This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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2000 Annual Report to Congress on the Evaluation
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CHAPTER SUMMARY
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The Comprehensive Community Mental Health Services for Children and Their Families Program initiated funding of tribal grant communities in 1994 with a service grant awarded to the Navajo Nation. Four additional tribal communities were awarded grants in 1997-98, and three more tribal communities received grants in the 1999 funding cycle.
Among the 560 federally recognized American Indian tribes, including approximately 200 Alaskan Native tribes in the United States, children and adolescents constitute 50 percent of the people living on reservations, and this percentage is expected to increase in the future (Beiser & Attneave, 1992; Cross, Earle, Echo-Hawk Solie, & Manness, 2000). Due to years of inadequate funding and resources, American Indian tribes have struggled with providing for children and families with special needs. Mental health services are among the largest unmet needs of tribal communities in the United States, and American Indian children with severe emotional disturbance, like most children living in the United States, often do not receive clinically, socially, or culturally appropriate care (Cross et al., 2000). The result is that children living in tribal communities, particularly on reservations, are vulnerable to developing and experiencing long-term effects of mental health problems.
During the past decade, a number of federally funded programs were established to support the provision of mental health services for tribal communities throughout the United States. Through these programs, resources were provided to facilitate the development of community-based mental health programs within tribal organizations. These programs were intended to facilitate the development of training, the expansion of provider networks, the availability of providers and provider education, the promotion of comprehensive health education in school systems, and the development of new models of mental health service delivery (Cross et al., 2000; Inouye, 1993). Though some, if not all, of these programs experienced some degree of success, most have been short-term, limited in scope, and limited in their capacity to serve the needs of all their community members. In addition, funding for efforts such as these is typically limited to a few communities and thus cannot meet the needs of all American Indian and Alaskan Native children and families who live in the United States. Thus, despite these efforts, mental health services remain inadequate, and the emotional and psychological health of Native children continues to be of concern.
CMHS funding of tribal communities provides support for the development of culturally appropriate systems of care that are rooted in traditional approaches and blended with Western practices to meet the needs of children, adolescents, and their families within tribal communities. |
Within the context of these Federal initiatives, CMHS funding of tribal communities provides support for the development of culturally appropriate systems of care that are rooted in traditional approaches and blended with Western practices to meet the needs of children, adolescents, and their families within tribal communities. The funding is intended to help communities identify the extent of children's emotional and mental health needs, develop a system-of-care approach to address these needs, and evaluate the extent to which the system of care improves outcomes. Federal funding serves as an investment to establish sustainable systems of care in tribal communities that can continue to impact positively these communities well into the future.
The SGR indicates that 20 percent or 1 in 5 children in the United States has a diagnosable mental health disorder at any one point in time. According to the report, approximately one-half of children with mental health disorders display significant impairment in their day-to-day functioning at school, at home, and in the community. Furthermore, children living in poverty are at a substantially higher risk of developing a mental health disorder and accompanying impairment. While numerous studies conducted during the past decade provide evidence to support the rate of mental health problems generally among children and adolescents, less information is available identifying the specific rate of mental health problems among American Indian and Alaskan Native children.
Any discussion of mental health disorders among Native children should be qualified by the limitations associated with diagnostic systems that are based in Western medicine. The applicability of diagnostic categories described by the American Psychiatric Association in the DSM-IV to American Indian and Alaskan Native children is quite complex (Manson, Bechtold, Novins, & Beals, 1997). Any assessment and report of the mental health functioning of these children and families needs to be considered within the cultural dynamics of individual tribes and the overall social context of tribal communities. Inclusion of culturally relevant information may improve the integration of cultural formulations into formal diagnostic assessments (Novins et al., 1997). Use of alternative approaches to describing differences among American Indian and Alaskan Native individuals may be more useful and salient than a direct application of diagnostic categories derived from Western medicine.
Despite the limitations associated with formal diagnostic assessments, recent research provides information regarding the level of mental health problems among American Indian and Alaskan Native children. The overall reported prevalence of mental health disorders among tribal communities is higher than rates generally reported for children from poor, impoverished families (Barlow & Walkup, 1998; Costello, Farmer, Angold, Burns, & Erklani, 1997; Dion, Gotowiec, & Beiser, 1998). The types of problems experienced by American Indian and Alaskan Native populations span the spectrum of mental health disorder categories and include cognitive deficits such as learning disabilities and mental retardation; emotional problems such as depression, anxiety disorders, and post-traumatic stress disorder (Jones, Daughinais, Sack, & Somervell, 1997); disruptive behavior disorders such as attention-deficit/hyperactivity disorder and conduct disorder (Dion et al., 1998); suicide attempts (Strickland, 1997); and substance abuse (Mitchell, Novins, & Holmes, 1999). Less is known about mental health disorders among specific subgroups of American Indian and Alaskan Native children. One study has shown that among Northern Plains tribes, higher-than-expected rates of disruptive behavior disorders, substance-related disorders, and comorbidity or the presence of more than one disorder were reported for youth aged 14 to 16 (Beals et al., 1997). Similar to the findings generally reported for all youth in the United States, American Indian and Alaskan Native adolescents entering the juvenile justice system display high rates of mental health disorders and substance abuse (Duclos et al., 1998).
Family caring and strong cultural identity have been identified as particularly important protective factors related to wellness among American Indian and Alaskan Native children. |
While research has offered information on rates of mental health disorders among American Indian and Alaskan Native children, it is equally important to understand the risk and protective factors associated with positive emotional health and wellness. For example, family caring and cohesion (Cummins, Ireland, Resnick, & Blum, 1999) and strong cultural identity (Garrett, 1999) have been identified as particularly important protective factors related to wellness among American Indian and Alaskan Native children. Furthermore, positive behaviors have been found to be a more important predictor of psychosocial outcomes than negative behaviors (Mitchell & Beals, 1997). A strengths-based approach is one of the cornerstones of the system-of-care model, with personal, family, and community strengths viewed as the foundation upon which care plans are created and positive changes are built. The national evaluation provides grant communities with the opportunity to contribute valuable information about factors associated with resiliency, well-being, and positive outcomes despite the numerous environmental and social challenges that children face. A better understanding of child protective and risk factors will help communities build system-of-care treatment plans and services that encourage children to thrive in their home, school, and community (Cummins et al., 1999).
