Substance abuse among children

Sanaa Mohamed Aly, Ahmed Omran, Jean-Michel Gaulier, Delphine Allorge

To cite this version:

Sanaa Mohamed Aly, Ahmed Omran, Jean-Michel Gaulier, Delphine Allorge. Substance abuse
among children. Archives de pediatrie organe officiel de la Societe francaise de pediatrie, 2020,
Archives de pediatrie organe officiel de la Societe francaise de pediatrie, 27 (8), pp.480-484.
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Review article

Substance abuse among children

Sanaa M. Aly a,b,*, Ahmed Omran c, Jean-Michel Gaulier b,d, Delphine Allorge b,d
a
Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
b
CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
c
Pediatrics and Neonatology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egyptd
d
Université de Lille, ULR 4483 – IMPECS – IMPact de l’Environnement Chimique sur la Santé humaine, Lille, France

A R T I C L E I N F O A B S T R A C T

Article history: Substance abuse (SA) among children is a recognized challenge for policymakers and law enforcement
Received 4 April 2020 and has life-threatening consequences owing to the impact on the children’s development and the
Received in revised form 21 July 2020 consequent increase in vulnerability. This work outlines several important issues related to SA among
Accepted 11 September 2020
children: (1) SA prevalence including onset, common examples, extent, and spectrum of SA; (2) the
Available online xxx
presence of new psychoactive substances, which are rapidly spreading worldwide with limitations
regarding their prevalence, detection, and interventions; (3) street children and their recruitment in
Keywords:
drug supply; (4) SA and substance use disorder pathways, risk and protective factors for the
Substance abuse
Children
development of SA; (5) SA consequences in the case of early initiation, including deaths; and (6) current
Prevalence preventive interventions for the pediatric population. In conclusion, this challenge requires consistent
Prevention and unremitting attention in order to execute effective prevention programs with continuous re-
evaluation of the situation.
C 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

1. Introduction SA consists of a maladaptive pattern of substance use leading to

clinically significant impairment or distress, including recurrent
The global substance abuse (SA) problem is a serious threat to substance use which is hazardous or continuous despite persistent
public health and the safety of children [1]. Any SA at early age is social or interpersonal problems. Substance use disorder (SUD) is
likely to interfere with normal development and may have an the use of a substance despite experiencing problems due to this
impact on the child’s future [2]. Initiation of SA at an early age has use. This term integrates SA and substance dependence into a
been associated with long-term physical, behavioral, social, and single disorder [7].
health risks [3]. In addition, the recreational use of drugs is an
under-recognized cause of mortality and morbidity in children. It is 2. Prevalence of drug abuse among children
currently a public health priority. Numerous adverse consequences
are linked to substance use by children, not least of which is the SA is mostly initiated between 15 and 17 years of age, but can
increased risk of dependence among those who began smoking, begin as early as the age of 10 years [3]. Most research suggests
drinking, and using substances before 18 years of age. Further- that early (12–14 years old) to late (15–17 years old) adolescence is
more, most adults with substance use disorder (SUD) initiated use a critical period for the initiation of substance use and that it may
during childhood [4]. The present work aims to outline these peak among young people aged 18–25 years [6].
issues. The onset of substance use among preparatory and secondary
Most countries define child as someone who is younger than students from Assiut Governorate in Egypt (n = 5476) was reported
18 years [5]. The population in many parts of the world is relatively to be 61% in the 10–15-year-old group, followed by 31% among
young. In 2016, more than 26% of the global population was aged those 15–19 years old, and 8% among children younger than
0–14 years and 16% was aged 15–24 years [6]. 10 years [8]. In 2013, another study was performed in eight
Egyptian governorates (n = 40,083), which showed that 29.3% of
the participants tried substances for the first time at the age of 16–
* Corresponding author at: Forensic Medicine and Clinical Toxicology Depart-
19 years, while 19.4% tried substances at the age of 8–15 years [9].
ment, Faculty of Medicine, Suez Canal University, Ismailia, Egypt. The most common substance use differs from country to
E-mail address: [email protected] (S.M. Aly). country depending on the social and economic environment.

