As part of our project, Strengthening Capacities – Empowering Children – funded by ForumCIV and implemented in Kerala, India together with Fourth Wave Foundation, we conducted mapping research on the awareness and availability of Treatment for Children in Kerala India. In total, 1199 respondents participated in the survey. Participants included childcare professionals, school and community stakeholders, and children and parents.

The research has been essential in showcasing the need for increased sensitised [in-house] treatment centres for children to ensure a sustainable recovery process. Additionally, collaboration and awareness among all stakeholders is essential to ensure the Rights of the Child to protection of substance use and its recovery process. The full research can be accessed here. Below is a summary of the report.

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A previous mapping research in the region of Kerala by the Fourth Wave Foundation (FWF) and World Federation Against Drugs (WFAD) in 2021 showed that while there is an increase in drug use among children, there is a growing need for children to enter drug treatment and care programmes. However, the mapping research showcased that child-centric [in-house] treatment centres were limited and increased awareness of substance use dependency (SUD) treatment is needed to reduce parental denial, stigma, and the lack of support systems. Providing child-centric treatment centres, while preventing the use of substances, falls under the child’s right, as signed and ratified by the UN Member States through the United Nations Conventions on the Rights of the Child (CRC). Articles 33, 24.1, and 27.1 clearly outline the need to promote the child’s right to prevention, protection from drugs, and accessibility to healthcare institutions for a healthy life.

Sensitised treatment for children below 18 years of age is proven to be essential by research, as is the urgency for treatment for children with SUD due to their development stage. Longer and more intensified use can increase the risks of a constellation of “problem behaviours, legal problems, and physical, sexual, and emotional abuse” (Sterling, et al. 2010) as the development stage “contributes to risky judgements, including the tendency to make choices based heavily on emotion” (Winters, et al. 2011). Hence, a lack of access to [sensitised] services can have adverse long-term health and psychological consequences. Yet barriers, such as the lack of and/or inconsistent treatment facilities in the area, poor health coverage, missing motivation among adolescents, and unsupportive caregivers (Winters, et al. 2011; Sterling, et al. 2010) intensify the treatment gap. Not including the child’s psychological, developmental, and social needs, diminishes the effectiveness and success of the treatment and recovery pathway (Winters, et al. 2011).

This research aimed to continue to map a wider range of stakeholders, to identify the gaps and available options for child-centric treatment. The research-led question was “Do children with substance use dependency have access to a supportive care system in Kerala, India, reflecting their Child Rights?”. By increasing the knowledge and understanding of current practices, the rights of the child can be adhered to through the improvement of services.

The mapping research is based on questionnaires distributed among children, parents, school and community-level stakeholders, and childcare professionals from 6 vulnerable districts in Kerala under the NAPPDAR – National Action Plan for Drug Demand Reduction. It should be noted that a substantial group of respondents are government-appointed counsellors/caretakers/ teachers and might be limited in expressing criticism or a reasonable representation of the actual conditions.

DISCUSSION
Attitude towards substance use dependence
Overall, the questionnaires showcased a positive attitude towards the awareness of substance use and treatment services offered by professionals, including the toll-free helpline for children. Drug awareness in schools seems to focus on prevention mechanisms and opens discussions on the topic within the community and among parents and peers. Parents, schools, and communities seem to be supportive when it comes to providing guidance and services of counselling to children with substance use dependence. Students are generally not being corporally punished nor expelled, which is positive when it comes to removing the stigma and shame around dependency and treatment. Yet, the number of schools that still practice corporal punishments does need to be sensitised and reduced to allow more children with drug dependence to come forward and receive the help needed. Besides this, there is still a large minority of school and community-level stakeholders that feel that children face negligence by their families, and segregation or exclusion in their peer groups/community due to their drug dependence (Figure 1). Hence, continuous efforts, awareness sessions, and open discussions are therefore required.

At first look, the responses to the questionnaires do not highlight stigma influencing the availability of treatment among children. However, when needing to access treatment, the fear of stigmatisation was marked as a barrier by many child respondents, as was the lack of knowledge of the procedures to access the facilities, the distance to the treatment centre, and the costs (See Figure in the report). Due to the mixed responses regarding the barriers, it is questionable whether the awareness of the available care facilities is enough to reduce barriers to accessing treatment. Treatment accessibility goes beyond awareness. It is evident that information about treatment availability and its access procedures need to be well-known. The financial implications of treatments also add to the fact that people don’t access, shy away from, or refuse them and, therefore, need to be addressed. Therefore, awareness classes on drugs [dependency] should also focus on treatment, sharing further information on the protocols and ‘normalising’ treatment to reduce stigma. Additionally, collective efforts should try to decrease the financial barriers.

