Grantee Types: Garrett Lee Smith Tribal

The White Mountain Apache Tribe (WMAT) has experienced high rates of youth suicide deaths and attempts for over two decades. Although Apache youth are exposed to a challenging constellation of risk factors, the WMAT has a long history of overcoming health disparities by implementing and evaluating evidence-based interventions in partnership with Johns Hopkins. Over the past six years, GLS funds have enabled our alliance to tackle Apache youth suicide through a comprehensive approach guided by an award-winning tribally mandated suicide surveillance system and research study of youth suicide attempters that identified tribal-specific risk and protective factors (NARCH 1S06 GM074004-02). While there is preliminary evidence that the surveillance system is working (e.g., increased awareness, identification and follow-up with treatment) and suicide rates have decreased (e.g., overall and in the 15-24 year old age range), rates still remain high (~3x times US All Races). The partnership is poised to contribute further innovations to the field with the unique foundation that the surveillance system provides to track changes with an incredible history and capacity to scale up.

This application will build upon lessons learned from past SAMHSA activities, while applying knowledge and strategies from the new National Strategy for Suicide Prevention (NSSP) in an integrated three-tiered prevention approach to address suicide among 10-24 year old Apache youth on a community, family/peer and individual level.

Tier 1: Universal: Broad community advocacy and education will promote understanding that suicide is preventable and reinforce core Apache beliefs as protective factors. Specific strategies include continued engagement of tribal leadership in prevention activities, community workshops, and mass media promotion. New innovations in this application include involvement of a broader range of community members such as Elders, young adults and veterans in leadership roles, incorporation of social media and targeted messaging for at-risk sub-groups, and inclusion of family activities in community education approaches.

Tier 2: Selective: This tier will target youth who have risk factors for suicide, and peers and adults with whom they have frequent contact. Evidence-based strategies will include ASIST training, a school-based peer leadership program (Sources of Strength- SOS), and survivor support groups. Innovations include experiential resilience activities for high-risk youth grounded by a curriculum led by Elders, and a community-based approach to the SOS program.

Tier 3: Indicated: Youth, ages 10-24, identified through the surveillance system as having suicide ideation or attempt will be targeted. All indicated youth will receive follow-up visits and assisted referral to care by Apache community mental health workers; youth who attempt will be offered a culturally adapted evidence-based Emergency Department linked intervention, called New Hope. New Hope goals include problem-solving barriers to treatment thereby promoting participation and retention in care. We are building on previous work by expanding New Hope to 20-24 year olds and increasing systems integration with the Indian Health Service and community mental health center.Tiers 1-3 will be coordinated by three circles of community support:

1) a tribal coalition called Apaches Helping Apaches, which includes the Elder Advisory Council serving in an executive committee role,

2) a tribal interagency coalition of service providers, and

3) team of Apache community mental health workers (ACMHW) employed by the project to carry out all activities and coordinate the efforts of these other two groups.

The White Mountain Apache Tribe, in partnership with John Hopkins, plans to amplify its existing youth suicide prevention program with the current grant. The proposed initiative, titled “Empowering our Spirits,” will deploy a three-tiered prevention strategy (universal, selective, indicated) including three culturally-adapted evidence-based interventions that build on unique tribally mandated suicide surveillance system. Primary intervention targets will include: community-wide education to promote protective factors and reduce risks; early identification and triage of high-risk youth; and intensive prevention intervention with youth who attempt suicide and their families.

Measurable Objectives:
Tier 1 Universal objectives are to promote broad community advocacy and education to increase understanding that suicide is preventable and reinforce protective factors that are core to the Apache belief system. Specific strategies will include engagement of tribal leadership in mandating prevention activities; community workshop series to build prevention skills among parents and youth caretakers; and mass media campaigns.
Tier 2 Selected intervention objectives are to increase early identification and continuity of care for youth. Strategies will include: tribally mandated inter-agency collaboration to coordinate care for high-risk youth; ASIST training for community gatekeepers; resilience promotion activities led by elders and community role models for high-risk youth; school-based life skills promotion for middle school youth utilizing the American Indian Life Skills Development Curriculum; and targeted workshops for relevant care providers about early identification and provider stress management.
Tier 3 Indicated intervention objectives are to prevent suicide and promote linkages to care, safety planning, problem-solving and coping among youth who attempt suicide and their families. Strategies will include implementation and evaluation of two-evidence based interventions for youth who attempt suicide and their families. These include the Specialized Emergency Department Intervention and American Indian Life Skills Development Curriculum adapted for use by the Apaches during current grant period.

