A STUDY ON DRUG ABUSE AMONG YOUTHS AND FAMILY RELATIONSHIP 青年濫藥與家庭關係的研究

THE FINAL REPORT (FINAL version) February 2011

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PREFACE
The project on the study on “DRUG ABUSE AMONG YOUTHS AND FAMILY RELATIONSHIP” (“the Study”) is being undertaken by the Centre for Suicide Research and Prevention and the Department of Social Work and Social Administration at the University of Hong Kong (“the Consultant”).

The research team comprises the principal investigator (PI), Professor Paul YIP, Director of the Centre for Suicide Research and Prevention and Professor of the Department of Social Work and Social Administration at the University of Hong Kong, and eight co-investigators (Co-Is), Dr. CHEUNG Siu Lan Karen (Demographer), Dr. Sandra Tsang (Social and Family Worker), Dr. Samson Tse (Focus group expert on mental health and drug abuse), Dr. Wong Oi Ling (Family therapist, Family Institute), Prof. Karen Laidler (Sociologist, expertise on assessing drug abuse problem), Dr. Paul Wong (Clinical psychologist), Ms. Frances Law (Social Worker), and Dr. Lilian Wong (Associate Consultant, Department of Pediatrics and Adolescent Medicine, Tseung Kwan O Hospital, Hospital Authority). We would like to thank Mr. Gary Ip, the research assistant of the Department of Social Work and Social Administration, Ms. Garlum Lau, the senior research officer

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of the Department of Sociology, the participants and NGOs for focus groups and case studies for their kind and valuable support on this project without which the completion of this study would not have been possible.

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TABLE OF CONTENTS
PREFACE ......................................................................................................................... 2 TABLE OF CONTENTS...................................................................................................... 4 EXECUTIVE SUMMARY ................................................................................................... 6 報告摘要...................................................................................................................... 12 LIST OF FIGURES ........................................................................................................... 17 LIST OF TABLES ............................................................................................................. 18 LIST OF APPENDICS ...................................................................................................... 19 CHAPTER 1: INTRODUCTION ....................................................................................... 20 CHAPTER 2: LITERATURE ON DRUG ABUSE ................................................................. 28 2.1 Drug-use situation among youth in Hong Kong............................................. 28 2.2 Theoretical framework .................................................................................. 50 2.3 Countries Analysis .......................................................................................... 95 2.4 Key Issues and the way forward .................................................................. 167 CHAPTER 3: SECONDARY DATA ANALYSIS ............................................................... 173 3.1 Overview & Data ......................................................................................... 173 3.2 Descriptive analysis ..................................................................................... 175 3.3 Statistical methods...................................................................................... 175 3.4 Framework of the study: Proposed pathways between family quality and drug use ...................................................................................................... 190 3.5 Research questions ..................................................................................... 194 3.6 Hypothesis................................................................................................... 196 3.7 Statistical methods...................................................................................... 198 3.8 Mediation analysis ...................................................................................... 203 3.9 Conclusion ................................................................................................... 208 CHAPTER 4: QUALITATIVE STUDY - FOCUS GROUPS................................................ 211 4.1 Background .................................................................................................. 211 4.2 Methodology................................................................................................ 212 4.3 Results .......................................................................................................... 218 4.4 Discussion and recommendation ................................................................ 231 4.5 Conclusion and recommendation ................................................................ 256 CHAPTER 5: IN DEPTH CASE STUDIES OF YOUTHS WHO DO NOT MATCH A DIAGNOSIS OF SUBSTANCE –RELATED DISORDER ..................................................... 260 5.1 Background ................................................................................................. 260 5.2 Methodology................................................................................................ 263 5.3 Analysis ........................................................................................................ 265 4

5.4 Results .......................................................................................................... 265 5.5 Discussion .................................................................................................... 280 5.6 Recommendation......................................................................................... 284 CHAPTER 6: CONCLUSIONS AND POLICY RECOMMENDATIONS ............................. 288 REFERENCES ............................................................................................................... 297

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EXECUTIVE SUMMARY
(1) Based on the extensive literature review on family role in helping teen drug abusers with a family perspective and the comparisons with the results and evidence of the local and overseas studies and Eastern and Western practices dealing with teen drug addictions, this final report makes policy

recommendations with regard to the key findings from the secondary data analysis, the focus groups and the case studies. (2) Some previous studies show that the overall trend of lifetime drug-taking secondary students rose from 3.3% in 2004/05 to 4.3% in 2008/09. The age of students starting to take drugs has become younger: for those aged 12 or below, there was a close to double increase in drug prevalence of 2.4% in 2004/05 to 4.6% in 2008/09. Among this group of students, 7.7% did not live with either of the parents, compared to 2.5% for their non-drug-using counterparts. From the experiences of front-line social workers and research studies, Hong Kong experiences the process of “normalization” of drug use, especially among marginal youth. The major problem is that they do not consider themselves as having problems or in need of help. (3) Chapter 2 summarizes overseas experiences, including Western countries such as Australia, Canada, the U.K., and the U.S. and Asian countries such as Taiwan, Mainland China and Singapore. In those Western countries, there are several initiatives to deal with drug taking and prevention: (i) identifying and reducing the risk factors related to youth substance use; (ii) enhancing protective factors and strengthening the family functioning and attached bonding, maintaining effective communications and harmonized relationships with adults through 6

family-based intervention like parental or family training, provision of nationwide meaningful youth engagement; (iii) addressing the needs of not only the adolescent themselves, but also the young adults, their families and the broader community; (iv) acknowledging the importance of supporting parents and the families to build healthy families at an early stage so that children and youth can benefit from growing up in a positive environment, thereby naturally building resistance against delinquent behaviors; (v) collaborating with different stakeholders (e.g. NGOs and government) to assist at-risk families, so as to

minimize drug and other social problems being spread inter-generationally (especially in the U.K. and Australia); (vi) mobilizing different sectors of the community to address the drug issue (especially in the U.S.); and (vii) emphasizing youth-focused community prevention initiatives involving different partners (especially in Canada). However, in Asian countries, such as Taiwan, Mainland China and Singapore: more emphasis on information dissemination, school drug education and law enforcement are placed. Little is to do with risk and protective factors or the ecological framework of drug use. (4) Chapter 3 shows that use of psychotropic substance has become more prevalent among boys in older adolescents (Form 3-7) than for younger adolescents (Form 1-2), and exceed the prevalence of using inhalant. There is about 5% prevalence of drug abuse among our youth of aged 15-24. The drug prevalence for working young adults soars up to 14% for males and 9% for females. The drug abusers have similar risk profiles with other deviant behaviors, e.g. deliberate self-harm, smoking and drinking. From the study of odds ratios of logistic regression models, there is a significant association between family structure and drug abuse among boys. The adjusted odds ratios showed that, compared to those who have 7

married parents, boys whose either or both parents has passed away were more likely to be drug users (OR=4.633, CI=2.294, 9.355), whereas girls whose parents were divorced or separated were more likely to be drug users (OR=2.367, CI=1.178, 4.759). Parents’ divorce, separation or passing away has a high influence on substance abuse among adolescents. Feeling happy about family life, good relationship with parents and acceptance to parenting are significant protective factors to substance abuse. (5) In Chapter 4, the results of focus groups show that there are four themes. First, young people’s initial drug use must be understood in the context and primacy of their peers. Second, both young people and their children recognize the lack of communication in the family as one of the risk factors, and want to develop the ability to have meaningful interactions. Third, youth and their family relationships are heavily shaped by parents’ work and other commitments in a culture which is perceived to place heavy emphasis on materialism. This can add further pressure on parents and their children. Fourth, at the community and education levels, young people tend to thrive in an environment of creativity. (6) Based on the four in-depth case studies as presented in Chapter 5, a number of risk and protective factors around five themes have been identified: including 1) family crisis; 2) attachment to family members; 3) factors attributable to drug use; 4) factors conducive to drug withdrawal; and 5) issues in tacking drug use. Youths seem to share a very similar pattern of taking drug and other deviant behaviors. These youths started to experiment with drugs after the occurrence of a family crisis (i.e., presence of parent’s physical illness, parents’ relationship problems) which strongly weakens the parental monitoring and family system. The results reveal a common pathway of marginal youths taking drug when they possessed 8

less family and school social capital, suffered from more educational disadvantages and failures, and had involvement with drug-taking peers. However, with the help of the attached parent(s) or significant others and efforts from professionals, the four cases demonstrated that they were able to stop using drugs. More importantly, the non-psychiatric medical services have helped the drug-taking youths have a better understanding of the physical harmfulness of drug use on them. They have also provided a platform for multi-disciplinary effort in dealing with recreational drug-taking youths who have yet to develop substance-use disorders that require psychiatric service. (7) In short, a common trajectory of the youths taking drug is ascertained in this study. Drug use like other adolescent behavioral issues involves a number of factors, some of which interact or operate jointly. Firstly, most of them are heavily affected by dysfunction families due to unstable family condition (e.g. poor marital relationship, family crisis, divorce, single-parent family), low income and long working hours of family members (e.g. limited family time, little attention to young people, poor attachment with parents/significant others), poor/ineffective communication between youth and his/her family (e.g. inadequate/poor parenting and bad relationship with parents). Secondly, easy access to drugs within immediate neighborhood (e.g. convenient supply and relatively cheap cost) increases the exposure of risk to drug. Thirdly, failure of school achievement, feeling boredom and affected by undesirable peer influence and intergenerational addiction are also the major risk factors. (8) Given the evidence and findings from this study, a public health approach with a multi-layered intervention is therefore recommended to empower family. Efforts on preventions and interventions should be made to enhance protective factors 9

through family-based intervention like parental or family training, provision of community-wide meaningful youth engagement, and reduce risk factors, instead of focusing on the drug issue per se and individual. The target would not only cover among the school youths, but also drop-out, unemployed or working youngsters. FOUR themes should be included youth-centered (for, with, and by the youth); family-focused (equal-finality proposition); neighborhood and community-sensitive (ecological, public health, social development, broken window (early intervention); cultural/contextual); and government-led (topdown directives especially for cross-departmental collaborations) approach focusing on transitional periods and developmental stages. Specific

recommendations should be included: (i) to identify and support high risk families: single-parent, inter-generational addictions (drug/gambling/drinking), poorer social economic status (e.g. receiving CSSA), having frequent family crises involving school-age children, out of school youths and working youths through the cooperation of different sectors of the community (i.e. outreach social workers, non-clinical & clinical professionals, teachers and schools, police, etc.) and link with referral of family services (e.g. in-home family support); (ii) to nurture positive family relationship: a family-friendly working environment should be promoted and reinforced in Hong Kong; (iii) to enhance community involvement: especially for poorer household income and at-risk districts.; (iv) to curb drug sources covering a wider range: such as random drug tests at the border between Mainland and Hong Kong to handle cross-border drug and liaison with the Mainland authority in making it more difficult for young people to get hold of the drug rather than just imposing drug tests at school; (v) to extend more professional trainings: which include to develop a manual to work 10

with children and parents in dysfunctional families, provide more trainings, seminars and workshops for identifying at-risk families and suggesting measures to strengthen family protective factors that can be held at the district level and school-based with the support of the parent association in the school; family and school social workers as trusted professionals in the neighborhood and in the workplace to provide family parenting education and early identification and to help family recover the resiliency of family function; (vi) to provide more efficient anti-drug programs: it is necessary to examine how different existing programs modify the youth’s drug-related attitude and behavior in the long run; (vii) to reform the mindset in the educational system: such as making school curriculum more attractive and developing interactive joint parental activities and to reinforce the importance of family values which can help the youths become a full competent, self-regulated and caring person. Incentives such as scholarships can be awarded to the students who might not perform well in academic, but in other domains such as sports and arts; (viii) to disseminate credible anti-drug and family-harmonized environment messages/slogans: youth-respite and drugfree and family-harmonized ambassadors should be appointed through public events to establish a positive idol to the youngsters and enhance parental relationship.

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報告摘要
(1) 這份報告書的政策建議是根據廣泛的文獻回顧、數據分析、焦點小組和 個案研究的結果所提出。並從家庭觀點上，綜合中西方在實踐處理青少 年濫用毒品成癮的結果和證據中找出家庭角色如何能幫助濫用毒品的青 少年。

(2) 從過往的研究顯示，中學生曾經濫用毒品的趨勢由 2004/05 年度的 3.3％ 上升至 2008/09 年度的 4.3％。濫用毒品的年齡更有年輕化的跡象；對於 12 歲或以下的學童，比率由同時期的 2.4％大幅增加至 4.6％，上升接近 一倍。這群濫用毒品的學生當中有 7.7％並非與父母同住，相比沒有濫用 毒品的學生祇有 2.5％為高。根據前線社工的經驗和調查結果，香港正經 歷濫用毒品「正常化」的問題，特別是對於邊緣青年，關鍵是他們不認 為自己有問題或需要幫助。

(3) 第二節綜合外國的經驗，包括西方國家如澳大利亞、加拿大、英國、美 國，及亞洲國家如台灣、中國大陸和新加坡。在這些西方國家中，已有 數項措施以應付及預防濫用毒品： （一）先找出和減少有關青年使用毒品 的風險因素； （二）加強保護因素和強化家庭關係及保持家庭成員之間有 效的溝通與和諧的關係，並通過以家庭為基礎的干預，如父母或家庭培 訓及提供更全面性和有意義的活動供青少年參與;（三）在處理這些濫用 毒品的問題時，不僅針對青少年本身的需要，還有他們的家庭及整個社 會;（四）確立支援家長及家庭的重要性，協助建立一個健康家庭，讓兒 童和青年在早期階段中能夠在一個積極的環境中成長，從而自然地抵抗 偏離的行為;（五）與不同的服務機構平台（如非牟利機構和政府）合 12

作，協助有問題的家庭，使濫用毒品和其他社會問題跨代傳播的風險降 至最低（參考如在英國和澳大利亞）;（六）動員社會各界人士來解決毒 品問題（參考如在美國）和（七）以青年為重點，與不同的夥伴合作的 制定社區預防措施（參考如在加拿大） 。但是，在亞洲國家，如台灣、中 國大陸及新加坡：則强調資料信息的傳播，特別集中加强在學校禁毒教 育和執法上的位置。對於利用風險和保護因素或是從社會生態學角度上 所做的工作仍然很少。

(4) 第三節顯示年紀較大並就讀中三至中七的男學生比就讀中一至中二的更 為普遍使用精神科藥物，這情況比使用吸入式的更為嚴重。在 15-24 歲 的青年中，濫用毒品的比率約為 5％。在職青年的的比率更飆升至男性 為 14％及女性為 9％。濫用毒品與其他偏差行為 (如蓄意自我傷害、吸煙 和酗酒) 都擁有類似的風險特徵。從羅吉斯的迴歸勝算比法中，家庭結構 與濫用毒品在男性中有顯著的關係。調整後的數值顯示，假若男孩的其 中一名或雙親已過世，他更有可能使用毒品（OR = 4.633，CI 為 2.294， 9.355） ；另一方面，假若女孩的父母已離婚或分居，她使用毒品的風險 亦相對增加（OR = 2.367，CI 為 1.178，4.759） 。父母離婚、分居或離世 均明顯地影響青少年濫用毒品。對家庭生活感到快樂、與父母有良好的 關係及接受父母的教導都是防止濫用毒品的保護因素。

(5) 在第四節中，聚焦小組結果顯示四個主題。首先，要了解年青人初次吸 毒必須從其背景和朋輩著手。第二，無論是兒童或年青人都認為缺乏家 庭溝通是其中一種風險因素，他們亦希望能在家庭中發展有意義的互動 交流。第三，青年與家庭的關係大部分受父母的工作和社會文化中「唯 物主義」所塑造，這樣會加重父母與子女間相處的壓力。第四，在社區 和教育層面上，年青人較希望能在富創造力的環境中成長。 13

(6) 在第五節中，根據四個深入的個案研究，分別找出一些風險和保護因素 並圍繞著五個主題：包括，一）家庭危機 ; 二）與家庭成員之間的情感; 三）導致使用毒品的因素 ; 四）停止使用毒品的因素 ; 及五）打撃使用毒 品的問題。在使用毒品及其他偏離的行為，青年似乎有著非常類似的模 式。這些青少年在經歷家庭危機後便開始嘗試毒品（如父母患病或父母 之間出現問題） ，這些情況強烈地削弱了父母的管教和家庭制度。研究結 果顯示，邊緣青少年吸毒都擁有一個共同模式，就是當他們在家庭及學 校獲得較少的資源、並在學業上觸礁和失敗、以及受周圍朋輩吸毒所影 響。可是，隨著父母或其他重要人物和專業人士的努力和幫助，他們亦 能夠停止使用毒品。最重要是，非精神科的醫療服務能幫助吸毒青年更 了解毒品對他們身體上的損害。這些服務還提供了一個平台作多方面的 接觸，處理一些吸毒情況未致於需要精神科服務及視毒品為「娛樂性 質」的青年。

(7) 總括而言，這項研究確定了青少年濫用毒品擁有一個共同軌跡。他們使 用毒品就如其他偏離行為問題一樣涉及多種因素，而這些因素亦彼此互 動及相連的。首先，大多數的因素是由於不穩定的家庭狀況影響，以致 喪失家庭功能（如父母關係變差、家庭危機、離婚及單親家庭） ，家庭成 員工作時間長或低收入（如缺乏家人相聚的時間、較少時間注意青少 年、與父母或重要人物有惡劣的關係） ，青年與他/她的家庭之間缺乏有 效的溝通（如管教不足及不善或與父母有惡劣的關係） 。其次，一個容易 獲得毒品的鄰舍（如方便供應和相對低廉的成本）亦增加使用毒品的風 險。第三，在學習上的失敗，感到厭倦和受不良朋輩影響及隔代毒癮也 是主要風險因素。

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(8) 根據這項研究的證據和調查結果，我們建議應該以家庭為基礎，並使用 公共健康的模式與多層次的干預。在防治和干預上應加強保護因素和降 低危險因素，如提供父母或家庭培訓，增加全體性及有意義的青年參與 行動；而不是只集中在個人或濫毒者身上。我們的目標不僅包括在學的 青少年；還有輟學、失業或在職的青年。四個主題包括以青年為核心 青年為核心 （給他們、與他們、並由他們的角度出發） ，以家庭為重點 家庭為重點（如平等及阻 家庭為重點 截性的建議） 針對鄰舍及社區 、針對鄰舍及社區 針對鄰舍及社區（如生態上、公共衛生、社會發展、破窗 理論（及早干預） 、文化及背景）和政府主導 政府主導（由上而下的指示，並進行 政府主導 跨部門的合作）的方式，並將焦點集中在過渡時期和成長階段。具體建 議應包括： （一）透過社會各界人士的合作 透過社會各界人士的合作（如外展社工、非臨床及臨床 專業人員、教師和學校、警察等）和轉介家庭服務 和轉介家庭服務（例如家庭探訪支 和轉介家庭服務 援）找出和支援一些高風險家庭 找出和支援一些高風險家庭：如單親，隔代成癮（毒品／賭博／酗 找出和支援一些高風險家庭 酒） ，經濟能力較差（如領取綜援人士） ，頻密發生家庭危機的學齡兒 童、輟學及在職青年； （二）培養正面的家庭關係 培養正面的家庭關係：應促進和加強一個友 培養正面的家庭關係 善家庭的工作環境； （三）加強社區參與 加強社區參與：特別是針對幫助貧困和低收入 加強社區參與 的家庭及高危的地區； （四）擴大毒品來源的涵蓋範圍 擴大毒品來源的涵蓋範圍 擴大毒品來源的涵蓋範圍：如在內地與香港 邊境之間作隨機驗毒，並聯繫內地當局及有關部門以處理跨境毒品，令 青少年更難得到毒品；而不是僅僅在學校實施驗毒計劃； （五）延長更專 延長更專 業的培訓：當中包括制定一本家庭手冊，或為高風險的家庭提供更多的 業的培訓 培訓、研討會和講習班，用以加強家庭保護因素；並以地區層面和學校 為基礎，透過家長會的支持，家人和駐校社工分別擔當在鄰舍和工作單 位中可信任的專業人士，目的是提供家庭教導孩子的教育、識別濫用毒 品的知識及幫助家庭重新恢復家庭功能； （六）提供更有效的禁毒計劃 提供更有效的禁毒計劃： 提供更有效的禁毒計劃 必須評估現階段不同研究計劃中青少年對毒品的態度和行為上的長遠影 響； （七）改革教育思維 改革教育思維 改革教育思維：如使學校的課程更具吸引力及發展和父母共同 15

參與互動的活動，以致力加強對家庭價值觀的重要性，從而幫助青少年 成為一個完整，自我調節和關懷他人的人。並可設置獎學金獎勵一些雖 在學業上不太理想，但在其他領域，如體育和藝術表現出色的學生；及 （八）傳播有公信力的反濫用毒品及強化和諧家庭的信息或標語 : 甚至 傳播有公信力的反濫用毒品及強化和諧家庭的信息或標語 傳播有公信力的反濫用毒品 推舉以青少年為主的無毒大使及和諧家庭大使，從而透過一些公眾活動 對青少年建立一個正面的形象及強化青年與父母之間的關係。

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LIST OF FIGURES
Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Number of reported substance abusers under aged 21 from 1997 – 2010 1st Quarter Percentage of youth drug use in U.K., U.S., Canada, and Hong Kong (note variation in age groupings across countries) Bronfenbrenner’s ecological systems theory The Public Health Model Building Protection: The Social Development Theory The Building Blocks of Family Pathfinders SAMHSA’s Strategic Prevention Framework Procedures for mediation analysis Path diagram (A) Path diagram (B) Path diagram (C)(for boys only) Character categorization of 4 case studies 30 32 52 58 66 106 120 200 208 208 208 265

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LIST OF TABLES
Table 1 Table 2 Table 3 Table 4 Table 4.1 Table 5 Table 5.1 Table 6 Table 6.1 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Overview of the frequency, type of drugs used, and location of drug use by group in 2008/09. Risk factors of adolescent problem behavior Prevalence of psychotropic substance and inhalant use among in-school respondents Cross tabulation of family antecedents and substances use among Form 3 to 7 respondents (both sexes) Mean score for scales for both sexes Cross tabulation of family antecedents and substances use among Form 3 to 7 boys Mean score for scales for boys Cross tabulation of family antecedents and substances use among Form 3 to 7 girls Mean score for scales for girls Prevalence of psychotropic substance and inhalant use among young adult respondents Cross tabulation of family antecedents and substances use among out-school respondents (both sexes) Cross tabulation of family antecedents and substances use among out-school male respondents Cross tabulation of family antecedents and substances use among out-school female respondents Univariate odds ratios of regular drinking, regular smoking and ever drug use from multiple logistic regressions Interaction effect between variables in Female. Mediation models 1. Results from the mediation analysis through multiple logistic regressions (All respondents) Mediation models 3. Results from the mediation analysis through multiple logistic regressions (All respondents were boys) Univariate odds ratios of regular drinking, regular smoking and ever drug use from multiple logistic regressions Focus group: Summary of focus group participants Research rigor in phase II study Changes in Satisfaction score on family relationship before and after receiving treatment service, Regular Teen Users Socio-demographic Background 31 64 178 179 180 182 183 185 186 187 188 189 190 202 203 206 207

Table 15 Table 16 Table 17 Table 18 Table 19

211 216 218 243 268

18

LIST OF APPENDICS
Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Major anti-drug websites Anti-drug initiatives in major countries 322 324

The distribution of drinking and smoking habits behaviors 328 in group 1 participants in focus group The distribution of drinking and smoking habits behaviors 332 in group 2 participants in focus group General guidelines: Key topics for discussion 335 Details of the pilot project Youth and/or family interview questions Involved clinicians/professionals interview questions 337 339 342

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CHAPTER 1: INTRODUCTION
Introduction
This project on the study of “drug abuse among youths and family relationship” (“the Study”) is being undertaken by a multidisciplinary team consisting of public health researchers, medical doctors, psychologist, and social worker, starting from 7 May 2010. The Principal Investigator, Professor Paul S F Yip is in the Centre for Suicide Research and Prevention at the University of Hong Kong. The ethical approval has been sought on 11 May 2010 and approved by the Human Research Ethics Committee for Non-Clinical Faculties (Reference No. EA380410).

Research Aims
This study aims to examine the underlying causes of the youth drug abusers and how they are related in his/her family and to identify problems and needs that young drug abusers are facing. The emphasis would be in understanding how to empower the family’s role for prevention of drug abuse in the community. Specific and evidence-based policy recommendations are expected.

