Utilization of Alcohol, Drug, and Mental Health Treatment Services Among American Indian Adolescent Detainees

Utilization of Alcohol, Drug, and Mental Health Treatment Services Among American Indian Adolescent Detainees DOUGLAS K. NOVINS, M.D. , CHRISTINE WILSON DUCLOS, M .P.H., CH ERYL MARTIN, B.A., CHASTITY S. JEWETT, B.A., AND SPERO M. MANSON, PH.D .

ABSTRACT Objective: To describe the relationsh ip between psychiatric status and the use of alcohol , drug, and mental health (ADM) services among a sample of American Indian (AI) juvenile detainees. Method: A structured diagnostic and service use interview was administered to 150 AI youths detained in a juvenile detent ion center located on a Northern Plains reservation. Results: Forty percent of AI youths with a diagnosed subs tance use disorder and 34 .1 % with a diagnosed anxiety, mood, or disruptive behavior disorder reported lifetime use of services for substance use and emot ional problems , respectively. While services for substance use problems were most commonly provided in residential settings , serv ices for emotional problems were most commonly provided in outpatient settings .Traditional healers and pastoral counselors provided services to 23.7% and 29.6 % of youths who received services for substance use and emotional problems , respectively. Detained youths were more likely to receive ADM services than AI adolescents living at-large in another, comparable Northern Plains reservation community. Still, the vast majority of youths in detent ion who suffered from psychiatric disorders did not report use of ADM services. Conclusions: Detention facilities serving AI adolescents need to screen carefully for the presence of psychiatric disorders and facilitate the use of ADM services. J. Am. Acad. Child Ado/esc.

Psychiatry, 1999, 38(9): 1102-11 08. Key Words: adolescence, North American Indians , juvenile delinquency.

American Indian adolescents are overrepresented within the juvenile justice system (Armstrong et al., 1996; Krisberg et al., 1987). In her study of the processing of white and Indian adolescents in one rural Wi sconsin county, Poupart (1995) found that while American Indian adolescents made up 7% of the county's population, they made up 38.7% of those entering the juvenile justice system. Indian adolescents also have higher rates of psychiatric symptomatology (May and Van Winkle , AcceptedApril 14, 1999. From the National Center for American Indian and Alaska NativeMental Health Research, Department of Psychiatry, University of Colorado Health Sciences Center, Denver. Presented in part at the 1997 Annual Meeting, American Public Health Association. This study was supported in part by NIMH grant R01-MH42473 (Dr. Manson); afellowshipfromthe OpenSociety's Center on Crime, Community, and Culture (Ms. Duclos); and NIMH Scientist Development Award for Clinicians K20-MHO1253 (Dr. Nouins). The authors grateftUy acknowledge thecontributionofJanette L. Beals, Ph.D. Correspondence to Dr. Nouins, CampusBoxAOll-13, University of Colorado Health Sciences Center, 4455 EastTwelfth Avenue, Denver, CO 80220;e-mail: douglas.novins@UCHSC edu. 0890-8567/99/3809-1102©1999 by the AmericanAcademy of Child and AdolescentPsychiatry.

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1994; u.s. Congress Office of Technology Assessment, 1990). In their comparison of community-based samples of American Indian and non-Indian youths, Beals et al. (1997) found that the Indian youths had higher rates of disruptive behavior (13.8% versus 7.3%) and substance use (18.3% versus 8.3%) than the non-Indian youths. Furthermore, the available evidence suggests that alcohol, drug, and mental health (ADM) services for adolescents living in American Indian communities are inadequate (Cunningham, 1993; Nelson et al., 1992). In 1989, the Indian Health Service (IHS), the keyorganization for the funding and delivery of health care services in Indian communities, employed only 17 child and adolescent- trained mental health professionals to serve a population of 400,000 American Indian children and adolescents (U.S. Congress Office of Technology Assessment, 1990). Despite these concerns , no published studies have examined the relationship between psychiatric disorders and utilization of ADM services among American Indian adolescent detainees. Such investigations are critical for improving our understanding of the need for ADM services among these youths as well as the relative

