The relationship between violence and youth suicide indicators among Asian
American and Pacific Islander youth
‘Iwalani R.N. Else a,b,
âŽ, Deborah A. Goebert a,b
, Cathy K. Bell a,c
, Barry Carlton a,c
, Michael Fukuda a
a National Center for Indigenous Hawaiian Behavioral Health, Department of Psychiatry, John A. Burns School of Medicine, University of Hawai’i at MÄnoa, USA b Asian/Pacific Islander Youth Violence Prevention Program, Department of Psychiatry, John A. Burns School of Medicine, University of Hawai’i at MÄnoa, USA c The Family Treatment Center, Department of Psychiatry, John A. Burns School of Medicine, University of Hawai’i at MÄnoa, USA
article info abstract
Available online 14 July 2009
The literature documents a relationship between interpersonal violence and suicide. One tool used to understand interpersonal violence is the Power Wheel, developed from clinical experience and originally used in
domestic violence education. We examine the relationship between Teen Power and Control Wheel domains
and suicidal indicators (seriously considered suicide, made a suicide plan, and attempted suicide) among Asian
American and Pacific Islander high school students, in terms of both victimization and perpetration. Data from
a 2007 survey of two multi-ethnic high schools on the island of O’ahu, Hawai’i were used. The survey assessed
interpersonal youth violence and a multitude of risk and protective factors. It found that females were
significantly more likely to seriously consider suicide and attempt suicide, compared to males. There were no
statistically significant differences in seriously considering suicide, making a suicide plan, and attempting
suicide by ethnic group, employment status, or hours worked per week. Using the Wheel, we found that
all dimensions for victimization and perpetration were associated with the three suicidal indicators. However,
the magnitude of this association was dramatically higher for victims than for perpetrators. School- and
healthcare-based prevention strategies should ensure that both suicide and violence intervention components
are addressed. Professionals who work with youth should be trained to feel comfortable, confident, and
competent in discussing suicide and violence, and be willing and capable to assess and intervene.
Â© 2009 Elsevier Ltd. All rights reserved.
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
2.1. Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
2.1.1. Domains of the Teen Power and Control Wheel for victimization and perpetration . . . . . . . . . . . . . . . . . . . . . 471
2.1.2. Sociodemographic variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
2.1.3. Suicidal indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
2.2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
4.1. Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
Suicide and interpersonal violence are leading health problems for
youth in the United States. Although a strong relationship between
them has been shown, most studies treat these outcomes separately.
Aggression and Violent Behavior 14 (2009) 470â€“477
Abbreviation: AAPI, Asian American and Pacific Islander.
âŽ Corresponding author. Department of Psychiatry, John A. Burns School of Medicine,
University of Hawai’i at MÄnoa, 1356 Lusitana St., 4th Floor, Honolulu, Hawai’i, 96813,
USA. Tel.: +1 808 586 2900; fax: +1 808 586 2940.
E-mail address: [email protected] (‘I.R.N. Else).
1359-1789/$ â€“ see front matter Â© 2009 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Aggression and Violent Behavior
This study examines the impact of interpersonal violence among
youth on suicide behaviors, specifically for Asian American and Pacific
Islander (AAPI) populations.
Over the past six decades, suicide has become the fastest growing
cause of death of American youth, with rates nearly tripling between
the 1950s and the mid-1990s (U.S. Public Health Service, 1999). After
nearly a decade of declining rates, there was an 8% increase in youth
suicides from 2003 to 2004, with elevated rates continuing into 2004
and 2005, indicating the increased rate was not a one-year anomaly
(Centers for Disease Control and Prevention [CDC], 2007). In 2005, the
overall age-adjusted suicide rate was 10.85 per 100,000 persons, while
the rate for youth aged 15â€“19 years was lower, at 7.66 per 100,000
(CDC, 2008a). Suicide is the third leading cause of death for youth
aged 15â€“19. Else, Andrade and Nahulu (2007) conducted a literature
review on AAPI populations, finding that disaggregated suicide data
were very limited. Where data are disaggregated, Asian groups have
been found to have substantially lower rates of completed suicide than
Whites (U.S. Department of Health and Human Services [DHHS],
1999), whereas rates of completed suicide among Pacific Island populations were some of the highest in the world (Booth, 1999). Furthermore, suicide among Native Hawaiians is clearly a phenomenon of
adolescents and young adults (Else et al., 2007). Mortality reflects
only a small portion of suicidal behavior, particularly among youth.
