Reducing Risks for Mental Disorders Frontiers for Preventive Intervention Research (1994) / Chapter Skim
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6 RISK AND PROTECTIVE FACTORS FOR THE ONSET OF MENTAL DISORDERS
6 RISK AND PROTECTIVE FACTORS FOR THE ONSET OF MENTAL DISORDERS
Pages 127-214
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From page 127... ...
These findings have led to a shift in risk factor research in both emphasis and complexity. Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected at random from the general population, will develop a disorder (Werner and Smith, 1992; Garmezy, 1983~.
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From page 128... ...
described this preoccupation as a "regrettable tendency to focus gloomily on the ills of mankind and all that can and does go wrong." But not everyone with risk factors goes on to develop a mental disorder, and the importance of protective factors is becoming more recognized. Recently, research has been directed toward understanding why some children appear to be resilient, and why they come to maturity relatively unscathed by the organic and psychosocial insults that prevent so many of their peers from achieving optimal intellectual, social, and emotional functioning (Werner and Smith, 1992~.
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From page 129... ...
The examination proceeds first within a categorical framework organized around the five major mental disorders that are used as illustrations throughout this report- Alzheimer's disease, schizophrenia, alcohol abuse and dependence, depressive disorders, and conduct disorder. Because these are disorders in which the relative potential contribution of biological risk factors (including genetic vulnerability)
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From page 130... ...
. European case-control studies, however, showed that although family history was an important risk factor, it did not account for all cases (van Duijn, Clayton, Chandra, Fratiglioni, Graves, Heyman et al., 1991~.
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From page 131... ...
Because identical twins share their genes, if both do not develop AD, this is strong evidence of nongenetic factors. At the very least, when the age of onset is different for a pair of identical twins, it indicates that environmental factors influence when symptoms begin, suggesting that prevention might work by delaying onset.
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From page 132... ...
A critical question concerns the mechanisms that favor a breakdown pathway for APP that generates amyloid (Hardy and Higgins, 1992~. In the case of DS, the three copies of the APP gene, due to its presence on chromosome 21, could result in a marked overexpression of APP in brain.
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From page 133... ...
A second gene on chromosome 21 may also modify the action of the APP gene or another gene, and hence show genetic linkage. It was aIready clear in 1988 that the molecular defect among several different families with an inherited form of AD resided on sites other
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From page 134... ...
Twin studies, genetic linkage studies, and searches for specific genes not only provide logical paths for scientific
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From page 135... ...
History of Head Trauma A history of head trauma has appeared as a risk factor for AD in several epidemiological studies (Henderson, form, Korten, Creasey, McCusker, Broe et al., 1992; Mortimer, van Duijn, Chandra, Fratiglioni, Graves, Heyman et al., 1991; Graves, White, Koepsell, Reifier, van Belle, Larson, and Raskind, 1990; Amaducci, Fratiglioni, Rocca, Fieschi, Livrea, Pedone et al., 1986; French, Schuman, Mortimer, Hutton, Boatman, and Christians, 1985; Mortimer, French, Hutton, and Schuman, 1985; Heyman, Wilkinson, Stafford, Helms, Sigmon, and Weinberg, 1984~. Recent studies show correlations with nonfamilial cases of AD, rather than familial cases (Henderson et al., 1992; Mortimer et al., 1991)
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From page 136... ...
These preliminary results suggest future research directions. Psychosocial Risk and Protective Factors Educational Level Several studies have shown a higher prevalence of dementia among those with less education, although findings are not entirely consistent from study to study.
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From page 137... ...
Smoking Epidemiological case-control studies looking for associations between AD and smoking over the past decade have produced conflicting results. Graves and colleagues recently reported a meta-analysis of data from eight of these studies, which individually had reached different conclusions (Graves, van Duijn, Chandra, Fratiglioni, Heyman, form et al., 1991~.
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From page 138... ...
Future Directions In Identification of Risk and Protective Factors In a recent minireview, Drachman and Lippa (1991) listed 17 different causal hypotheses for AD, and each has been pursued by one or more research groups.
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From page 139... ...
Future studies may more successfully dissect out risk factors by segregating disease subtypes, perhaps through identifying genetic subgroups (those showing linkage to different chromosome regions, for example) , or by separately analyzing cases arising from currently known risk factors such as head trauma or level of education.
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From page 140... ...
