INVOLVING PARENTS IN A COMMUNITY-BASED, CULTURALLY-GROUNDED MENTAL HEALTH INTERVENTION FOR AMERICAN INDIAN YOUTH: PARENT PERSPECTIVES, CHALLENGES, AND RESULTS

Abstract

An important predictor of youth well-being and resilience is the presence of nurturing adults in a youth’s life. Parents are ideally situated to fulfill this role but often face challenges and stressors that impede their ability to provide adequate support and guidance. American Indian parents may also be affected by intergenerational transmission of trauma and loss of traditional parenting practices, as a result of forced boarding school and/or relocation. Members of a community-university partnership sought to interrupt cycles of violence and poor mental health of youth through a culturally-grounded intervention for youth and their parents that focused on healing historical trauma, strengthening positive parenting practices and social skills, reconnecting to traditional cultural knowledge, and improving parent-child relationships/communication. This article describes parental involvement and its challenges and provides mixed-method results for 10 parents related to enculturation, parenting practices, parent-child communication, family cohesion, historical loss and associated symptoms, and community involvement.

Youth comprise a large part of the American Indian/Alaska Native (AI/AN) population; 33% are under the age of 18, compared to 26% of the overall U.S. population (Ogunwole, 2006). AI/AN parents play very important roles in nurturing this and future generations of AI/AN youth. Research suggests that nurturing parenting practices are related to more positive adjustment and relationships and more effective coping skills among youth (Masten & Coatsworth, 1998). Family support is also related to wellness and is a protective factor against substance use in adolescence and adulthood (Johnson et al., 1998). Conversely, lack of parental involvement is linked to increased risk of violence among youth (Hawkins et al., 2000). Research with AI/AN communities suggests that parental presence and availability is a key protective factor against youth delinquent behaviors (Mmari, Blum, & Teufel-Shone, 2010). However, given the 500-year history of colonial oppression of AI/AN peoples, many parents have experienced historical trauma, which is a legacy of individual, family, and community suffering that is experienced across generations. Parents therefore have the potential to transmit the negative effects of historical trauma to their children. For instance, Brave Heart identified parenting practices that have been shown to put youth at risk for alcohol abuse and linked these to the abusive institutional environment of boarding schools, the lack of nurturing and parental role models in these settings, and the loss of cultural knowledge and AI identity (Brave Heart, 2003).

Several parenting interventions have been tested with AI/AN parents. Brave Heart developed a psycho-educational intervention for Lakota parents with the goal of facilitating a sense of mastery and control in spite of oppression and historical trauma. Results of the intervention, which included exposure to historical traumatic memories and cognitive integration, discussion of Lakota-centric parenting skills, and traditional ceremonies, indicated increased parental knowledge about the impact of historical trauma on parenting, reconnection to Lakota culture and values, strengthened extended kinship networks, and empowerment (Brave Heart, 1999). Dionne and colleagues implemented an evidence-based parenting program (the Incredible Years) with explicit connections within each session to traditional AI beliefs and values and an additional motivational phase that included contextualization of parenting challenges within an understanding of historical trauma and current injustices. They found significant improvements in AI parenting and child behavior, as compared to a control group (Dionne, Davis, Sheeber, & Madrigal, 2009). These promising findings suggest that parenting interventions that address challenges within a historical trauma and healing framework can be helpful for AI parents.

In this report, we describe parent involvement and outcomes of a 6-month weekly intervention, Our Life, that aimed to promote youth mental health and reduce youth violence by involving AI parents and youth ages 7–17 together in four types of activities: recognizing and healing historical trauma; reconnecting to traditional culture and language; learning and sharing culturally appropriate parenting practices and social skills for youth; and building relationships between parents and youth through horse-assisted and other experiential activities. For a detailed description of the intervention, its development and implementation, see Goodkind et al. in this issue.

