A R T I C L E

AMERICAN INDIAN AND ALASKA NATIVE BOYS: EARLY CHILDHOOD RISK

AND RESILIENCE AMIDST CONTEXT AND CULTURE

MICHELLE SARCHE
University of Colorado Anschutz Medical Campus

GREG TAFOYA
University of New Mexico School of Medicine

CALVIN D. CROY
University of Colorado Anschutz Medical Campus

KYLE HILL
Johns Hopkins Bloomberg School of Public Health, Center for American Indian Health

ABSTRACT: American Indian and Alaska Native (AIAN) adolescent and adult men experience a range of health disparities relative to their non-AIAN
counterparts and AIAN women. Given the relatively limited literature on early development in tribal contexts, however, indicators of risk during early
childhood specific to AIAN boys are not well-known. The current article reviews sources of strength and challenge within AIAN communities for AIAN
children in general, including cultural beliefs and practices that support development, and contextual challenges related to socioeconomic and health
disparities and historical trauma affecting the AIAN population as a whole. The research literature on early development is reviewed, highlighting what
this literature reveals about early gender differences. The article concludes with calls to action on behalf of AIAN boys that align with each of the five
tiers of R. Friedens (2010) Public Health Pyramid.

Keywords: Native American, development, boys, culture

RESUMEN: Los hombres adolescentes y adultos indgenas americanos y originarios de Alaska (AIAN) experimentan una gama de disparidades de
salud en forma relativa con respecto a su contraparte que no son del grupo AIAN y las mujeres AIAN. Sin embargo, dada la relativamente limitada
literatura sobre el temprano desarrollo en contextos tribales, los indicadores de riesgo durante la temprana ninez especficos para los ninos varones
AIAN no son bien conocidos. El presente estudio revisa las fuentes de aspectos fuertes y de retos dentro de las comunidades AIAN en cuanto a los
ninos AIAN en general, incluyendo creencias culturales y practicas que apoyan el desarrollo, y los retos contextuales relacionados con las disparidades
socioeconomicas y de salud y el trauma historico que afecta la poblacion AIAN como grupo total. Se revisa la literatura investigativa sobre el temprano
desarrollo, subrayando lo que esta literatura revela acerca de las tempranas diferencias de genero. El ensayo concluye con una llamada a la accion en
favor de los ninos varones AIAN que estan a la par con cada uno de los 5 niveles de la piramide de salud publica de Frieden.
Palabras claves: indgena americano, desarrollo, ninos varones, cultura

RESUME: Les hommes adultes et adolescents des populations autochtones nord americaines et dAlaska (American Indian and Alaska Native, abrege
AIAN) font lexperience dun eventail de disparites en matiere de sante par rapport a leurs homologues non-AIAN et aux femmes AIAN. Du fait des

The authors report no conflicts of interest. We thank Rick Hill, Sr. for granting us permission to use his quote in this article. We felt that his quote embodied the
beauty and wisdom of AIAN beliefs that support the health and well-being of future generations.
Grant support: Administration for Children and Families (90PH0017; Novins, PI); National Institute on Drug Abuse (HHSN271201500717P; Whitesell &
Sarche, MPI).
Direct correspondence to: Calvin Croy, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Centers for American Indian and
Alaska Native Health 13055 E. 17th Avenue, Aurora, CO 80045; e-mail: calvin.croy@ucdenver.edu.

INFANT MENTAL HEALTH JOURNAL, Vol. 38(1), 115127 (2017)

C 2017 Michigan Association for Infant Mental Health

View this article online at wileyonlinelibrary.com.

DOI: 10.1002/imhj.21613

115
116 M. Sarche et al.

recherches relativement limitees sur le developpement precoce dans les contextes tribaux, cependant, les indicateurs de risque durant la petite enfance
specifiques aux garcons AIAN ne sont pas bien connus. Cet article passe en revue les sources de forces et de defis au sein des communautes AIAN
pour les enfants AIAN en general, y compris les croyances et les pratiques qui soutiennent le developpement et les defis contextuels lies aux disparites
socioeconomiques et de sante ainsi que le trauma historique affectant la population AIAN dans son ensemble. Les recherches sur le developpement
precoce sont passees en revue, mettant en valeur ce que ces recherches revelent sur les differences precoces de genre. Cet article conclut avec des appels
daction salignant sur chacun des 5 tiers de la pyramide de sante publique de Frieden, au nom des garcons AIAN.
Mots cles: Populations autochtones nord-americaines, developpement, garcons, culture

ZUSAMMENFASSUNG: Jugendliche und erwachsene Manner der Indianer und Ureinwohner Alaskas (AIAN) erleben eine Reihe von gesundheitlichen
Disparitaten im Vergleich zu nicht-AIAN und AIAN-Frauen. Angesichts der relativ begrenzten Literatur uber die fruhe Entwicklung in Stammeskontex-
ten sind die fur die AIAN-Jungen spezifischen Risikoindikatoren wahrend der fruhen Kindheit unbekannt. Der vorliegende Artikel untersucht Quellen
zu Starken und Herausforderungen fur AIAN-Kinder innerhalb der AIAN-Gemeinschaften im Allgemeinen, einschlielich kultureller Uberzeugungen
und Praktiken, die die Entwicklung unterstutzen sowie einschlielich kontextbezogener Herausforderungen im Zusammenhang mit soziookonomischen
und gesundheitlichen Ungleichheiten und historischen Traumata, die die AIAN-Bevolkerung insgesamt betreffen. Die Forschungsliteratur uber die
fruhe Entwicklung wird im Hinblick auf Erkenntnisse zu fruhen Geschlechterunterschieden uberpruft. Der Artikel endet im Auftrag der AIAN-Jungen
mit Aufrufen zum Handeln, die sich an den 5 Stufen der Gesundheitspyramide von Frieden ausrichten.
Stichworter: amerikanischer Ureinwohner, Entwicklung, Jungen, Kultur

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In the last census, there were 5.2 million people in the
United States who identified as American Indian or Alaska Native
(AIAN), either alone (2.9 million) or in combination with one or
more other races (2.3 million; U.S. Census Bureau, 2012). One
third of this population were children under the age of 18 (U.S.
Census Bureau, 2006). Children, especially young children, are
particularly vulnerable to the health disparities faced by the AIAN
population as a whole. However, they also are afforded special
protection related to the traditional belief held in nearly all AIAN
cultures that children are sacred (Sarche & Spicer, 2008). The

