Caring Adults, School Ties and Risk Among American Indian and Alaska Native Teens

American Indian and Alaska Native (AI/AN) communities draw strength from generations of Indigenous tradition, language, culture and knowledge. That strength has at times been lost or challenged by systemic, structural and social factors rooted in historical and intergenerational trauma — the result of U.S. government policies of assimilation, termination and relocation, military action and forced relocation. The health gaps that followed are best addressed through the strengths of the communities themselves.

Two protective factors are well established for students in general: a safe, stable upbringing with caring adults — parents, other relatives or community members — who meet a child's basic needs and keep track of where they are and who they are with; and school connectedness, the sense that people at school care about you, your well-being and your success. This CDC report asked how those factors relate to substance use, emotional well-being and suicide risk, and violence among AI/AN high school students.

Counting everyone

Health data for AI/AN people are often poor. Standard coding counts someone as AI/AN only if they choose that race alone — and one study found that approach captures just 18% of AI/AN high school students, because 82% also identify as Hispanic or Latino or as more than one race. Small samples add to the problem, producing imprecise numbers or results withheld altogether.

For the first time, the 2023 national Youth Risk Behavior Survey (YRBS) added a supplemental sample of AI/AN students, and it counted every student who selected AI/AN, whether alone, with another race, or as Hispanic. (Students who chose all five race categories, or skipped either race question, were left out.) The survey, run every two years since 1991, reached 20,103 students in grades 9–12 at public and private schools across the 50 states and the District of Columbia; 2,770 were AI/AN and 15,699 were not.

Students were asked three questions about protective factors:

• how often, in their lifetime, an adult in their household had tried to make sure their basic needs — safety, clothing, food — were met;
• how often their parents or other adults in the family knew where they were going and with whom (parental monitoring);
• how close they felt to people at their school (school connectedness).

The report then looked at 13 outcomes: five kinds of current substance use, four measures of emotional well-being and suicide risk, and four kinds of violence.

How AI/AN students compared

Across all students, 74.7% had an adult who always tried to meet their basic needs, 84.0% reported high parental monitoring, and 55.3% felt close to people at school. AI/AN students were less likely to have an adult always meeting their basic needs (67.7% vs. 75.3%). Four outcomes were more common among them:

What protected AI/AN students

After adjusting for sex and grade, each protective factor was tied to lower rates of some of the outcomes among AI/AN students:

For all students together, current use was 3.5% for cigarettes, 16.8% for vaping, 22.1% for alcohol, 17.0% for marijuana and 4.4% for prescription opioid misuse. Some 39.7% felt persistently sad or hopeless, 28.5% reported poor mental health, 20.4% had seriously considered suicide and 9.5% had attempted it. And 8.6% had ever been physically forced to have sex, 11.4% had experienced sexual violence, 19.2% had been bullied at school and 16.3% bullied electronically.

Adjusted prevalence ratios for substance use, emotional well-being and suicide risk, and experiences with violence among AI/AN high school students, by household adult caretaking, parental monitoring and school connectedness, adjusted for sex and grade; bars show 95% confidence intervals. Youth Risk Behavior Survey, 2023. CDC, MMWR.

Building on culture

The results match other research showing that engaged families, parental monitoring and school connectedness protect high school students. Among AI/AN students, two in three had an adult who always tried to meet their basic needs and three in four reported high parental monitoring — and the authors see caretaker engagement as a critical part of programs built on cultural resilience.

The federal government has embraced traditional Indigenous knowledge as a "valid form of evidence for inclusion in Federal policy, research and decision making," and programs for tribal and urban Indian communities must "acknowledge historical context and past injustice." AI/AN communities have long seen their traditions, language, culture and knowledge as protective for young people — what is sometimes called cultural, social or collective resilience. The 2019 National Indian Education Study found that Native language and culture programs supported achievement, motivation, self-esteem and pride among 4th and 8th graders, and that students whose families volunteered or joined a parent-teacher organization were more likely to perform well academically.

CDC's resources include guides on preventing adverse childhood experiences, preventing suicide and promoting mental health in schools, and its What Works in Schools program, which aims to strengthen school connectedness. CDC is also evaluating culturally informed strategies for AI/AN students.

Limitations and next steps

• The survey is a snapshot, so it cannot show cause and effect.
• Each protective factor was measured with a single question that cannot capture all of it — the basic-needs question, for example, does not say who the adult was or how consistently they were present.
• Schools funded by the Bureau of Indian Education, often on tribal lands, were not sampled, so the findings apply to AI/AN students at public and private schools only.
• The survey did not ask about tribal affiliation or whether students lived on tribal lands.
• Because this report counted multiracial and Hispanic AI/AN students, its figures should not be compared directly with reports limited to non-Hispanic AI/AN students of a single race.

The authors called for inclusive coding of AI/AN identity in all public health data, since single-race counting leads to misclassification, suppressed results and data lost in an "other" or multiracial category. They also pointed out that each of the 574 federally recognized tribes has its own culture, traditions, resources and needs. The YRBS system supports tribal nations in running their own surveys, giving them local data for their own decisions while respecting tribal data sovereignty.

If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline in the United States.

Sources

• Jones SE, Satter DE, Reece J, et al. "Adult Caretaker Engagement and School Connectedness and Association with Substance Use, Indicators of Emotional Well-Being and Suicide Risk, and Experiences with Violence Among American Indian or Alaska Native High School Students — Youth Risk Behavior Survey, United States, 2023." MMWR Supplements 73(4). CDC. The report's summary lists "sexual violence" among the experiences more common in AI/AN students; its results show that for being physically forced to have sex, which is the figure given here.