Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077

Perception of Parental Bonds and Suicide Intent Among

Egyptian Adolescents
Amira Y. Sharaf, DNSc, Elaine A. Thompson, PhD, RN, and Hoda F. Abd El-Salam, MDFM
Amira Y. Sharaf, DNSc, is Assistant Professor at Psychiatric Nursing and Mental Health, Faculty of Nursing, Alexandria University, Alexandria, Egypt;
Elaine A. Thompson, PhD, RN, is Professor Emeritus at Psychosocial & Community Health, School of Nursing, University of Washington, Seattle, WA,
USA, and Hoda F. Abd El-Salam, MDFM, is Professor at Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Alexandria,
Egypt

Search terms: PROBLEM: Suicidal adolescents, compared to their nonsuicidal peers, tend to per-
Adolescence, Egyptian youth, parental bonds, ceive their parents as less caring and more controllingwhich characterizes the
parenting style, suicide intent
affectionless control parenting style. Research findings are inconsistent regarding
Author contact: the distinct influence of mother versus father parenting on youth suicide intent;
amira_psych@yahoo.com, with a copy to the moreover, the influence of parents joint parenting styles on suicide intent has not
Editor: kathleen_r_delaney@rush.edu been investigated.
METHODS: Using a cross-sectional design and large sample (N = 150 youth, 1321
Conflict of Interest years old), currently hospitalized in a treatment center in Egypt for a recent suicide
The authors report no actual or potential
attempt, data were collected using the Suicide Intent Scale, Parental Bonding Instru-
conflict of interest.
ment, and Center for Epidemiologic Studies Depression Scale.
doi: 10.1111/jcap.12130 FINDINGS: Seventy percent of youth reported high suicide intent. Mother and fa-
ther parenting styles, assessed independently, were not associated with adolescent
suicide intent. The joint effect of both parents parenting style, however, was posi-
tively associated with suicide intent (Wald 2 = 8.79, p = .03). Suicide intent was
stronger among adolescents who experienced neglectful compared with optimal
parenting style (B = 1.93, Wald 2 = 4.28, p = .04).
CONCLUSIONS: The findings have direct implications for mental health nursing
interventions, signaling the critical need to engage both parents in family-based in-
terventions to address youth suicidal behavior.

Adolescent suicide remains a crucial public health issue
worldwide (Xing et al., 2010). For U.S. adolescents, suicide is
the third leading cause of death (Centers for Disease Control
& Prevention [CDC], 2012). The recent Youth Risk Behavior
Surveillance survey (CDC, 2012) revealed that 28.5% of the
high school youth experienced sad and hopeless feelings
that disturbed their daily activities, 15.8% seriously consid-
ered suicide, and about 8% had attempted suicide. In particu-
lar, evidence indicates that having a previous suicide attempt
with strong intent to die is a crucial risk factor, especially in
the year following an attempt (Spirito & Esposito-Smythers,
2006).
In Egypt, suicide is illegal by law and morally wrong by
religious principles (Okasha & Lotaif, 1979). Consequently,
suicide rates in Egypt are thought to be markedly underre-
ported, with reporting being neither systematic nor consis-
tent. Self-poisoning is high (70%) among youth admitted to
the Alexandria Poison Center in Egypt (Alexandria Poison
Center, 2007). Given the general prevalence and severity of
youth suicide attempts, early identification of suicide risks
with timely intervention is imperative.
Background/Theoretical Framework
Theoretical formulation and empirical evidence acknowl-
edge that parenting practices have a crucial developmental
role in shaping susceptibility to psychopathology during
adolescence and young adulthood (Dale, Power, Kane,
Stewart, & Murray, 2010; Rikhye et al., 2008). How effec-
tively a child bonds with his/her parents is essential for
positive psychosocial development and is linked to a sense
of security, emotion regulation skills (Kissil, 2011), and the
ability to establish healthy interpersonal bonds (Rigby, Slee,
& Martin, 2007). Although some parenting behaviors affect
bonding, Parker, Tupling, and Brown (1979) noted that the
core features of parental bonding can be captured in the
constructs of parental care and overprotection. Parker et al.
