Novalene Goklish

Toward Understanding Suicide Among Youths: Results From the White Mountain Apache Tribally Mandated Suicide Surveillance System, 2001-2006

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.

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.

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.

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.

Pneumococcal protein antigen serology varies with age and may predict antigenic profile of colonizing isolates

Background Several Streptococcus pneumoniae proteins play a role in pathogenesis and are being investigated as vaccine targets. It is largely unknown whether naturally acquired antibodies reduce the risk of colonization with strains expressing a particular antigenic variant. Methods Serum immunoglobulin G (IgG) titers to 28 pneumococcal protein antigens were measured among 242 individuals aged <6 months-78 years in Native American communities between 2007 and 2009. Nasopharyngeal swabs were collected >- 30 days after serum collection, and the antigen variant in each pneumococcal isolate was determined using genomic data. We assessed the association between preexisting variant-specific antibody titers and subsequent carriage of pneumococcus expressing a particular antigen variant. Results Antibody titers often increased across pediatric groups before decreasing among adults. Individuals with low titers against group 3 pneumococcal surface protein C (PspC) variants were more likely to be colonized with pneumococci expressing those variants. For other antigens, variant-specific IgG titers do not predict colonization. Conclusion We observed an inverse association between variant-specific antibody concentration and homologous pneumococcal colonization for only 1 protein. Further assessment of antibody repertoires may elucidate the nature of antipneumococcal antibody-mediated mucosal immunity while informing vaccine development.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001–2012

OBJECTIVES We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. METHODS Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. RESULTS The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. CONCLUSIONS Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.

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

ABSTRACT 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.