This article was downloaded by: [Northeastern University]On: 10 October 2014, At: 15:43Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Archives of Suicide ResearchPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/usui20

Ethnic Differences in Risk Factors ForSuicide Among American High SchoolStudents, 2009: The Vulnerabilityof Multiracial and Pacific IslanderAdolescentsShane Shucheng Wong , Jeanelle J. Sugimoto-Matsuda , Janice Y.Chang & Earl S. HishinumaPublished online: 02 May 2012.

To cite this article: Shane Shucheng Wong , Jeanelle J. Sugimoto-Matsuda , Janice Y. Chang & EarlS. Hishinuma (2012) Ethnic Differences in Risk Factors For Suicide Among American High SchoolStudents, 2009: The Vulnerability of Multiracial and Pacific Islander Adolescents, Archives of SuicideResearch, 16:2, 159-173, DOI: 10.1080/13811118.2012.667334

To link to this article: http://dx.doi.org/10.1080/13811118.2012.667334

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Ethnic Differences inRisk Factors For SuicideAmong American HighSchool Students, 2009: TheVulnerability of Multiracialand Pacific IslanderAdolescents

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 highschool students in the last decade. Data from the 1999–2009 Youth Risk BehaviorSurveys was analyzed by 8 self-reported ethnicity groups across 6 suicide-relateditems: depression, suicide ideation, suicide planning, suicide attempts, and suicideattempts requiring medical attention). Native Hawaiian=Pacific Islander adolescentshad the higher prevalence of risk factors for suicide. Multiracial adolescents were alsoat high risk for suicide-related behaviors, with a risk comparable to AmericanIndian=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 dictatea need to understand the vulnerability of the Pacific Islander, American Indian, andgrowing multiracial adolescent populations, in an effort to develop and implementsuicide prevention strategies.

Keywords adolescence, ethnic differences, high school students, mental health, minority health,

risk factors, suicide

INTRODUCTION

Suicide is a major public health concern forAmerican adolescents. As the third leadingcause of death among youth 14 to 18 yearsof age, it accounts for 11 percent ofall deaths in this age group (Centers for

Disease Control and Prevention, 2010).Unfortunately, completed suicides reflectonly a small proportion of suicide-relatedthoughts, behaviors and injuries amongyouth. There are many risk factors, fromdepression and suicide ideation to suicideplanning and suicide attempts, that predict

Archives of Suicide Research, 16:159–173, 2012Copyright # International Academy for Suicide ResearchISSN: 1381-1118 print=1543-6136 onlineDOI: 10.1080/13811118.2012.667334

159

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

suicide completion. These thoughts andbehaviors are important to assess beginningin adolescence, given that depression at anearly age of onset is a significant predictorof suicide completion, the probability oftransitions from suicide ideation and plansto attempts is high, and as one of the stron-gest predictors of future completed suicide,suicide attempts tend to peak between 16and 18 years of age (Gould, Greenberg,Velting et al., 2003; Kessler, Borges, &Walters, 1999; Mann, Waternaux, Haaset al., 1999).

Unfortunately, little is known aboutsuicide risk factors among ethnic minorities(Colucci & Martin, 2007). In particularly,an emerging issue is the prevalence ofhealth-risk behaviors among multiracialyouth, a minority population of 6.8 millionaccording to the 2000 Census and currentlythe fastest-growing demographic group inthe United States (United States CensusBureau, 2001, 2010). A growing literatureattests empirically to the emotional-,health-, and behavior-risk problems of thispopulation, including substance abuse andviolence (Choi, Harachi, Gillmore et al.,2006). However, other studies havedemonstrated conflicting findings with noelevation of risk behaviors among multi-racial youth (Danko, Miyamoto, Fosteret al., 1997; Johnson & Nagoshi, 1986).Furthermore, very few studies investigatingrisk factors for suicide among multiracialadolescents were found. These investiga-tions, based on data a decade or moreago, suggest that multiracial adolescentsare at an elevated risk for suicide (Olvera,2001; Roberts, Chen, & Roberts, 1997;Udry, Li, & Hendrickson-Smith, 2003;Whaley & Francis, 2006). There has yetto be any national studies comparing multi-racial adolescents to their peers on a rangeof suicide risk factors, including suicideattempts.

Another important issue is the ethnicdisaggregation of the Asian and PacificIslander (API) populations, which numbers

14.6 million in the United States (UnitedStates Census Bureau, 2010). Due to gener-ally low rates of health-risk behaviorsreported for aggregated API youth, includ-ing a recent study on risk factors forsuicide, this population has been describedas a ‘‘model minority’’ group—implying thatAPI adolescents do not require targetedsupport for success in society (Centers forDisease Control and Prevention, 2009;Grunbaum, Lowry, Kann et al., 2000;Schuster, Bell, Nakajima et al., 1998). How-ever, conclusions drawn from such researchare likely to be misleading given the hetero-geneity of the population. Recent studies onthe disaggregated API population haveindeed shown that the prevalence ofhealth-risk behaviors differ significantlybetween Asians and Pacific Islanders (Choi,2008; Sasaki & Kameoka, 2009).

The few studies on suicide among PacificIslanders have reported elevated suicide ratescompared to their peers in the United States(Booth, 1999; Wong, Klingle, & Price, 2004;Yuen, Andrade, Nahulu et al., 1996). Morerecent studies within the State of Hawaii sug-gest that suicidal thoughts and behaviors areindeed significantly higher among NativeHawaiian adolescents compared to theirnon-Hawaiian peers (Else, Andrade, &Nahulu, 2007; Yuen, Nahulu, Hishinumaet al., 2000). On the other hand, the risk fac-tors for suicide among the Asian Americanpopulation appears lower, although the litera-ture is not entirely conclusive (Evans, Haw-ton, Rodham et al. 2005; Kisch, Leino, &Silverman, 2005; Shiang, Binn, Bongar et al.,1997). To date, no studies on risk factors forsuicide using national samples of disaggre-gated Asian and Pacific Islander adolescentshave been reported.

