Friday, January 20, 2017

Forgetfulness and Memory Loss at Work

Forgetfulness and Memory Loss

Forgetfulness or failure to remember information, is a common complaint. All of us have at some time or the other forgotten to make that important call, to pick up some items from the store, an anniversary or birthday, or a colleague’s name. Students forget what they have “learnt” during exams. We often can’t remember where we have left our car keys, our wallet or that important document. Is it normal? And more importantly; when do we need to seek help?

Forgetfulness or memory loss and difficulty concentrating are common symptoms of mental health disorders. This is specially so in depression, anxiety disorders, ADHD (Attention Deficit Hyperactivity Disorder), and dementias as shown in the examples below.
A young working professional seeks help for increased forgetfulness and poor ability to focus at work. Further probing reveals decreased interest in doing things at work and home. She is also irritable, depressed and her sleep is disturbed. These symptoms of low mood can exist in the background of memory loss and problems with focus.
A student during exams has high anxiety causing memory loss. She cannot recall the answer to a certain question. She gets nervous. This causes her to make mistakes in the next question. She tends to panic; fail to recall what she studied. This vicious cycle is common in anxiety disorders and can manifest as problems with concentration, memory and forgetfulness.
An older person does not just forget the name of his neighbour (something that may happen to any of us); but also who she is. He has problems using money, and with shopping. Difficulties at work manifest towards the end of the career. Dementias affect the aged; cause memory loss and affect the context of the memory. 
A young professional person has problems organising and completing projects at work. There may be a history of attention and academic problems in school. Working memory gaps are common in this group. ADHD is a common cause of this problem in adults.

Memory Processing in the Brain

To understand further, it helps to know in brief how memory works. It is a 3 stage process
Encoding
The stage when sounds, images and other sensations are given meaning is called encoding. Sensations are coded electrically for access by other brain areas. (We hear a catchy song from a new movie).
Storage
The process of association or tagging the input with other bits of data to make it persist. The song thus gets stored in our long term memory. Initially, the song remains for a very short while. At this point it is in our working or short term memory. It is encoded. However, we forget the song as the next scene unfolds on screen. The song is repeated at the end of the movie; someone hums the song as we leave the hall. The visuals of the song, and the feelings evoked, the fact that it was a famous actor, then reinforce the memory and makes it persist.
Retrieval
When we need to use this stored data, the brain fishes it out from its long term memory. The more the associations or tags we formed earlier, the more easily the brain can access the information.
Problems in memory can therefore occur at any of these stages. Many of these occur at the stage of encoding because we are simply not paying attention; and many other distractions are vying for our focus at the same time. (e.g checking our FB messages while studying). The brain does not multi-task, it can only do one thing at a time.

Repetition, rehearsal and organisation help in fixing and storage of long term memory. The more widespread and elaborate the connections, and the more data available about an input, the more the connections formed by the brain, and the easier it is for the brain to retrieve the information when required. Many cases of forgetting are due to retrieval failures. The information is there in long term memory but we are unable to access it. This is why we can recall certain things at a later date.
Depression affects memory in many ways. Being unable to concentrate is a symptom of depression. Repeated depressive thoughts also block the learning process through distraction. This affects the stage of encoding. Disturbed sleep which is a common symptom in depression hampers fixing into long term memory.
Forgetfulness is common in ADHD of adults. ADHD lowers the power to focus. The person is easily distracted. The attention span is reduced. This impairs short term or working memory. ADHD persists in up to 40% of aduts.
Anxiety gives rise to pointless thoughts (“my father will be so angry if I don't crack this exam”) which frustrates attempts to retrieve the matter learned. The anxiety provoking thoughts distract from the text which is being studied and impedes the  encoding process.
In dementia there is destruction and loss of brain cells. Dementia blocks all stages of the memory and learning process. The process is not reversible.

Forgetfulness and Memory Loss – when to seek help?

