Keynote Innovation Conference Alameda County Behavioral Health Services

1. Carl C. Bell, M.D. Staff Psychiatrist – Jackson Park Hospital Family Practice Clinic Staff Psychiatrist – St. Bernard Hospital Inpatient Psychiatry UnitFormer Director of the Institute for Juvenile Research (Birthplace of Child Psychiatry) Professor Psychiatry and Public HealthDirector of Public & Community Psychiatry – Department of PsychiatryUniversity of Illinois at Chicago Keynote Innovation ConferenceAlameda County Behavioral Health Services

2. Triadic Theory of Influence • Sociological theories of social control and social bonding (Akers et al., 1979; Elliott et al., 1985) • Peer clustering (Oetting & Beauvais, 1986) • Cultural identity (Oetting & Beauvais, 1990-91) • Psychological theories of attitude change & behavioral prediction (Fishbein & Ajzen, 1975; Ajzen, 1985) • Personality development (Digman, 1990) • Social learning (Akers et al., 1979; Bandura, 1977, 1986) • Integrative theories (e.g., Jessor & Jessor's, Problem Behavior Theory; Brook’s Family Interaction Theory, Hawkins’ Social Development Theory) • See Petraitis, Flay and Miller (1995).

4. Community Psychiatry Protective Factor Field Principles • Rebuilding the Village/Constructing Social Fabric • Access to Modern and Ancient Technology – Biotechnical and Psychosocial • Connectedness • Social and Emotional Skills • Self Esteem - Activities that create a sense of power; Activities that create a sense of connectedness; Activities that create a sense of models; Activities that create a sense of uniqueness • Reestablish the Adult Protective Shield/Safety • Minimize the Effects of Trauma/Mastery

9. five protective factors Strengthening Families PARENTAL RESILIENCE SOCIAL CONNECTIONS KNOWLEDGE OF PARENTING AND CHILD DEVELOPMENT CONCRETE SUPPORT IN TIMES OF NEED SOCIAL AND EMOTIONAL COMPETENCE of CHILDREN

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

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

12. Risk Factor - Culture Destroys • Canada's monocultural ethnocentric culture had little value for First Nation culture. • Thus, First Nation children were removed from their families and told them their culture was not acceptable, resulting in First Nation people having to give up their cultural protective factors which ultimately led to many First Native people engaging in the risky behaviors of suicide and intra-group homicide.

13. Risk Factor - Culture Destroys • Within these communities, alcoholism is common and for every one child in Canadian juvenile detention centers without fetal alcohol syndrome there are 19 children with fetal alcohol spectrum disorders (Popova et al, 2011). • Bell (2012) has proposed many disruptive behaviors leading to incarceration results from fetal alcohol exposure (FAE).

14. Risk Factor - Culture Destroys • Fetal Alcohol Exposure is the leading cause of speech and language disorders, ADHD, Specific Learning Disorders, & Mild Mental Retardation which are often responsible for affect dysregulation leading to disruptive behaviors leading to incarceration. Stratton et al. (1996). Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. Washington, D.C. National Academy of Sciences, Institute of Medicine.

15. Risk Factor - Culture Destroys Youth Risk Behavior Surveillance The prevalence of having carried a weapon in general was higher among white males (27.2%) than among their black counterparts (21%). The prevalence of having carried a weapon onto school property was higher among white males (7.8%) than black males (6.7%).

16. Risk Factor - Culture Destroys The prevalence of having ever used cocaine was higher among white males (7.6%) than black males (4.2%). Yet, people of color make up a higher proportion of children and young adults who are incarcerated. In fact, in 2010, the imprisonment rate for black non-Hispanic males (3,074/100,000 U.S. black male residents) was almost seven times higher than it was for white non-Hispanic males (459/100,000) U.S. Bureau of Justice Statistics

17. Protective Factor - Culture Protects • While doing HIV prevention work in Durban, South Africa it was striking that 40 percent of the Zulu people were HIV-positive, 6 percent of the white South African people were HIV-positive, but only 1 percent of the Indian South African people were HIV-positive.

18. Photo by Aleta McLeod 2-29-08: Dr. Bell standing on 60ft cliff off Shipwreck beach in Kauai, Hawaii

19. Photo by Aleta McLeod 2-29-08: Dr. Bell jumping off a 60ft cliff off Shipwreck beach in Kauai, Hawaii

20. Fact • One-fifth of the U.S. adult population is flourishing - the rest are “languishing in life.” • Culture helps people flourish!

21. Positive emotions (i.e. emotional well-being) • Positive affect • Regularly cheerful, interested in life, in good spirits, happy, calm and peaceful, full of life. • Avowed quality of life • Mostly or highly satisfied with life overall or in domains of life.

