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Risk taking adolescents: When and how to intervene
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.