In 1999, the Centers for DiseaseControl and Prevention (CDC) began cod-ing Asians and Native Hawaiians=PacificIslanders as two separate ethnic categoriesfor the Youth Risk Behavior Survey(YRBS), and introduced the ‘‘multiple(Hispanic)’’ and ‘‘multiple (non-Hispanic)’’

Ethnicity and Adolescent Suicidality

160 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

ethnic groups. We test the hypothesis thatmultiracial and Pacific Islander adolescentsare at significantly higher risk for suicide incomparison to their peers.

METHODS

Sample Description

Demographic and suicide-relatedresponse data were utilized from the1999, 2001, 2003, 2005, 2007, and 2009YRBS, a nationally representative surveyof high school students administered every2 years. A total of 88,532 school question-naires were completed by students from1999 to 2009. Table 1 presents the sampledescription. The average age of respon-dents was 16.2 years old.

Measures

Demographics. Gender, grade level, yearand ethnicity were provided by the data.In the 1999 to 2003 surveys, ethnicity wasidentified by responses to the followingquestion: ‘‘How do you describe yourself?’’Respondents were allowed to select one ormore answers from six response options:‘‘American Indian or Alaska Native, Asian,Black or African American, Hispanic orLatino, Native Hawaiian or Other PacificIslander, or White.’’ In the 2005 to 2009surveys, this question was broken downinto two questions: ‘‘Are you Hispanic orLatino?’’ and ‘‘What is your race?’’ Forthe latter, respondents were allowed to sel-ect more than one answer from the fiveresponse options: ‘‘American Indian orAlaska Native, Asian, Black or AfricanAmerican, Native Hawaiian or OtherPacific Islander, or White.’’ Students whochecked Hispanic=Latino and one or moreother responses comprised the MultiracialHispanic group, and students who checkedmore than one response but not Hispanic=

Latino constituted the Multiracial non-Hispanic group. Ethnicity categories willhenceforth be abbreviated to AmericanIndian, Asian, Black, Hispanic, Multiracial(Hispanic), Multiracial (Non-Hispanic),Pacific Islander, and White.

Risk Factors for Suicide. Five YRBS ques-tions concerning different risk factors forsuicide were recoded into 6 responses eachwith a binary answer:

1. Depression: ‘‘During the past 12months, did you ever feel so sad orhopeless almost every day for twoweeks or more in a row that youstopped doing some usual activities?Yes, No.’’

2. Suicide ideation: ‘‘During the past 12months, did you ever seriously considerattempting suicide? Yes, No.’’

3. Suicide planning: ‘‘During the past 12months, did you make a plan abouthow you would attempt suicide? Yes,No.’’

4. Suicide attempt: ‘‘During the past 12months, how many times did you actu-ally attempt suicide? 0 times, 1 time, 2or 3 times, 4 or 5 times, 6 or moretimes.’’ To calculate the prevalence ofsuicide attempts, the response choiceswere recoded into binary choices: 0times were recoded as ‘‘0,’’ and 1 ormore times was recoded as ‘‘1.’’

5. Severe suicide attempt among all youth:‘‘If you attempted suicide during thepast 12 months, did any attempt resultin an injury, poisoning, or overdose thathad to be treated by a doctor or nurse?’’The three choices were: ‘‘Did notattempt suicide,’’ ‘‘Yes,’’ and ‘‘No.’’ Tocalculate the prevalence of severe sui-cide attempts requiring medical atten-tion, ‘‘Did not attempt suicide’’ and‘‘No’’ were recoded as ‘‘0,’’ and ‘‘Yes’’was recoded as ‘‘1.’’

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 161

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

7. Severe suicide attempt only among thosewho attempted: This variable was basedon the same question as ‘‘severe suicideattempt’’ above, but recoded: ‘‘No’’ wasrecoded as ‘‘0,’’ and ‘‘Yes’’ was recodedas ‘‘1.’’ ‘‘Did not attempt suicide’’ wasrecorded to be a missing score. Thisresponse is different from response 5because it studies the prevalence ofsevere suicide attempts only amongthose who made an attempt, rather than

among all youth who were administeredthe questionnaire.

Data Analyses

Analyses were conducted using SASVersion 9.2. YRBS weights based on gender,ethnicity, and grade level were applied toprovide representative prevalences of ado-lescents in the United States. Prevalence of

TABLE 1. Sample Description

Unweighted count Unweighted % Weighted %e

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

Note. aEthnicity (weighted): v2[7, N¼ 87,293]¼ 8,514.4, p< .0001.bGender (weighted): v2[1, N¼ 88,199]¼ 3.1, p¼ .08.cGrade Level (weighted): v2[3, N¼ 88,032]¼ 280.3, p< .0001.dYear (weighted): v2[5, N¼ 88,532]¼ 1.2, p¼ .94.eWeighted based on ethnicity, gender, and grade level.

Ethnicity and Adolescent Suicidality

162 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

suicide-related responses were calculatedbased on the four demographic variables:ethnicity, gender, grade level, and year. Uni-variate and multiple logistic regressionanalyses were utilized. Given the large sam-ple size, substantial statistical power, andmultiple comparisons, alpha was set at<.0001, 2-tailed test.

RESULTS

Table 2 reports the prevalence and 95%confidence interval for each suicide-relatedresponse by ethnicity, gender, grade level,and year. Between 1999 and 2009, 28.0%of high school students responded that, inthe 12 months preceding the survey, theyhad experienced feelings of sadness andhopelessness for two weeks that causedthem to stop doing some usual activities;16.7% responded that they had seriouslyconsidered attempting suicide in the pastyear; 13.5% responded that they had madea plan about how they would attempt sui-cide in the past year; 7.8% responded thatthey had actually attempted suicide at leastonce in the last year, of which 30.3% ofthose who attempted suicide required medi-cal attention; and overall 2.3% of all highschool students made a suicide attempt thatrequired medical attention in the past year.

