Navigating Adolescence: An Experimental Study on the Intersection of Addiction, Sexuality and Self-Regulation

Addiction among adolescents is a major problem in the world today. Be it substance abuse or behavioral addiction like internet or gaming. Adolescents are particularly vulnerable as their curiosity, and sensation-seeking tendencies increase during this period due to peer pressure, they might easily indulge in such risk-taking behaviors. Along with these, adolescents may also pander to sexually risky behaviors increasing the risk of sexually transmitted diseases. Other factors that lead to addiction are a biological predisposition to drug abuse, lack of social bonding, lack of good family relationships and communication, a history of being abused or neglected, low socioeconomic status, psychiatric problems, significant stressors, and insufficient coping skills and social support, drug-using peers, low commitment to education, failure at school, a history of anti-social behavior and delinquency and early initiation to drug use [1]. The addictive behaviors also develop as the resulting lack of a fully developed regulatory system in adolescents [2]. 

Research indicates that parental role modeling and cultural tolerance also contribute to the tendency of drug abuse in adolescents [3]. Inadequate social skills and rejection by peers due to lack of social skills are major factors for increasing addiction-related tendencies [4]. In a study, parental, peer, and sibling substance use proved to be a strong predictor in the initiation of substance use in adolescents [5]. Maltreatment in childhood like physical abuse, neglect, or sexual assault increases the risk of an adolescent getting involved with substance use [6]. Children and adolescents who face emotional abuse like witnessing domestic violence in the family also fall into substance use turning it into a coping mechanism [7]. Peer pressure and perceived popularity are also associated with increased risk for adolescent substance use. The belief among adolescents that the use of substances helps in improving their social image is a major cause of initiation [8]. There has been a significant positive association between gang affiliation, deviant peer groups, and substance use, especially in alcohol and marijuana use [9]. Exposure and initiation into substance use before teenage prove to be more harmful [10]. Individual factors like ADHD and depression also contribute to substance use. Several studies, including a meta-analysis of thirteen studies, have shown that childhood ADHD leads to an increased risk of developing a substance use disorder during adolescence or adulthood [11]. 

With substance abuse, adolescents are also concerned about their sexuality. Due to a lack of proper knowledge, they may indulge in risky sexual acts and can fall prey to sexually transmitted diseases including HIV. India’s culture still treats sex as a taboo topic and hence parents, elders, and teachers avoid talking openly about it. So, this lack of scientific knowledge may lead adolescents to explore on their own and they take the help of unreliable sources such as porn sites to satisfy their curiosity. However, the presence of strong stigma and controversy holds back the content of adolescent health programs, giving way to several negative sexual and reproductive health issues [12]. 

In addition to the issues discussed above, several evolving issues are pertinent today in the context of child sexuality and sexuality education. First, there are issues related to the manipulation and exploitation of child sexuality. Noticeable examples are child pornography, prostitution, child sexual abuse and poor parenting, adolescent dating violence or intimate partner violence, body image disorders, rape and abortion, and pornography consumption by adolescents. Second, in contemporary research on sexual behavior and attitudes of adolescents in India, major issues noticed were puberty and infertility; age at first sexual intercourse and engagement in premarital sex; the number of sexual partners and emergency contraception, substance use and attitudes about sexual behaviors, menstrual hygiene, and virginity [13]. In a study done in Pune, it was found that adolescents accessing pornography, being sexually abused in childhood, and having poor relationships with parents had a higher likelihood of early sex initiation [14]. 

These child sexuality issues impose a significant health-related, physical, and emotional burden on Indian adolescents. The need for formal comprehensive sexuality education is demanded by students, parents, and teachers. These programs should be creatively articulated focusing on the psychosocial needs of the adolescents. Comprehensive sexuality education should support adolescents’ ability to make decisions regarding sexual choices and prepare young people for skills and knowledge on healthy sexual behavior [15]. Sexuality education should include teaching adolescents about the important role their sexuality plays in their personality, the positive things sexuality brings to life, and the role sexuality plays in an individual’s connection to others. Such programs however must be carefully designed keeping the scientific evidence at the core for the adolescents in India [16]. 

In India, many studies on creating awareness about addiction and sexuality education for adolescents are conducted. But this need for comprehensive programs including awareness about addiction, and sexuality largely seemed to be unattended. Thus, the present study involving a comprehensive program for creating awareness about connections between addiction, sexuality, and self-regulation is implemented as an intervention. The main objective of this study was to create awareness about the ill effects of addiction and risky sexual behavior through psycho-education focusing on self-control and self-regulation among adolescents in Pune City.

This study was conducted on 8587 adolescents of 8^th, 9^th and 10^th standard from 61 government-aided and private schools in Pune city. A series of 25 intervention sessions was carried out by 195 trained teachers and volunteers. Two meetings with parents were also conducted to apprise them about the program. The design was Pretest-Posttest Quasi-Experimental design. Participants were assigned randomly in both groups. Intervention sessions consisted of training in sexuality education and changing attitudes towards addiction and self-regulation to enhance adolescents’ knowledge of sexuality, adolescents’ knowledge, awareness, and attitude about addiction and adolescents’ self-regulation tendencies. The techniques used to deliver sessions were role plays, stories, interactive games, worksheets, discussions and daily life examples. 

