The Impact of Individual and Parental American Indian Boarding School Attendance on Chronic Physical Health of Northern Plains Tribes.

This study investigated the relationship of American Indian boarding school attendance and chronic physical health. We hypothesized boarding school attendance would be associated with an increased number of chronic physical health problems. We also examined the relationship between boarding school attendance and the 15 chronic health problems that formed the count of the chronic health conditions. American Indian attendees had a greater count of chronic physical health problems compared with nonattendees. Father's attendance was independently associated with chronic physical health problems. Attendees were more likely to have tuberculosis, arthritis, diabetes, anemia, high cholesterol, gall bladder disease, and cancer than nonattendees.

The relationship of five boarding school experiences and physical health status among Northern Plains Tribes.

PURPOSE: American Indian (AI) boarding school attendance is related to poor physical health status; however, little is known about how specific aspects of this experience contribute to poor health. Five experiences (age of first attendance, limited family visits, forced church attendance, prohibition on practicing AI culture and traditions, and punishment for use of AI language) may be independently associated with physical health status in adulthood. We expected the effect to be greater for those who began boarding school at older ages. METHODS: Data on AI boarding school attenders (n = 771) came from the AI-Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project. Multiple linear regression models examined the association of these five experiences with physical health status. Additionally, we conducted a separate set of regressions to test for an interaction effect of age of first attendance. RESULTS: Each of the five experiences noted above were independently associated with poorer physical health status compared to those who did not have these experiences. An interaction effect for those punished for use of AI language and who were aged 8 or older was confirmed. CONCLUSIONS: Findings are consistent with reports that boarding school attendance is related to poor AI adult health. To inform AI health programs, the relationship of specific diseases and boarding school attendance should be considered.

AMERICAN INDIAN AND ALASKA NATIVE BOYS: EARLY CHILDHOOD RISK AND RESILIENCE AMIDST CONTEXT AND CULTURE.

American Indian and Alaska Native (AIAN) adolescent and adult men experience a range of health disparities relative to their non-AIAN counterparts and AIAN women. Given the relatively limited literature on early development in tribal contexts, however, indicators of risk during early childhood specific to AIAN boys are not well-known. The current article reviews sources of strength and challenge within AIAN communities for AIAN children in general, including cultural beliefs and practices that support development, and contextual challenges related to socioeconomic and health disparities and historical trauma affecting the AIAN population as a whole. The research literature on early development is reviewed, highlighting what this literature reveals about early gender differences. The article concludes with calls to action on behalf of AIAN boys that align with each of the five tiers of R. Frieden's (2010) Public Health Pyramid.

Toddler socioemotional behavior in a northern plains Indian tribe: associations with maternal psychosocial well-being.

M.C. Sarche, C.D. Croy, C. Big Crow, C. Mitchell, and P. Spicer (2009) provided first-ever information relating the socioemotional development of American Indian toddlers to the immediate context of their mothers' lives. The current study sought to replicate and build on their earlier work by examining the impact of additional maternal risk factors, identified in previous research with non-American Indian populations, on the development of American Indian toddlers: maternal depression, negative social influences, and mother's feelings of isolation. At 27 months, American Indian mothers (N = 110) completed the Parent Demographic Questionnaire, which measured maternal psychosocial characteristics (e.g., depressed affect, social support, drug and alcohol use, isolation) and demographics. Mothers also completed the Infant-Toddler Social Emotional Assessment (A.S. Carter & M.J. Briggs-Gowan, 2006) and the Parent-Child Dysfunctional Interaction subscale of the Parenting Stress Index (R.R. Abidin, 1995, 1997). Some results replicated the original study, but others did not. Reports of a dysfunctional mother-child relationship related to externalizing and internalizing problems, replicating the earlier study. This study also found associations between a dysfunctional mother-child relationship and socioemotional competence as well as dysregulation. The previous finding of a relationship between American Indian identity and socioemotional competence was supported. Adding the effects of maternal depressed affect and isolation significantly increased prediction of toddler behavior problems.

Religio-Spiritual Participation in Two American Indian Populations.

