Too Many And Not Enough Drugs Are A Critical Factor In Insane Violence

Severe mental illness is greatly reduced as a risk factor for violence in people who are taking their meds, and greatly increased as a risk factor for violence in people who self-medicate with illegal drugs.

The severely mentally ill make up only a minor share of violent crime perpetrators (and are often victims themselves), so treatment of the severely mentally ill isn't a major driver of violent crime, but they do, overall, have an elevated risk of committing violent crimes living in a world that deals with several mental illness the way that our society does. Also, they do represent a population for whom there is a fairly clear path to reducing violent crime commission risk. Moreover, some of the most sensational and shocking crimes in our society involve instances where severely mentally ill individuals run amok, even though these crimes are very rare and are difficult to predict or prevent.

[S]everely mentally ill people account for only 3 to 5 percent of violent crimes in the general population. . . . we refer only to severe mental illness—meaning schizophrenia, bipolar disorder or psychotic depression. . . .

In a 2009 meta-analysis, or quantitative review, of 204 studies exploring this connection, psychologist Kevin S. Douglas of Simon Fraser University and his associates found a slightly greater likelihood of aggressive behaviors among those with severe mental illnesses. Yet this connection is much weaker than the public seems to believe it is and does not necessarily mean that these serious disorders cause violence. The causation could be in the reverse direction: engaging in chronic aggression (stemming from some other source) may create stress that triggers the illness in those predisposed to it. Alternatively, a third factor could spawn both a psychiatric condition and violence. . . .

[T]he MacArthur Violence Risk Assessment Study in 1998, sociologist Henry J. Steadman of Policy Research Associates and his colleagues reported that almost a third of severely mentally ill patients with substance abuse problems engaged in one or more violent acts in the year after they left the hospital. For discharged patients who did not abuse drugs, the corresponding figure was only 18 percent. . . .

In its meta-analysis, Douglas’s team also flagged drug abuse as one of several factors that contributed to the connection between mental illness and violence. In addition, it found the link was even stronger for patients who suffered from delusions, hallucinations or disorganized thinking. Thus, a mentally ill person is more at risk of committing an act of aggression when that individual is also abusing a drug and shows particular symptoms. . . .

In the MacArthur study, Steadman’s team found no difference in the prevalence of violence between the severely mentally ill who were on their medications and mentally healthy people, whereas unmedicated patients lashed out at significantly higher rates. . . . improving adherence to treatment may lessen the chances that severely ill people will behave violently.

From Scientific American.

I am not quite as optimist as Hal Arkowitz and Scott O. Lilienfeld, who are the authors of this Scientific American article. For instance, individuals who have been hospitalized for mental health conditions (generally, because someone determines that they pose a risk of bodily harm to themselves or others as a result of one or more prior specific incidents), clearly pose a much greater risk to the public than individuals who have received merely outpatient mental health treatment. An 18% risk of engaging in violent acts is on the same order of magnitude as the risk that a felon about two years out of prison without incident will do so and is fantastically elevated relative to someone who has neither a criminal record nor a record of commitment to an institution for a mental health condition. A 33% risk of engaging in violent acts is on the same order of magnitude as the risk that a felon just release from prison will commit a new crime.

The claim that "severely mentally ill people account for only 3 to 5 percent of violent crimes" also fails to reflect that a much larger percentage of people whom the criminal justice system deems it necessary to incarcerate have moderate to several mental health issues. The number of mentally ill people in jail and prison vastly outnumbers the number of mentally ill people who are in civil institutional settings.

This account also fails to dissect the overall problem of mental health issues adequately. There are multiple very different paths linking mental health issues and crime.

One common path links traits like impulsivity, novelty seeking, and weak anger management capacity with "heat of passion" crimes, often under the influence of alcohol and aggravated by the possession of weapons. These traits do not mitigate guilt in the criminal justice system but often are considered in mitigation of a sentence for a crime.

A second common path links the concept of psychopathic absence of conscience, with pre-meditated crimes like first degree murder, serial rapes and fraud. The violent crimes seem to usually involve a plus factor of impulsivity with pscyhopathy. The white collar crimes and immoral but not illegal business practices tend to fit psychopaths who are at the opposite end of the conscientious to impulsive dimension of personality. Psychopathic traits, rather than being mitigating circumstances, are generally aggravating circumstances in the criminal justice system and closely overlap with circumstances justifying the death penalty.

The third common path is the one focused on in the article - the delusional, and also manic or depressed individual who goes amok, a path where illegal substance abuse greatly elevates the risk and taking prescribed meds

Fourth, a significant share of people who commit serious crimes are not mentally ill, per se, but are developmentally disabled, i.e. they have IQs so low that they are considered mentally retarded. In the extreme, a low IQ can affect guilt in the criminal justice system, but more often it mitigates a sentence and heightens scrutiny of the veracity of the individual's confessions to law enforcement officers, their capacity to carry out the crime, and their vulnerability to being framed or participating ineffectively in the criminal justice system. 

Fifth, a certain share of people who commit serious crimes do so in response to traumatic circumstances, extreme stress, abuse and manipulation, in a form of extended self-defense, in the form of poor judgment in connection with the mental breakdown of a not congenitally mentally ill individual, or in the form of an inability to resist the pressure from a dominant person in their life to commit a crime. Criminal justice responses to these circumstances are all over the map, sometimes producing leniency from one district attorney or judge or jury, while producing draconian responses from another just a few miles away.

READ MORE - Too Many And Not Enough Drugs Are A Critical Factor In Insane Violence

Crime Down In 2010 (Fifth Year In Row)

Crime levels fell across the board last year, extending a multiyear downward trend with a 5.5 percent drop in the number of violent crimes in 2010 and a 2.8 percent decline in the number of property crimes.

Year-to-year changes released Monday by the FBI in its preliminary figures on crimes reported to police in 2010 also showed declines in all four categories of violent crime in 2010. All categories for property crime went down as well. . . .

Violent crime last increased in 2005. Property crime last rose in 2002.

The FBI reported that violent crime fell in all four regions of the country last year — 7.5 percent in the South, 5.9 in the Midwest, 5.8 percent in the West and 0.4 percent in the Northeast.

From here.

Yesterday's new showed divorce rates down in Colorado. Teen pregnancy continues to hover near all time lows.

Also in the news, and possibly one explanation for the shift was the results of a new survey showing that the percentage of children ages 3-17 diagnosed with ADHD had increased from 5.7% for 1997-1999 to 7.6% for 2006-2008.

The economy can't explain the decline. The regional trends don't match immigration trends. Incarceration rates have been relatively stable in this time period. But, one thing that has changed and drives a disproportionate share of the year to year variation in crime, is the changing drug scene.

Domestic meth production is dramatically down. Illegal use of prescription drugs is up. A significant share of the illegal marijuana market has shifted to the legal medical marijuana market. Cocaine use isn't particularly high. There has been a pretty dramatic increase in legal use of drugs for mental health conditions.

One way to read the recent trend is that a lot of people who used to be self-medicating with illegal drugs supplied by a rough and tumble world of gangs and organized crime are finding chemicals to address their problems through distribution channels that don't drive street crime to nearly the same degree and provide a much more predictable product.

An alternative and not necessarily inconsistent possibility is that we are reaping the benefits of a long economic boom from the early 1980s until 2007, interrupted by only relatively brief and mild recessions. People may commit crimes on impulse, but a lifestyle that leads to commiting serious crime with little hesitation and routinely committing less serious crimes is decades in the making. A long period of relative plenty may have narrowed the pool of people who were in dire poverty as young children and became more predisposed towards crime as a result.

A third possibility is that technology is making it harder and less profitable to commit many crimes. People carry less cash. Cars have more anti-theft devices. Bank robbers and rapists are more likely to get caught. The decline in meth was driven by more strict control of the ingredients that go into it.

Whatever the reason, it is hard to deny that it is good news.

READ MORE - Crime Down In 2010 (Fifth Year In Row)

When Does Talk Therapy Work?

Some mental health conditions are utterly unresponsive to sessions spent talking with a psychologist or counselor, but very responsive to drugs.  For some conditions for some people, drugs and talk therapy support each other.  Others people with particular conditions are responsive to talking with someone, but the mere fact of having a conversation with someone who cares matters more than the content of the talk, the talking to a professional may not be the most cost effective solution.  How is one to make sense of what works and doesn't work in talk therapy for mental health issues?

A good place to start is an index of resources accompanying one of today's National Public Radio stories. 

For example, it includes a registry of 193 different interventions whose effectiveness is supported by scientific evidence.  For example, there are dozens of interventions proven to be effective in treating substance abuse problems of various types that are evidence based.  Others deal with issues connected to parenting, eldercare, PTSD, suicide prevention, general juvenile delinquency, aggression, ODC, workplace stress, and depression.

One common and basic deficiency in the status quo is a failure to know that there are approaches that have been proven to work with a condition or situation.  When there is good news, it needs to be spread far and wide.

While any list of evidence based talk therapies is necessarily driven by the funding and institutions incentives of programs to have their approaches validated with scientific research, it is also a good starting place to get a sense of what kinds of issues there is evidence to support benefits from this kind of treatment, and by inference, what issues there is no solid evidence at this time that this kind of treatment is effective in treating.  Thus, lists like these are a logical empirically driven starting point to a larger widely available resource for determing how best to deal with mental condition or emotionally difficult situations.  Moreover, as one puts together these lists, one ends up with a more practically relevant classification scheme for dealing with these conditions and situations than one that is more focused on cause and classification than in the availablity of treatment.

