Citation
Factors associated with alcohol, drug, and mental health service utilization among a sample of American Indian adolescent detainees

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Title:
Factors associated with alcohol, drug, and mental health service utilization among a sample of American Indian adolescent detainees
Creator:
Duclos, Christine Wilson
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Language:
English
Physical Description:
xiv, 165 pages : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Indian youth -- Mental health services -- United States ( lcsh )
Indian youth -- Drug use -- United States ( lcsh )
Indian youth -- Alcoholism -- United States ( lcsh )
Juvenile detention -- United States ( lcsh )
Adolescent Health Services -- organization & administration -- United States ( mesh )
Mental Health Services -- organization & administration -- United States ( mesh )
Adolescent -- United States ( mesh )
Indians, North American -- United States ( mesh )
Juvenile Delinquency -- United States ( mesh )
Socioeconomic Factors -- United States ( mesh )
Substance-Related Disorders -- therapy -- United States ( mesh )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (pages 144-166).
General Note:
"UMI number 9928109"--Title page verso.
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Christine Wilson Duclos.

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Source Institution:
|University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
69672702 ( OCLC )
ocm69672702
Classification:
LD1190.L566 1999d .D83 ( lcc )
2006 D-094 ( nlm )

Full Text
FACTORS ASSOCIATED WITH
ALCOHOL, DRUG, AND MENTAL HEALTH SERVICE UTILIZATION
AMONG A SAMPLE OF AMERICAN INDIAN ADOLESCENT DETAINEES
Christine
by
Wilson Duclos
B.A., University of Pittsburgh, 1975
M.P.H., University of Pittsburgh, 1977
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
mavioral Sciences
Health and Be
999


1999 by Christine Wilson Duclos
All rights reserved.


This thesis for he Doctor of Philosophy
degree by
Christii e Wilson Duclos
has been approved

Date


Duclos, Christine Wilson (Ph.D., Health and Behavioral Sciences)
Factors Associated with Alcohol, Drug, and Mental Health Services Utilization
Among A Sample of American
Indian Detainees
Thesis directed by Professor Craig Janes
ABSTRACT
The purpose of this exploratory study was to identify factors related to the use
of alcohol, drug, and mental health (ADM) service utilization for a sample of
detained American Indian youth, and differentiating these factors by types of
services. I also describe the social contiext of service utilization by which youth who
interface with the juvenile justice system do or do not use more appropriate ADM
services. The research incorporated quantitative and qualitative methods, with
logistic regression modeling and template type of analysis of interviews.
Quantitative data came from the Indian Detainee Adolescent Project of the
National Center for American Indian and Alaska Native Mental Health Research. A
structured diagnostic and service use interview and a self-report survey was
administered by local lay interviewers to 150 youths admitted consecutively to a
Northern Plains reservation detention facility. Utilizing the Behavioral Model of
Health Service Use, four logistic regression models tested predisposing, enabling, and
need factors for significant predictors of lifetime ADM service utilization, as well as
formal, informal and culturally traditional ADM services. Semi-structured individual
and focus group interviews probed for ir formation about the social context, other
factors influence, and the role of the detention center in the local community and
service ecology.
IV


A description of factors and social influences in youths utilization of ADM services
emerged from the research. The quantitative portion of the research found need
factors as the driving force for service use. Different types of need determined
different types of service use. It also round that the Behavioral Model for Health
Service Use, as tested, may not be appropriate for an adolescent and culturally
different population. Culture and external environment factors emerged as important
to service utilization. Different roles for the detention facility within the community
were important including brokering of^|ADM services for the youth, especially for
substance abuse/dependence. The facility and its staff assumed the extended family
roles for youths that had this need.
Beginning to explore and understand how troubled youth actually receive
services will better help the communit| plan for appropriate and effective systems of
care that includes juvenile justice.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
v


DEDICATION
I dedicate this dissertation to my father, Dr. Edmund G. Wilson, who always wanted
and encouraged me to be the other doctor in the family. I know you are smiling
from above.
vi


ACKNOWLEDGEMENT
It was the best of times, it was the worst of times.
- Charles Dickens
I wish to acknowledge Dr. Spero M. Manson, who supported my interests in
this topic from the beginning; Dr. Craig Janes, who was always there and opened
my eyes to all the possibilities; Dr. Jan Beals, who taught me what research
methodology was all about; Dr. Blair Gifford, who was so encouraging and never let
me forget the right perspective; Dr. Douglas Novins, who was indispensable in his
generous support and guidance of my anxious journey through research analyses;
and Dr. Debbi Main, who kept me on track weekly, validated coding, shared her
qualitative research expertise, and kept the process positive.
I also would be remiss if I did not mention my colleagues in the Health and
Behavioral Sciences program who enriched my learning experience, especially Cindy
Bryant who read every word and kept me going.
A very special thanks, I couldnt have done it without you, goes to
Marianne McCollum, my weekly Wednesday morning breakfast buddy. The
breakfasts together supported both of us through the survival of the process.
On a more personal note, DavidJ my husband, was instrumental in keeping the
home fires burning. I would not have accomplished this without his love and
support. All my friends and family worked wonders with their gentle pushes, and I
am grateful.
Last, but definitely not least, myj friends and colleagues from the reservation
were invaluable. Because of tribal confidentiality I can not list all that provided
support and assistance. My greatest gratitude goes to all who helped, provided
diligent hard work, and gave me enthusiasm and laughter even during the hardest
times. I want to thank this community in opening up their arms and lives to me, and
hope the information that I provide, in turn, aids them in their efforts of restoring the
balance. |
The Open Societys Center on Crime, Community and Culture provided
dissertation support as a Senior Fellowship.
vu


CONTENTS
Figures..
Tables...
CHAPTER
. xii
xiii
1. INTRODUCTION.........
The Problem.......
Prevalence........
Specific Aims.....
Overview of the Research Methods.
Organization of the Dissertation.
1
1
2
3
4
5
2.
REVIEW OF THE LITERATURE.
Introduction.......
American Indian Youth..
Indian Delinquent Behavior.
Reservation Detention Environment.
Mental Health Problems Among
Indian Detained Youih..........
..7
..7
..8
10
11
12
Alcohol, Drug, Mental Health Services and
Juvenile Justice...........................
ADM Service Utilization Theory.............
15
16
vui


Adolescent ADM Services Research...................18
General Population
.18
American Indian Adolescents.......................20
American Indian Detained Youth....................22
ice Utilization................26
Factors Related to Serv:
Factors That Influence Adult ADM
Service Utilization.
.26
Factors That Influence Adolescent
ADM Service Utilization............................27
3. QUANTITATIVE ANALYSIS..................31
General Framework.
Methods..........
.31
.32
Quantitative Study Design...........................32
............32
The Expanded Behavioral Model of
Health Service Use.
Study Population
IDAP Data Collectio
IDAP Measures.
Power Analysis.
Data Preparation
Analyses........
Results............
.34
p Procedures...................37
............................38
............................45
............................46
............................46
............................47
Description of Sample.............................47
Description of Variables..........................48
Bivariate Analyses To Describe
Relationships Between Variables...................50
Logistic Regressions
.55
IX


Discussion..
Limitations.
Summary....
Methods.
.65
.69
.69
QUALITATIVE ANALYSIS....................71
.72
Human Subjects Review...............................72
Sample Selection.
.73
Interview Instruments.............................73
Structure of Intervie
Analytic Methods....
Codebook.........
Results.
ws & Focus Groups...........74
..........................77
..........................77
Providing Description Summaries....................79
Factors Influencing
Service Utilization.
Emerging Themes..
'roubled Youths
.79
.79
.91
Role of the Detention Facility....................96
Discussion of Qualitative Finding....................102
What Are the Other Factors that Influence Youths
Utilizing ADM services?....................102
What Is the Role of Detentions in this Particular
ice ecology?.................103
..........................107
Community and serv
Limitations.........
CONCLUSION......
Review of Results.
.109
.110
Quantitative Review.!..............................111
x


Qualitative Review,
Clinical Implications....
Recommendations for F
uture Study
112
114
115
APPENDICES
.121
A. LITERATURE REVIEW TABLES............121
B.
VARIABLE MEASUREMENTS............126
ROC PLOT CURVES.
.134
D. CONSENTS & HUMAN SUBJECT APPROVALS..137
REFERENCES
144


FI
GURES
Figure 1.1 Study Multimethodology 4
2.1 American Indian Population by 3.1 The Behavioral Model of Healtl 3.2 IDAP Sampling Age 9 Service Use 33 37
3.3 Study Variables to be Tested Fo 3.4 Independent Variables Related t Service Use r First Regression 45 3 Lifetime ADM 51
3.5 Independent V ariables Related t Service Use 3 Formal ADM 54
3.6 Independent Variables Related t Service Use 3 Informal ADM 54
3.7 Independent Variables Related t Traditional ADM Service Use.. 3 Culturally 55
4.1 Interview Guide 75
4.2 Focus Group Guide 76



Table
2.1
2.2
2.3
3.1
3.2
3.3
3.4
3.3
3.4
3.5
3.6
3.8
3.9
TAB
,ES
Cross-Study Comparisons of Prevalence of Psychiatric
Disorder...................
The Relationship Between Psychiatric Diagnostic
Status and Service Use Among American Indian
Adolescent Detainees...........................
Comparison of Service Utilization Between Indian
Adolescent Detainees and Indian Youth at Large in
Another Northern Plains Community.....................
Demographic and Service Utilization of IDAP
Sample................................
Descriptive Statistics of Variables
Variables with Missing Values
Table of Relationships Between Variables........
Model Building for Lifetime Use of ADM Services
Odds Ratios and Confidence Intervals for Lifetime
ADM Service Use..............................
14
24
25
48
49
50
52
56
.58
Model Building for Formal Use of ADM Services
59
Odds Ratios and Confidence Intervals for Formal
ADM Service Use.............................
60
Model Building for Informal Use of ADM Services
Odds Ratios and Confidence Intervals for Informal
ADM Service Use.............
61
62
xm


3.10 Model Building for Culturally Service Utilization rraditional ADM 63
3.11 Odds Ratios and Confidence Ir Traditional ADM Service Use. 3.12 Gender Differences in Referra 4.1 Preliminary Codebook for Indi Group Interviews tervals for 65
Sources 67 /idual & Focus 77
4.2 Final Codebook for Individual Interviews & Focus Group 1 78

XIV


CHAPTER 1
INTRODUCTION
But a lot of kids dont think its
Because their parents are in jail
wrong to go to jail, either.
And their parents have gone
to jail. And theyve grown up seeing their parents [get] into
the cop car, and off to jail they go. And they come back, and
then their parents talk about what happened in the jail. And
they think thats all cool. So they grow up hearing that. Its
okay to go to jail. Because it was okay for their mom and
their dad. Or mom and dad together going to jail. Thats
what they know, (parent qualitalive subject).
The Problem
Services for adolescents with emotional and substance use problems are
clearly lacking in American Indian Country1 as well as in the mainstream (Knitzer,
1982; Stroul, 1996; US Congress, 1990). Tribal detention facilities, by default,
often serve as primary care facilities for youths with substance and mental health
problems (Duclos et al., 1998). This mirrors mainstream detention experience
(Cocozza, 1992; Eppright, Kashani, Robison, & Reid, 1993; McManus, Alessi,
Grapentine, & Brickman, 1984). Adolescents are detained until sober or mentally
stable, then released with no treatment or referral, only to return the next time the
behavior surfaces. This pattern is problematic, not only for the youths for whom
more effective treatment remains elusive, but also for the jail/detention system
with a restricted budget and staff. Increasingly, the juvenile courts are becoming
gatekeepers for adolescents in need of mental health services.
1 Indian Country is defined as on or adjacent to land within the exterior boundaries of an Indian
reservation as well as land outside those boundaries owned by Indians and held in trust by the
Federal government (O'Brien, 1989).
1


This experience is especially true for children of color. Children of color
are the fastest growing population witliin the United States. In 1995, minority
youths constituted about 31 % of the youth population in this country, it is
estimated by the year 2000, those under the age of 19 will comprise 33% of this
population (Isaacs-Shockley, Cross, Bazron, Dennis, & Benjamin, 1996; Hsia &
Hamparian, 1998). Americas continued prosperity depends in great part on the
successful development of this group. They continue to face, however, enormous
challenges to their maturing into productive and healthy adults. In particular, they
have limited access to alcohol, drug, and mental health (ADM) services. The need
for such services is great.
Prevalence
Recent studies suggest an overall youth prevalence rate of 15% to 19% for
emotional disturbance (Pumariega & Glover, 1998). Juvenile emotional/behavior
problems are thought to be greater on American Indian reservations than in non-
Indian communities, and a growing problem among Indian adolescents in general
(University of New Mexico, 1991; US Congress, 1990). While growing up under
stressful conditions, Indian adolescents often feel caught between two cultures,
placing them at high risk for behavioral] and emotional problems.
Behavioral and emotional disturbances may be present in as many as 70-
90% of all adolescents who enter juvenile justice systems (Brandenburg et al.,
1990; Cocozza, 1992; Teplin,. et al., 1997). These disturbances arise from
physical/biological, cognitive/intellectukl, emotional/affective, and
social/cultural/interpersonal contexts, hlly preliminary work for the Indian
Detainee Adolescent Project (IDAP) found that approximately 50 percent of
Northern Plains Indian youths entering a reservation-based juvenile detention
center had diagnosable DSM-III-R disorders ((Duclos et al., 1998).
The chances remain good that minority youths with emotional problems
will end up in the juvenile justice system, rather than in more appropriate
treatment settings to which his or her Caucasian counterpart would be referred
(Gibbs, 1990; Gibbs & Huang, 1989; Blum et al., 1992). Children of color are
under-served, inappropriately served or not served at all by most public and private
ADM systems (Isaacs & Benjamin, 1991; Isaacs-Shockley et al., 1996).
Incarceration/detention is the most expensive and least successful method of
handling juvenile offenders (Join Together, 1996). Nonetheless, until adequate
services for supervision and treatment aije available within the community, judges
have no other choice than to incarcerate jyouths (Simonsen, 1991). The detention
center serves as the entry point to the juvenile justice system, processing large
numbers of juveniles. This facility, therefore, becomes one of the system's most
2


important institutions, pointing to the very importance of justice programs in the
total community service system. Detention represents a potentially important
juncture in systems of care, providing opportunities to identify high-risk youths
for emotional problems early and refer appropriately, thus intervening
constructively in their lives.
Adolescent alcohol, drug, and mental health services research (ADM) is a
relatively new field in the health and behavioral sciences (Pumariega & Glover,
1998). This area of study involves mental health, physical health, social services,
and juvenile justice systems of care. While there is a significant body of research
about differential minority processing injustice systems, I find no information
about youths' use of available community services, including detention, to address
psychological and substance use dysfunction (Leonard et al., 1995; Poupart, 1995).
This becomes alarming given the significant unmet need, overrepresentation of the
minority population at all phases of justice systems, and the uncoordinated systems
of care that characterize service systems (Join Together, 1996; University of New
Mexico, 1991; US Congress, 1990). It is of particular concern for Indian
adolescents living on the reservation who can be detained without criminal charges
for lack of more appropriate substance abuse/mental health treatment
resources(Duclos et al., 1994). Culturally appropriate treatment planning requires
basic knowledge of minority youth experience in seeking care among alternative
community services. Except for my colleagues and my prior work, reservation-
based research of detained Indian youths is not available.
Specific Aims
The overall goal of this present study is to advance our knowledge about
the use of ADM services in a population that has not been previously studied,
American Indian detained adolescents. The secondary purpose is to inform policy
decision-makers about the provision ana best use of community services in order
to improve delivery of needed care to this special needs adolescent population.
The specific aims of this study are to:
(1) investigate, retrospectively, self-report factors related to the use of
alcohol, drug, and mental health services (ADM) for a sample of
detained Indian youths on si Northern Plains reservation,
differentiating these factors by types of services, and
(2) describe the social context of service utilization by which Indian
youths who interface with the juvenile justice system do or do not
use more appropriate ADM
services.
3


Overview of the Research Methods
To achieve these aims, I used both quantitative and qualitative methods.
The theoretical framework depends on the Behavioral Model of Health Service
Utilization (Andersen, 1995; Aday & Andersen, 1974; Andersen & Newman,
1973) because no adolescent and American Indian-specific model exists. The
objectives were to examine the relationship between need, predisposing, and
enabling factors as defined by Andersen et al. to detained adolescents utilization
of ADM services. I did secondary data analyses with a dataset from a sample of
incarcerated Indian adolescents on a Northern Plains reservation (description of
study setting and population is described in Chapter 3: Quantitative Analysis). I
then collected additional qualitative data in the form of in-depth and focus group
interviews (see Figure 1.1).
Northern Plains Reservation Community
Indian Detainee
Adolescent
Project
Provided
quantitative data.
Community
Provided focus
groups &
interviews
Quantitative Analyses
What predisposing, enabling, & need
factors predict mental health ADM
utilization for detained Indian adolescents?
Are these factors different for formal,
informal, and traditional services?

Qualitative Analyses
What other social factors and contexts
contribute to mental health ADM service
utilization for detained adolescents?
Model of Indian Detainee ADM Service Utilization
What are the ADM service utilization patterns for detained Indian youth, and what
factors contribute to them? How does thle juvenile detention center contribute to
these utilization patterns? |
Figure 1.1. Study Multimethodology
4


Important questions explored included:
How do predisposing and enabling factors contribute to the probability of use
of ADM services for this sample of youths?
How does need mediate this process?
Toward these ends, logistic regression models were developed to predict
the probability of use of ADM services and identified factors that predict each type
of services (formal, informal, and traditional services).
Qualitative analyses of in-depth and focus group interviews using template
analytic techniques provided descriptions and interpretations of the contributions
of the social and systems context to individual service utilization (Crabtree &
Miller, 1992). Questions explored included:
How do social factors influence ADM service utilization?
What other and whose other factors or processes must be included in the study
of troubled youths ADM service utilization?
What is the role of the detention facility in the communitys service ecology?
The final step combined the results of both analyses to summarize individual,
social, and system factors that influence ADM service utilization for these youths.
The summary sheds light on the role incarceration plays in the youths' experience
of receiving care. These findings, in turn, will inform mainstream urban and rural
communities, as well as other similar Indian reservations settings for
detention/community intervention policy and planning. The study provides a first
step toward addressing the scarcity of research surrounding adolescent service
utilization patterns, specifically minority experience.
Organization of the Dissertation
This chapter introduces the main issues; states the specific aims of this
study; briefly describes the research methods; and outlines the organization of
what is to follow. Chapter 2 presents an! overview of the Indian adolescent
population; a review of the pertinent literature on childrens mental health services
research; and a review of factors that influence ADM service utilization for
mainstream, American Indian, and detail led adolescents. Chapters 3 and 4 are
dedicated, respectively, to the quantitative and qualitative analyses, as well as
5


results, limitations, and discussions sp
provides my dissertation conclusions.
;cific to the separate analyses. Chapter 5
6


