How Do You Think?

I recently heard a RadioLab story that was, well, moving.  It touched upon a feeling that I have, a somewhat romantic notion of love, and I found it to be incredible.  By incredible, I mean unbelievable, and by unbelievable, I also mean, “It cannot be true!”  Of course, it is just a story.  But, stories like this have a way of touching us in profound ways.  They touch us at a spiritual level, a level that is seemingly, transcendent.  It inclines us to accept the story as being true.  This story had this affect on me.

The story was shared by Plato who attributed it to Aristophene in the 3rd century BCE, over 2400 years ago.  Aristophene was a Greek playwright, an Athenian comic poet.  This love story is interpreted by Robert Krulwich. Robert tells the three minute story in a way that is far more compelling than is the transcript below.  You can listen to it here (1-minute-50-seconds into the episode) or read it below.  It speaks for itself.

“Once upon a time, he says, people were not born separate from each other. They were born entwined, kind of coupled with each other. So there were boys attached to boys, and there were girls attached to girls, and of course, boys and girls together in a wonderfully intimate ball. And back then we had eight limbs. There were four on top,  four on the bottom, and you didn’t have to walk if you didn’t want to. You could roll, and roll we did. We rolled backwards and we rolled forwards, achieving fantastic speeds that gave us a kind of courage.

 

And then the courage swelled to pride.

 

And the pride became arrogance.

 

And then we decided that we were greater than the gods and we tried to roll up to heaven and take over heaven. The gods alarmed, struck back!  Zeus, in his fury, hurled down lightning bolts and struck everyone in two, into perfect halves. So all of a sudden, couples who had been warm and tight and wedged together, were now detached, and alone, and lost, and desperate, and losing the will to live.

 

And the gods see what they had done, worried that humans might not survive or even multiply again. Of course, they needed humans to give sacrifices and to pay attention to them, so the gods decided on a few repairs. Instead of heads facing backwards, or out, they would rotate our heads back to forward. They pulled our skin taut and knotted it at the belly button. Genitalia too, were moved to the front, so if we wanted to, we could.

 

And most important, they left us with a memory.  It was a longing for that original other half of ourselves –the boy or the girl who used to make us whole.  And that longing is still so deep in all of us, men for men, women for women, men for women, for each other, that it has been the lot of humans, ever since, to travel the world, looking for our other half. And when, says Aristophanes, when one of us meets another, we recognize each other right away. We just know this. We’re lost in an amazement of love and friendship and intimacy. We won’t get out of each others sight, even for a moment. These are people, he says, who pass their whole lives together, and yet if you ask them, they could not explain what they desire of each other.

 

They just do.”

As heard on Desperately Seeking Symmetry by Radiolab.

Mahatma Gandhi once said that Poverty is the worst form of violence.  At the very least it appears to be a neurotoxin.  Evidence continues to build a solid case for the notion that poverty itself is self-propagating and that the mechanism of this replication takes place in the neuro-anatomy of the innocent children reared in environmental deprivation.

In my article titled The Effects of Low SES on Brain Development I review an article that provides clear quantitative data that indicates that children raised in low SES environments have diminished brain activity relative to their more affluent peers.  The impact of low SES on brain activity was so profound that the brains of these poor kids were comparable to individuals who had had actual physical brain damage.  This data gathered through EEG is a non-specific measure that provides no clear understanding of what underlies this diminished functioning.  In other words, it evidences diminished brain activity, but it does not specifically identify what has occurred in the brain that is responsible for these differences.

Jamie Hanson and colleagues from the University of Wisconsin-Madison and Harvard University published a paper titled Association Between Income and the Hippocampus in the peer reviewed on-line journal PLoS ONE that points to one possible culprit.  Their study shows in a measurable way, how poverty actually hinders growth of the hippocampus, a very important brain region associated with learning and memory.

In non-human animal studies, it has been shown that environmental enrichment is associated with “greater dendritic branching and wider dendritic fields; increased astrocyte number and size, and improved synaptic transmission in portions of the hippocampus” (Hanson et. al. 2011).  This essentially means that environmental enrichment enhances the density and functioning capacity of the hippocampus.  In humans, parental nurturance, contact, and environmental stimulation has been associated with improved performance on tasks (long-term memory formation) greatly influenced by the hippocampus. On the flip side, it has also been demonstrated that stress, inadequate environmental nurturance and low stimulation have the opposite affect (thinning hippocapmal density).

Hanson et. al., (2011) hypothesized that hippocampus density would be positively related to gradients in parental income.  Affluent children would evidence more hippocampal density (associated with better learning, memory, emotional control) while their low income counterparts would evidence diminished levels of density.  They used datea from MRI imaging studies to measure the actual hippocampal gray matter density in a large cross section of children (ages 4-18 years old) across the United States.  They also collected data on the income and education level of each participant’s parents.  As a control measure, they also quantified the whole-brain volume and the density of the amygdala, a brain region that does not vary as a function of environmental perturbations or enrichment.   These latter variables were important because they assist in ruling out brain size variation associated with other confounding variables.  They hypothesized that these latter measures would not vary associated with income.

The top left brain slice shows a sagittal brain slice with the hippocampus highlighted in yellow and the amygdala in turquoise, while the top right brain image shows an axial slice (with the hippocampus again highlighted in yellow and the amygdala in turquoise). The bottom left brain picture shows a coronal slice with the amygdala in turquoise and the hippocampus in yellow.

Their measures confirmed each of their hypotheses.  Amygdala and whole brain volume did not vary associated with parental income but hippocampal density did.  Those with parents at the lower end of the income spectrum evidenced lower hippocampal density than those children from more affluent families.  They wrote that “taken together, these findings suggest that differences in the hippocampus, perhaps due to stress tied to growing up in poverty, might partially explain differences in long-term memory, learning, control of endocrine functions, and modulation of emotional behavior” (Hanson, 2011).

