HIGHLIGHTS
- •This study compared reservation American Indian students with national U.S. students on COVID-19 outcomes.
- •More American Indian students reported being tested and testing positive than national students.
- •More American Indian students reported family/friends testing positive and being hospitalized than national students.
- •Changes in substance use since COVID-19 began were variable by group.
- •More national students reported increases in negative emotional states than American Indian students.
Introduction
This study presents data from 2 population-based surveys of youth (reservation-area American Indian adolescents and U.S. adolescents) on self, family, and friend morbidity and changes in substance use and negative impacts during COVID-19.
Methods
Data were obtained in spring 2021 from surveys of American Indian students living on or near reservations (8th grade, n=398; 10th grade, n=367; 12th grade, n=290) and national students from Monitoring the Future (8th grade, n=11,446; 10th grade, n=11,792; 12th grade, n=9,022). The main outcomes were COVID-19 testing, perceived morbidity/mortality, substance-use changes, and emotional changes during COVID-19.
Results
The American Indian sample had a greater proportion of testing (e.g., American Indian 8th grade: 58.1% [95% CI=48.6, 68.8]; Monitoring the Future 8th grade: 43.6% [95% CI=39.8, 47.5]) and friend/family hospitalization (e.g., American Indian 8th grade: 36.2% [95% CI=26.2, 47.5]; Monitoring the Future 8th grade: 11.9% [95% CI=10.6, 13.3]). Across grades, greater proportions of the national sample reported increased anxiety, anger, boredom, loneliness, depression, worry, and trouble concentrating, whereas greater proportions of reservation-area American Indians reported decreased anxiety, loneliness, and depression.
Conclusions
Findings indicate that reservation-area American Indian youth experienced unique health consequences 1 year into the COVID-19 pandemic compared with national students, illustrating the need for American Indian‒specific COVID-19 public health monitoring and response.
Keywords
INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic has led to multiple deaths and disruptions in health, economic security, and well-being worldwide. Although youth may be at lower risk,
1
they are not immune from its effects. Even when not infected, youth experience stressors, including school disruptions, home confinement, grief, and uncertainty regarding safety and security.2
,- Cohen ZP
- Cosgrove KT
- DeVille DC
- et al.
The impact of COVID-19 on adolescent mental health:preliminary findings from a longitudinal sample of healthy and at-risk adolescents.
Front Pediatr. 2021; 9622608https://doi.org/10.3389/fped.2021.622608
3
Youth report worry related to COVID-19- Guessoum SB
- Lachal J
- Radjack R
- et al.
Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown.
Psychiatry Res. 2020; 291113264https://doi.org/10.1016/j.psychres.2020.113264
4
depression and substance-use coping, with those reporting depressive symptoms more likely to engage in substance-related coping.5
, 6
, - Romano I
- Patte KA
- de Groh M
- et al.
Substance-related coping behaviours among youth during the early months of the COVID-19 pandemic.
Addict Behav Rep. 2021; 14100392https://doi.org/10.1016/j.abrep.2021.100392
7
, 8
- Miech R
- Patrick ME
- Keyes K
- O'Malley PM
- Johnston L
Adolescent drug use before and during U.S. national COVID-19 social distancing policies.
Drug Alcohol Depend. 2021; 226108822https://doi.org/10.1016/j.drugalcdep.2021.108822
Reservation-area American Indian (AI) adolescents are at increased risk for depression, generalized anxiety,
9
substance use,10
and suicide,10
with disparities in substance use and psychological outcomes being especially striking, compared with national rates. The pandemic introduced new risks for AI populations who experienced higher levels of morbidity and mortality early in the pandemic, especially on reservations.11
, 12
, 13
In response, tribes took pivotal actions,14
shutting borders and instituting curfews despite institutional, medical, and social barriers.15
- Wang H.
Why the Navajo Nation was hit so hard by coronavirus: understanding the disproportionate impact of the COVID-19 pandemic.
Appl Geogr. 2021; 134102526https://doi.org/10.1016/j.apgeog.2021.102526
Although AI populations have suffered significant morbidity and mortality, youth data are sparse.
16
In this study, data from 2 national studies, one of reservation-area AI youth and one of youth in the contiguous U.S., are compared. These studies obtained comparable measures of perceived COVID-19 testing, morbidity and mortality, changes in substance use, and changes in emotional states. Monitoring the Future (MTF) is a nationally representative survey of 8th-, 10th-, and 12th-grade students, whereas Our Youth, Our Future (OYOF) annually surveys a nationally representative group of 6–12th-grade students living on or near AI reservations. This study assesses both similarities and differences in national and AI student COVID-19 experiences and responses.METHODS
Study Sample
The OYOF and MTF studies were approved by the Colorado State University and the University of Michigan IRBs, respectively. For OYOF, local school board and tribal IRB approvals were also obtained as required. Both IRBs approved passive consent procedures, with parents fully informed of the study and given the opportunity to opt their child out of the study. Assent was obtained from all participating students.
For the OYOF sample, study data represent a population-based sample of 20 schools participating during spring 2021. The OYOF study is described in Swaim and Stanley
17
where the sampling frame, sample and recruitment procedures, and survey procedures are described. Schools were randomly sampled to reflect the AI population from 7 culturally distinct U.S. geographic regions as described by Snipp.- Swaim RC
- Stanley LR.
Substance use among American Indian youths on reservations compared with a national sample of US adolescents.
JAMA Netw Open. 2018; 1e180382https://doi.org/10.1001/jamanetworkopen.2018.0382
18
For the MTF sample, study data represent a population-based sample of 319 schools in the contiguous U.S. participating in spring 2021. Johnston et al.
19
describe the sampling frame, sample and recruitment procedures, and survey procedures.For the OYOF sample, during spring 2021, schools still implemented modified procedures, operating remotely, in-person, or in hybrid forms. A total of 65% of sampled schools were in-person, and 35% were hybrid. Owing to a lack of online access for reservation-area students, no schools operating 100% remotely were surveyed. Before administration, parents could opt their child out of the survey (<1% chose this option). Surveys were administered online with Qualtrics software during classroom hours to all eligible 6th–12th-grade students. Responses were anonymous, and students were instructed to skip questions they did not wish to answer. Response rates averaged 60.4% of enrollment.
