Concepts and Experiences of Early Prevention
by Henri Parens
Prevention in Psychiatry lags far behind the widespread prevention efforts made, and successes achieved during the last two hundred years in Epidemiology, for nearly one century in Pediatrics, and now for several decades in Internal Medicine and in Ob-Gyn. The increase in longevity among humans achieved during this century points to the increasing successes of many of the efforts made in those specialties.
A reading of psychiatric prevention research efforts, on the other hand, is burdened with disappointments in the outcome of prior efforts, and by enormous obstacles put up by funding and by society in general. There is much evidence that Mental Health Specialties, especially Psychiatry, have long been among the most worrisome, indeed most feared, and consequently it seems least respected of the Health specialties and their importance least acknowledged by government and by society.
The fact is that we have made and continue to make many efforts toward the prevention of mental illness; and, I assert, we can do much more. In fact, I say that we can move into the realm of primary prevention in Mental Health. But before I say how we can move into the realm of the primary prevention of experience-derived emotional disorders in children, I have to address some critical problems of a conceptual nature that undermine the essence of Mental Health.
Does Prevention in Mental Health Make Sense?
To say that it does, we must first consider what we have found to be critical determiners of good or poor mental health, how mental health develops, and what of mental and behavioral illness we can prevent. If we want to prevent mal-development and mal-adaptation in humans, we must ask if experience is a sufficient co-determiner of personality formation, of the development of adaptive abilities, and of pathology? And with this, we have to ascertain that what happens early will affect how we are later, or more simply, does early childhood experience have a bearing on life-span development and adaptation? We recognize that woven into these questions are the „nature versus nurture“ problem (equivalent to the „heredity versus environment“ or „genotype versus experience“ problem), the „mind-body“ problem, and the „continuity/discontinuity“ problem of developmental theory. I want to briefly present some critical findings in order to cogently assert that, because biological givens and experience are powerfully co-determining of personality formation from the beginning of life, prevention efforts that would optimize the development of adaptive abilities and personality formation can be undertaken.
Biology and Experience Co-Determine Personality Formation from the Start
We are among those who assume that the nature versus nurture problem is best represented by the assumption that both nature and nurture, or genes and experience (environment), are crucial interacting co-determiners of personality formation and mental health. Freud (1924) held that nature and nurture interact in a complementary balance of the two factors that operates variably in individuals. Hartmann (1939) too emphasized that biogenetic factors determine characteristics evident already in the newborn’s adaptive (ego) functioning, such as in inborn reactivities (automatisms) and adaptive patterns of coping. Although we agree that an interactional nature and nurture concept best represents what happens, we think it is more complex than a simple complementary equation. We assume that in any given individual, some biogenetic factors are more powerfully determining of specific aspects of adaptive patterning and of personality formation and, thereby, of specific aspects of mental health while others are quite less so. And similarly, some experiential factors may be more powerfully determining of specific aspects of adaptive patterning and personality formation, while others are not. In addition, one individual may be heavily loaded biogenetically and also be heavily loaded experientially; another may be moderately loaded biogenetically and experientially; and most of us are probably a variable mix of heavy and light loading coming from both our nature and our experiences.
With regard to the „Mind-Body Problem“, Psychodynamic Mental Health clinicians and theorists have embraced a unitary mind-body theory. From the simpler unitary mind-body theory proposed in 1933 by von Bertalanffy (1962) and the later further evolved organic unity theory theory of Goodman, (1991, 1996), to the view expressed not long ago by Andreasen (1996), we have come to a more detailed view of the mind-body question. Pally (2000), integrating findings from recent Neuroscience research on emotions, tells us that it is not just the psyche that impacts on the body, but that „The body plays an active role in mental life“. She tells us that an emotion „is not just a mental state but a complex psychobiological state“. The body and the mind interact reciprocally, each directly influencing the other.
The Role of Experience in Brain Structure Formation and Development
Eric R. Kandel, recent and first Nobel Prize winner in Neuroscience, launched by his 1960s studies of the sea slug „Aplysia“ has progressively elaborated the role of experience on central nervous system synapse formation and modulation in early life and beyond. Kandel et al. (1991) proposed that there are three overlapping developmental stages of synaptic modification:
„The first stage, synapse formation, occurs primarily in the early stages of development and is under the control of genetic and developmental processes.