A control group with 900 adolescents was also included in this study. To them, a pretest was conducted, and after one month post-tests were conducted and intervention was imparted later. The tools used for baseline and impact assessment were developed by a group of volunteers and Psychologists working in the field of adolescent awareness about sexuality and addiction for more than 20 years at Jnana Prabodhini’s Institute of Psychology, Pune. Tools used were My Knowledge, My Health Test (MKMH): This test refers to information about sexuality issues. It includes scientific information related to anatomy, and physiology, myths, and misconceptions related to sexuality, medical and health issues, and gender sensitization issues with Cronbach Alpha 0.90 and 30 total items. Myths and Misconceptions about Addiction Test (MMAT): This test measures the adolescents’ knowledge, awareness, myths, and misconceptions related to addiction and attitudes about addiction with a reliability of 0.79 and a validity of 0.9 and has 30 total items. Me And My Emotions (Emotional Regulation Test or ERT): This test measures the awareness of self-regulation, locus of control, delay in gratification, frustration tolerance, and assertiveness in adolescents. It has 35 items with a Cronbach Alpha of 0.71. 

Teachers and volunteers were trained for four days in exhaustive training sessions by Master trainers who have experience working in the field of sexuality education for more than 20 years. It was extensive training with a standardized content manual, focused group discussion, videos, role plays, stories, paper-pencil tasks, presentations, group games, and discussed activities to be done in the class and expected queries from the students. Thorough lesson notes and manuals on each topic were made and given to the trainees. A total of 25 sessions of 1 hour each including the pre-test and post-testing were conducted in the schools. The main topics were personality, beauty, anatomy, and physiology of both sexes, friendship, sexual abuse, addiction, media, soft skills, gender complementarity, stress management, and goal setting. The sessions with students included group and individual activities, role plays, stories, discussions, presentations, and brainstorming. The data was entered through an Android application specially developed for this project and analysis was done on SPSS 23.

The data was cleaned, incomplete tests were discarded and the final statistics had data from students who were present for both pre-test and post-test. From table 1, in the experimental group, a change in mean (SD) in MKMH from 14.98(4.4) in Pretest to 18.39(5.3) in Post-test is seen. In MMAT, a change in mean from 35.29(9.1) in Pre test to 39.97(8.2) in Post test is noticed. In ERT, 96.29(11.76) in the Pretest to 99.56(11.65) in Post test is observed.

In the Control group, a change in mean (SD) in MKMH from 16.30(4.7) in Pretest to 15.45(4.7) in Post test is seen. In MMAT, a change in mean from 35.84(8.8) in the Pretest to 33.34(9.09) in Post test is noticed. In ERT, 97.89(11.96) in the Pretest to 99.53(11.70) in Post test is noticed (Table 2).

Table 1: Descriptive Statistics: Experimental Group (E) and Control group (C).

*My Knowledge, My Health Test,

** Myths and Misconceptions about Addiction Test

*** Emotional Regulation Test

Table 2: Gain scores analysis between Experimental and Control groups ( MKMH, MMAT and ERT): Independent samples ‘t-test’.

Independent t test is done on the gain scores (post test scores -pre test scores) of all the three tests. An independent samples t-test of MKMH shows the following result in table 3 in comparing the experimental and control groups. There was a significant difference in the scores for the experimental (M=3.4, SD=5.1) and control (M=-.85, SD=3.73) groups; t (6829) =20.43, p = 0.00. These results show that after intervention there is a significant change in the adolescent’s knowledge about sexuality education. 

An independent-sample t-test of MMAT was conducted to compare the experimental and control groups. There was a significant difference in the scores for the experimental (M=4.68, SD=10.19) and control (M=-2.50, SD=8.65) groups; t (7035) =17.43, p = 0.00. These results show that after intervention there is a significant change in the adolescents’ attitude toward myths and misconceptions about addiction. An independent-sample t-test of ERT was conducted to compare the experimental and control groups. There was a significant difference in the scores for the experimental (M=3.27, SD=11.64) and control (M=1.64, SD=11.68) groups; t (7280) =3.43, p = 0.001. These results show that after intervention there is a significant change in the adolescents of the experimental group for emotional regulation tendencies. Effect size was also calculated to find the magnitude of change. For MKMH, Cohen’s D is 0.97, for MMAT, it was 0.72, for ERT, the effect size was 0.39. The large effect size in MKMH and MMAT shows a greater impact of the intervention and the moderate effect size in ERT also denotes substantial change.

Table 3: Pearson Correlation between MKMH, MMAT and ERT (Total N = 4745).

