Transcript No Slide Title

Overcoming developmental risk:
A biopsychosocial foundation
for early interventions
Oslo—RBUP—June, 2009
Arnold Sameroff
[email protected]
Agendas for
Intervention Professionals
1. Academic
• How do we understand
children?
2. Social
• How do we improve
children?
3. Political
• Who is responsible for
children?
Agendas for
Intervention Professionals
2. Social Agenda
How can we improve children’s lives?
Opportunities for Prevention or Intervention
OTHER
SELF
INFANCY
CHILDHOOD
ADOLESCENCE
ADULTHOOD
Improving Developmental Success
1) Make Children More Resilient
2) Make Environments Less Risky
Infant Competence
•
•
•
•
•
•
Obstetrical Problems
Newborn Pediatric Problems
Newborn Brazelton Scores
4-Month Temperament
4-Month Development Scores
12-Month Development Scores
Infant Competence
Predicting to 4-Year Mental Health
Infant Competence
High
4-Year M. H.
4.2
Low
4.0
3.8
3.6
3.4
3.2
3.0
Low
Moderate
High
Early Social Risk
18-Year Mental Health
4-Year Mental Health
Predicting to 18-Year Mental Health
90
80
4-Year
High MH
Low MH
70
60
50
Low
Moderate
4-Year Social Risk
High
18-Year Mental Health
13-Year Mental Health
Predicting to 18-Year Mental Health
13-Year (Y)
Mental Health
90
High
Low
80
70
60
Low
Moderate
High
13-Year Social Risk
30-Yr. Mental Health
18-Year Mental Health
Predicting to 30-Year Mental Health (PIRS)
4
18-Year MH
High
Low
3
2
0
1 2 3 4+
18-Year Social Risk
30-Yr Physical Health
18-Year Mental Health
Predicting to 30-Year Physical Health
18-Year
Mental Health
High
4
Low
3
2
0
1
2
3
18-Year Social Risk
4+
Philadelphia
Adolescent Development Study
Todd Bartko, Jacque Eccles
Frank Furstenberg, Tom Cook, Glen Elder
500 11- to 14-year olds
Urban Setting
Examine Multiple Competencies
Examine Multiple Risks
Social Ecological Model
GEOPOLITICAL
COMMUNITY
FAMILY
PARENT
SCHOOL
CHILD
CHILD
PEERS
20 Negative
Environmental Influences
Proximal
• Parent-Child Interaction
• Parent Characteristics
• Family Structure & Economy
• Family Management
• Peers
• School
• Community
Distal
Indicators of Adolescent Success
• Psychological Adjustment
Depression
Anger
Self-Esteem
• Few Problem Behaviors
Substance Use
Early Sexuality
Delinquency
Violence
• Academic Competence
Grades
Psychological Adjustment
1
Problem Behavior
0.8
Academic Performance
Standardized means
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
0
1
2
3
4
5
Multiple Risk Score
6
7+
Resourcefulness
High
Low
Problem Behavior
Psychological Adjustment
1.0
1.0
Academic Performance
1.0
.8
.6
.5
.5
.4
.2
0.0
.0
0.0
-.2
-.4
-.5
-.5
-.6
-.8
-1.0
-1.0
LOW
MED
HIGH
Multiple Risk
Lines indicate means and 95% confidence intervals
-1.0
LOW
MED
Multiple Risk
HIGH
LOW
MED
Multiple Risk
HIGH
Question:
Can Personal Resilience
Overcome Environmental Adversity?
Answer:
Not for most people,
For most of the time!