20

Themes and Research Questions
This study focuses on a community based sample of youngsters aged 12-34 (involving different age developmental stages). FOUR MAJOR THEMES AND RESEACH QUESTIONS are investigated in the project: 1. Family antecedent of youth drug abusers – the forerunning family background of youth drug abusers will be juxtaposed. Research questions are developed in terms of family composition and structure e.g. whether the teen drug abusers have a broken family with a single-parent or not and whether only living with grandparents and relatives are more likely to hazard to take drugs. A combination of different family composition is taken into consideration as in the following matrix, (i) a completed family currently living with father and mother with siblings, such as brothers and/or sisters; (ii) a completed family currently living with father and mother without siblings, such as a single child in family; (iii) a single parent family currently living with either father or mother with siblings, such as brothers and/or sisters; (iv) a single parent family currently living with either father or mother without siblings, such as brothers and/or sisters; and (v) no parent family currently only living with grandparents and relatives with or without siblings. Step-father, step-mother and step-siblings are also taken into account as the divorce rate has been rising in Hong Kong over time. Family members’ socio-economic and demographic backgrounds are 21

also of prime importance in the study. The characteristics of family members including the level of educational attainment, the occupation of their parents, the length of work of their parents, income and financial situation, the place of residence, the type of housing, social class (i.e. whether CSSA family recipient), culture diversity (such as whether one of the parents (i.e. mother) coming from Mainland China in Hong Kong less than 1 year and whether the mother is still staying in Mainland China) etc. will be investigated. 2. Family members’ reactions to youth drug abusers – youth drug abuse affects the family unit. Family members’ reactions could also affect the decision of youth drug abusers. The discovery of proof of drug abuse may be devastating and making a familial relationship greatly deteriorated. Youngsters could become more hostile if they are not positively supported by the family. They could find themselves using drugs as escapist. Youth drug abusers’ interactions within family and family members’ reactions are essential to understand the mechanisms behind why some youth drug abusers have fallen prey to drugs. This aspect is also related to whether the youth drug abusers would be able to successfully get rid of the drugs. Reactions can widely cover on different aspects, such as verbal/linguistic responses and skills of communication which can be negative or positive, time dedication and understanding (i.e. how often and long parents and/or family members speak and 22

interact with the youth drug users), patience, realization and taking immediate actions (i.e. whether and/or when the parents discover or realize their child(ren) who have been involved with drug abuse and whether any immediate actions have been taken such as seeking professional advice and assistance from social workers from the community or at school). In this regard, the research question is to examine whether those adolescents with poor family relationship and interactions are more prone to be drug abusers. 3. How the family can cope and help the youth drug abusers – it is a proactive and multi-directional process between not only the youth drug abusers and the family members, but also clinical professionals (such as medical doctors and clinical psychologists) and non-clinical professionals (such as social workers and teachers) and peers and classmates. The process sets off from (i) a stage one - “realization of the facts” by a parent or other professionals (revealed the evidence that a teen is a drug addict that could be grouped into different extents such as causally/ recreationally abused, progressively used and severely addicted. The last refers to the occurrence of the psychiatric illusions and physical impairments; (ii) the family involvement – the addicted teen probably also hurts for transgressions. Learn and listen what the family members such as parents cope with this problem and whether they have any difficulty in accessing the trained addiction specialists to their 23

addicted child(ren) and themselves are one of the focuses in the study; and (iii) family and peers conjunction – the youth drug abusers could be affected by their peers group. The linkage between the family members and the peer groups reflects the familial relationship and how much the parents know the world of teen drug abusers. Questions are posed such as do the parents know with whom their teen addicted child(ren) is/are acquainted? How many? And how often they meet each other and where? Where did the parents seek help? Can the family relationship be improved after the treatment services? 4. Specific measures and recommendations will be given to the Family Council based on the results of the study.

Methodology and plan
This study is organized in two Phases (Phases I and II). Each part of the work is led by one Co-I and other team members and presented in each chapter individually. In PHASE I 1. An extensive and thorough literature review on family role in helping teen drug abusers – with a family perspective – review including the results and evidence of the local and overseas studies and Eastern and Western practices dealing with 24

teen drug addictions is being led by Dr. Sandra Tsang with the help of Miss Erica Tong. The literature review covers three major areas: (1)the trends and statistics in Hong Kong; (2) overarching framework of understanding the youth drug issues problem, and studies that utilize this framework; and (3) current practices and intervention strategies from seven countries (i.e. Australia, Canada, PRC, Taiwan, Singapore, the U.K. and the U.S.A.) on how to prevent youth drug use. The literature review is presented in Chapter 2. 2. For the secondary data analysis – to examine the prevalence of drug/substance abuses collaborated by the Centre, the Family Planning Association and Hospital Authority which is being led by Prof. Paul Yip and Dr. Karen Cheung with the help of Mr. Derek Cheung. Based on the Youth Sexuality Study (The Family Planning Association 2006), the longest running community-based sexuality survey in Hong Kong, we estimate the prevalence of substance use including alcohol, cigarettes, inhalants and psychotropic substances among Hong Kong in-school adolescents and young adults (aged 18-27) and examine how family relationship and qualities affect the likelihood of substance use. In the dataset, the participants of in-school survey were recruited from day schools through random sampling, while the young adults’ survey was conducted though random

25

household survey across the territory. The key findings of the secondary data analysis are shown in Chapter 3. In PHASE II 3. For the focus group – aims (i) to examine the underlying causes of young drug abusers and their relationship with family and assess the impact of drug using on the family as a whole and individually ; (ii) to identify risk and protective factors of the drug abuse problem – emphasis on the voices of young drug users and their family members to share their insiders' stories in relation to their personal experience into drug abuse; and (iii) to identify problems and needs that young drug abusers see as relevant to the road to recovery (led by Dr. Samson Tse and Prof. Karen Laidler). The key results are presented in Chapter 4. 4. For case studies among youth drug abusers – clinical and psychological analysis and assessments are used to characterize users’ profiles, patterns, problems and barriers of accessing to professional help (including relapse) (led by Dr. Paul Wong, Dr. Lilian Wong from Hospital authority, Dr. Wong Oi Ling and Ms. Frances Law). To understand diverse pathways of the young drug abuse problem and the roles of family in terms of the drug use pattern and "intervention", four idiographic examinations of four cases are proposed to explore the role of family involvement regarding the development of their drug use behaviors and help26

seeking patterns. A semi-structured interview procedure is adopted to investigate the role of the family plays in the adolescent drug use behavior. All 4 cases have been successfully interviewed. The findings are presented in Chapter 5.

27

CHAPTER 2: LITERATURE ON DRUG ABUSE
2.1. Drug-use situation among youth in Hong Kong
The dramatic increase in the use of drugs among students has raised concerns in Hong Kong. The finding of over 99% of sampled secondary school1 has drug-taking students from the latest Survey of Drug Use among Students was alarming to the society (Hong Kong Narcotics Division, 2010a). The percentage of lifetime drug-taking secondary students rose from 3.3% in 2004/05 (the last release of the survey) to 4.3% in 2008/09. The number of 30-day drug taking secondary students — a number that implies more frequent drug use — almost doubles from 0.8% in 2004/05 to 1.5% in 2008/09. The age of students starting to take drugs is also getting lower: for those aged 12 or below, there is a close to double increase in drug prevalence of 2.4% in 2004/05 to 4.6% in 2008/09 (Hong Kong Narcotics Division, 2010a). The results released in July 2010 from a large scale survey on over 2,700 senior primary school students aged 10 to 12 in 37 primary schools in the New Territories of Hong Kong further indicated that over 20% of these children assumed quite an accommodating attitude to drug taking. They under-estimated the risk of dependence and also considered drug-taking will not affect their peer relationship

1

Lifetime drug-taking students were reported in 111 out of the 112 secondary schools surveyed, 84 out of 94 primary schools surveyed, and all of the 17 post-secondary institutions surveyed.

28

and future development. Over 21% actually claimed they lacked confidence in their self-control to resist temptations for taking drugs (Barnabas Charitable Service
Association, 2010). These rising trend for youth drug use and weakening of resistance

is worrying to the public, as it has increased over 50% from 2,200 in 2005 to 3,360 in 2010 for the group under 21, as shown in Figure 1 (Hong Kong Narcotics Division, 2010a).

Figure 1. Number of reported substance abusers under aged 21 from 1997 – 2010 1st Quarter

3,500

3,000

s 2,500 e s a C d e 2,000 t r o p e R f o 1,500 r e b m u N

16 - 20 < 16 16 - 20 < 16

1,000

500

0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2009 Q1 2010 Q1

Year

(Source: Central Registry of Drug Abuse [CRDA] 56th Report, 2007 [ND, 2007] & 58th Report, 2009 [ND, 2009a], CRDA Drug Statistics, 2010)

29

Furthermore, contrary to popular belief, most young drug abusers actually
Group Upper primary (Primary 4 – 6) Frequency 1.6% (Lifetime), 0.8% (1-year), 0.5% (30-day) Type of Drugs Cough medicine (37.5%), Thinner (30.7%) Location of Use Own home (28.1%), Internet café (20.8%), Friend’s home (11.4%)

Secondary

4.3% (Lifetime), 2.6% (1-year), 1.5% (30-day)

Ketamine (49.4%), Cannabis (35.6%), Ecstasy (32.0%)

Friend’s home (36.2%), Karaoke/disco (25.15), Own home (25%)

Post-Secondary

Undergraduates

5.4% (Lifetime), 2.1% (1-year), 1.1% (30-day) 2.9% (Lifetime), 1.3% (1-year), 0.6% (30-day)

Cannabis (63.3%)

Cannabis (70.8%)

Karaoke/disco (47.4%), Friend’s home (34.6%), Pub (26.6%) Friend’s home (54.9%), Own home (28.8%), Karaoke/disco (26.4%)

take drugs at their own or friends’ home rather than in public places such as karaoke or disco (as shown in Table 1), reflecting the hidden nature of the issues. Table 1. Overview of the frequency, type of drugs used, and location of drug use by group in 2008/09.
Source: The 2008/09 Survey of drug use among students, [ND ,2010a])

The correlation between family structure and drug-using students is also noteworthy. Among this group of students, 7.7% do not live with either of the parents, compared to 2.5% for their non-drug-using counterparts (Hong Kong Narcotics Division, 2010a). There have been similar periods of drug trends found in other countries and Hong Kong. An example is a downward trend of illicit drug use in most western countries and Hong Kong since the year 2000. Yet, in the West the downward trend 30

continued until a surge reappeared in the U.S. and U.K. in 2007. In the U.S., the surge was largely contributed by an increase in cannabis use after a decade of downward trend. In the U.K., it can largely be explained by the increased use of cocaine and ketamine. In Canada, the trend continues to be downward. Hong Kong’s upward trend of illicit drug use, beginning in 2003/04, precedes that in the U.K., U.S. and Canada. Figure 2. Percentage of youth drug use in U.K., U.S., Canada, and Hong Kong (note variation in age groupings across countries)

40

35

U.S. (combined Grade 8,10,12th, all illicit drugs, past 1-yr use)

30
U.K. (age 16 - 24, all illicit drugs, past 1-yr use, data up to 2008/9)

25 e g a t n 20 e c r e P 15

U.K. (age 11 - 15, all illicit drugs, past 1-yr use, data up to 2008/9)

10

Canada (Ontario only, combined Grade 7,9,11th, all illicit drugs, past 1-yr use)

5

0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

Hong Kong (psychotropic drug use only, secondary school students, lifetime use, data up to 2008/9)

(Source: U.K.: British Crime Survey, 2008/092; U.K.: Smoking, drinking and drug use among young people in England, 20083; U.S.: Monitoring the Future survey, 20094; Canada: Drug Use among Ontario Students, 20095; Hong Kong: The 2008/09 Survey of drug use among students6.).
2

U.K.: British Crime Survey annually examines the prevalence and trends of illicit drug use among a nationally representative sample of 16 to 59 year olds resident (with a particular focus on young people aged 16 to 24) in households in England and Wales (Hoare, 2009). 3 U.K.: Smoking, drinking and drug use among young people in England is an annual secondary school survey examines young people age 11- 15. About 7,800 students in 264 schools were surveyed in 2008

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2.1.1. The changing attitude of drug abuse
From the experiences of front-line social workers and research studies, Hong Kong experiences what is considered the normalization of drug use, especially among marginal youth (Cheung and Cheung, 2006). It stems from the rise of dance club culture in the early 2000 spreading from the West to Asia and the rise of “club” drugs used (i.e., psychotropic drugs) (Joe Laidler, 2005). This normalization encompasses a few aspects: occasional use of psychotropic drugs is deemed acceptable for leisure and recreation (e.g., birthday parties and festivals); misconception (specifically, underestimation) about the level of harm these psychotropic drugs entail as compared to traditional drugs like heroin; misconception of the legal consequences of psychotropic drug use, e.g., unaware that even consumption of such drugs is illegal (Hong Kong Narcotics Division, 2008a). More importantly, the common terminology used to describe psychotropic drug use in Hong Kong — in Chinese it literally means “excessive use of medication” — does not carry the same connotation as “poisonous drug abuse” in its severity. The Task

(Fuller, 2009). 4 U.S.: Monitoring the Future is an annual study of the secondary school, college students, and young adults in the U.S. Approximately 50,000 are surveyed each year. Annual follow-up questionnaires are mailed to a sample of each graduating class for a number of years after their initial participation (Johnston, O’Malley, Bachman, & Schulenberg, 2009). 5 Canada: Drug Use Among Ontario Students is a survey conducted every two years for Ontario secondary school students. It surveyed about 9,000 students in 181 schools (Paglia-Boak, Mann, Adlaf, & Rehm, 2009). 6 Hong Kong: The survey of drug use is conducted once every four years for secondary school students. The latest issue also covers primary 4 students to post-secondary and university students. A total of about 150,000 students and over 1,000 schools were covered.

32

Force Report (Hong Kong Narcotics Division, 2008a) made recommendations on changing the terminology in the future. Before the introduction of the Trial Scheme on School Drug Testing in Tai Po District in the 2009–2010 academic year, the subject of youth substance abuse was still a taboo in many schools (The Hong Kong Federation of Youth Groups, 2008). All of the above suggest that some youth drug users regard drug use as an alternative way of life, being part of a social norm within the youth subculture, and that they can make a cost-benefit drug decision. Thus, they do not consider themselves as having problems or in need of help.

In fact, as early as in 2000 the United Nations has already warned about the rise of club drugs and cannabis, as well as their “recreational use” in developed countries in the West, that such use was no longer confined to a small number of marginalized youth (UN Economic and Social Council, 2001). Examples include drug abuse mentioned in the lyrics of popular songs, behavior of entertainment artists, and advertisement that targeted at youth. It had slowly become part of life among mainstream youth during their free time and become a subculture (UN Economic and Social Council, 2002). Drug use was then found not only in disco or at dance parties (UN Economic and Social Council, 2002), and it was portrayed as having a fashionable lifestyle (UN Economic and Social Council, 2001). Young people were 33

found to become more tolerant towards drugs experimentation (UN Economic and Social Council, 2001). The United Nations therefore called for increased sharing of information among countries to address the then emerging problem at an early stage, especially because youth cultures tend to globalize (UN Economic and Social Council, 2002).

This paper examines the prevention efforts in Hong Kong and other countries. Guided by Bronfenbrenner’s ecological theory of development (1979), the public health model (CADCA, 2008), and Hawkins and Catalano’s social development system (Hawkins et al., 1987, 2008, 2009; Kawkins, Catalano & Miller, 1992; Hawkins & Catalano, 2005), the complex interplay of factors that contribute to substance abuse in adolescents is investigated. In particular, the role of family is examined— a domain that has often not been addressed sufficiently in the anti-drug efforts in Hong Kong — in how it could become both a risk and a protective factor relating to youth substance use.

2.1.2. Hong Kong: Prevention Initiatives
2.1.2.1 Government bodies The anti-drug policy in Hong Kong encompasses five areas: preventive education and policy, treatment and rehabilitation, legislation and law enforcement, 34

external cooperation, and research. Narcotics Division (ND) is responsible for the formulation of anti-drug policy and the overall co-ordination in all five areas of the anti-drug strategy in Hong Kong. Action Committee Against Narcotics (ACAN) is an advisory body to the government on all anti-drug matters. In 2007 the Secretary for Justice was appointed to lead a high-level departmental task force to tackle the issues and make over 70 recommendations in a Task Force Report in 2008 (Hong Kong Narcotics Division, 2008a). In addition, in July 2009 the Chief Executive decided to lead relevant Principal Officials to expedite the implementation of the task force’s recommendation with five strategic directions: community mobilization, community support, drug testing, treatment, and law enforcement.

In Hong Kong, prevention education and policies are achieved in the following areas (ND, 2010b): 2.1.2.2 Central Publicity Campaign Anti-drug publicity activities are spread through mass media such as television dramas and video announcements in radio, slogan and theme songs, antidrug drama clubs, print media, roving exhibitions, and short-film competitions. Launched in June 2008, a two-year territory-wide campaign with the slogan “No Drugs, No Regrets. Not Now, Not Ever” conveys to the public the negative and 35

severe consequences of drug abuse and drug trafficking in all areas of life including health, legal implications, family, peer relationships, etc.

2.1.2.3 Hotline Anti-drug telephone enquiry service (186-186 run by ND), launched in August 2009, provides both information and counseling service regarding drug abuse. Parents and teachers can also call this hotline and request talking directly to a social worker from Tung Wah Group of Hospitals’ (TWGHs) CROSS center, a counseling center dedicated to youth drug use issues (TWGHs CROSS, 2009). 2.1.2.4 Community Sector: Funding and Programs Beat Drug Funds is the main source of funding provided by the government to community to launch anti-drug projects and programs ranging from preventive education and publicity, to treatment and rehabilitation, and to research. Sample projects include education seminars in various districts and in schools for teachers, parents, and students, workshops, sports and recreational activities, online radio station, and research by institutions and NGO that may contribute to the development of toolkits and resources for the wider community. Unlike the funding procedures in other countries such as U.S. and Canada, the ND currently does not require the Beat Drug Funds projects to adhere to a specific prevention or 36

intervention framework. However, they are required to provide progress report and have visits by ACAN or staff from the Funds or ND. The government is going to inject another HK $ 3 billion in 2010 to the Fund to support community projects in combating drugs (HKSAR Government, 2010).

Also, the “Community Program against Youth Drug Abuse” programs provide a wide range of activities to increase the youth’s positive engagement in 18 districts. The District Councils, Home Affairs Bureau, District Fight Crime Committee (DFCC), partnering with various NGOs, parent-teacher associations, uniformed groups, business groups and professional organizations such as the Hong Kong Medical Associations together organize various activities that can potentially attract young people. These include both sports and recreational activities, such as rock climbing and drama, and vocational training, such as sales and hair dressing. In addition, fitness tests, counseling services and treatment would be provided to participants if necessary. Under this umbrella, seminars and sharing sessions are organized for parents and teachers as a means to educate the public about the causes of the youth drug problem, and as ways to identify the physical symptoms and tackle the issue (Home Affairs Bureau, 2009). Anti-Drug Volunteer Group 37

The group, under ND, assists in drug education and publicity programs at the Hong Kong Jockey Club Drug Information Centre. Corporate volunteers participate in anti-drug activities organized by ACAN and help spread anti-drug messages to their staff members and families. There are currently 104 corporate volunteers and 350 individual volunteers (ND, 2010b). Path Builders Established in September 2008, it is a service platform led by ND to encourage and assist professional bodies and community associations to take up social responsibilities in caring for young people facing drug issues, guiding them to establish positive goals. They can do so by providing job or training opportunities, donations, mentorship, or as anti-drug ambassadors. Currently, over 200 organizations and individuals have pledged support for the Path Builders initiatives. Moreover, ND is in the process of matching the contributors’ officers with potential beneficiaries based on their preferences (ND, 2008b). District Youth Outreaching Social Work Teams and Young Night Drifters Operated under the Social Welfare Department (SWD), the teams teach and provide guidance and counseling to youth between 6–24 who are at risk of undesirable influences, such as juvenile gangs, as they are not reachable through conventional social and youth activities (Social Welfare Department, 2010). 38

The health sector also collaborates with the social work sectors in the prevention and early intervention on drug use. For example, the Northern District Hospital’s UROK Clinic is an outreach team comprised of psychiatrist, urologists, nurses, physical therapists, social workers and other professionals. They offer health check-up for young night drifters who are early substance users so that the youth can understand how their bodies are negatively affected by drugs, thereby motivating them to receive treatment (Hospital Authority, 2010). 2.1.2.5 Education Sector The Education Bureau (EB) leads and co-ordinates efforts in the institutionalization of the “Healthy School Policy” with an anti-drug element. The following details their anti-drug efforts. Drug Screening Starting in September 2009, the Trial Scheme on School Drug Testing was launched in Tai Po District for one year (ND, 2009b). It is a voluntary, random, nonpunitive urinalysis to test the five most popular drugs used by Hong Kong students: Ketamine, ecstasy, ice, cannabis, and cocaine. It has two purposes: (1) enhancing the resolve of non-drug-taking students to continue staying away from drugs, and (2) motivating drug-taking students to quit drugs and seek help, and providing 39

appropriate resources for them in doing so. School principals would be informed if the result is tested positive, and principal would inform the parents and the relevant teachers. For experimental users, they would continue school and receive counseling service from school social workers and designated teachers, and may join community-based support service (such as the Counseling Centers for Psychotropic Substance Abusers / CCPSA). As for dependent users, they may join voluntary residential programs in the treatment and rehabilitation centers, and return to school after completion.

The community has had a heated debate about this scheme concerning intrusion of privacy, chance for being persecuted, negative impact on the harmonious atmosphere in school, and its effectiveness to discourage drug use. As of today there have not been any student tested positives in his or her sample, yet the number of students seeking help on drug-related issues increase by more than twofold (ND, 2010c; Radio Television Hong Kong [RTHK], 2010). The government has yet to decide if the scheme will be implemented at other schools or districts until a research and evaluation of this scheme is completed by the third quarter in 2010. There are concern or questions raised about the drug testing in school in reducing the number of drug abusers among our youth (Yip, 2010, Mingpao) 40

Anti-drug resource kit for schools Anti-drug resource kit developed by the Hong Kong Federation of Youth Groups (HKFYG) and ACAN was distributed to schools in March 2010 to assist schools by providing a framework and practical guidelines to develop a healthy school policy. That includes promoting a healthy lifestyle, building positive values, acquiring practical life skills, acquiring resistance skill, and developing protocols for handling suspected or confirmed drug abuse case among students. A half-day on-site training for class and subject teachers and a two-day advanced training for guidance and discipline teacher would be provided to teachers to increase their anti-drug knowledge. This is done in addition to existing anti-drug elements in school curriculum and other activities. The government also intends to progressively extend the coverage of anti-drug education programs from senior primary to junior primary level especially on the use of cough medicine and inhalant. It also targets at enhancing anti-drug training for management and teachers in primary schools (HKFYG, 2010). Anti-drug talks and activities To enhance the students’ knowledge on drugs, ND, Social Work Department (SWD), the Police, NGO, and the Department of Health have always been responsible 41

for organizing or sponsoring talks and activities in upper primary (primary 4 and above) and secondary schools. The content includes common abused drugs and their harmful effects, reasons for drug abuse, refusal skills, and sharing session with rehabilitated persons. In 2010–11, the talks in primary schools would be extended to primary 3 and all secondary school students (Lam, 2010). Hong Kong Narcotics Division and Education Bureau also aim at reaching out to more parents for increased home-school cooperation with parent-teacher associations, the

Committee on Home-School Co-operation, and parent education service units. Anti-drug elements in school curriculum Currently, anti-drug elements are infiltrated in various courses in primary and secondary schools, including general studies in primary school, social studies in secondary school, humanities, biology, etc. Anti-drug elements were strengthened in the various stages of revised civic and moral education curriculum starting in 2008. Under the New Senior Secondary Academic Structure starting in 2009, Liberal Studies core curriculum and The Health Management and Social Concern course electives aim at enhancing drug education element. A new subject “Life and Society” will also be offered at junior secondary school students covering anti-drug topics (Lam, 2010).

42

Police School Liaison Program They provide assistance and advice to schools in handling crime related activities, and also take part in providing anti-drugs talk. The police school liaison officers under the Police School Liaison Program (PSLP), which has added 27 officers in 2008–09, would be further increased by 9 officers in 2010–2011 (Lam, 2010). Programs that promote the well-being and resiliency in students Several large scale personal growth development projects coordinated by Education Bureau, Social Welfare Department and 5 major universities, such as the Understanding Adolescent Project (UAP), P.A.T.H.S. (to Adulthood, Enhanced Smart Teen Project, are available to the students ranging from senior primary to junior secondary schools with potentially greater developmental needs. They help students to promote development of the students’ resiliency on their way to growing up, including learning the skills in anger management, conflict resolution, interpersonal relationships, self-discipline, teamwork, and building up resiliency, ultimately promoting psychosocial well being. Students with healthy attitude would be less prone to negative influences including drug abuse and other adolescent problem behaviors (Education Bureau, 2004; Education Bureau, 2006; P.A.T.H.S, 2005).

43

In addition, the Department of Health (DH) organizes the Adolescent Health Program (AHP) focusing on promoting adolescent’s psychosocial health through health knowledge, self-understanding, acceptance, emotion, stress management, interpersonal and problem-solving skills. Drug education has become a core basic life skill training for all Form 1 students enrolled with this program. Junior Health Pioneers Workshop, started in 2007, is a health workshop organized by the Student Health Centre under the Department of Health. Targeted at primary 3 students, it aims at enhancing their understanding of the harmful effects of smoking, drug abuse, and alcoholism, and at building resistance skills (DH, 2009). 2.1.2.6 Labor Sector The combined Youth Pre-employment Training Program (YPTP) and Youth Work Experience and Training Scheme (YWETS) are targeted at school leavers (i.e., those between schools and employment) aged 15–24 with sub-degree education level. It provides pre-employment courses and on-the-job training activities. It helps them improve self-understanding and work aptitudes, enhance work motivation and computer skills, and provide work experiences to enhance their employability. The project can also prevent the youth from being disengaged and prone to negative influences (Labour Department, 2009).

44

2.1.3. Treatment and Rehabilitation Programs
2.1.3.1 Counseling Centers for psychotropic substance abusers (CCPSA) Currently seven Counseling Centers for psychotropic substance abusers (CCPSA) provide counseling service, including information, counseling, treatment and rehabilitation services for drug abusers, and are resource centers for other professionals who may encounter issues of psychotropic drugs at their work. The length of service can range from three months to three years (ND, 2010b). 2.1.3.2 Voluntary In-patient Treatment / Residential Drug Rehabilitation Program 17 NGOs are running these programs, and they provide services to those who voluntarily seek residential treatment and rehabilitation, using different treatment models depending on the organization and the needs of the abusers (ND, 2010b). 2.1.3.3. Substance Abuse Clinic There are currently seven substance abuse clinics, operated by the Hospital Authority, that accept referrals through CCPSA, voluntary agencies, health care providers and by self-referral. They provide drug treatment, counseling and psychotherapy (ND, 2010b). 2. 1.3.4 Compulsory Placement Programs Operated by Correctional Services Department, this program targets at drug dependent persons convicted of related offences and deemed suitable by the Court 45

for treatment under such program. It focuses on preparing inmates for social reintegration without relapse into drug use (ND, 2010b). 2.1.3.5 Out-patient methadone treatment program Run by the Department of Health and targets for opiate addicts, it offers both methadone maintenance and methadone detoxification programs. Patients may choose to be maintained on methadone in the case where they are unable to achieve total abstinence, or detoxified through gradual reduction in the consumption of methadone (ND, 2010b).

2.1.4 Research
ND and ACAN also endorse universities and NGO to conduct research that covers a wide range of anti-drugs topics — parents’ engagement in anti-drug work, anti-drug efforts in school, underground rave culture, drug abuse in minorities, medical treatment — to broaden the general understanding of the drug situation in Hong Kong. Some of the research also leads to the development of toolkits that assist schools and parents in combating the drug issues around them (ND, 2010b).

