Indian Adolescent Mental Health

January 1990

OTA-H-446

NTIS order #PB90-254095
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Indian Adolescent Mental Health

OTA-H-446 (Washington, DC: U.S. Government Printing Office, January 1990).

Library of Congress Catalog Card Number 89-600775

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this special report)
Foreword

American Indians and Alaska Natives have a unique historical and legal relationship with

the Federal Government. In this “government-to-government” relationship, Federal programs for Indians are administered principally by the Department of the Interior’s Bureau of

Indian Affairs. Federal health programs are administered chiefly by the Indian Health Service,

a component of the Public Health Service in the Department of Health and Human Services.

In addressing the health needs of American Indians and Alaska Natives, mental health has

lagged behind.

The U.S. Senate Select Committee on Indian Affairs is considering the introduction

of legislation to address the mental health needs of American Indians and Alaska Natives. In

connection with a full OTA assessment of adolescent health issues, the Senate Select

Committee on Indian Affairs asked OTA to evaluate the mental health needs of American

Indian and Alaska Native adolescents.

Adolescents are among the most vulnerable of American Indians and Alaska Natives.

To the extent they were born with fetal alcohol syndrome, are abused or neglected, live in

distressed families and communities, or exhibit mental health problems such as depression,

anxiety, developmental disorders, learning disabilities, substance abuse, conduct disorders,

and suicidal behavior, Indian adolescents are both distressed themselves and affect the

collective future of Indians. This Special Report responds to the Committee’s request for

information on these problems and on the services available to respond to Indian adolescents'

mental health needs.

The Special Report is the second publication of OTA’s adolescent health assessment.

The first publication was Adolescent Health Insurance Status: Analyses of Trends in Coverage

and Preliminary Estimates of the Effects of An Employer Mandate and Medicaid Expansion

on the Uninsured, a Background Paper published in July 1989, and scheduled to be updated

in spring 1990. The full report on adolescent health will be published in 1990.1

u Directo r

lwi~ rewt t. tie over~l he~~ of American Indians and Alaska Natives, OTA also published fndian Heafrh Cwe. a

report addressing the healrh status of Indians of all ages and the Indian Health Service delivery system, in 1986.
OTA Adolescent Health Advisory Panel

Felton Earls, Chair Michael I. Cohen, Vice Chair

Department of Behavioral Sciences, Chairman, Department of Pediatrics

Harvard School of Public Health

Boston, MA

Claire Brindis

Co-Director

Center for Population and

Reproductive Health Policy

Institute for Health Policy Studies

San Francisco, CA

Ann W. Burgess

van Amerignen Professor of

Psychiatric Mental Health Nursing

University of Pennsylvania School

of Nursing

Philadelphia, PA

Delores L. Delaney

President

Virginia PTA

Virginia Beach, VA

Abigail English

Director, Adolescent Health Care

Project

National Center for Youth Law

San Francisco, CA

Jewelle Taylor Gibbs

School of Social Welfare

University of California

Berkeley, CA

Michael Graf

Director, Mental Health

Tanana Chiefs Conference, Inc.

Fairbanks, AK

David E. Hayes-Bautista

Professor, School of Medicine

Director, Chicano Studies Research

Center

University of California, Los Angeles

Los Angeles, CA

Karen Hein

Division of Adolescent Medicine

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx,

NOTE:

NY

Charles E. Irwin, Jr.

Division of Adolescent Medicine

Department of Pediatrics

School of Medicine

University of California

San Francisco, CA

Robert Johnson

Division of Adolescent Medicine

Department of Pediatrics

New Jersey Medical School

Newark, NJ

Alan Kazdin

Professor of Psychology

Department of Psychology

Yale University

New Haven, CT

Teresa LaFromboise

School of Education

Stanford University

Stanford, CA

Mary Nell Lehnhard

Vice President

Office of Government Relations

Blue Cross and Blue Shield

Association

Washington, DC

Barbara D. Matula

Director

State of North Carolina

Department of Human Resources

Division of Medical Assistance

Raleigh, NC

Robert B. Millman

Saul P. Steinberg Distinguished

Professor of Psychiatry and Public

Health

Director, Adolescent Development

Program

Director, Alcohol & Substance Abuse

Service

Cornell University Medical College—

New York Hospital

Montefiore Hospital

New York, NY

Daniel Offer

Director, Center for the Study

of Adolescence

Michael Reese Hospital Medical

Center

Chicago, IL

Leticia Paez

Associate Director

Area Health Education Center

Texas Technical University

School of Medicine

El Paso, TX

Cheryl Perry

Associate Professor

Division of Epidemiology

School of Public Health

University of Minnesota

Minneapolis, MN

Anne C. Petersen

Dean

College of Health and Human

Development

Pennsylvania State University

University Park, PA

Lee Etta Powell

Superintendent of Schools

Cincinnati, OH

Roxanne Spillett

Director, Program Services

Boys Clubs of America

New York, NY

Edward Tetelman

Assistant Commissioner

Intergovernmental Affairs

New Jersey Department of Human

Services

Trenton, NJ

Myron Thompson

Trustee

Bernice Pauahi Bishop Estate

Honolulu, HI

New York, NY

OTA appreciatesand is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel rnernbm

The p&el does not, how;ver, necessarily approve, disapprove, or endorse this s~cial report, OTA assumes full responsibility

for the special report and the accuracy of its contents.

iv
OTA Special Report—

Indian Adolescent Mental Health

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Denise Dougherty, Project Director

Kelly Metcalf, Research Analyst

Kirsten Rowe, Analyst

Administrative Staff

Virginia Cwalina, Administrative Assistant

Carol Ann Guntow, P.C. Specialist

Karen T. Davis, Word Processor Specialist

Carolyn Martin, Secretary

Contractors

Spero Manson

National Center for American Indian

and Alaska Native Mental Health Research

University of Colorado Health Sciences Center

Denver, CO

Lois Bergeisen

Gaithersburg, MD
OTA Indian Adolescent Mental Health Workshop Participants

Marva Benjamin

Minority Initiative Director

CASSP Technical Assistance Center

Georgetown University Child

Development Center

Washington, DC

Irving Berlin

Professor

Division of Child & Adolescent

Psychiatry

Department of Psychiatry

School of Medicine

University of Mexico

Albuquerque, NM

J.R. Cook

Executive Director

United National Indian Tribal

Youth Inc.

Oklahoma City, OK

Paul Dauphinais

School Psychologist

Turtle Mountain Community School

Bellcourt, ND

Kathryn Manness

Coordinator

American Indian Program

Development

Los Angeles, CA

Philip May

Department of Sociology

University of New Mexico

Albuquerque, NM

Teresa LaFromboise, Chair

School of Education, Stanford University

Stanford, CA

Henry Montes

Health Promotion Program

Henry J. Kaiser Family Foundation

Menlo Park, CA

Leonard Saxe

Visiting Professor

Bigel Institute

Florence Heller School

Brandeis University

Waltham, MA

Judi Siegfried

Director, Service Center

Pueblo of Laguna

Old Laguna, NM

Norine Smith

Director

Indian Health Board

Minneapolis, MN

Evelyn Tucker

Anchorage, AK

Indian Health Service:

Albert Hiat

Chief, Children’s Program

Indian Mental Health Branch

Indian Health Service

Albuquerque, NM

Scott Nelson

Chief

Indian Mental Health Branch

Indian Health Service

Rockville, MD

Bureau of Indiun Affairs:

Joe Little

Chief, Judicial Services

Bill Mehojah

Office of Indian Education

Gene Powers

Acting Director

Alcohol and Substance Abuse Office

Congressional Staff:

Yvette Joseph

Professional Staff Member

Select Committee on Indian Affairs

OTA Contractors:

Spero Manson

Director

National Center for American Indian &

Alaska Native Mental Health

Research

University of Colorado

Health Sciences Center

Denver, CO

Lois Bergeisen

Gaithersburg, MD

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the workshop participants.

The workshop participants do not, however, necessarily approve, disapprove, or endorse this special report. OTA assumes full

responsibility for the special report and the accuracy of its contents.

vi
CONTENTS

Page

CHAPTER 1: EXECUTIVE SUMMARY AND POLICY OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Guiding Principles and Options for a Community-based, Comprehensive,

Mental Health Services System for Indian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Obstacles to Implementing Guiding Principles, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Congressional Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Organization of the Special Report... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CHAPTER 2: MENTAL HEALTH PROBLEMS OF AMERICAN INDIAN AND

ALASKA NATIVE ADOLESCENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Diagnosable Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Substance Abuse and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Identity Disorder, Alienation, and Self-Esteem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Conduct Disorder, School Dropout, Delinquency, and Running Away . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Environmental Risk Factors for Mental Health Problems.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Physical Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Child and Adolescent Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Parental Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Family Disruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

School Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Other Life Stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Patient-Centered Data Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Surveillance Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Epidemiologic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

CHAPTER 3: DELIVERY OF MENTAL HEALTH SERVICES TO AMERICAN

INDIAN AND ALASKA NATIVE ADOLESCENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Agencies Involved in the Delivery of Mental Health and Related Services

to Indian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Indian Health Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Bureau of Indian Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Tribal Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Urban Indian Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

State and Local Service Agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Mental Health Treatment Settings and Services as Adapted To and By American Indians. . . . . . . . . . . . . . . 44

Treatment Settings . . . . . . . . . .. .., .. .. .. .$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Therapeutic Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Preventive and Promotive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Preventive and Promotive Efforts Specific to Indian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Cultural Sensitivity in Indian Mental Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Community Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Holding the System Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Coordination Efforts Among Indian-Serving Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Conclusions and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

APPENDIX A: EARLIER EVALUATIONS OF AMERICAN INDIAN AND ALASKA

NATIVE ADOLESCENTS’ MENTAL HEALTH NEEDS AND SERVICES, . . . . . . . . . . . . . . . . . . . , 57

APPENDIX B: POPULATION ESTIMATES FOR ESTIMATING SUICIDE DEATH RATES . . . . . . . . . 59

APPENDIX C: OVERVIEW OF INDIAN HEALTH SERVICE . . . . . . . . . . . . . . . . . . . .. .. . .. ... ... .....60

APPENDIX D: ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Figures

Figure Page

1. Distribution of Indian Health Facilities Throughout the Continental United States

and Alaska, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

C-l. Organization of the Indian Health Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

C-2. Health Services Managed by Indian and Alaskan Tribal Governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

C-3. Service Units, Hospitals, Health Centers and Stations, and Other Treatment Services

Operated by Indian Health Service Area Offices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

C-4. 1ndian-Operated Urban Projects Partially Supported by Indian Health Service.... . . . . . . . . . . . . . . . . . 63

Tables

Table Page

l. Child and Adolescent-Trained Mental Health Care Providers for Indian . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Studies Generating Estimates of Developmental Disabilities Among Indian

Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3. School-Related Handicapping Conditions of Ethnic Minorities, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4. Studies Generating Estimates o fDepression A Mong Indian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5. 1ndian and U.S. All Races Age-Specific Suicide Death Rates per 100,000 Population 1980-86 . . . . . . 17

6. Percentage of IHS and Contract Care Hospital Discharges for 10-to 19-Year-Olds

Involving a Suicide “E-Code,” 1980-86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

7. Percentage of Indian and Minnesota Adolescents in Grades 6Through 12 Ever Attempting Suicide. . 18

8. Percentage of Indian Adolescent Suicide Attempters and Non-Attempters Having

Suicidal Thoughts and Receiving Mental Health Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

9. Percentage of Indian Adolescent Males and Females Who Reporting Knowing of

Others’ Suicide Attempts and Suicide Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

10. Covariation of Suicide Attempts With Behavioral and Environmental Risk Factors . . . . . . . . . . . . . . . . 20

ll. Studies Generating Estimates of Anxiety Among Indian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

12. Estimates of Percentage Indian and Non-Indian Adolescents Overusing Alcohol and Illegal Drugs.. 22

13. Studies Generating Estimates o f Self-Esteem and Alienation Among Indian

Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

14. Reasons Given By Indian Adolescents for Running Away . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

15. Studies Generating Estimates of Abuse and Neglect Among Indian

Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

16. Percentage of Indian Adolescents Who Indicated Ever Being Abused by Family

Members or others ...,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

17. Percentage of Indian and Minnesota Adolescents Who Indicated Ever Being

Physically or Sexually Abused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

18. Covariation of Abuse With Behavioral Risk Factors and Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

19. Status of Biological Parents and Living Arrangements of Indian and Minnesota Adolescents . . . . . . . . 30

20. Perceptionsof School Environments by Indian and Minnesota Students . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

21. Perceptions o fSchool Environments by SouthwestPlains, and

Southeast Indian Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

22. School Pressures Experienced as Stressful by Indian Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

23. General Well-Being and Stress Among Indian and Minnesota Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 33

24. Indian Health Service Mental Health Programs Branch Staff April 1989 . . . . . . . . . . . . . . . . . . . . . . . . . 36

24b. Child- and Adolescent-Trained Mental Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

25. IHS Mental Health Programs Branch User Population, Budget Per Capita, and

Mental Health Providers Per 10,000 Population by IHS Service Area, FY 1988 . . . . . . . . . . . . . . . . . . . 37

26. Overview of IHS Alcoholism/Substance Abuse Program Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

27. Overview ofU.S. Department of the Interior, Bueau of Indian Affairs (BIA)

Educational programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

28. Responsibilities of Local Child Protection Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

29. Barriers to Effective Child Protection Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

30. Overview of Tribal Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

31. Overview of Urban Indian Mental Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

32. Single Issue Groups for Parent-Child Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

33. Single Issue Groups for Indian Youth at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

34. Family Involvement in Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

B-1, IHS Service Area Population Estimates Using Method#l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

B-2. IHS Service Area Estimates Using Method #2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

C-1. IHS Allocations by Budget Category, Fiscal Year 1988.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

. . . W/l
Chapter 1

Executive Summary and Policy Options

The Senate Select Committee on Indian

Affairs is considering legislation to enhance and

improve mental health services to Indians.l The

Committee asked the Office of Technology

Assessment to assist them in this effort by

reviewing the mental health needs of Indian

adolescents and the services available to them,

and to provide options that Congress might

consider when designing its legislation. This

chapter summarizes the findings of OTA’s

review, suggests options that Congress might

consider, and provides an overview of the

remainder of the Special Report.

FINDINGS

Scientifically acceptable information on the

extent of mental health problems among Indian

adolescents and on the availability, accessibility, and effectiveness of mental health services

specifically for Indian adolescents is scarce. The

information that does exist makes clear, however, that mental health services for Indian

adolescents are inadequate. The data that do

exist on mental health problems suggest that

Indian adolescents have more serious mental

health problems than the U.S. all races population with respect to:

developmental disabilities, such as mental

retardation and learning disabilities;

depression;

suicide;

anxiety;

alcohol and substance abuse;

self-esteem and alienation;

running away; and

school dropout.

While the causes of mental health problems

are not known with certainty, the life situations

of many Indian adolescents are filled with

stressors that can lead to emotional distress and

serious mental and behavioral problems. These

stressors include (in addition to those listed

above):

•Y•

●

●

●

●

●

recurrent otitis media and its consequences

for learning disabilities and psychosocial

deficits;

fetal alcohol syndrome and its consequences for mental retardation and less

severe forms of developmental disabilities,

as well as psychosocial deficits;

physical and sexual abuse and neglect;

parental alcoholism;

family disruption; and

poor school environments.

In addition, because of their developmental need

to establish their own identities, Indian adolescents often feel particularly caught between two

cultures.

The resources to cope with these serious

problems are clearly inadequate. While there are

at least 397,000 children and adolescents in

Indian Health Service (IHS) service areas, II-IS

funds only 17 mental health providers trained to

treat children and adolescents, a ratio of less

than one-half a mental health provider to every

10,000 children and adolescents. In total, approximately 1 to 2 percent of EM’s budget is

allocated to mental health services for Indians of

all ages. Only 3 percent of tribal and urban staffs

are mental health providers. Publicly funded

State and local services are either unavailable or

unacceptable to Indian people.~

Further, the distribution of the 17 mental

health providers trained to work with children or

adolescents varies considerably by IHS service

area (see table 1). The Bemidji area; California

lrn this specla] Repofi, the term Indians is used to refer to American Indians and Alaska Natives.

2~is spci~ Re~rt is tie second pub]icatlon from OTA’S full assessment of adolescent health. The full assessment will be published in late 1~.

3&N1ce~ may be ~acceptable for a number of reaWns, One of the longstanding concerns in providing mental health treatment and prevention

services to Indians is the need for cultural sensitivity. Currently, there is a shortage of trained minority mental health providers, and sometimes those

who have completed training fmd that the education offered by nonminority institutions serves to alienate them from their community rather than make

them a resource.

– l –
2 ● Indian Adolescent Mental Health

Table I<hild- and Adolescent-Trained Mental Health Care Providers for Indian Adolescents by IHS Service Area

Child- and adolescent-trained

Estimated Number of child- and mental health care providers

Reservation States adolescent user adolescent-trained mental per 10,000 adolescent

IHS service area included in service area population health care providers population

Aberdeen . . . . . . . . . . . . . ND, SD, NE, 1A 9,969 2 2.0

Alaska . . . . . . . . . . . . . . . . AK 10,922 1 0.9

Albuquerque . . . . . . . . . . NM, CO 15,434 1 0.6

Bemidji . . . . . . . . . . . . . . . MN, Wl, Ml 11,272 — 0.0

Billings . . . . . . . . . . . . . . . MT, WY 12,012 9 7.5

California . . . . . . . . . . . . . CA 8,388 — 0.0

Nashville. . . . . . . . . . . . . . AL, MS, LA, FL, NC, PA, 5,342 . 0.0

NY, CT, ME

Navajo . . . . . . . . . . . . . . . AZ, NM, UT 42,657 2 0.5

Oklahoma . . . . . . . . . . . . . OK, KS 48,090 1 0.2

Phoenix . . . . . . . . . . . . . . AZ 17,642 0.0

Portland . . . . . . . . . . . . . . OR, WA, ID

—

12,617 1 0.8

Tucson . . . . . . . . . . . . . . . AZc 5,077 — 0.0

Total adolescents aged 10-19

in IHS service areas. . . . . . . . . . . . . . . . . . . . . . . 199,422 17 0.8

Urban areas States with

urban programs

Various . . . . . . . . . . . . AZ, CA, CO, IL, KS, MA, Ml, 160,000d N/Ae N/A

MN, MT, NM, NV, NY, OK,

OR, SD, TX, UT, WA, WI

Calculated from percent distribution of adolescent population for IHS service areas by age based on 1980 U.S. Census Data (347). May not be current.

bIn some ways, these data Overestimate the number of mental health providers for adolescents. For example, the 17 IHS-funded providers are to serve both

adolescents aged 10 to 19 and children younger than 10. Older children are more likely to require and seek therapy, however.

‘South-central Arizona only.

dThe number of Indian adolescents living in urban areas sewed by Lhban Indian Health Programs is not known. OTA’s estimate is based on an estimated

total Indian population of approximately 1.5 million (estimate for 1985; 322), approximately 24 percent (360,000) of whom are estimated to be between 10

and 19 years old (see footnote b). If approximately 200,000 of these adolescents live in IHS service areas (see above), 160,000 would live in areas not

served by II-IS. This estimate is consistent with 1980 census figures showing that 50 percent of Indians live in metropolitan areas. However, not all of these

Indian adolescent live in urban areas with Urban Indian Health Programs, so this is probably an overestimate of the adolescent population sewed by Urban

Indian Health Programs. In addition, some Indians living in metropolitan areas are served by IHS (322).

eThe num~r of ~hi~- ~d ~ole=nt-tr~ned ment~ he~th prOVi&rS in u~an are= IS unknown. in any event, the number Would & sf’?l~l bUSe feWer

than 3 percent (15 to 20 providers total) of urban program staffs are mental health providers.

SOURCE: Office of Technology Assessment, 1990.

area; Nashville area; Phoenix area; and Tucson

area have no mental health providers trained to

work with children or adolescents. The Alaska,

Albuquerque, Oklahoma City, and Portland

areas have one each. The Aberdeen and Navajo

areas have two each. The Billings area has nine.

Note that in terms of provider to population

ratios, table 1 presents a conservative estimate

of the proportion of child- and adolescenttrained mental health providers available to the

Indian population by assuming that adolescents

aged 10 to 19 would be more likely than younger

children to seek mental health care.

There are no comparable data about the full

range of child- and adolescent-trained mental

health providers (i.e., including psychiatrists,

psychologists, social workers, and other mental

health professionals) for the U.S. all races

population, although some data, as well as a

recommended ratio of providers to children, are

available regarding child psychiatrists. These

data can be extrapolated to suggest that there be

a ratio of between 4 and 5 specially trained

mental health providers to every 10,000 children

19 and under. If this ratio were applied to the

II-IS service population, there would be an

increase from 17 to approximately 200 specially

trained mental health providers for reservationbased Indians alone.

In addition to the expansion of services,

important needs are to make any such expansion

responsive to the particular needs of Indian

adolescents and their communities and to improve coordination among service agencies.

Evidence for the effectiveness of mental health

treatment adapted to Indian adolescents is lack-
Chapter I-Executive Summary and Policy Options ● 3

E m

0

0

0

O N

EHuIl
4 . Indian Adolescent Mental Health

ing, although several promising models exist.

There is considerable evidence to suggest that,

in general, mental health treatment for children

and adolescents can be effective. OTA therefore

concludes that in order to meet the unmet mental

health needs of Indian adolescents mental health

services must be expanded in ways sensitive to

the needs of Indian adolescents and their communities.

These and other needs are addressed in the

following section on guiding principles and

options for a community-based, comprehensive,

mental health services system for Indian adolescents.

GUIDING PRINCIPLES AND

OPTIONS FOR A COMMUNITYBASED, COMPREHENSIVE,

MENTAL HEALTH SERVICES

SYSTEM FOR INDIAN

ADOLESCENTS

OTA’s evaluation of American Indian and

Alaska Native adolescents’ mental health needs

and the services available to them suggests a

number of principles for Congress to consider as

it designs legislation to improve the mental and

emotional health of American Indian and Alaska

Native adolescents. These guiding principles

were agreed upon by an OTA panel of experts

and are consistent with principles derived by

similar groups (e.g., 33,145,253,301,336,341).

First, the guidelines are summarized. Then,

obstacles to implementation of the guidelines

are discussed. Finally, options for congressional

consideration are presented.

Guiding Principles

A consensus exists that mental health services

for American Indian and Alaska Native adolescents should adhere to the following principles.

Mental health services for American Indian and

Alaska Native adolescents should:

●

●

●

●

●

●

●

●

●

●

●

●

●

be accessible to all American Indian and

Alaska Native adolescents, regardless of

geographic location or socioeconomic status;

be adequately funded and staffed;

be provided within a continuum of care, to

include, at a minimum, inpatient treatment

in a psychiatric hospital, a residential

treatment center, a partial hospital program, and an outpatient service;

be comprehensive, to include preventive

services, treatment, and community education;

be coordinated within and between service

agencies, including non-mental health system agencies, and State, local, and other

Federal (non-IHS and Bureau of Indian

Affairs (BIA)) agencies;

be provided in the community to the extent

possible;

include the affected community (including

adolescents) in the design, management,

and evaluation of services to the extent

possible;

be consonant with the cultural, spiritual,

and religious values of American Indian

and Alaska Natives;

be appropriate for adolescents;

be family-based to the extent clinically

possible;

be based on valid data about the extent of

need and availability and effectiveness of

services;

be of high quality; and

be provided on a timely basis.

Obstacles to Implementing Guiding Principles

Numerous obstacles exist before the guiding

principles listed above can be implemented.

This brief description of obstacles represents a

summary of the service conditions in IHS and in

other service systems (e.g., BIA, local, State,

and other Federal agencies) described in the

body of this report. Several of the conditions

described in this section present obstacles to

implementing more than one of the guidelines

described above. Not every obstacle may be

amenable to change through legislation.
Chupter l-Executive Summary and Policy Options ● 5

Obstacles to Accessibility, Adequate Staffing,

Continuous, Comprehensive, and Appropriate

Services

Little headway in improving services to

adolescents can be made with a total categorical

II-IS budget of $13 million for mental health

services. 4 Only 198 IHS staff members are

mental health professionals; only 17 of these are

specially trained to treat children and adolescents. There are only 21 inpatient psychiatric

beds for Indians; none of these are designated

for adolescents. Virtually no partial hospitalization, transitional living, or child residential

mental health treatment facilities exist in IHS

direct or tribal operations.

Obstacles to Providing Continuous,

Comprehensive, and Coordinated Services

Primarily because of funding disputes or

inadequate resources, local, State, and Federal

programs that are not based in IHS or BIA are

unlikely to serve Indians (322). Because they

have different objectives (e.g., education and

criminal justice for the BIA versus health for the

IHS), BIA and IHS programs often are not

coordinated. Within the II-IS, alcoholism, primary health programs, and mental health services are often not coordinated.

Obstacles to Providing Services Consonant With

the Cultural, Spiritual, and Religious Values of

American Indians and Alaska Natives

At present, few mental health service

providers are Indian, and cultural-sensitivity

training of providers is inadequate. Few opportunities exist to train additional Indian mental

health providers. Western-trained mental health

services providers may be insufficiently sensitive to cultural issues to work effectively with

Indian communities. Indian communities may

resist some of the prevention and treatment

recommendations of Western-trained mental

health professionals.

Obstacles to Services’ Being Designed by the

Affected Community

Many service programs originally under

the control of the Federal Government are

moving toward community control by Indians

themselves. However, numerous problems have

beset the full implementation of Indian selfdetermination (322).5 Issues common to all

health services, including mental health, include

the extent to which the IHS contracting process

either allows or undermines Indian control.

Another generic issue is whether Indian communities have developed the competence to design,

manage, monitor, and evaluate their own programs. For mental health services, and the

coordination of mental health with other health

services, a particular problem is presented by the

sometimes different interpretations (by tribes

and IHS and BIA professionals) of mental

health and emotional problems and their appropriate treatment.

Obstacles to Services’ Being Information-Based

With adequate information on the epidemiology and etiology of mental health problems, and

on the value and extent of services available to

help Indian adolescents with mental health and

emotional problems, Indian communities and

Federal agencies would be much better equipped

to provide appropriate and effective mental

health services. Such information is not currently available to Indian communities (322).

Epidemiologic, etiologic, and clinical research

is needed (88). Such research should be culturally sensitive (see 269).

4~e lol~t c~ngex “ot~ ~ tot~ appropriation of $21.5 million for ~S ment~ he~th progr~s for fiscal yea 1990 (fiblic Law 101-121). Of this

amount, $3.2 million was set aside by Congress for specific activities, $2.5 million was set aside by IHS for specific activities and resemes (including

$75,000 for regionally planned training to serve children and adolescents), and the remainder was allocated to area mental health programs to achieve

an approximate allocation of $12 per capita (McCoy, G,, U.S. Department of Health and Human Services, Public Health Service, Indian Health Service,

personal communication, Dec. 21, 1989).

5some of these issues Wem addressed in tie rwent ~en~ents to ~bllc Law 93.638 (~di~ Self-Determination ~d Education Assistance Act

Amendments of 1988 [Public Law 100-472]).
6 ● Indian Adolescent Mental Health

Obstacles to Assuring Mental Health Services of

High Quality

Evaluations of mental health and related

services to Indians have been few and far

between. Without such evaluations, it is difficult

to determine whether services of high quality are

being provided.b

Congressional Options

Many of the steps Congress could take to

improve the mental health of Indian adolescents

are expansions of legislation passed in the IOOth

Congress (e.g., aspects of Public Laws 100-297,

100-472, 100-713) or of changes already begun

in the Federal agencies serving Indians (353).

Others require substantial infusions of resources.

Options to Increase Both Dollar and Staffing

Resources for Mental Health Services for Indian

Adolescents Within IHS

●

●

Option l—Increase categorical funding for

IHS for mental health services. IHS’S

internal deliberations have determined that

H-IS needs at least twice the amount of

funds currently allocated to mental health.

If child and adolescent mental health services are to be increased, more funds than

that may be needed.

Option 2—Provide categorical funding for

mental health services specifically for Indian children and adolescents.

Increases in categorical funding would

help to ensure that the mental health needs

of Indian adolescents are met. However,

without an overall increase in funding for

IHS, these increases would decrease the

flexibility of IHS to meet the other health

and mental needs of Indians of all ages.

Further, any expansion of services should

be teamed with a qualitative change in the

service approach, to provide a culturally

competent, continuous system of care for

children and adolescents.

Option 3—Provide for a specific level of

full-time-equivalent mental health professionals, a portion of whom are to be for

children and adolescents. OTA concludes

that at least one to two child-or adolescenttrained mental health professionals in each

service unit seems necessary, at least

initially. Ideally, child- or adolescenttrained professionals would also be available in youth services centers and schools.

Option 4--Provide for training of nonmental health professionals (e.g., primary

care physicians) nurses, and nonprofessional mental health providers (e.g., mental

health technicians) to be better observers of

the need for mental health sources and

better providers of mental health care.

Option 5—Mandate that a specific portion

of Indian Health Professions scholarships

(see 25 U.S.C. 1613a) be for students who

pledge to work with adolescents.

Option 6-Expand retention bonuses (25

U.S.C. 1616j) to mental health professionals other than physicians and nurses, and

improve retention bonuses for physicians

and nurses.

Option 7—Ensure that the Indian Health

Care Improvement Fund (25 U.S.C. 1621)

is allocated at least in part to mental health

services.

Currently, it is “approved” but not

required for the Secretary to spend Indian

Health Care Improvement funds7 for mental health services.

