Overcoming developmental risk:  A biopsychosocial foundation

for early interventions

Oslo—RBUP—June, 2009

Arnold Sameroffsameroff@umich.edu

Agendas for Intervention Professionals

1. Academic

2. Social

3. Political

• How do we understand children?

• How do we improve children?

• Who is responsible for children?

Agendas for Intervention Professionals

2. Social Agenda

How can we improve children’s lives?

Opportunities for Prevention or Intervention

INFANCY CHILDHOOD ADOLESCENCE ADULTHOOD

BIOLOGY

PSYCHOLOGY

SOCIAL

ECOLOGYSOCIAL

ECOLOGY

OTHER

SELFSELF

Improving Developmental SuccessImproving Developmental Success

1) Make Children More Resilient1) Make Children More Resilient

2) Make Environments Less Risky2) 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

3.0

3.2

3.4

3.6

3.8

4.0

4.2

Low Moderate High

Early Social Risk

4-Y

ear M

. H

.

High

Low

Infant Competence

Infant Competence Predicting to 4-Year Mental Health

4-Year Mental Health Predicting to 18-Year Mental Health

50

60

70

80

90

Low Moderate High

4-Year Social Risk

18-Y

ear M

enta

l Hea

lth

High MH

Low MH

4-Year

60

70

80

90

Low Moderate High

13-Year Social Risk

18-Y

ear M

enta

l Health

High

Low

13-Year (Y)Mental Health

13-Year Mental Health Predicting to 18-Year Mental Health

18-Year Mental HealthPredicting to 30-Year Mental Health (PIRS)

18-Year MH

2

3

4

0 1 2 3 4+

18-Year Social Risk

30-Y

r. M

enta

l H

ealt

hHigh

Low

2

3

4

0 1 2 3 4+

18-Year Social Risk

30-Y

r Phy

sica

l Hea

lthHigh

Low

18-YearMental Health

18-Year Mental HealthPredicting to 30-Year Physical Health

PhiladelphiaAdolescent Development Study

Todd Bartko, Jacque Eccles

Frank Furstenberg, Tom Cook, Glen Elder

500 11- to 14-year olds Urban Setting

Examine Multiple CompetenciesExamine Multiple Risks

Social Ecological ModelGEOPOLITICAL

COMMUNITY

FAMILY

PEERSCHILD

PARENT

SCHOOL CHILD

20 Negative20 NegativeEnvironmental InfluencesEnvironmental Influences

20 Negative20 NegativeEnvironmental InfluencesEnvironmental Influences

Proximal• Parent-Child Interaction• Parent Characteristics• Family Structure & Economy

• Family Management• Peers• School• CommunityDistal

Indicators of Adolescent Success

• Psychological Adjustment

• Few Problem Behaviors

• Academic Competence

DepressionAngerSelf-Esteem

Substance UseEarly Sexuality DelinquencyViolence

Grades

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

0 1 2 3 4 5 6 7+

Multiple Risk Score

Sta

ndar

dize

d m

eans

Psychological Adjustment

Problem Behavior

Academic Performance

Resourcefulness

High

Low

Psychological AdjustmentProblem Behavior Academic Performance

Multiple Risk

HIGHMEDLOW

1.0

.8

.6

.4

.2

.0

-.2

-.4

-.6

-.8

-1.0

Multiple Risk

HIGHMEDLOW

1.0

.5

0.0

-.5

-1.0

Multiple Risk

HIGHMEDLOW

1.0

.5

0.0

-.5

-1.0

Lines indicate means and 95% confidence intervals

Question:

Can Personal ResilienceOvercome Environmental Adversity?

Answer:

Not for most people,For most of the time!

Improving Developmental SuccessImproving Developmental Success

1) Make Children More Resilient1) Make Children More Resilient

2) Make Environments Less Risky2) Make Environments Less Risky

Political Strategies for Social Intervention

Conservatives-----Preserve the Family

Liberals------------Eliminate Poverty

Psychological Adjustment

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Stan

dard

ized

mea

ns

Problem Behavior

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Academic Performance

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Preserve the Family

Single Parent

Two Parents

Psychological Adjustment

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Sta

ndar

dize

d m

eans

Problem Behavior

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Academic Performance

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Low (0-2) Moderate (3-5) High (6+)

Multiple Risk

Eliminate Poverty

Below Poverty Level

1 to 2 Times Poverty Level

> 2 Times Poverty Level

Percent of Families in High and Low Risk Groups

Percent of Families in High and Low Risk Groups

7%22%6%15%44%High (8+)

54%34%60%35%13%Low (0-3)

TwoParents

Single Parent>$30,00

0

$10-30,000>$10,00

0

Family Structure

IncomeRisk Group

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 20 Positive Environmental InfluencesEnvironmental Influences

20 Positive 20 Positive Environmental InfluencesEnvironmental Influences

Proximal• Parent-Child Interaction• Parent Characteristics• Family Structure & Economy• Family Management• Peers• School• CommunityDistal

-0.9

-0.6

-0.3

0

0.3

0.6

0.9

1.2

1 2 3 4 5 6 7 8 9 10 11 12 13+

Promotive Factors

Co

mp

eten

ce

Psychological Adjustment

Self-Competence

Problem Behavior

Activity Involvement

Academic Performance

-0.9

-0.6

-0.3

0

0.3

0.6

0.9

1.2

1 2 3 4 5 6 7 8 9 10 11 12 13+

Promotive Factors

Co

mp

eten

ce

Psychological Adjustment

Self-Competence

Problem Behavior

Activity Involvement

Academic Performance

Psychological Adjustment

Self-Competence

Problem Behavior

Activity Involvement

Academic Performance

Self-Competence

Problem Behavior

Activity Involvement

Academic Performance

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 ModelGEOPOLITICAL

COMMUNITY

FAMILY

PEERSCHILD

PARENT

SCHOOL CHILD

Family Setting

FAMILY

CHILD

PARENT

CHILD

Regulation Model

Development

Other-Regulation

Self-Regulation

Who’s Suffering?

