Children and Substance Abuse

Children and Substance Abuse
Substance Abuse and Drug Addiction among children
Introduction

Substance use in children and adolescents is increasing but prevention and treatment of child/adolescent substance use has not received adequate attention. Substance use often gets initiated in adolescence with use or licit substances such as tobacco and alcohol. Adolescence is a critical phase of development as it lays the foundation for development of life skills, social, vocational and emotional development later in life. Some amount of experimentation at this age does occur and most adolescents who experiment at this stage do not develop Substance Use Disorder. At the same time, any use in adolescence deserves attention. Alcohol and drug use is a leading cause of physical problems and death in adolescents due to motor vehicle accidents, suicidal behavior, violence, unprotected sexual activity, unplanned pregnancy and sexually transmitted diseases.
The prevalence of current drug use in children/adolescents is 21.4% for alcohol, 3% for cannabis and 0.1% for opiates as per the National Household Survey (Ray, 2004). As per the Global Youth Tobacco Survey which collected data from 12000 students from 180 schools, the prevalence of tobacco use is 14.6% with use in boys being about three times that of girls. The data also showed that awareness and negative perception about tobacco is increasing but the prevalence, accessibility and use inside schools is also rising (Gajalakshmi, 2009). There are very few school based studies that have examined the use of other substances besides tobacco. One school based study from West Bengal has shown that lifetime use of alcohol was 7.4% in rural and 5% in urban school students.Another school based study from Manipur with a sample of more than 1000 students showed last one year use was 27% for tobacco, 15% for alcohol, 7% for cannabis and 4% for solvents (Ningombam, 2011). Factors associated with substance use in these schools based surveys were substance use in family/peers, peer pressure and psychological factors. The studies also showed that substance use occurred despite knowledge about harm related to substances.
As per the data on treatment seekers from the Drug Abuse Monitoring SYSTEM (Ray. 2004) most persons who sought treatment at the drug dependence treatment centres initiated drug use during adolescence (9-10% at less than 15 years of age and 25-32% at 16-20 years of age). However only 5 percent of treatment seekers are adolescents suggesting that most persons seek treatment after a few years of onset of drug use after they have already stepped into adulthood.
The data from NGOs that provide services to vulnerable children and Nehru Yuvak Kendra showed that the age of onset in vulnerable children was much lower (63.6% of substance using children who access services had age of onset less than 15 years of age and 27.7% had age of onset at 16-20 years of age). The data from NGOs that provide services to these children showed that of substance using children, injecting drug use occurred in 14-20%, sharing of needles in 7-15%, sex with multiple partners in 5-19%, arrest by police in 19-34% and family violence related to drug use in more than 50%.
Drug use is an alarming problem in street children and occurs in 70-85% street children compared to a much smaller percentage in non-street children. The previous study on situation assessment (Ray et al, 2009) found that drug use in street children was associated with greater unsupervised exposure to street life, less education, better employment, poorer hygiene, more exposure to unsafe situations, fights, less contact with NGOs, more drug using friends, more income but not saving money with family and increased access to recreational pursuits.
Thus, although a few small scale studies have examined the issue of drug use in children, overall there is insufficient data on pattern of drug use in children/adolescents, profile of drug using children/adolescents and also the correlates of drug use.

AIM

1. To collection data on pattern of substance use and profile of children using substances
2. To collect data on family, peer, stress, psychological and physical health and legal aspects associated with drug use

METHODOLOGY

This is a cross-sectional study that involves collection of data by NGOs working in the area of substance use and NGOs that are working with street children. So, the study will have two distinct kinds of organizations collecting data and the target population for both the organizations will also be different. The NGOs that are working with street children will collect data on street children only while NGOs that are working in the area of substance use will collect data from school going and out of school children who are not street children.
Sample.

A. The inclusion and exclusion criteria for the study is as follows-

1) Inclusion Criteria
a) Age group 18 years or less
b) Children/adolescents who have used at least one other substance besides tobacco (alcohol, inhalants, cannabis, opiates, sedatives or any other substance) in last one year
c) Children who are being admitted in an institutional setting may be included only at the time of admission or within a period of 1 week after admission. For children admitted in institutional settings, the time frame for the questions refers to the period just prior to admission.
d) Informed written consent taken from the child or adolescent and the parent or NGO staff counselor (as a surrogate guardian, in case the parents are not available)

2) Exclusion Criteria
a) Use of tobacco only in last one year
b) Not willing to be included in the study
c) Unable to provide information
These children or adolescents may be studying in school or they may be school dropouts or may have never gone to school; they may be living with families or living alone; they may be living at home or may be street children or may be having some other living arrangements.
Children who are being admitted in an institutional setting may be included at the time of admission or within a period of 1 week. There is no lower age limit for inclusion in this study.

