Professional Documents
Culture Documents
To cite this article: Shane Shucheng Wong , Jeanelle J. Sugimoto-Matsuda , Janice Y. Chang &
Earl S. Hishinuma (2012) Ethnic Differences in Risk Factors For Suicide Among American High
School Students, 2009: The Vulnerability of Multiracial and Pacific Islander Adolescents, Archives
of Suicide Research, 16:2, 159-173, DOI: 10.1080/13811118.2012.667334
Download by: [Colorado State University] Date: 22 June 2017, At: 08:57
Archives of Suicide Research, 16:159173, 2012
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2012.667334
Ethnic Differences in
Risk Factors For Suicide
Among American High
School Students, 2009: The
Vulnerability of Multiracial
and Pacific Islander
Adolescents
Shane Shucheng Wong, Jeanelle J. Sugimoto-Matsuda,
Janice Y. Chang, and Earl S. Hishinuma
This study compared self-reported risk factors for suicide among American high
school students in the last decade. Data from the 19992009 Youth Risk Behavior
Surveys was analyzed by 8 self-reported ethnicity groups across 6 suicide-related
items: depression, suicide ideation, suicide planning, suicide attempts, and suicide
attempts requiring medical attention). Native Hawaiian=Pacific Islander adolescents
had the higher prevalence of risk factors for suicide. Multiracial adolescents were also
at high risk for suicide-related behaviors, with a risk comparable to American
Indian=Alaska Native adolescents. Overall, Native Hawaiian=Pacific Islander,
multiracial, and American Indian=Alaska Native adolescents reported a signifi-
cantly higher risk for suicide-related behaviors compared to their Asian, Black,
Hispanic, and White peers. The ethnic disparities in risk factors for suicide dictate
a need to understand the vulnerability of the Pacific Islander, American Indian, and
growing multiracial adolescent populations, in an effort to develop and implement
suicide prevention strategies.
Keywords adolescence, ethnic differences, high school students, mental health, minority health,
risk factors, suicide
159
Ethnicity and Adolescent Suicidality
suicide completion. These thoughts and 14.6 million in the United States (United
behaviors are important to assess beginning States Census Bureau, 2010). Due to gener-
in adolescence, given that depression at an ally low rates of health-risk behaviors
early age of onset is a significant predictor reported for aggregated API youth, includ-
of suicide completion, the probability of ing a recent study on risk factors for
transitions from suicide ideation and plans suicide, this population has been described
to attempts is high, and as one of the stron- as a model minority groupimplying that
gest predictors of future completed suicide, API adolescents do not require targeted
suicide attempts tend to peak between 16 support for success in society (Centers for
and 18 years of age (Gould, Greenberg, Disease Control and Prevention, 2009;
Velting et al., 2003; Kessler, Borges, & Grunbaum, Lowry, Kann et al., 2000;
Walters, 1999; Mann, Waternaux, Haas Schuster, Bell, Nakajima et al., 1998). How-
et al., 1999). ever, conclusions drawn from such research
Unfortunately, little is known about are likely to be misleading given the hetero-
suicide risk factors among ethnic minorities geneity of the population. Recent studies on
(Colucci & Martin, 2007). In particularly, the disaggregated API population have
an emerging issue is the prevalence of indeed shown that the prevalence of
health-risk behaviors among multiracial health-risk behaviors differ significantly
youth, a minority population of 6.8 million between Asians and Pacific Islanders (Choi,
according to the 2000 Census and currently 2008; Sasaki & Kameoka, 2009).
the fastest-growing demographic group in The few studies on suicide among Pacific
the United States (United States Census Islanders have reported elevated suicide rates
Bureau, 2001, 2010). A growing literature compared to their peers in the United States
attests empirically to the emotional-, (Booth, 1999; Wong, Klingle, & Price, 2004;
health-, and behavior-risk problems of this Yuen, Andrade, Nahulu et al., 1996). More
population, including substance abuse and recent studies within the State of Hawaii sug-
violence (Choi, Harachi, Gillmore et al., gest that suicidal thoughts and behaviors are
2006). However, other studies have indeed significantly higher among Native
demonstrated conflicting findings with no Hawaiian adolescents compared to their
elevation of risk behaviors among multi- non-Hawaiian peers (Else, Andrade, &
racial youth (Danko, Miyamoto, Foster Nahulu, 2007; Yuen, Nahulu, Hishinuma
et al., 1997; Johnson & Nagoshi, 1986). et al., 2000). On the other hand, the risk fac-
Furthermore, very few studies investigating tors for suicide among the Asian American
risk factors for suicide among multiracial population appears lower, although the litera-
adolescents were found. These investiga- ture is not entirely conclusive (Evans, Haw-
tions, based on data a decade or more ton, Rodham et al. 2005; Kisch, Leino, &
ago, suggest that multiracial adolescents Silverman, 2005; Shiang, Binn, Bongar et al.,
are at an elevated risk for suicide (Olvera, 1997). To date, no studies on risk factors for
2001; Roberts, Chen, & Roberts, 1997; suicide using national samples of disaggre-
Udry, Li, & Hendrickson-Smith, 2003; gated Asian and Pacific Islander adolescents
Whaley & Francis, 2006). There has yet have been reported.