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

majority of research on AIAN childrens health and development
has focused on adolescence, but science steadily points to early
childhood as a time during which the foundation for lifelong
physical and emotional health is built (Bullock, 2015; National In-
stitute on Drug Abuse, 2016; Shonkoff, Boyce, & McEwen, 2009).
The broader AIAN health literature has shown that both AIAN
adolescent and adult men are more likely to experience a range of
health disparities relative to non-AIAN males and AIAN females
(Yellow Horse Brave Heart, Elkins, Tafoya, Bird, & Salvador,
2012). Given the relatively small AIAN early childhood literature,
however, the early roots and developmental course of these
gender and ethnic disparities specific to AIAN boys are not well-
understood.
To begin to address this gap in understanding, the current ar-
ticle provides an overview of the health disparities affecting AIAN
adolescent and adult men and, from the limited literature relevant
to young AIAN boys, begins to discern the early childhood indi-
cators of these subsequent health outcomes. The article concludes
with an overview of some important efforts being implemented in
support of AIAN childrens health and development in general as
well as a call to action on behalf of young AIAN boys in particular
but relevant to all young AIAN children. We begin by providing
the reader with a broad understanding of the AIAN cultural and
contextual setting within which AIAN children live.
THE AIAN CULTURAL AND CONTEXTUAL SETTING
AIAN communities are diverse. There are 566 federally recog-
nized and 61 state-recognized tribal communities today (Federal
Register, 2015; U.S. Government Accountability Office, 2012),
each with its own governance structure, history, language, and
cultural beliefs and practices. Twenty-percent of the AIAN popu-
lation lives on federally- or state-recognized tribal lands, including
reservations, tribal statistical areas, and Alaska Native villages
(U.S. Census Bureau, 2012). The majority (71%) of the AIAN
population lives in urban areas across the country (Urban Indian
Health Institute, 2013); New York City has the largest population
of AIANs (112,000) while Anchorage has the largest percent-
age of AIANs (12%; U.S. Census Bureau, 2012). Urban AIAN
communities have histories and cultures of their own, influenced
by the diverse tribal cultures represented in urban communities,
as well as urban AIAN culture and experience in its own right
(National Urban Indian Family Coalition, 2008). Despite their
greater numbers, urban AIAN communities are vastly underrep-
resented in the extant health research literature (Yuan, Bartgis, &
Demers, 2014).
AIAN communities are rich in cultural beliefs and prac-
tices that shape child development and family life (Best Start,
2010; Chisholm, 1983). Beliefs and practices from preconception
through birth and adolescence ground children in their culture,
provide a sense of identity and belonging, reveal expectations for
behavior that align with cultural norms, and offer protection and
guidance along the way to adulthood (Markstrom, 2008; Peacock,
2002). Although traditions differ from tribe to tribe, they often
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 117
center on the belief that children are sacred gifts from the creator;
for example, the Lakota word for child is wakanyeja, which
translates to sacred little one (Daugherty, 2002). As sacred gifts,
children are to be protected and kept safe. Among many tribes,
amulets are placed at the head of a childs bed or on their cradle-
board for protection. Among the Lakota, amulets are beaded leather
animal figures (lizards for boys, turtles for girls, and snakes for
twins) within which the childs umbilical nub is placed (Ambler,
1994). As sacred beings, children are recognized for their purity
and beauty. Among the Ojibwe, young childrens preciousness and
perfection are believed to make them especially vulnerable at fu-
nerals where the spirits might be tempted to take them; to deter
the spirits, childrens faces were traditionally marked with ash, or
they may not have been allowed to attend at all (Mille Lacs Band
of Ojibwe, 2009).
Traditional beliefs and practices provide AIAN children a
strong sense of belonging and place (Best Start, 2010; Red Horse,
1983, 1997). AIAN children in many tribal cultures are raised in
extended families in which the responsibility for childrens health,
well-being, and learning rests on the shoulders of many, including
elders within their families and communities (Harrison, Wilson,
Pine, Chan, & Buriel, 1990; Red Horse, 1997). The practice of
burying a newborns placenta is one example of a specific practice
that reminds children throughout their lives of their spiritual home
and connection to the land from which they came (Molina, 2001).
Traditional names bestowed upon children further ground their
identities within their families, communities, histories, and cultures
(Red Horse, 1997). Within their extended kin networks and the
broader community, values for childrens behavior are conveyed,
including the importance of respect, humility, and learning through
quiet observation (Gokee-Rindal, 2009; Red Horse, 1997).
Traditional AIAN beliefs almost universally recognize the in-
terconnectedness of all beings not only in the present but also
across time. In this way, traditional AIAN beliefs have foretold
what modern science is only now beginning to unveil: that the lives
and experiences of previous generations intimately shape those of
future generations (i.e., epigenetics). The Seventh Generation
beliefs of tribes such as the Haudenosaunee are an embodiment of
this interconnectedness across time and are especially relevant for
child development. Seventh Generation beliefs place the respon-
sibility for the health and well-being of future generations at the
forefront of decisions made by generations today. In the words of
Rick Hill, Sr. (Tuscarora),
Were connected to the first Indians who walked on this earth, the very
first ones, however long ago that was. But were also connected to those
Indians who arent even born yet, who are going to walk this earth. And
our job in the middle is to bridge that gap. You take the inheritance from
the past, you add to it, your ideas and your thinking, and you bundle it up
and shoot it to the future. And there is a different kind of responsibility.
That is not just about me, my pride and my ego, its about all that other
stuff. We inherit a duty, we inherit a responsibility. And thats pretty well
drummed into our heads. Dont just come here expecting to benefit. You
come here to work hard so that the future can enjoy that benefit. (Public
Broadcasting System, n.d.)
118 M. Sarche et al.
The examples presented here demonstrate the ways in which
traditional AIAN beliefs and practices are in place to maximize
childrens potential for health and well-being in AIAN commu-
nities. As we will argue at the conclusion of this article, these
cultural and historical resources are among the most important
levers for addressing the disparities in health and wealth faced by
many AIAN communities today (Goodkind et al., 2010).
To understand the disparities in health and wealth faced by
AIANs today, one must recognize their historical roots, grounded
as they are in the history of colonization endured by indigenous
groups throughout the world (T. Cross & Blackstock, 2012). Like
other indigenous groups, AIAN tribes in what is now the United
States stood in the way of European colonizers plans for their
land and, as a result, faced hundreds of years of physical and cul-
tural assault in attempts to do away with the Indian problem
(Hays, 1997). Within the last 150 years, this has included forced
removal from their homelands, theft of their land and resources, re-
moval of Native children to religious and government-run boarding
schools, high rates of out-of-home placement of Native children
into non-Native foster and adoptive homes, and outlawed reli-
gious and spiritual practices (Beiser, 1974; Byler, 1977; T. Cross
& Blackstock, 2012; Fournier & Crey, 1998; Giago, 2006; Halver-
son, Puig, & Byers, 2002; Pevar, 2012; Sarche & Whitesell, 2012;
Whitbeck, Adams, Hoyt, & Chen, 2004). As a result, generations
of AIANs had their language, culture, communities, and families
taken from them at great physical, emotional, social, and spiritual
cost to their own and future generations (Brave Heart & DeBruyn,
1998; Campbell & Evans-Campbell, 2011; Duran & Duran, 1995).
The knowledge embedded in traditional beliefs and practices re-
lated to childrens development also was severely eroded (Gokee-
Rindal, 2009; Sarche & Whitesell, 2012).
AIAN communities today face enormous challenges related
to the ongoing legacy of historical trauma (T. Cross & Blackstock,
2012; Jones, 2006). Poverty is the foremost challenge with which
AIAN communities contend (Bass, Shields, & Behrman, 2004). It
is both the result and driver of other disparities faced by tribal com-
munities. Poverty is higher among AIANs as a whole than among
any other group in the United States. Twenty-seven percent of the
AIAN population lives below the federal poverty level, compared
to 11% of the White, 25% of the African American, and 22% of
the Latino populations (National Center for Education Statistics,
2008). AIAN children are especially likely to be living in poverty
(36% in 2014), relative to both AIAN adults and children from other
groups (Annie E. Casey Foundation, 2016a). Between 2008 and
2013, AIAN children experienced the greatest increase in poverty
(7 percentage points) relative to all other groups (National Cen-
ter for Education Statistics, 2013). AIANs are less likely than are
non-AIAN individuals to have a high-school, college, or graduate
degree and are more likely to be unemployed (National Center for
Education Statistics, 2014; U.S. Bureau of Labor Statistics, 2015).
AIAN communities are served by health, education, and legal sys-
tems that are underresourced and overburdened (Amnesty Inter-
national USA, 2006; Gone, 2004; Gone & Trimble, 2012; Jones,
2006; U.S. Commission on Civil Rights, 2003) while access to
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
nutritious food, adequate housing, and space for exercise and play
is limited (Adams, Harvey, & Brown, 2008; Bauer et al., 2012; Ed-
munds et al., 2013; Jernigan, Salvatore, Styne, & Winkleby, 2011;
Listokin, 2001).
These contextual challenges present structural barriers to fully
realizing the health potential of tribal communities and are impor-
tant for understanding the causes of and solutions to the physical
and mental health disparities experienced by tribal communities.
We also must keep in mind, however, that these contextual chal-
lenges alone do not define tribal communities or citizens (Cook-
Lynn, 1996). A reminder here of the diversity within and across
tribal communities is warranted.
HEALTH DISPARITIES AMONG AIAN ADOLESCENT
AND ADULT MEN
A central goal of this article to is to consider the early childhood
indicators of risk and resilience among AIAN boys. Knowing the
downstream challenges faced by AIAN adolescent and adult men
is useful for considering early childhood indicators. To this end, we
review the following health disparities faced by AIAN adolescent
and adult men: substance use, suicide, accidental injury and death,
violence, and adverse childhood experiences (ACEs).
Data from a large epidemiological survey of AI adults in
three tribal communities two in the Northern Plains (NP) and
one in the Southwest (SW) found approximately 30% of AI men
between 15 and 57 years of age had a lifetime diagnosis of alcohol
dependence, as compared to 20% of U.S. men and 8.7% of SW AI
females and 20.1% of NP females (Spicer et al., 2003). Similarly,
rates of substance use from this same study found that the lifetime
prevalence for any substance-use disorder among males ranged
from 14% (SW) to 15.4% (NP), with rates for marijuana (12.2%
SW, 14.1% NP) being the highest and exceeding those of females
(Spicer et al., 2003).
Studies of substance use among AIAN adolescents suggest
that AIAN adolescent males and females both begin drinking and
using drugs at younger ages relative to their non-AIAN peers,
and engage in riskier patterns of use (DeRavello, Everett Jones,
Tulloch, Taylor, & Doshi, 2014). One national study of AI ado-
lescent substance use found few differences by gender in terms
of rates of use and, in the case of some substances (e.g., alco-
hol), found higher rates among girls (Borowsky, Resnick, Ireland,
& Blum, 1999). Similarly, a study with young adolescents from
an NP reservation community also found few gender differences
(Whitesell et al., 2012), but did find that by age 11, among both
boys and girls, over one third had smoked cigarettes (boys: 36.2%,
girls: 42.3%), nearly one fourth had used marijuana (boys: 25.8%,
girls: 21.4%), and over 1 in 10 had used alcohol (boys: 12.7%,
girls: 15.9%). Using discrete time survival analyses to estimate the
risk of initiation of each of these substances between ages 10 and
13, the study found that boys and girls were at greater risk for ini-
tiating substance use with marijuana than initiating with alcohol,
unlike boys and girls in other groups who have been found to initi-
ate substance use with alcohol. This finding was true for both boys

