Review Reports - Association of Adverse Childhood Experiences with Non-Suicidal Self-Injury and Suicidality: Baseline Survey of the Chinese Adolescent Health Growth Cohort

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a manuscript that addresses the relationship between ACE and NSSI and suicidal behaviors mediated by symptoms of depression and anxiety.

The introduction justifies the study due to the lack of research on the subject in low- and middle-income countries. He argues that there could be cultural differences between high-income countries and low- and middle-income countries without further arguing.

Making the introduction in a single paragraph prevents identifying the most important arguments for doing the study. It is necessary to give more arguments for the study and improve the writing in the section.

It is essential to include the public policies implemented in the study sites to contain the covid-19 epidemic, particularly if the study regions were in lockdown or with limitations imposed on usual life.

Regarding the method, there are problems with the content. Line 87 mentions that the study was done in 2020, while line 91 mentions that it was done in 2021. The justification for including three sites for the study is not clear, nor is it clear how they were selected. It is necessary to clarify the universe of schools in the three sites, of which only 11 were selected. It is necessary to clarify whether the researchers were related to the schools at the research sites.

Regarding the instrument used, CTQ cites the original version of 70 items , when the 28- item version was used in the study . It is necessary to cite the relevant reference for the instrument used. The dollar amount of reported household income must be noted as a footnote.

The inclusion of adolescent tobacco use as an indicator of parental substance abuse is highly speculative. I do not consider it adequate, since the consumption of tobacco by adolescents is a risk factor associated with the behaviors evaluated, as has been widely reported in various studies ( for instance, Turecki et al., 2019). Frankly, its inclusion is not supported and can cause problems in the interpretation of the results.

Review the results, as there are typographic omissions.

In the discussion, I expected more reflection of the results based on possible cultural differences between high-income countries, compared to low- and middle-income countries (as anticipated in the introduction). Sadly, no reflection on this was included. The authors must include this.

It is essential to include in the discussion the possible effect of the covid-19 pandemic on the prevalence of NSSI and suicidal behaviors, depression and anxiety. It is reported that the covid epidemic increased the prevalence of mental health problems and suicidal behavior in different countries. This itself may be a limitation of the study (according to the rationale of the manuscript and not as a strength as considered by the authors).

Author Response

Dear Reviewers,

Thank you for providing us this opportunity to further revise our manuscript entitled “Association of adverse childhood experiences with non-suicidal self-injury and suicidality: Baseline survey of the Chinese Adolescent Health Growth Cohort” (future-2561500).

On behalf of my colleagues, I am submitting our revised manuscript. We appreciate the editor’s and the reviewer’s positive and insightful comments. We have carefully considered all the comments and revised the manuscript accordingly. In order to facilitate the review process, we provided a point-by-point response to each of the comments as you kindly requested. Changes made in response to the comments have been highlighted in yellow in our revised manuscript. The precise line in the revised manuscript where each change was made in response to the comments were provided as well.

We hope that the manuscript could be finally accepted by Future. Should you have any additional requests or questions, please do not hesitate to contact me.

We look forward to hearing from you.

Yours sincerely

Jie Tang, MD, PhD

On behalf of all co-authors

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study focuses on a crucial topic given the increased prevalence of non-suicidal self-injury and suicidality during the global COVID-19 pandemic and its implications for public health. It also contributes to understanding how a broader range of adverse childhood experiences affects adolescents' socioemotional adjustment.

Nevertheless, several structural changes are necessary in both the introduction and discussion sections to make the manuscript's publication possible. Of note, there is a lack of reflection on the pandemic context's influence on the target variables, which is a severe weakness. Furthermore, minor revisions in the remaining sections, along with grammatical edits, should also be considered. I have detailed my concerns section by section for clarity.

Abstract

The abstract could benefit from including information about the adolescents' gender, as well as the mean and standard deviation of their age. Additionally, it should specify the names of the questionnaires used to assess non-suicidal self-injury, suicidal ideation, suicide attempts, anxiety, and depressive symptoms. Usually, only significant statistical associations between variables are reported in this section, rendering the description of adjusted odds ratios unnecessary. Finally, consider adding a sentence on the practical implications of the study at the end of the abstract.

Introduction

The introduction needs further elaboration. Specifically, a more detailed analysis of the existing research on (i) the associations of adverse childhood experiences with depressive and anxiety symptoms, (ii) the associations of adverse childhood experiences with suicidality, and (iii) the associations of depressive and anxiety symptoms with suicidality would enhance its organization and clarity.

