Awareness of the unique cultural, historical, and political characteristics of the 566 nations that comprise the AI/AN communities will contribute to improved care of native youth. Of the 5.2 million people who identify themselves as AI/AN (including other ethnicities) in the 2010 US Census, about 3 million identified themselves as only AI/AN, with approximately 2 million reporting being members of federally recognized tribes.¹,² Membership in a federally recognized tribe is a political identity defined by the citizenship of a sovereign nation. An excellent overview of these complicated regulations can be found at http://www.bia.gov/FAQs/. Federal, State, and Tribal legislation dictates several aspects of the care provided to these communities and populations. AI/AN population has experienced rapid growth, increasing by 39% since 2000.² Most (78%) AI/AN and their families live outside state or federal lands dedicated for reservation sites. There were over 200 Aboriginal languages before 1492, and more than 150 of these languages are still spoken today.

Although there are similarities with Indigenous Peoples of Canada (First Nations) and Aboriginal Communities of Mexico and Latin America, the term “AI/AN” is used to describe the indigenous people of the continental US. Many other nonfederally recognized groups exist (approximately 100), with many seeking federal recognition of their status including those tribes that are state, but not federally recognized.

To effectively and competently provide behavioral and medical services for AI/AN adolescents and young adults (AYAs), it is critical to be cognizant of the diverse demographic and individual identity characteristics of the groups that make up North America’s indigenous populations. AI/AN reside in all the US states and have a younger median age than general population, that is, 22 versus 38 years.² Slightly more than half reside in urban areas, with the remainder living in rural villages and small rural communities as well as on reservations.³ Although many AI/AN youth are raised and practice traditional lifestyles, the actual rates of participation are unknown. The wide range of differences in culture, geography, spiritual beliefs, politics, and physical characteristics among AI/AN will challenge those who care for these AYAs.

The Indian Health Service (IHS), within the Department of Health and Human Services, annually provides inpatient and outpatient care to more than 2 million AI/ANs, through direct or contract services in 12 regional areas harboring approximately 772 facilities of hospitals, clinics, and satellite centers.³ A relatively new but growing component administers social service and mental health programs. Because of varying and limited resources, service provision can range from exemplary to extremely lacking. Many facilities are not able to provide mental health services due to staff shortages of psychiatrists and other licensed behavioral health providers.³,⁴

The AI/AN health service delivery system is a complicated mixture of multiple service entities guided and impacted by jurisdictional boundaries that create significant problems in the delivery of needed medical and mental health services. The agencies directly responsible for service provision include the IHS, Bureau of Indian Affairs, as well as the Department of Veterans Affairs. Other federal programs that provide health services include the Department of Justice—Office for Victims of Crime and the Office of Juvenile Justice and Delinquency, Urban Indian Health Organization, state and local service agencies, as well as tribal health programs and traditional healing resources. Moreover, the system of behavioral health services in Indian country (land within an existing Indian reservation under the jurisdiction of the US government) is complex due to an inconsistent mixture of tribal, federal, state, local, and community-based services.⁵ Often, there is little to no communication across these agencies, complicating an integrated health care network. The proliferation of services within the delivery structure outlined raises a large number of critical questions, the answers to which must guide greater efficacy in care for these youth.⁶

Treatment of youth varies widely across Indian country from having well-established medical centers to others having no trained service providers within a 200 mile range.³ Lack of psychiatric services for families as well as youth for serious psychiatric disturbance is at a critical level. Eligibility criteria for individuals to obtain any type of health services from the IHS as well as gaining tribal benefits are even more confusing and vary with the provider agency in question. Indeed, this confusion prompted a study sponsored by the US Department of Education, Office of Indian Education, to determine workable definitions of “Indian.”⁷ Despite the “definition” of Indian study, bureaucratic ambiguity remains, employing tribally defined membership criteria (which differ across tribes), blood quantum (frequently one-fourth, genealogically derived), personal identification/community consensus, and various permutations.⁸

While AI/AN AYAs experience similar health problems to their other ethnic peers, this is one of the highest at-risk subpopulations in the US because of the serious health disparities in a number of areas. In 2010, approximately 25% of AI/ANs lived on reservations or other US Census-defined tribal areas (http://www.census. gov/prod/cen2010/briefs/c2010br-10.pdf). Therefore, it is important for the provider to remember that the majority of AI/AN youth do not live on a federal reservation or on tribal lands, but will experience health conditions and problems at or above the rates reported by those AI/ANs living on tribal areas.