For the MTF sample, schools were recruited regardless of remote status; 26% of students reported remote schooling, 46% reported in-person schooling, and 28% reported hybrid schooling. Before administration, parents could opt their child out of the survey (<1% chose this option). Surveys were administered online with Illume software. Responses for 8th- and 10th-grade students were anonymous; 12th-grade students provided contact information for follow-up questionnaires. All students were instructed to skip questions they did not wish to answer. Response rates were 82% in 8th grade, 78% in 10th grade, and 69% in 12th grade.
For the OYOF sample, data for 8th-, 10th-, and 12th-grade students who self-reported as AI are reported. The sample consisted of the following: Grade 8, n=398; Grade 10, n=367; Grade 12, n=290 (mean age=15.5, SD=1.69; male=46.3%, female=51.0%, another=2.7%). The regional distribution was 3.5% Northeast, 39.3% Southwest, 8.1% Northern Plains, 8.9% Upper Great Lakes, 25.1% Southeast, 3.2% Northwest, and 10.8% Southern Great Plains. Observations were weighted to correct for over-representation or under-representation by region, with weights based on the U.S. 2010 Census reservation and off-reservation trust land state populations. Reservation residence was as follows: on reservation=44.8%, within 25 miles=36.6%, and >25 miles=18.7%. The percentage of students eligible for free or reduced lunch averaged 64.8% across schools.
For the MTF sample, the sample consisted of the following: Grade 8, n=11,446; Grade 10, n=11,792; and Grade 12, n=9,022 (mean age=15.9, SD=0.10; male=47.8%, female=47.0%, other or prefer not to answer=5.2%). The racial/ethnicity distribution was White (50.9%), Black or African American (11.4%), Hispanic (16.6%), Asian American (5.1%), AI (1.2%), Middle Eastern (0.8%), and >1 of these (13.8%). MTF is weighted with the demographic distribution mirroring that of the nation. Accordingly, the SES of MTF students mirrored that of the nation.
Measures
The following measures were compared: COVID-19 testing and perceived morbidity for self, family, and friends (Table 1); changes in substance use since the pandemic began (Table 2); and changes in emotional states (Table 3). For COVID-19 testing, morbidity, and mortality, measures from COVID-19 Adolescent Symptom and Psychological Experience Questionnaire Adolescent Self-Report Survey were used. OYOF participants were asked, Have you had COVID-19?, with 4 response alternatives (1=No, but I've never been tested; 2=No, I tested negative; 3=Yes, but I wasn't tested for COVID-19; and 4=Yes, I tested positive). Responses of 1 or 3 were counted as no for testing, and responses of 2 or 4 were counted as yes. MTF participants were asked, Have you been tested for COVID-19 at least once? (1=Yes, 2=No). They were then asked, Have you ever had a positive test for COVID-19? (1=Yes, 2=No) with comparisons with OYOF responses reported earlier as 4=Yes, I tested positive. For family and friend morbidity, OYOF participants were asked, How many of your family members or close friends have had COVID-19? (0=0, 1=1, 2=2−3, 3=4−6, 4=more than 6). MTF participants were asked, Have any of the following people that you know had COVID-19? (Anyone in your household, some other member of your family, anyone else that you know personally, none of these). Responses of 1 or greater for OYOF and any marked as yes for MTF were compared. OYOF participants were then asked, How many of your family members or close friends stayed in the hospital because of COVID-19? (0=0, 1=1, 2=2−3, 3=4−6, 4=more than 6). MTF participants were asked, Were any of the people you knew who had COVID-19 admitted to the hospital because of COVID-19? (1=Yes, 2=No). MTF responses of Yes were compared with OYOF responses of 1 or greater.
Table 1Percentage of AI and NS Students Tested for COVID-19 and Morbidity for Self and Others
| Measure | 8th grade | 10th grade | 12th grade | |||
|---|---|---|---|---|---|---|
| AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | |
| Tested | n=391 (59.1) (48.6, 68.8)** | n=10,333 (43.6) (39.8, 47.5) | n=357 (63.8) (53.5, 73.4)** | n=10,590 (45.2) (42.0, 48.5) | n=278 (69.1) (57.5, 78.7)* | n=8,025 (52.7) (48.5, 57.0) |
| Tested positive | n=391 (13.1) (8.7, 19.3)* | n=10,315 (8.7) (7.9, 9.6) | n=357 (17.3) (13.3, 22.1)** | n=10,577 (11.0) (9.7, 12.4) | n=278 (12.5) (10.1, 15.5) | n=8,013 (12.5) (11.3, 13.9) |
| Family or friends had COVID-19 | n=384 (71.9) (61.9, 80.2) | n=11,446 (66.0) (62.6, 69.3) | n=355 (76.4) (63.8, 85.6) | n=11,792 (69.3) (66.7, 71.8) | n=279 (86.0) (78.1, 91.3)** | n=9,022 (67.6) (64.2, 70.8) |
| Family or friends hospitalized owing to COVID-19 | n=387 (36.2) (26.2, 47.5)** | n=11,445 (11.9) (10.6, 13.3) | n=352 (36.8) (25.5, 49.9)** | n=11,788 (13.8) (12.7, 15.0) | n=279 (42.3) (34.8, 50.1)** | n=9,020 (12.7) (11.3,14.3) |
Note: Boldface indicates statistical significance (*p<0.05, **p<0.01) between AI and NS.
AI sample was from Our Youth, Our Future study, and NS was from Monitoring the Future study.
a Students who had not been tested for COVID-19 were coded to 0.
b Students who reported that they did not have any family or friends with COVID-19 are coded to 0.AI, reservation-area American Indian; NS, national sample.
