Teen Violence In Hawaii

Dating Violence Victimization: Associated Drinking and Sexual Risk Behaviors of Asian, Native Hawaiian, and Caucasian High School Students in Hawaii Suhasini Ramisetty-Mikler, Deborah Goebert, Stephanie Nishimura, Raul Caetano ABSTRACT: Ethnic minority groups such as Asian/Pacific Islanders (APIs) and native populations in Hawaii are seldom studied in the area of intimate relationships. Using the 1999 Hawaii Youth Risk Behavior Survey, this study examined gender and ethnic differences in experiencing physical dating violence and whether drinking (early initiation, binge drinking), unsafe sexual behaviors (early initiation, multiple partners, use of alcohol and drugs with sex, history of sexual abuse), and suicidality constitute risk for victimization among APIs, Native Hawaiian (NH), and Caucasian high school students in multiethnic state of Hawaii. The final analysis included 559 boys and 683 girls. The overall rate of experiencing physical violence was 7.8% with both genders reporting similar rates (boys 7.6%, girls 8.0%). Although not significantly different, NH students reported a higher rate (11.6%) than Caucasians (7.3%) and APIs (6.5%). Significant bivariate associations were found between victimization and many of the risk factors. Regression analyses indicated that students 16 years or older were nearly 3 times more at risk for experiencing dating violence. The risk was 8-fold if youth were sexually active by age 13 compared to those who abstained. The risk is 3-fold for those who reported prior sexual abuse. Early initiation of drinking (,12 years) and suicidality doubled the risk of being a victim. Clearly, the study highlights the risk of experiencing dating violence when a teen engages in sex very early or uses alcohol. Schools must routinely educate youth about various forms of dating violence, the effects of engaging in early sex, and drinking. Screening adolescents for associated risk factors such as drinking and depression is crucial to identify victimization. Dating violence is an antecedent for adult partner violence. Thus, by reducing youth dating violence, we may consequently reduce the incidence of adult partner violence. (J Sch Health. 2006;76(8):423-429)

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uring the last decade, there has been a continuous growth of research on dating violence focusing on high school and college students.1,2 There is no universal consensus on the definition of dating violence. The US Department of Justice defines dating violence as ‘‘the perpetration or threat of an act of violence by at least 1 member of an unmarried couple on the other member within the context of dating or courtship.’’3 The Centers for Disease Control and Prevention (CDC) defines dating violence as encompassing ‘‘any form of sexual assault, physical violence, and verbal or emotional abuse’’ within the context of dating.4 It occurs across all social-economic classes, and all racial groups with most victims being young women who are also at a higher risk for serious injury. Women aged 16-24 experience the highest rates of violence—nearly 20 per 1000 women.3,5 The terms ‘‘violence’’ and ‘‘dating violence’’ are used interchangeably in this paper and ‘‘partner violence’’ refers to violence between adult couples who are either married or cohabiting. Although society is becoming more aware of adult couple violence, the issue of dating violence among adoSuhasini Ramisetty-Mikler, PhD, MPH, Faculty Associate (Susie. [email protected]); and Raul Caetano, MD, PhD, Professor and Dean ([email protected]), University of Texas Houston School of Public Health, Dallas Regional Campus, 6011 Harry Hines Blvd. V8.112, Dallas, TX 75390-9128; Deborah Goebert, DrPH, Associate Professor of Psychiatry ([email protected]); and Stephanie Nishimura, MSW, Instructor ([email protected]. edu), Department of Psychiatry, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana Street, 4th Floor, Honolulu, HI 96813. Work on this paper was supported by a contract (N01AA01015) from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Center for Minority Health and Health Disparities (NCMHD), and the National Institutes of Health (NIH) to the University of Texas Houston School of Public Health, Dallas Campus, Dallas, Texas. Dissemination is supported by NIAAA and NCMHD Award (1 U01 AA014289-01).