(1979, p. 3) characterized parental care as varying along a

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Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents
continuum from caring versus indifference/rejection. Con-
trol, on the other hand, was characterized as varying from
control/overprotection versus allowance of autonomy and
independence. The dimensions of care and overprotection,
it was noted, can be combined to create four styles of parental
bonding. Optimal bonding reflects parenting with high levels
of parental care and distinct encouragement of autonomy.
Affectionate constraint describes a style of parenting that is
caring but also includes behaviors that constrain youth emo-
tions and simultaneously inhibit independence. Affectionless
control is reflective of low levels of parental care coupled with
excessive control and intrusion. Absent/neglectful bonding
is characterized by low levels of both parental care and
overprotection.
Evidence suggests that maladaptive parenting is a critical
suicide risk factor (Dale et al., 2010; Xing et al., 2010). Adoles-
cents with suicidal behaviors compared with those who have
never been involved in suicidal behaviors tend to perceive
their parents as being more restrictive and less affection-
ate (Adam, Keller, West, Larose, & Goszer, 1994; Goschin,
Briggs, Blanco-Lutzen, Cohen, & Galynker, 2013). Research
results, however, are inconsistent regarding the effects of ma-
ternal versus paternal parental bonding on suicidal behav-
iors. Some studies have documented detrimental effects as-
sociated with the maternal relationship (G. M. Diamond
et al., 2005), and other research has shown links between
adolescent suicidal behavior and the paternal relationship
(Bilgin, Cenkseven, & Satar, 2007; Hsu, Chen, & Lung, 2013).
Few studies have examined patterns of parenting in Egyptian
culture, where authoritarian parenting is conventional. To
date, investigators have not explored the distinct associations
of both mother versus father parenting and adolescent sui-
cide behaviors among Egyptian youth, and none worldwide
have addressed the joint effects of parents parenting style on
suicide intent.
This study sought to understand the relationship between
adolescents perceptions of parental bonds and reported
suicide intent in Egyptian youth hospitalized for suicide
attempts. This study examined if adolescents perceptions of
parental bonds, specifically linked to parent overprotection
and parent care, were related to adolescent suicidal intent
at the time of a suicide attempt. Uniquely, we examined the
separate contributions of both parents parenting style as
well as their combined or joint effects on adolescent suicide
intent. Elucidating this evidence is essential for the develop-
ment of intervention programs to enhance the formation of
healthy parental bonding, characterized by parent care and
support of autonomy, to buffer adolescents from suicidality.
We hypothesized that among Egyptian adolescents who have
had a recent suicide attempt (H1 ) suicide intent is positively
linked to adolescent perceptions of both mother and father
overprotection, and suicide intent is negatively associated
with adolescent perceptions of mother and father care, (H2 )
16
the effect of parenting style on suicide intent combined for
both parents would be stronger than the separate effect for
each parent, and (H3 ) suicide intent would be more intense
for youth whose parents parenting style was characterized
by affectionless control or absent/neglectful compared
with optimal parenting style.
Methods
Design
A cross-sectional research design was used with data col-
lected with youth hospitalized for recent attempted suicide.
Sampling and Participants
A convenience sample (N = 150) of youth (1321 years old)
hospitalized for a recent suicide attempt in a major poison
treatment center in Alexandria, Egypt, were invited to par-
ticipate in the study. Exclusion criteria included intellectual
disabilities, signs of marked psychological distress (e.g.,
anxiety, difficulty communicating, and protracted thinking
processes), or manifestations of psychoses (e.g., auditory
hallucinations, delusions, or other irrational thinking).
Power analyses for regression models demonstrated that a
sample size of 150 would be sufficient to detect significant
effects for comparisons of the parameter estimates by group
(power [1 ] = 0.90, = .05, two-tailed).