Improving Developmental Success
1) Make Children More Resilient
2) Make Environments Less Risky
Political Strategies for
Social Intervention
Conservatives-----Preserve the Family
Liberals------------Eliminate Poverty
Preserve the Family
Single Parent
Two Parents
Psychological Adjustment
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2
0
0
-0.2
-0.2
-0.2
-0.4
-0.4
-0.4
-0.6
-0.6
Low (0-2)
-0.6
Low (0-2)
0.8
Standardized means
Academic Performance
Problem Behavior
0.6
0.4
0.2
0
Low (0-2)
Moderate (3-5)
Multiple Risk
High (6+)
Moderate (3-5)
Multiple Risk
High (6+)
Moderate (3-5)
Multiple Risk
High (6+)
Eliminate Poverty
Below Poverty Level
1 to 2 Times Poverty Level
> 2 Times Poverty Level
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2
0.2
0
0
0
-0.2
-0.2
-0.2
-0.4
-0.4
-0.4
-0.6
-0.6
-0.6
-0.8
-0.8
-0.8
0.8
0.6
Standardized means
Academic Performance
Problem Behavior
Psychological Adjustment
0.4
-1
Low (0-2)
Moderate (3-5)
Multiple Risk
High (6+)
-1
Low (0-2)
Moderate (3-5)
Multiple Risk
High (6+)
-1
Low (0-2)
Moderate (3-5)
Multiple Risk
High (6+)
Percent of Families in
High and Low Risk Groups
Risk Group
Income
Family Structure
>$30,000
Single
Parent
Two
Parents
35%
60%
34%
54%
15%
6%
22%
7%
>$10,000
$1030,000
Low (0-3)
13%
High (8+)
44%
If single factors (money, parents)
don’t change children’s lives,
What about multiple factors?
Promotive Factors
Changing Many Settings
Making Big Changes
From Risk Factors
to
Promotive Factors
20 Positive
Environmental Influences
Proximal
• Parent-Child Interaction
• Parent Characteristics
• Family Structure & Economy
• Family Management
• Peers
• School
• Community
Distal
1.2
Psychological Adjustment
Self-Competence
0.9
Competence
Problem Behavior
Activity Involvement
0.6
Academic Performance
0.3
0
-0.3
-0.6
-0.9
1
2
3
4
5
6
7
8
9
10
Promotive Factors
11
12
13+
Social Agenda
What can be done to increase
developmental success?
Need to improve many settings
Making Small Changes
Early Interventions
and the
Transactional Model
Social Ecological Model
GEOPOLITICAL
COMMUNITY
FAMILY
PARENT
SCHOOL
CHILD
CHILD
PEERS
Family Setting
FAMILY
PARENT
CHILD
CHILD
Regulation Model
Other-Regulation
Self-Regulation
Development
Who’s Suffering?
• Infant
• Sleep, Feeding, Crying
• Parents
• Stress, Depression
• Professionals
• Abuse and Neglect
Who’s the Patient?
• Infant
• Parents
• The Relationship
• Themes
Structural Model
 Motherhood Constellation
Daniel Stern
Nadia Bruschweiler-Stern
Process Model
 Transactional Diagnosis
Arnold Sameroff
Barbara Fiese
Motherhood Constellation
Bact
Mact
Motherhood Constellation
Brep
Bact
Mact
Mrep
Motherhood Constellation
Trep
Tact
Brep
Bact
Mact
Mrep
Motherhood Constellation
Br
Ba
Mr
Ma
Br
Ba
Br
Mr
Ma
Ba
Ma
Mr
Transactional Diagnosis
Parent
Child
C1
P
P
2
4
C
3
time
C5
3-R’s of Intervention
Remediation
Redefinition
Reeducation
3-R’s of Intervention
Redefine
Parent
Parent
Reeducate
Remediate
Child
Child
time 1
time 2
Remediation
 Indicated Child Conditions
Parent
Remediate
Child
 Low Birth Weight
 Malnourishment
 Behavior/Emotional Problems
Remediation
Low Birth Weight Babies
 Problem
Parent
 Small, fragile appearance
 Weak responses
 Interventions
 Gentle Stimulation
Remediate
Child
 Deep Massage
 Passive Limb Movement
 Increases Activity/Alertness
 Non-nutritive sucking
 Accompanies Tube Feeding
 Increases Weight Gain
 Earlier Discharges
Remediation
Malnourished Infants
 Problem
Parent
 Unresponsive
 Inactive
 Feeding Intervention
Remediate
Child
 Greater Responsiveness
 Increased Energy Level
 Provide Stronger Cues
Remediation
Medical Interventions
 Surgery
Parent
Remediate
 Cleft Palate
 Down Syndrome
 Medication
Child
 Mood