2.1.5 Parent Education Program in Hong Kong
Regarding training specifically provided to parents to address substance use issues, the “Anti-Drug Resource Kit for Parents” was developed in June 2009 to offer training to parents via NGO and address general parents (universal prevention), 46

parents with high-risk children (selective prevention), and parents with drug-use history (indicated prevention) (ND, 2010b). A series of parenting talks were arranged in the 18 districts. In addition, train-the-trainer workshops were arranged to help teachers, parent education service units and parents to use the kit. The Community Drug Advisory Council (CDAC) also has workshop specifically on parenting skills (CDAC, 2010). The Life Education Activity Program (LEAP) provides health-based education program for young people including primary and secondary schools up to Form 3, and students from special-needs school. They also provide parents program, such as the parents “Safe and Successful” program, which includes enhancing parenting skills, foster effective communications, handle drug abuse and other crises, providing information about drugs, tips on how to positively nurture their children, and further their understanding on children’s developmental change and needs (LEAP, 2010).

2.1.6 Summary
The anti-drug prevention efforts in Hong Kong cover a few domains: for youth, events through the use of seminars, workshops, leisure events, dramas and movies, etc. These programs are typically isolated, and a systematic evaluation examining how they modify the youth’s drug-related attitude and behavior in the long run is severely limited. School is also an important platform in Hong Kong to 47

spread anti-drug messages through drug-testing, recreational activities, and classroom education. Meanwhile, community education is done through the media campaign, roving exhibitions and educational seminars in the district. Yet in the domain of family or parents, they are included in the prevention efforts in a few yet limited areas: (1) educational seminars or workshops organized through schools, ND, or District Councils and NGOs at the community level. (2) Drug-resources online and parent training, such as the “Anti-Drug Resource Kit for Parents”, short TV videos, and parenting and anti-drug leaflets for parents that are available on the ND and Education Bureau websites, and (3) Information and counseling service at 186-186 hotline. In the past ten years from 1999–2009, among the over 300 preventive programs subsidized by the Hong Kong Beat Drug Funds, only 17 of them have parents as their primary target (ND, 2010b). Family and youth drug abuse Drug abuse in adolescence does not merely emerge at that point of lifespan, but is a manifestation of deeper family issues and a symptom of an ongoing pattern of youth development problems (ND, 2008a; Northeast Center for the Application of Prevention Technologies [Northeastern CAPT], 1999). Numerous studies have developed various theories and models which outline the factors influencing youth substance use, and comprehensive approach involving different domains, including 48

communities, schools, peers, and families, is essential to tackling the issues. However, among all these spheres of influences and different approaches, parental and family factors are of paramount importance (Substance Abuse and Mental Health Services Administration [SAMHSHA], 2009; United Nations’ Office on Drugs and Crime [UNODC], 2009; Vellenman et al., 2005). Family environment is considered the major underlying factor determining whether young people would engage in disruptive behaviors, including substance abuse. Peer influence works more as a contributing factor closer to the time of substance use initiation (Gardner et al., 2006; Kumpfer et al., 2003; UNODC, 2009). More importantly, young people with healthy relationship with their parents are likely to choose peers with positive influences (UNODC, 2009), thereby reducing the chances of encountering drugs. This perspective also explains why prevention efforts focusing on knowledge dissemination and refusal skills have limited effects on drug issues, because they do not sufficiently address the underlying cause of the issues. According to the UNODC, evidence-based family skills training programs are considered to be the most effective measure to prevent substance abuse among youth after nurse homevisitation program (UNODC, 2009). From a policy perspective, little has been done in Hong Kong to specifically support family or parents in the anti-drug prevention efforts. In the following 49

sections, evidence from theories and previous literature to elucidate the importance of targeting family in combating the anti-drug battle is provided.

2.2. Theoretical framework
In this section, we focus on the three most common theories and models on youth substance abuse. We will first examine the ecological systems theory (Bronfenbrenner, 1979), followed by the public health model and the social development model (Hawkins and Catalano, 1992).

2.2.1. The Ecological System Theory
It provides a fundamental understanding of human behavior that can be explained by the “layers of systems”, and their interactions, around the person. Such interactions are also affected by relations between these settings and also by the larger contexts in which these settings are embedded (Bronfenbrenner, 1979). In other words, these systems are interrelated and interdependent (Waller, 2001). There are five levels of systems:

Microsystem: the person’s immediate environment (e.g., family, peer group, school, neighborhood).

Mesosystem:

interrelations

between

Microsystems

(e.g.,

mother

[family]

accompanies child to school [school])

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Exosystem: external settings that do not involve the person as an active participant but still affect the person, or affected by, the person (e.g., mother’s workplace, which affects the mothers’ mood, and mother carries that mood to the child when she returns from work to home)

Macrosystem: larger cultural and the underlying ideological context (e.g., filial piety in Chinese, subculture among youth, political and economic situation)

Chronosystem: the effect of time or the dimension of life span (e.g., physiological change for a child, timing when the significant change occur). Figure 3. Bronfenbrenner’s ecological systems theory

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In the context of youth substance abuse, the ecological theory emphasizes that it is the interaction of factors within these layers that contribute to the issues of substance abuse (Stormshak & Dishion, 2009). Indeed, scholars have called for interventions that should not focus on harm minimization and prohibition (Vimpani , 2005). The key to any prevention efforts should instead address each of the relevant layers as indicated by Bronfenbrenner. In the case of substance abuse in youth, examples that target prevention at relevant layers would include, but not limited to (Randall and Cunningham, 2003): Individual level: Address the youth’s positive attitude towards substance experimentation (microsystem) Family level: Enhance parents or carers to monitor the youth effectively (exosystem) School level: Increase youth’s attachment to school (exosystem) Political / economic / cultural level: Promote healthy lifestyle (macrosystem)

This model is used extensively in not only substance abuse prevention and intervention initiatives but also family intervention programs, such as Project Steps To Achieving Resilience (STAR), Strengthening Families Program (SFP), multisystemic therapy, multidimensional family therapy (MDFT), functional family therapy (FFT), 52

brief strategic family therapy (BSFT) (Kaminski, Ruth, Stormshak, and Elizabeth A., 2007; Swenson et al., 2009; Liddle, 2004). This theory provides a helpful framework for conceptualizing risk and protective factors (explained in later sections) for problem behaviors that exist at each level, and also interact at various levels. This theory also serves as the foundation in the U.S.’s Substance Abuse and Mental Health Services Administration (SAMHSA) in assisting communities to identify the multiple points of entry for drug problem intervention within their communities. This means an effective prevention strategy needs to address the underlying risk and protective factors that are present, and interacts in each of the layers in order to achieve positive outcomes (SAMHSA, 2009). This model has been tested applicable across culture, including Chinese (Deng and Roosa, 2007; Williams, 2010). Scholars in Hong Kong have also called for the need to use an ecological perspective and holistic approach in order to both understand and tackle the adolescent drug issue (Shek, 2007; Tsang & TWGHs, 2008). 2.2.1.1 Using this model to understand parents with substance abuse problems Parental substance abuse is highly disruptive to family functioning (Dawe et al., 2006). It is a risk factor towards negative parenting practices (Huxley and Foulger, 2008). Their children usually have a higher rate of exhibiting behavioral and emotional problems, and they also have a higher rate of child abuse and neglect 53

(Walsh et al., 2003). Children may receive from their drug-using parents limited time and attention, inconsistent care, and a lack of emotional availability and control, not to mention that the easier availability of drugs to the children and the parents’ positive attitudes towards drug use may lead to the likelihood of inter-generational substance abuse. All these could cause ineffective parenting and affect adversely the parent-child attachment (Scaife, 2008). Further, if we put the ecological model into context, parent substance abuse is not necessarily the causal factor responsible for poor child outcome (Dawe et al., 2006), as child outcome could be a result of personal, developmental, familial and environmental factors. More often, it is a combination of various factors associated with the parental substance abuse, such as poor parenting practices, poor or even violent marital relationship, limited social support, economic disadvantages, that make their children at risk (Bancroft et al., 2004). In addition, even if the parents see themselves as needing treatment help, current services may not sufficiently balance managing child protection issues with engaging the parent in treatment. This serves as a barrier for drug-using parents, especially mothers, when they try to access treatment services (Huxley and Foulger, 2008). Thus prevention and intervention strategies should not only focus on the parental substance use per se. Rather, based on the ecological model they should

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also address the factors in various domains, and the complex interplay among them (Dawe et al., 2006). 2.2.1.2 Using this model to understand parents of substance abusing children Such families typically suffer from deterioration of family relationships, and parents reported to have increased level of anxiety, stress and other behavioral disorders, as there is a pervasive worry about the well being of their drug-using children in their absence. A formerly loving, or at least stable parent-child relationship, is now characterized by suspicion and mistrust after the discovery of drug use by children (Barnard, 2005). As a large amount of time and energy are spent, often with a long period of time in both the discovery and also in treatment, this ongoing stress and anxiety pose threats to the parents’ job performance and marital relations. Some may even rely on substance such as alcohol to de-stress themselves (Frye et al., 2008). The social stigma attached to drug use also makes the parents and other family members, such as sibling, unwilling to seek support from friends in schools and relatives, as it is difficult to find others who can render support in a non-judgmental way (Frye et al., 2008). Needs of the non-drug-using sibling are pushed sidelines as the family is busy struggling with the issues stemming from the drug-using child (Gregg & Tombourou, 2003). Some studies also point out the increased financial strain on the family, and its related conflicts between the parents 55

and drug-using children, when the addicted children ask for money to buy more drugs (Barnard, 2005). Overall, drug use in children creates significant risk to their family members, causing tremendous negative impact on them physically, emotionally and financially. It exerts a ripple effect on the entire family and may extend to other domains such as the parents’ work, siblings’ schooling, and level of social support (Gregg & Tombourou, 2003). Like the drug-users, the family members also need support in managing the emotional and related physical impact as a result of drug use in the family.

2.2.2. The Public Health Model, Environmental Approach, and The Broken Windows Theory (TBD)
2.2.2.1 Public Health Model and the Environmental Approach The second commonly used model in prevention science is the public health model. It emphasizes the broader physical, social, cultural and institutional forces (Community Anti-Drug Coalitions of America [CADCA], 2008). This model believes that individual actions are a result of interactions among the environment (physical and social context), the person (host), and the agent (substance). Prevention initiatives that focus on the agent are generally considered supply reduction strategies. Initiatives that attempt to alter an individual’s demand are generally considered as demand reduction strategies. Initiatives that focus on the surrounding

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of the substance abuser are considered as environmental approach (National Institute on Drug Abuse [NIDA], 1997). By restructuring the settings or environment where the person lives, it can shape the individual’s behavior, and such an environmental approach can be used for both supply and demand reduction. They target at shaping the perception in communities, homes or schools, focusing on affecting a large number of people through systems change and ongoing effective enforcement (CADCA, 2008). Figure 4. The Public Health Model

Substance (Agent)

Individual (Host)

Physical & Social Context (Environment)

There are seven strategies which put such “environmental prevention” approach into actions. For example, in the case of preventing licit and illicit substance use (CADCA, 2008): 1. Provide information (e.g., educational presentation, media about the effects of alcohol and drug use) 57

2. Enhance skills (e.g., parenting class, model programs in school) 3. Provide support (e.g., provide alternative activities that reduce risk behaviors) 4. Enhance access / reduce barriers (e.g., taxes, fines, hours of sales) 5. Change consequences (e.g., incentives / disincentives) 6. Change physical design (e.g., more difficult outlet to purchase alcohol) 7. Modify / change policies (e.g., formal change in rules and law enforcement)

Hence, addressing the environment through policy and practice changes the community norm, which in turn would chance the individuals’ behavior (CADCA, 2008).

Within the public health classification of prevention, efforts are organized along a continuum of primary, secondary, and tertiary prevention (NIDA, 1997). Primary prevention aims at protecting individuals from developing the disease, and in the case of substance abuse, that means protecting the individuals who have not begun using substances from drug use initiation. Secondary prevention aims at preventing progression of the disease, or in other words, early intervention with 58

those at the beginning stage of substance use. Tertiary prevention aims at ameliorating the negative impact of established diseases, and in the case of substance abuse, it restores the individuals’ functions through treatment, rehabilitation, and relapse prevention.

In 1994, the U.S. Institute of Medicine (IOM) proposed a new framework for classifying all preventions efforts based on Gordon’s (1987) operational classification of disease prevention, namely, prevention, treatment, and maintenance. Within the prevention category, it is further divided into three classifications: universal, selective, and indicated prevention interventions, which replace the concept of primary, secondary and tertiary preventions (NIDA, 1997). Universal prevention strategies address the entire population without any prior screening for risk, and aim at deterring the onset of substance abuse by providing all individuals the information and skills to prevent the problem. Examples of universal prevention strategies specific to substance abuse include media and public awareness campaigns, and drug-free policies in schools, and for specific programs such as the “Guiding Good Choice” developed by Hawkins et al. (1987). Selective prevention strategies target subsets of the population who are deemed to be at a higher risk for substance abuse (e.g., children of adult alcoholics, school dropouts, or other biological, psychological, 59

social or environmental factors known to be associated with substance abuse). Selective prevention programs are typically presented to the entire subgroup regardless of the individual’s degree of risk within that group. Examples include special clubs and groups for children of alcoholics, and skills training programs specific to children of substance-abusing parents, and the Strengthening Families Program developed by Kumpfer et al. (1989). Indicated prevention strategies have the mission to identify individuals who are exhibiting early signs of substance abuse and to target them with special programs. These programs typically address risk factors associated with the individuals such as low self-esteem, conduct disorder, alienation from parents and positive peer group. Less emphasis is placed on addressing environmental influences such as community values (NIDA, 1997). They are designed to stop the progression of substance abuse and other related disorder, and can target multiple behaviors simultaneously. Examples of indicated preventions include student assistance programs where teachers and counselors would refer students exhibiting multiple issues (e.g., academic, behavioral, emotional problems) to counseling groups or family-focused programs for the prevention of substance abuse (NIDA, 1997), and specific programs such as the Reconnecting Youth developed by Eggert et al. (1990).

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The public health model and especially the environmental approach is widely adopted in the U.S., and in the field of prevention of alcohol consumption in particular (Wood et al., 2009). In Hong Kong, the public health approach is adopted in a parent education program in which evidence-based resources in the form of manuals for mass and group programs, case counseling and website resources are designed and disseminated for general parents, parents with children at risk, and parents with drug-taking history (Tsang & TWGHs, 2008). The public health model is also found applicable in suicide prevention work in Hong Kong (Yip, 2008; WHO, 2010). It stresses on intervention at three levels, namely universal, selected and indicated for different stage and phases of drug abusers. 2.2.2.2 The Broken Windows Theory Developed by Kelling and Wilson (1982) in the field of criminology, this theory suggests that effective crime prevention should start with what are considered as “minor” offenses within a city, such as vandalism, graffiti, etc. Ignoring such minor offenses and problems is an invitation for more serious crime. An analogy of broken window is used in this theory – within a neighborhood, if one window of a house is broken but is left unrepaired, the rest of the windows will soon be broken. That is because such neglect (of one unrepaired window over time) serves as a signal that “no one cares” about the house, making it susceptible to 61

vandalism and even burglary. Therefore, what is important in crime prevention is to fix and uproot a small issue before the situation deteriorates (Kelling and Wilson, 1982). Such analogy could also be applied in the field of drug abuse prevention among youth (Mak, 2010). If we consider the issue of drug use is still limited to a minority of youth and only the “marginal” youth, and does not sufficient address the root of the issue, the situation would deteriorate. Early identification and timely damage control and prevention are thus the key assertions of this theory.

2.2.3. Social Development Strategy / Model (SDS)
One of the most influential and helpful ways to understand youth drugs issues is by using the social development model, which addresses risk and protective factors. Developed mainly by Hawkins and Catalano (1992), this model is a synthesis of social learning, social control and differential association theory (Catalano et al., 1999). The SDS identifies risk factors that contribute to the development of the five most common adolescent behavioral problems, including (1) substance abuse, (2) delinquency, (3) teen pregnancy, (4) school drop-out, and (5) violence. Risk factors, as the name suggest, are shown to increase the risk or likelihood that the above problems would emerge in adolescence and young adulthood. On the contrary, protective factors buffer them from exposure to risks, and hence reduce the likelihood in exhibiting such behaviors (Hawkins and Catalano, 1992). Both risks and 62

protective factors encompass four spheres where young people grow up: (1) peer and individual, (2) school, (3) family, and (4) community (Hawkins and Catalano, 2005).

Table 2. Risk factors of adolescent problem behavior.
Substance Use Community Availability of drugs Availability of firearms Community laws and norms favorable towards drug use, firearms, and crime Media portrayals of violence Transitions and mobility Low neighborhood attachment and community disorganization Extreme economic deprivation Family Family history of the problem behavior Family management problem Family conflict Favorable parental attitudes and involvement in the problem behavior School Academic failure beginning in late elementary school Lack of commitment to school Peer and Individual Early and persistent antisocial behavior Rebelliousness Friend who engage in the problem behavior Gang involvement Favorable attitudes towards the problem behavior Early initiation of the problem behavior Constitutional factors X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Delinquency Teen Pregnancy School Drop-Out Violence

Source: Communities that Care (Hawkins and Catalano, 2005, p. 16)

While the table above lists the risk factors which are predictors of the problems, the presence of protective factors can neutralize the “harm” that are associated with risk factors. These protective factors include: 63

(1) Healthy beliefs and clear standards for behavior as communicated by families, schools, communities, and peer groups (2) Strong attached bonding and relationships with at least one adult (can be parents, grandparents, relative, mentor, etc.), who has healthy beliefs and clear standards for young people (3) Individual characteristic of the young person, such as a positive social orientation, high intelligence, and resilient temperament

SDS is concerned with the socializing processes of the children, and the process involving the following constructs: giving opportunities for children’s positive and meaningful engagement, providing the skills for children to participate in these involvements, and giving recognition and corrective feedback to them as reinforcement (Hawkins & Catalano, 2005). Family unit remains dominant in their socialization during the home and elementary school periods, and school plays a more important role later on (Fleming et al., 2002). Such risk and protective factors that influence the children’s path to socialization then make children internalize and normalize a standard of behaviors that are pro-social or anti-social.

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Figure 5. Building Protection: The Social Development Theory

The goal…

Healthy behaviors for all children and youth

Start with…

Healthy beliefs & clear standards
… in families, schools, communities and peer groups

Build…

Bonding - Attachment - Commitment
… to families, schools, communities and peer groups

By providing…

By providing…

By providing…

Opportunities

Skills
… in families, schools, communities and peer groups

Recognition

And by nurturing…

Individual characteristics

Source: Communities that Care (Hawkins and Catalano, 2005, p. 12)

It is important to note that these common risk factors would predict diverse problem behaviors, such as the five listed above. They can be present across development, with some factors becoming more salient than others depending on the course of human development. More importantly, the number of risk factors is 65

proportional to the chance of exhibiting problem behaviors, and the presence of protective factors would neutralize such effects (Harachi, Ayers, Hawkins and Catalano, 1996). In addition, these factors are present across racial groups (Choi et al., 2005; Fleming et al., 2002).

Therefore, it is essential for any prevention strategy to address both risk and protective factors in order to be effective (Harachi et al., 1996; Hawkins & Catalano, 2005). For example, most drug prevention efforts focus on community laws and norms on drug use, and the social influences that relates to them. The prevention approach most frequently used and also most evaluated, as a result, is resistance training for teenagers. Yet resistance skills training method do not change the basic developmental conditions experienced by children (Harachi et al., 1996). Those who have the highest risk of drug experimentation and abuse are likely to also experience poor family management, lower bonding to family, early and possibly persistent behavior problems, low commitment to school, and academic failure. They are likely to be unmotivated to refuse or avoid drugs by the time they are exposed to drugs (Harachi et al., 1996). Therefore, addressing these underlying problems shown in the risk factors, finding ways to minimize them, and increasing the protective factors are the most effective ways to tackle any adolescent issues including substance abuse. 66

Furthermore, if these various factors are tackled effectively, the result would also mean that the range of, and not just a single, adolescent problem behaviors can be reduced.

One of the most important domains that are addressed among these risk and protective factors in studies on adolescent problem behavior is family. In the following section we examine how the theoretical frameworks, especially from the ecological theory and risk and protective factors, relate family and youth substance abuse. We would examine family in various contexts: family members such as parents, sibling, grandparents, domestic helpers or nannies, relationship with youth in family and how they are related to substance abuse

2.2.4. Theories and family studies
Family vis-à-vis youth substance abuse Family factors play a critical role in substance abuse, and it is acknowledged in virtually every psychological theory on the subject (Bry et al., 1998). Supportive families are the key to raising well-adjusted children (UNODC, 2009). The children in these families tend to be healthier socially, mentally, and physically, thereby preventing later adolescent problems (UNODC, 2009). Families are building block of the society, and also the cradle where young people grow up (Tsang and Leung, 2005; 67

ND, 2008a), and is believed to be the first line of defense against any type of adolescent problem behaviors. Thus risk and protective factors within the family context are considered to have the greatest degree of influence over adolescent, as they play a critical role in the development of resilient children and adolescent (Patin, 2003; Dawe et al., 2006). As mentioned in Section 1.2, growing up in a supportive family is the underlying reason youth do not engage in a variety of disruptive behaviors that include substance abuse (Gardner et al., 2006; Kumpfer et al., 2003). Peer influence is at best a contributing factor near the time of drug use initiation (UNODC, 2009). In contrast, exposure to familial conflict increases the risk of substance use disorders during late adolescence due partly to higher levels of externalizing problems (Skeer et al., 2009). Local study also agrees that family functioning is significantly related to adolescent delinquent and substance abuse behavior (Shek, 2002a). Thus, by altering the family functioning, it could likely prevent substance abuse (Bry et al., 1998).

Family dynamics plays an important role in youth development, and competent parenting is a powerful protective factor (UNODC, 2009; Cummings et al., 2000). Specifically, healthy parent-child attachment, functional family structure, appropriate parental monitoring, authoritative parenting style, and communications 68

of pro-social values by family members all laid the foundations of family factors that prevent youth substance abuse (UNODC, 2009). In contrary, parental conflicts serve as a significant risk factor for youth substance abuse. 2.2.4.1 Parents This section on parents includes parent-child relationships, parental monitoring, parenting style, family structure, parent-child communication and long work hours, and parental conflicts. Parent-child relationships In families with frequent outburst of anger and hostility, and where relationships among family members are cold and irresponsive, children are more vulnerable to problematic behavior and substance abuse (Repetti, Taylor, and Seeman, 2002). Parents who are low in warmth and high in hostility are associated with having children who are prevalent in conduct issues and tobacco use (Melby, Conger, Conger, and Lorenz, 1993). Parent-child connectedness is inversely associated with substance use and other health indicators such as depressive symptoms and self-esteem (Ackard et al., 2006). In cases where the biological parent fails to become the person whom the child or young person can attach to, a sense of belonging and closeness to at least one caring and competent member of the family (who may be grandparents, an older sibling, a relative, hired caregivers, 69

adoptive/foster parents, etc.) is a protective factor, because it is likely that this person can provide surrogate care-giving and play a mentoring role (Dawe et al., 2006; UNODC, 2009). In addition, adolescents who have high conflicts with parents are less likely to conform to the parents’ supervision, as evident from a study in Taiwan (Yen et al., 2007). Youth who are satisfied with the relationship with their parents have a lower chance to be heavy substance users (Pasch et al., 2010). Alienated relationship among family members, especially between parents and the teenagers, is a push factor that drives certain adolescents away from home to become night drifters in Hong Kong (Lee, 2000). Such night drifting makes them more susceptible to negative influences including substance abuse, involvement with gangs, and risky sexual behaviors (Lee, 2000).

Certain research also examines the relative influence between fathers versus mothers on children (Shek, 2005; Tsang, 1996). In a study that focused on homeless and runaway youth, Stein et al. (2009) found that positive paternal relationships significantly predicted less substance use and less criminal behaviors, whereas positive maternal relationships predicted less risky sex behaviors. Differential contributions of fathers versus mothers on adolescent developmental outcomes also vary with the gender of the adolescent children (Shek, 2005). A local study on 70

Comprehensive Social Security Assistance (CSSA) recipients showed that fathers exerted influences on adolescent boys in terms of existential well being and delinquency, but not on adolescent girls. In contrast, mothers exerted influences on adolescent girls in terms of mental health and problem behavior, but not on adolescent boys (Shek, 2005). Another study on intact families indicated that positive influence of father-child relationship is stronger for adolescent males than females (Bronte-Tinkew, Moore & Carrano, 2006). A more positive father-child relationship (defined as having both emotional closeness and father involvement) is associated with a reduced risk of first delinquency and substance use after controlling for mother-child relationship, maternal monitoring, other maternal characteristics, family- and household-level characteristics, and child-level characteristics (Bronte-Tinkew et al., 2006). Family structure As indicated by the drug use statistics in Hong Kong, a larger proportion of drug-taking students are not living with either of their parents compared to the nondrug-taking counterparts (7.7% vs. 2.5%) (ND, 2010a). In fact, substantial amount of studies are dedicated to examining relationships between multiple family structure and adolescent drug use (e.g., single-parent family, foster-parents family, traditional biological two-parent family, grandparent-led family), as transitions in family 71

structure can affect attachment and have a profound effect on children (Krohn et al., 2009). Hemovich and Crano pinpointed the two schools of thought popular in explaining the relationship between family structure and substance use, namely maternal hypothesis (i.e., children staying with the mother are less prone to delinquent behavior because of better overall supervision and stronger affective bonds than staying with the father), versus the same-sex hypothesis (i.e., same-sex parent-child pairings have the strongest protection of children against drug use) (Hemovich and Crano, 2009).

