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Effective Interventions Unit - Young people with, or at risk of developing, problematic substance misuse: A guide to assessment
Chapter 7: Levels of Assessment
The evidence shows that young people with, or at risk of developing, substance misuse problems, are likely to have
other difficulties in their lives for which they will require support. It is essential therefore that assessment addresses these wider needs. The evidence also suggests a need for
different levels of assessment in order to inform decisions about the right treatment, care and support at the right time for the individual.
Our evidence gathering and, in particular, our consultations with practitioners indicate that, while there is a consensus about the need to recognise, and work within, different levels of assessment, there is
currently no consensus on definitions or descriptions of those levels. We anticipate that the work being done by the Scottish Executive to develop an integrated assessment framework for children and young people will address this issue further.
For the purposes of this guide, however, we believe it may be helpful to set out some of the
key considerations and
useful resources on levels of assessment that we have identified during the course of preparing this guide.
The evidence that we have gathered about current practice in the assessment of young people seems to indicate that the main differentiation is between
initial assessment or identification of substance misuse needs and a
more in-depth assessment. At this stage, prior to completion of the work being carried out by the Executive, it is difficult to make any further distinction in levels of assessment. Those who wish to explore the question of levels further may find it helpful to look at the previous EIU work on assessment.
A. Initial assessment/identification of substance misuse needs
Initial assessment (sometimes referred to as screening) usually involves collecting fairly basic information, to identify whether there is a substance misuse problem and, if appropriate, to facilitate a referral to another agency. This level of assessment could be carried out by a range of workers in a range of agencies when a young person presents with a need or problem. It may be
specific to substance misuse or part of a wider initial assessment to identify the spectrum of the young person's needs. It should be a helpful non-threatening experience designed to encourage the young person to engage in a more in-depth exercise, if appropriate, and ultimately to promote the development of a therapeutic relationship.
There are some slightly differing views about the purpose and nature of
initial assessment. The basic principle is that, where young people have substance related needs, it is important that these
needs are identified, and addressed, at an early stage. There are potentially two, equally valid, aspects to this early identification which will depend on the needs and circumstances of the young person:
prevention of (even) more problematic substance misuse. This may apply particularly when the young person's substance misuse has not progressed to regular and/or high-risk practices. Interventions might involve information giving or education on the risks associated with substance misuse.
identification of a substance misuse problem, assessing of the seriousness of the problem and arranging further assessment and support, or appropriate referral(s).
One of the key messages from the EIU's consultations with practitioners is that the way the initial assessment is conducted can help to
establish a trusting relationship with the young person at the start of the assessment process. There was a view that there is benefit in the initial assessment being carried out by an individual the young person already knows, and has built a relationship with. This may not always be possible but our evidence strongly suggests that the principle of engaging with the young person in a way that promotes trust is fundamental to the success of the overall assessment process (
see Chapter 4).
Other key messages from our consultations about the benefits of effective early identification of substance misuse needs is that it can:
determine
who requires further assessment
avoid young people entering
assessment too early
avoid
duplication of multiple assessments for young people and for services
identify a
service(s) suitable for the young person and ensure onward referral
prevent 'flooding of services' with
inappropriate referrals
identify unmet needs, and if this information is collated,
allow services to develop to meet these needs. For example, the Fife Youth Drug Team now address alcohol misuse, having changed the criteria for who they work with.
In 2003, the Home Office/Drugscope published 'First steps in identifying young people's substance related needs'. This describes the aim of the identification process as "not to police a young person's drug use but to support the young person's substance related needs".
They may simply require information, or they may need to be referred on for more detailed assessment.
The guidance highlights
the responsibility of everyone working with young people to identify substance related needs. It also provides a framework for identifying such needs
within existing assessment procedures.