CHAPTER 2
REVIEW 0F|
THE LITERATURE
We dont. I dont know. Some people might say Im wrong. But we
dont really have any bad [italics added] kids out there. Or I feel we
dont. The bad kids that we doj have, if and when they act up, they
have enough evidence against them to get them off the street and get
them off, you know, get them off the reservation right away. They
may hold them here for two or three days. But they can get them out
of here right away. So we dont have those kids out there, (officer
respondent).
Introduction
Adolescents live in a world today that is different than it was a decade ago.
They need to be more emotionally mature, socially responsible, and sure of their own
goals and values earlier than ever before. Successful maturation does not come easily.
One in five youths lives in poverty, whether in inner-city neighborhoods plagued by
crime, gangs, and drugs; at the social fri nges of suburbia; in blighted rural areas; or
on American Indian reservations (Conger & Galambos, 1997). Those, whose needs
are the greatest, are being hit hardest by massive cutbacks in all areas of youth
programming, especially in mental health and substance abuse care. Only juvenile
justice and detention services remain a growth enterprise in services.
Three decades of literature have focused on the problem of selection biases in
this expanding service arena. Minority Souths are more likely than majority youths to
be over-represented in juvenile justice systems (Feld, 1995; Leonard et al., 1995;
Pope, 1989; Pope & Feyerherm, 1995; Poupart, 1995). This over-representation
seems to be a growing problem. In 1995j, minority youths represented 65% of
juveniles in secure detention while constituting only 32% of the youth population in
7


the country (Hsia & Hamparian, 1998). This figure reflects significant increases over
1983, when minority youths representsd 53%. Documentation suggests that
American Indian youths, in particular, are vastly over-represented at all points in
juvenile justice processing (Armstrong et al., 1996). The lack of empirical
information on the causes of this over-representation, and the accompanying
utilization of lesser restrictive community alternatives, continues to plague the ability
to respond to this crisis.
Thus, my research investigates factors that predict utilization of other
community ADM alternatives for American Indian youths who appear in detention,
and the role detention plays in the local service ecology. There have been no
previous studies on this specific topic. However, I will present overviews of the
study population as well as mental health service utilization theory and research for
mainstream and American Indian youths. It also seems appropriate to include a
review of previous studies of factors found to be related to youth ADM service
I will convince the reader that there is a
information concerning American Indian
adolescents use of alternatives to incarceration for emotional and substance abuse
problems.
utilization. By the end of this chapter,
serious lack of, and need for, empirical
American Indian Youths
The term American Indian evokes many images. For some people the
image is one of romantic mystique; others see people without social discipline,
violent by nature, suicidal, and suffering from alcoholism. Indians do not fit these
stereotypes (Bachman, 1992). Some Indians are traditional, some receive welfare,
and others earn a living as farmers, ranchers, labors, artists, or professionals.
American Indians have a special historical and political status within the
United States. The Indian population is extremely diverse and varied. Approximately
280 federal and state reservations and over 280 tribal groups recognized by the
federal government are located around tie nation. Each of these groups has status as
a sovereign semi-independent nation, and most with US Trust and Treaty rights2
(O'Brien, 1989; Snipp, 1996). One-third of all American Indians live on the
reservations. The American Indian self identification movement during the past 30
: Trust and treaty rights lie in international law,
, , treaties, legislation, and judicial decisions. The trust
relationship is constantly changing since legislation is continually passed and courts continually make
decisions. Presently, by law, the United States is responsible for protecting Indian lands and resources,
providing services such as health and education, and serving tribal autonomy. These rights are owed to
tribes as a result of promises made by the federal government in return for the cession of more than
97% of Indian land (O'Brien, 1989).
8


years resulted in a tremendous growth
population increased from 552,000 to
of this population. Between 1960 and 1990 the
[, 959,000 (Sandefur et al., 1996). As Figure
2.1 shows the population is quite young. The median age of 24.4 years compares to
34.4 years for US All Races. Thirty-three percent of the population is younger
than 15 years-old (US Department of Health, 1997).
Nationally, the unemployment rates for Indian is approximately 17 percent for
Indian males, significantly higher than] the 6.4 for the All Races counterpart.
Approximately 23 percent of Indians lijVe below the poverty line, compared to 7
percent of Whites and 26.5 percent of Blacks (Nielsen, 1996). Indians are more
likely to suffer from ill health and the average life span is about eight to ten years
below the national average (US Department of Health, 1997; Young, 1994).
Population by
Asa
MtadltAtfAlaka
batfca*
Figure 2.1.
American Indian Population by Age
Note : Adapted from US Department of Health & Human Services, Indian
Health Service: 1996 Trends in Indian Health.
Death rates are especially high for younger persons (Snipp, 1996). Moreover,
an overwhelming majority of these deattis are preventable. Mortality data indicate
that suicide and homicide are the seconci and third leading causes of death,
respectively, for Indian youths 15 to 24 years of age, exceeded only by accidents. At
31.7 and 20.1 per 100,000, they occur at two to three times the national average (US
Department of Health, 1997). Along wijth cultural conflicts and paternalistic
government policies, factors as described above has contributed to the development
of alcohol abuse/dependence, violent behavior, suicide, and crime (Nielsen, 1996).
9


Juvenile emotional and behavior problems are thought to be relatively greater
on Indian reservations than in non-Indian communities, and are thought to be a large
and growing problem among Indian adolescents in general (Duclos et al., 1998;
University of New Mexico, 1991; US Congress, 1990). Available evidence makes
clear that mental health services for mainstream and Indian adolescents are
inadequate (Neligh, 1990). Increasingljy, mainstream and Indian juvenile justice
systems are forced to manage and supervise juveniles who are delinquent and/or have
emotional, physical, or mental problem^ (Simonsen, 1991; Duclos et al., 1998).
Mental/substance use problems have compounded the low level of success that
juvenile detentional programs have hadj with delinquency. The University of New
Mexico (1991) found a wide disparity among tribes regarding services available to
adolescent detainees. They concluded lhat in many sites youths "slip through the
cracks" quite frequently and that too often Indian youths are detained when detention
may not be appropriate.
Indian Delinquent Behavior
Minority youths are over-represented within the criminal justice system
(Armstrong et al., 1996; Krisberg et al.,
Morales, 1989; National Council of Juv
1995; Devine et al.,). This occurs at al!
1987; Leonard et al., 1995; Pope, 1989;
mile and Family Court Judges, 1990; Poupart,
stages of the system. Although a sizable
amount of research about African- Ameijican experience exists, Indian issues of crime
and justice have been neglected. Only a handful of studies examine the experience of
American Indians. Information regarding Indian crime has focused largely upon the
adult Indian population. A small number of dated studies described or offered
insights in juvenile offending on specific reservations.
Flowers (1988) found that Indian juveniles had relatively high rates of arrest.
Although Indian youths at the time comprised 0.6 % of the general youth population,
they made up 0.9 % of all arrests, 1.0 % of index crimes, and 1.5 % of all alcohol-
related offenses. Minnis (1963) examining adult and juvenile delinquency on the
Shoshone-Bannock Indian Reservation in Ft. Hall, Idaho, found an arrest rate of 161
per 1,000 compared to 46.4 for other rurkl towns in the United States. He found that
a majority of the arrests were for non-senous offenses. Examining juvenile
delinquency on the Wind River Reservation, Forslund and Meyers (1974) found
Indian youths five times more likely to appear in court than the general population.
They also found that a large proportion of the cases involved minor incidents such as
status and alcohol-related offenses.
OBrien (1977) compared Forslund and Meyers findings with experience on
the Warm Springs Reservation in central Oregon. He stated that in 1973, Indian
10


juveniles comprised .64 percent of Oregons general population, but accounted for 7
percent of all referred juvenile offenses. Although the delinquency rate was 5 to 6
times higher than the national average,
offenses. Parry examined delinquency
most referrals were for status and victimless
among Alaskan Native youths. In 1985, he
noted that the arrest rate for these youths appeared to be higher than the national
average; however, for serious offenses the Alaskan rate was considerably lower.
More recently, confirming these earlier studies, Duclos et al. (1998) found that the
official charges for their detained India!n adolescent sample reflected less severe, non-
victim offenses; 77% of the charges eniailed status offenses.
This literature suggests that Indian youths are over-represented in arrest
statistics; however, offenses have been minor in comparison to those reported for the
general delinquent population. Contradictory rates have been reported by the
National Task Force on Juvenile Justice for Native Americans and Alaska Natives in
making recommendations to Congress with regard to reauthorization of the Juvenile
Justice and Delinquency Prevention Acjt cited rates of serious crimes against persons
committed by juveniles three times higher in Indian Country than in the general
juvenile population (Armstrong et al., 1996). This contradiction points to the need for
more methodologically sound studies focusing specifically upon the rates of
delinquency among Indian youths.
Reservation Detention Environment
For many youths, detention represents their first prolonged contact with the
criminal justice system. The mentally troubled youths chance of returning from this
setting to a non-delinquent lifestyle seems remote when one considers the lack of
services or programs available to or utilized by detained youths (OJJDP, 1994). The
extent to which Indian youths are being confined in state correctional facilities
suggests a disproportionate rate of incarceration (Armstrong et al., 1996; Camp &
Camp, 1992). Krisberg et al. (1987) ex* mined the 1979 American Indian
incarceration rates (second only to African-Americans) in all public juvenile
correction facilities. Indian males were incarcerated at a rate of 362.8 per 100,000.
In addition they found that Indian females were incarcerated at a rate of 73.3 per
100,000 which is close to African-American females, who had the highest female-
specific rate at 76.9.
Poupart (1995), in the most recent study to date, examined the processing of
White and minority youths in the juvenile court of one rural Wisconsin county. This
study found that significantly fewer Indian youths had their cases closed or resolved
at intake, and that their detention rate was nearly two times greater. This study did not
address the causes of this experience, thus emphasizing the need for further research.
11


With few exceptions, the existing reservation-based detention facilities are
inadequately staffed, lack basic and community coordinated services, and are located
far from health service sites (Duclos et al., 1994). During the first day of
incarceration, a detainee is at greatest medical and mental health risk of any other
time of imprisonment (Hayes & Rowan, 1988). For example, alcohol withdrawal
carries a significant mortality (MacDonald et al., Baltimore, MD). The risk of
completed suicides is highest within the first 3 hours of incarceration. With high
arrest and subsequent incarceration rates, American Indian youths are being placed at
very high risk when placed in detention for seemingly not-so-serious crime.
Mental Health Problems Among Indian Detained Youths
According to national estimates! between 14 and 33% of all adolescents have
some type of emotional or behavioral disturbance (Otto et al., 1992; Shaffer et al.,
1996) Life situations of many Indian zdolescents are filled with stressors that can
lead to emotional distress and serious behavioral problems.
A small number of rigorous empirical studies suggest that Indian adolescents
have more serious mental health problems than adolescents in the general population
(Beals et al., 1997; Blum et al., 1992; Djauphinais et al., 1991; Jones et al., 1997; US
Congress, 1990). Higher rates have been found specifically for suicide (Duclos et al.,
1994; May & Van Winkle, 1994), depression (US Congress, 1990), conduct disorder
(Beals et al., 1997), anxiety (US Congress, 1990), trauma-related symptomatology
(Jones, Dauphinais, et al., 1997), 1997), and alcohol and substance abuse (Duclos et
al., 1998; Costello et al., 1997; Beauvais, 1996; May, 1989; Oetting et al., 1985).
Thus, Indian youths entering the criminal justice system would more likely than
others have a mental health or emotional problem.
A number of studies attempted to estimate the prevalence of mental health
disorders among detained youths in genjeral. Considerable variation exists in then-
research methods, assessment techniques, and settings which makes drawing general
conclusions very difficult. Otto et al. (1992) published a comprehensive review of
the prevalence literature for juveniles wno interface with the criminal justice system.
As they expected, their review found conduct disorder more prevalent than any other
diagnosis (50-90%). No studies employed instruments specifically designed for
diagnoses of attention deficit and hyperactivity. The studies used parent/teacher
rating scales and case review to determine estimated prevalence rates of 0 to 46%.
Actual studies utilizing proven diagnostic tools are warranted here. Anxiety
disorders prevalence estimates ranged ffjorn 6 to 41%. Surprisingly, they found few
studies that examined substance abuse/dependence, even though it is widely believed
that substance use highly correlates with
deviant behavior. Estimates of prevalence
12


of substance abuse estimates ranged from 25 to 50%. Only two studies were found
that addressed comorbidity (estimates of 75%). Otto et al. found one study that
examined post traumatic stress disorder in this population, despite the large number
of youths in the system who have been severely abused or otherwise traumatized
(41%) (McPherson, 1991).
Studies of personality disordeis that were not reported in distinct subtypes
yielded prevalence estimates varying from 2 to 46%. Clinical interview studies
reported rates of affective disorders be ween 32 and 78%.
Otto et al. emphasized a number of limitations of the studies reviewed: (1)
the vast majority reported only a single diagnosis; (2) research paid little attention to
the issue of comorbidity; (3) methodology was not always appropriate; (4) changing
diagnostic systems made comparisons (difficult; (5) there was an over reliance on
retrospective record reviews; (6) inadequate descriptions of the sample and sampling
procedures were given; and (7) it was unclear at what point in the youths retention in
the system they were being evaluated.
ject is currently studying prevalence rates
sample of urban mainstream detained youths.
Findings have not yet published. However, preliminary results show 79.7% of the
sample have met criteria for disorder. The most prevalent problem is conduct
disorder (41.6%) followed by marijuana abuse/dependence. Affective disorders are
diagnosable in 19.3% of the sample; anxiety, 21.9%; substance abuse/dependence,
46.7%; and disruptive disorders, 45.1/^ (Teplin et al., 1997). When comparing these
statistics to the reservation-based experience, we have to keep in mind that this is an
urban sample of mainstream delinquents.
Only one study to date has published prevalence rates for psychiatric disorders
among detained Indian youths (Duclos et al., 1998). My colleagues and I reported
prevalence of disorders for the sample analyzed for this dissertation study- the Indian
Detainee Adolescent Project (IDAP). To compare findings of psychiatric need to
other detained and non-detained peers, ihe current literature was reviewed for
potential comparison samples. Mentioned earlier, appropriate published samples of
detained youths are rare. However, two studies adequately permitted comparison with
community-based youths. Beals and colleagues (1997) reported prevalence data for
a school-based sample of Northern Plains adolescents based on DSM-III-R criteria.
The Northwestern Juvenile Pro
based on DSM-III-R3 criteria among a
The National Institute of Mental Health
Adolescent Mental Disorders (MECA)
Methods for the Epidemiology of Child and
itudy yielded estimates for a community
sample of 1,285 children between the ages of 9 and 17 (Shaffer et al., 1996).
3 The third revised edition of the American Psychiatric Associations Diagnostic and Statistical
Manual of Mental Disorders contains descriptions of the diagnostic categories for mental disorders
incorporating a psychobiologic view that mental disorders represent reactions of the personality to
psychological, social, and biological factors.
13


Although the latter did not report rates
adequate sample of non-detained, non-
i (separately by age group, it provides an
Indian youths. Rates of all disorders among the
IDAP sample were higher than those reported by Shaffer et al.; however, the degree
of significance could not be determined because standard errors were not published.
All studies used diagnostic algorithms that included measures of impairment. Since
Beals et al. reported standard errors, statistical comparisons to IDAP are possible.
Table 2.1 shows prevalence of psychiatric disorders found in the IDAP sample
compared with Indian adolescent schoql-based and community mainstream samples.
Nearly 49% of the 150 IDAP adolescents interviewed met criteria for a psychiatric
disorder and can be assumed to need mental health and/or substance abuse care.
Close to 20% of the youths required both. The most prevalent disorder was substance
abuse/dependence, followed by disruptive disorders. The rate of conduct disorder was
surprisingly low (16.7%) in comparison to those reported for other detained samples
cited previously (50-to 90%).
Table 2.1.
Cross-Study Comparisons of Prevalence of Psychiatric Disorders
Disorder
IDAP
(m=I50)
n ( Vo) Beals et. al (1997) (/7=108) (%) Shaffer et. al (1996) (=1,285) (%)
Alcohol Abuse/Dependence 51 34 .0* 11.0
Marijuana Abuse/Dependence 21 14 .0 8.6
Any Abuse/Dependence 57 38 .0* 18.3 2.0
Conduct Disorder 25 16 .7* 3.8 2.7
ADHD 3 2 .0 10.6* 1.2
Major Depression 15 11 1.0 4.7 3.2
Dysthymia 0 1.9
Generalized Anxiety 5 3.3 1.9
Overanxious Disorder 8 5.3 1.9 3.7
Post Traumatic Stress Disorder 2 1 B 3.0
*p < .001, two-tailed Fisher Exact Test. I
Note: Only the IDAP and the Beals samples are being compared statistically. IDAP= Indian
14


Detainee Adolescent Project; ADHD = attention-deficit hyperactivity disorder. Adapted from (Duclos, Beals, et al., 1998).
Detained IDAP Indian youths were significantly more likely than their non-
detained Indian counterparts to have a diagnosable substance abuse/dependence,
alcohol abuse/dependence, and /or conduct disorder. Approximately 21% of IDAP
youths reported experiencing at least one traumatic event. Thus, while exposure to
traumatic events was high among this group, the lifetime rates of PTSD (2%) were
approximately equal for both Indian samples.
Attention deficit and hyperactivity disorder (ADHD) was significantly less
prevalent in the detained sample. The ADHD findings were more in line with those
for adolescents in general. Beals et al. (1997) suggested several reasons for the
elevated rates of ADHD in their sample. One included changes between versions of
the ADHD diagnostic instrument. Modifications included the requirement of a 6-
month duration for at least 5 of the eight symptoms. There were no duration
requirements in the earlier version. In addition, questions were added and rephrased
to improve the reliability and validity cf the interview. In summary, these detained
Indian teens exhibited higher rates of disorder than either non-detained Indian youths
or adolescents in general.
To begin planning for more appropriate care, we need information about the
existing patterns of ADM utilization by detained youths. The search for information
led me to adolescent alcohol, drug, and mental health services (ADM) research.
Alcohol. Drug. Mental Health Services and Juvenile Justice
Both the juvenile justice system and child and adolescent psychiatry emerged
in the early to mid-twentieth century (Maloy, 1995; Bernstein, 1996). The first child
guidance clinic in the United States was founded to provide assistance to juvenile
courts in Chicago, indicating an early recognition that many youths who became
involved with the justice system had mental health problems (Maloy, 1995). In
contrast to the adult justice system that has a punitive orientation, the juvenile justice
system did then and still does today pla:e fundamental emphases on individualized
treatment and rehabilitation.
Troubled youths and their families who become involved in the juvenile
justice system present are very similar to youths and families served by the mental
health and child welfare/social service agencies (Maloy, 1995; National Conference
of State Legislatures Health and Mental Health Program, 1989). Unfortunately,
despite early historical connections between alcohol, drug, and mental health services
and the juvenile justice system, current relationships between the two are generally
considered insufficient (Novins et al., Submitted; Institute of Medicine, 1994; Maloy,
1995). Although many of the detention facilities in this country are beginning to
develop treatment programs, few currently have them, and information is lacking on
15


their number and type, efficacy and effectiveness, and availability. Part of the
problem is structural. ADM services are seen as complex, disconnected, and difficult
to negotiate. The systems are often viewed as totally independent because they have
different points of entry (courts vs. a variety of referral sources such as schools,
parents, etc.). These structural constraints lead to a lack of integration and
coordination between the ADM and juvenile justice systems.
Empirically- based knowledge about the appropriate use of mental health
interventions for detained youth population (Indian or non-Indian) can only be drawn
from the general research literature on jhe effectiveness of mental health treatment for
children and adolescents. Researchers have been limited by the historic poor funding,
fragmentation, inaccessibility, and narrow focus of mental health services for
adolescents (Knitzer, 1993; Knitzer, 19:82; Maloy, 1995). This lack of empirically-
based information about the utilization and outcomes of mental health services in
general creates a significant problem for policy makers and service providers. Most
important for this study, evidence concerning the effectiveness of alternative,
community-based mental health services, though promising, is based on limited data
(Rog, 1992).
Although more concentrated po
intervention for juvenile offenders is ap
the utilization patterns remains lacking.
icy and evaluation research in mental health
Dpearing, empirically based knowledge about
Researchers have identified some levels of
psychopathology among incarcerated youths, and family therapy and community-
based supervision programs have been evaluated (Maloy, 1995; Tolan et al., 1987;
Tolan et al., 1986; Barton & Butts, 1990), Aber & Reppucci (1987) spoke to the
including poorly designed and inconsistently
tion.
abundance of methodological problems
executed research in this type of evalua
ADM Service Utilization Theory
How do youths, especially those who have problems, come to utilize formal
care systems? Pescosolido, Gardner, &
Lubell (1998) gave us a very thorough
historical overview of theories of how such adult and family behavior have been
studied in the past. Sociological theorists have studied adult behavior from three
different perspectives. The first applied general medical utilization models
(Andersen, 1968; Andersen, 1995; Kohn R. & White, 1976; Hollingshead & Redlich,
1958). Exploration of factors that contribute to utilization of general health services
came into its own during the late 1960s. Notably, Ronald Andersen developed a
model to assist the understanding of why families use health services; to define and
measure equitable access to health care; and to assist in developing policies to
promote equitable access (This model will be described in more detail in Chapter 3).
16


