Etiological factors
in substance abuse
Ms. Giovanna Campello
UNODC Prevention, Treatment and
Rehabilitation Section
Forming the evidence base for prevention
Brain function in a social context
Outline
• Developmental stages
• Influences on drug use
– Personal characteristics
– Micro-Level risk factors
– Macro-Level risk factors
• Implications for prevention
Developmental phases
Drug use is a developmental problem
Developmental Phases
• Each stage of development, from infancy to early
adulthood, is associated with a certain expected range
of:
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intellectual ability
language development
cognitive, emotional and psychological functioning
social competency skills
• Each needs attention to prevent the onset of drug use
and dependence!!!
Infancy
Infancy
• Protective Traits, Skill Sets & Experiences:
– Responsiveness to the environment and caregivers’
interactions
– Caregivers who are responsive
– Surroundings that provide stimulation
– Learning how to be effective in having needs met
– Easy to soothe
– Not temperamental
Early Childhood
• Factors Predictive of Later
Social Competence:
Language
Cooperation
Control of emotions
Collective conscience
Social and emotional skills
(including perception of others’
emotions)
– Problem solving
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Milestones in Middle Childhood
• Emerging Executive Cognitive and Emotional
Regulatory Functions:
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Maintaining attention
Controlling emotions
Social inclusivity
Effective communication
Receptivity to others
Accurate perception of emotion in self and others
Adolescence
Adolescence
• Integral to self-regulation of emotion and behavior to
prepare for adulthood:
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Social and emotional skills to establish stable relationships
Sensitivity to feelings & needs of others
Conflict resolution
Prosocial skills
Impulse control
Decision making
Problem solving
Even under normal conditions, the adolescent
prefrontal cortex is not completely connected!
The “Imbalanced” Adolescent Brain
 Emotional responses are
heightened
 Cognitive controls are
immature
Double Jeopardy!
Emotional
Reactivity
Cognitive
Regulation
Significance of Developmental Phases for
Prevention
• Behavioral problems underlying drug use all involve poor selfregulation.
• Social and physical environmental risk factors impact on
executive-cognitive functions and emotion regulation.
– This impact depends on:
• Personal characteristics (e.g., depression, high activity levels, attention deficit
disorder, etc.) which develop and evolve over time.
• Developmental period of exposure to risk factors.
• Not only adolescence!!!
• Developmental phase determines what program components
and policies will be understandable and executable.
Interaction of Personal Characteristics and the
Micro- and Macro-Level Environments
Primary Developmental Outcomes and their
Environmental and Personal Influences
Types of Influences on Behavior
• Personal Characteristics
– Neurological delays
– Stress reactivity
– Mental health and personality
traits
• Micro-Level Factors
– Family
– School
– Peer
• Macro-Level Factors
– Income and resources
– Social environment
– Physical environment
Neurological Deficits and Delays
• When the prefrontal cortex is slow to develop or not
functioning properly:
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Inability to accurately interpret social cues
Negative emotions dominate
Impulsivity & low self control
Insensitivity to consequence
But…heightened sensitivity to rewards
Sensation-seeking
Poor stress reactivity
Inattention
Implications of Delays in Brain Development for
Behavior
• The signs of poor self-regulation due to deficits and delays vary
as a function of developmental stage:
– In younger children: language delays, poor school readiness and
academic achievement, conduct problems, negative affect, insensitivity to
consequences, and impulsivity.
– In late childhood and early adolescence: aggression, sensation-seeking,
delinquency, negative affect, and poor decision making and coping skills.
• Detrimental environmental conditions (stress, maltreatment, poor
nutrition, and other adversities) further compromise brain
development and increase risk for drug use and addiction.
Stress Exposures and Reactivity
• Stress compromises development of brain systems that are at
the basis of social, behavioral, cognitive, and emotional
functioning
• Stress disrupts hormones that regulate these functions
Stress, drug use and addiction
Stress, drug use and addiction
• Stress activates the same brain [reward] systems responsible for
the positive reinforcing effect of drugs
– It may damage and cause further delays to the brain & ECFs
– It increases physiological sensitivity to drugs
– It increases desire to improve mood with drugs after exposure to stress
• Stress more strongly predicts drug use when there is a
psychiatric disorder, poor parenting, family dysfunction, and
adverse neighborhood characteristics.
• Stress, lack of social supports, and poor coping skills predict
early onset and escalation of drug use, relapse, and treatment
resistance.
Mental Health Problems (1/2)
• Mental Health Disorders are
strongly linked to drug use
and dependence.
• Internalizing Disorders
(PTSD, Depression, Anxiety
disorders, Bipolar disorder)
– Brain responses are
heightened in response to
stress.
– Tendency to self-medicate the
anxiety & depression this
process causes.
