D rug and Alcohol Review (199 9) 18, 453 •475
C O M P R E H E N S IV E R E V IE W
C auses an d co rrelates o f ad o le sce n t d r u g
abu se an d im p lic atio ns fo r treatm en t
C AT H E R IN E SP O O N E R
N ational D ru g and A lcohol Research C entre, U niversity of N ew South Wales/Ted
N offs Fou ndation, Sydney, Australia
A b s tract
O n th e b asis o f th e lite ratu re , th e fo llo w in g risk facto rs fo r d ru g a bu se by a do le sce n ts w er e id e n tifie d:
b io lo gic al p re d isp o sitio n to d ru g a bu se ; p e rs o n ality traits th at re fle ct a lack o f so c ial b o n d in g; a
h isto r y o f lo w q u ality a n d co n sist e n cy o f fa m ily m a n age m e n t, fam ily co m m u n ic atio n , fam ily
re la tio n sh ip s an d p are n tal ro le -m o d e llin g, a h isto r y o f be in g ab u s e d o r n e gle cte d ; lo w so cio e co n o m ic statu s; e m o tio n a l o r p sy ch iatric p ro b le m s ; sig n ific an t stre sso rs an d/o r in a de q u a te co p in g
sk ills a n d so cia l su p p o rts; in a d eq u ate so cial sk ills; h isto r y o f ass o cia tin g w ith dr u g-u sin g p e e rs,
re jectio n by p ro so cial p e e rs d u e to p o o r s o cial sk ills; a h is tor y o f lo w c o m m itm e n t to e du catio n ,
failu re at sch o o l; a h isto r y o f a n ti-so cial b e h a vio u r an d d e lin q u e n c y an d e arly in itiatio n to d ru g u se .
M o d e ls fo r co n c e ptu a liz in g th e a e tio lo gy o f d ru g ab u se are disc u sse d , n a m e ly J e sso r˜s p ro b le m
b e h av io u r sy n d ro m e an d R h o d e s & J aso n ˜s S o c ial S tre ss M o d e l. It is cle ar th a t the p ath to dr u g
ab u s e is co m ple x , so sim p le so lu tio n s to th e p ro ble m are u n like ly to b e e ffe ctive . [S poon er C . C auses
and co rrela tes of ad oles cen t d ru g ab use and im plica tion s for treatm en t. D rug A lcohol Rev 1 999;18 : 453 •475 ]
K e y w o rd s: you th/adolesce nts, treatm en t, risk fa ctors , predictors .
In tro du ctio n
E ffectiv e he alth inter ven tion s seek to red uce risk
fa ctors and/or pro m ote protective fac to rs fo r health co m prom ising beh aviou rs [1 ,2]. Acco rdingly, drug preven tio n and d rug -treatm en t prog ram m es are g en era lly based u pon know n risk and protective factor s fo r
dru g m isu se. T here have been a larg e num ber o f
stud ies of the risk fa ctors for dru g u se and m isuse [ 3,4] , bu t there is still m uch con trad ic tio n am on g
stud ies [ 5]. T his pap er rep orts the m ain co nclu sio ns
fo r w hich there seem to be som e support and presen ts
im plicatio ns for treatm en t. B efo re d oin g so, som e
issues ab ou t risk facto rs are d iscussed.
C au s e s o f u se ?
T he aetiolo g y of drug abu se is com plic ated for a
num ber of rea sons. First, distin ction need s to be m ad e
betw een variab les that:
C a therine S pooner B A (H ons), M P H , N ational D rug and A lcohol R esearch C entre, U niversity of N ew S ou th Wales, S yd ney 2 052 , Australia.
C orresp ondence to: C atherin e S pooner.
R eceiv ed 1 M ay 19 98 ; a ccepted fo r pub lication 1 M arch 19 99 .
ISSN 09 59 •52 35 print/IS S N 146 5 •337 0 online/9 9/0 404 53 •23 © Austr alian Professio n al S ociety on A lcoho l and O ther D rug s
454
C atherine Spooner
Ÿ are associa ted w ith d rug abu se (p reced e, follow, o r
co -ex ist w ith d rug u se), but are not cau sally rela ted ,
fo r exam ple, be cause bo th are —
cau sed ˜ by som e
oth er fac to rs (cor relates);
Ÿ co ntrib ute to dru g abuse (risk factor s);
Ÿ m ediate o r m od erate risk fac to rs (p rotective
fa ctors );
Ÿ are cau sed by drug abu se (con seq uen ces); and
Ÿ are co ntrib utors to drug u se, as w ell as con sequen ces o f d rug use.
S econ d ly, risk fa ctors are not alw ays risk facto rs:
differe nt risk fa ctors are salien t at d ifferen t tim es in the
de velop m en t o f adolesce nts. For exam ple, poor aca de m ic ach iev em en t in G rad es 1 and 2 have no t been
fo und to be predictiv e o f ad ole scen t d rug m isuse, but
poo r pe rfo rm ance has been fo und to be predictiv e
w hen evid en t in later g rad es [6] . T hirdly, there is no
single pathw ay to the d evelo pm en t of prob lem atic
dru g use [7•10 ]. T he num ber o f risk factor s has been
fo und to be m or e predictiv e of subseq uen t dru g use
and m isuse than any individu al risk factor [1 1,12] .
In su m m ary, a variab le that is associate d w ith drug
ab use cou ld be a risk factor, a pro te ctive fac to r, a
co rrela te and /or a con sequ en ce; and that relation ship
ca n change over tim e. Furtherm or e, it is the net effect
of the com bination of risk fac to rs and pro tectiv e
fa ctors , rathe r than any individu al risk fa ctor, that
pred icts drug abuse. Sim ple answ e rs to the q uestio n
—
w hat causes d rug ab use?˜ do n ot exist.
A e tio lo gy o f u se v e rsu s ab u s e
T he ae tiolo gy of drug use is not the sam e as the
aetio log y o f drug abu se, and m ig ht even vary fo r the
ab use of particu lar drug s. T his no tion has been
su ppo rted by Stein and collea g ues˜ analyses o f their
lo ngitu dinal study of d rug u se by A m erican stud en ts
that indicated that d rug u se and prob le m atic d ru g u se
w ere differ en tially determ ined [13 ]. G orsuch no te d
that researc hers no lo nger :
. . . assum e that initia l d rug use and dru g
ad diction have the sam e ca uses. Adm itted ly, som e
theories do take a sing le-s tage , —
take it on ce and
hoo ked for life˜ ap proa ch. H ow ever, w e fo und the
evid en ce stron g that m any w ho d o have an initial
experien ce w ith a particu la r d rug do not becom e
co ntin ual u sers, and that m any w ho becom e
co ntin ual users do not bec om e add icts. H en ce,
the cau ses for e ach stage m ay be d ifferen t, and a
set o f stages is neces sary [14 , p. 20] .
It has be en argu ed, for exam ple , that the use o f d rug s
oc curs as a resu lt of soc ial influ en ces, w herea s
prob le m atic d rug u se results fro m psycho log ica l
proc esses su ch as self-m edicatio n fro m em otion al
distress [15] . T he fo llo w ing lite rature review is con cer ned w ith risk factor s for d rug abu se, rather than fo r
initiatio n o f d rug use.
O rd e r o f p re se n tatio n
T he or der of presen tatio n o f fa ctors that con tribu te to
dru g abu se d oes not reflec t the im portan ce of those
fa ctors , bu t it doe s reflec t an attem pt to d iscuss those
fa ctors that are pertin en t ear lier in ado lesc en ts˜ live s
(su ch as g en etic fa cto rs) befo re fac to rs that ten d to be
m ore pertin en t later in their lives (su ch as bein g lab elle d
as an —
ad dict˜). T his system of prese ntation has been
used as a m ea ns of por traying the cu m ula tive effec ts o f
risk factor s from birth to ado lesc en ce. It also reflec ts the
notio n that risk factor s (for exam ple, personality) can
co ntrib ute to the develop m en t o f subsequ en t risk
fa ctors for dru g ab use (such as anti-so cial beh aviou r).
T hat is, the risk fac to rs do not exist in iso latio n.
G e n e tic fac tors
Re search since the m id -1960s on drug use has
su ppo rted the view that g en etics play a m od est, but
sign ific ant, role in the d evelo pm e nt of drug -use
prob le m s in som e ind ivid uals [16 •1 8]. For exam ple,
C ad oret rep or ted the results of resea rch th at had
ind ica te d that ge netic factor s are influ en tia l in the
transition fr om drug u se to drug m isuse [ 19] . M o st
su ch w o rk has been in the area of alco holism , larg ely
becau se o f the high prevalen ce of alc oh olism com pared
to illicit d rug m isuse. Afte r review ing the literature o n
beh aviou ral gen etic research in relation to alco holism ,
M cG ue con clude d that (a) g en etic fa ctors exert a
m od erate influ en ce on m ale and fem ale risk fo r
alcoh o lism ; (b ) the g en etic diath esis that und erlies
m ale alcoh o l abu se is not spec ific to prob lem s w ith
alcoh o l, bu t also includes o the r m anifes tation s of
beh aviou ral u nder-con tro l; (c) en viro nm en tal factor s
that are shared by fam ily m em ber s ca n exert a
sign ific ant influ en ce o n both m ale and fe m ale risk fo r
alcoh o lism ; (d ) rear ing by an alc oh olic paren t d oes not
ap pear to be a critica l fa ctor to the d evelop m en t of
alcoh o lism ; and (e ) the specific g en es invo lved in the
pathop hysiolo gy of alco holism , alth oug h no t as yet
id en tified , are likely to rep resen t a w id e rang e o f
und erly ing m ech anism s [20 ].
C auses and correlates of adolescent drug use
B ig elow and colleag ues d iscussed the treatm en t
im plicatio ns of bio log ica l vulne rab ility to dru g ab use
and con clud ed that the state of kno w le dg e is cu rren tly insuffic ien t to assist treatm en t-m atch ing [ 21] .
Perh ap s, these authors state d, biolog ical vu lnera bility
has m o re im plic ation s for preven tion than for trea tm en t. In sum m ary, gen etic pred ispo sitio n app ea rs to
be a co ntrib utin g risk fa ctor to pro blem atic alcoh o l
use and prob ab ly o the r d rug m isu se; ho w ever, oth er
fa ctors ca n exac erb ate or m od erate the influ en ce o f
g en etics .
G e n de r
In gen eral po pulatio ns, m ales ten d to (a) start drinking
alcoh o l at an earlier ag e than fem ales, and (b ) be m or e
likely than fem ales to d rink alcoh o l, to d rink heavily
and to experien ce alco hol-re lated prob lem s [2 2,23] .
