1. Janet E. Johnson, MD, MPH Department of Psychiatry The Human Life Cycle: Development and Disease

2. Learning Objectives for Life Cycle Lecture Be familiar with the major stages of the life cycle as defined by different theorists Be able to recognize normal stages and psychological reactions across the life cycle Be able to discuss the “Adverse Childhood Experiences” study and its’ implications Be able to list different types of divorce and consequences of divorce Be familiar with attitudes and reactions to death across the life cycle

3. Why Should I Care About Development? Your patients are people first Each of us begins and ends the same way: Biological Psychological Social

4. Life I don’t want to gain immortality through my work; I want to gain immortality through not dying Woody Allen

6. Individual Factors: “Personality” What determines someone’s personality?

7. What forces push development? Development is exceedingly complex Humans are biological beings and social beings… Many theories have been posited –Neurological/Cognitive –Psychosexual –Psychosocial –Separation/individuation –Others

8. Neurological Development Rapid maturation and growth Inborn reflexes: Moro, rooting, Babinski, endogenous smiling, orients to voice Inborn reflexes: Moro, rooting, Babinski, endogenous smiling, orients to voice 8 weeks: see shapes and colors 16 weeks: stereoscopic vision, holds head up 40 weeks: sits alone, pulls up to stand 52 weeks: walks with hand held 15 months: walks alone, crawls stairs Forms foundation for psychological development

9. Cognitive Development Pioneered by Jean Piaget (1896-1980) First paper published age 10 on a species of sparrow Developmentally precocious by his system Studied his own children in formulating his theories

10. Piaget’s Theory of Cognitive Development Provides a framework for understanding the cognitive capabilities of children, informing effective communication and treatment Four stage theory Sensori-motor (0-2) Preoperational (2-6) Concrete Operational (6-11) Formal Operational (11-adult)

11. Sigmund Freud Psychoanalytic theory of development –Very complex theory. –Major forces behind development were not observable! –Theory was influenced strongly by the culture of the time in which Freud practiced.

12. Sigmund Freud Libido Theory Ages Oral phase (0-1 yr) Anal phase (1-3 yrs) Phallic phase (3-6 yrs) Latency (6-puberty) –Stage of relative inactivity of sexual drive –Objective is consolidation of sex role identity and sex role behaviors –Generally a time when children look outside the family (teachers, coaches, other adults)

13. Erikson: Psychosocial Theory Trust v Mistrust (0 to ~1 year) Autonomy v Shame/Doubt (~1 to 3 years) Initiative v Guilt (~3 to 5 years) Industry v Inferiority (~6 to 11 years) Identity v Role Diffusion (~11 to 21 years) Intimacy v Isolation (~21 to 40 years) Generativity v Stagnation (~40 to 65 years) Integrity v Despair (~65 years and up)

14. Ethology-I Ethologists view behavior as being: –Strongly influenced by biology, –Tied to evolution, –Characterized by critical periods (sensitive periods) in which characteristics develop. Konrad Lorenz and his geese

15. The Goose Guy*--Imprinting *Nobel Prize Winner

16. Weaknesses of Ethology Limited evidence for critical periods in humans. Views biology as key determinant of behavior Impact of evolutionary forces is difficult to study experimentally.

17. Ecology-I Ecologists believe that behavior is: –Strongly influenced by the environment (the context in which the individual lives), –Environment exists in levels or layers of influence, –Environmental levels may change rapidly, such that the timing of when we grow up is important.

19. Weaknesses of Ecology De-emphasizes the role of inherent (biological/genetic) differences. New evidence that a person’s genetic makeup may shape their environment.

20. ECOLOGYETHOLOGY NATURE NURTURE BIOLOGYENVIRONMENT

21. What are the components of Biology? Genes, Genes, Genes… TeratogensPathogensDisease

22. What are the components of Environment? What isn’t? –Experience! CulturePoverty

24. Risk and Protective Factors May be “biological” or “psychosocial.” Individual risk or protective factors generally do not predict specific outcomes. High total risk index predicts poor outcomes (often in several areas). Exposure to risk, if overcome, may be protective.

