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 [email protected] 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

21 Tier 2 Purpose: Frontline of specialist services. Youth oriented services delivered by practitioners with specialist youth knowledge and some knowledge of drugs and alcohol Population: All young people, but in particular those with more problematic drug use or additional vulnerabilities Key Areas: Screening and assessment, Positive Futures, Named Drug Worker programme, drug prevention in secure units, Connexions, workforce development Key Gaps: Knowledge: effectiveness of targeted drug prevention interventions for school truants and excludees and young people in local authority care, pathways between service tiers Practice: pre-release preparation in many juvenile secure establishments DESCRIPTION APPROACHES AND INTERVENTIONS 5.1 The main aims of tier 2 service delivery are to reduce risks and vulnerabilities and reintegrate and maintain young people in mainstream services. 5.2 Professionals working in tier 2 services may include workers from CAMHS, education, voluntary youth services, social services, Connexions personal advisors, accommodation providers, YOT youth workers, counsellors and mentors. This also includes other professionals with a specialist remit working within universal services. Those practitioners with addiction skills should be incorporated into services rather than working in isolation. 5.3 Primary functions of services provided at this tier include carrying out a holistic assessment of the young person to clarify the degree of substance use problem in the context of other vulnerabilities. Clear referral pathways should be established with services provided at tiers 1 & 3. Tier 2 workers may also operate in a case worker role, ensuring continuity of care, including maintaining contact with the young person during their involvement with tier 3/4 services. 5.4 Interventions that may be provided at this tier include the provision of information and advice, and practical assistance with associated issues [for example, housing]. Tier 2 workers would also deliver targeted prevention programmes, including programmes to address offending. Other interventions delivered may include outreach, crisis support, generic counselling, family support and other appropriate therapies [e.g. family therapy]. 5.5 The aims of tier 2 provision require a specific focus on vulnerable young people. Particular consideration needs to be given to provision for the following 'at risk' groups: children of problem drug users; persistent truants and school excludees; looked after children and young people in contact with the criminal justice system [DfES et al., 2005], as well as other vulnerable young people, including those that are homeless or at risk of sexual exploitation. This corresponds with the vulnerable young people Key Performance Indicators [see Table 3] and the government response to the Hidden Harm report [ibid.]. 5.6 In order to avoid unnecessary duplication, the reader is referred to Drug prevention among vulnerable young people [Edmonds et al., 2005, available from for more detailed discussion of evidence-based interventions targeted at vulnerable young people. This report identified a paucity of robust evaluations of interventions although approaches described include the use of communications to target an excluded audience, training of care workers in drug use issues, a whole community approach to tackling drug use problems among a Black & Minority Ethnic [BME] community and guidance related to drug education for those excluded from school. 5.7 Only evidence not included in the previous report will be considered here. The lack of government-sponsored research into effective drug prevention among school excludees and looked after children means there is little to add to earlier discussions. Due to the work of the YJB much of the available recent literature focuses on young offenders. An evaluation of a Sure Start project to help children of problem drug users is also considered. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 21

22 Screening and Assessment Positive Futures 5.8 Britton and Noor [2003] argue that a holistic assessment of a young person's needs should be undertaken which can identify drug and alcohol needs, and this identification and assessment should be a 2-tiered approach. Referral can then be made to specialist drug and alcohol treatment providers to undertake comprehensive assessments of drug and alcohol use and misuse, and determine appropriate interventions to meet these needs. Assessment should be a continuing process to reflect the dynamic nature of a young person's drug use [YJB, 2004]. As drug use is often only one type of risky behaviour exhibited, it is important that screening takes place in the context of the wider health and social needs of the individual Positive Futures is a national social inclusion programme using sport and leisure activities to engage with disadvantaged and socially marginalised young people. As the approach was examined in 'Drug prevention among vulnerable young people' [Edmonds et al., 2005, available from only the most recent research is presented here and the reader is referred to the earlier briefing for further details. The programme aims include reconnecting marginalised young people with local services and opportunities while ensuring that the complex needs associated with problematic substance misuse are addressed. This links well with the aims and purpose of tier 2 service provision. 5.9 Among the young offenders in custody, ASSET was the most common screening tool [Dillon et al., 2005]. However, a comparison of prevalence rates from a variety of samples indicated that young people may not fully declare their substance use during ASSET interviews or medical screenings [YJB, 2004]. Disclosure is shown to be affected by the presence of parents at interview, the young person's relationship with the screener, and uncertainty around confidentiality and timing of interview [young people were perceived to be less willing to disclose at pre-sentence report stage] [Dillon et al., 2005; YJB, 2004]. Alternative or complimentary tools include the Assessment of Substance Misuse in Adolescents [ASMA] screening instrument [Willner, 2000], which is a modified version of the Substance Misuse in Adolescence Questionnaire [SMAQ]. ASMA has been proposed as a screening instrument for problem drug use in adolescents, including those not already identified as drug users While ASSET aims to provide a holistic view including offending behaviour and educational experience, non-dependent, but problematic, use of drugs can be overlooked, particularly if it is not related to a young person's offending behaviour. Counselling, Assessment, Referral, Advice, and Throughcare [CARAT] 13 substance misuse assessments are more comprehensive. However, they occur only if the young person volunteers to see the CARAT worker or has an obvious problem identified by other screening methods. The ASSET tool is designed to be used as part of a continuing process, however there is little evidence of this occurring [YJB, 2004] Evidence suggests that some staff undertaking screening or assessment work lack sufficient knowledge of drugs to be able to identify risky practices among young people [YJB, 2004]. Hammersley and colleagues [2004] have suggested that the quality of the forms used is of secondary importance to the quality of the staff doing the assessment Preliminary findings from case study research suggested that less formal referral mechanisms are more effective at engaging the more at risk, disengaged young people than formal referral systems, for example, pragmatic outreach approaches, opening access to projects and making use of informal relationships with a network of partners [Crabbe, 2005] There should be an emphasis on long-term engagement, with pathways for development identified. Routes of progression from user, to volunteer, to paid worker may offer the ideal pathway. While no evidence is presented that project staff are seen as role models, those that have progressed through the projects to become employees may, as peer support workers, capture the imagination of other young people and demonstrate realisable goals [Crabbe, 2005] Recently, inclusion of substance misuse interventions has increased. Interventions are typically delivered as part of a joint effort between specialist agencies and the lead Positive Futures agency, although interventions are increasingly being delivered in-house as confidence is increased through training and greater involvement of the D[A]ATs. Interventions include basic information provision, informal advice, drop in centres and other more creative methods, for example film making [Home Office, 2005]. There has been no assessment made of the overall or relative effectiveness of this multifaceted approach Positive Futures has been described as having had some success in developing links with tier 1 services. The profile of Positive Future's has been raised within local secondary schools, encouraging schools with young people at risk of disengaging to link with Positive Future's community based work. The programme has reported success in educational reintegration; between February 2004 and October 2004, 493 young people participating in Positive Futures projects on a regular basis returned to full-time education, almost 2,500 were doing better at school and over 500 had shown other educational improvements [Home Office, 2005] The Positive Futures approach relies heavily on the skill of the workforce and their ability to engage and identify with the young people. Flexibility is required to engage with young people on their own terms and act as cultural intermediary. Relationship building may be assisted by the competency of the worker in the activity delivered but is more likely to be associated with socio-cultural background and approach of workers [Home Office, 2005]. 13 CARAT services were made available across the secure estate from October 1999 and are part of the Drug Interventions Programme [DIP] The services are commissioned by the Prison Service and are provided by substance misuse specialist treatment services and are designed to provide treatment and support for problematic drug users while in custody. 22 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

