Suicidal Behaviors Among Dominican Youth

“US Cultural Involvement and its Relationship with Suicidal Behaviors among Dominican Youth:Findings from the Dominican Republic Youth Survey ” Juan B. Peña, Ph.D., LCSW

Acknowledgment• Substance Abuse and Mental Health Services Administration (SAMHSA), Minority Fellowship Program – Predoctoral and Postdoctoral Fellowships, T06 SM56573-01 (PI: Francis)• National Institute of Mental Health (NIMH) – 1R03MH069102-01 (PI: Peña) – T32MH020061-06 (PI: Conwell) – Contract No. 263-MD-507221 (PI: Peña) – 1R01MH070689-01A1 (PI: Zayas) – 1R03MH085203-01A1 (PI: Peña)• Center for Diseases Control and Prevention (CDC) – Profiling Risk and Need for Mental Health Services among a National Cohort of Youth Suicide Attempters, 1R49CE001510• Center for Latino Family Research – Pilot Study of Suicidal Behavior Among Dominican Youth – National Survey of Suicidal Behavior Among Dominican Youth

Acknowledgment• Universidad Autónoma de Santo Domingo (UASD) – Gloria Madera• Fundación Familia Sana – Ludovina Rodriguez – Romero Rodriguez – Wayne Westhoff• Secretaria de Estado de Educación – Cristina Molina

Acknowledgment

Enola K. Proctor Luis H. Zayas Brett Drake Melissa Jonson-Reid

Eric D. CaineCenter for the Study and Prevention of SuicideWilliam A. VegaEdward R. Roybal Institute on AgingJohn LandsverkChild and Adolescent Services Research Center

Overview• Research – Dominican Republic Youth Survey – U.S. Cultural Involvement and its Association with Suicidal Behavior among Dominican Youth • Study 1 • Study 2 • Study 3 – Next Steps• Service

Dominican Republic Youth Survey PI Juan B Pena

Overview• Nationally representative school-based survey of risk behaviors among youth in the Dominican Republic – 2009 – 2010• Modeled after US-based surveys such as the CDC’s Youth Risk Behavior Survey and Monitoring the Future – School-based, anonymous, voluntary• Designed to take into account context, place, and culture• Designed to allow for comparisons across regions, nations, and time• Designed to test and explore different theoretical frameworks

Rationale for Study• Dominican Republic currently has no national youth risk behavior survey• Dominicans are among the largest Latino immigrant group in the United States – Effects of immigration to the US• Dominican Republic provides excellent natural setting to study processes related to cultural globalization

Theoretical Frameworks• Ecological Systems Theory• Psychiatric eco-epidemiology• Family Systems Theory• Social Learning Theory• Social Control Theory• Anomie Theory• Interpersonal-psychological Theory of Suicidal Behavior• Cultural Globalization• Healthy Immigrant Effect

Samples• DR 2009• DR 2010• NYC 2009 YRBSS – Added 4 questions to the survey – Nativity of parents – Language in household – Time lived in US

Sampling Frame - Public High Schools in DR Total public high schools in DR = 812 Strata – 18 Educational Regions in DR Random selection of 80 public high schools by cohort year, and proportionate representation by educational region. Grade 9 Grade 10 Grade 11 Grade 12A B C D A B C D A B C D A B C D Students sample N= 10,334 (2009) & N= 9,139 (2010) Sample weights created - approximately 415,000 youth

Proportion of Schools by Educational RegionN = 80 high schools per cohort year, 160 in total 1. Barahona 2% 2. San Juan 7% 3. Azua 7% 4. San Cristobal 4% 5. San Pedro de M. 5% 6. La Vega 6% 7. San Francisco de M. 7% 8. Santiago 10% 9. Mao 4% 10. Santo Domingo I 9% 11. Puerto Plata 5% 12. Higuey 4% 13. Monte Cristi 4% 14. Nagua 4% 15. Santo Domingo II 8% 16. Cotui 5% 17. Monte Plata 4% 18. Bahoruco 4% Total 100% = 812 schools

