Emerging Priorities for the Health of First Nations and Inuit Children and Youth

November 30, 1999

The views expressed in this paper are those of the authors and do not necessarily reflect those of the First Nations and Inuit Health Branch.

Table of Contents

• Executive Summary
• Introduction
  • Background
  • Purpose and objectives
  • Methodology
• Diagnostique
  • First Nations children and youth
  • Inuit children and youth
• Literature Review and Analysis
  • Literature on First Nations children and youth
  • Literature on Inuit children and youth
• Conclusion: Opportunities for Action
  • Gaps in Literature
  • Towards a framework for action
  • Early childhood development
  • Providing early and continuous learning experiences
  • Fostering strong development in the pre-teen years
  • Creating supportive, safe and violence-free communities
• Works Cited
• Appendix

Executive Summary

Background

In partnership with First Nations and Inuit organizations, Health Canada's First Nations and Inuit Health Branch is currently engaged in the task of identifying strategic opportunities to contribute to the improvement of the health and well-being of First Nations and Inuit children and youth. This paper seeks to contribute to these deliberations in three principal ways:

• By outlining key health issues and concerns pertaining to First Nations and Inuit children and youth.
• By reviewing, synthesizing and analyzing relevant documents and recommendations that have been produced in recent years by federal, provincial and territorial governments, First Nations and Inuit organizations, and NGOs.
• By identifying current and emerging opportunities for action that will serve to enhance the health and well-being of First Nations and Inuit children and youth.

Summary of findings and recommendations

Two principal policy tracks for addressing critical health issues and concerns emerge. The first identifies the underlying conditions needed for healthy child and youth development in First Nations and Inuit communities: resiliency, wellness, early child development, the evolving capacity of children and youth, and community mobilization. The second policy track identifies specific issues that are currently most in need of attention by decision-makers, community members and individuals, including Syndrome d'alcoolisme foetal (FAS)/E, Sudden Infant Death Syndrome (SIDS), injury prevention, special needs children, and positive mental health. Concrete action to address these concerns is vital if First Nations and Inuit children are to grow up to become healthy, productive members of society. Four priority areas include early childhood development, providing early and continuous learning experiences, creating supportive, safe and violence-free communities and fostering strong development in the pre-teen years.

Early childhood development

Child health experts agree that the first six years of life is a crucial stage in personal development. More than one third of First Nations and Inuit people are 14 years of age or younger. Interventions are likely to have a powerful, long-lasting effect when focused on this segment of the population. First Nations and Inuit children are considerably less healthy than their non-Aboriginal counterparts. For example, both populations are characterized by high levels of FAS/FAE, SIDS, poor nutrition and healthy birth-weights. First Nations and Inuit communities also face problems like environmental contaminants and the unavailability of high quality, community-controlled child care services.

1. In partnership with First Nations, Inuit and other stakeholders, develop a national strategy on community-based FAS/FAE prevention, awareness and surveillance programming.
2. Expand the Aboriginal Head Start Program which focuses on nutrition, education, social supports, health promotion, parental involvement and culture/language.
3. Support the development and/or expansion of a comprehensive system of child- and family-focused services for First Nations and Inuit, encompassing early child development, supports to parents and families, and safe, supportive communities.
4. Support the development of a SIDS awareness campaign directed towards expectant and new First Nations mothers.

Providing early and continuous learning experiences

According to the Royal Commission on Aboriginal Peoples (Canada 1996a), many Aboriginal people see education as a means of acquiring marketable knowledge and skills, and as a way of learning about their history and traditions. It has been frequently noted that traditional language and culture training can play an important role in empowering First Nations and Inuit youth, enhancing their self-esteem and engaging them in positive lifestyle choices. The lack of special needs programs for First Nations and Inuit youth with developmental or physical disabilities and the difficulties young Inuit and First Nations people living in remote areas face when wishing to pursue a formal education beyond the secondary level, suggest the need increased commitment to ensuring all First Nations and Inuit have appropriate early and continuous learning opportunities.

1. In partnership with First Nations, Inuit, provinces and territories, work to expand and retain Aboriginal language and culture programs within primary and secondary schools through and through existing community-based programs.
2. Support the development of initiatives to facilitate the early detection of learning disabilities by providing appropriate training to educators and day care personnel.

Creating supportive, safe and violence-free communities

In many cases, the quality of life available to First Nations and Inuit children and youth living on-reserve or in Northern communities is undermined by sub-standard housing conditions, homelessness and a lack of healthy recreational or fitness opportunities. Supporting the development of a wide range of recreational and fitness programming in communities would promote child and youth wellness. Community environments that are marked by violence, lack of parenting skills and young people's alienation increase chances of injury-related morbidity and mortality. Among First Nations and Inuit children and youth living in remote Northern communities in particular, there is evidence to suggest that food insecurity is a serious issue, especially for expectant mothers and families with young children.

1. Promote child and youth wellness by supporting the development of a wide range of recreational and fitness programming in First Nations and Inuit communities.
2. Support the development of disability and injury prevention and awareness programs in First Nations and Inuit communities, with an emphasis on the identification and replication of best practices in recreation and fitness programs.

Fostering strong development in the pre-teen years

First Nations and Inuit in their pre-teen and teenage years experience many health and social problems, like high suicide rates, STDs and early pregnancies, signaling their mental health status and their attitudes towards sexuality and reproduction. These are routed in complex socio-economic conditions.

1. Support the creation of strong inter-generational relationships between young people and Elders e.g., supported through wilderness camps, mentoring and other related activities.
2. Address high-risk behaviours associated with poor self-esteem, poor infrastructure and community supports e.g. high teen pregnancies, high levels of substance use.
3. Support the development of peer counseling and intervention initiatives in First Nations communities experiencing high rates of youth suicide.
4. Adopt proactive measures towards health promotion e.g., integration of positive role models, promote employment and recreation opportunities for youth, engage young people with health promotion messages through health and sexual education, schools etc.
5. Expand reproductive and maternal health services, to ensure that young First Nations and Inuit women living in remote communities have access to basic counseling, screening and assessment facilities.

Introduction

Background

Federal, provincial and territorial governments (with the exception of Quebec) jointly agreed in May 1999 to develop and implement a National Children's Agenda (NCA). Through its emphasis on cooperative approaches and community involvement in addressing children's needs, the NCA is founded on such principles as good health, safety and security, success at learning and social responsibility. Working in partnership with First Nations and Inuit organizations, the execution of the Agenda involves the elaboration of an integrated, comprehensive system of health and social services that supports parents and children through pregnancy, birth and child rearing.

The governments' demonstrated commitment to the cause of children's rights suggests that some populations have been less well-served than others. First Nations and Inuit children are a case in point. Not only do they suffer from significantly higher rates of morbidity and mortality than other Canadian children, but poverty is endemic in many First Nations and Inuit communities, resulting in a sub-standard quality of life and widespread alienation (Canadian Institute of Child Health 1994; First Nations and Inuit Regional Health Survey National Steering Committee 1999). This adds challenges for Canada to meet all of the year 2000 targets to which it agreed at the 1990 World Summit for Children, including its commitments to reduce infant mortality by one third and to provide enhanced protection to children in difficult circumstances. Thus, if First Nations children's health status is to be significantly enhanced, the Canadian Institute on Child Health (1994), among others, has emphasized the importance of allocating sufficient resources to develop an integrated, comprehensive system of health and social services for children and their families, whether on- or off-reserve (National Strategy on Healthy Child Development Advisory Committee on Population Working Group 1999).

Purpose and objectives

Under the terms of the Constitution Act of 1982, First Nations and Inuit peoples enjoy a special relationship with the Government of Canada (GOC). It is on account of this relationship that Health Canada, through its First Nations and Inuit Health Branch (FNIHB), has responsibility for addressing the health needs and concerns of status Indians and Inuit. Given this mandate, along with the particularly serious nature of the health issues facing First Nations and Inuit children in Canada, FNIHB is currently engaged in the task of identifying strategic opportunities to contribute to the improvement of the health and well-being of First Nations and Inuit children and youth⁽¹⁾.