B. Identification of the sample

The children will be identified from the following settings-
a) NGOs who are working in the area of substance abuse could take children or adolescents from-

• Their own or other drug treatment centres
• Using snowballing to contact children in the community (getting children or adolescents with the help of other children or adolescents who come to them)
• Children of adult substance users who come to them for treatment
• Through awareness programmes/information in schools/community/recreational areas/Nehru Yuvak Kendras/youth organizations
• From slums/places where child labour takes place
• Shops from where purchase of substances occurs
They should not visit schools to get children directly from within the school setting although they can organize awareness activities in schools and inform them about availability of services in the NGO, thus encouraging them to come to the NGO for help. They should also not collect data on street children as this data will be collected separately by NGOs working with street children. So, they should not approach NGOs working with street children and also should not approach the street children directly in the community or in Juvenile justice/children homes to collect data from there.
b) NGOs who provide services to street children should take children or adolescents who access their services based on the inclusion criteria mentioned earlier or could include street children from the community.
Definition of street children for the purpose of this study – Children who spend lot of time on the streets largely unsupervised by adults and includes children who sleep on the streets or live at home, irrespective of whether they are in contact with their families or not.

C. Sample size

Data on 30 children will be collected by each NGO. Each organization should fill the questionnaire for the first 30 children/adolescents who they screen and who fulfill the criteria based on the inclusion and exclusion criteria. A total of more than 100 NGOs will collect the data. A list of the NGO (142 NGO) who will be collecting the data is attached as Annexure 1. So, the total sample will be approximately 4000 children. This will include data from 46 NGOs working with street children and 96 NGO working in the field of substance use. The data will be collected from 30 states and from approximately 100 cities/towns of the country.

Instrument

The questionnaire has 67 items and the following sections-1) Demographic factor 2) Family and peer related factors 3) Stress, physical and psychological health 4) Substance Use 5) Legal issues
It was developed after modification of a questionnaire that was developed for the study on Inhalant use among street children in Delhi and Bangalore-A Situation Assessment funded by WHO (India) (Ray et al, 2009). The questionnaire has been modified to include school going and out of school children who are not living on the streets besides street children. It was shared with the Working Group on “Substance Abuse & Drug Addiction among Children”. The modifications suggested by the group were incorporated. The questionnaire was field tested by administering to children and based on the feedback, further modifications were made.
The following are the characteristics of the questionnaire-
1. The questionnaire provides adequate information to enable us to get a comprehensive picture of demographic and substance use profile of the individual.
2. The questionnaire is brief and concise to enable the interviewer to complete the interview within a reasonable period of time (50 to 60 minutes).
3. Since target population is expected to be a mixed one with respect to literacy levels, an interviewer-administered questionnaire was regarded more appropriate rather than a self-administered one.
4. The language and format of the questionnaire has been kept simple, considering the expected level of expertise of the interviewers.
5. Most of the variables in the questionnaire, in strict statistical terms, are categorical in nature. Following analysis, it will be possible to comment upon frequency of a variable in the sample.
6. All the questions are pre-coded, minimizing the need for the interviewer to note down a response. This will also make the task of data entry and subsequent analysis easier. At selected places however, there is provision for nothing the response of the subject as well.
7. The questionnaire itself serves as an instruction manual describing the individual questions and defining the possible responses.
The questionnaire will be translated to the local language and back translated to English. The English version after back translation will be compared to the original English version. If any item seems to suggest that the content has been modified, then the translation in the local language may be modified.
Administration of the questionnaire

The questionnaire will be administered by the staff of the NGOs who will be graduates or post graduates with some experience of working in the field. The staff will be paid an honorarium for collecting the data.

Procedure
1. This study will involve data collection by more than 100NGOs who will be trained and monitored by about 15 monitoring NGOs. The tasks assigned to the monitoring NGOs include the following-
a) Translation of the questionnaire to the local language as per procedure mentioned earlier in instrument
b) Data entry
c) Monitoring of data
d) Training of the staff of NGO

2. The monitoring NGOs were selected based on the following criteria-
a) RRTC/NGOs who have been involved in training activities/have capacity to conduct training and have a good track record
b) Willingness of the NGO to participate as a trainer and to conduct further training activities
An effort has been made to get representation from all regions of the country.
3. Training of trainers programme

A five day training programme for 19 participants from more than 15 organizations was held. This programme was funded by NISD, Ministry of Social Justice and Empowerment. Most of these organizations were working in the area of substance use and two organizations were working with children in need of care and protection.