Economic, political, and environmental injustices contribute to the mental health problems experienced by children today (Barlow & Walkup, 1998). American Indian and Alaskan Native people continue to heal and repair their communities as a result of historical and ongoing losses suffered over hundreds of years. Historically, Native people have experienced a loss of tribal identity, including a degradation of their lands, loss of cultural identity, increased acculturation, and loss of thousands of lives. Considering the losses suffered, it is understandable that American Indian and Alaskan Native children experience stressful lives and high rates of mental health problems.
This loss of cultural heritage coupled with the current poor socioeconomic conditions creates additional challenges for American Indian and Alaskan Native children and families who often live in isolated regions. American Indian and Alaskan Native people shoulder the highest rates of poverty, the poorest economic conditions, and the lowest educational attainments of any racial or ethnic group in the U.S. (Barlow & Walkup, 1998). Geographic isolation is common within reservation life. The result is communities that are challenged to coordinate services and supports across multiple child-serving agencies and systems frequently spread throughout large geographic areas. In response to these challenges, tribal grant communities have emphasized community restoration and healing as a core principle in developing system-of-care services for children and families.
Within tribal communities, strong community bonds exist and children are surrounded by an extended family consisting of neighbors and family members who collectively contribute to raising children. The family unit and extended community network can have a powerful influence on the successful development of children. While the insular nature of tribal communities creates certain problems, it also has the potential to bring about rapid change through protective community-based interventions (Barlow & Walkup, 1998). One of the largest health and behavior studies recently conducted surveyed a national sample of over 13,000 American Indian and Alaskan Native children to determine which factors may be associated with positive health and emotional well-being among high-risk children. Among several protective factors, the study found that connection to the family remains a consistently powerful factor in the lives of children and is associated with decreased risk and positive health in high-risk populations (Cummins et al., 1999).
Many tribal cultures view the child within the context of the entire community. For example, the cultural approach to rearing children as described by the Oglala Lakota Tribe in South Dakota focuses on caring for one's tiospaye (extended family) wherein a child is born into a natural supportive circle of care. The extended family has a sacred obligation and teaching role in child rearing, thereby ensuring the continuation of a strong, healthy nation. The child with serious emotional disturbance is viewed as sacred. The goal of system-of-care grant funded programs is to create a system-of-care model grounded in culturally appropriate mental health practices based on the strengths of children, families, and the community.
While each tribal community maintains unique traditions, cultures, values, and practices based on their geographic and historical background, common among the tribal grant communities is the desire to combine traditional healing, knowledge, and practices with current Western medicine as part of a comprehensive mental health service delivery system. |
While each tribal community maintains unique traditions, cultures, values, and practices based on their geographic and historical background, common among the tribal grant communities is the desire to combine traditional healing, knowledge, and practices with current Western medicine as part of a comprehensive mental health service delivery system. The use of culture to achieve community wellness is illustrated in the Center for Mental Health Services' Promising Practices monograph entitled "Cultural Strengths and Challenges in Implementing a System of Care Model in American Indian Communities" (Cross et al., 2000). Through data collected from focus groups and key informant interviews, the monograph describes the variety of cultural and traditional healing approaches offered in system-of-care grant communities that form the foundation for creating positive change in the lives of American Indian and Alaskan Native children and families. Despite the differing program structures, levels of program development, and populations served, the most prevalent theme embedded within the promising practices identified in this monograph is the use of "culture as strength" to address successfully the needs of children and their families with serious emotional and behavioral challenges.
Interventions with American Indian and Alaskan Native communities often include an emphasis on the education of children about their cultural identity. Incorporation of tribal-specific traditional healing practices and spiritual ceremonies is only recently being accepted in the field as a viable treatment intervention. Treatment planning utilizing traditional practices often involves the extended family as well as traditional healers and other members of the local tribal community. The Comprehensive Community Mental Health Services for Children and Their Families Program has provided opportunities for the tribal communities to develop systems of care that include traditional healing approaches that not only improve the mental health of their children but also support the revitalization of their culture, which in turn provides a more secure and stable environment for the tribal community in general. Conceptually and theoretically, it has been noted in the literature (e.g., Barlow & Walkup, 1998) that the losses of cultural identity and traditional cultural practices are primary factors that have negatively impacted the lives of American Indian and Alaskan Native children and families (Cross et al., 2000).
The American Indian and Alaskan Native staff in tribal grant communities are particularly interested in measuring the benefits of traditional healing approaches to children's mental health as part of mental health service provision. To this end, several of the grant communities have begun to incorporate methods to determine the impact cultural activities have on child healing and long-term well-being. A description of tribal grant communities funded by the Comprehensive Community Mental Health Services for Children and Their Families Program is provided below. This is followed by an overview of local evaluation activities.
Funded in 1993, the Navajo Nation K'é Project of the Children's and Families' Advocacy Corporation (CFAC) was the first American Indian or Alaskan Native grant community to receive funding from CMHS. The program began providing services in the summer of 1995.
While CMHS funding for the K'é project ended in October 1999, the project has since become a viable component in the delivery of behavioral health services on the Navajo Nation. Lessons learned during this initial groundbreaking project have provided a foundation upon which currently funded tribal grant communities have constructed their systems of care. More information regarding the K'é Project can be found on pages 184-186 in the Graduating Grant Communities section of this report.
The two tribal grant communities initially funded in 1997 entered their third year of operation during FY 2000. The infrastructures for their systems of care have been established, and they have been serving children and their families for at least 2 years. Programs are well developed at this point in their Federal funding cycle. Evaluation activities are underway, with communities utilizing data to make decisions about program development and to leverage other sources of funding to promote sustainability in the future.
Kmihqitahasultipon Project Values Statement We believe that individuals should be treated with respect, honoring the paths we all have taken through past challenges and successes. We believe people grow, change and react in ways to accommodate individual differences and past pain. We support and encourage the best in each family and individual, acknowledging that people do the best they can. |
The Kmihqitahasultipon Project ("We Remember") was initially developed in 1996 with funding through a subcontract from the Wings initiative, a CMHS grant community funded in 1994 and located in Bangor, Maine. Funds were provided to establish a system of care specifically designed to meet the unique needs and culture of the Passamaquoddy Tribe. In 1997, the administration of the Indian Township Health Center, with the approval and support of the Tribal Council, directly submitted a proposal to CMHS to obtain funding that would allow the project to continue to build on these earlier efforts. The CMHS grant was awarded in the fall of 1997.