to be any national studies comparing multi- In 1999, the Centers for Disease
racial adolescents to their peers on a range Control and Prevention (CDC) began cod-
of suicide risk factors, including suicide ing Asians and Native Hawaiians=Pacific
attempts. Islanders as two separate ethnic categories
Another important issue is the ethnic for the Youth Risk Behavior Survey
disaggregation of the Asian and Pacific (YRBS), and introduced the multiple
Islander (API) populations, which numbers (Hispanic) and multiple (non-Hispanic)
ethnic groups. We test the hypothesis that Latino constituted the Multiracial non-
multiracial and Pacific Islander adolescents Hispanic group. Ethnicity categories will
are at significantly higher risk for suicide in henceforth be abbreviated to American
comparison to their peers. Indian, Asian, Black, Hispanic, Multiracial
(Hispanic), Multiracial (Non-Hispanic),
Pacific Islander, and White.
METHODS
Sample Description
Risk Factors for Suicide. Five YRBS ques-
tions concerning different risk factors for
Demographic and suicide-related
suicide were recoded into 6 responses each
response data were utilized from the
with a binary answer:
1999, 2001, 2003, 2005, 2007, and 2009
YRBS, a nationally representative survey
of high school students administered every 1. Depression: During the past 12
2 years. A total of 88,532 school question- months, did you ever feel so sad or
naires were completed by students from hopeless almost every day for two
1999 to 2009. Table 1 presents the sample weeks or more in a row that you
description. The average age of respon- stopped doing some usual activities?
dents was 16.2 years old. Yes, No.
2. Suicide ideation: During the past 12
months, did you ever seriously consider
Measures
attempting suicide? Yes, No.
3. Suicide planning: During the past 12
Demographics. Gender, grade level, year months, did you make a plan about
and ethnicity were provided by the data. how you would attempt suicide? Yes,
In the 1999 to 2003 surveys, ethnicity was No.
identified by responses to the following 4. Suicide attempt: During the past 12
question: How do you describe yourself? months, how many times did you actu-
Respondents were allowed to select one or ally attempt suicide? 0 times, 1 time, 2
more answers from six response options: or 3 times, 4 or 5 times, 6 or more
American Indian or Alaska Native, Asian, times. To calculate the prevalence of
Black or African American, Hispanic or suicide attempts, the response choices
Latino, Native Hawaiian or Other Pacific were recoded into binary choices: 0
Islander, or White. In the 2005 to 2009 times were recoded as 0, and 1 or
surveys, this question was broken down more times was recoded as 1.
into two questions: Are you Hispanic or 5. Severe suicide attempt among all youth:
Latino? and What is your race? For If you attempted suicide during the
the latter, respondents were allowed to sel- past 12 months, did any attempt result
ect more than one answer from the five in an injury, poisoning, or overdose that
response options: American Indian or had to be treated by a doctor or nurse?
Alaska Native, Asian, Black or African The three choices were: Did not
American, Native Hawaiian or Other attempt suicide, Yes, and No. To
Pacific Islander, or White. Students who calculate the prevalence of severe sui-
checked Hispanic=Latino and one or more cide attempts requiring medical atten-
other responses comprised the Multiracial tion, Did not attempt suicide and
Hispanic group, and students who checked No were recoded as 0, and Yes
more than one response but not Hispanic= was recoded as 1.
Ethnicitya
American Indian 1,053 1.2 0.9
Asian 2,953 3.4 3.3
Black 19,597 22.4 14.2
Hispanic 17,242 19.8 10.3
Multiracial (Hispanic) 5,975 6.8 4.6
Multiracial (Non-Hispanic) 2,589 3.0 4.2
Pacific Islander 770 0.9 0.8
White 37,114 42.5 61.7
Genderb
Female 44,833 50.8 49.3
Male 43,366 49.2 50.7
Grade Levelc
9th Grade 21,741 24.7 29.0
10th Grade 21,825 24.8 26.1
11th Grade 22,313 25.3 23.4
12th Grade 22,153 25.2 21.5
Yeard
1999 15,349 17.3 17.4
2001 13,601 15.4 15.4
2003 15,214 17.2 17.2
2005 13,917 15.7 15.7
2007 14,041 15.9 15.9
2009 16,410 18.5 18.5
Total 88,532 100.0 100.0
7. Severe suicide attempt only among those among all youth who were administered
who attempted: This variable was based the questionnaire.