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lescents has not received sufficient attention.6 Further, fewer studies have addressed risk factors of dating violence and the mechanism by which these factors operate. The majority of adolescents tend to date steadily by 16, and many experience an episode of violence as early as age 15, suggesting that those who begin dating earlier are more likely to become a victim.7 However, studies report varying prevalence rates (lifetime or 12 month), for a wide range of aggressive and coercive behaviors. Research indicates that dating violence occurs at fairly high rates with the lower bound around 8-9% when a specific type such as physical violence that is most often and easily measured is considered. When several forms are considered, the rates are as high as 96%. For example, the prevalence of dating violence including verbal, physical, and sexual among adolescents ranges from 9% to 39%.6,8,9 Recent studies estimate that 28-96% of adolescents are victims of dating violence with some studies reporting rates as high as 60%.2,10,11 Gender differences exist in the type and rates of dating violence experienced. Females are frequently victimized as well as experience more severe dating violence perpetrated by their male partners. For example, female teens perpetrate more or less minor acts of violence than do male teens but are also likely to receive physical injuries and are more likely to be sexually abused.11 Female teens reported that male dates initiated abuse 70% of the time, and males reported that their female dates initiated abuse 27% of the time.12 Approximately 1 in 5 high school girls have reported being abused by a boyfriend,13 and approximately 1 out of every 3 high school and college students have experienced sexual, physical, verbal, or emotional violence while dating.1,14 A recent review reported that physical violence victimization among girls range from 8% to 57% and 6% to 38% among boys.15,16 Another study found that 45% of female and 43% of male high school

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students were victimized by their dating partners at least once. Males report physical abuse (eg, being slapped and hit with a fist or an object) more often than females, while females report significantly more sexual abuse than males. Both males and females report that males are frequently the initiators of dating violence.17 The CDC reports 12-month prevalence of only physical violence (hit, slap, or physically hurt) resulting in lower estimates as compared to the estimates reported above. Based on the national Youth Risk Behavior Survey (YRBS) data, dating violence victimization among high school students remained constant (8.8%, 9.5%, and 8.9% in 1999, 2001, and 2003 respectively), with apparent gender and ethnic disparities. A higher proportion of females (12.5%) compared to males (5.2%) and minority students (Black 11.6%, Hispanic 10.5% in 1999; Black 13.9%, Hispanic 9.3% in 2003) compared to White (6.7% in 1999; 7.0% in 2003) students experienced dating violence.4,18 Research on adolescent dating violence includes Caucasian, Latino, and/or African American samples19-22 and ethnic minority groups reported the highest rates of victimization.16 Data on other minority groups such as APIs and native populations are very sparse. A recent study conducted in Hawaii23 reported on verbal/psychological dating violence victimization among adolescents in Asian American (Filipino and Japanese) and 2 Pacific Islander (Native Hawaiian [NH] and Samoan) groups. More than one half (58.3%) of adolescents who were surveyed experienced psychological or emotional dating violence including verbal abuse and controlling behaviors. However, this study did not measure physical abuse. The demographic profile of Hawaii provides an ideal setting to study minority groups including Asians, NHs, and Pacific Islanders.24 The current study used the 1999 Hawaii YRBS data to examine gender and ethnic differences in experiencing physical dating violence and whether drinking (early initiation, binge drinking), unsafe sexual behaviors (early initiation, multiple partners, use of alcohol and drugs with sex, history of sexual abuse), and suicidality constitute risk for victimization. Risk behaviors including early sexual initiation, multiple partners, and drinking increase the chances of dating violence. Research has identified several risk factors of victimization including maltreatment at home, mental health factors, early sexual activity, and tobacco, alcohol, and drug use causing interpersonal difficulties with peers and dating partners.10,25,26 Adolescent girls who have experienced dating violence may also demonstrate sequelae such as unhealthy weight control behaviors, sexually transmitted diseases, and suicidal ideation.13,22 In addition to a negative impact on mental and emotional health, victimization may result in poor health.17,27 Our prior work with this sample indicated a strong association between drinking and sexual risk behavior,28 and drinking and suicidal behavior.29 Thus, suicidality, which is used as an indicator of mental health, is included as a covariate in the multivariate analyses.

