Young people experiencing harms from alcohol and drugs: literature and evidence review

4. Children and Younger People and Treatment and Recovery Services in Scotland

4.1 Alcohol and Drug Treatment and Recovery Services for Younger People in Scotland

4.1.1 Provision of Alcohol and Drug Services in Scotland

The provision of alcohol and drug treatments services in Scotland follows a tiered model (a full description of these tiers are provided in Appendix I).

Pathways for Children (0-18 years)

NHS Scotland Child and Adolescent mental Health Services (CAMHS) form the core of referral and treatment pathways for problematic alcohol and drug use among children and young people (under 18 years of age) in Scotland. CAMHS are multi-disciplinary teams who provide assessment and treatment or interventions for children and young people experiencing mental health problems, including substance use. These CAMHS are provided within a stepped and matched, tiered care model (Figure 4.1)^[102]

Figure 4.1 – Tier Model for Treatment by NHS Scotland CAMHS

• tier 4 (highly specialised inpatient CAMH units and intensive community treatment services).
• tier 3 (specialist multidisciplinary outpatient CAMH teams)
• tier 2 (a combination of some specialist CAMH services and some community-based services including primary mental health workers);
• tier 1 (universal services consisting of all primary care agencies including general medical practice, school nursing, health visiting and schools);

Source: ISD Scotland 2020

Pathways for Younger Adults

Alcohol and drug treatment services for adults are also delivered through the tiered model detailed in Appendix I. Specialised alcohol and drug-treatment services are primarily provided in tiers 3 (community-treatment) and tier 4 (residential treatment), with brief interventions and referrals occurring in tiers 1 and 2.

Alcohol and Drug Partnership (ADP) Annual Reports 2019/20

Scotland’s Alcohol and Drug Partnerships (ADPs) Annual Reports for 2019/20 provide the latest information mapping the extent and nature of alcohol and drug support, treatment and recovery services for younger people. At the time of writing, ADP Annual Reports were available for 30 of 31 ADPs in Scotland^[103].

• Overall Provision – 26 (84%) ADPs reported the availability of alcohol and/or drug treatment and support services specifically targeted towards children and young people (under the age of 25) with problematic alcohol and/or drug use within their ADP area.
• Provider Types – Just under half of ADPs (n=15, 48%) stated that these services were provided by third-sector organisations (in some cases commissioned by ADPs). Eight ADPs (26%) stated that tailored services were available from statutory providers, while two ADPs (6%) reported services offered by a mix of third-sector and statutory providers across their area.
• Disparity of Services – There was marked disparity in the services reported by ADPs in their open-ended answers as being available within their area, suggesting that the services available to young people in Scotland strongly depends on where they live.^[104]
  • Tier 1 – Most commonly, ADPs reported services offering Tier 1 interventions including educational interventions and information-based prevention activities, and generalised support and advice while providing more targeted support on a needs-based basis.
  • Tier 2 – Services offering Tier 2 interventions were described by a smaller number of ADPs. Some offered generalised or targeted mental health support; either through trained mental health services or through counselling and mental health support provided by volunteers, with some highlighting that these services were trauma informed. A wide range of other services were offered. Less frequently, ADPs described services offering transition planning and goal setting and Motivational Interviewing. A small number of ADPs described services which adopted a ‘whole families approach’, involving home visits and the provision of counselling services to family members of those experiencing alcohol and drug issues. Assertive referral to alternative activities for individuals at risk (including linkages with football clubs and providers in the creative arts) were also reported.
  • Tier 3 and Tier 4 – No ADPs reported structured community (tier 3) or residential (tier 4) services which were tailored towards the specific needs of children and younger people.
• Age-Barriers – Within open-ended replies, the majority of ADPs reported that the services within their area operated a complex range of more specific age limitations. It was challenging to determine whether those who did not report age-boundaries were due to having no boundaries or due to non-reporting. The majority of these reported minimum age limits (typically admitting individuals over 15 years or over 12 years) or maximum age limits (of 18 or 21 years). Some described services as targeting those of a specific age range (typically around 12-18 years). Across the majority of ADPs, those over 18 were typically referred to generalised adult services.

Residential Rehabilitation

A recent Scottish Government mapping report of residential rehabilitation and specialist supported accommodation services for alcohol and drug issues, undertaken in December 2020^[105], found that there were no residential services tailored towards the specific needs of children and younger people in Scotland. While residential services may not be suited to many of those of younger age (if still in full-time education, for example), the lack of services tailored towards younger people is concerning given the markedly different profile of drug use among this population group, and the focus on opioid and benzodiazepine addiction across many of the generalised adult services. Further, the report found that facilities across Scotland typically operated with minimum age requirements of 16 or 18 years.

