CCPR: Hello, Dr. Shatkin. Your latest book, Born to Be Wild, is about understanding why adolescents are impulsive and take so many risks. Why did you decide to write about this topic?

Dr. Shatkin: I’ve long been interested in the public health perspective of psychiatry and the importance of prevention, and I began further exploring the reasons for risky adolescent behavior after NYU brought me to campus to develop a psychological wellness program. In 2003 and 2004, 7 NYU students died—at least 6 of them from suicides—so the university asked me to help with a prevention strategy. The book was the result of my further interest in the topic while researching and creating that program.

 

CCPR: In your book, you help us gain a deeper understanding of adolescent risk-taking behavior both on a neurobiological and an evolutionary level. Can you tell us more about that?

Dr. Shatkin: I speak about neurodevelopmental imbalance in the book. It’s this idea that the frontal lobes mature more slowly than the limbic system or emotional centers of the brain, which is complemented by the fact that when we are young, we have the highest levels of dopamine in our brains that we will ever have (Spear L, Neuroscience & Biobehavioral Reviews 2000;24(4):417–463). This is probably why our memories of high school and college are so profound. The love we once had, or the trip we took with our friends, or the college break seemed like the best thing in the world, and it probably was because our dopamine levels were so high.

 

CCPR: Can you remind us how dopamine works in the brain?

Dr. Shatkin: There’s a misconception that dopamine equates to pleasure. It’s not pleasure; it’s the promise of pleasure. Dopamine is the idea that something great might happen. And so high dopamine levels drive kids into high-risk situations with high amounts of potential pleasure. This is aggravated by the fact that the frontal cortical areas are not well myelinated yet and not well connected to the limbic system. So, when kids are younger, they have less control over those impulsive drives.

 

CCPR: So, dopamine is part of what drives adolescent behavior. What else is going on?

Dr. Shatkin: You’ve also got testosterone, which is about status seeking. We tend to associate testosterone with physical and mental toughness, which is part of the story, but emotionally it makes you very concerned with how people perceive you. How you are perceived matters, especially from an evolutionary perspective. These peer effects are huge because they are adaptive. You have to care what your peers think because this is the time of life when you bond, build connections, and make a family. Kids become sexually mature around ages 12 to 14 so that they can start having babies when they are in the healthiest phase of life. And those who make a family, who are social and engage well and make good eye contact—those are the ones who are more likely to succeed since you can’t do it alone in this world, and you especially couldn’t do it alone 100,000 years ago.

 

CCPR: Fascinating. So all these adolescent behaviors that we think of as problematic, such as being excessively swayed by peer pressure and risk-taking behavior, are inevitable consequences of evolution?

Dr. Shatkin: Exactly. They need that brain to be geared to taking risks and bonding really quickly, and to having that great promise of pleasure. Otherwise, our species wouldn’t have survived (Casey BJ et al, Dev Rev 2008;28(1):62–77). In the book, I say that “evolution is willing to sacrifice thousands to save millions.” Our kids are driven by risk because we need them to take risks; we need them to be the frontline soldiers who will stay up late at night to guard the fires and the caves so the older people can sleep and won’t get hurt. This might explain why teens’ circadian rhythm is shifted later and why, as we age, we wake up earlier in the morning—so we can relieve the kids and let them sleep in.

 

CCPR: So, when teens refuse to get out of bed to make it to school, they are responding to an evolutionary imperative? They’ve been taking risks to protect the herd until late at night, and they have to sleep in?

Dr. Shatkin: Yes, but the world has obviously changed, and there are fewer advantages to risk-taking behavior than in the past. It did you a lot of good to run across the savannah to find a new food source, but it does you very little good to drive 100 miles an hour down the freeway.

 

CCPR: Let’s paint a high-risk scenario. Say a 13-year-old female is having unprotected sex. What are some ways that we can talk to her about it, while not making her think that her doctor is just another adult trying to tell her what to do?

