Kelley Sittner

We describe stages of opioid and psychostimulant use (i.e., onset of use and progression to dependence) over the early life course within Indigenous communities where drug overdose impacts have been most extreme. This community-based participatory research includes 9 waves of survey data collected prior to and during the unfolding of the overdose epidemic in North America (2002-2017) on/near 8 distinct American Indian reservations or First Nation reserves. Substance use (psychostimulants, prescription pain pill misuse, and heroin) was assessed via structured diagnostic interviews. Discrete time survival analysis was used to estimate hazard rates for substance use initiation, dependence, and transitions from first use to dependence. Cumulative probability of lifetime use by age 27 years was 29 % for psychostimulants (e.g., methamphetamine), 35 % for prescription pain pills, and 22 % for heroin. New cases of prescription pain pill misuse peaked in the early 2000s, followed by rapid increases in psychostimulant and heroin use starting around 2008. We found that 37 %-51 % of drug users eventually met criteria for dependence, and progression from use to dependence was typically within one year for this sub-group. Socio-demographic factors were differentially associated with probability of substance use, depending on drug type. Findings highlight the critical need for culturally grounded prevention, harm reduction, and treatment strategies to address substance use inequities in Indigenous communities.

Indigenous Peoples experience the highest age-adjusted prevalence of type 2 diabetes of any racial group in the U.S. Though the management of type 2 diabetes requires regular healthcare visits, North American Indigenous individuals with diabetes do not always utilize the healthcare available to them, and this lack of utilization may lead to poor health outcomes over time. Drawing on literature showing that North American Indigenous patients experience discrimination in healthcare and that experiencing discrimination in healthcare is associated with healthcare avoidance and/or delay, the current study conceptualized unmet healthcare utilization as healthcare avoidance and used path analysis with longitudinal data (four points of data collection) to examine the relationships between healthcare discrimination, healthcare avoidance, and self-rated health in a sample of 192 Indigenous adults with type 2 diabetes from the northern Midwest U.S. We found that healthcare avoidance was negatively associated with baseline self-rated health, and that healthcare avoidance partially explained the negative effect of lifetime healthcare discrimination on self-rated health at the final follow-up of the study. These results show that healthcare avoidance statistically mediates the relationship between healthcare discrimination and self-rated health and suggest that healthcare avoidance is an important mechanism linking healthcare discrimination to worse self-rated health over time. Ultimately, we argue that creating more inclusive and less microaggressive healthcare spaces is important for individual health outcomes and macro-level health inequities. Continued efforts to understand instances of and to diminish healthcare mistreatment of Indigenous Peoples are recommended.

OBJECTIVE: <AbstractText Label="OBJECTIVE" NlmCategory="OBJECTIVE">Indigenous communities in the United States and Canada have endured generations of historical trauma. In the face of ongoing marginalization, Indigenous Peoples persist, resist, and thrive. Simultaneously, the consequences of historical trauma are vast and enduring. For instance, there is significant variation in how depression symptoms unfold over the life course. The aim of this study is to examine longitudinal, intergenerational associations between historical trauma and depression symptoms among Indigenous young adults.</AbstractText> METHOD: <AbstractText Label="METHOD" NlmCategory="METHODS">Analyses include data from target participants (ie, children at baseline) and their primary female caregivers (eg, parents) from Healing Pathways (HP), a community-based participatory study that began in 2001/2002 with families from 8 First Nations in the United States and Canada. All eligible children (10-12-years of age at baseline, enrolled tribal members, living on/near reserve land) and at least one of their caregivers were invited to participate, and were interviewed annually for 8 years. Three additional years of interviews were conducted starting in 2017 with baseline-enrolled children, now young adults. Caregivers and their now young adult children completed measures of depression symptoms, family boarding/residential school (BRS) history, and other family sociodemographic variables.</AbstractText> RESULTS: <AbstractText Label="RESULTS" NlmCategory="RESULTS">Group-based trajectory modeling identified 4 depression symptom trajectory groups: low (28.7%), decreasing (26.6%), increasing (22.4%), and high (22.3%). Multinomial logistic regression analyses, with the low symptom group as the referent group, revealed that familial BRS history doubled the odds of being in the high symptom group (odds ratio = 2.05, p &lt; .05) compared to the low symptom group. Being female, experiencing discrimination, and caregiver (eg, parental) history of depression increased the odds of being in the high symptom group, whereas experiencing warm and supportive parenting decreased the odds of being in the high symptom group.</AbstractText> CONCLUSION: <AbstractText Label="CONCLUSION" NlmCategory="CONCLUSIONS">The intergenerational effects of historical trauma remain ongoing and harmful to Indigenous populations. Current findings illuminate several factors that may be particularly salient among subsequent Indigenous generations, and provide implications for prevention efforts.</AbstractText> PLAIN LANGUAGE SUMMARY: <AbstractText Label="PLAIN LANGUAGE SUMMARY" NlmCategory="CONCLUSIONS">This study examined longitudinal data of children and their primary female caregivers from Healing Pathways, a community-based participatory study with 525 Indigenous families from 8 First Nations in the US and Canada that began in 2001 and 2002 when the child participants were 10 to 12 years old and followed them until they were 24 to 29. Multinomial logistic regression analyses revealed that having a familial boarding residential school history, being female, experiencing discrimination, and caregiver history of depression increased the odds of having depression, while experiencing warm and supportive parenting decreased the odds of depression into adulthood for Indigenous now-young adults. That both discrimination and familial experiences of historical trauma were associated with depression symptoms underscores the need for the development of population-based mental health interventions.</AbstractText> DIVERSITY & INCLUSION STATEMENT: <AbstractText Label="DIVERSITY &amp; INCLUSION STATEMENT" NlmCategory="UNASSIGNED">We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. Diverse cell lines and/or genomic datasets were not available. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list.</AbstractText>