Interventions leading to treatment

The 13 principles by NIDA (2014) on effective treatment for children below 18 years of age are reflected in the questionnaire responses. The first principle of identifying and addressing adolescent substance use is made possible through the availability of counsellors and general awareness at schools. However, when a child with substance use dependency is identified, a substantial minority are unaware whether the child has entered treatment or not (See Figure 3). While the child with substance use dependency remains in the shadows without the correct intervention, it risks long-lasting effects on the quality of life and social relationships of the child. Therefore, it is essential to address and include follow-ups when substance use dependency is identified. Parents and teachers are important during the intervention as they can help the child to come forward and become motivated to enter treatment. As recognised in the questionnaires as well as by the twelve principles by NIDA (2014), the motivation to enter treatment among children is generally low. NIDA suggests legal interventions, sanctions, or mandated treatment as an additional effective tool to stimulate treatment enrolments. However, Winters, et al. (2011) do warn about the negative attitude that can be caused by a “concerned parent, mental health clinician, or school staff” and highlights the positive interactions by peers to be influential to the motivation level.

Treatment

Overall, the questionnaire results align with the NIDA principles when it comes to addressing the child as a whole person rather than focusing on their drug use in treatment. In treatment, the focus is mainly on behavioural change to determine the roots of drug use. Yet, there is still a small group focusing mainly on limiting drug use and stopping further use. Behavioural therapies are advised by NIDA as is the integration of families and community in treatment. The latter is of significance in the recovery process. The childcare respondents highlight that family is often involved as bystanders or does accompany the children for a visit. Overall, the principle to identify and treat other mental health conditions is recognised by childcare professionals as most consider mental health and address traumas and adverse childhood experiences during treatment. Additionally, even though there are more males than females in treatment, both receive separate treatment. When comparing it to adults, the child is monitored more closely during the treatment.The principles also highlight the importance of tailored treatment programmes to the unique needs of adolescents. Whereas most childcare professionals shared counselling, outpatient, and family interventions as their treatment method and have sensitised it to the child’s needs, the results showcase that it was recognised that certain special needs tend to be overlooked and are missing in treatment. Examples of needs that are said to be missing are mental support, family care, financial support, lack of institutions in child deaddiction, emotional support from family, school, and peers, recreational facilities, alternative pleasures, and behavioural interventions. An important aspect missing in treatment services for children is in-patient treatment centres (Figure 4).

Preventing relapse

Children need to stay in treatment for an “adequate period and [receive a] continuity of care afterwards” (NIDA 2014) as treatment for children is typically shorter than for adults (Winters, et al. 2011). The questionnaire results do not showcase a particular average length of treatment for the child. The length of treatment among the childcare respondents varied from two weeks to a year plus. Even though children usually complete their treatment, most childcare professionals recognise that children do sometimes have to come back to treatment due to relapse, with a few seeing children having to come back often (Figure 5). It is important to note that relapse among adolescents is rather common (Winters, et al. 2011). Reasons for relapse considered by childcare professionals are the lack of aftercare or change in the child’s environment, unstable homes, or traumas. To limit the rate of relapse, further continuum of [after]care, including regular follow-ups, should be offered while considering the child’s environment and traumas in the treatment and aftercare plan.

CONCLUSION

Overall, drug awareness is well integrated into the social structure of the child in Kerala, India. Drug awareness sessions are being given to the children, counselling is offered, school counsellors are approachable, and discussions on the topic happen among children, parents, and the community. Other children are being supported and guided to available treatment when a drug dependency is noticed. However, a substantial minority of children with substance use dependency still face corporal punishments in schools and negligence by their families, segregation, or exclusion in their peer groups. Additionally, generally, procedures to access treatment are rather unknown, financial barriers are visible, and stigma is faced by those accessing treatment. Hence, the social support system should broaden its focus not only on drug awareness, including preventive measures but also on active support to treatment when a child faces SUD to ensure the full rights of the child.
Substance use treatment is available to children in Kerala, India. Treatment services offered provide counselling, outpatient treatment, and family interventions, integrate other issues, such as mental health, adverse childhood experiences, and traumas, and are gender sensitive. However, no clear average time of treatment is seen, whereas the length of treatment is important for the child. Simultaneously, it is recognised that certain special needs are overlooked and missed in treatment. To limit relapses among children, these special needs as well as the environment outside treatment need to be reflected upon and integrated into treatment. Additionally, the use of national and international manuals can improve [evidence-based] services. Most importantly, more inpatient treatment services need to be offered while limiting the geographical distance between treatment services and children to ensure that children can get the help they need.

Hence, it can be concluded that children with substance use dependency do have a supportive care system in Kerala, India. However, to ensure that all their rights and needs are met and barriers to access treatment are reduced, the system needs to be further established in more detail.