By gender, females reported higherrates of depression symptoms, suicide idea-tion, suicide planning, suicide attempts, andsuicide attempts requiring medical attention(overall). However, among only those whoattempted suicide, males reported a higherproportion of suicide attempts thatrequired medical attention. Results by highschool grade level indicated that youngerstudents reported higher rates of suicidalideation, planning, and attempts. However,there were no significant differencesamong grade levels for depression andseverity of suicide attempts among thosewho attempted in the past. By year, the pre-valences decreased over the last decade,

except for severe suicide attempts amongonly those who attempted suicide, whichremained relatively constant.

To investigate the differences in sui-cide-related responses by ethnicity, we firstconducted a logistic regression with eth-nicity as the categorical independent vari-able. Overall, there was a significantdifference (p< .0001) by ethnicity fordepression, suicide ideation, suicide plan-ning, suicide attempts, and severe suicideattempts overall (see Table 2). Severe sui-cide attempts among only those whoattempted was statistically significant onlyat the p< .001 level.

Using the five suicide-related questionsthat were significantly different by ethnicity(p< .0001), we conducted pair-wise com-parisons for all ethnic groups and com-puted the odds ratios (see Table 3). Theratio is more than 1.0 when the first group(first column of Table 3) in the comparisonis at greater risk than the second group(first row of numbers in Table 3), and theratio is less than 1.0 when the first groupis at lower risk. For example, Pacific Islan-ders had a statistically significant 1.78-foldincreased risk of depression as comparedto Whites. If the two groups are at equalrisk, their odds ratio is not significantly dif-ferent from 1.0 (evaluated here at thealpha< .0001 level, 2-tailed test).

To determine the overall pattern ofresults (see Table 3), a calculation for eachethnicity was made by comparing the num-ber of the odds ratios significantly greaterthan 1.0 against the number of ratios signifi-cantly less than 1.0. This was done for eachethnicity in comparison to the other sevenethnicities, on each of the five suicide ques-tions significantly different by ethnicity.Pacific Islanders had the highest proportionof ‘‘greater than’’ vs. ‘‘less than’’ odds ratios,(21:0), whereas Whites had the lowestproportion (2:27). Ratios of the ethnicgroups were as follows: Pacific Islander¼21:0; Multiracial (non-Hispanic)¼ 20:0;American Indian¼ 15:0; Multiracial

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 163

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

TABLE 2. Prevalences and 95% Confidence Intervals of Risk Factors for Suicide by Ethnicity,Gender, Grade Level, and Year

Depression %95% CI

Suicideideation %95% CI

Suicideplan %95% CI

Suicideattempt %95% CI

Severeattemptamong allyouth %95% CI

Severe attemptamong only thosewho attempted %

95% CI

Ethnicity

American Indian 32.7 23.3 19.6 16.2 5.9 39.0

28.4–37.0 19.7–26.9 15.5–23.7 13.0–19.4 3.2–8.6 25.4–52.4

Asian 26.4 17.2 16.2 7.9 2.5 32.4

23.9–28.8 15.2–19.2 14.1–18.2 6.3–9.4 1.6–3.4 23.1–41.7

Black 28.2 13.2 10.2 7.9 2.6 34.9

27.2–29.1 12.5–14.0 9.5–10.9 7.2–8.6 2.1–3.0 30.7–39.2

Hispanic 33.9 16.1 13.8 10.3 2.9 29.1

32.7–35.0 15.1–17.1 12.3–15.2 9.6–11.1 2.4–3.3 24.6–33.6

Multiracial (Hispanic) 37.0 20.4 16.5 10.9 3.6 33.3

35.2–38.7 18.8–22.1 15.2–17.9 9.7–12.2 2.9–4.3 27.6–39.0

Multiracial

(Non-Hispanic)

35.0 27.2 21.6 13.1 4.1 31.8

31.8–38.2 24.3–30.1 19.0–24.2 11.2–15.0 2.9–5.3 22.9–40.7

Pacific Islander 37.9 25.7 23.4 17.4 6.5 40.4

33.5–42.3 21.5–30.0 18.8–28.0 13.0–21.8 3.1–9.9 25.8–55.0

White 25.5 16.3 13.0 6.6 1.8 28.2

24.8–26.3 15.7–16.9 11.9–14.0 6.1–7.0 1.6–2.0 26.0–30.5

Gender

Female 35.3 21.3 16.3 10.3 2.8 27.5

34.5–36.1 20.6–22.0 15.4–17.1 9.7–10.8 2.5–3.0 25.3–29.7

Male 20.8 12.2 10.7 5.4 1.8 35.4

20.2–21.5 11.7–12.7 9.9–11.5 5.0–5.8 1.6–2.0 32.3–38.6

Grade Level

9th Grade 28.1 17.2 14.0 9.4 2.8 30.4

27.1–29.1 16.3–18.0 13.0–15.1 8.7–10.1 2.4–3.1 27.3–33.5

10th Grade 28.3 17.6 14.5 8.8 2.5 28.3

27.4–29.2 16.8–18.4 13.6–15.4 8.2–9.5 2.2–2.7 25.6–31.0

11th Grade 27.9 16.4 13.2 6.9 2.1 31.4

27.0–29.0 15.5–17.2 12.2–14.3 6.3–7.4 1.8–2.4 27.8–35.1

12th Grade 27.2 15.1 11.4 5.3 1.6 29.8

26.3–28.2 14.3–15.8 10.5–12.4 4.9–5.8 1.3–1.8 26.1–33.6

Year

1999 28.3 19.3 14.5 8.3 2.6 31.0

26.9–29.6 18.1–20.4 13.2–15.9 7.3–9.3 2.0–3.2 24.9–37.2

2001 28.3 19.0 14.8 8.8 2.6 29.9

26.9–29.6 17.8–20.3 13.7–15.9 8.0–9.7 2.3–3.0 26.9–32.9

(Continued )

Ethnicity and Adolescent Suicidality

164 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

(Hispanic)¼ 13:4; Hispanic¼ 8:14; Asian¼3:14; Black¼ 3:26; and White¼ 2:27.Therefore, these findings show a higherprevalence of suicide risk factors forsuicide-related behaviors among PacificIslander, American Indian, and bothMultiracial adolescent groups compared tothe Hispanic, Asian, Black, and Whitegroups.