Understanding the role of place in connection to Indigenous youth participation in nature-based traditional and spiritual activities (NBTSA) is of primary concern as exposure to both nature and culture collectively contribute to overall health and wellbeing. From oppressive historical Indian policies to contemporary barriers by way of climate change and increased use of technology, Indigenous youth continue to face risk of detaching from nature and losing pieces of their cultural identity. Qualitative and quantitative features of place in predicting NBTSA participation among Indigenous youth are not well understood and may offer key insights that connect youth to land, water and their cultures. Moreover, application of the Indigenous Traditional Ecological Knowledge (ITEK) theoretical model to inform the social sciences has largely been absent. In this study, we sought to investigate the role of place measured by residing in a sovereign Tribal or First Nation (qualitative) and increased presence of greenspace (quantitative) exposure on participation in NBTSAs among Indigenous youth. Our findings demonstrate that although increasing residential exposure to greenspace had a positive association, residing in a Tribal Nation was a stronger predictor for NBTSA participation. Applying an Indigenous methodology to research with Indigenous populations and communities allows us to move beyond general notions of what (e.g., greenspace) promotes human-nature interaction and, instead, identify place-based determinants. Namely, the ITEK framework guided our rationale to include Tribal Nations in our study. Sovereign Nations connect youth to traditional knowledge holders that share Indigenous knowledges and practices of the land and water through story and experiential learning. Significance. This study is one of the first to measure both qualitative and quantitative features of place that influence human-nature interaction among youth that collectively identify as Indigenous. Our research found that residing in a sovereign Tribal Nation is a stronger predictor than increasing exposure to greenspace for participating in land- and water-based traditional and spiritual practices providing evidence and public health implications for Indigenous determinants to health and wellbeing.

<b>Background:</b> American Indians (AIs) endure the most severe health inequities in the nation, including disproportionately high rates of Type 2 diabetes (T2D). We describe baseline characteristics for AI participants enrolled in a culturally grounded, intergenerational, home-based T2D preventive intervention called <i>Together Overcoming Diabetes</i> (TOD). <b>Methods:</b> This community-based participatory research collaboration between five tribal nations and university-based researchers launched recruitment for a waitlist randomized control trial (RCT) design in 2021. Eligible participants were adults diagnosed with T2D who self-identified as AI, lived on or near participating reservations, and were caregivers to youth aged 10-16 years. Participants completed baseline assessments upon enrollment before being randomized to the intervention or waitlist group. <b>Results:</b> A total of <i>N</i> = 162 individuals (81 adults and 81 youth) enrolled in the study. Most of the adult (Indigenous) sample reported being female (77.8%) and were on average 49.5 years old. Average age of youth participants was 13.2 years, with similar representation of girls and boys. Mean adult HbA1c (primary outcome for the trial) was 7.93 (SD = 1.99) at baseline. Around 19% of youth participants reported a T2D or prediabetes diagnosis. Additional demographic and holistic health results are presented. <b>Conclusion:</b> This study provides comprehensive information about physiological, psychological, behavioral, and sociodemographic characteristics for a sample of AI families enrolled in a T2D intervention study. Findings suggest that intervention goals to improve behaviors like diet and physical activity are warranted and highlight the need for policy changes to address the social determinants of health. <b>Trial Registration:</b> ClinicalTrials.gov identifier: NCT04734015.

