate parental care) after parental death may
be a factor that mediates the development of
adult psychopathology such as depression. A
more recent study by Kwok and colleagues
(2005) found that positive parenting medi-
Impact of Parental Suicide
ated the effect of emotional distress among
children who lost a parent. Likewise, Brier
and colleagues (1988) reported that how well
a child adjusts to parental loss is inversely
associated with adult psychiatric disorder.
Cerel and colleagues (2006) reported that
low family socioeconomic status, changes in
household/living circumstances, other family
stressful events, and depression in the surviv-
ing parent are notable risk factors for off-
spring psychopathology among individuals
who experienced childhood parental death.
Few studies have examined psychoso-
cial outcomes among suicide survivors. The
current evidence among child survivors sug-
gests that short-term behavioral functioning
and social competence may not differ from
non-suicide bereaved children (Cerel et al.,
1999; Pfeffer et al., 2000). Nevertheless, the
majority of studies found a potential differen-
tial impact of suicide in terms of blame,
shame, guilt, and anger. These findings paral-
lel the bereavement literature, which suggests
that suicide elicits different societal and emo-
tional responses compared to other causes of
death. According to Jordan (2001), the grief
process from suicide differs in the thematic
content of grief, social process surrounding
the survivors, and impact of suicide on family
systems (page 91). Whether or not suicide
survivors experience social stigma is another
research area that is being investigated (Cvi-
nar, 2005) that could be contigent upon soci-
ocultural context.
CONCLUSION
The cross-sectional, qualitative, longi-
tudinal, and case-control studies taken to-
gether offer inconsistent evidence about the
psychiatric and psychosocial outcomes of off-
spring of suicide decedents. The case-control
studies noted an association of parental sui-
cide and offspring psychiatric outcomes with
the following results: 1) an increased risk for
the development of suicide and bipolar disor-
der among child and adolescent offspring of
parental suicide, 2) a stronger impact of ma-
ternal than paternal suicide on offspring out-
Kuramoto, Brent, and Wilcox
comes, and 3) a greater risk of psychiatric
disturbance in offspring if parents suicide oc-
curred at a younger age. The findings were
weaker and less consistent among the cross-
sectional and longitudinal studies. Many al-
luded to possible resilience among these chil-
dren, but disparate or lack of findings could
have also been attributed to differences in
family contexts prior to suicide, different
study designs, sample selection bias (e.g.,
mainly volunteer or clinical samples), and
small sample sizes. Additionally, research has
noted significant variability in grief responses
among suicide survivors, more so than indi-
viduals who experienced loss from other
causes (Bailley, Kral, & Dunham, 1999).
Such heterogeneity within suicide survivors
may have also contributed to the inconsistent
findings across these studies.
Ongoing bereavement interventions
among child survivors of suicide, in addition
to interventions among suicide survivors in
general, contribute to a better understanding
of survivors and their needs (Brown et al.,
2007; Jordan & McMenamy, 2004; Mitchell,
2007). Meanwhile, a population-based longi-
tudinal study and/or multi-center studies are
also needed to further elucidate the long-
term impact of parental suicide on psychoso-
cial and psychiatric outcomes of surviving
offspring. Specifically, examining the trajec-
tory of risk among child and adolescent sur-
vivors will inform the timing of intervention
and the potential long-term effect of parental
suicide. Kendler, Sheth, Gardner, and Pres-
cott (2002) found that the risk for the depres-
sion after parental death reduces to baseline
around twelve years after the death. Whether
similar trajectories extend to individuals who
lost a parent to suicide will greatly inform the
design of interventions. Many of the re-
viewed studies examined depressive symp-
toms as the primary outcome of interest. Fu-
ture studies examining multiple outcomes
will be necessary to understand if parental
suicide affects a broad spectrum of disorders
or is specific to certain disorders. Examining
multiple psychiatric outcomes may also help
elucidate the mechanism of possible differen-
tial impact of maternal or paternal loss. A
149
stronger impact of maternal suicide com-
pared to paternal suicide across multiple out-
comes may be attributed to the loss of a pri-
mary caregiver, who is usually the mother, in
accordance with Harris et al.s (1986) frame-
work (i.e., nurture). If the loss is specific to
certain psychiatric outcomes such as bipolar
disorder, however, this may provide stronger
support for a biological or parent-of-origin
effect (i.e., nature).
In addition, future studies should also
identify modifiable individual, familial, and
social factors associated with vulnerability
and resilience among child and adolescent
survivors of suicide and control for genetic
predisposition (e.g., family history) for sui-
cide and other psychiatric disorders. Some
studies reviewed herein have examined the
family context after the suicide of a parent.
However, more studies will be necessary to
examine the extent of generalizability of
these findings to other populations and to
better inform the components that interven-
tions should emphasize. Also, a majority of
the studies suggested that grief response may
differ depending upon the type of death.
Whether this results in complicated grief and
contributes to later psychosocial problems
may deserve further attention (Mitchell,
2005). The impact of suicide and how the
family adapts to the tragedy may also depend
upon the culture in which the suicide took
place. Further research will be needed to ex-
amine the extent of cultural differences and
whether culturally sensitive postvention ef-
forts among suicide survivors will be neces-
sary. Additionally, it is important to consider
age and developmental differences in surviv-
ing offspring, as younger children may not
have the ability to cognitively process the
concept of suicide or death in general
(Mitchell et al., 2006). Future studies should
also examine gender differences in the psy-
chiatric and psychosocial outcomes of off-
spring of suicide decedents. Such a distinc-
tion may be important since other studies
have noted a differential impact of parental
loss in general between daughters and sons
(McLeod, 1991). Overall, this review pro-
vides modest yet inconsistent evidence of the
150
impact of parental suicide during childhood
and adolescent on offspring psychosocial out-
come. Further methodologically rigorous re-
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Manuscript Received: March 4, 2008
Revision Accepted: April 27, 2008