Presentation on theme: "The Developing Brain & Youth High Risk Behaviors: Updates, Barriers & Opportunities for Interventions Yifrah Kaminer MD, MBA Alcohol Research Center UConn."— Presentation transcript:
1The Developing Brain & Youth High Risk Behaviors: Updates, Barriers & Opportunities for InterventionsYifrah Kaminer MD, MBAAlcohol Research CenterUConn Health Center, Farmington, CTLatest December 17, 2008
2The 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)?
3ObjectivesAccept that youths are not mini adults. they are evolving and are more vulnerable than they believe & knowClarify adolescent elevated risk for high-risk behavior with an emphasis on Driving, substance (ab)use from a scientific developmental perspectivePlace clinicians, parents, educators, public health professionals, policy makers, and youth on the same pageImprove: 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 casualtiesDiscuss implications of findings on future directions in prevention and public health policy
4The High-Risk Maturational Gap: The Take Home Message Youth reach Intellectual maturation around age 16HOWEVERThey reach Emotional maturation ONLY around age 25Post college ageThe age that alcohol risk plateaus
6Anderson CA et al. (2008); Ybarra ML (2008) Linkage Between Internet and Other Media Violence With Serious Violent Behavior by YouthExposures 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)
7Watching 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)
8The 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” effectThe strongest support of MLDA-21 is associated with data that 25,000 have been saved since it was established in Barnett (2008)
9Extended Adolescence in Western Societies Hormonal surges that lead to puberty are beginning earlier than in previous decadesThe maturational gap is wider in Western societies compared to traditional societiesIn 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)
10Adolescent 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 consolidationExposure 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)
11Adolescent High-Risk Behaviors Occur in a Developmental Context Biological-Puberty: hormonal, brain neuro-anatomical and neuro-transmitters interchangesCircadian 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 dysregulationCognitive: information processing, executive functioningBehavioral: novelty seeking, risk taking, impulsivitySocial: increased conflicts with parents/adults, increased peer interactions and influence, and forming intimate relationsBehavioral 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
12Adolescence is a Developmental Phase With Specific Functional Purposes Prepare youth for adult rolesImprove: separation individuation, industrialization, relationship with peers and intimate othersHowever, 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 consequencesOften looks like a caricature. However, it is not funny. Spears as a mother?
13Why Didn’t Life problems Hit Me When I was a Teenager and Knew Everything? (a bumper sticker)
14Childhood Vs. Adolescence Mortality Compared with children , teens show improvements in strength, reaction time, reasoning capabilities, and immune functionOverall morbidity and mortality rates soar X4-5 folds between childhood and adolescence/young adulthoodIn 2003, about 7,000 U.S. children aged 5-14 years died of all causes. Compared to 33,500 youth aged years Dahl, (2008)
15U.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 injuriesHomicides = 5570 between the ages of 10-24Suicide = 4599 between the ages of 10-24-17% of high schoolers seriously considered attempting and 8.4% attempted suicide in 2005)Three main causesAlmost 30 per days-the war within!3 times 9/11 per year!
16High 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 actsSuicidal behavior: Linked to IA commonly an uninhibited impulse to act on self-directed angerSexual behavior: Precocious, coercive/traumatic, unprotected (STDs and pregnancy)Substance use and gamblingGang and illegal activity including school bullyingIndication for Youth VulnerabilitySuicide in youth less associated with depression as is the case ain adults
17Social Forces in (Pre) Adolescence CuriositySocial desirability/acceptance (Cool factor)Social normsSocial pressure?Cannabis use in in California
18Einstein’s: Mass-Energy equivalence E=MC2 Applies to Youth Networking?
19PubertyHormones have been implicated in behavioral changes during adolescencePuberty means Youth “on Steroids”: fold increase in Male Testosterone level fold increase in Female Estradiol levelHormonal changes affect: motivation circuits, response to stress, increased sensitivity to novel sexual, social & aggression stimuli
20Puberty and the Adolescent Brain Adolescence is a period of brain structural and functional changesPruning (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 stressExecutive cognitive functions (ECF) developPlasticity=Adaptation. Any insult including toxic or emotional affects brain developmentHormones increase vulnerability to stressAl in the service of better energy utilization typical in adulthood
22Executive 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)
23Brain 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
25The Importance of the Frontal & Pre-Frontal Brain for Development Thinking skills: Identify, prioritize, problem solving and integrateExecutive Functions (EF): language-processing, emotion regulation, cognitive flexibility, & social skillsYouth dysregulate: affect, cognitive process, impulses, and self perceptionEmotional development (i.e., maturation) “meets” cognitive development only around age 26The pivotal questions is how to proactively address triggers before the emergency sets in?Green & Ablon, (2006)Flexibility and frustration toleranceDefine impulsivityActivation: organizing, prioritizing, and getting to workFocus: Tuning in, sustaining focus, and shifting attention when appropriateEffort: Regulating alertness, sustaining effort, and adjusting processing speedEmotions: Managing frustration and modulating emotionsMemory: Holding on to and working with information, retrieving memoriesAction: Monitoring and regulating one’s actions
26Catecholaminergic Neurotransmission Serotonin (5-HT)DopaminePrefrontal ACTIONMesolimbic: Ventral tegmental (VT) area- Nucleus accumbens (NA)Reward pathwaysPleasureReinforcing behaviorsPrefrontal INHIBITIONMidbrain raphe projections to motivational circuitry including VT, NA, amygdala, hippocampus areasDopamine the ACTION neurotransmitter (gas)Serotonin the inhibitory neurotransmitter (break fluid)During adolescence: the highest ratio of serotonin to dopamine productsAmygdala indicated as a central smoking responsible area.
