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Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi'kmaq Community: A Process Paper

Authors:
  • Independent Researcher

Abstract

In April of 2006, a team of researchers consisting of both uni-versity and community partners from a Mi'kmaq reserve in Nova Scotia began the data-collection phase of a high school-based research study that had been two years in planning. The study examines the possible relationships between youth-reported childhood maltreatment, posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, alcohol misuse, and resilien-cy factors. The aim of the research study is to provide informa-tion about adolescent alcohol misuse that is of practical benefit to community-based service providers, and capable of making a scholarly contribution to the scientific study of the relations of anxiety/mood symptoms and addictive behaviours. The primary aim of this paper is to present both the context from which the project grew, and the steps involved in conducting research with our school partners and the community service providers. A sec-ondary aim is to present some of the preliminary data from the study, with a specific focus on resiliency.
First Peoples Child & Family Review
A Journal on Innovation and Best Practices in Aboriginal Child Welfare
Administration, Research, Policy & Practice
27
Building a Collaborative Understanding of Pathways to
Adolescent Alcohol Misuse in a Mi’kmaq Community: A
Process Paper
Marc Zahradnika, Doreen Stevensb, Sherry Stewarta,c, M. Nancy Comeaua,d, Christine
Wekerlee and Christopher Mushquasha
Volume 3, Number 2, 2007, Special Issue, pp. 27-36
Abstract
In April of 2006, a team of researchers consisting of both uni-
versity and community partners from a Mi’kmaq reserve in Nova
Scotia began the data-collection phase of a high school-based
research study that had been two years in planning. The study
examines the possible relationships between youth-reported
childhood maltreatment, posttraumatic stress disorder (PTSD)
symptoms, depressive symptoms, alcohol misuse, and resilien-
cy factors. The aim of the research study is to provide informa-
tion about adolescent alcohol misuse that is of practical benefit
to community-based service providers, and capable of making
a scholarly contribution to the scientific study of the relations of
anxiety/mood symptoms and addictive behaviours. The primary
aim of this paper is to present both the context from which the
project grew, and the steps involved in conducting research with
our school partners and the community service providers. A sec-
ondary aim is to present some of the preliminary data from the
study, with a specific focus on resiliency.
aDepartment of Psychology, Dalhousie University, Halifax, NS,
Canada
bDepartment of Psychology, Mount Saint Vincent University,
Halifax, NS, Canada
cDepartment of Psychiatry, Dalhousie University, Halifax, NS,
Canada
dAdjunct Professor, School of Health and Human Performance,
Faculty of Health Professions and Research Fellow, Institute of
Integrative Science and Health, Cape Breton University
eFaculty of Education, Department of Psychology, University of
Western Ontario, London, ON, Canada
Correspondence may be addressed to:
Marc Zahradnik
Department of Psychology
Dalhousie University
Halifax, Nova Scotia
B3H 4J1, Canada
(902) 494-3793 (lab)
(902) 494-6585 (fax)
Electronic mail may be sent to mzahradn@dal.ca
Introduction
Childhood maltreatment1 and subsequent alcohol
misuse are frequently linked together across cultural
groups. They are a concern for most Canadian com-
munities. Although there is very little published lit-
erature that either reports on or explores the connec-
tion between child maltreatment and alcohol misuse
in First Nations’ communities, the published research
that is available seems to suggest that rates of violence
exposure and alcohol use/misuse are high in some
communities (Health Canada, 2003). For example,
the 1991 Statistics Canada Aboriginal People’s Sur-
vey revealed that 62% of First Nations respondents
reported that alcohol was a problem in their commu-
nity, while 39% of respondents reported that family
violence was a problem in their community (Indian
and Northern Affairs Canada, 2004). It is recognized,
though, that a complex web of ecological factors
support the maltreatment-substance abuse issue. For
example, a study by Blackstock, Trocmé, and Bennett
(2004) found that Aboriginal families, compared to
non-Aboriginal families, face worse socioeconomic
conditions, are more often investigated because of
neglect, and report higher rates of substance abuse.
