KIMBERLEY BURRELL LISA JONES HARRY SUMNALL JIM MCVEIGH MARK A BELLIS

Transcription

1 Tiered approach to Drug Prevention and treatment among young people KIMBERLEY BURRELL LISA JONES HARRY SUMNALL JIM MCVEIGH MARK A BELLIS Centre for Public Health

2 Contents ACKNOWLEDGEMENTS This work was funded by the Department of Health through the National Institute for Health and Clinical Excellence [NICE]. The authors would like to express thanks to all those organisations and individuals who have contributed to the production of this document. We are especially grateful to the Evidence Based Steering Group of the National Young People and Drugs Programme Board; Lynne Wilkinson [NCCDP]; Jason Grugan; Terry White; members of the NCCDP Network Group of drug prevention experts. CONTACT National Collaborating Centre for Drug Prevention, Centre for Public Health Liverpool John Moores University Castle House North Street Liverpool L3 2AY Lead Author Kimberley Burrell, Researcher tel: Additional Authors Lisa Jones, Researcher tel: Dr Harry Sumnall, Principal researcher tel: Jim McVeigh, Manager tel: Professor Mark A Bellis, Director m.a.bellis@ljmu.ac.uk tel: The views expressed are those of the authors, not necessarily those of the National Institute for Health and Clinical Excellence or the Department of Health. National Collaborating Centre for Drug Prevention Executive Summary Introduction The Tiered Approach Context Tier 1 Tier 2 Tier 3 & 4 Discussion References Table 1 Summary of young persons' substance misuse prevention and treatment tiers Table 2 Public Service Agreements Table 3 Key Performance Indicators Table 4 Examples of tier 3 and tier 4 practice Table 5 The four tiered approach to substance misuse prevention and treatment among young people in the key drug prevention and treatment policy and guidance Figure 1 Young persons' substance misuse prevention and treatment tiers model Figure 2 Pathways to Intervention Box 1 Every Child Matters Box 2 Consent and confidentiality Box 3 Dual diagnosis App 1 Ten key policy principles for young people's service provision App 2 Acronyms

3 Executive Summary EXECUTIVE SUMMARY The National Collaborating Centre for Drug Prevention [NCCDP] is undertaking a review of recent [ ] government sponsored research and policy related to drug prevention. The aim of the work is to encourage evidence based practice through the dissemination of research evidence to practitioners and commissioners and making recommendations to policy makers. This is the second 1 in the series of updates and considers the effectiveness of interventions within the context of the young persons' drug prevention and treatment tiers. AIMS The aim of this briefing is to describe the four tiered approach to drug prevention and treatment of young people; it's efficacy and relationship to current drug prevention policy; and within this context, to present evidence from recent government sponsored research into the effectiveness of interventions within each tier. Gaps in knowledge and practice are highlighted and recommendations made. This report is of particular importance to practitioners and commissioners working in young people's services, with relevance for those working in adult drugs services and policy makers. This is not intended to be a comprehensive review of research evidence for interventions at all tiers. STRUCTURE The first section explains the origins of the model before describing key concepts and practical application in detail. The second section places the tiered approach within the context of recent drug prevention policy and targets. Subsequent sections focus on each tier in turn. Tiers 3 and 4 are considered together, as tier 4 services are considered to be an adjunct to tier 3 provision. Within each of these sections the tiers are described in more detail and evidence from the review of government-sponsored literature relating to approaches and interventions is presented. IMPLICATIONS AND RECOMMENDATIONS Policy, practice and research implications and recommendations derived from the review are included in the relevant sections and summarised below. Readers are encouraged to consider these in the context of the evidence presented for each tier. 1 The first briefing, Drug Prevention among Vulnerable Young People [Edmonds et al., 2005], considered drug use and prevention interventions among specific groups of young people and is available at Tier 1 Practice: Standardised substance misuse training for tier 1 workers to be included in the Every Child Matters Common Core of Standards workplan [Box 1]. Effective teacher training is a strong predictor of success of school-based approaches [4.15]. An emphasis should be placed on ensuring effective and sustained teacher training [4.37]. While teachers should maintain overall responsibility for drug education, appropriate external contributors have a valuable role to play [4.20; 4.38]. Consideration should be given to drug prevention interventions at the transition between different levels of education [e.g. primary secondary] [4.33; 4.39]. The media has potential to help support the drug strategy, and specific drugs policies and services, so active media relations should be prioritised [ ; 4.41]. The use of media advocacy warrants further investigation, as it has the potential to contribute to community-level drug prevention efforts and to actively engage young people in local and community based projects [4.27;4.42]. Caution should be exercised when verifying the robustness of findings indicating that particular drug interventions had reduced self-reported drug use in young people as accuracy of self-report and level of recanting may be unknown [4.7; 4.43]. Knowledge: There is a lack of evidence for the effectiveness of schoolbased interventions among primary school age children in respect of drug use behaviour [equivalent to Key Stages 1 and 2]; this should be explored [4.35; 4.44]. Multi-component programmes based on a social influence approach have shown the most consistent effects on reducing drug use. Research is needed to elucidate effective features of multi-component programmes and their applicability to UK practice [4.10; 4.45]. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 3

4 Tier 2 Tier 3 & 4 Practice: Standardised training provision may help to ensure that tier 2 workers undertaking screening or assessment work possess sufficient knowledge of drugs to be able to identify risky practices among young people [5.11; 5.43]. Diversionary and social inclusion projects such as Positive Futures should place emphasis on long-term engagement and identify pathways for development for young people [5.14; 5.44]. A change in culture is needed within juvenile secure units towards a more child centred approach [5.25; 5.45]. Pre-release preparation in many juvenile secure establishments is inadequate and improvements are needed [5.31; 5.46]. In the first instance, unless there is immediate danger, services should respond to a young person's prioritisation of the substance use pattern they would like to alter, in order to foster motivation and maintain engagement [5.26; 5.47]. Young people may not fully declare their substance use during ASSET interviews or medical screenings [5.9]. Therefore ASSET should not form the sole basis of prevalence rates or treatment plans [5.48]. Knowledge: Child centred approaches to support children whose parents are problematic drug users warrant further exploration [5.35; 5.49]. Research is required into the effectiveness of targeted drug prevention interventions for school truants and excludees and young people in local authority care [5.42; 5.50]. Practice: Psychological therapies, such as cognitive behavioural therapy, in combination with other interventions, may be relevant to the treatment of young substance users [6.27; 6.41]. Younger drug users, males and those with no previous experience of treatment have been shown to be at higher risk of dropping out of treatment programmes. Emphasis should be placed on retaining young people in treatment [6.19; 6.42]. Prescribing of pharmacological interventions to young substance users should be undertaken with caution and only after full consideration of the individual's circumstances [6.14; 6.43]. Harm reduction services should be available to young people, preferably separate from adult services [6.21; 6.44]. Knowledge: Further research is needed in the use of brief interventions to reduce young people's drug use [6.28; 6.45]. There is a general paucity of research regarding young people's tier 3 and 4 service provision in the UK. An emphasis on the evaluation of current practices is recommended and in particular, tier 4 service provision for young people [ ; 6.46]. DISCUSSION The four tiered model of young persons' substance misuse services links well with current drug prevention and treatment policy as it embraces the multi-agency approaches advocated by Every Child Matters [DfES, 2003], the Updated Drug Strategy [Home Office, 2002], and Choosing Health [DH, 2004a]. KNOWLEDGE GAPS There is a lack of research into the effectiveness of service provision for young people, particularly in relation to services provided at tiers 3 & 4, including harm reduction services and pharmacological therapies. There is also a lack of research into service provision for particularly vulnerable groups, for example school excludees, cared for children, and those with a dual diagnosis. There is a need for research into the pathways and transitions between services provided at different tiers and between young persons' and adult service provision. Finally, there is a need for the effectiveness of multi-agency collaborative working to be explored. A key element of the four tiered approach is the ability of a range of agencies to work closely together to provide a seamless service. However, little research was identified that examined the effectiveness and processes of multi-agency approaches to working. There was evidence of interventions and programmes that embraced the approach [for example, Positive Futures [PF] being used to engage young people at tier 2 and reintegrate them into mainstream provision i.e. back into schools]. However, other literature identified areas where the model had not been adopted effectively and gaps were identified in service provision. In particular, support for young people with dual diagnosis [e.g. mental health problems], was highlighted as a concern. 4 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