  • When it affects our work, or the quality of our work
  • When the failure to learn and recall affects our daily activities and functioning
  • When there are also problems including sleep, appetite, inter-personal or behaviour changes.
  • When it is strange - leaving keys in the fridge 
  • When it can harm - often leaving cooking burner on, leaving doors unlocked at night
In normal forgetfulness, the person may recall the memory when some cues are given. The memories were encoded, they just needed some reminder to access them. In clinical disorders resulting in memory loss the memories were never laid down in the first place, or the storage structures in the brain are destroyed. Access to these memories may not be possible. 
References
  1. Brydges CR, Ozolnieks KL, Roberts G. Working memory - not processing speed - mediates fluid intelligence deficits associated with attention deficit/hyperactivity disorder symptoms. J Neuropsychol. 2015 Dec 31. doi: 10.1111/jnp.12096. [Epub ahead of print]

Monday, April 13, 2015

Aptitude Testing & Work Choice – evolutionary perspective

aptitude testing and work-choice history
Aptitude testing for responsible work choice
Aptitude testing for career guidance has existed only since the 1930s. Aptitude testing was not needed until work choice became freely available about 200 years ago. Before that a person had no choice in his field of work. People trained for whatever their parents did. If they had access to patronage or money they could take up a profession. Now, with the concept of Right to Education, governments seek to extend career choice to all socioeconomic strata. With this new privilege of work choice comes the responsibility of choosing wisely. Aptitude testing takes into account abilities, personality, intelligence and motivation for making a career choice.

Work choice

a brief history

For 10,000 years we did the work our parents did. In the initial millennia of mankind’s existence, work was necessary for survival. Primitive man was a hunter-gatherer to fulfil the biological need for food. As the first human settlements evolved man became a cultivator. He learnt to fashion tools, and make storage vessels. This gave rise to occupations like farming, pottery, and weaving. Densely populated centres evolved, as in Jericho. Families specialised in different trades. Son followed father in the family occupation. Skills were learnt and passed on from one generation to the next. Social hierarchies were formed loosely based on occupation. This often comprised a ruling class of administrators, the merchants, and then the labourers.

In India, occupation formed the initial basis of the caste system. Did an individual have the freedom to choose his profession or trade? The Mahabharat tells us the story of Eklavya, a tribal who wished to become an archer. Drona, the greatest teacher of the time, refuses to take him on. Eklavya through an extraordinary feat of dedication and disciplined study becomes a better archer than Prince Arjuna. However, though he had undoubted skill, aptitude and interest; he was not allowed to transgress the rules of society. Martial art was reserved for the warrior caste – the Kshatriyas – and Ekalavya was punished for aspiring to the same.

5000 years ago the first script evolved. Writing of language in a cuneiform script developed in Mesopotamia (Sumer) in 3200BCE. This heralded a radical change in the way knowledge was communicated and disseminated. Education was imparted informally to groups of children until the age of 13-14yrs. Thereafter these usually followed in the profession of their fathers.

2000 years ago we see the first example of career screening. The Jews selected brighter boys to continue studies as disciples of the rabbi. They would then become masters and rabbis themselves. However, the individual himself had no choice in the matter.

1000 years ago the elite had access to education through universities. The University of al-Qarawiyyin in Fes, Morocco, is the oldest existing, continually operating and the first degree awarding educational institution in the world. An important development in choice of education is the concept of academic freedom. This concept originated in University of Bologna (est 1088 CE, still extant) which was the first to guarantee students freedom in the interests of education. The university also gave students a choice in the curriculum to be studied. However, university education was still for a privileged few and limited to a career in the church or as a professional (law or medicine).

500 years ago formal apprenticeship was first originated. A young person usually between the ages of 10-15yrs was formally bound to a master craftsman for 3-7 years. A supply of labour in a particular trade and a certain standard was thus ensured. In the early 17th century children of paupers and vagrants were put under compulsory apprenticeship – refusal could lead to imprisonment. Later children of the gentry apprenticed to merchants, manufacturers, doctors and lawyers. By the 18th century, apprenticeship existed in every level of society except the highest. However even then, the boy himself had little or no say in his career. Career was dictated by the financial situation of the father and availability of a master. The poor had no choice.

200 years ago educational reforms were initiated when the UK National Education League began its campaign for free, compulsory and non-religious education for all children in the 1870s. Students can now take up any of a whole gamut of ever increasing fields. There is now a surfeit of careers to choose from. Students are now forced to choose between subjects when they transition from secondary school to high school. From an absence of choice they are confronted with an array of career choices. It is now important to choose a career in which the individual has a high chance of success and job satisfaction.

