Why Do They Do That? Brain Development During Adolescence Daniel Krowchuk, M.D. Departments of Pediatrics and Dermatology Wake Forest University School of Medicine

Objectives Describe changes in brain structure and function that occur during adolescence Discuss the implications of these changes with respect to adolescent behavior and health promotion strategies

The leading cause of death for teenagers in the U. S. is A. AIDS B The leading cause of death for teenagers in the U.S. is A. AIDS B. cancer C. homicide D. suicide E. unintentional injury

Deaths, Percent of Total Mortality, and Death Rates by Cause, 15-19 year olds, U.S., 2004 Number Percent Rate/100,000 All Causes 13,706 100.0 66.1 Unintentional injury 6,825 49.8 32.9 Homicide 1.932 14.1 9.3 Suicide 1,700 12.4 8.2 Malignancy 731 5.3 3.5 -Data reviewed 4/10/09 – this table is most recent analysis that contains 15-19 yo data (more recent reports have data for 15-24 yo) Among those 15-24 years of age, of accidents 76% were due to MVA -Homicide is the leading cause of death for AA males (63.2/ 100,000) -US has the highest youth homicide and suicide rates among the 36 wealthiest nations in the world Heron M. National Vital Statistics Reports 2007;56(5)

What percent of high school seniors report having been drunk. A. 25% B What percent of high school seniors report having been drunk? A. 25% B. 40% C. 55% D. 70% E. 85%

Lifetime Prevalence of Use (%) of Various Substances by High School Seniors 1980 1985 1990 1995 2000 2003 2006 2007 2008 Any illicit drug 65.4 60.6 47.9 48.4 54.0 51.1 48.2 46.8 47.4 Marijuana 60.3 54.2 40.7 41.7 48.8 46.1 42.3 41.8 42.6 LSD 9.3 7.5 8.7 11.7 11.1 5.9 3.3 3.4 4.0 Ecstasy - 11.0 8.3 6.5 6.2 Cocaine 15.7 17.3 9.4 6.0 8.6 7.7 8.5 7.8 7.2 Been drunk 63.2 62.3 58.1 56.4 55.1 54.7 Cigarettes 71.0 68.8 64.4 64.2 62.5 53.7 47.1 44.7 Study begun with class of 1975 Low for marijuana (32.6) and any illicit drug (40.7) in 1992 Ecstasy: first asked in 1996 (6.1) Been drunk: first asked in 1991 (65.4) http://monitoringthefuture.org/ (1/09)

Adolescence Physical Development (Puberty) Early Adolescence Middle Late Adolescence Social and Emotional Maturation Adolescents aged 11-21 years represent >40 million persons or 14% of the US population Physical development: gain 20% of adult height and 50% of adult weight; physical changes occur transforming the individual from a child to an adult 10 – 13 years 14 – 16 years 17 – 21 years Cognitive Development

Social and Emotional Maturation Emotional separation from parents Develop a sense of personal identity and self-image Identify with a peer group Explore romantic relationships With respect to developing a positive self-image, parents should notice an adolescent’s positive qualities and offer praise for these Physical illness can have a significant impact on self-esteem – can make adolescent feel flawed or different from peers. May also interfere with ability to separate from parents. Hazen E, et al. Pediatr Rev 2008;29:161-168

Cognitive Development Increased ability to think abstractly Greater impulse control Improved ability to assess risk vs. reward Improved use of working memory (the information in memory available for working on a problem) Young drivers seem more likely than older ones to underestimate the probability of the specific risks of certain traffic situations and to overestimate their own ability to manage such risks. Thus, adolescents engage in risky behaviors because of problems in judging risk appropriately and in accurately perceiving their own vulnerability. Working memory: functioning in the world requires one to consider antecedents and consequences and place the steps of a plan in the proper order Cognitive alterations are associated with changes in brain structure and function Hazen E, et al. Pediatr Rev 2008;29:161-168 Casey BJ. Ann NY Acad Sci 2008;1124:111-126

Neuroanatomy Review Gray matter (cerebral cortex): White matter: Contains nerve cell bodies Processes and routes information Increases in pre-adolescence then decreases White matter: Composed of nerve cell extensions (axons) that convey information (e.g., from gray matter) Color results from myelin coating of axons (acts as insulation that allows nerve impulses to travel more rapidly and efficiently)

Changes in Brain Anatomy Each new experience results in new connections between neurons By the end of adolescence, the brain contains 10 - 100 billion neurons Forming 100 trillion connections with one other 100 billion – 1 trillion support cells Increased intelligence, reasoning, problem-solving New experiences like new vocabulary word, dance step, etc. The more one is involved in an activity, the more dendrites grow and the more synaptic connections develop Weinberger DR, et al. The Adolescent Brain: A Work in Progress. National Campaign to Prevent Teen Pregnancy; 2005.