Also worth noting from the list is that many effective approaches take a group or community orientation rather than an individual psychotheraputic one.  Some issues are not best dealt with in a self-referring patient medical model and can look more like generalized character education.

There is probably a siginificant residual of conditions (for example, Alzheimer's disease) for which the answer is that there are no evidence based treatments, talk based or drug based, available.  Knowing that, too, has value as well, both in counseling skepticism towards unrealistic claims about proposed treatments and fostering inquiry about a broad range of treatment modalities to see if any look like a promising source of a future evidence based intervention.  Knowing this also favors an inquiry approach that focuses on minimizing harm and side effects, given that positive benefits aren't well established.

READ MORE - When Does Talk Therapy Work?

How Common Is Geriatric Dementia?

[T]he incidence of all-cause dementia almost doubles with every 5 years of age and that the prevalence of dementia rises from approximately 2 percent to 3 percent in those 65 to 75 years to 35 percent in those 85 years and older.

From here.

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Deinstitutionalization Legacy Persists

According to Pete Earley, former Washington Post intelligence journalist and author of "Crazy: A Father's Search Through America's Mental Health Madness" (2006) the United States has made a little dramatic but little noticed change in the way it handles mental health issues from a medical model to a criminal justice orientation:

In 1955, about 560,000 Americans were being treated in state mental hospitals. Based on population growth since then, you would expect more than 930,000 people in such hospitals today. There are only 55,000. Nearly 300,000 are imprisoned. Another half-million are on probation.

The largest public mental-health facility in the U.S.? The Los Angeles County Jail, home to 3,000 mentally ill inmates.

A dramatic shift towards the deinstitutionalization of those with mental health conditions in the 1980s from being the developed nation with the highest institutionalization rate for mental health conditions in the world, to the lowest, afforded some more freedom, but rather than producing a reinvestment of funds previously used for a public sector mental health care into community based programs led to a massive disinvestment in public sector funded mental health care that ended up funnelling many people who had trouble functioning in the absence of that care or family support, into the criminal justice system. Now, it can be hard to find services for anyone but the most affluent, even for bureaucratically savvy middle class families.

The trend is ongoing, with Colorado having seen many of its psychiatric hospital beds taken out of service over the last few years in the face of their high cost, and declining funding support since these programs receive less federal support or budget process protections than programs that have been preserved and often lack of visible constituency.

Earley cites conditions like schizophrenia and bipolar disorder, rather than psychopathy, as driving the trend. Some criminologists, such as Bernard Harcourt, have identified the size of the total institutionalized population as an important driver of crime rates, despite the mystery that the demographics of mental health institutions are very different from those of prisons (particularly in the number of women institutionalized). Early's identification of the large number of people with mental health conditions who are on probation or in jails, rather than prisons also helps to shed light on this demographic mystery; many people who would formerly have been institutionalized in mental health institutions are now in the criminal justice system, but only through probation or jail rather than prison, while many other individuals convicted of crimes are now more likely to be incarcerated in prison than in the past as criminal sentences have grown stiffer.

The brief excerpt in the linked story doesn't shed light on the question of how the United States experience compares to our peers in the developed world. It isn't clear, for example, if Europe and Japan have deinstitutionalized (or never institutionalized) their individuals with mental health conditions to the same extent as the United States, and if so, what the consequences of doing so have been there. The mental health institutionalization rates are indeed higher in Europe compared to a rate of about 25 per 100,000 in the United States (down from a peak in the 1950s of over 600 per 100,000), although they are declining in Europe from past levels:

Among countries in the European Union, the highest rate regarding the number of beds in psychiatric hospitals per 100,000 inhabitants in 2000 was in the Netherlands, which had a rate of 188.5. Other highs were posted in Belgium (161.6), Switzerland (119.9), France (113), and Finland (102.9). The average for the 25 European Union countries in 2000 was 90.1, down from 115.5 in 1993.

Japan's mental health institutionalization rate of 282 per 100,000 is the highest in the world, something particularly notable because the overall prevalence of mental health conditions in Japan is below the developed world average.

It is also worth pointing out that even if the residential mental health institution population were similar now to what it was in 1955, that it would still only be a tiny percentage of the population that receives or needs mental health care. For example, 60% of the population experiences depression, anxiety disorders, alcohol dependence and/or marijuana dependence by age 32. About 11% of adults in Colorado have experienced significant psychological distress (other than substance abuse issues) within the last year. Schizophrenia has a prevalence rate of about 1% in the general population, in contrast, and is about 80% genetic, and the prevalence rate and genetic component of bipolar disorder are on the same order of magnitude, but is more common and less strongly genetic.

The link between mental health issues and criminal justice involvement tends to be a "mental health plus" relationship. In one recent study, for example:

Mental illness alone is not a meaningful predictor of future violent acts, but is very significant when accompanied by a history of violence and substance abuse.

There were 3,089 people deemed to have severe mental illness—schizophrenia, bipolar disorder and major depression—but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10.

As the same linked post notes, relying on Colorado Department of Corrections date, in Colorado, "Moderate to severe substance abuse is a problem for 82.0% of male and 82.4% of female inmates. Moderate to severe mental health problems exist for 27.8% of male and 34.2% of female inmates."

Mental health problems are also much more likely to lead to serious criminal justice system involvement for individuals who are high school dropouts or have high school diplomas or GEDs but no college degree of any kind.

READ MORE - Deinstitutionalization Legacy Persists

Time-Slip Common In Autism

Neuroskeptic notes that a phenomena known as time-slip has been associated with autism spectrum disorders in Japan but not been discussed in the psychiatric literature elsewhere. The comments to his blog post suggest that the association is in fact widespread, despite the fact that it hasn't been discussed formally in the academic literature on autism.

The omission sheds light on a larger issue, which is the failure of mental health researchers to thoroughly characterize mental health conditions once a bare bones set of diagnostic criteria that are sufficient to but mental health conditions into boxes have been established. Once the box is in place, it is easy to let inertia take hold and accept it uncritically, so this concern may extend to a wide variety of formally recognized mental health conditions. The hope would be that identification of non-diagnostic traits associated with particular mental health condition, like time-slip in autism, might help us to better understand what is going on in those conditions.

READ MORE - Time-Slip Common In Autism

Physiological Test Predicts Effectiveness of Talk Therapy For Depression

[A] quick, inexpensive, and easy to administer physiological measure, pupil dilation in response to emotional words, not only reflects activity in brain regions involved in depression and treatment response but can predict which patients are likely to respond to cognitive therapy[.]. . . activity in the brain's cortical emotion regulatory systems is strongly related to pupil size when people are viewing emotion-laden words . . . It is because of this relationship between eye and brain that pupil measurements predict the response to cognitive therapy."

Cognitive therapy is a type of psychotherapy designed to help individuals overcome difficulties by modifying negative or irrational thoughts and behavior, which, in turn, can improve mood and reduce stress. It is usually completed in weekly sessions, with 10-20 sessions being effective for most individuals who benefit.

From here, citing Greg J. Siegle, Stuart R. Steinhauer, Edward S. Friedman, Wesley S. Thompson, Michael E. Thase. "Remission Prognosis for Cognitive Therapy for Recurrent Depression Using the Pupil: Utility and Neural Correlates." Biological Psychiatry, 2011; 69 (8): 726 DOI: 10.1016/j.biopsych.2010.12.041.

The abstact of the paper provides more details:

Although up to 60% of people with major depressive disorder respond to cognitive therapy (CT) in controlled trials, clinicians do not routinely use standardized assessments to inform which patients should receive this treatment. Inexpensive, noninvasive prognostic indicators could aid in matching patients with appropriate treatments. Pupillary response to emotional information is an excellent candidate, reflecting limbic reactivity and executive control. This study examined 1) whether pretreatment assessment of pupillary responses to negative information were associated with remission in CT and 2) their associated brain mechanisms.

We examined whether pretreatment pupillary responses to emotional stimuli were prognostic for remission in an inception cohort of 32 unipolar depressed adults to 16 to 20 sessions of CT. Twenty patients were then assessed on the same task using functional magnetic resonance imaging. Pupillary responses were assessed in 51 never-depressed controls for reference.

Remission was associated with either low initial severity or the combination of higher initial severity and low sustained pupillary responses to negative words (87% correct classification of remitters and nonremitters, 93% sensitivity, 80% specificity; 88% correct classification of high-severity participants, p < .01, 90% sensitivity, 92% specificity). Increased pupillary responses were associated with increased activity in dorsolateral prefrontal regions associated with executive control and emotion regulation. For patients with higher severity, disruptions of executive control mechanisms responsible for initiating emotion regulation, which are indexed by low sustained pupil responses and targeted in therapy, may be key to remitting in this intervention. These mechanisms can be measured using inexpensive noninvasive psychophysiological assessments.

The small study obviously needs to be replicated in a larger sample before being used on a widespread basis, but the 88% rate at which this simple test determines if high severity depressed patients will respond to cognitive therapy, compared to a 60% response rate in the absence of screening, is a major improvement for a technique that requires no investment in drugs or equipment and only minimal additional training for mental health practitioners. This test could spare more than half of severely clinically depressed individuals time and misery trying cognitive therapy that is unlikely to be effective for them, allowing them to use alternative therapies like drug treatments that are likely to be more effective for them immediately, while allowing about half of severely clinically depressed individuals to receive cognitive therapy, knowing that it has a very high probability of being successful, and avoiding the need for them to undergo a psychiatric drug treatment regime that is unnecessary for their recovery. The fact that the benefit is statistically significant at the 99% level in this small study also makes a study calculated to replicate this result look like a promising good investment.