Poor socioeconomic conditions, substance abuse,
and poor parenting skills (e.g., neglect and abuse),
to name a few, are problems that are now well un-
derstood to be consequences of a history of coloni-
28
Author Notes
This project was supported in part by a Canadian Institutes of Health Research New Emerging Team (CIHR NET)
grant held by Drs. Christine Wekerle and Sherry Stewart, as well as an Atlantic Aboriginal Health Research Program
(AAHRP), a CIHR-Institute of Aboriginal Peoples Health (CIHR-IAPH) funded Aboriginal Capacity and Developmen-
tal Research Environment (ACADRE) research allowance held by Marc Zahradnik. Mr. Zahradnik is also funded
by an AAHRP graduate student award. Dr. Stewart is supported through an Investigator Award from the CIHR and
a Killam Research Professorship from the Faculty of Science at Dalhousie University. Christopher Mushquash
is supported by a University of Toronto/McMaster University Indigenous Health Research Development Program
Graduate Scholarship, funded by the CIHR-IAPH. The authors would like to thank Dr. M. Nancy Comeau for her as-
sistance and support while at Dalhousie University; Dr. Comeau is now at Cape Breton University.
zation, as pointed out by the Royal Commission on
Aboriginal People; a most pernicious manifestation
of colonization that has had immeasurable deleteri-
ous consequences on Aboriginal health, culture, and
identity, is the residential school system (Indian and
Northern Affair Canada, 1996).
The residential school system failed miserably
in its deplorable goal of attempting to “civilize”
Aboriginal children. In its attempt “to transport Ab-
original children through the classroom to the desired
assimilative destination,” the system more often than
not produced individuals who felt marginalized from
both their home communities and the communities of
their colonizers, leaving many with few constructive
alternatives to a life of prostitution and/or alcohol-
ism (Indian and Northern Affairs Canada, 1996).
Furthermore, the structure sewed the seeds for gen-
erational cycles of family violence because these
schools disrupted the transference of parenting skills
from one generation to the next, so that many survi-
vors, lacking the necessary parenting skills, came to
rely on the lessons they learned at these schools: that
adults often maintain power, control, and obedience
through abuse (Indian and Northern Affairs Canada,
1996). Because so many cases of sexual and physi-
cal abuse went ignored and unhealed, giving rise to
numerous unhealthy coping behaviours, including
the perpetration of violence, such behaviours often
became “normal” and were subsequently passed on to
subsequent generations, resulting in intergenerational
or multi-generational trauma (Wesley-Esquimaux &
Smolewski, 2004).
The authors of this paper recognize the historical
and cultural roots to maltreatment-substance misuse
problem in some Aboriginal communities, but the
present study was not designed to test the contribution
of these historical factors. Rather, our research team
focused on the current circumstances of exposure to
violence, psychological effects of such exposure to
violence, and subsequent relations to alcohol mis-
use among teens living in an Aboriginal community
today. Our school-based research study is attempt-
ing to not only make a contribution to an area that
is presently lacking—the relationship between child
maltreatment and alcohol misuse—but to also pro-
vide the community service providers with tailored
evidence for intervention recommendations. As this
study is on-going, the purpose of this paper is not to
report on the final research findings, but to provide a
brief summary of the research process. This shall in-
clude: 1) briefly describing the community; 2) briefly
locating the purpose of the research within the com-
munity context; 3) briefly locating the purpose of the
research within the scientific literature; 4) discussing
the process of ethical approval and community con-
sent; 5) discussing the implementation of the study;
and 6) sharing some preliminary findings based on
the information we have collected thus far.
Community Organization
The Mi’kmaq community is a self-governing First
Nations Community. It is one of the largest First Na-
tions communities in Atlantic Canada, and its origins
go back to the first half of the 19th century, though it
was not until the half way point of the 20th century
that the community’s population increased dramati-
cally. Shortly thereafter, the community became self-
governed by establishing its own Band Council. The
community has its own Board of Education, Board of
Health, local police, fire department, and ambulance
service.
Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi’kmaq
Community: A Process Paper
29
First Peoples Child & Family Review, Volume 3, Number 2, 2007, Special Issue
Community Context
In the fall 2002, our research group was invited
to the Atlantic Region First Nation community by the
principal of the community high school and the de-
tachment commander of the RCMP2 to discuss ways
of dealing with issues of alcohol and other substance
abuse among community youth. These discussions
lead to further collaboration between members of our
research team (led by post-doctoral fellow Dr. M.
Nancy Comeau) and school staff (from two schools)
and the eventual participation of community youth
in the development of a culturally relevant early
intervention program for alcohol misuse, entitled
“Nemi’simk, Seeing Oneself” (see Mushquash et al.,
2007; see also Comeau et al., 2005). The present
study evolved from the voices of those adolescents
who participated in “Nemi’simk.”
