Ontario Youth Screening Project Brantford and Brant County

Transcription

Ontario Youth Screening Project
Brantford and Brant County
Funded through a CIHR Emerging Team Grant
Ontario Youth Screening Project: Brantford and Brant County
For more information, please contact:
Joanna Henderson, Ph.D.
Gloria Chaim, MSW
Child, Youth and Family Services
Clinician Scientist
[email protected]
Deputy Clinical Director
[email protected]
Centre for Addiction and Mental Health
80 Workman Way, Toronto, ON M6J 1H4
Production of this report has been made possible through funding from the Canadian Institutes of Health Research (CIHR) –
Emerging Team Grant: CIHR Team in Innovations in Child and Youth Concurrent Disorders CBG101832. The views expressed
herein do not necessarily represent the views of CIHR. © 2014 CAMH
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Acknowledgments
The Ontario Youth Screening Project Team would like to acknowledge the commitment, dedication and hard work of the
many people representing agencies in Brantford and Brant County, one of six participating communities across Ontario.
Sincere appreciation is due to Kim Baker for providing on-going leadership to the network and working diligently to
ensure full implementation of the project protocol; to the agency leads who were prepared to commit to participate
in a cross-sectoral collaboration, adapt program protocols to integrate consistent administration of a screening tool
and dedicate staff time to participate in the project; to front-line service providers who were willing to take the time
to explore new practices, and to engage youth in a screening process for clinical and research purposes; and, most of
all, to the youth who participated in completing the screeners and consented to sharing them with the project team.
We would also like to thank the Canadian Institutes of Health Research (CIHR) for the funding support that made
this project and dissemination of the findings possible.
Ontario Youth Screening Project Partner Agencies:
Brantford & Brant County
The following agencies participated in one or more of the four key project activities: Capacity Building, Network
Development, Screening Implementation and Data Collection (Refer to Appendix A for agency descriptions and
Appendix B for key project activity descriptions).
Partner Agencies
Agency Leads
Contact Brant ................................................................................................................................................................................................................. Jane Angus
Brant County Health Unit ................................................................................................................................................................................. Marie Green
Woodview Children’s Centre................................................................................................................................................................... Lorraine Jeffrey
St. Leonard’s Community Services, Addiction and Mental Health Services ............................................................. Julie Smith
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Project Team: Centre for Addiction and Mental Health (CAMH)
Project Leads
Joanna Henderson
Gloria Chaim
Network Coordinator
Kim Baker
Project Coordinators
Megan Barker
Megan Anne Tasker
Research Support
Annie An
Lin Bao
Stephanie Luca
Andra Ragusila
Vivian Zhang
GAIN SS License
Chestnut Health Systems: Copyright holder for all Global Appraisal of Individual Needs instruments, including
Global Appraisal of Individual Needs - Short Screener (GAIN SS)
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Table of Contents
7
List of Figures
8
List of Tables
9
9
Overview
9
Context
13
13
Summary
13
Development
14
Partners
14
Roles
16
Implementation Process
17
Materials
19
Findings
34
Clinical Needs of Youth Based on the GAIN SS
45
Concurrent Substance Use and Mental Health Concerns
57
Service Provider Survey
58
Utility and Feasibility of the GAIN SS
61
Summary of Findings
63
Discussion
65
Recommendations
69
Appendix A: Brantford and Brant County Network Member Agency Descriptions
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Appendix B: Key Project Activity Descriptions
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Appendix C: Agency Project Activity Participation
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Appendix D: Project Timeline
74
Appendix E: Project Flow Chart
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Appendix F: References
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List of Figures
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Figure 1: Age Distribution of Participants
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Figure 2: Age Distribution by Service Sector
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Figure 3: Sex Distribution of Participants
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Figure 4: Sex Distribution by Service Sector
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Figure 5: Service History by Service Sector
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Figure 6: Ethnicity Distribution of Participating Youth
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Figure 7: Living Arrangements
29
Figure 8: Living Arrangements by Sex Categories
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Figure 9: Living Arrangements by Age Categories
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Figure 10: Living Arrangements by Service Sector
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Figure 11: Number of Concerns Endorsed by GAIN SS Domain
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Figure 12: Clinical Needs using Moderate Threshold
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(1+ Endorsements) by Service Sector
Figure 13: Clinical Needs using High Threshold
(3+ Endorsements) by Service Sector
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Figure 14: Internalizing Concerns by Age and Sex Categories
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Figure 15: Externalizing Concerns by Age and Sex Categories
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Figure 16: Substance Use Concerns by Age and Sex Categories
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Figure 17: Crime and Violence Concerns by Age and Sex Categories
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Figure 18: Suicide Concerns by Age and Sex Categories
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Figure 19: Additional Concerns by Sex Categories
44
Figure 20: Additional Concerns by Age Categories
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Figure 21: Concurrent Disorders
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Figure 22: Concurrent Disorders by Sex
48
Figure 23: Concurrent Disorders by Age
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Figure 24: Concurrent Disorders by Age and Sex Categories
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Figure 25: Concurrent Disorders by Service Sector and Sex Categories
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Figure 26: Concurrent Disorders by Living Arrangement
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Figure 27: Endorsement of Concurrent Disorders by Legal System Involvement
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Figure 28: Endorsement of Concurrent Disorders by Legal System Involvement and Sex
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Figure 29: Endorsement of Concurrent Disorders by Student Status
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Figure 30: Endorsement of Concurrent Disorders by Student Status and Sex
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Figure 31: Complexity of Needs
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Figure 32: Service Provider Perceptions of GAIN SS Utility and Feasibility
List of Tables
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Table 1: Demographic Comparison of Male and Female Participants
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Overview
Project Summary
The Ontario Youth Screening Project (OYSP) was funded under the Canadian Institutes of Health Research
(CIHR) through an Emerging Team Grant to work collaboratively with cross-sectoral youth serving networks in
six communities across Ontario. The goal of the project was to implement a common screening tool to identify
youth substance use and mental health concerns. Each network was composed of a minimum of two sectors that
included addictions, mental health, justice, child welfare, education, housing, outreach and support and health.