Following a previous investigation of religio-spiritual beliefs in American Indians, this article examined prevalence and correlates of religio-spiritual participation in two tribes in the Southwest and Northern Plains (N = 3,084). Analysis suggested a "religious profile" characterized by strong participation across three traditions: aboriginal, Christian, and Native American Church. However, sociodemographic variables that have reliably predicted participation in the general American population, notably gender and age, frequently failed to achieve significance in multivariate analyses for each tradition. Religio-spiritual participation was strongly and significantly related to belief salience for all traditions. Findings suggest that correlates of religious participation may be unique among American Indians, consistent with their distinctive religious profile. Results promise to inform researchers' efforts to understand and theorize about religio-spiritual behavior. They also provide tribal communities with practical information that might assist them in harnessing social networks to confront collective challenges through community-based participatory research collaborations.

Lifetime prevalence of posttraumatic stress disorder in two American Indian reservation populations.

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest (n = 1,446) and Northern Plains (n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities.

PURPOSE: To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. METHOD: Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. RESULTS: Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. CONCLUSIONS: Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

Maternal correlates of 2-year-old American Indian children's social-emotional development in a Northern Plains tribe.

The developmental experiences of very young American Indian children today are not well documented in the current literature. The present study sought to explore the social-emotional development of American Indian toddlers living on a Northern Plains reservation, as a function of maternal variables. Mothers completed self-report questionnaires about their experiences and their children's development. Observer ratings of children's development also were conducted. Maternal stress, substance use/abuse, perceptions of stress in the mother-child relationship, social support, and American Indian cultural identity were significantly related to children's social-emotional development. This study is the first to explore these relationships in a Northern Plains American Indian sample of young children and their mothers. Results suggest possible points of intervention for improving the developmental outcomes of very young American Indian children.

Methods for measuring utilization of mental health services in two epidemiologic studies.

OBJECTIVES OF STUDY: Psychiatric epidemiologic studies often include two or more sets of questions regarding service utilization, but the agreement across these different questions and the factors associated with their endorsement have not been examined. The objectives of this study were to describe the agreement of different sets of mental health service utilization questions that were included in the American Indian Service Utilization Psychiatric Epidemiology Risk and Protective Factors Project (AI-SUPERPFP), and compare the results to similar questions included in the baseline National Comorbidity Survey (NCS). METHODS: Responses to service utilization questions by 2878 AI-SUPERPFP and 5877 NCS participants were examined by calculating estimates of service use and agreement (kappa) across the different sets of questions. Logistic regression models were developed to identify factors associated with endorsement of specific sets of questions. RESULTS: In both studies, estimates of mental health service utilization varied across the different sets of questions. Agreement across the different question sets was marginal to good (kappa = 0.27-0.69). Characteristics of identified service users varied across the question sets. LIMITATIONS: Neither survey included data to examine the validity of participant responses to service utilization questions. RECOMMENDATIONS FOR FURTHER RESEARCH: Question wording and placement appear to impact estimates of service utilization in psychiatric epidemiologic studies. Given the importance of these estimates for policy-making, further research into the validity of survey responses as well as impacts of question wording and context on rates of service utilization is warranted.

Correlates of Motivational Interviewing Use Among Substance Use Treatment Programs Serving American Indians/Alaska Natives.

Motivational interviewing (MI) offers a treatment modality that can help meet the treatment needs of American Indians/Alaska Natives (AI/ANs) with substance use disorders. This report presents results from a national survey of 192 AI/AN substance abuse treatment programs with regard to their use of MI and factors related to its implementation, including program characteristics, workforce issues, clinician perceptions of MI, and how clinicians learned about MI. Sixty-six percent of programs reported having implemented the use of MI in their programs. In the final logistic regression model, the odds of implementing MI were significantly higher when programs were tribally owned (OR = 2.946; CI95 1.014, 8.564), where more than 50% of staff were Certified Alcohol and Drug Counselors (CADCs) (OR = 5.469; CI95 1.330, 22.487), and in programs in which the survey respondent perceived that MI fit well with their staff's expertise and training (OR = 3.321; CI95 1.287, 8.569).

Childhood characteristics associated with stage of substance use of American Indians: Family background, traumatic experiences, and childhood behaviors.

