ADOLESCENT BRAIN DEVELOPMENT

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ADOLESCENT BRAIN DEVELOPMENT

• TIME OF TURMOIL AND TRIUMPH
• BARBARA SULLIVAN, Ph.D.
• September 14 and 15, 2009

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GOALS

• To increase participant understanding of
• the structures, functions, and stages of
  development of the brain
• how adolescence has changed over the last 150
  years
• the differences between adult and adolescent
  thinking
• the impact of abuse and neglect on the brain
• current trends in adolescent alcohol use
• the impact of alcohol use on the brain
• what clinicians, prevention specialists, and
  communities can do to support healthy
  adolescent development

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CAVEATS

• New discoveries research is still in its
  infancy
• Do NOT over-interpret or interpret too
  simplistically
• Research is not to the point that it can inform
  causal models
• Most research has been conducted on male animals
  we assume the information transfers to people
• Behavior is the result of complex interactions
  among individual, environment, genetics,
  situation, cultural expectations, and numerous
  other factors

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• BRAIN STRUCTURES AND FUNCTIONS

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BRAIN FACTS

• Brain weighs approximately 3 pounds
• Brain has approximately 100 billion neurons and 1
  trillion supporting cells
• Neurons grow and organize themselves into
  efficient systems that operate a lifetime

• Brain controls ALL activities
• Emotion and cognition are intertwined
• Neurons can re-route circuits
• Brain and environment involved in delicate duet
• Brain never stops adapting and changing

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(No Transcript)
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Illustration by Lydia Kibuik, 2003
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EVOLUTION OF THE NEW BRAIN
Every mammals brain has the same basic
structure- cortex, cerebellum, and brain
stem cortical surface area is key
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CHALLENGE OF UNDERSTANDING THE BRAIN

• What is the link between the anatomy of a brain
  and the workings of the mindour thoughts,
  emotions, memories, and behaviors?
• There are no moving partsit does not operate
  mechanically as our hearts, legs, hands, and
  lungs do. So what is going on in there?

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BRAIN STRUCTURES

• Frontal Lobe
• Parietal Lobe
• Temporal Lobe
• Occipital Lobe

• Cerebellum
• Corpus Callosum
• Brain Stem

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INTEGRATION OF THE LOBES

• The different lobes of the brain work together
  like instruments in an orchestra to play music or
  letters in the alphabet to form words
• Each area makes specialized contributions to
  certain functions, but many brain regions
  participate in forming human thoughts and
  behaviors

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FRONTAL LOBE

• Seat of personality, judgment, reasoning, problem
  solving, and rational decision making
• Provides for logic, understanding of
  consequences, and emotional/behavioral regulation
• Governs impulsivity, aggression, ability to
  organize thoughts, and plan for the future
• Controls capacity for abstraction, attention,
  cognitive flexibility, and goal persistence
• Undergoes significant changes during adolescence
  not fully developed until mid 20s (Geidd, 2002)

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FRONTAL LOBE

• As the prefrontal cortex area of the frontal
  lobe matures, through experience and practice,
  teens can reason better, develop more impulse
  control, and make better judgments
• Prefrontal cortex is one of the last areas of the
  brain to fully develop (Sowell, 2001)
• Increased need for struc-
• ture, mentoring, guidance

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COMPONENTS OF EXECUTIVE FUNCTIONS AND SAMPLE
BEHAVIORS
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Brown et al., 2008
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TEMPORAL LOBES

• Responsible for hearing, understanding speech,
  and forming an integrated sense of self
• Responsible for sorting new information and for
  short term memory
• Contains the limbic-reward system (amygdala,
  hippocampus, nucleus acumbens, and vta)
• Developmental delays, deficits, or
  over-stimulation of the limbic area may increase
  vulnerability to high risk behaviors (Clark,
  Thatcher, Tapert, 2008)
• Matures around ages 18-22

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TEMPORAL LOBE/LIMBIC SYSTEM

• Limbic system regulates emotions and motivations
  particularly those related to survivalsuch as
  fear, anger, and pleasure (sex and eating)
• Feelings of pleasure/reward are very powerful and
  self-sustaining. Pleasurable behaviors activate
  a circuit of specialized nerve cells in the
  limbic area that is devoted to producing and
  regulating pleasure called the reward system

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REWARD SYSTEM

• Drugs of abuse activate the reward system in the
  limbic area of the brainproducing powerful
  feelings of pleasure
• Desire to repeat drug using behavior is strong
• Drugs of abuse can/do exert powerful control over
  behavior because they act directly on the more
  primitive, survival limbic structures over-ride
  the frontal cortex in controlling our behavior

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PARIETAL LOBES

• Integrate auditory, visual, and tactile signals
• Right lobe coordinates visual/spatial
  relationships
• Left lobe coordinates spoken or written language
• Matures around ages 16-17

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OCCIPITAL LOBES

• Primarily responsible for coordinating sight
• Primary visual area where pictures are received
  from the eyes and relayed to other parts of the
  brain for interpretation
• Visualization requires more than seeing the
  primary visual cortex processes information,
  temporal lobe recognize what we see, and the
  parietal lobes process information as we move
  through the space we see.