The authors carefully noted that this correlation is not necessarily indicative of causation – and that more specific longitudinal measures along with direct measures of cognitive functioning, environmental stress,  and stimulation are necessary to truly understand the association between income and these neurobiological outcomes.  But they also warned that the data set was limited to children unaffected by mental health issues or low intelligence.  As such, the data set likely underestimates the actual hippocampal volume variation because children at the lower end of the income spectrum have disproportionately high levels of these mental health and low intelligence issues.

These results confirm and fit with a growing and already substantial set of findings that implicate poverty as a neurotoxin that causes a self sustaining feedback loop.  Poverty seems to weaken the foundation on which fundamental skills and capabilities are built that ultimately facilitate adaptive functioning and positive societal contributions.  A weak foundation hinders such capacities.

I have previously posted articles titled Halting the Negative Feedback Loop of Poverty: Early Intervention is the Key, Poverty Preventing Preschool Programs: Fade-Out, Grit, and the Rich get Richer, and The Economic, Neurobiological, and Behavioral Implications of Poverty.  In these articles I review various other studies that address this issue, but I also highlight the steps that can be taken to remediate the problem.  There really is not much question about the needed steps we as a society should take.    A recent series of articles published in the UK’s Lancet, drives this point home!

In one particular article, titled Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries, the authors noted that:

“A conservative estimate of the returns to investment in early child development is illustrated by the effects of improving one component, preschool attendance. Achieving enrolment rates of 25% per country in 1 year would result in a benefit of US$10·6 billion and achieving 50% preschool enrolment could have a benefit of more than $33 billion (in terms of the present discounted value of future labour market productivity) with a benefit-to-cost ratio of 17·6. Incorporating improved nutrition and parenting programmes would result in a larger gain.”

The monetary value alone seems sufficient to motivate implementation.  For each dollar spent on quality preschool programs, we ultimately gain up to $17.60 in labor market productivity alone.  This does not account for the decreased expenditures on special education, incarceration, and other social safety net programs.  Quality preschool programing has been shown to increase high school graduation rates and home ownership rates.  If we as a society, are truly driven to promote human flourishing, equal opportunity for all, and a level playing field, then we must, I argue, take action with regard to providing universal access to quality preschool programs particularly for poor children.  What I propose is not a hand-out, but a fiscally responsible hand-up that benefits each and every one of us.

References:

Engle, P., L., Fernald, L. CH., Alderman, H., Behrman, J., O’Gara, C.,  Yousafzai A.,  de Mello M. C., Hidrobo, M.,  Ulkuer, N., Ertem, I., Iltus, S., The Global Child Development Steering Group. (2011).  Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, Early Online Publication, 23 September 2011. doi:10.1016/S0140-6736(11)60889-1

Hanson, J.L., Chandra, A., Wolfe, B. L., Pollak, S.D., (2011).  Association between Income and the Hippocampus. PLoS ONE 6(5): e18712. doi:10.1371/journal.pone.0018712

I’m not an emotional man.  As such, I rarely experience the extremes of sadness or joy.  This is not to say that I do not experience joy or sadness – I do.  I take great pleasure in life and also feel the pain that comes with it.  But, I am very stable and steadfast – very familiar and comfortable with the middle of the emotional spectrum.  Some might say that I am too serious, and that they have.

Because of this disposition, I don’t cry very often – in fact it takes a lot to make me cry.  It is not as though I actively resist crying, or that I view it as a weakness.  I just seem disinclined to go to such places.  It is my composition.

Lately however, things have changed and I have found myself more inclined to tear up.  My wife was diagnosed with breast cancer about six months ago and has since endured a great deal.  I guess one might say that I too am a bit more vulnerable and raw.

The tears that I have shed have not sprung from fear or even from empathy.  I have sustained confidence that she will survive this.  And at times when she has been fearful or just exhausted and frustrated, I have instinctively been her rock.   My tears instead, have fallen quite unexpectedly at times of great relief.

I vividly recall meeting with my wife’s surgeon just after her diagnosis and tearing up as he left the office having reassured Kimberly that she will be okay. I held Kimberly firmly in my arms and we both wept.

On the day of the lumpectomy I sat with my mother and our college aged children as we anxiously awaited news from the surgeon. At that point in time Kimberly had also been diagnosed with thyroid cancer and we did not know whether her breast cancer had moved to her lymph nodes. It was a very tense and scary time. When her surgeon called me out for the post surgical conference, he shared with me the good news that her lymph nodes were clear.  I choked back tears as I thanked him.  The emotional relief emerged forcefully and tearfully when I walked back into the waiting room to share this news with my family. I’m sure that my children have never before seen me in such a state.  A few minutes later, as I tried to share this news with Kimberly’s mother on the telephone, I could not talk and again tears streamed down my recently moistened cheeks.

Since that Spring day, Summer has come and gone, and Kimberly has endured prolific post surgical bleeding, mammosite radiation, a reevaluation of her thyroid nodules (negative for cancer), completed 50% of her chemotherapy treatments and I have resumed my steadfastness.  I have been a rock – steady and sure.  Of course this is not completely true.  I am less able to endure violence for entertainment on the television and I have little patience for the malicious or ignorant forays of others.  But generally, I have held it together.