https://doi.org/10.1016/j.arcped.2020.09.006
0929-693X/ C 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Please cite this article as: S.M. Aly, A. Omran, J.-M. Gaulier et al., Substance abuse among children, Archives de Pédiatrie, https://doi.org/
10.1016/j.arcped.2020.09.006
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Cannabis remains the most commonly used drug. With the cannabis use among those aged 15–24 showed an increase during
exception of tobacco and alcohol, cannabis is considered the most the same period [6].
commonly used drug among young people. Its use is typically In 2017, the national Egyptian survey of substance use reported
initiated in late adolescence and peaks in young adulthood. A the prevalence of substance use among secondary school students
global estimate by the UN is based on available data from (n = 5048 in 146 schools) in 13 governorates as being 12.8, 7.7, and
130 countries in 2016: 13.8 million young people (mostly 8.3% for smoking, psychoactive substances, and alcohol, respec-
students) aged 15–16 years used cannabis at least once in the tively. The minister revealed that 36% of persons who called the
previous 12 months. A high prevalence of cannabis use was hotline for consultation and seeking treatment were children
reported in West and Central Europe (20%) and North America (< 18 years old) during the first half of 2017 [19].
(18%) in 2016. A comparative study of substance use among Polysubstance use remains common among both recreational
university students (18–25 and older) in Bolivia, Colombia, and regular users. However, polysubstance use among young
Ecuador, and Peru in 2016 showed that cannabis was the most adults is linked to an increased risk of developing long-term
commonly used substance after alcohol and tobacco [6]. Cannabis problems and engaging in acute risk-taking through binge drinking
is often used with other substances and the use of other drugs is or binge use of stimulants such as ‘‘ecstasy’’ [20].
typically preceded by cannabis use [10,11]. Evidence collected in some countries shows examples of
Alcohol is the most commonly abused substance among youth combinations of substances typically used by young people. In
in the United States [12]. Although it is illegal for individuals under Europe, a wide variation in the patterns of polysubstance use
21 years of age to drink alcohol in the United States, people from among the population of drug users was reported, ranging from
12 to 20 years of age consume about one tenth (11%) of all alcohol occasional alcohol and cannabis use to the daily use of
consumed in that country. More than 90% of this alcohol is combinations of heroin, cocaine, alcohol, and benzodiazepines
consumed in the form of binge drinks [12]. In 2013 in the United [6]. In a Brazilian survey among students, cannabis, amphetami-
States, there were approximately 119,000 emergency room visits nes, inhalants, tranquillizers, and hallucinogens were the most
by persons aged 12–21 for injuries and other conditions linked to frequently used substances along with alcohol [21]. Cannabis,
alcohol [13]. cocaine, and ecstasy were the most commonly reported substances
The 2018 World Drug Report highlighted the critical challenge concurrently used among university students in Bolivia, Colombia,
related to the tramadol crisis in some countries in Africa and other Ecuador, and Peru in 2016 [6].
regions [6]. An Egyptian study that was carried out in Sharkia
Governorate in 2013 among preparatory and secondary school
students (n = 204) showed that the most common substance used 3. New psychoactive substances (NPS)
by students was tramadol (83.3%) [14]. This high prevalence of
tramadol use was supported by a previous Egyptian study (2010), The European Monitoring Center for Drugs and Drug Addiction
which reported 32.1% prevalence of tramadol use among children in 2015 reported approximately 560 NPS with almost 380 detected
and adolescents who presented to the Emergency Unit of the in the last 5 years only [22]. There are limitations regarding the