and girls and suggested the importance of focusing on marijuana
as a gateway drug among AI adolescents an issue that may be
especially relevant given the growing legalization of recreational
marijuana use in states around the country including those in close
proximity to tribal communities in bordering states (Eid, 2014,
July 25).
Alcohol and substance use are intimately connected to the
disproportionate rates of suicides, accidental injury and death, and
violence experienced by adolescent and adult AIAN men (Beau-
vais, Chavez, Oetting, Deffenbacher, & Cornell, 1996; Grossman,
Sugarman, Fox, & Moran, 1997; Robin, Long, Rasmussen, Al-
baugh, & Goldman, 1998). The suicide rate among 18- to 24-year-
old AIAN males from 2012 to 2013 was 34.3 deaths/100,000 a
rate higher than that of all other groups and exceeding the U.S.
all-male rate of 20.4/100,000 by 1.68 times and the AIAN female
rate of 9.9/100,000 by 3.46 times (Jiang, Mitran, Minino, & Ni,
2015). A history of physical or sexual abuse, exposure to suicide
among family and friends, and mental health problems are addi-
tional risk factors for suicide for AIAN males and females alike
(Grossman et al., 1991; Mullany et al., 2009). Understanding these
risk factors is important for implementing effective approaches for
reducing suicide in AIAN communities (Mullany et al., 2009).
Reporting on Indian Health Service data, Murphy et al. (2014)
reported that the overall rate of unintentional injury deaths among
AIAN men was greater than that of U.S. men and AIAN women
by 2.47 and 2.16 times, respectively. Unintentional injuries include
injuries and deaths due to motor vehicle accidents, poisoning, falls,
drowning, and fire or burns, all of which are greater in the AIAN
population as a whole than those among Whites by 1.5 to 3 times.
In addition to unintentional injuries, AIAN men also experience the
highest rate of violent victimization, including assault, aggravated
assault, and robbery, as compared to all other groups of men as well
as AI and other women (Justice Center, 2000; U.S. Department of
Justice, 2004).
The higher rates of unintentional injuries and violent victim-
ization among AIAN men must be understood within the broader
context of structural disadvantage experienced by many tribal com-
munities. Motor vehicle fatalities, for example, are linked to the
condition, quality, and maintenance of roads and vehicles as well
as the quality of available emergency services (Campos-Outcalt,
Prybylski, Watkins, Rothfus, & Dellapenna, 1997; Porvaznik &
Jensen, 1988). Violent victimization, on the other hand, is perpet-
uated by a legal system that falls tragically short of protecting the
safety of tribal citizens. According to a recent report by the Indian
Law and Order Commission (2013):
The imposition of a non-Indian criminal justice institution in Indian coun-
try extracts a terrible price: limited law enforcement; delayed prosecutions,
too few prosecutions, and other prosecution inefficiencies; trials in distant
courthouses; justice system and players unfamiliar with or hostile to Indi-
ans and Tribes; and the exploitation of system failures by criminals, more
criminal activity, and further endangerment of everyone living in and near
Tribal communities. When Congress and the Administration ask why the
crime rate is so high in Indian country, they need look no further than the
archaic system in place, in which Federal and State authority displaces
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 119
Tribal authority and often makes Tribal law enforcement meaningless.
(p. ix)
In light of the suicide, injury, and violence experienced by
AIAN adolescent and adult men, it is important to consider mental
health concerns as well. In a large, community-based sample of
one SW and two NP tribal communities, rates of posttraumatic
stress disorder (PTSD) among men between 15 to 57 years of age
were significantly greater than those of U.S. males. In the SW, the
lifetime prevalence of PTSD among males was 12.8% whereas in
the NP, the lifetime prevalence of PTSD was 11.5% compared to a
lifetime prevalence among U.S. males of 4.3% (Beals et al., 2005).
Although the lifetime prevalence of PTSD was higher among AI
males than among U.S. males, it was significantly lower than the
lifetime prevalence among AI females in both communities (SW
females: 22.5%, NP females: 20.2%). By contrast, rates of depres-
sion tended to be lower among both groups of AI men relative to
those of men in the U.S. population (SW: 9.8%, NP: 7.2%, United
States: 12.8%) as well as relative to that of both groups of AI fe-
males (SW females: 14.3%, NP females: 10.3%). Together, these
findings suggest that AI men are more likely to experience PTSD
than depression, to experience greater PTSD than U.S. males but
lower PTSD than AI females, and to experience less depression
than both U.S. males and AI females. The different rates of PTSD
likely reflect greater exposure to traumatic events than that for U.S.
males, but less exposure than AI females (Beals et al., 2013). The
lower rates of depression than both U.S. males and AI females are
similarly lower among other U.S. minority groups (U.S. Depart-
ment of Health and Human Services, 2001), which may reflect true
differences, different cultural patterns in the expression of distress,
or different cultural norms around reporting feelings of depression.
Mental health problems are more likely in the presence of
ACEs (Koss et al., 2003; Libby et al., 2004; Whitesell et al.,
2007). In a recent study of AI adolescents and young adults (ages
1524), 40% of males reported childhood emotional abuse, emo-
tional neglect, or physical neglect; 35% of males reported physi-
cal abuse and witnessing domestic violence against ones mother;
and 14% of males reported sexual abuse (Brockie, Dana-Sacco,
Wallen, Wilcox, & Campbell, 2015). Significant gender differ-
ences were found for emotional and sexual abuse (with females
reporting more) and physical neglect (with males reporting more).
Individually and collectively, ACEs increased the odds of experi-
encing depressive symptoms, polydrug use, PTSD symptoms, and
suicide attempts by factors of 1.5 to over 5 times. Not surpris-
ingly, the more ACEs an adolescent experienced, the greater the
odds of problems in any one of these areas. Looking closely at the
mechanisms by which early adversity was related to substance-use
disorders, Whitesell et al. (2009) found early initiation of use to be
a mediator, particularly for males.
Important efforts are under way to promote the health and
well-being of AIAN adolescent men through culturally-grounded
and strengths-based interventions. The RezRIDERS Project is one
such approach. Project (Tosa et al., 2016). This positive youth-
development program has been implemented with two tribes in
120 M. Sarche et al.
New Mexico: the Pueblo of Jemez funded by the National Insti-
tute on Drug Abuse and the Santa Clara Pueblo funded by the
U.S. Department of Justice in partnership with the University of
New Mexico. RezRIDERS was developed using a community-
based participatory research (CBPR) approach to target youth at
risk for drug use and depression. Through participation in extreme
sports such as snowboarding, whitewater rafting, and rock climb-
ing, RezRIDERS promotes protective factors such as prosocial
peer and adult networks and self-regulation, and fosters existing
tribal-youth strengths such as stewardship, leadership, and pride.
The year-round curriculum connects directly to the sacred water
cycle of mountain snow in the winter, rivers in the spring, and
rain and cloud cover in the summer and fall. The RezRIDERS
curriculum was developed by an AI man (second author of this
article), who himself was an at-risk tribal youth.
Key to RezRIDERS success has been the Tribal Research
Team (TRT) that advances the role of traditional community ad-
visory boards commonly found with CBPR (Tosa et al., 2016).
The TRT is an action body and knowledge network of carefully
selected individuals who are responsible for cultural mentorship
and who serve as a communal resource for cultural knowledge.
Due to the nature of the extreme sports in RezRIDERS, physical
and emotional safety is a priority. Because the TRT experiences ex-
treme sport activities alongside tribal youth, they are able to make
program and curriculum decisions based on direct experience.
This strengths-based program is grounded within indigenous
values of honor, strength, and resilience and built upon the beliefs
of positive psychology. These values and beliefs are maintained
throughout with use of affirmative qualitative and quantitative
methods for evaluation, all of which result in a fun, humorous
environment while tackling important health disparities and juve-
nile justice outcomes through an approach that builds upon existing
capacities that only AIAN mentors retain. RezRIDERS is an ex-
ample of much-needed action on behalf of tribal youth. Based on
preliminary data, RezRIDERS outcomes are promising (Tosa et
al., 2016).
EARLY CHILDHOOD INDICATORS AMONG AIAN BOYS
BIRTH TO 8 YEARS
AIAN communities have relied on personal, familial, and cultural
sources of strength to endure the hardships introduced by the colo-
nial past and its ongoing legacy. AIAN communities today are
vibrant in individual, family, and community life, but also have
suffered in ways already described. There is little in the existing
research literature that has addressed the unique needs or early
indicators of risk among young AIAN boys within these contexts.
Here, we discuss some of the challenges and early indicators of risk
facing young AIAN children in general and, where the literature
permits, highlight gender differences.
In tribal communities, there are many indicators of risk dur-
ing early childhood (Sarche & Spicer, 2008). These risks are in-
herently shaped by the risks that are faced by their communities
as a whole. Seventy percent of AIAN children under the age of
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
6 years are living in poverty (42%) or in low-income families
(28%)1 rates comparable to their African American and His-
panic counterparts and double those of White children (Addy, En-
gelhardt, & Skinner, 2013). AIAN children of all ages are more
likely to be living in single-parent households (53%) than are peers
of all other races except African American children (66%; An-
nie E. Casey Foundation, 2016b). Single-parent households, es-
pecially those headed by single mothers, are more likely to be
living in poverty (55% of single AIAN mother households and
40% of single AIAN father households; National Center for Edu-
cation Statistics, 2013). Compared to non-AIAN children, AIAN
children are less likely to have a mother or father in excellent or very
good physical and emotional health (U.S. Department of Health &
Human Services, 2013). Parents of AIAN children have reported
more stress than parents of White children (U.S. Department of
Health & Human Services, 2013). AIAN parents are more likely to
smoke (Barnes, Adams, & Powell-Griner, 2005), and fathers have
reported higher rates of lifetime substance abuse (Neault et al.,
2012). AIAN children are exposed to violence at rates higher than
those of children from other groups in the United States (Dorgan
et al., 2014). AIAN children face risks associated with instability of
caregiving when grandparents raising children struggle with their
own health and financial concerns (S. Cross, Day, & Farrell, 2011).
In many states, AIAN children are vastly overrepresented in the
child welfare system (Marcynyszyn et al., 2012) while effective
early intervention services are limited (Grossman et al., 2002).
These contextual challenges contribute to health and devel-
opmental impacts that emerge early. In a national survey, parents
of AIAN children were more likely than parents of White children
to report one or more concerns about their childs development
between 0 and 5 years of age (58.6 vs. 34.9%; U.S. Department of
Health and Human Services, 2013). In a study with a reservation-
based sample of AI toddlers aged 6 to 26 months whose primary
language was English, Mitchell, Croy, Spicer, Frankel, and Emde
(2011) found that both boys and girls dropped below national norms
in critical areas of cognitive and language development over the
first years of life relative to national age-based norms. Both boys
and girls fell below the Early Learning Composite age norms of
the Mullen Scales of Early Learning (Mullen, 1995) at 15 months,
and remained below through 36 months. In expressive and recep-
tive language development, both boys and girls were below age
norms at 6 months and then dropped further below age norms at
15 months, where they remained. Significant gender differences
were observed for both receptive and expressive language, with
boys performing worse than girls in both areas of language devel-
opment. Both boys and girls fell below and remained below age
norms for visual reception between 15 and 27 months, and started
below gross motor age norms at 6 months, where they remained
through age 36 months.
1
In this report, low income was defined as 100 to 199% of the Federal Poverty
Level (FPL). In 2011, the date of this report, the FPL was $14,710 for a family
of two, $18,530 for a family of three, and $22,350 for a family of four.

