sandra a. brown, ph.d. professor of psychology and psychiatry university of california, san diego...
TRANSCRIPT
Sandra A. Brown, Ph.D.Professor of Psychology and
PsychiatryUniversity of California, San
DiegoChief, Psychology Service Veterans Health Service
System
Research Supported by Grants from: NIAAA, NIDA, and NIMH
ADOLESCENT ALCOHOL PROBLEMS, INTERVENTION AND
OUTCOMES
Adolescence: Biological Onset and Behavioral Offset
• Rapid Changes in all systems (biological, social, emotional, behavioral)
• Accelerations in Experimentation and Risk Taking
• Progression to Independence Dominates Adolescent Development
• Development of Self-Regulation - neurocognitive foundations - affect management is priority - behavioral choice & control - new environmental contexts
Copyright ©2004 by the National Academy of Sciences
Gogtay, Nitin et al. (2004) Proc. Natl. Acad. Sci. USA 101, 8174-8179
Fig. 3. Right lateral and top views of the dynamic sequence of GM maturation over the cortical surface
Structure and Function Changes as Brain Maturation continues into the 20s
Maturation Sequence:
-Structures that Underlie
Coordination& Affect First
-Planning and Inhibition More
Slowly
Image Removed – Awaiting Copyright Permissions
Alcohol’s Unique Role in our Society: Preferred Drug of Youth
Source: Monitoring the Future, 2003
0
5
10
15
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50
8th 10th 12th
Grade
Pe
rce
nt
Us
ing
in P
as
t M
on
th
Alcohol
Cigarettes
Marijuana
• Use less often
• Greater intensity
Youth Drink More Dangerously than Adults: Less often but at Higher Doses
TEENS DRINK HALF AS OFTEN BUT TWIICE AS MUCH AS ADULTS
Source: SAMHSA National Survey on Drug Use and Health, 2002
4.79
2.67
4.87
8.91
0
1
2
3
4
5
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10
Underage Adults
Drinks per Occasion Drinking Days per Month
(12-17) (26 and older)
Youth Who Drink Commonly Report Alcohol Related Problems in Domains
Critical to Successful Development
• 38% of 12-17 year olds who drank last year reported 1 or more alcohol related problems
• Binges most common at 16-17 for girls and 17-19 for boys (National Epidemiological Survey on Alcohol and Related Conditions, NESARC)
• 53% of high school seniors drank 10 or more times last year and
2/3 had at least 1 alcohol problem1/3 had 3 or more problems
(National Household Survey on Drug Abuse, SAMHSA)
(Monitoring The Future; O’Malley, Johnston & Bachman)
Progress through School
• Enter and
Complete High School
Alcohol: integrated into school activities
Academic Problems
Low Involvement
Mortality/Morbidity
1 IN 3 REPORT ALCOHOL HURT
GRADES
Drivers License
• Permit• License
Alcohol: Accidents Injuries Deaths1 IN 5 UNSAFE DRIVING
½ SINGLE VEHICLE CRASHES RELATED
New Types of Relationships
• Stable Friendships• Romance• Sex• Children
Alcohol:Early/Risky/
Unwanted SexDysynchronies
1 in 2 regret behavior1 in 5 relationship problem
Prevalence of Past-year DSM-IV Alcohol Dependence: United States, 2001-2002
0%
2%
4%
6%
8%
10%
12%
14%
Grant, B.F. et al., Drug and Alcohol Dependence, in press 2004.
PEAK IS BEFORE SUBSTANCE IS LEGAL NESARC
No Use
Users
Hazardous Use
½ High School students binge
Abuse/Dependence
Need for Youth Alcohol Interventions
Many youth are not screened or diagnosed
3.7 million have AUD, < 10% with AUD receive treatment in Alcohol/Drug Facility
Institute of Medicine
Routine Screening is a Critical Link in the Prevention and Early Treatment
of Drinking, Drug Use and MH Problems
• Screening – Sends a message of concern
– Is an opportunity for youth to ask knowledgeable adults about alcohol
– Is an opportunity to intervene before or after problems develop
– Should be standard in multiple settingsSurgeon General’s Call to Action, 2007
Screening with Brief Intervention Works
Youth expect and are open to discussing alcohol and drug use (Steiner, 1996. Stern, 2006)
And that screening and brief interventions can reduce alcohol, tobacco and marijuana use. (Knight, 2005, McCambridge, 2004, Oze et al, 2003)
Brief Interventions in emergency rooms can reduce both adolescent alcohol use and problems (Monti et al, 2004)
Diverse longitudinal patterns of alcohol use across adolescence and young adulthood
1. Non or infrequent heavy drinkers (63%)
2. Developmentally limited/or decreasing (16%)
3. Late Onset or Increasing heavy drinkers(8%)
4. Chronic Heavy Drinkers (12%)Jackson, Sher & Schulenberg (2008)
In general alcohol use increases to early 20s and then decrease across the rest of lifetimePatterns of Heavy (5+drinks) drinking from ages 18 to 26:
For AUD/SUD youth in treatment: Alcohol continues as top drug
(over represented in relapse)
0
10
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30
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70
80
Perc
ent U
sing
6-Month 1-Year 2-Years 4- Years 6-Years 8-Years
Alcohol
Marijuana
Other Drugs
Multiple
Brown et al (2006) Frontlines NIAAA
10 Year Alcohol/Drug Use Trajectories of Treated Adolescents
1. Abstainers-infrequent use (30%)
2. Late Adolescent Resurgence (18%)
3. Early 20’s Resurgence (14%)
4. Heavy Drinkers –no drugs (16%)
5. Heavy Drinkers/Drug Dependent (16%)
6. Chronic Severe (6%)
Anderson et al (2008)
10 Year Alcohol and Drug use Trajectories
following Adolescent Treatment:
Anderson et al (2008)
Frequency of use related to: • dependency symptoms • substance problems• functional life problems
Image Removed – Awaiting Copyright Permissions
Co morbidityCo morbidity
•Disruptive Disorders
•Depression & Anxiety
•Reduces Success-6 mo.
