2016 shakopee gal training
TRANSCRIPT
9/1/2016
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HOW ALCOHOL AND OTHER
DRUGS AFFECT ADOLESCENT
DEVELOPMENT, INCLUDING THE
DEVELOPING BRAIN
Michael Brunner, Ph.D., LP, ABPP
Fountain Centers Clinical Director
Training Objectives
1. Identify drugs that adolescents most commonly use and others
to which they have access.
2. Describe the most common factors associated with adolescent
drug use and risks for the development of substance use
problems.
3. Understand how problem substance use affects the developing
brain.
4. Establish a connection between early-life and chronic exposure
to alcohol and other drugs and adult symptoms and behaviors.
5. List several strategies for intervening with substance using teens
which promote engagement and enhance collaboration.
DRUGS USED BY ADOLESCENTS
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Drug Use in Adolescence
30-Day
Prevalence
Lifetime
Prevalence
Alcohol 21.8 45.2
Marijuana 14.0 30.0
Cigarettes 7.0 21.1
All Other
Illicit Drugs 5.1 16.1
Monitoring the Future (2015)
Percent 8th, 10th and 12th Grades Combined
Rates steady over the last decade +.
Not much in the way of racial
differences.
Increasing use with age.
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Rates steady for whites over the last decade +,
increasing for blacks and Hispanics.
Not much in the way of racial differences.
Increasing use with age.
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Rates mostly declining over the last decade +, although steady
(perhaps increasing) for black teens.
Black teens least likely to use drugs other than marijuana.
Increasing use with age.
Rates declining over the last decade +.
Black teens are least likely to use alcohol.
Increasing use with age.
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Rates dramatically declining over the last decade +.
White teens most likely to smoke cigarettes.
Slight increase in use with age.
The use of e-cigarettes in 2015 had higher use among
teens (16.2% for 12th graders) than traditional
tobacco cigarettes (11.4%) or any other tobacco
product.
Annual Prevalence of Various Drugs Grades 8, 10, and 12 Combined
Drug Percent 5-Year Trend Marijuana 23.7 NC
Synthetic Marijuana (e.g., Spice) 4.2 ↓
Inhalants 3.2 ↓
Hallucinogens 2.8 ↓
Cocaine 1.7 ↓
Heroin (Opioid) 0.4 ↓
Vicodin (Prescription Opioid) 2.5 ↓
Amphetamines 6.2 NC
Adderall 4.5 NC
Methamphetamine 0.6 ↓
Bath Salts/Plant Food 0.7 ↓
Tranquilizers (e.g., Benzodiazepines) 3.4 ↓
Cough Medicine (DXM, Triple C) 3.1 ↓
Alcohol 39.8 ↓
Monitoring the Future (2015)
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THC (tetrahydrocannibinol)
Concentrate – Butane Hash Oil High potency THC oil extracted from the
marijuana plant, using a solvent such as butane.
The result is a sticky oil that has a THC potency of between 40 to 80% compared to 7 to 15% potency of marijuana.
The THC concentrate (dab) is inhaled from a pipe (rig) after vaporizing the drug on a heated metal element (nail). Sometimes smoked in e-cigarettes (6-7% in the MTF study).
The higher potency causes increased euphoria and more adverse effects, such as psychosis.
Slang terms include dabs, glass, shatter, wax, ear wax, honey, BHO, butter. . .
Drug Use in Adolescence
Main Finding From 2015 Monitoring the
Future Study:
• The use of alcohol and cigarettes reached their
lowest levels since the study began in 1975.
• The use of several other illicit drugs including
MDMA (ecstasy), heroin, amphetamines, and
synthetic marijuana also declined in 2015.
• Marijuana use remained comparable to 2014. Use
has remained steady over the last 20 years.
Cigarette Use and Attitudes
Use declines . . . as perceived risk and
disapproval increase. Monitoring the Future (2015)
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Marijuana Use and Attitudes
Use has remained
steady. . .
even as perceived risk and
disapproval have declined.
Monitoring the Future (2015)
Marijuana Use and Attitudes
Use has remained
steady. . .
even as perceived risk and
disapproval have declined.
Monitoring the Future (2015)
Marijuana Use and Attitudes
Use has remained
steady. . .
even as perceived risk and
disapproval have declined.
Monitoring the Future (2015)
HOWEVER, recent research looking at over 200K
people ages 12 and older found that there is a strong
relationship (-.72 correlation) between perceived risk
and marijuana use.* * http://www.samhsa.gov/data/sites/default/files/report_2404/ShortReport-2404.html
This means:
• Regions in the U.S. with high use are associated with
lower perceived risk of harm, and
•Regions in the U.S. with low use are associated with
higher perceived risk of harm.