 Colic
Redefinition
Parent
Parent
 Indicated Parent Conditions
 Failure to adapt to exceptional child
 Failure to distinguish mother perception from
child behavior
 “Ghosts in the Nursery”
 Negative attributions
Redefinition
Parent
Parent
Failure to Adapt to Exceptional Child
 Problem
 Disability, Low Birth Weight
 Parent feels unqualified to care for child
 Only professionals competent
 Intervention
 Emphasize Typical within Atypical
 Sleeping, Eating, Plays, Attends
 Demonstrate Responsiveness
 Brazelton Demonstrations
Redefinition
Parent
Parent
Failure to Distinguish
Mother Perception from Child Behavior
 Problem
 Poor fit between parent beliefs and infant behavior
 Crying interpreted as opposition or “bad”
 Intervention
 Relabeling
 Reinterpreting age-appropriate behavior—intentionality
Redefinition
Parent
Parent
“Ghosts in the Nursery”
 Problem
 Carryover from own experience of being cared for
 Own mother’s voice
 Insecure attachment experience (AAI)
 Inconsistent, unreliable, abusive
 Carried forward into new attachment relationship
 Intervention
 Infant-Parent and Infant Toddler Psychotherapy
 Parent Treatment
Redefinition
Parent
Parent
Negative Attributions
 Problem
 Parent’s negative view of others (self?)
 Intervention
 Positive Adjective-Bugental
Reeducation
 Indicated Parent Conditions





High Risk Parents
Teenage Parents
Low Birth Weight Infant
Developmental Disabilities
Overachieving Parents
Parent
Reeducate
Child
Reeducation
High Risk Parents
 Problem
 Low Resource Parents
 Retarded Parents
 Maltreating Parents
Parent
Reeducate
 Intervention
 Interaction Guidance—McDonough
 Project STEEP—Erickson & Egeland
 Infant Team—Zeanah & Larrieu
Child
Reeducation
Interventions
 Teenagers
 School Programs
 Teenage Fathers Involvement
 Low Birth Weight Infant
Parent
 Vermont Program
 Infant Health & Development Program
 Developmental Disabilities
 OT, PT, ET
 Overachieving Parents
 Integrating Parenting and Teaching Roles
Reeducate
Child
3-R’s of Intervention
Redefine
Parent
Parent
Reeducate
Remediate
Child
Child
time 1
time 2
Relationships Affecting Relationships
Intervener
Intervener
Redefine
Parent
Parent
Reeducate
Remediate
Child
Intervener
time 1
Child
time 2
Motherhood Constellation
Trep
Tact
Brep
Bact
Mact
Dynamic System
Mrep
Relationships Affecting Relationships
GEOPOLITICAL
COMMUNITY
FAMILY
PARENT
SCHOOL
CHILD
PEERS
Transactional Diagnosis
Over-Simplified Decision Tree
Is Child
Treatable?
YES
Remediation
NO
Do Parents Have
Child Rearing
Skills?
NO
Reeducation
YES
Redefinition
Agendas for
Infant Mental Health Professionals
3. Political Agenda
Who’s responsible for children?
Unlocking Doors
• Identifying who controls resources
• Changing allocation of resources
• Understanding what motivates
funding decisions
H.M.S. Titanic
Locking Doors
Fatality Rate for Women on the Titanic
50%
40%
30%
20%
10%
0%
1st Class
2nd Class
3rd Class
Unlocking Doors
• Identifying who controls resources
• Changing allocation of resources
• Understanding what motivates
funding decisions
Opportunities for Prevention or Intervention
OTHER
SELF
INFANCY
CHILDHOOD
ADOLESCENCE
ADULTHOOD
Unlocking Doors
• Identifying who controls resources
• Changing allocation of resources
• Understanding what motivates
funding decisions
Motivation for Political Funding
• Conservatives vs. Liberals
Family vs. Government Control
Personal Responsibility
• Medical Disease vs. Psychological Problem
Toxic Brain
• Prevention vs. Treatment
Public Health—Something for nothing
Cost-Benefit Analysis
?
X
Babies
Y
Successful
Adulthood
X
Children
Y
Adult
Mental Health
“Everything should be
as simple as possible
. . . but not simpler. "
Albert Einstein