Finally, multiple logistic regressionanalyses were conducted to examine two-way demographic interactions withethnicity for each of the suicide-relatedresponses, to determine whether theprevalence of self-reported risk factors forsuicide changed for ethnicity across thevalues of gender, grade level, or year. Forexample, the first model entailed ethnicityas a main effect, grade level as a main

effect, and the ethnicity-gender interactioneffect with depression as the dependentmeasure. Results show that five two-wayinteraction effects were statistically signifi-cant (p< .0001; see Table 4).

1. #1: Over the past decade, suicideplanning generally decreased for mostethnicities, but American Indian, Asian,Hispanic, White, and Multiracial (non-Hispanic) youth showed a peak inprevalence in 2003.

2. #2 & #3: Over the past decade, severesuicide attempts both overall andamong only those who attempted gen-erally remained constant or decreased sli-ghtly for most ethnicities, but AmericanIndians showed sharp decreases whileAsian, Hispanic, Pacific Islander, and

TABLE 2. Continued

Depression %95% CI

Suicideideation %95% CI

Suicideplan %95% CI

Suicideattempt %95% CI

Severeattemptamong allyouth %95% CI

Severe attemptamong only thosewho attempted %

95% CI

2003 28.6 16.9 16.5 8.5 2.6 33.0

26.7–30.5 16.1–17.6 13.0–20.0 7.4–9.5 2.0–3.1 28.0–38.0

2005 28.5 16.9 13.0 8.4 2.3 28.4

27.1–29.8 15.9–17.8 12.1–13.8 7.5–9.3 1.9–2.7 24.2–32.6

2007 28.5 14.5 11.3 6.9 1.9 28.3

27.1–29.8 13.3–15.6 10.3–12.2 6.2–7.7 1.6–2.3 24.7–31.9

2009 26.1 13.8 10.9 6.3 1.9 30.6

24.8–27.4 13.1–14.6 10.0–11.7 5.7–7.0 1.6–2.3 26.9–34.4

Total 28.0 16.7 13.5 7.8 2.3 30.3

27.4–28.6 16.2–17.1 12.7–14.2 7.5–8.2 2.1–2.5 28.5–32.2

DepressionSuicideideation

Suicideplanning

Suicideattempt

Severe attemptoverall

Severe attempt forthose whoattempted

Probabilities (p values) of Univariate Logistic Regressions

Ethnicity <.0001 <.0001 <.0001 <.0001 <.0001 .0007

Gender <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

Grade level .1008 <.0001 <.0001 <.0001 <.0001 .2678

Year <.0001 <.0001 <.0001 <.0001 <.0001 .1768

Note. Bolded numbers indicate the prevalence of the suicide risk factor in each specified demographic group.

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 165

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

TABLE 3. Odds Ratios for Pair-Wise Comparisons by Ethnicity

Suicide-relateditem White Black Asian Hispanic

Multiracial(Hispanic)

AmericanIndian

Multiracial(Non-Hispanic)

PacificIslander

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 )

Ethnicity and Adolescent Suicidality

166 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

Multiracial (Hispanic) youth showedpeaks in prevalence in 2003.

3. #4 & #5: Across grade levels, bothsuicide attempts and severe suicideattempts overall generally decreasedslightly for most ethnicities, but Asiansand Pacific Islanders showed an increas-ing trend.

DISCUSSION

This study fills a scientific gap of knowledgeregarding youth risk factors for suicideamong ethnic minorities, by comparingmultiracial youth to monoracial youth, andby disaggregating the heterogeneous Asianand Pacific Islander ethnic group. Our find-ings support the conclusion that multiracialand Pacific Islander adolescents are groupsat high-risk for suicide. The first hypothesisof greater risk status for multiracial adoles-cents compared to their monoracial peers

is supported by our results. Both groupsof multiracial adolescents, similar to Amer-ican Indians, had at least 13 odds ratios sig-nificantly greater than 1.0. For example,both groups of multiracial adolescents weremore likely to report depression symptoms,suicide ideation, suicide planning, and sui-cide attempts in the past year compared toWhite and Black youth (OR: 1.32–2.45;p< .0001). Notably, non-Hispanic multira-cial youth reported a significantly higherprevalence of suicide ideation and planningcompared to Hispanic multiracial youth(OR: 1.45, 1.39; p< .0001).

The second hypothesis of greater riskstatus of Pacific Islanders compared toAsians is strongly supported. Comparedto Asians, Pacific Islander adolescentswere more likely to report depressivesymptoms, serious consideration of suicide,suicide planning, suicide attempts, and sui-cide attempts requiring medical attention

TABLE 3. Continued

Suicide-relateditem White Black Asian Hispanic

Multiracial(Hispanic)

AmericanIndian

Multiracial(Non-Hispanic)

PacificIslander

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 atgreater risk than the second group (first row of numbers in Table 3), and the ratio is less than 1.0 when thefirst group is at lower risk. For example, Pacific Islanders had a statistically significant 1.78-fold increased riskof depression as compared to Whites. The odds ratios on the upper-left of the table are reciprocals (1=oddsratio) of the bottom-right odds ratios. For example, Pacific Islanders had a 1.78-fold increased risk fordepression as compared to Whites (upper-left of table), and Whites had 0.56 the risk for depression as comparedto Pacific Islanders (bottom-right of table). 1=0.56¼ 1.78.�p< .0001.

