This chapter provides a comprehensive critical literature review of a small number of sources that are considered to be particularly useful in exploring the two key themes of this dissertation. The first of these themes is the impact of drug abuse on the health of the teenagers aged 13-19 in London, while the second is the impact of governmental strategies in tackling drug abuse amongst teenagers aged 13-19 in London. These themes are discussed using the resources selected, and the quality, methodological approach, relevance and ethical and anti-oppressive practices are all part of the critical review. The chapter finishes with a short summary bringing these key ideas together.
1.1 The Impact of Drug Abuse on the Health of Teenagers Aged 13 – 19 in London
The first theme investigates the impact of drug abuse on specific aspects of health on teenagers in London. There are two key sources that form the core of this critical review for this theme. Even so, neither of these relate solely to the target population, and in each case some extrapolation of findings is made in order to describe the likely characteristics of 13 – 19 years’ olds in London. The first is source is the case-controlled study carried out by Di Forti et al (2015:1), and briefly discussed in Chapter Two above. Looking more closely at this study, and reviewing it critically, it still remains a useful article, as it focuses on the mental health impacts of cannabis and shows a clear association between the use of the drug in its high potency form (skunk) and psychosis. It might not at first appear that the study is relevant given that it started in 2005. However, it continued recruiting for over 6 years, and amassed a wealth of data on those individuals abusing drugs – specifically high potency and easily available cannabis. The research study used a primary research methodology. For the recruitment of cases, the authors approached all patients (18 – 65 years) with first episode psychosis presenting at the inpatient units of the South London and Maudsley Hospital. They invited people to participate in the study only if they met the International Classification of Diseases 10 criteria for a diagnosis of non-affective (F20–F29) or affective (F30–F33) psychosis, which they validated by administering the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (Di Forti et al, 2015:2). For the controls, the authors used internet and newspaper adverts and also distributed leaflets on public transport and in shops and job centres. The controls were given the Psychosis Screening Questionnaire and were excluded if they met the criteria for a psychotic disorder. While the two groups only included the last two years of the target population group for this study i.e. 18 and 19 year olds, it was a study located in London, and on analysis appeared to indicate a number of characteristics that were felt to be useful for providing information that would also be useful for younger teenagers. All participants (cases and controls) included in the study gave written informed consent under the ethical approval obtained from the Institute of Psychiatry Local Research Ethics Committee. There did not appear to be any unethical practices, but the study had the potential to be oppressive as by the nature of the patients presenting at the clinics, and by the nature of their access to skunk, being more likely to be of certain ethnic groups – especially of black West Indian origin – it could be argued that the study to some extent misrepresented the populations of south west London, and more specifically, the West Indian communities found there. In other words, the inclusion of participants from these origins might be likely to give observers an unjust view of the ethnic group or of the population of that area of London as a whole. The method used with the participants was quantitative and involved questionnaire assessments, specifically socioeconomic data and the Cannabis Experience Questionnaire modified version (CEQmv) which included data on history of use of alcohol. tobacco, alcohol, any other use of recreational drugs, and detailed information on cannabis use (i.e. first use age, use duration, frequency of use, type of cannabis used) (Di Forti et al, 2015:2). Between 2005 and 2011, the researchers approached 606 patients of which 145 (24%) refused to participate, therefore 461 patients with first-episode psychosis were recruited. Using a range of statistical tests, and adjusting for a number of variables including the variables for frequency of cannabis use and the type of cannabis used, and in combining these the authors found that controls were more likely to be occasional users of hash, whilst the frequent users were more likely to be using skunk. They also found, using logistic regression, that those people who had started using cannabis at a younger age had a greater risk of developing psychotic episodes (Di Forti et al, 2015:5). The second resource to be analysed was the study by McCardle (2004). This was a literature review focusing on the impacts of substance abuse by children and young people. Although this did not use primary research, it provided a useful analysis of a number of other studies. Although the age of this study meant that it might have had limited relevance to teenagers in 2017, in fact the study related directly to the findings of the later Di Forti et al study. This was because McCardle (2004:1) found that cannabis was becoming stronger than it had been in the past – just as Di Forti et al found that skunk use was increasing and that it was of a much higher potency than previously. McCardle (2004:2) also found that there was a range of mental health issues resulting from the use of cannabis, including an increased risk of suicide, and an increase in aggressive, disassociated behaviours, anxiety, depression and other similar problems (McCardle, 2004:2). Another useful aspect of this research was that it identified the problems of terminology relating to the gathering and analysis of data – so many different terms are used that it is often difficult to ascertain accurate trends and outcomes (McCardle, 2004:3). While it would have been preferred to have used a London based source or one that engaged participants of the target age group though a primary method, the lack of sources of academic literature meant that this study was valuable in that it analysed other studies, and also existing datasets from the UK government. The article also focused on the social impacts of cannabis, for example, looking at the developmental impacts, and the negative effects on education, both of which could lead to poor outcomes in terms of quality of life and attainment in later life. The findings from these two articles provided valid evidence of the relationship between the use of cannabis and mental, emotional, social and physical health of teenagers and young people. Although there was limited focus on the population age target group for the dissertation specifically, both articles provided relevant points of interest, and it is possible to extrapolate from them to state that teenagers in London engaged in cannabis abuse are very likely to be at risk of experiencing the various health effects identified above.
