1. Etiological factors in substance abuse
Ms. Giovanna Campello
UNODC Prevention, Treatment and Rehabilitation Section

2. Forming the evidence base for prevention Brain function in a social context

3. Outline Developmental stages Influences on drug use
Personal characteristics
Micro-Level risk factors
Macro-Level risk factors
Implications for prevention

4. Developmental phases

5. Drug use is a developmental problem

6. Developmental Phases
Involvement of each of these factors has implications for the ways in which children’s brains develop and function which, in turn, determines their ability to:
make sound decisions
problem solve
inhibit impulses
accurately perceive and process emotion
gauge consequences of their actions
self-regulate behavior and emotions.
Each stage of development, from infancy to early adulthood, is associated with a certain expected range of:
intellectual ability
language development
cognitive, emotional and psychological functioning
social competency skills
Each needs attention to prevent the onset of drug use and dependence!!! 6

7. Infancy

8. Infancy Protective Traits, Skill Sets & Experiences:
Responsiveness to the environment and caregivers’ interactions
Caregivers who are responsive
Surroundings that provide stimulation
Learning how to be effective in having needs met
Easy to soothe
Not temperamental

9. Early Childhood Factors Predictive of Later Social Competence:
Language
Cooperation
Control of emotions
Collective conscience
Social and emotional skills (including perception of others’ emotions)
Problem solving

10. Milestones in Middle Childhood
Emerging Executive Cognitive and Emotional Regulatory Functions:
Maintaining attention
Controlling emotions
Social inclusivity
Effective communication
Receptivity to others
Accurate perception of emotion in self and others

11. Adolescence

12. Adolescence
Integral to self-regulation of emotion and behavior to prepare for adulthood:
Social and emotional skills to establish stable relationships
Sensitivity to feelings & needs of others
Conflict resolution
Prosocial skills
Impulse control
Decision making
Problem solving

13. % in each age group who develop first-time cannabis use disorder
1.6%
1.4%
1.2%
1.0%
% in each age group who develop first-time cannabis use disorder
0.8%
0.6%
0.4%
0.2%
0.0% 5 10 15 18 25 30 35 40 45 50 55 60 65 70
Age
Age at cannabis use disorder as per DSM IV
NIAAA National Epidemiological Survey on Alcohol & Related Conditions, 2003 13

14. Even under normal conditions, the adolescent prefrontal cortex is not completely connected!
Under Construction
In adolescence, ECFs have not reach maturity
In contrast, demands for coping with competing social, biological, and academic changes are high
How they are handled has important long-term implications for emergence of risk behaviors. 14

15. The “Imbalanced” Adolescent Brain
Emotional responses are heightened
Cognitive controls are immature
Double Jeopardy!
Emotional Reactivity
Cognitive Regulation

16. Executive cognitive function (ECF) A multi stage process

17. Executive cognitive function (ECF) A multi stage process
Developmental milestones reflect extent to which executive cognitive functions (ECFs) are maturing:
They begin to form in early childhood and coalesce in late 20s.
Based on development of the prefrontal cortex (PFC) that regulates regions responsible for processing emotion and reacting to stress (limbic system).
Poor PFC control over limbic regions increase rewarding aspects of novelty seeking behaviors and addictive properties of drugs
ECF integrity thus forms the basis for behavioral self-regulation.

18. Significance of Developmental Phases for Prevention
Behavioral problems underlying drug use all involve poor self-regulation.
Social and physical environmental risk factors impact on executive-cognitive functions and emotion regulation.
This impact depends on:
Personal characteristics (e.g., depression, high activity levels, attention deficit disorder, etc.) which develop and evolve over time.
Developmental period of exposure to risk factors.
Not only adolescence!!!
Developmental phase determines what program components and policies will be understandable and executable.
This was addressed in slide 10? Merge with it and leave here or delete and use as speaking points to previous one?

19. Interaction of Personal Characteristics and the Micro- and Macro-Level Environments
Two broad categories of factors contribute to risk: genetic and environmental. Genetic variants that confer risk are like switches, either “on” or “off”. Their position is largely predetermined. For every genetic switch that is “on”, there may be some incremental increase in risk. Environmental factors are like dials, turned up or down depending on experience. As adversity dials are ramped up, risk is increased. No factor alone is sufficient to cause addiction; there is likely some critical combination of the number and type of switches that are on and dials that are turned up that crosses a liability threshold, in essence priming the brain for addiction. The threshold can be reached by any number of combinations of these factors, unique for each individual. The functional relationship between factors is also complex and not necessarily additive; e.g., some genetic risk variants may require specific environmental influences to increase liability (i.e., via epigenetics). Similarly the relationship between factors can be synergistic or even antagonistic. Finally, there are environmental dials that confer resiliency and may counteract or reduce the effect of genetic switches that are on.