American Indian (AI) people experience disproportionate exposure to stressors and health inequities, including type 2 diabetes (T2D) and mental health problems. There is increasing interest in how historical trauma and ongoing experiences of discrimination and marginalization (i.e., historical oppression) interact to influence AI health. The purpose of this study is to examine the relationships between historically traumatic experiences (i.e., boarding schools, relocation programs, and foster care), current reports of historical cultural loss, microaggressions, and their relationship to internalizing symptoms among AI adults living with T2D. This community-based participatory research study with five AI tribal communities includes data from 192 AI adults with T2D recruited from tribal clinics. Results from structural equation modeling revealed that personal experiences in foster care and ancestral experiences in boarding schools and/or relocation were associated with increased reports of historical loss, and indirectly associated with internalizing symptoms through racial microaggressions and historical losses. The findings highlight the importance of considering multiple dimensions of historical trauma and oppression in empirical and practice-based assessments of mental health problems.

Juvenile arrest serves as a critical turning point in the life-course that disrupts the successful transition to adulthood and carries numerous consequences including diminished socioeconomic status. Despite their disproportionately high rates of contact with the criminal justice system (CJS), Indigenous people's experiences remain largely invisible in extant research. Further, colonization has left them in an extremely marginalized position in terms of social, economic, and political power, which is compounded by CJS involvement. In the current study, we apply propensity score matching to investigate whether being arrested in adolescence impacts early adult socioeconomic outcomes (i.e., education, employment, and income). Data come from the Healing Pathways project, a longitudinal, community-based participatory study of North American Indigenous young people that includes eight waves of data in adolescence and three waves in early adulthood. We find that being arrested at least once in adolescence is associated with significantly less education and income, and lower rates of full-time employment in young adulthood (mean age = 26.2 years). Criminal justice system involvement widens existing socioeconomic disparities, and remedying these consequences requires changes in how CJS policies are enacted as well as larger structural changes to address significant inequities in income, education, and employment for Indigenous people.

OBJECTIVE: Indigenous Peoples and scholars call for strengths-based approaches to research inclusive of Indigenous resiliency and positive outcomes. The purpose of this study was to examine positive mental health for Indigenous adults with type 2 diabetes and to determine if positive mental health is linked to community connectedness (a coping resource) and active coping (a coping response). METHODS: Participants (N  = 194 at baseline) were randomly selected from clinical records, at least 18 years old with a type 2 diabetes diagnosis, and self-identified as American Indian. RESULTS: Latent growth curve models revealed that average positive mental health was predicted to decrease over the four waves of the study, although not for participants with above-average active coping at baseline. Community connectedness at baseline was associated with higher initial levels of positive mental health. Within-person change in active coping and community connectedness were both associated with increases in positive mental health. CONCLUSION: This study aligns with previous research demonstrating that coping can influence health outcomes, and furthers the stress process literature by showing that active coping and community connectedness can impact positive mental health for Indigenous adults with Type 2 Diabetes.

"Volunteer participation" refers to free engagement in activities that benefit someone or something else. Volunteering can produce many benefits for individuals and communities. However, current research examining volunteer participation often excludes diverse viewpoints on what constitutes volunteering, particularly the perspectives of North American Indigenous youth. This oversight may result from researchers' conceptualization and measurement of volunteering from a Western perspective. Utilizing data from the Healing Pathways (HP) project, a longitudinal, community-based participatory study in partnership with eight Indigenous communities in the United States and Canada, we provide a detailed description of volunteer participation and community and cultural engagement. Overall, we employ a community cultural wealth lens to emphasize the various strengths and sources of resilience that these communities possess. At the same time, we encourage scholars and the wider society to broaden their views of volunteering, community involvement, and giving back.

We used a novel measure of cultural efficacy to examine empirical pathways between enculturation, efficacy, and two wellbeing outcomes. Cultural factors are not consistently linked to better wellbeing in the academic literature despite widespread understanding of these processes in Indigenous communities. Healing pathways is a community-based participatory study with eight reservations/reserves in the upper Midwest and Canada. This study uses data collected in 2017-2018 (n = 453, 58.1% women, mean age = 26.3 years) and structural equation modeling to test the relationships between enculturation, cultural efficacy, and mental health. The direct effect of enculturation on anxiety was positive. The indirect effect of enculturation via cultural efficacy was negatively associated with anxiety and positively associated with positive mental health. Cultural efficacy is an important linking variable through which the protective effects of culture manifest. The complex nature of culture must be met with innovative measures and deep understanding of Indigenous peoples to fully capture the protective role of culture.

