Drug and Alcohol Dependence 31 (1992) 77-83 Elsevier Scientific Publishers Ireland Ltd.
Psychiatric
77
symptoms
in drug abusing adolescents
Harith Department
of Child Psychiatry,
Swadi
St. Thomas Hospital, Lambeth Palace Road, London SE1 7EH (UK) (Accepted
May 2nd, 1992)
Psychiatric symptoms and psychosocial variables were investigated in 46 adolescent drug abusers referred to a psychiatric clinic. There were high rates of behavioural symptoms (mostly oppositional and delinquent), emotional symptoms (mostly depressive) and an abundance of adverse life events and family dynamics. When compared to a control group of non-abusing adolescents, drug users were only more behaviourally disturbed. Cluster analysis of the drug abusing adolescents showed that they fell into three distinct groups of (1) behavioural dysfunction (76%); (2) family dysfunction (16%); and (3) emotional dysfunction (8%). The clinical implications of these findings are discussed. Key word-s: adolescents;
drug abuse; psychiatric symptoms
Introduction There is an increasing interest in studying the relationship between adolescent drug abuse and psychopathological/psychosocial factors. This arose mainly from the concern that such factors may predispose to drug abuse initiation and the effects they can have on its course and outcome. Several studies found that drug use in adolescents was closely associated with inappropriate sexual behaviour, general delinquency, school and social misbehaviour and poor academic performance [ 1- 51. Two recent studies confirmed the association between delinquency and substance abuse, but suggested that the relationship is skewed; the severity of delinquent behaviour can explain the severity of substance abuse but not vice versa [6,7]. Other studies found a relationship between emotional problems and substance abuse. In a cross-sectional Norwegian study, among 177 adolescents, higher rates were recorded for Correspondence to: Harith Swadi, Department of Child Psychiatry, St. Thomas Hospital, Lambeth Palace Road, London SE1 7EH, UK.
psychosomatic complaints, anxiety, depression, interpersonal conflict and social dysfunction among drug users than controls [8]. In the San Diego suicide study [9] it was found that 53% of young suicides had a principal diagnosis of substance abuse. Follow-up studies showed an elevated rate for suicide [lo] and depressive symptoms [ll] among substance abusers. Affective symptoms, mainly depressive, were also reported among a sample of 45 solvent abusers in London [ 51. Family background and parenting styles, including parental divorce/discord, family disruption, parental non-directiveness, negative communication, inconsistent parental discipline and lack of closeness have been found to predict later adolescent drug use [12 - 161. Families of drug abusing children were characterised as being those whose fathers were distant and disengaged and whose mothers were too involved and enmeshed [15,17]. Upbringing and parenting may be, at least partly for some addicts, influential as antecedents. In an American study of life events among adult opiate addicts [Ml, it was found that about one third of addicts experienced substantial disruptive events in
03’76~8716/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd Printed and Published in Ireland
childhood prior to their drug use. Higher rates of bereavement were found among users than non-users [15,16]. Very few longitudinal studies which addressed the influence of psychopathology on the outcome of adolescent drug abuse are available. Of the signs of poor prognosis, most important are history of child psychiatric care, early use of drugs, truancy, poor academic performance, high frequency of use and delinquency for boys and ‘nervous complaints’ for girls [19]. Some suggested that those who use drugs in response to social influences are more likely to stop using them than those who use them for psychological reasons such as stress relief [20]. However, some evidence exists to suggest that there is a slight tendency among adolescents with more psychiatric symptoms to improve more with treatment [21]. The present study, utilizing a clinical population, aims at investigating whether drug abusing adolescents are a homogenous group; and if not, to assess the nature of any ‘within group’ differences in terms of their psycho-social and psychological presentation. It also aims at investigating the types of symptoms and psychosocial variables that coexist with drug abuse. Both issues have much relevance to the clinical assessment of such adolescents and the direction and nature of the therapeutic approaches adopted in their management. Method Subjects Data on 46 drug abusing adolescents referred consecutively to a community-based Child Mental Health Clinic in an urban area of Kent County, in Southeast England, over a period of 20 months were analyzed. Three hundred and fiftytwo adolescents (age 12+) were referred to the clinic for various reasons, out of 1002 total referrals of all ages. The assessment of all cases involved investigating and filling out a checklist of a constellation of symptoms by clinicians. The clinicians involved were child psychiatrists, clinical psychologists and psychiatric social workers who worked in three separate multi-