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HOW TO THINK ABOUT SUBSTANCE USE PROBLEMS
Substance Use Problems –
A Continuum
• Not all drug use represents a “substance use disorder” –
a diagnosable condition that may need treatment.
• However, all AOD use has the potential to cause
problems, even life endangering problems. So, the case
can be made that any substance use by adolescents is in
need of attention.
When thinking about drug use, consider a continuum.
Use Problem
Use
Substance Use
Disorder Addiction
Signs of Problem Use
Changes in behavior
◦ Not abiding by caregivers’ rules
◦ Emotional and reactive, especially when expectations are
set
◦ Appearing intoxicated
◦ Unwilling to provide specifics of whereabouts
◦ Declining grades
New social group
Increased alienation from caregiver(s)
Secretive
In possession of drugs or drug paraphernalia
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Moving Towards a Disorder
Unwilling or unable to stop
Placing self in dangerous situations due to use
Repeated problems or consequences due to use
Use of drugs such as pills (e.g., opioids,
benzodiazepines, cold medicines),
methamphetamine, heroin, cocaine, “designer
drugs” (e.g., synthetic marijuana, “plant food”/
“bath salts”), high potency marijuana (e.g.,
“dabs”)
Diagnostic and Statistical Manual of Mental
Disorders – 5th Edition (DSM-5)
• The DSM-5 is used by behavioral health professionals to
classify and diagnose mental health and substance use
disorders.
• The DSM-5 reclassified substance use disorders based on
severity level – mild, moderate, and severe.
Use Problem
Use
Substance Use
Disorder Addiction
Mild Moderate Severe
DSM-5 Categories
DSM-5 Symptoms
1. Taken in a larger amount or longer than intended
2. Persistent desire or unsuccessful in efforts to cut down or control
use
3. A great deal of time is spent obtaining, using, or recovering from use
4. Craving
5. Failing to fulfill major life obligations due to use
6. Continued use in spite of consequences
7. Important activities are given up or reduced due to use
8. Recurrent use in situations that are physically hazardous
9. Use in spite of persistent physical or psychological problems caused
or exacerbated by the drug
10. Tolerance
11. Withdrawal
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FACTORS ASSOCIATED WITH
SUBSTANCE USE & RISKS FOR
DEVELOPING A SUBSTANCE
USE PROBLEM
Why Teens Use AOD - Normative
Reasons
• Normative adolescent exploration
and risk taking
• Peer-influenced substance use –
acceptance
• Modeling adult or peer behavior or
what is portrayed as acceptable in the
popular media
• Age-typical rebellion and separation
from family of origin
Why Teens use AODs –
Unhealthy Reasons
• To manage stress and decrease
distress
• Alienation from others – parents
and peers
• Ignored or unattended by parents
• Given too much
freedom/responsibility
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Risk Factors for Addiction
Born with a “challenging” temperament, especially impulse control and behavior problems.
AOD use during adolescence, especially before the age of 15.
Having mental health problems in addition to AOD use problems.
Experiencing abuse, neglect, parental absence or disruptions (like divorce or death), parental mental illness or substance use problems, poverty.
Progressive use of drugs - - increase in frequency and consequences and use of several different drugs.
In drug-supporting environment(s) – family, peers.
Alienation from parents/caregivers and most supportive adults.
Socially rejected, bullied, isolated.
Creating an Addiction Frankenstein
Risk Factors for Addiction
Born with a “challenging” temperament, especially impulse control and behavior problems.
AOD use during adolescence, especially before the age of 15.
Having mental health problems in addition to AOD use problems.
Experiencing abuse, neglect, parental absence or disruptions (like divorce or death), parental mental illness or substance use problems, poverty.
Progressive use of drugs - - increase in frequency and consequences, and use of several different drugs.
In drug-supporting environment(s) – family, peers.
Alienation from parents/caregivers and most supportive adults.
Socially rejected, bullied, isolated. An Addiction “Frankenstein”
ADOLESCENCE: THE DEVELOPING BRAIN
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Parents will say about teens: This is
not the child I raised.
Image from: National Institute of Health
Brain Maturation Ages 5 to 20. Red indicates more gray matter, blue less gray matter.
Gray matter wanes in a back to front wave as the brain matures and neural
connections are pruned. Areas performing more basic functions mature earlier; areas
for higher-order functions (emotion, self-control) mature later. The pre-frontal cortex,
which handles reasoning and other "executive" functions, emerged late in evolution,
and is among the last to mature.
Gogtay et al.(2004)
Neural Development in Adolescence
Brain Maturation Ages 5 to 20. Red indicates more gray matter, blue less gray matter.