23 5.18 The Workforce Quality Initiative has been introduced to provide training around five different areas; youth work, sport, project management, delivering quality service and substance misuse, to ensure that individuals working on projects have the knowledge, skills and personal qualities needed be effective in their roles. With the involvement of the Sector Skills Councils, this initiative has now emerged as the industry standard for vocational training in the sport-base social intervention sector [Crabbe, 2005]. The national occupational standards covered by the substance misuse training are: recognise indications of substance misuse and refer individuals to specialists; raise awareness about substances, their use and effects; support individuals who are substance users; assess and act upon the immediate risk of danger to substance users; enable children and young people to be supported by substance misuse services; contribute to the prevention and management of aggressive and abusive behaviour [Home Office, 2005] The training evaluation suggests that the level of staff expertise and confidence in relation to dealing with aggressive and abusive behaviour and issues associated with substance misuse in particular was significantly raised [Home Office, 2005]. Named drug workers 5.20 The aim of the Named Drug Worker [NDW] programme is to reduce drug use and related offending among young people. All young people who are in contact with a Youth Offending Team [YOT] should be screened for drug use as part of their initial assessment. Where specific drug use is identified or suspected the NDW will carry out a more detailed assessment and identify interventions appropriate to the young person's needs [Dillon et al., 2005] There was no clear evidence presented that the initiative reduced drug use, reported changes in drug use included both increased and decreased use. However, successful impacts on offending were only evident if a reduction or cessation of drug use had occurred. The programme was perceived to have had a positive impact on YOT officers' awareness of drug use issues, improving screening for drug use and leading to more appropriate referrals and interventions. The key to effective implementation of the scheme was the establishment and communication of clear policies and procedures to all those involved [Dillon et al., 2005] A good drug worker was characterised by young people as having credible drugs knowledge, being approachable, reliable and non-judgemental, respecting confidentiality and caring about them. Confidentiality was found to be the most influential factor [Dillon et al., 2005] Factors positively affecting voluntary referral included; perception of their own drug use as problematic, desire to appease YOT officer, desire to increase knowledge around the implications of their drug use and feelings of obligation. Nervousness about the encounter and a lack of understanding of the programme negatively impacted on engagement [Dillon et al., 2005]. Juvenile secure estate 5.24 The YJB funded a study of substance use in the juvenile estate [YJB, 2004], which highlighted several issues around tier 2 service provision It is suggested that while the juvenile secure estate is child centred [one of the 10 key principles of working with young people, see appendix 1] in relation to the law, there was evidence of some underestimation of the psychological differences between young people and adults. Engaging young people and responding effectively to their needs is unlikely to be achieved through the adaptation of adult approaches [YJB, 2004] In some cases concerns about risk superseded the views of the young person and resulted in inappropriate treatment that did not fit the young person's motivational stage, risking disengagement. Few programmes were identified that were designed to increase the young person's motivation to change [YJB, 2004] Little evidence was presented of the transition between service tiers within custody. While some drug users stated that they preferred to learn about drugs issues in PHSE classes, as it avoided stigmatisation as a drug user, there was little evidence that these sessions were used to motivate young people to engage with more specialist services. It was suggested that further training in the four tier model and effective practice may be required in order to help staff to understand how their role fits into the wider four tier framework [YJB, 2004] It was suggested that teaching young people how to reduce or cease their use of legal substances may give them skills to resist or better manage their use of illicit drugs. However, at present, there is a lack of effective smoking cessation and alcohol related interventions for this population [White and Pitts, 1998]. Furthermore, the relationship between use of different types of drugs, and attitudes and perceptions of use, is not simply a function of a substance's legal status YJB has developed a national qualifications framework to address training needs. Training provision is mapped against the National Occupational Standards.Youth Justice National Occupational Standards include five units specific to substance misuse: assess children and young people's use of substances and the effect of these on their lives; enable children and young people to be supported by substance use services; enable others to develop their knowledge and skills about substance use and its effects in the interests of children and young people; enable children and young people to address their substance use; raise awareness about substances, their use and effects [DrugScope & Colin Wright Associates, 2004]. CARAT 5.30 Two thirds [68%] of young offenders interviewed were satisfied with the service provided by CARAT 14 teams. However it is difficult to evaluate the system as a whole as there is a lack of standardisation. Complaints around the service suggested that there were not enough workers to cope with demand, and workers complained that they spent too much time on issues such as resettlement or benefits [YJB, 2004]. It was also suggested that the model of provision might be flawed as it allows the Young Offenders Institute [YOI] to abdicate responsibility for the young person's substance related needs. 14 See footnote 13 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 23