4.2 Treatment and Recovery Services: Barriers to Children and Younger People

4.2.1 Attendance of Drug Treatment Services in Scotland

Children (0-18 years)

While data is not available solely for substance abuse services, data is available on the provision and availability of mental health treatment for children. The latest data from the quarter ending June 2021^[106] shows that 4,552 children and young people started treatment at CAMHS during this quarter; an increase of 11.1% from the previous quarter. This was of a total of 10,193 children and young people referred in this quarter; more than twice as many as the 4,052 referred in the quarter ending June 2020. Just over seven out of ten (72.6%) waited less than 18 weeks for treatment; lower than the Scottish Government aim of 90% starting treatment within 18 weeks of referral. Waiting times varied considerably by NHS Board; from 98.8% being seen within 18 weeks in NHS Ayrshire & Arran, to only 36.4% being seen within 18 weeks in NHS Dumfries & Galloway. At the end of the quarter, there were 11,722 children and young people waiting for treatment at a CAMH service in Scotland. While it is not possible to determine how many of these children and young people had co-occurring substance use issues the data demonstrates that there are considerable pressures on the system.

Adults

While hospital admissions and drug-related deaths are rising among younger people, the Scottish Drug Misuse Database data for 2019/20^[107] shows that fewer younger people are accessing Tier 3 and Tier 4 drug treatment services. This may be due to services not being suited to the particular needs of younger people, and, particularly, due to the different profile of drugs causing harms (primarily in relation to hospital admissions) among younger people. This was identified as an issue within the 2009 Audit Scotland report on alcohol and drug services in Scotland^[108], and is a more pressing today given the transition in drug profile causing harms among younger people.

• Younger people make up a smaller proportion of overall clients recorded on Scottish Drug Misuse Database. While they contributed 26% in 2006/07, this has declined to 14% (n=1,490) in 2019/20 (Figure 4.2).
• Reported heroin use has declined sharply among younger people; the percentage of individuals aged under 25 years reporting heroin use in the month prior to assessment fell from 58% (1,587 out of 2,736) in 2006/07 to 18% (236 out of 1,313) in 2019/20.

Source: ISD SDMD 2019/20

4.2.2 Barriers to Children and Younger People seeking treatment

Relatively few children and younger people seek treatment for substance use problems. Compared to research highlighting the barriers faced by younger people accessing mental health services, research into the barriers that confront younger people seeking to access alcohol and drug treatment services is lacking. Wisdom and colleagues’ 2010 review was structured around the following typology of barriers; structural, problem recognition, and negative perceptions surrounding treatment.

• Structural Barriers – Studies highlight logistical and material obstacles, including high cost, insufficient coverage, a lack of knowledge of services, geographic barriers and waiting lists. While data was not available for substance use treatment alone, data for CAMHS services, as highlighted above, found that a substantial proportion of children had to wait more than 18 weeks for treatment^[109]. The latest data from the Drug and Alcohol Treatment Waiting Times database^[110] shows that 95.3% of those starting their first drug or alcohol treatment waited 3 weeks or less (95.1% for alcohol treatment and 95.5% for drug treatment). Entry criteria may also work to exclude younger people^[111]. The ADP Annual Reports highlight age-barriers for young people’s services, generating gaps in provision. Dundee City ADP stated that individuals between 18-25 were often disengaged at the point of referral as they were too old for youth services but felt that adult services were not appropriate.
• Problem Recognition – The recognition of problems in relation to alcohol and/or drug use forms the primary component in treatment seeking, and is shaped by contextual and cultural factors. Youth – particularly adolescence – is a period of change, instability, and risk-taking, often including experimentation with substances. In a country where this is normalised, individuals, their family and peers may view substance abuse as a ‘phase’ that the younger person will ‘outgrow’, or perceive it not to be severe enough for treatment^[112]. Lack of desire to stop using also forms a common barrier among younger people^[113].
• Negative perceptions and attitudes towards treatment – Negative views about treatment, both in the eyes of the caregiver or the younger person, form a barrier to accessing alcohol and drug services. These include stigma, negative attitudes towards services, and perceiving available services as unsuitable^[114]. Stigma, in particular, has been assessed as an issue within the Scottish context^[115]. This lack of suitability may be due to the adult-focussed service, which may often be suited to the particular drugs which younger people experience problems.

Further research to understand barriers from multiple perspectives – younger people’s, caregivers’, and providers’ viewpoints – would be desirable in order to capture a fuller picture of obstacles confronting younger people in Scotland experiencing harms from alcohol and drugs.

