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Drug Treatment Services for Young People: A Research Review
Chapter 2 CHILDREN AND YOUNG PEOPLE MISUSING DRUGS
This chapter sets out our findings on the characteristics and predicaments of children and young people with problems including significant substance misuse,
as they present to the services covered in the case study work. It does
not aim to be a general account of the prevalence of misuse or need in Scotland. It is an account drawn from our qualitative findings - the perceptions of those working with children and young people, and the accounts of some service users from these groups.
The research involved only service users. It did not directly involve children or young people who may have treatment or care needs associated with substance misuse, but who for some reason have not accessed services. Insofar as we can make any comments regarding these non-engaged individuals, they are based on the perceptions of service users and workers. Service users, however, generally report that they live among individuals with similar needs who have not accessed services.
The discussion incorporates some information on the prevalence of drug use amongst children. This provides a context for the description of the characteristics of young service users in the current study. The intention is to describe the characteristics and needs of service users in the examples studied. The services described in subsequent chapters can thus be understood as responses to these needs. The characteristics of the children and young people discussed here are likely to differ in important ways from those of the wider group described in prevalence studies.
Following this brief review of data for Scotland, the chapter looks at three aspects affecting the target group:
the range and interrelated nature of individual issues and needs;
the spectrum of substance misuse;
predicaments faced by children and young people.
The Prevalence of Drug Use in Scotland
In order to locate the more qualitative discussion of need that follows, it is useful to look briefly at what is currently known about the prevalence of drug use by children in Scotland.
Information on drug taking among secondary school children aged 12 to 15 was collected via a survey of over 4,700 pupils in 150 schools, in autumn 2000. The
Smoking, drinking and drug use among young people in Scotland in 2000 survey was commissioned by the Department of Health and the Scottish Executive. This was the latest in a series of national surveys of secondary school children in this age group; questions on the prevalence of drug use were first included in 1998.
Ten per cent of children reported taking drugs within the past month - this proportion remained at the same level between 1998 and 2000. The proportion reporting that they had taken drugs in the last year was 14%, and the proportion who had ever taken drugs was 17%. These figures were both down by one percentage point from 1998 levels, although neither of the changes was statistically significant.
Reported drug use in this group varied markedly by age. Only 1% of 12 year olds had used drugs in the last month, but 22% of 15 year olds had done so. There was a decrease between 1998 and 2000 in 15-year-olds reporting drug use within the last year (from 35% down to 30%).
Boys were a little more likely than girls to have used drugs in the last month (11% compared with 8%) and were also likely to have used drugs in the last year or to have ever used drugs.
Many more pupils had been offered drugs than had tried them. More than one third (39%) had been offered one or more drugs, and boys were more likely to have been offered them than girls (41% compared with 36%). As with the use of drugs, the likelihood of ever having been offered them increased sharply with age.
The drugs reported as having been
offered were (in order of prevalence):
cannabis (32% having been offered this);
glue or gas (15% offered);
ecstasy (10%);
heroin or methadone (7%);
amphetamines (7%);
cocaine (6%).
In terms of drugs used in the last year, the order of prevalence was similar:
cannabis (13% having used it);
stimulants (including ecstasy, cocaine, crack, amphetamines and poppers) (3%);
heroin or methadone (1%).
A Range of Needs
As noted above, the children and young people we met, or discussed with practitioners during the research, differed from the wider group of drug users described above. They were accessing services, and thus it is reasonable to assume that their drug misuse was associated with problems which are not typical of all young drug users. In general, drug misuse was only one of the factors presenting them with problems. Recognition of this fact is of fundamental importance in understanding the nature of the needs of this group and in service planning and delivery.
Behaviours such as offending, for example, can begin as relatively minor secondary effects of drug misuse or of other issues such as family breakdown, but may develop into key driving factors in the case. The main specific feature of drug misuse when compared to other issues affecting children and young people, is that in some cases it can become a cause of dependence and hence of chaotic behaviour. In these cases it may result in a range of harmful physical and psychological effects which can be very difficult to reverse after a certain point.
The cases of 'Daniel' and 'Philippa', taken from our Treatment Pathways interviews, (Boxes 1 and 2) provide examples of young people with a range of needs closely related to the misuse of drugs. In these cases they include mental and physical health problems, difficult family relationships, and self-harming or suicidal tendencies. Others encountered during the fieldwork included accommodation problems, often as a result of family difficulties, and offending behaviour and problems arising from this.