For exam ple, a househ old su rve y of 1 000 ado lesc en ts
in S ydney fou nd that m ales w ere tw ic e as likely as
fem ales to be hea vy d rinker s and fo ur tim es as likely to
rep o rt ca nnab is u se [24 ]. Further, m ales are m o re
likely to u se illic it drug s, to en ga ge in polyd rug use, to
use illic it d rug s at an ear lier ag e and to use dru gs to
de al w ith prob le m s than fem ales [ 25] . T he g en d er
effect is prob ab ly the resu lt o f bo th g en etic and
en viron m en tal fa ctors . T he m ain treatm en t im plicatio n
is the ne ed to ad dress gen d er-specific influ en ces on
alcoh o l and oth er dru g use, particu la rly w ith
m ales [25,26].
A ttitu d e s a n d p e rso n a lity tra its
C on tro l theor y po sits that devian ce arises w hen
ad olesce nts la ck suffic ien t ties w ith con ven tio nal socia l
g rou ps such as the fam ily, scho ols and churches [27 ].
S pe cifical ly, alien atio n fro m the prevailin g valu es o f
society has been associate d w ith dru g use [ 28,29 ].
Perso nality traits that reflec t a lack o f social bon d ing
and that have bee n fo und to be predictiv e o f ea rly o r
fr eque nt d rug u se includ e reb elliou sness [ 30,32 ]; n on co nfor m ity to tradition al values [1 3,32] ; lo w sen se of
socia l respon sibility [33] ; hig h to lera nce o f d eviance [ 29,3 1]; resistance to trad ition al au tho rity [34] ; a
strong need fo r indep en d en ce [32 ]; no rm les sness [ 35] ; —
co ntracultu ral˜ values (a com plete disen g ag em en t fro m m ain stream culture as ind ica ted by
num erous indic ators such as low schoo l com m itm en t,
uncon ven tio nal d ress, no n-con form ist values, and peer
dru g-u sing cultu re) [36] ; and alien ation and he alth co m prom ising be havio urs [3 7].
45 5
C o nverse ly, con ve ntion ality or ties to soc iety (b ein g
co -op erative, ea ger to pleas e, physically cau tiou s, neat,
and rese rved ) am on g 3-year- old s has been associa ted
w ith non -p rob lem atic dru g u se in la ter life [ 38] .
C alab rese has w ritten exten sively on how a sense o f
alienation con trib u tes to a rang e of physical and
em otio nal hea lth pro blem s [39] and beh aviou ral prob lem s such as drug ab use and delin q uen cy [40 ,41] .
C alab rese has d ep icted alien ation as fo llo w s: —
In
g en era l, alien ation d esc rib es the rela tion ship o f ind ivid uals to their e nviro nm en t, and specifica lly, it
de scrib es that relation ship in ter m s of iso la tio n,
m ean ingless ness,
no rm les sness
and
pow erlessness˜[ 39, p. 1 4]. C alab rese has noted that these
fee lin g s need to be cou nter ed be fore any positiv e
beh aviou ral change s ca n be initiated or m aintain ed .
C alab rese argu ed that alien ation is cau sed by socie tal
fo rces that alien ate ad ole scen ts and that ado lesc en ts
respon d by form ing su ppo rtive su bcultures w hich
reject the no rm s of society, estab lish their ow n m o dels
to w orship and cen tre on self-gr atifica tio n. Ad ole scen ts, sug g ested C alab rese, need a m o re —
hum an˜
en viron m en t w hich fa cilitates assim ilation into respon sible societa l activ ities, provides them w ith a sen se o f
m ean ing and rea l en fran chise m en t into the decisio nm ak in g pro ces s. R esea rch con d ucted by C alab rese &
S chum er has ind ica ted that invo lvem en t of ado lesc en ts
in com m u nity ser vic e activities ca n reduce their sense
of alien atio n [ 42]. Suppor t for the need fo r atten tion
to this are a co m es from a stud y of treatm en t ou tcom e
fo r ado lesc en ts, w hich fou nd that ide ntific ation w ith
m id dle -cla ss value s pred icted po sitiv e outco m es [43 ].
T hese person ality traits have been fou nd to be
assoc iated no t on ly w ith d rug abuse, but w ith a
broa der spec tru m o f health -p rob lem beh aviou rs. For
exam ple, D on o van, Jessor & C o sta have fou nd that
conv entionality is related to all health beh aviou rs [44 ].
T hat is, there is a prob lem -b eh aviou r sy ndro m e at o ne
en d o f the spectr um ,an d a set of hea lth beh aviou rs at
the o the r en d, and co nven tion ality help s de ter m ine
w here an individual is plac ed o n that spectr um .
S pe cifical ly, they fou nd that (a) psych o -soc ial con ven tio nality co rrela ted w ith m o re invo lvem en t in
health -rela ted beh avio ur (fo r exam ple, physical activ ity,
atten tion to a hea lth y d iet) and (b ) les s invo lvem en t in
prob le m beh avio urs (su ch as cannab is u se, prob lem
drinking o r d elin q uen cy) w as also assoc iated w ith
g reater invo lvem en t in hea lth beh aviou rs. D on o van
and collea g ues noted that —
at-risk˜ado lesc en ts m ig ht be
partic ula rly resistant to effo rts to en co urage them to
—
be health y ˜ if bein g h ealth y is see n as con ven tio nal:
456
C atherine Spooner
. . . the fin dings show ing that uncon ven tio nality is
lin ked to less involv em en t in health -m aintain ing
beh avior sug ges t that those you th w ho are m ost
uncon ven tio nal, that is, the so -called hig h-risk
you th, m ay be in d ouble jeop ardy. N ot on ly do es
their u ncon ve ntion ality place them at g rea ter risk
fo r en g ag ing in health -co m prom ising prob le m
beh avior, but it also m ay lead them to eschew
health -m aintain ing beh avior to the exten t that the
la tter is seen as con ven tio nal. Insofar as con ven tio nality is lin ked to the con ce pt o f health ,
those yo uth w ho cou ld ben efit m o st from effort s
at health pro m o tion m ay be the very o nes m ost
resistan t (p . 6 0).
Ÿ poor fam ily relation ship s, as ind ica ted by nega tive
fa m ily rela tion ship s [51,52], lo w bo nding to fam ily [ 53], a lac k of sh arin g o f affect ion and
co m m u nica tion w ith ch ild ren o r paren tal interes t in
the children˜s ac tivities [5 4] and child ab use [ 55] ;
Ÿ pare ntal ro le-m od ellin g :
– pare ntal
crim inality
or
anti-so cia l
beh aviou r [4 9];
– pare ntal d rug use [5 6,57] ;
– perc eiv ed ad ult dru g u se [58 ,59] ;
– positive attitud es tow ard s d rug s by paren ts [30 ,54] ; and
– pare ntal m od ellin g o f d rug use as a cop ing
strateg y [60] .
A noth er perso nality trait lin ked w ith d rug ab use is
sensatio n-seek ing [45 ]. H o w ever, as sensation -seek ing
is no rm ative in ad olesce nce and ca n be a positive
source of m otiv ation , it doe s no t ap pear to be
rea son ab le to recom m en d that prog ram m es try to stifle
sensatio n-seek ing. Perh aps the m ost reaso nab le o ption
is to help to chan nel this en erg y in to activ ities that are
eq ually attractive, but less risky o r harm fu l than drug
ab use.
In sum m ary, eviden ce sug ges ts that alien atio n
fr om soc iety can co ntrib ute to pro blem atic d ru g use
and it is like ly to be a sign ific ant barrier to
ad olesce nts w antin g to add ress that d rug use, or any
oth er pro blem beh aviou rs. Prog ram m e s that facilit ate
societal bo nding ca n assist ad ole scen t clien ts˜ m o tivatio n to en g ag e in pro soc ial and health -en hancin g
beh aviou rs.
Paren tal m o dellin g factor s ap pear to have les s influ en ce than the abo ve fac to rs relating to the q uality o f
the pare nt •child relatio nship and pa ren tal fa m ily
m anagem en t tech nique s [61] .
T hese risk factor s can w or k in co m bin ation and
have direct and indirect e ffec ts upo n an ad oles cen t˜s
dru g use. Fo r exam ple, S herid an˜s stud y of the
histo ries of in carc erated adu lt d rug ab users ind ica te d
sign ific ant direct and in direct relatio nships am on g
pare ntal d rug ab use, fam ily dynam ics and exp o sure to
both child and adu lt m altrea tm en t:
Fam ily facto rs
T he fam ily has be en described as —
the sing le m o st
influ en tia l child hood fa ctor in bu ffe ring the child and
in shapin g later ad ap tation˜[46 , p. 22]. T he influ en ce s
of the fam ily on adolesc en t d rug ab use are fu nd am en tally im po rtant, bu t co m plex [47,4 8]. Fa ctors ab out
the qu ality and con sistency o f fam ily m anag em en t,
fa m ily co m m unica tion , fam ily relatio nship s and paren tal role-m ode llin g have been co nsiste ntly id en tified
as pred ic tive o f drug m isuse [ 46,4 9]. Spec ific fam ily
fa ctors include :
Ÿ ineffec tive pare ntal fam ily m anagem en t tec hniqu es;
fo r exam ple, lack o f discipline or incon sisten t
discip lin e [50 ];
co m m unic ation
pattern s
(blam ing ,
Ÿ neg ative
criticis m ) [ 49];
A lth ou gh paren tal dru g ab use w as fou nd to be
directly related to child m altrea tm e nt, results
su gg est it m ay also be ind irec tly associate d
throu gh its rela tion ship w ith fa m ily-of- orig in
co m peten ce. Spec ifically, the neg ative im pac t of
pare ntal d ru g ab use m ay best be und ersto od as
having adverse con sequ en ces o n fam ily dynam ics;
w hich in turn, incre ases the likelih ood o f expo su re to child ab use and neg lect [62, p. 526] .
Furthe r, these variab les w ere fou nd to be sign ific antly
assoc iated w ith the respon d en ts˜ o w n dru g ab use.
T hese resu lts w ere seen to indic ate that these pa ttern s
co ntin ue in to successive g en era tion s. C o nsistent w ith
these results is the fin ding that d rug d ep en den ce is
presen t in at lea st half of the fam ilies w ho com e to the
atten tion of child w elfare autho rities fo r child ab u se
and neg lec t [63 ].
B ein g in a single-p aren t hou sehold has often been
purpo rte d as a m ajor risk fac to r for d rug abu se [64 ].