Table 2Percentage of AI and NS Students Reporting Substance Use Changes Since COVID-19 Began With Sample Sizes for Each Substance
| Measures | 8th grade | 10th grade | 12th grade | |||
|---|---|---|---|---|---|---|
| AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | |
| Cigarette smoking | n=22 | n=727 | n=35 | n=989 | n=32 | n=1,281 |
| Decreased | 44.7 (20.6, 71.6) | 52.0 (47.6, 56.3) | 38.3 (14.1, 70.1) | 45.6 (41.6, 49.7) | 39.4 (22.7, 59.0) | 43.5 (39.5, 47.6) |
| Increased | 23.2 (3.7, 70.4) | 11.6 (9.0, 14.7) | 20.7 (8.9, 41.1) | 12.6 (9.9, 15.7) | 30.1 (13.7, 53.7)* | 13.8 (9.3, 19.9) |
| Nicotine vaping | n=70 | n=1,272 | n=116 | n=2,123 | n=73 | n=2,111 |
| Decreased | 39.3 (27.7, 52.4) | 34.4 (31.8, 37.0) | 23.3 (15.6, 33.3) | 31.2 (28.2, 34.3) | 33.5 (14.8, 59.3) | 34.8 (31.0, 38.8) |
| Increased | 37.5 (17.9, 62.2) | 37.0 (34.0, 40.1) | 35.8 (26.0, 46.9) | 39.0 (35.8, 42.3) | 32.3 (21.1, 46.0) | 34.2 (30.9, 37.6) |
| Alcohol use | n=62 | n=1,702 | n=105 | n=3,071 | n=102 | n=3,910 |
| Decreased | 24.5 (15.8, 36.2) | 31.2 (28.2, 34.3) | 20.1 (9.9, 36.6) | 22.9 (20.3, 25.8) | 33.3 (13.2, 62.0) | 27.0 (24.6, 29.7) |
| Increased | 25.2 (9.4, 52.1) | 27.3 (24.1, 30.7) | 29.2 (18.4, 43.0) | 35.8 (33.1, 38.7) | 29.1 (13.0, 52.9) | 33.3 (30.6, 36.1) |
| Getting drunk | n=42 | n=1,691 | n=76 | n=3,058 | n=75 | n=3,901 |
| Decreased | 15.0 (2.8, 52.2)* | 35.2 (32.1, 38.4) | 28.9 (13.4, 51.7) | 25.0 (22.1, 28.0) | 34.5 (16.4, 58.5) | 29.3 (27.0, 31.6) |
| Increased | 30.7 (15.3, 52.0)* | 17.6 (14.8, 20.9) | 31.8 (21.2, 44.7) | 28.2 (25.9, 30.6) | 29.5 (19.6, 41.8) | 27.1 (24.6, 29.7) |
| Marijuana smoking | n=67 | n=869 | n=100 | n=2,020 | n=75 | n=2,467 |
| Decreased | 32.7 (21.7, 46.1) | 30.9 (27.1, 35.0) | 17.9 (12.3, 25.5)* | 25.9 (23.4, 28.6) | 27.3 (15.0, 44.4) | 25.2 (22.5, 28.2) |
| Increased | 48.5 (42.4, 54.6)* | 35.0 (30.7, 39.5) | 44.6 (31.2, 58.8) | 42.0 (38.6, 45.6) | 35.7 (22.8, 51.0) | 39.5 (35.6, 43.5) |
| Marijuana edibles | n=43 | n=862 | n=64 | n=1,996 | n= 43 | n=2,446 |
| Decreased | 27.4 (17.5, 40.3) | 34.6 (30.1, 39.4) | 19.2 (4.5, 54.5) | 30.6 (27.5, 33.8) | 21.4 (12.0, 35.3) | 30.9 (27.5, 34.6) |
| Increased | 35.1 (21.4, 51.8) | 27.5 (23.2, 32.2) | 30.7 (12.1, 58.7) | 27.0 (23.2, 31.1) | 22.6 (5.6, 58.7) | 26.2 (22.9, 29.7) |
Note: Boldface indicates statistical significance (*p<0.05, **p<0.01) between AI and NS.
AI sample was from Our Youth, Our Future study, and NS was from Monitoring the Future study. Only students who had used a substance in the last 12 months were included in the calculations for that substance.
AI, reservation-area American Indian; NS, national sample.
Table 3Percentage of AI and NS Students Reporting Changes in Emotional States Since COVID-19 Began
| Measures | 8th grade | 10th grade | 12th grade | |||
|---|---|---|---|---|---|---|
| AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | AI (%) (95% CI) | NS (%) (95% CI) | |
| Feeling anxious | n=227 | n=10,021 | n=204 | n=10,370 | n=165 | n=7,827 |
| Decreased | 34.0 (26.2, 42.7)** | 19.5 (17.8, 21.3) | 28.1 (23.8, 32.9)** | 16.2 (14.9, 17.6) | 28.6 (19.4, 40.1)** | 15.8 (14.2, 17.6) |
| Increased | 31.8 (25.2, 39.1)** | 45.6 (43.8, 47.4) | 34.6 (24.2, 46.6)** | 51.8 (49.8, 53.8) | 34.2 (27.5, 41.6)** | 51.5 (48.1, 54.9) |
| Feeling angry | n=225 | n=10,019 | n=204 | n=10,364 | n=158 | n=7,812 |
| Decreased | 24.4 (15.9, 35.6) | 18.4 (16.9, 20.0) | 31.7 (17.7, 50.0)** | 16.0 (14.7, 17.4) | 32.7 (19.4, 49.5)** | 15.5 (13.9, 17.2) |
| Increased | 33.6 (29.2, 38.3)** | 40.6 (39.3, 42.0) | 28.8 (17.6, 43.2)** | 43.2 (41.7, 44.6) | 25.6 (19.1, 33.4)** | 42.2 (40.0, 44.5) |
| Feeling bored | n=223 | n=10,024 | n=210 | n=10,365 | n=156 | n=7,813 |
| Decreased | 19.0 (13.2, 26.5)** | 10.9 (9.9, 12.0) | 20.1 (11.9, 31.9)** | 8.9 (8.0, 10.0) | 16.0 (6.8, 33.1) | 10.5 (9.3, 11.9) |
| Increased | 50.2 (41.1, 59.3)** | 71.4 (69.8, 73.0) | 46.9 (27.4, 67.4)** | 73.2 (71.2, 75.0) | 37.6 (28.3, 47.8)** | 67.4 (64.6, 70.1) |
| Feeling sad | n=224 | n=10,002 | n=204 | n=10,343 | n=157 | n=7,801 |
| Decreased | 25.4 (15.5, 38.7) | 17.7 (16.0, 19.6) | 31.4 (20.1, 45.4)** | 13.4 (12.2, 14.7) | 36.1 (29.4, 43.4)** | 13.3 (11.8, 15.0) |
| Increased | 44.7 (38.1, 51.6) | 47.6 (45.8, 49.3) | 37.2 (31.7, 43.2)** | 55.8 (53.4, 58.2) | 31.5 (25.7, 38.0)** | 54.2 (50.8, 57.4) |
| Feeling lonely | n=224 | n=9,996 | n=204 | n=10,329 | n=158 | n=7,790 |
| Decreased | 29.5 (18.8, 43.2)** | 17.7 (16.2, 19.4) | 35.9 (26.8, 46.2)** | 14.3 (13.2, 15.5) | 35.3 (27.5, 44.1)** | 14.4 (12.8, 16.2) |
| Increased | 37.3 (27.1, 48.7)* | 48.2 (46.5, 50.0) | 32.7 (27.0, 39.1)** | 55.6 (53.5, 57.6) | 29.6 (21.2, 39.6)** | 53.5 (50.1, 56.8) |
| Feeling depressed | n=226 | n=9,978 | n=205 | n=10,335 | n=165 | n=7,794 |
| Decreased | 33.9 (27.4, 41.1)** | 20.9 (19.0, 22.9) | 32.2 (22.5, 43.8)** | 15.8 (14.6, 17.2) | 31.8 (21.3, 44.6)** | 15.0 (13.5, 16.7) |
