1

Volatile Inhalant Dependence and Intoxication among a Sample of

Egyptian Street Children

*Okasha Y.A. , **Abou-Hatab M.F.

*Yaser Amin Khalifa Okasha: Lecturer of Child Health (Clinical Toxicology)

**Maha Fouad Abou-Hatab: Assistant Professor of Child Health (Child & Adolescent Psychiatry)

Kindergarten Education Department; Faculty of Education, Helwan University

Abstract:

One hundred Subject attending drop out units for street children were investigated using: (1)

Short interview sheet for street children,(2) Inhalant Dependence and Intoxication Checklist for

Street children,(3) Inhalant Dependence and Intoxication diagnostic criteria DSM IV (Diagnostic

and Statistical Manual for Mental Disorders-4th edition) (4) urine screen for hippuric acid; a

metabolite of toluene which is the organic solvent found in glue and other commonly used

inhalants and responsible its side effects . The study aims at identification of common

manifestations of volatile inhalants (glue, fuel, and thinner) dependence and intoxication among

a sample of Egyptian street children. Research subjects were using volatile inhalants (100%)

with variable amounts and sometimes in combination with other substances such as: Nicotine

and Hashish (25%) and oral drugs (cough sedatives) (15%). According to DSM IV criteria,

inhalant dependence and intoxication were reported among all research subjects. Dizziness, in-

coordination, lethargy, slurred speech, tremors, blurred vision and euphoria were the commonly

reported signs of intoxication. Street children diagnosed as intoxicated were vulnerable to many

disadvantages. They are using inhalants despite their knowledge of its harmful effects on

physical and psychological wellbeing. There is a great need to develop integrated rehabilitation

medical services directed towards such vulnerable individuals especially detection, detoxification

and mental health services.

Introduction:

Street children constitute a marginalized population in most urban centers of the world. There are

major difficulties in trying to estimate their number and the magnitude of difficulties they

experience. They are not covered by, nor find a place in: the national census, educational or

health data; largely because they are highly mobile and have no fixed address (UNICEF; 1998).

According to rapid situation assessment report 2001 (RSA), there are between 200,000 and

1,000,000 homeless children in Egypt, most of them in the cities of Cairo and Alexandria. Indeed

the RSA team believed that when all children defined as street children are included, their

numbers exceed one million (WFP, UNCF, UNODC; 2001).

WHO estimates that globally, 25% to 90% of street children indulge in substance use of

psychoactive substances of some kind. The word ‘substance’ describes any psychoactive

material which when consumed affects the way people feel, think, see, taste, smell, hear or

behave. A psychoactive substance can be a medicine or an industrial product, such as glue. Some

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substances are legal such as approved medicines, alcohol and cigarettes, and others are illegal,

such as heroin and cannabis. Each country has its own laws about substances. The percentage of

substance users among street children varies greatly depending on the region, gender and age

(WHO; 2002).

Inhalation of volatile substances for mind alerting is a long-standing problem in developed

world. Research has shown that volatile substances abuse is primarily an adolescent phenomenon

and it gives rise to dose-related effects similar to those of other hypno-sedatives (UNODC, 2004)

In Egypt, None of the Non Governmental Organizations (NGOs) has a current program targeting

substance abuse among street children, at least at the time when the RSA (2001) was carried out.

Although data received indicated that most street children are substance abusers, the problem has

not been directly targeted. Most reception centers do not admit street children who are under the

effect of drugs, and many NGOs do not permit chronic substance abusers to the centers, even if

not under the effect of the drug for fear that they might interrupt their daily programs. On the

other hand there is no detoxification programs carried out in any of the shelters of the NGOs.

Perhaps this is a main reason for a high rate of escape. As for the Social Defense there is no

program as such. Residential care and control of behavior and activities of children seem to be

the only solutions provided (WFP, UNCF, UNODC; 2001).

According to the pilot study made by researchers prior to conduction of the current research,

there are still no direct services for substance abuse (identification or management) available in

major governmental and non-governmental organizations (GOs & NGOs) targeting street

children in great Cairo.

Aim of the work:

The present study aims at identification of common medical, toxicological, and psychological

manifestations of volatile inhalant dependence and intoxication among a sample of Egyptian

street children.

