From the 2010 Annual Meeting….
BY Dominic Ferro, M.D.
In his address, Dr. Koplewicz displayed the erudition and eloquence that made him a most deserving recipient of ASAP’s Schonfeld Award. His address was entitled “More than Moody: Adolescent Angst, Depression and Suicide Risk”.
The concept of adolescent angst dates back to Anna Freud’s assertion that an adolescent not experiencing angst is missing an important stage of development. Adolescence is a period of dramatic change. The adolescent must adapt to the physical changes of puberty, to the demands of individuation from parents or guardians, to the development of complex social networks, to begin to conceive vocational goals and to define their sexual orientation. Modern neuroscience validates and clarifies the challenges faced by the adolescent.
In the human frontal cortex, the seat of executive functions, adolescents undergo an intense pruning of synaptic connections. An astounding peak of synaptic connectivity occurs during the second year of life, and it is during adolescence that connectivity declines to the modest levels of adults.
These neurological findings are consistent with the findings of cognitive scientists regarding executive functioning during adolescence. They have demonstrated that adolescents are about as capable as adults at discerning the risks and benefits of behavioral choices. However, they are not as adept at conforming their behavior. For instance, adolescents demonstrate awareness of the risks of driving while intoxicated, yet teen driving is the number one killer of adolescents. Similarly, adolescents understand the risks involved, but also have high rates of unprotected sex, smoking, vandalism and stealing.
Other findings indicate that adolescents do not process the facial expressions of others as well as adults. This correlates with imaging evidence that during tests of facial expression recognition, adolescents have greater activity in the amygdala than adults, whereas adults evidence greater activity in the prefrontal cortex. The amygdala is associated with emotional reactivity, particularly fear response, where as the prefrontal cortex is more involved in pattern recognition.
Adolescents are subject to intense passions, which contribute to increased risk behavior. They are also subject to high reward sensitivity, and as a result they tend to seek high levels of stimulation. So, it is not surprising that adolescents are more subject to peer influence and emotional arousal than adults.
Dr. Koplewicz reflected on the role of this constellation of changes in the adolescent brain and the resulting increase in risky behavior. In order to elucidate what adaptive function this might serve, he drew a parallel with the behavior of adolescent monkeys. He noted that in many species, the adolescent male takes a tremendous risk by leaving the safety of family and of familiar environs. Singly and in small groups, adolescent males seek to join and mate in other troops, thus increasing genetic diversity. Yet, in so doing they may be rejected or attacked by the troop members. The individual must become insensible to the individual risks and press on in service of improved survival as a species.
Dr. Koplewicz clarified the emerging picture of adolescent development and pathogenesis. He noted that 75% of serious mental illness starts during adolescence. He noted that, given all these changes, it is not surprising that suicidal ideation is a common phenomenon during this time of life. The roots of suicide contagions can be seen in light of the frequency of suicidal ideation, coupled with the increased vulnerability to peer influence. Impulsivity increases the risk of substance use disorders, which complicates treatment for depression and increase the risk of suicidal behaviors.
With regard to treatment, it is important to increase the adolescent’s future orientation, as their increased impulsivity and affective intensity tend to narrow their focus to the immediate term. Evidence suggests that more active treatments which engage the adolescent with greater interaction and which challenge latent cognitive abilities, such as CBT and DBT, are more effective for adolescents. The immediacy of the adolescent brain may necessitate more frequent sessions, perhaps even more frequent that once per week.
Dr. Koplewicz also spoke about incorporating what we know about adolescent strengths in our interventions. For instance, he noted that data reflect that adolescent males tend to use their seatbelt when they drive with adolescent females, but not when they drive with other adolescent males. He coupled this with data indicating that increased use of condoms can be attributed to increased demands made by female adolescents. Public health interventions are therefore more likely to be effective if they are directed at the female adolescents.
Our profession is fortunate to have a leader like Dr. Koplewicz working to apply clinical and basic sciences to aid in the formulating and intervening in the lives of our adolescent patients. The opportunity to honor him was one of the special moments of the 2010 Annual Meeting.