Symposium : Behavioural Pediatrics-II Indian J Pediatr 1999; 66 : 569-575

S u b s t a n c e A b u s e in C h i l d r e n and A d o l e s c e n t s
B.M. Tripathi and Rakesh Lal

Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical
Sciences, New Delhi

Abstract. Consumption of licit and illicit substances has increased all over the world and the age of
initiation of abuse is progressively falling'. The common drugs of abuse amongst children and
adolescents in India are tobacco and alcohol. Use of illicit drugs like cannabis and heroin have also
been reported. A high prevalence of drug use and even intravenous use among street chilaren and
working children is a matter of concern. Although initiation to drug use usually occurs during
adolescence, the adolescent drug users are seldom seen in various treatment centres. Thus
community based programmes are beneficial for prevention and treatment of substance abuse
among children and adolescents. (Indian J Pediatr 1999; 66 : 569-575)

Key words : Drug abuse; Street children; Heroin.

In recent years consumption of licit (tobac- substance abuse should be investigated by

co and alcohol) and illicit (heroin, cocaine)
substances has increased greatly through-
out the world. Particularly disturbing is the
fact that the age of initiation into substance
abuse is progressively falling TM. Conse-
quences of abuse such as increased mor-
bidity and mortality, increased criminality,
decreased productivity and absenteeism
are the social costs the family and the com-
munity have to bear. This assumes greater
relevance in developing countries like ours
already b u r d e n e d b y inadequate health
care facilities consequent to overpopula-
tion, poverty and illiteracy. Early initiation
of alcohol and drug use is usually associat-
ed with a poor prognosis and a life long
pattern of deceit and irresponsible behav-
four. W h e n e v e r confronted with behav-
ioural problem d u r i n g the teenage years,
Reprint requests : B.M. Tripathi, Drug Depend-
ence Treatment Centre, Department of Psychia-
try, AIIMS, New Delhi-110 029.
the clinician.
Epidemiology
Tobacco, inhalants, cannabis products,
alcohol and stimulants are most commonly
abused drugs by adolescents in the West~.
Multiple d r u g use has become more com-
m o n and tobacco smoking has increased
among teenage girls ~. Heroin and cocaine
use has increased among high school stu-
dents in recent years 3.6,7. The prevalence
rates of drug abuse are higher in the school
surveys than the household surveysL Ex-
tent and pattern of substance abuse among
children and adolescent in India is different
from the West. Substance abuse among
girls is uncommon. Data from student and
non-student populations indicate that alco-
hol, tobacco, minor tranquilliser3, analge-
sics and cannabis are the c o m m o n drugs
being abused 9''~ Inhalant use c o m m o n l y
reported from the West is not so c o m m o n
570 B.M. TRIPATHI A N D R. LAL
in India. A general population survey re-
ported use of tobacco or alcohol in 0.2-0.3%
of children less than 15 years of age. The
figure rose to2.5 -3.4% in the age group 15-
20 years. Only a few cases of opioid de-
pendence were reported u.
A somewhat higher prevalence of sub-
stance abuse was reported among school
students with alcohol (4-13%) being the
commonest followed by tobacco (3-6%)
and minor tranquillizers (1-4%). These
studies conducted in eighties did not re-
port any cannabis or opiate use 9,12.In recent
years opioid use has been reported in
school children13"14.Initiation to heroin use
was before the age of 16 years in 8% of her s
oin abusers in the north-eastern part of the
countryTM. A similar age of initiation of her-
oin abuse has been reported from other
parts of the country as well. A country pro-
file documented by the Ministry of Wel-
fare, Government of India reported mean
age of initiation to heroin as 14 years.
A high prevalence of tobacco, alcohol
and opioid use has been reported amongst
street children and child labour. Inhalants,
sedatives, cough syrups and smokeless to-
bacco is also common. Most street children
are multiple drug users who start with to-
bacco and graduate to alcohol and charas.
One study reported alcohol use (75%) as
most common followed by charas (50%)
and heroin (5-10%) amongst this group 16.
Drug use in 91% of s ~ e t c h i l d r e n was re-
ported from Madurai including intrave-
nous use of heroin and pethidinelL
Extent of substance abuse in college stu-
dents ranges from 1.5-19% (excluding alco-
hol and tobacco). Heroin use wasflrst re-
ported in 1986 by college students (0,02-
0.04%). Alcohol use was commonest (40%)
followed by cannabis (5.4%); l:~sychotropics
(3.0%), heroin (1.1%) and o~her opiates
Vok66, No. 4,1999
(1.3%) 18"
R i s k Factors
Most drug use begins during the second
decade of life. The most frequently in-
volved reasons are curiosity, pleasure seek-
ing and personal or family problems. There
are a number of risk factors which have
been correlated to serious substance abuse
in adolescents (Table 1). The presence of a
parent or other relative with substance
abuse in the family is the most influential
factor. Lack of achievement, especially in
school and poor self esteem correlate with
alcohol and substance abuse. An aggres-
sive and impulsive teenager is at higher
risk for substance abuse. Parental separa-
tion, divorce and disturbed family relation-