This discussion paper hopes to contribute to these deliberations in three principal ways:

• By providing an overview of key health issues and concerns as they pertain to First Nations and Inuit children and youth⁽²⁾.
• By reviewing, synthesizing and analyzing relevant documents and recommendations that have been produced in recent years by federal, provincial and territorial governments, First Nations and Inuit organizations, and NGOs.
• By identifying current and emerging opportunities for action that will serve to enhance the health and well-being of First Nations and Inuit children and youth.

Please note that while the age range for 'early childhood' is normally considered to be 0-6, in many studies this population is subsumed under the larger 0-14 age category. It is for this reason that some of statistical data presented in this paper encompass all children aged 14 years or younger.

Methodology

This project involved a number of information-gathering activities. These are summarized below:

• Key informant interviews were conducted with senior managers at the Assembly of First Nations (AFN), Inuit Tapiriit Kanatami (ITK) and Pauktuutit Inuit Women's Association, which provided much of the literature for this project.
• A key word search was undertaken of major CD-ROM databases (including SOCIOFILE and Social Work Abstracts) and the library catalogues of Carleton University and University of Ottawa.
• The library holdings of Health Canada, Indian and Northern Affairs Canada (INAC), AFN, ITK and Pauktuutit Inuit Women's Association were reviewed.

While severe project time lines limited the search to the most directly relevant work on the health and well-being of Inuit and status Indian children and youth, every effort was made to adopt a balanced approach reflective of the key priorities and concerns of the two peoples concerned.

Diagnostique

First Nations children

As the Royal Commission on Aboriginal Peoples (RCAP) report makes clear, Canada's Aboriginal population is young, with well over half (56.2 percent) under the age of 25 (Canada 1996a). Among First Nations in particular, this relative youthfulness is reflected both in the high birth rate, which is roughly double that of the Canadian average, and in the fact that roughly 281,000 people, or 35 percent of the total Indian population, falls into the 0-14 age category (see Appendix for a breakdown of the population by age) (Canadian Institute of Child Health 1994; Young 1994). Meanwhile, among non-Aboriginal Canadians, only 21 percent of the population is 14 years of age or younger (Ibid).

The Canadian Institute on Child Health has argued that these children are "among the most disadvantaged of all Canadians" (1994, p.131). Nine percent of their mothers are under 18 years of age (compared to one percent for Canadian mothers in general), and there are nearly twice as many families on-reserve led by a single parent (24 percent) than is the case elsewhere in Canada (where the rate is 13 percent) (Ibid; Joint First Nations/Inuit/Federal Child Care Working Group nd).

In this regard, lone and teenage parent families tend to experience high rates of poverty and marginalization. This is particularly true in the case of First Nations families, of whom a significant majority are deemed to be at or below the poverty line, as well as residing in housing that fails to meet basic standards set by the Canadian Mortgage and Housing Corporation (Assembly of First Nations 1998a).

Continuing evidence of racism and institutionalized discrimination against Aboriginal peoples in Canada (Canada 1996b) spills over to First Nations children and youth, who end up experiencing significant difficulties at home and at school. Not only are Indian children being taken into foster care at well over four times the rate of non-Aboriginal children (Assembly of First Nations 1994), but an alarmingly high proportion of First Nations youth (64 percent) never complete high school. By contrast, only 31 percent of non-Aboriginal Canadians fail to obtain a secondary school diploma (Frideres and Reeves 1993).

Meanwhile, the infant mortality rate for First Nations babies is roughly twice the Canadian average (Indian and Northern Affairs Canada 1996c), and levels of morbidity and mortality among Indian children and youth remain high throughout their first 18 years of life. Contributing factors include an injury rate three times the national average (Young 1994); elevated levels of respiratory and infectious diseases in many First Nations communities (First Nations and Inuit Regional Health Survey National Steering Committee 1999); along with rates of suicide, depression and childhood sexual or physical abuse that are deemed to be significantly higher than those of the non-Aboriginal population (Canada 1995; Research from the Centre for Studies of Children at Risk 1998). Finally, First Nations youth are at elevated risk of suffering from a physical, developmental or learning disability (Assembly of First Nations 1997), with one regional study going so far as to suggest that Foetal Alcohol Syndrome (FAS) and Foetal Alcohol Effects (FAE) are responsible for nearly 75 percent of these cases (Asante and Nelms-Matzke 1985).

Inuit children

While Canada's Inuit population is relatively small - only 37,800, according to the Royal Commission on Aboriginal Peoples (Canada 1996b) - it is currently undergoing rapid growth (see Appendix for a breakdown of the population by age category). This is a function both of the population's youthfulness (39 percent, or approximately19,000 people, were 14 years of age or younger in 1991), and of Inuit women's high fertility rate, which is more than double that of the general Canadian female population (Young 1994; Canada 1996c).

Like their First Nations counterparts, Inuit children and youth are more likely than their non-Aboriginal counterparts to grow up in a family headed by a teenager or lone parent. In Nunavik, for example, nearly one quarter of households are led by a single parent (Santé Quebec 1994). Given the close correlation between lone parenting and economic distress, many expectant Inuit mothers do not have a sufficient energy intake, and problems associated with iron and Vitamin D deficiency are thought to be widespread among Inuit infants (Moffatt 1991).

Food security is also a problem in Canada's North, with 12.7 percent of Inuit people over the age 15 reporting food availability problems in the past 12 months, compared to 7.5 percent among Canadians in general (Canadian Institute on Child Health 1994). Of concern as well is the contamination of 'country foods' with toxic substances such as heavy metals and organochlorines (Usher et al. 1995). While the precise health effects of these substances remain a matter of considerable debate, it is well established that foetuses and young children are especially vulnerable (Raphael 1999).

Inuit children's health is also being placed in jeopardy by crowded or inadequate housing conditions. Such conditions appear to have contributed to an unusually high incidence of respiratory and digestive diseases among Inuit children living in Northern communities (Pauktuutit 1995a; Moffatt et al. 1992). These problems are also exacerbated by widespread tobacco use among the Inuit. As one study has put it, "[Inuit] children start smoking as early as five years old and by the time they are teenagers 69 percent are smoking regularly" (Pauktuutit 1995b, p.1).

Alienation, depression and childhood sexual or physical abuse have also been identified as serious problems in Inuit communities, with as many as 35 percent of Inuit teenagers who reside in Keewatin, North West Territories (NWT) reporting that they feel 'unhappy and depressed' (Moffatt et al. 1992). Such feelings contribute to the low secondary school graduation rates of Inuit youth in NWT (Northwest Territories Health 1991), and are also likely to have a bearing on the exceedingly high Inuit suicide rate. According to Claudia Brann (1996), the rate of suicide among Inuit men aged 16 to 30 is roughly ten times that of non-Aboriginal men in the same age category.

However, suicide is not the only factor contributing to high mortality among Inuit children and youth. As in First Nations communities, infant mortality rates are twice to three times the national average, and injuries are extremely common, constituting the leading cause of death in every childhood age category outside of infancy (Young 1994; Moffatt 1991). Inuit children have also been found to suffer elevated levels of tooth decay, ear infections (often resulting in hearing loss) and diseases of the respiratory, digestive and nervous systems (Ibid; Pauktuutit 1995; Tremblay 1991; Houde et al. 1991). Finally, substance abuse remains widespread in many Inuit communities, and as such is implicated in a range of health and social problems, including family violence and FAS-related disability (Pauktuutit 1998).

Discussion

First Nations and Inuit children and youth are faced with many of the same challenges in their day-to-day lives. However, these commonalities cannot justify a homogenous view of these two populations and the issues they face. For instance, many key Inuit concerns are grounded in the realities of the harsh Northern environment. While this is not to suggest that Native peoples living in remote communities do not face similar challenges, policy makers must not assume that one solution is applicable to both populations.

Dion Stout and Kipling (1998) have noted a longstanding tendency to pathologize Aboriginal peoples' problems, at the cost of losing sight of the complexities at work, along with the concrete steps being taken by communities themselves to affect positive, long-lasting change. Therefore, it is important to identify and celebrate best practices that highlight the resiliency and coping skills of Aboriginal peoples, especially children and youth.

