The Developing Brain & Youth High Risk
Behaviors: Updates, Barriers &
Opportunities for Interventions
Yifrah Kaminer MD, MBA
Alcohol Research Center
UConn Health Center, Farmington, CT
Latest December 17, 2008
The Developing Brain & Youth High Risk
Behaviors Why Don’t They Get it?
Or,
Why Don’t We Get It (Right)?
Objectives
• Accept that youths are not mini adults. they are evolving and are more
vulnerable than they believe & know
• Clarify adolescent elevated risk for high-risk behavior with an
emphasis on Driving, substance (ab)use from a scientific
developmental perspective
• Place clinicians, parents, educators, public health professionals, policy
makers, and youth on the same page
• Improve: 1) Knowledge Base that will lead to 2) Increased Public
Awareness and conclude with 3) Political Will: Engagement of
community stake-holders and politicians in order to convince them that
it is a crucial step towards the goal of reducing youth mass casualties
• Discuss implications of findings on future directions in prevention and
public health policy
The High-Risk Maturational Gap: The
Take Home Message
• Youth reach Intellectual maturation around
age 16
HOWEVER
• They reach Emotional maturation ONLY
around age 25
Linkage Between Internet and Other
Media Violence With Serious Violent
Behavior by Youth
• Exposures to violence in the media, both online
and off-line, were associated with significantly
elevated odds for concurrently reporting
aggression and seriously violent behavior (in
Japan and the USA).
Anderson CA et al. (2008); Ybarra ML (2008)
Watching Sex on TV Predict Teen
Pregnancy
• Teens exposed to high level of television sexual
content (90th) percentile were twice as likely to
experience a pregnancy in the subsequent 3 years,
compared with those with lower levels of
exposure (10th percentile). Chandra et al (2008)
The Minimum Drinking Age Debate
•
•
•
•
Initiated by founder of “Choose Responsibility” that focuses on
Responsible Drinking (RD) and increasing awareness of the harms
associated with alcohol use.
Supporters of a Minimum Legal Drinking Age of 18 argue that: 1) it
should be consistent with other legal rights, 2) Youth can and should
be taught RD., 3) that MLDA-21 is unrealistic and leads to
underground dangerous drinking.
Supporters of MLDA-21 are concerned with “trickle down” effect
The strongest support of MLDA-21 is associated with data that
25,000 have been saved since it was established in 1984.
Barnett (2008)
Extended Adolescence in Western
Societies
• Hormonal surges that lead to puberty are
beginning earlier than in previous decades
• The maturational gap is wider in Western societies
compared to traditional societies
• In traditional societies there is a shorter 2-to 4year gap between the onset of puberty and the
taking on of adult roles.
Schlegel & Barry (1999)
Adolescent Maturation
• Although maturation is progressive, it is not uniform in
speed or timing and individual differences are the rule,
rather than the exception. Moss (2008)
• There are periods of rapid transition, reorganization, spurts
of growth, alternating with periods of consolidation
• Exposure to stress and substances during critical periods of
development have behavioral consequences and may
increase liability to disorders if the mismatch between
capacities and demands is too severe for compensatory
physiological responses and behaviors that in time may
affect brain structures. Lenroot & Giedd (2006)
Adolescent High-Risk Behaviors
Occur in a Developmental Context
• Biological-Puberty: hormonal, brain neuro-anatomical and neuro-transmitters
interchanges
• Circadian rhythm: circadian shift and school schedule are causing youth sleep
deprivation (6-7 instead of the necessary 8-9 hours of sleep necessary for
optimal function)
• Emotional-Affective: emotional lability and dysregulation
• Cognitive: information processing, executive functioning
• Behavioral: novelty seeking, risk taking, impulsivity
• Social: increased conflicts with parents/adults, increased peer interactions and
influence, and forming intimate relations
Adolescence is a Developmental Phase
With Specific Functional Purposes
Prepare youth for adult roles
• Improve: separation individuation, industrialization,
relationship with peers and intimate others
• However, often done by trial and error (not internalizing
well the experience, wisdom and codes of elders of the
tribe/society)
• Narcissistic defenses such as omnipotence-invulnerability,
devaluation of the elders and societal/legal codes (unless it
suits them)
Leads often to imbalance between needs and wants and may
result with problems and dire consequences
Why Didn’t Life problems Hit Me When I
was a Teenager and Knew Everything?