on the same question as severe suicide
attempt above, but recoded: No was
recoded as 0, and Yes was recoded Data Analyses
as 1. Did not attempt suicide was
recorded to be a missing score. This Analyses were conducted using SAS
response is different from response 5 Version 9.2. YRBS weights based on gender,
because it studies the prevalence of ethnicity, and grade level were applied to
severe suicide attempts only among provide representative prevalences of ado-
those who made an attempt, rather than lescents in the United States. Prevalence of
suicide-related responses were calculated except for severe suicide attempts among
based on the four demographic variables: only those who attempted suicide, which
ethnicity, gender, grade level, and year. Uni- remained relatively constant.
variate and multiple logistic regression To investigate the differences in sui-
analyses were utilized. Given the large sam- cide-related responses by ethnicity, we first
ple size, substantial statistical power, and conducted a logistic regression with eth-
multiple comparisons, alpha was set at nicity as the categorical independent vari-
<.0001, 2-tailed test. able. Overall, there was a significant
difference (p < .0001) by ethnicity for
depression, suicide ideation, suicide plan-
RESULTS ning, suicide attempts, and severe suicide
attempts overall (see Table 2). Severe sui-
Table 2 reports the prevalence and 95% cide attempts among only those who
confidence interval for each suicide-related attempted was statistically significant only
response by ethnicity, gender, grade level, at the p < .001 level.
and year. Between 1999 and 2009, 28.0% Using the five suicide-related questions
of high school students responded that, in that were significantly different by ethnicity
the 12 months preceding the survey, they (p < .0001), we conducted pair-wise com-
had experienced feelings of sadness and parisons for all ethnic groups and com-
hopelessness for two weeks that caused puted the odds ratios (see Table 3). The
them to stop doing some usual activities; ratio is more than 1.0 when the first group
16.7% responded that they had seriously (first column of Table 3) in the comparison
considered attempting suicide in the past is at greater risk than the second group
year; 13.5% responded that they had made (first row of numbers in Table 3), and the
a plan about how they would attempt sui- ratio is less than 1.0 when the first group
cide in the past year; 7.8% responded that is at lower risk. For example, Pacific Islan-
they had actually attempted suicide at least ders had a statistically significant 1.78-fold
once in the last year, of which 30.3% of increased risk of depression as compared
those who attempted suicide required medi- to Whites. If the two groups are at equal
cal attention; and overall 2.3% of all high risk, their odds ratio is not significantly dif-
school students made a suicide attempt that ferent from 1.0 (evaluated here at the
required medical attention in the past year. alpha < .0001 level, 2-tailed test).
By gender, females reported higher To determine the overall pattern of
rates of depression symptoms, suicide idea- results (see Table 3), a calculation for each
tion, suicide planning, suicide attempts, and ethnicity was made by comparing the num-
suicide attempts requiring medical attention ber of the odds ratios significantly greater
(overall). However, among only those who than 1.0 against the number of ratios signifi-
attempted suicide, males reported a higher cantly less than 1.0. This was done for each
proportion of suicide attempts that ethnicity in comparison to the other seven
required medical attention. Results by high ethnicities, on each of the five suicide ques-
school grade level indicated that younger tions significantly different by ethnicity.
