Kevin Leehey M.D. Child, Adolescent, and Adult Psychiatry Board Certified

1. Kevin Leehey M.D.Child, Adolescent, and Adult PsychiatryBoard Certified 296-4280 leeheymd.com

2. Salpointe Catholic High SchoolCommunity of Concern What’s Brain Got To Do With It ? leeheymd.com

3. Nature vs. Nurture • Nature means biology, inheritance, genetics. • Nurture means environment, experiences. • Color perception is almost purely genetic. • Ability to learn language is genetic. But what language we learn is purely environmental. • Neither controls how we turn out in life. It’s both, the interaction of nature and nurture.

4. The brain develops at a different rate than the rest of the body. • Brain development allows physical, intellectual, emotional, moral, and spiritual development to occur. • The brain (biology, nature, genetics, inheritance) must interact with and be shaped by environment (experiences, nurture, parenting) to develop normally. • Understanding the process of brain (and body) development clarifies the need for parenting.

5. Brain Development • If a child is not played with, interacted with, nurtured, exposed to stimuli, or is rarely touched he/she will develop a 25% smaller brain. • Experiences shape and reshape the structure of the brain.

6. By the time a child is 6, his or her brain is 90 to 95 % of adult size. • Between age 6 and 12 neurons grow bushier by each neuron adding dozens of connections based on what is reinforced by learning and experience. • This is why such things as learning a second language, riding a bike, swimming, learning to play a piano, or to throw a ball are easier when young and can last a lifetime.

7. Neuron connections peak at 11 in girls and 12 to 13 in boys. • Unused connections are further pruned out in the teen years at the same time the white matter protective coating around neurons called Myelin Sheath cells increase. • The brain is becoming more efficient but also losing its raw potential for learning and ability to recover from trauma, drugs, alcohol, or injury.

8. Synapses that are used often are kept and reinforced. • Those that are not used are lost. • How you spend your time and the experiences you have or don’t have are critical.

9. The part of the brain that makes teens responsible is still under construction. • Brain development proceeds from back to front and bottom to top. • The Frontal Lobe, which controls impulses, motivation, and judgement is the last to develop. • Teen’s inconsistent Melatonin production contributes to irregular sleep patterns.

10. Normal Sleep Architecture

11. Neuron drawing; grown in lab; and as occur in layers in brain

12. What is a memory ? • “A memory is merely the probability that a certain group of neurons will fire again in the same way” • Short term vs long term memory • Role of dreams • Hippocampus (temporal lobe) • Thus cramming and little sleep is poor learning method • What and when you eat matters too

13. Normal Sleep Architecture

14. The left side of the brain is shown. Source: Shaywitz – Overcoming Dyslexia

15. Phineas Gage On 9/3/1848 at age 26, a 13 lb 3.5 feet long tamping iron blasted through his left ventromedial prefrontal lobe. He lived 12 more years but “Gage was no longer Gage”

16. A Neural Signature for DyslexiaUnder-activation of Neural Systems in the Back of the Brain Frontal (PFC, VMFC), Temporal (Limbic system - Hippocampus, Amygdala etc); Basal Ganglia> Striatum> Nucleus Accumbens Source: Shaywitz – Overcoming Dyslexia

17. Nucleus Accumbens is a collection of neurons within the Striatum with major role in reward, pleasure, addiction, and more. Amygdala is next to Hippocampus in the Temporal Lobe; is key for emotional learning, fear conditioning and memory. MFB = Medial Forebrain Bundle (collection of axons connecting these areas and more) VTA = Ventral Tegmentum Area (in midbrain near basal ganglia) drawing from Psychology Today

18. In Children, neither PFC (self control, impulse control, cognitive control) nor Striatum (risk taking, pleasure seeking) have developed much. In Adolescents the Striatum has developed but not the PFC. Finally in Adults both Striatum and PFC have developed a balance. Note the Striatum (includes Nucleus Acccumbens) develops in a spurt in Adolescence while the PFC develops consistently but slower. This is one reason why teens who know better get in a car with a drunk driver. JAACAP Vol 49 Issue 12 pgs 1189-1201

