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Follow the guidelines and write a short literature review of 4 articles. 1200-1300 words. lau_et_al__2002__correlates_of_suicidal_behaviors_among_asian_american_outpatients_youths.pdf else_et_al__2009__the_relationship_between_violence_and_youth_suicide_indicators_among_asian_american_and_pacific_islander_youth.pdf bennett_and_joe__2015__exposure_to_community_violence__suicidality__and_psychological_distress_among_african_american_and_latino_youths.pdf deluca_et_al__2012__latina_adolescent_suicide_ideations_and_attempts.pdf guidelines.doc Unformatted Attachment Preview R E S E A R C H R E P O R T This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Correlates of Suicidal Behaviors Among Asian American Outpatient Youths ANNA S. LAU NADINE M. JERNEWALL University of California, Los Angeles NOLAN ZANE University of California, Santa Barbara HECTOR F. MYERS University of California, Los Angeles Medical record abstraction was conducted at an ethnic-specific mental health outpatient clinic to identify correlates of suicidal behaviors in a sample of 285 Asian American youths. Some risk factors, such as parent–child conflict and age, which have been associated with suicidality in majority group youths, predicted suicidality in this sample, whereas other risk factors, such as gender, did not generalize to this sample. Acculturation interacted with the risk factor of parent–child conflict to predict suicidality. Less acculturated Asian youths were at proportionally greater risk for suicidality under conditions of high parent–child conflict than were their more acculturated counterparts. This finding underscores the importance of culture as a context for determining the relevance of stressors for potentiating psychopathology. • suicidal behaviors • acculturation • Asian American youths • Anna S. Lau, Nadine M. Jernewall, and Hector F. Myers, Department of Psychology, University of California, Los Angeles; Nolan Zane, Graduate School of Education, University of California, Santa Barbara. Anna S. Lau is now at the Child and Adolescent Services Research Center, Children’s Hospital, San Diego, California; Nadine M. Jernewall is now at the Department of Psychology, George Washington University; and Nolan Zane is now at the Department of Psychology, University of California, Davis. This study was conducted with the support of the National Research Center on Asian American Mental Health and funded by a grant from the National Institute of Mental Health (No. MH-44331). We thank the following individuals for their contributions to the project: Terry Gock and staff at the Asian Pacific Family Center, Jeannie Huh-Kim, Betty Horng, Bob Chen, Takako Hara, Ed Lee, Mike Shen, and Andrew Yamamoto. Correspondence concerning this article should be addressed to Anna S. Lau, Child and Adolescent Services Research Center, 3020 Children’s Way, MC 5033, San Diego, California 92123. E-mail: alau@casrc.org Cultural Diversity and Ethnic Minority Psychology Vol. 8, No. 3, 199–213 Copyright 2002 by the Educational Publishing Foundation 1099-9809/02/$5.00 DOI: 10.1037//1099-9809.8.3.199 199 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 200 LAU, JERNEWALL, ZANE, Nonfatal suicidal behaviors (i.e., suicidal ideation, threats, gestures, and attempts) are common symptoms among child psychiatric outpatients, with prevalence estimates ranging between 15\% and 33\% (Milling, Gyure, Davenport, & Blair, 1991; Pfeffer, Plutchik, & Mizruchi, 1986). The importance of symptoms of suicidality in youths must be underscored because suicidal attempts and ideation are indicators of the severity, course, and outcome of depression (Lewinsohn, Rohde, & Seeley, 1993) as well as risks for completed suicide (Maris, 1991). Across numerous studies, risk factors including psychopathology, female gender, and maladaptive family situations have been associated with suicidal behaviors among clinic-referred and hospitalized youths. However, our understanding of risk factors for suicidal behavior in children has been based on data from predominantly Euro American samples (e.g., Asarnow, 1992; Harter, Marold, & Whitesell, 1992; Kovacs, Goldston, & Gatsonis, 1993; Lewinsohn et al., 1993). Ethnic-specific studies may help provide culturally relevant information on risk of suicidality and needed interventions in historically underserved and understudied ethnic minority communities. Ethnic variations in rates of completed and attempted suicide have been widely documented. For example, Native Americans have the highest rate of completed suicide of any ethnic group (U.S. Congress, 1986), whereas African Americans are reported to have the lowest completed suicide rate (Bingham, Bennion, Openshaw, & Adams, 1994; U.S. Bureau of the Census, 1986). Comparisons of suicide rates among other ethnic groups yield differing