Drug Treatment Services for Young People: A Research Review
EXECUTIVE SUMMARY
In August 2001 York Consulting Limited (YCL) and the School of Nursing and Midwifery, Dundee University (SNMDU) were commissioned by the Effective Interventions Unit (EIU) to undertake a study of treatment and care services in Scotland for children and young people with developing or established problems with drug misuse. The study combined a survey of Drug Action Teams (DATs), and service providers, case study work including interviews with young service users, and literature reviews.
Aims
The aim was to review current provision and to identify issues for delivery and future development of these services. The study focused on services for under-16s but also considered services and issues relating to 16-18 year olds. Services focusing primarily on prevention, education or the recreational use of drugs were not covered. Links to alcohol were considered but services focusing on alcohol related problems were not included.
Service user characteristics
The children and young people accessing the case study services typically faced a range of issues, not all of which would be related to drug misuse. The severity of drug misuse in itself can vary widely between services and individual cases. In the cases encountered or discussed with key workers, there was a spectrum of misuse ranging from regular use of cannabis, often combined with alcohol, to smoking or injecting heroin on a daily basis. Poly-drug use could start from the age of 11 or 12 in some cases. The findings were broadly consistent with data from prevalence studies based on surveys of 12-15 year olds in Scottish schools.
Children using services often felt that they lacked support and were disapproved of, and distrusted some agencies and staff. They often lacked knowledge of the consequences of their actions and of potential sources of help, and had difficulty in committing to positive action to help themselves. Most children interviewed were not well equipped to articulate their needs or the priorities for meeting them.
Current provision in Scotland
Key findings from the mapping survey were:
there is a limited but significant base of existing provision; 42 relevant services were identified;
provision is distributed unevenly across Scotland; the 42 services were based in twelve of the 22 DAT areas, with another ten DATs being unaware of any relevant services;
in large areas of Scotland (predominantly rural) there is no drug related treatment and care available with any degree of specialisation for children and young people;
services coverage is often confined to the immediate locality or specific groups; coverage is usually incomplete even in DAT areas with relevant services;
services display varying degrees of specialisation in terms of their targeting of and capacity to deal with children and young people;
there is great variety in terms of the aims and methods involved, with little overall consistency of approach across Scotland;
DAT plans include the introduction or expansion of relevant services; many current services have been in operation for one or two years only; this is a rapidly developing area of provision;
the survey indicated that over 400 children and over 800 young people (16-18) accessed services in the twelve months to autumn 2001.
current services exist to a great extent in isolation from each other; DAT officers may not be familiar with the details of services, and services within a DAT area or across DAT boundaries may have only limited contact with each other;
there has so far been limited opportunity to exchange ideas and disseminate effective practice between services.
Counselling and the provision of advice are common to almost all the services, with other services such as needle exchange and access to legal support. Detoxification treatment is available, but prescribing of methadone to under-16s is very rare.
There are many gaps in service availability in specific areas. There is no specialist residential rehabilitation available in Scotland, although some services have used residential services in England. Practitioners' views on the need for such services in Scotland differed. There is no evidence of services targeted by gender or ethnic group.
Respondents felt there was a need for further guidance to service teams on issues such as confidentiality, joint assessment, and linkages to family and general social work services.
International evidence on effectiveness
In international research literature, effective interventions in terms of drug use reduction are identified as:
behaviour therapy;
culturally sensitive counselling;
family therapy;
the Minnesota 12-Step Programme;
therapeutic community and residential care.
The mapping findings suggest that, of the five most effective interventions identified via the literature review, only counselling is widely delivered by relevant children's services in Scotland. While there are instances of the other four, they are limited in scale and distribution.
Factors contributing to the success of interventions were:
low pre-treatment substance abuse and reduced psychopathology;
peer and parental support;
self motivation and completion and having better coping/relapse skills;
better school attendance and performance;
comprehensive interventions including non-drugs related issues;
longer term, well funded programmes;
school facilities for low risk groups and to target high risk groups;
experienced, stable staff teams;
multi-agency working.
Although comparisons between the international findings and those for Scotland should not be made simplistically, there were some key similarities and contrasts worth noting:
The review emphasis on comprehensive, multi-agency interventions complements the finding that children are faced by a range of needs, not all drug-related;
The importance of addressing lower and higher risk groups via specific targeted interventions supports the findings relating to a spectrum of misuse among children and young people using services;
Counselling is a key component of treatment in both contexts, although the exact significance of the term may vary. The review findings on 'culturally sensitive' counselling contrast with an apparent lack of ethnic or gender targeted services in Scotland;
The lack of evidence for other effective treatment types in Scotland (behaviour and family therapy, 12-Step programmes, therapeutic community and residential care) may partly reflect the low numbers of children involved in individual services and the pressure on professional time;
There is some limited evidence of the involvement of families, but these do not amount to structured family therapy programmes in the sense discussed in the review (which involve all relevant family members on a group or individual basis, focusing on family structures and/or interactions). In Scotland, DAT plans and recently established projects embody an increased awareness of the family dimension.
Review of the legal framework
The key legislation is the Children (Scotland) Act 1995. The review identified problems in implementing the statutory framework as regards:
upholding children's rights to health and health care;
upholding children's rights to participate in decisions;
upholding children's rights to consent to medical treatment;
sharing of information.
Problems included practitioners' lack of experience and confidence with the legal and ethical issues, the illegal status of drug taking as a deterrent to seeking help, and conflicts which can arise between the rights of children and those of parents.
Issues and effectiveness in current provision
The findings from the literature reviews were reflected in case study work which gave examples of practical issues in relation to:
planning a complete, integrated service;
applying appropriate 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.
DATs and practitioners, faced as they are with many existing demands, will need to continue to work in a number of areas to develop and implement effective services:
to establish a better understanding of the scale and nature of need;
to fill existing service gaps;
to promote awareness of rights and responsibilities and overcome legal or associated practical difficulties;
to plan and implement effective multi-agency working;
to support effective delivery.
This implies continued prioritisation of this area of policy in Scotland.