The purpose of this analysis is to examine childhood characteristics associated with stage of substance use in adulthood in two American Indian (AI) populations. Data were drawn from an epidemiologic study of two AI reservation populations for persons age 18-44 years (n=2070). We used descriptive and multivariate analysis to examine correlates of four mutually exclusive stages of substance use: lifetime abstinence (Stage 0), use of alcohol only (Stage 1A), use of marijuana/inhalants with or without alcohol (Stage 1B), and use of other illicit drugs with or without the previously listed substances (Stage 2). Problematic substance use by parents, younger age of first substance use, initiating substance use with a drug (with or without alcohol), and adolescent conduct problems were associated with higher stage substance use. Persons who experienced sexual abuse, witnessed family violence, or experienced other traumatic events before the age of 18 were more likely to be at Stage 1B than Stage 1A. These findings underscore the importance of providing effective interventions during childhood and adolescence to reduce the risk of substance use progression.

The influence of community-based participatory research principles on the likelihood of participation in health research in American Indian communities.

OBJECTIVES: Advocates of community-based participatory research (CBPR) have emphasized the need for such efforts to be collaborative, and close partnerships with the communities of interest are strongly recommended in developing study designs. However, to date, no systematic, empiric inquiry has been made into whether CBPR principles might influence an individual's decision to participate in research. DESIGN, SETTING, AND PARTICIPANTS: Using vignettes that described various types of research, we surveyed 1066 American Indian students from three tribal colleges/universities to ascertain the extent to which respondent age, gender, education, cultural affiliation, tribal status, and prior experience with research may interact with the implementation of critical CBPR principles to increase or decrease the likelihood of participating in health research. RESULTS: Many factors significantly increased odds of participation and included the study's being conducted by a tribal college/university or national organization, involving the community in study development, an American Indian's leading the study, addressing serious health problems of concern to the community, bringing money into the community, providing new treatments or services, compensation, anonymity, and using the information to answer new questions. Decreased odds of participation were related to possible discrimination against one's family, tribe, or racial group; lack of confidentiality; and possible physical harm. CONCLUSIONS: Employing CBPR principles such as community involvement in all phases of the research, considering the potential benefits of the research, building on strengths and resources within the community and considering how results will be used is essential to conceptualizing, designing, and implementing successful health research in partnership with American Indians.

The use of telemedicine to evaluate competency to stand trial: a preliminary randomized controlled study.

To investigate whether forensic evaluations can be performed reliably using telemedicine, we compared the results on a standard competency assessment instrument using telemedicine (TM) and live interviews (LI). Two board-certified forensic psychiatrists used the Georgia Court Competency Test (GCCT) to evaluate 21 forensic psychiatric inpatients. Half of the patients were randomly assigned to a telemedicine interview and half were assigned to a live interview. Total scores on the GCCT were similar for both raters, indicating high levels of agreement between telemedicine and live interviews. Patient and provider satisfaction were measured and indicated that, although patients did not express a preference for a particular interview modality, providers reported greater satisfaction with live interviews. Findings suggest that one aspect of competency to stand trial can be reliably evaluated using telemedicine and that patients perceive telemedicine as an acceptable alternative to a standard live interview. The limited sample size precludes definite conclusions and further studies involving a larger forensic study population are warranted.

National Overview of Medication-Assisted Treatment for American Indians and Alaska Natives With Substance Use Disorders.

OBJECTIVE: American Indians and Alaska Natives (AI/ANs) experience higher rates of substance use disorders and less access to high-quality care compared with other racial-ethnic groups. The objective of this study was to better understand the use of medication-assisted treatment (MAT) of substance use disorders for AI/ANs and barriers to broader implementation. METHODS: Representatives of 192 substance abuse treatment programs completed a survey about their use of MAT. On the basis of implementation science frameworks, the authors examined survey items about program structure, workforce, and other services provided in order to develop logistic regression models that explored significant associations between workforce and program characteristics and use of MAT. RESULTS: Of the 192 programs, 28% reported implementing MAT. Multivariate logistic regression models indicated that programs with staff that perceived MAT to be consistent with their program's treatment approach and philosophy and programs reporting that MAT fit with staff expertise and training were more likely to implement MAT. Programs with nurses on staff and those reporting a perceived gap in the use of evidence-based treatments (EBTs) were less likely to implement MAT. CONCLUSIONS: Low rates of MAT implementation suggest racial disparities in access to MAT among AI/ANs, a population with historically high rates of substance use disorders. Study findings also highlight the important role of treatment culture and organizational fit in the implementation of MAT in treatment programs serving AI/AN populations. Results also speak to the importance of adapting existing EBTs in a culturally competent way to best serve the needs of the AI/AN community.