5 Introduction 1.1 This briefing focuses on recent [ ] 2 government sponsored research, evaluation and policy related to drug prevention and treatment among young people [defined as under 25 year olds], and considers how this relates to the four tier young people's treatment model. Following Drug Prevention among Vulnerable Young People [Edmonds et al., 2005, available this briefing is part of a series forming a complete review of all recent evidence derived from government sponsored research and evaluation of drug prevention work. 1.2 It is the aim of this review to synthesise published research findings produced or sponsored by different government departments and bodies, in order to provide evidence-based recommendations and to highlight gaps in research, which require attention. The review process has proceeded in accordance with protocols established by the former Health Development Agency [HDA]. 1.3 A full methodology, which has undergone peer review by National Institute for Health and Clinical Evidence [NICE] research specialists, is available on request from the corresponding author. 1.4 The findings here must all be considered within the context of relevant policy, which is discussed on p16. Drug prevention and treatment among young people is a key element of the Updated Drug Strategy [Home Office, 2002]. In addition, the 2004 Spending Review [HM Treasury, 2004] Public Service Agreement [PSA] states that by 2008 there should be a reduction of use of all Class A drugs and the frequency of use of any illicit drugs among all young people under the age of 25, especially by the most vulnerable young people. To help achieve this, 65 million has been allocated for local delivery of the young people aim of the National Drug Strategy under the Young People Substance Misuse Partnership Grant [2004]. 1.5 The Every Child Matters, Change for Children programme aims to reform children's services, tackling not only substance use but also the risk factors that may promote it. 'Choose not to use Illegal Drugs' is part of the 'Be Healthy' objective. This work is closely linked to the Updated Drug Strategy and will contribute to the target above. The Every Child Matters Change for Children: Young People and Drugs strategic guidance outlines national expectations for local delivery of young people's substance misuse services [see 44/ECM_YPD.pdf]. 1.6 The Choosing Health agenda, while not specifically focussing on drug use, aims to reduce health inequalities and improve the provision of information and advice to vulnerable groups of young people. 1.7 While it is acknowledged that the four tier model relates to substance misuse [therefore including the use of alcohol and tobacco] among young people and that there is evidence [Tobler et al., 2000] that this inclusive approach may be beneficial, only the implications for the prevention and treatment of illicit drug use are within the scope of this work. 1.8 Whilst recognising that the evidence base is sparse, the National Treatment Agency for Substance Misuse [NTA] is developing a young people's strategy for completion by the end of 2005, and is likely to include a briefing document on care planning and retention; prescribing guidelines for community interventions [in partnership with the Youth Justice Board for England and Wales [YJB]]; guidance on assessing drug use; the production of a directory of residential services that work with substance misuse issues from both the generic children's field and specialist substance misuse services; the identification of appropriate criteria for referring a young person to residential care; and the identification of different forms of service provision that will enable CAMHS staff to contribute to the substance misuse system. 1.9 The report is divided into 5 sections. The four tier young people's prevention and treatment model is described and placed in the context of relevant policy and targets. The evidence base for interventions at each tier is then considered. This evidence is drawn primarily from recent government sponsored research related to drug prevention and treatment among young people as described, but as this is limited some appropriate adult literature has also been included. Relevant scientific or academic research has been incorporated, although UK studies are limited in number and scope and caution must be used when generalising from foreign [typically US] studies. Tiers 3 and 4 are considered together, as tier 4 services are considered to be an adjunct to tier 3 provision. Each section contains a summary box outlining key contents. As the model is intended to provide seamless service provision there will necessarily be some overlap between tiers A discussion is provided considering implications for drug prevention and treatment with young people. 2 Some policy and guidance documents published before 2002 have been included due to their continuing relevance to the subject area. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 5

6 The Tiered Approach Origins: Based upon a model used by Child and Adolescent Mental Health Services [CAMHS], adapted for substance misuse in Health Advisory Service [HAS] 1996 Description: Tier 1 Universal, generic or primary services Tier 2 Youth oriented services offered by practitioners with some drug and alcohol experience and youth specialist knowledge Tier 3 Services provided by specialist teams Tier 4 Very specialised services Target Audience: Both commissioners and practitioners working in the substance use prevention and treatment field. For example, Practitioners - role and responsibilities; Commissioners - as an audit and planning tool ORIGINS 2.1 It is acknowledged that many young people who develop problematic substance use have multiple antecedent and co-occurring mental health, social and educational difficulties. The tiered approach to the prevention and treatment of substance misuse among young people was originally introduced by the Health Advisory Service [HAS] in Children and Young People: Substance misuse services; The Substance of Young Needs [1996] in order to ensure more comprehensive and integrated service provision. 2.2 The model was first developed in relation to Child and Adolescent Mental Health Services [CAMHS] with the aim of integrating the elements of a comprehensive child and adolescent service and to enable workers to increase their skill base through the development of service networks [HAS, 1995]. The approach was introduced in Child and Adolescent Mental Health services: Together we stand. The commissioning role and management of Child and Adolescent Mental Health services [1995]. The four tier model was developed further by the HAS in Standards for Child and Adolescent Mental Health Services [2000]. 2.3 The approach was adapted to relate to substance misuse services to address the problem of children and young people falling between services, particularly between those services provided by the non-statutory sector and the social services departments and the National Health Service [HAS, 1996]. The white paper Tackling Drugs Together [Home Office, 1995] emphasised the need for multi-agency working and collaboration and established Drug Action Teams to be the facilitator. 2.4 The young persons' substance misuse tiers are used to model the full range of substance misuse services and interventions to be available to young people under the age of 19 and demonstrate how they relate to one another. The model has 4 tiers, explained in detail later. 2.5 In 2001, the HAS updated the model to reflect changes in policy, service delivery and increased knowledge about the treatment and prevention of substance misuse [The Substance of Young Needs Review]. The tiered approach was further developed and explained in detail. 2.6 The four-tier structure was also introduced for adult drug users [over 18 years of age] in 2002 by the NTA as part of Models of Care for the treatment of adult drug misusers [2002]. The similarity of the adult and young persons' tiered approach models, the overlap in target population [18 year olds] and an emphasis on the provision of services for those in transition from adolescence to adulthood [aged 16 to 21] [NTA, 2002] should help facilitate a smooth transition to adult services. 2.7 A consultation of the models of care approach is underway. A summary of the first stage of the consultation suggests support for the four tier model, 83.5% of respondents [majority from adult treatment service providers and Drug [and Alcohol] Action Teams] felt that it should be retained although 42% felt that there were some treatment modalities missing from the current model. More than half [58.5%] of respondents felt that models of care for young people should be developed as a separate document, a quarter [26.0%] thought the documents should be merged. DESCRIPTION 2.8 The tiered model is intended to be a flexible and dynamic framework that enables the components needed for an integrated and comprehensive young persons' service to be conceptualised [HAS, 2001]. The tiers should not be viewed as compartments as the model is designed to reflect an integrated service system. 2.9 The approach is intended to benefit both providers and commissioners working in the substance use prevention and treatment field. Utilising the model should enable providers to gain a greater understanding of the role and responsibilities of their own, and other agencies allowing for greater collaboration and avoiding duplication and professional rivalry. This approach is intended to facilitate skills transfer and enable practitioners to address the needs of young people in a more holistic manner. For service commissioners, the model can be used as an audit and planning tool to examine service provision and organisational relationships in order to provide comprehensive, integrated services. 6 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

