Best Practices - Early Intervention, Outreach and Community Linkages for Women with Substance Use Problems

3. Key Informant Interviews

3.1 Selection of Key Experts

Key experts were identified in consultation with the members of the Health Canada ADTR Working Group. The list included those who had expertise in providing outreach and early intervention services or facilitating community linkages for youth with problem substance use. Participants interviewed had on average 15 years of direct work or clinical experience in the area of youth or broader-based addictions. Tables 4, 5 and 6, respectively, provide the locations, the professional roles and the academic backgrounds of the interviewees.

Table 4: Geographic Distribution of Key Experts

Geographic Location (number)		Number of Key Experts
North	Yukon (1)	1
West	British Columbia (4)	4
Prairies	Alberta (2) Saskatchewan (2) Manitoba (2)	6
Central	Ontario (3) Quebec (1)	4
East	Newfoundland and Labrador (2) Nova Scotia (1)	3

Table 5: Professional Roles of Key Experts

Professional Roles	Number of Key Experts
Service delivery managers and/or clinicians	11
Senior departmental or agency directors	4
Researchers	3

Table 6: Educational Backgrounds of Key Experts

Educational Backgrounds	Number of Key Experts*
Psychology, Counselling, Psychiatric Nursing	7
Social Work	5
Philosophy, Sociology, Criminology	3
Public Policy, Administration, Leadership	3
The Trades/Community College	1

* Some key experts had a background in more than one field.

3.2 Key Expert Interview Process

The key experts, representing each province and territory in Canada, were contacted in summer and fall 2006. Eighteen interviews were carried out across the country. The major areas of focus included:

• circumstances faced by youth with substance use problems;
• key actions for working with youth with substance use problems;
• important considerations for specific youth populations;
• early intervention and outreach approaches;
• roles for individuals in supporting early intervention and outreach;
• evaluation of early intervention and outreach strategies;
• community linkages.

The data gathered from the 18 interviews were merged to provide a unified data set. Content analysis was used to identify emergent theme categories. Specific theme categories were included based on endorsement of a minimum of three informants. The major findings for each area of inquiry are presented in the following sections.

3.3 Key Client Considerations

3.3.1 Circumstances Faced by Youth with Substance Use Problems

Initially, participants were asked to describe the unique circumstances facing youth with problem substance use. They outlined a range of key challenges and need areas related to the current life situations of many youth. These included:

Complex family problems

Various long-standing family problems were highlighted, including exposure to violence, traumatic events, physical and/or sexual abuse, parental discord, inconsistent or harsh discipline, lack of positive parent--youth communication, introduction of new or changes in adult figures in the home.

Instability in living conditions

Many youth with substance use problems were reported to have experienced frequent moves or changes in primary care relationships. These shifts often precipitated significant changes in both home and school routines, as well as loss in continuity of support or needed services.

Concurrent mental health issues

Many youth with problem substance use often have concurrent mental health issues. Areas of concern included depression, anxiety and grief related to loss or pain regarding family circumstances or relationships.

Lack of positive community attachments or connections

Youth with substance use problems were described as having limited or no involvement in structured community-based activities. Participants reported that many were not actively engaged in school, leisure or work. Lack of positive community connections was viewed as increasing the likelihood of developing negative peer associations, potential conflict with the law and continued substance use problems.

Minimal educational success

Participants indicated that problem substance use often impedes youths' successful functioning in school. Inconsistent attendance, poor academic performance and early school leaving were identified as consequences associated with prolonged substance use.

Basic need concerns

For some youth, lack of basic needs was associated with developing problem substance use behaviours. Areas of concern included the need for shelter, long-term stable housing, food and clothing.

Program policies that exclude youth

In some jurisdictions, age restrictions of some support programs or resources may limit youth access to essential support services, including residential options, financial assistance or alternate options for academic advancement.