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 167

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

TABLE 4. Prevalences of Significant Two-Way Interaction Effects (p< .0001)

1999 (%) 2001 (%) 2003 (%) 2005 (%) 2007 (%) 2009 (%)

A. Suicide Planning: Ethnicity�Year

American Indian 24.3 20.0 26.5 13.8 14.7 17.0

Asian 17.9 18.1 24.5 13.3 10.8 12.6

Black 11.7 10.3 10.4 9.6 9.5 9.8

Hispanic 15.8 13.3 17.9 13.5 10.4 10.1

Multiracial (Hispanic) 25.1 19.1 16.0 16.3 15.3 15.1

Multiracial (Non-Hispanic) 24.2 17.9 26.7 26.4 15.3 13.2

Pacific Islander 29.5 23.3 26.9 28.1 21.3 13.2

White 12.4 15.3 16.2 12.5 10.8 10.3

B. Severe Suicide Attempt Overall: Ethnicity�Year

American Indian 15.4 6.6 3.6 5.4 2.2 1.9

Asian 1.9 2.4 5.5 1.9 2.1 1.4

Black 2.9 3.3 2.9 1.9 2.3 2.5

Hispanic 2.5 3.3 4.5 2.6 1.9 1.8

Multiracial (Hispanic) 4.6 3.9 3.7 4.1 3.8 2.8

Multiracial (Non-Hispanic) 4.9 3.6 4.4 1.6 3.3 4.2

Pacific Islander 4.6 3.2 13.9 9.9 1.4 3.8

White 1.9 2.3 1.6 2.0 1.5 1.6

C. Severe Suicide Attempt Among Only Those Who Attempted: Ethnicity�Year

American Indian 80.1 33.8 30.6 33.8 15.5 19.7

Asian 27.0 24.5 39.2 28.1 38.0 34.1

Black 39.0 38.0 40.9 29.4 29.9 31.4

Hispanic 19.7 27.4 43.1 25.3 21.7 26.1

Multiracial (Hispanic) 35.5 29.1 52.5 34.2 33.2 28.5

Multiracial (Non-Hispanic) 39.4 30.2 25.1 13.9 30.1 33.5

Pacific Islander 21.8 18.2 74.5 51.6 14.9 39.5

White 28.5 29.4 24.7 28.8 26.8 31.4

Grade 9 (%) Grade 10 (%) Grade 11 (%) Grade 12 (%)

D. Suicide Attempt: Ethnicity�Grade Level

American Indian 18.7 18.6 16.2 8.0

Asian 7.9 6.0 8.0 8.7

Black 8.5 8.2 7.2 7.3

Hispanic 11.5 12.0 8.8 7.4

Multiracial (Hispanic) 12.2 10.9 8.6 9.3

Multiracial (Non-Hispanic) 16.9 14.0 10.5 9.4

Pacific Islander 12.9 17.5 15.9 24.2

White 8.2 7.9 5.9 3.8

E. Severe Suicide Attempt Overall: Ethnicity�Grade Level

American Indian 6.6 5.4 8.7 2.0

Asian 2.5 1.1 1.9 3.6

(Continued )

Ethnicity and Adolescent Suicidality

168 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

(OR: 1.58–2.69; p< .0001). Indeed, PacificIslander adolescents endorsed the highestrisk for suicide-related responses by eth-nicity, with 21 out of 35 odds ratios signifi-cantly greater than 1.0 overall.

Our findings demonstrate that multira-cial adolescents are at relatively high risk ofsuicide, with a risk comparable to that ofAmerican Indian youth. The literature hasrecognized American Indian adolescents asan at-risk population, but empirical researchhas only recently emerged to suggest similarvulnerabilities among multiracial youth.Such studies have found that multiracialadolescents report higher rates of poormental health and academic adjustment,and greater risk behaviors, such as substanceuse and violence (Choi, Harachi, Gilmoreet al., 2006; Cooney & Radina, 2000; Olvera,2001; Roberts, Chen, & Roberts, 1997;Udry, Li, & Hendrickson-Smith, 2003;Whaley & Francis, 2006). Given the con-tinuing growth of the multiracial popula-tion, there is a vital need to understand themental health concerns of this youth group.

This is also the first national study toshow that by ethnicity, Pacific Islanderadolescents are at the highest risk for sui-cide in the United States. Over 1 in 6(17.4%) Pacific Islander adolescentsreported a suicide attempt in the past yearand nearly 1 in 15 (6.5%) made a suicideattempt that required medical attention—prevalences more than double the nationalrates of 7.8% and 2.3%, respectively.Compared to Asians, Pacific Islander youth

endorse significantly greater risk factorssuicide. This finding is consistent with pre-vious literature illustrating considerable dif-ferences in health-risk behaviors betweenthe two API ethnic groups (Choi, 2008;Sasaki & Kameoka, 2009; Wong, Klingle,& Price, 2004).

It is critical to explicate the root causesfor these findings. Further research isneeded on how culture and cultural identi-fication influence methodological andpsychological issues of risk factors for sui-cide. For example, methodologically, alower prevalence for Asians may be par-tially due to shame in self-disclosure of riskfactors for suicide. From a psychologicalperspective, the higher rates for PacificIslanders, including Native Hawaiians,may be related to issues of acculturativestress and cultural conflict.