22. Positive psychological functioning (i.e. psychological well-being) • Self-acceptance • Holds positive attitudes toward self, acknowledges, likes most parts of self, personality. • Personal growth • Seeks challenges, has insight into own potential, feels a sense of continued development

23. Positive psychological functioning (i.e. psychological well-being) • Purpose in life • Finds own life has direction and meaning. • Environmental mastery • Exercises ability to select, manage, and mold personal environs to suit needs. • Autonomy • Is guided by own, socially accepted, internal standards and values. • Positive relations with others • Has, or forms, warm, trusting personal relationships

24. Positive social functioning (i.e., social well-being) • Social acceptance • Holds positive attitudes toward, acknowledges, and is accepting of human differences • Social actualization • Believes people, groups, and society have potential and can evolve or grow positively • Social contribution • Sees own daily activities as useful to and valued by society and others.

25. Positive social functioning (i.e., social well-being) • Social coherence • Interested in society and social life and finds them meaningful and somewhat intelligible. • Social integration • A sense of belonging to, and comfort and support from, a community.

26. Community Psychiatry Protective Factor Field Principles • Rebuilding the Village/Constructing Social Fabric • Access to Modern and Ancient Technology – Biotechnical and Psychosocial • Connectedness • Social and Emotional Skills • Self Esteem - Activities that create a sense of power; Activities that create a sense of connectedness; Activities that create a sense of models; Activities that create a sense of uniqueness • Reestablish the Adult Protective Shield/Safety • Minimize the Effects of Trauma/Mastery

27. Oakland’s Innovations • Helping people "rebuild their villages," • “Mental Health Friendly Congregations” • Providing access to modern and ancient technology - both biotechnical and psychosocial." • “Co-Occurring Healing” • “The Sakhu Project: Incorporating the Illumination of Culturally Congruent Well-Being and Wholeness into the Planning and Delivery of Services to African American Populations”

28. Oakland’s Innovations • Increasing connectedness," • “His Health: Gender Responsiveness & Culturally Appropriate Counseling with African American Urban Male Youth” •  Giving people a "sense of power, models, and uniqueness - a.k.a. self-esteem," • “Healthy Teens” & “Understanding the Impact of Trauma on the Well-being of Young African American Children & Their Families” • “Conscious Voices”

29. Oakland’s Innovations •  Teaching "social and emotional skills," • “Healing Trauma and Overcoming Stress: Creating Health & Well-Being Through The Use of Cultural Genograms, Storytelling, and Mindful Based Practices” •  Providing an "adult protective shield," • “Community Healing Circles: For African American Men and Adolescents on Probation” • “African American Faith Mental Health Anti-Stigma Campaign” & “Safe Transitions”

30. Oakland’s Innovations • Minimizing trauma," • “Healing Trauma Through Support and Care: Trauma Awareness Group (TAG)” • “Girls Far Above Rubies” & “Developing Trauma Informed Practices for Young People Caught in the Crossfire”

31. The Critical Role of Self-Regulation Neuroscience and behavioral research are converging on the importance of self-regulation for successful development Children who do not develop the capacity to inhibit impulsive behavior, to plan, and to regulate their emotion are at high risk for behavioral and emotional difficulties Bell CC & McBride DF. Affect Regulation and the Prevention of Risky Behaviors. Journal of the American Medical Association, Vol. 304, No. 5: 565 –566, August 4, 2010

32. Prevalence of FASD • Fetal Alcohol Syndrome (FAS) occurs far more frequently than generally believed: FAS: 1 per 1000 live births • Although estimates vary widely, when combined with the milder afflictions of Fetal Alcohol Spectrum Disorders (FASD), the Centers for Disease Control puts the frequency of FAS/FASD as high as one in 100.

33. Prevalence of Drinking while Pregnant • In the US 13% knowingly drink while pregnant • 1% drink heavily while pregnant • 3-4% binge drink during pregnancy (SAMHSA) • 12% of pregnant women consume 5 or more drinks per month • 50% of pregnancies are unplanned

34. The Critical Role of Self-Regulation A - more than minimal exposure to alcohol during gestation B - impaired neurocognitive functioning; C - impaired self-regulation; D - impairment in adaptive functioning; E - onset of the disorder occurs in childhood; F - the disturbance causes clinically significant distress or impairment in social, academic, occupational functioning; G - the disorder is not better explained by the direct physiological effects associated with postnatal use of a substance, a general medical condition, another known tetratogen, a genetic condition, or environmental neglect.

36. The Critical Role of Self-Regulation 1979 – 88.5% (246) of the 274 children in Pupil Service Center on Chicago’s Southside had Childhood Neurodevelopmental Disorders (CND) 1985 – 20% of inmates in Texas Department of Corrections were “mentally retarded.” 2011 - chart audit on 162 children in several nurse-based school clinics estimates 39% (63) of those children met the DSM-5 Condition for Further Study - “Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (NDA-PAE) a (CND). 2012 prior to the closure of the Community Mental Health Council, Inc. - chart audit of 330 randomly selected patients revealed that 12% (39 of 330 patients) met criteria for CND.

37. The Critical Role of Self-Regulation 2013 - work on an inpatient psychiatric unit at St. Bernard Hospital (in the heart of Englewood - one of the poorest African-American communities in Chicago) reveals of 93 patients consecutively admitted patients, 32% (30) meet the criteria for CND-PAE. 2013 - a random sample of 20% of consecutively seen outpatients in Jackson Park Hospital's Family Practice Clinic (JPH-FPC) reveals that out of 100 patients, 29% (29) fit the criteria for NDA-PAE 2014 – of 613 psychiatric patients at JPH-FPC – 1/3rd have CNDs and half of those are NDA-PAE – the other half could not be confirmed due to absence of the mother’s to provide a history

38. IDEAS TO COMBAT THE EFFECTS OF FAE Do public service announcements to grandmothers who are care giving for grandchildren who have learning disorders, mild intellectual disability, ADHD, speech and language disorders, explosive tempers and who know their daughters or daughters-in-law were drinking during pregnancy. Have correctional facilities who incarcerate pregnant women screen those women for drinking while pregnant before they knew they were pregnant.

39. IDEAS TO COMBAT THE EFFECTS OF CND - PAE Educate Obstetricians about the damage CND - PAE can do and suggest to them that choline supplements may decrease the outcome of FAE exposed children (let them know that prenatal vitamins do not have choline in them). Work with Oakland Public Schools to identify children in special education who have the characteristic histories of CND - PAE, and have their parents supplement those children’s nutrition with choline, folate, and vitamin A.

40. IDEAS TO COMBAT THE EFFECTS OF CND - PAE Work with Alameda County to identify children in their facility who have the characteristic histories of FAE, and supplement those children’s nutrition with choline, folate, vitamin A, and Omega-3. Get in touch with the Oakland’s Child Protective Services and have them to identify children in their facility who have the characteristic histories of FAE, and supplement those children’s nutrition with choline, folate, vitamin A, and Omega-3.

41. IDEAS TO COMBAT THE EFFECTS OF CND-PAE Get vitamin companies to put choline in their prenatal vitamins. Get drug stores to supply choline supplements in their stores. Others?

42. TABLE 3 - Standard set of interview questions to explore the possibility of Childhood Neurodevelopmental Disorder 1) How far did you go in school? 2) If the patient did not finish grammar or high school ask: Why didn’t you finish grammar school/high school? 3) Did you have problems learning – math, reading, or comprehension? 4) Were you in special education classes? 5) Did the teachers and adults in your family think you were hyperactive? 6) Did you have speech or language problems in school?

43. TABLE 3 - Standard set of interview questions to explore the possibility of Childhood Neurodevelopmental Disorder 7) Were you teased as a child? 8) If the patient was teased, ask the patient: What were you teased about? 9) Did you have a bad temper as a child/have you had a bad temper your whole life? 10) Did you have poor emotional control as a child/have you had poor emotional control your whole life. 11) How is your memory? 12) If the patient reports having a poor memory ask: Has your memory been poor since childhood?

44. TABLE 3 - Standard set of interview questions to explore the possibility of Childhood Neurodevelopmental Disorder 13) When you were in school did you have problems with comprehension? 14) Serial 7 subtractions from 100, and spell “world” forwards and backwards. 15) Gather evidence of clinically significant distress or impairment in social, academic, occupational functioning by asking about the patient’s ability to get along with others and their employment history.

45. DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure A. More than minimal exposure to alcohol during gestation, including prior to pregnancy recognition Confirmation of gestational exposure to alcohol may be obtained from maternal self-report of alcohol use in pregnancy, medical or other records, or clinical observation. B. Impaired neurocognitive functioning as manifested by one or more of the following: Impairment in global intellectual performance (i.e. IQ of 70 or below) Impairment in executive functioning (e.g. poor planning and organization, inflexibility, difficulty with behavioral inhibition)

46. DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure B - Impaired neurocognitive functioning as manifested by one or more of the following: Impairment in learning (e.g. lower academic achievement than expected for intellectual level; specific learning disability) Memory impairment (e.g. problems remembering information learned recently; repeatedly making the same mistakes; difficult remembering lengthy verbal instructions) Impairment in visual-spatial reasoning (e.g. disorganized or poorly planned drawings or constructions; problems differentiating left from right)

47. DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure C. Impaired self-regulation manifested by one or more of the following: Impairment in mood or behavioral regulation (e.g. mood liability,; negative affect or irritability ], frequent behavioral outbursts). Attention deficit (e.g. difficulty shifting attention; difficulty sustaining mental effort). Impairment in impulse control (e.g. difficulty waiting turn; difficulty complying with the rules). D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2): Communication deficit (e.g. delayed acquisition of language; difficulty understanding spoken language) Impairment in social communication and interaction (e.g., overly friendly with strangers, difficulty reading social cues; difficulty understanding social consequences)

48. DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2): Impairment in daily living skills (e.g. delayed toileting, feeding, or bathing; difficulty managing daily schedule) Impairment in motor skills (e.g., fine motor development; delayed attainment of gross motor milestones or ongoing deficits in gross motor function; deficits in coordination and balance. E. Onset of disorder (symptoms in Criteria B, C, and D) occurs in childhood.

49. DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure F. The disturbance causes clinically significant distress or impairment in social, academic, occupational or other important areas of functioning. G. The disorder is not better explained by the direct physiological effects associated with postnatal use of a substance (e.g. medication, alcohol or other drugs); medical condition (traumatic brain injury, delirium, dementia);