3.3.2 Key Actions for Working with Youth Who Have Substance Use Problems

Participants were also asked to identify important considerations for working with youth to address concerns about problem substance use. They identified a range of key actions that service providers should consider in their outreach or early intervention approaches:

Recognize that the motivations for substance use may vary

Experts underscored that youths' experimentation with substances may reflect their curiosity, an expression of their autonomy or even their resistance to rules identified by adults. Such motivations were noted to be consistent with developmental stages related to emergence of autonomy and the identity formation of adolescents. Others noted that substance use may be linked to social interactions with other youth or a way to deal with difficult personal or family-related circumstances. Participants stressed the importance of listening to youth and eliciting their perceptions about their current needs, situations and substance use.

Convey understanding and acceptance

The use of a non-judgmental approach and expression of acceptance of youth were viewed as critical for establishing a strong relationship. In contrast, the use of labels or professional "jargon" and "telling approaches" were identified as ineffective for engaging youth.

Engage youth as collaborators

Although many youth are dependent on adult, family or specific community supports for meeting basic needs, service providers should be cognizant of youths' need for autonomy and strive to engage them as collaborators in developing and implementing community-based activities.

Be flexible and creative in meeting and planning activities

Participants stressed that case plan activities should be developmentally appropriate, flexible in terms of meeting places and approach, include content related to interests and strengths of youth, and be tailored to meet their individual needs.

Incorporate and build upon positive family or community connections

Working in the context of the family and using positive sources of support from family or community members were viewed as important for strengthening and sustaining intervention efforts in the community.

Express concern regarding youths' health and well-being

Along with delivery of needed services or support, the importance of conveying an attitude of concern and expressions of caring were seen as critical for building and maintaining rapport with youth.

Maintain a positive connection during the process of change

The importance of remaining open to youth, even when they push away relationships or make decisions that impede their positive functioning in the community, was identified as a critical protective factor and a means for sustaining positive sources of influence in their lives. Continued openness to youth during and following such periods provides increased opportunities to re-engage them in activities that could ultimately reduce continued substance use and contribute to their positive growth and development.

Reach out using youth-focused media formats

Participants highlighted the potential benefits associated with using current media strategies for reaching out to youth (music, websites, online chat forums/bulletin boards). Such formats may be advantageous for creating awareness of substance use problems and facilitating engagement in early intervention services.

Select developmentally appropriate approaches

Informants noted that intervention strategies should be designed to match the developmental needs and circumstances of youth. For example, activity-based approaches may be useful for all adolescent ages, but particularly important for younger age groups.

Address family relationship concerns as part of early intervention efforts

Interviewees stressed the importance of addressing family relationship issues or areas of concern when intervening with youth with substance use problems. This may include working with parents/guardians and extended family, or others who act as role models to the youth. Efforts should emphasize development of collaborative interactions with family members and build on their areas of identified strengths and coping capacities.

Increase service provider awareness of barriers to youths' access

Participants emphasized the importance of service providers being sensitive to program operations or approaches that impede youths' access to or continued participation in needed support services. Barriers might include lengthy referral processes, lack of transportation, risk of stigmatization or lack of positive support from adults in their lives.

Include recreation activities as part of outreach and early intervention activities

Key experts stressed the importance of including fun and recreational components in outreach and intervention activities. These activities provide structured opportunities for building rapport with youth and also contribute to expanding and strengthening youths' interests in community-based activities and relationships that may be sustained over time.

3.3.3 Important Considerations for Specific Youth Populations

Key experts were asked to identify the major considerations that should be taken into account in providing early intervention and outreach services. They also provided insights about enhancing community linkages for youth with problem substance use. Sufficient data were gleaned from participants to identify key implications for eight specific youth populations.

Early adolescent substance users

Participants emphasized the importance of collaborating with parents/guardians, family members and school personnel in identifying and addressing areas of concern related to young adolescents at risk for problem substance use. Key aspects of effective approaches in working with younger youth included involving counsellors trained in child and youth care methods, incorporating youths' strengths and interests, avoiding technical language or jargon, and creating a comfortable, less formal environment.