24 Throughcare 5.31 Pre-release planning is inadequate in many institutions. There is a lack of involvement of the young person in this process and while all juveniles are supposed to have a named drug worker less than one third of the sample of recently released offenders reported that they had been informed about this. One fifth of those interviewed spoke of going on post-release celebratory binges. While some adult prisons have pre-release drugs awareness sessions aimed at reducing the risks of overdose, there was no evidence of a targeted pre-release interventions for juveniles at risk of harm from post release bingeing. There is also inadequate opportunity to continue interests developed in custody, few of the diversionary interventions aimed at at-risk youth are available to those following custody [YJB, 2004]. suggested included fast tracked nursery placements to provide routine and a safe environment for the child and one to one support for children while the parent attended a group session with facilitated play between parent and child afterwards [Barnard et al., 2003]. This would support the aims of the Hidden Harm agenda [DfES, 2005a]. Connexions A customer satisfaction survey found that while some young people who used the service felt that Connexions had had an impact through increasing awareness of the options available, overcoming educational difficulties or providing practical help and support, some respondents were unaware that Connexions dealt with issues aside from education, training and employment [Joyce et al., 2003] The Drugs Intervention Programme for children and young people was launched in 2003 to pilot arrest referral schemes for young people aged and on charge drug testing of year olds in 10 pilot sites. Drug treatment and testing requirements have been introduced to action plan orders and supervision orders in 5 of the pilot sites. Early evaluation findings for the initiative highlighted the following issues for further development of the schemes: a clear focus on the scheme objectives is required, interventions need to be embedded into the practice of police custody staff, how the arrest referral scheme will operate with other agencies but be considered in order to facilitate case management roles, clarity is needed on the legal requirements relating to the role of parents/appropriate adults in drug testing or arrest referral contacts in custody, and it must be ensured that the young people being engaged are the intended target population [Matrix research and consultancy, 2005]. Project based work 5.33 A national evaluation of drug and alcohol projects funded by the Youth Justice Board [YJB] development fund found that many of the projects experienced operational difficulties due to rushed design, or implementation without a thorough understanding of local needs. Key points identified as contributing to successful project establishment included engagement of stakeholders and negotiation of protocols for information sharing, referral, confidentiality and working practices, a well managed workforce of appropriate size and experience, data collection to monitor progress and use of suitable accommodation. Interventions that were highlighted as not working well with young offenders were: group work rather than individual counselling, outreach work and arrest referral [Hammersley et al., 2004] The Youth Matters white paper [DfES, 2005b] outlines plans to withdraw funding from Connexions and redirect it to local authorities in order to facilitate a more integrated system in line with the principles of Every Child Matters. However, high performing Connexions services are expected to be retained. GAPS AND INCONSISTENCIES Practice 5.38 There is a lack of involvement of the young person in pre-release planning in many institutions including targeted pre-release interventions for juveniles at risk of harm from post release bingeing Across the juvenile estate there is a lack of low intensity motivational work for users who opt out of structured treatment [YJB, 2004]. Knowledge 5.40 There is a need for examination of young people's pathways between service tiers There is a need for investigation of the use of child centred approaches to support young children whose parents are problematic drug users As described by Edmonds and colleagues [2005], there is a lack of research on successful targeted drug prevention interventions for school truants and excludees and young people in local authority care. IMPLICATIONS AND RECOMMENDATIONS 5.34 The evaluation concluded that there is a substantial demand for substance misuse services and that these projects can impact on substance use and offending by some young offenders. However further research involving the use of control groups would be useful to substantiate and quantify this [Hammersley et al., 2004] A study considering the potential role of Sure Start 15 in working with families affected by problematic parental drug use identified that parents are the main focus of efforts made by Sure Start Local Programmes to support families with drug misuse problems. It is suggested that limiting the intervention to the parent may not be enough to assist the children. Possible child centred interventions Practice 5.43 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] 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]. Characteristics underlying perceived Positive Futures successes should be empirically tested and not simply assumed on an intuitive level. 15 A national programme for families with young children 16 The Connexions service was established in response to recommendations made by the Social Exclusion Unit [1999] and DfEE [1999] to respond to a wide range of issues affecting young people aged 13-19, including drug use and associated problems. 24 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

25 5.45 A change in culture is needed within juvenile secure units towards a child centred approach. Simple adaptation of adult approaches should be avoided and more child friendly policies and protocols adopted [5.25] ASSET should not form the basis of prevalence rates or treatment plans [YJB 2004] [5.9]. Knowledge 5.46 Improvements are required in pre-release preparation in many juvenile secure establishments. The process should involve the young person and include meetings between YOT named drugs worker and young person; sessions for parents, including how to support their child and where to go for help; and targeted prevention programmes aimed at reducing the risks of post-release celebratory binges [5.31] In the first instance, 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. The provision of low intensity motivational work for users who opt out of structured treatment may also help maintain engagement [5.26] In their review of the literature on the impact of parental problem drug use on children, Barnard and McKeganey [2004] suggest more rigorous evaluation of prevention interventions is needed. In particular, the use of child centred approaches to support young children whose parents are problematic drug users warrants further exploration to build on the work of Barnard and colleagues [2003] and Bauld and colleagues' work [2004] [5.35] 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]. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 25

