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

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

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

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

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

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

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

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

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

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

Why do people drink? AMSP 2017

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EMA Example for JoAnne Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 8am 6pm 2am AMSP 2017

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

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

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

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

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

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

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, AMSP 2017

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

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

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

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