Option 8—Provide a mechanism to use

underutilized IHS hospital general medical

beds for adolescent psychiatric patients.

Options to Increase Funding for Mental Health

and Related Services for Indian Adolescents in

Non-IHS Programs

The amount of mental health care received

by Indian adolescents from non-IHS sources is

not known, but it is believed to be very small.

%e quality of services can also be determined in part by the extent to which services adhere to standards (325). IHS has recently developed national

mental health program standards as part of its quality assurance efforts (355); OTA did not evaluate these standards.

71n fiscd yews IWO ad 1991,$19 million for the Indian Health Care Improvement Fund was authorized, and $29 million for fiscal year 1992(25

U.S.C. 1621).
Chapter l--Executive Summary and Policy Options ● 7

Congress could help Indian adolescents receive

services from non-IHS sources by providing

set-asides for Indian adolescents in general

legislation. However, these may not be sensitive

to Indian cultures, and so may not be used by

Indian adolescents unless some provision is

made to increase the sensitivity of non-IHS

service providers.

Precedent for set-asides for Indians, including

Indian adolescents, exists. For example, recent

legislation designed to combat alcohol and drug

abuse (the Drug-Free Schools and Communities

Act [Section 51 12(a)(2) of the August F.

Hawkins-Robert T. Stafford Elementary and

Secondary School Improvement Amendments

of 1988 (Public Law 100-297)]8

) reserved 1

percent of the authorized funds for drug education and prevention programs for Indian youth.

As another example, the Indian Education Act

of 1988 (Title V, Part C, of Public Law 100-297)

provided financial assistance to local education

agencies to develop and carry out elementary

and secondary school programs specially designed to meet the special education and culturally related academic needs of Indian students.

Vocational rehabilitation legislation allows for

the making of grants to Indian tribes (29 U.S.C.

750). Set-asides and mandated funding would

ensure that Indian adolescents are included in

innovative programs available to non-Indians.9

Option 9—Provide set-asides for Indian

adolescents in general legislation, such as

the Alcohol and Drug Abuse and Mental

Health Block Grant (Public Law 100-690),

Juvenile Justice and Delinquency Prevention Act (Public Law 100-690), Vocational

Rehabilitation Act, Sec. 130, and Maternal

and Child Health (MCI-I) Services Block

Ž

●

—

Grant (Title V of the Social Security

Act).Ž

Option 10-Clarify the intent of Public

Law 98-509, which permits the United

States Department of Health and Human

Services (U.S. DHHS) to provide alcohol,

drug abuse, and mental health (ADM)

block grant funds directly to Indian tribes.

Public Law 98-509 permits U.S. DHHS

to provide ADM block grant funds directly

to Indian tribes (42 U.S.C. 300x-la(b)(l)).

However, paragraph 2 of the same section

of the U.S. Code limits the amounts to be

so distributed to Indian tribes to ‘‘the

amount which bears the same ratio to the

State’s allotment for the fiscal year involved as the total amount provided or

allotted for fiscal year 1980” (42 U.S.C.

300x-la(b)(2)). Thus, unless tribal organizations applied for and received such

grants in fiscal year 1980, they are ineligible to take advantage of this provision

(245).

Option 11 —Mandate services to Indian

adolescents under Federal programs such

as Medicaid (Title XIX of the Social

Security Act).

There are already precedents for this in

other acts. For example, States are required

to provide vocational rehabilitation services to American Indians with disabilities

residing in a State to the same extent as the

State provides such services to other significant segments of the resident population of

individuals with disabilities residing in the

State (29 U.S.C. 721( B)(20)). States are

also required to consult with Indians in the

development of State plans (29 U.S.C.

721( B)(20)).

8~e ]egi~]ation ~mitt~ the Dep~men( of Education (Do~) t. con~act with lndi~ tribes, using tie provisions of the Indian Self-Determination

Act. (Section 5133 of Public Law 100-297).

gF~ ex~ple, the ADM Block Grmt mandates that at least 10 percent of ment~ he~th funds be used to provide services and progf~s for SeriOUS1y

emotionally disturbed children and adolescents (PubIic Law 100-690, SW. 2033(A)). Half of this amount is to be used to provide new or expanded

services and programs (Public Law 100-690, Sec. 2033(B)).

l~e Matern~ md (liId He~th (MCI-I) services Block Grant provides health services to mothers and children, particularly those with low income

or limited access to health services. The purposes of the block grant include reducing infant mortality; reducing the incidence of preventable disease

and handicapping conditions among children; and increasing the availability of prenatal, delivery, and postpartum cam to low-income mothers. Mothers

and children whose incomes fall below the poverty level may not be charged for services. States determine the services to be provided under the block

grant. In fiscal year 1987, $478 milIion was appropriated for the MCH Block Grant.
8 ● Indian Adolescent Mental Health

Options to Provide for, and Evaluate the

Effectiveness of, Alternative Models for

Access to Mental Health Services

Even if overall resources and staffing were

improved, small community sizes and wide

geographic distribution of Indian populations

would make the provision of professional mental health services difficult. Some Indian communities are located in rural areas where mental

health services are not available from anyone.

Thus, alternative models for access are needed,

such as mobile practitioners, additional use of

the village support worker model, consultation

and technical assistance to indigenous mental

health workers, and transportation to available

services. In general, the effectiveness of these

alternative methods has not been evaluated A

precedent exists in legislation providing for

grants to local educational agencies (LEAs) for

the cultural enrichment of Indian children; this

legislation allows for funds to be used for pilot

projects to demonstrate effectiveness of these

models (Title V, Part C, of Public Law 100-

297).

● Option 12—Provide for demonstration project-

 for alternative models for access to

mental health services, such as mobile

practitioners, additional use of the village

support worker model, consultation and

technical assistance to indigenous mental

health workers, and transportation to available services.

Options to Support Intra- and Inter-Agency

Coordination for Mental Health Problems

. Option 13—Mandate coordination of child

and youth services at the highest levels of

the IHS, the BIA, other Federal youth

services programs, and States in which

Indians reside.

The programs to be coordinated could

include, but not be limited to:

—II-IS mental health, maternal and child

health, alcohol and drug abuse, community health nursing, CHR, and health

education programs;

-Child Sexual Abuse Treatment Demonstration Programs (25 U.S.C. 1680i);

—BIA Juvenile Detention Centers (25

U.S.C. 2453 [4220 subsection b])12

;

—BIA Model Indian Juvenile Code (25

U.S.C. 2454);

—BIA Office of Alcohol and Substance

Abuse Indian Youth Programs (25 U.S.C.

2413(c));

—IHS regional youth detoxification and

treatment programs (25 U.S.C. 2474(a);

25 U.S.C. 2474(b));

—IHS community-based rehabilitation and

follow-up services for Indian youth who

are alcohol and substance abusers (25

U.S.C. 2474(d)) .13

Precedent for such coordination exists. For

example, Public Law 99-570 required that a

memorandum of agreement be developed between IHS and the BIA that would identify the

scope of alcohol and substance abuse problems

among Indian youth; identify relevant resources

and programs of the BIA, the IHS, and other

Federal, tribal, State, local, and private resources; develop and establish appropriate minimum standards for each agency’s program

responsibilities; and coordinate BIA and IHS

alcohol and substance abuse programs (25

U.S.C. 2411; 25 U.S.C. 2431; 25 U.S.C. 2433;

25 U.S.C. 2441).14

1 Ifiblic hw 100-690 au~otied fimds for ~mmuni~ Health Representatives, but did not require that their effectiveness be evduatd

12For exaple, fiblic ~w 100.690 legi~lat~ hat he IHS ‘‘sh~] not refuse to provide necessq intetim ~eatment for any Indian youth referred

pursuant to subsection(a) who has been charged or is being prosecuted for any crime unless such referral is prohibited by a court of competent jurisdiction

or the youth is determined by a court of competent jurisdiction to be a danger to others” (Public Law 100-690, Title II, Sec. 2210).

ls~cludes a provision that mental health professionals are to ~ SenictX.

14~oMer ~mvi~lon rq~r~ im~late medic~ exmlnation by IHS (d~ect or con~act cue) of juveniles ~st~ f~ alcohol or substance abuse to

determine the juvenile’s mental or physical state (25 U.S.C. 2452(a)).
Chupter I-Executive Summary and Policy Options Ž 9

Options to Provide for Community Involvement

in the Design and Implementation of Mental

Health Services and to Increase the Ability of

Indian Communities to Design and Implement

Mental Health Programs Responsive

to Their Own Needs and Consonant With Their

Community Values

Indian participation in the design of services is a major theme of recent legislation, but

such control primarily takes the form of turning

over responsibility for the delivery of services to

Indian tribes themselves. Indians could also

increase their participation in the design of

services delivered directly by the II-IS. In this

way, Indians could gain experience in designing

and delivering programs at the same time the

programs would become more responsive to

Indian needs. Precedent for such participation

exists, for example, in legislation providing for

grants to LEAs for the cultural enrichment of

Indian children (Title V, Part C, Section 5314 of

Public Law 100-297, The Tribally Controlled

Schools Act of 1988). This legislation requires

that programs be developed and operated with

the participation of parents of Indian children,

teachers, and where applicable, secondary

school students themselves.l·15 Public Law 99-

570 authorized $1 million a year (for each of

fiscal years 1989, 1990, 1991, and 1992) for

BIA grants to tribes for development of Tribal

Action Plans to coordinate available resources

and programs to combat alcohol and substance

abuse among tribal members (25 U.S.C. 2412(d)).

In general, U.S. DHHS is to provide technical

assistance directly to tribes and to make grants

to tribes for obtaining technical assistance from

entities other than IHS (Public Law 100-472).

An example of legislation that goes further in

helping to train tribal leaders is the provision in

Public Law 100-713 for demonstration projects

for tribal management of health care services

(25 U.S.C. 1680h). Importantly, during the

demonstration period, the Secretary was to

award all health care contracts (including community, behavioral, and preventive health care

contracts) to the Indian tribe in the form of a

single grant (25 U.S.C. 1680h(b)), and was

permitted to waive provisions of Federal procurement law. lb An evaluation of the demonstration project is required.

. Option 14-Mandate a mental health programs advisory board in every service unit

and area office of the IHS, and at the IHS

headquarters level. It would be important

that the Mental Health Programs advisory

board integrate its activities with advisory

boards for other health and social problems.

The 1984 IHS Ad Hoc Group on Mental

Health recommended that a standing IHS

Mental Health Council be formed but the

IHS and the Health Resources and Services

Administration (HRSA)17 rejected that recommendation (265).

Option 15—More adequately specify the

mental health aspects, if any, of the evaluation component of the tribal management

demonstration project authorized in 25

U.S.C. 1680h.

Options to Improve the Sensitivity of Mental

Health Providers to Cultural, Religious, and

Spiritual Considerations in Mental Health

Services Delivery

Precedents for implementing this option

include the Indian Education Act of 1988, which

authorizes grants to prepare teachers, social

workers, and ancillary personnel to serve Indian

students (Public Law 100-297). Public Law

100-713 requires the IHS to establish a program

to provide educational instruction in the history

and culture of ‘‘particular Indian tribes’ to

appropriate employees (25 U.S.C. 1616f). A

similar provision requires training for Community Health Representatives to ‘‘promote traditional health care practices of the Indian tribes

15~ in~~uc~g ~en~ for ~b~]y c~ntrollcd schools, Congess s~ted that ‘ ‘we ~lf.determination in any sOc,i@y of people is dependent upon till

educational process which will ensure the development of qualified people to fulfill meaningful leadership roles” (25 U.S.C. 2501).

lb~ovid~ +Jat my such w~ver ‘‘does not diminish or endanger the delivery of health cwe services to Indians. ’

IT~ 1984, II-IS WaS part of the HRSA; it has since been elevated to agency status.
10 ● Indian Adolescent Mental Health

served consistent with the [Indian Health] Service standards for the provision of health care,

health promotion, and disease prevention” (25

U.S.C. 1616(b)(2)(B)(6)).

● Option 16-Require that training under the

tribal culture and history program of Public

Law 100-713 (25 U.S.C. 1616f) be provided to all mental health professionals,

particularly those who work with children

and adolescents.

Options to Make the Delivery of Mental Health

Services to Indian Adolescents InformationBased

More efficient collection and sharing of

information by IHS and BIA would assist Indian

communities, the IHS, and BIA to design

programs and evaluate their effectiveness. Epidemiologic, service, and effectiveness data are

necessary. For example, the BIA is required to

provide IHS, affected tribes, and Tribal Coordinating Committees with data relating to ‘‘calls

and encounters, arrests and detention, and disposition of cases by BIA or tribal law enforcement

or judicial personnel involving Indians where it

is determined that alcohol or substance abuse is

a contributing factor’ (25 U.S.C. 2455), and

with data on child abuse and neglect cases (25

U.S.C. 2434(b)).

Option 17—Mandate the regular collection

of epidemiologic data about the mental and

emotional health status of Indian adolescents, perhaps beginning with demonstration projects.

Option 18—Mandate the timely sharing of

IHS and BIA service data with tribes.

Option 19-Expand the provision of information required in 25 U.S.C. 2475 and 25

U.S.C. 2455 from information about alcohol and substance abuse to information

about other mental and emotional health

problems.

Option 20-Mandate and support evaluation studies of IHS and BIA programs

related to the mental and emotional health

of Indian adolescents. Precedent for this

approach is included in Public Law 99-570,

●

which required that pilot programs monitor

the effectiveness of summer youth programs in furthering the prevention of

alcohol and substance abuse (25 U.S.C.

2431(a)).

Option 21—Provide for involvement of

Federal research agencies in basic and

applied research on mental health problems

and service needs of Indian adolescents.

For example, issues relevant to Indian

adolescents could become part of the

National Plan for NIMH-sponsored Child

and Adolescent Mental Disorders Research

(144).

There can be no doubt that the mental and

emotional health problems of Indian adolescents

need to be addressed, and that the potential

exists for helping Indian adolescents to improve

the quality of their lives and reach a satisfying

and productive adulthood. The discussion above

of precedents for congressional options suggests

that the Federal Government has shown its

willingness to commit resources to mitigating

the problem of alcohol and substance abuse

among Indian youth. However, alcohol and

substance abuse may be symptoms of other

severe problems among Indian youth. A similar

commitment to the mental and emotional health

needs of adolescents and their families before

they are manifested as alcoholism and substance

abuse may be equally effective.

ORGANIZATION OF THE

SPECIAL REPORT

This Special Report focuses on current knowledge about the mental health problems of

American Indian and Alaska Native adolescents

and the service systems that have evolved to

treat such problems.

Chapter 2 considers mental health problems

of American Indian and Alaska Native adolescents along a continuum ranging from diagnosable mental disorders through serious mental

health concerns to stressful life events. Where

possible, underlying causes have been highlighted and rates compared to those of the
Chapter l—Executive Summary and Policy Options ● 11

general adolescent population. The chapter closes

by outlining the most pressing information

needs and the challenges that to be faced in

addressing them.

Chapter 3 focuses on the nature and scope of

mental health care that is available to Indian

adolescents. It opens with a synopsis of the

Federal, tribal, urban Indian, State, and local

systems that play major roles in the delivery of

services to adolescents. The report then outlines

the various treatment settings that constitute a

continuum of care, which represents the optimal

framework for organizing and coordinating the

necessary array of interventions. It next describes the spectrum of treatment modalities,

considers their current status in Indian programs, and provides specific examples.

The report subsequently turns to preventive

and promotive interventions, and summarizes

the salient characteristics of those reported in the

published literature as well as those identified

by a field survey of actual practice. The related

needs for sensitivity to the variety of Indian

cultures and values and to community involvement are also addressed in this chapter. This

section closes on the need to develop a more

articulated, responsive, and comprehensive system which capitalizes on the best of all available

means of intervention and personnel. Appendix

A summarizes a number of earlier evaluations of

the mental health needs of Indian adolescents.

The primary focus of this Special Report is on

Indian adolescents from 10 to 19 years of age.

Younger children inevitably have been included

in some areas of discussion, largely as a function

of antecedent conditions that become manifest

as mental health problems in adolescence.

Notable examples include developmental disabilities and fetal alcohol syndrome.

The Special Report is somewhat limited in

that some areas of mental health concern have

engendered surprisingly little research and even

less published material. Consequently, information sources are limited and often difficult to

access. In addition, understanding of the mental

health problems of childhood and adolescence is

in flux. There is not the same clarity about such

phenomena among youth as there is among

adults. Finally, and perhaps most important to

an analysis of Indian mental health issues, with

rare exceptions the IHS, BIA, tribal, and urban

Indian health care program utilization data do

not lend themselves to ready analysis of mental

health problems.
Chapter 2

Mental Health Problems of American Indian

and Alaska Native Adolescents

The following discussion of mental health problems among American Indian and Alaska Native

youth has been organized in terms of a continuum of

concerns. It begins first with problems that are

considered diagnosable mental disorders. Diagnosable mental disorders represent serious difficulties

that are usually associated with readily observable

distress or functional impairment. Examples include

developmental disabilities, depression, anxiety, and

substance abuse and dependence. DSM-111-R, the

Diagnostic and Statistical Manual, Version Three

(Revised) of the American Psychiatric Association

(12), provides a widely accepted, although not

uncontroversial, nomenclature for describing and

classifying such mental health problems (323).

The discussion then turns to still serious, but less

diagnostically specifiable problems of childhood

and adolescence. These include school dropout,

delinquency, and runaway youth. Many mental

health professionals assume that these types of

problems either mask, are caused by, or lead to the

psychological dysfunction and illness embodied in

the major mental disorders.

The last portion of the discussion provides a

broader view of the stresses that Indian adolescents

experience and that, consequently, may render them

more vulnerable to serious mental and emotional

problems in question.

The causes of most childhood mental health

problems remain unknown (144,323). However,

related risk factors, often multiple and interlocking,

are noted in the context of each mental health

problem reviewed.

DIAGNOSABLE MENTAL

DISORDERS

A significant portion of DSM-111-R is devoted to

disorders usually first evident in infancy, childhood,

or adolescence. Other mental disorders may afflict

children and adolescents but are usually more

common in adults. The weight of clinical experience

suggests that most DSM-HI-R disorders are represented at least as frequently among American Indian

and Alaska Native adolescents as in the adolescent

population at large. Clinical experience, and some

research evidence, suggests that several disorders

may occur more frequently among Indian adolescents. These include mental retardation, specific

developmental disorders, post-traumatic stress disorderl

, identity disorder, substance use/abuse disorder, depression disorders, and adjustment disorders.2

Anorexia nervosa and bulimia nervosa would appear

to be less frequent among Indian adolescents. More

valid estimates of the extent of diagnosable mental

disorders among Indian adolescents (and non-Indian

adolescents) await systematic epidemiologic study.3

Developmental Disorders

The prevalence of mental retardation and other

developmental (disabilities among Indian adolescents is not well established, although several

studies suggest that they occur with greater frequency in this population than in others (238,262;

see table 2). Based in large part on sources published

before 1979, the Native American Rehabilitation

and Training Center concluded that neurosensory

disorders and certain developmental disabilities

appear to be from 4 to 13 times greater for American

Indians than for the U.S. population in general

(234a).

A more recent analysis of national data from 1984

found smaller differences (238; table 3). However,

this study found that almost 10 percent of American

Indian students in public schools had some form of

developmental disability. O’Connell reported that,

for the Nation as a whole, the frequency of learning

disabilities was greatest for American Indians among

public school students (5.28 percent of all Indian

students, compared to 4 percent for all minorities on

average and slightly more than 4 percent for Anglo

students). Indian students were second only to

blacks in the proportion of educable and trainable

mentally retarded. O’Connell and her colleagues

also analyzed BIA data gathered in 1986; these data

suggested that 8.72 percent of those enrolled had

INot discussed in his Special Report because of a lack of research evidence.

zNot discus~d in this Special Report because of a lack of research evidence.

3The U.S. DHHS NIMI-I bps to make such a study one of its 1991 initiatives (248).

-13-
14 • Indian Adolescent Mental Health

Table 2-Studies Generating Estimates of Developmental Disabilities Among Indian Children and Adolescents

Studya Setting Sample Method Findings

Reschly and Jipson,

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public schools

Pima County AZ

Ramiriz and Smith,

1978 . . . . . . . . . . . . . . . BIA Schools,

nationwide

Joe, 1980 . . . . . . . . . . . . . Navajo Nation

May, 1983 . . . . . . . . . . . . . MH programs

IHS Albuquerque Area

Office

Students; K-12; stratified

random sample

Students; K-12

Disabled tribal members

identified by multiple

sources in IHS, BIA, and

tribes; average age = 12

years

Clients 10- to 19-years old

1981 (n= 2,168)

1982 (n = 3,540)

WISC-R 1470 Papago

8% Black

6°A Hispanic

2% White

mental retarriation

Staff survey 38%; all handicapping

conditions

Survey Percent males more than

percent femafes; 5%

educable mentally

handicapped; 12%

developmental disabled; 34°/o

learning disabled; 10%

multiply handicapped

Service utilization 50/0 (1981 )

review 4.4% (1982)

mental retardation

SOURCE: Offii of Technology Assessment, 1990.

Table 3__---- -Reiated Handicapping Conditions of Ethnic Minorities, 1984

Percent of ethnic group with disability

Disability American Total

category Indian Asian Hispanic Black minority Anglo

Educable mentally retarded . . . . 1 .34% 0.33% 1 .02% 2.62°A 1.9070 0.92%

Trainable mentally retarded . . . . 0.32 0.18 0.25 0.38 0.32 0.25

Speech impairment . . . . . . . . . . . 2.33 1.34 1.76 2.20 1.99 2.50

Severely emotionally disturbed . 0.61 0.12 0.39 0.85 0.64 0.70

Learning disabled . . . . . . . . . . . . 5.28 1.66 4.14 4.26 4.01 4.14

Totals . . . . . . . . . . . . . . . . . . . . 9.88% 3.63% 7.560/o 10.31?0 8.860/0 8.510/o

SOURCE: J.C. O’Connell (cd.), “A Study of the Special Problems and Needs of American Indians With Handicaps, Both On and Off the Reservation,” report

prepared for the Office of Special Education and Rehabilitation Services, U.S. Department of Education, 19S7.

learning disabilities alone (238). These data suggest

that developmental disabilities are a serious problem

among Indian adolescents. There is evidence to

suggest that they are related to the high prevalence

of otitis media and fetal alcohol syndrome among

Indian children (discussed below).

Depression

Depression—whether taken as a set of nonspecific symptoms of psychological distress which

includes sadness, or as a psychiatric disorder with

characteristic symptoms, course, and prognosis—

has long been a concern with respect to Indian

adolescents. Numerous clinicians and investigators

argue, for example, that many behavioral difficulties

such as conduct disorder, learning problems, or even

substance abuse may reflect underlying depression

(50). Unfortunately, the systematic study of depression among adolescents in general, much less their

Indian counterparts, has advanced more slowly than

among adults. This lag is largely due to stillevolving theories about depression in childhood

which must account for highly situational stresses

and fluctuating maturational processes (323). It is

not surprising, then, that the available diagnostic

tools are neither as well-tested nor widely applied as

comparable methods for adults.

Nonetheless, depression is frequently cited among

the troubles experienced by Indian youth. As shown

in table 4, of the studies comparing the level of

depression among Indian adolescents with a sample

of non-lndians (3,170,366), most reported more

depression among Indian adolescents. The total

prevalence of depression among Indian adolescents
Chapter 2-Mental Health Problems of American Indian and Al@a Native Adolescents . 15

Table 4-Studies Generating Estimates of Depression Among Indian Adolescents

Study Setting Sample Method Findings

Studies using screening instruments for depressive symptoms:

Kleinfeld and Bloom, -

1977 . . . . . . . . . . . . . . . BIA boarding school

(Alaska)

Manson, Ackerson, Dick,

et al., in press. . . . . . . . Tribally administered

boarding school

(Southeastern U.S.)

NCAIANMHR, College

Student Life Transitions

Project, 1989 . . . . . . . . State-supported

university (AK, MT, NM,

AZ)

University of Minnesota,

IAHS, 1989 . . . . . . . . . . Schools (Plains,

Southeast, Southwest)

Surveys of practitioners:

Development Associates,

1983 . . . . . . . . . . . . . . . Title IV counseling

programs

- .

Eskimo students grade 9

(n= 132)

Students grades 9-12

(n= 188) age range 12-20;

average age 16

College students, (n= 605)

age range 17-54; average

age 25

7th-12th grade students

lst-12th grade students

Studies using mental health service utilization review:

Beiser and Attneave,

1982 . . . . . . . . . . . . . . . Mental health programs Mental health clients

(nationwide) (1974) 15 to 19

May, 1983 . . . . . . . . . . . . . Indian Health Service Mental health clients 10 to

mental health program 19 yrs old (n= 1,898) 1981

(Albuquerque area) (n= 3,541) 1982

Self-report survey;

HOS;b Symptom

check-lists

Self-report survey

using CES-DC

Self-report survey

using CES-D

IAHSd

Survey of counselors

Chart review

Chart review

Studies using diagnostic criteria for clinical depression In self-report surveys:

Krush, Bjork, Sindell,

et al., 1966 . . . . . . . . . . BIA boarding school Northern Plains students MMPlK CPlh

(South Dakota) grades 11-12 (n= 222)

Ackerson, Dick, Manson,

et al., in press. . . . . . . . Tribally administered Students grades 9-12 self report survey

boarding school (n= 177) age range 12:20; (lDD)j

(Southeastern US.) average age 16

(1987-88)

49°A of student body

emotionally disturbed,

including depression (25°/0

serious)

58% met cutoff

48%0 met cutoff; no

significant difference

between males and

females; slightly more than

white students

20%. report being

“depressed” in the last

monthe; 34°/0 report feeling

“sad, discouraged,

hopeless”f

560/. reported students

were frequently troubled by

depression (fifth most

frequent problem)

8% of all females

3.30/0 (1981) 3.2%(1 982)

Significanyly more than nonIndiansi

5.30% met criteria; no

significant difference

between males and

females; slightly more than

white students

aReferen~s are located at end of report.

b~alth opinion survey.

ccenter for Epidemiologic Studies-Depression Scale.

dlndian Adolescent I-hlth survey.

eMore males (zle~] ~ep~~ fWling depressed than ~males (1 S,6VO). The per~nt feeling depres~d was approximately the same as in the Minnesota

sample.

fMore female$ (38.1%) than ma& (29,4~0) reported feeling sad, di~ouraged, or h@ess. Indian students Were more likely than Minnesota students

(approximately 20%) to report feeling sad, hopeless, or discouraged in the last month.

9Minnesota Multiphasic Personality Inventory.

hcalifornia psychological klVentOry.

‘Did not report data.

Inventory to Diagnose Depression.

SOURCE: Office of Technology Assessment, 1990.

cannot be calculated from existing studies because serious depressive symptoms (166,190,232,233).

the studies used different methods for estimating Not surprisingly, when the more restrictive diagnosdepression. When self-report screening methods are tic criteria for clinical depression are used, the

used, half or more of Indian adolescents report proportion of Indian adolescents found to be de-
pressed is smaller (3,29,202). Based on these geographically diverse data, rates of depression among

Indian adolescents do not appear to differ by are%

although not all Indian areas are represented in the

research base.

Some researchers have concluded that boarding

school environments contribute to depression among

Indian adolescents (166,170). Much of the research

has been conducted with boarding school populations, so it is difficult to disaggregate the effects of

boarding schools from other risk factors for depression.4

Overall, the numbers of Indian adolescents reporting depressive symptoms provide cause for concern.

Suicide

Suicide is perhaps the most tragic manifestation

of mental health problems among Indian adolescents. An attempted suicide by an adolescent is a

distinct call for help. This section provides information about the extent of the suicide problem among

Indian adolescents and discusses the individual and

environmental risk factors that are known or believed to be associated with Indian adolescent

suicide.

Suicide Deaths

Suicide is the second leading cause of death for

American Indian and Alaska Native adolescents. In

1986, the age-specific mortality rate for suicide for

15- to 19-year old Indians was an estimated 26.3

deaths per 100,000 population (table 5). In comparison, the figure for the same age group for U.S. all

races was 10.0 per 100,000 population. Suicide

deaths for 10- to 14-year olds are approximately four

times higher than that for U.S. all races.

For 15 to 19 year olds, age-specific death rates

from suicide have decreased somewhat from 30.9 in

1980 to 26.3 in 1986; however, rates for 10 to 14 year

olds have increased steadily (table 5).

As with the general population, death from

suicide is more likely to affect Indian males because

males are more likely than females to use particularly lethal methods such as shotguns and hanging

In 1986, the death rate for adolescent males 10 to 19

was approximately 10 times higher than for females

of the same age. Suicide deaths for Indian females

aged 10 to 19 climbed steadily during the first part

of the 1980s, peaking in 1985 with 9.0 deaths per

100,000 population. In contrast, the figure for U.S.

all races females aged 10 to 19 was 2.3 deaths per

100,000 population. In 1986, the rate for Indian

females dropped to 3.4 deaths per 100,000, while the

rate for U.S. all races females remained somewhat

level at 2.2 deaths per 100,000.

While suicide is the second leading cause of death

for Indian adolescents, the actual number of deaths

is relatively low (e.g., 30 deaths among 10- to

19-year-old Indians in 1986). At the area level, these

numbers are considerably smaller. Therefore, any

area-specific death rates for suicide, even with

reliable population estimates, are subject to large

fluctuation on a year-by-year basis.