In addition to providing services at the child and family level, a major component of the Kmihqitahasultipon Project is to serve as a community-level intervention, providing all children and families in the community with opportunities to reintegrate the Passamaquoddy culture into their lives. By fostering the traditional community culture, the project supports caregivers in maintaining family structure as well as promoting and enlivening the traditional and spiritual heritage of the Passamaquoddy. The overarching goals of the project are to (a) promote community development by training community members to provide services, (b) provide early intervention services, and (c) work with families to design and plan services individually that are culturally and uniquely appropriate to the child and family.
The Kmihqitahasultipon Project serves the Indian Township Reservation community, which is home to 700 members of the Passamaquoddy Tribe and an additional 200 descendants and non-tribal members. Located in northeastern Maine and parts of Canada, the tribe has a 12,000-year history; however, much of their history and culture has disappeared during the past 400 years of European occupation. In recent years, the Passamaquoddy have attempted to re-establish their values and traditions within the community to assure the continued survival of tribal culture. The Kmihqitahasultipon Project staff realize that Native communities have human resources that frequently go unrecognized. These resources, when blended with mainstream clinical expertise, create treatment modalities and service delivery approaches that are thought to be effective for Native children, their families, and the community.
The service delivery model for the Kmihqitahasultipon Project offers a broad approach that integrates Western clinical services with American Indian cultural practices. This system of care provides community-based services and supports, Western traditional clinical services, expert consultation, and cultural activities. Depending on their needs, children receive anywhere from 8 to 40 hours of services per week.
The project established a team of community members that provides a core set of in-home services and supports to children and families in the community. The in-home services include (a) behavioral specialists who provide children with in-home therapy and parents with assistance in behavior management; (b) in-home mentors who address children's unique developmental needs and provide recreational activities and support; and (c) respite care providers who afford parents some temporary release from their childcare responsibilities.
In addition to these services, the project provides parent education and training services to help prepare expectant mothers and fathers for parenting. Parent educators, who work in their clients' homes, provide one-on-one training on topics such as child development, age-appropriate behaviors, behavior management, and child care. The parent educators also teach formal parenting classes in the health center according to community needs.
The project offers other behavioral health services, including play therapy and home-based substance abuse services provided by a certified substance abuse counselor. During the past year, the project also developed a family advocate position. The family advocate works with individual families and is available to provide support at agency meetings such as the Pupil Evaluation Team (PET) meetings. In addition, the family advocate leads a women's support group, a support group for respite workers, and a group for foster parents.
Traditional mental health services such as diagnosis, evaluation, and outpatient counseling are available directly through the project's clinical staff. Previously these services were provided by referral to and in consultation with staff in the mental health services unit of the health center. Although the project had established a close, collaborative relationship with mental health staff, they had encountered significant delays in accessing services. The project's hiring of clinical staff has markedly improved access to these services.
A unique aspect of the program is the availability of off-site consultation through teleconferencing technologies. Access to psychiatrists, psychologists, and neurologists is available through a contract with staff at Harvard University Medical School's Telepsychiatry Program. Videoconferencing technology is used to access these services. Program staff consult with the medical school team on a weekly basis to obtain input for children and families served by the program. The staff from Harvard and the program attend face-to-face meetings on a quarterly basis to review consultation progress and to develop and maintain relationships that facilitate the videoconferencing process.
A major emphasis of the Kmihqitahasultipon Project is to reintegrate Passamaquoddy culture into both the lives of the children and families served by the project and the community as a whole. |
A major emphasis of the Kmihqitahasultipon Project is to reintegrate Passamaquoddy culture into both the lives of the children and families served by the project and the community as a whole. A full-time cultural coordinator position was created at the onset of grant funding to develop cultural activities. The primary goals of the position are to enhance cultural activities and to instill in tribal members knowledge of their heritage.
The grant program is aimed at creating a positive, lasting, and sustainable impact on children's mental health in conjunction with a much broader agenda of improving community well-being as a whole. In this effort, the program is trying to revive old customs (the "old ways") as well as preserve the Passamaquoddy language. Consequently, there is a large cultural component to the program, with a variety of services offered to the entire community, not only the children enrolled in the program. Classes teaching tribal language, drum making, and ribbon shirt making; summer camp experiences where hunting and gathering skills are taught; and field trips where children are taught how to identify medicinal plants are among the many cultural programs integrated with Western approaches to mental health services. There are also community social events (e.g., potluck suppers) and special programs throughout the year. The cultural coordinator also works with the school system to promote the tribal language. In addition, staff have investigated the use of the Internet as a means to promote cultural activities and tribal crafts to a broader audience.
Services available through the tribal school include special education services, one-on-one tutoring provided in the home, one-on-one aides who provide intensive special education support in the classroom, and individual and group counseling.
A critical expansion of substance abuse treatment services is in the early planning stages. With a recently awarded Center for Substance Abuse Treatment (CSAT) grant, the health center will be able to pursue a separate license to add an intensive substance abuse treatment program. Other grant proposals to evaluate welfare-to-work programs and to train community elders as mentors will be submitted in the future.
In addition to the national evaluation requirements described elsewhere in this report, families complete a short satisfaction questionnaire every 6 months. The grant community is also documenting many of the social and cultural activities being offered by the program. Attendance at social events and language classes and involvement in special projects are being documented. In fall 2000, the project plans to conduct a series of qualitative interviews with health center staff, families, and tribal leaders regarding changes that they perceive resulting from grant-funded programs and services. In addition, rates of child maltreatment reports and investigations are being compared over the past 5 years. Other measures of the program's impact include the monitoring of high school dropout and completion rates, foster home placements rates, police reports of domestic violence, and reports of adolescent suicides and attempts. These and other social indicators are expected to reflect improved community health.
It is inappropriate to single out one person for special recognition or attention in many American Indian communities. It is also inappropriate to single out one child as having emotional problems. Consequently, there is a reluctance to identify one child in a family as the "problem child" or the "targeted individual" for an intervention or services. To honor the Passamaquoddy community's mental health belief system, the entire family is entered into the system-of-care program. This community also believes that progress toward building "healthy" families must include collection of information from multiple sources, including the child, family, and community perspectives. Primary caregivers and all children who receive services in the program are enrolled into the national evaluation. This approach provides interesting challenges. For example, caregivers respond to family measures based upon their experiences with all children as opposed to one target child. The practice of including all children in a family in determining responses to these measures creates unique interpretation issues when analyzing evaluation data.
As of June 2000, the Kmihqitahasultipon Project had enrolled 183 children into their system of care. Descriptive information had been collected on 90 children, and among those, 89 children had been entered into the longitudinal outcomes study of the national evaluation. Descriptive information about the children and families served by this project is found in Table 34.