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• INFO FROM DANA BOOK

Robert Finkbeiner, Dana Brain Book
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CEREBELLUM

• Located at the base of the brain
• Responsible for motor coordination
• Recent research suggests that it is involved in
  coordinating thinking processes mental
  clumsiness (Geidd, 2002)
• Physical exercise is important for the
  development of the cerebellum undergoes
  significant change during adolescence

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CORPUS CALLOSUM

• Thick bundle of nerves that connects the two
  sides of the brain and relays information between
  the two cerebral hemispheres
• Involved in creativity and problem solving
• Influences language, learning, and associative
  thinking
• Changes significantly during adolescence (Geidd,
  1999)

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BRAIN STEM

• All nerve fibers pass through this area
• Performs sensory, motor, and reflex functions
• Contains vital nerve centers that control
  breathing, heart rate, body temperature, and
  gastrointestinal activity
• Connects the brain with the body

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BRAIN CIRCUITRY
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Brain Circuitry

• NEURON specialized cell designed to transmit
  information to other nerve cells and muscles
• Each neuron consists of a cell body, axon, and
  dendrite
• Axon an electricity conducting fiber that
  carries information away from the cell body
• Dendrite receives messages from other neurons
• Synapse contact point where one neuron
  chemically communicates with another neuron

Brain Facts, The Society for Neuroscience, 2002
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(Illustration by Lydia Kibiuk, 1996)
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BRAIN CIRCUITRY

• Neurons communicate by transmitting electrical
  impulses along their axons
• Axons send chemical neurotransmitter messages
  across a synapse to the receiving dendrite of the
  target neuron
• Each neuron has an average of 6,000 dendrite
  receptors
• Dendrite receptor sites are specialized areas
  lock and key or molecular handshake

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BRAIN CIRCUITRY

• A neuron may receive many different messages at
  the same time (Prioritize)
• Each neuron has to interpret incoming messages
• Neuronal communication is currently under intense
  study because it plays such a critical role in
  health and well being

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BRAIN CIRCUITRY

• Electrical impulses travel along axon at speeds
  up to 250 mph (mylenation)
• Neurons forging connections with other neurons
  underpin learning
• Our brains are adaptable and can reflect on and
  learn from experience
• Neural connections are shaped by genetics and
  experience

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BRAIN CIRCUITRY

• Gray matter contains neurons that are responsible
  for thinking (100 billion)
• White matter contains suportive cells with
  nutritive roles (dendrites1 trillion)
• Myelin is a layer of insulation that
  progressively insulates these supportive cells
  and is whitish in color
• Myelin makes white matter more efficientjust
  like insulation on electric wirescontributes to
  overall cognitive functioning (100x faster)
• Myelin affects the speed and quality of brain
  activity (Paus, et al., 1999)

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NEUROTRANSMITTERS

• All messages are passed to connected neurons
  through a form of chemicals called
  neurotransmitters
• Neurotransmitters are released from the end of
  the axon, cross the synapse, and bind to the
  specific receptors on the dendrites of the
  targeted neuron
• Neurotransmitters bind with specific receptor
  sites on the receiving dendrite

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MAJOR NEUROTRANSMITTERS

• Acetylcholine regulates memory
• Dopamine produces pleasure through the reward
  system multiple functions including controlling
  movement, regulates hormonal responses, important
  to cognition and emotion abnormalities in
  dopamine levels have been implicated in
  schizophrenia
• Serotonin plays a role in sleep involved in
  sensory perception and involved in controlling
  emotional states such as anxiety and depression

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MAJOR NEUROTRANSMITTERS

• Glutamate excites the firing of neurons, aids
  process of memory
• Gamma-aminobutyric (GABA) inhibits the firing
  of neurons

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DEVELOPMENTAL VULNERABILITY

• During adolescence, the prefrontal cortex (PFC),
  limbic system areas, and the white matter myelin
  are undergoing many changes (Chambers, 2003
  Spear, 2000)
• These areas serving cognitive, behavioral, and
  emotional regulation may be particularly
  vulnerable to adverse alcohol effects
• Deficits or developmental delays in these
  structures and their functions may underlie
  vulnerabilities to alcohol use/abuse (Clark,
  Thatcher, Tappert, 2008)

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OVERPRODUCTION AND PRUNING

• CRITICAL PEAKS OF BRAIN DEVELOPMENT

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OVERPRODUCTION AND PRUNING

• Brain development occurs in 2 basic stages
  growth spurts/overproduction of neurons and
  pruning
• Critical phases in utero
• 0-3 years
  overproduction
• 10-13 years
• Overproduction results in significant increase in
  the number of neurons and synapses
• Exuberant growth during these 3 phases gives the
  brain enormous potential

Begley, 2000 Geidd, 1999
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PRUNING

• These 3 critical phases are quickly followed by a
  process in which the brain prunes and organizes
  its neural pathways
• LEARNING is a process of creating and
  strengthening frequently used synapses (brain
  discards unused synapses)
• Brain keeps only the most efficient and strong
  synapses
• Children/teens need to understand that they
  decide which synapses flourish and which are
  pruned away (Geidd, 1999)

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PRUNING

• USE IT OR LOSE IT Reading, sports, music,
  video games, x-box, hanging outwhatever a
  child/teen is doingthese are the neural synapses
  that will be retained
• How children/teens spend their time is CRUCIAL to
  brain development since their activities guide
  the structure of the brain (Geidd, 1999)