7 2.10 The tiers may be summarised, albeit simplistically, as follows: Tier 1 Universal, generic or primary services Tier 2 Youth oriented services offered by practitioners with some drug and alcohol experience and youth specialist knowledge Tier 3 Services provided by specialist teams Tier 4 Very specialised services [HAS, 2001] 2.11 A detailed summary of the aims and key tasks for each tier, with a description of appropriate practitioners, interventions and target populations is available in table 1. Figure 1 is a schematic diagram illustrating the original four tiered model introduced in 1996, it is acknowledged that there may be overlap between agencies The ability of multiple agencies to work closely together to improve service provision is central to the tiered approach. However, despite intuitive benefits there has been little research into the effectiveness of multi-agency working. A study of professionals working as part of a multi-agency service for disabled children found that although concerns existed about the limited impact multi-agency working would have on the children and their families, staff were overwhelmingly positive about this collaborative way of working, reporting improvements in professional development, communication, service efficiency and relationships with the children and their families [Abbott et al., 2005]. In an examination of a multi-agency childcare network Wigfall and Moss [2001] identified one of the key challenges as finding and maintaining the balance between the autonomy of specific services and collective action as this was a difficult and delicate process The model is intended to respond to the specific needs of the young person. Over time, young people may need to access a range of services available at different tiers of service provision. However, services provided at tiers 1 or 2 should maintain continuity of care throughout in order to ensure a holistic approach to the young person's needs. Young people's needs should be met in the lowest possible tier in order to normalise the situation for the young person and avoid stigmatisation for them and their family. In particular, it is essential that health and education services at tier 1 continue to be involved Effective referral between services is crucial to the success of the four-tiered model. The Integrated Care Pathway [ICP] approach is increasingly used in many areas of health and social care in order to achieve comprehensive and integrated service delivery. An ICP is a description of the anticipated course of interventions that a young person may need [NTA, 2002]. Protocols detailing referral 'pathways' may help this process. Figure 2 is an illustration of a referral pathway produced by Standing Conference on Drug Abuse [SCODA, 1999] A package of interventions or care plan should be developed to respond to the specific needs of the individual and their family. The Substance of Young Needs Review [HAS, 2001] recommended the employment of a key/case worker approach to ensure delivery of comprehensive care plans and maintain continuity of care. The role is likened to that of the appointment of a social worker as case coordinator following children being placed on the child protection register. The key worker could be from any involved agency at tier 1 or 2, and would maintain contact with the young person and their family and review the care plan. The worker would need to be in regular contact with other involved agencies, through care planning meetings and/or working as part of a multi agency Young Persons Substance Misuse Team. Information sharing issues will also need to be considered All young people in substance misuse treatment should have a transitional care plan outlined before they reach the age of 18 and a nominated care co-ordinator. Service providers of adult and young persons' services should work together, and in association with mainstream services as required [NTA, 2005a]. It may be necessary for young people over the age of 18 to continue to access young people's services, if this provision is more appropriate for them It is important to ensure that there is a seamless fit between the young persons' substance misuse tiers and those of the CAMHS and Models of Care for adult drugs services. Services should always be provided on the basis of need, not on the criterion of age [NTA, 2005a]. Transition between youth and adult services needs to be carefully managed and the needs of the young person must be considered. The National Service Framework for Children, Young people and Maternity services makes recommendations for the transition to adult services as part of standard 4 Growing Up into Adulthood [DH, 2004b] There is an expectation that services from all tiers will be locally available for young people, although gaps have been highlighted in availability for specific populations and locations [e.g. rural areas, Cragg Ross Dawson, 2003; Henderson, 1998] Finally, the approach recognises the role of the family in young people's substance misuse with an emphasis on parental/carer/family involvement and support Please refer to Substance of Young Needs Review 2001 [HAS] for more in depth discussion of the approach. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 7

8 Table 1: Tiers summary - Adapted by National Collaborating Centre for Drug Prevention from Health Advisory Service 2001 TITLE TIER 1 TIER 2 TIER 3 TIER 4 SUMMARY Universal and generic. Frontline of service delivery with direct access for young people and their families Frontline of specialist services. Youth oriented services delivered by practitioners with specialist youth knowledge and some knowledge of drugs and alcohol Services provided by specialist teams Very specialised services AIMS & PURPOSE To ensure universal access to all generic services for young people and to identify those vulnerable to substance misuse issues To reduce risks and vulnerabilities, reintegrate and maintain young people in mainstream services To respond to the complex and often multiple needs of the young person, not just in relation to substance use problems. To reintegrate the young person into their family, community, school, training or work To provide specialist intervention[s] and setting for a particular period of time and for a specific function, as an adjunct to and backstop for the services provided in other tiers TARGET POPULATION All young people All young people, but in particular those with more problematic drug use or additional vulnerabilities Young people with tobacco, alcohol and drug problems that significantly interfere with other aspects of the individual's life. Multiple underlying problems often also exist Young people with complicated substance problems requiring specific interventions and/or care and protection PRACTITIONERS Include teachers, voluntary agencies, social services, police, school medical staff, GPs, nurses in primary care, potentially young people as confidantes and peer educators Include CAMHS, voluntary youth services, paediatric & psychology staff, Connexions personal advisors,yot drugs workers, and others with a specialist remit within universal services. Practitioners with addiction skills must be incorporated into services and not work in isolation Multi disciplinary teams tailored to meet the specific needs of the young person and capable of responding to problems of high complexity. Teams could include mental health, paediatric and addiction specialists working in close collaboration with education, social services and YOTs Include child/adolescent addiction and forensic psychiatry, social services, paediatrics and voluntary sector KEY TASKS Assessment of all young people for tobacco, alcohol, drug use and misuse & identification of those that are more vulnerable or at risk. Appropriate referral as necessary Holistic assessment of the young person, to clarify degree of substance use problem in the context of other vulnerabilities. Clear referral pathways and links with tier 1 & 3 services. Case worker role, including maintaining contact with the young person during involvement with tier 3/4 services Comprehensive assessment and formulation of an overall care plan. Delivery of a spectrum of interventions. All substance interventions set within the context of integrated and comprehensive packages of care Particular interventions or focused work over short or temporary periods. Continuity of care to be maintained through the continued involvement of tiers 2 and 3 before, during and after admission. Responding to child protection and other dangerous situations. Adding further depth of understanding to comprehensive assessments carried out at tiers 2 & 3 INTERVENTIONS Information and advice, health promotion, drug prevention programmes, support for young people and their families Proactive outreach [including use of non-professional staff, young people and communities to conduct outreach work], information and advice, practical advice on associated issues [eg housing], crisis support, delivery of targeted prevention programmes, appropriate therapies [e.g. family therapy], generic counselling Provision of multi-component, multi-faceted and multi-agency interventions for complex problems facing young people and their families. Pharmacotherapy provision and ongoing monitoring, harm minimisation and uncomplicated detoxification Inpatient adolescent units or forensic units supported by specialist young people's addiction teams, adolescent paediatric beds, intensive day centres, crisis management, specialised housing or fostering, multi component or highly intensive therapies that have a residential component, complicated detoxification and pharmacological interventions 8 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