As immigrants from their nativeislands, non-Hawaiian Pacific Islandersresiding in the United States have had toovercome cultural and socioeconomic bar-riers that cause acculturative stress and lossof ethnic identity. For Native Hawaiians,similar to other indigenous peoples, coloni-alism (e.g., loss of the ‘aina or land, over-throw of the monarchy by the UnitedStates), ‘‘foreign’’ diseases, and a dramaticshift to more individualistic values havehad a devastating inter-generational effecton the family structure, health, and well-being of Native Hawaiians (Blaisdell, 1993).Indeed, investigations into the higher youthsuicide rates among aboriginals in Canada

TABLE 4. Continued

Grade 9 (%) Grade 10 (%) Grade 11 (%) Grade 12 (%)

Black 2.4 2.9 2.5 2.4

Hispanic 3.2 3.3 2.8 1.8

Multiracial (Hispanic) 3.1 3.3 3.5 3.0

Multiracial (Non-Hispanic) 3.8 4.7 4.2 3.7

Pacific Islander 2.8 10.2 5.3 9.2

White 2.6 2.0 1.6 1.0

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 169

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

and indigenous Polynesians in NewZealand suggest risk factors including his-torical oppression, and disruptions to adeveloping sense of personal and culturalpersistence (Beautrais & Ferusson, 2006;Chandler, Lalonde, Sokol et al., 2003;Kirmayer, Brass, & Tait, 2000).

Native Hawaiians have the shortestlife expectancy in their own homeland ascompared to the other major ethnic groupsin Hawaii (Park, Braun, Horiuchi et al.,2009). Moreover, there is a disproportio-nately high prevalence of psychiatric symp-toms and disorders among NativeHawaiian youth, and risk factors for suicidemay be a manifestation of this psychologi-cal distress (Andrade, Hishinuma, McDer-mott et al. 2006; Conwell, Duberstein, &Cox, 1996). Notably, a series of psychologi-cal autopsies of Pacific Islander and Hawai-ian youth who committed suicide foundthat the act of suicide was often precededby emotions described as depression, withthe act itself having connotations of anappeal to older family members (Else,Andrade, & Nahulu, 2007).

A different set of reasons may underliethe risk factors for suicide among multira-cial adolescents, as suggested by thedecrease in suicide attempts with gradelevel, a trend that contrasts the increaseseen among Pacific Islanders. The mostcommon explanation for the high preva-lence of health-risk behaviors among multi-racial adolescents is their struggle withpositive identity formation, an importantdevelopmental factor for reducing riskand enhancing resiliency (Lalonde, 2006).The most common subcategories withinthe multiracial population are White andBlack, White and Asian, White and Ameri-can Indian, and White, and ‘‘some otherrace’’—a box checked mainly byHispanics (United States Census Bureau,2001). Because of their multiple heritages,multiracial youths may face greater dif-ficulty forming a positive ethnic identity,due to feelings of ambivalence and=or

divided loyalties between two or more setsof cultural values. Indeed, a recurring themein interviews with multiracial adolescentswas a sense of inauthenticity and shamewith regard to identity (Bowles, 1993). Thislack of positive identity formation maylead to social isolation and low self-esteem(Gibbs, 1987; Root, 1992). In addition,peer acceptance may be a salient stressorfor multiracial youths due to their poten-tially ambiguous racial status and theabsence of a natural peer group (Root,1992). The need to be accepted has beentheorized to cause increased engagementof high-risk behaviors in this population(Gibbs, 1987). Finally, family dynamicsmay play a role, with one study finding thatmultiracial boys are less communicativeand emotionally close with their fathers(Radina & Cooney, 2000).

A few limitations should be notedgiven the nature of the YRBS as self-reported secondary survey data. First, wewere not able to control for socioeconomicstatus, and thus unable to investigatewhether these ethnic disparities were dueto socioeconomic stressors or other psy-chosocial influences. Second, the YRBSdata set does not include corroboratingobjective data to supplement the self-reportdata. However, given the underestimationof internalizing disorders by parents andteachers, self-report data are importantin determining difficulties being experi-enced by adolescents. Third, although thepresent study examined cross-sectional pre-valences across time, the data were notlinked per youth, thus precluding risk fac-tor analyses involving longitudinal growthmodeling and group trajectories. Fourth,the YRBS is administered only in schools,and therefore, may not capture data fromyouth who are absent, suspended ordropped out from school—an adolescentsubgroup at higher risk for suicide (Gould,Fisher, Parides et al., 1996). Thus, theprevalence of risk factors of suicidereported in the present study are likely to

Ethnicity and Adolescent Suicidality

170 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

be under-estimates of the population rates.And fifth, the YRBS fails to disaggregatewithin each of the Asian, Pacific Islander,and multiracial populations. Studies ofAsian subgroups have already demon-strated that ethnic subgroups within thesecategorical umbrellas may show divergingtrends of youth risk behavior prevalence(Choi, 2008; Mayeda, Hishinuma, Nishi-mura et al., 2006). Our findings also showthat within the multiracial population,those identifying as part-Hispanic reporteda lower prevalence of suicide ideation andplanning compared to their non-Hispanicmultiracial peers. Additional studies shouldbe conducted to better understand suicideacross ethnic subgroups.

Despite these limitations, given ourfindings of significant ethnic disparities inyouth risk factors for suicide, furtherresearch should focus on identifying alter-able risk and protective factors that thatmay be unique to certain populations. Ofparticular importance in the context of eth-nicity, cultural identification, and adjustmentis to assess and intervene from astrengths-based, positive youth develop-ment approach whereby constructs such asresilience play a more prominent role(Werner & Smith, 2001). Furthermore,research is also needed on the intersectionbetween culture and methodology, such associo-cultural influences that may discour-age self-disclosure and contribute to ethnicdisparities in risk factors for suicide. Furtherknowledge of the determinants of youth sui-cide will greatly enhance the development ofculturally responsive prevention interven-tions and policies to eliminate youth suicideand ethnic disparities in mental health.