20. Primary Developmental Outcomes and their Environmental and Personal Influences
Research has identified these environmental influences as key in determining ultimate behavioral outcomes. They do not act alone, however; they interact on personal characteristics to alter pathways to substance use and abuse. Thus, it is important that prevention strategies take into account these complex interactions to identify relevant targets for programs and policies in any given individual, community or population.

21. Types of Influences on Behavior
Personal Characteristics
Neurological delays
Stress reactivity
Mental health and personality traits
Micro-Level Factors
Family
School
Peer
Macro-Level Factors
Income and resources
Social environment
Physical environment

22. Neurological Deficits and Delays
When the prefrontal cortex is slow to develop or not functioning properly:
Inability to accurately interpret social cues
Negative emotions dominate
Impulsivity & low self control
Insensitivity to consequence
But…heightened sensitivity to rewards
Sensation-seeking
Poor stress reactivity
Inattention
Could the title here be neurological delays to be in line with the terms used in the previous slide? And the use corresponding headings in all related slides?
And explain in notes that it is especially the development of the prefrontal lobe that is crucial?
If you find this is different from the neurological delays, it could be moved back to be right after ECF – I was just trying to avoid repetition (but this is a very good slide and we would want to keep it regardless of the place)

23. Implications of Delays in Brain Development for Behavior
The signs of poor self-regulation due to deficits and delays vary as a function of developmental stage:
In younger children: language delays, poor school readiness and academic achievement, conduct problems, negative affect, insensitivity to consequences, and impulsivity.
In late childhood and early adolescence: aggression, sensation-seeking, delinquency, negative affect, and poor decision making and coping skills.
Detrimental environmental conditions (stress, maltreatment, poor nutrition, and other adversities) further compromise brain development and increase risk for drug use and addiction.
The part in italics repeats the previous slide, and the rest is good, but is also already addressing micro- & macro-level influences – should we still leave the parts that are not in italics or just delete this one, and perhaps move the text to speaking points? It would be good to mention the effects of enviromental conditions and stress, even if only in speaking points, to lead the presentation smoothly to the stress-part

24. Stress Exposures and Reactivity
Stress compromises development of brain systems that are at the basis of social, behavioral, cognitive, and emotional functioning
Stress disrupts hormones that regulate these functions
Exposure to repeated and/or severe stressors, such as child abuse, neglect, witnessing or experiencing violence, discrimination, poverty, etc., affect functioning in profound ways.
Physiological responses to stress include heart rate, blood pressure, skin conductance, etc.
This process impairs learning, memory, decision making, and other functions that support self-regulation .
Effects are associated with poor behavioral and emotional regulation and cognitive and coping skill deficits. 24

25. Stress, drug use and addiction

26. Stress, drug use and addiction
Stress activates the same brain [reward] systems responsible for the positive reinforcing effect of drugs
It may damage and cause further delays to the brain & ECFs
It increases physiological sensitivity to drugs
It increases desire to improve mood with drugs after exposure to stress
Stress more strongly predicts drug use when there is a psychiatric disorder, poor parenting, family dysfunction, and adverse neighborhood characteristics.
Stress, lack of social supports, and poor coping skills predict early onset and escalation of drug use, relapse, and treatment resistance.

27. Sex Differences in Stress Responses
Girls report more negative life events during adolescence than boys and are more adversely affected by them, especially interpersonal stressors.
Depression and anxiety are more common in girls starting in early adolescence.
Interestingly, Post-Traumatic Stress Disorder (PTSD) often precedes drug use in girls, but occurs more often after drug use in boys.
Girls are at increased risk for substance abuse when exposed to the stressors of family violence and alcoholism.
Preventive Implications: Sex differences should be taken into account in identifying factors that contribute to drug use and in the development of a prevention or treatment plan.
Delete this one and mention key points is the speaking points of previous slide? Sex differences are expalined in the background paper, and perhaps here we would not need to go in to the detail on this?
Girls may be self-medicating their symptoms.
Boys may be more likely to experience a trauma due to the risk situations associated with drug use.

