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The impact of fathers' physical and psychosocial work conditions on attempted and completed suicide among… Aleck, Ostry; Stefania, Maggi; James, Tansey; James, Dunn; Ruth, Hershler; Lisa, Chen; Amber, Louie; Clyde, Hertzman Mar 27, 2006

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ralssBioMed CentBMC Public HealthOpen AcceResearch articleThe impact of fathers' physical and psychosocial work conditions on attempted and completed suicide among their childrenOstry Aleck*1, Maggi Stefania2, Tansey James3, Dunn James4, Hershler Ruth1, Chen Lisa1, Louie Amber1 and Hertzman Clyde1Address: 1Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada, 2University College of the Cariboo-Thompson Rivers University, Kamloops, Canada, 3Oxford University, Oxford, UK and 4University of Toronto, Toronto, CanadaEmail: Ostry Aleck* - ostry@interchange.ubc.ca; Maggi Stefania - smaggi@tru.ca; Tansey James - james.tansey@sbs.ox.ac.uk; Dunn James - jim.dunn@utoronto.ca; Hershler Ruth - hershler@interchange.ubc.ca; Chen Lisa - lisachen@interchange.ubc.ca; Louie Amber - ammlouie@interchange.ubc.ca; Hertzman Clyde - clyde.hertzman@ubc.ca* Corresponding author    AbstractBackground: Adverse employment experiences, particularly exposure to unemployment and thethreat of unemployment, have been strongly associated with several adverse mental and physicalhealth outcomes including suicide. However, virtually no research has been conducted on thetrans-generational impact of parental working conditions on attempted or completed suicideamong their children.Methods: We conducted a nested case control study based on a cohort, gathered in the westernCanadian province of British Columbia, of male sawmill workers and a second cohort of theirchildren. Physical and psychosocial work conditions to which fathers were exposed during the first16 years of their children's lives, measured using the demand/control model, were linked to hospitalsuicide records (attempted and completed) among their children.Results: Two hundred and fifty children in the cohort attempted or committed suicide between1985 and 2001. Multivariate models, with partial control for father's mental health outcomes priorto their child's suicide demonstrate, 1) a strong association between low duration of father'semployment at a study sawmill and attempted suicide for their male children, 2) elevated odds forattempted suicide among female children of fathers' employed in a sawmill job with low controland, 3) a strong association between fathers in jobs with low psychological demand and completedsuicides among male children.Conclusion: Exposure of fathers to adverse psychosocial work conditions during the first 16 yearsof their children's life was associated with greater odds for attempted and completed suicide amongtheir children.Background been associated with a range of adverse mental and phys-Published: 27 March 2006BMC Public Health2006, 6:77 doi:10.1186/1471-2458-6-77Received: 06 December 2005Accepted: 27 March 2006This article is available from: http://www.biomedcentral.com/1471-2458/6/77© 2006Aleck et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 9(page number not for citation purposes)Adverse employment experiences, particularly exposure tounemployment and the threat of unemployment, haveical health outcomes [1-3] including suicide [4-6]. How-ever, virtually no research has been conducted on theBMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77trans-generational impact on the health of their childrenof adverse parental working conditions.Exposures to varying socio-economic circumstances, dur-ing childhood and beyond, constitutes a unique "lifeexposure trajectory," which will manifest as differentexpressions of health and well-being over the life-course[7]. The possible long-term exposure/expression relation-ships can be conceptualized in three generic models:latency, cumulative, and pathway. Latency refers to relation-ships between an exposure at one point in the life courseand a health outcome years or decades later, irrespectiveof intervening experience. Cumulative refers to multipleexposures over the life course whose effects on healthcombine. These may be either multiple exposures to a sin-gle recurrent factor (e.g., chronic poverty) or a series ofexposures to different factors. Finally, pathways aredependent sequences in which an exposure at one stage ofthe life course influences the probability of other expo-sures later in the life course, which are the proximatecauses of disease