Acta Psychiatr Scand 2008: 117: 50–56 Copyright  2007 The Authors

All rights reserved Journal Compilation  2007 Blackwell Munksgaard

DOI: 10.1111/j.1600-0447.2007.01124.x ACTA PSYCHIATRICA
SCANDINAVICA

Perception of rejecting and neglectful

parenting in childhood relates to lifetime
suicide attempts for females – but not for
males
Ehnvall A, Parker G, Hadzi-Pavlovic D, Malhi G. Perception of
rejecting and neglectful parenting in childhood relates to lifetime suicide
attempts for females – but not for males.
Objective: To examine the hypothesis that lifetime suicide attempts in
a sample of depressed individuals is greater among those who
remember their parents as rejecting or neglecting in childhood.
Method: Database analyses of patients referred to a public hospital
Mood Disorders Unit in Sydney, over a consecutive 10-year period.
Patients met DSM-IV criteria for depression, had completed a self-
report questionnaire regarding perception of parental rearing, and had
responded to a probe question assessing lifetime suicide attempts
(n = 343).
Results: Female patients who perceived themselves as
rejected ⁄ neglected by either parent in childhood had a greater chance
of making at least one lifetime suicide attempt. No such associations
were found for males.
Conclusion: Perception of rejecting ⁄ neglectful parents was associated
with lifetime suicide attempts in females only, inviting research
explicating any such gender specificity.
A. Ehnvall1, G. Parker2,3,
D. Hadzi-Pavlovic2,3, G. Malhi3,4
1
Research and Development Unit, FoU, Varberg
Hospital, Varberg, and Department of Psychiatry,
Institute of Clinical Neuroscience, Gçteborg University,
Gothenburg, Sweden, 2School of Psychiatry, University
of New South Wales, Sydney, 3Black Dog Institute,
Prince of Wales Hospital, Sydney and 4Department of
Psychology, Northern Clinical School, University of
Sydney, Sydney
Key words: suicide attempts; treatment-refractory
depression; parental rejection; parental neglect;
attachment
Anna Ehnvall, Research and Developmental Unit, FoU,
Varberg Hospital, SE-432 81 Varberg, Sweden.
E-mail: anna.ehnvall@lthalland.se
Accepted for publication October 10, 2007

Significant outcomes
• Perception of indifferent parenting in childhood is associated with suicide attempts over a lifetime for
depressed females – but not for males.

Limitations
• The retrospective design of the study might cause recall bias in perceived parenting style.
• Data regarding perception of parental rearing was obtained via self-report questionnaires and not by
interviews.
• There were no specific self-report questions assessing memories of sexual abuse – only on perception
of verbal and physical abuse.
• The results apply to patients with treatment-resistant and ⁄ or severe depressive disorders and may not
be generalizable to all depressive mood disorders.

previously attempted suicide (2). Thus, depressed

Introduction
It is well recognized that depression is associated
with a higher risk of committing suicide (1).
Further, it has been quantified that depressed
patients who complete suicide are 10 times
more likely than other depressed patients to have
individuals with a history of previous suicide
attempts are a high-risk group warranting research
into both proximal and distal risk factors that might
increase their risk of further suicide attempts.
In this paper, we explore the relationship
between self-reported current recall of parenting