Literature Review and Analysis

Literature on First Nations children and youth

Although federal, provincial and territorial governments, along with First Nations themselves, deliver a wide array of programs targeting Indian children and youth, significant gaps remain. While some of the latter are the product of jurisdictional disputes between GOC and the provinces (as in the case of child care services on-reserve), others are related to the distinction made between those who reside on- and off-reserve, and those whom the Indian Act classifies as 'status' and 'non-status' Indians.

In general, the federal government has taken the position that its chief responsibility is for status Indians living on-reserve. However, many of the neediest First Nations children and youth live in large urban centres, and as such are often left without access to the culturally appropriate health and social services available to their counterparts on-reserve. While it is beyond the scope of this paper to address the needs of this latter population in depth, relevant issues and interventions will be highlighted in the discussion below, as appropriate.

Supporting parents and strengthening families

Healthy childhood development is to a significant degree dependent upon the health and lifestyle choices of the mother while pregnant. Substance abuse is a case in point. Despite continuing uncertainty as to the precise number of First Nations children affected by FAS and FAE, it is believed to be a serious problem within this population, leading many to argue that more needs to done to support women in making the decision not to drink or to take drugs while pregnant or breast feeding.

However, as Marion Mussell emphasized in her presentation at a recent AFN health conference (Assembly of First Nations 1997), interventions should not make women feel guilty for drinking. Rather, "FAS prevention must be connected to understanding .. why people drink and the abuses suffered in our communities" (Ibid, p.48). To minimize the number of future cases, warning labels on bottles have repeatedly been called for (Canada nd), along with the development of a national strategy on FAS that encompasses prevention, education, assessment and support (Assembly of First Nations 1997; First Nations Health Secretariat 1997; Canadian Council on Social Development 1998). The development of innovative treatment options for pregnant First Nations women who are alcohol or substance abusers (Namyniuk et al. 1997), and the use of pre-natal nutrition programs as a vehicle for the discussion and promotion of good lifestyle choices (Robinson et al. 1985) are seen as two workable strategies.

Meanwhile, at a recent roundtable meeting on diabetes hosted by the National Association of Friendship Centres, the high rate of gestational diabetes among Native women prompted the participants to call for enhanced screening and education programs for First Nations children, youth and women of child-bearing age (Dion Stout and Kipling 1999a). Evidence also suggests that First Nations women are breast feeding at a considerably lower rate than their non-Aboriginal counterparts (Blythe 1995; First Nations and Inuit Regional Health Survey National Steering Committee 1999). Despite the relative success of breast feeding promotion programs, scholars like Moffatt (1991), have argued that they have now reached the point of diminishing returns, and thus that "we should begin to focus scarce .. resources on other problem areas in infant nutrition" (p.555). In contrast, moving beyond individual counseling towards measures that help to create a supportive community environment for breast feeding mothers, presents a solution of a different kind (Macaulay et al. 1991).

Broad-based community and government support is also essential if First Nations parents are to have access to high-quality, culturally-appropriate child care. However, as the Joint First Nations/Inuit/Federal Child Care Working Group (nd) has argued, "quality child care services do not currently exist on most First Nations reserves" (p.4) despite the youthfulness of the population, and the high proportion of single and unemployed parents (Ibid). For this reason, the Assembly of First Nations (1989; 1993; 1994), the Royal Commission on Aboriginal Peoples (1996a) and the National Council of Welfare (1999), have all called for the immediate funding of community-controlled Native child care programs across the country. While it is expected that such an intervention would help to promote capacity building and economic development in reserve communities (Little and Prince 1993), it would also provide a unique opportunity to contribute to First Nations' healing, through the design of programs grounded in Native values, traditions and languages (McCallum 1997; Assembly of First Nations 1989; Joint First Nations/Inuit/Federal Child Care Working Group nd).

Closely related to the question of Native child care is the adoption and fostering of First Nations children⁽³⁾. Many First Nations children are placed with non-Aboriginal parents, thereby exacerbating the fragmentation of Native families while providing the children themselves with few opportunities to be exposed to their ancestral languages and traditions. First Nations have called repeatedly for policies that facilitate the placement of children within the extended family or, failing this, within environments where provisions are actively made to help them understand their cultural heritage (Assembly of First Nations 1989, 1993; Yellowhead Tribal Services Agency 1997).

Enhancing early childhood development⁽⁴⁾

In a recent report, the Working Group on the National Strategy on Healthy Child Development (1998) argues that, "[t]here is a strong body of evidence indicating that healthy child development is fundamental to the well-being of society" (p.1). In this context, the first six years of life is a period when children develop the coping skills and resistance to health problems that are essential if they are to live long, healthy and productive lives (Ibid). As was highlighted in the previous section of this paper, First Nations children are characterized by elevated levels of morbidity, mortality and family dysfunction, which serve to erect barriers that many of these children will spend the rest of their lives attempting to overcome.

If First Nations children's health status is to be significantly enhanced, the Canadian Institute on Child Health (1994), among others, has emphasized the importance of allocating sufficient resources to develop an integrated, comprehensive system of health and social services for children and their families, whether on- or off-reserve (National Strategy on Healthy Child Development Advisory Committee on Population Working Group 1999). On the one hand, this would involve the further development, through programs like Aboriginal Head Start, of a service network that supports parents through pregnancy, birth and child rearing, and provides First Nations children with screening, risk assessment and referral (Ibid, pp.6-9). On the other, it would encompass efforts currently underway to incorporate traditional Aboriginal medicine into the primary health care system (Assembly of First Nations 1993, 1994; Aboriginal Nurses Association of Canada 1993). While there is already significant common ground between the two approaches (eg: emphasis on health promotion, personal responsibility), the integration of traditional practitioners into the established system would serve to validate the latter's expertise while providing families with ready access to a range of holistic health and social services, from midwifery to nutrition counseling (Ibid).

There is also a need to put into place professional development and training programs to prepare First Nations individuals for careers in pediatrics, social work and early childhood education (Assembly of First Nations 1997; National Strategy on Healthy Child Development Advisory Committee on Population Working Group 1999). In addition, non-Aboriginal health providers need to be sensitized to First Nations realities and traditions, and they should be encouraged to relocate to remote communities where health services for children are lacking (Assembly of First Nations 1993). Also relevant in this regard are calls for the training of practitioners in the area of FAS/FAE assessment and diagnosis, since this continues to be an area where professional awareness is at a sub-optimal level (Assembly of First Nations 1997; Blythe 1995; Cook et al..

Meanwhile, sudden infant death syndrome (SIDS) has emerged as an area of serious concern for researchers and policy makers, particularly in the wake of the publication of a recent study showing that Aboriginal infants in Alberta are ten times more likely to die as a result of SIDS than their non-Aboriginal counterparts (Assembly of First Nations 1999). This finding serves to validate previous work undertaken in this field, such as a study by the British Columbia Ministry of Health suggesting that status Indian infants are at an increased risk of being stricken with SIDS (MacMillan 1996; British Columbia 1997). Although its causes are not well understood, risk factors for SIDS include poor economic and health conditions; lack of breastfeeding; and exposure to high levels of cigarette smoke (Ibid; Assembly of First Nations 1999).

Attention must also be focused on questions related to the oral health of First Nations children. With regional studies showing rates of tooth decay at least four times that of non-Aboriginal children (Manitoba Health 1995), this issue is garnering increased attention within the Aboriginal health community. While the poor state of Native children's teeth is believed to be the result of poor dietary and feeding practices, treatment is almost always expensive and traumatic, since it typically involves evacuation to a southern hospital and surgery under general anesthetic (National Indian and Inuit Community Health Representatives Organization and Health Canada 1998). Among the measures proposed to counteract this problem are the promotion of dental health careers for Aboriginal youth, fluoridation of First Nations communities' water supply and the development of community-based awareness and prevention programs (Moffatt 1991; Blythe 1995).