Infrastructure: The proposed efforts will be strengthened by three levels of community support: 1) a team of Apache Natural Helpers trained by Johns Hopkins mental health experts and employed by the project to carry out all activities; 2) an inter agency “Health and Safety Coalition;” and 3) an Elders’ Advisory Council. Numbers to be Served: Tier 1 universal activities will expose 85% of the entire community (~13,000 of 15,500). Tier 2 will reach 150 community “caretakers” through ASIST trainings; 320 middle school youth; 50 providers through technical training workshops; and 300 high risk youth served though Elder-youth activities. Tier 3 strategies will serve 75 youth who attempt suicide and their families. Continued implementation of the tribally mandated suicide surveillance system will ensure ~90% of youth reported for attempts or ideation will receive follow-up from Natural Helpers to assess imminent suicide severity and refer to treatment.

United Indian Health Services, Inc. (UIHS) will implement culturally appropriate prevention and early intervention strategies through education program to address suicide and suicidal ideation of American Indian (AI) clients age 10-24 living in Northwestern California. Prevention efforts will include evidence-based training and education to youth, families, community members, health care providers, school and other educational institutions, juvenile justice systems, foster care systems, substance abuse and mental health programs and other child and youth serving providers that address suicide risks and interventions.

Goals of the project include: (1) 75% of 200 persons in youth serving organizations will indicate an increase in knowledge and skills in suicide identification, referral systems and community resources for AI youth and communities, (2) 75% of 200 health, mental health and substance abuse providers will indicate an increase in knowledge about suicide assessment, management and treatment, (3) Increase referral and follow-up with youth who are identified by family, tribal, and community members as at risk for suicide to behavioral health care services by 50%, and (4) Increase follow-up with youth identified as at risk for suicide discharged from emergency department and inpatient psychiatric units to provide a seamless approach to continuity of care by 50%, (5) 2-3 Tribal Programs and 3-5 schools will adopt policy establishing referral procedures when an at-risk youth is identified.

UIHS will utilize a combination of the Native Helping Our People Endure (HOPE), a best practice youth suicide prevention program and/or Gathering of Native Americans (GONA) a peer training and community building curriculum, as well as Sources of Strength utilizing the power of peer social networks and QPR Gatekeeper training model for suicide prevention. Combining these programs UIHS will implement a campaign to provide a strong community based approach through education and facilitation by: improving systems and trainings for referrals, implementing strategic plans addressing suicide prevention with tribes, reducing stigma surrounding suicide and obtaining behavioral health services and improving continuity of care post-discharge.

UIHS, founded in 1970, is a primary health care organization that includes behavioral health, outreach, and a strong health education program.

Ko’l ha koom’ma (Yurok- Working Together) United Indian Health Services, Inc., (UIHS) will implement culturally appropriate prevention and education programs to address suicide and suicidal ideation of American Indian (AI) clients age 10-24 living in Northwestern California. Prevention efforts will include evidence-based training and education to youth, families, community members, health care and youth-serving providers that address suicide risks and interventions.Objectives of the project include:1.Increase knowledge of 100 youth-serving providers about suicide identification, referral systems, and community resources by 50%,2.Increase knowledge of 100 health, mental health and substance abuse providers about suicide assessment, management and treatment by 30%,3.Increase the number of youth identified as at-risk for suicide who are then referred to behavioral health (BH) care services by 100%, and4.As a result of implementing a community education and media campaigns, the number of youth at risk seen by BH care will increase by 100%.UIHS will utilize a combination of the American Indian Life Skills Development (AILSD) and the Native Helping Our People Endure (H.O.P.E.) program curriculum and implement a media and educational campaign to provide a strong community-based approach through education and facilitation by setting up systems and trainings for referrals, developing strategic plans addressing suicide prevention with tribes, providing opportunities for community-wide collaborations to address suicide prevention, reducing stigma surrounding suicide and obtaining BH services.United Indian Health Services, Inc., founded in 1970, is a primary health care organization that extends care beyond customary medical concerns to include substance abuse and mental health programs as well as to provide a strong health education program. UIHS is governed by tribal and community representatives from seven Rancherias and two tribes. With five satellite clinics located within this two-county area of California (4,500 square miles- comparative to the State of Maine) UIHS provides service to over 18,000 American Indian residents.”We honor the dignity of every person. We value working together with the individual, the family, and our community. By sharing our strengths and resources we bring wellness to ourselves, our community and our world.” UIIHS Core Philosophy- Ko’l ha koom’ma