Then one day my wife came to me in tears after reading a letter sent to her by my daughter (Meghan), her step-daughter.  I read it and it shook me to my core.  I cried as thoroughly as I ever recall.  She wrote (this is just an excerpt):

All of the things you are going through really, really, really suck and it is out of everyone’s control. I’m sure you’ve heard it all before with the flood of cards you have been receiving since mid May. But maybe you haven’t heard what I am going to say…

 

Life is amazing.  We are all so truly lucky to be here. Out of all the stars, out of all the systems WE are here. It is a one in infinity probability. And despite all the suffering, you are here and you are unique; the only one that thinks like you… you are the only one that hears your thoughts… you are the only one here right now experiencing what you’re experiencing and feeling how you feel about it. And maybe that makes people feel lonely, but I feel lucky and I hope you do too.  So whenever you’re having one of those moments when you’re hating everything, “Why me?!” turn it around to “I am lucky to be here and living the life I’m living.” You’re the only person who can have the relationship you have with me, my Dad, with Alec and Paige, with your siblings. With this random chance of us all being in the same time, we are all so lucky… So keep going, hang in there, stay strong, let weakness, vulnerability, and sadness take over when you feel it fitting, but after,  breath deeply (because you are the only one in that moment feeling what you feel, breathing that 78% nitrogen, 20% oxygen & remaining percentages, that is your breath and only yours).  We have to cherish and recognize the awesomeness of it all, it is truly incredible and it blows me away almost daily.  So the next time we are all together at dinner or bumming around, take a second to think “Wow, there will be no moment like this, we are truly unique!”

My daughter in that moment became the rock and I could let go.   And I did let go!  This morning I read a quote posted on Facebook by a friend that read:

People cry not because they’re weak.  It’s because they have been strong for too long.

It is immensely touching and life changing when your “child” rises and shows the capacity and wisdom to be the rock.  And I am thankful that I had the capacity to let go of that role in that moment.  I am fortunate to have a wife that helped nurture such love in my daughter, and a daughter who has herself persevered through adversity and grown into an incredible woman.  Meghan is right, we are so very fortunate to be here at all, to be together, to be loved, and to be aware of the uniqueness and improbability of it all.  A wise person of unknown identity once said “Adversity does not build character, it reveals it.” This cancer has given us the opportunity to appreciate the strength and character of those around us who take turns being the rock.  It is this strength of others that gives me the occasion to let go, and shed some tears.

I have often said: “Life has a way of getting in the way of itself.”  I had been implying that life plans don’t necessarily work out due to the vagaries of life itself.  In my wife’s case, a more literal interpretation is fitting.  A DNA replication error set in place a rapid cell duplication process resulting in invasive ductal carcinoma.  Her breast cancer, this life gone amok, has taken center stage.

Talk about a game changer – this changes everything.  In my role as a psychologist I long ago became acutely aware of just how wrong things can go in life, and these professional experiences solidified in me the importance of appreciating the things that go well.  It has also instilled in me the knowledge that absolutely nothing is permanent.  But this cancer diagnosis has taken this enlightenment to a whole new level.

Thomas Hobbes once noted, “… the life of man, [is] solitary, poor, nasty, brutish, and short.”  Historically, this has been true for many of our ancestors, and it remains true for many today.  Such is not the case for many of us who have been fortunate to be born into a time and place where survival is not an everyday struggle.  But when facing a diagnosis of cancer,  Hobbes’ perspective seems particularly cogent.  I can only imagine how true this perspective must be for Kimberly.  Although her family surrounds her with love and support, only she alone, faces the scaring scalpel and the life sucking chemotherapy.

In the vast configuration of things, we all know that she is not alone.  Many people go through this, but none of those near and dear to her, know what she endures and fears.  Life for her has temporarily, and most certainly, become at times, nasty and brutish.  There is an ebb and flow to this process, but the difficult times rob her of the many activities that filled her with zest.  Even at relatively good times, her quality of life is a poor reflection of what it had been. Often food is less tasty, if desirable at all.  Restful sustained sleep is hard to come by and endurance and fortitude seem to be a thing of the past: as is her gorgeous full head of hair.  It’s one thing to be a man and gradually lose one’s hair over a period of decades (I know it well).  It’s quite another to be a woman and leave a trail of hair where ever you go.  And really feeling good – it’s an occasional visitor that does not stick around long.  I know this is torturous for her.  It breaks my heart.

On the plus side, there is the reality that this life-run-amok has changed perspectives and brought our family closer together.  From my point of view, it has brought into focus what really matters in life.  It has freed us from the banal fruitless issues du jour.

But underneath this greater closeness is a universal fear.  We all share it, but I am certain that it resonates deeper in Kimberly’s mind.  The fear is: “What if this isn’t over?”  We have no certain answers, but the statistics are on her side.  Long term survival is the norm.  This is one form of cancer that science and medicine has effectively constrained.

Her chemo is a preventative measure, not one aimed at eking out a few months or years.  With this in mind, I try to frame this phase of treatment within the context of a physical challenge.  One of our favorite activities is riding our tandem bicycle.  We don’t just get on a clunky unwieldy tandem and leisurely putz around town.  We ride a high tech machine and we ride it hard and fast.  A typical ride covers 20 to 30 miles and often involves ascending some of the biggest hills in our area.  These climbs are often long and brutal – requiring a special focus and tenacity.  The reward however, is the effortless descent that is sweeter for the effort that made it possible.  Over the next few months we will be climbing a new and even more difficult hill – struggling as we go.  We shall strive to endure it for the rewards on the other side.  We will make it.

And once we reach the top, it is my sincerest hope that all of us who have fought this battle with Kimberly will make the best of the rest of the ride.   Life, with or without cancer,  is short and exceptionally precious.  This experience has certainly and deservedly taken center stage, but it has also put a spotlight on what is truly meaningful.  The other stuff is just clutter.  Meanwhile, the slow arduous slog continues – and we endeavor upward with anticipation of the sweet descent.  All the while we take solace in the warm glow of love that sustains us and powers us up and ever onward.

Do you believe that economic success is just a matter of having a good work ethic and strong personal motivation?  Most people do.  But in reality this is a perfect example of the Fundamental Attribution Error and the Self Serving Bias.