Method

Participants

Of 30 families invited, 13 completed the intervention (see Figure 2 in Goodkind, et al., this issue, for intervention flowchart). Overall, we found that youth were more engaged in the intervention than their parents, particularly in the case of three families in which youth frequently attended the sessions without their parents. Thus, we include here data from the 10 parents considered to have received a meaningful intervention (attending at least 33% of the sessions). All parent participants were mothers of youth participants and ranged in age from 29 to 51 years (M=41.4, SD=7.54). Although they lived on the tribal reservation at the time of the study, all had lived off of the reservation for at least one year (M=6.9, SD=9.1). Most were married (70%) and employed (70%). All had graduated from high school or earned their GED and half reported they spoke their tribal language “moderately” or “very well.” Most faced significant life stressors. Thirty percent reported that they ‘never’ or “almost never’ had enough food to eat, 30% ‘never’ or “almost never’ had enough health care, and 30% were receiving food stamps. Three of the ten women had been raped in their lifetime, six had experienced intimate partner violence, and nine had witnessed violence in their families other than partner violence. Finally, 40% reported that someone close to them had committed suicide and 30% had suicidal ideation in the past (none reported in the preceding 12 months). We undertook analyses to compare these 10 parents with those: 1) who completed the initial interview but did not attend any sessions, and 2) those who completed between 1–8 sessions. There were no significant differences between these three groups on any baseline measures.

Research Design and Analysis

Although the primary aim of the Our Life intervention was to improve the well-being of AI youth, we recognized the important role of parent well-being and parenting practices in achieving this. Our conceptual model suggested that decreasing thoughts of historical loss and associated symptoms and increasing enculturation might help to buffer the effects of community stressors (e.g., poverty, poor living conditions, discrimination) that lead to mental health problems and substance abuse, and could help to increase the ability of AI youth and parents to work together towards social change to eliminate these stressors. In addition, we hoped the intervention would impact parenting practices and increase parent-child communication in order to improve the supportive context available for AI youth. We employed a mixed-method, within-group design to explore these effects. We interviewed parents five times over 18 months and tested four quantitative hypotheses regarding change over time during and following the intervention: 1) thoughts about historical loss and symptoms associated with historical loss would decrease; 2) enculturation would increase; 3) authoritative parenting practices would increase and permissive and authoritarian parenting practices would decrease; and 4) parent-child communication would increase. The interviews also contained sections of open-ended questions, which focused on parents’ current stressors and strengths, their goals for the intervention (pre) and their experience in the intervention (mid, post, and two follow-ups). Interviews ranged in length from 67–140 minutes and were conducted by trained student interviewers from the same tribe. Parents received $15 for their time.

The quantitative data analysis in this small sample focused on description and characterization of change over time. A repeated-measures ANOVA with a post-hoc polynomial contrast was examined first for all outcomes. Unplanned contrasts were examined with paired t-tests for comparisons of pairs of time-points. With 5 timepoints and only 10 participants, we sought to maximize the information gained from the analyses; this was guided by visual inspection of means plots. Because of the exploratory nature of the analyses and the limited power, no alpha adjustments were made for multiple comparisons.

Measures

The Historical Loss Scale and Historical Loss Associated Symptom Scale (HLS; Whitbeck, Adams, Hoyt, & Chen, 2004) are 12-item measures that assess the frequency with which respondents think about losses experienced by AI populations (e.g., loss of land, language, culture and family ties) and experience symptoms specifically associated with thoughts of historical loss (e.g., sadness, anger, or re-experiencing), respectively. Average Cronbach’s α’s were .89 for the HLS and .95 for the HLASS. Enculturation, defined as parents’ connection to and involvement in their tribal culture, was measured by an adult Enculturation Scale (Whitbeck, Chen, Hoyt, & Adams, 2004), which includes: involvement in cultural activities (checklist adapted to 17 tribal-specific items in our study), cultural identity (three items assessing degree to which respondents participate in and live by their tribal culture), and traditional spirituality (three items assessing participation in and importance of traditional spiritual activities). The sum of participants’ Z-scores was used in analysis. Average Cronbach’s α was .65. We assessed parenting practices using a shortened (41 item) and modified version (Sullivan, Nguyen, Allen, Bybee, & Juras, 2001) of the Parenting Styles and Dimensions Scale (Robinson, Mandleco, Olsen, & Hart, 1995), which measures three domains of parenting: authoritative (warmth, reasoning involvement, and democratic participation), authoritarian (verbal hostility, physical coercion and punitive), and permissive (lack of follow through, ignoring misbehavior, lack of confidence) on a 5-point Likert scale. Average Cronbach’s α for the three domains was .89. Parent-child communication was assessed by a 4-item measure created by the community advisory council, which asked parents to rate how often, on a 5-point Likert-type scale, they talked to their child about schoolwork, other things he/she did at school, friends, and how he/she was feeling. Average Cronbach’s α was .76.