Suicide Attempts

Suicide deaths provide only one dimension of

the problem of adolescent suicide. For every suicide,

there are many more suicide attempts. Hospital

admissions and self-reports by adolescent provide

some information on suicide attempts.

In 1988, there were 424 hospitalizations in IHS or

contract health care facilities (discharges also include deaths) for adolescents age 10 to 19 which

involved a suicide attempt (ICD-9 suicide E-code)

(table 6). Seventy percent (298) were females, with

the majority (55 percent) of female suicide discharges among 15 to 17 year olds. Ingestion of pills

was the most common method of attempt (94

percent) (351). Likewise, nearly half (47 percent) of

all suicide discharges for males were for 15 to 17

year olds.

While ingestion of pills was also the most

common method of attempted suicide for males (74

percent), males were more likely than females to

attempt suicide via hanging (4 percent), firearms (10

percent), or cutting (10 percent). Younger males (10

to 14), however, tended to use less violent means

than those in the 15- to 19-year-old age range. - - —

dIt maybe possible to compare responses to relevant items for depression among students in different types of schools participating in tie UnivemitY

of Minnesota Indian Adolescent Health Smey (366). However, no off-reservation boarding schools were included in the IAHS.

SE~fiating dea~ rates for ~di~s in MS ~mlce me= is difficult ~ause of unce~ainty in tie pop~ation denorninatort OTA’S mefiod of estimating

the Indians adolescent population is described in app. B. For additional details concerning problems with II-E data sources, see U.S. Congress, OTA

(322).

Comparable data on suicide methods for non-Indian youths are not available because the use of ICD-9 E-codes is optional on hospital discharges.
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 17

Table 5-lndian and U.S. All Races Age-Specific Suicide Death Rates per 100,000 Population, 1980-86

Indian U.S. all races

Age Ages 10-19 Ages 10-19 Age Age Age

10-14 15-19 Males Females 10-14 15-19 Males Females

1980 ........, 0.0 30.9 29.7 2.1 0.8 8.5 7.5 1.6

1981 . . . . . . . . . 2,2 30.4 28.1 5.3 0.9 8.7 7.4 2.0

1982 . . . . . . . . . 2.2 19.6 16.9 5.4 1.1 8.7 7.9 1.8

1983 ....., . . . 4.5 30.4 27.8 7.7 1.1 8.7 7.6 1.9

1984 . . . . . . . . . 2.3 33.0 27.1 8.9 1.3 9.0 7.1 2.0

1985 . . . . . . . . . 5.7 35.7 33.0 9.0 1.6 10.0 9.1 2.3

1986 . . . . . . . . . 6.9 26.3 29.8 3.4 1.5 10.2 9.3 2.2

SOURCES: Indian: Office of Technology Assessment, 1989, calculated from U.S. Department of Health and Human Services, Public Health Service, Indian

Health Service, unpublished mortality data, Rockvllle, MD, 1989; U.S. all races: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Center for Health Statistics, unpublished mortality data from table 292A, “Deaths From 282

Selected Causes,” Hyattsville, MD, no date.

Table 6-Percentage of IHS and Contract Care Hospital Discharges for 10-to 19-Year-Olds

Involving a Suicide “E-Code,” 1980-88

1980 1981 1982 1983 1984 1985 1986 1987 1988

All areasa . . . . . . . . . . . . . . .

Aberdeen . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . .

Albuquerque . . . . . . . . . . . .

Bemidji . . . . . . . . . . . . . . . . .

Billings . . . . . . . . . . . . . . . . .

Navajo . . . . . . . . . . . . . . . . .

Oklahoma City . . . . . . . . . .

Phoenix . . . . . . . . . . . . . . . .

Portland . . . . . . . . . . . . . . . .

Tucson . . . . . . . . . . . . . . . . .

2.60%.

3.5

2.9

3.1

3.7

1.9

2.4

0.9

9.0

0.7

0.9

2.8%

3.2

3.9

4.2

3.2

1.8

2.1

1.1

4.7

0.5

0.6

2.70/o

4.3

3.3

3.0

3.6

1.1

2.3

0.6

3.8

0.9

2.9

2.9%

4.0

2.8

4.3

7.3

1.2

2.4

1.2

4.1

0.2

3.3

3.l~o

4.9

4.2

2.4

4.0

1.7

2.5

0.8

5.2

1.9

1.8

3.20/o 3.9%

4.6 5.5

3.1 4.5

4.1 4.4

8.1 11.2

2.7 4.0

2.2 3.0

0.7 0.9

4.4 4,9

1.3 2.1

1.1 2,5

3.7%

7.6

4.4

4.2

9.7

3.1

2.5

1.2

3.6

3.3

2.8

4.3 %

6.5

3.1

6.3

15.5

5.5

3.1

1.3

5.2

4.4

4.1

alncludes Nashville in total, Individual data on Nashville not presented since one IHS hospital became a “838” (tribally run) facility during this period.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Indian Health Servicej Rockvllle, MD, unpublished IHS hospital discharge

data, 1989.

During the period 1980-1988, adolescent hospital gestures with minimal health risk; others may be

discharges involving a suicide E-code increased more serious. Still, suicide attempts often go undefrom 2.6 percent of all discharges to 4.3 percent

(table 6).

tected by parents or the medical community. Because suicide is such a major problem in Indian and

Because of the way IHS maintains ambulatory

care data, it is not possible to know how many

adolescents were referred for mental health services

in conjunction with a suicide attempt.

Alaska Native communities, a recent survey of

Indian adolescents (the Indian Adolescent Health

Survey [AHS]) included a number of questions

pertaining to suicide attempts of respondents and

friends. For this Special Report, only a subset of

For every hospitalization for a suicide attempt, IAHS data, collected from approximately 2,700

there are many more which never become part of the students in some Plains, Southeast, and Southwest

system. Some of these attempts may be suicide tribes, is available.7

7

In general, in analyzing data from the IAH, several points must be kept in mind. First, the data are a subset of 2,672 respondents drawn from the

larger IHS survey which is still not complete. (Approximately 15,000 students completed surveys as of the end of spring 1989 but not all of these data

were available at the time this special report was being prepared; an additional 3,000 additional surveys will be completed in the future.) Secondly, while

the data may be indicative of trends in Indian adolescent health behavior they are not necessarily representative of all Indian adolescents. The subset

used for this analysis involves a limited representation of students, primarily in Southwestern tribes; it does not include Alaska Native youth because

survey work in Alaska was still in progress when this special report was being prepared. Also, the data are self-reported. While this method may be an

acceptable one for collecting sensitive information regarding behavior and thoughts that only the respondent is aware of, there is the potential that items

may not be answered truthfully. Extensive edits to detect false responses were performed on the data. However, it is not possible to detect false response

patterns for all questions. Despite this latter limitation, the IAHS responses show remarkable consistency in response patterns when compared to other

groups who have used a comparable instrument, Because a nearly identical survey was completed by over 36,000 Minnesota adolescents in grades 7

through 12 (365), data from the IAHS can be compared to this larger group. A third limitation of the IAHS (and MAHS) was that data collection was

limited to students and does not include adolescents who have left school.

19-756 0 - 90 - 2 : QL 3
Table 7—Percentage of Indian and Minnesota Adolescents in

Grades 6 Through 12 Ever Attempting Suicide

Males Females

b-lumber Percent Number Percent

Indian Adolescent Health Survey

Total . . . . . . . . . . . . . . . . . . . . . . . . . 150 11 .60/0 276 20,30/o

Southwestern tribes . . . . . . . . . . 64 11.3 106 18.3

Plains tribesa . . . . . . . . . . . . . . . . 69 12.8 136 23.1

Southeastern tribesa . . . . 

. 

. 

. . . . 17 8.2 34 16.7

MJnneaota Adolescent Health Survey

Metro . . . . . . . . . . . . . . . . . . . . . . 936 7.7 1,846 16.0

Greater Minnesota . . . . . . . . . . . 372 5.9 829 13.2

Only surveyed grades 7 through 12.

SOURCES: Indian Adolescent Health Survey: University of Minnesota, Adolescent Health Program, Indian

Adolescent Health Survey, unpublished preliminary data, 1989; Mlnnesota Adolescent Health Survey:

University of Minnesota, Adolescent Health Program, Minnesota Adolescent Health Survey, unpub]lshed .

data, 1987.

Nearly 12 percent of Indian males and 20 percent

of Indian females in the IAHS subset (see table 7)

indicated that they had ever attempted suicide. This

compares with 7 percent of males and 14 percent of

females in the Minnesota Adolescent Health Survey

(ratios of 1.7 and 1.4, respectively). Data from the

National Adolescent School Health Survey, based

on a representative national sample of adolescents in

grades 8 and 10, show that just over 11 percent of

males and 17 percent of females had ever attempted

suicide (9).8

Less than one-fifth of Indian adolescents indicated that they sought medical care after their last

suicide attempt, an item included to assess the

seriousness of the attempt. Of those who did not seek

medical care, over a fifth of females indicated that

they told their best friend about their attempt.

However, nearly the same proportion indicated they

told no one. Males were more likely to not tell

anyone about their attempt (366).

Over half of the males and females who reported

having tried to kill themselves indicated that they

had attempted to kill themselves more than once.

Not surprisingly, Indian adolescents who had previously attempted suicide were much more likely than

those who hadn’t attempted suicide to indicate that

they continued to have suicidal thoughts (table 8).

Clearly, adolescents who have attempted suicide

once are in need of some kind of intervention. Thus,

it may be encouraging that Indian adolescents who

have previously attempted suicide were more likely

than those who hadn’t to indicate that they had ever

received mental health care (see table 8). However,

the extent and effectiveness of such care cannot be

determined from the IAHS survey. It is noteworthy

that 75 percent of adolescents who had attempted

suicide report that they received no mental health

care.

Completed suicides and suicide attempts of others

can have a profound impact on a wide range of

individuals, particularly in small communities such

as those on reservations. Nearly one-third of females

and one-fifth of males indicated that a friend had

attempted suicide. One out often Indian adolescents

reported that a friend had actually died from suicide.

About one-fifth of those surveyed in the IAHS

indicated that a family member had either committed or attempted suicide (table 9).

Risk Factors for Indian Adolescent Suicide

A wide range of individual risk factors has been

considered in regard to Indian suicide (288). Frequent interpersonal conflict (209,226,273), prolonged, unresolved grief (79,150), chronic familial

instability (86,206,263,304), depression (234,307),

alcohol abuse/dependence (379) and unemployment

(291,314,315,318) have been shown to be major

correlates of this phenomenon. In addition, a family

history of psychiatric disorder—particularly alcoholism, depression, and suicide—often has been

noted (286).

The suicide rate also is higher among Indian

adolescents who have been seen for psychiatric

problems, who have physical illnesses, who have

s~e average rates ~ tie ~meWta (WHS, IAHS) and National Adolescent School Health Survey (NASHS) differ because NASHS res~icted its

sample to older students. Older adolescents are more likely than younger ones to attempt suicide.
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 19

Table 8-Percentage of Indian Adolescent Suicide Attempters and Non-Attempters Having Suicidal Thoughts and

Receiving Mental Health Treatment

Attempters Non-attempters

Males Females Males Females

In the last month:

No thoughts about suicide . . . . . . . . . . . . . . . . . . . . . . . 40.0% 36.3% 77.3% 79.9%

Thoughts but would not carry them out . . . . . . . . . . . . 36.6 38.5 13.0 15.7

Would like to kill self. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.2 12.4 3.7 1.8

Would kill self if had the chance . . . . . . . . . . . . . . . . . . 8.2 12.8 6.0 2.6

Ever received treatment at a mental health clinic

in hospital for any personal, emotional, or

behavioral problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.8 19.0 9.1 9.5

SOURCE: University of Minnesota, Adolescent Health Program, Indian Adolescent Health Survey, unpublished preliminary data, 1989.

Table 9-Percentage of Indian Adolescent Males and

Females Who Reported Knowing of Others’ Suicide

Attempts and Suicide Deaths

Percent Percent

males females

Suicide-related items (n= 1,297) (n= 1,360)

Have any family members

attempted or died from a

suicide attempt . . . . . . . . . . . . 18.00/0 23.00/.

Have any of your friends

attempted suicide . . . . . . . . . . 18.4 32.4

Have any of your friends died

from a suicide attempt. . . . . . 8.8 10.7

SOURCE: University of Minnesota, Adolescent Health Program, Indian

Adolescent Health Survey, unpublished preliminary data, 1989.

previously attempted suicide, who have frequent

encounters with the criminal justice system, and who

have experienced multiple home placements (37,86,106).

Preliminary analysis from some of the Indian

Adolescent Health Survey data suggests that individuals who have attempted suicide are more likely

to engage in risk behaviors such as chinking, using

marijuana, and sexual intercourse. Furthermore,

they are also much more likely to rate themselves in

poorer health than their peers, indicate that their

school performance is below average, worry about

physical and sexual abuse, and report that their

parents have a drinking problem (table 10).9

Social disintegration and acculturation also have

captured a great deal of attention as possible causes

of suicide among Indian and Native adolescents

(169,180,181,183,367,377,378). Culture conflict and

concomitant problems in identity formation are

believed to produce a chronic dysphoria and anomie

which render Indian youth vulnerable to suicidal

behavior during periods of acute stress (137).

Suicide victims more typically belong to tribes

with loose social integration-which emphasize a

high degree of individuality—and that are undergoing rapid socioeconomic change. However, despite

this fairly common pattern, actual rates vary dramatically, ranging from well below the national average

in some Southwestern communities to well above

the national average in inter-mountain tribes of the

Rockies (284,285,323).

Cultural dynamics specific to certain Indian tribes

also appear to be at work in determining risk for

suicide among Indian adolescents. For example,

Levy and Kunitz (183) illustrate that suicide rates

are not only high among the Hopi in ‘‘progressive

villages and off-reservation bordertowns, but in

traditional villages as well. Specifically, Hopis at

special risk for suicide include the children of

parents who entered into traditionally disapproved

marriages, e.g., across tribes, mesas, and even clans

of disparate social status. The labeling of parents as

“deviant” in this regard stigmatizes their children,

thereby engendering a distinct series of stressors.

In another example, Levy (180) suggests that

suicide among Navajo males may indicate their

relative lack of integration into a changing, matrilineal society. Moreover, he describes how these

individuals seem to employ suicide to withdraw

from intolerable situations, and yet, by virtue of its

social, cultural, and spiritual affront to the survivors,

accomplish a final act of aggression. Lastly, tribes

which emphasize a high degree of individuality

generally exhibit higher rates of suicide than those

which emphasize conformity. Classic comparisons

include the Apache, Navajo, and Pueblo communities, with the former representing “looser” social

9B~au~the IAHS W* cross-section~, it is not possible to know with certainty whether these are risk factors for or consequences of suicide attempts.
20 ● Indian Adolescent Mental Health

Table l0--Covariation of Suicide Attempts With

Behavioral and Environmental Risk Factors

Males Females

(n=l,297) (n=l,360)

Worry about abuse from parents:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide. . . . . . . . . . . .

Worry about being forced to do

something sexual:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . . .

Ever had sexual intercourse:

Never attempted suicide . . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . .

Feeling depressed in last month:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . .

Ever drink beer or wine:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide. . . . . . . . . . . .

Drink beer or wine at least weekly:

Never attempted suicide. . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . .

Ever use marijuana:

Never attempted suicide, . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . .

Use marijuana at least weekly:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide. . . . . . . . . . . .

Parental drinking problems:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide . . . . . . . . . . . .

Feel in poor or fair health:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide. , . . . . . . . . . .

Perform below average in school:

Never attempted suicide . . . . . . . . . .

Ever attempted suicide. . . . . . . . . . . .

14.0

16.8

13.3

13.2

24.4

48.6

14.0

31.7

54.8

73.8

11.3

24.5

35.8

57.6

10.2

23.8

17.0

26.1

16.7

28.1

10.9

20.1

23.5

32.0

28.0

33.9

16.0

36.5

15.0

30.3

48.8

71.4

6.6

19.8

27.4

51.9

5.6

17.6

21.1

32.5

19.7

31.6

9.4

13.4

SOURCE: University of Minnesota, Adolescent Health Program, Indian

Adolescent Health Survey, unpublished preliminary data, 1989.

integration and that latter two representing ‘tighter’

integration (203,367).

Suicide Clusters

There appears to be an increasing tendency for

suicides to occur in clusters, defined as any series of

three or more suicides closely related in time and

space (61). Several articles have recently appeared in

the literature specific to Indian and Native adolescents population (26,71,184) but on the whole little

is known about this phenomenon among adolescents

in general, much less among Indian adolescents.

Conventional wisdom holds that clustering occurs

more frequently among females than males, despite

higher overall rates among males (250). Reports of

cluster suicides among Indian adolescents differ

slightly in that the victims are predominantly males,

although many attempts by females occur, usually

by less lethal means, at similar points in time.

Subsequent suicides may be stimulated by personal

knowledge of the victim, of the circumstances

surrounding the death, and by interpersonal proximity in a relatively closed community. Extensive

media coverage may also contribute to the increased

probability of serial suicides by dramatizing the

death and focusing widespread attention on the

victim (1 18). Bechtold’s (26) analysis suggests that

serial suicides by Indian adolescents are fueled by

the same interpersonal and social dynamics as those

which underpin this phenomenon in the population

at large.

Anxiety

Like depression, anxiety-related disorders

recognized but not well delineated among

emotional problems associated with childhood

are

the

and

adolescence. The most salient features include

excessive fearfulness accompanied by muscular

tension, avoidant behavior, somatic complaints without an organic basis, and repeated nightmares.

Separation from parents, family, or familiar surroundings, fear of strangers, and various phobia are

common forms of anxiety which can impair function.

Information about anxiety among Indian and

adolescents derives from the same set of studies

summarized above in regard to depression.

Beiser and Attneave (29) reported that anxiety

was the fourth most common mental health problem

for youth seen through IHS mental health programs

in 1974, nearly equal to the frequency of depression

(table 11). Eight percent of all boys and girls

between the ages of 15 and 19 were identified as

suffering from anxiety. May’s (202) survey revealed

that in 1981 and 1982, about 18 percent of all males

and nearly 10 percent of all females seen for anxiety

in the IHS Albuquerque Area Office mental health

program were between 10 and 19 years of age.

Studies of boarding school and college students

conducted by the National Center for American

Indian and Alaska Native Mental Health Research

also included measures of anxiety symptoms. These

studies suggest remarkably high levels of different

forms of anxiety among Indian adolescents.
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 21

Table 1 l-Studies Generating Estimates of Anxiety Among Indian Adolescents

Study a

Setting Sample Method Findings

Studies using mental health service utilization review:

Beiser and Attneave,

1982 . . . . . . . . . . . . . . . IHS mental health programs

(nationwide) (1974)

May, 1983 . . . . . . . . . . . . . IHS mental health programs

(Albuquerque area)

Studies using self-reports of symptoms:

NCAIANMHR,

Indian Boarding School

Project, 1989 . . . . . . . . Tribally administered boarding

school (Southeastern U. S.)

NCAIANMHR,

Indian Boarding School

Project, 1989 . . . . . . . . BIA administered boarding

school (Western U. S.)

NCAIANMHR,

College Student Life

Transitions Project,

1989 . . . . . . . . . . . . . . . State-supplement universities

AK, MT, NM, AZ

clients 15 to 19

clients 10 to 19

students grades 9-12

(n=188)

age range = 12-20

average age = 16

students, grades 9-12

(n=225)

college students,

(n=605),

age range= 17-54

average age =25

aReferences are located at end Of report.

80 SOURCE: Office of Technology Assessment, 1990.

chart review 8% of clients

chart review 13% of clients (1981)

11 .3% of clients (1982)

self-report survey 24% physiologic reaction;

44% phobic reaction;

40% performance reaction

self-report survey 27% physiologic reaction;

51% phobic reaction;

43% performance reaction 

self-report survey 23% physiologic reaction;

48°/0 phobic reaction;

56°/0 performance reaction

Substance Abuse and Dependence

Given the high rate of deaths among young

Indians due to causes related to substance use,

particularly alcohol (322), there is considerable

interest in this problem among Indian tribes and

health providers. Several recent surveys point to

different conclusions about the extent of substance

use among Indian adolescents (table 12). Surveys by

Beauvais and Oetting and their colleagues have

found high rates of alcohol and drug experimentation among Indian adolescents relative to non-Indian

adolescents (25). For example, in 1986-87 an

average

10 of 81 percent of Indian students in grades

7 to 12 had used alcohol at some time; 61 percent had

used marijuana; 24 percent had used inhalants; 25

percent had used stimulants; 8 percent had used

cocaine; 10 percent had used hallucinogens; 11

percent had used sedatives; and 5 percent had used

heroin (table 12). Comparable data for non-Indian

students are not available, but non- Indian adolescents surveyed by NIDA for their 1985 and 1988

household surveys were much less likely than Indian

adolescents to have used each of these drugs (table

12). Preliminary data from the more recent IAHS

found much lower use of drugs among Indian

adolescents than did the Beauvais and Oetting

surveys. Minnesota students were not asked about

the same range of drugs that Indian students were

asked about, but when they were asked, alcohol and

cocaine use were comparable, and marijuana use

was higher among Indians than among the mostly

non-Indian Minnesota sample. *1

What is not clear from the data on lifetime

prevalence (i.e., “ever” having used a drug) is the

number of adolescents who are dependent on or

otherwise abuse drugs, as opposed to experimenting

with them once. In a survey of attitudes towards

drugs on the Wind River reservation in Wyoming,

adolescents were found to have a more favorable

attitude toward the use of marijuana and other drugs,

loObviously, in surveys, fewer younger adolescents than older adolescents are found to have ever used drugs. When the Percent ever having used drugs

is averaged across all age groups, the overall percent is lower than it would be if only the older adolescents were counted.

11The reasons for tie app~ent difference between the Beauvais and Oetting and the IAHS surveys of Indian adolescents ~ not CleiW. Both smeys

were conducted among adolescents attending school, so they cannot differ because of possibly unequal drug use by school dropouts, There are subtle,

but not striking, differences in questiomaire wording between the two surveys that may account for some of the differences, Also, the IAHS data are

preliminary and may not reflect the prevalence of drug use among all Indians.
22 ● iNDIAN Adolescent Mental Health

Table 12-Estimates of Percentage Indian and Non-Indian Adolescents Ever Using Alcohol and illegal Drugs

Indian adolescents Non-Indian adolescents

Estimates from surveys Estimates from survey N IDA National Minnesota

by Oetting and Beauvais by University of Minnesota Household Surveys Adolescents

1984-85a 1986-87a 1988-89a 1985a 1988’ 1987-88d

Alcohol . . . . . . . . . . . . . 79% 81% 570/0 570/’ 50% 611%0

Marijuana. . . . . . . . . . . 57 61 32 24 17 20

Inhalants . . . . . . . . . . . 24 24 13 9 9 N/A

Stimulants . . . . . . . . . . 25 25 11 6 4 N//aAAaaaa

Cocaine . . . . . . . . . . . . 8 5 5 3 <5

Crack . . . . . . . . . . . . . . N/A N/A 2 N/AIA 1 N/Ae

Hallucinogens . . . . . . . 9 10 4 3 4 N/A

Sedatives . . . . . . . . . . . 10 11 3 4 2 N/A

Heroin . . . . . . . . . . . . . 5 5 1 <5 1 N/A

aReServatiOn baaed Sampie; Indian adolescents attending school, grades 7-12.

bFteservatiOrl/serv~ unit samples; Indian adolescents attending school, grades 6-12.

cHousehold based survey of youth aged 12-17.

dschool based Sarnpie; Minnesota adolescents in grades 7-12.

elnclud~ in Cocaine total.

SOURCES: 1 884-85, 1988-87 Indian data: F, Beauvais, E.R. Oetting, W. Wolf, et al., “American Indian Youth and Drugs, 1976-1987: A Contmumg

Problem,” American Journal of Pubhc Heakh 79(5):634-636, 1989; 1988-89 Indian data: LJniverslty of Minnesota, Adolescent Health Program,

Indian Adolescent Health Survey, unpublished preliminary data, 1989; 1985 non-lndlan data: U.S. Department of Health and Human Services,

Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, IVat/ord Househcdd Survey on

Drug Abuse: Population Estimates 1985, DHHS Pub. No. (ADM) 87-1539 (Rockville, MD: 1987); 1988 non-lndlan data: U S. Department of

Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse,

Division of Epidemiology and Prevention Research, National Household Survey on Drug Abuse. 1988 Population Est/mates, DHHS Pub. No.

(ADM) 89-1636 (Roclwille, MD: 1989): 1987-88 Minneaota non-lndlan data: Unwersitv of Minnesota, Adolescent Health Proqram, The State of

Adolescent Health in Minnesota, February 1989,

to be more likely to try using marijuana and other

drugs, but no more likely to continue using such

drugs after trying them than white adolescents from

the same geographical area (58). Nonetheless, observers have noted cause for concern. Persistently

high drug use is still the norm across most categories

for young Indian people, especially in regard to

marijuana, inhalants, and stimulants (25,239). In

addition, Oetting and Goldstein’s work (242) revealed that American Indians begin abusing various

substances at a younger age than their white

counterparts (also see 373). Further, once they enter

adolescence, Indian youth seem particularly prone to

using alcohol and other drugs in combination with

one another (239). Inhalant use appears to decline,

however, as other substances such as marijuana and

alcohol become more accessible.

Finally, the potential for affecting the family and

community exists because of financial considerations (185) and possible physical damage due to

drug usage. These factors are especially salient

because of the low socioeconomic levels of most

Indian people and the strong traditional value placed

on the family as a unit.12

Identity Disorder, Alienation, and Self-Esteem

Identity disorder refers to the severe subjective

distress that stems from one’s inability to integrate

various aspects of the self into a coherent and

acceptable sense of personhood (12). It is typically

characterized by uncertainty across a number of

areas relating to identity, such as long-term goals,

friendship patterns, religious membership, moral

values, and group loyalties. Though obviously

relevant to the life experiences of many Indian

adolescents, Indian adolescent identity disorder has

yet to appear in the published literature as a formal

focus for discussion. However, this same literature

is replete with studies that address elements which

are central to identity disorder, namely self-esteem

and alienation. The missing dimension is the associated degree of functional impairment, and thus this

topic marks an area of transition from the mental

disorders to serious, but less diagnostically specifiable, problems.

For the most part, studies on self-esteem and

alienation suggest that Indian adolescents have

negative views of themselves (see table 13). However, a review by Development Associates concluded that while Indian students test at lower than

lz’1’he topic of substance use by Indians will be covered more extensively in a forthcoming paper on the physical health of Indian adolescents. cle~ly,

however, substance abuse has mental health implications.
Chupter 2-Mental Health Problems of American Indian and Alaska Native Adolescents . 23

normative levels with respect to their personal

self+ oncept, they hold their own cultural group in

high regard (76). They may characterize themselves

as being friendly, helpful, easy-going, and more

interested in happiness than in success, but not as

being particularly smart, strong, good- looking, or at

ease in front of groups. The type of school attended—

a segregated BIA school or an integrated public

school-does not appear to affect self-esteem or

sense of alienation according to Development Associates (76).

Conduct Disorder, School Dropout,

Delinquency, and Running Away

By definition, conduct disorder is almost entirely

restricted to children and adolescents.13 The essential feature of conduct disorder is “a persistent

pattern in which the basic rights of others and major

age-appropriate societal norms or rules are violated” (12). To meet the diagnostic criteria for

conduct disorder, an adolescent would have to have

a disturbance of conduct lasting at least 6 months,

during which at least 3 of 13 specified symptoms

would exist. These behavioral symptoms include

running away from home overnight at least twice,

lying often, truancy from school, the deliberate

destruction of others’ property, stealing, fighting,

and other behaviors (12).

The literature does not allow an analysis of the

incidence and prevalence of diagnosable conduct

disorder among Indian adolescents. However, studies exist concerning several of the symptoms characteristic of conduct disorder, including dropping out

of school, running away, and delinquent behavior.

These studies provide some information about the

possibility of conduct disorder among Indian adolescents. It is important to keep in mind that these are

only single behaviors and do not necessarily mean

that the adolescents involved have a diagnosable

mental disorder. Running away, dropping out of

school, and delinquent behavior may indicate that an

adolescent is experiencing emotional stress. In some

instances the behaviors involved may be a relatively

rational response to environmental problems.

School Dropout

The available literature reveals that Indian

students drop out of school at rates substantially

higher than the general population. At least 10

studies conducted since 1959 place dropout rates for

Indian students between 15 and 60 percent, whereas

the frequency of dropout in the general population

reported by the same studies ranges from 5 to 30

percent (49,63,72,76,120,309,326,320). Five regional

studies confirm these findings, although the differences between Indian and non-Indian students appeared to be negligible in two surveys of New

Mexico schools (20,66,140,280,293,358,388).

There are culture-specific factors that help to

account for Indian students dropping out of school.

Szasz (305), for example, argued that lack of

participation and failure within the educational

system---coupled with its historic failure to address

Indian cultural values and ideals-has led Indian

people to perceive schools as irrelevant. In addition,

many Indian families still function on the basis of

mutual sharing and reciprocity, wherein family

needs assume priority over personal desires and

larger societal demands. It is no accident, then, that

Indian dropouts have frequently cited being needed

at home to care for younger siblings and older family

members as a reason for leaving school (129). Other

family-related factors like mobility and instability

also contribute to Indian student dropout. Wax and

Wax (372) found a strong relationship between

dropping out and irregular employment of fathers

among Indian high school students. Brown (47)

demonstrated that the families of many Indian

school dropouts are characterized by marital conflict, divorce, unstable residence patterns, and parental alcoholism.