Aboriginal youth

Problem substance use was widely recognized as a concern for many Aboriginal communities. Experts stressed the importance of community members being engaged in developing their own solutions for addressing areas related to problem substance use among youth. When implementing problem substance use awareness or intervention services, they also stressed that approaches should be culturally sensitive and may benefit from including specific content or activities that reflect community values or traditions. The influence and participation of immediate and extended family members, as well as community elders may be important considerations for planning and executing outreach or early intervention activities.

Homeless and transient youth

Participants reported that homeless and transient youth have often experienced significant losses, including home and community attachments. These youth often form strong bonds with other peers who have experienced similar circumstances. They also indicated that higher prevalence of substance use is evident among this population. In addition to substance use, these youth face a wide range of concerns, including the need for shelter, food, clothing, safety and transitional housing. It was also asserted that outreach and early intervention services for these youth should be accompanied by adequate supports or resources to address their basic needs; otherwise, intervention efforts will likely be impeded and problem substance use will continue.

Youth with concurrent mental health problems

Participants indicated that youth with problem substance use may also exhibit concurrent mental health issues. Some informants noted that substance use by youth may also intensify existing mental health conditions. Screening for both substance use and mental health problems was therefore regarded as important in providing early intervention for youth. Collaborative efforts among youth-focused service providers, including school, mental health and addictions personnel, were seen as critical for providing early intervention. Other informants stressed the importance of providing service providers with training opportunities to gain increased knowledge and understanding of substance use and mental health problems in youth.

Youth who inject drugs

Participants emphasized that youth who inject drugs are not a homogeneous group, and that service providers should expect variations in age, culture, geography of origin and socio-economic status. Focusing on small-step successes were recommended strategies for engaging and working with these youth. Other informants identified the need to increase youths' awareness and knowledge about the risks associated with intravenous drug use, including transmission of blood-borne pathogens. It was also noted that youth who inject drugs may be inappropriate participants in group-based intervention sessions with peers who had never initiated injection practices.

Youth in conflict with the law

Participants indicated that most youth involved with the justice system have also experimented with or regularly used substances. Many are estranged from both structured school and community-based programs, and have formed peer associations that are linked with substance use and criminal activity. When youth first come into conflict with the law, it is imperative that screening for substance use be done as part of cautioning, diversion or community-based sentencing. Many youth in conflict with the law have long-standing histories of behavioural and academic difficulties that become evident during early school years. Providing early intervention services in the school may also address identified risk factors associated with problem substance use and strengthen youths' attachment to school.

Rural youth

Many youth residing in rural areas may not have access to problem substance use intervention services. Outreach and transportation were identified as important for connecting with youth in more remote locations. Participants highlighted the potential benefits of working with regional educational authorities and schools in providing early intervention efforts.

Youth in care

Participants indicated that many youth in care experience frequent changes in their living circumstances and relationships. Their past often includes trauma, significant loss, attachment difficulties and complex family-related issues. For those with problem substance use, participants placed importance on ensuring that early intervention substance use services are implemented in conjunction with residential placements and mental health counselling services.

3.4 Early Intervention and Outreach Approaches

3.4.1 Theoretical or Applied Orientations for Early Intervention and Outreach

Participants were asked to identify the theoretical orientations that provide the basis for organizing and delivering early intervention and outreach services for youth with problem substance use. Most informants highlighted the potential benefits of applying motivational interviewing concepts in conjunction with Prochaska and DiClemente's model of stages of change. Motivational interviewing practices were identified as easily adaptable to the various stages of readiness to change. Positive features associated with this framework included:

• an empathic and respectful approach for engaging youth;
• a small-step approach for addressing positive change;
• a strength-based focus designed to increase youths' desire for change.

