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Int Public Health J 2016;8(2):137-154 ISSN: 1947-4989
© 2016 Nova Science Publishers, Inc.
Risk and protective factors related to the wellness
of American Indian and Alaska Native youth:
A systematic review
Catherine E Burnette, PhD,
and Charles R Figley, PhD
School of Social Work, Tulane University, New Orleans,
Louisiana, United States of America
Correspondence: Catherine E Burnette, School of Social
Work, Tulane University, 6823 St Charles Ave, Bldg 9,
Rm 208, New Orleans, LA 70118, United States. E-mail:
cburnet3@tulane.edu
Abstract
In comparison with the general population, research
indicates a need for greater health equity among American
Indian and Alaska Natives (AI/AN). AI/ANs have
demonstrated remarkable resilience in response to centuries
of historical oppression, yet growing evidence documents
mental health disparities. Consequently, some AI/AN
youth, defined as 18 years or younger, experience elevated
rates of suicide, substance use disorders, conduct and
oppositional defiant disorders, attention deficit-
hyperactivity disorders, and posttraumatic stress disorders.
In this article we systematically review the growing body of
research examining the culturally specific risk and
protective factors related to AI/AN youth wellness. This
review includes published, peer-reviewed qualitative and
quantitative research on AI/AN youth between the years
1988 to 2013. Organizing risk and protective factors within
a ecosystemic resilience framework, the following broad
risk and protective factors are critically reviewed: societal
factors (historical oppression and discrimination), cultural
factors (ethnic identity, spirituality, and connectedness),
community factors (community environment, school
environment, peer influence, and social support), family
factors (family support, family income, parental mental
health, family trauma and stressful life events), and
individual factors. The review includes a discussion of the
risk and protective factors accounting for AI/AN youth
mental health disparities, implications for correcting
disparities, and importance of incorporating familial and
community level interventions for AI/AN youth.
Keywords: American Indian, Alaska Native, disparities,
mental health, protective factors, risk factors, substance
abuse, systematic review, wellness
Introduction
A goal of the United States Affordable Health Care
Act is to move the nation a step closer toward health
equity, a priority of the Healthy People 2020 initiative
Catherine E Burnette and Charles R Figley
138
(1, 2). If health equity, or reaching and maintaining
the highest health for all people, is a desired outcome,
then understanding the current inequalities is of
utmost importance (2). American and Alaska Natives
(AI/AN) inequities experience some of the most
widely documented health disparities in the United
States (3, 4). This is due, in part, to the disconnect
between the paradigms employed in mainstream
social work practice and research and the worldviews
more salient among AI/AN populations (5, 6). For
example, rather than separating mental health from
physical health, many AI/AN populations value the
strong connection between physical, mental,
emotional and spiritual health (7, 8); emotional health
is viewed from a perspective of wellness (7,8). We
argue that the AI/AN nations deserve medical and
mental health services that complement their cultural
heritage that have sustained them for many centuries.
We define wellness as the balance between the
intertwined mind, body, soul, and spirit, (7).
Researchers recommend this holistic and strengths-
based perspective about health (7, 8). Therefore, this
systematic review focuses on wellness, which we
view as resilience in the form of prosocial emotional
and academic outcomes, as well as mental health
disparities.
With a trust responsibility, based on treaty
agreements with sovereign tribes requiring the United
States federal government to provide for the
healthcare of AI/AN populations in exchange for 400
million acres of land (9), a critical barrier to health
equity among AI/AN populations exists. Great
heterogeneity exists across AI/AN populations, and
research consistently finds significant differences in
prevalence of mental health disparities across these
populations (3, 4, 10-12). Despite this variability,
psychiatric distress in the form of mental health
disorders tends to be disproportionately high across
populations (3).
AI/ANs represent over five million people and
1.7% of the U.S. population (13). With rapidly
changing demographics, AI/ANs increased by almost
twice the rate of the general U.S. population between
the years 2000 and 2010. In total, 78% of AI/ANs live
off of reservation land (13). Yet, this percentage
differs among people who identify as either
multiethnic or solely AI/AN, with more AI/AN’s
living off of reservation land in the former than the
latter (13). On average, these populations are more
likely to live in poverty, experience violent
victimization and traumatic loss, domestic violence,
and educational inequities than non-AI/AN
populations (4). AI/AN youth between the ages of 12
and 19 are more likely than non-AI/AN youth to
experience serious violent crime and be affected by a
sudden traumatic death (4). Rates of witnessing
intimate partner violence and experiencing child
maltreatment are also elevated (4). Given the
disproportionately high rates that AI/AN youth
experience inequity in income and education, as well
as traumatic stressors, it is not surprising that many
also experience mental health disparities (4).
Resilience among AI/AN youth
Although the research available on AI/AN youth is
relatively small, studies document elevated rates for
substance use disorders, conduct and oppositional
defiant disorders, attention deficit-hyperactivity
disorders, and posttraumatic stress disorders (PTSD)
(3,4). Moreover, the suicide rate for AI/AN youth
ranges from three to six times higher than non-AI/AN
peers (4). Indeed suicide is the 2nd leading cause of
death for AI/ANs ages 15-34 years (14).