For every suicide death, 32 adolescents are treated for self-inflicted
injuries (Ikeda, Mahendra, Saltzman, Crosby, Willis, Mercy et al.,
2002) and one in six U.S. high school students report seriously
considering suicide in the past year (Grunbaum, Kann, Kinchen, Ross,
Hawkins, Lowry et al., 2004). Although the percentage of youth in
Hawai’i who contemplated suicide has decreased significantly since
1993 (27.8% in 1993 versus 18.5% in 2007), it remains consistently
higher than the U.S. average (14.5%; CDC, 2008b). The percentage of
youth in Hawai’i who attempted suicide also remains higher than the
U.S. average (12.0% versus 6.9%). Native Hawaiian youth have higher
rates of suicide behaviors than non-Hawaiian youth. Using Youth Risk
Behavior Survey (YRBS) data for Hawai’i by ethnic group, Nishimura
et al. (2005) found that Native Hawaiian youth had higher rates of
considering (27.2%), planning (21.4%), and attempting suicide (13.2%)
than Other Asian/Pacific Islanders (23.1%, 18.2%, and 10.1%) and Caucasians (24%, 16.5%, and 8.7%). Additionally, a community epidemiologic survey of youth in Hawai’i found that Native Hawaiian youth
have higher rates of attempted suicide than their non-Hawaiian peers
(12.9% versus 9.6%; Yuen, Nahulu, Hishinuma, & Miyamoto, 2000).
In the 15â€“19 age group, homicide surpasses suicide as a leading
cause of death, ranking second (CDC, 2008a). This pattern is also found
among AAPI adolescents. For every youth homicide in the U.S., there
are 127 violence-related injuries resulting in emergency room visits,
and countless others go untreated. Interpersonal youth violence can
take many forms, including fighting, pushing, name-calling, ignoring,
and gossiping (Van der Wall, De Wit & Hirasing, 2003). For example,
one in three high school students report being in a physical fight in the
past year (Grunbaum, Kann, Kinchen, Williams, Ross, Lowry, et al.,
2002). In fact, more than one in two (54.8%) Hawai’i youth reported
that bullying by other students was a problem at their school (Saka,
2008). Among young adolescents, roughly three of four youth experienced bullying by their peers (Bosworth, Espelage & Simon, 1999;
Nansel, Overpeck, Pilla, Ruan, & Simons-Morton, 2001), victimization resulting in poor school outcomes (Juvonen, Nishina, & Graham,
2000), and dating violence becoming an increasing concern (CDC,
2006). These rates have been shown to vary significantly among AAPI
adolescents. Mayeda et al. (2006) reported that Samoan adolescents
engaged in violence-related behaviors at rates that exceeded all other
groups. Hishinuma et al. (2005) found that Pacific Islander and
Caucasian youth had the highest victimization rates, whereas Asian
American youth had the lowest rates. Given that interpersonal violence
and suicide occur at high rates among youth, adolescence is clearly
a period of elevated risk behavior.
Several adolescent studies have shown that suicide attempts are
related to interpersonal violence, irrespective of gender and ethnic
subsamples (Borowsky, Ireland, & Resnick, 2001; Orpinas, BasenEngquist, Grunbaum, & Parcel, 1995; Sosin, Koepsell, Rivara, & Mercy,
1995). Both violence victimization and violence perpetration are robust risk factors for attempting suicide (Borowsky et al., 2001). These
studies have focused on a specific form of violence and have not
investigated the breadth of interpersonal youth violence in relation to
The purpose of this study is to examine the relationship between interpersonal violence and suicide indicators among AAPI
youth, using the teen version of the Power and Control Wheel. The
Wheel is a conceptual aid to understanding the impact of multiple
violence domains used by perpetrators to attain control over their
victims. In our model, we explore the relationships between these
violence domains and suicide behaviors in adolescents.
In the spring of 2007, 881 students in grades 9â€“12, from two high
schools on the island of O’ahu, were surveyed on health and violence
dimensions. A recruitment script was read to students in core classes
explaining the purpose of the survey, what the survey entailed, and
the consent procedures. Parental consent forms were distributed to all
students. Staff also visited the classes two weeks prior to the survey
to make reminder announcements, distribute extra parental consent
forms, and answer any questions about the survey. On the day of the
survey, students who returned a parental consent form and who were
interested in taking the survey were given an assent form to sign.
Parental consent and student assent were required to participate
in the survey. The survey was read to participants by trained research
assistants. Survey administration lasted approximately one hour (one
class period). Non-participants were given another quiet activity to
complete during the class period. At one school, participants received
a movie ticket and a class party if their class participation was greater
than 70%, while participants at the other school received a money
order as compensation. Incentives were based on school preference.
Thirty-three percent of students who were approached participated in
the survey. All procedures were approved by the Institutional Review
Board (IRB) of the University of Hawai’i.