Attribution Error occurs when we negatively judge the unfortunate circumstances of others as being a reflection of their character traits rather than as a result of environmental circumstances (e.g., growing up in poverty).  What is even more interesting is that when we mess up, we tend to blame it on environmental factors rather than accepting personal responsibility.  When we are successful however, we take credit for the outcome assigning credit to internal personal attributes and devaluing environmental contributors.  This latter error is the Self Serving Bias.

This erroneous thinking is universal, automatic, and it is what drives a wedge between people on different points of the socio-economic spectrum.  If you believe that poor people are impoverished simply because they are lazy free-loaders, you are likely a victim of this thinking error.  The same is true if you believe that your success is completely of your own doing.

I have written numerous articles on the impact of poverty on early childhood development (i.e., The Effects of Low SES on Brain Development) and the bottom line is that economic deprivation weakens the social and neurobiological foundation of children in ways that have life-long implications.  In this post I will summarize a review article by Knudsen, Heckman, Cameron, and Shonkoff entitiled: Economic, Neurobiological, and Behavioral Perspectives on Building America’s Future Workforce.  This 2006 article published in the Proceedings of the National Academy of Sciences provides an excellent review of the research across many fields including developmental psychology, neuroscience, and economics.  It highlights the core concepts that converge with regard to the fact that the quality of early childhood environment is a strong predictor of adult productivity.  The authors point to the evidence that robustly supports the following notions:

1. Genes and environment play out in an interdependent manner. Knudsen et al., (2006) noted that “… the activation of neural circuits by experience also can cause dramatic changes in the genes that are expressed (“turned on”) in specific circuits (58-60). The protein products of these genes can have far reaching effects on the chemistry of neurons and, therefore, on their excitability and architecture.”  Adverse experiences can and do fundamentally alter one’s temperament and capacity to learn throughout life.
2. Essential cognitive skills are built in a hierarchical manner, whereby fundamental skills are laid down in early childhood and these foundational neural pathways serve as a basis upon which important higher level skills are built.
3. Cognitive, linguistic, social, and emotional competencies are interdependent – all nascent in early childhood, when adverse environmental perturbations reek havoc on, and across, each of these fundamental skill sets.
4. There are crucial and time-sensitive windows of opportunity for building these fundamental competencies.  Should one fail to develop these core skills during this crucial early developmental stage, it becomes increasingly unlikely that later remediation will approximate the potential one had, if those skills were developed on schedule.  A cogent analogy here is learning a new language – it is far easier to learn a new language early in development when the language acquisition window is open, than it is later in life when this window is nearly closed.

In my last two posts (Halting the Negative Feedback Loop of Poverty: Early Intervention is the Key and Poverty Preventing Preschool Programs: Fade-Out, Grit, and the Rich get Richer) I discussed two successful early intervention programs (e.g., Perry Preschool Program & Abecedarian Project) that demonstrated positive long-term benefits with regard to numerous important social and cognitive skills. Knudsen, et al, (2006) noted:

“At the oldest ages tested (Perry, 40 yrs; Abecedarian, 21 yrs), individuals scored higher on achievement tests, reached higher levels of education, required less special education, earned higher wages, were more likely to own a home, and were less likely to go on welfare or be incarcerated than individuals from the control groups.”

These findings converge with research on animal analogues investigating the neurodevelopmental impact of early stimulation versus deprivation across species.  Knudsen et al., (2006) point out that:

1. There are indeed cross species negative neurodevelopmental consequences associated with adverse early developmental perturbations.
2. There clearly are time sensitive windows during which failure to develop crucial skills have life-long consequences.  Neural plasticity decreases with age.
3. However, there are time sensitive windows of opportunity during which quality programs and therapies can reverse the consequences of adverse environmental circumstances (i.e., poverty, stress, violence).

Early learning clearly shapes the architecture of the brain.  Appropriate early stimulation fosters neural development, while conversely, impoverished environments diminish adaptive neural stimulation and thus hinders neural development.  Timing is everything it seems.  Although we learn throughout our lifespan, our capacity to learn is built upon a foundation that can be strengthened or impaired by early environmental experiences.  It is very difficult to make up for lost time later in life – much as it is difficult to build a stable building on an inadequate foundation.  Stimulating environments during these crucial early neurodevelopment periods are far more efficient than remediation after the fact.  These realities provide further justification for universally available evidence based early preschool services for children at the lower end of the socio-economic spectrum.  Proactive stimulation fosters stronger and more productive citizens – yet, we continue to respond in a reactive manner with remedial and/or punitive measures that miss the mark.  The necessary proactive response is clear.

References:

Knudsen, E. I., Heckman, J. J., Cameron, J. L., and Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce.  Proceedings of the National Academy of Sciences.  v. 103, n. 27. 10155-10162.

In my last post, Halting the Negative Feedback Loop of Poverty: Early Intervention is the Key I looked at the evidence from two quality studies of preschool intervention programs that substantiated a capacity to counteract the impairing impact of growing up in economic deprivation.  Both studies,  Perry Preschool Program and the Abecedarian Project demonstrated positive long-term benefits with regard to numerous important social and cognitive skills.  In this post I shall discuss some interesting issues and concepts that underlie the gains made at Perry and Abecedarian, including fade-out, grit, and positive and negative feedback loops.

The issue of fade-out, and its implications, are very important.  In both the Perry and Abecedarian Programs there were substantial positive outcomes with regard to immediate IQ and other cognitive scores.  Once the children entered typical school age programs,  some of their gains, particularly their IQ (which had a 10-15 point boost during treatment) faded away.  This fade-out was strikingly true for the Perry Preschool Program but not so for the Abecedarian Project, which had a substantially more intensive program, involving both longer school days and more school days per year.  See Figure 1 below.

