Risk Factors are not predictive factors due to protective factors Carl C. Bell, MD

1. Prospects for the Prevention of Mental Illness: New Developments and New Challenges Risk Factors are not predictive factors due to protective factors Carl C. Bell, MD

2. Committee Charge • Review promising areas of research • Highlight areas of key advances and persistent challenges • Examine the research base within a developmental framework • Review the current scope of federal efforts • Recommend areas of emphasis for future federal policies and programs of research

3. Committee Members • KENNETH WARNER (Chair), School of Public Health, University of Michigan • THOMAS BOAT (Vice Chair),Cincinnati Children’s Hospital Medical Center • WILLIAM R. BEARDSLEE, Department of Psychiatry, Children’s Hospital Boston • CARL C. BELL, University of Illinois at Chicago, Community Mental Health Council • ANTHONY BIGLAN, Center on Early Adolescence, Oregon Research Institute • C. HENDRICKS BROWN, College of Public Health, University of South Florida • E. JANE COSTELLO, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center • TERESA D. LaFROMBOISE, School of Education, Stanford University • RICARDO F. MUNOZ, Department of Psychiatry, University of California, San Francisco • PETER J. PECORA, Casey Family Programs and School of Social Work, University of Washington • BRADLEY S. PETERSON, Pediatric Neuropsychiatry, Columbia University • LINDA A. RANDOLPH, Developing Families Center, Washington, DC • IRWIN SANDLER, Prevention Research Center, Arizona State University • MARY ELLEN O’CONNELL, Study Director

4. IOM: Reducing Suicide Report where the notion that risk factors were not predictive factors due to protective factors developed.

5. Categories of Adverse Childhood Experiences • Psychological abuse • Physical abuse • Sexual abuse • Violence against mother • Living with household members who were substance abusers • Living with household members who were mentally ill or suicidal • Living with ex-offender household members.

6. RESULTS • More than half of respondents (52%) experienced > 1 category of adverse childhood exposure • 6.2% reported > 4 exposures.

7. RESULTS • Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none had: • 7.4 fold increase for alcoholism • 10.3 fold increase for drug abuse • 4.6 fold increase for depression • 12.0 fold increase in suicide attempts.

8. RESULTS • Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none had • 2.2 fold increase in smoking • 2.2 fold increase poor self-rated health • 3.2 fold increase in > 50 sexual intercourse partners • 2.5 fold increase in sexually transmitted disease.

9. RESULTS • Persons who experienced 4 or more categories of childhood exposure compared to those who had experienced none had • 2.2 fold increase in ischemic heart disease • 1.9 fold increase cancer, • 3.9 fold increase in chronic lung disease (bronchitis and emphysema), • 1.6 fold increase in skeletal fractures, • 2.4 fold increase in liver disease.

10. Facts about Depression & Suicide • 20,000 out of 100,000 people get depressed • 5,000 out of 100,000 people attempt suicide • 11-20 out of 100,000 people complete suicide. • Something must be protecting the 19,980 people who are depressed and the 4,980 people who have attempted suicide.

11. Trauma is Ubiquitous • Bell & Jenkins (1985) found that 25% & 30% of inner-city Chicago youth, ages 7-15, had seen a shooting & stabbing. • Using structured telephone interviews in a national sample of 4,008 adult women, Resnick et al (1993) found a lifetime rate of exposure to any type of traumatic event of 69%. • Kessler et al (The National Comorbidity Survey - 1995) found that more 50% of nearly 6,000 subjects, ages 15 – 54, had experienced a traumatic event during their lifetime & most people had experienced more than one. • Breslau et al (1998) examined trauma exposure & the diagnosis of PTSD in a community sample of 2,181 individuals in the Detroit area and found that the lifetime prevalence of trauma exposure was 89.6%.

