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The Crisis in Youth Mental Health: Experience Matters Hiram E

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1 The Crisis in Youth Mental Health: Experience Matters Hiram E
The Crisis in Youth Mental Health: Experience Matters Hiram E. Fitzgerald, Ph.D. Michigan State University ODMHSAS Children’s Mental Health State of the State January, 2008 Tulsa, Oklahoma Relationship between Brain Development and Experience Provide Conditions for a Great Start Interconnectedness of Experiences Barriers to a Great Start: Risk and Risk Cumulation Prevention: The key to overcoming Risk and Promoting pathways to a great finish.

2 Experience Matters!!!!

3 Experience Regulates the Organization of Development
Biological Psychological Three major divisions of Outreach and Engagement Office Social

4 Sagittal Section Through the Human Brain
Schematic drawing showing regions vulnerable to alcoholism-related abnormalities

5 Allostasis: Stability through Change (Sterling & Eyer, 1988).
Neural & Neuro-Endocrine Systems Adaptive Processes & Functions Extra-Familial Systems STRESS Behavioral & Psychological Systems Three major divisions of Outreach and Engagement Office

6 STRESS: Hypothalamic-Pituitary-Adrenal Axis
Childhood Trauma & Abusive Experiences Social Regulators Three major divisions of Outreach and Engagement Office Environmental Regulators

7 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)


9 It’s Not All Timing, but Time does Matter

10 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.

11 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 Orienting in space Emotional attachment Birth to age 2 Emotional and social systems Language acquisition Birth to age 4 Communication Cognition/thought Second language 1 year to age 4 Math/logical thinking Cognitive processing Music and rhythm 3 years to age 5 Creative expression

12 Experiences have Multiple Origins and are Interconnected

13 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

14 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) These are the factors that are highly predictive of normative development or of development that exceeds the norm.

15 Possible Transactional Linkages in a Primary Family System
Boundaries Stories Exogenous Influences Father Mother Codes Rituals Transitions The influences on the developing individual include parental and sibling relationships, but also go beyond the family and include relatives, neighborhoods, friends. They also include all of the external factors that may have an impact on parents, factors such as the workplace, religious institutions, child care settings. Sibling 1 Sibling 2 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 ). New York: Guilford. Roles


17 Establishing Risk Through family characteristics
Through individual characteristics Through social environments

18 Establishing Risk Through family characteristics
Children of alcoholics Children of drug abusing or drug addicted parents Children of parents with antisocial personality disorder

19 Establishing Risk Through family characteristics
Through individual characteristics Externalizing behavior, aggression, behavioral undercontrol, oppositional defiant disorder Negative emotionality, depression Attention problems, ADHD Shyness, social withdrawal, social phobia

20 Establishing Risk Through family characteristics
Through individual characteristics Through social environments High drug use environments High stress environments (violence, poverty, unemployment)

21 Etiology of Alcohol Use Disorders Illustrating the Impact of Early Experience
Developmental life course perspective Systemic organization and probabilistic Multiple pathways

22 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)

23 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

24 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)

25 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

26 Understanding Etiology of Alcoholism From a Risk Development Perspective

27 Primary Onset of Substance Use Occurs Between Ages 12 and 20
100- 80- 60- 40- 20- 0- Age Alcohol Tobacco Any Drugs Cannabis 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.

28 Percent First Use among High School Students Less than Age 13 in Oklahoma and US
Alcohol Marijuana Oklahoma 25.2% 9.4% US % 8.7% Adapted from: Focus on Children’s Behavioral Health, Oklahoma Institute for Child Advocacy 2007

29 Course of the Comorbid and Primary Alcoholisms
Age Stages Prenatal Infancy Preschool Years Middle Childhood Adolescence Young Adulthood Middle Adulthood Late Adulthood 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 ). New York: Wiley.

30 What Predicts Early Alcohol and Other Drug Use?

31 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

32 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

33 Structure of Common and Disorder-Specific Genetic Risk for Common Psychiatric and Substance Use Disorders Internalizing Common Factor Externalizing Major Depression Generalized Anxiety Disorder Phobias Other Drug Use Disorders Adult Antisocial Behavior Conduct Alcohol Dependence 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 ). New York: Wiley.

34 Moos Family Environment Scale scores
Relation of Preschool Family Environment Indicators to Early First Drink Experience Moos Family Environment Scale scores

35 The combination of both early child risk (individual risk) and family environment (social risk) structures differences in life course from early childhood to adolescence…..

36 The Different Adaptation Groups During the Preschool Years
Child Psychopathology Normal Range High Family Adversity Low Non-Challenged Troubled Resilient Vulnerable

37 Externalizing Symptoms During Early Childhood and the Elementary School Years

38 Stability and Change in Externalizing Symptoms During the Transition Into High School

39 Internalizing Symptoms

40 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

41 Three Developmental Pathways Into Substance Use Disorder

42 Strong Continuity Pathway
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 Adapted from Fitzgerald, Zucker, Puttler, Caplan & Mun, (2000) and Fitzgerald and Das Eiden (2007)

43 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

44 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 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)

45 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.

46 Traditional Approach to Change: Linear Modeling, Linear Thinking

47 When in reality, things are not linear…
Intervention Outcome Foster-Fishman, 2007

48 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).

49 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

50 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.

51 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.

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