Comparing households headed by single-fathers versus singe-mothers, adolescents reportedly have more delinquent behaviors in single-father families. However, this is entirely accounted for by the weaker direct and indirect controls exerted by single fathers and not the family structure per se (Demuth and Brown, 2004). No significant impact is found by family structure on adolescent delinquency once they account for family processes including parental involvement, parental supervision, parental monitoring, and parent closeness. In addition, indirect control (defined as parent-child closeness in that study) imposes a more significant impact than direct control (defined as parental involvement and monitoring) in determining the prevalence of delinquent behavior. Parents’ psychological and emotional 72

presence appears to have a bigger impact than their physical presence (Demuth and Brown, 2004). Booth, Scott and King (2010) also found that adolescents benefit more from a close bond to a nonresident father than a weak bond to a resident father. Hemovich and Crano (2009)’s study found that daughters in single-father household reported significantly higher chance of substance abuse than in single-mother household. Gender of custodial parent is unrelated to sons’ chances of substance abuse. It’s noteworthy that this is not a causal relationship but only correlation, and the study did not account for parental attachment. And even if adolescents have a poor relationship with their mothers, strong ties with nonresident father alone are found to be associated with having fewer internalizing behaviors and less acting out at school when they are compared to adolescents who have weak ties with both parents (King and Sobolewski, 2006).

Yet, regardless of the family structure, strong parent-child attachment with parental involvement, supervision and monitoring are found to reduce the negative effects of living in a single-parent or step family on delinquency (Demuth and Brown, 2004). Thus it is the quality of the relationship between the parent and the children, rather than the family structure per se, that could become either a risk or protective factor for adolescent problem behavior (Krohn, Hall and Lizotte, 2009). 73

Parental monitoring Parents are regarded as an influential factor in determining whether youths use substance, including licit or illicit ones (SAMHSA, 2009). Low parental supervision and monitoring have been found to be a strong predictor of tobacco and alcohol use in children and other delinquent behaviors (Griffin, Botvin, and Scheier, 2000; Robertson and Stein, 2008). Parental attitudes regarding drug use exert a strong influence on adolescent (Peterson, 2010; Sawyer & Stevenson, 2008). Explicit expression of disapproval by parents about substance use, and appropriate involvement in their daily activities, are found to be the key deterrent against substance use (SAMHSA, 2009). Adolescents are found to benefit from having clear rules from their parents concerning substance, and from believing that there are consequences attached to their behaviors (Parsai, Marsiglia, and Kulis, 2010). In contrast, parents who indicate a permissive attitude towards substance use increase the likelihood of their children actually using it (Frye et al., 2008). Effective parental monitoring therefore is a significant protective factor against adolescent drug abuse. However, previous research shows that many parents are unaware of the influence — including their beliefs, languages, behavior — that they exert on their children (Mallick & Stein, 1999). In addition, the prerequisite for appropriate parental monitoring is having a strong parent-child relationship (Frye et al., 2008) 74

Parenting style Those who practice “authoritative parenting” — namely, parents who are supportive, expect compliance with rules, show consistency and fairness in their discipline, and encourage their children to become independent — usually can raise children who are resilient (UNODC, 2009), which is also a significant protective factor against drug abuse and other adolescent problematic behaviors. Support and nurturance should be combined with structure and control in order to have a positive and lasting impact on children, which is exemplified in school achievement, psychological well-being, social adjustment, and less delinquency (Baumrind, 1996). This can have an enormous impact on how children develop self-control and compliance with social rules (Dawe et al., 2006). Such positive effects are found to even last until middle and late adulthood (Rothrauff, Cooney and An, 2009). Gender differences are also found in terms of how boys and girls react to different parenting quality. A local longitudinal study examining parenting quality and parent-adolescent conflict shows that earlier negative parenting quality predicted a heightened level of later parent-adolescent conflict for adolescent girls but not for boys (Shek, 2002b).

On the contrary, negative parenting practice could increase the risk of youth substance use. Physical abuse and exposure to violence increase the likelihood of 75

substance abuse (Dembo et al., 1992). A Hong Kong study found that physical maltreatment at home is associated with a higher prevalence of psychoactive drugs use among students and a higher likelihood of approving others using such substances, although the study did not examine the direction of the causality (Lau et al., 2005). Parent-child communication and long work hours Positive parent-child communication is also a protective factor. Open and frequent communications could become a protective factor in situations like alcohol use (Pasch et al., 2010; Wills et al., 2003). Some scholars call for the need to enhance parental communication competence and improve family communication

environments to capitalize on the influence that parents still have on their children to reduce the chance of substance use (Miller-Day, 2008). Also, adolescents who engage in more regular family activities (such as frequent dining together), greater parent’s knowledge of their children’s friends and teachers all report a lower level of substance use through mid adolescence than their counterparts (Coley, VotrubaDrzal, and Schindler, 2008). Yet in Hong Kong, finding time to dine or even communicate with the children becomes a luxury because of long working hours. The latest work-life balance survey in Hong Kong indicates that over 70% of employees spend less than two hours per day on personal or private activities in 76

2009 (Ng and Bernier, 2009). The same survey conducted in 2008 found that over half of the survey respondents need to work late in the evenings (Welford, 2008). As indicated by Bittman (1999), leisure time is important for not only the employees but also their children and the family. More time at work also means less time spent by parents supervising the children, engaging in meaningful activities with them, or simply accompanying them. Work-family conflict remains a concern in Hong Kong, and long work hours definitely exert impact on parenthood (Lau, 2009; Wharton and Blair-Loy, 2006). Parental conflicts While family cohesion and positive attachment to significant caregivers serve as a protective factor, family conflicts and family transitions could be disruptive to adolescents. For instance, transition events such as divorce are linked to the loss in the effectiveness of parenting. Supervising the children could become more difficult, as this is related to the hostility and lower attachment caused by an addition or subtraction of a parent figure in the household (Krohn, Hall and Lizotte, 2009). The negative outcomes of divorce on children are well studied (Strohschein, 2005), although the impact on the children prior to the separation versus after the divorce may differ by gender (Doherty & Needle, 1991). Even not in the case of divorce, constant exposure to inter-parental conflict has significant negative impact on the 77

children’s well being (Ali, 2010). They often become triangulated in the marital conflict and display their distressed experience through physical and psychological symptoms (Ali, 2010). These may exhibit through externalizing behavior (such as substance abuse and delinquency) or internalizing behaviors (such as depression and self-inflict injuries) (Ali, 2010). Also, these children often show a higher rate of substance use, and score poorer on both physical and mental health (Hair et al., 2009). In Hair’s study, the adolescents who indicate the worst physical and mental health outcomes are those with poor parents’ marital quality coupled with poor relations with their parents. Family discord is also linked to higher instances of major depressive disorder and substance disorder in offspring, which can have lasting impact (Pilowsky et al., 2006). Marital relationship could therefore have a spillover effect on parent-child relationship and young people’s well being (Bradford et al., 2008). A local study on Hong Kong Chinese pinpointed that such spillover could be mediated by other factors such as parental well-being. Yet the spillover effect of marital quality to parent-child relationship is stronger in fathers than in mothers (Shek, 2000). In summary, poor marital relation is a risk factor increasing the susceptibility of young people to negative influences and, in turn, causing the increase of problematic behaviors.

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2.2.4.2 Sibling Sibling can be an important source of influence for many children and adolescence (Engels et al., 2005). There is high similarity in drinking and drug use in siblings (Latimer et al., 2004; Poelen et al., 2007). If siblings are less than two years apart in age, of the same sex, and spend time together at home or outside of home with little parental monitoring, siblings can become significant role models (Windle, 2000; Boyle et al., 2001). This is true especially related to the effects that older siblings have on younger ones, and if they are of the same gender (Vorst et al., 2007). This is not surprising since the access to licit drugs such as alcohol and tobacco is determined by age, and hence the presence of an older sibling who engages in substance use would naturally provide the means for the younger sibling to obtain it (Boyle et al., 2001). In addition, it is found that siblings of drug abusers are at a greater risk compared to peers of the same age to use various types of drugs (Bamberg, Toumbourou and Marks, 2008). Rather than attributing to genetic predisposition, it is more likely that the environmental influence the non-user faces, and the shared environment that both siblings are exposed to, cause the higher prevalence of drug use. That includes easier access to drugs (nonuser getting drugs from his or her sibling), exposure to family conflict and violence, and disruption of school in case of a crisis (Gregg & Tombourou, 2003). However, a study by Fagan and 79

Najman (2005) argued that it is the sibling relationship itself, rather than the shared family environment, that best accounts for sibling resemblance in drug use. Also, it is found that exposure to siblings’ substance use may contribute to affiliation with substance-using peers (Windle, 2000). That is likely because the younger sibling may develop a more positive attitude towards drug use than their counterpart in these cases (Frye et al., 2008).

Some studies even argue that, when comparing sibling versus parental influences, the former serves as a more powerful role model especially during adolescence (Epstein, Williams, and Botvin, 2002; Fagan and Najman, 2005). Siblings have a long history of shared experiences that peers cannot replace and cannot have an effect of “peer selection” (Gregg & Tombourou, 2003). In addition, families with drug-using children likely have a pervasive negative atmosphere in the family, as the entire family may focus their attention on the drug-using sibling, making the nonuser sibling feel marginalized. Sense of shame and embarrassment would also increase the sense of isolation felt by the non-drug-using sibling, and leading to a decrease in family attachment (Gregg & Tombourou, 2003), and also an unwillingness to seek social support from outside the family because of fear of disclosure and the intense feeling of shame (Frye et al., 2008; Bamberg et al., 2008). 80

They are likely to be expected to play “good” in the family and not to elicit more troubles to their families, often requiring more maturity beyond their ages (Frye et al., 2008). It is reported that young people with drug-taking older siblings typically have a pervasive sense of loss about “losing” a former, more “normal” relationship with his/her sibling, and experience more anxiety and concern of the well being of their siblings. They also need to cope with seeing their parents struggle with their drug-using sibling (Frye et al., 2008). Thus a sibling with drug use may present a risk factor for sibling who is a not (Lloyd, 1998).On the other hand, in view of the growing number of single child in Chinese families, sibling support or the lack of it should become another focus when it comes to drug prevention and intervention (Fagan & Najman, 2005; Bamberg et al., 2008). 2.2.4.3 Grandparents It is worth noticing that in the latest student drug survey in Hong Kong, more than 7% of the secondary school students who use drugs live with neither of their parents (ND, 2010). Grandparents, especially grandmothers, often assume surrogate parenting when one or both of the biological parents are unavailable for various reasons, for example, parents’ long hours of work, family crisis such as divorce, drug or alcohol abuse in parents, mental or other illness in parents, or incarcerated parents (Frederick, 2010; Tan et a., 2010). 81

The issues with grandparenting often relate to child management, for instance, whether the grandparents have the sufficient stamina to have proper monitoring of “unruly” adolescents (Frederick, 2010), especially for grandparents who are older. Grandparents also face challenges in assuming the role as caregivers, especially if the arrangement is developmentally off-time and if they take the role with ambivalence (Landry-Meyer and Newman, 2004). Such psychological distress could increase the possibility of dysfunctional parenting. There are occasions where grandparents may not understand sufficiently the basis of their grandchildren’s disturbance, or believe blindly that the children will outgrow the difficulty or the problem that they are facing (Mayer, 2002). Earlier studies found that some grandchildren under the custodial care of grandparents may make attempts to stretch limit setting, being manipulative, resist authority, and struggling over grief and rage as they feel that their parents have abandoned them (de Toledo & Brown, 1995). Children under kinship care are found to possess more behavioral, emotional, and school-related problems than other children (Smith & Palmieri, 2007; Billing, Ehrle, and Kortenkamp, 2004).

However, the above findings do not suggest a causal relation between grandparenting and increased level 82 of youth delinquent behavior. As

aforementioned, most children who need extensive kinship care are those who are also exposed to high-risk environment in their immediate family characterized by family crisis and conflicts, such as having substance-misusing parents, or incarcerated parents, or parents undergoing divorce (Frederick, 2010).

Grandchildren who establish reliable and loving relationships with their grandparents and who live in a structured environment can have some of the risk offset. For instance, a study indicated that comparing single-parent family-raised versus grandparents-raised children, the latter performed significantly better across health, academic and behavioral dimensions (Solomon and Marx, 1995). Again it shows that the presence of protective factors (in this case, good parenting role performed by grandparents) could offset the harm brought about by risk factors (e.g., family issues that lead to the need to use extensive grandparenting). This is also one reason, as we will explore later, that countries such as the U.K. has stepped up efforts in providing resources and support for grandparents who take up this role. 2.2.4.4 Domestic helpers and nanny In Hong Kong, hiring live-in foreign domestic helpers (FDH) and nannies is a common solution to household chores and child care for working mothers, number for over 250,000 in Hong Kong (Hong Kong Census & Statistics Department, 2009). This is a practice found also in other parts of Asia, Middle East, and parts of North 83

America (Statham & Mooney, 2003; Tam, 2001). In Hong Kong, although many working mothers still prefer close kin to FDH to have a child care role (Tam, 2001), the norm of having nuclear family and the relative affordability of FDH makes FDH still a more viable options (Chan, 2005; Tam, 2001).

The FDH in Hong Kong have live-in stipulation and technically can provide “round the clock” care around the household. These domestic workers do all types of work related to infant, children and teenager’s need at home: escort them to and from school and extra-curricular activities, feeding, laundry, monitor their homework, entertain them, and even share the same room with the children. Some FDH and even their employers would consider the workers as “surrogate mother”, as the time spent with them, their level of interactions (and sometimes affection), and the roles and responsibilities are comparable to that of a mother (Lai, 2009). However, as employees, they often do not have the same status in the live-in family. In fact, their role as employees in the family likely makes them feel that they are the subordinates of the children (Hong Kong Christian Service, 2002). Thus there is essential a conflicting role in terms of child care – as surrogate mother they should have certain power to discipline the children, yet as the children’s subordinate they may not have the power to, or has reservation about, when and how to discipline the children. 84

They are therefore likely to seek for the children’s cooperation rather than playing a role in teaching or disciplining them (Ip et.al., 2008; Hong Kong Christian Service, 2002). In their study in Singapore, Ebbeck and Gokhale (2004) found that majority of the parents surveyed do not expect the FDH as being one of the disciplining adults, although they spend a disproportion amount of time (compare to the parents) to care for the children. The author hence raised concerns about if children have a clear understanding of boundaries and misbehavior and their consequences if consistent behavior and correcting strategies are not enforced by FDH versus by parents.

Roumani (2005), based on the study in Saudi Arabia, raised the awareness of using housemaids as caregivers to their young children. Since FDH are not trained childcare professional and given their low positions in the family, the author is especially concerned with the social and emotional development of young children, including attachment issues, separation anxiety (especially involved in change of maids), issues in children’s personality and social attitudes if FDH spent extensive amount of time with the children. And yet if non-parental child care is with highquality, it could still have a positive impact on children’s social competence and positive development (Ip et al., 2008). 85

In terms of relating FDH with risk factors for youth development, there have been relatively few studies conducted on that topic. However, the aforementioned issues about inconsistent parenting practice by FDH versus parents, ineffective monitoring, and poorer attachment to parents (especially facing FDH more than parents because of long work hours) that are exhibited in childhood could also transcend to youth. This can be an issue especially if the quality of childcare is not high.

2.2.5. Religion and Spirituality
Religion and spirituality have a significant role in both preventing and treating substance abuse. Religious affiliation — be it Christianity, Judaism, Hinduism, Islamism, Buddhism, etc. — is found to be negatively correlated with substance abuse in both adolescence and adults (National Center on Addiction and Substance Abuse at Columbia University, 2001). It has been shown to be a protective factor against substance abuse (SAMHSA, 2007). This can be explained as follows: First, proscriptions from religious groups likely prohibit and restrict substance use in various ways. It works as a form of social control and provides guidelines for behaviors (Koenig, 2009). Second, the spiritual community can play a supportive role, including the family’s religious values that typically discourage substance use, and involving with peers who are less likely to be using drugs. Adults also tend to have a 86

more stable connection with community and social network (NSDUH, 2007). Third, a relation with God or a “higher power” greater than self often produces a psychological or physical reaction that satisfies an individual’s spiritual, physical and mental needs (NSDUH, 2007). In terms of substance abuse treatment and recovery, values such as respect, forgiveness and honesty that are emphasized by many religious faiths can be helpful to recovering addict and their families. Feelings of acceptance and instillation of hope for the future are important components in the recovery process, and these needs can often be met in a religious or spiritual context (Miller, 1998). Positive outcomes are found in substance abuse treatments that include greater commitment in the treatment program, and active and sustained involvement during and after treatment (Hill, Burdette, Weiss, and Chitwood, 2009). Furthermore, this positive impact is not limited through participation in specific or tradition religion per se, but also in a broader sense of faith and spirituality such as an individual’s search for the ultimate meaning and purpose in life (Grodzicki, 2005). One prime example of using faith-based approach in treatment is the twelve-step programs adopted by Alcoholics Anonymous (AA) in North America to combat alcoholic use. Local examples include Fresh U Christian New Being Fellowship and Christian Zheng Sheng Association, which use Christianity as a means to drug rehabilitation. Notwithstanding the positive impact of religious influences, there are 87

cases that work the opposite. For instance, individuals who practice religion that advocate strict substance abstinence may completely withdraw from their religious involvement when they start using drugs, thereby worsening their psychological health due to guilt, shame and increased social isolation (Koenig, 2009). Yet overall, systematic research to date generally suggests positive influences of religious affiliations (Koenig, 2009). In addition, regardless of the various styles and structures of the faith-based program such as faith-permeated, faith-centered, faith-affiliated, or merely having background of faith (Tangenberg, 2005), religiosity and spirituality can be an important correlate for success in a variety of treatment programs including substance abuse (Walton, 2007).

2.2.6. Family well-being: facilitative and hindering factors
An extensive body of research confirms that family functioning has a significant impact on the life chances of individual family members (Stevens, Dickson and Poland, 2005). So the question remains — what constitutes a healthy family? A family study from New Zealand conducted in 2005 (Stevens et al., 2005) may shed light on the issue. The three key facilitative characteristics of what is considered a “successful” family are, reportedly, (1) family has the resilience to cope with change and adversity, (2) parents possess positive parenting skills, and (3) a strong communication among 88

family members. Other successful outcomes for a family include a continuous, ongoing relationship between family members and children, reciprocity of support among family members, and transmission of cultural, spiritual and religious values to their children. The study also found that the parents’ aspirations for their families largely focus on desired outcomes for their children, such as to achieve good educational outcomes so that they can become responsible, happy, and selfsufficient adults. The success of their children and the overall family functioning are considered a more important indicator of family well-being than wealth.

Yet, there are several factors hindering such positive family outcomes. First and foremost is being economically disadvantaged. A reasonable income through employment is critical to building family well-being through meeting the family’s basic needs, achieving a reasonable standard of living, and supporting the aspirations of individual family members. This is also necessary to increase the chance of achieving successful outcomes both in the short run and across generations (Stevens et al., 2005). Another issue is time constraints. One of the most prevalent challenges reported is the ability to balance family time and income without compromising the standard of living. Work-life balance seems even more challenging for low-income and single-parent families. Third, a lack of parenting 89

knowledge and poor communication skills within the family is also problematic. Many respondents indicate the benefits they receive from participating in parenting courses. Most of them acknowledge the parents’ need for parenting advice, and encourage greater community access to such advice and parent education — while many people still consider it embarrassing to seek help or are unsure where to go for help when needed. Fourth, poor access to resources such as an adequate income, good education, health services, housing, and transportation is also a barrier hindering the well-being of families. Furthermore, conflicts between social expectations of their role as parents and as contributors to the economy, societal and cultural values on materialism, expectations of young people, etc., all serve as a source of tension and hinder the functioning of the families if not addressed appropriately (Stevens et al., 2005).

It is also noteworthy that low-income and “non-traditional” family structures, such as single-parent families, face more challenges than others in achieving family well-being. Fewer economic resources and possibly longer working hours make them less flexible and with less control in their time management, in contrast with families with greater economic resources who can hire domestic helpers to take up a part of the household chores to compensate for the time lost from, for instance, commuting 90

to work. These all have implications on the family functioning (Ma, Wong, Lau and Pun, 2009). Another local study on low-income families also argues that the social capital of marginal communities in Hong Kong cannot sufficiently mediate the stress of the poor (Wong, 2004). For single-parent families, juggling between work and family commitment such as child care is more serious than families that can have shared-parenting (Stevens et al., 2005).

Informal networks from friends, neighbors and families also have a key role to play on impacting children and family well-being. Quality networks such as a stable and resourceful neighborhood, and where families (the core and / or extended families) are willing to render support, can improve outcomes for families. Factors in the work setting can also have significant impacts on families as it directly affects the amount and quality of time people can spend with family members (Stevens et al., 2005). Flexible working conditions, supportive employers, reduced working hours, availability of longer annual and parental leave, and increased wage levels can all contribute positively to building healthy families (Hand, 2005).

Thus, achieving family well-being requires an ecological understanding and tackling of the issues involving different “layers” of the systems, which include family 91

dynamics, friends, communities, workplace, government policies and services, and the broader economic and social environment (Stevens et al., 2005). Inevitably, the influences from the immediate environment such as family dynamics, friends, communities and workplace are often more salient and direct than from the macrosystem such as government policies and services. What is important, however, is to ensure a “family perspective” to be integrated in the development and evaluation of policies and program in order to reflect the importance of family unit — in both the workplace and public policies — which in turn can make a stronger impact on family well-being (Stevens et al., 2005).

A Hong Kong study conducted in 2008 revealed what is considered to be family well-being in a local context. An ideal family is regarded as a harmonious family (and in a majority of case, a “nuclear family” with parents and children). Such harmonious family should be able to provide emotional and/or financial support, having feeling of togetherness, have happiness and fun with each other family members (Chow and Lum, 2008). Specifically, harmony refers to effective communication, acceptance, and lack of conflict. Similar to the aforementioned survey conducted in New Zealand, income could become a major source of conflict as pointed out by participants from more economically disadvantaged areas such as 92

Sham Shui Po and Tin Shui Wai. Yet survey participants also agree that money is necessary but not sufficient to contribute to harmonious family relationship. Most survey participants also indicate that people are always too busy, making it difficult for family to spend time together (Chow and Lum, 2008). While parents spend long hours on work, children in Hong Kong also spend disproportional amount of time on homework assignment and meeting other demands from school that they have little time to spare to spend with family members. Education also becomes a source of conflicts between parent and children and between the couple. The report therefore calls for more family-friendly policies in both the public and private sectors. Examples include setting a limit for maximum number of working hours, “happy learning initiatives” in schools, increased flexibility in work schedule, etc (Chow and Lum, 2008). The close to 20-year advocacy in Hong Kong on home-school cooperation to promote child development is also another approach to enhance child and family well-being through better communication between the parent and school systems. The movement has led to the setting up of the Committee on HomeSchool Cooperation in 1993, and the establishment of Parent-Teacher Associations in nearly all primary and secondary schools and some of the kindergartens by 2010 (Committee on Home School Cooperation, 2010). However, evidence on the impact

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of such on the enhancement of children and family well-being has yet to be established.

2.2.7. Summary
As we see in this section, family functioning has significant impact on adolescent substance abuse. Simultaneously, substance abuse can have a significant impact on family members. As family encompass parent-child relationships, interparental relationships, sibling, grandparents, and domestic helpers, etc., prevention and intervention efforts should therefore not only address the drug user per se but different parties within the family and the drug-user’s surrounding in its entirety, i.e., the most significant risk and protective factors in the person’s development system. After in-home family support, family skills training programs are proven to be the most effective approach in preventing substance abuse(UNODC, 2009). It is stated in the UNODC report lessons learned from the alcohol abuse prevention. The effects of family skills training tend to sustain over time. In comparison, positive impact from community-based prevention tends to decrease over the years (UNODC, 2009). This is because family programs focus on strengthening powerful protective factors, which in turn reduce the risks and thereby changing the family environment that the youth are facing. The most effective programs are those who have an emphasis on active parental involvement, and developing skills in the young people’s social 94

competence and self-regulation (Petrie, Bunn, and Byrne, 2006). They focus not only on the issue of substance abuse, but on a broader topic such as maintaining good familial bonds and setting clear standards. Also, the best time to deliver the programs is found to be the major transition period, such as the change from primary to secondary school (Petrie et al., 2006; Lockman and Steenhoven, 2002). This is a key developmental point where there is a normative change in peer and family relationships, the increasingly independent nature of the academic studies, and increased peer pressure (Lockman and Steenhoven, 2002). By addressing these baskets of risk and protective factors, family skills training programs could prevent not only substance abuse but also other problematic adolescent behaviors which are shown to have similar factors as substance abuse (UNODC, 2009).

2. 3. Countries Analysis
In this section, we will provide an overview of anti-drug prevention initiatives in certain countries: U.K., U.S., Australia, Canada, Taiwan, PRC, and Singapore.

2.3.1. United Kingdom
Overview Family is their priority in addressing drug issues. U.K. drug strategy, as they have put it, has a long-term view about drug prevention issues. They believe that parents and families have the ultimate responsibilities to protect and educate their 95

own children about drugs, and hence the government’s role is to equip families in doing this job.

