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American Indian children and adolescents suffer from a high prevalence of alcohol, drug, and mental (ADM) disorders. Unfortunately, the systems of services for these children and youth have never been able to address adequately their mental health needs. Thus, the revolutionary changes now taking place within these service systems, in particular the marked increase in the direct provision of services by Indian tribes and organizations, provides a unique opportunity to address these historical shortcomings. In this paper, we describe our existing knowledge concerning the quality of ADM services for American Indian children and adolescents and their critical sociodemographic, sociocultural, and epidemiologic contexts. We then consider the implications of these studies for improving the quality of care as well as its measurement and monitoring. [ABSTRACT FROM PUBLISHER]

Abstract Background A variety of forces are now shaping a passionate debate regarding the optimal approaches to improving the quality of substance abuse services for American Indian and Alaska Native communities. While there have been some highly successful efforts to meld the traditions of American Indian and Alaska Native tribes with that of 12-step approaches, some American Indian and Alaska Natives remain profoundly uncomfortable with the dominance of this Euro-American approach to substance abuse treatment in their communities. This longstanding tension has now been complicated by the emergence of a number of evidence-based treatments that, while holding promise for improving treatment for American Indian and Alaska Natives with substance use problems, may conflict with both American Indian and Alaska Native and 12-step healing traditions. Discussion We convened a panel of experts from American Indian and Alaska Native communities, substance abuse treatment programs serving these communities, and researchers to discuss and analyze these controversies in preparation for a national study of American Indian and Alaska Native substance abuse services. While the panel identified programs that are using evidence-based treatments, members still voiced concerns about the cultural appropriateness of many evidence-based treatments as well as the lack of guidance on how to adapt them for use with American Indians and Alaska Natives. The panel concluded that the efforts of federal and state policymakers to promote the use of evidence-based treatments are further complicating an already-contentious debate within American Indian and Alaska Native communities on how to provide effective substance abuse services. This external pressure to utilize evidence-based treatments is particularly problematic given American Indian and Alaska Native communities' concerns about protecting their sovereign status. Summary Broadening this conversation beyond its primary focus on the use of evidence-based treatments to other salient issues such as building the necessary research evidence (including incorporating American Indian and Alaska Native cultural values into clinical practice) and developing the human and infrastructural resources to support the use of this evidence may be far more effective for advancing efforts to improve substance abuse services for American Indian and Alaska Native communities.

Background: For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources., Objective: To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen., Methods: Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy., Results: Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process., Conclusions: The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Alaska Native communities experience high rates of alcohol and substance abuse and face challenges accessing quality, culturally appropriate treatment. Telepsychiatry could help bridge this gap, but no publications have examined its impacts for alcohol and substance abuse treatment directed at Alaska Native communities. This study explores one telepsychiatry clinic's impact on a residential substance abuse treatment serving the Alaska Native community in Anchorage, Alaska. Methods: Using a matched case - control design, 103 cases receiving telepsychiatry services between 2007 and 2012 were matched with 103 controls who did not. Outcome measures included length of stay, discharge plans, emergency room visits, and hospital admissions; clinical history, including previous suicide attempts, history of violence, and trauma history; social stressors such as current legal issues, unemployment, and homelessness; mental health, medical, and substance abuse diagnoses; and number of telepsychiatry appointments and nature of telepsychiatry services rendered. Results: Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telepsychiatry group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete treatment. Discussion/Conclusions: Our study highlights this telepsychiatry clinic's real-world difference serving the complex substance abuse treatment needs of Alaska Native individuals. It also reinforces telepsychiatry's promise in serving other communities facing a high burden of addiction and mental illness yet facing barriers to high-quality, culturally competent services.

Background : Starting in 2013, the Mental Health Youth Action Board, made up of 15 teens ages 15-18, was created to advise a large children's hospital on improvements in mental health care and produce social action projects to impact community perceptions of mental health. Methods : This participatory qualitative case study explored the experiences of 14 young people who participated in the Mental Health Youth Action Board between 2013 and 2016. Results : There were two higher order themes: process and outcomes. Process-related themes included how this was a unique leadership experience, the importance of the arts-based approach, and value of the intentionally constructed storytelling process. These processes led to youth growing as advocates for mental health. Conclusions : Arts-based approaches to social action that allow youth to share personal experiences of stigmatized topics can promote healing and support their growth as leaders.

