A One-Way Street?
Report on Phase I of the Street Children Project
Part 2 of 9
This report is reprinted in nine parts with permission of the World Health Organization, Programme on Substance Abuse, 1993. The document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the
responsibility of those authors.
WORLD HEALTH ORGANIZATION
PROGRAMME ON SUBSTANCE ABUSE
CH-1211 Geneva 27
Tel 791. 21.11
WORLD HEALTH ORGANIZATION
DRUG USE OF YOUNG PEOPLE
It is generally accepted that the best predictor of experimentation with licit and illicit substances by young people is being young. Adolescence is a time of experimentation, exploration, curiosity and identity search and part of such a quest involves some risk taking. However, in some countries, by the time many young people reach adolescence they have been out of home for some time; working, begging, abandoned or sick. By adolescence they have also been exposed to many drugs, especially those easily available or associated with work--glue, petrol, cannabis, tobacco and alcohol. Within a milieu of social and peer influence and expectations, together with easy drug availability, drug use becomes one aspect of the developmental process, and even a part of life.
Most individuals who initiate drug use do not develop significant problems, with experimentation and a variable pattern of use and cessation being quite common. Much use of drugs is not mindless or pathological, but functional. When surveyed, young people in developed or developing countries often indicate that boredom, curiosity and wanting to feel good are perceived as the main reasons for drug use. Other functions served by drug use are to relieve hunger, to adopt a rebellious stance, to keep awake or get to sleep, and to dream.
However, the aetiologies of initiation into drug use and regular, harmful or dependent use may be quite different. It is generally believed that those young people who maintain and escalate their use of drugs are more vulnerable due to the presence of more problematic backgrounds. They usually also lack accessible internal and external resources.
Earlier onset of use and continued use are strongly associated with other behaviours, such as precocious sexual activity, crime and educational failure. They are also associated with such environmental variables as: family disintegration, poverty, lack of accessible and useful recreational activities, lack of suitable alternative accommodation if the child cannot stay at home, relocation, oppression and discrimination, the availability of drugs and, in some cases, the pressure of dealers.
Research findings show that drug use by young people is more likely to occur where families: have low quality and inconsistent support of their children; model drug use; approve of use (explicitly or implicitly); lack closeness and involvement in the children's activities; have low educational aspirations; exert weak control and discipline; and emotionally, physically or sexually abuse their children. It is obvious that weak or negative bonds to the family would occur for children growing up in such environments.
Likewise, bonds to society can also be weakened by bad experiences at school. Failure, prejudice, a rejecting school environment (teachers, authorities and/or other students), not being able to stay awake or maintain attention because of needing to work at night to support the family, or being kept awake at night by domestic violence will all impact on educational achievement. In addition, poverty takes its toll: not being able to buy education, educational equipment, or transport to school, or not being able to pay to go on excursions. Families may be embarrassed that they are not able to provide adequately for their children, such as school clothing and books and may choose not to send their children to school to protect them from potentially embarrassing experiences. Bonds may also be weakened where young people work in environments where there is exploitation and adverse working conditions.
It is little wonder then that children from unhappy homes and schools would want to find comfort and support with others with whom they could identify. The streets and their occupants provide such peers, a sense of belonging to a new and often more caring replacement 'family', and a degree of freedom which may not have been possible previously. However, the price paid for this may be a near total absence of privacy, supervision, education, nurturance and security, and the likelihood of hunger, violence, marginal employment and exploitation.
It must also be remembered that not all young people who have experienced such familial and societal abuse end up in trouble or use drugs at dysfunctional or harmful levels. Many survive and do well. Their stories are very important, for in them we may be able to see resilience at work in the face of adversity, and be able to identify effective strategies for better assisting those who appear to be as vulnerable but not as resilient.
The aetiology of problematic drug use by young people, then, is clearly multi-determined and that the individual, the environment and the drugs themselves cannot be considered in isolation.
