Allison Barlow

Paraprofessional-Delivered Home-Visiting Intervention for American Indian Teen Mothers and Children: 3-Year Outcomes From a Randomized Controlled Trial

OBJECTIVE The Affordable Care Act provides funding for home-visiting programs to reduce health care disparities, despite limited evidence that existing programs can overcome implementation and evaluation challenges with at-risk populations. The authors report 36-month outcomes of the paraprofessional-delivered Family Spirit home-visiting intervention for American Indian teen mothers and children. METHOD Expectant American Indian teens (N=322, mean age=18.1 years) from four southwestern reservation communities were randomly assigned to the Family Spirit intervention plus optimized standard care or optimized standard care alone. Maternal and child outcomes were evaluated at 28 and 36 weeks gestation and 2, 6, 12, 18, 24, 30, and 36 months postpartum. RESULTS At baseline the mothers had high rates of substance use (>84%), depressive symptoms (>32%), dropping out of school (>57%), and residential instability (51%). Study retention was ≥83%. From pregnancy to 36 months postpartum, mothers in the intervention group had significantly greater parenting knowledge (effect size=0.42) and parental locus of control (effect size=0.17), fewer depressive symptoms (effect size=0.16) and externalizing problems (effect size=0.14), and lower past month use of marijuana (odds ratio=0.65) and illegal drugs (odds ratio=0.67). Children in the intervention group had fewer externalizing (effect size=0.23), internalizing (effect size=0.23), and dysregulation (effect size=0.27) problems. CONCLUSIONS The paraprofessional home-visiting intervention promoted effective parenting, reduced maternal risks, and improved child developmental outcomes in the U.S. population subgroup with the fewest resources and highest behavioral health disparities. The methods and results can inform federal efforts to disseminate and sustain evidence-based home-visiting interventions in at-risk populations.

Cluster and regional influences on suicide in a Southwestern American Indian tribe

Suicide is the second leading cause of death among American Indian youth. Elevated rates of suicide in Indian communities have been attributed both to outbreaks and to regional trends. We assessed the contribution of these two factors for a single tribe, and attempted to define a profile of individuals at risk. Data came from the tribes registry of suicide attempts and completions for 1990-1993 and analysis of death certificates for the period 1985-1996. Using combined tribal and death certificate data, the average annual (age-adjusted) rate of completed suicide among tribal members was 44.7/100,000 for 1990-1993. Within the 45 suicide deaths and serious attempts in this time period, we identified one grouping of seven cases taking place in a 40-day period. All seven involved hanging and youth (13-28 years old). Using death certificate data alone, the average annual rate of suicide death for non-natives in the surrounding county in the period 1985-1996 was 22.7/100,000. Age-adjusted to the county population, the tribal rate for the same period was not significantly different (24.6/100,000). Tribal and county suicide patterns differed by age distribution and method but not by gender. We concluded that both regional trends and clustering contribute to suicide in this community. Further prevention efforts may need to focus on both unique tribal characteristics and shared factors among non-native neighbors.

Understanding the Relationship between Substance Use and Self-Injury in American Indian Youth

Background: American Indian communities compared to other US populations are challenged by the largest health disparities in substance abuse and suicidal behavior among youth ages 15–24. Objectives: This article examines the co-occurrence of substance use and self-injury among reservation-based youth in the US. Methods: White Mountain Apache tribal leaders and Johns Hopkins University formed a partnership to address self-injury and substance abuse among Apache youth. Data on suicide (deaths, attempts, ideation), non-suicidal self-injury, and substance use were analyzed from the White Mountain Apache tribally mandated self-injury surveillance registry from 2007 to 2010, including 567 validated incidents from 352 individuals aged 15–24 years. Findings regarding characteristics of co-occurrence – including differences in the type of self-harm behavior, gender, and reported reasons for the act – were interpreted through a community-based participatory research process. Results: From 2007 to 2010, 64% (n = 7/11) of Apache youth ages 15–24 were “drunk or high” at the time of suicide death with data missing for 2/11 deaths; 75.7% (n = 118/156) were “drunk or high” during suicide attempt; 49.4% (n = 83/168) during suicidal ideation; and 49.4% (81/166) during non-suicidal self-injury. Co-occurrence of substance use was higher for more lethal acts and among males. Conclusion: High rates of co-occurring self-injury and substance use within this population highlight the importance of research to understand relationships between these behaviors to design preemptive and integrated interventions. Scientific Significance: Tribal-specific and culturally informed data on the co-occurrence of self-injury and substance use hold promise for reducing the combined toll of years of productive life lost among American Indian youth.

