Family Conflict and Suicidal Behaviour in Adolescence: The Mediating Role of the Assertive Interpersonal Schema

Round 1

Reviewer 1 Report

1. In the literature review section, please do an integrative literature view on the assertive interpersonal schema framework, given its central role in the empirical investigation that ensues. 

2. Please explain further why the age range of 14-18 was zoned in, rather than between 13-17 or a smaller interval. Entering college (usually around 18 in the U.S.) can be a stressful time and the external factor alone can contaminate the hypothesis that you seek to validate. Also, adolescence is a period where rapid changes occur. The broader the age range included, the more challenging it is to definitively conclude that family tensions/conflicts are the only or even the main factor that contributes to suicidal ideation. Please better discuss or address these concerns in the Introduction and Discussion sections. 

3. In section 2.21, please be specific about "The 116 Spanish adaptation of the PSS has demonstrated adequate psychometric properties" by reporting internal consistency in your current sample, validity from the test manual, and/or test-retest reliability.

4. Same applies to sections 2.22 and 2.23.

5. For Section 3.1, please succinctly describe what types of mediation analyses were performed, and using what program (e.g., Hayes' SPSS Macro, Sobel tests, SEM models, or some other approaches).

6. For Section 3.2, please explain the rationale for needing to perform a reverse mediation analysis. How does a reverse mediation analysis enhance the readers' understanding of the hypotheses? Please make the linkage explicit for the readers.  

7. The Discussion section can be more compact and needs to be condensed.

8. Please clarify "Along similar lines, a recent meta-analysis [21] showed that adolescents with a history of suicide attempts presented more parental-related stress" in terms of the directionality of the effects--i.e., does family conflicts cause suicidal behaviors or the causal direction is inconclusive? If the latter, can you provide evidence to buttress that if there is indeed a mediational linkage among the variables you tested, the direction of influence is likely to flow from what you specified in your original hypothesis? If no experimental studies exist, please do a comprehensive review of the literature and deduce that relationship based on theories and prior empirical results. Then, point the readers to the future directions of follow-up studies. 

 

Author Response

We thank the reviewer for the detailed feedback on our manuscript, providing constructive comments and specific suggestions for the study, which we believe have helped us to improve the manuscript. In addition to clarifying each point, you can find the changes highlighted in yellow in the manuscript.

 

1.1 In the literature review section, please do an integrative literature view on the assertive interpersonal schema framework, given its central role in the empirical investigation that ensues. 

Thanks for the suggestion. We have added information that, along with the explanation already provided on the importance of the assertive interpersonal schema in dealing with conflicts, we consider that it frames the phenomenon under study (lines 62 - 72).

“For many adolescents, conflict in the family may overwhelm their coping mechanisms, making those with poorer coping skills particularly vulnerable [21]. Healthy development and adjustment are related to the ability to establish positive social interactions with peers and adults [28]. One important variable associated with healthy social relationships is assertiveness, defined as the ability to express opinions and needs, respecting the opinions and needs of others [29]. Assertiveness is associated with cognitive interpretations of the social world, including one's views of oneself and others and the interactions between the two [30]. These cognitive interpretations are interpersonal schemas, defined as beliefs associated with interpersonal events and relationships. Moreover, the assertive interpersonal schema could be viewed as the personal ability to understand interpersonal conflicts as normal and manageable [31].”

1.2. Please explain further why the age range of 14-18 was zoned in, rather than between 13-17 or a smaller interval. Entering college (usually around 18 in the U.S.) can be a stressful time and the external factor alone can contaminate the hypothesis that you seek to validate. Also, adolescence is a period where rapid changes occur. The broader the age range included, the more challenging it is to definitively conclude that family tensions/conflicts are the only or even the main factor that contributes to suicidal ideation. Please better discuss or address these concerns in the Introduction and Discussion sections. 

Thank you for your comment and thoughtful contribution, which helped us detect a typo. The age we mean was adolescents from 14 until 18, being the correct age range 14-17. We have fixed it in the manuscript. This range has been chosen because these are the ages when secondary school is attended in Spain (line 103).