conclusions. Some studies report that Euro Americans have higher rates of completed suicide than Asian and Hispanic Americans (Hope & Martin, 1986; Shiang, 1998), whereas others report similar rates across these groups (Bingham et al., 1994). However, enumeration of completed suicide is problematic. Published suicide rates may underestimate actual rates for ethnic AND MYERS minorities because they rely on public records and official coroners’ verdicts that may be biased with respect to ethnicity and national origin (Neeleman, Mak, & Wessely, 1997). For example, African American youth suicide may be underenumerated because actual suicidal behavior may be masked by high-risk behaviors, such as street violence and substance abuse (Gibbs, 1990). Nevertheless, there is ample evidence that rates of suicidal behaviors vary by ethnic group (Roberts, Chen, & Roberts, 1997), and it is also likely that the correlates of these behaviors vary by group and perhaps within groups. For example, ethnic minority status is a risk factor for suicide in areas in which the density of ethnic minority groups is low, but it appears to be a protective factor in areas with large coethnic communities (Neeleman & Wesseley, 1999). In this article, we hope to elaborate on risk factors for suicidality for Asian American youngsters. Asian American youths from predominantly immigrant families may encounter unique developmental challenges not shared by majority group youths. They are faced with stressors associated with minority and immigrant status, such as racism, discrimination, and cultural rifts within their own families. In view of these ecological differences, it is unclear if the nature and extent of psychosocial risk factors for psychopathology among majority youths hold for Asian American children and adolescents. The present study had two important objectives. First, we sought to determine whether risk factors for suicidal behaviors as identified in studies of majority youths appear culture-bound or whether they are generalizable to Asian American outpatient youths. We reviewed selected risk factors for suicidality identified in studies of majority group youths, including gender, internalizing and externalizing disorders, and poor parent–child relationship. We also considered risk factors that may be culturally relevant to Asian American youths, including stress associated with acculturation. One of the major goals of ethnic minority psychology is to test the external validity of the con- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SUICIDAL BEHAVIORS IN ASIAN AMERICAN YOUTHS clusions generated from the study of majority culture to culturally diverse groups. The second aim of the study was to identify within-group differences in risk factors for suicidal behavior among Asian American outpatient youths. The vast heterogeneity within the Asian American population is widely recognized (Uba, 1994), yet existing research on Asian Americans often fails to attend to issues of intragroup differences in acculturation and ethnicity. Within the Asian American population, some ethnic groups (e.g., Southeast Asian, Korean) appear to have greater mental health needs than others (e.g., Chinese, Japanese; Kuo, 1984; Uehara, Takeuchi, & Smukler, 1994; Ying & Hu, 1994). These findings have been attributed to differences in immigration history, refugee status, trauma experience, and socioeconomic and acculturative stress. These ethnic differences within the Asian American population are obscured when groups are combined in studies (Uehara et al., 1994). Risk Factors for Suicidality Among Majority Group Youths Studies of the correlates of suicidal behaviors among majority group youths indicate that girls appear more likely to demonstrate suicidal ideation and attempts than boys (Kovacs et al., 1993; Woods et al., 1997). This gender difference in suicidal behavior may be related to the tendency for girls to display more internalizing behavior problems (Achenbach, Bird, et al., 1990; Achenbach, Hensley, et al., 1990), which are in turn consistently associated with increased risk of suicidality (Lewinsohn et al., 1993). Regardless of population (inpatient, outpatient, or community), depression is widely recognized as the major risk factor for suicidal behavior. Youths displaying suicidal behaviors have high rates of diagnosable depression (e.g., Brent et al., 1988), and depressed youngsters have elevated levels of suicidal thoughts and attempts (e.g., Myers et al., 1991). 