Indigenous communities lack representation in psychiatric epidemiology despite disproportionate exposure to risk factors. We document the cumulative and 12-month prevalence of psychiatric disorders across the early life course among a sample of Indigenous young adults and compare prospective and retrospective reporting of lifetime mental disorders. This community-based participatory research includes data from 735 Indigenous people from 8 reservations/reserves. Personal interviews were conducted between 2002–2010 and 2017–2018 totaling 9 waves; diagnostic assessments of DSM-IV-TR alcohol abuse/dependence, marijuana use/dependence, other substance abuse/dependence, generalized anxiety disorder, major depressive disorder, dysthymic disorder, and attention deficit/hyperactivity disorder occurred at waves 1 (mean age = 11.1 years), 4 (mean age = 14.3 years), 6 (mean age = 16.2 years), 8 (mean age = 18.3 years), and 9 (mean age = 26.3 years). Cumulative lifetime psychiatric disorders reached 77.3% and lifetime comorbidity 56.4% by wave 9. Past-year prevalence and comorbidity at wave 9 were 28.7% and 6.7%, respectively. Substance use disorders (SUDs) were most common with peak past-year prevalence observed when participants were on average 16.3 years old then declining thereafter. Trends in early life course psychiatric disorders in this study with Indigenous participants highlight cultural variations in psychiatric epidemiology including surprisingly low rates of internalizing disorders in the face of risk factors, disproportionately high rates of early-onset and lifetime SUD, and lower rates of past-year SUD in early adulthood compared with prior research.

Poor glucose control can be viewed as a stressor, possibly promulgating diabetes distress. We examined the relationship between perceived blood glucose control and diabetes distress over time using a partially controlled cross-lagged path analysis model. After controlling for demographics, control at 6 months was directly related to change in distress at 12 months. Subsequently, distress at 12 months was directly related to change in control at 18 months. Both 6-month control and distress had significant indirect effects on 18-month control and distress. This demonstrates the nuanced bi-directional relationship between the stress of poor perceived control and diabetes distress.

Exposure to violence and substance abuse are salient public health concerns among Indigenous people (i.e., American Indian and Canadian First Nations). Despite this, little research has examined the association between the two among community-based reservation/reserve samples, or factors within the broader social environment that may moderate this association. As such, the purpose of the study is to examine ecological moderators of the association between direct (i.e., dating violence victimization) and indirect (i.e., current perceptions of community violence and prospective caretaker-reported victimization exposure) exposure to violence and meeting diagnostic criteria for a substance use disorder among a large longitudinal sample of Indigenous youth and their caretakers in the upper-Midwest of the United States and Canada (<i>N</i> = 521). Data come from the last two waves of the study, when the adolescents were between the ages of 16 and 19 years. The results show relatively high rates of direct and indirect violence exposure by late adolescence. Logistic regression models with added interaction terms were examined to test moderating effects. Per capita family income and remote location both amplified the positive association between current community violence exposure and substance use disorder risk. Family warmth and support buffered the association between caretaker victimization exposure and substance use disorder risk, whereas dating violence victimization exposure amplified this association. The findings are contextualized for Indigenous communities, and substance abuse prevention and intervention implications are discussed.

OBJECTIVE: The current study examined the developmental interrelationships between alcohol and marijuana use trajectories from ages 10 to 18 years in a sample of North American Indigenous adolescents. Distinct co-use groups were formed to create profiles of young adult outcomes. METHOD: Dual group-based trajectory models of marijuana and alcohol frequency were estimated using data from a longitudinal community-based participatory study of Indigenous adolescents from the upper Midwest and Canada. Joint probabilities were used to create co-use groups, and profiles were created using early adult (Mean Age - 26.28 years) outcomes. RESULTS: Four joint trajectory groups were identified: 1) no marijuana and no/low alcohol use (34.4%), 2) mid-onset alcohol only (14%), 3) mid-onset co-use starting at age 13 (24%), and 4) early-onset co-use starting at age 11 (22%). High probabilities existed that adolescents would use marijuana early if they began drinking alcohol at the youngest ages, and that adolescents would not use marijuana if they drank infrequently or delayed drinking until mid-adolescence. Adult outcomes were poorer for the early- and mid-onset co-use groups, but there were few differences between the no/low use and alcohol-only groups. CONCLUSION: Co-use of marijuana and alcohol was associated with poorer outcomes in early adulthood, particularly for the group with an earlier age of onset. Abstaining from either substance in adolescence was associated with better outcomes.