Delinquency

Delinquency is thought to be a large and

growing problem among Indian adolescents. There

is, however, relatively little information to substantiate this assumption.

Forslund and Meyers summarized the studies that

appeared in the 1960s and early 1970s (104). These

studies indicated that delinquency among Indian

youth was characterized by a preponderance of petty

offenses and misdemeanors. Forslund and Meyers’

own detailed analyses of available records for

lso~er dls~ptive ~havior~ disorders include attention-deficit hyperactivity disorder and oppositional defiant disorder (12). Conduct disorder is

classified as one of the disruptive behavioral disorders.
24 ● IndianAdolescent~ MentalHealth

Table Studies Generating Estimates of Self-Esteem and Alienation Among Indian Children and Adoieecents

Studya Setting Sample Method Findings

Melville, 1968 . . . . . . . Public school rural Utah

Dankworth, 1970 ..., Urban/rural public school

Washoe County, Nevada

Hoffman, 1969 . . . . . . Public school, mission

school, BIA School

(Montana, South Dakota)

Lammers, 1969. . . . . . Segregated and

desegregated public

schools, New York, NY

Corrigan, 1970 . . . . . . BIA and public boarding

school Riverside, CA

Gardner, 1972 . . . . . . . BIA school, Gila River

Reservation, AZ

Fuchs and

Havighurst, 1973. . Public school

Martig and

DeBlassie, 1973 . . . Pubficschool Tularosa, NM

Benjamin, 1973 . . . . . . Public schools and

boarding schools;

Anchorage, Beltz, Bethel

and St. Mary’s, AK

Withycombe, 1973 . . . Public schools, rural and

urban Nevada

Navajo students grades 9-

12 (n = 99)

Students in grades 7-12

(n= 178)

Male students grades 9-12

economically

disadvantaged (n= 147)

Onondaga students grades

1-6 (n= 120)

Students (BIA = 145)

(Public=106) grades 1-6

Pima students grade 4

(n= 102)

Students (n= 2,000)

69 Mescalero and 60 white

students, grades 1-4

Eskimo students, grade 9

(n= 90)

Paiute and white students

grade 1 and 5 (n = 108)

Self-concept scale

Self-concept inventory

Brownfain Self-Rating

inventory; Herriott Your

Future Plans

Self-Social Symbols Tasks

Self-Concept of Ability

Scale

Interviewer-assisted

testing; Tennessee SeifConcept Scale

Self-Esteem Inventory;

California Short Form Test

of Mental Maturity

Self-report survey

Interviewer-assisted

testing; Primary SelfConcept Scale

Self-report survev:

“This is Me” scale; Bills

index of Adjustment

Navajo ratings lower than

white ratings; no

relationship between selfconcept and achievement

Self-ratings strongly relate

to achievement

Ratings increased w/SES;

decreased with family

instability

Indian ratings equal to white

ratings

Indian students scored lower

than white norms;

significant gender

differences

Pimaratings Iowerthanwhite

and related to reading

achievement

Indian ratingsgenerally high;

self-ratings equal to white

ratings

Indian ratings equal to white

ratings; male less than

female

Mixed; high ratings on

interpersonal aspects; low

ratings on intelligence

Paiute ratings lower than

white ratings; Paiute

ratings decline with age

a~~ren~s are Iooated at end of report.

Arapaho and Shoshone youth on the Wind River

Reservation (Wyoming) revealed similar trends.

Forslund and Cranston (103) followed up with a

self-report survey among adolescents drawn horn

the same community. While youth from both Indian

and non-Indian backgrounds reported having frequently engaged in delinquent acts, there were

significant differences between Indian and nonIndian males on only 7 offenses and between Indian

and non-Indian females on only 16 offenses. Jensen,

Strauss, and Harris (148) demonstrated that factoring out alcohol-related offenses (e.g., arrests for

drunkenness)--to which Indian youth, in their data,

were three times more prone than Anglo or Hispanic

children—rendered delinquency rates comparable

across different populations.

May’s (202) analyses of BIA law enforcement

data from the Albuquerque Area are consistent with

earlier findings from the Wind River Reservation. In

1982, the most frequent causes for arrest were

disorderly conduct (25.9 percent), liquor law violations (11.2 percent), curfew violations (9.8 percent),

drunkenness (9.6 percent), and running away from

home (6.6 percent). Fifty-eight percent of juvenile

arrests were for alcohol use: 63 percent for males and

37 percent for females.

Running Away

Runaway Indian youth are reportedly a growing problem and have captured recent interest. Data

are relatively sparse, however, reflecting the difficulty in identifying and reaching this population.

In an extensive study, the Indian Center, Inc., of

Lincoln, Nebraska, and the Department of Sociology

at the University of Nebraska (143) collaborated in

a survey of 120 runaway Indian adolescents and 91

of their parents. In this survey, the typical runaway

was female (53 percent), 15 years of age, in the 8th

grade (although 46 percent had been expelled or

suspended and another 20 percent had dropped out
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 25

Table 13-Studies Generating Estimates of Self-Esteem and Alienation Among

Indian Children and Adolescents-Continued

Study a Setting Sample Method Findings

Rosenthal, 1974 . . . . . Community-wide Lac du

Flambeau, WI

Thornburg, 1974 . . . . . Public school rural

Arizona

Lefley, 1974 . . . . . . . . . Tribal school Miccoskkee

and Seminole, FL

Ross, 1975 . . . . . . . . . Public school, BIAschool;

on/off reservation Navajo

Nation

Beuke, 1978 . . . . . . . . Public school

northeastern Arizona

Howell, 1979 .., . . . . . Public School Denver, CO

McClary, 1979 ...., . . Public school Buffalo, NY

Holmgren, 1981 . . . . . Public school Wyoming

Sampson, 1981 . . . . . Public schools; urban and

rural

Development

Associates, 1983 . . Schools nationwide

Chippewa; age range 3-10

years

Students (n= 265) grade 9

Miccosukee and Seminole

students; grades 1-6; age

range 7-14 years; average

age = 10 (n = 72)

Navajo students, grades

7-8

Students grades 5-8

(n =574)

Students grades 1-6

(n =132)

Students grades 9-1 2;

average age = 16 (n = 63)

Students Arapaho,

Shoshone, grades 9-12

(n= 114)

Students Lumbee, Black,

Puerto Rican and white;

grades 3-12 (n= 908)

Students grades 4-12

(n= 12,000)

Interviewer

administered picture

identification test

Self-report survey;

Tennessee SelfConcept Scale

Piers-Harris Children's Self--

Concept Scale

Michigan State SelfConcept of Academic

Ability

Self-Esteem Inventory

Interviewer-assisted selfreport; Self-Esteem

Inventory

Bills Index of

Adjustment

Alienation Scale

Self-Concept Inventory

1 O-item self-esteem and

academic self-concept

Chippewaratings lower than

white and black ratings

Indian ratings lower than

Black or Mexican-American

ratings

Indian ratings lower than

white ratings; related to

acculturation

Ratings more frequently

positive than negative;

significant difference by type

of school

Indian ratings lower than

white ratings

Indian ratings lower than

Black and Hispanic ratings

Indian ratings lower than

white ratings

Indian ratings lower than

white ratings; related to

drinking

No differences by ethnicity;

rural Indians higher than

urban Indians

Ratings generally high

aReferences are located at end of report.

80URCE: Office of Technology Assessment, 1990.

of school), living at home (62 percent) with both

parents (83 percent); and had at least three siblings.

Her father was either unemployed (21 percent) or

underemployed (23 percent) and on public assistance (16 percent). Her mother was either unemployed (26 percent) or underemployed (17 percent)

and on public assistance (46 percent); was not a

native language speaker (90 percent); and did not

come from a traditional family background (71

percent).

According to the study authors, these runaway

Indian youth in many ways are comparable to

runaway youth in general. The majority of the

adolescents in the Indian Center study had run away

from two to five times (50 percent); 9 percent had

runaway more frequently. While almost one-third

stayed away from home only 1 day the most recent

time out, nearly half stayed away from 2 to 10 days.

The remainder were gone even longer. Fifty-six

percent of the runaway Indian youth stayed within a

10-mile radius of home, while a relatively small

number (15 percent) traveled more than 50 miles

away. Most stayed with a relative (36 percent) or

friend (53 percent). Only 1 percent stayed in a

shelter; another 1 percent stayed in a group home, 3

percent lived in the streets, and 1 percent spent some

time in jail. Adolescents in the study almost never

sought or received assistance from the police, legal

services, child protective services, runaway hot

lines, counseling, the clergy or other spiritual

leaders, local Indian centers, or drug or alcohol

programs. As one might expect, age (16 and older)

was strongly and positively related to the frequency,

duration, and distance of running away as well as to

the likelihood of using public services.

Conflict with parents and home-related problems

were the predominant causes of running away but

some have run away because of school difficulties

and other problems (table 14). Older respondents

were more likely to run away because of problems
26 ● Indian Adolescent Mental Health

Table 14-Reasons Given By Indian Adolescents

for Running Away (n= 120)

Reasons Percentage

School performance:

Poor attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kicked out of school . . . . . . . . . . . . . . . . . . . . . . . . .

Problems with the teacher . . . . . . . . . . . . . . . . . . .

Bad grades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other school problems . . . . . . . . . . . . . . . . . . . . . .

Family problems:

Argumentswith parents . . . . . . . . . . . . . . . . . . . . . .

Can’t talk to parents . . . . . . . . . . . . . . . . . . . . . . . . .

Parents’ problems with alchohol or drugs... . . . . .

Parents too strict . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sibling problems. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neglected by parents . . . . . . . . . . . . . . . . . . . . . . . .

Abused by parents . . . . . . . . . . . . . . . . . . . . . . . . .

Parents divorce. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Parents kicked youth out of home..... . . . . . . . .

Domestic violence . . . . . . . . . . . . . . . . . . . . . . . . . .

Sexual abuse by parents. . . . . . . . . . . . . . . . . . . .

Want to live with other parent . . . . . . . . . . . . . . . . . . . .

Other home problems . . . . . . . . . . . . . . . . . . . . . . . . . .

Youth in trouble with law . . . . . . . . . . . . . . . . . . . . . . . .

Youth in trouble with peers . . . . . . . . . . . . . . . . . . . . . .

Alcohol or drug problem . . . . . . . . . . . . . . . . . . . . . . . .

Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Friend ran away. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Feared consequences of misbehaving . . . . . . . . . . . .

Other personal problems . . . . . . . . . . . . . . . . . . . . . . . .

17

9

7

5

23

38

29

21

19

12

8

8

6

5

4

1

12

29

12

10

15

6

15

12

13

SOURCE: lndian CenteL inc., Lincoln, K,and University of Nebraska,

Lincoln, Department of Sociology, Bureau of Sociological

Research,’’TheNativeAmerican Adolescent Research Project:

Reporton lnterviewSurveysof Runaways,Parents,Community

Leaders and Human Service Workers:’ unpublished report,

Lincoln, l$E, July 19S6.

withtheirsiblings. Males weremore likelytoreport

legal problems or trouble with alcohol and drugs,

while females more often indicated that they ran

awaybecauseafriendhada.lsorun away.Comparisons between youths who had run away only once

and those who frequently did so revealed that the

latter were more likely to mention parental strictness, arguments with parents, not being ableto talk

to parents, andparenta.1 alcohol and drug abuse.

While away from home, the following problems

were most frequently encountered: lack of money

(47 percent); lack of clothing (35 percent); lack of

transportation (18 percent); trouble finding work (17

percent); getting into trouble with the law (10

percent); and alcohol and drug problems (10 percent). Physical and sexual abuse, loneliness, illness,

absence of other Indian people, inability to contact

family, and racial discrimination were seldom mentioned, and usually only by older adolescents who

had been farther and longer away from home.

In returning home, most of the runaway Indian

youths surveyed indicated that the problems which

led them to leave were still present. Few (17 percent)

reported using services that might help them cope

more effectively with these stresses.

The authors concluded that since the vast majority

of runaway Indian youth stay with friends and

family, resources should be redirected from shelters

and other public services to those who actually

shelter them.

ENVIRONMENTAL RISK

FACTORS FOR MENTAL HEALTH

PROBLEMS

A wide range of stressors contribute to mental

health problems among Indian adolescents. Many

Indian communities experience high rates of unemployment, poverty, alcohol abuse, physical illness,

and death (322). These problems have been associated with mental health problems of children and

adolescents (323). This section discusses the prevalence and consequences of several environmental

risk factors as discussed in the Indian health

literature. These include: otitis media, fetal alcohol

syndrome, child abuse and neglect, parental alcoholism, family disruption, and school problems. In

addition, Indian adolescents have recently been

asked about the extent to which they experience

stress, both relative to specific life situations and

generally; these data are also reported.

Physical Disorders

Otitis Media

Otitis media (middle ear infection) is widely

regarded as the most frequently-identified disease of

Indian children. Its special significance for adolescent mental health lies in the learning and developmental consequences that may follow from subsequent mild to moderate hearing loss (218,220).

Otitis media is most prevalent from birth to

approximately 7 years of age (142,215), which

coincides with critical periods in language acquisition. Considerable evidence has been amassed that

demonstrates the contribution of otitis media to

hearing loss (17,96,247), delays in cognitive and

psycholinguistic development (159,157,389), low-
Chapter 2--Mental Health Problems of American Indian and Alaska Native Adolescents . 27

ered educational achievement (83,107,219,319), and

reading problems and emotional difficulties (32,295).

The potential scope of these problems is reflected in

estimates that as many as 75 percent of all Indian

children experience otitis media, that 13,000 Indians

are in need of hearing aids, and that as many as

22,000 may require otologic surgery (296).

Fetal Alcohol Syndrome

No review of environmental risk factors is

complete without considering Fetal Alcohol Syndrome and Fetal Alcohol Effects and their potential

for engendering neurosensory and developmental

disabilities. The pioneering work in this area was

conducted by May and his colleagues (207,208). In

a detailed comparative analysis of selected IHS

service units and reservations on which there was

adequate case-finding, May and his colleagues

found that one group of Indians had a higher

incidence of FAS than any that had been reported

previously. Two other Indian groups had lower rates,

comparable to those reported in samples in Seattle,

Sweden, and France, but the incidence appeared to

be growing. Of all the fetal alcohol children, 73

percent had been adopted or placed in foster homes

because of abandonment or neglect by their natural

mothers. Twenty-three percent of biological mothers had died, almost always from an accident,

cirrhosis of the liver, or other alcohol-related trauma

and illness.

One unanticipated finding noted by May and his

colleagues was the relatively small number of

mothers responsible for the prevalence of FAS and

FAE. This finding suggests that prevention can be

targeted to high-risk mothers.

Child and Adolescent Abuse and Neglect

Child and adolescent abuse and neglect is of

increasing concern in Indian communities (327).

The mental and emotional health of adolescents can

be affected by abuse and neglect because they

themselves are abused and neglected, or because of

lasting emotional scars from abuse and neglect in

their earlier years. There is wide variation in

estimates of the prevalence of child and adolescent

abuse and neglect (see table 15). At present, it is

unclear whether this variation is due to widely

divergent definitions of the phenomena. to differential reporting methods, or to true epidemiologic

differences that reflect the particular stresses and

strains of local communities14 (383).

Not surprisingly, a review of medical records of

hospitalized children found the lowest rate of abuse

and neglect (5.7 per 1,000 population [99]); few

abused and neglected children are hospitalized.

Recent data indicate that more than 6,500 referrals

for suspected child abuse and neglect were made to

BIA in fiscal year 1988 (360). Eighty-one percent

(5,338) of the referrals were substantiated within the

year. The BIA data underestimate the extent of abuse

and

●

●

●

neglect of Indian children for several reasons:

Referrals to BIA do not represent all cases. In

some States (e.g., Alaska and California), State

social service agencies rather than BIA may

play a central role in handling suspected Indian

child abuse and neglect cases.

There is no mechanism for formal and systematic reporting of child abuse and neglect cases

to BIA or tribal contract social services programs.

These data do not include urban Indians.

Nevertheless, these data reflect that a minimum of

1 percent15 of Indian children in BIA service areas

may have been abused or neglected in a single year.

Self-reports by Indian adolescents bear out these

estimates. In the IAHS survey, 8.3 percent of male

and 24 percent of female 7th- to 12th-graders

reported that they had been abused physically,

sexually, or both at some time in their lives (table 16)

(366). Minnesota students were much less likely to

report either physical or sexual abuse but were more

likely than Indian adolescents to indicate that they

had ever discussed the abuse (table 17). The students

were not asked whether they had been neglected.

Risk Factors for Abuse and Neglect

Causes of child abuse and neglect in Indian and

Native communities span the full spectrum of

possibilities. Interpersonal conflict, marital disruption, parental alcoholism, inadequate caregiver- . —

14The issue of what constitutes child abu~ and neglect in Indian communities has engendered a great deal of debate. Korbin ( 168) hti suggested hat

it be defined as ‘‘the idiosyncratic depmw from cultur~ly and socially acceptable standwds (of childreting) that result in harm to a child or

compromises his/her physical, emotional, cognitive, social, or cultural development. This view has found considerable currency in recent studies among

Indians (98,186). However, regardless of the prewnt differences in definition, there seems to be no question that, in virtually every report, the rates of

child abuse and neglect among Indian communities equal or exceed those of their non-Indian counterparts,

tSRate b- on estimated IHS child service population of 3%’,065.
28 ● Indian Adolescent Mental Health

Table 15-Studies Generating Estimates of Abuse and Neglect Among Indian Children and Adolescents

Studya Setting Sample Method Findings

Jones, 1969 . . . . . . . . .

Wichlacz, Lane

and Kempe, 1978 :.

White and Cornley,

1981 . . . . . . . . . . . . .

Fischler, 1985 . . . . . . .

Hauswald, 1987 . . . . .

Lujan, DeBruyn, May,

et al., 1989 . . . . . . .

. . . . . — Participant observation;

records review

Native village (Alaska) 1/3 of all children

Cheyenne River Sioux

Navajo Nation human

service agencies

IHS hospital (San Carlos)

Navajo Nation

Sante Fe IHS Hospitals,

Entire Alaskan village

(n= 201)

65 reported cases; average

age = 4.5 years old

Clients under 9 years old

Service population

(N= 6,000)

Mothers in 110 normal and

problem families in Fort

Defiance and Chinle

agencies

53 reported cases; age

range O to 21 years old,

median age 10 years old

1,155 children in mental

health treatment, in need of

same or abused or

neglected; age range O to

18 years old; average age

= 13 years old

Register of suspected

cases

Rate 26 per 1,000

Service utilization

review

Medical chart review;

staff survey

Ethnography; agency

reports

Rate 13.5 per 1,000

Rate 5.7 per 1,000

Rate 13.5 per 1,000

Hospital records review Frequent co-occurrence of

abuse and neglect; related

to family disruption

NM

Piasecki, Manson, Hiat,

et al., 1989 . . . . . . . Albuquerque and

Phoenix IHS Service

Area

Key informant

interviews of Federal

human service

providers

670/! had experienced

abuse or neglect; more

girls than boys; strong

relationship to family

stability; associated with

more psychiatric

symptoms, substance use,

delinquency

University of

Minnesota, IAHS,

1989 . . . . . . . . . . . . . Schools (Plains, 7th-1 2th graders

(n= 2,700)

IAHS 8.3?4. of males, 24.0% of

females report being

abused physically,

sexually, or both

Southeast, Southwest)

Plantz, Hubbell, Barrett,

et al., 1989 . . . . . . . BIA service areas nationwide, except for “280”

States

All referred cases Report of referred

cases

Referrals; 58°/0 of

investigated cases

substantiated

aReferen~s are located at end Of report.

SOURCE: Office of Technology Assessment, 1990.

child bonding, severe educational deficits, chronic

physical illness, unemployment, and violent death

are common among the families of abused and

neglected Indian children (99,147,237,380,382). In

this respect, the dynamics probably mirror those of

families in general (60,135). Contributors more

specific to Indian communities include stresses

resulting from rapid sociocultura1 change, gender

role changes, failed parenting skills, the changing

nature of the extended family, and special risks

attached to boarding schools (27,1 19,133).

neglect had experienced a higher frequency of each

disruptive event except having a single parent.

It is not surprising that, in this study, more Indian

children residing with foster or adoptive families

had had histories of abuse and/or neglect than their

counterparts who lived either with parents or in such

institutional settings as boarding schools. In both

Indian and non-Indian communities, child abuse and

neglect are common reasons for out-of-home placement. The troublesome aspect of these findings lies

in the observation that, at the time of the survey, 61

percent of the children with histories of abuse and/or

neglect resided within the familial households that

likely gave rise to these conditions. Several recent,

highly publicized cases of sexual abuse in BIA

schools, such as the 1980 and 1987 incidents at

In the Piasecki et al. (251) survey (see table 15),

children with histories of abuse or neglect were more

likely to have experienced parental alcoholism,

divorce, single parenting, or a chaotic family situation. Children with histories of both abuse and
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 29

Table 16-Percentage of Indian Adolescents

Who Indicated Ever Being Abused by Family

Members or Othersa

Table 17—Percentage of Indian and Minnesota

Adolescents Who Indicated Ever Being Physically

or Sexually Abused

Both

physical

Physical Sexual and

Region only only sexual

Total IAHS subsample:

Males (n= 1,297) . . . . . . . . . 6.0% 1 .1% 1 .2%

Females (n= 1,360) . . . . . . . . . 9.9 6.3 7.8

Plains subsample:

Males (n = 529) . . . . . . . . . . 5.7

Females (n = 565) . . . . . . . . . . 11.5 5.5 8.2

Southwest subsample:

Males (n= 564) . . . . . . . . . . . 6.2 1.6 1.5

Females (n = 575) . . . . . . . . . . 9.4 6.8 6.6

Southeastern subsample:

Males (n = 204) . . . . . . . . . . 6.0 0.7 2.2

Females (n = 200) . . . . . . . . . . 6.3 7.4 9.7

a

ltems were:

Have you ever been physically abused or mistreated by anyone in your

family or by anyone else?

Have you ever been sexually abused? Sexual abuse is when someone in

your family or someone else touches you in a place you did not want to be

touched or does something sexually which they shouldn’t have done.

SOURCE: University of Minnesota, Adolescent Health Program, Indian

Adolescent Health Survey, unpublished preliminary data, 1989.

Navajo and Hopi, respectively, indicate, however,

that home is not the only arena in which Indian

children are at risk for abuse (327).

Consequences of Abuse and Neglect

Children who have been abused and/or neglected exhibit behavioral, social, developmental,

and cognitive deficits when compared to children

who have not experienced abuse or neglect

(48,94,121,174,198,312). Results from studies using

clinical samples are mixed, however, with respect to

whether and how abused and neglected children

suffer from different or more severe mental disorders

than other non-abused, but emotionally disturbed

children (56,160,230; 268). Monan, Leichter, and

Lewis (230) indicated that abused and/or neglected

children did not differ diagnostically from other

emotionally disturbed children, except that the

abused and neglected children were more violent.

The study by Carmen, Rieker, and Mills (56) found

no differences between the diagnoses assigned

psychiatric inpatients with and without abuse histories. However, female patients who had been abused

were more self-destructive than nonabused females

and abused males were more aggressive than nonRegion Phvsical Sexual Both

IAHS subsample:

Males (n= 1,297) . . . . . . . . . 6.00/0 1 .1% 1 .2%

Ever discuss . . . . . . . 44.2 34.7 N/A

Females (n= 1,360) . . . . . . . . . 9.9 6.3 7.8

Ever discuss . . . . . . . 60.4 15.6 N/A

Minnesota AHS:

Metro males (n = 12,155) . . . 5.1 2.1 N/A

Ever discuss . . . 58.0 49.5 N/A

Rural males (n = 6,300) . . . . 4.2 1.7 N/A

Ever discuss . . . 50.2 40.0 N/A

Metro females (n = 11 ,538) . . . 14.5 15.5 N/A

Ever discuss . . . 71.2 62.6 N/A

Rural females (n = 282) . . . . . . 11.5 13.2 N/A

Ever discuss . . . 65.7 57.8 N/A

SOURCES: IAHSsubsample: University Minnesota, Adolescent Health

Program, Indian Adolescent Health Survey, unpublished

preliminary data, 1989; Minnesota AHS: University of Minnesota, Adolescent Health Program, Minnesota Adolescent

Health Survey, unpublished data, 1987.

abused males. Kazdin and his colleagues (160)

found that physically abused subjects (ages 6 to 13)

showed greater depression and hopelessness than

the non-abused controls, but only on self-report

measures, not diagnostically. Rogeness, Amrung,

Macedo, et al. (268) reported increased conduct

disorder in abused or neglected boys and in abused

girls, and more borderline, conduct, and concentration symptoms in abused or neglected children than

in non-abused, non-neglected children.

Data from the Piasecki et al. study are consistent

with previous findings that children who have

experienced abuse only or neglect only do not differ

psychiatrically from those who have experienced

neither abuse nor neglect. But, those children who

suffered both abuse and neglect did evidence greater

frequencies of symptoms of mental health problems

than any of the other children. In addition, they were

more likely to have been expelled from school or run

away from home.

Students responding to the IAHS who had been

abused were more likely to be more worried about

abuse, to feel depressed, to feel in poor or fair health,

to perform below average in school (males only),

and to have engaged in the risk behaviors of sexual

intercourse, l6alcohol and marijuana use, and attempted suicide (table 18).

16This may & a misinterpretation, because the sexual abuse may have involved forced sexual intercourse. Thus, the sexual intercourse could not

properly be considered a risk behavior of the adolescent. However early voluntary sexual intercourse maybe a consequence of childhood sexual abuse

(264,271). Evidence also shows that sexually abused children may later experience feelings of increased vulnerability, stress, and sexual dysfunction

(264,332).
30 ● Indian Adolescent Mental Health

Table 18-Covarlation of Abuse With

Behavioral Risk Factors and Stress

Percentwhoexperienced

or did not

experience abuse

Males Females

Worry about abuse from parents:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Worry about being forced to do

something sexual:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Ever had sexual intercourse:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Feeling depressed in last month:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Ever drink beer/wine:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

At least weekly use of beer/wine:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Ever smoke marijuana:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

At least weekly use of marijuana:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Feel in poor or fair health:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Ever attempted sucide:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

Perform below average in school:

Both physical & sexual abuse . . . . . . .

Physical abuse only . . . . . . . . . . . . . . .

Sexual abuse only . . . . . . . . . . . . . . . .

No abuse . . . . . . . . . . . . . . . . . . . . . . .

20.0%

18.1

34.5

13.3

22.0

16.9

21.8

12.7

40.0

39.1

33.9

25.9

32.7

21.9

22.4

14.5

72.2

65.4

57.1

55.8

18.5

19.1

12.5

12.4

57.4

46.1

35.1

37.3

18.6

18.5

14.1

10.4

33.6

21.8

19.0

17.5

41.7

22.2

30.6

9.5

18.5

15.6

22.4

11.2

36.1%

35.5

31.3

23.6

41.2

30.0

35.8

27.8

49.8

34.5

36.0

14.4

32.6

27.3

17.2

15.4

72.0

66.4

66.8

48.8

12.6

13.1

12.6

7.8

47.6

45.1

37.8

29.0

10.3

11.7

10.1

6.9

37.8

26.4

27.2

19.9

43.0

35.2

22.7

13.8

11.0

13.6

12,8

10.0

SOURCE: University of Minnesota, Adolescent Health Program, Indian

Adolescent Health Survey, unpublished preliminary data, 1989.

Thus, the abuse and neglect of children and

adolescents deserves preventive intervention, if

possible, and intervention with the victim if prevention efforts are not successful.

Parental Alcoholism

The extent of alcohol abuse in Indian communities is of longstanding concern (322). Alcohol use is

implicated in many of the major causes of morbidity

and mortality for Indians. Recently, a total of 22.5

percent of Indian adolescents surveyed perceived

that their parents had a drinking problem (366). This

compares to 14 percent of Minnesota adolescents

who were asked a similar question (364).

Family Disruption

Family disruption may, of course, be related to

parental (or adolescent) alcoholism, poverty, unemployment, physical illnesses, or all of the above. It

can result in mental health problems for adolescents

(323). Two recent surveys found substantial evidence of family disruption among Indian adolescents.

Compared to Minnesota students, Indian students

reported that their biological parents were less likely

be living together (64 v. 49 percent), and, not

surprisingly, more likely to be divorced or separated

(22 v. 34 percent) (table 19). Perhaps most disturbing, 12 percent of Indian adolescents reported that

one or both parents were dead, compared to approximately 3 percent of Minnesota students reporting

Table 19-Status of Biological Parents and Living

Arrangements of Indian and Minnesota Adolescents

Biological Parental status

Percent

total IAHS Minnesota

(n= 2,672) (n= 36,284)

Living together . . . . . . . . . . . . 49.3% 64.00/0

Divorced or separated . . . . . . 12.2 22.0

One/both parents dead . . . . . 4.7 3.0

Don’t know . . . . . . . . . . . . . . . 4.7 2.0

Students’ living arrangements

IAHS Minnesota

Single parent household . . . . 39.770 16.8Y0

Two parents/blended . . . . . . . 39.8 80.3

Other . . . . . . . . . . . . . . . . . . . . 20.5 2.9

SOURCE: Indian student data: University of Minnesota, Adolescent

Health Program, Indian Adolescent Student Health Survey,

unpublished preliminary data, 1989; Minnesota biological

parent status data: Minnesota Department of Education,

Minnesota Survey Report, unpublished data, 1989; Minnesota

student living arrangement data: University of Minnesota,

Adolescent Health Program, Minnesota Adolescent Health

Survey, unpublished data, 1987.
Chapter 2-Mental Health Problems of American Indian and Alaska Native Adolescents ● 31

such a tragedy. As a consequence, Indian adolescents were more than twice as likely to report living

in a single-parent household, and almost 10 times as

likely to report living without a parent as the

Minnesota students.