26 Tier 3 and 4 Purpose: Services provided by specialist teams to respond to the complex needs of the young person. Population: 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 may be referred to tier 4 services Key Areas: Pharmacological management; harm reduction services; crisis intervention; psychological interventions Key Gaps: Knowledge: There is a general paucity of studies regarding young people's tier 3 and 4 service provision DESCRIPTION 6.1 The purpose of tier 3 services is to respond to the complex and often multiple needs of the young person and not just those in relation to their substance use problems. An additional purpose is to help reintegrate the young person into their family, community, school, training or work place. 6.2 Tier 4 services are aimed at providing specialist intervention[s] and settings for a particular period of time and for a specific function, as an adjunct to, and backstop for, the services provided in tiers 1-3. Only a very small number of young people will have a need for this type of intensive intervention. 6.3 Tier 3 services are delivered by multi-disciplinary teams, tailored to meet the specific needs of the young person and capable of responding to problems of high complexity. Teams are likely to include mental health, paediatric and addiction specialists working in close collaboration with education, social services and YOTs. Practitioners and agencies involved in the delivery of tier 4 services include child and adolescent addiction specialists and forensic mental health services, social services, paediatrics, and the voluntary sector. 6.4 At tier 3, a comprehensive assessment and formulation of an overall care plan should be undertaken. Tier 3 services involve the delivery of a spectrum of interventions and all substance use interventions should be set within the context of integrated and comprehensive packages of care. 6.5 Essentially, tier 3 services should be accessible and appealing to young people with multiple access points, linked with the voluntary sector, outreach teams, YOTs, CAMHS, health providers, Connexions and education and social services. Tier 3 services include the provision of multi-component, multi-faceted and multi-agency interventions for complex problems facing young people and their families. Interventions delivered are likely to include the provision of pharmacotherapy and ongoing monitoring, harm minimisation and uncomplicated detoxification. 6.6 Tier 4 services involve the delivery of particular interventions or focused work over short or temporary periods. The continuity of care is to be maintained through the continued involvement of tier 2 and 3 services before, during and after admission to treatment. The majority of children and adolescents engaged in heavy drug use and attending specialised services will have multiple problems, which tier 4 services should be in a position to recognise and treat, as well as responding to child protection issues and other dangerous situations [HAS, 2001]. APPROACHES AND INTERVENTIONS 6.7 Due to a lack of government sponsored research, and a lack of material from the wider evidence base, considering young people requiring the types of services covered by tiers 3 and 4, the information here is mainly summarised from two guidance documents; Substance of Young Needs Review [HAS, 2001]; and Young people's substance misuse treatment services - essential elements [NTA, 2005a]. Evidence from research into adult services is presented where relevant. 6.8 The National Treatment Agency [NTA] will publish a briefing on what treatment works in young people in March 2006 [NTA website]. 6.9 While there is an absence of evaluations of tier 3 and 4 interventions for young people, some services are being provided either through dedicated young persons' services or through adult provision. According to National Drug Treatment Monitoring System 17 [NDTMS] data, 29,616 people aged and 6, year olds were reported as in treatment in 2003/04 [NTA, 2005d]. Before April 2005, reporting to NDTMS was only mandatory for adult services Specialist drug and alcohol treatment providers should undertake comprehensive assessments of drug and alcohol use and misuse with support from other services in order to fully assess all aspects of the young person's needs and plan appropriate interventions [Britton & Noor, 2003] Assessment at tier 4 should add further depth to assessments carried out in tiers 2 and TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

27 6.12 Engagement and retention in treatment is important. A guide for retaining clients in treatment highlights the following interventions that have been shown to improve retention in adult substance users accessing services: encouraging reminders, motivational interventions to encourage engagement, quicker entry into treatment, client induction, and client escort. Reviews of adult services have shown that the relationship between drug users and their key worker/practitioner is one of the most important factors in retaining clients in treatment, and that this relationship should be established early in treatment [NTA, 2005c]. Pharmacological management 6.13 Evidence for effective pharmacological interventions to treat substance misuse in young people is lacking. The NTA will publish guidelines on prescribing in young people in October 2005 [NTA website] Pharmacological interventions should be used in conjunction with other types of therapy and be designed to meet the needs of the young person. Because of the difficulties in the pharmacological management of young people, issues of consent 18, parental involvement, confidentiality and competence of the prescriber should be addressed. Careful monitoring by trained staff and parents/carers should also be carried out [HAS, 2001] Factors to consider when making decisions about the pharmacological management of young people are: the level and type of social support an individual can access; individual engagement with substance misuse services; level of dependency and polydrug use; previous attempts to become drug-free; likelihood of use of alcohol or illicit drugs; likelihood to relapse or overdose; co-morbidity factors. [NTA, 2005a] An additional precaution to consider is that many young people will be engaging in treatment for the first time and may not have a full understanding of the risks associated with taking a controlled substance. Supervised consumption by a pharmacist may be supported by the involvement of other professionals engaged in prescribing to the young person to enhance safety measures [NTA, 2005a]. Box 3: Dual Diagnosis The term dual diagnosis covers a broad spectrum of mental health and substance misuse problems. Increasing rates of substance misuse are found in individuals with mental health problems and substance misuse is a major contributory factor in the development of mental health problems in young people. Most people with dual diagnosis report their first mental disorder occurred at an earlier age than their first substance disorder [Kessler, 2004] Treatment should be staged according to the individual's readiness for change and a flexible and adaptive approach adopted. Integrated treatment in the UK should be delivered within the mental health services following training and with close liaison and support from substance misuse services [Department of Health, 2002]. There is evidence of difficulties with engaging Child and Adolescent Mental Health Services [CAMHS] in cases of dual diagnosis. In a study of substance misuse in the juvenile secure estate, many of the prison staff and representatives from drugs agencies interviewed felt there was inadequate provision for dual diagnosis cases and less than half of the institutions returning the audit questionnaire had formal protocols for these cases. In many cases the input from CAMHS was seen as poor. For example, some CAMHS workers refused to engage with young people with a substance use problem and psychiatric work was often isolated from substance misuse issues [YJB, 2004]. The development of protocols for managing dual diagnosis in juvenile secure units may facilitate improved engagement with CAMHS. YOT workers have also found access to mental health provision outside the YOT to be problematic, especially if the health worker is not a member of CAMHS. It is argued that if substance misuse funding is to remain available for YOTs, health secondments may benefit from better links to CAMHS [Pitcher et al., 2004]. There is the potential for a gap in service provision for young people with dual diagnosis as many CAMHS services consider only children up to the age of 16, and those up to the age of 18 within full time education, while young people's drug services consider young people up to the age of 18. At present the 'best practice' is implementation of what works for adults with addiction and young people with psychiatric disorder [Crome, 2004]. This includes psychosocial interventions such as motivational enhancement techniques and cognitive behavioural treatment, as well as appropriate short-term use of a range of pharmacological agents. 17 The NDTMS monitors the number of people receiving treatment for drug problems and is the basis for monitoring the Government's 10 year drug strategy. 18 For more information regarding issues of consent and confidentiality see Box 2 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 27