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strengths and weaknesses of the existing service system. For example, such studies might identify specific sets of disorders (such as mood disorders) that are less likely to be associated with service use than other disorders (such as disruptive behavior disorders). Such findings could then lead to targeted recommendations and interventions, such as improved screening techniques for depressive disorders, that are most likely to improve the function of these specific systems as services. In a previous report, Duclos et al. (1998) assessed the 6month prevalence of DSM-III-R (American Psychiatric Association, 1987) psychiatric disorders among American Indian adolescents entering a juvenile detention facility on a Northern Plains reservation. When compared with a community-based sample of Indian adolescents living in another Northern Plains reservation community (Beals et al., 1997), the former had a higher prevalence of substance use disorders and conduct disorder.The goal of this report is to describe the use of ADM services and its relationship to psychiatric diagnostic status among the same sample of Northern Plains American Indian adolescent detainees studied by Duclos et al. (1998). METHOD Sample and Study Procedures Data were collected becween Jul y 1995 and April 1996 by means of a structured lay interview, self-report survey, and booking records review (Duclos er al., 1998) . The sample consisted of 150 adolescents who were consecutively admieeed to a reservation-based juvenile detention facility and met the following criteria: (1) they were members of an American Indian tribe, (2) they were at least 12 years old, and (3) they lived within the local jurisdiction of rhe detention facility. There were 454 official bookings of 226 individuals during the study period. Eighty-two percent of the 199 adolescents meeting the above criteria agreed to participate. Most of the participants were accending school (87.4%); a majority were male (57%). Their mean age was 15.7 years (SD = 1.55, range = 12-18). Fifty-six percent of the participants reporced prior arrests, with a mean of 5 previous police contacts. Participants were officially charged wirh a toral of 211 offenses or holds. Seventy-seven percent entailed status offenses or crimes for behaviors that bring one to courc only in the case of juveniles (i.e., truancy, curfew violation, etc.), Curfew violation was the most prevalent charge (62 .1 % ). Property destruction was the most common nonstatus offense (24 .7%). Seven youths were detained for suicide aeeempcs (3% ). Two local lay interviewers, who completed an elaborate training protocol, administered the interview and a self-report survey. Interviews with consent/assent were audiotaped, and a random sample (10 %) of the audiotaped interviews was reviewed. A strict consent/assent protocol was used. If a youth was identified as a ward of the court, a tribally assigned courc advocate as well as the juvenile couer judge were required to provide consent. For other youths, parent or legal guardian consent was obtained. Finally, the interviewer approached the youth for his/her assent to interview. Overall the refusal rate for parent and youth combined was 18% (n = 33).

Depending on the duration of the assent/consent process, interviews were completed either within the detention facility or within the community after the youth 's release. The very nature of a large reservation setting with many oudying communities, weather conditions that hampered travel, the transient nature of the youths, and numerous households without telephones often made the location of parents and youths problematic. Yet the location rate was 92% (n = 183) . Fifty-six percent of the final sample was located and interviewed within 30 days of booking with a median of 5.5 days ftom intake to interview. Some youths cook longer than 30 days to locate and interview; the median number of days was 97. The interview cook an average of 2 hours to complete.

Community and Service Ecology In working with Indian communities, protecting the confidentiality of tribes is considered as important as protecting the confidentiality of the individual participants (Norton and Manson, 1996) . Therefore, this tribal community is described simply as a Northern Plains reservation community. This community has a high unemployment rate (10.3%) and low median household income ($20,404). Forty-one percent of people younger than age 18 live in poverty (Bureau of the Census, 1999). At the time of data collection, the local service ecology for ADM disorders included school-based, outpatient, inpatient, and residential services. School-based services included self-help groups and counseling. Community outpatient services included an IHS behavioral health clinic, a tribally operated substance abuse treatment program, and a recreational therapy program. Adolescents could also be referred to 3 different residential substance abuse treatment facilities that offered specialized services for adolescents, all within a 3-hour drive of this community. Complementary forms of care included a rich variety of traditional healing options as well as pastoral counseling . The juvenile detention facility was the newest addition co this service system, having opened 6 months prior to the commencement of the study. A single judge was involved in the adjudication process for all the youths detained in this facility, and a nurse from the IHS hospital visited the facility co provide medical care a half-day a week.