With these concerning statistics, the fact that the
majority of AI/AN youth are healthy and not
experiencing mental health disparities can often be
overlooked (12). Despite the undoubted resilience of
AI/AN populations after centuries of historical
trauma, loss, and oppression, current research tends to
focus on risk factors (15). Given the over-focus on
problems, resilience, or positive adaptation in
response to adversity is especially relevant (11, 16,
17). Adversity is typically characterized by
challenging life experiences, such as experiencing
discrimination or trauma (17). These challenging life
experiences can be thought of as risk factors, which
increase the probability of negative outcomes, such as
mental health disparities (11, 12, 18). Protective
factors, in contrast, are associated with positive life
outcomes and bolster individual and family resilience.
The ecosystemic perspective emerged within
social work literature (17). According to this
perspective, rather than being a static “trait” or
concept, resilience is a multi-determined and
American Indian and Alaska Native youth 139
constantly changing result of people’s interaction
within the ecosystemic context (17). An ecosystemic
resilience framework highlights the interconnections
and interactions among individuals, families,
communities, and societies (17). Thus, researchers,
not only examine characteristics and patterns within a
given system, but they also examine how multiple
systems interact. A focus is the continual adaptation
and interaction between individuals and families with
their environments (17). Therefore, a risk factor in
one context may be protective in other contexts (17).
Resilient individuals and families are often able to
withstand and recover from adversity with greater
skills and capacity than before experiencing the
challenge (11, 12, 18).
Culturally specific risk and protective
factors
Distinct tribes have varying historical contexts,
languages, cultural practices, values, and social
structures. Despite this variability, there is an absence
of localized understanding of culturally specific risk
and protective factors relating to AI/AN populations
youth (19-21); this absence persists, even with a
research emphasizing the variability of resilience
across contexts the need for its greater understanding
(19-21). Although overlap between AI/AN and non
AI/AN risk and protective factors exist, such as social
support, self-esteem, family support, school factors,
community safety, parental education and mental
health, and exposure to traumatic events (15, 16, 22-
27), culturally distinct factors are also significant for
AI/AN youth, such as historical loss, spirituality,
extended family, ethnic identity, and connectedness
(25-31).
A major societal risk factor health inequity is
historical trauma and oppression (32). Indeed, any
examination of mental health disparities incorporate
the ubiquitous effects of the disproportionate rates of
historical and contemporary traumas continually
experienced by AI/AN populations (4,10).
Intergenerational trauma and historical trauma are
concepts used to indicate the trauma inflicted on
groups sharing an ethnic or national background (33-
35). Campbell and Evans-Campbell (34) emphasize
the pervasive effects of historical trauma on AI/AN
youth, families, and communities. The historical loss
and oppression incurred by AI/AN peoples
throughout colonization, including widespread
disease, warfare, starvation, cultural genocide, forced
relocation and boarding school participation,
discrimination, and poverty, are linked to mental
health disparities among AI/AN youth (8, 8, 24, 26,
31, 34, 36, 37). Burnette (38) has extended the
concept of historical trauma to incorporate historical
oppression, to not only encompasses the pervasive
and continued effects of chronic, internalized,
insidious, and intergenerational experiences of
subjugation, but to also include daily experiences of
oppression, such as discrimination and poverty.
Although the relationship of historical oppression and
health inequities is commonly proposed in research,
empirical support for this relationship is in its
preliminary stages (39).
Because it influences how people approach,
appraise, and respond to adversity, the influence of
culture is thought to be an essential component for
research on resilience (20, 21, 40, 41). Culture
encompasses the beliefs, values, rituals, and norms of
social groups, which are affected by historical and
social factors (42). Identification with one’s culture is
thought to have a buffering effect against mental
health problems (16, 43-45), yet complexities related
to its measurement and understanding have created
the need for more research (46). Relatedly, spirituality
and connectedness have been found to be particularly
important for AI/AN youth (47-51). Finally,
community, and especially extended family, are
thought to be particular instrumental to AI/AN youth
(4, 7, 12, 15, 19, 41, 44, 52, 53). AI/AN extended
families can include blood relations, as well as clan,
tribe, and adopted family relationships (54). Likewise,
resilience research tends to examine individual
resilience including stress management, sleeping
success, and other variables. Very few studies have
focused on the risk and protective factors at the
family, community, cultural, or societal levels (19,
20); this is a severe limitation, given the primacy of
family and community to AI/AN youth (12).
With the absence of systematic reviews
examining the risk and protective from an
ecosystemic resilience framework, this review fulfills
several purposes. First, although connections among
risk and protective factors related to AI/AN and non-
Catherine E Burnette and Charles R Figley
140
AI/AN populations exist, AI/AN sovereignty and
heterogeneity make culturally distinct factors
important to uncover. This review examines AI/AN
youth distinctly. Second, this review examines the
existing empirical evidence validating culturally
specific risk and protective factors, such as historical
oppression, spirituality, and ethnic identity. Third, the
majority of existing research examines isolated risk
and protective factors in relationship to an outcome.
However, many risk and protective factors relate to
multiple outcomes. Therefore, a holistic, ecosystemic
examination is needed to understand the context of
mental health disparities and the wellness of AI/AN
youth across multiple levels (17).
This holistic examination of risk and protective
factors can identify gaps in current research and
inform social work interventions, which can be
developed based on relevant factors. Therefore, this
review fills the gap in understanding about the context
of mental health and substance use disparities that
could not be understood through individual
component studies. This systematic review examines
the following question: What are the risk and
protective factors related to AI/AN wellness across
societal, cultural, community, familial, and individual
levels?
