The origins of the curriculum lie in grief and resolve. Following devastating youth losses, a delegation of White Mountain Apache Tribal leaders met with the Johns Hopkins Center for Indigenous Health to expand their long-standing public health partnership into mental health. In 2001, exercising its political sovereignty, the Tribal Council passed a resolution establishing the Celebrating Life System, a tribally mandated suicide surveillance and case management system that has been linked to documented decreases in suicide deaths and attempts. Building on that foundation, an Elders’ Council formed and emphasized the importance of passing Apache language and traditions to youth as an upstream defense against suicide risk, which peaks between ages 15 and 24. The Elders chose to intervene earlier, at a developmental stage when children can comprehend and retain teachings about identity, belonging, and resilience. Since 2015 the curriculum has been delivered in reservation schools through monthly lessons that include Elders speaking Apache, sharing songs and stories, and assigning seasonal responsibilities for youth to practice with their families.

Scientifically, the study addresses a stubborn gap in prevention science. Culturally grounded interventions — those designed from the ground up with culture, values, and Indigenous worldviews at the forefront — are deeply valued by Native communities, yet they remain under-evaluated in the empirical literature. Standard Western frameworks assume a linear pipeline from intervention development to efficacy testing to scale-up, an approach rooted in Eurocentric knowledge construction that privileges cognition over lived experience, spirit, and relationality. The research team, led by Victoria M. O’Keefe of the Cherokee Nation and Seminole Nation, deliberately Indigenized this process, replacing the linear model with a relational, orbital, and iterative one. The goal was twofold: to identify the core components of the Elders’ Resilience Curriculum and the mechanisms through which it works, providing a theoretical basis for evaluation and future scaling, while safeguarding Apache teachings that have historically been shared orally and never disseminated outside the Tribe.

The study employed a non-parallel convergent mixed methods design embedded in Indigenous Community-Based Participatory Research. Rather than treating community members as subjects, the team worked with a Community Advisory Board of ten White Mountain Apache members who reviewed the design, interpreted results, and shaped dissemination. Language itself was decolonized: partners preferred the term “youth strength factors” over “protective factors against suicide,” reframing the work as strengths-based life promotion rather than deficit reduction. The research unfolded in deliberate steps, beginning with a consensus survey completed by faculty and staff involved in the program, who rated 31 potential core components and 13 potential youth outcomes for importance. A virtual consensus meeting then resolved ambiguities, ultimately confirming 28 core components rated very important or useful, spanning program activities, format and setting, curriculum delivery, organizational support, and Elder knowledge and training.

The qualitative phases brought the community’s voice to the center of the analysis. Focus group discussions with Elders and in-depth interviews with youth, caregivers, teachers, and Tribal leaders illuminated what makes the program meaningful. Participants described the intergenerational bonds forged when Elders enter classrooms, with one Tribal leader noting that Elders carry the wisdom to navigate life’s hardships and that connection between generations is “definitely needed.” Another leader described the ripple effect of a single lesson: a student goes home, shares an Elder’s words about respect with a parent, and plants seeds of dialogue that spread through the classroom, the school, the home, and the larger community. Elders spoke of pride in carrying forward the tools their own ancestors shared with them, now teaching children how to use those tools to weather storms and solve problems.

To identify the theoretical mediators — the youth strengths the curriculum is meant to build — the team used Nominal Group Technique, a participatory method in which participants independently generate, rank, and prioritize ideas. Community mental health specialists, youth ages 11 to 13, and youth ages 14 to 17 each produced ranked lists of what keeps young people strong and connected. The final consensus identified four paramount strength factors: connection to family, connection to religion and spirituality including prayer, connection to Elders through learning from and helping them, and connection to culture, encompassing cultural history, activities, and traditional foods. Notably, youth prioritized sleep and sports, factors not currently addressed in the curriculum — an input that points toward possible new lesson topics as Elders continue iterating the program. Community members framed expected outcomes as “positive changes,” spanning mental, emotional, spiritual, and social health, academic achievement, identity, belonging, Apache language, and cultural continuity.

The study’s most innovative methodological step came with pile sorts, in which Elders, youth, and community mental health specialists sorted notecards representing core program activities, youth strengths, and potential outcomes, mapping the relationships among them. Participants consistently described the elements as interconnected rather than sequential — a reciprocal, relational web rather than a causal chain. When the research team drafted a conventional linear theoretical model showing activities producing strengths that produce outcomes, Community Advisory Board members pushed back decisively. One member explained that everything moves back and forth constantly, a give and take rather than “this causes this causes that.” The model, they insisted, had to be circular.