Analyzing Early Childhood Longitudinal Study-Kindergarten
cohort data, Marks and Garcia Coll (2007) found a similar pattern:
AIAN childrens math and reading skills fell increasingly behind
their White peers across the first 4 years of school. A positive
attitude about school at school entry was an important promoter of
skills whereas poverty, low parent education, and living in a rural
area had negative impacts. Gender differences were not explored
in the Marks and Garcia-Coll study.
Research has documented the importance of AIAN culture
and language for young childrens cognitive development (Tseth-
likai, 2015). Based on a latent variable path analysis, Tsethlikai
(2011) found that children of higher income parents were more
likely to be involved in cultural activities, which in turn pre-
dicted higher verbal IQ based on the Vocabulary and Similarities
subtests of the Wechsler Abbreviated Scale of Intelligence. This
study also showed that children who spoke their tribal language
initially scored lower on norm-referenced tests of cognitive skills,
but by age 9, scored equal to or higher than national norms. In a
subsequent study in the same community, Tsethlikai and Rogoff
(2013) found that AI children who spoke their traditional language
and who were more engaged in traditional AI cultural activities re-
called more details of a story that they overheard than did children
who were less culturally-engaged. This finding highlights the im-
portance of culturally-based practices in teaching AI children and
affecting their development (e.g., self-regulation) more broadly
(Tsethlikai, 2015).
In one of the few studies to implement and evaluate the im-
pact of a culturally adapted intervention on AI childrens academic
performance, investigators worked with a tribal college to cultur-
ally adapt the Families and Schools Together (FAST) curriculum
for AI children ages 4 to 9 years (Kratochwill, McDonald, Levin,
Young Bear-Tibbets, & Demaray, 2004). Although the intervention
did not have a significant impact on direct measures of academic
performance, socioemotional factors within the school setting that
influence academic performance were impacted. Children partic-
ipating in the culturally-adapted FAST intervention had fewer in-
ternalizing and externalizing symptoms as measured by parent and
teacher report on the Child Behavior Checklist, and greater aca-
demic competence as measured by teacher report on the Social
Skills Rating System.
In addition to early cognitive and academic skill development,
studies have looked at AIAN childrens early socioemotional de-
velopment (Frankel et al., 2013; Sarche, Croy, Crow, Mitchell,
& Spicer, 2009). Both Sarche et al. (2009) and Frankel et al.
(2013) found that a larger percentage of young AIAN children
(ages 1236 months) were rated in the of concern range on
the externalizing and competence domains of the Infant Toddler
Social Emotional Assessment compared to the normative sample
(ITSEA; Carter & Briggs-Gowan, 2006). Between 14.1% (Frankel
et al.) and 18.6% (Sarche et al.) of AIAN toddlers were rated
by their mothers as scoring in the of concern range for ex-
ternalizing behavior problems, as compared to 10% of the nor-
mative sample. In addition, between 22.1% (Sarche et al.) and
24.7% (Frankel et al.) were rated by their mothers as having fewer
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 121
socioemotional competencies relative to the normative sample
(10%).
Both Sarche et al. (2009) and Frankel et al. (2013) ex-
plored maternal-, relational-, and child-level predictors of so-
cioemotional competencies and problems. Across both studies,
maternal ratings of dysfunction in the parentchild relation-
ship (as measured by the ParentChild Dysfunctional Interac-
tion subscale of the Parenting Stress Index) were related to chil-
drens externalizing and internalizing symptoms. Alternatively,
both studies found that mothers self-rated AI identity showed
a positive relationship with maternal ratings of childrens com-
petence, such that mothers with stronger self-rated AI identity
rated their children as more socially and emotionally competent.
Both studies also found significant gender differences in maternal
ratings of childrens socioemotional competence, with girls rated
significantly higher than boys. Added variables in the Frankel et al.
model included maternal ratings of social isolation and depression,
both of which were significant in predicting externalizing, internal-
izing, and dysregulation problems. Added variables in the Sarche
et al. study were income and social support, both of which were
positively related to competence, and maternal substance use in
the last 12 months, which was positively related to externalizing
problems.
AI culturally-grounded interventions have been effective for
addressing socioemotional problems in young AI children. In their
seminal tribal home visiting work Barlow et al. (2013; 2015)
conducted a randomized-controlled trial of the Family Spirit
home-visiting intervention. Family Spirit was developed in close
collaboration with tribal communities in the SW to deliver cul-
turally congruent, developmentally relevant parenting lessons to
increase parental monitoring and to decrease coercive parent
child interactions; harsh, unresponsive, or rejecting parenting; and
abuse/neglect. Family health educators delivered 43 structured
lessons in participants homes starting in the third trimester of
pregnancy through 36 months postpartum. Significant differences
between the treatment and control groups were found for both
mothers and their children. Mothers in the home visiting inter-
vention demonstrated significantly greater parenting knowledge,
greater internal parental locus of control, fewer depressive and
externalizing symptoms, and lower past month use of marijuana
and illegal drugs. Children in the home visiting intervention were
rated as having fewer externalizing, internalizing, and dysregula-
tion problems at 12 (Barlow et al., 2013) and 36 months (Barlow
et al., 2015).
While early cognitive and socioemotional development are
critical domains of growth, so too are physical health and devel-
opment. Two important indicators of early risk are oral health
and overweight/obesity. Seventy-nine percent of AIAN children
2 to 5 years of age have tooth decay while the rate of tooth de-
cay among 2- to 4-year-old AIAN children is five times the U.S.
average (Nash & Nagel, 2005). Food insecurity in some tribal
communities is prevalent, affecting as many as 40% of AIAN fam-
ilies with young children (Bauer et al., 2012). Food-insecure fam-
ilies report eating less healthy diets, including food purchased at
122 M. Sarche et al.
convenience stores, and low access to fresh fruits and vegetables
of good quality (Bauer et al., 2012). Although not found in the
Bauer et al. (2012) study, food insecurity is a contributor to over-
weight and obesity (Metallinos-Katsaras, Sherry, & Kallio, 2009).
Zephier, Himes, Story, and Zhou (2006) found that at 5 years of
age, 47% of boys and 41% of girls were overweight whereas 24%
of children overall were obese rates that exceeded those of U.S.
averages for both boys and girls, and that increased as children
grew older.
SUPPORTING THE HEALTH AND DEVELOPMENT OF AIAN
BOYS
To this point, this article has provided an overview of the cul-
tural and contextual setting of tribal communities today. Cultural
beliefs and practices related to childrens development have been
reviewed, as has the role of historically traumatic events in dis-
rupting those practices and in producing the sociodemographic
challenges and health disparities experienced by tribal communi-
ties today. As we turn to this last section, we acknowledge that
historical trauma is only half of the story. Historical strength is
the other (Kirmayer, Dandeneau, & Williamson, 2011). Despite
centuries of assault from the outside, AIAN culture has endured.
Traditional spirituality, traditional practices, and cultural identity
are protective for both AIAN adults and children (Gone, 2010;
Gone & Alcantara, 2007; Kading et al., 2015; Shendo et al., 2012;
Tsethlikai, 2011; Tsethlikai & Rogoff, 2013; C. Wexler, 2006;
L. Wexler, 2014; Whitbeck, Walls, Johnson, Morriseau, & Mc-
Dougall, 2009). Here, we highlight home visiting and Head Start
as two important efforts to support the health and development of
young tribal children, including boys, that have not yet had a strong
presence in the research literature for reasons that are beginning to
be addressed.
Maternal, Infant, and Early Childhood (MIECHV) Tribal
Home Visiting funding through the Affordable Care Act supports
home visiting services to expectant families and families with
young children in tribal communities across the country (Lyon
et al., 2015). Between 2012 and 2014, there were 1,523 fami-
lies enrolled in 25 tribally-run home visiting programs funded
through the Tribal MIECHV set-aside funds administered by the
Administration for Children and Families, and nearly 20,000 home
visits made (Lyon et al., 2015). The Tribal MIECHV program
has substantially increased the reach of home visiting services to
tribal communities across the country. Many grantees have worked
closely with home visiting model developers to make adaptations
to increase the cultural and contextual attunement of services, and
in turn, it is hypothesized, home visitings effectiveness for AIAN
children and families. A recently disseminated report to Congress
describes the work of the first three cohorts of Tribal MIECHV
grantees, highlighting lessons learned related to child and fam-
ily outcomes, capacity-building, and cultural adaptation and en-
hancement (Lyon et al., 2015). A special issue of this journal is in
preparation, further detailing the valuable lessons learned from this
seminal effort.
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
The reach of AIAN Head Start programs is greater still. Head
Start programs are operated by over 150 federally-recognized tribal
communities in the United States and serve over 35,000 children
and families, the majority of whom (87%) are AIAN. AIAN Head
Start programs provide high-quality early education services to
communities that might not otherwise have access. Culturally-
based early education is at the heart of AIAN Head Start program-
ming. The research literature is absent studies that deepen our
understanding of AIAN Head Start programs or the children and
families they serve; this is because AIAN Head Start programs have
not been included in any of the national studies of Head Start until
very recently. In the fall of 2015, the first national study of Region
XI Head Start was implemented, having been designed and imple-
mented with intensive consultation and guidance from tribal Head
Start directors and researchers with backgrounds in tribal child de-
velopment research. A technical report and a series of topical briefs
are currently in preparation and will become available in the next
year. These reports will provide a first, nationally-representative,
look at tribal Head Start programs and the children and families
they serve.
CONCLUSION AND A CALL TO ACTION
AIAN men and adolescent boys experience a number of health
disparities compared to their non-AIAN male counterparts and
AIAN women. These disparities are linked to the poverty and
structural disadvantage experienced by many AIAN communities
that was set into motion by a history of colonization and the atroc-
ities committed against the original inhabitants of this land. At
the same time, tribal communities and individuals have not only
endured but have flourished in the face of the adversities placed
before them, particularly when traditional cultural practices are
maintained (Kading et al., 2015). As we conclude our review, we
are reminded of Friedens (2010) five-tier public health pyramid.
Friedens pyramid emphasizes the foundational importance of so-
cioeconomic and structural factors for yielding the largest societal
health benefits, with the need for more targeted intervention ap-
proaches moving up the pyramid to its apex. Here, we suggest calls
to action on behalf of AIAN boys at each level of Friedens public
health pyramid.
1. Public Health Pyramid Tier 1 Improvements in Socioe-
conomic Factors: The first, most broad-based tier of Friedens
Public Health Pyramid acknowledges the role of socioeconomic
status and educational attainment as critical social determinants
of health. Examples of calls to action on behalf of AIAN boys
include:
a. AIAN boys need mothers and fathers who have access to edu-
cational opportunities, which will in turn lead to jobs with living
wages and health benefits.
b. AIAN boys themselves need access to high-quality, culturally-
grounded early care and education to support a strong socioemo-
tional and academic start in life.