It assumes that a sequence of conditions contributes to the volume of health services
an individual uses. Use is dependent on : (1) the predisposition of the individual to
use services; (2) the ability to secure services; and (3) the illness level.
The other influential medically-oriented theory was the Health Belief Model
that targeted health behavior or prevention (Rosenstock, 1966). Being conceived
within social psychology, it was further refined by Marshal Becker (1974,1983).
This model focuses on perceptions, beliefs, and other social psychological
characteristics that influence perception| of risk for problems, readiness to change
health behaviors, and the utilization of health care services. Individualistic, these
models were criticized for not address social influences and individual health beliefs.
Individuals are clearly seen as rational decision-makers with choice. Utilization
depends on individuals beliefs about ciire, their need for help, their access to
resources, and their subjective evaluation of outcomes.
The second perspective explores legal coercion as a means to services
(Monahan et al., 1996; Hiday V., 1992), This view focuses on legal holds and
court-ordered treatments that indicate m any individuals are pushed into care by
family, friends, and/or police or courts. Individuals have no control over what
happens to them. They enter treatment aot by their own volition. Two distinctions
have been made by researchers when de scribing coercive pathways: legal or hard
coercion (e.g., involuntary commitment) and extra-legal or soft coercion (e.g.,
pressures from family, government, and/or others to get and stay in treatment,
persuasion to sign oneself into treatment)(Gardner et al., 1993; Monahan et al., 1996;
Estroff, 1981). These dominant models were static and criticized for noninclusion of
process-oriented explanations.
The third view makes no assumption about how individuals come into care
systems. These theories focus on the dy namic processes underlying use, especially,
the mode of entry into services (Pescosc lido, 1992; Pescosolido et al., 1998).
Pescolsolidos Network-Episode Model (NEM) examines the importance of social
influence on when, how, and if care is received. Utilization can be both an active,
rational choice like the medical utilization models, or a decision taken from the
individual similar to the coercion perspectives. This model does not negate either the
role of the individual or other correlates or contingencies of service use. Rather, it
allows a difference between how individ uals perceive and report what they do when
faced with need and what they then actually did. It incorporates a community social
network approach to the process of utilization. It believes that only by exploring both
the influential individual factors and the dynamic processes can we adequately
understand utilization and its outcomes. The NEM is primarily centered around
illness career and the process of entering treatment and allows for system entry to
take many forms, including choice, coer
:ion, and muddling through. Thus, this
view does not replace concern for how different contingencies like predisposing,
17


enabling, and need factors affect service use, but rather provides a bridge between
illness and multifactor correlate models.
Critics have found the NEM model complex and very difficult to measure
which placed health psychologys Theory of Reasoned Action in the foreground of
explanatory models (Weinstein, 1993; Pescosolido et al., 1998). This model returns
to the emphasis on individual, rational decision-making, rather than community
influences. The above overview of theory and research models suggests that we must
consider all the various ways individuals come into care. Social networks,
community-based influences, and the impact of individual factors that shape all
modes of entry are important and should be included in utilization research.
Adolescent ADM Services Research
Adolescent ADM services resezrch is a relatively new field, but one that is
gaining increased attention and significance (Pumariega & Glover, 1998). It
involves the access, utilization, financing, and clinical- and cost-effectiveness of
services provided to adolescents, as we il as the functioning and effectiveness of
ADM, health, and social service systems of care. Two important trends have led to
the increased importance of this field. 7irst, there has been an increase in utilization
and demonstrated need, and second inceasingly limited resources are available to
address the need. These changes increese pressures on providers and systems of care
to demonstrate improved clinical and cost-effectiveness so as not to face lose of
funds. Evaluation of services systems typically focused on service use, costs, and
client outcomes (Lambert et al., 1998). There are no currently widely accepted
measures to describe utilization patterns of children and adolescents (Padgett et al.,
1992). Published studies address quality (evaluation), quantity of services, and
quantity vs. need.
General Population
We know little about the use of ADM services by adolescents with psychiatric
disorders (Leaf et al., 1996). What we do know is that adolescents need different
services and modalities than adults; that) most children in need of alcohol, drug,
and/or mental health care do not receive it; that those who are receiving care are often
receiving inappropriate or inadequate cere; and, more recently, that there is a lack of
coordination across systems to meet the needs (Koyanagi, 1995). Even more than
adults, adolescents receive mental health and substance abuse services in a variety of
settings and from numerous professionals (Regier et al., 1993). Bums (1991)
18


examined use of mental health services
by adolescents between 1975 and 1986 by
levels of care. She found that major increases of utilization occurred during this time
period for all levels of care. Her clinical and treatment variables proved only
moderately helpful in differentiating levels of care.
From its earliest origins, ADM services for youths emphasized a community
orientation (child guidance clinics mentioned earlier). The publication of Unclaimed
Children initiated the modem era of community-based systems of care (Knitzer,
1982). This groundbreaking book exposed the consequences of neglecting
community-based mental health services for youths and their families. Through this
and other advocacy, the Child and Adolescent Service System program (CASSP)
began. The conceptual work of Stroul and Friedman (1986), who coined the phrase
community-based system of care for seriously emotionally disturbed children and
advocated interagency coordination among all of the service agencies supported the
CASSP initiative. They promoted services as close to the youths home and
community as possible to avert the use of more restrictive levels of care (Pumariega
& Glover, 1998). I
Research methodology emerged
community-based approaches to delivery
population-survey approaches using rein
to support the systems-of-care and
It involved the use of systematic
able and valid instruments that are acceptable
and appropriate for the study population. These very recent advances influenced the
development of mental health epidemio
utilization (Stroul & Freidman, 1986).
One of the CASSP projects, The
care model for delivering mental health
ogical research that included surveys of
Fort Bragg Evaluation Project (FBEP),
utilized a quasi-experimental design to evaluate a demonstration of a continuum-of-
services to children and their families
(Lambert et al., 1998). The aim of the study was to identify multivariate descriptions
of mental health service utilization. The
wave of the FBEP (i.e. within 30 days o
provider). This study adopted a pattern
clinical data were collected during the first
f the child entering treatment with a current
of-care perspective which recognizes that
services tend to be longitudinal, interrelated, and multidimensional. Utilizing cluster
analytic techniques, the study identified
brief outpatient; (b) extended outpatient
six patterns of child services utilization: (a)
(c) hospital with outpatient; (d) non-
residential more-than-outpatient; (e) extended residential; and (f) atypical heavy-
service outliers. Not surprisingly, children in high-cost clusters had above-average
clinical severity. Children identified in a care that was on-going used three patterns
(b, d, and e) more often. Those served through a traditional fee-for- service system
used two clusters (a and c) more often.
Studies indicate that only 16 to 29.0 % of mainstream youths who meet
criteria for current mental health disorders receive care (Anderson & Harthom, 1989).
Zimmer-Gembeck, Alexander, & Nystrq:
m (1997) found in their analysis of the Youth
19


Risk Behavior Surveliance Survey that male adolescents more likely to have received
care for drug/alcohol problems, while female were more likely to receive care for
personal/emotional disorder. Stiffman et al. (1997) reported in their study of 792
youths from juvenile justice, education, primary health care, and child welfare
sectors, that a high percent of youths (12-15%) met DSM-IV criteria for disorder, yet
the sector clients were not identified asj having disorder. Juvenile justice and child
welfare identified the highest percentage of youths with need, and provided the most
services, while primary care recorded ijo disorders and provided the least services.
As part of the recent Methods for the Epidemiology of Child and Adolescent
Mental Disorders Study (MECA) (Lahey et al., 1996), Leaf et al. found that one
quarter of the youths studied had some reported mental health service contact, with
36.5 percent of those meeting criteria for a psychiatric disorder reporting a mental
health service (Leaf et al., 1996). In one community, as many as a third of the youths
with a psychiatric disorder and significant impairment received services from a
mental health specialist.
The authors found mental health service utilization was related to the
existence of a mental health disorder or! need. However, interestingly, they found that
impairment had an independent effect ojn the use of mental health services that
warranted further investigation. Dysfunction in children and adolescents may
precipitate the seeking of help regardless of the perceived cause of these problems,
and help-seeking may relate to emotionlal distress, rather than to a specific
diagnosable psychiatric disorder. This p aper highlighted the roles played by
educational, social service, and juvenile justice agencies in the detection and
treatment of youths with emotional dist irbances. These studies based on pilot data for
a larger scale uncompleted child epidemiological study, documented the need for
services by youths. They did not, however, adequately explore additional factors that
mediate the process of utilization. As the variety of treatment alternatives increases,
understanding the actual patterns of utilization as well as the factors the influence
utilization will become increasingly important (Lambert et al., 1998).
American Indian Adolescents
Utilization becomes more comp!
illness and health are added. Services re
icated when culturally distinct perspectives of
search literature on minority youths continues
to be sparse. It initially focused on documenting racial differences in services
provided (Pumariega & Glover, 1998). Studies have also been limited to one service
area and not across ranges of services. Researchers suggest that ethnic minority
fic Islander, African American, and Hispanic
non-mainstream views of illness, etiology,
(American Indian, Asian American/Paci
American) individuals and families have
20


help seeking, help providers, relevant providers, and appropriate treatments
(Pumariega & Glover, 1998; Mason et al., 1996; Sue & Sue, 1990; Swinomish Tribal
Mental Health Project, 1991). Each group has its own set of beliefs or world views.
Therefore, there are hundreds of belief and value systems held by minorities that are
different from each other and mainstreams. These beliefs greatly influence health
care behavior.
Minority youth experience higher levels of stressors, such as poverty,
discrimination, acculturation stress, and exposure to violence and trauma associated
with their minority status (Pumariega & Glover, 1998; US Congress, 1990; Denver
Post Wire Service, 1999). Minority adolescents receive help from different types of
providers than do their mainstream counterparts (Hoberman, 1992). They tend to not
use formalized mainstream settings. Scjme studies suggest different service use
patterns reflect programmatic biases; others argue cultural belief differences (Alegria
et al., 1991; Rogler & Cortes, 1993; Wallen, 1992).
A handful of studies speak to mental health service utilization among Indian
youths. The Great Smoky Mountains Study examined prevalence of psychiatric
disorders and service utilization among! Cherokee and non-Indian youths in western
North Carolina (Costello et al., 1997). Rates of overall service use were slightly, but
not significantly, lower for American Indian youths than for White youths. It was
found that one in seven Cherokee children with a diagnosable DSM-III-R mental
disorder received treatment, comparable to one in eight of white children. Looking at
insurance status, the researchers found that rates of service use were lower for Indian
than for White youths with public insurance. One Indian child in seven had seen a
mental health care professional compared to one in four White youths with a disorder
and public insurance. Cherokee children were more likely to receive this treatment
through the juvenile justice system than were the non-Indian children despite the fact
that basic mental health services were available to the children through Indian Health
Service (IHS). This study was based on only one wave of data collection so the
direction of any causality remains unclear.
Novins et al. (1996) examined factors associated with alcohol treatment
services of Indian school-based youths. While finding that increased age and males
significantly associated with treatment, they also discovered that students who access
treatment had fewer prosocial values ana more antisocial behavior than did students
who do not access treatment. The presence of an important adult with an alcohol or
drug problem was associated with service utilization. Recommendation for treatment
exhibited the strongest association with reported use. Receiving a recommendation
for treatment produced a fifteen-fold greater likelihood of receiving service compared
to those who did not receive a recommendation.
Describing the use of mental heallth treatment by an Indian adolescent
residential substance abuse treatment population, Novins et al. (1996) found females
21


were more likely than males to receive mental health treatment even though males
had at least equal need. The authors f aund no significant relationship between
measures of psychopathology and subsequent receipt of mental health treatment. A
more recent study looked at service utilization by school-based sample of American
Indian youths who were diagnosed with a psychiatric disorder (Novins et al.,
Submitted). The researchers found that only 39% of the diagnosed youths reported
some lifetime service use. The majority received services through school (68%); only
one adolescent received services from a mental health specialist. A majority (57.1%)
of diagnosed youths who did not receive services were recognized by an adult as
needing treatment. Youths with two or more ADM diagnoses reported the highest
rate of service utilization (50%), highest rate of recognizing a problem among non-
service users (60%), and lowest rate of unmet unrecognized need (20%). This was a
school-based study, thus users of non-school based services may be unrepresented in
this sample. The small sample size precluded statistical testing to evaluate the
relationships between psychiatric diagnostic groups and service use.
American Indian Detained Youths
As mentioned earlier, studies have shown culturally diverse youths to be
underrepresented in mental health service systems and overrepresented in child
welfare and juvenile justice settings anil placements (Pumariega & Glover, 1998).
Studies have also shown that even wheii the two groups are equally psychiatrically
impaired, African-American adolescents are more likely to be incarcerated and white
adolescents are likely to be hospitalized (Cohen et al., 1990; Pumariega & Glover,
1998). A large study in South Carolina! showed that 70% of incarcerated African-
Americans had higher levels of psychopathology than youths treated in community
treatment settings but had previously received lower levels of mental health services
(Pumariega et al., 1996).
Bias in diagnostic assessment was one explanation for the different patterns in
service utilization outcomes for minority youths (Pumariega & Glover, 1998). Mood
and anxiety disorders, as well as substance abuse were more often diagnosed in
Whites than African Americans. One tile other hand, African American adolescents
were more often diagnosed with conduct and disruptive disorders leading often to
involuntary institutionalization (Fabrega et al., 1993; Mezzich, 1990; Kilgus et al.,
1995). I
Only one study which provided the foundation for this dissertation, has
examined the utilization of ADM treatment services for Indian detained youths
(Novins et al., Submitted). Again, from
the IDAP dataset, we were able to show a
clear and substantial relationship between psychiatric diagnostic status and the use of
22


ADM services among the detained Northern Plains youths. As Table 2.2 shows
service use for substance use problems was significantly related to the presence of
both a substance use disorder and a dis ruptive behavior disorder. This is consistent
with our early findings of the patterns of psychiatric comorbidity of substance
abuse/dependence being found comorbid with disruptive behavior in this particular
sample (Duclos et al., 1998). The majority of youths in that report (62.5%) diagnosed
with a disruptive behavior disorder weie also diagnosed with a substance use
disorder.
Every psychiatric diagnostic category examined was significantly related to
service use for emotional problems. We also found that most service for substance
use problems was provided in residential settings, while most services for emotional
problems were most commonly provided in outpatient facilities. Youths receiving
services for substance abuse problems ieported using Indian traditional health
methods more commonly than a biomedically-oriented outpatient facility. Neither
this tribe nor the IHS operates inpatient
facilities specifically for substance abuse, so
youths who need treatment are sent to three different residential substance abuse
are available. This may explain the
facilities off the reservation where beds
discrepancy in utilization.
Service utilization was also related to psychiatric comorbidity. Youths
diagnosed with three or more psychiatric disorders including substance
abuse/dependence were significantly more likely than youths with one diagnosis to
report service use for emotional problems. Since the number of psychiatric diagnoses
is in part an indication of the severity of an individuals problems (Lewinsohn et al.,
1995; Kessler et al., 1994), it is primarily the most severely affected detainees who
receive treatment for emotional problems. Our findings also suggested that the
threshold for providing services for emo tional problems is higher than for substance
use problems. This result is consistent with the relative emphasis on substance abuse
treatment in Indian Country (US Congress, 1990). While comorbidity was common
in the IDAP sample (49.1% of youths with a substance use disorder and 63.6% of
youths with a mental disorder), very few youths (6.7%) reported receiving services
for both emotional and substance use problems.
23


Table 2.2. The Relationship Between Psychiatric Diagnostic Status and Service Use Among American Indian
Adolescent Detainees
Six Month Detainee Service Use
Prevalence
rt % Substance Use Problems Emotional Problems
%b ORc 95% cF %b OR0 95% Cld
All Participants 150 - 25.3 - - - 18.0 - - -
Diagnostic Categories Any Disorder 73 48.7 38.4 4.17 1.85, 9.42*** 28.8 4.78 1.80, 12.67**
Anxiety/Depressive Disorder 23 15.3 39.1 2.17 0.85, 16.80*** 47.8 6.36 2.51, 16.80***
Disruptive Disorder 32 21.3 50.0 4.36 1.90, 8.21** 34.4 3.34 1.36, 8.21**
Substance Use Disorder 57 38.0 40.4 3.52 1.64, 5.62* 26.3 2.41 1.03, 5.62*
Number of Diagnoses
None 77 51.3 13.0 0.29 0.11, 0.73* 7.8 0.26 0.09, 0.78*
One Disorder' 41 27.3 34.1 1.00 - - 24.4 1.00 - -
Two Disorders 19 12.7 31.6 0.89 0.28, 2.42 15.8 0.58 0.14, 2.42
Three or More Disorders 13 8.7 61.5 3.09 0.85, 18.67* 61.5 4.96 1.32 18.67*
-Column Percent
b-Row Percent
c- Odds ratios report the relative odds of service use among the youths included within a particular diagnostic category compared to youths not included in
that category. When examing the relationship between number of diagnoses and service use, the OR report the relative odds of service use among youths
with one, two, and three or more disorders to youths with one disorder.
d-95% Confidence Intervals
-Reference group for contrasting respondents based on the number of diagnoses
*p<.05, **p<.01, ***/K.001
Adapted from (Novins et al., Submitted)


Analyses of offender status by service use provides insight into how the
detention center and courts function within the communitys ADM service system.
Repeat offenders compared to first time offenders were more likely to report ADM
service use for substance abuse problems but not for emotional problems. While
45% of the repeat offenders who received treatment for substance use problems
were court-ordered into treatment (%2=k.63,1 df, p{FET} < .05 based in the Fishers
Exact Test), only 8.7% of the repeat offenders who received treatment for emotional
problems were court-ordered into treatjnent (x2=0.14,1 df, p{FET> =.75). Court
orders appeared to be the key factor leading to treatment for substance use
problems. This finding suggests more jsensitivity to these types of problems than to
emotional problems. Table 2.3 shows a comparison with community-based youths.
The detained adolescents were more likely to use ADM services, consistent with a
higher prevalence of psychiatric disorders and greater involvement in court referral
for treatment.
Table 23.
Comparison cf Service Ut
lization Between Indian Adolescent Detainees
and Indian Youths at Large in Another Northern Plains Community
Service Use Contrast
Detainees'"
Comparison
< /oa served %a served x2 df
All Participants DIAGNOSTIC CATEGORIES 36.7 22.9 5.58* 1
Any Disorder 57.5 39.1 2.28 1
Anxiety/Depressive Disorder 65.2 44.4 l.ie^ 1
Disruptive Disorder 71.9 33.3 6.30* 1
Substance Use Disorder NUMBER OF DIAGNOSES 56.1 45.0 0.74 1
None 16.9 18.6 0.08 1
One Disorder 51.2 30.8 1.66 1
Two Disorders 47.4 66.7 0.39(fet) 1
Three or More Disorders 92.3 42.9 5_93*(fet) 1
-Column Percent
b- Substance use problems, emotional problems, or both
^^-Fishers Exact Test
*/K.05, **p< .01, *** p<.001
Adapted from (Novins et al., Submitted)
25