The COVID-19 pandemic has had disproportionately severe impacts on Indigenous peoples in the United States compared to non-Indigenous populations. In addition to the threat of viral infection, COVID-19 poses increased risk for psychosocial stress that may widen already existing physical, mental, and behavioral health inequities experienced by Indigenous communities. In recognition of the impact of COVID-19 related psychosocial stressors on our tribal community partners, the Johns Hopkins Center for American Indian Health Great Lakes Hub began sending holistic wellness boxes to our community partners in 11 tribal communities in the Midwestern United States and Canada in summer of 2020. Designed specifically to draw on culturally relevant sources of strength and resilience, these boxes contained a variety of items to support mental, emotional, cultural, and physical wellbeing. Feedback from recipients suggest that these wellness boxes provided a unique form of COVID-19 relief. Additional Johns Hopkins Center for American Indian Health offices have begun to adapt wellness boxes for the cultural context of their regions. This case study describes the conceptualization, creation, and contents of these wellness boxes and orients this intervention within a reflection on foundations of community-based participatory research, holistic relief, and drawing on cultural strengths in responding to COVID-19.

OBJECTIVE: The objective of this study is to understand how Indigenous language and spirituality revitalization efforts may affect mental health within Indigenous communities. Although Indigenous communities experience disproportionate rates of mental health problems, research supporting language and spirituality's role in improving mental health is under-researched and poorly understood. METHOD: Data for this study are from a Community-based Participatory Research Project involving five Anishinaabe tribes in Minnesota and Wisconsin. Participants were sampled from clinic records of adults with a diagnosis of type 2 diabetes, living on or near the reservation, and self-identifying as American Indian (mean age = 46.3; <i>n</i> = 191). RESULT: Structural equation modeling illustrates that language use in the home is associated with positive mental health through spiritual connectedness. CONCLUSION: Results support tribal community expressions of the positive effects of cultural involvement for Indigenous wellbeing, and improve what is known about the interconnectedness of language and spirituality. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

INTRODUCTION: North American Indigenous people (ie, American Indian/Alaska Native and Canadian First Nations) have the highest rates of commercial cigarette smoking, yet little is known about long-term trajectories of use among this population. The purpose of this study is to examine heterogeneous trajectories and profiles of Indigenous cigarette use frequency from early adolescence (mean age: 11.1 years) to young adulthood (mean age: 26.3 years). AIMS AND METHODS: Data come from a nine-wave prospective longitudinal study spanning early adolescence through young adulthood among Indigenous people in the Upper Midwest of the United States and Canada (N = 706). Smoking frequency was examined at each wave, and latent class growth analysis was used to examine heterogeneous patterns. Early adolescent and young adult demographics and smoking-related characteristics were examined across these latent trajectory groups. RESULTS: In young adulthood, 52% of participants smoked daily/near-daily, and an additional 10% smoked weekly or monthly. Four latent trajectory groups emerged: low/non-smokers (35.2%) who had low probabilities of smoking across the study; occasional smokers (17.2%) who had moderate probabilities of smoking throughout adolescence and declining probabilities of smoking into young adulthood; mid-adolescent onset smokers (21.6%) who showed patterns of smoking onset around mid-adolescence and escalated to daily use in young adulthood; and early-adolescent onset smokers (25.9%) who showed patterns of onset in early adolescence and escalated to stable daily use by late adolescence. CONCLUSIONS: The findings suggest multiple critical periods of smoking risk, as well as a general profile of diverse smoking frequency patterns, which can inform targeted intervention and treatment programming. IMPLICATIONS: Nearly two-thirds (62%) of this sample of Indigenous people were current smokers by early adulthood (mean age = 26.3 years), which is substantially higher than national rates in the United States and Canada. Moreover, in all but one trajectory group, smoking prevalence consistently increased over time, suggesting these rates may continue to rise into adulthood. The longitudinal mixture modeling approach used in this study shows that smoking patterns are heterogeneous, and implications for public health policy likely vary across these diverse patterns characterized by timing of onset of use, escalation in frequency of use, and stability/change over time.