2. Public Health Pyramid Tier 2 Changing the Context to
Make Individuals Default Decisions Healthy: The second
tier of the Public Health Pyramid considers the importance of
community/societal-wide supports that facilitate, or even auto-
mate, healthy choices. Examples include fluoridated water, clean
air and water, improved roads, and elimination of environmental
hazards. In addition to these examples, calls to action for AIAN
boys include:
a. AIAN boys and their families need access to high-quality food
and safe spaces to play.
b. AIAN boys and their families need communities that are safe,
have adequate law enforcement, and have enough good housing
to meet demand.
3. Public Health Pyramid Tier 3 Long-Lasting Protective
Interventions: The third tier of the Pyramid includes protective
interventions for individuals who do not require ongoing clinical
care. Examples include immunizations and health screenings. A
call to action on behalf of AIAN boys includes:
a. Screening for socioemotional and developmental delays should
be implemented universally, capitalizing on existing resources
such as the Birth to 5: Watch Me Thrive! coordinated federal effort
to promote universal screening (Administration for Children and
Families, 2015).
4. Public Health Pyramid Tier 4 Clinical Interventions: The
fourth tier of the Pyramid calls for access to ongoing and routine
clinical care. A call to action on behalf of AIAN boys includes:
a. Trust obligations must be honored, and improvements in the
quality of and access to routine medical and dental care should
be made. Important strides in this direction were made when the
Indian Health Care Improvement Act was made permanent in
2010 (Indian Health Service, 2010; The White House, 2010).
5. Public Health Pyramid Tier 5 Counseling and Educational
Interventions: The fifth tier of the Pyramid refers to targeted
counseling and educational efforts to promote individual-level
health behavior change. Examples of calls to action in support of
AIAN boys development at this level include:
a. Increased availability of and access to culturally-resonant, effec-
tive mental health care services for AIAN boys and their families
to address socioemotional, behavioral, mental health, and sub-
stance abuse problems at the individual level.
Should these calls to action be realized, so too, we believe,
will the potential for all AIAN boys to thrive and grow into strong
men who will in turn lead future generations.
REFERENCES
Adams, A.K., Harvey, H., & Brown, D. (2008). Constructs of health and
environment inform child obesity prevention in American Indian
communities. Obesity, 16(2), 311317.
Addy, S., Engelhardt, W., & Skinner, C. (2013). Basic facts about low-
income children: Children under 6 years, 2011. Retrieved May 25,
2016 from http://www.nccp.org/publications/pub_1076.html.
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 123
Administration for Children and Families. (2015). Birth to 5: Watch
me thrive! Retrieved from http://www.acf.hhs.gov/programs/ecd/
watch-me-thrive.
Ambler, M. (1994). Releasing reservations from isolation: The tribal
library as storyteller. Tribal College: Journal of American Indian
Higher Education, 6(1), 20.
Amnesty International USA. (2006). Maze of injustice: The failure to
protect indigenous women from sexual violence in the USA. New
York, NY: Author. ISBN 978-1-887204-47-7.
Annie E. Casey Foundation. (2016a). Kids Count Data Center: Children
in poverty by race and ethnicity. Retrieved from http://datacenter.
kidscount.org/data/tables/44-children-in-poverty-by-race-and-
ethnicity#detailed/1/any/false/869,36,868,867,133/10,11,9,12,1,
185,13/324,323.
Annie E. Casey Foundation. (2016b). Kids Count Data Center: Children
in single parent families by race. Retrieved from http://datacenter.
kidscount.org/data/Bar/107-children-in-single-parent-families-
by-race?loc=1&loct=1#1/any/false/869/10,11,9,12,1,185,13/431.
Barlow, A., Mullany, B., Neault, N., Compton, S., Carter, A., Hastings, R.
et al. (2013). Effect of a paraprofessional home-visiting intervention
on American Indian teen mothers and infants behavioral risks: A
randomized controlled trial. American Journal of Psychiatry, 170(1),
8393. doi:10.1176/appi.ajp.2012.12010121
Barlow, A., Mullany, B., Neault, N., Goklish, N., Billy, T., Hastings, R.
et al. (2015). Paraprofessional-delivered home-visiting intervention
for American Indian teen mothers and children: 3-year outcomes
from a randomized controlled trial. American Journal of Psychiatry,
172(2), 154162. doi:10.1176/appi.ajp.2014.14030332
Barnes, P.M., Adams, P.F., & Powell-Griner, E. (2005). Health charac-
teristics of the American Indian and Alaska Native adult popula-
tion: United States, 19992003. Advance data from Vital and Health
Statistics.
Bass, S., Shields, M.K., & Behrman, R.E. (2004). Children, families, and
foster care: Analysis and recommendations. The Future of Children,
14, 429.
Bauer, K.W., Widome, R., Himes, J.H., Smyth, M., Holy Rock, B., Han-
nan, P.J. et al. (2012). High food insecurity and its correlates among
families living on a rural American Indian reservation. American
Journal of Public Health, 102(7), 13461352.
Beals, J., Manson, S., Croy, C., Klein, S., Whitesell, N., Mitchell, C., &
the AI-SUPERPFP Team. (2013). Lifetime prevalence of posttrau-
matic stress disorder in two American Indian reservation populations.
Journal of Traumatic Stress, 26, 512520. doi:10.1002/jts.21835
Beals, J., Novins, D.K., Whitesell, N.R., Spicer, P., Mitchell, C.M., Man-
son, S.M., & the AI-SUPERPFP Team. (2005). Prevalence of mental
disorders and utilization of mental health services in two American
Indian reservation populations: Mental health disparities in a national
context. American Journal of Psychiatry, 162, 17231732.
Beauvais, F., Chavez, E.L., Oetting, E.R., Deffenbacher, J.L., & Cor-
nell, G.R. (1996). Drug use, violence, and victimization among
White American, Mexican American, and American Indian dropouts,
students with academice problems, and students in good aca-
demic standing. Journal of Counseling Psychology, 43(3), 292299.
doi:10.1037/0022-0167.43.3.292
124 M. Sarche et al.
Beiser, M. (1974). A hazard to mental health: Indian boarding schools.
American Journal of Psychiatry, 131(3), 305306.
Best Start. (2010). A child becomes strong: Journeying through
each stage of the life cycle. Retrieved from http://www.beststart.
org/resources/hlthy_chld_dev/pdf/CBS_Final_K12A.pdf.
Borowsky, I.W., Resnick, M.D., Ireland, M., & Blum, R.W. (1999). Sui-
cide attempts among American Indian and Alaska Native youth.
Risk and protective factors. Archives of Pediatrics and Adolescent
Medicine, 153, 573580.
Brave Heart, M.Y.H., & DeBruyn, L.M. (1998). The American Indian
holocaust: Healing historical unresolved grief. American Indian and
Alaska Native Mental Health Research, 8, 6082.
Brockie, T.N., Dana-Sacco, G., Wallen, G.R., Wilcox, H.C., & Camp-
bell, J.C. (2015). The relationship of adverse childhood experi-
ences to PTSD, depression, poly-drug use and suicide attempt in
reservation-based Native American adolescents and young adults.
American Journal of Community Psychology, 55(34), 411421.
doi:10.1007/s10464-015-9721-3.
Bullock, A. (2015). Getting to the roots: Early life intervention and adult
health. American Journal of Psychiatry, 172, 108110.
Byler, W. (1977). The destruction of American Indian families. In S. Unger
(Ed.), The destruction of American Indian families (pp. 111). New
York: Association of American Indian Affairs.
Campbell, C.D., & Evans-Campbell, T. (2011). Historical trauma and Na-
tive American child development and mental health: An overview. In
M.C. Sarche, P. Spicer, P. Farrell, & H.E. Fitzgerald (Eds.), American
Indian children and mental health: Development, context, prevention,
and treatment. Westport, CT: Praeger.
Campos-Outcalt, D., Prybylski, D., Watkins, A., Rothfus, G., & Del-
lapenna, A. (1997). Motor-vehicle crash fatalities among American
Indians and non-Indians in Arizona, 1979 through 1988. American
Journal of Public Health, 87(2), 282285.
Carter, A.S., & Briggs-Gowan, M.J. (2006). Infant-Toddler Social Emo-
tional Assessment (ITSEA): Examiners manual. San Antonio, TX:
PsychCorp.
Chisholm, J.S. (1983). Navajo infancy: An ethological study of child
development. New Brunswick, NJ: Aldine Transaction.
Cook-Lynn, E. (1996). American Indian intellectualism and the new Indian
society. American Indian Quarterly, 20(1), 5776.
Cross, S., Day, A., & Farrell, P. (2011). American Indian and Alaska Native
grandfamilies: The impact on child development. In M. Sarche, P.
Spicer, P. Farrell, & H.E. Fitzgerald (Eds.), American Indian and
Alaska Native children and mental health: Development, context,
prevention, and treatment (pp. 4362). Denver, CO: Praeger.
Cross, T., & Blackstock, C. (2012). Special Forward: We are the manifes-
tations of our ancestors prayers. Child Welfare, 91(3), 914.
Daugherty, D.J. (2002). Children are sacred: Looking beyond best interests
of the child to establish effective tribal-state cooperative child support
advocacy agreements in South Dakota. South Dakota Law Review,
47, 282.
DeRavello, L., Everett Jones, S., Tulloch, S., Taylor, M., & Doshi, S.
(2014). Substance use and sexual risk behaviors among American
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Indian and Alaska Native high school students. Journal of School
Health, 84(1), 2532.
Dorgan, B.L., Shenandoah, J., BigFoot, D.S., Broderick, E., Brown, E.F.,
Davidson, V. et al. (2014). Attorney Generals Advisory Committee
on American Indian and Alaska Native children exposed to violence:
Ending violence so children can thrive. Retrieved from https://www.
justice.gov/sites/default/files/defendingchildhood/pages/attach
ments/2014/11/18/finalaianreport.pdf.
Duran, E., & Duran, B. (1995). Native American postcolonial psychology.
Albany: State University of New York Press.
Edmunds, D.S., Shelby, R., James, A., Steele, L., Baker, M., Perez,
Y.V., & TallBear, K. (2013). Tribal housing, codesign, and cultural
sovereignty. Science, Technology, and Human Values, 38(6), 801
828. doi:10.1177/0162243913490812.
Eid,T.A.(2014, July 25).Indian youth huirt by Colorados marijuana ex-
periment. The Denver Post. Retrieved from http://www.denverpost.
com/2014/07/25/indian-youth-hurt-by-colorados-marijuana-
experiment/
Federal Register. (2015). Tribal leaders directory. Indian entities rec-
ognized and eligible to receive services from the United States
Bureau of Indian Affairs. Available at: https://federalregister.
gov/a/2015-00509.
Fournier, S., & Crey, E. (1998). Stolen from our embrace: The abduction of
First Nations children and the restoration of Aboriginal communities.
Vancouver, Canada: Douglas & McIntyre.
Frankel, K.A., Croy, C.D., Kubicek, L.F., Emde, R.N., Mitchell, C.M.,
& Spicer, P. (2013). Toddler socioemotional behavior in a Northern
Plains Indian tribe: Associations with maternal psychosocial well-
being. Infant Mental Health Journal, 35(1), 1020.
Frieden, T.R. (2010). A framework for public health action: The health
impact pyramid. American Journal of Public Health, 100(4), 590
595.
Giago, T. (2006). Children left behind: The dark legacy of Indian mission
boarding schools. Santa Fe, NM: Clear Light.
Gokee-Rindal, D. (2009). The teachings of our ancestors: A vision
of Ojibwe language and culture revitilzation for young children
in the Red Cliff community. Unpublished doctoral dissertation,
University of Minnesota, Minneapolis. Retrieved from http://
conservancy.umn.edu/bitstream/handle/11299/53540/GokeeRindal_
umn_0130E_10563.pdf?sequence=1
Gone, J. (2004). Mental health services for Native Americans in the 21st
Century United States. Professional Psychology: Research and Prac-
tice, 35(1), 1018. doi:10.1037/0735-7028.35.1.10
Gone, J.P. (2010). Psychotherapy and traditional healing for American
Indians: Exploring the prospects for therapeutic integration. Coun-
seling Psychologist, 38(2), 166.
Gone, J.P., & Alcntara, C. (2007). Identifying effective mental health
interventions for American Indians and Alaska Natives: A review of
the literature. Cultural Diversity and Ethnic Minority Psychology,
13(4), 356.
Gone, J.P., & Trimble, J.E. (2012). American Indian and Alaska Native
mental health: Diverse perspectives on enduring disparities. Annual

