Inequalities in health, inequalities in health care: four generations of discussion about justice and cost-effectiveness analysis

The focus of questions of justice in health policy has shifted during the last 20 years, beginning with questions about rights to health care, and then, by the late 1980s, turning to issues of rationing. More recently, attention has focused on alternatives to cost-effectiveness analysis. In addition, health inequalities, and not just inequalities in access to health care, have become the subject of moral analysis. This article examines how such trends have transformed the philosophical landscape and encouraged some in bioethics to seek guidance on normative questions from outside of the contours of traditional philosophical arguments about justice.     

The Adolescent Brain and the Emergence and Peak of Psychopathology

Adolescence is a period of heightened emotionality and increased risk for mental illness, affecting as many as one in five persons. This article reviews recent human imaging and animal studies that demarcate adolescent specific changes in brain and behavior that may help to explain this period of increased risk for psychopathology. We highlight adolescence as a sensitive period when: 1) the environment has particularly strong influences on brain and behavior and 2) normative changes in brain development can lead to an imbalance between rapidly changing limbic circuitry and relatively slower developing prefrontal circuitry. This imbalance can be exacerbated by both genetic and environmental influences leading to less capacity to regulate emotions and higher risk for psychopathology. We discuss these findings in the context of understanding who may be at greatest risk for psychopathology and when and how to best treat symptoms of emotional dysregulation.     

Adolescent-specific patterns of behavior and neural activity during social reinforcement learning

Humans are sophisticated social beings. Social cues from others are exceptionally salient, particularly during adolescence. Understanding how adolescents interpret and learn from variable social signals can provide insight into the observed shift in social sensitivity during this period. The present study tested 120 participants between the ages of 8 and 25 years on a social reinforcement learning task where the probability of receiving positive social feedback was parametrically manipulated. Seventy-eight of these participants completed the task during fMRI scanning. Modeling trial-by-trial learning, children and adults showed higher positive learning rates than did adolescents, suggesting that adolescents demonstrated less differentiation in their reaction times for peers who provided more positive feedback. Forming expectations about receiving positive social reinforcement correlated with neural activity within the medial prefrontal cortex and ventral striatum across age. Adolescents, unlike children and adults, showed greater insular activity during positive prediction error learning and increased activity in the supplementary motor cortex and the putamen when receiving positive social feedback regardless of the expected outcome, suggesting that peer approval may motivate adolescents toward action. While different amounts of positive social reinforcement enhanced learning in children and adults, all positive social reinforcement equally motivated adolescents. Together, these findings indicate that sensitivity to peer approval during adolescence goes beyond simple reinforcement theory accounts and suggest possible explanations for how peers may motivate adolescent behavior.     

Double Jeopardy: Child and School Characteristics That Predict Aggressive-Disruptive Behavior in First Grade

High rates of aggressive-disruptive behavior exhibited by children during their initial years of elementary school increase their risk for significant behavioral adjustment problems with teachers and peers. The purpose of the present study was to examine the unique and combined contributions of child vulnerabilities and school context to the development of aggressive-disruptive student behavior during first grade. Parent ratings and child interviews assessed three child characteristics associated with risk for the development of aggressive behavior problems in elementary school (aggressive-disruptive behaviors at home, attention problems, and social cognitions) in a sample of 755 first-grade children in four demographically diverse American communities. Two school characteristics associated with student aggressive-disruptive behavior problems (low-quality classroom context, school poverty levels) were also assessed. Linear and multilevel analyses showed that both child and school characteristics made independent and cumulative contributions to the development of student aggressive-disruptive behavior at school. Although rates of student aggressive-disruptive behavior varied by gender and race, the predictive model generalized across all groups of children in the study.