From the qualitative data already collected about
these adolescents’ perceptions of their reasons for al-
cohol misuse (Comeau, Stewart, & Collins, 2004), it
appeared that themes of violence exposure and anger
might be important contributing factors. Furthermore,
the guidance counselor from one of the community
schools, who also became a co-investigator of the
present study, in a letter addressed to the Dalhousie
Health Sciences Research Ethics Board, underscored
the relevance of this project to her community when
she noted that both she and her colleagues had ob-
served a recent increase in disclosures and reports of
childhood trauma.
Based on some of the findings of the previous
work with the schools, and the observations of school
guidance counselors and mental health professionals
in the community, it was felt that a well-designed
study might be able to shed some light on the possible
relationship between maltreatment and adolescents’
alcohol misuse. Furthermore, given the well-docu-
mented relationships between interpersonal violence,
post-traumatic stress disorder (PTSD) symptoms, de-
pressive symptoms, and alcohol and other substance
misuse in non-Native populations (see reviews by
Stewart, 1996, and Stewart & Israeli, 2002), the em-
pirical literature in this area helped ground our con-
ceptualization of the project in a scientific context.
Scientific Context
Interpersonal Violence
Interpersonal violence witnessing domestic
violence, child maltreatment, school bullying, teen
dating violence and date rapes can bring on PTSD
symptoms that may become chronic, or remain an “ac-
tive” risk factor for later onset of post-traumatic stress
(Wekerle & Wall, 2002; for a meta-analytic review
see Brewin, Andrews, & Valentine, 2000). Trauma
researchers suggest that early exposure increases the
risk for developing post-traumatic stress beyond the
risk associated with other traumatic experiences like
motor vehicle accidents, natural catastrophes, and
other life stressors (e.g. Kilpatrick, Acierno, Saun-
ders, Resnick, Best, & Schnurr, 2000). It is the in-
terpersonal nature of the violence, especially when a
caregiver or attachment figure is involved, that render
it a “high impact” event that challenges coping and
long-term adaptation.
Post-traumatic Stress Disorder (PTSD)
Symptoms
The purpose of the study is not to diagnose stu-
dents with the psychiatric disorder of PTSD, but
instead to show that greater levels of symptom sever-
ity might be driving alcohol misuse behaviour, since
alcohol may be used as a means of “self-medicating”
the unpleasant emotions and memories that result
from the trauma. Therefore, although the term ‘PTSD
symptoms’ is used throughout this paper, the results
of the study cannot be used to diagnose students with
the actual disorder.
PTSD3 is a complicated disorder that is precipi-
tated by exposure to a traumatic stressor. The Diag-
nostic and Statistical Manual-IV (APA, 1994) defines
a traumatic stressor as any event that is experienced
or witnessed that involves actual or threatened death/
serious injury, or a threat to the physical integrity of
the self or another, and is accompanied by a sense of
fear, helplessness, or horror. The disorder is marked
by three key symptom clusters that persist for lon-
ger than one month: 1) re-experiencing the traumatic
event through intrusive thoughts, nightmares and/or
flashbacks; 2) emotional numbing and the avoidance
of trauma related reminders; and 3) hyper-arousal, in-
cluding hyper-vigilance (i.e., over-scanning the envi-
Marc Zahradnik, Doreen Stevens, Sherry Stewart, M. Nancy Comeau, Christine Wekerle
and Christopher Mushquash
©
30
ronment for signals of danger or threat) and increased
physiological arousal (e.g., difficulty calming, sleep
problems, restlessness). As interpersonal violence can
be a risk factor for the development of PTSD, current
research indicates that having PTSD symptoms can
be a risk factor for alcohol misuse.
Alcohol Misuse and Post-traumatic Stress
Much of the research indicates that PTSD and
alcohol and other substance abuse commonly occur
together in the same individuals and that this co-oc-
currence is far more common than can be explained by
chance alone (Stewart, 1996; Wekerle & Wall, 2002).
For example, in a national probability sample of
3,906 adolescents, Kilpatrick et al. (2003) found that
the prevalence rate for having PTSD with a substance
abuse disorder (n=50) was almost the same as the
base rate for PTSD alone (n=55). Furthermore, from
that same study, sexual assault, physical assault, and
witnessing violence were all variables that increased
the risk for a diagnosis of co-morbid PTSD and sub-
stance abuse. Given the co-occurrence of PTSD with
alcohol and other substance misuse, researchers have
posited several possible causal pathways to explain
their relationship.