H ow e ver, w hen statistica l ad justm en ts fo r soc ial and
co ntex tual fac to rs su ch as fa m ily rela tion s and soc io eco nom ic status have been m ad e, fa m ily structu re has
been fou nd to have little o r no direct effec t on dru g
ab use [ 65 •68] .
C auses and correlates of adolescent drug use
A s is the case w ith m ost risk factor s discussed here,
their reverse ca n be pro tec tive from d rug m isuse. For
exam ple, fa m ily attach m en t ca n ser ve as a d eter ren t to
dru g use [5 3]; carin g and con n ected ness w ith the
fa m ily in the lives o f ad olesce n ts is hig hly pro te ctive
ag ain st actin g -o ut beh av iou rs, including poly drug
use [ 67] , and hig h lev els o f fam ily support have been
fo und to redu ce the effect o f risk fa ctors (tole rance for
de vian ce and beh aviou ral u ndercon trol) and increase
the effect of pro te ctive fa ctors (beh aviou ral cop ing and
ac ade m ic co m peten ce) [ 69] .
Pare ntal influ en ces have been fou nd to be stron g est
and m o st d irec t ear ly in the life of child ren , w hen
experim en tation w ith drug u se is an issue . H ow ever,
w hen the child beco m es an ado lesc en t, the fam ily ˜s ro le
is ind irec t by influ en cin g the choice o f peer s [ 70] .
Furthe rm ore, o nce ad oles cen ts becom e in volv ed in
m od erate d rug u se, paren tal attem pts at con trol ten d to
be in effe ctive in preven tin g m o re serio us drug
use [ 71] .
H o w do es the fam ily influ en ce drug u se? A s
m en tion e d ab ove, fam ily influ e nces are com plex and
vary w ith the age o f the child. For exam ple, fro m the
perspec tive o f attac hm en t theor y, B ren nan has argue d
that fam ily relatio nship s are im portan t to the deve lop m en t of socia l co m peten ce in ad oles cen ce and that
socia l com peten ce is crucial fo r resilience aga inst
psychop atholo gy [7 2].
It is w ell reco gn ized that the fam ily need s to be
co nsid ered in adolesc en t trea tm e nt [73 •75] . If fam ily
issues are a co ntrib utin g fa ctor to the adolesce nt˜s drug
prob le m , ado lesc en ts w ho return to the sam e hom e
en viron m en t are likely to relap se. C on ve rsely, the
fa m ily can be a protective fa ctor and ca n support the
treatm en t prog ram m e and the ado lesc en t in ac hiev ing
treatm en t go als. T he attitu de s and beh avio urs o f the
fa m ily and/or o f the ado les cen t co uld need to chang e
fo r the fam ily to be a protective, rather than a risk
fa ctor. R esea rch has de m o nstrated th at fam ily invo lvem en t in treatm en t has a positive im pa ct o n treatm en t
ou tcom e [76] . Fam ily invo lvem en t can be difficu lt to
ac hiev e, and is even less lik ely if it is not activ e ly
rec ruited . A pp roac hes em plo ying activ e en g ag em en t
of the fa m ily have been trialled w ith positive
effect [ 77,7 8], alth ou gh the y m ig ht need som e m od ifica tion w ith differe nt cultural g rou ps [ 79] .
In ca ses w here fam ily invo lvem en t is not possib le , it
is still im por tant to d eal w ith fa m ily issue s w ith
ad olesce nt clien ts [ 80] . In som e cases sep aration fr om ,
rather than involv em en t w ith , the fam ily cou ld be
ind ica te d. A s H ow ard has stated :
45 7
Fa m ily issues shou ld no t be ig nor ed as m any
you ng peop le can return hom e if both they and
the fam ily learn better adaptive an d cop ing skills.
O thers ne ed to sep arate adeq uately and be able to
lea ve the fam ily beh ind rather than exp lo de out of
it, carrying the residu e of su ch co nflicts w ith
them [ 81, p. 1 10].
Fin ally, the paren ts are no t the on ly sig nifican t
fa m ily m em bers. S ib lin g s, uncles, au nts, cou sins,
g rand paren ts or sig nifica nt oth ers m ig ht have a role in
the aetio log y and/or co ntin uatio n of an ado les cen t˜s
dru g abuse [8 2].
In sum m ary, the fa m ily experie nce is an im portan t
fa ctor in the aetiol og y and treatm en t of drug ab use and
ad dressing fa m ily issues and fa m ily involv em en t are
im por tant com pon en ts of tre atm e nt.
Trau m atic life e v e n ts
C hild ren w ho have exp erien ced traum atic life even ts
(fo r exa m ple, sexual, em otio nal or ph ysica l abu se;
neg lect; or refu g ee cam ps) are at a high risk o f
de trim en tal outco m es such as illicit drug use and
de lin q uen t/crim inal be havio ur, and self-d estru ctive
and suicid al beh aviou r [ 83 • 87]. T he causal m ec hanism is no t clear. D em bo and colleag ues have
prop o sed a m od el, ba sed u po n a d evelo pm en tal
dam ag e view of the effect s o f child physical and sexual
m altre atm e nt [5 5]. Su ch children are seen to suffer
fr om an ab no rm ally poo r self-im ag e that ne ga tively
affec ts subseq uen t sociali zation and to feel that the
w o rld is a ge nerally unsafe plac e. D rugs are used to
de al directly w ith the em o tion al pain of the abu se or
w ith the subseque nt self-d ero ga tio n (ch ildren w ho
have su ffer ed physical ab use often feel that they
de ser ved the pu nishm en t).
Jan ikow ski & G lo ver have arg ued that peo ple
rec overin g fro m a d ru g ab use o r d ep en de nce disord er
w ho d o no t rec eiv e thera py fo r their exp erien ces o f
childho od abuse are hig hly likely to relap se beca use the
sham e, g uilt and ange r, that m ig ht have been bein g
allev ia te d by the d rug use, w ill con tin u e to
exist [8 8].
S tew art revie w ed and d iscussed the issu e o f
ad olesce nt su rvivors of traum a w ith in drug -trea tm en t
prog ram m e s [ 89] . For exa m ple, su ch ad olesce n ts have
ten ded to drop o ut of treatm en t d ue to (a) fea r o f reexperien cin g the orig inal traum a, (b) trou ble in
trusting adu lts, as ad ults have g en erally bee n the
perp etrators of traum atic experien ces , (c) fe elin g
458
C atherine Spooner
hop eless abo ut the w o rld and their o w n place in it, an d
(d ) feelin g as thou gh they have no con trol as they are
vic tim s. Stew art discu ssed the treatm en t n eed s o f
trau m atized ad olesce nts, includ ing —
co ping and stressred uctio n strateg ies . . . com bined w ith cog nitive and
insig ht-or ien ted therap y ˜ (p . 418 ) w ith in an en viron m en t that pro vides structure and a sen se o f safety. Van
de r Kolk & Sapo rta argu ed that som e issues can be to o
pain fu l to d iscu ss w ith out m edic ation , so th at refer ral
to a psychiatrist cou ld be ind ica te d in som e
ca ses [9 0].
T he pace and tim ing of d ealin g w ith trau m as ca n
sign ific antly influ en ce o utcom es. Jar vis and collea g ues
rep o rte d that fem ale sexual ab use sur vivors co nsistently em phasized the need to co ntrol the pace of
their o w n d isclos ure [9 1,92] . Fu rthe rm ore, H o w ard
has ca ution ed ag ain st tack lin g issu es such as child hood
sexual assault that ca nnot be ad equ ately ad dressed by
the prog ram m e [81] . In partic ula r, H ow ard sug ges ted
that a 2 -w eek detoxific ation pro gra m m e is to o shor t to
de al w ith such em ergen t issues and refer red to
rep o rts [ 93] that have reco m m en ded that —
fa m ily o f
or ig in˜ issues be d ealt w ith la te r in rec overy. W hile it is
neith er po ssible, nor app rop riate, to sto p d isclos ure o f
trau m atic even ts, the task is to help the clien t ho ld o nto
the issue fo r the tim e bein g, u ntil the pro blem ca n be
de alt w ith prop erly.
In sum , traum atic life exp erien ces su ch as child
ab use or experien ce as a refu gee are risk fac to rs fo r
dru g abuse, and som e ado les cen t clien ts co uld be
experien cin g post-tra um atic stress disor der. T he ir
beh aviou r co uld sug ge st that the y are eith er not co op eratin g w ith or respo nding to trea tm en t. Screen ing
fo r sign ific ant stressors ca n assist in the iden tifica tion
of individ uals w ho have expe rien ced trau m atic life
even ts and allo w refe rral to speciali st services. D isclosu res o f sign ific ant stressors sho uld not be ig nored ,
nor sho uld they be d ealt w ith by untrain ed staff as this
co uld , inadverten tly, exa cerb ate the pro blem .
E th n ic ity
S tu dies o f eth n icity and d ru g use are fra ugh t w ith
prob le m s. For exam ple , eth nicity can be d efin ed in
num erous w ays su ch as la ngu ag e spo ken at ho m e,
relig ion , cou ntry of birth, cou ntry of paren ts˜ birth an d
natio nal heritag e. S econ dly, nation al bord ers chang e
w ith tim e and nation s can in clud e a variety of cu ltures.
T hirdly, w ith the larg e nu m ber of eth nic gr oups in
m ulti-c ultural countries it is difficu lt to ob tain relia ble
data for eac h g rou p. Fou rthly, the influ en ce of a new
lo cal culture on any particu lar ind ivid ual fro m any
eth nic g roup can vary, acc ord ing to fac to rs su ch as
len g th of resid en ce in the new co untry and com m itm en t o f the in dividual and his/her fa m ily to ado ptin g
the cu ltu re o f the new cou ntry.
M o re research into drug use by eth nic g ro ups has
been con d ucted in A m erica [22 ,94 •1 01] than in
Australia [1 02] , alth ou gh there has be en som e sig nifica nt resea rch into dru g use by indigen o us Australians [ 103 •1 05]. O vera ll, e thnicity ten ds not to be
a usefu l indicator of pro blem atic d rug use am on g
ad olesce nts in Australia. If anything , firm er fa m ily
co ntrols have been fou nd to redu ce the prevalen ce o f
dru g use am on g som e Au stralian eth nic co m m unities .
O n the o ther hand , ind ig en ous Au stralian ado lesc en ts
do ap pear to be m or e likely to have d rug-u se prob le m s
than no n-in d ig en ous Australia n ad olesce nts. W hile a
hig her percen tag e of ind ig en ou s Australians ab stain
fr om dru g u se than non -in d ig en ou s Australia ns, those
w ho d o d rink are m ore like ly to drink exce ssively [10 3]. Furtherm or e, volatile drug ab u se (p articularly petro l-sniffin g) am on g indigen ous Australian
ad olesce nts has bee n a m ajor issu e o f con cern in m any
ind ig en ou s Australia n com m u nities [1 06].
