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14
Preventing Underage Drinking in American Indian and Alaska Native Communities: Contexts, Epidemiology, and Culture

Douglas K. Novins, Paul Spicer, Janette Beals, and Spero M. Manson*

The use and abuse of alcohol among American Indian and Alaska Native (AI/AN) adolescents is a major public health concern (Beauvais, 1996; U.S. Congress Office of Technology Assessment, 1990). Compared to their non-AI counterparts, AI youth are more likely to use alcohol regularly (Beauvais, 1992b; Beauvais, 1996), more likely to become problem drinkers (Beauvais, 1996), more likely to meet diagnostic criteria for alcohol abuse and dependence (Beals et al., 1997; Costello, Farmer, Angold, Burns, and Erkanli, 1997), more likely to use alcohol in combination with drugs (Beauvais, 1992a; Novins, Beals, and Mitchell, 2001a), and more likely to have both an alcohol use disorder and a psychiatric disorder (Beals, Novins, Mitchell, Shore, and Manson, 2002; Beals et al., 1997; Costello et al., 1997). From service system data and vital statistics, we

*  

This paper from the National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, Aurora, was commissioned by the National Academy of Sciences Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. The authors acknowledge the contributions of Drs. Candace Fleming and Christina Mitchell to their assessment of the theory and science of underage drinking in American Indian and Alaska Native communities. The research of the National Center for American Indian and Alaska Native Mental Health that is reviewed here is supported in part by the following National Institutes of Health grants: NIAAA grant R01-AA08474 (Dr. Manson), NIDA grant R01-DA10039 (Dr. Mitchell), NIMH grants R01-MH42473 (Dr. Manson) and K20-MH01253 (Dr. Novins).



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Reducing Underage Drinking: A Collective Responsibility 14 Preventing Underage Drinking in American Indian and Alaska Native Communities: Contexts, Epidemiology, and Culture Douglas K. Novins, Paul Spicer, Janette Beals, and Spero M. Manson* The use and abuse of alcohol among American Indian and Alaska Native (AI/AN) adolescents is a major public health concern (Beauvais, 1996; U.S. Congress Office of Technology Assessment, 1990). Compared to their non-AI counterparts, AI youth are more likely to use alcohol regularly (Beauvais, 1992b; Beauvais, 1996), more likely to become problem drinkers (Beauvais, 1996), more likely to meet diagnostic criteria for alcohol abuse and dependence (Beals et al., 1997; Costello, Farmer, Angold, Burns, and Erkanli, 1997), more likely to use alcohol in combination with drugs (Beauvais, 1992a; Novins, Beals, and Mitchell, 2001a), and more likely to have both an alcohol use disorder and a psychiatric disorder (Beals, Novins, Mitchell, Shore, and Manson, 2002; Beals et al., 1997; Costello et al., 1997). From service system data and vital statistics, we *   This paper from the National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, Aurora, was commissioned by the National Academy of Sciences Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. The authors acknowledge the contributions of Drs. Candace Fleming and Christina Mitchell to their assessment of the theory and science of underage drinking in American Indian and Alaska Native communities. The research of the National Center for American Indian and Alaska Native Mental Health that is reviewed here is supported in part by the following National Institutes of Health grants: NIAAA grant R01-AA08474 (Dr. Manson), NIDA grant R01-DA10039 (Dr. Mitchell), NIMH grants R01-MH42473 (Dr. Manson) and K20-MH01253 (Dr. Novins).

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Reducing Underage Drinking: A Collective Responsibility know that AIs generally are more likely to develop a variety of physical health conditions related to alcohol use (Hisnanick, 1992; Indian Health Service, 1999; Sugarman and Smith, 1992) and to die from alcohol-related causes (Campos-Outcalt, Prybylski, Watkins, Rothfus, and Dellapenna, 1997; Gilliland, Becker, Samet, and Key, 1995; Indian Health Service, 1999; May, 1996; May and Van Winkle, 1994; Singh and Hoyert, 2000). Research to date also suggests that rates of alcohol use and related problems vary substantially across AI/AN tribes (Indian Health Service, 1999; May, 1996; Novins, Beals, Roberts, and Manson, 1999). Prevention of underage drinking in AI/ANs requires an appreciation of the historical, cultural, and sociodemographic contexts of alcohol use and related problems as well as an understanding of its epidemiology and theoretical relationships to key cultural contexts. Several promising prevention efforts have either been transferred successfully to AI/AN communities or emerged from these communities themselves. Although these efforts demonstrate community-level impacts, research suggests that efforts through the mid-1990s had failed to reduce high-risk substance use among AI/ANs overall (Beauvais, 1996). The goal of this paper is to review our current knowledge regarding the prevention of underage drinking in AI/AN communities. We will include descriptions of the key contexts and epidemiology of underage drinking among AI/ANs, prevention efforts to date, and the role of cultural constructs in understanding and preventing underage drinking and related problems. KEY CONTEXTS Sociodemographics AI/ANs are a diverse and heterogeneous population. There are more than 500 federally recognized tribes with a population of 4.1 million as of 2000 (U.S. Census Bureau, 2001). These tribes differ substantially in terms of language, customs, family structures, religions, and social relationships (U.S. Department of Health and Human Services, 2001). Most AIs live in western states, including California, Arizona, New Mexico, South Dakota, Alaska, and Montana, with 42 percent residing in rural areas, compared to 23 percent of whites (Rural Policy Research Institute, 1999). They are also relatively young, with a birth rate 1.6 times that of the U.S. all-races rate (U.S. Department of Health and Human Services, 1998). The Indian Health Service (IHS) reported that 65.3 perecnt of the AI/AN population living in reservation states have completed high school and 8.9 percent have completed 4 years of college—much lower than the 75.2 percent and 20.3 percent, respectively, for the U.S. as a whole (U.S. Department of Health and

