The Crisis in Youth Mental Health: Experience Matters Hiram E. Fitzgerald, Ph.D.Michigan State University fitzger9@msu.eduODMHSASChildren's Mental Health State of the StateJanuary, 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 Creative expression 3 years to age 5 Music and rhythm Cognitive processing 1 year to age 4 Math/logical thinking Communication 1 year to age 4 Second language CommunicationCognition/thought Birth to age 4 Language acquisition Emotional and social systems Birth to age 2 Emotional attachment Orienting in space Birth to age 2-3 Visual processing Self control Birth to age 2-3 Emotion regulation Exploration Prenatal to age 4 Motor development System Maximum Period of Organization Developmental Process 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 achievedFacilitation: Hastens the appearance of endpointsMaintenance: Keep achieved endpoints functional Factors Highly Related to Positive Early Organizational Processes Ongoing nurturing relationships with the same adultsPhysical protection, safety, and regulation of daily routineExperiences responsive to individual differences in such characteristics as temperamentDevelopmentally appropriate practices related to perceptual-motor, cognitive, social stimulation, and language exposureLimit-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 2 Sibling 1 RISKY EXPERIENCES PRODUCE RISKY BEHAVIORS Establishing Risk Through family characteristicsThrough individual characteristicsThrough social environments Establishing Risk Through family characteristicsChildren of alcoholicsChildren of drug abusing or drug addicted parentsChildren of parents with antisocial personality disorder Establishing Risk Through family characteristicsThrough individual characteristicsExternalizing behavior, aggression, behavioral undercontrol, oppositional defiant disorderNegative emotionality, depressionAttention problems, ADHDShyness, social withdrawal, social phobia Establishing Risk Through family characteristicsThrough individual characteristicsThrough social environmentsHigh drug use environmentsHigh stress environments (violence, poverty, unemployment) Etiology of Alcohol Use DisordersIllustrating the Impact of Early Experience Developmental life course perspectiveSystemic 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 PovertyLow birth weightTransiencePoor nutritionLack of quality child careUnemployed parentsLack of access to health and medical careLow 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 AlcoholMarijuanaOklahoma25.2%9.4%US25.6%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 LateAdulthood Middle Adulthood Young Adulthood Adolescence Middle Childhood Preschool Years Infancy Prenatal 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 ChildhoodSchemas are Social Constructions, Representations, Autobiographical Memory Components of an Organizing Schema for Alcohol Abuse/Dependence and Co-active Psychopathology Sensory-PerceptualSensory identification of substancesPerceptual discrimination of substancesCognitive-MotivationalAttributions about who are appropriate usersExpectancies related to outcomes based on useAffectiveSelf-regulatory, self-control processesInterpersonal relationshipsSocialRole modelsPeer relationshipsDominance hierarchies/powerBiologicalFamilial historyCongenital 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 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 Vulnerable Resilient High Troubled Non-Challenged Low Family Adversity High Normal Range Child Psychopathology Externalizing Symptoms During Early Childhood and the Elementary School Years Stability and Change in Externalizing Symptoms During the Transition Into High School Internalizing Symptoms 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) Antisocial personality disorder, mood disorder, substance abuse disorder Adulthood Earlier onset of alcohol and other drug involvement, heavier alcohol and other drug problems, delinquency, depression. Adolescence Family disorganization (divorce/separation, loss of job, health or social problems or other family members), poorer parent monitoring Late middle childhood Behavioral problems, oppositional behavior, impulsivity, social withdrawal, poor school performance Childhood Lower self-regulation, externalizing behavior problems, social withdrawal, poor school readiness Preschool to kindergarten Difficult temperament, poor parenting, insecure to disorganized attachment, regulatory difficulties Infancy and early childhood Social Costs of the Strong Continuity Trajectory Academic difficulty and failureDate 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 School Adapted from: Zucker, Chermack, & Curran (2000) 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. 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. Adolescence 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); poorer parent monitoring; shift in more deviant peer network; increasing emergence of externalizing behavior, developing pattern of internalizing problems. ChildhoodGood school adaptation and performance; good friendship network. PreschoolSchool readiness, behavior within normal limits, adaptive temperament. Late Middle Childhood Infancy and Early ChildhoodNormative patterns of development during infancy Discontinuity Pathway 2 Discontinuity Pathway 1 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 supportsSustained exposure to cumulative risk factors minimizes chances for a great finish because it organizes dysfunctionEarly experiences influence later outcomes and depending on the nature of maintenance processes may determine outcomesHigh quality, sustained and systemic prevention programs can help children overcome bad startsEarly 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.