Figure 1

Despite this apparent fade-out, when the recipients of this specialized programing where assessed decades later, they did much better than non-recipients on relative life issues such as high school graduation, four-year college attendance, and home ownership.  These results are encouraging on the one hand, yet puzzling on the other.  Such fade-out renders programs like Head Start vulnerable to those who cherry pick  data in order to advance ideologically driven political agendas.  Regardless, this does raise some important questions.

1. Why do gains in IQ appear to fade-out?
2. What skill gains account for the long-term gains made?

Some prominent researchers (e.g., David Barnett) question whether there is actually any true fade-out at all – suggesting that faulty research design and attrition may better explain these results.  Regardless, IQ is not the sole variable at play here – if anything, this data highlights the questionable validity of the IQ construct itself, relative to important life skills.  If improved IQ is not the variable that results in improved social outcomes we need to understand what happens to these children as a result of the programming they receive.  One likely hypothesis has been proffered to explain these data:

“…the intervention programs may have induced greater powers of self-regulation and self-control in the children, and … these enhanced executive skills may have manifested themselves in greater academic achievement much later in life.” (Raizada & Kishiyama, 2010).

Evidence has been substantiated for this hypothesis by Duckworth et al., (2005, 2007, 2009) who demonstrated that self discipline and perseverance or “grit” is more predictive of academic performance than is IQ and other conventional measures of cognitive ability (Raizada & Kishiyama, 2010).  It appears that enhancing one’s grit has the effect of triggering long-term capabilities that are self-reinforcing.  Improved self-control and attentiveness fosters achievement that ultimately feeds-back in a positive way making traditional school more rewarding and thus promoting even more intellectual growth (Raizada & Kishiyama, 2010).  Poor children, without intervention, on the other hand, appear less able to focus, attend, and sustain effort on learning and thus enter a negative feedback loop of struggle, failure, and academic disenchantment.

The bottom line is that success begets success and failure begets failure.  Stanovich (1986) offered an analogous explanation for reading proficiency: “…learning to read can produce precisely such effects: the better a child can read, the more likely they are to seek out and find new reading material, thereby improving their reading ability still further.” (Raizada & Kishiyama, 2010).

Both the Perry Preschool and Abecedarian Programs have impressive long-term outcome data.  See figures 2 & 3 below for a summary of those data.

Figure 2

Figure 3

The efficacy of each program has spawned other programs such as Knowledge is Power Program and the Harlem’s Children’s Zone.  Both of these intensive programs lack randomized assignment to treatment and non-treatment (control) groups.  As a result, it is difficult to make any claims about their treatment impact on important cognitive and social skills.  Given what we learned from the Perry and Abecedarian Programs, I have to wonder whether it would be ethical to withhold such treatment from those children randomly assigned to the control group.  It now seems to me, that we absolutely have an ethical obligation to short circuit the negative feedback loop of poverty and put into place universally accessible programs that diminish and/or eradicate poverty’s crippling life long impact.

We all pay a heavy price for poverty, but no one pays a greater cost than those children, who have been thrust into their circumstances, with little hope of rising out of poverty unless we join together to give them a fair shot at economic and social equality.

Yes, such programs cost money, but the long term economic costs of the status-quo are much greater.  Pay me now and build positive contributors to society, or pay me later and pay greater costs for special education, prisons, medicaid, and public assistance.  It certainly pays to step back from ideology and look at the real costs – both in terms of human lives and in terms of dollars and cents.  It makes no sense to continually blame the victims here.  Early intervention is good fiscal policy and it is the right thing to do.  It just makes sense!

NOTE: In a future post I will look at the evidence put forward by cognitive neuroscience for such programs.  Also see The Effects of Low SES on Brain Development for further evidence of the negative impact low SES has on children.

References:

Knudsen, E. I., Heckman, J. J., Cameron, J. L., and Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce.  Proceedings of the National Academy of Sciences.  v. 103, n. 27. 10155-10162.

Raizada, R. D. S., and Kishiyama, M. M. (2010). Effects of socioeconomic status on brain development, and how cognitive neuroscience may contribute to leveling the playing field.  Frontiers in Human Neuroscience. v. 4 article 3.

The United States is the richest nation in the world, nevertheless, 2007 Census data indicates that 17.4% of our children live in poverty.  That translates into 1 in 6 kids living in a state of economic deprivation.  These huge numbers of our most vulnerable are growing up in circumstances completely beyond their control; yet, they, and ultimately all of us, pay for the lifelong consequences of this state of affairs.

A large and growing body of research has been devoted to understanding the real world developmental implications of such deprivation.  It is widely believed that poverty is bad for kids.  Genetic and cognitive neuroscience seems to be substantiating that this relationship does in fact impede the development of important life-long social and cognitive skills.  For example: children who grow up in poverty evidence diminished: (a) phonemic awareness, (b) vocabulary, (c) verbal math skills,  (d) control over attention to task, (e) working memory, (f) executive functioning, and (g) incidental learning capabilities (Knudsen, et al., 2006, Raizada and Kishiyama, 2010).  Diminished capacity in any of these areas degrades one’s ability to make the best of learning opportunities provided.

Many folks comfortably blame those in poverty for their circumstances, suggesting that genetic inferiority, personal character traits, or irresponsible choices land poor people in their circumstances.  Some comfortably point at the “culture of poverty” as the culprit while believing that their own superior work ethic and drive for success solely differentiates them from their poor brethren. Despite a plethora of data indicating that this thinking essentially blames the victim, it persists.