level, all classes in a required subject were included in the sampling frame. Systematic equal probability sampling with a random start was used to select classes from each school that participated in the survey. All students in the selected classes were eligible to participate and only those who obtained parental permission were surveyed. The questionnaire contained 87 multiple-choice items in 6 categories of health risk behaviors among youth: behaviors that contribute to unintentional and intentional injuries; tobacco, alcohol and other drug use; unsafe sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases; dietary behaviors; and physical inactivity and individual information (gender, age, grade, and ethnicity). Measurements Dating Physical Violence Victimization (Outcome Variable). Students were asked if their dating partner ever hit, slapped, or physically hurt them on purpose during the past 12 months. Those who reported ‘‘yes’’ were identified as victims of physical abuse by dating partners. Sexual Experiences. Age of sexual initiation: Students were asked at what age they had their first sexual intercourse. Multiple partners (lifetime): The students were asked to indicate the number of people they had sex with in their lifetime. Based on their responses, students were categorized into 2 groups—‘‘yes,’’ 2 or more partners; and ‘‘no,’’ multiple partners (those who never had sex or those who had only 1 partner). Substance use before sex: Students were asked about the use of alcohol or any drugs (yes/no) in conjunction with the last intercourse. Ever been forced to have sex: Students were asked whether they had ever been forced to have sexual intercourse when they did not want to. Alcohol Use. Age of initiation: This is the age when they first drank an alcoholic beverage including more than a few sips. Drinking pattern (past 30 days): This variable was constructed based on the standard measurement of episodic drinking in alcohol research.4,30,31 Two items based on their alcohol use pattern during the past 30 days were used: (a) On how many days did you have at least 1 drink of alcohol? Response categories included number of days: 0, 1, 2, 3-5, 6-9, 10-19, 20-29, and all 30 days; (b) On how many days did you have 5 or more alcoholic drinks in a row, that is, within a couple of hours? Response categories included number of days: 0, 1, 2, 3-5, 6-9, 10-19, and 20 or more days. These 2 items were cross-tabulated to determine students drinking pattern and then placed into 1 of 3 categories: never drank (abstainer), drank 31 days but not 5 or more drinks at any time within a 2-hour period (nonepisodic), and episodic (drank 1 or more times 5 drinks or more any time within a 2-hour period). Suicidality (Past 12 Months). Suicidality measure used 3 questions that concern suicidal thoughts or attempts. Students were asked if, during the past 12 months, they seriously considered attempting suicide; whether they had made plans about suicide; and how many times they actually attempted committing suicide. Response choices for these questions were either ‘‘yes’’ or ‘‘no.’’ A positive response to any 1 of these 3 items was considered a risk for suicide. Demographic Variables. Gender, age, grade (9th-12th), and ethnicity: A 4-level categorical variable was derived

METHODS Sample and Procedures A 3-stage cluster sample design produced a representative sample of students in grades 9-12. Schools were selected systematically with probability proportional to enrollment in grades 9-12 using a random start. At class

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from 2 items that asked students to identify their ethnicity on the standard list and also whether or not they identify themselves as ‘‘Native Hawaiian’’ (yes/no). In the 1999 survey, the NH category was added to the standard list and students who chose NH from the standard list and those who said ‘‘yes’’ that they were NHs were included under the NH category. All others were coded based on ethnicity identified by students as ‘‘Asian/Pacific Islander,’’ ‘‘Caucasian’’ (reference group), and other/mixed or multiple races. Data Analysis Each student record was weighted to adjust for nonresponse and for varying probabilities of sampling procedures, and included a poststratification adjustment factor calculated by gender within grade.4 The data were representative of high school students in Hawaii public schools. Due to the multiclustered sampling design, analyses were conducted using SUDAAN software to adjust the standard errors.32 Cross-tabulations with chi-square statistic option were performed to examine the bivariate associations between dating violence victimization and ethnicity, drinking practices (early initiation, binge drinking), unsafe sexual behaviors (early initiation, multiple partners, use of alcohol and drugs with sex, history of sexual abuse), and suicidality. Results are reported in weighted percentages with their unweighted sample size. For multivariate analyses, logistic regression model was run for dating violence victimization as the dependent variable with sexual experiences, episodic drinking pattern, age at first drink, as independent variables controlling for covariate suicidality and demographic factors.