4.3 What Works in Treatment and Recovery for Children and Younger People?

Research examining treatment and recovery among young people trails the adult literature^[116]. There is therefore a need for further exploration of what kind of treatment and recovery services are effective for younger people in Scotland and more widely.

In 2020, Christie et al undertook a review of the existing literature on effective treatment of problem alcohol and drug use among young people. While undertaken in the US, there are a number of areas of relevance for the Scottish context. Existing research suggests that treatment services for younger people improve outcomes in the short to medium term, while emergent studies of longer-term outcomes showing modest benefit, particularly in those with moderate issues^[117]. The literature also suggests that, for those with less complexity and comorbidity, increased intensity of treatment does not necessarily lead to better outcomes. Following a stepped-care approach, a more intensive approach should be used for more severe or complex problems, or where community treatment has failed. Treatment should also be flexible and informed by an understanding of the developmental challenges that young people face. As noted, younger people tend not to recognise their substance use as problematic as readily as adults, and are facing harms from a different profile of drugs than those of older age-groups in Scotland.

Drawing on the existing evidence-base relating to their efficacy, their review identified a number of treatment and service delivery principles which they suggest should be applied to treatment settings for young people. However, it must be foregrounded that these suggested treatment and recovery delivery principles primarily target individual and contextual determinants; generating a lasting reduction in harms from alcohol and drugs across the population requires changes to the structural (primarily socioeconomic) determinants of problem alcohol and drug use.

• Promote screening, brief intervention and referral to treatment – The evidence shows that screening, brief intervention and referral to treatment is effective in reducing alcohol- and drug-related problems, and should be promoted in primary care, medical, youth justice and school settings to address early problematic use and support young people into treatment.
• Incorporate peer networks in service delivery – Peer relationships form a key developmental factor for younger people and, as such, the evidence shows that a range of interventions which incorporate peers are effective in reducing problematic alcohol and drug use.
• Support harm reduction – The evidence demonstrates that incorporating harm reduction as a treatment outcome within services (including when abstinence is a treatment goal) is evidenced to improve outcomes. This can include progressive steps, such as using less of a substance, or using in a safer way, if the individual does not feel ready for abstinence at that point in time. However, the reasons underpinning this lack of readiness should be identified, and addressed within treatment.
• Undertake proactive engagement – The data highlights that those in adolescence and young adulthood are less likely than those across all ages to seek treatment. Service flexibility and responsiveness, a focus on establishing good therapeutic alliance, offering practical support and semi-formal contact, and family involvement are key steps. Younger people are more likely to engage with a service if it is interesting, responsive, confidential, respectful, trustworthy, and staffed by caring, committed and optimistic professionals, often those with lived experience of problematic substance use. Youth participation in service development, delivery and feedback are also supported by the evidence base.
• Individual therapy should include motivational interviewing and cognitive behavioural therapy – When working with young people on an individual basis, motivational interviewing (MI) and cognitive behavioural therapy (CBT) are generally the approaches best supported by evidence.
• Addressing co-occurring problems is essential – Comorbidity has been associated with poorer substance use treatment outcomes, including non-completion and earlier relapse, with a large body of existing evidence highlighting the importance of screening for co-occurring mental health and substance use problems among young people presenting to both addiction and mental health services.
• Family interventions are fundamental – Family involvement improves treatment outcomes; thus, it is best established from the outset of treatment if possible. The research shows that even minor levels of involvement are usually better than none, securing early changes in substance use and behaviour, and enhancing engagement in later treatment.
• Computer and e-health interventions are developing – Technology-based interventions offer the possibility of reaching individuals who otherwise might not seek treatment such as those in remote areas, those not perceiving a need for treatment, or others who may resist face-to-face treatment. For adolescents, interventions delivered via computer or mobile phone may be appealing as they can manage the pace of treatment, ensure privacy and tailor content to their needs. Effective implementation of such services is vitally important in the context of the COVID-19 pandemic, with a number of services in Scotland having moved wholly or partly online in 2020.

The evidence supports the use of a range of interventions for problematic alcohol and drug use in children and younger people, but is less definitive about which type of treatment or service is better for specific population groups. Services that can provide a range of treatment modalities will be best placed to respond to the specific needs of the young person, and their family if relevant. Treatment planning should be tailored for each young person, taking into account co-existing disorders, developmental issues and their family and social environment. The evidence shows that services are best set up separately and specifically for young people (rather than integrated with adult services) to ensure a developmental and engagement-focussed approach. The implementation of effective treatments for young people in Scotland with alcohol and drug use disorders is critical, not only to alleviate suffering within a vulnerable sector of the population, but also as a means of altering trajectories of harmful alcohol and drug use that can persist into adulthood.