In conjunction with brief intervention strategies such as motivational interviewing, experts stressed the importance of developing positive interactions with youth. Youth should actively participate in the development of their own goals and plans related to problem substance use. The use of active listening and approaches that focus on solutions, in contrast to more directive or "lecture/telling" methods, is imperative for increasing youths' willingness to become involved in intervention activities with community-based or professional helpers. Relationship-based approaches should also take into account youths' developmental level and the potential benefits of designing activities tailored to their interests and need for active involvement.

Participants also emphasized systemic approaches that include creating collaborative alliances with significant and influential adults in the lives of the youth from the home, school and community. Identifying and using the capacity of family members, school personnel and members of the wider community is important when developing wrap-around services to meet the comprehensive needs of some youth.

3.4.2 Structuring Early Intervention Approaches

Key experts stressed that early intervention approaches should be informal, comfortable and inviting. Ideally, early intervention approaches should be designed to provide youth with interactive opportunities to:

• examine key issues and their perceptions and reasons for reducing or not reducing substance use;
• share their perspectives and areas of personal concern/stressors related to the family, school or community;
• explore strategies for sustaining and enhancing school connectedness;
• formulate specific approaches or strategies to address identified personal needs;
• identify and engage sources of positive peer supports in their current school or community settings.

Early intervention was described in terms of individually focused or small group approaches carried out in settings where youth spend time with peers. Particular emphasis was placed on undertaking efforts in conjunction with youth-serving agencies or contexts such as schools, recreational facilities, boys and girls clubs and community youth groups. Other locations to implement early intervention initiatives included drop-in centres, outreach clinics and other street settings where youth congregate or meet one another.

When designing and implementing early intervention programs, participants emphasized the importance of collaborating with community service providers, agency managers and community volunteers. For youth already involved with government-based support services such as justice, child protection services or mental health, early intervention activities should be coordinated in conjunction with existing case plans. Although collaboration with specific professionals and community agencies may be required when developing early intervention approaches, delivering such activities should be done by people who have the qualities and skills to engage youth effectively in conversation and build rapport with them. Participants asserted that early intervention workers should possess knowledge and competencies in child and youth care methods or social work practices, and be skilled in designing interactive approaches for engaging youth at a wide range of developmental levels. Participants also spoke about benefits of offering training opportunities for community service providers and youth workers on problem substance use and early intervention practices.

3.4.3 Implementing Early Intervention Screening and Assessment Approaches

Problem substance screening processes were identified as a key aspect of early intervention activities. According to participants, screening processes were beneficial for:

• engaging youth in conversation and establishing rapport;
• defining problem substance use patterns or risk factors;
• exploring other areas of need or concern related to family, school or peer relationships and routines;
• exploring the strengths, interests and preferences of youth;
• identifying potential support networks and coping strategies;
• matching needs with available resources or sources of support.

Informal approaches to screening were described as being a semi-structured format that elicited information from youth through a conversational interview style. Screening activities can also be done with others who have direct knowledge of youth functioning, such as parents/guardians, counsellors or other service providers. Participants emphasized that interactions must be undertaken in a non-judgmental manner and convey respect to the youth or adult interviewees. Participants also identified key areas of inquiry that might be included in screening protocols. These included:

• substance use history (drugs used, quantity and frequency, routes of administration, age of first use, any negative experiences);
• youths' perception of substance use patterns and impact on major life areas;
• family members' perspectives on substance use;
• existing mental health status and past history;
• suicide risk and self-harm history;
• other service providers involved with the youth or family;
• school performance, educational level and vocational interests;
• nature of family relationships, interactions and potential stressors;
• peer associations and influences;
• areas of community involvement;
• youth and family strengths, significant relationships and sources of support.

Ideally, screening should provide a comprehensive profile of youths' current functioning, as well as priority areas that should be targeted by subsequent intervention activities.

3.4.4 Internet-Based Intervention Support Materials

In-person approaches may be supplemented by written or Internet-based early intervention resources. Participants stressed that youth are comfortable with emerging technology and that websites provide opportunities to engage them through use of youth-friendly language and presentation styles.