It is simplistic to assume that caregivers win respond consistently to any given intervention, but it is reasonable to assume that the availability of information and support services will reduce the stress and stressrelated health effects among caregivers. Preventive intervention strategies for these high-risk family members-no matter what the nature of the prevailing mental disorder therefore might include methods already in use, but inadequately evaluated, such as self-help support groups and psychoeducational programs (Falloon, Boyd, McGill, Razani, Moss, Gilderman, and Simpson, 1985; Bernheim, Lewine, and Beale, 1982; Vine, 1982~.
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From page 141... ...
Therefore the risk and protective factors associated with onset may be different for the various syndromes included within the disorder. Risk factors may bear different
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From page 142... ...
The most prominent biological risk factor is heredity, although some legitimate controversy exists. Although there is widespread acceptance that genetic factors contribute to schizophrenia, two studies have questioned whether narrowly diagnosed schizophrenia is a familial disorder (Abrams and Taylor, 1983; Pope, [ones, Cohen, and Lipinski, 1982)
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From page 143... ...
for developing schizophrenia (Gottesman, 1991) , but they are also at considerable risk for developing other mental disorders.
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From page 144... ...
Taken as a body of work, these studies collectively indicate that the offspring of schizophrenic individuals have a greatly increased risk of developing schizophrenia and that schizophrenics do not transmit this vulnerability to their nonbiological families. This evidence points to a strong role for genetics as a risk factor.
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From page 145... ...
Viral Exposure A recent study by Bracha and colleagues provides new evidence that second prenatal trimester insult may be associated with the expression of schizophrenia (Bracha, Torrey, Gottesman, Bigelow, and Cunniff, 1992~. These researchers found that monozygotic twins discordant for schizophrenia had more differences in their fingerprints than normal twins.
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From page 146... ...
Such individuals are "phenocopies," because they have an illness that resembles one caused by genetic factors, but which arises from a nongenetic cause or in interaction with a subset of such factors. However, caution must be exercised in using birth complications as a risk factor to target in preventive interventions.
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From page 147... ...
Like all risk factors, these markers do not necessarily mean that the disorder is or will be expressed. Although they may be apparent in high-risk children and some have been shown to be present in a high proportion of children who go on to develop schizophrenia (ErIenmeyer-Kirnling, Rock, Squires-Wheeler, Roberts, and Yang, 1991; Erlenmeyer-Kimling et al., 1982)
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From page 148... ...
Neurointegrative DeActs. In infancy and early childhood, neurointegrative defects, including sensorimotor problems, visual motor defects, and soft neurological signs, may be a risk factor for the onset of schizophrenia (Marcus, Hans, Mirsky, and Aubrey, 1987; Mednick, Parnas, and Schulsinger, 1987; Erlenmeyer-Kimling et al., 1982; Marcus, Auerbach, Wilkinson, and Burack, 1981~.
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From page 149... ...
Psychosocia1 Risk Factors Low Socioeconomic Status Social status has been assessed in at least 25 epidemiological studies, most of which show heightened prevalence of risk for schizophrenia in the lower cIass (Eaton, 1974~. This association could be the result of adversities and stresses connected to living in a lower social cIass, or it
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From page 150... ...
When the factors that can be reliably rated from contemporary discourse were examined, it was found that disrupted communication was the major risk factor predicting the onset of psychopathology. The authors have suggested that this supports a notion that genetic factors confer a vulnerability that requires an environmental trigger for the development of the disorder.
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From page 151... ...
Although there is some consistency in these two precursor behaviors exhibited by high-risk children who ultimately develop schizophrenia, there is little specificity. For example, the aggressive symptom pattern is also seen in a variety of other childhood disorders, such as attention deficit hyperactivity disorder, mood disorders, and conduct disorder.
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From page 152... ...
Caregiver Burden Schizophrenia in a family member can become a risk factor for stress-related disorders in other family members. Many factors affect caregiver burden, including financial difficulties, self-blame, degree of severity of the disease, social isolation, the caregiver's own health, the caregiver's coping skills, and the stigma attached to mental illness (Geiger, Hoche, and King, 1988; Fadden, Bebbington, and Kuipers, 1987~.
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From page 153... ...
Results regarding the importance of most of these risk factors-both biological and psychosocialremain equivocal. Only genetic factors have been demonstrated and quantified in repeated and varied experimental designs, but researchers are as yet unable to specify a mode of inheritance, a chromosomal localization of schizophrenia genes, or what function such genes might carry out.
