Mental health, family functioning, and sleep in cultural context among American Indian/Alaska Native urban youth: A mixed methods analysis.

Mental health problems contribute significantly to the global burden of disease. Driven in part by family stressors and insufficient sleep, mental health disproportionately affects low SES urban adolescents. In the United States, American Indian/Alaska Native (AI/AN) youth exhibit excessively high rates of mental health problems. Family functioning is strongly associated with adolescent mental health, and sleep problems may serve as a pathway between family functioning and mental health. Using mixed methods we examine the associations among family functioning, subjective- and actigraphy-measured sleep, mental health (depressive and anxiety symptoms), and cultural identity in a sample of urban AI/AN youth. All participants (N = 142) completed surveys; a random subsample (n = 26) completed qualitative interviews to assess family and cultural dynamics related to sleep, which informed hypothesized direct and indirect effects that were tested using survey data. Narratives identified mechanisms of family cohesion (e.g., daily interactions that build perceived family togetherness and family-centered traditional activities) and the role that family cohesion plays in sleep (e.g., ensuring stability of sleep environments). Path analysis showed direct effects of improved family functioning on fewer depressive and anxiety symptoms, and indirect effects through lower self-reported sleep disturbance (but not through greater actigraphy-measured sleep duration or efficiency). Cultural identity did not moderate effects in quantitative tests. Our findings illustrate the complex associations among family functioning, sleep, and mental health in AI/AN youth. Family-based interventions to improve adolescent mental health should address modifiable intervention targets such as sleep, and address sources of both risk and resilience relevant to urban AI/AN families, including extended family and cultural practices.