The second stage, the fine tuning of newly developed synapses, occurs during critical periods of development and requires appropriately patterned activity in neurons usually provided by environmental stimulation.
The third stage, the regulation of both the transient and long-term effectiveness of synapses, occurs daily throughout life and also is determined by experience.“
That experience is thought to critically impact on development during critical periods is much supported by the work of Harry Harlow and his collaborators. Harlow’s classical studies of Rhesus monkeys from birth through adulthood dramatically documented the effects of specific parental attachment deprivation experience – peer attachment was insufficient to compensate – on the infant, and eventually adult, monkey’s behavior and adaptation.
More recent studies of animals found to provide well-founded physiological bases for inference into human functioning, further document the effects of maternal deprivation in infancy (Braun, 2001). Presenting a controlled study of infant rats subjected to a programmed series of transient separations from their mothers, Braun (2001) reported significant shifts in 4 key brain neurotransmitters in consequence of these even transient maternal deprivations.
Another among a number of studies documenting the influence of experience on brain development and structuring, is that of Garbareno et al. (1996) who have shown that emotional trauma produces neurological damage in children which can subsequently lead to impaired social and cognitive functioning. We have also learned that childhood trauma impacts on brain physiology and on the development of cognitive function, memory and adaptive reactivity.
Stress (Experience) and Genetic Expression
In 1979, Meyersburg and Post joined efforts and postulated an experience-neurobiologic-integrated model of early brain development. They proposed that „during the early months [of life] the striatic and limbic systems subserve the task of integrating and storing emotional and perceptual experiences. Severely painful emotional loading of early experiences may establish memories which have disruptive potentialities not only by facilitating disphoric responses to a repetition of the early stimuli but possibly exerting (…) influence on the subsequent development and maturation of neural structure. (…) The memories of these experiences will replicate the disphoric tone of the primary episode as well as the general state of being which prevailed at that time. (…) If disphoric experiences are too intense, correspondingly intense memory processes evolving in the limbic substrates may remain inadequately modulated by higher neocortical centers and may evolve into autonomous excitational foci“. Meyersburg and Post furthermore assume that there are critical periods for neuronal development and that „trauma occurring during a vulnerable period may evoke aberrant neuronal development and may leave permanent effects on neuro-organization“.
More than a decade later, Robert M. Post (1992) reported further findings supportive of the hypothesis that experience powerfully influences brain structure and physiology by virtue of the reactive functioning demanded of it. Following on the line of thought he already stated in 1979, Post now assumed that sensitization to specific stressful life events occurs and that these are encoded at a genetic level. Taking the model of amygdala-kindled seizures, Post tells us that recent findings in neurobiology regarding how electrical and chemical stimulation and psychosocial stressors affect gene expression provides an explanatory model whereby an acutely stressful event can acquire long-lasting effects on subsequent reactivity in the individual. For instance, regarding major affective disorders, he believes that psychosocial stressors and the biochemical concomitants these activate „can induce (…) transcription factors, which then affect the expression of transmitters, receptors, and neuropeptides that alter responsivity in a long-lasting fashion“. Post proposes that genetic expression, in this way, could be regulated by experience.
Stress (Experience), Immunology, and Disease
A number of studies during the last two decades clarified dramatically the role of stress on the immune system. Numerous studies have supported the finding that stress reduces immune system cells, including T cells, CD4 cells, B cells, and other blood cells that combine to fight infection and other foreign body experiencing. This correlation has been further studied by a number of investigators.
Thus the clinical assumptions made by Cannon and Selye have found documentation in „stress à immune suppression“ studies. Engel and Schmale narrowed the focus in their „object loss may lead to somatic illness“ hypothesis, asserting the effects on the soma of a specific experiential-emotional stress. Clearly a unitary mind-body theory is well supported by this line of research.
Studies in Support of Continuity in Development from Childhood into Adulthood
The „continuity/discontinuity problem“ in development – though interpreted differently by theorists – is pertinent to the question „Does experience from early life on, play a key role in personality formation and in mental health?“ We are not all in agreement on this issue. Kagan (1984) for one has proposed that early childhood experiences do not leave evidence of their influence in later life. Also, Wagner Bridger in his 1989 Presidential Lecture to the Society for Biological Psychiatry held that the influence of early life experience on the early patterning of modes of adaptation is not continued for life, that past adaptations do not influence later developments.