Methods
This review includes peer-reviewed quantitative and
qualitative research articles on the wellness of AI/AN
youth published between the 25 year span of 1988 to
2013. These years were chosen because research on
mental health equity and inequity is relatively new;
articles published within this period encompass all
relevant research that could be located by this review.
To offset the tendency of research to focus on
problems and deficits (19), the inclusion criteria were
empirical research articles relating to AI/AN youth
wellness as measured by resilience and pro-social
outcomes and mental health a disparities experienced
by AI/AN youth, such as suicide, PTSD, attention-
deficit disorder, conduct disorder, and substance use
disorders. Only empirically-based research articles
with samples incorporating AI/AN youth were
included; articles with solely adult samples were
excluded.
Initial decisions about articles that were included
were made based on articles’ full reports by the first
author and were reviewed by the second author to
assess reliability. An example of an article that was
included was an article with a sample of 221 AI/AN
youth to investigate risk and protective factors related
to alcohol and drug use (43), whereas a study
investigating the relationship between intimate partner
violence and alcohol, drug, and mental health
disparities among AI/AN adult women was excluded
(55).
A multitude of social science and health related
databases were used to search for relevant articles,
including Google Scholar, Social Work Abstracts,
SocINDEX with Full Text, Social Sciences Full Text,
PsychARTICLES, PsychINFO, The Educational
Resource Information center (ERIC), Academic
Search Complete, Family Studies Abstracts,
MEDLINE, Race Relations Abstracts, and Health
Source: Nursing/Academic Edition. Search terms
included the following:
“American Indian,” OR “Alaska Native,” OR
“Native American,”
AND “Mental Health,” OR “Substance
Abuse,”
AND “Risk Factor ,” OR “Protective Factor,”
OR “Resilience,” OR “Resiliency,”
AND “Youth,” OR “Adolescent.”
Based on inclusion criteria, 51 empirical studies
are included in this systematic review. Among this
research, 47 articles used quantitative research
methods, whereas four articles employed qualitative
methods. With exception of these qualitative
inquiries, the vast majority of research examined
isolated independent variables in relationship to
dependent variables, such as mental health or
substance use outcomes. Articles described ages of
samples either by grade or age, with other research
identifying “adolescents” or “middle schooler.” The
age inclusion criterion for this article was that the
research article included participants ages 18 or
younger. Research articles that did not include
participants 18 or younger were excluded from this
review article. The majority of articles described
grades between six and twelve and ages ranging from
10 to 18. Three articles included ages that ranged
American Indian and Alaska Native youth 141
from 15 into the mid-50’s and described their samples
as adolescents and young adults (56-58).
Regarding geographic context, 58% of reviewed
articles sampled reservation AI/AN populations, 20%
of samples were urban, 14% had samples from both
urban and reservation based populations, and 8% did
not specify whether the AI/AN population was
reservation or urban based (See Figure 1).
Note. Figure 1 portrays the percentages of reviewed articles that drew samples from reservation based populations, urban
based populations, both urban and reservation based populations, as well as articles that did not specify geographic
locale.
Figure 1. Percentages of Reservation and Urban Based AI/AN Samples.
Note. Figure 2 depicts the percentage of samples in this systematic review that originated from National U.S. Samples, as
well as those from the Southwest, Upper Midwest and Northern Plains, West, South Central Southeast, Alaska Native,
Northeast, Not specified.
Figure 2. Percentages of Samples by Geographic Region of the United States.
Figure 2 portrays the percentages of samples
drawn from differing geographic regions with 7% of
articles not specifying geographic region, and
approximately 20% of articles sampling multiple
regions.
Three articles who sampled multiple tribes
included those from Canada and the upper
Midwestern United States. These articles were
retained in the review. The majority, 32% of articles
had samples from the southwestern United States,
with 26% of samples being drawn from each the
Catherine E Burnette and Charles R Figley
142
Northern Plains and Upper Midwest. National
samples and samples from the West compromised
11% of samples, and 7% came from either the south
central United States. The remaining samples came
from Alaska Natives or the Southeast, with these
compromising only 3% of the total. No identified
samples were included from the Northeast. Thus,
there was a significant deficit of tribes sampled from
these regions, with only 2 articles attending to each
the Southeast and Alaska Natives and none from the
Northeast.
Results
Using an ecosystemic framework, overarching risk
and protective factors for AI/AN youth mental health
and substance use disparities and resilience are
organized by societal, community, familial, and
individual levels. Figure 3 presents the overarching
factors organized within this framework.
Note. Figure 3 portrays risk and protective factors arranged across an ecosystemic framework at the societal, cultural, community,
familial, and individual levels.
Figure 3. Risk and Protective Factors for AI/AN Youth within an Ecosystemic Framework.
Note. Along with identified factors, 59% of factors had a relationship aspect. The factors with the most research supporting their
relevancy were both within the family level and included family support, as well as family trauma and stressful life events.
The second and third most supported risk factors were within the community level and included peer influence and school
environment.
Figure 4. Percentages of Factors with Empirical Support across Ecosystemic Levels.
American Indian and Alaska Native youth 143
Among the total number of risk and protective
factors reported to be relevant within studies, 7%
were at the societal level, 16% were at the cultural
level, 23% were at the community level, 41% were at
the family level, and 13% were at the individual level
(See Figure 4). Taken as a whole, 59% of factors had
to do with relationships. Because risk and protective
factors can vary by context and situation (17), the
details of these factors are delineated within each
subheading.