In su m m ary, w hile drug -trea tm en t ser vic es nee d to
en sure cultural ap prop riaten ess o f their services fo r the
clien t g ro up [ 107] , eth n icity is no t g en era lly a usefu l
ind ica to r o f risk fo r ad olesce n t d rug ab use.
S o cio -e co n o m ic sta tu s
Attrib utin g d rug ab use to en viron m en tal influ en ces
su ch as socio -econ om ic status (SE S) h as an intu itive
ap peal [ 81,10 8]. H o w ever, there ap pears to be som e
discrep ancy in the litera tu re ab ou t a relation ship
betw een SE S and drug ab use [2 2]. H aw kin s and
co llea gu es con clude d o n the basis o f their review o f the
aetio log y of d rug abuse that there is no su ch
relation ship [ 4], w hereas D ryfoo s˜s review sug ges te d
that S E S (for exam ple, living in a de prived neigh bou rhoo d) is an im po rtant risk fa ctor fo r prob lem
beh aviou rs, includ ing dru g ab use [6 5]. Perh aps, as
discu ssed by Joh nsto ne, this d iscrep ancy can be
expla ined by the fact that S E S has an indirect effect o n
dru g abuse:
Tak en tog eth er, the recen t literature seem s to
su gg est that cla ss effe cts on adolesc en t d rinking
m ay be principa lly indirect o r co ndition al on
oth er characte ristic s of soc iod em og rap hic status
or drinking o utcom e. Z ucker (19 79) no ted that
C auses and correlates of adolescent drug use
pare nts˜ socio eco nom ic statu s structures peer
assoc iatio ns, fa m ily dynam ics, and oth er significa nt influ en ces on ado les cen t drinking . B idd le
et al . (19 80) rep orted that m id dle class adolescen ts ten d to ad here to peer gr oup norm s ab ou t
drinking , w hile w o rking class youth place g reater
em phasis on paren ts˜ norm s. R elativ e ly high
person al inco m e am on g adolesce nts has also been
rep o rte d to prom o te increased alc oh ol use (M addahia n et al . 19 86; B achm an et al . 198 8) [ 22, p.
180 ].
S upport fo r this no tio n co m e s fr om Ferg usson and
co llea gu es˜ m ultivariate analyses of data fro m their
lo ngitu dinal stud y of 9 53 children fro m birth to ag e
16 [2 3]. Fam ily soc ial po sitio n (F S P ) w as ind ica ted by
a com posite m easure o f paren tal e ducation lev els ,
fa m ily o ccupation al status, pa ren tal age , eth nicity and
fa m ily structure. T heir analyses iden tified that F SP
w as not directly associa ted w ith alcoh o l ab use at ag e
16, but that it w as sig nifica ntly associate d w ith alcoh o l
co nsum ption at age 14 and w ith peer affilia tion s at ag e
15, both of w hich w ere sig nifican tly associa ted w ith
alcoh o l ab use at age 16 . T he au tho rs co nclu ded that
F SP influ en ced ear ly drinking be havio ur and peer
affilia tio ns that, in tu rn, d eterm ined later alco hol ab use
at age 1 6.
S m art, Adla f & Walsh hypoth esized that previou s
fa ilu res to fin d a lin k betw een SE S and d rug abu se
w ere d ue to ado lesc en ts o ften no t know ing the S E S
character istics o f their fam ilies [1 09]. T hese resea rchers used the ado lesc en t˜s postco de as an ind ica to r of
S E S, as m ost ad oles cen ts know their postcod e and the
S E S characteristics o f each postco de area w ere ab le to
be ascertained . S pe cific iden tifiers o f low SE S areas
w ere low -cos t sub-stand ard ho using, social prob le m s,
racia l pro blem s and d elin que ncy. T he authors fou nd
the hig hest drug u se and prob lem s existed in the area s
w ith the low est SE S character istic s and con clud ed that
S E S doe s co ntrib ute to d ru g abuse.
In su m m ary, it ap pears that S E S do es influ en ce
dru g-u se beh aviou rs am on g ad oles cen ts, at le ast
ind irec tly.
M ac ro -e n v ir o n m e n ta l facto rs
M ac ro -en viron m en tal fac to rs that influ en ce drug
m isuse inclu de advertisin g , leg islatio n and la w
en force m e nt (d eter ren ce strateg ies), taxation and the
availa bility o f d rugs. T here has been con sidera ble
de ba te abo ut the issu e of le ga l con tro ls fo r spec ific
45 9
dru gs such as alcoh o l [110 ,111] , can nabis [112 ,113]
and oth er d rug s [ 114 ,115] and alc oh ol adve rtising
and lab ellin g [ 116] . A de tailed review of the litera tu re
on these con trol strategie s is beyo nd the scop e of this
pap er. Su ffice it to say these have an im pact u pon drug
use, directly u po n ind ivid uals, as w ell as ind irectly, via
their im pa ct on social value s.
A noth er aspect o f the m acro -en viro nm en t is —
soc iety ˜. R ic hard E cker sley has w ritten exten sively o n the
pred ica m e nt o f ado lesc en ts in Australia [ 117 ,118] .
E ckersley ˜s revie w of the litera tu re has pain ted a
de pressing pic tu re of social and psycholog ica l prob lem s am on g ad oles cen ts, caused by rap id chang es in
society :
. . . increases in fam ily con flict and bre ak do w n,
increasing poverty, hig h you th unem ploy m e nt,
soarin g you th hom eless ness an d gro w ing edu cation pressures. U nderlying these de velop m en ts
are soc ial, eco nom ic and tec hnolo gical chang es
that m ay, in the m selv es, be im posin g a gr ow ing
psycholo gic al stress o n child ren and you ng
ad ults – a stress that fin ds bleak expressio n in the
fea r and pessim ism w ith w hich m any o f th em
reg ard the fu ture . . . g row ing num bers of yo ung
peop le feel there is no esca pe; they feel pow erle ss
and hop eless . . . T hose w ho fail, or feel they
never had a chance, are giv ing up, and resor tin g
to crim e, drug -in d uce d ob livion , and suicid e
(p . 1).
H en ce, curren t soc iety ap pears to be creatin g a
ten den cy for ad oles cen ts to d eta ch fro m society.
S ervices ca nnot chang e society overnig ht, but it could
be im po rtant to try to instill a sense of hop e in
ad olesce nt clien ts w ho have g iven up, eith er on their
ow n ab ility to succeed in society or o n the need to
try.
L o cu s o f co n tro l
L ocu s o f co ntrol has been purpo rted to be associa ted
w ith drug abu se and de pen den ce . H ow ever, the
evid en ce has been w eak [ 119 ] o r incon sisten t, indic ating that it cou ld w ork differ en tly fo r d ifferen t peo ple,
differe nt dru gs and in d ifferen t co ntex ts [ 120] .
M e n tal h e alth
N um erou s studies h ave investig ated the influ en ce o f
psycholo gic al d istress and psychia tric disor ders on
ad olesce nt drug u se [121 ]. D esp ite nu m erou s claim s
460
C atherine Spooner
and indicatio ns that psy cholo gical d istre ss, in clud ing
lo w self-e steem and d ep ression , con tribu te to the
initiatio n and m ain te nance of d rug use, these variab les
have ten d ed not to be relia ble or stron g predic to rs o f
dru g u se [12 2,123 ].
W hile H aw kins and co llea gu es have fou nd no
evid en ce for high e r rates of psy chop atholog y am on g
dru g users com pare d w ith non -u sers, excep t w here the
users are very you ng [4 ], psychop atho log y has ten d ed
to be d isprop ortio nately prevalen t am on g ado lesc en ts
w ith dru g-u se prob lem s [ 124 •12 6]. Variou s rela tion ship s have been prop osed betw ee n d ru g ab use and
psychiatric d iso rde rs [12 7]. For exam ple, d rug u se
co uld indu ce psychiatric pa th olo gy in vu lnera ble
ind ivid uals or drug use could begin as a form of selfm ed icatio n,
partic ula rly
am o ng
schizo phren ic s [ 128 ,129] . Fr ied m an and collea g ues have rep or ted
that ea ch exacer ba te s the oth er in an add itive
m anner [ 130] .
In sum m ary, research d oes not clearly id en tify
m en tal health prob lem s as a sign ific ant risk factor fo r
dru g abu se. H ow e ver, there is a ten d en cy fo r
ad olesce nts w ho have pro blem s relatin g to d rug ab use
or d rug dep en d en ce to have high er rates of em otion al
or psychia tric prob lem s than oth er ad oles cen ts. C on sequ en tly, d rug -treatm en t ser vic es fo r adolesc en ts nee d
to be able to iden tify and dea l w ith m en tal health
prob le m s am o ng their clien ts.
K n o w le dge
D rug u se and m isuse have been attribu te d to a la ck o f
know led ge of the risks associate d w ith use. S upportin g
evid en ce fo r such an assu m ptio n com es fr om K andel˜s
prospectiv e stu dy of drug u se by ado lesc en ts, that
fo und that adolesc en ts w e re m o re likely to start u sing
spirits, can nab is or o ther illicit d rug s if they be liev ed
that casual use o f the specific d rug s is not harm fu l [131 ]. C on seque ntly, ea rly effort s to change o r
preven t d rug -using beh aviou r relied upo n th e assum ption that increased know ledg e ab out the co nseq uen ces
of d rug use w o uld be an effect ive deter ren t (ration al
respon se) and/or fe ar arousal m e ssages w ou ld scare
ind ivid uals
from
using
drug s
(em otion al
respon se) [3 ]. K now ledg e-b ased inter ven tio ns have
typically had e ith er no effect o n drug use [ 132] o r
increased d rug use [1 33,13 4]. It is likely that the
fa ilu re o f m o st ed ucatio n pro gra m m es has been a
result o f a relian ce upo n the assu m ptio n that sim ply
increasing know ledg e w ill ca use chang es in be havio ur.
H ow e ver, as argu ed in this pap er, the m ultip le factor s
that co ntrib ute to drug -use beh aviou rs need to be
ad dressed. Atten tion to a sin gle risk fa ctor is u nlike ly
to be effect ive .
In sum , w hile an und erstan d ing of the spec ific
harm s associated w ith spe cific beh aviou rs is not
su fficien t to elim inate risky or harm fu l be havio urs [ 135 •13 7], it is an essentia l elem en t of the
de cision -m akin g proces s. T he provision of accu rate
and no n-ju dg em en tal info rm atio n on the hea lth and
leg al con sequ en ces of spe cific d ru g-u se beh aviou rs to
ad olesce nt clien ts of drug -treatm en t pro gra m m es is
rec om m en de d [138 ].