(a bumper sticker)
Childhood Vs. Adolescence Mortality
• Compared with children , teens show
improvements in strength, reaction time, reasoning
capabilities, and immune function
• Overall morbidity and mortality rates soar X4-5
folds between childhood and adolescence/young
adulthood
• In 2003, about 7,000 U.S. children aged 5-14
years died of all causes. Compared to 33,500
youth aged 15-24 years
Dahl, (2008)
U.S.A. Youth Mortality From Top 3
Preventable Causes- 2004 CDC Data
• Vehicles accidents ages 16-19= *4767
*41% associated with alcohol/substance use; 23%BAC>0.08g/dl;
74% of drinkers were unrestrained
*30% of teens rode with a driver who has been drinking in past month
-Persons aged 15-24 represent 14% of the US pop., account for 30% of
costs of injuries
• Homicides = 5570 between the ages of 10-24
• Suicide = 4599 between the ages of 10-24
-17% of high schoolers seriously considered attempting and 8.4%
attempted suicide in 2005)
High Risk Behaviors in Youth
• Driving in general and driving under the influence
in particular (52 fold increase for an accident)
• Impulsive aggression (IA): Deliberate yet
nonpremeditated acts
• Suicidal behavior: Linked to IA commonly an
uninhibited impulse to act on self-directed anger
• Sexual behavior: Precocious, coercive/traumatic,
unprotected (STDs and pregnancy)
• Substance use and gambling
• Gang and illegal activity including school bullying
Social Forces in (Pre) Adolescence
•
•
•
•
Curiosity
Social desirability/acceptance (Cool factor)
Social norms
Social pressure?
Einstein’s: Mass-Energy equivalence
E=MC2 Applies to Youth Networking?
Puberty
• Hormones have been implicated in behavioral
changes during adolescence
• Puberty means Youth “on Steroids”:
18 fold increase in Male Testosterone level
8 fold increase in Female Estradiol level
• Hormonal changes affect: motivation circuits,
response to stress, increased sensitivity to novel
sexual, social & aggression stimuli
Puberty and the Adolescent Brain
• Adolescence is a period of brain structural and
functional changes
• Pruning (reduction) nerve connections (synapses)
• Myelinization increases by 100%
• Limbic System: early development of arousal
pathways of the 4 Fs (feeding, fighting, fleeing
and sex)
• Puberty increases susceptibility to stress
• Executive cognitive functions (ECF) develop
Executive Cognitive Functions (ECF)
“The individual ability to carry out “higherorder” cognitive processes such as strategic
goal planning, abstracting, working
memory, attentional control, thinking
flexibility, self-monitoring, and the ability
to use feedback when regulating behavior”
Giancola & Moss, (1998)
Brain Neuroimaging
“More than any previously available neurobiological
technique or research tool, imaging offers the
opportunity to define the neural systems that
mediate the genetic and environmental
determinants of brain development with their
cognitive, emotional, and behavior consequences”.
Gerber & Peterson, (2008)
Both structural and functional changes are involved
in the maturation process
http://www.brainchannels.com/evolution/evolutionmedia/halfbrain.jpg
The Importance of the Frontal & PreFrontal Brain for Development
• Thinking skills: Identify, prioritize, problem solving and
integrate
• Executive Functions (EF): language-processing, emotion
regulation, cognitive flexibility, & social skills
• Youth dysregulate: affect, cognitive process, impulses, and
self perception
• Emotional development (i.e., maturation) “meets” cognitive
development only around age 26
• The pivotal questions is how to proactively address triggers
before the emergency sets in?
Green & Ablon, (2006)
Catecholaminergic Neurotransmission
Serotonin (5-HT)
•
•
Prefrontal
INHIBITION
Midbrain raphe
projections to
motivational circuitry
including VT, NA,
amygdala,
hippocampus areas
Dopamine
• Prefrontal ACTION
• Mesolimbic: Ventral tegmental
(VT) area- Nucleus accumbens
(NA)
• Reward pathways
– Pleasure
– Reinforcing behaviors
.
Dopamine-Serotonin Ratio
• Ratio of Dopamine metabolite to 5-HT metabolite
suggest a high rate of DA to 5-HT turnover
• These findings indicate that adolescents may be
characterized by greater activity in
promotivational dopamine systems than in
inhibitory serotonin systems
• Relatively low levels of mesolimbic DA activity in
youth may contribute to risk taking and seeking
rewarding stimuli (boredom effect?)
• Hormonal changes contribute to promotivational
functioning of dopamine systems
Dopamine Mesocortical Pathway
Basal ganglia
Nucleus accumbens
Ventral
tegmental area
• Attention
•Arousal
•Concentration
•Other cognitive fxns
BOREDOM
I Am Bored: “I Am The Chairman of The
Bored” (Iggy Pop)
• A Biological explanation for Boredom
Based on a primates model. During
adolescence Dopaminergic activity migrates
from the limbic system to the pre frontal
cortex, leaving the limbic system with a
relatively lower levels of Dopamine then
before. This might explain sensation
seeking, X-treme activities etc.