Daniel, 16 [Box 1] Daniel is 16 and has been a heavy user of alcohol and cannabis. He spoke generally of 'smoking', to include tobacco use. The workers in his case believed that there were underlying difficulties in family relationships which needed to be addressed alongside Daniel's drug use and health problems. Daniel himself associates his health problems with his substance misuse. He has seen a doctor 'once or twice' for bronchitis, and complains that he easily becomes breathless and does not find it as easy as before to play football. The doctor told him to cut down smoking and 'I took it seriously'. Daniel has also spent some time in hospital (around 6 months prior to the interview) as a result of developing a 'nephrotic syndrome': a kidney condition which he believes is related to smoking. He was an in-patient for two months during which time he was unable to smoke - 'it wasn't worth it - I was too ill and I was watched'. He has now cut down his use of cannabis 'quite a lot' and hopes to make more progress in future, and eventually to stop. He believes that to do this he will continue to need 'somebody to speak to who will encourage me'. He is deterred from further misuse by the example of some friends who are 'using harder stuff… scary'. He does not feel that they are aware of the existence of services which might be able to help them with related issues, other than the local needle exchanges. |
Philippa, 18 [Box 2] Philippa's case spans several years, from the age of 15 when she first accessed the local drug agency, to 18, her current age. She was a heavy user of gas, which she sniffed from tins, up to 8 or 9 times daily. She was prone to self-harm and at times displayed suicidal tendencies. The agency felt that she needed a range of support measures, and arranged for a social worker to be attached to the case, and for attendance at the Child and Adolescent Mental Health Service. The latter provided what the agency described as a '
de factodetox'. |
Cases such as these present a challenge for agencies working together to assess the nature of and relationships between the issues, and to produce a treatment and care plan for the individual which addresses them effectively.
The Spectrum of Substance Misuse - Examples from Case Studies
Individuals accessing case study projects present with a wide range of substance misuse. This range applies to:
Figure 1 gives an example to illustrate this point, using information on children and young people accessing one of the case study services. It shows the incidence of daily and non-daily use of a number of substances for 41 children assessed for entry to one service in a semi-rural area. All of these children had used cannabis, the majority on a daily basis. The next group in terms of prevalence of use included Ecstasy, Valium, and amphetamines, but few children used these on a daily basis. However the proportions using these drugs more occasionally are much higher in relation to the use of cannabis than for children in general (as evidenced by the survey results cited). For example, the national survey indicates that only 3% had used stimulants in the last year as against 13% using cannabis. In these results, the entire group were using cannabis daily or less frequently, and half of these were also using amphetamines on a non-daily basis. The difference presumably indicates the success of this particular service in targeting children with heavier and more problematic misuse.
Almost half the children had used mushrooms, (perhaps reflecting the semi-rural nature of the area). A smaller group had used solvents, and a few individuals had used LSD, 'poppers' and cocaine. Small numbers reported having used methadone and heroin, but most of these had been using them on a daily basis, reflecting the more addictive nature of these opiate drugs. The project had not encountered any heroin injectors in this age group.
Alcohol was reported as widely associated with misuse of these substances in all case studies. In this case, over three-quarters of the children admitted to alcohol use, but very few of these were drinking on a daily basis.
Data on use by gender and first onset indicated that for some of these children cannabis use could start as early as 8 years old and poly-drug use from the age of 11 or 12. There was a tendency towards increased use of 'harder' drugs with age.
Girls in this group were more likely than boys to have used amphetamines or ecstasy, but in general their patterns of use were similar to those of boys. Less than a quarter of those assessed (9 of 41) were girls.
This is a very small and local sample. However, the general picture of initial cannabis use, from a relatively young age, often combined with alcohol use and later with a range of other substances, agrees with our findings in interviews with young people across Scotland.
This early use of cannabis may be recreational and perhaps not particularly problematic in itself. However in our case studies we found that it had often occurred within an overall set of problems. Children were often already in contact with a range of agencies in connection with other issues before their drug use was recognised as a significant factor. At this stage risks, behaviour problems or offences while under the influence of alcohol were also often a trigger for considering drug and/or alcohol specific treatment options.
In this sense one might say that the substance misuse issues faced by these children are not usually the core issues for them, or at least are part of a set of issues from which they cannot sensibly be detached. The design of the service concerned reflected this. It aimed to reduce offending behaviour not by addressing it directly but by focusing on the drugs related aspects of cases. A key criterion for acceptance onto the programme was the willingness of individuals to address their drug misuse issues.