Total sample of Total HS Educational Region students Students (2009 & 2010)1. Barahona 10,609 7522. San Juan 14,577 12183. Azua 21,394 11764. San Cristobal 27,191 9155. San Pedro de M. 25,738 8966. La Vega 29,460 11237. San Francisco de M. 22,578 12888. Santiago 45,348 16919. Mao 10,843 78210. Santo Domingo I 62,150 243511. Puerto Plata 16,641 90012. Higuey 10,852 62013. Monte Cristi 10,893 53614. Nagua 14,734 79515. Santo Domingo II 52,538 208116. Cotui 19,776 86317. Monte Plata 10,184 65418. Bahoruco 8,294 748 Total 413,800 19,473

2009 2010 Demographics -- Violence and Delinquency -- Suicidal Behavior -- Cigarette Use -- Alcohol Use -- Marijuana Use -- Other Drug Use -- Sexual Behaviors -- Parents Level of Education -- Socio Economical Status -- US Exposure Nutrition & Physical Activity -- Academic expectations Violence and Delinquency -- Youth attitude Familism, Respect, Religiosity, towards delinquency -- Friends Substance Gender Roles, Material success,A Use -- Friends perception of SU -- Attitudes towards school -- School Environment -- Availability of Substances - Independence, Competition, Belonging, Burden Violence and Delinquency -- Youth attitude Familism, Respect, Religiosity, towards delinquency-- Family control – Gender Roles, Material success,B Religiosity -- Suicidal Thoughts -- Parents Independence, Competition– Friends attitudes towards SU -- Same age attitudes Substance Use -- Family Environment towards SU -- Close friends attitudes towards (Cohesion) -- Family Environment SU -- Social activities involvement -- Family (Conflict) Environment (Cohesion) -- Family Environment (Conflict) Relationship with Mother -- Relationship with Friends Substance Use -- Violence andC Father -- Familism Delinquency -- Familiy control – Religiosity -- Social activities involvement -- Youth attitude towards delinquency “Impulsiveness” (BIS)

DR NYC Youth Risk Behavior Surveillance (YRBS)National Survey on Drug Use and Health (NSDUH)Monitoring the Future (MTF)The National Longitudinal Study of Adolescent HealthBidimensional Acculturation Scale (BAS)Family Environment Scale (FES) - CohesionFamily Environment Scale (FES) - ConflictLugos Familism Scale Mutual Psychological Development Questionnaire (MPDQ)Interpersonal Needs Questionnaire (INQ)Mexican American CulturalValues Scale (MACVS)Conflict Behavior Questionnaire (CBQ)Denver Youth SurveyBarratt Impulsiveness Scale (BIS)

Dominican Republic Youth Survey• Data will be used to publish manuscripts about: – US cultural involvement/cultural globalization and youth risk behavior – suicide attempts, substance use, violence, sexual risk etc. – Cross national comparisons including with Dominicans in NYC – testing factors related to healthy immigrant effect – Identifying cultural protective factors related to youth risk behaviors – Identifying mechanisms for how cultural factors relates to risk behaviors via family, peers, school, and individual level factors – Setting an agenda for prevention of youth risk behaviors of Dominican Youth• Research will inform practice and policy in US and DR related to Latino youth and family, in particular Dominicans

U.S. Cultural Involvement and itsAssociation with Suicidal Behavior among Dominican Youth Manuscript 1

Rational for Examining Suicide Attempts forLatino Youth• While rare during childhood, the rates of suicide attempts peak during adolescence and young adulthood and steadily decline through adulthood (Gould et al., 2003; Nock et al., 2008).• A major source of morbidity, attempts are associated with hospitalization, future attempts, and death by suicide and other causes (Ostamo & Lonnqvist, 2001; Pfeffer et al., 1993; Suokas et al., 2001).• They also serve as an expression of serious and costly underlying conditions such as mood and substance-use disorders and the co-occurrence of multiple behavioral problems (Gould et al., 2003).• Latino youth have higher attempt rates than their non-Hispanic African American and White Counterparts (CDC, YRBSS) and are largest ethnic minority group• Suicide Attempts vs. Suicide vs. Suicide Ideation

Background• Suicide behavior is related to immigrant generation status among Latino youth in the USA• Findings are consistent with Healthy Immigrant Effect