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From page 154... ...
Genetic and psychological factors as well as the environment shape drinking behavior. Alcohol abuse and dependence arise through a complex interaction of biological risk factors, including genetic factors, and psychosocial risk factors, including personality features and contextual factors, involving the social environment in which an individual lives.
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From page 155... ...
The evidence for genetic factors for alcohol abuse is less well substantiated (Schuckit, 1994, 1992~. About 70 percent of alcoholics have a positive family history of alcoholism in first- or second-degree relatives (M.
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From page 156... ...
Biochemical Markers. Studies of platelet enzymes have led to two potential markers of increased risk for alcohol abuse.
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From page 157... ...
, and the results that are found may pertain only to subgroups of children with multiple risk factors, such as those whose mothers had high-risk pregnancies and those with fetal alcohol effects. Psychosocial Risk Factors The majority of studies on psychosocial risk factors focus on adolescent onset.
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Almost all of the studies on psychosocial risk factors fail to control for parental alcoholism or other mental disorder. Finally, many studies do not differentiate between alcohol use and other substance use.
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From page 159... ...
Psychosocial Aspects of Parental Alcoholism Parental alcoholism is associated with a constellation of other risk factors, and it is these factors plus the alcoholism itself that lead to poor outcomes in children-of which alcohol abuse is only one (see Box 6.2~. Protective Factors Although much investigation has focused on identifying and assessing the magnitude of various risk factors involved in alcohol use, less is known about factors that may protect individuals from abusing alcohol.
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From page 160... ...
, but the evidence is not substantial. Children raised under such volatile circumstances may well be deficient in their socialization, and, also, a strong association between parental alcoholism and conduct disorder has been demonstrated (Steinhausen, Gobel, and Nestler, 1984)
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The first was a strong attachment, or bond, between parent and adolescent and the second was a strong attachment between adolescent and father, which potentiated the positive effects of other protective factors, such as positive maternal characteristics. Genetic Factors Modifying Expression of the Disorder There are four clearly delineated polymorphic genetic loci that appear to modify the expression of alcoholism.
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From page 162... ...
Studies examining psychosocial risk factors for the onset of alcohol abuse and dependence have often failed to control for family history of alcoholism or other mental disorders, especially antisocial personality disorder and depression. As psychosocial risk factor research improves, more will become known about the relative and attributable risks associated with specific factors and with clusters of factors.
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From page 163... ...
When the older term "affective disorder" from DSM-III was used in the original research, that term is used here. Biological Risk Factors Genetic Vulnerability In terms of genetic influences, an individual's risk for mood disorders becomes larger the larger the proportion of genes shared with a mood-disordered individual.
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From page 164... ...
There is important work in progress regarding the forms of heritability of mood disorders. Most research has focused on bipolar disorder, but there has been some work regarding major depression.
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From page 165... ...
However, it has long been observed that there is an association between various kinds of learning difficulties, in particular difficulties in learning to read, and subsequent problems with low self-esteem, which can predispose to depression. Psychosocial Risk Factors Severe and Traumatic Life Events The presence of severe and traumatic events in an individual's life is associated with increased rates of major depression (Beardslee and Wheelock, in press; Coyne and Downey, 1991~.
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From page 166... ...
Sociod~emographic Factors Although in general, the foregoing risk factors are well established, detailed prospective studies of the influence of various risk factors over time and the mitigating effects of other variables, for the most part, have not been conducted in large samples. Two notable exceptions are the Epidemiologic Catchment Area (ECA)
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From page 167... ...
These factors dealt primarily with sociodemographic information. The major risk factors that predicted episodes of major depression were being female, being separated or divorced at initial assessment, and not having paid employment or a job with prestige.
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From page 168... ...
In fact, most studies show that during adolescence the majority of children of parents with mood disorder are functioning reasonably well. At any one point in time, complex interaction between risk and protective factors operates in children of depressed parents, and an understanding of these factors across the developmental course highlights opportunities for prevention (see Box 6.3~.
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From page 169... ...
. Documentation of the Risk Factor For decades, it has been well established that severe mental disorder in parents is associated with increased rates of mental disorder in offspring.
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Some children develop anxiety disorders, some have school problems, and some develop depressive symptoms or disorders. Thus, at least for children and adolescents, preventive interventions targeting a single risk factor need to consider not a single diagnosis but a range of outcomes and a range of diagnoses.