Measures Except for offender status, which was obtained from the booking records review, all measures were derived from the structured lay interview. This interview consisted of the following sections: (1) the Diagnostic Interview Schedule for Children, Child Version 2.3 (DISC-2.3C) (Shaffer et' aI., 1996); (2) the Substance Abuse and Posttraumatic Stress Disorder modules of the American Indian Vietnam Veterans Project's version of the Composite International Diagnostic Interview (AIVVP-CIDI); and (3) a separate set of questions that focused on use of ADM treatment services. Psychiatric Diagnoses. The DISC-2.3C ascercains the presence, severity, and duration of sympcoms for a variety of DSM-III-R diagnoses for the most recent 6-month period. The AIVVP-CIDI similarly ascertains the presence, severity, and duration of a variety of DSM-III-R diagnoses for the most recent 12-month period and generates diagnoses of substance use and dependence as well as posttraumatic stress disorder. The decision co use these porcions of the AlVVP-CIDI was 2-fold. First , the DISC-2.3 generates specific diagnoses for alcohol and marijuana only, placing all remaining substances into an "oth er substances" category; We felt that the ability to distinguish specific substance abuse/dependence disorders was particularly important. Second, the AIVVP study sought to increase the validity of these measures by using focus groups to elicit local infor-

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mation to render items more culturally appropriate. This process, described in a paper byT. O'Nell (1992, available from the authors), is similar to that used by Oesterheld and Haber (1997) in their study of the acceptability of the Conners Parent Rating Scale and Child Behavior Checklist to Dakotan/Lakotan parents. The University of Michigan version of the CIDI, and, thus, subsequently the AIWPCIDI, was chosen for its cross-cultural utility and known reliability and validity (Cower et al., 1991; Robins et al., 1988). All measures were pretested with a group of Denver-based Indian youths before commencement of the full interview and survey. Similarly, the DISC-2.3C has demonstrated cross-cultural utility and known reliability and validity (Bealset al., 1997; Shaffer et al., 1996). Diagnoses were rendered by computer algorithms. We developed 3 summary categories for the psychiatric diagnoses reported by Duclos et al. (1998): (1) anxiety/depressive disorders (major depressive, dysthymic, generalized anxiety, overanxious, and posttraumatic stress disorders); (2) disruptive behavior disorders (attention-deficit hyperactivity, conduct, and oppositional defiant disorders); and (3) substance use disorders (abuse and dependence of alcohol, marijuana, and 9 other substances). In addition, participants were classified on the basis of the presence of any of the above diagnoses, as well as in terms of the number of diagnoses (none, 1,2, or 3 or more). ADM Service Use. The ADM service use section of the interview was developed from a similar interview used in the AIWP (Manson et al., 1996) and asks the adolescent to report any lifetime service use for substance and emotional problems, which were separatelyqueried. Substance use problems ("problems with alcohol or drugs") were described as including "drinking under age, over-dosing, getting sick from alcohol/drugs, having problems due to drinking or drugs, like DUI/DWI [i.e., driving under the influence/driving while intoxicated], missing school or getting into fights or trouble while drinking or high." Emotional problems ("emotional or personal problems") were described as including "feelingsad, irritable, anxious or any other feeling that upset you ... [aswell as] problems with family or friends, being angry, fighting, getting into trouble, or losing your temper." Youths who reported receiving serviceswere asked to identify where they receivedthese servicesas well as referralsources (including courtordered treatments) for the 3 servicesmost recently used. Offender Status. The relationship between offender status and ADM service use was examined to determine whether a youth with a history of prior detention (repeat offenders) was more likely to report ADM service use than first-time offenders. Such a result would suggest that this detention facility may function as an important referral service to ADM treatment facilities.

