The Crisis in Youth Mental Health: Experience Matters

Hiram E. Fitzgerald, Ph.D.Michigan State University fitzger9@msu.edu

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.