•Influences Relapse
negative affect
cog/beh symptoms
relapse alone
2/3 report worse MH symptoms after relapse
AUD Adolescents With MH Disorders Do More Poorly after Alcohol/Drug Treatment than
Other Adolescents and Adults
0
20
40
60
80
100
0 3 6 9 12
Months After Treatment
% A
bstain
ers
Project MATCH Aftercare
Project MATCH Outpatient
Adolescents
Adolescents: Comorbid
Tomlinson et al (2004)Ramo et al (2005)
Early Life Risk Factors are linked to Neural Response, Expectancies & Adolescent Drinking
Neural Activation
Personality(Trait Disinhibition)
Cognitions(Expectancies)
Alcohol/Drug Use
Working MemoryCue Reactivity
Response Inhibition
Positive Social
Activating
RI linked to: Sustained/selective attentionInhibitory control of habitual behaviorRisk taking decisions
Anderson et al (2005)
Why Be Concerned about Alcohol Exposure During Adolescence?
Evidence from Animal StudiesCompared to Adults, Adolescent animals are:
• Less sensitive to sedative effects of acute intoxication• More sensitive to disruption of memory, impairment of
neurotransmission in hippocampus and cortex, and social facilitation
• Greater vulnerability of neural progenitor cell proliferation and survival in hippocampus
Binges during adolescence produces long-lasting memory effects and damage to frontal-anterior cortical regions.
Prolonged ethanol exposure enhances withdrawal and produces changes in cortex and hippocampus.
BASIC RESEARCH SUGGESTS WE UNDERESTIMATE IMPACT OF ALCOHOL ON ADOLESCENTS
Goldman, NIAAA, 2005; Crews et al, 2006
Neurocognitive Impact of Alcohol on Youth: > 100 Drinking Episodes
Middle Adolescence -Fewer Learning Strategies -Memory/Recall Impairment Late Adolescence -Attention Decrement -Visuospatial Impairment Withdrawal May Impact Different Abilities than Use.
Most Consistent
AUD youth Retain 10% less of learned information 20 minutes after acquisition
compared to Matched Community Teens
Brown et al (2000)
75%
80%
85%
90%
95%
100%
VerbalInformation
NonverbalInformation
Ret
enti
on R
ate
AlcoholDependent
NonabusingComparisons
•Gender•Age •Grade •SES•FH•3 wks abstinent•20 minute delay test
10%10% 10%10%
Neurocognitive Functioning Deteriorates with Continued Alcohol Use After Treatment
20
25
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50
55
60
Treatment Four-Year Follow-Up
Timepoint
Vis
uo
sp
ati
al T
-sc
ore
Good treatmentoutcome
Post-txwithdrawal butNo recent use
Post-txwithdrawal andRecent use
Tapert & Brown (1999)
Teen Drinking & Brain Activity During Spatial Working Memory: Compensation to
Deactivation Hypothesis? Non-Drinkers Heavy Drinkers
Activation
Activation
De-activation
De-activation
Age 16
Age 20
Brown & Tapert (2004)
Greater Alcohol Cue Reactivity of AUD Adolescents compared to Controls
Non-Alcohol Pictures
++
Alcohol Pictures
+
+ +
Tapert et al (2003)
AUD Adolescent Brain Response to Alcohol Cues is Pronounced Even with Abstinence
• Orange: AUD teens had greater increase in response to alcohol pictures relative to other beverages (3 weeks abstinent)
LEFT HEMISPHERE
Anterior cingulate & NAc
Orbital/prefrontal (BA11)
•Emotion
•Interest
•Craving
Tapert et al (2003)
No Use
Users
Hazardous Use
Abuse/Dependence
Few Alcohol Interventions are Available Before Youth get in Trouble with Authority
Prevention
Secondary Prevention
Secondary Intervention
Treatment
Cognitive Behavioral
Family Therapy
Community Reinforcement
Motivational Enhancement
12 Step
Building Developmentally Informed Preventive Interventions for Youth
Youth Preferences -Formats Enhance -Context Engagement -Content
Intervention Research -Perceived Norms Improve -Quit Attempts Effectiveness -Change Strategies -MET & CBT -Facilitators/Barriers
Developmental Issues - Brief/Accessible Foster - Confidential Healthy - Support Autonomy & Development
Decision MakingBrown (2001)
. ***
.19*.00
.17 +
.04
.11
.20*
.18*
.42***
.31***
.05