Subjects and method:

Subjects:

One hundred subject attending drop out units for street children in Helwan, Cairo, Egypt, were

investigated after their legal guardian consent. Inclusion criteria include: cooperative subjects,

attending drop out unit with a positive history of inhalant abuse (glue, fuel, and thinner) within

the last 6 hours, with a positive history of chronic inhalant use and positive detection of hippuric

acid in urine (a metabolite of toluene which is the organic solvent found in glue and other

commonly used inhalants and responsible its side effects), within the last 12 months and

fulfilling assessment at the same day (20 subjects were excluded as they did not show up).

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Procedures:

Tools:

I. Short interview sheet for street children (made by researchers).

II. Inhalant Dependence and Intoxication Checklist for Street children (made by

researchers).

III. Inhalant Dependence and Intoxication Criteria (Diagnostic and Statistical Manual for

Mental Disorders-4th edition-DSM IV).

IV. Hippuric acid (a metabolite of toluene) detection in urine by visibile absorption

spectrophotometry at 410nm wave length (NIOSH manual, method 8003, 1994).

I- Short interview sheet for street children:

Interview sheet made by researchers for the purpose of the study.It is designed for rapid

collection of important data as regard Personal and family information of the child. Personal

information include: Name, age, sex, education and grade, occupation, duration and frequency of

drop in service use. Family information includes data of mother, father, siblings, other caregivers

(e.g. grandfather, grandmother…etc) as regard: name, age, education, occupation and relation

with the child.

II-Inhalant Dependence and Intoxication Checklist for Street:

It is a self report DSM IV based scale scored Yes/No. A total result is calculated for each subject.

Both the interview sheet and the Inhalant Dependence and Intoxication Checklist for Street

children were judged before there practical use. Items accepted by more than 75% of the judges

were included in the final assessment form.

III-DSM IV criteria for Inhalant Dependence and Intoxication.

A. DSM IV criteria for Inhalant Dependence:

According to DSM IV, subjects should positively experience 3 out of the following:

1. Tolerance as defined by either a or b :(a)A need for markedly increased amounts of the

substance to achieve intoxication or desired effect, (b)Markedly diminished effect with

continued use of the same amount of the substance.

2. Withdrawal as manifested by either a or b: (a) criteria for withdrawal from the

substance, (b) the same or a closely related substance is taken to relieve or avoid

withdrawal symptoms.

3. The substance is often taken in larger amounts or over longer period than was intended.

4. There is persistent desire or unsuccessful efforts to cut down or control substance use.

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5. A great deal of time is spent in activities necessary to obtain the substance, use the

substance or recover from its effects.

6. Important social, occupational or recreational activities are given up or reduced because

of substance use.

7. The substance use is continued despite knowledge of having a persistent or recurrent

physical or psychological problem that is likely to have been caused or exacerbated by

the substance.

B. DSM IV criteria for Inhalant Intoxication:

According to DSM IV, diagnostic criteria for inhalant intoxication include 3 major items, as well

as the at least 2 of the signs that develop during or shortly after inhalant use or exposure. They

are as follows:

I. Recent intentional use or short-term, high-dose exposure to volatile inhalants.

II. Clinically significant maladaptive behavioral or psychological changes (e.g. belligerence,

assaultiveness, apathy, impaired judgment, impaired social or occupational functioning)

that developed during or shortly after use of or exposure to volatile inhalants.

III. Two (or more) of the following symptoms, developing during, or shortly after, inhalant

use or exposure:

1. Dizziness

2. Nystagmus

3. In coordination

4. Slurred speech

5. Unsteady gait

6. Lethargy

7. Depressed reflexes

8. Psychomotor retardation

9. Tremor

10. Generalized muscle weakness

11. Blurred vision or diplopia

12. Stupor or coma

13. euphoria

IV. The symptoms are not due to general medical condition and are not better accounted for

by another mental disorder (Need more detailed investigations and was excluded as part

of diagnoses).

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Method:

Descriptive analysis of the data collected was used for more identification of the phenomena of

inhalant dependence and intoxication among research subjects.

