Evidence-Based Reviews

Risk taking adolescents: When and how to intervene

Current Psychiatry. 2004 October;3(10):40-55

References

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.

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.

Related resources

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.