One way of conceptualizing the use of drugs is the Modified Social Stress Model which was developed by PSA from the work of Rhodes and Jason (1988), and which emphasizes competence and coping. The modified model differs from that of Rhodes and Jason by incorporating environmental, social and cultural variables which may influence drug use, and also by acknowledging the role of the physical properties of the drugs used and their interactions with the user. It posits increased risk for problematic use of drugs as a function of the level of perceived personal (distress)stress, the image that drugs have in the particular community or subculture and the perceived effects on the individual of particular drugs, being offset by positive attachments, the possession of adequate coping strategies and skills, and access to necessary resources.
The model may be represented as follows:
RISK FOR DRUG USE =
(DIS)STRESS+NORMALIZATION OF DRUG USE+DRUG EFFECT
For example, risk may be greater when stress levels are high, drug use is promoted and condoned in the community, the drug effects experienced by the user are perceived as positive, positive attachments to family do not exist, coping skills are poor and access to resources blocked.
The model appears to lend itself to attributing numeric values to each of the variables, which may have positive or negative valance and/or weighting, to assess risk. However, this form of analysis is difficult, time consuming and open to many interpretations. Consequently, the model is suggested as a conceptual framework which can organize information and assist in the formation of plans and interventions.
The model should not be assumed to be complete. People do not exist within a vacuum, and models such as this one do not exist outside large-scale social, political, cultural, religious and economic contexts. These macro-variables will impact on risk of drug use, but are usually outside the capacity of local workers to significantly influence. However, as Rhodes and Jason (1989) suggest "... both baby steps and giant steps are important." (p. 18)
Five levels of stress were identified by Rhodes and Jason from the literature:
--Major life events--
These include such events as parental death or abandonment, natural disasters and personal injury. They tend to occur suddenly, without warning, with the adolescent having no control over the situation. It is likely that the event will result in shock and require a period of adjustment. Drug use may be an attempt to cope with the pain and to assist in the period of adjustment.
It is not unusual for young people in developing countries to have experienced at least one major life event. Natural disasters, such as earthquakes, droughts and floods; migration or mass population movements; civil unrest and armed conflict; industrial accidents; and disease are common and have tragic consequences for the young. Often whole communities are affected. The young may see their family and community devastated, family members die or may themselves experience physical harm.
As with adults, young people also experience daily "hassles", day to day conflicts and pressures. For most young people these are likely to include "nagging" from parents, parental arguing, school and household "chores". These daily "hassles" may be considered insignificant when compared with those day to day problems which are encountered by young people on the streets. Many problems for these groups relate to daily "hassles" such as conflicts over finding shelter, clothing and food, the avoidance of violence and sexual abuse, and having to cope with the inequality of treatment by the police, criminal justice systems, and street peers. Drug use can be an attempt to escape from this chronic conflict.
--Enduring life strains--
These include stresses which persist over time, are not easily resolved and are often related to a deprived socioeconomic environment, such as poor housing, lack of adequate food, clothing, money, and access to employment and recreation. Drug use is one of a number of different behaviours used to provide excitement in an otherwise bleak environment.
Survival for children in such circumstances can be the all- consuming daily task. Finding adequate shelter, food, clothing, and health care leaves little time for much else. There may be no time to look for educational, recreational or job opportunities, or to plan for a future. The hopelessness of some situations can contribute to feelings of depression and low self-esteem. They are in no position to change their economic situation or poor living conditions, and there may be few models of success in their community. The only models of success may be individuals involved in the drugs industry, for example the "gold chains, fast cars and smart suits" of the drug dealers in ghetto communities. Dreaming of a future often occurs, and drugs can assist this dreaming.
A further consideration is the stress associated with chronic pain and illness. Children out of home are at greater risk of experiencing health problems which lead to chronic pain or discomfort, such as trauma leading to bone and joint pain, malnutrition and hunger, and chronic infections. Drugs may be used to relieve this pain or discomfort.