AUTHOR NOTE

Shane Shucheng Wong, Department ofPsychiatry and Behavioral Sciences, Divisionof Child and Adolescent Psychiatry, School

of Medicine, Stanford University, Stanford,California; Asian=Pacific Islander YouthViolence Prevention Center (APIYVPC),Department of Psychiatry, University ofHawaii at Manoa, Honolulu, Hawaii, USA.

Jeanelle J. Sugimoto-Matsuda, Janice Y.Chang, and Earl S. Hishinuma, Asian=Pacific Islander Youth Violence PreventionCenter (APIYVPC), Department of Psy-chiatry, University of Hawaii at Manoa,Honolulu, Hawaii, USA.

This manuscript was supported bythe Centers for Disease Control andPrevention (CDC; R49=CCR918619-05;Cooperative Agreement #1 U49=CE000749-01), University of Hawaii atManoa, Department of Psychiatry, andthe Stanford University Medical ScholarsProgram (Mr. Wong).

The contents of this article are solelythe responsibility of the authors and donot necessarily represent the official viewsof the funding agencies. The authors wouldalso like to express their appreciation to theresearchers and administrators of theAsian=Pacific Islander Youth ViolencePrevention Center (APIYVPC) andDepartment of Psychiatry, University ofHawaii at Manoa.

Correspondence concerning this articleshould be addressed to Shane ShuchengWong, Department of Psychiatry andBehavioral Sciences, Division of Child &Adolescent Psychiatry, Stanford UniversitySchool of Medicine, 401 Quarry Road,Stanford, CA 94305. E-mail: wongss@-stanford.edu

REFERENCES

Andrade, N. N., Hishinuma, E. N., McDermott, J. F.,

Johnson, R. C., Goebert, D. A., Makini, G.K. . . .Waldron, J. A. (2006). The National Center on

Indigenous Hawaiian Behavioral Health study of

prevalence of psychiatric disorders in Native

Hawaiian adolescents. Journal of the American Academy

of Child and Adolescent Psychiatry, 45(1), 26–36.

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 171

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

Beautrais, A. L., & Fergusson, D. M. (2006). Indigen-

ous suicide in New Zealand. Archives of Suicide

Research, 10(2), 159–168.

Blaisdell, R. K. (1993). The health status of Kanaka

Maoli (indigenous Hawaiians). Asian American and

Pacific Islander Journal of Health, 1(2), 116–160.

Booth, H. (1999). Pacific island suicide in compara-

tive perspective. Journal of Biosocial Science, 31(4),

433–448.

Bowles, D. D. (1993). Bi-racial identity: children

born to African-American and White couples.

Clinical Social Work Journal, 21(4), 417–428.

Centers for Disease Control and Prevention. (2009).

Alcohol and suicide among racial=ethnic popula-

tions – 17 states, 2005–2006. Morbidity and Mortality

Weekly Report, 58(23), 637–641.

Centers for Disease Control and Prevention. (2010).

WISQARS leading causes of death reports, 1999–2007.

Retrieved from http://webappa.cdc.gov/sasweb/

ncipc/leadcaus10.html

Chandler, M. J., Lalonde, C., Sokol, B., & Hallett, D.

(2003). Personal persistence, identity development,

and suicide: A study of Native and Non-native

North American adolescents. Monographs of the

Society for Research on Child Development, 68(2), 1–138.

Choi, Y. (2008). Diversity within: subgroup differ-

ences of youth problem behaviors among Asian

Pacific Islander American adolescents. Journal of

Community Psychology, 36(3), 352–370.

Choi, Y., Harachi, T. W., Gillmore, M. R., &

Catalano, R. F. (2006). Are multiracial adolescents

at greater risk? Comparisons of rates, patterns and

correlates of substance use and violence between

monoracial and multiracial adolescents. American

Journal of Orthopsychiatry, 76(1), 86–97.

Colucci, E., & Martin, G. (2007). Ethnocultural

aspects of suicide in young people: A systematic

literature review. Part 1: Rates and methods of

youth suicide. Suicide and Life Threatening Behavior,

37(2), 197–221.

Conwell, Y., Duberstein, P. R., Cox, C., Herrmann, J.

H., Forbes, N. T., & Caine, E. D. (1996). Relation-

ships of age and axis I diagnoses in victims of

completed suicide: a psychological autopsy study.

American Journal of Psychiatry, 153(8), 1001–1008.

Cooney, T. M., & Radina, M. E. (2000). Adjustment

problems in adolescence: Are multiracial children

at risk? American Journal of Orthopsychiatry, 70(4),

433–444.

Danko, G. P., Miyamoto, R. H., Foster, J. E., Johnson,

R. C., Andrade, N. N., Yates, A., & Edman, J. L.

(1997). Psychiatric symptoms in offspring of within

vs. across racial=ethnic marriages. Cultural Diversity

and Mental Health, 3(4), 273–277.

Else, I. R., Andrade, N. N., & Nahulu, L. B. (2007).

Suicide and suicidal-related behaviors among

indigenous Pacific Islanders in the United States.

Death Studies, 31(5), 479–501.

Evans, E., Hawton, K., Rodham, K., & Deek, J.

(2005). The prevalence of suicide phenomena in

adolescents: A systematic review of population-

based studies. Suicide and Life Threatening Behavior,

35(3), 239–250.

Gibbs, J. T. (1987). Identity and marginality: Issues in

the treatment of biracial adolescents. American

Journal of Orthopsychiatry, 57(2), 265–278.

Gould, M. S., Fisher, P., Parides, M., Flory, M., &

Shaffer, D. (1996). Psychosocial risk factors of

child and adolescent completed suicide. Archives

of General Psychiatry, 53(12), 1155–1162.

Gould, M. S., Greenberg, T., Velting, D. M., &

Shaffer, D. (2003). Youth suicide risk and preven-

tive interventions: A review of the past 10 years.

Journal of the American Academy of Child and Adolescent

Psychiatry, 42(4), 386–405.