Although they did not compare Indian students’

sources of stress with those of non-Indian students,

recent surveys by the NCAIANMHR found that 75

percent of Indian students in either universities,

tribal boarding schools, or BIA boarding schools had

experienced stress as a result of personal problems

of family members, the death of a relative, the health

of a close family member, or bad news from home.

School Environment

The world of school constitutes one of the most

important environments in an adolescent’s life.

Perhaps second only to family, it is in the school

environment where children learn the socialization

skills necessary for life. While the manifest purpose

of schools is to educate, they also are the main social

arena for youth of all ages. It is in this arena where

peer pressure to conform builds. The following

section profiles how American Indian adolescents

see their school environments.

Students completing the IAHS and Minnesota

Adolescent Health Survey were asked a series of

questions about how much certain behaviors go on

in and around their school (table 20). Alcohol

consumption is seen as the most frequently occurring behavior for both Indian and Minnesota students, although rural Minnesota youth saw drinking

behavior going on more than either metropolitan

Minnesota or Indian students. On the other hand,

Indian students were much more likely to indicate

that students were using drugs, destroying property,

getting into fights, and stealing.17

Contrasting Indian students by geographic/tribal

afllliation shows that Plains adolescents are more

likely to see drinking, fighting, and drugs as more

common in their environment (see table 21). Perceptions of somewhat lower alcohol usage by Southeast

Indian adolescents is probably reflective of restrictive liquor laws in the area around the reservation.

Southeast students differed in drug use, they were

much more likely to perceive that students were

sniffing substances (glue, paint, liquid paper, etc.)

than students elsewhere but less likely to perceive

the use of other drugs. Fights are more likely to be

perceived by Plains students; this may be reflective

of the level of alcohol usage.

The series of studies in three different types of

institutions by NCAIANMHR that asked about

sources of family-related stress also asked students

about school-related stress. As shown in table 22,

school pressures were a substantial source of stress

for students. School-related problems were more

common among the college sample, perhaps because of the greater commitment required and close

ties between academic performance and financial

issues. Indian adolescents in high school were more

likely to identify concerns about families and

friends. Comparisons to data reported for their

Anglo, middle-class counterparts (84) indicate that

many more Indians report having had these kinds of

stressful experiences and found them of equal or

greater concern.

Other Life Stressors

In addition to the stressors of specific life

situations such as physical handicaps, family disruptions, and school, stress can be measured by asking

questions about general well-being. While not always more commonly than their non-Indian counterparts, a substantial minority of Indian respondents

reported to the IAHS experiencing extreme stresses

and strains, dissatisfaction with their personal lives,

and feeling tired and worn out (table 23). Indian

students were twice as likely as Minnesota students

to feel that life was uninteresting and to feel

emotionally insecure, with almost one-half of Indian

adolescents reporting these feelings.

CONCLUSIONS AND POLICY

IMPLICATIONS

As may be apparent from the foregoing discussion, making sense of the current mental health

status of American Indian and Alaska Native youth

is not unlike trying to sew a large, predesigned quilt

from pieces of cloth that vary in size, shape, texture,

and color. Clearly, many Indian children and adolescents live under stress. Many experience mental

health problems, at rates that usually exceed their

mainstream counterparts. Yet anecdotal evidence

ITSome of the differences between perceptions maybe due to a slightly younger sample of Indian youths, with nearly 56 percent be@ 14 @ ~der

compared to approximately 42 percent for Minnesota youth. Preliminary analyses of Minnesota data suggest that stealing, fighting, and vandalizing

behaviors were more likely to occur with students in junior high.
32 ● 1ndian Adolescent Mental Health

Table 20-Perceptions of School Environments by Indian and Minnesota Students

Percent responding quite a bit or very much

Indian students Minnesota metro students Minnesota rural students

Perceived other students: Males Females Males Females Males Females

Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 .80/0 50.20/. 45.30/0 48.50/0 55.7% 62.60/o

Using drugs ., . . . . . . . . . . . . . . . . . . . . . . . . . . 29.1 34,1 21.7 26.3 12.0 14.5

Sniffing glue, paint, liquid paper, etc. . . . . . . . 17.0 19.8 —

Destroying property . . . . . . . . . . . . . . . . . . . . .

— — —

23.0 27.8 18.0 18.8 15.2 14.1

Getting into fights . . . . . . . . . . . . . . . . . . . . , . . 37.7 45,3 24.3 25.5 20.5 20.7

Stealing things . . . . . . . . . . . . . . . . . . . . . . . . . . 29.3 28.9 22.9 21.9 18.7 18.3

SOURCES: Indian student data: University of Minnesota, Adolescent Health Program, Indian Adolescent Health Survey, unpublished preliminary data,

1989; Minnesota metro and rural student data: University of Minnesota, Adolescent Health Program, Minnesota Adolescent Health Survey,

unpublished data, 1987.

Table 21—Perceptions of School Environments by Southwest, Plains,

and Southeast Indian Students

Percent responding quite a bit or very much

Perceived other students: Total Southwest Plains Southeast

Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.17. 39.4% 58.6% 30.l%

Using drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.6 34.2 37.9 6.7

Sniffing glue, paint, liquid paper, etc. . . . . . . . . . . . . . . . . . . . 18.4 10.8 12.2 56.5

Destroying property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.4 26.2 27.2 18.1

Getting into fights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.6 31.1 54.7 32.0

Stealing things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.6 28.8 31.2 30.2

SOURCE: University of Minnesota, Adolescent Health Program, Indian Adolescent Health Survey, unpublished preliminary data, 1989.

Table 22-School Pressures Experienced as Stressful by Indian Students

Tribal BIA

Universities boarding school boarding school

Receiving a D or F on a test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xa x x

Personal Pressure to get good grades . . . . . . . . . . . . . . . . . . . . . . . . x x x

Pressure to get an A or B in a course . . . . . . . . . . . . . . . . . . . . . . . . . x x x

Fear of failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x x x

Failing to complete assignments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x x x

Studying for a test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x x x

Taking a test a class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x x x

Difficulty getting motivated for classwork . . . . . . . . . . . . . . . . . . . . . . x x x

Completing a term paper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x x

Conflict between my goals and those others have for me . . . . . . . . x x

Giving a class presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

—

x

Fear of failure to meet family expectations . . . . . . . . . . . . . . . . . . . .

— —

x

Deciding what to do after graduation . . . . . . . . . . . . . . . . . . . . . . . . . —

— —

x x

Not enough recreational activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . — x x

Students gossiping and spreading rumors . . . . . . . . . . . . . . . . . . . . . — x

Being so far from family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —

—

x

Being written up forincidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —

—

x

Serving restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —

—

— x

a“x” indicates that 75 percent of the students surveyed responded that they had both experienced the event and found It to be stressful to some degree.

SOURCES: National Center for American Indian and Alaska Native Mental Health Research, college student Life Transitions Project, unpublished

preliminary data, 1989; National Center for American Indian and Alaska Native Mental Health Research, Indian Boarding School Project, unpublished

preliminary data, 1989.
Chapter 2--Mental Health Problems of American Indian and Alaska Native Adolescents . 33

Table 23--General Well-Being and Stress Among Indian and Minnesota Adolescents

IAHSa Metro Minnesota Greater Minnesota

Males Females Males Females Males Females

(n= 1,297) (n= 1,360) (n= 12,155) (n= 11 ,538) (n= 6,308) (n= 6,282)

Percent responding quite a bit or very much to:

In the last month have you felt:

Extreme stresses and strains ., . . . . 18.30/~ 23.90/o 27.30/o 28.30/. 22.50/o 23.2%

Dissatisfied with personal life . . . . . . 18.3 23.8 22.4 25.2 21.9 22.7

Life was uninteresting . . . . . . . . . . . . 45.4 40.8 19.8 21.4 23.4 22.7

Not feeling emotionally secure. . . . . . 43.0 42.9 19.3b 19.7b

Tired, worn out . . . . . . . . . . . . . . . . . . 23.3

— —

30.9 24.5 26.4 22.2 23.5

alndian Adolescent Health sUtVey.

bM~eS and females combined.

SOURCE: lndlan student data: University of Minnesota, Adolescent Health Program, Indian Adolescent Health Survey, unpublished preliminary data, 1989;

Mlnnoaota atudont data: University of Minnesota, Adolescmt Health Program, Minnesota Adolescent Health Survey, unpublished data, 1987.

indicates that many Indian youth thrive psychologically despite these circumstances. Unfortunately,

the present knowledge base and means of adding to

it lag far behind the desire to appropriately target,

deliver, and extend needed treatment and preventive

interventions. Almost every report on the mental

health status of Indian children and adolescents has

reached the same conclusion: systematic procedures

for gathering basic epidemiologic and patientcentered service utilization data are nonexistent and

the lack thereof cripples thoughtful and effective

planning (123,28,29,205,235). This section discusses what could be done to improve the availability of information about Indian adolescents’ mental

health. Chapter 3, which follows, charts the services

available to treat and prevent Indian adolescents’

mental health problems.

Several courses of action maybe taken to remedy

the lack of information. These include: 1) establishing patient-centered, diagnosis-sensitive data systems that link different service agencies; 2) developing surveillance units within existing service agencies; and 3) conducting a national community-based

epidemiologic study of child and adolescent mental

health problems.

Patient--Centered Data Systems

The IHS relies on service utilization data to

estimate the mental health needs of Indian communities. A number of computerized reporting systems

are currently in use by tribes and the IHS but they are

not used consistently across tribes or IHS service

units. The two most common are the Ambulatory

Patient Care (APC) system and the Patient Care

Information System (PCIS). The APC system uses a

list of 11 categories of mental disorders and three

categories of neurological disorders on a checklist

form. These classifications encompass the general

categories of neuroses, schizophrenia and other

psychoses, organic brain syndromes, personality

disorders, etc. In addition to not conforming to

modern diagnostic terminology, they do not allow

for more specific coding of mental health problems,

especially those relevant to children and adolescents.

Three of the 12 IHS Area and Program Offices—

Alaska, Tucson, and Billings—utilize PCIS. This

system employs diagnostic coding from the International Classification of Diseases, 9th rev. (ICD-9)

(338). However, the strengths of the PCIS are

tempered by inadequate field staff training and

continued reliance on program contacts rather than

individual patients. Recognizing these limitations,

the IHS has formed a task force to revise its patient

information systems. Though planning in regard to

medical diagnostic codes has proceeded fairly swiftly,

numerous questions remain with respect to mental

health problems. Considerable debate has arisen

over nomenclature and coding procedures. Current

estimates by IHS administrators are that an operational system for systematically coding and recording mental health problems in general will be in

place in 1994.

An additional problem has arisen with the advent

of yet a different IHS patient information system.

The Alcohol Treatment and Guidance System (ATGS)

was introduced in 1980 and fully adopted 3 years

later as a means of monitoring IHS and tribal alcohol

treatment and prevention programs. It is designed to

provide information about treatment activities, training needs, client progress, and program effectiveness. The ATGS consequently offers a rich and
34 . Indian Adolescent Mental Health

potentially useful database which, to date, remains

virtually unexamined. It is hoped that ATGS will

soon be used to generate estimates of “treated”

prevalence, of the proportions and types of services

delivered to youth, and of their efficacy. These data,

however, are not linked with either medical or

mental health records, thereby frustrating attempts

to discover possible relationships among these

different illnesses and systems of treatment. This

latter point is particularly important in light of May’s

(205) demonstration that significant quantities of

IHS medical and mental health services are consumed by individuals suffering from alcoholism.

Social service, special education, law enforcement, and child welfare data, which may be compiled by the BIA, local tribes, and urban Indian

health care programs, are rarely computerized. For

example, the BIA has only recently initiated computerization of data pertaining to the use of its social

services. Psychoeducational evaluations, often conducted routinely by psychologists and social workers in BIA schools, are seldom accessible in any

systematic fashion. Urban Indian health care programs do not employ a common means of recording

and reporting mental health problems.

One of the first challenges is to upgrade the IHS

patient information systems with respect to diagnostic sophistication, relevance to the mental health

problems of children and adolescents, caseorientation, and linkage across different systems of

care. The information systems for other agencies are

far less advanced and will require much greater

effort to move in the same direction.

Surveillance Units

The development ot these information capabilities ought to be accompanied by the establishment of

surveillance units within each agency. Such units

should be charged with the analysis of the resulting

data to inform program planning. Products could

include “treated” prevalence and incidence rates of

select mental health problems among Indian adolescents, patterns of risk among adolescents in treatment, descriptions of the types and quantities of

services used, identification of “high” users of

services, and evaluations of treatment effectiveness.

None of this information is currently available.

Epidemiologic Data

The mental health problems of Indian adolescents

can only be partially understood from service

utilization data. Numerous biases affect who seeks,

obtains, or is identified as needing treatment. Such

factors include cultural acceptability, accessibility,

staff skills and training, as well as program history.

Consequently, the insights generated by program

information systems must be supplemented by

community-based epidemiologic studies. This requirement is widely acknowledged among health

professionals and service planners. A number of

recent examples include the National Institute of

Mental Health Epidemiologic Catchment Area studies (261) and the National Center for Health

Statistics’ biannual household survey (146). Yet no

comparable epidemiologic studies have been undertaken with Indian adolescents nor have Indians ever

been included to a meaningful degree in any national

survey. Indeed, it is not surprising, then, that a recent

draft report by the IHS Office of Mental Health

Programs--based on a survey of providers, planners,

and investigators--listed a large-scale psychiatric

epidemiologic study of children and adolescents as

among the highest priorities for future Indian mental

health research (355). Another series of recommendations in regard to IHS alcohol research initiatives

recently reached the same conclusion (352).

Current information and research technologies are

capable of meeting the challenges of obtaining better

information about the mental health of Indian

adolescents. The real barriers to future advances are

the lack of available resources and organizational as

well as philosophical schisms that preclude meaningful collaboration across the agencies charged

with delivering needed mental health care to American Indian and Alaska Native adolescents.
Chapter 3

Delivery of Mental Health Services to American Indian

and Alaska Native Adolescents

There is no single system for delivering mental

health treatment to Indian and Native youth. Rather,

there are a series of agencies and institutions with

different responsibilities that create a patchwork of

resources that varies from community to community. This chapter describes, to the extent information is available, the agencies relevant to the mental

health of adolescents. It also describes the way in

which contemporary mental health treatment approaches and settings have been adapted by Indian

communities. The chapter makes clear that mental

health services for Indian adolescents appear to be

inadequate, given the mental health needs described

in chapter 2.

AGENCIES INVOLVED IN THE

DELIVERY OF MENTAL HEALTH

AND RELATED SERVICES TO

INDIAN ADOLESCENTS

The agency most directly responsible for providing mental health services to Indian adolescents is

the Indian Health Service’s Mental Health Programs

Branch. IHS’S Alcoholism/substance abuse Programs Branch, the Bureau of Indian Affairs, tribal

health programs, urban Indian health programs, and

State and local service agencies also play a role in

providing mental health services.

Indian Health Servicel

Mental Health Programs Branch

The mission of the Indian Health Service

Mental Health Programs Branch (MHPB) is to

provide access for all Indian persons to high-quality

and culturally appropriate mental health services

that are appropriate to the nature and severity of their

mental illness (355). The MHPB, which is one

component of the Division of Clinical and Preventive Services in the IHS Office of Health Programs,

has two geographic locations. Mental health and

social services staff are located in IHS headquarters

offices in Rockville, Maryland. Staff responsible for

field services-e. g., quality assurance, planning,

data, research, community consultation, special

projects, children’s services, and training-are located in the IHS Headquarters West Mental Health

Office in Albuquerque, New Mexico. Branch staff

work closely with area and service unit personnel,

and with major Indian organizations.

As of April 1989, IHS reported that 251 staff were

supported by mental health categorical funds (355)

(table 24). Of these, 198 provide direct care, while 53

are administrative or clerical staff or professionals

who work at one of the headquarters offices. The

estimated total of 200 clinical staff means that on the

average, between one and two mental health direct

treatment personnel are available in each of IHS’S

127 service units. In actual practice, 80 percent of the

service areas have a mental health presence and 20

percent do not2 (355) (see table 24).

The distribution of mental health resources and

staff varies considerably from area to area as does

the availability of mental health professionals

trained to work with children or adolescents (tables

24 and 25). As shown in table 25, in fiscal year 1988

the per capita budget for mental health services for

persons of all ages in IHS areas ranged from $6.00

per person in California to $23.30 per person in the

Billings and Portland areas.3 Only 17 (9 percent) of

the 198 direct care professionals were trained to

work with children or adolescents, while children

aged 19 and younger account for approximately 43

percent of the Indian population (355). This amounts

to an average of 0.43 providers per 10,000 children

and adolescents. In 4 of the 12 IHS areas, there are

no child- and adolescent-trained mental health

professionals. 4

Given the mental health problems of adolescents

described in chapter 2, the resources to provide

mental health services are clearly inadequate. IHS’S

ISW appendix C of this Special Report and U.S. Congress, OTA, April 1986, for MI overview of the IHS.

zTable 2(I shows tie difibution of personnel by IHS area office rather than by the smaller Organizational service Unit.

Swith its incre=d ~ppropnation for fiscal Yem ]990 (xc ~h. 1), IHS plans to increase mental heal~ allocations to at Ieast $12 per capita (fOr dl

ages combined) in each area.

qEstimated ment~ he~th providers per 10,000 adolescents by area is shown in table 1 in chapter 1 of this SPCcid Repofi.

-35-
Table 24-lndian Health Service Mental Health Programs Branch Staff, April 1989

All staff

Combined IHS Direct and 638 programsa

Social Mental Other Administration

Social work health mental health and

Area Psychiatrists Psychologists Nurses wo~ers associates technicians professionals clerical Total

Aberdeen . . . . . . . . . . . 2 3 2 8 — 14 4 5 38

Alaska . . . . . . . . . . . . . . 4 2 1 1 . — — 3 11

Albuquerque . . . . . . . . . 1 10 — — . 11 3 25

Bemidji . . . . . . . . . . . . . —

—

2 — 3 3

Billings . . . . . . . . . . . . . —

— — — 8

2 3 12 1 2 4 6 30

California . . . . . . . . . . . — 1 — —

Nashville . . . . . . . . . . . . —

— — — — 1

1 — —

Navajo.. . . . . . . . . . . . . 10

— — — — 1

2 — 4 — 9 8 9 42

Oklahoma City . . . . . . . 1 2 1 15 — — 9 4 32

Phoenix . . . . . . . . . . . . 2 10 1 1 — 3 2 8 26

Portland . . . . . . . . . . . . 1 2 — 8 2 3 5 21

Tucson . . . . . . . . . . . . . 1

—

— — — — — — — 1

Total Area Direct

or 638 Mental

Health programs . . . 22 37 7 52 3 45 32 38 236

Headquarters staff . . . . 1 2 — 3 — — 3 6 15

Total IHIS Direct

or 638 Mental

Healthprograms . . . . 23 39 7 55 3 45 35 44 251

aDir@and &t6 Mental Health Pr~rams: Positions counted against Mental Haafth Program’s position ceiling and funded with Mental I-Mth pwram dollas.

Table 24b-Child- and Adolescent-Trained Mental Health Professional@

Combined IHS Direct and 638 programsa

social Mental Other

Social work health

Area

mental health

Psychiatrists Psychologists Nurses workers associates technicians professionals Total

Aberdeen . . . . . . . . . . . . . . . . . . . . 1 — — — 1 2

Alaska . . . . . . . . . . . . . . . . . . . . . .

— —

1 — —

Albuquerque . . . . . . . . . . . . . . . . . —

— — — — 1

1 — —

Bemidji . . . . . . . . . . . . . . . . . . . . . —

— — — 1 — — —

Billings . . . . . . . . . . . . . . . . . . . . . . —

— — — —

2 2 4 1 9

California . . . . . . . . . . . . . . . . . . . . —

— —

— — —

Nashville . . . . . . . . . . . . . . . . . . . . —

— — — —

— — —

Navajo . . . . . . . . . . . . . . . . . . . . . .

— — — —

2 — — — 2

Oklahoma City . . . . . . . . . . . . . . .

— — —

1 — — — 1

Phoenix . . . . . . . . . . . . . . . . . . . . . —

— — —

— — —

Portland . . . . . . . . . . . . . . . . . . . . —

— — — —

— — 1 1

Tucson . . . . . . . . . . . . . . . . . . . . . . —

— — —

— — — — — — —

Total . . . . . . . . . . . . . . . . . . . . . . . . 5 3 2 5 — — 2 17

aprqrm i~icates num~r of professionals ~ified who are trained to work with the mental health pdMms of Chikfren Or ado~==nts.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Mental Health Programs Branch, “A National Plan for Native American Mental Health

Services,” IOth draft, unpublished report, Rockville, MD, June 26, 19S9.
Chapter 3--Delivery of Mental Health Services to American Indian and Alaska Native Adolescents . 37

own draft National Plan for Native American Mental

Health Services concluded:

While Native Americans suffer from the same

types of mental disorders as other Americans, the

prevalence and severity of these disorders appear to

be greater, the availability of services lower, the

cultural relevance of treatment plans more challenging, and the social context more disintegrated than in

almost any part of American society. Failure to

address these issues will result in more severe

emotional problems for future generations of Native

American individuals, families, and communities.

What constitutes an adequate number of mental

health professionals for children and adolescents?

The question is difficult to answer. IHS’S draft

Plan’s major recommendations included more than

doubling the current number of direct treatment staff

and assuring that trained staff are available to

“provide services to Native American populations

with special needs, especially children” (355).

OTA has attempted to estimate the number of

child-and adolescent-trained mental health professionals that would optimally be available to serve

Indian children and adolescents, Such an estimate is

made difficult by the fact that both the total number

of such specially trained mental health professionals

in the United States and standards for provider-topopulation ratios are generally not available.s In

1981, the Graduate Medical Education National

Advisory Committee (GMENAC) recommended to

the Secretary of the U.S. Department of Health and

Human Services that 8,000 to 10,000 child psychiatrists be available by 1990 (339). A GMENAC panel

estimated, however, that psychiatrists would be

needed to treat approximately 25 percent of the

mental health needs of children and adolescents,

with the other needs being treated by primary care

physicians, pediatricians, and other mental health

professionals.d7 Since then, the advisability of primary care physicians’ treating mental disorders has

been questioned (260). Thus, OTA concludes that

Table 25-IHS Mental Health Programs Branch

User Population, Budget Per Capita, and

Mental Health Providers Per 10,000 Population

by IHS Service Area, FY 1988

Mental health

Budget direct care

User per capita providers per

IHS service area population 1988a 10,000 population

Aberdeen . . . . .

Alaska . . . . . . . .

Albuquerque . . .

Bemidji . . . . . . .

Billings , . . . . . . .

California. . . . . .

Nashville . . . . . .

Navajo . . . . . . . .

Oklahoma . . . . .

Phoenix . . . . . . .

Portland . . . . . .

Tucson . . . . . . .

78,677

88,511

62,284

44,837

49,800

39,866

25,022

167,741

217,211

75,522

54,059

19,877

$18.14

9.86

16.83

9.83

20.30

6.00

14.84

10.29

6.15

15.34

20.30

12.56

4.2

.9

3.5

1.8

4.8

.2

.4

2.5

1.5

3.4

3.9

.5

Totals-all ages . 923)407 11.89 2.1

Totals-ages

O-19C . . . . . . . 397,065 NIA 0.4

aCalculated on basis of $10,983,340.

b~e table 24 for numbers of provders, Ratio of mental health providers to

population by area is for all ages,

cFlgures are not available for ages 10-19.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Indian Health service, Mental Health Programs

Branch, “A National Plan for Natwe American Mental Health

Serwces,” IOth draft, unpublished report, Rockville, MD, 1989.

GMENAC’S recommended total number of child

and adolescent mental health professionals can be

increased to between 32,000 and 40,000 in 1990.

This estimate remains somewhat conservative in

that an oversight panel of GMENAC reduced an

original recommended projection of child psychiatrists from 25,000 to between 8,000 and 10,000 in

part because of a lack of capacity to train adequate

numbers of professionals to treat the large unmet

need by 1990” (339).

With an estimated total U.S. child and adolescent

population aged O-to 19-years-old of 89.6 million in

1990 (328), OTA concludes that a provider-topopulation ratio of 4 to 5 child- and adolescenttrained mental health professionals to every 10,000

she available estimate is from the Anlerican Academy of Child and Adolescent Psychiatry, which approximates that 5,000 child- and

adolescent-trained psychiatrists alone are currently available in the United States (67). In 1981, the USDHHS NIMH had proposed a survey to determine

the number of available mental health treatment professionals in 1981, but the r~uest was refused by the U.S. Office of Management and Budget as

having no practical utility for the Federal Government (187).

~he panel estimated psychiatrists should se ne~ly all children with psychoses and those in hospital settings, but only 25 percent of children with

neuroses, personality disorders and other nonpsychotic mental illnesses (339). Because very few children and adolescents suffer from psychoses, and

because children and adolescents in hospital settings are also treated by mental health professionals other than psychiatrists (323), OTA used an overall

estimate of 25 percent of children and adolescents with mental health problems being seen by psychiatrists. The issue of the appropriate professionals

to treat adolescents will be addressed in OTA’s adolescent health assessment,

7The GMEINAC panei alSO attempted to correct for the percentage of child mental health care provided by “general” psychiatrists and for the

percentage of adult mental health care that child psychiatrists would provide (339).
38 ● Indian Adolescent Mental Health

children and adolescents is needed. Within IHS

service areas alone, this would translate to an

increase in child- and adolescent-trained mental

health professionals from 17 to between 160 and

200, or at least 1 to 2 for every 1 of the 127 service

units. g OTA’s conclusion concurs somewhat with

the IHS’s recommendation, except that it substantially more than doubles the current number of direct

mental health treatment staff for children and

adolescents.

As for a standard percent of expenditures for child

and adolescent mental health problems (see table

25), few data are available. Few States are able to

disaggregate expenditures for children from those

for other age groups; those that were able to do so

estimated spending $9 per capita for services specifically for children in 1985 (231). For all ages

combined, average per capita expenditures by States

averaged $25.30 in 1985 (231). It is important to

note that most State spending is for inpatient mental

health care,9 but that private and third-party expenditures for outpatient and inpatient care are not

included in State per capita expenditures.10

Primary Health Care Services

Most of IHS’s budget is devoted to the provision of primary acute health care services (see app.

C). Because of the paucity of mental health professionals, primary care practitioners may be the

principal source of detection and treatment of mental

health problems for Indian adolescents. The extent

of such screening and treatment is not known,

however. In every IHS service area, medical providers are scarce (323, 324, 87). The ratio of providers

to population is well below accepted standards

(324,87). This overextension is due to a combination

of widespread needs among Indians for physical

health care, the fact that II-Ms’ financial resources

have not increased relative to inflation since 1978,

and difficulties in recruiting clinical personnel to

IHS service areas.

Even if there were a sufficient number of primary

care physicians to treat adolescents with mental

health problems, the delivery of mental health

services by non-psychiatric physicians is a problem

of sufficient magnitude that the 1990 objectives for

the health care of the Nation focused on improving

this facet of the health care delivery system (333).

The National Institute of Mental Health is devoting

substantial resources to this problem on a national

level (see 260). Yet, little coordinated effort has been

brought to bear to meet this objective within the II-M.

One exception has been the recent training, funded

through the 1986 Drug Omnibus Act, of IHS

physicians and other allied health personnel in the

awareness, recognition, and treatment of substance

disorders (350). However, no systematic evaluation

has been undertaken to determine if such training

has improved actual practice nor have provisions

been made to continue in-service education to

reinforce the lessons learned. In addition, these

efforts are focused on substance abuse disorders, not

other mental health problems. This may be particularly serious with respect to the treatment of

adolescents because most physicians report that they

do not understand adolescents’ problems (43).

While this problem is not specific to IHS physicians,

IHS physicians come from the same pool of practitioners trained nationally.

Alcoholism/Substance Abuse Program Branch

The Alcoholism/Substance Abuse Program

Branch (A/SAPB) of the IHS, originally known as

the Office of Alcohol Programs, was established in

March of 1978. Title II of Public Law 94-437 (Indian

Health Care Improvement Act) authorized the transfer of mature (6 years of operation) Indian alcoholism projects from the administrative jurisdiction of

the National Institute of Alcohol Abuse and Alcoholism (NIAAA) to the II-IS. The transition of all

(158) Indian alcoholism programs funded by the

NIAAA was completed at the beginning of fiscal

year 1983. Presently, the IHS funds 309 Indian

alcoholism service contracts in Indian reservations

and urban communities.

A/SAPB was situated in the Office of the Director

until April 1984, when it was placed in the Division

of Clinical and Preventive Services in IHS’s Office

of Program Operations. Organizationally, the A/

SAPB consists of seven headquarters positions.

three located in Rockville, Maryland, and four in

Albuquerque, New Mexico. The administrative staff

link with IHS service areas and programs through

SThe act~ num~r would deWnd on the child user population in the Wrvice Unit.

gAs a result, ~~atow Cwe is kliev~ to be inadequate in publicly funded *ttings (323).