Improving economic security for families

Since nearly one quarter of all Native families on-reserve are led by a single parent (the proportion rises to 30 percent off-reserve), many First Nations children live in poverty, a condition that correlates closely with negative health outcomes (Canadian Public Health Association 1997). Many factors are at work in perpetuating lone mothers' economic marginalization, including lack of employment opportunities, marketable skills, affordable day care and sexism. On the one hand, it is the latter that makes Native women far more likely than their male counterparts to report an annual income of less than $10,000 (Canada 1996c). On the other hand, women often encounter difficulties when attempting to obtain child support from fathers, with some First Nations going so far as to refuse to cooperate in the enforcement of such payments (Ibid 1996a).

One initiative that has received much attention of late is the National Child Benefit (NCB), jointly launched by the federal, provincial and territorial governments in June 1998 (Canadian Council on Social Development 1998). It is a means of reducing child poverty while promoting attachment to the waged labour force⁽⁵⁾. Aboriginal leaders have criticized participating governments for failing to enter into a meaningful consultation with First Nations during the NCB's design phase. This suggests that the initiative, as currently formulated, risks further alienating First Nations rather than helping them to address child poverty in their communities, not least because beneficiaries are forced to apply for a credit through the income tax system, which many Native people see as an infringement upon First Nations' sovereignty (Assembly of First Nations 1998b; Organizational Development Services 1998). Native leaders have also called for complete community control over the disbursement of reinvested funds, so as to ensure that they are used to support programs which are consistent with First Nations' holistic perspective and cultural values (Ibid). Of course, also relevant in this regard is the question - currently being raised in some quarters - of whether or not resources allocated to First Nations children and youth are actually reaching those in need.

Providing early and continuous learning experiences

As the Report of the Royal Commission on Aboriginal Peoples states, young people feel that education should serve two principal ends: "to build and enhance their understanding of themselves as Aboriginal people; and to prepare them for life in the modern world" (Canada 1996a, p.161). This encapsulates the range of expectations held by First Nations communities with respect to the role of education in their lives.

The importance of teaching Native children Aboriginal languages and traditions from a very early age has been stressed repeatedly (Assembly of First Nations 1994; Joint First Nations/Inuit/Federal Child Care Working Group nd). Substantial returns are possible should governments decide to expand investment in Aboriginal language programs, and to support the development of comprehensive Aboriginal curricula from kindergarten to grade 12, or even schools set up by and for Aboriginal people (Canada 1996a; Fleras 1993; Frideres and Reeves 1993). By empowering First Nations children and youth through such vehicles as ancestral language training and the instillation of pride in their culture and traditions, improved outcomes are likely on a number of fronts, ranging from personal health to economic productivity (Canada 1996a).

Since the educational system can play a useful health promotion role in First Nations communities, teaching materials need to be developed and incorporated into existing curricula in such areas as HIV/AIDS education, addictions and FAS prevention (Robinson et al. 1985; Assembly of First Nations 1997; First Nations Health Commission 1995). Similarly, Native children with disabilities need expanded special needs programs within First Nations schools (Ibid; Assembly of First Nations 1997). Given the disproportionately large number of First Nations children suffering from a serious developmental or physical disability, such programs could be made part of a comprehensive FAS/FAE strategy encompassing prevention, diagnosis and counseling (First Nations Health Secretariat 1997; Asante and Nelms-Matzke 1985).

Fostering strong development in the pre-teen years

While there has been much focused attention on the needs of children in the 0-6 age category, recent years have seen a growing interest in the health of older First Nations children, who also experience much higher levels of morbidity and mortality than their non-Aboriginal counterparts. To a large extent, this interest stems from the realization that socio-economic marginalization, lack of positive role models and dysfunctional home environments experienced by many First Nations children places them at high risk of becoming caught in a cycle of self-destructive behaviour. Suicide figures prominently here, as experts and community members attempt to come to terms with the reasons underlying the alarmingly high rate of suicide deaths in many Native communities, and to propose workable, cost-effective solutions (Canada 1994, 1995; Innu Nation and Mushuau Innu Band Council 1992; Assembly of First Nations 1993, 1997). Although there is widespread agreement on many of the community characteristics associated with elevated suicide rate, including poverty, family dysfunction, crowded housing conditions, a relative absence of elders and disconnection from traditional languages and culture (Canada 1994), there exists a considerable range of opinion on how best to address this issue. Whereas the majority of RCAP commissioners endorsed a comprehensive strategy encompassing local prevention and crisis intervention services, community development to address the most pressing local causes of suicidal hopelessness, and the opportunity for Aboriginal peoples to achieve self-determination, a minority refused to abide by this position, arguing that public awareness initiatives may in fact encourage vulnerable individuals to attempt suicide (Canada 1995). However, be this as it may, at a recent national health conference, Bill Mussell of the Sal'i'shan Institute proposed a nuanced approach to suicide prevention, involving the implementation of comprehensive mental health programs, targeted community development and the fostering of inter-generational links between young people and elders (Assembly of First Nations 1997).

Substance abuse is an issue that is often considered in parallel with Native suicide, since individuals attempting to kill themselves are frequently under the influence of alcohol at the time (Canada 1994). Experts are for the most part agreed that the adoption of proactive measures is crucial if young people are to make healthy lifestyle choices and thereby avoid excessive drinking and drug use. To this end, it is important to address the lack of meaningful employment and recreation opportunities for First Nations youth (Canadian Public Health Association 1997; Kaweionnehta Human Resource Group 1994), while at the same time engaging young people with health promotion messages that are at once culturally appropriate and reflective of Native social realities (First Nations Health Commission 1995; Assembly of First Nations 1997).

A health promotion approach is equally applicable in a number of other areas of young people's lives, with healthy sexuality being an obvious example. Recognition that First Nations youth are at elevated risk of becoming pregnant at an early age or contracting a sexually transmitted disease (STD) has prompted many communities to enhance sex education programs and adopt harm reduction strategies (eg. by making condoms readily available to all those who might be sexually active) (Aboriginal Nurses Association of Canada 1996). However, there is clearly scope for further action in this area. Among the measures proposed at recent health conferences are the incorporation of a gender sensitization component within existing sex education programs for boys and male adolescents, and the implementation of a research program exploring Native peoples' attitudes towards sexuality and reproductive health (Dion Stout and Kipling 1999b; Assembly of First Nations 1997).

Creating supportive, safe and violence-free communities

Fitness and recreation activities can play a useful role in promoting a healthy lifestyle and enhancing self-esteem among First Nations youth. Given the elevated level of behavioral problems and anomie within this population, there is considerable support within the literature for making a broad-based investment in recreation programming (Canada 1996a). This is a particularly pressing need given that many First Nations children and youth are watching uncensored violence and pornography on the Internet, television and videos. In short, an investment in healthy recreational activities would help to enhance the health, well-being and fitness levels of Native children and youth, but it would also foster in the latter strong leadership, teamwork and interpersonal skills (Ibid).

Of course, healthy recreational activities can also play an important role in suicide prevention, which is critical given that many First Nations communities are characterized by exceedingly high rates of youth suicide. Acknowledging this fact, participants attending a recent First Nations youth mental health workshop in Vancouver argued that alienation and addictions are key factors leading young people to engage in suicidal behaviour (First Nations Youth Health Steering Committee 1999). This in turn prompted them to call for programs and activities that empower First Nations youth and re-connect them to their culture and traditions, for example by supporting the creation of youth activity groups and camps for young people and Elders (ibid.).

Injury prevention strategies are needed to address the extremely high rates of injury-related morbidity and mortality within First Nations communities. As Moffatt (1991) puts it, "prevention must involve all areas of the community and it must become part of the collective conscience. Child care, education, health and social service sectors must all make it a primary focus" (p.555). A number of areas require attention, ranging from the effects of gambling and bingo-playing on parents' attentiveness to the safety of their children, to the potential for injuries caused by the poor state of repair of houses and infrastructure in many reserve communities (Canadian Medical Association 1994). While Moffatt calls for a comprehensive, community-based approach in dealing with this problem, there is also a need for more rigorous standards, improved surveillance and partnerships designed to identify and publicize best practices in First Nations injury prevention (National Strategy on Healthy Child Development Advisory Committee on Population Working Group 1999).

