Risk behavior and addiction in adolescence – Literatuur
Week 1
‘Addiction, adolescence, and the integration of control and motivation’ (Thomas E. Gladwin, et al.)
- The likelihood of initiating addictive behaviors in higher during adolescence than during any
other developmental period. The differential developmental trajectories of brain regions
involved in motivation and control processes may lead to adolescents’ increased risk taking in
general, which may be exacerbated by the neural consequences of drug use. Neuroimaging
studies suggest that increased risk-taking behavior in adolescence is related to an imbalance
between prefrontal cortical regions, associated with executive functions, and subcortical
brain regions related to affect and motivation. Dual-process models of addictive behaviors
are similarly concerned with difficulties in controlling abnormally strong motivational
processes. We acknowledge concerns raised about dual-process models, but argue that
they can be addressed by carefully considering levels of description: motivational processes
and top-down biasing can be understood as intertwined, co-developing components of more
versus less reflective states of processing. We illustrate this with a model that further
emphasizes temporal dynamics. Finally, behavioral interventions for addiction are discussed.
Insights in the development of control and motivation may help to better understand – and
more efficiently intervene in – vulnerabilities involving control and motivation.
- In this review, we will focus on symmetries between adolescence- and addiction- related
changes in motivation and cognitive control that may help explain increased the likelihood of
substance abuse and the onset of addiction in adolescence.
- Adolescence is the developmental period between childhood and adulthood, shared by humans
and other mammal species. During adolescence, children increasingly master the ability to
control their behavior for the benefit of longer-term goals. These advances in self-
regulation abilities in adolescence, however, are accompanied by pronounced changes in
motivational processes. These can have profound consequences for health in adolescence, as
the imbalance between relatively strong affective processes and still immature regulatory
skills might contribute to the onset of developmental disorders.
- Adolescents are known to have a tendency to take more and greate risks than individuals in
other age groups in many life domains, such as unprotected sex, criminal behavior, dangerous
behavior in traffic, and experimenting with and using alcohol, tobacco, and legal or illegal
drugs. Typically, the occurrence of these risk-taking behaviors follows an inverted U-shape
pattern across development, being relatively low in childhood, increasing and peaking in
adolescence and young adulthood, and declining again thereafter.
- Insights from anatomical and functional changes in the rodent and the human brain have led to
neurobiological models characterizing the ‘adolescent brain’ by two interacting systems: The
first is the relatively early maturing and ‘hot’ affective-motivational bottom-up system and the
second is the more slowly developing ‘cold’ top-down control system. The hypothesis that
these brain systems develop at a different pace during childhood and adolescence and into
young adulthood has received support from anatomical brain development studies. The
above frontostriatal model of adolescent decision-making thus describes a potential for
imbalance in motivational bottom-up versus controlling top-down processes.
Obviously, there are individual differences in the extent to which adolescents and adults
are prone to take risks. Nonetheless, in adolescence individuals are more likely to take risks
than in adulthood, and therefore especially in this phase of life, it is important to understand
the triggers that may cause some adolescents to take unhealthy risks, such as in the case of
addiction.
- Drug use is an example of risky behavior that is of particular concern in adolescence.
Current neurobiological research has identified two broad types of neuro-adaptations that
result from repeated alcohol and drug use:
, o 1) First, neural sensitization leads to strong impulsive reactions to classically
conditioned cues that signal alcohol or drugs, and there is evidence from animal
research that this occurs more rapidly during adolescence.
o 2) Second, there is evidence that heavy alcohol and drug use results in impaired
control functions, especially when heavy use takes place during adolescence.
In summary, while most adolescents experiment with at least some addictive substances,
only few of them become addicted. This highlights the importance of better understanding
individual differences, especially in development, that form risk or protective factors for
addiction. Further, there is mounting evidence that adolescent substance use may
exaggerate the normal inverted U curve of risky behavior in adolescence, and may in some
cases postpone or even prevent the decrease in risky behaviors normally starting in early
adulthood.
‘Developmental Risks for Substance Use in Adolescence: Age as Risk Factor’ (Manuel Lopez-Leon,
et al.)
- The use, abuse, prevention, and treatment of substance use disorders in children and
adolescents is of grave concern; not the least since its prevalence is rising, the age of first
usage is falling, and the morbidity and mortality of youths with any substance use is
increasing. Substance use can interfere with natural growth and normal interaction and
development, including relationsips with peers, performance in school, attitudes toward low
and authority, and acute and chronic organic effects.
- Consideration of the factors that create risk that adolescents will use a substance of abuse must
first address that these are individuals who are undergoing a peculiar phase of their lives
where their own peer, social, family, biological, and educational domains are themselves risk
factors for the initiation or the maintenance of substance misuse. The greatest risk for
substance use of any form in adolescence is the effect of peers, which may be followed by
psychiatric conditions, genetic components, and other social forces. But for each individual
adolescents other non-diagnostic forces include thrill-seeking or sensation-seeking behavior,
insufficient impulse control, insufficient abstract reasoning or planning, and omnipotent
feelings.