Changes in Brain Anatomy Pruning Information that is regularly used is retained – that which is unimportant or used infrequently is lost as the result of pruning (a loss of cells or connections) Adolescents may lose 15% of synaptic connections/year (compared with 1-2% for adults) Results in greater efficiency Myelination Fatty covering of axons that acts as insulation Permits more rapid (100-fold) and efficient communication Increases into the third decade Brain operates on a “use it or lose it” philosophy Pruning: eg, important dates of battles in the Civil War may be lost but cause of Civil War and important ramifications are retained Myelination increases speed at which signals can travel up to 100-fold compared with unmyelinated axons Weinberger DR, et al. The Adolescent Brain: A Work in Progress. National Campaign to Prevent Teen Pregnancy; 2005.

Brain Development and Risk Taking Lateral prefrontal cortex (Cognitive control) Impulse control Setting priorities Formulating plans Decision-making Envisioning consequences of actions Risk taking is the product of an interaction between two brain networks the socioemotional network (located in the limbic and prelimbic areas [amygdala, ventral striatum, orbitofrontal cortex, medial prefrontal cortex, and superior temporal gyrus]) and the cognitive-control network (lateral prefrontal and parietal cortices). The former becomes more assertive during puberty and the latter gains strength over time. Limbic system develops before the prefrontal cortex is mature (ie, accelerator but no brakes) – also, myelination is not complete until the 30s so the speed and efficiency of communication with the prefrontal cortex is not optimal Limbic system (Socioemotional) -Impulsiveness -Sensation-seeking

Risky Business – The Role of Peers Among adolescents, many high risk behaviors take place in groups Substance use Reckless driving Crimes Are adolescents more susceptible to the influences of risk-prone peers? When compared with adults, adolescents who commit crimes ranging from vandalism to rape or homicide tend to do so in the company of one or more indviduals

Risky Business – The Role of Peers Risky decision-making asessed in: 106 adolescents (13-16 yrs) 105 youths (18-22 yrs) 95 adults (>24 yrs) Decision-making assessed using video game Alone In group with 2 other subjects who could offer advice Watch car move across screen until yellow traffic light appears Stop car before red light and wall appear More points the further the car moved without crashing into wall Gardner M, Steinberg L. Dev Psychol 2005;41:625-635

Risk Preference Scale 5 hypothetical scenarios Having sex without a condom Riding in a car driven by someone who has been drinking Trying a new drug one knows nothing about Breaking into store to steal something one wants Driving over 90 mph on highway at night Ranked 1 (risks are much greater than benefits) to 4 (benefits are much greater than risks) Gardner M, Steinberg L. Dev Psychol 2005;41:625-635

Risky Business – The Role of Peers Younger individuals: Allowed car to move further after yellow light Chose riskier course of action on questionnaire Were more likely to be affected by peer influences Gardner M, Steinberg L. Dev Psychol 2005;41:625-635

Risk-Reward and Brain Activity Nucleus accumbens Component of the limbic system Involved in processing rewards Cortex receives stimulus indicating reward Nucleus accumbens and other areas are activated leading to repetition of the gratifying behavior Develops earlier than the prefrontal cortex When the cortex has received and processed a sensory stimulus indicating a reward, it sends a signal announcing this reward to a particular part of the midbrain–the ventral tegmental area (VTA)–whose activity then increases. The VTA then releases dopamine not only into the nucleus accumbens, but also into the septum, the amygdala, and the prefrontal cortex. The nucleus accumbens then activates the individual’s motor functions, while the prefrontal cortex focuses his or her attention. These regions are connected by what is called the pleasure or reward bundle. In neuroanatomical terms, this bundle is part of the medial forebrain bundle (MFB), whose activation leads to the repetition of the gratifying action to strengthen the associated pathways in the brain. Galvan A, et al. J Neurosci 2006;26:6885-6892