disciplinary teams. Adolescents qualified for inclusion in the study if drug use was confirmed (either by the adolescent or by parents/legal guardians/teachers) and was considered either by the referring agency or the assessing clinician, as being an issue of concern and putting at risk or actually affecting the adolescent’s physical or mental health, education or social functioning. Those 46 adolescents were also compared to another group in whom substance abuse was not an issue of concern, matched for age, gender and area of residence. Variables Family dynamics variables were the following: poor/absent family communications; relationship problems between family members; parental violence; and marital problems. They were assessed on the basis of a family interview. Life events variables were the following: parental separation; parental divorce; parental remarriage; bereavement within the previous’ 18 months; family moving home; adolescent changing school; and adolescent leaving home. Emotional symptoms investigated were: anxiety; phobic, dissociative, obsessive-compulsive and depressive symptoms. Behavioural symptoms investigated were: truancy; delinquency; aggression; defiance; and other difficult behaviour such as lying and petty theft. Other clinical categories. Data from other clinical categories are also presented because of relevance to drug-taking their possible behaviour: history of being a victim of sexual abuse and deliberate self harm. Results Adolescent referrals made 35% of all referrals to the clinic. The incidence of drug abuse among adolescents was 13.1% (16.3% among boys and 9.3% among girls). The study population was comprised of 15 (33%) girls and 31(67%) boys. Their age ranged between 12 and 16 and were distributed as follows: Five (11%) aged 12 years, 6 (13%) aged 13
79
years, 19 (41%) aged 14, 9 (20%) aged 15 years and 7 (15%) aged 16. More than 60% of adolescent drug users were 14 - 15 years of age. The age prevalence of drug abuse among adolescents referred was as follows: 18% among 14-year-olds; 10% among 15-year-olds; 14% among 16-year-olds. These age and gender distributions are not surprising and confirm the results of most clinical and community sample studies [22,23]. Of the study population, 17 (37%) lived with both natural parents, 14 (30%) came from a step-family, 9 (20%) came from a single-parent family and 6 (12%) were either in residential care or with fosterparents or lived with their grandparents. There were no significant differences in that respect between the index group and the controls. However, the index group was slightly more represented in regard to single-parent family background (20% compared to 13% in the comparison group). Of the 46 adolescents 31 (67%) used solvents only (mainly lighter gas fuel) and 15 (33%) used cannabis only. About half the adolescents (22) used solvents as well as cannabis. A number of others used other drugs: 5 used stimulants; 4 tranquilisers; 1 heroin. Almost all (45) used alcohol with 83% using at
Table I, Prevalence Variable
Parental separation Parental divorce Family reconstitution Bereavement Changing school Moving home Leaving home Family discord Marital problems Poor communications Violence in family t-Test: ‘P = 0.028. *‘P = 0.041.
levels which brought concern by parents/ guardians. Tables I and II show the frequencies of family dynamics variables, life events and psychiatric symptoms among the index population and the control group. Most drug abusers showed disturbed family dynamics, most notably poor or absent communications. Half came from families where there were problems between parents (marital problems) and in about one third, one or both parents was/were reported as violent. Life events prior to drug use were mostly related to parents, such as divorce or separation. Eleven percent were victims of sexual abuse and about a quarter had an episode of deliberate self-harm necessitating admission to hospital. In the category of emotional symptoms, depressive symptoms were most common (59%). This is in line with the relatively high rates of deliberate self harm reported in 24% of cases. There were relatively high rates of behaviour problems especially defiance and delinquent behaviour. Compared to the controls, the index group were significantly more represented in parental divorce, leaving home, truancy, delinquency, defiance and other problem behaviour such as petty theft and lying. However, when compared
of life events and family variables among drug abusing adolescents
and controls (n = 46). Control
Index 12
%
n
%
22 28 10 03 09 03 07 23 22 32 15
48 61 22 07 20 06 15 50 48 70 33
21 17 10 02 10 06 01 23 20 28 14
46 37” 22 04 22 13 02** 50 43 60 30
80
Table II.
Prevalence
of psychiatric
symptoms among drug abusing adolescents
Symptom
Index
and controls (n = 46). Control
n
%
n
%
Anxiety Phobic Dissociative Obsessive compulsive Depressive Truancy Delinquency Aggression Defiance Other Unmanageable
13 01 01 00 27 32 33 29 43 38
28 02 02 00 59 70 72 63 93 84
13 00 01 01 22 07 16 23 32 25
28 00 02 02 48 15: 35** 50 70*** 55****
Behaviour Other variables: Victim of sexual abuse Deliberate self-harm
05 11
11 24
07 07
15 15
t-Test: *P = 0.002. **p = 0.001. **+p = 0.01. ****p = 0.004.
