ken winters. this is your brain on adolescence: a developmental view of problem gambling and other...

Dr. Ken Winters This is Your Brain on Adolescence: A Developmental View of Problem Gambling and Other Addictions

This is Your Brain on Adolescence: A Developmental View of Problem Gambling and Other Addictions

Ken Winters, Ph.D.Professor, Department of PsychiatryUniversity of MinnesotaMinneapolis, MN USAwinte001@umn.edu

New Horizons in Responsible Gambling ConferenceVancouver, CAJanuary 29, 2014

www.psychiatry.umn.edu/research/casar/home.html

2. Neuro-development

1. Background

4. Summary

3. Neurodevelopment and gambling

#1 Conclusion

Adolescence is a developmental period often characterized by poor decision making.

#1 Conclusion

Adolescence is a developmental period often characterized by poor decision making.

Brain maturation may be a significant determinant of tendencies for non-thoughtful decision making.

#2 Conclusion

Brain development may also be a contributing factor that places youth at risk for gambling and other addictive disorders.

#3 Conclusion

Most adult gamblers begin to gamble in their youth; early onset gambling is a common feature of the pathway toward developing a gambling problem.

1. Background

Terms of “severe-end” gambling often used when referring to youth

• Gambling Disorder (DSM-5) (GD) = repeated and compulsive involvement in gambling that continues in the face of financial, social, psychological and vocational consequences.

(level 4)

• Problem gambling (not official) = gambling that contributes to financial, social, legal, psychological, school and vocational consequences (level 3)

Point 1: First generation of youth exposed to ready access and varied gambling venues

• Minimum legal age to place a bet varies across countries and games, but many opportunities for youth in the Westernized countries.

U.S. as an Example:43 states with a lottery (blue) 39 states allow age 18 as legal minimum age

U.S. as an Example43 states with casino/slots

14 states allow 18 as legal minimum age

casinos/slots legal

casinos/slots legal

casinos/slots not legal

U.S. Study: Youth Participation in Gambling (age 14 – 21) (Welte et al., 2008)

3330 29

23 21

129 7

68

0

10

20

30

40

50

60

70

cards office pools lottery sportsbetting

skill games bingo dice games casino all gambling

perc

en

t

U.S. Study: Past Year Problem Gambling Prevalence Rate by Age Group (Welte et al., 2002, 2008)

1.32.1

4.3

5.2

3.3 3.3

1.2

0

2

4

6

8

10

<19 19 - 25 26-30 31-40 41-50 51-60 61+

perc

en

t

Some epidemiology studies estimate teen rates are higher than

adult rates

U.S. Data: Estimates of Problem Gambling, Past Year (included U.S. and Canada data; school-based surveys)(National Research Council, 1999)

PercentageGroup Range Median

Adult <1 - 2% 0.9%

Adolescent 1 - 9% 6%

Estimates based on meta-analysis of surveys conducted 1988-1997 (National Research Council, 1999). Problem gambling defined in most studies by the SOGS/SOGS-RA.

Point 2: The newest “waves” of gambling expansion, online gambling and poker, further strengthen involvement in gambling by teens

Online Gambling (internet, online, social networks)

• Various forms of online gambling are legal and regulated in many countries

• U.S. – very limited; permitted in some States

• U.K. and Australia – examples of relatively permissive internet regulations

• Recommended reading:Remote gambling in adolescenceGriffiths, Parke, & Derevensky (2010). In J. Derevensky, D. Shek & J. Merrick (Eds.), Youth gambling problems: The hidden addiction. Berlin: De Gruyter

Gambling Severity by Sample (McBride & Derevensky, 2007)

0

10

20

30

40

50

60

70

80

Fre

qu

en

cy

%

Non-gambler Social gambler Problem gambler

High School

College/University

Internet Sample

University journalism student Mike Schneider won top prize - $1 million - in the Limit Hold'em PartyPoker.com Million V

tournament.

