Transcript Slide 1

The Crisis in Youth Mental
Health: Experience Matters
Hiram E. Fitzgerald, Ph.D.
Michigan State University
[email protected]
ODMHSAS
Children’s Mental Health State of the State
January, 2008
Tulsa, Oklahoma
Experience Matters!!!!
Experience Regulates the
Organization of Development
Biological
Psychological
Social
Sagittal Section Through the Human Brain
Schematic drawing showing
regions vulnerable to alcoholism-related abnormalities
Allostasis: Stability through
Change (Sterling & Eyer, 1988).
Neural &
NeuroEndocrine
Systems
Adaptive
Processes &
Functions
Extra-Familial
Systems
STRESS
Behavioral &
Psychological
Systems
STRESS: Hypothalamic-PituitaryAdrenal Axis
Childhood
Trauma &
Abusive
Experiences
Social
Regulators
Environmental
Regulators
Results Associated with Allostatic Load
(McEwen & Stellar, 1993)
Chronic exposure to stressful experience
(frequent stress)
Failure of homeostatic mechanisms to restore
balance (failed shutdown)
Negative feedback systems producing chaotic
system overload (Inadequate response)
It’s Not All Timing, but
Time does Matter
Organizational Periods During Prenatal Development: Vulnerability
to Environmental Teratogens
Adapted from: (K. L. Moore (1977). The developing human: Clinically oriented embryology. (2 nd edition, p. 136). Philadelphia: W. B. Saunders.
Postnatal Sensitive Periods
Developmental
Process
Maximum Period of
Organization
System
Motor development
Prenatal to age 4
Exploration
Emotion regulation
Birth to age 2-3
Self control
Visual processing
Birth to age 2-3
Orienting in space
Emotional
attachment
Birth to age 2
Emotional and social
systems
Language acquisition Birth to age 4
Communication
Cognition/thought
Second language
Communication
1 year to age 4
Math/logical thinking 1 year to age 4
Cognitive processing
Music and rhythm
Creative expression
3 years to age 5
Experiences have Multiple
Origins and are Interconnected
Roles of Experience in Neural, Biological, and
Behavioral Development
Induction: If experience does not occur, endpoints are not achieved
Facilitation: Hastens the appearance of endpoints
Maintenance: Keep achieved endpoints functional
Factors Highly Related to Positive Early
Organizational Processes
Ongoing nurturing relationships with the same adults
Physical protection, safety, and regulation of daily routine
Experiences responsive to individual differences in such characteristics as
temperament
Developmentally appropriate practices related to perceptual-motor,
cognitive, social stimulation, and language exposure
Limit-setting (discipline), structure (rules and routines), and expectations
(for positive outcomes)
Stable, supportive communities (violence free) and culture (a sense of
rootedness, connectedness, identity)
Possible Transactional Linkages in a Primary Family
System
Boundaries
Stories
Exogenous Influences
Mother
Father
Codes
Rituals
Sibling 2
Sibling 1
Roles
Transitions
Source: Loukas, A., Twitchell, G. R., Piejak, L.
A., Fitzgerald, H. E., & Zucker, R. A. (1998).
The family as a unity of interacting
personalities. In L. L’Abate (Ed.), Family
psychopathology: The relational roots of
dysfunctional behavior (pp. 35-59). New York:
Guilford.
RISKY EXPERIENCES PRODUCE
RISKY BEHAVIORS
Establishing Risk
a) Through family characteristics
b) Through individual characteristics
c) Through social environments
Establishing Risk
a) Through family characteristics
– Children of alcoholics
– Children of drug abusing or drug addicted parents
– Children of parents with antisocial personality disorder
Establishing Risk
a) Through family characteristics
b) Through individual characteristics
– Externalizing behavior, aggression, behavioral
undercontrol, oppositional defiant disorder
– Negative emotionality, depression
– Attention problems, ADHD
– Shyness, social withdrawal, social phobia
Establishing Risk
a) Through family characteristics
b) Through individual characteristics
c) Through social environments
– High drug use environments
– High stress environments (violence, poverty,
unemployment)
Etiology of Alcohol Use Disorders
Illustrating the Impact of Early Experience
• Developmental life course perspective
• Systemic organization and probabilistic
• Multiple pathways
Family Risk: Marital Conflict
Higher marital conflict is a significant
longitudinal predictor of quality of parenting
in the infant and toddler years.