While the results of this study [provide an important first look at the cross-
sectional associations of ADM service; use by need among a detained Indian
adolescent sample, they do not adequately describe the relationship between multiple
factors including need that predicts ADM service use, nor do they assess whether
these multiple factors might be different for different types of services- thus this
dissertation study.
Factors Related to Service Utilization
The review of the relevant general adolescent literature concerning factors
related to mental health service utilization is organized with guidance from the
Behavioral Model of Health Services Utilization that was cited earlier in this Chapter
(Andersen, 1968,1995; Andersen & Newman, 1973. The factors are categorized into
three subtypes or factors: predisposing!, enabling, and need. This theoretical
framework will be utilized later in the quantitative methodology and analysis study of
this dissertation.
Factors That Influence Adult ADM Service Utilization
The vast majority of the literature has reported on the adult service experience
for psychopathology. Howard et al. (1996) reported the most recent study of adult
factors that influence mental health service utilization. They reviewed the findings of
the (1) Epidemiological Catchment Area (ECA) Program and (2) the National
Comorbidity Survey (NCS). Results showed that persons with major depression
(needfactor) were the most likely to receive services, while those suffering from
substance abuse disorders the least likely. Social networks or social support
(predisposing factor) proved highly positively correlated with service utilization.
Higher educational levels and income (enabling factors) were significantly associated
with more service use.
Leaf et al (1988) studied factors associated with adult specialty (mental health
and/or substance abuse) and general medical health services. Using the ECA dataset,
they focused their analyses on the Andersen and Newman model. All indicators of
need were significantly associated with service contacts. However, it was reported
that the vast majority of individuals in need did not receive care. Of predisposing
factors examined, age, marital status, being receptive to mental health services, and
unacceptability of general practitioners or clergy as mental health providers were
significantly associated with mental health specialty visits. Gender was the only
predisposing factor associated with contacting a general medical provider. The only
26


enabling factor significantly associated with mental health visits was perceived family
resistance. Income and usual source o:
utilization. When controlling for need
significance. Thus, need again remain
care were enablers for general medical
all predisposing and enabling factors lost
sd the strongest predictor of utilization.
Burke (1995) found in his review of the literature that the individual
characteristics associated with using ipental health services included being white,
The study controlled carefully for diagnostic
status. This study provided important confirmation that being young or old,
nonwhite, and male decrease the likelihood that people with mental disorder will
receive treatment for their disorders.
Factors that Influence Adolescent ADM Service Utilization
Leaf et al. (1996), evaluating instrumentation for the National Institute of
Mental Health Methods for the Epidemiology of Child and Adolescent mental
Disorders (MECA) Study, found that the majority of children meeting criteria for a
disorder based on DSM-III-R criteria reported some mental health-related service use
in the previous year. Although, in two of the four sites, fewer than 25% of these
youths were seen in the mental health sector. Results also identified the importance
of schools in the provision of services and the independent effects of symptomatology
and dysfunction on the use of services. This study had specific goals to evaluate the
community survey methodology for assessing service utilization. While the results
show great promise for this methodology, test-retest reliability of the questions
related to service use were not evaluated. Also, service use was defined as a contact
with a mental health professional or other provider related to a mental health,
behavioral or substance abuse problem. Some of the contacts included treatment
(e.g., a provider could have referred, and school-based services might have delivered
only testing or even punishment). Even with the limited scope of the research and its
limitations, this report emphasized strongly that greater attention in supportive
resources needs to be paid to the many jlifferent professionals who play a critical
roles for youths in identifying problems including educational, social services, and
juvenile justice agencies.
Zahner & Daskalakis (1997) more recently analyzed the data sets from two
cross-sectional Connecticut surveys of the late 1980s to identify factors associated
with mental health, general health, and school-based services. Though their sample
includes 2519 children, 6 to 11 years of
findings seems appropriate. This study
age, not adolescents, mention of their
is one of a very few recent investigations that
employed population survey data. The researchers examined three groups of variables
(socio-demographics, parental attitudes [predisposingfactors], and childs illness
27


profile [need factor]) through multivariate logistic regression. Most
sociodemographics showed moderate positive associations with all settings. The
family stressors measure was the only jfactor associated with mental health service use
when the childs illness and parental attitudinal measures were controlled in the
analysis. The researchers found elevated service use for boys relative to girls and for
single-parent relative to two partner households. They did find lower use of services
by Black and Hispanic minority groups even when controlled for socioeconomic
status. Most illness profile variables wjere significant with increased use across all
settings including mental health. Also significant were maternal distress and
perceived service need. Propensity to seek care and provider preferences were related
to use of mental health services. Parental belief that the child needed help was most
strongly associated with all service usd
Several limitations of this studyj include findings of extensive use of school-
based services, which likely reflected the age range of the study sample. Different
patterns of services and associated factors might be found in older children. The
study also relied on a single informant, the childs parent which might have biases
some findings. The study did not examine enabling factors such as insurance, which
may have determined the use of school-based free services vs. the use of mental
health services that charge fees. Finally need (psychiatric disorder) was not assessed
using the criteria of the American Psychiatric Association (1994). This report did
confirm Leaf et al.s (1996) findings that settings other than mental health services
are widely used for treatment of emotional and behavioral problems in school-aged
children. Utilization of these settings is influenced by a number of sociocultural and
illness factors that have previously been examined only for traditional mental health
settings.
Appendix A provides tables that summarize other studies I reviewed for
factors influencing adolescent or child ADM service utilization by type of
determinant or factor. This review found age, gender, family stress, parent
perceived need, increased number of barriers, place of residence (urban vs. rural),
self efficacy, race, mother's perception^ of need, and social support as important
predisposing factors for youths seeking help and/or using ADM services. Some
gender discrepancies are found between studies results that suggest the need for
further exploration. The majority of the studies examined school-based samples and
usually employed survey design.
Enabling factors that have been studied and appear influential arefamiliarity
with someone that has already sought help, recommendation, and socio-economic
status (SES). Again, discrepancies with SES factors need further exploration. Except
for the impact of SES, enabling influences seemed to be rarely studied. More
research would help clarify other significant enabling factors that might be more
easily amenable to intervention.
28


The studies of needfactors point to the obvious, that more symptoms of
distress and, one would surmise, impairment will lead to more help-seeking and
contact with service providers. All the: literature that examined need agreed that need
is the most important predictor of service utilization. Externalizing behavior that are
displayed outward (e.g., conduct disorder, etc.) seem also to increase the likelihood
of receipt of appropriate services, while more internalizing disorders that are
displayed more inward (e.g., depression, etc.) decrease this likelihood.
The burden of mental disorder^ in the population is a large one. All the
literature reviewed shows that access is uneven; that the general medical system is
important in providing care, that discrepancies exist in current research as to factors
that interplay with utilization patterns;
such as jails/detention centers come in
and that non-medical providers and institutions
contact with large populations with need for
service, and could possibly play a large part in actual delivery of service. However,
we know little about the pathways and processes for minority youths through the
various components of service sectors ihe interactions between sectors, and resultant
outcomes.
The juvenile justice system holds a unique position in mental health service
delivery (Maloy, 1995). Juvenile courts continue to be the repository of children and
adolescents with a wide variety of needs. Troubled youths and their families who
come to the attention of the state are usjually served by one of three systems: child
welfare, mental health, or juvenile justice (Maloy, 1995; National Conference of State
Legislatures Health and Mental Health [Program, 1989). The children served by these
three systems are remarkably alike, with similar characteristics and service needs:
high need, high-risk juvenile offenders, with substance abuse problems, dysfunctional
home environments, histories of abuse ;md neglect, and serious learning problems
(Towberman, 1992). As a result, juvenile courts often function as the catalysts for
access to services for troubled children and families. The courts are not the only
avenue for adolescents access to needed services, but courts have clearly been a
vehicle to allocate limited public resources to youths most at risk and most in need of
services. Children living in poverty, stressful socioeconomic environments, and
abusive families are likely to be most alj risk for emotional disorders and most in need
of mental health services (Knitzer, 1993j). These are situations in which the juvenile
justice system will most likely intervene, due to either custody issues associated with
dependent, neglected children or juvenil e delinquency issues associated with
emotional acting out.
In most states, juvenile judges have the jurisdictional authority and legal
responsibility to order and enforce the provision of services necessary to ensure stable
and therapeutic environments for youths (Hardin, 1992). Consequently, juvenile
courts are frequently in the position of determining as well as ensuring access to the
services that will allow a child to return to his or her family, be diverted from an
29


institutional setting, or receive care that he or she would not otherwise receive.
However, we, as society, still do not recognize or support the importance of this
system in mental health delivery for prevention, assessment, and treatment.
Interagency coordination becomes critical for a more community-based model
of prevention or intervention. Integrated comprehensive services are hindered by the
lack of knowledge of the services actually provided by multiple agencies such as
social service, medical services, cultural programs, juvenile justice, schools,
churches, and special education programs (Bums & Friedman, 1990). Literature
reviewed above cited that youths with mental health problems present themselves to
these programs more often than in the mental health system.
A new paradigm is emerging for children and adolescent mental health. The
focus of service is shifting from the traditional approach of treating children in
institutional environments, away from|family and without the involvement of other
systems, to an approach emphasizing individualized, family-based services delivered
by a broadly defined, community-based system of care with enhanced cultural
sensitivities (Knitzer, 1993; Maloy, 1995; Blau & Brumer, 1996; Stroul & Freidman,
1986).
In summary, while we know very little about factors that affect American
Indian adolescent service utilization patterns prior and subsequent to incarceration,
the literature does suggest that cultural! community, psychological, social, and
institutional factors are all crucial to this understanding. Broad systems are required
to ensure that care and treatment are available to meet the actual needs of American
Indian youths who have behavioral projblems. This calls for a fundamental change in
the policy and planning of current service delivery which includes the juvenile justice
system. The research reported here stujdies, for the first time, factors and contextual
issues surrounding adolescent and community conceptions and perceptions of mental
health/substance abuse service and juvenile detention use practices. Many tribes and
the Bureau of Indian Affairs (BIA) are involved in detention planning. Results of this
study will provide important building blocks in efforts to improve the interface
between mental health/substance abuse services and the criminal justice system. In
fact, coordination of criminal justice and substance abuse/mental health services has
been identified as a national priority (SAMHSA, 1993). Comprehensive intervention
strategy tailored to community issues and resources has been cited to be best
implemented and coordinated at the community level (Blau & Brumer, 1996). Basic
information about the community, role of the detention, and correlates of troubled
youth help-seeking behavior provided tjy this study will support community planning
and implementation efforts.
30


CHAPTER 3
ATIVE ANALYSIS
QUANTIT.
I remember back in my courtroom, there was one girl that was
requesting, Please, keep me in the JDC (juvenile detention
center). Dont send me home.
(judge respondent)
General Framework
To address the complex questions of community, family, culture,
delinquency, disorder, and service experience, this study incorporated a combination
of both quantitative and qualitative me
delinquency, mental problems, and sul
socially shaped behavior. Quantitative
ithods. It rested upon assumptions that
sequent help seeking are culturally and
methods illuminated potential relationships
through correlation and regression analysis based on surveys; focus groups and in-
depth interviews qualitatively interpreted social context (Shi, 1997). This chapter
describes the quantitative methods and results of a secondary data analysis that
identified factors that predict lifetime ^lDM service utilization for a sample of
Northern Plains adolescents detained in a reservation-based detention facility. This
analysis also pinpointed factors that influence various types of service utilization.
The analysis addressed part one of the overall studys specific aims:
To investigate, retrospectively, sett-report factors related to the use of
alcohol, drug, and mental health services (ADM) for a sample of detained
Indian youths on a Northern Plains reservation and differentiate these
factors by types of services.
This dissertation study built upon a parent study, the Indian Detainee
Adolescent Project (IDAP), which I directed during my tenure with the National
Center for American Indian and Alaska Native Mental Health Research
(NCAIANMHR), University of Colorado Health Sciences Center.
31


Methods
Quantitative Study Design
Using Andersens Behavioral Model of Health Services Use (BMHSU;
1995) as the theoretical foundation, I examined the IDAP dataset for predisposing,
enabling, and need factors potentially associated with lifetime ADM service (mental
health and/or substance-related), as well as types of services (formal, informal, and
culturally traditional). This secondary
logistic regression methods.
data analysis utilized correlational and
The Expanded Behavioral Model of Health Services Use
Due to the lack of a more cultui-ally- and adolescent-specific framework, I
chose BMHSU to provide the conceptual basis for the examination of factors
influencing health service utilization patterns by these Indian incarcerated youths
(Andersen, 1995; see Figure 3.1). Andersen (1968) presented the original model in
his study of equity of access to health services. It lumps together social-
psychological and socio-cultural characteristics, as well as basic socio-
demographics into a category of predisposing factors. They emphasized two
additional categories: 1) the enabling factors for access to care and 2) the actual
need for care. Andersen (1995) commented, This model suggests an explanatory
process or causal ordering. This model proceeded through three additional
iterations that expanded the model to include the influence of the health care system,
health practices, outcomes, and complex causal relationships reflecting policy and
researcher concerns (Pescosolido & Kronenfeld, 1995; Aday, 1993). The current
iterations purpose is to discover conditions that either facilitate or impede
utilization. Andersen felt that the while! the model remains primarily one of use of
services, he acknowledges the external mvironment as an important input to the
study population characteristics. However, he did not expand his inquiry or
explanation beyond this statement (see figure 3.1).
I tested the portion of the model that assesses how predisposing, enabling,
and need factors actually predict (ADMj) service use. Wolinsky, Cole et al. (1983)
argued that the range of variables and differing levels of analyses make analyses
very difficult (Wolinsky et al., 1983). I, however, felt that this model provided a
useful mechanism in my first step for deconstructing important components of the
32


current health care delivery system, as well as the individual psycho-social
indicators and predictors of use. I subsequently addressed other areas of the model
with qualitative interviews and focus groups (see Chapter 4). Because Andersen
generated their model in a dominant society adult population, it may not adequately
describe this specific age and cultural group. It is, however, the best model
currently available for testing. This ini tial framework once tested will aid in the
future development of a more culturally- and age- appropriate service utilization
SOCIAL
STRUCTURES
CHARACTERISTICS
HEALTH
BEHAVIOR
OUTCOMES
T
Healthcare
System
External
Environment
Predisposing ^ Enabling Need
Characteristics Resources
model.
Health Perceived
Practices Health Statu* I
1 Evaluated
Health Status
Us< i of |
Health Consumer
Services 1 Satisfaction 'i t
Figure 3.1. Adaptedfrom The Behavio
1995)
ral Model of Health Service Use (Andersen,
33


The delivery system component of the
processes that potentially render care
The unit of analysis here is usually the
The effect of health policy on altering the utilization of and access to
medical care is what health policy mak ers and administrators often wish to evaluate.
: model refers to those structures and
It includes both availability and organization,
community, rather than the individual. Thus,
this part of the model was not explored in the quantitative analyses but examined in
the qualitative analyses and interpretations.
ljaracteristics of this adolescent risk group: the
Donents. Predisposing variables include those
My primary interests are the ch
predisposing, enabling, and need comp
that describe the propensity of individials to use services including basic
demographic characteristics (e.g., age, gender, ethnicity, education, employment
status), and beliefs (e.g, general beliefs and attitudes about the value of health
services). The enabling component describes the means individuals have available
to use and gain access to services. It includes both available resources and attributes
of the community or region in which an individual lives (e.g., place of residence,
insurance coverage). Need refers to health status or illness, which is the most
immediate and important cause of help seeking (Andersen, 1995).
Andersen termed characteristics that are biological or social givens, such
as age, gender, ethnicity, and place of residence immutable. Health policy cannot
directly alter these attributes, but they help to define the population of interest.
Other characteristics such as beliefs ana certain enabling variables can be
manipulated. These variables then are mutable or alterable by health policy.
In my use of this expanded framework, the principal outcomes of interest are
the measures of lifetime ADM services utilization for substance abuse and
emotional problems, and the types of formal, informal, or culturally traditional
services. What are the factors that influence these outcomes? Are these factors
mutable or immutable by community policy changes? Is this theoretical model an
appropriate model for youth studies?
Study Population
Setting. In Indian communities! protection of the confidentiality of the tribes
is considered as important as that of the individual participants (Norton & Manson,
1996). Therefore, in reports of the parent study and this dissertation, the community
is described simply as a Northern Plains reservation community with a landscape of
gently rolling range covered with prairie grass. It is a land of long, hard winters and
hot, dry summers. It is also a land of deep spirituality. Multi-million acres of land
base includes many small towns. The reservations economic livelihood comes
from cattle ranching; income from leased lands; and employment from the tribe,
34


Indian Health Service (IHS), and Bureau of Indian Affairs (BIA). This community
has a high unemployment rate (roughly 80%) and low individual annual per capita
income (65% of all families live on less than $3,000/year) (O'Brien, 1989).
Approximately 10% of the population lack complete plumbing facilities, and
approximately 50% are without telephone in their home.
The reservation is governed by the Tribal Council which is constitutionally
empowered to enter into negotiations with federal, state, and local governments on
the tribes behalf; to protect tribal land and political rights; to appoint tribal
officials, boards, and organizations; to evict nonmenbers whose presence maybe
injurious to the tribe; to administer the tribal budget; to regulate property and to pass
lawas and establish courts for the administration of justice. Appointed by the
Chairman, committees oversee the woik of various tribal programs and make
recommendations to the council about problems and goals. Council representatives
report directly to their district councils. It continues its ongoing efforts to improve
the tribes economic status by trying to attract with varying success local businesses
and to attract labor-intensive and light industrial factories. Thirty-nine percent of
the population is under the age of twenty. Currently the community perceives a
gang problem within the adolescents whose activities are escalating in dangemess
and violence. When the parent study was done, 32 gangs were identified by the
youths in their survey response. It now seems that these gangs are re-organizing
into fewer more powerful forces.
The long history of cultural oppression of American Indians has been well
documented (Swinomish Tribal Mental Health Project, 1991). It includes genocide,
prohibition of native ceremonies or ways of life, a boarding school system that
destroyed language and extended family structures, a relocation program that
separated families and communities, and the adoption of children by non-Indian
families. All of these traumatic events caused negative consequences including
disruption of family structures; lack of iunctional parenting skills; alcohol and
substance abuse; loss of language and traditions; and violence in many forms
including confrontations between families, assaults between community members of
all ages, and suicide or attempted suicic e.
Service System Description. With all of the stresses placed on the
community and the unresolved histories! and ongoing trauma, the need for mental
health and substance abuse services for youths and their families is tremendous.
Unfortunately, resources were and still are inadequate and typical of other
reservation settings. IHS budgets permi t only two mental health service providers
per 10,000 youths and adolescents (US Congress, 1990). While there are additional
programs available through the state sys tem, many of these services lack cultural
competence and sensitivity, and most programs require youths and adolescents to be
35


sent off the reservation far from home, In addition, no funding supports families or
programs for use of traditional healers or community-based counseling by elders.
At the time of the parent study, the local service ecology for ADM problems
were school-based, outpatient, inpatient, and residential services. School-based
services were self-help groups and counseling. Federal services comprised BIA
special education and social services. Tribal services were child protection services,
mental health, substance abuse, and a youth and family rehabilitation center.
Private and/or nonprofit agencies provided an adolescent shelter and mental health
consultation services. Adolescents could also be referred off-reservation to three
different residential substance abuse treatment facilities. Complementary forms of
care included a rich variety of traditional healing options as well as pastoral
counseling. The juvenile detention facility, the newest addition to this service
system, opened 6 months prior to the commencement of the parent study. A single
judge adjudicated all the youths intersecting with the juvenile justice system. One
full-time nurse from IHS served both ttie juvenile and adult jails. Services lacked
coordination. Heavy caseloads and a shortage of adequate staff put stress on the
system.
IDAP Sample. Many studies ojf adult ADM service use assessed subjects
who had successfully negotiated formal systems of services, and thus were
conveniently available for sampling. Most emotionally disturbed youths, however,
do not, which led to my interest in adolescents who intersect with criminal justice
services. Subjects were recruited at a juvenile detention facility on this reservation
from mid-July 1995 through mid-April 1996 (Duclos, Beals, et al., 1998). One
hundred and fifty youths admitted consecutively completed lay-administered
interviews and self-report surveys. During this time period there were 454 official
bookings4 of 226 individuals into the detention facility (see Figure 3.2).
4 Booking is the official term that describes
arresting officer turns the proposed offender ovi
screenings are usually done at this time.
the
detention intake process. It is at this time that the
er to detention staff. All paperwork and initial
36