28 6.17 There are a number of pharmacological agents available for the pharmacological management of young substance users including lofexidine, methadone, clonidine, and buprenorphine. The effectiveness of these agents is limited without additional psychological interventions and social support. A very small number of young heroin users may benefit from methadone stabilisation and slow reduction. However, for the majority of cases methadone maintenance is not generally advocated. The prescription of pharmacological therapies, such as naltrexone, as adjuncts in relapse prevention should be considered with caution and only by specialist services [HAS, 2001] There is an absence of evidence regarding the effectiveness of pharmacological treatments for young people. In addition, current evidence does not strongly support the use of any pharmacological treatments for adult stimulant [e.g. cocaine, amphetamines] users. However, the NTA advises that some treatments [e.g. dextroamphetamine and the use of selective serotonin re-uptake inhibitors [SSRIs] to alleviate withdrawal symptoms] used in specialist settings should be made available [NTA, 2003] Evidence from community-based adult services indicates that the strongest predictor of retention and completion of treatment may be related to the service [Miller et al., 2004]. Clients were most likely to drop out in the first two weeks, and younger drug users, males and those with no previous experience of treatment were at the highest risk for dropping out. Patients receiving a combination of substitute prescribing and counselling had better outcomes. Uncomplicated detoxification 6.20 The prescribing expert group established by the NTA recommend that lofexidine, methadone and buprenorphine should all be available as pharmacological therapies for detoxification in adult opiate users. Newer approaches to detoxification such as rapid detoxification under sedation or anaesthetic remain controversial [NTA, 2003]. No evidence was identified as to the use of these therapies with young people. Harm reduction services 6.21 Harm reduction services should be available for young people and this should include, but not exclusively, safer injecting advice [NTA, 2005a] Information should be provided in relation to a young person's needs on: safer drug use; safer injecting; blood borne viral transmission [e.g. HIV, hepatitis B and C]; hepatitis B vaccination; overdose prevention and responses to overdose; related sexual or physical health advice. [DrugScope & Colin Wright Associates, 2004] There may be a need to provide needle or syringe exchanges for under 16 year olds, in which case the following issues should be addressed: welfare of the young person; consent for the intervention is gained; parents/carers are involved; harm reduction is part of a care planned activity; the young person is aware of the risks of injecting and has the ability to understand these risks; there is an awareness of confidentiality issues and duty in relation to child protection [see Box 2]; procedures are in place to safeguard young people when necessary [NTA, 2005a] Evidence from adult services has generally been in favour of needle and syringe exchange facilities. They have been shown to reduce risky behaviour, such as frequency of sharing, and it is likely that they have contributed to the control of HIV among injectors [NTA, 2002]. However, needle exchange services for young people should not adopt the adult model of minimal information gathering and contact [DrugScope & Colin Wright Associates, 2004]. Psychological therapies 6.25 Psychological therapies, which may be relevant to the treatment of young drug users, include counselling, brief interventions, and individual psychological therapies, such as behavioural and cognitive approaches [HAS, 2001] Counselling and other psychological therapies should be planned and delivered as a specific treatment intervention. Goals should be set with regard to behavioural/emotional change related to substance use and should be regularly reviewed [DrugScope & Colin Wright Associates, 2004] Family therapy has been found to be effective in engaging and retaining adolescents in treatment and reducing their drug use. Evidence from adult services has shown that the combination of psychological treatments with pharmacological interventions [such as substitute prescribing] is often more effective than these treatments alone. In addition, psychological therapies may be effective in changing drug use behaviour in adults when substitute prescribing is not available e.g. cannabis, cocaine [Wanigaratne, 2005]. Brief Interventions 6.28 Young non-injecting stimulant users, who are not yet in contact with treatment services, may benefit from brief interventions. In a study comparing motivational interviewing with an 'information only' intervention, both improved outcomes such as frequency and intensity of stimulant use [_<12 months] as well as increasing knowledge of local treatment services [Marsden et al., 2004] McCambridge and Strang [2004] found that single session motivational interviewing could be used simultaneously to target the use of a number of different drugs among young people. Benefits were gained mainly through the moderation of drug use rather than cessation. 28 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

29 Tier 4 interventions 6.30 The NTA is working with local authority and voluntary sector children's homes to establish which services are able to support a young person with substance misuse problems, in tandem with tier 3 specialist services. This might include a consideration of accessing mainstream support for the delivery of tier 4 services, by applying tier 3 provisions in a mainstream residential setting [NTA, 2005a] A national survey of retention in adult residential rehabilitation services showed that retention and drop out rates can be predicted at a service level, and that services can be structured to improve retention rates. Factors associated with better client retention in services surveyed were fewer beds, less housekeeping duties, higher service fees and between 1-2 hours per week of individual counselling. Higher rates of single room occupancy and higher ratios of staff to clients were also associated with improved retention profiles in participating services [Meier, 2005] Tier 4 services are not solely about rehabilitation or dependency, they should address issues of safety, security or respite and be flexible services that are commissioned or purchased around the needs of young people. Consideration should be given to each young person's individual situation [NTA, 2005a] Interventions should follow a comprehensive assessment and be part of an overall care and management plan, adapted to the intensity and complexity of the presenting problems. Interventions which come under tier 4 services might include 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. They may include parental and family support and guidance, as well as motivational and brief therapies, counselling, and may then move onto intensive therapies such as more structured family therapies, individual psychological and pharmacological therapies. Interventions should take into account factors such as educational needs, family attachments, physical and psychological health, any child protection concerns, sexual and physical health, peer relationships, and psychological distress [HAS, 2001] Currently, no government-sponsored research has been undertaken which has assessed the needs and outcomes of young people requiring the types of specialist services delivered by tier 4 services Young people should preferably stay in their community, referral should only be made to a distant residential rehabilitation unit where local services cannot meet the needs of the young person, and in agreement with specialist drug and alcohol services. If placed in residential treatment, clear arrangements should be made for the young person to return to the local community and this should include provision for consistent drug and alcohol treatment and/or relapse prevention [Britton & Noor, 2003] Findings from adult services indicate that inpatient detoxification may be of benefit to adults who are socially unstable, severely dependent, have co-existing medical or psychological problems or who have failed one community-based detoxification. There is evidence that inpatient units facilitate adults who use multiple substances to achieve reductions in substance use. Factors that influence the likelihood of treatment success and improved outcomes for adults in inpatient detoxification are: length of stay, linking of detoxification with rehabilitation and aftercare, and provision of treatment in specialist facilities [Day, 2005]. GAPS AND INCONSISTENCIES Knowledge 6.38 There is a lack of research evaluating the effectiveness of tier 3 and 4 services for young people, including: needs of young people referred to tier 4 services; effectiveness of harm reduction strategies in reducing risk-taking behaviour in young problematic substance users, the literature covers alcohol but not illegal drug use; factors determining successful retention, outcomes and relapse prevention, e.g. importance of routes of referral, social engagement, family and peer support The relative effectiveness of pharmacological agents for the management or uncomplicated detoxification of young substance users and the ability of services to provide crisis intervention also need considering, however, these issues are part of the ongoing NTA work programme No research has been undertaken which has examined what methods or interventions may be useful for helping young substance users reintegrate into their community following treatment. IMPLICATIONS AND RECOMMENDATIONS Practice 6.41 Psychological therapies, in combination with other interventions, may be relevant to the treatment of young substance users. In particular, family therapy has been shown to be effective [6.27] 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] Guidance suggests prescribing of pharmacological interventions to young substance users should be undertaken with caution and only after full consideration of the individual's circumstances. Issues of consent and parental involvement should be addressed [6.14; 6.15] The NTA recommends that harm reduction services are available to young people, preferably separate from adult services [6.21; 6.22] No one method of detoxification is effective for all adult drug users and even successful detoxification is often followed by lapse or relapse [Griesbach, 2004]. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 29

