These areas are particularly important for adolescents’ processing of social information . The greater activation of these regions during the neurodevelopmental period of adolescence may be the result of substantive neurodevelopmental changes . These changes peak during adolescence, resulting in a relatively greater release of DA during this time frame . Practically, this means that risk taking behaviors, which are inherently exciting, frightening, and fun, may indeed feel much more rewarding during middle adolescence While it is clear that peers take on newfound significance during adolescence and that this shift has the potential to increase risk behaviors, an important body of work is beginning to reveal important caveats to this thesis. First, peer influence is also a powerful motivator for prosocial behavior during adolescence . Relatedly, while neural reward circuits are linked to a variety of risk behaviors during adolescence, VS and vmPFC reactivity to social cues also portend positive, prosocial development . Second, while peers become increasingly important during adolescence, this does not render parents as unimportant. Despite spending less time with parents, connectedness with parents can attenuate the impact of the enhanced reward circuit responses typical during adolescence, serving as a protective force insulating adolescents against risk behavior, stress and even depression . In fact, when compared with peers, parents show a significantly greater impact on adolescent decision-making . Understanding how adolescents navigate not only risk,growing cannabis but also prosocial peer interactions is one of the ultimate challenges for adolescent addiction treatment developers. We believe that this challenge is not insurmountable . Our task is to determine how best to channel youths’ drive and developmentally-unique cognitive systems to help them make more healthy choices. Summary.
These four developmental domains interact dynamically throughout adolescence , and are highly relevant to the adolescent addiction treatment context. For example, an adolescent’s environment can impact the nature and timing of puberty and vice versa; adolescents who look older may be treated differently than same-age adolescents who appear younger . These pubertal changes can alter the social spheres that adolescents are introduced to and experience . Moreover, social experiences, in turn, shape adolescents’ cognitive opportunities and related development early . Considering the interplay of these factors is crucial for understanding adolescent development as well as cultivating impactful programs to prevent and treat adolescent substance use. Throughout the past 3 decades, adolescent addiction treatment has shown some degree of capacity to catalyze and sustain behavior change in adolescents, but overall, results have been underwhelming . More specifically, despite several decades of efforts by experts to identify the best avenues to prevent and reduce adolescent substance use, few youth receive treatment . Of those who do, even when the treatment is grounded in evidence-based approaches and works well for adults, many youth do not show significant long-term changes in their substance use , with 86% returning to use within a year of treatment . As reviewed in Feldstein Ewing , this contrasts with the adult addiction literature, wherein a number of psychosocial interventions have much stronger impact in terms of instantiating and sustaining meaningful behavior change . For example, meta-analyses examining the efficacy of motivational interviewing indicate that in the context of addiction treatment, MI’s effect sizes are notably less robust for adolescents as compared with their impact with adults . At issue is that most of the interventions clinicians use with adolescents are “borrowed” from adult clinical addiction research . Yet the samples and populations utilized in large scale adult addiction studies, such as Projects COMBINE and MATCH , included inherently different populations, such as adults who largely self-referred to treatment. As a result, there is a notable gap between the nature of adults from whom these treatments were derived, and the nature of adolescents that we are trying to implement the same interventions with . Ultimately, better targeting with adolescent neurodevelopment in mind is likely to improve adolescent addiction treatment outcomes.
The poor generalizability of “adult” treatment to adolescents revolves around the significantly different conditions that make interactions within adolescent addiction treatment highly disparate from adults; within treatment sessions, adolescents face inherently different neurodevelopmental issues , disparate sociodevelopmental concerns , are on a different addiction trajectory , and in turn, have different treatment outcome goals than adults . Here, we include a brief overview of the challenges facing adolescent addiction treatment and its reporting, and our recommendations for avenues to improve best practices for clinicians and clinical research in this critical area of adolescent addiction treatment development.Absence of uniformly-agreed upon outcome in the adolescent addiction treatment literature. The current status of the field renders it quite difficult, if not impossible, to compare adolescent treatment outcomes across different treatment approaches . This is in contrast to the adult literature, wherein there are common, widely-agreed upon outcome metrics, such as percent days abstinent or drinks per drinking day . In this brief examination, numerous different categories of outcome variables were reported. The most common included number of substance use days, substance-related consequences, and quantity of substance use. This range of outcomes is likely to reflect a number of issues; one, as observed throughout the adolescent addiction treatment literature, there may simply be different targets for adolescent treatment response. More likely, this reflects that adolescents often show behavior change within one dimension of substance use , while still retaining high scores on another . Of greater concern to adolescent addiction practitioners, variance on outcomes may reflect reporting bias that favors treatment outcomes that withstood the test of statistical significance. One avenue to improve the field may be to report on commonly-agreed upon adolescent treatment outcome measures and do so regardless of statistical significance. We believe that this recommendation, to move toward a core outcome set in the field of adolescent addiction treatment, is highly important, and follows recent relevant initiatives, including the Scottish National Health System’s core outcome work , and the Core Outcome Measure in Effectiveness Trials Initiative . Notably, while these examples serve as excellent models, they have thus far been largely implemented with adult, rather than adolescent, clinical research studies. This fact again highlights the need for identifying and rolling out jointly-agreed upon core outcome metrics for adolescents in addiction treatment.Additionally, even when effect sizes are significant, it is not clear the degree to which reported outcomes are clinically meaningful with adolescent addiction patients. For example, one less drinking day per month may achieve statistically significance, but not a meaningful clinical change in terms of adolescents’ overall health, social, cognitive, and academic outcomes. In the adult literature, clinical impact has been defined as a statistically significant reduction in initial rates or problem scores, or a halving of initial symptoms . As with many other forms of adolescent health risk behaviors , a central measurement challenge is that adolescents engage in substance use sporadically and inconsistently . This makes treatment outcome measurement quite different from adults, whose use is often characterized by heavy, consistent patterns. For example, an adolescent may use alcohol very heavily , but then not drink at all during the initial months of the school year . Another avenue to improve the field is to examine pre-to-post changes in interference in functioning for youth; this represents changes in the degree to which alcohol or other substance use disrupts interactions with peers, with family, with school/other academic,cannabis growing and/or other relevant work/extracurricular obligations. To this end, examining reductions in interference in functioning is likely a more meaningful metric .