Mental Health Problems (2/2)
• Externalizing Disorders (Conduct Disorder, Attention
Deficit Hyperactivity Disorder, Oppositional Defiant
Disorder, Antisocial Personality Disorder)
– Low level of arousal in these disorders is related to an
insensitivity to consequences and a need for more
stimulation.
– Heightens risk for continued drug use to relieve symptoms
– Tend to be resistant to substance abuse treatment
– Exacerbates stress reactivity problems
Personality & Temperament
• A difficult temperament and
certain personality
characteristics are
consistently related to
heightened risk for drug use.
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Impulsivity
Aggressiveness
Sensation or novelty-seeking
Negative affect
Impaired judgment
– High activity level
– Risk taking tendencies
– Lack of regard for negative
consequences
– Lack of pain avoidance
responses
– Abnormal levels of arousal in
response to stress.
Importance of Personality in Adolescence
• Normal adolescence is characterized by greater reward
anticipation, sensitivity, and sensation seeking—particularly
social rewards (e.g., peer regard, gains in social status).
– It follows that adolescence is the period during which drug use onset is
most common.
– And, therefore, that adolescents with especially high levels of any
combination of these traits are at heightened risk.
• Preventive Implications: These traits can be redirected through
psychosocial means to decrease risk for drug use. Prevention
programs must be designed to specifically redirect this
developmental track.
Micro-Level Influences: family, school, peers
Micro-Level Influence: Parents and Family
• The home environment is the single most profound
influence on every aspect of child development
– Effects of poor parenting are longstanding
– Parents need to instill social and emotional regulatory skills
early in life to resist substance use
– Parenting and family continue to be important through
adolescence when youth have more autonomy and
opportunities for risky behaviors
• Preventive Implications: Intervening at the parent level
is crucial to improve child outcomes.
Parenting Styles That Interfere with Healthy Child
Development
• Negative influences
– Insecure attachment
– Lack of warmth & affection
– Lack of supervision &
monitoring
– Poor disciplinary tactics
– Inconsistent
– Reinforcements for negative
behaviors
• Severely negative influences
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Harsh
Restrictive
Domestic violence
Abuse & neglect
Hostile
High in conflict
Emotionally triggered
Caregivers who are not
responsive
Links to Aggressive Behavior & drug use
• Children exposed to stress and conflict in the home are more
likely to:
– Become more behaviorally and emotionally maladjusted
– Have high levels of mental and physical health issues
– Manifest high levels of aggressive behavior, the strongest predictor of
later drug use and other risk behaviors
– Characteristics of the family (e.g., cohesion, supportive, communicative)
influence the ability to develop resiliency skills.
• Preventive Implications for Exposed Children: Training in parent
skills, relieving the stressors and mental health problems of
caregivers, and trauma prevention and treatment strategies.
Micro-level influences: school and education
• Lack of education or poorly equipped schools and teachers:
Slows child development, particularly cognitive functioning
Interferes with development of self-regulatory and social skills
Increases levels of stress, perceptions of inadequacy and failure
Related to lack of parental involvement in schooling
Compromises attachment to school (a resiliency factor)
Prevents us from availing ourselves of opportunities for early detection,
intervention and treatment
– Compromises children’s ability to succeed in life
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• Preventive Implications: Quality of schools, its teachers,
curriculum, and students’ social networks in school are major
socializing influences to be taken advantage of.
Micro level influences: peers
Micro-level influence: peers (1/2)
• Peer relationships are influential socializing experiences
that affect attitudes, skills, and “normative” behaviors:
– Can supersede parent influences.
– Presence of peers undermines executive decision making.
– Time spent in unstructured settings (e.g., on street) heightens
this effect.
Micro-level influence: peers (2/2)
• Social networking technology removes parents from
interactions with the child, further reducing their
influence
• Preventive Implications: Parents’ use of rules to monitor
adolescents’ activities and encouraging healthy outsidethe-home activities are critical to reducing negative peer
influence.
Sex differences in peer influences
Sex differences in peer influences
• Girls are influenced by peers differently than boys:
– More likely to use drugs if friends & partners are using or introduces drugs
to them.
– Concerns about peer approval, depression and body image – all
interrelated – increase susceptibility to drug use in girls.
– Early onset of puberty increases risk for risky behaviors.
• Tend to date at younger ages and be with older risk taking males
• More conflict with parents around issues like dating, selection of friends, and
shifting behavioral expectations.
• Higher levels of conduct problems
• Living in a poor community exacerbates the effect of peers on
drug use risk for both sexes.