Photo by Charlie Knutson, from The Minnesota Daily, March 22, 2006

Point 3: There is a disconnect between estimates of youth problem gambling and utilization of clinical services

• From 1999- 2009 in Minnesota:• over 10,000 calls to the problem gambling hotline …

15 calls pertained to teen gambling (< 19 years old)

• over 3,700 referrals to a treatment program…..

0 referrals of teenagers (< 19 years old)

Point 3: There is a disconnect between estimates of youth problem gambling and utilization of clinical services

• From 1999-2009 in Minnesota:• over 10,000 calls to the problem gambling hotline …

14 calls from teenagers (<19 years)

• over 3,700 referrals into the treatment system…..

19 referrals of 19 – 25-years old

Why?• Low public awareness

• Low problem recognition

• No youth-specific services

• Other, more observable problems are viewed as more pressing

• No or minimal financial losses

But there are clinical cases

• Minnesota High School Football Star; was an honor student and had a football scholarship to a Division I school.

• Became an habitual blackjack player at the local casino after he turned 18.

• To finance his habit, he fenced stolen property.

• Was arrested for the thefts.

Point 4: There is a developmental feature to problem gambling

Adolescentgambling

Adult problemgambling

Onset of Gambling Variables and Number of Lifetime Symptoms (Kessler et al., 2008)

23.9

18 18.316.7

0

5

10

15

20

25

30

No Sym 1-2 Sym 3-4 Sym 5+ Sym

Age OnseGambling

mean

ag

e

Age Onset: F = 15.4, p < .001

Earlier onset among those 5+

Onset of Gambling Variables and Number of Lifetime Symptoms (Kessler et al., 2008)

23.9

0

18

26.7

18.3

23.8

16.7

24.3

0

5

10

15

20

25

30

No Sym 1-2 Sym 3-4 Sym 5+ Sym

Age Onset

Age Onset Prb

mean

ag

e

NA

Age Onset Prb: non sig.

ProblemBehaviors

ADHDdelinquency

maledruguse

gambling

sexualbehavior

Point 5: Youth problem gamblingoccurs with other problem behaviors

Gambling Group

Psychosocial problems

Cross-Sectional Study of Adolescents:Association of Psychosocial Problems and Gambling Involvement(Faregh & Derevensky, 2011)

emotional

family

anger

conduct

cognitive

Longitudinal Study of Youth:Association of Psychosocial Problems and Future Gambling(Pagani et al., 2009)

• These variables measured in the kindergarten sample:• Impulsivity• Emotional distress• Family functioning• Maternal education• Parental gambling• Gender

• Measured gambling behavior when they were sixth graders.

Pagani et al., 2009

Childhood Self-Control (Age 3) as a Predictor of Adult (Age 21) Problem Gambling (Slutske et al., 2012)

undercontrolled group > gambling

The children with undercontrolled temperament at 3 years of age were more than twice as likely to evidence disordered gambling at ages 21 than were children who were well-adjusted at age 3.

2. Neuro-development

1. Background

Adolescence is a period of profound brain maturation.

We thought brain development was complete by adolescence

We now know… maturation is not complete until about

age 25 !

An Immature Brain = Less Brakes on the “Go” System

Maturation Occurs from Back to Front of the BrainImages of Brain Development in Healthy Youth

(Ages 5 – 20)

Source: PHAS USA 2004 May 25; 101(21): 8174-8179. Epub 2004 May 17.

Blue represents maturing of brain areas

Earlier: Motor Coordination Emotion Motivation

Later: Judgment

• Preference for ….1. physical activity2. high excitement and rewarding activities3. activities with peers that trigger high

intensity/arousal4. novelty

• Less than optimal..5. control of emotional arousal6. consideration of negative conseq.

• Greater tendency to…7. be attentive to social information8. take risks and show impulsiveness

Implications of Brain Development for Adolescent Behavior

Novelty Activates the Dopamine System

• Compared to adults, adolescents have lower baseline levels of dopamine activity and greater sensitivity to dopamine-triggering activities, such as novelty.

• Thus, adolescents may seek novelty more and may experience a greater reward from novelty as a result of this ‘robust’ dopamine system.