Internet resources may provide the catalyst for conversations with youth or be used as discussion starters for small group interventions. Participants stressed that web-based formats should be appealing to youth and incorporate visual or graphic material that catches their attention and effectively conveys the intended intervention messages. They also emphasized that youth should be directed to sites hosted by reputable agencies that have web security features to ensure user safety.

Limitations associated with online approaches were also noted. These included:

• the lack of information reliability on some websites;
• the time required to supervise and guide youth in identifying credible and useful Internet sites;
• the literacy level of some website content and the challenges it may pose to youth with reading lags or disabilities;
• specific risks of unsecured online discussions or forums.

Participants stressed that the Internet as a stand-alone approach for early intervention is inadequate for effectively addressing problem substance use among youth; however, this medium is strengthened when applied in the context of establishing positive alliances between youth and early intervention workers.

3.4.5 Outreach Approaches

Partnerships

Participants indicated that community partnerships are important when planning and delivering outreach services. Organized exchanges among community agencies provide valuable opportunities to increase providers' understanding of the complex needs of youth at risk, and the range of available youth-focused services in the community.

Community-based non-profit agencies and service clubs that focus on youth and family engagement may play a central role in organizing effective methods for reaching out to youth. Youth may have regular or more frequent contact with these types of agencies than with health-related services that require set appointment times. Participants highlighted the value of addiction services personnel providing specialized training to community-based agency staff to enhance their knowledge and skills for working with youth with problem substance use.

Settings and delivery times

Participants stressed that outreach services should strive to reach youth in their "own space"-- places where they regularly spend time with their peers. Locations may include formal or structured settings where youth are engaged in activities, such as schools, recreation facilities, after-school programs or community activities, or informal places frequent, such as street meeting locations, parks, shelters, drop-in centres and malls. A third type of outreach included the use of mobile services that have the capacity to reach out to multiple locations and often involve the delivery of basic need or health services along with early intervention efforts.

Experts emphasized that outreach sites, in contrast to formal office-based settings, should be in the youths' social environment and conducive to rapport building. Initial contacts with youth should be non-threatening, respectful and include brief informal conversations over frequent encounters. In structured settings, outreach services must adapt to set program times. In contrast, outreach in informal settings is most effective when meeting times are flexible and provide opportunities for multiple contacts with youth. Hours of operation for outreach activities should include both evenings and weekends.

3.4.6 Outreach Workers

Qualities of outreach workers

Participants indicated that outreach workers should demonstrate a non-judgmental attitude in responding to youths' perspectives and choices, enjoy working with youth, and have an understanding of developmental milestones and attachment issues. With respect to professional competencies, youth outreach workers should have the capacity to:

• establish and sustain rapport with youth who mistrust or challenge authority;
• actively listen and elicit youth perspectives;
• set personal limits and seek consultation when necessary;
• collaborate with other service providers without comprising their alliance with the youth;
• deal effectively with stressful events and de-escalate potential conflict situations;
• identify and incorporate youths' strengths in intervention activities.

Areas of academic training for outreach workers included child and youth care, psychology, education, social work and counselling. Specialized training in addictions, mental health and motivational interviewing was also viewed as important. In addition to training and education, participants stressed the importance of having outreach workers who have substantial personal experience in the targeted outreach group.

Activities and tasks

The first task of outreach workers is to establish a point of connection with youth that facilitates dialogue and potential intervention. Participants highlighted a range of key activities that can be undertaken by outreach workers, including:

• meeting and conversing with youth in their settings;
• educating youth on specific health risks associated with substance use and sexual practices;
• screening for potential problem substance use and mental health concerns;
• linking youth with services that address basic needs, such as shelter, food and clothing or health care;
• assisting youth in navigating the system and understanding referral processes;
• collaborating with youth to plan specific action steps to address problem substance use or concurrent needs;
• referring youth to treatment or rehabilitation services;
• accompanying youth to preliminary appointments with health care providers;
• re-engaging youth with positive sources of family and community support;
• providing supportive counselling services.