Measures
Suicide Intent Scale. The Suicide Intent Scale (SIS; Beck,
Schuyler, & Herman, 1974) was used to assess the intensity
of a youths wish to die. The scale, widely used internation-
ally, includes 15 items: eight items identify characteristics
of the suicide attempt, such as degree of isolation, timing,
strategies used to prevent detection by others, help-seeking
behaviors, and extent of suicide plan and seven items cap-
ture the youths thoughts and feelings associated with the at-
tempt, including reported purpose, preparation, expectation
that death would occur, and perceived likelihood that some-
one would intervene. The standardized Arabic version of SIS
was used (Hamdi, Amin, & Matter, 1991). Each item is rated
on with a 3-point response option (02). Item response val-
ues are summed to provide a suicide intent score, with the
total score ranging from 0 to 30 and high scores indicating
greater intention to die. The scale has established validity and
reliability in samples of suicidal adults (Beck et al., 1974) and
adolescents (Freedenthal, 2008). In the present study, Cron-
bachs was .70.
Parental Bonding Instrument. The Parental Bonding In-
strument (PBI; Parker et al., 1979) measured adolescents
perceptions of key parent attitudes and behaviors reflective
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 Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents
of parentadolescent bonding. The instrument has 25 items
that yield two subscales coined by Parker as follows: care
(12 items) and overprotection (13 items). Items are rated
using 4-point Likert-type response options that range from
0 (very unlike) to 3 (very like). Total scores range from 0 to
36 and 0 to 39, respectively. Adolescents reported on their
overall experiences with their parents from age 6 until the
time of interview. Adolescents perceptions of parent care and
overprotection were assessed separately for each biological
parent (or substitute parent identified as the primary care-
giver). Higher scores indicated greater degrees of these two
attributes. Combined parenting attributes were calculated by
summing mother and father care and mother and father over-
protection. The PBI has established reliability and concurrent
and predictive validity (Parker, 1989), with demonstrated va-
lidity and reliability in other research (Grotmol et al. 2010;
Meites, Ingram, & Siegle, 2012). In this study, internal consis-
tency was .91 and .93 for mother and father care, respectively,
and .79 for mother and father overprotection.
Center for Epidemiologic Studies Depression Scale. Ado-
lescent depression was assessed using the Center for Epi-
demiologic Studies Depression Scale (CES_D Scale; Radloff,
1977). It consists of 20 items measuring symptoms of depres-
sion during the past week. Each item is rated on a 4-point
Likert-type scale ranging from 0 (rarely/none of the time) to
3 (most/all of the time), with higher scores indicating greater
depression. This commonly used scale has established valid-
ity and reliability. Cronbachs was .86 in the current study.
Structured Demographic/Background Interview. A brief
interview schedule was used to gather information about
adolescent and parental history of suicidal thoughts, prior
to suicide attempt(s), substance/alcohol use, and/or mental
illness, as well as demographic characteristics.
Procedures
Pilot Study. The primary author translated the PBI and
CES-D to Arabic language (cf., Sharaf, Ossman, & Lachine,
2012). Two bilingual faculty in nursing systematically re-
viewed the translated versions for face validity, and a third
faculty member, not familiar with the original English lan-
guage measures, back-translated the instruments. The origi-
nal English and back-translated versions of the instruments
were linguistically equivalent. We conducted a pilot study
with a separate youth sample (n = 15), and determined that
translated instruments did not necessitate revisions.
Ethical Considerations and Data Collection. Study pro-
cedures were reviewed and approved by the Ethical and
Human Subjects Protection Committee of the Faculty of
Nursing, Alexandria University. The director of the poison
center also reviewed the research proposal and provided per-
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mission to carry out the study. Nursing staff informed the re-
searcher when there was an admission of an adolescent meet-
ing the study inclusion criteria. The medical records of the
potential study participants were reviewed to verify that the
identified adolescent had described the suicide attempt as in-
tentional. An existing research-based protocol to assess indi-
viduals at risk for suicide was adapted for this study (Sharaf
et al. 2012; Thompson, Eggert, & Herting, 2000).