• Preference for ….1. physical activity2. high excitement and rewarding activities3. activities with peers that trigger high

intensity/arousal4. novelty

• Less than optimal..5. control of emotional arousal6. consideration of negative conseq.

• Greater tendency to…7. be attentive to social information8. take risks and show impulsiveness

Implications of Brain Development for Adolescent Behavior

Risk-Taking

• Based on science of brain development, a modern view of risk taking in adolescence …• is normative; important to development

• has evolutionarily adaptive value

• significant individual differences

• not a result of poor assessment of risk; rather, is due primarily to self-control and contextual factors, not cognitive influences

An Immature Brain =

Low Brain Power

An Immature Brain =

Absence of Judgmentreward incentives >

perception of consequences

2. Neuro-development

1. Background

• youth in general• ADHD youth

3. Neurodevelopment and gambling

• Preference for ….1. physical activity2. high excitement and rewarding activities3. activities with peers that trigger high intensity/arousal4. novelty

• Less than optimal..5. control of emotional arousal6. consideration of negative consequences

• Greater tendency to…7. be attentive to social information8. take risks and show impulsiveness

Point 1: Normal brain development may contribute to adolescent susceptibility to gambling involvement.

Point 2: The neuro-plasticity of normal brain development may contribute to continued, and perhaps accelerated, gambling involvement.

Point 3: ADHD may put a person at heightened risk for gambling involvement

• Individuals with ADHD suffer from problems with judgment and self-regulation, believed to be linked to pre-frontal cortex deficits.

• These deficits in pre-frontal cortex contribute to a disorder likely related to another addictive disorder - drug addiction. (Barkley, 1997; Martin, Earlywine, Blackson et al., 1994)

Link of ADHD and Drug Abuse

Teenagers with a childhood diagnosis of ADHD are about 2 – 4 times more likely to have a Substance Use Disorder compared to teenagers without ADHD.

adapted Molina et al., unpublished

Is There a Link between ADHD and Problem Gambling?

• Adult studies

• Youth studies

Among Adults With and Without a Gambling Disorder

(Carlton et al., 1987; Rugle & Melamed, 1993)

Gambling Disorder psych., non-GD

Rate of childhood ADHD 15-36% 4-8% (sig.)

Adult: Link of ADHD and Gambling Disorder

Among Adults With and Without a Gambling Disorder

(Specker et al., 1995)

Gambling Disorder psych., non-GD

Rate of adulthood ADHD 21% < 1% (sig.)

Adult: Link of ADHD and Gambling Disorder

Among Adults With and Without ADHD(Harrow, 2009)

Gambling Disorder controls

Rate of adulthood GD 12% < 1% (sig.)

Adult: Link of ADHD and Gambling Disorder

“ADHD”+ “ADHD”- (n = 231) (n =2105)

Groups (N = 2336) % %

Nongamblers (30%) 6 94

Social (54%) 8 92

At-Risk (8%) 20 80

Prob. Path. (5%) 34 661 Based on the ADHD Index (Conners & Wells, 1997)

X2 = 113, p < .001

Association of Adolescent Gambling and Probable ADHD Status1

(Derevensky et al., 2007)

Derevensky JL, Pratt LM, Hardoon KK, Gupta R. (2007). Gambling problems and features of attention deficit hyperactivity disorder among children and adolescents. Journal of Addiction Medicine, 1, 165-172.

Youth: Link of ADHD and Problem Gambling

ADHD-persis ADHD-desist Controls sig.

any gambling (%) 79 77 80

PG among all1 (%) 19 5 5 (p < .05)

PG among gamb1 (%) 24 7 7 (p < .01)

SOGS-RA score (mean) 0.5 0.2 0.2 (p < .05)

Count games played (mean) 3.0 2.4 2.7

1 PG = SOGS-RA 2+

Minnesota ADHD Study(Breyer, Winters, August, & Realmuto, 2009)

Youth: Link of ADHD and Problem Gambling

2. Neuro-development

1. Background

4. Summary

3. Neurodevelopment and gambling

Summary

1. Evidence is accumulating that…

• most youth gamble, yet many do so infrequently

• the prevalence of “problem gambling” is noteworthy

Summary

2. Possible links between neurodevelopment and gambling behavior

• Gambling may be a very attractive activity for the developing brain

• Neuro-plasticity may impact future risk.