50
 Perception of rejecting and neglectful parenting in childhood
style in childhood and lifetime suicide attempts in
severe and ⁄ or treatment-resistant depressed
patients. Perceptions of parental rearing have
shown high stability over time, despite clinically
significant changes in the severity of depression (3).
Empirical studies have demonstrated links between
suicidal thoughts and suicidal behaviour in
individuals and their perception of rejecting,
guilt-engendering and neglecting parents (4–6).
Childhood abuse (7), and specifically childhood
sexual abuse, has also been found to relate to
suicidality (8). Mediating mechanisms have been
considered by several theorists. BeckÕs cognitive
model argues that those at risk of depression, and
at risk of suicidality, are more likely to have been
exposed to certain types of negative experiences in
childhood, having acquired a set of dysfunctional
structures or schemas (9, 10). Bowlby detailed an
attachment theory model for child development
that also supposes that dysfunctional inner Ôwork-
ing modelsÕ of the self and the environment develop
as a function of the negative experiences the child
has had in his family (11). According to Bowlby,
the perception of being rejected or neglected in
childhood would, in adulthood, lead to the per-
ception of feeling unwanted in general (12) – and
hence contribute to suicidal risk.
The suicidal process, from suicidal thought to
committed suicide, is sometimes conceptualized as a
state of feeling trapped, with the individual unable to
deal with life circumstances (13). Problem solving
capabilities have been found to be low in suicidal
individuals (14, 15). If, in addition, the suicidal
individual feels rejected or neglected (i.e. unwanted),
he or she might be even less prone to approach others
or receive help in solving the problem, thereby
exacerbating the sense of entrapment.
Aims of the study
In this paper, we chose to pursue a previously
unexamined hypothesis that lifetime suicide
attempts in a sample of difficult-to-treat depressed
individuals would be greater among those who
specifically remembered their parents as rejecting
or neglecting in childhood.
Material and methods
Study design
We accessed the database of patients referred to the
tertiary referral Mood Disorders Unit Clinic (now
The Black Dog Institute) at Prince of Wales Hos-
pital, Sydney. Over the 20 years of its existence, it
has prioritized assessing patients with treatment-
resistant and ⁄ or severe depressive disorders, and
with a consistent assessment structure – with
patients completing a set of self-report question-
naires, being interviewed by a research psychologist
and psychiatrist, and with structured and semi-
structured probe sheets allowing data to be collected
in standardized ways. For the current study, we
accessed two of the more recent databases, compris-
ing one study which assessed three principal con-
tributing events to the onset of depressive disorders
(i.e. PAL-I assessing Personality, Anxiety and Life
event stressors) and a study pursuing causes of
treatment-resistant depression (CORD or Causes of
Resistant Depression), with recruitment proceeding
over a consecutive 10-year period.
Patients were included in the present study if
they fulfilled DSM-IV criteria for depression,
completed a self-report questionnaire regarding
perception of parental rearing (the Measure of
Parental Style or MOPS) (16), and responded to a
probe question assessing lifetime suicide attempts.
Other relevant database variables are detailed in
the relevant section of the Results section.
Measure of parental style
Perception of parental rearing was assessed using
the self-report questionnaire MOPS; (16). The
MOPS measures fundamental parenting styles of
indifference, overprotection and abuse and has
demonstrated high construct validity, as well as
convergent validity with the Parental Bonding
Instrument or PBI (17), another widely used
measure of perceived parenting (16). The MOPS
consists of 15 statements describing the perceived
negative behaviours and attitudes of parents
during the respondentÕs first 16 years. Respondents
are recorded on a four-point scale ranging from
Ônot true at allÕ to Ôextremely trueÕ, resulting in
scores from zero to three. Consequently, the higher
the scores on each MOPS item, the more negative
the subject perceived their parent on that item.
Diagnoses of depression
Symptom data collected by research psychologists
and psychiatrists generated the DSM-IV diagnoses.
The 21-item Hamilton Depression Rating Scale
(HDRS) (18) was used to measure depression
severity. Melancholic depression was defined
according to DSM-IV criteria (19).