Safety and security issues in Native communities include family violence and sexual abuse. Although First Nations communities are not alone in having to contend with this emotionally and physically devastating issue, colonialism, racism and the residential school system have left a particularly destructive legacy within Native families and communities (LaRocque 1994). In turn, this has resulted both in high levels of communal and family violence, and in what one Elder has described as 'deadly parenting' (Dion Stout and Kipling 1999b). This term is used to refer to parents who are so protective or defensive of their children that they will not allow anyone to criticize or discipline them, even when they are engaged in such dangerous behaviour that they are at risk of hurting or killing themselves.

In sum, First Nations children and youth are at heightened risk of being victimized in one of the ways described above, which is itself thought to be a key predisposing factor in subsequent involvement in a destructive relationship (Martens 1988; Rundle 1990). So many studies on the magnitude of violence in Aboriginal communities have been undertaken that Pasquali (1991), for one, believes that such work is no longer necessary: "further research would only serve to illustrate that the gap between available services and needed services is even greater than we believe it to be" (p.586). What is needed, according to family violence experts, is long-term evaluations of existing treatment programs; restoration of Aboriginal spiritual values; effective suicide prevention programming; access to parenting education; and provision of individual and group counseling to sexual offenders so as to re-order personal values and support emotional development (Pasquali 1991; Rogers 1988).

Literature on Inuit children and youth

Although Canada's Inuit population is relatively small, it enjoys a distinctiveness that is grounded in the climate and geography of the far North, and is reinforced by its unique historical relationship with the federal government. Therefore, policies and programs cannot be applied to the Inuit that have been developed with other Aboriginal peoples in mind (Canada 1996a).For the ITK and Pauktuutit, Inuit-specific programming is essential if there is to be significant positive change in the health status of Inuit children and youth, and inappropriate and misguided interventions are to avoided.

Supporting parents and strengthening families

It has been consistently shown that Inuit women tend to become pregnant at an earlier age and have larger families than either First Nations or non-Aboriginal women (Canada 1996c; Young 1994; Northwest Territories Health 1991; Santé Quebec 1994). Given the close relationship between teenage pregnancy, socio-economic marginalization and negative infant health outcomes, considerable policy attention has been focused on this issue. Of particular concern is the frequency with which very young teenagers (aged 12-15) are becoming pregnant (Okalik 1999; Santé Quebec 1994).

Many forces contribute to this situation, including social attitudes and a lack of healthy recreational opportunities. Therefore, interventions are necessary to address the generally low levels of birth control use in the North, with a particular focus on Inuit children and adolescents in the 7-12 and 13-15 age categories (Ibid; Paukuutit 1995a). Initiatives designed to improve parenting skills, especially in areas related to nutrition and smoking habits, are also required (Blythe 1995; Pauktuutit 1995a, 1995b, 1995c). Not only must these initiatives be tailored to local community contexts, but materials must be Inuit-oriented in their content and language (Ibid 1995a, 1995b).

The level of alcohol consumption by Inuit women while pregnant is also a matter of concern. Although reliable data are not available on the incidence of FAS/FAE within the Inuit population, it is believed to be a significant problem in the North, prompting Pauktuutit Inuit Women's Association to devote considerable attention to the issue in recent years (Pauktuutit 1995a, 1995d, 1998). Although there are a number of resources in Inuktitut which offer guidance and support to communities dealing with this problem, additional measures are being proposed, including the implementation of FAS/FAE awareness programs in all northern birthing centres, training of community members to act as prevention and education resources, and funding for research to ascertain the extent of the problem in northern communities (Paukuutit 1998).

There also continues to be a certain degree of friction between traditional approaches to birthing and child-rearing, and those of the dominant society. The evacuation of Inuit women to southern hospitals for the delivery of their babies illustrates this well. A significant proportion of Inuit women are dissatisfied with their current childbirth experiences, and many would prefer to give birth in their home communities (O'Neill et al. 1991; Linehan 1992; Lowell 1995).'Regional' birthing centres offer a compromise solution between the two extremes of evacuation and home community births, but the need to re-integrate traditional midwives into the birthing process in the North remains (Pauktuutit 1995; Linehan 1992; Lowell 1995), as does the practice of adoption in Inuit communities. As Santé Quebec's (1994) survey of the Inuit of Nunavik has found, nearly one quarter (23 percent) of the population aged 15 years or older has been adopted. Although the reasons for this practice are complex, Inuit observers are unsettled by the emergence of legal or bureaucratic barriers to customary adoption.

Enhancing early childhood development

The impact of environmental contaminants on human and ecosystem health is troubling for Inuit people (Canadian Polar Commission 1996; Canada 1996a). Since the early 1970s, the results of a number of highly publicized studies have circulated in the media showing elevated levels of methylmercury and organochlorines in wildlife and women's breast milk (Usher et al. 1995). While the human health effects of exposure to such substances remain unclear, in many cases Inuit people have taken it upon themselves to limit their consumption of country foods, believing that canned and other goods brought in from the South to be better for their health (Santé Quebec 1994). As Usher et al. (1995) have argued, this has resulted in a situation where potentially misleading information is causing individuals to adopt eating habits that may be less healthy than their traditional diet, while the underlying causes and dangers posed by contaminants remain unaddressed. A possible relationship between PCB exposure and learning disabilities and lower birth-weights in newborns (Canadian Polar Commission 1996) calls for "research on the links between contaminants and disease and developmental abnormalities in humans" (p.8).

The dangers posed by toxic substances in the North is by no means the only health issue with which Inuit children and their parents must contend. Sub-optimal nutrition places a substantial proportion of Inuit infants at risk of suffering from iron and Vitamin D deficiency (Moffatt 1991; Moffatt et al. 1992) and, as they progress through their childhood, of becoming obese (Canada 1992; First Nations and Inuit Regional Health Survey National Steering Committee 1999). Therefore, both parents and children need nutrition education and support programs, so that the latter might develop healthy eating habits from an early age.

Ear infections and tooth decay are two other key problems affecting Inuit children's health. Inuit dental caries rates are extremely high, even among children as young as two, and they result from such factors as poor oral hygiene, inappropriate infant feeding habits and a lack of access to professional care (Gagnon et al. 1991; Houde et al. 1991). Even though tooth decay among Inuit children is not a life-threatening condition in and of itself, it is expensive to treat, and may affect children's ability to eat and speak (National Indian and Inuit Community Health Representatives Organization and Health Canada 1998).

Inuit children have a high incidence of middle ear infections, with as many as 81 percent showing a history of infection in at least one ear (Tremblay 1991), and 10 percent suffering significant hearing loss by their twelfth birthday (Pauktuutit 1995a). While there is some evidence to suggest that the number of new cases has leveled off in the past ten years, Inuit children continue to face an elevated risk of suffering hearing loss (Pauktuutit 1995a; Moffatt et al. 1992). Even a partial loss of hearing can seriously impact a child's language development and learning abilities (Baxter 1991). Given this, the root causes of otitis media (ie: inadequate housing, a smoke-filled environment and poor nutrition) and its effects need attention. Interventions focusing on the latter would include the development of awareness programs for parents, and enhanced coordination among health, social and education services in the assessment and support of Inuit children with hearing problems (Blythe 1995; Pauktuutit 1995a).

Improving economic security for families

The Canadian Public Health Association (1997) makes clear that poverty has a significant and long-lasting effect on children's health outcomes. Many problems, including iron deficiency, poor oral health and otitis media, have been closely linked with low income and a lack of formal education (Ibid; Moffatt et al. 1992; Blythe 1995). This correlation is significant precisely because poverty is so widespread among Inuit families, with well over half of Inuit women reporting an annual income in 1991 of less than $10,000 (Canada 1996c; Moffatt et al. 1992).