2.1.1. Domains of the Teen Power and Control Wheel for victimization
The original Power and Control Wheel, created by the Minnesota
Domestic Abuse Intervention Project (2008), was labeled the â€œDuluth
Modelâ€ (Shepard, Eliott, Falk, & Regal, 1999; Yllo, 1998). Developed by
battered women in Duluth, it has been used in numerous programs
as an educational tool. Additional wheels have been developed for
gender equity, Native Americans, teens, and other groups. The wheels
are conceptual ways of looking at domains of violence tactics used by
perpetrators. Using a modified Teen Power and Control Wheel (Fig. 1),
the authors selected all questions pertaining to violence from the
Asian/Pacific Islander Youth Violence Prevention Center School Survey. The majority of these questions were from the CDC compendium
of assessment tools for youth violence (Dahlberg, Toal, Swahn, &
Behrens, 2005). The authors then matched each of the questions to
one of the eight domains based on face validity for both victimization
and perpetration: 1) Anger/Emotional Abuse; 2) Social Status; 3)
Intimidation; 4) Threats; 5) Sexual Coercion; 6) Isolation/Exclusion;
7) Peer Pressure; and 8) Physical Violence. One of the original domains (Minimize/Deny/Blame) was excluded because there were no
corresponding survey questions. All authors agreed on the categorization. For victimization, the questions were selected based on the
student’s experience as a victim of violence (â€œMy partner insulted me
‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477 471
with put-downsâ€). For perpetration, questions were selected based on
the student being a perpetrator of violence (â€œI insulted my partner
with put-downsâ€). To calculate overall subscale mean scores for the
eight domains, response sets (a variety of Likert-point scales) were
rescaled for consistency between questions. Domains 1, 3, 4, 7, and 8
were rescaled for response sets from 0 to 3. Domain 2 was rescaled to
responses from 1 to 5. Selected items were reverse-coded as appropriate, with higher scores reflecting higher levels of the eight
domains. Domain examples are presented in Fig. 1. Appendix A contains a complete list of questions for each domain.
2.1.2. Sociodemographic variables
Students were asked to self-report their gender (male or female),
ethnicity, grade level, socioeconomic status (if students received a free
or reduced lunch [yes or no]), and if they were employed in the past
12 months (yes or noâ€”if yes, how many hours they worked).
2.1.3. Suicidal indicators
Students were asked three questions using wording from the
YRBS regarding suicide behaviors during the past 12 months (Centers
for Disease Control and Prevention, 2004). The first two questions,
â€œseriously considered attempting suicideâ€ and â€œmade plans about
suicideâ€ had response choices of yes or no. The third question asked
students to report how many suicide attempts they had made in the
past 12 months. Given the sample size of the study, few individuals
reported more than one suicide attempt. Therefore, the original
responses of 0 to 6 or more times were dichotomized into 0 times (no)
or 1 or more (yes).
Data were analyzed using SAS 9.0. Chi-square was used to test the
statistical significance between the prevalence rates and demographic
characteristics for the three suicide indicators of seriously considered
suicide, made a suicide plan, and attempted suicide. Logistic regression
was used to determine significant mean differences for victimization
and perpetration using the eight domains of the modified Teen Power
Wheel as predictors for the three suicide indicators.
The sample (Table 1) included 881 students from two schools on
the island of O’ahu. Of the sample, 60.2% were female; nearly half were
Filipino (45.7%); 44.6% received a free or reduced lunch; most
students were in grades 9â€“11; and one third (32.5%) had been
employed in the past 12 months. Of those employed, a large number
(42.5%) worked 16 h or more per week in addition to attending school.
For the three suicide indicators, the rates for seriously considered
suicide (20.4%) and made a suicide plan (17.7%) were higher than for
the U.S. (14.5%, 11.3%) and the State (18.5%, 17%), respectively. The
overall suicide attempt rate for this study was 11.1%, which was
slightly lower than the State (12%) but much higher than the U.S.
Table 2 provides demographic differences by the three indicators of
suicide. Females had significantly higher rates than males for seriously
considering suicide and attempting suicide. Students in grade 11 and
those with low SES had higher rates on all three indicators. Females
and low SES students reported nearly twice the rate for attempted
suicide. There were no significant differences for ethnicity, employment status, or hours worked per week.
Table 3 presents the mean differences for the three suicidal
indicators for violence victimization. All of the eight power and control domains for victimization were significantly higher for all three
suicide indicators.When violence victimization was experienced, most
mean differences for suicidal indicators being present (yes) or not
(no) were two times higher, and in one occurrence three times higher
Fig. 1. Modified teen power and control wheel.
472 ‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477
(peer pressure and attempted suicide). Those who had considered,
planned, and attempted suicide had significantly higher mean scores
of being a victim of anger/emotional abuse, social status, being intimidated, threatened, sexually coerced, isolated/excluded, and experiencing peer pressure and physical violence.
