American Indian and Alaska Native (AI/AN) populations have substantial health inequities, and most of their disease entities begin in childhood. In addition, AI/AN children and adolescents have excessive disease rates compared with the general pediatric population. Because of this, providers of pediatric care are in a unique position not only to attenuate disease incidence during childhood but also to improve the health status of this special population as a whole. This policy statement examines the inequitable disease burden observed in AI/AN youth, with a focus on toxic stress, mental health, and issues related to suicide and substance use disorder, risk of and exposure to injury and violence in childhood, obesity and obesity-related cardiovascular risk factors and disease, foster care, and the intersection of lesbian, gay, bisexual, transgender, queer, and Two-Spirit and AI/AN youth. Opportunities for advocacy in policy making also are presented.

We acknowledge that this policy statement was written together on Coast Salish and Pueblo lands, both diverse, strong, and enduring communities that uphold a sacred legacy of protecting future generations. As American Indian (AI) authors and physicians ourselves, we acknowledge that we intend to represent a diverse and far-reaching group of Indigenous peoples. We humbly submit that not all aspects of caring for our communities could be captured in our article. We ask that this policy statement be used to support and advocate for improved health outcomes and the well-being of children and youth from all tribal and urban AI communities. Many solutions to the problems illustrated below can be found within these very communities.1 

American Indian and Alaska Native (AI/AN) children and adolescents are found throughout the United States, with more now living in urban rather than rural areas.2  Many tribal nations have their own languages, and all have rich histories, but most AI/AN people now live in metropolitan areas that may include many different tribal groups. Care for this special population presents a unique and complex clinical opportunity for pediatricians, other providers of pediatric care, and pediatric care organizations because of the high level of documented health inequities within a sociocultural context unfamiliar to most practicing providers of pediatric care. Not only do AI/AN youth face medical access barriers, but they also have a higher prevalence of chronic stress and adverse childhood experiences (ACEs) and exposure to environmental hazards resulting in poorer health outcomes3  when compared with the general population.4  In addition, several other significant barriers to care deserve mention. These include conventional barriers for underresourced families, such as lack of transportation, difficulty finding child care, inability to miss work, caring for elders, and other family and work obligations, as well as other socioeconomic challenges. Moreover, less well-recognized issues exist, such as long-standing mistrust of governmental agencies, discrimination in clinical settings attributable to implicit and explicit bias leading to mistrust of health care and of health care–related research, and the cumulative burden of generations of unresolved traumas and racism.58  This policy statement explores the roles historical trauma and health inequities have played in shaping the current socioeconomic and health status of AI/AN youth. Disproportionate needs in mental and cardiovascular health and disease processes that are overrepresented in AI/AN youth are discussed to provide a summary of salient issues for pediatric care providers. This statement also provides strategies for culturally sensitive family-centered care to mitigate morbidity and policy recommendations to facilitate institutional and system changes needed for improved health outcomes.

Of note, Native Hawaiians and Pacific Islanders are considered a unique population of Indigenous people who live within the territories discussed but are not considered AI. They have their own distinct cultural identity as well as distinct health outcomes and needs. In addition, they are not considered tribes by the US federal government, so they are not beneficiaries of the Indian Health Service (IHS) or eligible for funding from the Bureau of Indian Affairs. Given these differences and the need for them to be addressed fully, this policy statement does not address this population.

Many of the cited publications in this document compare AI/AN youth to non-Hispanic white youth; the authors would like to note that this phenomenon can lead to white centering. Where possible, we avoided comparing racial groups in this way but were somewhat limited by the available studies.

The call to pediatricians to employ strategies to mitigate toxic stress caused by ACEs is especially critical for AI/AN children.9  In a landmark study of more than 13 000 adults, categories of childhood abuse, neglect, and other forms of household dysfunction were linked to adult mortality and morbidity. Risk was quantified by using an ACE score, or the number of categories experienced by an individual before age 18 years.10  A higher ACE score’s association with poor health outcomes is postulated to stem from altered neurodevelopment with subsequent social, emotional, and neurocognitive impairment, which in turn leads to detrimental health behavior and poor health outcomes. For example, compared with those without ACEs, adults with an ACE score of 3 or more are twice as likely to smoke or have cardiovascular disease and 1.5 times more likely to have severe obesity or diabetes.11,12  AI adults and children experience a disparate number of ACEs compared with the general US population. A recent study of 516 AI adults from South Dakota revealed an ACE score of 3 or more in 45.4% of participants as compared with 17.4% of region-matched controls.13  Among AI adults from 7 geographically diverse tribes, AI adults were 5 times more likely than non-AI adults to have had 4 or more ACEs.14  According to the National Survey of Children’s Health data collected in 2011 and 2012, 1453 AI children and adolescents aged 0 to 17 years were more likely to have had multiple ACEs compared with non-Hispanic white (NHW) children.15  In that study, >25% of AI youth had 3 or more ACEs, compared with only 11.5% of NHW children. Regarding the types of ACEs endured, AI populations suffer from a disproportionate prevalence of emotional and physical neglect, substance use disorder, and incarceration among family members, as well as witnessed intimate partner violence, when compared with the general population.1316  The authors of another study of AI adolescents and young adults also found that historical loss–associated symptoms and perceived discrimination are relevant factors in considering ACEs for Indigenous children and youth, suggesting the importance of considering loss of culture and structural racism as contributors to childhood adversity in this population.16 

Obesity prevalence in AI/AN youth is among the highest of all races and ethnicities.1719  Obesity onset occurs at a younger age compared with other racial and ethnic groups in the United States; AI children between 2 and 5 years of age have a higher combined prevalence of overweight and obesity (58.8%) than children of all other races or ethnicities (30%).17,20,21  Moreover, AI/AN children experienced an increase in obesity prevalence between 2003 and 2008, whereas the prevalence for other US racial groups declined. Recent data have revealed an alarmingly high prevalence of obesity compared with the general US population but suggest that obesity prevalence (29.7%) in AI/AN children 2 to 19 years of age may have stabilized.22,23  Although recent research from 2010–2014 suggests a decline in severe obesity among children 2 to 4 years of age from low-income families, severe obesity remains high for young AI/AN children and is among the highest of all racial and/or ethnic groups receiving benefits through the Special Supplemental Nutrition Program for Women, Infants, and Children.24  It follows that a significant portion of AI children with obesity have significantly abnormal blood lipid levels, higher blood glucose levels, and higher abdominal adiposity compared with children with normal-weight.25 

Obesity may largely be determined in infancy, with excess prenatal maternal weight gain, macrosomia, and premature cessation of breastfeeding significantly predicting BMI at 1 year of age in a previous study.26  In the same children, overweight or obesity status at age 1 year persisted to ages 5 to 8 years and was associated with unhealthy levels of low-density lipoprotein. In AI children, once obesity is established, it likely persists into adulthood and increases the risk of chronic disease.27,28  The prevalence of disproportionate rates of obesity emerge in early childhood17,20,29 ; thus, tailored prevention and intervention strategies are needed for young AI/AN children.