on the four domains, the index group were only different in that they showed significantly more behaviour problems. Table III shows the weighted mean scores for the four domains, in both groups. Cluster analysis (Table IV) of the psychological and the psychosocial variables in the index group showed that they fell into the following clusters: The first cluster (behavioural dysfunction group) making 76% of the sample was mainly younger boys, average age of 14 years (S.D. f 15 months) with high rates of Table III. Mean variable group score (weighted to a maximum of 1.0000 for a full compliment of variables). Category
Users
Non-users
Emotional Behavioural Family dynamics Life events
0.1360 0.7526 0.4000 0.2196
0.1587 0.4878* 0.4263 0.2091
t-Test: ‘P < 0.001.
behavioural problems and adverse family dynamics. Significantly minimal emotional symptoms and life events were reported. Despite the high rates of behaviour problems, it was noteworthy that 48% also showed depressive symptoms. The most commonly reported behavioural problems were delinquency and aggression (89% for each) and truancy in 84% of cases. The second cluster (family dysfunction group) making 16% of the sample was mainly younger boys, average age 13 years and 6 months (SD. A 10 months) with an abundance of adverse family dynamics. To a lesser extent, they also showed a mixture of emotional and behavioural symptoms. The third cluster (life events/emotional dysfunction group) making 8% of the sample was mainly significantly older girls (T-value 4.54 P = 0.004), average age 15 years and 8 months (S.D. f 7 months), who did not live with their natural parents and showed high rates of significant and adverse life events. They showed significantly higher rates of emotional (especially
81 Table IV. Cluster analysis: mean scores of users among the three clusters, for the four groups of variables (Weighted to a maximum of 1.0000 for a full compliment of variables).
Cluster
(1) n = 35 (76%) (2) n = 7 (16%) (3) n = 4 (8%)
Variable Groups Emotional
Behavioural
Family
Life Events
0.1150
0.8966
0.4160
0.2000
0.1875
0.4000
0.5333
0.2083
0.2083
0.0667
0.0000
0.3750
depressive) than behavioural symptomatology. No adverse family dynamics were reported in this group. Discussion Studying the relationship between psychopathology and drug abuse among adolescents is a methodological minefield because many psychopathological variables can have different meanings in individual users. The majority can pre-date, coincide with, or be consequences of drug abuse. Furthermore, a third independent variable can operate to bring about both psychopathology and drug use. Also, in nonclinical samples, many drug users do not display overt psychopathology. In any case and irrespective of substance use, psychopathological symptoms in adolescents are relatively common [24,25]. A good case for studying psychiatric symptoms rather than syndromes was made by Costello [26]. This point is highlighted more so in studies of adolescent populations where psychiatric symptoms are more prevalent than syndromes. Insisting on a ‘syndrome’ approach in a study like the present one, would unnecessarily further complicate an already complicated and complex issue of research. Furthermore, the belief that psychiatric symptoms are more influential in determining and shaping drug abusing behaviour was behind choosing ‘symptom’ rather than ‘syndrome’ variables in this study. The association between specific life
events and drug abuse was an incidental finding in the present study; a point that deserves a more systematic appraisal in further studies preferably those of a longitudinal design. The association between behaviour problems and substance abuse is well established. However, this is the first time a study of a clinical population suggests that substance abusing adolescents are in fact more behaviourally disturbed than non-substance-abusing (referred) adolescents. The high rates of truancy confirm the previous suggestion that truancy can be a useful marker in the detection of drug abuse 1271. The studies carried out so far examined the correlation between emotional symptoms and psychopathology (see above). Very few studies examined this issue from a ‘psychiatric syndrome’ perspective, although it is not clear yet whether looking for ‘syndromes’ rather than ‘symptoms’ is a more useful approach in studying this correlation and understanding it. There are, however, a few exceptions. Deykin et al. [28] applied the Diagnostic Interview Schedule to a sample of 424 college students aged 16 - 19. They found an association between alcohol abuse and major depressive disorder (MDD) but not with other psychiatric diagnoses. However, drug abuse was associated with all diagnoses including MDD. They also found that the onset of MDD pre-dated alcohol and drug abuse suggesting the possibility of self-medication as an initiating factor. This study in conjunction with others suggests
82