S tre ss an d co p in g/su pp o rt m e ch an ism
Ac cor ding to strain theo ry, variou s fo rm s o f d evian ce,
includ ing drug ab use, are m ec hanism s that help
peop le co pe w ith the stresses of life [13 9]. W hile there
is som e eviden ce to sug ges t that stress lev els ca n be
positively associa ted w ith d rug ab use am on g ad oles cen ts [1 40] , the results of a study on the predictiv e
ab ility of the strain theor y pro duced in con clusive
results [1 41]. Perh ap s it is not sim ply the existen ce o f
stressors that con tribu te to d rug ab use, but the
person˜s ab ility to cop e w ith those stressors. T his
notio n is supported by resear ch that has indicated that
the inte nsity of stre ss experien ced by a perso n is not
on ly a fu nction of the stre ssful even t or con d ition , it is
m ed iated by a person˜s cop ing skills and social
su ppo rts [139 ].
C oping skills
C op ing skills includ e a varie ty of cog nitive and
beh aviou ral strategie s that can be used to dea l w ith a
prob le m [1 42] . C ognitive strateg ies includ e self-assu rance, com parin g on eself to oth ers w ho are d oin g w orse
than on eself, rein terp retin g the pro blem in a m o re
positive m anner and exerc ising self-c on trol by thinking
ab ou t the neg ative co nseq uen ce s o f an unde sirable
beh aviou r. Beh avioural co ping strate gies inclu de prob lem -solv ing activ ities, w ith draw al, assertiven ess, seek ing su ppo rt and rela xation .
Social support
H urrelm ann has co m m e nted that health is o nly
possib le w hen a per son ca n establish con stru ctive
C auses and correlates of adolescent drug use
socia l relation ship s [1 43]. B ren n an has d iscu ssed ho w
relation ship s buffer ad oles cen ts aga inst social stresses
su ch as tho se associated w ith socio -ec on om ic disad vantag e, fa m ily prob lem s and the physiolog ica l
stress assoc iated w ith puberty [72] . To be effe ctive
m ed iators o f stress, rela tion ship s w ith socia l support
need to includ e trust an d intim acy [139 ].
C o pin g skills and social su pp o rt are lin ked in that
the d evelo pm en t of inte rperso nal/social skills ca n assist
in the d evelo pm en t o f supportiv e soc ial suppor ts.
Relapse-prevention skills
S hiffm an & W ills have distin gu ishe d betw een cop ing w ith stressful life even ts in g en eral (stressco pin g) and co ping w ith relap se risk situatio ns
(tem ptation -co pin g) [1 44]. M arlatt & G o rdo n have
rec om m en de d that specific co pin g skills are req uire d
to dea l w ith tem ptatio n-cop ing : that is, relap sepreven tio n skills [14 5]. R elap se-p reven tion skills train ing incorp or ates iden tify ing hig h-risk situatio ns
fo r a lap se, and g en era tin g idea s for avoid ing o r fo r
de alin g w ith those situation s. S pec ific skills used in
relap se-p reven tion include the cop in g skills id en tified abo ve, as w ell as specific skills in co ping w ith
urges /cravings.
R hode s & Jason have arg ued that the exten t to
w hich ado lesc en ts can have acces s to and u se e ffec tive
su ppo rts and co ping skills influ en ces their likelih ood
of using dru gs as a m e ans of cop ing w ith stress [ 146 ].
Ac cor ding ly, increasing adolesc en ts˜ acces s to and use
of socia l su ppo rts and cop ing skills can assist them to
co pe w ith stress w ith out dru gs [1 47] . T his is supported by num erous resea rch stud ies [ 148] . Fo r
exam ple, a lo ng itu dinal stud y in dic ated that pre-schoo l
children w ho w e re less resilien t, les s sociall y co m pe ten t
and m ore rebellio us w e re m ore likely to be drug
ab users at age 14 than the oth er child ren [149 ].
R ic hte r and colle ag ues fou nd that the num ber of no ndru g-u sing su pp o rts and satisfac tion w ith socia l
su ppo rt w ere positiv ely associa ted w ith m ain ten an ce of
positive tre atm e nt ou tcom es am o ng ad oles cen t d rug
ab users [1 50] .
It is also w orth notin g that the previou s expe rien ce s
of som e adolesc en ts in dru g-trea tm en t prog ram m es
co uld m ak e those clien ts unw illin g to em brace
su ppo rtive relation ship s. T his ca n be due to a num ber
of co ncurren t factor s, such as low self-esteem (feelin g
that they have no thing to offer a relatio nship ), d istrust
of o thers or a lac k of aw aren ess o f the ben efits of
su ppo rtive relation ship s [1 51]. Keo gh has argu ed that
46 1
prog ram m e s need to instill a sen se of belief in the valu e
of relation ship s:
. . . as w e g row, if ou r experie nces are —
goo d
en o ugh ˜ w e de velop em otio nal ca pa cities and
related skills that en able u s to m eet the challen g es
of life . . . Part of this proces s, invo lves the
de velop m en t o f a belief in con structive, repa rative, and lo ving cap acities w hich have had the
op por tu nity to de velop in rela tion sh ip s w ith
sign ific ant oth ers . . . T his ne ed for rela tio nship,
and the feelin g that o ne has som eth ing go od,
g en era tive and resto rative in on eself to bring to a
relation ship , are crucial to ou r und erstan d ing of
w hat w ill ultim ately influ en ce change. T his is
espec ially true of those w ith narcissistic and
psychop athic perso nalities, w here it is stron g ly
de nied be cau se it threa te ns . . . U ltim ately then ,
w e need to ad op t a m ultis ystem ic m e ans to help
clien ts ach iev e a rep arative, respon sible, con structive
and
lov ing
o utcom e [1 51,
pp .
149 •58 ).
In sum m ary, cogn itive and beh aviou ral cop ing skills
and acces s to quality supports have been fou nd to be
protective from ado les cen t d rug abu se. Tea ching
co pin g skills (g en era l co pin g skills as w ell as rela psepreven tio n skills) and fac ilita tin g acces s to q uality
su ppo rts can assist ado lesc en ts to m anag e their drug
use. Add ition ally, som e su pp o rt to d eal w ith ad ole scen ts˜ em otion al ba rrier s to socia l relatio nships co uld
be need ed.
Pe e r facto rs
A ssoc iatio n w ith peers w ho use d rugs is on e of the
stronges t
predicto rs
of
ado lesc en t
drug
use [ 23,5 3,152 •156] , particularly w hen that d rug use
is ca nnab is or polyd rug use [ 157] . T he se fin d ing s are
co nsiste nt
w ith
d ifferen tial
assoc iatio n
theor y [1 41,15 8] and soc ial le arning theor y [159 ,160] .
S pe cific pred ictor s includ e d rug use by pe ers, drug related attitu de s of peers , pe rceiv e d use o f drug s by
oth ers, perc eiv ed su ppo rt fo r d rug use by peers and
peer preferen ce.
T he influ en ce o f peer s is not sim ple. Firs t, drug ab using peer s do no t ten d to sud den ly app ea r in a
child˜s life and —
pressure˜ that child to ab use
dru gs [ 161] . It is m or e usu ally the ca se that child ren
w ho are pron e to pro blem beh aviou r ten d to affilia te
w ith like-m ind ed peers and that affilia tio n w ith these
peers ten d s to en courag e and rein forc e prob lem
462
C atherine Spooner
beh aviou rs, inclu ding d rug abu se [162 ,163 ]. S nyd er
& H u ntley d iscussed how the relatio nship s of child ren
w ith coer cive interac tion styles (fo r exam ple, ch ild ren
w ho ten d to w hine o r throw tantrum s) d eterio rate w ith
pare nts, then tea chers and peers so that they do not
lea rn social and cog nitive skills and en d up assoc iatin g
w ith anti-so cia l peers w ith com patib le attitu des and
beh aviou rs [ 164] . H en ce, affilia tio n w ith prob lem
ad olesce nts ten d s to be preced ed by reje ction by
prosocial pee rs d ue to po or social skills [47] .
T here is evid en ce fo r a lack of socia l skills am on g
dru g ab users [16 5,166 ]. Fo r exa m ple, a stud y of socia l
skills and drinking beh aviou r am on g ado lesc en ts in
Q u een sland fou nd that:
11% o f drinkers and 50 % o f prob lem d rinkers
w ere in the inco m peten t rang e of socia l skills
perform ance w hile no non -d rinkers scor ed in this
range. N on e of the pro blem drinkers scor ed in
the hig hly com peten t range of pe rfo rm ance
w hereas 22 % of d rinkers and 40% o f non drinker s d id [1 67, p. 20 7].
T hese fin ding s sug ge st the n eed for social- skills
train ing fo r ad olesce n ts in d rug -treatm en t pro g ram m es, and fo r en cou rag em en t of ad ole scen t clien ts
to m ake new fr ien d s w ith pe ers w ho se lifesty les d o not
fo cus on d rug use and oth er pro blem beh avio urs.
T he tim ing of such inte rven tio ns is im po rtant. Peer s
have d ifferen t effect s at differe nt stages o f dru g use.
Follow ing a revie w of the literature and som e o rig inal
researc h, D ielm an and co llea gu es co nclud ed that peer
dru g-u se beh aviou r is the prim ary predictor o f
ad olesce nt alcoh o l use ; peer nor m s, how ever, are m o re
im por tant in the predic tion o f ad ole scen t alcoh o l
misuse [ 168] .
Add ition ally, the influ en ce of peers te nds to increa se
as the influ en ce o f fam ily d ecre ases. Rese arch ind ica te s
that involv e m e nt w ith antisocial peers can occ ur befo re
the ag e of 1 0 and is high ly predic tive of later
invo lvem en t w ith d evian t peers [ 169] . N eve rthe less,
strong bo nds w ith fa m ily and schoo l can atten uate pee r
influ en ces [17 0]. For exam ple , paren tal norm s and
beh aviou r co uld influ en ce ad oles cen ts˜ attitud es and
co nseq uen t attra ction to a partic ula r pee r gro up [ 168] .
H offm ann w arns, ho w ever, that the in flu e nces o f
pare nts and peer s are com plex , so sim plistic cause •
effec t relatio nships can be m islead ing [1 57] .