Home-visiting programs have become a key component of evidence-based services for pregnant women, new mothers, their infants, and their families. When Congress authorized the Maternal Infant and Early Childhood Home Visiting Program (MIECHV) in 2010, it set aside 3% of the $1.5 billion in funding to support home-visiting programs operated by tribes, Tribal MIECHV programs have been funded in 14 states and have served over 3,100 families, providing nearly 55,000 home visits to families at risk for poor child, maternal, and family outcomes. In this Introduction to the Special Issue of the Infant Mental Health Journal on the Tribal MIECHV initiative, we provide some key contexts of the work of the Tribal MIECHV grantees as well as an overview of the issues covered in the other articles., (© 2018 Michigan Association for Infant Mental Health.)

Objectives: To examine the extent to which law enforcement agencies (LEAs) and gun retailers are willing to offer voluntary, temporary storage as a part of an overall suicide prevention effort., Methods: We invited all LEAs and gun retailers in 8 US states to respond to questionnaires asking about their willingness to offer temporary gun storage and their recommendations to gun owners about safe storage., Results: We collected data in 2016 from 448 LEAs and 95 retailers (response rates of 53% and 25%, respectively). Three quarters of LEAs (74.8%; 95% confidence interval [CI] = 72.1, 77.5) indicated they already provided temporary storage compared with 47.6% (95% CI = 39.2, 56.0) of retailers. LEAs were most willing to provide storage when a gun owner was concerned about the mental health of a family member. Retailers were more receptive than were LEAs to providing storage when visitors were coming or for people wanting storage while traveling. Both groups recommended locking devices within the home, but LEAs were slightly more favorable to storing guns away from the home., Conclusions: Law enforcement agencies and gun retailers are important resources for families concerned about suicide.

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

Previous studies suggest that youth with anxiety disorders experience their sleep as more disrupted and unsatisfying than their healthy peers. However, it is unclear whether these subjective complaints align with objective measures of sleep quantity and quality. The purpose of this preliminary study was to assess subjective and objective sleep parameters, and their relationships with anxiety symptomatology, among adolescents (62.8% female, 81.4% Caucasian), ages 12 to 18 (M = 15.29 years), with generalized anxiety disorder (n = 26) and controls without any psychopathology (n = 17). We measured sleep over 7 nights using sleep diaries and actigraphy and collected self- and parent-report questionnaires pertaining to sleep, anxiety, and depression. Repeated-measures mixed models were used to examine relationships between nightly sleep duration and morning anxiety. We found a number of differences in sleep between our anxious and healthy participants. Via sleep diary, our anxious participants had longer sleep onset latencies and lower satisfaction with sleep relative to controls, whereas via actigraphy we found longer sleep onset latencies but greater overall sleep duration among anxious versus control participants. Actigraphic measures of sleep disturbance were associated with parent-report of anxiety and depression. Our mixed-model analyses revealed that decreases in nightly sleep duration were associated with increased morning anxiety, but only among our participants with generalized anxiety disorder. Findings suggest that sleep disturbance among anxious adolescents can be detected using both subjective and objective measures and that, for these individuals, fluctuations in sleep duration may have real consequences for daytime anxiety.

Introduction: A youth's emergency department (ED) visit for suicidal behaviors or ideation provides an opportunity to counsel families about securing medications and firearms (i.e., lethal means counseling)., Methods: In this quality improvement project drawing on the Counseling on Access to Lethal Means (CALM) model, we trained 16 psychiatric emergency clinicians to provide lethal means counseling with parents of patients under age 18 receiving care for suicidality and discharged home from a large children's hospital. Through chart reviews and follow-up interviews of parents who received the counseling, we examined what parents recalled, their reactions to the counseling session, and actions taken after discharge., Results: Between March and July 2014, staff counseled 209 of the 236 (89%) parents of eligible patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the intervention; 48% of those eligible. Parents had favorable impressions of the counseling and good recall of the main messages. Among the parents contacted at follow up, 76% reported all medications in the home were locked as compared to fewer than 10% at the time of the visit. All who had indicated there were guns in the home at the time of the visit reported at follow up that all were currently locked, compared to 67% reporting this at the time of the visit., Conclusion: Though a small project in just one hospital, our findings demonstrate the feasibility of adding a counseling protocol to the discharge process within a pediatric psychiatric emergency service. Our positive findings suggest that further study, including a randomized control trial in more facilities, is warranted.