The Sacred Child Project emerged from a concern among the United Tribes of North Dakota about the large number of Native children sent to long-term care facilities outside of their community. Due to limited community-based services, American Indian children are placed in out-of-home settings at an alarming rate, with many of them over-represented in some of the most restrictive environments, including the State industrial school (36 percent), State hospital (39 percent), and juvenile detention (28 percent). The goal of the Sacred Child Project is to reduce the high number of North Dakota American Indian children who are sent to residential facilities and to assist in the re-entry of those who are returning from out-of-community placements.
Sacred Child Project Mission Statement "To join with families to ensure that all children grow naturally in mind, body, spirit, and emotions." |
The American Indian communities in the State of North Dakota believe that a fundamental reason for the disproportionate representation of their children in residential care is the lack of connection they feel to their communities and culture. For this reason, the Sacred Child Project has developed a system of care around American Indian culture and has given ownership of the system to local communities. Through partnerships with tribal, State, and Federal entities, the Sacred Child Project is involved in identifying ways to develop community-based children's mental health services within tribal organizations.
The Sacred Child Project operates in five sites across the State of North Dakota, including four reservations (Standing Rock, Fort Berthold, Spirit Lake, and Turtle Mountain) and one affiliated service area (Trenton Indian Service Area). Each tribe operates as a quasi-sovereign nation with its own government, law enforcement, and array of health services, and each tribe has a community that is distinct from the other American Indian communities in the State. The five sites are briefly described below.
North Dakota has a very young American Indian population, with approximately 45 percent of all tribal members under the age of 18. Approximately 11,629 American Indian children reside in North Dakota.
To reduce the increasing number of children being placed in inappropriately restrictive, long-term residential settings and to assist children with the transition back to their homes and communities, the Sacred Child Project is based on the wraparound model, which works well within the context of the American Indian culture. This model involves assembling representatives from all of the systems in a child's life to work collectively to conduct comprehensive planning within 12 identified domains. The domains from which representatives are drawn include family, social, behavioral, educational, safety, legal, health, crisis, spiritual, cultural, financial, and housing. Families choose their priority domain(s). The wraparound process builds on the strengths of the child, family, natural support system of the child, and community in each domain to address issues and to develop goals within a foundation of American Indian culture. The process also incorporates important American Indian traditions of group healing and community-based resources. Wraparound Review Intake Teams craft comprehensive care plans that are implemented at the community level by care coordinators.
One notable feature of the Sacred Child Project is the accessibility of care coordinators and the unconditional support they provide to families. At most of the program sites, two care coordinators are trained to support, guide, and mentor children and families while facilitating the wraparound-based plan of care, drawing upon diverse local resources and services (e.g., natural supports, traditional healing ceremonies, extended family members). When possible, the care coordinators are recruited from the community so that they will be familiar with local customs and resources. Each site also has a "data coordinator" who is responsible for supporting administrative and organizational functions, receiving and organizing referrals, scheduling meetings of Sacred Child Project and agency staff, keeping files, and collecting information for the evaluation. Finally, through a contract with the North Dakota Federation of Families, a parent coordinator (family advocate) is recruited and provided in each site.
Services provided by care coordinators recently have been approved for Medicaid reimbursement by the State of North Dakota. These financial supports will assist with being able to sustain the Sacred Child Project model of service provision in the future.
As in other American Indian and Alaskan Native grant communities, significant challenges exist for the Sacred Child Project in conducting the national evaluation because the national evaluation instruments have not been normed nor sufficiently contextualized within American Indian communities. Because many constructs from Anglo-European clinical evaluation tools do not have similar concepts in Native communities, staff frequently have to explain many words and concepts. In addition to having to interpret the instrument questions, staff also must interpret child and family responses through a cultural lens. Thus, there is a high probability of subjective or erroneous interpretation of instrument items. The use of copyrighted instruments limits modifications and creates training challenges for staff. The community is concerned that the national protocol instruments, which are primarily deficit based and heavily focused on impairment, are contrary to the strengths-based wraparound philosophy embraced by the program. Furthermore, the administration of a lengthy instrument package is of great concern. Because building rapport and relationships is an important cultural protocol used when discussing sensitive issues, the time needed to complete an interview is significantly longer than typical estimates provided in training materials.
Despite these challenges, the Sacred Child Project has recognized the importance of preparing their communities in advance for evaluation activities. The staff have made tremendous efforts to gain support from local community members, tribal councils, and other key stakeholders. In the process, they have found the need to address a number of other important issues and challenges specific to Native communities:
Involvement in the national evaluation has brought about positive changes. Project staff have gained a better understanding, awareness, sensitivity, and responsiveness to tribal concerns related to evaluation and research. Tribal involvement has also had a positive impact on community involvement in the research process as more community members have gained increased knowledge in evaluation, including technology, data collection, data analysis, and information dissemination. In addition, knowledge of demographic characteristics, risk factors, and clinical outcomes has provided greater insight into mental health problems faced by the children and families served by tribal systems of care.
As of June 2000, the Sacred Child Project had enrolled 123 children into its system of care. Descriptive information had been collected for 89 children, and 63 children had been enrolled into the national outcomes evaluation. A description of the participants is found in Table 35.
The two tribal grant communities initially funded in 1998 entered their second year of operation during FY 2000. The infrastructures for their systems of care have been established, and they are initiating service delivery activities. Evaluation activities also have been initiated during this year following training and technical assistance site visits by the national evaluation team.
The Wind River Reservation is home to the Northern Arapaho and Eastern Shoshone Nations. The With Eagle's Wings project began when CMHS awarded a grant to the Arapaho Governing Council in September 1998. The prevalence of serious emotional disturbance among the children living on the Wind River Reservation is thought to be associated with historic, geographic, and economic factors. Many of the mental health issues that affect children living on the Wind River Reservation today may be related to a former Federal policy that removed many children from their communities to distant boarding schools. Children removed from communities often were denied the right to practice their religion or cultural traditions, and family members of these children often experienced depression. As a result of this period of removal, generations Northern Arapaho and Eastern Shoshone people suffered emotional and physical abuse and experienced a loss of traditional social and parenting practices. The effects on the community were devastating and manifested in growing reports of family violence, substance abuse, and child abuse and neglect.
The With Eagle's Wings Project Goal To provide comprehensive mental health services to seriously emotionally and behaviorally challenged children on the Wind River Indian Reservation. |
Compounding these problems resulting from these historical injustices is the lack of available and appropriate services. Services that have been available are based on Western treatment models. Geographic distances to services, limited availability of services, and a limited service array are barriers to receiving treatment for those living on the reservation. Furthermore, lack of access to crisis-prevention services often leads to inappropriate off-reservation placement in treatment centers or psychiatric hospitals.