students reported higher rates of suicidal Pacific Islanders had the highest proportion
ideation, planning, and attempts. However, of greater than vs. less than odds ratios,
there were no significant differences (21:0), whereas Whites had the lowest
among grade levels for depression and proportion (2:27). Ratios of the ethnic
severity of suicide attempts among those groups were as follows: Pacific Islander
who attempted in the past. By year, the pre- 21:0; Multiracial (non-Hispanic) 20:0;
valences decreased over the last decade, American Indian 15:0; Multiracial
TABLE 2. Prevalences and 95% Confidence Intervals of Risk Factors for Suicide by Ethnicity,
Gender, Grade Level, and Year
Severe
attempt Severe attempt
Suicide Suicide Suicide among all among only those
Depression % ideation % plan % attempt % youth % who attempted %
95% CI 95% CI 95% CI 95% CI 95% CI 95% CI
Ethnicity
American Indian 32.7 23.3 19.6 16.2 5.9 39.0
28.437.0 19.726.9 15.523.7 13.019.4 3.28.6 25.452.4
Asian 26.4 17.2 16.2 7.9 2.5 32.4
23.928.8 15.219.2 14.118.2 6.39.4 1.63.4 23.141.7
Black 28.2 13.2 10.2 7.9 2.6 34.9
27.229.1 12.514.0 9.510.9 7.28.6 2.13.0 30.739.2
Hispanic 33.9 16.1 13.8 10.3 2.9 29.1
32.735.0 15.117.1 12.315.2 9.611.1 2.43.3 24.633.6
Multiracial (Hispanic) 37.0 20.4 16.5 10.9 3.6 33.3
35.238.7 18.822.1 15.217.9 9.712.2 2.94.3 27.639.0
Multiracial 35.0 27.2 21.6 13.1 4.1 31.8
(Non-Hispanic) 31.838.2 24.330.1 19.024.2 11.215.0 2.95.3 22.940.7
Pacific Islander 37.9 25.7 23.4 17.4 6.5 40.4
33.542.3 21.530.0 18.828.0 13.021.8 3.19.9 25.855.0
White 25.5 16.3 13.0 6.6 1.8 28.2
24.826.3 15.716.9 11.914.0 6.17.0 1.62.0 26.030.5
Gender
Female 35.3 21.3 16.3 10.3 2.8 27.5
34.536.1 20.622.0 15.417.1 9.710.8 2.53.0 25.329.7
Male 20.8 12.2 10.7 5.4 1.8 35.4
20.221.5 11.712.7 9.911.5 5.05.8 1.62.0 32.338.6
Grade Level
9th Grade 28.1 17.2 14.0 9.4 2.8 30.4
27.129.1 16.318.0 13.015.1 8.710.1 2.43.1 27.333.5
10th Grade 28.3 17.6 14.5 8.8 2.5 28.3
27.429.2 16.818.4 13.615.4 8.29.5 2.22.7 25.631.0
11th Grade 27.9 16.4 13.2 6.9 2.1 31.4
27.029.0 15.517.2 12.214.3 6.37.4 1.82.4 27.835.1
12th Grade 27.2 15.1 11.4 5.3 1.6 29.8
26.328.2 14.315.8 10.512.4 4.95.8 1.31.8 26.133.6
Year
1999 28.3 19.3 14.5 8.3 2.6 31.0
26.929.6 18.120.4 13.215.9 7.39.3 2.03.2 24.937.2
2001 28.3 19.0 14.8 8.8 2.6 29.9
26.929.6 17.820.3 13.715.9 8.09.7 2.33.0 26.932.9
(Continued )
TABLE 2. Continued
Severe
attempt Severe attempt
Suicide Suicide Suicide among all among only those
Depression % ideation % plan % attempt % youth % who attempted %
95% CI 95% CI 95% CI 95% CI 95% CI 95% CI
Note. Bolded numbers indicate the prevalence of the suicide risk factor in each specified demographic group.
(Hispanic) 13:4; Hispanic 8:14; Asian effect, and the ethnicity-gender interaction
3:14; Black 3:26; and White 2:27. effect with depression as the dependent
Therefore, these findings show a higher measure. Results show that five two-way
prevalence of suicide risk factors for interaction effects were statistically signifi-
suicide-related behaviors among Pacific cant (p < .0001; see Table 4).
Islander, American Indian, and both
Multiracial adolescent groups compared to 1. #1: Over the past decade, suicide
the Hispanic, Asian, Black, and White planning generally decreased for most
groups. ethnicities, but American Indian, Asian,
Finally, multiple logistic regression Hispanic, White, and Multiracial (non-
analyses were conducted to examine two- Hispanic) youth showed a peak in
way demographic interactions with prevalence in 2003.