These include stresses which require adaptation to new situations, such as moving schools, leaving home or entering into a relationship. Street children may move between communities/cities to escape threats from police and peers, or move from family to family or other sources of accommodation. Such transitions usually involve a disruption in peer relationships. Drugs may be used to facilitate acceptance among new peers and deal with the discomfort associated with the transition.
--Developmental changes of adolescence--
The developmental changes that are a necessary part of adolescence can be extremely stressful for any adolescent. These changes include the physical changes of puberty, the development of a sexual and self identity, the gaining of independence and planning for the future. Specific issues arise for girls as they reach a reproductive capacity.
For many young people, in or out of home, there is little time to gradually complete the developmental tasks of adolescence. Some have had to be parents to their own parents and even their siblings, due to such factors as: death of a parent, parents' need to work long hours, parental drug dependence, illness or imprisonment. Others need to adopt a parenting role following teenage pregnancy. These young people have lost their childhood and adolescence, and have had to adapt to adult roles while still in the process of growth and development. Using drugs, possibly as an attempt to cope with their lives and stress, can further impede development. This can be described as a "maturational or developmental lag", and it can be related to deficits in the development of "formal operational thinking"; that is, a capacity to engage in role reversal, empathic communication and to progress beyond the concrete thinking of younger children.
Apart from adolescence, the developmental changes of childhood can also be extremely stressful, and must be considered. It is not uncommon to find street children under the age of 10 years in many developing countries.
Infectious diseases and malnourishment, common among street children, may result in retardation of growth, delayed puberty, skin diseases and bone deformity. These events can significantly influence self image and also require recognition.
The variable "normalization" refers to a number of environmental, social and cultural factors which have been shown to, or are considered likely to contribute to or influence drug use. In particular, it refers to the extent to which particular drug use or drug-using behaviour may be considered "normal" in a society or sub-culture (in that it is widespread, visible, fairly resilient to law enforcement interventions and supply reduction strategies) and how that society reinforces this belief. These factors include:
The price of a drug will significantly impact on the extent to which that drug is used. This is particularly so for young people and other populations where finances are severely restricted. When the price of a drug increases, the user with limited financial resources may use one or more of at least five options. First, the user can choose to stop using the drug. Unless something else is offered in its place, it is unlikely that this option would be acceptable to the user. Second, the user may reduce his or her level of drug use while maintaining the same expenditure on drugs. This appears to be a common approach particularly for non-dependent drug users. Third, the user could choose to change to a less expensive alternative drug. This is more likely to occur if the drug user has no preferred drug of use, or if he or she is not entrenched in a certain pattern of drug use. Younger drug users often fall into this group. Fourth, the drug user could use the drug more efficiently. As the drug becomes more expensive, or its purity decreases, the user may change from ingesting or inhaling the drug to injecting it, thereby increasing its bio-availability. This has significant implications as the health risks for injecting drugs are far greater than those for using other routes of administration. Finally, the user can make available more money or services, so that he or she can maintain the same level of drug use. To do this, the user may divert money from other living expenses (e.g. food, rent, clothing) to pay for drugs, or he or she may increase his or her earning power, such as working longer hours, committing more crime, selling more drugs, or using sex to earn money or pay for drugs.
Where incomes are low, the cheapest drugs tend to be consumed. Inhalants, such as glue, solvents and petrol, are cheap and widely used, particularly in developing countries, as may be alcohol in communities where in local brewing occurs, and cannabis and cocaine in producer and trans-shipment countries. Often combinations of drugs are used to achieve the greatest level of intoxication for the cheapest price.
The availability of drugs to a large extent is culturally determined. The community determines whether a drug is accepted or not and its legal status. Of those drugs which are licit, the community determines which drugs should be controlled and how they should be controlled. There are also those drugs for which there are no formal controls on their availability in different communities, such as caffeine and traditional drugs, including kava, betel nut and pitchuri.