12. Exposure To A Traumatic Event Does Not Automatically Put A person On A Path To Develop PTSD: The Importance of Protective Factors To Promote Resiliency • Kessler et al (1995) found 8% of males and 20% of females • Breslau et al (1992) found 10% of males and 14% of females who were exposed to trauma had a lifetime prevalence rate of PSTD) • Exposure to a traumatic stress does automatically mean a victim of trauma is predisposed to develop PTSD. • Most people affected by a trauma event will adapt in a period of 3 – 6 months following trauma (Riggs et al, 1995) and only a small proportion will develop long-term psychiatric disorders (Bryant, 2006; Bryant 2006).

13. Paradigm Shift “Risk factors are not predictive factors because of protective factors.”

17. The Contribution of Prevention Science • The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.

18. Disorders Are Common and Costly • Around 1 in 5 young people (14-20%) have a current disorder • Estimated $247 billion in annual costs • Costs to multiple sectors – education, justice, health care, social welfare • Non-monetary costs to the individual and family

19. Dr. David Satcher’s Children’s Mental Health Conference suggested our Nation focus on: • Children in Child Protective Services • Children in Juvenile Justice Facilities • Children in Special Education

20. Preventive Opportunities Early in Life • Early onset (¾ of adult disorders had onset by age 24; ½ by age 14) • First symptoms occur 2-4 years prior to diagnosable disorder • There are common risk factors for multiple, different problems and disorders

21. NIMH Prevention Spending - 2008 • Prevention (RCDC FY2008) = $208,278,505 695 grants in this pile but only 60 (8.6%) were prevention grants. • Prevention Effectiveness Research (RCDC FY2008) = $34,281,125 107 grants in this category and about 32 (29.9%) were prevention grants. • Prevention Health Services Research (RCDC FY2008) = $28,970,981 100 grants here but only 15 (15%) were prevention grants (liberal definition). • Dissemination and Implementation Research = $23,746,062 67 of these grants and 6 (9%) were prevention grants. • Dissemination and Implementation Research in Prevention = $4,703,195 18 grants and 6 (33%) were prevention grants & some PI's were in the above category. • Effectiveness Research (RCDC FY2008) = $76,805,163 217 grants and 32 (14.5%) were prevention grants. • Health Services Research (RCDC FY2008) = $94,273,008 328 grants and 16 (4.9%) were prevention grants & some PI’s were in the above category.

22. Research Funding Illustration

23. Key Core Concepts of Prevention • Prevention requires a paradigm shift • Mental health and physical health are inseparable • Successful prevention is inherently interdisciplinary • Mental, emotional, and behavioral disorders are developmental • Coordinated community level systems are needed to support young people • Developmental perspective is key

24. Explosion in Randomized Trials

25. Resource silos Activity-driven Different language Different goals How are we functioning?

26. Evidence based Outcome driven Common language Maximize resources We need Synergy and a Integrated System

27. Common Risk Factors for Multiple Problems Risk Factors Are Not Predictive Factors Due To Protective Factors • Poverty • Coercive processes in families • Lack of self-regulation • Aggressive social behavior that is developmentally appropriate

28. The Critical Role of Self-Regulation • Neuroscience and behavioral research are converging on the importance of self-regulation for successful development • Children who do not develop the capacity to inhibit impulsive behavior, to plan, and to regulate their emotion are at high risk for behavioral and emotional difficulties

29. Prevention Window

30. Defining Prevention and Promotion • Prevention should not include the preventive aspects of treatment • Prevention and promotion overlap, but promotion has important distinct role • Mental health not just the absence of disorder

31. Mental Health Promotion Aims to: • Enhance individuals’ ability to achieve developmentally appropriate tasks (developmental competence) • Enhance individuals’ positive sense of self-esteem, mastery, well-being, and social inclusion • Strengthen their ability to cope with adversity

32. Prevention AND Promotion

33. Preventive Intervention Opportunities

34. Generic Features of Preventive Interventions • Reduce or minimize toxic biological and psychological processes • Richly reinforce self-regulated, prosocial behavior • Teach prosocial skills and values • Foster acceptance