Additionally, there is a significant gap in this section, as the impact of the COVID-19 pandemic on the study's target variables is not explored thoroughly. While the authors state that an increase in non-suicidal self-injury and suicidality was observed during the pandemic, they do not provide additional evidence to support this assertion. Further analysis of the pandemic's context is needed. It would be relevant to include information on the containment measures implemented during data collection, the modality of adolescents' class attendance (in-person or online), and how the pandemic affected their socioemotional functioning and adjustment, especially concerning the study's target dimensions.

Materials and Methods

Separating the description of the participants and the procedure (incorporating subsections concerning participants' recruitment and data collection) into distinct subsections would clarify methodological issues. Including the "participants' characteristics" in the methodological section, rather than in the results section, would be beneficial. Moreover, information on the temporal context in which participants completed the questionnaires is crucial, as data were collected during the pandemic.

Consider replacing "measurement" with "measures" (line 117), which is more commonly used.

Clearly identify the target population and the objectives of the questionnaires used to measure anxiety and depressive symptoms.

Results

The authors use "sex" and "gender" interchangeably, which is unclear. Specify whether the variable considered was biological sex or the gender with which the adolescents identified themselves.

Discussion

Although the authors mention that their findings are useful for exploring associations between the target variables during the COVID-19 pandemic, they do not reflect on the pandemic's effects. This is a significant weakness, as the detrimental impact of the COVID-19 pandemic on adolescents' mental health is widely supported.

Lines 62-67 are redundant, as results regarding associations of childhood adverse experiences with non-suicidal self-injury, suicidality, and mediation effects are already described in specific subsections.

Regarding the study's limitations, it may not be possible, even with a longitudinal design, to establish linear causal relationships, due to the complexity of the target constructs. Consider adding a conclusion section that focuses on the clinical, social, and political implications of the study to highlight its relevance.

Comments on the Quality of English Language

A grammatical revision is needed.

Author Response

Dear Reviewers,

We hope that the manuscript could be finally accepted by Future. Should you have any additional requests or questions, please do not hesitate to contact me.

We look forward to hearing from you.

Yours sincerely

Jie Tang, MD, PhD

On behalf of all co-authors

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper, which sets out to investigate the associations between ACEs, NSSI and suicidality among children and adolescents.

The abstract should be within 200 words. I understand there is much information to be conveyed. Some information may need to be simplified. The reporting for mediation are rather confusing. May I suggest that the abstract is rewritten to reflect the results accurately, and that the mediation results are not lumped together?

The introduction is written in one paragraph, and focusses on the research gap. I would like to suggest to provide some background. To what extent is this a problem? Why is this a problem among Chinese adolescents?

Also, to rewrite the introduction by providing some definitions. It is not clear, in line 49-50, the risk factors are for..?

It is unclear why depressive and anxiety symptoms are mediators, perhaps more literature could be provided.

In line 75, the aim of the study was stated, and the target population was stated to be children and adolescents. However, in the methods section, it is stated that the sample comprised seventh grade students. Sorry, I am not familiar with the Chinese education system, I believe these are adolescents? Finally, in line 228-229, it was stated the adolescents ranging from 11 to 16 years old. Thanks for clarifying.

It would be good to separate the data collection and study participants, so that more information could be provided for the sample. for example the inclusion and exclusion criteria.

How were the investigators identified and trained?Physical examinations were made. What data were collected through physical examinations, and what type of physical examinations were carried out?

More information is needed for the emotional management ability scale and social support.

Some spelling mistakes in 2.2.3, should be CES-D

Line 208, did the authors mean conceptual framework?

In Table 1, it is not clear why participants were analysed based on sex (please use sex exclusively in the manuscript, rather than interchangeably with gender). Some indication should be provided in the text that this is important and perhaps is a part of the study objective?

Perhaps some of the content in discussion, such as definitions, and past studies that justified the study, could be reflected in the introduction.

Please have a concluding paragraph summarising the most important study findings

The results of depressive symptoms and anxiety symptoms as mediators are explained in one paragraph. It would be good to organise this section in a meaningful way and present them systematically, so as to convey the importance of the findings.

It would be a waste not to have an implications section for the findings. I think these findings are important, and would like to suggest how specifically the results could be important for this population in China. Thank you.

Comments on the Quality of English Language

Perhaps the authors could engage a language editor.

Author Response

Dear Reviewers,

We hope that the manuscript could be finally accepted by Future. Should you have any additional requests or questions, please do not hesitate to contact me.

We look forward to hearing from you.