The identification of a young person's substance related needs should go
beyond the question 'Do you use drugs?' to establish
:
a young person's knowledge of drugs, alcohol and solvents
if the young person takes drugs, alcohol or solvents
if the young person misuses drugs, alcohol or solvents
if the young person is in immediate danger
if substance use is part of complex troubling behaviour
unusual behaviour for that age group in relation to their substance use.
Further, the key to identifying substance related needs is to
"keep it simple".
CASE STUDY EXAMPLE |
Perth Connect used the Drugscope guidance to develop their referral and screening form. In doing so, they were conscious of the need to keep the form brief, but at the same time to get the information they needed. The project's target group is "young people whose substance misuse is causing them significant problems". However, prior to introduction of the referral and screening form, they were receiving a lot of inappropriate referrals, for example, young people who had limited substance use, but were doing well at school, had good relationships with family and friends and whose substance use was not causing them problems with other aspects of their lives. Such young people might benefit rather from a brief intervention to give advice on, and raise awareness of, the risks involved with substance use. Introduction of the new form has seen
a reduction in inappropriate referrals, and an improvement in the referral information received on new clients coming to the service. Another positive feature of the form is that it is intended to be completed by the referrer, together with the young person.
Contact:
kathryn@alcoholtayside.com |
Drugscope have produced a series of factsheets, which provide:
a checklist for implementation (actions and resources)
the principles for identifying substance related needs
a process for identifying young people's substance related needs
guidance on confidentiality.
These are available at:
http://www.drugs.gov.uk/ReportsandPublications/YoungPeople/1045138394/Insert.pdf
B In-depth assessment
In-depth or further assessment usually covers more detailed information on substance use and other aspects of the young person's life: physical and mental health, social and economic circumstances, education issues, family relationships and offending behaviour. This level of assessment might be carried out by staff in social care (e.g. children and families, or youth justice), primary care, community mental health teams or substance misuse services. Whoever carries out the assessment should be
skilled and competent in assessment. One of the outcomes may be a referral to a more specialist assessment.
One of the main sources of help with assessment for young people with drug and alcohol problems is 'Assessing young people's drug taking: Guidance for drug services' published in 2000 by the Standing Conference on Drug Abuse (SCODA)
. This document provides
guidance to those developing assessment forms and procedures specifically for use with young people who misuse drugs. Although the title refers to 'drug' services, it is acknowledged that "young people's drug taking is often inextricably linked with the consumption of alcohol".
The guidance suggest that the assessment should establish:
the level of the young person's knowledge in relation to their drug taking
the level of harm in relation to the young person's drug taking
if an intervention is required
if there are any child protection concerns
whether a referral or joint working is required
the appropriate intervention where required.
Chapter 4 of the SCODA guidance 'assessing and planning' sets out in more detail the information that should be gathered. A key message is that "
practitioners should tailor the questions and style of discussion to suit the young person being assessed. Some information areas may not be relevant to every young person (e.g. assessment of their parenting skills), while others may need more attention (e.g. criminal behaviour)". There are
nine information sections:
demographic details (e.g. age, address, name of responsible adult)
current and past drug taking (e.g. length and pattern of drug taking, risk assessment)
the young person's perspective on their drug taking
social situation and history (e.g. support system or lack of it, offending behaviour)
assessing whether there are child protection concerns
assessment of competency i.e. to give consent if under 16
medical situation and history (e.g. psychological problems, sexual activity)
assessing injecting drug use (e.g. frequency, sharing behaviour)
other problems (e.g. poor social or family networks, housing needs).