Community-based surveillance and case management for suicide prevention: an American Indian tribally initiated system

The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and self-injurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.

Exploring Risk and Protective Factors with a Community Sample of American Indian Adolescents Who Attempted Suicide

American Indian adolescents are at disproportionate risk for suicide, and community-based studies of this population, which allow a deeper understanding of risks and resilience to inform interventions, are rare. This is a cross-sectional study of N = 71 Apache adolescents. Strengths include the role of the community and American Indian paraprofessionals in the design, implementation, and interpretation of findings. Participants were M = 16.0 years old, 65% female, and 69% multiple attempters. Risks included suicidal behavior among peers and family (68%), caregivers with substance problems (62%), and participant substance use history, namely alcohol (91%) and marijuana (88%). Areas of resiliency included lower depression scores (M = 23.1) and cultural activity participation. A multi-tiered intervention at individual, family, and community levels is needed.

Risk Pathways for Suicide Among Native American Adolescents

Native American (Native) adolescents have the highest suicide rates in the United States, yet no conceptual models describing risk factors specific to this population exist. We sought to further hone a Native-specific conceptual model developed from quantitative data with qualitative data collected from a longitudinal series of interviews with (N = 22) Native adolescents who had attempted suicide. Four levels of suicide risk emerged, detailing individual, family, community, and societal factors that affect youths’ pathways to suicide, along with a variety of subthemes and constructs. Some themes parallel established models of suicide risk; however, others are unique to the experience of this sample, including the impact of overtaxed households and family composition, significant grief burden, contagion, and stigma surrounding treatment seeking. We suggest adaptations of existing themes and constructs in the model. We discuss practical implications for research and intervention development, along with strengths and limitations of the study.

The First Americans Have Much to Teach Us

In this month_s issue of the Journal, Whitbeck et al. report that indigenous adolescents living on the northwest border of the United States experienced a striking increase in mental disorders between 10 and 12 and 13 and 15 years of age. The rates in this population were accounted for by increases in conduct disorder and substance use disorders. According to the authors, the study participants_ rates for these disorders were two to four times the rates of adolescents in general population studies and similar to lifetime prevalence rates for adults. The article by Whitbeck et al. sounds the alarm on a mental health crisis for indigenous youths in rural reservation communities. However, two caveats must be noted. First, the Indian Health Service consistently reports large regional differences in all health trends across tribes, so caution must be exercised before generalizing these findings to all Native American youths. Second, as Whitbeck et al. have acknowledged, mental health measures have not been well tested with Native American youngsters, and cultural differences may produce measurement biases. Nonetheless, it is essential to counter those caveats with other evidence that supports the reality of a mental health crisis for Native American youths. First, the environmental and developmental risks that Whitbeck et al. describe for childhood behavior problems and substance use disorders are common in rural indigenous populations across the United States and the world. Second, although mental health measures used in the study may lack some degree of cultural sensitivity, measurement biases would likely result in underreporting in general, especially substance use disorders and internalizing disorders. Disruptive behavior, which is more overt, may be less subject to reporting bias, but may still be underreported in indigenous communities. Third, the findings of Whitbeck and colleagues are harbingers of the painful truth that Native American youths as they move through adolescence and into young adulthood (ages 15Y24) shoulder an eightfold greater rate of alcohol-related deaths and twofold or higher rates for suicide, motor vehicle accidents, and all injury-related deaths. Coming to grips with the pivotal association of early disruptive behavior and substance use disorders with these tragic statistics is critical to finding the solution to high rates of mental health morbidity and mortality in Native American youths. Thus, the article by Whitbeck et al. begs the question: how do we prioritize scarce research dollars and clinical resources for Indian country to address the mental health crisis and resulting mortality of this generation of adolescents and young adults? Is more research needed to rediscover the causal pathways from cultural oppression and economic and psychosocial adversity to poor mental and behavioral outcomes for indigenous children? We would argue no. Rather, we propose that the field accept that a constellation of historical, demographic, and sociological factors have precipitated a mental health crisis for Native American youths and move on to seek approaches to deploy cost-effective, evidence-based solutions that reflect indigenous cultural strengths and community will. To begin to address these problems, we would ask what the existing research tells us about the antecedents of early disruptive behavior and substance use. What are critical time points for intervention and targets for prevention? A large body of research points to early childhood as the critical stage for intervention and family-based approaches, specifically early parenting training, as a key strategy for the prevention of children_s future disruptive behavior problems and substance use disorders. Parent training and family-based approaches have a natural cultural fit within pan-Native American world views. There are numerous examples of how Native Americans traditions favor Bfamily[ above any other domain as the nexus of strength for individuals. Native Americans often introduce themselves by name and clan, underscoring the link between personal identity and family lineage. Many healing traditions and puberty ceremonies involve extended family members who represent stabilizing and restorative forces. In addition, E D I T O R I A L