30 Knowledge EXAMPLES OF PRACTICE 6.45 Evidence suggests that brief interventions may successfully reduce young people's drug use. This should be further explored to determine whether general lifestyle assessment and information provision alone may achieve positive changes in drug use [6.28] 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 [ ] Due to the lack of evidence for the delivery and outcomes of tier 3 and 4 services to young people the following section briefly describes four examples of different approaches to the delivery of these services to young people. These examples are drawn from the following document: Key Elements of Effective Practice - Substance Misuse [DrugScope and Colin Wright Associates, 2004]. NB These services are not presented as, nor are they intended as, best practice examples but are an example of how services at tiers 3 and 4 might be organised. 30 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

31 Table 4: Examples of tier 3 and tier 4 practice PROJECT INTERVENTION SUMMARY The Zone, Dudley Provides a range of interventions on substance misuse for young people including prescribing interventions. Prescribing is not offered in isolation and the young person may only engage in a prescribing programme in conjunction with a contracted care plan. Buprenorphine is prescribed by daily, supervised consumption and parents/guardians are contracted to supervise the weekend doses. Methadone prescribing is available at the service, but only in extreme circumstances. The stabilisation period is negotiated in the client's treatment plan, between the young person and their key worker to allow the young person time to adjust to buprenorphine and to engage in relapse prevention work. The programme is reviewed weekly. Urine samples are taken to ensure that the young person is using their prescription properly and is not using illicit substances in addition to their prescription, or selling or giving away their prescribed substances. Know the Score, Rotherham Prescribing in this service is undertaken by child and adolescent psychiatrists. A range of medications is available according to clinical need including methadone, buprenorphine, lofexidine and naltrexone. Medication is carefully prescribed and available to those over 14 years. Doses are tailored to body mass and titrated. The majority of service users who receive medical interventions are aged over 16 years and a significant number receive treatment with methadone. The rationale of the service is stabilisation leading to reduction and abstinence. There is no set programme for reduction; the programme is based on how a young person reacts to the reducing dose. Community Harm Reduction for Young People [CHRYP], Surrey Tier 3, community-based service for young people [21 years and under]. The service provides a young person-centred service [separate and distinct from adult services] delivered by specialised workers. Each young person has an allocated key worker, and a care plan, which includes access to support and counselling. The majority of service users receive a methadone prescription, with a larger proportion receiving maintenance or stabilisation prescription than undergoing detoxification. Buprenorphine, lofexidine or hypnotic medication prescriptions are also available. Richmond House, Norwich The service offers a broad range of interventions, including prescribing, and an aim of the service is to maintain contact and involvement with the young person after prescribing is discontinued. Prescribing is not initiated until there is a good understanding of the young person, their competence to consent to treatment, pattern of use and motivation to change. Clinical services are provided as part of the mental health care trust. If a prescribing service is required, a consultant psychiatrist specialising in addictions conducts the work, with support from a child and adolescent psychiatrist. Buphrenorphine is the main drug prescribed. Methadone is available for those with a clinical need. The rationale of the service is reduction but some young people will have breaks from reducing, and stabilise on a dose for a period of time. Generally, the process of reduction takes between 6 and 9 months. Each young person is regularly reviewed, receives daily pick-ups and has a prescribing contract. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 31

32 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 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS Updated Drug Strategy [2002] Home Office Tiers1-4, Criminal Justice System The national drug strategy [2002] does not directly refer to the young persons' tiers. However, it is acknowledged that drug problems do not occur in isolation and that therefore a range of agencies including schools,youth Offending Teams [YOTs], social services, Local Authorities [LAs] and Primary Care Trusts [PCTs] will need to work together. The role of referral between agencies is highlighted and the need for a range of universal and targeted resources is stressed. Section 1 Every Child Matters [2003/04] Department for Education & Skills [DfES] Young people's services, tiers 1-4 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. Integrated service delivery for children and young people's services is to be achieved through the establishment of children's trusts, based in local government but involving a range of agencies to commission integrated services. Relevant services commissioned by Drug [and Alcohol] Action Teams [D[A]ATs] are to be included in this process. Workforce issues central to the successful implementation of the four tier model are also highlighted, 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. Section 3 [Change for Children] 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. Choose not to take illegal drugs is an objective of the Be Healthy aim. 32 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