Dr. Shatkin: What we need to do is give her a clear sense of the consequences. In your scenario, we want to give this girl a deep, emotional understanding of what it means to get pregnant, because the more she can internalize the sense of what that means, the more she is likely to get the gist that this is a risk. Ask her what happens if she gets pregnant—deeply dig into that experience. Ask what she will do, whom she will tell, what decisions she might have to make on her own, and really emotionally connect her to those serious risks. I have found that the more emotionally connected kids feel to the risk, the more likely they are to say, “Oh, I really have to be careful here.”

 

CCPR: I also know that parents need to be involved in connecting to their kids. But what are some of the strategies we should recommend that parents use with kids in the home?

Dr. Shatkin: This is a very important question. One thing is to have parents recognize “red alerts.” A red alert means danger is imminent. One example of a red alert is your 16-year-old daughter being left home alone with her boyfriend, which presents a risk that they might have sex. You need to work with parents to identify the red alerts so that they are aware of those situations and can head off risk in advance. Other examples of red alerts are things such as breaking curfews and too much screen time alone on social media. Even if it’s by only an hour, tell parents to not be OK with it if their kid breaks curfew.

 

CCPR: You mention social media. Since it’s such a huge part of life now, can you tell us more about why we should advise parents to limit screen time?

Dr. Shatkin: Parents, and teens as well, need to know that the social attachment system in the brain has piggybacked on the brain’s physical pain system. In other words, when our kids are socially excluded (which happens even more now with social media, like when someone isn’t tagged in a Facebook photo), they feel genuine pain. And what might a kid do to avoid pain? How about take a risk, like race down the freeway in his car because his friend is doing it? (Masten CL et al, Soc Cog and Affect Neurosci 2008;4(2):143–157).

 

CCPR: Then, what advice should we give parents on limiting social media use?

Dr. Shatkin: You should make parents acutely aware of the peer effects social media can have. I like to joke with parents that this is why God created the fruit bowl—to store their kids’ phones in until the homework is done. You need to be 18 to get a phone contract, which means parents own those devices. Parents should make this fact clear to their teens when they give them their phone: “It’s mine, and I’m letting you use it. You can call it your phone, but it’s mine. I pay for it, and I’m giving you this device as a privilege that you must continue to earn in order to keep it.” During homework time and again at night, the phones should go into the fruit bowl. Phones are one of many examples where it’s really important for parents to closely monitor their kids. I know it’s hard—it’s really hard. I have two teens myself. But it’s what we must do to manage risk.

 

CCPR: In addition to monitoring their adolescent’s activities, and watching for those red alerts, what else should we be telling parents?

Dr. Shatkin: Tell parents to find ways to use positive reinforcement. For example, there is nothing my 16-year-old son loves more than driving, so he would do anything to earn that privilege. He will even clean up his room to drive! So, this is an opportunity to prompt a lot of good behavior with kids by using the positive things that kids want. Tell parents to look for ways to connect those things with rewards that are meaningful.

 

CCPR: What advice do we give parents who feel that they’ve done it all wrong, yet their child is now on the verge of adulthood? Is there anything we can do to rehabilitate somebody who’s already 18 and is still exhibiting risky behaviors after not experiencing the greatest of child-rearing practices?

Dr. Shatkin: Parenting books, advice, or talks should not be geared toward making parents feel bad. Throughout the book, I talk about my own mistakes. So yes, I think parents can still, if not achieve total rehabilitation, at least get their kid back on track. Just because kids got drunk at 16, that doesn’t mean they will be abusing alcohol at 18, 19, or 20. Some kids actually do learn from those things. Can you rehabilitate a kid? Absolutely. That’s what therapy is about. That’s what a lot of parenting is about.

 

CCPR: So, what are some specific strategies we can give parents for their young adult children?

Dr. Shatkin: Even at 18 and older, young adults need lots of positive reinforcement from their parents. The other thing is to build self-efficacy. Tell parents to encourage young adult children to believe that they are powerful, and that they can make a difference if they work hard and exhibit discipline. We want to turn the good feelings and the rewards toward academics, arts, creativity, and good work habits, while turning them away from alcohol and sex. Kids and young adults often gravitate to alcohol, drugs, and sex when they are not successful in the other areas.

 

CCPR: How does this understanding of adolescent behavior relate to how we deal with adolescents who cut themselves or otherwise self-harm? I’d like to get your thoughts on that.