12-Step Participation Helps Youth Remain Abstinent by Sustaining Motivation
Coping Skills
Self-Efficacy
Motivation for Abstinence
Days Abstinent
Coping Skills
Self-Efficacy
Motivation for Abstinence
Days Abstinent
12-Step Attendance
.37***
Treatment Intake 1-3 Months Follow Up 4-6 Months Follow Up
Kelly et al (2000); Kelly et al (2008)
44
Project Options: Example of Youth Focused Early Intervention for Alcohol Problems1. Approach and content appealing to youth
•Motivational Interviewing Style•Alter Perceived Norms and Expectancies for Use/ Non-Use•Encourage Cognitive and Behavioral Strategies of Teens
•Facilitators and Barriers•Multiple Formats and Topics/Teen Concerns
2. Market to attract youth with diversified alcohol involvement histories
3. Test intervention•Voluntary Engagement•Satisfaction with Services•Mediators and Proximal Outcomes•Distal Alcohol Outcomes
Developmental Social Information Processing Model: Designed to Support
Decision Making and Self Regulation Skills
Use & Cessation
Expectancies Change Efforts
Self-Selected Treatment
Perceived Norms
Motivation
Alcohol Use & Problems
Engagement Proximal Outcomes
Distal Outcomes
MediatorsBrown et al (2005)
Project Options: Brief Intervention
FormatsFormats SessionsSessions LocationLocation TimeTime
Group <6 Classroom Lunch
Individual <6 Classroom Lunch
Website <6/Unlimited Anywhere Anytime
•Normative Feedback
•Use/Abstain Expectancies
•Successful Quits
•Alternative Activities
•Behavior/Affect Regulation
•Relations/Communication
ENGAGEMENT = Voluntarily Attendance and Satisfaction with Services
• 10% of Students Self-Select the Intervention• 30% Freshmen 36% Juniors/Seniors
• 34% Sophomores
• 55-78% Current Drinkers– 1.4-2.0 times school base rate for frequent, binge drinking
and alcohol problems
• Proportional Representation of Gender/Ethnic Groups
•Boys and Hispanics Group
•Boys and Asians Website
•Seniors Individual
• SATISFACTION = 1.3-1.6 (1=Great to 5=Poor) D’Amico et al (2006)
Decision Making Influences are Changed: Perceived Norms
0
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70
Monreal et al (2008)
Per
cen
tage
Pre-Treatment Proportion
Post-Treatment Level of Reduction
OVERESTIMATION
Alcohol Quit Attempts for Project Options and Matched No Intervention Use Groups
0
10
20
30
40
Limited Moderate Frequent
No InterventionProject Options
*p<.05. SIGNIFICANT REDUCTIONS IN PROBLEMS
(physical, school, relationships)
Brown et al (2005)
This Developmentally Informed Model of Early Intervention Design may fit for High Risk Populations and Emergent Mental Health
Problems of Adolescents
• Minorities in same or greater proportion than at the schools
• Youth in Project Options reflect base rates of depression (20-25% of students)
• Higher rates of bullying and harassment are reported in Project Options sample than school samples (2X)
• Advertising focuses on issues salient to youth at risk for other drug and mental health problems
Copyright ©2004 by the National Academy of Sciences
Gogtay, Nitin et al. (2004) Proc. Natl. Acad. Sci. USA 101, 8174-8179
Fig. 3. Right lateral and top views of the dynamic sequence of GM maturation over the cortical surface
Developmental Neuroscience and Behavioral Science suggests such “SCAFFOLDING” approaches may Protect
and Facilitate Skill Development as the Brain Matures
Maturation Sequence:
-Structures that Underlie
Coordination& Affect First
-Planning and Inhibition More
Slowly
Image Removed – Awaiting Copyright Permissions
UCSD ADDICTION RESEARCH LAB
Maryam Kia-KeatingSuzette GlasnerKevin CumminsMichelle DrapkinKaren HansenSonya Norman
Marya SchulteTeresa MonrealSeth BergerKatherine PattersonMark PrinceAlecia Schweinsburg
Mark AppelbaumMark MyersSusan TapertSusan TateJohn KellyDenis McCarthyDean Delis
Jane MetrikKevin FrissellKristen AndersonJohn ChalekianJohn LightDanielle RamoKristin Tomlinson