The mean differences in violence perpetration for the three suicidal
indicators are presented in Table 4. Students who had considered,
planned, and attempted suicide had significantly higher mean scores
of perpetrating anger/emotional abuse; intimidating, threatening,
isolating/excluding, or exerting pressure on peers; and committing
physical violence. Social status and sexual coercion were significant
only for perpetrators who attempted suicide. Mean differences for
perpetrators who isolate/exclude others were nearly double on all
three suicide indicators.
The present study sought to examine the relationship between
multiple domains of interpersonal youth violence and three suicide
indicators among a sample of AAPI adolescents. The rates of suicidality
in our sample are alarming, with 20% seriously considering suicide,18%
Demographic characteristics by suicidal indicators.
Demographic Seriously considered suicide Made a suicide plan Attempted suicide
n (%) n (%) n (%)
Sex Ï‡2= 4.7, df= 1, p= .031 Ï‡2= 1.4, df = 1, p= .236 Ï‡2= 10.0, df = 1, p= .002
Female 117 (22.9%) 97 (19.1%) 71 (13.9%)
Male 56 (16.8%) 53 (15.9%) 23 (6.9%)
,16.8, df = 3, pb.001 Ï‡2= 14.8, df = 3, p= .002 Ï‡2= 10.5, df = 3, p= .015
9th 35 (15.6%) 34 (15.2%) 24 (10.6%)
10th 53 (18.9%) 38 (13.3%) 24 (8.6%)
11th 65 (29.7%) 57 (26.0%) 37 (16.9%)
12th 20 (16.0%) 21 (16.9%) 10 (8.0%)
Receive free/reduced lunch Ï‡2= 13.2, df = 1, pb.001 Ï‡2= 8.6, df = 1, p= .003 Ï‡2=âˆ’9.9, df = 1, p= .002
Yes 96 (25.8%) 81 (21.8%) 54 (14.5%)
No 73 (15.7%) 65 (14.0%) 36 (7.7%)
Note: There were no significant differences for ethnicity, employment status, and hours worked per week.
Sample description of two multi-ethnic schools on O’ahu (N= 881).
Demographic characteristics n %
Female 525 60.2
Caucasian 37 4.2
Filipino 403 45.7
Japanese 68 7.7
Native Hawaiian 196 22.3
Samoan 61 6.9
Other 136 15.4
9th 230 26.2
10th 294 33.5
11th 225 25.7
12th 128 14.6
Low socioeconomic status: Receive free/reduced lunch 385 44.6
Employed in past 12 months 284 32.5
b=16 h 161 57.5
N 16 h 119 42.5
Seriously considered suicide 174 20.4
Made a suicide plan 151 17.7
Attempted suicide 95 11.1
Mean differences of suicidal indicators by violence victimization dimension.
Violence victimization suicidal
indicators (Yes or No)
Seriously considered suicide mean (SD) Made a suicide plan mean (SD) Attempted suicide mean (SD)
1) Anger/Emotional abuse F= 34.67, df= 1,852, pb.001 F= 35.31, df= 1,850, pb.001 F= 15.20, df= 1,852, pb.001
Yes .97 (.69) .99 (.70) .96 (.71)
No .66 (.60) .66 (.60) .69 (.62)
2) Social status F= 9.68, df= 1,852, p= .002 F= 18.77, df= 1,850, pb.001 F= 4.85, df= 1,852, p= .028
Yes 2.89 (.59) 2.95 (.58) 2.89 (.60)
No 2.75 (.54) 2.74 (.54) 2.76 (.55)
3) Intimidation F= 46.06, df= 1, 852, pb.001 F= 32.89, df= 1,850, pb.001 F= 42.23, df= 1,852, pb.001
Yes .45 (.60) .43 (.61) .52 (.65)
No .20 (.38) .21 (.39) .22 (.40)
4) Threats F= 62.29, df= 1,852, pb.001 F= 55.80, df= 1,850, pb.001 F= 47.41, df= 1,852, pb.001
Yes .45 (.58) .46 (.59) .51 (.61)
No .18 (.34) .19 (.35) .20 (.37)
5) Sexual coercion F= 9.31, df= 1,607, p= .002 F= 12.31, df= 1,605, pb.001 F= 18.22, df= 1,606, pb.001
Yes .40 (.66) .42 (.67) .51 (.72)
No .24 (.50) .23 (.50) .23 (.50)
6) Isolation/Exclusion F= 57.69, df= 1,852, pb.001 F= 40.84, df= 1,850, pb.001 F= 50.65, df= 1,852, pb.001
Yes .85 (.74) .82 (.74) .95 (.77)
No .47 (.53) .49 (.55) .49 (.56)
7) Peer pressure F= 11.66, df= 1,605, pb.001 F= 8.32, df= 1,603, p= .004 F= 21.46, df= 1,604, pb.001
Yes .45 (.91) .44 (.89) .60 (1.01)
No .22 (.60) .23 (.62) .22 (.61)
8) Physical violence F= 21.26, df= 1,850, pb.001 F= 16.00, df= 1,850, pb.001 F= 8.38, df= 1,850, p= .004
Yes .66 (.84) .65 (.84) .64 (.81)
No .39 (.63) .40 (.64) .42 (.66)
‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477 473
making a plan for suicide, and 11% attempting suicide. Although we
found no ethnic differences in suicidal indicators, our sample was
predominantly Filipino and Native Hawaiian youth, suggesting these
groups are at extremely high-risk. Else et al. (2007) describe sociocultural practices that may explain suicidality among indigenous
Pacific Islander youth, including Western role designations that do not
match traditional family roles, especially at the beginning and end
of the lifespan (children/adolescents and elders), with males being
particularly alienated. In addition, through acculturative stress (loss
of land, language, customs, and much of its culture and population),
