Exploring Binge Drinking and Drug Use among American Indians: Data from Adolescent Focus Groups

Background: Risk factors for binge substance use and non-suicidal self-injury (NSSI) are similar, suggesting the importance of exploring how binge substance use and self-injury interrelate. Objectives: To gain insight from a sample of American Indian (AI) adolescents regarding how binge drinking and drug use function in their lives, including as overlapping forms of self-injury, and to identify community-based ideas for dual prevention strategies. Methods: A total of N?=?58 White Mountain Apache (Apache) adolescents participated in ten mixed gender (n?=?33 males, 55.9%) focus group discussions. Results were interpreted and categorized by Apache researchers and compared to Nock's behavioral model of NSSI. Results: Participants reported substance use most commonly with "family" and "friends," "at a house," or "around the community." Substance use was not confined to a particular time of day, and often occurred "at school." Commonly endorsed reasons fell into two main categories: "to avoid problems" or "to reduce negative feelings," versus "to be cool" or "to feel part of a group." All adolescents but one thought that some youths use substances excessively as a way to harm/injure themselves (n?=?25 responses). Prevention approaches included encouraging healthy relationships, teaching about consequences of use, providing alternative recreation, and changing/enforcing laws on the reservation. Conclusion: Tribal-specific data support the idea that binge substance use sometimes functions as a form of self-injury. Home/school environments are critical prevention settings, in addition to improved law enforcement and increased recreation. Scientific Significance: Understanding possible shared root causes and functions of binge substance use and self-injury may advance integrated prevention approaches.     

Toward Understanding Suicide Among Youths: Results From the White Mountain Apache Tribally Mandated Suicide Surveillance System, 2001�C2006

Objectives. We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions.Methods. Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations.Results. Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict.Conclusions. An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.Suicide is the third leading cause of death among US youths aged 10 to 24 years,¹ and suicide attempts are a major source of adolescent morbidity in the United States. As behavioral scientists have increasingly recognized youths'' suicide behavior as an important and preventable public health problem, Healthy People 2010 has set specific objectives to reduce suicide and suicide attempt rates among youths. Past evidence supports the premise that youth suicide can be prevented by addressing risk factors and promoting early identification, referral, and treatment of mental and substance use disorders. However, risk factors vary across races, ethnic groups, and regions, necessitating targeted formative research and community-specific prevention approaches.²It is well-documented that American Indians and Alaska Natives have the highest rates of suicide of all US races.³ American Indian and Alaska Native (AIAN) suicides occur predominantly among youths ( < 25 years), in contrast to the US general population, in which deaths from suicide are concentrated among the elderly ( ≥ 65 years).⁴ Further, there is significant variability in suicide rates among youths across tribes and rural versus urban AIAN populations. Among the 1.3 million American Indians and Alaska Natives residing on or near rural reservation lands tracked by the Indian Health Service, the average rate of suicide per 100 000 is 20.2, with a range of 7.7 (Nashville area) to 45.9 (Alaska area).⁵ In comparison, for all 4.1 million American Indians and Alaska Natives identified by the US Census, the suicide rate is 11.7.⁶ Because urban AIAN residents compose approximately 60% of the US Census AIAN population,⁷ the lower overall census suicide rate indicates that rural reservation suicide rates are higher than urban AIAN suicide rates.To date, little reservation-specific information on suicide behavior or related risk factors exists to explain differences in rates across AIAN communities and in comparison with other US populations. Developing the means to collect and analyze local tribal data is key to discerning unique risk factors that are driving local and national disparities in suicide among AIAN youths, and to the public health mission of reducing suicide among youths across the United States and the world.There are approximately 15 500 White Mountain Apache (Apache) tribal members who reside on the 1.6 million acre Fort Apache Reservation in east-central Arizona. More than half (54%) of the tribal members are younger than 25 years, compared with approximately 35% of the US all-races population.⁸ In 2001, a cluster of suicides among youths on the Apache reservation led the Tribal Council to enact a resolution to mandate tribal members and community providers to report all suicidal behavior (ideation, attempts, and deaths) to a central data registry. The resulting surveillance system is the first of its kind, gathering data from both community-based and clinical settings.In 2004, as part of the Johns Hopkins Center for American Indian Health, we partnered with the Apaches to conduct a community-based participatory research (CBPR) project that included formalizing the mandated reporting process, transferring the registry system to an electronic format, analyzing quarterly trends, and engaging community leaders in interpreting surveillance data to inform prevention strategies. Because of the contentious history of research in tribal communities, CBPR methodologies are essential to ensuring a culturally sensitive interpretation of findings and culturally relevant interventions.⁹ A CBPR approach is particularly important in the complex area of mental health because explanatory models for cause and treatment of mental illness can vary widely across tribal and nontribal cultures.¹⁰We describe the Apache suicide behavior surveillance system, report patterns of Apache youths'' suicide and suicide attempts between 2001 and 2006, and compare those rates with those of other tribal and North American populations. We discuss the relevance of the paraprofessional-administered surveillance system and its findings to public health prevention of suicide behavior among youths.     

