Risk taking adolescents: When and how to intervene
In counseling teens and their parents, weigh potential consequences of sensation seeking
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