The goal of the With Eagle's Wings project is to develop a comprehensive system of care that offers culturally appropriate providers and services to children and families living on the reservation.
Currently, the Indian Health Service is the only mental health service provider on the Wind River Reservation. The project staff are trying to have their project community designated as a mental health catchment area so that project services will be eligible for Medicaid reimbursement. In addition, they would like to be eligible to apply for block grants. Obtaining this designation will have a significant impact on the project's sustainability by establishing a structure that will extend well beyond the grant-funded period.
With Eagle's Wings provides services to any resident of the Wind River Reservation. Residents include 2,500 enrolled members of the Northern Arapaho Nation, 3,800 members of the Eastern Shoshone Nation, and a few members of other American Indian tribes. Located in west central Wyoming, the Wind River Reservation spans 2.6 million acres or 3,500 square miles, and it is composed of the Fort Washakie and Crowheart communities, which span all of Fremont County and part of Hot Springs County. These communities range from 15 to 45 miles in distance from one another, presenting major transportation issues for residents. The Wind River Reservation is the second largest in the United States in terms of square miles. At least one family member from each family living on the reservation is in need of mental health services, and counseling agencies located off the reservation simply cannot meet the demand for services. Given the geographic isolation, high prevalence of mental health needs, and lack of resources, the need for comprehensive system-of-care services for American Indian children with severe emotional and behavioral disorders on the reservation is paramount.
One successful program is a community-wide intervention that occurs through the Young Warriors Society. This is a cultural program in which young adults are hired to research Arapaho and Shoshone traditions and to teach these cultural practices that instill pride, independence, and self-esteem to children and youth. |
With Eagle's Wings has supplemented the existing array of services with service components that the project classifies from least to most intensive levels of care. At the basic level, the program provides transportation services for children and families between homes, schools, and other locations for services. In addition, care coordination and family advocacy are provided. These services may be classified as support services and may be provided in a family's home. Mentors provide support for children through outreach activities, transportation services, and assistance provided to care coordinators.
One of the most successful prevention programs is a community-wide intervention that occurs through the Young Warriors Society. This is a cultural program in which young adults are hired to research Arapaho and Shoshone traditions and to teach these cultural practices that instill pride, independence, and self-esteem to children and youth. Additional features of this program include the teaching of various arts and crafts and cultural presentations that are made in the schools and other community settings.
An array of more intensive community-based services is available to children who present with more significant needs. This includes respite care provided through the Welcome House, which is a short-term (24-72 hours) shelter for children whose parents need respite and for children who have been abused and neglected, are victims of domestic violence, or whose parents have a substance abuse problem. The Welcome House offers safety and protection for children in a non-threatening, community-oriented environment. The program is designed to lessen the effect of trauma in a child's life. Care coordinators and family advocates also provide community-based services, including in-home support services. They are joined by community mentors who assist with informal support services in the community. To date, approximately 500 children have received services at the Welcome House. This program is under the direction of and receives partial funding from the With Eagle's Wings program. It is also funded by the Federal Department of Health and Human Services Administration on Children, Youth and Families.
The most intensive and comprehensive level of service provided by the project is wraparound. Wraparound teams evaluate the needs, strengths, and preferences of families. These teams develop comprehensive care plans that include a mixture of community-based support services, clinical interventions, and cultural teachings. These plans are adjusted periodically to meet the evolving needs of the clients being served at the highest intensity level.
While the services described above are offered directly on the reservation, many crisis prevention services are offered off the reservation in towns located up to 2 hours away. Outpatient counseling services are provided primarily by Fremont County Counseling Services, located in Riverton, Wyoming, although the Indian Health Service on the reservation also provides counseling to a smaller number of children and families.
With Eagle's Wings is implementing a full-scale, community-based evaluation. Given the historical mistrust associated with research activities conducted in Native communities, the project has emphasized gaining full community support and involvement for national- and local-level evaluation activities. Evaluation implementation has become an extended process in part due to the substantial investment made in involving local community members in the process.
For the local evaluation, the on-site evaluator has trained staff and parents to conduct focus groups to assess the appropriateness of the national evaluation protocol for families living on the Wind River Reservation. Family involvement in evaluation activities is also being promoted in other ways. Parents and a staff member are attending grassroots evaluation training workshops. The project has adopted an outcomes accountability perspective to undergird program development. The on-site project evaluator is conducting an in-depth audit of evaluation issues of the project, utilizing both theory of change and logic model assessment strategies (Hernandez, Hodges, & Worthington, 2000) to ground and support program and evaluation development for local communication campaigns. The models are being presented to staff, stakeholders, and the community for review and clarification. An informational and explanatory status report on evaluation and accountability issues has been presented to project staff, the Northern Arapaho Business Council, and project advisory stakeholders for comment and for strategic planning purposes.
Additional evaluation activities involve collecting information from interviews with stakeholders of the initiative, including, but not limited to, the Indian Health Service, Bureau of Indian Affairs, Tribal Health system, Eastern Shoshone and Northern Arapaho Departments of Social Services, Department of Family Services, local school districts, State of Wyoming Departments of Health and Behavioral Health, representatives of the Wind River Reservation Parent Advocacy Organization, and community and family members. A survey of stakeholders is also underway to clarify the logistics of community participation in evaluation efforts.
As of June 2000, the With Eagle's Wings project had enrolled 106 children into system-of-care services. Descriptive information collected on 26 children through April 2000 is profiled in Table 36. No children had been enrolled into the longitudinal outcomes study of the national evaluation.
The Sault Ste. Marie Tribe of Chippewa Indians (the Sault), in partnership with the Bay Mills Tribe of Chippewa Indians (Bay Mills) and the Hiawatha Behavioral Health (Hiawatha) community mental health center, received CMHS funding in October 1998. The purpose of the grant is to establish a system of care to serve tribal children with severe emotional disturbance and their families in the primarily rural area of eastern Upper Peninsula Michigan. This program is known in the tribal Ojibwa language as Mno Bmaadzid Endaad, which translated into English means "be in good health at his house." The program began serving children and their families in May 1999.