33 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS Young People and Drugs. Every Child Matters: Change for Children [2005] DfES Young people's services, tiers 1-4 Explains how those responsible for young people's services and drugs services are to work together to achieve the aims of the Updated Drug Strategy and Every Child Matters. The approach has 3 main objectives: reforming delivery and improving accountability; ensuring provision is built around the needs of vulnerable young people; building service and workforce capacity. Local priorities and targets for the development and operation of responses to children and young people's drug use should be jointly agreed by Directors of Children's Services [or equivalents] and Drug Action Team Chairs with all partner agencies fully engaged in the planning process. The need to implement interventions supported by evidence of effectiveness is stressed. Drug education, advice and information, prevention through access to core services, social inclusion programmes, early assessment, care management, integrated information systems, specialist treatment and services for families are all identified as necessary. Building workforce capacity through the introduction of the common core of skills is outlined. Youth Matters [2005] DfES Young people's services, tiers 1-4 Consultation document for strategy for reforming young people's [age 13-19] services. Although there is little reference to drug prevention or treatment, the aims support those of the four tiered approach. The four main areas of work are to be around engagement of young people in positive activities, community involvement and volunteering, provision of information and advice and intensive support for those who need it. One of the aims is 'making services more integrated, efficient and effective'. Clear assessment processes to be introduced and lead caseworkers for each individual. Also highlights the need for strong links between universal and targeted interventions. Sections 2, 6 & 7 Choosing Health [2004] Department of Health [DH] Healthcare services, tiers 1-4 While Choosing Health makes little direct reference to drug prevention or treatment, or to local service delivery or pathways through/between services, the integrated planning and service delivery for young people through Children's Trusts is highlighted and the need for linked up services for children and young people is stressed. Section 3 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 33

34 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS NTA Business Plan 2005/06. Towards treatment effectiveness [2005] National Treatment Agency for Substance Misuse [NTA] Primarily tiers 3 & 4 This plan sets out key achievements made since 2001 and provides timetables for action on key areas of delivery.young people are one of the areas of work. See Context section for targets related to young people. It is acknowledged that in order to achieve treatment aims the NTA has to work closely with a range of departments, agencies and organisations. Section 4 Treatment is described as a journey rather than an event and this is broken down into four overlapping stages: treatment engagement, delivery, completion and community integration. Actions to be taken to achieve targets in each of these areas are presented. Government's response to Hidden Harm [2005] DfES Tiers 1-4 Sets out how the government plans to respond to the recommendations made in the Hidden Harm report, the Advisory Council on the Misuse of Drugs [ACMD] inquiry into the needs of children of problem drug users. There is an emphasis on multi-agency collaboration, data collection, service provision, training and raising the profile of the issue. Although many of the recommendations are to be delivered across tiers the emphasis on early intervention and integration fit well with the model. Young people's substance misuse treatment services - essential elements [2005] NTA Primarily tiers 3 & 4 This guidance provides an overview of what is expected to be delivered locally by D[A]ATs, substance use and young people's services including models of delivery, specific intervention types and availability and performance management. The main emphasis is on flexible joined up working using the integrated care pathways through the four tier approach. The need for services to work together to establish integrated pathways, provide services at the lowest possible tier, make appropriate referral, maintain contact after referral, share information and work in virtual teams is stressed. The main emphasis is on service provision at tiers 3 and 4. Sections 2 & 3 Details are provided of the types of interventions that should be accessible to all young people with substance misuse problems by 2006, including comprehensive assessment within 5 days of referral, care planned interventions to respond to identified need, harm reduction services, family support, psychosocial interventions, community based pharmacological intervention within 10 days of referral and access to specialist residential treatment services. 34 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

35 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS First steps in Home Office Primarily tier 1, This guidance highlights the responsibilities of all Sections 1-4 identifying some tier 2 professionals working with young people in relation to young people's identifying substance related needs, providing a substance framework for identifying substance related needs related needs within existing assessment procedures. [2003] The young persons' tiers are described and used to show how practitioners fit into service delivery for children with substance use problems. The Young Persons' Substance Misuse Plan [YPSMP] provides the foundation for joined up local approaches to developing children's drug services within a broader context of service delivery. The need to ensure that YPSMPs consider all tiers is highlighted. The identification of substance misuse problems is represented as a multi agency responsibility. Examples of local screening tools are included in the guidance and explain how and when referrals should be made. The expected response to identified need is explained including provision of or referral to tier 2-4 services or referring to a tier 2 case worker to manage this process. Assessing Home Office Drug [and The aim of this guidance is to help D[A]ATs to carry Sections A, B, D local need: Alcohol] Action out assessments for the development of YPSMPs. Planning Teams It is recommended that consideration of the tiered model services for [D[A]ATs] may aid the analysis of service provision, and the young people importance of the local availability of services across all [2002] four tiers is stressed.the need to consult widely to carry out the assessment of local need is stressed. When considering drug service co-ordination it is recommended that the level of co-operation and integration is assessed and plans made to fill any gaps. Although the need to assess the pathways between service tiers is not expressly suggested assessment of referral, screening and assessment from tier 1 services is recommended. Young People's Substance Misuse Plans: DAT guidance [2001] Home Office D[A]ATs While perhaps a little outdated now, this guidance explains the process of developing plans, their relationship with funding streams and associated initiatives.the tiered model is the basis for the framework employed. Sections 3-5 Each D[A]AT was to provide an annual young persons'substance misuse plan in order to plan for, deliver and monitor the four tier model of service provision. The importance of the development of services in each tier in conjunction with each other is stressed to ensure that services are not overloaded or underused. YPSMPs are seen as the foundation for a more integrated approach, integrating substance misuse services with wider children's services.the need for involvement of a wide range of agencies in the development of the plan is also stressed. TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 35