Randomized Controlled Trial of a Paraprofessional-Delivered In-Home Intervention for Young Reservation-Based American Indian Mothers

ObjectiveTo evaluate the efficacy of a paraprofessional-delivered, home-visiting intervention among young, reservation-based American Indian (AI) mothers on parenting knowledge, involvement, and maternal and infant outcomes.MethodFrom 2002 to 2004, expectant AI women aged 12 to 22 years (n = 167) were randomized (1:1) to one of two paraprofessional-delivered, home-visiting interventions: the 25-visit “Family Spirit” intervention addressing prenatal and newborn care and maternal life skills (treatment) or a 23-visit breast-feeding/nutrition education intervention (active control). The interventions began during pregnancy and continued to 6 months postpartum. Mothers and children were evaluated at baseline and 2, 6, and 12 months postpartum. Primary outcomes included changes in mothers' parenting knowledge and involvement. Secondary outcomes included infants' social and emotional behavior; the home environment; and mothers' stress, social support, depression, and substance use.ResultsParticipants were mostly teenaged, first-time, unmarried mothers living in reservation communities. At 6 and 12 months postpartum, treatment mothers compared with control mothers had greater parenting knowledge gains, 13.5 (p < .0001) and 13.9 (p < .0001) points higher, respectively (100-point scale). At 12 months postpartum, treatment mothers reported their infants to have significantly lower scores on the externalizing domain (β = ?.17, p < .05) and less separation distress in the internalizing domain (β = ?.17, p < .05). No between-group differences were found for maternal involvement, home environment, or mothers' stress, social support, depression, or substance use.ConclusionsThis study supports the efficacy of the paraprofessional-delivered Family Spirit home-visiting intervention for young AI mothers on maternal knowledge and infant behavior outcomes. A longer, larger study is needed to replicate results and evaluate the durability of child behavior outcomes. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(6):591-601.     

Postpartum Depression Prevention for Reservation-Based American Indians: Results from a Pilot Randomized Controlled Trial

Background  

Postpartum depression is a devastating condition that affects a significant number of women and their offspring. Few preventive interventions have targeted high risk youth, such as American Indians (AIs).     

Designing a Clinical Decision Support Tool That Leverages Machine Learning for Suicide Risk Prediction: Development Study in Partnership With Native American Care Providers