When the nursing staff confirmed that the effect of the
drug/poison substance(s) had dissipated and the adolescent
would be able to safely participate and communicate in a
coherent and relevant manner, the researcher explained the
study purpose and procedures to the potential participant
and his or her parent or substitute parent. In the consent
process, the researcher informed adolescents and their par-
ent(s) that research participation was fully voluntary. The re-
searcher assured individuals that their privacy would be pro-
tected, their interview responses would be confidential, and
that the data would be fully anonymous. The one exception
was explained: if the researcher learned of new and/or im-
minent suicide risk, then this information would be shared
with the nursing staff and the physician, in order to provide
the necessary care, safety, and assistance. Written informed
adolescent assent (for youth below 18 years of age) or con-
sent and parent consent were obtained.
Over a 5-month period, 170 adolescents were contacted
by the first researcher, who is experienced in adolescent sui-
cide risk assessment. Of these, 7.6% (n = 13) did not describe
the suicidal act as deliberate and 4.1% (n = 7) refused to par-
ticipate due to fear of stigma and/or medico-legal aspects of
suicidal acts in Egypt. Eligible youth participants who had
signed the assent/consent form were interviewed individu-
ally in a private room at the center. Interviews generally took
about 25 minutes. At the conclusion, the researcher iden-
tified and acknowledged the adolescents specific strengths,
discussed a no self-harm contract, conferred with the ado-
lescent regarding how to communicate about the interview
with his/her parents, and discussed means to obtain support
from mental health professionals and trusted adults, thereby
increasing the adolescents access to social support and
services.
Data Analysis
Preliminary analysis included computation of descriptive
statistics (mean, median, SD, kurtosis, skew), used to de-
scribe the study sample and to assess the assumptions un-
derlying the statistical tests. To test H1 , separate sets of Pear-
son point biserial correlations were used to determine the
strength of associations between perceived care and overpro-
tection and suicide intent. To test H2 and H3 , the PBI sub-
scales were divided into high/low care and high/low overpro-
tection using median splits. Following the strategy proposed
17
Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents
Table 1. Distribution of Adolescents by Parenting Style for Mother,
Father, and Parents Combined
Mother Father Combined parents
Parenting style n (%) n (%) n (%)
Optimal 49 (32.7) 52 (36.4) 46 (32.2)
Affectionate constraint 24 (16.0) 19 (13.2) 21 (14.6)
Affectionless control 51 (34.0) 50 (35.0) 48 (33.6)
Absent/neglectful 26 (17.3) 22 (15.4) 28 (19.6)
Total 150 143 143
by Parker et al. (1979), we defined four types of parental
bonding based on high versus low levels of care and overpro-
tection: optimal bonding characterized by high care/low over-
protection, affectionate constraint by high care/high overpro-
tection, affectionless control by low care/high overprotection,
and neglectful parenting by low care/low overprotection. Ten
cases were excluded from analysis because there was no fa-
ther figure (n = 7) or the mothers educational level was un-
known (n = 3, Table 1). Generalized linear modeling (GLM)
with maximum-likelihood estimation was used to examine
the separate and combined effects of parents parenting style
on suicide intent, controlling for relevant covariates. The op-
timal parenting group served as the referent group. Reported
significance values are two-tailed (p .05).
Results
Sociodemographic and Clinical Characteristics
Youth. Youth ages ranged from 13 to 21 years (M = 17.84,
SD = 1.97). Mean education was 8.97 (SD = 3.65) years;
46% of the total sample were students. Females and never
married participants were predominant (92.7% and 92.0%,
respectively) in the sample.
More than half of the sample (62.8%) reported having sui-
cidal thoughts prior to the current attempt; close to one-third
(31.3%) had attempted suicide at least once. A previous his-
tory of mental illness was reported by 14.7%. A small propor-
tion of the youth reported using alcohol (0.7%) and/or other
addictive substances (2.0%). Relative to the current suicide
attempt, most participants (70.0%) reported high suicide in-
tent (11) with a mean of 12.9 (SD = 4.23). Approximately,
83% were using medications at the time of the suicide at-
tempt. Twelve percent were admitted to the ICU for a median
stay of 24 hr.