Review of Clinical Psychology, 8, 131160. doi:10.1146/annurev
clinpsy-032511-143127.
Goodkind, J.R., Ross-Toledo, K., Johns, S., Lee, H.J., Ross, L., Free-
land, L. et al. (2010). Promoting healing and restoring trust: Pol-
icy recommendations for improving behavioral health care for
American Indian/Alaska Native adolescents. Journal of Commu-
nity Psychology, 46(34), 386394. doi:10.1007/s10464-010-9347-
4.
Grossman, D.C., Baldwin, L., Casey, S., Nixon, B., Hollow, W., & Hart,
L.G. (2002). Disparities in infant health among American Indians
and Alaska Natives in US metropolitan areas. Pediatrics, 109(4),
627633.
Grossman, D.C., Millgan, C., & Deyo, R.A. (1991). Risk factors
for suicide attempts among Navajo adolescents. American Jour-
nal of Public Health, 81(7), 870874. doi:10.2105/AJPH.81.7.
870
Grossman, D.C., Sugarman, J.R., Fox, C., & Moran, J. (1997).
Motor-vehicle crash-injury risk factors among American In-
dians. Accident Analysis and Prevention, 29(3), 313319.
doi:10.1016/S0001-4575(96)00085-1
Halverson, K., Puig, M.E., & Byers, S.R. (2002). Culture loss: American
Indian family disruption, urbanization, and the Indian Child Welfare
Act. Child Welfare, 81(2), 319336.
Harrison, A.O., Wilson, M.N., Pine, C.J., Chan, S.Q., & Buriel, R. (1990).
Family ecologies of ethnic minority children. Child Development,
51(2), 347362.
Hays, R. (1997). Editorializing The Indian Problem: The New York
Times on Native America, 1860-1900. Carbondale: Southern Illinois
University.
Indian Health Service. (2010). Press release: Indian Health Care Improve-
ment Act made permanent. Retrieved from https://www.ihs.gov/news
room/pressreleases/2010pressreleases/indianhealthcareimprove
mentactmadepermanent/.
Indian Law & Order Commission. (2013). A roadmap for making Na-
tive American safer: Report to the President & Congress of the
United States. October 12, 2016. Retrieved from https://www.aisc.
ucla.edu/iloc/report/.
Jernigan, V.B.B., Salvatore, A.L., Styne, D.M., & Winkleby, M. (2011).
Addressing food insecurity in a Native American reservation us-
ing community-based participatory research. Health Education Re-
search, 27(4), 645655.
Jiang, C., Mitran, A., Minino, A., & Ni, H. (2015). Racial and
gender disparities in suicide among young adults aged 18-
24: United States, 2009-2013. Retrieved from http://www.cdc.
gov/nchs/data/hestat/suicide/racial_and_gender_2009_2013.pdf
Jones, D.S. (2006). The persistence of American Indian health disparities.
American Journal of Public Health, 96(12), 21222134.
Justice Center. (2000). Victimization among American Native peoples.
Alaska Justice Forum, 16(4), 23.
Kading, M.L., Hautala, D.S., Palombi, L.C., Aronson, B.D., Smith,
R.C., & Walls, M.L. (2015). Flourishing: American Indian pos-
itive mental health. Society and Mental Health, 5(3), 203217.
doi:10.1177/2156869315570480
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 125
Kirmayer, L.J., Dandeneau, S., & Williamson, K.J. (2011). Rethinking
resilience from indigenous perspectives. Canadian Journal of Psy-
chiatry, 56(2), 8491.
Koss, M.P., Yuan, N.P., Dightman, D., Prince, R.J., Polacca, M., Sander-
son, B., & Goldman, D. (2003). Adverse childhood exposures and
alcohol dependence among seven Native American tribes. American
Journal of Preventive Medicine, 25(3), 238244.
Kratochwill, T.R., McDonald, L., Levin, J.R., Young Bear-Tibbets, H., &
Demaray, M.K. (2004). Families and Schools Together: An exper-
imental analysis of a parent-mediated multi-family group program
for American Indian children. Journal of School Psychology, 42(5),
359383. doi:10.1016/j.jsp.2004.08.001
Libby, A.M., Orton, H.D., Novins, D.K., Spicer, P., Buchwald, D., Beals,
J. et al. (2004). Childhood physical and sexual abuse and subsequent
alcohol and drug use disorders in two American-Indian tribes. Journal
of Studies on Alcohol and Drugs, 65, 7483.
Listokin, Y. (2001). Confronting the barriers to Native American home-
owners on tribal lands: The case of the Navajo Partnership for Hous-
ing. Urban Law, 33, 433.
Lyon, K., Geary, E., Sparr, M., Buckless, B., Slavador, M., & Morales, J.
(2015). Tribal maternal, infant, and early childhood home visiting:
A report to Congress (OPRE Report No. 2015-88). Retrieved from
https://www.acf.hhs.gov/sites/default/files/ecd/tribal_home_visiting
_report_to_congress.pdf
Marcynyszyn, L.A., Small Bear, P., Geary, E., Conti, R., Pecora, P.J.,
Day, P.A., & Wilson, S.T. (2012). Family Group Decision Making
(FGDM) with Lakota families in two tribal communities: Tools to fa-
cilitate FGDM implementation and evaluation. Child Welfare, 91(3),
113134.
Marks, A.K., & Garcia Coll, C. (2007). Psychological and demographic
correlates of early academic skill development among American In-
dian and Alaska Native youth: A growth modeling study. Develop-
mental Psychology, 43(3), 663674.
Markstrom, C.A. (2008). Empowerment of North American Indian girls:
Ritual expressions at puberty. Lincoln: University of Nebraska Press.
Metallinos-Katsaras, E., Sherry, B., & Kallio, J. (2009). Food insecurity
is associated with overweight in children younger than 5 years of
age. Journal of the American Dietetic Association, 109(10), 1790
1794.
Mille Lacs Band of Ojibwe. (2009). Culture and traditions. Retrieved from
http://archive.millelacsband.com/Page_culture.aspx?id=125
Mitchell, C., Croy, C., Spicer, P., Frankel, K., & Emde, R. (2011). Tra-
jectories of cognitive development among American Indian young
children. Developmental Psychology, 47(4), 991999.
Molina, J.W. (2001). Traditional Native American practices in obstetrics.
Clinical Obstetrics and Gynecology, 44(4), 661670.
Mullany, B., Barlow, A., Goklish, N., Larzerlere-Hinton, F., Cwick, M.,
Craig, M., & Walkup, J. (2009). Toward understanding suicide among
youths: Results from the White Mountain Apache tribally mandated
suicide surveillance system, 2001-2006. American Journal of Public
Health, 99(10), 18401848. doi:10.2105/AJPH.2008.154880
Mullen, E.M. (1995). Mullen Scales of Early Learning manual (AGS ed.).
Circle Pines, MN: American Guidance Service.
126 M. Sarche et al.
Murphy, T., Pokhrel, P., Worthington, A., Billie, H., Sewell, M.,