In this regard, the lack of a substantial cash income makes Inuit families especially vulnerable to changes in the price of store-bought food. Santé Quebec (1994) and the Canadian Institute on Child Health (1994) indicate that a substantial minority of Inuit (ranging from 12.7 to 30 percent) are experiencing food shortages on a regular basis. While the federal government has indicated that it is committed to the task of strengthening the northern economy through training, investment in infrastructure and support for business development (Canada 1997b), sustainability and active community involvement must underpin all program planning and implementation activities (Canada 1996a).

Providing early and continuous learning experiences

In comparison with Canada's non-Aboriginal population, Inuit people have a low level of formal educational attainment. For example, in the Northwest Territories in the early 1990s, the high school graduation rate for Inuit youth was 10 percent, compared to 40 percent among non-Aboriginal young people in NWT (Northwest Territories Health 1991). On-going and broad-based intervention in this area is necessary if the future economic and social development of the North is to be secured (Canada 1996a). It is with this end in mind that an Arctic university is being advocated in some quarters to provide Inuit and other northern peoples with a measure of autonomy in educational matters, and to allow students to pursue their post-secondary studies in a familiar environment, thereby combating the alienation and home-sickness that is common among Inuit people who relocate to the South in order to attend university (Okalik 1999).

The extent to which Inuit languages and traditions are being transmitted from one generation to the next presents special challenges. Regional studies have shown that Inuktitut continues to be the mother tongue for the majority of the population, including children and youth (Santé Quebec 1994). However, even in regions where Inuktitut remains strong, traditional knowledge is not always being passed down to young people effectively (Ibid). In Nunavut, camps for Elders and youth are being organized, so that the latter have an opportunity to be immersed in their ancestral language while learning traditional skills from the older generation (Okalik 1999).

Fostering strong development in the pre-teen years

In discussing the health status of Inuit children and youth, Ruby Arngna'naaq (1999) placed great stress upon the concept of 'usefulness', arguing that it is central to Inuit people's sense of self, family and community, and wards off apathy, lack of confidence and depression. Notwithstanding, a large proportion of Inuit youth report being depressed (Moffatt et al. 1992; Brann 1996; Santé Quebec 1994), prompting observers like Brann (1996) and Moffatt et al. (nd), to call upon governments to institute skilled, culturally-relevant mental health services throughout the North.

As in First Nations communities, causal factors contributing to the high suicide rate among Inuit youth are many and varied, ranging from cultural stress, loss of spirituality and family breakdown, to alcohol, death of loved ones and lack of recreational facilities (Canada 1994, 1995; Brann 1996; Thorslund 1991). That the problem is exacerbated by a somewhat permissive attitude towards suicide among Inuit youth is a viewpoint that appears to be changing, with increasing numbers of young people now reporting that suicide attempts are 'stupid' rather than 'cool' (Brann 1996). To head off this problem, governments need to continue to shift their focus away from crisis response and towards activities that are meant to address the underlying causes of suicide (Canada 1994, 1995). As well, surveillance, prevention and crisis intervention programs in the North must be expanded, with a strong focus on initiatives that are designed and implemented by communities themselves (Brann 1996; Berger et al. 1991; Canada 1995).

The prevalence of tobacco use among Inuit people, particularly young women aged 15 to 19, is another issue that has received widespread attention (Canada 1992; Pauktuutit 1995b; Santé Quebec 1994; Northwest Territories Health 1991). Because Inuit children start smoking at a very early age, in some cases as young as five, the effects of smoking are pervasive throughout the community. As one report put it, "[m]any children are exposed to cigarette smoke from the day they are born, and as a result, suffer higher rates of asthma, ear infections and problems with lung development" (Pauktuutit 1995b, p.1). For the most part, Inuit youth lack a basic understanding of the human health effects of smoking, and awareness of the dangers of second-hand smoke is low to non-existent (Ibid). Therefore, Pauktuutit, along with others, has called for action on a number of fronts, including the design and implementation of a social marketing campaign, and the development of resource kits for communities and schools across the North, with priority attention focused on children and youth in the 5-9 and 10-14 age categories (Ibid; Santé Quebec 1994).

Other high risk behaviour in which Inuit youth are frequently involved include unsafe sex and substance abuse. Despite the lack of detailed information concerning prevalence and use patterns throughout northern Canada, community leaders and researchers express concern at what appears to be widespread substance use among the Inuit youth population. Solvents, marijuana and hashish are reported to be widely used. By contrast, teenage abuse of alcohol was deemed by some to be less of a problem (Santé Quebec 1994; Kawionnehta Human Resource Group 1994; Moffatt et al. 1992; First Nations and Inuit Regional Health Survey National Steering Committee 1999). The spectre of the close correlation between substance abuse and unsafe sex is raised when Moffatt (1991) argues that rates of STD infection are "extremely high and suggest that the entire sexually active population is at high risk" (p.556). Infection with an STD is also a risk factor for HIV/AIDS, as are low self-esteem and irregular condom use among individuals with multiple partners. Since these are all problems areas for Inuit youth (Santé Quebec 1994; Moffatt et al. 1992; Young et al. 1991), it is critical that culturally relevant HIV/AIDS awareness and prevention initiatives be developed and implemented in the North (Pauktuutit 1995).

Creating supportive, safe and violence-free communities

Fitness and recreation activities can play a role in promoting positive lifestyle choices, and be a means of addressing the problems discussed above, along with the alienation and low self-esteem that underpin them (Canada 1996a). The organization of such activities in northern communities can also serve to mitigate against high levels of injury-related morbidity and mortality (First Nations and Inuit Regional Health Survey National Steering Committee 1999), since many of these injuries are the product of risk-taking behaviour (eg: operating a motor vehicle or water craft while impaired) or lack of supervision (Young 1994; Moffatt 1991).

Inadequate or crowded housing also contributes to the high injury rate among Inuit children and youth, and as such is an area of key concern for community members (Arngna'naaq 1999). As studies by Santé Quebec (1994) Moffatt et al. (1992) have shown, the average number of occupants per house ranges from 4.6 in Keewatin to 5.0 in Nunavik. Meanwhile, the Canadian average is much lower at 2.8 (Ibid). A substantial proportion of Inuit households also contain more than one family (13 percent in Keewatin; 28.4 percent in Nunavik). While suicide attempts are one outcome of such stress (Brann 1996), family violence is another. Of course, in this regard it need hardly be added that family violence, along with the physical or sexual abuse of children, are believed to be serious social problems throughout much of the North (Abbey et al. 1991; Moffatt et al. 1992; Santé Quebec 1994).

Conclusion: Opportunities for Action

Gaps in Literature

There are notable gaps in the literature on the health of First Nations and Inuit children and youth. The lack of detailed, longitudinal health data is perhaps the most obvious example. Notwithstanding the empirical research in the First Nations and Inuit Regional Health Surveys, focused research on specific issues (eg: FAS/FAE and its prevalence) and particular sub-populations (ie: age- or sex-specific studies) is still not being done. Long-term evaluations of existing child and youth programming are also missing from the literature. Moreover, the literature focuses enormous attention on a limited range of 'high-profile' issues (such as breast-feeding), while showing relatively little interest in identifying and addressing emerging problems and concerns.

The impact of violence and pornography on First Nations and Inuit children and youth is a case in point. Little or no research has been undertaken on the sexual expression and street gang involvement of First Nations and Inuit young people. Although there is considerable anecdotal evidence in First Nations and Inuit communities to suggest that exposure to violent or pornographic images is having a negative impact, there is no comprehensive research program to explore this issue in detail. Other key concerns that have received relatively little attention in the literature include rates of child and youth HIV infection, substance abuse (particularly in relation to cocaine and heroin), homelessness and the movement of First Nations children between reserves and urban areas as a result of Bill C-31. At a more general level, the existing literature tends to over-emphasize the determinants of health, while it gives short shrift to existing and emerging diseases among First Nations and Inuit children and adolescents. The role of the health care system in this regard is virtually non-existent.

There are also gaps in the literature on Inuit parenting among First Nations and Inuit peoples. On the one hand, there is little exploration of traditional approaches to birthing and child rearing, and how these might be drawn upon to promote healthy, life-affirming practices among First Nations and Inuit parents today. On the other, still ill considered are the implications of the lack of male involvement in the parenting process, or the growing popularity of gambling and bingo-playing among many First Nations parents. Furthermore, almost no literature exists on how to mobilize the community around the issue of child and youth health and, no less importantly, how to put into the hands of children and youth the tools that would help them improve their own health status.