Societal factors
Historical oppression. Perceived historical loss,
including loss of language, land, traditional
spirituality, culture, and respect for elders, has been
associated with emotional and behavioral
consequences among AI/AN youth (59). For instance,
AI/AN youth reported experiencing daily thoughts of
historical loss, which were positively associated with
depressive symptoms (59). Furthermore, using a focus
group study with elders, parents, youth workers and
youth, across three tribal communities, loss of
language and culture were identified as major risk
factors for delinquent behaviors among adolescents in
the Southwest (12).
Perceived discrimination. A form of historical
oppression, perceived discrimination, is a well-
established risk factor for mental distress across
populations (60-65), and this finding extends to
AI/AN groups. For example, perceived discrimination
was an identified risk factor substance abuse and
externalizing behaviors among AI/AN youth (24, 26).
Likewise, perceived discrimination significantly
contributed to internalizing symptoms (66) and
suicidality among AI/AN youth (53, 67). Finally,
perceived discrimination predicted AI/AN’s
depressive symptoms, even when controlling for other
factors (31). Therefore, the effects of historical
oppression and perceived discrimination and AI/AN
youth’s mental health are increasingly substantiated in
research.
In summary, although the vast majority of
research includes societal factors, such as historical
oppression, in the explanation of challenges
experienced by AI/AN populations, additional
empirical research supporting this explanation is
needed. Difficulty in measuring historical effects
undoubtedly present research challenges, yet studies
have begun to substantiate societal factors relating to
AI/AN disparities (12, 59). For instance, historical
loss was associated with depressive symptoms and
delinquent behaviors among AI/AN youth (59). More
research is needed to disentangle the relationship
between historical oppression and mental health
disparities. Contextual information on the experiences
of oppression, such as relocation, discrimination,
poverty, and boarding schools, and their effects on
AI/AN populations will add necessary information to
further knowledge development in this substantive
area. Finally, perceived discrimination is a well-
established risk factor across populations (60-65), and
this finding extended to AI/AN youth, as it is related
to substance use, externalizing behaviors,
internalizing symptoms, depressive symptoms, and
suicidality (24, 26, 31, 53, 67). The focus now shifts
to cultural factors that have buffered risk factors and
bolstered resilience among AI/AN youth.
Cultural factors
Ethnic identity. Enculturation, or the degree that
individuals learn about, identify with, and are
embedded in their ethnic culture, is reported as
protective against substance abuse and mental distress
(68). Among AI/AN youth living on or near
reservation communities in the Upper Midwest,
increased levels of enculturation were predictive of
decreased suicidal behavior (69). Similarly,
enculturation has been predictive of prosocial
outcomes, such as academic achievement and
substance non-use (16, 26). Finally, using the
National American Indian Adolescent Health Survey,
involvement in traditional activities was found to be
protective against suicidal attempts and ideation for
males (30).
Other research has found mixed results for
enculturation as a protective factor (10). For example,
ethnic pride was associated with fewer alcohol
symptoms; however, engagement in generic pow
wows was not protective in this context, as it they
were associated with a social group engaged in
informal drinking (27). Contrarily, other researchers
identified tribal language, engagement in ceremonies
Catherine E Burnette and Charles R Figley
144
and pow wows to be protective against adolescent
delinquent behaviors (12). However, ethnic identity
was not predictive of alcohol involvement directly or
indirectly in other research (22, 70, 71). Although
ethnic identity did not directly affect mental health
and substance abuse outcomes among AI/AN
adolescents in another study, it was positively
associated with social support, which was protective
against negative outcomes (43); therefore,
enculturation may indirectly affect mental health and
substance use disparities (43).
Finally, biculturalism, or identifying and
navigating effectively in more than one culture
without comprising either, has been protective for
self-esteem, mental health, and substance abuse
among AI/AN populations (25, 72-75). Indeed,
modest support was reported for bicultural skills in
preventing substance abuse AI/AN adolescents
residing on two reservations in the Northwest (74).
Spirituality. Related to enculturation, engagement
in traditional spiritual practices and religious
activities, more broadly, have been found to be
protective for AI/AN youth. Religious affiliation and
spirituality have been identified as protective against
adolescent alcohol abuse/dependence (27, 28). In one
study, Christian beliefs and belonging to the Native
American Church were associated with lower levels
of substance abuse (49). Because they were associated
with anti-drug attitudes, norms, and behaviors,
traditional spiritual beliefs are thought to serve
protective functions for AI/AN populations (49).
However, in contrast to commitment to Christianity or
beliefs in cultural spirituality, commitment to cultural
spirituality was associated with a reduction in suicide
attempts among AI/AN populations (57). Therefore,
although spirituality and religious involvement may
have a protective effect, this effect is dependent on
complex factors such as belief systems, commitment
beliefs, measurement issues, and the social context.
Connectedness. Connectedness emerged as
protective across multiple dimensions and domains of
AI/AN wellness. Hill’s research uncovered
connectedness, or interrelatedness to community,
family, nature, the Creator, land, environment, and
ancestors, as a protective factor for adult AI/AN
populations against suicide (47). Extreme alienation
from family and community, in contrast, was a
reported risk factor for suicide attempts among AI/AN
adolescents (76). Likewise, relationship loss and
feeling unsupported were risk factors for impaired
AI/AN youth resilience, whereas connectedness
fostered youth resilience (41, 77, 78). Finally, feeling
cared for and connected to others was protective
against depression and negative health outcomes (15).
