Research article
Adverse childhood exposures and alcohol dependence among seven Native American tribes

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Abstract

Background

Alcohol abuse and alcoholism are leading causes of death among Native Americans. Little is known about the impact of negative childhood exposures, including parental alcoholism, childhood maltreatment, and out-of-home placement, on risk of lifetime DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) diagnosis of alcohol dependence in this population.

Methods

Face-to-face interviews were conducted with 1660 individuals from seven Native American tribes from 1998 to 2001. Logistic regression was used to estimate the impact of specific types and number of different adverse childhood experiences on alcohol dependence. Relationships between tribe-specific cultural characteristics and alcohol dependence were also examined.

Results

There were significant tribal differences in rates of alcohol dependence and several adverse childhood exposures. Lifetime prevalence of alcohol dependence was high among all tribes (men: 21%–56%, women: 17%–30%), but one (men: 1%, women: 2%). High prevalence rates were documented for one or more types of adverse childhood experiences (men: 74%–100%; women: 83%–93%). For men, combined physical and sexual abuse significantly increased the likelihood of subsequent alcohol dependence (odds ratio [OR]=1.58; 95% confidence interval [CI], 1.10–2.27). For women, sexual abuse (OR=1.79; 95% CI, 1.21–2.66) and boarding school attendance increased the odds of alcohol dependence (OR=1.57; 95% CI, 1.03–2.40). Two separate patterns of dose–response relationships were observed for men and women. Significant inter-tribal differences in rates of alcohol dependence remained after accounting for tribe-specific cultural factors and geographic region.

Conclusions

Effects of childhood exposures on high-risk behaviors emphasize screening for violence in medical settings and development of social and educational programs for parents and children living on and near tribal reservations.

Introduction

A lcohol abuse and alcoholism contribute to high mortality rates among Native Americans.1 From 1994 to 1996, alcoholism death rate among Native Americans was over seven times the rate for the U.S. general population.2 The rate is conservative because deaths from alcohol-abusive causes, such as accidents, suicides, and homicides, were not included. Alcohol-related deaths are also shown to be high among this population.1 These findings are part of a growing literature that points to alcoholism, along with other high-risk behaviors, as leading causes of death.3

Previous studies identified childhood abuse as a risk factor for alcohol disorders,4, 5, 6 whereas others have not.7 Two recent large-scale investigations have contributed to research in this area. Felitti et al.8 found a link between alcoholism and number of childhood exposures in a primary care setting. Another study showed that combined childhood sexual and physical abuse was associated with heavy drinking among women, whereas physical abuse alone increased the risk among men.9 These findings suggest that childhood experiences are often, but not uniformly, associated with subsequent alcohol problems.

Few studies have been conducted with Native Americans, a population at risk of childhood adversity because of problems with alcoholism and low economic levels.10 Findings from two studies are inconsistent. Researchers found that childhood physical abuse, but not sexual abuse, increased the odds of alcohol dependence,11 whereas others documented a significant relationship between child sexual abuse and several psychiatric disorders among women, but not men.10 Less is known about other common adverse events, such as separations from families.12 Historically, many Native American children were removed from homes for involuntary boarding school placement,13 adoption, or foster care.14 To date, there is limited empirical support for an association between out-of-home placement and alcohol abuse. Two studies found no significant associations between boarding school experiences and alcohol dependence.15, 16 The inconsistent findings are difficult to evaluate because each study was limited to a single tribe.

The Native American population is vastly diverse, comprising over 557 federally recognized tribes across more than 35 states.17 The impact of culture on responses to adverse experiences and alcohol abuse is unknown. Inter-tribal variability in alcohol use might be influenced by tribal integration, language, degree of ancestry,18 as well as demographic and lifestyle characteristics.19 Many Native Americans believe that the loss of culture contributes to alcohol-related problems.19 Unfortunately, virtually all studies have used single-tribe data sets and lacked measurement of cultural beliefs and practices.

This is the first study to examine alcohol dependence and childhood maltreatment among several, geographically diverse, Native American communities. This article reports results from the Ten Tribes Study, a collaboration of Native American Nations and Confederations, the University of Arizona (UA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project measured genetic and environmental vulnerability factors of alcoholism among seven tribes. In the present investigation, the authors examined the prevalence of lifetime DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) alcohol disorders and adverse childhood experiences. The impact of specific types and number of categories of adverse childhood exposures on alcohol dependence was estimated. Childhood exposures under investigation included parental alcoholism, maltreatment, and out-of-home placement. The relationship among tribal, cultural, and regional characteristics and alcohol dependence was also examined.

Section snippets

Methods

Tribes were recruited by solicitation with the aim of representing geographic diversity. Seven tribes participated in the project: one tribe each from the Bemidji (Minnesota), Oklahoma City (Oklahoma), Portland (Oregon), and Nashville (Tennessee) Indian Health Service (IHS) areas and three tribes from the Phoenix (Arizona) area. The human research protocol was approved by the UA Institutional Review Board, NIAAA, and each collaborating community. A memorandum of agreement was developed,

Data analysis

Analyses were conducted using SPSS (SPSS, Inc., Chicago IL, 2001). The prevalence of alcohol disorders and negative childhood exposures was estimated. Using chi-square tests, the authors determined group differences by gender and tribe. Logistic regressions were conducted to investigate the relationships between adverse childhood experiences and alcohol dependence. Because few studies have been conducted with Native Americans, each childhood exposure was screened for a significant association

Prevalence of alcohol disorders

Table 1 presents the prevalence rates of lifetime alcohol disorders for each tribe. Among men, 9% were diagnosed with alcohol abuse and 30% with alcohol dependence. Among women, 5% were diagnosed with alcohol abuse and 18% with alcohol dependence. Both alcohol disorders varied significantly by gender (men: p<0.01; women: p<0.001). Alcohol dependence varied significantly by tribe (p<0.001).

Prevalence of childhood exposures

Table 2 shows the prevalence rates of adverse childhood experiences for each tribe. More than half of men

Discussion

Lifetime prevalence of alcohol dependence was high among all (21%–56% among men, 17%–30% among women) but one tribe (1% among men, 2% among women). These findings were generally lower compared to other research. Robin et al.28 found that 83.4% of men and 50.5% of women were diagnosed with alcohol dependence. This difference might reflect the use of different measurement tools. Researchers28 previously made modifications to limit cultural biases, whereas the present study did not. Lifetime

Acknowledgements

This study was funded by a contract from the National Institute of Alcohol Abuse and Alcoholism (contract no. N01AA51012). The authors would like to acknowledge the tribal leaders, community workers, focus group members, community members who invited interviewers into their homes, and those who did ceremonies for the study. In addition, we express our deepest appreciation to the indigenous people who chose to participate, share their darkest life experiences, and still gave thanks when we

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