expression [7-13].While this framework is useful to describe the biologicalmechanism by which the impacts of adverse family socio-economic environments might act to affect the health ofchildren, it tells us little about which dimensions of fam-ily socio-economic environment may be most salient.Research conducted over the past 75 years has shown thatparental access to employment (or lack thereof) directlyimpacts the psychological health, behaviour, and educa-tional outcomes of their children likely through the"sequential effects on parents' job-related affect andparenting behaviours" [14-17].In order to test the possibility that exposure of parents toadverse employment conditions may impact their chil-dren's mental health status, unusual data sets are requiredwhich bring together occupational exposure informationfor the parent(s) and mental health outcome data for theirchildren. Over the past 15 years we have gathered a cohortof approximately 30,000 sawmill workers in BritishColumbia (BC) and a second cohort consisting of theirchildren with the appropriate data elements in place toconduct this type of study. The purpose of this paper isinvestigate the impact of fathers' psychosocial and physi-cal work conditions during the first 16 years of their chil-dren's life on attempted and completed suicides amongtheir children, during childhood through to middle-adult-hood.Individuals exposed to adverse socio-economic circum-stances during childhood tend to be less healthy later inent in well-designed longitudinal studies across manyphysical health outcomes into adulthood (e.g., self-reported health, coronary heart disease, body mass index,and other chronic conditions) [18-24]. These results alsohold for a range of psychological and behavioural out-comes [18,25]. And, the way in which such exposures inchildhood might manifest in later adverse health out-comes has biological plausibility [7].In a literature originating in the Great Depression of the1930s and continuing through to the present, adversefamily income and employment circumstances have beenlinked to negative mental health, behavioural, and physi-cal health outcomes among children. Several studies haveshown that major family income losses between 1929 and1933 increased the emotional instability of fathers but notmothers [26,27]. These studies indicate that male reactionto income loss was increased anger and a tendency forfathers to be punitive and arbitrary when discipliningtheir children [14,15,28].After a hiatus of five decades, several American and Cana-dian studies were conducted on the impacts of family jobinsecurity on children's mental health outcomes andschool-related problems [16,17]. Most of this researchidentified an association between father's punishing andrejecting behaviours and adverse school behaviours andacademic outcomes among their children [29,30]. Anumber of researchers have further postulated that paren-tal punishing behaviour predicts externalizing behaviours(i.e., anger-based acting out behaviours) in their childrenwhereas parental rejecting behaviours predict internalizedsymptoms (i.e. depression and anxiety) [31].Only one study was found that explored the link betweenthe psychosocial work conditions experienced byemployed fathers and outcomes among their children. Inthis Canadian study, conducted among 189 grade 4 and 5students, utilizing Karasek's demand/control model,Stewart and Barling [17] demonstrated that fathers psy-chosocial conditions at work influenced their parentingbehaviours, which in turn affected their children's' behav-iour.These studies indicate first, that father's work may have agreater influence on children's behaviour and educationaland health outcomes than mother's work. Second, theyindicate that the potential pathway linking father's workconditions to their children's health may be throughaltered parenting behaviour, in particular, more disciplin-ing and authoritarian behaviours meted out to childrenwhen fathers come under pressure at work.Page 2 of 9(page number not for citation purposes)life compared to individuals who experienced a moreadvantaged childhood. This relationship appears consist-The present study investigates the impact of fathers' psy-chosocial and physical work conditions on attempted andBMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77completed suicides in a cohort of children residing mainlyin rural forest-industry dependent communities in theprovince of British Columbia in Western Canada.MethodsThis study is based on a cohort of male sawmill workersfor whom we have obtained