The first Americans have much to teach us.

In this month_s issue of the Journal, Whitbeck et al. report that indigenous adolescents living on the northwest border of the United States experienced a striking increase in mental disorders between 10 and 12 and 13 and 15 years of age. The rates in this population were accounted for by increases in conduct disorder and substance use disorders. According to the authors, the study participants_ rates for these disorders were two to four times the rates of adolescents in general population studies and similar to lifetime prevalence rates for adults. The article by Whitbeck et al. sounds the alarm on a mental health crisis for indigenous youths in rural reservation communities. However, two caveats must be noted. First, the Indian Health Service consistently reports large regional differences in all health trends across tribes, so caution must be exercised before generalizing these findings to all Native American youths. Second, as Whitbeck et al. have acknowledged, mental health measures have not been well tested with Native American youngsters, and cultural differences may produce measurement biases. Nonetheless, it is essential to counter those caveats with other evidence that supports the reality of a mental health crisis for Native American youths. First, the environmental and developmental risks that Whitbeck et al. describe for childhood behavior problems and substance use disorders are common in rural indigenous populations across the United States and the world. Second, although mental health measures used in the study may lack some degree of cultural sensitivity, measurement biases would likely result in underreporting in general, especially substance use disorders and internalizing disorders. Disruptive behavior, which is more overt, may be less subject to reporting bias, but may still be underreported in indigenous communities. Third, the findings of Whitbeck and colleagues are harbingers of the painful truth that Native American youths as they move through adolescence and into young adulthood (ages 15Y24) shoulder an eightfold greater rate of alcohol-related deaths and twofold or higher rates for suicide, motor vehicle accidents, and all injury-related deaths. Coming to grips with the pivotal association of early disruptive behavior and substance use disorders with these tragic statistics is critical to finding the solution to high rates of mental health morbidity and mortality in Native American youths. Thus, the article by Whitbeck et al. begs the question: how do we prioritize scarce research dollars and clinical resources for Indian country to address the mental health crisis and resulting mortality of this generation of adolescents and young adults? Is more research needed to rediscover the causal pathways from cultural oppression and economic and psychosocial adversity to poor mental and behavioral outcomes for indigenous children? We would argue no. Rather, we propose that the field accept that a constellation of historical, demographic, and sociological factors have precipitated a mental health crisis for Native American youths and move on to seek approaches to deploy cost-effective, evidence-based solutions that reflect indigenous cultural strengths and community will. To begin to address these problems, we would ask what the existing research tells us about the antecedents of early disruptive behavior and substance use. What are critical time points for intervention and targets for prevention? A large body of research points to early childhood as the critical stage for intervention and family-based approaches, specifically early parenting training, as a key strategy for the prevention of children_s future disruptive behavior problems and substance use disorders. Parent training and family-based approaches have a natural cultural fit within pan-Native American world views. There are numerous examples of how Native Americans traditions favor Bfamily[ above any other domain as the nexus of strength for individuals. Native Americans often introduce themselves by name and clan, underscoring the link between personal identity and family lineage. Many healing traditions and puberty ceremonies involve extended family members who represent stabilizing and restorative forces. In addition, E D I T O R I A L