Estudo brasileiro sobre abuso de substâncias por adolescentes

8/9/2019 Estudo brasileiro sobre abuso de substncias por adolescentes

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Rev Bras Psiquiatr 2003;25(3):133-8

artigo original

Brazilian study on substance misuse in adolescents:associated factors and adherence to treatmentEstudo brasileiro sobre abuso de substncias por adolescentes: fatoresassociados e adeso ao tratamento

Vilma A da Silvaa, b, Aline S de Aguiara, Felippe Felixa, Gabrielle P Rebelloa, Renata C Andradea and Helcio F Mattosa

aIntegrated Regional Center for Attention of Adolescents. Fluminense Federal University (CRIAA/UFF). Department of Psychiatry and Mental Health. Niteri,RJ, Brazil. bDepartment of Physiology and Pharmacology. Fluminense Federal University. Niteri, RJ, Brazil

This study was supported by Foundation for Childhood and Adolescence (FIA Process n. E-23/301609/2001), by Brazilian Development Bank (BNDES Process n. 99.2.455.2.1), andby National Council for Scientific and Technological Development (CNPq Process n. 103960/99-6).Received on 25/7/2002. Approved on 12/5/2003.

Objectives: To investigate developmental and environmental factors associated to substance misuse in adolescentsseen at a university day-hospital in Brazil and to verify the correlations between those factors and adherence totreatment. To compare factors associated to substance misuse in adolescents with the available scientific literatureand to suggest specific preventive interventions for a national policy in Brazil.Methods: Eighty-six adolescents guardians were evaluated at admission to the service by using asemistructured interview including sociodemographic data, family relationship, perinatal and pregnancyhistories, psychomotor and educational development, social relations, history of previous illnesses and familydiseases, including drug abuse.Results: The sample was predominantly male (90%). Adolescents referred from the criminal justice were olderthan those originating from other sources (16.4 x 15.4 years old p=.00). Forty-four percent of adolescentsreported school failure, a level which is two times higher than Brazilian statistics. Forty percent of the samplehad criminal involvement, mainly drug dealing. Cannabis was the most prevalent reported drug. Living withboth parents was protective, delaying the age of initiation by one year. Domestic violence was more frequentamong parents with illicit drugs abuse (38.1% x 12.5%, p


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Substance misuse in adolescentesSilva VA et al

IntroductionDrug dependence is a growing disorder in modern society

and is closely related to environmental urban problems of in-creasing prevalence such as the violence associated to drugdealing. In a study carried out in institutions in charge of ado-lescents who had been involved in criminal situations1 theauthor found that 30% of the adolescents arrested in Rio deJaneiro, Brazil, had drug dealing as their main charge, thusshowing the importance of this delinquent behavior in the

city. Many adolescents engaged in drug dealing behavior orusing illicit substances will never become drug dependents.2

However, substance misuse was suggested as the most im-portant factor associated to violent behavior in adolescents.1

Easy and premature access to drugs that can reduce anxietyand inhibitions to dangerous risk behaviors may be a risk foryoung people, especially those born in poor neighborhoodswhere drug dealing offers one of the only real opportunitiesfor a well-paid job. Together with the availability of drugs,these children and adolescents still do not have the copingskills to deal with difficult situations and are used to seeingfriends and relatives dealing with life stressors by taking

drugs.3

The medical and social problem described above fur-ther complicates the already complex theoretical issues de-scribed in the international scientific literature on substancemisuse and drug addiction in adolescents. The diagnosis ofdrug dependence in adolescence is itself a subject of discus-sion. Substance use disorder diagnostic structures have beeninvestigated in adult populations. However, it is unknownwhether or not the current diagnostic scheme for substancedisorders can accurately represent the development of sub-stance use disorders in adolescents because research on diag-nostic criteria has been conducted almost exclusively onadults. 4 While there are separate childhood criteria for mood,psychotic and antisocial personality disorders, substance use

disorder criteria are not age-specific. The study by Fulkersonet al4 concluded that DSM-IV substance abuse and depen-dence criteria may be more optimally structured as a unidi-mensional construct rather than a bidimensional construct foradolescents. The study did not find empirical justification forthe distinction between abuse and dependence in adolescents.The authors point out that as the appropriate goal of any in-tervention with substance-using adolescents is the cessationof use (the only defensible treatment goal for minors), theremay be no clinical utility for such a distinction. However, itis useful to know that abuse symptoms do not necessarilyprecede dependence symptoms in adolescents, as occurs in

lao entre os fatores investigados e adeso ao tratamento.Concluso: Os dados desse estudo indicam que os programas devem incluir o tratamento dos adultos e educaodos pais e futuros pais. O abandono do tratamento no primeiro ms parece ter causas externas ao adolescente.