“Most of the target population agreed to participate (98.71%) and the final study sample comprised 229 participants (52.8% boys, Mage = 15.76 years; SD = 1.24, range = 14-17).”

1.3. In section 2.21, please be specific about "The 116 Spanish adaptation of the PSS has demonstrated adequate psychometric properties" by reporting internal consistency in your current sample, validity from the test manual, and/or test-retest reliability.

1.4. Same applies to sections 2.22 and 2.23.

We answer here to question 3 and 4. Thank you for this suggestion. As you recommended, we have added the Cronbach’s alpha of our current sample for each measure (lines 118, 126 and 134)

“2.2.1. Paykel Suicide Scale (PSS)

[...] In this sample, the Cronbach’s alpha is 0.66.

2.2.2. Strategic Family Evaluation (EFE)

[...] In this sample, the Cronbach’s alpha for family conflict is 0.86.

2.2.3. Assertive Interpersonal Schema Questionnaire (AISQ)

[...] In this sample, the Cronbach’s alpha is 0.90.”

5. For Section 3.1, please succinctly describe what types of mediation analyses were performed, and using what program (e.g., Hayes' SPSS Macro, Sobel tests, SEM models, or some other approaches).

You can find the information in section 2.4. We have added the model to clarify (lines 148 - 150).

“Simple mediation analyses were performed using Model 4 of the PROCESS macro, which is an interface applied to SPSS to conduct ordinary least squares (OLS) and logistic regression path analysis modeling [39].

6. For Section 3.2, please explain the rationale for needing to perform a reverse mediation analysis. How does a reverse mediation analysis enhance the readers' understanding of the hypotheses? Please make the linkage explicit for the readers.  

Thanks for your question and the opportunity to clarify this. We have rephrased the information in section 2.4 in order to facilitate readers' understanding of the hypotheses (lines 163 - 165).

“Due to the cross-sectional nature of the data prevents the establishment of causal relationships, reverse models were also conducted for each outcome variable to evalu-ate the hypothesized models’ specificity [40].

7. The Discussion section can be more compact and needs to be condensed.

We appreciate your suggestion. We are aware of the value of condensing the information. However, we consider the importance of the discussion since it is the place where we reflect on our findings. If the editor has no problem, we prefer to keep it and thus maintain its richness.

8. Please clarify “Along similar lines, a recent meta-analysis [21] showed that adolescents with a history of suicide attempts presented more parental-related stress” in terms of the directionality of the effects—i.e., does family conflicts cause suicidal behaviors or the causal direction is inconclusive? If the latter, can you provide evidence to buttress that if there is indeed a mediational linkage among the variables you tested, the direction of influence is likely to flow from what you specified in your original hypothesis? If no experimental studies exist, please do a comprehensive review of the literature and deduce that relationship based on theories and prior empirical results. Then, point the readers to the future directions of follow-up studies. 

Thanks for your suggestion, we understand the doubts that have arisen. However, our study does not intend to study causality since such complex phenomena are beyond the scope of our research. Nor are there any related experimental studies in the literature.

 

Reviewer 2 Report

The relevance of the study is beyond doubt. Indeed, suicidal behavior of adolescents is a serious problem. And, as it is well known, family conflicts is one of the factors affecting suicidality and other behavioral problems in adolescence. It can also be assumed that assertiveness opposes suicidal tendencies. But the authors' claim that the cause of assertiveness is family conflicts is very controversial. The opposite statement is more plausible. Assertiveness is an individual, personal disposition, while family conflict, as well as suicidality, belong to more volatile states. Thus, it is more plausible to consider assertiveness not as a mediator, but as a moderator of the influence of family conflict on suicidality.

A simple example based on correlations from Table 2. The correlation of Family Conflict (FC) and Suicidal Thoughts (PSS-SI) is 0.21 and statistical significant. Simple calculations show that the partial correlation FC and PSS-Si, taking into account the influence of the AISQ-total (moderator), is approximately 0.14, i.e. significantly less and hardly statistically significant.

