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

Executive Summary

The purpose of this project was to develop guidelines for best practices related to early intervention, outreach and community linkages for youth with substance use problems. The intention is to provide a wide range of health and community professionals with updated information about specific challenges in these areas and encourage further best practice research. The final report is organized into five main sections:

• Project background and description: A summary of methodology and research activities.
• Literature review: A critical analysis of relevant research.
• Interviews with key experts: A summary of key insights from experts across Canadian provincial and territorial jurisdictions representing academia, managers and clinical professionals.
• Focus groups with youth: The perspectives of youth who are or have been in need of early intervention, outreach or community linkage services to address problem substance use
• Best practice statements: Guidelines related to early intervention, outreach and community linkages for youth with substance use problems. The sections of the document that support each best practice statement are cited in Appendix B.

Youth with Substance Use Problems

Statistics Canada estimated that youth 15 to 24 years of age represented approximately 13.6% of the population in 2005. The most frequently used substances by youth are alcohol and cannabis. Early initiation of substance use has been predictive of longer-term problem substance use for both males and females. For most substances, research indicates that male youth are more likely than female youth to use substances at problematic levels; however, female youth have a lower threshold to the effects of alcohol and drug consumption than males.

Youth with problem substance use have diverse life experiences, circumstances and concerns that extend beyond their problem substance use. Assisting them requires sensitivity to and understanding of their current life situations and the development of responsive strategies.

Early Intervention

Early intervention refers to specific measures undertaken for populations identified as being at risk for or already engaged in harmful behaviours or practices. With respect to youth with problem substance use, the challenge for families, clinicians and policy makers is to prevent or stop use before it becomes persistent or more difficult to change. Theorists assert that early intervention is important for decreasing the psychosocial consequences that accompany problem substance use and disrupt the educational, occupational and social development of youth.

Outreach

Outreach refers to services that actively "reach out" and provide help to those who would not otherwise look for support in the community. Providing outreach services is critical for reducing the problems associated with substance use for youth who are not connected to mainstream services or supports.

Community Linkages

Creating positive community linkages for youth is critical for their positive growth and development. Community linkages refer to community-based services that are sources of social support and interaction and have the potential to act as protective factors to prevent and reduce the consequences associated with problem substance use. These include family and peer interactions, and attachments to school and community. Community linkages need to be accessible, responsive and valuable for youth early on in their addiction behaviour.

Best Practice Statements

The best practice statements reflect current research, key expert interviews with service providers, and focus group sessions with youth who have had substance use problems. As research continues, these statements will need to be reviewed and modified to reflect new knowledge. Sections of the document that support each best practice statement are cited in Appendix B.

Strengthening Service Delivery Orientations

Readiness to Change Model

Prochaska and DiClemente's Stages of Change model is a practical framework for understanding and assessing readiness to change. This model supports the creation of collaborative interactions with youth who are at varying levels of readiness to pursue change, and is applied in conjunction with brief interventions and motivational interviewing strategies.

Strength-Based Methods

Strength-based approaches are designed to promote positive change through recognizing and engaging the strengths of youths, their respective families and communities. Strength-based methods are also beneficial for engaging and intervening with high-risk youth populations.

Youth Perspectives

The perspectives of youth should be elicited and their leadership skills utilized when organizing and delivering community-based youth-focused services and programs. Feedback from non-users, as well as those at risk for problem substance use should be taken into consideration.

Youth-Specific Services

In some jurisdictions, only adult-focused interventions are available to youth. Service providers should strive to adopt outreach and early intervention services that are responsive to the developmental needs of youth. When youth request assistance or communicate a readiness to pursue change, service providers should act upon this "window of opportunity" and provide youth specific-services in a timely manner.

Inclusive vs. Exclusionary Policies

Inclusive policies that focus on relationship development and incorporate the influence of positive adult or peer roles will foster youths' sense of belonging and attachment to school and community. Exclusionary policies and sanctions alone are regarded as ineffective for motivating positive changes in youth with substance use problems or in linking them with needed intervention services.

Client-Focused Considerations

Histories of Abuse and Trauma

Histories of sexual, physical abuse and trauma have been positively associated with the early initiation and development of problem patterns of substance use among youth. Counselling services should be made accessible to youth and family members as appropriate, to avert the emergence or escalation of substance use problems.

Basic Needs

Early intervention services, especially for street and homeless youth, should be accompanied by adequate supports and resources to address basic living concerns, including shelter, clothing, food and transitional housing. Without these services intervention efforts will likely be impeded and problem substance use will continue.