- Given that any exposure to some substances can have lasting deleterious effects, it is
important to consider the factors that lead to occasional, experimental or sub-diagnostic use
among adolescents. Such factors include peer or family influences, as well as curiosity,
judgement, impulse control, sensation-seeking or thrill-seeking behavior, or challenges to
authority.
- As part of the process of developing into a young adult, adolescents undergo a series of
changes in their attitudes and behaviors. This developmental period produces several
phenotypic behaviors that may impact both misuse and advanced forms of use:
o 1) Inexperience and risky behaviors Risk-taking behavior may or may not include
substance experimentation, but does include several dangerous activities.
o 2) Rebelliousness In their search for identity and independence, adolescents often
demonstrate a desire to resist authority and experiment the opposite of whatever is
conventional.
o 3) Sensation-seeking Interest in sensations may come from boredom or from som
ereaction to one’s psychological environment.
o 4) Identity formation Adolescence is a period in which youths develop sexual
maturity and establish their identity as individuals in society.
- Given the importance of understanding, treating, and preventing all forms of substance use
among adolescents, it is also valuable to appreciate theories of how this use progresses:
o 1) The Gateway Hypothesis: the Risk of “Experimental” Use Kandel’s Gateway
Hypothesis was developed in the 1970s; it posited a progressive causal chain sequence
of psychoactive substance use that begins with experimentation with legalized
psychoactive substances (i.e., alcohol and/or tobacco), followed by cannabis use, and
, then continues with other illegal psychoactive substances, for example, cocaine,
heroin, amphetamines, and LSD. The “gateway drugs” are considered “softer”
psychoactive substances, that is, alcohol, tobacco, and cannabis. They are the
“stepping stones” to “harder” psychoactive substance use. This hypothesis assumes
that the “gateway drugs” increase the proportion of users going onto more potent
substances.
Prevention programs based on Kandel’s hypothesis are directed toward preventing
the use of specific “gateway drugs,” which in turn might help reduce the initiation of
more potent ones.
There are frequent exceptions to the gateway sequence model. Besides the
gateway sequence model, other variables can affect the course of psychoactive
substance use. For example:
1A) Substance availability
1B) Birth cohort
1C) Comorbid psychiatric illnesses/dual diagnoses
1D) Non-diagnostic personal characteristics
o 2) The Reverse Gateway Hypothesis The Reverse Gateway Hypothesis posits that
for some nicotine smokers, cannabis use precedes nicotine. Thus, it assumes that
cannabis use predicts later nicotine initiation and/or nicotine dependence in those who
had not used nicotine before. Thus, cannabis might be a “gateway drug” to
nicotine.
- Conclusion = While “experimentation” may be difficult to define, it is understood that many
people experiment with addictive substances for the first time during adolescence, and some
people will continue to use these substance into adulthood. There are risk factors associated
with experimentation including availability, attitudes, andd family dynamics. The
clinician’s job is to assess for both experimentation and the risk of experimentation as well as
to continually assess fort he risk of experimentation transitioning to substance abuse or
dependence.
‘A General Introduction to the Concept of Addiction and Addictive Effects’
- The subsequent sections of this chapter discuss variously used definitions or conceptions of
addiction. Both substance and behavioral (process) addictions describe behavior that results
in clinically significant impairment:
o 1) Substance addiction pertains to repetitive intake of a drug (such as alcohol) or of
food.
o 2) Behavioral addiction pertains to engaging in types of behaviors repetitively which
are not directly taken into the body such as gambling or sex.
- A variety of behaviors very recently have become to be considered addictions by researchers
and practitioners, delineated by common features (e.g., appetitive effects, preoccupation,
subjective sense of loss of control, negative consequences).
- The etymology of the word ‘addiction’ has a rather long history, though the concept of
addiction as a serious type of problem in living is relatively new: At its origin, addiction
generally referred to ‘giving over’ or being ‘highly devoted’ to a person or activity, or
engaging in a behavior habitually, which could have positive or negative implications.
- History of substance addictions A brief glimpse at different substances of abuse provides
evidence of common features of addiction, including achieving an appetitive effect,
preoccupation, loss of control, and a variety of negative social or situational consequences.
- History of behavioral addictions The historical literature presents descriptions of gambling
and sex addictions. Other behavioral addictions have been less often discussed in historical
writings, or more ambiguously depicted.
In the article by Gladwin et al. (2011) you can skip the text and model on page 369 and 370, up to
the heading “6. Interventions”. This part will not be part of the exam material! Just to prevent
misunderstandings, the tekst under “6. Interventions” is part of the exam material.