Buffalo Longitudinal Study
(Fitzgerald & Das Eiden, 2007)
Parenting Risk: Alcoholic fathers
display higher levels of aggravation with their 12 month old infants
(Eiden & Leonard, 1999).
display lower levels of sensitivity, positive engagement, and
verbalizations toward their 12 month old infants (Eiden, Chavez &
Leonard, 1999)
perceive their infants as having more difficult temperaments, and
higher rates of behavior programs as early as 18 months of age
(Edwards, Leonard & Eiden, 2001)
have children who do not show normative declines in aggression
between 3 and 4 years of age (Edwards, Eiden, Colder & Leonard,
2006)
Buffalo Longitudinal Study
Parenting Risk: Protective Factors
Children with alcoholic fathers who have a
secure attachment relationship with their
mothers have significantly lower
externalizing behavior problems, compared
with those who have an insecure attachment
relationship with their mothers.
Buffalo Longitudinal Study
(Fitzgerald & Das Eiden, 2007)
Risk Cumulation Predicts Poor Outcomes
•
•
•
•
•
•
•
Poverty
Low birth weight
Transience
Poor nutrition
Lack of quality child care
Unemployed parents
Lack of access to health
and medical care
• Low parent education
levels
Understanding Etiology of Alcoholism
From a Risk Development Perspective
Primary Onset of Substance Use Occurs
Between Ages 12 and 20
100-
80-
60Alcohol
40-
Tobacco
20-
Any Drugs
Cannabis
012
20
30
40
50
Age
60
70
80
Source: Anthony, J.C., & Arria, A.M. (1999). Epidemiology of substance abuse in adulthood. In P.J. Ott, R.E. Tarter, & R.T. Amerman (Eds). Sourcebook on substance abuse. Etiology,
epidemiology, assessment and treatment. Boston, MA: Allyn and Bacon.
Percent First Use among High School
Students Less than Age 13 in Oklahoma and
US
Oklahoma
US
Alcohol
25.2%
25.6%
Marijuana
9.4%
8.7%
Adapted from: Focus on Children’s Behavioral Health,
Oklahoma Institute for Child Advocacy 2007
Course of the Comorbid and Primary Alcoholisms
Age Stages
Prenatal
Infancy
Preschool
Years
Middle
Childhood
Young
Adulthood
Adolescence
Middle
Adulthood
Late
Adulthood
A: The Comorbid Alcoholisms
>
>
>
>
Antisocial Alcoholism
Developmentally Limited Alcoholism
>
>
>
>
>
>
Negative Affect Alcoholism
B: The Primary Alcoholisms
(Alcoholisms without initial continuity or comorbidity)
Isolated Alcohol Abuse
>
Episodic Alcoholism
Developmentally Cumulative Alcoholism
Source: Figure 17.6, p. 639, in Zucker, R. A. (2006). Alcohol use and the alcohol use disorders: A developmental-biopsychosocial systems formulation covering the life course. In
D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp. 620-656). New York: Wiley.
What Predicts Early Alcohol
and Other Drug Use?
Mental Representations
(Cognitive Schemas/Motor Neuron
Networks/Expectancies/Contingency Awareness)
Schemas for Alcohol use Disorders Organize
during Infancy and Early Childhood
Schemas are Social Constructions,
Representations, Autobiographical Memory
Components of an Organizing Schema for Alcohol
Abuse/Dependence and Co-active Psychopathology
Sensory-Perceptual
– Sensory identification of substances
– Perceptual discrimination of substances
Cognitive-Motivational
– Attributions about who are appropriate users
– Expectancies related to outcomes based on use
Affective
– Self-regulatory, self-control processes
– Interpersonal relationships
Social
– Role models
– Peer relationships
– Dominance hierarchies/power
Biological
– Familial history
– Congenital history
Structure of Common and Disorder-Specific Genetic Risk
for Common Psychiatric and Substance Use Disorders
Internalizing
Common Factor
Major
Depression
Generalized
Anxiety
Disorder
Externalizing
Common Factor
Phobias
Alcohol
Dependence
Other
Drug Use
Disorders
Specific
Risk
Specific
Risk
Specific
Risk
Adult
Antisocial
Behavior
Conduct
Disorder
Specific
Risk
Key: Width of arrows is an indicator of relative strength of the relationship.