Evidence suggests that genes may in fact play a part in this affluence disparity, but, it is becoming increasingly clear that environment plays a crucial role in how those genes are expressed.  Specifically, “some genes are turned on or off, or can have their expression levels adjusted by experience.” (Knudsen, et al, 2006). Clearly environment impedes the development of the important social and cognitive skills described above and thus creates a negative feedback loop that sustains folks in perpetual poverty.  With this knowledge in hand, it is becoming ethically and fiscally necessary to understand the mechanism through which deprivation actually affects brain development.

Cognitive neuroscience, through brain imaging studies, is increasingly providing an understanding of this mechanism.  More to come on this in subsequent posts.  It is equally important to understand whether there are intervention strategies that can remediate or limit the implications of such deprivation.

There are two robust and reasonably well designed studies of Early Intervention Programs for disadvantaged children that do appear to remediate, to a substantial degree, the negative impact of growing up in poverty.  These include the Perry Preschool Program and the Abecedarian Program.  Each of these programs set out to see if intervention has any hope of blocking this negative feedback.  Each study used randomized child assignment and long-term follow up to evaluate the implications of the provided interventions on social behavior and cognitive development. The summary below is from Knudsen, et al, 2006.

The Perry Program was an intensive preschool program that was administered to 64 disadvantaged, black children in Ypsilanti, MI, between 1962 and 1967. The treatment consisted of a daily 2.5-h classroom session on weekday mornings and a weekly 90-min home visit by the teacher on weekday afternoons. The length of each preschool year was 30 weeks. The control and treatment groups have been followed through age 40. The Abecedarian Program involved 111 disadvantaged children, born between 1972 and 1977, whose families scored high on a risk index. The mean age at entry was 4.4 months. The program was a year-round, full-day intervention that continued through age 8. The children were followed up until age 21, and the project is ongoing.

 

In both the Perry and Abecedarian Programs, there was a consistent pattern of successful outcomes for treatment group members compared with control group members. For the Perry Program, an initial increase in IQ disappeared gradually over 4 years after the intervention, as has been observed in other studies.  However, in the more intense Abecedarian Program, which intervened earlier (starting at age 4 months) and lasted longer (until age 8), the gain in IQ persisted into adulthood (21 years old).  This early and persistent increase in IQ is important because IQ is a strong predictor of socioeconomic success.

See the figures below (Knudsen, et al, 2006) for the data on these programs.

Perry Preschool Data

Abecedarian Program Data

As can be seen above, the positive effects of these interventions were also documented for a wide range of social behaviors. Again from Knudsen, et al, 2006:

At the oldest ages tested (Perry, 40 yrs; Abecedarian, 21 yrs), individuals scored higher on achievement tests, reached higher levels of education, required less special education, earned higher wages, were more likely to own a home, and were less likely to go on welfare or be incarcerated than individuals from the control groups. Many studies have shown that these aspects of behavior translate directly or indirectly into high economic return. An estimated rate of return (the return per dollar of cost) to the Perry Program is in excess of 17%.  This high rate of return is much higher than standard returns on stock market equity and suggests that society at large can benefit substantially from these kinds of interventions.

Clearly, poverty inherently impedes individuals’ potential and renders them less able to contribute to society in a meaningful way. There is ample reason to consider social programs that have proven capacity to limit the negative and disabling consequences of growing up poor. All of us pay a price for poverty whether it be through the criminal justice system, income assistance programs, special education programs, or publicly assisted medical care. Doesn’t it make sense to invest proactively in our children so that we don’t have to respond in a reactive manner after the damage has already been done?

It was once said that “every society is judged by how it treats the least fortunate amongst them.”  I believe that this is true.  Even if you don’t believe this to be true, from an economic perspective, it just makes good sense to halt this negative feedback loop – and early intensive intervention is the key to success.  This will benefit all of us.

References:

Knudsen, E. I., Heckman, J. J., Cameron, J. L., and Shonkoff, J. P. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce.  Proceedings of the National Academy of Sciences.  v. 103, n. 27. 10155-10162.

Raizada, R. D. S., and Kishiyama, M. M. (2010). Effects of socioeconomic status on brain development, and how cognitive neuroscience may contribute to leveling the playing field.  Fontiers in Human Neuroscience. v. 4 article 3.

Having a loved one with cancer is a life changing experience.  It necessitates coping with the medical demands and perhaps equally challenging, the psychological ones.  One of the most curious issues my wife has had to deal with are the things people say.  Many people do say the right thing, but often she recounts horrible things that leave me wondering “What were they thinking?”

Dealing with a diagnosis is quite overwhelming and really quite scarey.  It demands a grieving process and coming to terms with the reality of it all.  The new learning and the scheduling of appointments are substantial demands by themselves; but, dealing with the psychological issues may readily constitute the biggest early challenge.

Fear and uncertainty abound when you first get such a diagnosis.  No matter how hard one tries to internalize the notion that ductal carcinoma is perhaps one of the most successfully remedied forms of cancer, this knowledge is often overpowered by the fear that the word CANCER elicits.  For most of history, a diagnosis of cancer has been a death sentence.  This is hard to get past.

A person in the early stages of diagnosis does not need to hear the horror stories no matter how factual they are.  It only feeds the fear.  What has been most surprising to me is the fact that some people, who have had a personal encounter with cancer, seem to forget the vulnerability one feels early in the experience.  Some seasoned survivors seem to latch onto the novice and assume that they have license to unload their painful personal stories.  I do not know what it is like to be on the other side of this diagnosis, but it is my sincerest hope that all of my loved ones will remember the vulnerability one feels at this stage, and will hereafter provide only calming sensitivity when dealing with the newly diagnosed.

Clearly it is ill advised to recount the number of people one knows who have been defeated by this dreadful disease, but unfortunately, this is the most common offense.  There are other well intentioned things people say like: “You’re so healthy, you’ll beat this!”  Well you know, it’s damn hard to consider yourself healthy, no matter how fit you are, when you HAVE CANCER!