Pathways Connecting PTSD and Substance
Misuse
There are three major hypotheses that attempt to
explain the link between PTSD and substance misuse4.
The high-risk hypothesis suggests that misusing sub-
stances elevates the risk of exposure to trauma (and
thus of developing PTSD) due to a “dangerous/risky
lifestyle.’ The susceptibility hypothesis suggests that
the misuse of substances can cause physiological and
neurochemical changes that make an individual more
susceptible to developing PTSD following exposure
to a trauma (Brown & Wolfe, 1994). The third and
presently best-supported view is the self-medication
hypothesis (De Bellis, 2002; Chilcoat & Breslau,
1998; Stewart, 1996).
The self-medication hypothesis reasons that
central nervous system depressants like alcohol, can-
nabis, opioids, and benzodiazepines may help reduce
certain fear/startle responses, as well as the intrusive
memories that are characteristic of PTSD. People
suffering PTSD, having experienced symptom relief
with substance(s) use, come to expect that it may re-
lieve suffering, and are then motivated to engage in
continued substance use to manage their PTSD symp-
toms. Although there is substantial empirical support
for the self-medication theory as it relates to explain-
ing the relation of PTSD with alcohol abuse, it is cur-
rently recognized that the self-medication explanation
is overly simplistic (Stewart, 1996). For example,
alcohol and other drugs may control certain PTSD
symptoms in the short term, but once the effects of the
substance have worn off, the PTSD symptoms return.
Furthermore, sometimes when symptoms return, they
return in even greater severity due the physiological
after-effects of substances like alcohol. Particularly,
hyper-arousal symptoms can return with even greater
severity due to the physiological arousal resulting
from substance withdrawal (Jacobsen, Southwick, &
Kosten, 2001). It has also been suggested that alcohol
can interfere with the body’s natural habituation to
traumatic memories (De Bellis, 2002). Thus, through
a process of mutual maintenance, substance misuse
can actually serve to maintain PTSD symptoms in the
longer term creating a “vicious cycle” between PTSD
symptoms and substance misuse. Although our study
does not examine symptom severity across time, and
therefore does not allow us to test a mutual mainte-
nance hypothesis, the variables we are collecting data
on do allow us to explore a self-medication model as
it relates to the misuse of substances in young, poten-
tially traumatized individuals.
Based on both community need and the best avail-
able empirical information, we have hypothesized, in
accordance with the self-medication hypothesis, that
PTSD symptoms will mediate the relationship be-
tween childhood maltreatment and substance misuse
in a community sample of adolescents. Information
has been collected using self-report measures on ex-
posure to violence (Childhood Experience of Violence
Questionnaire, CEVQ; Walsch et al., in press ) post-
traumatic stress symptoms (Child PTSD Symptom
Scale, CPSS; Foa et al., 2003), depressive symptoms,
(Centre for Epidemiological Studies Depression
Scale, CESD; Radloff, 1977), alcohol related prob-
lems (Rutgers Alcohol Problem Index, RAPI; White
& Labouvie, 1989), and resiliency (Child and Youth
Resilience Measure, CYRM; International Resilience
Project, Dalhousie University).
The data collection for this study has been ad-
ministered in groups, but various safeguards have
been prearranged so as to ensure that the study is
anonymous with respect to data privacy. An active
informed consent was sought from the high school
Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi’kmaq
Community: A Process Paper
31
First Peoples Child & Family Review, Volume 3, Number 2, 2007, Special Issue
students who chose to participate in this study, while
a passive consent process was used with parents.
Based on both community relevance and scientific
merit, we brought forward our research proposal to
the larger body of community stakeholders, so as both
to ensure their consent and to give them an oppor-
tunity to modify the proposed project in accordance
with their needs.
Ethical Approval and Community Consent
Ethical Approval
In the summer of 2005, two variations of the same
ethics proposal were submitted to both the Mi’kmaq
Ethics Watch at Cape Breton University, and the
Dalhousie Health Sciences Research Ethics Board
(REB). Approval to conduct research was granted by
the Mi’kmaw Ethics Watch in November of 2005 and
by the Dalhousie REB in April of 2006. The project
proposal that was originally presented to both ethics
boards in the summer of 2005 was revised, based on
community input (see Community Participation),
with respect to what mental health related constructs
were being measured, and both ethics boards were
informed of and approved these amendments to the
project.