In fulfilling their duties rightfully, families can significantly offset risk factors that cause youth substance abuse, and potentially other youth problematic issues. Also, UK emphasizes the collaboration among agencies and groups in delivering families and in youth service. Thus the government urges both children and adult services and delivery systems to think from the “whole family” perspective and preventing youth drug abuse by managing their parents and family issues in a holistic manner, especially those with the higher risks. This new “Think Family” approach is still undergoing its initial stage for national-wide implementation and would undergo regular review. 2.3.1.1 U.K. Drug Strategy The ten-year drug strategy (2008 – 2018) prioritizes families for the first time (Department for Children, Schools and Families [DCSF] web site, 2008). It places sharp focus on effective prevention and intervention before problems arise (Home Office, 2008). This new approach emphasizes family support, intervening early with at-risk families (such as families with substance-abuse parents), improve drug education by strengthening the role of schools, provide targeted youth support for 96

vulnerable youth (i.e., youth that at the verge of displaying problematic behaviors), and provide effective treatment. On prevention, the strategy focuses on the following key actions – Family-specific (1) Utilize family-based intervention, which strengthens and supports more families, and in turn builds young people’s resilience and hence reduce the harms caused by substance abuse. This can be done through providing better information and training to strengthen parents and carers’ (including grandparents) role in preventing youth substance abuse (2) For parents with substance abuse issues, ensure prompt access to treatment for all drug-misusing parents. All assessments will take account of the needs of the entire family so that the children are under appropriate care during and after treatment. (3) Deliver a package of interventions for families at risk to improve parenting skills, helping parents to educate their children about the risk of drugs, supporting families to stay together and break the intergeneration transfer of problems (4) Support kin carers (e.g., grandparents caring for children with substance-abuse parents) by improved information for them, and exploring the options to make payments to children classified as “in need”. 97

Mainstream prevention It aims at intervening early through school and youth services rather than through specialist service only when substance misuse occur (1) Strengthen the role of mainstream prevention, such as reinforcing the roles of schools in delivering drug education in school, and identify at-risk young people early (2) Improve access to social inclusion programs. (3) Provide integrated responses for vulnerable youth, such as through Targeted Youth Support, to address related issues such as youth crime, teenage pregnancy. Public information campaign (1) Extend the use of FRANK (media campaign) to provide access to support and intervention (2) Improved support and information for parents The strategy also calls for making improvements to the treatment system for young people and building a U.K. evidence base of what works (Home Office, 2008). 2.3.1.2 Family Programs The paragraphs below outline the programs that are directed specifically towards families. It is noteworthy that these initiatives do not address only substance abuse. Rather, they use families as a unit and target at assisting families at risk who 98

typically face multiple problems including substance abuse, as drug abuse is a manifestation of the underlying problems within the family. Parenting Early Intervention Programs (PEIP) Background PEIP: Pathfinder (2006 – 2008) PEIP is a large-scale implementation of parenting programs in the local communities. There are three main publications and campaigns that drive the development of PEIP. First, “Every Child Matters: Change for Children” was published in December 2004 and proposed an improved and integrated children services’ delivery to improve outcomes for children and young people7. It aims at achieving five outcomes for children: be healthy, stay safe, enjoy and achieve, make a positive contribution, and achieve economic well-being. In “Every Child Matters: Change for Children – Young People and Drugs” (Department for Education and Skills, 2005), it further identifies parents, carers and families are having a key role in preventing drug use among young people.

7

“Every Child Matter” was a Green Paper published by the British Government in 2003 in partial response to a unique child abuse case in Britain. Victoria Climbié, an eight year old girl, was horrifically abused when she was under the care of her great aunt and her boyfriend, and died in 2000. Her death caused tremendous awareness in the severe lack of coordination, insensitivity and bureaucracy in public services including health services, welfare agencies, child services system, police, etc., as Victoria’s abuse case was repeatedly handled by various public service systems yet none of them seemed to take the ultimate accountability to ensure her safety. A public inquiry was conducted after her death which led to major changes in the child welfare system in the U.K (DCSF, 2008a).

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Second, the “Respect” Campaign and hence its Action Plan in 2006 mainly addresses issues of anti-social behaviors (ASB), with drug abuse and its related crime being one of the ASB. It recognizes parents are fundamental to the children’s development and committed to develop further parenting services especially to those families needing the most help with developing and maintaining proper parenting role.

Third, alongside it is The Children’s Plan (December 2007), which has an aim of making “England the best place in the world for children and young people to grow up”. The plan clearly states that as it is parents, and not government, who bring up children, and hence the government needs to do more to back parents and families. As families are considered the bedrock of society and the first place that happy, capable and resilient children are nurtured (DCSF, 2007a), the government is responsible for assisting parents to do the best for the family, offer advice and prevent problems to arise.

Therefore, based on the notion of early intervention, PEIP were first rolled out from September 2006 – March 2008 to support parents in “doing their jobs as parents”. The pathfinder program (Wave 1), targeting children from 8 to 13 years old 100

at risk of negative outcomes (and anti-social behavior in particular). It utilized three evidence-based parenting programs: Incredible Years Triple P Strengthening Families Strengthening Communities (SFSC)

Results of PEIP Pathfinder The three programs were found to be equally effective in improving parents’ mental well-being, parenting skills, the sense of being a parent, and in the behavior of the child (Lindsay et al., 2008). The number of parents who classified their children as having significant behavioral difficulties cut by half by the end of the program. Parents reported to be calmer and giving more time to communicate with their children – both talk and listen to them. They perceived their relationship with children have improved, although one point to note is that these are based on parents’ perceptions rather than direct measure of behavioral change. PEIP (2008 – 2011) With its successful pilot from Wave 1, the DCSF decided to expand this program across most of the country from 2008 – 2011. Local authorities (LA) are allowed to select parenting programs other than the three used in Wave 1, and in addition, Strengthening Families (8-14) and Families and Schools Together (FAST) are 101

added (DCSF, 2008b) Family Intervention Projects (FIPs) Background Stemming from the Respect Action Plan, FIPs aims at stopping the anti-social behaviors of problematic families that are causing threats to the neighborhood, and achieve the five outcomes outlined in the “Every Child Matters”. Launched in January 2006, FIPs deal with the most challenging families showing intergenerational disadvantages, likely having multiples issues such as drug and alcoholic abuse, domestic violence, school absenteeism, youth crime, unemployment and debt (White et al., 2008).

FIPs employs an “assertive” and “persistent” working style to both challenge and support families to address the root causes of their ASB (Home Office, 2008), with an aim of reducing ASB, preventing youth crime, and tackling child poverty (Home Office, 2010). Services were conducted in two ways: outreach support to families in their own home, or a 24-hour support in a residential core unit where the family live with project staff, and they will move out when the behavior of the family improves. Specific support provided to these families include one-to-one parenting support, provide meaningful activities for parents and children, financial 102

management, locate education and job opportunities, etc. Results Periodic review in July 2008 and March 2010 indicated that the outcomes for families are overwhelmingly positive. A 64% reduction in ASB were recorded, 89% reduction in four or more ASB problems, 58% reduction in truancy, exclusion and bad behaviors at school, and 70% reduction in substance abuse problem. Early indications suggest that these outcomes are able to be sustained up to 9 to 14 months after they exited from FIPs (National Centre for Social Research, 2010) for the 10% of the families that have been followed-up. Think Family Pathfinders and the Think Family Approach Background The Think Family Pathfinder was launched from May 2008 to 2011 and it is the latest approach in U.K. on dealing with drug abuse and other social issues related to at-risk families. By “Think Family”, it means an approach that aims at delivering well coordinated, multi-agency interventions to join up both the children and adult’s services to families in need, and offer PEIP to improve parenting skills for at-risk families. Its mentality is based on the report published in January 2008 by the Cabinet Office, “Think Family: Improving the Life Chances of Families at Risk” which studies families at risk – families who are the most vulnerable with multiple and 103

complex problems. Typically, these families are characterized by having these common risk factors: Substance abuse Mental health issues (adult mental health in particular) Domestic violence Anti-social behavior Housing issues Adult learning difficulties and disabilities Unemployment School attendance and behavior

The Cabinet Office’s report findings argue that in order to break the intergenerational cycle of disadvantage, all systems and services should meet the individual needs in the context of the entire family. In other words, clients should not be seen just as individuals but as parents or family members (Cabinet Office Social Exclusion Task Force, 2008). Such “whole family” and “integration of services” approaches also draws on the success of projects such as the FIP (Cabinet Office Social Exclusion Task Force, 2008; DCSF, 2010a). It also coincides with theme from the Children’s Plan in 2007. 104

The program aims at reaching families with highest level of need so that families would not “yo-yo” in and out of the thresholds for statutory interventions, and also to carry out more preventative work for those whose situation may exacerbate without preventative support (DCSF, 2010a). Besides the 15 Family Pathfinders who initially led the implementation of the Think Family, six more Extended Family Pathfinders and in November 2009, 12 two-year Young Carer Pathfinders were launched to prevent inappropriate caring from a young person in a family (DCSF, 2010). Figure 6. The Building Blocks of Family Pathfinders

Interagency governance Integrated strategy Integrated processes Families at the centre Integrated frontline delivery

Families at the centre: Families are involved in the design of their support wherever possible and empowered through devolved budgets and family-led decision making. Integrated frontline deliver: Empowered and assertive practitioners provide tailored 105

and joined-up support around the whole family. The identify needs early and proactively engage families. Integrated processes: Shared assessments and information across agencies give a full picture of a family’s needs and help ensure support is fully co-ordinated. Integrated strategy: Joined-up planning and commissioning drive a focus on families at risk across all agencies. Inter-agency governance: Accountability for family outcomes is clear, with strong leadership at the top and protocols setting out agreed responsibilities between agencies.

Besides an integration of service delivery, the LA would offer PEIP to improve parenting skills using evidence-based programs to parents of 8 – 13 years old whose children are at risk. Ideally, the program should provide a more effective and costeffective models for service delivery (DCSF, 2010a). Interim Results and Challenges for Think Family Pathfinders Based on the latest (being the first) update published in early 2010, there are emerging positive impacts on families: 1. the program is able to streamline package of support offered to a family who

is at the verge of disengagement . Otherwise there are, in some cases, more than 20 106

agencies working with the same family simultaneously. 2. In some cases where both parents have alcohol misuse issues and the child is

still young, detoxification program has factored in both parents need to be detoxified at the same time but at different locations so that one parent can take care of the child at home while the other is at residential care.

Challenges are found at both the strategic and operational level. At the strategic level, there is lack of clarity regarding their positioning as there are no senior leaders driving the development of the Pathfinder. There is also a need to develop data sharing protocols on the family’s data. And currently, as this program is led by the DCSF, it is viewed locally to be a children’s services initiative and thus seems to be too focused on children’s services. At the operational level, different thresholds for accessing services across different services led to difficulties in constructing cross-service packages of support for families (DCSF, 2010b). Lack of referral of adult services is also a challenge. Suitability of existing assessment tools as the basis for the “Think Family” assessment varied. Staff issues such as key personnel on sick leave would also impact on delivery.

As this “Think Family” approach is still underway, there will be periodic 107

update over the next 12 months. Other Family-related Initiatives Children’s Workforce Development Council (CWDC)’s parenting academy CWDC takes up the parenting academy’s functions in March 2010. Formerly known as the National Academy for Parenting Practitioners (NAPP) which was originally established in November 2007, they provide parenting skills training to practitioners that parents turn to for advice. They provide advice on the best practice in parenting support that is evidence-based. A Commissioning Toolkit was created in December 2008 to serve as a database that help Children’s Trusts to deliver effective parenting strategies (CWDC, 2009). Parent Support Advisors (PSA) Parent Support Advisors are provided in schools and aims at helping parents to increase their involvement in their children’s learning, behavior and attendance in school. Evaluation of PSA during their pilot run from 2006 – 2008 found that it improves parents’ engagement with their child’s learning, improved relationships between parents and schools and most importantly, improve pupil attendance. Secondary schools’ persistent absentees were reduced by a quarter during that period (Lindsay et al., 2009).

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Support for Young Parents The DCSF has launched a refreshed strategy improve outcomes for teenage parents and their children. The guideline required Local Authorities to bring together different services including midwifery, health visiting, children's centers and targeted youth support (TYS) services to provide integrated, tailored support for young parents. It aims at improving child health outcomes (including infant mortality and birth weight), emotional health and well-being experienced by teenage mothers, and economic well-being. Examples of such support for young parents include Sure Start’s Children Centers that bring together early education, childcare, health and family support (DCSF, 2009a). They cover a wide range of programs – both universal and those targeted on particular local areas or disadvantaged groups within England. The “Care to Learn” scheme provides financial help with childcare if the applicant is in college, at school or taking part in a work-based learning program. In addition there is the Family Nurse Partnership (FNP) Program. Originated from the U.S., it is an intensive nurse home visitation programs that run in certain U.K. locations as part of their aforementioned Early Intervention Program to break cycles of intergenerational underachievement and deprivation. Target participants of FNP are first time young parents and nurse home visitations which continue until the child is two years old.

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Their roles encompass helping young women engage in good preventative health practices including antenatal care, healthy diet and reduction in smoking and substance misuse; increase the involvement with fathers and improvements in the child’s readiness to attend school; support parents to provide responsible and competent care; improve the economic self sufficiency of the family by supporting parents to develop a vision for their own future; plan future pregnancies; and make plans to continue education and finding work (Department of Health, 2009). The Teenage Pregnancy Independent Advisory Group (TPIAG) was set up in 2000 to advise the Government on the Teenage Pregnancy Strategy and to monitor its implementation. The strategy aims at reducing the rate of conceptions to under-18s by 2010 by half, and to increase the participation of teenage parents in education, training and employment (DCSF, 2009b). Drug education in school and Blueprint Drug education is one component within a wider strategic approach on targeted prevention for vulnerable youth who are most at risk (DCSF, 2008c). Currently, drug education in the U.K. is incorporated as part of the statutory requirement of science (Sc) and citizenship (Ct) programs of study. Drug education is also an important element in the UK’s Personal, Social and Health Education (PSHE) in the school curriculum, which as of to-date is not yet a statutory subject. Plans to 110

make it statutory in September 2011 are underway, subject to the legislation. Drug education starts in their curriculum Key Stage 1 (i.e., beginning of primary school), and the content progress as pupils develop their knowledge (Department for Education and Skills, 2004).

In fact, the UK drug policy in school and drug education has been undergoing significant review. Based on the 2004 Drug Guidance for School, drug testing and use of sniffer dog is allowed, yet schools are strongly advised to state clearly the school’s drug policy which should be developed after consulting students, parents, staff, governors, the whole school community, and police (if involve sniffer dog and determine whether search warrant is necessary). Schools are also reminded to use these measures with extreme caution. They are also reminded that these measures should not be an isolated action but part of a whole-school approach to manage drugs issues in school. On drug education, the project “Blueprint” was used to guide the piloting of appropriate approaches in school drug education (Home Office, 2009). Blueprint was a research-based multi-component approach to school-based drug education including school, parent, community, health policy, and media. Held between 2004 – 2005 for children at their first two years of secondary school (i.e., age 11-12), the key findings provided the basis for the Substance Misuse Education 111

Review. The findings also help revise the current Drug Guidance for Schools. Key learning points from the Blueprint program include: a. increase the pupil and parent components and co-coordinating pupil’s education with parental support, and less on community, health policy and media components (Home Office, 2009) b. Introduction of drug education program before the average age of drugs experimentation (quoted as age 11 in UK), such as in primary school, could pre-empt this stage in their development (Home Office, 2009) c. PSHE education should be made statutory in the school curriculum (target to be implemented in 2011 subject to legislation). 2.3.1.4 Positive Futures It a national sports and leisure activities-based social inclusion program for people aged 10 – 19, with priorities given to deprived neighborhood (Home Office, 2010). These activities include football, canoeing, climbing, biking and creative arts and drama. Young people in the program receive coaching skills in sports and opportunities to play competitively in sports clubs. Also, they receive educational opportunities such as through Sports Leaders UK and Open College Network. The program also provides them opportunities to volunteer, to have meaningful engagement by involving them in casual and part-time work, train up to have 112

leadership skills, and have pathways to full-time employment. Substance abuse preventions and interventions are infiltrated in this program, such as through drop-in surgeries and discussion through sport sessions and healthy lifestyle programs and workshops. Most importantly, by creating new opportunities for alternative lifestyles, solid personal relationships are built between responsible adults and participants so that the younger generations are steered towards educational and employment opportunities. 2.3.1.5 Targeted Youth Support (TYS) Under the “Youth Matter” green paper (2005)’s commitment TYS was formed as a pilot scheme in 2006. It is not a specific program. Rather, it is an approach to reform young people’ service that emphasize a collaboration of services and agencies to work more efficiently. Staff are trained at universal settings (e.g., health visitors, voluntary sector staff, youth workers) to be enhanced their awareness of youth risk factors and intervene early. The establishment of “Contact Point”, a secured online directory shared by agencies and community organizations so that they know who are working with the same individual at the same time. And by using the Common Assessment Framework (CAF), government, voluntary and community organization work together to achieve a holistic understanding of the needs of the identified young person. A multi-agency panel would be formed and strengthen the response 113

to early problems in universal settings. TYS also emphasize support in transitions period, e.g., transitions into and out of specialist or statutory interventions – young people coming to the end of a youth justice disposal or period in care or returning to school. TYS also work alongside with parenting strategies and family support service so that parents of these youth are also taken care of while the targeted youth are served. In addition, outreach programs, more convenient opening hours for drop-in centers, provision of more attractive activities, using communication channels (e.g., texting messages) to promote activities are among the means that TYS use (DCSF, 2007b). 2.3.1.6 Public Information Campaign: FRANK FRANK is a U.K. government’s national drug media campaign. It encompasses a wide variety of domains including advertising, print media, a 24/7 helpline for young people and parents, email to ask questions anonymously, and website with lots of resources about drugs and for concerned family members. The campaign targets to ensure young people to make informed decisions by understanding the risks and dangers of drugs, and know the place to go for advice and help. It also equips parents with confidence and knowledge to discuss drug issues with their children (Home Office, 2007). 2.3.1.7 U.K. Summary 114

Family is at the center of their drug strategy. Using the “think family” approach, they also target at bringing efforts in service integration to minimize intergeneration cycles of poor outcomes. In addition, engaging parents in their work, family skills training program that target not only drugs but other issues, meaningful engagement for young people, drug education in school, and the use of the mass media campaign and national hotline “FRANK”, are all involved to combat the battle against drugs.

2.3.2. United States
Overview The drug strategy in the U.S. is characterized by its emphasis on “communitybased” strategies. By community, it means the local neighborhood where everybody lives, work, and go to school. And hence, participation from representatives from all sectors of the community is essential to contribute to the success of any drug prevention and intervention efforts. In 2010, the strategy is moving towards a direction to require agencies to collaborate and deliver evidence-based programs that address common risk factors that cause a range of youth problems across different segment of the communities. In this new strategy, it has the plan to reduce the 30-day prevalence of drug use among 12 – 17 year olds by 15% by 2015 (White

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House, 2010a). 2.3.2.1 U.S. Strategy New in 2010: Prevention-Prepared Communities Program (PPC) PPC supplements existing community-based efforts and focuses on youth and young adults age 9 – 25. This pilot program include an effort in conducting epidemiological needs assessments, creating comprehensive strategic plan, implement evidence-based prevention services through multiple venues, and address common risk factors for mental, emotional and behavioral problem. In other words, the previous approach on giving prevention grant that focus on single outcome (e.g., drug abuse, bullying) to a narrow segment of the communities (e.g., a school district, a police department) is no longer encouraged. PPC’s aim to encourage agencies to co-ordinate their grant and technical assistance so that their communities could be surrounded by a range of protective factors rather than protected only in a single setting or at a single age group. SAMHSA would be responsible for the design, implementation and evaluation of PPC (Office of National Drug Control Policy, U.S [ONDCP], 2010). Drug Free Communities Program (DFC) DFC is the U.S.’ leading effort to mobilize communities in preventing drug abuse (ONDCP, 2009). It provides the federal funding necessary for communities to 116

identify and respond to local substance use problems. It is based on the notion that communities must be organized and equipped to deal with their individual substance abuse problem in a comprehensive and coordinated manner (CADCA, 2009). Local communities, commonly called “coalitions”, who apply for such grant needs to have the goal of reduction in youth substance abuse, and address multiple drugs. Most importantly, each coalition supported by DFC funding must have the representation of the following 12 community sectors from its target community to be eligible for funding: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Youth (under 18 years old) Parents Business Media School Youth-serving organization Law enforcement Religious / fraternal organization Civic / volunteer group Healthcare professional (i.e., doctor, nurse, dentist, pharmacist, etc.) State / local/ tribal government agency with expertise in substance abuse 117

12.

Other organization involved in reducing substance abuse The National Community Anti-Drug Coalition Institute, which is part of the

Community Anti-Drug Coalitions of America (CADCA), provides training and assists the communities in their anti-drug efforts and also to get the DFC funding. They propose using the “environmental strategies”, which is grounded in the field of public health and emphasizes the broader physical, social, cultural and institutional forces that contribute to the problems that coalitions address. Therefore, they are asked to incorporate prevention efforts aimed at changing community conditions, standards, institutions, structures, systems and policies. The ultimate goal is to modify the settings where a person lives, which in turn would influence how the person behaves (CADCA, 2008). As mentioned in the literature review section (page XX-XX), there are seven strategies of the “environmental prevention” approach into actions that can affect community changes: provide information, enhance skills, provide support, enhance access and reduce barriers, change consequences, change physical design, and modifying change policies. Examples of such strategies in use include local coalitions on alcohol, tobacco and other drugs that limit youth access to alcohol at grocery and convenience stores by training retailer employees, increases penalties for retailers that sell to minors, media campaign to educate parents on the dangers of smoking and underage drinking, etc. 118

Strategic Prevention Framework – State Incentive Grants (SPF-SIG) and Communities that Care (CTC) SAMHSA’s mission is to reduce the impact of substance abuse and mental illness. Center for Substance Abuse Prevention (CSAP) is her working arm directed at substance abuse. SAMHSA requires all the prevention programs run in the U.S. to uptake their Strategic Prevention Framework (SPF), which is a five-step process (Assessment, Capacity, Planning, Implementation and Evaluation) to promote youth development, reduce risk-taking behaviors, build assets and resilience, and prevent problem behaviors across the life span (SAMHSA, 2004). Their SPF is built based on a community-based risk and protective factors. Evidence-based prevention programs are expected to be used within this grant to build capacity within each State. Figure 7. SAMHSA’s Strategic Prevention Framework

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One of the most important tools that SAMHSA utilizes is “Communities that Care” (CTC), a prevention-planning system that assists communities to identify issues and implement changes. CTC has two important components: (1) Using the public health approach – a comprehensive and community-wide mobilization. The entire community is involved to promote behavior change. The “heart disease model” is often quoted as an illustration of such approach. (2) Assessing the risk and protective factors, and addressing them by using evidence-based programs, with the ultimate goal of developing healthy and positive behaviors among young people

Grounded on the Social Development Strategy (SDS), CTC provides a researchbased framework for developing the processes necessary for positive youth development (Hawkins and Catalano, 2005). Communities are asked to identify the elevated risk factors and depressed protective factors with the help of the CTC youth survey, prioritize the targeted factors that they will address, select the evidencebased programs to tackle the factors, implement them in their communities, and monitor and evaluate the progress.

SAMHSA has identified tested and effective prevention programs, policies and 120

strategies that are proven to increase protective factors, reduce risk factors and in turn, reduce adolescent problem behaviors. Examples of these evidence-based programs include Guiding Good Choice (formerly known as the Preparing for the Drug-Free Years), Celebrate Families! (CF!), Strengthening Families Program (SFP), Project ALERT, etc. CTC would help the communities to match their unique risk and protection profile and current resources with such proven programs and practices – programs can range from birth through adolescence and cover all areas of young people’s lives. CTC would also help the community to implement such program, develop action plan, and conduct evaluation at both program-level (annually) and community level (every two years).

In fact, various adolescent problem behaviors including substance abuse, delinquency, teen pregnancy, school drop-out, and violence can be predicted by a series of common risk and protective factors (Hawkins & Catalano, 2005). These factors exist at all levels including the community, family, school, and peer and individual. This basket of risk factors was outlined in Table 2 in Section Two. Thus by implementing evidence-based programs that address these factors effectively, they can have positive effects on multiple behaviors. It is hypothesized by CTC that it takes from two to five years to observe community level effects on risk factors, and five or 121

more years to observe effects on adolescent delinquency or substance use (Hawkins et al., 2008).

The evaluations of CTC are promising. The youth in communities that implement CTC have significantly lower substance abuse and delinquency than others in the controlled communities (Hawkins et al., 2008; Hawkins et al., 2009).

SAMHSA’s SPF and CTC system’s approach align with the latest 2010 U.S. drug strategy. With SAMHSA being delegated the task of reviewing the brand new PPC program grant, it is likely that the SPF framework and CTC would be used significantly across the U.S. in all prevention efforts to address a range of youth problems.

Other SAMHSA websites, such as “A Family Guide to Keeping Youth Mentally Healthy and Drug Free” (target at families with youth between 7 to 18 years old), and “Building Blocks for a Healthy Future” (target at families with young children ages 3 to 6), are public education websites for parents and carers providing numerous resources on tips to effective parenting, communication skills, importance in spending quality time with children, how to monitor children’s activities, activity suggestions for family-time and information on drug facts. Both websites are 122

designed with the purpose of promoting protective factors – the situations and conditions that decrease chances for children to engage in risky behaviors including drug abuse – within families. Substance Abuse Prevention and Treatment (SAPT) Block Grant Such funds are administered by SAMHSA and 20% of the grant is used on substance abuse primary prevention. The programs are based on five broad strategies: Information dissemination, education, alternative activities, problem identification and referral, community-based processes, and environmental strategies (ONDCP, 2010).