<i>Background.</i> Medication adherence is negatively related to both diabetes distress (DD) and depressive symptoms (DS). Past research suggests gender differences in adherence, DD, and DS. A gap exists in determining if gender differences in adherence are mediated by DD and DS, or if gender moderates differences in adherence by DD/DS. <i>Aims</i>. This study investigated the relationship between gender, DD, DS, and medication adherence and tested for mediating and moderating effects on medication adherence among American Indian adults with type 2 diabetes. <i>Method</i>. The Maawaji idi-oog mino-ayaawin (Gathering for Health) study was a community-based participatory research collaboration with five American Indian tribes. Participants, randomly recruited from clinic records, shared information during computer-assisted personal interviews. This study includes the 166 participants who reported using medications to treat their diabetes. The relationship between gender, DD, DS, and medication adherence are explored. Possible mediating and moderating effects on medication were tested using regression and path analysis. <i>Results.</i> Females had higher levels of DD and DS and lower levels of medication adherence. Higher levels of DD and DS were both associated with lower medication adherence. No evidence was found that gender moderates the relationship between DD or DS and medication adherence. Instead, DD and DS mediated the relationship between gender and medication adherence. <i>Conclusions</i>. Medication adherence differences in male and female patients may be attributable to DD and DS. The present research highlights both DD and DS as targets for clinicians and researchers alike.

OBJECTIVES: Drawing from an integrated general strain theory framework, the purpose of the study is to examine the longitudinal mediating and moderating mechanisms linking perceived racial discrimination with aggressive delinquency among North American Indigenous (i.e., American Indian and Canadian First Nations) youth. METHODS: Data come from an eight-year longitudinal study of Indigenous youth residing on reservations/reserves in the upper-Midwest and Canada (N = 659). Scales were created for discrimination, depressive symptoms, school bonds, and delinquent peer associations at years 2 and 3, and a count measure of aggression was created at years 2, 3, and 5. Cross-lagged path analysis models were estimated to examine possible mediating effects of depressive symptoms, school bonds, and delinquent peer associations. Separate regression models were examined to test for possible moderating effects of the aforementioned variables. RESULTS: The results of a longitudinal path analysis model showed that discrimination indirectly increased aggression through decreased school bonds and increased delinquent peer associations. Depressive symptoms was the only significant moderator, and contrary to expectations, the effect of discrimination on aggression declined in magnitude as depressive symptoms increased. CONCLUSIONS: Discrimination is a key criminogenic stressor among Indigenous youth and is linked with multiple adverse outcomes through the adolescent years.

North American Indigenous (i.e., American Indian and Canadian First Nations) youth experience inequities in rates of substance abuse and dependence. Despite this, few longitudinal studies examine the developmental course of substance use disorders (SUD) among community-based samples of Indigenous youth. The purpose of the study was to examine onset and predictors of nicotine dependence, alcohol use disorders, marijuana use disorders, any SUD, and multiple SUDs across the entire span of adolescence among a longitudinal sample (N = 744) of reservation/reserve Indigenous youth in the upper-Midwest of the United States and Ontario, Canada. Using discrete time survival analysis, the results show that rates of meeting criteria for SUDs by late adolescence were 22% for nicotine, 43% for alcohol, and 35% for marijuana. Peak periods of risk for new nicotine dependence and marijuana use disorder cases occurred around 14 years of age, whereas peak periods of risk for new alcohol use disorder cases emerged slightly later around 16 years of age. We found high rates of SUD comorbidity, and the cumulative probability of developing two or more SUDs during adolescence was 31%. Internalizing disorders increased the odds of nicotine dependence and multiple SUDs, while externalizing disorders increased the odds of all outcomes except nicotine dependence. Gender, age, and per capita family income were inconsistently associated with SUD onset. The findings are embedded within broader substance use patterns identified among Indigenous youth, and prevention, intervention, and treatment implications are discussed.

American Indian (AI) communities experience a disproportionate rate of Type 2 diabetes (T2D) and cumulative exposure to stress. Although this link is well researched among various populations, it has not been examined among AI communities. Path analysis was used to examine a multiple-mediator model to explain how caregiver stress influences self-reported mental and physical health among 100 AI participants with T2D. Caregiver stress was negatively associated with physical and mental health. Physical health was positively associated with family/community connectedness and mental health was positively associated with both family support and connectedness. The relationship between caregiver stress and mental health was partially mediated by family/community connectedness; caregiver stress had no indirect effects on physical health via either hypothesized mediator. Findings demonstrate the importance of integrating individuals' connection to family and community and its influence on caregiver stress and mental health in intervention programs targeting diabetes management and care among AI communities.