Thus, this study, correlative in its design, does not allow us to state with any certainty about the direction of the relationships between variables that the authors suggest.

Author Response

We thank the reviewer for the suggestion and hope to have clarified the doubts. We have responded with the relevant information and the location, which can be found highlighted in yellow in the manuscript as well.

 

2.1 The relevance of the study is beyond doubt. Indeed, suicidal behavior of adolescents is a serious problem. And, as it is well known, family conflicts is one of the factors affecting suicidality and other behavioral problems in adolescence. It can also be assumed that assertiveness opposes suicidal tendencies. But the authors' claim that the cause of assertiveness is family conflicts is very controversial. The opposite statement is more plausible. Assertiveness is an individual, personal disposition, while family conflict, as well as suicidality, belong to more volatile states. Thus, it is more plausible to consider assertiveness not as a mediator, but as a moderator of the influence of family conflict on suicidality.

A simple example based on correlations from Table 2. The correlation of Family Conflict (FC) and Suicidal Thoughts (PSS-SI) is 0.21 and statistical significant. Simple calculations show that the partial correlation FC and PSS-Si, taking into account the influence of the AISQ-total (moderator), is approximately 0.14, i.e. significantly less and hardly statistically significant.

Thus, this study, correlative in its design, does not allow us to state with any certainty about the direction of the relationships between variables that the authors suggest.

We thank the reviewer for his contributions and suggestions. We would like to point out that our study does not present causal relationships, but to establish associations. We apologize if it was not clear enough. In addition, you can find this reflection in the limitations (lines 296 and 297).

“Our study does have some limitations. Firstly, it was a cross-sectional study, and causal and temporal associations cannot be established.”

 

Reviewer 3 Report

Dear Authors

The article is presented in a clear, relevant and well-structured manner.

Cited references are mostly recent publications (within the last 5 years) and relevant. It does not contain many self-citations.

The manuscript is scientifically sound and the design is suitable for hypothesis testing.

The results of the article can be reproduced according to the details given in the methods section.

The conclusions are consistent with the evidence and arguments presented.

 

The ethics statements and data availability statements are available.

You should describe relevant dates, including periods of recruitment.

You should add explanation for PROCESS macro model.

You should explain your survey language. You should give references for scales validity and reliability study for adolescents in survey language.

The authors should edit references that are not in English.

For Example

[Empirically Supported Psychological Treatments for Children and Adolescents: State of the Art]. Psicothema. 2021 Aug;33(3):386-398. Spanish. doi: 10.7334/psicothema2021.56. PMID: 34297668

Best wishes

 

Author Response

We would like to thank the reviewer for the suggestions on our manuscript, which we believe have helped us to improve our work. In addition to clarifying each of the points, you can find the changes highlighted in yellow in the manuscript.

 

3.1 The article is presented in a clear, relevant and well-structured manner. Cited references are mostly recent publications (within the last 5 years) and relevant. It does not contain many self-citations. The manuscript is scientifically sound and the design is suitable for hypothesis testing. The results of the article can be reproduced according to the details given in the methods section. The conclusions are consistent with the evidence and arguments presented. The ethics statements and data availability statements are available.

We appreciate your assessment of these points in the manuscript.

3.2 You should describe relevant dates, including periods of recruitment.

We appreciate the reviewer recommendation. We have added the information (line 103).

“Data was collected during 2019-2020 academic year.”

3.3 You should add explanation for PROCESS macro model.

Thank you for your suggestion. We have added the following information in section 2.4. (lines 148 – 149) of the manuscript.

“Simple mediation analyses were performed using Model 4 of the PROCESS macro, which is an interface applied to SPSS to conduct ordinary least squares (OLS) and logistic regression path analysis modeling [39].”

3.4 You should explain your survey language. You should give references for scales validity and reliability study for adolescents in survey language.

Thanks for the recommendation. Now, we have included the information (lines 106 – 108).

“An ad hoc questionnaire in Spanish was administered to collect sociodemographic information (age, sex, ethnicity, school year). The following instruments were used to collect specific data.”