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There are at least two subtypes of conduct disorder-early onset and adolescent onset. Biological Risk Factors Genetic Vulnerability The role of genetic influences in the development of conduct disorder has been difficult to sort out.
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From page 172... ...
reported that a heritable contribution to adult criminality appears more clearly established than to conduct disorder and delinquency. Some studies thus support a role for genetic factors, but the data are inconsistent, inconclusive, and suffer from instability of diagnosis and other methodological flaws.
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, the rate of conduct disorder, using a much broader definition than that in DSM-III-R, in 10- and 11-year-olds showed a boy:girl ratio of 3.8:1. Similarly, in the Ontario Child Health Study (Offord et al., 1987)
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From page 174... ...
Although these results are encouraging, the evidence for temperament as a risk or protective factor for conduct disorder is still incomplete. Hyperactivity There is considerable co-morbidity between attention deficit hyperactivity disorder (ADHD)
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From page 175... ...
Psychosocial Risk Factors Precursor Symptoms in the Child Identification of patterns of early precursor symptoms may lead to identification of children and adolescents who are at especially high risk for developing conduct disorder. Beginning at ages four to six, aggression predicts later delinquency (Loeber and Dishion, 1983~.
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From page 176... ...
The number of symptoms appears to be a better indication of the potential for serious disorder than the pattern at any one point in time (Robins and Ratcliff, 1980; Robins and Wish, 1977~. Likewise, the earlier the first symptoms appear, the higher the risk may be for subsequent conduct disorder, and early onset of the disorder has been consistently linked to poorer outcomes, including serious and chronic antisocial behavior (Farrington, Loeber, Elliott, Hawkins, Kandel, Klein et al., 1990; Loeber, Brinhaupt, and Green, 1990; Tolan, 1987; Loeber and Dishion, 1983; Robins, 1966~.
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From page 177... ...
Other dysfunctional parenting practices, especially harsh, erratic, and abusive forms of discipline, also predispose to the development of conduct disorder. Patterson, Reid, and their colleagues have carefully documented how aversive behavior on the part of both child and parent, combined with parental inconsistency, create negative reinforcement patterns in which child aggression and coercion (increasingly demanding interaction)
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From page 178... ...
Offord and colleagues found that low income was one of the most significant risk factors for the onset of conduct disorder, but it had its effect on children aged 4 to 11, not on adolescents (Offord, Alder, and Boyle, 1986~. In an exceptionally lengthy risk study a 30-year follow-up to measures taken in the first five years of life Kolvin and co-workers demonstrated that low socioeconomic status of a child's family at age 5 is a powerful risk factor (Kolvin, Miller, Fleeting, and Kolvin, 1988~.
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From page 179... ...
indicate that the three most significant risk factors exerting independent effects on conduct disorder were family dysfunction (relative odds = 3.1) , parental mental disorder (relative odds = 2.2)
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From page 180... ...
Protective Factors The protective factors that reduce the chance that a child at risk will develop conduct disorder include good intelligence; easy disposition; an ability to get along well with parents, siblings, teachers, and peers; an ability to do well in school; having friends; being competent in nonschool skill areas (Rae Grant, Thomas, Offord, and Boyle, 1989~; and having a good relationship with at least one parent and with other important adults (Werner and Smith, 1992~. The presence of a positive warm bond between parent and child in early childhood can lead to greater compliance and reciprocity.
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From page 181... ...
Findings and Leads Much still remains unknown about conduct disorder, including its subtypes, the risk factors involved in its onset, and the protective factors in the child, family, and community that lead to more favorable outcomes. Both prospective, longitudinal studies that begin early in life and well-designed efforts at prevention are needed for progress to occur (Tonry, Ohlin, and Farrington, 1990~.
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From page 182... ...
RISK AND PROTECTIVE FACTORS COMMON TO MANY DISORDERS It has become evident that even though some risk factors may be specific to a particular disorder, other risk factors are common to many disorders. A continuing emphasis solely on the identification of risk factors unique to specific mental disorders is not likely to be productive.
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From page 183... ...
Community institutions such as schools can either enhance or detract from intellectual and social growth and development and thus can function as a community risk or protective environment for children and adolescents (Rutter et al., 1979~. Although protective factor research has made major advances, it is less well developed than risk factor research, and several conceptual and methodological issues remain inadequately resolved (Luther, 1993~.
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From page 184... ...
