Parental Intoxication and Adolescent Suicidal Behavior

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Parental Intoxication and AdolescentSuicidal BehaviorIngeborg Rossow a b & Inger Synnøve Moan ba National Centre for Suicide Research and Prevention, University ofOslob Norwegian Institute for Alcohol and Drug Research, Oslo, Norway

Available online: 30 Jan 2012

To cite this article: Ingeborg Rossow & Inger Synnøve Moan (2012): Parental Intoxication andAdolescent Suicidal Behavior, Archives of Suicide Research, 16:1, 73-84

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Parental Intoxication andAdolescent SuicidalBehavior

Ingeborg Rossow and Inger Synnøve Moan

The objective of this study was to explore whether parental heavy drinking isassociated with suicidal behavior in adolescents, and if so, whether this associationis stronger among younger adolescents and whether a possible impact of one parent’sintoxication adds to that of the other parent. Two cross-sectional school surveys wereconducted in 2002 and 2004 in Norway and comprised 11,637 and 20,703 stu-dents, respectively (ages 13 to 19). Suicidal ideation and suicide attempts increasedwith increasing exposure to parental intoxication, after controlling for adolescents’intoxication frequency. The association between exposure to parental intoxicationand suicidal ideation was significantly stronger among younger than among older ado-lescents. There was a significant positive correlation between frequency of mother’s andfather’s intoxication. Hence, exposure to one parent’s intoxication did not add to theimpact of the other on suicidal ideation. The results suggest that parental heavydrinking is a risk factor for adolescents’ suicidal behavior, and more so for youngerthan older adolescents.

Keywords adolescents, parental intoxication, suicide attempt, suicidal ideation, surveys

INTRODUCTION

Suicide attempts and other acts of deliber-ate self-harm (DSH) are fairly prevalentamong adolescents (Evans, Hawton,Rodham et al., 2005; Safer, 1997). It hasbeen well demonstrated that alcohol intoxi-cation and heavy drinking are significantrisk factors for suicidal behavior (Hufford,2001; Rossow, 2005) and among adoles-cents, heavy drinkers and those who fre-quently drink to intoxication have ahigher risk of attempted suicide and otherforms of DSH, compared to others(Bridge, Goldstein, & Brent, 2006; Evans,Hawton, & Rodham, 2004; Rossow,Ystgaard, Hawton et al., 2007; Windle,

Miller-Tutzauer, & Domenico, 1992).However, studies of alcohol consumptionand suicidal behavior have almost entirelyfocused on associations and mechanismspertaining to the possible harmful effectson the drinker himself.

The research literature on possibleharm from parental alcohol abuse to chil-dren and adolescents has demonstratedthat children of heavy drinkers are morelikely to be exposed to a variety of unfortu-nate conditions, such as: poor parentingskills and poor family functioning; highconflict levels in family; parental neglectand abuse; and family isolation (Christof-fersen & Soothill, 2003; Johnson & Leff,1999; Steinhausen, 1995; Windle & Searles,

Archives of Suicide Research, 16:73–84, 2012Copyright # International Academy for Suicide ResearchISSN: 1381-1118 print=1543-6136 onlineDOI: 10.1080/13811118.2012.640576

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1990). In line with this a number of studieshave documented that children of heavydrinkers are more likely than their peersto experience a variety of psycho-socialproblems such as: emotional problems;feelings of inadequacy and low self-esteem;impulsiveness; mental health problemssuch as depressive mood, anxiety and per-sonality disorders; and violence victimiza-tion, child abuse and sexual assaults(Christoffersen & Soothill, 2003; Johnson& Leff, 1999; Rossow, 2000; Steinhausen,1995; Windle & Searles, 1990). These areall problems that tend to co-occur with sui-cidal behavior (Beautrais, 2000; Bridge,Goldstein, & Brent, 2006; Evans, Hawton,& Rodham, 2004) and one might thereforeassume that parental heavy drinking mayincrease the risk of adolescents’ suicidalbehavior by increasing the adolescents’ vul-nerability for self-destructive behavior invarious domains. So far, few studies seemto have assessed whether parental heavydrinking is associated with suicidal beha-vior in adolescents. However, some studieshave found that adolescents who attemptedsuicide tended to report parental substanceabuse more often than others (Borowsky,Resnick, Ireland et al., 1999; Dube, Anda,Felitti, Chapman et al., 2001; Fergusson &Lynskey, 1995; Howard-Pitney, LaFrom-boise, Basil et al., 1992). More specificallyrelated to parental alcohol use, Grøholtand co-workers found that adolescentswho frequently observed their parentsdrunk were more likely than others to haveattempted suicide (Grøholt, Ekeberg, Wich-strøm et al., 2000) and Grossman andco-workers found that parental heavy drink-ing was associated with suicide attemptsamong Navajo adolescents (Grossman,Milligan, & Deyo, 1991). In the presentstudy we wanted to expand the empiricalliterature on this topic by addressingthe relationship between parental heavydrinking and adolescents’ suicidal behavior.