35. Evidence that Some Disorders Can be Prevented • Risk and protective factors focus of research • Interventions are tied to these factors • Multi-year effects on substance abuse, conduct disorder, antisocial behavior, aggression and child maltreatment

36. Evidence that Some Disorders Can be Prevented • Indications that incidence of adolescent depression can be reduced • Interventions that target family adversity reduce depression risk and increase effective parenting • Emerging evidence for prevention of clinical schizophrenia

37. Nurse-Family Partnership* • Pregnancy through infancy • Focus on • Prenatal care • Maternal smoking • Mothering • Contraception • Work life * Funded in part by NIDA

38. Nurse-Family Partnership • Evaluated in three randomized trials for poor, teenager single mothers, • Significant effects on • Abuse and neglect • Children’s behavioral development • Mother’s economic wellbeing • Time to next baby • Children’s arrest as adolescent

39. Adjusted rates of arrests, 15-year olds, Elmira PC-NP & C-NPI = .005

40. CPS CRADLE TO CLASSROOM • Collaborative initiative with Chicago Public Health Department, six hospitals, & other agencies for pregnant & parenting teens • Trains teens in the development of parenting skills and accessing community resources • Provides teens access to prenatal, nutritional, medical, social, and child care services • Provides counseling to new mothers around issues of domestic violence

41. CPS CRADLE TO CLASSROOM • Some 2000 teenagers in 54 Chicago schools that offer this program had babies in 2002. All 495 seniors graduated, and 78% of them enrolled in 2- or 4-year college programs. • Only 5 of the women had a repeat pregnancy while still in school; 4 were graduating seniors, and the other, a junior, stayed in school. Eighty-five teen fathers also participated in the program, learning parenting skills under the supervision of a male mentor at each school. • The program's annual budget was $3.7 million

42. Positive Parenting Program—Triple P* * Funded in part by NIDA • A community-wide system of parenting supports that includes • brief media communications, • brief advice for specific problems, and • more extensive interventions when needed • Multiple randomized trials showing benefit • Including an RCT in 18 counties in South Carolina

43. Substantiated Child Maltreatment Before Triple P After Triple P Effect size = 1.09, p <.03. Triple P stopped a rising trend of substantiated child-maltreatment in counties using Triple P, compared to counties not receiving Triple P.

44. Child Out-of-Home Placements Before Triple P After Triple P Effect size = 1.22, p <.01, showing Triple P decreased medical injuries in counties using Triple P, compared to control counties not receiving Triple P increasing.

45. Strengthening Families 10-14(Spoth et al., 2001)* • Group-based parenting program for parents of early adolescents • Effects up to six years later • Reduced tobacco, alcohol, & drug use—including methamphetamine use • Reduced delinquency • Cost-effectiveness (Aos et al., 2004) • Savings of $7.82 per dollar invested • Total savings of $5,805 per youth * Funded by NIDA

46. The Family Check-Up* • Provides parenting support to families of adolescents via a family resource center in middle schools • Effects as much as five years later • Reduced substance use • Fewer arrests • Better school attendance & academic performance • Cost-effectiveness (Aos et al., 2004) • Savings of $5.02 per dollar invested • Total savings of $1,938 per youth * Funded in part by NIDA

47. New Beginnings Program (NBP) • Small group program for divorcing families • Emphases on learning new skills and applying them in the family

49. CMHC’s Work in McLean County, Illinois • The twin cities of Bloomington/Normal and Peoria, Illinois are located in McLean and Peoria counties, respectively, 135 -160 miles South of Chicago. • The two cities have a combined population base of 227,000 residents (Brinkhoff, 2005), approximately 25 percent of whom are African-American (Children and Family Research Center, 2003).

50. CMHC’s Work in McLean County, Illinois • Of the counties in this Central Illinois area (Fulton, Marshall, McLean, Peoria, Tazwell, and Wollford), McLean and Peoria are the only two with a substantial African-American population – 10.2% and 37.6% respectively, with all the rest having less than 1% (Children and Family Research Center, 2003).