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What sorts of media are young people consuming?
Every year young people will see about 1,000
commercials advertising beer. 2/3 of young people
have a TV in their room, 61 have no parental
guidelines. Annually alcohol manufactures spend
over 1 BILLION in TV, radio, print, and internet
advertising.
Young people sped an average of 1-2 hours daily
listening to music. 63 of rap songs make
reference to drug use, as do 10 of songs in
other genres.
Young people spend an average of 10 hours per
week on the internet. 58 of young people have
accessed websites of a violent or sexual
nature. 82 of websites target youth.
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BRAIN DEVELOPMENT

• Continued synaptic pruning, neural
  connection/integration, capacity to process
  information, and mylenation (driven by experience
  and practice) these structural changes are
  believed to underlie the functional integration
  of frontal regions with the rest of the brain
  adolescent into adult (Luna Sweeny, 2004)

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BRAIN DEVELOPMENT

• White matter development may underlie advancing
  executive functioning (Luna and Sweeney, 2004
  Luna et al., 2001)
• Delays or deficits in the development of PFC may
  result in neurodevelopmental dysmaturation
  which can lead to psychological dysregulation
• Psychological dysregulation is a deficiency in
  the ability to regulate attention, emotions, and
  behavior in response to environmental challenges
  (Clark and Winters, 2002)

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PSYCHOLOGICAL DYSREGULATION

• Alcohol Use Disorders (AUD) typically do not
  happen in isolation instead they appear to be
  correlated with persistent behavioral
  characteristics including
• attentional deficits ADD, ADHD
• conduct disorders anti-social
• irritability aggression, diminished
  constraint
• major depressive disorder depression, anxiety

Clark et al., 2005 Tappert et al., 2002 Chassin
et al., 1999 Tarter et al., 1999
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DEFINING ADOLESCENCE
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ADOLESCENCE HAS ALWAYS BEEN CHALLENGING

• Youth are heated by nature as drunken men by
  wine Aristotle (350 B.C.)
• I would that there were no age between 10-23,
  for theres nothing in between but getting
  wenches with child, wronging the ancientry,
  stealing, fighting Shakespeare The Winters
  Tale, Act III (..1594)

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DISPARITIES OF ADOLESCENCE

• Adolescence is a time of triumph, high energy,
  great potential, resilient health, new found
  skills, creativity, humor..
• Adolescence is also a time of turmoil often
  associated with high risk behaviors, impulsivity,
  and poor decision making
• Dramatic increase in death, disability, suicide,
  homicide, serious accidents, aggression,
  violence, emotional disorders, substance use, and
  risky sexual behaviors

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REWARD SENSITIVITY

• Changes in reward sensitivity that occur at
  puberty lead adolescents to seek more novelty and
  require a higher level of stimulation to achieve
  the same subjective feeling of pleasure
• Changes in the limbic system, neuro-
  endocrinology, and an immature self regulatory
  system are implicated (Steinberg, 2004)

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ADOLESCENCE

• Awkward period between sexual maturation and the
  attainment of adult roles and responsibilities
• Begins with the domain of physical/biological
  changes related to puberty, but it ends in the
  domain of social roles
• Encompasses the transition from the status of a
  child (one who requires monitoring) to that of an
  adult (responsible for behavior) Dahl, 2003

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STUDY OF ADOLESCENTS

• G. S. Hall, psychologist, began the modern study
  of adolescence about 100 years ago
• Increase in adolescent-related research in the
  early 1990s second increase began focusing on
  adolescent brain development in 1998
• Most research is conducted on babies and toddlers

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ADOLESCENCE

• Adolescence is much broader and longer than the
  teenage years alone (has changed significantly
  over the past 150 years)
• Adolescence now stretches across more than a
  decade, with pubertal onset often beginning by
  age 9-12 and adult roles delayed until mid
  twenties (Worthman, 1995)

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ADOLESCENCE

• In the early 1900s, the interval between puberty
  and achieving adult status was typically 2 years
  for girls and 4 years for boys (Schlegel and
  Barry, 1991)
• While puberty is occurring earlier in many
  industrial societies, marriage and other adult
  roles are often delayed in the U.S. the average
  age of menarche is 12 and average age of 1st
  marriage is 26 (Dahl, 2004)

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ADOLESCENCE

• Most elements of cognitive development show a
  trajectory that follows age and experience rather
  than the timing of puberty (Dahl, 2004)
• Research conducted by Martin, 2003, demonstrates
  a significant positive correlation between
  pubertal maturation and sensation seeking

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ADOLESCENCE

• PUBERTY
• Romantic motivation
• Sexual interest
• Emotional intensity
• Sleep cycle changes
• Appetite
• Risk for affective disorders (girls)
• Increase in risk taking, sensation seeking, and
  novelty seeking

• AGE/EXPERIENCE
• Planning
• Logic, reasoning
• Inhibitory control
• Problem solving
• Understanding consequences
• Affect regulation
• Goal setting and pursuit
• Judgment and abstract thinking

Dahl, 2004
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ADOLESCENCE VS. ADULTS