Gray matter wanes in a back to front wave as the brain matures and neural
connections are pruned. Areas performing more basic functions mature earlier; areas
for higher-order functions (emotion, self-control) mature later. The pre-frontal cortex,
which handles reasoning and other "executive" functions, emerged late in evolution,
and is among the last to mature.
Gogtay et al.(2004)
Gray matter declines during
adolescence. This is referred to as
“pruning.”
White matter increases during
adolescence. White matter consists
of nerves wrapped in a sheath of
myelin.
Myelination promotes efficient
neuronal communication.
Synaptic pruning – elimination – of
inefficient neuronal connections
takes place.
Neural Development in Adolescence
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The Brain Changes Dramatically During
Adolescence Time Lapse 4-21 Years of Age
Movie from: http://www.youtube.com/watch?v=LT7elnCz6SM
Age in
Years
Age in
Years 4 8 12 16 21
1 Giedd et al (2006)
Losing Brain Cells – Gaining Connections
Lebel & Beaulieu (2011)
Reward Sensitivity and Executive Control
Children Adolescents
Adults
Develo
pm
en
t
Age
Striatum
Prefrontal Cortex
Striatum
Striatum
Striatum
PFC PFC
PFC
Reward sensitivity: Emerges in
childhood, strengthens during
adolescence, and then diminishes in
adulthood.
Decision-making and impulse control are
weaker during the early years and increase
in strength in adulthood.
Casey & Jones (2010)
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The Critical Balance – Executive Control and
Reward Sensitivity
Teens at greatest risk
for progressive drug
use were those who
had weakened
2 Khurana et al (2014)
PFC
Striatum
executive control (PFC) and high
reward sensitivity (striatum).
Maturation of the Reward Circuit
Adolescents are more motivated to
engage in high-reward behavior because
their reward circuit is overly sensitive.
Adolescents respond to “reward” 30-
45% more than adults.
Males respond to reward 4.6 times
more than females.
Sensitivity to reward declines
significantly by adulthood.
Galvan (2010)
See also: Jacobus et al (2015)
• Adolescents are more motivated to
engage in high-reward behavior because
their reward circuit is overly sensitive.
Adolescent Development and Emotions
The part of the brain that reacts to
emotions is more active in adolescents vs.
adults when confronted with negative
emotions.1
Compared to adults, adolescents have an
exaggerated emotional response, and
negative emotions are more disruptive to
them.2
With brain maturation there is improved
processing of negative emotions.1, 2, 3
Improved control over negative emotions is
related to maturation of the PFC.1, 2, 3
3 Yurgelun-Todd & Kilgore (2006)
1 Casey, Jones, & Hare (2008)
2 Hare et al (2008)
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Adolescent Brain Development Summary
The brain changes dramatically during
adolescence.
The brain loses cells that aren’t used, and
connections are strengthened between
those regions that are communicating.
Reward and risk-taking are strong
motivations during adolescence.
Emotional control is compromised during
adolescence.
As the frontal regions develop, greater
control over impulses and emotions emerge.
CONSEQUENCES OF EARLY AND CHRONIC SUBSTANCE USE ON ADULTS
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Initiating Substance Use in Adolescence:
Setting the Stage for Adult Drug Use Problems
Ninety percent of all Americans with a substance use disorder began using alcohol, tobacco, or other illicit substances before age 18.
The National Center on Addiction and Substance Abuse at Columbia University
(June 2011)
After age 21
Prior to age 18
A person’s risk of a
substance use
disorder is 6 times
lower if they start
using after age 21
versus before age 18.
Only one in 25 who start
using after the age of 21
will go on to have a
substance use disorder.
One in four Americans who
start using any substance of
abuse prior to age 18 will go
on to have a substance use
disorder in adulthood.
Marijuana Effects Impairs decision making, planning, organization,
problem-solving, memory, motor coordination, reaction time, and learning.1
Persistent use (over many years) shows an average decline of 8 IQ points.2
◦ Uncertain recovery after discontinuation.