1OOTA>S adolescent he~~ assessment will estimate & total cost of ment~ he~~ problems ~ong U.S, adolescents, a fi~e that will include an

estimate of expenditures for mental health treatment semices for adolescents.
Chapter 3---Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 39

area alcoholism coordinators. Area alcoholism coordinators, in turn, relate to local-level alcoholism and

substance abuse programs through project officers,

who may be members of an IHS service unit or area

staff.

The most extensive summary of IHS alcoholism

programming efforts can be found in PeakeRaymond and Raymond’s (249) report that identifies and assesses a series of model projects. PeakeRaymond and Raymond and other reports (e.g.,

5,6,57,343) found that virtually no alcoholism services were designed for Indian adolescents and that

there was little coordination or continuity of care

among alcoholism, social service, and mental health

programs.

The A/SAPB is responding to these deficiencies

(345,349) (table 26). Recent initiatives, made possible through 1986 Omnibus Drug Act funding, led to

the development of a youth services component that

began in fiscal year 1987 (349). IHS reports three

elements to its A/SAPB youth services component:

prevention, outpatient treatment, and residential

treatment. In fiscal year 1987, 445 Indian youths

were treated as outpatients, and 147 were treated in

residential facilities (349). Two 24-bed regional

adolescent substance abuse treatment centers were

providing services by fiscal year 1988.11 By the time

all residential treatment facilities for substance

abuse have been opened, there will be one in each of

eight areas (350).12

In 1988, IHS reported a commitment to providing

services to all Indian adolescents diagnosed as

needing alcohol and drug abuse treatment, to providing community-based aftercare to all adolescents

and adults hospitalized for alcohol and drug abuse

treatment, to fully integrating alcohol and drug

abuse treatment services into the IHS health care

delivery system, and to funding and evaluating five

demonstration projects for innovative Indian alcohol

and drug abuse prevention projects (349). IHS

concluded, however, that community commitment

to change held the key to reducing Indians’ alcohol

and substance abuse.

Table 26-Overview of IHS Aicoholism/Substance

Abuse Program Branch

hh8dS identified:

. New, more reliable diagnostic tools

. New discharge classification system

. New program models for treatment and prevention

. More specific contract requirements

. Eligibility criteria for services

. Education/training program to ensure competence

. Overall plan to improve program operations

Objectives developed to address deficiencies:

. Standardize development of prevention programs, with

emphasis on Indian youth and families

. Standardize and develop a network of community-based

treatment services for alcoholics and family members

. Develop a series of research projects on alcohol abuse among

Indians

. Develop a system that meets the needs of IHS and Indians for

alcoholism data

. Establish standards of care and staffing resource methodology

. Develop evaluation and quality assurance measures

● Provide technical assistance to staff of alcoholism programs,

and to all IHS professional staff

. Provide additional resources to projects with the greatest need

. Integrate alcoholism treatment into the overall IHS health care

delivery system

SOURCES: Needs: M.P. Peake-Raymond and E.V. Raymond, “ktentification and Assessment of Model Indian Health Serviee

Alcoholism Projeets,” contract No. 240-083-0100, unpublished report submitted to the U.S. Department of Health and

Human Serviees, Public Health Service, Health Resourees

and Serviees Administration, Indian Health Serviee, Roekville,

MD, 1984; Objeettves: U.S. Department of Health and Human

Serviees, Public Health Serviee, Health Resourees and Services Administration, Indian Health Service, Off& of Health

Programs, “11-tS Alcoholism/Substance Abuse Prevention

Initiative” (Rockville, MD: 1985).

Bureau of Indian Affairs

The Bureau of Indian Affairs (BIA) was established in 1824 as part of the War Department and

became apart of the U.S. Department of the Interior

(DOI) in 1849, when DOI was created. In 1977, DOI

established the position of Assistant Secretary for

Indian Affairs for the supervision and direction of

the BIA.

The BIA works with Indian tribal governments

and Alaska Native village communities. It provides

educational programs to supplement those provided

by public and private schools. BIA assistance also is

available for Indian college students, vocational

training, adult education, gifted and talented stuIIThe= were locat~ at tie ACL Hospital in San Fidel, New Mexico, and the Cherokee Nation of Oklahoma in Tahkquah

12T~ ~e~ (Bemidji, Billings, Poflland) decided to continue to purchase care on a contract basis, some because no Federal facilities that co~d ~

renovated existed (350). The Office of General Counsel for U.S. DHHS had advised II-IS that funds provided by Public Law 99-570 could only be utilized

for renovation or construction of Federal facilities. The Phoenix and Tucson areas will share a facility.

In total, $8.6 million was made available to IHS, and through IHS, the tribes, for renovation, construction, and staffing of residential treatment

facilities in fiscal years 1987 and 1988, In fiscal year 1987, a Model Staffing Pattern for a 24-bed facility was developed and distributed to each IHS

Area Dirwtor for use in approving applications; in fiscal year 1988, because funds were more limited, approximately $350,000 was distributed to each

area to develop, with tribal consultation, a mechanism to provide residential treatment to youth in their Areas (350).
40 . Indian Adolescent Mental Health

dents programs, and single parent programs. Finally,

the BIA collaborates with tribal governments to

provide a variety of social services, police protection, and economic development efforts.

In recent years, two major laws have resulted in a

restructuring of mental health-related BIA programs. In 1975, the passage of the Indian Self

Determination and Education Assistance Act (Public Law 93-638; amended in 1988 by Public Law

100-472) facilitated contracting for the operation of

education programs by tribal groups. The passage of

Public Law 95-561, the Education Amendments Act

of 1978 with technical amendments in Public Law

98-511 (Education Amendments of 1984) and Public Law 99-89 (Indian Education Technical Amendments Act of 1985), mandated a major change in the

operation of both BIA-operated and tribally contracted schools. The implementation of Public Law

95-561 (Education Amendments of 1978) resulted in

decisionmaking powers for Indian school boards,

local hiring of teachers and staff, direct funding to

the schools, and increased authority for the Indian

education programs within the Bureau.

In the 1987-88 school year, the BIA funded a total

of 182 education facilities (table 27). BIA education

programs furnish BIA-funded schools with curriculum materials and technical assistance to develop

and implement alcohol and substance abuse programs, with special emphasis on identification,

assessment, prevention, and crisis intervention

through the use of referrals and additional counselors at the schools. Boarding schools also depend on

a number of BIA personnel, typically social workers,

educational psychologists, and special educators, to

screen for, intervene with, as well as monitor

students who experience social and mental health

problems. Much of this effort takes place within the

context of the local Intensive Residential Guidance

program. In 1988, the BIA reported that 19.2 percent

of all Indian children were in BIA-funded schools

(359).13

The BIA also funds Indian Child Welfare Act

programs that provide a wide range of human

services. These services, which are managed by

tribes, often address the social and mental health

problems of Indian adults seeking to retain or

reassume parental responsibility for their children as

well as of Indian children subject to the stresses

inherent in foster care and adoption. Although the

Table 27-Overview of U.S. Department of the Interior,

Bureau of Indian Affairs (BiA) Educational Programs

8/A operates directly?

. 57 day schools

. 40 on-reservation boarding schools

. 6 off-reservation boarding schools

● 9 dormitories (to facilitate attendance in public schools)

Operated by tribes with BIA contracts?

. 54 day schools

● 10 on-reservation boarding schools

. 1 off-reservation boarding school

● 5 dormitories (to facilitate attendance in public schools)

Under Johnson--O’Malley Act of 1934

(46 Stat. 596), the BIA provides funds:

For special education for 201,162 Indian students in public

schools

Under Education for All Handicapped Chiidren Act

(Pubiic Law 94-142), the BIA provides funds:

For handicapped Indian students in approximately 25 facilities

aFigures for FY 1987-88.

SOURCES: Development Associates, “Final Report: The Evaluation of the

Impact of the Part A Entitlement Program Funded Under Title

IV of the Indian Education Act,” Ariington, VA 1983; and U.S.

Department of the Interior, Bureau of Indian Affairs, Report on

BIA Education: Excellence in Indian Education Through

Effective Schoo/Procass (Washington, DC: U.S. Government

Printing Office, 1988).

ultimate disposition of the cases is not well documented, Indian Child Welfare workers are known to

play a role in identifying abused adolescents in need

of mental health services, and in attempting to see

that these needs are met (table 28). However, a lack

of treatment resources for children and their families

was among the barriers identified in a 1989 BIA/IHS

Forum on Child Abuse (362) (table 29).

The BIA also plays a major role in the law

enforcement and criminal justice systems in many

reservation communities. These systems frequently

encounter mental health-related issues, such as the

detention and diversion of Indian adolescents involved with alcohol and substance abuse, and those

who experience serious emotional disturbance. This

involvement is likely to increase, as outlined in the

joint BIA-IHS Organizational Management Action

Plan (361).

Tribal Health Programs

As a consequence of Public Law 93-638, the

Indian Self-Determination and Education Assistance Act, many tribes have assumed administrative

control of local health programs, either partially or

in their entirety. Scopes of work and monitoring are

negotiated on an individual basis, leading to considlsln 1938, approxfiately 39 percent of Indian children were in BIA-funded beading schools (359).
Chapter 3--Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 41

Table 2&Responsibilities of

Local Child Protection Teams

Table 29--Barriers to Effective Chiid Protection

Services

Prow/de oversight:

. Monitor child abuse and neglect activities to ensure adequate

preventive, protective, and corrective services are provided

. Review and track alll child abuse and neglect cases which have

been referred

. Investigate cases to determine whether the best interests of

the children are being met

● Review case plans for their adequacy

. Maintain confidentiality of information

. Send local CPT data to area CPT

Facilitate provtsion of services:

. Receive child abuse and neglect referrals, assign case

managers to track cases

. Identify available community resources, programs, and services

● Provide recommendations to various pertinent agencies

. Promote cooperation, communication, and consistency among

agencies

. Provide a forum for debating what actions would be best to

promote the well-being of Indian children

. Respond to inquiries from the community, area CPT, and other

individuals and groups

Provide technical assistance:

Develop procedures to provide effective and efficient preventive, protective and corrective child abuse and neglect services

Develop standards to determine which cases are to be

investigated

Provide information and technical recommendations to decisionmaking agencies

Educate communities about child abuse and neglect problems

and solutions

Identify danger signs which prompt intervention and/or preventive actions

Assist in the development and implementation of plans to

promote long-term well-being of children and their families

Assist in the development and implementation of strategies bv

communities to create environments which provide opportunitiesties for community members to lead meaningful, productive,

self-fulfilling, and rewardinag lives

SOURCE: U.S. Department of the Interior, Office of the Secretary,

Assistant Secretary, Indian Affairs, and Director, Indian Health

Service, Washington, DC, “Establishment of Child Protection

Teams and Mandatory Child Abuse and Neglect Reporting and

Referral Procedures,” memorandum to ail BIA Area Directors,

all BIA Area Education Programs Administrators, and all IHS

Area Directors, signed Apr. 2, 1987.

erable variance in reports of program activities and

services. A recent analysis by the IHS Office of

Health Program Development (OHPD) provides one

of the few, albeit limited, overviews available of this

system of care (344).

OHPD identified 174 tribal health programs that

received substantial IHS funding under Public Law

93-638 in fiscal year 1985 programs. Eighty-five

percent (148) of the existing programs completed

and returned the profiles. Approximately 42 percent

of the tribal health programs reported providing

mental health services, but only 3 percent of tribal

health staff worked in mental health services,

Prevention IS not a priority:

. health promotion/disease prevention are low priorities

. alcohol substance abuse prevention lacking

● worker time is consumed in crisis management

Community barriers:

. lack of awareness/denial

. lack of community education

● Prevalent alcohol ldrug abuse

. lack of alcohol/drug abuse prevention treatment

. voice from tribal leadership for child advocacy missing

. lack of treatment resources

. interference in tribal court proceedings

Disorganized chiid abuse management:

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

suspected cases are not always reported

register and tracking system not in place

mutually agreed procedures are not established

unauthorized release of confidential information

lack of agreement on definitions

no local interagency memorandum of agreement

lack of communication between workers; no team case

manager not identified

delayed investigations

delayed prosecutions

cases submitted to tribal courts after Federal declination

inconsistent and unsympathetic investigators/prosecutors

inadmissible evidence

unclear team leadership

dysfunctional team

uncertain information exchange

decisions not clearly documented

failure to develop and mandate treatment plans for dysfunctional families

violations of Indian Child Welfare Aot (ICWA)

statistical surveillance is inconsistent/cumbersome

Inadequate chiid protection services:

. lack of foster homes (especially Indian/Native) in home

communities

. lack of emergency shelter for children

. unacceptable foster homes

. ICWA grants are competitive

. unavailable treatment in home community

● insufficient staffing due to: lack of funds, unfilled positions, staff

turnover, staff burnout

● inadequate staff expertise: lack of appropriate specialists, lack

ongoing training programs

● excessive staff workfoads

● insufficient mental health treatment resources

SOURCE: U.S. Department of the Interior, Bureau of Indian Affairs, and

U.S. Department of Health and Human Services, Public Health

Service, Indian Health Service, National Oversight Committee

on Child Protection, “Forum on Child Protection in Indian

Country: A Report,” unpublished report, April 1989.

indicating limited provision of such services (table

30). Ten percent of the tribal health programs

reported that mental health services were not available at all. Programs were not asked about mental

health services specifically for adolescents, but the

paucity of mental health staff suggests that adolescents would not be provided adequate mental health

care.
42 ● Indian Adolescent Mentall Health

Table 30-Overview of Tribal Health Programsa

Eligibie population:

. Total IHS support was $206.5 million

. Tribes received another $31.6 million from other sources

● $23.7 million from IHS was earmarked for alcoholism programs

c $28.5 million from IHS was dedicated to community health

programs

Percent of tribai community heaith programs providing

specific services:

. 75.2%: alcoholism

● 64.7°/0: drug abuse

. 50,50/.: social services

● 85.7°/0: outreach and referral

● 64.9°/0: health education

● 54.8°/0: home health

. 50.0°/0: community health nursing

. 41 .7°/0: mental heafth

Maental heaith services:

● Are reported as totally not available by nearly 10°/0 of programs

. 22?% of the programs provide mental health services through

IHS

. 10.2% of the programs provide mental health services through

contract care

Staff (fuii-time equivaient):

. 13.5% work on alcoholism/substance abuse programs

● 3.10/0 work in mental health

● 2.9°/0 Work in social service

aFigUreS repre~nt self-reporting by 148 tribal health programs; this

represents 850/. of all tribal health programs in the United States.

SOURCE: U.S. Department of Health and Human Services, Public

Health Service, Health Resources and Services Administration, Indian Health Service, Office of Health Program Development, “Final Report: Descriptive Analysis of Tribal Health

Systems,’ May 1987.

Urban Indian Health Programs

In 1972, the IHS began to fund urban programs

through its community development branch under

general authority of the Snyder Act. Since then, 42

different projects have received financial support

from IHS. The Indian Health Care Improvement Act

of 1976 authorized urban Indian organizations to

contract with IHS to operate health centers and to

increase Indian access to public assistance programs. There are currently 35 urban Indian health

programs that encompass 40 urban areas in 20

States. A recent study by the American Indian

Health Care Association (AIHCA) (11) provides

insight into the nature and scope of these programs,

although the data are not specific to adolescents

(table 31).

Urban Indian health projects are different from

IHS reservation-based clinics in their emphasis on

increasing access to existing services funded by

other public and private sources rather than providing or paying for services directly. However, their

single largest source of funding is the IHS Urban

Indian Health Program. This source of funding is

followed by some IHS funding for categorical

services such as alcohol and substance abuse services. Urban Indian health programs have not been

eligible for mental health funding through IHS,

however, because such funds are used only to

provide mental health services to Indians remaining

on or near reservations. This creates a problem for

the large percentage (estimated to be about 50

percent [322,355]) of American Indians who live in

cities, as they have severely limited access to

culturally specific mental health services.

Many smaller urban Indian health programs offer

mental health services as part of primary medical

care; mental health problems that cannot be managed by the primary care provider are referred to

outside resources. Other urban programs receive

categorical funding for substance abuse or child

welfare problems, and address mental health problems within the context of these services. Still other,

larger urban programs are able to provide a range of

onsite mental health services with funds received

through such sources as mental health Block Grants

and community mental health center funds. On

average, expenditures for mental health services

represent about 3.8 percent ($600,000 per year) of all

ambulatory health services provided by urban Indian

health programs.

As is evident in table 31, the mental health

counseling needs that urban Indians present are not

those which respond to short-term, crisis-oriented

counseling. Among these needs are child abuse and

child behavioral problems. Each of the 35 urban

Indian health programs surveyed by AIHCA identified mental health needs among their client populations that could not be addressed for lack of staff,

funding, and referral sources. Between 1985 to 1987,

the total number of onsite mental health providers

ranged from 15 to 20 for all urban programs,

representing less than 4 percent of the entire staff.

During this period the average number of users per

full-time provider more than doubled, and the

number of visits per provider also increased. Several

of the respondents in the AIHCA study reported that

available services are of poor quality and that

waiting periods for services are excessively long.
Chapter---.Delivery of Mental Health Services to American Indian and Alaska Native Adolescents . 43

Table 31-Overview of Urban Indian Mental Health Programs

Mental health problems encountered,

Mental health expenditures: in descending order of tiequency

. Have remained about 4°/0 ($600,000 per year)

. Expenditures were up in 1986 due to one-time

grants to three programs

c Per person expenditures declined by almost

50%from 1985 to’1987

. Per visit expenditure declined about 10% in

that same period

Usageof mental health services

. Ranged from a low of about 10,000 contacts in

FY 1985 to a high of about 22,000 in FY 1984

. In 1987, there were 12,000 mental health

encounters

● Follow-up declined from 6.2 per user in 1985

to 3.8 per user in 1987

. While usage was up dramatically, funding and

staff did not increase; this may explain the

decline in follow-up visits

Mental health services offered

(in descending orderof frequency):

● Referral to outside agencies (most frequent)

. Drug and alcohol abuse services

. Child counseling

. Community outreach

. Marital counseling

. Domestic abuse counseling

. Various group counseling services

● Group support

● Psychological testing

. Family counseling

. Crisis intervention

●

●

●

●

●

●

●

●

●

●

●

●

●

●

Drug and alcohol abuse - -

Cultural adjustment issues

Family problems and dysfunction

Child abuse, depression,

and low self-esteem

Domestic violence

Spousal violence

Poverty

Anxiety

Child behavioral problems

Suioidal tendencies

Unemployment

Stress

Grief

Racism

Staff (in descending order of frequency):

● M.S.W. social workers

● Drug and alcohol counselors

. B.S.W. social workers

. M.S. psychologists

. M.S. counselors

. Ph.D. psychologists

. Psychiatrists

● Prevention specialists

. Indian Child Welfare counselors

. Interns

SOURCE: American Indian Health Care Association, “Mental Health Services Delivery: Urban Indian Programs,” St Paul, MN, 1988.

State and Local Service Agencies

Very little information exists about the extent to

which such local agencies as community mental

health centers and State psychiatric facilities serve

Indian communities. It seems fair to assume that

numerous Indian people obtain care from these

settings, especially in urban communities. However,

the diverse points of entry into this system—e.g.,

State hospitals, day treatment centers, Social Security Administration, the criminal justice system,

detoxification facilities, and vocational rehabilitation centers—yield a confusing and often unmanageable set of service use data. For exampie, in the

State of Oregon alone, there are over 30 service

agencies that potentially may see emotionally disturbed Indians (244). A recent survey by Denver

Indian Health and Family Services, Inc., an urban

Indian health program, revealed that 71 municipal,

county, State, and private agencies offered mental

health services within the immediate metropolitan

area (75). Less than 40 percent of these agencies’

patient information systems track ethnicity, although virtually all of them (91 percent) answered

affirmatively when asked if they could recall having

had an Indian patient in care during the month prior

to the survey. This is not, of course, an indication of

the extent of care available to Indians from non-IHS

agencies.

Though established in part for the purpose of

reaching high-risk minority populations, community

mental health centers (CMHCS) tend to underserve

them (386). This occurs even in catchment areas that

have significant numbers of non-White residents.

American Indians, in particular, appear to use these

facilities far less frequently than other segments of

the American population (302,303,381). Sue (302),

in a 3-year survey of 17 community mental health

centers in Seattle, Washington, reported that 55

percent of the Indian patients seen were highly

unlikely to return after the initial contact. This was

a much more significant non-return rate than that

observed for Black, Asian, Hispanic, or White

patients. Information specific to adolescents is not

available.
MENTAL HEALTH TREATMENT

SETTINGS AND SERVICES AS

ADAPTED TO AND BY

AMERICAN INDIANS

Treatment Settings

There is a consensus that a well-integrated,

community-based continuum of services could improve the mental health of children and adolescents

(301,323). This consensus applies as well to Indian

and Native communities. An array of treatment

settings is needed to promote more rapid movement

to less restrictive environments and to decrease

reliance on more expensive forms of treatment.

Graduated, transitional aftercare programs in the

community can sustain and enhance therapeutic

improvement.

In discussing the array of treatment settings,

however, it is important to distinguish between the

needs of the community as a whole and each

individual. Communities may require the full array

of treatment settings in order to meet the diverse

needs of individual adolescents. Only the most

disturbed individuals will require the full array of

treatment settings, from psychiatric hospitalization

to aftercare services. If treatment is effective and

made available in time, less restrictive alternatives

such as outpatient care may be sufficient, although

they may be required on a continuing basis. A

general principle of mental health care, especially

for children and adolescents, is that it be provided in

the least restrictive setting (323).

From the community perspective, and sometimes

from the perspective of the individual, a continuum

of settings includes, at a minimum, inpatient treatment in a psychiatric hospital, a residential treatment

center, a partial hospital program, and an outpatient

service. Conceived more broadly, the continuum

encompasses a wider range of services, especially

those involving child welfare, such as therapeutic

foster and group homes and home-based interventions. Other possibilities include structured recreational activities, before- and after-school programs,

case management, and respite programs. *4

Each element in the continuum performs a special

function and employs different admission criteria.

For example, typically psychiatrists and nurses in

psychiatric hospitals diagnosis and treat patients

who are extremely disturbed and require intensive

mental health intervention. Hospitalized patients

often attempt, threaten, or contemplate suicidal or

assaultive behaviors, although adolescents may be

hospitalized for much less serious disturbances (e.g.,

running away from home, experimentation with

drugs). Hospitalized patients may also suffer from

severe cognitive, behavioral, and/or affective disorders that preclude independent functioning in the

home, school, or community. The psychiatric hospital can provide specialized diagnostic services,

facilitate the stabilization of medication regimens,

and introduce therapeutic leverages that are lacking

in less restrictive settings.

Residential treatment centers also provide 24-

hour supervision, but usually serve more chronic

patients who are either less severely disturbed or

already stabilized in their treatment. Limited psychiatric or nursing care is available; neither close

observation nor individualized care are typical.

Patients are not actively suicidal or homicidal,

though the potential may exist. They generally do

not pose a significant danger to themselves or to

others.

Partial hospitals offer special schooling and a

structured, intensive, therapeutic milieu to patients

who are able to live at home. Such settings are not

designed to manage assaultive or suicidal adolescents, or those who may need seclusion or restraint.

Families or guardians are expected to support the

child’s treatment and provide transportation on a

daily basis.

Outpatient care enables children to remain in or

return to their families, schools, and communities

while continuing to progress or maintaining gains

achieved through other therapeutic settings. Outpatient care can be provided in publicly funded clinics,

the offices of private practitioners, and in comprehensive, youth service centers (e.g., 73).

For adolescents, a recent innovation has been to

provide mental health services in or immediately

adjacent to schools, thus making the services more

immediately available and accessible (59,90,227).

Because of limited funding and the wide range of

services that school-linked youth services centers

attempt to maintain, the mental health services

available are often limited. However, when pro- .

14For mom detail, see U.S. Congress, OTA (323).
Chapter 3-Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 45

vialed, they have proven to be one of the most

sought-after of the school-linked health services,

and through them, schools have uncovered numerous mental health problems that previously had gone

undetected.

A comprehensive continuum of care also augments more traditional mental health programs

through ancillary services. Therapeutic foster homes

are operated by specially trained and clinically

supported couples who serve in parental roles for

several foster children. Such homes offer a highly

structured living environment that is well suited for

younger children whose major needs include stability, security, and nurturance.

Therapeutic group homes are better suited for

older adolescents. They live together with perhaps

10 to 12 peers and a trained couple, who function as

adult role models and staff. Like therapeutic foster

homes, group homes provide a living environment

that falls somewhere between institutional and

family care. Both foster homes and group homes

may serve as the child’s or adolescent’s primary

form of treatment, or may work in tandem with

partial hospitalization or outpatient care.

Home-based interventions introduce treatment

directly into the family setting. Generally supportive, directive, and practically oriented, home-based

interventions are usually indicated for highly disorganized, hard-to-reach families who will not participate in office-based therapies. Home-based interventions may be used alone or in concert with other

elements of the continuum.

Although the continuum of care just described is

the ideal, the general paucity of treatment options for

Indian children has been a recurrent theme over the

last two decades. Schools and social service programs seem to play more prominent roles than in

non-Indian communities but the major setting for

treatment is clinic-based outpatient care. Innovative

home-based and group home interventions are much

less common, but still in evidence (276). Intensive

care in residential treatment centers and partial as

well as full psychiatric hospitalization is almost

nonexistent. Such intensive care requires the mobilization of extremely scarce resources, poses significant transportation problems, and almost always

removes the child or adolescent entirely from

family, community, and the other supports.

An equally serious problem in these communities

is the fragmented and discontinuous nature of care

within and across treatment settings, regardless of

their scope. In part, this lack of coordination springs

from the rural, isolated environments typically

associated with Indian communities. However, disciplinary, institutional, and jurisdictional barriers

may pose even greater barriers. Within the IHS, for

example, collaboration between mental health and

alcohol programs is rare, because of different

perceptions of illness and competing philosophies of

care. Well-coordinated efforts among IHS, BIA, and

tribal agencies are also the exception. Interagency

rivalries, differing views of accountability, different

eligibility requirements, and incompatible program

goals often undermine necessary working relationships. Mistaken assumptions about jurisdiction and

governmental obligations impede ready access to

the treatment settings. Perhaps one of the toughest

challenges that faces any attempt to develop a

coordinated continuum of care is to blend and

coordinate community resources and talents with

those of the mainstream systems of care provided

directly by II-IS and other agencies. None can stand

alone in meeting the mental health needs of Indian

children; together, they hold considerable promise

for maximizing the impact of the available care.

Therapeutic Interventions

A wide array of types of therapeutic interventions

is in use in American Indian and Alaska Native

communities today. In planning for a broadly based

mental health program, it may be helpful to understand the major categories of approaches to therapy,

some typical forms of each, and their relative

strengths and liabilities. Unfortunately, despite increasing efforts to offer much needed care to Indian

youth, very little is known about the availability or

effectiveness of these services. Systematic evaluation is virtually nonexistent; even careful description

of content, form, and related aspects of process is

rare. In order to get a sense of the range of therapies

being used in Indian communities, OTA searched

the social, behavioral, and health sciences literature,

including fugitive documents such as program

reports and organizational newsletters. Descriptive

information obtained from these sources is included

in the following discussion. A more general treatment of these therapeutic interventions can be found

in the reviews by the U.S. Congress, Office of

Technology Assessment (323) and the Institute of
Medicine (144).1s Where the effectiveness of specific treatments has been evaluated, it is noted in the

discussion.

Psychopharmacology

In their comprehensive review of recent developments in psychopharmacology for children and

adolescents, Campbell and Spencer (54) concluded

that many questions remain unanswered in regard to

the efficacy and safety of numerous medications

(also see 144,323). Much work needs to be done with

respect to optimal drug choices for treating such

illnesses as schizophrenia and depression. Nonetheless, psychopharmacological forms of intervention

are being employed with increasing frequency

among adolescents in the non-Indian population.

Though potentially beneficial, the use of medications with Indian adolescents deserves close study

especially since Indian patients taking psychotropic

drugs frequently receive their prescriptions from

primary care physicians and often are not seen by

mental health and/or social service providers (124).

Medication is most effective when taken in the

context of a psychotherapeutic relationship (323).

Individual Psychotherapy

If any single therapeutic modality can be said to

be the mainstay of mental health treatment, it is

psychotherapy. The relationship between a therapist

and client or patient is the best known means of

treating mental health problems, although there is a

great diversity in the approaches psychotherapists

use. These include psychoanalytic, behavior and

learning theory-based approaches, and supportive

and client-centered approaches. A great variety of

approaches or schools of psychotherapy can be

found in Indian and Native communities.lb

Psychoanalytic Therapy—Devereux’s description (77,78) of his work with Plains Indians, though

dated, remains the most significant discussion of the

psychoanalytic approach to individual psychotherapy although it was not specific to adolescents. He

focused on issues pertaining to transference, to

dreams and visions, and to therapeutic objectives.

Devereux recalled examples of each of these issues

from his own practice and demonstrated how the

correct interpretation of, as well as the response to,

transference behavior among Plains Indians requires

an understanding of their familial roles and patterns

of social interaction. Boyer (45), Jilek-Aall (149),

Duran (91), and others have written more recently

about various aspects of psychoanalysis with American Indian patients, sometimes adolescents, but they

do not approach Devereux’s description and explanation of the inherent therapeutic dynamics.

Psychoanalytic thought has given rise to a number

of other schools and techniques of psychotherapy,

including transactional analysis, gestalt therapy, and

existential therapy. These approaches are practiced,

usually infrequently, in Indian communities. None,

unfortunately, has occasioned any written accounts

of their application with Indian adolescents or

adults.

