the crisis in youth mental health: experience matters hiram e. fitzgerald, ph.d. michigan state...
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The Crisis in Youth Mental Health: Experience Matters
Hiram E. Fitzgerald, Ph.D.Michigan State University [email protected]
ODMHSASChildren’s Mental Health State of the State
January, 2008Tulsa, 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
Adaptive Processes & Functions
STRESS
Neural & Neuro-Endocrine Systems
Extra-Familial Systems
Behavioral & Psychological Systems
Allostasis: Stability through Change (Sterling & Eyer, 1988).
STRESS: Hypothalamic-Pituitary-Adrenal 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. (2nd 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 CommunicationCognition/thought
Second language 1 year to age 4 Communication
Math/logical thinking 1 year to age 4 Cognitive processing
Music and rhythm 3 years to age 5 Creative expression
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
Exogenous Influences
Boundaries
Transitions
Stories
Codes Rituals
Roles
Father Mother
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.
Sibling 2Sibling 1
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 characteristicsb) 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)
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)
Parenting Risk: Alcoholic fathers
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
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.
100-
80-
60-
40-
20-
0- 12 20 30 40 50 60 70 80 Age
Alcohol
Tobacco
Any Drugs
Cannabis
Percent First Use among High School Students Less than Age 13 in Oklahoma and
US
Alcohol Marijuana
Oklahoma 25.2% 9.4%
US 25.6% 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 InfancyPreschool
YearsMiddle
ChildhoodAdolescence
Young Adulthood
Middle Adulthood
LateAdulthood
A: The Comorbid Alcoholisms
B: The Primary Alcoholisms
Antisocial Alcoholism
Developmentally Limited Alcoholism
Negative Affect Alcoholism
(Alcoholisms without initial continuity or comorbidity)
Isolated Alcohol Abuse
Developmentally Cumulative Alcoholism
Episodic 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 Alcoholand 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
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.
Structure of Common and Disorder-Specific Genetic Riskfor Common Psychiatric and Substance Use Disorders
InternalizingCommon Factor
ExternalizingCommon Factor
MajorDepression
Generalized AnxietyDisorder
Phobias OtherDrug UseDisorders
AdultAntisocialBehavior
ConductDisorder
AlcoholDependence
SpecificRisk
SpecificRisk
SpecificRisk
SpecificRisk
Key: Width of arrows is an indicator of relative strength of the relationship.
Relation of Preschool Family Environment Indicators to Early First Drink Experience
Moos Family Environment Scale scores
7.05
6.195.84
5.12
2.55
3.87
0
1
2
3
4
5
6
7
8
Cohesion Organization Conflict
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 GroupsDuring the Preschool Years
Child Psychopathology
Normal Range High
Family Adversity
LowNon-
ChallengedTroubled
High Resilient Vulnerable
Externalizing Symptoms During Early Childhood and the Elementary School
Years
5
7
9
11
13
15
17
3-5 years 6-8 years
9-11 years
Troubled
Non-Challenged
Vulnerable
Resilient
Stability and Change in Externalizing Symptoms During the Transition Into High
School
5
7
9
11
13
15
17
3-5 years 6-8 years
9-11 years
12-14 years
Troubled
Non-Challenged
Vulnerable
Resilient
Internalizing Symptoms
4
5
6
7
8
9
10
3-5 years
6-8 years
9-11years
12-14 years
Troubled
Non-Challenged
Vulnerable
Resilient
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
Adapted from Fitzgerald, Zucker, Puttler, Caplan & Mun, (2000) and Fitzgerald and Das Eiden (2007)
Infancy and early childhood
Difficult temperament, poor parenting, insecure to disorganized attachment, regulatory difficulties
Preschool to kindergarten
Lower self-regulation, externalizing behavior problems, social withdrawal, poor school readiness
Childhood Behavioral problems, oppositional behavior, impulsivity, social withdrawal, poor school performance
Late middle childhood
Family disorganization (divorce/separation, loss of job, health or 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
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 SchoolDiscontinuity Pathway 1 Discontinuity Pathway 2
Infancy and Early ChildhoodNormative patterns of development during infancy
PreschoolSchool readiness, behavior within normal limits, adaptive temperament.
ChildhoodGood 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 self-correcting.
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 preventive-intervention programs may be most effective.
Traditional Approach to Change: Linear Modeling, Linear Thinking
INTERVENTION OUTCOME
Intervention
Outcome
When in reality, things are not linear…
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.