Background: Substance abuse continues to exact a significant toll, despite promising advancements in treatment, and American Indian and Alaska Native (AI/AN) communities remain disproportionately impacted. Understanding the challenges to providing quality substance abuse treatment to AI/AN communities could ultimately result in more effective treatment interventions, but no multi-site studies have examined this important issue., Methods: This qualitative study examined the challenges of providing substance abuse treatment services for American Indian and Alaska Native (AI/AN) communities. We conducted key informant interviews and focus groups at 18 substance abuse treatment programs serving AI/AN communities. Seventy-six service participants (21 individuals in clinical administrative positions and 55 front-line clinicians) participated in the project. Interview transcripts were coded to identify key themes., Results: We found that the challenges of bringing effective substance abuse treatment to AI/AN communities fell into three broad categories: challenges associated with providing clinical services, those associated with the infrastructure of treatment settings, and those associated with the greater service/treatment system. These sets of challenges interact to form a highly complex set of conditions for the delivery of these services., Conclusions: Our findings suggest that substance abuse treatment services for AI/AN communities require more integrated, individualized, comprehensive, and longer-term approaches to care. Our three categories of challenges provide a useful framework for eliciting challenges to providing quality substance abuse treatment in other substance abuse treatment settings.

Objective: Culture figures prominently in discussions regarding the etiology of alcohol and substance abuse in American Indian and Alaska Native (AI/AN) communities, and a substantial body of literature suggests that it is critical to developing meaningful treatment interventions. However, no study has characterized how programs integrate culture into their services. Furthermore, reports regarding the associated challenges are limited., Methods: Twenty key informant interviews with administrators and 15 focus groups with clinicians were conducted in 18 alcohol and substance abuse treatment programs serving AI/AN communities. Transcripts were coded to identify relevant themes., Results: Substance abuse treatment programs for AI/AN communities are integrating culture into their services in two discrete ways: by implementing specific cultural practices and by adapting Western treatment models. More important, however, are the fundamental principles that shape these programs and their interactions with the people and communities they serve. These foundational beliefs and values, defined in this study as the core cultural constructs that validate and incorporate AI/AN experience and world view, include an emphasis on community and family, meaningful relationships with and respect for clients, a homelike atmosphere within the program setting, and an “open door” policy for clients. The primary challenges for integrating these cultural practices include AI/AN communities' cultural diversity and limited socioeconomic resources to design and implement these practices., Conclusions: The prominence of foundational beliefs and values is striking and suggests a broader definition of culture when designing services. This definition of foundational beliefs and values should help other diverse communities culturally adapt their substance abuse interventions in more meaningful ways.

American Indian (AI) youth experience significant mental health disparities. The majority of AI youth live in urban areas, yet urban AI youth are underserved and unstudied. This manuscript describes a qualitative study of community mental health needs in an urban population of AI youth, conducted as part of the planning process for a system of care (SOC). Participants included 107 urban AI youth and families that participated in one of 16 focus groups assessing mental health needs and services. Forty-one percent of participants were youth or young adults. Data were coded and analyzed using qualitative software and then further analyzed and interpreted in partnership with a community research workgroup. Results indicated various community characteristics, mental health and wellness needs, and service system needs relevant to developing a system of care in this community. Key community, cultural, and social processes also emerged, reinforcing the importance of broader system changes to promote a sustainable SOC. These systems/policy changes are reviewed in the context of previous literature proposing necessary systems change to support behavioral health care in AI communities as well as to ensure that SOC implementation is consistent with core values and philosophy across all communities.

In their recent article, N. Spillane and G. Smith suggested that reservation-dwelling American Indians have higher rates of problem drinking than do either non-American Indians or those American Indians living in nonreservation settings. These authors further argued that problematic alcohol use patterns in reservation communities are due to the lack of contingencies between drinking and "standard life reinforcers" (SLRs), such as employment, housing, education, and health care. This comment presents evidence that these arguments were based on a partial review of the literature. Weaknesses in the application of SLR constructs to American Indian reservation communities are identified as is the need for culturally contextualized empirical evidence supporting this theory and its application. Cautionary notes are offered about the development of literature reviews, theoretical frameworks, and policy recommendations for American Indian communities., ((c) 2009 APA, all rights reserved.)

Telepsychiatry may involve working with clinicians, patients and systems of care that are both geographically and culturally distinct. In this context, culturally appropriate care is an important component of telepsychiatry. The outline for cultural formulation from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides general principles for addressing these issues. Two components of the outline are particularly relevant in telepsychiatry: (1) how the cultural background of patients (i.e. their cultural identity) influences their comfort with technology; and (2) the effect of cultural differences on the patient-provider relationship. Cultural differences between patient and provider are often highlighted in telepsychiatry by the patient and provider location (e.g. rural versus urban differences). Familiarity with the rural community and regular contact and feedback are important. Future research should examine the effect of telepsychiatry on patient-provider relationships, patient attitudes towards care and, most importantly, patient outcomes.