Abuso de substncias. Adolescentes. Adeso. Tratamento.Descritores

adults. It is also of importance to know that evidence sug-gests that most substance-dependent subjects start drug mis-use before 20 years old,2 thus indicating that interventionduring adolescence is of particular relevance in preventingthe consequences of this behavior. Adolescents experiencemany life events and drugs will accompany most of them.Many will experiment with drugs and will quit drug use inadulthood.5 However it is by this time that drug dependencewill start for some of them and it is still difficult to determine

which adolescents will be at risk of becoming dependent.2Another important issue is that adolescence is a time of

onset of many psychiatric disorders and these may increasethe risk for drug dependence.5 Identifying these disorders andestablishing appropriate treatment is a responsibility for thehealth professional in charge of the adolescent engaged insubstance misuse.

Treatment of substance misuse at this age group is particu-larly challenging. Some authors concluded6 only that some treat-ment is better than none and that no treatment demonstratedsuperiority over the others. Relapse rates vary across studiesbut can be fairly high. It has been suggested that in treating

adolescents, care should be provided to many aspects of theirlives and should not be directed to the drug problem exclu-sively. For instance, sexual education, leisure activities andformal education should be provided.5 Apparently, broad di-rected treatments are more effective. The new perspective offacing drug addiction as a chronic disease, as suggested byMcLellan,7 brings some optimism to the field of evaluation oftreatment efficacy. According to this author, analogously toother chronic diseases, benefits for the drug-dependent patientwould occur during treatment and appropriate support shouldbe given after discharge in order to achieve long-lasting suc-cess. Evaluation of treatment months after its interruption wouldnot be precise underestimating the efficacy of the different

methods of treatment. It has been accepted that to obtain ben-eficial effects of any treatment for drug dependence patientsshould remain under treatment at least for three months.8 How-ever, this is not easily achieved.

Adherence to treatment is an important challenge withchronically-dependent patients in general and may present evengreater difficulties when working with adolescents. Factorsdetermining adherence are intrinsic to the patient and extrinsic,regarding procedures, staff and setting. Understanding thesefactors is crucial for the success of any treatment approach.

The aims of the present study were:To investigate developmental and environmental factors


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associated to substance misuse in adolescents assisted at theonly university day-hospital targeting this population in Brazil.

To follow up the same adolescents evaluated at their admis-sion to the service to look for correlations between the investi-gated factors and adherence to treatment

To compare the investigated factors with the available scien-

tific literature and suggest specific preventive interventions fora national policy for drug abuse prevention in Brazil.

MethodThe study was carried out at the Integrated Regional Cen-

ter for Attention of Adolescents (CRIAA) which belongs tothe Department of Psychiatry and Mental Health of the Fed-eral University of Niteri, Rio de Janeiro. The center offerstreatment to adolescents aging 12 to 18 years engaged in sub-stance misuse. A brief description of its function has beenpublished elsewhere.9 The service receives referrals from thecommunity and from the criminal justice. Treatment is free

of charge for the patient. The theoretical background of itsmethodology supposes teaching patients to deal with theirconflicts, including drug problems as well as working to in-crease protective factors (family intervention, education, pro-fessional skills, leisure activities, sexual education). Althoughthe number of patients reported in the present study is rela-tively small, it is representative of the total sample assisted atthe 4-year old service. All adolescents seen during the first18 months of functioning were invited to participate. Therewere no refusals but 10% of the subjects were excluded dueto mistakes in research schedules, leading to missing data.Important changes in the functioning of the service were sug-gested as a result of the research and will be presented. Al-

though a relatively new service, CRIAA intends to continueworking in a well-documented way, suited to research andevaluation, due to its strong links with the university. Conti-nuity in a service of this kind is unusual in Brazil. The in-volvement of the university will improve the likelihood of along future for CRIAA. Data presented here represent the firstefforts of this implantation and aim to contribute to the un-derstanding of substance abuse in adolescents. Adolescentsincluded in the present study were experiencing problems (in-cluding emotional, physical, legal, social, or educational) as-sociated to the use of drugs. We defined this condition as sub-stance misuse.