For those drugs which are illicit, availability is determined by the supply of the drug and the vigilance of the drug enforcement agencies. The guaranteed attractive profit margins for supplying certain drugs ensures a continuing supply of those drugs. The trade is so vast, that any increase in the vigilance of law enforcement agencies to increase the probability for detection and punishment for illicit drug production, importation, trafficking, dealing or using is likely to result in only a small impact. The level of vigilance adopted by the authorities varies over time, across communities, and is very sensitive to both the local and international political mood. Such vigilance, and the very fact of the illicit nature of certain drugs, contributes to the problems which are experienced by the drug user. The illicit nature of these drugs makes the user a criminal, marginalizes him or her within the society, and requires the user to use more drastic means to acquire the drug. It also increases the possibility of corruption on the part of those charged with vigilance.
--Advertising and sponsorship--
While contentious, certain studies indicate that young people are particularly susceptible to advertising messages; that alcohol and tobacco advertising may reinforce their use of these drugs; and that youth are often targeted in alcohol and tobacco advertising. Young people with little bonding to society are particularly vulnerable, when lacking hero figures and attractive models in their own communities, and having to rely on sporting and entertainment celebrities who may actively promote products such as alcohol and tobacco.
The portrayal of drug use on television and in movies, especially from developed nations, often highlight attractive elements such as danger and excitement, or place drug use in such a context that it is seen to be a normal, everyday event. Rarely are the harmful and unappealing consequences of drug use demonstrated, and when they are it is usually in a stereotyped portrayal. Many young people, having come from a severely disturbed home life, often rely on such media as a window into what may be considered a normal life.
--Societal attitudes and reference group norms--
Drug use has always been an integral part of most, if not all, societies. Each society has its own attitudes, beliefs and rules in relation to drug use. For any one drug, it may have a different role and pattern of use in different societies. Drug use may be encouraged, such as alcohol for celebrations in Western cultures, coca leaf chewing to ward off hunger and altitude sickness in the Andes, and opium smoking for relaxation in areas of Asia. Societal rules exist, where deviation from accepted drug using practice is negatively viewed within that community.
It is important to consider the reference group that different populations relate to. Many sub-cultures appear to condone drug use which in the wider community would be considered deviant. Examples include the ghetto cultures of certain USA cities, and some favelas in Brazil, where drug dealers often maintain a respected and hero profile in the community due to their material success as compared to the other ghetto/favela dwellers. In such communities it is not surprising to see young people aspire to follow in the same footsteps as these successful "businessmen", and further to this, such goals are achievable for them.
This variable refers to the inherent properties of the drugs which may be used and their interaction with the user and the setting within which he or she uses drugs. This variable comes into operation once drug use has been initiated. Drugs vary in their physiological actions; a certain drug is more likely to be used if the subjective experience of using that drug (an interplay of the drug's pharmacology on the individual in a certain environment with certain expectations) is an experience which was desired.
Characteristics of the drug user significantly influence drug effects, the potential for dependence and the risk of drug-related harm. These characteristics include the individual's physical condition, other substances being used at the same time, his or her expectations and his or her past drug-related experiences. The drug experience does not necessarily have to be positive for the person to continue such drug use. It is not uncommon for street children to report negative experiences through their drug use, however it is claimed that any altered mood or state of conscious provides a welcome escape from the boredom or misery of reality.
Rhodes and Jason describe how bonding tends to occur within three distinct groups: the family, the school/work, and the peer group. Within these three groups, three variables determine the level of attachment and the behaviour expressed: a) the youth's exposure to opportunities and influences within the group, b) the youth's skillfulness of performance within the group, and c) the rewards which the youth receives from the group. Strong attachments to a group are likely to occur if a young person has high exposure to that group, is seen to perform well in that group through learning the necessary skills (such as skate-boarding, busking or pick-pocketing), and is consistently rewarded by that group. Young people who have established strong, positive attachments to their family and/or school/work are therefore less likely to develop attachments to drug using peer groups who use drugs in a harmful and/or dysfunctional manner, and who expect and reward these and other socially unaccepted behaviours.
