The risk and protective factors influencing mental health in Indigenous children and adolescents may vary from non-Indigenous peers due to their Indigenous status and upbringing in ethnic diverse contexts. Ethnic contexts are categorized according to the density of Sami inhabitants; Norwegian dominated context by a low density of Sami members (<25%), the Mixed context by a medium density of Sami (25%–60%), and the Sami dominated context by a high density (>60%) of Sami. The impact of cultural factors, such as Indigenous identity, cultural activities, and Indigenous language competence on Indigenous children’s´ health is sparsely studied. In previous studies, cultural determinants accounted for significant variation in mental health in Sami high school students, but mainly for emotional problems. Later studies have broadened our knowledge of the effect of cultural issues´ impact on Sami adolescents. The aim of this chapter is to suggest specific features of the Sami culture and Indigenous status are important to consider in the treatment and prevention of mental health problems in Sami youngsters.
Key Terms: Indigenous, Sami, adolescents, mental health, culture, determinants
The health condition of Indigenous Sami children and adolescents has only been a topic of research for the last two decades. An increase in suicide rates in Sami adolescents and young adults in the late eighties forced policy makers, health professionals and researchers to place attention on the mental health conditions in the Sami population and the need for more knowledge. Later research has shown that Indigenous Sami adolescents have, in general, good mental health and well-being and do not differ from their non-Indigenous peers in rates of health problems (Margrethe Bals, Turi, Vittersø, Skre, & Kvernmo, 2011; Eckhoff & Kvernmo, 2014; S. Heyerdahl, Kvernmo, & Wichstrøm, 2004; Omma, Jacobsson, & Petersen, 2012). However, significant variation in mental health across groups of young Sami does occur (Kvernmo & Heyerdahl, 1998; 2003). A variety of cultural factors, as well as individual, family, and community characteristics can explain part of this variation. The impact of ethnic identity, acculturation, and cultural-related issues on mental health in Sami adolescents is the aim of this chapter.
In a recent systematic review of mental health in Indigenous young people in a diverse sample of high income countries, the prevalence of mental health problems was consistently high (Young, Hanson, Craig, Clapham, & Williamson, 2017). Across countries, children and young Indigenous peoples shared many of the same risks and protective factors. Children’s negative relationship with their families and experience with adverse life events, including the experience of ethnic discrimination, were found as the most reliable predictors of mental health problems (Young et al., 2017). On the other hand, positive peer and family relationships, strong self-esteem, and optimistic attitudes seemed to contribute to positive mental health outcomes.
Although Young et al.’s (2017) study did not include areas of the Arctic, other studies of Arctic adolescents – Indigenous, as well as non-Indigenous – show that several of the identified risk and protective determinants in Young et al.’s (2017) study remain valid for Sami adolescents (Kvernmo & Heyerdahl, 2003; Kvernmo, Heyerdahl & Wichstrøm, 2004; Spein, Kvernmo & Sexton, 2004; Silviken & Kvernmo, 2007; Bals, Turi, Skre & Kvernmo, 2011; Reigstad & Kvernmo, 2017). A limited number of studies investigating the impact of cultural determinants on mental health in Indigenous people are found. This chapter presents those ethnic and cultural determinants among Arctic Indigenous adolescents with a particular focus on Sami adolescents.
Ethnic Group Differences
The Sami population is, according to the ILO convention, no. 169, recognized as the Indigenous population in Norway. In some regions, they are the majority population as in the Sami core areas, but mainly they are in a minority position.
Studies among Indigenous and non-Indigenous adolescents in the Arctic area in Norway and Sweden have revealed few and small ethnic differences in mental health. Anxiety and depression, or emotional problems often referred to as the broader concept of “internalizing” mental health problems, have been studied in students in junior high school and high school students (Omma et al, 2012; Omma, Sandlund, & Jacobsson, 2013). While rates of anxiety and depression in Indigenous Sami students were not worse off or even similar in rates (Bals, Turi, Skre, & Kvernmo, 2010; Heyerdahl, Kvernmo, & Wichstrøm, 2004; Omma et al., 2012), substance use among Norwegian Sami adolescents and their parents, and internalizing problems (anxiety and depression) in Swedish Sami adolescents were less frequent compared to non-Sami peers (Spein, Sexton, & Kvernmo, 2007; Omma et al., 2012).