Given the high rates of obesity, AI/AN youth also experience high rates of type 2 diabetes mellitus (T2DM). Testing, as recommended by the American Diabetes Association, for prediabetes and T2DM should be considered in AI/AN children and adolescents with overweight or obesity.30,31  Further information is available in American Academy of Pediatrics technical and clinical reports on management of T2DM for children32  and specifically for AI/AN youth.33 

The benefits of human milk nutrition for infants are well documented and include wide-ranging effects, such as the reduction of respiratory tract infections, obesity and diabetes incidence, atopic disease, and infant mortality.34  Although the breastfeeding initiation rate for the general US population is 75%, minority populations experience significant disparities in initiating and continuing breastfeeding at 6 and 12 months.35  AI/AN women have the second-lowest prevalence of breastfeeding initiation, duration, and exclusivity compared with all other US racial and ethnic groups. In a previous study, only 59% of AI women initiated breastfeeding, and most of those (76%) stopped breastfeeding within 4 months.26  Encouragingly, those who continued to breastfeed for 6 months tended to continue through infancy.36  Health benefits of breastfeeding have been demonstrated in all populations, including AI/AN populations. For example, in a retrospective cohort study, a lower BMI was reported among AI/AN adolescents breastfed for >6 months.37  Breastfeeding promotion is needed in AI/AN tribal communities and would ideally be coordinated by tribal entities and would involve community members, elders, and health care providers, including paraprofessionals.38,39 

AI/AN children and youth with special health care needs (CYSHCN) are at particular risk of health disparities. Although there is no evidence of a higher prevalence of special health care needs among AI/AN children compared with NHW children, AI/AN children are more likely than NHW children to meet criteria for special health care needs on the basis of functional difficulties.40  In addition, AI/AN CYSHCN are more likely than NHW CYSHCN to have 3 or more functional difficulties,40  which can be interpreted as AI/AN CYSHCN likely having more disability. Although there are no studies on the prevalence of developmental delay, functional difference, or disability among AI/AN children, it is possible that there is a higher prevalence in AI/AN children, compared with the general population, because of a disproportionate burden of injury,41  inadequate prenatal care,42,43  preterm birth,43  environmental stressors,42,44  and other social determinants of health and function.

CYSHCN benefit from the accessible, comprehensive, and coordinated care provided by a medical home, but AI/AN CYSHCN are significantly less likely than children without special health care needs to receive care meeting the medical home definition (odds ratio 0.2; 95% confidence interval 0.1–0.4).7  In addition to difficulties receiving medical home–based primary care, AI/AN CYSHCN may have challenges accessing subspecialty medical care or pediatric rehabilitation therapies; those who live in rural or remote communities may have to travel many hours to access specialized care. Even among urban AI/AN CYSHCN, there may still be barriers related to transportation,45,46  funding, and wait times.47  The care used by AI/AN CYSHCN may not be sensitive to the family’s values7  or address the child’s functional needs related to their tribal culture.48  Efforts should be made to identify CYSHCN in a timely manner, implement culturally sensitive medical home–based care for AI/AN CYSHCN, and facilitate access to services that will help AI/AN CYSHCN achieve their full functional potential and be included in their communities.

Suicide is the second-leading cause of death for AI/AN and non-AI/AN youth 10 to 24 years of age,49,50  but the 2016 age-adjusted suicide mortality rate among AI/AN youth (15.59 per 100 000) is more than 1.5 times higher than that of the general population (9.60 per 100 000).51  There is significant regional and intertribal variation in AI/AN youth suicide mortality, with some tribes having youth suicide rates 7 times higher than the national AI/AN rate and 12 times higher than the general population rate.52,53 

In previous studies, differences in risk and protective factors that may attenuate that risk (such as having a connectedness to family and having the ability to discuss problems with family and friends54 ) explained the higher prevalence of suicidal behaviors among AI/AN students compared with other students.55,56  ACEs were also associated with suicide attempts; after controlling for multiple factors, each additional ACE increased the risk of lifetime suicide attempt by 37% for AI youth.16  AI/AN individuals of all ages who died by suicide were less likely than NHW individuals to have received mental health diagnoses or treatments and were more likely to have a family member or friend’s death precipitate suicide.57 

Suicide prevention initiatives that are strengths based, community driven, and culturally centered have been used in several AI/AN communities to reduce youth suicide behaviors.57,58  For AI/AN youth who do not have access to a community-specific suicide prevention program, efforts should be made to identify youth with an increased burden of suicide risk factors and to strengthen protective factors, particularly cultural protective factors.55  If available, school-based health centers may be used for adjunctive mental health care.59 

Lesbian, gay, pansexual, bisexual, transgender, gender queer, intersex, and Two-Spirit AI/AN youth experience exponential increases in risk for health disparities.6063  “Two-Spirit” is a unifying term that encompasses both gender identity and traditional Indigenous understandings of identity and is a widely used term in Indigenous communities across North America. In the 2015 US National Transgender Health Survey, AI/AN transgender respondents reported having experienced harassment (86%), physical assault (51%), and sexual assault (21%). Fifty-seven percent of AI/AN youth identifying as transgender have attempted or contemplated suicide, compared with 4.6% of the general US population and 33.7% of transgender youth as a whole.64,65  In this same study, 23% of transgender respondents (all ages) identifying as AI/AN experienced unemployment in the last year.66  In another study, youth at the intersection of gender and racial identity had higher rates of risk behaviors and emotional distress (Table 1). Careful attention to gender-affirming care and risk assessments may mitigate these effects.67 

TABLE 1

Risk Behaviors and Emotional Distress Reported by Ninth- and 11th-Grade Students in a Minnesota Student Survey Sample