The case of 'Liz' (see Box 3) from another case study provides an example of the more severe end of the misuse spectrum. This involves heroin injecting and fairly advanced dependency. Dependency has become a prime factor and leads to behaviour usually described as 'chaotic'. The service emphasis has been very much on the direct drug-related issues, focusing on the reduction of misuse and dependency.
Liz, 16 [Box 3]
First contact with Liz took place in January 2001. Contact was sporadic and Liz agreed to be referred on to a newly established service in September 2001. At this time she was spending between £50 and £70 per day on heroin and injecting unsafely. After assessment a co-working approach was taken to address both her drug misuse and offending behaviour. Liz was quite defensive and the first part of the counselling treatment was spent getting to know her and gaining her trust. Over a period of time, her drug use reduced to approximately £20 per day, (taking heroin twice a day). Liz appeared healthier and better cared for. At this time Liz was taken to hospital suffering from an infection. Whilst in hospital she was given a 50 ml methadone script while investigations took place. She was prescribed antibiotics and on discharge, the methadone script was stopped. Liz's drug use stabilised at about £20 per day and her attitude and motivation had improved to an extent where detox was appropriate. Detox using Lofexidine commenced at home where Liz lives with her mother. Unfortunately, Liz used heroin on her second and third day of detox and the regime was abandoned. She claims that her heroin use is still approximately £20 per day but it is suspected that it is somewhat higher. |
Liz's drug use stabilised at about 20 per day and her attitude and motivation had improved to an extent where detox was appropriate. Detox using Lofexidine commenced at home where Liz lives with her mother. Unfortunately, Liz used heroin on her second and third day of detox and the regime was abandoned. She claims that her heroin use is still approximately 20 per day but it is suspected that it is somewhat higher.
The detailed characteristics of this 'spectrum of misuse' cannot be understood in full via a small qualitative exercise. But it is important to emphasise that a spectrum exists. Not all substance use by children, even when problematic, is of the same degree of severity or centrality in terms of the overall handling of the case. This has important implications for the ways in which drug agencies and others supporting children co-operate.
For example, assessments need to include consideration of the severity and importance of the drugs misuse problems, along with the possible range of non-drugs issues, and the relationships between them. These findings then need to be shared by a range of relevant agencies as a basis for effective shared treatment or care.
Predicaments of Young Drug Users
The child or young person facing issues such as these is not usually well equipped to articulate his or her needs or the priorities for addressing them. In our study, they usually faced at least some of the following difficulties:
lack of family and peer support to address their problems;
lack of awareness of the likely consequences of their actions (particularly of substance misuse);
lack of knowledge of who to approach for help or how;
distrust or fear of official agencies and staff, including social workers;
an assumption that they are disapproved of by most other social groups;
danger of victimisation or exploitation by others (including dealers and pimps);
difficulty envisaging and committing to a positive course of action to help themselves.
Some of the problems outlined above were explicitly recognised by young interviewees. Statements made to us included:
Some of my friends have got turned away when they looked for help. Because they take drugs, people treat [young drug misusers] differently from people who don't take drugs. But they still need help like other people.
When I was 16 I just wanted to party. When I started coming here it made me more aware of the effects of drugs and I calmed down.
Nobody listened to me before - they just told me what to do.
Agency workers mentioned other predicaments in relation to specific cases (examples included family difficulties and victimisation) or in relation to their young service users generally.
Children can be afraid to approach our workers - they are often from children's homes or from drug using families. If they are involved in the sex industry, for example, they will be aware that under-age sex is illegal, and they may be being pimped, or subjected to family pressures.
The predicaments faced by individuals will be affected by their position on the 'substance misuse spectrum' and on their particular set of needs. One delivery worker, for example, commented on the sense of separation, and even mutual hostility, between cannabis and heroin users on the programme.
The kids that are just using cannabis look down on the heroin users as scum - they have no time for them. We have to be careful how we mix kids from these two groups in our programmes - it takes time for them to settle down and work together.
Many of the interviewees facing these difficulties were supported by families, carers, or social workers or other agencies, and so might receive support to help them overcome these difficulties. However the children and young people interviewed usually suggested that there were others who did not have access to such support - who were in danger of 'falling through the gaps' in provision. The nature of this study precluded us going beyond this initial identification to assess the likely scale of this problem in Scotland.
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