Given that clinical unipolar depression is one of the most common mental health conditions, and is by far the most common one that is not typically congenital, which makes it disproportionately likely to be a condition dealt with by a primary care physician as opposed to a specialist mental health care professional, this kind of advance has particularly great practical relevance. Also, since unipolar depression is so common, the cost savings to the health care system of a diagnostic tool for determining what kind of treatment will be most effective could be an evidence based medicine technique that could make a material dent in the overall cost of mental health care.

Since this is a diagnostic approach, rather than a drug or device, it also doesn't need a long and costly approval process from the Food and Drug Administration. Funding of a simple large scale replication of this study which could be completed in a year or two, would be enough to include this diagnostic technique as part of the standard by the book treatment regime for unipolar depression nationally. Of course, since this isn't an approach would have a biotech company backing it, this kind of study almost necessarily would need to be funded by the public sector, for example, through a National Institute of Mental Health (NIHM) grant.

The real value of treatment effectiveness prediction tools as a means to improve the quality of patient care while reducing health care costs, a field which is coming into its own as a subfield of psychiatry and psychology, also suggests another funding possibility. Health insurance companies have historically viewed themselves primarily as financial institutions and as institutions through which patients can collectively bargain for provider health care pricing. But, the health insurance industry might be well advised to develop and fund a non-profit research foundation to develop treatment effectiveness prediction tools that do not have drug companies or medical equipment makers to fund them, as a way to promote health enhancing quality control.

The benefits of this little study aren't just practical in an immediate sense either. This is some of the hardest empirical evidence yet that there are medically relevant subtypes of unipolar depression in existence, with some indication of what the underlying neurological basis of that subtyping might involve. One of the deep issues in psychiatric classification of mental health conditions, for which the DSM-IV is the current industry standard, is that diagnosis of psychiatric conditions is almost entirely based upon non-physiological symptoms. It is entirely possible that some common DSM-IV conditions are really a cluster of separate conditions with similar symptoms but different causes (and hence different courses of treatment that are likely to be effective), and that other common DSM-IV conditions currently viewed are in fact merely distinctive syndromes that arrives when separate co-morbid conditions are present.

For example, this study shows that there are at least two types of unipolar depression, one of which is talk therapy responsive and one of which is not. This very likely indicates that the causes of the two types of unipolar depression are different. If this insight in incorporated into prior research on the causes of unipolar depression, the sometimes muddy and contradictory theories about what causes unipolar depression and how it can best be addressed might be clarified. One leading theory regarding the cause of unipolar depression conceptualizes it as a situation where prolonged stress and anxiety cause the body's normal responses to stress to shut down and try the new strategy of becoming depressed to deal with the situation. This might be a primary causal mechanism in one but not the other of subtypes of unipolar depression. If so, somewhat muddy data linking this cause to depression might become much more definitive with regard to the relevant subtype of depression, while clearing the decks for a search for one or more alternative causal mechanisms for the other subtype of depression.

Another possibility is that the pupil dilation response to emotion laden words may be a congenital element of a person's personality that is present even in the absence of unipolar depression. If this is the case, this trait might be one of many that is routinely tested for in children or young adults along with traits like blood type. Children with the trait might be at higher risk for the cognitive therapy responsive subtype of depression. Similarly, medical records could indicate which children are at risk for non-responsiveness to cognitive therapy as a treatment for unipolar depression. Since the physiological test for this trait is quite objective and easy to administer on a mass basis, it might also be possible to see if this trait corrolates with other mental health conditions, particularly those which are often co-morbid with unipolar depression (a co-mordidity pattern that might be more stark when restricted to a particularly subtype of depression), and to determine if it has a hereditary component. Patterns of co-morbidities associated with a particular subtype of unipolar depression might shed insight into the causal mechanism of a variety of mental health conditions which in turn might shed light on the kind of treatment regimes that are likely to be effective for those co-morbid mental health conditions.

Indeed, it might even be possible to provide these children or young adults, on a prophylactic basis, the kind of cognitive training that people with unipolar depression receive after they are diagnosed to help these individuals deal with situations that could lead to clinical depression before they happen.

There is no obvious reason that the benefits of cognitive behavioral therapy, which boils down to teaching people habits of thinking and mental tools for coping with certain kinds of problematic cognitive habits or tendencies, in general, can't be almost as effective when administered in advance as they are when administered as therapy after the fact. It might be possible to put together a set of empirically validated cognitive behavioral therapy regimes into a comprehensive set of coping skills that could be transmitted on a mass basis in a manner not unlike the model by which we instruct people in first aid, CPR, rescue breathing, the use of abdominal thrusts to respond to choking incidents, the proper way to respond to house fires, tornados and tsunamis, or suicide and bullying prevention programs. People who experience cognitive behavioral therapy responsive conditions anyway may benefit for refresher instruction and may be able to make more sense of what these therapies involve when they actually have the conditions that they are designed to alleviate, but it isn't unreasonable to think that this kind of public health preparedness model could materially reduce the overall incidence and impact of many common mental health conditions, some of which are subclinical or would otherwise never be diagnosed as such.

READ MORE - Physiological Test Predicts Effectiveness of Talk Therapy For Depression

Misery suppresses suicide

The happiest countries and happiest U.S. states tend to have the highest suicide rates[.] . . . "This result is consistent with other research that shows that people judge their well-being in comparison to others around them. These types of comparison effects have also been shown with regards to income, unemployment, crime, and obesity."

From here.

The relationship is strong and statistically robust, but theories to explain it are merely guesswork.

READ MORE - Misery suppresses suicide

Suicide More Common In Rural Areas Than Cities

Suicides are more common in rural areas than cities, a result that is robust across multiple world cultures. Some of this appears to be due to increased access to effective means of killing oneself in rural areas like guns and pesticides. Some of this appears to be due to social factors like reduced tolerance of mental illness.

READ MORE - Suicide More Common In Rural Areas Than Cities

Prenatal Environmental Exposures Produce Mental Health Harms

Researchers found that within a sample of 215 children monitored from birth, those children with high levels of a pollution exposure marker in their cord blood had more symptoms of attention problems and anxiety/depression at ages 5 and 7 than did children with lower exposure.

The researchers measured a biologic marker or "fingerprint" of exposure to polycyclic aromatic hydrocarbons (PAH) and other combustion-related pollutants in newborns' cord blood. When inhaled by the mother during pregnancy, these pollutants can be transferred across the placenta and bind to the DNA of the fetus, forming "adducts" in blood and other tissues and providing a biologic measure of pollutant exposure. Mothers completed a detailed assessment of their child's behavior.

In urban air, traffic emissions are a dominant source of the pollutants measured in the study. The authors accounted for other sources such as environmental tobacco smoke and diet in their analyses. None of the mothers in the study were smokers.

From here citing Frederica P. Perera, Shuang Wang, Julia Vishnevetsky, Bingzhi Zhang, Kathleen J. Cole, Deliang Tang, Virginia Rauh, David H. Phillips. PAH/Aromatic DNA Adducts in Cord Blood and Behavior Scores in New York City Children. Environmental Health Perspectives, 2011; DOI: 10.1289/ehp.1002705.

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The Sociology of Brain Disorder Treatment

There are two medical specialties that deal with brain disorders and conditions. One is neurology. The other is psychiatry. Where does one draw the line between the two?

Neuroskeptic compares the number of articles on particular conditions in leading academic journals for each specialty (Neurology and the American Journal of Psychiatry), to look empirically at how the line has been drawn within the medical profession.

The division doesn't seem to be very strongly linked to the extent that a condition is biologicallly based. As he notes:

Schizophrenia, which is probably considered "the most neurological" psychiatric disorder, is in fact the least talked about in Neurology.

Both mental retardation and autism are middle ground between the two specialties, with mental retardation leaning towards neurology, and autism leaning towards psychiatry.

Eyeballing the data, one way to think of the way that the conditions have been allocated is that psychiatrist deal with conditions that influence your personality and social interactions, other than pure cognition, while neurologists deal with other conditions and conditions that impact pure cognition.

This explains the mental retardation v. autism divide, for example. While both have a cognitive function element, explaining the neurological interest in both conditions, what distinguishes an autism diagnosis from a mental retardation diagnosis that is not autism is the diagnostic and treatment focus on how autism affects personality, social interaction and empathy, particularly in the case of autism spectrum disorders like Asperger's, where IQ is often in the normal range.

The gray area for ADHD, likewise, can be explained as a product of the lingering ambiguity over whether to think of the condition as a personality disorder that is a cogential part of who someone is, or as a developmental disorder of something large is part of a larger cognition process.

Psychaitry is concerned with "who you are" while neurology is concerned with "what you are" even though there isn't obviously any fundamental difference between the kind of brain functions that lead to schizophrenia and those that lead to congential epilepsy. The looming question behind Neuroskeptic's post is whether the divide says more about perhaps unfounded biases about mental health that pervade even the supposedly enlightened medical profession, than it does about science.

There are other ways to see the distinction, of course. One is that neurologists deal with issues that are believed to be exclusively "hardware" issues, while a core issue for psychiatrists is to parse "hardware" from "software" issues and address each appropriately. Some conditions may not neatly fit that divide today simply because historical ambiguity led a condition to be assigned to one category or the other, and given that all of the physicians involved have a similar allopathic medical background and training, there is no compelling reason to upset the apple cart of institutional and funding and bureaucratic arrangements based on the distinction at this point, even if it isn't terribly logical.

In the same way, no one is urgently pushing to have responsibility for counterfeiting enforcement removed from the duties of the United States Secret Service even though this doesn't logically have much to do with is primary responsibility to provide bodyguard protection to the President and other senior federal officials and candidates, because the skill set for the two tasks is similar.

Still, the divide has a strong impact on treatment modality. Neurologists use drugs and sometimes surgery, while seeing little place for therapy. Psychiatrists, while also prescribing drug treatments, recognize the value of psychological talk therapies as a complementary treatment modality to a much greater extent.

A footnote to the post in the study is also interesting:

"Gathering" this data took me 15 minutes. 20 years ago, it would have taken... well, you'd have had to read and manually categorize 30,000 abstracts. Even at 2 minutes per abstract (bare minimum) that's, er, 1000 man-hours of work.

READ MORE - The Sociology of Brain Disorder Treatment

Deconstructing the Concept of Health Care And Options For Dealing With It

The convention of lumping all of the issues that fit under the rubric of health care is necessarily somewhat arbitrary. As we look to improve ways to control costs and find better ways to finance care, which is a never ending process despite the passage of the Affordable Health Care Act, which makes major reforms, it is worth examining ways to break the overall field of health care into parts, and to see if there are things that we commonly don't define as health care that are appropriate to address with the same tools.

Group health insurance plans and Medicare define health care quite broadly, but exclude certain procedures and treatments commonly deemed to be cosmetic or recreational or fitness related; long term care in nursing homes or with home health care services; and sometimes abortion. Medicaid often includes a broader definition that includes, for example, nursing home care.

Individual health insurance plans, out of concerns about moral hazard in the purchase of health insurance, have narrower definitions of covered health care. Routine services are often covered by a deductible on the theory that the tax advantage that applies to group health care plans creating an incentive to include as much as possible in the plan coverage scope for tax reasons does not apply in individual plans of employees who are not self-employed where risk management and price negotiation with providers, but not tax minimization is the goal.

Individual health insurance plans also usually exclude, or include only at prohibitively expensive rider rates (far more than this kind of care contributes to the whole in group health insurance plans) types of health care for which moral hazards exist because patients can know that they will need coverage in advance and buy it only if they need it. These conditions include pregnancy related care, mental health coverage, and coverage for pre-existing conditions (mitigated by a variety of devices to allow pre-existing condition coverage where moral hazard risks are not as serious, such as quasi-group COBRA continuation coverage).

Pregnancy is very expensive to insure against in individual health insurance plans because it is highly controllable by the insured, even though the lifetime costs of pregnancy related care frequently don't vary much from one woman to the next.

Mental health coverage has been further divided into categories that look more or less medical (biologically based conditions). There is dispute over whether some treatment regimes such as non-allopathic medical approaches (such as chiropractic, aromatherapy, herbal remedies, psychological therapy, acupuncture, personal training, and massage therapy remedies) are really health care in the sense intended, and over whether treatments such as fertility treatments are genuinely necessary as opposed to recreational.

Long term care coverage is an example of a very expensive, high probability event, with moderate risks regarding duration and costs, that is further complicated by the fact that long term care typically covers not only medical-like expenses but also non-medical-like expenses such as rent and food costs for the resident. Similarly, loss of income due to disability, or the disabilities presumptively inferred from old age called retirement, are typically handled separately from medical care.

We make distinctions between "emergency care" which everyone who comes to an emergency room is entitled to regardless of ability to pay, at least until stabilized, and other kinds of medical care.

We have different financing regimes for dental care, vision care, work related injuries (worker's compensation or the equivalent), non-work related accidental injuries (tort remedies and casualty insurance), health care for foster children, health care for Medicaid v. non-Medicaid patients, health care for the uninsured who can and cannot pay in cash, health care for certain veterans, out-of-pocket and insurance paid care, over the counter and prescription treatments, and so on.

Within the area of Medicaid covered health care, there are two groups of beneficiaries whose care is very expensive: older people who need nursing home care, and people with disabilities, and another, poor people who are not disabled or old served by the minority of providers willing to accept new Medicaid patients for below market rate reimbursements, for whom it is very inexpensive to provide health care.

A large share of all people covered by health insurance or governmental health care programs are entitled to that coverage not in their own right, but by virtue of their status of dependents of someone else. Medicare is one of the few programs that does not cover the entire family (although individual policies and CHIP enrollment in Medicaid for children only in a family are another).

The Affordable Care Act has made several strategic choices, which made political sense at the moment, but may not be the best long term solutions. One is to focus on a scope of care similar to bare bones group health insurance plans. Group plans are encouraged. Individual plans are made more like group plans through prohibitions on pre-existing condition denials, through mandatory coverage, and through expanded scope of coverage, in order to address moral hazard issues. The scope of Medicaid is expanded to include the near poor. And, tax credits and incentives ease the ability to pay problem for both group and individual plans.

There are other ways that the task could have been divided.

We could have chosen to deliver some or all health care services to children (and even college students) through educational institutions. Most school districts have school nurses and psychologists already, administer a few routine screening tests, provide health education (mostly, but not entirely sex education and illegal drug use propaganda), and refer children who seemed to be in need of medical attention but are denied it to social services authority. But, it wouldn't have been hard to establish a system of comprehensive, single payer health care for children through the school system. This would prevent the current system from suffering strain from the fact that large families do not fully bear the cost of their own care in many cases (particularly with more generous employers), and would in some ways reinforce the notion of connecting health care to one's place of employment - extending the idea to school aged children.

Colorado until recently, and some other states, have experimented with no fault automobile accident medical coverage, in which care for automobile accident injuries are financed through the injured person's car insurance, with particularly severe cases to be settled via subrogation actions by the insurer who pays for the care. There have been proposals to make such no fault coverage universal and finance it with a gas tax or other excise tax that functions as a "pay at the pump" user's fee. Worker's compensation, in theory, at least, covers work related injuries and diseases without regard to fault.

With a universal health care system, it would be possible to remove health care payments from the domain of automobile insurance, casualty insurance, tort judgments and worker's compensation entirely, by making health insurance the primarily responsible party for all health care, with legal responsibility for medical expenses related to fault in accidents or on the job injuries or diseases limited to subrogation actions. This would take a great many personal injury cases outside the tort law system entirely, and narrow dramatically the scope of the issues presented in these cases. Even more dramatically, we could decide that compensation for lost income due to disabilities that arise from injuries or diseases (or perhaps otherwise) ought to be entirely the province of insurance or social safety net programs, rather than the courts, perhaps via a more robust version of Social Security, or mandatory comprehensive disability insurance, in lieu of separate regimes for work related injuries, general tort cases, sick leave policies, and cases covered partially by private disability insurance policies and social security. Subrogation cases could allocate fault in cases where it was necessary to provide the proper incentives not to engage in negligent conduct (although in a society where everyone is adequately insured, this is harder to justify, particularly for small cases where the burden of the risk faced by different insurance companies can be expected to average out over time). In a regime like this one, only "pain and suffering" and dignitary injuries would be left to litigate.

Less radically, health insurance companies would process all health care claims, regardless of the nature of the injury, and then would be reimbursed by casualty insurance companies, with their actual costs entitled to presumptive validity. Tort lawsuits might establish liability for medical costs, but simply order the insurer for the tortfeasor to pay those costs as they come due, avoiding litigation involving expert witnesses over the validity of medical costs incurred and the estimated future medical costs involved in a personal injury case. Casualty insurers and health insurers could resolve medical expense disputes in individual cases through intercorporate arbitration.

We could have had a single payer system for some conditions, perhaps mental health care, or pregnancy care, or congenitally disabled people whose high cost of care is a certainty at the outset, that are hard to deal with through individual insurance due to moral hazard issues, while utilizing the Affordable Health Care Act insurance regime approach only for more ordinary cases. Mental health care or pregnancy care could be quite affordable to provide via a single payer system since they are a small part of the total national health care expense.  Failure to provide adequate mental health and/or pregnancy care has immense externalities for the rest of society as well, so perhaps these need to be redefined as public health issues.

We could have medical care in all trauma cases handled by one program or insurance regime, and handle non-trauma causes in another regime.  The public interest in universal trauma care is greater than the public interest in many kinds of universal non-trauma care.
Pregnancy care could be insured not through employers, but on a basis similar to universal life insurance or long term care policies, with premiums made over a lifetime or many years, to cover a lifetime of coverage. Rather than expiring for want of premium payments, these policies could create non-dischargable debts, a bit like student loans, which insurers could collect with bad debt figured into their pricing. Alternately, we could have a system of guaranteed pregnancy care loans that is directly analogous to the student loan regime, allowing births to be paid for over the course of a decade or two, rather than all at once, and could focus on transparency in pricing as a way to control costs in this area.

Guaranteed medical care loans also make sense as a back stop to a regime with catastrophic coverage in which not all patients have funds in a health savings account or otherwise sufficient to pay their current out of pocket costs.

We could distinguish between catastrophic care, which might be handled by a government program or secondary tier of insurers (a bit like umbrella insurance), and ordinary health care which would de-emphasize risk sharing and emphasized price negotiating and cash flow management. The greater ability of patients to pay for non-catastrophic care would make more ordinary market-like arrangements such as those seen in the area of dental health, seem more workable.

If coupled with a system of guaranteed medical loans, non-catastrophic care could be optional, and only catastrophic care would have to be universal either because it is mandatory in some form, or is a tax financed government program. The downside of making this a mandatory form of insurance, is that compliance can be difficult to secure for a program that actually makes insurance payments to the people who pay the bills only very infrequently, while accounting for something on the order of half of the cost of health insurance. But, catastrophic care on an umbrella insurance model would have very low administrative costs relative to premiums, and relatively few of the really controversial insurance coverage issues involve catastrophic care cases. This could give a government program a fairly large economic role in health care without having much of a day to day administrative role in it that people would fear would interfere with doctor-patient relationships.

Medicare and Medicaid are currently mostly programs that pay providers directly on a fee for service basis, but could be organized to pay for a menu of health insurance options, or to pay providers on capitation or similar basis. The Ryan plan that would provide mere flat dollar vouchers to buy health insurance would be problematic standing alone, but if there was a core set of coverages that could be purchased with the voucher without additional expenses from a vendor of last resort who was required to provide it, this would not be worrisome.

It would be possible to structure health care claim processing a bit like the way we structure credit card progressing today, where cooperatives like Mastercard and Visa process claims and adjudicate billing disputes, but the loans are extended by member banks that set interest rates, set credit limits, and establish their own reward programs. The vast majority of health insurers could be united in a small number of cooperatives, which would receive claims from providers and process them in a standardized process, set provider compensation rates for member providers, and leave the actual health insurers with only a few key terms like copay amounts or deductibles being set by the actual health insurer which would bear the financial cost of claims processed for its insureds, but would not actually administer those claims. This could produce many market efficiencies even if the claim processing cooperative had no formal monopoly.

Of course, to some extent, this is the easy part of the equation. Once you have universal health insurance coverage, it is a relatively bloodless affair to reshuffle the expense from one pocket to another in the interests of more efficient administration and more sensible cost distribution that is consistent with ability to pay. The really hard part of the issue is figuring out which scenario is not going to be to reduce just administrative and marketing costs to a minimum, giving health care consumers the best value for their money. This is the low hanging fruit, which shouldn't be that hard to realize.

The truly hard part of the health care reform question, which still remains largely unanswered, is who is both willing and able to effectively negotiate lower compensation rates for providers that will translate into lower compensation for doctors, nurses, pharmacists, drug companies, medical equipment makers, hospital administrators, and so on. The deepest problem with the American health care system is that the people who are currently making these decisions, with other people's money, are leaving American providers much better compensated than those anywhere else in the world by a large margin, for the same or less or inferior work. And, very few people in the policy world are entirely clear on what precise flaws in the provider rate system is most to blame. Notably, the truly iconic seats of medical excellence in the United States, like Mayo and Bethesda, are not the ones with the most highly paid providers.

Even in a perfect world with high levels of transparency, the sick and the injured are simply not in a good position to bargain for lower provider costs at the time of treatment as one would with many goods and services. They need intermediaries to handle this for them. But, how do we get the intermediaries (who might be civil servants or insurance company bureaucrats that we have never met) the clout that they need visa-a-vis medical providers who we know and love and the incentive to do their job well?

READ MORE - Deconstructing the Concept of Health Care And Options For Dealing With It

Beyond Heritable IQ in Socioeconomic Success

IQ is one of the stronger predictors of socio-economic success in life, and success on a wide variety of other measures, and a lot of a person's IQ is heritable.

Personality, IQ and Success

In a result, largely contrary to the claims of Malcolm Gladwell in his book, "Outliers" in which he claimed that the famous Terman study which looked at life outcomes for a large cohort of California students with an  IQ of 135 or higher on the Stanford-Binet in 1921-1922, over their entire lifetimes, a recent analysis of that data has shown that IQ is a significant predictor socio-economic success at all levels within this elite subgroup.  Male teman study members with IQs in the bottom of the range for inclusion, IQ 135 (roughly the 99th percentile), had lifetime earnings (in 2008 dollars from ages 18 to 75) of about $2,350,000.  Those in the top 10% of the study group (roughly the 99.9th percentile), had lifetime earnings of about $2,700,000, a statistically significant 15% difference of $350,000 that was stronger at the end of their careers than at the beginning.  Averaged over 40 years, the average annual income of those at the bottom of the IQ range was $58,750 (in 2008 dollars) and the average annual income of those at the top of the IQ range was $67,500.

Thus, there were lifetime economic benefits to being a genius, rather than merely "gifted" but the benefits weren't huge either.

More interestingly, the study also had data on the "Big Five" personality traits (conscientiousness, extraversion, agreeableness, openness and neuroticism) of the the study participants, the most widely uses psychological description of general temperament.  Wikipedia notes regarding the Big Five that:

A number of meta-analyses have confirmed the predictive value of the Big Five across a wide range of behaviors. Saulsman and Page examined the relationships between the Big Five personality dimensions and each of the 10 personality disorder categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Across 15 independent samples, the researchers found that each disorder displayed a unique and predictable five-factor profile. The most prominent and consistent personality predictors underlying the disorders were positive associations with Neuroticism and negative associations with Agreeableness.

In the area of job performance, Barrick and Mount reviewed 117 studies utilizing 162 samples with 23,994 participants. They found that conscientiousness showed consistent relations with all performance criteria for all occupational groups. Extraversion was a valid predictor for occupations involving social interaction (e.g. management and sales). Furthermore, extraversion and openness to experience were valid predictors of training proficiency criteria.

The personality impacts of Big Five personality traits in the general population were largely confirmed in high IQ populations.  Moreover, Big Five personality traits are independent of IQ in high IQ populations:

[E]ven though the Terman sample has a restricted range of IQ, there is substantial variation in personality. In fact, the Terman men do not differ from the general population in terms of personality.

Evolutionary pressures appear to quite consistently favor higher IQ in the long run, but some models suggest that evolutionary pressures on personality traits favor an ecological mix of personality types rather than a single personality, so no one personality trait has translated into "fitness" in the long run (of course, if it had, we wouldn't notice it, since it would mathematically fold into IQ by virtue of the way that IQ is constructed by psychologists).

Big Five traits are heritable, but not as strongly as IQ, although some of the weaker association may be a product of a less refined measurement instrument, as the Big Five personality traits have been consensus personality measurements only since the early 1980s, while the concepts of "g" and IQ are among the oldest in psychology, which has allowed more time to refine the measurement of the concept.

Of four recent twin studies, the mean estimated broad heritabilities on self-report measures for the Big Five traits were as follows:

Openness: 57%

Conscientiousness: 49%

Extraversion: 54%

Agreeableness: 42%

Neuroticism: 48% . . .

Many studies of longitudinal data, which correlate people's test scores over time, and cross-sectional data, which compare personality levels across different age groups, show a high degree of stability in personality traits during adulthood. More recent research and meta-analyses of previous studies, however, indicate that change occurs in all five traits at various points in the lifespan. The new research shows evidence for a maturation effect. On average, levels of Agreeableness and Conscientiousness typically increase with time, whereas Extraversion, Neuroticism, and Openness tend to decrease.  . . .

Cross-cultural research from 26 nations (N = 23,031 subjects) and again in 55 nations (N = 17,637 subjects) has shown a universal pattern of sex differences on responses to the Big Five Inventory. Women consistently report higher Neuroticism and Agreeableness, and men often report higher Extraversion and Conscientiousness. Sex differences in personality traits are largest in prosperous, healthy, and egalitarian cultures in which women have more opportunities that are equal to those of men. Both men and women tend to grow more extraverted and conscientious and less neurotic and agreeable as cultures grow more prosperous and egalitarian, but the effect is stronger for men.

Conscientiousness overlaps with ADD inattentive symptoms, and both of these traits are also correlated with digit ratio which is an easy to measure physical trait associated with natal testosterone level exposures.  Specifically: "More masculinized finger-length ratios show associations with ADHD symptoms, possibly acting through the trait mechanism of conscientiousness."  This is in line with the cross-cultural gender discrepencies observed in onscientiousness.

The second digit to fourth digit finger ration has been shown to be a reliable indicator of testosterone exposure in utero. If your fourth finger (your ring finger) is longer than your second finger (the one next to your thumb) you had a high exposure to testosterone when your mother was pregnant with you. This ratio has also been associated with genital size, aggression, ADHD and now conscientiousness.

Thus, a significant cause of conscientious personality and ADHD is congenital, but not hereditary.  Digit ratio and IQ over 130 are also associated.


Conscientiousness and neuroticism are both strongly correlated with ADHD inattentive type, in that order, and agreeableness, neuroticism, and conscientiousness are strongly correlated with ADHD hyperactive type in that order).  ADHD, with the strength of the relationship being strongest between conscientiousness and ADD inattentive type diagnosis (r=-0.59), is the strongest of the Big Five/ADHD correlations.

The Big Five personality traits aren't perfectly independent of each other, but they are sufficiently independent of each other than a four factor model captures significantly less of the variation in personality from person to person, and the Big Five measure was created with the express purpose of identifying maximally independent factors.

Four of the Big Five personality traits had a measurable impact on lifetime earning of men with IQs of 135 of more.  Neuroticism, surprisingly, was completely unrelated to lifetime income.  In 2008 dollar terms, comparing the lowest decile to the highest decile in each of the other four traits, the lifetime impact of being high in each of the traits was approximately as follows (reading from a line chart):

Conscientiousness:  $800,000.
Extraversion: $650,000
Agreeableness: -$350,000
Openness: -150,000

Each of these traits showed a more or less linear relationship between decile in a personality trait and its economic impact.

Thus, an extremely conscientious, extroverted, disagreeable, and close minded individual with an IQ of 135 of more would earn an average of $1,950,000 more than an extremely non-conscientious, introverted, agreeable and open minded individual.  The combined effects of these four personality traits was about five and a half times as great as differences in IQ between the 99th and 99.9th percentile.

Even the difference between being in the sixth and tenth decile for conscientiousness has as much of an economic impact as the difference between being in the 99th and 99.9th percentile for IQ.

These four out of five personality factors and IQ influenced both the amount of education that a person received and the amount that a person earned independent of education:

Our results highlight the importance of personality and intelligence on our outcome variables. We find that personality traits similar to the Big Five personality traits are significant factors that help determine educational attainment and lifetime earnings. Even holding the level of education constant, measures of personality traits have significant effects on earnings. Similarly, IQ is rewarded in the labor market, independently of education. Most of the effect of personality and IQ on life-time earnings arise late in life, during the prime working years.

This adds to a growing literature on traits other than IQ that are important to lifetime successes.

Grit and Success

Another recent study looked at "grit" as a factor in spelling bee success.  The famous rule of thumb, also discussed by Gladwell, is that it take "10,000 hours of intense training (plus or minus a few thousand hours)" to reach the pinnacle of expertise in a pursuit.  But, Gladwell glosses over the question of what traits are necessary to be able to stick to an intense training regime for that quantity of time. 

The spelling bee study first found that the key to performance in spelling bees was the amount of deliberate practice that a kid put into it, which "involved studying and memorizing words while alone, often on note cards" as opposed to alternatives like being quizzed by others or leisure reading:

With each year of additional preparation, spellers devoted an increasing proportion of their preparation time to deliberate practice, despite rating the experience of such activities as more effortful and less enjoyable than the alternative preparation activities.

But:

Why were some kids better at drilling themselves with note cards? What explained this variation in hours devoted to deliberate practice? After analyzing the data, Duckworth discovered the importance of a psychological trait known as grit. In previous papers, Duckworth has demonstrated that grit can be reliably measured with a short survey that measures consistency of passions (e.g., ‘‘I have been obsessed with a certain idea or project for a short time but later lost interest’’) and consistency of effort (e.g., ‘‘Setbacks don’t discourage me’’) over time using a 5-point scale. Not surprisingly, those with grit are more single-minded about their goals – they tend to get obsessed with certain activities – and also more likely to persist in the face of struggle and failure. . . . Here are the scientists: "Grittier spellers engaged in deliberate practice more so than their less gritty counterparts, and hours of deliberate practice fully mediated the prospective association between grit and spelling performance."

In other words, practice is what produces results, but "grit" (a.k.a. "tenaciousness" a.k.a.  “perseverance and passion for long-term goals.”) is the key psychological trait that determines how much someone practices.  And, like the Big Five personality traits, grit is largely unrelated to intelligence:  "Grit was found to be either orthogonal to or slightly inversely correlated with intelligence."  It is not independent of the Big Five personality traits, however, although it doesn't completely overlap:

Grit was strongly correlated with conscientiousness (r = .77, p <.001 and r = .73, p <.001) (2009). While Grit is related to conscientiousness measures, it also differs from conscientiousness in important ways. For example, while both Grit and conscientiousness are often associated with short term accomplishments, Grit is also associated with longer term and multi-year goals. This long-term persistence and dependability are important aspects that make Grit unique from conscientiousness.

Grit has been validated in settings other than spelling bees.

Grit provided incremental predictive validity . . . above and beyond the Big 5 personality traits; . . . higher levels of Grit were more highly associated with cumulative grade point average (GPA) in an Ivy league sample when compared to those with lower Grit levels (r = .25, p<.01); [and] that Grit predicted retention after their first summer in two classes of cadets at the United States Military Academy[.] . . . Grit predicts beyond the typical and unrelated cognitive construct of IQ and can account for variance over and above what is observed in the Big 5 personality construct of conscientiousness.

Grit also predicts the performance of Teach For America teachers in "under resourced public schools.", as does life satisfaction prior to entering the program.

A refined version of the test that Duckworth and Quinn used in the spelling bee study from 2009, with four fewer items and a different means of using answers to produce a scaled score strengthened  "the positive relationships between Grit and educational attainment, GPA, retention in college, and success in a national spelling bee competition."

As Jonah Leher notes in a blog post as Wired, one take away lesson from these studies is that there are personality traits that are largely unrelated to IQ which are important to socio-economic sucess other than IQ, which Steve Hsu sums as as the "W" factor, and which we are increasingly starting to be able to describe with psychological testing; like IQ, a meaningful part of these traits are genetic, congenital, or arise early in life, although there isn't good research on the relatively recently well defined trait "grit."

The other is a bit more subtle and I'll reproduce his observation in his words:

[T]here’s a major contradiction between how we measure talent and the causes of talent. In general, we measure talent using tests of maximal performance.

Think, for instance, of the NFL Combine: Players perform in short bursts (40 yard dash, short IQ test, catching drills, etc.) under conditions of high motivation. The purpose of the event is to see what players are capable of, to determine the scope of their potential. The problem with these tests, however, is that the real world doesn’t resemble the NFL Combine.

Instead, success in the real world depends on sustained performance, on being able to work hard at practice, and spend the weekend studying the playbook, and reviewing hours of game tape. Those are all versions of deliberate practice, and our ability to engage in such useful exercises largely depends on levels of grit.

The problem, of course, is that grit can’t be measured in a single afternoon on a single field. (By definition, it’s a metric of personality that involves long periods of time.)

The end result is that our flawed beliefs about talent have led to flawed tests of talent. Perhaps that explains why there is no “consistent statistical relationship between combine tests and professional football performance.” We need  . . . a test that measures how likely people are to show up, not just how they perform once there.

Mostly, we measure traits like "grit" or "W" indirectly, by looking at how well people perform academically or otherwise, after controlling for traits like IQ.

Poverty and IQ

So, we know that IQ is important to socio-economic success, and that there are independent contributions from at least a handful of personality traits that are independent of IQ.

We also know that IQ is related to poverty in a manner more complex than a Bell Curve model with highly hereditary IQ in which the stupid tend to be both poor and prone to have low IQ children, while the smart tend t obe both rich and prone to have high IQ children is involved.  This is because the measured heritability of IQ is lower, while the importance of environmental impacts is higher, in the poor than in the well to do.

Also, a large subset of mental retardation cases are not genetic and instead depended on enviromental factors like fetal alcohol syndrome, lead exposure and inadequate pre-natal nutrition, and labor and delivery medical care.  While high IQ appears to be rooted in a large number of small, cumulative factors, low IQ frequently has a single dominant cause that is different in kind from the causes of IQ levels within the normal range.  Alleviation of these mental retardation drivers is an important factor in the Flynn Effect (secular long term trends towards higher IQ in the same population from generation to generation over time).

Put another way, you are born with a maximum potential IQ, but seriously adverse environmental conditions, mostly associated with poverty, can prevent you from reaching that potential.  These environmental effects appear to be particularly strong during pregnancy and in the first few years of life. 

With that key observation in mind, the relationship between American performance on international tests of academic ability and poverty can be put in context in the nature v. nuture debate:

[T]he brutal reality is that U.S. schools that contain more than 25% poor children do abysmally--they are literally pulling the scores down:

If we subdivide the U.S. data in a very obvious way, we observe something, well, rather obvious:
But data available now tells us that poverty, as usual, had a huge impact on PISA reading test scores for American students. American students in schools with less than 10% of students on free and reduced lunch averaged 551, higher than the overall average of any OECD country. Those in schools with 10 to 25% of students qualifying for free and reduced lunch averaged 527, which was behind only Korea and Finland.

In contrast, American students in schools with 75% of more of children in poverty averaged 446, second to last among the 34 OECD countries.

We might not be living in a nation where one-third of a nation is ill-housed, ill-clad, ill-nourished. It's only one in five, give or take. . . . Until we get serious about reducing poverty, as well as breaking up large geographic concentrations of poverty, our average test scores will be poor.

This poverty effect is not simply a product of poor students having lower maximum potential IQ at birth because their parents are below average in IQ and poor as a result.  The conditions of poverty prevent thse children from achieving their potential.

You don't have to go far afield to see this effect, even within different schools that are mostly poor in the same district.  A child identified as "gifted" who attends North High School in the Denver Public Schools is far more likely to go to college and not require remedial work than a child identified as "gifted" who attends West High School, with an even more impoverished student body, a mile or two away.

In a nutshell

IQ,  which has a strong hereditary component in the absence of adverse environmental factors, has an impact on socio-economic success at all levels, but among the smartest, personality factors, which can mostly be summed up in a quite small number of measures like extraversion, conscientiousness, grit, agreeableness, and openness, are even more important with the high IQ population.  These personality traits also have some hereditary component, although probably significantly less than for IQ.  Envirommental conditions strongly assocaited with poverty, particularly during pregnancy and early childhood, prevents children from reaching their genetic IQ potential and also has a measurable impact (generally negative) on personality traits associated with socio-economic success.