data on their history ofunemployment and physical and psychosocial work con-ditions. Using birth files from the provincial vital statisticsregistry, we developed a second cohort consisting of mostof their children. This cohort was linked to the BC LinkedHealth Database (BCLHDB) in order to obtain attemptedand completed suicide outcomes. Ethical approval wasobtained from the University of British Columbia and theBC Ministry of Health to conduct this study.A) The original cohortThe original cohort was gathered in order to conduct anoccupational study on the effects of chlorophenol anti-sapstain exposure among BC sawmill workers. We identi-fied 14 sawmills located in BC and accessed personnelrecords for workers who had worked, for at least one year,in one of these mills anytime between 1950 and 1998.The cohort consists of 28,794 males. Personal identifyinginformation for eligible workers and complete job historyrecords were abstracted from personnel records (SeeHertzman et al. [32] for a complete description of meth-ods used to assemble this cohort).B) Exposure assessmentFrom the job history records we obtained the number ofepisodes of unemployment, job mobility (classified asupward, downward or stable), and occupation (manager,skilled trades, machine operator, or unskilled). Weobtained historical estimates of job control, demands,noise, and social support in two ways: 1) 4 experiencedjob evaluators (two union and two management) in theBC sawmill industry filled out the demand/control ques-tionnaire to obtain a retrospective estimation for all basicjob titles prior to 1975 (See Ostry, Marion, & Green et al.[33], for these methods); 2) a panel of senior workers wasselected in each mill and filled out Karasek's question-naire for basic job titles in their mill for two time periods(1975 to 1985), (1985 to 1998) (See Ostry, Marion &Green et al. [34], for these methods). These expert esti-mates for control, psychological demand, physicaldemand, social support, and noise were then applied tothe job history database in the fathers' cohort.C) The children's cohortThe cohort of adult sawmill workers was linked to the BCbirth file in order to identify all of the children of theseworkers born in British Columbia between 1952 and2000 (see Dimich-Ward et al. [35] for these methods).There were 37, 827 children in the cohort of whom19,833 satisfied our eligibility criteria (i.e. father had atleast one year of work in a study sawmill while their childor children were aged 0 – 16).D) The dependent variablesUsing probabilistic linkage techniques the children'scohort was linked to the BC Linked Health Database(BCLHDB), consisting of person-specific, longitudinalrecords on all British Columbians (see Hertzman et al.[32] for these methods. We were able to link 88 percent ofthe members of the children's cohort to the BCLHDB.These files contain data on deaths, hospital discharges,and other medical encounters for the years 1985 throughto 2001. The records are stored separately but have beenindexed with an individual service-recipient-specific codeso that the records of groups of individuals can be linkedacross files for specific research projects.A Data Access Subcommittee consisting of health ministrypersonnel, staff from the BC Ministry of Information andPrivacy, and the Centre for Health Services and PolicyResearch has been established to handle requests for link-age to the BCLHDB and to ensure that such requests meetscientific and ethical standards, are in the public interest,and conform with the Freedom on Information and Pro-tection of Privacy Act.Using ICD9 codes available in the hospital discharge data-base we were able to identify any suicide case (completedand attempted) that occurred between Jan 1985 andMarch 31st, 2001. A suicide case was defined as anyonewith a hospital discharge or death record coded with ICD9code 950 to 950.9.E) Building the exposure fileWe determined children's exposure to adverse familysocio-economic circumstances by applying father's expo-Table 1: Attempted and completed suicides by gender among members of the children's cohort from 1985 to 2001Suicides Male Female Unknown gender TotalCompleted 20 (77%) * 4 (15%) 2 (8%) 26 (100)Attempted 81 (35.8%) 145 (64.2%) 226 (100)Total 101 (40.1) 149 (59.1) 2 (0.8) 252 (100)Page 3 of 9(page number not for citation purposes)* Numbers in parentheses are row percentsBMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77sure (in terms of job mobility, unemployment experience,and exposure to control, psychological demand, physicaldemand, social