1. 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

2. 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 at age 25 The imbalance between the development of the cognitive control and affective systems may be at the core of risk- taking behavior Rutherford, Mayes, Potenza (2010). Neurobiology of Adolescent SUD. In: Kaminer & Bukstein (Eds.). Clinical Manual of Adolescence substance Abuse Treatment. APPI,NY

6. 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 (90 th ) percentile were twice as likely to experience a pregnancy in the subsequent 3 years, compared with those with lower levels of exposure (10 th 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 1984. 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

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

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 15-24 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 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)

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

17. Social Forces in (Pre) Adolescence 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)

18. Einstein’s: Mass-Energy equivalence E=MC 2 Applies to Youth Networking?

19. 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

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

22. 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

23. http://www.brainchannels.com/evolution/evolutionmedia/halfbrain.jpg

24. 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)

25. The Importance of the Frontal & Pre- Frontal 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)

26. 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)

27. “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)

28. Catecholaminergic Neurotransmission Prefrontal INHIBITION Midbrain raphe projections to motivational circuitry including VT, NA, amygdala, hippocampus areas Prefrontal ACTION Mesolimbic: Ventral tegmental (VT) area- Nucleus accumbens (NA) Reward pathways –Pleasure –Reinforcing behaviors Dopamine Serotonin (5-HT).

29. 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

30. Dopamine Mesocortical Pathway Attention Arousal Concentration Other cognitive fxns Ventral tegmental area Nucleus accumbens Basal ganglia Chambers, et al. 2003

32. BOREDOM

33. 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)

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

35. 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

36. 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)

37. 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

38. 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)

39. Schepis et al. 2008

40. 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)

41. Reclaiming Our Children: Empower Parents & Teachers

42. 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)

43. 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)

44. 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)

45. 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..

46. 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.

47. The Utilitarian View A 19 th 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)

48. 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; 1 st amendment vs. Hate Speech) Sense and sensibility: driving at 16, enlisting at 18, and drinking legal age at 21?

49. 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. 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)

51. 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

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?

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)

55. 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

56. 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.

57. 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: Meta- analytic review reveals the reliable linkage of parental monitoring with adolescent marijuana use. Perspectives on Psychological Science 4(6):578-586.

58. 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.