Attitudes of urban American Indians and Alaska Natives regarding participation in research.

OBJECTIVE: To determine what factors influence participation in health research among American Indians and Alaska Natives. METHODS: Using vignettes that described 3 types of research studies (a behavioral intervention trial, a genetic association study, and a pharmacotherapy trial), we surveyed 319 patients and 101 staff from an urban Indian health care facility to ascertain how study design, institutional sponsorship, community involvement, human subjects' issues, and subject matter influence participation. RESULTS: Overall response rates were 93% for patients and 75% for staff. Hypothetical participation was highest for the genetic study (patients=64%; staff=48%), followed by the behavioral intervention (patients=46%; staff=42%), and the pharmacotherapy trial (patients=32%; staff=23%). The odds of participation (odds ratio [OR]) were generally increased among patients and staff when the study was conducted by health care providers (OR=1.3 to 2.9) and addressed serious health problems (OR=1.2 to 7.2), but were decreased if the federal government led the study (OR=0.3 to 0.5), confidentiality might be broken (OR=0.1 to 0.3), and compensation was not provided (OR=0.5 to 0.7). CONCLUSION: Close attention to study type, institutional sponsorship, community involvement, potential risks and benefits, and topic are essential to conceptualizing, designing, and implementing successful health research with American Indian and Alaska Native populations.

The relationship between patterns of alcohol use and mental and physical health disorders in two American Indian populations.

AIMS: First, define alcohol use categories among two reservation-based American Indian (AI) populations based on the relationship between alcohol consumption and dependence. Secondly, examine associations between the alcohol use categories and other indicators of health status. DESIGN, PARTICIPANTS AND MEASUREMENTS: Epidemiological data on 1287 AIs aged 18-57 years who consumed alcohol during the past year. CHAID tree analysis, a hierarchical partitioning method, was used to analyze alcohol quantity (highest number of drinks consumed during 1 day) and frequency (number of days drank during the past month) data to define quantity-frequency categories distinguished by differing rates of alcohol dependence. Multivariate analyses assessed relationships between the alcohol use categories thus identified and a number of health outcomes. FINDINGS: People who reported drinking 12 or more drinks during 1 day and more than 4 days a month had the highest prevalence of alcohol dependence. Among the males who drank > 18 drinks the prevalence was 42.12% and among females who drank 12 or more drinks, 44.58%. The prevalence among males who drank > 18 drinks yet drank less frequently was also high (24.06%). Although findings differed by gender, drinkers in the highest risk category for alcohol dependence were most likely to report drug use disorders, mood/anxiety disorders, alcohol-related physical disorders and lower quality of life. CONCLUSIONS: The quantity thresholds defined to identify AIs at highest risk for alcohol dependence in this study differed by gender and were higher than typically reported for non-AIs. They are consistent with previous findings regarding the pattern of high-quantity, low-frequency alcohol consumption among AIs residing on reservations.

Use of evidence-based treatments in substance abuse treatment programs serving American Indian and Alaska Native communities.

BACKGROUND: Research and health surveillance activities continue to document the substantial disparities in the impacts of substance abuse on the health of American Indian and Alaska Native (AI/AN) people. While Evidence-Based Treatments (EBTs) hold substantial promise for improving treatment for AI/ANs with substance use problems (as they do for non-AI/ANs), anecdotal reports suggest that their use is limited. In this study, we examine the awareness of, attitudes toward, and use of EBTs in substance abuse treatment programs serving AI/AN communities. METHODS: Data are drawn from the first national survey of tribal substance abuse treatment programs. Clinicians or clinical administrators from 192 programs completed the survey. Participants were queried about their awareness of, attitudes toward, and use of 9 psychosocial and 3 medication EBTs. RESULTS: Cognitive Behavioral Therapy (82.2%), Motivational Interviewing (68.6%), and Relapse Prevention Therapy (66.8%) were the most commonly implemented psychosocial EBTs; medications for psychiatric comorbidity was the most commonly implemented medication treatment (43.2%). Greater EBT knowledge and use were associated with both program (e.g., funding) and staff (e.g., educational attainment) characteristics. Only two of the commonly implemented psychosocial EBTs (Motivational Interviewing and Relapse Prevention Therapy) were endorsed as culturally appropriate by a majority of programs that had implemented them (55.9% and 58.1%, respectively). CONCLUSIONS: EBT knowledge and use is higher in substance abuse treatment programs serving AI/AN communities than has been previously estimated. However, many users of these EBTs continue to have concerns about their cultural appropriateness, which likely limits their further dissemination.