| Increased | 31.8 (25.7, 38.7)** | 39.3 (37.8, 40.9) | 36.2 (28.9, 44.3)** | 47.8 (46.0, 49.7) | 36.9 (28.0, 46.8)* | 47.1 (43.4, 50.8) |
| Feeling worried | n=220 | n=9,958 | n=210 | n=10,336 | n=155 | n=7,791 |
| Decreased | 27.3 (14.5, 45.3) | 17.5 (15.8, 19.4) | 24.0 (16.8, 33.1)** | 14.5 (13.3, 15.9) | 21.0 (16.8, 25.8)* | 14.0 (12.5, 15.8) |
| Increased | 31.5 (25.4, 38.4)** | 45.7 (43.9, 47.5) | 36.4 (27.8, 45.9)** | 50.9 (48.8, 53.0) | 32.2 (25.4, 39.8)** | 51.8 (48.3, 55.3) |
| Difficulty in sleeping | n=226 | n=9,976 | n=205 | n=10,350 | n=165 | n=7,797 |
| Decreased | 30.0 (19.9, 42.5)** | 18.8 (17.4, 20.2) | 25.4 (19.1, 33.0)** | 15.7 (14.5, 17.0) | 24.9 (11.8, 45.0) | 16.2 (14.9, 17.7) |
| Increased | 40.1 (34.3, 46.1) | 40.3 (38.8, 41.8) | 33.4 (25.2, 42.7)** | 43.7 (42.2, 45.1) | 39.5 (30.7, 49.2) | 41.7 (39.6, 43.8) |
| Interest in normal activities | n=224 | n=9,982 | n=204 | n=10,345 | n=158 | n=7,792 |
| Decreased | 29.3 (23.3, 36.2)* | 37.1 (35.6, 38.7) | 26.8 (19.6, 35.5)** | 43.9 (42.2, 45.7) | 24.8 (12.2, 44.0)* | 42.8 (40.5, 45.1) |
| Increased | 32.9 (24.5, 42.5) | 18.9 (17.5, 20.4) | 37.8 (34.1, 41.8) | 15.1 (14.0, 16.2) | 35.9 (28.7, 43.8) | 15.1 (13.7, 16.7) |
| Trouble concentrating | n=221 | n=9,990 | n=210 | n=10,351 | n=155 | n=7,803 |
| Decreased | 25.2 (17.7, 34.4)** | 15.9 (14.3, 17.7) | 18.0 (15.0, 21.4)** | 12.0 (10.9, 13.3) | 11.8 (6.4, 20.7) | 12.7 (11.3, 14.3) |
| Increased | 31.6 (22.2, 42.9)** | 44.6 (42.8, 46.4) | 43.5 (31.3, 56.5)** | 54.3 (51.4, 57.1) | 39.3 (29.1, 50.4)** | 51.3 (48.1, 54.5) |
Note: Boldface indicates statistical significance (*p<0.05, **p<0.01) between AI and NS.
AI sample was from Our Youth, Our Future study, and NS was from Monitoring the Future study. Only students who had used a substance in the last 12 months were included in the calculations for that substance.
AI, reservation-area American Indian; NS, national sample.
For changes in substance use, the OYOF students were asked, After COVID-19 started, how much did your use of (name of substance) change? The MTF students were asked, How has your use of the following changed since the COVID-19 pandemic started? Both surveys used these response categories (1=decreased a lot, 2=decreased, 3=didn't change, 4=increased, 5=increased a lot). Responses of 1 or 2 were coded as decreased, and responses of 4 or 5 were coded as increased.
For changes in emotional states, the OYOF students were asked, Compared to before COVID-19, are you... (more or less anxious now, etc.) (1=much less, 2=less, 3=about the same, 4=more, 5=much more). The MTF students were asked, How have the following changed for you since the COVID-19 pandemic started? (feeling anxious, depressed, etc.) (1=decreased a lot, 2=decreased somewhat, 3=didn't change, 4=increased somewhat, 5=increased a lot). Although the wording of responses was slightly different, scaling was comparable. Responses of 1 or 2 from both surveys were coded as decreased, and responses of 4 or 5 were coded as increased.
Statistical Analysis
Proportions of study variables with 95% logit CIs were calculated using survey commands of Stata statistical software to account for clustering of students within schools. Only participants who reported the use of a substance in the last 12 months were included in calculations for changes in substance use, resulting in substantially lower sample sizes for both samples (Table 2).
Differences between proportions for the 2 samples were tested using a z-test for independent proportions. To account for the nesting of students within schools, effective sample sizes for each variable within a sample were computed as the actual sample size divided by that variable's design effect.
RESULTS
For COVID-19 testing and morbidity, Table 1 provides results by grade. For each grade, a significantly higher percentage of AI students reported testing for COVID-19 than the NS students, with an average difference across grades of 17.1 percentage points. More AI 8th and 10th graders reported testing positive than their NS counterparts, with rates of positivity the same for 12th graders. More AI students reported having family or close friends who contracted COVID-19, but the difference was significant only for 12th graders. Finally, a significantly higher percentage of AI students in each grade reported having family and friends hospitalized, with an average difference of 25.6 percentage points across grades.
Table 2 presents results for changes in substance use since the pandemic began for students who had used a substance in the last 12 months. For 8th graders, more AI students reported an increase in getting drunk and smoking marijuana than NS students. Conversely, more NS students reported a decrease in getting drunk than AI students. Only 1 significant difference was found for 10th graders; more NS students reported a decrease in marijuana smoking than AI students. Finally, for 12th graders, more AI students reported an increase in cigarette smoking than NS students.
