Engaging young people in treatment for a sufficient length of time and ensuring their involvement in the therapeutic process is almost universally endorsed as central to achieving program or intervention delivery (Brannigan et al., 2004; Crago, Wigg, & Stacey, 2004; De Rosa et al., 1999; Henderson et al., 2008; Henderson et al., 2007; Henggeler, Pickrel, Brondino, & Crouch, 1996; Kazdin, 1990; McKay, Stoewe, McCadam, & Gonzales, 1998; Pead, Virins, & Morton, 1999; Waldron, Kern-Jones, Turner, Peterson, & Ozechowski, 2007). Evidence suggests that young people who remain in treatment do better than those who drop out, regardless of the level of impairment (Gilvarry, 2000).
Thus consensus-based lists of the characteristics of effective AOD treatment programs include employment of focused engagement and retention strategies (Brannigan et al., 2004; Henderson et al., 2007).
Access to services and continuity of care are widely understood as critical components of effective youth AOD service provision.
Young people in general are less pro-active than adults in seeking treatment for health concerns, particularly psychosocial concerns. Studies of service utilisation for substance use and mental health problems generally find that adolescents have lower access or utilisation than adults (Sawyer & Patton, 2000).
For young people experiencing serious disadvantage and contending with a range of co-occurring health and behavioral problems issues around access to services are highly complex.
Previous or current involvement with statutory authorities is highly prevalent for youth with AOD combined with other psychosocial difficulties, but contact with this particular component of health and social care systems does not necessarily translate into appropriate or adequate access to other parts of these systems such as AOD and mental health services. Young people in child protection and youth justice systems tend to have higher rates of AOD and mental health problems than the general population (Aarons, Brown, Hough, Garland, & Wood, 2001; Aarons et al., 2008; Chassin, 2008; Dworsky & Courtney, 2009; Keller, Salazar, & Courtney, 2010), as well as higher rates of service use for these problems (Keller et al., 2010; Ungar, 2005a). However, studies have found unacceptably high proportions of young people with AOD and mental health problems in these systems who are not receiving appropriate services (Chassin, 2008; Dworsky & Courtney, 2009). It is well documented that adolescents’ substance use problems often go undetected by service providers in youth justice, primary care, mental health, education and social service systems (Ozechowski & Waldron, 2010). Furthermore, two studies have found a dramatic decline in use of mental health services as young people exit child protection systems (Dworsky & Courtney, 2009; McMillen & Raghavan, 2009). These findings highlight the important contribution of mechanisms such as protocols to facilitate smooth transitions between service systems such as child to youth and youth to adult.
More generally there is a body of opinion that many youth with complex needs miss out on the types of services they need relative to youth with less complex needs (Barry, Ensign, & Lippek, 2002; Busen & Engebretson, 2008; Crome, Christian, & Green, 2000; Muck et al., 2001; Statham, 2004; Ungar, 2005a; Waldron et al., 2007). In particular, several studies have found that homeless youth have very high rates of substance use and mental disorders, but very low rates of access to these services relative to need (Busen & Engebretson, 2008; De Rosa et al., 1999; Rosenthal, Mallett, Milburn, & Rotheram-Borus, 2008).
Effective youth AOD services ensure that services are accessible to all young people who need them. Strategies include:
- Providing multiple and varied points of entry to services
- Taking referrals from a variety of sources
- Using outreach as a pro-active approach to making initial contact with potential clients. This can involve practitioners conducting regular visits to ‘hot spots’ where young people at risk of alcohol and other drug related harm tend to gather.
- Maintenance of strong links with potential referrers including Child Protection and Youth Justice Services. This can include early engagement in joint care planning to facilitate effective engagement with young people subject to statutory referrals for AOD treatment.
- Maintaining a presence in local communities and service networks to ensure that the range of youth AOD services and how they can be accessed are clearly understood.
For more information on creating accessible services and programs that engaging young people effectively see the toolbox module on ‘Engaging’
Ensuring that young people are engaged and retained within services for a sufficient period of time to benefit from their involvement requires more than accessibility and engagement strategies at the level of individual services. Young people with multiple and complex needs frequently fail to receive some of the assistance they need even when they are engaged with one or more services. For this reason, providing a variety of different services or programs in a single location is well recognised as an effective strategy for enhancing access and continuity of care for young people with complex needs (Meade & Slesnick, 2002).
Where possible youth AOD providers offer a continuum of services including outreach, day programs, residential withdrawal and residential rehabilitation. Each of these components needs to be accessible if young people are to engage and obtain maximum benefit from what is on offer. Providing a continuum of services
The practice wisdom and health services research literature provides strong consensus that care coordination or case management is critical to the ongoing engagement of young people with complex needs, including AOD issues (Schuetz & Berry, 2009). Strong referral networks, awareness raising, and collaborative links among ‘gateway service systems’ such as youth justice, mental health, child welfare, school counselling, and homeless support also help facilitate identification and referral of young people to AOD services (Ozechowski & Waldron, 2010).
Due to the complexity of issues experienced by many clients youth AOD services providers cannot cater for all of the needs that young people have. This requires a strong emphasis by youth AOD services on creating and maintaining strong links with other services and supporting clients to engage with other services.
Lack of advocates such as parents or stable carers has been identified as one of the reasons why young people with complex needs often miss out on services (Statham, 2004), so the role of a key worker in advocacy is even more critical. Effective youth AOD services place particular attention on ensuring that young people are linked into ongoing supports before they come to the end of an episode of care.
A fundamental aspect of our approach to maximising continuity of care is a commitment to the therapeutic relationship and be prepared to work with young people over the long term. Patterns of response to therapeutic interventions vary dramatically. Bruun and Hynan (2006) have described the approach of practitioners in terms of a ‘guide’ who walks alongside the young person on their journey, helping them to find a path that suits them and to stay on track. This journey is often a long one and the guide needs to be prepared to ‘hang in’ with the young person over the long haul.