Parents. About 63.3% of youth lived with their biologi-
cal parents, mostly in suburban areas. Approximately 60%
perceived their income as adequate. For the vast ma-
jority (98.0%), the biological mother was the mothering
figure. The mean years of education for mothers was 6.61
(SD = 5.19); most mothers identified their occupations as
18
housewife (74.0%). For the majority of youth (83.4%), the
biological father was the fathering figure. Fathers had a mean
of 8 years of education and typically worked full-time (71%).
A minority of adolescents reported a history of maternal sui-
cide behaviors (4.7%) and mental illness (5.3%). None of the
mothers used alcohol or other addictive substances. A small
proportion of youth reported a history of paternal alcohol
use (2.1%), addictive substance use (8.4%), or mental illness
(5.6%). None reported a history of paternal suicide behaviors.
Preliminary Analyses
Suicide intent was not related to adolescent demographic
variables. Suicide intent was higher (M = 13.06) for ado-
lescents whose mothers had no or some primary education
compared with adolescents whose mothers had completed
secondary education (M = 11, F [4, 142] = 2.49, p = .03).
Suicide intent was positively associated with adolescent de-
pression (r = .40, p < .001). Higher levels of depression were
linked to elevated mother and father overprotection (r = .31,
p < .001; and r = .25, p = .003, respectively) and lower levels
of mother and father care (r = .41, p < .001; and r = .25,
p = .002, respectively). Study participants admitted to the
ICU, who reported prior suicide thoughts and/or a prior sui-
cide attempt(s) compared with those who did not, reported
significantly higher suicide intent (t(26.85) = 2.49, p = .02;
t(148) = 2.46, p = .02; and t(148) = 3.19, p = .002, respectively).
Hypothesis 1: Maternal and Paternal Care and Overprotec-
tion and Youth Suicide Intent. As hypothesized, perceived
overprotection by mother was positively correlated with sui-
cide intent (r = .20, p = .02), but overprotection by father
was not (Table 2). On the other hand, perceived care for both
mother and father was negatively correlated with suicide in-
tent (r = .30, p < .001; and r = .26, p = .002, respectively).
Hypothesis 2: Maternal, Paternal, and Combined Par-
enting Styles and Youth Suicide Intent. Participants were
classified into one of four parenting styles determined by
parent care and overprotection. Controlling for mothers
education and adolescent depression, maternal parenting
style was not associated with suicide intent (Wald 2 = 4.49,
p = .21). Mothers education (B = 1.89, Wald 2 = 7.34, p =
.007) and adolescent depression (B = .12, Wald 2 = 17.22,
p <.001) were associated with intent. Paternal parenting style
had no influence on suicide intent, controlling for adolescent
depression (Wald 2 = 5.03, p = .17); adolescent depres-
sion was linked to suicide intent (B = .13, Wald 2 = 21.51,
p < .001). As hypothesized, analysis of combined parenting
style significantly influenced suicide intent (Wald 2 = 8.79,
p = .03).
Hypothesis 3: Four Parenting Styles and Youth Suicide In-
tent. Suicide intent was stronger among adolescents who
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 Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents

Table 2. Means, Standard Deviations, and Correlations Among Key Study Variables (N = 150)

Variables M SD 1 2 3 4 5 6

Suicide intent 12.87 4.23 .40*** .30*** .20* .26** .16

Depression 39.34 12.13 .41*** .31** .25** .25**
Mother care 19.09 10.11 .53*** .19* .14
Mother overprotection 20.86 8.45 .05 .31***
Father care 17.27 11.31 .52***
Father overprotection 18.94 8.71
*
p < .05; ** p < .01; *** p < .001.