In a study from the 90’s of suicide thoughts and attempts, no ethnic differences were found among Indigenous and non-Indigenous Norwegian high school students (Silviken & Kvernmo, 2007). Due to the difference in determinants of suicide attempts, the authors stated that, “Clinicians should take into account that risk factors can differ between ethnic groups and should be sensitive to culturally divergent behavior”. In both ethnic groups, suicidal ideation, anxious/depressed problems, and eating behavior problems were associated with more suicide attempts. However, for Sami adolescents, factors diverging from the traditional cultural norms were associated with suicide attempts, such as alcohol intoxication, single-parent home and paternal overprotection, while among majority peers, vocational studies, not living together with parents, current smoking and experienced sexual intercourse were ethnic specific risk factors associated with suicide attempts. These findings correspond with results from a Swedish study of Sami and non-Sami young people (Omma et al, 2013).
A more recent study on junior high school students, the Norwegian Arctic Adolescent Health Study (NAAHS) showed a higher rate of suicide attempts and adverse life events in the Sami group compared to non-Sami peers (Reigstad & Kvernmo, 2017). In a comparison study between Sami and Greenlandic adolescents, Sami students rated their health considerably better than Greenlandic counterparts (89% versus 62%, respectively). In both ethnic groups, suicidal thoughts (risk) and physical activity (protective) were associated with poor and good self-rated health, respectively (Spein et al., 2013).
In spite of no or small ethnic group differences in mental health outcomes between Sami and non-Sami youngsters, research thus far has revealed significant variation within the Sami group. Culture-specific factors can partly explain this variation. The most prominent determinants will be presented in the following sub-sections.
Ethnic context and minority positions
Sami adolescents grow up and live in different ethnic contexts. Ethnic contexts are often categorized according to the density of Sami inhabitants (Kvernmo & Heyerdahl, 1996). The Norwegian dominated context is characterized by a low density of Sami members (<25%); the coastal context by a medium density of Sami (25%–60%); and the Sami dominated context by a high density (>60%) of Sami. Although the context categories are mainly based on density of Sami members and cultural features, such as different levels of forced assimilation, language, loss of ethnic identity and stigmatization, they are also characterized by revival of the Sami culture.
Sami-dominated contexts provide stronger ethnic support, cultural practice in daily life, and cultural safety than majority mixed and Norwegian dominated contexts, which often expose the Indigenous youngsters to prejudice and racism. Sami-dominated contexts are found to promote stronger ethnic or Indigenous identity, ethnic pride and practice, as well as better mental health. In contrast, Sami adolescents living in a distinct minority position in Norwegian dominated context seem to struggle with more internalizing, as well as externalizing (conduct and delinquent behavior) and attention problems than peers in majority Indigenous positions (Kvernmo & Heyerdahl, 1998, 2003). The ethnic context is therefore of importance for Sami children’s and adolescents’ mental health.
Acculturation attitudes refer to the cultural and psychological changes, i.e. attitudes or behaviors, that occur as a result of continuous contact between people of different ethnic or cultural origin. The strategies the individual use in this process are mainly defined as four types: assimilation, integration, separation, or marginalization. The different strategies are associated with different mental health outcomes (Berry 1990; Berry & Sam, 1997). In the Young in North Study, separation attitudes, i.e. withdrawal into the original cultural group, was a risk factor and predicted internalizing problems in females. Among males, integration attitudes acted as a protective factor for externalizing, as well as social problems, while marginalization (not connected to any cultural group) was associated with mainly internalizing problems (Kvernmo & Heyerdahl, 2003). It must, however, be mentioned that the empirical basis for the four acculturation strategies have been questioned (Rudmin & Ahmadzadeh, 2001). Lacking evidence for the existence of the four ways of acculturating and the benefit of integration have been claimed by Rudmin (2001). However, in a study by Berry, Phinney, Sam, and Vedder (2006), more than 5000 immigrant youth from 13 countries which assessed among other concepts attitudes toward the four types of acculturation, supported the acculturation model.
