Native Adolescent Substance Use and Mental Illness: A Catalyst for Disaster Denver, Colorado

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Native Adolescent Substance Use and Mental Illness: A Catalyst for Disaster Denver, Colorado May 11, 2006 Dale Walker, MD Laura Loudon, MS Patricia Silk Walker, PhD Douglas Bigelow, PhD Denise Middlebrook, PhD Michelle Singer

2. Native Communities Advisory Council / Steering Committee One Sky Center

3. One Sky Center Partners

4. One Sky Center Outreach

6. Presentation Overview • An Environmental Scan • Behavioral Health and Education System Issues • Fragmentation and Integration • Discuss Behavioral Health, Suicide, Disaster • Integrated care approaches and interagency coordination are best overall solutions

7. Six Missions Impossible? • How do we define health, education, and social problems? • How do we define disaster? • How do we ask for help? • How do we get Federal and State agencies to work together and with us? • How do we build our communities? • How do we restore what is lost?

11. A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country, July 2003 Funding not sufficient to meet needs for: • Health care • Education • Public safety • Housing • Infrastructure development needed

12. Native Health/ Educational Problems Alcoholism 6X Tuberculosis 6X Diabetes 3.5X Accidents 3X Suicide 1.7 to 4x Health care access -3x Poverty 3x Poor educational achievement Substandard housing

13. AmericanIndians • Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

14. Agencies Involved in Edn. & B.H. 1. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 2. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 3. Tribal Education/Health 4. Urban Indian Education/Health • State and Local Agencies • Federal Agencies: SAMHSA, Edn

15. Disconnect Between Education/Behavioral Health • Professionals are undertrained in one of the two domains • Students as patients are under diagnosed and under treated • Students have less opportunity for education • Neither system integrates well with medical, emergency, legal, and social services

16. Difficulties of System Integration • Separate funding streams and coverage gaps • Agency turf issues • Different philosophies • Lack of resources • Poor cross training • Consumer and family barriers

17. Different goals Resource silos One size fits all Activity-driven How are we functioning? (Dale Walker, Carl Bell, 7/03)

18. Best Practice Culturally Specific Outcome Driven Integrating Resources We need Synergy and an Integrated System (Dale Walker, Carl Bell, 7/03)

19. BIA Schools • 184 elementary and secondary schools and dormitories (55) as well as 27 colleges • In 23 states • 60,000 total students • 238 different tribes • Majority of the schools are located in Arizona and New Mexico • Second greatest number of schools in the states of North Dakota and South Dakota • Third greatest lie in the northwest

20. Why should schools be involved? • Schools cannot achieve their mission of education when students’ problems are barriers to learning and development.From Carnegie Task Force on Education. • Schools are at times a source of the problem and need to take steps to minimize factors that lead to student alienation and despair. • Schools also are in a unique position to promote healthy development and protective buffers, offer risk prevention programs, and help to identify and guide students in need of special assistance.

21. Adolescent Problems In Schools Alcohol Drug Use Fighting and Gangs Bullying Weapon Carrying School Environment Sale of Alcohol and Drugs Sexual Abuse Unruly Students Truancy Attacks on Teachers Staff Domestic Violence Drop Outs 12

22. Emergency situation Event where, in order to protect the people, goods and the environment, requires a quick response for which the normal proceduresand resources of an organisation are adequate.

23. Disaster Event, endangering the safety of people, goods and the environment, that exceeds the organisation’s normal response capabilities (resources or procedures)

24. When Does an Emergency Become a Disaster? • A disaster depends largely on the community itself. What is it’s size, it’s resources, it’s experience in dealing with a certain hazard.

25. Suicide: A National Crisis • In the United States, more than 30,000 people die by suicide a year.1 • Ninety percent of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder.2 • The annual cost of untreated mental illness is $100 billion.3 1 The President’s New Freedom Commission on Mental Health, 2003. 2 National Center for Health Statistics, 2004. 3 Bazelon Center for Mental Health Law, 1999.

26. Our Native Community Issue • For every suicide, at least six people are affected.4 • There are higher rates of suicide among survivors (e.g., family members and friends of a loved one who died by suicide).5 • Communities are closely linked to each other, increasing the risk of cluster suicide. 4 National Center for Health Statistics, 1999. 5 National Institute of Mental Health, 2003.

