American Indian and Alaska Native Early Childhood Health: A Systematic Review

1. American Indian and Alaska Native Early Childhood Health: A Systematic Review Nicolette Teufel - Shone, PhD College of Public Health, University of Arizona 2014 Native Research Network Conference, Phoenix, AZ

2. Conceptual framework Using the Life Course Approach, this review examines the social and political determinants that shape AIAN early childhood health For all populations, childhood development and health has both lifelong and intergenerational effects (Shonkoff et al. 2012) Identifying contextual factors that impact resilience and stress early in life is essential to guide public health action for a healthier population

3. Objective of this review Understand the state of the science which serves as the foundation for public health action to health equity Identify how social determinants of health and the socio-ecological model are used in understanding and improving the health of young AIAN children Understand context

4. Methods • Standard procedures of the Cochrane Collaboration (2008) for systematic review of primary research in health care and policy • Three databases searched: PubMed, Web of Science and EBSCO which includes PsycINFO and CINAHL • Search terms: American Indian (AI) Children, AI Early Childhood; Native American Children; Native American Early Childhood; Alaska Native (AN) Children; AN Early Childhood; AI Children and Families, Native American Children and Families; and AN Children and Families

5. Study Inclusion and Exclusion Criteria Available in English; peer-reviewed Available electronically. published by April 1, 2014 Target population was predominantly AI and/or AN children, < 12 yrs Described a nonclinical encounter that addressed the context of health outcomes and/or an intervention designed for AI/AN children Applied socio-ecological or social determinants of health framework Limited to AI/AN children of US tribes who entered into treaty agreements and endured a unique set of stressors linked to the residential, educational and governance requirements of the US government (Gone & Trimble, 2012) Native Hawaiians not included, not covered by Indian Health Service, an agency having a distinct, homogenizing impact on the services provided to young AI/AN children

6. Nominal Categorical Analysis of Literature: American Indian and Alaska Native Early Childhood Number of different articles identified in database search (n=287) Titles and abstracts excluded, focus not early childhood (n=195) Articles reviewed by primary categories (n=77) Excluded as Other ( n= 10) Over-nutrition in AIAN early childhood (n=37) Dental health in AIAN early childhood (n=16) Family dynamics and influence (n=17) Community dynamics and influence (n=7) Excluded, socio-ecological framework not applied ( n= 70) Articles included (n=7), all address family dynamics and influence

7. Results Of the initially identified 287 articles addressing AI/AN early childhood health, only 7 met the criteria that included use of socio-ecological framework, addressing context All 7 addressed family dynamics or family oriented services influence on childhood health Four addressed socio-cultural resources and stressors in AI families that influence childhood physical, mental and emotional health Three 3 addressed family behaviors grounded in AI/AN values, worldviews and experiences that shape early childhood physical, mental and emotional wellness

8. Resources and stressors of AI families with young children • Cunningham-Sabo et al. (2008) Focus groups with 41 parents and staff of Navajo Head Start Program • Identified need for: 1) community-level action to change the food environment; 2) stronger parenting skills to control the food environment; and 3) culturally relevant strategies for caregivers • Bauer et al. (2012) Survey of 432 parents or caregivers of Lakota children • Food insecurity associated with: 1) practice of feeding children calorically dense foods linked to history of food scarcity and desire to have heavier children; and 2) pervasive feeling of inadequacies, stress and depression

9. Resources and stressors of AI families with young children • Crofoot and Harris (2012) Review of historical practices that devastated AI families and policies of Indian Child Welfare Act • Child welfare systems retain elements of systematic bias from 200 years of US policy challenging AI families. • Need systems based on AI strengths, e.g., interdependence of extended family, respect, and role of elders in leadership, discipline and spiritual guidance • Bussey and Lucero (2013) Case study of Denver Indian Family Resource Center (DIFRC) and AI families in the Denver area • DIFRC implemented a Family Preservation Model that addresses family stressors and mental health, cultural strengths (extended family/kinship) and referral to materials resources. • System change and improvement in staff training

10. Family Behaviors that shape the early childhood experience • Cheshire (2001) Interviews with 10 dyads, AI mothers + children • Cultural transmission - Children expected to be quiet, observe and learn • Listeningis highly valued; asking questions is non-traditional transmission • Red Horse (1997) Literature review and counseling experience with AI families • In traditional families, children raised in extended kin systems; household residents are multi-generational , related by blood, marriage or adoption • Family members are always reminded of their place and responsibilities in the kinship system • Simmons et al. (2004) SAMSHA funded (Circle of Care) AIAN communities work to redefine serious emotionally disturbed (SED) children • Definitions assert the role of the social and cultural environment in shaping children’s physical, emotional, spiritual, and intellectual health • SED Children with SED are from families who experienced trauma and suffer from historical wounding. Shame and anger are acted out in addiction, suicide attempts, violent acts and other ant-social behaviors

11. Discussion • Seven articles quite different, commonality is focus on context • Literature on early AI childhood health has • Focused on epidemiology of health conditions, predominantly over-nutrition and dental health • Have applied a framework that guides assessments and interventions that emphasizes responsibility of parents • Reflections of the socio-political-historical context of family resources, stressors and behaviors influencing the physical, mental and emotional health of young AI children is not prevalent in the literature

12. Conclusions • Impact of social injustice on AIAN childhood health can not be change in period of most external funding sources • Identification of short-term indicators of change in social determinants of health is needed and acceptable as feasible outcomes • Future public health efforts to understand and enhance AI childhood health should • Examine contexts that yield healthy physical, mental and emotional outcomes; identify factors linked to positive health outcomes • Identify, discontinue and change social-political and historical systems that reinforce family trauma by blaming families; • Need to focus on AI values that supporting raising healthy children in balance with their social and physical environment

13. Questions?

14. Contact Information • Nicolette I. Teufel-Shone, PhD • teufel@email.arizona.edu • Work supported by: • Center for American Indian Resilience ( CAIR) • NIH – NIMHD P20 Exploratory Center of Excellence (1P20MD006872) • Awarded to Northern Arizona University • Subcontracted to University of Arizona and Diné College