Grunbaum, J. A., Lowry, R., Kann, L., & Pateman, B.

(2000). Prevalence of health risk behaviors among

Asian American=Pacific Islander high school stu-

dents. Journal of Adolescent Health, 27(5), 322–330.

Johnson, R. C., & Nagoshi, C. T. (1986). The adjust-

ment of offspring of within-group and interracial=intercultural marriages: A comparison of person-

ality factor scores. Journal of Marriage and the Family,

48(2), 279–284.

Kessler, R. C., Borges, G., & Walters, E. E. (1999).

Prevalence and risk factors for lifetime suicide

attempts in the National Comorbidity Survey.

Archives of General Psychiatry, 56(7), 617–626.

Kirmayer, L. J., Brass, G. M., & Tait, C. L. (2000).

The mental health of Aboriginal peoples: Trans-

formations of identity and community. Canadian

Journal of Psychiatry, 45(7), 607–616.

Kisch, J., Leino, E. V., & Silverman, M. M. (2005).

Aspects of suicidal behavior, depression and treat-

ment in college students: Results from the spring

2000 National College Health Assessment Survey.

Suicide and Life Threatening Behavior, 35(1), 3–13.

Lalonde, C. E. (2006). Identity formation and cul-

tural resilience in Aboriginal communities. In R.

J. Flynn, P. M. Dudding, & J. G. Barber (Eds.),

Promoting resilience in child welfare (pp. 52–71).

Ottawa, ON: University of Ottawa Press.

Mann, J. J., Waternaux, C., Haas, G. L., & Malone,

K. M. (1999). Toward a clinical model of suicidal

Ethnicity and Adolescent Suicidality

172 VOLUME 16 � NUMBER 2 � 2012

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014

behavior in psychiatric patients. American Journal of

Psychiatry, 156(2), 181–189.

Mayeda, D. T., Hishinuma, E. S., Nishimura, S. T.,

Garia-Santiago, O., & Mark, G. Y. (2006).

Asian=Pacific Islander Youth Violence Prevention

Center: Interpersonal violence and deviant

behaviors among youth in Hawaii. Journal of

Adolescent Health, 39(2), 276.e1–11.

Olvera, R. L. (2001). Suicidal ideation in Hispanic

and mixed-ancestry adolescents. Suicide and Life

Threatening Behavior, 31(4), 416–427.

Park, C. B., Braun, K., Horiuchi, B., Tottori, C., &

Onaka, A. T. (2009). Longevity disparities in

multiethnic Hawaii: An analysis of 2000 life tables.

Public Health Reports, 124(4), 579–584.

Radina, M. E., & Cooney, T. M. (2000). Relationship

quality between multiracial adolescents and their

biological parents. American Journal of Orthopsychia-

try, 70(4), 445–454.

Roberts, R. E., Chen, Y. R., & Roberts, C. R. (1997).

Ethnocultural differences in prevalence of ado-

lescent suicidal behaviors. Suicide and Life Threaten-

ing Behavior, 27(2), 208–217.

Root, M. P. P. (1992). Racially mixed people in America.

Newbury Park, CA: Sage.

Sasaki, P. Y., & Kameoka, V. A. (2009). Ethnic var-

iations in prevalence of high-risk sexual behaviors

among Asian and Pacific Islander adolescents in

Hawaii. American Journal of Public Health, 99(10),

1886–1892.

Schuster, M. A., Bell, R. M., Nakajima, G. A., &

Kanouse, D. E. (1998). The sexual practices of

Asian and Pacific Islander high school students.

Journal of Adolescent Health, 23(4), 221–231.

Shiang, J., Binn, R., Bongar, B., Stephens, B.,

Alison, D., & Schatzberg, A. (1997). Suicide in

San Francisco, CA: A comparison of Caucasian

and Asian groups, 1987–1994. Suicide and Life

Threatening Behavior, 27(1), 80–91.

United States Census Bureau. (2001). Census 2000

summary file (SF 1) 100-percent data: Table p3

race. Retrieved from http://www.factfinder.cen-

sus.gov

United States Census Bureau. (2010). Annual popu-

lation estimates: t3-race. Retrieved from¼ http://

www.factfinder.census.gov

Udry, J. R., Li, M. R., & Hendrickson-Smith, J.

(2003). Health and behavior risks of adolescents

with mixed-race identity. American Journal of Public

Health, 93(11), 1865–1870.

Werner, E. E., & Smith, R. S. (2001). Journeys from

childhood to midlife: Risk, resilience, and recovery. Ithaca,

NY: Cornell University Press.

Whaley, A. L., & Francis, K. (2006). Behavioral

health in multiracial adolescents: The role of

Hispanic=Latino ethnicity. Public Health Reports,

121(2), 169–174.

Wong, M. M., Klingle, R. S., & Price, R. K. (2004).

Alcohol, tobacco and other drug use among Asian

American and Pacific Islander adolescents in

California and Hawaii. Addictive Behaviors, 29(1),

127–141.

Yuen, N., Andrade, N., Nahulu, L., Markini, G.,

McDermott, J. F., Danko, G., . . . Waldron, J.

(1996). The rate and characteristics of suicide attemp-

ters in the Native Hawaiian adolescent population.

Suicide and Life Threatening Behavior, 26(1), 27–36.

Yuen, N. Y., Nahulu, L. B., Hishinuma, E. S., &

Miyamoto, R. H. (2000). Cultural identification

and attempted suicide in Native Hawaiian adoles-

cents. Journal of the American Academy of Child and

Adolescent Psychiatry, 39(3), 360–367.

S. S. Wong et al.

ARCHIVES OF SUICIDE RESEARCH 173

Dow

nloa

ded

by [

Nor

thea

ster

n U

nive

rsity

] at

15:

43 1

0 O

ctob

er 2

014