9 Figure 1: Young Persons Treatment Tiers CHILDREN ADOLESCENTS PARENTS CARERS Tier 1: Universal and Generic SOCIAL WORKERS GPs HEALTH VISITORS TEACHERS SCHOOL MENTORS & PEER EDUCATORS POLICE NON STATUTORY AGENCIES SCHOOL MEDICAL STAFF HEALTH PROMOTION SERVICES NURSES IN PRIMARY CARE YOUTH JUSTICE SERVICES REFERRALS SELF REFERRALS Tier 2: Frontline and Specialist Services YOUTH WORKERS CHILD PROTECTION PSYCHO- THERAPISTS COMPREHENSIVE ONE STOP SHOP PAEDIATRIC & CHILD HEALTH SERVICES SOME TEACHERS E.G. IN PRUs SOCIAL WORKERS FROM CHILD & FAMILY SERVICES EDUCATIONAL PSYCHOLOGISTS NON STATUTORY AGENCIES SOME SCHOOL MEDICAL STAFF CONNEXIONS PERSONAL ADVISORS CAMHS HEALTH PROMOTION SERVICES ACCIDENT & EMERGENCY SERVICES PROBATION OFFICERS YOT WORKERS REFERRAL PROCEDURES AND PROTOCOLS SERVICE LEVEL AGREEMENTS CONTRACTS Tier 3: Services provided by Specialist Teams SECURE UNITS RESIDENTIAL UNITS SPECIALIST FOSTER CARE NON STATUTORY AGENCIES SPECIALIST NON STATUTORY AGENCIES SOCIAL WORKERS JOINT CLINICS SPECIALIST ASSESSMENT SERVICES CAMHS SUBSTANCE MISUSE TEAMS YOT DRUGS WORKER SOME INPATIENT SERVICES CARAT TEAMS IN JUVENILE SECURE UNITS OBSTETRICS FOR PREGNANT ADOLESCENTS REFERRAL PROCEDURES AND PROTOCOLS SERVICE LEVEL AGREEMENTS CONTRACTS Tier 4: Very Specialised Services SPECIALIST DRUG / ALCOHOL RESIDENTIAL TREATMENT &/OR REHABILITATION SERVICES ADOLESCENT FORENSIC MENTAL HEALTH SERVICES CHILD & ADOLESCENT INPATIENT SERVICES NEURO- PSYCHIATRIC SERVICES HEALTH SERVICE CRIMINAL JUSTICE SERVICES NON-STATUTORY SERVICES LOCAL AUTHORITY JOINTLY COMMISSIONED &/OR PROVIDED SERVICES Adapted from Health Advisory Service [1996] TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 9

10 Figure 2: Pathways to Intervention PROFESSIONAL REFERRAL SELF REFERRAL PARENTAL REFERRAL CHILD PROTECTION CONCERNS? CONFIDENTIAL INITIAL CONTACT AND DRUG EDUCATION PARENTAL ADVICE EXIT CHILD PROTECTION CONCERNS? CONFIDENTIAL ASSESSMENT INCLUDING PROPOSED TREATMENT INTERVENTION DRUG EDUCATION REFERRAL GO NO FURTHER UNTIL CONSENT FOR TREATMENT HAS BEEN GAINED CHILD PROTECTION CONCERNS? CONFIDENTIAL ASSESSMENT OF YOUNG PERSON S COMPETENCE TO CONSENT TO TREATMENT PARENTAL CONSENT TO TREATMENT TREATMENT CAN ONLY BE PROVIDED WITH PARENTAL CONSENT OR IF YOUNG PERSON IS COMPETENT TO CONSENT TO TREATMENT CHILD PROTECTION CONCERNS? CONFIDENTIAL TREATMENT INTERVENTION EXIT CHILD PROTECTION CONCERNS? CONFIDENTIAL REGULAR REVIEWS OF TREATMENT AND YOUNG PERSON S COMPETENCE TO CONSENT WHERE APPROPRIATE EXIT CHILD PROTECTION CONCERNS? CONFIDENTIAL CONTINUED INTERVENTION AND REGULAR REVIEWS Reproduced from Young People and Drugs [SCODA, 1999] 10 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