The variety and complexity of underly-ing mechanisms that may explain the

observed associations between parentalheavy drinking and children’s risk of vari-ous psycho-social problems are probablynot well understood. Studies in most areasof alcohol-related harm have assessed out-come measures as a function of increasingexposure to alcohol consumption or intoxi-cation frequency (Anderson & Baumberg,2006). Yet, when it comes to studies ofpossible third party harm to children andadolescents from parental drinking, the vastmajority of studies have merely comparedvarious outcome measures in children ofheavy drinkers to those in other children(control groups) (Rossow, 2000). However,it is possible that parents who are not heavydrinkers may also expose their children todrinking episodes that may have a negativeimpact. In that case, we may assume that anelevated risk of problems associated withparental heavy drinking is not confined tothe relatively few families of heavydrinkers, but probably also exists withinfamilies with less significant drinking prob-lems. So far this has rarely been addressedin the literature but is supported by someempirical evidence. First, parents who areintoxicated may pay less attention to theirchildren (Lang, Pelham, Atkeson et al.,1999) and they may become more impul-sive and aggressive (Hoaken & Stewart,2003). Moreover, clinical experience sug-gests that parents’ altered behavior andcommunication in the state of intoxicationmay be perceived as less predictable, caring,and attentive by the children, and thereforeworrisome or frightening (Mortensen,1994). It is most likely that children’s abilityto interpret and cope with parents’ andothers’ drunken behavior depends on theircognitive maturity and experience withtheir own and others’ intoxication. There-fore we hypothesized that a possible impactof parental intoxication on adolescent suici-dal behavior would decrease with age andhence that the association would bestronger among younger adolescents thanamong their older peers.

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Another aspect of this possible associ-ation to be addressed here concerns thequestion of whether exposure to both par-ents’ heavy drinking constitutes a higherrisk for suicidal behavior compared toexposure to one parent’s heavy drinking.Whether owing to lack of statistical poweror to insufficient information about par-ental substance abuse, this has not beenaddressed in previous studies of parentalsubstance use and adolescents’ suicidalbehavior (Dube, Anda, Felitti, Chapmanet al., 2001; Fergusson & Lynskey, 1995;Grøholt, Ekeberg, Wichstrøm et al.,2000). However, Dube and co-workers(Dube, Anda, Felitti, Croft, et al., 2001)found that the likelihood of having hadadverse childhood experiences (e.g., physi-cal violence, sexual assaults, psychologicaltrauma) was larger when both parents hadan alcohol problem as compared to oneparent. Moreover, they found that the like-lihood of negative experiences duringchildhood was greater if only the motherhad an alcohol problem than if it was onlythe father who had a problem with alcohol.Given the aforementioned increased risk ofsuicidal behavior related to adverse child-hood experiences, it might be assumed thatif there is an association between parentalheavy drinking and suicidal behavior inadolescents, the risk of suicidal behaviorwould depend on whether one or bothparents drink heavily.

The purpose of this study was toaddress a possible association betweenparental intoxication and adolescent suici-dal behavior. The availability of twolarge-scale national surveys among adoles-cents applying relevant measures providedan opportunity to explore whetherexposure to parental heavy drinking is asso-ciated with suicidal behavior in adolescents,and if so, whether this association is stron-ger among younger adolescents. We alsowanted to explore whether a possibleimpact of one parent’s intoxication addsto that of the other parent.