• Being a responsible adult requires developing
  self-control over behavior and emotions must be
  able to appropriately inhibit behaviors despite
  STRONG FEELINGS
• The ability to integrate these multiple
  components of behavior, cognition, and affect in
  the service of long term goals involves
  neurobehavioral systems that are among the last
  regions of the brain to fully mature (Dahl, 2004)

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NAVIGATING ADOLESCENCE

• The most widely implicated factor associated with
  maladaption vs. resilience in adolescence is
  REGULATORY CAPACITY (RC) Kupfer Woodward,
  2004
• Behavioral control (RC) requires tremendous
  effort adolescents need practice being
  consistent and integrating RC
• PFC and white matter development are needed for
  regulatory capacity

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NAVIGATING ADOLESCENCE

• What makes this possible?
• Driven by experience and practice
• Psychological regulation of attention, emotions,
  and behavior
• Continued synaptic pruning and mylenation
• Mentoring appropriate response patterns in the
  face of everyday life and decision making

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Critical Differences Between Adult and Adolescent
Thinking
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Why is it that a young person is not able to
drive a car until 16, vote until 18, drink
alcohol until 21, rent a car from a commercial
agency until 25, but in some states, can stand
trial for murder at age 12 or 13? (Dahl, 2004)
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DISPARITIES OF ADOLESCENCE

• Adolescence is a TRANSITIONAL period during which
  a child is becoming, but is not yet, an adult
• Adolescent brains are far less developed than we
  previously believed
• Normal adolescent development includes conflict,
  risk taking, facing insecurities, creating an
  identity, mood swings, self-absorption, etc.

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ADOLESCENT BRAIN DEVELOPMENT

• Underdevelopment of the frontal lobe/prefrontal
  cortex and the limbic system make adolescents
  more prone to behave emotionally or with gut
  reactions (Yurgelun-Todd, 1999)
• Adolescents tend to use an alternative part of
  the brain the AMYGDALA (emotions aggression)
  rather than the prefrontal cortex (reasoning) to
  process information

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Illustration by Lydia Kibiuk, 2003
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ADOLESCENT BRAIN DEVELOPMENT

• Amygdala and nucleus acumbens (limbic system
  within the temporal lobes) tend to dominate the
  prefrontal cortex functions this results in a
  decrease in reasoned thinking and an increase in
  impulsiveness
• Because of immature brains, adolescents do not
  handle social pressure, instinctual urges, and
  other stresses the way adults do
• A major part of adolescence is learning how to
  assess risk and consequences adolescents are
  not yet skilled at these tasks (Dahl, 2004)

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HOT AND COLD COGNITION

• Thoughts and emotions are intertwined teens
  need to develop a balance between cognitive and
  affective systems of the brain
• COLD cognition refers to thinking under
  conditions of low emotions and/or arousal
• HOT cognition refers to thinking under
  conditions of strong feelings or arousal
• Decisions made under conditions of strong affect
  are difficult to influence by cool rational
  thought alone

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HOT AND COLD COGNITION

• Decision making in teens cannot be fully
  understood without considering the role of
  emotions and the interaction between thinking and
  feeling (Dahl, 2003)
• Teen decisions are unlikely to emerge from a
  logical evaluation of the risk/benefits of a
  situation rather decisions are the result of a
  complex set of competing feelings desire to
  look cool, fear of being rejected, anxiety about
  being caught, excitement of risk, etc.

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HOT AND COLD COGNITION

• Adolescent brain is a vulnerable system that
  could fail under hot high demanding situations
  where the circuitry is not sufficiently
  established to sustain adult level cognitive
  control of behavior in the face of heightened
  states of emotion, motivation, distracting
  stimuli, or competing tasks (Luna Sweeny, 2003)

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ADOLESCENT BRAIN

• DLPFC is linked to the ability to inhibit
  impulses, weigh consequences, prioritize, and
  strategize this area is still under
  construction until late 20s (Giedd, 1999)
• Wernickes area (reception of speech) and Brocas
  area (production of speech) undergo substantial
  changes during the teen years impacts ability
  to listen and express oneself

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ADOLESCENT BRAIN DEVELOPMENT

• Adolescents are not very skilled at
  distinguishing the subtlety of facial expression
  (excitement, anger, fear, sadness, etc.)results
  in a lot of miscuesleads to lack of
  communication and inappropriate behavior
• Differences in processing, organization, and
  responding to information/events leads to
  misperceptions and misunderstanding verbal and
  non-verbal cues

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Adult Brain
Adolescent Brain
YURGELUN-TODD, 1999
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ADOLESCENT BRAIN DEVELOPMENT

• To appreciate consequences of risky behavior, one
  has to have the ability to think through
  potential outcomes and understand the permanence
  of consequences, due to an immature prefrontal
  cortex, teens are not skilled at doing this
• Teens do not take information, organize it, and
  understand it in the same way that adults dothey
  have to learn how to do this

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ADOLESCENT BRAIN DEVELOPMENT

• Important to understand that teens often fail to
  heed common sense or adult warnings because they
  simply may not be able to understand and/or
  accept reasons that seem logical and reasonable
  to adults (difference in evaluating positive
  negative consequences Fromme et al., 1997)
• Adolescents may know right from wrong, but they
  may not be able to prioritize when stressed with
  social/peer pressure
• NEVER assume that you and a teen are having the
  same understanding of a conversation