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Reducing Underage Drinking: A Collective Responsibility Human Services, 1998). Furthermore, unemployment is generally higher among AI/ANs (16.2 percent versus 6.4 percent nationally). Not surprisingly, poverty is often quite severe in AI/AN communities. In 2000, the median family income was $33,144 compared to $49,628 for the general population (U.S. Census Bureau, 2002). Thus, the AI/AN population is younger, is less educated, and has fewer economic resources than the rest of the U.S. population (U.S. Department of Health and Human Services, 1998). However, it is important to recognize that there is considerable variability across tribes and regions of the country (U.S. Department of Health and Human Services and Indian Health Service, 1997). History Although there was some exposure to alcohol among AI/ANs prior to European contact, it was confined mostly to agricultural peoples of the Southwest (Waddell, 1980). The majority of tribes gained their first experience with alcohol from frontiersmen, trappers, and traders—often under exploitative circumstances. Given the relatively rapid nature of this introduction and a lack of indigenous mechanisms to control alcohol use, problems with alcohol developed in many, but by no means all, AI/AN cultures (Abbott, 1998; Levy and Kunitz, 1974; MacAndrew and Edgerton, 1969; Mancall, 1995). Stereotypes of the “drunken Indian” soon abounded and tribal leaders—and then the federal government—attempted to control the use of alcohol (Mancall, 1995). Although AIs became U.S. citizens in 1924, federal laws prohibiting their use of alcohol remained in effect until 1953. Interestingly, up to 50 percent of tribes still limit access to alcohol within their reservation borders (Abbott, 1998). Institutions Educational, human, and health services in AI/AN communities have undergone radical changes in recent years. These are largely the result of the Indian Self-Determination and Educational Assistance Act (Public Law 93-638), which has given AI/AN tribes greater flexibility and autonomy to restructure human services. These changes are well illustrated by changes in health services delivery for AI/ANs. Since 1965, IHS has developed a system of ambulatory mental health services for Indian communities at no cost to those eligible. Hospitals and clinics are operated either by IHS or by tribes. Three distinct funding and provider models have evolved in AI/AN communities. In the first and original model, commonly referred to as direct service, federal agencies such as IHS function as both funders and providers of services. In the second model, federal agencies provide funding and tribes are the contracted providers (i.e., the federal agencies oversee the types and

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Reducing Underage Drinking: A Collective Responsibility quality of services offered). In the third model, federal agencies provide funding and tribes serve as “compacted” providers (i.e., federal funds are transferred directly to the tribes, who then determine the types of services they will offer; Dixon, 2001; Dixon, Bush, and Iron, 1997). This movement to local control of services has not been uniform. While some tribes have embraced this process, others have raised concerns that the contracting and compacting of educational, health, and human services to tribes allow the federal government to avoid meeting its treaty obligations (Dixon et al., 1997; Sternberg, 1997). Small tribes are in a particularly poor position to take advantage of this process because their shares of federal funds under current compacting schemes are small and they are less able to draw on other resources than are larger tribes (Dixon et al., 1997). In some communities, a loose network of IHS, Bureau of Indian Affairs, state, private, tribally operated, and traditional services has emerged that creates substantial administrative barriers to the coordination of services. These problems are even more complex in urban areas. In the area of health service delivery, Urban Indian Health boards, which were chartered by the IHS, receive very limited funding (about 1 percent of the IHS budget), even though half of all Indian people live in urban and suburban areas (Kauffman, Johnson, and Jacobs, 1997; Sternberg, 1997; U.S. Congress Office of Technology Assessment, 1990). Overall, health, education, and human services systems serving AI/ANs are complex, often fragmented, and chronically underfunded (Dixon, 2001; Dixon et al., 1997; Kauffman et al., 1997; Nelson, McCoy, Stetter, and Vanderwagen, 1992; Novins, LeMaster, Sharma, and Manson, 2001b; Sternberg, 1997). This situation creates significant institutional barriers to the development of effective prevention programs in AI/AN communities. NATURE AND EXTENT OF UNDERAGE DRINKING IN AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES A series of community-based studies provides critical information regarding the prevalence and correlates of underage drinking. Beauvais and colleagues have conducted an ongoing annual survey of AI 7th to 12th graders that has been a key resource for monitoring the prevalence and patterns of alcohol and drug use among rural reservation AI adolescents since 1975. Five to seven tribes are chosen each year (albeit in a way that does not allow for tribal comparisons) and a companion effort has allowed correction of their rates to account for school dropouts (Beauvais, 1992a, 1992c; Beauvais, 1996; Beauvais, Oetting, Wolf, and Edwards, 1989; Swaim, Beauvais, Chavez, and Oetting, 1997). When compared to studies of non-AI adolescents such as Monitoring the Future and the National Household Survey on Drug Abuse, Beauvais and colleagues have consis-

