Years before an individual with heart disease has a myocardial infarct, there are risk factors that serve as warning signs. Obesity, genetics, and a poor diet may be a few examples. Addiction is also a chronic condition, and likewise, there are risk factors that predate the development of symptomatic addiction. In fact, young people at highest risk for developing alcohol or drug addiction can be identified in elementary school, years before they experiment with any substance. These kinds of assessment don't require brain imaging or genetic testing to date, usually just a computer questionnaire backed of course by decades of research. You might be wondering what kinds of questions are in these assessments. Or better yet, what exactly are the risk factors for the development of alcohol and drug addiction in youth? In what ways are at risk youth different than their peers? Allow me to give you a glimpse under the hood so to speak and provide my interpretation of the research. Many young people who are at high risk for addiction have some tells that show up in their attitudes, behaviors, or even their choice of peers. These traits then say something about how their brains work, and possibly how their genetics might be a bit different from others. And again, many at risk youth demonstrate these traits long before they start using substances. Here are some brief descriptions of the traits I commonly observe. Most of the young people I see would be classified as risk takers, even without drug or alcohol use. Risk taking is not exactly the same as impulsivity. People take risks when they are impulsive, but impulsivity has to do with poor decision making in the heat of a moment whereas risk taking can be more calculated. For example, if some youth decide to sneak out of our treatment center to buy cigarettes (something that has never happened, ha ha), the initial decision may be impulsive. They might be upset about something or they might have pressured each other. But then they have to decide how to go off campus, and how to get funds, and how to keep it all a secret. That isn't impulsivity, that's risk taking behavior. People who are more risk taking are less daunted by potential consequences. They may have a hard time appraising consequences looking forward. They also sometimes struggle to learn from prior consequences. So while all youth are relatively thrill seeking and impulsive, some youth at risk for substance abuse are far more risk taking. Young people who are more risk taking tend to discount rewards more rapidly than other peers as a function of time. This roughly means that they have a harder time delaying gratification or waiting for long term rewards. Conversely, they also tend to discount the impact of negative consequences more rapidly than other peers. Let Me Illustrate If you've ever been in a near car accident, the fear from that event generally causes you to drive with vigilance. That is, you may pull up your car seat or adjust your mirrors. For a time, you are going to drive with extreme caution. But then, as time goes on, you revert to how you drive at baseline. While you retain the memory of the near accident, the memory no longer has a grip on you. Well, that's exactly what it's like for at risk youth but at a much faster rate. At time zero, they make a mistake. Maybe they stole something, or lied to someone they care about, or got a DUI. They have morals and are good people and in that moment may feel genuine regret. They may vow to change their behaviors, to set a new course. But as a function of time, that experience fades, not from their memory but from their hearts, and the experience extinguishes faster than it would for other peers. Sooner or later, they revert to a high risk state of mind, filled with rationalizations and emotional justifications for another round of poor judgments. As this cycle repeats, self-hatred and depression weigh on them, and restless anxieties diminish the hope once seen in their gaze. Young people who are risk taking are practical decision makers. They are more likely to be consequentialists, and tend to have a "no harm no foul" or "all's well that ends well" kind of outlook. They want to control near outcomes as much as possible and can panic with any uncertainty or matters requiring faith. Putting it all together, risk taking youth tend to make decisions based on their appraisal of risk/outcomes but continually have a hard time learning from previous bad outcomes. If you think about it, this is a very dire combination indeed. Having done thousands of mini biographies now, it is more the rule and not the exception that these traits are present in some form years before an at risk person touches any addictive substance. For one, at risk youth may tell white lies or manipulate others from a young age. This is not due to a moral deficiency. The way they think about it, if no one gets hurt and they get what they want, then it didn't really matter. Of course drug and alcohol addiction adds fuel this fire and in that context the above is clearly seen. Less risk taking youth, motivated less by immediate rewards, might have a more empathic perspective in telling that white lie. They might reason that even if there are no major consequences from their deception, they themselves wouldn't want to be manipulated in that manner, and so they don't. This is where the power of empathy works in recovery from addiction. Empathy is the ability to walk in the experiences of another, while recognizing that they are not that person. We could do better to note it formally, but the Hazelden Betty Ford Foundation's youth program is all about empathy. That's why they share their stories with one another, do activities together, and resolve conflicts together. They spend time in the family program with someone else's parents, to gain an empathic perspective aside from any familial resentments or bias. When one peer breaks a rule, we pay attention not only to whether other peers show integrity in holding up the rule, but more critically "how" those peers redirect each other. Do they address each other's mistakes in a manner that they would want to be spoken to, in a way that they would talk to their best friend or brother? Or do they uphold the rule but turn callous and write off those they deem unfit? When I'm often asked about "progress" in drug rehab, I'm often trying to describe the gains in empathic perspective within a young person. This is why empathy matters for recovery. Imagine an at risk youth is in some office. On the desk in that office is a 20-dollar bill. Now it so happens that it's late in the day and nobody is around. Let's assume that the young person does the right thing and doesn't steal the 20-dollar bill. Again, what's more important in the above situation is "why" that young person didn't steal. A person with risk taking tendencies may do the right thing, but usually do so with a calculation of risk and reward. So they may reason that they might get caught or that 20 dollars isn't worth stealing as a reward. In the above scenario, we can see the inconsistent but cyclical peril that at risk youth encounter by changing just a couple of variables. If we made the 20-dollar bill a 200-dollar bill, and we knew for a fact that no one would be around to know it was taken…now the risk has gone down and the reward has increased 10 fold. In this variation, that same risk/reward analysis may now very well lead to stealing. And this is also what happens with at risk youth. Even if they make a series of good decisions, every risk/reward calculation that involves a weighty decision can become their undoing. Let's repeat the 20-dollar scenario. This time, the young person still doesn't steal but reasons not only with risk and reward but with empathy. They might say, "If I had 20-dollars stolen from me, I would be pretty upset." While the end point behavior is the same, the "why" is very different. Now watch what happens. If we change the same variables as before and make the 20-dollar bill a 200-dollar bill, and no one will ever know they took it, the risks still go down and the rewards still increases 10 fold. But so does their empathy. If they had 20-dollars stolen from them they might be upset, but they would really be troubled if someone took 200-dollars from them. So they are less likely to steal in this new situation because their empathic perspective has risen along with the reward. In short, empathy becomes the compass that aligns our youth to their intrinsic values. Empathic perspective short circuits the predisposition for risk taking. Empathy sets the foundation for youth in recovery, giving them a truer playbook for their decision making, and liberating them to grow spiritually on their journey to a healthy adulthood. There are two other values that I see as core to a young person's recovery from alcohol and drug addiction. They are grace and humility. Without grace and humility, our efforts at empathic capacity building fall short. But that is a story for another time.