3.2 The Impact of Government Strategies in Tackling Drug Abuse Amongst Teenagers Aged 13-19 in London
Finding academic research sources that focused on recent government strategies aimed at the target group based in London was very challenging. For the most recent strategy – the Troubled Families Programme, Lambert and Crossley (2017:1) get to the very heart of the ethical and oppressive practices issue, as they argue that this government strategy is one of a wider spectrum of policies that locates problems within the family itself, and which emphasises behaviour as the target for action irrespective of the socio-economic influences that exist. This is a review study – critically reviewing a strategy – and is very current, as the TFP has recently been revisited by the Government, who are considering an extension, despite evidence that it has not met its targets or expected outcomes. While this article is not based on a piece of primary data, the authors have conducted primary data about this issue through interviews in the very recent past, and the article refers to these. They have found that TFP has continued the view of target families as an ‘underclass’, as ‘neighbours from hell’ and as expensive and very difficult to ‘treat’. While the TFP took a holistic approach, using one individual or team to work with families on all of their problems, Lambert and Crossley (2017:4), and others (Bonell et al, 2016) argue that the underlying attitude of the Government and of the strategy meant that its approach was unlikely to succeed.
This chapter showed that there were clearly associated health impacts with the use of cannabis; some of these impacts were severe, and often included mental illness and behavioural change, especially where high potency cannabis was used. It also showed that despite many years of government strategies and policies, there still does not appear to be a solution that can reduce the use or impacts of cannabis and other drugs. The final chapter provides a reflection on the research undertaken for this dissertation, and provides some brief conclusions and recommendations.
CHAPTER FOUR – REFLECTIONS, CONCLUSIONS AND RECOMMENDATIONS
In this final chapter, three tasks are completed. First, a reflective account of the research is undertaken. In research and practice, reflection on a task and outcome is very important because it provides the author with the opportunity to look back and learn from their actions. There are in fact two types of reflection, both of which might be applicable to this work. The first definition is that of ‘reflection’ which is considered to be a ‘process or activity’ that involves thinking and is judged to include cognitive processes of problem finding and problem solving (Leitch and Day, 2000:180). The second type of reflection is that of ‘reflective practice’. This is the use of reflection and reflective skills to transfer learnt knowledge i.e. theories to the application of those theories to the everyday practices of an individual. It has been shown to be very important for individual practitioners as it aids their ability to learn from their actions and associated outcomes, and enables them to develop improvements based on experience and theoretical knowledge (White et al, 2016:9). There are two main models of reflection that can be used to support the reflective researcher or the reflective practitioner. These are Kolb’s model of experiential learning (Kolb, 1984) and Gibbs’ reflective cycle (Gibbs, 1988). Gibbs developed his model as a refinement of the earlier Kolb model, and it is Gibbs’ model that is used in this dissertation. The Gibbs Model provides a researcher with the opportunity to gain a deep understanding of what they have learned (Park and Kastanis, 2009:11) and the strengths and weaknesses of their work, their underlying values, the insufficiency of their approach, and areas of improvement (Park and Son, 2012:3). For these reasons the Gibbs Model will be applied below.
4.1 Reflection on the Process of the Research
4.1.1 The Experience The process of writing the dissertation was both challenging and enjoyable. It was enjoyable because any research activity is one of problem solving and of searching for information, and these two activities can be very satisfying when they result in finding out something new. While primary research is often seen as the most valid form of activity, in fact secondary research, based as it is on the gathering of existing data, and the synthesis of that data to suggest new outcomes or findings, can be just as valid, and just as difficult as carrying out processes that collect new or primary data. 4.1.2 The Challenges and the Achievements As alluded to a number of times throughout this dissertation there were a number of difficulties or challenges. The choice of the topic was in retrospect a good one because it focussed on a population group in a particular location, London, that had clearly received little research focus previously. While there has been substantial data gathered on drug use and abuse more generally in the UK and more generally across age ranges, very little has been done in relation to the 13 – 19 year old age group. In fact, it was this aspect that caused the greatest difficulty in completing the dissertation – the lack of resources and data available that were relevant to this age group, in London, for any kind of drug abuse other than newspaper articles that often used the issue of drug abuse in relation to crime, ethnic minorities or deprivation, meant that the data that was available had to be used carefully. For example, it was possible to obtain academic resources such as that of Di Forti et al, that looked at drug abuse, specifically, cannabis, in London, but only two years of respondents in that study (18 and 19 year olds) fit into this dissertation, whilst the study by McCardle (2004) provided relevance to the wider age group (15 – 24) but was not based in London, so could point to some useful outcomes but did not have specific locational knowledge. In relation to the strategies developed to address the issue, again the resources of an academic nature were very limited, made even more challenging because the most recent strategies, i.e. those that had occurred in the past five years, have yet to undergo much academic analysis, but as they are a very different approach from those used a decade or so ago, there is little point in trying to evaluate those older approaches. Despite the difficulties outlined above, it was felt that there were a number of positives obtained from the research. As there was such a dearth of resources available, this dissertation appears to