201 Although depression is most commonly thought of as a precursor to suicidal behavior, externalizing disorders have also been implicated as conferring risk. Conduct disorder, antisocial behaviors, and substance abuse are often associated with suicidal behavior, probably due to the shared impulsive nature of these behavioral patterns (Brent et al., 1988; Hoberman & Garfinkel, 1988; Kovacs et al., 1993). In various samples, between one third and one half of suicide attempters displayed antisocial behaviors or substance abuse or conduct disorders (Spirito, Stark, Hart, & Fristad, 1988; Trautman, Rotheram-Borus, Dopkins, & Lewin, 1991). However, the association between externalizing behavior problems and suicidal behaviors has not been consistently replicated (e.g., Garrison, Jackson, Addy, McKeown, & Waller, 1991; Robbins & Alessi, 1985). Externalizing disorders may serve as an aggravating condition rather than a primary risk factor for suicidal behaviors (Kovacs et al., 1993). Another major risk factor for adolescent suicidal behavior involves the lack of parental stability, warmth, or support (Summerville, Kaslow, Abbate, & Cronan, 1994). Suicide attempters have more instability with regards to their caretakers and experience more separations from a parent than do depressed and nondepressed adolescents (De Wilde, Kienhorst, Diekstra, & Wolters, 1992). Just as lack of parental support is a risk factor, high levels of parent–child conflict are associated with increased risk of suicidal behaviors in youths (Asarnow, 1992; Hollis, 1996). The quality of relationships with parents may be more directly related to suicidal ideation than the quality of peer relationships (Harter et al., 1992). Culturally Relevant Risk Factors for Asian American Youths In addition to the risk factors discussed above, ethnic minority youths may have unique experiences that potentiate distress This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 202 LAU, JERNEWALL, ZANE, and suicidal behaviors. Stressful conditions associated with an ethnic minority child’s acculturation to the majority culture include discrimination, feelings of alienation, and identity confusion. These stressors may heighten risk for poor self-esteem, hopelessness, depression, and suicide (Huang, 1994). In the process of acculturation, minority youths who fail to achieve bicultural competence and an adaptive ethnic identity are prone to maladjustment (Berry, Kim, Minde, & Mok, 1987; Phinney, Lochner, & Murphy, 1990). Liu, Yu, Chang, and Fernandez (1990) reported that the rate of completed suicide among foreign-born Asian American youths is higher than for U.S.born Asian American youths. This study explored whether low levels of acculturation are associated with risk for suicidal behaviors among Asian American youths. In addition to the stress inherent in acculturation, increased levels of intergenerational conflict are associated with the acculturation gap between Asian American parents and their children (Lee, Choe, Kim, & Ngo, 2000). Typically, the ethnic minority child acculturates more readily to the dominant culture than do their parents and older generations. Conflicts can arise when Asian American parents disapprove of their children’s adoption of American values and behaviors, taking these as evidence of laxed morality and disregard for their native culture (Yew, 1987). Yet, Asian American parents may in some ways encourage rapid behavioral acculturation so that their children may become interpreters and negotiators in the new culture (Huang, 1994). Asian American youths may experience confusion and conflict when their parents send mixed messages about acculturation. Both acculturation stress and intergenerational acculturation conflicts have been identified as contributing influences in suicidal behavior among Asian youths in Great Britain, where young South Asian women are overrepresented among patients who have attempted suicide (Bhugra, Desai, & Baldwin, 1999; Handy, Chithiramohan, Ballard, & Silveira, 1991; Merrill & Owens, AND MYERS 1986). Among Asian youths who received emergency medical attention for suicide attempts, 76\% reported some form of cultural conflict as a contributing factor to their attempt, with a disciplinary crisis between parent and child as the most common precipitating factor (Handy et al., 1991). These cultural conflicts included disagreements with parents over issues such as style of dress, dating, relationships with Caucasian peers, and rules governing communication. The relationship between intergenerational conflict and child distress may be even more pronounced for Asian American youths than for Euro American youths. In contrast to Western cultural norms valuing individuation and independence, Asian cultural values are collectivistic in nature and are governed by notions of hierarchy, role obligations, and promotion of harmony. The values of family and filial piety include reverence for elders, obedience, and maintenance of family traditions. These tenets discourage or prohibit open conflict between children and their parents. In the interest of maintaining harmony, individuals are expected to avoid confrontation, conform to rules of propriety, and give “face” or respect to others (Chan, 1992). Although