Rational for Understanding theHealthy Immigrant Effect• Significance for Social Work and Public Health – Inform interventions for immigrant youth and families – Inform policies and advocacy for immigrant youth and families• “A greater understanding of the healthy immigrant effect has the potential to help improve the health and health outcomes of all children. Precise identification of the salutary components of traditional Latino culture and unhealthy aspects of US culture could produce fresh approaches and innovations to prevent morbidity and mortality in children from all racial/ethnic and socioeconomic backgrounds.” (Flores, 2005)

Background• Potential Explanations – Selection processes – Cultural protective factors – Intergenerational value discrepancies and conflict• A limitation of many studies : – Lack of differentiation between Latino groups – Lack of measures to test mechanism – Lack of international samples to differentiate between self-selection processes and the cultural protective factors – Lack of attention to cultural globalization processes• A new approach – Focus on one group – Collect data from country of origin to allow for cross national comparisons – Examine how processes related to cultural globalization may influence youth risk behaviors among non-immigrant populations

Study Aim• To test if indicators of US cultural involvement are related to suicidal behavior among a sample of youth residing in the Dominican Republic

Sample• Dominican Republic 2009

Measures• Independent Variables – Latent factor 1: English proficiency – Latent factor 2: Use of English and US electronic media – Time lived in the US (9% lived in US) – Number of friends lived in US• Dependent Variable – Suicide attempt during past year

Measures• Control Variables – Demographic characteristics – Residency in Urban Area – Family Structure – SES indicators • Corrugated Zinc Roof • Parental level of education

Analysis• Logistic regression• Design effect of study was taken into account using “Type = Complex” command in Mplus• Sample weights were created by statistician and used in analysis to ensure representativeness• We used a combination of observed and latent variables

Use of US electronic media and English

Odds Ratio and 95% Confidence Intervals forSuicide Attempt during Past Year Variable Unadjusted Odds Adjusted Odds Ratio Ratio1 Lived in US, 1 year or more 2.54 (1.67, 3.87)* 2.11 (1.35, 3.29)* Lived in US, 1 year or less 1.65 (1.19, 2.27)* 1.53 (1.10, 2.11)* No. best friends have lived in the 1.07 (1.03, 1.11)* 1.05 (1.01, 1.09)* US US electronic media and English 1.20 (1.10, 1.30)* 1.16 (1.02, 1.31)* English proficiency 1.15 (1.05, 1.26)* 0.98 (0.87, 1.11) 1. Adjusted for age, gender, SES indicators, family structure, urban residency, and all US cultural involvement variables.

Discussion• There is a robust relationship between variables related to US cultural involvement and suicide behavior among youth in the DR• This finding is consistent with previous research showing increase risk for suicide behavior for US vs. foreign born Latinos• This finding is not consistent with self-selection processes being the predominant reason for the healthy immigrant effect• Future research needs to identify and test mechanisms related to this association

Limitations and Strengths• Limitations – Self-report – Exclusion of youth not attending school or attending private school – Did not include US comparison group – Results have not been replicated• Strengths – This study used a non-immigrant population – Nationally representative of students attending public high school in the DR

A Binational Study on U.S. CulturalInvolvement and Suicidal Behavior among Dominican Youth Pena J.B., Vega W.A., Chaves D., Zayas L.H., & Caine E.D. Manuscript 2

Sample• NYC 2009 Dominican• Dominican Republic 2009• Dominican Republic 2010

Measures• Independent Variables – DR 2010 Sample • Latent factor: Use of English and US electronic media • Time lived in the US • Number of friends lived in US – NYC 2009 Sample • Spanish-speaking vs. English-speaking household – DR and NYC 2009 Sample • NYC Dominicans vs. DR Youth that never lived in US• Dependent Variable – Suicide attempt during past year

Measures• Control Variables – Demographic characteristics – Residency in Urban Area – Family Structure – SES indicators

Analysis• Logistic regression• Design effect of study was taken into account using “Type = Complex” command in Mplus• Sample weights were created by statistician and used in analysis to ensure representativeness• A combination of observed and latent variables were used

