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The Crisis in Youth Mental Health: Experience Matters Hiram E. Fitzgerald, Ph.D. Michigan State University fitzger9@msu.edu ODMHSAS Children

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Title: The Crisis in Youth Mental Health: Experience Matters Hiram E. Fitzgerald, Ph.D. Michigan State University fitzger9@msu.edu ODMHSAS Children


1
The Crisis in Youth Mental Health Experience
Matters Hiram E. Fitzgerald, Ph.D. Michigan
State University fitzger9_at_msu.edu ODMHSAS Child
rens Mental Health State of the State January,
2008 Tulsa, Oklahoma

2
Experience Matters!!!!
3
Experience Regulates the Organization of
Development
Biological
Psychological
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
6
STRESS Hypothalamic-Pituitary-Adrenal Axis
Childhood Trauma Abusive Experiences
Social Regulators
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)
8
(No Transcript)
9
Its 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 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 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
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)
15
Possible Transactional Linkages in a Primary
Family System
Boundaries
Stories
Codes
Rituals
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. LAbate (Ed.), Family
psychopathology The relational roots of
dysfunctional behavior (pp. 35-59). New York
Guilford.
Roles
16
  • RISKY EXPERIENCES PRODUCE
  • RISKY BEHAVIORS

17
Establishing Risk
  1. Through family characteristics
  2. Through individual characteristics
  3. 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
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 25.6 8.7

Adapted from Focus on Childrens Behavioral
Health, Oklahoma Institute for Child Advocacy 2007
29
Course of the Comorbid and Primary Alcoholisms
Age Stages Age Stages Age Stages Age Stages Age Stages Age Stages Age Stages Age Stages
Prenatal Infancy Preschool Years Middle Childhood Adolescence Young Adulthood Middle Adulthood Late Adulthood






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.
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

33
Structure of Common and Disorder-Specific Genetic
Risk for Common Psychiatric and Substance Use
Disorders
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.
34
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 Child Psychopathology
Normal Range High
Family Adversity Low Non-Challenged Troubled
Family Adversity High 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 Infancy and Early Childhood Normative patterns of development during infancy Infancy and Early Childhood Normative patterns of development during infancy Infancy and Early Childhood Normative patterns of development during infancy Infancy and Early Childhood Normative patterns of development during infancy
Preschool School readiness, behavior within normal limits, adaptive temperament. Preschool School readiness, behavior within normal limits, adaptive temperament. Preschool School readiness, behavior within normal limits, adaptive temperament. Preschool School readiness, behavior within normal limits, adaptive temperament. Preschool School readiness, behavior within normal limits, adaptive temperament.
Childhood Good school adaptation and performance good friendship network. Childhood Good school adaptation and performance good friendship network. Childhood Good school adaptation and performance good friendship network. Childhood Good school adaptation and performance good friendship network. Childhood Good school adaptation and performance good friendship network.
Late Middle Childhood Late Middle Childhood Late Middle Childhood Late Middle Childhood 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) 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. 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 Adolescence Adolescence Adolescence 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) Adapted from Zucker, Chermack, Curran (2000) Adapted from Zucker, Chermack, Curran (2000) Adapted from Zucker, Chermack, Curran (2000) 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
OUTCOME
INTERVENTION
47
Intervention
When in reality, things are not linear
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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