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Drug Treatment Services for Young People: A Research Review

CHAPTER 6 EXAMPLES FROM CURRENT PROVISION

In this chapter we review issues raised earlier in the report. The themes emerging from Chapters 2-5 provide a framework for discussion of the issues faced by DATs and practitioners in this area. The themes overlap or are closely related to each other, but can be summarised as follows:

• planning a complete and integrated service;

• applying an appropriate range of interventions;

• fostering awareness and motivation in target groups;

• involving schools;

• involving families and carers;

• upholding children's rights;

• reconciling the rights of parents/carers;

• implementing comprehensive, multi-agency interventions;

• developing service capacity;

• assessing and improving service effectiveness.

Case Study Selection

This account of issues 'on the ground' is based mainly on the case study work undertaken with eight services or service 'clusters' in Scotland. The characteristics of the case studies are summarised in Table 6.

These eight cases provide a good spread geographically and in terms of rural/urban/inner city coverage; they include local authority, voluntary sector and NHS services, and one case focusing on the operation of a range of services in a single city. There are new services just completing their first year of operation, and some which have been operating for ten years and more. The number of under-16s seen varies from a very few to sixty per annum, and there are varying degrees of specialisation for this and the 16-18 year old group. The eight include some non-statutory services, and all the main types of service delivery are represented in one or more cases.

Planning a Complete and Integrated Service

The mapping survey established that services are incompletely available both across Scotland and within specific DAT areas. Some DATs are moving forward quickly in terms of planning to make provision accessible to all children in all areas. For example the Glasgow City Implementation Group on Alcohol and Drugs has reviewed the current situation, in which there has been patchy coverage of services, mainly focusing on looked after and accommodated children. Current capacity restrictions, the existence of wider needs, and the need to integrate planned service extensions with other developments, have all been recognised and addressed in new service specifications.

The literature review points to the importance of adequate funding and long term planning and delivery for service effectiveness (Table 4). Some of the services studied have begun life as ad-hoc solutions to problems in local areas. Some have piloted responses to particular issues with specific target groups. In many cases, limitations of targeting and funding have constrained the capacity of the programmes to be flexible in meeting the needs of individuals from outside their catchment areas.

The literature review also notes the importance of experienced and well trained staff (Table 4), and this should be seen as linked to the theme of longer term funding. Annually renewed funding can create uncertainty and restrict the ability of some services to retain and develop staff. Some commissioned services rely on many separate funding streams. However this can soak up senior worker and administrative time and divert resources from the effective management and implementation of services.

Finally, the case study work suggests the importance of ensuring that strategies for child treatment and care are firmly integrated within the overall strategy for service development, and within the strategies of all partner agencies. This can be complex given the range of development strategies currently being taken forward, but failure to make these links can result in confusion or contradictions in strategy and hence in delivery work.

Applying an Appropriate Range of Interventions

The mapping survey shows that a range of interventions is available for children in Scotland, with counselling forming the common basis for almost all services. It is seen as critically important to build a relationship and gain the trust of the young person, and this is a common core function of counselling throughout the projects studied.

However some of the interventions identified as effective in the international literature, especially behaviour therapy, family therapy, and more structured 'step' programmes, do not appear to be widely available.

The literature review also suggests that the duration of programmes, and the availability of 'booster sessions' where needed, are factors supporting effectiveness. The experience of 'Neville' (Box 4) illustrates this point and also how the Rushes service provides support beyond 18 for those who need this.

The literature review points to the need to provide early interventions (for low risk groups) to take advantage of the increased chances of success when dealing with children with lower misuse and psychopathology and higher school achievement and motivation (Table 4). Early interventions to access children before misuse and associated problems become established appeared rare. An exception is the Early Interventions service in Glasgow. This is a small team set up, originally as the Arrest and Referral service, to work with local police to identify and intervene in cases where children and young people are coming into contact with officers and where drugs issues appear to be involved.

There is a range of residential accommodation for children and young people in Scotland (essentially residential schools, secure units for under-16s, and Young Offenders' Institutions for 16-21 year olds). These will generally include some provision to support children and young people with misuse problems. However this is a relatively new development.