11 Context Policy: Few policy documents refer to young persons' substance misuse tiers but the approach links well with policy aims Targets: Public Service Agreement [PSA]: Reduce the use of Class A drugs and the frequent use of any illicit drug among all young people under the age of 25, especially by the most vulnerable young people. Key Performance Indicators [KPIs] for education, treatment and specific groups of vulnerable young people [school truants/excludees, young offenders and looked after children] POLICY 3.1 The four tiered approach to substance misuse prevention and treatment among young people must be considered within the context of relevant policy and guidance, in order to consider how the model links with broader delivery approaches and adult services. 3.2 There is little specific mention of the four-tiered young people's substance misuse model in the key policy documents relating to young people, drug prevention and treatment. This may be because young people or drugs are not the primary focus of the policy and as the approach is primarily related to local, rather than national, delivery. Drug [& Alcohol] Action Teams [D[A]ATs] develop plans and deliver services at a local level based on the four tiered model. However the principles of integrated service provision and multi agency working are integral to the policies highlighted. 3.3 All recent key policy documents recognise the need for a holistic response to drug prevention and treatment and the provision of an integrated system. In particular, this is fundamental to the Every Child Matters reform of young people's services. As described in the previous section, the four tiered model may be useful in conceptualising an integrated system and as an audit and planning tool to identify any gaps or overlaps in service provision. 3.4 The Updated Drug Strategy, Every Child Matters, and Choosing Health all require the collaboration of a range of agencies to deliver an integrated approach. The four tier model aims to facilitate multi agency working through improving agencies' understanding of their own role and responsibilities and that of other agencies which may facilitate greater collaboration and avoid duplication. The model relies on skilled staff able to work at all tiers, collaborate with others and make appropriate referrals. 3.5 Development of the workforce is a key element of Every Child Matters with the utilisation of Drug and Alcohol National Occupational Standards [DANOS] and the Common Assessment Framework to aid the early identification of problems [including drug use] through consistent assessment. First steps in identifying young people's substance related needs [Britton & Noor, 2003] illustrates the development of specific local tools for identification and assessment and adapting established identification processes to co-exist with other existing assessment procedures. 3.6 Every Child Matters Change for Children programme requires all people working within these services to have basic substance misuse knowledge and understanding within their core competences [DfES et al., 2005]. A Common Core of skills and knowledge for all those working within the children's workforce has been published [HM Government, 2005] and includes the following themes: effective communication and engagement with children, young people and their families and carers; child and young person development; safeguarding children and promoting the welfare of the child; supporting transitions; multi-agency working; and sharing information. 3.7 The development of services should be in line with the 10 key policy principles for young people's service provision [SCODA & CLC, 1999]. See appendix Table 5 summarises the key relevant policy and guidance and it's relationship with the young persons' substance misuse tiers. TARGETS Public Service Agreements [PSAs] 3.9 The Spending Review [HM Treasury, 2004] sets out crossdepartmental government targets for the action against illegal drugs, with the aim to reduce the harm caused by illegal drugs to individuals, their families and the wider community The primary target with relevance to young people is: Reduce the use of Class A drugs and the frequent use of any illicit drug among all young people under the age of 25, especially by the most vulnerable young people However, drug prevention and treatment among young people also contributes to the other two Action Against Illegal Drugs PSAs. Key Performance Indicators [KPIs] 3.12 In order to strengthen delivery and accountability and to support achievement of the PSA, KPIs for young people 2005/06 are set out in the drug strategy performance management framework. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 11

12 Box 1: Every Child Matters As the central focus of the Every Child Matters programme is on integrated commissioning and multi agency working at a local level, this links well with the young persons' substance misuse tiers. The four tier model aims to facilitate multi agency working through improving agencies' understanding of their own role and responsibilities and that of other agencies which may facilitate greater collaboration and avoid duplication. The tiered model relies on skilled staff able to work at all tiers, collaborate with others and make appropriate referrals. Development of the workforce is a key element of Every Child Matters, in particular, the need for a common core of skills, knowledge and experience among people working with children, including the ability to be able to identify, assess and respond to substance misuse problems among young people. Every Child Matters: Change for Children [2004] introduces the Common Assessment Framework [CAF], designed to standardise the way that young people's needs are assessed across agencies to aid multi-agency working in ensuring that all the needs are met. This could support the pathway that the young person takes through services. The need for universal, targeted and specialist services is discussed and the integrated approach could potentially ease transition between tiers. National Treatment Agency for Substance Misuse [NTA] targets 3.13 The recently published NTA Business plan 2005/06 [NTA, 2005b] outlines the NTAs objectives, performance indicators and actions for 2005/06. Those that are specifically related to young people are: By March 2008, the young people's treatment system will have expanded to engage at least 9,795 individuals during the year [a 50% increase on the 2003/04 baseline figure]. Key milestone 2005/06: The young people's treatment system will have expanded to engage at least 8,162 individuals during the year. Actions by March 2006: All local partnerships able to offer a comprehensive range of services to young people. Launch of young peoples' effectiveness strategy. Table 2: Public Service Agreements TARGET RESPONSIBILITY YOUNG PEOPLE Reduce the use of Class A drugs and the frequent use of any illicit drug among all young people under the age of 25, especially by the most vulnerable young people. Within the Home Secretary's overall responsibility for the drugs strategy, the Secretary of State for Education and Skills will take lead responsibility on policy for preventing young people from becoming problematic drug users and sharing responsibility with the Home Secretary for the target's delivery. GENERAL Reduce the harm caused by illegal drugs [as measured by the Drug Harm Index encompassing measures of the availability of Class A drugs and drug related crime] including substantially increasing the number of drug misusing offenders entering treatment through the Criminal Justice System. Increase the participation of problem drug users in drug treatment programmes by 100% by 2008 and increase year on year the proportion of users successfully sustaining or completing treatment programmes. The Home Secretary takes the lead with the support of the Secretary of State for Health, the Secretary of State for Education and Skills, the Economic Secretary to the Treasury and the Foreign Secretary. The Secretary of State for Health has lead responsibility. 12 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

13 Table 3: KEY PERFORMANCE INDICATORS [KPI] SERVICE AREA KPI LEAD DEPT / AGENCY INSPECTORATE NATIONAL TARGET UNIVERSAL Education Percentage of schools Department for Office for 100% of schools with more than achieving National Healthy Education & Standards in 20% pupils entitled to free Schools Standard 3 Skills [DfES] education [Ofsted] school meals to reach level 3 by 2006 [old Standard] Half of all schools to have achieved the standard by All schools 'working towards' the standard by 2009 INDICATED Truants/excludees To be decided 4 DfES Looked after KPI on substance misuse DfES Commission for children among looked after children Social Care under development. Inspection and Data collection to begin in Joint Area Review October The collection will cover identification, assessment and interventions Young Offenders Ensure that all young people Youth Justice Joint inspections 100% of partnerships reaching are screened for substance Board [YJB] including Audit the required level of performance misuse. Of those screened & NTA Commission, by March 2008 ensure that those with Specialist Commission for identified needs receive services Social Care appropriate assessment Inspection [CSCI], within 5 working days and, Her Majesty's following the assessment, Inspectorate of access the early intervention Constabulary treatment and services [HMIC], HM they require within Inspectorate of 10 working days Probation, Ofsted SPECIALIST SERVICES Treatment Specialist services DH/NTA Healthcare 50% increase by 07/08 compared Numbers of young people Commission with 03/04 aged 18 and under entering, receiving and completing treatment Adapted from DfES et al., The National Healthy Schools Standard [NHSS] accreditation process requires local health and education partnerships managing local healthy schools programmes to provide evidence of how the standards and components of the NHSS guidance are being met [ See Table 5 for further information. 4 DfES will explore the feasibility of developing a substance misuse KPI on truants and excludees, for implementation in 2006/07 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 13

14 National Drug Treatment Monitoring System [NDTMS] Local targets 3.14 All drug treatment agencies must provide a basic level of information to the NDTMS on their activities each month - known as the core data set. From April 2005, this requirement extends to include agencies dedicated to young people's service provision. For more information visit Drug Action Team Chairs and Directors of Children's Services or their equivalents should jointly agree priorities and targets for addressing the needs of children and young people affected by drugs and include these in both in the Children and Young People's Plan and Drug Action Team annual plan [DfES et al., 2005]. 14 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