BackgroundMachine learning algorithms for suicide risk prediction have been developed with notable improvements in accuracy. Implementing these algorithms to enhance clinical care and reduce suicide has not been well studied.ObjectiveThis study aims to design a clinical decision support tool and appropriate care pathways for community-based suicide surveillance and case management systems operating on Native American reservations.MethodsParticipants included Native American case managers and supervisors (N=9) who worked on suicide surveillance and case management programs on 2 Native American reservations. We used in-depth interviews to understand how case managers think about and respond to suicide risk. The results from interviews informed a draft clinical decision support tool, which was then reviewed with supervisors and combined with appropriate care pathways.ResultsCase managers reported acceptance of risk flags based on a predictive algorithm in their surveillance system tools, particularly if the information was available in a timely manner and used in conjunction with their clinical judgment. Implementation of risk flags needed to be programmed on a dichotomous basis, so the algorithm could produce output indicating high versus low risk. To dichotomize the continuous predicted probabilities, we developed a cutoff point that favored specificity, with the understanding that case managers’ clinical judgment would help increase sensitivity.ConclusionsSuicide risk prediction algorithms show promise, but implementation to guide clinical care remains relatively elusive. Our study demonstrates the utility of working with partners to develop and guide the operationalization of risk prediction algorithms to enhance clinical care in a community setting.     

Suicide Prevention Gatekeeper Training: Can They Advance Prevention in Indian Country?

American Indian youth have the highest suicide rates in the United States; however, many do not use services and access barriers exist. This study was a cross-sectional evaluation of 6 gatekeeper trainings conducted on 1 reservation with N = 84 individuals. Analyses examined participant characteristics, impact on training objectives, and satisfaction. The majority of participants were American Indian and female (89.3%). Significant increases in knowledge (p < 0.001) and self-efficacy (p < 0.001) were observed post-test, as well as high satisfaction (3.53/5) and intent to use skills daily (36.4%) or monthly (66.3%). Lowest rated was how the training addressed cultural differences (2.93). While results support the promise of gatekeeper training, they identify a clear need for adaptation; specific implementation and research recommendations are discussed.     

Risk and protective factors for heavy binge alcohol use among American Indian adolescents utilizing emergency health services

Background: American Indian (AI) adolescents are disproportionately burdened by alcohol abuse and heavy binge use, often leading to problematic drinking in adulthood. However, many AI communities also have large proportions of adults who abstain from alcohol. Objective: To understand these concurrent and divergent patterns, we explored the relationship between risk and protective factors for heavy binge alcohol use among a reservation-based sample of AI adolescents. Methods: Factors at individual, peer, family, and cultural/community levels were examined using a cross-sectional case–control study design. Cases were adolescents with recent heavy binge alcohol use that resulted in necessary medical care. Controls had no lifetime history of heavy binge alcohol use. 68 cases and 55 controls were recruited from emergency health services visits. Participants were 50% male; average age 15.4 years old, range 10 to 19. Independent variables were explored using logistic regression; those statistically significant were combined into a larger multivariate model. Results: Exploratory analyses showed adolescents who were aggressive, impulsive, had deviant peers, poor family functioning or more people living at home were at greater risk for heavy binge alcohol use. Protective factors included attending school, family closeness, residential stability, social problem-solving skills, having traditional AI values and practices, and strong ethnic identity. Confirmatory analysis concluded that school attendance and residential stability reduce the probability of heavy binge alcohol use, even among those already at low risk. Conclusions: Findings deepen the understanding of AI adolescent heavy binge alcohol use and inform adolescent intervention development fostering trajectories to low-risk drinking and abstinence.     

Informing Precision Home Visiting: Identifying Meaningful Subgroups of Families Who Benefit Most from Family Spirit

Prevention Science - The Maternal, Infant, and Early Childhood Home Visiting Program was reauthorized February 8, 2018, and invests $2 billion over 5&nbsp;years to improve mothers’ and...     

Motivators and Influences on American Indian Adolescent Alcohol Use and Binge Behavior: A Qualitative Exploration

We explore the four-class drinking motives model within the context of peer and family influence on American Indian (AI) adolescent alcohol use, specifically binge behavior. A qualitative cross-sectional case-control study design was utilized; in-depth interviews were collected with 38 AI adolescents from one tribal community. Results suggest a three-class model more accurately captures drinking motives among cases and that family influence is as important as peer. Cases weren't connected to school whereas controls were strongly attached, and engaged in extracurricular programs. Adolescents illuminated culturally relevant prevention strategies that are family based, teach coping skills, and promote school bonding and structured community-based activity.