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.
Adolescent risk taking almost always starts early
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