Faced with these gaps and weaknesses in the existing First Nations and Inuit child health literature, a culturally-based framework is needed in order to ensure that their needs are met by the National Children's Agenda. This approach is necessary because Canada's First Nations and Inuit population, including its children, enjoy a special relationship with the Government of Canada. Moreover, First Nations and Inuit peoples have a profound consciousness of themselves as the descendants of the original inhabitants of North America, and as such they want to be recognized as distinct. Their children and youth are among those with the most well-developed consciousness of their ancestors' legacy, since they are typically involved from a very early age in cultural activities which reinforce and strengthen the power of First Nations and Inuit traditions, values and histories.

At a more pragmatic level, First Nations and Inuit children require special treatment because they suffer from different - and more serious - health problem than their counterparts within the general Canadian population. This is all the more significant because the First Nations and Inuit population is generally very young, thereby lending an urgency to child and youth health matters. Issues like the residential school syndrome are also pertinent in this regard, contributing to a cycle of "deadly" parenting in First Nations and Inuit families (discussed earlier). In turn, these issues raise the profile of child care issues and lend further impetus to community demands for complete control over all programming related to the health and well-being of their young people.

Towards a Framework for Action

At a minimum, this proposed framework would addresses a number of serious weaknesses within the existing policy literature. At present, there is no mechanism in place to draw together actions and research dealing with First Nations and Inuit children's health, nor has any serious attempt been made to compare these two groups with each other. Instead, the reference point is always Canada's non-Aboriginal population.

Greater emphasis needs to be placed on the resiliency of First Nations and Inuit children and youth, along with the promotion of best practices in this area and the involvement of young people in research and decision-making. As is clear from the discussion in preceding sections, the literature on Inuit children and youth is considerably richer than that for First Nations, perhaps because the Inuit-specific literature places greater emphasis on the daily challenges faced by children and youth. Thus, there is a need for a balanced approach to child and youth health where all relevant issues are given due regard.

In the paragraphs below, discussion and recommendations are centered around four key theme areas, each of which is critical to the task of addressing the health challenges facing First Nations and Inuit children and youth.

Early childhood development

There is widespread agreement among child health experts that the first six years of life are a crucial stage in one's personal development. However, as the discussion in previous sections of this paper has shown, First Nations and Inuit children are considerably less healthy than their non-Aboriginal counterparts. For example, both populations are characterized by elevated levels of FAS/FAE, relatively poor nutrition and low birth-weights. Meanwhile, other concerns, such as environmental contaminants and the availability of high quality child care services, tend to be deemed either Inuit- or First Nations-specific in the literature. It is for this reason that the recommendations outlined below have been grouped according to their target population.

First Nations-specific recommendations

1. Support the development of additional on- and off-reserve child care services that are community-based, First Nations directed and controlled, and staffed by trained personnel.
2. Support the development of a sudden infant death syndrome (SIDS) awareness campaign directed towards expectant and new First Nations mothers.
3. In partnership with First Nations and other stakeholders, develop a national strategy on FAS/FAE prevention, awareness and surveillance.
4. Allocate additional resources to community-based FAS/FAE prevention and awareness programming.
5. Identify opportunities to integrate FAS/FAE prevention messages into existing programs and services for new or expectant parents.
6. In partnership with First Nations organizations, develop a strategy to foster community-wide acceptance and support of breast feeding, with priority attention focused on young children and adolescents of both sexes.
7. Promote health and social service careers among First Nations peoples in areas related to childhood health, development and education.
8. Identify opportunities to integrate traditional midwives and medicine people into the primary health care systems serving First Nations communities.
9. Provide funds to support the creation of a national First Nations adoption and repatriation bureau.
10. Expand funding for the First Nations Child and Family Services Program, while identifying and publicizing, in consultation with First Nations, 'best practices' in the area of child and family services.
11. Support research into the effects on First Nations children and youth of gambling, bingo-playing, and unrestricted access to television, Internet and videos.
12. Expand both the on- and off-reserve components of the Aboriginal Head Start Program, which focuses on nutrition, parenting skills, education, social supports, health promotion, parental involvement and culture/language.

Inuit-specific recommendations

1. Support the development of a smoking cessation and awareness program targeting expectant Inuit mothers.
2. Continue to fund and conduct research exploring the links between environmental contaminants and disease and developmental abnormalities in humans.
3. Develop clear guidelines and standards related to contaminant exposure levels and their likely impact on human health.
4. Develop a multi-sectoral ear infection/hearing loss strategy for the North, encompassing awareness, prevention, assessment and support.
5. Support the development and implementation of community-based child tooth decay prevention and awareness initiatives in Inuit communities.
6. In partnership with Inuit and other stakeholders, develop a national strategy on FAS/FAE prevention, awareness and surveillance.
7. Allocate additional resources to community-based FAS/FAE prevention and awareness programming.
8. Identify opportunities to integrate FAS/FAE prevention messages into existing programs and services for new or expectant parents.
9. In partnership with Inuit organizations, develop a strategy to foster community-wide acceptance and support of breast feeding, with priority attention focused on young children and adolescents of both sexes.
10. Promote health and social service careers among Inuit people in areas related to childhood health, development and education.
11. Identify opportunities to integrate traditional midwives and medicine people into the primary health care systems serving Inuit communities.
12. In collaboration with Inuit and government partners, explore means of streamlining the child adoption process for Inuit families.
13. Support the development of an expanded, comprehensive system of child- and family-focused services, encompassing parenting education and support, nutrition counseling, health promotion and family violence prevention.
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Providing early and continuous learning experiences

According to the Royal Commission on Aboriginal People (RCAP) commissioners (Canada 1996a), education is seen by many First Nations and Inuit people both as a means of acquiring marketable knowledge and skills, and as a way of learning about the history and traditions of one's community. Indeed, it has been frequently noted in the literature that traditional language and culture training can play an important role in empowering First Nations and Inuit youth, enhancing their self-esteem and engaging them in positive lifestyle choices. Other key concerns noted during the course of the literature review include the lack of special needs programs for First Nations and Inuit youth and the difficulties in the way of Inuit young people wishing to pursue a formal education beyond the secondary level.

First Nations-specific recommendations

1. Work with First Nations, provinces and territories to expand Aboriginal language programs within primary and secondary schools.
2. Support the identification and celebration of best practices which highlight the resiliency and coping skills of First Nations children and youth.
3. Expand funding for special needs education programs targeting First Nations children with developmental or physical disabilities.
4. Support the development of initiatives to facilitate the early identification of learning disabilities among First Nations children, for example through the provision of additional training in assessment to educators and day care personnel.

Inuit-specific recommendations

1. Work with Inuit communities to identify means of improving traditional language and culture retention among Inuit children and youth.
2. Improve school graduation rates in the North through continuing support for public awareness initiatives and community-based high school programs.
3. Explore the feasibility of creating an 'Arctic university' with one or more campuses throughout the North.
4. Support the identification and celebration of best practices which highlight the resiliency and coping skills of Inuit children and youth.
5. Expand funding for special needs education programs targeting Inuit children with developmental or physical disabilities.
6. Support the development of initiatives to facilitate the early identification of learning disabilities among Inuit children, for example through the provision of additional training in assessment to educators and day care personnel.

Fostering strong development in the pre-teen years

To a significant degree, First Nations and Inuit teenagers share many of the same health and social problems, including Sexually Transmitted Diseases (STDs), early pregnancies and an elevated suicide rate. However, Inuit youth stand out among Aboriginal peoples on account of their heavy use of tobacco, which is all the more troubling because a large proportion have already started smoking by the age of nine.