ReportedAI/AN LGBTQ (n = 149 Ninth- and 11th-Graders)Full MSS Sample (n = 81 885 Ninth- and 11th-Graders)All LGBTQ (n = 8758 Ninth- and 11th-Graders)
Substance use    
 Smoked cigarettes (past 30 d) 32.9 6.1 14.1 
 Drank alcohol (past 30 d) 25.2 17.2 22.3 
 Binge drinking (past 30 d) 16.8 8.4 10.7 
 Smoked marijuana (past 30 d) 33.1 10.8 17.0 
Sexual behaviors    
 Ever had sex 33.8 22.1 28.8 
 ≥2 partners (past year)a 18.3 8.7 14.7 
Emotional distress    
 Depressive symptoms 51.7 22.3 48.1 
 Self-harm (past year) 52.1 15.4 43.7 
 Suicidal ideation (ever) 60.5 21.0 53.6 
 Suicide attempt (ever) 37.7 7.7 24.4 
ReportedAI/AN LGBTQ (n = 149 Ninth- and 11th-Graders)Full MSS Sample (n = 81 885 Ninth- and 11th-Graders)All LGBTQ (n = 8758 Ninth- and 11th-Graders)
Substance use    
 Smoked cigarettes (past 30 d) 32.9 6.1 14.1 
 Drank alcohol (past 30 d) 25.2 17.2 22.3 
 Binge drinking (past 30 d) 16.8 8.4 10.7 
 Smoked marijuana (past 30 d) 33.1 10.8 17.0 
Sexual behaviors    
 Ever had sex 33.8 22.1 28.8 
 ≥2 partners (past year)a 18.3 8.7 14.7 
Emotional distress    
 Depressive symptoms 51.7 22.3 48.1 
 Self-harm (past year) 52.1 15.4 43.7 
 Suicidal ideation (ever) 60.5 21.0 53.6 
 Suicide attempt (ever) 37.7 7.7 24.4 

Minnesota Student Survey (MSS) data were provided by public school students in Minnesota via local public school districts and are managed by the Minnesota Student Survey Interagency Team (M. Eisenberg, ScD, MPH, personal communication, 2018). LGBTQ, lesbian, gay, bisexual, transgender, and queer.

a

Among sexually active ninth- and 11th-grade students only.

Violence affects AI/AN youth in unique but disproportionate ways. In a study using data from the National Trauma Data Bank, 11.8% of AI/AN children hospitalized for traumatic injury experienced injury as a result of violent assaults, compared with only 4.2% of NHW children.68  Many communities have started to focus on the crisis of missing and murdered Indigenous women and girls. Although limited data exist on rates of missing and murdered Indigenous women and girls and underreporting is extremely likely, a recent study completed by the Urban Indian Health Institute reveals staggering rates of violence toward Indigenous women and girls.69  Pediatricians have an opportunity to advocate for better data collection and unbiased media coverage. The Urban Indian Health Institute has created a tool kit (https://www.uihi.org/resources/mmiwg-we-demand-more-partner-toolkit/) on how further work in this area can be tailored in a culturally appropriate manner.69 

AI/AN youth and communities are also vulnerable to sex trafficking.70  It is estimated that 30% of AI girls between 11 and 17 years old have a history of sexual abuse, and 11% have reported being raped.71,72  Alaska Native women and girls make up 8% of the population in Alaska but represent 33% of sex-trafficking victims.73  In turn, AI/AN girls are 5 times more likely to be incarcerated for prostitution than NHW girls.73  It is important to recognize that men and nonbinary-gendered youth can also experience trafficking, and often times, finding data on these groups proves to be challenging. Identifying, preventing, and addressing trafficking and reducing violence is an integral part of caring for AI/AN communities.74 

The National Child Abuse and Neglect Data System, the Bureau of Indian Affairs, and the IHS report high rates of child protective services referrals for AI/AN youth.75,76  In a previous study, AI/AN youth in foster care were more likely to have special health care needs compared with others in foster care.77  Historically, AI/AN children were systematically removed from their homes in an effort to assimilate them into mainstream culture and to terminate the existence of tribal culture. Rates of ongoing referrals reflect both historical trauma and ongoing social and environmental determinants of inequities at work. The Indian Child Welfare Act was ratified in 1978 after decades of fierce advocacy by tribes for the right to keep their children within families that identify as AI/AN. Often used as a leverage point to threaten the sovereignty of tribal nations, the Indian Child Welfare Act remains an opportune protection for AI/AN children and adolescents.78 

The poor oral health status of AI/AN children is a major public health concern. AI/AN children have the highest rates of tooth decay among any racial and ethnic group in the United States.79  The prevalence of tooth decay among AI/AN children between 2 and 4 years of age is 5 times greater than the average US rate.79,80  AI/AN children also have limited access to dental services because of ongoing difficulties with recruitment and retention of qualified dentists in the IHS.79  More severe early childhood caries frequently requires extensive treatment under general anesthesia, creating an additional health care access barrier for AI/AN children. More information is available in the joint American Academy of Pediatrics and Canadian Paediatric Society policy statement on early childhood caries and its impact on Indigenous communities.81  In addition to oral health conditions, chronic otitis media and many other conditions disproportionally and inequitably affect AI/AN children and adolescents.82,83  The authors have chosen some of the most prominent to focus on but do not consider this an exhaustive list.

The delivery of health care to AI/AN children is influenced by governmental policy at the federal, state, and tribal level. Treaties between the federal government and sovereign tribal nations established a trust relationship for health care. Although these treaties are unique agreements between tribal nations and the US government, failure of the government to honor them has also shaped mistrust among many AI/AN people and communities. Today, that treaty-based health care system is organized through the IHS, an agency within the US Department of Health and Human Services. Many health care settings serving AI/AN people receive funding through the IHS, including IHS federally operated clinics and hospitals, tribally operated clinics and hospitals, and urban AI clinics run by urban AI health organizations in metropolitan areas. Yet many AI/AN children receive health care services at clinics that are not associated with the IHS, including private clinics and federally qualified health centers.

Not all people who identify as AI/AN are members of tribes that have been federally recognized. Tribes that are not federally recognized are not eligible for federal funding from the IHS or the Bureau of Indian Affairs.

The IHS is chronically underfunded, with the budget determined by annual federal appropriations. By way of comparison, in 2017 the IHS was funded at $4078 per person, whereas the US government spent $10 692 per person in the Veterans Affairs system.80  An underfunded IHS results in workforce instability and reduced ability to effectively deliver a full spectrum of necessary health care. Chronic underfunding leads to infrastructure issues as well. Many facilities are overdue for updates, many locations have trouble providing housing for staff and providers, and much of the equipment is outdated. Furthermore, funding shortages lead to challenges in providing specialty care through contract health services.

Medicaid payment rates are directly tied to the likelihood of a practice accepting Medicaid patients, which is subsequently correlated with access to health care for children with Medicaid.84,85  It follows, therefore, that increasing Medicaid payment rates and access to Medicaid coverage would potentially improve health care access for AI/AN youth. With more than 300 000 AI/AN children covered by Medicaid, there is an obvious need for continued and improved access to health services.86,87  Continuing to expand access to Medicaid coverage for AI/AN children is essential for ensuring access to needed services.

