Childhood Addiction in Iran: A Grounded Theory Study

1. BACKGROUND

Nowadays, drugs and addiction are one of the major world crises, which threatens many people [1] and imposes serious damage on the family, society, and especially children who are the most vulnerable social group [1, 2].

The statistics of drug abuse in today's world is increasing rapidly. A toxicologist named Luding says that excluding food, there is no substance like opiates in the world that has easily entered the life of human beings [3]. The location of Iran and its neighboring countries that are major world drug producing countries is probably one of the reasons for the high and growing incidence of drug abuse and addiction in Iran and alarmingly the age of onset is declining as well [3]. Addiction means drug dependency, which is harmful to individuals and the society, and illicit drugs are any type of chemical compound that alter brain function causing excitement, depression, abnormal behavior, anger or impairment in judgment [4].

According to the UN (United Nations) definition, addiction is an acute or chronic poisoning that is harmful for an individual or community and is caused by using natural or industrial illicit drugs. Drug addiction creates a sense of urgency to continue drug abuse and supply it in every possible way, and an intense interest to increase the amount of drug consumption, leads to psychological and physical dependence [5]. Newborns, infants and young children are the most innocent individuals involved with narcotics, because they are often involved without their own will and due to the irresponsibility or ignorance of adults [6].

Addiction leads to the disintegration of an individual's character and family foundation and also contributes to social life degradation and destruction of the society. This phenomenon destroys the ability to organize and manage a healthy society, disrupts normal social performance, and imposes a crisis to the human society [1].

In addition to the physical and psychological consequences of drug abuse in children, the social consequences of these drugs are also very alarming, as these children should become the workforce of the community in a close future [7]. Improving the mental and social health of the community depends on empowering children and given the fact that drug control is a complicated process, early interventions should start before the children enter elementary school [8]. Children under 12 years of age whose personality and values are still not fully developed tend to abuse drugs because of more external reasons such as substance use by their parents [7]. Studies have shown that in families with drug addiction, children are more attracted to using drugs [8]. Hajli et al. studied the attitudes of individuals about the causes of drug abuse. Based on their findings, the most important causes were bad friends, addiction in the family, living in notorious neighborhoods, unemployment and parental divorce [9]. Heidari et al. studied the causes of drug abuse among addicts referred to a public rehabilitation center in Khorramabad. The results of this study showed a significant relation between addiction and low self-esteem, successive failures in life, mimicking the drug abuse behavior of family members, economic inequalities, unemployment and lack of job opportunities, urging of friends and peers, relief from pain and physical illness, pleasure in using and positive attitudes toward drugs [3]. Another research done in Zanjan, Iran indicated that there was a significant correlation between socializing with notorious friends, pleasure, poverty or high income, illiteracy, family problems, unemployment, relief from pain and tendency to addiction [10].

In Iran, cultivation of poppy, coca and cannabis for drug production, importing, shipping, exporting, manufacturing, holding, shipping, purchasing, distribution, delivery, transit, supply and sale of opioid drugs, establishing or administering a place for opioid drug use, manufacturing, purchase, sales, and maintenance of equipment and tools for the manufacture or use of drugs, and drug use in any way are offenses and crimes [11].

Most previous research so far have studied addiction among adults, but there has not been enough research about children’s addiction. Authors of this study hope that information obtained from this project can be used to find effective ways for supporting vulnerable children and coming up with solutions to prevent addiction in children, as well as providing suggestions to authorities.

The purpose of this research was to explain the phenomenon and causes of addiction among young children in Iran.

2. METHODS

This study utilizes the grounded theory qualitative method to explain the process and factors influencing addiction among children. Grounded theory is a kind of field research that studies phenomena in their natural settings, and it’s purpose is to deeply understand behaviors, practices, beliefs and attitudes of individuals and groups in their real life, in a such way that it tries to explain and clarify the social processes [12].

This study was approved by the Ethics Committee of Kerman University of Medical Sciences, Kerman, Iran (Ethics Code: IR.KMU.REC.1394.166).

After obtaining the necessary permits, participants were initially selected based on the study purpose among aid workers of Kerman welfare centers. Subsequently, the researcher performed theoretical sampling with the help of personnel from welfare centers. Participants were selected from social workers, educators, donators, psychologists with at least four years of work experience, parents or care takers with addicted children, and addicted children themselves. People, who did not give consent or did not cooperate or were not willing to answer the questions, were excluded from the study.

In this study, with the collaboration of the Kerman welfare center a number of children from 6 to 16 years old that had a history of addiction to opium, heroin, hashish, or alcohol were identified and enrolled in the study. The researchers initially talked with the social worker in charge of the child or the child’s parents, and explained the objectives of the study for them. Then, after obtaining verbal consent from the child and the child’s guardian, the first author (a male interviewer) performed interviews with children who were all boys. Because of the special situation of the interviewees and the fact that this study was not a clinical trial, the Ethics committee allowed the researchers to proceed with only verbal consent.

The location of the interview was selected by the participants and was mainly the rehabilitation or welfare centers in which the participant (worker, psychologist, philanthropist, mentor and child) lived or worked.