& Bill, N. (2014). Unintentional injury mortality among Amer-
ican Indians and Alaska Natives in the United States, 1990-
2009. American Journal of Public Health, 104(S3), S470S480.
doi:10.2105/AJPH.2013.301854
Nash, D.A., & Nagel, R.J. (2005). Confronting oral health disparities
among American Indian/Alaska Native children: The pediatric oral
health therapist. American Journal of Public Health, 95, 13251329.
National Center for Education Statistics. (2008). Status and trends in the
education of American Indian and Alaska Natives: 2008. Available
at: https://nces.ed.gov/pubs2008/nativetrends/tables/table_1_6a.asp.
National Center for Education Statistics. (2013). Children living in
poverty. Available at: https://nces.ed.gov/programs/coe/pdf/coe_cce.
pdf.
National Center for Education Statistics. (2014). Rates of high school
completion and attainment of bachelors or higher degree by race and
sex among people age 25 or older for year 2014. Available at: https://
nces.ed.gov/programs/digest/d14/tables/dt14_104.10.asp?current=
yes.
National Institute on Drug Abuse. (2016). Principles of sub-
stance abuse prevention for early childhood: A research-based
guide. Retrieved from https://www.drugabuse.gov/publications/
principles-substance-abuse-prevention-early-childhood/index
National Urban Indian Family Coalition. (2008). Urban Indian
America: The status of American Indian and Alaska Na-
tive children and families today. Available at: http://www.aecf.
org/m/resourcedoc/AECF-UrbanIndianAmerica-2008-Full.pdf.
Neault, N., Mullany, B., Powers, J., Coho-Mescal, V., Parker, S., &
Walkup, J. (2012). Fatherhood roles and drug use among young
American Indian men. American Journal of Drug and Alcohol Abuse,
38(5), 395402.
Peacock, T.M.W. (2002). Ojibwe Waasa Inaabidaa: We look in all direc-
tions. Afton, MN: Afton Historical Society.
Pevar, S.L. (2012). The rights of Indians and tribes (4th ed.). New York:
Oxford University Press.
Porvaznik, J., & Jensen, G.H. (1988). Motor vehicle accidents and emer-
gency medical services on Indian reservations. Military Medicine,
153, 453456.
Public Broadcasting System. (n.d.). Warrior in two worlds. Retrieved from
http://www.pbs.org/warrior/content/timeline/opendoor/roleOfChief.
htm.
Red Horse, J. (1983). Indian family values and experiences. In G.J. Powell,
J. Yamamoto, A. Romero, & A. Morales (Eds.), The psychosocial
development of minority group children (pp. 258272). New York:
Brunner/Mazel.
Red Horse, J.G. (1997). Traditional American Indian family systems.
Families, Systems, and Health, 15(3), 243250.
Robin, R.W., Long, J.C., Rasmussen, K., Albaugh, B., & Goldman, D.
(1998). Relationship of binge drinking to alcohol dependence, other
psychiatric disorders, and behavioral problems in an American Indian
tribe. Alcoholism: Clinical and Experimental Research, 22(2), 518
523. doi:10.1111/j.1530-0277.1998.tb03682
Sarche, M., & Spicer, P. (2008). Poverty and health disparities for Ameri-
can Indian and Alaska Native children: Current knowledge and future
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
prospects. Annals of the New York Academy of Sciences, 1136(1),
126. doi:10.1196/annals.1425.017
Sarche, M.C., Croy, C.D., Crow, C.B., Mitchell, C.M., & Spicer, P. (2009).
Maternal correlates of 2-year-old American Indian childrens social-
emotional development in a Northern Plains tribe. Infant Mental
Health Journal, 30(4), 321340. doi:10.1002/imhj.20217
Sarche, M.C., & Whitesell, N.R. (2012). Child development research in
North American Native communities Looking back and moving
forward: Introduction. Child Development Perspectives, 6(1), 42
48. doi:10.1111/j.1750-8606.2011.00218.x
Shendo, K., Toya, A., Tafoya, E., Yepa, M., Tosa, J., Yepa, T. et al. (2012).
An intergenerational family community-based participatory research
prevention program: Hemish of Walatowa Family Circle Program.
The Indian Health Service Primary Care Provider, 37(8), 185191.
Shonkoff, J.P., Boyce, W.T., & McEwen, B.S. (2009). Neuroscience,
molecular biology, and the childhood roots of health disparities:
Building a new framework for health promotion and disease preven-
tion. Journal of the American Medical Association, 301(21), 2252
2259. doi:10.1001/jama.2009.754
Spicer, P., Beals, J., Mitchell, C.M., Novins, D.K., Croy, C.D., Man-
son, S.M., & The AI-SUPERPFP Team. (2003). The prevalence
of DSM-III-R alcohol dependence in two American Indian
reservation populations. Alcoholism: Clinical and Experimental
Research, 27(11), 17851797. Retrieved from http://www.ncbi.nlm.
nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=
Citation&list_uids=14634495
The White House. (2010). Statement by the President on the reauthoriza-
tion of the Indian Health Care Improvement Act. Retrieved from
https://www.whitehouse.gov/the-press-office/statement-president-
reauthorization-indian-health-care-improvement-act
Tosa, J., Tafoya, G., Sando, S., Sando, E., Yepa, K., Wiley, J. et al.
(2016). RezRIDERS: A tribally-driven extreme sport intervention
and outcomes. Journal of Indigenous Social Development. Under
review.
Tsethlikai, M. (2011). An exploratory analysis of American Indian chil-
drens cultural engagement, fluid cognitive skills, and standardized
verbal IQ scores. Developmental Psychology, 47(1), 192202.
Tsethlikai, M. (2015). The cultural patterning of cognitive development:
Commentary on Allen and Lalonde. Human Development, 58, 97
102. doi:10.1159/000381652.
Tsethlikai, M., & Rogoff, B. (2013). Involvement in traditional cul-
tural practices and American Indian childrens incidental re-
call of a folktale. Developmental Psychology, 49(3), 568578.
doi:10.1037/a0031308.
U.S. Bureau of Labor Statistics. (2015). Labor force characteristics by
race and ethnicity, 2014 (Report No. 1057). Available at: http://www.
bls.gov/opub/reports/cps/labor-force-characteristics-by-race-and-
ethnicity-2014.pdf.
U.S. Census Bureau. (2006). We the People: American Indians and Alaska
Natives in the United States. Retrieved from https://www.census.
gov/prod/2006pubs/censr-28.pdf.
U.S. Census Bureau. (2012). The American Indian and Alaska Na-
tive population: 2010. Retrieved from http://www.census.gov/
prod/cen2010/briefs/c2010br-10.pdf.