Peer Influences

Lower levels of substance use by peers may decrease availability of substances, provide less social reinforcement for using substances, and provide models for healthier behaviours. Although forming new peer connections is challenging, providing opportunities for youth to engage in social activities with non-using peers is important for them to adopt healthier choices in daily living routines.

Concurrent Mental Health Disorders

Current evidence indicates that effective interventions for youth must provide an integrative approach to co-morbid mental health and substance use problems. These interventions require the development of a single point of entry for assessment and a coordinated service response with a focus on including family members when appropriate.

Cultural Sensitivity

Barriers to intervening with ethnoculturally diverse youth include stigma associated with disclosing problem substance use, lack of openness to involve external service providers, and language barriers. Recommendations for addressing these barriers include undertaking outreach efforts to youth and their families, providing services in the language of the client, and increasing sensitivity of service providers to the values and culture of specific ethnic groups.

Aboriginal Youth

In delivering problem substance use interventions to Aboriginal youth, it is important to assess the importance of spiritual values and traditions for the target population to ensure cultural congruence. Early interventions can incorporate traditions and cultural practices (legends, storytelling), bringing together positive family and community role models in the planning process, and integrating crafts and recreational activities to present and reinforce positive directions for change.

Youth in Conflict with the Law

Early intervention activities should be implemented at the "front end" of the justice system when youth first become involved with legal authorities. At this point, screening and assessment should be undertaken to identify substance use or mental health problems as part of cautioning, diversion or community-based sentencing.

Screening Processes

Role of Community-Based Service Providers

Emergency department personnel, health specialists and other community service providers are in unique positions to identify problematic patterns of use in youth. Questions about substance use should be incorporated as part of health and rehabilitation screening protocols.

Areas of Inquiry for Screening

Screening approaches should not be limited to exploring patterns of substance use. Other information related to aspects of the youth's life can be critical to understanding the dynamics underlying current problem substance use. Areas for investigation include family functioning, peer influences, school performance, areas of stress and coping, as well as readiness to change.

Early Intervention

Early Intervention with Young Adolescents

Early intervention efforts should be targeted at middle and junior high schools. Times of transition from middle/junior high to high school are often accompanied by increased exposure to older youth who use substances and to decreased supervision by school personnel and parents.

Brief Interventions

Recent research lends support for the use of brief intervention approaches for working with adolescents with substance use problems. These methods are generally defined as having a limited number of helping sessions and incorporate cognitive-behavioural approaches, motivational interviewing concepts and a focus on clients' areas of ability and strength.

Group Interventions

Group-based early interventions are enhanced by incorporating culturally based activities, applying discussion-oriented approaches and using incentives (free food or snacks) or other socially acceptable reasons for program attendance. Although small group approaches involving youth peers have been described as beneficial for reducing problem substance use, some research suggests that peer associations also have the potential to counter such efforts. Caution needs to be used when grouping youth with high-risk behaviours because unstructured time may reinforce existing problem substance use patterns.

Outreach

Outreach Locations and Times

Outreach should focus on meeting youth in their natural settings and community contexts where they spend time on a regular basis with their peers. Points of contact include street corners, coffee shops, drop-in agencies, parks, shelters, hospitals, custody settings, school-based activities and programs. A mobile service (e.g. van) that makes contacts in a variety of places can reach youth in rural or more isolated areas. Outreach is most effective when times can be flexible and include both evenings and weekends, and when it provides opportunities for multiple contacts.

Outreach Worker Competencies

Outreach workers must be able to communicate effectively with the target youth population and demonstrate an understanding of developmental milestones. It can be advantageous for outreach workers to have personal experience in the targeted outreach context and specialized training in addictions, mental health and motivational interviewing.

Preliminary Outreach Activities

Preliminary outreach activities should focus on building trust and fostering positive interactions between youth and outreach workers. Initial contacts with youth should be non-threatening, respectful and include brief informal conversations over frequent encounters.

Follow-Up Outreach and Intervention Activities

As relationships are developed with youth, interactions may then begin to incorporate a wider range of early intervention efforts, including focussing on increasing awareness of the risks of ongoing substance use; screening for concurrent mental health and substance use problems; linking youth with basic need services, such as shelter, food and clothing; health care; and identifying community supports to help sustain small positive changes.