Simple Logistic Multiple Logistic Regression RegressionDR 2010 Sample US Electronic Media and Language 1.08 (1.03, 1.13)*** 1.16 (1.06, 1.28)*** Lived in US > 1 a 2.70 (1.78, 4.11)*** 2.57 (1.64, 4.02)*** Lived in US < 1 a 1.59 (1.26, 2.00)*** 1.47 (1.14, 1.89)** Number of Friends Lived in US 1.03 (1.00, 1.06)* 1.03 (0.99, 1.07)NYC 2009 SampleEnglish-speaking household 1.58 (1.00, 2.47)* 1.63 (1.00, 2.65)*DR and NYC 2009 SampleEnglish-speaking household 2.39 (1.67, 3.43)*** 2.70 (1.87, 3.90)***Spanish-speaking household 1.52 (1.03, 2.24)* 1.61 (1.08, 2.39)*

Discussion• There is a robust relationship between variables related to US cultural involvement and suicide behavior within the context of the DR, NYC, and between DR and NYC• This finding is consistent with previous research showing increase risk for suicide behavior for US vs. foreign born Latinos, replicates previous findings for 2009 sample, and other binational comparisons that have been made using Mexican samples.• This finding is not consistent with self-selection processes being the predominant reason for the healthy immigrant effect.• Future research needs to identify and test mechanisms related to this association

Limitations and Strengths• Limitations – Self-report – Exclusion of youth not attending school or attending private school• Strengths – This study used a non-immigrant and immigrant populations – Showed robust effects across multiple indicators and context – Nationally representative of students attending public high school in the DR and NYC

The Role of Substance Use in Explaining the Relationship between U.S. CulturalInvolvement and Suicidal Behavior among Dominican YouthPena J.B., & Vega W.A., Hausmann-Stabile C.H., & Caine E.D. Manuscript 3

Sample• NYC 2009 Dominican• Dominican Republic 2009

Drugs and Depression Hypothesis

0.31 (0.78)*** 0.53 (0.53) *** 0.29 (0.73)*** 0.54 (0.54) *** 0.68 (0.68)*** 0.24 (0.62)*** Problematic Alcohol Use Repeated Marijuana Use Repeated Other Drug Use Depressive Symptoms R2 = 0.13 R2 = 0.21 R2 = 013 R2 = 0.07 0.27 (0 0. 46 * (0 ** -0. .4 8) .11)*** 04 6) .4 (- 0.0 * ** (0 0.05 4) 21 0. * (0.0 5) )* * 53 2 (0. * 0.2 9)* 0.3 7( 9) 0.1 (0.1 0.03 Suicide Attempt 0.31 (0.68)*** 6) * ** R2 = 0.45 )** )* .2 50 (-0 77 . .24) 5 0.11 (0 (0. (0 .0 23 -0 3 0. 0.3 6) (0.2 0.12 Second-Generation 1,2 Later-Generations 1,2Pena, J. B., Wyman, P. A., Brown, C. H., Matthieu, M. M., Olivares, T. E., Hartelfooter, D., et al.(2008). Immigration generation status and its association with suicide attempts, substance use,and depressive symptoms among

100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Low SU-VB High SU-VB Extreme SU-VB Low SU-VB High SU-VB Extreme SU-VBPena J.B., Matthieu M.M., Zayas L.H., Masyn K.E., & Caine E.D. Co-occurrence of risk behaviorsamong White, Black, and Hispanic US high school adolescents who have attempted suicide1999 to 2007. Social Psychiatry and Psychiatric Epidemiology

Analysis• Structural Equation Model• Design effect of study was taken into account using “Type = Complex” command in Mplus• Sample weights were created by statistician and used in analysis to ensure representativeness• A combination of observed and latent variables were used

Substance Substance use with use without depressive depressive symptoms symptoms US Cultural SuicideInvolvement Attempt Indicators Depressive symptoms with no substance use

23.4%Substance Use with Depressive Symptoms 18.2% 12.6% 0.0 5.0 10.0 15.0 20.0 25.0 NYC Dominicans English Speaking Households NYC Dominicans Spanish Speaking Households DR Youth Never Lived in US

Substance Use with Depressive SymptomsUS Cultural SuicidalInvolvement Behavior Substance Use Depressive with no Symptoms with Depressive no Substance Use Symptoms

Discussion• Substance use and depressive symptoms for Dominican youth mediates the relationship between US cultural involvement and suicidal behavior within DR context, NYC context, and between DR and NYC context• Exploring cultural and social factors related to substance use may provide important clues to mechanisms related to increase propensity for suicidal behavior among Dominican youth

Limitations and Strengths• Limitations – Self-report – Exclusion of youth not attending school or attending private school – Relationship between substance use and depressive symptoms unclear – Relationship between substance use and suicidal behavior unclear• Strengths – This study used a non-immigrant and immigrant populations – Showed robust effects across multiple indicators and context – Nationally representative of students attending public high school in the DR and NYC

Next Steps

Exploring Mechanisms Related to US CulturalInvolvement and Suicidal Behavior amongDominican and Other Youth1. Mining the Dominican Republic Youth Survey to further identify potential mechanisms – Latino cultural values – American cultural values – Family, peer, and school environments – Individual level data2. Follow up study in NYC and DR – Mixed methods approach – Further explore the role of substance use – Build on findings from current study to examine mechanisms explaining “healthy immigrant effect” for suicidal behavior among Dominican Youth such as role of culture, family environment, peer environments etc.3. Follow up study to examine if similar phenomena is occurring in other developing nations and groups

Next Steps• Develop models that can inform practice and policy in the US and abroad – Integrate the strengths of immigrant and native populations in family and youth interventions designed to reduce risk behaviors in context of acculturation and cultural globalization – Promote polices that embrace biculturalism to reduce risk behaviors among adolescence and improve health and educational success among youth

Developing Prevention Framework forYouth Risk Behaviors in Dominican Republic1. Funding to help develop the research and prevention infrastructure to respond to youth risk behaviors in the Dominican Republic – Create surveillance system for youth risk behaviors • Model - CDC YRBSS, Monitoring Future – Create goals, objectives, and strategies to reduce risk behaviors among youth in the Dominican Republic • Model - Healthy People 2020 – Create dissemination system for surveillance results, goals, objectives, and strategies to reduce risk behaviors among youth in the Dominican Republic – Develop social work field and presence in prevention work in DR

Prevention of Youth Risk Behaviors amongDominican Youth

Report in Spanish for the Dominican Republic- Results 2009 -

Prevention of Suicidal Behavior amongDominican Youth1. Study to test a comprehensive public health approach to suicide prevention and related behaviors among youth within school settings – Universal program to decrease number of youth within the school population with suicide risk factors such as substance use and violence – use existing evidence based programs – Selective programs to treat and reduce risk factors for youth that are starting to exhibit risk factors such as substance use, violence, and depressive symptoms – use existing evidence based programs – Indicated programs for youth exhibiting suicidal ideation or behaviors – use existing evidence based programs

Service

Team members in the Dominican Republic, from left to right: Juan Isidro Rodríguez, Diana Chaves, Juan Peña, Ludovina Rodríguez, Cristina Molina, Luis Zayas, Gloria MaderaTeam members working on thelogistics for the national study in theDominican Republic

Presentation at the 3rd Subregional Meeting in Education,sponsored by the UNESCO Regional Office of Culture inLatin America and the Caribbean

Motivational Interviewing Workshop at the AutonomousUniversity of Santo Domingo in Bonao

“Service Across Borders” summit, sponsored by theNY State Senate Puerto Rican/Latino Caucus

Comments from teaching evaluations “Juan Penas expansive “This has been by far my favorite class that I knowledge and commitment to have taken at Brown! Professor Pena was a students is amazing. He is very fantastic teacher, and I learned a lot. I was well organized, and structures happy that this class was both interesting as the class very well. I liked that well as required a fair amount of student there were a variety of small work outside of class, which made me feel like assignments rather than one my tuition money was being well spent. huge paper or test. Also, Dr. Pena Professor Pena loves the material he is is very engaging and teaching, he knows it well, and he encourages understanding, he seems to take class participation, and he is very personable”. students learning very seriously”. “His understanding towards the diverse issues and different culture.“The professor did an outstanding job teaching the The instructor is very helpful andmaterial and keeping the class engaged through his encouraging. He uses differentpower points. I also really enjoyed the skills lab of materials: videos, online resources,Motivational Interviewing and found it very etc. The instructor is open andrelevant in terms of practice and was able to use flexible”.this type of therapy at my practicum”.

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Suicidal Behaviors Among Dominican Youth

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