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

20

25

30

35

40

45

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

6

7

8

9

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

20

30

40

50

60

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

30

35

40

45

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

10

20

30

40

50

60

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

QUESTIONS?

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