Suicide attempts
Assessment of suicide attempts was established by
research psychologists and psychiatrists asking the
51
Ehnvall et al.
patient if they had ever committed a suicide
attempt. Suicide attempts did not include self-
harm without lethal intention. The number of
lifetime suicide attempts was classified as Ô0Õ, Ô1Õ,
Ô2–5Õ or Ô>5Õ attempts in each sample.
Analyses
Statistical programs from SPSS (Chicago, IL, USA)
were used. Chi-square analyses (for dichotomous
variables) and Mann–Whitney test (for continuous
variables) were used to compare variables across
and within the databases. Multiple regression anal-
yses examined if perception of parental rearing was
dependent on the severity of current depression.
Multiple logistic regression analyses determined
eight independent clinical variables (including
age, past week Hamilton scores, sex, the melan-
cholic ⁄ non-melancholic distinction, Ôrejection sen-
sitivityÕ as well as either maternal indifference,
maternal abuse and maternal overcontrol or
paternal indifference, paternal abuse and paternal
overcontrol) distinguishing suicide attempters
from non-suicide attempters, contrasting nil vs.
one or more suicide attempts.
Results
Demographics
Depressed patients were included from the two
most recent databases at the Sydney Mood Disor-
ders Unit Clinic (now The Black Dog Institute)
into the present database analyses only if they had
completed the MOPS and had also responded to a
probe question assessing lifetime suicide attempts.
The whole sample included 496 subjects at base-
line. One hundred and fifty-three subjects (30.8%)
were excluded from further analyses as they did not
fulfil inclusion criteria. These excluded individuals
had a mean age of 46.3 ± 17.25 years, 61.4% were
female, 29.4% had never been married, their
mean years of education was 13.5 ± 10.6 years,
19.0% were in full-time employment and 29.4%
were on a disability pension or receiving sickness
benefits.
Inclusion criteria resulted in a total sample of
343 patients across the two study groups. Included
patients were significantly younger than the exclu-
sion group (mean age 41.7 ± 13.1 years, Mann–
Whitney test; P = 0.026), but there were no other
significant differences between inclusion and exclu-
sion group on demographic variables. In the
inclusion group, 60.6% were female, 34.1% had
never been married, their mean years of education
was 14.1 ± 8.9 years; 24.5% were in full-time
52
employment and 25.7% were on a disability
pension or receiving sickness benefits. In the
included sample, there were no significant differ-
ences between the two study groups derived from
the two latest databases on any demographic
variable.
Diagnostic and clinical variables
Across the two study groups, 39.9% met DSM-
IV criteria for melancholic depression and 5.0%
for psychotic depression. In the total sample,
69.4% had never made a suicide attempt; 11.1%
had made one attempt; 14.9% had made two to
five suicide attempts and 4.7%, had made more
than five attempts. There was similar representa-
tion of diagnostic subgroupings and suicide
attempt prevalence across the two samples,
allowing consolidation of samples for our princi-
pal analyses.
Gender
Females were more likely to have made suicide
attempts than males (v2 = 15.54, df = 3, P =
0.000). The percentages of females (n = 208) who
had committed ÔnoÕ, ÔoneÕ, Ôtwo to fiveÕ and Ômore
than fiveÕ attempts were 67%, 12%, 15% and 6%
respectively, compared to 73%, 10%, 15% and 2%
respectively for the 135 males.
Perception of rejection in childhood and later rejection sensitivity
Across the two data bases, a personality style of
Ôrejection sensitivityÕ had been rated by the psychi-
atrist at clinical assessment, using a four-point
scale of presence and severity. Females who were
scored as moderately to severely high on Ôrejection
sensitivityÕ as adults were more likely to perceive
their mothers as ÔmoderatelyÕ to ÔseverelyÕ rejecting
during childhood (v2 = 8.71, df = 1, P = 0.003,
OR = 3.49, CI = 1.47–8.30,) and perceive their
fathers as ÔmoderatelyÕ to ÔseverelyÕ rejecting during
childhood (v2 = 9.65, df = 1, P = 0.002, OR =
3.37, CI = 1.52–7.44), as opposed to scoring their
mothers and fathers as Ônot trueÕ or Ôslightly trueÕ
on the question of being rejecting. Males showed
no such relationship between perceiving either
mother or father as rejecting during childhood
and later rejection sensitivity.
Predicting perception of parental rearing
To examine if perception of parental rearing was
dependant on the severity of current depression,
a multiple linear regression analyses examined
 Perception of rejecting and neglectful parenting in childhood

