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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

Brunner.michael@mayo.edu

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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