Objective: To determine the response of children with childhood-onset schizophrenia to a 1-year prospective, open-label trial of olanzapine., Methods: Twenty children (age range 6-15 years) with childhood-onset Diagnostic and Statistical Manual of Mental Disorders (fourth edition) schizophrenia participated. The treating clinician was free to vary or discontinue dosing and use additional medications. Symptoms were assessed by the Brief Psychiatric Rating Scale-Child version (BPRS-C), Scale for the Assessment of Positive Symptoms, and Scale for the Assessment of Negative Symptoms. Extrapyramidal symptoms, akathisia, temperature, and weight were monitored., Results: BPRS-C subscales of thought disturbance and psychomotor excitation, and the Scale for the Assessment of Positive Symptoms demonstrated significant decreases by 6 weeks of treatment; BPRS-C anxiety and the Scale for the Assessment of Negative Symptoms (SANS) showed significant improvement after 1 year of treatment. Seventy-four percent of subjects were considered treatment responders, with a greater than 20% reduction in total BPRS-C score and overall impairment of mild or better. Weight gain (body mass index) was above that expected for normal development in every child. No child developed neuroleptic-related dyskinesias. Seventy-four percent (n = 14) of patients completed this 1-year, open-label trial. Of the 5 subjects who discontinued, weight gain was noted as the reason for 4 subjects., Conclusions: Olanzapine appears useful in the treatment of childhood-onset schizophrenia, although there may be a delayed onset of benefit for anxiety and negative symptoms. Weight gain is problematic, but the emergence of dyskinesias may be rare. Additional controlled trials are indicated.

Studies have found high prevalences of conduct disorder among youth in residential substance abuse treatment programs, but no studies have examined this issue among American Indian adolescents while taking into account gender differences. The Diagnostic Interview Schedule for Children, Youth Version and the Composite International Diagnostic Interview, Substance Abuse Module were used to determine the diagnostic status of 89 American Indian adolescents aged between 13 and 18 years who were admitted to a residential treatment program. Seventy-four percent of the adolescents met full DSM-IV criteria for conduct disorder. More than 85% of the participants met at least one criterion for conduct disorder. Conduct disorder was common among both boys and girls in this sample of American Indian adolescents, but the specific antisocial behaviors displayed and their relationships to other psychiatric disorders varied by gender.

Objective: To determine whether the predominant pattern of the sequence of use of different classes of substances among a large sample of American Indian (AI) adolescents is consistent with Stage Theory [i.e., (1) alcohol, (2) marijuana, (3) other illicit drugs, and (4) cocaine]., Method: Data came from surveys completed by 1,562 AI high school students in 1993. Pairwise comparisons of age of first use for alcohol, marijuana, inhalants, cocaine, and other illicit drugs were examined, as were the prevalence rates of specific sequences of substance use., Results: Thirty-five percent of the AI youths who had used both alcohol and marijuana reported using alcohol first. Seventy-five percent of youths who had used three or more substances reported a sequence of first use that was inconsistent with Stage Theory. However, a general pattern of using alcohol, marijuana, and/or inhalants prior to the use of cocaine and other illicit drugs was observed. Sequences of first use varied by gender, age of first substance use, community, and number of classes of substances used., Conclusions: To enhance the validity of Stage Theory for AI adolescents, the authors recommend its revision to include alcohol, marijuana, and inhalants as initiating substances.

Objective: This study described service use among American Indian veterans, compared use patterns across biomedical care and traditional healing options, and tested whether utilization varied as a function of need or availability., Methods: A cross-sectional survey of 621 male combat veterans selected from tribal rolls was conducted between 1992 and 1995 in American Indian reservation communities in the Southwest and in the Northern Plains. Measures included assessments of demographic characteristics, physical and mental health conditions, and self-reports of any use during the past year of Veterans Administration (VA), Indian Health Service (IHS), and other biomedical services as well as participation in traditional ceremonies and use of indigenous healing options., Results: Tribal groups were similar in sociodemographic characteristics and in number of health problems and mental and substance use problems during the past year. The same types of services from IHS were available to the two groups, and the geographic distance to these services was similar. VA facilities were more readily available in the Northern Plains than in the Southwest, where they were far from reservation boundaries. Use of IHS services was similar for the two tribal groups, but use of VA services was significantly less in the Southwest. Overall, biomedical services were used more in the Northern Plains, reflecting greater use of VA facilities. However, these differences in overall health service disappeared when traditional healing options were considered. Use of traditional healing was greater in the Southwest, offsetting lower biomedical service use., Conclusions: When the full array of options is examined, service use functions according to need for health care, but the kind of services used varies according to availability.