454 Hookings
226 Uniq ^Individuals
l
Ineligible f43. 19%1
< age of 12(12, 28%)
nonlndian ( 1, 2.3%)
hold other (12,28%)
nonlocate (16,37%)
other ( 2, 5%)
(1
Eligibles H83, 81%^
Participants
50, 82%)
Non-participants
(33, 18%)
Figure 3.2. IDAP Sampling: Non-Indian are those who do not identify
themselves as American Indian; hold other notes those holds for other
jurisdictions; and non-locate are those adolescents who we could not locate for
interviews.
Approximately 50% of the group constituted repeat bookings. Twelve
percent were excluded by protocol: youths younger than 12 (=13; children 11 years
and younger are less reliable in reporting psychiatric symptoms than older youths
(Edelbrock et al., 1985; Schwab-Stone et al., 1994; Schwab-Stone et al., 1996), non-
Indians (=2), and holds for other jurisdiction (n= 12). Eighty-eight percent
(n=199) were eligible to participate. Of those eligible, 150 adolescents agreed to the
interview, yielding a response rate of 82%. Comparisons between participants and
nonparticipants found no significant differences in gender and charges or the reason
for containment.
IDAP Data Collection Procedures
Two local lay-interviewers admi:
informants (parents were not interviewi
nistered the interview and survey to youth
ed). Formal training of interviewers took
37


place over a 2-week period. The first week involved structured interviewing
concepts, consent/assesst procedures, interviewing techniques, and instructions on
how to comply with the IDAP protocol. During the second week, interviewers
completed audiotaped test interviews. These interviews were reviewed to determine
competency. Interviewers were required to obtain an error rate of less than 5%
before beginning the study (errors included not asking the question appropriately or
noting something different than response given, etc.).
A strict consent protocol was fallowed. Participation of a youth identified as
a ward of the court required a consent from a tribally assigned court advocate and
the juvenile court judge. For other youths, parent or legal guardian consent
preceded adolescent assent. The refus il rate by adolescents or parents was 18%
(n=33).
Depending on the duration of the assent/consent and location process,
respondents completed interviews either within the detention facility or within the
community after release. The very namire of a large reservation setting with many
outlying communities, winter and spring weather conditions that hampered travel,
the transient nature of the youths (many of whom moved from house to house or off
and on the reservation), and numerous households without telephones often made
the location of parents and youths problematic. Yet, the location rate was 92%
(h=183). Fifty-six percent of the final sample completed interviews within 30 days
of booking, with a median of 5.5 days from intake to interview. The remaining
youths took longer than 30 days to interview; the median number of days for these
youths was 97. Place of interview was not coded, so we could not ascertain
differences between those interviews taking place in the detention facility and those
out in the community. For quality control of interviews, project staff from Denver
reviewed a random sample (10%) of ths actual study interviews tapes.
IDAP Measures
Measures included in these analyses came directly from the IDAP interview
and survey data. The IDAP interview aind survey were developed in the first year of
that project. A group of Denver Indian youths pilot tested it, and we refined it
before implementation. The following subsections describe the variables included
in these analyses. The description of measurement scales include a measure of
internal consistency, Cronbachs a, whire appropriate.
Outcome (Dependent) Variables. Lifetime use of ADM services distinguished
between those who had used a service for an emotional or substance use problem
and those who had not. If a youth responded yes to either of the following
questions, a variable (specever) was coded 1, if not, 0. A preliminary review of the
38


data indicated that fifty-five of youths (36.7%) out of the total sample of ISO
reported use of services for emotional and/or substance abuse problems. Three
dichotomous outcome variables (0 = no use of service, 1= use of service) measured
lifetime use of formal, informal, and culturally traditional ADM services.
Responses to die following questions provided the data. These questions were
asked for each yes response above. To protect confidentiality of the tribe, I have not
identified the specific services.
Turn back to page IS of the Respondent Booklet, and look at the list of various
places people go to get help with problems. Have you ever gone to any of these
places or anywhere else to get help, such as counseling, treatment or self-help
groups, for emotional or personal problems, not due to alcohol or drugs? Emotion
problems include feeling sad, irritable, anxious, or any other feelings that upset you.
Personal problems include problems with family or friends, being angry, fighting,
getting into trouble, or losing your temper.
No.........0 (Skip to #18, page 147)
Yes........1
On page 15 of the Respondent Booklet, there is a list of various places people go to
get help with problems. Have you ever gone to any of these places or anywhere else
to get help, such as counseling, treatment or self-help groups for problems with
alcohol or drugs? Problems include drinking under age, overdosing, getting sick
from alcohol/drugs/ having problems due to drinking or drugs, like DUI/DWI,
missing school or getting into fights or trouble while drinking or high.
No.......0 (Skip to #9, page 140)
Yes......1
39


IF YES, Which places have you gone to?
help for problems with alcohol or drugs (em
on the list or not.
Treatment Facilities:
_______(Three specific regional ones were!
please tell me all the places you have gone to get
lotional or personal problems), whether the place is
listed.)
IHS:
Clinic
Hospital
Emergency room
Tribal Programs:
______Tribal health clinic
______(Tribal) counseling services
______(Tribal) Alcohol and drug prevention brogram
______School Programs (self-help groups, counseling)
______Recreational Programs (nature retreat^, Outward Bound)
Traditional Elders/Indian Ways:
______Certain Indian ceremony
______Sweat Lodge
______Certain ceremony performed by spiritual healer
______Native American Church prayer service
Traditional healer
Other Facilities:
______Doctors office
______Clinic
______Hospital
______Emergency room
______Health maintenance organization (HMO)
______Pastoral counseling/church counseling
______School counselor
______Self-help groups
Emergency shelter
______Other (not on list)
Please specify_________________________
The variable formal ADM service use (formal) measured yes responses using
treatment facilities, clinic, hospital, emergency room, tribal health clinic, tribal
counseling, tribal alcohol and drug prevention program, doctors office, or HMO.
40


The variable informal ADM service usie
school programs, recreational programs,
help groups, or emergency shelter. Sin
traditional healing practices, I wanted
for emotional/substance abuse problem
indicated the youths responded yes to
certain other ceremony, Native Amelia
healer.
(informal) indicated a yes response to
, pastoral counseling, school counselor, self-
ce we knew that youths used culturally
o predict factors that distinguished their use
A variable traditional service use (tradit)
s.
using certain Indian ceremony, sweat lodge,
an Church prayer service, or traditional
Explanatory (Independent) Variables. The review of the literature reported
in Chapter 2 as well as the nature of IDAP dataset determined the choice of the
independent or predictor variables. Andersens BMHSU provided the theoretical
foundation; thus, I categorized the independent variables and their measures using
this framework. Some measures were taken directly from the Voicies of Indian
Teens Project (VOICES), a five year study of the NCAIANMHR that involved
semiannual school-based data collection in 10 primarily Indian high schools in five
westerns sites including the Northern Plains.
Scales and Inventories that Measure Predisposing Factors. The initial
stages of the interview requested age and gender. Age in these analyses was a
continuous variable, gender, a dichotomous variable (0= male, 1= female).
Family arrest history (famarr) comprised responses to one item asking if
any of the youthss family/household members have ever been arrested (0=no,
l=yes).
A scale specifically developed by the NCAIANMHR for their VOICES
Project measured stressful life events (stress) (Piasecki et al., In progress). The
stress measure comprised 18 items. Eleven items assessed the occurrence of
significant life events in the past six mcjnths. Examples included entering a new
school, a parents not being able to find work, and breaking up with girlfriend or
boyfriend. Seven items assessed whethler very important events had ever occurred
(death of mother, father, sibling, divorce of parents, serious illness of parents or
youths). For events occurring in the past six months, the average six-month kappa
was 0.32, suggesting low to moderate test-retest stability over time for the VOICES
dataset, an appropriate statistic given their non-overlapping time frames of data
collection periods and the short-term or transient nature of many of these events.
For the lifetime events, the average six-month kappa was 0.67 representing fairly
good consistency. For use here, a summed scale score was created: higher scores
indicated more stressful events.
Seven items used from the VOICES study measured perceived competencies
(compet). Questions tapped six social and instrumental competencies; making other
41


kids feel comfortable, finding fun thin gs to do in free time, being good at creative
things, making others laugh, being good at sports and athletic games, and making
friends with people. VOICES reliability kappas for 9th-, 10th-, 11th, and 12th grades
were 0.79,0.83, 0.79, and 0.83 respectively. Summative scale scores were
computed: the higher the score, the higher the perceived competency level.
Perceived social support (socsup) from peers and family appears to predict
service utilization and/or problem behaviors especially in instances where family
support is low and peer support is Ihigh (Empey, 1991). IDAP again used a
VOICESs adapted scale, of six items from the. Multidimensional Scale of Perceived
Social Support (Zimet et al., 1988): two items asked about support from a special
person, two from family, and two from a friend. All items had a reliability of
a=.85. Summative scale scores were computed: the higher the score, the higher the
perceived social support.
Scales and Inventories that Measure Enabling Factors. Parent education
(parented), a dichotomous variable, ind icated if the youthss parent or significant
caretaker went to college or technical school (0=no, l=yes).
Perceived barriers (barriers) to care measured perceptions of impediments
to accessing or receiving care that could influence actual utilization of care. Within
the individual services utilization modules for the two types of services of interest
(emotional, substance abuse), the interviewer asked if there were times when
someone had recommended that they get help but they or their parents decided not
to go and then asked why. A dichotomous variable indicated the presence (1) or
absence (0) of any barriers in utilization of services for emotional and/or substance
abuse problems.
Enough money (money) measured youths perceptions if they felt that their
the last six months for food, clothing, and
stimes or often, the dichotomous variable
families did not have enough money in
housing. If the youths answered some
was coded 1; if never or rarely, then it was coded 0
Caretaker job status (job), a die
lotomous variable, indicated whether the
parent or caretaker had a full-time job (0=no, l=yes).
Scales and Inventory that Measure Need Factors. Common mental health
diagnostic assessment for the IDAP study used the Diagnostic Instrument Schedule
for Children, Version 2 (DISC-2.3) (Shaffer, Fisher, et al., 1996). The DISC is a
structured psychiatric diagnostic instrument designed for use by lay interviewers in
community epidemiological studies of children and adolescents 9-17 years of age.
Two parallel versions of the instrument are available: the Youth version (DISC-C)
and the Parent version (DISC-P). A limited teacher version (DISC-T) addresses
symptoms that would normally be expected to be observable by teachers. Past
42


studies have shown mixed DISC-C and DISC-P reliabilities (Shaffer et al., 1996).
In many instances the youth version proved more reliable than the parent. Other
times the parent version was more reliable than the child version. At this time, there
is no consensus on the best way to incorporate data from both the child and the
parent in reaching a diagnosis. Considerable evidence suggests that the two sources
yield different results if used separately
poor (Shaffer et al., 1988; Jensen et al.
because of limited project funding and
' because parent-child agreement tends to be
1995). IDAP utilized only the DISC-C
timeline. Since it has been reported that
children 11 years and younger are fairly unreliable in their symptom reporting with
the use of the DISC-C, youths 11 years! old and younger were excluded from the
IDAP sample (Schwab-Stone et al., 1994; Schwab-Stone et al., 1996).
Recently published studies reported on a methodological pilot use of the
DISC -2.3 prior to a planned national psychiatric epidemiological study of children
and adolescents, the UNOCCAP (Lahey et al., 1996; Leaf et al., 1996; Schwab-
Stone et al., 1996; Shaffer et al., 1996)j These studies (the Methodology for
Epidemiology in Children and Adolescents; MECA) focused on the concordance of
the DISC-2.3 diagnoses with clinician-generated diagnoses, the reliability of this
most recent version of the instrument, and its appropriateness for use among a
variety of community and patient groups. MECA findings indicated that the DISC-
C is an acceptable instrument with good inter-rater reliability, adequate to good test-
retest reliability, excellent sensitivity and moderate specificity, and adequate
concurrent validity.
The DISC-2.3 has 19 diagnostic sections. Six modules categorize related
disorders: anxiety, mood, disruptive, substance abuse, psychotic, and miscellaneous
disorders. The DISC 2.3 covers symptomology during six months preceding the
interview, except for conduct disorder end dysthymia, for which the time frame
includes both 6 and 12 months. However, all diagnoses were current, i.e.,
symptoms must have been present withjm the six months prior to the interview. We
excluded expected low prevalence disorders because of the substantial interview
time required to assess them. The included diagnostic modules comprised:
generalized anxiety and overanxious disorders, major depression and dysthymia
disorders, attention deficit and hyperactivity disorder, oppositional defiant disorder,
and conduct disorder. The study excluded simple phobia, social phobia,
agoraphobia, panic disorder, separation anxiety, avoidant disorder, obsessive
compulsive disorder, and psychosis disorders. Diagnostic algorithms and the
disorder-specific impairment criteria (DSIC) guided the calculations of prior six-
months prevalence rates. Specifically, to receive a diagnosis, a respondent had to
endorse one of the three impairment questions at the end of the individual diagnostic
modules as well as to have met the diagnostic criteria (Duclos et al., 1998) (Chapter
2 described prevalence findings).
43


abuse/dependence and post traumatic s
AIWP utilized the UM-CIDI to acces
choosing it for its cross-cultural utility
The NCAIANMHRs America! Indian Vietnam Veteran Project (AIWP)
adaptation of the University of Michigan version of the Composite International
Diagnostic Interview (UM-CIDI) provided prior 12-month diagnosis of substance
tress disorder (Manson et al., 1996). The
s adult psychiatric disorder prevalence,
and its known reliability and validity (Cottier
et al., 1991; Cottier et al., 1989; Farmer et al., 1987; Robins et al., 1988; Wittchen et
al., 1989; Wittchen et al., 1991). ID AT staff decided not to use the DISC for the
substance abuse/dependence diagnoses because the instrument diagnoses only
general substance abuse/dependence, aid not specific substance categories. In
addition, AIWP increased the validity of these two modules by adding culturally
appropriate items based on focus group s that elicited important cultural feedback
(Manson & Beals, 1995).
Dichotomous variables measured the presence of a disorder [(0) absent and
(1) present]. From these results three new independent variables were constructed:
youths meeting criteria for disruptive disorders (disrupti; conduct, oppositional
defiant, attention deficit and hyperactivity disorders), mood and anxiety disorders
(moodanx; depressive, generalize anxiety, overanxious, and post-traumatic stress
disorders), and substance use disorders (drugalch; abuse and dependence of alcohol,
marijuana, and nine other substances).
IDAP utilized the Suicide Ideati.on Questionnaire (SIQ- JR) to measure
suicide ideation (suicidea) (Reynolds, 1988). The SIQ-JR consists of 15 items
which ask the respondent to assess the frequency with which the thought has
occurred in the past month. Responses span a 7-point Likert scale ranging from I
never had this thought to Almost eveiy day. Items scores range from 0 to 6 in
terms of increasing frequency of suicidal cognition. The SIQ-JR was designed to
assess suicidal ideation in general, not to be a comprehensive list of all suicidal
cognition. In the standardized sample, Reynolds (1988) found the reliability of the
SIQ-JR to be excellent with Cronbachs a equal to 0.93, 0.94, and 0.94 for seventh-,
eighth-, and ninth-graders respectively. An American Indian high school sample
generated a similar a (Keane, R.W., et al., 1995). Reynolds recommendeded that
adolescents who score at or above 31 on the SIQ-Jr should be referred for further
evaluation of psychopathology and suic
was developed for these analyses, the hi]
idal tendencies. A summative scale score
gher the score the higher the ideation. A
review of court records for past police/court contacts generated a dichomtomous
indicator of past criminal history (crimnis).
44


Appendix B contains actual scjales and interview questions. Figure 3.3 shows
a summary of all independent and dependent variables eligible for inclusion in the
first logistical regression analyses (lift
regressions for types of services utilized these same independent variables.
time use of ADM services). The remaining
INDEPENDENT VARIABLES
DEPENDENT
VARIABLE
PredisDOsins Enabli Need | Service Use
Age Enough Mood/Anxiety Use or No Use
Gender Money Disorders of ADM
Family Arrest History Caretaker Full- Disruptive Disorders services for
Stressful Life Events time Job SubstanceAbuse' emotional/
Perceived Social Support Caretaker Dependence substance abuse
Perceived Problem-Focused College Suicide Ideation problems
Coping Perceived Criminal History
Perceived Competencies Barriers
Figure 3.3. Study Variables to be Tested for First Regression
Power Analysis
A power analysis for service utilization determined adequate power to detect
moderate effect. Based on conservative
assumptions probability of use of service
of .36, correlation between the covariates in the model from 0.1 to 0.6, two-sided
alpha level of 0.05, and power of 0.8
would be 1.6-1.8.
the smallest detectable odds ratio (OR)
45


Data Preparation
The IDAP data consisted of cleaned SAS files; however, further analyses
required additional data preparation. Selections of the needed data items from each
of the six data files were merged into a
single file. Construction of new variables
and scale scores followed basic descriptive univariate analyses.
Analyses
Analytic techniques included descriptive, psychometric, and logistic
regression analyses using SAS 6.12. For prediction of factors associated with
service use as well as types of service use, I developed four separate logistic
regression models. Development of these models followed guidelines of Hosmer
and Lemeshow (1989) for variable selection and modeling.
I began with descriptive summaries (frequencies, means, modes, medians,
normality tests, continous scale score Gronbachs a, and standard deviations). These
procedures not only provided description, but also checked for data problems, such
as missing data or outliers, and internal consistency. Examining relationships
between variables (correlations or odds ratios) guided the potential omission of
highly correlated variables and assisted in the interpretation of the models. I used
the 2-tailed Fisher exact test for all 2x2 classification tables as suggested by experts
(Hatcher & Stepanski, 1994; Cody & Smith, 1991).
BMHSU suggests that a number of factors contribute sequentially to service
use. Thus, I conducted hierarchical multiple logistic regressions to model the
probability of using ADM services, as well as type of services. I entered categories
of common variables (predisposing, enabling, and need) into the model sequentially
with backward elimination where appropriate within each step following similar
studys of service utilization (Harman et al., 1993; Cohen & Cohen, 1983). On the
completion of each step, I assessed the significance of interaction terms. I utilized
the a priori probability of 5% (p<0.05) to evaluate the significance of all contrasts.
Entering categories in this way permitted examination of incremental effects of
factors as proposed by the BMHSU.
Variable Selection for Regression Analyses. Pruning the number of
variables leads to parsimonious, numerically stable, and more easily generalized
regression models (Hosmer & Lemeshow, 1989). Too large a number of
independent variables for the sample size increases the estimated standard errors.
To avoid this, I adhered to the ten times rule, which advises ten times as many
subjects as there are independent variables.
46


To narrow the number of varia bles entering the model, the selection process
began with analysis of a bivariate relationship between each independent variable
and dependent variable (Table 3.4). Fishers exact test in 2x2 contingency tables
assessed the relationship between the nominal or ordinal variables and the outcome
variables. I used the likelihood ratio test in logistic regressions for assessing
relationships between continuous independent and dichotomous dependent
variables.
The occcurrence of a zero cell ii any contingency table (IV x DV) would
require collapsing categories in some sensible fashion, eliminating the category or
variable, or, if the variable were ordina ., modeling it as if it were continuous. The
analyses resulted in no zero cells.
Assessing Goodness of Fit. I utilized SAS software to run Hosmer and
Lemeshow Goodness-of-Fit tests on ea ;h of the final models. If the test statistic
proved nonsignificant, I could not rejected the null hypothesis that the model was a
good fit to the data (Hosmer & Lemeshow, 1989).
Predictive Accuracy. I developed receiver operating characteristic curves
(ROC) for each of the final models. If he slope of the curve rose quickly and the
area under the curve was large then the model had high predictive accuracy. The
ROC curve is a plot of sensitivity against 1 minus the specificity (the number of
false positives divided by the number of nonevents) The ROC curve rises quickly
when both sensitivity and specificity ars high (SAS Institute, 1995). All the ROC
curves are depicted in Appendix C.
Results
Description of Sample
Table 3.1 presents demographics and basic service utilization patterns of the
sample. Fifty-seven percent of the sample were male, with median age of 15 years
(range 12-18 years). Fifty-six percent reported prior arrests; median age of first
police contact was 13 years. The mean
Of those enrolled in school (87.4%), the
number of prior police contacts was five (5).
median grade level was 9th. Status
47


offenses5 most often caused detainmenlt (77.0%). Sixty-seven percent of the sample
indicated use of alcohol at the time of alleged delinquent activity.
Table 3.1 Demographic and Service
Utilization of IDAP Sample
Variable
Results
Median Age
Gender
Prior Arrests
Mean of Previous Police Contacts
Enrolled in School
Met Criteria for Mental
Health/Substance abuse Disorder(s)
Disorder ADM Service Use
Overall ADM Service Use
Use of Service for Substance Abuse
Use of Service for Emotional Problems
15 Years (12 18 Years-of-Age)
56% male
56%
5
87%
49%
58%
37%
23%
18%
Description of Variables
Table 3.2 shows the results of univariate analyses for each variable. I
reviewed these statistics for problems of which I had none. The measurement of the
respective variables determined the particular types of statistics reported.
None of the continuous variables were normally distributed (Shapiro-Wilk
test of a normal distribution.) Since the data were psychosocial and the detained
subjects would be expected to answer ri a skewed fashion to questions, we would
expect an abnormal distribution in these variables. Additionally, logit analysis
assumptions does not include multivariate normality and variance-covariance
matrices across groups. I did not make any transformations (Hair et al., 1995).
5 Status offenses are those offenses that only apply to youth, because of their age (e.g., drinking,
truancy, curfew violation, and running away, etc.). Youth can be legally processed for any of these
problems, but adults can not. In some areas, status offenses are so broadly defined and so subjective
that almost any youth could be referred to court if some parent or official believed court action was
warranted (Empey, 1991).
48


