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

2.5 Community Linkages

Key Points

• Community linkages consist of sources of social support and interaction that have potential as protective factors to prevent and reduce problem substance use.
• Early assessment and screening provided by community-based agencies should facilitate timely referrals to essential services for youth.
• Community-based case planning should be structured to reflect the developmental stages of youth and incorporate the use of strength-based methods.
• Areas of community connectedness for youth include having a safe place to live, receiving support from family or other community members, being involved in an educational or career-related program, and participating in recreational activities.
• Creating service delivery alliances among mental health and addiction services providers involves developing a multidisciplinary perspective and coordinating programs across agencies to ensure a planned continuum of care.

2.5.1 Introduction to Community Linkages

Community linkages for youth contribute to positive growth and development, and can be protective against problem substance use. Positive linkages are a source of social support, be it with family, peers or school (Murray and Belenko, 2005). Community linkages also refer to community-based services that are accessible and responsive to youth early on in their addiction behaviour (Dembo and Walters, 2003).

Positive community linkages for youth should focus on:

• strengthening youths' attachment to pro-social relationships, activities, agencies and programs;
• reducing exposure and bonds to anti-social groups and norms;
• enhancing school attendance and academic performance;
• increasing opportunities to learn and practise skills that facilitate achievement of personal educational and career goals;
• engaging youth and family members in planning;
• encouraging collaborative responses among health providers, community members and police in addressing specific substance use problems in the community;
• creating service networks among agencies that effectively address the needs of youth at risk (Collaborative Community Health Research Centre, 2002; Murray and Belenko, 2005).

2.5.2 Essential Community Linkages

Early intervention efforts are strengthened when youth are meaningfully connected to a variety of community activities and relationships. Without these linkages, efforts to reduce problem substance use may be significantly impeded (MacLean and d'Abbs, 2002). Areas of community connectedness include having a safe place to live, receiving support from family or other community members, being involved in an educational or career-related program, and participating in recreational services.

Residential options

Many jurisdictions do not have emergency shelter programs or longer-term residential options designed to meet the needs of youth. Rooming houses are often unregulated and potentially unsafe for youth. Substance use is often more frequent in these locations, placing youth at increased risk for developing problematic use. It is critical that service providers and community leaders collaborate to address gaps in basic services in conjunction with substance use interventions (Collaborative Community Health Research Centre, 2002; Human Resources Development Canada, 2006; Nyamathi et al., 2005).

School connectedness

Schools are a potential location for providing early intervention supports for youth substance use problems (Kirby and Keon, 2004; Welsh, Domitrovich, Bierman and Lang, 2003). Early intervention efforts should emphasize academic achievement and incorporate strategies for strengthening youth participation in educational and career-readiness activities (Collaborative Community Health Research Centre, 2002). Strategies can include academic support services, establishing school transition programs and providing in-school mental health and addiction-related supports. School sites can be central locations for delivering coordinated services for youth and their families, supported by local police, mental health services, addiction counsellors and other providers representing a range of health and social programs (Welsh et al., 2003).

Recreational activities

Recreational activities provide youth with an opportunity to develop positive peer associations and increase their sense of belonging in the community. Intervention strategies that incorporate time-limited wrap-around services need to emphasize youth involvement in sustainable recreational programming (Eckstein, 2005; N.B. Department of Public Safety, 2000). Participation in structured community-based recreational activities can have a protective effect against substance abuse by students (AADAC, 2003).

Family and social supports

Intervention plans and outcomes are enhanced when positive family and community supports are elicited to encourage youth to pursue and sustain positive changes in their lives. Support is particularly crucial for youth in transition to the community from residential treatment or custodial settings. Organizing community support entails inviting family and community members to fulfill key roles that communicate to youth that they will "be there" for them as they experience challenges and successes associated with reducing problem substance use (Boyd-Ball, 2003).

Community support may also include youth mentorship programs where youth are linked with an adult who understands their needs and models positive life skills. Mentors provide social support and friendship. Mentorship programs have been found to have a positive influence, especially where youth are matched with mentors who have experienced similar issues and have a genuine respect for youth. Research on these programs has shown increased school participation, reduced involvement with negative peer associations, and enhanced skills to refuse alcohol and substance use. Of particular importance is the matching of adult mentors to youth. Key areas for consideration in mentoring relationships include creating a comfortable environment for youth and adults, finding common interests, and developing approaches to address areas of difficulty or challenge (Collaborative Community Health Research Centre, 2002).