Thus, existing research indicates enculturation,
spirituality, and biculturalism are protective in certain
contexts. Ethnic identity emerged as a powerful
protective factor (16, 26, 30, 69). That said, other
research reports were mixed (22, 27, 70, 71). This is
not surprising when considering the complexity of
measurement of social variables and heterogeneity
across AI/AN populations (43). Spirituality was
another empirically supportive protective factor (27,
28, 49). Like ethnic identity, however, it depended on
the content and context of research investigations
(57).
Lending support to the notion that any one factor
can serve as a risk factor or protective factor,
depending on the context, all factors, including
spirituality must be assessed holistically within the
social environment. There is some evidence that
connectedness was a culturally-specific protective
factor associated with suicide risk, level of resilience,
level of depression, among other health outcomes (41,
76-78). Finally, modest support was found for
biculturalism being protective against substance (74),
yet more research is needed to provide additional
evidence. More investigation about factors that may
account for variability is warranted. Risk and
protective factors at the community level are now
examined.
Community factors
Community environment. AI/AN adolescents are
situated within broader environments. Community
and school environments may serve as either
protective or risk functions, depending on their
quality. For example, community support was found
to be protective in fostering adolescent prosocial
behaviors (26). However, gang involvement and gun
availability were risk factors for suicide attempts (23).
Moreover, neighborhood safety, particularly the
presence of crime and drug sale, predicted depressive
symptoms and substance abuse among AI/AN
American Indian and Alaska Native youth 145
adolescents (79). Not only were unsafe communities
risk factor, a positive association was reported
between neighborhood poverty and lifetime alcohol
use, but not illicit drug use (80).
School environment. Connectedness extended to
the domain of school, and school belonging was
protective against substance abuse (29). Likewise,
school connectedness was protective against violent
perpetration among AI/AN urban youth (81) and
negative emotional health outcomes (52). School
safety emerged as a key issue, and an unsafe school
environment to be a risk factor for substance abuse,
whereas school attachment was a protective factor
(82). Furthermore, a negative school environment was
risk factor for substance abuse (27).
Parallel to these findings, school bonding was
protective against substance abuse among AI/AN
students (83). Moreover, positive feelings about
school were protective against suicidality,
hopelessness (30), suicide attempts (71), and
substance abuse (24). Educational prevention efforts,
such as anti-drug use campaigns were reported to be
protective against AI/AN drug use (84). A non-
parental adult role model was protective against
alcohol use (28). Finally, school mentors and role
models were found to be protective, whereas a lack of
teacher support was a risk for AI/AN adolescent
delinquent behavior (12).
Peer influence. Parallel to school environment,
peer influence was highly predictive of AI/AN mental
health and substance use outcomes. Specifically, peer
alcohol use and peer deviance were risk factors,
whereas peer support was protective against substance
abuse and mental health problems (22, 23, 27, 80, 83,
85-87). First, peer encouragement of alcohol use was
a risk factor for substance abuse (87). Second, peer
alcohol use predicted substance abuse (22), a finding
paralleled in more recent research (83). Third, peer
deviance, defined as those engaging in substance
abuse or who have non-negative attitudes about
missing school, stealing things, picking a fight, or
attacking with the intent of harm, is an additional risk
factor for AI/AN adolescent substance abuse (27, 80,
83, 86, 88).
Among protective factors, discussing problems
with friends, in contrast, was protective and
associated with decreased levels of suicidality (23).
Having prosocial peers was also protective against
suicide attempts (84, 89), whereas a friend attempting
suicide was a risk factor for suicide ideation (90).
Finally, peer support was found to be protective
against substance use and risk behavior among AI/AN
adolescents (43).
Social support. Social support is protective within
the general population, a finding also evident among
AI/AN populations. Social support was protective
against suicide attempts among AI/AN (71, 90).
Furthermore, caring adults, neighbors, and tribal
leaders were protective against suicidality, suicide
attempts, and hopelessness for AI/AN adolescents
(30, 89). Finally, adult warmth and social support is
negatively associated with depressive symptoms (31,
43). Social support from peers, adults, and community
members is integral, and the focus shifts now to the
centrality of family for AI/AN resilience.
To summarize, among many AI/AN populations,
community is especially instrumental in facilitating or
impairing the resilience of their youth. It is not
surprising that empirical research parallels this
finding (23, 26, 79, 80). Although community support
fostered prosocial behaviors and resilience(26), a lack
of neighborhood safety, manifested through the
presence of gangs, firearms, crime, drugs, and
poverty, was a risk for depressive symptoms,
substance abuse, and suicide attempts(23,79). The
school environment and peer influence were the third
and fourth most frequently supported factors relating
to AI/AN wellness. A positive school environment
along with school connectedness and bonding were
protective against negative emotional health
outcomes, violent perpetration, substance abuse,
suicidal thoughts and actions (29, 30, 52, 81, 83).
Unsafe schools and a lack of school bonding, in
contrast, were associated with substance abuse (27,
82). Education-based prevention programs were
linked with less drug use (84), and school role models
were protective against delinquent behaviors and
substance use (12, 28).