Another complicating factor for many AI/AN communities is the inconsistent and overenforcement of punitive drug laws targeting pregnant women. Punitive drug screening practices for pregnant women lead to a decrease in prenatal visits, which, in turn, increases the risk of preterm birth.88,89  Often, tribal laws differ from state and local laws, and in some instances, tribal jurisdictional boundaries may cross multiple states. Federally operated IHS facilities are bound by federal laws and policies. This overlap of governing bodies often results in confusing policies and a lack of standard and universal screening of pregnant AI/AN women, leading to late or inadequate detection of infants with a history of in utero substance exposure, including infants with neonatal opioid withdrawal syndrome.

Pediatric care providers, because of their early interaction with AI/AN youth and their families, have a distinct opportunity to promote resilience and improve the health of these children, which will have far-reaching benefits as they age and raise their own children. Pediatricians and other pediatric care providers can implement systems in their practice that can help all patients and families, including AI/AN families, feel that they are welcome and will be treated respectfully and that high-quality family- and patient-centered care will be delivered regardless of social class, personal history, or cultural, spiritual, gender, racial, or ethnic identity. These strategies include providing trauma-informed care,9092  screening for substance use93  and social determinants of health,9496  connecting to substance use prevention and treatment programs,93  home visiting,97  literacy programs,98,99  and leveraging school-based health centers if available.59  Addressing social determinants of health also includes addressing housing insecurity100  and food insecurity.101  The inclusion of the AI/AN perspective and disaggregated data in early childhood initiatives should be sought to improve outcomes within broader systems-based efforts. When implementing these strategies, pediatricians are encouraged to seek programs and interventions that incorporate AI/AN culture, tradition, and practices.102  The following recommendations reflect the issues raised above and provide opportunities for pediatricians and others who provide care to AI/AN pediatric patients:

  • Partner with local tribes and communities to set health priorities, understand historical experiences, and combine efforts already underway, such as cultural enrichment and preservation programs.

  • Provide opportunities for adequate training of clinical and office staff in culturally sensitive care practices. Advocate for local and regional models that incorporate culturally and linguistically appropriate services tailored for local tribes.

  • Provide evidence-based supports for parents and young children by promoting the use of home visiting models, high-quality child care, and early childhood programs, such as Early Head Start, Head Start, and Nurse-Family Partnership (https://www.nursefamilypartnership.org).103 

  • Start a Reach Out and Read program in AI/AN clinics and any clinic serving these families. Include books representing AI/AN and Indigenous children and families.

  • Assess patients for ACEs and social determinants of health (eg, poverty, food insecurity, homelessness, lack of neighborhood safety, incarceration of parents or other family members, mental health conditions of parents or other household family members, housing inequity, access to schools, academic achievement, intimate partner violence, child abuse and neglect, and involvement with the juvenile legal system) to help families identify and implement practical solutions.

  • Identify strengths and screen youth and families for protective factors to promote positive youth development.

  • Create efforts to promote and strengthen protective factors for youth, focusing on cultural preservation–based efforts.

  • Consider testing for prediabetes and T2DM in AI/AN children and adolescents with overweight or obesity, as recommended by the American Diabetes Association.

  • Promote breastfeeding in AI/AN tribal communities, ideally coordinated by tribal entities and involving community members, elders, and health care providers, including paraprofessionals.

  • Include early childhood oral health as part of overall childhood health and well-being. Perform oral health screening during early childhood health assessments and provide referrals as needed to dental health providers. Be knowledgeable of fluoride levels in the drinking water for local tribal communities in your area.81 

  • Create a medical home that acknowledges and is sensitive to discrimination in clinical settings and generations of unresolved traumas and racism that AI/AN children and families experience. Work with local community hospitals and pediatric emergency departments, which may serve as a referral source, to become a medical home for AI/AN children whose families use emergency departments rather than seek primary care.

  • Create a medical home model that facilitates access to services that will help AI/AN CYSHCN achieve their functional potential. Identify AI/AN CYSHCN, engaging staff, including care coordinators, in cultural competency training and partnering with the community.

  • Assess patients for mental health conditions, including signs of posttraumatic stress, anxiety, grief, depressive symptoms, and suicidality, as well as their mothers for perinatal depression104  using validated screening tools and a trauma-informed approach. Participate in strengths-based, community-driven, and culturally centered suicide prevention programs.58 

  • Screen AI/AN youth for substance use, and if identified, conduct a brief intervention and then refer for ongoing treatment.105107 

  • Work with local schools to identify AI/AN students in need of mental health and educational services.

  • Offer gender-affirming care in line with the previously published American Academy of Pediatrics policy statement.67 

  • Work to prevent, identify, and address sex trafficking in AI/AN youth.

Pediatricians also have an opportunity to advocate for systems change that addresses health inequities and other systemic factors that contribute to ongoing health disparities experienced by AI/AN children and youth. The following recommendations are intended to support the policies and systems needed to promote and protect the health of AI/AN children and youth:

  • Advocate for community initiatives and develop partnerships to address health disparities, such as altering practices of frequent consumption of sugar-sweetened beverages through education and improving the selection of foods locally available, to address healthy weight and oral health.

  • Share information with the US Congress, state legislatures, foundations, and other appropriate advocacy groups about the inequities and tremendous health disparities that exist between AI/AN populations and the general US population.

  • Invest in new research and clinical pathways to create culturally relevant screening and interventions for ACEs.

  • Advocate for federal, state, and local policy to end AI/AN homelessness through consultation and engagement with tribal leaders, AI/AN communities, and AI/AN young people with lived experience of homelessness. Advocate for the investment in improved data collection on homelessness among both rural and urban AI/AN youth and culturally responsive interventions to address homelessness among diverse tribal nations.

  • Work with local tribes and communities to address the need for research and advocacy around missing and murdered Indigenous women and girls.69 

  • Advocate for the protection and enforcement of the Indian Child Welfare Act.

  • Advocate for increased Medicaid coverage for children and families as well as increased payment for services.

  • Advocate for improved IHS budget and funding, which is chronically underfunded. IHS expenditures are among the lowest per capita compared with other federal health care expenditures, such as Medicare and the Veterans Health Administration. This disparity contributes significantly to the ongoing health inequities experienced by AI/AN people. Advocate for policies such as advanced appropriations or mandatory funding to provide the IHS with predictable and continuous funding.

  • Work with local government and tribal communities to understand and mitigate the negative effects of punitive drug laws for pregnant women.