Table 3 presents findings for changes in emotional states by grade. Significant differences in changes in emotional states were found, and similar patterns were found across grades. NS students were significantly more likely than AI students to report increases in anxiety, anger, boredom, loneliness, depression, worry, and trouble concentrating at each grade level. For 10th and 12th graders, NS students were also more likely than AI students to report increases in sadness, whereas 10th-grade NS students were more likely to report increases in difficulty sleeping.
In contrast, AI students at each grade were significantly more likely than NS students to report decreases in anxiety, loneliness, and depression. At 8th and 10th grades, AI students were also more likely than NS students to report decreases in boredom, difficulty in sleeping, and difficulty in concentrating, whereas for 10th and 12th graders, AI students were more likely to report decreases in anger and sadness than NS students.
Tables 4 and 5 present the results for changes in emotional state stratified by whether students had family or friends who were hospitalized owing to COVID-19. These results show that overall, students who had family or friends hospitalized owing to COVID-19 fared more poorly on emotional states in both groups of students than students with no family or friends hospitalized. In results not tabled, we computed weighted proportions across grades for each sample for those students who reported having family/friends hospitalized and increases in negative emotional states. Generally, more NS students reported experiencing increases in emotional distress than AI students (more anxious: NS=59.8%, AI=37.8%; angrier: NS=49.9%, AI=36.4%; more bored: NS=78.2%, AI=48.0%; sadder: NS=63.4%, AI=44.4%; more lonely: NS=62.8%, AI=38.3%; more depressed: NS=53.4%, AI=37.5%; more worried: NS=61.3%, AI=39.2%; more difficulty in sleeping: NS=49.7%, AI=45.2%; more interest in normal activities: NS=10.9%, AI=44.3%; more trouble in concentrating: NS=58.8%, AI=41.4%).
Table 4Percentage of AI Students Reporting Changes in Emotional States Since COVID-19 Began, by Respondent Reporting Whether a Family Member/Friend Had Been Hospitalized by COVID-19
| Measures | 8th Grade | 10th Grade | 12th Grade | |||
|---|---|---|---|---|---|---|
| F/f hospitalized (95% CI) | None hospitalized (95% CI) | F/f hospitalized (95% CI) | None hospitalized (95% CI) | F/f hospitalized (95% CI) | None hospitalized (95% CI) | |
| Feeling anxious | n=71 | n=153 | n=64 | n=137 | n=65 | n=99 |
| Decreased | 31.7 (18.6, 48.4) | 35.3 (22.8, 50.2) | 26.0 (20.6, 32.3) | 30.3 (24.8, 36.5) | 25.4 (12.9, 44.0) | 32.3 (18.1, 50.9) |
| Increased | 37.9 (22.7, 56.0) | 28.2 (21.6, 35.9) | 35.4 (15.5, 62.1) | 35.3 (25.6, 46.4) | 40.1 (29.4, 51.7) | 30.5 (15.8, 50.5) |
| Feeling angry | n=69 | n=153 | n=60 | n=141 | n=61 | n=96 |
| Decreased | 22.9 (14.9, 33.5) | 25.7 (15.4, 39.7) | 30.2 (17.5, 47.0) | 33.0 (18.4, 51.9) | 15.0* (9.0, 23.9) | 43.5 (23.7, 65.6) |
| Increased | 31.7 (19.2, 47.6) | 33.9 (26.2, 42.6) | 41.1** (24.5, 60.1) | 23.4 (15.8, 33.4) | 37.2 (22.8, 54.4) | 17.8 (8.2, 34.4) |
| Feeling bored | n=67 | n=154 | n=70 | n=138 | n=53 | n=103 |
| Decreased | 24.7 (18.9, 31.5) | 16.2 (8.3, 29.1) | 14.1 (4.8, 34.9) | 24.1 (10.4, 46.6) | 14.8 (4.4, 39.9) | 16.8 (8.0, 31.9) |
| Increased | 48.9 (37.1, 60.7) | 50.2 (42.3, 58.1) | 50.9 (28.6, 72.9) | 45.0 (27.7, 63.7) | 42.8 (23.1, 65.1) | 34.0 (22.2, 48.2) |
| Feeling sad | n=68 | n=153 | n=60 | n=141 | n=61 | n=95 |
| Decreased | 20.9 (8.9, 41.8) | 27.6 (16.0, 43.2) | 21.3 (12.3, 34.5) | 36.9 (20.7, 56.6) | 25.6 (13.7, 42.6) | 41.7 (30.9, 53.4) |
| Increased | 51.2 (42.1, 60.4) | 40.8 (30.3, 52.2) | 44.8 (29.5, 61.1) | 34.1 (30.2, 38.2) | 37.4 (24.7, 52.1) | 28.2 (19.4, 39.0) |
| Feeling lonely | n=68 | n=153 | n=60 | n=141 | n=61 | n=96 |
| Decreased | 27.0 (16.7, 40.5) | 31.5 (18.0, 49.0) | 25.8 (7.0, 61.5) | 41.5 (24.1, 61.2) | 26.7 (9.3, 56.5) | 39.6 (29.4, 50.7) |
| Increased | 37.0 (23.1, 53.4) | 37.5 (26.0, 50.7) | 40.5 (27.4, 55.0) | 29.4 (21.3, 38.9) | 38.0* (24.9, 53.2) | 24.3 (13.8, 39.2) |
| Feeling depressed | n=71 | n=152 | n=64 | n=138 | n=65 | n=99 |
| Decreased | 31.3 (21.6, 42.9) | 34.7 (23.7, 47.7) | 30.6 (19.8, 44.0) | 34.3 (20.8, 51.0) | 29.1 (10.8, 58.2) | 35.2 (22.7, 50.2) |
| Increased | 31.9 (25.8, 38.9) | 32.0 (25.8, 38.9) | 37.5 (18.0, 62.1) | 36.8 (22.9, 53.3) | 43.8 (33.8, 54.4) | 32.6 (17.2, 52.9) |
| Feeling worried | n=65 | n=153 | n=70 | n=138 | n=53 | n=102 |
| Decreased | 29.7 (19.8, 42.0) | 25.7 (10.8, 49.7) | 18.7 (12.9, 26.2) | 27.7 (18.2, 39.8) | 26.0 (15.6, 39.9) | 17.6 (11.3, 26.2) |
| Increased | 32.1 (18.4, 49.7) | 31.0 (22.1, 41.6) | 43.3 (27.8, 60.2) | 32.9 (25.7, 40.9) | 42.6 (27.2, 59.5) | 25.1 (14.6, 39.6) |
| Difficulty with sleeping | n=71 | n=152 | n=64 | n=138 | n=65 | n=99 |
| Decreased | 28.0 (17.7, 41.4) | 31.1 (19.7, 45.3) | 24.9 (10.9, 47.3) | 26.6 (19.1, 35.8) | 22.6 (9.9, 43.8) | 27.7 (9.1, 59.4) |