U.S. Commission on Civil Rights. (2003). A quiet crisis: Federal
funding and unmet needs in Indian country. Retrieved from
http://www.usccr.gov/pubs/na0703/na0204.pdf.
U.S. Department of Health and Human Services. (2001). Mental health:
Culture, race, and ethnicity. Supplement to Mental Health: A Report
to the Surgeon General. Rockville, MD: Public Health Service.
U.S. Department of Health and Human Services, Health Resources and
Services Administration, & Maternal and Child Health Bureau.
(2013). The health and well-being of American Indian and Alaska
Native children: Parental report from the National Survey of Chil-
drens Health, 2007. Rockville, MD: Author.
U.S. Department of Justice. (2004). A BJS statistical profile,
1992-2002: American Indians and crime. Retrieved from
http://www.bjs.gov/content/pub/pdf/aic02.pdf
U.S. Government Accountability Office. (2012). Federal funding for
non-federally recognized tribes. Retrieved from http://www.gao.
gov/assets/600/590102.pdf.
Urban Indian Health Institute. (2013). U.S. Census marks increase in
urban American Indians and Alaska Natives. Retrieved from http://
www.uihi.org/wp-content/uploads/2013/02/Broadcast_Census-
Number_FINAL1.pdf.
Wexler, C. (2006). The importance of identity, history, and culture in the
wellbeing of indigenous youth. Journal of the History of Childhood
and Youth, 2, 267276.
Wexler, L. (2014). Looking across three generations of Alaska Natives
to explore how culture fosters indigenous resilience. Transcultural
Psychiatry, 51(1), 7392.
Whitbeck, L.B., Adams, G.W., Hoyt, D.R., & Chen, X. (2004). Concep-
tualizing and measuring historical trauma among American Indian
people. American Journal of Community Psychology, 33(3/4), 119
130.
Whitbeck, L.B., McMorris, B.A., Hoyt, D.R., Stubben, J.D., & LaFrom-
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
American Indiana and Alaska Native Boys 127
boise, T. (2002). Perceived discrimination, traditional practices, and
depressive symptoms among American Indians in the upper Midwest.
Journal of Health and Social Behavior, 43(4), 400418.
Whitbeck, L.B., Walls, M.L., Johnson, K.D., Morriseau, A.D., & Mc-
Dougall, C.M. (2009). Depressed affect and historical loss among
North American indigenous adolescents. American Indian and
Alaska Native Mental Health Research Journal, 16(3), 1641.
Whitesell, N.R., Beals, J., Mitchell, C.M., Keane, E.M., Spicer, P., &
Turner, R.J. (2007). The relationship of cumulative and proximal ad-
versity to onset of substance dependence symptoms in two American
Indian communities. Drug and Alcohol Dependence, 91, 279288.
Whitesell, N.R., Beals, J., Mitchell, C.M., Manson, S.M., Turner, R.J., &
The AI-SUPERPFP Team. (2009). Childhood exposure to adversity
and risk of substance-use disorder in two American Indian popula-
tions: The mediational role of early substance-use initiation. Journal
of Studies on Alcohol and Drugs, 70(6), 971981.
Whitesell, N.R., Kaufman, C.E., Keane, E.M., Big Crow, C., Shangreau,
C., & Mitchell, C.M. (2012). Patterns of substance use initiation
among young adolescents in a Northern Plains American Indian
tribe. American Journal of Drug and Alcohol Abuse, 38(5), 383
388. doi:10.3109/00952990.2012.694525
Yellow Horse Brave Heart, M., Elkins, J., Tafoya, G., Bird, D., & Salvador,
M. (2012). Wicasa Wasaka: Restoring the traditional strength of
American Indian boys and men. American Journal of Public Health,
102(S2), S177S183.
Yuan, N.P., Bartgis, J., & Demers, D. (2014). Promoting ethical research
with American Indian and Alaska Native people living in urban areas.
American Journal of Public Health, 104(11), 20852091.
Zephier, E., Himes, J.H., Story, M., & Zhou, X. (2006). Increasing preva-
lences of overweight and obesity in Northern Plains American Indian
children. Archives of Pediatric and Adolescent Medicine, 160(1), 34
39. doi:10.1001/archpedi.160.1.34