Here are some other important realizations.  Most caring people offer their prayers and thoughts and ask if there is anything they can do.  Many others advise staying positive or offer alternative therapies as if these are the key to success.  All these offers and advice, no matter how well intentioned, do little other than making the speaker feel empowered and supportive.  Although this may be important for you, for the person afflicted, it misses the mark.

Okay, so you have some idea of what not to say, here is my advice on what might be helpful. Bottom line: take the time to really listen.  The newly diagnosed individual needs to be able to process and work through the fear.  It will also be important to spend time with loved ones and to live life as if the malignancy has not engulfed everything and everyone.  One needs to laugh and feel loved.

It is hard to know what to say, but the key to success lies in listening to what’s really going on inside the person.  Skip the self soothing cliches and use real empathy.  Instead of asking if you can do something – do something.  Tell the person what he or she means to you.  Express your love – spend some time with the person doing something fun.  Go to a show, eat dinner out, go for a walk, or stop in for a visit and don’t feel the need to say the right thing.  Instead, ask questions and listen.  Be there, allow for the grief and fear without squelching it.  Focus on his or her feelings, not your own.  Take the risk of not knowing what to say.

To make yourself feel better, do some research and learn about the disease.  You may want to contribute to a worthy cause like Relay for Life and get your solace from that. Don’t expect to garner hero status – do it because it is a good thing to do.  Rally coworkers and friends, wear pink (or other appropriate symbolic color) as a tribute, and take a picture of the group and share it in loving support.  Actions speak louder than words.

It’s not magic – its what you do when some one is grieving or scared.  If you need more concrete guidance, read this or this.  Know that I am saying this not to offend those who have reached out in an errant fashion.  I fear that I may come across as ungrateful or unappreciative, but, if you really want to be helpful – take this constructive feedback and touch someone in a truly meaningful way.

I have little tolerance for unabashed patriotism. When you look closely at the facts with regard to important quality of life indicators, the good ole US of A falls short in many areas.  Life, liberty, and pursuit of happiness and unalienable rights seem to apply more to corporate entities than they do to we the people. And freedom now has more to do with economic opportunity in other countries than it does with civil liberties for our own citizens.  Don’t get me wrong, I am happy to be an American.  Thanks to my brave and industrious parents and their forefathers, I have had a steady launching pad and subsequently have done moderately well for myself.  However, I am very fortunate not to have been born Gay, a minority, or poor.  To paraphrase an old Seinfeld episode “Not that there is anything wrong with being any of these,” but the reality is that these folks suffer at disproportionate levels in this country.  And I suggest that this is a direct result of social and economic policies.

Somehow, patriotism has become the exclusive domain of those on the Right who through Conservative policy support deregulation, free markets, hawkish military doctrines, government downsizing and subsequent cuts in social services and regulatory agencies.  Even the Democrats have shifted to the right and this has been particularly true since the Clinton Administration. These policies certainly bolster corporate interests and the financial portfolios of the very wealthy.  But those gains have come at the expense of the vast majority of Americans.  The income divergence between wealthy Americans and the rest of us is no secret.  Charts and graphs, easily accessible, have uniformly detailed the relative economic flat line that most of us have endured for decades while those in the top 1% show skyrocketing and seemingly geometric growth rates.  Meanwhile, policies that may level the playing field for most Americans, have somehow been castigated as “Socialist” and “Anti-American.”  This latter thinking is wrong on so many different levels.

Regardless of the real world consequences, nearly half of Americans latch onto and support the Conservative – pro-business policies that are clearly at odds with their well being.  One important way this plays out is in healthcare.  When it comes to life expectancy, the USA ranks number 37 in the world.  That’s right 37!  There are 36 nations that, as a people, take better care of each other than we do.

In a recent study published in Population Health Metrics on life expectancy in the United States, data regarding life expectancies in every county from 2000 to 2007 shows how U.S. mortality compares with that from other wealthy nations.  The results indicate that life expectancy in the United States has not kept pace with other nations.  In fact, the data suggests that life expectancy has fallen in many counties, particularly in Appalachia and the deep south.   Women in such settings have fared far worse than men.

Here are some of the highlights from the study.  The highest life expectancy for women in 2007 turned out to be in Collier County near Naples, Florida – where women lived on average for 86 years.  In contrast for women from Holmes County, Mississippi the average age at time of death was 73.5 years.  That is nearly a 13 year discrepancy.  Further it was indicated in the report that:

In 2007, life expectancy at birth for American men and women was 75.6 and 80.8 years, ranking 37th and 37th, respectively, in the world. Across US counties, life expectancy at birth ranged from 65.9 to 81.1 years for men and 73.5 to 86.0 years for women (Figure 1a). Geographically, the lowest life expectancies for both sexes were in counties in Appalachia and the Deep South, extending across northern Texas. Counties with the highest life expectancies tended to be in the northern Plains and along the Pacific coast and the Eastern Seaboard. In addition to these broad geographic patterns, there are more isolated counties with low life expectancies in a number of western counties with large Native American populations. Clusters of counties with high life expectancies for males and females are seen in Colorado, Minnesota, Utah, California, Washington, and Florida.

What accounts for this gap and the lower relative ranking among our fellow longer living earthlings from other nation states?   On June 16th, 2011, Melissa Block from NPR – Talk of the Nation discussed the results of this study with Dr. Ali Mokdad, a global health professor at the Institute for Health Metrics and Evaluation at the University of Washington.   Dr. Mokdad noted that: “there are four factors – three are equally affecting men and women in this country.”   He then indicated that the three equal opportunity factors included:  (1) socioeconomic status;  (2) access to healthcare/health insurance or no insurance; and (3) quality of medical care.  In other words, if you’re poor, you don’t have medical insurance, and you live in remote areas with poor medical facilities, with less proficient professionals, you are more likely to die early.  On the other side of the coin, it is true that we have the best quality medical care in the world, BUT, many Americans do not have access to this Tier 1 level of care.  It’s only true for certain pockets of the population who are relatively affluent and living near major medical institutions.