Poison Control Center of Ain Shams University Hospitals in Egypt prevalence data of NPS usage. The recent rapid proliferation and
for toxicological assessment [15]. diversity of NPS have made it difficult for surveys to keep up and
An Egyptian study performed in 2014 among preparatory and accurately reflect the use of new drugs [23]. Because of alterations
secondary school students (n = 5476) in Assiut Governorate in their molecular structure, they are usually not detected on
showed that cigarettes was the most common substance used commonly used drug screens. Moreover, pediatricians face a
(89.80%), followed by hashish (5.30%), beer and alcohol (1.80%), greater challenge because the clinical presentation in younger
and tramadol (1.50%) [8]. In 2013, another study reported that patients may be different than that reported for adults [22].
cannabis was the drug mostly misused in Egypt; alcohol was a In the United States, the most prevalent classes of NPS used are
distant second among the population aged 15+ in eight governo- synthetic cannabinoid receptor agonists (SCRA), synthetic cathi-
rates (n = 40,083) [9]. A study conducted in focus groups recruited nones (SC), and new synthetic opioids (NSO). An American survey
from two different Egyptian areas (Cairo and Alexandria) found found that, aside from alcohol and tobacco, SCRA are the third most
that smoking cigarettes and using hashish were the most common popular drug among 10th- and 12th- graders after marijuana and
practices, and that tramadol was the drug of choice reported by all. amphetamines, and the fourth most popular among 8th-graders
Inhalant misuse is also prevalent among early adolescents after marijuana, inhalants, and amphetamines. Nearly half of calls
[16]. Another small Egyptian study in 2011 was carried out in regarding SCRA (48.8%) between 2009 and 2012 involved patients
Menoufiya Governorate (n = 150) revealed the most prevalent aged 13–19 years. The number of emergency visits related to SCRA
substance of abuse was tobacco (15.3%) and cannabis (2%) [17]. increased from 11,406 in 2010 to 28,531 in 2011. More specifically,
The extent of drug use among young people remains higher emergency department visits involving teenagers aged 12–17
than that among older people [6]. Moreover, the use of substances years doubled (3780 visits in 2010, 7584 in 2011) and for patients
that have emerged more recently is reportedly much higher among aged 18–20 years they tripled (1881 in 2010, 8212 in 2011) within
young people. Most drug use and associated health consequences 1 year. Annual self-reported SC use by US adolescents has
are highest among young people [6]. The changing perceptions of remained fairly constant since 2012 at around 1% of 8th-, 10th-,
the risks associated with substance use and a debate around and 12th-graders. On the other hand, there are scarce data
substance legalization that in turn might have influenced their use available about the prevalence of NSO use [22].
and could explain the rise in substance use [6,18]. In the United Kingdom, 10% of individuals aged 15–24 years
It is important to report estimations of the annual prevalence in have tried NPS compared with 8% in Europe. According to a survey
order to assess changes in the extent of substance use. Between in England and Wales (2013–2014), the prevalent substances
2006 and 2016, data about the use of any substance in the United among 16–24-year-olds were generally the more traditional ones:
States showed no change in the prevalence rate among those aged cannabis (15.1%), cocaine (4.2%) and ecstasy (3.9%), and nitrous
12–17 [6]. The increase in past-year cannabis use among those oxide (7.6%) [23]. In the past few years, two popular NPS – known
aged 15–24 in Western Europe countries has been much less as Strox and Voodoo (SCAR) – have hit the Egyptian market
pronounced, and substance use seemed to be stable (or with [24]. Nevertheless, to our knowledge, there are no publications
minimal changes) during the 2005–2014 period. In France, available on the prevalence of NPS use among Egyptian children.