Mno Bmaadzid Endaad Vision Statement To develop an integrated, seamless and multidisciplinary service delivery system that provides for appropriate, culturally sensitive services. Services shall be client oriented, easily accessible, and focused toward measured positive outcomes. |
The service delivery collaboration among the Sault and Bay Mills Tribes and Hiawatha Behavioral Health is a significant achievement for this community. The partnership of these two tribes is unusual, as they have not collaborated in any significant way in the past. The additional integration with a county community mental health agency is an even more innovative undertaking. At the time the Sault Tribe applied for the children's mental health grant in 1998, there were only four behavioral health workers in the county, none of whom focused on children's mental health. The Bay Mills Tribe likewise had no outreach workers targeting children's mental health. Since it has been only in recent years that the two tribes (rather than the Federal government) began operating their own health programs, the infrastructure and service delivery systems are still in the developmental stage. In addition, Hiawatha had no previous experience serving tribal members prior to the grant, unless these individuals came for services as county residents. The overall goal of the grant project is to create a home-based, family-focused approach to support tribal children with severe emotional disturbance and their families. The vision statement of the Sault Tribe's lead health and human services center, Anishnabek Community and Family Services (ACFS), guides the goals and objectives of the program.
The Sault Tribe is located within the seven easternmost counties of the Upper Peninsula of Michigan and is the largest federally recognized tribe in the State. Tribal members number approximately 27,700. In early 1998, there were 4,774 children aged 21 and under residing within the seven-county service area, with over half of these in Chippewa County. The Bay Mills Tribe, a small, isolated rural community, is located in the extreme northeastern end of the Upper Peninsula. Its total tribal enrollment is approximately 1,245. Of these children, 487 were under the age of 22 in early 1998.
The primary target population for the grant program is all American Indian children aged 22 and under who are identified with or at risk for developing severe emotional disturbance and their families who reside in Chippewa, Mackinac, and Schoolcraft Counties.
The target population is served by a dual system of State and tribal agencies. Both the tribes and the State provide mental health, physical health, juvenile justice, education, foster care, and protective services. Hiawatha Behavioral Health, the community mental health agency, provides a respite coordinator who is funded by the grant. Hiawatha also provides outpatient psychiatric services, medication management, and emergency and crisis services. ACFS and the Bay Mills Wellness Center offer counseling services for adults and substance abuse services, which means that some family members may receive other behavioral health services through these tribal agencies in addition to children's mental health services. These agencies also provide a range of social services as well as child protective and child placement services. The Bay Mills Wellness Center also has a juvenile justice worker. Both tribes have their own physical health care systems as well, which are common referral sources for the project.
Prior to receiving the grant, services that were available to the target population included primarily outpatient psychiatric services and institutionalized care through the county community mental health agencies. Grant-funded staff now offer community-based care through home-based therapists who provide outpatient individual and family counseling, case management and coordination services, and intensive home-based services. Hiawatha provides both respite care and medication management services to children served through the grant. Emergency and crisis services are also available through home-based therapists, Hiawatha, and the child welfare agency. Steps are being taken to convert the existing tribal group home into a therapeutic environment.
A unique focus of the project is that of cultural awareness, which includes not only opportunities for training non-Native providers in American Indian cultural practices but also includes activities to enhance the mental health and healing of children and their families. |
A unique focus of the project is that of cultural awareness, which includes not only opportunities for training non-Native providers in American Indian cultural practices but also includes activities to enhance the mental health and healing of children and their families. The home-based therapists often help children and their families to become involved in American Indian cultural events that help to build self-esteem, to create a sense of community, or to find healing for personal and tribal injuries and injustices. The Sault Tribe and the Bay Mills Tribe are working as communities to rebuild a sense of tribal identity after years of forced assimilation into the dominant White culture. Few individuals still speak the native language, for example, and the project supports efforts to reclaim the language and other cultural practices as part of a movement toward overall improved mental health of tribal children and their families.
The Sault Ste. Marie Tribe of Chippewa Indians in Sault Ste. Marie, Michigan, is a highly assimilated tribal community with high rates of intermarriage within the larger non-Native population of Sault Ste. Marie and the surrounding counties. Tribal members by and large rely on Western categorical approaches to mental illness and treatment modalities. However, community members also experience a great sense of loss and grief in relation to the almost complete disappearance of their language, customs, and values. As a result, tribal leaders and tribal elders are committed to an across-the-board "cultural renaissance." Both project staff and community leaders agree that Anishnabe (Ojibway) cultural values are a critical component of system development, system reform, and system evaluation.
Recently, the Inter-Tribal Council of Michigan, in collaboration with the Sault Tribe, developed a cultural stakes assessment of children's (or adults') degree of identification with the culture and values of the Anishnabe (Ojibway) people. This fully computerized assessment system will be used by the Mno Bmaadzid Endaad project to begin to evaluate the interaction between children's or caregivers' identification with the culture and the services being provided by project staff.
In addition to assessing perceptions about Native culture, the project has recently initiated the use of a self-administered structured psychiatric diagnostic instrument designed for use by lay interviewers in the community. By using this structured interview at intake and follow-up, the project hopes to reduce the variability related to field diagnosis and to provide the system with more standardized and accurate diagnoses for children with mental health disturbances.
Beyond the national evaluation requirements, the grant community would like to integrate a more qualitative approach to data collection and analysis. The Sault Tribe is one of the participants in a Circles of Care grant administered by the Inter-Tribal Council of Michigan. As part of that grant, Circles of Care staff along with Mno Bmaadzid Endaad staff have been conducting "talking circles" with Native community members focusing on what makes a healthy Anishnabe child and family as well as identifying gaps in and barriers to services. The results of the Circles of Care grant will be used to plan culturally appropriate services and approaches to the local evaluation of those services. In addition, a retreat is planned with the Community Evaluation Advisory Committee to discuss how traditional Native activities and healing practices can be measured and their impact assessed.
Finally, high rates of domestic violence are of great concern to the community. The staff would like to focus evaluation efforts on this issue to help improve programs and services for victims of domestic violence.
As of June 2000, the project had enrolled 122 children into system-of-care services. Descriptive information had been collected on 118 children, and 26 children had been enrolled into the national outcomes study, as shown in Table 37.
The two American Indian and one Alaskan Native grant communities funded in 1999 were in the early stages of their first year of operation during FY 2000. This period of time has been devoted primarily to the development of the infrastructure for providing services within a system-of-care framework. This includes establishing governance mechanisms and interagency agreements, expanding service arrays, further defining the underlying framework and conceptual model for the program, and recruiting and training evaluation staff.