METHODS

The study is based on two largecross-sectional study samples; the Youngin Norway in 2002 (2002 survey) and abaseline survey from an evaluation studyof a community prevention project in Nor-way in 2004 (2004 survey). There were tworeasons for applying two data sets. Whereasthe two data sets are identical in targetpopulation and data collection method,and cover many identical variables, theydiffer somewhat with respect to outcomevariables and exposure variables and aretherefore complementary. Moreover, bycomparing analyses from two data sets,external validation and robustness offindings can be evaluated.

2002 Survey Sample

In 2002, 12,600 students in grades 8through 13 (ages 13 to 19) from 73 schoolsfrom all parts of Norway were invited toparticipate in the Young in Norway 2002study (Rossow & Bø, 2003). Informed con-sent from all students as well as informedwritten parental consent from students ingrades 7 through 9 and informed passiveparental consent from all other studentsbelow 18 years were a prerequisite for studyparticipation. The survey was approved bythe Norwegian Social Science DataServices. The procedures for data collectionare described in more detail elsewhere(Rossow, Grøholt, & Wichstrøm, 2005).The response rate was 92.3% and the netsample comprised 11,637 students. Sixteensubjects were excluded because they hadobviously given incorrect or humorousresponses. The sample mean age was 15.8years and 51% were girls. Only a small pro-portion of the respondents (5.0%) hadimmigrant background from non-westerncountries, which corresponds to the pre-valence of children 17 years and youngerwith a non-western immigrant background

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in Norway in 2000 (Statistics Norway,2000).

2004 Survey Sample

This study is also based on data from aschool survey among students in grades 8through 13 (ages 13 to 19 years) in 2004.All junior and senior high schools in 16municipalities in Norway were invited toparticipate in the study (primarily conduc-ted for other purposes) (Baklien, Pape,Rossow et al., 2007). The municipalitiescomprised a variety of rural areas, towns,and cities across all parts of Norway. Alto-gether 91 of 93 schools took part in thesurvey. All students had to give aninformed consent to participate and all stu-dents under 18 years were also requested tohave written parental informed consent toparticipate. The survey was approved bythe Norwegian Social Science Data Ser-vices. The procedures for data collectionare described in more detail elsewhere(Pape, Rossow, & Storvoll, 2005). A totalof 80.2% of all students (85.7% in juniorhigh school and 75.5% in senior highschool) participated in the study resultingin a net sample of 20,703 respondents(after exclusion of 17 respondents whohad given obviously humorous or improb-able responses).

Reasons for non-response were of sev-eral kinds and most prevalent wasnon-response due to absence from schoolon the day of the data collection. In bothsurveys, but more so in the 2004 survey,whole classes were absent from school onthis day (due to, e.g., excursions,extra-mural vocational training). Failure toobtain informed parental consent wasanother reason for non-response and moreso in the 2004 survey.

Possible sample overlap was little.Among students participating in the 2002survey a total of 3.6% were in schoolsand classes that implied a possibility thatthey were also included in the 2004 survey.

Measures

Suicidal Behavior. Suicidal ideation wasassessed by one item from the SymptomsCheck List (Derogatis, Lipman, Rickelset al., 1974): ‘‘During the past week, haveyou been bothered by thoughts about endingyour own life?’’ with the response categories‘‘Not bothered at all,’’ ‘‘Bothered a little bit,’’‘‘Bothered quite a bit,’’ and ‘‘Very muchbothered.’’ This measure was obtained inidentical ways in both surveys and theresponses were grouped into ‘‘Yes’’ (both-ered quite a bit and very much bothered),and ‘‘No’’ (not bothered at all and bothereda little bit). Only in the 2002 survey, the stu-dents were asked about attempted suicide.The question was: ‘‘Have you ever attemptedsuicide?’’ with response categories ‘‘Yes’’ and‘‘No,’’ which is equivalent or fairly similar towhat has been used in numerous previousstudies (Evans, Hawton, & Rodham, 2004;Evans, Hawton, Rodham et al., 2005).

Exposure to Parental Intoxication. In 2002the question on parental intoxication wasformulated as ‘‘How often have you seenyour parents intoxicated?’’ with theresponse categories ‘‘Never,’’ ‘‘A fewtimes,’’ ‘‘Some times per year,’’ ‘‘Sometimes per month,’’ and ‘‘Some times perweek.’’ This measure has previously beenapplied in several school surveys amongNorwegian adolescents (e.g., the Young inNorway surveys; Strand & von Soest,2007). In 2004, the students were asked‘‘How often have you seen your motherintoxicated?’’ An identical question wasposed with respect to father’s intoxication.The response categories for these twoquestions were identical to those on par-ental intoxication in the 2002 survey. Forsome analyses these variables were dichot-omized separating adolescents who werefrequently exposed to parental intoxication(monthly or more often) from those whowere less frequently or not exposed.