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Reducing Underage Drinking: A Collective Responsibility tently shown that AI youth are as likely to drink as other youth, more likely to start drinking at a younger age, more likely to drink heavily, more likely to use drugs, and more likely to suffer more alcohol- and drug-related negative consequences than their non-AI counterparts (Beauvais, 1992a; Beauvais, 1996; Beauvais, 1998; Beauvais et al., 1989). Correlates of alcohol and drug use include living on a reservation (Beauvais, 1992a), having dropped out of school, legal problems, antisocial behavior (Beauvais, 1996), and associating with alcohol- and drug-using peers (Beauvais, 1992a). The Indian Adolescent Health Survey questioned 13,454 AI middle and high school students from across the United States in 1989 and compared them to a sample of white students in rural Minnesota (Blum, Harmon, Harris, Bergeisen, and Resnick, 1992). This study focused on risk behaviors and self-reported health status. The prevalence of weekly alcohol use increased by age for both AI females and males, although males were more likely to use alcohol in all age groups. When compared to their non-AI counterparts, AI adolescents were less likely to use alcohol weekly (17.1 percent versus 14.1 percent, respectively for males; 15.8 percent versus 10.2 percent for females). The major exception to this was AI males in 12th grade, who were more likely to use alcohol weekly than their white counterparts. AI youth had consistently higher rates of drug use and history of suicide attempts, and were more likely to report being a victim of physical abuse (Blum et al., 1992). AI adolescents were more likely to report driving after drinking and riding in a car with a driver who had been drinking or using drugs. Regular alcohol consumption was associated with having attempted suicide for both male and female AI students, even after controlling for other variables such as having a family member or friend attempt or complete suicide or reporting poor emotional health (Borowsky, Resnick, Ireland, and Blum, 1999). The Great Smoky Mountains Study, a longitudinal study of 9- to 15-year-olds residing in rural Appalachia, included 431 AI children from the Eastern Band Cherokee Tribe. This study generated Diagnostic and Statistical Manual of Mental Disorders-based diagnoses (American Psychiatric Association, 1994) of alcohol and drug abuse/dependence as well as a number of psychiatric disorders (e.g., major depression). Although lifetime and 3-month prevalences of alcohol use were comparable for the AI and white participants (Federman, Costello, Angold, Farmer, and Erkanli, 1997), AI participants were more likely to have an alcohol or drug disorder. Consistent with Kandel’s Stage Theory (Kandel and Yamaguchi, 1993), alcohol use usually preceded drug use (Federman et al., 1997). Although those using substances were at greater risk for the development of later psychiatric disorders in both samples (Federman et al., 1997), such comorbidity was more common in the AI sample (2.5 percent versus 0.9 percent; Costello et al., 1997).

