Etiological factors

in substance abuse

Ms. Giovanna Campello

UNODC Prevention, Treatment and
Rehabilitation Section
Forming the evidence base for prevention
Brain function in a social context
Outline

• Developmental stages
• Influences on drug use
– Personal characteristics
– Micro-Level risk factors
– Macro-Level risk factors
• Implications for prevention
Developmental phases
Drug use is a developmental problem
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!!!
Infancy
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
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
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
Adolescence
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
Even under normal conditions, the adolescent
prefrontal cortex is not completely connected!

ti o n
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o n s
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 The “Imbalanced” Adolescent Brain

 Emotional responses are  Cognitive controls are

heightened immature

Double Jeopardy!

Emotional Cognitive
Reactivity Regulation
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.
Interaction of Personal Characteristics and the Micro-
and Macro-Level Environments
Primary Developmental Outcomes and their
Environmental and Personal Influences
Types of Influences on Behavior
• 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
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
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.
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
Stress, drug use and addiction
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.
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.
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
Personality & Temperament

• A difficult temperament and – High activity level

certain personality – Risk taking tendencies
characteristics are – Lack of regard for negative
consistently related to consequences
heightened risk for drug use. – Lack of pain avoidance
responses
– Impulsivity
– Abnormal levels of arousal in
– Aggressiveness
response to stress.
– Sensation or novelty-seeking
– Negative affect
– Impaired judgment
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.
Micro-Level Influences: family, school, peers
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.
Parenting Styles That Interfere with Healthy Child
Development
• 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
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.
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.
Micro level influences: peers
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.
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.
Sex differences in peer influences
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.
Macro level influences:
poverty, social and physical environment
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
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
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!
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.
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
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
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.
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
Macro influences of the physical environment
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
Some conclusions
Implications of the research
for 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.
Implications of the research
for drug prevention (2/2)
– Appropriately targeted interventions may be particularly
impactful for disadvantaged children who experience social
ills.
• A comprehensive evidence-based set of solutions to
prevent drug use operates to enhance multiple domains
of brain function.
Take away message 1
The earlier, the better

• The earlier the intervention, the more effectively we

can…
– Redirect behavioral pathways
– Increase resiliency
– Reduce exposure to the potentially long-term adverse effects
of the above etiological conditions, including the early use of
drugs itself.
Take away message 2
Prevention is timeless

• Even very young children can manifest early signs of

future mental, emotional, and behavioral disorders that
increase risk for later drug use.
• A great deal is known about how to prevent, monitor,
and treat these problems to ensure children reach their
highest potential.
• In all cases and ages, an enriched environment,
external supports, and high quality education is
essential.
Take away message 3
It’s never too late!
• Many mental health, emotional, and behavioral problems stem
from impulsive, sensation-seeking activities in adolescence
• Problems important to monitor and prevent include:
– Early alcohol, tobacco, and other drug use
– Violent and delinquent behaviors
– Depression and suicide
– Risky sexual behaviors
• In adulthood, influences persist and require address to prevent
further escalation of use, addiction and relapse.
• Fortunately, there is tremendous brain plasticity and maturation
of functions through adolescence and early adulthood
– Provides a solid window of opportunity to improve outcomes
Thank you!