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Co-Variate. Asparentalandadolescentdrink-ing behavior are positively associated (Barnes,1990) and prevalence of suicidal behavior isassociated with adolescents’ drinking beha-vior, we applied a measure on adolescents’frequency of drinking to intoxication in theprevious 12 months as a co-variate in theanalyses. Seven response categories rangedfrom None to Several times per week and the vari-able was transformed into a semi-continuousvariable applying the values 0, 3, 8, 13, 30, 50,and 80 times last year.

Statistical Analyses

Bivariate associations were assessedusing contingency tables applying chisquare statistics. Crude and adjusted asso-ciations between exposure to parentalintoxication and suicidal behavior wereestimated in logistic regression modelsand the latter by entering intoxication fre-quency as co-variate. The associations arepresented as odds ratios with 95% confi-dence intervals. A possible mediating effectof intoxication frequency was tested usingSobel test (Sobel, 1982).

To assess whether an associationbetween parental intoxication and ado-lescent suicidal behavior differed betweenyounger (junior high school) and older(senior high school) adolescents, a multipli-cative interaction term was entered into themodels, and if the interaction term wasstatistically significant, separate modelswere estimated for younger and olderadolescents.

In order to assess whether a possibleimpact of one parent’s intoxication addsto that of the other parent, the two vari-ables on mother’s and father’s intoxicationwere entered into the model applyingmodel fit criteria (log likelihood ratio) andchange in �2 Log Likelihood. This analysiswas conducted for the 2004 survey amongadolescents who lived with both parents(n¼ 13,171).

RESULTS

Bivariate analyses showed that for bothoutcome measures, prevalence of suicidalbehavior (suicidal ideation and suicideattempts) increased with increasingexposure to parental intoxication (Table 1).

TABLE 1. Prevalence of Suicidal Ideation and Attempted Suicide by Categories of Exposure toParental Intoxication

Never(%)

A fewtimes(%)

Some timesper year(%)

Some timesper month

(%)

Some timesper week

(%)Chi square

test

Suicidal ideation 2002 by

exposure to parental

intoxication

5.7 5.1 6.6 10.5 21.9 113.0 p< .001

Attempted suicide 2002 by

exposure to parental

intoxication

7.3 10.9 11.3 20.6 32.0 215.9 p< .001

Suicidal ideation 2004 by

exposure to mother’s

intoxication

3.6 5.4 6.3 9.7 20.5 144.6 p< .001

Suicidal ideation 2004 by

exposure to father’s

intoxication

3.2 4.8 6.7 7.7 22.0 282.7 p< .001

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TABLE2.CrudeandAdjustedORsforAssociationsbetw

eenExposure

toParentalIntoxicationandLikelihoodofReportingSuicidalIdeationand

AttemptedSuicide

Unadjustedoddsratios

Adjustedoddsratios

Afew

times

Sometimes

peryear

Sometimes

permonth

Sometimes

perweek

Afew

times

Sometimes

peryear

Sometimes

permonth

Sometimes

perweek

Su

icid

alid

eati

on

2002

by

exp

osu

reto

par

enta

lin

toxi

cati

on

0.9

(0.7

,1.1

)1.2

(0.9

,1.5

)1.9

(1.4

,2.6

)4.6

(3.3

,6.6

)0.8

(0.7

,1.0

)1.1

(0.8

,1.4

)1.8

(1.3

,2.4

)4.4

(3.1

,6.3

)

Att

emp

ted

suic

ide

2002

by

exp

osu

re

top

aren

tal

into

xica

tio

n

1.6

(1.3

,1.8

)1.6

(1.3

,2.0

)3.3

(2.6

,4.2

)6.0

(4.4

,8.2

)1.3

(1.2

,1.6

)1.3

(1.0

,1.6

)2.6

(2.1

,3.4

)4.8

(3.5

,6.7

)