Drs Bell, Deen, Fuentes, and Moore were equally responsible for conceptualizing, writing, and revising the manuscript, while also considering input from all reviewers; and all authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

     
  • ACE

    adverse childhood experience

  •  
  • AI

    American Indian

  •  
  • AI/AN

    American Indian and Alaska Native

  •  
  • CYSHCN

    children and youth with special health care needs

  •  
  • IHS

    Indian Health Service

  •  
  • NHW

    non-Hispanic white

  •  
  • T2DM

    type 2 diabetes mellitus

1
Brave Heart
MY
.
The historical trauma response among natives and its relationship with substance abuse: a Lakota illustration
.
J Psychoactive Drugs
.
2003
;
35
(
1
):
7
13
2
US Census Bureau
. Facts for Features: American Indian and Alaska Native Heritage Month: November
2018
. Available at: https://www.census.gov/newsroom/facts-for-features/2018/aian.html. Accessed February 25, 2021
3
Hoover
E
,
Cook
K
,
Plain
R
, et al
.
Indigenous peoples of North America: environmental exposures and reproductive justice
.
Environ Health Perspect
.
2012
;
120
(
12
):
1645
1649
4
Sarche
M
,
Spicer
P
.
Poverty and health disparities for American Indian and Alaska native children: current knowledge and future prospects
.
Ann N Y Acad Sci
.
2008
;
1136
:
126
136
5
Call
KT
,
McAlpine
DD
,
Johnson
PJ
,
Beebe
TJ
,
McRae
JA
,
Song
Y
.
Barriers to care among American Indians in public health care programs
.
Med Care
.
2006
;
44
(
6
):
595
600
6
Puumala
SE
,
Burgess
KM
,
Kharbanda
AB
, et al
.
The role of bias by emergency department providers in care for American Indian children
.
Med Care
.
2016
;
54
(
6
):
562
569
7
Barradas
DT
,
Kroelinger
CD
,
Kogan
MD
.
Medical home access among American Indian and Alaska native children in 7 states: National Survey of Children’s Health
.
Matern Child Health J
.
2012
;
16
(
suppl 1
):
S6
S13
8
Trent
M
,
Dooley
DG
,
Dougé
J
;
Section on Adolescent Health
;
Council on Community Pediatrics
;
Committee on Adolescence
.
The impact of racism on child and adolescent health
.
Pediatrics
.
2019
;
144
(
2
):
e20191765
9
Garner
AS
,
Shonkoff
JP
;
Committee on Psychosocial Aspects of Child and Family Health
;
Committee on Early Childhood, Adoption, and Dependent Care
;
Section on Developmental and Behavioral Pediatrics
.
Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health
.
Pediatrics
.
2012
;
129
(
1
). Available at: www.pediatrics.org/cgi/content/full/129/1/e224
10
Felitti
VJ
,
Anda
RF
,
Nordenberg
D
, et al
.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study
.
Am J Prev Med
.
1998
;
14
(
4
):
245
258
11
Dong
M
,
Anda
RF
,
Felitti
VJ
, et al
.
The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction
.
Child Abuse Negl
.
2004
;
28
(
7
):
771
784
12
Anda
RF
,
Felitti
VJ
,
Bremner
JD
, et al
.
The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology
.
Eur Arch Psychiatry Clin Neurosci
.
2006
;
256
(
3
):
174
186
13
Warne
D
,
Dulacki
K
,
Spurlock
M
, et al
.
Adverse childhood experiences (ACE) among American Indians in South Dakota and associations with mental health conditions, alcohol use, and smoking
.
J Health Care Poor Underserved
.
2017
;
28
(
4
):
1559
1577
14
Koss
MP
,
Yuan
NP
,
Dightman
D
, et al
.
Adverse childhood exposures and alcohol dependence among seven Native American tribes
.
Am J Prev Med
.
2003
;
25
(
3
):
238
244
15
Kenney
MK
,
Singh
GK
.
Adverse childhood experiences among American Indian/Alaska native children: the 2011-2012 National Survey of Children’s Health
.
Scientifica (Cairo)
.
2016
;
2016
:
7424239
16
Brockie
TN
,
Dana-Sacco
G
,
Wallen
GR
,
Wilcox
HC
,
Campbell
JC
.
The relationship of adverse childhood experiences to PTSD, depression, poly-drug use and suicide attempt in reservation-based Native American adolescents and young adults
.
Am J Community Psychol
.
2015
;
55
(
3–4
):
411
421
17
US Department of Health and Human Services
. Obesity and American Indians/Alaska natives. Available at: https://aspe.hhs.gov/basic-report/obesity-and-american-indiansalaska-natives. Accessed December 2, 2016
18
Lindsay
RS
,
Cook
V
,
Hanson
RL
,
Salbe
AD
,
Tataranni
A
,
Knowler
WC
.
Early excess weight gain of children in the Pima Indian population
.
Pediatrics
.
2002
;
109
(
2
):
E33
19
Salbe
AD
,
Weyer
C
,
Lindsay
RS
,
Ravussin
E
,
Tataranni
PA
.
Assessing risk factors for obesity between childhood and adolescence: I. Birth weight, childhood adiposity, parental obesity, insulin, and leptin
.
Pediatrics
.
2002
;
110
(
2 pt 1
):
299
306
20
Dalenius
K
,
Borland
E
,
Smith
B
,
Polhamus
B
,
Grummer-Strawn
L
.
Pediatric Nutrition Surveillance 2010 Report
.
Atlanta, GA
:
Centers for Disease Control and Prevention
;
2012
21
Schell
LM
,
Gallo
MV
.
Overweight and obesity among North American Indian infants, children, and youth
.
Am J Hum Biol
.
2012
;
24
(
3
):
302
313
22
Centers for Disease Control and Prevention (CDC)
.
Obesity prevalence among low-income, preschool-aged children - United States, 1998-2008
.
MMWR Morb Mortal Wkly Rep
.
2009
;
58
(
28
):
769
773
23
Bullock
A
,
Sheff
K
,
Moore
K
,
Manson
S
.
Obesity and overweight in American Indian and Alaska native children, 2006-2015
.
Am J Public Health
.
2017
;
107
(
9
):
1502
1507
24
Pan
L
,
Park
S
,
Slayton
R
,
Goodman
AB
,
Blanck
HM
.
Trends in severe obesity among children aged 2 to 4 years enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children from 2000 to 2014
.
JAMA Pediatr
.
2018
;
172
(
3
):
232
238
25
Tomayko
EJ
,
Prince
RJ
,
Cronin
KA
,
Adams
AK
.
The Healthy Children, Strong Families intervention promotes improvements in nutrition, activity and body weight in American Indian families with young children
.
[published correction appears in Public Health Nutr. 2017;20(2):380].
Public Health Nutr
.
2016
;
19
(
15
):
2850
2859
26
Lindberg
SM
,
Adams
AK
,
Prince
RJ
.
Early predictors of obesity and cardiovascular risk among American Indian children
.
Matern Child Health J
.
2012
;
16
(
9
):
1879
1886
27
Institute of Medicine
.
Early Childhood Obesity Prevention Policies
.
Washington, DC
:
National Academies Press
;
2011
28
Whitaker
RC
,
Wright
JA
,
Pepe
MS
,
Seidel
KD
,
Dietz
WH
.
Predicting obesity in young adulthood from childhood and parental obesity
.
N Engl J Med
.
1997
;
337
(
13
):
869
873
29
Pan
L
,
May
AL
,
Wethington
H
,
Dalenius
K
,
Grummer-Strawn
LM
.
Incidence of obesity among young U.S. children living in low-income families, 2008-2011
.
Pediatrics
.
2013
;
132
(
6
):
1006
1013
30
American Diabetes Association
.
Type 2 diabetes in children and adolescents
.
Diabetes Care
.
2000
;
23
(
3
):
381
389
31
American Diabetes Association
.
2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes-2018
.
Diabetes Care
.
2018
;
41
(
suppl 1
):
S13
S27
32
Springer
SC
,
Silverstein
J
,
Copeland
K
, et al
;
American Academy of Pediatrics
.
Management of type 2 diabetes mellitus in children and adolescents
.
[published correction appears in Pediatrics. 2013;131(5):1014]
.
Pediatrics
.
2013
;
131
(
2
). Available at: www.pediatrics.org/cgi/content/full/131/2/e648
33
Gahagan
S
,
Silverstein
J
;
American Academy of Pediatrics Committee on Native American Child Health
;
American Academy of Pediatrics Section on Endocrinology
.
Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska native children
.
Pediatrics
.
2003
;
112
(
4
). Available at: www.pediatrics.org/cgi/content/full/112/4/e328
34
Section on Breastfeeding
.
Breastfeeding and the use of human milk
.
Pediatrics
.
2012
;
129
(
3
). Available at: www.pediatrics.org/cgi/content/full/129/3/e827
35
Jones
KM
,
Power
ML
,
Queenan
JT
,
Schulkin
J
.
Racial and ethnic disparities in breastfeeding
.
Breastfeed Med
.
2015
;
10
(
4
):
186
196
36
Sparks
PJ
.
Racial/ethnic differences in breastfeeding duration among WIC-eligible families
.
Womens Health Issues
.
2011
;
21
(
5
):
374
382
37
Zamora-Kapoor
A
,
Omidpanah
A
,
Nelson
LA
,
Kuo
AA
,
Harris
R
,
Buchwald
DS
.
Breastfeeding in infancy is associated with body mass index in adolescence: a retrospective cohort study comparing American Indians/Alaska natives and non-Hispanic whites
.
J Acad Nutr Diet
.
2017
;
117
(
7
):
1049
1056
38
Houghtaling
B
,
Byker Shanks
C
,
Ahmed
S
,
Rink
E
.
Grandmother and health care professional breastfeeding perspectives provide opportunities for health promotion in an American Indian community
.
Soc Sci Med
.
2018
;
208
:
80
88
39
Walkup
JT
,
Barlow
A
,
Mullany
BC
, et al
.
Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers
.
J Am Acad Child Adolesc Psychiatry
.
2009
;
48
(
6
):
591
601
40
Kenney
MK
,
Thierry
J
.
Chronic conditions, functional difficulties, and disease burden among American Indian/Alaska native children with special health care needs, 2009-2010
.
Matern Child Health J
.
2014
;
18
(
9
):
2071
2079
41
Wong
CA
,
Gachupin
FC
,
Holman
RC
, et al
.
American Indian and Alaska native infant and pediatric mortality, United States, 1999-2009
.
Am J Public Health
.
2014
;
104
(
suppl 3
):
S320
S328
42
Cappiello
MM
,
Gahagan
S
.
Early child development and developmental delay in indigenous communities
.
Pediatr Clin North Am
.
2009
;
56
(
6
):
1501
1517
43
MacDorman
MF
.
Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: an overview
.
Semin Perinatol
.
2011
;
35
(
4
):
200
208
44
Barros
N
,
Tulve
NS
,
Heggem
DT
,
Bailey
K
.
Review of built and natural environment stressors impacting American-Indian/Alaska-native children
.
Rev Environ Health
.
2018
;
33
(
4
):
349
381
45
Itty
TL
,
Hodge
FS
,
Martinez
F
.
Shared and unshared barriers to cancer symptom management among urban and rural American Indians
.
J Rural Health
.
2014
;
30
(
2
):
206
213
46
Call
KT
,
McAlpine
DD
,
Garcia
CM
, et al
.
Barriers to care in an ethnically diverse publicly insured population: is health care reform enough?
Med Care
.
2014
;
52
(
8
):
720
727
47
Fuentes
MM
,
Thompson
L
,
Quistberg
DA
, et al
.
Auditing access to outpatient rehabilitation services for children with traumatic brain injury and public insurance in Washington State
.
Arch Phys Med Rehabil
.
2017
;
98
(
9
):
1763
1770.e7
48
Fuentes
M
,
Lent
K
.
Culture, health, function, and participation among American Indian and Alaska native children and youth with disabilities: an exploratory qualitative analysis
.
Arch Phys Med Rehabil
.
2019
;
100
(
9
):
1688
1694
49
Centers for Disease Control and Prevention
. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Details of leading cause of death: 2016, United States, suicide, ages 10-24, American Indian/Alaska native, both sexes. Available at: www.cdc.gov/injury/wisqars. Accessed November 29, 2018
50
Centers for Disease Control and Prevention
. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Details of leading cause of death: 2016, United States, suicide ages 10-24, all races, both sexes. Available at: www.cdc.gov/injury/wisqars. Accessed November 29, 2018
51
Centers for Disease Control and Prevention
. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. 2016, United States, suicide injury deaths and rates per 100,000, all races, both sexes, ages 10-24. Available at: www.cdc.gov/injury/wisqars. Accessed November 29, 2018
52
Herne
MA
,
Bartholomew
ML
,
Weahkee
RL
.
Suicide mortality among American Indians and Alaska natives, 1999-2009
.
Am J Public Health
.
2014
;
104
(
suppl 3
):
S336
S342
53
Mullany
B
,
Barlow
A
,
Goklish
N
, et al
.
Toward understanding suicide among youths: results from the White Mountain Apache tribally mandated suicide surveillance system, 2001-2006
.
Am J Public Health
.
2009
;
99
(
10
):
1840
1848
54
Borowsky
IW
,
Resnick
MD
,
Ireland
M
,
Blum
RW
.
Suicide attempts among American Indian and Alaska native youth: risk and protective factors
.
Arch Pediatr Adolesc Med
.
1999
;
153
(
6
):
