Breaking the Silence! Participatory Research for Asian American Youth

1. Breaking the Silence! 2014 Participatory Research for Asian American YouthSummer Finding Presentation Introduction JiangHong, Li, M.D., Msc Senior Research Scientist, Institute for Community Research Member, Asian & Pacific Islander Addiction Science Network August 14, 2014. Hartford, CT

2. Low rate of substance use – true prevalence or misperception? • National surveys shows the lowest prevalence of major substances among AAPIs compare to other racial/ethnic groups • Inconsistent results among sub-groups within AAPI category • Persons of mixed race have high rates, which obscure correct readings for Hispanics and Asians • Problem of many survey data: small sample size, reluctance in participating research

3. Limited research findings about AAPIs (1) • AAPI stimulant admissions are nearly four times higher than for total admissions. (The DASIS Report, 2002) • Treatment Episode Data Set (TEDS): <1% of all patients admitted to national treatment surveys report themselves as AAPI.The primary reason for admission, among AAPI, is alcohol, marijuana, stimulants, opiates, and cocaine. • Rates of alcohol use disorders close to non-AAPI populations, even among AAPI that experience the flushing syndrome thought to protect from alcoholism. (Fong and Tsuang 2007) • Methamphetamine dependence is particularly high (approximately 10%) among the Pacific Islander population. Pathological gambling addiction is gaining more attention among

4. Limited research findings about AAPIs (2) • Substance use treatment utilization: AAPI received a greater number of legal services and fewer medical and psychiatric servicesthan the comparison group. AAPI also received fewer total services within their treatment program. (Niv, Wong & Hser 2007) • The number of AAPI that enter treatment increase in the past decade. Low number presenting to treatment probably represents the larger healthcare disparity that exists between those that need treatment and those that actually present to treatment. (Fong and Tsuang 2007)

5. Asian American Suicide Facts • Leading cause of death:8th (11th) all, 2nd (=) age 15-34 (=national), highest age 14-24 • Risk: depressive and anxiety disorders are strongest predictor; family conflict, viewing one‘s self as a burden to others；chronically illness • Protective: ethnic group identification, family cohesion and support

6. APA Office of Ethnic Minority Affairs (OEMA) is raising public awareness concerning the chronic condition of stress among America’s Asian and Asian-American populations. The focus is on family expectations and demands as it relates to stress.  “By seeking professional help, many individuals who have suicidal thoughts are able to resist suicide.” - Joel Wong, PhD 

7. Barriers to Access of Psychiatric and Addiction care • Cost, awareness of service exist, immigration status, no insurance, cannot speak English, transportation. • Lack trained health and social service providers that are familiar with AAPI beliefs and values, health-seeking behaviors, and culturally relevant treatment strategies – low engagement and high dropout • Lack of evidenced-based programs that have demonstrated to be effective in the treatment of addictive disorders among AAPI. • AAPI may be more likely to go to a non-Western treatment for addictive disorders including acupuncture, traditional Chinese herbal medications, or other religious healers. (Fong and Tsuang 2007)

8. Barriers to Access of Psychiatric and Addiction care Cultural Barriers: • Most recognized issue: feeling of shame in asking for help for an addictive disorder. • The traditional AAPI response to crises is either denial or attempting to handle problems within the family itself. • Lack of recognition or identification of an addiction problem is another important barrier to accessing care. Example: somatize mental health problems and/or consequences of substance abuse and report them as physical symptoms • Familial insulation can be another significant barrier. Many immigrant families live in isolation due to language and cultural barriers. (Fong and Tsuang 2007)

9. Why do we study stress coping in Asian American families? • The “model minority” stereotype has led to the invisibility of AAPI population -- time to face mental health and addiction • The two issues often share common risk and protective factors(e.g. stress, peer pressure, social support, efficacy …) • Stop ignoring preventable problems when they are much easier to manage • To build foundation to develop evidence based, culturally appropriate, and effective intervention programs for AAPI populations. • Lack of AAPI researchers in the field of social behavioral science • Lack of general public awareness

10. How do we run this program? • NIDA AAPI Workgroup annual summer internship program (central program/national program) • standard 6 weeks program • central meetings every Tuesday and Thursday • opportunities to learn from other students and experts in diverse fields • sense of belonging to a larger community • certification from NIDA for committed students with demonstrated excellence • Local one year study with focused aims featuring participatory research approach • Intensive summer phase, and slower later phase

11. 2013 Summer Research Methods Research skill training literature review, theoretical model building, hypothesis development, qualitative and quantitative data collection methods, peer recruitment, in-depth interviewing, qualitative data coding and analysis Participatory Approach within the scope of the supplemental study Each intern select his/her own study questions Each intern develop his/her own theoretical model Integrate all interns’ interview questions and develop one interview guide so that every interview contains data for all interns Develop central coding theme for each intern to code for all Analyze data collaboratively, prepare presentation separately with team support