Results:

One hundred subjects, aged 9-17 years were investigated. They started inhalants abuse from the

age of 7 to the age of 12. Eighty percent were school dropout (from early school grades: 1st - 5

th

primary) and 20% were illiterate. They stated using inhalants for a duration range 2-7

years.100% were inhalant users as proved by positive detection of hippuric acid in their urine

samples, 60% reported using inhalants alone and 40% in combination. 25% were inhalant users

in combination with nicotine and hashish and 15%with oral drugs (Table-1).

According to DSM IV Volatile Inhalants Dependence and Intoxication were reported among all

research subjects (100%). Tolerance (with physiological dependence) was also reported among

all research subjects (100%).As all subjects under consideration experienced a need for markedly

increased amounts of the substance to achieve intoxication or desired effect (100%) as well as

markedly diminished effect of the substance with continued use of the same amount (Table-2).

Ninety percent of research subjects use the same substance (glue) or a closely related substance

(fuel, thinner) to relieve or avoid withdrawal symptoms (Table-2).

Inhalants were often taken in larger amounts or over longer period than intended among (72%)

of research subjects. The substance is often taken in larger amounts than was intended among

(54%) and was used for longer period among (18%) of subjects under consideration (Table-2).

Unsuccessful efforts to cut down or control substance use was reported only among (20%) of

research subjects. On the other hand, none of them reported that there was a great deal of time

spent to obtain inhalants although use and recovery may take some time (40%). Social,

occupational malfunction were reported among all of them in different forms (100%). They were

using inhalants despite recurrent exposure to physical and mental problems because of the use of

the substance (100%) (Table-2) .

Maladaptive changes and symptoms characteristic of inhalant intoxication that developed during

or shortly after glue sniffing commonly reported were: Dizziness, in-coordination, lethargy,

slurred speech, tremors, blurred vision and euphoria (Table-3).

Discussion:

Inhalant abuse is a major public health problem that has been associated with numerous acute

and chronic medical problems. Inhalants are defined as volatile organic substances, found in

common household and commercial products that are easily accessible, inexpensive, and legally

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obtained. Inhalants have been labeled as gateway drugs. Significant social, economic, and

medical consequences are associated with their use (Meadows and Varghese, 1996).

Although early reports have linked inhalant abuse to poor school adjustment, with high truancy

and dropout rates, increased criminal activity, and an elevated incidence of psychopathology

(Oetting and Webb 1988). The problem of early childhood substance use is out of organized

Governmental Organizations (GOs) and Non-Governmental Organizations (NGOs) services.

Almost none of the major NGOs working with street children in Egypt have a current organized

program directly targeting the issue of substance use and detoxication.

However volatile substances (e.g. fuel, paint, Kolla….) were classified as inhalants if they were

used for the purpose of being intoxicated ( American Psychiatric Association;1994). All of the

research subjects were inhalant users for many reasons especially reaching euphoric mood,

headedness, pain and cold relief, and induction of sleep. 60% of them were using inhalants alone

and 40% in combination.

Research subjects with an average age 14.5 were using inhalants for a duration range 2-7 years.

They started substance use from the age of 7 to the age of 12. According to Mith Samlah/Friends

survey (2001); multi-drug use continued to increase sharply as older boys (over 16 years) are the

ones using the most different substances with a significant increase in the use of 3 and more

different drugs. However, a slight increase in the use of other substances as well as younger

children involvement, seem to indicate that children are always experimenting new substances. It

is, therefore, possible that substance use will continue to increase and community is increasingly

facing problems and disturbances from young boys under influence.

The relationship between the use of solvents and other drugs is a complex one. Although a

possibility can be linked, research is unable to answer if the use of solvents leads to abuse of

more potent addictive drugs in the future or not (Ginzler etal 2003). However research subjects

reported the use of the same inhalants in an increasing amount and the use of other oral drugs or

addictive substances to decrease negative effects or relief symptoms especially aches.

Evidence of recent intake of the substance can be obtained from history, physical examination

and toxicological analysis of body fluids (urine-blood).However it is accessible to obtain rapid

history and do physical examination at drop out units although some individuals seem

uncooperative. On the other hand toxicological analysis was reported not to be easily available at

drop out units because of refusal of street children to offer blood samples easily. On the other

hand, direct assay for inhalants is rarely used clinically and is generally not a part of routine

screening for drugs of abuse (American Psychiatric Association; 1994).