ethnicity for each of the suicide-related 2. #2 & #3: Over the past decade, severe
responses, to determine whether the suicide attempts both overall and
prevalence of self-reported risk factors for among only those who attempted gen-
suicide changed for ethnicity across the erally remained constant or decreased sli-
values of gender, grade level, or year. For ghtly for most ethnicities, but American
example, the first model entailed ethnicity Indians showed sharp decreases while
as a main effect, grade level as a main Asian, Hispanic, Pacific Islander, and
Pacific Islander
Depression 1.78 1.56 1.70 1.19 1.04 1.26 1.13
Ideation 1.78 2.27 1.66 1.80 1.35 1.14 0.93
Plan 2.05 2.68 1.58 1.91 1.54 1.25 1.11
Attempt 3.00 2.45 2.47 1.83 1.72 1.09 1.40
Severe attempt 3.75 2.61 2.69 2.34 1.85 1.10 1.62
Multiracial
(Non-Hispanic)
Depression 1.57 1.37 1.50 1.05 0.92 1.11 0.88
Ideation 1.92 2.45 1.79 1.95 1.45 1.23 1.08
Plan 1.85 2.42 1.43 1.73 1.39 1.13 0.90
Attempt 2.15 1.75 1.77 1.31 1.23 0.78 0.72
Severe attempt 2.32 1.62 1.66 1.45 1.15 0.68 0.62
American Indian
Depression 1.42 1.24 1.36 0.95 0.83 0.90 0.80
Ideation 1.56 1.99 1.46 1.58 1.18 0.81 0.88
Plan 1.64 2.14 1.26 1.53 1.23 0.88 0.80
Attempt 2.75 2.25 2.27 1.68 1.57 1.28 0.92
Severe attempt 3.41 2.38 2.44 2.13 1.68 1.47 0.91
Multiracial
(Hispanic)
Depression 1.71 1.49 1.64 1.14 1.21 1.09 0.96
Ideation 1.32 1.68 1.24 1.34 0.85 0.69 0.74
Plan 1.33 1.74 1.02 1.24 0.81 0.72 0.65
Attempt 1.75 1.43 1.44 1.06 0.64 0.81 0.58
Severe attempt 2.03 1.41 1.45 1.27 0.59 0.87 0.54
Hispanic
Depression 1.49 1.31 1.43 0.87 1.06 0.95 0.84
Ideation 0.99 1.26 0.92 0.75 0.63 0.51 0.55
Plan 1.07 1.40 0.83 0.81 0.66 0.58 0.52
Attempt 1.64 1.34 1.35 0.94 0.60 0.77 0.55
Severe attempt 1.60 1.11 1.15 0.79 0.47 0.69 0.43
Asian
Depression 1.04 0.91 0.70 0.61 0.74 0.67 0.59
Ideation 1.07 1.36 1.08 0.81 0.69 0.56 0.60
Plan 1.30 1.70 1.21 0.98 0.79 0.70 0.63
Attempt 1.21 0.99 0.74 0.69 0.44 0.56 0.40
Severe attempt 1.39 0.97 0.87 0.69 0.41 0.60 0.37
(Continued )
TABLE 3. Continued
Black
Depression 1.14 1.10 0.77 0.67 0.81 0.73 0.64
Ideation 0.78 0.73 0.80 0.59 0.50 0.41 0.44
Plan 0.76 0.59 0.71 0.58 0.47 0.41 0.37
Attempt 1.23 1.01 0.75 0.70 0.45 0.57 0.41
Severe attempt 1.44 1.03 0.90 0.71 0.42 0.62 0.38
White
Depression 0.87 0.96 0.67 0.58 0.71 0.64 0.56
Ideation 1.28 0.94 1.02 0.76 0.64 0.52 0.56
Plan 1.31 0.77 0.93 0.75 0.61 0.54 0.49
Attempt 0.82 0.82 0.61 0.57 0.36 0.47 0.33
Severe attempt 0.70 0.72 0.63 0.49 0.29 0.43 0.27
Note: The odds ratio is more than 1.0 when the first group (first column of Table 3) in the comparison is at
greater risk than the second group (first row of numbers in Table 3), and the ratio is less than 1.0 when the
first group is at lower risk. For example, Pacific Islanders had a statistically significant 1.78-fold increased risk
of depression as compared to Whites. The odds ratios on the upper-left of the table are reciprocals (1=odds
ratio) of the bottom-right odds ratios. For example, Pacific Islanders had a 1.78-fold increased risk for
depression as compared to Whites (upper-left of table), and Whites had 0.56 the risk for depression as compared
to Pacific Islanders (bottom-right of table). 1=0.56 1.78.
p < .0001.
1999 (%) 2001 (%) 2003 (%) 2005 (%) 2007 (%) 2009 (%)
(Continued )
TABLE 4. Continued
(OR: 1.582.69; p < .0001). Indeed, Pacific endorse significantly greater risk factors
Islander adolescents endorsed the highest suicide. This finding is consistent with pre-
risk for suicide-related responses by eth- vious literature illustrating considerable dif-
nicity, with 21 out of 35 odds ratios signifi- ferences in health-risk behaviors between
cantly greater than 1.0 overall. the two API ethnic groups (Choi, 2008;
Our findings demonstrate that multira- Sasaki & Kameoka, 2009; Wong, Klingle,
cial adolescents are at relatively high risk of & Price, 2004).
suicide, with a risk comparable to that of It is critical to explicate the root causes
American Indian youth. The literature has for these findings. Further research is
recognized American Indian adolescents as needed on how culture and cultural identi-
an at-risk population, but empirical research fication influence methodological and
has only recently emerged to suggest similar psychological issues of risk factors for sui-
vulnerabilities among multiracial youth. cide. For example, methodologically, a
Such studies have found that multiracial lower prevalence for Asians may be par-
adolescents report higher rates of poor tially due to shame in self-disclosure of risk
mental health and academic adjustment, factors for suicide. From a psychological
and greater risk behaviors, such as substance perspective, the higher rates for Pacific
use and violence (Choi, Harachi, Gilmore Islanders, including Native Hawaiians,
et al., 2006; Cooney & Radina, 2000; Olvera, may be related to issues of acculturative
2001; Roberts, Chen, & Roberts, 1997; stress and cultural conflict.