27Dopamine-Serotonin Ratio Ratio of Dopamine metabolite to 5-HT metabolite suggest a high rate of DA to 5-HT turnoverThese findings indicate that adolescents may be characterized by greater activity in promotivational dopamine systems than in inhibitory serotonin systemsRelatively 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 systemsHomovanilic acid vs. 5-HIAA
28Dopamine Mesocortical Pathway Basal gangliaNucleus accumbensAnother 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.)AttentionArousalConcentrationOther cognitive fxnsVentral tegmental area
31I 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)
32ImpulsivityAn innate trait for rapid response (Consider Latency Period) to internal or external stimuli REGARDLESS of potential negative consequencesSwan (2001)
33Cognitive Aspects of Impulsivity Inability to delay immediate gratificationDistractibility: inability to maintain task oriented attentionDisinhibition: inability to restrain behavior as expected based on social norms and constraints
34Evolutionary 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 termsParticular 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
35Biological Basis of Impulsivity A deficiency of central serotonin the chief inhibitory substrate (5-HT =hydroxytryptamine) is associated with greater impulsivityThis includes outward and self directed violence, suicide, fire setting, pathological gambling, binge eatingFrontal lobe lesions in humans are correlated with impulsive behaviorsConversely, pro-serotonergic agents decrease social aggression and impulsivity
36Neurobehavioral 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 youthTarter et al. (2003/4)
37Youth Substance Use and SUD: Definitions Occasional Use - in social settingRegular Use - on a weekly or more regular basisMisuse - Emergence of pattern of useAbuse - Misuse with impairment in one or more domains within a 12-month periodDependence - Pervasive pattern of use with associated impairment, inability to control use, use despite consequences, tolerance, and physiological symptomsSubstance Use Disorders - Abuse & dependence
38Causality “After this, therefore, because of this = Fallacy of misplaced connectedness”Tarter (2008)
39LiabilityThe 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 SUDThere 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)
40Deficient 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 rewardIncreased sensitivity to reward is associated with use (e.g., getting “high”,) that are salient to developmental increase in thrill-seeking & need for peer approvalDecreased 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)
41Drug 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 relapseNicotine availability=drug reinforcementSocial cues= conditioned reinforcementPairing the two creates even stronger urge to smoke
42Drugs 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 madeMore specifically, the site of control over Motivation, behavior, and Inhibitions of behaviorsThe 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 adulthoodDopamine: Mesolimbic Pathways linking the Ventral Tegmental area to the Nucleus Accumbens or Ventral Striatum underlying pleasure are rewarding and reinforcing addictive behaviorsSerotonin systems have been involved in impulse control. Low levels of %HIAA in CSF found in pathological gambling and AUDs* Metabolites: Homovanillic acid to 5HIAA
43Social 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 subordinateThe 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 BehaviorVolkov N (2006)
46The Utilitarian ViewA 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 onesJeremy Bentham’s ( ) “An introduction to the Principles of Morals and Legislation”Cost-benefit analysis is based on a utilitarian application (David Stewart, 1998)
47Rights and DutiesHow should we balance our duties with our obligations to the communityAre 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?
48Contextual Features that Promote Positive Outcomes for Youth 1. Physical & psychological safety2. Appropriate structure3. Supportive relationships4. Opportunities for belonging5. Positive social norms6. Support for efficacy and mattering7. Opportunities for skill building8. Integration of family, school , and communityEccles & Gootman, (2002)
50Parental 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 developmentConsistent, emphatic, and authoritative parental style generates best outcomes. Clark DB (2005)
51Barriers to Healthy (Pre)Teenhood: The Ubiquitous Perception & Excuses Every one does it: Not trueExamples: 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 OperaExample: youth car crashesCommercial exploitation of youth: Trivializing trauma and harmful/dysfunctional relatioshipsExample: exposure to violence and sex in commercials for TV shows (dead/bloody/traumatized people, bed scenes)
52Present Preventive Measures High taxes on alcohol and tobaccoLegal age of use is 21No car rental until 25 Y.O. ageInsurance rates for youth are elevated (however, parents pay insurance )How about increasing driving age to 18-21?CT toughest Gun Laws
53The 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 culturesNot everybody is in agreement that schools should be providing prevention strategies that engage the entire schoolQuestions central to the identity of school-based programs are :what is at stake, how services are integrated, and who paysSome states have legislatively mandated support to promote social emotional health in schoolsDeveloping community/parents support for these initiatives is essentialBold state action can dismantle incompatible policies and culturesPublic state policies should promote funding for services based on clear expectations for agreed upon operation and outcomesCooper, (2008)
54ConclusionsThink 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 availableDevelop a coalition to optimize dissemination and implementation of new approachesEradicate 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 USFind 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 strategyA review by Woolston JL (2005) Implementing evidence-based Txs in organizations JAACAP 44:1313Iron 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
55Select ReferencesChambers 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 , NYRomer 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.
56Contact InformationYifrah Kaminer MD; MBA,Professor of Psychiatry,Alcohol Research Center; Division of Child & Adolescent Psychiatry,University of Connecticut Health Center,Farmington, CT