There are no residential rehabilitation units specifically for children and young people with drug misuse issues in Scotland. There are a few such units in England; an example of where referral to this residential treatment was considered is the case of Philippa (Box 5).

We asked case study interviewees if they felt that the lack of such a facility in Scotland caused problems. Opinions varied: some felt that this would be a useful addition to services, since children or young people had to be sent a great distance from parents or carers for the duration of the residence. Others felt that the number of cases requiring such a service was very small, and that the service was inherently expensive; as such, it might not be the best application of scarce resource. In some cases it was actually beneficial to ensure that the individual was removed to some distance, due to security factors.

Physical separation from adult services is widely regarded as important, to avoid children coming into contact with adult users, and possibly dealers. The avoidance of stigma is also key. In general children attend on an appointment basis, do not spend long periods of time in delivery locations, and mix with others primarily during group work or diversionary activities, when they are well supervised. A slightly different approach to separation was seen in one case where the children's service has its own entrance which is off-street and unobtrusive, but the same building also houses an adult addictions unit, for which the same manager is responsible. There is an internal connection used by staff only. The manager feels that this arrangement is effective in maintaining the required separation between child and adult users, while easing the transition of individuals to the adult service. At this transition, they can work with some of the same staff, the adult team will be familiar with their case, and they will be visiting a familiar location.

Fostering Awareness and Motivation in Target Groups

Findings from the mapping and literature review indicate the importance of first engaging children with services, and then building individual motivation to change. These two separate points were illustrated in the case studies and service user interviews.

Obtaining individual consent and commitment to the drugs programme is one of the key issues facing the Polmont service. Despite induction sessions and repeated opportunities to join the programme, 35% of referrals in the period January to October 2001 refused the help being offered. The case of 'Jez' is an example, (Box 6) which (albeit in an untypical setting) illustrates the fact that many children and young users will resist attempts to define drug use as a problem. The second case (Box 7) illustrates how one service attempts to overcome the problem of engaging young people.

Involving Schools

The literature review, although identifying some contradictory indications of the effectiveness of school based work, underlines the potential importance of school links. We did not identify strong links between most services and their local schools. This may be due to the emphasis on treatment and care rather than on education and prevention work. There were some exceptions (see Box 8), but this area appears to be one where there is considerable potential for further development. If early interventions are indeed more likely to be effective then liaison with schools is an important avenue to explore.

One should bear in mind that the literature review also raises the possibility of negative effects, if work in schools is negated by peer pressures, or if it leads to a wider acceptance of drug taking as a normal recreational activity (Chapter 4). This suggests the need for careful design of such activities.

Involving Families and Carers

The literature review also identified the importance of family-based work. This was seen as involving all family members in co-joint or individual programmes, aimed at improving family interactions and functioning. As previously noted, no well-developed examples of programmes of this type were identified in Scotland. In two cases where figures for referrals from parents were available, the numbers and percentages of referrals overall were low (Glasgow, ten referrals, 11% of the total; Fife Youth Drug Team, 3 referrals, 7% of the total). This suggests that one benefit of more work with families might be to encourage referrals via this route, which might also facilitate earlier intervention.

However, the importance of involving family members is a common theme in guidelines and advice to practitioners (see the legal framework review, Chapter 5), and many practitioners have recognised the need to engage parents or families, with a variety of approaches being adopted (Box 9). The future plans of many DATs or partners include the further development of family oriented services. Examples include provision of a drug education service for parents and carers and others involved with young users or those at risk of misusing drugs (Dundee DAAT), and new Family Support posts linked to local addiction services to support vulnerable families (Greater Glasgow DAT).

Upholding Children's Rights: Awareness, Consent and Prescription

The legal framework review (Chapter 5) identifies key rights of children (to access to treatment, participate in decisions, and to give consent) and a number of difficulties in relation to these. Clearly, where appropriate specialist provision is not available, as it is not in large areas of Scotland, rights to access are limited in reality.

In general we found that practitioners were very much aware of the principle that the welfare of the child should be the primary consideration in the final analysis. Staff in relevant services were also well aware of the principles underlying interventions made through the Children's Hearing system (the 'no order principle' that action should only be taken in response to an identified need). The rights of children to access treatment were perhaps less to the fore, although this probably reflected not so much unawareness of the principle, as recognition of the difficulty of upholding this where appropriate services were difficult to access.