Native Hawaiians, an indigenous population, have historical legacies
that contribute to ongoing intergenerational trauma, unresolved grief,
and historical trauma response often linked with self-destructive
behaviors such as suicide, substance abuse, depression, anxiety, and
anger (Brave Heart, Horse, & DeBruyn, 1998; Brave Heart, 2003),
behaviors which are prevalent among Native Hawaiian youth
(Andrade, Hishinuma, McDermott, Johnson, Goebert, Makini, et al.,
2006; Else et al., 2007; Goebert, Nishimura, & Hishinuma, 2005;
Makini, Andrade, Nahulu, Yuen, Yates, McDermott, et al., 1996; Makini,
Hishinuma, Kim, Cartlon, Miyamoto, Nahulu, et al., 2001; Yuen,
Andrade, Nahulu, Makini, McDermott, Danko, et al., 1996; Yuen et al.,
2000). The acculturative stress hypothesis can also play a role in the
elevated suicide rates among Filipino youth as they struggle with
immigration to a new country, parents with English as a second language who often work multiple jobs, and limited financial resources
and family support (Guerrero, Hishinuma, Andrade, Nishimura, &
Cunanan, 2006). A long history of Western colonization may explain
higher rates of mental health problems among Filipinos (Rimonte,
Lorenzo, Frost, and Reinherz (2000) found that Asian American
adolescents not only reported more social problems than their peers,
including peer rejection, teasing, and being too dependent on others,
but also had increased vulnerability to depression and suicidality.
Goldston et al. (2008) postulated that this may be a consequence of
AAPI adolescents experiencing increased distress and peer conflict in
navigating between culturally valued interdependence and establishment of an independent identity. This emphasis on interdependence
may result in the use of indirect communication, suppression of conflict, concealment of emotional disturbance, and ultimately suicidality
among AAPI adolescents (Uba, 1994).
Although the Teen Power and Control Wheel is most often used
preventively by counselors to educate youth about the stages of dating
violence, it is also a useful tool for understanding the relationship
between interpersonal violence and suicide among AAPI youth. Using
this Wheel, we found that all dimensions for victimization and perpetration are associated with the three suicidal indicators (consider,
plan, and attempt). However, the differences in the mean scores of
suicide indicators were dramatically higher for victims than perpetrators. This may be related to depression (as a result of victimization)
being a robust risk factor for victimization and not for perpetration
(Stith, Smith, Penn, Ward, & Tritt, 2004).
Research shows that suicidal indicators and interpersonal violence
share a number of important risk and protective factors across multiple
domains of influence (DHHS, 2001; Felitti, Anda, Nordenberg,Williamson, Spitz, Edwards, et al., 1998; Fergusson, Woodward, & Horwood,
2000; Perkins & Hartless, 2002; Reiss and Roth, 1993). These include
individual (information processing, social problem-solving, and coping skills), family (parental monitoring, social supports, and family
functioning), and community environments that include intolerance
and prejudice. Despite this growing body of research, current efforts
to develop and implement effective suicide and violence prevention
strategies continue to occur in relative isolation from one another
(Lubell & Vetter, 2006).
Although evidence-based approaches for youth violence prevention are more advanced than for suicide prevention, these primary
prevention strategies address components of the overlapping core
risk and protective factors for violence and suicide (Lubell & Vetter,
2006). They are also based on similar strategies, such as skills-building, coping, developing positive relationships, character development,
and strengthening connectedness within the environment. For example, skills-building curricula such as Positive Action (Flay & Allred,
2003), Open Circle (Taylor, Liang, Tracy, Williams, & Seigle, 2002), and
Second Step (Grossman, Neckerman, Koepsel, Liu, Asher, Beland, et al.,
1997) have demonstrated increases in interpersonal problem-solving
skills and pro-social behaviors; decreases in antisocial, aggressive, and
impulsive behaviors; and decreases in symptoms of anxiety, sadness,
and depression. Additionally, gatekeeper programs train key
Mean differences of suicidal indicators by violence perpetration dimension.