that psychopathology may have a role in the initiation and stability of use. In this respect, depressive mood seems to be influential. Some suggest that certain depressed adolescents may begin to use marijuana in order to relieve depression [29]. When marijuana use fails as a mood regulator, they turn to other drugs for relief. The reinforcing mechanism helps to continue use. In addition to depression, low selfesteem and lack of self control have been described as predating the onset of drug use [30]. Furthermore, disturbing life events may contribute indirectly to the onset of drug use through such individuals’ vulnerability to depression, low self-esteem and poor stress management [31]. This study confirms an important observation in adult opiate addicts, showing that a substantial proportion of them had significant and adverse life events prior to the onset of their drug dependence [18]. This study showed a lower rate of sexual victimisation (11%) than the rate of 46% previously reported [32]. Furthermore, in the whole adolescent population referred there were 89 who were sexually abused; among them 7 (8%) had a drug use problem. Compared with 46% among a population of sexually abused adolescents [33], the difference is most likely the result of sampling differences. The populations in the two were mentioned studies more disturbed adolescents; the first was juvenile offenders and the latter was adolescents admitted to hospital. The current study highlights several points: 1. Drug abusing adolescents are not a homogenous population. This is a fact that needs to be borne in mind when assessing such adolescents before treatment. The assessment should focus just as equally on the adolescent as a whole (including psychopathology) as it does on the substance abusing behaviour. This has a service implication in that those who deal with substance abusing adolescents should have formal training in adolescent psychological assessment as well as substance abuse. 2. Although the majority show high levels of behaviour disturbance, there is a group, albeit small, that shows high levels of disrupting life events and emotional symptoms. This is
especially so in drug abusing girls. In this sample, this group was small in number, thus not allowing for an examination of the relationship between life events and emotional problems. It is reasonable to hypothesize that life events can be the precursors to emotional difficulties [34]. 3. Drug abusing adolescents generally have a relatively high frequency of emotional symptoms especially depressed mood. These symptoms can be seen within the context not only of the prevalence of depressive symptoms, but also of the high levels of significant and disturbing life events. In the midst of the concern surrounding the antisocial behaviour that such adolescents commonly show, it is easy to overlook the emotional symptoms present. In fact some of the behavioural disturbance can be the result of emotional distress. 4. The need for a theoretical framework for the assessment of drug abusing adolescents. Cluster analysis in this study seems to suggest that there are three distinct groups of drug abusing adolescents, a point which is bound to have some influence on the therapeutic approach adopted: (a) a behaviourally disordered group; (b) a family dysfunction group; and (c) an emotionally disordered group. Finally, this study highlights the need for further research to try to answer a number of questions, for example, is there any specific correlation between different symptoms or constellation of symptoms and specific substances of abuse? What is the temporal relationship between psychopathology and substance abuse?. What are the psychopathological antecedents and consequences of substance abuse? What is the contribution of substance abuse to psychopathology in adolescents? What is the influence of psychopathology and substance abuse on the outcome of each other? - to name but a few in a scarcely researched area of adolescent behaviour. References 1 2
Hundleby, J., Carpenter, R., Ross, R. and Mercer, G. (1982) J. Child Psychol. Psychiatr. 23, 61-68. Jessor, R. and Jessor, S. (1977) Problem behaviour and
83
3
4 5 6 7 8 9 10 11 12 13
14
15 16 17
psychosocial development: a longitudinal study of youth, Academic Press, New York. Bachman, J., O’Malley, P. and Johnston, L. (1978) Youth in transition, The Institute for Social Research, University of Michigan, Ann Arbor, Michigan. Malcolm, S. and Shephard, R. (1978) Am. J. Drug Alcohol Abuse 5, 87-96. Skuse, D. and Burrell, S. (1982) Hum. Toxicol. 1, 321- 329. Fagan, J., Weis, J. and Cheng, Y. (1990) J. Drug Issues 20, 351-402. Hammersley, R., Forsyth, A. and Lavelle, T. (1990) Br. J Addict. 85, 1583 - 1594. Lavik, N. and On&d, S. (1986) Acta Psychiatr. Stand. 73, 437 - 440. Fowler, R., Rich, C. and Young, D. (1986) Arch. Gen. Psychiatr. 43, 962 - 965. James, I. (1967) Br. J. Addict. 62, 391-398. Weissman, M., Pottenger, M. and Kleber, H. (1977) Arch. Gen. Psychiatr. 34, 854-862. Reily, D. (1979) Family Ther. 11, 149-171. Robins, L. (1980) The Natural History of Drug Abuse. In: Evaluation of treatment of drug abusers. (Lettieri, D., Sayers, M. and Pearson, H., eds.). Acta Psychiat. Stand., Suppl. 284. Baumrind, D. (1985) Familial antecedents of adolescent drug use: a developmental perspective. In: Etiology of Drug Abuse: Implications for Prevention, pp. 13-44, NIDA Res. Monogr. No. 56, US Department of Health and Human Services. Stoker, A. and Swadi, H. (1990) Drug Alcohol Depend. 25, 293-297. Isohanni, M., Moilanen, I. and Rantakallio, P. (1991) Br. J. Addict. 86, 391-398. Kaufman, E. and Kaufman, P. (1979) Family Therapy of Drug and Alcohol Abuse, Gardner Press, New York.