Comparison Study To provide a reference point for the service utilization rates identified in this study, the youths described here were compared with a group of American Indian adolescents residing at large in a similar Northern Plains reservation community studied by Bealset al. (1997). Data for the comparison study were collected between March and June 1991 (Beals et al., 1997). The sample consisted of 109 adolescents who participated in a prior school-based epidemiological project and were still living on their home reservation. Most of the participants were attending school (92%); half were male (50.5%). Their mean age was 15.6 years (range = 13-18 years). Diagnostic and ADM service use information was obtained by using the DISC-2.1C (compared with the DISC-2.3C, AIWP-CIDI, and separate services section in this study). Local lay interviewers administered the interview after completing an elaborate training protocol. A strict consent/assent protocol was used.Twenty-one percent of the sample met criteria for at least one DSM-III-R disorder. Duclos

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et al. (1998) reported that the detained youths in the present study were more likelyto have a substance use disorder and conduct disorder than the American Indian youths from the comparison study. The comparison study community was similar to the detainee study community in many respects.Aswas true of the detainee study community, the comparison study community had a high unemployment rate (12.7%) and low median household income (mean = $18,070), with 57.1% of people younger than age 18 living in poverty (Bureau of the Census, 1999). The service ecologies of these 2 communities were similar as well. As in the case of the detainee community, the comparison study community services included schoolbased services, community-based outpatient mental health and substance abuse services, residential substance abuse treatment programs, pastoral counseling, and a rich variety of traditional healing options. The major differences between the 2 service ecologies were as follows: (1) the comparison study community included 2 outpatient substance abuse treatment facilities compared with 1 in the detainee study community; and (2) the comparison study community included 1 in-community center and 1 remote (a 3-hour drive) residential substance abuse treatment center with specialized servicesfor adolescents compared with 3 remote centers that served the detainee study community. One summary variable was constructed to facilitate these analyses. Because the comparison study did not discriminate between service use for emotional and substance use problems, we developed a summary variable with regard to the detained youths that combined these 2 service use categories into a single, ADM service use variable. If a participant endorsed receiving services for substance use problems and/or emotional problems, he/she was classified as receiving servicesfor ADM problems for this summary variable. Because the study of detained youths focused on use of specific service sites (e.g., a specific outpatient clinic) and the comparison study focused on the use of specific providers (e.g., psychiatrists), we were unable to contrast the types of servicesused across the 2 studies.

Analytic Plan Data were analyzed using SPSS for Windows, version 7.5 (Norusis, 1997). Two-tailed t tests and X2 tests were used to examine potential differences in service utilization by age and gender, respectively. Crude (unadjusted) odds ratios and confidence intervals were calculated to report the relative odds of service use among the youths included within a particular diagnostic category compared with youths not included within this category. Odds ratios and confidence intervals were also calculated to report the relative odds of service use among youths with either none, 2, or 3 ADM diagnoses compared with individuals with 1 ADM diagnosis (the reference group). Chi-square tests (Fisher exact tests [FETs] when fewer than 5 respondents were present in any particular cell) were used to contrast service use rates by offender status and to contrast service use rates between this effort and comparison study.