Risk-Reward and Brain Activity Functional MRI performed during tasks weighing risk and reward Adolescents activate the nucleus accumbens more than adults Nucleus accumbens activity correlates with anticipation of a positive consequence of a risky behavior (which, in turn, correlates with the likelihood of engaging in risky behaviors) – more pronounced in adolescents Ad Individuals who expect a negative consequence of a behavior show less accumbens activity and are less likely to participate in the behavior Individual variations in neurobiology influence risky behavior – for some individuals, the perceived immediate benefits (of sex, substance use) may outweigh negative long-term consequences. Increased accumbens activity likely related to impulsivity. Galvan A, et al. J Neurosci 2006;26:6885-6892 Galvan A, et al. Dev Sci 2007;10:F8-F14

Substance Use and the Brain Limbic system - prefrontal cortex connections grow into early adulthood. Certain of these neurons use dopamine to relay messages These neurons increase capacity for more mature thought (choices based on memory not impulse) Cocaine and amphetamines target these dopaminergic neurons. Connections are necessary for communication between the 2 areas and to facilitate (ultimately) the delay of gratification necessary to achieve desired outcomes (ie, override inappropriate choices in favor of goal-related ones). Myelination also continues into the 30s. Important if one is to follow an idea in pursuit of a goal (rather than acting on instinct). Alcohol affects structures that use GABA as a neurotransmitter (cortex, cerebellum, hippocampus, amygdala, nucleus accumbens) – alcohol inhibits normal neurogenesis, the process by which new neurons are created (higher levels of intake have greater effects) Weinberger DR, et al. The Adolescent Brain: A Work in Progress. National Campaign to Prevent Teen Pregnancy; 2005.

“Hot” and “Cold” Cognition “Hot” cognition Decision made in an emotionally-charged situation Adolescent surrounded by peers in a stimulating environment may make an emotionally-based decision “Cold” cognition Decision made in a calmer, quieter environment Adolescent may make a more intellectual, consequence-based decision Social skills training (i.e., role-playing) may be beneficial in moderating “hot” cognitions.

Recognizing Emotions Adolescents often misinterpret body language and words that are spoken A parent stares at their adolescent waiting for a response to a question – the adolescent interprets the stare as the parent being angry. An adolescent looks across the lunchroom at an acquaintance; the acquaintance happens to turn her head in the other direction – the adolescent may interpret that she has been shunned. Adapted from Feinstein S. Secrets of the Teenage Brain. Thousand Oaks, Ca: Corwin Press; 2004

Recognizing Emotions Complex network of brain regions involved in recognizing Basic emotions (fear) Social emotions (guilt, embarrassment, shame) Network includes: Amygdala Medial prefrontal cortex Anterior insula Superior temporal sulcus The network above all are components of the limbic/prelimbic system discussed earlier The mPFC is different than the lateral PFC (involved in more restraint, executive functions) Blakemore S-J. Nat Rev Neurosci 2008;9:267-276

Do Adolescent and Adults Differ? Adults and adolescents presented with the photograph of a woman with an expression of fear on her face All adults correctly interpreted the emotion as fear Half of adolescents thought that the woman expressed shock or surprise Blakemore S-J. Nat Rev Neurosci 2008;9:267-276

Processing Emotions 19 adolescents (10 - 18 years) and 10 adults (22 – 32 years) underwent functional MRI scanning1 while thinking about scenarios involving: Basic emotions (e.g., disgust, fear) Social emotions (e.g., embarrassment, guilt, shame) Requires awareness on your part of others’ opinions of your action Study performed to examine neural processing of social emotions in adolescents and adults Embarrassment scenarios: “Your father dances in the supermarket” or “Your were picking your nose and someone saw you” or “You were eating with a friend and dropped food on your shirt” Burnett S, et al. J Cogn Neurosci 2009;21:1736-1750 Burnett S, Blakemore S-J. Ann NY Acad Sci 2008;1167:51-56

Processing Emotions Adolescents activate more of the medial prefrontal cortex Experiencing social emotions is different in adolescents Perhaps adolescents are still “working out” social situations Less efficient and automatic Adults activate more of the anterior temporal horn than adolescents Still working out social situations based on accumulating experience or developing social skills With age, processing may become less effortful, more automatic, and more reliant on stored social knowledge Inefficient thinking is characteristic of adolescents. As a result they may not be able to shut out extraneous input and may be more distractable (for young drivers, a reason to limit the number of passengers in the car, avoid the radio and cell phones) Burnett S, et al. J Cogn Neurosci 2009;21:1736-1750 Burnett S, Blakemore S-J. Ann NY Acad Sci 2008;1167:51-56