28. Mental Health Problems (1/2)
Mental Health Disorders are strongly linked to drug use and dependence.
Internalizing Disorders (PTSD, Depression, Anxiety disorders, Bipolar disorder)
Brain responses are heightened in response to stress.
Tendency to self-medicate the anxiety & depression this process causes.
Daily social challenges may cause hyperreactivity of stress responses so that minor events become more difficult to master and/or produce anxiety and decline in self-efficacy.
More difficult to meet social task challenges which require intact neurocognitive and emotional functions that are often compromised in people with mental health issues 28

29. Mental Health Problems (2/2)
Externalizing Disorders (Conduct Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Antisocial Personality Disorder)
Low level of arousal in these disorders is related to an insensitivity to consequences and a need for more stimulation.
Heightens risk for continued drug use to relieve symptoms
Tend to be resistant to substance abuse treatment
Exacerbates stress reactivity problems
Conduct disorder and aggression in particular is the biggest risk factor for drug use. 29

30. Personality & Temperament
A difficult temperament and certain personality characteristics are consistently related to heightened risk for drug use.
Impulsivity
Aggressiveness
Sensation or novelty-seeking
Negative affect
Impaired judgment
High activity level
Risk taking tendencies
Lack of regard for negative consequences
Lack of pain avoidance responses
Abnormal levels of arousal in response to stress.

31. Importance of Personality in Adolescence
Normal adolescence is characterized by greater reward anticipation, sensitivity, and sensation seeking—particularly social rewards (e.g., peer regard, gains in social status).
It follows that adolescence is the period during which drug use onset is most common.
And, therefore, that adolescents with especially high levels of any combination of these traits are at heightened risk.
Preventive Implications: These traits can be redirected through psychosocial means to decrease risk for drug use. Prevention programs must be designed to specifically redirect this developmental track.
We have already seen how a good temperament can affect the attachment of caregivers (parents) to children, but it is in adolescence that this can get out of hand.
Prevention strategies will be most effective if they focus on these underlying traits, in conjunction with particular forms of environmental supports as indicated by the needs of targeted individuals, their families, and their neighborhoods 31

32. Macro-Level Environments Beliefs Attitudes Behaviors
Interaction of Personal Characteristics and the Micro- and Macro-Level Environments
Macro-Level
Environments
Personal
Characteristics
Beliefs
Attitudes
Behaviors
Micro-Level
Environments
Two broad categories of factors contribute to risk: genetic and environmental. Genetic variants that confer risk are like switches, either “on” or “off”. Their position is largely predetermined. For every genetic switch that is “on”, there may be some incremental increase in risk. Environmental factors are like dials, turned up or down depending on experience. As adversity dials are ramped up, risk is increased. No factor alone is sufficient to cause addiction; there is likely some critical combination of the number and type of switches that are on and dials that are turned up that crosses a liability threshold, in essence priming the brain for addiction. The threshold can be reached by any number of combinations of these factors, unique for each individual. The functional relationship between factors is also complex and not necessarily additive; e.g., some genetic risk variants may require specific environmental influences to increase liability (i.e., via epigenetics). Similarly the relationship between factors can be synergistic or even antagonistic. Finally, there are environmental dials that confer resiliency and may counteract or reduce the effect of genetic switches that are on.

33. Micro-Level Influences: family, school, peers

34. Micro-Level Influence: Parents and Family
The home environment is the single most profound influence on every aspect of child development
Effects of poor parenting are longstanding
Parents need to instill social and emotional regulatory skills early in life to resist substance use
Parenting and family continue to be important through adolescence when youth have more autonomy and opportunities for risky behaviors
Preventive Implications: Intervening at the parent level is crucial to improve child outcomes.

35. Parenting Styles That Interfere with Healthy Child Development
Negative influences
Insecure attachment
Lack of warmth & affection
Lack of supervision & monitoring
Poor disciplinary tactics
Inconsistent
Reinforcements for negative behaviors
Severely negative influences
Harsh
Restrictive
Domestic violence
Abuse & neglect
Hostile
High in conflict
Emotionally triggered
Caregivers who are not responsive

36. Links to Aggressive Behavior & drug use
Children exposed to stress and conflict in the home are more likely to:
Become more behaviorally and emotionally maladjusted
Have high levels of mental and physical health issues
Manifest high levels of aggressive behavior, the strongest predictor of later drug use and other risk behaviors
Characteristics of the family (e.g., cohesion, supportive, communicative) influence the ability to develop resiliency skills.
Preventive Implications for Exposed Children: Training in parent skills, relieving the stressors and mental health problems of caregivers, and trauma prevention and treatment strategies.