18 19 20 21 22
23 24 25 26 27 28 29 30 31
32 33 34
Rounsaville, B., Weissman, M., Wilber, C. and Kleber, H. (1982) Br. J. Psychiatr. 141, 437-446. Holmberg, M. (1985) Acta Psychiatr. Stand. 71, 80-91. Kandel, D. and Raveis, V. (1989) Arch. Gen. Psychiatr. 46, 109 - 116. Friedman, A. and Glickman, N. (1987) J. Nerv. Ment. Dis. 175, 425-433. Johnston, L., O’Malley, P. and Bachman, J. (1987) National trends in drug use and related factors among American High School Students and Young Adults. 1975 - 1986. NIDA, Rockville, Maryland. Swadi, H. (1988) Br. J. Addict. 83, 935-942. D’Arcy, C. and Siddique, C. (1984) Psychol. Med. 14, 615-628. Hill, P. (1989) Adolescent Psychiatry, Churchill Livingstone, London. Costello, C. (1992) Br. J. Psychiat. 160, 304-308. Swadi, H. (1992) Drug Alcohol Depend. 29, 253 - 254. Deykin, E., Levy, J. and Wells, V. (1987) Am. J. Publ. Health. 77, 178-182. Paton, S., Kessler, R. and Kandel, D. (1977) J. Gen. Psychol. 131, 267 - 289 Carroll, J. (1981) Am. J. Drug Alcohol Abuse 8, 259-282. Johns, A. (1990) What is dependence? In: Substance Abuse and Dependence (Ghodse, H. and Maxwell, D., eds.), pp. 5-29. Macmillan, London. Dembo, R., Dertke, M., Borders, S., Washburn, M. and Schmeidler, J. (1988) Int. J. Addict. 23, 351-378. Singer, M. and Petchers, M. (1989) Child Abuse Negl. 13, 319-325. Goodyer, I. (1989) J. Child Psychol. Psychiatr. 31, 839 - 848.
Psychiatric
77
symptoms
in drug abusing adolescents
Harith Department
of Child Psychiatry,
Swadi
St. Thomas Hospital, Lambeth Palace Road, London SE1 7EH (UK) (Accepted
May 2nd, 1992)
Psychiatric symptoms and psychosocial variables were investigated in 46 adolescent drug abusers referred to a psychiatric clinic. There were high rates of behavioural symptoms (mostly oppositional and delinquent), emotional symptoms (mostly depressive) and an abundance of adverse life events and family dynamics. When compared to a control group of non-abusing adolescents, drug users were only more behaviourally disturbed. Cluster analysis of the drug abusing adolescents showed that they fell into three distinct groups of (1) behavioural dysfunction (76%); (2) family dysfunction (16%); and (3) emotional dysfunction (8%). The clinical implications of these findings are discussed. Key word-s: adolescents;
drug abuse; psychiatric symptoms
Introduction There is an increasing interest in studying the relationship between adolescent drug abuse and psychopathological/psychosocial factors. This arose mainly from the concern that such factors may predispose to drug abuse initiation and the effects they can have on its course and outcome. Several studies found that drug use in adolescents was closely associated with inappropriate sexual behaviour, general delinquency, school and social misbehaviour and poor academic performance [ 1- 51. Two recent studies confirmed the association between delinquency and substance abuse, but suggested that the relationship is skewed; the severity of delinquent behaviour can explain the severity of substance abuse but not vice versa [6,7]. Other studies found a relationship between emotional problems and substance abuse. In a cross-sectional Norwegian study, among 177 adolescents, higher rates were recorded for Correspondence to: Harith Swadi, Department of Child Psychiatry, St. Thomas Hospital, Lambeth Palace Road, London SE1 7EH, UK.