3.5 The authors should edit references that are not in English.

We apologize for the mistake. Now, we have edited references that were not in English (lines 341 - 478).

“Al-Halabí, S.; García Haro, J. M.; Gutiérrez López, B. Tratamientos psicológicos para la conducta suicida en niños y adolescentes [Psychological treatments for suicidal behavior in children and adolescents.]. In Manual de tratamientos psicológicos: Infancia y adolescencia [Psychological treatment manual: Childhood and adolescence.]. Fonseca-Pedrero, E. Coord.; Ediciones Pirámide: Madrid, Spain, 2021; pp. 577 – 609.

Instituto Nacional de Estadística [National Statistics Institute]. Defunciones según la causa de muerte [Defunctions according to cause of death] [Database] 2022. https://www.ine.es/jaxiT3/Tabla.htm?t=7947

Fonseca Pedrero, E.; Pérez-Albéniz, A.; Al-Halabí, Suicidal behavior in adolescents under review: fostering hope through action. Psychologist Papers 2022, 43, 173-184; DOI:10.23923/pap.psicol.3000.

Al Halabí, S.; García Haro, J. M. Tratamientos psicológicos para la conducta suicida [Psychological treatments for suicidal behavior]. In Manual de tratamientos psicológicos: Adultos [Psychological Treatment Manual: Adults]; E. Fonseca-Pedrero (coord). Pirámide: Spain, 2021; pp. 639-670.

Fonseca-Pedrero, E.; Pérez-Álvarez, M.; Al-Halabí, S.; Inchausti, F.; López-Navarro, E. R.; Muñiz, J.; Lucas-Molina, B.; Pérez-Albéniz, A.; Baños Rivera, R.; Cano-Vindel, A.; Gimeno-Peón, A.; Prado-Abril, J.; González-Menéndez, A.; Valero, A. V.; Priede, A.; González-Blanch, C.; Ruiz-Rodríguez, P.; Moriana, J. A.; Gómez, L. E.; Navas, P., … Montoya-Castilla, I. Tratamiento Psicológicos Empíricamente Apoyados Para la Infancia y Adolescencia: Estado de la Cuestión [Empirically Supported Psychological Treatments for Childhood and Adolescence: State of the Field]. Psicothema, 2021, 33, 386-398. DOI:10.7334/psicothema2021.56.

Bousoño Serrano, M.; Al-Halabí, S.; Burón, P.; Garrido, M.; Díaz-Mesa, E. M.; Galván, G.; García-Álvarez, L.; Carli, V.; Hoven, C.; Sarchiapone, M.; Wasserman, D.; Bousoño, M.; García-Portilla, M. P.; Iglesias, C.; Sáiz, P. A.; Bobes, J. Substance use or abuse, internet use, psychopathology and suicidal ideation in adolescent. Adicciones 2017, 29, 97–104; DOI:10.20882/adicciones.811.

Fonseca-Pedrero, E.; Inchausti, F.; Pérez-Gutiérrez, L.; Solana, R. A.; Ortuño-Sierra, J.; Lucas-Molina, B.; Domínguez, C.; Foncea, D.; Espinosa, V.; Gorría, A.; Urbiola-Merina, E.; Fernández, M.; Merina Díaz, C.; Gutiérrez, C.; Aures, M.; Campos, M. S.; Domínguez-Garrido, E.; de Albéniz Iturriaga, A. P. Suicidal ideation in a community-derived sample of Spanish adolescents. Journal of Psychiatry and Mental Health 2017, 11, 76-85; DOI:10.1016/j.rpsm.2017.07.004.

Morell-Gomis, R., García, J. A., Gázquez, M.; García, Á. Cuestionario para la evaluación de variables familiares relacionadas con el consumo de drogas en estudiantes universitarios [Questionnaire for the evaluation of family variables related to drug use in university students]. Salud y Drogas 2011, 11, 143-162.