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Reducing Underage Drinking: A Collective Responsibility The Voices of Indian Teens Study (VOICES) was a longitudinal study of more than 2,000 AI adolescents from 4 AI communities conducted by our research group. This study led to a number of key findings. In a comparison to regionally matched non-AIs from the Monitoring the Future Study, AI youth had comparable rates of lifetime alcohol use, but were more likely to report past-month use (Plunkett and Mitchell, 2000). Novins et al. (1999) found that AI alcohol use was associated with suicidal ideation in two of three VOICES communities studied. Another study by Novins et al. (2001a) found that most AI adolescents who used alcohol also used another substance (79.2 percent). Many of these youth reported a pattern of substance use progression that was inconsistent with Kandel’s Stage Theory, in contrast to findings from the Great Smoky Mountains Study (Novins et al., 2001a). The patterns of substance use progression varied by community, with marijuana more likely to serve as an initiating substance in communities in which alcohol possession and consumption are illegal for adults (Novins et al., 2001a). Other studies amplify these findings. Analyses of data from Monitoring the Future have shown that AI adolescents exhibit comparable 12-month and 30-day prevalences of alcohol use, but are more likely to report daily use of alcohol (Bachman et al., 1991). King and Thayer (1993) found that having alcohol-using peers was associated with alcohol use among AI adolescents attending a boarding school. Beals et al. (1997) reported a higher prevalence of alcohol abuse/dependence in a sample of 109 Northern Plains high school students (11.6 percent) compared to a sample of white adolescents from Oregon (4.6 percent). In this study, 15 percent of those youth with a substance use disorder (60 percent of whom had alcohol abuse or dependence) had a comorbid depressive disorder; 10 percent had a comorbid anxiety disorder and 40 percent had a comorbid disruptive behavior disorder (the latter being more common than the comparison sample of white adolescents, who had a prevalence of 25 percent). In a companion study to Beals et al., Duclos and colleagues (1998) found that 150 AI adolescents admitted to a juvenile detention center in a Northern Plains community had a much higher prevalence of alcohol abuse and dependence (34.0 percent) than did Beals et al.’s (1997) high school sample (11.6 percent), suggesting an association between legal problems and alcohol use disorders. The relationships of alcohol use to drug use and nonsubstance use psychiatric disorders are amplified by our recent study of 89 AI adolescents admitted to a residential substance abuse treatment facility (Novins, Fickenscher, and Manson, 2002a). Ninety-five percent of these adolescents had an alcohol use disorder, 90 percent had at least one drug use disorder, and 85 percent had at least one comorbid psychiatric disorder. In addition, this study shows that adolescents admitted to this residential substance abuse treatment program bring with them problems in a number of do-

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Reducing Underage Drinking: A Collective Responsibility mains, including family (only 25.3 percent came from a family with both biological parents present; 73 percent had been a victim of physical or sexual abuse), educational (22.9 percent were not in school prior to their admission to this program), and legal (32.3 percent were referred by the legal system) problems (Novins et al., 2002a; Novins, Fickenscher, and Manson, 2002b). In summary, these studies suggest that although AI adolescents are as likely as non-AI youth to use alcohol, they use alcohol more frequently, drink more heavily when they do use alcohol, and are more likely to meet criteria for alcohol abuse/dependence than many other American youth. AI youth often use alcohol in combination with drugs, and have a high prevalence of comorbid psychiatric disorders and emotional problems (e.g., suicidal ideation and attempts). Correlates of alcohol use appear to be similar to those of non-AIs, although the patterns of substance use progression may deviate substantially from non-AIs in some AI communities. KEY CULTURAL CONSIDERATIONS IN UNDERSTANDING UNDERAGE DRINKING IN AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES Designing and implementing prevention programs in a way that is consonant with the culture of the participating community is critical (Institute of Medicine, 1994). This is certainly true for AI/AN communities (Fleming, 1992). Indeed, researchers and AI/AN communities have had a keen interest in the relationship of a number of cultural constructs to underage drinking and related problems. Aboriginal social organization, societal disruption, ethnic identity, and historical trauma are the most commonly mentioned cultural constructs that may be related to underage drinking and related problems, although researchers have had difficulty identifying relationships between their operationalizations of these constructs and underage drinking and related problems. We will consider each of these constructs in turn. Social Organization and Societal Disruption Researchers have had a long-standing interest in the relationship of culture and societal disruption and alcohol use in AI/AN communities. In terms of culture, much of this research has focused on a theory developed by Field (1962) that builds on the well-established anthropological observation that societies differ in the degree of control they exert, or seek to exert, over individual behavior. Using ethnographic data from 56 tribes and rating scales intended to capture salient aspects of social organization and degrees of drunkenness at a societal level, Field found higher levels of