15 Tier 1 Purpose: Universal drug education and interventions targeted at all young people, regardless of their level of risk. Any professional group with contact with young people delivers tier 1 services; specialist knowledge is not necessarily needed Population: All young people Key Areas: Effectiveness of curricular, media and information approaches; screening of young people; responses to drug use Key Gaps: Knowledge: effectiveness of school-based interventions among primary school age children; effective features of multi-component programmes and suitability for UK practice. Practice: drug prevention intervention provision at the transition between different levels of education; standardised substance misuse training for tier 1 workers DESCRIPTION Identification at tier Tier 1 services are generic and offer direct access, primary prevention [i.e. prevent or delay the onset of drug use] to all young people regardless of their level of individual risk. Services are mainstream and are concerned with education, information, health, and the identification of those who are at risk or vulnerable to drug use. It is the overall aim of tier 1 services to reduce risk and promote resilience to drug use. 4.2 There is diversity in the type of providers that deliver tier 1 services. In school settings, police officers, health professionals [drugs and alcohol service workers, specialist drug services for young people, school nurses], community groups, personal advisors from Connexions, theatre groups, ex-users, youth services, parents of former drug users and charities such as Life Education Centres have been used, as well as teachers and peers [White et al., 2004]. Other professional groups delivering tier 1 services include GPs, health visitors and health promotion services, Youth Justice services, and social workers. Social marketing approaches, which are a popular means of drug information delivery, use concepts and techniques derived from commercial marketing and rely on dissemination within peer and social groups through personal, social, and commercial networks [Bennett & Henderson, 1999]. The National Social Marketing Strategy for Health programme has been established to examine, review and propose ways to improve development, delivery and evaluation of health related social marketing activity in England [Department of Health & National Consumer Council, 2005]. 4.3 Tier 1 services such as substance misuse education, universal prevention, and substance misuse training for professionals working with young people can be funded through the Young People Substance Misuse Grant. Relevant minimum service requirements include supporting schools to achieve National Healthy Schools Standards [NHSS] level 3 [see 4.12]. 4.4 Locally commissioned screening and referral processes should proceed in consultation with local services and young people. Screening should be conducted when a young person requests advice for self or others on drugs, or if there is a drug related incident. Guarantees of confidentiality cannot be given, as the welfare of the child may be in question [see Box 2]. Confidentiality limitations may also differ according to position, for example a teacher may have to disclose information to a head teacher, while a school nurse may work within specific confidentiality guidelines. The screening procedure should be conducted by someone the young person feels confident talking with [e.g. a trusted teacher] and should provide information on drug related knowledge, patterns of use, risky behaviours, adverse consequences, and connection [if any] to other problematic behaviour. When the screening has been completed the young person should be asked to comment upon whether they feel that their current needs have been met or whether they would like further intervention [Britton and Noor, 2003]. 4.5 Every Child Matters: Change for Children [2004b] introduced the Common Assessment Framework [CAF], designed to standardise the way that young people's needs are assessed across agencies, to aid multi-agency working in ensuring that all the needs are met. This could support the pathway that the young person takes through services. Using the CAF as a screening tool may de-stigmatise substance misuse and puts young people at the centre of service delivery, addressing all their needs. During 2005/06 CAF will be trialled within local areas who decide, on a multi-agency basis, to do so. A revised version will be produced for April 2006, when all local areas should implement the Framework [DfES website]. A consultation has been undertaken to develop training materials [Training Advice Consultancy, 2005]. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 15

16 4.6 As a result of screening, appropriate action must be taken; the objective of the assessment is not to police drug use but to support the young person and ensure that their needs are being met. This may include provision of information and education [which should not be delivered in isolation], discussion with parents or carers, referral to tier 2 services and/or referral to children's services. Staff require training to ensure that they are able to pursue the most appropriate outcome. 4.7 Screening at tier 1 may also be affected by false reporting. In studies undertaken on behalf of FRANK, boys were twice as likely as girls to report that they had taken drugs when they had not [Social Issues Research Centre, 2004]. Seventeen percent of year-olds, 21% of year olds and 22% of over-16 year olds thought that their friends pretended to have taken drugs when they had not. Other recent research supports these findings [e.g. Siddiqui et al., 1999; Fendrich and Rosenbaum, 2003]. In samples of young people [mean age 12.5] in Northern Ireland, recanting [i.e. positive reporting of drug use that was later denied] of previously disclosed drug use was high one year later [ranging from 7% for alcohol use up to 87% for psilocybin containing mushrooms [Percy et al., 2005]]. The highest levels of recanting were in those young people who had received drugs education, which suggests caution when verifying the robustness of findings indicating that particular drug interventions had reduced self-reported drug use in young people. APPROACHES AND INTERVENTIONS 4.8 It is beyond the scope of this work to provide a thorough narrative of tier 1 approaches, but in initial attempts to build an evidence base, the HDA [now part of the National Institute of Health and Clinical Excellence [NICE]] published its Evidence Briefing [EB] for drug prevention among young people [McGrath et al., 2005; Canning et al., 2004], to which the reader is referred. It provides a review of tertiarylevel evidence 5 on drug prevention aimed at young people aged between 7 and 25. A summary of main approaches is included in the following sections, with emphasis placed upon education and media. 4.9 The National Collaborating Centre for Drug Prevention [NCCDP] will publish an Action Briefing on ways to implement the evidence base in practice and planning later in This will be of particular interest to those planning and delivering tier 1 services, and will be summarised in part in the next NCCDP briefing Many tier 1 programmes have more than one type of intervention. Multi-component programmes may combine school-based curricular interventions with school-wide environmental changes, parent training programmes, mass media campaigns, and/or community-wide interventions [Flay, 2000]. Multi-component programmes based on a social influence approach have shown the most consistent effects on reducing drug use [Canning et al., 2004; McGrath et al., 2005; Faggiano et al., 2005]. Few attempts have been made to elucidate effective features of multi-component programmes [Canning et al., 2004; Flay, 2000; Allot et al., 1999] Universal approaches generally receive little support from parents [Ofsted, 2005]. However, government-sponsored research [Velleman, 2000] has demonstrated that it is possible to engage parents in drug prevention activities. Parental involvement in drug prevention activities can be aided by establishing active networks with schools, local agencies, and community groups, delivering courses with a wide focus and having the flexibility to fit with parents commitments. Engaging hard to reach parents in drug prevention initiatives requires intensive and sustained outreach into the community [Mir, 2004]. Educational approaches 4.12 The drug education component of the NHSS outlines principles for school based drug education and standards that have to be met [Butcher, 2004]. Section 1 of the standard is related to multi agency working; section 2 developing appropriate systems; and section 3 delivering a whole school approach. Minimum criteria include having a named staff member and governor responsible for drug education; a planned drug education programme; a policy for managing drug related incidents; staff understand their contribution to the school's drug strategy; partnership working with police, youth service and drug agencies. However, the standards do not specify the level of training and competence required by named drug staff Drugs: Guidance in Schools suggests that school drug policies should proceed with guidance from parents, pupils, governors, police, D[A]ATs, and local schools drugs advisers [Department for Education and Skills, 2004a]. They should proactively prepare for drug incidents, so that they do not cause unnecessary detrimental effects to a young person's education Blueprint is a drug educational research programme developed by the Home Office, Department of Health and DfES. It is a multicomponented programme targeting pupils aged through work with schools, families, media, communities and health policies. The pilot involves 29 schools in the North West and East Midlands. Twenty-three schools have adopted an enhanced drug education curriculum, and the other six are acting as control schools, delivering their current education programme. The first research findings are expected in 2007 and may go some way to provide evidence for effective features of school based prevention in the UK As with all prevention providers, effective and sustained teacher training is a strong predictor of success of school-based approaches [Department for Education and Skills, 2004; Tobler and Stratton, 1997]. The Qualification Curriculum Authority [QCA] has developed standardised drug, alcohol and tobacco curriculum materials for Key Stages Predominantly included in science, Personal Social and Health Education [PSHE], and citizenship, the materials recommend teaching about nomenclature [terminology], health effects, social attitudes, legal implications, and peer pressures to take drugs. However, the delivery of these materials is not mandatory. Complimentary and general personal skills approaches have greater effects on drug use than specific programmes [Canning et al., 2004]. 5 Reviews and syntheses of existing systematic reviews and meta analyses 6 Key Stage 1: Ages 5-7; Key Stage 2: Ages 7-11; Key Stage 3: Ages 11-14; Key Stage 4; Ages For more information see: TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