Week 1
‘Addiction, adolescence, and the integration of control and motivation’ (Thomas E. Gladwin, et al.)
- The likelihood of initiating addictive behaviors in higher during adolescence than during any
other developmental period. The differential developmental trajectories of brain regions
involved in motivation and control processes may lead to adolescents’ increased risk taking in
general, which may be exacerbated by the neural consequences of drug use. Neuroimaging
studies suggest that increased risk-taking behavior in adolescence is related to an imbalance
between prefrontal cortical regions, associated with executive functions, and subcortical
brain regions related to affect and motivation. Dual-process models of addictive behaviors
are similarly concerned with difficulties in controlling abnormally strong motivational
processes. We acknowledge concerns raised about dual-process models, but argue that
they can be addressed by carefully considering levels of description: motivational processes
and top-down biasing can be understood as intertwined, co-developing components of more
versus less reflective states of processing. We illustrate this with a model that further
emphasizes temporal dynamics. Finally, behavioral interventions for addiction are discussed.
Insights in the development of control and motivation may help to better understand – and
more efficiently intervene in – vulnerabilities involving control and motivation.
- In this review, we will focus on symmetries between adolescence- and addiction- related
changes in motivation and cognitive control that may help explain increased the likelihood of
substance abuse and the onset of addiction in adolescence.
- Adolescence is the developmental period between childhood and adulthood, shared by humans
and other mammal species. During adolescence, children increasingly master the ability to
control their behavior for the benefit of longer-term goals. These advances in self-
regulation abilities in adolescence, however, are accompanied by pronounced changes in
motivational processes. These can have profound consequences for health in adolescence, as
the imbalance between relatively strong affective processes and still immature regulatory
skills might contribute to the onset of developmental disorders.
- Adolescents are known to have a tendency to take more and greate risks than individuals in
other age groups in many life domains, such as unprotected sex, criminal behavior, dangerous
behavior in traffic, and experimenting with and using alcohol, tobacco, and legal or illegal
drugs. Typically, the occurrence of these risk-taking behaviors follows an inverted U-shape
pattern across development, being relatively low in childhood, increasing and peaking in
adolescence and young adulthood, and declining again thereafter.
- Insights from anatomical and functional changes in the rodent and the human brain have led to
neurobiological models characterizing the ‘adolescent brain’ by two interacting systems: The
first is the relatively early maturing and ‘hot’ affective-motivational bottom-up system and the
second is the more slowly developing ‘cold’ top-down control system. The hypothesis that
these brain systems develop at a different pace during childhood and adolescence and into
young adulthood has received support from anatomical brain development studies. The
above frontostriatal model of adolescent decision-making thus describes a potential for
imbalance in motivational bottom-up versus controlling top-down processes.
Obviously, there are individual differences in the extent to which adolescents and adults
are prone to take risks. Nonetheless, in adolescence individuals are more likely to take risks
than in adulthood, and therefore especially in this phase of life, it is important to understand
the triggers that may cause some adolescents to take unhealthy risks, such as in the case of
addiction.
- Drug use is an example of risky behavior that is of particular concern in adolescence.
Current neurobiological research has identified two broad types of neuro-adaptations that
result from repeated alcohol and drug use:
, o 1) First, neural sensitization leads to strong impulsive reactions to classically
conditioned cues that signal alcohol or drugs, and there is evidence from animal
research that this occurs more rapidly during adolescence.
o 2) Second, there is evidence that heavy alcohol and drug use results in impaired
control functions, especially when heavy use takes place during adolescence.
In summary, while most adolescents experiment with at least some addictive substances,
only few of them become addicted. This highlights the importance of better understanding
individual differences, especially in development, that form risk or protective factors for
addiction. Further, there is mounting evidence that adolescent substance use may
exaggerate the normal inverted U curve of risky behavior in adolescence, and may in some
cases postpone or even prevent the decrease in risky behaviors normally starting in early
adulthood.
‘Developmental Risks for Substance Use in Adolescence: Age as Risk Factor’ (Manuel Lopez-Leon,
et al.)
- The use, abuse, prevention, and treatment of substance use disorders in children and
adolescents is of grave concern; not the least since its prevalence is rising, the age of first
usage is falling, and the morbidity and mortality of youths with any substance use is
increasing. Substance use can interfere with natural growth and normal interaction and
development, including relationsips with peers, performance in school, attitudes toward low
and authority, and acute and chronic organic effects.
- Consideration of the factors that create risk that adolescents will use a substance of abuse must
first address that these are individuals who are undergoing a peculiar phase of their lives
where their own peer, social, family, biological, and educational domains are themselves risk
factors for the initiation or the maintenance of substance misuse. The greatest risk for
substance use of any form in adolescence is the effect of peers, which may be followed by
psychiatric conditions, genetic components, and other social forces. But for each individual
adolescents other non-diagnostic forces include thrill-seeking or sensation-seeking behavior,
insufficient impulse control, insufficient abstract reasoning or planning, and omnipotent
feelings.