Violence perpetration suicidal
indicators (Yes or No)
Seriously considered suicide mean (SD) Made a suicide plan mean (SD) Attempted suicide mean (SD)
1) Anger/Emotional abuse F= 26.16, df= 1,852, pb.001 F= 15.54, df= 1,850, pb.001 F= 15.17, df= 1,852, pb.001
Yes 1.26 (.59) 1.23 (.61) .1.28 (.67)
No 1.01 (.56) 1.03 (.56) 1.03 (.56)
2) Social status F= 2.23, df= 1,847, p= .136 F= 0.44, df= 1,845, p= .507 F= 10.32, df= 1,847, p= .001
Yes 3.30 (.53) 3.27 (.54) 3.41 (.54)
No 3.23 (.55) 3.24 (.54) 3.23 (.54)
3) Intimidation F= 5.12, df= 1,847, p= .024 F= 5.59, df= 1,845, p= .018 F= 6.85, df= 1,847, p= .009
Yes .34 (.55) .35 (.58) .39 (.58)
No .25 (.44) .25 (.43) .25 (.44)
4) Threats F= 16.18, df= 1,852, pb.001 F= 20.12, df= 1,850, pb.001 F= 6.40, df= 1,852, p= .012
Yes .59 (.54) .62 (.57) .57 (.58)
No .42 (.49) .42 (.49) .44 (.50)
5) Sexual coercion F= 1.47, df= 1,606, p= .226 F= 3.18, df= 1,604, p= .075 F= 5.90, df=1,605, p= .016
Yes .07 (.33) .08 (.36) .11 (.43)
No .04 (.21) .04 (.21) .04 (.20)
6) Isolation/Exclusion F= 53.93, df= 1,851, pb.001 F= 36.33, df= 1,849, pb.001 F= 50.75, df= 1,851, pb.001
Yes .65 (.54) .63 (.56) .74 (.58)
No .38 (.41) .39 (.41) .40 (.42)
7) Peer pressure F= 12.02, df= 1,849, pb.001 F= 10.73, df= 1,847, p= .001 F= 17.62, df= 1,849, pb001
Yes .63 (.59) .64 (.62) .72 (.70)
No .48 (.51) .48 (.51) .48 (.50)
8) Physical violence F= 12.08, df= 1,852, pb.001 F= 16.00, df= 1,850, pb.001 F= 11.39, df= 1,852, pb.001
Yes .64 (.60) .69 (.62) .71 (.59)
No .49 (.56) .48 (.56) .50 (.57)
474 ‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477
individuals in identification and referral of those at risk and may be
implemented in school, community, or healthcare settings. Gatekeeper programs in Hawai’i that teach participants to identify and
assist those at risk for suicide have been well received and attended
(A. Tani, personal communication regarding Applied Suicide Intervention Skills Training [ASIST] evaluations, October 3, 2007). These
approaches provide a promising foundation for integrating suicideand violence-prevention activities. To apply them to AAPI communities, cultural grounding may be necessary. This strategy entails
determining the salient identities (e.g., age, gender, ethnicity) that cut
across target populations to reach one or more identities for each
person (Hecht & Krieger, 2006). More research is needed to determine
which programs are the most effective among AAPI youth.
Native Hawaiian youth are disproportionately represented in the
state of Hawai’i juvenile justice system (MacDonald, 2003) and the
Hawai’i Youth Correctional Facility (Kim, Ando, Hishinuma, Nishimura, Winterheld, Hyn So, et al., 2001) where nearly all who
underwent psychiatric evaluation (99.1%) were given a psychiatric
diagnosis. These youth often present not only as perpetrators of
violence, but also as victims. When adjudicated, these youth receive
psychiatric assessments and treatments; however, they rarely have
access to community-based programs shown to improve skills,
decrease violent behaviors, and decrease other psychiatric symptoms
as noted above. Linking more intensive professional services with
evidence-based community approaches may be a better and more
cost-effective way to help these youth lead healthier and more
productive lives. Effective anticipatory guidance for children and
adolescents requires developmentally appropriate discussions of
preventive health issues (Adelman & Ellen, 2002). Primary care
providers, including counselors at the school level, can serve in
gatekeeper roles by identifying, intervening, and referring high-risk
youths and families. To provide quality guidance, these providers must
feel comfortable discussing interpersonal violence and suicide
(Frankenfield, Keyl, Gielen, Wissow, Werthamer, & Baker, 2000). The
American Medical Association’s Guidelines for Adolescent Preventive
Services, the American Academy of Pediatrics, the American Academy
of Family Physicians, and the Society for Adolescent Medicine
recommend that adolescent patients be screened routinely for
psychosocial problems (Eisenberg & Aalsma, 2005; Elster & Kuznets,
1994; Frankenfield et al., 2000). Screening should include suicidal
ideation and attempt, as well as victimization and perpetration.