Yours sincerely

Jie Tang, MD, PhD

On behalf of all co-authors

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors made some changes to the manuscript. Comments on the methodology and results were addressed.

However, some aspects were left unattended.

The introduction argues that there could be cultural differences between high-income countries and low- and middle-income countries in ACE and NSSI and suicidal behaviors without further discussion. This also happened in the discussion of the findings. They included only one sentence about it, without argumentation or references in it.

The modifications made caused a large number of typos. There are countless middle dashes in inappropriate places in various paragraphs.

Author Response

Reviewer 1

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

While I acknowledge the authors' commendable efforts in enhancing the manuscript's quality, particularly in the realm of methodology, I continue to observe significant weaknesses in the introduction and discussion. There remains a need for additional evidence to support the study's objectives and hypothesis, as well as a clear definition of the target constructs. The absence of a reflection on the effects of the pandemic also represents a substantial gap. Consequently, significant revisions are still required to render the manuscript suitable for publication. As in my initial review, I have organized my comments section by section to enhance clarity.

Abstract

The revised version of the abstract now incorporates the previously omitted details about the participants and the instruments used. The presentation of the results has also been improved, although there is a need for greater concision in this regard. Moreover, a sentence addressing the practical implications of the study is still missing.

Introduction

While there have been improvements in both the structure and content of this section, I believe it still requires further elaboration and reorganization, particularly regarding the dimensions highlighted during the initial review: (i) the impact of adverse childhood experiences on the development of depressive and anxiety symptoms, (ii) the associations of adverse childhood experiences with suicidality, and (iii) the connections between depressive and anxiety symptoms and suicidality. Additionally, the analysis of the effects of the COVID-19 pandemic remains somewhat superficial, which presents a notable deficiency in this section.

Furthermore, in addition to the mentioned issues, there is a need for a clear definition of the target constructs (i.e., non-suicidal self-injury, suicidal ideation, suicidal attempts, and adverse childhood experiences). Additionally, the exploration into the theoretical framework upon which these definitions are founded is needed.

Materials and Methods

The revisions carried out by the authors have improved the clarity and informativeness of this section. However, in line with my previous suggestions, it would be important to incorporate a description of the sample in this section since it only addresses the participants’ recruitment. Additionally, please note that the section labeled 'Study's participants' seems to pertain to 'Participants' selection,' which is typically expected to be part of the Procedure section (usually including two subsections: participants' selection and data collection). Typically, the first subsection of the methodological section contains a description of the participants, including their sociodemographic characteristics. Therefore, I maintain the perspective that it would be highly advantageous to add a description of the participants' sociodemographic characteristics within the Method section while retaining the presentation of descriptive statistics related to ACE, depressive and anxiety symptoms, emotional management ability, and social support within the Results section.

Discussion

Although the participants attended schools situated in regions with a low risk of COVID-19 transmission, it is important to acknowledge that they were still exposed to the broader pandemic context and its adverse consequences, particularly concerning mental health. Indeed, several studies have reported an increase in anxiety and depressive symptoms associated with the pandemic context. Therefore, it is imperative to take these effects into account in the discussion.

Conclusion

While the authors have included a section in the revised version of the manuscript that focuses on the practical implications of the study, I still believe that further exploration of these practical implications would significantly enhance the quality of the manuscript, due to the clinical relevance of the study's target constructs.

Comments on the Quality of English Language

A grammatical revision is still needed.

Author Response

response letter

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript again. I find that the authors have sufficiently addressed my concerns. However, there is a minor editorial detail, which is that the abbreviations used in tables should be explained by a note. Tables should be understood independently, and common readers may not understand what SA, SI, ACE, NSSI are. The full terms should be reflected in the footnote. Thank you.

Author Response

response letter

Author Response File: Author Response.pdf

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

This revised version of the manuscript meets the criteria needed for publication. The authors have made substantial efforts to address the theoretical and methodological weaknesses identified in previous revisions. However, I have a few minor suggestions to enhance both the theoretical framework and the methodology.

In the introduction, the authors have significantly improved this section by further exploring the association of adverse childhood experiences with both suicidality and symptoms of anxiety and depression. Nonetheless, I still believe that providing clear definitions of the target constructs would be helpful.

In the method, the changes made by the authors have improved the clarity and informativeness, especially in the description of the participants. However, data collection is usually presented after describing the measures in the procedure section.

As for the discussion, the authors have acknowledged the potential impact of COVID-19 on the socioemotional adjustment of adolescents."

Comments on the Quality of English Language

Moderate editing of English language required

Author Response

Please see attached document.

Author Response File: Author Response.pdf