RESULTS Demographics Respondents included 559 male and 683 female high school students, and the overall student response rate was 63% (53% female and 47% male). Nearly one half were APIs (45.3%) and one fifth were NHs (17.3%), followed by Caucasians (14%). The remaining students were from other ethnic backgrounds or of multiple backgrounds (23.4%). Dating Violence Experience The overall prevalence of experiencing dating violence in this sample is 7.8% (n ¼ 101). As indicated in Table 1, similar rates of experience of dating violence were observed among both boys (7.6%) and girls (8.0%). Although not significantly different from other ethnic groups, NH students reported experiencing violence at the highest rate and APIs at the lowest rate. Significant age differences were observed in reporting violence with the highest rate around 16 years of age. No specific grade differences were observed. Experiencing dating violence is significantly associated with all the risk factors under consideration (Table 2). Those who never engaged in sex experienced the lowest rate of violence, and those who initiated sexual activity very early, 13 years or younger, experienced the highest. Those who reported lifetime multiple partners, those who used alcohol and drugs in conjunction with sex, and those who were victims of forced sex in their lifetime reported higher rates of dating violence. Those who initiated drinking very early in their life ("12 years), those who binge drink, and those with suicidal thoughts reported higher rates.

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Predictors of Dating Violence Victimization The results from the multivariate analyses (Table 3) indicate that 16-year-olds were nearly 3 times more at risk for experiencing violence compared to 18-year-olds. Teens engaging in sexual activity, particularly at very young age 13 years or younger were at greatest risk (8-fold) compared to students abstaining from sex. Students who reported prior experience of forced sex were also at risk of being abused. Drinking at younger age (,12 years) doubles the risk of being a victim compared to those who never drank. Suicidal tendency, which represents adolescents’ mental and emotional state, makes them vulnerable for being victimized.

DISCUSSION The present study examined the prevalence of physical dating violence victimization among high school students in Hawaii. No significant differences were found for rates of dating victimization between male and female students. The overall 12-month rate of victimization is comparable to the national victimization rate reported by the YRBS. Although not statistically significant, NH students reported the highest rate (12%) that is 2 times higher than the rate reported by the majority group, API students (6.5%).

Table 1 Demographic Characteristics of Students Who Experienced Dating Violence Victimization Experienced Dating Violence Statistic (Weighted Percent) v2 (df) Gender Male (n ¼ 555) Female (n ¼ 680) Ethnicity Asian/Pacific Islander (n ¼ 564) Native Hawaiian (n ¼ 200) Other/multiple/ American Indian/ Black/Hispanic (n ¼ 284) White (n ¼ 170) Age (in years)*** 13-14 (n ¼ 159) 15 (n ¼ 317) 16 (n ¼ 328) 17 (n ¼ 294) #18 (n ¼ 140) Grade 9th (n ¼ 341) 10th (n ¼ 324) 11th (n ¼ 314) 12th (n ¼ 258)

7.6 8.0

0.05 (1)

6.5

6.4 (3)

11.6 8.0

7.3 5.5 6.0 11.8 8.5 4.3

38.2 (4)

8.4 7.7 7.4 7.7

0.3 (3)

*** p , .001.

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In this sample, 16-year-olds, compared to 18 or older, are nearly 3 times more at risk for experiencing violence. As research suggests, many adolescents experience some form of dating violence before they graduate from high school,7 and as a dating relationship becomes more serious the potential for and nature of violent behavior also escalates.33 Several studies have shown that victims of violence tend to be more absent from school and some drop out of school prematurely,34 leading therefore to decrease in rates assessed in the school settings over time. The study findings clearly indicate that the risk of being victimized is greater if teens begin to engage in sexual activity at a very young age. Drinking at younger age (,12 years) doubles the risk of being a victim compared to those who never

drank. Early sexual activity was also associated with the risk of having multiple partners and alcohol use. Our prior work with this sample indicated that the younger the age of initiation, it is more likely that teens would have multiple sexual partners. NHs and Caucasian students are more likely to have multiple partners in their lifetime as they also tend to initiate sex earlier. Findings also suggest that adolescents who drink (episodic or nonepisodic) or use drugs are more likely to be sexually active as well as engage in unsafe behaviors such as sex with multiple partners.28 Victims of forced sex were also more likely to experience physical abuse in dating relationships. The violence

Table 3 Odds Ratios and 95% CI From Logistic Regression Model Predicting Dating Violence Victimization (n ¼ 1035)

Table 2 Drinking, Sexual Risk Behaviors, and Mental Health Associated With Dating Violence Victimization