The Yukon-Kuskokwim Health Corporation (YKHC) is a tribally owned and operated nonprofit health corporation authorized by the governing councils of the 58 federally recognized tribes in the region to provide health services. Currently the YKHC administers a comprehensive array of services through a regional hospital in Bethel, several subregional clinics, and a network of village health aides. It also administers over 30 distinct health care programs that address direct care, health promotion, disease prevention, and community-based care.
YKHC serves a rural area covering 75,000 square miles consisting of remote villages located in the Delta region of Alaska, a geographic area the size of Pennsylvania. YKHC serves approximately 22,000 people in the area. The region is faced with unique geographic challenges. There are no roads connecting the villages; all travel is by airplane, boat, snowmobile, or dogsled. Most residents of the region live active subsistence lifestyles; food sources include fish, moose, caribou, seal, some whale species, berries, and local plants. Many residents speak Yup'ik, Cup'ik, or other Alaskan Native language as their first or only language. Extreme weather conditions (wind, ice, temperatures below -50o F) prevent or slow travel during much of the year. Each village is governed independently and represents one or more distinct tribes.
The critical need for enhanced mental health services in the Delta region is illustrated by alarming statistics describing the adolescent and child population. The high rate of serious emotional disturbance is compounded by substance abuse and suicide rates, low socioeconomic status, and the substantially younger Alaskan Native population. In Alaska, 1 in 10 children experience emotional problems so severe that their functioning is impaired, and the Alaska teen suicide rate is the fourth highest in the nation. According to the Center for Mental Health Services, there were 14,700 children aged 5-18 years old identified as having serious emotional disturbance in Alaska in 1997. The rate of suicide in the Delta region is six times the national average, and the area is plagued by widespread substance abuse and a rate of fetal alcohol syndrome that exceeds the State average of 4.3 per 1,000.
Few communities have a designated mental health provider, and frequently multiple providers serve children across various child-serving agencies. Children with serious emotional disturbance are frequently referred to restrictive care settings outside the home village, located from 25 to 500 miles away. As a result, families have minimal involvement with planning or delivery of mental health services for their children. The project anticipates serving 200 to 300 children and their families over the course of the grant-funded period.
The YKHC is creating a collaborative, integrated system of care based on a holistic approach. The integration of multiple service delivery systems involves families as full partners in the care of their children. The primary goals of the project are (a) to form formal partnerships among fragmented, categorical child-serving providers across the Yukon Delta region in order to create a single system of care that delineates clear lines of referral and accountability within a culturally sensitive and comprehensive array of services; (b) to establish core multidisciplinary teams at subregional hub villages to provide holistic, culturally competent diagnosis and service planning as well as adequate supervision and support for providers in individual villages across the region; (c) to support families in such a way as to guarantee participation at all levels of the system from leadership and policy making to program evaluation; and (d) to establish formal agreements among providers to create a single system to manage funding related to billing arrangements and to attract new funding sources to Alaska.
Since the YKHC serves over 50 villages region-wide, leadership and support for system-of-care development is being established at multiple levels through policy steering committees. These committees, located at the village level, function as an adjunct to individual tribal councils. At the subregional level, core treatment teams are being developed, led by village-based coordinators and clinicians serving those villages. Village-based coordinators are the primary vehicles of the plan, marketing the system-of-care philosophy and principles to community groups. Communication and support for the system-of-care program service development will be accomplished through the regional level via a board of directors of the YKHC, the Mental Health Advisory Board, and the annual Tribal Gathering.
Local staff plan to implement the wraparound service delivery model throughout the nine regions in the Yukon Delta region of Alaska. At each of the nine regional hubs, the wraparound model of care will be implemented by a core team consisting of an elder, a clinician in behavioral health, a family advocate, a village-based coordinator of community health aids for the region, and a wellness counselor. During the first year, nine family advocates will be hired to form multidisciplinary teams and provide services based on the wraparound model for each family being served. Along with the core team, family advocates will create an intervention plan specific to the needs of each family; assist families in negotiating the system of care; and provide support, advocacy, and linkages to village-based and regional resources. Family advocates also will be responsible for data collection at the local level.
Evaluation challenges are consistent with those experienced by other indigenous peoples. A challenge unique to this project is related to language, which can be a barrier, particularly in cases where family members speak only the native language. Many constructs from Anglo-European clinical evaluation tools do not have similar concepts in Yup'ik, Cup'ik, or other Alaskan Native languages.
In designing an evaluation that is sensitive to the cultural beliefs and traditional practices of the Alaskan Native population, the YKHC project recommends the use of culturally relevant evaluation methods that are appropriate to the geographic and social environments in which Alaskan Natives reside. A successful approach to measuring outcomes is being implemented in the grant community. Local evaluation staff are working in conjunction with other American Indian and Alaskan Native evaluators as part of a Center for Substance Abuse Treatment (CSAT) grant. The "cluster group" of evaluators for the CSAT grant has designed quantitative methods that include a matrix of relevant questions and methods for collecting data individualized for each community. The project also utilizes structured interviews and community focus groups to reflect project outcomes that are not captured in the national evaluation. With the exception of the Government Performance and Results Act (GPRA) requirements, specific assessment tools have not been prescribed for mandatory use.
For the system-of-care grant, the grant community would like to integrate more culturally relevant measures that will reflect accurately the cultural beliefs and practices of the people living in the Yukon Kuskokwim Delta region. Their approach involves using community-based facilitators to conduct focus groups in Alaskan Native languages. YKHC has trained community members in focus group facilitation. Analysis of the information is conducted by the evaluation team, which includes the on-site evaluator, project staff, family members, and researchers from the University of Alaska, Anchorage. Evaluators at the university have the capacity to manage large qualitative data sets with software that can quantify results for better reporting. Project staff believe that a more culturally relevant approach will result in more accurate outcomes data for Alaskan Native communities and ultimately ensure continued funding for the project.
The Pine Ridge Reservation is comprised of a 1.8-million-acre land base. Shannon, Bennett, and Washabaugh Counties lie within the boundaries of the area. The environment is characterized by a harsh climate, poor road conditions, lack of public transportation, and overcrowded public housing areas. The economy is entirely dependent on Federal programs, and Shannon County has the lowest per capita income rate in the country, according to the 1990 census. The tremendous social and economic pressures experienced on the reservation pose serious problems for Lakota children and families. Serious emotional and mental health issues affecting families stem from substance abuse, child abuse, suicide, depression, domestic violence, homelessness, extreme economic deprivation, developmental disabilities, and other mental health problems. Lakota family structures have been impacted by a series of abrupt historical and cultural transitions disrupting language, culture, and values transmission. Consequently, families have had to endure continuous challenges to maintain their health and well-being.