2.3.2.2 National Youth Anti-Drug Media Campaign It is a media campaign targeting to influence youth attitudes towards drugs. They launched the youth-targeted “Above the Influence” brand using televisions and websites, and national hotline (the “Nineline”), providing drug information and antidrug message to both parents and teenagers. While its branding strategy is very successful (as measured by the brand’s awareness among youth comparing to megabrands such as Coca-Cola and Nike, and on average of 800,000 website visits a month), the 2010 National Drug Control Strategy decided to revamp and reenergize this campaign. This is because, according to the US government, the current media 123

increasingly includes pro-drug content which normalizes drug use. It recognizes the importance of delivering anti-drug messages in the media to neutralize that. Such revamp effort would include increasing its emphasis on paid advertising (teen-centric television, print, internet and digital media), public communications (community events, corporate partnership with youth brands, youth-centered activities), and place more relevant content on teen destination websites. In addition, it would include both a national component that delivers broad prevention message to teens ages 12 – 17, and a local component which will target to be tailored to high-risk youth at the local community level. 2.3.2.3 Drug Education in School The latest Education “Blueprint for Reform” (March 2010) propose the elimination of the former “Safe and Drug Free School” program and replace it with the “Successful, Safe, and Healthy Students” program. It calls for using data-based decision making and achieving an accurate understanding of the students’ issue in order to devise all school safety strategies – drug use being one of the many components of such safety issues (Department of Education, U.S., 2010). In addition, school districts need to compete on a national basis for funding their programs, unlikely previously it was a federal-to-state funding to all school districts on a noncompetitive basis. There are also critics saying such elimination would make the anti124

drug efforts in school from “being explicit to implicit”, thereby undermining the effects of the program (CADCA, 2010). Voluntary, non-punitive drug testing is used in the U.S., mainly for athletic teams and students who involved in certain competitive extra-curricular activities. Each community within the 50 State has its discretion to decide if they would use such means to screen students. As for drug education, again the community can have its discretion of what to include in their curriculum. Before the 1990s, the Drug Abuse Resistance Education (D.A.R.E) was very popular in the U.S. and was implemented in about 70% of nation’s school district. Yet its effectiveness was under scrutiny; by the year 2001 it was classified by Surgeon General of the United States that this program was ineffective (Department of Health and Human Services, U.S., 2001). Currently there is no national strategy that governs drug education in school although elements of drug education could be infiltrated in their health curriculum. 2.3.2.4 Mentoring at-risk youth Children with incarcerated parents, alcoholics or drug users are also exposed to high risks of initiating substance abuse and also other risky behaviors. The White House’s Office of Faith-Based and Neighborhood Partnerships Initiatives provide funding to support mentorship of children with incarcerated parents, and the Department of Justice’s Office of Juvenile Justice and Delinquency Prevention also 125

support training and administering such grant (White House, 2010b). 2.3.2.5 Spread Prevention to the Workplace Since parents spend a significant part of their day at work, the U.S. government believes that the workplace is an excellent place to educate parents about youth drug use. Workforce-focused strategies, including more widespread adoption of effective drug-free workplace programs encompassing employee education, supervisor training, testing programs, and treatment referral, is believed to be able to deliver prevention messages to employees and their families(White House, 2010b). 2.3.2.6 Mobilize Parents to Educate Youth to Reject Drugs In addition to supporting parents by using family-focused and evidence-based programs, the White House’ Office of Faith-Based and Neighborhood Partnerships Initiatives and the Administration for Children and Families (ACF) try to foster greater engagement of fathers in the lives of their children. A national fatherhood tour was launched to hear from local communities on how to strengthen the nation’s families (White House, 2010b). 2.3.2.7 Support Substance Abuse Prevention on University campuses The U.S. government believes that prevention efforts should continue after secondary school education, as the largest drug-using population is among 18 to 25126

years-olds in the U.S. (White House, 2010b). 2.3.2.8 Expand Research on New Drugs Inhalants, pain killer and “study drugs” such as Ritalin become increasingly popular among youth but they are currently understudied in scientific research. Thus the National Institute of Drug Abuse (NIDA) would actively support research in to these areas (White House, 2010b).. 2.3.2.9 Increase Collaboration: Criminal Justice and Prevention Organizations Law enforcement officers would increase their participation in the local drug prevention campaigns according to the 2010 new drug strategy, since they are believed to be able to garner the attention of youth. This is especially so in the High Intensity Drug Trafficking Areas (HIDTA) (e.g., Southwest Border). Drug courts, Border Patrol program, youth service organizations, community coalitions and public awareness campaigns all work together to education the community about drug use (White House, 2010b). 2.3.2.10 Support for Young Parents Maternal-child health program such as the Nurse Family Partnership (NFP) assisted first time, low-income mother and provide in-depth relationship between nurse and client through intensive home visits. Client is visited throughout her pregnancy and the first two years of her child's life. The nurse offers guidance on 127

breastfeeding, child development, parenting skills, future pregnancy planning, preventive health measures such as help with alcohol or cigarette dependency, better diet information, advice on better financial planning and advice for mothers wanting to go back to education or employment. Improve pregnancy outcomes It has the purpose of improving child health and development outcome, prepare for the mother’s future school readiness and achievement, and improving parents’ economic self-sufficiency (Nurse Family Partnership, 2009). In terms of financial assistance, The Temporary Assistance for Needy Families (TANF) program provides cash assistance and supportive assistance to low-income families. Minor parents (those under 18) can only receive TANF if they participate in education or training activities. They also need to adhere to a living arrangement rule whereby they need to live with a parent, legal guardian, or another adult relative, or in a living arrangement approved by the state (Department of Health and Human Services, U.S., 2006). 3.2.11 U.S. Summary U.S. emphasizes using community-based approach in dealing with drug prevention, requiring the community to examine and address the relevant risk and protective factors for substance use in different ecological environment. The use of evidence-based programs is also increasingly important as noticed by the 128

introduction of the Prevention-Prepared Communities program in the 2010 strategy which encourage funding to use only with such programs. SAMHSA’s Strategic Prevention Framework provides a national framework that encourages prevention efforts in communities to address risk and protective factors and systematically evaluate their progress. The “Communities that Care” system also assists community to use evidence-based programs in combating drug issues. These programs target to build the resilience in youth in the schools and community settings, strengthen parenting abilities, and improve family functioning.

2.3.3. Australia
Overview Their national drug strategy reflects strongly that family and children are their priority. Similar to U.K.’s emphasis on family support, Australia’s latest initiative Kidsin-Focus – Family Drug Support also calls for cross-agencies collaboration to help the most vulnerable families and kids suffering from substance abuse within the family. Also, school-based drug education is not meant to carry out through classroom education (although it is still mostly covered by health curriculum at this point), or using drug-testing or screening. Rather, they emphasize a whole-school approach that uses evidence-based information to make strategic decision in designing the 129

methods to manage drug issues on school premise. 2.3.3.1 National Drug Strategy: 2004 – 2009 The Australian government is still drafting their latest drug strategy and will be available in the first half of 2010. 2.3.3.2 Strengthening Families Program, Family Support Program and “Kids In Focus” Strengthening Families Program The former “Strengthening Families Program” was part of a broader National Illicit Drug Strategy (NIDS), funded by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). It focused on family support rather than the health, education or criminal aspect of the strategy, and assists families by adopting early intervention and family-focused strategies to combat impacts of substance abuse (FaHCSIA, 2008). Family members could include parents, grandparents, kinship carers, and children of drug-using parents. Strengthening Families Program reflects the Australian Government understands that substance abuse by one person within a family can have significant negative impacts on other family members, and has far reaching implications for the broader community. The program is comprised of series of programs including parent education, counseling, advice, therapeutic group programs, case management, and services for Indigenous families (FaHCSIA, 2008). They also include counseling and support for families with 130

young person suffering from drug problem, and support children of drug-using parents the opportunity to participate in normal children activities such as playgroup, music and sports activities (FaHCSIA, 2009a). Family Support Program (FSP) In February 2009 the new Family Support Program (FSP) was formed and will be in full implementation in July 2011 nation-wide. It is a re-focusing of the Strengthening Family Program which now target at supporting vulnerable families and their children. It utilizes an integrated approach by linking the existing family, children and parenting services under a single umbrella program, so that there is a seamless approach where clients would have “no wrong door” and can receive appropriate support through entering any FSP service (FaHCSIA, 2009b). The ultimate goal of FSP is to support families and nurture children to enable them to better manage life’s transitions and contribute to building stronger and more resilient communities. It involves three core service streams: 1. Family and Parenting Services – provide early intervention and prevention

services to families to build and strengthen relationships, develop skills and support parents and children 2. Community and Family Partnerships – provide intensive and coordinated 131

support targeted at significantly disadvantaged communities and families 3. Family Law Services (through Attorney-General’s Department) – assist families

to manage the process and impacts of separation in the best interests of children

The new Family Support Program operates within the context of broader government priorities, including: National Framework for Protecting Australia’s Children (2009 – 2020): It is an important framework developed in response to the dramatic increase of child abuse and neglect found in Australia in the past 10 years National Plan to Reduce Violence against Women and their Children; National Compact between the Government and the non-profit sector; and Social inclusion agenda.

The FSP hope to enhance the outcomes for families and their children through the following six means: 1. Strengthening collaboration between and amongst providers and

Government and community. 2. 3. Improving access to relevant services Ensuring services link families and children with other relevant community 132

support services. 4. 5. 6. Offering more flexible and responsive service delivery approaches. Operating within an outcome based accountability framework Improving the business environment for providers

Kids in Focus – Family Drug Support With regards to the subject of drug abuse, “Kids in Focus – Family Drug Support” is an initiative (under the Family and Parenting Services stream of the broader FSP) starting in May 2010 which targets at assisting substance-abusing parents, their children and their families. It is an early intervention, family-focused program. This service model focuses on providing integrated, long-term and intensive support to families dealing with substance abuse (FaHCSIA, 2009c). That would mean meeting the goal of supporting parents more effectively, to overcome their substance abuse, and supporting the children by normalizing their lives (including school, sport, regular routines) through targeted counseling and if necessary, intervention through the child protection system. That could include one-on-one long term family support, residential parenting support, advice / referral service, brokerage to assist the children to normalize their experiences, and intensive aftercare support for families where parents have left alcohol and other drug rehabilitative service, telephone 133

advice service, and early intervention support for at-risk parents. Thus the focus is an integrative direct service delivery requiring a strong collaboration of NGOs and government systems’ service.

The long-term goal of Kids in Focus is to increase access to and timely provision of integrated services for vulnerable families, and to improve child development, safety and family functioning. Specifically, the program targets to achieve the following outcomes (FaHCSIA, 2009d): 1. The emotional, social and economic impact of substance misuse on children

and the families of substance using people is minimized and family capacity is strengthened. 2. Reduced psychological and physical harm caused to substance users, their

children and other family members. 3. Enhanced or improved family-functioning and relationships through provision

of services to drug using parents and their children. 4. To increase access to and timely provision of integrated services for families in

a community context, particularly vulnerable and at-risk families, to improve child development, safety and family functioning. 5. Improve parenting skills. 134

6.

Normalize experiences of children with substance using parents or family

members (e.g. involvement in sport, child care places) and building resilience. 7. Increased collaboration and partnerships within the family support, child

welfare and AOD sectors.

Currently, Kids in Focus is not yet in operation but it is hoped that service delivery will start in the near future.

In a way, the “Kids in Focus” is similar to the “FIP” approach in the U.K. where intensive and integrated “case by case” service is offered to those at highest risk – in this case, substance-abuse parents and their families; it is also similar to the “Think Family” approach in the U.K. where service is based on not only individual but as members of the entire family. However, in Australia’s “Kids in Focus”, they intentionally prioritize children’s well-being (hence its name “Kids” in Focus), whereas in the U.K. the focus is placed on the entire family. Other initiatives under FSP The Family Relationship Education and Skills Training (FREST) assist families to increase awareness of family and marital relationship issues at the earliest intervention point. They provide training to improve parenting capabilities and style, 135

assist parents and families to foster positive and stable relationships between partners, specific family members or the entire family, positively manage transitions across relationship cycle (including separation and divorce), increase family resilience, and to resolve conflict effectively. In addition, the Raising Children Network is a national information, online and hotline services providing parenting advice. Both of these initiatives are under the broader “Communities for Children” (which also is under the umbrella of FSP) and mainly provides services for families with children up to 12 years. Facilitating partners in each site that require funding need to establish a committee with broad representation from stakeholders in the community to manage the initiatives (FaHCSIA, 2009e). 2.3.3.3 The former Community Partnerships Initiative (CPI) It was developed in 1997 under their National Illicit Drug Strategy (NIDS) aiming at reducing drug-use and drug-related harm through community projects, and focus on young people. These projects include peer programs, parent-based programs, basic life skills, job preparation, and recreational activities. Evaluation of CPI in 2003 prove them effective in delivering to the community the intended outputs of education on illicit drugs, information resources, training and community development project. Yet the evaluation did not assess their long-term outcomes of behavioral change in community. In March 2008 this Initiative has been redirected to 136

focus on binge drinking since it is believed to be of more concern than illicit drugs (Siggins Miller, 2009). 2.3.3.4 Other Funding Initiatives: Local Answers and Community Investment Program The former “Local Answers” initiatives provide funding to local, small-scale, time-limited projects that focused on children, family and community capacity building under the Stronger Families and Communities Strategy 2004 – 2009. And currently some projects under “Local Answers” are funded under the “Community Investment Program” that aims at strengthening communities and promote social inclusion of vulnerable members of the community. These projects include mentorship, parenting workshop, alternative schooling, and range of activities for the community (FaHCSIA, 2009f). 2.3.3.5 Support for Young Parents Local Answers provided funding to community projects that support high-risk young parents (typically under the age of 25). That could include ante and post natal education and intensive support, positive parenting training, create sustainable relationships with key services and peers, and develop their ability to access ongoing employment, education and training opportunities. There are also community projects that work with local hospitals, health service organizations and NGO that deliver financial assistance, emergency accommodations, parenting skills training, 137

and online information to support young parents, especially teenage or single mothers, who are in need. Further examples include the Young Parents Early Intervention Parenting Program (YPEIPP) and Positive Parenting for Young Parents (PPYP) [(under the Child, Youth and Women’s Health Program (CYWHP)) , which were funded earlier to support young parents, with the latter program specifically targeted for young parents having substance abuse problems (Youth Action and Policy Association, 2007; Department of Health and Ageing, 2004). 2.3.3.6 Communities that Care (CTC) Australia The CTC initiated in the U.S. is also rolled out in Australia. Since 2001, there had been three communities that piloted CTC in Australia. In 2008 the survey report provided evidence that shows positive outcomes such as indication of positive improvement in adolescent health behaviors. More randomized trials are currently under progress in 14 of the communities in Victoria, Queensland and Western Australia (Royal Children’s Hospital, 2010). 2.3.3.7 Drug Education in School In Australia, there is currently no mandatory drug education curriculum nation-wide, although elements of drug education are usually covered under the health and physical education program / curriculum. Some states (such as Victoria) would conduct review of its effectiveness in the schools within the state. Schools can 138

use the “Principles of Drug Education in School” published by the Department of Education, Science and Training in 2004 that outlines 12 principles that guide schools in designing their own school’s drug education strategy and programs – with the first principle being that their programs and initiatives need to be evidence-based (Department of Education, Science and Training, 2004). Australian National Council on Drugs (ANCD) also does not recommend a “compulsory” curriculum within school on drug education since the effect on reducing drug use in such case is found to be not sustainable. As for drug test, ANCD does not recommend this approach since it is found to be ineffective in deterring drug use in students, especially while other better alternatives are available. The approach they propose would rather be a comprehensive, whole-school (e.g., healthy school, develop resiliency among students) approach that address a range of risk and protective factors in different “layers” of relationship (e.g., peers, family, school and community) that influence health and education outcomes and help students to make choice on drug use (Roche et al., 2008). 2.3.3.8 National Drug Campaign (NDC) The Campaign includes the use of different media such as radio, print, outdoor, online and in-venue advertising, website, and a national information hotline. It has an important mission of meeting the information needs of youth, parents, 139

carers and the broader community. Different phases of the campaign (which started in 2001) focusing on different drugs depending on the emerging drug trend at that phase of the campaign, and use different strategies to enhance prevention in youth and their families (Department of Health and Ageing, 2007). While the current phase of the campaign aims at reinforcing the negative perceptions of certain drugs – ice, ecstasy, speed and marijuana, earlier phases of the campaign contain other important elements such as: 1. Encourage parents to play an active role in preventing drug use by

encouraging them to talk with their children about drugs and provide them the strategies to communicate, and providing them with drug-related information and treatment option 2. 3. 4. Parent television commercials Promote positive alternatives to drug use Recognize the important role of family relationships, and how health, welfare

and education professionals can provide support for youth 5. Normalize treatment with people facing drug problems, rather than

emphasizing law enforcement

Information on how parents can talk to their children about drugs, drug 140

knowledge information, where to get help, etc. are provided on the internet and through the national phone lines for children and adults – but those are generic phone lines and not drug-specific. 2.3.3.9 Australia Summary In combating drug abuse, Australia’s anti-drug efforts reflect their priority on children and their family. Besides FSP’s Kids in Focus, certain phases of their media campaign also emphasize the need for parents to communicate with children on drugs. The government put a lot of resources in strengthening family protective factors especially at the early years of children’s life, such as training and educating parents how to strengthen their marital relationship, and how to improve the role of parenting. When drug-use do occur in family (such as parental drug use), the government tackles the issues by placing children first such as through activities that can normalize the children’s life. This is important in reducing risk factors, and can prevent inter-generational substance use and other behavioral problems later on. Also, recognizing that drug abuse not only affects the drug users but also the people around them, Australia government center their prevention and intervention services on all members of the entire family and not only on individuals. Another key element indicated by the Kids in Focus initiative is the steps to integrate services delivery so that the family in need would not need to go through multiple agencies to receive 141

services. Australia’s school drug education also acknowledge the importance of using an ecological approach that address risk and protective factors in different layers in order to achieve sustainable effects in anti-drug prevention on school premise.

2.3.4 Canada
Overview Their drug prevention strategy (2007 – 2012) intends to work on the risk and protective factors in youth before they initiate substance use and spreading to the community about “evidence-based drug prevention messages” (Government of Canada, 2009). It is a response towards a national priority identified by the “National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada, 2005” (National Framework, 2005). The strategy summarizes three major approaches to reduce youth drug use: (1) Media/Youth Consortium, (2) Establishing Canadian National Standards for Prevention, and (3) Sustainable partnership. Currently, their support for family or parents focuses mainly on providing information in toolkits, and emphasizes the importance of parents to communicate with their children on drugs. It is primarily the National Crime Prevention Centre (NCPC) who provides grant that emphasize the use family-focused, “crime-prevention” model program, and Health Canada provide funding resources on 142

health promotion and prevention projects. Participation of parents and evidencebased family training is one of the many elements embedded in the larger school environment within the Canadian National Standards for School-based Prevention. The upcoming establishment of Canadian National Standards for community-based and family-based preventions reflects their approach in combating drugs would be further strengthened in the community and the family. 2.3.4.1 Media / Youth Consortium To raise public awareness of the harms of illicit drugs, it is mainly an advertising campaign using TV, internet, radio, print media, and advertisement in transportations. The websites under Canadian Center on Substance Abuse (CCSA), Health Canada, “Xperiment.ca” and “not4.me.ca”, contain easy-to-access-

information and tools for both parents and teenagers on drug-related information, tips on talking to teens, and drug-refusal skills. The website “Xperiment.ca” was carefully created by, and created for, youth through significant testing using youth surveys and focus group. For the tools for parents, it also aims at convincing parents that they have great influences towards their children, and the importance of constant communications with them. While the media would focus on teens and their parents, the Consortium also hopes to target a larger group of 10-24 years old and the high-risk populations. It will also work with youth-serving organizations to 143

embed the campaign message into their program materials and provide positive youth engagement in order to promote alternative healthy lifestyle and make informed and responsible choices about illicit drugs. The creation of the innovative Xperiment.ca website and the inclusion of youth representatives in the Youth Substance Abuse Prevention (YSAP) National Advisory Group are a few examples that they attempt to engage youth in a meaningful way (CCSA, 2010a). 2.3.4.2 Canadian Standards for Youth Substance Abuse Prevention The Canadian government recognizes the need to establish national standards for the design and delivery of substance abuse prevention program across Canada in the settings where children grow up: schools, communities, and families. Schoolbased Standards is the first one that was established in May 2009 and an updated version in June 2010 (CCSA, 2010b). There will be upcoming Standards for Community- and Family-based Youth Substance Abuse Prevention Standards in the summer and fall of 2010 respectively. The ultimate goal is to strengthen the quality of youth-oriented drug prevention programs in Canada and provide a means for communities, schools and families to access and implement evidence-based programs.

The established standards are used in elementary (starting at 6 years old) and 144

secondary schools. In their “Building on our strengths: Canadian Standards for school-based substance abuse prevention”, it calls for a comprehensive healthpromoting school approach that includes strong parent and community connections. Substance abuse efforts in Canadian Standards are also regarded as “initiatives” rather than “program or project”, which means they should be infused into school’s daily work and should not be treated as a separate, time limited “add-on”. It involves an ongoing process rather than just running an individual program, and substance abuse prevention is only one piece of a bigger puzzle of an ultimate aim of promoting the well being of the children. The 17 Standards involves four phases (which is somewhat similar to the SAMHSA’s SPF): 1. Assess the situation. 2. Prepare a plan and build capacity. 3. Implement a comprehensive initiative. 4. Evaluate the initiative. In other words, schools are required to examine the current protective and risk factors of students in their own schools, determine current substance use pattern, engage students in the design of the initiatives, conduct professional (teachers) development, connect with parents and communities, deliver 145

developmentally appropriate instructions, implement and maintain such initiatives and policies, and have regular evaluations of such initiatives. Two databases are developed by CCSA to encourage schools to update the Canadian Standard: “Database of prevention resources” on world-wide prevention resources (catalogued by the Standards they reflect), and “Database of Canadian Prevention Initiatives” on examples of Canadian-specific prevention initiatives and programs that has been assessed against the Standards, which is currently under construction.

One of the aspects mentioned is the importance of school-based drug prevention education to be connected with parents and community initiatives. As parents are key influencers of family cohesion, stability, sense of belonging, communication styles, etc. that can affect family health have significant impact on child and youth health. Community norms and leisure options, which also have impact on children’s decisions on substance abuse, are also outside school boundaries. Therefore, a concerted attention to engaging and supporting parents (such as through evidence-based family training) particularly in the early school years can provide significant protections to children. Such protections can snowball and provide ongoing benefits in extended areas when the children grow up. 2.3.4.3 Sustainable Partnerships 146

New and existing partnership between the government and organizations with various strength and areas of expertise would guide the implementation of the strategy. In particular, the National Advisory Group on Youth Substance Abuse Prevention (YSAP), composed of 35 experts in the drug prevention field and several youth participants, was established to design a nationwide consultative process to ensure the communities achieve the Strategy’s objectives successfully. CCSA’s Health, Education and Enforcement in Partnership (HEP) Program, Scientific Advisory Council, and Canadian Network of Substance Abuse and Allied Professionals would all bring together their expertise in carrying out the strategy. Specifically, in 2008 YSAP identified seven priority areas for action on youth substance abuse: Family support Risk and protective factors Special populations (e.g., developing gender/diversity-based analysis, which is currently the focus) Youth engagement Evidence-based prevention messages Translating research into practice Alcohol 147

It is important to note that during their last meeting, the YSAP National Advisory Group approved a re-focus on parenting nurturing – instead of merely creating a toolkit, it will take a “systems approach”, but no specific action or elaboration has yet been mentioned (CCSA, 2009). 2.3.4.4 Major Funding: Drug Strategy Community Initiatives Fund and Public Safety Canada – National Crime Prevention Centre The following two paragraphs described the funding that support communities in their anti-drug prevention work. The Drug Strategy Community Initiatives Fund (DSCIF) Funded through Health Canada, these are community projects aiming at health promotion and prevention targeting youth aged between 10 to 24. The projects engage intermediaries (parents of youth, educators, health service providers, social service providers, recreation and sport service providers, enforcement officials, etc.), and stakeholders (all orders of government, NGOs, professional associations and private sector interested in address drug use in youth). They can focus either on universal prevention that does not distinguish the level of risk within the target populations (e.g. general parents , students), or on selected / indicated prevention strategies that target populations demonstrating higher risk factors with illicit drug use (e.g., drug-using parent, dysfunctional families, lesbian /gay /bisexual / 148

transgendered/ aboriginal youth etc.) (Health Canada, 2009).

Each province decides which population or sector has the greatest needs to receive the service and priorities would be given to projects that match those target audience. The projects need to achieve one of the following outcomes: Increased awareness and understanding of healthy lifestyle choices, and of illicit drugs and their negative consequences Acquired/improved capacity (knowledge and skills development) to avoid illicit drug use. Increased engagement of community structures, and networks in activities to promote healthy lifestyle choices & prevent illicit drug use among youth.

However, unlike the U.S.’s SPF – State Initiative Grant where the programs need to adhere to the SAMHSA’s strategic framework, the programs funded under Canada’s DSCIF do not need to adhere to specific framework although they still need to submit a process evaluation and outcome evaluation of the project. Yet with the Canadian Standard for Communities-based prevention being established soon, this (no) requirement may change in the future.

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Public Safety Canada – National Crime Prevention Centre (NCPC) and Crime Prevention Action Fund (CPAF) Substance abuse has strong association with delinquency. In Canada, the Public Safety Department’s National Crime Prevention Center (NCPC) emphasizes tremendously the relationship between families and juvenile delinquency. The NCPC, through their Crime Prevention Action Fund, financially support initiatives that are directed at preventing and reducing substance-related crime among at-risk populations under Canada’s National Crime Prevention Strategy (NCPS). Specifically, they highly encourage the province or territory applying for their funding to utilize evidence-based “model” or “promising” programs that are found to be empirically effective in prevention. NCPC provides a list of programs (based on information from various resources including OJJDP, SAMHSA, Blueprints for violence prevention and other anti-crime specific bodies) that address risk and protective factors of at-risk youth, parental training, family issues, school-based programs, etc. NCPC also develop and disseminate crime prevention related knowledge through their publications in a few areas: Families, children and youth at risk, general crime prevention, high crime neighborhood, youth gangs, and aboriginal people. NCPC also publishes a list of school-based drug abuse prevention model programs that they encourage schools to adopt, and explains in details the risk and protective factors for 150

drug use in such publications (Public Safety, 2010). Another source of major funding comes from Department of Justice, but they focus on treatment and rehabilitation. 2.3.4.5 Drug Education and Drug Testing As mentioned, the new Canadian Standards for School-based Youth Substance Abuse Prevention provides guideline for designing initiatives within school related to substance abuse. The topics of drug are usually covered in health and physical education curriculum (e.g., starting in Grade 2 [about 8 years old] in Ontario). As for drug testing, it is quite uncommon in Canadian schools; the latest Canadian Standard for School-based Substance Abuse Prevention does not provide guideline on this subject (CCSA, 2010b). 2.3.4.6 Support for Young Parents Young Parent Programs (YPP) in Canada is partnership between and across community and public sector services. NGOs, Public Health, Board of Education , child care providers and in some instances secondary schools collaboratively provide young parents a chance to improve parenting capacity, further their education and increase employability in a supportive environment (BC Council for Families, 2009). Initiatives include but not limited to childcare, antenatal and postnatal health education, nurse home visit, life skills training, and parenting education and support 151

while young mothers finish their high school educations or upgrade their skills. Individualized, self paced programs for young parents to take regular or modified Grade 11 and 12 courses are provided. Licensed on-site child care at NGO, parenting and child development credit course, healthy nutrition and lifestyle credit courses are also provided, which also includes provide healthy snacks and meals daily. Bus pass assistance and support and advocacy of a full-time Youth and Family Worker are also available (Vancouver School Board, 2009). In addition, Young/Single Parent Support Network (YSPSN) is partnership of four agencies at Ottawa and they target support services to pregnant teens, as well as to young and single parents and their children aged birth to five years. They provide numerous programs and support services including a residential program, counseling, education, housing, support, parenting training and child care, anger and stress management, and life skills training (YSPSN, 2009). 2.3.4.7 Canada Summary Currently, as a national strategy they emphasize youth’s active participation, and not merely their presence, in their anti-drug prevention efforts as this serves as the best way to exemplify meaningful youth engagement. In terms of support for family and parents, support are mainly through: information dissemination to parents via online toolkits, reinstating to parents about the importance of 152

communication, and providing the information about negative drugs effects for the community so as to help youth stay informed and make their own smart choice. In terms of parent training or tools to build family cohesion, it is mainly led by the National Crime Prevention Centre under the National Crime Prevention Strategy who provides grants for such programs. Although preventions focusing on risk and protective factors are considered important in Canada’s overall drug strategy, and the use of evidence-based prevention programs are strongly encouraged, the use of family as the platform is not as salient as countries such like U.K. and Australia. Yet recently YSAP’s national advisory group has re-focused on risk and protective factors and family functioning. Also, in the near future there is the establishment of Canadian Standards for Community- and Family-Based substance abuse prevention. Implementation of these standards via various programs would likely join the forces of family and community at large to combat the substance abuse issues.