United American Indian Involvement, Inc. (UAII) will implement a Youth Suicide Prevention and Early Intervention Project, Red Hawk Project, targeting American Indian and Alaska Native children and youth (ages 10-24) in Los Angeles County. The goals of the program include:

1. The UAII’s Youth Suicide Prevention and Early Intervention Project will evaluate the existing service delivery system available to American Indian children and families in Los Angeles County through the input of key service providers and the American Indian community of Los Angeles County. This needs assessment will help describe services, identify access barriers, and assess the cultural appropriateness of services.
2. The Red Hawk Project will collaborate with other agencies, providers, and organizations to share information and resources by promoting awareness that suicide is preventable.
3. The project will develop a culturally appropriate youth suicide prevention and early intervention project. This level of intervention will include screening programs, gatekeeper training for “frontline” adult caregivers and peer “natural helpers,” support and skill building groups for at risk Indian youth, and enhanced accessible crisis services and referrals sources.
4. The Red Hawk Project will implement the public health approach to suicide prevention as outlined in the Institute of Medicine report, Reducing Suicide: A National Imperative. This approach focuses on identifying broader patterns of suicide and suicidal behavior, which will be useful in analyzing data collected and monitoring the effectiveness of services provided.

The Turtle Mountain Band of Chippewa Indians live on a 6 by 12 mile reservation in Rolette County, extreme north-central North Dakota.  Tribal members have long suffered from severe poverty and accompanying social stresses which threaten the social fabric of our community.  Median household income is less than two-thirds of national levels; 65% of adults on the reservation are unemployed.  Between 2003 to 2009, 144 of our youth, ages 5-24 years, exhibited suicide behaviors—42% involving substance use.  There were 7 completions during this period.  Our program targets our youth between the ages of 10 and 24, struggling with historic and present-day multi-generational trauma and chronic sever poverty, and afflicted by multiple risk factors including:  suicide attempts, depression, hopelessness, despair; recent loss of family or friends by death or suicide; alcohol, meth or other substance abuse; family dysfunction; increased anger, conflicts, aggression, violence; isolating behaviors; doing poorly in school.
Our Goal is to strengthen the health and wellness of our children and youth—their physical, mental, social, cultural and spiritual awareness, balance and well-being—so that they may resist destructive factors, and help heal their families and community.  We have five Objectives:

1. Facilitate and expand communication and collaboration among all local agencies and individuals that provide services and support our children, youth and families;
2. Engage our entire community in an intensive public education and awareness campaign;
3. Train staff of participating agencies to conduct and evaluate evidence-, practice- and culture-based prevention and early intervention activities;
4. Coordinate and evaluate the implementation of evidence-,practice-and culture-based prevention and early intervention activities; and
5. Establish and operate a community-wide Crisis and Survivor Intervention process.

We will implement two Evidence-based programs—TeenScreen and the American Indian Life Skills Development Curriculum (AILSDC)—and two practice- and culture-based programs:  QPR (Gatekeeper Training) and Sources of Strength.  We will serve at least 1,750 youth and additional family members each year of our program – some 5,250 youth over three years. In this way, we will strengthen our children’s self-esteem, positive bonding, and resilience:  by end of the project the majority of our youth will no longer be at risk of suicide.