Table 3. Generalized Linear Modeling: Parents Combined Parenting The present study partially supported the first hypothesis
Style and Suicide Intent (H1 ), as the perception of mother but not father over-
Variable B SEB Wald 2 protection was linked to increased suicide intent among
adolescents. This finding may reflect the importance of ma-
Type of parenting style ternal bonding in the genesis of adolescent suicide attempts,
Affectionless control 1.53 0.87 3.07
particularly if maternal versus paternal parenting behaviors
Affectionate constraint 0.60 1.03 0.34
Absent/neglectful 1.93* 0.93 4.28
play a more significant role in child emotional development
Control variables (Freudenstein et al., 2011; Kowk & Shek, 2010; Oshino,
Mothers education 1.73* 0.73 5.61 Suzuki, Ishii, & Otani, 2007). In Egyptian culture, mothers
Adolescent depression 0.12** 0.03 18.73 spend considerably more time with adolescents than fathers,
Note. The optimal parenting style group served as the referent group for
whose primary family role is as breadwinner. Fathers are
the comparisons. less involved in both care giving and discipline. Girls are not
*
p < .05; ** p < .001. encouraged to individuate from the family, but are expected
to remain enmeshed within the family, primarily within
the mothers influence, until marriage. Thus, authoritarian
experienced neglectful parenting compared with those with
fathering, specifically in this authoritarian culture, may not
optimal parenting (Table 3; B = 1.93, Wald 2 = 4.28, p =
contribute significantly to adolescent social development
.04). Adolescents experiencing affectionless control versus
or psychological well-being. The findings parallel stud-
optimal parenting reported higher suicide intent, although
ies of Palestinian (Dwairy, 2004) and Egyptian (Dwairy
the difference was nonsignificant (B = 1.53, Wald 2 = 3.07,
& Menshar, 2006) adolescents, in which adolescent mental
p = .07).
illness was unrelated to authoritarian parenting. Moreover,
in the present study the vast majority of participants were
Discussion
female. Egyptian mothers are expected not only to nurture
This study examined adolescents perceived parent care and but also to protect their daughters against freedoms that
parent overprotection and the joint effects of parenting style challenge Egyptian traditions regarding female modesty,
on adolescent suicide intent. Suicide intent was the highest mobility, and sexual behavior. Mothers tend to restrict their
among adolescents who perceived their mothers and fathers daughters mobility and limit interaction with peers of either
as less caring, consonant with other studies that have exam- sex. Some families do not allow their daughters to complete
ined associations between parent care and adolescent suici- their educations and compel them to marry to protect against
dality (Sguin, Lynch, Labelle, & Gagnon, 2004). Dale et al. perceived or actual sexual misbehavior.
(2010) found that low levels of parent care contribute to the The adverse effects of maternal bonding on suicidality
development of an adolescent self-schema that is intrinsi- were also socioeconomically dependent. The findings re-
cally and socially alienating, and that this estranged sense of vealed that maternal parenting style did not influence sui-
self mediates the relationship between parental bonding and cide intent with mothers education controlled. Mothers with
repetitive suicide behavior. In addition, low parent care may lower education tend to be less responsive to adolescents
lead to adolescent feelings of rejection and worthlessness, emotional needs and less confident in parenting, inhibit self-
which can undermine adolescent self-esteem and promote regulated behavior, and value punitive and fearful measures
helplessness and hopelessness, thereby increasing suicide be- rather than explore for solutions to problems. These forms of
haviors. This explanation is consistent with arguments that parenting may inhibit autonomy and sense of personal con-
adverse parenting contributes to low self-esteem (Zakeria & trol, and thereby contribute to feelings of inadequacy and
Karimpour, 2011), helplessness, and hopelessness (Kowk & being incapable of making decisions, which are well docu-
Shek, 2010). mented risk factors for adolescent suicide. Consonant with

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Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents
this idea, Dwairy et al. (2006) and Flouri (2005) noted that so-
cioeconomic disadvantage might explain the association be-
tween authoritarian parenting and child psychological well-
being, given that it is linked to both variables.
In analyzing the joint influence of parents in terms of
care and overprotection, we found that the separate influ-
ences of parenting style on suicide intent were not significant,
when controlling for adolescent depression. In such cases, an
adolescent suicide attempt may reflect a need to cope with
depression arising from weak parental bonding, and perhaps
to communicate emotional desperation. This argument was
partially supported by findings that showed low care and
high perceived overprotection by mother/father contributes
to adolescent depression and suicidality. It has been shown
that weak parent bonding is associated with increased vul-
nerability to depressive symptoms (Kraaij et al., 2003). On
the other hand, as predicted, the combined effect of both
parents parenting style independently influenced suicide in-
tent, possibly reflecting a potentiating effect of both parents
behavior on suicide vulnerability. For instance, a negative
self-view influenced by a critical mother may be potentiated
by an intrusive father (Meites et al., 2012). Consequently,
suicide, beyond the effect of depression, may be under-
stood as a means to escape from a hostile, unbearable family
climate.