ship and peer drug use increase the likeli-
hood of the adolescent drug problem zs'19'2~
Other risk factors for substance abuse in-
clude social isolation and unconventional
behaviour patterns. Personality patterns
exhibited by children with substance de-
pendence include behavioural deviance,
TArts 1. Risk Factors for Substance Abuse in
Adolescents
9 Peer factors, personality, attitudes (e.g.
drug using peers, poor self esteem, aggres-
sion)
9 Family factors (e.g.family drug use, family
conflictand instability)
9 School factors (e.g. poor academic per-
formance, low intelligence)
9 Co-existingpsychiatric disorder (e.g.atten-
tion deficit disorder, depression, conduct
disorder)
9 Socialdisorganisation
9 Early and persistent problem behaviour
(e.g.early onset of drug use)
Vol. 66, No. 4,1999 SUBSTANCEABUSEIN CHILDRENAND ADOLESCENTS
delinquency, violence, vandalism and hos-
tility. These children have more behaviour-
al and psychiatric problems. They exhibit
low self esteem and increased anxiety. Con-
duct disorder, attention deficit disorder,
hyperactivity disorder, learning disabilities
and depression have been correlated with
adolescent d r u g use. It has also been re-
ported that inattention, impulsivity and
hyperactivity consequent to poor behav-
iour self regulation predispose to substance
abuse4~,7,21,22.
Material affection and family support,
non substance abusing family members
and peers, healthy behaviour patterns (in-
volvement in work, studies, sports, reli-
gion) and personal characteristics of self
acceptance, self esteem and low aggression
act as protective factors against substance
abuse.
Though genetic and biological factors
have also been implicated, no firm conclu-
sions can be d r a w n 2a.
Diagnosis
A substance abuser could either be cate-
gorised as a harmful user or dependent on
a substance based on guidelines involving
cognitive, behavioural and biological phe-
nomenon u (Table 2). One should be aware
of the various groups of substances being
abused (Table 3).
One should also assess presence of any
comorbidity like attention deficit hyperac-
tivity disorder, mood, and personality dis-
order. Urine screening is helpful in detect-
ing recent drug use which can also be de-
tected in body fluids like saliva and blood.
Cannabinoids can be detected upto 4
weeks after last use, although most other
drugs are present for less than a week.
Course and Outcome
Though the majority of adult addicts
571
TABLE2. Guidelines for Diagnosis of Substance
Abuse
Harmful Use
A pattern of psychoactive substance use that is
causing damage to health
(i) actual damage to the mental or physical
health of the user.
(ii) harmful pattern often criticised by others
associated with social consequences.
Harmful use should not be diagnosed if
dependence syndrome, psychotic disorder
or other drug or alcohol related disorder is
present.
Dependence Syndrome
A cluster of physiological, behavioural and
cognitive phenomenon in which the use of a
substance is given higher priority than other
behaviours. A diagnosis is made if three or
more of the following are experienced at some
time during previous year.
1. a strong desire or sense of compulsion to
take the substance.
2. difficulty in controlling substance taking
behaviour.
3. physiological withdrawal state
(a) as characteristic withdrawal symptom
for the substance
Co) the same or related substance is taken
to relieve or avoid withdrawal s y m p -
toms.
4. evidence of tolerance (need to markedly in-
crease the substance to achieve desired ef-
fect or minimised effect with use of the
same amount).
5. Progressive neglect of alternative pleasures
or interest.
6. Persistent substance use despite evidence
of harmful consequences.
The dependence syndrome may be present for
a specific substance (e.g. tobacco), a class of
substance (e.g. opioids) or a wide range of dif-
ferent substances.
Modified from WHO : The ICD-10 classifica-
tion of Mental and Behavioural Disorders. Ge-
neva; World Health Organization, 1992.
572 B.M.TRIPATHIAND R. LAL
TASLE3. Substances of Abuse
Class
CNS depressants
CNS stimulants
Opiates
Cannabinols
Hallucinogens
Solvents
Other drugs
Nicotine
starts drug use during adolescence, the
subsequent course of substance abuse is
less clear. The adolescents usually start
with tobacco and alcohol and subsequently
prosress to harder drugs like cannabis, her-
oin or cocaine. The teenagers tend to be
multiple drug users. Fortunately, amongst
the adolescents who experiment with
drugs, only a small proportion progress to
the regular use and drug dependency4.
These findings from the West seem to be
broadly applicable in Indian settings as
well. However, there are no Indian studies
on course and outcome of alcohol and sub-
stance abuse among children and adoles-
cents.
Treatment Strategies
Adolescents are more likely to be in-
volved in tobacco and alcohol abuse. Some
of them progress to regular use of illicit
drugs like cannabis and opioids. Treatment
strategies should be specifically designed
taking into account the substance of abuse,
pattern and severity of abuse, and environ-
mental factors. For experimental or social
users education and counselling is enough
to bring the desired change in behaviour.
For regular or dependent users psychoso-
Vol.66, No. 4, 1999
Examples
Alcohol, hypnotics, antianxiety drugs
Amphetamine~Cocaine
Opium, Heroin, Morphine, Buprenorphine
Ganja, Bhang, Charas