In sum m ary, peer s have a su bstantial im pact o n
dru g-u se beh aviou rs and this im pact is influ en ced by
oth er factor s, particu larly tho se fa ctors that relate to the
cho ice o f peer g roups such as fa m ily influ en ces and
socia l skills. S ocial skills -train ing and fac ilita tin g socia l
intera ction s w ith non -d ru g-a busing ado lesc en ts ca n
assist ado lesc en t d rug ab users to m ak e new fr ien ds
w ith pro social 0eer s.
S ch o o l facto rs
L ow com m itm en t to education has been associa ted
w ith
d rug
m isuse
and
de lin q uen t
beh avio ur [27 ,49,17 1]. D rug users are m o re likely than
non -drug users to be absen t fro m scho ol [5 1,152 ],
skip classes [31 ,51] and per for m poo rly [31 ,172] ,
drop o ut o f scho ol early, d islike scho ol, perceiv e
co urse-w or k as irrelev ant, spen d less tim e on hom ew o rk [ 31] and be suspen ded fr om school [ 152] .
T he tim in g of acad em ic prob le m s ap pe ars to be
im por tant for its pred ictiv e valu e. S pivack fou nd that
ac ade m ic failu re in G rad e 1 d id not pred ict la ter
de lin q uen cy, but aca dem ic failu re in G rade 5 did
pred ict d elin q uen cy [ 173] . S pivack also fou nd that
anti-social and m alad ap tive co ping be havio urs in
G rad e 1 con trib uted to , and w ere exace rbated by, the
ac ade m ic failu re in G rad e 5.
Acad em ic pro blem s m ig ht be a con tribu to r to, or a
co nseq uen ce o f, d rug abuse. T he im plica tion fo r
ad olesce nt clien ts is that a poor acad em ic rec ord co uld
be a ba rrier to train ing and em plo ym en t that m igh t
then co m prom ise rein teg ratio n into society. S er vice s
sho uld eith er assess and add ress edu catio nal and
voc ation al issues or refer ado lesc en t clien ts to ser vices
that can do this.
A n ti-so cial b e h av io u r an d de lin q u e n cy
A nti-social beh aviou r, d elin q uen cy and co nduct disor der in ear ly child hoo d have been con sisten tly
assoc iated w ith drug m isu se (rather than o cca sio nal o r
experim en tal u se) [17 4,175 ]. —
A nti-so cia l beh aviou r ˜ is
beh aviou r that is unsocia ble o r con trary to the intere sts
of soc iety. U nsociab le beh aviou r is no t nec essarily
de lin q uen t be havio ur. —
D elin q uen cy ˜ refe rs to offen ce s
or m isd eed s. A s stated by D ryfoo s, d elin q uen cy:
. . . co vers a w id e rang e o f beh avio urs fro m
socia lly unaccep tab le acts perfo rm ed in ea rly
childho od that pa ren ts de scrib e as —
naug hty ˜ and
psycholo gis ts call —
ac tin g out˜ to vio len t and
de structive illeg al beh avio rs [65 , p. 29] .
—
C on du ct disor der ˜ is a d ia gn o sis ap plic ab le w hen
three o r m or e desig nated delin qu en t be havio urs co oc cur in a 6-m on th-p erio d before ag e 15 and the child
C auses and correlates of adolescent drug use
is co nsid ered u nm anag eab le or ou t of co ntrol. T he
de sig nated beh aviou rs include truancy, stea lin g , cheating , ru nning aw ay, lig htin g fires, cruelty to anim als o r
peop le , —
u nusu ally early˜ sexual interco urse, drug
ab use, brea king and en terin g, and exces sive figh ting [176 ]. T hus, the re is o verla p betw ee n anti-so cia l
beh aviou r, delin qu en cy and con d uct d iso rd er but the
term s are no t interch angea ble.
S ig nifica nt associa tion s have been fou nd for:
Ÿ m ale agg ressive ness in the first g rad e of schoo l,
espec ially w hen coupled w ith shy ness, and the
fr eque ncy of dru g u se 1 0 year s la ter [ 6];
Ÿ ag g ression an d actin g -out w ith alc oh ol abuse and
heav y can nabis u se [71 ];
Ÿ ag g ression and co ercio n as m ea ns of o btain ing
rew ard s and d rug ab use [ 50,17 7];
Ÿ vio len ce and po or m en tal health , dru g use, d rop ping ou t o f schoo l and d elin q uen cy [ 178] ;
Ÿ childho od reb elliou sness and daily cannabis
use [ 31] ;
Ÿ de lin q uen cy and su bsequ en t d rug u se [29 ,179] ,
daily cannab is use [3 1], reg ular dru g use [ 152 ]
and d ru g prob lem s in ad ulth oo d [18 0]; and
Ÿ the num ber of sym ptom s o f co ndu ct d isord er and
the num ber o f d rug -dep en d en ce d ia gn o ses [1 81] .
W hile an ti- soc ial beh avio ur g en erally preced es drug
ab use there is substantia l evide nce for view ing
de lin q uen cy and dru g ab u se as parts of a pro blem beh aviou r synd rom e [6 5,182 ]. H o w ever, D ryfoo s
ca ution s th at —
w hile m o st d elin q uen t ad olesce nts m ay
be d rug ab u sers, no t all d rug ab users are d elin q uen ts˜
(p . 24 6).
W hat ca uses anti-social beh aviou r? A review plus
or ig inal resea rch by Patterson and colleag ues have
em phasized the notio n o f a stag e m o del, based u pon
socia l learn ing theo ry, w here eac h stag e stron g ly
pred icts m oving to the next stage [50 ]. Stag e o ne is
initiated by a g en etic pred isposition to use aversive
beh aviou rs to shap e and m anip u late the social en viro nm en t, to avoid resp on sib ility and to m axim ize im m ediate g ratification . T he child w ith an anti-so cia l trait, if
exposed to ineffect ive pare ntin g, is unlikely to develop
positive perso nal and soc ial skills and is lik ely to
experien ce paren tal rejectio n, low self-estee m and
de pression . E nviro nm en tal stress such as soc ial disad vantag e and paren tal anti-so cial beh aviou r ca n
exac erb ate the effect s of poo r pa ren tin g skills. In stag e
tw o the child is likely to d o poo rly aca dem ic ally, be
rejected by peers and to d evelop anti-so cia l attitu des.
In stag e three the child soc ializ es w ith o the r anti-so cia l
46 3
children w ho su pp o rt, or at lea st acc ep t, anti-so cia l
beh aviou r, and is m or e likely to en g ag e in dru g ab use
and d elin q uen cy. T hro ug hout adolesce nce and into
ad ulth oo d, the anti-so cial person is pro ne to prob le m s
w ith d rug ab use, interp erson al relation ship s, e m ploym en t and m en tal hea lth . Shaw & B ell˜s review o f
de velop m en tal theo ries of paren tal co ntrib utors to antisocia l beh aviou r supports an d exte nds Patter son and
co llea gu es˜ m od el [18 3].
T here is som e inco nsistency in view s ab ou t the lifeco urse of anti-socia l beh aviou r. H aw kins and co llea gu es have noted that, w hile nearly all seriou s antisocia l prob lem s (in clud ing drug m isu se) are prec eded
by child hoo d anti-social beh avio ur, les s than half the
children w ho exhib it child hoo d anti-soc ial beh avio ur
de velop m or e seriou s pro blem s in later life [ 49] . M ost
oth er review s, on the o the r hand, have de scribe d antisocia l
beh aviou r
as
relativ ely
stable
o ver
tim e [50,1 84] . T he refo re, w ith ou t a spec ific inte rven tio n, —
it is unlik ely that they w ill sim ply gro w ou t o f
it˜[ 184, p. 187] .
In sum m ary, ea rly anti-social beh aviou r an d delin qu en cy have been associated w ith la te r, prob lem atic
dru g use. T hese beh avio urs ten d to co -oc cur d uring
ad olesce nce as part of a prob lem -b eh aviou r syndro m e,
su gg estin g that the y have co m m on antece den ts, rather
than that the anti-social beh aviou r/delin qu en cy —
causes˜
dru g ab u se [65] . T he stag es m od el of anti-so cia l
beh aviou r prese nted abo ve sug ges ts the im portan ce o f
teach ing ad oles cen ts intra-p erson al skills (fo r exa m ple,
m oo d m anag em en t and im pulse co ntrol) and soc ial
skills , as w ell as teac hing paren ts effect ive paren tin g
skills (for exam ple, pa ren tal m on ito ring in co m bin ation w ith ap pro priate con tin g en cies fo r d evia nt and
prosocial beh aviou rs).
A ge o f first u se
E arly initia tion into d ru g use has been id en tifie d w ith
prob le m atic d rug use [ 22,31 ,185,1 86] and alcoh o l
ab use at age 16 [2 3], as w ell as w ith anti-so cia l
beh aviou r [1 87]. T he rea son for the effec t o f ag e o f
first use o n prob lem use is no t clear and variou s
expla nation s have been pro po sed [ 22] . For exa m ple,
Kum pfer and colleag ues ascrib e ea rly o nset of an
em otio nal or beh aviou ral disor der as a sig n of hig her
g en etic lo ad ing for that diso rder [ 188] . Yam agu chi has
de m on strated that postpo nem en t of the ag e o f o nset o f
alcoh o l u se shorten s the period of hig h risk for
initiatin g ca nnab is u se [185 ]. T hat is, as d em on strated
by K andel and colleag ues, d ru g users te nd to fo llo w a
464
C atherine Spooner
pattern of use, beg ining w ith leg al d rug s follow ed by
illeg al drug use and ado lesc en ts w ho have not beg un
using ille ga l drug s by the late teen s o r early tw e nties
are unlikely to eve r d o so [189 ]. A ge of fir st use has
m ore im plica tion s for preven tion (fo r exam ple , dela ying the on set of u se) than for trea tm en t
inter ven tion s.
A d o le sce n ce
Ad olesce nce is a hig h-risk period fo r d rug ab use for
num erous reason s [1 90] . For exam ple, gr ow ing up is
stressful: there is stress associa ted w ith puberty, the
de velop m en t of a new id en tity and sep aration from
pare nts, to nam e a few. It is not surprising , then , that
on e in fou r ad olesce nts und erg o serio us psycho log ica l
je op ard y in that era of life [ 191] . Ad olesce nce is a tim e
of experim en tatio n and sociali zation . H ow ever, ad oles cen ts are ju st d evelo ping the d ecis ion -m akin g skills
that req uire fo rm al op era tion al thoug ht su ch as
en visio ning differe nt op tio ns and w eigh in g up the
alter natives; the ab ility to m ake d ecisio ns abo ut risky
beh aviou rs has n ot yet d evelo ped. G iven that som e
ad olesce nt dru g abu sers d o g row up, they could
m ature out o f their d rug ab use. H ow ever, not all o f
them w ill m ature su cces sfu lly and sim ply w aitin g to
see w ho g row s ou t of it is shirk ing ou r societa l
respon sibility to those w ho are having difficu lty in
their m atu ratio n proce ss.