Table 3.2. Descriptive Statistics of Variables
VO
VARIABLE NAME TYPE MEAN SD MIN MAX NORMALITY (Shapiro-Wilks Test) COEFF. ALPHA DESCRIPTION
Dependent:
Use of Service Binary .367 0 1 1 if used lifetime ADM services
Formal Use Binary .247 0 1 1 if used lifetime formal services
Informal Use Binary .067 0 1 1 if used lifetime informal services
Traditional Use Binary .087 0 1 1 if used lifetime traditional services
Independent:
PredisDOsine
Age Contin. 15.2 1.6 12 18 .91 <.001 age in years
Gender Binary .43 0 1 gender (0=male, l=female)
Family Arrest Binary .79 0 1 1 if member of familv arrested
Stress Contin. 3.5 2.7 0 14 .91 <.001 .63 (KR20)a summative score of stressful events
Social Support Contin. 3.9 .93 1 5 .91 <.001 .89 mean score of social support
Competencies Contin. 2.7 .60 1.3 4 .96 <.003 .87 mean scale score of competencies
Problem - Contin. 2.7 .85 1 4 .93 <.001 .88 mean score of problem-focused
Coping coping skills
Enabling Parent Education Binary .25 0 1 lif caretaker has college/ technical ed.
Barriers Binary .07 0 1 1 if youths indicated a barrier to use
Money Binary .32 0 1 lif youths perceives not enough money
Parent Job Binary .39 0 1 lif caretaker has a full-time job
Need Mood/Anxiety Binary .15 0 1 1 if met criteria for mood/ anxiety
Disruptive Binary .21 0 1 1 if met disruptive disorder
Substance Abuse Binary .38 0 1 1 if met drug/alcohol disorder
Suicide Ideation Contin. 9.77 15. 0 79 .67 <.001 .95 mean score of suicidal ideation
Criminal History Binary .87 6 0 1 1 if youths had prior offenses
Note = 150 SD = Standard Deviation MIN = Minimum Value MAX= Maximum Value K20 used here for dichotomous scale
reliability


Missing Values. A large number of cases with missing information can create biased
or inaccurate results (Cohen & Cohen,
variables with missing values.
Table 3.3. Variables with Missing
1983; Aday, 1989). Table 3.3 presents the
Values
VARIABLE NAME
Dependent:
None
% MISSING
Independent:
Predisposing
Family Arrest History (Famarr)
Perceived Social Support (Socsup)
Perceived Competencies (Compet)
Problem-focused Coping (Probcope)
Enabling
Perceived Money (Money)
Need
Suicide Ideation (Suicidea)
9%
5%
5%
4%
6%
4%
Aday (1989) and Cohen & Cohen (1983) suggested that imputation should be
done for major variables that have miss ing data for 10% or more of the sample. I
decided not to impute any of the variables but to use casewise deletion of data. This
entails eliminating observations with m issing values for the response or explanatory
variables from the analyses (Norman & Streiner, 1998).
Bivariate Analyses To Describe Relationships between Variables
To narrow the number of variables for the regression analyses and to assess
potential problems of collinearity in the final models, I tested for the existence and
strength of the relationship between variables, then between independent variables
and the dependent variables. Table 3.4 presents the level of significance or p values
of each test the only common statistic across analyses (Fishers exact test, logistic
regression, and linear regression). The values cited do not reflect direction but only
the strength of the relationship.
50


Age and gender related significantly with other independent variables. Since
the literature suggested that age and gender influence utilization, I adjusted for these
confounders in the regressions.
Factors highly correlated with ifetime use of services included mood/anxiety
and/or substance abuse disorders and having a past criminal history (all need factors).
More formal service utilization correlajted highly with perceived fewer problem-
focused coping skills {predisposing factor) and disruptive and/or substance abuse
disorders {needfactors). Mood/anxiety and substance use disorders influenced
informal service use significantly {needfactors). Perceived competencies (a
predisposing factor) and having a disruptive disorder were significantly correlated
with culturally traditional services. Multivariate analyses included all independent
variables whose bivariate test resulted in ap- value of less than 0.25. A more
INDEPENDENT VARIABLES
^ DEPENDENT
VARIABLE
Predisposing Enablir g Need i 1 Service Use
Age Mood/Anxiety Use or No Use
Gender Disorders 1 of Lifetime
Perceived Problem Disruptive Disorders ADM
Coping SubstanceAbuse/ 1 Services for
Family History of Arrest Dependence emotional/
Criminal History 1 substance abuse
problems
I
i
traditional level such as 0.05 often fails to identify important variables (Hosmer &
Lemeshow, 1989). Figures 3.4,3.5,3.6, and 3.7 present the factors related to each
dependent variable.
Figure 3.4. Independent Variables R
'.elated to Lifetime ADM Service Use


Table 3.4
Table of Relationships Between Variables
La.
ro
Variable Age__________Gender Probcope
IV
Age -
Gender
Probcope wm
Stress p=.07c
Socsup p=.9lc
Compet p=. 37
Famarr p=.29b
Parented p=A\b
Barriers p=. 66b
Fulljob p=.06b
Money p=.17b
Moodanx i8§;0$b
Disrupti /7=. 10
Drugalch p=.29b
Suicidea Ejjoolg
Crimhis p=.44b
DV
Specever p=. 35 b
Formal p=.82b
Inform p=A7b
Tradit p=. 82 b
p=. 98
p=. 73c
p=. 54c
p=. 72 b
p=.67b
p=. 18b
p=.25b
p=. 81b
-----p=.75
p.51a p=.43b
P=. 82 p=. 29 b
p=.09b p=.19c
p=.308 p=.36b
p=A5a p=. 07 b*
n=45a
p=.35a p=.69b
p=.99a p=.36b
p=.56b
p=. 09 b
p=.99a
p=.\9a
p=. 10a
p=.87
p=A7a
Stress
p=A7e
p=. 06c
p=.22 b
p=.07 b
p=.87b
p=.06-
p=.35b
p=.69b
p=.32b
p=. 90 b
/?=.83b
p=.66b
p=.43b
Socsup Compet Famarr Parented

p=.69b p=.23b
p=. 71 b p=.96b
p= 17b p=6 8b
p=.15b p=.44b
p=.34b p=. 12 b
-p=r73- p=.48b
p=.40 b p=.12b
p=.54b p=.76b
p=. 22 p=. 63c
p=.32b p=. 84 b
p=A9b p=. 95 b
p=.52b p=.83b
p=. 84 b p=.12b*
p=.30b ISB3b
p=.99a -
p=. 68a p=.458
p=.9V W8
p=. 508 HT
P=.i2a
p=. 138 p=.ir
p=.29a p=.09a
p=.\0b p=.66b
^1 p=. 78
p=.ll8 p-.70a
p=. 34 p=. 988
p=. 688 p=. 988
p=.99 p=.98a


Table 3.4 (Continued)
Variable Barriers Fulljob Money Moodanx
IV
Age Gender Probcope Stress Socsup Compet Famarr Parented Barriers
Fulljob />=.74
Money llffiSI8
Moodanx 8
Disrupti p=. 98
Drugalch fHH"
Suicidea b<;001 c
Crimhis p=. 62
DV
p=.82-*
p=. 16
ml* ,.1
p=.62
p=.9S
p=.98 a p=. 74a
Specever
Formal
Inform
Tradit
p=. 50a
p=.26 a
p=.16*
/>=.821
p=. 60a
/>=.85
p=.75 a
p=.ll'
IV = Independent variables DV = Dependent variables
Fishers Exact Test
bLogstical regression
Linear regression
* p<.25; Shading indicates significance at or below .05
Disrupti Drugalch
p=. 07b p=. 89b
p=. 37 p=.13
ila* p=.20 *
gloafa* P==03 *
p=.10*
p=. 15 * MOSS8*
Suicidea Crimhis
p=.21b -
/>=.98 b IllSiii8*
/?=. 89 b p=.41
/?=. 98 b p=.36
p=. 93 b p=.37


INDEPENDENT VARIABLE
S
^ DEPENDENT
VARIABLE
Predisposing__________
Age
Gender
Perceived Problem-Focused
Coping
Enabling
___________Need
Mood/Anxiety
Disorders
Disruptive Disorders
Substance Abuse/
Dependence
Service Use
Use or No Use
of Formal
ADM
Services for
emotional/
substance abuse
problems
Figure 3.5. Independent Variables Related to Formal ADM Service Use
INDEPENDENT VARIABLES
^ DEPENDENT
VARIABLE
Predisposing Enabling. Need 1 Service Use
Age Perceived Mood/Anxiety Use or No Use
Gender Barriers Disorders of Informal
Perceived Competencies Disruptive Disorders ADM
SubstanceAbuse/ Services for
Dependence emotional/
substance abuse
problems
I
Figure 3.6.
Independent Variables Related to Informal ADM Service Use


INDEPENDENT VARIABLES
^ DEPENDENT
VARIABLE
Predisposing
Age
Gender
Perceived Competencies
Enablin
f
Need \ Service Use
Disruptive Disorders Use or No Use
Substance Abuse/ of Traditional
Dependence ADM
Services for
emotional/
substance abuse
problems
i
Figure 3.7. Independent Variables Related to Culturally Traditional ADM Service
Use
Logistic Regressions
Fitting the Multivariate Model. I utilized hierarchical stepwise approaches in
model building. This approach builds models sequentially. I introduced variables in
clusters of predisposing, enabling, and need. After each clusters entrance, I did a
backward elimination and tests for interaction terms. The variables importance was
verified with examination of the Wald statistic. Variables that did not contribute
(p>0.05) were eliminated and a new mojdel fit. The new model was compared to the
old with a likelihood ratio test. Variable coefficients were examined for marked
change indicating the importance of the excluded variables in providing needed
adjustment of remaining variable effect (Hosmer & Lemeshow, 1989). The process
of deleting, refitting, and verifying continued until all important variables appeared to
be included. Table 3.4 outlines the steps taken for predicting lifetime use of ADM
service use.


Table 3.5. Model Building for Lifetime Use cfADM Services (n=135)
STEP Variables Entered Log- Likelihood G p-value P GF b SE Wald Odds Ratio 95%CI
1 Predisoosine 176.88 12.85 4 .012 2.83 12.93 p=. 07
Agea -0.17 0.12 1.91 .85 0.66, 1.07
Gender* -0.04 0.38 0.01 .95 0.45, 2.02
Problem-Focused Coping -0.62 0.23 7.08 .54 0.33, 0.83
History of Family Arrest (Kept all variables) 0.97 0.52 3.45* 2.65 0.99, 8.01
2 Need 176.88 47.05 8 .0001 2.13 7.01
p=. 54
Mood/Anxiety 1.49 0.66 5.07* 4.45 1.25, 17.60
Disruptive Disorder 0.93 0.54 2.97 2.53 0.88, 7.46
Substance Abuse/Dep 1.30 0.48 _ _ 7.37 3.66 1.45, 9.58
Criminal History 2.05 1.17 3.05 7.77 .99,165.74
2.1 Eliminate Disruptive 176.88 44.06 7 .0001 2.78 10.33
Disorder p=. 24 1.76 0.65 7.37** 5.81 1.71, 22.50
Mood/Anxiety 1.44 0.47 9.54 4.22 1.72, 10.85
Substance 2.08 1.15 3.29 8.02 .99,165.15
Abuse/Dependence Criminal History
2.2 Eliminate Criminal Historv 176.88 39.16 6 .0001 3.91 4.14 p=. 84
Mood/Anxiety 1.55 0.61 6.50 4.72 1.48,16.56
Substance Abuse/Dependence 1.61 0.46 12.37* 5.01 2.09, 12.74
G= -2 Log-likelihood Test Statistic SE= Standard Error of p
df= Degrees of freedom Wald= Wald test
P= Slope coefficent (change in log odds for increase of 1 unit in x) 95% CI= 95% Confidence Interval
GF=Hosmer & Lemeshows Goodness of Fit test Control Variables
* ** **=/)< 05, <.01, <.001, respectively


Lifetime ADM Service Use. The first step in the logistic regression procedure
confirmed the relationship suggested b y correlation comparisons. Fewer problem-
focused coping skills (negative slope) and history of family arrest were significant in
explaining service use. Thus, I retained these predisposing variables. I tested for the
need for interaction terms. I found no interaction terms significant at p< 0.05.
In Step 2 I entered the need vaiiables, no enabling variables correlated
significantly with the outcome. Substaice abuse/dependence disorder was the most
highly significant variable, followed by mood/anxiety disorder significance. Adding
the need variables reduced the effect of family history of arrest. However, following
the stepwise strategy, I did not eliminate this variable in this step. Disruptive disorder
did not contribute to the fit, thus was eliminated in Step 2.1. Substance
abuse/dependence and mood/anxiety disorders (p=.002 and .006, respectively)
continued to contribute significantly. Eliminating criminal history, I found substance
abuse/dependence and mood/anxiety disorder remained significantly important
(p=.0004 and .011, respectively).
The final model, adjusting for age and gender, included fewer problem-
focused coping skills (predisposing), history of family arrest (predisposing),
mood/anxiety disorder (need), and substance abuse/dependence (need). The
introduction of these powerful need predictors increased the influence of fewer
problem-focused coping skills, while decreasing that of history of family arrest (final
p=.20) I again tested for interactions, and found none significant at p<0.05.
Collinearity Testing. I found larger than expected estimated standard errors in my
control variables in the final model. Age correlated with gender, problem-focused
coping skills, and mood/aniexty disorder. Thus, I would expect some confounding
and collinearity with these control variables.
Goodness of Fit. Wanting to see how well the model described the outcome
variable, I ran a Hosmer and Lemeshow Goodness-of-Fit Test using the SAS
software. The test statistic proved non-:;ignificant (p=. 84), indicating that I could not
reject the hypothesis that the model fit the data.
Predictive Accuracy. A receiver o
developed for the final model (i.e., if the
curve is large and the then the model
The area under the curve also correspon
lifetime use indicated moderate predictive
moderate to high range, the rise in curve
perating characteristic curve (ROC) was
curve rises quickly and the area under the
high predictive accuracy) (see Appendix C).
Lded to the c statistic, which at 0.80 for
e accuracy. Even with this statistic in the
was not steep as I would want.
57


Coefficient of Determination. Nagelkerke (1991) proposed an adjusted
coefficient of determination for logisti: regressions. This coefficient, consistent with
maximum likelihood as an estimation method, explained the proportion of variance
explained by the regression model. SAS softwares adjusted R2 equaled 0.34, i.e.,
34% of the variance was explained by this final model.
Odds Ratios. Youths with substance abuse/dependence and/or mood/anxiety
disorders were 5 times more likely to receive lifetime ADM services after controlling
for all other variables than those not having these disorders (see Table 3.5). The
results for each independent variable were the values for that variable after
completion of the backward elimination at the step it was entered
Table 3.5. Odds Ratios and Confidence Intervals for Lifetime ADM Service Use
Odds 95%CI
Ratio
Age 0.85 0.66, 1.07
Gender 0.95 0.45, 2.02
Problem-focused coping 0.54 0.33, 0.84**
Family Arrest 2.65 0.99, 8.02
Mood/Anxiety 4.72 1.48, 16.56**
Substance 5.01 2.09, 12.74***
Abuse/Dependence
95% CI= 95% Confidence Interval
*** ***=^<.05, <.01, <.001, respectively
Formal Use of ADM Services.
Table 3.6 summarizes the steps taken for
logistic regression model building for more formal types of ADM service utilization.
Following procedures as explained previously, I entered predisposing variables while
controlling for age and gender. Fewer problem-focused coping skills contributed
significantly. I retained this variable anjd tested for interactions. There were none.
Need factors were then entered in Step 2. Substance abuse/dependence proved to be
significant, while mood/anxiety and disiuptive disorders were not. I eliminated the
mood/anxiety variable (Step 2.1) and fo und substance abuse/dependence remained
significant. Step 2.2 eliminated disruptive disorder resulting in a final model
adjusting for age and gender and included fewer problem-focused coping skills and
substance abuse/dependence. No significant interactions were found at this final
stage. Once again, inclusion of need (substance abuse/dependence) increased the
impact of having fewer problem-solving; coping skills on receipt of more formal
services, as indicated by changes in parameter estimates.
58


Table 3.6. Model Building for Formal ADM Service Utilization (n=144)
Step Variables Entered Log- G Df P- P GF b SE Wald Odds 95%CI
Likelihood value Ratio
1 Predisposing 161.95 5.51 3 .14 0.37 5.90
p=. 66
Agea -0.02 0.13 0.03 .98 0.76, 1.26
Gender0 0.38 0.40 0.91 1.46 0.67, 3.22
Problem-Focused Coping (Kept all variables) (Tested for Interactions none significant) -0.50 0.24 4.55' .60 0.33, 0.95
2 Need 161.95 17.23 6 .009 -0.19 6.25
p=. 62
Mood/Anxiety 0.28 0.58 0.24 1.33 0.41, 4.08
Disruptive Disorder 0.73 0.50 2.12 2.07 0.77, 5.55
2.1 lUIUiSUUILV ALU13U L/VpCllX Eliminate Mood/Anxietv 144.96 17.00 5 .005 -0.09 4.88 u.yo U.45 4.47 2.61 1.08, 6.48
p=.n
Disruptive Disorder 0.79 0.49 2.58 2.19 0.83, 5.71
Substance Abuse/Depen. 1.01 0.44 5.19* 2.75 1.16, 6.66
2.2 Eliminate Disruptive Disorder 147.49 14.46 4 .006 0.78 3.16 p=. 92
Substance Abuse/Depend. (Tested for Interactions none signicant) 1.23 0.42 8.60* 3.43 1.53, 8.00
(7= -2 Log-likelihood Test Statistic SE= Standard Error of P
df= Degrees of freedom Wald= Wald test
P= Slope coefficent (change in log odds for increase of 1 unit in x) 95% Cl= 95% Confidence Interval
GF=Hosmer & Lemeshows Goodness of Fit test =Control Variables
*, **, ***=p<.05, <.01, <.001, respectively


Odds Ratios. Youths with substance abuse/dependence were approximately
3 Vi times more likely to receive formal ADM services than those not having this
disorder after controlling for all other variables (see Table 3.7). After adjusting for
age, gender, and need, youths perceiving themselves as having fewer problem
focused coping skills were approximately 2/3 as likely to receive services.
Table 3.7 Odds Ratios and Confidence Intervals for Formal ADM Service Use
Odds 95%CI
Ratio
Age 0.98 0.76. 1.26
Gender 1.46 0.67. 3.22
Problem-focused coping 0.60 0.38. 0.95*
Substance 3.43 1.53] 8.00**
Abuse/Dependence
95% CI= 95% Confidence Interval
*,**, ***=p<.05, <.01, <.001, respectively
Collinearity Testing. The control vajriables in the model had larger than expected
estimated standard errors.
Goodness of Fit. Hosmer and Lemeshows Goodness-of-Fit test proved non-
significant (p=. 92), indicating I could n
data.
5t reject the hypothesis that the model fit the
Predictive Accuracy. The area under the curve corresponded to the c statistic of
0.71 for formal use indicating moderate
predictive accuracy. However, once again
the curve did not rise as quickly as I warned.
Coefficient of Determination. Nagelkerkes (1991) adjusted coefficient of
determination (adjusted R2 indicated that 14% of the variance was explained by this
final model.
60