Furthermore, healthcare professionals are encouraged to intervene
early when any of these behaviors are detected, and to discuss
interventions with youth and their parents. Primary care providers
can provide leadership and education to community organizations on
these issues. Another article in this issue, by Guerrero and colleagues,
highlights important principles for training health professionals in
AAPI youth violence prevention. Populations at highest risk should be
targeted for intervention (e.g., Native Hawaiians, Filipinos, youth from
lower SES classes, and those in grade 11). Professionals and
community leaders who come in contact with these high-risk groups
should be trained to intervene. Such people may include professionals
in schools, churches, and healthcare settings, as well as laypeople that
work with youth in informal community settings, such as sports and
other extracurricular activities.
This study has several limitations. It is likely that suicidal indicator
rates for considering, planning, and attempting suicide and victimization and perpetration have been underreported based on sample bias
of students who did not participate in the survey, especially those who
were absent from school, suspended, expelled, dropped out, or did not
have a parent or guardian to give consent. Although our response rate
was only 33%, our findings were not significantly different from the
2007 YRBS rates for Hawai’i, a representative sample for the State, for
considering (20.4% versus 18.5%), planning (17.7% versus 17.0%), and
attempting suicide (11.2% versus 12.0%). However, the sample may
or may not reflect AAPI adolescents in the United States as a whole.
The study design also cannot test the well-documented relationship
between exposure to parental domestic violence and developing
either physical aggression (perpetration) or depression and anxiety
(Evans, Davies, & DiLillo, 2008). Finally, due to the nature of a study
that examines multiple domains of violence, a large number of analyses had to be conducted on a relatively small sample size. However,
because of the intercorrelation among the suicide indicators, it did not
make sense to treat these analyses separately. Therefore we did not
adjust the significance level for multiple tests.
Future research should also focus on any mediating factors between
violence and suicide in order to identify effective intervention strategies.
For example, if depression and/or alcohol and substance use are found to
be mediating factors, then frontline gatekeepers should be trained in
assessing for depression and alcohol and substance use, and appropriately referring youth for treatment.
This article was supported by the National Center for Indigenous
Hawaiian Behavioral Health (NIMH; R24 MH5015-01, R24 MH57079-
A1, The Queen Emma Foundation and The John A. Burns Foundation),
the Asian/Pacific Islander Youth Violence Prevention Center (Centers
for Disease Control and Prevention; R49/CCR918619-05; 1 U49/
CE000749-01), and National Center on Minority Health and Health
Disparities. The authors would also like to express their appreciation
to Janice Chang, Psy.D., for statistical assistance.
Survey questions for victimization and perpetration by the Teen
Power Wheel violence dimensions.
Note: Words in parenthesis reflect wording in the stem question.
(Have you) Been teased by a
(Have you) Teased other
(Have you) Been called a bad
name by a student?
(Have you) Called other students
(Have you) Had something made
up about you by a student?
(Have you) Said things about
another student to make other
(Have you) Had a student make
sexual comments, jokes or
gestures about you?
When mad, I’ve tried to damage
another student’s reputation by
passing on negative information.
Has anyone posted embarrassing,
threatening or mean information
(blogs, pictures, video clips)
about you on a website (such as
Have you posted embarrassing,
threatening or mean information
(blogs, pictures, video clips)
about someone on a website
(such as MySpace)?
My partner insulted me with
I insulted my partner with putdowns.
When angry, I give others the
There are situations where I feel
inferior because of my ethnic/
Although bad things might have
happened to some racial groups,
it shouldn’t matter, because those
things happened in the past.
I look bad because of what other
people in my ethnic group do.
Minorities are given an unfair
advantage (i.e., in school or jobs).
I do not fit in with others. Most girls like to show off their
I get the help and attention I need
at my school.
Most boys want to go out with
girls just for sex.
Teachers treat me fairly. Sometimes it is okay for a man to
hit his wife.
Counselors treat me unfairly. Girls are emotional.
Boys should be in charge.
‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477 475
Adelman, W., & Ellen, J. (2002). Adolescence. In A. Rudolph, R. Kamei, & K. Overby (Eds.),
Rudolph’s fundamentals of pediatrics (pp. 70âˆ’109)., 3rd ed. New York, NY: McGraw-Hill.
Andrade, N. N., Hishinuma, E. S., McDermott, J. F., Johnson, R. C., Goebert, D. A., Makini,
G. K., Jr., et al. (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, 26âˆ’36.
Booth, H. (1999). Pacific Island suicide in comparative perspective. Journal of Biosocial
Science, 31, 433âˆ’448.
Borowsky, I. W., Ireland, M., & Resnick, M. D. (2001). Adolescent suicide attempts: Risks
and protectors. Pediatrics, 107, 485âˆ’493.