The Nagi Kicopi ("Calling the Spirit Back") project is an opportunity to integrate ancient Lakota healing and cultural practices with current Western therapeutic medical and social practices. Traditional healers and interpreters provide healing knowledge to advance the health and well-being of children with serious emotional disturbance and their families of the Oglala Lakota Nation. The project is committed to healing the spirit of children by creating a holistic circle of comprehensive Lakota and clinical approaches to help children and families overcome the effects of historical trauma and cultural oppression and reclaim their Lakota identity through language, values, beliefs, and ceremonies.
During the first year of implementation, the grant community has been integrating the Calling the Spirit Back project activities into a collaborative relationship with the Wakanyeja Wape Tokeca Project, a SAMHSA Circles of Care planning grant to develop a comprehensive system of care for children and families. Service delivery will be provided based upon a wraparound model of services. This is based on the notion that families can provide an active voice within a circle of supportive persons dedicated to improvement of the quality of life. This approach is considered a paradigm shift in mental health service delivery in Pine Ridge. The tribe believes this approach to service delivery will enable a positive, strengths-based interaction among team members in working with the child and family and will focus on family participation and decisionmaking relative to their perceived needs. A Lakota community-based wraparound referral and intake committee is being organized to create a case review process. The Oglala Lakota Tribe multidisciplinary team, a child protection interagency networking committee comprised of tribal, State, Bureau of Indian Affairs, Indian Health Service, public safety, schools, court, and housing agencies, will serve to promote collaborative partnerships.
The Tiwahe (Family) advocacy group is being formalized during the first year of the project. The group has since contributed to the development of the system of care and will continue to provide leadership at every level of project implementation. The Nagi Kicopi project will integrate existing service providers, community resources, and parent skills. Service providers will include care coordinators trained to provide case management services and traditional healers to provide spiritual and healing ceremonies. The project will develop program capacity to provide more intensive clinical services.
This grant community received funding in May 2000 as part of the 1999 fiscal year funding initiative. It has initiated the process of building infrastructure for developing its system of care.
Founded in 1970 by the efforts of the local American Indian community, the United Indian Health Services, Inc. (UIHS) was established with the purpose of providing health care services to all tribes living in Humboldt and Del Norte counties. UIHS is the coordinating agency responsible for assuring appropriate, individualized system-of-care approaches for American Indian children. Within the organization, the Child and Family Services Department (CFS) was established to develop family treatment and preservation programs. The department provides culturally competent wraparound services to children with serious emotional disturbance and their families who are referred into the system of care. Mental health issues of greatest concern to project staff include school failure; the risk of removal from the home; out-of-home placement of children in non-Indian foster care; and the risk of violence, including child abuse, spousal abuse, sexual abuse, and suicide. The overall objectives of the project are (a) to deliver culturally competent, individualized services to children and families while addressing the geographic barriers of the region; (b) to establish a sustainable, comprehensive system of care that consolidates existing public services under one organization maintained by American Indians and their clients; and (c) to develop mutually supportive relationships with State and local agencies as they pertain to wraparound services.
The service area for the project includes Humboldt and Del Norte Counties located in the northernmost coastal region of California, encompassing over 4,500 square miles of both urban and rural areas. Current estimates indicate that approximately 15,000 American Indians reside in this area, and 10,500 are registered clients within the UIHS system.
Meeting the vast mental health needs of their population is the greatest challenge for these communities that are experiencing a continual rise in behaviors such as family violence, suicide, and crime. |
Meeting the vast mental health needs of their population is the greatest challenge for these communities that are experiencing a continual rise in behaviors such as family violence, suicide, and crime. According to UIHS 1998 statistics for this region, among the clients served under the age of 19 years old, 90 percent presented with symptoms of serious emotional disturbance. Similar to other rural communities, the challenge related to providing mental health services to children and families is compounded by geographic isolation and limited resources in the region.
Currently the project provides the following services to children with serious emotional disturbance and their families: (a) counseling for school-age children, including alcohol and drug prevention programs and a referral system to mental health services; (b) counseling services provided at Juvenile Hall; (c) foster home or therapeutic foster care placement in consultation with tribal organizations and Indian child welfare programs; and (d) clinic- and community-based counseling and parenting programs. As a result of receiving grant funds, the project anticipates significant reforms. Primarily the project will reduce burden on county mental health and child welfare services by providing a fuller range of psychiatric and case management services, assuring the delivery of culturally competent mental health services in all public schools, reducing the over-representation of American Indian children in the juvenile justice system through the development of community-based mental health service delivery, and providing American Indian case managers to develop and to participate in community-based, multidisciplinary teams.
CMHS funding to these eight American Indian and Alaskan Native communities has provided the opportunity to develop unique and culturally responsive systems of care in settings that vary greatly in geographic area, cultural traditions, and pre-existing infrastructure for service delivery. Each community has fashioned a unique approach to combining traditional healing practices with Western concepts of mental health service delivery. The programs are contextualized locally within specific American Indian and Alaskan Native cultures that differ among themselves along several dimensions. An important lesson to be derived here is the importance of an appreciation for the uniqueness of each tribal culture. The flexibility of the system-of-care approach has allowed each community to integrate their values and belief systems into a meaningful and appropriate service delivery program that effectively addresses the needs of children, adolescents, and their families within community settings.
Evaluation activities are progressing across these programs, and many lessons are being learned. Key issues that continue to challenge evaluation implementation revolve around the sensitivity and cultural appropriateness of measurement and the burdens on families and staff who participate in the comprehensive, longitudinal outcomes protocol. The ultimate success with which these issues are addressed can only be judged in the future as more experience is gained with evaluation implementation. Additional local-level protocols that are being implemented include a wide range of data collection procedures, from structured diagnostic interviews to computerized assessment of cultural beliefs, to qualitative, focus group approaches. Many of these communities that are relatively self-contained also will be able to track changes in community-level indicators of health across time. These additional measurement features should add substantial information about the effectiveness of system-of-care approaches in American Indian communities.
The ultimate, long-range outcomes for system-of-care programs in American Indian communities will depend heavily upon their abilities to leverage other sources of funding and to sustain their programs after CMHS funding ends. Utilizing the lessons learned and the data gathered to inform program development through outcomes accountability and to communicate program effectiveness are two important routes for insuring program sustainability. Several of these programs have already demonstrated the ability to leverage other sources of funding to expand service arrays and to support program activities into the future.
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