Participants also emphasized the importance of worker accountability and supervision. Being part of a staff team provides opportunities for debriefing, ongoing professional development and use of feedback to enhance ongoing practices.

3.4.7 Supporting Early Intervention and Outreach

Key informants described possible roles for various individuals in supporting early intervention and outreach to youth. They provided comments on potential contributions of family members, school personnel, community service providers, and addictions and mental health personnel.

Family members

Participants emphasized that family members have a crucial role to play in supporting early intervention efforts; however, assistance may be needed to help families develop and implement effective strategies for addressing concerns related to youth problem substance use. Approaches for helping families include providing education on adolescent experimentation patterns, signs or basic features of drug use, stages of readiness to change, brief intervention approaches, and methods for effective communication and problem solving. Referrals to family counselling agencies can be made. In some cases, problem substance use is not limited to the youth, but can involve other family members; therefore, ways to pursue change or to engage in collaborative family actions may vary. Family members can often assist youth by providing transportation to appointments or ensuring that basic needs are met. For younger adolescents, family members should have increased involvement in supervising and structuring youths' daily activities and monitoring their peer associations.

School personnel

School personnel are in a unique position to identify early experimentation and problem substance use patterns. Participants emphasized that school personnel must know how to engage youth and link them with appropriate early intervention services. School personnel should work collaboratively with other youth-focused agencies, including mental health, addiction services and justice. Outreach efforts should also attempt to elicit the support of family members in intervention activities. Ideally, outreach and early intervention efforts should not only address problem substance use, but also strengthen the youth's connectedness at school and support successful educational and career advancement.

Community service providers

Community service providers are also in a position to identify early patterns of problem substance use among youth. Participants emphasized the possible benefits associated with training service providers in problem substance use screening and early intervention approaches. Community service providers may also refer youth and families to basic need or treatment services.

Addictions and mental health personnel

Addictions and mental health personnel are in a position to act as consultants for other service providers who routinely encounter youth at risk for potential problem substance use. Consultation may include organized professional development sessions or individual consultations on a range of topics, including substance use patterns, screening methods, co-morbid mental health concerns, protocols for accessing community mental health and addiction services, motivational interviewing approaches, and stages of readiness to change.

3.4.8 Evaluation of Early Intervention and Outreach Strategies

Participants stressed that evaluation processes should be developed as part of the initial planning and design of outreach and early intervention services. Evaluation plans should take into account both process and outcome approaches to program review. Process components focus on evaluating how the program is implemented. Outcome evaluation measures the extent to which the program has had a positive impact on client functioning or other areas targeted for change. The creation of logic models was cited as useful to guide program design, implementation and subsequent evaluation.

Carrying out pilot projects evaluations was cited as beneficial. These were considered useful for providing constructive and practical information for refining intervention programs. In designing program evaluations, participants indicated the importance of:

• pre-post intervention measures;
• control group comparisons;
• longer-term follow-up data collection;
• quantitative and qualitative data;
• participatory approaches that include personnel, youth and family feedback/perspectives;
• indicators for youth functioning in school, family or community;
• indicators for reduction in substance use problems.

Participants indicated that program reviews should include daily or regular operational reporting requirements. Accountability indicators should include a range of outputs, such as number of contacts, assigned caseloads, referral patterns, attendance at meetings, type of outreach or intervention activities implemented. Participants emphasized the importance of valuing the youth perspectives in the evaluation process. They recommended that youth be given "a voice" in determining the focus of evaluation activities and identifying indicators of success.

3.5 Essential Community Linkages

3.5.1 Essential Community-Based Services and Supports

Key informants were asked to identify the kinds of community services or programs that should support early intervention approaches for youth with substance use problems. Important community linkages for youth include schools, recreation activities, mentorship programs, basic need supports and youth and family-focused counselling. Participants stressed the value of inviting youth to participate in designing and evaluating community-based services and supports.