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ADOLESCENT BRAIN DEVELOPMENT

• Risky adolescent behaviors are not simply
  impulsive behaviors, but generally occur in the
  context of evaluating positive and negative
  consequences and immediate vs. delayed rewards
  (Wulfert et al., 2002)
• PFC activation during risk-reward conflict
  appears less active in adolescents compared to
  adults (Bjork et al., 2007)

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ADOLESCENT VULNERABILITY

• Adolescents who prefer immediate rewards vs
  delayed rewards may have underdeveloped neural
  circuitry for maintaining motivation and
  inhibiting behaviors
• These adolescents may also anticipate that risky
  behaviors will lead to positive outcomes
  (Chambers et al., 2003)
• Deficits in cognitive, behavioral, and emotional
  regulation comprise a common vulnerability for
  increasing risk for AUDs

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ADOLESCENT BRAIN DEVELOPMENT

• With experience and PFC development, teens are
  able to temper their instinctive gut reaction
  with more rational, reasoned responsesthey are
  able to apply the brakes to emotional
  responses. During this time of development,
  teens need adult mentors and role-models who
  demonstrate how to make good decisions and how to
  control emotions

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ADULT GUIDANCE

• Adult monitoring is too frequently and too
  prematurely withdrawn during the vulnerable
  period leaving the adolescent to navigate
  difficult situations alone or with peers
  (Dahl,2004)

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ADULT GUIDANCE

• Adult thinking is guided by self regulation and
  delayed gratification
• Interrupting risky behavioral trajectory
  getting off a runaway train
• Thinking before acting jumping the gun
• Choosing between two alternative courses of
  action-- doing the right thing (Steinberg,
  2004)
• Risk perception, internal planning, endogenous
  control of behavior (functions of the PFC)

Steinberg, 2004)
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ADOLESCENT BRAIN DEVELOPMENT

• Critical developmental changes in brain pathways
  controlling emotions, cognitive and attentional
  functions, and reward sensitivity during
  adolescence
• Strong increases in the connectivity between the
  amygdala (critical for emotional learning) and
  the PFC (critical for decision making) Kelly,
  Schochet, Landry 2004

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ADOLESCENT BRAIN DEVELOPMENT

• Adolescence involves the maturation of
  self-regulation of behavior and emotionsteens
  need to learn how to navigate complex social
  situations under conditions of strong emotions
  such as social anxieties, romances, academic
  pressures, immediate gratification vs long term
  goals, moral dilemmas, and success or failure

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IMPACT OF ABUSE ON BRAIN DEVELOPMENT AND FUNCTION
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SCARS THAT WONT HEAL

• Growing evidence of altered brain development and
  functioning as the result of abuse and neglect
• Our interactions with the world organize our
  brains development and shapes the person we
  become (Shore, 1997)
• Brain will develop to respond to a positive or a
  negative environment

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BRAIN ADAPTATION

• Life experiences (positive or negative) set off
  cascades of change that influence gene expression
  and brain organization (Masten, 2004)
• Life experiences exert a profound influence on
  brain architecture (Spessot, Plessen,
  Peterson, 2004)

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SCARS THAT WONT HEAL

• Chronic stress, abuse, and neglect sensitize
  certain neural pathways and over-develop certain
  regions of the brain (limbic region) involved in
  anxiety and fear. This often results in the
  under-development of other regions of the brain
  (frontal lobe) (Perry, 2000)
• Chronic stress from fear, violence, abuse,
  hunger, pain, etc. focuses the brains resources
  on survival and other areas of the brain are not
  available for learning social and cognitive
  skills

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BRAINS RESPONSE TO THREAT

• Brain is uniquely designed to mobilize the body
  in response to threatall body responsefight or
  flight
• Neurochemical systems cause a cascade of changes
  in attention, impulse control, sleep patterns,
  and fine motor control (DeBellis, 2001)
• Chronic activation of the neural pathways
  involved in fear creates memories which shape a
  persons perception of and response to the
  environmentindelible perception of the world
  (attitudinal change?)

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BRAINS RESPONSE TO STRESS

• PFC is extraordinarily sensitive to stress. Even
  mild stressors can impair PFC cognitive
  functioning if the person feels no control over
  the stressor (frequent in teens)
• High levels of Dopamine are released during
  stress this impairs the regulation of thought
  and behavior may explain why teens are
  vulnerable to loss of judgment and insight during
  emotional or stressful situations (Arsten
  Shanksy, 2003)

84
GENDER DIFFERENCES IN RESPONSE TO STRESS

• Corticosterone response to stress differs in male
  and female rats (in females-greater overall
  response, faster rise in blood levels, and blood
  levels binding increased) Young Altemus, 2003
• Estrogen may amplify many aspects of the stress
  response significant implications for our
  understanding of depression and anxiety in
  females

85
STRESS AND LEARNING

• Hormones involved with the HPA axis have profound
  influence on brain circuits that are integral to
  learning, memory, emotional regulation, and
  behavioral affect (Cameron, 2003)
• Neurobiological factors that amplify
  stress-induced PFC dysfunction during
  adolescence, may increase susceptibility to
  impaired judgment, substance abuse, and
  psychiatric disorders (Arsten Shanksy, 2003)

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NEUROBIOLOGY OF ABUSE

• Chronic activation of certain parts of the brain
  involved in the fear response -
  hypothalamic-pituitary-adrenal-(HPA) axis can
  wear out other parts of the brain such as the
  hippocampus (memory, cognition, communication)
• HPA axis significantly influences cognitive
  development as well as behavioral and emotional
  regulation
• Abuse and addiction impact learning, behavior,
  and psychological and moral development on a
  cellular level (issue of choice?)