One specific finding has been used to cast doubt on the continuity model of development proposed by Erikson (1959). It is the discontinuity through development of manifest symptoms as, for example, the 8 year-old child who suffered from phobias but did not become a 28 year-old with phobias, rather he exhibited a well defined obsessive-compulsive disorder. The assumption made is that were continuity to persist from one phase of development to another, the continuation of a specific symptom picture would be predictable. Forty years ago, Anna Freud (1965) stated that symptom continuity is not predictable. Indeed, from the 1920s to the present, child analysts have held the view that we cannot securely predict future adaptation from those evident during the early years of life. This is because we cannot predict with certainty that specific developmental challenges, even traumatic ones, may be experienced adversely or, on the contrary, may even be reparatory and development-promoting for any given child. Mental Health clinicians know only too well, that prediction in our field is burdened with too many unknowns.
Following their research on the continuity/discontinuity question, Kohlberg, Ricks and Snarey (1984) note that despite weakness in development predictability, they take the position, as do most psychodynamic development theorists, that
„(a) There is continuity between mental health in childhood and mental health in adulthood, and
(b) [that] environmental factors contributing to mental health or illness are more amenable to social intervention in childhood than later in life. (…) The notion that mental health dispositions are largely formed in childhood assumes continuity in development, but it does not imply that this continuity is one of fixation or stabilization of mental-health traits in the childhood years. Theories of ego development assume that humans move through a series of stages and developmental tasks or crises and that retardation or conflict at one stage color task solutions at later stages. They do not assume that the adult’s traits or mental-health status are [necessarily] the same as those he showed in childhood“.
The proponderence of mental health developmentalists hold that an individual traverses his or her life span starting with biogenetically determined inborn dispositions, tendencies and reactivities that predetermine – allow and limit – the ever-evolving individual he or she becomes over time, day by day, month by month, into the declining years. Inborn patterns of reactivity evidenced already in the 30 to 40 week old fetus become known by parents, become typical and predictable. Newborns in neonatal nurseries show evidence of dispositions, tendencies, and reactivities – temperament, in short – that seem stable, readily identifiable, and soon become predictable by nurses, doctors, and especially by the infants‘ mothers and fathers (who are involved consistently enough from birth on).
As is held in biology, the phenotype is forged over time out of the genotype by the organism experiences. The simple but sweeping paradigm affirming the importance of experience-environment on development asserts that two peas from the same pod planted in different soils, conditions of heat, food and water, will thrive or not thrive by virtue of these variable environmental conditions. We all know this.
Psychoanalytic Studies that Support Continuity Theory
Longitudinal studies by some psychoanalysts provide findings in support of continuity in development and personality formation. Louis Sander who studied a limited population of subjects over 4 decades has reported that their attempt to predict recognition of adults from their early childhood profiles was not successful. What was recognizable, however, were their patterns of coping, their patterns of adaptation. J. B. McDevitt (1991) reported finding continuity in the cluster of defense mechanisms used and therewith patterns of coping by adults who had been studied longitudinally in M. S. Mahler’s study at the Masters Children’s Center in the 1960s. In their ongoing prospective study of children they have been following now into their third decade, Egeland and his group have been finding continuity in the children’s attachment characteristics and patterns of coping. They are finding that those children whose attachment is typed in category B (secure attachment) have faired developmentally more positively and successfully than those who formed A, C, and D category attachments (all anxiety laden or disorganized) (Ainsworth, et al, 1978; Main, 1986; Crittenden, 1988).
In Summary, the findings detailed above provide powerful documentation in support of affirming that experience, from early life on, plays a key role in personality formation, including the development of adaptive abilities, and the patterns of coping, and of psycho-pathology. It is this line of thought, strongly supported by my own research and clinical findings that leads me to assert that mental health prevention strategies are possible, are warranted, and are highly promising.
Toward the Prevention of Experience-Derived Emotional Disorders in Children via Parenting Education
Take 2 equally healthy newborns:
Mother A has a good relationship with her baby, is capable of „growth-promoting“ parenting. The result when her baby is 12 months: she is positively attached, has developed sound basic trust, and is physically and emotionally well-developed.
Mother B, a 17 year old with a well endowed, healthy infant who developed beautifully to age 6 months while living with her aunt and teenage boyfriend, when abandoned by her boy friend after moving out of the aunt’s home, became depressed, then neglectful and abusive of her baby, as a result of which at 14 months he looked about 8 months old, an infant failing to thrive, depressed, morose, poorly attached, suspicious, subject to rage reactions and destructive.
