How & Why Alcohol Use Disorders (AUDs) Develop in Adolescents

1. How & Why Alcohol Use Disorders (AUDs) Develop in Adolescents Hayley Treloar Padovano, Ph.D. Department of Psychiatry & Human Behavior Center for Alcohol & Addiction Studies Brown University AMSP 2017

2. Alcohol Use By Teens Is Common • Most used substance by teens • 80% high school seniors ever drink • 30% freshman through seniors ever drunk • Drinking to drunkenness ↑ in adolescence AMSP 2017

3. Teen Alcohol Use Can Be Harmful • Short-term effects • Unintentional injuries • Physical/sexual assault • Depression/suicide • Blackouts (memory loss) • ↓ grades • Risky sexual behavior • Alcohol poisoning/death • Long-term effects • Heavy drinking persists • ↑ later problems • ↑ risk of AUDs AMSP 2017

4. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

5. Clinical Case (JoAnne) • Is she at risk for AUD? • Follow her from age 12 to 17 • Typical child of a well-functioning family • At 12, no experience with alcohol • Familial history of AUD AMSP 2017

6. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

7. Heavy Drinking: Many Definitions • Typically • Amount: 5+ drinks • Timeframe: “in a row” or “in a sitting” • National Institute on Alcohol Abuse and Alcoholism • Pattern of drinking  breath alcohol .08g% • 4+/5+ drinks for women/men • 2 hour period AMSP 2017

8. Alcohol Use Disorder (AUD) • Recurring problems • Affecting multiple life areas • 5th Diagnostic manual of Amer Psychiat Association • (DSM5) ≥ 2 of 11 criteria, any 12 months • Diagnosis associated with • Long-term alcohol problems • Earlier death AMSP 2017

9. Alcohol Use Disorder (AUD) • ↓ Role obligations • Hazardous use • Strong craving • Interpersonal problems • Use despite problems • ↑ time obtain/use/recover • ↑ amount/time use • ↓ Other due to use • Desire/inability to ↓ use • Tolerance • ↑ amount for effect • ↓ effect/drink • Withdrawal (wtdwl) • Withdrawal syndrome • Drink to ↓/avoid wtdwl AMSP 2017

10. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

11. Why do people drink? AMSP 2017

12. Expectations (Expectancies) • What do I expect to happen? • If ____________; then ____________ • Ø drinking required • Will change with drinking experience AMSP 2017

13. JoAnne’s Expectancies at 12 &17 • J’s expectancies at 12 • If people drink, they fall, slur words, act funny • After alcohol experience, J’s expectancies at 17 • If I drink, I enjoy parties more AMSP 2017

14. Motives: Reasons for Drinking • What do I want to happen? • Motivational component • Drinking required • J drinks to • feel less anxious around people • be more social AMSP 2017

15. How AUDs Develop • Risk is genetic & environmental • Genes explain 50 to 70% risk • No single gene • Operate through intermediate characteristics: • How a person responds to alcohol • Impulsivity (acting without thinking) AMSP 2017

16. Low Level of Response (Low LR) • Initial alcohol responses • Can be seen first time drink • Sensitivity ≠ tolerance • ↑ drinking to get same effect • Changes expectancies & motives AMSP 2017

17. Low LR & JoAnne • Genetic risk  Environmental risk • To get desired effect, J drinks • More heavily • More often • J associates with friends who drink • More heavily • More often • J’s expectancies for + outcomes of drinking ↑ AMSP 2017

18. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

19. Adolescent Vulnerability • Adolescent heavy drinking predicts later problems • AUDs onset prior to legal drinking age • Not all “mature out” • 1 in 3 persistent problems AMSP 2017

20. Adolescent Vulnerability • By 17, JoAnne may have experienced • Blackouts (periods of memory loss) • Risky sexual behavior • Use in hazardous situations, e.g., driving while drunk • Trouble with police, e.g., minor in possession of alcohol • In college, J’s positive expectations & drinking persist AMSP 2017

