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
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3. 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
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4. Lecture Covers Definitions How an AUD develops Why adolescents
Unique research challenges & solutions
Clinical example
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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
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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
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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
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9. 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
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10. Lecture Covers Definitions How an AUD develops Why adolescents
Unique research challenges & solutions
Clinical example
AMSP 2017

11. Why do people drink?
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12. Expectations (Expectancies)
What do I expect to happen?
If ____________; then ____________
Ø drinking required
Will change with drinking experience
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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
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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
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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)
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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
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17. 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 ↑
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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
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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
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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
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22. Adolescent Sensitivity to Alcohol
Primarily preclinical (animal) studies
↓ sensitivity aversive & impairing effects
↑ sensitivity social-facilitation & rewarding effects
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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
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24. Summary: Why this Matters?
Drinking often starts & ↑ rapidly in adolescence
Sensitivity & expectancies  AUDs
Adolescent brains  AUDs
Adolescence sets stage for AUD development
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25. Lecture Covers Definitions How an AUD develops Why adolescents
Unique research challenges & solutions
Clinical example
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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?
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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)
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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?
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29. EMA Example for JoAnne Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 8am
6pm
2am
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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
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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?
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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
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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.”
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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?”
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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,
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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.”
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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
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39. Lecture Covered Definitions How an AUD develops Why adolescents
Unique research challenges & solutions
Clinical example
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40. Takeaway Points Adolescent drinking is common but not without harms
Adolescents are not tiny adults: differences  AUD
Research & intervention during adolescence is key
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