support, and noise) during each year ofthe child's life from age zero to the end of their 16th birth-day.F) Case control analysisCases were identified for each completed and attemptedsuicide. Using survival-time to case-control on STATA 8.0,three controls were selected for each case matched on ageand gender. Controls were chosen randomly with replace-ment from the set at risk. The set at risk were all the chil-dren in the cohort, born between 1952 and 1998, whosefather worked in a study sawmill for at least one year dur-ing the first 0–16 years of the child's life. These could beanyone at risk who also satisfied the matching criteriawho had not attempted suicide at the time of diagnosis ofthe case.Other socio-demographic characteristics of father's thatwere available in the cohort database and, potentially ofimportance in relation to children's suicides, were father'smarital status (married, divorced, widowed, or single) andrace (East-Indian, Chinese and other). As well, we wereable to determine, from the BCLHDB, whether a fatherhad a completed or attempted suicide, mental healthdiagnosis, or alcohol-related mental health diagnosis,prior to their child's attempted or completed suicide.Statistical analyses were conducted using conditionallogistic regression on STATA 8.0. Univariate models werefirst run with each independent variable. Multivariatemodels were developed in three steps. Father's socio-nosis, or alcohol-related mental health diagnosis prior totheir child's suicide attempts or completion were control-led. Fathers' occupation at the time prior to their child'ssuicide was added to the final model.ResultsOf the 19,833 children in the cohort, 252 attempted orcommitted suicide between 1985 and 2001 (Table 1).Approximately three quarters of children completing sui-cide were male whereas approximately two-thirds of chil-dren attempting suicide were female. More children ofunmarried fathers attempted and completed suicide com-pared to children of married fathers and, more children ofCaucasian fathers attempted or completed suicide com-pared to children of non-Caucasian fathers (Table 2).For male and female children, univariate results show thatfather's marital and ethnic status was not associated withattempted suicide. For males, father's prior diagnosis foran alcohol-related mental health condition was associ-ated with elevated odds for their child's attempted suicide.For females, father's prior diagnosis for a mental healthcondition was associated with elevated odds forattempted suicide (Table 3).Additionally, for males, father's employment in anunskilled sawmill job prior to their child's suicide wasassociated with increased odds for their child's attemptedsuicide. Lower duration of employment at a sawmill wasalso associated with elevated odds for attempted suicidefor male children. Univariate analyses demonstrated thatfathers' lower duration of employment at a sawmill, lowcontrol and high physical demand were also associatedTable 2: Socio-demographic and occupational characteristics of the fathers of case and control childrenIndependent Variables Attempted SuicidesCompleted SuicidesCases Controls Cases ControlsFather's Marital Status% Unmarried (N) 13.9 (29) 8.0 (50) 12.5 (3) 8.0 (6)% Married (N) 86.1 (179) 92.0 (572) 87.5 (21) 92.0 (69)Father's Ethnicity% Caucasian (N) 88.1 (199) 85.3 (578) 88,5 (23) 69.2 (54)% Sikh (N) 10.6 (24) 13.3 (90) 11.5 (3) 25.6 (20)% Chinese or Other Asian (N) 1.3 (3) 1.5 (10) 0 5.1 (4)Father's Occupational Status% Manager (N) 6.2 (14) 6.9 (47) 3.8 (1) 5.1 (4)% Tradesman (N) 30.1 (68) 34.5 (234) 26.9 (7) 39.7 (31)% Skilled (N) 17.7 (40) 19.8 (134) 30.8 (8) 19.2 (15)% Unskilled (N) 46.0 (104) 38.8 (263) 38.5 (10) 35.9 (28)Father's average duration (years) of employment at sawmill (sd) 5.7 (4.1) 6.8 (4.1) 5.8 (3.9) 7.9 (3.9)Father's average # of episodes of unemployment (sd) 1.05 (1.2) 1.12 (1.3) 1.08 (1.23) 1.14 (1.34)Page 4 of 9(page number not for citation purposes)demographic characteristics were controlled for in model1. In the second step, father's suicide, mental health diag-with elevated odds for attempted suicide among femalechildren. Univariate analyses also demonstrated that maleBMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77children of tradesmen had significantly lower odds forattempted suicide relative to other occupations (Table 3).As only 4 female children completed suicide univariatemodels were not run for female children. For male chil-dren, univariate models demonstrated no associationbetween father's socio-demographic status and