17 4.16 In a small evaluation of pilots of the drug components of PSHE certification, teachers believed participation had improved their drug knowledge, understanding and skills [Warwick et al., 2004]. In contrast, teachers reported difficulty in generating evidence about the role of drugs in society, the use of local and national policies, drug effects, and support services available. At Key Stages 1 and 2, teachers had difficulties drawing links between drug use and sexual health. In general, teachers requested more support in identifying examples of good drug educational practice In an evaluation of stakeholder perceptions of the DfES Drug, Alcohol and Tobacco teacher training package [DATE] 7, school drug advisers saw their role as providing impetus to establish networks and facilitate activities. Teachers believed that such a network would bring about whole school changes to the planning and delivery of DATE [Warwick et al., 2004]. There is currently no independent evidence to indicate whether the beliefs held by this type of population are justified in practice Curriculum based programmes will be most relevant to a young person's life experiences by providing programmes during periods when most are experiencing initial exposure to drugs [Department for Education and Skills, 2004a]. World Health Organisation [WHO] guidance recommends planning interventions in two phases; early relevancy ensures that students gain information and skills at a time when they have most meaning; later relevancy phases are appropriate for times when prevalence of use and its context increase in later adolescence [WHO, 1998]. Reviews of drug prevention support this, and suggest that interventions should be age and culturally appropriate [e.g. Canning et al., 2004] Drama or theatre has been used in the UK as a method for drug prevention or education, and during the 1990s was identified as an innovative and popular approach to drug education by several government departments [Department for Education and Employment, 1995; Office for Standards in Education, 1997; Standing Conference on Drug Abuse, 1998]. Whilst there is a lack of wide ranging evidence from published literature with regard to the efficacy of these drama methods in changing health-related behavioural intentions, they appear to be relatively more effective at changing drug-related attitudes than information dissemination approaches [i.e. knowledge about the adverse effects of drugs, e.g. Canning et al., 2004; Denman et al., 1995; McGrath et al., in press], perhaps due to utilising the communication skills of professional actors. Theatre in Education is introduced into the National Curriculum via citizenship and PSHE, and new companies tend to offer education through young person's theatre [Sextou, 2003]. This type of approach is considered to be useful support for existing drug education, rather than a means in its own right [Starkey & Orme, 2001] DfES guidance [DfES, 2004a] suggests that while teachers should maintain overall responsibility for drug education, external contributors have a valuable role to play. White and colleagues [2004] found that in general, there is no difference in effectiveness between different types of external contributors who support school-based drug education [e.g. police, health workers]. This suggests that it is the preparatory and follow up work that is critical. Clear roles and expectations should be assigned to external contributors to ensure co-ordinated approaches which avoid duplication of effort and deliver consistent messages to the young people [e.g. police officers in schools should talk about legal and not health consequences of drugs]. External contributors should share and support the ethos of the organisation's prevention strategy. The value of external contributors appears to be the special knowledge that they have, and the novelty of their approach. Each type of external programme provider has the potential to make unique contributions to school drug prevention programmes. For example, children felt that peer-led group sessions created a natural and safe environment for honest dialogues, and peer educators from outside schools can be viewed as positive role models for the audience [ibid.] In a study exploring illegal drug use among pre-teenage children [aged 10 to 12], McKeganey and colleagues found that they held clear preferences in relation to the delivery of drug education [McKeganey et al., 2003]. Many children felt they lacked the skills necessary to refuse drug offers, and most wanted to know more about drug effects. They expressed a preference for interactive methods of delivery, involving the contribution of ex-users or external specialists. However, it is important to note that whilst this is a popular approach, no work has yet explored the effectiveness or the utility of ex-users. It is also likely that the more problematic experiences of such contributors, which often coincide with other life challenges, hold little relevance to most young drug users There is little work examining the effectiveness of primary prevention interventions such as the introduction of drug-trained sniffer dogs or random forensic testing in schools [comprehensively reviewed by McKeganey, 2005]. These type of approaches may undermine trust built up through effective school drugs policies and education. Ofsted [2005] reported that most schools did not wish to introduce such measures In an analysis of drug education in 60 primary and secondary schools in England and Wales it was concluded that the quality and effectiveness of drug education had improved since 1997 [Ofsted, 2005]. However, there were particular gaps. Whilst pupils' knowledge and understanding of illicit drugs had increased there was little consideration of associated behaviours, and the role of alcohol and tobacco in the recreational pharmacopoeia. Furthermore, many pupils reported that their needs were not being met by secondary schools at an appropriate level of detail and individuality. Many primary schools had failed to implement updated drugs curricula and policy. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 17

18 Media 4.24 FRANK is the Government's national communications campaign for drugs information in England and Wales 8 [Know the Score provides a similar service in Scotland] 9. Launched in 2003, and supported for three years in the first instance, FRANK allows local and regional drug services to provide drug initiatives in the context of a nationally recognisable brand. Since 2005, FRANK activities have become more closely aligned with drug prevention policies set out by the DfES, the Home Office, and Department of Health, and in particular the Every Child Matters Change for Children programme. The target audience for FRANK is to be extended to vulnerable groups of young people in 2005 [please refer to Edmonds et al., 2005, available from for detailed discussion of approaches in this population]. FRANK has not been subject to outcome evaluation, so it is not possible to discuss whether the campaign has had an effect upon drug using behaviours There are a wide range of media products, and sources are extremely diverse, including television, radio, DVD, video, books, posters, flyers, and magazines [either bearing the FRANK logo or not]. Most of the general population is exposed to a significant amount of information through the media every day and young people are no exception to this [Cragg, 2003]. International research suggests that media interventions, although popular with parents, are not effective in preventing drug use if they are used as a stand-alone intervention [Hornik et al., 2002]. They are generally useful for improving knowledge or inspiring public debate. More positive outcomes may be gained if they are included as a form of delivery in a multi-component drug prevention programme, although this has yet to be assessed Research findings revealed that the value of a good press relationship is widely recognised by media advocacy 11 organisations [Eadie et al., 2002]. The use of the media was regarded as a useful method to raise the intervention or agency profile, and assist in securing support from key stakeholders and investors. However, the level of pro-activeness with local media often varies between organisations delivering tier 1 services. Media can have a positive impact on decreasing unhelpful perceptions associated with drug use or users and may therefore increase engagement Negative attitudes towards the media held by some service deliverers appear to be strengthened by a perception most hold of a 'hard-line editorial position' on drugs. However, negative reporting often appears to be associated with weak media relations and a reluctance to reply to enquiries from the media, rather than the media's hostile attitudes towards drugs [ibid.] Case studies of D[A]AT media activities in the community have highlighted how local media environment and local authority cultures affect engagement and whether a high priority is placed upon public relations [Eadie et al., 2002]. Regardless of the community context and its media environment, engaging all local media in community wide drug prevention is beneficial [Canning et al., 2004]. D[A]ATS can provide a natural forum for a constructive dialogue between the media, professionals and community delivering tier 1 services, and centralised responses to reporting local drug issues. These types of strategies may help reduce the risk of negative reporting. Media training is valuable, when it focuses on building and maintaining relations with local media, as has been successfully demonstrated by some D[A]ATs [Eadie et al., 2002] In meta analytical 10 studies of the relative effectiveness of different media sources in the US, video was associated with the largest positive effect for three drug related outcomes [behaviour, attitudes and knowledge] [Derzon and Lipsey, 2002]. In addition, radio and TV were associated with a positive effect but not printed material. In contrast, the use of print was associated with a positive effect for attitude change but not for knowledge change. Self reported levels of drug use generally remain unaffected, and so there is a need to examine the relationship between knowledge, attitudes, and behavioural change Meta-analysis is a set of statistical procedures designed to accumulate experimental results across several independent studies 11 Media advocacy is the strategic use of resources such TV, video, radio and print to promote public debate, and generate community support for changes in community norms and policies 18 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