Implications

This has several implications of importance:

1.  If we want to measure likelihood of success most accurately in a wide range of academic and occupational fields, a multi-dimension measure that captures both IQ and "W" factors is necessary. 

2.  While many "g" intensive activities that are proxies of IQ have been identified, less systematic work has been done to identify "W" intensive activites, like spelling bees, that are proxies for factors like "grit" and can be used to identify children who excel in these non-IQ dependent traits.

3. We should also devote research to ascertaining which occupational and academic pursuits are more or less "W" heavy, and whether there are pursuits like math and physics in the IQ demain within academics, where there appear to be theshold effects, i.e. where a minimum level of certain "W" factors are a minimum for real success, rather than making a linear contribution to outcomes.  Does one need a minimum level of "W" factors, for example, to make it as a special forces soldier or a medical doctor or an accomplished musician?  Similarly, are there occupational or academic pursuits to which individuals who are high in IQ but low in W factors, or high in W factors but low in IQ, are likely to be best suited?

4.  Much but not all socio-economic benefits of both IQ and W factors are mediated through practice and educational opportunities that must be available for people to take full advantage of what these traits offer.  Identifying IQ and W rich individuals is a beginning, not an end point in developing human potential.

5.  Research into the existent to which "W" factors are malleable and the environmental impacts that influence these factors is worthwhile because research on this for IQ has been exhaustive, but research for other factors has not been, because W factors as important to societal success as IQ, and because W factors appear to be less strong hereditary than IQ.  Indentification of enviromental factors that enhance "W" factors should be a priority for researchers.  What parenting and educational approaches best foster the non-environmental components of "W" factors and to a lesser extent IQ. 

6.  Long term success in activities from probation and parole to high school retention to college retention to adherence of mental health medications may be strongly related to W factors that vary from person to person.  This makes these factors attractive as components of validated statistical prediction tools to determine what management approach should be supervising people in these situations.  Individuals who have low conscientiousness or little grit may require more intensive supervision than those who lack it.

7.  The single most promising way to improve aggregate IQ and socio-economic performance in American society is to identify and address ways that poverty inhibits them.  Particularly attention should be devoted to reducing hardship and improving medical care for pregnant women and young children.  Another area where there is an already identified problem that can be addressed is to improve the quality of pre-college educational opportunities, college counseling and collegiate financial aid for children with established strong academic ability from less affluent families.

8.  To the extent that we can psychometric for selected "W" factors that are at least as good as those for IQ, there should be an active and open ended inquiry into what kind of patterns are seen in the residuals of performance in these combined measures.  This inquiry is useful even if the residual factors turn out to be matters such as pure luck or cohort timing that demonstrate that psychological factors related to socio-economic success have been exhausted.

READ MORE - Beyond Heritable IQ in Socioeconomic Success

It Still Sucks To Be Poor

Low levels of household income are associated with several lifetime mental disorders and suicide attempts, and a decrease in income is associated with a higher risk for anxiety, substance use, and mood disorders[.]

From here.

READ MORE - It Still Sucks To Be Poor

Fuzzy Descriptions Of What Should Be

Sometimes ideas about how to solve the problems in our society are fuzzy.  You have an intuitive notion about what they should look like before you have a rigorous argument for why they should be that way or how we will get there.  The intuition may be accurate, may be nostalgia for a past that may never have even been, or may be inaccurate products of cognitive biases.  But, it doesn't hurt to articulate and examine them in incomplete form.  This is what I'm doing today.

* We need to develop more middle ground in our economy and social class system between winner-take-all successes and those who are just getting by; to invigorate the middle class.

For example, lawyer income is bimodal.  The high end is a cluster of lawyers making very high earnings working at big firms (or sometimes botiques) for big businesses and their senior managers; it also has a modest number of plaintiff's lawyers who have been very successful at taking them on in big dollar case.  The low end has lawyers in small and medium sized firms and government agencies dealing with the issues presented by small businesses and individuals.  There is very little middle ground.

The absence of middle ground is surprising, because there is an obvious niche to fill.  In theory, it makes sense to have lawyers making in between incomes, with credentials that are good but not top ten law school honors and law review and Supreme Court clerkship class, working less insane hours than large firms, doing what they call in the trade "commodity work" (i.e. recurring, predictable, moderate stakes matters, as opposed to "bet the company" disputes and deals that big firms want) , doing competent work in an assembly line fashion, and charging less for it.  There are some specific areas where this happens: foreclosure practice, a few tax dispute resolution shops and insurance defense law firms.  But, there are lots of kinds of practice where one would expect it, but you don't see it: employment cases and a lot of business planning work.

We also have a lot of valueable legal work that isn't done, or is done by overworked and underpaid idealists, because it is hard to make pay.  This includes a lot of family law in low asset/low income households, a lot of termination of parental rights litigation, a lot of criminal defense work for moderate to low income individuals, representation of consumer defendants in debt collection and eviction and foreclosure cases, a fair amount of probate litigation in low asset estates, and immigration law work in areas other than employer visas.  Lawyers with seven years of post-high school education are very expensive ways to meet the public need to counsel and advocacy in these areas, but many individuals who are involved in these kinds of disputes aren't qualified to represent themselves competently.  If independent specialized paraprofessionals who could just hand child custody cases, or just handle criminal defense work, or just handle immigration work could do these kind of cases with an associates or undergraduate pre-professional degree, rather than a law degree, unmet legal needs could be filled in an affordable way that is more competent than the status quo without really impacting the market for existing lawyers much, and a lot of middle class jobs would be created in the process.  In some cases, the most sensible way to handle these cases would be the way we handle most criminal cases - with their services provided by a government agency with professional employees on payroll, but this wouldn't have to be the case.

This has happened somewhat in the area of tax law, where certified financial planners and certified public accountants, tax preparers, and enrolled agents before the IRS fill the gap between what people need and what they can afford that lawyers cannot bridge.  In the area of bankruptcy, in theory, independent paraprofessionals are mere scrivners, but in practice, they subtly provide more guidance to bankruptcy petitioners than their formal duties suggest.  There is also a very small niche conceirge/personal assistant niche of people who help people with personal consumer disputes sometimes formalized as a "health care advocate" when it involves medical bills.

Another example is in the mental health field.  We have psychiatrists, whose investment in becoming an M.D. makes them very expensive and gives them an immense amount of training that is irrelevant to what they actually do, who can prescribe mental health medications but are too expensive to take a more wholistic view, and a lot of psychologists, counselors, and the like who have some relevant education and credentials, but can't prescribe the medications that would be necessary to best address some of the cases that they encounter.  Some states are experimenting with empowering lower paid mental health professionals to write some prescriptions.  Colorado has a provision that allows some non-medical doctors to do this, but the rules are very restrictive. 

It would also be good if mental health could move to a less transaction/fee for service/medical model, to something closer to a pastoral care kind of model where anyone in the appropriate group, however defined, would receive care as needed, despite the tendency (often desirable) toward commodification in other parts of professional practice.  Some mental health issues are episodic and succeptible to being "cured" but many are life long conditions that are fundamentally a part of who someone is and always will be.  An injury/disease model of care is a poor way to address those cases.

We are seeing the development of middle ground to some extent with the establishment of urgent care centers as middle ground between family practice and the ER, and the establishment of retail location based clinics staffed mostly by RNs at places like Walgreens, Wal-Mart and King Soopers that handle not-so-urgent primary care needs like vaccinations and well child checkups and minor infectious diseases and pregancy testing.  We are also seeing the resurgence of the midwife who is not an M.D. as a middle ground health care provider.  Indeed, to some extent, the evolving health care industry model of having many different professions dealing with specialized parts of the total problem, after receiving intermediate levels of training and receiving intermediate levels of pay, is a model that would make sense in other.

* We need a more healthy environment for medium sized businesses.

Another area where a gap has emerged, not unrelated to the gap in legal services, is the gap between the truly small business and the large publicly held business.  There aren't mid-range lawyers because there aren't mid-range enterprises for them to represent in the numbers that there used to be. 

The United States is particularly deficient in the ranks of its medium sized businesses - small restaurant and retail chains, manufacturing ventures that employ a few hundred people, and so on.  We have some really impressive very national and multinational firms that account for an increasing share of our economy, and we have a large sector of not very economically important proprietorships or very small businesses, but surprising few that involve dozens to hundreds of employees, that involve single or double digit millions of dollars of revenues, that involve dozens to hundreds of equity investors.  Venture capitalist and angel investors can funnel small businesses to the big time, and consolidators come along and turn industries dominanted by small firms into industries dominated by big business now and then, but somehow, medium sized businesses seem to lack staying power.

Some of the areas where small and medium sized businesses thrive are dying out or on borrowed time.  Liquor stores in Colorado fiercely defend their perogatives, because they know that if grocery stores can sell their goods that they will die.  Wal-Marts have shuttered thousands of small town independent businesses because they are more competitive on price.  Better quality control and marketing have led franchises to squeeze a large share of the independent fast food businesses out of the market.  Blockbuster pretty much wiped out the independent videostore industry through consolidation and competition before it collapsed itself.  Small evangelical churches are losing ground to megachurches.

There are exceptions.  Craft brewing of beer and spirits and small vinyards seem to be holding their own.  Medium sized venture charter schools seem to be springing up left and right.  Urgent care centers and ambulatory surgery centers are cutting into the near monpology that large hospitals used to have on those kinds of medical services.  There are a host of new medium sized medical marijuana ventures.  Farming seems to be shifting from proprietorships to medium sized operations.