completedsuicide. Further, univariate models showed associationwith completed suicide except for low psychologicaldemand which was associated with elevated odds forcompleted suicide (OR = 0.46; CI = 0.26–0.79; p = 0.00).Fully controlled multivariate models demonstrate astrong association between low duration of father'semployment at a study sawmill and attempted suicide formale children. (Table 4). Fully controlled multivariatemodels demonstrate that elevated odds for attempted sui-cide among female children is associated with prior men-tal health diagnosis for their fathers and employment in asawmill job with low control (Table 5). Finally, fully con-trolled models indicate that father's employment in a jobwith low psychological demand is associated with ele-vated odds for completed suicides among male children(Table 6).DiscussionFour main results arise from this study. First, even afterpartially controlling for the impact of a father's own his-Table 3: Univariate models for attempted suicides among children of sawmill workers during the first 16 years of the child's life.Independent Variables Males FemalesFather's ethnicity (ref = Caucasian)Sikh .42 (.16,1.12)* (.08)** 1.0 (.58,1.73) (1.0)Chinese 1.0 (.10,.88,1.14) (.95) .85 (.17,4.31) (.84)Father's marital status (ref = married) 1.00 (.88,1.14) (.95) .97 (.88,1.07) (.52)Father's suicide attempt *** 3.0 (.61,14.86) (.18) -Father's mental health diagnosis 1.42 (.79,2.57) (.24) 1.97 (1.19,3.25) (.01)Father's alcohol diagnosis 3.75 (1.00,13.96) (.05) 1.5 (.45,4.98) (.51)Father's Occupational Status (ref = manger)Tradesman .56 (.32,1.0) (.05) .99 (.66,1.49) (.96)Skilled 1.0 (.52,1.91) (1.0) .80 (.49,1.32) (.39)Unskilled 1.84 (1.08,3.14) (.03) 1.17 (.79,1.73) (.43)Father's average duration (years) of employment at sawmill .92 (.86,.97) (.00) .95 (.91,.997) (.04)Father's average # of episodes of unemployment .92 (.75,1.13) (.42) .97 (.84,1.13) (.72)Psychosocial and physical work conditionsControl .94 (.86,1.02) (.14) .92 (.86,.99) (.03)Psychological demand .91 (.78,1.07) (.27) .99 (.88,1.12) (.86)Physical demand 1.55 (.86,2.80) (.14) 1.60 (1.00,2.57) (.05)Social support .88 (.59,1.3) (.52) .95 (.70,1.29) (.75)Noise .80 (.46,1.39) (.43) 1.02 (.62,1.68) (.93)* 95% Confidence intervals; ** p-value; ***data are missing as no father attempted or completed suicide prior to their female child's suicide attempt.Table 4: Multivariate models for attempted suicides among male children of sawmill workers during the first 16 years of the child's lifeIndependent Variables Model 1 Model 2 Model 3Father's ethnicity (ref = Caucasian)Sikh .55 (.20,1.53)* (.25)** .58 (.21,1.63) (.30) .52 (.18,1.49) (.22)Chinese 1.05 (.11,10.32) (.96) 1.09 (.11,10.7) (.94) 1.12 (.11,11.47) (.92)Father's marital status (ref = married) .98 (.86,1.11) (.73) .96 (.85,1.1) (.59) .95 (.83,1.08) (.44)Father's suicide 1.98 (.36,10.93) (.43) 1.75 (.31,9.94) (.53)Father's mental health diagnosis 1.26 (.65,2.45) (.50) 1.26 (.65,2.47) (.49)Father's alcohol diagnosis 3.58 (.87,14.71) (.08) 3.68 (.87,15.50) (.08)Father's Occupational Status (ref = manger)Tradesman 1.03 (.29,3.69) (.96)Skilled 1.48 (.41,5.36) (.55)Unskilled 1.83 (.55,6.12) (.33)Father's average duration (years) of employment at sawmill .92 (.87,.98) (.01) .92 (.86,.98) (.01) .93 (.87,1.00) (.05)Page 5 of 9(page number not for citation purposes)* 95% Confidence intervals; ** p-value.BMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77tory of mental health, male children of fathers with lowduration of employment at a study sawmill while theirchild or children were less than age 16 had a greater oddsof attempting suicide than children of fathers with highduration of employment. Second, female children offathers who experienced low job control during the first16 years of their child's life had significantly greater oddsfor attempting suicide. Third, after partially controlling forfather's history of mental illness and other potential con-founders, male children of fathers employed in jobs withlow psychological demand showed significantly greaterodds for completing suicide.These results indicate that adverse work conditions forfathers experienced while their children are growing upmay have serious psychological outcomes for these chil-dren. This investigation also shows that the impact offathers' work experience may differ for males and femalesin relation to attempted suicide. This is consistent with theliterature which shows that economic downturns mayimpact mental health outcomes among children and thatthe impact may differ for boys