psychosomatic complaints, anxiety, depression, interpersonal conflict and social dysfunction among drug users than controls [8]. In the San Diego suicide study [9] it was found that 53% of young suicides had a principal diagnosis of substance abuse. Follow-up studies showed an elevated rate for suicide [lo] and depressive symptoms [ll] among substance abusers. Affective symptoms, mainly depressive, were also reported among a sample of 45 solvent abusers in London [ 51. Family background and parenting styles, including parental divorce/discord, family disruption, parental non-directiveness, negative communication, inconsistent parental discipline and lack of closeness have been found to predict later adolescent drug use [12 - 161. Families of drug abusing children were characterised as being those whose fathers were distant and disengaged and whose mothers were too involved and enmeshed [15,17]. Upbringing and parenting may be, at least partly for some addicts, influential as antecedents. In an American study of life events among adult opiate addicts [Ml, it was found that about one third of addicts experienced substantial disruptive events in
03’76~8716/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd Printed and Published in Ireland
childhood prior to their drug use. Higher rates of bereavement were found among users than non-users [15,16]. Very few longitudinal studies which addressed the influence of psychopathology on the outcome of adolescent drug abuse are available. Of the signs of poor prognosis, most important are history of child psychiatric care, early use of drugs, truancy, poor academic performance, high frequency of use and delinquency for boys and ‘nervous complaints’ for girls [19]. Some suggested that those who use drugs in response to social influences are more likely to stop using them than those who use them for psychological reasons such as stress relief [20]. However, some evidence exists to suggest that there is a slight tendency among adolescents with more psychiatric symptoms to improve more with treatment [21]. The present study, utilizing a clinical population, aims at investigating whether drug abusing adolescents are a homogenous group; and if not, to assess the nature of any ‘within group’ differences in terms of their psycho-social and psychological presentation. It also aims at investigating the types of symptoms and psychosocial variables that coexist with drug abuse. Both issues have much relevance to the clinical assessment of such adolescents and the direction and nature of the therapeutic approaches adopted in their management. Method Subjects Data on 46 drug abusing adolescents referred consecutively to a community-based Child Mental Health Clinic in an urban area of Kent County, in Southeast England, over a period of 20 months were analyzed. Three hundred and fiftytwo adolescents (age 12+) were referred to the clinic for various reasons, out of 1002 total referrals of all ages. The assessment of all cases involved investigating and filling out a checklist of a constellation of symptoms by clinicians. The clinicians involved were child psychiatrists, clinical psychologists and psychiatric social workers who worked in three separate multi-
disciplinary teams. Adolescents qualified for inclusion in the study if drug use was confirmed (either by the adolescent or by parents/legal guardians/teachers) and was considered either by the referring agency or the assessing clinician, as being an issue of concern and putting at risk or actually affecting the adolescent’s physical or mental health, education or social functioning. Those 46 adolescents were also compared to another group in whom substance abuse was not an issue of concern, matched for age, gender and area of residence. Variables Family dynamics variables were the following: poor/absent family communications; relationship problems between family members; parental violence; and marital problems. They were assessed on the basis of a family interview. Life events variables were the following: parental separation; parental divorce; parental remarriage; bereavement within the previous’ 18 months; family moving home; adolescent changing school; and adolescent leaving home. Emotional symptoms investigated were: anxiety; phobic, dissociative, obsessive-compulsive and depressive symptoms. Behavioural symptoms investigated were: truancy; delinquency; aggression; defiance; and other difficult behaviour such as lying and petty theft. Other clinical categories. Data from other clinical categories are also presented because of relevance to drug-taking their possible behaviour: history of being a victim of sexual abuse and deliberate self harm. Results Adolescent referrals made 35% of all referrals to the clinic. The incidence of drug abuse among adolescents was 13.1% (16.3% among boys and 9.3% among girls). The study population was comprised of 15 (33%) girls and 31(67%) boys. Their age ranged between 12 and 16 and were distributed as follows: Five (11%) aged 12 years, 6 (13%) aged 13
79
years, 19 (41%) aged 14, 9 (20%) aged 15 years and 7 (15%) aged 16. More than 60% of adolescent drug users were 14 - 15 years of age. The age prevalence of drug abuse among adolescents referred was as follows: 18% among 14-year-olds; 10% among 15-year-olds; 14% among 16-year-olds. These age and gender distributions are not surprising and confirm the results of most clinical and community sample studies [22,23]. Of the study population, 17 (37%) lived with both natural parents, 14 (30%) came from a step-family, 9 (20%) came from a single-parent family and 6 (12%) were either in residential care or with fosterparents or lived with their grandparents. There were no significant differences in that respect between the index group and the controls. However, the index group was slightly more represented in regard to single-parent family background (20% compared to 13% in the comparison group). Of the 46 adolescents 31 (67%) used solvents only (mainly lighter gas fuel) and 15 (33%) used cannabis only. About half the adolescents (22) used solvents as well as cannabis. A number of others used other drugs: 5 used stimulants; 4 tranquilisers; 1 heroin. Almost all (45) used alcohol with 83% using at
Table I, Prevalence Variable
Parental separation Parental divorce Family reconstitution Bereavement Changing school Moving home Leaving home Family discord Marital problems Poor communications Violence in family t-Test: ‘P = 0.028. *‘P = 0.041.