How Not to Embarrass a Teen1 Don’t correct or reprimand her in front of others. Don’t fix his clothes, straighten his tie, or tuck in his shirt in public. Don’t call her by a pet nickname in front of her friends. Don’t kiss, hug, or show affection on school grounds. Don’t run into the middle of class to bring something he’s forgotten. In early to mid adolescence, teenagers become aware of and concerned about other’s opinions of them; they also believe that others spend time observing them 1Elias Z, Goldman T. How Not to Embarrass Your Kids: 250 Don’ts for Parents of Teens. New York, NY: Warner Books; 2009

Conclusions Adolescents see and react to the world differently than children or adults Late maturation of areas of the brain responsible for complex thought processes helps explain Delayed psychosocial maturation Adolescent behavior (including involvement in risky endeavors) Adolescents need supportive parents, adults, and institutions that provide guidance and help them learn appropriate skills and adult behaviors One study found that young drivers seem more likely than older ones to overestimate the probability of specific risks of certain traffic situations and to overestimate their own ability to manage such risks. Involvement in risky behaviors (experimentation with alcohol, involvement in sexual activity) occurs because teens have difficulties judging risk appropriately and in accurately perceiving their own vulnerability.

Implications Health promotion Public policy

Tobacco Use 9.4% of high school students use cigarettes frequently (>20 of 30 days/month)1 Half of the 3000 adolescents who begin smoking each day will become daily smokers2 90% of adult smokers began smoking as adolescents2 1Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance. http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf 2Ziedonis D, et al. Adolesc Med Clin 2006;17:381-410

Preventing Tobacco Use Standard approach: Advise adolescent of adverse effects of tobacco use Developmentally appropriate approach: Parental supervision Policy making: Prohibiting sale of tobacco to minors Prohibit tobacco advertising Prohibit tobacco use on school grounds (students, staff, parents)

Preventing Tobacco Use 3834 youths 12-17 years interviewed 3 times over a 4-year period Odds of progressing from experimentation to established smoking reduced by 40% in towns with strong restaurant smoking regulations 9.6% risk in towns with weak regulations vs. 7.9% for towns with strong regulations Rationale: Reduce youths’ exposure to tobacco in public places (lowers perception of smoking prevalence) Change perceived social acceptability of smoking Smoking can be influence by community-level factors not just personal-level ones 3834 in baseline sample (interviewed 1/2/01-6/18/02); 2791 (72.8%) of these reinterviewed 1/30/03-7/31/04; 2045/2791 reinterviewed 2/16/05-3/26/06. Weak regulations: smoking not restricted or nonsmoking section; medium: enclosed separately ventilated space; strong: no smoking Other variables assoc with progression to established smoking: older age group (18-21) at baseline (OR 2.02), previous experimentation with cigarettes, adult smoker in house (OR 1.54), presence of a close friend who smokes (OR 1.91) Both of the rationale statements would influence transition from experimentation to regular use. Parental smoking and education level are significant predictors of smoking experimentation (but not transition to regular smoking). Siegal M, et al. Arch Pediatr Adolesc Med 2008;162:477-483

Brain Development and Policy Roper v. Simmons (2005, US Supreme Court) 17-year-old convicted of murder and sentenced to death American Psychological Association (APA) and AMA filed briefs arguing that adolescents’ still developing brains made them different than adults. Death penalty was outlawed if offender <18 years of age when crime committed. Hodgson v. Minnesota (1990, US Supreme Court) Case challenged Minnesota law requiring parental consent for abortion. The APA argued that by age 14 or 15 years, adolescent decision making was essentially equivalent to that of an adult. Decision in Roper v. Simmons hinged on culpability which involves the offender’s state of mind at the time of the offense, including factors that would mitigate, or lessen, the degree of responsibility. The apparent inconsistency of these 2 decisions could be argued from the standpoint of hot and cold cognitions (ie, cold cognition in the context of an abortion related decision (employs more mature judgment) as opposed to the hot cognition context of a murder. The year after Roper v. Simmons, Kansas used neuroscience research to expand the state’s child abuse statute to include any consensual touching between minors under the age of 16. Johnson SB, et al. J Adolesc Health 2009;45:216-221