| Increased | 49.6 (37.4, 61.7) | 34.8 (28.1, 42.1) | 39.4 (13.2, 73.5) | 31.0 (22.5, 41.2) | 46.1 (31.4, 61.4) | 31.9 (12.0, 61.9) |
| Interest in normal activities | n=68 | n=153 | n=60 | n=141 | n=61 | n=96 |
| Decreased | 29.0 (20.5, 39.3) | 30.0 (22.6, 38.7) | 16.4 (7.4, 32.3) | 32.0 (22.4, 43.4) | 12.8 (2.2, 48.8) | 31.1 (15.6, 52.4) |
| Increased | 37.0 (24.1, 52.1) | 30.7 (22.1, 40.8) | 44.9 (30.0, 60.7) | 35.3 (27.8, 43.6) | 52.0** (41.7, 62.1) | 25.1 (14.7, 39.6) |
| Trouble concentrating | n=66 | n=153 | n=70 | n=138 | n=53 | n=102 |
| Decreased | 36.8* (21.5, 55.3) | 18.8 (12.3, 27.7) | 15.5 (9.9, 23.4) | 19.8 (13.9, 27.5) | 6.9* (2.8, 15.8) | 15.1 (8.8, 24.6) |
| Increased | 28.5 (17.7, 42.6) | 32.9 (22.4, 45.7) | 48.6 (25.6, 72.3) | 40.8 (33.2, 48.9) | 48.2 (30.2, 66.9) | 33.1 (22.8, 45.4) |
Note: Boldface indicates statistical significance (*p<0.05, **p<0.01).
AI, reservation-area American Indian; F/f, family and friend.
Table 5Percentage of NS Students Reporting Changes in Emotional States Since COVID-19 Began, by Respondent Reporting Whether a Family Member/Friend Had Been Hospitalized by COVID-19
| Measures | MTF 8th grade | 10th grade | 12th grade | |||
|---|---|---|---|---|---|---|
| F/f hospitalized (95% CI) | None hospitalized (95% CI) | F/f hospitalized (95% CI) | None hospitalized (95% CI) | F/f hospitalized (95% CI) | None hospitalized (95% CI) | |
| Feeling anxious | n=1,257 | n=8,764 | n=1,619 | n=8,753 | n=1,249 | n=6,579 |
| Decreased | 12.3 (10.4, 14.5) | 20.6 (18.8, 22.5) | 12.2 (10.0, 14.7) | 17.0 (15.5, 18.6) | 8.2 (6.3, 10.5) | 17.1 (15.4, 19.1) |
| Increased | 55.8 (52.6, 59.0) | 44.0 (42.1, 46.0) | 60.5 (56.6, 64.3) | 50.2 (48.0, 52.4) | 63.6 (57.5, 69.3) | 49.4 (46.0, 52.8) |
| Feeling angry | n=1,259 | n=8,760 | n=1,619 | n=8,747 | n=1,248 | n=6,565 |
| Decreased | 12.3 (10.1, 14.9) | 19.3 (17.7, 21.1) | 10.7 (8.9, 12.7) | 16.9 (15.5, 18.5) | 8.7 (6.8, 11.0) | 16.7 (15.0, 18.5) |
| Increased | 48.3 (45.2, 51.4) | 39.5 (37.9, 41.0) | 50.3 (47.5, 53.0) | 41.9 (40.4, 43.4) | 51.3 (45.0, 57.6) | 40.7 (38.7, 42.7) |
| Feeling bored | n=1,261 | n=8,764 | n=1,616 | n=8,751 | n=1,251 | n=6,563 |
| Decreased | 8.0 (6.4, 9.9) | 11.4 (10.3, 12.6) | 4.5 (3.3, 6.0) | 9.7 (8.6, 10.9) | 4.7 (3.4, 6.5) | 11.5 (10.1, 13.1) |
| Increased | 77.0 (73.7, 79.9) | 70.6 (68.8, 72.3) | 80.8 (78.0, 83.3) | 71.8 (69.8, 73.7) | 74.0 (67.8, 79.4) | 66.3 (63.6, 68.9) |
| Feeling sad | n=1,256 | n=8,746 | n=1,617 | n=8,728 | n=1,248 | n=6,554 |
| Decreased | 11.8 (9.7, 14.3) | 18.6 (16.7, 20.7) | 7.8 (6.2, 9.8) | 14.4 (13.0, 15.8) | 6.1 (4.6, 8.2) | 14.5 (12.8, 16.3) |
| Increased | 59.7 (56.0, 63.4) | 45.7 (43.9, 47.4) | 64.6 (60.5, 68.5) | 54.2 (51.9, 56.5) | 67.2 (61.7, 72.3) | 51.9 (48.6, 55.3) |
| Feeling lonely | n=1,257 | n=8,739 | n=1,617 | n=8,714 | n=1,247 | n=6,544 |
| Decreased | 12.8 (10.5, 15.5) | 18.5 (16.8, 20.3) | 8.3 (6.7, 10.3) | 15.4 (14.1, 16.7) | 8.3 (6.3, 10.8) | 15.5 (13.7, 17.4) |
| Increased | 59.8 (56.3, 63.3) | 46.4 (44.6, 48.2) | 65.3 (61.5, 68.8) | 53.8 (51.8, 55.8) | 62.7 (57.2, 68.0) | 51.9 (48.5, 55.3) |
| Feeling depressed | n=1,252 | n=8,726 | n=1,617 | n=8,720 | n=1,247 | n=6,548 |
| Decreased | 14.2 (11.7, 17.1) | 21.9 (19.9, 24.1) | 11.7 (9.8, 13.9) | 16.6 (15.3, 18.0) | 8.6 (6.7, 10.9) | 16.1 (14.5, 17.9) |
| Increased | 48.2 (44.5, 52.0) | 38.0 (36.4, 39.5) | 54.2 (51.6, 56.7) | 46.7 (44.6, 48.8) | 57.7 (53.0, 62.4) | 45.3 (41.4, 49.2) |
| Feeling worried | n=1,250 | n=8,708 | n=1,614 | n=8,724 | n=1,246 | n=6,546 |
| Decreased | 11.5 (9.3, 14.0) | 18.5 (16.6, 20.5) | 7.9 (6.4, 9.6) | 15.7 (14.3, 17.2) | 7.1 (5.4, 9.3) | 15.2 (13.5, 17.1) |
| Increased | 58.1 (54.7, 61.4) | 43.8 (42.0, 45.6) | 60.4 (57.4, 63.4) | 49.2 (46.9, 51.4) | 65.7 (60.1, 70.9) | 49.4 (46.0, 52.9) |
| Difficulty with sleeping | n=1,251 | n=8,725 | n=1,616 | n=8,736 | n=1,244 | n=6,554 |
| Decreased | 15.5 (13.0, 18.4) | 19.3 (17.8, 20.8) | 9.6 (7.7, 11.9) | 16.8 (15.5, 18.2) | 10.3 (8.0, 13.3) | 17.3 (15.7, 18.9) |
| Increased | 46.1 (42.6, 49.5) | 39.4 (37.9, 40.9) | 52.2 (49.6, 54.9) | 42.1 (40.6, 43.6) | 50.0 (44.8, 55.2) | 40.3 (38.1, 42.5) |
| Interest in normal activities | n=1,256 | n=8,726 | n=1,617 | n=8,730 | n=1,245 | n=6,548 |
| Decreased | 43.9 (40.4, 47.4) | 36.1 (34.6, 37.7) | 50.5 (47.1, 54.0) | 42.7 (40.7, 44.8) | 53.0 (48.2, 57.7) | 41.0 (38.9, 43.2) |
| Increased | 14.3 (11.9, 17.0) | 19.6 (18.1, 21.3) | 10.3 (8.1, 13.0) | 15.9 (14.7, 17.3) | 8.5 (6.6, 11.0) | 16.3 (14.7, 17.9) |
| Trouble concentrating | n=1,257 | n=8,733 | n=1,616 | n=8,737 | n=1,250 | n=6,554 |
| Decreased | 11.9 (9.7, 14.4) | 16.6 (14.8, 18.5) | 6.6 (5.0, 8.5) | 13.0 (11.8, 14.4) | 5.5 (4.1, 7.4) | 14.0 (12.5, 15.7) |
| Increased | 53.6 (50.1, 57.2) | 43.2 (41.3, 45.0) | 60.2 (56.1, 64.2) | 53.2 (50.3, 56.0) | 62.5 (57.0, 67.6) | 49.4 (46.3, 52.5) |
Note: All differences by hospitalization reports are significantly different (p<0.05).
F/f, family and friend; MTF, Monitoring the Future.
DISCUSSION