RESULTS

Service Utilization Among Detained Youths

Thirty-eight detained youths (22.9%) reported utilizing services for substance use problems during their lifetime, 27 (18.0%) for emotional problems. There were no significant differences among them in the prevalence of service use by gender (substance use problem service use

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TABLE 1 Relationship Between Psychiatric Diagnostic Status and Service Use Among American Indian Adolescent Detainees Detainee 6-Month Prevalence %4 n All participants Diagnostic categories Any disorder Anxiety/depressive disorder Disruptive behavior disorder Substance use disorder No. of diagnoses None One disorder' Two disorders Three or more disorders

150

Detainee Service Use Substance Use Problems

%b

ORe

95% CI

Emotional Problems d

25.3

%b

ORe

95% CId

18.0

73 23 32 57

48.7 15.3 21.3 38.0

38.4 39.1 50.0 40.4

4.17 2.17 4.36 3.52

1.85, 9.42*** 0.85,5.53 1.90, 10.04*** 1.64,7.56**

28.8 47.8 34.4 26.3

4.78 6.36 3.34 2.41

1.80, 12.67** 2.51, 16.80*** 1.36, 8.21 ** 1.03,5.62*

77

51.3 27.3 12.7 8.7

13.0 34.1 31.6 61.5

0.29 1.00 0.89 3.09

0.11,0.73**

7.8 24.4 15.8 61.5

0.26 1.00 0.58 4.96

0.09,0.78*

41 19 13

0.28,2.85 0.85, 11.21

0.14,2.42 1.32, 18.67*

4 Column percent. b Row percent. c Odds ratios reporting the relative odds of service use among the youths included within a particular diagnostic category compared with those youths not included in that particular diagnostic category. When examining the relationship between number of diagnoses and service use, the odds ratios report the relative odds of service use among individuals with none, 2, and 3 or more disorders to those of individuals with 1 disorder. dNinety-five percent confidence intervals. , Reference group for contrasting respondents based on the number of diagnoses. * p < .05; **P < .01; ***P < .001.

x2 =0.46, 1 df,P =.50; emotional problem service useX2 = 0.40, 1 df,P = .53) or age (substance use problem service use t = -0.34, 148 df,P = .73; emotional problem service use t = 1.18, 148 df,P = .24). Ten respondents (6.7%) reported utilizing services for both problem types. The relationships between lifetime service use for substance and for emotional problems to psychiatric diagnostic status are summarized in Table 1. Twenty-eight detained youths (38.4%) with any ADM disorder reported using services for substance use problems during their lifetime; 21 (28.8%) for emotional problems. Whereas only the presence of a substance use disorder and/or a disruptive behavior disorder was associated with lifetime service use for substance use problems, each of the 4 diagnostic categories we examined was associated with lifetime service use for emotional problems. Youths with 3 or more psychiatric disorders were significantly more likely to report ADM service use for emotional problems than youths with 1 disorder. We were unable to identify a similar relationship between number of psychiatric diagnoses and service use for substance use problems. The types of services used for emotional and substance use problems are summarized in Table 2. As

youths could report using more than one type of service, the percentage totals of each column are greater than 100%. Also, because service use for each problem was not mutually exclusive, meaningful statistical contrasts were not possible. Nonetheless, it is notable that while TABLE 2 Types of Services Used Among American Indian Adolescent Detainees Services Used Substance Use Problems (n = 38)

Emotional Problems (n = 27)

Outpatient service use School-based Outpatient facility Pastoral counseling Traditional healer

2.0 18.4 0.0 23.7

7.4 44.4 18.5 ILl

Inpatient service use Hospital Residential

2.6 60.5

14.8 ILl

5.3

0.0

Other

Note: Values represent column percent. The columns total more than 100% because youths could report using more than one type of service. Statistical -testing was not performed because service use items for these problems are not mutually exclusive.

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the most common service site for substance use problems was a residential substance abuse facility (60'yVo of youths who received services for substance use problems), the common service site for emotional problems was an outpatient facility (44.4%). A substantial number of youths reported receiving services from traditional healers (23 .7 % and 11.1 % for substance and emotional problems, respectively); 18.5% of youths who received services for emotional problems reported using pastoral counseling. Service Use and Offender Status