We were unable to assess parental awareness of rights and the statutory framework, although the low proportions of parental referrals, noted earlier, may reflect a lack of knowledge or confidence in referring amongst parents and carers. Children interviewed were not aware of general rights to treatment, beyond the availability of specific local services; their awareness of these was generally incomplete.

In the cases studied, it was made explicit to children that their participation in treatment was on a voluntary basis. Confidentiality policies and situations in which disclosure might be made were also explained. This indicates practitioner awareness of the child's right to participate in treatment decisions and consent to treatment. For some practitioners, considerations of the child's welfare may at times obscure these rights, especially in crisis situations, or where the child appears at risk of harm. Nevertheless this is counterbalanced by the fact that participation in programmes is generally voluntary (or perhaps semi-voluntary where it results from a recommendation in a Hearing). Practitioners agree that trust, empathy and motivation are key components of successful treatment.

The review mentions 'professional reluctance to become involved in upholding children's rights to health and health care' (Chapter 5). We did not interview GPs, but this point arose in two interviews suggesting difficulties in obtaining support from GPs. This is clearly insufficient evidence to support any general conclusions, but if there are difficulties they may relate to doubts or perceived lack of consensus about treatment options, or about the legal issues involved in treatment. GPs do not generally figure as a significant source of referrals, where breakdowns are available.

Other difficulties can include apparent conflicts between the welfare and the rights of the child (see Box 10). These issues are presumably not restricted to the drugs treatment field.

Prescription Principles and Practice

Prescription is an area where the issues around children's rights and appropriate practice are particularly prominent. Practitioners report that they meet with very few children who might benefit from prescription of opiate substitutes. The guidelines emphasise that for children 'drug misuse, even with some significant dependence, is not in itself an indication to prescribe substitute medication' (Annex 6, 'Drug Misuse and Dependence - Guidelines on Clinical Management', 1999). In the one case we did become aware of where methadone prescription had been used, the service user herself was sceptical about the ultimate value of the approach, as she felt it had led to substitute dependence.

Other, non-substitute drugs may be prescribed to children as aids to detoxification or to treat psychological or physical difficulties associated with misuse. Opiate antagonists, which block the effect of heroin, may also be used. An example where Buprenorphine hydrochloride (Subutex) was used for this purpose on a trial basis is shown below (Box 11).

Reconciling The Rights Of Parents/Carers

In the literature review it was noted that, although family therapy can be an effective intervention, care must be taken to ensure that this is not neutralised by negative family pressure (Chapter 4). The evaluation of the parent-child relationship and the prospects for positive engagement of the family are at the heart of the issues facing practitioners when deciding how far to uphold parental rights:

• existing family difficulties may underly drug misuse and associated problems, and these may be exacerbated by upholding parental rights;

• in more serious cases, child protection issues and associated orders may restrict parental rights on a statutory basis;

• parental collusion or pressure may exist in relation to the drug use of the child; this may be known to practitioners through their contacts in the field, but not be provable in any sense which would provide 'cover' for restriction of parental rights;

• information on family conditions may not be fully available to the drugs practitioner due to maintenance of client confidentiality by other agencies involved in the case.

Despite these difficulties, the services we studied subscribed to the guideline view, that in principle informing and involving parents or carers was desirable and should be encouraged wherever possible.

Implementing Comprehensive, Multi-Agency Interventions

The literature review and case study work both indicate the importance of making comprehensive interventions, where problems including non-drugs related issues can be dealt with in a coherent fashion. This implies the need for multi-agency co-operation, which is also identified as a factor supporting effectiveness in the literature (Table 4). The following note some difficulties experienced in multi-agency working.

Establishing Consistent and Shared Assessment

In order to have an agreed and consistent view of service user needs and the treatment plan, it is important that initial assessments are made which meet, as far as practical, the needs of all partners and which can be shared between them. If this is not done:

Children can end up having to tell their story three or four times to different agencies. They can find this upsetting, and they don't understand why the people involved can't just talk to each other and share the originalinformation. It doesn't give [the children] confidence that they are being helped in the best way. (Practitioner interview)

Ensuring Consistency of Treatment and 'Routing'

One obvious assessment issue is whether the case is defined as primarily a 'drugs' case, or as some other kind of case with a drugs facet. This may determine the main agency responsibility, with implications for the resources and partners accessed.