Behavioral and Learning Therapies—Several

well-known interventions with Indian adolescents

have been based on behavior modification. Goldstein (114) described a program implemented in a

BIA boarding school that employed dormitory

counselors to reshape problems of student living

using reward, mild punishment, desensitization,

discrimination learning, and extinction techniques.

His experience underscored the need to understand

culturally meaningful contingencies and to draw on

natural reinforcers that are specific to the social

ecology. Galloway and Mickelson (110) reported

another school-based program that sought to modify

North Carolina Indian children’s “passive resistance to adults, withdrawal in the face of threat, and

peer orientation with a subsequent lack of attention

to adults” (p. 150). They recognized that such

behaviors are deeply rooted in the cultural rearing of

the children, but argued that their academic success

depends on the ability to act in accordance with

mainstream classroom expectations. The highly

structured intervention, which used material and

ls’rhese Souces do not separate children’s stxvices from adolescents’ services. The U.S. Congress, Office of Technology Assessment, will be

addressing mental health services specifically for adolescents in its forthcoming full report on adolescent health.

16There is tide diversity of ~inion about tie eff~tiveness and f~d~en@ ch~acteristics of psycho~erapy, A dectie ago, studies appeared to

demonstrate that the process of psychotherapy depended not on the learning and formal training of the therapist, but on personal characteristics such

as genuineness, warmth, and empathy ( 172). Therapeutic orientation seemed to make no discernible difference in the overall course of treatment. Indeed,

studies of the time supported the contention that formal training makes little or no difference to therapeutic outcome, and that untrained people with

warmth, genuineness, and empathy produce, overall, as good or better results than trained therapists. The last decade has modified these conclusions;

a number of psychotherapeutic interventions have been shown to be effective for specific problems (323,374). However, considerable work remains to

be done on the effectiveness of individual psychotherapy with adolescents ( 144,323). Almost no systematic research has been done on the effectiveness

of individual psychotherapy with Indian adolescents.
Chapter 3--Delivery of Mental Health Services to American Indian and Alaska Native Adolescents . 47

social reinforcements, extinguished the undesirable

behaviors and gave rise to behaviors valued by the

teachers. The authors, however, highlighted another

major issue that may arise in using behavioral

therapies with Indian adolescents. They found reason to be concerned that such changes may extend

beyond the situations for which they were originally

intended, thereby engendering conflict in other

social arenas such as families and communities.

Thus, there are potential disadvantages, as well as

advantages, to using behavioral and learning theorybased therapies with Indian youth. Behavioral therapies tend to pay little attention to internal states or

feelings, usually require a high level of motivation

and activity, and are seldom satisfying intellectually.

Consequently, some clinicians report that such

behavioral techniques meet marked resistance with

many Indian patients who hold strong cultural

beliefs that will and intellect can master mood and

behavior. For these reasons, cognitively based

therapies tend to be more easily accepted by Indian

adolescents. The relatively new school of cognitive

therapy (see ref. 323), for example, assumes that

internal thought models about people, relationships,

and events give rise to actions and feelings. The

therapist and the patient attempt to develop new

ways of conceptualizing events and relationships in

order to counteract cognitive models that lead to

maladaptive thought and behavior.

SupportiveandClient-CenteredPsychotherapy—

Supportive and client-centered therapies are linked

more by their use in the field then by their

ideological roots. Supportive psychotherapy evolved

in the context of the psychoanalytic movement, as a

vehicle for caring for patients too ill or incapable of

forming the relationships necessary for psychoanalytic or insight-oriented psychotherapy. Clientcentered psychotherapy, in contrast, was developed

by Carl Rogers, a psychologist, as a reaction to the

“medical model” of mental health espoused by

behaviorists, psychoanalysts, and some psychiatrists

(130).

Supportive and client-centered techniques tend to

merge in practice. Supportive psychotherapy is not

intended to produce change in the patient through

the therapist. Instead, the objective is to make the

patient feel better about him-or herself, and to

provide gentle help and advice about activities of

daily living. The therapist assists the patient’s return

to a prior functional level, and helps him or her to

learn to tolerate difficult situations.

Client-centered or “Rogerian” therapy is predicated more explicitly on the relationship between the

client and the therapist. Unlike psychoanalytic

psychotherapy, the aim is for the patient to experience the therapist as a genuine, accurately empathic,

caring person, who reflects the patient back to

him-or herself. Rogerian therapy is built around a

number of concrete interviewing techniques that

almost all trained therapists learn at some point.

Taken together, these two forms of therapy are

often employed by beginning therapists and those

who practice in difficult and uncertain situations.

Those most likely to respond to supportive and

client-centered therapies typically are at risk for

deterioration as the result of more severe illnesses,

or suffer from situational problems and normal grief.

Clinical observation suggests that supportive and

client-centered therapies are probably the most

common of all the different techniques in use in

Indian mental health programs. An overwhelming

number of young Indian people experience situational problems and grief. Consequently, these

techniques may be initially appropriate for most of

them who are seen in Indian mental health programs.

In addition, relatively little training is required to

provide either type of intervention. However, supportive therapies by themselves may be ineffective

for some patients, and some clinicians believe that

political safety may be one of the more disconcerting

reasons for the popularity of these therapies in Indian

communities. In some other therapies, a patient may

become angry with his or her therapist as a normal

part of the therapeutic process. The supportive

therapist is not required to do anything that might

endanger his or her standing in the clinic or in the

community.

Group Psychotherapies

As Edwards and Edwards (93) noted, the use of

group therapy is growing in programs that serve

Indians and Natives, as it is in many public mental

health settings. One explanation of this trend is that

it is an outgrowth of the natural emphasis on groups

in the social ecology of most Indian communities.

Another explanation is the low cost of group

psychotherapy compared to individual psychotherapy.
48 . Indian Adolescent Mental Health

This relatively new movement contrasts sharply

with prior assertions that group psychotherapy is

inapplicable with American Indians and Alaska

Natives. These assertions stemmed from three assumptions. First, Indians have been stereotyped as

being stoic and silent. Second, it was presumed that

an unspoken solidarity among Indians would preclude the involvement of non-Indians as either

fellow patients or group leaders. Third, it was

believed that Indians’ social norms, which disapprove of setting oneself apart from others, would

repress the therapeutic expression of fear, weaknesses, or problems. An increasing number of

examples of the apparently successful adaptation of

group approaches in the treatment of young Indian

and Native patients suggests otherwise. As with

other forms of mental health treatment for Indian

adolescents, group psychotherapies have not been

systematically evaluated. It may be important to

note that most of these group psychotherapy described here is not group psychotherapy in the

traditional sense, but consists more of support and

self-help groups.

Single Issue Groups—Probably the most common form of group therapy in Indian communities is

the support group organized around a single issue or

topic. The format is often mixed, incorporating

lectures on various aspects of the primary topic,

testimonials, and support for troubled members. The

group provides a context for mutual help and

protection even outside of formal meetings, a

tendency that is often discouraged in non-Indian

therapy techniques. This model is one of the most

rapidly growing therapeutic movements in Indian

mental health today, and assumes a variety of forms

in these communities.

A large number of single-issue support groups

currently focus on parent-child relationships (table

32). Adolescent parents and parents of adolescents

can participate in the more generic groups (193), but

few groups are focused specifically on adolescents,

either as parents (except see Salt River PimaMaricopa) or children (except see United Tribes

Educational Technical program for parents of students at tribal boarding school).

There are also therapeutic groups organized

around specific problems such as sexuality abused

adolescents, rather than general psychosocial issues.

Ashby, Gilchrist, and Miramontez (13) chronicled

the development of a therapeutic group for Indian

females who were experiencing problems of self-

-esteem and difficulties in relating to peers and/or

adults. Wolman (385) described and analyzed the

interpersonal dynamics of group therapy with late

adolescent and young adult male and female Navajo

alcoholics at a treatment ward in the Gallup (New

Mexico) Indian Hospital. Merrill (224) systematically tested the effects of group therapy with Indian

teenagers who exhibited significant symptoms of

depression, anxiety, and substance abuse. Other

popular types of support groups can be found in

school settings and involve Indian youth at risk for

a range of mental health problems (see table 33).

Currently the greatest impetus for single-issue

groups among American Indians and Alaska Natives

stems from the rapid growth of alcoholism programs. Anecdotal observations attest to the value

and utility of these techniques. Systematic outcome

research to determine the nature and extent of their

efficacy has yet to be conducted and very few of

them have been extended to Indian adolescents.

Self-Help Groups

Unlike other mental health interventions, selfhelp groups do not use a therapist. Rather, the group

is organized and directed by its members, often

helped initially by someone with a mental health

background. Group members generate their own

therapeutic movement and support, usually according to a set of known rules or principles. Self-help

groups of many sorts operate in Indian communities

around a wide variety of problems. Sexual abuse

victims, children of severely mentally ill parents,

and surviving relatives of suicide victims are among

the most frequent types of local self-help groups.

The Navajo Nation supports peer self-help groups

which include tribal youth aged 12 to 25 many of

whom have histories of abuse and/or neglect. The

purpose of groups is to enhance the participants’

self-esteem and to help them to feel more confident,

but these groups have not been evaluated.

Family Involvement in Therapy

Family therapy is common in non-Indian mental health programs. It is a way to help disruptive

families and thus their adolescent children or to help

adolescents or their own families. However, family

therapy is not nearly as common in Indian communities (15,101,1 36). Clinicians have observed that it is

difficult to obtain the participation of all relevant

family members or couples in the treatment process,
Chapter Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 49

Table 32-Single Issue Groups for Parent-Child Relationships

Tribe/agency Program Participants Focus Format

Salt River Pima-Maricopa Teenage Parents

Support Group

Parenting Education

Parental Support

Parenting Skills (Twopart program)

Parents Are Teachers

Child Care Referral and

Education

Parents in Need of

Special Services (Twopart program)

Titie II Child Welfare

Program

Intensive Parent Aide

Program

Group Parent Training

Program

Parent Support Groups

Parent Training Program

Teen parents and

significant relatives

Well being of teen

parents and their children

Individual/group

counseling and group

activities; parent

instruction

Behavior management;

Self-esteem/actualization

Support groups and

parent aides

Yavapai Prescott Parents and children

Parents

Non-abusive child

behavior management

Colorado River Indian

Tribes

Fort McDowell Mohave/

Apache

Family management,

parenting, job-search

skills, goal development

Part One: Home/

Behavior Management

Part Two: Parenting skills

training

Self-reliant mothers

being a positive force in

children’s lives

In-home parent aides and

classroom instruction

Parents

Pima/Maricopa Mothers and children Twelve-week training that

both mothers and

children attend

Shasta County Schools Parents Parental control and

involvement in schools

In-home outreach

workers and support

groups

In-home family aides and

weekly group meetings

Cook Inlet Native

Association

Fort McDowell Mohave/

Apache

Parents Decrease parental

neglect and abuse

Parents Recognition and

reduction of child

behavior problems

Promote family stability

and basic parent

education

Parenting skills

Six-week course and

monthly community

education meetings

Michigan Indian Child

Welfare Agency

Minnesota Souix

Parents and foster care

parents

Parents

Parent aides and support

groups

“Systematic Teaching of

Effective Parenting”

(STEP)

Phoenix Indian Center Parents Parenting skills Weekly sessions

incorporating traditional

values

Red Cliff Band Lake

Superior Chippewa

Support groups using

local tribal members as

facilitators

Parents Parenting skills

Shoshone-Bannock Parental Training for Pre- Parents

school Children

Parent Effectiveness Parents of students at

Training (PET) Tribal boarding school

Positive Parenting Parents

Basic and Advanced Parents

Parenting Skills

Child development and

behavior modification

In-home and group

meetings dealing with

social and traditional

values

United Tribes Educational

Technical

Urban Indian Child

Resource Center

Vern Jackson Receiving

Home: Warm SrNVMs

Parenting skills Twenty-hour/twelveweek group training

Parental communication Two-hour/six-week group

sessions

Culturally relevant

parenting skills

Eight- and six-week

group sessions

SOURCE: Office of Technology Assessment, 1990.

especially adult men. Yet, as summarized in table Network Therapy and Related Techniques

34, at least five programs have adapted such Attneave (14) was the first to suggest that techniques to local Indian families as part of their therapy with American Indians and Alaska Natives

services to families at risk. Two of the programs

focus on troubled adolescents (Warm Springs,

ought logically to proceed within the context of the

extended family. The family and kin relationships of

Navajo Area Office), but none of the programs have Indians and Natives represent their most potent and

been evaluated for their effectiveness. lasting socializing influence (257,281).
50 ● Indian Adolescent Mental Health

Table 33~Single Issue Groups for Indian Youth at Risk

Tribe/agency Program Participants Focus Format

Indian High School

Various

Tohono O’odham

Navajo, Zuni, Oglata Sioux,

Great Lakes Inter-Tribal

Council

Support for teen girls at

risk

Counseling for children at

risk

Reservation school group

therapy program

Foster grandparents

Pregnant ~olescents

4th, 5th, and 6th graders

from dysfunctional

alcoholic families

Potential school dropouts

Tribal elders and needy,

troubled, disturbed, and

disabled Indian youth

Child care/parenting with

parent and roles

Dealing with feelings of

abandonment

Decrease arrests, school

absences, and dropouts

Retention of culture

SOURCE: Office of Technology Assessment, 1990.

Network therapy is useful in precisely the kind of

complex social networks that exist among the

agencies and extended families that occur in Indian/

Native communities. It is particularly appropriate

for troubled, multiple problem families.

Several recent efforts to apply family-network

intervention with American Indians stand out. One,

described by John Red Horse (258), involved

mobilizing the extended families of Indians in crisis

to assist in problem-recognition and problemsolving, to work through role conflicts, and to

provide a collective form of therapeutic support.

Other examples of the application of family-network

intervention with American Indians can be found in

Yvonne Red Horse’s work (259) with young,

pregnant, unmarried Indian adolescents. Neither of

these programs have been evaluated. The difficulties

with this form of intervention include expense

arising from the number of professionals that it takes

to accomplish the therapy and the fact that few

therapists are trained in this technique.

Recreational and Outdoor Therapy

Recreational and outdoor therapy provide good

opportunities for older children and adolescents to

confront relationship issues with their peers, to

master new and unfamiliar situations, and to establish constructive relationships. Recreational therapy

is practiced in a variety of ways.

One distinction is between competitive and noncompetitive forms of recreation. Competitive sports

teach some lessons about adulthood and the need to

work cooperatively with others. However, unless

great care is taken, competitive sports can tend to

diminish the self-esteem of children and adolescents

who are uncoordinated, or who are inept at acquiring

group membership. Noncompetitive sports and outdoor programs offer several therapeutic advantages

Classes/experience in

day care, etc.

Individual and group

counseling

Paid to participate in

group therapy

Individual and group

instruction in native

songs, danoe, crafts, and

customs

over competitive activities. By challenging one’s

self or nature, the adolescent learns valuable lessons

about personal mastery and self-efficacy.

Examples of both competitive and noncompetitive recreational therapy are numerous in Indian

communities (30). There is little evidence, however,

to document the outcomes of these forms of therapy.

Generally, recreational and outdoor therapies are

nonspecific in their effects and are not central to the

treatment of seriously emotionally and mentally ill

adolescents. Such programs can, when used improperly, exacerbate an adolescent’s problems and may

provide the greatest benefit to those least in need

(297). However, in the context of an overall treatment plan there may be a place for them to improve

the functioning of children and adolescents, and as

a tool for promoting physical health.

Traditional Indian Therapeutic Interventions

Many traditional Indian and Native healing

practices are gradually being incorporated into

contemporary approaches to mental health treatment

of Indian adolescents (81). Indeed, there is increasing collaboration between health care providers and

traditional healers. However, this collaboration has

not been without the kinds of problems that one

would expect from any cross-disciplinary effort

(189). Several traditional therapeutic strategies have

received considerable attention and invited attempts

at integration into approaches to intervention with

Indian adolescents: the four circles, the talking

circle, and the sweat lodge (196).

The four circles refers to a symbolic process that

uses a series of concentric circles to visualize and

analyze the significant relationships in one’s life.

This approach is commonly used in counseling

troubled youth among Northern Plains communities.
Chapter 3--Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 51

Table 34-FamiIy Involvement in Therapy

Tribe/agency Program Participants Focus Format

Minneapolis Indian Family Mental

Health Board Health Program

Yakima Nak-nu-we-sha

Warm Springs Whipper Man

Confederated Tribes

Salt River Family Support

Pima/Maricopa Program

Navajo Area Office,

Indian Health Service

Traditional elders;

representatives of major

tribes; families in crisis

Indian paraprofessionals,

abused children and their

families

Troubled children and

adolescents

Parents from community

acting as parent

advocates

Depressed Navajo

adolescents and their

extended families

Prevent breakup of families by

Child Protective Services

End inappropriate removal of

abused children from their

kinship system; halt adoption

of children off the reservation;

increase community

awareness of child *use/

neglect; develop positive

alternatives to abuse/neglect

Reduce adolescent jail time;

reduce off-reservation referral

for foster care

Family crisis intervention.

Providing culturally

appropriate role models to

families

Treatment of depression and

family dynamics

Rituals, ceremonies,

traditional healing practices,

POW WOWs; routine crisis

Counseling/case

management; use of extended

family for child placement;

comprehensive network

review model

Foster care, medical

counseling and receiving

home services; case

management; coordination of

community resources and

services with focus on the

family. Intensive casework and

advocacy services

Tribally operated group home;

short- and long-term

placement counseling;

intensive outreach family

counseling; out patient

followup and case

management

During crisis, advocates spend

time in homes of in-need

families, doing counseling and

assessment

Weaving together of

traditional. Navajo medicine

with typical therapeutic tasks

of family-based interventions

SOURCE: Office of Technology Assessment, 1990.

The talking circle is a unique form of group

therapy and is a part of many Indian treatment

programs. For example, in 1984, the Phoenix Indian

Center began to use talking circles to help urban

Indian families cope with child abuse and neglect

(128). Between 1984 and 1988, more than 5,000

persons participated in the Indian Center’s circles,

and demand increases steadily. Other well-known

examples include the Seattle Indian Health Board’s

program for street youth and the Native American

Rehabilitation Association’s youth alcoholism treatment program in Portland, Oregon.

The sweat lodge, best likened to a sauna that

combines individual prayer and group therapy, has

been incorporated into a number of IHS alcoholism

and mental health treatment programs (127).

The IHS has not fared well in past efforts to admit

traditional Indian psychotherapeutic interventions

into its daily operations, Thus, such interventions are

more characteristic of tribal programs contracted

through the 638 mechanism.

Approaches Integrating Traditional and

Western Techniques

A relatively new and apparently promising

approach to improving the mental health of Indian

adolescents (and Indian adults) is to combine both

western-style professional mental health care with

traditional Indian approaches. Written materials,

although no rigorous evaluations, are available

concerning programs implemented on the SalishKootenai Indian Reservation in western Montana

(62,100,101). Three components distinguish the

Salish-Kootenai approach:

. a strong clinical component using mainstream

mental health care providers;

. a cultural program using tribal elders, meetings

in long-houses, and a cultural specialist; and

● coordination with other community programs

(62).

In an earlier youth-specific component of the

program, young Indians chosen from the local

mental health program participated in a class organ-
ized around cultural activities such as beading.

Tribal elders taught traditional values and an experienced psychologist provided client-centered psychotherapy (100,101).

The Salish-Kootenai program is regarded highly

by both the tribe (62) and the IHS (236), and similar

approaches have begun to be used around the

country (102). Such techniques may play a major

part in Indian mental health programs of the future,

especially for adolescents at high risk of mental

health problems as a consequence of alienation and

cultural adjustment problems. However, clinicians

have expressed concern that efforts like this represent a highly sophisticated form of intervention that

should not be confused with the extensive array of

cultural heritage classes and traditional value groups

that perform important, but not necessarily therapeutic, functions in many Indian communities.

PREVENTIVE AND PROMOTIVE

INTERVENTIONS

Overview

Debate continues about the most appropriate set

of terms by which to distinguish the broad domain

of prevention from other approaches to or activities

in mental health (161). The tripartite division of

primary, secondary, and tertiary prevention, each

with separate methodological emphases, enjoys the

greatest currency (55). As Bloom (41) noted, the

goal of primary and secondary prevention is to

reduce the prevalence of disease or disorder in a

given population, whereas the object of tertiary

prevention is to ameliorate the discomfort or disability that attends an existing disease condition. Bloom

(41), Wagenfeld (369), and others have argued that

the latter actually falls outside of the realm of

prevention since such efforts are not designed to

decrease the occurrence of disease.

Primary prevention, which seeks to lower the

prevalence of disease by reducing its incidence, can

be accomplished in three ways: health promotion

and enhancement, disease and disorder prevention,

and health protection (42). Health promotion and

enhancement involves building or augmenting adaptive strengths, coping resources, survival skills, and

general health. In addition to focusing on the

capacity to resist stress, health promotion and

enhancement require an understanding of the conditions which generate stress and may negatively

affect psychosocial functioning. There is very little

research of this nature in the Indian mental health

literature (188). Exceptions include work by Dinges,

Yazzie, and Tollefson (82) on developmental task

accomplishment among Navajo parents and children. by Kleinfeld (163) in her study of the

characteristics of successful boarding school parents

for Alaska Native students, by Lefley (178) in her

research on the familial and social correlates of

psychological health among Miccosukee children,

and by Goldstein (1 15) in the Toyei model dormitory project.

Disease and disorder prevention encompasses a

much narrower spectrum of concerns. It targets a

specific disorder and, based on an analysis of risk

factors, attempts to manipulate one or more conditions to forestall the occurrence of the disease. The

vast bulk of primary prevention research in Indian

mental health is of this type, but seldom moves

beyond the identification of risk factors. Hence, the

literature is replete with profiles of the “typical”

Indian alcoholic, delinquent, addict, and suicide, and

lacks data on the effectiveness of potential responses.

Health protection techniques employ regulatory

and legislative action to reduce the probability that

the disease agent and host will come into contact.

Bonnie (44) discussed health protection in terms of

four legal strategies: establishing the conditions of

contact (availability), deterring undesired behavior

through punishment, symbolizing an official posture

toward the behavior, and influencing the content of

messages in the mass media. With respect to Indian

communities, the classic ‘‘experiment” in health

protection has been the federally imposed (and in

many places now tribal) prohibition of liquor sales

and liquor consumption on reservation lands. Levy

and Kunitz (182) and May (201) clearly demonstrated that the prevalence of ‘‘problem drinking’

and of associated phenomena (accident, arrest, and

homicide rates) are not necessarily lower and may be

even higher on “dry” reservations than on “wet”

reservations. 17

Secondary prevention seeks to reduce the prevalence of disease or disorder through early case

finding and treatment. A reduction in the duration of

IV-iowever, the more recent IAHS found a lower prevalence of alcohol use among Indian adolescents on reservations with more restrictive drifiing

laws (see ch. 2 of this Special Report).
Chapter 3-Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 53

a case consequently. decreases the total number of

active cases at any given point in time. Research of

this nature is extremely sparse in the American

Indian and Alaska Native mental health literature.

To permit earlier intervention and more appropriate

treatment, researchers have begun to identify the

relationships among psychophysiological symptoms,

indigenous categories of illness, and research diagnostic criteria for depression within various tribes

(e.g.,195). McShane and Plas’ (220) study of the

psychoeducational impact of otitis media, specifically of parent reports of the number of a child’s ear

infections as a means of early detection of psychoeducational problems, is another example. However, as with primary prevention efforts, these are

not evaluations of the effectiveness of secondary

prevention strategies.

Preventive and Promotive Efforts Specific to

Indian Adolescents

A recent review of the published literature revealed approximately 45 articles that specifically

describe prevention and/or promotive programs

targeted to Indian adolescents (193). The interventions reported in this literature largely represent

examples of promotional (65 percent) and primary

prevention (73 percent) programming. There were

no studies of how effective these efforts have been

in accomplishing their respective intervention goals.

In an earlier review for the IHS of school- and

community-based alcohol and substance-abuse prevention programs, counseling and referral, workshops and training, self-help and support groups, and

driver education were the most numerous types of

activities found (346). Adolescents were the most

frequently mentioned target groups. This review

also reported infrequent evaluation of program

outcomes. Objective measures were employed in

fewer than 30 percent of the identified preventive

interventions. The greatest gains included increased

participant involvement in outreach programs and

increased reporting of abuse, family violence, and

other forms of antisocial behavior. Actual decreases

in such alcohol and substance abuse problems as

arrests, suicide, abuse and neglect, and chemical

dependency ranged from minimal to negligible.

Unfortunately, the published record does not

reflect the extent to which preventive and promotive

activities are currently underway in Indian communities. In order to get a sense of the range of such

interventions, the NCAIANMHR contacted tribal

agencies and community-based organizations requesting the following information: program sponsor, title, participant characteristics, intervention

focus, and format. As of May 9, 1988, 194 programs

were identified with significant preventive intervention activities. Nearly one-half of these programs

were operated or sponsored by local tribes or native

organizations; one-third were managed by private

nonprofit groups, and one-quarter were administered

by IHS. Of the actual preventive interventions,

two-thirds involved counseling or psychotherapy

and one-half provided education and training or case

and program consultation. Roughly one-third emphasized recreational or cultural events. Programs

were asked about the effectiveness of their approaches to which many responded affirmatively,

but few acknowledged having gathered empirical

data to support such conclusions. Clearly, additional

work is needed to determine the characteristics of

effective prevention programs.

CULTURAL SENSITIVITY IN

INDIAN MENTAL HEALTH

PROGRAMS

“Mental health” and “mental illness” can be

controversial terms, involving as they do implications for the way a person thinks and the ways in

which he or she interacts with others. In their effort

to help meet the goal of the U.S. DHHS National

Institute of Mental Health’s (NIMH) Child and

Adolescent Service System Program (CASSP) that

services to minority children be appropriate, the

CASSP Technical Assistance Center at Georgetown

University recently published a monograph geared

toward developing a‘ ‘culturally competent’ system

of care (68). The needs of Indian children were

among those considered when the CASSP team

developed its report.

The CASSP analysis suggested that problems

related to cultural variation can arise at several levels

in the intervention system for mental health problems: policy. resources, training, practice, and research. At the policy level, the most important

problem is that States have not had a specific focus

in the area of services to children of color. Indians

theoretically have their own source of health care in

the II-IS, but, as described previously, resources are

scarce. In general, according to the CASSP team,

minority-controlled programs and agencies continu-
ally struggle for survival: “With scarce resources it

is difficult for such programs and agencies to

develop culturally-specialized approaches or materials for use with their clients. Consequently they

remain underdeveloped. ” The training of mental

health professionals is troublesome in that there is a

shortage of trained minority persons to work in the

field, and the existing curricula for mental health

providers inadequately address the needs of minority communities. When minority persons have

successfully completed training, they sometimes

find that the education offered by the nonminority

institution serves to alienate them from their community rather than make them a resource (e.g., see

171).

Some of the practice issues uncovered by the

CASSP analysis are cross-cultural issues, while

others are applicable regardless of the service

provider’s identity. Cross-cultural issues include

such areas as historic distrust, language and communication barriers, and culturally biased assessment

techniques. Value conflicts, stereotypes, and unrealistic fears of minority clients can arise regardless of

the service provider’s identity. Many of these issues

are of longstanding concern in the provision of

mental health treatment and prevention services to

Indians, and the need for cultural sensitivity is

repeated whenever an evaluation of services is

conducted (e.g., 355). These issues are of particular

concern to adolescent mental health. One characteristic of adolescence is the experience of an ‘identity

crisis” (97), and thus Indian adolescents may be

more likely than Indians of other ages to experience

distress as a result of feeling caught between two

cultures (368). Problems with policy, training, and

practice may be due in part to an inadequate

research base on the characteristics and mental

health needs of minority children and adolescents.

According to Cross and his colleagues, current

research too often fails to consider culture as a

variable, and funding sources for research historically have not been sensitive to minority needs and

thus do not follow direction from minority communities.

With the support of Congress, IHS has made an

effort to bring more Indian mental health providers

into the system. One hundred nine of the 198 mental

health providers are Indians. However, most are

social workers and mental health technicians (355).

only 4 of the 37 clinical psychologists are Indian.

No psychiatrists are Indian.

Even Indian heritage does not guarantee “cultural

competence. There is considerable diversity in

language and heritage among the more than 500

Indian tribes (355). For example, differences among

Alaska Native tribes can be as great as between

Native and non-Natives. The Oklahoma City region

serves members of more than 60 tribes who were

originally from different areas of the North American continent but who were induced or forced to

resettle in the Oklahoma area.

Thus, there is a long-recognized need for enhanced cultural awareness and training among

health care providers of all kinds. The draft IHS

MHPB National Plan recommended that:

A more systematic program for orienting new

mental health providers and for upgrading the skills

of mental health staff and of other human service

providers regarding mental health care and relevant

cultural issues should be developed and implemented. New mental health staff should be fully

oriented to the mental health program and to the

cultural traditions and community of the tribe/tribes

which are served: Such orientation should emphasize

that Native Americans often fail to acceptor respond

to western mental health treatment procedures because of inherent socio-cultural factors, and that

these factors must be taken into account and

integrated into planning treatment strategies at all

levels (355).

COMMUNITY INVOLVEMENT

Throughout the Nation and abroad, consumers are

becoming increasingly involved in planning mental

health services (19), and providers of services for

young people are beginning to seek their continuing

assistance. Not only is community involvement

consonant with the spirit of Indian Self-Determination (Public Law 93-638 as amended), but it can

enhance the feelings of self-efficacy and control that

may be important to improved mental health (e.g.,

18a).