Peers influence could be protective or a risk; peer
deviance, suicide attempts, and substance use were
risk factors for substance use, suicide attempts, risky
behaviors, and mental health problems, whereas
discussing problems with friends, peers support, were
protective factors (22, 23, 27, 43, 80, 83, 85-90).
Parallel to the general population, social support was
found to be protective against suicide attempts and
Catherine E Burnette and Charles R Figley
146
depressive symptoms (31, 43, 71, 90). Peer influence
clearly plays an integral role in AI/AN adolescent
functioning, and bolstering individual resilience may
warrant community and school based efforts.
Familial factors
Family support. Family is especially instrumental to
the wellness of AI/AN adolescents and youth, and the
following research provides its empirical support.
Family satisfaction was protective against suicide
(67), and family support, caring, parental warmth and
communication protect against substance use and
risky behavior (28, 80, 91, 92). First, family
communication was reported as protective against
AI/AN adolescent substance abuse (28). Second,
family support was found to be protective against
depression (15). Discussing problems with family, as
well as family connectedness were protective against
suicide attempts (23). Family could have a differential
effect based on gender and ethnic background. A
caring family, family attention, and parental
expectations were protective against suicidality and
hopeless for AI/AN adolescent girls, whereas,
a caring family was protective for adolescent boys
(30).
Parental warmth emerged as a protective factor in
four studies (26, 31). First, maternal warmth was
protective for academic success and abstaining from
substance abuse (26). Second, parental warmth was
protective against depressive symptoms (31). Third,
parental warmth was associated with positive feelings
about school, which protected against AI/AN
adolescent problem drinking (24). Fourth, family
caring explained 15% of the variance in emotional
health outcomes among AI/AN adolescents (52).
Similarly, parental attachment was protective against
substance abuse (80). Coercive parent, such as
yelling, and caretaker rejection, in contrast, was
predictive of suicidality (53). Therefore, the quality of
family relationships had measurable direct and
indirect effects on behaviors related to AI/AN mental
health and substance use disparities.
Positive family relationships (27) and family
sanctions against drugs and alcohol were protective
against substance abuse (22, 84, 93). Importantly,
family sanctions against drug use had direct and
indirect influence on AI/AN adolescent drug use,
which differed from the Anglo sample (93). Parental
disapproval of substance abuse was similarly
protective (88). In a focus group study, sibling and
cousin influence were found to be particularly
important in the substance abuse decision-making
among AI/AN youth (54). Moreover, family members
could either serve as a protective or protective
function against or risk function on substance abuse
decisions, depending on family members’ attitudes
toward substance abuse (54).
Family income. Family income could also be a
risk or protective factor for AI/AN mental health and
substance use outcomes. For instance, in a quasi-
experimental and longitudinal study, family income
supplements were protective against mental health
disorders (94). Family financial strain, in contrast,
was a risk factor for both mental health problems and
substance abuse (27, 31, 58). Parental education,
which could affect family income, was protective
against substance abuse among AI/AN adolescents
(80, 95).
Parental mental health. Parental mental health
and substance use behaviors were also relevant to
AI/AN wellness. For example, parental substance
abuse was identified as a risk factor for lifetime
substance abuse of participants (24). Parental
substance abuse was also associated with substance
abuse and mental health problems, including
suicidality, in other research (27, 58, 67). Having a
parent with major depression also placed AI/AN
adolescents at greater risk for substance abuse (24).
Finally, having a family member attempt or complete
suicide tended to be a risk for AI/AN adolescent
mental health disorders and suicidality (67, 76, 85).
Clearly, family affected AI/AN mental health and
substance related outcomes based on factors,
including the quality of communication, parental
caring and warmth, parental expectations, norms
against substance use, family income, and parental
wellness.
Family trauma and stressful life events. Parallel
to the influence of family, the impact of experiencing
trauma and stressful life events are well-documented
risk factors. Stressful life events, family violence, and
experiencing trauma and abuse are well documented
risk factors for mental health and substance use
problems, and often, family is the context for which
American Indian and Alaska Native youth 147
this trauma occurs (96). Stressful life events and
adverse childhood experiences, such as having a
loved one attempt suicide, having family member
with substance abuse problems, experiencing abuse,
unemployment, experiencing a breakup, experiencing
a death/loss of a loved one, the serious injury of a
family member, and being gossiped about, have been
associated with mental health and substance abuse
problems among AI/AN adolescents (43, 69, 70, 87,
91, 97-99).
Family violence is another major risk factor for
AI/AN youth. Witnessing family violence and trauma
are risk factors for substance abuse among AI/AN
adolescents (56, 95, 99). Paternal violence problems
were associates for youth and adolescent mental
health problems (58). Experiencing violent
victimization in childhood was a risk for both
substance abuse and suicide attempts among AI/AN
adolescents (89, 100), and perpetrating violence was a
risk factor for suicide attempts among male AI/AN
adolescents (101). Parallel to non-AI/AN samples,
experiencing childhood physical and sexual abuse
was also an overwhelming risk factor for negative
outcomes including suicide attempts, substance abuse,
and mental health disorders (23, 27, 52, 56, 58, 76,
82, 100).