levels which brought concern by parents/ guardians. Tables I and II show the frequencies of family dynamics variables, life events and psychiatric symptoms among the index population and the control group. Most drug abusers showed disturbed family dynamics, most notably poor or absent communications. Half came from families where there were problems between parents (marital problems) and in about one third, one or both parents was/were reported as violent. Life events prior to drug use were mostly related to parents, such as divorce or separation. Eleven percent were victims of sexual abuse and about a quarter had an episode of deliberate self-harm necessitating admission to hospital. In the category of emotional symptoms, depressive symptoms were most common (59%). This is in line with the relatively high rates of deliberate self harm reported in 24% of cases. There were relatively high rates of behaviour problems especially defiance and delinquent behaviour. Compared to the controls, the index group were significantly more represented in parental divorce, leaving home, truancy, delinquency, defiance and other problem behaviour such as petty theft and lying. However, when compared
of life events and family variables among drug abusing adolescents
and controls (n = 46). Control
Index 12
%
n
%
22 28 10 03 09 03 07 23 22 32 15
48 61 22 07 20 06 15 50 48 70 33
21 17 10 02 10 06 01 23 20 28 14
46 37” 22 04 22 13 02** 50 43 60 30
80
Table II.
Prevalence
of psychiatric
symptoms among drug abusing adolescents
Symptom
Index
and controls (n = 46). Control
n
%
n
%
Anxiety Phobic Dissociative Obsessive compulsive Depressive Truancy Delinquency Aggression Defiance Other Unmanageable
13 01 01 00 27 32 33 29 43 38
28 02 02 00 59 70 72 63 93 84
13 00 01 01 22 07 16 23 32 25
28 00 02 02 48 15: 35** 50 70*** 55****
Behaviour Other variables: Victim of sexual abuse Deliberate self-harm
05 11
11 24
07 07
15 15
t-Test: *P = 0.002. **p = 0.001. **+p = 0.01. ****p = 0.004.
on the four domains, the index group were only different in that they showed significantly more behaviour problems. Table III shows the weighted mean scores for the four domains, in both groups. Cluster analysis (Table IV) of the psychological and the psychosocial variables in the index group showed that they fell into the following clusters: The first cluster (behavioural dysfunction group) making 76% of the sample was mainly younger boys, average age of 14 years (S.D. f 15 months) with high rates of Table III. Mean variable group score (weighted to a maximum of 1.0000 for a full compliment of variables). Category
Users
Non-users
Emotional Behavioural Family dynamics Life events
0.1360 0.7526 0.4000 0.2196
0.1587 0.4878* 0.4263 0.2091
t-Test: ‘P < 0.001.
behavioural problems and adverse family dynamics. Significantly minimal emotional symptoms and life events were reported. Despite the high rates of behaviour problems, it was noteworthy that 48% also showed depressive symptoms. The most commonly reported behavioural problems were delinquency and aggression (89% for each) and truancy in 84% of cases. The second cluster (family dysfunction group) making 16% of the sample was mainly younger boys, average age 13 years and 6 months (SD. A 10 months) with an abundance of adverse family dynamics. To a lesser extent, they also showed a mixture of emotional and behavioural symptoms. The third cluster (life events/emotional dysfunction group) making 8% of the sample was mainly significantly older girls (T-value 4.54 P = 0.004), average age 15 years and 8 months (S.D. f 7 months), who did not live with their natural parents and showed high rates of significant and adverse life events. They showed significantly higher rates of emotional (especially
81 Table IV. Cluster analysis: mean scores of users among the three clusters, for the four groups of variables (Weighted to a maximum of 1.0000 for a full compliment of variables).