573
580
55
Mackin
J
,
Perkins
T
,
Furrer
C
.
The power of protection: a population-based comparison of native and non-native youth suicide attempters
.
Am Indian Alsk Native Ment Health Res
.
2012
;
19
(
2
):
20
54
56
Qiao
N
,
Bell
TM
.
Indigenous adolescents’ suicidal behaviors and risk factors: evidence from the National Youth Risk Behavior Survey
.
J Immigr Minor Health
.
2017
;
19
(
3
):
590
597
57
Leavitt
RA
,
Ertl
A
,
Sheats
K
,
Petrosky
E
,
Ivey-Stephenson
A
,
Fowler
KA
.
Suicides among American Indian/Alaska natives - National Violent Death Reporting System, 18 states, 2003-2014
.
MMWR Morb Mortal Wkly Rep
.
2018
;
67
(
8
):
237
242
58
Allen
J
,
Rasmus
SM
,
Fok
CCT
,
Charles
B
,
Henry
D
;
Qungasvik Team
.
Multi-level cultural intervention for the prevention of suicide and alcohol use risk with Alaska native youth: a nonrandomized comparison of treatment intensity
.
Prev Sci
.
2018
;
19
(
2
):
174
185
59
Koenig
KT
,
Ramos
MM
,
Fowler
TT
,
Oreskovich
K
,
McGrath
J
,
Fairbrother
G
.
A statewide profile of frequent users of school-based health centers: implications for adolescent health care
.
J Sch Health
.
2016
;
86
(
4
):
250
257
60
Almeida
J
,
Johnson
RM
,
Corliss
HL
,
Molnar
BE
,
Azrael
D
.
Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation
.
J Youth Adolesc
.
2009
;
38
(
7
):
1001
1014
61
Kessler
RC
,
Borges
G
,
Walters
EE
.
Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey
.
Arch Gen Psychiatry
.
1999
;
56
(
7
):
617
626
62
Institute of Medicine Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities
.
The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding
.
Washington, DC
:
National Academies Press
;
2011
63
Angelino
A
,
Evans-Campbell
T
,
Duran
B
.
Assessing health provider perspectives regarding barriers American Indian/Alaska native transgender and two-spirit youth face accessing healthcare
.
J Racial Ethn Health Disparities
.
2020
;
7
(
4
):
630
642
64
Perez-Brumer
A
,
Day
JK
,
Russell
ST
,
Hatzenbuehler
ML
.
Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students
.
J Am Acad Child Adolesc Psychiatry
.
2017
;
56
(
9
):
739
746
65
Bostwick
WB
,
Meyer
I
,
Aranda
F
, et al
.
Mental health and suicidality among racially/ethnically diverse sexual minority youths
.
Am J Public Health
.
2014
;
104
(
6
):
1129
1136
66
James
SE
,
Herman
JL
,
Rankin
S
,
Keisling
M
,
Mottet
L
,
Anafi
M
.
The Report of the 2015 U.S. Transgender Survey
.
Washington, DC
:
National Center for Transgender Equality
;
2016
67
Rafferty
J
;
Committee on Psychosocial Aspects of Child and Family Health
;
Committee on Adolescence
;
Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness
.
Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents
.
Pediatrics
.
2018
;
142
(
4
):
e20182162
68
Fuentes
MM
,
Moore
M
,
Qiu
Q
,
Quistberg
A
,
Frank
M
,
Vavilala
MS
.
Differences in injury characteristics and outcomes for American Indian/Alaska native people hospitalized with traumatic injuries: an analysis of the National Trauma Data Bank
.
J Racial Ethn Health Disparities
.
2019
;
6
(
2
):
335
344
69
Urban Indian Health Institute
.
Missing and Murdered Indigenous Women & Girls: A Snapshot of Data from 71 Urban Cities in the United States
.
Seattle, WA
:
Urban Indian Health Institute
;
2018
70
Greenbaum
J
,
Bodrick
N
;
Committee on Child Abuse and Neglect
;
Section on International Child Health
.
Global human trafficking and child victimization
.
Pediatrics
.
2017
;
140
(
6
):
e20173138
71
National Center on Domestic and Sexual Violence
. Sexual violence/assault. 2012. Available at: www.ncdsv.org/publications_Sexual-Violence-Assault.html. Accessed November 11, 2019
72
Pierce
A
.
Shattered Hearts: The Commercial Sexual Exploitation of American Indian Women and Girls in Minnesota
.
Minneapolis, MN
:
Minnesota Indian Women’s Resource Center
;
2009
73
Wiltz
T
.
American Indian Girls Often Fall Through the Cracks
.
Philadelphia, PA
:
The Pew Charitable Trusts
;
2016
. Available at: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/03/04/american-indian-girls-often-fall-through-the-cracks. Accessed November 11, 2019
74
Administration for Children and Families
. Combating Trafficking: Native Youth Toolkit on Human Trafficking. Washington, DC: Administration for Children and Families;
2017
. Available at: https://www.acf.hhs.gov/blog/2018/01/combating-trafficking-native-youth-toolkit-on-human-trafficking. Accessed November 11, 2019
75
Children’s Bureau
. Child maltreatment 2017. Available at: https://www.acf.hhs.gov/cb/resource/child-maltreatment-2017. Accessed November 11, 2019
76
Williams
SC
. State-level data for understanding child welfare in the United States. Available at: https://www.childtrends.org/publications/state-level-data-for-understanding-child-welfare-in-the-united-states. Accessed November 11, 2019
77
Hill
KM
.
The prevalence of youth with disabilities among older youth in out-of-home placement: an analysis of state administrative data
.
Child Welfare
.
2012
;
91
(
4
):
61
84
78
Earle
K
,
Cross
A
.
Child Abuse and Neglect Among American Indian/Alaska Native Children: An Analysis of Existing Data
.
Seattle, WA
:
Casey Family Programs
;
2001
79
Nash
DA
,
Nagel
RJ
.
Confronting oral health disparities among American Indian/Alaska native children: the pediatric oral health therapist
.
Am J Public Health
.
2005
;
95
(
8
):
1325
1329
80
Indian Health Service
.
The 1999 Oral Health Survey of American Indian and Alaska Native Dental Patients: Findings, Regional Differences and National Comparisons
.
Rockville, MD
:
US Department of Health and Human Services
;
2001
81
Holve
S
,
Braun
P
,
Irvine
JD
;
American Academy of Pediatrics Committee on Native American Child Health and Section on Oral Health
;
Canadian Paediatric Society First Nations, Inuit and Métis Committee
.
Early childhood caries in indigenous communities
.
Pediatrics
.
2021
,
In press
82