This could have been prevented! There are many such cases in the world.
How We Got to Where We Are
The major project that led to the following prevention efforts began in 1969. In a group of 10 mothers with their infants and young children, we attempted to correlate qualitative aspects of the mother-child relationships with the development of constructive adaptive abilities in their children. Within two years of twice weekly observations and communications pertaining to their children, we found that the mothers‘ questions gave us unexpected opportunities to help them optimize the rearing of their children. We had found a method for enhancing parents‘ efforts in their child rearing work. We saw that this was in effect an educational method. Following on this experience, in 1975, we began to develop two projects: (1) Toward Preventing the Development of Excessive Hostility in Children, and (2) Curriculum for Students Parenting Education For Emotional Growth (not reported in this article).
As we continued with our educational-interventional research, we saw remarkable gradual changes in the ways our project mothers were handling their children. Based on our understanding and experiences as clinicians, we could see clearly that the ways the mothers were rearing their children would be mental health promoting. The eventual changes in our mothers parenting was much clearer and larger than we had anticipated. Although as clinicians we could see the microscopic but crucial beneficial effects of the mothers’ parenting on their growing children, the outcome in a decade or more would be measurable.
Prevention/Early Intervention Project – 19 Year Follow-up Study
A follow-up study conducted 19 years from the start of our prevention/early intervention project yielded the findings stated below (Parens, Bockoven and Goldberg, 1993). The data were collected: (1) by means of mother and child questionnaires, which were followed (2) by one or two open-ended, semi-structured interviews of each mother and each child. The population consisted of seventeen children, thirteen girls and four boys. All families were from lower socioeconomic and lower middle socioeconomic groupings. Because it is the pregnant mothers who were admitted to the program, our population of children was un-selected, boys/girls distribution uneven, and one child suffered from cerebral palsy. Our findings on this small group of subjects support the prediction that the educational parent-child group can produce significant and enduring benefits for both children and their parents. These benefits significantly contributed to their developing into productive, socially responsible young people.
(1) General Adaptation Questions
Trouble with the Law: None of the youngsters had any encounters with legal authorities. By contrast, in the population at large, there were 118.6 arrests per 1,000 among 14- to 17-year-old youths in the United States in 1985. In Philadelphia 21.4 percent of high school students were suspended at least once in 1986-1987.
Drug Abuse: Of fifteen subjects, one used metamphetamine, which she reported to her parents and for which she went into treatment. The incidence for the study group was 6.7 percent. With regard to the population at large, among U.S. high school seniors in 1986 any illicit drug use ever was reported at 57.6 percent. Any alcohol use ever was reported at 91.3 percent (U.S. Department of Education 1988).
Teenage Pregnancy (including boys‘ involvement): Twelve of the subjects were 14-years-old and older; of these, two became pregnant, a 13 percent rate. One interrupted her pregnancy. The Philadelphia Inquirer (1988) reported that 10 percent of girls aged 15 to 17 become pregnant each year. Pregnancies among U.S. high school seniors were reported at 72.3 per 1,000 in 1983 (U.S. Department of Education 1988). Other reports suggest higher rates for community peers of the group we studied.
Teenage Parenthood (including boys‘ involvement): One 18-year-old with 2 children attributed her pregnancies to the failure of birth control. Therefore, of the twelve youngsters over 14 years of age, one became a parent, yielding a 6 percent incidence. In the population at large, reports suggest a higher rate of parenthood in the population groups from which these youngsters come.
School Performance: One out of fifteen dropped out of high school, yielding an incidence of 6.7 percent. In the population at large, approximately 40 percent drop out of high school in the population from which these youngsters come. Except for the retarded child, none of these children failed to achieve grade level work. Several of the younger children expressed interest in going to college.
Going on to College: Four of the 18-year-olds went on to college. One left college after one semester due to financial problems, but wishes to return. The other three are faring well in college. This yields three of six college age youngsters to be in college, an incidence of 50 percent. In the population at large, 20 percent go on to college.
We believe the study group was not predestined by life conditions to do well.