The community’s answer to how to visualize that circularity came from Apache teachings themselves. A community mental health specialist and artist shared that he pictured the model as a cottonwood tree, a symbol whose specific teaching cannot be written or shared outside the Tribe. In his visualization, the core components form the roots, the youth strength factors form the trunk, and the positive changes form the branches and leaves. Other specialists added that trees hold knowledge and keep growing, and that new leaves replacing old each year mirror how youth learn, grow, and gain strength. Elders on the Elders’ Council affirmed the teaching, noting that the color yellow in the artist’s painting represents life in Apache tradition. A White Mountain Apache graphic designer then digitized the model, producing a theoretical framework grounded entirely in the community’s own Knowledge System — a living, growing structure rather than a static flowchart.

The implications extend well beyond one reservation. Other American Indian and Alaska Native communities have expressed interest in adapting the curriculum, and this research offers a pathway for scaling culturally grounded programs while respecting their origins: other communities can follow the same participatory process to integrate their own languages, knowledges, and practices rather than importing Apache content. The study also carries lessons for mainstream prevention science, challenging rigid fidelity requirements and suggesting that Indigenous interventions should remain dynamic, evolving documents shaped by community experts rather than academic ones. Limitations include COVID-19 pandemic delays that forced retrospective reporting and a purposive sample not designed for generalizable statistics. Yet the strengths are substantial: the research supported the re-implementation of the curriculum in fall 2023, empowered local interpretation at every stage, and culminated in community dissemination. Ultimately, the cottonwood tree model stands as both a scientific framework and a cultural statement — evidence that suicide prevention can be rooted in sovereignty, sustained by Elders, and measured in the flourishing of the next generation.

Subject of Research: Co-developing a theoretical model for the Elders' Resilience Curriculum, an Indigenous culturally grounded school-based suicide prevention intervention of the White Mountain Apache Tribe

Article Title: The Elders’ Resilience Curriculum: Co-developing a theoretical model of an Indigenous culturally grounded preventive intervention

Article References: O’Keefe, V. M., Goklish, N., Sinquah, F. L., Grubin, F., Haroz, E. E., Sierra, V., Cwik, M., Suttle, R., Cosen, E., Velasquez-Brawley, V., Garcia, M., Rock, H., Pablo, E., Cosen, R., Whitesell, N., Gallo, J. J., Keshen, R., & Barlow, A. (2026). The Elders’ Resilience Curriculum: Co-developing a theoretical model of an Indigenous culturally grounded preventive intervention. SSM – Mental Health, 10, Article 100701. https://doi.org/10.1016/j.ssmmh.2026.100701

Image Credits: AI Generated

DOI: 10.1016/j.ssmmh.2026.100701

Keywords: White Mountain Apache Tribe, Indigenous mental health, suicide prevention, Elders' Resilience Curriculum, culturally grounded intervention, Community-Based Participatory Research, Apache language, intergenerational connection, cultural continuity, prevention science, youth resilience, self-determination

The essence of this study is captured by the voices of eighteen care providers—ten foster carers and eight kinship carers—asked about how they perceive barriers, enablers, and ultimately, possibilities for improving family inclusion. While foster care is provided by individuals recruited for this specific role (who might initially have no personal relationship with the child), kinship care is performed by relatives or close family friends who already know the child, often grandparents or aunts and uncles. The caregivers’ testimonies reveal that such differences in background and relationship to the child can significantly shape the kind of family inclusion that is realized.

Participants in the research voiced concern that the out-of-home care system, in which agencies and caseworkers typically manage contact between children and birth parents, often fails to make family inclusion a priority. Both foster carers and kinship carers recounted examples of rigid rules, limited policy guidelines, or top-down agency directives that sometimes forbade even casual contact. Many said it was difficult to juggle the demands placed upon them—particularly foster carers who might be looking after several unrelated children, each with a different family that might wish to see them. They also described feeling under-resourced and unprepared to manage relationships with parents, even if they believed firmly in the value of that connection for the child.