Table 3.8. Model Building for Informal ADM Service Utilization (n=143)
Step Variables Entered Log- G Df P- P GF b SE Wald Odds 95%C1
Likelihood value Ratio
1 Predisposing 71.50 1.00 3 .32 -1.83 3.63
p=. 89
Age8 -.001 0.21 0.001 0.99 0.67, 1.54
Gender8 -0.625 0.73 0.72 0.11 0.11, 2.10
Perceived Competencies -0.19 0.57 0.11 0.83 0.26, 2.51
(Dropped Competencies)
2 Enabling 70.00 3.48 3 .32 -2.78 5.81
p=. 56
Perceived Barriers 1.69 0.92 3.37 5.41 0.69, 31..07
(Dropped Barriers)
3 Need 60.09 13.39 5 .02 -5.39 5.45
P=-71
Mood/Anxiety Disorder 2.35 0.88 7.18 10.53 1.94, 65.69
Disruptive Disorder 0.33 0.75 0.20 1.39 0.30, 5.89
Substance Abuse/Depen. 1.12 0.78 2.05 3.06 0.69, 16.41
3.1 Eliminate Disnmtive Disorder 60.28 13.20 4 .01 -5.31 9.81
p=.20
Mood/Anxiety Disorder 2.40 0.87 7.64 10.98 2.07, 67.14
Substance Abuse/Depen. 1.17 0.77 2.30 3.22 0.75, 17.02
3.2 Eliminate Substance Abuse 62.74 10.74 3 .01 -5.18 8.65
p=. 28
Mood/Anxiety Disorder 2.55 0.81 9.84** 0.51 2.70, 70.61
(Interactions tested -
none significant)
G= -2 Log-likelihood Test Statistic SE= Standard Error of P
df= Degrees of freedom Wald= Wald test
p= Slope coefficent (change in log odds for increase of 1 unit in x) 95% CI= 95% Confidence Interval
GF=Hosmer & Lemeshows Goodness of Fit test =Control Variables
*, **, ***=p<.05, <.01, <.001, respectively


Informal ADM Service Use.
and gender as well as perceived comp
competencies did not contribute to the
n Step 1,1 entered the control variables of age
stencies (see Table 3.8). Perceived
model and was eliminated. In Step 2,1 entered
an enabling variable (perceived barriers); it also was found to be non-significant and
dropped. I entered the need variables in Step 3. Mood/anxiety disorder contributed
significantly to the model while disrup tive and substance abuse/dependence did not. I
eliminated disruptive disorder and refit the model (3.1). Again, mood/anxiety
disorder remained influential, while substance abuse/dependence did not. I
eliminated (Step 3.2) substance abuse/dependence and refitted the final model. After
adjusting for age and gender, mood/anxiety disorder (needfactor) predicted more
informal service use. In fact (see Table 3.9), youths having this disorder were 13
rvices than youths who did not have the
Odds Ratio 95%CI
times more likely to utilize informal se:
disorder.
Table 3.9 Odds Ratios and Confidence Intervals for Informal ADM Service Use
Age 0.99
Gender 0.54
Mood/Anxiety 12.83
0.67, 1.54
0.11, 2.10
2.70, 70.l**
95% CI= 95% Confidence Interval
*** ***=p<.05, <.01, <.001, respectively
Collinearity Testing. Confounding and collinearity with the controls was
expected and resulted in larger than expected estimated standard errors.
Goodness of Fit. Hosmerand Le
significant (p=.28), indicating I could n
meshow Goodness-of-Fit test proved non-
at reject the null hypothesis.
Predictive Accuracy. The area under the curve corresponding to the c statistic
( 0.74) indicated moderate predictive accuracy. However, once again the curve did
not rise as quickly as I wanted.
Coefficient of Determination. Na gelkerkes (1991) adjusted coefficient of
determination (adjusted R2) indicated that 18% of the variance was explained.
For informal types of services, need (mood/anxiety disorder) alone drove
utilization. Neither predisposing nor enabling factors were important in this model.
62


Table 3.10. Model Building for Culturally Traditional ADM Service Utilization (n=143)
Variables Entered Log- G Df P- P GF b SE Wald Odds 95%CI
Step Likelihood value Ratio
1 Predisoosine 76.42 6.02 3 .11 -6.90 5.69 p=. 68
Agea 0.06 0.20 0.10 1.07 0.73, 1.62
Gender5 -0.38 0.65 0.34 0.68 0.18, 2.43
Perceived Competencies (Kept all variables) (Tested for Interactions none significant) 1.27 0.54 5.47* 3.58 1.28, 11.09
2 Need 68.22 14.22 5 .01 -8.20 13.16
p=.U
Disruptive Disorder 0.51 0.74 0.49 1.68 0.37, 7.06
Substance Abuse/Depen. 1.69 0.73 5.32* 5.43 1.40.27.10
2.1 Eliminate Disruntive Disorder 68.70 13.74 4 .008 -7.67 4.12 p=. 85
Substance Abuse/Depen. (Tested for Interactions none signicant) 1.82 0.71 6.55* 6.14 1.68, 29.60
G= -2 Log-likelihood Test Statistic SE= Standard Error of P
df= Degrees of freedom Wald= Wald test
P= Slope coefficent (change in log odds for increase of 1 unit in x) 95% CI= 95% Confidence Interval
GF=Hosmer & Lemeshows Goodness of Fit test =Control Variables
*,**,***=p<.05, <.01, <.001, respectively


Traditional ADM Service Utilization. Investigating culturally traditional
service utilization for these youths is increasingly important as more and more tribes
provide cultural interventions for youths problems. Table 3.10 presents the model
building for these special services. In Step 1 of this model, age and gender as well as
perceived competencies (predisposing factor) were entered into the model. Perceived
competencies contributed significantly to the model, and thus was maintained. Step 2
introduced the need variables (disruptive and substance abuse/dependence disorders).
Disruptive disorder did not contribute significantly, but, substance abuse/dependence
did. I then eliminated disruptive disorders and refit the final model. The final
model included perceived competencies and substance abuse/dependence after
controlling for age and gender. Need in this model did not mediate perceived
competencies as indicated by no change in parameter estimates.
Collinearity Testing. Confounding
expected and did result in larger than expected estimated standard errors
and collinearity with the controls was
Goodness of Fit. Hosmer and Lemi
significant (p=.85), indicating I could n
data.
qshow Goodness-of-Fit test proved non-
ot reject the hypothesis that the model fit the
(0.79) for lifetime use indicated moder:
Predictive Accuracy. The area under the curve corresponding to the c statistic
te predictive accuracy. However, once again
the curve did not rise as quickly as I expected.
|
Coefficient of Determination. Nagelkerkes (1991) adjusted coefficient of
determination (adjusted R2) indicated that 21% of the variance was explained by this
final model.
Odds Ratios. Controlling for all other factors, youths who experienced
substance abuse/dependence problems were 6 times more likely to use traditional
ADM services than youths not having tnose problems (see Table 3.11). The effect of
perceived competencies is harder to interpret. Youths who had higher scores in
perceived competencies were 4 times more likely to use traditional service use (e.g.,
sweats, specific Indian ceremonies) than those who had have lower scores. The
cross-sectional nature of the data makes it impossible to determine if this could be a
treatment effect.
64


Table 3.11. Odds Ratios and Confidence Intervals for Traditional ADM Service
Use
Odds Ratio 95% Cl
Age 1.07 0.73) 1.62
Gender 0.68 0.18. 2.43
Competency 3.58 1.28) 11.09*
Substance 6.14 1.68, 29.60**
Abuse/Dependence
95% CI= 95% Confidence Interval
*,**, ***=p<.05, <.01, <001, respectively
Summary of Final Models. All models found that need factors contributed
significantly to prediction, thus confirm ing other studies that have cited need drives
utilization. Although it is clear that ind icators of need are strongly related to use of
ADM services, the analyses showed that a large proportion of individuals do not
receive treatment.
Review of the results of the fine! models indicated that different types of need
predict different of types of service use. Mood/anxiety disorder was influential for
informal service use, while substance abuse/dependence was important for formal and
traditional service use. Two predisposing factors contributed to three final models
(few problem-focused coping skills with lifetime and formal service use; perceived
competencies with traditional service use). Enabling factors were not important in
any of the models.
While the likelihood ratio and goodness of fit tests were significant for all four
models, the proportion of variance not explained by the models (66% for lifetime,
86% for formal, 82% for informal, and 79% for traditional ADM service use)
suggested that other factors not measured here have substantial effects.
Discussion
I hoped with this study to facilita t
use of service for troubled youths. This
investigated, retrospectively, self-report
a sample of detained Indian youths. The
e narrowing the gap between need for and
quantitative portion of my research
factors related to the use of ADM services by
Behavioral Model for Health Services Use


the research. The goals were to examine
.ate the factors by types of services. Results
ssociated with receipt of ADM services by this
provided the theoretical framework for 1
overall utilization and then to different*
yielded some insight into the factors;
group. It also raised more questions.
Four of five indicators of need ivere associated with some kind of ADM
service use. Suicide ideation did not relate significantly to receipt of services, even
though the detention center is the usual source for placement of suicidal youths within
the community. The 9.77 mean value of the suicide ideation variable shows low
probability. Quantiles 1-3 have a value of 13. Ninety percent of the scores fall under
the value of 30. The value of 31 is recommended by Reynolds (1988) for further
evaluation. Ten percent of the youths fall into that category. Saunders et al. (1994)
found in their study that suicide ideatioja was related to a lower probability of
obtaining help in their study of formal nealth-seeking in a school-based sample of
mainstream adolescents.
Conceptual theoretical models reviewed in Chapter 2 suggested that
predisposing and enabling factors have significant effects on utilization only in the
presence of need. Results here confirm that need is indeed important, but youths
predisposing characteristics and beliefs might not be. One predisposing factor -
problem-focused coping skills influenced lifetime use of services and also use of
more formal types of services. However, this factor may be more a characteristic of
the detained sample than a predictor. Tie type of coping skills measured included a
youths attempts to directly alter the worrisome conditions. Those detained youths
who used service or more formal types of service perceived themselves having fewer
of these direct action skills could this characteristic have landed them in detention
: the lack of more focused coping skills might
of the criminal justice system more than any
other system, so that it became the gatekeeper of the more formal types of substance
abuse services. A study of a community sample of youths could help explain this
finding.
Another predisposing factor, positive perceived competencies, significantly
affected culturally traditional service utilization. The cross-sectional nature of these
analyzes makes it impossible to determine the direction of effect between treatment
and potentially important predictors. However, this result raised an interesting
question do youths who perceive themselves having competencies seek traditional
services, or does the receipt of such services make them feel more competent?
Whatever the direction, the result supported the provision of more culturally based
services for troubled youths. It also confirmed Andersens (1995) suggestion that
utilization studies need to examine use in context of outcomes.
Enabling factors that were measured did not significantly influence any of the
models. Only one-- perceived barriers entered the informal model, but quickly
in the first place? It is also possible that
have brought the youths to the attention
66


f
dropped out when need variables were
added. This could result from reservation-
based American Indian health care, which provides formal services through IHS
without cost. It might also suggest that the more adult-, rational choice-, and
economically-oriented enabling variables such as insurance coverage and money have
little importance to adolescent use. The BMHSU model assumes that the individual
recognizes a need and then can makes a rational decision about seeking care. Youth
behavior challenges this assumption, ckn youths identify that they have a need, then
rationally act on it? Some argue yes, some argue no (Shaffer et al., 1989). Either
way, different types and measures of enablers or the social network in which the
youths interaction need to be explored. Andersen (1995) felt that social relationships
in which the individual interactions would fit in as enabling resources. However, he
did not elaborate how.
Novins et al. (1996) found that referrals were extremely important for Indian
adolescent receipt of alcohol treatment. We only asked IDAP youths who had
received services if they had a referral (enabler), thus I could not include referral as
a variable in models utilizing the whole sample. We asked this subpopulation if
anyone had told them to go to services and then who. The analyses indicated a high
correlation between referral and lifetime use (pFET =.001) as well as use of all three
types of services (formal, /?FET =.001; informal, pFET =.001; traditional, p?E1 =.02)
confirming Novins et al.s results. Referral also was significantly related to youths
parents higher education (pFET =.02). Relatives including parents were reported as
source of referral by 56.4% of the youths who had received services (see Table 3.12).
Table 3.12. Gender Differences in Referral Sources
Referral Male. (n=31) Females ( n =24)
n %a n %a
Relative 16 51.6 15 62.5
Adult Friend 5 16.1 9 37.5
Peer Friend 3 9.7 9* 37.5
Court 10 32.3 8 33.3
School 5 16.1 3 12.5
Pastor 9 29.0 5 20.8
Note: n= 55
*= Column percent
*p<.Q5
Approximately 22% of youths indicated peer referrals. Females were more
likely to be referred by peers. One-third reported being referred by the courts. I
looked at referral as either a soft or hard coercive factor. Soft coercion would be a
referral from school counselor, peer, etc. Hard coercion would be a court referral.
67


Social dynamics seem to markedly me diate use of needed ADM services. Once we
more fully understand these social dynamics we can design interventions that target
the factors that are changeable or muta ble. Could measurement of referral
characteristics (e.g. parental/family, court, etc.) as enabling factors rather than the
childs predisposing factors be imporfcint as factors for adolescent ADM utilization?
These above findings also imply that coercive (soft or hard) theoretical
models as explained in Chapter 2 have a bigger role to play for adolescents use of
services than for adults. Previous studies have not identified these and other more
socially-oriented enabling factors that influence use for these youths. Results here
suggest the next important step in research.
Need variables of mood/anxiety disorder and substance abuse/dependence
were the only significant need factors, especially for lifetime use of ADM service. It
seemed surprising that disruptive disorders did not play an important role given the
high prevalence of conduct disorder in this group and the significant bivariate
correlations with lifetime and formal ADM services. Collinearity between conduct
disorder and substance abuse/dependen ce explained the absence of an effect. I re-ran
the final models substituting disruptive disorders for substance abuse/dependence.
Two of the models (lifetime use, p-0.01; and formal use, /7=0.01) found disruptive
disorders contributing to the model as e xpected, while the remaining two models did
not.
Differentiation between types of need became apparent when looking at
predictors of types of services. Mood/knxiety disorder was not important for formal
or culturally traditional service use, sufcjstance abuse/dependence was. However,
mood/anxiety disorders, whose symptoms are more internal, were most important for
informal services. Substance abuse/dependence entered the model initially because
of its correlation with use, but was elimiinated during the final modeling. Thus,
informal services such as school, recreational, and pastoral counseling seemed to be
utilized more readily than more formal services by youths with more internalizing
disorders. j
The need indicator for substance abuse/dependence was markedly important
predictor for receipt of services for this 'group of troubled youths, confirming earlier
work (Novins et al., Submitted). This v^as consistent again with the relative emphasis
on substance abuse treatment in Indian Country, and the relative under-emphasis on
other more mental health-related services (US Congress, 1990; Novins et al., 1996).
An additional intrinsic objectivejof this study was testing the appropriateness
of Behavioral Model of Health Service Use for adolescents. These findings suggest
that BMHSU might not include the righi; factors for troubled youths and/or this
culture. However, it remained a good s
tarting place from which to develop or adapt
a more useful model for the study of youths within different cultural environments.
68


imitations
Some caution is in order with respect to interpreting the results of these
analyses. The study used a small deter tion-based sample. It was possible that
conducting some interviews in the detention facility itself may have introduced
unmeasured bias into the youths responses. Future studies should examine these
issues on a broader community level.
ita from the adolescents themselves. The
rents, teachers, police, and staff of the
iderestimation of both the prevalence of need
on youths to report use for substance and/or
The study relied on self-report <
lack of other key informants such as pa
detention faculty may have led to an
and the use of ADM services. Reliance
emotional problems separately may have resulted in some misclassification of the
reasons for use. However, the utilization patterns were consistent with the local
service ecology as described in the methodology section of this chapter. Also there
was broad consensus that self-report information is critical when examing youths
emotional health, attitudes, beliefs, and behaviors (Saunders et al., 1994; Weissman et
al., 1977).
A mismatch of the time frames for service use (lifetime) and diagnostic
symptomology for certain disorders cot Id have increased the likelihood of failing to
see significant differences between use md diagnoses (type II statistical errors).
Significant variation in cultural characte ristics and service ecologies exists, thus
caution needs to be taken in generalizing these results to other Indian communities.
Summary
The results of these analyses show youths illness/need once again emerged as
the force most strongly related to the likelihood of ADM service use. They also
suggest that external and social environment factors not included in the tested
theoretical model could be the driving factors. The results also imply that the tested
portion of the BMHSU might not be appropriate for the study of adolescent service
utilization. The important finding of referral (a soft or hard coercive push) as
significantly correlated with use suggests that individual-based rational decision-
making models also might not be useful. This study shows that youths internal
belief systems, characteristics, and enabling structures as suggested by BMHSU may
not be as important in understanding their service use patterns as the people that
enable the process. It might be more important to study referral characteristics
69


(coercive or not) and beliefs, as well as social networks and structure as the enabling
factors in the presence of adolescent need. Thus, I suggest that we need to redefine
enabling/coercive factors with respect to the use of services by children and
adolescents.
My results also add support for the Pescosolido et al.s (1995) advocacy for
including social networks and interactions in studies of service utilization. Though
their work is adult-based, it does seem applicable to youth-oriented studies as well.
Traditional utilization approaches conceptualize service use as an individual choice
although acknowledging the importance of social factors. Pescosolido et al.s theory
makes room for other social influences, like soft or hard coercion:
Briefly stated, the availability of social networks (e.g., size, range)
determines the potential influence of social networks to affect use. But
their content (e.g., support, beliefs, values) aligns the direction of the
push toward or away from fomial medical care providers, (p. 1058)
Their Network Episode Model (NEM) Suggests that exploration
the dynamic successful or failed proces
correlates. Specifically in this case, whai
must be included in the study of trouble
Qualitative study can identify these fact
based qualitative inquiry.
must occur in both
ses involved in receiving care as well as their
it other and whose other factors or processes
d youths ADM service utilization?
ors. The next chapter describes an interview-
70


HAPTER4
QUALITATIVE ANALYSIS
Qualitative methods make it possible to uncover many untold
stories concerning the issue under study. Understanding and describing
these issues may eventually lead to changes in complex social phenomenon
such as the behaviors described by a detention administrator:
I like to think that we [detentic
n staff] help, perhaps its, you
know, theres a problem at home.. .they sign a complaint on the
child.... It would give them a chance to cool down, think about
their situation.
.. .because for a while thsre, the foster home in town was
sending a juvenile to JDC for breaking their rules. For their
punishment...Were they breaking any laws though? They [foster
home] were just using the jail to punish youth... Because you
know, they would call the cops and try to charge them with
disorderly conduct. All they had really done ...was violate one of
their rules.
ime to work and see a parent
that that was their punishment
.. .1 really dont like to coi
picking up a kid. And you now
[going to jail]. I dont like to think of that.
This chapter describes the qualitat;
ADM service utilization for troubled yo
knowledge gained through quantitative
ive portion of the multi-method study of
uth. The purpose is to extend on current
analysis by increasing our understanding of


contextual factors that influence servic i
for future exploration. This methodolqg;
e use. These results suggest new hypotheses
;y addressed my second specific aim:
(2) describe the social context of service utilization by which Indian
youth who interface with the juvenile justice system do or do not use
more appropriate ADM services.
My specific research questions for this
What are the other factors that inflin
What is the role of the detention ce
qualitative portion of the study are:
ence youths utilizing ADM services?
nter in the communitys service ecology?
This chapter describes the methods used to begin to answer these questions
and the results of the analysis. It includes a description of sampling, interviews of
both individuals and focus groups, qualitative analytic methods utilized, and results
and discussion of the analysis.
Methods
Because of my interest in generating information that will describe meaning
and culture, I chose naturalistic inquiry, which is also termed constructivist inquiry or
hermeneutics (Crabtree & Miller, 1992). This form of inquiry considers all aspects of
reality interrelated: it is not possible to isolate one aspect from its context without
altering its meaning (Erlandson et al., 1993). It also assumes that there is not a single
reality, but multiple ones of which I, as observer, must be aware.
I chose the methods of both sem i-structured interviews and focus groups so
that inferences could be made from both individuals and groups. The individual
interviews provided more depth in questioning, and the focus groups generated
greater breadth of information.
Human Subjects Review
It was necessary to have this portion of the research protocol reviewed by four
human subjects review committees or internal review boards (IRB). They included
the University of Colorado at Denvers Human Research Committee, IHS Regional
Area IRB/Research and Publication Committee, National IHS IRB, and the tribes
72