21. Adolescent Brains • Immature brain  More efficient, mature brain • Back to front • Emotions before planning • “Gas pedal before brakes” • Forebrain critical for restricting behaviors • Adolescent brains focus on • Social interaction / peer affiliation • Novelty seeking / risk taking AMSP 2017

22. Adolescent Sensitivity to Alcohol • Primarily preclinical (animal) studies • ↓ sensitivity aversive & impairing effects • ↑ sensitivity social-facilitation & rewarding effects AMSP 2017

23. Adolescent Expectancies • Learned at early ages, before experience • Expectancies for positive outcomes ↑ • What we think happens when we drink  later problems • Predict • Intentions to drink • Onset of drinking • Heavy drinking • Problems • AUDs AMSP 2017

24. Summary: Why this Matters? • Drinking often starts & ↑ rapidly in adolescence • Sensitivity & expectancies  AUDs • Adolescent brains  AUDs • Adolescence sets stage for AUD development AMSP 2017

25. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

26. Challenges for Adolescent Research • Human laboratory studies often prohibited for adolescents • Legal & ethical restrictions • Precludes real-time understanding • What are J’s responses to alcohol in the moment? • What are J’s motivations to drink on a given day? AMSP 2017

27. Ecological Momentary Assessment • (EMA) • Observations in daily life • Repeated, real-time, real-world • Evolution of methods • Paper-and-pencil diaries • Repeated online surveys • Interactive voice response • Smartphones • Physiological (heart rate, breathalyzer) AMSP 2017

28. Ecological Momentary Assessment • Various formats • User-initiated or device-prompted • Report types • Check box, text or # entry, sliding bars • Schedule • When? Where? How many? How often? AMSP 2017

29. EMA Example for JoAnne AMSP 2017

30. Benefits • Increased ecological (real-world) validity • Avoids mis-remembering: “here & now” not “there & then” • Not only whether drinking  effect • Also for whom & under what circumstances AMSP 2017

31. Lecture Covers • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

32. Summary of Jo-Anne • Typical teenager, well-functioning family, genetic risk • Insensitivity to alcohol, ↑drinking, ↑drinking peers • Expectations & social norms change to be more positive • By 17 • J had consequences • + expectations still persist • What will her future hold? • Likely to drink heavily in college • Mature out or persistent AUD? AMSP 2017

33. How Might We Intervene for J? • Brief Motivational Interviewing • A style of conversation about change • Non-confrontational • Collaborative • Guide JoAnne to strengthen own motives/reasons to change AMSP 2017

34. Brief MI for JoAnne • Non confrontational “I want you to know right up front, I’m not going to tell you whether you should continue to drink alcohol or should cut down. Nobody can tell you want to do; only you can decide whether a change is right for you.” AMSP 2017

35. Brief MI for JoAnne • Identify + & − expectancies • Understand her reasons for & against “If it’s okay with you, I’d like to learn what you like and dislike about drinking & take a closer look at why you drink. How does that sound?” AMSP 2017

36. Brief MI for JoAnne • Draw out her own motivations & goals “Of the things you like about drinking, such as having more fun at parties and feeling less nervous, which effect matters most to you?” “Of the things you dislike about drinking, such as not remembering things and getting sick, which effect matters most to you?” AMSP 2017

37. Brief MI for JoAnne • Explore her ambivalence about change “On one hand you have really enjoyed drinking alcohol because it helps you to have fun & to relax. On the other hand, it has had a negative impact too in terms of not remembering things you’ve done or said while drinking & getting physically sick.” AMSP 2017

38. JoAnne’s Outcomes • J identified goal to ↓ drinking • Drank socially in college • Limited amounts & no harms • Went on to get law degree • Pictured with her son AMSP 2017

39. Lecture Covered • Definitions • How an AUD develops • Why adolescents • Unique research challenges & solutions • Clinical example AMSP 2017

40. Takeaway Points • Adolescent drinking is common but not without harms • Adolescents are not tiny adults: differences  AUD • Research & intervention during adolescence is key AMSP 2017