Su

icid

alid

eati

on

2004

by

exp

osu

reto

mo

ther

’sin

toxi

cati

on

1.5

(1.3

,1.8

)1.8

(1.4

,2.3

)2.8

(2.0

,4.0

)6.8

(4.4

,10.5

)1.3

(1.1

,1.6

)1.5

(1.1

,1.9

)2.3

(1.6

,3.3

)5.2

(3.3

,8.2

)

Su

icid

alid

eati

on

2004

by

exp

osu

reto

fath

er’s

into

xica

tio

n

1.5

(1.3

,1.8

)2.2

(1.7

,2.7

)2.5

(1.8

,3.4

)8.5

(6.3

,11.4

)1.4

(1.2

,1.6

)1.9

(1.5

,2.8

)2.1

(1.5

,2.8

)6.9

(5.0

,9.4

)

Note.

Ref

eren

ceca

tego

ry:

nev

erex

po

sed

top

aren

tal

into

xica

tio

n.

Co

-var

iate

inth

ean

alys

es:

ado

lesc

ents

’in

toxi

cati

on

freq

uen

cy.

95%

Co

nfi

den

ceIn

terv

als

inP

aren

thes

es.

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Four logistic regression models wereestimated for the association betweenexposure to parental intoxication and ado-lescent suicidal behavior (Table 2). Whencontrolling for adolescents’ intoxicationfrequency, this association was significantlymoderated in all four models (z-values inSobel test ranging between 5.8 and 8.2).Yet, a significant association still remainedfor both outcome variables in all four mod-els and the likelihood of reporting suicidalbehavior increased with increasingexposure to parental intoxication (Table 2).

There was a statistically significantinteraction between exposure to parentalintoxication and age on likelihood of suici-dal ideation in both surveys; the associationbeing stronger among younger than amongolder adolescents (Table 3). Such an inter-action was not found in the analysis ofsuicide attempt in the 2002 survey.

Finally, we addressed whether theimpact of exposure to one parent’s intoxi-cation added to that of the other parentby assessing whether model fit improvedstatistically significantly when exposure toone parent’s intoxication was added to thatof the other in the logistic regressionmodel. The analysis was conducted among

those who lived with both parents and theadolescent’s own intoxication frequencywas also entered into the model. The corre-lation between exposure to mother’s andfather’s intoxication was 0.67 and addingexposure to mother’s intoxication to thatof father’s intoxication did not improvemodel fit (Change in �2 Log Like-lihood¼ 6.64, df¼ 4, p¼ .156).

DISCUSSION

The present study has shown that exposureto parental intoxication was associated withsuicidal behavior in their adolescent off-spring. Moreover, the findings demon-strated that suicidal behavior inadolescents was associated with frequencyof parental intoxication also when adoles-cents’ own drinking behavior was takeninto account and that the association wasstronger among younger than among olderadolescents. Although causal inferencescannot be drawn on the basis of this studyapplying cross-sectional data, the observedassociations suggest that an elevated riskof suicidal behavior is not only foundwithin the small fraction of adolescents

TABLE 3. Adjusted ORs for Associations between Exposure to Parental Intoxication and Likelihoodof Reporting Suicidal Ideation and Attempted Suicide

A fewtimes

Some timesper year

Some timesper month

Some timesper week

Suicidal ideation 2002 by exposure to parental intoxication

Junior High School 0.9 (0.7, 1.2) 1.5 (1.0, 2.1) 2.0 (1.3, 3.2) 6.3 (3.9, 10.1)

Senior High School 0.8 (0.6, 1.1) 0.9 (0.6, 1.4) 1.5 (0.9, 2.4) 2.6 (1.4, 4.8)

Suicidal ideation 2004 by exposure to mother’s intoxication

Junior High School 2.0 (1.6, 2.5) 2.2 (1.4, 3.3) 3.2 (1.8, 5.8) 8.1 (4.2, 15.5)

Senior High School 1.1 (0.9, 1.3) 1.2 (0.9, 1.7) 1.9 (1.2, 3.0) 2.3 (1.1, 5.0)

Suicidal ideation 2004 by exposure to father’s intoxication

Junior High School 1.8 (1.4, 2.3) 2.9 (2.0, 4.1) 3.7 (2.3, 6.0) 9.0 (5.5, 14.8)

Senior High School 1.1 (0.9, 1.5) 1.5 (1.1, 2.1) 1.5 (0.9, 2.3) 4.9 (3.2, 7.6)

Note. Reference category: never exposed to parental intoxication. Co-variate in the analyses: adolescents’intoxication frequency. 95% Confidence Intervals in Parentheses. Age Specific Analyses.