37. Micro-level influences: school and education
Lack of education or poorly equipped schools and teachers:
Slows child development, particularly cognitive functioning
Interferes with development of self-regulatory and social skills
Increases levels of stress, perceptions of inadequacy and failure
Related to lack of parental involvement in schooling
Compromises attachment to school (a resiliency factor)
Prevents us from availing ourselves of opportunities for early detection, intervention and treatment
Compromises children’s ability to succeed in life
Preventive Implications: Quality of schools, its teachers, curriculum, and students’ social networks in school are major socializing influences to be taken advantage of.
Unqualified teachers, ineffective teaching practices, and low-quality curriculum lead to academic failure which will prevent young people from succeeding in a variety of social domains in childhood and later in adulthood. And eventually poor quality education results in an inability to compete in the workforce and obtain jobs that pay a good wage for doing satisfying work which is also associated with substance abuse.
On the other hand, a child’s attachment to school is a component of resilience, suggesting that effective and responsive teachers, an evidence-based curriculum, classroom reinforcements, positive school culture, opportunities for school participation, and maintaining school building structures may play an important role in drug use prevention. 37

38. Micro level influences: peers

39. Micro-level influence: peers (1/2)
Peer relationships are influential socializing experiences that affect attitudes, skills, and “normative” behaviors:
Can supersede parent influences.
Presence of peers undermines executive decision making.
Time spent in unstructured settings (e.g., on street) heightens this effect.
Social networking technologies are very recently being used to exert positive effects by providing services and supportive messages to children who need them most (e.g., homeless, delinquent, or stressed).
Exposure to violence, drug use and crime can be an extension of peer influence. 39

40. Micro-level influence: peers (2/2)
Social networking technology removes parents from interactions with the child, further reducing their influence
Preventive Implications: Parents’ use of rules to monitor adolescents’ activities and encouraging healthy outside-the-home activities are critical to reducing negative peer influence.

41. Sex differences in peer influences

42. Sex differences in peer influences
Girls are influenced by peers differently than boys:
More likely to use drugs if friends & partners are using or introduces drugs to them.
Concerns about peer approval, depression and body image – all interrelated – increase susceptibility to drug use in girls.
Early onset of puberty increases risk for risky behaviors.
Tend to date at younger ages and be with older risk taking males
More conflict with parents around issues like dating, selection of friends, and shifting behavioral expectations.
Higher levels of conduct problems
Living in a poor community exacerbates the effect of peers on drug use risk for both sexes. 42

43. Macro level influences: poverty, social and physical environment

44. Macro-level influences of poverty (1/2) Societal level
Affects the quality of the environment
Limits choices and opportunities for adults to help children
Places a strain on social systems and supports
Increases conflict
Has adverse effects on parent and child health
Breaks down cooperation among residents and between community organizations
Consequences for children:
Difficult to teach children effective social skills they will need to interact with peers and other adults
Poor children are much more likely to grow up to be poor adults and raise children who suffer the same problems

45. Macro-level influences of poverty (1/2) Harming individual child and youth development
Increases stress in caregivers
Less able to attend to basic and emotional needs of the child
Child maltreatment and neglect is more common
Reduces ability to invest in learning & educational opportunities in school and day care
Compromises ability to be involved, patient, responsive and nurturing parents to their children throughout development.
The caregiving environment is more disorganized and lacking in appropriate stimulation and support
Creates conditions that are stressful for children
Interferes with growth, ability to respond adaptively to stress, development of psychological health and self-regulatory skills

46. The Good News!
High quality parenting has potential to mitigate the effects of poverty, particularly for girls!
This is one important target for preventive interventions!

47. Implications for Impoverished Children
Prevention strategies to develop skills to improve chances of success in school and life:
Increase availability of badly-needed services
Political and health care involvement
Increase efforts to reduce poverty and to avoid detrimental consequences on child development
Particularly with respect to learning the skills needed to escape poverty and succeed in life
Facilitate the implementation of comprehensive programs
Enact programs to alleviate the sources of poverty.