Source: Figure 17.6, p. 639, in Zucker, R. A. (2006). Alcohol use and the alcohol use disorders: A developmental-biopsychosocial systems formulation covering the life course. In
D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp. 620-656). New York: Wiley.
Relation of Preschool Family Environment
Indicators to Early First Drink Experience
8
7.05
7
6.19
6
5.84
5.12
5
3.87
4
3
2.55
2
1
0
Cohesion
Organization
Conflict
Moos Family Environment Scale scores
NFD
FD
The combination of both early child risk
(individual risk) and family environment
(social risk) structures differences in
life course from early childhood to
adolescence…..
The Different Adaptation Groups
During the Preschool Years
Child Psychopathology
Normal Range
High
Low
NonChallenged
Troubled
High
Resilient
Vulnerable
Family
Adversity
Externalizing Symptoms During Early
Childhood and the Elementary School
Years
17
15
Troubled
13
Non-Challenged
11
Vulnerable
9
7
Resilient
5
3-5 years
6-8
years
9-11
years
Stability and Change in Externalizing
Symptoms During the Transition Into High
School
17
Troubled
15
13
NonChallenged
11
Vulnerable
9
7
Resilient
5
3-5 years
6-8
years
9-11
years
12-14
years
Internalizing Symptoms
10
9
Troubled
8
NonChallenged
Vulnerable
7
6
Resilient
5
4
3-5
years
6-8
years
9-11
years
12-14
years
Indicators of High Risk: UC (under control)
and NA (negative affect).
• The most damaged children (and those at
highest risk) are those who temperamentally
have behavioral indicators of undercontrol,
roughness, irritability, early mood
dysregulation, sadness, depression, sleep
problems, and who show higher levels of
antisocial behavior early.
• They also are growing up in highly adverse,
very difficult environments.
Michigan Longitudinal Study, Zucker & Fitzgerald
Three Developmental Pathways Into
Substance Use Disorder
Strong Continuity Pathway
Infancy and Difficult temperament, poor parenting, insecure to disorganized
early childhood attachment, regulatory difficulties
Preschool to Lower self-regulation, externalizing behavior problems, social
kindergarten withdrawal, poor school readiness
Childhood Behavioral problems, oppositional behavior, impulsivity, social
withdrawal, poor school performance
Late middle Family disorganization (divorce/separation, loss of job, health or
childhood social problems or other family members), poorer parent
monitoring
Adolescence Earlier onset of alcohol and other drug involvement, heavier
alcohol and other drug problems, delinquency, depression.
Adulthood Antisocial personality disorder, mood disorder, substance abuse
disorder
Adapted from Fitzgerald, Zucker, Puttler, Caplan & Mun, (2000) and Fitzgerald and Das Eiden (2007)
Social Costs of the Strong Continuity
Trajectory
• Academic difficulty and failure
• Date rape/sexual assault
• Other kinds of physical injury to self and others (e.g.
automobile accidents)
• Impaired social relationships
• Loss of human and social capital; foreclosure of future
opportunities, higher poverty risk, incarceration
Two Discontinuity Pathways Suggesting Differentiation
Occurring During the Transition from Elementary to
Middle School
Discontinuity Pathway 1
Discontinuity Pathway 2
Infancy and Early Childhood
Normative patterns of development during infancy
Preschool
School readiness, behavior within normal limits, adaptive temperament.
Childhood
Good school adaptation and performance; good friendship network.
Late Middle Childhood
Family disorganization (divorce/separation, loss of job,
health or social problems of other family member);
poorer parent monitoring; shift in more deviant peer
network; increasing emergence of externalizing behavior,
developing pattern of internalizing problems.