Participation in structured community youth programs

Youth-focused recreation programs or clubs were identified as forums in which youth may engage in wellness-oriented activities with positive peer and adult supports. Participation in these programs was viewed as beneficial for fostering both skill development and lifelong interest in meaningful pastime activities. For some youth, providing financial support or bursaries may be required to support long-term participation in some community-based programming.

Enhanced school connectedness

Participants stressed the importance of strengthening youth attachment to their school and their commitment to educational advancement. Strategies for enhancing connectedness included peer mentorship programs, participation in organized school-based physical or social activities, on-site early intervention activities and counselling, involvement in drama/music/arts programs, academic assistance, and opportunities for vocation or supervised work experiences.

Involvement in mentorship programs

Participants highlighted the importance of organizing mentorship opportunities for youth with positive adult role models in the community. Such relationships were identified as providing youth with sources of support that could be sustained over the long term.

Provision of basic need supports

For some youth, basic needs must be addressed in conjunction with early intervention approaches. This may require collaboration between community-based and government agencies, developing coordinated case plans and accessing income supports or transitional housing.

Access to youth- and family-focused counselling services

Timely access to counselling services for youth and their families should be offered by counsellors who are comfortable addressing a wide range of issues related to family stressors, mental health concerns and problem substance use.

3.5.2 Service Delivery Challenges

Participants were asked to identify challenges that impede the efforts of community service providers to work collaboratively to deliver services for youth with problem substance use. Key barriers were identified as:

• competition for limited resources;
• differences in service delivery orientations;
• waiting lists and complex intake processes;
• large case loads and time constraints;
• lack of established protocols for information exchange and communication among service departments or agencies;
• inflexible program mandates and policies;
• inadequate service options in rural or remote areas.

Many of the service delivery challenges could be addressed through strengthened collaboration and interagency consultation among service providers; however, commitment from agency leaders and directors was viewed as important for developing and realizing long term solutions.

3.5.3 Policy and Service Gaps

Participants indicated that in some jurisdictions significant policy and service gaps exist for youth between 16 and 18 years of age related to the lack of housing and basic need services. Other concerns related to practices and policies included the lack of effective school-based strategies for re-engaging youth with substance use problems who no longer attend school, waiting lists for addictions and mental health services for youth, and the lack of coordination or integration of services among addiction and mental health services. In addressing policy or service gaps, participants emphasized the importance of remaining youth focused rather than program driven.

3.5.4 Coordinated and Integrative Service Delivery Approaches

Youth with problem substance use often face a range of concurrent psycho-social needs. Providing early intervention efforts often requires implementing a multifaceted community plan involving the participation of a variety of community service providers. Participants highlighted the benefits associated with developing integrative service delivery approaches that build on shared resources and capacities of existing community-based agencies. Key actions that support the development of interagency collaboration include:

• eliciting support for service delivery
• cooperation from senior administrative and operational managers;
• enhancing understanding among front-line workers regarding their respective mandates and referral protocols;
• developing mechanisms for timely information exchange;
• offering interagency and multidisciplinary training opportunities, including workshops and conferences to share better practices;
• establishing protocols for interagency consultation, communication and case planning activities;
• implementing memorandums of understanding to support consistent service delivery cooperation among agency personnel;
• co-locating and co-facilitating front-line services.

Participants noted the potential advantages of having specific mechanisms in place to identify gaps in policy and practice that may emerge as services are coordinated or integrated. Identifying these issues could result in implementing more timely responses to support interagency cooperation and improved outcomes. Evaluation of integrative service delivery efforts was viewed as challenging. Participants indicated the value of eliciting feedback from clients and service providers when evaluating regional or pilot projects. The use of key informant interviews, focus groups or distributed surveys were suggested for documenting perspectives of key stakeholders.