Udry, Li, & Hendrickson-Smith, 2003; As immigrants from their native
Whaley & Francis, 2006). Given the con- islands, non-Hawaiian Pacific Islanders
tinuing growth of the multiracial popula- residing in the United States have had to
tion, there is a vital need to understand the overcome cultural and socioeconomic bar-
mental health concerns of this youth group. riers that cause acculturative stress and loss
This is also the first national study to of ethnic identity. For Native Hawaiians,
show that by ethnicity, Pacific Islander similar to other indigenous peoples, coloni-
adolescents are at the highest risk for sui- alism (e.g., loss of the aina or land, over-
cide in the United States. Over 1 in 6 throw of the monarchy by the United
(17.4%) Pacific Islander adolescents States), foreign diseases, and a dramatic
reported a suicide attempt in the past year shift to more individualistic values have
and nearly 1 in 15 (6.5%) made a suicide had a devastating inter-generational effect
attempt that required medical attention on the family structure, health, and well-
prevalences more than double the national being of Native Hawaiians (Blaisdell, 1993).
rates of 7.8% and 2.3%, respectively. Indeed, investigations into the higher youth
Compared to Asians, Pacific Islander youth suicide rates among aboriginals in Canada
and indigenous Polynesians in New divided loyalties between two or more sets
Zealand suggest risk factors including his- of cultural values. Indeed, a recurring theme
torical oppression, and disruptions to a in interviews with multiracial adolescents
developing sense of personal and cultural was a sense of inauthenticity and shame
persistence (Beautrais & Ferusson, 2006; with regard to identity (Bowles, 1993). This
Chandler, Lalonde, Sokol et al., 2003; lack of positive identity formation may
Kirmayer, Brass, & Tait, 2000). lead to social isolation and low self-esteem
Native Hawaiians have the shortest (Gibbs, 1987; Root, 1992). In addition,
life expectancy in their own homeland as peer acceptance may be a salient stressor
compared to the other major ethnic groups for multiracial youths due to their poten-
in Hawaii (Park, Braun, Horiuchi et al., tially ambiguous racial status and the
2009). Moreover, there is a disproportio- absence of a natural peer group (Root,
nately high prevalence of psychiatric symp- 1992). The need to be accepted has been
toms and disorders among Native theorized to cause increased engagement
Hawaiian youth, and risk factors for suicide of high-risk behaviors in this population
may be a manifestation of this psychologi- (Gibbs, 1987). Finally, family dynamics
cal distress (Andrade, Hishinuma, McDer- may play a role, with one study finding that
mott et al. 2006; Conwell, Duberstein, & multiracial boys are less communicative
Cox, 1996). Notably, a series of psychologi- and emotionally close with their fathers
cal autopsies of Pacific Islander and Hawai- (Radina & Cooney, 2000).
ian youth who committed suicide found A few limitations should be noted
that the act of suicide was often preceded given the nature of the YRBS as self-
by emotions described as depression, with reported secondary survey data. First, we
the act itself having connotations of an were not able to control for socioeconomic
appeal to older family members (Else, status, and thus unable to investigate
Andrade, & Nahulu, 2007). whether these ethnic disparities were due
A different set of reasons may underlie to socioeconomic stressors or other psy-
the risk factors for suicide among multira- chosocial influences. Second, the YRBS
cial adolescents, as suggested by the data set does not include corroborating
decrease in suicide attempts with grade objective data to supplement the self-report
level, a trend that contrasts the increase data. However, given the underestimation
seen among Pacific Islanders. The most of internalizing disorders by parents and
common explanation for the high preva- teachers, self-report data are important
lence of health-risk behaviors among multi- in determining difficulties being experi-
racial adolescents is their struggle with enced by adolescents. Third, although the
positive identity formation, an important present study examined cross-sectional pre-
developmental factor for reducing risk valences across time, the data were not
and enhancing resiliency (Lalonde, 2006). linked per youth, thus precluding risk fac-
The most common subcategories within tor analyses involving longitudinal growth
the multiracial population are White and modeling and group trajectories. Fourth,
Black, White and Asian, White and Ameri- the YRBS is administered only in schools,
can Indian, and White, and some other and therefore, may not capture data from
racea box checked mainly by youth who are absent, suspended or
Hispanics (United States Census Bureau, dropped out from schoolan adolescent
2001). Because of their multiple heritages, subgroup at higher risk for suicide (Gould,
multiracial youths may face greater dif- Fisher, Parides et al., 1996). Thus, the
ficulty forming a positive ethnic identity, prevalence of risk factors of suicide
due to feelings of ambivalence and=or reported in the present study are likely to
Beautrais, A. L., & Fergusson, D. M. (2006). Indigen- vs. across racial=ethnic marriages. Cultural Diversity
ous suicide in New Zealand. Archives of Suicide and Mental Health, 3(4), 273277.