As this project is school-based, feedback from
the Dalhousie REB that concerned issues around the
methodology of the study (e.g., using an active versus
passive parental consent) were always first discussed
with our school partners from both participating
schools. Decisions that came from those discussions
were then reported back to the Dalhousie REB both
in the form of amendments to the ethics protocol, as
well as in the form of letters of approval from the
guidance counsellors of both Mi’kmaq high schools
and their Director of Education for the community
school board.
Community Consent
Although this section of the paper will outline the
steps involved in establishing community consent,
it is first necessary to specify whom we mean when
we employ the term ‘community’. When this paper
refers to community, it is referring to those agencies
or institutions whose service mandate, in one form or
another, includes the health and well being of children/
adolescents that reside within the administrative juris-
diction of these agencies/institutions. For the purpose
of this paper, ‘community consent’ shall be distinct
from ‘participant consent’, in that the community had
to first consent to participating in the collaborative re-
search process as a whole, before participant consent
could be sought from potential teen participants. The
process of participant consent is described in the sec-
tion entitled Study Implementation.
Seeing as how this is a school-based study, the
primary community partners for this study were the
First Nation School Board and the principals and
guidance counselors of the community high schools.
Furthermore, because this study includes questions
that might prove upsetting to some students, and
could lead to the disclosure of child maltreatment,
our community partnership extended to the commu-
nity Mental Health and Social Work Services (MH &
SWS)5. We also gained the consent of other child /
adolescent health and welfare related service provid-
ers (see below for a list).
Formal community contact began in the fall of
2005, where a joint community-research team was
invited to present a research proposal to the com-
munity based collaborative and therapeutic team
(Case Management) and the Inter-Agency, which
jointly consist of representatives from the following
service providers/institutions: Native Alcohol and
Drug Abuse Counselling Association (NADACA),
the Health Centre, Home Care, Mi’kmaq Family and
Children’s Services, the Regional Hospital’s Child
and Adolescent Services, the RCMP, as well as three
schools under the jurisdiction of the School Board.
Representatives from the various agencies were
given the opportunity to become active participants/
advisors in shaping the project by asking questions,
voicing concerns, and suggesting modifications.
Both groups requested updating throughout the vari-
ous stages of research, and to deliver a full disclosure
of the research results and recommendations that
the community will be able to utilize in a produc-
tive manner. Furthermore, it was agreed that Mental
Health & Social Work Services be allowed to use the
data from this study to hopefully increase their ca-
pacity to secure funding for issues and programming
around dealing with the consequences of childhood
maltreatment.
Critical to the study was gaining approval at an
administrative level by individuals appointed to di-
rectorial positions by Chief and Council. The Direc-
tor of Education was formally contacted in the fall of
2005, and her approval was immediate. The Director
Marc Zahradnik, Doreen Stevens, Sherry Stewart, M. Nancy Comeau, Christine Wekerle
and Christopher Mushquash
©
32
of Health was also contacted in the fall of 2005, and
she invited the lead researcher to present the study
proposal to the Board of Health in the spring of 2006.
After both the board—a body of 12 appointed com-
munity representatives that included 3 elders—and
the Director of Health were satisfied that their ques-
tions and concerns had been met with appropriate
responses, they approved the project. The Director of
Health also desired projects updates and a disclosure
of the results.
Community Participation
Our school partners have been crucial to the suc-
cess of this study. Our “internal champion”, had both
passion for the content area, a job specifically to sup-
port teens, and was obtaining a graduate degree that
included research (see Commentary, this issue, by
Doreen Stevens). As someone born in the commu-
nity, and a school/mental health professional of the
community, she could often answer questions about
the project from a position and perspective unavail-
able to university-based researchers. Such key com-
munity partners played a critical role in formulating
a process of consent for students and parents that was
both practical and ethically sound. While our school
partners helped plan and concretize the methodologi-
cal and ethical issues of the study, representatives
from MH & SWS had an influence on the scope of
the project as a whole.
Based on the recommendation of the former Case
Management Team coordinator who was also a psy-
chologist for Mental Health and Social Work Services
(MH & SWS), the project was modified so as to also
focus on resiliency. In addition to having information
on exposure to violence and its possible consequenc-
es (e.g., PTSD symptoms), MH & SWS staff were
equally keen to know about those factors—whether
they be personal, interpersonal, cultural, or communi-
ty-based—that might be buffering or shielding certain
adolescents from experiencing post-traumatic stress
symptoms or depression, or misusing alcohol. This
suggested addition to the project has had the further
benefit of strengthening and extending the partnership
between MH & SWS and the academic community at
Dalhousie, as the first author of the resiliency mea-
sure adopted for the study, Dr. Michael Unger (www.
resilienceproject.org) from the Dalhousie School of
Social Work, agreed to come to the community to de-
liver a workshop on the topic of resiliency. Further-
more, based on the data sharing agreement with MH
& SWS, the research team decided to remove two
measures that although of academic interest were of
less tangible benefit to the community, and to replace
them with a measure of depression.