CASE STUDY EXAMPLES |
Youth Addiction Services in Glasgow City Council's Community Addiction Teams are currently developing an
assessment framework for use with their clients. They used the SCODA guidance on assessing young people's drug taking as a starting point for developing the content of their draft assessment form. The form was piloted with some of their Youth Addiction workers to find out how the questions worked in practice. This identified some areas where workers felt the questions could be modified or improved. Further development of the assessment framework will take account of Glasgow City's Single Shared Assessment for adult drug and alcohol users and explore whether there are aspects that would be transferable to an assessment for young people. They are also keen to look at aspects of existing assessment tools in use locally, such as the EuroADAD (
one of the tools described in Chapter 6, Assessment Tools) and the possibility of incorporating components of these. Initial work has confirmed the importance of young people's
understanding of any assessment process and the importance of
using appropriate language in both the questions and in the final recording. Staff have suggested that questions
need to be specific, especially with regard to the young peoples' perspective on their own substance use. Contact:
gemma.mcneill@sw.glasgow.gov.uk Hype provides support to young people in Edinburgh experiencing difficulties with drug, alcohol or volatile substance use. They have developed an
assessment booklet, adapted from the SCODA guidance. One of the key features of the booklet is its
flexibility (note: it is loose-leaf). Also, the young people choose how they complete the assessment, which might be self-completion, the worker filling it in for them or they may prefer simply to sit down and have a dialogue with the worker. Another message from the project is the importance of being mindful of young people's varying literacy skills and the need to
offer a range of ways to complete the assessment. The assessment takes place over a number of weeks, and allows for individuals to work through it at their own pace. They can choose which issues/priorities to address first. However, contact details, information sharing and confidentiality, and rights and responsibilities of the client - the 'ground rules' (
see Hype 'Rights and Responsibilities' leaflet in Appendix7) are always covered at the first appointment. There is also
flexibility in the frequency of the assessment meetings, and where the assessment takes place. Additional features of the assessment include: child and young person friendly language, it is very holistic, it looks at the young person's hopes and aspirations (for example there may be a hobby they have always wanted to try), continual revision and improvement of the booklet and the ability to offer interventions and support at the same time as the assessment is going on. Contact:
schype@mail.nch.org.uk |
For some young people, whose substance misuse problems are severe, there may be a need for a
specialist substance misuse assessment: for example, a young person who is engaged in chaotic drug taking, regular offending behaviour and who has mental health problems.
One group who may require a more specialist or specialised assessment are those young people considered to be
particularly vulnerable.
The EIU's 'Guide to Services for Young People' recognised that there may be particular groups of young people "at greater risk of developing problems with drugs". These particularly vulnerable young people may not be taking larger quantities of drugs than their peers but may be
more likely to make the transition from experimentation to problematic use. These included young people who were:
getting involved in
crime
homeless or insecurely housed
excluded from school or persistently truant
currently or previously,
accommodated or looked after by local authorities
involved in
prostitution or
sexual exploitation
exposed to substance misuse in their
family.
McKeganey and Beaton's research (2001) into 96 young people resident in children's units found that 45.8% had used an illegal drug in the preceding month. The research also identified a close association between illegal drug use and involvement in other anti-social and risk taking behaviours: nearly 70% of the drug using young people had ridden in a stolen car compared to a third of the non-drug users. Research undertaken in 2000 by Melrose and Brodie found that young people who were offenders, excluded from school and 'looked after' were more likely to use drugs compared with those who only had one 'vulnerability'.
Vulnerable often means young people who are at risk of harm (physical, sexual, or psychological) to themselves because of their lifestyle, or influences on them. The SCODA guidance notes "
Working with highly vulnerable young people can be challenging and can raise complex issues……". The particular sensitivities and problems for these young people may necessitate
more specialist services.
There will be 'hard to reach groups' of vulnerable young people with whom the initial challenge is to establish contact (
see Chapter 4). There are also young people, who have been known to social work and other services for years, who are very challenging to engage with and to maintain a relationship with.
