Factor structure and validity of the SIQ-JR in a southwest American Indian tribe.

Previous literature is severely limited in evaluation of psychometric properties of suicide screening methods in American Indian (AI) populations, despite the disproportionate burden of suicide faced within AI communities. The purpose of the current study was to examine the psychometric properties of the Suicidal Ideation Questionnaire-Junior (SIQ-JR) for AI youth using 2 community samples of AI adolescents from a Southwestern tribe. The present study sample was comprised of 114 participants (n = 91 and n = 23), ages 10-19 years of age, from 2 studies, both of which were administered the SIQ-JR within 90 days of an index suicide attempt. Findings indicated that a two-factor model resulted in appropriate fit indices with AI youth, a general ideation index and an active ideation index. Scores on the active ideation and general ideation indices were also related to cumulative stress, self-reported suicidal ideation and previous suicide attempt, providing a measure of convergent validity. Finally, use of cutpoint of 20, rather than published cutpoint of 31, evidenced marginally better positive and negative predictive values, with sensitivity within acceptable ranges. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Exploration of Pathways to Binge Drinking Among American Indian Adolescents.

Binge drinking is a serious public health problem among American Indian adolescents, yet few theoretical models specific to this population and type of problematic drinking have been tested. The White Mountain Apache Tribe has begun surveillance of binge drinking and a related line of research to inform tailored prevention efforts. The goal of this paper is to use structural equation modeling to understand the relationships between different individual, family, peer, and cultural factors that predict or protect against binge drinking behavior among Apache adolescents ages 10-19 years old. A cross-sectional case-control study was completed with N = 68 Apache adolescents who required medical attention due to a recent binge event (past 90 days) and N = 55 controls with no lifetime history of binge drinking. The hypothesized model was estimated with Mplus using the WLSMV robust least squares estimator. In the final model, stressful life events were related to family functioning and peer relationships. In turn, family functioning affected peer relationships and adolescent impulsivity, which were both associated with greater risk of binge drinking. The path between peer relationships and having engaged in binge drinking was statistically significant for those expressing lower cultural identity, but not for those reporting higher cultural identity. Findings suggest preventive interventions should emphasize teaching coping skills to manage life stressors and handle impulsivity, strengthening families, and changing peer dynamics with social network-based approaches as well as social skill training. The model highlights the potentially important role of culture in strengthening positive peer relationships to reduce binge drinking risk.

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

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

Entrepreneurship education: A strength-based approach to substance use and suicide prevention for American Indian adolescents.

American Indian (AI) adolescents suffer the largest disparities in substance use and suicide. Predominating prevention models focus primarily on risk and utilize deficit-based approaches. The fields of substance use and suicide prevention research urge for positive youth development frameworks that are strength based and target change at individual and community levels. Entrepreneurship education is an innovative approach that reflects the gap in available programs. This paper describes the development and evaluation of a youth entrepreneurship education program in partnership with one AI community. We detail the curriculum, process evaluation results, and the randomized controlled trial evaluating its efficacy for increasing protective factors. Lessons learned may be applicable to other AI communities.

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

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

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

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

Exploring risk and protective factors with a community sample of American Indian adolescents who attempted suicide.

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

Latent class analysis of substance use and aggressive behavior in reservation-based American Indian youth who attempted suicide.

American Indian (AI) adolescents who attempt suicide are heterogeneous. A latent class analysis was used to identify subgroups of reservation-based AI adolescents with recent suicide attempts. Indicators of class membership were substance abuse and aggressive behaviors; clinical correlates of subgroup membership included risky sexual behavior and recent exposure to suicidal behavior. Three subgroups were identified, representing low, medium, and high substance use and aggressive behavior. Suicide exposure was associated with membership in the lowest risk behavior subgroup; risky sexual behavior was associated with membership the highest risk behaviors subgroup. Findings suggest a continuum of risk behaviors in reservation-based AI youth who attempt suicide.

Risk pathways for suicide among Native American adolescents.