Our rationale for including a measure of depres-
sion was based on both community need and em-
pirical literature. The literature on the relationship
between exposure to violence and depression, and the
literature on substance misuse and co-occurring prob-
lems certainly supports enquiry into a mediational
relationship between maltreatment, depression, and
alcohol misuse within this community. For example,
childhood exposure to violence is predictive of both
subsequent major depression and PTSD (Kessler et
al., 1997; Kendler et al., 2000). Furthermore, Hall
and Farrell (1997) report that for those with alcohol
problems, the most prevalent cluster of co-occurring
disorders, next to anxiety disorders (where PTSD is
classified as an anxiety disorder), are mood disorders
like depression. Therefore, we reasoned that measur-
ing a pathway from maltreatment through to alcohol
misuse that only involves post-traumatic stress symp-
toms might be casting too small a net, but that if we
included a measure of depression, we might be able
to provide the community with a more complex view
of the roots of adolescent alcohol misuse.
Study Implementation
After receiving both community consent and ethi-
cal approval (from the Mi’kmaw Ethics Watch and
Dalhousie University REB) the study was implement-
ed in April of 2006. As this is a school-based study,
only adolescents attending either of the two high
schools in the community were invited to participate.
Originally, the study was to use an active parent/
guardian consent process in which parents/guardians
would be mailed a consent form that they would then
have to read, sign, and return (to the school). Only
students whose parent/guardian returned the signed
form would then be invited to participate in the study,
at which point these students would then be eligible
to give their own informed consent to participate in
the study. However, the Dalhousie University REB
was concerned about a possible sample bias, in that
students who were being exposed to parental/guard-
ian violence would be less likely to have parental
consent to participate in the study; thereby, reducing
the value of the information obtained. This concern
Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi’kmaq
Community: A Process Paper
33
First Peoples Child & Family Review, Volume 3, Number 2, 2007, Special Issue
was reported back to our community partners, and
with their support a passive parent/guardian consent
process was proposed to the Dalhousie University
REB, which they accepted once it was made clear that
school personnel would use school records, school
history, and professional judgment to assess whether
or not students had the capacity to give informed
consent themselves. It was decided that, for those
students who were deemed ineligible to give their
own informed consent, an informed parent/guardian
consent process would be used.
In order not to be in conflict with the Mi’kmaq
Ethics Watch provision that all children under the age
of 14 need active parent/guardian consent before be-
ing invited to participate in research, we ensured that
all student participants were at least 14 years of age.
As the study uses questionnaires, students requiring
the aid of an assistant for reading comprehension
were not invited to participate, but an individual flu-
ent in both English and Mi’kmaq was on hand at all
times during data collection to assist in translation of
key words if necessary.
Community stakeholders were given two weeks
notice prior to data collection. At the same time, pas-
sive parental/guardian consent forms were distributed
to the parents/guardians of all students under the age of
majority by the schools. By way of the passive con-
sent letter, parents/guardians were informed about the
purpose, tasks, and risks of the study. They were made
aware of the collaborative nature of the study, and were
encouraged to call university-based researchers or the
school staff should they wish to seek more information
about the study, and/or to refuse to allow their child
to participate in the study. No parents exercised their
right to refuse to allow their child to participate in the
study. On the day of data collection, the university-
based researcher reviewed the consent form with those
adolescents that were eligible to participate in the study
to provide them the opportunity to ask questions and
ensure an informed process. Students who were not in-
terested in participating in the study were free to leave
at any time, and some students did choose this option,
though records were not kept for how many students
choose not to participate. Guidance counsellors and
teachers were on hand during the administration of the
questionnaires, and students were told that they could
talk to their schools guidance staff at any point. Fur-
thermore, MH & SWS were informed well in advance
about when data collection would take place, and this
agency made arrangements to attend to any students
who sought services as a consequence of participating
in the study.