Predictor Experienced Dating Violence (Weighted Statistic Percent) v2 (df) Age of sexual initiation (in years)*** 16 or older (n ¼ 126) 14-15 (n ¼ 229) 13 or younger (n ¼ 151) Never had sex (n ¼ 700) 2 or more sexual partners (lifetime)*** (n ¼ 311) One partner or never had sex (n ¼ 895) Used alcohol or drug last sexual activity** (n ¼ 126) Did not use or no sexual activity (n ¼ 1078) Ever been forced to have sex*** (n ¼ 105) Never been forced (n ¼ 1134) Age of first drinking (in years)*** 15 or older (n ¼ 223) 13-14 (n ¼ 274) 12 or younger (n ¼ 366) Never drank (n ¼ 256) Drinking pattern (past 30 days)*** Binge drinking (n ¼ 326) Drank, but no binging (n ¼ 204) Never drank (n ¼ 664) Suicidality (past 12 months)*** Serious thoughts about suicide, planned or attempted suicide (n ¼ 289) Did not feel suicidal (n ¼ 938)

9.8 13.0 21.8 2.5 17.0

Male (ref: female) Ethnicity (ref: white) Asian/Pacific Islander Native Hawaiian Other/multiple/ American Indian/ Black/Hispanic Age (ref: #18 years) 13-14 15 16 17 Age of sexual initiation (ref: never had sex) 13 or younger 14-15 16 or older Multiple (2 or more) sexual partners (lifetime) (ref: 1 person or no sex) Used alcohol or drug last sexual activity (ref: no) Ever been forced to have sex (ref: no) Age of first drinking (in years) (ref: never drank) 12 or younger 13-14 15 or older Drinking pattern past 30 days (ref: never drank) Binge drinking Drank, but no binging Suicidality (past 12 months) (ref: no)

68.3 (3)

32.0 (1)

4.3 15.1

7.5 (1)

6.8 27.4

22.5 (1)

6.2 8.6 8.0 13.1 3.0 14.6 8.3

69.2 (3)

27.1 (2)

4.8 15.5

21.6 (1)

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1.3

0.7-2.4

1.0 1.4 0.8

0.6-1.8 0.7-3.0 0.3-2.6

2.3 1.7 2.8* 2.3

0.7-7.5 0.5-5.7 1.1-7.0 0.9-6.0

7.6*** 3.9** 3.5*** 0.9

2.5-23.4 1.5-10.0 1.8-6.9 0.4-1.9

0.5*

0.3-0.9

3.1**

1.6-5.7

2.2** 1.3 1.8

1.3-3.8 0.5-3.4 0.7-4.7

1.2 1.0 1.9**

0.5-2.5 0.4-2.6 1.2-3.1

* p " .05; ** p " .01; *** p " .001.

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95% CI

R2 ¼ 9.3%

5.8

** p , .01; *** p , .001.

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Adjusted Odds Ratio

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literature provides concrete evidence that childhood experiences of physical and sexual abuse are risk factors for being a victim of domestic violence in adulthood30 as well as alcohol abuse and problems.35,36 In this study, however, it is not possible to explore at what age these adolescents have been victims of forced sex and who the perpetrator was. Studies37,38 note that children exposed to violence exhibit elevated rates of many behavior problems including externalizing and internalizing problems, substance abuse problems, separation anxiety, social skill deficits, school problems, attention deficits, posttraumatic stress disorder and higher rates of aggression and violence in their own behavior patterns. Evidence linking these predictors to violence is also based on Bandura’s social learning theory, which suggests that conflict resolution through violence in adult life can result from learned models of behavior during childhood. Regrettably, these variables were not included in the current study as they were not assessed in the YRBS. Findings suggest that suicidality, the state of emotional and mental health, makes them vulnerable to being victimized. Many adolescents experience intense emotional states and depression, and in an effort to develop intimate relationships, they may be tolerant of minor forms of violence to begin with. The rate of suicide among American adolescents increased nearly 3-fold between the early 1960s and the late 1980s;39 however, there has been a general decline in adolescent suicides since 1994.40 Nearly 3 million 12- to 17-year-old adolescents in the United States contemplated suicide, and 37% of these adolescents attempted suicide.41 Depression has been identified as one of the risk factors for adolescent suicide behaviors40,42 along with alcohol use.29 Previous local studies indicate that the NH adolescents have higher rates of suicide attempts in comparison to non-Hawaiian adolescents.43 NH adolescents were found to have a risk for suicide attempts nearly 3 times higher than non-Hawaiian adolescents aged 10-14 and greater than 7 times higher than non-Hawaiian adolescents aged 15-19.44 Although not significantly different, NH students reported experiencing violence at a higher rate. Our earlier studies using this sample indicated that drinking was the best predictor for all suicide indicators.29 However, further studies might be helpful to understand the mechanism of alcohol use coupled with depression and early sexual activity in this ethnic group. Because of the cross-sectional nature of the study, the temporality and the mechanism cannot be addressed. For instance, a student might be depressed and attempts to commit suicide as a result of their current dating violence experiences or vice versa. Further, a student might be drinking because of the pressure from his or her dating partner. Dating partners may not necessarily be their own classmates; they could be outsiders and older college students. Violence between 2 individuals in a relationship is a complicated and multifaceted problem, and many variables including family environment, demographic region, ethnicity, and substance use contribute to abusive relationships. Findings of this study clearly recognize the role of alcohol use and engaging in sexual activity at an earlier age in increasing the risk of experiencing dating violence. Adolescent’s experience of forced sex is also associated with dating violence. According to Riggs and O’Leary,45 aggressive behaviors are set into motion by situational vari-