**. Correlation is significant at the 0.01 level (2-tailed).

In this table, it is apparent that there is a moderate correlation of 0.338 between MMAT and MKMH. This shows knowledge of awareness about addiction and sexuality education together is effective as an intervention. A negligible negative correlation of -0.096 between ERT and MMAT was noticed. A negligible correlation of 0.091 between MKMH and ERT denotes that emotional regulation has not contributed to increasing awareness and knowledge about sexual health issues. 

Regression analysis between MKMH and MMAT reveals that MKMH predicts MMAT, R2 = 0.11, F (1, 4743) =612.7, p = 0.000. This shows that knowledge about addiction and sexuality contributes to changing attitudes towards addiction.

The present study has shown the effectiveness of the combined intervention regarding awareness about addiction and responsible sexuality for the prevention of addiction. Prevention is an effective way to reduce or limit drug use in the world [17]. The findings of the present study indicate that before the intervention, students lacked proper scientific information about addiction and psychosocial aspects of sexuality. This can be due to adolescents’ eagerness to know about addictive substances and sex-related information. Inappropriate and distorted information that they get from unauthentic sources also could be one of the reasons behind this. The increase in awareness of these issues seems to be instrumental in preventing vulnerability to addiction and more appropriate sexually responsible behavior. 

Many such intervention programs are steered in this direction. Studies of peer networks and peer-led interventions have proved to be successful in the prevention of addiction in adolescents [18]. Life skills training with self-monitoring, social skills for adolescents and family-based prevention programs for parents with teaching communication skills, and prosocial skills training to their children have been demonstrated to be very effective in preventing substance use in adolescents [19,20]. A model for self-regulation and motivation to regulate the appetitive response tendency is given to promote the prevention of addiction in adolescents [2]. Studies done with adolescents in Pune have shown improvement in knowledge and change in attitude about sexuality and addiction after the educational intervention [21,22]. 

A study done to find out the role of social skills in refraining from addiction tendencies showed that positive social behaviors, assertiveness, and purposeful communication were factors associated with the tendency to refrain from substance use [4]. Another innovative approach used for the prevention of addiction in one study in Iran was the narrative approach or storytelling-based education which proved to be quite effective [23]. 

In the present study, it was evident from the correlation between the variables that initiating a comprehensive psycho-educational model is required and the results have proven the efficacy of the model. In a study, a meta-analysis was done of school-based drug prevention programs and it was found that interactive programs that inculcate interpersonal skills were much more effective than non-interactive lecture-based programs [24]. Another study mentioned prevention programs for four areas namely substance abuse, risky sexual behavior, school failure, juvenile delinquency, and violence, and the effective prevention programs found had the following characteristics-comprehensiveness, diverse teaching methods, theory-driven, provided opportunities for positive relationships, were appropriately timed, were socio-culturally relevant, included outcome evaluation, and involved well-trained staff [25]. A primary prevention program done for ‘tweens’ i.e. for children before grade sixth has shown positive results as children after this age show resistance to intervention [10]. 

The findings from the present study also reveal the efficacy of this prevention program when applied efficiently. It is evident from the significant changes noticed between the experimental group and the control group. Similar results were found in a study done on high-risk youth for addiction who received the prevention program, reported a reduction in smoking, drinking, inhalant use, and polydrug use in the one-year follow-up assessment as compared to youth at high risk in the control condition that did not receive the intervention [26]. The findings of this study are supported by similar school-based drug abuse prevention programs [27,28]. 

A similar effect of educational intervention was seen in a meta-analysis of various Brief alcohol interventions implemented for adolescents [29,30]. A major feature of the present study was raising awareness about addiction and its ill effects by generating self-regulation in adolescents. It has proven to be effective. Self-regulation is needed to overcome the initial urge to resist addictive substances and during addiction to quit it. Similar results are seen in the intervention studies with self-control and self-regulation as key components [31,32]. Self-control and self-efficacy increased as a result of the self-regulatory efficacy improvement program on self-control, self-efficacy, internet addiction, and time spent on the internet among middle school students in South Korea [33]. Along with life skills training, self-regulation skills training based on neuropsychological models should also be incorporated into school-based prevention programs [34].

Our findings have shown the effectiveness of the comprehensive intervention model for raising awareness about sexual health, the ill effects of addiction, and developing self-regulation among adolescents. With the inclusion of a control group, a noticeable improvement in adolescents with intervention is observed. Hence, these models should be incorporated into the curriculum along with the syllabus to create awareness, and long-term programs with follow-up sessions should be conducted to notice the change in their attitude. Such awareness programs can be scaled up across different groups and communities. All the stakeholders in adolescents’ well-being should also be included in the program.

We would like to extend our sincere thanks to all the volunteers, trainers, participants, teachers, and Principals of the various schools for participating in the study and to Tarachand Ramnath Seva Trust for funding the project.

Conceptualization of the Program: Dr. Anagha Lavalekar. Data collection is done by Sujata Gokhale and Sandhya Khasnis. Data verification and Data analysis were performed by Prerna Karulkar. The manuscript was written by Prerna Karulkar and Dr. Anagha Lavalekar commented on all the versions of the manuscript. All authors read and approved the final manuscript.

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