In contrasting the two types of care, a salient difference emerges: kinship carers largely come to the role because they are already connected to the child, whether as a grandparent, aunt, cousin, or close family friend. They tend to assume that maintaining a child’s sense of identity and belonging within the extended family is crucial. Kinship carers in this study almost universally said they believe children benefit from regularly seeing their parents, even if those parents lead troubled lives. Rather than trying to shield the child from any knowledge of those difficulties, these kinship carers described offering the child safe opportunities to witness and understand the complexities in the parent’s life. They saw this as a critical part of the child’s identity formation. It was not only about a single “visit” policy but forging a continuing family relationship that ensures children know precisely who their parents are, both the good and the bad, thereby preventing any illusions that might form if parental contact was completely blocked. This approach, though, required the kinship carers to become adept at handling very real risks. Some parents struggled with mental health issues, addictions, or even criminal behavior, but the kinship carers felt their prior knowledge of the parent gave them enough insight to manage those risks effectively. They would time visits to align with the parent’s more stable moments and maintain strict boundaries, like prohibiting arguments in the child’s presence. Because many kinship carers were older or had personal experiences of trauma themselves, they had taken it upon themselves to learn about trauma-informed care or counseling approaches, which helped them in these delicate negotiations.

Foster carers’ experiences overlapped in some ways but departed from that of kinship carers in others. Foster carers likewise tended to endorse the principle that continuing to see parents could be beneficial for the child’s emotional well-being, but the way they enacted inclusion often revolved around formal, agency-sanctioned visits. Rather than embedding the parent in everyday routines (like bedtime phone calls or casual outings), foster carers sometimes relied on structured “family time,” which might be supervised by agency staff or bounded by certain conditions. Nonetheless, many foster carers signaled a desire to do more, to be more flexible in letting the child communicate with parents or grandparents, but said they felt stymied by official policies that either prohibited casual contact or demanded an extra layer of logistical planning with minimal agency support.

One key barrier reported by foster carers was the sheer burden of multiple obligations. Some were caring for up to four or five children from different families, meaning they had to coordinate each child’s unique case plan, therapy sessions, medical appointments, and visits with distinct birth families. They worried about being overwhelmed. Without additional support from caseworkers, it was hard to handle all those obligations. The net effect was that parents’ requests to see or speak to their child outside of scheduled visits were often turned down, not necessarily because the carer opposed it, but because they simply could not juggle the demands. That underscores a basic systemic issue: with too few foster carers available, the system strains both children and adults.

Despite these obstacles, foster carers in long-term placements sometimes described a remarkable evolution in their relationship with birth parents, even when the initial relationship was tense or stilted. Over time, if the parent demonstrated stability and the foster carer could remain open and empathetic, they might develop a cooperative, almost co-parenting dynamic. These examples stood out because they illustrated the possibility that even in a complex system—one that often sets up foster carers and birth parents as adversaries—people can learn to collaborate if given space and time.

Across both carer groups, formal or informal learning experiences were cited as transformative. Some kinship carers obtained specialized counseling or trauma training, while a few foster carers enrolled in courses to understand generational poverty or addiction. These forms of education helped them empathize with birth parents rather than simply seeing them as irresponsible or unworthy. This shift in perspective proved crucial. By intentionally setting aside judgment, empathizing with the parent’s life, and focusing on the best interests of the child, carers discovered that they could actively promote family inclusion in meaningful ways. One kinship carer, for instance, made sure the child’s mother could attend key events at school or extracurricular activities, so the child felt a continuity of family life. Some foster carers reported sending the birth mother text updates about the child’s day, thereby allowing the mother to maintain her sense of mothering identity.

Yet the system seldom rewards such initiatives or trains caregivers to manage them. In multiple stories, participants lamented that caseworkers rarely asked, “How can we help you build a better rapport with the mother or father?” Instead, the primary focus was often on risk management or compliance with a checklist. Carers observed that agencies sometimes used formulaic planning processes that paid little attention to the individual child’s situation or the parent’s particular struggles. This context forced carers to decide on their own whether to attempt more inclusive practices. Many described pushing back against the agency, advocating for parents who had been sidelined or outright dismissed.

In short, family inclusion rose and fell not just with policy directives but with the personal attitudes and skills of carers. Kinship carers, who already knew the parent, more readily accepted that parents should remain in a parenting role, no matter how complicated. Foster carers similarly believed children benefit from seeing parents, but found themselves constantly negotiating structural roadblocks and time constraints. Both kinds of carers appealed for more training, peer support, and caseworker buy-in to strengthen their ability to make family inclusion a reality. This call for assistance echoes findings from other research that parents benefit from structured support if they are to maintain healthy connections with children in care. Here, the unique perspective is that carers also need that support, because it is they who are at the center of daily life with the child, noticing changes in behavior and mood.