Negative relationships also exist, sometimes called negative attachments. They lack the positive qualities of a relationship which is fulfilling, affirming and pro-social. They describe situations where, say, a young person is dependent on someone whom he or she despises, feels trapped in a relationship or has attached to anti- or asocial influences.
It would appear that those young people who are detached from their families are at greatest risk. They may have minimal or no opportunities for developing attachments within a family, school or work environment, their exposure often being limited to peers who are in a similar position to themselves. This lack of exposure to such positive environments further compromises their capacity to learn how to behave in such situations. They may feel more comfortable with their peers who behave in a similar way and who hold similar attitudes and interests to them.
Even for those young people who do maintain contact with their families, they may find that the rewards that they receive from their peers are more attractive and consistent than those received from their families. If, in these circumstances, their peers are using drugs, or hold positive attitudes towards drug use, these youths are more likely to take up similar drug-using behaviours.
Childhood and adolescence are important times for the acquisition of coping and social skills. This process is in itself dependent on having positive attachments, the opportunity and resources to learn the skills and an absence of overwhelming stressors. To cope effectively, individuals require a wide repertoire of coping and social skills to deal with the wide range of stressors which are likely to be encountered. A young person skilled in one area may not have the necessary skills to cope with problems that may appear in another part of his/her life. If a young person has the capacity to access and utilize effective coping skills at a time of stress it is less likely that he or she will choose to use drugs as a coping strategy.
Rhodes and Jason describe how these skills may be cognitive or behavioural. Cognitive skills include self-assurance, cognitive restructuring, cognitive distraction and self-control. Behavioural skills include problem solving, direct action through negotiation or compromise, withdrawal through leaving or avoiding the situation, communication skills, assertiveness, social networking, engaging in alternative activities, and relaxation.
Apart from coping and social skills, well developed physical and performance skills are critical for life on the streets. The capacity to fight, to run, to react quickly and to weather physical harm will determine whether they may survive in such an environment. Practical performance skills such as juggling, singing, bartering, making crafts and vending provide the means for an income.
For some youth who are out of home, learning survival skills which the broader community may even consider aberrant or anti-social may be very important. These skills are usually learned from others who have been longer in the same situation. Felsman (1989) provided some examples of these:
"To steal a set of windshield wipers, cross town to the black market, successfully negotiate a price with a fence, and then purchase a T-shirt requires a complex range of visual-perceptual, analytic, and social skills. Begging in open-air restaurants requires equally complicated skills - assessing and choosing an audience, gaining access to them, and creating and producing a successful performance. These survival strategies reveal levels of ego development (cognitive, moral, psychosocial) that might remain unacknowledged by quantitative assessments not attuned to the contextual factors of the environment." (p. 69)
"On weekends, various gamins regularly traveled to the beach in Buenaventura, some three to five hours away by automobile. To reach the edge of Cali, negotiate a ride on a freight truck, raise enough money by shining shoes and begging to feed himself, swim at the beach, and successfully negotiate transportation back to Cali within a set time frame is no small accomplishment for an unsupervised 10-year-old." (p. 73)
The availability of, and access to resources significantly affects a young person's ability to learn new skills and effectively implement them. Information and education also have the potential to change attitudes and perceptions. Access to health, welfare, educational, vocational and recreational services have the potential to ameliorate some of the stresses that an individual may be experiencing. The lack of resources is a common problem for poor, marginalized and minority communities, those communities where stress levels tend to be highest.
Not all resources may have a positive influence on a person. Research has demonstrated that some prevention and intervention programmes have actually had a negative impact on the audience targeted, resulting in an increase in drug use, curiosity and drug related harm. Just providing interventions or resources does not mean that they are going to produce the desired effect. Therefore it is essential that resources are carefully evaluated to determine their validity, utility, appropriateness, cultural sensitivity, and impact within a community. Educational materials developed for the general population or adolescents may be inappropriate for street children. Consideration of literacy levels is essential. Street children may not be able to relate to images, language and story lines which have been designed for a general audience.