80 years ago aptitude testing for job screening and career guidance was developed by the US Employment Service to improve the fit between the individual and the job. Many other aptitude tests have been developed since. Aptitude tests are used in career guidance to measure different abilities and match them with the requirements of various work fields. Given the importance of work in relation to individual well-being, aptitude testing is now a basic tools in job selection. Aptitude testing combined with assessments of soft skills like personality and work style provides comprehensive data for individual career guidance. However, even today, society at large believes that career decisions happen ‘naturally’. Though so much has changed – higher education is easily available, social and gender restrictions have eased and we can choose to do what we are good at – many of us still follow the path of least resistance and do just as our forefathers did 10,000 years ago.

References

  1. Kathleen Mary Kenyon. Encyclopedia Bratannica. Jericho. http://www.britannica.com/EBchecked/topic/302707/Jericho Accessed 21-Apr-2015
  2. The History of Education. Ed Robert Guisepi. http://history-world.org/history_of_education.htm Accessed 21-Apr-2015
  3. Wikipedia. University of al-Qarawiyyin. http://en.wikipedia.org/wiki/University_of_al-Qarawiyyin . Accessed 02-Apr-2015
  4. Wikipedia. University of Bologna. http://en.wikipedia.org/wiki/University_of_Bologna Accessed 06-Apr-15
  5. Family Search. Apprenticeship in England. https://familysearch.org/learn/wiki/en/Apprenticeship_in_England Accessed 08-Apr-2015
  6. The 1870 Education Act. http://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/school/overview/1870educationact/ Accessed 09-Apr-2015
  7. John F. Reeves. Aptitude Assessment for Career and Educational Guidance. http://www.theworksuite.com/id15.html Accessed 08-Apr-2015

Thursday, August 14, 2014

Work style and employee selection

Work style, ability and job performance
Use work style assessment to hire the best - and avoid the rest

Work style is a combination of personality traits that are relevant and specific to the workplace. Work style is highly predictive of job performance and employee behaviour. Differences in working style explain how people with similar knowledge, ability, goals, and desire to perform differ in the actual performance of their jobs. In today's complex business environment talent selection is critical and is at the top of a manager's list of priorities. Selecting employees for job-relevant personality traits improves job performance in the organisation.

Work style and job performance

Individuals differ in job performance despite having similar task abilities. The personality traits the individual brings to the organization along with abilities, interests, education, and experience, are responsible for this difference. Personality traits are a major contributor to variations in job performance. The unique personality an individual brings to the workplace is visible as working style - a combination of work habits and self-regulatory ability. Work style has two aspects - work habits and self-regulation.

Work habits are patterns of behavior that people learn over time that can facilitate or interfere with job performance. They include characteristic motivational responses such as choices for the amount, intensity, and duration of effort to expend. They explain why you would give the job to Neha in certain situations and to Riya in some others.  Work habits include characteristic responses that are not necessarily motivational in nature. This is seen when Rahul, your sales representative who has been trained in the best way to deal with an angry customer and has shown the ability to do so,occasionally reverts to pre-training habits of reacting with hostility.

Self-regulation is the thinking process that allocates attention, time, and effort toward attaining a goal. Self-regulation protects an intention from distraction. Priya’s characteristic tendency may be to exert as little effort as possible, but she may choose to go against that tendency in response to the new bonus structure that rewards productivity. Habits influence behavior despite intentions to behave otherwise because they require very little attention. To implement an intention that goes against habitual tendencies and distractions, one must engage self-regulatory or volitional mechanisms. This self-regulatory construct of working style is very important because it is strongly related to personality.

Modern psychometric tools that accurately measure human potential have been proven to
  1. enhance overall productivity
  2. reduce employee attrition
  3. reduce overall hiring costs significantly.

Work style assessment measures traits such as initiative, integrity, persistence, leadership, stress tolerance, analytical thinking, and interpersonal skills. Higher performance can be obtained across all jobs if one hires employees who are highly conscientious and emotionally stable. Other personality traits (Extraversion, Agreeableness, and Openness to Experience) result in higher performance depending on whether these traits are relevant to the actual job activities.  Hiring right mitigates short- and long term damage to the business from a very bad hire. Work style assessment generates a profile of personality traits that can be matched with requirements for successful performance in a particular job.