Ochi
JW
,
Wheelbarger
L
,
Dautenhahn
LW
.
Chronic otitis media in ancient American Indians
.
Pediatrics
.
2018
;
141
(
4
):
e20172308
83
Curns
AT
,
Holman
RC
,
Shay
DK
, et al
.
Outpatient and hospital visits associated with otitis media among American Indian and Alaska native children younger than 5 years
.
Pediatrics
.
2002
;
109
(
3
). Available at: www.pediatrics.org/cgi/content/full/109/3/e41
84
Atherly
A
,
Mortensen
K
.
Medicaid primary care physician fees and the use of preventive services among Medicaid enrollees
.
Health Serv Res
.
2014
;
49
(
4
):
1306
1328
85
Polsky
D
,
Richards
M
,
Basseyn
S
, et al
.
Appointment availability after increases in Medicaid payments for primary care
.
N Engl J Med
.
2015
;
372
(
6
):
537
545
86
Alker
J
,
Wagnerman
K
,
Schneider
A
.
Coverage Trends for American Indian and Alaska Native Children and Families
.
Washington, DC
:
Georgetown University Health Policy Institute
;
2017
87
Artiga
S
,
Ubri
U
,
Foutz
J
.
Medicaid and American Indians and Alaska Natives
.
San Francisco, CA
:
Henry J. Kaiser Family Foundation
;
2017
88
Vintzileos
AM
,
Ananth
CV
,
Smulian
JC
,
Scorza
WE
,
Knuppel
RA
.
The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions
.
Am J Obstet Gynecol
.
2002
;
187
(
5
):
1254
1257
89
Stone
R
.
Pregnant women and substance use: fear, stigma and barriers to care
.
Health Justice
.
2015
;
3
:
2
90
Soleimanpour
S
,
Geierstanger
S
,
Brindis
CD
.
Adverse childhood experiences and resilience: addressing the unique needs of adolescents
.
Acad Pediatr
.
2017
;
17
(
suppl 7
):
S108
S114
91
Marsac
ML
,
Kassam-Adams
N
,
Hildenbrand
AK
, et al
.
Implementing a trauma-informed approach in pediatric health care networks
.
JAMA Pediatr
.
2016
;
170
(
1
):
70
77
92
Ginsburg
KR
,
Kinsman
SB
, eds..
Reaching Teens: Strength-Based Communication Strategies to Build Resilience and Support Healthy Adolescent Development
.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2014
93
Swaim
RC
,
Stanley
LR
.
Substance use among American Indian youths on reservations compared with a national sample of US adolescents
.
JAMA Netw Open
.
2018
;
1
(
1
):
e180382
94
American Academy of Family Physicians
. The EveryONE project toolkit. Available at: https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project/eop-tools.html. Accessed December 5, 2018
95
Giuse
NB
,
Koonce
TY
,
Kusnoor
SV
, et al
.
Institute of Medicine measures of social and behavioral determinants of health: a feasibility study
.
Am J Prev Med
.
2017
;
52
(
2
):
199
206
96
Arthur
KC
,
Lucenko
BA
,
Sharkova
IV
,
Xing
J
,
Mangione-Smith
R
.
Using state administrative data to identify social complexity risk factors for children
.
Ann Fam Med
.
2018
;
16
(
1
):
62
69
97
Duffee
JH
,
Mendelsohn
AL
,
Kuo
AA
,
Legano
LA
,
Earls
MF
;
Council on Community Pediatrics
;
Council on Early Childhood
;
Committee on Child Abuse and Neglect
.
Early childhood home visiting
.
Pediatrics
.
2017
;
140
(
3
):
e20172150
98
Klass
P
,
Dreyer
BP
,
Mendelsohn
AL
.
Reach out and read: literacy promotion in pediatric primary care
.
Adv Pediatr
.
2009
;
56
:
11
27
99
American Indian Library Association
. American Indian youth literature award. Available at: https://ailanet.org/activities/american-indian-youth-literature-award/. Accessed December 5, 2018
100
Morton
MH
,
Chávez
R
,
Moore
K
.
Prevalence and correlates of homelessness among American Indian and Alaska native youth
.
J Prim Prev
.
2019
;
40
(
6
):
643
660
101
Thomas
MMC
,
Miller
DP
,
Morrissey
TW
.
Food insecurity and child health
.
Pediatrics
.
2019
;
144
(
4
):
e20190397
102
Blue Cross Complete of Michigan
. Culturally and Linguistically Appropriate Services (CLAS) provider cultural competency. Available at: https://www.bcbsm.com/content/dam/microsites/blue-cross-complete/blue-cross-complete-clas-training-presentation.pdf. Accessed January 15, 2019
103
Donoghue
EA
;
Council on Early Childhood
.
Quality early education and child care from birth to kindergarten
.
Pediatrics
.
2017
;
140
(
2
):
e20171488
104
Earls
MF
,
Yogman
MW
,
Mattson
G
,
Rafferty
J
;
Committee on Psychosocial Aspects of Child and Family Health
.
Incorporating recognition and management of perinatal depression into pediatric practice
.
Pediatrics
.
2019
;
143
(
1
):
e20183259
105
Committee on Substance Use and Prevention
.
Substance use screening, brief intervention, and referral to treatment
.
Pediatrics
.
2016
;
138
(
1
):
e20161210
106
Levy
SJ
,
Williams
JF
;
Committee on Substance Use and Prevention
.
Substance use screening, brief intervention, and referral to treatment
.
Pediatrics
.
2016
;
138
(
1
):
e20161211
107
Patrick
SW
,
Schiff
DM
;
Committee on Substance Use and Prevention
.
A public health response to opioid use in pregnancy
.
Pediatrics
.
2017
;
139
(
3
):
e20164070

Shaquita Bell, MD, FAAP

Jason F. Deen, MD, FAAP

Molly Fuentes, MD, MS

Kelly Moore, MD, FAAP

Shaquita Bell, MD, FAAP, Chairperson

Daniel Calac, MD, FAAP

Allison Empey, MD, FAAP

Kristen Nadeau, MD, FAAP

Jane Oski, MD, MPH, FAAP

Ret CPT Judith Thierry, DO, FAAP

Ashley Weedn, MD, FAAP

Melanie Mester, MD – Section on Pediatric Trainees

Joey Bell, MD – Association of American Indian Physicians

Nelson Branco, MD, Chair – Indian Health Special Interest Group

Rebecca Daily, MD – American Academy of Child and Adolescent Psychiatry

Angela Kueck, MD – American College of Obstetricians and Gynecologists

Radha Jetty, MD – Canadian Paediatric Society

Madra Guinn-Jones, MPH

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Moore was a paid consultant for the Public Health Institute (Oakland, CA); and Drs Bell, Deen, and Fuentes have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Moore was a paid consultant for the Public Health Institute (Oakland, CA); and Drs Bell, Deen, and Fuentes have indicated they have no financial relationships relevant to this article to disclose.