48. Macro-Level Influences of the Social Environment
The social environment of the larger community influences drug use risk through:
Shaping social norms
Enforcing patterns of social control
Influencing beliefs about the risks and consequences of using drugs
Effecting stress responses
Critical to maintain neighborhood viability and cohesiveness
Peers during adolescence are especially influential
Neighborhood viability includes issues such as observable violence, child maltreatment, public consumption of illegal drugs and other risky behaviors.
Those who believe substances will harm the body or mind, or will get them into trouble are less likely to use. For example, teens who view substance use favorably in terms of the benefits of substance use (e.g., being cool or population, weight control, self-medication, stress relief, or coping) are more likely to smoke, drink and use other drugs than those who perceive use less favorably or have stronger perceptions of risk 48

49. Social cohesion
Social Cohesion = attachment to and satisfaction with the neighborhood
Involves trust and support for one another in a community
Maintains norms for positive social behavior
Associated with lower drug use and lower drug-related mortality

50. Discrimination
Discrimination and social exclusion have profound negative effects:
Physical and mental health disorders, including drug use and dependence
Poor educational attainment & lower levels of employment
Restricted access to services and social supports
Effects are compounded for immigrants.

51. Political instability
Disrupts basic services; housing, sanitation, water, & health care
Orphaned, living alone on the street, or forced to be soldiers
Violence, unhealthy conditions, traumatized, and victimized
Deficits and delays in numerous functional domains
Preventive solutions could be found in governments that:
Protect child welfare
Prohibit them from entering war zones
Meet rehabilitation needs
Provide shelter, food and clean water
Provide psychosocial support to overcome damage
Political instability causes profound stress and adversity

52. Macro influences of the physical environment

53. Many aspects of the physical environment harm child development
Affects social relations, crime and drug use:
Decayed and abandoned buildings
Ready access to alcohol and drugs
Neighborhood disorder: vandalism, graffiti, noise, and dirt
Urbanization of the area
Neighborhood deprivation
Neurotoxins: lead, cadmium, mercury, arsenic, second-hand smoke
Prenatal exposure to drugs, alcohol, toxins, and nicotine
Negative [pro-drug] media messages
For all these external exposures, including media messages, they will impact each individual differently depending upon their personality and temperament and the extent to which their ECFs are in tact and the extent to which they have been exposed to social stressors and adversities. 53

54. Some conclusions

55. Implications of the research for drug prevention (1/2)
Behavioral problems underlying drug use all involve poor self-regulation and are preventable if appropriately addressed.
Evidence-based programs are designed according to information on etiology
Programs that target mechanisms underlying self regulation and, in turn, drug use is the key to prevention
Vast brain plasticity in childhood means there is great potential to improve functioning
Targeting socio-emotional and cognitive skills can redirect and normalize the developmental pathway.

56. Implications of the research for drug prevention (2/2)
Appropriately targeted interventions may be particularly impactful for disadvantaged children who experience social ills.
A comprehensive evidence-based set of solutions to prevent drug use operates to enhance multiple domains of brain function.

57. Take away message 1 The earlier, the better
The earlier the intervention, the more effectively we can…
Redirect behavioral pathways
Increase resiliency
Reduce exposure to the potentially long-term adverse effects of the above etiological conditions, including the early use of drugs itself.

58. Take away message 2 Prevention is timeless
Even very young children can manifest early signs of future mental, emotional, and behavioral disorders that increase risk for later drug use.
A great deal is known about how to prevent, monitor, and treat these problems to ensure children reach their highest potential.
In all cases and ages, an enriched environment, external supports, and high quality education is essential.
Children who are more aggressive with other children are more likely to have problems making friends and are more likely to have serious behavior problems, including criminal activity and drug use, as adolescents and adults. Children who refuse to follow instructions from teachers and adults are more likely to have difficulties in the classroom and more often find themselves in unsafe situations at home and in the neighborhood. Persistent sadness or excessive worry can signal larger problems like depression or anxiety that can cause difficulties in many areas of life. 58

59. Take away message 3 It’s never too late!
Many mental health, emotional, and behavioral problems stem from impulsive, sensation-seeking activities in adolescence
Problems important to monitor and prevent include:
Early alcohol, tobacco, and other drug use
Violent and delinquent behaviors
Depression and suicide
Risky sexual behaviors
In adulthood, influences persist and require address to prevent further escalation of use, addiction and relapse.
Fortunately, there is tremendous brain plasticity and maturation of functions through adolescence and early adulthood
Provides a solid window of opportunity to improve outcomes

60. Thank you!