Therefore, the relationship between family and
AI/AN wellness was ubiquitous along multiple
dimensions, and families, encompassing 41% of the
reported risk or protective factors related to wellness,
are particularly instrumental to many AI/AN
communities (102). Family satisfaction, caring,
warmth, support, and positive communication, were
protective against depression, suicide attempts, risky
behaviors, substance abuse, whereas, coercive
parenting predicted suicidality (15, 24, 26, 28, 30, 52,
53, 67, 80, 91, 92). Families could also deter
substance abuse by imposing sanctions or expressing
their disapproval of substance use, and parents,
siblings, and cousins could also increase the
likelihood of substance abuse depending on their own
attitudes and orientations (22, 54, 84, 88, 93). Family
income and education were protective against mental
health disorders; whereas financial strain could
heighten the risk of substance abuse and mental health
challenges (27, 31, 58, 80, 94). Family influence
seemed to supersede non-family influence, and is thus
an important factor for continued investigation (54).
Parental mental health and substance abuse challenges
were associated with substance abuse,
suicidality, and mental health problems (24, 27, 58,
67, 76, 85).
Stressful life events, adverse child experiences,
and family violence are all associated risk factors for
substance abuse and mental health problems. Similar
to non-AI/AN samples, experiencing childhood
physical and sexual abuse was an ubiquitous risk
factor for negative outcomes including suicide
attempts, substance abuse, and mental health
disorders across the life course (97, 103-105).With
extended family being especially relevant to many
AI/ANs (75), more information about the effects of
siblings, grandparents, as well as aunts, uncles, and
cousins is needed. Furthermore, contextual factors
about the family environment need to be delineated,
and this may be best achieved through ethnographic
and qualitative inquiry (17). Finally, we shift focus to
research examining risk and protective factors at the
individual level.
Individual factors
Individual lever risk factors also played a role in
AI/AN mental health and substance abuse outcomes.
Self-esteem and subjective wellness fostered prosocial
outcomes, such as substance non-use, and was
protective against suicide ideation among AI/AN
adolescents (16, 23, 90). Low self-worth, in contrast,
was a risk factor for substance abuse (76, 86).
Moreover, embodying an internal locus of control was
protective against suicide ideation (90). Similarly,
positive perceptions about oneself and one’s family
were protective against mental health problems (70).
Pride in one’s body was also protective for emotional
health (52). Embodying an academic orientation was
found to be protective against AI/AN adolescent
substance abuse and suicide (98). Negative views
about substance use were protective against abuse
(88). Associated positive affect, in contrast, was
protective against violent perpetration for AI/AN
youth, whereas, risk factors included substance abuse
and suicidal thoughts (81,101).
Risk factors interacted and tended exacerbate
each other. Impulsivity was a risk factor for substance
abuse (80). Further, substance abuse, feeling
Catherine E Burnette and Charles R Figley
148
depressed, feeling life had no purpose, anxiety,
antisocial behavior, and depression were risk factors
for suicide attempts among AI/AN adolescents (53,
67, 71, 82, 89, 90). Finally, Substance abuse, angry
feelings, delinquent behavior, and sexual activity to
be risk factors for depression and health
compromising behaviors, including substance abuse
(15, 23, 66, 76, 85, 95, 106, 107). Therefore, mental
health and substance use outcomes were
simultaneously risk factors for subsequent negative
outcomes; the interactions between these factors must
be considered holistically.
In closing, individual factors are the well-studied
among youth in the general population, and many of
these are also relevant to AI/AN populations. Within
this review, impulsivity, delinquent behavior, mental
health problems, substance abuse, were
simultaneously risk factors and negative outcomes
related to each other (15, 23, 53, 67, 71, 76, 82, 85,
89, 90, 106, 107). Self-esteem, subjective wellness, an
internal locus of control, positive self and family
perceptions, pride in one’s body, an academic
orientation, and positive affect were protective factors
for mental health and substance use disparities (16,
23, 52, 70, 76, 81, 86, 88, 90, 101).
Discussion
This systematic review examined risk and protective
factors across the societal, cultural, community,
familial, and individual levels across several
outcomes. Results reveal considerable overlap of risk
factors across mental health outcomes. Depression
and suicide, for example, share similar risk factors as
substance abuse. These overlapping risk factors
compound the potential for mental health service
disparities related to AI/AN wellness.
Despite overlap, much of the research found
significant variability in risk factors based on specific
demographic information, namely gender, geographic
region, and urban versus reservation dwelling
populations. First, variability was consistently found
by gender (22, 24, 30, 37, 52, 58, 69, 70, 76, 78, 100,
106). For instance, family sanctions against alcohol
use was protective for females but not for males (22).
Likewise, the risk factor of child sexual abuse was
more prevalent among females (100). Clearly, gender
is an important construct in the examination of risk
and protective factors.
Second, although the majority of AI/AN
populations reside in urban areas, almost 60% of
research focused on reservation dwelling samples
(13). Despite this imbalance, some research
conducted research across regions and with both
urban and reservation-based populations. Third,
regional differences and variability among samples
was consistently reported (10). Despite this
variability, there was an absence of research with
AI/AN populations residing in Alaska, the Southeast,
and the Northeast. With variability across AI/AN
populations, more research is needed from these
regions.
With the majority of risk and protective factors
being present at the family, community, and cultural
levels, these are particularly important areas for
intervention development. Moreover, additional
research is needed to empirically delineate the
relationship of historical oppression to AI/AN
wellness to further delineate this societal factor.
