1 FOUNDATIONS OF ADDICTIVE PROBLEMS: DEVELOPMENTAL, SOCIAL AND NEUROBIOLOGICAL FACTORS

Adolescence is characterized in two opposing ways. The first is as a period of fun-filled excitement, growth and experimentation, a launch pad into a progressive and productive young adulthood. The second is as a period of inner conflict and familial perturbations that are necessary precursors to growth, but also possibly to dysfunction, apathy and alienation. Arguably, adolescence can be primarily one or the other, but there can be no doubt that it offers windows of both opportunity and vulnerability for each and every adolescent. This text focuses on one major window of vulnerability – addiction.

In this chapter we open the volume by concentrating our attention on a few tasks. Our efforts, if we are successful, will direct and guide your thinking as you read the remaining chapters. We will explore issues regarding the definitions of addiction, and indicate the challenges of conducting scientific inquiries into the subject – such as estimating its prevalence. Next, we shall explore some of the more interesting and promising theories of addiction. Finally, we will examine just a few of the many developmental, social and neurobiological factors contributing to adolescent addiction. This overview should help you bridge the many ideas and chapters in this book.

DEFINITIONS OF ADDICTION

Ideas about the concept of addiction abound. It is often conceived as being both a personal and a social problem – in the former case, addiction is viewed as a weakness residing within the adolescent who lacks control and motivation; in the latter, addiction is associated with impoverished environments and lack of opportunity. Definitional criteria regarding addiction are ambiguous.

There are at least two factors that contribute to a lack of clear understanding of the concept of addiction. The way addiction is conceptualized has changed over time, and there is no universally accepted (or utilized) definition – the definition of addiction has gradually evolved. In earlier times, addiction was equated with physiological dependence (West, 2006). Traditionally, addiction was considered to be a response to a substance taken by a person – as physiological adaptation to a drug, without which the person would experience withdrawal. That is, addiction was perceived as being a condition in which a person requires a substance (i.e., a drug) in order to function without physical and psychological reactions to its absence, and which often involves tolerance and dependence (Carpenter, 2001).

This idea that addiction results solely from substance use is believed even now. Some professionals (including addiction counsellors) still hold this view (Walters and Gilbert, 2000). Likewise, expert definitions can be found that restrict the object of addiction to drugs. For example, in The Merck Manual, a biomedical manual, addiction has been defined within the spectrum of substance use disorders (Berkow et al., 1997: Sec. 15, Ch. 195), especially in comparing and contrasting ideas of physical and psychological dependence:

Addiction, a concept without a consistent, universally accepted definition, is used here to refer to a lifestyle characterized by compulsive use and overwhelming involvement with a drug; it may occur without physical dependence. Addiction implies the risk of harm and the need to stop drug use, whether the addict understands and agrees or not.

Consistent with biomedical definitions, addiction has also been described as a biobehavioral disorder (Leshner, 2001) resulting from a series of changes in the brain, these neuroadaptations being caused by repeated exposure. It is hypothesized that damage to the frontal cortex of the brain impairs the decision-making abilities influencing behavioral inhibition toward, in this case, the drug. The concept of addiction portrayed from this perspective, although perhaps too narrowly focused on drugs, is helpful for understanding concepts shared with substance use disorders.

Even within the strict application of addition to a substance (i.e., a drug), there has been a loosening of the concomitant ideas of dependence. Current understanding of addiction appears to be moving even further toward a broader definition encompassing a syndrome with heterogeneous symptoms, including a problem of compulsive behavior (and perhaps compulsive cognitions) regarding an object of desire. There is an expanded application of the term “addiction” to a wide range of items of pleasure – that is, in other arenas it has been extended to include various objects of desire, such as gambling, the Internet, and sex addictions. Other key inclusions are ideas of compulsivity, risk of harm, and problems with motivation.

West (2006) provides a definition of addiction as a syndrome involving reward-seeking behavior which results in significant harm. In this view, addiction is defined as a problem in a person’s motivational system. Addiction also involves impulses or cravings, perceived needs, and a person’s sense of identity (West, 2006). It may involve dependence – physical or psychological – and intoxication. There does appear to be an effect on the choices people make, the emotional attachment they have to the object of desire; this has elements of habitual behavior, and largely involves behavior and feelings.

Common to these definitions is compulsive behavior, regarding an object of desire, which implies a risk of harm and problematic actions. How addiction is viewed influences how society and experts respond, and how research into addiction is conducted.

Walters and Gilbert (2000) have attempted to elucidate an operational definition of addiction. In previous work, Walters (1999) determined that there might be four key elements to an operational definition: a general progression element (comprising physical and psychological dependence), preoccupation, perceived loss of control, and persistence in the face of mounting negative consequences. Walters and Gilbert (2000) asked clients enrolled in a drug education class (n = 31), and Fellows (n = 20) of the American Psychological Association (Division on Addictions only), to define the concept of addiction. Not one subject provided a definition that contained all four elements. Furthermore, there was significant disagreement between the two groups. The modal response (50%) of experts was physical dependence, and collectively they defined addiction as a discrete set of behaviors. However, “older experts were significantly more likely to include physical dependence in their definition than younger experts” (Walters and Gilbert, 2000: 218). Younger experts were more likely to define addiction as compulsive-habitual behavior. This difference is perhaps an indication of the evolution of the concept. In contrast, the modal response (approximately 30%) of clients was diminished control, and collectively they defined addiction as a state of mind (a focus on loss of control, the perceived need to continue the behavior, and an overriding urge to reinitiate). Walters and Gilbert suggested that there might be formal definitions, but the person with the addiction may have a simple working definition. Thus, addiction criteria may vary as a function of age and expertise. Nonetheless, without an operational definition, it is difficult for the concept of addiction to have scientific credibility.

Addiction has also been described as a dynamic process (Shaffer and Albanese, 2005) which fluctuates in intensity – that is, people with addictions can experience episodes of abstinence, exacerbation, and control over the use of their object of addiction. Opinions regarding the concept of addiction also appear to differ somewhat amongst professionals and clients, but more so between professionals and clients (Walters and Gilbert, 2000). However, clients of psychological services for addiction tended to view addiction as needs, urges and diminished control. Experts (psychologists in addictions) revealed a tendency to view addiction as compulsive aspects of behavior, the presence of physical dependence, and diminished control.

Various definitions of addiction exist. An elusive meaning and a lack of consensus of clear definition promote problems in application in research and clinical practice, such as determination of prevalence rates and research on epidemiology, assessment and treatment. Nonetheless, a body of research evidence has accumulated on the nature of addictions and adolescence.

OVERVIEW OF THE THEORIES OF ADDICTION

Numerous theories have been offered to explain addiction, ranging from personal and interpersonal to contextual explanations. The seemingly opposing theories may suggest that the pathways to addiction vary for different people, and that addiction is manifested uniquely.

In the stepping-stone hypothesis, marijuana was believed to be the first step toward other drugs. Cohen (1972) suggested that people with drug addiction usually try several different drugs before becoming addicted. Kandel (1975) proposed a multiple-stage progress theory, suggesting that adolescents who used substances (drugs) usually progressed through four sequences or stages, starting with beer or wine or both, progressing to include cigarettes or hard liquor, then marijuana, and...