The study results illustrate the substantial impacts of COVID-19 on the adolescent population 1 year into the pandemic. Students in both samples saw significant numbers of friends and family hospitalized; many students reported increases in negative emotional states, whereas others reported decreases, and substance use increased for some students and decreased for others.
For COVID-19 testing and morbidity, the significantly higher testing among AI students likely reflects actions taken by tribal nations to protect their citizens early in the pandemic. With COVID-19 disproportionately affecting reservations, especially for elders, reservations quickly and proactively developed responses, including curfews, enforcement of stay-at-home orders, and mask mandates. Tribes were among the first to institute widespread testing programs, and they were successful in delivering vaccinations as well.
20
Regarding outcomes of COVID-19 tests, the higher positive tests for AI 8th and 10th graders may reflect higher levels of testing and may also reflect the disproportionate COVID-19 impact on tribal nations early in the pandemic where AIs were at elevated risk of contracting and dying.16
,21
Finally, AI students were significantly more likely to report knowing someone hospitalized owing to COVID-19. Several reasons may account for this difference, including higher underlying comorbidities among the AI population that would lead to more severe disease21
and greater COVID-19 infection risk in the early days of the pandemic owing to factors, including more crowded conditions in homes and more work in front-facing occupations.16
Changes in substance use varied by grade and substance. Overall, there were far more similarities than differences. However, because only students who had used a substance in the last 12 months were included in the calculations for that substance, the AI cell sizes were low, resulting in wide confidence intervals. This may, in part, cause meaningful differences in changes to be nonsignificant.
NS and AI students at all grade levels were more likely to report decreases than increases in cigarette smoking, with in-sample differences between increases and decreases, especially stark for national rates. The only significant difference between the samples was at Grade 12, where a higher percentage of AI students than NS students reported increased cigarette smoking. This difference may be because of lower availability and/or increased parental monitoring owing to stay-at-home orders. This pattern was not observed for nicotine vaping wherein the percentage of students increasing use was similar to percentages decreasing use and wherein percentages were similar between samples (with AI 10th graders showing an exception to this pattern). Differences in vaping and cigarette smoking may be owing to vaping being easier to hide than cigarette smoking.
5
No differences were found for changes in alcohol use or intoxication, except for 8th grade where significantly fewer AI students reported a decrease in drunkenness. Among NS students, 10th and 12th graders were more likely to report increased alcohol use than decreased alcohol use. This mirrors an increase in national rates of alcohol use during the first year of COVID-19.
22
,23
- Pollard MS
- Tucker JS
- Green HD.
Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US.
JAMA Netw Open. 2020; 3e2022942https://doi.org/10.1001/jamanetworkopen.2020.22942
Generally, more students reported increased marijuana use than decreased use, and at 8th and 10th grades, AI students were more likely to report increases than NS students. Marijuana use among reservation-area AI students is significantly higher than national rates, especially at 8th and 10th grades.
17
Given their higher rates of use, AI students who use may be using more often, possibly to cope with negative emotional states or boredom. Frequent marijuana use among AI adolescents has been linked to use for coping.- Swaim RC
- Stanley LR.
Substance use among American Indian youths on reservations compared with a national sample of US adolescents.
JAMA Netw Open. 2018; 1e180382https://doi.org/10.1001/jamanetworkopen.2018.0382
24
Finally, no significant differences were found for marijuana edibles, and overall, results suggest that students were as likely to increase use as to decrease use, with about 40%–50% not changing use.The starkest differences between the samples were for changes in emotional states. For both, a relatively high percentage of students reported increased negative emotional states. However, for nearly all measures at each grade level, the percentage of students reporting an increase was greater for the NS sample than for the AI reservation-area sample, whereas the percentages of students reporting decreases in negative emotional states were greater for the AI reservation-area sample than for the NS sample. For example, significantly more NS students reported increases in anxiety, anger, boredom, loneliness, depression, and worry at all grade levels, whereas significantly more AI students reported decreases in anxiety, loneliness, and depression at all grade levels.