2.5.3 Barriers to Community Linkages

In some instances, youth experience difficulty establishing meaningful attachments or accessing supports. Barriers can include:

• rigid and inflexible program protocols and/or admission requirements that impede participation in essential support services;
• previous negative experience with formalized services, leading to reluctance to engage in structured community programs;
• conflicting mandates and competition among agencies that inadvertently create barriers to service coordination;
• lack of transportation, which interferes with access to services (Caputo, Weiler and Green, 1996; Nissen et al., 2004).

In addition, when youth are faced with long wait times they may lose the motivation to pursue change and hence continue with problem substance use and illicit activities. Early assessment and screening provided by community-based agencies should facilitate timely referrals to essential services (Dembo and Walters, 2003).

2.5.4 Case Management

Case management strategies are used to reduce obstacles associated with service accessibility and to facilitate the development of community linkages. This approach requires assigning a youth worker or professional to assess, in conjunction with the youth and/or family, areas of need/concern, and to access services and supports. Case managers need to ensure that treatment plans are coordinated and tailored to meet the unique needs of the youth (Murray and Belenko, 2005). Throughout the planning process, case managers should encourage youth to explore and evaluate alternatives, set goals, and project the consequences of their actions. They should be comfortable with motivational interviewing approaches, knowledgeable about cultural backgrounds and able to discuss the "pros and cons" of behaviours in a respectful and caring manner (Nyamathi et al., 2005).

Case planning should be structured to reflect the developmental stages of youth and incorporate the use of strength-based methods (Nissen et al., 2004). Case management involves:

• meeting individually with youth and family members to engage them in the case planning process;
• arranging meetings between the youth, parents and key service providers;
• organizing case conferences among community service agencies and professionals to ensure coordination of essential services (Murray and Belenko, 2005).

Case management can be closely linked or integrated with outreach programs to enhance youths' positive connections in the community and support their subsequent access to needed services (Martinez et al., 2003). Family members are often included as key participants in the case management process. They play an important role by identifying barriers that may impede the youth's efforts to reduce problem substance use, and can be a key source of support and motivation for youth. Case planning may also incorporate culturally relevant traditions or practices that strengthen or support early intervention (Boyd-Ball, 2003).

2.5.5 Step Care Methods

Case management can include Step Care approaches as part of the community planning process. This entails a graduated approach to intervention intensity that is matched to the youth's needs and level of readiness to pursue change. The preliminary step involves inviting the youth to reduce substance use without providing external supports or treatment. If self-initiated change does not take place, then a "stepped-up" response might include engaging the youth in a motivational interviewing session to enhance commitment to action or to seek supports from others. If this is not successful, then administration of a more intense alternative, such as eliciting the youth's participation in a self-help or pre-treatment group, may be required. The strengths of the Step Care approach is that it can be tailored to address the needs of the individual and uses existing resources cost-effectively. From a community planning perspective, this approach is valuable for targeting and using community service linkages to execute early intervention strategies (Hawkins, Cummins and Marlatt, 2004).

2.5.6 Coordinating Mental Health and Problem Substance Use Services

Community-based interventions must often address both problem substance use and mental health issues (Collaborative Community Health Research Centre, 2002). Some key challenges associated with providing concurrent mental health and problem substance use services include:

• fragmented and uncoordinated service delivery approaches;
• lengthy wait times for services;
• lack of services designed especially for youth;
• the need for helping professionals to be trained in both addictions and mental health issues (Kirby and Keon, 2004).

Some theorists have noted the potential benefits of establishing centralized intake facilities that screen and assess youth for co-morbid mental health and substance use problems (Dembo and Walters, 2003). This involves the collaborative efforts of various community and government-based agencies that represent justice, mental health, social services and addictions. The purpose is to facilitate access to key services for youth and ensure that interventions are coordinated and implemented in a timely fashion (Dembo and Walters, 2003; Jenson and Potter, 2003; Kirby and Keon, 2004), especially for high-risk youth, such as those who are homeless or at risk of homelessness. A one-stop multi-service setting can include a range of primary health care services in addition to mental health and addiction services (Nyamathi et al., 2005).