12. 2013 Summer Participatory Research Study Aim • Explore general exposure to peer substance use • Explore attitude toward and behavioral norm of substance use among AAPI high school and college students • Understand main stressors faced by AAPI students, risk and protective factors

13. 2013 Summer Data Collection Methods • Participatory approach • Free list focus group • Pile sort • In-depth interview

15. Cause of Drug Use Pre-training mental model

16. 2013 Student Research Questions • Are high academic parental expectations the main factor for stress Among AAPI youth? • How do two parenting styles (authoritative and authoritarian) influence children’s risk behaviors? • What is the Relationship between self-esteem, stress, and drug use • What is the effect of societal stereotypes on Asian American youths’ identity? • What’s the association between self identity and stress?

17. Pre-Research Conceptual Model

18. Conceptual Model at Graduation

19. Pre-Research Conceptual Model

20. Conceptual Model at Graduation

21. Participant Recruitment • Interns recruit friends and peers in person, • Via online media (mostly via Facebook, occasional cell phone texting) • Email to interns of other sites of the same national program • Recruit from local Chinese church youth and student groups

22. Samples • 73 contacted, 37 responded • 12 participated in focus group • 18 participated in online pile sort survey • 14 participated in in-depth interview

23. 2013 Summer Research Findings

24. Types of Drugs common I’ve tried Have seen peer use Safe/Legal uncommon social drugs Party drugs Ilicit more acceptable serious drugs harmful Performance enhancement Stimulants medicaluse

25. Stereotype exist among participants themselves • “ASIANS DO NOT DO DRUGS. Or if they do, then they hide it well.” • “…I guess if an Asian were to take drugs, he'd take Adderall or some ADHD drug so he could focus and do better in school. That'd only really be applicable to the saddest specimen in the universe … (discriminatory comments) … so I guess he's gotta take like adderol or something to catch up with all the other asians “ (CT high school male)

26. Causes of drugs • Performance enhancement • To excel academically • Rebellion against parents/authority • Escape from reality • Early trauma, were abused • Depressed • Mental illness • To celebrate at parties or special events • Easily accessed • Habit • New-found freedom and independence (in college) • Wealthy upbringing • Disregard for consequences • Peer pressure • Stress relief • To look more mature • Curiosity • Have the money to be able to • To feel good, to have fun, to relax • Imitate idols or role models • Impress people • Know friends who do drugs • Job requires it (drug dealer) • Wanting to fit in, to be cool • Going to college • Rejection of Asian culture

27. Sources of Stress Academic Culture/tradition Family Society

28. Parental pressure to succeed • Academic excellence: A/A+, ivy league • Certain career path (doctor, lawyer, IT – high status, high pay) • Obligation to take care of parents when they are older • Fulfill expectations • Extra-curricular activities (e.g. music – be the best)

29. High Expectations are from both parents and students “I'm lucky in the sense that I'm far removed from what can be a sometimes unhealthy modern Asian culture of competition (hello suburban L.A.) and my parents are more or less liberal. That is, they disliked the toxic environment of hardcore studying and grade grubbing that their primary education system had formed (and been transplanted to pockets of California where there is a high Asian population). … Nevertheless, I understand and hear about my other Asian peers who deal with their "tiger" parents… but honestly, look at any upper middle class professional (all races included) and you'll see that they do everything they can to make sure their children are educated bright and early. Yes, these are all things that are on the back of my mind, tradition and whatnot, but it's not so much a stresser as it is that I find it an unhealthy way to live… I've pushed myself to always do my best. The things listed under are things that are immediately stressful for me as I have to think about colleges and my future. My friend and I like to call ourselves the "underachievers of the overachievers" I've accepted long ago that I'm not going to be the smartest and the best, but I still work very hard day in and day out. ” (college female)

30. Prestigious professions: medical, science, engineering, not humanities and art “Math/Science courses kind of freak me out because that's the field that my parents highly encourage me to go into. I'm more comfortable in the humanities, but it's definitely a struggle for me to go between practicality and ambition, as they aren't lined up right now. Over the years, my parents and I have come to a better understanding of what each other want, but sometimes they drive me crazy since they remind me YET AGAIN that I really should go into a medical profession since they do not have enough money to support me in the future. Ok, point taken! ” • High parental control of social activities, and influence of friends choices • Child’s “failure” affects parents reputation. Competition among relatives and friends circles. • Social obligation of “paying back”.