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with heavy drinking parents, but also withina larger group who are occasionallyexposed to parental intoxication. Indeed,for many types of alcohol-related harm,we do not find these only among—or inthe context of—the heaviest drinkers, butalso in relation to drinkers further downthe consumption scale (Skog, 1999).

The study adds to a meager researchliterature on parental heavy drinking andrisk of suicidal behavior in adolescents.Yet, our findings are line with those ofGrøholt and co-workers (Grøholt,Ekeburg, Wichstrom et al., 2000) whofound a significantly elevated risk of hospi-talization for attempted suicide amongthose who were frequently exposed to par-ental intoxication, and they are in accord-ance with studies demonstrating a higherprevalence of suicidal behavior amongrespondents reporting parental substanceabuse during childhood or adolescence(Dube, Anda, Felitti, Chapman et al.,2001; Fergusson & Lynskey, 1995). Thefindings are also well in line with a broaderliterature demonstrating an increased riskof various psycho-social problems amongadolescent off-spring of heavy drinkers(Johnson & Leff, 1999; Steinhausen, 1995;Windle & Searles, 1990).

Several possible pathways may explainthe observed associations between parentalintoxication and adolescents’ suicidal beha-vior. First, adolescents’ own drinking beha-vior may mirror that of their parents(Barnes, 1990) and this was found toaccount for some of the observed associ-ation. Second, heavy drinking may impairparenting skills and family functioning,e.g., by causing high conflict levels; poorproblem-solving abilities and parentalneglect and abuse (Christoffersen &Soothill, 2003; Johnson & Leff, 1999;Steinhausen, 1995; Windle & Searles,1990) and=or may cause stressful lifeevents and circumstances such as pooreconomic resources and poor social sup-port (Johnson & Leff, 1999; Steinhausen,

1995). Such adversities and circumstancesmay in turn increase the adolescents’ vul-nerability for suicidal behavior (Beautrais,2000; Bridge, Goldstein, & Brent, 2006;Evans, Hawton, & Rodham, 2004; Wagner,1997). Third, heavy drinking parents oftenhave additional problems that tend to behereditary, such as depressive disorders(e.g., Ellis, Zucker, & Fitzgerald, 1997;Sullivan, Neale, & Kendler, 2000) andimpulsivity (Dawe & Loxton, 2004;Plutchik & Van Praag, 1989), and that arealso significant risk factors for suicidalbehavior (Beautrais, Joyce, & Mulder, 1999;Brent, 1995; Evans, Hawton, & Rodham,2004). Still, many children who grow upwith heavy drinking parents do not appearto show signs of poor psycho-socialadjustment (Steinhausen, 1995). Thus, itseems likely that a possible impact ofparents’ heavy drinking on their childrenis part of a complex web of interactingconditions.

In contrast to what we expected basedon some previous studies of children inalcoholic families (Dube, Anda, Felitti,Croft et al., 2001; Haugland, 2005) wefound that the likelihood of suicidal idea-tion did not differ statistically significantlydepending on whether one or both parentswere frequently observed intoxicated. Yet,in this respect it should be noted that fre-quently intoxicated parents in our studymay comprise parents with less heavy andless harmful drinking than those in clinicalsamples of alcoholic families.

Methodological Considerations

The analyses were based on surveys withgood response rates and large samples, allow-ing for analyses of associations between fairlylow-prevalent phenomena. By applying twodifferent data sets within the same age groupand target population as well as similar vari-ables for exposure measures and outcomes,the fairly similar results from the two

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different data sets suggest robustness andexternal validity of the findings.

However, several shortcomings of thisstudy should be noted. First, usingsingle-item measures is likely to haveresulted in weaker correlations than if mea-sures containing multiple items were used,e.g., as shown in a meta-analysis of 185studies of the relationship between variouspsychosocial variables and a wide range ofhealth and risk behaviors (Armitage &Conner, 2001). Second, the variable onexposure to parental intoxication is notvalidated with respect to assessing possiblethird-party harm. On the one hand, it islikely that adolescents’ perceptions of par-ental intoxication may vary significantlybetween adolescents (as well as within ado-lescents over time in teenage years). Thus,what one adolescent perceives as a parentbeing drunk may be perceived differentlyby another. On the other hand, it is alsopossible that some children may sufferfrom parental heavy drinking withoutnecessarily observing the parents drunk.Third, although we found that suicidalbehavior in adolescents was associated withfrequency of parental intoxication, infer-ences of causality should not be drawnfrom analyses of cross-sectional data. Sui-cide attempt and exposure to parentalintoxication were lifetime measures. Hence,in cases where adolescents reported bothsuicidal behavior and exposure to parentalintoxication, we do not know whether par-ental intoxication preceded or followed thesuicidal behavior event. Finally, it should benoted that the non-response may be sys-tematic and imply that adolescents withsuicidal behavior and adolescents exposedto parental intoxication are under-represented in the net sample. However,the relationship between exposure to par-ental intoxication and suicidal behavior isprobably less affected by such non-response bias, as there were fairly similarfindings in the two surveys with differentresponse rates.

Implications

The findings of this study suggest thatparental heavy drinking may increase therisk of suicidal behavior in their adolescentchildren. Previous studies have shown thatthese children in general have a higher riskfor a variety of health and social problems(Christoffersen & Soothill, 2003; Johnson& Leff, 1999; Steinhausen, 1995; Windle& Searles, 1990) and therefore in particularare in need of attention and care. Thus,assessment of suicidal risk and preventionof suicidal behavior may well be part ofthe health and social services that areoffered to this group of vulnerable youngpeople, particularly focusing on youngeradolescents.

While some services, e.g., counselingfor mental health problems, may help chil-dren of heavy drinkers directly and indi-vidually, other services, e.g., familycounseling, may help family processes andin this way curb the risk of harm to chil-dren. For instance, it seems that the extentto which children of heavy drinking parentssuffer various psycho-social problems var-ies with the level of family functioning. Infamilies that are able to maintain stable pat-terns with respect to, for instance, regularmeals and holiday traditions, the childrenseem to suffer less psycho-social problemscompared to families where such patternshave fallen apart (Haugland, 2005). Thus,helping families with heavy drinking par-ents to maintain such patterns of ordinaryfamily activities is therefore possibly usefulto prevent or curb various psycho-socialproblems in the children, including suicidalbehavior.

Apart from strategies targeting familieswith heavy drinkers, one may also take intoconsideration alcohol control policies thatare effective in curbing harmful drinking.In particular restrictions on alcohol avail-ability and increased prices by use of exciseduties have been shown to be effective inreducing alcohol consumption and related

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harm, also among the heavy drinkers(Babor, Caetano, Casswell et al., 2010).

By demonstrating a correlationbetween how often adolescents haveobserved their parents intoxicated and thelikelihood of suicidal ideation and suicideattempts, this study adds to the sparseresearch literature on possible third-partyharm from parental drinking, yet furtherresearch is needed. In order to understandthe likely complexity and possible mechan-isms of causality in this context better,prospective longitudinal cohort studiesas well as qualitative methods andmixed methods studies are needed.Such knowledge will be of significantimportance to the alcohol policy debateand of relevance for choice of preventionstrategies.

AUTHOR NOTE

Ingeborg Rossow, National Centre for Sui-cide Research and Prevention, Universityof Oslo; and Norwegian Institute for Alco-hol and Drug Research, Oslo, Norway.

Inger Synnøve Moan, NorwegianInstitute for Alcohol and Drug Research,Oslo, Norway.

The authors are grateful for the valu-able comments on an earlier version of thispaper by Berit Grøholt, Erlend Mork, andother colleagues at the National Centrefor Suicide Research and Prevention atthe University of Oslo.

The authors’ work with this study wasfunded by the National Centre for SuicideResearch and Prevention, University ofOslo and the Norwegian Institute forAlcohol and Drug Research. The data col-lection for the 2002 school survey wasfunded by the Norwegian Research Coun-cil and Norwegian Social Research. The lat-ter institute generously allowed access toanalyze these data for the present study.The data collection for the 2004 schoolsurvey was funded and organized by the

Norwegian Institute for Alcohol and DrugResearch.

Correspondence concerning this articleshould be addressed to Ingeborg Rossow,Professor, National Centre for SuicideResearch and Prevention, University ofOslo, Sognsvannsvn 21, N-0372 Oslo,Norway. E-mail: [email protected]

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