At the time of admission, 86 adolescents guardians (74mothers; 3 fathers; 2 couples and 7 other relatives) were in-terviewed in a private room by a previously-trained medicalstudent, after giving informed consent. A semistructured in-terview was used and included information onsociodemographic data, family relationships, perinatal andpregnancy history, psychomotor development, educationaldegree, social relations, history of previous illnesses and fam-ily diseases (including drug abuse). All other relevant com-ments given by the informant were registered, especially aboutthe family environment and violence towards the child. His-tory of drug involvement, drug use pattern, problems relatedto drugs and previous treatments were also collected in a sepa-

rate interview with the adolescent which was carried out bythe psychologist in charge of treatment. This procedure aimedto avoid biases related to the collection of information fromthe adolescents guardian who might ignore details of the drugintake history. The instrument used to collect data on druguse was adapted from the intake form used at the Alcohol

and Drugs Unit of the Federal University of So Paulo (Uniad,Unifesp). Briefly, this instrument collected information onage and circumstances of the first contact with alcohol, nico-tine, cocaine, marihuana and any other drug reported by theadolescent . Information on the pattern of use of each drugwas also collected, that is, amount used, frequency, and lastepisode of drug intake before the interview. Difficulties withprevious treatments for substance misuse and involvementwith the criminal justice were also investigated.

After the admission procedure the adolescent was referredto the treatment schedule of the institution with no further in-terference from the research procedures. Files of each indi-

vidual patient were examined to assess adherence, and timeremaining under treatment was registered. When the adoles-cent was no longer under treatment, the reason for dischargewas recorded. As criteria for data analysis, six months or morein treatment was defined as good adherence and no adherencewas defined as less than one month in treatment. Another studyfound out that after six months under treatment considerableimprovement could be detected in the consumption of illicitsubstances and criminal involvement.10 Characteristics of thesample were analyzed by taking the sample as a whole for thestudy of correlations and then by comparing the two subsets ofextreme adherence (good adherence x no adherence). Correla-tions between variables were performed as pertinent to the

studys objectives. The SPSS program was used to analyze data.Non-parametric or parametric analysis were used in accordanceto the variables analyzed and are specified in each table. Dif-ferences between groups were considered as significant whenp values were .05 or less.

ResultsTable 1 shows the general characteristics of the sample. The

sample was predominantly male (90%), in spite of the servicebeing available for both genders. There was a statistical sig-nificant difference between the age of adolescents criminallyinvolved and those who were not. Those coming via the crimi-

nal justice aged 16.41.1 (n=34) and those coming from thegeneral community aged 15.41.2 (n=50) (t=3.668, p=.000).Schooling (years at school) was 5.21.9 (mean sd) and asignificant correlation was detected between this and parentaleducational level (Spearman non-parametric correlation, p


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the availability of our service to the criminal courts. Cannabiswas the most prevalent reported drug. Age of onset of drug usewas between 12 and 13 years old, with some of them startingas early as 7 years old. An interesting finding was a differencebetween the age of initiation in adolescents with parents whowere not living together when compared to those living to-gether with both parents (12.22.1 x 13.51.5 t=2.2, p


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students.17 These data, collected from adolescents who werenot seeking treatment, agree with those collected in the presentstudy in which a considerable part of the sample was exposedto additional risks and had criminal involvement. It has beenconsidered that cannabis seems to be particularly dangerousfor adolescents with conduct problems.18 Although the diag-

nosis of conduct disorders has not been established for eachadolescent of our sample, the high percentage of criminal jus-tice involvement (40%) suggests that this may be important.Crowley et al18 investigated a teenage sample referred forsubstance and conduct problems. They concluded that in ado-lescents with conduct problems cannabis potentially producesboth dependence and withdrawal. In the present study, if in-volvement with criminal activities is considered as indica-tive of a conduct problem, 40% of the sample should be con-sidered at risk for cannabis effects and should deserve spe-cial clinical attention. It is relevant to consider that the ado-lescents engaged in criminal activities were older than those

who were not. However, age of initiation on drugs did notdiffer between groups. Apparently, involvement with crimessevere enough to result in the intervention of criminal courts,or repetition of illegal activities leading to intervention wouldstart later in the lives of adolescents engaged in substancemisuse, thus leaving time to prevent this outcome. Preven-tive activities must be directed both to children and adoles-cents who are not yet using drugs but also to the ones whohave started drug consumption and are close to get involvedin criminality. In this study, criminality was mostly drug deal-ing. Early contact with illicit drugs would favor social rela-tionships with criminals and introduce the adolescent to drugdealing. We may remind that it has been believed that in-

volvement with the law might precede the approach of thehealth system for drug dependents.