Specific to Indian adolescents, the LagunaAcoma Teen Center in rural New Mexico was

developed with community participation (73). Teenagers themselves were involved in the planning and

design of the Center, and continue to serve as an

ongoing Teen Advisory Group, consulting with the

adult program directors. The teens also prepare a

peer-targeted, teen health-oriented newsletter, produce videotapes and skits, help teach fellow students

and elementary school children, and are involved in
Chapter 3 Delivery of Mental Health Services to American Indian and Alaska Native Adolescents ● 55

evaluating the Center’s programs. As part of the

United National Indian Tribal Youth (UNITY)

organization, Indian youth have been involved in

needs assessments and have provided testimony to

Congress on their views of the needs of Indian

adolescents. One of the most pressing concerns

identified by UNITY members at a May 1987

UNITY Conference was to improve communication

between themselves and tribal government officials

(306).18

Recognizing the importance of youth involvement, II-IS and BIA are developing a plan to promote

the involvement of youth in community actions

involving alcohol and substance abuse, including

encouraging the selection of youth as members of

Tribal Coordinating Committees (361). It is important to note, however, that mental health treatment is

a health care specialty like any other. In addition,

Indian communities are unusual in that it they may

be host to two mental health approaches: westernoriented psychotherapy and traditional medicine.

Thus, conflicts concerning approaches to treatment

among mainstream mental health professionals,

traditional medicine specialists, and communities

may be inevitable (19).

HOLDING THE SYSTEM

TOGETHER

In planning a mental health system, it is not

adequate simply to know the mental health needs of

Indian people in a particular area and to be aware of

available treatment and prevention. Treatment plans

for patients often require that several interventions

be used simultaneously. Patients need to be able to

have access to services, or the services will not work.

Overview

In planning the development of a comprehensive

mental health system, it is useful to consider the

system as a continuous whole. Several types of

deficiencies may exist. Test (308) described them as:

a) “gaps” in the system—places where the components to meet some unmet need are inadequate or

non-existent; b) “cracks” in the system—spaces

between existing system elements resulting from a

lack of communication, coordination, or clearly

defined responsibilities; and c) difficulty in keeping

the patient or client involved in the system.

All of these problems exist in the health care

delivery systems in Indian communities, as Manson

and Neligh (194) have noted. There are a variety of

barriers to good care for the patient who must receive

services from an array of different providers and

agencies.

Bachrach(18) urged thinking of continuity of care

as having several dimensions:

1.

2.

3.

4.

5.

a temporal or longitudinal dimension that

implies a course of treatment, unencumbered

by the patient’s having to put together discrete,

unconnected episodes of service;

an individual dimension in which care is

planned with and for the patient and his family;

a cross-sectional dimension consisting of comprehensiveness and continuity of care.

flexibility such that a patient is relieved of

pressures to exhibit “progress” or to move

“forward” along a continuum;

a relationship dimension in which contacts with

the service system are, ideally, of a primary

nature and are characterized by familiarity and

closeness;

6. an accessibility dimension that ensures one the

ability to reach the services ystem when needed;

and

7. a communication dimension such that different

agencies and individuals may be responsible

for a patient’s helpers.

McArthur (210) and Albaugh (7) provide concrete,

practical examples of how these dimensions can be

incorporated into local programming of services for

Indian adolescents and their families.

Coordination Efforts Among

Indian-Serving Agencies

Recently, IHS and other agencies in the U.S.

Department of Health and Human Services have

begun to address the issue of inter-and intra-agency

coordination. These efforts primarily address the

problem of alcohol and substance abuse among

Indian people, including adolescents, and were

stimulated by Public Law 99-570. Among these

~sMOrc ~an XXI India youth reprc~nting 53 tribes from 21 States participated in the UNITY conference, which was sponsored by Youth 2000, a

joint U.S. Department of Health and Human Services and U. S. Department of Labor campaign. The Indian youth identified their most pressing needs

as: 1) alcohol, drug, and other substance abuse; 2) suicide; 3) teenage pregnancy; 4) preservation of tribal culture and traditions; 5) communication

between themselves and tribal government officials; 6) funding for higher education; 7) motivation and self-esteem; 8) school dropout; 9) lack of

recreational facilities; and 10) unemployment.
56 ● Indian Adolescent Mental Health

coordinating efforts are a U.S. DHHS Inter-Agency

Task Force consisting of IHS, Office of Human

Development Services, the Administration on Aging,

the Alcohol, Drug Abuse and Mental Health Administration, and the Office of Minority Health (349).

Memoranda of agreement (MoAs) have been signed

between the IHS, these agencies, and others (i.e.,

Administration for Native Americans, Administration for Children Youth and Families) resulting in

coordinated Discretionary Grant Programs to provide support to Indian communities which face

alcohol and substance abuse problems. In addition,

BIA and IHS have signed MOAS on child protection

and alcohol and substance abuse (356,357). As a

result of the Child Protection MoA, IHS and BIA

formed a National Oversight Committee for Child

Protection; the Committee is attempting to work

more closely with tribes, the FBI (222) and the

Office for Victims of Crime on child abuse (51). The

purpose of the alcohol and substance abuse MoA

was to develop a management framework for

implementation of the Indian Alcohol and Substance

Abuse Prevention and Treatment Act of 1986

(Public Law 99-570) resulted in an OMAP (361). In

response to longstanding concerns about lack of

coordination, IHS MHPB and A/SAPB also signed

an MoA dated October 31, 1988 (353).

CONCLUSIONS AND

POLICY IMPLICATIONS

Very little systematic research has been conducted on the effectiveness of specific therapies with

Indian adolescents, Where success has been noted in

the literature, it often reflects the judgment of the

clinician providing the treatment rather than the

conclusion of an objective observer conducting

rigorous research. This situation is true of much

research on mental health services (144,323). Nonetheless, OTA and others have concluded that,

overall, more is known about how to provide mental

health treatment to children, including adolescents,

than is generally put into practice (323). Thus, it is

unfortunate that even in the Nation at large, children

and adolescents represent an underserved population. Among Indians, the situation is more critical,

with only 17 child and adolescent-trained mental

health professionals in the IHS mental health system

and extremely limited access to inpatient care,

residential treatment centers for emotionally disturbed children, and the other forms of care that

constitute a desirable continuum of care. Tribally

run programs such as parent groups are available to

adolescents but few are specifically designed to

meet their special needs.

OTA concludes that approximately 160 to 200

mental health providers especially trained to treat

children and adolescents are needed in IHS service

areas. OTA was unable to calculate an increase for

urban areas because the number of Indian children

and adolescents in urban areas is unknown. However, a ratio of 4 to 5 mental health professionals per

10,000 children, including adolescents, seems warranted.
Appendix A

Earlier Evaluations of American Indian and Alaska Native

Adolescents? Mental Health Needs and Services

Public concern for the mental health of American

Indian and Alaska Native youth arose initially within the

context of their education, dating to an often-quoted

publication entitled The Problem of Indian Administration, more commonly known as the Meriam Report (223).

The Meriam Report highlighted a number of serious

school-related conditions that threatened Indian youth’s

physical and emotional well-being. Sweeping reforms

were encouraged. For example, the Meriam Report

recommended raising food and clothing allowances,

introducing Indian culture into the curriculum, and

increasing the number and qualifications of school

personnel. It also urged the construction of local day

schools to serve as community centers. The intent was to

improve the educational environment and render it more

relevant to the daily life experience of Indian youth,

thereby enhancing their sense of ‘personal security’ and,

consequently, the authors presumed, their academic

competence. Many of these reforms were pursued by John

Collier during his tenure as Commissioner of Indian

Affairs from 1933 to 1945. However, ensuing administrations presided over the reversal of most of these advances

(305).

It was not until nearly a quarter of a century later, with

the issuance of the Kennedy Report in 1969, that the

public spotlight returned to these concerns, and therefore

to the mental health of Indian youth (326). Congressional

forces, tribal leadership, and professional opinion coincided. As a result, the Senate Special Subcommittee on

Indian Education reached extraordinarily negative conclusions about the impact of Federal policy on Indian

adolescents in boarding schools, citing a “dismal record

of absenteeism, dropouts, negative self-image, low achievement, and, ultimately, academic failure . . .‘ (326). Its

recommendations echoed many of those advanced by the

Meriarn Report, 40 years earlier. Slow, but definite

progress became evident (305) as new attempts at

educational enrichment were undertaken, embodied in

subsequent initiatives such as the Office of Economic

Opportunity Headstart, Title IV of the Indian Education

Act and the remolding of Johnson-O’ Malley programs

(305).

Though education, especially boarding schools, continued to serve as a major forum for the discussion of Indian

children’s mental health, other areas of concern began to

emerge. Kane and Kane (156) pointed out that the IHS’S

1

preoccupation with infectious diseases, though important,

ignored the social and psychological welfare of Indian

people, and youth in particular (156). The consequences

of ignoring adolescents’ social and psychological problems were thought to be far-reaching and included

alienation, adjustment difficulties, child abuse and neglect, alcohol dependence and abuse, and suicide. IHS

mental health programming had begun just shordy before,

in 1965-66, with a small outpatient clinic on the Pine

Ridge Reservation and the formation of the Office of

Mental Health Programs.

Interest in mental health services soon spread to other

IHS areas. Yet these efforts almost exclusively emphasized adult services, as demonstrated by Attneave and

Beiser’s system-wide evaluation in 1974 (16). In their

evaluation, the authors concluded that ‘‘services to

children tend to be sporadically dispersed throughout IHS

mental health programs. In part the focus on this age

group depends on the activities of other programs such as

Maternal and Child Health within IHS and Headstart and

Day Care outside of IHS. ”

Public attention to the mental health needs of and

services for Indian youth reached its zenith between 1976

and 1978. It came about through the convergence of three

separate but related lines of advocacy. One effort focused

on child welfare services. In 1976, the Children’s Bureau

within the Ofilce of Human Development published a

major study by the Denver Research Institute entitled

Indian Child Welfare: A State-of-the-Field Study (329). It,

together with a similar volume issued by the Indian

Family Defense Fund (53), documented the alarming

rates at which Indian youth were removed from their

homes and placed for either foster care or adoption with

non-Indian families. Major mental health problems were

believed to follow from this practice, attributed in large

part to the subsequent disruption of the child’s stillevolving social and cultural identity. The well-known and

still controversial Indian Child Welfare Act (Public Law

95-608) resulted from these and related endeavors, giving

rise to local Indian Children’s Welfare programs that have

played an important role in identifying and caring for

troubled youth and their families.

Another effort continued earlier criticisms of the

general state of Indian health care. The Final Report of the

American Indian Policy Review Committee, delivered to

Congress in 1977, opened with a broad condemnation of

Federal and State policies regarding human services in

Indian communities (321). Stating that the quality of

Indian life ranked lowest by virtually any statistic, the

I In 1955, responsibility for ~dian heal~ was transferred from the U.S. Department of the Interior, Bureau of Indian Affairs (BIA), to tie hen U.S.

Department of Health, Education, and Welfare (now DHHS), and the Indian Heatth Service (IHS) was formed,

-57-
Committee concluded that it was not surprising that so

many Indian tiunilies had been devastated by social

disintegration caused by mental illness and alcoholism.

The third effort sprang from the 1978 President’s

Commission on Mental Health. The Report of the Special

Populations Subpanel on the Mental Health of American

Indians and Alaska Natives (253) reaffirmed the findings

of these previous reports and strongly endorsed their

recommendations. 1n addition, it briefly highlighted the

special mental health needs of handicapped youth, of

juveniles in the criminal justice system, and of youth

experiencing rapid sociocultural change. The subpanel

called for the development of a wide array of child mental

health services, including family-oriented resource centers to provide diagnostic assessments, counseling, and

followup, foster care and adoption services, and youth

group homes. Their report frequently repeated the need to

coordinate across State, tribal, and agencies.

1n response to these reports, the IHS outlined plans for

a series of regional 1ndian Children’s Programs that

would render and/or coordinate a continuum of mental

health care, ranging from basic screening efforts to

intensive residential treatment. The first program began in

1979 at Albuquerque, New Mexico, and was founded on

a then unique interagency agreement between the IHS and

BIA. Unfortunately, effective advocacy for Indian child

mental health services gradually dissipated in the face of

a major economic recession and severe budget cuts of

federally supported health and human services. The

Albuquerque-based Indian Children’s Program proved to

be the only one of its kind ever funded. Eventually even

it was dismantled, having been unable to shift to the

national scope required for successful justification of

continued support. However, before closing, the program

conducted a review that determined that Indian ‘‘children

with social and mental health problems are not well

served’ (342). This report, Phoenix IHS Area Review:

Perceptions of Service for Special Needs Children (342),

indicated that younger children in need of care are not

identified appropriately and are the most difficult to link

with appropriate services, that the urban Indian population is essentially unaware of available services for

children, and that the youth of rural Indian families are

least likely to receive specialty care. As the highest

priority for future programs, the Indian Children’s Program report stressed coordination among tribes, State, and

Federal Government. The proposed mechanism involved

teams involving multiple disciplines and agencies, with

case management, a registry system, and an interagency

resource directory.
Appendix B

Population Estimates for Estimating Suicide Death Rates

0fficial estimates of the II-IS service population (those

persons living on or near reservations or in urban settings

where IHS has facilities) by age and gender are currently

not available. Therefore population estimates used to

calculate rates for this report should be considered as

‘‘unofficial.

Two methods for estimating the IHS adolescent service

population were considered. The first method, which was

used for this report, uses the following calculations:

●

●

●

The age and sex distribution for adolescents from the

1980 census data on the reservation states population

was applied to the 1980 estimated service population

(those living on or near reservations) to obtain a

count of 10-14 and 15-19 year olds. (No count of the

actual 1980 service population is available.)

Five year age cohorts for the ages 5-9 (to be used for

step #3), 10-14, and 15-19 were calculated for males

and females using the age and gender distribution for

reservation states in 1980. Each five year cohort was

divided by five to obtain single year age estimates.

Also, for step #3, estimates of 4 year old males and

females were calculated for 1980.

For the years 1981 through 1986, the population was

1980 became 11 year olds in 1981 and so forth. Since

mortality data for the IHS service population is

available by single year of age and gender, deaths

occurring in each single year age group were

subtracted.

An alternative method would have been to calculate

population estimates using the 1980 reservation states age

and gender distribution and apply it against the total IHS

service population estimates developed for the IHS chart

series (355a). These estimates show that the overall IHS

population is increasing by approximately 2 percent per

year. However, using this technique would also imply that

all age groups are growing at an even rate when, in fact,

this is not the case. The increase in the IHS service

population is occurring primarily through increased births

and decreased deaths in the older age cohorts. If this

method for calculating the adolescent population were

used in computing either age-specific death or fertility

rates, those data would show artificially sharp declines

(due to increases in population versus a decrease in the

absolute number of events) in comparison to other

adolescent populations.

Tables B-1 and B-2 show a comparison of the results

“aged” forward by one-year. Thus, 1O-year olds in for the two population estimation methods.

Table B-1-II-IS Service Area Population Estimates Using Method #1

1980 f981 1982 1983 1984 1985 1986

females:

10-14 . . . . . . . . . . 45,665 45,150 44,637 44,134 43,633 43,167 43,305

15-19 . . . . . . . . . . . 49,725 46,864 48,012 47,169 46,340 45,522 45,017

Total . . . . . . . . . 95,390 94,014 92,649 91,303 89,973 88,689 88,322

Males:

10-14 . . . . . . . . . . . 47,155 46,511 45,862 45,226 44,575 43,949 44,174

15-19 . . . . . . . . . . 50,535 49,728 48,962 48,233 47,555 46,969 46,310

Total . . . . . . . . . 97,690 96,239 94,824 93,459 92,130 90,918 90,484

S0URCE: Office of Technology Assessment, 1990.

Table B-2—IHS Service Area Population Estimates Using Method #2

1980 1981 1982 1983 1984 1985 1986

Females:

10-14 . . . . . . . . 45,665 46,810 48,013 49,790 51,708 53,107 54,518

15-19 . . . . . . . . . . . 49,725 50,972 52,282 54,217 56,306 57,828 59,365

Total . . . . . . . . . 95,390 97,288 100,295 100,407 108,014 110,935 113,883

Males

10-14 . . . . . . . . . . . 47,007 48,186 49,424 51,253 53,228 54,668 56,120

15-19 . . . . . . . . . . . 50,537 51,804 53,135 55,102 57,225 58,773 60,334

Total . . . . . . . . . 97,554 99,990 102,559 106,355 110,453 113,441 116,454

SOURCE: Office of Technology Assessment, 1990.

-59-
Appendix C

Overview of Indian Health Service

The U.S. Department of Health and Human Services

(U.S. DHHS), primarily through the Indian Health

Service (IHS) of the Public Health Service (PHS), is

responsible for providing Federal health services to

American Indians and Alaska Natives. Federal Indian

health services are based on the laws which the Congress

has passed pursuant to its authority to regulate commerce

with the Indian Nations as explicitly specified in the

Constitution and in other pertinent authorities.1 The goal

of the IHS program is to raise the health status of

American 1ndians and Alaska Natives to the highest

possible level (Indian Health Care Improvement Act

[Public Law 94-437 as amended]). IHS defines its service

delivery responsibilities to include a comprehensive

range of inpatient and ambulatory medical services,

dental care, mental health and alcoholism services,

preventive health (immunizations and environmental

services such as sanitation and water safety), health

education, and Indian health staff development programs

(322).

IHS provides these health and health-related services to

eligible Indians in a variety of ways. The approximately

1 million Indians2 (355a) who live on or near reservations

are theoretically eligible to receive the comprehensive

range of services at no cost to the individual Indian,

regardless of other health insurance coverage or ability to

pay. This program of services is provided in facilities

owned and operated by IHS, and is known as the direct

care program.

Although in principle II-IS services are comprehensive

and readily available at no user cost, in fact they are

limited by IHS budget constraints and by the uneven

distribution of services among IHS areas that has developed over the years (322). When no IHS facility is

accessible or when specific services are not available from

IHS facilities, Indian patients may require referral to

private providers under the IHS corm-act care program.

It is important to note that contract care is a separate item

in the overall IHS budget, and that contract care budgets

sometimes have been so limited that needed referrals

cannot be made. Thus, while they may not be directly

affected by ability to pay, Indians may face serious

obstacles in obtaining health care services through IHS.

Another obstacle to obtaining contract care is that

eligibility for such services is more restricted than for

direct care.

Another factor in the IHS delivery system since the

Indian Self-Determination and Education Assistance Act

of 1975 (Public Law 93-638), amended in 1988 (Public

Law 100-472), has been the operation of health facilities

and service programs by Indian tribes. Direct care

facilities, contract care programs, facilities construction,

and special programs such as community health representatives, mental health and drug abuse, and health education initiatives may be administered by tribes under

self-determination or 638 contracts. Most of these services, like IHS’S own services, are reservation based, and

they are provided to IHS-eligible Indians at no cost to the

individual. But Indian tribes may also use non-Federal

sources of payment and may treat non-Indians (322).

About half of Indians today reside in urban areas rather

than on reservations.3 However, urban Indian health

projects operate separately from the reservation-based

IHS system. Unlike IHS-direct programs, urban projects

may receive funds from non-IHS sources, are likely to

treat non-Indians, and may request payment from Indians

and non-Indians alike based on a sliding fee scale. Urban

projects are similar to tribally operated programs in that

they are more active than IHS programs in treating and

billing non-Indians and in coordinating their efforts with

other non-IHS health delivery programs (322). Primarily,

urban programs must be more active in securing other

funds because IHS only partially supports urban programs.

Although IHS programs provide health, dental, mental

health, alcoholism, and preventive health services, most

of II-IS’S resources are, apparently of necessity, used to

provide hospital-based and ambulatory services for acute

and chronic physical conditions. As shown in table C-1,

for example, $723 million (77 percent) of IHS’S total

fiscal year 1988 budget of $935 million was used for

hospitals and clinics, exclusive of dental, mental health,

and alcoholism services. Another 9 percent of the budget

was used for direct clinical dental, mental health, and

alcoholism treatment services: 3 percent for direct and

tribal dental services, 1.3 percent for direct and tribal

mental health services, and 3.1 percent to direct and tribal

alcoholism services. Of the clinical budget, $183 million

lsoci~ and he~~ ~Wices have &n provided to Indian tritxs since the time the United States became an independent nation. Until 1921s when the

Snyder Act (42 Stat. 208; 25 U.S.C. section 13) was passed, Congress provided funds without specific authorization. Since 1921, the Snyder Act has

been the basic authorizing mechanism to provide funds for Indian health services (322). However, while Congress has consistently provided funds for

Indian service programs, the courts so far have ruled that these benefits are voluntarily provided by Congress and not mandated under the Federal

Government’s trust responsibility for Indian tribes. Appropriated funds are “public moneys” and not treaty or tribal funds ‘‘belonging really to the

Indians” (SchuMer v. United States, 428 F. 2d 1123 [%h Cir., 1970], cert. denied, 400 U.S. 942 [1970].

The exact number of Indians in the se~ice population is not known with certainty (322).

sHistoric~ remns for this are discussed in U.S. Congress, OTA (322).

-60-
Appendix C-overview of Indian Health Service ● 61

Table C-1-IHS Allocations by Budget Category,

Fiscal Year 1988

Total area Percent

Activity/subactivity allocations of total

Clinical services:

Hospital and clinics . . . . . . . . .

Dental . . . . . . . . . . . . . . . . . . .

Mental health . . . . . . . . . . . . . .

Alcoholism . . . . . . . . . . . . . . . .

Maintenance and repair . . . . .

Reimbursements . . . . . . . . . . .

Total health care delivery . . . . . .

Contract care. . . . . . . . . . . . . .

Total clinical services . . . . . . . . .

Preventitive health

Sanitation . . . . . . . . . . . . . . . . . . . . .

Public health nursing . . . . . . . . . .

Health education . . . . . . . . . . . . . .

Community health reps . . . . . . .

Immunization . . . . . . . . . . . . . . . . . .

Total preventive health . . . . . . . .

Urban projects . . . . . . . . . . . . . . . .

Indian health manpower . . . . . .

Tribal management . . . . . . . . . . . .

Direct operations . . . . . . . . . . . . . .

Total allowances lssued . . . . . . .

$533,614,000

28,974,000

12,466,000

29,335,000

11,359,000

6,227,370

$621,975,370

183,481,000

$805,456,370

$23,907,000

14,113,000

4,413,000

27,282,000

395,000

$70,110,000

9,624,000

7,646,000

3,094,000

39,104,000

$925,034,000

57%

3

1

3

1

.

66%

19

86%

3

2

—

3

—

7%

1

1 —

4

1 OO%

a

less than 1 percent of total.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Indian Health Service, “Fiscal Year 1990 Justification

of Appropriation Estimates for Committee on Appropriations,

Volume Xl-Indian Health” (Washington, DC: U.S. Department

of Health and Human Services, Public Health Service, 1989).

(25 percent of the clinical budget) was used to provide

contract care services.4

Seven percent of IHS’s budget was used for preventive

health services (i.e., sanitation, public health nursing,

health education, community health representatives, and

immunizations) in fiscal year 1988. Of IHS'S total budget,

$9.6 million (1.2 percent) was allocated to 35 urban

projects. Although it is not shown separately in table C-1,

approximately $218 million was used to support Indian

self-determination (638) grants and contracts in fiscal

year 1988.

Organizationally, IHS comprises 12 regional administrative units called Area Offices (see figure C-1). 5

Currently, the Area Offices oversee 127 basic administrative units called Service Units. Of the 127 service units,

52 are operated by tribes (see figure C-2). IHS operates 43

hospitals, 131 health centers and stations, and 37 other

treatment locations (figure C-3), while tribes operate 7

hospitals, 313 health centers and stations, and 11 other

treatment locations (figure C-2) (355a). Thirty-five urban

health projects are partially supported by IHS (figure

C-4). With the partial exception of the urban projects, IHS

facilities are concentrated in the Western part of the

Nation, where most reservation-based Indians live (figure

c-5).

Asomc con~act care funds are used for dental, mental health, and alcoholism services.

sT~hnic~]y, tie IHS Offie in ~cson is a headq~ers office for the Office of Health Program Development, which is responsible for administering

health services delivery. For statistical purposes, II-M considers lkc.son an Area Office.
62 ● Indian Adolescent Mental Health

Figure C-l-Organization of the Indian Health Service

I

1- IHS headquarters ‘ — Rockvil!e, M D

Indian and IHS area office Ind i an Alaskian tribal operated urban governments

7

projects

I

I

1

Hospitals

I

1

[ —

care

L__---l Heal t h

c I i n i cs

r-- —————lr—————— I

I

Heal t h

c1inics

1 SOURCE: U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Office of Planning, Evaluation and Legislation,

Division of Program Statistics, Trends in Indian Heath, 1989 (Rockville, MD: 1989).
Appendix C--Overview of Indian Health Service . 63

Figure C-2—Health Services Managed by Indian and Figure C-3-Service Units, Hospitals, Health Centers

Alaskan Tribal Governments and Stations, and Other Treatment Services

Operated by Indian Health Service Area Offices

Indian and

Alaskian tribal

govern m e n t a

—

I

Servic e

units ~

(52)

I

Hospitals Health centers

(7) and stat ions

(313) ~

I . ~ —

~

Other

Iocations

(11)

L —

~

IHS area

offices

I

1 1

I

Servic e

I

LxU

Hospitals Health centers I

I Other

(43 )

a n d s tat i o ns ; Iocations

I

(131) I I

(37)

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Indian Health Service, Office of Planning, Evaluation

and Legislation, Division of Program S1 tatlstics, Trends in SOURCE: U.S. Department of Health and Human services, Public Health

/ndian Hea/th, 1989 (Rockville, MD: 1989). Service, Indian Health Service, Office of Plannlng, Evaluation

and Legislation, Dwision of Program Statistics, Trends in Indian

Hea/th, 1989 (Rockville, MD: 1989).

Figure C-4-lndian-Operated Urban Projects

Partially Supported by Indian Health Service

Indian operated

u r ban projects

(33 )

1 1

Heal th c1 in ics

(28 )

Communit y

se rv ices

I (5)

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Indian Health Service, Office of Planning, Evaluation

and Legislation, Division of Program Statistics, Trends in Indian

Health, 1989 (Rockville, MD: 1989).
64 ● Indian Adolescent Mental Health

E m

0

0

0

O m

EHllll

%
Appendix D

Acknowledgments

Lynn Ackerson

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Michael Arfstan

American Indian Health Care

Association

St. Paul, MN

Katherine Armstrong

U.S. Department of Health and

Human Services

Office of Disease Prevention and

Health Promotion

Washington, DC

Fred Beauvais

Colorado State University

Fort Collins, CO

Donald Bechtold

University of Colorado Health

Sciences Center

Denver, CO

George Breneman

Indian Health Service

Rockville, MD

Thomas Burns

Indian Health Service

Rockville, MD

Phyllis Old Dog Cross

U.S. Public Health Service

Rapid City, SD

Terry L. Cross

Northwest Indian Child Welfare

Institute

Portland, OR

Sally Davis

Center for Indian Youth Program

Development

University of New Mexico

Albuquerque, NM

Dennis P. DeGross

Alaska Native Health Board

Anchorage, AK

Rhonda Dick

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Christine DUC1OS

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Aaron Handler

Indian Health Service

Rockville, MD

Kathleen Hedrick

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Al Hiat

Indian Health Service

Albuquerque, NM

Ken Hunt

Center for Indian Youth program

Development

University of New Mexico

Albuquerque, NM

Emery A. Johnson

Rockville, MD

Steve Kaufman

Indian Health Service

Rockville, MD

Judy Kuntze

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Jerry M. Lyle

Indian Health Service

Rockville, MD

Russell Mason

Indian Health Service

Rockville, MD

Ron Meeks

Indian Health Service

Rockville, MD

Gordon Neligh

University of Colorado

Department of Psychiatry

Denver, CO

Scott Nelson

Indian Health Service

Albuquerque, NM

John O’Connor

National Indian Health Board

Denver, CO

Judy Palier

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Delores Parron

National Institute of Mental Health

Rockville, MD

Lillian Rendon

National Center for American Indian

and Alaska Native Mental Health

Research

Denver, CO

Rock R. Richardson

Oklahoma Department of Mental

Health

Oklahoma City, OK

Gayle Riddles

Indian Health Service

Rockville, MD

William H. Sack

The Oregon Health Sciences

University

Portland, OR

Sherry Saddler

Indian Health Service Flathead

Service Unit

St. Ignatius, MT

Sheppard Salusky

Seattle Indian Health Board

Seattle, WA

Valerie Shangreaux

Indian Center, Inc.

Lincoln, NE

David E. Simmons

Northwest Indian Child Welfare

Association

Portland, OR

Andrea Solarz

Carnegie Corporation of New York

Office of Technology Assessment

Maria E, Stetter

Indian Health Service

Albuquerque, NM

-65–
66 ● Indian Adolescent Menta[ Health

James W. Thompson

The University of Maryland

Baltimore, MD

Susan Thornton

National Center for American lndian

and Alaska Native Mental Health

Research

Denver, CO

Joseph Trimble Eddie Wadda

Western Washington University Youth Council/ UNITY

Bellingharn, WA Wind River Reservation

Fort Washakie, WY

Lillian Vigil

National Center for American Indian Diane J. Willis

and Alaska Native Mental Health University of Oklahoma

Research Oklahoma City, OK

Denver, CO
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