(2) Anger and Hostility
Our findings were collected using the Fitzgibbons Anger Inventory (1984), a questionnaire that measures anger/hostility expressed in four modes: overall anger, violence potential, passive aggression, trust/mistrust. The FAI test population scores are from samples of adolescents in comparable communities to those of the subjects. Fitzbiggons considered „moderate“ to be an indicator of potentially troublesome behavior.
Overall anger: Our study group scored in the lowest category, mild anger. The community average for adolescents was moderate anger. The study group average was 37.8 (cut-off = 45); their urban population scored 50.1.
Violence potential: This score estimates that excessive hostility may be expressed in violent actions toward others. The study group score was 5.1, in the mild range, while the population at large scored 7.96, exceeded the cut-off (= 7), indicating moderate potential violent dangerousness.
Passive aggression: This category expresses the tendency of people to express anger only in indirect ways, sometimes with defiance and self-defeating consequences. The study group is at the high end of the mild range, while the population at large falls within the moderate range. The study group registered an 8.8 score (cut-off = 9); the population at large scored an average of 10.11.
Trust/mistrust: Both study group population and the population at large scored at about the cut-off mark of 6.0.
(3) Changes in Parenting
Changes in parenting were determined by assessments on four parameters of central importance in determining growth-promoting or growth-disturbing parenting (Parens et al. 1986, 1989).(1) The mother’s understanding of her child’s behaviors and needs and the tasks of child rearing to optimize her parenting efforts and her child’s development. (2) The shift in the balance of her loving and hating her child, much of which grows out of the mother’s feeling her efforts to succeed/fail as reflected in her child’s success/failure in development and adaptation. (3) The manifest and subjective feeling of her evolving effectiveness as a parent. And (4) the degree to which her functioning as a parent has contributed to her overall feelings of self worth and competence as a parent and as an individual.
Two assessments were made: one by the mothers and one by the Early Child Development Program staff. Assessments are made on a 10 point scale (1 = least/worst, 10 = most/best); each figure represents the mean for the mothers as a group. Ten mothers participated from 1 year and 4 months to 5 years and 6 months duration (average 4.4 years; median 4.1 years) for 1 to 4 hours weekly (average attendance was 79 percent). Of the ten mothers, eight rated themselves; one mother did not return her self-assessment, and one could not be contacted. The ECDP staff evaluated all ten mothers.
The results from the mothers‘ self-assessments indicate a rate of change toward better functioning of more than five points for each of the four parameters: 5.4 on understanding child and rearing, 5.2 on shift in ambivalence, 5.3 on effectiveness of parenting, and 5.6 on increase in feelings of self-worth and competence. The range of change was from a pre-experience self-assessment mean of 3.3 to a post-experience assessment mean of 8.5+. The results from the ECDP staff (there were four raters) indicated an evaluated change of 3.5+ on average for the 4 parameters, changes of 3.9, 2.7, 3.8, and 3.8 respectively. The range of change was from a pre-experience assessment mean of 4.3 to a post-experience assessment mean of 7.7. We evaluate parenting along the parameter of growth-promoting to growth-disturbing; if this is stated on a ten point scale, a change toward improvement in parenting of 3.5 (staff evaluation) to 5.4 (parent self-rating) can effect a significant shift toward growth promoting parenting.
As we found in the 19-Year Follow-up Study, when parents feel equipped with better understanding of their children and more options with which to parent constructively, this increases their confidence, reduces their anxiety, and generates more adaptive responses in themselves and their children. As with the limited findings of the 19-Year Follow-up, although these findings are preliminary, the message is not. These findings support the key assumption that mental-health-informed parenting facilitating programs as these can have a significant prevention potential.
Let me close with asserting that the prevention of tomorrow’s violence and malignant prejudice must be undertaken today. Society has fallen victim to the promotion of fast foods, to the advocacy of short, quick, and low cost solutions that, many of us know have no chance of resolving these problems. Long term strategies and more money than we like to think, are needed to do the job necessary to deal with violence and malignant prejudice, and to prevent their perpetuation and predictable increase in the next generation. But whatever the cost, I submit to you that the cost of preventing tomorrow’s violence and malignant prejudice is far less than would be required to handle next generation’s violence if it continues on its present course.
Die vollständige Fassung einschließlich der Tabellen und Literaturangaben ist über die Geschäftsstelle erhältlich.
Prof. Dr. Henri Parens ist Kinderpsychiater am Jefferson Medical College in Philadelphia (USA)