The main approach for collecting data in this study was deep semi structured interviews. Each interview took 30 to 60 minutes depending on the condition and willingness of the participant. As well as doing interviews; the researchers, took notes in the field from their observations, feelings and the participants' behaviors. The participants were assured about the confidentiality of their information.

The interview started with talking about the experiences and feelings of the participant about addiction or working with addicted children. The interview was conducted with questions based on the Strauss and Corbin grounded theory methods; such as “What do you think can be the underlying or facilitating factors of addiction in children? What would be the inhibiting factors and ...?” As these interviews were conducted with different people with different levels of understanding, such as a psychologist, benefactors and addicted child, based on the type of person interviewed, the dialogue and the level of transparency needed was different and in order to avoid ambiguity, simple words were used or further explanations were provided to the participants. Also, if necessary the interviewer attempted to ask additional questions to better understand the participants' thoughts and experiences. All interviews were conducted by one interviewer (AJ).

In the qualitative analysis, the researcher should immerse in the information and read the transcriptions again and again in order to be able to extract the core statements and concepts by encoding the transcriptions [12]. Analysis of data in grounded theory requires the simultaneous collecting, coding, and analyzing of data starting from the first interview.

All interviews were recorded on MP3 and then, they were transcribed word for word and then coding was performed. In this study, the Strauss and Corbin method was used for data analysis which includes the 3 stages of open, axial, and selective coding [12].

The first stage of analyzing was open coding in which the researchers read the interviews several times in order to attain a general understanding of the concepts. Then, they read the interviews line by line and word by word and specified the main concepts of each paragraph and coded them and made the first classification and description of latent concepts. In the axial coding, the researchers compared the coded data with each other and shaped it as categories that fitted together. Researchers compared each open code with the other open codes and put the same codes in one category. Then, they compared each class with the other classes to ensure that the classes are distinct from each other. The Strauss and Corbin’s paradigm focuses on issues, such as causal conditions, phenomenon, context, interventional conditions, practical strategies and outcomes that are the basis of linking these classes to each other. During the data analysis, the researchers discovered the themes that played the main roles in the phenomenon, interventional conditions or context and connected them by using the Strauss and Corbin paradigm.

In the selective coding, the researchers attempted to find the main and central class and the connections between the classes; so that, the elementary framework of the theory was identified [12]. The MAX QD 2007 software was used for storage, management and data restoration. The analysis and coding of each interview were done before the next interview.

Although qualitative researchers do not generalize their findings as quantitative researchers do, they try to truly explain the actual experiences of their participants. For this purpose, four criteria including credibility, dependability, confirmability, and transferability were taken into consideration to assess the trustworthiness of the qualitative data.

Long-term involvement with research data and participants provided the opportunity for researchers to examine the phenomena from more angles and achieve a more comprehensive understanding of the participants’ experiences. In order to ensure that the participants acknowledge the findings of the study against their experiences, researcher presented the initial extracted codes to some of the participants and asked their opinion. Also for more credibility after coding the interviews and determining the classes, an academic member acquainted with qualitative methods was asked to check and confirm the coding.

At the start of the study, a very limited literature review was performed. To prevent researchers from being influenced by the results of other studies during data collection and analysis, the researchers also tried to bracket their previous knowledge about this topic.

In order to show confirmability, the researchers tried to clearly explain the path of research and the measures taken so that it could be tracked by others. And for transferability, the research findings were shown to a number of people similar to the participants who had not participated in the research in order to verify the results of this research with their own experiences.

In this study, the necessary permits were obtained from Kerman University of Medical Sciences and the Welfare Organization of Kerman Province. Verbal informed consent was obtained from participants to conduct interviews and do audio recordings. Privacy and data confidentiality and deleting the interviewee’s identity information on the recorded audios, the transcribed texts and field notes was observed during the study. The participants had the right to withdraw from the research at any time during the study.

The methodology and results were reported according to COREQ-32 (Consolidated criteria for reporting qualitative research) [13].

3. RESULTS

The research participants were 13 people including 5 males and 8 females. Three people were interviewed two times; and a total of 16 interviews were conducted. The adult participants had working experience from 4 to 15 years. One person was a PhD in Clinical Psychology, two persons had MSc, and were the head of their centers at that time, six persons had bachelors, and one person had a graduate diploma. Also three addicted male children participated in this study. The children who participated in this study were addicted to opioids; not alcohol, cocaine, hallucinogens, designer drugs, or tobacco (Table 1).

In this study, 1315 initial codes were extracted. Analysis of the data led to the formation of four main categories: 1.The meaning of addiction 2. Causal conditions 3.Consequences of drug abuse and 4. Preventive factors (Table 2). The research paradigm can be seen in Fig. (1).

4. DISCUSSION

Findings of this study showed that familial, economic, social, cultural, and religious factors can be effective in children’s addiction.

According to our participants’ comments, addiction is less likely to be seen in children whose parents have strong religious beliefs. Studies from Algeria and Iran have reported that religious beliefs played an important role in prevention of addiction. Religious beliefs, and performing prayers define a framework of right deeds for the family; and thus strengthening religious beliefs in families especially in parents can be a strategy to prevent addiction [10, 14, 15].