Ethnic identity can be defined as the sense of belonging to one’s ethnic group of origin and is a developmental process mainly taking place in adolescence as a part of the identity formation in general (Phinney, 1990). It is a salient issue in identity development for ethnic minority adolescents, Indigenous adolescents included. Ethnic identity is supposed to develop from a diffused/foreclosed stage, through exploration to achievement. In general, a strong and achieved Indigenous or ethnic identity is associated with good mental health in minority adolescents. Surprisingly, earlier studies among Sami adolescents revealed that amongst high school students, ethnic identity was a predictor of more mental health problems, but mainly in males (Kvernmo & Heyerdahl, 2004). On the other hand, ethnic identity was found to protect against substance use (Bals, Turi, Skre, & Kvernmo, 2010) .
When examining the different concepts of ethnic identity in young Sami adolescents, the Norwegian Arctic Adolescent Health Study (NAAHS) more recently found that ethnic exploration protects against both internalizing and externalizing problems, while ethnic identity achievement acted the opposite way, particularly for those living in a Norwegian dominated area. Sami adolescents with a strong ethnic identity are possibly those individuals who expose themselves most as Sami and fight for their culture and people. This hypothesis was supported by the finding in the same study that ethnic discrimination was closely connected to externalizing problems (Bals, Turi, Skre & Kvernmo, 2010).
An interesting finding from the same study was the protective role of having a strong sense of national or Norwegian belonging. Youngsters who strongly identified as Norwegian had less anxiety and depression, which possibly expressed their bicultural competence and the advantage of this competence. Overall, the NAAHS study confirmed that externalizing problems in young junior high school students were more vulnerable to cultural determinants than internalizing problems were. In Canadian Indigenous adolescents, ethnic identification is found to fluctuate over time, but also to influence their psychosocial function. Students who consistently defined as Indigenous over time had the highest drop-out rate from school. In contrary, peers that, at first, did not declare Indigenous belonging, but later did, were more likely to complete school (Hallett et al., 2008).
Studies have shown that Sami adults and adolescents, similar to other ethnic minorities and Indigenous group, still have to deal with ethnic discrimination and racism, and the health outcomes of this adversity (Bals et al., 2010; Hansen, 2015). When ethnic context, socioeconomic status, and other cultural determinants controlled for, ethnic discrimination seem to contribute most to mental health problems in Sami adolescents.
Overall, Indigenous Sami adolescents are in good mental health. In contrast to other Indigenous peers, they are not in a worse position than their non-Indigenous counterparts. However, the variation in mental health within the Sami group highlights the need of a further attention on cultural determinants to be considered. The impact of cultural factors, such as Indigenous identity, cultural activities, and Indigenous language competence on Indigenous children’s health is sparsely studied. The concept of ethnic identity and ethnic discrimination are particularly relevant cultural determinants which should be included in studies of mental health in Indigenous youngsters.
Canino, I.A., & Spurlock, J. (2000). Culturally Diverse Children and Adolescents
Assessment, Diagnosis, and Treatment. New York: The Guilford Press.
Kvernmo, S. Mental health of Sami youth. Int J Circumpolar Health. 2004 Sep, 63(3):221-34.
Bals, M., Turi, A. L., Skre, I., & Kvernmo, S. (2010). Internalization symptoms, perceived discrimination, and ethnic identity in Indigenous Sami and non-Sami youth in Arctic Norway. Ethnicity & Health, 15(2), 165-179. https://doi.org/10.1080/13557851003615545
Bals, M., Turi, A. L., Vittersø, J., Skre, I., & Kvernmo, S. (2011). Self-reported internalization symptoms and family factors in Indigenous Sami and non-Sami adolescents in North Norway. Journal of Adolescence, 34(4), 759–766. https://doi.org/10.1016/j.adolescence.2010.08.005
Berry, J. W. (1997). Immigration, acculturation and adaptation. Applied Psychology, 46, pp. 5-68.
Berry, J.W., Phinney, J.S., Sam,D.L., & Vedder, P. (2006). Immigrant youth in cultural transition. Lawrence Erlbaum Associates. Mahwah, NJ.