36 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS Drugs: DfES Schools, tier 1 This guidance makes recommendations for schools Sections 1-3 Guidance for and 2 services on how to deal with drugs incidents, deliver drugs Schools [2004] education, identify drug use problems and respond appropriately. The tiered model is used to place the work of the school in a wider drug prevention context. The need for a holistic approach is noted. The role of schools role as a tier 1 service is acknowledged and they have a responsibility to provide drug education and pastoral support while identifying young people with additional needs and responding in school or through appropriate referral. Extended schools may have the capacity to respond to a young person's substance misuse needs and provide tier 2 services, these may include counselling, behaviour support plans and inter-agency programmes. Teachers need to link effectively with tier 2 and 3 services. Identifies some potential referral pathways when a drug problem is identified including working with YOT named drug workers. National Service DfES, DH Primarily Establishes common standards to facilitate joined up Standards 1, Framework for healthcare working. As the framework has been developed as 2 & 4 Children, Young professionals part of the Every Child Matters Change for Children People and programme multi agency working is a central focus Maternity of these standards. As with the four tier model the Services [2004] emphasis in relation to substance use is on 'Promoting health and well being, identifying needs and intervening early' [standard 1] and 'supporting parenting' [standard 2]. Standard 4 'Growing into adulthood' identifies the contribution that can be made to targets set in the Updated Drug Strategy [2002]. Principles for substance misuse education and support are set out including the need for a holistic approach, preference for meeting needs through mainstream services, support for complex needs and young people specific services. 36 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

37 TITLE LEAD DEPT / AGENCY TARGET AUDIENCE SUMMARY PARTICULARLY RELEVANT SECTIONS National DfES Schools, Outlines principles for school based drug education Sections 1 & 3 Healthy School tier 1/2 and standards that form one of the eight themes Standard: Drug contributing to the National Healthy School Standard education [2004] [NHSS]. Section 1 of 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; planned drug education programme; policy for managing drug related incidents; staff understand their contribution to drug strategy; work with police, youth service and drug agencies. Table of minimum criteria, quality standards and indicators for evaluation is included. Identifies link to and role within the four tier model. Further information can be found at a DfES/DH website designed to disseminate information on NHSS and provide information on health and young people. Common DfES All young Aims of the Common Assessment Framework [CAF] Assessment people's are to support earlier intervention, improve multi-agency Framework services. working and reduce bureaucracy for families. [2005] Primarily CAF consists of a pre-assessment checklist, process for tier 1/2 undertaking the assessment and a standard form, and is designed to help practitioners carry out assessments in a more consistent manner. It is intended that, after training, all agencies working with children and young people will adopt the CAF. While not necessarily addressing the issue of drug use, the holistic nature of the assessment should enable all problematic issues to be identified. A revised CAF will be issued in early 2006 and all local authority areas will be expected to implement the approach between April 2006 and the end of During 2005/6 all areas should be working to prepare for this. During 2005/6 some LA areas are implementing the framework and this learning will be incorporated into the revised version in TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 37

38 Discussion 7.1 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]. 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 examines the effectiveness of a multi-agency approach. Findings were mixed, highlighting positive impacts of the approach as well as a range of concerns. 7.2 While there was little reference to the four-tiered model in the reviewed literature, there was evidence of service provision that embraced the approach [for example, Positive Future's 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 was highlighted as a concern. Governmental guidance suggests that for these young people, integrated treatment should be delivered within the mental health services following training and with close liaison and support from substance misuse services. However, among a sample of prison staff and drugs agencies working with young offenders the input from CAMHS was seen as poor. The need for protocols for managing dual diagnosis was identified and the role of caseworkers in trying to bring together this work was highlighted. There is also inconsistency in the ages at which young people are considered as such, with potential for overlap and gaps in provision. For example, some CAMHS services consider only children under the age of 16 while young people's drug services consider young people up to the age of Sure Start Local Programmes [SSLPs] found difficulties arose between adult focused drugs services and the child and family oriented services [Barnard et al., 2003]. Several YOT and CARAT workers expressed frustrations with the number of agencies that they were required to liaise with [YJB, 2004]. Development of joint protocols between agencies, that define roles and responsibilities, could facilitate more systematic partnership working [Barnard et al., 2003]. One multi agency centre may be the most appropriate way to co-ordinate services for young offenders [YJB, 2004]. 7.4 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 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. 38 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

39 Appendix 1 Ten key policy principles for young people's service provision 1 A child or young person is not an adult. 2 The overall welfare of the individual child or young person is extremely important. 3 The views of the young person are of central importance, and should always be considered. 4 Services need to respect parental responsibility when working with a young person. 5 Services should recognise the role of, and co-operate with, the local authority in carrying out its responsibilities towards children and young people. 6 A holistic approach, taking account of psychological, physical and social factors that can affect a person, is vital at all levels as young people's problems tend to cross professional boundaries. 7 Services must be child-centred. 8 A wide range of services should be provided. 9 Services must be competent to respond to the needs of the young person. 10 Services should aim to operate according to the principle of good practice. [SCODA & CLC, 1999] TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE 39

40 Appendix 2 ACRONYMS ACMD Advisory Council on the Misuse of Drugs BME Black & Minority Ethnic CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CARAT Counselling, Assessment, Referral, Advice, and Throughcare CSCI Commission for Social Care Inspection D[A]AT Drug [and Alcohol] Action Team DANOS Drug and Alcohol National Occupational Standards DfES Department for Education & Skills DH Department of Health HAS Health Advisory Service HDA Health Development Agency HMIC Her Majesty's Inspectorate of Constabulary KPI Key Performance Indicator NCCDP National Collaborating Centre for Drug Prevention NDTMS National Drug Treatment Monitoring System NDW Named Drug Worker NHSS National Healthy Schools Standard NICE National Institute for Health & Clinical Excellence NTA National Treatment Agency for substance misuse Ofsted Office for Standards in Education PCT Primary Care Trust PF Positive Futures PSA Public Service Agreement PSHE Personal Social & Health Education SCODA Standing Conference on Drug Abuse WHO World Health Organization YJB Youth Justice Board YOT Youth Offending Team YPSMP Young People's Substance Misuse Plans 40 TIERED APPROACH TO DRUG PREVENTION AND TREATMENT AMONG YOUNG PEOPLE

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44 National Collaborating Centre for Drug Prevention Centre for Public Health Liverpool John Moores University Castle House North Street Liverpool L3 2AY ISBN Centre for Public Health