Research, 10(2), 159168. Else, I. R., Andrade, N. N., & Nahulu, L. B. (2007).
Blaisdell, R. K. (1993). The health status of Kanaka Suicide and suicidal-related behaviors among
Maoli (indigenous Hawaiians). Asian American and indigenous Pacific Islanders in the United States.
Pacific Islander Journal of Health, 1(2), 116160. Death Studies, 31(5), 479501.
Booth, H. (1999). Pacific island suicide in compara- Evans, E., Hawton, K., Rodham, K., & Deek, J.
tive perspective. Journal of Biosocial Science, 31(4), (2005). The prevalence of suicide phenomena in
433448. adolescents: A systematic review of population-
Bowles, D. D. (1993). Bi-racial identity: children based studies. Suicide and Life Threatening Behavior,
born to African-American and White couples. 35(3), 239250.
Clinical Social Work Journal, 21(4), 417428. Gibbs, J. T. (1987). Identity and marginality: Issues in
Centers for Disease Control and Prevention. (2009). the treatment of biracial adolescents. American
Alcohol and suicide among racial=ethnic popula- Journal of Orthopsychiatry, 57(2), 265278.
tions 17 states, 20052006. Morbidity and Mortality Gould, M. S., Fisher, P., Parides, M., Flory, M., &
Weekly Report, 58(23), 637641. Shaffer, D. (1996). Psychosocial risk factors of
Centers for Disease Control and Prevention. (2010). child and adolescent completed suicide. Archives
WISQARS leading causes of death reports, 19992007. of General Psychiatry, 53(12), 11551162.
Retrieved from http://webappa.cdc.gov/sasweb/ Gould, M. S., Greenberg, T., Velting, D. M., &
ncipc/leadcaus10.html Shaffer, D. (2003). Youth suicide risk and preven-
Chandler, M. J., Lalonde, C., Sokol, B., & Hallett, D. tive interventions: A review of the past 10 years.
(2003). Personal persistence, identity development, Journal of the American Academy of Child and Adolescent
and suicide: A study of Native and Non-native Psychiatry, 42(4), 386405.
North American adolescents. Monographs of the Grunbaum, J. A., Lowry, R., Kann, L., & Pateman, B.
Society for Research on Child Development, 68(2), 1138. (2000). Prevalence of health risk behaviors among
Choi, Y. (2008). Diversity within: subgroup differ- Asian American=Pacific Islander high school stu-
ences of youth problem behaviors among Asian dents. Journal of Adolescent Health, 27(5), 322330.
Pacific Islander American adolescents. Journal of Johnson, R. C., & Nagoshi, C. T. (1986). The adjust-
Community Psychology, 36(3), 352370. ment of offspring of within-group and interracial=
Choi, Y., Harachi, T. W., Gillmore, M. R., & intercultural marriages: A comparison of person-
Catalano, R. F. (2006). Are multiracial adolescents ality factor scores. Journal of Marriage and the Family,
at greater risk? Comparisons of rates, patterns and 48(2), 279284.
correlates of substance use and violence between Kessler, R. C., Borges, G., & Walters, E. E. (1999).
monoracial and multiracial adolescents. American Prevalence and risk factors for lifetime suicide
Journal of Orthopsychiatry, 76(1), 8697. attempts in the National Comorbidity Survey.
Colucci, E., & Martin, G. (2007). Ethnocultural Archives of General Psychiatry, 56(7), 617626.
aspects of suicide in young people: A systematic Kirmayer, L. J., Brass, G. M., & Tait, C. L. (2000).
literature review. Part 1: Rates and methods of The mental health of Aboriginal peoples: Trans-
youth suicide. Suicide and Life Threatening Behavior, formations of identity and community. Canadian
37(2), 197221. Journal of Psychiatry, 45(7), 607616.
Conwell, Y., Duberstein, P. R., Cox, C., Herrmann, J. Kisch, J., Leino, E. V., & Silverman, M. M. (2005).
H., Forbes, N. T., & Caine, E. D. (1996). Relation- Aspects of suicidal behavior, depression and treat-
ships of age and axis I diagnoses in victims of ment in college students: Results from the spring
completed suicide: a psychological autopsy study. 2000 National College Health Assessment Survey.