28. Suicide Rates by Age, Race, and Gender 1999-2001 Source: National Center for Health Statistics

29. Native Suicide: A Multi-factorial Event Psychiatric Illness& Stigma -Edn,-Econ,-Rec Cultural Distress Impulsiveness Substance Use/Abuse Hopelessness Family Disruption Domestic Violence Suicide Family History Negative Boarding School Psychodynamics/ Psychological Vulnerability Historical Trauma Suicidal Behavior

30. Current Cluster Suicide Crisis in a Tribal Community • 300+ attempts in last 12 months • 70 attempts since November • 13 completions in 12 months • 8 completions in 3 months • 4 to 5 attempts per week • Some attempts are adult • Age range of completions: 14-24 years of age • Most completed suicides are female • 80% Alcohol related • All hanging

31. Ecological Model Society Community/Tribe Peer/Family Individual

32. Suicide: Individual FactorsRiskProtective • Cultural/religious beliefs • Coping/problem solving skills • Ongoing health and mental health care • Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathy • Intellectual competence, reasons for living • Mental illness • Age/Sex • Substance abuse • Loss • Previous suicide attempt • Personality traits Incarceration • Failure/academic problems

33. Suicide: Peer/Family FactorsRiskProtective • Family cohesion (youth) • Sense of social support • Interconnectedness • Married/parent • Access to comprehensive health care • History of interpersonal violence/abuse/ • Bullying • Exposure to suicide • No-longer married • Barriers to health care/mental health care

34. Suicide: Community FactorsRiskProtective • Access to healthcare and mental health care • Social support, close relationships, caring adults, participation and bond with school • Respect for help-seeking behavior • Skills to recognize and respond to signs of risk • Isolation/social withdrawal • Barriers to health care and mental health care • Stigma • Exposure to suicide • Unemployment

35. Suicide: Societal FactorsRiskProtective • Urban/Suburban • Access to health care & mental health care • Cultural values affirming life • Media influence • Western • Rural/Remote • Cultural values and attitudes • Stigma • Media influence • Alcohol misuse and abuse • Social disintegration • Economic instability

36. Four Phases of Emergency Management • Mitigation • Preparedness • Response • Recovery

37. Tips for talking to children after a disaster • Provide opportunities to talk about what they are seeing on television and to ask ? • Don’t be afraid to admit you don’t know all the answers • Answer ? At a level the child can understand • Establish a family emergency plan (Sense of doing something is helpful) • Monitor children’s TV watching..don’t need to see event over & over) Watch with children • Help kids to understand there are no bad emotions • Try to not focus on blame • In addition to tragic things seen, also help kids focus on good things such as heroic actions, reuniting of families, assistance offered by people throughout the world

38. Tips for children closer to disaster • Disasters often reawaken a child’s fear of loss of own parents when parents are preoccupied with own fears … consider family counseling • Families may permit some regressive behavior weaning off by leaving bedroom door open, night lights, extra time with parents • Parents may have trouble leaving child after a disaster,,,may be able to use child’s problem as a way of asking for help themselves • Get the children into some sense of routine of school and play even if displaced • Teachers can help kids with art, and play activities, encouraging group discussions and presentations about the disaster

39. Stress Management • Mental health professionals with child/family training • Information, information, information • Provide energy outlets for kids • Provide parents with time away from kids • Provide best possible sleep environment • Therapeutic play (drawing, role play)

41. Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample

42. Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years Percentage ever used Percentage ever used R. Dale Walker, M.D. (4/99) * 100% Completion Sample

43. Age of Onset of Substance Use Among Urban American Indian Adolescents, by Substance Used R. Dale Walker, M.D. (5/2000) *Cohorts 4 & 5 were sampled every third year; recall and sampling bias apply

44. Momentary power Freedom Love Euphoria Peer acceptance Alleviate pain Boredom Self concept problems Loneliness Loss Nothingness Depression Shame Reasons for Use

45. How Teens View Counseling What to do: • Witch Hunt • Helpless • Target • Danger • Waste of time • Non - judgmental • Honesty • Consistency • Confidentiality • Always a ? of accuracy

46. PreventionPrograms Should . . . . Target all Forms of Drug Use . . .and be Culturally Sensitive

47. Prevention ProgramsReduce Risk Factors • ineffective parenting • chaotic home environment • lack of mutual attachments/nurturing • inappropriate behavior in the classroom • failure in school performance • poor social coping skills • affiliations with deviant peers • perceptions of approval of drug-using behaviors

48. Prevention ProgramsEnhance Protective Factors • strong family bonds • parental monitoring • parental involvement • success in school performance • pro social institutions (e.g. such as family, • school, and religious organizations) • conventional norms about • drug use

49. Implications for Treatment • Teach adolescents how to cope with difficulties and adversity • Increase their repertoire of coping strategies • Cognitive therapy is most effective approach

50. WHAT ARE SOME PROMISING SCHOOL-BASED STRATEGIES?