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behavior in middle school students. Journal of Early Adolescence, 19, 341âˆ’362.
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Healing historical unresolved grief. American Indian and Alaska Native Mental Health
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behavior surveillance system. Morbidity and Mortality Weekly Report, 53(No. RR-12).
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high school studentsâ€”United States, 2003. Morbidity and Mortality Weekly Report,
Centers for Disease Control and Prevention. (2007). Suicide trends among youths and
young adults aged 10â€“24 years; United States, 1900â€“2004. Morbidity and Mortality
Weekly Report, 56(35), 905âˆ’908.
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Control. Web-based injury statistics query and reporting system (WISQARS) [online].
(2008a). WISQARS injury mortality reports, 2005. Retrieved August 22, 2008, from
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and U.S. studentsâ€”2007 YRBS. Retrieved December 26, 2008, from http://www.cdc.
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attitudes, behaviors, and influences among youths: A compendium of assessment tools,
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Injury Prevention and Control.
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among indigenous Pacific Islanders in the United States. Death Studies, 31, 479âˆ’501.
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the Society for Adolescent Medicine. Journal of Adolescent Health, 36, 88âˆ’91.
Evans, S. E., Davies, C., & DiLillo, D. (2008). Exposure to domestic violence: A meta-analysis
of child and adolescent outcomes. Aggression and Violent Behavior, 13, 131âˆ’140.
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(1998). Relationship of childhood abuse and household dysfunction to many of the
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associated with the onset of suicidal behaviour during adolescence and early
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American Journal of Health Behavior, 27(Suppl 1), S6âˆ’21.
Frankenfield, D. L., Keyl, P. M., Gielen, A., Wissow, L. S., Werthamer, L., & Baker, S. P. (2000).
Adolescent patientsâ€”Healthy or hurting? Missed opportunities to screen for suicide
risk in the primary care setting. Archives of Pediatrics and Adolescent Medicine, 154,
Goebert, D. A., Nishimura, S. T., & Hishinuma, E. S. (2005). Alcohol use, violence, and
ethnocultural identity among adolescents in Hawaii. [Abstract]. Proceedings of 28th
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risk behavior surveillanceâ€”United States, 2003 (Abridged). Journal of School Health,
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Pacific Islanders. Violence and Victims, 20, 561âˆ’575.
3) Intimidation My partner destroyed or
threatened to destroy something I
I destroyed or threatened to
destroy something my partner
(Have you had) Something stolen
or damaged property?
I threatened or deliberately tried
to frighten my partner.
When angry with the same-sex
peer, I try to steal that person’s
4) Threats (Have you been) Threatened with
(Have you) Carried a weapon?
(Have you) Been told you were
going to be hit by a student?
(Have you) Said you would hit a
My partner threatened me or
deliberately tried to frighten me.
I threaten to share private
information with others in order
to get them to do what I want.
My partner has threatened to
commit suicide to get me to stay
My partner touched me sexually
when I didn’t want to be touched.
I touched my partner sexually
when he/she didn’t want to be
My partner forced me to have sex
when I didn’t want to.
I forced my partner to have sex
when he/she didn’t want to.
(Have you) Been left out on
purpose by a student?
(Have you) Left another student
out on purpose when it was time
to do an activity?
My partner kept track of whom I
was with and where I was.
I kept track of whom my partner
was with and where he/she was.
My partner went through my cell
phone to check my calls or text
I went through my partner’s cell
phone to check his/her calls or
My partner went through a
personal website (like a MySpace
or Friendster page) to check up on
who I was communicating with.
I turned friends against my
My partner did something just to
make me jealous.
I did something just to make my
Has anyone sent you
embarrassing, threatening or
mean text message on a cell
I went through my partner’s
personal website (like a MySpace
or Friendster page) to check up on
who he/she was communicating
Has anyone sent you
embarrassing, threatening or
mean email or instant message?
Have you sent someone
embarrassing, threatening or
mean text message on a cell
(Have you) Told another student
you wouldn’t like them unless
they did what you wanted them
(Have you) Not let another
student be in your group anymore
because you were mad at them?
My partner turned some of my
friends against me.
(Have you) Tried to keep others
from liking another student by
saying mean things about him/
(Have you) Spread rumors or
gossip to create drama?
(Have you) Made up rumors
because you were mad at the
I intentionally ignore others until
they agree to do what I want.
(Have you) Dealt with anger by
(Have you) Been pushed, shoved
or hit by a student?
(Have you) Pushed, shoved or hit
a student from your school?
My partner threw something at
I threw something at my partner.
My partner slapped me or pulled
I slapped my partner or pulled
My partner pushed, shoved, or
I pushed, shoved, or shook my
Appendix A (continued)
476 ‘I.R.N. Else et al. / Aggression and Violent Behavior 14 (2009) 470â€“477
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