In the Kauai Longitudinal Study, three clusters of protective factors differentiated the resilient group from other high-risk youth who developed serious and persistent problems in childhood and adolescence (Werner and Smith, 1992~. These were (1)
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From page 185... ...
. MODELS FOR UNDERSTANDING RISK AND PROTECTIVE FACTOR INTERACTION Understanding that risk and protective factors are common to many disorders is only a first step.
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The protective model suggests that protective factors modulate or buffer the impact of risk factors by, for instance, improving coping, adaptation, and competence building. The concept of causal or etiological chains is helpful in understanding risk and protective factor interaction.
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From page 187... ...
The patterns of interaction between the child's personal attributes and risk and protective factors in the family, school, and community environments are not linear, but are interwoven like the threads in a Jacquard tapestry in patterns of increasing complexity. Initially, parents develop a pattern of interaction with their infants that is dependent on many factors, including their own childhood experiences, marital relationships, and the quality of their social support systems.
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From page 188... ...
Child maltreatment serves as a useful illustration of the complexities associated with identifying and addressing risk and protective factors in an etiological chain encompassing both social problems and mental disorders. It is both a social problem, with its own set of risk and protective factors, and a risk factor in itself for several mental disorders.
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From page 189... ...
. Studies of physical child abuse and child neglect consistently highlight physical aggression and antisocial behavior among the outcomes associated with these forms of child maltreatment (Kaufman and Cicchetti, 1989; Walker, Downey, and Bergman, 1989; Rohrbeck and Twentyman, 1986; HoffmanPlotkin and Twentyman, 1984; Salzinger, Kaplan, Pelcovitz, Samit, and Kreiger, 1984; Perry, Doran, and Wells, 1983)
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From page 190... ...
found that a disproportionate number of maltreated children met diagnostic criteria for one of the major mood disorders. Inappropriate sexual behavior, such as frequent and overt self-stimulation, inappropriate sexual overtures toward other children and adults, and play and fantasy with sexual content, are the most commonly studied symptoms in studies that compare sexually abused children to children in control groups (Kendall-Tackett, Williams, and Finkelhor, 1993)
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MAJOR FINDINGS AND PROMISING LEADS Mental health outcomes depend on the interactions of risk and protective factors in the child, the family, and the wider environment. The nature, timing, severity, and length of particular risk factors and the
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From page 192... ...
Conversely, if the number of protective factors can be increased in the individual, family, and community, then resilience is likely to be increased and the disorder may be avoided. General risk factors may lend themselves to universal preventive interventions consonant with broad community mental health efforts
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(1991) Suspected risk factors for depression among adults 18~4 years old.
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(1993b) Comparison of preventive interventions for families with parental affective disorder.
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(1988) Sexual assault and mental disorders in a community population.
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(1989) Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect.
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(1989) Post-traumatic stress in sexually abused, physically abused, and nonabused children.
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(in press) Oppositional-defiant and conduct disorders.
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Advances in Clinical Child Psychology.
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Journal of Nervous and Mental Disorders; 171~1~: 441 147. Garmezy, N
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(1992) Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention.
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(1992) Environmental risk factors for Alzheimer's disease: Their relationship to age of Onset and to famili~1 or ~nor~rlir tome P~`rrbr~lr~oir:~1 Medicine; 22: 429~36.
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(1989) Reduction of antisocial behavior in poor children by nonschool skill-development.
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(1983) Observations on genetic and environmental influences in the etiology of mental disorders from studies on adoptees and their relatives.
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(1988) Post-traumatic stress disorder in sexually abused children: A prospective study.
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(1993) The neuropsychology of conduct disorder.
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(1991) Head trauma as a risk factor for Alzheimer's disease: A collaborative re-analysis of case-control studies.
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(1989) Conduct disorder: Risk factors and prevention.
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(1989) Risk, protective factors, and the prevalence of behavioral and emotional disorders in children and adolescents.
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(1980) Childhood conduct disorders and later arrest.
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Preventing Mental Disorders: A Research Perspective. Rockville, MD: Department of Health and Human Services; 76.
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(1990) Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8145 Families.
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Torgensen, Eds. Etiology of Mental Disorders.
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American Journal of Orthopsychiatry; 63~1~: 55~9. Zhang, M.; Katzman, R.; Salmon, D.; fin, H.; Cal, G.; Wang, Z.; Qu, G.; Grant, I.; Yu, E.; Levy, P.; Klauber, M
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