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Reducing Underage Drinking: A Collective Responsibility drunkenness in societies with a more personal (informal) organization than in those with a more corporate (formal) organization. Among the most robust predictors of relative sobriety in Field’s study were the presence of corporate kin groups, patrilocal residence (i.e., postmarital residence in the husband’s community), the institution of bridewealth (i.e., the transfer of goods from the husband’s family to the wife’s family in the context of marriage), and a village settlement pattern (Field, 1962). Field’s theory was soon applied to AI/AN drinking by Levy and Kunitz (1974) in their classic study of AI drinking in the southwestern United States, where it informed the interpretation of different drinking styles of the Hopi and the Navajo: The Hopi fell closer to the corporate (formal) and the Navajo closer to the personal (informal) end of Field’s continuum of aboriginal social organization. Both Navajo and Hopi societies are matrilineal and organized on the basis of clans, so this was perhaps not the best empirical test of Field’s hypothesis in North America, but the theory did appear to make sense of the fact that the Navajo drinking style was more public than that found among the Hopi. Subsequent research among diverse tribes in Oklahoma, conducted by Stratton and his colleagues using administrative data sets on arrests and mortality, also confirmed Field’s hypothesis, in that the former hunting and gathering societies of western Oklahoma evidenced higher rates of alcohol-related arrest and death than did the formerly agricultural tribes of eastern Oklahoma (Stratton, Zeiner, and Paredes, 1978). The application of Field’s theory to North America was subsequently systematized by May (1982), who suggested that the more general principle at work in these findings was the degree of social integration in a society. In addition to drawing on Levy and Kunitz’s use of Field’s theory, May suggested that societies will also vary in their level of integration as a function of what he called “acculturative stress.” Thus, the level of integration in an American Indian society was seen as a function of (1) the degree of control exerted over individual members in aboriginal social organization, and (2) the degree of disruption that a society has experienced under European colonization and control. The integration of these two separate dimensions by May (1982) generated a 2 × 3 typology in which societies could have high, medium, or low levels of integration in their aboriginal social organization as well as higher or lower levels of acculturative stress because of their subsequent historical experiences (May, 1982). Illustrating his typology, May suggested that many Pueblo tribes as well as those of Eastern Oklahoma evidenced high levels of integration in their aboriginal social organization, while hunting and gathering tribes of the Plains and the Southwest had low levels. Intermediate between these two extremes were agricultural and pastoral peoples of the Southwest, as well as many tribes from the Northwest coast. In terms of the second

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Reducing Underage Drinking: A Collective Responsibility dimension of his typology, “acculturative stress,” May argued that the tribes of eastern Oklahoma such as the Cherokee and Choctaw had experienced higher levels of these stressors than had some of the more isolated Pueblos of the Southwest. At the other end of his continuum of aboriginal social organization, he placed many of the Plains tribes of the United States that he argued had been subjected to more intense pressures than had more isolated Canadian Plains communities. Thus, the insights derived from Field’s and May’s work have continued to shape our thinking about the American Indian experience with alcohol in important ways. But despite the dominance of this view, our ability to adequately test the claims in new data on alcohol use has been severely constrained by the fact that limited work has been conducted simultaneously in more than two different American Indian tribal communities. In our analysis of data from the Voices of Indian Teens Study, we examined explicitly the relationship between May’s 2 × 3 typology of aboriginal social organization and social disruption described above with alcohol use among 1,923 youth from four culturally distinct AI tribes. In addition, we examined whether tribal differences could be explained by other variables such as gender, age, parental alcohol use, stressful life events, and association with alcohol-using peers (Spicer, Novins, Mitchell, and Beals, 2003). Our findings indicated that the prevalence of alcohol use as well as the quantity/frequency and negative consequences of such use did vary across the four AI tribes, but the patterns did not fit those predicted by Field or May. Furthermore, these cultural differences were fully accounted for by the sociodemographic, familial, stress, and peer association measures noted earlier. Among these variables, peer association made the greatest contribution to regressions modeling the quantity/frequency and negative consequences of alcohol use. Thus, in these analyses, cultural group and, by implication, the kind of social organization found in these societies aboriginally was of limited utility in understanding the patterning of contemporary young people’s experiences with alcohol. However, this does not suggest that social and cultural factors are irrelevant. The paramount importance of peers in our final model indicates quite clearly the extent to which adolescent drinking in these AI communities is patterned in social, and probably cultural, ways. But the fact that the drinking of these adolescents does not follow the predictions of Field’s (1962) and May’s (1982) theories, combined with our finding that the cultural differences that do exist are explained by peer dynamics, makes clear that new conceptualizations of social and cultural influences on drinking will be required if we are to advance theory and research in this area.