provide new research and new analysis of data for this group of the population in this location. As a result, the author felt that the validity of their choice of topic and their research approach was justified to some extent. In terms of time management, it was felt that the research was planned well, and even though the search for data and resources took longer than expected, it was still possible to incorporate the timing required into the overall research schedule. The research also challenged the overall beliefs and judgements held by the author at the start of the process. Whilst it was felt that some degree of knowledge was held about these issues, there were some preconceptions held about the type of teenagers that participated in drug abuse. The gathering of the data enabled the author to begin to challenge those preconceptions especially in relation to the factors that cause people of this age to start abusing drugs. This new understanding allowed the author to start to view the issues differently. 4.1.3 Changes Required There are a number of changes that could be implemented to make the research easier and to address the question of limited resources. Firstly, the age range would be extended to include children from the age of 0 years to 24 or 25 years, as this would enable a greater number of data sources to be used, and they could be more easily analysed and extrapolation made for teenage years. Second, the inclusion of drug abuse by parents impacting on the health of their children would be included, as this issue has consistently emerged as a key problem for children and teenagers throughout the data collection, and can be a major factor in determining whether teenagers participate in drug use and abuse. Finally, although London would still be the locational focus, because a lot of data that is collected for London and the South-East, the locational boundaries would be stretched to incorporate this area within the research. If these changes were put into place, it would be a positive exercise to undertake the research process again to see if it was possible to obtain data and achieve findings that were even more valuable than those already developed. 4.1.4 Applying the Gibb’s Model of Reflection Having applied Gibbs’ model of reflection it is helpful to see that the reflection that is carried out in stages can lead to a targeted plan of action, which can form the framework for new research. Gibbs’ model does not necessarily allow for complexity, however, as it is a linear-cyclical model, and used in this way cannot represent the many complexities and variables that characterise the issue of drug abuse amongst teenagers.
The research question that this dissertation set out to examine was: What patterns of drug abuse occur amongst teenagers in London, and what are the causes, health impacts and possible solutions? Despite the difficulties in obtaining specific data for teenagers aged 13 – 19 in London, there was sufficient information available to be able to provide an answer to this research question. From the prevalence perspective, the data showed that while the prevalence of drug abuse was decreasing overall, there were areas of London that had disproportionately higher levels, especially amongst specific ethnic groups. However, amongst all drug abusers, cannabis was the most used drug. The causes of drug abuse amongst teenagers was found to be a complex mixture of environmental, emotional, mental health and peer pressure related factors, meaning that addressing the problem is always going to be challenging for policy makers and healthcare providers. In relation to the health impacts, the previous chapter has revealed that there is clear evidence that its use can be clearly associated with health outcomes of mental health including psychosis and the development of schizophrenia for drug abusers of any age. Not only that, but it is also quite apparent that teenagers engaging in drug abuse are much more likely to experience other health related problems because of their attitude to risk, and their participation in high-risk behaviours when they are under the influence of the drug. These other problems include contracting STIs, teenage pregnancy, the taking of other drugs and substances that have more severe health impacts, participating in criminal activities that can lead to violence in an attempt to obtain money to buy drugs and so on. Looking at the strategy that has most recently been developed to try and address the problem of teenage drug use in London, it is apparent that it has not succeeded in its aims, objectives or targets. This seems to be the result largely of the oppressive nature of all such strategies held by UK Governments over recent years – an attitude that views those with drug abuse and other problems, as ‘problem families’ that need to be ‘solved’, instead of trying to really understand what it is about society in general that leads to such families existing in the first place. A focus on social, economic and environmental issues rather than on the families themselves might result in a better outcome.
Having carried out a review of the literature surrounding this issue, there are some key recommendations that can immediately be made. The first of these recommendations relates to the data available for this issue – as indicated previously, one of the challenges of completing this dissertation was the paucity of data relating to the specific population being studied. It is, therefore, recommended, that research studies, or government agencies collecting data, should target this age group specifically when data is being collected about drug use or abuse. An alternative to this is for researchers to obtain the raw data from the various data collection agencies and sources, and to extrapolate the data that crosses the boundaries of the targeted populations group, and reprocess that data for the target age group. The second recommendation relates not to the data, but to the issues. It appears that controlling the availability of drugs is difficult, especially as there are so many types, and some, like cannabis, appear to be regularly available. As there seems to be an ongoing reduction in the number of young people using these illegal drugs, it would seem sensible to capitalise on this trend by providing better educational initiatives to inform people of the dangers to their health. It would also be appropriate to try and determine which factors were most likely to cause teenagers to start abusing drugs and to find ways of addressing these factors more effectively than has been the case to date.
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