1. 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

2. The Developing Brain & Youth High Risk Behaviors Why Don’t They Get it
The Developing Brain & Youth High Risk Behaviors Why Don’t They Get it? Or, Why Don’t We Get It (Right)?

3. 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

4. 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
Post college age
The age that alcohol risk plateaus

6. Anderson CA et al. (2008); Ybarra ML (2008)
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)

7. 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)

8. 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 Barnett (2008)

9. 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 4-year gap between the onset of puberty and the taking on of adult roles. Schlegel & Barry (1999)

10. 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)

11. 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
Behavioral challenges including risk taking are normative rewarding adaptive significance. However, >50% of adolesentsengage in drunk driving, unprotected sex, drug use, fighting and other high risk behaviors

12. 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
Often looks like a caricature. However, it is not funny. Spears as a mother?

13. Why Didn’t Life problems Hit Me When I was a Teenager and Knew Everything? (a bumper sticker)

14. 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 years Dahl, (2008)

15. 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 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)
Three main causes
Almost 30 per days-the war within!
3 times 9/11 per year!

16. 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
Indication for Youth Vulnerability
Suicide in youth less associated with depression as is the case ain adults

17. Social Forces in (Pre) Adolescence
Curiosity
Social desirability/acceptance (Cool factor)
Social norms
Social pressure?
Cannabis use in in California

18. Einstein’s: Mass-Energy equivalence E=MC2 Applies to Youth Networking?

19. Puberty
Hormones have been implicated in behavioral changes during adolescence
Puberty means Youth “on Steroids”: fold increase in Male Testosterone level fold increase in Female Estradiol level
Hormonal changes affect: motivation circuits, response to stress, increased sensitivity to novel sexual, social & aggression stimuli

20. 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
Plasticity=Adaptation. Any insult including toxic or emotional affects brain development
Hormones increase vulnerability to stress
Al in the service of better energy utilization typical in adulthood

22. Executive Cognitive Functions (ECF)
“The individual ability to carry out “higher-order” 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)

23. 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

25. The Importance of the Frontal & Pre-Frontal 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)
Flexibility and frustration tolerance
Define impulsivity
Activation: organizing, prioritizing, and getting to work
Focus: Tuning in, sustaining focus, and shifting attention when appropriate
Effort: Regulating alertness, sustaining effort, and adjusting processing speed
Emotions: Managing frustration and modulating emotions
Memory: Holding on to and working with information, retrieving memories
Action: Monitoring and regulating one’s actions

26. Catecholaminergic Neurotransmission
Serotonin (5-HT)
Dopamine
Prefrontal ACTION
Mesolimbic: Ventral tegmental (VT) area- Nucleus accumbens (NA)
Reward pathways
Pleasure
Reinforcing behaviors
Prefrontal INHIBITION
Midbrain raphe projections to motivational circuitry including VT, NA, amygdala, hippocampus areas
Dopamine the ACTION neurotransmitter (gas)
Serotonin the inhibitory neurotransmitter (break fluid)
During adolescence: the highest ratio of serotonin to dopamine products
Amygdala indicated as a central smoking responsible area .

27. 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
Homovanilic acid vs. 5-HIAA

28. Dopamine Mesocortical Pathway
Basal ganglia
Nucleus accumbens
Another pathway related to the mesolimbic pathway is the mesocortical DA pathway. Its cell bodies arise in the ventral tegmental area and project to areas of the cerebral cortex.
This is an important pathway for mediating attention, arousal, concentration, and other cognitive functions.
Mesocortical DA projections play a role in mediating cognitive functions such as verbal fluency, serial learning, vigilance for executive functioning, sustaining and focusing attention, prioritizing behavior, and modulating behavior based on social cues.
(Unlike the nigrostriatal pathway, and like the mesolimbic pathway, these neurons are lacking in presynaptic DA receptors [inhibitory autoreceptors])
ADHD symptoms could be caused by underactivity in the mesocortical system. Therapeutic doses of stimulant medications are hypothesized to increase postsynaptic DA effects and promote the integration of relevant inputs from other cortical regions, thus enhancing executive functions.
(This pathway is thought to mediate negative and/or cognitive symptoms of schizophrenia through a deficit in DA.)
Attention
Arousal
Concentration
Other cognitive fxns
Ventral tegmental area

30. BOREDOM

31. 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)

32. Impulsivity
An innate trait for rapid response (Consider Latency Period) to internal or external stimuli REGARDLESS of potential negative consequences
Swan (2001)

33. 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

34. 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)
Adolescent impulsivityin monkeys predicts adult dominance attainment

35. 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

36. 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)

37. 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

38. Causality “After this, therefore, because of this =
Fallacy of misplaced connectedness”
Tarter (2008)

39. 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)

40. Deficient Response Modulation (DRM):Youth Response to Drugs
One factor that characterizes youth who experience SU-related 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)

41. 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

42. 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
Dopamine: Mesolimbic Pathways linking the Ventral Tegmental area to the Nucleus Accumbens or Ventral Striatum underlying pleasure are rewarding and reinforcing addictive behaviors
Serotonin systems have been involved in impulse control. Low levels of %HIAA in CSF found in pathological gambling and AUDs
* Metabolites: Homovanillic acid to 5HIAA

43. 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)

44. Reclaiming Our Children: Empower Parents & Teachers

45. Schepis et al. 2008

46. 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 ( ) “An introduction to the Principles of Morals and Legislation”
Cost-benefit analysis is based on a utilitarian application (David Stewart, 1998)

47. 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?

48. Contextual Features that Promote Positive Outcomes for Youth
1. Physical & psychological safety
2. Appropriate structure
3. Supportive relationships
4. Opportunities for belonging
5. Positive social norms
6. Support for efficacy and mattering
7. Opportunities for skill building
8. Integration of family, school , and community
Eccles & Gootman, (2002)

50. 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)

51. 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)

52. 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?
CT toughest Gun Laws

53. 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)

54. 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
A review by Woolston JL (2005) Implementing evidence-based Txs in organizations JAACAP 44:1313
Iron rule of Hierarchy Rosenheck (2001) “the higher in the H the decision-making coalition is, the wider the dissemination will be within the organization, but the more difficulty there will be in achieving consensus and therefore implementation.
Outcome needs to be compared with tx as usual.
Decision –making coalition at the middle level of an organization is crucial to optimize the Iron Law of Hierarchy. “Skunk works” is usually more effective than an individual champion. They are a group of motivated and empowered leaders, innovators and managers who can develop. Adapt, implement , and refine the innovation

55. Select References
Chambers RA et al. (2003). Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability. Am J Psychiatry 160:
Clark DB, Tapert SF (2008). Alcohol and adolescent brain development. Alcoholism: Clin Exper Research (a Special Section) 32:
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.

56. Contact Information
Yifrah Kaminer MD; MBA,
Professor of Psychiatry,
Alcohol Research Center; Division of Child & Adolescent Psychiatry,
University of Connecticut Health Center,
Farmington, CT