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Archives of Suicide Research

ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20

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 &
Earl S. Hishinuma

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

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

Published online: 02 May 2012.

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Download by: [Colorado State University] Date: 22 June 2017, At: 08:57
Archives of Suicide Research, 16:159–173, 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 1999–2009 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

INTRODUCTION Disease Control and Prevention, 2010).
Unfortunately, completed suicides reflect
Suicide is a major public health concern for only a small proportion of suicide-related
American adolescents. As the third leading thoughts, behaviors and injuries among
cause of death among youth 14 to 18 years youth. There are many risk factors, from
of age, it accounts for 11 percent of depression and suicide ideation to suicide
all deaths in this age group (Centers for planning and suicide attempts, that predict

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’’ group—implying 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)’’

160 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

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.’’

ARCHIVES OF SUICIDE RESEARCH 161
Ethnicity and Adolescent Suicidality

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, N ¼ 87,293] ¼ 8,514.4, p < .0001.
b
Gender (weighted): v2[1, N ¼ 88,199] ¼ 3.1, p ¼ .08.
c
Grade Level (weighted): v2[3, N ¼ 88,032] ¼ 280.3, p < .0001.
d
Year (weighted): v2[5, N ¼ 88,532] ¼ 1.2, p ¼ .94.
e
Weighted based on ethnicity, gender, and grade level.

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

162 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

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 ¼
who attempted in the past. By year, the pre- 21:0; Multiracial (non-Hispanic) ¼ 20:0;
valences decreased over the last decade, American Indian ¼ 15:0; Multiracial

ARCHIVES OF SUICIDE RESEARCH 163
Ethnicity and Adolescent Suicidality

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
28.4–37.0 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 35.0 27.2 21.6 13.1 4.1 31.8
(Non-Hispanic) 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 )

164 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

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

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
Severe attempt for
Suicide Suicide Suicide Severe attempt those who
Depression ideation planning attempt overall attempted

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.

(Hispanic) ¼ 13:4; Hispanic ¼ 8:14; Asian ¼ effect, and the ethnicity-gender interaction
3:14; Black ¼ 3:26; and White ¼ 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

ARCHIVES OF SUICIDE RESEARCH 165
Ethnicity and Adolescent Suicidality

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

Suicide-related Multiracial American Multiracial Pacific
item White Black Asian Hispanic (Hispanic) Indian (Non-Hispanic) Islander

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 )

166 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

TABLE 3. Continued

Suicide-related Multiracial American Multiracial Pacific
item White Black Asian Hispanic (Hispanic) Indian (Non-Hispanic) Islander

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 ¼ 1.78. 

p < .0001.

Multiracial (Hispanic) youth showed is supported by our results. Both groups
peaks in prevalence in 2003. of multiracial adolescents, similar to Amer-
3. #4 & #5: Across grade levels, both ican Indians, had at least 13 odds ratios sig-
suicide attempts and severe suicide nificantly greater than 1.0. For example,
attempts overall generally decreased both groups of multiracial adolescents were
slightly for most ethnicities, but Asians more likely to report depression symptoms,
and Pacific Islanders showed an increas- suicide ideation, suicide planning, and sui-
ing trend. cide attempts in the past year compared to
White and Black youth (OR: 1.32–2.45;
DISCUSSION p < .0001). Notably, non-Hispanic multira-
cial youth reported a significantly higher
This study fills a scientific gap of knowledge prevalence of suicide ideation and planning
regarding youth risk factors for suicide compared to Hispanic multiracial youth
among ethnic minorities, by comparing (OR: 1.45, 1.39; p < .0001).
multiracial youth to monoracial youth, and The second hypothesis of greater risk
by disaggregating the heterogeneous Asian status of Pacific Islanders compared to
and Pacific Islander ethnic group. Our find- Asians is strongly supported. Compared
ings support the conclusion that multiracial to Asians, Pacific Islander adolescents
and Pacific Islander adolescents are groups were more likely to report depressive
at high-risk for suicide. The first hypothesis symptoms, serious consideration of suicide,
of greater risk status for multiracial adoles- suicide planning, suicide attempts, and sui-
cents compared to their monoracial peers cide attempts requiring medical attention

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Ethnicity and Adolescent Suicidality

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 )

168 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

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

(OR: 1.58–2.69; 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

ARCHIVES OF SUICIDE RESEARCH 169
Ethnicity and Adolescent Suicidality

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
race’’—a box checked mainly by youth who are absent, suspended or
Hispanics (United States Census Bureau, dropped out from school—an 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

170 VOLUME 16  NUMBER 2  2012
S. S. Wong et al.

be under-estimates of the population rates. of Medicine, Stanford University, Stanford,
And fifth, the YRBS fails to disaggregate California; Asian=Pacific Islander Youth
within each of the Asian, Pacific Islander, Violence Prevention Center (APIYVPC),
and multiracial populations. Studies of Department of Psychiatry, University of
Asian subgroups have already demon- Hawaii at Mānoa, Honolulu, Hawaii, USA.
strated that ethnic subgroups within these Jeanelle J. Sugimoto-Matsuda, Janice Y.
categorical umbrellas may show diverging Chang, and Earl S. Hishinuma, Asian=
trends of youth risk behavior prevalence Pacific Islander Youth Violence Prevention
(Choi, 2008; Mayeda, Hishinuma, Nishi- Center (APIYVPC), Department of Psy-
mura et al., 2006). Our findings also show chiatry, University of Hawaii at Mānoa,
that within the multiracial population, Honolulu, Hawaii, USA.
those identifying as part-Hispanic reported This manuscript was supported by
a lower prevalence of suicide ideation and the Centers for Disease Control and
planning compared to their non-Hispanic Prevention (CDC; R49=CCR918619-05;
multiracial peers. Additional studies should Cooperative Agreement #1 U49=
be conducted to better understand suicide CE000749-01), University of Hawaii at
across ethnic subgroups. Mānoa, Department of Psychiatry, and
Despite these limitations, given our the Stanford University Medical Scholars
findings of significant ethnic disparities in Program (Mr. Wong).
youth risk factors for suicide, further The contents of this article are solely
research should focus on identifying alter- the responsibility of the authors and do
able risk and protective factors that that not necessarily represent the official views
may be unique to certain populations. Of of the funding agencies. The authors would
particular importance in the context of eth- also like to express their appreciation to the
nicity, cultural identification, and adjustment researchers and administrators of the
is to assess and intervene from a Asian=Pacific Islander Youth Violence
strengths-based, positive youth develop- Prevention Center (APIYVPC) and
ment approach whereby constructs such as Department of Psychiatry, University of
resilience play a more prominent role Hawaii at Mānoa.
(Werner & Smith, 2001). Furthermore, Correspondence concerning this article
research is also needed on the intersection should be addressed to Shane Shucheng
between culture and methodology, such as Wong, Department of Psychiatry and
socio-cultural influences that may discour- Behavioral Sciences, Division of Child &
age self-disclosure and contribute to ethnic Adolescent Psychiatry, Stanford University
disparities in risk factors for suicide. Further School of Medicine, 401 Quarry Road,
knowledge of the determinants of youth sui- Stanford, CA 94305. E-mail: wongss@-
cide will greatly enhance the development of stanford.edu
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