predictors of each continuous MOPS scale for Table 1. Previous suicide attempts (dichotomized as groups of ÔzeroÕ and Ôone or
moreÕ attempts) predicted by maternal and other study variables in multivariate
mother and father separately. Independent predic-
logistic regression analysis
tors were past week Hamilton scores and gender.
For perception of maternal indifference, the overall Estimate SE Wald P-value
model was significant (n = 343; summary of fit;
Intercept 0.668 0.612 1.183 0.28
R2 = 0.041; adjusted R2 = 0.035; F = 7.011; Age )0.026 0.011 6.285 0.012
df = 2; P = 0.001) but the only significant con- Past week HDRS 0.041 0.019 4.900 0.027
tributor to the model was gender (female sex) (B = Maternal indifference 0.078 0.036 4.662 0.031
)0.042
)1.79; SE = 0.50; t = )3.60; P = 0.000). HDRS Maternal abuse 0.049 0.731 0.39
Maternal overcontrol 0.051 0.045 1.290 0.25
severity scores did not reach significance (B = 0.035; Sex [1;2] )0.124 0.265 0.217 0.64
SE = 0.034; t = 1.05; P = 0.293). For perception Melancholia [0;1] )0.444 0.270 2.699 0.10
of maternal abuse, the overall model was also Rejection sensitivity [0;1] 0.245 0.266 0.850 0.36
significant (n = 343; summary of fit; R2 = 0.032; Analyses of log likelihood: v2 = 26.2; P = 0.004; Nagelkerke = 0.093.
adjusted R2 = 0.026; F = 5.436; df = 2; P =
0.005) with the only significant contributor again Table 2. Previous suicide attempts (dichotomized as groups of ÔzeroÕ and Ôone or
being gender (female sex) (B = )1.25; SE = 0.38; moreÕ attempts) predicted by paternal and other study variables
t = )3.25; P = 0.001). HDRS scores were again
Estimate SE Wald P-value
not a significant predictor (B = )0.012; SE =
0.026; t = )0.47; P = 0.64). Finally, for percep- Intercept 1.321 0.650 4.124 0.042
tion of maternal overcontrol the overall model Age )0.017 0.011 2.384 0.12
Past week HDRS 0.043 0.020 4.875 0.027
reached significance (n = 343, summary of fit; Paternal indifference 0.082 0.031 7.197 0.007
R2 = 0.022; adjusted R2 = 0.016; F = 3.77; df = Paternal abuse )0.059 0.042 1.958 0.16
2; P = 0.024) with the only significant contributor Paternal overcontrol 0.074 0.048 2.345 0.13
again being gender (female sex) (B = )1.06; SE = Sex [ 1;2] )0.296 0.266 1.236 0.27
Melancholia [ 0;1] )0.328 0.277 1.401 0.24
0.39; t-ratio = )2.72; P = 0.007). HDRS scores Rejection sensitivity [0;1] 0.363 0.279 1.692 0.19
again did not contribute to the model (B = )0.008;
SE = 0.026; t = )0.30; P = 0.76). Perception of Analyses of log likelihood: v2 = 24.4; P = 0.002; Nagelkerke = 0.018.
paternal rearing on all three MOPS scales could not
be predicted by the independent variables. variable were significant partial predictors
(P = 0.012, P = 0.027 and P = 0.031).
Table 2 shows previous suicide attempts (dichot-
Predicting suicide attempts
omized as groups of ÔzeroÕ and Ôone or moreÕ
To rule out collinearity problems between MOPS attempts) as predicted by eight independent clinical
Maternal and Paternal subscales (i.e. the risk that variables including perception of paternal rearing
there is a high correlation between Maternal and in a multiple logistic regression analysis. The
Paternal subscales and therefore a risk of interfer- overall model was significant (Nagelkerke =
ence between these scales in later regression anal- 0.108; n = 343; P = 0.002). Past week Hamilton
yses) the degree of Maternal – Paternal association scores and the paternal indifference variable were
for each of the three MOPS subscales was exam- significant partial predictors (P = 0.027 and
ined using Pearson correlation analyses. Modest P = 0.007).
maternal–paternal correlations were found for all
three subscales: maternal indifference and paternal
Predicting suicide attempts in relation to gender
indifference (r = 0.482; P < 0.01), maternal and
paternal abuse (r = 0.359; P < 0.01), maternal To examine possible gender differences, prediction
and paternal overcontrol (r = 0.304; P < 0.01). of previous suicide attempts (dichotomized as
As a result of these collinearity problems, maternal groups of ÔzeroÕ and Ôone or moreÕ attempts) was
and paternal MOPS subscales were analysed sep- examined for females only in a multiple logistic
arately in further regression analyses. regression analysis as predicted by the same
Table 1 shows previous suicide attempts (dichot- independent clinical variables (apart from
omized as groups of ÔzeroÕ and Ôone or moreÕ gender), firstly including perception of maternal
attempts) as predicted by eight independent clinical rearing as shown in Table 1 – that is, past week
variables including perception of maternal rearing Hamilton scores, the melancholic ⁄ non-melancholic
in a multiple logistic regression analysis. The distinction, age, Ôrejection sensitivityÕ, maternal
overall model was significant (Nagelkerke = indifference, maternal abuse and maternal
0.093; n = 343; P = 0.004). Age, past week overcontrol. The overall model was significant
Hamilton scores and the maternal indifference (v2 = 20.48; P = 0.005; Nagelkerke = 0.135;