The agenda for the training of trainers programme will include the following-

a) Presentation on overview of drugs of abuse, substance use in children and street children
b) Familiarization with the questionnaire
c) Role plays to practice the questionnaire
d) Discus the guideline for filling the questionnaire
e) Pilot testing the questionnaire in the field

4. Training by trainers programme

The 142 NGOs who will collect the data will be trained by the trainers based on a similar pattern as the training of trainers that was conducted. The training will be of two days duration and will include

a) Presentation on overview of drugs of abuse, substance use in children and street children
b) Familiarization with the questionnaire
c) Role plays to practice the questionnaire
d) Discuss the guidelines for filling the questionnaire
e) Field visits to practice filling the questionnaire
Eight such training by trainers’ programmes will be held, four in each region of the country. The monitoring NGOs will support each other to conduct the training programmes and efforts will be made so that at least one person from the expert group can join.
5. Each organization should fill the questionnaire for the first 30 children/adolescents who they screen and who fulfill the criteria based on the inclusion and exclusion criteria. The questionnaire can be filled either in the NGO or community setting. The guidelines for filling the questionnaire include the following-

a) Rapport building with the child is important before filling up the questionnaire and may take some time. The help of the NGO personnel who the child is familiar with can be taken four building rapport.
b) Written informed consent form has to be signed by the child and also by the parent/guardian
c) Ensure that the child has understood each question. Rephrase the question if required without changing its meaning.
d) Adequate time should be given to the child to give responses to the items on the questionnaire.
e) Ensure as much privacy as possible when administering the questionnaire to the child
f) Confidentiality has to be respected. This means that once the questionnaire is filled up for the child, the information in the questionnaire should not be shared with the parent or guardian although the child can be encouraged to seek help, if required.
g) Non-judgmental-The attitude of the person who is filling up the questionnaire has to be non-judgmental
Monitoring of the data
The monitoring of data entry has to be done by the monitoring NGO. Data from 10%of the NGOs will be checked for its reliability. Efforts will be made so that one person from the expert group can join for some of these monitoring exercised.

Data analysis

1. All the questions are pre-coded, minimizing the need for the interviewer to note down a response. At selected places however, there is provision for noting the response of the subject as well. The data entry has to be done as per the format for data entry that will be provided by AIIMS on excel sheet to the monitoring NGOs. The qualitative data analysis will be done by the monitoring NGOs by extraction of themes.
2. Most of the variables in the questionnaire are categorical in nature. Following analysis, it will be possible to comment upon frequency of a variable in the sample.

Ethical issues

A written informed consent will be taken for filling the questionnaire from the child and a parent/guardian.

The composition of the Working Group will be as follows:         

    S. No.   Name & Address   Designation
  1. 1.       
Shri Vinod Kumar TikooMember
National Commission For Protection of Child Rights
New Delhi.
  Chairperson
  1. 2.       
  Dr. Dinesh LaroiaMember
National Commission for Protection of Child Rights
New Delhi.
  Member
  1. 3.       
  Dr. Bharti Sharma, Ex-Chairperson, Child WelfareCommittee &Convener
Delhi Committee for Protection of Children & Preventive Action, Gurgaon, Haryana
  Member
 

  1. 4.     
  Shri. Anant K. AsthanaLegal Aid Counsel
Juvenile Justice Board-3
Kingsway Camp, Delhi.
  Member
  1. 5.       
Dr. Jayant KumarDirector, Galaxy Club & Head of RRTCs
Imphal
  Member
  1. 6.       
  Dr. Anju Dhawan, M.D.Additional Professor
National Drug Dependence Treatment Centre and
Department of Psychiatry
  Member
  1. 7.       
  Dr. Shubhangi R> PARKAR DPM MD MSc PhDProfessor and Head
Department of Psychiatry
Chief: Bombay Drug Deaddiction Center, Bombay.
  Member
  1. 8. 
Mr. Debashis MukherjeeResearch Officer
United Nations Office on Drugs and Crime,
New Delhi
  Member
 

  1. 9.     
  Dr. Shekhar SheshadriProfessor
Department of Child Psychiatry
NIMHANS, Bangalore.
Member
  1. 10.   
  Ms Kiran JyotiDirector, Salaam Baalak Trust
New Delhi.
  Member
  1. 11.   
  Dr. RajeshExecutive Director
Society for Promotion of Youth & Masses (SPYM),
New Delhi
  Member
  1. 12.   
  Fr. Mathew Thomas SDBSecretary & Executive Director
YaR FORUM INDIA
Don Bosco National Forum for the Young at Risk (YaR)
New Delhi
  Member
  1. 13.   
Dr. Mrs. ZoengpariGeneral Secretary
Volunteers for Community Mental Health (VOLCOMH)
2ND Floor, Central Y.M.A. Building
Sikulpuikawn, Aizawl-796001, Mizoram
  Member
  1. 14.   
  Mr. Sunil KumarDeputy Director, NISD, Min. of SJ&E, GOI
R K Puram, New Delhi
  Member
  1. 15.   
  Shri Sanjay GuptaExecutive Director
Childhood Enhancement Through Action & Training (CHETNA),New Delhi
  MemberCo-Convenor
  1. 16.   
  Shri Lov VermaMember Secretary
National Commission for Protection of Child Rights
New Delhi
  Convener

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