25. The Adverse Childhood Experiences (ACE) Study The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan. (~18,000 participants) The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan. (~18,000 participants) Conducted by a group at Kaiser Permanente— a series of papers published in major medical journals over the last 15 years Conducted by a group at Kaiser Permanente— a series of papers published in major medical journals over the last 15 years

26. Categories of Adverse Childhood Experiences Abuse by Category Psychological (by parent) Physical (by parent) Sexual (anyone) Household Dysfunction by Category Substance Abuse Mental Illness Mother Treated Violently Household Member Imprisoned

27. Categories of Adverse Childhood Experiences Abuse by Category Prevalence of positive response Psychological (by parent)11% Physical (by parent)11% Sexual (anyone)22% Household Dysfunction by Category Substance Abuse26% Mental Illness19% Mother Treated Violently13% Imprisoned Household Member 3%

28. Research Questions How does self-reported exposure to adverse childhood experiences relate to major health indicators?

29. All-Star List of Health Indicators Smoking Smoking Severe Obesity Severe Obesity Physical Inactivity Physical Inactivity Depression Depression Suicide Attempt Suicide Attempt Alcoholism Alcoholism Illicit Drug Use Illicit Drug Use Injected Drug Use Injected Drug Use 5+ Sexual Partners 5+ Sexual Partners History of STDs History of STDs

30. Adverse Childhood Experiences & Risk for Obesity ACEScoreObesityBMI>35 No Physical Activity 0-15%19% 2-37%22% 4 or more 9%25%

31. Aversive Childhood Experiences Vs. Adult Alcoholism ACE Score % Alcoholic

32. Childhood Experiences Underlie Chronic Depression ACE Score Percent with Lifetime History of Depression

33. Childhood Experiences Underlie Suicide ACE Score % Attempting Suicide

34. ACE Study Summary of Findings Adverse Childhood Experiences are very common. Adverse Childhood Experiences are very common. ACEs are strong predictors of later health risks. ACEs are strong predictors of later health risks. This combination makes ACEs one of the leading, if not the leading determinant of the health and social well-being of our nation. This combination makes ACEs one of the leading, if not the leading determinant of the health and social well-being of our nation.

35. Early Death Disease & Disability Adoption of Health Risk Behavior Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences Felitti’s General Model

36. Social History? What percentage of your patients do you believe will walk into your office and state: “You know, doc, I was abused as a kid.”

37. Divorce Divorce risk factors: Early marriage Different backgrounds Serious illness or death in an infant (75%) Time, money, work (SES) Drug abuse and alcoholism Untreated depressive illness!!! Extramarital affairs (60% of men, 40% of women by middle age)

38. Divorce- types Psychic divorce-loss of the love object –may take 2 years to recover Individuation Transfer the love to another love object Legal divorce 50-60% of women remarry within 3 years 80% of men remarry within 3 years

39. Divorce - types Economic divorce –division of property Failure of a father to comply with court ordered child support reveals much about how that person might respond to medical treatments (compliance etc.) Community divorce- loss of friends Co-parental divorce- separation from child’s perspective

40. Outcomes for children of divorce Good outcome –continued relationship with both parents –Genuine concern by both parents –removal from abusive parent –dissipation of parental friction

41. Outcomes for children of divorce Poor outcome –35% of children –rejection by one or both patents –(disinterested custodial parent) –infrequent or unreliable visits by –noncustodial parent lonely or depressed or physically ill mother –Continued parental strife –impoverished social supports

42. Other effects on children Depends on age at which divorce occurred Preschool-regression (fear of abandonment) Latency age-depression (fear of replacement and fantasy of reunion) Pre-adolescence-(anger at one or both parents and splitting) Adolescents-anxiety about becoming an adult

43. Life Span The age in which the average individual would die if there were not premature deaths from accidents or disease. This is approximately 85-95 years and has not changed for centuries, and probably millenia. Life span, like maximum life potential, is probably a fixed biological constant for each species.