But, we need to better understand what leads medium sized ventures to be optimal from an economy of scale perspective, and look at the possibility that modest policy changes that don't do undue damage to consumer prices can make the economy more attractive to medium sized businesses in parts of the economy. 

We also need to get a better philsophical grasp on what medium sized ventures can offer the economy that big businesses and small businesses do not so that we can promote medium sized ventures in parts of the economy where they add value that the current economic system may not be adequately capturing.  For example, one of the lessons of the financial crisis has been that there are systemic risks involved in having "too big to fail" enterprises in the economy.  It is also becoming increasingly clear that the existing model of management dominated publicly held corporations that are highly insultated from shareholders is an ineffective way of keeping senior management performing well, making prudent judgments for the long term, and keeping senior management from self-dealing in its own compensation.

Some of the gap is less monetary.  We need to have more institutions where it is easier to reach someone in the organization with real authority.  We need to have more firms that have humanity and individuality.  We need to break up centers of wealth and power so that our society is not dominated by plutocrats.  We need the "warm glow" that comes from dealing with something other than a massive impersonal bureaucracy.  We need institutions that recognize that consumers would prefer not to deal entirely with robots and powerless bureacrats on the other side of the phone in who knows where when you have a problem.

Put another way, what benefits to big businesses have over medium sized businesses and why?  Is the problem that our securities laws and tax laws don't facilitate the financing of these businesses well?  Is the problem that big businesses have better economies of scale in regulatory compliance?  Is it a matter of marketing?  Is it a shortage of executive leadership?

In the legal industry, this is central to the discussion about the "death of big law".  Big law firms seem to be offering increasingly little value added simply by being big.  There seem to be few common assets and synergies.  Whole departments routinely jump ship to form their own firms or join other firms.

The approach to regulating unnecessarily large firm size in all industries, through anti-trust laws has largely been a bust.  So, we need to throw out that model and look for different ways to create the right incentives for these businesses to thrive when it is appropriate.

* We need to find better options for members of the less educated working class.

One of President Clinton's iconic stances was his plea that working people who played by the rules should get a fair deal in life.  If you graduate from high school, marry before having children, stay married even when times are tough, make your best efforts to find work when you are not disabled, don't commit crimes, and do your job reasonably competently, you ought to be able to expect a decent, if modest life for your family like a decent place to live in a safe neighborhood, access to the health care you need, an ability to send your kids to college if they are academically up to it, a safety net when you can't find work for no fault of your own, a chance to retire when you are old.  Few developed countries in the world do a worse job of fulfilling that promise.

In truth, we need an even broader promise.  We need to have an economy that makes playing by the rules going forward a good option, even if you aren't married to the other parent of your children, even if you somehow or other failed to get a high school diploma in your late teens, even if you have committed a crime in the past, even if you really screwed up on your job in the past and were fired for good cause, or if you incurred more debts than you could pay destroying your credit, or what have you.

We need to have a system in which somebody feels responsible for finding the most productive and meaningful thing that we can put each person who is able and ready to work to do, to insure that people who take that path get what they need to have a decent life, and to subsidize the difference between the value that they create and what it costs to provide a decent life if necessary.

We should find something for people to do that adds value to society first and figure out how to turn that value into money second.  Better to have someone doing work that has a market value of $5 an hour and to subsdize the rest of the cost of having them live a decent life, than having that person sit idle and trying to deal with the costs that are created when that person's family can't get by.

There are some people whose lives are screwed up because they are simply dysfunctional people.  But, most of the people in the United States whose lives are screwed up are willing to work, would place a lot fewer burdens on the public if they had the resources to meet their basic needs, but can't manage to earn enough to meet their basic needs.

For example, there are some hard core homeless people who are just incapable of functioning in normal society, often due to severe untreated mental health issues or disabilities or disagreeable personalities.  But, there are far more for whom the problem is simply not having enough money to afford a modest apartment.

A lot of child abuse and neglect, a lot of families that have trouble staying together, a lot of crime, a lot of failure in the education system, is driven by poverty pure and simple, and would go away with a steady job that pays enough to support a family.

Sometimes a little skill training or further education will allow the person to find employment and provide for their family without further assistance, but often it won't.  Some people will need help finding decent work only in periods of high unemployment, others will be persistently hard to employ.  In a minority of cases, it may be easier simply to let someone have a pension and not trying to find anything for them to do, as we do in the case of people who are classified as having total disabilities or are retired.

* We probably devote too many resources to selling things.

Economics suggests that the amount of a particular good or service that is sold and the number of people involved in selling it, are only dimly related.  Supply, demand and price are the key factors in sales volume.  If labor was more scarce, we could sell just as many cars and refrigerators and annuities and nails and houses with fewer people.  Commission sales have Malthusian tendencies.  The sales force expands until everyone involved in selling is barely making it, instead of staying at a size just large enough to sell what the market wants with a minimum of staff making maximal compensation.  Big box stores have made their fortune, in part, by recognizing this fact and having smaller sales staffs per dollar of revenue so they can offer lower prices.

In part, this is a good thing.  Selling stuff is often a mid-level job that lots of people can do that seems to create demonstrable value, so it has picked up a lot of the slack as farming, fishing, forestry, mining, manufacturing, utilities, and so on have become more efficient and no longer require such a large share of the labor force.  But, the ratio of people who actually make the stuff we need in the economy, to the people who are selling and administering and financing the distribution of that stuff once it has been made seems like it has gotten out of hand.  It takes nine administrators to send out bills for the work of two and a half doctors.  Marketing costs have become a substantial share of the costs of all sorts of goods and services compared to the cost of the goods itself.

It isn't that marketing and administration aren't important.  We don't want to end up like the Soviet's with factories churning out goods that nobody wants to buy because marketing isn't given the importance that it deserves.  But, is our economy really better off with an Aurora Mall that has a third or more of its retail space devoted to selling cell phones and associated accessories, with large number of locations at the same mall often all competing to sell goods made at the same factory and services provided by the same operations company?

* Our society is goods rich and service poor.

People who would often really benefit from services don't receive them because they can't afford them from their own earnings.  Our nursing homes and hospitals are frequently understaffed.  Our probationers and parolees are frequently undersupervised.  Our classrooms could benefit from having more teacher's aides in them.  Our kids could use more mentoring and tutoring.  Our neighorhoods would be nicer is our sidewalks were professionally clearned every time it snowed and our sidestreets were professionally cleared by people with the right equipment, rather than waiting for snow to melt off roads and for individual households to clear these sidewalks.  Our jobless could use more career guidance and training.  Our ailing bridges and road could use more repairs.  Our addicts could use more counselers.  Our criminal defendants could use more public defenders and investigators to manage the crushing case loads.  Our old houses could use more maintenance and rennovations.  Our call centers could use shorter waits and better quality service.  We would benefit from a society with more art and more performing artists.  Lawn care professionals would probably do a better job that the do it yourselfer homeowners usually do.

Efficiency is a good thing.  But, when it comes to providing services it is harder to sever the amount of labor provided and the amount of benfit confered by the services.  The quality of a refrigerator is an objective thing, and is no worse if it can be achieved with fewer man hours.  Fifteen minutes of therapy can rarely be as helpful as two hours of therapy, even with an extremely qualified therapist.

We need some better way to turn idle labor into beneficial services, and to turn beneficial services into money for the people who provide those services, so that we can increase the size of the pie and as a result, make our society more affluent.  But, for some reason, the market economy is failing to do that, in part, because the people who need services often have trouble affording them when they need those services.

We seem close to the point where we are producing all the goods that our society needs.  But, we need to find a way to redirect effort that goes towards selling goods and services and administrating their provision and potential work that goes idle because no one has found an economic way to utilize it, into efforts to create additional services that have value. 

The mismatch between ability to pay, and need for goods and services is reducing our society's productivity. 

* We need more authoritative attention to complicated problems.

No court system in the world has as few judges per lawyer, or per case, as the United States.  As a result, our court procedures tend to focus on reducing judicial effort even when more judicial effort would create value.  There are some classes of cases where this is not a problem, because they are largely pro forma, or where this merely shifts work from the public sector judiciary to the litigants who really care about the outcome.  But, there are lots of cases where taking the time to understand and deal meaningfully with the merits of a dispute early on would make a huge difference in the maount of private sector time devoted to resolving it.

The tendency isn't limited to the courts.  Public policies that are clearly failing, like the crack-powder cocaine differential in the criminal justice system, persisted for a couple of decades before legislators did something about the problem.  Judicial calls for legislative reform of an issue that comes up in a case producing a bad result frequently go unheeded.  Prison administrators who know that abuses are taking place under their watch don't have the inclination or the authority to solve those problems.  Failing schools fester for decades, for want to guidance and leadership from someone with authority on what to do about them.

One of the bigger problems in a democracy is that the need for an electoral or legislative mandate denies people on the ground the authority to deal with problems that they understand better than anyone else and solve them, even if they know of a solution that would work.

* We work too much.

Americans work more hours per year than any other country in the world.  We take few vacations.  We have very little maternity leave.  We rely heavily on day care.  We retire late.  We have few holidays and little personal time.  Part-time jobs are often not viable alternatives even for those who would prefer to work fewer hours for less money.  We need to find a way to negotiate more balanced alternatives.

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