31. Social stress • Desire to be liked and popular “I worry about my social life. Simply put, I take pride that I've worked my way up the ladder and I don't want to go down. I'd like to think (haha who knows?) that I'm generally well-liked and well-known in school, but I still have to worry about appearances and being (fake) nice to so many people. ” • Social awkwardness • Smart Asian steroetype type “Let me explain. ... it always bothers me when certain people judge based on the fact that I'm Asian. "Oh you're only smart because you're Asian right?" and it's like, honey no that's not how it works. My culture definitely impacted my belief in a strong education, but it's me as a person who has worked diligently, not me as your standard Asian nerd. Stereotypes can be funny in a joke and some may be true, but people have got to learn it's rude to always assume someone is something they're not.”

32. How individual AAPI student cope with above stressors? • How individual student develop identity when they process stress from parent, academic and social life? 

33. Ineffective Stress Coping • Emotion focus (self harm, eating disorder, get angry at people with stereotypes) • Focus on competition to please others and self • Choose career path or major based on obligations oppose to self interest (practical reasons?) • Reduce communication with parents • Perceive parents’ different opinion as rejection or lack of love • Turn to peer with similar issues as sole source of support • Perceive peers, especially other Asian peers as competition targets

34. IDI 001 High achieve female high school studen. She has mental health issues and has engaged in self harm, drug use and eating disorder as stress coping mechanisms. She identify herself as gay, and has used alcohol, marijuana and study drugs and some meth. She is a leader, has many contacts but has very little emotional support from friends and family. She is very high achieving and a bit of an activist. “for example, we've been hearing of a boy in our school who took 20+ AP *AP's, and another person who is president of every single science club in our school that's what we feel we have to beat, or at least be as good as” “ Because i'm in such a rigorous program, people tend not to get much sleep, and they also tend to have a negative outlook on things so basically my entire peer group has issues as well, and they often come to me for help - but i'm not exactly able to help them much, since i have the same problems”

35. “…i do feel like i have to live up to the expectations, yes, but i'm not sure if i can sometimes it's like a confidence boost…then it turns into this fear that i'll disappoint all of them and end up failing them, the expectations, just make me more sensitive to failure, i guess” • “i wasn't accustomed to this kind of competition, and i was already having issues that started in 8th grade; my coping mechanism took the form of self harm, specifically cutting and burning, and starving myself… in freshman year, i also became involved with drug use, and sometimes even lack of sleep would be my way to deal with it” I: “Do you ask someone for help or suggestion?” R:  “you mean right now? not really, i'm still going on mostly on my own i try to not constantly be a burden to my friends”

36. “they (parents) just kept telling me how idiotic I was and how they can't believe they raised such a failure, and that didn't help, so my eating disorder and self harm got significantly worse after that” “my parents screamed at me for hours” “they also worried about my "reputation", since they figured that not giving my peers a good impression of myself was more important than my mental health” “i knew of at least 12 girls who were self harming, had an eating disorder, or did drugs and then i did a preliminary survey for research and i got the results that 18/46 girls were struggling with some kind of mental health issue or substance abuse”

37. Effective Stress Coping Styles • Problem solving focus • Use positive facts of prior success to adjust negative emotional responses to failure • Perceive hard work as a necessary part of future career of own choice, or agree with parents • Attending church reduced sensitivity to stereotype against ethnic identity • Effective communication with parents • Social support from others (older friends, accepting and safe peer group, opportunity to talk to other adults such as youth leaders and pastor)

38. Church’s Role in Resilience Find self-identity or self worth through faith – ignore stereotype Seek God’s help via prayer and believe He is countable Supported by a trusted peer prayer group Improve social capital: parents (improved relationship and support), other adults Bond with a peer group with positive norm – efficacy to resist peer pressure to use substance Danger: without positive norm, it can be a place of enhanced competition and gossip

40. What this presentation is, and isn’t? • Not educational (take brochures and information sheets !!) • Qualitative In-depth exploration, not conclusive • Not for generalization • Aimed to set directions for future large scale epidemiology study and inform prevention intervention studies • Preliminary findings of a one year pilot study • Based on self-reported data

41. Potential parent concerns about interviewing teens on sensitive topic • Low risk nature of the study – they do talk to their peers about these stuff • Teens are capable of judge the risk and benefit of participating in a study like this, and a make decision for themselves • In compliance with federal and local regulations regarding rights of minors • Strict protocol to protect confidentiality – IRB • The benefits of reflection on own behavior, talking to someone who cares, and service referral as needed

42. Be Sensitive! • Protect participant’s identity and confidentiality • Don’t ask don’t tell • Minimal demographic data in following presentation

43. Future Studies • Development and Feasibility Testing of a Social Media Enhanced Peer Recruitment and Sampling Method • Large scale epidemiology study test the theoretical model developed and modified based on the current study. • Prevention Intervention for COEAA Youth and Parents • improve mental/emotional health, prevent ATOD use • increased social support from parents, other adults, and safe peer group • increased self-efficacy to resist peer pressure, • peer norm change (stigma + • in collaboration with local Chinese and Korean churches