87
JANUARY 22, 2007 A CHILD HOLDS A WEAPON IN A
BAGHDAD PROTEST IN DECEMBER, 2006
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NEUROBIOLOGY OF ABUSE

• Chronic stress may have neurotoxic effects and
  lead to learning and concentration impairments
  secondary to the damage to the hippocampus
  including
• -- accelerated loss of neurons (Smythies,
  1997)
• -- delays in myelination (Dunlop, 1997)
• -- abnormalities in developmentally
  appropriate pruning (Todd, 1992)
• -- inhibition of neurogenesis (Tanapat, 1998)

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Child Abuse and Neglect
OUTCOMES
PTSD Symptoms in Childhood
Compromised Cognition Psychosocial Effects
Alterations of the Catecholamine HPA Axis
Changes in Brain Metabolism (enhanced neuron
loss, anterior cingulate dysfunction)
Adverse Effects on Brain Development (smaller
cerebellum, corpus callosum)
De Bellis, 2001
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THE EFFECTS OF ABUSE AND NEGLECT

• Diminished growth in the left hemisphere may
  increase risk for depression (Teicher, 2000)
• Irritability in the limbic system can set the
  stage for the emergence of panic disorder and
  post-traumatic stress disorder (Teicher, 2000)
• Smaller growth in the hippocampus can increase
  the risk for dissociative disorders and memory
  impairment (Teicher, 2000)

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CLINICAL PRESENTATION

• Cognitive problems
• Anxiety
• Suicidal ideation
• Depression
• Attention problems
• Attachment problems
• Impulsive behavior
• Aggression
• Acting out
• Antisocial behaviors

• Persistent fear
• Hyper-arousal
• Dissociation
• Disrupted attachments
• Lack of empathy
• Sleep problems
• Tachycardia
• Hypertension
• Memory problems
• Explosive anger

(Perry, 2000)
92
CURRENT TRENDS IN ADOLESCENT ALCOHOL USE
93
More Adolescents Use Alcohol Than Use Cigarettes
Or Marijuana
Percent
The Surgeon Generals Call to Action to Prevent
and Reduce Underage Drinking, 2007
94
Adolescents Drink Less Often But More Per
Occasion Than Adults
Usual number of drinks/occasion
Drinking days/month
The Surgeon Generals Call to Action to Prevent
and Reduce Underage Drinking, 2007
95
Among Adolescents Who Drink, The Number Of Binge
Drinking Days Increases With Age
Days
Age
The Surgeon Generals Call to Action to Prevent
and Reduce Underage Drinking, 2007
96
18-20 Year Olds Have The Highest Prevalence Of
DSM-IV Alcohol Dependence
Percent
Age
The Surgeon Generals Call to Action to Prevent
and Reduce Underage Drinking, 2007
97
Alcohol Use and Binge Drinking Vary by
Race/Ethnicity and Gender
Percent
Gender and Racial/Ethnic Subgroups
Source SAMHSA, Office of Applied Studies, NSDUH
(special data analysis)
98
ALCOHOL AND ADOLESCENTS

• Alcohol is the drug of choice among Americas
  adolescents used more than tobacco or illicit
  drugs (Johnson et.al., 2006a)
• Underage drinking is deeply embedded in our
  culture many view it as a rite of passage
• Parents can influence a teens thinking about
  drinking
• A substantial number of adolescents begin
  drinking at a very young age and this often
  occurs at home this increases their chances of
  developing an alcohol use disorder

99
ALCOHOL AND ADOLESCENTS

• Nearly 1/3 of American youth begin drinking
  before age 13 (Grunbaum et.al., 2004)
• The peak years for alcohol initiation are 7th
  8th grades (Faden, 2006)
• Underage drinking contributes to serious
  adolescent health and social problems including
  death from injuries, risky sexual behaviors
  (Cooper Orcutt, 1997), increased risk of
  physical sexual assault (Hingson et al., 2005),
  and academic failure (Grunbaum et al., 2005)
• Parents need to talk to their teens about
  drinking and set specific no-use expectations

100
IMPACT OF ALCOHOL ON ADOLESCENT BRAIN DEVELOPMENT
101
ALCOHOL AND ADOLESCENTS

• The developing adolescent brain may be
  particularly vulnerable to negative effects from
  alcohol (Brown, et al., 2000 Crews, et al., 2000
  De Bellis, et al., 2000)
• Youth with school, personal, or family problems
  are more likely to begin drinking early (Brown
  Tappert, 1999)
• Youth who begin drinking prior to age 14 have a
  41 chance of developing alcohol dependence
  during their lifetime compared with those who
  wait until age 21 when lifetime risk is reduced
  to 10 (Brown Tappert, 1999)