Family disorganization (divorce/separation, loss of job,
health or social problems of other family member); shift
in peer network; increasing emergence of externalizing
behavior.
Adolescence
Alcohol and other drug involvement, minor
delinquency. Poor or adverse outsider or parent
response: undependability of both parents, less
available prosocial network; difficulties selfcorrecting.
Alcohol and other drug involvement, minor
delinquency. Poor or adverse outsider or parent
response and/or personal concern moving back on
track; shorter clinical course.
Adapted from: Zucker, Chermack, & Curran (2000)
Identifying Best Times for
Prevention and Intervention
• We now can identify risk for substance abuse during
infancy and early childhood.
• We now understand that there are multiple life course
pathways of risk and resilience for alcohol use
disorders.
• These findings inform us about when preventiveintervention programs may be most effective.
Traditional Approach to Change: Linear
Modeling, Linear Thinking
INTERVENTION
OUTCOME
When in reality, things are not linear…
Intervention
Outcome
Foster-Fishman, 2007
Summary
• Normative development occurs in a minimal risk
environment with strong familial and social supports
• Sustained exposure to cumulative risk factors minimizes
chances for a great finish because it organizes dysfunction
• Early experiences influence later outcomes and depending
on the nature of maintenance processes may determine
outcomes
• High quality, sustained and systemic prevention programs
can help children overcome bad starts
• Early prevention programs are cost effective, later
remediation programs are not (nor is incarceration).
The work reported here was supported by National
Institute on Alcohol Abuse and Alcoholism grants
R37 AA 07065, R01 AA 12217, and T32 AA 07477,
Michigan State University Biomedical Sciences
Support Grant
Collaborators
Robert A. Zucker, Ph.D.
Hiram E. Fitzgerald, Ph.D.
Leon I. Puttler, Ph.D.
Susan Refior, M.S.W.
Maria M. Wong, Ph.D.
Ann Buu, Ph.D.
Margit Burmeister, Ph.D.
Scott F. Stoltenberg, Ph.D.
Andrea Hussong, Ph.D.
Kirk J. Brower, M.D.
Frank Floyd, Ph.D.
Joel Nigg, Ph.D.
Susan Nolen-Hoeksema, Ph.D.
Deborah A. Ellis, Ph.D.
Jennie Jester, Ph.D.
Kenneth M. Adams, Ph.D.
Jennifer Glass, Ph.D.
James Cranford, Ph.D.
Mary J. McAweeney, Ph.D.
Colleen Corte, R.N., Ph.D.
Edwin Poon, Ph.D.
Laura Sheridan Pierce, Ph.D.
Michelle Martel, Ph.D.
Past Collaborators
Eve E. Reider, Ph.D.
Alexandra Loukas, Ph.D.
Fernando E. Gonzalez, Ph.D.
Roseanne D. Brower, Ph.D.
Lucilla Nerenberg, M.D.
Michael A. Ichiyama, Ph.D.
Sondra Wallen, Ph.D.
Michelle Klotz Dougherty, M.A.
Helene M. Caplan, Ph.D.
Gregory Hanna, M.D.
Ed Cook, M.D.
Gregory S. Greenberg, Ph.D.
William J. Curtis, Ph.D.
Robert R. Mueller, Ph.D.
Diane M. Pallas, Psy.D.
Marcel Montenez, Ph.D.
Robert B. Noll, Ph.D.
C. Raymond Bingham, Ph.D.
Roni Mayzer, Ph.D.
Cynthia L. Nye, Ph.D.
Eun-Young Mun, Ph..D.
Eugene T. Maguin, Ph.D.
W. Hobart Davies, Ph.D.
Steven Kincaid, Ph.D.
Roger Jansen, Ph.D.
Lisa Piejack, Ph.D.
Geoffrey Twitchell, Ph.D.
Karley Y. Little, M.D.
Ellen E. Whipple, Ph.D.
Hae-Young Yang, Ph.D.
Hazen P. Ham, Ph.D.
Keith P. Sanford, Ph.D.