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ables such as a history of personal exposure to violence and use of drugs and/or alcohol. However, adolescents being young and highly impulsive and emotional, they may interpret aggression as a legitimate response to conflict. In order to have a meaningful change in the incidence of dating violence, a strategic plan at the school level must be implemented to identify at-risk students and provide timely intervention through education. The incidence of dating violence among youth is substantial and predicts future interpersonal risk for unhealthy, harmful relationships. Prevention of domestic violence will require coordinated efforts of local communities, schools, health care providers, and all levels of government.46 All 50 states and the District of Columbia have laws against dating violence including sexual assault and stalking. However, the specific term ‘‘dating violence’’ is almost never used in these laws. Age requirements and the language of the laws vary by state.3 School-based interventions such as Safe Dates are promising in preventing and reducing dating violence for as many as 4 years after the program47 by positively changing cognitive mediating variables.1 Implementing such cognitive and behavioral-based programs in schools is necessary and crucial in reducing dating violence. There are several limitations to this study that need to be acknowledged. These limitations include low student response rate, underreporting of violence experiences due to the content of the questionnaire, and reluctance to disclose sexual and substance use behavior. These data represent only public school students present on the day the survey was administered and, therefore, do not represent all persons in this age group. Extent of under- or overreporting of behaviors cannot be determined. The survey questions demonstrated good test-retest reliability, but several items need to be examined further.48 The crosssectional nature of the study does not allow the establishment of a causal relationship and is limited in explaining complex interactions among risk behaviors. For example, sexual experience such as forced sex was a strong predictor of victimization. However, the directionality is hard to establish because of the cross-sectional nature of the data. Further, because of the ambiguity of the question asked in the survey by the CDC, the context in which the dating violence has occurred, frequency of occurrences, severity of violence, and whether it is in retaliation from male to female or female to male is unknown. Regression models included only individual factors but not family/parental factors (parental alcohol/drug use, childhood experiences of violence) as they were not collected in the survey. Nevertheless, the study findings suggest that alcohol use and unhealthy sexual behaviors rather than ethnicity significantly predicted victimization among high school students in Hawaii. Finally, the study is limited to the experiences of physical violence and does not address other forms of violence such as sexual, verbal, or psychological abuse that are perhaps widely prevalent.

CONCLUSIONS Dating violence is a antecedent for partner definition and scope of in order to plan future

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public health concern as it is an violence in adulthood. Accurate the problem must be determined interventions. The study findings