Repeat offenders were more likely to report ADM service use for substance use problems (28.2% versus 5.3% for first-time offenders; X2 = 4.63, 1 df,P [FET] < .05), but not for emotional problems (17.6% versus 21.1 % for first-time offenders; X2 = 0.14 , 1 df,p [FET] = .75). This was apparently related to court-ordered treatment: whereas 15 (45.0%) of the repeat offenders who received treatment for substance use problems were court-ordered into treatment, only 2 (8.7%) of the repeat offenders who received treatment for emotional problems were . court-ordered into treatment. Contrast of Detained Youths and Comparison Study

TABLE 3 Comparison of Service Utilization Between American Indian Adolescent Detainees and Indian Youths at Large in Another Northern Plains Community (Comparison Study) Service Use Contrast

All participants Diagnostic categories Any disorder Anxiety/ depressive disorder Disruptive behavior disorder Substance use disorder No. of diagnoses None One disorder Two disorders Three or more disorders

Detainees 4 (n= 150)

Comparison Stud y (n = 109)

(%) b

(% )b

X2,df

36.7

22.9

5.58, 1*

57.5

39.1

2.38, 1

65.2

44.4

1.16, JC

71.9 56.1

33.3 45.0

6.30, 1* 0.74,1

16.9 51.2 47.4

18.6 30.8 66.7

0.08,1 1.66, I 0.39, F

92.3

42.9

5.93, F*

4 Service use for substance use problems, emotional problems, or both. b The percentage of youths from each study who received services by diagno stic status (as indi cated in each row). C Fisher exact test. * p < .05.

Service Utilization

The contrast of service utilization by detained and nondetained youths is presented in Table 3. Overall , participants in the detention study were significantly more likely to receive ADM services than participants in the comparison study. More specifically, detained youths with a disruptive behavior disorder and/or 3 or more psychiatric disorders were significantly more likely to receive ADM services than the their nondetained counterparts. DISCUSSION

Service use for substance use problems was significantly related to the presence of both a substance use disorder and a disruptive 15ehavior disorder, consistent with Duclos and colleagues' (1998) report of the patterns of psychiatric comorbidity in this population. Specifically, 62.5% of youths with a disruptive behavior disorder also had a diagnosed substance use disorder. In contrast, every diagnostic category examined was significantly related to service use for emotional problems. These relationships were also related to psychiatric comorbidity. Youths with 3 or more psychiatric diagnoses were significantly more likely than youths with 1

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diagnosis to report service use for emotional problems. As Lewinsohn et al. (1995) and Kessler et al. (1994) suggest, the number of psychiatric diagnoses is in part an indication of the severity of an individual's problems; thus it is primarily the most severely affected detainees who receive treatment for emotional problems. These results also suggest that the threshold for receiving services for emotional problems is higher than the threshold for receiving services for substance use problems. This is also consistent with the relative em phasis on substance treatment in Indian communities (U.S. Congress Office ofTechnology Assessment, 1990). Youths needing care for anxiety, mood, or disruptive behavior disorders have fewer options than youths suffering from substance use disorders. It is also likely that a general wariness of mental health services , which has been observed in Indian communities (Costello et al., 1997; Red Shirt, personal communication, 1993) , contributed to this finding. Finally, while comorbidity was common in this sample (49.1 % of youths with a substance use disorder and 63.6% of youths with a mental disorder) , very few