• Infant

• Parents

• Professionals

• Sleep, Feeding, Crying

• Stress, Depression

• Abuse and Neglect

Who’s the Patient?

• Infant

• Parents

• The Relationship

• Themes

Structural ModelMotherhood Constellation

Daniel SternNadia Bruschweiler-Stern

Process ModelTransactional Diagnosis

Arnold SameroffBarbara Fiese

Motherhood Constellation

Bact Mact

Motherhood Constellation

Bact Mact MrepBrep

Motherhood Constellation

Bact Mact MrepBrep

Tact

Trep

Motherhood Constellation

Ba MaMrBr

Ba MaMrBr

Ba MaMrBr

Parent

Child

time

Transactional Diagnosis

P2

P4

C1 C3 C5

3-R’s of Intervention3-R’s of Intervention

Remediation

Redefinition

Reeducation

3-R’s of Intervention

Parent Parent

Child Child

Remediate Reeducate

Redefine

time 1 time 2

Remediation

Indicated Child Conditions Low Birth Weight Malnourishment Behavior/Emotional Problems

Parent

Child

Remediate

Remediation Low Birth Weight Babies

Problem Small, fragile appearance Weak responses

Interventions Gentle Stimulation

Deep Massage Passive Limb Movement Increases Activity/Alertness

Non-nutritive sucking Accompanies Tube Feeding Increases Weight Gain Earlier Discharges

Parent

Child

Remediate

Remediation Malnourished Infants

Problem Unresponsive Inactive

Feeding Intervention Greater Responsiveness Increased Energy Level Provide Stronger Cues

Parent

Child

Remediate

Remediation

Medical Interventions Surgery

Cleft Palate Down Syndrome

Medication Mood Colic

Parent

Child

Remediate

Redefinition

Indicated Parent Conditions Failure to adapt to exceptional child Failure to distinguish mother perception from

child behavior “Ghosts in the Nursery” Negative attributions

Parent Parent

Redefinition

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

Parent Parent

Redefinition

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

Parent Parent

Redefinition

“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

Parent Parent

Redefinition

Negative Attributions Problem

Parent’s negative view of others (self?)

Intervention Positive Adjective-Bugental

Parent Parent

Reeducation

Indicated Parent Conditions High Risk Parents Teenage Parents Low Birth Weight Infant Developmental Disabilities Overachieving Parents

Parent

Child

Reeducate

Reeducation

High Risk Parents Problem

Low Resource Parents Retarded Parents Maltreating Parents

Intervention Interaction Guidance—McDonough Project STEEP—Erickson & Egeland Infant Team—Zeanah & Larrieu

Parent

Child

Reeducate

ReeducationInterventions

Teenagers School Programs Teenage Fathers Involvement

Low Birth Weight Infant Vermont Program Infant Health & Development Program

Developmental Disabilities OT, PT, ET

Overachieving Parents Integrating Parenting and Teaching Roles

Parent

Child

Reeducate

3-R’s of Intervention

Parent Parent

Child Child

Remediate Reeducate

Redefine

time 1 time 2

Relationships Affecting Relationships

Parent Parent

Child Child

Remediate Reeducate

Redefine

time 1 time 2

Intervener

Intervener

Intervener

Motherhood Constellation

Bact Mact MrepBrep

Tact

Trep

Dynamic System

Relationships Affecting Relationships

GEOPOLITICAL

COMMUNITY

FAMILY

PEERSCHILD

PARENT

SCHOOL

Transactional DiagnosisOver-Simplified Decision Tree

Is ChildTreatable?

Do Parents HaveChild Rearing

Skills?

Remediation

Redefinition

Reeducation

YES

YES

NO

NO

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

0%

10%

20%

30%

40%

50%

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

INFANCY CHILDHOOD ADOLESCENCE ADULTHOOD

BIOLOGY

PSYCHOLOGY

SOCIAL

ECOLOGYSOCIAL

ECOLOGY

OTHER

SELFSELF

Unlocking Doors

• Identifying who controls resources

• Changing allocation of resources

• Understanding what motivates funding decisions

Motivation for Political Funding

• Conservatives vs. LiberalsFamily vs. Government Control

Personal Responsibility

• Medical Disease vs. Psychological ProblemToxic Brain

• Prevention vs. TreatmentPublic Health—Something for nothing

Cost-Benefit Analysis

YX

SuccessfulAdulthood

Babies

?

YX

Children Adult Mental Health

. . . but not simpler. "

“Everything should be as simple as possible

Albert Einstein