Cañón Buitrago, S. C.; Carmona Parra, J. A. Ideation and suicidal behaviors in adolescents and young. Revisión Pediátrica en Atención Primaria 2018, 20, 387-395.”

 

Reviewer 4 Report

It is an interesting topic with an importan stigma. Authors are brave to develop it which is verye relevant.

It is perfect in all aspect.

Congratulations

Author Response

4.1 It is an interesting topic with an importan stigma. Authors are brave to develop it which is verye relevant. It is perfect in all aspect. Congratulations

Thank you for taking the time to read this manuscript. We appreciate your review and your kind words.

Round 2

Reviewer 1 Report

The manuscript has addressed the concerns previously raised.

Author Response

We thank the Reviewer for his work and evaluation of the manuscript.

Reviewer 2 Report

The answers to my questions/comments in the previous review are not entirely convincing. Before testing the hypothesis of the intermediary role of "assertive interpersonal schemes", it is necessary to present convincing arguments that "conflicted families" affects a) "rigid interpersonal schemes", and b) "suicidal behavior". It is recommended to supplement the literary review with such argumentation.

Author Response

We thank the reviewer for the thoughtful comments, and for giving us the opportunity to resubmit a new version of the manuscript. Changes on the manuscript can be found highlighted in yellow.

The answers to my questions/comments in the previous review are not entirely convincing. Before testing the hypothesis of the intermediary role of "assertive interpersonal schemes", it is necessary to present convincing arguments that "conflicted families" affects a) "rigid interpersonal schemes", and b) "suicidal behavior". It is recommended to supplement the literary review with such argumentation.

We appreciate the reviewer's suggestion. As recommended, we have added information and new references of studies supporting our argumentation and hypothesis (lines 56 - 83). We hope that these changes ease the understanding of the Introduction section.

Understanding suicidal behaviour in adolescence requires considering the quality of parent-child relationships [22]. Family conflict is one of the most widely studied [23] since it is associated with a higher likelihood of suicidal ideation [24] and has been found to be one of the most consistent, robust factors related to suicidality and other behavioural problems during adolescence [25, 26]. Similarly, the family component is an essential aspect in managing this problem in the adolescent population [15, 10, 27], being a key element in evidence-based interventions such as Dialectical Behavior Therapy [28], and also having a crucial role in implementing suicide-prevention strategies outside of treatment [29].

For many adolescents, conflict in the family may overwhelm their coping mechanisms, making those with poorer coping skills particularly vulnerable [21]. Moreover, a negative interpretation of these conflicts, in which there is a pessimistic view of the course of family events, may influence the adolescent's well-being and distress reaction in the following disputes [30, 31], being associated this distress to suicidal behavior [32]. One important variable associated with healthy social relationships is assertiveness, defined as the ability to express opinions and needs, respecting the opinions and needs of others [33]. Assertiveness is associated with cognitive interpretations of the social world, including one's views of oneself and others and the interactions between the two [34]. These cognitive interpretations are interpersonal schemas, defined as beliefs associated with interpersonal events and relationships. In this vein, the rigidity of schemas and limited responses are related to interpersonal problems [35], and interpersonal misperception [36], constituting a risk factor for psychological distress [37]. In contrast, the assertive interpersonal schema could be viewed as the personal ability to understand interpersonal conflicts as normal and manageable [38]. The assertive interpersonal schema has been studied in relation to other adolescent problems, such as teen dating violence [39], however, no studies have specifically examined this variable in relation to suicidal behaviour. The influence of the cognitive aspect of assertiveness could be important because the interpretation of social interactions has a relevant role in adolescents’ psychosocial adjustment [40, 41].

Thank you again for your attention to this manuscript.

Author Response File: Author Response.pdf

Round 3

Reviewer 2 Report

Doubts remain about the direction of cause-and-effect relationships. In particular, "the assertive interpersonal schema", as a more stable personality trait, can hardly be a consequence of "family conflict". Rather, on the contrary, "the assertive interpersonal schema" affects the features of the manifestation of family conflicts. Nevertheless, I consider it is possible to publish the article, since the authors took into account most of my comments.