The questionnaires were administered in groups
(organized by class/grade when possible). Students
were informed that in order to increase their privacy,
three different versions of the same survey package
would be circulated. Due to the variable finishing
times of the students who participated in the survey,
there was no group debriefing. However, during the
process of informed consent, students were made
aware that they would have immediate access to the
on hand guidance counsellors, and that other commu-
nity services were ready to assist them on demand.
Furthermore, all students received a ‘help sheet’ that
was co-written by the primary investigator, MZ, and
the former Case Management co-ordinator. Each
help sheet included the name, summary statement,
and contact information of support services that are
both external (e.g., Kids Help Phone) and internal
(e.g., MH & SWS) to the community.
Students were informed that any information that
they provided on the survey booklet or answer sheet
would be anonymous, providing that they did not share
their answers with anyone or write any personally
identifying information on either the survey booklet
or the answer sheet. They were also made aware that
any information they did share with either researchers
or the school staff would be kept confidential, unless
it pertained to child maltreatment. It was made very
clear to the students that if they did share information
that pertained to child maltreatment, they would be
interviewed in private so as to determine whether or
not to report to the RCMP, the agency responsible for
child protection. Based on an agreement between re-
searchers and the schools, students were also informed
that any information they shared with the researcher
that pertained to child maltreatment would be shared
with the guidance department of their school.
Given the group/classroom testing context, and
the ways in which disclosures were made, verbal
disclosures during testing were directed to a private
discussion with the school guidance counsellor. Of-
ten, maltreated youth use humour to “test the waters”
for tolerating personal information and to obtain
some sense of mastery over an essentially hurtful and
humiliating experience. One student, when reviewing
a sexual abuse question, voiced a seemingly flippant
remark about an example “like when you wake up
Marc Zahradnik, Doreen Stevens, Sherry Stewart, M. Nancy Comeau, Christine Wekerle
and Christopher Mushquash
©
34
and someone is on top of you?” The youth was told
that that this comment may disturb other students
for whom such an experience was true and the youth
was subsequently asked to speak in private with the
guidance counsellor. As that discussion proceeded,
this particular youth disclosed his own maltreatment
background. This was the only verbal disclosure of
child maltreatment at either school that resulted im-
mediately from the questionnaire completion. As the
adolescent was over 15 years old, and the perpetra-
tor was no longer connected to the family, a formal
report was not filed. The adolescent did not wish to
report the incident, nor did he seek further services
from either the guidance counsellor or the community
service providers.
There was one other incident that necessitated a
follow up. A young adolescent woman had written her
name on the survey package and asked for help. The
researcher followed up on her request for help by way
of a telephone call to her (via the school). The young
woman assured him that she was not in any need of
help, and that she felt that she could both depend on
the school guidance counsellor for any problems that
she might have, and that she also knew how to avail
herself of the relevant community services. Outside
of these two incidents, none of the adolescents who
participated in the study demonstrated any signs of
distress nor did they communicate any desire for a
referral to any of the community service providers.
Preliminary Findings
Based on data we have obtained from 102 ado-
lescent student participants who have completed the
measures thus far, we are able to report the following
associations between the variables measured in our
school-based study. As can be seen in Table 1, the
exposure to violence (CEVQ; Walsch et al., in press)
total score is associated with post-traumatic stress
(CPSS; Foa et al., 2003) symptom clusters, depres-
sion (CESD; Radloff, 1979), and problem alcohol use
(RAPI; White & Labouvie, 1989; e.g., missing school
due to drinking). All measured aspects of maltreat-
ment (emotional abuse, physical abuse, and sexual
abuse) were associated with problem alcohol use (r
from +.24 to +.37). The exposure to violence total
score was most strongly correlated with the following
variables: the total PTSD score (r = +.36), PTSD-re-
lated avoidance (r = +.35), and problem alcohol use (r
= +.26). With respect to problem alcohol use (RAPI),
both depression (r = +.47), and PTSD symptoms (to-
tal score) were related (r = +.39). However, PTSD-re-
lated hyper-arousal had the strongest association with
problem alcohol use (r = +.54). This suggests that the
more agitated and restless the teen, the more likely
they were to report problematic alcohol use.