Health and Welfare Committee. I originally tried to include adolescent subjects as I
felt strongly that they would be the best source of their experiences. However, one of
the internal review boards (IRB) felt talking with adolescents might entail special
risks, and thus requested a NIH Office of Protection for Research Risk (OPRR)
review. It took approximately six months for this particular IRB to come to this
conclusion. Not wanting to prolong the research for this additional review, I changed
the protocol to include only youths 18
years old could probably provide input
years of age or older. I felt youths 18-20
of their or other adolescents experience
without too much bias. This decision also simplified the consent process by
eliminating the need for parental consent. Appendix D provides the IRB approved
informed consent forms, as well as the IRBs approvals. I did not include the tribal
approval resolution in the Appendix to protect tribal confidentiality.
Sample Selection
The sampling strategy used was opportunistic and required following leads
and taking advantage of the unexpected (Crabtree & Miller, 1992). All subjects were
residents of the reservation. I recruited and interviewed subjects during three on-site,
three-day visits in December 1998 and January and February 1999. Knowing that
qualitative sample sizes are hard to predict, I continued the interviewing process until
I reached saturation, i.e., until no new information seemed to be forthcoming.
Recruitment. All subjects were identified by key informants whom I have
known from my prior IDAP work. The Department of Public Safety, Tribal Health
Department, and the Restoring The Bah nee Project (one of the tribal planning
projects) helped locate appropriate subje cts, requested their participation, and
arranged for necessary consents and meeting logistics. Participants other than
community or tribal service providers received $15 money orders as incentives.
Semi-structured Interviews. I conducted interviews with 11 community
leaders, service providers, and elders to identify social and systemic/policy-oriented
factors that influence adolescent help-seeking behavior. Respondents included three
elders (two female & one male, assisted by an interpreter), the cultural center director,
the chief deputy of detentions, the chief j)f police, the juvenile probation officer, the
juvenile detention administrator, the juvenile police officer, the Restoring the Balance
project director, the cultural coordinator for the Restoring the Balance project, and a
19-year-old male youth leader. I attempted to secure interviews with both the tribal
chairman and the mental health director on each of my three visits. Their busy
73


schedules made that impossible. How ever, the tribal mental health director was very
supportive of the study and did provide many leads to both interview and focus group
subjects.
Focus Groups. I convened five focus groups: one of service providers (child
protection team, which included 10 agency representatives), one of parents
(approximately 12), one of tribal coun cil members (5), one of 19 to 20 year-old males
(4), and one of 19 to 20-year-old femdes (4).
Interview and Focus Group Instruments
The semi-structured interview
Instrument guided and focused inquiry with
individual subjects (See Figure 4.1). The questions and probes were written in the
form of a flexible interview guide. This interview guide solicited information
specifically about a number of issues c f youth help seeking and the role of the
detention center.
I developed a focus group interview guide as a framework within which
decisions could be made about which information to pursue in greater depth or not at
all (see Figure 4.2). This guide kept discussions focused but flexible for
unanticipated but important contextual
information.
Structure of the Interviews and Focus Groups
I called each prospective participant to explain the nature of the interview and
solicit participation. All agreed to be interviewed and selected the interview locations
most convenient for them. The interviews took place at work sites, the Restoring the
Balance Project offices, or homes. Each interview took approximately 45-60
minutes. The interview guide cited above provided structure, but conversations
tended to expand beyond its questions. All subjects seemed genuinely interested in
the topic and appeared to contribute thoughtfully and completely. An interpreter was
used for three of the elders interviews.
Focus groups took place where end when most convenient to subjects. The
focus group of parents was held in the evening at the tribal housing authority offices.
The councilmen focus group took place jduring morning hours at the council offices.
I was able to visit a monthly child protection team meeting to interview service
providers whose main focus was youth issues. The young womens group took place
at a special program for young mothers in a neighboring town, while the young mens
74


focus group was held at a tribally-run
interested and contributed freely.
educational program. People were very
IN-DEPTH INTERVIEW QUESTIONS:
I was part of the study that was done a few years ago of the adolescents that came
into the detention center that looked a t the youths emotional status as well as risk
factors. Now the Tribe and I would like to take this study further by asking those in
leadership positions some questions about youth issues, tribal policy, and help
seeking.
What do you think are the current issues that youth face?
Where do they go to get help?
* Probes: How much does this he;lj
Where wont they go?
P
Why?
What are some things that the commi
* Probes To what extent do these
What doesnt work?
What else is needed?
What are some barriers
unity as whole does that helps youth seek help?
things work?
or things that get in the way?
How do youth end up in jail?
* Probes To what extent does thejjail help the community? In what way?
To what extent does the jail help the youth? In what way?
How can the jail better Kelp the youth?
How can the jail better hjelp the community?
What else might be needed?
What role does the jail play for the community?
Thinking of tribal or community overall policy, what was successful for youth?
* Probes What is the biggest hindrance?
Dream a little, envision a system that helps troubled youth in this community. What
would it look like?
Probes What needs to be done to
make this happen?
Can you think of anything else that I msed to know or understand so that I can help
the Tribe address issues of troubled youth?
Figure 4.1. Interview Guide
75


FOCUS GROUP QUESTIONS:
I would like to start this session by asking some questions about what youth worry about
What kinds of things do you think youth worry about?
* Probes When these issues come up, how do you think youth in this community get
help?
Who do they listen to or ask for help?
Who do you think are the most important?
Who do you think are the least important?
Is this different for youth that end up in trouble with the police and/or end up
detention?
m
Now I would like to ask you to tell me about someones experience in seeking help.
Think of a youth you know who has trild to get help to deal with emotional or substance
abuse problem, then answer the next questions based on what you know about that
youths experience getting help.
What was that experience like?
> Probes What point will a youth seek help?
What, kinds of services will they most likely go to? Why?
What kinds of services will they least likely go to? Why?
How will they get there?
How helpful are they?
Are there any other ways a youth might seek help?
I now want to ask you some qu estions about the jail/detention center.
In this community, how does a youth ;nd up in jail?
* Probes What is the role of the jai
in the community?
In what ways (if any) does it help the youth?
In what ways (if any) does it not help the youth?
What else could it do to better help youth?
Before we finish for the day, is there anything else we havent talked about that will help
me understand how youth seek help?
Figure 4.2. Focus Group Interview Guide
76


Nine of the individual interviews and four of the focus groups were
audiotaped. One focus group and three interviews were not taped due to difficulty
with the audio-recorder. Complete notes of all interviews were entered into a word
processing file. A hired transcriptionist transcribed the audiotapes into computer text
files, for analyses using ATLAS/ti software. To validate the files, I reviewed each
transcript and made necessary corrections.
Analytic Methods
I used the template approach to analyze my text as outlined by Crabtree and
Miller (1992). I created an a priori template of codes and then applied the codes to
the text to organize it for subsequent description and interpretation. I then sorted and
identified segments of text and made fuijther abstractions and added codes where
necessary. I began with a basic codebook based on the interview and focus group
questions and expanded these during multiple readings of the text. ATLAS/ti
software facilitated the coding and sorting process. I then sorted segments of related
text to develop descriptions and interpreiations. This inquiry was an iterative process
which required continual interaction with the data.
Codebook
My first goal was to capture two broad categories around the initial questions
to be explored: 1) factors that influence ssrvice and 2) role of the detention facility in
the community and service ecology (see Table 4.1). I included a general code of
help-seeking knowing this would be complex where subconstructs might emerge. I
retrieved and read the text segments associated with each code and developed more
refined subcodes based on these larger segments of text. This process led to my
revised codebook displayed in Table 4.2.1
Table 4.1 Preliminary Codebook for Individual and Focus Group Interviews
Concept Codes
Influential Factors Role of Detention Facility Youth Help-seeking Other Factors Role Help-seeking
This final codebook contains the o detailed subcodes. It incorporates additio identified key factors that provided deepei riginal a priori codes (in bold) and the tal codes that emerged. These latter codes insights into youths experiences.
77


Table 4.2 Final Codebook for Individual and Focus Group Interviews
Concept Codes
Influential Factors Other Factors
Cultural Influences Culture
Historical Influences History
Spiritual Ways Spiritual
Traditional Ways Traditional
External Factors External
Issues Issues
Community Policy Policy
Community Resources Resources
Lack of funds Funds
Barriers Barriers
Service Ecology Services
Characteristics of Enablers Enablers
Counselors Counselors
Parents Parents
Family Structure Family Structure
Parental Discipline Parental Discipline
Service Providers Service Providers
Individual Individual
Courts Courts
Help Seeking Help Seeking
Attention Attention
Needs Needs
Parental Needs Parental Needs
Who Youth Go To Go To
Trust Trust
Who Wont Go To Wont Go
Dreams Dreams
Coercion Coercion
Basketball Basketball
Politics Politics
Role of Detention Facility Role
Protection of Community Protection (Community)
Protection of Youth Protection (Youth)
Shelter for Youth Shelter
Time Out for Youth Time Out for Youth
Brokering of Service Broker
Punishment of Youth Punishment
Deterrent for Youth Deterrent
Parental Discipline Parent Discipline
Baby-sitting of Youth Baby-sitter
Meeting Space for Community Meeting Space
Earned Badge of Honor Honor
78


Providing Description Summaries
Once my segments were coded bid sorted, I summarized the data to describe
context. I determined which themes seemed to be recurring regularly. I then
reviewed text segments from the subcodes for further refinement. This procedure
allowed a coherent description while exploring hypotheses. Triangulation or
confirmation from other respondents and focus group discussion verified the
credibility, dependability and confirmaoility of these analyses (Crabree and Miller,
1992). I
Results
The qualitative results are presented in three subsections. The first section
identifies factors from the interviews and focus groups that were not explored
quantitatively in Chapter 3. The second section focuses on emerging themes. Lastly,
the role of the detention facility within the community and service ecology is
described.
Factors Influencing Troubled Youths Service Utilization
While no direct questions were asked about factors that influence service
utilization, I did ask questions concerning where youths seek help and where they
would not go. These questions were very simple to encourage respondents to tell
their stories. Two broad categories emerged from this analysis: 1) cultural
history/heritage, and 2) the youths external environment. Each of these broad
categories was subcoded for further refinement.
ofte
Cultural Historv/Heritage. We often believe that we are destined to be who
were are because of who we come from. Our personal identity is linked with our
history. Indian people are no exception. Stories emerged from mostly the adult
respondents, groups of parents, and councilmen concerning the perceived discordance
between their traditional and presently modem expressed values. Youth groups did
not mention this loss. One example included the discord between past reverence for
children and elders with the current tribal and individual priorities that did not include
these age groups. These stories emerged ir
the context of perceived loss of
79


traditional cultural values in the areas
Indian identity, and gender roles. One
of responsibility, parenting, cultural activities,
parent said:
We need to have more caring, th at used to be shown to elders in our
community, or in our bands, or whatever. This held the families together
as a unit, with a lot of care and pride.. .we say we love our elders and
children, but we are doing nothing for them
Another parent commented:
I was raised by a mother who grew up in boarding school, and a non-
native father on the east end of the reservation. I would say, I came
from the Hang Around the Fort people. But the native culture,
traditionally, it was ideal... There were safeguards built in to prevent
this kind crap thats going on. I mean, no one messed with it. Its like
the extended family with safeguards built in...we lost all that. Right in
the middle of it came chemical dependency, and the government that
our tribe has adopted.
Responsibility. Another emerging issue from the adult interviews and
discussions was related to defining who is responsible for youths. My general
assumption was that if no one assumes responsibility for the youth, no one aids in
their seeking of services. Although everyone knew who needed the help, no one
took responsibility for getting that help. Service providers were most concerned.
Youths did not mention this as an issue for them. An officer stated:
Thats the double standard we now live by. We say, traditionally,
our children were safe here. Thai
was one of the things that we
learned from [legendary spiritual figure]. Two things she said, That
you respect and take care of your elders. And again you take care of
the children. We say it but we dont practice it. The other thing
80


weve gone away from is that people dont believe that they should be
responsible for other children. Again, were so afraid. Close our
doors and were just not going to pay attention. Its not my child, I
dont have to deal with it.
A parent concurred:
I guess its just a lack of parental.. .wanting to do it. To take the place of
that, you have to have a special person that really knows what hes doing
and take that parents place... Je dont have that anymore.
A council member agreed:
.. .one of the things is that its coming to the point where social services
is getting involved in legally bringing the father and mother of these kids
and taking them to court and mailing them be responsible. Because right
now, theyre [cared for] by a lot of grandparents picking up, a big
number of grandparents watching these kids.
Loss of Indian Identity. Many adults cited the loss of Indian identity as a big
problem for youth and their adult caretakers, and they felt this has led to the
breakdown of caring in the traditional way. This issue did not emerge in youth
discussions. One council member remarked, identity has to be brought back. Right
now, our .. .kids are all wearing baggy paints and listening to rap music. And that [is]
a culture that belongs to somebody else.
now, theyre not black, theyre not Hispanic, theyre Native American children. But
its almost like theyre ashamed of that.
An officer concurred, but the kids right
One council member remarked, So they
need to come back to the XXX Indians. Parents dont teach their children the XXX
way. So without knowing that, they pick pp other cultures. One parent talked to the
adults loss of identity:
It needs to lead us toward traditional ways because they were
ideal... we all helped each other then. Some want to belong to



the dominant society, and adopt those dominant society
values... nowadays some parents dont want their children
taught the old ways.
One service provider commented:
But there are a lot of parents on this reservation that dont want
their children getting into the cultural stuff. I found that out. I
even had people that said, I dont want to see her. I dont
believe in that.
Loss of Cultural Activities. The elders did not speak in terms of loss of
culture, but loss of cultural activities. They believed that youth need to be kept
busy to stay out of trouble. One way to keep them busy was by turning to cultural or
things that they did activities. One elder remarked:
I think horses played a big part in it. Yeah, when we were
children, we had horses and wed go horseback riding.
Nowadays, you dont see horseback riders. The kids dont
know how to ride. Yeah, we always were busy and we always
felt safe. Being with nature and nding horseback. The [river]
was our playground. I think the kids would love that.
Another elder concurred:
Another thing, we make costumes for them and they dance at
pow-wows. And that keeps them from running around. Like
me, I danced for [many] years. For prize money, you know. I
always talk to them.. .you can be a
basketball player or
82


whatever you want but you still
yourselves busy, make money.
can be a dancer.. .keep
Another elders dream for youth included a garden:
A big community garden that all youth can learn from. Id teach them
how to make the soil just right, how to pray, the right way to seed, how
to tend....then the ceremony around harvest would come.. .yes, that is
what I would do.
Another said, Yeah, I think ...it was easier for us at home when we were children
because we were always busy. We always had something to do. And we always had
to have our work done before we went swimming.
Almost all individuals and groups including the youths noted a lack of
activities for youths. The youths, howev
sr, mentioned their want of activities as a
need for a youth center that has an arcade, movies, basketball,... stuff like that.. .you
know recreational. There was no mention of the more traditional activities. A
parent concurred, Theres nothing recreational, really positive for them to do. There
are not a lot of options. If youre not a star basketball player.. .then what do you do?
Loss of Cultural Roles. Two couijtcilmen emphasized the loss of the
traditional male role in their society and its affect on youth. They talked about how
women have taken over most of the burden of providing for the family. Their
.. .bringing home the bacon resulted in less time to properly take care of the family.
One councilman said:
The Indian culture always.. .has been the Indian males as providers of
the family. ..we dont have a lot off opportunities for jobs here, so we
the males have a tendency to fall djown.. .have to approach the welfare
office, then you are sucked into the system. The welfare people are
protective of the children which then .. .a wedge in between the parent
and the children. The Indian males lose their integrity, and in turn it is


hard to feel good about themsel ves, and they take it out on the children.
Indian males are sort of lost.
The women have stood up and taken the leadership roles now
too. Im not against that. But the balance that were talking about,
once the women start doing this, then I think the balance kind of went
out of balance. But theyre doing that because the males are not
fulfilling their responsibility. Theyre saying If youre not going to do
it, then Im going to do it. Then who is left for the family?
Another councilman stated:
Be able to stand up and work, be able to earn money for our families.
That should be brought back. In
before the white men came, the
the olden days, the ancestor days,
amily structures were already there.
The men took care of the whole village... It was their responsibility.
Loss of Parenting Skills. In the last quarter of the 19th and first half of the
20th centuries during boarding school removal, whole generations of children were
separated from their traditional caregivers, the extended family. This removal
resulted in childrens loss of their cultural ways (Swinomish Tribal Mental Health
Project, 1991). Literature cites one generational consequence of this experience as
loss of traditional child rearing skills. This experience somehow resulted in the
widespread belief that Indian people could not be good parents. Generations of
parents were denied the experience of a normal nurturing Indian life and thus
parenting role models. Some of these children are now in their parenting and
grandparenting years. This loss came up
groups, and hit especially home with the
admitted:
juite frequently in the adult interviews and
discussion with parents. One parent

There's a lot of truth to all of that.
My mother was, my grandmother
I'm a product of a boarding school,
was. I didn't always agree with how mom
raised us. She did the best she could knowing, what she did. I don't know if
that's so much an excuse. I find that in this community, because we're aware of
84


all this information and to me, for a lot of people, it's a cop out. That, we're a
product of XXX school, so we don't know how to parent our children, so it's not
our fault, so we're off the hook.
Another parent remarked:
Because I missed, growing up... I didnt understand the Indian religion
and all that... through drinking and through boarding school, I lost all of
that. I said all of us kids used to [speak the language] at the boarding
school. All that got taken away. We were stripped of everything. And
with alcohol... everything that my grandma taught, my grandfather, we
lost it all. I lost it all.
External Environmental Factors,
apparent that external factors influenced
While reviewing the text segments, it was
youths help seeking. The locus of these
outside influences were generally 1) community-wide or 2) involved characteristics
of those who had some power or control of youth help-seeking .
Community-wide Factors. The m
into categorizes of resources, community
ore general overarching factors clustered
policy, and service ecology .
Resources. Most adult discussion of resources centered around the
lack of people and money for needed services. Service providers, parents, and
councilmen seemed to be resigned to this fact and felt helpless. Some determined
parents, on-the-other-hand, kept pushing the system to create change. Lack of
resources was not important in youth discussions. One councilman stated, Theres
no way that we have genuine resources available to attack this problem. I think at the
present time, were sitting back hoping that this problem is going to go away.
Another one said, But maybe... it will take money, to create jobs, so they can feel
good about themselves and assume their responsibilities as role models, as parents.
One service provider felt that she had to remind me that, .. .our people come from
great poverty. And they do what they need to do in their lives. One parent related,
How do youth go to treatment anymore? XXX outpatient doesnt have the funding
to send all these kids out that need inpatient. However, she also admitted:


You kind of have to work the system. Youve go to go out there, work
with XXX mental health, other places. Youve got to know what the
resources are...you have to beat the bushes to find how you can get help
for your own child. No ones out there saying we can serve your child.
A lot of people do nothing, were not all the same.
Many service providers made comments about the high caseloads. As an
example, Then the problem comes bade to another problem, it is the number of
people to help kids. XXX is seeing kids constantly. XXX has way too many kids on
her caseload. As another one said, It comes down to the numbers game, the number
of people that will help these kids, when were full, there are no options, because of
the money thing.. .its kind of a circle. One service provider summed it up: Theres
not enough juvenile probation officers, theres not enough child protection service
workers, theres not enough time on the court docket to deal with this.
One youth said, Like even if they build a big huge youth center, theres no
transportation there. Community members and councilmen spoke of the availability
of employment. Jobs and social development is what we need one pointed out, and
another added:
1
Were in a depressed area. The reservation sometimes can compare to a
third world country, because of the lack of opportunities. I envision
mainstream America, like Knots L
anding: nice house, cement driveways,
basketball hoops, paved and lighted streets. A father and mother for
parents. And the reservation life is totally opposite. The streets are
muddy, theres no sidewalk, to play basketball you have to go to a
gymnasium. Single parents.. .Kids: are growing up in broken homes, in
some cases, the parents refuse to rdse them anymore, they abandon them.
They have no place to go but to the grandparents. Can the grandparents
handle them?... they end up at the JDC.
Community Policy. It was widely
their needs did not receive enough attentio
felt that as a policy issues, youths and
n. Both adult and young adult respondents
86