Etiological factors in substance abuse

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

2. Forming the evidence base for preventionBrain 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 • 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!!!

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. Even under normal conditions, the adolescent prefrontal cortex is not completely connected! Under Construction

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

15. 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.

16. Interaction of Personal Characteristics and the Micro- and Macro-Level Environments

17. Primary Developmental Outcomes and their Environmental and Personal Influences

18. 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 Types of Influences on Behavior

19. 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

20. 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.

21. 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

22. Stress, drug use and addiction

23. 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.

24. 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.

25. 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

26. 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. Personality & Temperament

27. 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.

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

29. 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.

30. 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 Parenting Styles That Interfere with Healthy Child Development

31. 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.

32. 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.

33. Micro level influences: peers

34. 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.

35. 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.

36. Sex differences in peer influences

37. 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.

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

39. 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

40. 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

41. 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!

42. 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.

43. 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

44. 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

45. 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.

46. 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

47. Macro influences of the physical environment

48. 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

49. Some conclusions

50. Implications of the researchfor 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.