Use of mental health and substance abuse services was examined among 109 American Indian adolescents in a Northern Plains reservation community. Each was interviewed to assess psychiatric diagnosis and service use and to determine whether an adult had recognized a problem in the adolescent-a critical determinant of receipt of services. Of the 23 youths who had a disorder, nine (39 percent) reported lifetime service use. Of the 25 who received services, 17 were treated by a school counselor; only one received services from a mental health specialist. Eight of the 25 youths with a psychiatric or substance use diagnosis who did not receive services reported that an adult had recognized a problem.

Data from self-report surveys of 1,353 high school students representing three culturally distinct American Indian tribes were analyzed for tribal differences in factors associated with suicidal ideation. In the multivariate analysis, no single correlate of suicide ideation was common to all three tribes. The correlates of suicide ideation were consistent with each tribe's social structure, conceptualization of individual and gender roles, support systems, and conceptualization of death. These results underscore the heterogeneity of suicide ideation across three distinct American Indian tribes consistent with their cultural heterogeneity. Suicide prevention and screening programs may be difficult to adapt from one tribe to another.

Objective: To describe the relationship between psychiatric status and the use of alcohol, drug, and mental health (ADM) services among a sample of American Indian (AI) juvenile detainees., Method: A structured diagnostic and service use interview was administered to 150 AI youths detained in a juvenile detention center located on a Northern Plains reservation., Results: Forty percent of AI youths with a diagnosed substance use disorder and 34.1% with a diagnosed anxiety, mood, or disruptive behavior disorder reported lifetime use of services for substance use and emotional problems, respectively. While services for substance use problems were most commonly provided in residential settings, services for emotional problems were most commonly provided in outpatient settings. Traditional healers and pastoral counselors provided services to 23.7% and 29.6% of youths who received services for substance use and emotional problems, respectively. Detained youths were more likely to receive ADM services than AI adolescents living at--large in another, comparable Northern Plains reservation community. Still, the vast majority of youths in detention who suffered from psychiatric disorders did not report use of ADM services., Conclusions: Detention facilities serving AI adolescents need to screen carefully for the presence of psychiatric disorders and facilitate the use of ADM services.

Objective: To describe the developmental course of marijuana use among a group of American Indian adolescents, aged 14 through 20 years., Method: A group of 1,766 American Indian adolescents from 3 culture groups provided repeated measures of 30-day marijuana use twice a year across a 3-year period. Linking 5 age cohorts, hierarchical linear modeling was used to model a curvilinear trajectory of marijuana use. Gender and community differences were examined as well., Results: Support was found for a "maturational" model of marijuana use across time: Use increased in middle adolescence, peaked in later adolescence, and began to decrease in early adulthood. Both gender and community differences in trajectories were significant as well., Conclusions: Marijuana use among American Indian adolescents follows a clear developmental trajectory. Growth curve analysis can provide an additional tool for studying the effects of interventions that may not be apparent in a traditional evaluation design.

Aim: To examine the characteristics of marijuana users among a large sample of American Indian high school students., Design: High school survey., Setting: Seven predominantly American Indian high schools in four communities west of the Mississippi., Participants: 1464 Indian adolescents who: (1) completed a survey in November, 1993, (2) were in grades 9 to 12, (3) were members of one of four Indian tribal groups; and (4) had a complete set of data for these analyses., Measurements: Logistic regression models were developed to predict the probability of low-frequency (1-3 times over the last month) and high-frequency (11 or more times) marijuana use. Independent variables included measures of socio-demographics, stressful life events, personal characteristics and beliefs, psychiatric symptomatology and other substance use., Findings: Forty per cent of these American Indian adolescents had used marijuana at least once in the last month. The prevalence of marijuana use varied across the four tribes. Males were no more likely than females to use marijuana at a low frequency, but were more likely to use at a high frequency. The factors associated with marijuana use varied with the frequency of use and by gender. In the final multivariate models, low-frequency marijuana use among females was associated with reporting that peers encouraged alcohol use as well as use of alcohol and stimulants. Among males, low-frequency use was associated with greater positive alcohol expectancies, lower grades in school and alcohol use. While high-frequency marijuana use was associated with use of alcohol, stimulants and cocaine among females, such use was associated with higher scores on the antisocial behavior scale as well as the use of alcohol, stimulants and cocaine among males. Overall, the strongest associations were with the use of alcohol and other illicit substances., Conclusion: Low-frequency and high-frequency marijuana use are distinct patterns of use and have different correlates across genders. Marijuana use among American Indian adolescents is a complex phenomenon that is best understood within the context of other substance use.