Relevant Community-Based Supports

Youth-Focused Agencies

Community-based non-profit agencies and service clubs that focus on youth and family engagement have a central role to play in reaching out to youth. Outreach and early intervention activities can be implemented in conjunction with community agencies where youth are already receiving services.

Housing Options and Policies

Many jurisdictions do not have access to emergency shelter programs or longer-term residential options designed to meet the needs of youth. Conditions of available rooming houses are often unregulated and potentially unsafe for youth. Substance use problems may often be more frequent in these locations, placing youth at increased risk for development of addictions and associated problems. Service providers and community leaders must collaborate to address policies and service gaps related to safe and regulated housing options for youth.

Family Collaboration

Early intervention activities should engage family support when appropriate to address problem substance use with youth. Approaches for helping families include providing methods for effective communication, education on adolescent patterns, signs and basic features of substance use, stages of change and problem solving. Family members can provide assistance by providing transportation to appointments, ensuring basic needs are met, and supervision for younger adolescents. Access to counselling services for youth and family members should be offered in a timely manner.

School-Based Strategies

School-based strategies to address youth substance use should consist of multiple components, including staff and student team members, individual counselling, small-group interventions, as well as policies and procedures for student assessment, referral and support.

Youth Mentorship

Mentorship programs for youth have been associated with increases in school participation, reduced involvement with negative peer associations and enhanced skills to refuse substance use. Key areas to consider when establishing mentorship relationships include creating a safe and comfortable environment for both the youth and adult, finding common interests and having mechanisms for problem solving difficulties or challenges.

Recreational and Leisure Activities

Recreational activities provide structured opportunities for building rapport with youth and contribute to expanding and strengthening youths' confidence and interests in community-based activities and relationships that can be sustained over time.

Coordinating and Integrating Community Approaches

School-Based Service Collaboration

School sites may be used for delivering coordinated services for youth and their families. School-based services might include support from local police, mental health services, addiction counsellors and other service providers representing a range of health and social programs.

School Engagement Strategies

Re-engaging youth in school following substance use problems is an important consideration in strengthening their links to the community and addressing their learning needs. Motivation to return to and stay in school is facilitated by providing individual academic assistance, mentorship, hands-on learning activities, basic life skills instruction, and opportunities to participate in apprenticeship (e.g. trades) or co-op learning experiences in the community.

Information Exchanges

Information exchanges among service providers help to increase the awareness of potential service delivery capacity and opportunities for developing coordinated and collaborative service delivery approaches in the community. They may include developing regional resource directories outlining youth and family-focused services, organizing community fairs and open houses where service providers can promote their services, and implementing community-wide planning sessions to address policy gaps or concerns.

Case Management Practices

Case management strategies have been applied to reduce barriers associated with service accessibility, and to encourage the development of positive community linkages. Case managers should ensure that community plans are coordinated and tailored to meet the unique needs and circumstances of the youth.

Coordinated and Collaborative Service Delivery Approaches

Coordinated and collaborative service delivery practices can reduce duplication of services and provide opportunities for integrating interventions. Services should develop protocols for common intake, assessment and referral; interagency consultation; communication and case-planning; memorandums of understanding to support consistent service delivery; cooperation among agency personnel; and co-locating and co-facilitating front-line services.

Consultation and Community Awareness

Addiction personnel should be available to consult with other service providers who routinely encounter youth at risk for problem substance use. Consultation may include organized professional development sessions or individual consultations on a range of topics, including substance use patterns among youth, screening methods and co-morbid mental health. Educating service providers and other community members is important in community-based outreach and early intervention activities to reduce stereotypes and foster greater readiness for community members to reach out to youth.

Evaluation

Early intervention and outreach programs should be reviewed regularly to ensure the extent to which they are efficient and effective.

Future Research

The outcomes of this project pointed to specific gaps in research and knowledge related to early intervention, outreach and community linkages for youth with substance use problems. The following summarizes these areas:

Youth and Sexual/Gender Orientation

An estimated 10% of the population may comprise individuals who are lesbian, gay, bisexual, transsexual, transgendered or questioning (LGBTTQ) (CCSA, 2006). Minimal research has focused on the needs of youth in these populations or on effective approaches for addressing the needs of those with problem substance use (Noell and Ochs, 2001).

Internet-Based Early Intervention Approaches

Some theorists have stressed the potential benefits of integrating motivational enhancement content with Internet-based approaches for intervening early with youth. More research is needed to further explore the potential efficacy of early intervention approaches that use Internet-based applications.