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Reducing Underage Drinking: A Collective Responsibility Ethnic Identity Another cultural construct that has received considerable attention in relationship to underage drinking and related problems among AI/ANs is ethnic identity. The theoretical work of Oetting and Beauvais (Oetting, 1993; Oetting and Beauvais, 1990-91) has been particularly influential. Their theory states that identification with Native and majority culture are independent of one another or orthogonal—individuals may view themselves as a part of Indian or white culture, neither culture, or both cultures. Furthermore, Oetting and Beauvais (1990-1991) argued that AI youth with a bicultural identification would be less likely to use substances, particularly when compared to youth lacking identification with either culture. However, research on the relationship of ethnic identity and alcohol use and other problems among AI youth has been mixed at best. For example, Oetting and Beauvais conducted two studies on this issue. In one, AI youth with bicultural ethnic identity were less likely to use drugs, but they were unable to identify such a relationship in a second study (Oetting and Beauvais, 1990-1991). Bates, Beauvais, and Trimble (1997) were also unable to identify a relationship between ethnic identity and alcohol use. In our own analyses of data from the Voices of Indian Teens study, while we did identify relationships between bicultural ethnic identity and self-perceived social competencies, personal mastery, self-esteem, and social support (Moran, Fleming, Sommervell, and Manson, 1999), we were unable to find a relationship between ethnic identity and marijuana use or suicidal ideation (Novins et al., 1999; Novins and Mitchell, 1998). Historical Trauma The fourth cultural construct that has been put forth as an explanation for drinking patterns among AI/ANs is historical trauma. Although similar to May’s construct of acculturative stress, the concept of historical trauma (Berlin, 1987; Duran and Duran, 1995; Gray, 1998) focuses more specifically on the present impacts of past traumatic events on a community. For AI/AN communities, these historical traumas include genocidal experiences such as war, massacres, seizure of tribal lands, forced migration to reservations, forced attendance at boarding schools, laws outlawing traditional practices, racism, and induced migration from reservations to urban areas (Gray, 1998; Novins et al., 2001b). Historical trauma has been conceptualized as an intergenerational, communitywide version of post-traumatic stress disorder (PTSD; American Psychiatric Association, 1994). While PTSD describes a set of symptoms that occurs in reaction to a traumatic event experienced or witnessed by an individual, historical trauma refers to community-level consequences of these historical events, which are trans-

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Reducing Underage Drinking: A Collective Responsibility mitted from generation to generation. The community-level impacts of historical trauma include poverty, domestic violence, school failure, low self-esteem, cultural confusion, mental health problems, and the use and abuse of alcohol and drugs (Berlin, 1987; Duran and Duran, 1995; Gray, 1998; Novins et al., 2001b). The concept of historical trauma resonates strongly with many AI/AN people (Novins et al., 2001b), but has been problematic for researchers to operationalize. While several research groups, including our own, have developed measures that inquire about an individual’s awareness of these historical traumas and whether he or she connects these traumatic events to any personal and community-level difficulties, the utility of these measures is limited because an individual in a community does not necessarily need to be aware of these traumas to be impacted by them. Although ethnographic inquiries have also pointed to this construct (O’Nell, 1996), the evidence supporting the assertions of the existence of historical trauma remains elusive. PREVENTION EFFORTS IN AMERICAN INDIAN/ALASKA NATIVE COMMUNITIES A variety of prevention efforts have been pursued in AI/AN communities, many of which have included a focus, but rarely an exclusive one, on underage drinking. For the purposes of this discussion, we will divide them into two groups: policy focused and population focused. Policy-Focused Prevention Efforts As we noted previously, alcohol use was not a part of the vast majority of aboriginal AI/AN cultures, and many AI/AN tribes were introduced to drinking under exploitative circumstances absent indigenous mechanisms to control alcohol use (Abbott, 1998; Levy and Kunitz, 1974; MacAndrew and Edgerton, 1969; Mancall, 1995). The federal government subsequently prohibited alcohol use by AI/ANs, a policy that remained in effect until 1953 (Abbott, 1998). Approximately 50 percent of tribes have, in effect, continued this policy by prohibiting access to alcohol within their reservation borders. Research to date suggests that these policies impact AI communities differently from AN communities. In the lower 48 states, results from the Voices of Indian Teens Study reveal that while communities that prohibit the possession of alcohol do have lower prevalences of underage drinking than those communities that permit alcohol possession, they may not reduce the overall prevalence of substance use. Indeed, adolescents from “dry” communities were more likely to use other drugs, particularly marijuana, than adolescents from “wet” communities (Novins et al.,