Results

Quantitative Data

Hypothesis 1

The mean score on the Historical Loss Scale at baseline was 32.5 (SD=9.6), which equates roughly to a response of ‘weekly’ thoughts about these losses. Although the overall ANOVA was non-significant, visual inspection of the means plot indicated that scores rose between the pre-intervention measurement and the 6-month follow-up in a linear fashion, but then sharply dropped off (reached baseline levels) between the 6 month follow-up and the 12 month follow-up (see Figure 1). A paired-samples t-test testing this difference was marginally significant, t(9) = 1.65, p < .10 (d = .14). For Historical Loss Associated Symptoms, sadness was the most frequently reported symptom. Visual inspection suggested a linear increase between the pre and mid time points, with a subsequent decline until the final follow-up. The linear trend between pre and 6 month follow-up was marginally significant F(1,9) = 3.33, p = .11 (partial η² = .60). Thus, although symptoms increased during the beginning when historical trauma was discussed, they decreased at the end and following the intervention, which may be related to the intervention focus on healing and transcending historical trauma.

Figure 1.

Graphs of parent outcomes.

Hypothesis 2

Enculturation – no patterns of change were observed.

Hypothesis 3

For authoritative parenting, the linear effect was significant and positive, F(1,9) = 5.41, p < .05 (partial η² = .44), indicating a continual increase in warm, involved, reasoning parenting over time. For authoritarian parenting, both the linear and quadratic effects were significant – the quadratic is presented and interpreted here, F(1,9) = 16.69, p < .01, indicating a consistent decline in scores between pre and post, with a reversal between post and 6-month follow up (partial η² = .65). For permissive parenting there were also significant omnibus and quadratic effects, F(1,9) = 8.98, p < .05, indicating a U-shaped function, with the lowest scores occurring at post (partial η² = .78). The patterns for authoritarian and permissive parenting suggest that during the intervention, parents lowered the use of these strategies, but that these effects were not maintained after the end of the intervention.

Hypothesis 4

The expected increase in parent-child communication was partially supported with a marginally significant quadratic effect, F(1,9) = 2.59, p = .14 (partial η² = .27), indicating that the increase occurred after the end of the intervention.

Qualitative Data

Given that this was a pilot study with a small sample size, it was particularly important that the interviews included in-depth qualitative components. This rich data enabled us to triangulate and/or further explain our quantitative findings, as well as to understand participants’ experiences. In addition, we were able to explore parents’ observations of change at multiple levels (youth, parent, family, and community). We identified six main themes that related to parents’ participation and how it impacted them. The first three were linked to our a priori quantitative hypotheses about enculturation, parenting practices, and parent-child communication. Interestingly, these three themes were found within all parents’ qualitative data and were the most frequently discussed topics. Historical loss/trauma (our fourth quantitative hypothesis) was almost never mentioned in the interviews. Although this was an explicit component of the intervention, past trauma is usually not discussed because of traditional cultural prohibitions against this. The other three salient themes we found were family, community involvement/collective action, and barriers to participation/life challenges/current stressors.

Enculturation

Although the quantitative data did not reveal significant changes in parents’ enculturation, the traditional component of the intervention and parents’ increased understanding of, interest in, and connection to their tribal culture, history, and ways of life were the most frequently discussed topics in the qualitative data. Parents also described understanding their tribal culture in new ways:

Our culture is beautiful. Everything revolves the earth, the plants, the sky, the clouds. I thought that was very pretty…it all revolves around Mother Earth… I never looked at it that way.

I think that the main thing I learned is culture is not a religion. The way we live our lives is not our religion… That’s just the way, from my understanding, how they lived a long time ago that’s just being brought down. It’s not a religion. You can still live every day, get up early and live your life. That’s part of being healthy and being in harmony with your whole surrounding.

