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Understanding adolescent responses to differently worded suicide attempt questions

Article in Review: Hatkevich, C., Grupp-Phelan, J., Brent, D., Barney, B.J., Casper, T.C., Melzer-Lange, M. C, Wik, M… & King.C.A. (2020). Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample. Psychological Medicine,


Could the language we use to describe suicide risk and behaviour influence how conversations on the topic are interpreted and understood? A recent study has suggested this might be the case. The study confirmed that young people respond differently to differently phrased questions related to suicide attempts.

Communicating about suicide
The discussion of suicide is likely to be deeply embedded within cultural and societal norms. There is no previous research conducted to assess whether young people respond differently when questions about suicide attempts are phrased directly or indirectly. By extension, there is also no research that considers whether the social demographic background of a young person may have a relationship with how questions about suicide attempts are understood and endorsed.

What we do already know, however, from broader research on cross-cultural communication is that some cultures prefer direct and explicit verbalisations while Chinese and Hispanic cultures tend to involve more indirect language and more emphasis on nonverbal cues and exchanges. These communication tendencies have been considered in relation to discussions about mental health, with best practices strategies for dealing with cultural differences often forming part of training for professionals in the field. One notable example is the recommendation to use metaphors and proverbs during therapy support sessions with people from Latino backgrounds.

This study attempted to address the gap in the research to better understand how young people respond to differently phrased questions, with the intent to carry out suicide risk assessments that a young person can most easily identify with and understand.

Participants and method
A sample group of young people aged 12-17 years was recruited upon presentation to 13 pediatric emergency departments between 2015 and 2017. Criteria for inclusion in the study included that the young person is English-speaking and is medically stable. Demographic data considered in the analysis included:
• Age
• Sex at birth
• Ethnicity/race
• Mother’s education
• Father’s education
• Current public assistance
• Mental health service history and variables

The young people were also assessed using the Columbia Suicide Severity Rating Scale, (C-SSRS) and responses to two questions as part of this assessment were a key focus of the analysis. All responses to these two questions were recorded as a dichotomous yes or no. The questions were:
• A direct question- have you ever in your life made a suicide attempt?
• An indirect question- have you ever in your life tried to harm outsell because you were at least partly trying to end your life?

A majority of participants responded consistently to both questions about previous suicide attempts. The high degree of consistency in response to the differently worded questions may imply that young people perceived the questions to be related to the same behaviours.
• 83.75% reported no to both questions
• 10.1% reported yes to both questions
• 6.2% reported a discordant respondent, answering yes to one question and no to the other

Further insights from the study
Assessing the data found that multiple demographic and mental health service usage variables predicted discordant responses to the questions when variables were considered concurrently.

Sex at birth and father/ stepfather’s education were significant predictors of endorsement of only the directly phrased item when including mental health variables. Specifically, females were twice as likely to a ensures the direct item only and young people whose fathers or stepfathers had less than high school or completion of high school were twice as likely to endorse the direct statement only.

Young people were more likely to endorse only the indirect item if they had a history of receiving therapy or counselling.

Learning and future opportunities
A small but statically useful subsample of survey respondents provided inconsistent answers to the questions related to a suicide attempt. It is acknowledged that multiple factors may contribute to the participants providing different answers; their own academic attainment, comprehension or linguistic preferences. A tentative correlation could be that young people who are the children of fathers or stepfathers with low academic attainment may have difficulties fully understanding an indirect question.

Young people with more experience in mental and public health systems and those who had received mental health support or therapy might be more likely to answer no to the direct question because they fear a yes answer might lead them to be hospitalised or admitted and more ‘risky’ than endorsing an indirect question.

There is plenty of work to be done to explore how we should describe and discuss suicide with young people from diverse cultural and linguistic backgrounds.

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