Macro level influences:
poverty, social and physical environment
Macro-level influences of poverty (1/2)
Societal level
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Affects the quality of the environment
Limits choices and opportunities for adults to help children
Places a strain on social systems and supports
Increases conflict
Has adverse effects on parent and child health
Breaks down cooperation among residents and between
community organizations
• Consequences for children:
– Difficult to teach children effective social skills they will need to interact
with peers and other adults
– Poor children are much more likely to grow up to be poor adults and raise
children who suffer the same problems
Macro-level influences of poverty (1/2)
Harming individual child and youth development
• Increases stress in caregivers
– Less able to attend to basic and emotional needs of the child
– Child maltreatment and neglect is more common
• Reduces ability to invest in learning & educational opportunities
in school and day care
• Compromises ability to be involved, patient, responsive and
nurturing parents to their children throughout development.
– The caregiving environment is more disorganized and lacking in
appropriate stimulation and support
• Creates conditions that are stressful for children
– Interferes with growth, ability to respond adaptively to stress, development
of psychological health and self-regulatory skills
The Good News!
• High quality parenting has
potential to mitigate the
effects of poverty, particularly
for girls!
• This is one important target
for preventive interventions!
Implications for Impoverished Children
• Prevention strategies to develop skills to improve chances of
success in school and life:
• Increase availability of badly-needed services
• Political and health care involvement
• Increase efforts to reduce poverty and to avoid detrimental
consequences on child development
– Particularly with respect to learning the skills needed to escape poverty
and succeed in life
• Facilitate the implementation of comprehensive programs
• Enact programs to alleviate the sources of poverty.
Macro-Level Influences of the Social Environment
• The social environment of the larger community influences drug
use risk through:
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Shaping social norms
Enforcing patterns of social control
Influencing beliefs about the risks and consequences of using drugs
Effecting stress responses
• Critical to maintain neighborhood viability and cohesiveness
• Peers during adolescence are especially influential
Social cohesion
• Social Cohesion =
attachment to and
satisfaction with the
neighborhood
• Involves trust and support for
one another in a community
• Maintains norms for positive
social behavior
• Associated with lower drug
use and lower drug-related
mortality
Discrimination
• Discrimination and social exclusion have profound
negative effects:
– Physical and mental health disorders, including drug use and
dependence
– Poor educational attainment & lower levels of employment
– Restricted access to services and social supports
– Effects are compounded for immigrants.
Political instability
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Disrupts basic services; housing, sanitation, water, & health care
Orphaned, living alone on the street, or forced to be soldiers
Violence, unhealthy conditions, traumatized, and victimized
Deficits and delays in numerous functional domains
Preventive solutions could be found in governments that:
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Protect child welfare
Prohibit them from entering war zones
Meet rehabilitation needs
Provide shelter, food and clean water
Provide psychosocial support to overcome damage
Macro influences of the physical environment
Many aspects of the physical environment harm
child development
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Affects social relations, crime and drug use:
Decayed and abandoned buildings
Ready access to alcohol and drugs
Neighborhood disorder: vandalism, graffiti, noise, and dirt
Urbanization of the area
Neighborhood deprivation
Neurotoxins: lead, cadmium, mercury, arsenic, second-hand
smoke
• Prenatal exposure to drugs, alcohol, toxins, and nicotine
• Negative [pro-drug] media messages
Some conclusions
Implications of the research
for drug prevention (1/2)
• Behavioral problems underlying drug use all involve
poor self-regulation and are preventable if appropriately
addressed.
– Evidence-based programs are designed according to
information on etiology
• Programs that target mechanisms underlying self regulation and, in
turn, drug use is the key to prevention
• Vast brain plasticity in childhood means there is great potential to
improve functioning
• Targeting socio-emotional and cognitive skills can
redirect and normalize the developmental pathway.
Implications of the research
for drug prevention (2/2)
– Appropriately targeted interventions may be particularly
impactful for disadvantaged children who experience social
ills.
• A comprehensive evidence-based set of solutions to
prevent drug use operates to enhance multiple domains
of brain function.
Take away message 1
The earlier, the better
• The earlier the intervention, the more effectively we
can…
– Redirect behavioral pathways
– Increase resiliency
– Reduce exposure to the potentially long-term adverse effects
of the above etiological conditions, including the early use of
drugs itself.
Take away message 2
Prevention is timeless
• Even very young children can manifest early signs of
future mental, emotional, and behavioral disorders that
increase risk for later drug use.
• A great deal is known about how to prevent, monitor,
and treat these problems to ensure children reach their
highest potential.
• In all cases and ages, an enriched environment,
external supports, and high quality education is
essential.
Take away message 3
It’s never too late!
• Many mental health, emotional, and behavioral problems stem
from impulsive, sensation-seeking activities in adolescence
• Problems important to monitor and prevent include:
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Early alcohol, tobacco, and other drug use
Violent and delinquent behaviors
Depression and suicide
Risky sexual behaviors
• In adulthood, influences persist and require address to prevent
further escalation of use, addiction and relapse.
• Fortunately, there is tremendous brain plasticity and maturation
of functions through adolescence and early adulthood
– Provides a solid window of opportunity to improve outcomes
Thank you!