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document that use of alcohol and early initiation of sex increase the risk of violence victimization. Research documents that behaviors such as drinking, one of the most powerful predictors of risky sexual practices such as having multiple sexual partners, depend directly on selfcontrol and life skills. The detrimental effect of alcohol on sexual behavior is evident and supports previous research based on problem-behavior theory signifying that early age of onset for substance use is associated with engaging in multiple health risk behaviors among adolescents.49 These findings also underscore the importance of abstinence, thus helping teens to delay sexual activity and suggest a need for programs emphasizing abstinence from alcohol and sex. Healthy ways of interacting must be integrated into the health education curriculum to enhance skills that promote nonviolent conflict resolution. Dating violence, including minor acts such as a simple slap or being pushed or shoved, must be addressed because they are the precursors of partner violence in adult relationships. Pediatricians and school health counselors must provide routine guidance to increase awareness regarding various forms of violence and how to identify early signs of abusive relationships. Reducing adolescent dating violence may consequently reduce the incidence of partner violence in adulthood. j

16. Howard DE, Wang MQ. Psychosocial factors associated with adolescents boys’ reports of dating violence. Adolescence. 2003;38(151):519533. 17. O’Keefe M, Trester L. Victims of dating violence among high school students. Violence Against Women. 1998;4(2):195-223. 18. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2003. MMWR. 2004;53(SS-02):1-96. Available at: http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf. Accessed June 15, 2005. 19. Schwartz M, O’Leary SG, Kendziora KT. Dating aggression among high school students. Violence Vict. 1997;12(4):295-305. 20. Howard DE, Wang MQ. Risk profiles of adolescent girls who were victims of dating violence. Adolescence. 2003;38(149):1-14. 21. Valois RF, Oeltmann JE, Waller J, Hussey JR. Relationship between number of sexual intercourse partners and selected health risk behaviors among public high school adolescents. J Adolesc Health. 1999;25(5):328-335. 22. Wingood GM, DiClemente RJ, McCree DH, Harrington K, Davies SL. Dating violence and the sexual health of black adolescent females. Pediatrics. 2001;107(5):E72. 23. Choi-Misailidis S, Mayeda DT, Hishinuma ES, Nishimura ST, Chesney-Lind M. Dating violence victimization among Asian American and Pacific Islander youth. Manuscript under review. 2006. 24. US Census Bureau. 2000 US Census Bureau. Available at: http:// quickfacts.census.gov/qfd/states/15000.html 2000. Accessed June 20, 2005. 25. Rogosch FA, Cicchetti D, Aber JL. The role of child maltreatment in early deviations in cognitive and affective processing abilities and later peer relationship problems. Dev Psychopathol. 1995;7(4):591-609. 26. Shields A, Cicchetti D. Parental maltreatment and emotion dysregulation as risk factors for bullying and victimization in middle childhood. J Clin Child Psychol. 2001;30(3):349-363. 27. Coker AL, McKeown RE, Sanderson M, Davis KE, Valois RF, Huebner ES. Severe dating violence and quality of life among South Carolina high school students. Am J Prev Med. 2000;19(4):220-227. 28. Ramisetty-Mikler S, Caetano R, Goebert D, Nishimura S. Ethnic variation in drinking, drug use, and sexual behavior among adolescents in Hawaii. J Sch Health. 2004;74(1):16-22. 29. Nishimura ST, Goebert DA, Ramisetty-Mikler S, Caetano R. Adolescent alcohol use and suicide indicators. Cultur Divers Ethnic Minor Psychol. 2005;11(4):309-320. 30. Caetano R, Cunradi C, Clark CL, Schafer J. Intimate partner violence and drinking patterns among White, Black, and Hispanic couples in the US. J Subst Abuse. 2000;11(2):123-138. 31. Naimi TS, Brewer RD, Mokdad A, Denny C, Serdula MK, Marks JS. Binge drinking among US adults. JAMA. 2003;289:70-75. 32. Research Triangle Institute. SUDAAN Software for the Statistical Analysis of Correlated Data. Version 13.0. Research Triangle Park, NC: Research Triangle Institute; 2005. 33. National Coalition Against Domestic Violence. Teen Dating Violence Resource Manual. Denver, Colo: Dating Violence Resource Center; 1997. Available at: www.ncvc.org/dvrc. Accessed June 15, 2005. 34. Dyregrov A. Educational consequences of loss and trauma. Educ Child Psychol. 2004;21(3):77-84. 35. Ireland T, Widom CS. Childhood victimization and risk for alcohol and drug arrests. Int J Addict. 1994;29(20):235-274. 36. Miller BM. Investigating links between childhood victimization and alcohol problems. In: Martin SE, ed. Alcohol and Interpersonal Violence: Fostering Multidisciplinary Perspectives (Vol. NIAAA Research Monograph No. 24). Rockville, Md: NIAAA; 1993:315-323. 37. Barnett OW, Miller-Perrin CL, Perrin RD. Family Violence Across the Lifespan. Thousand Oaks, Calif: Sage; 1997. 38. Bisson JI, Shepherd JP. Psychological reactions of victims of violent crime. Br J Psychiatry. 1995;167(6):718-720. 39. National Center for Health Statistics. Vital Statistics Mortality Data, 1950-1995. Hyattsville, Md: Centers for Disease Control and Prevention; 1997. 40. U.S. Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide. Washington, DC: U.S. Public Health Service; 1999. 41. Substance Abuse and Mental Health Services Administration. Suicide, depression, and youth drinking. National Clearing House for Alcohol and Drug Information Report. U.S. Department of Health and Human Services. Prev Alert. 2002;5(17). 42. Johnson GR, Krug EG, Potter LB. Suicide among adolescents and young adults: a cross-national comparison of 34 countries. Suicide Life Threat Behav. 2000;30(1):74-82.