19 Box 2: Consent and Confidentiality Issues of consent and confidentiality in relation to young people span all four treatment tiers. CONSENT Consent is required for treatment, including counselling or other psychological intervention, and physical interventions including the provision of medication. Consent is not required for advice and information provision. Young people aged 18 or over are by law considered to be competent to consent to their treatment; those aged years are generally regarded as competent. Treatment should not proceed in children under the age of 16 without informed consent from either a parent or legal guardian. When a young person under the age of 16 requests treatment without parental consent an assessment of competency to consent must be undertaken, in line with Fraser guidelines 12. Failure to gain consent to treatment in law constitutes assault [Britton & Noor 2003]. For further information about consent to treatment when working with young people see Department of Health [2001] Seeking consent: working with children. CONFIDENTIALITY It is essential that a young person can engage with a service knowing that their confidences will not automatically be passed on. However services should be clear that they cannot offer absolute guarantees of confidentiality. Principles of confidentiality should be explained prior to identification or assessment conversations, and the consequences of the identification of drug use needs should be clearly explained to the young person. It is recommended that services restate the confidentiality policy regularly and check the young person's understanding of this. Confidential information should not be used against the child. However, professionals may need to share information in order to create a comprehensive care package, this should be on a 'need to know' basis only. It is also good practice to inform the young person prior to any confidentiality breach and if possible gain their consent. Confidential information should be disclosed to social services or the police if concerns exist that the young person may be 'suffering, or at risk of suffering, significant harm' as a direct result of their substance using behaviour. The following should be considered: the age and maturity of the young person, the degree of seriousness of drug misuse, whether harm or risk is continuing or increasing and the general context in which drug taking is set [Britton & Noor, 2003]. GAPS AND INCONSISTENCIES Practice 4.35 There is a lack of evidence for the effectiveness of school-based interventions among primary school age children in respect to drug use behaviour [equivalent to Key Stages 1 and 2] Many approaches favoured by tier 1 workers have been shown to be ineffective, unless delivered as part of a comprehensive approach [McGrath et al., 2005; Canning et al., 2004]. IMPLICATIONS AND RECOMMENDATIONS Practice 4.31 The PSHE curriculum has recently expanded, but not in proportion to the amount of allocated time. This has presented challenges to teachers in terms of preparation and delivery of effective drugs education No evidence of standardisation in training for tier 1 workers was identified There has been little consideration of the transition between different levels of education [e.g. primary secondary], despite young people having been shown to be particularly vulnerable during and immediately following this transition [e.g. Drugscope & Department of Health, 2000] The inclusion of standardised substance misuse training for tier 1 workers in the Every Child Matters Common Core of Standards workplan would help to provide the workforce with the core competence in substance misuse knowledge and understanding required as part of the Every Child Matters Change for Children programme. A common understanding may improve agencies' ability to work together to provide an integrated service [Box 1] An emphasis should be placed on ensuring effective teacher training as this is a strong predictor of success in school based drug prevention approaches [4.15]. Knowledge 4.34 There is little research examining the relative effectiveness [e.g. outcomes and cost] of tier 1 approaches in the UK [McGrath et al., 2005; Canning et al., 2004]. However, the Blueprint evaluation [see 4.14] may contribute relevant knowledge. 12 Fraser guidelines suggest that young people under 16 have a right to confidential medical advice and treatment if the provider assesses that: the young person understands the advice and has the maturity to understand what is involved, their physical and/or mental health will suffer if they do not have treatment, it is in their best interest to give such advice/treatment without parental consent, the young person will continue to put themselves at risk of harm if they do not have advice/treatment, the young person cannot be persuaded by the doctor/health professional to inform parental responsibility holder[s], nor allow the doctor to inform them. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 19

20 4.38 External contributors may have a role to play in school based drug education approaches, however, teachers should maintain overall responsibility and ensure a consistent message is delivered. The utility, or otherwise, of ex-users in this work has not, as yet, been established [4.20] Caution should be exercised when verifying the robustness of findings indicating that particular drug interventions had reduced self-reported drug use in young people as accuracy of self-report and level of recanting may be unknown [4.7] Consideration should be given to drug prevention intervention provision at the transition between different levels of education [e.g. primary secondary]. If screening and assessment are introduced at this stage it may also be possible to identify those most at risk while avoiding stigmatisation [4.33] Establishing active networks with schools, local agencies and community groups may help to engage parents in drug prevention activities. Flexible courses with a broad health focus may help to maintain parental involvement [4.11]. Knowledge 4.44 The effectiveness of school-based interventions among primary school age children [Key Stages 1 and 2] in respect of drug use behaviour should be explored. Recent US research [Freeman, 2005] has begun to explore young children's [aged 7-8 and years] attitude toward, beliefs about, and life-style associations with cigarette smoking. This could potentially provide a model for similar research to be undertaken with regard to substance use in order to help inform the development of effective interventions for primary school age children [4.35] The media has potential to help support the drug strategy, and specific drugs policies and services. National bodies and Government departments have an important role in setting the communications agenda and public debate climate, as regional papers are highly interested in stories and events that make the national press [ ] The use of media advocacy warrants further investigation, as it has the potential to contribute to community-level drug prevention efforts and to actively engage young people in local and community based projects [4.27] While findings suggest multi-component programmes based on a social influence approach are the most consistent in reducing drug use, UK-based evaluations of drug prevention initiatives should be undertaken in terms of outcomes and costs. The Blueprint project may go some way in addressing this problem. Research is also needed to elucidate effective features of multi-component programmes [4.10]. 20 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE