Treatment of Native Youth Requires Incorporating Culture, Recognizing Trauma

When the respective presidents of the American Academy of Child and Adolescent Psychiatry (AACAP) and the Canadian Academy of Child and Adolescent Psychiatry (CACAP) were deciding the topic of a joint town hall for their annual meeting in Toronto, they immediately agreed on an issue of enormous significance to both organizations and countries: the mental health of Indigenous youth.

“As we grapple with our histories related to the treatment of Indigenous people, it is critically important that we expand our understanding of their experiences, build better relationships with Indigenous communities, and ensure equitable mental health care for Indigenous youth,” said CACAP President Claire De Souza, M.D.

During the town hall, experts agreed that child and adolescent psychiatrists can best support Indigenous youth by incorporating their cultures into treatment. They also emphasized that Indigenous youth need greater support from the systems that are in place to protect them, particularly child welfare systems, in which Indigenous youth are overrepresented in both countries.

Mae Katt is a nurse practitioner from Temagami First Nation who lives in Thunder Bay, Ontario, where she works at a high school with a large Indigenous student body. Many students are flown to the school from remote communities in northern Ontario. The Indigenous community there has had a suicide crisis since the early 1990s, she said, and it has also been hit hard by the opioid epidemic.

In 2010, more than 40% of the student population had an opioid addiction, Katt said. Through treatment with suboxone, counseling, and extending treatment to those in students’ home communities, addiction rates plummeted over the next several years, she said. Providing care in the students’ home communities was especially meaningful, Katt said.

“We were able to prevent fentanyl overdoses because we had a lot of people in treatment,” she said. “We were also able to provide cultural programing that was community based, as well as land based.” Land-based programs highlight the enormous importance that the land plays in the health and cultural identities of Indigenous people.

Recognizing the students’ trauma has been hugely important as well, Katt said. “They were pretty much babies when they were left without food and caregivers because of the high rates of addiction in their home communities,” she said. “Their sense of safety was impacted.”

In addressing their trauma, Katt explained that she and her team have implemented a non-medical model that relies on culture. Helping students feel proud of their cultures is essential to helping them overcome the racism they experience. “Culture is an intervention,” Katt said. “Our students go hunting, and that means giving them guns. I realize that may raise a few flags with some of you. But this is all in the context of our traditional pursuits, where we have been able to go hunting, fishing, and gathering in our culture, and it’s always done in a safe way.”

During the session, Barbara Fallon, Ph.D., spoke about the overrepresentation of First Nations children in the Canadian child welfare system. She presented on the findings from the 2019 First Nations/Canadian Incidence Study of Reported Child Abuse and Neglect. This study was published four years after the Truth and Reconciliation Commission of Canada made 94 calls to actions, calling for all levels of Canadian government to change programs, policies, and structures to address the harms of residential schools. Residential schools were a system of boarding schools whose mission was to assimilate children, amounting to cultural genocide.

Despite the commission’s work, however, Fallon’s 2019 study had grim findings: First Nations children were three to four times more likely than non-Indigenous children to be reported for a concern related to child maltreatment. Further, investigations involving First Nations children were 17 times more likely to lead to placement in formal out-of-home care compared with non-Indigenous children.

Wendy Watson, M.D., M.P.H., noted that the United States has a similar problem of overrepresentation of native children in the child welfare system. According to the National Indian Child Welfare Association, American Indian/Alaska Native children are two times more likely to be investigated for allegations of abuse or neglect and four times more likely to be placed in foster care compared with the general population. Watson is a psychiatrist with Gila River Health Care, which serves the Gila River and Ak-Chin Indian communities, and the program director of the Creighton University Arizona Child and Adolescent Psychiatry Fellowship.

She also pointed out that the Supreme Court is considering arguments in the Haaland v. Brackeen case, which seeks to overturn the Indian Child Welfare Act. This law, passed in 1978, prevents Native children in the child welfare system from being separated from their families and/or tribes. It requires that a Native child’s extended family be the first preference for foster and adoption placements, then other members of their tribe, then a home with a family in a different tribe.

Watson expressed her concern about the case, emphasizing that placing Native children with their families or communities “is the way it should be,” she said.

She also spoke of the importance of training the next generation of psychiatrists to better understand the needs of Native patients. She encouraged child and adolescent psychiatrists to look into working with Native patients, noting that expertise of the various cultures is not required.

“All of the communities are different and have different belief systems,” she said. “You don’t have to learn about every single thing. Just bring your humanity with you.” ■