Each agency agreed to participate in one or more of four key project activities: Network Development, Capacity
Building, Screening Implementation and Data Collection (see Appendix D). Through this process, the team had
the opportunity to examine rates of co-occurring substance use and mental health concerns (frequently referred
to as concurrent or co-occurring disorders (CD)) in different service sectors, across the adolescent and emerging
adulthood age spectrum. As well, the project aimed to explore service provider perceptions of interagency referrals;
perceived interagency collaboration; and youth CD-related attitudes, knowledge, and practices at different time
points in the project.
The overall objective of OYSP was to enhance service provider Concurrent Disorder (CD) capacity, increase early
intervention opportunities, and improve pathways to treatment for youth (aged 12-24 years) with substance use and
mental health problems, and their families. This was done through building sustainable stakeholder collaborations
and providing CD-related capacity development opportunities in six communities.
Context
Background
In Ontario, 467,000 to 654,000 children and youth have at least one diagnosable mental health disorder, and there
are indications that these disorders are increasing in frequency (Ministry of Children and Youth Services, 2013).
Substance use in adolescents is also common. In the most recent Ontario Student Drug Use and Health Survey
(OSDUHS), forty percent of Ontario youth in grades 7 to 12 reported use of drugs, one-half reported using alcohol,
and one-fifth reported binge drinking in the past year (Boak, Hamilton, Adlaf & Mann, 2013). Within community
samples, adolescents with a substance use disorder are up to six times more likely to be diagnosed with a mood
disorder, two times more likely to be diagnosed with an anxiety disorder and 14 times more likely to be diagnosed
with a conduct/oppositional disorder (Roberts, Roberts, & Xing, 2007). Similarly, children with externalizing
(disruptive) behaviour disorders and internalizing disorders (anxiety or depression) initiate substance use at earlier
ages and are more likely to develop problematic substance use than children without these disorders (Armstrong &
Costello, 2002).
Youth with CDs have multiple vulnerabilities including impairments in functioning, behavioural problems, poor
academic/vocational performance, increased suicide risk, and adverse health effects – including increased risk
for substance dependency and psychiatric disorders continuing into adulthood (Clark, Power, Le Fauve, & Lopez,
2008; King, Gaines, Lambert, Summerfelt, & Bickman, 2000; Lewinsohn, Rohde, & Seeley, 1995; Rush, Castel, &
Desmond, 2009). Notably, the extent of co-morbidity appears to be higher among youth than among adults (Roberts
et al., 2007; Grisso, Vincent, & Seagrave, 2005) resulting in calls for special attention to youth-focused screening,
assessment and treatment planning (Grisso et al., 2005). CDs are also associated with greater severity of disorder,
poorer prognosis, increased treatment challenges and greater unmet need for treatment compared to individuals
with mental health or SU disorders alone (Bijl & Ravelli, 2000; Clark et al., 2008; Kessler, Chiu, Demler, Merikangas
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& Walters, 2005; Urbanoski, Cairney, Bassani, & Rush, 2008; Vida, Brownlie, Beitchman, Adlaf, Atkinson, Escobar,
Johnson, Jiang, Koyama, & Bender, 2009). The majority of children and adolescents with significant mental health
or substance use concerns do not receive specialized treatment, although they often present to other service systems
such as primary care, emergency services or the youth justice system (Waddell, McEwan, Shepherd, Offord, & Hua,
2005; Reid, Evans, Brown, Cunningham, Lent, Neufeld, Vingilis, Zaric, & Shanley, 2006). This is partly a result of
the lack of adequate problem identification in service systems as well as poor cross-sectoral communication and
coordination. The term “no wrong door” has been aptly embraced across sectors as a way to meet the need for a
collaborative approach that facilitates timely access to care (e.g., National Treatment Strategy Working Group, 2008;
Mental Health Commission of Canada, 2009).