Objectives: To examine the prevalence of common psychiatric disorders among adolescents detained on a Northern Plains reservation., Methods: Prevalence data were gathered using lay interviewers administering structured diagnostic instruments based on DSM-III-R criteria to 150 youths booked into a reservation-based juvenile detention center from July 1995 through April 1996., Results: Approximately 49% of the sample had at least one alcohol, drug, or mental health disorder; 12.7% had two disorders; and 8.7% had three or more disorders. The most common diagnoses were substance abuse/dependence (38%), conduct disorder (16.7%), and major depression (10%). Females were significantly more likely than males to have major depression and/or anxiety disorders and were significantly more likely to have three or more disorders. These rates were higher in comparison with general and Indian adolescent community samples., Conclusions: These American Indian adolescent detainees had a high prevalence of psychiatric disorders. Local juvenile justice systems should be vigilant for the presence of psychiatric disorders and appropriately connected with psychiatric services to address this considerable need. Careful psychiatric assessment is necessary to ensure a more coordinated community service response to juvenile delinquency.

Objective: The publication of DSM-IV is notable for the improved coverage of cultural issues in the diagnosis of mental disorders. In particular, Appendix I of DSM-IV includes an "Outline for Cultural Formulation" (Outline) which assists the clinician in evaluating the impact of an individual's cultural context on diagnosis and treatment. However, the capacity of the Outline to facilitate the development of comprehensive cultural formulations for children and adolescents has not been established. In this article the use of the Outline with American Indian children is reviewed critically., Method: Based on the Outline, cultural case formulations for four American Indian children were developed and their comprehensiveness was assessed., Results: Applied to the case material, the Outline provided a clear template for the development of cultural formulations. Nonetheless, several gaps in the material required by the Outline were identified, particularly in the areas concerning cultural identity and cultural elements of the therapeutic relationship., Conclusions: Clinicians working with children should recognize the strengths as well as the limitations of the Outline and expand their cultural descriptions accordingly. Several additions to the text of the Outline that will facilitate the development of comprehensive cultural formulations specific to children and adolescents are proposed.

Objective: To describe the patient population and use of mental health treatment at a residential substance abuse treatment program for American Indian and Alaska Native adolescents. Specifically, this article (1) reports the level of psychiatric symptomatology among the patient population; (2) compares male and female patients in terms of demographics, symptomatology, and receipt of mental health treatment; and (3) examines the degree of association between patient psychiatric symptomatology and the receipt of mental health treatment., Method: Medical records were reviewed for all 64 patients admitted over a 1-year period. Data included patient characteristics such as substance use and psychiatric symptomatology as well as the receipt of mental health treatment., Results: Sixty-eight percent of patients screened positive for at least one psychiatric symptom type. Females reported greater substance use and were more likely to report that they were victims of abuse. Females also were more likely than males to receive mental health treatment even though males had at least equal need. Finally, there was no significant relationship between measures of psychopathology and subsequent receipt of mental health treatment., Conclusions: Reassessment of the methods for identifying and treating patients with comorbid psychopathology within programs of this nature is indicated.

Objective: This study examines factors potentially associated with the receipt of alcohol treatment services among a large sample of American Indian adolescents., Method: Data for this study were drawn from the Voices of Indian Teens project, a 5-year, longitudinal project involving school-based survey data collection at 10 primarily American Indian schools. In November 1992 a total of 2,077 American Indian youths in grades 9 through 12 completed self-report surveys. Of these, 1,681 had a complete set of data for these analyses. Three logistic regression models were developed to predict the probability of (1) receipt of treatment, (2) treatment recommendation, and (3) receipt of treatment among those teenagers who received a treatment recommendation., Results: The probability of an individual receiving treatment was 15 times greater if treatment was recommended. Treatment recommendation mediated the relationship of several measures of psychological distress and alcohol use, abuse, and dependence with actual treatment., Conclusions: Recommendation for treatment is strongly associated with receiving treatment. Community education about the risks, signs, symptoms, need, and mechanisms for obtaining treatment of alcohol abuse among youths might help alcohol-abusing individuals receive the help they need.