Many participants also commented on their lack of previous knowledge of traditional culture but said they had a desire to raise their children with these values. For instance:

What really got me interested was the traditional portion of this whole thing…and my kids are not traditional…I’m a single parent mother. My brother’s around but they don’t know the traditional male role model, so that caught my attention right there and maybe the parenting skills…and I’m trying to put them together… because it does go hand in hand.

Parenting Practices

Changes in parenting practices were also frequently discussed. In regards to authoritative parenting as defined in the quantitative analyses, some participants reported an increase in warmth and encouragement for their children, as well as in reasoning:

Like…encouraging them more and kind of helping them grow their self esteem. Just trying to make more time for them…

When [daughter] needs to be disciplined, how you discipline her in a positive way instead of a negative way.

Yeah, on rules, on consequences…explain it more to them, the consequences of their actions. Simultaneously, participants reported a decrease in less effective parenting practices, such as using punitive strategies, not involving children in family decisions, or being overly permissive:

…how to do it [parenting] instead of pushing them out or something, like hitting or something.

Just that when you say something, just to follow through. Probably just to work together. Give their input—take their input.

Parents also highlighted an increase in knowledge of resources to support their parenting:

It has helped me to think a lot more, to take into consideration of how I can improve my parenting skills. How I can deal with my children and who can provide me with some assistance.

I felt that I learned a lot from other parents that were there that talked about how they handled their children, or their child. That was very helpful.

Another aspect of parenting that was frequently mentioned was increased ability to manage their anger:

Parenting practice I learned a lot of how I shouldn’t take out my anger on my daughter, or even when I’m sick. I’ve got to take a moment and pull myself together when I’m tired, and always be willing to listen to her, and just be there for her.

Parent-Child Communication

Consistent with the quantitative findings, most parents described increased communication with their children. Some focused on increased contact and interaction with their children, and several said that the quality of the communication with their children was also better:

Before we had dinner, everybody just hid their face. Now everybody wants to all sit at the table and talk. I kind of think that’s good.

I’ve learned that we have to work together. We have to communicate and communication is the main thing. We have a lot of difficulty in that because we think that we know what the other is talking about but we really don’t and then we do the wrong thing. Here [in the Our Life program] we communicate and I’m trying to do that and then to work at that because that’s the main thing for us. The family meetings was good too because we worked on that. Like you can’t read the mind of what the other person’s thinking. You’ve got to sit down and talk.

I also did this mostly for my other, youngest daughter, because she was going through a period of depression… and that’s why I went into this program with them to learn about their culture… That really brought out a lot of her thoughts and her feelings, and helped her cope a lot better. She’s been doing pretty good ever since. She started doing good in school. Outspoken. A lot brighter person—happier person. We can communicate more than before we started this program. I’m trying to just interact with my girls, to be closer I guess you could say. I pretty much am very busy, and thought maybe they’ll do everything on their own, because they were getting older, but probably that’s why I missed it. That’s why I wanted to be involved in this program—maybe it would help them, especially my daughter. It did. It really did help her.

As this the last quote illustrates, in addition to improved communication with their children, parents observed many positive changes in their children’s well-being and behavior. Another mother explained:

Her improvement in her [daughter’s] grades… and she’s actually stayed in school. In the past she had problems in school, and she would be suspended or something like that. This is the longest she’s been in school, and she likes it. She likes going to school. Actually, before that, she didn’t like going to school, and I was having problems with her with the principal or the police always calling. I haven’t had any problems like that since January after the program ended. She’s really improved since the program. She was kind of sad that the program had ended.

Family

Parents also frequently reported that their families had become closer emotionally and spent more time together as a result of their involvement in the intervention. For instance:

Pretty much I’ve been interacting with my children… I tend to listen to them, what their problems are… I know that [daughter] wasn’t really opening up, but now she’s kind of like seeking for help, and she talks to me, and, you know, she’s—her attitude is kind of improving.

Just the communication is a lot better with my family, and we’re all pretty much getting more involved with each other now than we used to be before. It really brought us all together.