L a be llin g
In a d eta ile d an d co m plex stud y of the fac to rs that
pred icted an esca latio n of d rug u se und er variou s
circu m stances , K aplan & Joh nson fo und that the
stronges t pred ictor o f increa sed d rug u se w as the
effect s of specific la be llin g : drug use increased as a
result o f g ettin g into trou ble be cau se o f initial drug
use [ 15] . K ap la n and colleag ues explain ed that neg ative social sanction s (lab ellin g) lea d to an e scalatio n of
dru g use via three paths [1 92]: (a) by perc eiv ing the
la be l of —
drug user ˜ as a positive thing , d rug users can
have a m ore positiv e self-ev aluation and gr eater selfac cep tance; (b ) having been alien ated by society
becau se of bein g a dru g user, the d rug user lose s
m otiv ation to con fo rm to that society ; and (c) having
been alien ate d by society bec ause of bein g a drug user,
the d ru g user has les s o pp o rtu nity to sociali ze w ith
non -drug u sers; this lea ds to increa sed in volv em en t
w ith dru g-u sing gro ups, hen ce g rea te r o ppo rtunity
and e ncou rag em en t to use dru gs. B ein g la belled as a
—
jun ky˜ o r an —
ad dict˜ is a po w erfu l phen o m en on that
ca n g ive ad olesce n ts the id en tity that they have been
search ing for, as per the ir d evelo pm en tal task. B y
servin g the pu rpose of su pplying a read y-m ad e
id en tity and socia l g rou p, su ch la bels can be a barrier
to chang e. For these rea sons it is prefera ble that
servic es neith er initia te no r perp etuate la be llin g ad ole scen ts as —
ad dicts˜. E ven the nam e of a service can be
im por tant. For exa m ple, it m igh t be preferable to call
a speciali st service for ado les cen t d rug ab users a
—
perso nal d evelo pm en t prog ram m e˜ rather than a
—
drug -treatm en t prog ram m e ˜.
D r u g v aria b le s
W heth er or not drug s are u sed at all, how m uch and
how often the y are used, and the nature and exten t of
prob le m s relating to use are also dep en d en t upon the
dru g itself. D rug s differ in their poten tia l for ab use as
a result of their individ ual pharm aco log ica l prop ertie s,
as w ell as the variou s socia l and psych olo gic al v alue s
and exp ec tation s of the dru gs [1 93] . Trea tm en t strateg ies need to be plan ned w ith co nsid era tion for the
partic ula r d ru gs used by the ad oles cen t clien t as issues,
su ch as rea sons for u se and cravin g, are likely to vary
ac cor ding to the pattern o f d rug use.
P re lu d e to a s u m m a r y : th e p ro b le m -b e h av io u r
sy n d ro m e
D rug ab use is o ne of the risk beh aviou rs id en tified by
Jessor an d collea gue s as part o f a prob le m -beh aviou r
synd ro m e [ 182,1 94]; that is, a pattern of risk beh avio urs that co m prom ises the psycho -social aspects o f
su cces sful ad ole scen t de velop m en t, includ ing d rug
ab use, w ith draw al fro m schoo l involv em en t, u npro tected sexu al interco urse and delin qu en cy. O ther
stud ies and liter ature review s have su pp o rte d the
co ncep t of a prob lem -b eh aviou r synd ro m e [6 5]. T he
co nstella tion o f pro blem beh aviou rs m ig ht be not
sim ply the result of their having com m on ca uses.
Jessor has d iscu ssed how th e socia l ecolog y o f
ad olesce nt life co uld pro vid e socia lly org anized op portunities to learn risk beh avio urs sim ulta neou sly and
nor m ative expectatio ns to en ga ge in m o re th an on e risk
beh aviou r [1 82].
Failu re to see d rug ab use as pa rt of a la rg er pattern
of beh aviou r can be a ba rrier to effect ive inter ven tion s,
partic ula rly as eac h risk beh aviou r co uld be con trib uting to ano the r risk beh avio ur. For exam ple, the review
ab ove has id en tified ho w delin qu en cy an d dru g ab use
C auses and correlates of adolescent drug use
ca n exacer ba te ea ch oth er in a spirallin g fa shio n. T he
g ood ne w s, how ever, is that, g iven their shared
aetio log ies , the inter ven tion s that can chang e an
ad olesce nt˜s risk status for o ne prob lem beh aviou r are
likely to be effect ive in changin g the oth er risk
beh aviou rs. O n the o ther hand , w e need to be ca refu l
to not over-ge neraliz e: ad oles cen ts w ho en ga ge in o ne
prob le m beh aviou r do not alw ays en ga ge in oth er
prob le m beh aviou rs; each ad olesce n t clien t ne eds to be
co nsid ered as an indiv idu al [80 ].
S u m m ar y a n d th e o re tical in te gra tio n fo r
p lan n in g
Ad olesce nts d o not sim ply ab use d rug s becau se they
are sick or m ora lly w ea k [1 95]. A rang e of ind ivid ual,
fa m ily, soc ial, en viron m en tal and o ther risk factor s
have been ide ntified for dru g ab use. C le arly, eac h o f
these risk fac to rs are related and there is not a sim ple
ca usal chain . Variou s m ode ls and theor ies have been
prop o sed to predict dru g u se an d m isuse on the basis
of risk fa ctors [ 196 •1 98] . N o m od els are ab le to
ac curate ly pred ict or com preh en sively de scribe drug
ab use by ad ole scen ts. S uffice it to say that (a) d rug use
is de ter m ined by num ero us, inter- rela ted risk factor s,
as w ell as protective fac to rs [1 46,19 3]; (b ) the
ind ivid ual, the en viron m e nt and the d rug s them selves
need to be con sidered w hen con sid erin g the aetio log y
of d rug use [ 199 ,200] ; and (c) d rug ab use is often
part o f a pro blem -b eh avio ur syndrom e that includ es
de lin q uen cy, d rug ab u se, ad oles cen t pregn ancy and
school fa ilure [ 65,1 94,20 1].
C o nseq uen tly, inte rven tio ns that try to d eal w ith
single-risk fac to rs or risk beh aviou rs are hig hly
unlikely to be effect ive. A lso, w ith the em phasis on risk
fa ctors , m any researc hers and pla nners fail to co nsid er
protective fac to rs. T hat is, for ea ch risk fac to r, its
reverse co uld be protective. Fo r exam ple, positive pe er
influ en ces co uld act as a restraint on dru g m isuse [ 202] ; and co m m itm en t to con ve ntion al socia l
g rou ps, such as the fa m ily, relig io n and schoo l, can act
as a restrain ing force aga inst partic ip atio n in devian t
ac tivities [1 86]. W hen con sid erin g a treatm en t pla n
fo r an individu al, ca se plan ne rs need to con sid er w hat
fa ctors have supported non -p rob lem atic use, as w ell as
those fa cto rs that have con trib uted to prob le m atic
use.
It is im po rtant to note the lim ita tion s of review s of
the aetiolo g y o f drug ab use. First, the re is still m u ch
that is no t kno w n o r not cle ar. T he histor y of drug
ab use researc h and inter ve ntion s has been on e of m u ch
46 5
su ppo sitio n, inco nsiste ncy and e rror [5,203] . E ven
m od els that have receiv ed co nsid era ble suppor t o ver
the year s d o not accou nt for all the varia nce. We are
not yet ab le to predic t accu rately w ho w ill beco m e a
dru g ab user; w e can on ly be aler t to the risk fac to rs
cu rren tly id en tified .
S eco ndly, the abo ve review has relied u po n qu antitative researc h to test for associa tion s betw een suspec ted
risk factor s and beh avio urs. H ow e ver, q ualitative
researc h m eth ods, su ch as eth nog rap hy, have played a
valuab le role in d escrib ing and explain ing drug ab use
and pro viding reco m m en dation s for practice. Fo r
exam ple, M oo re˜s eth no gr ap hic rese arch w ith skinhead s [2 04] and psychostim ula nt users [ 205 ] has led
to usefu l reco m m en dation s and insig hts into subg rou ps, particu larly situ ation al influ en ces on drinking
and dru g u se, that w o uld be difficu lt to o btain by oth er
m eth od s [ 206 ]. G iven these lim itation s, assessm en ts
of the fac to rs that co ntrib ute to prob le m beh aviou rs for
eac h ind ivid ual clien t or clie nt g ro up need to be able to
id en tify factor s that are not listed in liter ature review s
su ch as this on e. T hat is, risk fac to rs and protective
fa ctors need to be explo red w ith an op en m ind an d
m any q uestion s need to be asked to ascertain the
pertin en t factor s fo r the clien t or gro up at hand.
W heth er d evelop ing a ca se-p la n for a sing le clien t
or pla nning an inter ven tion fo r a gr oup, all the factor s
that co ntrib ute to the pro blem , all the stakeh old ers and
sign ific ant oth ers, and all the reso urces at hand to
assist w ith d ealin g w ith the pro blem need to be
co nsid ered . T h ere are vario us tex ts to assist w ith the
de velop m en t of pla ns. For exa m ple, on e strateg y fo r
plan ning inter ven tion s for dru g-a bu sing ado lesc en ts
has bee n d evelop ed by the Pro gra m m e o n D rug A bu se
fr om the World H ealth O rg anization [2 07]. T his
strateg y uses the —
M o dified S oc ial S tress M od el˜
(b ased upon R ho des & Jason˜s socia l stress
m od el [14 6]) to help w o rkers to con sid er all the risk
fa ctors and protective fa ctors w hen plan ning an
inter ven tion (Fig . 1).
Stress inclu des m ajor life even ts such as child sexual
assau lt, lon g-term pro blem s su ch as poverty or lack o f
rec reatio nal op portu nities, everyd ay pro blem s such as
de alin g w ith a vio len t en viro nm en t, m ajor life changes
su ch as m oving ho use and ad ole scen t d evelo pm en tal
changes .
N orm alization of a d rug is affect ed by law en for cem en t, availa bility, pric e, ad vertis ing , m edia presen tation , culture and peer no rm s.
E xperience of dru g u se is affec ted by variab les
assoc iated w ith the user (fo r exa m ple, the u ser ˜s
466
C atherine Spooner
(risk factors)
(Dis)stress + no rm alization + exp erience
Attachm ents + skills + reso urces
(protective factors)
F igu re 1 . M odified Social Stress M odel.
expectatio ns of effect ); the d rug (for exam ple, type o f
dru g or ho w pure it is); and the settin g (fo r exa m ple,
the m oo d o f the oc casion ).