- Given that any exposure to some substances can have lasting deleterious effects, it is
important to consider the factors that lead to occasional, experimental or sub-diagnostic use
among adolescents. Such factors include peer or family influences, as well as curiosity,
judgement, impulse control, sensation-seeking or thrill-seeking behavior, or challenges to
authority.
- As part of the process of developing into a young adult, adolescents undergo a series of
changes in their attitudes and behaviors. This developmental period produces several
phenotypic behaviors that may impact both misuse and advanced forms of use:
o 1) Inexperience and risky behaviors Risk-taking behavior may or may not include
substance experimentation, but does include several dangerous activities.
o 2) Rebelliousness In their search for identity and independence, adolescents often
demonstrate a desire to resist authority and experiment the opposite of whatever is
conventional.
o 3) Sensation-seeking Interest in sensations may come from boredom or from som
ereaction to one’s psychological environment.
o 4) Identity formation Adolescence is a period in which youths develop sexual
maturity and establish their identity as individuals in society.
- Given the importance of understanding, treating, and preventing all forms of substance use
among adolescents, it is also valuable to appreciate theories of how this use progresses:
o 1) The Gateway Hypothesis: the Risk of “Experimental” Use Kandel’s Gateway
Hypothesis was developed in the 1970s; it posited a progressive causal chain sequence
of psychoactive substance use that begins with experimentation with legalized
psychoactive substances (i.e., alcohol and/or tobacco), followed by cannabis use, and
, then continues with other illegal psychoactive substances, for example, cocaine,
heroin, amphetamines, and LSD. The “gateway drugs” are considered “softer”
psychoactive substances, that is, alcohol, tobacco, and cannabis. They are the
“stepping stones” to “harder” psychoactive substance use. This hypothesis assumes
that the “gateway drugs” increase the proportion of users going onto more potent
substances.
Prevention programs based on Kandel’s hypothesis are directed toward preventing
the use of specific “gateway drugs,” which in turn might help reduce the initiation of
more potent ones.
There are frequent exceptions to the gateway sequence model. Besides the
gateway sequence model, other variables can affect the course of psychoactive
substance use. For example:
1A) Substance availability
1B) Birth cohort
1C) Comorbid psychiatric illnesses/dual diagnoses
1D) Non-diagnostic personal characteristics
o 2) The Reverse Gateway Hypothesis The Reverse Gateway Hypothesis posits that
for some nicotine smokers, cannabis use precedes nicotine. Thus, it assumes that
cannabis use predicts later nicotine initiation and/or nicotine dependence in those who
had not used nicotine before. Thus, cannabis might be a “gateway drug” to
nicotine.
- Conclusion = While “experimentation” may be difficult to define, it is understood that many
people experiment with addictive substances for the first time during adolescence, and some
people will continue to use these substance into adulthood. There are risk factors associated
with experimentation including availability, attitudes, andd family dynamics. The
clinician’s job is to assess for both experimentation and the risk of experimentation as well as
to continually assess fort he risk of experimentation transitioning to substance abuse or
dependence.
‘A General Introduction to the Concept of Addiction and Addictive Effects’
- The subsequent sections of this chapter discuss variously used definitions or conceptions of
addiction. Both substance and behavioral (process) addictions describe behavior that results
in clinically significant impairment:
o 1) Substance addiction pertains to repetitive intake of a drug (such as alcohol) or of
food.
o 2) Behavioral addiction pertains to engaging in types of behaviors repetitively which
are not directly taken into the body such as gambling or sex.
- A variety of behaviors very recently have become to be considered addictions by researchers
and practitioners, delineated by common features (e.g., appetitive effects, preoccupation,
subjective sense of loss of control, negative consequences).
- The etymology of the word ‘addiction’ has a rather long history, though the concept of
addiction as a serious type of problem in living is relatively new: At its origin, addiction
generally referred to ‘giving over’ or being ‘highly devoted’ to a person or activity, or
engaging in a behavior habitually, which could have positive or negative implications.
- History of substance addictions A brief glimpse at different substances of abuse provides
evidence of common features of addiction, including achieving an appetitive effect,
preoccupation, loss of control, and a variety of negative social or situational consequences.
- History of behavioral addictions The historical literature presents descriptions of gambling
and sex addictions. Other behavioral addictions have been less often discussed in historical
writings, or more ambiguously depicted.
In the article by Gladwin et al. (2011) you can skip the text and model on page 369 and 370, up to
the heading “6. Interventions”. This part will not be part of the exam material! Just to prevent
misunderstandings, the tekst under “6. Interventions” is part of the exam material.