2.3.5 Taiwan
Overview School is the major platform used by Taiwan in their anti-drug effort. Mandatory and punitive drug test for targeted, at-risk students is the main tool used to identify drug-using students. Counseling would be offered to them and family 153

members, with the aim of deterring them from further drug use. At the community level, Taiwan provides education seminar and launching of healthy activities to promote healthy lifestyle in youth (Ministry of Education, Ministry of Justice, Ministry of Foreign Affairs, Department of Health Executive Yuan, 2009). 2.3.5.1 Drug testing and counseling in school Taiwan government regards mandatory drug testing in school as an important means to deter illicit drug use among students. Taiwan subsidizes the rapid drug screening in schools, and students identified as needing “intense care” (verbatim) are required to take urinalysis drug test. Those students needing “intensive care” actually means “at risk” students whom they suspect may have taken drugs. Seminars are organized through schools and professionals are invited to explain the legal implications and drug testing procedures in schools. The after-school counseling committee, parents, and the police’s juvenile delinquency prevention brigade would be notified should the student refuse to take the drug test (Ministry of Education, 2008).

“Spring Sun” working group – a group that provide counseling in schools and help students on issues including illicit drugs, alcohol, tobacco, HIV, and betel nuts, will be set up in schools within three days when there are cases of drug use in 154

schools. Follow-up counseling sessions would be provided to students who have positive test results via the group, counseling teachers, and parents, volunteers for “Spring Sun” working group, and “student counseling center” with professional counseling. The student would be tested again in three months. If the follow-up tests for the individual is still tested positive, those using Category 1 and 2 drugs (heroin, amphetamine, etc) will be reported to the juvenile court on top of receiving counseling help and professional healthcare for treatment; for Category 3 and 4 drugs users (ketamine, diazepam, etc.), students would be required to undergo counseling sessions again, and will be tested again afterwards. If the test result is still positive, they will be sent to juvenile court, together with requiring the family to attend mandatory “health and counseling education” sessions.

“Spring Sun” working group from different schools meet regularly by organizing sharing sessions and workshops to share the skills and best practices used in different schools on anti-drug efforts. They also form teams to spread anti-drug messages in the community. Workshops on drug and legal knowledge and refusal skills are organized. Teacher Training and Drug Education in School Teachers in the elementary, middle and high school need to take courses and 155

complete drug education materials within three years. Ministry of Education also requires elementary school, middle school and high school to have at least one class in each school term in the health curriculum to include anti-drug class. Ageappropriate education is currently being developed by teachers to complement the health curriculum on drug education. Furthermore, Spring Sun project training program are given to train teachers in high schools, vocational schools, middle schools, and elementary schools. Extra-curricular activities with anti-drug theme such as drama contests, poster design competitions, and writing contests are also organized.

In addition, after-school counseling programs also assist school counselors and police to do after-school patrol (involving teachers, instructors and police) in places such as internet café, clubs and karaoke; the students found in those places will be asked to take the drug test when they return to schools (Ministry of Education, 2008). Involvement of parents or families After-school student counseling committees in school provide parent-student symposium which educate parents on drug, current teenage sub-cultures and their slangs used. Before long school vacation, schools are also encouraged to provide 156

reminders for parents to care about the children’s activities during the period, and encourage schools to organize healthy activities for them to engage. Schools are also encouraged to organize parent-student leisure activities such as parent-student hiking, singing contests, painting to promote closer relationship among students, school and families. Direct intervention (i.e., counseling) would be used when necessary (Ministry of Education, 2008). 2.3.5.2 Community Level The community-based prevention is done by working with NGOs to incorporate anti-drug education element into the activities that they organize. These include community traditional culture activities, evening art performance, setting up drug-information booths major music festivals, etc. NGOs and schools are encouraged to organize attractive, healthy activities for young people to participate to engage them meaningfully and promote healthy lifestyle. Educational seminars (mainly involve drug information dissemination and law education) are held in schools and the communities. Outreach services are done by NGOs to reach the vulnerable youth and family and provide counseling and support. Local drug prevention centers are established to enhance the anti-drug collaborations among medical, education, vocational training, and legislation sectors.

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Community counseling station for drug abuse preventions are set up in the community. Community Pharmacists are stationed at the stations to provide antidrug education and counseling service so that the public has constant, easy access to the service. The Ministry of the Interior has also established anti-drug ambassadors to go to schools and organizations to promote anti-drug information. They train teenagers and general public to become volunteers and educate the public (Ministry of Education, Ministry of Justice, Ministry of Foreign Affairs, Department of Health Executive Yuan, 2009). 2.3.5.3 Youth between school and work “Youngsters’ On Light” is a project coordinated by NGO and government to train teenagers between 15 – 19 who are out of school and out of work for them to “keep learning” in a four-month career-exploratory, experiential learning. They also provide two-month on the job training for those who decide to work (Younger, 2010). 2.3.5.4 Media Taiwan also makes great use of the media, slogan, short films, using celebrities to participate in anti-drug advertisement, print media, internet that contains drug information and internet games for teenagers, anti-drug helpline, and distribution of anti-drug information and games VCD for use in the family (Ministry of Education, Ministry of Justice, Ministry of Foreign Affairs, Department of Health 158

Executive Yuan, 2009). 2.3.5.5 Taiwan Summary School is the major platform emphasized by Taiwan to fight the anti-drug battle. The government encourages drug test in school as a screening tool to prevent students from using drugs. Drug testing is combined with law enforcement (if the drug is tested positive after counseling). There seems to be little concern in Taiwan regarding the labeling effect or stigma associated with drug-testing in schools. “Spring Sun” working group in schools and “after-school programs” team have an important role to play in anti-drug effort. Prevention efforts that involve families and parents are driven also by school programs. At the community level, it involves providing educational seminar on drugs and laws to the community, and organizes healthy activities for young people to engage in. There is yet little to be done to conduct the long-term effect on behavioral change and sustainability of such efforts. Certain scholars in Taiwan have called for the need to address risk and protective factors and family-focused approaches to deal with the root cause of drug abuse in Taiwan (Executive Yuan Report, 2005).

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2.3.6 PRC
Overview In the mainland, drug prevention rests primarily on “education”, and it is believed that school should be the major platform for drug-education, probably because of the great diversity in the parents’ levels of literacy and resourcefulness. The nine years of free education when children need to stay in school is regarded as the best opportunity to promote a healthy lifestyle and resist drugs. And it utilizes schools as the basis and community education as assisting the overall drug education (Narcotics Control Bureau & Ministry of Education, 2006). 2.3.6.1 Drug education in school As a national strategy, starting in 2003 the Ministry of Education requires primary 5 to secondary 2 students to receive two hours (originally one hour) of drugeducation per academic year. The content covers the effects of drugs, refusal skills, and related laws and regulations. They particularly emphasize secondary 2 students as they believed that it is the most critical year in determining if students would take drugs based on their physical and psychological needs and the school curriculum arrangement. Schools are also encouraged to use interesting and interactive ways to strengthen students’ anti-drug knowledge and nurture good self-management and social skills so that students can live a healthy life. Schools are required to collaborate 160

with parents and encourage them to receive drug-information education and assist them on how to help their children to resist drugs (Narcotics Control Bureau & Ministry of Education, 2002).

Apart from the mandatory drug education nation-wide, individual municipals and counties varies with the way they carry out the school and drug education, although all education materials and curriculum need to be approved by China Narcotics Control Foundation and the Ministry of Education. For example, in the city of Shanghai, the Shanghai Museum of Anti-drug Scientific Education was revamped and opened in 2009. Primary and secondary school students are required to visit there four times per year as part of their anti-drug education curriculum (Shanghai Museum of Anti-drug Scientific Education, 2009).

PRC also encourage schools to organize activities and seminars for parents on drug information, so that parents can teach the children to stay away from drugs, monitor their children, and collaborate with school on anti-drug effort. Volunteers from schools, universities, communities are recruited year-round to spread anti-drug messages by distributing pamphlets are also popular. The youth website and the Narcotics Control Bureau also provide drug and legal information (Narcotics Control 161

Bureau, 2010).

The government encourages each province and city to integrate effort from various sectors such as legal, media, social work, medical, mental health, teachers with drug-education expertise, rehabilitated drug-users, etc. to produce anti-drug educational resources and spread the anti-drug message in their community. It is noteworthy that PRC has strict law with regards to drugs, and capital punishment is allowed. Whether these laws are strictly enforced is yet another question. 2.3.6.2 PRC Summary Although certain scholars and even the government acknowledge the importance of parents and families to prevent children from trying drugs (Yuan, 2004), currently the emphasis is to use school as the main interface, supplemented with media campaigns, education seminars, use of celebrity to spread anti drug messages.

2.3.7 Singapore
Singapore’s drug abuse prevalence rate is among the lowest internationally – with over five million populations in Singapore, the number of new abusers in 2009 was 553 (Central Narcotics Bureau, 2010; Statistics Singapore, 2010). 162

Their prevention strategy mainly targets educating students on the danger and consequences of drug abuse, especially on school dropouts who are considered high risk. Prevention efforts include assembly talks in schools by officers from the Central Narcotics Bureau, the Police, anti-drug exhibitions, inter-school dance competitions “DanceWorks!”. For high-risk youths, Volunteer Guidance Officers under a program by Singapore Anti-Narcotics Association (SANA) would befriend and encourage dropouts to return to school or acquire specific skills. For prevention efforts at the community level, community education, parent-kid camps, mass media, exhibitions and celebrity were used to spread the anti-drug message. The activities are tailored to meet the languages and other needs of different ethnic group in Singapore. Media campaign is also used.

As for the support for parents and families, the National Council against Drug Abuse (NCADA) provides communication skills tips for parents through the website; a counseling hotline is also run by SANA (NCADA, 2010).

Similar to PRC, Singapore also has strict law enforcement on drugs. Strokes of cane can be used, and capital punishment is allowed for illegal traffic of certain illicit 163

substance such as cannibals and cocaine; possession or consumption of ketamine can lead to up to 10 years of imprisonment or a fine or SGD 20,000 or both. And if necessary, known drug offenders are detained without trial to prevent them from “contaminating others” (verbatim).

2.3.7.1 Singapore Summary Singapore being one of the countries with the lowest drug abuse prevalence would not be possible without the efficient and effective anti-drug and drug prevention strategies. High-risk youths such as school dropouts are always considered as the targets. Through the mass media and different means of propaganda, the anti-drug messages are widely spread in Singapore irrespective of ethnicity and language. On the other hand, the support of parental and communication skills for high-risk and drug abuse families and strict law enforcement on drugs are of prime importance.

2.3.8 Summary
Few points are evident from the review of the substance abuse prevention practices across different countries (see Appendices A and B).

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First, initiatives in countries such as the U.K., U.S., Australia, and Canada focus tremendously on addressing the risk and protective factors in causing youth substance abuse. Instead of merely focusing on the drug issue per se, efforts are made to enhance protective factors, such as strengthening the attached bonding and relationships with adults through family-based intervention like parental or family training, provision of nation-wide meaningful youth engagement, and reduce risk factors such as normalizing the lives of children suffering from parental drug use.

Second, the prevention efforts address the needs of not only the adolescent themselves, but also the young adults, their families and the broader community. Best practices from some countries show they utilize an ecological framework to both understand and tackle the substance abuse issue, although the emphasis in each country may be different. U.K. and Australia acknowledge the importance of supporting parents and the families to build healthier family at an early stage so that the children and youth can benefit from growing up in a positive environment, thereby naturally build resistance against delinquent behavior including substance abuse. Both countries currently target at collaborating different service platform (NGOs and government) to assist at-risk families, so as to minimize drug and other social problems being spread inter-generationally. U.S.’s public health approach 165

emphasizes the mobilization of different sectors of the community to address the drug issue. The use of the Communities that Care systems invite members in the community to identify and change the environmental context in which the young people live in. Canada emphasizes youth-focused community prevention initiatives involving different partners. Their current projects in establishing the school-based, community-based and family-based Canadian Standards again shows that anti-drug efforts are not limited to working in one setting alone but also the broader environment surrounding young people. Asian countries such as Taiwan, PRC and Singapore place more emphasis on information dissemination, school drug education and law enforcement and have less to do with risk and protective factors or the ecological framework of drug use. In the U.S. and Canada, the increased non-medical use of prescription drugs is also of concern to the government.

Third, use of parenting or training that strengthen family functioning are common in U.K., U.S., Australia and Canada, although they are conducted under different government authorities – some countries place them under their department of family affairs while others are under the crime prevention bureau. In any case, these countries believe the same “basket” of factors is responsible for causing not only substance abuse but also other adolescent behavioral issues. Thus 166

tackling the same risk and protective factors mean not only a reduction in substance abuse but multiple problems as well. Fourth, although the strategies to support parents varies, most countries acknowledge the importance of communication between parents and their children and the benefit of parents being the “first person” to talk to their children about negative consequences on drug use. Fifth, western countries provide more concrete assistance to teenage and young parents encompassing health, emotional, educational and financial support. This is one of the steps they take to prevent intergeneration transfer of poverty and improve the health and well-being of both the children and the young parents.

2. 4. Key Issues and the way forward
In the first section, we examined the adolescent drug use and the current prevention efforts in Hong Kong. In the second section, we highlighted the common framework used in understanding adolescent drug use problem, namely, the Bronfenbrenner’s ecological systems theory, the public health model, and the Hawkins and Catalano’s social development model. We explored how these theories are applied in previous studies relating family and adolescent drug use, including family in various contexts. In the third section, we examined the current and prospective anti-drug efforts from a few countries: the U.K., the U.S., Australia, Canada, Taiwan, PRC and Singapore, and explored the best practices from them. A 167

few lessons are salient:

(1) Ecological understanding and tackling problems are essential. Adolescent substance abuse involves a combination of factors encompassing different layers of internal and external influences. And as Randall and Cunningham (2003) suggested, if adolescent is influenced by peers, family, school, and neighborhood factors, then it is essential to change the environmental contexts that they live in. Therefore prevention and intervention efforts needs to be “ecologically valid” in order to be effective. (2) Reducing risk factors and enhancing protective factors are imperative. Both the theories and the best practices from the leading countries demonstrated that prevention efforts that focus on training refusal skills and drug knowledge dissemination are insufficient, because they do not sufficiently address the underlying cause of the issues of drug use. Countries such as the U.K., U.S., Australia and Canada not only emphasize universal prevention strategies such as the media campaign, national hotline, one-off educational seminars or isolated leisure activities that promote positive youth engagement. They also prioritize their resources by focusing on selected and indicated prevention strategies. These include targeting on assisting families-at-risk to prevent inter-generational 168

transfer of social problem; cross-agencies collaboration to help the most vulnerable families and children suffering from substance abuse within the family; and requiring the communities to identify the elevated risk factors and depressed protective factors within their community and address those factors using evidence-based programs. Positive and meaning engagement is also very important in providing youth the alternatives to healthy lifestyle. As evidenced from the best practices overseas, these engagements should not be one-off events but should have the ultimate goal to steer towards education or employment opportunities. Preventions and early interventions efforts should also extend beyond adolescents to include young adults so that substance use would not become a habit when they become mature adults. Last but not least, prevention and intervention initiatives should be systematically and regularly evaluated to examine their effectiveness.

(3) Family intervention is the key. Family interventions are found to be most effective in addressing significant risk factors for substance abuse (UNODC, 2009; Spooner, Hall, and Lynskey, 2001). Such interventions focus not only on the issue of substance abuse, but on a broader topic such as maintaining good familial bonds and setting clear standards. Healthy parent-child attachment, good 169

parental modeling, effective parental monitoring can have huge, positive impact on adolescent attitudes towards drug and adolescent peer selection – all these can reduce the likelihood that youth to experiment drug. Such positive impact is sustainable since these factors facilitate youth in being nurtured in a healthy and positive environment, thereby building their natural resistance against delinquent behavior. In addition, as we found that most countries acknowledge the importance of communication between parents and their children, we should also equip parents in Hong Kong to do this job. Since various adolescent behavioral problems are often caused by a series of similar risk and protective factors, family interventions that sufficiently address these factors may reduce not only substance abuse but also other problematic behavior. Also, the best practices from other countries, like frameworks for engaging parents in preventive work (Randolph, Fincham & Radey, 2009)show that it is critical that prevention and intervention efforts to be based on evidence (Social Care Institute of Excellence, 2009a and 2009b) as guided by some principles of effectiveness (Small, Cooney & O’Connor, 2009). They also need to be systematically and regularly evaluated.

As mentioned, adolescent drug abuse is a manifestation of deeper family 170

issues and a symptom of an ongoing pattern of youth development problems (Hong Kong Narcotics Division, 2008a; CAPT, 1999). For prevention efforts to be effective and sustainable, it is essential to have an ecological understanding of the drug use issue and focus on the underlying factors causing youth substance use. Various theories and models attempt to explain the combination of factors influencing youth initiation and use of substance, and comprehensive approach involving communities, schools, peers, and families are necessary to tackle the issues. Yet parental and family factors still have the key role to play – especially in the long run – leading adolescents to or preventing them from substance abuse (SAMHSHA, 2009; UNODC, 2009; Vellenman et al., 2005). Despite the importance of peer influence, it works more as a contributing factor near the time when they start using substance (UNODC, 2009). Positive, supportive family environment is the underlying reason youth do not engage in a variety of disruptive behaviors, including substance abuse (Gardner et al., 2006; Kumpfer et al., 2003). Although peer influence should not be undermined, it is imperative to note that young people’s choice of friends are largely influenced by their relationships with their parents, as poor parent-child bond was found to be associated with drug-use peer (Brook et al., 2009). In other words, those who have a positive and healthy relationship with their parents are likely to also choose peers who also have positive influences (UNODC, 2009). 171

While using family intervention as a universal prevention strategy may induce high cost and self-selection (i.e., “the worried well”) issues, it is a promising form of early intervention if they are used as a selected or indicated strategy targeted for atrisk families (Spooner et al., 2001). They are a cost-effective tool if they are considered in bringing multiple benefits to children on co-occurring delinquent behaviors, rather than treating it as merely a drug prevention program (Spooner et al., 2001).

We need to be mindful that using such family interventions or by appropriately addressing risk and protective factors may not bring us immediate results in the short run. Yet previous studies repeatedly demonstrated that they can bring about significant, observable and sustainable effects on substance abuse in the long run (Hawkins et al., 2009). Effective prevention initiatives should therefore take a long-term perspective. Such initiatives should include family to play an active role in early prevention and intervention, go beyond the universal prevention strategies, and sufficiently address the underlying risk and protective factors for drug use.

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CHAPTER 3: SECONDARY DATA ANALYSIS
3.1 Overview & Data
Variables definition Regular use of alcohol (drinking): Self-reported habitual alcohol use of every week Regular smoking: Self-reported current smoking (included occasional smoking and at least one time every week) Ever drug use: Self-reported use of drugs (included ice, marijuana, ecstasy, ketamine or other drugs which are not prescribed by doctors) Parental relationship: How do you think about the relationship between your father and mother? 5-point scale (1=very bad, 5=very good) Happiness about family life: Do you feel happy about your family life? 5-point scale (1=very unhappy, 5=very happy) Good relationship with father: rating “good” or “very good” to the question “Your relationship with father is…” 4-point scale (1=very unhappy, 4=very happy) Good relationship with mother: rating “good” or “very good” to question “Your relationship with mother is…” 4-point scale (1=very unhappy, 4=very happy) Acceptance to father’s parenting: rated “accept” or “very accept” to question “Do you accept your father’s parenting?” 4-point scale (1=very unhappy, 4=very happy)

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Acceptance to mother’s parenting: rated “accept” or “very accept” to question “Do you accept your mother’s parenting?” 4-point scale (1=very unhappy, 4=very happy) Impulsiveness: 7-item about impulsiveness from Eysenck and Eysenck (1978) I usually act without careful thought I am an impulse person I usually speak out without careful thought I usually give promise but failed to commit them I need to be very self-restraint to avoid running into trouble I enjoy excitement, but would not think about the consequences I always run into trouble because I usually act without thinking about the consequence

Depressive symptoms: 10-item related to depressive symptoms (CESD-10) Could not shake off the blues even with the help of family and friends Feeling depressed Feeling that everything done was much effort Life has been in failure Feeling fearful Feeling lonely Feeling that people are unfriendly Feeling sad Feeling that people dislike me Appetite is bad

Social support: 4-item related to social support from friends Do you consider yourself as important to your friends? Do you have any friend who can support you and help you make important decisions? When you feel annoyed or angry, do you have any friend who can cheer you up? Do you have any friend you can spend time with?

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3.2 Descriptive analysis
This section demonstrates the prevalence of substance abuse and characteristics of family structure and relationship with basic descriptive statistics. For the prevalence of substance abuse, all data from in-school survey (Form 1 to 7) and out-school survey (aged 18-27) would be used. For the cross-tabulation showing the association between family quality and drug use, data from in-school survey of Form 3 to 7 and out-school survey would be used.

3.3 Statistical methods
The descriptive analysis generates some basic statistics showing the prevalence of substance abuse with regard to different characteristics of family structure, relationship and acceptance to parenting. The prevalence of three specific patterns of substance abuse was studied: The regular drinking (Drink alcohol for at least one day every week), current smoking (Occasional smoker or smoke at least 1 cigarette every week) and drug use (Ever used either psychotropic substance or inhalant). In all the cross-tabulations, chi-square testing was conducted to compare drug users and non-drug users regarding to categorical family-related characteristic, while independent sample t-test was used for comparing scale variables between drug users and non-drug users.

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Group 1 (Form 3-7) the demographic analysis and prevalence by drug users and non-drug users and by sex
Prevalence of psychotropic substance and inhalant use The prevalence of psychotropic substance use, inhalant use and use of either one of them for junior boys (Form 1 to 2) were 2.4%, 3.3% and 5.0% respectively. The prevalence rates for older boys were 5.6%, 2.7% and 6.9% respectively. Junior boys have significantly lower prevalence of using psychotropic substance than older boys (Form 3 to 7) (2.4% vs 5.6%). Among in-school boys, Form 5 students have the highest prevalence of using psychotropic substances, inhalant and both drugs among all grades.

The prevalence of psychotropic substance use, inhalant use and use of both for junior girls (Form 1 to 2) were 2.1%, 1.4% and 3.2% respectively. Such prevalence rates for older girls were 2.0%, 2.4% and 4.2% respectively. Junior girls and older girls have similar prevalence of using psychotropic substance and inhalant as shown in Table 3.

Among those Form 1 to 2 respondents who reported psychotropic substance use in life time, 7 males (63.6%) and 4 females (44.4%) of them reported they used 176

the substances in the past 30 days. Among those Form 3 to 7 respondents who reported psychotropic substance use in life time, 34 males (57.6%) and 13 females (50%) of them reported they used the substances in the past 30 days.

Table 3. Prevalence of psychotropic substance and inhalant use among in-school respondents
Boys Psychotropic substance use N 224 234 276 240 251 134 151 458 1052 n 5 6 12 14 21 7 5 11 59 (%) 1.9 2.7 4.3 5.8 8.4 5.2 3.3 2.4 5.6 95% C.I. (0.9, 5.4) (1.2, 5.7) (2.5, 7.7) (3.5, 9.8) (5.5, 12.8) (2.5, 11.0) (1.4, 8.0) (1.3, 4.3) (4.3, 7.2) n 7 8 7 6 11 2 2 15 28 Inhalant use (%) 3.1 3.4 2.5 2.5 4.4 1.5 1.3 3.3 2.7 95% C.I. (1.5, 6.6) (1.7, 6.8) (1.2, 5.3) (1.1, 5.6) (2.4, 7.9) (0.4, 6.0) (0.3, 5.3) (2.0, 5.4) (1.8, 3.9) n 11 12 16 18 25 8 6 23 73 Either drug type (%) 4.9 5.1 5.8 7.5 10.0 6.0 4.0 5.0 6.9 95% C.I. (2.7, 8.9) (2.9, 9.0) (3.6, 9.5) (4.7, 11.9) (6.7, 14.7) (3.0, 11.9) (1.8, 8.8) (3.3, 7.6) (5.5, 8.7)

Grade

1 2 3 4 5 6 7

F.1-2 F.3-7 Girls

Psychotropic substance use n 211 2 224 7 276 4 245 7 341 9 222 2 189 4 435 9 1273 26 N (%) 0.8 3.0 1.4 2.9 2.6 0.9 2.1 2.1 2.0 95% C.I. (0.2, 3.8) (1.5, 6.6) (0.5, 3.9) (1.4, 6.0) (1.4, 5.1) (0.2, 3.6) (0.8, 5.6) (1.1, 4.0) (1.4, 3.0) n 2 4 7 5 15 2 1 6 30

Inhalant use (%) 0.9 1.8 2.5 2.0 4.4 0.9 0.5 1.4 2.4 95% C.I. (0.2, 3.8) (0.7, 4.8) (1.2, 5.3) (0.8, 4.9) (2.7, 7.3) (0.2, 3.6) (0.1, 3.8) (0.6, 3.1) (1.6, 3.4) n 4 10 11 12 23 4 4 14 54

Either drug type (%) 1.9 4.5 4.0 4.9 6.7 1.8 2.1 3.2 4.2 95% C.I. (0.7, 5.1) (2.4, 8.3) (2.2, 7.2) (2.8, 8.6) (4.5, 10.1) (0.7, 4.8) (0.8, 5.6) (1.9, 5.4) (3.2, 5.5)

Grade

1 2 3 4 5 6 7

F.1-2 F.3-7

Comparison of drug users and non-drug users All respondents Table 4 shows that adolescents whose parents were married had a lowest likelihood of reporting drug use in lifetime (4.4%). The prevalence of drug abuse

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among respondents whose parents were separated or divorced was 8.8%. Those adolescents whose mother or both parents passed away had an even higher prevalence of drug use, 16% and 66.7% respectively.