Research examining wellness holistically is needed to
synthesize the many overlaps across factors and
outcomes.
However, rather than examining resilience
holistically, which is recommended for work with
AI/AN populations (17, 19), the majority of research
tends to use quantitative methods to examine distinct
risk and protective factors in isolation and relate them
to specific mental health disparities. Despite the
undoubted benefit of identifying the effects of specific
variables related to mental health disparities, there is
first a need to establish a comprehensive
understanding of how risk and protective factors are
culturally defined and situated within localized
contexts. Toward this aim, qualitative research (16),
and in particular, ethnographic research is
recommended for the study of human resilience (17).
As Waller elaborated (17), important protective
factors, that may not be readily apparent to
researchers, are illuminated with a holistic
understanding of how people appraise experiences of
adversity. Without this comprehensive understanding,
important mechanisms that promote or prevent
resilience may be missed (20, 21).
American Indian and Alaska Native youth 149
Implications for treatment
The identified culturally specific risk and protective
factors are not only important for future research to
delineate in more complexity, they can inform social
work interventions development. Indeed, the
incorporation of family, spirituality, and community
are recommended for suicide prevention and
intervention development (108). Concepts, such as
“mental health” are socially constructed, however,
AI/AN constructions typically involve a holistic
understanding of wellness, which includes body,
mind, and spiritual dimensions and the balance
between these dimensions (7, 8). Indeed, risk and
protective factors, such as spirituality and
connectedness consistently predicted mental and
substance abuse outcomes for AI/AN youth. Rather
than addressing risk and protective factors separately,
this systematic review indicates that the balance and
reciprocal interaction between factors across
ecosystemic levels are important foci in developing
interventions to address health inequities related to
mental health and substance abuse. Bolstering
protective factors and reducing risk factors within an
culturally congruent ecosystemic framework is a
promising approach for mitigating health disparities
experienced by AI/AN youth.
In reviewing the research, a paucity of evidenced-
based prevention and interventions for AI/AN youth
were uncovered (109). Current available interventions
for AI/AN youth span along a continuum between
culturally-based and culturally relevant programs to
evidenced-based programs, typically developed with
non-AI/AN populations (109). Research has identified
barriers to effective social work interventions in the
form of underfunded health care systems, disregard
for AI/AN traditional practices, and the uncritical use
of evidence-based practices (EBP) (4, 37). Many
interventions are used from existing EBPs, which are
assumed to be culturally appropriate and superficially
adapted for AI/AN populations (109). The challenge
with EBPs is that traditional healing tends to be
excluded from these practices, and these practices
haven’t included AI/AN samples (37, 110). Moreover,
some AI/ANs have felt that the reliance on EBP has
led to the imposition of Euro-American worldviews,
which is thought to be a continued form of
colonization (111). Within these interventions, lies a
reported failure to integrate adequate cultural
sensitivity (110, 112). Some scholars state that these
interventions are internally flawed and culturally
irrelevant to AI/AN youth (109). Indeed, some
AI/ANs have been found to be uncomfortable with
the dominance of Euro-American approaches to
substance abuse treatments (111).
Culturally-based and culturally relevant
prevention and interventions programs, in contrast,
emerge from AI/AN worldviews, but largely lack and
empirical basis (109). Indeed, one study found no
manualized interventions to address the need of
AI/AN youth in a culturally appropriate manner
(113). Recent research documents that many AI/AN
populations prefer traditional healing (111, 113, 114),
and there is a growing body of work that delineates
traditionally informed intervention and prevention
efforts (44, 108-115). However, with the
heterogeneity across AI/AN populations, preferences
are variable and context specific; individuals and
families preferences vary along a continuum of
traditionally-based to more conventional treatments.
Thus context-specific and individualized treatment
options are needed. Clearly, more culturally relevant
and culturally specific prevention and interventions
are needed. Integrating culturally definitions of
wellness and mental health and culturally relevant
interventions are recommended (8).
EBTs, then, are recommended to be integrated
within culturally specific and culturally relevant
AI/AN social work interventions rather than the
reverse, which is most commonly the case (111).
Whitbeck (116) proposed a promising multi-stage
model for developing evidenced based culturally
specific intervention and assessment models for
AI/AN populations. First, familiarity with key risk
and protective factors are gained, such as those
synthesized in this review (116). Second, familiarity
with culturally specific research is followed by a
cultural partnership with cultural experts (116).
Finally, culturally specific measures and interventions
are developed in partnership with AI/AN
communities (116).
In closing, culturally specific risk and protective
have been identified across ecosystemic levels,
including the societal, cultural, community, familial,
and individual levels. With family, community, and
culture being especially salient to many AI/AN
Catherine E Burnette and Charles R Figley
150
communities, prevention and treatment interventions
should be situated within the historical context and
reflect the their prominence. These factors are largely
represented in the personal connections among
community members. Given that almost 60% of
factors identified in this review were relationship
oriented, interventions that highlight the relational
context are recommended. Culturally relevant,
sensitive, and specific interventions, developed by
and with AI/AN communities are needed to build
upon identified protective factors. It is the
responsibility of those aware of these factors to work
cooperatively to build a system of care for the AI/AN
communities, families, and individuals that ameliorate
risks, and work toward uncovering and applying
additional factors that bolster wellness.
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Submitted: January 12, 2015. Revised: February 16, 2015.
Accepted: February 22, 2015.