Community Involvement/Collective Action

Another result of the program that was evident in parents’ interviews was their increased involvement in their community, both in terms of interaction with other community members and participation in community groups and activities. For example, when asked about changes in their lives that occurred because of their participation in the Our Life program, parents replied:

Well, first I’m still in contact or involved with a lot of the people that were in this program…see them all the time, and you know, we continue to keep in touch.

I have one good friend, and she went to [Our Life]… She’s a good friend, and we’ve been close ever since then. We help each other both ways… She understands what kind of situation I’m going in. I understand what she’s been through…We met each other through the program.

In addition, parents reported increased interest in knowing more about their community and making improvements to it and increased ability to collectively solve community problems:

I just like the interactions with other families. Listening to what their problems were, because some of them—even though we’re neighbors, I don’t really talk to them. I mean I say, “hi and bye,” but you don’t really know them until you go into a program like this. You hear about their problems and what their feelings are. What their feelings towards your community, any problems that they have or rise in the community, and their concerns.

Problem solving as a group, we can solve anything. Maybe we have to go round and round and round but I think we can solve things together.

Barriers to Participation/Life Challenges/Current Stressors

Among parents who completed the program, average attendance was 63% of the sessions. However, over half of the parents who initially expressed interest did not complete because they did not want to attend or were unable due to challenges and stressors they faced. Although we did not hear directly from most of these parents about why their participation was limited, it was clear even among completers that families in this community faced numerous stressors that were more pressing priorities than program participation, or that interfered with their ability to consistently attend. Although we attempted to provide rides to families that needed them, lack of transportation in this rural setting affected many families. Parents also mentioned challenges and stressors related to their jobs, financial stability, substance abuse, caretaking responsibilities for other family members, and legal issues. When balancing all of these issues, participation in a voluntary program may be the first time demand that is sacrificed, particularly if more pressing survival needs are not being addressed.

Discussion

The overarching goal of this study was to promote mental health and well-being of American Indian youth through fostering positive change at multiple levels: youth, parent, family, and community. We report here preliminary results from ten parents who participated in a relatively long intervention with their children ages 7–17. Consistent with our youth results (see Goodkind et al., this issue), we found that it was difficult to engage and retain parents in the intervention. However, parents who completed the intervention demonstrated evidence of decreases in symptoms related to historical loss, increases in supportive parenting practices, decreases in punitive and permissive parenting practices, and increases in parent-child communication. Qualitative data provided rich, descriptive support for these findings and also highlighted the importance of the traditional cultural foundation of the intervention to parents, parents’ increased community involvement and connections, and the positive effects parents observed in their families. It may be that a shorter intervention would result in higher retention; however, our community-university partnership felt strongly that meaningful and sustainable change required long-term engagement. The positive effects we observed, some even 12 months after completion of the intervention, suggest that this type of change may have occurred for many parents.

As noted in our report of youth data, the findings from this small pilot study should be interpreted with caution, particularly given issues with retention and the lack of a control group. In addition, future research should examine more in-depth the similarities and differences of parents who complete this type of intervention and those who are more challenging to engage. Although we did not observe any baseline differences in parenting practices, enculturation, mental health, quality of life, employment, or government assistance among these groups in our study, qualitative interviews with non-completers might reveal additional barriers to participation or reasons for lack of satisfaction with the intervention. It would also be important in future studies to utilize more innovative methods for assessing family and community changes. Within the context of these limitations and challenges, the triangulation of our qualitative and quantitative data provides compelling, although preliminary, support for further development and testing of the Our Life intervention. In fact, almost all of the parents expressed a desire for the program to continue. As one mother explained:

My kids miss it [Our Life program]. They’re asking if—asking again to see if there was any program that’s going to be coming up again. I, too, would like to see that the program continues, because it’s—it’s something that my kids need, and I need, you know, to keep me strong, and I know it’s been a—life has been really a struggle for me, and just seeing the program again in our community, I think, will benefit myself and then my children also.

Although short-term mental health interventions are appealing, the multi-level changes that are needed to reverse 500-years of colonialism may require culturally-grounded, long-term approaches that build on individual, family, and community strengths while also addressing ongoing challenges and stressors.