It seems that addiction was higher among children whose parents were in prison. It is likely due to the fact that parent’s presence in the family would cause more monitoring and attention to children; therefore, the presence of parents at home can be an effective factor in preventing addiction among children.

It also appeared that addiction was more observed in children who had lost their parents. In fact, the death of one parent has a much hard impact on the lives of family members especially children. Parents fulfil both physical (such as food, clothing, etc.) and spiritual needs (affection, attention and understanding) of their children. Another point is that children learn their behavioral from the interaction of their parents with other family members and friends. However, children who have lost one of their parents are drawn towards people outside home like addicted peers to compensate for the lack of their presence and eventually fall into the trap of addiction. It can be concluded that children who find themselves alone and are not cared for; may consciously or unconsciously get drawn toward drugs to offset or mitigate the absence of their parents. In a research, about the causes of addiction in Varamin city, Iran, death of a parent was considered as one of the reasons for addiction [16].

In this study parent disputes were also among the reasons mentioned that led to children’s addiction. Studies in Iran and abroad have reported that divorce in the family leads to tendency of children towards addiction [10, 16, 17].

The participants of this study commented that parent behavior, such as attention to children and love can be effective in the prevention of child addiction. Studies comparing families with addicted and non-addicted members, have shown that most adolescents who are not involved in substance abuse were those who did not experience family tensions. Researchers think drug abuse does not happen in isolation and familial factors are often engaged [10]. In a study performed on the causes of addiction among young people in Iran, the addicts thought their family was more to blame for their addiction [10]. And another study showed that the family in which people live has a direct impact on the formation of the individual's psycho-social personality, either before marriage or after it. Like the mentioned studies, this study also considers the major influential role of family in the individual’s tendency toward addiction [18].

According to results of the study, it seems like children whom one of their family members is addicted are more inclined to drug abuse. This can be justified, because children have a close interaction with their family members, and place family members as their role models. The presence of addicted family members can make drug abuse seem moral for the children and incline them toward drug abuse. In research conducted among family members, researchers found that if the elder of the family is addicted, this misbehavior is accepted by other family members and leads to children’s tendency toward addiction [10]. In a study conducted in Iran, a significant percentage of studied addicts become addicted under the influence of other addicted family members, and they directly blamed their parents and/or other family members for their addiction [19]. Other studies have also reported that an addicted family member or addicted parent (especially addicted father) has a major impact on addiction in children [10, 20].

The present study showed that parental literacy and awareness can be a deterrent factor for addiction in child. A study, from Iran stated that low parental literacy is one of the reasons for individuals tendency toward addiction [21].Other research from Iran consider lower than high school education [22] or parental illiteracy and low literacy as important social variables affecting tendency toward drug abuse [14]. Other studies in Iran indicated that the less the parents’ education and awareness about the effects of drug abuse, the higher the possibility of drug abuse among the youth [23].

Our findings indicated that family poverty is a facilitating and driving factor for children toward drug abuse. It is obvious that a poor family which cannot buy or rent a good home and lives in low socioeconomic suburbs or slums; cannot afford food and clothing and may have to earn money through begging or committing crimes and this can further facilitate children’s addiction. Other studies conducted in Iran have also reported that poverty is a predisposing factor for addiction [14, 21]. Research findings suggest that life skills like the power to say no, creative thinking and etc can be a deterrent factor for children’s addiction. It may be stated that the courage to say no should be taught by the family, parents, school, teacher, social worker and psychologist. It is clear that a child who has learned life skills such as the power to say no, decision-making and critical thinking before doing something can show better and more accurate responses in critical circumstances.

Some of the participants in this study believed that easy access to drugs can be a facilitating factor for children’s tendency to addiction. Another study in Iran stated that easy access to drugs is the most important social variable influencing tendency to drug abuse [22].

It seems that another reason for children’s addiction is the addicted peers. Studies conducted in Iran have indicated that there is a significant relation between socializing with bad friends and tendency to addiction [3, 9, 10, 15, 17, 24-34]; however, these were quantitative studies conducted on mainly adult populations, which makes comparisons difficult.

We hope that the findings of this research can help policymakers and formal institutions control drug abuse in children. Also, solutions and long term programs can be proposed to control addiction in children through cooperation among various sectors, such as welfare centers, the municipality, police forces, and rehabilitation centers.

One limitation of the present study was that we could not do interviews with parents of addicted children due to their lack of cooperation or lack of access. Also we were not able to interview girls because of the objection of the welfare centers.

A few qualitative studies has been conducted so far about children’s addiction. The strength of this qualitative study was that it was able to depict some related social risk factors and provide suggestions for their control.

CONCLUSION

The results of this study suggest that providing support to orphans or children from low income families, life skills training, parental supervision, teaching parenting skills, and tracking and monitoring the child's peers; through welfare organizations, the municipality, police forces, charities and donors can help to prevent, reduce, and control addiction in children.

REFERENCES