and girls [15].Most of the children in this investigation were resident insmall rural resource dependent communities in BritishColumbia during their childhood. Given that resourcedependent communities in British Columbia have beenexposed to continuous and intensive restructuring anddownsizing since the early 1980s, these children may havebeen particularly "at risk" for adverse mental health out-comes including suicide. Research from Australia, Nor-way, and the United Kingdom have found the largestTable 5: Multivariate models for attempted suicides among female children of sawmill workers during the first 16 years of the child's lifeIndependent Variables Model 1 Model 2 Model 3Father's ethnicity (ref = Caucasian)Sikh .86 (.49,1.54)* (.63)** .73 (.14,3.77) (.70) .76 (.15,3.96) (.74)Chinese .85 (.13,3.33) (.61) .73 (.14,3.77) (.70) .76 (.15,3.96) (.74)Father's marital status (ref = married) .96 (.87,1.06) (.43) .97 (.87,1.07) (.52) .96 (.87,1.07)(.49)Father's Occupational Status (ref = manger)Tradesman .76 (.31,1.85) (.54)Skilled .53 (.20,1.40) (.20)Unskilled .45 (.16,1.22) (.12)Father's average duration (years) of employment at sawmill .96 (.91,1.01) (.09) .96 (.91,1.01) (.10) .95 (.90,1.00) (.06)Psychosocial and physical work conditionsControl .95 (.88,1.02) (.15) .95 (.88,1.02) (.20) .90 (.81,.99) (.04)Physical 1.31 (.77,2.22) (.32) 1.37 (.80,2.36) (.25) 1.51 (.82,2.76) (.18)Father's suicide *** - -Father's mental health diagnosis 1.95 (1.13,3.37) (.02) 2.01 (1.16,3.49) (.01)Father's alcohol diagnosis .93 (.22,3.87) (.92) .82 (.19,3.50) (.79)* 95% Confidence intervals; ** p-value; ***data are missing as no father of a female child who attempted suicide had attempted or completed suicide prior to their child's attempt.Table 6: Multivariate model for completed suicides among male children of sawmill workers during the first 16 years of the child's lifeIndependent Variables Model 1 Model 2 Model 3Father's ethnicity (ref = Caucasian)Sikh .37 (.04,3.37)* (.38)** .33 (.04,3.08) (.33) .36 (.03,4.56) (.43)Chinese*** - - -Father's marital status (ref = married) 1.13 (.78,1.61) (.52) 1.13 (.76,1.67) (.56) 1.23 (.76,1.98) (.40)Father's suicide - - -Father's mental health diagnosis .11 (.01,1.42) (.09 .12 (.01,1.42) (.09) .13 (.01,1.47) (.10)Father's alcohol diagnosis **** - - -Father's Occupational Status (ref = manger)Tradesman .82 (.05,13.78) (.89)Skilled 3.14 (.17,57.56) (.44)Father's average duration (years) of employment at sawmill .98 (.86,1.13) (.82) .99 (.86,1.14) (.89)) .97 (.80,1.16) (.71)Psychosocial and physical work conditionsPsychological demand .53 (.30,.95) (.03) .40 (.18,.90) (.03) .42 (.20,.98) (.04)Page 6 of 9(page number not for citation purposes)* 95% Confidence intervals; ** p-value; ***data are missing as no Chinese fathers had a male child who completed suicide; ****data are missing as no father of a case or control had an alcohol-related mental health diagnosis.BMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77increases in suicide rates for young adults since the 1970soccurred among residents in rural regions [36-41].There are several limitations to this study. First, the litera-ture indicates that an important mediating factor betweenlow family social economic circumstances during child-hood and future health status of the children may befather's parenting behaviour. However, much of the evi-dence (but not all) for this was obtained in studies datingfrom the 1930s and the 1980s when father's role as bread-winner was more prominent than at present. Today, withfemale labour force participation rates approaching thoseof males, it is much more important to understand bothmothers and fathers employment circumstances in rela-tion to their children's health.We have no data on mother's employment circumstancesin this study. This limitation may be ameliorated to someextent because the investigation was conducted both his-torically and in a labour market characterized by fairly"traditional" gender roles. Thus, father's employmentconditions were likely, given the context of this particularstudy, to have in fact been more important than the moth-ers'.Second, data on place of residence for children was notavailable. These analyses assume that children residedwith their fathers while he was working at a study millduring his children's first 16 years of life. However, it isquite likely that divorces took place and some of thesechildren were residing with their mothers and thereforeunder-exposed to adverse paternal work circumstancesduring their childhood. Given that the socio-economicrange