The Tohono Oodham Nation, a federally recognized Tribe, respectfully submits this proposal for a Cooperative Agreement under the Garrett Lee Smith State/Tribal Youth Suicide Prevention Grants Initiative, CFDA No. 93,245. The proposed project builds on findings of the previously awarded Garrett Lee Smith Youth Suicide Prevention grant to implement a Nation-wide system addressing the risk factors leading to youth suicide, an increasing tragedy among the Nation youth, ages 11-24, their families, and communities. Through the present proposal, suicide intervention and prevention programs will be implemented, with support from the tribal government level, to meet local critical needs to suicide prevention strategies and programs.There continues to be a dramatic need to address youth suicide and the risk factors that lead to the Nations young people completing suicide at a disproportionate rate. The relationship of substance abuse as a risk factor for suicide is well established. The Tohono Oodham Nation has a rate of substance abuse and early deaths related to substance abuse disproportionate among all populations in the State of Arizona and the U.S. A Prevention Planning Committee was established in 2005 following an unprecedented number of suicides among youth, two of which were under 15 years of age. Conducted with community members and professionals from all departments of the Nation, the planning process included a needs assessment of program and services. The resulting comprehensive Prevention Plan identified community needs and strategies to address the identified risk factors. One strategy implemented was the creation of an on-going Prevention Coalition which will collaborate with this project.

The proposed project will address youth suicide prevention and the highest risk factors contributing to youth suicide.Results from the previous Garrett Lee Smith award indicate, based on the Tribal Prevention Plan, further focused strategies include: 1) thorough assessments and referral to appropriate treatment for highest risk youth ages 11-24 including those under the Child Welfare and Justice Systems for alcohol and drug related offenses; 2) case management for youth in those systems, identified as being at high risk for suicide; 3) community-based life skills and gatekeeper training for youth and adults that support youth; 4) implementation of an effective data management system to provide retrievable, comprehensive data to enable all providers in the Prevention Coalition to better meet the needs of high risk youth; 5) implementing a social marketing plan to promote access to suicide prevention resources and education; and 6) partnering with Tohono Oodham Community College to ensure effective prevention strategies through on-going evaluation services and the creation of a Prevention Specialist curriculum.

The Tanana Chiefs Conference Community Suicide Prevention project provides culturally appropriate suicide prevention activities to Interior Alaska Native youth ages 10-18, one of the highest risk groups for suicide in our nation.  The purpose of our project is to support local and regional community efforts to prevent suicide.  Our goals and objectives support this by addressing direct service gaps in the suicide prevention continuum within the TCC region.
We will provide two culturally relevant evidence-based practices in schools within our target communities using local teachers, adult advisors and peer leaders to provide education and training to youth.  American Indian Life Skills Development is a school-based suicide prevention curriculum designed to reduce suicide risk and improve protective factors among American Indian adolescents 14 to 19 years old.  Sources of Strength is a comprehensive wellness program that uses the combined power of peer and caring adult relationships to improve social norms, enhance coping and social support, and increase help-seeking behaviors in order to reduce conditions that give rise to suicide and other risk-taking behaviors.

Achievement of these goals will result in long term changes within the target population.  It will:  increase community responsiveness to and engagement in suicide prevention efforts; decrease youth suicide; increase youth connectedness, resiliency and life skills; and increase community and agency efficiency and responsiveness to suicide.

Goal 1:  To raise awareness and increase community knowledge of suicide prevention.
Objective 1.1: 3,641 individuals exposed to suicide prevention/awareness messages
Objective 1.2: 47 youth craft Hope, Help Strength messages

Goal 2:  Increase youth-centered prevention strategies.
Objective 2.1: 16 school teams prepared to provide suicide prevention education and training
Objective 2.2: 661 students participate in life skills training
Objective 2.3: 47 youth became peer leaders

Goal 3: Improve the system of care to prevent suicide in Alaska Native communities
Objective 3.1: School personnel in 16 schools participate in ASIST or Gatekeeper training
Objective 3.2: 100% of youth referred for suicide will receive a mental health intervention within one hour of referral
Objective 3.3: 3,641 individuals exposed to system responsiveness messages

We will provide services to 2,698 unduplicated individuals in Year 1; 1,311 in Year 2; and 956 in Year 3 for a total of 4,965 clients over the lifetime of the grant.