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Such estimations are of utmost importance as they give us production, trafficking to local-level dealing. The recruitment of
indication of the extent of these new dangerous substances. children for drug trafficking is preferred by organized crime groups
The use of NPS has grown rapidly over the past decade in for many reasons: first, the recklessness associated with younger
contrast to the prevalence rates for the use of internationally age groups, even when faced with the police; second, their
controlled drugs, which generally seem to have stabilized in the obedience; and third, drug traffickers perceive children as cheap,
same time period. Producing and marketing NPS holds the promise expendable, easily controlled, and often able to operate under the
of high profits without penalty in the case that these substances are police’s radar and to smuggle illegal substances across borders [6].
not covered by the respective country’s legislation [25]. The number of children younger than 16 years arrested on
suspicion of supplying drugs has been increasing in recent years in
various countries as well as in the United Kingdom. Data from over
4. Street children 40 countries show that about 3% of people arrested or cautioned for
possession of drugs in 2015 were aged under 18 [6].
There are two expected scenarios regarding the spectrum of Egyptian authorities have tried to eliminate drug dissemination
substance use among young people: (i) club drugs such as sources among children and have been performing routine
‘‘ecstasy’’, methamphetamine, and cocaine are common among investigations of school bus drivers in 103 schools in seven
rich children and (ii) inhalants among poor street children [26]. governorates since 2015. The prevalence of substance use among
The existence of street children is a global phenomenon with this group dropped from 12% in 2015 to 2.4% in 2017 [19].
considerable variation between high-, middle-, and low-income
countries regarding factors that drive children to the streets
[27]. Street children not only live, survive, and grow up in an unsafe 5. Pathways to SA and SUD
environment, but they also might be abused by local gangs or
criminal groups to engage in street crimes or sex work [6]. The The interplay of many factors may facilitate the vulnerability of
most commonly used substances among those living on the streets young people to substance use. These factors lie at the personal,
are likely to be inhalants, which include glue, paint, and correction micro (family, schools, and peers), and macro (socioeconomic and
fluid. These substances that induce rapid euphoria are usually physical environment) levels. This vulnerability is mainly deter-
abused because of their low price and availability. At the same mined by the presence of risk factors and the absence of protective
time, many street children are exposed to physical and sexual factors that make a difference in susceptibility to substance use.
abuse, and substance use is part of their coping mechanism in the Knowledge of the risk factors that determine whether users will
harsh street-life environment [26]. continue on a path to harmful use of substances is important to
Studies on substance use among street children in resource- better understand, predict, and properly intervene in these distinct
constrained settings reported that inhalants were the most etiological pathways. On the other hand, an abundance of positive
common substance used, putting lifetime prevalence of their experiences, such as protective factors, can strengthen the neural
use among street-involved children and youth at 47% [28]. While connections underlying self-regulation, impulse control, and
the use of inhalants was found in all regions, use of cocaine among executive decision-making [6].
street-involved children was reported mainly in South and Central It is of great importance to understand the biology of the
America, and alcohol use mostly in Africa as well as South and development of the neurological system. Brain development is
Central America [29]. The prevalence of use was higher among sensitive to psychosocial experiences. Such experiences affect the
those categorized as children of the street (i.e., homeless children), brain (developmentally and physiologically) and have a direct
compared with children on the street (i.e., children who have a impact on a child’s ability to self-regulate and on their
home but spend the day and most of the night on the street) susceptibility to substance use. Normal development during
[27,30]. adolescence is characterized by heightened levels of impulsivity
An Ukrainian study reported that 15% of the street children are and novelty-seeking, in part due to dramatic fluctuations in
substance injectors and 75% were sexually active [26]. In a study hormone levels that affect brain development and other systems.
from Pakistan, cannabis and glue were the most commonly used Mental health is also an effective element. Mood and anxiety
substance among street children (80% and 73%, respectively), while disorders double the risk of developing SUD [6].
9% smoked or sniffed heroin and 4% injected it [26]. In a Canadian The prefrontal cognitive regulation of subcortical regions is
study among street-involved youth, 43% of participants reported somewhat functionally disconnected throughout adolescence. This
injecting drugs, in particular methamphetamine, heroin, or cocaine translates into the natural tendency of adolescents to act on
[31]. A Brazilian study reported that more than half of the emotional stimuli, with little cognitive control [34]. In addition,
participants had been sexually active before the age of 12 with brain circuits, such as the ventral striatum, that are involved in
more than three sexual partners in the previous year [31]. processing rewards, show rapid maturation during the adolescent
Street children remain one of the most vulnerable and years, heightening sensitivity to rewarding experiences. This
stigmatized groups. They are exposed to abuse and violence, drug development may play a unique role in the initiation of substance
use, and other behaviors that put them at high risk of HIV and use in early to mid-adolescence [35].
tuberculosis infection. Despite these vulnerabilities, they are often Studies have demonstrated the associations between increasing
the most likely to be omitted from receiving any form of social or levels of emotional and physiological stress (poverty, child
healthcare support to correct their condition [32]. maltreatment, and divorce) and decreases in behavioral control
In addition to violence, abuse, and sexual activity with multiple with higher levels of impulsivity and maladaptive behaviors
partners, more than half (62%) of street children in a study from [36]. Stress exposures disrupt both the hormonal and the
Egypt (n = 857 from Cairo and Alexandria governorates) had used physiological systems that regulate cognitive and behavioral
drugs, while only 3% reported current use of injecting drugs. Over functions, impairing learning, memory, decision-making, and
one-third (35%) reported alcohol consumption, and this was more other functions that normally support the self-regulation of
common among males than females [33]. behavior [37]. These biological stress responses activate the same
Young people may be involved in the drug supply chain. They neural systems that underlie the positive reinforcing effects of
may be recruited by organized crime groups and coerced into drugs [38]. Adverse experiences, especially in early life, have the
working in the drug supply chain starting from cultivation, potential to modify gene expression or suppression. Ongoing