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Reducing Underage Drinking: A Collective Responsibility 2001a). We have theorized that these policies limit the easy availability of alcohol, and youth who want to use substances turn to nonalcohol alternatives. In Alaska, changes in state policy, known as “local option,” have allowed AN villages to choose whether to allow or prohibit the possession of alcohol in their communities (Berman, Hull, and May, 2000). Results of studies of this policy change have shown that AN villages that moved from “wet” to “dry” status significantly reduced their injury death rates, particularly in terms of homicides and accidents (Berman et al., 2000). Similar results were reported for alcohol-related hospital visits (Chiu, Perez, and Parker, 1997). These policies are likely to have had similar impacts on underage drinking, although no data specific to this outcome are available. Researchers have hypothesized that these impacts are likely the result of the extreme isolation of AN villages, many of which have no roads connecting them to other communities, making such policies far more effective than in less isolated AI reservations. Population-Focused Prevention Efforts A number of population-focused prevention efforts have been pursued in AI/AN communities. These have included programs that are aimed at developing skills at the individual, family, and community levels that should reduce problem behaviors such as underage drinking. Other programs have focused more specifically on using traditional AI/AN culture as a solution to a variety of problems, including underage drinking. Examples of the former types of programs include “D.A.R.E. to be you” (Miller-Heyl, MacPhee, and Fritz, 1998), which was originally developed with an AI pilot site and has been disseminated to other AI communities and “Communities that Care” (Hawkins, Catalano, and Arthur, 2002; Lonczak, Abbott, Hawkins, Kosterman, and Catalano, 2002; O’Donnell, Hawkins, Catalano, Abbott, and Day, 1995), which has been piloted with a multiethnic sample that included a substantial number of AIs living in an urban area. Results to date suggest both are effective in developing targeted skills and reducing problem behaviors (Hawkins et al., 2002; Miller-Heyl et al., 1998). Although both of these programs are designed to allow customization for use in a variety of communities, and thus permit the incorporation of cultural elements specific to the target community, they may not reflect the critical grassroots understandings of the risk and protective factors surrounding alcohol use by youth in these communities. In contrast, the demonstration projects from the Robert Wood Johnson Foundation’s Healthy Nations’ Initiative supported model prevention programs developed by AI/ AN communities themselves, drawn substantially from local cultures and beliefs. Although originally conceived as an extension of the Robert Wood Johnson Foundation’s Fighting Back Program (Brodeur, 2002), which

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Reducing Underage Drinking: A Collective Responsibility would have made it similar to the two programs just noted, the Healthy Nations’ Initiative departed from this approach by encouraging participant communities to use local knowledge of their strengths and traditions to design their respective prevention programs. Healthy Nations grantees developed and successfully implemented a broad range of creative and interesting community-based activities. For example, the Seattle Indian Health Board developed technology-focused youth mentoring projects with the Boeing Corporation, Microsoft, and the American Indian Science and Engineering Society. The Cherokee Nation of Oklahoma actively engaged up to 1,000 members in increasing physical activity and healthy lifestyles and instituted a school-based health promotion curriculum, smoking cessation classes, and cultural heritage projects. Norton Sound Health Corporation, based in Nome, Alaska, instituted a Village-Based Counselor program to provide much needed behavioral health services to its 17 remote villages. Most of the grantees incorporated traditional healing practices such as sweat lodges and talking circles into their community’s treatment and aftercare options. In addition, many of the grantee communities used traditional language and arts and crafts projects as aftercare activities (Noe, Fleming, and Manson, 2003). Although data regarding the effectiveness of these programs are not yet available, analyses of Healthy Nations’ Initiative suggests that these programs show evidence of substantial community change (using a hierarchy of results that are strongly related to this phenomenon, such as generating interest, engagement, community capacity enhancement, and policy as well as institutional changes; Capra and Steindl-Rast, 1991; Cohen and Kibel, 1993; Noe et al., 2003). CONCLUSIONS AND RECOMMENDATIONS Research to date suggests that underage drinking is a substantial public health problem in AI/AN communities. Underage drinking in these communities is highly comorbid with the use of other substances and nonsubstance use psychiatric disorders as well as school, legal, and family problems. Key institutions, including education, health, and human services, are chronically underfunded and fragmented, creating substantial barriers to the adoption of community-based prevention efforts. Although a few programs have demonstrated effectiveness and others appear promising for reducing underage drinking and related problems in AI/AN communities, research suggests that efforts through the mid-1990s failed to reduce high-risk substance use among AI/ANs overall (Beauvais, 1996). Though scientists and AI/AN community members have suggested that underage drinking and related problems are associated with a variety of cultural constructs (e.g., aboriginal social organization, social disruption,