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youths (6.7%) reported receiving services for both emotional and substance use problems. The differential patterns of types of services used by problem were also striking. The most common service used for substance use problems was residential settings, while the most common service used for emotional problems was an outpatient facility. Youths who received servicesfor substance use problems reported using traditional healing methods more commonly than a biomedically oriented outpatient facility. These results are consistent with the service ecologies of this and other Indian communities. In this community, youths requiring substance treatment could be sent to 3 different residential substance abuse treatment facilities. In contrast, neither this tribe nor the IHS operates inpatient facilities specifically for adolescents with non-substance-related psychiatric disorders. Instead, both tribes and the IHS contract these services with hospitals that serve the general population. The relative abundance of residential beds for substance abuse treatment in this service ecology likely results in this discrepancy in utilization. These results also underscore the importance of complementary forms of care (i.e., traditional healers and pastoral counselors) in addressing the ADM service needs of American Indian youths. This is consistent with other studies of Indian (Gurley et al., 1997) and non-Indian (Eisenberg et al., 1993) populations. The results concerning the relationship of offender status to service use provide some insight into how this detention facility functions within the community's ADM service system. Court orders from the sole judge involved in the adjudication process appeared to be a key factor leading to treatment for youths with substance use problems. That most court orders were targeted toward treatment for substance use problems suggests that this facility and court system is more sensitive to the presence of these types of problems than emotional problems, and thus more likely to order such treatment. Contrasting detained adolescents to the comparison study's community-based participants is also instructive. The former were more likely to use ADM services, which is consistent with a higher prevalence of psychiatric disorders and greater involvement in a juvenile detention facility that facilitates referrals for ADM treatment through court orders. Some caution is in order with respect to interpreting the results of these analyses. Except for the information concerning offender status, which came from booking

records, the only informants for this study were the adolescents themselves. The lack of other key informants such as parents, teachers, police, and staff of the detention facility may have resulted in the underestimation of both the prevalence of psychiatric disorders and ADM service use. It is also possible that conducting some interviews in the detention facility itself may have introduced some unmeasured bias into the youths' responses. Relying on these youths to separately report service use for substance and/or emotional problems may have resulted in a misclassification of the reasons for such use. However, the diagnostic and service use patterns for each problem were consistent with the local service ecology, which supports the validity of this division in the process of inquiry. Contrasts with the comparison study were complicated by the use of different diagnostic interviews (DISC-2.3C and AIVVP-CIDI for the detention study and DISC2.1C for the comparison study), different sets of service use questions, studies within different communities and service ecologies (albeit with substantial similarities), and possiblecohort effects (due to the 4-year differencein data collection). We therefore approached comparisons across these 2 studies, aswell as their interpretation, with considerable caution. The above limitations, along with both the relatively small sample size and mismatch of the time frames for serviceuse (lifetime) and diagnostic status (past 6 months or past year), may have increased the likelihood of type II statistical errors. Such errors may have resulted in a failure to define fully the relationships of psychiatric diagnostic status, offender status, and comparisons of ADM service use across studies. Finally, significant variation in cultural characteristics and service ecologies necessitate considerable caution in applying these results to all Indian communities. Nevertheless, this study provides important insights into the patterns of ADM service use among AI adolescent detainees. Clinical, Policy, and Research Implications

These results have important implications for the administrative, correctional, judicial, and clinical staff of the ADM service system in this and similar American Indian communities. Addressing the high prevalence of psychiatric disorders and low prevalence of ADM service use for youths detained in this facility should be a high priority. This detention facility and others like it need to develop

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more effective screening techniques for psychiatric disorders. The results of these screenings should be disseminated to key participants in the system, such as parents, judges, probation officers, and social workers. These participants, in turn, should be educated in terms of the potential significance of screening outcomes as well as options for further evaluation and treatment. These results also have important implications for policymakers. While we were able to identify guidelines for identifying youths with substance use disorders in the juvenile justice system and facilitating their entry into treatment (McPhail and Wiest, 1995), we were unable to identify similar procedures for non-substance use psychiatric disorders. The results of this study suggest that the development of such guidelines should be a high priority. Specific guidelines for American Indian juvenile detainees may be necessary because of the variation in assessment techniques necessitated by the unique cultural attributes of American Indian people (Fleming, 1992) as well as the unique service ecologies of Indian communities (U.S. Congress OfliceofTechnologyAssessment, 1990). Finally, the results of this study have important research implications. Whereas the results of this study provide an important first look at the cross-sectional patterns of ADM service use among American Indian adolescent detainees, longitudinal studies are necessary to provide a clear documentation of the treatment paths of such youths. These studies should also consider the impact of novel screening, assessment , and treatment models on short- and long-term outcomes. The considerable heterogeneity of Indian communities strongly suggests that these studies should involve multiple sites.

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