A consistent refrain throughout the interviews is that there is a fundamental mismatch between what children need—ongoing family relationships—and the system’s risk-averse, compliance-oriented processes. Carers described that the fear of liability sometimes prompts an agency to prohibit the simplest interactions, such as letting a father, who happens to pass by on the street, spontaneously talk to his child. This can breed resentment, confusion, or heartbreak for both parent and child. Indeed, the system’s approach can feel so harsh that some carers spoke of it as hostile to the very idea of family. They saw case plans that cut out parents from any role in decision-making, or superficial “cut-and-paste” planning documents that do not consider each family’s unique situation.

In the face of these systemic challenges, the small everyday acts of resourcefulness by carers—contacting incarcerated parents to ensure the child hears their voice, inviting the parent over to help with a child’s medical anxiety, preparing an older child to spend time with a mother going through mental health struggles—underscore that family inclusion is not a matter of one-size-fits-all. It is, rather, a nuanced, context-specific approach. Parents with severe mental health disorders may require different boundaries or scheduling. Other parents might be able to step back into a co-parenting role if provided some training and support. It is precisely the individual knowledge that carers cultivate—particularly kinship carers—that allows for these flexible, responsive approaches.

All of this suggests that there is vast potential for out-of-home care agencies to bolster their training regimens, systematically encouraging empathy, open communication, conflict resolution, and insight into social disadvantage. One can envision a suite of modules delivered not just to new foster carers, but also to kinship carers, birth parents, and even caseworkers. The goal would be to develop a shared language and understanding that helps them function as a “team around the child,” a phrase some participants used to highlight the value of family inclusion. Such a reorientation would require, however, more than just a handful of training sessions; it would entail systemic changes that give foster and kinship carers a consistent voice in decision-making, relieve them of unwieldy administrative tasks, and allow for deeper planning with parents.

Where does all this leave the concept of family inclusion in child welfare? The research underscores that practice and policy must shift to truly honor a child’s right to maintain family connections. If some parents remain dangerous, then the focus must be on strategies for safe interaction, not total erasure. If a parent’s problems are mild or well-managed, agencies should consider how best to maximize the child’s contact, ensuring that they have a sense of continuity and belonging. In both these scenarios, the carer’s cooperation is essential, but it cannot thrive in a vacuum; they need well-designed case planning, a supportive culture, and training that takes seriously the complexities of family dynamics.

One of the most positive findings is that, despite the heavy demands on them, both foster carers and kinship carers can and do assume a “toward parent” posture, genuinely seeking to include parents in daily activities that matter to the child. And in the face of a system that sometimes sidelines parents, carers can choose to fill the gap, positioning the parent not merely as a visitor but as someone whose voice matters in the child’s life. The recognition that parents can provide love, knowledge of cultural heritage, and an anchor for the child’s identity remains a powerful motivator, especially for kinship carers but also for many foster carers who have discovered that better outcomes result from respecting birth families.

At a broader level, it remains critical to acknowledge that Aboriginal children in particular face an even greater risk of being cut off from their families and cultural communities, creating yet another layer of injustice. Ensuring family inclusion for Indigenous children is doubly urgent, given the legacy of forcible removals and the ongoing trauma faced by many Indigenous families. This article’s emphasis on kinship care resonates with the well-documented principle that culturally appropriate placements with extended family can provide a sense of belonging and continuity that mainstream approaches often lack.

In conclusion, the findings demonstrate that out-of-home care, as it currently operates, does not uniformly or robustly support family inclusion in ways that best serve children. Yet, ironically, caregivers—both kinship and foster—are willing, if sometimes under-prepared, to make family inclusion a priority. Many do so through their own ingenuity and empathy, forging relationships with parents and integrating them into the child’s life in small but significant ways. If child welfare agencies and policymakers were to systemically encourage and train carers to facilitate family inclusion, and if they were to provide resources and flexibility to balance safety with a child’s relational needs, the gains could be substantial: stronger identity, improved well-being, and a deeper sense of familial continuity for children who otherwise might feel unmoored. That is the promise of family inclusion, and the voices in this study ring out as a powerful call for reforms that recognize and advance it. By centering the experiences of both kinship and foster carers, it becomes evident that the entire ecosystem of child welfare can be reshaped so that children do not simply “survive” outside their birth family environment, but thrive in connection with it, even after legal removal. Family inclusion, then, emerges not only as a moral imperative tied to the child’s rights, but as a pragmatic strategy for better outcomes—an approach that fosters belonging, identity, and resilience.

Subject of Research: Family inclusion for children in care
Article Title : Family inclusion for children in care: How foster and kinship carers make it work
News Publication Date : 2024
Article Doi References : https://doi.org/10.1016/j.childyouth.2024.108106
Keywords : Family Inclusion, Foster Care, Kinship Care, Best Practice, Carer Recruitment