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Reducing Underage Drinking: A Collective Responsibility ethnic identity, and historical trauma), empirical research to date has failed to demonstrate strong relationships in this regard. Indeed, results from studies of AI adolescents suggest that underage drinking and related problems are strongly correlated with many of the same factors that are found among non-AIs, including stress, parental alcohol use, and association with alcohol-using peers. However, because of the complexities in operationalizing these cultural constructs (particularly historical trauma, which does not require conscious awareness to have an impact), it is not possible to completely dismiss them as potential contributors to these problems. This is further complicated by the extraordinary diversity of AI/AN communities, making it difficult to draw firm conclusions about these issues from even the largest of these studies. In fact, research to date demonstrates substantial variation in the prevalence of underage drinking and related behaviors across AI/AN communities. While these differences can be explained largely by purportedly noncultural factors such as association with alcohol-using peers, “neighborhood” factors (National Research Council and Institute of Medicine, 2000)—including cultural factors—likely play a role in the relative prevalence of these correlates across AI/AN communities. Dismissing these cultural factors as unimportant in understanding these problems—and preventing them—is even more difficult simply because of the significance many AI/AN communities attach to them (Novins et al., 2001b). Indeed, notable prevention efforts in AI/AN communities have either incorporated cultural elements into a western conceptualization of prevention, or built directly on communities’ knowledge, beliefs, and practices. Even prohibition can be viewed as a culturally based prevention effort because alcohol was not present in the vast majority of AI/AN communities prior to European contact. However, this policy-level approach appears to be effective only in highly isolated AN villages. Because of the diversity of AI/AN communities, a variety of approaches probably should and will be used to prevent underage drinking and related problems. The vast majority will draw on cultural approaches, either as their core component or as an adjunct to a more western-based approach. These components may be critical not only to the effectiveness of these interventions, but also to their acceptance and maintenance by AI/AN communities (Kumpfer, Alvarado, Smith, and Bellamy, 2002). Another aspect of AI/AN culture that is critical for prevention efforts is the widespread belief across AI/AN communities that all things are interconnected, and that it is not possible, or appropriate, to separate an issue such as underage drinking from both its comorbidity with other substance use and emotional, behavioral, familial, and social problems (Fleming, 1992; Novins et al., 2001b). Indeed, this is one area in which research findings resonate strongly with the beliefs of AI/ANs, which demonstrate strong interconnections of these problems. Thus, prevention efforts that focus

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Reducing Underage Drinking: A Collective Responsibility exclusively on preventing underage drinking face the danger of failure because they are both too narrow from a scientific perspective to be effective, and also fail to resonate with the beliefs of AI/AN communities that are most critical for their adoption. REFERENCES Abbott, P.J. (1998). Traditional and western healing practices for alcoholism in American Indians and Alaska Natives. Substance Use and Misuse, 33(13), 2605-2646. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Washington, DC: Author. Bachman, J.G., Wallace, J.M., Jr., O’Malley, P.M., Johnston, L.D., Kurth, C.L., and Neighbors, H.W. (1991). Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. American Journal of Public Health, 8, 372-377. Bates, S.C., Beauvais, F., and Trimble, J.E. (1997). American Indian adolescent alcohol involvement and ethnic identification. Substance Use and Misuse, 32, 2013-2031. Beals, J., Novins, D., Mitchell, C., Shore, J., and Manson, S. (2002). Comorbidity between alcohol abuse/dependence and psychiatric disorders: Prevalence, treatment implications, and new directions for research among American Indian populations. NIAAA Research Monograph Series, 37, 371-410. Beals, J., Piasecki, J., Nelson, S., Jones, M., Keane, E., Dauphinais, P., Red Shirt, R., Sack, W., and Manson, S. M. (1997). Psychiatric disorder among American Indian adolescents: Prevalence in Northern Plains youth. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 1252-1259. Beauvais, F. (1992a). Characteristics of Indian youth and drug use. American Indian and Alaska Native Mental Health Research, 5, 50-67. Beauvais, F. (1992b). Comparison of drug use rates for reservation Indian, non-reservation Indian and Anglo youth. American Indian and Alaska Native Mental Health Research, 5, 13-31. Beauvais, F. (1992c). Trends in Indian adolescent drug and alcohol use. American Indian and Alaska Native Mental Health Research, 5, 1-12. Beauvais, F. (1996). Trends in drug use among American Indian students and dropouts, 1975 to 1994. American Journal of Public Health, 86, 1594-1599. Beauvais, F. (1998). Cultural identification and substance use in North America: An annotated bibliography. Substance Use and Misuse, 33, 1315-1336. Beauvais, F., Oetting, E.R., Wolf, W., and Edwards, R. (1989). American Indian youth and drugs, 1976-87: A continuing problem. American Journal of Public Health, 79, 634-636. Berlin, I.N. (1987). Effects of changing Native American cultures on child development. Journal of Community Psychology, 15, 299-306. Berman, M., Hull, T., and May, P. (2000). Alcohol control and injury death in Alaska Native communities: Wet, damp and dry under Alaska’s local option law. Journal on the Studies of Alcohol, 61(2), 311-319. Blum, R.W., Harmon, B., Harris, L., Bergeisen, L., and Resnick, M.D. (1992). American Indian-Alaska Native youth health. Journal of the American Medical Association, 267, 1637-1644. Borowsky, I.W., Resnick, M.D., Ireland, M., and Blum, R.W. (1999). Suicide attempts among American Indian and Alaska Native youth: Risk and protective factors. Archives of Pediatric and Adolescent Medicine, 153, 573-580.

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