19. A- sensation seeking and impulsivity with age B – brain activity focused on reward (L) and effort needed for self control (R) JAACAP Vol 49 Issue 12 pgs 1189-1201

20. Neurobiology of the Adolescent Brain and Behavior : Implications for Substance Use Disorders by BJ Casey PhD and Rebecca Jones MS JAACAP Vol 49 Issue 12 Dec. 2010 pages 1189-1201 “…heightened vulnerability to risk taking in adolescence ‘may be due to the combination of relatively higher inclinations to seek excitement and relatively immature capacities for self control…’ “

21. ADHD – Deficits in Brain Reward System JAMA 9/9/09 pgs 1084-91 • “…Nucleus Accumbens and midbrain are 2 key regions for reward and motivation …” • “…impaired dopamine reward pathway in ADHD” • “The reward deficits in ADHD are characterized by a failure to delay gratification, impaired response to partial schedules of reinforcement, and preference for small immediate rewards over larger delayed rewards.” • This explains “why the attention deficits in ADHD are most evident in tasks that are considered boring (tasks or assignments that are not intrinsically rewarding.” • Dopamine reward deficit “…underlies the higher vulnerability to substance abuse in this population.”

22. The interaction of Nature and Nurture The Parenting you give to your child up to 18 to 25 years old is how the “Top – Down” cognitive, human thinking brain’s self control system develops and learns to over ride and integrate the emotional and sensation seeking animal brain’s focus on impulses and pleasures of the moment.

26. Thus you must parent. • You are the most powerful and important environmental (“nurture”) force. • Remember it’s the interaction between nature (biology) and nurture (environment) that determines the outcome. • Parenting is “hands on” thru 11-13, “hands around” thru 17-19, “hands under” thru 18-25, then “hands off”. • Parenting is the building of character, instilling values and self discipline, and teaching independent living skills. This develops the brain.

27. The teen brain is more vulnerable to the stimulating, damaging, and addicting effects of nicotine, alcohol, and other drugs. • One in three teens who start smoking as a teen will die of a tobacco related disease. • 90% of adult smokers began as teens. • Almost 45% of kids who start drinking alcohol by 13 will become alcoholic, while only 10% of those who wait till 21 will. • Substance use in youth thus becomes hard wired in as a tendency for life. This is in addition to any genetic predisposition.

28. Healthy Subject watching video of using Substance abuser in remission watching video of using

29. Computers can be trained to recognize what a person is thinking about by comparing patterns of brain activation. For example, when a person thinks about hitting a tennis ball, the supplementary motor area and other regions are activated (blue), but when the same person thinks about moving from room to room, the parahippocampal place area and other regions are activated (red). (Reprinted) JAMA, January 19, 2011—Vol 305, No. 3 page 237

30. Bad things can happen to Good kids • Typically people don’t say, “I think I’ll get a DUI and ruin lots of lives today.” • No one says or thinks, “Gee, today I’m gonna drink, smoke, or use a drug so I can become an alcoholic or addict.”

31. Causes of death ages 15-24 : • Accidents -primarily motor vehicle, many are substance impaired. • Suicide • Homicide These 3 account for 75% of all deaths in our kids. Suicide and homicide are mostly by guns and many are substance impaired.

32. Suicide Rate for Age Group 15-19 by Year AACAP NEWS

33. 2011 Trends – Good • Teen birth rate lowest in 70 years • MVA deaths lowest in 60 years – safer cars, DUI enforcement, attitude change • Teen use of methamphetamine, alcohol, ecstasy, cocaine, cigarettes are slightly down • Youth suicide rate is down again

34. 2011 Trends – Bad • Drugs kill more than cars do in > 16 states • Prescription medicine and Marijuana abuse continue to rise • Teens + College age use: #1 alcohol, #2 marijuana, #3 cigarettes, #4 “pills”= Adderall (stimulants), opiates, benzos, DXM, Soma • Spice, K-2, synthetic (legal) cannabanoids

35. 2011 Trends - Ugly • Smoke (Head) shops • Cigarettes, snuff, dip, chew, cigars, hookah. Tobacco in all its forms is by far #1 preventable cause of death. Alcohol is #3 • Opiates, Benzodiazepines, Ambien, Soma, Stimulants (includes ADHD meds), DXM • Be aware, legal drugs + medicines are just as dangerous to abuse as illegal drugs are

36. Marijuana, pot, grass, weed • Perceptual distortions • Short term memory loss • Apathy, lack of, motivation • Out of touch with own feelings, denial of sad, mad, down, etc • The point of substance use is to alter feelings, thoughts, perceptions, reality • Relationship problems • Self medication of MH and life problems • MJ can cause or worsen mental illness

37. Safer cars; more opiates abuse Drug related death rate doubled in 10 years. 8 states 2004; 12 in ‘05; 16 in ’06; ? now Opiates (Vicodin, Oxycontin, oxy and hydrocodone, methadone, heroin), Cocaine MA, NH, RI, CT, NY, NJ, MD, PA, OH, MI, IL, CO, NV,OR, UT, WA Drugs now kill more people than cars do in 16 states.

38. Actual Causes of Preventable Deaths

40. Opiates and more… • Vicodin, Percodan, Percocet, methadone, oxycontin • Oxycontin 50 cents to $1/ mg • HEROIN - smoked, foil, $40/gram, IV • Benzos – Xanax “bars”, Klonopin, Ativan, Valium • Sleeping pills - Ambien • “Triple C’s”, “DXM”, Robitussin, dextromethorphan • Spice, K-2, Salvia, Head and Smoke shops; fake urine • ADHD medicine abuse, stimulants like Adderall • Meth, Crystal, methamphetamine • Soma, muscle relaxers • Ecstasy, “club drugs”, hallucinogens, PCP, Inhalants • Hookah, Shisha do contain nicotine • energy drinks – caffeine, guarana, taurine, Four Loco

41. Tobacco kills more than all drugs and alcohol together. • Youth drink to get drunk - binge on as much as possible as fast as possible. Drinking games. • 60% HS seniors have had intercourse. • >50% HS seniors drink regularly. • 25% HS seniors smoke cigarettes. • 33% HS seniors use other drugs • 60% teens will try other drugs by end of HS

42. Parenting Tips • Don’t leave town and leave your teen home alone. Don’t rent hotel rooms, etc for kids. • Cell phones make “flash” parties possible. • Don’t trust sleepovers and campouts. • Call other parents. • If you’re the host check what’s up. • Have your teen wake you up when they come home. Talk to them, get close. • Seat belts, air bags, slower speeds, less passengers, home before midnight, and safer cars save lives.

43. Parenting Tips II : • Teen’s main source for alcohol and prescription medicines to abuse is your and their friends’ homes. • 2% of us over age 40 smoke marijuana daily. • Teens know homes where parents allow or give alcohol, “weed”, other drugs, or sex to your kids. • If you want your kids to come out of their rooms keep the electronics out. • Internet and gaming are best monitored out of their bedrooms.

44. Parenting Tips III • Social networking (Facebook, MySpace, Twitter, YouTube, etc) is here to stay. Check, know passwords, teach what’s OK, not OK, why. • High schools now require internet, word processing. College requires even more. Ensure they learn now – with supervision. • Offer a phone, computer, gaming with features that fit the age and developmental level of your child or teen. Increase with age and trust. Agree on a plan of you checking for appropriate use. • You can control calling, texting, internet use, hours, phone numbers allowed and banned – all of it. All cell companies have these controls – use them.

45. Parenting Tips IV • YOU are your child’s + teen’s #1 influence ! • If they see you drunk/impaired/partying they are 33% more likely to drink or use. • If you say, imply, or even think it’s OK or inevitable that they’ll drink or use, then they are 10X more likely to do so. • If you repeatedly (not nag) tell them not to, then they are 10X less likely to drink or use. • Say “No”, Don’t try to be the “Cool” parents, and don’t try to be your kids’ “Best Friends” ! • Read the C of C booklet - it’s very useful !

46. Thank you and good luck… Kevin Leehey M.D. leeheymd.com 296-4280