Marijuana use associated with health impairments years later including injury, illness, or emotional problems, psychological distress, and subjective well-being.3
Degree of impairment is related to age of onset4, recency and frequency of use5, amount used6, and duration of use.2
1 Chang et al (2006)
2 Meier et al (2012)
4 Jacobus et al (2015):
Gruber et al (2014)
5 Crane, Schuster, & Gonzalez (2013):
Lisdahl & Price (2012)
6 Silens et al (2014)
3 Arria et al (2016)
2 Meier et al (2012)
Alcohol Effects
Teens with alcohol use disorders found to have
neurocognitive impairments including problems with
memory, visuospatial performance, sustained
attention, retrieval, information processing, language,
and executive functioning.1
Alcohol use disrupts the transition into early
adulthood with those using alcohol having more
negative outcomes such as poorer health, truncated
education, financial problems, and increased
substance use problems.2
The earlier the age at which a youth takes their first
drink of alcohol, the greater the risk of alcohol use
problems.3
1 Jacobus & Tapert (2014)
2 Rose et al (2014)
3 Blomeyer et al (2013)
Image from: http://vedicviews-
worldnews.blogspot.com/2010/06/teen-girls-use-alcohol-drugs-to-cope.html
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Strong Connections = Strong Brain
Healthy Development = Strong white matter connections
Drug use = “Frayed” white matter connections
Jacobus & Tapert (2013, 2015); Squeglia et al (2015)
Strong Connections = Strong Brain
Healthy Development = Strong white matter connections
Drug use = “Frayed” white matter connections
Weakening of the Executive
• AOD have a profound effect on the
prefrontal cortex (PFC), the part of
the brain responsible for impulse
control, decision making, judgement,
planning, emotion regulation, and
many other “executive” processes.
• The PFC appears to be less effective
after repeated exposure to AOD.
• Studies have found that use of AOD
decreases activity in the PFC1 and is
associated with loss of gray matter
in this and other areas of the brain2.
1 Volkow & Goldstein (2002); Goldstein & Volkow (2011)
2 Connolly, Bell, Foxe, & Garavan (2012)
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ADULT PROBLEMS –
REFLECTING AND
BROADENING OF
CHILDHOOD AND
ADOLESCENT PROBLEMS
Early Onset – Substance Use Disorders
SU problems begin very early in life.
1/2 By the age of 21
3/4 By the age of 27
Kessler et al (2006)
Lifetime Risk 14.6%
Adolescence to Adulthood:
Normative Substance Use Trajectory
Adolescence
◦ Occasional Use
◦ Narrow range of
drugs
◦ Smaller quantities
Adulthood
◦ Consistent Use
◦ Broader range of
drugs
◦ Larger quantities
Chassin et al (2000)
Li, Duncan, & Hops (2001)
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Early Onset – ANY MH or SUD
MH and SU problems begin very
early in life.
1/2 Before the age of 14
3/4 Before the age of 24
http://www.nimh.nih.gov/news/science-news/2005/mental-illness-exacts-heavy-toll-beginning-in-youth.shtml
Kessler et al (2006)
Lifetime Risk 46.4%
Most Common MH Problems
Amongst Adolescents with SUDs
Co-Morbid Disorder SUD Present % SUD Absent %
Disruptive Behavior Disorder 68.0 10.1
Mood Disorder 32.0 11.2
Anxiety Disorder 20.0 15.7
Kandel et al (1999)
Disruptive Behavior Disorder = attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder
Mood Disorder = dysthymia, hypomania, major depression, mania
Anxiety Disorder = agoraphobia, avoidant, generalized anxiety, obsessive-compulsive, overanxious, panic, simple phobia, social
phobia
Compared to adolescents, what do
MH and SUDs look like in adults?
Typical Trajectory
More deeply entrenched Habit-driven
More intense distress
More cognitive impairment (less control)
Adults
Adolescents
Low High
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AMY
NA
PFC
DS
NA – Reward +
Motivation
DS - Habit
PFC – Planning
Primary Regions/Structures Associated with
each of the Regions are in
AMY – Stress
A Brain Unaffected by AOD
Brain Structures and Function Affected
By Chronic Use of AOD
Reward
Stress
Habit
Decision Making
Problem
Use Disease
Problem Use
Onset
Adaptive
Zone
Over
Activation
Under
Activation
Disorder Use
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Addiction and Functional Control
Frontal to Striatal
Ventral to Dorsal
Reward + Motivation to
Habit
Deliberative to Automatic
processing
INTERVENTION STRATEGIES
FOR PROMOTING
ENGAGEMENT AND
ENHANCING COLLABORATION
The Critical Factors
1. The Relationship
2. Deactivating the stress center
3. Activating the PFC
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Relationship-Building Strategies
Use “collaboration” language
Join with them around resolving the problem
Reserve the right to be flexible
Provide abundant positive reinforcement
Minimize punishment
Support autonomy
Be consistent
Remain calm Model calm
Avoid judgment – have teen evaluate their actions
Set and hold to limits
Establish clear expectations
Provide guidance Teach teen how to manage emotions
Deactivating the Stress Center: Interventions that Calm
PFC-Activating Strategies
Ask open-ended questions about desired behaviors.
Reinforce “change” statements.
Have teen verbalize problem-solving strategies.
Serve as the teen’s frontal lobe.
Help teen think through problems and possible outcomes of decisions.
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