First Nations-specific recommendations

1. Provide additional funds to support the development of community-based suicide prevention and wellness initiatives targeting First Nations children in the 7-12 age category and adolescents.
2. Support the development of peer counseling and intervention initiatives in First Nations communities experiencing high rates of youth suicide.
3. Promote wellness and positive self-esteem through the expansion of traditional language and culture educational programs.
4. Expand availability of professional group and family counseling services in First Nations communities.
5. Support the creation of strong inter-generational relationships between young people and Elders through wilderness camps, mentoring and other related activities.
6. Support research activities exploring the attitudes of First Nations children and youth towards sexuality and reproduction.
7. Allocate additional resources to the expansion of reproductive and maternal health services, to ensure that young First Nations women living in remote communities have access to basic counseling, screening and assessment facilities.
8. Promote the core values of respect and tolerance in all sex education programs targeting First Nations children and youth.
9. Allocate additional resources to the development of diabetes education and primary prevention initiatives directed towards First Nations and Inuit children and youth.
10. Continue to provide funding in support of the First Nations and Inuit Youth Employment Strategy.

Inuit-specific recommendations

1. Provide funds to support the development and implementation of a social marketing campaign to raise awareness in the North of the dangers posed by tobacco use.
2. Develop anti-smoking resource kits for use in primary and secondary schools, with priority attention focused on Inuit children and youth in the 5-9 and 10-14 age categories
3. Provide additional funds to support the development of community-based suicide prevention and wellness initiatives targeting Inuit children in the 7-12 age category and adolescents.
4. Support the development of peer counseling and intervention initiatives in First Nations communities experiencing high rates of youth suicide.
5. Promote wellness and positive self-esteem through the expansion of traditional language and culture educational programs.
6. Expand availability of group and family counseling services in Inuit communities.
7. Support the creation of strong inter-generational relationships between young people and Elders through wilderness camps, mentoring and other related activities.
8. Support research activities exploring the attitudes of Inuit children and youth towards sexuality and reproduction.
9. Allocate additional resources to the expansion of reproductive and maternal health services, to ensure that young Inuit women living in remote communities have access to basic counseling, screening and assessment facilities.
10. Promote the core values of respect and tolerance in all sex education programs targeting Inuit children and youth.
11. Continue to provide funding in support of the First Nations and Inuit Youth Employment Strategy.

Creating supportive, safe and violence-free communities

As is suggested in the literature review section of this paper, the quality of life available to First Nations and Inuit children and youth living in reserve or Northern communities is often undermined by sub-standard housing conditions and a lack of healthy recreational or fitness opportunities. As one might imagine, this state of affairs contributes to young people's alienation, while enhancing the scope for intentional and unintentional injury-related morbidity and mortality. Moreover, among Inuit children and youth in particular, there is evidence to suggest that food insecurity is a serious problem, requiring targeted interventions to ensure that this population does not go hungry.

First Nations-specific recommendations

1. Promote child and youth wellness by supporting the development of a wide range of recreational and fitness programming in First Nations communities.
2. Support the development of injury prevention and awareness programs in First Nations communities, with an emphasis on the identification and replication of best practices in this area.
3. Integrate a family violence prevention component into all parenting education and support initiatives currently being delivered in First Nations communities.
4. Support the expansion of in-community counseling programs available to perpetrators of physical and sexual abuse.
5. Support First Nations children and youth with disabilities by ensuring that they and their families are provided with accessible buildings, counseling, advocacy and respite care.

Inuit-specific recommendations

1. Support measures which enhance food security in the North, with priority attention focused on expectant mothers and families with young children.
2. Convene a national conference to explore means of addressing the severe shortage of adequate housing in many Inuit communities.
3. Support Inuit children and youth with disabilities by ensuring that they and their families are provided with accessible buildings, counseling, advocacy and respite care.
4. Promote child and youth wellness by supporting the development of a wide range of recreational and fitness programming in Inuit communities.
5. Support the development of injury prevention and awareness programs in Inuit communities, with an emphasis on the identification and replication of best practices in this area.
6. Integrate a family violence prevention component into all parenting education and support initiatives currently being delivered in Inuit communities.

Works Cited

Abbey, S., Hood, E., Young, L. and Malcolmson, S. (1991) 'New perspectives on mental health problems in Inuit women' in Postl, B., Gilbert, P., Goodwill, J., Moffatt, M., O'Neil, J., Sarsfield, P. and Young, T. [eds.] Circumpolar Health 90: Proceedings of the 8th International Congress on Circumpolar Health, Whitehorse, Yukon, May 20-25, 1990, pp.285-287.

Aboriginal Nurses Association of Canada (1996) HIV/AIDS and its Impact on Aboriginal Women in Canada, Ottawa: The Association.

Arngna'naaq, R. (1999) Personal interview, July 16.

Asante, K. and Nelms-Matzke, J. (1985) Report on the Survey of Children with Chronic Handicaps and Fetal Alcohol Syndrome in the Yukon and Northwest British Columbia, Whitehorse: Council for Yukon Indians.

Assembly of First Nations (1989) National Inquiry into First Nations Child Care, Ottawa: The Assembly.

(1993) Reclaiming our Nationhood, Strengthening our Heritage: Report to the Royal Commission on Aboriginal Peoples, Ottawa: The Assembly.

(1994) First Nations Child Well-Being Project: 'Taking Responsibility for the Well-Being of our Children', Ottawa: The Assembly.

(1997) Sharing our Healing: National Health Conference, Beaupré, Quebec, June 25-27, 1997, Ottawa: The Assembly.

(1998a) First Nations Children, our Future: A Comprehensive Review of the Cultural Conflicts contributing to First Nations Child Poverty, Ottawa: The Assembly.

(1998b) Discussion Paper: A First Nations' Agenda for the National Child Benefit, Ottawa: The Assembly.

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Appendix

Population by Aboriginal groups and sex, showing age groups, for Canada
Source: 1996 Census

Aboriginal groups and sex	Total - Age groups	Under 15 years	15-24 years	25-44 years	45 years and older
Total population (Canada)	28,528,125	5,899,200	3,849,025	9,324,340	9,455,560
Male (Canada)	14,046,875	3,024,420	1,955,240	4,595,415	4,471,800
Female (Canada)	14,481,245	2,874,775	1,893,785	4,728,930	4,983,755
First Nations (total)	529,040	192,530	94,750	158,295	83,460
Male (First Nations)	258,335	98,520	46,900	73,915	38,995
Female (First Nations)	270,700	94,010	47,850	84,385	44,465
Inuit (total)	40,220	16,510	7,605	10,865	5,240
Male (Inuit)	20,180	8,355	3,880	5,345	2,600
Female (Inuit)	20,040	8,160	3,725	5,520	2,640

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1. The definitions of child and youth vary. The United Nations Convention on the Rights of the Child defines a child as anyone under the age of 18, while other bodies, such as the US Department of Education, considers a child to be a person aged 0 to 13 and a youth to be a person aged 14 to 24 (US, 1994). In this report, children are considered to be persons aged 0 to 18, and youths to be persons aged 19 to 24.

2. First Nations and Inuit Health Branch is mandated principally to provide health services to Inuit people and status Indians living on-reserve. Accordingly, this report is limited to these two populations. The needs and concerns of Métis and First Nations peoples residing off-reserve are thus not addressed in this report.

3. Thrust most recently into the national consciousness in the wake of a high profile court case pitting a child's non-Aboriginal grand-parents against his biological grand-father, a member of the Sagkeeng First Nation, this issue continues to generate anger and resentment within Native communities.

4. Under the terms of the National Child Benefit, federal transfers to the provinces and territories are to increase through the Canada Child Tax Benefit, making it possible for provincial and territorial governments to reduce social assistance payments on behalf of children, so long as they agree to reinvest any money saved in other programs and services for low-income families. Moreover, benefits are organized in such a way as to ensure that it always more lucrative for parents to be working rather than collecting social assistance (Assembly of First Nations 1998b; Mendelson 1999; Canada 1997a).

5. In implementing these recommendations, particular attention should be paid to First Nations and Inuit children and youth in the 0-14 age category. Not only is this group significant in terms of its numbers (more than one third of First Nations and Inuit people are 14 years of age or younger [Young 1994]), but it is also a segment of the population where policy interventions are likely to have a powerful, long-lasting effect.