Integrated models of service delivery are needed across the continuum of care to improve outcomes and reduce the
high individual and societal costs associated with CDs (Rush et al., 2009). Routine and effective screening for; and
assessment of, mental health and substance use concerns among children and adolescents is needed, particularly in
service delivery settings where children, youth and families already present themselves for assistance. Many national
(Health Canada, 2002) and international (Elster & Kuznets, 1994) expert panels and organizations have advocated
for routine screening for mental health and substance use concerns in childhood and adolescence.
Choosing a Screening Tool for Youth
The importance of screening for both mental health and substance use concerns across sectors has been identified
through a number of initiatives. From 2002 to 2006, the emphasis was primarily on the identification of useful
adult tools and practices (Health Canada, 2002; Centre for Addiction and Mental Health, 2006).
In 2006, Rush and colleagues initiated a process to identify youth screening tools and processes, and conducted
a comprehensive review and synthesis of screening tools for substance use and mental health disorders among
children and adolescents (Rush, Castel, & Desmond, 2009).
Through these initiatives, the Global Assessment of Individual Needs Short Screener (GAIN SS) was identified as an
ideal first stage screening tool for substance use and mental health concerns for youth and adults. In particular, it
was recommended because it:
•
Screens for both substance use and mental health issues;
•
Is reliable and valid;
•
Is brief (five to seven minutes to complete);
•
Can be self-administered;
•
Has been validated for individuals aged 10 years and older (including adults);
•
Is low cost;
•
Can be used in different service settings (e.g., treatment, primary care, etc.).
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Collaborative Screening Initiatives 2003 - 2010
In 2003, CAMH merged its children’s mental health and youth substance use services into the Child, Youth and
Family Services (CYFS) and in 2005 a project was initiated to identify and implement a common screening tool for
substance use and mental health concerns across the merged program. Based on the work of Rush and colleagues
(2006), the GAIN SS was chosen and implemented. In addition, substance use and mental health-related staff
attitudes, knowledge and practices were measured and staff feedback was gathered. Findings from that project
demonstrated that many youth endorsed co-occurring substance use and mental health concerns, regardless of
“presenting problem” and initial service request. As well, participating staff indicated that implementing a consistent
substance use and mental health screening tool was feasible across diverse services and provided clinically useful
information (Henderson, Chaim, & Rush, 2007; Skilling, Henderson, Root, Chaim, Bassarath, & Ballon, 2007).
Discussion about this project at workshops, conferences and network meetings generated interest within the Torontobased Mental Health and Addiction Youth Network (MAYN) in replicating the project within their own agencies. In
2008, as a pilot project, a cross-sectoral network of 10 Toronto-based youth serving agencies (all members of MAYN),
led by Gloria Chaim and Joanna Henderson, committed to administer the GAIN SS, along with a standardised
background information form to the youth (aged 12-24 years) seeking service at their agencies for a 6-month period.
The GAIN Collaborating Network research findings resulted in a report describing youth needs across sectors and about
the feasibility and utility of consistent screening and the GAIN SS in particular. Stakeholder discussion about the
findings generated a number of service, system and research initiatives and suggested that the GAIN SS is a feasible
and useful clinical instrument (Chaim & Henderson, 2009). The GAIN SS is also available in French.
Upon completion of the GAIN Collaborating Network project, findings were presented to local stakeholders including
service providers, agency leaders and policy makers as well as at multiple international, national, and local conferences,
meetings, and forums, most notably the Annual Convention of the American Psychological Association (2009) and Issues
of Substance (2009). Through these knowledge sharing opportunities, interest in implementing the GAIN SS in youth
serving agencies and in participating in collaborative research was generated in communities across Canada. In
2009, CIHR had a call for proposals for Emerging Teams interested in research on health issues of high importance
to Canadians (CIHR, 2008). Henderson, Chaim and colleagues included in their Emerging Team grant proposal a
replication of the GAIN-CN in four communities across Ontario (OYSP). Later in 2009, the Health Canada, Drug
Treatment Funding Program had a call for proposals. With interest and stakeholder support from several provinces,
Chaim and Henderson submitted a proposal to engage youth-serving agencies in an effort to examine the feasibility
and utility of implementing a common screening tool across youth serving agencies in diverse communities in
provinces and territories across Canada outside Ontario.