53
Ehnvall et al.
n = 208;). Age, past week Hamilton score and the
maternal indifference variables were significant
partial predictors (Wald = 3.94; P =0.047;
Wald = 5.24; P = 0.022 and Wald = 5.40;
P = 0.020).
Prediction of previous suicide attempts (dichot-
omized as groups of ÔzeroÕ and Ôone or moreÕ
attempts) was then examined for females only in a
multiple logistic regression analysis as predicted by
the same independent clinical variables (except for
gender), this time including perception of paternal
rearing as shown in Table 2 – that is, past week
Hamilton scores, the melancholic ⁄ non-melancholic
distinction, age, Ôrejection sensitivityÕ, paternal
indifference, paternal abuse and paternal overcon-
trol. The overall model was highly significant
(v2 = 25.19; P = 0.001; Nagelkerke = 0.177;
n = 208). Past week Hamilton scores and the
paternal indifference variable were significant par-
tial predictors (Wald = 5.60; P = 0.018 and
Wald = 8.23; P = 0.004).
Following this, prediction of previous suicide
attempts (dichotomized as groups of ÔzeroÕ and
Ôone or moreÕ attempts) was examined in a multiple
logistic regression analysis for males only, firstly
including perception of maternal rearing. Indepen-
dent predictors were again past week Hamilton
scores, the melancholic ⁄ non-melancholic distinc-
tion, age, Ôrejection sensitivityÕ, maternal indiffer-
ence, maternal abuse, and maternal overcontrol.
The overall model was robustly non-significant,
(v2 = 3.601; P = 0.824; Nagelkerke = 0.041;
n = 135).
Finally, prediction of previous suicide attempts
(dichotomized as groups of ÔzeroÕ and Ôone or moreÕ
attempts) was examined in a multiple logistic
regression analysis for males only, this time
including perception of paternal rearing. Indepen-
dent predictors were again past week Hamilton
scores, the melancholic ⁄ non-melancholic distinc-
tion, age, Ôrejection sensitivityÕ, paternal indiffer-
ence, paternal abuse, paternal overcontrol. Again,
the overall model was robustly non-significant,
(v2 = 2.700; P = 0.911; Nagelkerke = 0.032;
n = 135).
The ratio of females who had made at least one
suicide attempt to females who had made no
suicide attempts over a lifetime was 69 : 139.
Univariate comparisons of these two groups
showed that females who has made at least one
suicide attempt over a lifetime had significantly
higher scores on the MOPS scale (i.e. a more
negative perception) on maternal indifference than
females who had no history of suicide attempts
(mean MOPS scores on maternal indifference:
5.10 ± 5.38 vs. 3.20 ± 4.68; Mann–Whitney test;
54
P = 0.039). Females who had made at least one
suicide attempt also had significantly higher scores
on the MOPS scales for paternal indifference than
females who had no previous suicide attempts
(mean MOPS scores on paternal indifference:
7.23 ± 5.94 vs. 4.28 ± 5.36; Mann–Whitney test;
P = 0.001).
The ratio of males who had made at least one
suicide attempt to males who had made no suicide
attempts over a lifetime was 36 : 99. Males who
had made at least one suicide attempt over a
lifetime did not have significantly higher scores on
the MOPS scale for maternal indifference or
paternal indifference than males with no history
of suicide attempts (maternal indifference: Mean
MOPS scores: 1.91 ± 3.12 vs. 2.05 ± 3.22;
Mann–Whitney test: P = 0.665; paternal indiffer-
ence: Mean MOPS scores: 5.63 ± 5.48 vs.
4.92 ± 5.30; Mann–Whitney test: P = 0.466).
Discussion
The principal finding of this study was that female
depressed patients who perceived themselves as
rejected or neglected by either parent in childhood
had a greater chance of committing at least one
lifetime suicide attempt. This is consistent with
earlier research where suicide attempts, as well as
suicidal thoughts, have been linked to a perception
of rejecting ⁄ neglecting parenting (4–6). The per-
ception of being rejected in childhood could
possibly lead to rejection sensitivity as an adult,
thereby making the individual less prone to
approach others to request or receive help when
suicidal. While the current study found this rela-
tionship of parental perception of rejection and
later rejection sensitivity to be true, the association
was restricted to females. Being sensitive to rejec-
tion could, when suicidal, increase isolation and
the perception of hopelessness, which has been
identified as a strong predictor of suicidal behav-
iour (20). The hypothesis that the perception of
rejecting parents in childhood is an important risk
factor for suicidal individuals is further supported
by results showing that merely keeping in touch
with vulnerable people by correspondence or by
telephone appears to reduce suicide rates (21, 22),