• Romer & Walker (2007)
Impulsivity
An innate trait for rapid response
(Consider Latency Period) to internal
or external stimuli REGARDLESS of
potential negative consequences
Swan (2001)
Cognitive Aspects of Impulsivity
• Inability to delay immediate gratification
• Distractibility: inability to maintain task
oriented attention
• Disinhibition: inability to restrain behavior
as expected based on social norms and
constraints
Evolutionary Approaches to
Impulsivity
• Risk Aversiveness Versus Impulsivity (over vs.
under estimated harm)
• It has been argued that impulsive symptoms can
be understood in adaptive evolutionary terms
• Particular environments favor “Response Ready”
individuals (e.g., hyper vigilant, quick to respond)
over “Problem Solvers”
– Fairbanks LA et al. (2004) ; Williams J, Taylor E (2007)
Biological Basis of Impulsivity
• A deficiency of central serotonin the chief inhibitory
substrate (5-HT =hydroxytryptamine) is associated with
greater impulsivity
• This includes outward and self directed violence, suicide,
fire setting, pathological gambling, binge eating
• Frontal lobe lesions in humans are correlated with
impulsive behaviors
• Conversely, pro-serotonergic agents decrease social
aggression and impulsivity
Neurobehavioral Disinhibition (ND)
• ND is a trait derived from using measures of ECF, affect
modulation, and behavioral control, discriminates youth at
high and average risk for substance use disorders and
significantly predicts the SUD between late childhood and
young adulthood.
• Deficits in frontal activation in youth with high amounts
of ND, suggesting a possible developmental delay of
executive processes in high-risk youth
Tarter et al. (2003/4)
Youth Substance Use and SUD: Definitions
Occasional Use - in social setting
Regular Use - on a weekly or more regular basis
Misuse - Emergence of pattern of use
Abuse - Misuse with impairment in one or more domains
within a 12-month period
Dependence - Pervasive pattern of use with associated
impairment, inability to control use, use despite
consequences, tolerance, and physiological
symptoms
Substance Use Disorders - Abuse & dependence
Causality
“After this, therefore, because of this
=
Fallacy of misplaced connectedness”
Tarter (2008)
Liability
• The individual tendency to develop or contract the
disease= susceptibility Falconer (1965)
• No diagnosis captures the liabilty. The common traits are:
sensation seeking, temperament, negative affectivity, and
externalizing disorders (Transmissible Liability Index-TLI)
• The capacity to maintain self regulatory capacity under
stress is crucial. Inability may increase risk for SUD
• There is a common genetic vulnerability to develop
dependence to all drugs (PCP 100%; Stimulants 73%;
Cannabis 67%; Sedatives 81%, and heroin/opiates 30%).
Tarter (2008)
Deficient Response Modulation
(DRM):Youth Response to Drugs
• One factor that characterizes youth who experience SUrelated problems, is the difficulty considering negative
consequences specifically in the presence of a well
established, competing reward
• Increased sensitivity to reward is associated with use (e.g.,
getting “high”,) that are salient to developmental increase
in thrill-seeking & need for peer approval
• Decreased sensitivity to negative consequences (e.g.,
“hangovers”, others disapproval, punishment)
• The rewards aspects of SU are often more proximal to the
decision to use than are the negatives
Justus (2008)
Drug Use Conditioned
Reinforcement
• Reinforcing effects of drugs are repeatedly paired with
environmental stimuli (e.g., sight, smell, use situations)
• Social situation = become a “cue” exposure leading to a
stimulation for drug use or relapse
• Nicotine availability=drug reinforcement
• Social cues= conditioned reinforcement
• Pairing the two creates even stronger urge to smoke
Drugs and The Adolescent Pre-Frontal
Cortex
• Drugs exert persistent neurobiological effects that extend
beyond the midbrain centers of pleasure and reward to
disrupt the function of the frontal cortex where risks and
benefits are weighed and decisions are made
• More specifically, the site of control over Motivation,
behavior, and Inhibitions of behaviors
• The developing adolescent brain is more sensitive to drug
effects. Delaying onset from age 14 to 21 is associated
with 7-and 5-fold increase for binge drinking and SUD
respectively.
Chambers et al. (2003)
Exposure to nicotine >addictive than in adulthood
Social Stressors Affect Neurobiology
(Expression of Heterogeneity)
• In experiments with young monkeys in isolation
the dominant animal has shown changes in
expression of receptors compared to subordinate
• The dominant monkeys did not abuse cocaine
>placebo while the subordinate did!
• The addicted brain manifests loss of control even
when the behavior is not pleasurable any more
Impulsive Compulsive Behavior
Volkov N (2006)
Reclaiming Our Children:
Empower Parents & Teachers
Schepis et al. 2008
The Utilitarian View
• A 19th century Consequentialist thinking that places the
moral worth of an action in its consequences or outcomes
and emphasizes the good of the total society (“greatest
good for the greatest numbers”, as opposed to benefits
accruing by individuals or a group of individuals.