• Deficits in brain structures responsible for self-regulation may place youth with ADHD at elevated risk for problem gambling

Summary

3. Relatively easy access to online gambling and popularity of poker games and tournaments poses a new risk for youth who may be inclined to over-indulge in e-gambling

“Maryland CPA hit it big, but he worries about those who won’t”(Jon Saraceno, USA Today, August 1, 2006)

“Steve Dannenmann, who honed his skills with online poker-playing, won $4.25 million

as runner-up in the 2005 World Series of Poker tournament.

This summer, while playing poker in Vegas for a few weeks, he has made it his personal

project to quiz young people who have fallen for the allure of the game and its potential

financial bonanza.”

Steve: “I’ve met so many kids who have packed it in and came out here with a $2,000-$3,000

bankroll thinking they’re going to make it big. They’ve quit college or their jobs. I quiz them

like I do my clients who come in with money concerns.”

‘Why did you quit school? What’s your bankroll? What is your back-up plan?’

“If they don’t give a good answer, I call their bluff.” ‘What are you thinking?’

“It’s absolutely crazy, and pretty sad.”

Summary

4. Clinical issue: Screen for problem gambling among youth with drug abuse or ADHD

Brief Screen - AdultLie/Bet Screen (Johnson et al., 1997)

2-question version of the DSM-5 criteria:1. Have you ever had to lie to people important to you about how much you gambled?

2. Ever felt the need to bet more and more money?

Score of 1+ is a red flag.

SOGS-RA• Winters, Stinchfield, & Fulkerson,

1989/1993

DSM-IV-J• Fisher, 1992

Brief Screens - Youth

1. There is money missing from the parents.

2. The teenager asks for an increase in allowance.

3. The parent finds evidence of internet gambling when searching the teenagers computer.

4. The teenager is secretive about how they are spending their money.

Sampling of Themes from Adolescent Problem Gambling Screens

Summary

5. Clinical issue: For youth being treated for a substance use disorder or ADHD:• raise insights as to the risks of gambling; educate that gambling may be a source of relapse

Summary

• 6. Prevention programs exist • Gambling prevention can be

integrated into a school’s drug prevention program

• International Centre for Youth Gambling

• www.youthgambling.com/

• Illinois Institute for Addiction Recovery• www.addictionrecov.org

• Williams, Woods & Currie: Stacked Deck

Summary

CollegeGambling.org

• Tools for• Students• College health professionals• College administrators

THANK YOU!winte001@umn.edu

extras

Internet and Youth Study (McBride & Derevensky, 2007)

• High-school students, Montreal: N = 1113

• College/University students, Canada and U.S.: N = 1273

• Young adults and adults, on-line gaming newsletter link: N = 546

Gambling for Money on the Internet (McBride & Derevensky, 2007)

0

10

20

30

40

50

60

70

80

90

100

Fre

qu

en

cy

%

never less than oncea month

monthly weekly

High School

College/University

Internet Sample

Past Year Gambling(McBride & Derevensky, 2007)

0

10

20

30

40

50

60

70

80

90

100

Fre

qu

en

cy

%

Male Female

High School

College/University

Internet Sample 18-24

Internet Sample 25+

Session Evaluation

1. The information presented was useful to me

a. Strongly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Strongly disagree

2. The information presented was clear and organized

a. Strongly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Strongly disagree

3. I would recommend this session to a friend/colleague

a. Strongly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Strongly disagree

4. I learned something new

a. Strongly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Strongly disagree

5. The presenter(s) was/were engaging

a. Strongly agree

b. Somewhat agree

c. Neither agree nor disagree

d. Somewhat disagree

e. Strongly disagree

6. Please rate this session overall

a. Very good

b. Good

c. Average

d. Poor

e. Very poor