CASE STUDY EXAMPLES |
Kerelaw School, in Stevenson, is home to 50 (under review) young people who are at serious risk because of the circumstances in which they live or because of their own behaviour. Most are referred from Glasgow, but there are also a growing number of places being sought for young people from all over Scotland. There are two facilities within the school: a secure unit for 24 and an open school unit for 26 young people. The school takes young people aged between 12 and 17 years. All of the children and young people have serious behavioural problems. Many of the young people have a serious substance misuse problem and this has been approached over the last few years in an inclusive and participative way. A supportive drug and alcohol service has been developed and is provided by two experienced counsellors. Young people with substance misuse problems are offered this service. The service is available to all
if they wish to participate. The take up of the service is high and the young people enjoy their time with the counsellors and find it helpful.
The voluntary aspect of the service, person-centred approach, the informal atmosphere and the ability of the counsellors to relate to the young people make this a very positive experience for the clients. The staff are aware that their popularity may also be attributed to the fact that the young people miss a school lesson to attend counselling sessions! The workers are committed to their own professional standards and are experienced and skilled at engaging with young people on their own terms.
The counsellors are trusted and are seen as someone with time to listen to them, by the young people. This is an added safeguard for the young people. The clients are encouraged to talk about their problems and to identify how they might tackle them. Some might see this approach as slow and not one which brings quick results. However, with this very vulnerable client group this approach is proving to be effective. The service links directly to the provision of youth addiction staff within Glasgow City Council's Social Work Services Community Addiction Teams. This ensures there is a seamless service for young people returning to their local community, or on entry to the school, and that work on their substance misuse problems can continue to be addressed.
Contact:
gemma.mcneill@sw.glasgow.gov.uk Streetwork Edinburgh works with young people (12-25yrs) who are at risk on the streets and rough sleepers. The project provides education, support and prevention around homelessness, drugs and crime. The project workers work (and walk) around the city to find people who may need a service. Young people also access the service themselves and can be referred by other agencies. The philosophy behind the project is that it undertakes 'detached' work - 'detached' meaning an open agenda - the project workers find out what people want from the project and then provide it. Streetwork works with people who do not easily fit into existing provision or meet service expectations.
Contact :
www.streetwork.org.uk |
The 'Looked After Children' materials developed by the Department of Health in England and now used by most Scottish local authorities provide a national framework for
assessing the needs of children who are looked after.
Young people may also be parents. Those working with young people will need to take account of the needs of any children of their clients. 'Getting our Priorities Right: Good practice guidance for working with children and families affected by substance misuse' (Scottish Executive 2003) highlights the importance of addressing children's needs and welfare in the assessment process and incorporates an
assessment framework for assessing problem substance use and its impact on parenting.
Scottish Executive: Achieving an integrated assessment framework for Scotland's children
The Scottish Executive have established a multi-agency
Assessment Working Group (AWG) chaired by Professor Norma Baldwin, whose task is to prepare an overarching framework for assessment (and related information sharing) for use by all agencies and individuals working with children, both in universal and targeted services.
The working group's achievements so far include:
reaching consensus across all disciplines on the purpose of assessment and core definitions and terminology.
agreement that any assessment framework must be able to
assess the needs of any child, not just a child 'in need' - a shift away from delivering a framework for specialist services to one which
is applicable for universal services. This is a fundamental change towards ensuring that the needs of any child can be appropriately assessed,
wherever the child presents; it also ensures that any lack of understanding or agreement about thresholds or definitions about 'what is a child in need?' can be avoided.
careful adaptation of the
Department of Health assessment framework 'triangle', which is shown below. In doing so, the group is conscious of the need to reflect the move towards practice implications for universal services, e.g. schools and health services, and for the language to be easily understood by children and young people. They are considering organising information under
3 headings: what the child or young person needs to grow and develop (personal factors), what the child or young person needs from family/carers/significant people (family and significant others; living arrangements etc), and wider influences (communities, social networks, income, housing etc).
The Scottish Executive have also commissioned research into the implementation of integrated assessment thus far in a number of local partnerships, with the aim of identifying important lessons for anyone trying to develop an integrated framework for assessment. This is due to be completed by the end of 2004.
More information about the work of the group is available at
www.iaf.intranets.com
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