Congruent with the third hypothesis (H3 ), adolescents
experiencing optimal parenting reported lower suicide in-
tent than those experiencing either neglectful (low care/low
overprotection) or affectionless control (low care/high over-
protection) parenting. This interesting finding, where low
parent care is a principle factor of both parenting styles, high-
lights the potentiating effects of low care. Conversely, a high
level of parent care may buffer the negative effects of high
parent overprotection. A similar report by G. M. Diamond
et al. (2005) revealed that parent control can be experienced
differentially depending on the affective context. Thus, for an
adolescent, controlling behaviors might also be experienced
as caring, when provided by a concerned and empathetic
parent.
Limitations
Interpretation of the study findings warrants discussion of
study limitations. First, the cross-sectional design precludes
reaching conclusions about a causeeffect relationship be-
tween variables. It might be the case that suicide vulnera-
ble adolescents perceive their parents negatively as a conse-
quence of depressed mood. Nonetheless, Parker (1989) has
shown that the PBI measure of parental bonding is unre-
lated to variations in adolescent mood, diminishing this as a
competing hypothesis. Second, despite depression being the
main psychological variable contributing to suicide among
adolescents, the current study did not examine how cogni-
20
tive distortion (e.g., negative schemas or poor problem solv-
ing) might influence the relationship between parenting style
and adolescent suicide behavior. Third, convenience sam-
pling limits the generalization of the findings. More specif-
ically, the sample was predominantly female; thus, findings
might not apply to males more generally. Fourth, data on
parental bonding were drawn from adolescent self-report.
Though a valid measure, assessment of parenting style from
both adolescents and parents perspectives will strengthen
future studies. Finally, the current study did not examine
broader psychosocial factors that may contribute to poor par-
enting style, such as economic and job pressures, family ill-
ness, or the lack of social support.
Conclusions
This study is the first to explore the joint effects of both par-
ents parenting style on adolescent suicide intent. The study
sheds light on the deleterious additive influence of parent-
ing negligence by both parents. Importantly, the unique study
design provided evidence from a large sample of vulnerable
youth in close time proximity to the suicide attempt.
The findings indicate that parental bonding should be
an integral part of assessment and intervention for ado-
lescent suicide behavior. As Hooven, Walsh, Pike, and
Herting (2012) have reasoned, genuine parent concern and
empathetic responsiveness enhance communication and
strengthen parentadolescent bonding. Attachment-based
Family Therapy (ABFT) is one promising family-centered
approach to treating adolescent depression and suicide risk
behaviors (G. S. Diamond et al., 2010). ABFT improves the
parentadolescent relationship by increasing family capacity
to discuss and negotiate relevant relationship issues. Rela-
tionship improvements improve adolescent affect regulation
and trust in the caregiver as a reliable source of protection
and support, buffering against suicide and other health risks.
Integrating the study findings with existing empirical ev-
idence, practice recommendations include the need to de-
velop suicide preventive approaches for parents that are
culturally relevant, acceptable, and feasible. Interventions
should include essential, evidence-based strategies to pro-
mote (a) empathetic communication and problem solving;
(b) fewer family power struggles; (c) the use of I message
to convey caring; (d) parent sensitivity to adolescents emo-
tional needs; (e) adolescent autonomy and circumscribed
parent control; and (f) parent limit setting through reason,
discussion, and appropriate and timely rewards.
Acknowledgments
Special appreciation is extended to the many youths whose
participation in this study enriched our understanding and
to the staff of Alexandria Poison Center who facilitated the
data collection process.
Journal of Child and Adolescent Psychiatric Nursing 29 (2016) 1522
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 Perception of Parental Bonds and Suicide Intent Among Egyptian Adolescents
Funding
No external or intramural funding was received for this re-
search.
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