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The Crisis in Youth Mental Health: Experience Matters Hiram E. Fitzgerald, Ph.D.Michigan State University fitzger9@msu.eduODMHSASChildren's Mental Health State of the StateJanuary, 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 Creative expression 3 years to age 5 Music and rhythm Cognitive processing 1 year to age 4 Math/logical thinking Communication 1 year to age 4 Second language CommunicationCognition/thought Birth to age 4 Language acquisition Emotional and social systems Birth to age 2 Emotional attachment Orienting in space Birth to age 2-3 Visual processing Self control Birth to age 2-3 Emotion regulation Exploration Prenatal to age 4 Motor development System Maximum Period of Organization Developmental Process 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 achievedFacilitation: Hastens the appearance of endpointsMaintenance: Keep achieved endpoints functional Factors Highly Related to Positive Early Organizational Processes Ongoing nurturing relationships with the same adultsPhysical protection, safety, and regulation of daily routineExperiences responsive to individual differences in such characteristics as temperamentDevelopmentally appropriate practices related to perceptual-motor, cognitive, social stimulation, and language exposureLimit-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 2 Sibling 1 RISKY EXPERIENCES PRODUCE RISKY BEHAVIORS Establishing Risk Through family characteristicsThrough individual characteristicsThrough social environments Establishing Risk Through family characteristicsChildren of alcoholicsChildren of drug abusing or drug addicted parentsChildren of parents with antisocial personality disorder Establishing Risk Through family characteristicsThrough individual characteristicsExternalizing behavior, aggression, behavioral undercontrol, oppositional defiant disorderNegative emotionality, depressionAttention problems, ADHDShyness, social withdrawal, social phobia Establishing Risk Through family characteristicsThrough individual characteristicsThrough social environmentsHigh drug use environmentsHigh stress environments (violence, poverty, unemployment) Etiology of Alcohol Use DisordersIllustrating the Impact of Early Experience Developmental life course perspectiveSystemic 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 PovertyLow birth weightTransiencePoor nutritionLack of quality child careUnemployed parentsLack of access to health and medical careLow 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 AlcoholMarijuanaOklahoma25.2%9.4%US25.6%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 LateAdulthood Middle Adulthood Young Adulthood Adolescence Middle Childhood Preschool Years Infancy Prenatal 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 ChildhoodSchemas are Social Constructions, Representations, Autobiographical Memory Components of an Organizing Schema for Alcohol Abuse/Dependence and Co-active Psychopathology Sensory-PerceptualSensory identification of substancesPerceptual discrimination of substancesCognitive-MotivationalAttributions about who are appropriate usersExpectancies related to outcomes based on useAffectiveSelf-regulatory, self-control processesInterpersonal relationshipsSocialRole modelsPeer relationshipsDominance hierarchies/powerBiologicalFamilial historyCongenital 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 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 Vulnerable Resilient High Troubled Non-Challenged Low Family Adversity High Normal Range Child Psychopathology Externalizing Symptoms During Early Childhood and the Elementary School Years Stability and Change in Externalizing Symptoms During the Transition Into High School Internalizing Symptoms 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) Antisocial personality disorder, mood disorder, substance abuse disorder Adulthood Earlier onset of alcohol and other drug involvement, heavier alcohol and other drug problems, delinquency, depression. Adolescence Family disorganization (divorce/separation, loss of job, health or social problems or other family members), poorer parent monitoring Late middle childhood Behavioral problems, oppositional behavior, impulsivity, social withdrawal, poor school performance Childhood Lower self-regulation, externalizing behavior problems, social withdrawal, poor school readiness Preschool to kindergarten Difficult temperament, poor parenting, insecure to disorganized attachment, regulatory difficulties Infancy and early childhood Social Costs of the Strong Continuity Trajectory Academic difficulty and failureDate 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 School Adapted from: Zucker, Chermack, & Curran (2000) 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. 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. Adolescence 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); poorer parent monitoring; shift in more deviant peer network; increasing emergence of externalizing behavior, developing pattern of internalizing problems. ChildhoodGood school adaptation and performance; good friendship network. PreschoolSchool readiness, behavior within normal limits, adaptive temperament. Late Middle Childhood Infancy and Early ChildhoodNormative patterns of development during infancy Discontinuity Pathway 2 Discontinuity Pathway 1 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 supportsSustained exposure to cumulative risk factors minimizes chances for a great finish because it organizes dysfunctionEarly experiences influence later outcomes and depending on the nature of maintenance processes may determine outcomesHigh quality, sustained and systemic prevention programs can help children overcome bad startsEarly 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.