Attachments can be positive or n ega tive and can be
w ith oth er adolesce nts, the fa m ily, w o rkers and so
on .
Skills includ e co m peten cies that help peop le su cceed
in life (for exam ple, lead ership) and cop ing strateg ies
su ch as skills in assertiven e ss, prob lem solving and
relax ation .
Resources are an ything that ca n he lp tow ard s
physical and em o tion al need s bein g m et and can be
intern al (fo r exam ple, intellig en ce) or exter nal (fo r
exam ple, fa m ily, ad olesce nt w orke rs).
E ach of these factor s have been add ressed in the
ab ove review. T he essence o f the m od el is that, w hen
plan ning inter ve ntion s, w e are trying to red uce the risk
fa ctors and build u p the protective factor s. T he socia l
stress m od el is one w ay o f puttin g tog eth e r the risk
fa ctors and pro tec tive fa ctors in a w ay that assists
plan ning inter ven tion s.
S e lf-re p o rte d re aso n s fo r u s e
If a researcher w as asked w hy ad oles cen ts use and
m isuse dru gs they cou ld cite the aetiolo gical risk
fa ctors discussed ab ove, m o st of w hich d en ote som ething w ron g w ith ind ivid uals and /or their en viron m en t
as be ing causes o f dru g-u se beh avio urs. H ow ever, if
ad olesce nt d ru g u sers are asked w hy the y u se d rugs, a
qu ite differ en t perspectiv e on the reason s for ad olescen t d rug use and m isu se is g iven .
R eilly & H om el asked a sam ple o f 10 71 ad olesce nts
ag ed 15 •18 in S ydney w ho had u sed an illicit drug
(oth er than, or as w e ll as, ca nnab is) w hy they used
psycho -activ e dru gs [ 208] . A bo ut half the respon de nts said they used psycho -activ e dru gs be cau se they
en joyed the high (31 % ) or for social fu n (16% ). A
m ino rity of the sam ple said that they use d rug s to cop e
w ith neg ative feelin gs (7 % ), to allev iate bo red om
(11% ) or as a result o f peer pressure (8% ). A nalyses
id en tified a relation ship existed be tw een the type o f
dru gs the respon de nts used and their rea son s for u se.
Re spon d en ts w ho had u sed am ph e tam ines, co cain e,
hallu cinog en s and/or d esig ner d rug s in the previou s
m on th ten ded to u se d rugs for soc ial o r psycho log ica l
en joym en t. R esp on den ts w ho had used tranq uilliz ers,
barb iturates, o pioid s and/or inhalan ts ten de d to use
dru gs to co pe w ith n ega tive fee lin g s, bo redo m or peer
pressure.
T his stud y hig hligh ted that adolesc en t illicit dru g
users have fu nctio nal (often hedo nistic ) reason s fo r
illicit drug u se and that the reason s for use vary
ac cor ding to the type of d rug u sed . H ow ever, this
stud y did not ask resp o nden ts to distin g uish (a) w hy
dru gs w ere first u sed and w hy the y co ntin ued to be
used and (b ) the reason s fo r u se of eac h spec ific illicit
dru g that they u sed .
A su bsequ en t stud y by S poon er (p reviou sly R eilly )
and co llea gu es add ressed the se issu es by asking
respon de nts, for each illicit drug u sed , w h y they first
used it and w hy they con tin u ed to use it [2 09]. T his
stud y sur veyed 58 1 yo uths ag ed 16 •21 in Syd ney w ho
had used an illicit dru g (o the r than, or as w ell as,
ca nnab is). T he m ain reaso n for initial use o f all drug
types w as to try som eth ing new, or for the experien ce.
T his reason w as g iven fo r u p to 72% o f the tim e for all
dru g types, exc ep t sedative s (38% ). O ther reaso ns fo r
trying oth er d rugs rarely accou nte d fo r m or e than 10%
of the resp o nses. T ho se that did w ere the d esire to u se
som eth ing stron g er (h eroin , 10% ), bor edo m (sed atives, 10% ) and peer g roup pressu re (cannab is,
13% ).
A s to w hy resp on den ts con tin ued to use spec ific
illicit d rug s, abo ut half the users o f all dru gs, excep t
inhalan ts and sed atives, repo rtedly used those d rug s
becau se they —
like d them ˜. O n avera ge, 2 9% o f the
users of ea ch d rug repo rted th at they u sed that d rug to
g et high . T his resp on se w as lea st com m on am on g
sedative users (18 % ) and he roin users (22 % ).
C auses and correlates of adolescent drug use
O the r rep o rted reason s fo r u se w ere m ore drug spec ific than those describe d abo ve. O ne- third o f
hero in u sers said that they used heroin becau se they
w ere —
ad dic te d˜. T his reason w as rarely g iven fo r the
use of an y oth er drug . S edatives (20% ) and cannab is
(10% ) w ere also u sed to rela x or slee p, w hile
am phetam ine s w ere used to ke ep aw ake (11% ). N o
oth er sing le reaso n acc ounted for m o re than 1 0% o f
the respon ses. In sum m ary, S poon er and co llea gu es˜
researc h has in dic ated that m o st yo ung illicit drug
users use d rug s fo r fu n, a m inor ity u se to cop e or
becau se o f a d epe nden cy. T hose w ho rep or t the latter
rea son s are m o re likely to be using heroin and /or
sedatives than those w ho use drug s for fu n.
In sum m ary, ea ch of the abo ve studies fo und that
the m ajor reaso ns giv en for illicit dru g use have been
to party and to have fu n. T his is co nsisten t w ith stu dies
that have assoc iated sen sation -seek ing w ith drug
use [ 210] . H ow ever, the m ajor reason s giv en fo r the
use o f illicit drug s by users of sedatives, op io id s,
inhalan ts and , to som e exte nt, ca nnab is have ten d ed to
be bored om and to dea l w ith w o rries. Sim ilar fin d ing s
have been fou n d els ew here [ 45,21 1,212 ]. T he u se o f
differe nt d rug s for differ en t rea son s refle cts the
differe ntial effect s o f ea ch d ru g [1 99,21 3].
In co ntrast to the abo ve stud ies , the m ost freq uen tly
g iven reason fo r d rug u se giv en by clien ts o f a
resid en tial d rug -treatm en t ser vice for ado lesc en ts w as
—
to fo rg et˜. T his respon se w as g iven by abo ut 30% o f
clien ts, w heth er their m ain d rug of abu se w as alcoh o l,
hero in, ca nnab is or am phetam ines. D rug use fo r —
fu n˜
w as repo rted by less than 10% o f the sam ple, and by
on ly 1% o f he roin users. It app ea rs that reason s fo r u se
am o ng ado lesc en t drug abu sers differ fr om the rea sons
fo r d rug use g iven by o th er adolesce nts. T his
differe nce is co nsiste nt w ith an assoc iatio n be tw een
rea son s for u se and drug -p ro blem seve rity, as id en tified by M cK ay & B uka [80 ].
T hese self-rep o rted rea sons high lig ht an issue that
is often o verlo oked by researc hers, plan ners and
servic e pro viders: that d ru gs are used for a reaso n an d
that there are usually ben efits to the u ser fo r d rug use.
M oo re & S aund ers have w ritten ab ou t the ben efits o f
dru g u se in the co ntext of preven tion pro gr am m e
plan ning ; how ever, their d iscussio n also has relev ance
fo r treatm en t pro gra m m es [214 ]. T hey have argue d
that d rug users are no t patholo gical, that d rug use is
fu nction al (even tho ug h it m igh t be d ang erou s), has
im m ed iate ben efits and is part o f the social con struction of m ean ing fo r m any individ uals. Sim ilar ly, B ro w n
noted th at:
46 7
T ho se y oung peo ple w hose illicit dru g use
rea ches the atten tio n of the w elfare o r co rrectio nal
syste m , of ten have experie nced d isrupted fa m ily
back g rou nds and are fin ding life in ten sely d isag reea ble in the presen t. T heir u se o f illicit and
oth er drug s as a source of relief hold s com pellin g
and – in the lig ht of the ad versities w hich m any
are ob lig ed to fac e – q uite un derstandable attraction s fo r them [ 215, p.6 9].
In sum m ary, the reaso ns fo r u se vary am on g
ad olesce nts and acro ss tim e w ith in ado lesc en ts. Fo r
exam ple, d rug use m igh t beg in as a result of cu rios ity
or peer pressu re, the n con tin ue fo r social/recr eation al
purpo ses. Fo r som e, use m ig ht then con tin ue o r
increase w hen it is used to help co pe w ith life , or
spec ific pro blem s. R eason s for use ca n even vary day
by day, o r de pe nd upo n the situatio n. For exa m ple,
som e u se cou ld be soc ial/recre ation al at o ne tim e, then
to help d eal w ith prob le m s at ano the r tim e. D ifferen t
dru gs and settin g s m ig ht be in volv ed w ith these
differe nt purposes. Fu rtherm or e, stud ies o f rea sons fo r
use ten d to o btain differe nt patter ns o f respon ses,
de pe nding upo n the com position o f the sam ple.
S tu dies of adolesce nts w ho are pred om inantly not
having pro blem s w ith their drug use (such as the
stud ies by Reilly /S poon er) iden tified that m ost ad oles cen ts rep orted that the y use drug s be cause it is fu n.
H ow e ver, as the sam ples con tain m o re prob le m atic
dru g u sers (su ch as the sam ple fro m D unsm o re
H ouse), the rea sons for use ten d to shift aw ay fr om
—
fu n˜ tow ard s —
to for get˜. S im ila rly, rep o rted rea sons fo r
use ca n also vary be tw een cu ltures [2 16] .
In co nclu sio n, the reason s for drug use are an
im por tant factor for service provisio n as these ca n vary
as a resu lt o f m any factor s such as the po int o f tim e in
a drug -use ca reer, the spe cific situatio n and cultu re.
S om e drug use m igh t be fu nctio nal and not prob lem atic . H ow e ver, w here dru g use is interfer ing w ith
ad olesce nts dea lin g w ith their prob le m s or th eir life in
g en era l, prog ram m es sho uld assist tho se ad oles cen ts to
explo re altern ative m ean s o f dea lin g w ith prob le m s,
socia lizing and having fu n.
A c kn o w le d ge m e n ts
I w ould like to thank A ssocia te Professor R ich ard
M attick , Wes ley N offs and D r Jo hn H ow ard for their
su ppo rt in the prep aration of this pap er, and the N ew
S outh Wale s D ep artm en t of H ealth fo r the fu nding
req uired to prep are this revie w.
468
C atherine Spooner
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