I have concerns about consistency in dealing with cases. For example if we first become aware of a child when they self refer, or are referred by a parent, to the [non-statutory] community drugs service, we are likely to view that as a "drugs case" and deal with it as part of the Addictions Service caseload. If the same case came to us via a Hearing or from a school referral to Social Work, it would be on the Social Work caseload and the drugs issue might not be recognised for some time. (Addiction Service Interviewee)

Sharing Information

There can be a possibility that sharing of information with statutory agencies may trigger responses which, while they reflect the responsibilities of that agency, may have a detrimental effect on the therapeutic relationship established with the service user:

If we have someone who has self referred to us, we may want to provide the information on that child to Social Work. However once they are aware of the circumstances they may have a statutory obligation to take action of some kind. Even if the action is helpful, the trust between our worker and the child will be broken and that may have consequences which are more harmful in the long run. (Practitioner interview)

Some voluntary sector interviewees perceived other reasons why statutory services might be reluctant to pass information to them;

I think, as well as the worries about confidentiality and data protection, there are sometimes some tendencies to distrust non-statutory sector workers or to see them as less professional in some way. There can even be an element of competition between services. All these things can hinder information sharing.
(Practitioner interview)

Caseloading Issues and Clarity on Responsibilities

Where more than one agency is involved in a case, it can be problematic to establish who is the key worker. Normally the key worker will be a social worker, but this could be unclear in practice.

Because of the way we need to work, we will build up a very close and supportive relationship with the client. For the social worker this is much more difficult because they get involved in decisions and enforcements that the child may resent. So you can get a 'good cop-bad cop' situation where the child thinks of the drugs worker as the most important person for them, and this may lead to them taking on a wider role than they originally planned.
(Practitioner interview)

In many areas, social work resources are stretched, and this can contribute to a blurring of responsibilities.

When social workers are very heavily loaded, they might go along with the tendency to regard the drugs worker as the key person in the case, and we end up doing things that we think they should really be doing.
(Addictions Service interviewee)

Onward Transition at 16 and 18

There can be difficulties in multi-agency working at the points at which service users make the transition out of childhood, and beyond 18. At these points, the statutory responsibilities of the relevant agencies change, and as the transitions approach this may affect the handling of the case. However it was not clear how widespread these issues were. Both the overcoming resource issue and onward transition at 16 and 18 issue is illustrated in the case of Philippa (Box 12). In Chapter 2 we described the range of needs that Philippa has, and earlier in this Chapter we highlighted that residential treatment was thought to be an appropriate treatment option, but there was a difficulty as Philippa was now 17.

Developing Service Capacity

Partly because many services are new, there appears to be limited sharing of information on interventions or effective practice between providers, particularly outside DAT areas. Many DATs have provider fora which are intended to facilitate this communication, but perceptions of the effectiveness of these arrangements vary.

There were some problems with the provider forum. There were some differences between service leaders and practitioners, and the forum seemed to feel that the DAT didn't take it seriously. The DAT people felt that the providers tended to bring complaints rather than firm, constructive proposals to the table. There has been a review of the forum which is nearly complete and will lead to changes which should improve relationships between DAT and providers.
(DAT interview)

Effective communication can help meet the need for wider agreement: for example, on the legal framework, particularly consent and confidentiality issues; treatment concepts and effectiveness; and on co-ordinated capacity development.

Assessing and Improving Service Effectiveness

Services in this field can face particular problems in monitoring and assessing the effectiveness of approaches. The aims and objectives of services may be broad and may not lend themselves to straightforward outcome measurement. Some services have developed targets and measures which can be used to aid planning and service review (see Box 13). This is easier for more tightly focused interventions. In other cases it may be difficult to demonstrate that the most appropriate action has been taken in individual cases, due to the conflicts of rights and practicalities discussed earlier. There may be cases in the future when the accountability of such services is tested.

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