102
ALCOHOL AND ADOLESCENTS

• Hippocampus (memory area of the brain) is
  sensitive to the acute effects of ethanol during
  adolescence (White and Swartzwelder, 2004)
• Hormonal fluctuations, differences in metabolism,
  gender specific drinking patterns may account
  for the mounting evidence that female teens
  suffer greater alcohol related problems than male
  teens

103
ALCOHOL AND ADOLESCENTS

• Compared with controls, adolescents with AUDs
  have been found to have smaller prefrontal white
  matter volumes (DeBellis, 2005)
• Some research has suggested that adolescents and
  adults with AUDs have smaller amygdala,
  hippopocampal, and ventral striatum volumes than
  controls (Koob, 1999 Mill et al., 2001 Makris
  et al., 2004)
• Implications for reward sensitivity, inhibition,
  impulsivity, and decision making

104
ARE ADOLESCENTS MORE SUSCEPTIBLE TO ALCOHOL THAN
ADULTS?

• Adolescent rats are LESS sensitive to the
  aversive effects of alcohol such as sedation,
  hang over, motor impairment effects
  (consequently they may drink more than adults)
  Doremus et al., 2003 Varlinskaya Spear, 2004
  
• Adolescent rats are MORE sensitive to the social
  disinhibition induced by alcohol use
  (consequently they feel the stimulating/fun
  aspect of drinking sooner than adults) Doremus
  et al, 2003 Varlinskaya Spear, 2004

105
ALCOHOLS EFFECTS

• Family characteristics, such as history of
  alcoholism, psychopathology, gender, and age of
  first use, must be carefully considered when
  studying the influence of teen drinking on
  cognition (Brown Tappert, 2004)
• Extensive literature suggests that COAs (children
  of alcoholics) exhibit verbal, non-verbal, and
  memory deficits on cognitive tests (Hill, 2004)

106
ALCOHOLS EFFECTS

• Alcohol use during adolescence may lock in the
  insensitivity to alcohols sedative effects
  (Varlinskaya Spear, 2004 White Swartzwelder,
  2004)
• Changes in the neurochemical components of
  insensitivity may raise the hedonic (pleasure
  seeking) set point leading to compulsive alcohol
  and drug use (Hill, 2004)

107
ALCOHOL EXPECTANCIES

• Alcohol expectancies form early and shift over
  time
• 3-5 year olds associated alcohol with neutral,
  adult behavior
• 9-10 year olds associated alcohol with
  negative, wild, dangerous behavior
• 10-12 year olds associated alcohol with more
  positive, fun behavior

Windle et al., 2008
108
Brain Circuits Involved in Drug Addiction
OFC
SCC
MOTIVATION/ DRIVE (saliency)
109
One mechanism contributing to addiction may be
the ability of drugs to induce damage in the
nucleus acumbens impacting the serotonin and
dopamine neuromodulator systems (both implicated
in impulsivity) further promoting impulsive
choices and drug taking behaviors (Cardinal,
Winstanley, Robbins, Everitt, 2004)
110
CONTROL CIRCUITS

• fMRI studies demonstrate abnormalities in the
  PFC area for decision making and inhibitory
  control
• These abnormalities could be involved in the
  changes in decision making, judgment, and
  cognitive control that occur in addiction
• Changes in the PFC could lead to loss of
  self-directed/willed behavior in favor of
  automatic sensory driven behavior (Goldstein and
  Volkow, 2002)

111
WHAT PREVENTION AND TREATMENT STAFF AND
COMMUNITIES CAN DO
112
ADOLESCENTS AND ALCOHOL

• Underage alcohol use is a highly complex problem
• Biological, social, familial, cultural, genetic,
  environmental factors all contribute to an
  adolescents decision to use alcohol
• Parents, schools, governments, and the entire
  community need to be involved in prevention
  underage drinking

113
PROGRAMMING AND POLICY ISSUES

• Teens are not adults BRAIN development is not
  complete
• Teens operate from the emotional, impulsive,
  reward oriented part of the brain
• Communication is a complicated process
• Technology is transforming the world
• Disparities between knowing/feeling
  understanding/behaving

114
PROGRAMMING AND POLICY ISSUES

• Adolescent alcohol use is influenced by the
  availability, price, cultural and subcultural
  norms, adult monitoring (schools, family, law
  enforcement), and peers as well as individual
  motives, desires, expectancies, values, and
  vulnerabilities (Masten et al., 2008)
• Prevention and treatment interventions must
  address the physical, relationships, cultural
  groups, and media/virtual contexts that
  adolescents live in

115
PROGRAMMING AND POLICY ISSUES

• Teens need strong, consistent social scaffolding
  structures/people that provide support, guidance,
  constraints, monitoring, encouragement, a
  safety net (Dahl, 2004)
• Emergence of teen regulatory skills requires a
  solid, consistent foundation and maturation of
  the PFC (Masten, 2004)

116
PREVENTION INTERVENTIONS

• Domain family, school, neighborhood, peers,
  workplace, policy, or multiple domains
• Target Population adolescent, parents, siblings,
  peers, or community
• Type of Strategy universal, selective, or
  indicated
• Most successful strategies are multi-component
  which place emphasis on increasing parenting
  skills and increasing adolescent regulatory
  capacity