overt parent–child conflict is a normative part of development in Euro American culture, it may be more distressing for Asian Americans. Greenberger, Chen, Tally, and Dong (2000) reported that the quality of family relationships has stronger influences on depression among Chinese youths than among U.S. youths. We hypothesize that parent–child conflict may be more distressing to less acculturated Asian American youths who hold more traditional values than it is to highly acculturated Asian American youths. In a similar manner, acculturation may moderate the association between diagnosis and risk of suicidal behaviors. It has been observed that there is cultural variability in the expression and manifestation of depression (Marsella, Sartorius, Jablensky, & Fenton, 1985). For example, much has been written about the tendency of Asians to re- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SUICIDAL BEHAVIORS IN ASIAN AMERICAN YOUTHS port a predominance of somatic complaints and vegetative symptoms rather than the core cognitive and affective components of depression (Kleinman, 1977). If feelings of existential despair and suicidal thoughts are bound by ethnocultural lines and are associated with a Western manifestation of depression, we might expect that less acculturated depressed Asian American youths may be less likely to exhibit suicidal behaviors than their more highly acculturated counterparts. In this way, individual differences in acculturation may moderate the relationship between a diagnosis of depression and suicidality. In summary, the present study explored the following research questions: (a) Do the risk factors for suicidality found in the general literature hold for Asian American youths? (b) Are there ethnic differences in risk of suicidality among Asian American youths? (c) How do intragroup differences in acculturation among Asian American youths affect the risk of suicidal behaviors? (d) Does one’s level of acculturation moderate the relationship between other risk factors and suicidality? Method Sample The participants were 285 Asian American children and adolescents between the ages of 4 and 17 years (M = 12.94) who had received outpatient mental health services at the Asian Pacific Family Center in Rosemead, California, between March 1985 and February 1993. The sample was comprised of a complete enumeration of closed child and adolescent cases at the time of data collection in 1995. This clinic was established specifically to meet the cultural and linguistic needs of the local Asian American community. The participants were defined either as suicidal (displaying suicidal ideation at intake or having a history of suicide attempts 203 or gestures) or as nonsuicidal. Thirteen percent of the sample (n = 37) were categorized in the suicidal group, and 87\% (n = 248) were categorized as nonsuicidal. Of the 37 suicidal youths, 15 had a history of suicidal self-injurious behavior, 12 displayed active suicidal ideation at the time of intake, and 10 had both a history of suicide attempt and displayed active ideation at intake. This rate of suicidal involvement is on the low end of the range found in previous studies of youth outpatient samples (Milling et al., 1991; Pfeffer et al., 1986). Procedure Undergraduate research assistants were trained in data extraction procedures to code information from closed client charts. Coders were trained in a sequential method of searching through standardized chart forms for information pertinent to the variables of interest. Most forms were completed by the clinician, with one bilingual form (English and client’s native language) filled out by the parent. All forms in the client charts were documented in English, although clinical interviews may have occurred in the client’s native language. Thus, no translation procedures were required for data extraction. Because all data were gathered from secondary sources (clinic archives), there was no direct contact with participants, thus requirements for informed consent were waived by the institutional review board governing this project. A National Institute of Mental Health Certificate of Confidentiality was issued to protect against third-party subpoena of data accessed for the study. All of the research assistants were trained regarding research ethics and procedures for protecting the confidentiality of the participants. No primary identifying information (e.g., names, social security numbers) was extracted from the client records. Recording of secondary identifiers was avoided (e.g., addresses, zip codes), with the exception of date of birth, which was used to calculate age. A team of 10 raters gathered and 204 LAU, JERNEWALL, ZANE, coded the data, with each client chart being independently coded by 2 raters. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Mea ... Purchase answer to see full attachment