Our measure of resiliency (CYRM, International
Resilience Project, Dalhousie University, 2006),
which includes personal, relational, community, and
cultural aspects, was not related to any aspect of mal-
treatment. However, higher resiliency scores were as-
sociated with lower depression scores (r = -.27), lower
total PTSD symptoms (r = -.30), and lower PTSD
avoidance / emotional numbing in particular (r = -
.41). These associations are particularly encouraging,
especially since the avoidance symptoms of PTSD
are most strongly associated with the development
(Nemerhoff et al., 2006) and maintenance (Wenzlaff
& Wegner, 2000) of PTSD symptoms. In other words,
our findings can be interpreted to indicated that resil-
ient adolescents are less likely to suffer depression
or PTSD symptoms, and that furthermore, resilient
adolescents are less likely to avoid reminders of a
trauma (e.g., places where they were abused), which
may facilitate their recovery following exposure to a
traumatic event. Surprisingly though, higher scores
on resiliency were not associated with fewer alcohol
related problems. In our planned future analyses, a
more thorough exploration of the CYRM’s compo-
nent parts might shed some insight into whether cer-
tain aspects of resiliency (e.g., relational) may indeed
be protective from problem drinking. Developing
resiliency early in childhood may be one prevention
strategy for teen mental health, particularly, to the
degree that PTSD and depression promote problem
alcohol use as suggested here, a focus on enhancing
youth resilience may be effective in the longer term in
preventing escalation of alcohol use.
Although it is too early to come to any firm con-
clusions, it is encouraging for our mediational analy-
sis that maltreatment and PTSD symptoms (particu-
larly the hyper-arousal scale) are positively related
to problems related to alcohol use, as both of these
relationships are necessary precursors to demonstrat-
ing statistically that PTSD might be mediating the
relationship maltreatment and alcohol misuse. Such
a finding would direct practice to target PTSD symp-
toms as a more direct route for reducing or interven-
ing early with alcohol abuse. These are promising
Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi’kmaq
Community: A Process Paper
35
First Peoples Child & Family Review, Volume 3, Number 2, 2007, Special Issue
times for youth intervention, as the one key program
Trauma-Focused Cognitive Behavioral Therapy
(TF-CBT) is available to all practitioners free on a
web training site. To date, over 5,000 therapy students
and health care professionals have been certified with
TF-CBTWeb (see www.musc.edu/tfcbt and, to regis-
ter for the course, www.musc.edu/tfcbt and click the
Register tab). While there is presently no treatment
efficacy data on this training program, those that com-
plete the program demonstrate an increase in TF-CBT
based knowledge, and prospective studies are being
planned for the future.
We remain confident that in addition to providing
workshops and training opportunities to community
service providers, we will also be able to deliver in-
formation from this project that can be used to de-
velop ideas around prevention and intervention that
are commensurate with the community’s needs and
resources. Thus, the community can be ensured that
our mutual goal of creating a truly collaborative rela-
tionship that has the best interests of the community
at heart will be achieved.
Endnotes
1. Childhood maltreatment is defined as experiences
that were witnessed or direct victimization in terms
of sexual, physical, emotional abuse and neglect. In
this study, childhood refers to the teens’ lifetime expe-
rience of maltreatment, including witnessing domestic
violence. The measure used here, however, did not
tap neglect.
2. There is no collaboration between the RCMP and
the research team with regards to the present school-
based study, though the RCMP was made aware
of the study through contact with the community
Inter-Agency.
3. Although the literature cited for this section typical-
ly focuses on PTSD, recent theory on the biological
workings of responding to stress have emphasized
post-traumatic stress symptoms over the disorder
(e.g., DeBellis, 2002). Similarly, our work is consistent
with this view in that we are examining post-traumatic
stress reactions across a continuum that ranges from
lower levels of symptom severity to higher levels of
symptom severity, instead of taking a categorical ap-
proach where individuals either have the disorder or
do not have the disorder.
4. Although our studys emphasis is on alcohol use/
misuse and problems that follow from its misuse, the
empirical literature suggests that substances other
than alcohol (e.g., benzodiazepines, like Ativan or Vali-
um) have a high co-occurrence with PTSD (Jacobsen,
Southwick, & Kosten, 2001), and therefore, this section
employs the more general term substance misuse.
5. Though the original MH & SWS supporters of the
project—the director and psychologist—are no longer
with MH & SWS (due to retirement and relocation,
Marc Zahradnik, Doreen Stevens, Sherry Stewart, M. Nancy Comeau, Christine Wekerle
and Christopher Mushquash
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36
respectively), the new acting director continues to
support the study.
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Marc Zahradnik, Doreen Stevens, Sherry Stewart, M. Nancy Comeau, Christine Wekerle
and Christopher Mushquash
©
Building a Collaborative Understanding of Pathways to Adolescent Alcohol Misuse in a Mi’kmaq
Community: A Process Paper
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