Review
Automatic and controlled processes and the development of addictive behaviors in adolescents: A review and a model

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Abstract

This paper presents a review and a model of the development of addictive behaviors in (human) adolescents, with a focus on alcohol. The model proposes that addictive behaviors develop as the result of an imbalance between two systems: an appetitive, approach-oriented system that becomes sensitized with repeated alcohol use and a regulatory executive system that is not fully developed and that is compromised by exposure to alcohol. Self-regulation critically depends on two factors: ability and motivation to regulate the appetitive response tendency. The motivational aspect is often still weak in heavy drinking adolescents, who typically do not recognize their drinking as problematic. Motivation to regulate use often develops only years later, after the individual has encountered serious alcohol-related problems. Unfortunately, at that point behavioral change becomes harder due to several neurocognitive adaptations that result from heavy drinking. As we document, there is preliminary support for the central elements of the model (appetitive motivation vs. self-regulation), but there is a paucity of research directly addressing these mechanisms in human adolescents. Further, we emphasize that adolescent alcohol use primarily takes place in a social context, and that therefore studies should not solely focus on intra-individual factors predicting substance use and misuse but also on interpersonal social factors. Finally, we discuss implications of the model for interventions.

Introduction

This paper proposes a model for the development of addictive behaviors in (human) adolescents, with a focus on alcohol, the most popular drug among teenagers in many parts of the world (NIAAA, 2005). In most general terms, the model proposes that addictive behaviors develop as the result of an imbalance between two systems: (1) an appetitive, approach-oriented system that becomes sensitized with repeated alcohol use, leading to relatively automatic action tendencies to approach alcohol (or other drugs), and (2) a regulatory executive system that is not fully developed until young adulthood and that is compromised by sufficient exposure to alcohol. In addition, there is evidence that the controlled regulatory processes are strongly weakened by the acute effects of alcohol, whereas more automatic, approach-oriented processes are not and can even be primed by drinking alcohol. Self-regulation does not only depend on ability to inhibit appetitive tendencies, an individual should also be motivated to do so. Usually, the motivation to regulate addictive behaviors is low in adolescents, because adolescents often do not recognize their alcohol and drug use as problematic. As our review will show, there is preliminary support for both central elements of the model (appetitive motivation vs. self-regulation), but it should be emphasized that there is a paucity of research directly addressing neurocognitive mechanisms involved in the development of addictive behaviors in (human) adolescents. The model is conceptually related to several other recent models of addictive behaviors that posit the importance of both sensitized reward processes and compromise inhibitory control as a result of prolonged alcohol or drug abuse (e.g., Jentsch and Taylor, 1999, Robinson and Berridge, 2003, Volkow et al., 2003, Lubman et al., 2004, Dawe et al., 2004). The model we present differs from those earlier reviews primarily in terms of the research tradition on which it is based. Specifically, whereas previous reviews were based on the neurobiological animal literature (e.g., Jentsch and Taylor, 1999, Robinson and Berridge, 2003), human neuroimaging and neuropsychological studies (e.g., Volkow et al., 2003, Lubman et al., 2004) and personality research (e.g. Dawe et al., 2004), the present model is primarily based on behavioral and electrophysiological research in human adolescents and young adults, with a focus on recent studies that have tried to assess relatively automatic cognitive motivational processes. Throughout the paper, where possible, we attempt to link the concepts and findings to underlying neurobiological mechanisms and models. We also devote attention to individual differences in relation to different aspects of the model, concentrating on data in which high-risk individuals like children of alcoholics (COAs) are compared with low risk controls. Intra-individual factors such as sensitized, appetitive response systems and a dysfunctional regulatory system are emphasized, but it is recognized that adolescent alcohol use is typically contextualized in social interactions in peer groups. Finally, we discuss implications of the model for intervention.

Section snippets

Explicit measures of appetitive motivation

Much research has been focused on the prediction of alcohol use with explicit, self-report measures of appetitive motivation to consume alcohol. The pioneering work of Goldman and Brown and their colleagues on alcohol expectancies (Brown et al., 1980, Goldman et al., 1999), and the work by Cooper and colleagues on drinking motives (Cooper, 1994, Cooper et al., 1995), are key examples of this approach. The general idea in these approaches is that individuals differ in their expected

Control over appetitive motivation

Once an individual has initiated drinking (and/or the use of other drugs) and as a result the appetitive motivation to use alcohol has increased (especially after exposure to drug cues), it becomes important whether he or she gives in to this impulse or controls it. In line with other dual process models in psychology (e.g. Fazio, 1990, Fazio and Olson, 2003, Metcalfe and Mischel, 1999, Payne, 2005), we propose that there are two crucial factors which determine whether the impulse to drink or

Acute and chronic effects of alcohol and drugs

When consumption of alcohol and other drugs is seen as the result of a dynamic interplay between relatively spontaneous appetitive motivational processes on the one hand, and controlled regulatory processes on the other hand, it becomes important to consider what happens to both processes as a result of alcohol and drug use, while distinguishing acute and chronic effects.

Regarding acute effects, there is evidence that a small dose of alcohol primes appetitive motivational processes (e.g.

Individual risk factors

From the present perspective, individual risk factors can be related to all aspects of the model. First, there is evidence that individual differences in sensitivity to rewarding effects of a drug are related to the risk to develop an addiction (e.g. Kambouropoulos and Staiger, 2001). It is well established that children of alcoholics (COAs) are at enhanced risk for the development of addiction (see Sher, 1991). There is also evidence that they demonstrate stronger psychomotor stimulant

A caveat: it's the environment, dummy!

In all of the above, the emphasis has exclusively been on intra-individual factors that may predict why one adolescent develops an alcohol or drug problem, while the other does not. An important caveat is that researchers often ignore the fact that most alcohol and drug use in adolescence takes place in the social environment (e.g., Knibbe et al., 1993), and that the social environment itself is already an important predictor of alcohol use and misuse. A (social) context can trigger appetitive

Implications for interventions

From the present perspective, there are different strategies one can employ in interventions tailored to adolescents. The most important thing appears to be to try to minimize alcohol and drug use during adolescence, given the effects described above (sensitization of stimulant response and weakening of self-regulating abilities). Of course, the million dollar question is how to effectively achieve this. Given the fact that most alcohol- and drug use takes place in a social context, approaches

Conclusions and issues for further research

From the present perspective, the development of addictive behaviors in adolescence goes through different phases. In the first phase the individual is still able to regulate cue-induced appetitive motivational tendencies, but is not motivated to do so. In later phases, once enough alcohol- or drug-related problems are experienced, the individual may be more motivated to regulate appetitive inclinations. However, at this point, the ability to do so is compromised, due to two effects of chronic

Acknowledgements

Reinout W. Wiers is supported by “VIDI” grant 452.02.005 from the Dutch National Science Foundation (N.W.O.) and N.W.O. Addiction grant 31.000065. Bruce D. Bartholow is supported by a Research Board Grant from the University of Missouri. Carolien Thush by N.W.O. Addiction grant 31.000065. Susan L. Ames, Jerry Grenard and Alan W. Stacy are supported by grant DA16094 from the National Institute on Drug Abuse (NIDA). We thank T. van Uijen, D. Schaafsma and M. van de Braak for help in the

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