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43. Yuen NY, Nahulu LB, Hishinuma ES, Miyamoto RH. Cultural identification and attempted suicide in Native Hawaiian adolescents. J Am Acad Child Adolesc Psychiatry. 2000;39(3):360-367. 44. Goebert D, Birnie KK. Injury and disability among Native Hawaiians. Pac Health Dialog. 1998;5(2):253-259. 45. Riggs DS, O’Leary KD. A theoretical model of courtship aggression. In Pirog-Good MA, Stets JE, eds. Violence in Dating Relationships. New York: Praeger; 1989:53-71. 46. Close SM. Dating violence prevention in middle school and high school youth. J Child Adolesc Psychiatr Nurs. 2005;18(1): 2-9.

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47. Foshee VA, Bauman KE, Ennett ST, Linder GF, Benefield T, Suchindran C. Assessing the long-term effects of the Safe Dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration. Am J Public Health. 2004;94(4):619-624. 48. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey Questionnaire. J Adolesc Health. 2002;319(4):336-342. 49. DuRant RH, Smith JA, Kreiter SR, Krowchuk DP. The relationship between early age of onset of initial substance use and engaging in multiple health risk behaviors among young adolescents. Arch Pediatr Adolesc Med. 1999;153(3):286-291.

P A R T N E R S

President’s Diamond Endowment Partner e e

American Diabetes Association, 1701 North Beauregard St., Alexandria, VA 22311 McGovern Fund for the Behavioral Sciences, 2211 Norfolk, Suite 900, Houston, TX 77098-4044

Platinum Endowment Partner e

California Division of the American Cancer Society, 1710 Webster St., Oakland, CA 94612

Gold Endowment Partner e e e e e e e

Comchoice, http://www.comchoice.com/main.html Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405 Glencoe/McGraw-Hill, 148 Princeton Heights Road, Hightstown, NJ 08520 Hart Sharp Video, www.supersizemestore.com Met Life Foundation, Blake Works Preventing Chronic Disease Journal, 4770 Buford Highway, NE, K-85, Atlanta, GA 30341 School Health Corp., 665 Muirfield Drive, Hanover Park, IL 60133

Silver Endowment Partner e e e e e

American Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 30329 Blackwell Publishing, 350 Main St., Malden, MA 02148 Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, P.O. Box 118210, Gainesville, FL 32611-8210 National Association of State School Nurse Consultants, Inc., P.O. Box 708, Kent, OH 44240 Walk for Life, Inc., 12137 Rhea Drive, Plainfield, IL 60544

Sustaining Partner e e e

College of Health and Social Services, New Mexico State University, MSC: 3446, Educational Services Center, Las Cruces, NM 86003-8001 ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066 ASHA Board of Directors and Finance Committee members: Jeffrey Clark, Susan Clark, Mary Doyen, Candace Hendershot, Patricia Kardambikis, Darrel Lang, David K. Lohrmann, Susan W. Spalt, Robert F. Valois, William H. Zimmerli

AMERICAN SCHOOL HEALTH ASSOCIATION 7263 State Route 43 e P.O. Box 708 e Kent, OH 44240 e 330/678-1601 e www.ashaweb.org

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