The associations of other variables related to family relationship and drug use were significantly present with chi-square tests as shown in Table 4.1. In short, those who had very poor parent’s marital relationship, very unhappy family life, bad relationship with parents, being refused to accept parenting would had a higher prevalence of drug use.

Table 4. Cross tabulation of family antecedents and substances use among Form 3 to 7 respondents (both sexes)
Row total Parents' marital Married status Separated/divorced Father passed away Mother passed away Both parents passed away Others Chi-sq test Relationship Very poor between parents Poor 71 177 721 646 600 62 204 783 767 471 9 12 34 25 34 12 17 40 33 18 1935 239 97 20 9 18 Drug users % 4.4 8.8 7.2 15.0 66.7 27.8 ** 12.7 6.8 4.7 3.9 5.7 * 19.4 8.3 5.1 4.3 3.8

n 85 21 7 3 6 5

Fair Good Very good
Chi-sq test Happiness about Very unhappy family life Unhappy

Fair Happy Very happy

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Chi-sq test Good Yes relationship with No father Chi-sq test Good Yes relationship with No mother Chi-sq test Accept father's parenting 1609 343 1959 140 1491 504 1773 321 72 32 90 19 58 46 77 32

** 4.5 9.3 ** 4.6 13.6 ** 3.9 9.1 ** 4.3 10.0 **

Yes No
Chi-sq test

Accept mother's Yes parenting No Chi-sq test

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

Table 4.1 Mean score for scales for both sexes
Drug users Yes No 17.72* 16.12* 7.79** 5.64** 11.89 11.73 16.71* 16.34*

Impulsiveness CESD-10 Social support Age

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

Boys

Parents’ marital status has a close relationship with boys’ initiation of substance abuse. Boys whose father or/and mother passed away had much higher prevalence of drug use than those whose parents were married. Boys whose parents were divorced or separated or father passed away had slightly higher prevalence of drug use than those whose parents were married.

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Relationship between parents perceived by adolescents was not quite associated with initiation of substance abuse. Feeling happy about family life is associated with reduction of likelihood of substance abuse among boys. The prevalence of ever using drugs among those who felt very unhappy about family life was 21.2%, while the corresponding figure for those who felt very happy was 1.4% respectively.

Good relationships with father or mother were also protective factors to current smoking and using drugs. Table 5 shows that 11.2% of those who did not have good relationship with father and 19.7% of those who did not have good relationship with mother reported ever use of drugs, compared to about 6% among those who had good relationship with parents. 10.8% of those who did not accept father’s parenting and 12.1% of those did not accept mother’s parenting reported ever use of drugs, compared to less than 5% among those who accepted parents’ parenting.

Acceptance to parenting is highly associated with lower prevalence of drug use. Those who did not accept their father’s or mother’s parenting have a higher proportion of having initiation of regularly using alcohol, cigarettes and drugs. 180

Generally, there is no significant difference between male substance users and male non substance users in impulsiveness, depression symptoms and social support, except that drug users are shown to be more depressed than non drug users as presented in Table 5.1. Male users of various kinds of substance tend to have an older age than non substance users. Table 5. Cross tabulation of family antecedents and substances use among Form 3 to 7 boys
Row-total Parents' marital Married status Separated/divorced Father passed away Mother passed away Both parents passed away Others Chi-sq test Relationship between parents Very poor Poor Fair Good Very good Chi-sq test Happiness about Very unhappy family life Unhappy Fair Happy Very happy Chi-sq test Good relationship with father Good relationship with mother Accept father's parenting Yes No Chi-sq test Yes No Chi-sq test Yes No Chi-sq test 642 241 31 26 871 61 48 12 714 161 40 18 33 79 372 328 211 10 10 21 16 12 30.3 12.7 5.6 4.9 5.7 ** 5.6 11.2 * 5.5 19.7 ** 4.8 10.8 ** 31 70 297 320 271 4 5 19 13 20 875 105 44 5 8 8 n 47 9 6 1 6 3 Drug users % 5.4 8.6 13.6 20.0 75.0 37.5 ** 12.9 7.1 6.4 4.1 7.4

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Accept mother's Yes parenting No Chi-sq test

751 173

37 21

4.9 12.1 **

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

Table 5.1 Mean score for scales for boys
Drug users Yes No Impulsiveness CESD-10 Social support Age

18.52** 8.09** 12.07 16.52

16.06** 6.11** 12.20 16.40

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

Girls Those female respondents whose parents were divorced or separated or having their mother passed away had a higher prevalence of drug use than those who have married parents. About 3% of those whose parents were married were drug users, but those whose parents were separated or divorced had a prevalence of 9% of ever using drugs. 13.3% of those whose mother had passed away were drug users.

Relationship between parents and happiness about family life were not highly associated with drug abuse among girls. From chi-square tests, relationship between parents and happiness about family life were not associated with drug use among girl respondents. 182

Having good relationship with father and mother is slightly protective against drug abuse among girls. Among those who did not have good relationship with father, 7.7% of them reported that they were drug users respectively, compared with 3.6% among those had good relationship with mother.

Compared with boys, acceptance of parenting has a moderate influence to use of drugs among girls. Among those who did not accept father’s parenting, the prevalence of drug use was 7.6%. The corresponding figures for those who accept father’s parenting were 1.4%, 2.6% and 3.2%. Among those who did not accept mother’s parenting, the prevalence of using drugs was 7.4%. The corresponding figures for those who accept father’s parenting was 3.9%.

The differences of impulsiveness and depression symptoms between female substance users and non users were noticeable among boys and girls. Female regular users of alcohol, current smokers and drug users were shown significantly to have higher impulsiveness and depression symptoms on average as shown in Table 6.1. Differences in age and amount of social support were not significant.

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Table 6. Cross tabulation of family antecedents and substances use among Form 3 to 7 girls
Row-total Parents' marital status Married Separated/divorced Father passed away Mother passed away Both parents passed away Others Chi-sq test Relationship between parents 1060 134 53 15 1 10 40 107 424 326 329 29 125 411 439 260 895 182 1088 79 849 263 1022 148 n 38 12 1 2 0 2 5 7 15 12 14 2 7 19 17 6 32 14 42 7 27 20 40 11 Drug users % 3.6 9.0 1.9 13.3 0.0 20.0 * 12.5 6.5 3.5 3.7 4.3 6.9 5.6 4.6 3.9 2.3 3.6 7.7 * 3.9 8.9 * 3.2 7.6 ** 3.9 7.4 *

Very poor Poor Fair Good Very good
Chi-sq test

Happiness about family life

Very unhappy Unhappy Fair Happy Very happy
Chi-sq test

Good relationship Yes with father No Chi-sq test Good relationship Yes with mother No Chi-sq test Accept father's parenting

Yes No
Chi-sq test

Accept mother's parenting

Yes No
Chi-sq test

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

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Table 6.1 Mean score for scales for girls
Drug users Impulsiveness CESD-10 Social support Age

Yes 17.31** 6.77* 11.54 16.7

No 16.09** 6.54* 12.6 16.4

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

Group 2 (out school, aged 18-27) the demographic analysis and prevalence by drug users and non-drug users and by sex
Prevalence of psychotropic substance and inhalant use Generally, the prevalence for inhalant use is relatively lower than use of psychotropic substances among young adults. There is an apparent contrast of prevalence of using psychotropic substances between studying and working young adults. The prevalence for studying and working males were 3.8% and 21.5%, while the prevalence for females were 2.2% and 9%.

Among those who reported psychotropic substance use in life time, 10 males (17.2%) and 5 females (11.9%) of them reported they used the substances in the past 30 days.

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Table 7. Prevalence of psychotropic substance, inhalant use and either drug type among young adult respondents
Male Psychotropic substance use N Studying 255 Working 350 605 n 10 48 58 (%) 3.8 21.5 5.9 95% C.I. (2.1, 7.3) (10.3, 18.2) (7.4, 12.4) n 0 4 4 Inhalant use % 0.0 1.1 0.7 95% C.I. N/A (0.4, 3) (0.2, 1.8) Either drug type n % 10 3.8 49 14.0 59 9.8 95% C.I. (2.1, 7.3) (10.6, 18.5) (7.6, 12.6)

Grade Overall

Female Psychotropic drug use N Studying 225 Working 343 568 n 5 31 36 % 2.2 9.0 6.3 95% C.I. (0.9, 5.3) (6.4, 12.9) (4.6, 8.8) n 4 2 6 Inhalant use % 1.8 0.6 1.1 95% C.I. (0.7, 4.7) (0.1, 2.3) (0.5, 2.4) Combine 2 drugs n % 7 3.1 31 9.0 38 6.7 95% C.I. (1.5, 6.5) (6.4, 12.9) (4.9, 9.2)

Grade Overall

Comparison between drug users and non-drug users The drug prevalence for respondents whose parents were married was 7.2%. Such prevalence surged to 15.8% for those respondents whose parents were separated or divorced. The drug prevalence for respondents whose father or mother passed away were 8.7% and 11.8% respectively.

The chi-square tests show that the relationship with mother, relationship between parents and happiness about family life were associated with adolescent drug use. Those respondents who had poor relationship with mother, poor parental relationship or unhappy family life had a higher prevalence of drug abuse. When the

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analysis is separated by sex, the association between family relationship and drug use is less significant for males, while the association is much higher for females.

Drug users had a higher score of impulsiveness and depressive symptoms than non drug users. Also, drug users tend to be older than non drug users. Table 8. Cross tabulation of family antecedents and substances use among outschool respondents (both sexes)
Row total Marital status of parents Still married Separated/ divorced Father deceased Mother deceased Both deceased Chi-sq test Relationship with father Very Poor Poor Good Very good Chi-sq test Relationship with mother Very Poor Poor Good Very good Chi-sq test Relationship between parents Very Poor Poor Average Good Very good Chi-sq test Happiness about family life Very unhappy Unhappy Average Happy Very happy Chi-sq test 904 158 92 17 2 25 91 579 356 7 41 523 548 51 74 302 343 344 20 69 375 446 257 Use of psychotropic substances or inhalant Yes n % 65 7.2 25 15.8 8 8.7 2 11.8 0 0.00 * 5 20.0 10 11.0 44 7.6 24 6.7 2 7 44 40 9 9 31 24 18 4 9 42 27 17 28.6 17.1 8.4 7.3 * 17.7 12.2 10.3 7.0 5.2 ** 20.0 13.0 11.2 6.1 6.6 *

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

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Mean score for scales for both sexes
Drug users Impulsiveness CESD-10 Social support Age

Yes 16.95** 7.00** 12.17 22.57*

No 14.75** 4.94** 12.35 21.94*

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

Table 9. Cross tabulation of family antecedents and substances use among outschool male respondents
Row total Marital status of parents Still married Separated/ divorced Father deceased Mother deceased Both deceased Chi-sq test Relationship with father Very Poor Poor Good Very good Chi-sq test Relationship with mother Very Poor Poor Good Very good Chi-sq test Relationship between parents Very Poor Poor Average Good Very good Chi-sq test Satisfaction with family life Very unhappy Unhappy Average Happy Very happy Chi-sq test Use of psychotropic substances or inhalant Yes n % 467 39 8.4 78 15 19.2 43 4 9.3 6 0 0.0 0 0 0.0 * 12 2 16.7 51 6 11.8 283 23 8.1 14 7.6 184 4 20 283 258 27 31 148 186 170 11 35 201 227 114 0 3 28 23 4 3 18 13 13 2 2 27 14 12 0.0 15.0 9.9 8.9 14.8 9.7 12.2 7.0 7.7 18.2 5.7 13.4 6.2 10.5

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

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Mean score for scales among males
Drug users Impulsiveness CESD-10 Social support Age

Yes 17.44** 7.19** 12.44 22.42

No 15.05** 4.97** 11.93 21.90

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

Table 10. Cross tabulation of family antecedents and substances use among outschool female respondents
Row total Marital status of parents Still married Separated/ divorced Father deceased Mother deceased Both deceased Chi-sq test Relationship with father Very Poor Poor Good Very good Chi-sq test Relationship with mother Very Poor Poor Good Very good Chi-sq test Relationship between parents Very Poor Poor Average Good Very good Chi-sq test Happiness about family life Very unhappy Unhappy Average Happy Very happy Chi-sq test Use of psychotropic substances or inhalant Yes n % 437 26 6.0 80 10 12.5 49 4 8.2 2 18.2 11 2 0 0.0 13 40 296 172 3 21 240 290 24 43 154 157 174 9 34 174 219 143 3 4 21 10 2 4 16 17 5 6 13 11 5 2 7 15 13 5 23.1 10.0 7.1 5.8 66.7 19.1 6.7 5.9 ** 20.8 14.0 8.4 7.0 2.9 ** 22.2 20.6 8.6 5.9 3.5 **

Remarks: Numbers in brackets represent sizes of respondents in the category. Percentages shown are proportions of substance use within the row categories **. Association is significant with chi-square test at the 0.01 level (2-tailed). *. Difference is significant with chi-square test at the 0.05 level (2-tailed).

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Mean score for scales among females
Drug users Impulsiveness CESD-10 Social support Age

Yes 16.30* 6.72* 11.81* 22.77

No 14.46* 4.93* 12.78* 21.99

**. Difference is significant with independent sample t-test at the 0.01 level (2-tailed). *. Difference is significant with independent sample t-test at the 0.05 level (2-tailed).

3.4 Framework of the study: Proposed pathways between family quality and drug use
Background

The relationship between family antecedents and initiation of substance use has been studied. Family antecedents include family structure, quality of relationship and parenting practices. 3.4.1 Family structure Brown (2004) found that children with step parents or single parents are more likely to be troubled by behavioral and emotional problems than those who are borne by couples in a traditional marriage relationship. Past longitudinal studies further pointed out that adolescents who did not reside with both parents had a higher likelihood of developing drug use problems (Hemovich and Crano, 2009; Hoffmann, 2002; Hoffmann and Johnson, 1998; Lansford et al., 2001), whereas such difference of drug prevalence was not evident in those who live with foster parents and biological parents (Lansford et al., 2001). However, the impact arising from

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family structure on adolescents’ drug use behavior may not be as conspicuous when other family variables are also taken into consideration. Carlson and Corcoran (2001) identified the predictive effect of family structure on behavioral problems of children, but the effect is shown to be confounded by other variables like family economic status and mother’s psychological functioning.

The risk of adolescent drug use is not necessarily the same among families which exhibit disrupted relationships. For instance, girls who live only with their fathers are at significantly greater risk for illicit drug use than girls living only with their mothers (Hemovich and Crano, 2009). Also, a strong bonding with the mother serves as a stronger protective factor for adolescent drug use than that with the father (Bahr et al., 1998). These two findings suggested that the gender of parents would pose a moderation effect on the relationship between family structures and adolescent drug use. This result corresponds with the maternal hypothesis that youths who live with mothers and cultivate a closer relationship with mothers are less likely to be involved in delinquent behavior than those who live with fathers (Eitle, 2006). Although there has never been consensus on the gender that would provide better parenting to children, these findings have highlighted the fact that

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while disrupted family structure is a risk factor for adolescent drug use, parenting style and parent-child relationship could serve as strong moderating factors. 3.4.2 Family relationships Further to the conclusion just drawn, numerous studies have found that the effect of disrupted family structure on adolescent drug use is indeed confounded by the quality of family relationships. A better relation between couples and more parent-child discussions have been found to reduce the influence of marital disruption on adolescent drug use (Sun, 2001). Children who exhibit stronger bonding with parents would also have stronger protection against adolescent drug use (Bahr et al., 1998). In contrast, children in families with a high degree of conflict and low family bonding are more prone to have drug use experiences (Guo et al., 2002). Moreover, hostile parent-child relationships pose a direct impact on children’s problematic behaviors (Buehler, 2006). In a survey targeting run away and homeless youngsters in Taiwan, those who left home because of unsatisfactory family relationships had a higher risk of illegal drug or inhalant use compared to those who left home simply because of seeking for excitement (Wang et al., 2010). 3.4.3 Parenting practices In particular, positive parenting practice has been identified as an important protective factor for adolescent drug use. Adequate parental monitoring on 192

children’s behavior mediates the effect of parent-child relationships on children’s problematic behavior (Buehler, 2006). Clearly specified behavioral expectations from parents and parents’ reinforcement by praise and encouragement also reduce the risk of adolescent drug use (Coombs and Landsverk, 1988). In addition, effective supervision and monitoring in middle childhood by parents or guardians might induce a delay or prevent onset of drug use among youths (Chilcoat and Anthony, 1996). However, a high level of parental monitoring cannot guarantee a low level of peer drug use for their children, which is a strong risk factor for initiation of drug use (Bahr et al., 1998). As a result, despite parents’ close monitoring on children’s behavior, drug use due to peer influence within the social network is hardly avoidable.

As opposed to positive parenting practice, negative parenting practice would lead a higher risk of adolescent drug use. Aggravation in parenting, such as experiencing feelings of hardship when taking care of the children as well as feelings of being bothered by the children’s behavior, predicts behavioral and emotional problems of children (Brown, 2004). A local large scale study found that adolescents who experienced physical punishment (體罰) by family members, were more likely to be current users of psychoactive substances and heroin (Lau et al., 2005). 193

3.5 Research questions
There is a local research gap about how the above family antecedent factors interacted with each other and protect the adolescents from substance abuse. The relationship between children’s acceptance of parenting and adolescent drug use among local adolescents has not been studied thoroughly with quantitative study in a large representative sample, to the best of research team’s knowledge.

The key research questions in this quantitative research are whether local adolescents with disrupted family structure are more prone to be drug abusers and whether parenting style and parent-child relationship could serve as strong moderating factors. Two streams of the countervailing hypotheses are therefore set:

(1) one-parent or no parent family structure (where parents are divorced, separated or passed away) has direct influence on substance abuse, adjusted for variables of family relationship and acceptance to parenting.

Separated / divorced / passed away parents

Adolescent drug abuse

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(2) one-parent or no parent family has indirect influence on substance abuse, where family relationship and acceptance to parenting act as mediators.
Bad relationship with father or mother

Separated / divorced / passed away parents

Adolescent drug abuse

Not accept father’s or mother’s parenting

There is no absolute parenting style which can prevent from delinquent behavior, but children’s acceptance towards parenting seems to play an important role in determining their compliance to rules and respect towards parents, hence may serve as a mediator between family structure and adolescent substance abuse, and between family relationships and adolescent substance abuse.

On the other hand, according to the maternal hypothesis, the role of mother tends to be more important than father to protect adolescents from substance abuse. This part of the work also attempts to specify the influence from father’s parenting and mother’s parenting on initiation of substance abuse. Further analysis focuses on whether father’s influence is directly associated with substance abuse

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among adolescents, and how it is correlated with mother’s influence and indirectly influence substance abuse problem.

Bad relationship with mother

Bad relationship with father / not accept father’s parenting Not accept mother’s parenting

Adolescent drug abuse

3.6 Hypothesis
Based on the two streams of the countervailing hypotheses and the maternal hypothesis are proposed in the previous section, 14 sub-sets of the hypotheses are further detailed and verified as below: Direct influence of family structure, family relationship and parenting on adolescent drug abuse:1. Adolescents having their parents divorced or separated are more likely to have drug abuse problem than those who have married parents 2. Adolescents whose either or both parents passed away are more likely to have drug abuse problem than those who have married parents 3. Adolescents having better satisfaction to their family life are less likely to have drug abuse problem than those who have less satisfaction 4. Adolescents whose parents have better relationship are less likely to have drug abuse problem than those who have worse relationship 196

5.

Adolescents having better relationship with their parents are less likely to have drug abuse problem than those who have worse relationship

6.

Adolescents who accept parents’ parenting are less likely to have drug abuse problem than those who do not do so

Indirect influence of family structure on adolescent drug abuse:7. The relationship between having parents divorced or separated and initiation of drug abuse can be mediated by non-acceptance to father or mother's parenting 8. The relationship between having parents divorced or separated and initiation of drug abuse can be mediated by bad relationship with father or mother 9. The relationship between having parents passed away and initiation of drug abuse can be mediated by non-acceptance to father or mother's parenting 10. The relationship between having parents passed away and initiation of drug abuse can be mediated by bad relationship with father or mother Maternal hypothesis:11. Good relationship with mother can mediate the relationship between good relationship with father and initiation of drug abuse 12. Good relationship with mother can mediate the relationship between acceptance to father’s parenting and initiation of drug abuse 13. Acceptance to mother's parenting can mediate the relationship between acceptance to father's parenting and drug abuse 14. Acceptance to mother’s parenting can mediate the relationship between good relationship with father and initiation of drug abuse

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3.7 Statistical methods
The analysis is divided into 3 parts: (1) Investigate the univariate impact of each family factor (2) Multivariate impact of all family factors, and (3) Mediation analysis. In the first part, Multiple logistic regressions is conducted to explore the risk or protective effect of each family characteristic towards drug abuse, controlled with age, impulsiveness, depressive symptoms, social support. Each family characteristic is entered into the model separately to study their univariate impact on substance abuse. Adjusted odds ratios with p-values and 95% confidence intervals are obtained to compare the influence of the family characteristics. The odds ratio is the ratio of the odds of an event occurring in one group to the odds of it occurring in another group. An odds ratio greater than 1 indicates that the condition or event is more likely to occur in the first group (Bohrnstedt and Konke, 1994).

In the second part, all family structure and relationship variables and controlled variables were incorporated into a single logistic regression model in an exploratory manner. A backward elimination is applied to remove those variables with less explanatory power towards the outcome, according to their p-values. The final model would be noted when all remaining family factors are significant.

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Mediation analysis is a kind of path analysis to examine the presence of mediator between the risk/protective factors and the outcome variable. Mediation is assessed by using 3 rounds of regression models according to 3 criterion suggested by Baron & Kenny (1986).

Figure 8. Procedures for mediation analysis Mediator B
Criterion 2: Direct association between factor A and mediator B Criterion 3: Mediator B mediate the relationship between factor A and outcome

Risk / Protective factor A
Criterion 1: Direct association between factor A and outcome

Outcome

Univariate analysis of risk and protective factors for drug abuse among youths Figure 8 shows the procedures for the mediation analysis which consists of three criteria: (1) the risk or protective factor A correlates with the outcome with a regression model (criterion 1); (2) the risk or protective factor A correlates with the potential mediator (factor B) with the second regression model (criterion 2); and (3) when factor A and factor B are in the same regression model for the outcome, factor (B) is significantly predictive to the outcome (criterion 3). If factor A is no longer significant to predict the outcome in the third regression model and the factor B is still significant, this criterion is fulfilled and then factor B would be proved as a 199

mediator fully mediating the association between the factor A and the outcome. If both factor A and factor B are significantly predictive to the outcome in the third regression model, there would be a partial mediation effect from factor B.

From the study of odds ratios of logistic regression models, there is significant association between family structure and drug abuse among boys. The adjusted odds ratios showed that, compared to those who have married parents, boys whose either or both parents has passed away were more likely to be drug users (OR=5.003, CI=2.451, 10.212), whereas girls whose parents were divorced or separated were more likely to be drug users (OR=2.367, CI=1.178, 4.759) (Table 11).

Good family relationship and acceptance to parents’ parenting are also significant protective factors to drug abuse among boys. The adjusted odds ratios of happiness about family life, acceptance to father’s control and acceptance to mother’s control were significantly lower than 1 for all outcome variables. Good relationship with father and mother is protective to ever drug use.

Among girl respondents, the associations between family antecedents and initiation of drug abuse were less apparent as boys. When family factors were 200

controlled with other covariates in the regression models, the influence from family towards drug use was reduced. Girls whose parents were divorced or separated were more likely to have drug use (OR=2.399, CI=1.199, 4.799), and acceptance to father’s parenting reduced the risk of being drug use (OR=0.475, CI=0.251, 0.90) (Table 15). Table 11. Univariate odds ratios of regular drinking, regular smoking and ever drug use from multiple logistic regressions (Adjusted for age, impulsiveness, depressive symptoms, social support)
Boys Ever drug use OR
Parents are divorced or separated Either parent are passed away Parents relationship Happiness about family life Good relationship with father Good relationship with mother Acceptance to father's parenting Acceptance to mother's parenting

p-value .128 .000 .491 .004 .031 .000 .013 .000

1.796 5.003 .914 .684 .493 .216 .467 .335

95% C.I.for OR Lower Upper .844 3.822 2.451 10.212 .706 1.182 .528 .886 .259 .937 .100 .463 .255 .853 .181 .617

Girls Ever drug use OR
Parents are divorced or separated Either parent are passed away Parents relationship Happiness about family life Good relationship with father Good relationship with mother Acceptance to father's parenting Acceptance to mother's parenting

p-value .016 .766 .510 .412 .373 .057 .022 .216

2.367 .799 .912 .878 .715 .421 .475 .628

95% C.I.for OR Lower Upper 1.178 4.759 .183 3.498 .694 1.199 .644 1.197 .342 1.495 .173 1.026 .251 .900 .300 1.313

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Multivariate analysis of risk and protective factors to drug abuse (With backward elimination)

In the process of backward elimination, a number of variables have been filtered as they have less explanatory power to the drug use outcome variable. 4 variables related to family structure and family relationship was left in the final reduced model: Parents divorced or separated (OR=2.277, p