The comparisons between samples on emotional states based on whether they reported having family/friends hospitalized owing to COVID-19 were also markedly different. A much higher percentage of NS students reported an increase in negative emotional states than AI students. These results may seem surprising for AI youth given comparatively higher levels of morbidity and mortality among members of tribal nations. However, several potential explanations are worth noting. Levels of negative emotional states among reservation-area AI 6th–12th-grade students since the start of COVID-19 were relatively high, with substantial numbers of students reporting feeling a negative emotional state often or very often.
25
For example, 47.2% of the AI sample reported feeling sad or lonely often or very often, whereas 69.6% reported feeling bored often or very often. Given that fewer AI students noted an increase in negative effects than NS students, it is possible that negative emotional states were higher in reservation-area AI adolescents than nationally before the pandemic, a pre-existing ceiling effect. These results are also potentially explained by stress inoculation, in which individuals subjected to high levels of previous stress may not react as strongly to a novel stressor when compared with those with less previous stress.- Stanley LR
- Crabtree MA
- Swaim RC
- Prince MA.
Self-reported illness experiences and psychosocial outcomes for reservation-area American Indian youth during COVID-19.
JAMA Netw Open. 2022; 5e2231764https://doi.org/10.1001/jamanetworkopen.2022.31764
26
AI youth, historically, are subject to numerous stressors in addition to COVID-19 in the form of intergenerational transmission of historical trauma, systematic cultural genocide, and displacement, the consequences of which continue to this day.- Fergus S
- Zimmerman MA.
Adolescent resilience: A framework for understanding healthy development in the face of risk.
Annu Rev Public Health. 2005; 26: 399-419https://doi.org/10.1146/annurev.publhealth.26.021304.144357
27
,28
These findings are similar to those from a study that found that healthy adolescents reported large increases in anxiety and depression after COVID-19, whereas adolescents with early life stress reported high but stable levels of anxiety and depression.2
Although data on the psychological states of AI youth are sparse, national and regional data are suggestive of higher negative emotional states before pandemic on the basis of measures of depressed mood and suicide measures.- Cohen ZP
- Cosgrove KT
- DeVille DC
- et al.
The impact of COVID-19 on adolescent mental health:preliminary findings from a longitudinal sample of healthy and at-risk adolescents.
Front Pediatr. 2021; 9622608https://doi.org/10.3389/fped.2021.622608
29
, - Brockie TN
- Heinzelmann M
- Gill J.
A framework to examine the role of epigenetics in health disparities among Native Americans.
Nurs Res Pract. 2013; 2013410395https://doi.org/10.1155/2013/410395
30
, 31
, 32
, 33
, 34
Reservation-area students may also be responding more positively to changes in the family environment because of COVID-19 policy stay-at-home orders, which were strongly enforced on many reservations.14
Data support the latter argument; among AI 6th–12th-grade students, a larger percentage reported greater closeness with their families during the pandemic. Research has shown that close-knit families are particularly protective against psychological and behavioral health issues for AI adolescents.35
, 36
, 37
Limitations
It is important to note that this study reports on data obtained for only 1 school year during which COVID-19 was active. As the pandemic continues, new and different findings may emerge. Unlike the MTF study, the OYOF study did not include schools operating only remotely owing to a lack of online access for many students. However, dropping remote students from the NS sample revealed minor differences in the national percentages for all measures except one―the number of family or friends with COVID-19. For all grades, the percentage of family or friends with COVID-19 was approximately 10 percentage points higher in the in-school MTF sample than in the full MTF sample. This resulted in 1 change in significance; the significant difference between the 12th-grade NS and AI samples for family/friends with COVID-19 became nonsignificant, consistent with the original findings for 8th and 10th graders.
Neither sample contains adolescents who dropped out of school. Therefore, the results generalize to adolescents who attend school, the vast majority of school-age adolescents.
38
In addition, the study relies on self-reported responses, which may be subject to social desirability bias. The anonymity (OYOF and 8th- and 10th-grade MTF) and confidentiality (12th-grade MTF) of these studies work to diminish this potential bias. Respondents who do not provide personally identifying information on the questionnaires have little motivation to distort their reports in socially desirable directions. Finally, the numbers of AI students used in calculations of changes in substance use and emotional outcomes were small, causing potentially meaningful differences in changes in these variables across samples to be nonsignificant. Such small sample sizes may also bias the estimates. Although AI sample sizes for each grade were substantially less than national sample sizes, this AI sample is the only representative sample of reservation-area AI adolescents, and each sample was selected to represent each population.CONCLUSIONS
Compared with national adolescents in general, reservation-area AI adolescents show unique health COVID-19 consequences 1 year into the pandemic. In particular, AI students had more COVID-19 testing and positive test results than NS students. Differences in substance use were inconsistent across grades. However, AI students were also buffered from some of the negative impacts of COVID. In fact, NS students reported greater increases in anxiety, depression, and other indicators of mental health difficulties. These results document the need for careful tracking of mental health and substance use as potential COVID-19 youth outcomes. In addition, they highlight that AI youth have been protected from some negative mental health impacts, perhaps owing to having lived with the inoculating effects of other stressors before COVID-19. Future research is needed for Indigenous youth and AI-specific populations to assess the full extent of these consequences and to inform efforts aimed at addressing them through public health dissemination and treatment.
CRediT authorship contribution statement
Randall C. Swaim: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Writing – original draft, Writing – review & editing. Linda R. Stanley: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Writing – original draft, Writing – review & editing. Richard A. Miech: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Writing – original draft, Writing – review & editing. Megan E. Patrick: Funding acquisition, Project administration, Writing – review & editing. Meghan A. Crabtree: Writing – review & editing. Mark A. Prince: Funding acquisition, Writing – review & editing.
ACKNOWLEDGMENTS
The research presented in this paper is that of the authors and does not reflect the official policy of the NIH. The NIH and the National Institute on Drug Abuse had no role in the study design and collection, analysis, or interpretation of the data.
RCS, LRS, MAC, and MAP were funded by the National Institute on Drug Abuse (R01 DA00371). RAM and MEP were funded by the National Institute on Drug Abuse (R01 DA001411).
Declaration of interest: none.
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