Dr. Shatkin: What we have learned is that kids keep self-harming because it makes them feel better. The physical pain sort of substitutes for the emotional pain. Think right now for a moment about the most painful experience you’ve ever had in your life. If you’re like most people, you’re probably thinking of something emotional, like a breakup or the loss of a parent. The reality is that kids cut because they’re in so much emotional pain that they can’t take it, so cutting becomes a way to convert that pain into something more tolerable. I think this is useful to speak with kids about directly. We can explain to them that, in a way, it makes sense that they would cut because the physical pain is more tolerable than the emotional pain. They might be supplanting some of that feeling of being left out, feeling not engaged, with something physical.

 

CCPR: Once adolescents understand why they are self-harming, what should we do next?

Dr. Shatkin: We then work to improve their emotional regulation, and DBT (dialectical behavior therapy) is all about that. In my work with the students, and in my resilience program at NYU, what we teach is mindfulness and cognitive behavior therapy skills. We teach them how to relax and breathe. We teach them the importance of exercise and good sleep in terms of managing emotions. That’s the kind of stuff that DBT focuses on as well, along with building self-efficacy—getting more self-confidence so that you don’t have to do this. And then there are all sorts of other techniques, such as substitutions. We try to substitute self-harm with something like squeezing ice cubes, which exerts some level of pain but doesn’t hurt your body. But the kids who self-injure are a subset of the kids who take risks, and it’s a very specific thing. I think the behavior draws on a lot of the same parameters, but I don’t think it’s the same thing, and most kids who self-harm are considerably mentally distressed.

 

CCPR: Do you think you are using less medication than you used to?

Dr. Shatkin: No, I don’t think so. The reality is that most of my kids that I see have a major psychiatric diagnosis—depression, ADHD, bipolar disorder, or the like. So, it’s not that I’m just seeing a generally well population. I’m a psychiatrist, and I don’t think that simply educating kids and talking to them is always enough. That said, I also don’t reach for the pill bottle right away. I want to understand them first and do what I can do to help them in every way possible.

 

CCPR: As you’ve been learning more about the adolescent brain and these other factors, has it changed the way you’ve practiced in your clinic? By extension, how should it affect our practices?

Dr. Shatkin: I now focus on the things that drive adolescents—for example, peers. What are their peers doing? What do they want to be doing with their peers? What makes them feel good with their peers? Where else can they feel popular or well-liked, and how can they accomplish that without taking risks? I will do some teaching about the brain and where they are at and say, “It makes perfect sense where you’re at. This is how we are designed by evolution, but you know what? Those behaviors don’t make sense anymore, so we have to find ways to help you to manage them.” And I focus on those emotional cues, recognizing red alerts, understanding how to use risk statistics, planning decision pathways, and role modeling.

 

CCPR: Are there any other tips you’d recommend for us when it comes to dealing with our adolescent patients?

Dr. Shatkin: It sounds pretty basic, but starting appointments on time is really important. It shows the kids that this is what an adult does and this is how we handle things. Sometimes I’m late for an appointment, and I’ll say, “Look, I’m sorry. I had an emergency; something came up.” But it’s important to give them an example of how to act.

 

CCPR: Thank you for your time, Dr. Shatkin.

 

Motivational Interviewing

Motivational interviewing (MI) is an effective technique that can be used to change risky behaviors with adolescent patients, including substance abuse. In a recent study, MI was associated with significant reduction in rule-breaking behaviors by adolescents at a 6-month follow-up (Brown RA, J Substance Abuse Treat 2015;(59):20–29). Here are some basic elements of MI:

Providing advice: Ask-Tell-Ask

• What do you know about how drugs work in the brain?


• Is it alright if I share what we know from research?


• What do you think about the information I just talked about?

Affirmative statements

• Even though you aren’t getting along with your parents, you still have been helping out around the house and making it to school each day.

Reflective listening

• I get the sense that this has been really hard for you, but you aren’t sure what to do.

Change talk

• What is the best thing you can imagine coming from decreasing your drug use?


• On a scale of 1 to 10, how confident are you that you could decrease your drug use?


• What would make that number an X (increase number by 1–2 points)?