• Measurement is quantitative by adding up the positive
aspects and contrast them with the negative ones
• Jeremy Bentham’s (1784-1832) “An introduction to the
Principles of Morals and Legislation”
• Cost-benefit analysis is based on a utilitarian application
(David Stewart, 1998)
Rights and Duties
• How should we balance our duties with our
obligations to the community
• Are there cases when individual rights
should be sacrificed or restricted for the
sake of a greater good? (e.g., CT Gun
Control; 1st amendment vs. Hate Speech)
• Sense and sensibility: driving at 16,
enlisting at 18, and drinking legal age at 21?
Contextual Features that Promote
Positive Outcomes for Youth
1.
2.
3.
4.
5.
6.
7.
8.
Physical & psychological safety
Appropriate structure
Supportive relationships
Opportunities for belonging
Positive social norms
Support for efficacy and mattering
Opportunities for skill building
Integration of family, school , and community
Eccles & Gootman, (2002)
Parental Role in AUD Prevention:
Supervisory Neglect
• Among community subjects ages 14-17, those with
inadequate supervision were significantly more likely to
drink alcohol, to have AUD, to develop AUD later and less
likely to be free of AUD symptoms over 1-year follow-up.
• Family structure was not significantly correlated with
supervision group ( e.g., single vs. 2-parent family)
• Complementary to adolescents’ pursuit of independence
parental supervision remains critical to their development
• Consistent, emphatic, and authoritative parental style
generates best outcomes.
Clark DB (2005)
Barriers to Healthy (Pre)Teenhood: The
Ubiquitous Perception & Excuses
• Every one does it: Not true
Examples: 1) substance use; 2) sexual behavior particularly
for females that rests mainly on social values and not on
testosterone level as in boys (Weisfeld GE & Woodward L, 2004)
• Media “emotional” reports: Make it a “learning
opportunity” and not a Soap Opera
Example: youth car crashes
• Commercial exploitation of youth: Trivializing trauma
and harmful/dysfunctional relatioships
Example: exposure to violence and sex in commercials for TV
shows (dead/bloody/traumatized people, bed scenes)
Present Preventive Measures
•
•
•
•
High taxes on alcohol and tobacco
Legal age of use is 21
No car rental until 25 Y.O. age
Insurance rates for youth are elevated
(however, parents pay insurance )
• How about increasing driving age to 18-21?
The Federal & State Case for School-Based
Health Prevention/Intervention Services
• Use of empirically-based agenda in schools appear to be blocked by
counter-productive politics and cultures
• Not everybody is in agreement that schools should be providing
prevention strategies that engage the entire school
• Questions central to the identity of school-based programs are :what is
at stake, how services are integrated, and who pays
• Some states have legislatively mandated support to promote social
emotional health in schools
• Developing community/parents support for these initiatives is essential
• Bold state action can dismantle incompatible policies and cultures
• Public state policies should promote funding for services based on
clear expectations for agreed upon operation and outcomes
Cooper, (2008)
Conclusions
• Think outside of the box in order to create a new flexible box
that will enable us to incorporate new tested effective data
continuously when it becomes available
• Develop a coalition to optimize dissemination and
implementation of new approaches
• Eradicate ignorance, self interest and hypocrisy by educating
and creating political and financial pressure on decision makers
and agencies who ignore or hamper the well being of youth in
US
• Find a fit between the intervention and the context of delivery
therefore, effective mandated primary and secondary
prevention of specific high-risk behaviors in schools is THE
central strategy
Select References
•
•
•
•
•
•
•
•
Chambers RA et al. (2003). Developmental neurocircuitry of motivation in
adolescence: A critical period of addiction vulnerability. Am J Psychiatry
160:1041-1052.
Clark DB, Tapert SF (2008). Alcohol and adolescent brain development.
Alcoholism: Clin Exper Research (a Special Section) 32:373-429
Cooper JL (2008). The federal case for school-based mental health services and
supports. JAACAP 47:4-8.
Kaminer Y, Bukstein OG (2008). Adolescent Substance Abuse: Psychiatric
Comorbidity and High-Risk Behaviors. Routledge/Taylor & Francis , NY
Romer D, Walker EF (2007). Adolescent psychopathology and the developing
brain. Oxford.
Schepis TS et al. (2008). Neurobiological processes in adolescent addictive
disorders. Am J Addictions 17:6-23.
Schlegel A, Barry H (1999). Adolescence: An Anthropological Inquiry. New
York, Free Press.
Weisfeld GE, Woodward L (2004). Current evolutionary perspectives on
adolescent romantic relations and sexuality. JAACAP 43:11-19.
Contact Information
Yifrah Kaminer MD; MBA,
Professor of Psychiatry,
Alcohol Research Center; Division of
Child & Adolescent Psychiatry,
University of Connecticut Health Center,
Farmington, CT 06030-2103
Kaminer@psychiatry.uchc.edu.