Examples of measures that can effectively access and assess this factor include the Rutgers Alcohol Problems Index and the Marijuana Problems Index . Substance substitution? While it is clear that adolescents tend to gravitate toward poly substance, rather than mono-substance, use , many adolescent treatment studies do not report treatment outcomes for non-target substances of abuse. For example, many measured treatment outcomes in alcohol , cannabis , tobacco ; some examine 2 substance categories, but include inconsistent pairings across each study . This is relevant, as many contemporary adolescent addiction treatment teams are trying to disaggregate whether or not youth are “swapping” out one substance for another, particularly in the changing cannabis and opioid landscapes . Our fourth recommendation to the field is our encouragement to explicitly examine and report outcomes across all types of substance use, to ensure that we can disaggregate the differential impacts and interactions that each substance might be having with the developing brain . This is likely to become an increasingly important issue in the field of addiction treatment as researchers move towards a precision medicine lens for understanding the genetic, lifestyle, psychological, social, and other bio-behavioral markers associated with treatment responsiveness . Of course, it should be noted that this point applies equally to adult studies, and to psychosocial interventions for most kinds of behavior disorders. Sadly, adolescent treatment has continued to lag behind advances made in other age groups in the journey towards precision medicine . Summary. Many adolescent addiction treatments appear to have clinically meaningful outcomes, but cross-treatment comparison and interpretation is not truly possible in the literature’s current state. At this time, inconsistent targets and timing obscure careful detection of comparative clinically-meaningful treatment gains . In turn, it is currently quite difficult to access the driving mechanisms and their intersection with potential developmental cognitive factors, and true treatment success in this age group. In turn, we make these recommendations for the assessment of adolescent treatment outcomes, with examples of how each recommendation maps onto relevant neural targets . It will be fascinating to continue to see if and how these developmental neuroscience findings translate to the clinic.While the previous section indicates that existing treatments available to adolescents have had difficulty examining behavior change, it is our position that actively considering the nature of the developing adolescent brain can inform the revision and approach of interventions with this age group. In other words, the developing brain gives us an invaluable perspective regarding what might “work” better in this age group in terms of prevention/ intervention. As summarized in Figure 1, we propose four key neurodevelopmental features of adolescence, and encourage approaching addiction interventions from this foundation as a promising first step in articulating prevention and intervention to the adolescent age group. Compellingly, in largely overlapping neural networks, those four features include: Puberty; Surge of cognitive skills Sculpting out of self; and Changing social landscape. Collectively, consideration of these factors, and their interplay, highlights several important themes to consider in developing novel clinical addiction approaches with this age group. Benefit of a prosocial perspective on prevention and intervention. First, consistent with G. Stanley Hall’s “storm and stress” perspective of adolescence, many existing adolescent-focused prevention and intervention approaches hinge on “problem focused” perspectives in substance use and its resolution. However, this does not play to the nature of the adolescent brain, which is increasingly being recognized as evolving and adaptive . As cited by Ellis , integrating considerations of adolescent neurodevelopment would likely generate more positive treatment outcomes if we took a positive, adaptive-focused perspective that plays to and enhances adolescents’ existing strengths in resilience, natural penchant to cognitive flexibility, and socially-adaptive and prosocial growth. This is an arena that is gaining increasing traction in adolescent addiction contexts . Non-traditional, but potentially highly impactful examples here could include clinical approaches that engage adolescents in helping younger peers, pairing problem users up with more successful youth in the same age group, and engaging adolescents in avenues for more successful positive change in their peer and greater social communities . A relevant point in this examination is that while a handful of emerging studies are beginning to include prosocial, resilience-focused models of adolescent behavior , a careful synthesis of these models has not yet been created. This is a critical avenue for future work, and will likely require not only examination of quantitative, but also mixed method, and qualitative research, as much of this emerging research is still in its inception and early stages of implementation. Maximizing their drastically developing cognitive skills. Adolescents are in the midst of experiencing a surge of new cognitive skills; at the most fundamental level, adolescents’ brains are organized toward and ready for adaptation .