Community-based cross-system mental health and addiction services may be particularly beneficial for youth involved in the justice system. One U.S. study examined the effects of a coordinated mental health and substance use intervention strategy for 154 youth involved with the justice system. During their detention, these youth participated in a psychoeducational group on co-occurring mental health and substance use problems. They also met with a child psychiatrist and with case managers to plan for post-program coordinated mental health and addiction-related support in the community. Individualized case planning services were continued for three months after their release. Of the original sample, 69% were located for follow-up. At six months, youth reported significant reductions in severity of mental health symptoms, decreased use of alcohol, cannabis, hallucinogens and cocaine, and reductions in property, person and drug-related offending behaviour. Although these outcomes provide some evidence for the efficacy of an integrative mental health and addiction intervention approach, the authors cautioned that their outcomes may be influenced to some extent by the exclusion of youth who were not located at the time of follow-up (Jenson and Potter, 2003).

Creating service delivery alliances among mental health and addiction services providers involves developing a multidisciplinary perspective and coordinating programs across agencies to ensure a planned continuum of care. This requires mutual understanding, an appreciation of cross-sectoral approaches, and a willingness to collaborate with others (Letters and Stathis, 2004).

2.5.7 Creating Linkages Among Service Providers

Service providers must have adequate knowledge of the range of available programs and resources in the community to intervene effectively with youth exhibiting substance use problems. Strategies for enhancing service providers' awareness of existing community capacity include:

• developing regional or community resource directories outlining youth and family focused services;
• organizing community fairs and open houses where providers may promote their services and exchange program information;
• implementing community-wide planning sessions to strengthen collaborative efforts and develop strategies that address policy gaps or concerns (Gleghorn et al., 1998; Murray and Belenko, 2005).

Other actions may also be undertaken to develop coordinated and collaborative service delivery approaches in the community. These include implementing common intake, assessment and referral protocols, developing complementary service delivery policies among service providers, and creating mechanisms to address gaps in policy and service accessibility barriers (Nissen et al., 2004). Ideally, developing coordinated service delivery care networks for youth reduces duplication of services and provides opportunities for integrating complementary intervention efforts (Woods, et al., 2002).

2.5.8 Implementing Community-Wide Approaches

Establishing community linkages contribute to creating community-wide plans or strategies for addressing problem substance use. Approaches are often broad-based and aimed at addressing a wide range of family- and community-level risk factors. One example, the Community Empowerment Method, uses social awareness and promotional strategies to increase knowledge and change norms related to problem substance use among youth. The direct involvement of community leaders, role models and decision makers is central to implementing this approach (Hawkins et al., 2004).

In addressing community-wide approaches, some theorists assert the importance of assessing the community's readiness to change. The Community Readiness Model provides a beneficial framework for community leaders in planning regional strategies to reduce problem substance use and its consequences among youth. This model serves as a guide for evaluating the level of community readiness to embrace and sustain early intervention programs for youth. The underlying theory postulates that unless the community "is ready" to initiate a program, it is conceivable that it will not happen or succeed. The underlying principles of this model are:

• Communities are at various stages of readiness with respect to specific issues or problems.
• The stage of readiness can be assessed and documented.
• Communities can proceed through a series of stages to formulate, implement and sustain positive changes in health and behaviour.
• It is essential to structure specific intervention approaches based on the community's level of readiness (Edwards et al., 2000).

The Community Readiness Model includes a nine-stage awareness process (Edwards et al., 2000; Hawkins et al., 2004). The following provides an adapted summary of the community-readiness stages:

1. No awareness: Community members or leaders do not recognize the issue as a problem. Community climate may inadvertently encourage problematic behaviour among certain groups.
2. Denial: There is some recognition of a problem; however, there is minimal confidence in local capacity to address identified areas of concern.
3. Vague awareness: There is a general consensus regarding areas of concern; however, a lack of leadership or motivation impedes the development of strategies to move toward actions.
4. Pre-planning: There is a clear recognition of the local issue or problem. There are also identified community leaders or working groups that acknowledge the necessity of addressing the area of concern.
5. Preparation: During this phase, planning is ongoing and details for taking action are worked through.
6. Initiation: Adequate information has been gathered to justify implementing key actions or responses.
7. Stabilization: One or two initiatives are implemented and supported by local community and service providers.
8. Confirmation expansion: Actions are evaluated and lessons learned are used to modify existing approaches. Innovative and expanded efforts are implemented.
9. Professionalization: Implemented actions may include both community-wide approaches and specific intervention efforts targeted at reducing specific risk factors. Services are coordinated by trained personnel, involve participation of community members, and are routinely evaluated to ensure that evidence-based practices are implemented.

Interventions designed to facilitate communities' move along the readiness continuum may be developed in conjunction with this theoretical framework. Appendix A provides a summary of example strategies that match each stage of the community-readiness process. Further research is required to document the effectiveness of such community-wide interventions and to understand accurately the most beneficial aspects of these programs.