117
PREVENTION INTERVENTIONS

• Consider including strategies addressing
• alcohol expectancies,
• peer/sibling use (everybody does it)
• hot/cold situational role plays
• impulse/inhibition activities
• strategy/team activities
• group problem solving activities

118
DEVELOPMENTAL PROCESSES/TRANSITIONS THAT MAY
AFFECT RESPONSES TO PREVENTION OR TREATMENT
INTERVENTIONS
119
(Wagner, 2008)
120
TREATMENT INTERVENTIONS

• Most treatment interventions are borrowed from
  adult treatment system
• Adolescent focused treatment can be effective
• Maturation of PFC and limbic system including
  self-regulation, executive function, and
  cognitive capacity, as well as family conflict,
  depression, and aggression need to be considered
  and addressed in treatment

121
TREATMENT INTERVENTIONS

• Successful treatment models include
• Family based, multisystemic therapy,
• Motivational Enhancement therapy,
• Behavioral therapy,
• Cognitive behavioral therapy
• Pharmacotherapy
• Reward sensitivity needs to be considered and
  addressed in treatment
• Because 2/3 of adolescents relapse within 6
  months of treatment, ongoing aftercare needs to
  be enhanced and expanded

122
AREAS TO REVIEW

• Policies
• Procedures
• Interactions
• Expectations
• Protocols/ Services
• Sanctions

123
CORTICAL INTEGRATION

• Strengthens the frontal cortexjudgment,
  reasoning, rational decision making, problem
  solving, etc
• Increases the ability of the cortex to process,
  inhibit, and organize reflexes, impulses,
  information, and emotions
• Increases ability to engage thought with affect,
  words with emotion, and reason with unconscious
  behavior (Seigal,1999)

124
LIMBIC REGULATION

• Limbic system plays a critical role in the
  regulation of emotion and memory
• Primed clients need to re-wire their brains by
  learning new skills/options
• Clients need to be in a state of attentive calm
  to learn new cognitive or behavioral
  skills/options
• Emotions/impulses Logic/reason

125
ELEMENTS OF EFFECTIVE THERAPEUTIC INTERACTIONS

• COMPREHENSIVE ASSESSMENT -- conduct
  comprehensive assessment that includes substance
  abuse issues, mental health issues, head trauma
  information, cognitive impairment, and
  abuse/neglect history
• HOPE -- provide an internalization of a better
  way of life, change is possible, re-wiring the
  brain is possible, world does not have to be a
  negative and threatening place

126
ELEMENTS OF EFFECTIVE THERAPEUTIC INTERACTIONS

• SAFETY provide understanding of persistent fear
  and hyper vigilance. Help client develop a state
  of attentive calm. Calm client uses cortex and
  can engage in abstract thinkinganxious client
  uses limbic system and focuses on non-verbal
  information and survival.
• ROLE PLAYING, MUSIC, IMMEDIATE REWARDS, AND ROLE
  MODELS provide corrective experiences, activate
  several areas of the brain including frontal
  cortex, and create new memories/options

127
ELEMENTS OF EFFECTIVE THERAPEUTIC INTERACTIONS

• CORRECTIVE THINKING correct false assumptions,
  reframe thinkingclient is not bad, stupid, sick,
  or damaged
• STRUCTURE provide a safe, predictable,
  consistent environment that helps to reduce
  anxiety
• DISCERNMENT provide experiences in which
  clients practice reading facial expressions
  and social situations

128
ELEMENTS OF EFFECTIVE THERAPEUTIC INTERACTIONS

• INFORMATION help clients understand how their
  brains develop how brain function impacts
  behavior and process for re-wiring the brain
• HOT/COLD COGNITION during stressful, emotional,
  or threatening situations problem solving
  information in the cortex is not easily accessed
  clients need practice and concrete ways to access
  information and skills

129
SUMMARY

• Coping behaviors are the result of an
  interaction between genetics and environment. If
  relationships are negative, threatening, and/or
  fear inducing, the lower brain responses become
  dominant and the cognitive regulating structures
  do not develop to their full capacity
  consequently, an individual may not develop the
  cognitive ability to control emotions or behavior.

130
SUMMARY

• Professionals need to educate themselves and
  their clients about brain development
• Interventions must activate those portions of the
  brain that have been altered or underdeveloped
  (Perry, 2000)
• Positive therapeutic experiences can contribute
  to healing and growth

131
SUMMARY

• Start efforts as early as possible preschool
• Engage teens in discussing the rules and
  consequences
• Provide monitoring and mentoring for teens
• Provide opportunities to practice decision making
  during hot cognition situations

132
SUMMARY

• Educate teens regarding health risks
  consequences of their decisions
• Provide high stimulation pro-social activities
• Provide opportunities for teens to be involved in
  community service (bigger picture)
• Provide repetition (neural connections)

133
SUMMARY

• Stay actively involved in teens lives
• Despite scientific advancements basic tenets of
  spending loving, quality time with teens is
  critical to provide strong scaffolding
• Provide supportive services when difficulties
  occur do not assume that teens will grow out
  of it

134
LEARNING IS A PROCESS OF CREATING AND
STRENGTHENING NEURAL SYNAPSES AND CORTICAL
INTEGRATION
135
Barbara Sullivan, Ph.D.Utah Addiction
CenterUniversity of Utahbarbara.sullivan_at_hsc.uta
h.edu