LSD, Mescaline, Psilocybin
Petrol, paint thinner, glues
Antihistaminics, cough syrups
Tobacco and tobaccoproducts
cial and pharmacological treatments are
needed 5. Tobacco use by adolescents does
not require detoxification. Alcohol use in
adolescents is often episodic and depend-
ence to alcohol develops over many years.
However, alcohol and sedatives can have
life threatening withdrawal symptoms in
some adolescents. Dependence to opioids
develops after a short period of abuse and
adolescent opioid users usually have opio-
id withdrawal symptoms which should be
treated with appropriate medication. (i.e.
buprenorphine or dextropropoxyphene).
Adolescent drug users can have co-existing
psychiatric disorders, which need to be as-
sessed and treated adequately for preven-
tion of relapse. Psychosocial treatment
comprises of individual, group and family
therapy, rehabilitation and after care pro-
grammes including self-help groups. Most
of the programmes involve the family at
some stage of the treatment. Residential
treatment programmes do not have signifi-
cant advantage over out-patient pro-
grammes4. Cognitive behaviour therapy is
helpful in some adolescentsz~.
In view of high prevalence of drug
abuse among street children and child la-
bour in India, programmes need to be de-
veloped keeping in mind the special prob-
Vol. 66, No. 4, 1999 SUBSTANCEABUSEIN CHILDRENAND ADOLESCENTS
lems of these children which include intra-
venous use and sexual abuselL Harm mini-
misation strategies are also suggested in
adolescents with serious substance abuse
problems. Many non-governmental organi-
sations are working with these groups.
Prevention
For many adolescents involvement with
substances of abuse m a y be short lived and
may have no psychosocial or medical con-
sequences. In other cases it may lead to de-
pendence and serious disability. Though
substance abuse usually starts during ado-
lescence, children and adolescents are rare-
ly referred to psychiatric services for neces-
sary intervention. In view of the falling age
of initiation, the prevention p r o g r a m m e s
should be directed towards younger chil-
dre1~. Initiation to drug use is less likely to
occur if it can be delayed sufficientlylL The
c o m m u n i t y oriented p r o g r a m m e s and
school based p r o g r a m m e s are likely to be
beneficial in the long run 4,26-28.Community
based programmes have effect on delaying
onset rates and in some cases decreasing
prevalence rates 29. Most of the community
based programmes emphasise less on med-
ical approach and focus more on psychoso-
cial m e t h o d s of treatment. These pro-
grammes can be directed t o w a r d s one or
multiple substances of abuse and vary sig-
nificantly in their approach. The emphasis
in a given p r o g r a m m e m a y be on health
education and counselling, health promo-
tion, d e m a n d reduction, harm minimisa-
tion, life skills training, behaviour self reg-
ulation, rehabilitation and after care or a
combination of these 263~ Tobacco use,
(smoking and s m o k e l e s s tobacco - SLT)
most common in preadolescents and ado-
lescents, leads to short and long term
573
health problems and is a risk factor for oth-
er substance abuse. Hence c o m m u n i t y
based p r o g r a m m e s need to focus on pre-
venting tobacoo use in children and ado-
lescents. In recent years m a n y community
oriented p r o g r a m m e s for prevention of
substance abuse (opioids, cannabis) have
been d e v e l o p e d and applied in different
settings in India b y various governmental
and non governmental organizations 14'3~
However, impact of these programmes are
yet to be assessed. Only a few pl"ogrammes
have specifically targeted the children and
adolescents.
I m p l i c a t i o n s for Clinical Practice
Whenever treating a child or adolescent
for behavioural problems substance abuse
should be suspected. The clinician should
be aware of the risk factors and clinical fea-
tures of substance abuse in adolescents and
the substances being abused. The problem
of substance abuse is often associated with
other psychiatric problems which should
b e evaluated and treated accordingly.
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HEIGHT GAIN I N TURNER'S SYNDROME USING GROWTH HORMONE

A study in Southampton, UK analysed 485 girls with Turner's syndrome treated with growth
hormone (GH). The changing patterns of treatment were assessed. Over the decade of
analysis, it was found that the mean age of starting GH treatment fell from 10.4 to 8.5 years
and the starting dose increased from 0.55 to 0.95 IU/kg/week. The frequency of injections
escalated from 3-6 or 7/week. In order to assess the height gain at final height, 52 girls who
were prepubertal at the start of the treatment (>__4 years) and who had attained the final
height or had a growth velocity <2 cm/year were taken.
It was found that their mean gain in final height was 5.2 cm and the GH dose was 0.78 IU/
kg/week over 5.8 years. The final gain in height was seen to correlate with duration of
treatment, total dose received and first year response.
It was summarised that since even with suboptimal dosing beginning prepubertally, mean
height gain was 5mm. Thus, a greater height gain can be expected with a GH dose of 30 IU/
kg/week in 6-7 injections each week starting at an early age.

Abstracted from: Arch Dis Chlldh March 1999; VoL 80 (3) : pp 221-225