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

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

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

Understanding the relationship between substance use and self-injury in American Indian youth.

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

Nonsuicidal self-injury in an American Indian reservation community: results from the White Mountain Apache surveillance system, 2007-2008.

OBJECTIVE: To describe characteristics and correlates of nonsuicidal self-injury (NSSI) among the White Mountain Apache Tribe. NSSI has not been studied before in American Indian samples despite associated risks for suicide, which disproportionately affect American Indian youth. METHOD: Apache case managers collected data through a tribally mandated surveillance system. Data from 2007 and 2008 (N = 182) were examined for rates, methods, precipitants, functions, past history of self-injury and service use, by age and gender. RESULTS: The rate of NSSI among all ages was 600 in 100,000, with individuals 10 to 14 years old disproportionately affected at a rate of 3,000 in 100,000. More females (65%) reported NSSI, and cutting was the preferred method (98%) for both genders combined. Most frequently reported precipitants were peer pressure/copying, conflict with boy/girlfriend and "depression." A substantial proportion (22%) was intoxicated/high at the time. More reported the function of NSSI was to "effect internal state" (45%) than "effect circumstances" (15%). More than one-third (39%) received ED treatment and referrals for aftercare (36%). Of those referred, only 30% followed up with services. Most (79%) reported past NSSI; 30% reported past suicidal ideation and 25% attempts. CONCLUSIONS: NSSI is a significant, largely unaddressed mental health problem among the White Mountain Apache Tribe and likely other reservation communities, especially as NSSI could serve as a precursor to suicide in this population. Interestingly, another self-destructive behavior, severe substance use, was reported to the surveillance system by Apaches and described in terms similar to NSSI, an important preliminary finding worth further exploration.

Toward understanding suicide among youths: results from the White Mountain Apache tribally mandated suicide surveillance system, 2001-2006.

OBJECTIVES: We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions. METHODS: Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations. RESULTS: Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict. CONCLUSIONS: An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.

Changing epidemiology of invasive pneumococcal disease among White Mountain Apache persons in the era of the pneumococcal conjugate vaccine.

BACKGROUND: Prior to the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7), the rate of invasive pneumococcal disease (IPD) was 8-fold higher among White Mountain Apache persons of all ages than it was among the general US population, . We aimed to assess the impact of PCV7 and 23-valent pneumococcal polysaccharide vaccine on the rate of IPD among White Mountain Apache persons. METHODS: From 1991 through 2006, we conducted active laboratory- and population-based surveillance among Native American residents of the White Mountain Apache reservation. Charts were reviewed and pneumococcal isolates were collected for serotype testing. Three time periods were defined: the pre-PCV7 baseline period (1991-1997), the PCV7 efficacy trial period (1998-2000), and the PCV7 routine-use period (2001-2006). RESULTS: We identified 246 cases of IPD; the mean annual IPD rate fell from 126 cases per 100,000 person-years in the period 1991-1997 to 87 cases per 100,000 person-years in the period 2001-2006 (p = .01). The rate of IPD attributable to PCV7 serotypes of Streptococcus pneumoniae decreased by 252 cases per 100,000 person-years (92%) among children aged <5 years, and that attributable to non-PCV7 serotypes of S. pneumoniae decreased by 87 cases per 100,000 person-years (44%) among children aged <5 years. Among adults, the rate of IPD remained unchanged; PCV7 serotypes of S. pneumoniae accounted for only 25% of adult cases during the period 1991-1997. CONCLUSIONS: Since the introduction of PCV7, the rate of IPD among White Mountain Apache children aged <5 years has decreased to the lowest rate ever (122 cases per 100,000 person-years), but it remains 5.7-fold greater than the rate of IPD among children in the general US population. In contrast to some other high-risk populations, there is no evidence of non-vaccine-type replacement disease in this age group. Among White Mountain Apache adults, the rate of IPD remains substantially higher than that observed in the general US population. Vaccines with broader serotype coverage are needed to further reduce the disparity in the rate of IPD between the White Mountain Apache and general US populations.