Berry, J.W., & Sam, D.L. (1997). Acculturation and adaptation. In
Berry, J.W., Segall, M.H.,& Kagitcibasi, C.(Eds.). Handbook of cross-cultural psychology, Vol. 3, Social behavior and applications. Boston: Allyn and Bacon pp. 291-326
Eckhoff, C., & Kvernmo, S. (2014). Musculoskeletal pain in Arctic Indigenous and non-Indigenous adolescents, prevalence and associations with psychosocial factors: A population-based study. BMC Public Health, 14(1), 1-10. https://doi.org/10.1186/1471-2458-14-617.
Hallett, D., Want, S. C., Chandler, M. J., Koopman, L. L., Flores, J. P., & Gehrke, E. C. (2008). Identity in flux: Ethnic self-identification, and school attrition in Canadian Aboriginal youth. Journal of Applied Developmental Psychology, 29(1), 62–75. https://doi.org/10.1016/j.appdev.2007.10.008
Hansen, K. L. (2015). Ethnic discrimination and health: the relationship between experienced ethnic discrimination and multiple health domains in Norway’s rural Sami population. International Journal of Circumpolar Health, 74, 25125. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25683064
Heyerdahl, S., Kvernmo, S., & Wichstrøm, L. (2004). Self-reported behavioural/emotional problems in Norwegian adolescents from multiethnic areas. European Child and Adolescent Psychiatry, 13(2), 64-72. https://doi.org/10.1007/s00787-004-0359-1
Kvernmo, S., & Heyerdahl, S. (1998). Influence of ethnic factors on behavior problems in Indigenous Sami and majority Norwegian adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 743–751. https://doi.org/10.1097/00004583-199807000-00014
Kvernmo, S., & Heyerdahl, S. (2003). Acculturation strategies and ethnic identity as predictors of behavior problems in arctic minority adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 42(1), 57-65. https://doi.org/10.1097/00004583-200301000-00011
Kvernmo, S., & Heyerdahl, S. (2004). Ethnic identity and acculturation attitudes among Indigenous Norwegian Sami and ethnocultural Kven adolescents. Journal of Adolescent Research, 19(5), 512-532. https://doi.org/10.1177/0743558403259991
Omma, L., Jacobsson, L. H., & Petersen, S. (2012). The health of young Swedish Sami with special reference to mental health. International Journal of Circumpolar Health, 71, 18381. https://doi.org/10.3402/ijch.v71i0.18381
Omma, L., Sandlund, M., & Jacobsson, L. (2013). Suicidal expressions in young Swedish Sami, a cross-sectional study. International Journal of Circumpolar Health, 72, 19862. https://doi.org/10.3402/ijch.v72i0.19862
Phinney, J. S. (1990). Ethnic identity in adolescents and adults: A review of research. Psychological Bulletin, 108, 499-514.
Reigstad, B., & Kvernmo, S. (2017). Concurrent adversities and suicide attempts among Sami and non-Sami adolescents: the Norwegian Arctic Adolescent Study (NAAHS). Nordic Journal of Psychiatry, 71(6). https://doi.org/10.1080/08039488.2017.1315175
Rudmin, F.W., & Ahmadzadeh, V. (2001). Psychometric critique of acculturation psychology: The case of Iranian migrants in Norway. Scandinavian Journal of Psychology, 42, 41-56.
Silviken, A., & Kvernmo, S. (2007). Suicide attempts among Indigenous Sami adolescents and majority peers in Arctic Norway: Prevalence and associated risk factors. Journal of Adolescence, 30(4), 613-626. https://doi.org/10.1016/j.adolescence.2006.06.004
Spein, A. R., Pedersen, C. P., Silviken, A. C., Melhus, M., Kvernmo, S. E., & Bjerregaard, P. (2013). Self-rated health among Greenlandic Inuit and Norwegian Sami adolescents: Associated risk and protective correlates. International Journal of Circumpolar Health, 72(1), 19793. https://doi.org/10.3402/ijch.v72i0.19793
Spein, A. R., Sexton, H., & Kvernmo, S. (2007). Substance use in young Indigenous Sami: an ethnocultural and longitudinal perspective. Substance Use & Misuse, 42, 1379–1400. https://doi.org/10.1080/10826080701211693
Young, C., Hanson, C., Craig, J. C., Clapham, K., & Williamson, A. (2017). Psychosocial factors associated with the mental health of Indigenous children living in high income countries: a systematic review. International Journal for Equity in Health, 16, 153. https://doi.org/10.1186/s12939-017-0652-5