Poly-substance use was predominant in the present study.This finding is consistent with previous data on adolescents intreatment for alcohol and drug use.19

Males are reported to be more susceptible to substance mis-use and conduct problems. However, many of the best studieson conduct problems have used male samples and several stud-ies indicate that major gender-related differences in prevalencerates are related to the most serious antisocial acts.20

Insufficient attention has been devoted to gender differencesand conduct problems among girls. It has been suggested that

premature puberty and early sexual debut are possible elementsof a female trend to conduct problems and substance use. 20

CRIAA is available for both genders and the predominance ofboys was not an expected finding. Apparently, Brazilian fe-male teenagers engage less in substance misuse than they do inother countries. Another possibility is that girls have a differ-ent pattern of substance abuse and are less involved in crimi-nal problems. A study in Brazil reported that male adolescentspresent more involvement with the police than female adoles-cents.21 As the criminal system is one of the sources of refer-rals to CRIAA, this might explain the small number of girls atthe institution.

There is only one unit for delinquent girls in the city of Rio

de Janeiro. This paucity of services for girls presumes that theywill need them less. However, this same paucity of residentialplaces for girls correlates to the fact that there will be a re-duced likelihood of a custodial outcome post-arrest. Studieson the profile of delinquent girls are necessary.

Our data is in accordance with the literature which suggests

that drug consumption by parents and by people in the childrensenvironment poses a risk for drug problems. Over and abovethe genetic susceptibility already established for alcoholismsuch environmental exposure offers a negative social learningprocess problem. Basically, the child would grow up observ-ing adults dealing with their own problems by taking drugsand would learn this behavior as the only coping skill. Expec-tations regarding drug effects and acceptance by peers wouldreinforce this behavior.3

None of the investigated factors were related to adherence.This lack of significance may be a consequence of lack of sen-sitivity in a relatively small sample, but it is suggestive that

determinant factors for adherence in this particular sample arenot inherent to the patients, but are probably related to the treat-ment process in itself and to the characteristics of the staff. Ithas been pointed out7 that when approaching other psychiatricdiseases, researchers and doctors search for external causes ofnon adherence, such as complicated schedules. The same doesnot occur with chemical dependent subjects, who are oftenblamed for non-compliance. A reflection about treatment sched-ules is necessary. A comprehensive understanding of theseexternal variables would require a different procedure. Adher-ence to treatment is one of the main challenges in treating drugdependence and it is perhaps more challenging when patientsare adolescents. It is crucially important to understand this if

one is interested in improving recovery rates. Another studyshowed that in CRIAA, one to 12 months in treatment wasassociated with some improvement in the patients conditionespecially in criminal behavior.10

Motivation towards treatment is more likely to be an adultcharacteristic. They usually have fewer adverse conse-quences due to drug use. The treatment setting must be at-tractive in order to keep the adolescent for enough time. Inconclusion, early alcohol or drug use is associated with con-tinuous use. Therefore, prevention and treatment duringadolescence is fundamental. The impact of the age of onsetof substance use and delinquency has also been reported.

Preventive programs have been traditionally focused on strat-egies of refusal and on behavioral problems. Data from thepresent study indicate that any conceived preventive mea-sures must include treatment of adults and education of par-ents and parents to be. Drug consumption by the familieswas clearly one of the most important factors associated tosubstance misuse among adolescents in the present study.The impact of suggested changes in the result of treatmentat this institution should be further evaluated.

Our study was not able to detect why so many adolescentswithdrew from treatment at early stages. Data showing thatthis was more important in the first month of treatment led thestaff to create a special motivating group which takes place in


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the first month of admission at CRIAA. The impact of thisnew procedure is under evaluation. Our data suggest that theproblem of adherence is extrinsic to the adolescent.

AcknowledgmentsWe wish to thank Mr. Glyn Halksworth for his help in the

preparation of the manuscript, FIA, BNDES and CNPq for fi-nancial support and the patients of CRIAA and their parentsfor their kind collaboration during the study. We are also in-debted to the technical team of CRIAA, especially Dr. AndrFrancisco da Silva and Dra Gabriela Albuquerque for their helpin collecting some of the initial data.

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Correspondence:

Vilma A. da SilvaRua Hernani Melo, 10124210-130 Niteri, RJ, BrasilE-mail: [email protected]

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Estudo brasileiro sobre abuso de substâncias por adolescentes