The fourth factor, preventable risk factors (e.g., smoking, obesity, poor diet, lack of physical activity), affects both genders but women and particularly poor women disproportionately.  The study points out that in more than 300 counties in the United States, life expectancy declined over 20 years for women.

It is time to wake up America!  These statistics are appalling and embarrassing.  Look at the the real world human costs of economic policies that create and sustain such divergence.  The most recent recession, clearly the result of financial deregulation and unfettered free market greed, has had catastrophic global consequences that have reshaped the landscape.  Budgetary discussions center around deep government cuts to education and social services – further compromising the very people who have been hurt the worst.  Elimination of continued tax breaks to the richest Americans is absolutely off the table.  And now the Conservative agenda is to abolish “Obama Care?”  Look at the evidence people – its all around you.  Before you buy into an ideology – look at the real world consequences – look at the evidence, and ask yourself how you and your loved-ones are affected.  It scares me that such callus disregard for our fellow citizens is the new chic.

I find myself in an unfortunate spot.   Both my mother and father are suffering from seemingly intractable health problems and my wife was just diagnosed with breast cancer.  My parents, each suffering for years with chronic pain have been victimized by aimless care in an over burdened, understaffed, and misguided healthcare system.   The maladies of a healthcare system driven by economists has left us with a patient care system that is often just mediocre and sometimes atrocious.  More evidence for this has played out in the sequence of events that has left cancer undiagnosed and unabated inside my wife’s breast for six months after she first detected a lump.

What I have personally witnessed over the last year has left me appalled.  There is not enough time, space, or reader interest, I suppose, to take you through these respective journeys.  And my anecdotes, as deeply meaningful as they are to me, tell only a minute fraction of a complicated story.   Multiple factors have coalesced to degrade healthcare, and these forces have been primarily dictated by the motive for profit, austerity, or the quest for financial viability.  These interests have seemingly superseded the drive for quality care.

When I had my own private practice (as a Licensed Psychologist) the reimbursement schedules set up by insurance companies provided financial incentives for care provision that were incompatible with my training and my personal and ethical care standards.  Viability as a service provider demanded either compliance or unsustainable practices.  In large part due to these realities I chose a different career path.  This is all too common.  Two of the best medical doctors I’ve known have left the field because of similar issues.  When you can’t do what’s right and you feel like you have to thin your care to stay in business, the whole patient care scenario becomes compromised.

Medical care for run of the mill ailments seems adequate (if you are fortunate enough to have health insurance); however, when issues are complex or they involve multiple body systems, the quality of care seems to break down.  My father, for instance has many health issues.  His care, when any of these issues becomes acute, pits one specialist against another and thus one body system against another.   Just recently his acute pulmonary difficulties landed him in the ER and there, the care, as prescribed by an ER Doc, resulted in an adverse reaction necessitating yet another ER visit that resulted in a worsening response necessitating admission to the hospital.

His care has been so fragmented and communication so compromised that he experienced in this circumstance, a doctor induced overdose.  Looking back over the last several months, he has experienced intolerable amounts of pain and suffering – the likes of which no one should have to experience.

While in the Hospital after his initial diagnosis of pneumonia, he fell and injured his back causing significant and persistent pain that was initially misdiagnosed as pleurisy.  Months of pain and misdiagnoses left lingering unresolved pain. My mother likewise has an idiopathic issue that results in protracted and unimaginable pain.  The poor women has experienced dumbfounded docs and care that resulted in multiple re-admissions and ultimately no resolution of the issue.   We have traveled to distant cities to see experts with hopes that we can get her issue under control.  An appointment just this week left even the Doctors at Cleveland Clinic shrugging their shoulders in ignorance.  Idiopathic pain unresolvable by the best.  This isn’t anyone’s particular fault, but it leaves my mother wondering when the next episode will incapacitate her with pain. That is no way to live. She now needs experts in pain management.

My parents are strong, independent, self-reliant, humble and unassuming people who do not have a bone of entitlement in their make-up.  They have worked hard throughout their lives as solid contributors to society.  They are careful and cautious people trying to do what is right.  What they have gone through in their golden years is tragic.  And some of it, certainly not all of it, lies at the feet of modern health care.

Now, we have cancer care on the immediate horizon. I cannot and will not tolerate the mediocrity that pervades the healthcare system in pursuit of my wife’s recovery.  We will advocate for the best possible care available, and will not accept less than best practices should our insurance company attempt to compromise my wife’s care to save a buck.  This will not be easy and perhaps not cheap, but life and time are precious.  Far more precious than the material possessions that surround us.  I keep saying that if Lance Armstrong can survive the extensive cancer he had and go on to win a record number Tours de France, than we can beat this.  The only question is – will we get Tier 1 level of care?

Clearly there are three tiers of healthcare in the United States.  There is the reactive or non-existent care received by the poor and those at the lower end of the SES spectrum who cannot afford insurance.  Then there is the care for those of us with health insurance – adequate for run of the mill ailments – but stressed by complexity.  Then there is Tier 1 care for those with no financial restraints.  Money talks and it can buy you the best care in the world.

We do not have limitless resources or the fame and backing that Lance had, but but we do have resolve, determination, and the best breast cancer surgeon in Western New York.  I laid it out on the table when we met with her doctor:

“Only the best for my wife! I don’t want an insurance bureaucrat making medical decisions for us.  I’ll sell my house if I need to – Tier 1 Care – nothing less!”

And so the journey begins. We have a lot to learn and a formidable opponent. Cancer can be tough too.