i.e. by helping these people approach others and
hereby receive help.
For males there was no relationship between
having felt rejected ⁄ neglected in childhood and
suicide attempts. This intriguing finding is in line
with findings amongst adolescents in relation to
suicide attempts (23). Structured qualitative inter-
views in suicidal adolescents showed females to be
more ÔblamingÕ towards both parents in correlation
 Perception of rejecting and neglectful parenting in childhood
to suicide attempts, whereas males were found to
be more idealizing of their parents in relation to
suicide attempts (23). These results are interpreted
as males being more dismissive of negative emo-
tions when compared with females and have been
replicated in several studies (24, 25). Females have
been shown to be more sensitive to rejection in
general when compared with males (26),which
could be explained by the same proposed under-
lying mechanism as above (i.e. females are more
sensitive towards negative situations and emotions,
and more readily phrase negative situations and
emotions such as ÔI am rejectedÕ, ÔI am not
wantedÕ). The current study also revealed specific
gender differences in the actual perception of
parents; depressed females perceived their mothers
in general in a significantly more negative way
compared to depressed males, whereas the percep-
tion of fathers did not differ between the sexes. In
relation to suicide attempts and actually committed
suicide, these proposed gender differences regard-
ing the observation and phrasing of negative
emotions may shed light on the fact that females
commit suicide attempts more often than males
(27), whereas males die from suicide more often
than females (28). It might well be that women
address negative life experiences and emotions
earlier in the suicidal process, when being more
ambivalent about dying, and therefore use less
lethal methods, which results in them more often
surviving the suicide attempt as compared to men.
On the other hand, men might, due to being more
dismissive of negative emotions, become aware of
their feeling of hopelessness later in the suicidal
process when ambivalence is low and therefore be
likely to use highly lethal methods and conse-
quently have a higher risk of dying.
In conclusion, this studyÕs findings support the
hypothesis that the perception of rejecting and
neglectful parents is a vulnerability factor for
lifetime suicide attempts. The distinct gender dif-
ference may reflect differences in the ways in which
men and women process negative emotions and
experiences. Most studies examining risk factors to
suicide focus on stressors occurring shortly before
suicide attempts – so-called ÔproximalÕ stress vari-
ables. Further research should seek to explore the
intriguing findings linking distal events and suicide,
and the even more intriguing gender differences.
Limitations
The study is a retrospective data base analysis and
therefore is subject to the potential limitations of
such studies. Specifically, data regarding percep-
tion of parental rearing may have been influenced
by several factors. Firstly, data regarding percep-
tion of parental rearing was obtained via self-
report questionnaires and not by interviews, and
there were no specific self-report questions on
memories of sexual abuse – only of perception of
verbal and physical abuse. Secondly, it is impor-
tant to consider the possibility of specific mood-
congruent memory bias associated with depression
(29). In this study, however, no correlation was
found between perception of parental rearing and
past week Hamilton scores, and other studies have
found similar results (3). Thirdly, retrospective
reports made in adulthood of major adverse
experiences in childhood, have been shown to
involve false negatives (30). In this case studying
perception of parental rearing might well be
studying present perception of parental rearing –
that is, studying not what actually happened
during childhood, but rather how it is remembered
today. The perception of parental rearing is still
worthwhile studying, however, if present percep-
tion and the specific way in which we remember
developmental issues can influence our vulnerabil-
ity to psychopathology (31).
Acknowledgements
We would like to thank the Gothenburg Medical Society, the
Swedish Medical Society and the Research Society in Halland
County, Sweden, for financial support of AE, and an Austra-
lian NHMRC Program grant (223708). Special thanks to
Christine Boyd (Black Dog Institute) for study assistance, and
to Hans Ågren for statistical advice.
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