American Journal of Psychiatry, 153(8), 10011008. Suicide and Life Threatening Behavior, 35(1), 313.
Cooney, T. M., & Radina, M. E. (2000). Adjustment Lalonde, C. E. (2006). Identity formation and cul-
problems in adolescence: Are multiracial children tural resilience in Aboriginal communities. In R.
at risk? American Journal of Orthopsychiatry, 70(4), J. Flynn, P. M. Dudding, & J. G. Barber (Eds.),
433444. Promoting resilience in child welfare (pp. 5271).
Danko, G. P., Miyamoto, R. H., Foster, J. E., Johnson, Ottawa, ON: University of Ottawa Press.
R. C., Andrade, N. N., Yates, A., & Edman, J. L. Mann, J. J., Waternaux, C., Haas, G. L., & Malone,
(1997). Psychiatric symptoms in offspring of within K. M. (1999). Toward a clinical model of suicidal
behavior in psychiatric patients. American Journal of San Francisco, CA: A comparison of Caucasian
Psychiatry, 156(2), 181189. and Asian groups, 19871994. Suicide and Life
Mayeda, D. T., Hishinuma, E. S., Nishimura, S. T., Threatening Behavior, 27(1), 8091.
Garia-Santiago, O., & Mark, G. Y. (2006). United States Census Bureau. (2001). Census 2000
Asian=Pacific Islander Youth Violence Prevention summary file (SF 1) 100-percent data: Table p3
Center: Interpersonal violence and deviant race. Retrieved from http://www.factfinder.cen-
behaviors among youth in Hawaii. Journal of sus.gov
Adolescent Health, 39(2), 276.e111. United States Census Bureau. (2010). Annual popu-
Olvera, R. L. (2001). Suicidal ideation in Hispanic lation estimates: t3-race. Retrieved from http://
and mixed-ancestry adolescents. Suicide and Life www.factfinder.census.gov
Threatening Behavior, 31(4), 416427. Udry, J. R., Li, M. R., & Hendrickson-Smith, J.
Park, C. B., Braun, K., Horiuchi, B., Tottori, C., & (2003). Health and behavior risks of adolescents
Onaka, A. T. (2009). Longevity disparities in with mixed-race identity. American Journal of Public
multiethnic Hawaii: An analysis of 2000 life tables. Health, 93(11), 18651870.
Public Health Reports, 124(4), 579584. Werner, E. E., & Smith, R. S. (2001). Journeys from
Radina, M. E., & Cooney, T. M. (2000). Relationship childhood to midlife: Risk, resilience, and recovery. Ithaca,
quality between multiracial adolescents and their NY: Cornell University Press.
biological parents. American Journal of Orthopsychia- Whaley, A. L., & Francis, K. (2006). Behavioral
try, 70(4), 445454. health in multiracial adolescents: The role of
Roberts, R. E., Chen, Y. R., & Roberts, C. R. (1997). Hispanic=Latino ethnicity. Public Health Reports,
Ethnocultural differences in prevalence of ado- 121(2), 169174.
lescent suicidal behaviors. Suicide and Life Threaten- Wong, M. M., Klingle, R. S., & Price, R. K. (2004).
ing Behavior, 27(2), 208217. Alcohol, tobacco and other drug use among Asian
Root, M. P. P. (1992). Racially mixed people in America. American and Pacific Islander adolescents in
Newbury Park, CA: Sage. California and Hawaii. Addictive Behaviors, 29(1),
Sasaki, P. Y., & Kameoka, V. A. (2009). Ethnic var- 127141.
iations in prevalence of high-risk sexual behaviors Yuen, N., Andrade, N., Nahulu, L., Markini, G.,
among Asian and Pacific Islander adolescents in McDermott, J. F., Danko, G., . . . Waldron, J.
Hawaii. American Journal of Public Health, 99(10), (1996). The rate and characteristics of suicide attemp-
18861892. ters in the Native Hawaiian adolescent population.
Schuster, M. A., Bell, R. M., Nakajima, G. A., & Suicide and Life Threatening Behavior, 26(1), 2736.
Kanouse, D. E. (1998). The sexual practices of Yuen, N. Y., Nahulu, L. B., Hishinuma, E. S., &
Asian and Pacific Islander high school students. Miyamoto, R. H. (2000). Cultural identification
Journal of Adolescent Health, 23(4), 221231. and attempted suicide in Native Hawaiian adoles-
Shiang, J., Binn, R., Bongar, B., Stephens, B., cents. Journal of the American Academy of Child and
Alison, D., & Schatzberg, A. (1997). Suicide in Adolescent Psychiatry, 39(3), 360367.