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environmental change can further modify epigenetic processes three-dimensional healthy lifestyle pyramids already includes
(the interaction between genes and the environment), either for non-smoking as well as non-alcohol and non-drug consumption
better or worse [39]. as a requirement for the acquisition of healthy habits at young
Regarding micro-level factors that may vary across cultures ages [4].
such as parent, family, and peer influences, an Egyptian study in In addition to legislations, the success of prevention can be
2011 confirmed that bad relationships between children and their achieved by correcting misconceptions through health education
families, conflicts between family members, and physical abuse by and workshops. One of the misconception was mentioned in the
a family member are significantly higher among children with SA. 2018 World Drug Report, that all young people are equally
Moreover, peers have a significant role in SA [17]. vulnerable to substance use because of their ignorance of the
Another Egyptian study (2012) was conducted with focus scientific evidence about SA [6]. In this context, the Egyptian
groups aged 12–14 years and 15–18 years. The respondents authority established a health education program among students
reported that peer pressure from friends stood out as the most to correct misconceptions about substance use. This program is
common reason to start and to continue using substances, aimed at increasing awareness among 2 million young persons in
followed by adverse life events and having a parent or family educational and youth institutes in Egypt [19].
member who used substances. Strict parenting, religious influen- In regard to substance use, research in Arab countries was
ces, having non-user friends, and living in good neighbourhoods assessed in 2014: It was found that research in this field was
were among the reasons perceived by youth as preventing them largely neglected [44]. Therefore, it is recommended to set up
from using substances or helping them to quit substance use [16]. governmental funding with a main goal. Indeed, advanced
understanding of the biology of addiction involves the translation
of this knowledge into improved prevention, treatment, and policy
6. Consequences of SA
strategies. As an example, the use of instructions derived from
cognitive behavioral therapies for addiction in adult tobacco
One of the goals of prevention programs is to increase
smokers has been shown to increase connectivity between
awareness in society regarding consequences of SA. Usually,
prefrontal cortical regions implicated in behavioral control and
chronic use of substances is associated with deficits in domains
subcortical regions implicated in cravings [45]. This proves the
including physical health, cognitive functioning, educational
importance of basic research in support and aiding practical work,
achievement, and psychology. It also involves overall impairment
especially prevention.
in social competencies and relationships [40]. Physical health
The American Academy of Pediatrics (AAP) has highlighted the
problems experienced by young drug users include an increased
importance of the role of pediatricians regarding the prevention of
risk of overdose, accidental injury such as motor car accidents or
SA and the diagnosis and management of problems related to SA.
falls, and attempted suicide.
Pediatricians should include discussion of SA as part of routine
Especially in the case of drug abuse among children, regular
healthcare, starting with the prenatal visit. They should incorpo-
substance use can affect growth and development and profoundly
rate SA prevention into daily practice, acquire the skills necessary
compromise their neurodevelopment. Substance-induced altera-
to identify young people at risk for SA, and provide assessment,
tions affect mainly memory, attention, and executive functions
intervention, and treatment as necessary [46].
[41]. The use of multiple substances confers greater health risks
The AAP recommends a ban on all tobacco advertising in all
and negative consequences, as well as poorer outcomes.
media, limitations on alcohol advertising, avoiding exposure of
Medical research shows that those who use cannabis before the
young children to substance-related (tobacco, alcohol, prescription
age of 16 face the risk of acute harm and increased susceptibility to
drugs, illegal drugs) content on television and in movies,
developing SUD (1:6 of those who initiate substance use in
incorporating the topic of advertising and media into all SA
adolescence develop cannabis use disorders) and mental health
prevention programs, and implementing media education pro-
disorders including personality disorders, anxiety, and depression
grams in the classroom [47]. The same was noted in relation to
[10,11]. The prevalence of SUD among preparatory and secondary
tramadol: The unplanned indirect media advertising of tramadol
school students in Assiut Governorate in Egypt (n = 5476) was
abuse through movies and television series also played a
22.9%. The prevalence of abuse/dependence was 28.50%, with
significant role in promoting tramadol abuse [15]. A national
occasional and recreational use of drugs being higher (34.63%) than
survey in Egypt in 2017 of substance use found that 72% of students
regular use (27.15%). The prevalence of SUD in the group aged 12–
got their knowledge from media and television series. Therefore,
16 years was 50%, while in group aged > 19 years it was 49.68%
the ministry of social insurance in Egypt introduced financial
[14].
penalties in such cases [19].
Death as a result of substance use is the extreme outcome.
Reducing substance uses require community-based efforts to
Globally, deaths directly caused by substance use increased by 60%
monitor the activities of youth and decrease access of youth to such
from 2000 to 2015 [6]. Excessive drinking is responsible for over
substances. Many strategies for the prevention of underage
4300 deaths per year among underage youth in the United States
drinking were suggested as an example, such as enforcement of
[42]. Deaths resulting from SUD account for a higher proportion of
minimum drinking age laws, national media campaigns targeting
mortality among younger people including children, with almost
youth and adults, increasing alcohol excise taxes, reducing youth
one quarter (23%) of deaths among those aged 15–29 years, mostly
exposure to alcohol advertising, and development of comprehen-
related to opioid use. Europe followed by the Americas rank in the
sive community-based programs [13].
top two for recorded deaths among different age groups, including
children. Deaths resulting from SUD account for a higher
proportion of mortality among males than females (2/1) aged
8. Conclusion
15–29 years [6].
This review article of SA among children highlights important
7. Current preventive intervention for the pediatric population related issues to help identify this significant problem and
recognize the associated threats. These threats affect not only
Contributions to the emergence of SA in the pediatric the youth but also the community as a whole, especially with the
population are multifactorial [43]. A suggested proposal for rapid development of NPS. In conclusion, SA is a complex challenge

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