A National Study of American Indian and Alaska Native Substance Abuse Treatment: Provider and Program Characteristics.

American Indians and Alaska Natives (AIANs) experience major disparities in accessing quality care for mental health and substance use disorders. There are long-standing concerns about access to and quality of care for AIANs in rural and urban areas including the influence of staff and organizational factors, and attitudes toward evidence-based treatment for addiction. We conducted the first national survey of programs serving AIAN communities and examined workforce and programmatic differences between clinics located in urban/suburban (n=50) and rural (n=142) communities. We explored the correlates of openness toward using evidence-based treatments (EBTs). Programs located in rural areas were significantly less likely to have nurses, traditional healing consultants, or ceremonial providers on staff, to consult outside evaluators, to use strategic planning to improve program quality, to offer pharmacotherapies, pipe ceremonies, and cultural activities among their services, and to participate in research or program evaluation studies. They were significantly more likely to employ elders among their traditional healers, offer AA-open group recovery services, and collect data on treatment outcomes. Greater openness toward EBTs was related to a larger clinical staff, having addiction providers, being led by directors who perceived a gap in access to EBTs, and working with key stakeholders to improve access to services. Programs that provided early intervention services (American Society of Addiction Medicine level 0.5) reported less openness. This research provides baseline workforce and program level data that can be used to better understand changes in access and quality for AIAN over time.

Methods for addressing missing data in psychiatric and developmental research.

OBJECTIVE: First, to provide information about best practices in handling missing data so that readers can judge the quality of research studies. Second, to provide more detailed information about missing data analysis techniques and software on the Journal's Web site at www.jaacap.com. METHOD: We focus our review of techniques on those that are based on the "Missing at Random" assumption and are either extremely popular because of their convenience or that are harder to employ but yield more precise inferences. RESULTS: The literature regarding missing data indicates that deletion of observations with missing data can yield biased findings. Other popular methods for handling missing data, notably replacing missing values with means, can lead to confidence intervals that are too narrow as well as false identifications of significant differences (type I statistical errors). Methods such as multiple imputation and direct maximum likelihood estimation are often superior to deleting observations and other popular methods for handling missing data problems. CONCLUSIONS: Psychiatric and developmental researchers should consider using multiple imputation and direct maximum likelihood estimation rather than deleting observations with missing values.

Documenting natural recovery in American-Indian drinking behavior: a coding scheme.

OBJECTIVE: This report describes a coding scheme developed to analyze how some American Indians changed their drinking behavior and explores the contributions of this approach to our understanding of natural recovery in American-Indian communities. METHOD: We analyzed the responses to two open-ended questions about drinking in an epidemiological survey. The first question asked what helped respondents to quit or cut down on their drinking; the second asked respondents what they did instead of drinking when they wanted to drink. Codes were developed using anthropological analyses of content and then refined through analyses of frequencies and attempts to establish reliability. The frequencies of these codes were then examined by gender, age and current drinking status. RESULTS: Reliability was attained for the coding of responses to both questions. Their content reflects salient themes in the literature on natural recovery. The distribution of these codes across gender, age and current drinking status reveals interesting insights into what prompts and supports quitting and change for different members of these American-Indian communities, especially for women, older respondents and those who abstain from alcohol. CONCLUSIONS: This approach points the way to a consideration of a broad set of factors related to changes in drinking behavior in American-Indian populations that can be applied in future studies, both in American-Indian communities and, potentially, in other populations as well.