44. Life Expectancy The age of which the average individual would die when accidents and disease have been taken into consideration.

45. Life Expectancy In 2001, life expectancy for women in the U.S. A.: 80.05 years 80.05 years and for men 74.37 years

46. Variability in Life Expectancy Worldwide Life Expectancy at birth (years), 2007 ██ over 80 ██ 77.5-80 ██ 75-77.5 ██ 72.5-75 ██ 70-72.5 ██ 67.5-70 ██ 65-67.5 ██ 60-65 ██ 55-60 ██ 50-55 ██ 45-50 ██ 40-45 ██ under 40 ██ not available

47. Death and Dying Meaning of death –Reaction/experience of death depends on context Timely: one’s expected survival and actual life span are approximately equal –Erikson: Integrity versus despair Untimely: unexpected or premature death –Death of a young person –Sudden death –Catastrophic death associated with violence or accident

48. Definitions Thanatology: study of the phenomenon of death and the emotional and psychological processes involved in the reaction to death, including grief, bereavement, and mourning Grief: subjective feelings that are precipitated by the death of a loved one Bereavement: to be deprived of someone by death and refers to being in the state of mourning Mourning: process by which grief is resolved; societal expression of post bereavement behavior and practices Grief work: complex psychological process of withdrawal of attachment and working through the pain of bereavement

49. Definitions Intentional –Suicide Unintentional –Trauma, disease Sub-intentional –Substance abuse, cigarette smoking Sudden death of psychogenic origin –Emotional factors alone MI after sudden psychological stress Voodoo death

50. Elisabeth Kubler-Ross

51. Stages Do not necessarily go in order Can alternate between stages Not all patients will experience each stage Do not always get to final stage Stage I: Denial and Isolation; Shock –Can be adaptive or maladaptive –Depends on whether patient continues to obtain treatment, even while denying diagnosis and prognosis

52. Stages Stage II: Anger –May be directed at God, fate, family, friends, medical staff, other caregivers –Why me? –Patients are difficult to help while in this stage Stage III: Bargaining –Attempts to negotiate with doctors, friends, God, etc –In return for a cure, patient will fulfill certain promises –By being “good”/compliant, doctors and other health care providers will cure them

53. Stages Stage IV: Depression –Withdrawal, psychomotor retardation, sleep disturbance, hopelessness, possible SI –May be reaction to effects of illness on their lives –May be in anticipation of the loss of life that will occur –Treatment will meds or ECT may be indicated Stage V: Acceptance –Realize death is inevitable; accept universality of the experience

54. Attitudes toward Death across the Life Cycle Children < 5 years –Animistic  everything, even inaminate objects, is alive. Death is a separation similar to sleep. 5-10 years (concrete operations) –Fear parents will die and they will be abandoned 9-12 years –Death conceptualized as something that can happen to the child, as well as the parents Puberty and above –Universal, irreversible and inevitable –Same as adult view

55. Specific Concerns Children: creates major emotional stresses on caregivers Adolescents: need for independence and control Young adults: (intimacy versus isolation) –May focus on never getting married, having kids Middle age adults: (generativity vs. stagnation) –May feel frustrated in plans to enjoy hard-earned pleasures Elderly: (integrity versus despair)

56. Success To laugh often and much; to win the respect of intelligent people and affection of children, to earn the appreciation of honest critics and endure the betrayal of false friends. To appreciate beauty, to find the best in others, to leave the world a bit better, whether by a healthy child, a garden patch, a redeemed social condition; to know even one life has breathed easier because you have lived. This is to have succeeded. Ralph Waldo Emerson