within this fairly homogenous group of sawmillworkers was fairly narrow it is unlikely that divorce ratesdiffered systematically for cases and controls.Third, we were able to link 88 percent of the children tothe BCLHDB. Most of the 12 percent of children in thecohort who we were unable to link to the BCLHDB werelikely younger healthy children who had not yet had con-tact with hospitals or physicians. Given that very youngchildren are unlikely to attempt or commit children thiswill not bias our study. However, to the extent that we didnot link to older children, because they were healthyenough to have avoided the healthcare system and there-fore not be present in the BCLHDB, this could have intro-duced bias to slightly strengthen the observed associationsin this study. Given the relatively high probabilistic link-age efficiency in this study this is likely to be of minimalconcern.Fourth, the study is based on cases admitted to acute-carefacilities. As well, some people who attempted suicidemay not present to physicians and may not even acknowl-edge their attempts to friends and family so that someunknown number of attempted suicides will have beenmissed in this study. However, given that the mentalhealth care system in the province is heavily weightedtowards hospital care, it is likely that only a very fewattempted suicides would have been missed.Fifth, the average age of men in the fathers cohort wouldhave been about 50 years in 1985, the date when informa-tion on their mental health outcomes became available.This means that suicide and mental health outcomes thatoccurred when these men were younger, prior to 1985,were not recorded. This means that our statistical adjust-ment for father's suicides, alcohol-related mental healthand other mental health outcomes are only partial. Fulladjustment for father's mental health status (i.e., adjust-ment taking account of mental health events going backto father's childhoods) may slightly attenuate theobserved associations between psychosocial work condi-tions and their children's suicide outcomes.A strength of this investigation arises because of the com-plex data sets developed including the ability to control,at least partially, for the impact of father's history of men-tal health prior to an attempted or completed suicide bytheir child. In order to move these kinds of trans-genera-tional analyses forward, unusual data sets of this type arerequired.Furthermore, a full history of employment for fatherswould have been ideal for use in this study. We only hadfather's employment while employed in a study sawmill.But, we applied fathers sawmill employment exposure toa specific window of time during their children's lives (i.e.,during their first 16 years). Thus, we have utilized the datain a way that is consistent with the now well developedmodels of the importance of exposure to adverse socio-economic conditions early in life. This too is a strength ofthe analytical approach taken in this investigation.ConclusionUsing a unique data set, this investigation builds upon anolder literature that has linked paternal exposure toadverse employment conditions during the early stages oftheir children's lives to adverse mental health outcomesamong these children. While this earlier literature focusedmainly on paternal exposure to unemployment this inves-tigation has also demonstrated that prolonged exposureof children to adverse paternal psychosocial work condi-tions may also be implicated in suicide outcomes for thesechildren.Page 7 of 9(page number not for citation purposes)and to psychiatric hospitals across BC. It does not recordadmissions for attempted suicide at community treatmentBMC Public Health 2006, 6:77 http://www.biomedcentral.com/1471-2458/6/77AbbreviationsBC = British ColumbiaBCLHDB = British Columbia Linked Health DatabaseICD = International Classification of DiseaseOR = Odds RatioCI = 95% Confidence IntervalCompeting interestsThe author(s) declare that they have no competing inter-ests.Authors' contributionsASO guided the analyses, developed the methods, anddrafted the paper. JT helped guide the analysis and aidedin writing the paper. SM guided the analysis and aided inwriting the paper. JD aided in the analysis RH conductedthe analysis. LC conducted the analysis. AML conductedand wrote the literature review. CH guided the analysis,and developed the methods. All authors read andapproved the final manuscript.AcknowledgementsThis work was funded by the Canadian Population Health Initiative. 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