Acute intoxication from inhalation primarily affects the CNS, causing euphoria, dizziness,

confusion, CNS depression, headache, vertigo, hallucinations, seizures, ataxia, tinnitus, optic

neuropathy, peripheral neuropathy, stupor, and coma (Martin, 2006). According to American

Psychiatric Association (1994), intoxication symptoms include disturbance of: perception,

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wakefulness, attention, thinking, judgment, psychomotor and interpersonal behavior. Impairment

in cognitions or mood is the most common symptoms associated with toxic substances. Although

hallucinations, delusions or seizures can result, symptoms usually disappear when individual is

no longer exposed to the substance but resolution of symptoms may take weeks or months and

may require treatment. Many of such symptoms were reported among research subjects

especially Dizziness, in-coordination, lethargy, slurred speech, tremors, blurred vision and

euphoria.

The majority of short term effects of inhalants reported by the responding children in Nepal were

hallucinations. Various experiences such as illusions of seeing actors, seeing money, being able

to talk with gods and the like were the most popular immediate experiences accounted by street

children after glue sniffing (Abinash etal, 2002).

Substance intoxication is mostly involved by dose, duration, chronicity of dosing, personal

variability , personal tolerance for the substance, period of time since the last dose and the

expectations of the person as to the substance’s effects and the environment or setting in which

the substance was taken (American Psychiatric Association-1994).Small doses can rapidly lead

to euphoria and other disturbances of behavior similar to those caused by ethanol(alcohol) and

may also induce delusions and hallucinations(UNODC,2004).

Both dose and duration of use of inhalants and other substances used with them in combination

were variable among research subjects.90% of research subjects were using inhalants and other

drugs for the last 2 years almost on daily basis. Most commonly inhalants are used in group

setting using and increasing the dose according to street circumstances and targeting euphoric

mood and headedness.

Information gathered from the key informant interviews, documented a very unsatisfactory

knowledge and awareness of issues related to street children, and more importantly the

understanding of solvent abuse among this extremely high-risk group. An overall lack of clarity

was observed regarding detoxification of solvent abuse in the existing drug treatment facilities,

compounded by absolutely no rehabilitation program for these children (UNODC, 2004)

Further research should encounter the role of antioxidant therapy or supplementation in children

with inhalant abuse considering the possible consequences of oxidative damage and lipid

peroxidation, including the risk of severe damage to various tissues and organs such as bone

marrow, liver, kidney, brain, and heart (Ruþen etal, 2003).

Conclusion and Recommendations:

Research subjects using inhalants, diagnosed as inhalant dependent and intoxicated according to

DSM IV. They were inhalant users alone or in combination. Regardless their negative effects on

their physical and mental wellbeing they were continuously using such substances. Dizziness,

hallucinations (especially visual hallucinations) in-coordination, lethargy, slurred speech,

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tremors, blurred vision and euphoria were the commonly experienced symptoms of volatile

inhalant intoxication. There is a great need to develop integrated rehabilitation medical services

within drop out units for street children including mental health and detoxification services.

Table (1): Socio-demographic data and substances used: characteristics among research

subjects

Age range 9-17 Mean:14.5

Items number %

*Educational background

-Dropped out school

-Never been to school

80

20

80%

20%

*Characteristics of Substances used

-Inhalants

-Inhalants alone(glue)

-Inhalants in combination(fuel, thinner)

-Inhalants in combination with nicotine and hashish

-Inhalants in combination with oral drugs(cough sedatives)

100

60

40

25

15

100%

60%

40%

25%

15%

Table (2): Inhalant dependence according to DSM IV among research subjects

DSM IV criteria-Inhalant Dependence number %

1-Tolerance

1-1 A need for markedly increased amounts of the substance to

achieve intoxication or desired effect

100 100%

1-2 Markedly diminished effect with continued use of the same

amount of the substance.

100 100%

2-Withdrwal 90 90%

2-1 Criteria for withdrawal from the substance 0 0%

2-2 The same or a closely related substance is taken to relieve or

avoid withdrawal symptoms.

90 90%

3-Larger amount/longer time of use 72 72%

3-1 The substance is often taken in larger amounts than was

intended.

54 54%

3-2 The substance is often taken over longer period than was

intended.

