Sex Differences in Cingulo-Opercular Activation During Risky Decision-making in Youth with Externalizing Disorders

Background: Risky decision-making deficits predict unsafe behaviors, but sex differences in decision-making are underexplored in high-risk youth with externalizing disorders. While boys with externalizing pathology are more likely to make risky decisions, it remains unclear how these patterns manifest in girls, whose brains may process risks differently. Our study investigates sex differences in risky decision-making neurobiological activation among at-risk adolescents to identify sex-specific vulnerabilities for risky behaviors.

Method: 168 adolescents divided into four groups of 81 externalizing males, 39 externalizing females, 33 control males, and 15 control females completed a risky decision-making task, the Balloon Analog Risk Task, during functional magnetic resonance imaging.

Results: Our primary finding was that externalizing males showed greater activation in the right dorsomedial prefrontal cortex/dorsal anterior cingulate cortex as the chance of a balloon explosion increased while making riskier choices over safer choices, compared to all other groups.

Conclusions: These findings highlight key sex differences in the neurobiology of risky decision-making in youth with externalizing psychopathology within the cingulo-opercular network. With this network's involvement in cognitive control and impulse inhibition-functions critical for managing risky behaviors-understanding its role in the interaction between sex and externalizing disorders is crucial for targeted, sex-specific interventions preventing risky behaviors.