References
  1. Bouton M, Moore M. J Med Pract Manage. The cult of personality testing: why assessments are essential for employee selection. 2011 Nov-Dec;27(3):144-9.
  2. Jeff W. Johnson. Toward a Better Understanding of the Relationship Between Personality and Individual Job Performance. In: Personality and work : reconsidering the role of personality in organizations. Murray R. Barrick, Ann Marie Ryan, editors; foreword by Neil Schmitt. John Wiley & Sons, USA. 2003. Pg 83-120


Saturday, April 13, 2013

Adult ADHD - Attention Deficit Hyperactivity Disorder at work

adult ADHD workplace effects and statistics

ADHD (Attention Deficit Hyperactivity Disorder) is thought to be a childhood disorder. However ADHD persists in adults in up to 50% of children diagnosed with the disorder. Hyperactivity, impulsivity and inattention; the hallmark symptoms of Attention Deficit Disorder in childhood have been described earlier. In Adult ADHD, symptoms change to reflect the child's development into adulthood. The symptoms related to hyperactivity gradually disappear by adulthood; however, those related to inattention persist. Adults with attention deficit disorder (ADD) are often distracted, and avoid tasks requiring sustained mental effort. This impairs functioning at home and at work.

Adult ADHD at work

Adults with ADHD experience employment impairments at every level; from the initial job search, to the interview and then during the employment itself. People with Attention Deficit Disorder are more likely to be have poor job performance, lower occupational status, less job stability and absenteeism. Men and women with attention deficit disorder earn less money, and are more likely to be unemployed.

Attention Deficit Disorder (ADD) has at times been portrayed as advantageous from a work perspective, as in the Economist, "in praise of misfits". This may be so in certain sectors where
  • Hyperactivity and distractability find an outlet in the need to multi-task with multiple apps at a time.
  • Impulsivity manifests as risk taking and an apparent fearlessness. 
This works for Attention Deficit Hyperactivity Disorder adults at the entry level of the IT industry. The physical, social and cultural environment help overcome functional limitations of adult ADD. However, the lack of focus, disorganisation and procrastination become evident when they are promoted in the organisation. It is at this mid-career stage that the adult with Attention Deficit Disorder seeks our help.

ADHD friendly workplace adjustments

SymptomAdjustment
Inattention and impulsivity Quieter room/positioning in office
Flexi-time arrangement
Headphones to reduce distractions
Regular supervision to maintain course
Buddy system to maintain stimulation
Hyperactivity/ restlessness Allow productive movements at work
Encourage activity
Structure breaks in long meetings
Disorganisation,
procrastination, and
forgetfulness
Provide beepers/alarms, structured notes
Regular supervision with feedback, mentoring
Delegate tedious tasks
Incentive/reward systems
Regularly introduce change
Break down targets and goals
Supplement verbal information with written material

Adult ADHD is a treatable medical condition. Medication to correct the underlying neurochemical imbalance is the cornerstone of treatment for ADHD adults. The adverse impact of adult ADHD is experienced by the employee and the organisation. At the organisational level, workplace adjustments can provide a safe nidus for the ADHD adult to function effectively. At the individual level treatment can help reduce the associated emotional problems and absenteeism of adult ADHD.

References
  1. Marios Adamou and colleagues. Occupational issues of ADHD adults. BMC Psychiatry 2013, 13:59 doi:10.1186/1471-244X-13-59
  2. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry. 2000 May;157(5):816-8.
  3. de Graaf R, et al: The prevalence and effects of Adult Attention-Deficit/hyperactivity Disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008.
  4. Jane L. Ebeje, Sarah E. Medland, Julius van der Werf, Cedric Gondro, Anjali K. Henders, Michael Lynskey, Nicholas G. Martin, and David L. Duffy. Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence, Persistence, Conduct Problems and Disadvantage. PLoS One. 2012; 7(10): e47404. Published online 2012 October 10. doi: 10.1371/journal.pone.0047404
  5. Schultz S, Schkade JK. Occupational adaptation: toward a holistic approach for contemporary practice, Part 2. Am J Occup Ther. 1992 Oct;46(10):917-25.

Wednesday, November 21, 2012

Job Satisfaction & Work Stress in the IT Industry

job satisfaction and work stress in IT
Work stress and low job satisfaction are the primary drivers for help-seeking in IT professionals. PR a 34-yr old software engineer employed in an IT company came to us for guidance while considering a career change. He felt stressed, and experienced his work as meaningless. He felt alienated from his colleagues and his job dissatisfaction was high.

PR’s is not a one-off case. A PPC Worldwide study reported that 62% of all employees experience work stress. Responses to a poll specifically studying IT related work stress are as depicted in the chart above.

Work stress contributes to job dissatisfaction and increased attrition in the workforce. Most burnout prevention methods focus on personal responsibility for wellness. They require sacrifice of personal time with the perverse goal of being more effective at work. We have already seen what the individual needs to do to manage stress with a health promoting lifestyle,  Even 15 minutes of exercise is effective. We now need to look at the organisational factors resulting in committed employees.

Job satisfaction involves certain obligations that exist in an employment relationship. Pay is largely considered to be the single-most contributor to job satisfaction, and perceptions of fairness in compensation have a direct influence on commitment to the organisation. However, intrinsic motivators contribute greatly to resistance to work stress. These include
Nature of work
Nature of work is an intrinsic motivator measured by an individual’s feeling that their job is meaningful. They feel engagement, and a sense of pride in the job. Humiliation at work does not foster this sense of engagement. For many of our clients humiliation is a prime driver to distress and burnout.
RK came to us when he was thinking of quitting his job. He had been 'de-promoted' into his own team when they were unable to meet a target. His self-esteem was low and he was depressed. He recovered with treatment and counselling. He could then decide his next career move from a position of strength.
Relationship with co-workers
Work plays an important part in fulfilling an individual’s social needs. Co-worker acceptance and a sense of belonging to a group and culture affect job satisfaction. Unfortunately the culture in many IT organisations continues to reflect the ‘in’ and ‘out’ groupings of the college hostels through which their managers have emerged. This only adds to the job dissatisfaction of IT professionals who may be contributing at their jobs but do not feel a part of the organisation.
The motivated and stress tolerant employee shows commitment to the organisation in two ways
  1. Emotional
  2.  Job dissatisfaction is inversely associated with emotional commitment. IT professionals who are satisfied feel more emotionally attached to and involved with their organisations.
  3. Obligational
  4. Job satisfaction is associated with feeling more obliged to remain with the organisation.
  5. Continuance
  6. Continuance commitment (cost associated with leaving the company) is not related to job satisfaction; pay does not matter disproportionately to the IT professional.
Work stress and work pressure are correlated with job dissatisfaction and poor employee engagement. The IT professional’s decision to stay with the company due to feelings of attachment and obligation results from job satisfaction rather than the costs associated with leaving the company. A working atmosphere that validates the individual and their differences will enhance that attachment and commitment to the organisation.


References
  1. E.J. Lumley, M. Coetzee, R. Tladinyane, N. Ferreira. Exploring the job satisfaction and organisational commitment of employees in the information technology environment. Southern African Business Review Volume 15 Number 1 2011.
  2. Kaluzniacky, Eugene. Stress Management. In: Managing psychological factors in information systems work : an orientation to emotional intelligence. Idea Group. London, 2004. Pg238-245.
  3. Psychol Rep. 2009 Dec;105(3 Pt 1):759-70. Employee engagement and job satisfaction in the information technology industry. Kamalanabhan TJ, Sai LP, Mayuri D.
  4. Saradha.H. Employee engagement in relation to organizational citizenship behaviour in information technology organizations. Submitted in partial fulfillment of the requirements for the degree of Master of Philosophy. Institute of Management, Christ University, Bangalore. 2010.

Tuesday, May 17, 2011

Treatment of social anxiety, phobia and self-consciousness

social phobia
Avoiding social situations because they make you self conscious and anxious? You are likely to have a social phobia or social anxiety disorder. One in 10 persons experiences social phobia between the age of  9-33years. The incidence is highest in adolescence (Beesdo et al 2007). Men and women are equally likely to suffer. However, men are more likely to seek treatment when their performance at work is impaired.