18 18%

4-Unsuccessful efforts to control volatile inhalant use 20 20%

5-A great deal of time is spent in activities necessary to obtain the

substance, use the substance or recover from its effects.

40 40%

5-1 Great time spent to obtain volatile inhalants 0 0%

5-2 Great time spent in use/recovery from volatile inhalant effects 40 40%

6-Social, occupational malfunction 100 100%

7-The substance use is continued despite knowledge of having a

persistent or recurrent physical or psychological problem that is

likely to have been caused or exacerbated by the substance.

100 100%

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Table (3): Inhalant intoxication according to DSM IV among research subjects

DSM IV criteria-Inhalant Intoxication number %

A-Recent intentional use of volatile inhalants 100 100%

B-Maladaptive changes after use of volatile inhalants 100 100%

C-Two or more Signs of volatile inhalant use 100 100%

D-The symptoms are not due to general medical or mental problem Need more

detailed

investigations

References:

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in Kathmandu Valley. Child workers in Nepal(CWIN).Indreni offset press. Anamnagar,

Kathmandu.

2. Abou-Hatab M.F. (2004): Street Children: Children at risk for Psycho-social

Disadvantages. Current Psychiatry; March 2004.

3. American Psychiatric Association (A.P.A) (1994): Diagnostic and Statistical Manual of

Mental Disorders-4th edition (DSM IV). Washington DC.

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homeless youth: An empirical investigation of the gateway theory. Substance use misuse.

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818939/overview.

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11. Ruþen D, Tümer T, Cemal A, S. Ümit S, Ahmet A ,Metin D, Erdal G(2003):Antioxidant

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12. UNICEF (1998): Children at Risk: United Nations, New York 1998.

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13. UNODC (2004): Solvent abuse among street children in Pakistan. United Nations system

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Alexandria, including the children’s drug abuse and health/nutritional status-Cairo.

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االعتماد والسمية للمواد الطيارة لدى عينة من أطفال الشوارع المصريين

مها فؤاد عبد اللطيف أبوحطب** ,ياسر أمين خليفة عكاشة *

(ى لألطفالالطب النفس)ستاذ مساعد صحة الطفلأ**-(السموم االكلينيكية)مدرس صحة الطفل*

جامعة حلوان-كلية التربية-رياض األطفالقسم

تهدف هذه الدراسة الوصفية الى معرفة الخصائص المميزة لالعتماد والسمية للمواد الطيارة لدى عينة من

طفل من االطفال المترددين على مراكز االستقبال الخاصة 011تم دراسة وقد.أطفال الشوارع فى مصر

(ناعداد الباحثي(ألطفال الشوارع استمارة المقابلة المختصرة(0): باستخدام كل منبأطفال الشوارع

لمحكات التشخيصية الخاصة باالعتماد ا (3)،(اعداد الباحثين)ألطفال الشوارع والسميةقائمة االعتماد (2)،

مسح لعينات البول الكتشاف حمض (4) ، (الدليل التشخيصى االحصائى الرابع) والسمية للمواد الطيارة

لوين و هو المذيب العضوي المسستخدم في هذه المواد منتجات االيض لمركب التو هو أحد الذي الهيبيوريك

" بكميات متفاوتة وأحيانا%(011)مستخدمة من قبل جميع األطفال عينة الدراسة الموادهذه وكانت . الطيارة

طفال جميع األ استوفى وقد %(.02)والعقاقير %(22)حشيش والسجائريتم االستخدام مع مواد أخرى مثل ال

للدليل التشخيصى " تبعالكل من االعتماد والسمية للمواد الطيارة التشخيصيهلمحكات اعينة الدراسة

عدم -الدوخة:وكان من أهم أعراض السمية للمواد الطيارة التى توصلت اليها الدراسة.االحصائى الرابع

ارتفاع الحالة -الرؤية الغير واضحة-ارتجاف االطراف-الكالم الغيرواضح-النعاس-الحركىالتناسق

يخبرون العديد من همأن هؤالء األطفال يستخدمون المواد الطيارة مع أن" وقد كان واضحا.المزاجية

ل متضمنة وقد بات من المؤكد ضرورة اقامة خدمة طبية متكاملة لهؤالء األطفا.المشكالت الصحية والنفسية

.خدمات الصحة النفسية وعالج التسمم