Exploring sexual risk taking among American Indian adolescents through protection motivation theory.

ABSTRACT This paper examines decision-making around sexual behavior among reservation-based American Indian youth. Focus group discussions were conducted with youth ages 13–19 years old. Through these discussions, we explored youth’s knowledge, attitudes and behaviors related to sexual risk taking through the lens of the protection motivation theory to inform the adaptation of an evidence-based HIV prevention intervention. Findings suggest that condom use self-efficacy and HIV prevention knowledge is low, vulnerability to sexually transmitted infections is lacking and alcohol plays a significant role in sexual risk taking in this population. In addition, parental monitoring and peer influence may contribute to or protect against sexual risk taking. Results suggest that future HIV prevention interventions should be delivered to gender-specific peer groups, include a parental component, teach sexual health education and communication skills, integrate substance-use prevention, and work to remove stigma around obtaining and using condoms.

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.

Respecting the circle of life: one year outcomes from a randomized controlled comparison of an HIV risk reduction intervention for American Indian adolescents

Potential for widespread transmission of HIV/AIDS among American Indian (AI) adolescents exists, yet no evidence-based interventions (EBIs) have been adapted and evaluated with this population. Intensive psychoeducation may improve knowledge and decision-making which could potentially translate to reductions in HIV risk behaviors. A peer group randomized controlled comparison of an adapted EBI vs. control was delivered over an eight-day summer basketball camp in one reservation-based tribal community to adolescents ages 13–19. Outcome data were gathered immediately post-camp and at 6 and 12 months follow-up. Self-selected peer groups were randomized to intervention (n = 138) or control (n = 129) conditions for a total sample of 267 participants (56.2% female), mean age 15.1 years (SD = 1.7). Intervention participants had better condom use self-efficacy post-camp (Adjusted Mean Difference [AMD] = −0.75, p < 0.005) and at 6 (AMD = −0.44, p < 0.005) and 12 months (AMD = −0.23, p < 0.05) follow-up. Intervention participants also had higher HIV prevention and transmission knowledge (post-camp: AMD = 0.07, p < 0.01; 6 months: AMD = 0.06, p < 0.01) were more likely to believe condoms prevent sexually transmitted infections (post-camp: RR = 1.41, p < 0.005; 6 months: RR = 1.34, p < 0.05), to talk with an adult about HIV/AIDS (post-camp: RR=1.78, p < 0.005; 6 months: RR = 1.14, p < 0.005), had higher partner negotiation efficacy related to substance use during sex (post-camp: AMD = 0.37, p < 0.01), and were more likely to intend to use a condom (post-camp: RR = 1.39, p < 0.01). The adapted intervention had short- and medium-term impacts on AI adolescent risk for HIV/AIDS, but attenuated at 12 months. Intervention delivery through a community-based camp is feasible and acceptable with strong retention. Additional study is needed to evaluate the adapted interventions impact on sexual risk behaviors and if booster sessions and parent involvement translate to long-term impacts.