Social anxiety usually begins in childhood or early adolescence. There is often a history of childhood shyness. A stressor or humiliating social experience can precipitate the problem. In fact paediatric social phobia affects 5-10% of children. In children it is often associated with ADHD (Attention Deficit Hyperactivity Disorder), depression or separation anxiety disorder. Longstanding social phobia increases the risk of depression, substance abuse, and alcoholism later in adulthood.

Recognising social phobia

“My mind went blank during the interview. I break into a sweat, my voice changes. I know what is being asked but I am just not able to concentrate and answer with confidence.”
You have social phobia when you feel that everyone is staring at you or judging you during social interactions. There is a persistent and intense fear of being embarrassed and humiliated by your own actions. This especially occurs in public places such as at work, during office 14meetings, while shopping and at social gatherings. The feelings persist even though rationally you know its not true. These fears may become so severe that they interfere with your work, school or college. They make it hard for you to socialise and make or keep friends.

When you decide to confront these fears and join the party or attend a meeting, you are anxious for days beforehand in anticipation of the dreaded situation. Thoughts of a discussion with your boss make you break into a sweat. You may have panic attacks. Your sleep may be increasingly disturbed as the day of the meeting approaches. Reasoning and reassuring yourself as to the non-threatening nature of the situation brings no relief. You are sweating and can feel your heart race during the encounter. After the encounter you worry about how you were judged for hours afterwards. You feel ashamed that you did not perform better. It becomes easier for you to just stay away from social situations and avoid other people altogether.
“I hesitate to enter the room when the group is already seated. When it comes to my turn to speak my mouth goes dry and I feel choked. I don't speak a word during the meeting even when I have something to contribute.”
People with social anxiety can present with different secondary symptoms
  • Some people cannot write in public (as on a blackboard), their hand will shake, their cheques bounce
  • They experience severe anxiety about eating and drinking in public and often spill food and drop their cutlery
  • Others find it a torture to speak in front of people, they just ‘clam up,’ speak in monosyllables or stammer
  • One of the worst circumstances is meeting people who are authority figures- bosses, supervisors, interviewers at work; or teachers & examiners at school. A job interview is torture, more so because the person knows that he would be good at the job if only he could get through the interview.

People with social phobia avoid situations in which they feel embarrassment and anxiety. Initially they are comfortable with this avoidance. Later, they see avoidance as an impediment to achieving their full potential in their chosen careers. They see their social lives as stale and restricted. To address these problems people mistakenly enrol for ‘personality development’, meditation and other courses. But this is not the shyness of introversion. This shyness results from overwhelming anxiety and embarrassment. They are frustrated when there is no resolution. The underlying social phobia has not been addressed.

In a child with social phobia this anxiety expresses itself as tantrums, crying or just “freezing up”. In school, the child typically does not participate in classroom activities, is reluctant to stand up and answer, has no friends and frequently misses school with complaints of stomach ache or headache. Outside school these children have few or no friends. They may communicate only with family members.
“My daughter doesn't speak a word when we have visitors. The other children are playing together, she has to be pulled out of her room to join them.”

How is social phobia best treated?

The best treatments of social anxiety include
  1. Medication: is usually for a limited period, under supervision. Do not stop taking medication abruptly. Discuss any side effects, if any, with your psychiatrist.
  2. Cognitive Behaviour Therapy – CBT: and systematic desensitisation properly administered for 6-12 sessions can produce long lasting, permanent relief. You have to be motivated to persist in the practice of the simple methods and techniques that are explained to you. Do not use any advice available online without due thought and discussion with your psychiatrist

What you can do for a family member with social phobia

  • Be supportive. Help the individual seek psychiatric treatment. Many a career has been advanced or saved by a supportive spouse. Family interaction and communication also improves.
  • Don’t trivialise (‘its normal to be nervous when you meet new people, you do not have to go for therapy’).
  • Don’t perpetuate their symptoms (‘let it be, stay at home if you are not feeling well’).
Family support helps during behavioural desensitisation therapy and decreases the social isolation of the individual. Social phobias and anxieties are treatable conditions. Treatment and therapies are effective and easily accessed.

References
  1. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug;64(8):903-12.