Cluster
(1) n = 35 (76%) (2) n = 7 (16%) (3) n = 4 (8%)
Variable Groups Emotional
Behavioural
Family
Life Events
0.1150
0.8966
0.4160
0.2000
0.1875
0.4000
0.5333
0.2083
0.2083
0.0667
0.0000
0.3750
depressive) than behavioural symptomatology. No adverse family dynamics were reported in this group. Discussion Studying the relationship between psychopathology and drug abuse among adolescents is a methodological minefield because many psychopathological variables can have different meanings in individual users. The majority can pre-date, coincide with, or be consequences of drug abuse. Furthermore, a third independent variable can operate to bring about both psychopathology and drug use. Also, in nonclinical samples, many drug users do not display overt psychopathology. In any case and irrespective of substance use, psychopathological symptoms in adolescents are relatively common [24,25]. A good case for studying psychiatric symptoms rather than syndromes was made by Costello [26]. This point is highlighted more so in studies of adolescent populations where psychiatric symptoms are more prevalent than syndromes. Insisting on a ‘syndrome’ approach in a study like the present one, would unnecessarily further complicate an already complicated and complex issue of research. Furthermore, the belief that psychiatric symptoms are more influential in determining and shaping drug abusing behaviour was behind choosing ‘symptom’ rather than ‘syndrome’ variables in this study. The association between specific life
events and drug abuse was an incidental finding in the present study; a point that deserves a more systematic appraisal in further studies preferably those of a longitudinal design. The association between behaviour problems and substance abuse is well established. However, this is the first time a study of a clinical population suggests that substance abusing adolescents are in fact more behaviourally disturbed than non-substance-abusing (referred) adolescents. The high rates of truancy confirm the previous suggestion that truancy can be a useful marker in the detection of drug abuse 1271. The studies carried out so far examined the correlation between emotional symptoms and psychopathology (see above). Very few studies examined this issue from a ‘psychiatric syndrome’ perspective, although it is not clear yet whether looking for ‘syndromes’ rather than ‘symptoms’ is a more useful approach in studying this correlation and understanding it. There are, however, a few exceptions. Deykin et al. [28] applied the Diagnostic Interview Schedule to a sample of 424 college students aged 16 - 19. They found an association between alcohol abuse and major depressive disorder (MDD) but not with other psychiatric diagnoses. However, drug abuse was associated with all diagnoses including MDD. They also found that the onset of MDD pre-dated alcohol and drug abuse suggesting the possibility of self-medication as an initiating factor. This study in conjunction with others suggests
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that psychopathology may have a role in the initiation and stability of use. In this respect, depressive mood seems to be influential. Some suggest that certain depressed adolescents may begin to use marijuana in order to relieve depression [29]. When marijuana use fails as a mood regulator, they turn to other drugs for relief. The reinforcing mechanism helps to continue use. In addition to depression, low selfesteem and lack of self control have been described as predating the onset of drug use [30]. Furthermore, disturbing life events may contribute indirectly to the onset of drug use through such individuals’ vulnerability to depression, low self-esteem and poor stress management [31]. This study confirms an important observation in adult opiate addicts, showing that a substantial proportion of them had significant and adverse life events prior to the onset of their drug dependence [18]. This study showed a lower rate of sexual victimisation (11%) than the rate of 46% previously reported [32]. Furthermore, in the whole adolescent population referred there were 89 who were sexually abused; among them 7 (8%) had a drug use problem. Compared with 46% among a population of sexually abused adolescents [33], the difference is most likely the result of sampling differences. The populations in the two were mentioned studies more disturbed adolescents; the first was juvenile offenders and the latter was adolescents admitted to hospital. The current study highlights several points: 1. Drug abusing adolescents are not a homogenous population. This is a fact that needs to be borne in mind when assessing such adolescents before treatment. The assessment should focus just as equally on the adolescent as a whole (including psychopathology) as it does on the substance abusing behaviour. This has a service implication in that those who deal with substance abusing adolescents should have formal training in adolescent psychological assessment as well as substance abuse. 2. Although the majority show high levels of behaviour disturbance, there is a group, albeit small, that shows high levels of disrupting life events and emotional symptoms. This is
especially so in drug abusing girls. In this sample, this group was small in number, thus not allowing for an examination of the relationship between life events and emotional problems. It is reasonable to hypothesize that life events can be the precursors to emotional difficulties [34]. 3. Drug abusing adolescents generally have a relatively high frequency of emotional symptoms especially depressed mood. These symptoms can be seen within the context not only of the prevalence of depressive symptoms, but also of the high levels of significant and disturbing life events. In the midst of the concern surrounding the antisocial behaviour that such adolescents commonly show, it is easy to overlook the emotional symptoms present. In fact some of the behavioural disturbance can be the result of emotional distress. 4. The need for a theoretical framework for the assessment of drug abusing adolescents. Cluster analysis in this study seems to suggest that there are three distinct groups of drug abusing adolescents, a point which is bound to have some influence on the therapeutic approach adopted: (a) a behaviourally disordered group; (b) a family dysfunction group; and (c) an emotionally disordered group. Finally, this study highlights the need for further research to try to answer a number of questions, for example, is there any specific correlation between different symptoms or constellation of symptoms and specific substances of abuse? What is the temporal relationship between psychopathology and substance abuse?. What are the psychopathological antecedents and consequences of substance abuse? What is the contribution of substance abuse to psychopathology in adolescents? What is the influence of psychopathology and substance abuse on the outcome of each other? - to name but a few in a scarcely researched area of adolescent behaviour. References 1 2
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