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 rs 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
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

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); co ntrib ute to dru g abuse (risk factor s); m ediate o r m od erate risk fac to rs (p rotective fa ctors ); are cau sed by drug abu se (con seq uen ces); and 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 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

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] .

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

45 5

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].

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-riskado 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:

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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). 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] ; 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] . 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: 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] .

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.

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 : 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 , neg ative criticis m ) [ 49];

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

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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.

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 o cio -e co n o m ic sta tu s

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

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

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

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

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

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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 ].

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.

S tre ss an d co p in g/su pp o rt m e ch an ism

K n o w le dge

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 ].

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.

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.

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

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

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

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C atherine Spooner
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

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

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: 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]; ag g ression an d actin g -out w ith alc oh ol abuse and heav y can nabis u se [71 ]; 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]; 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] ; childho od reb elliou sness and daily cannabis use [ 31] ; 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 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

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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

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

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

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

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

46 5

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

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

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(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.

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