The Developing Brain & Youth High Risk
Behaviors: Updates, Barriers &
Opportunities for Interventions
Yifrah Kaminer MD, MBA
Dept of Psychiatry & Pediatrics
UConn Health Center, Farmington, CT, USA
CHIP presentation, February 4, 2010
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 at age 25
• The imbalance between the development of the cognitive
control and affective systems may be at the core of risktaking behavior
Rutherford, Mayes, Potenza (2010). Neurobiology of Adolescent SUD. In: Kaminer &
Bukstein (Eds.). Clinical Manual of Adolescence substance Abuse Treatment. APPI ,NY
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
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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
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Curiosity
Social desirability/acceptance (Cool factor)
Social norms
Social pressure?
During transition to adulthood, adolescents increased
independence from their parents redirects their resources
and goals toward establishing relationships with peers
Erikson (1959)
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
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
PFC Regulation of Higher Brain
Function and Complex Behaviors
Examine mechanisms by which the developing
and mature PFC interacts with other brain systems
in the regulation of higher brain functions and
complex behaviors. The focus is on manipulation
of neural circuits.
(NIH Challenge Grants 2009)
The Importance of the Frontal & PreFrontal Cortex 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)
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)
“Parents Lend their Frontal Lobes
to Kids”
• In contrast to adults, children and adolescents rely on the
PFC to do ALL WORK rather than distributing the
workload to other specialized regions of the brain, such as
the AMYGDALA & INSULA that are activated when
making quick decisions that affect safety and survival.
• Activating executive skills takes more conscious effort
with youth than it does with adults, which explain why
they are less inclined to engage their working memory
(I.e., to draw on past learning/experience to apply to the
situation at hand or to project into the future) to perform
tasks of daily living.
Dawson & Guare (2009)
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Catecholaminergic Neurotransmission
Serotonin (5-HT)
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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
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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
Chambers, et al. 2003
Chambers, et al. 2003
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)
Schepis et al. 2008
Psychology of Resilience
• A relative resistance to environmental risk experiences or
the overcoming of stress and adversity.
• The basis of this resistance is both constitutional and
environmental. It may be influenced by genetic effects on
both susceptibility and response to environmental risks
• Resistance is not Invulnerability it is a”‘relative” concept
that varies over time and according to circumstances
• The shift from risk/protective concepts to resilience
requires an exploration of underlying mechanisms.
• Behavioral-cognitive techniques may promote resilience
Stein DJ CNS Spectrum 14:2 (Suppl 3; 2009)
Reclaiming Our Children:
Empower Parents & Teachers
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)
Parental Role II
• Parenting moderates a genetic vulnerability factor
that increases in youths’ substance use. Genetic
association was reduced in youths receiving high
levels of supporting parenting. Brodey GH. et al. (2009)
• Long-term effects of the strong African American
families program for prevention of drinking is also
effective in preventing the development of
conduct problems. Brodey GH. et al. (2008)
Parental Monitoring (PM) Matters
• Meta-analytic review based on associations of adolescents’
perceptions of parental monitoring of marijuana use
• (17 studies; N>35,000).
• A common theme in theories is that parents serve as
socialization agents by instilling values and world views.
• PM is a product of positive parent-child relations
positively associated with family: involvement, cohesion,
communication and warmth.
• PM measurement has been inconsistent and is composed of
critical practices: attention, structuring, and tracking.
• PM is commonly viewed as a factor that attenuates social
behaviors such as: substance use, problematic gambling ,
and sexual activity.
Lac & Crano (2009)
Monitoring constructs & Moderators
• PM is a construct measuring parental knowledge (PK) of
the child’s activities, whereabouts, and relationships. PK is
the critical factor responsible for the association of PM and
positive child behavior. Statin & Kerr (2000) Confirmed
• Females are monitored more closely than males.
• Gender was a statistically significant moderator of PM and
reduced (negative R value) cannabis use. Large effect sizes
were observed in a female-only samples. Lac & Crano (2009)
• Minority-only status and age did not emerge as statistically
significant moderators of the critical relationship.
• .
Heritability and Family Influence
• The importance of genetic effects on drinking
increases with age
• Genetic influences at age 14 (significant only in
girls); 16; and 18 (for both sexes) account for less
than 1/5; 1/3; and 1/2 of the variation respectively.
• Conversely, the importance of environmental
effects decrease with age accounting for >70% of
the variance at age 14 but only ~15% by age 18.
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.
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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)
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)
Media and Youth High-Risk
Behaviors
• Violence-contributes about 10% of the variance
• Media has become the leading sex educator.
• Drugs-advertising leads to favorable opinion and use of cigarette and
alcohol.
• Obesity-there is a link , however, the mechanism unclear
• Eating disorders-leads young girls to believe they are “fat” in
comparison to underweight actresses/models.
• Language development-regardless of exposure to “educational” media,
viewing may delay LD.
• TV has potential for pro-social effects that is generally not taken
• Am Acad Pediatrics recommends< 2hrs of viewing daily and non for
infants <2 Y.O.
Strasburger V (2009) Arch Dis Child 94: 655-7
Present Preventive Measures
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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
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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.
Select References
• Meyers J. Dick D, (In Press). Genetic and family risk
factors for adolescentonset SUD. Kaminer Y (Ed.). Child
and Adolescent Psychiatric Clinics of North America.
• Lac A, Crano WD (2009). Monitoring Matters: Metaanalytic review reveals the reliable linkage of parental
monitoring with adolescent marijuana use. Perspectives on
Psychological Science 4(6):578-586.
Contact Information
Yifrah Kaminer MD; MBA,
Professor of Psychiatry & Pediatrics
Alcohol Research Center; University of
Connecticut Health Center,
Farmington, CT 06030-2103
Kaminer@psychiatry.uchc.edu.