In 2010, Chaim and Henderson, in collaboration with the Toronto Concurrent Disorders Support Services Network,
supported by the Toronto Central Local Health Integration Network, launched another screening project, working
with a cross-sectoral group of 10 Toronto-based health and social service agencies focused on youth and adults
seeking or receiving service at their agencies. Similar to the GAIN Collaborating Network Project, service providers’
attitudes regarding feasibility and utility of the GAIN SS were positive and stakeholders reported that the research
results were useful in identifying gaps in service and training needs for staff (Hillman, Chaim, & Henderson, 2011).
The Ontario Youth Screening Project was granted funding as part of a CIHR Emerging Team Grant in 2010. Also in
2010 the National Youth Screening Project was funded by the Health Canada Drug Treatment Funding Program. The
National Youth Screening Project was completed in 2013 and the Ontario Youth Screening Project had the opportunity
to benefit from the learnings of this project.
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Objectives
•
To build collaboration amongst youth service providers across sectors by
developing/enhancing community based networks in Ontario;
•
To use a common screening tool with youth seeking services to facilitate consistent
identification and treatment for youth with substance use and mental health concerns;
•
To obtain feedback from service providers regarding the feasibility & utility of the GAIN-SS as
a screening tool;
•
To examine the effectiveness of cross-sectoral collaboration as a knowledge translation
strategy;
•
To inform planning processes within agencies that relate to:
(a) Identifying commonalities and differences in youth seen;
(b) Identifying gaps in the continuum of services.
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Ontario Youth Screening Project:
Summary
Discussion regarding the participation of Brantford and Brant County in the Ontario Youth Screening Project began
in March 2012. A number of presentations were made to area planning tables between March and July 2012 including
the Student Support Leadership Initiative (SSLI) group which spanned Haldimand, Norfolk and Brant Counties, and
the Brant Children’s Services committee. Subsequent teleconference and face to face meetings were then arranged
with interested parties to further detail the project and expectations for involvement. As a result, four agencies in
Brantford and Brant County committed to project involvement.
Following the initial engagement and information sharing, a series of planning meetings were held with involved
agencies between August and November 2012. These planning meetings were held in conjunction with Haldimand
and Norfolk area agencies also participating in the project given geographic proximity, shared school board boundaries
and a shared SSLI table. All necessary Research Ethics Board (REB) submissions were approved and legal agreements
were signed by December 2012.
Data collection for this collaborative project began in January 2013 with service providers administering the
GAIN SS and a demographic information form to youth aged 12 – 24 years seeking services at the participating
agencies. Training on youth substance use and concurrent disorders, with an emphasis on evidence-based screening
practices, clinical use of the GAIN SS and implementation of the project protocol was delivered to prepare agencies
for participation. Brant County also collaborated with Haldimand and Norfolk regarding the educational sessions.
Two sessions were offered, one in each area, with staff having the option of attending either. Approximately 30
service providers from Brantford/Brant took part in the sessions. Service providers completed pre/post surveys
about their own knowledge, attitudes and practices related to youth substance use and mental health concerns. They
also provided feedback about their perceptions of the feasibility and utility of implementing the screening tool in
their practices and the impact of screening in particular and project participation more generally on their referral
practices. Presented in this report are the background and service needs of youth who participated in this study as
well as service provider perceptions of the screening tool and related processes.
Development
In March 2012, discussion regarding participation in the Ontario Youth Screening Project was initiated at the Student
Support Leadership Initiative (SSLI) table for Haldimand, Norfolk and Brant. A subsequent presentation to the
local Brant children’s services system table along with a project specific teleconference and face to face meeting for
interested parties further detailed what was encompassed by project involvement. After this series of presentations
and information sessions, four local agencies expressed interest in participating in this project to build capacity to
identify and address the complex needs of the youth who access their services as well as to have the opportunity to
document the needs of youth seeking service in their respective agencies, sectors and community.
Each agency identified a lead contact and coordinator to participate in a local collaborative network to implement the
GAIN SS[1] with youth seeking service at the agencies. The project team held a one-day training workshop for service
providers, repeated on two days (November 29 and 30, 2012) to allow for all agency staff to be trained. In addition,
web-based training though Adobe Connect was provided to staff who could not participate in the onsite training.
Prior to the training, the service providers were surveyed regarding their attitudes, knowledge and practices related
(1)
Chestnut Health Systems granted a license to all agencies involved in the screening activities with the exception of St. Leonard’s Community Services as they already had a license prior to the project’s implementation.
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to youth substance use, mental health and co-occurring concerns. A Brantford/Brant referral resource guide was
developed by Contact Brant. In January 2013, the agencies launched the data collection phase.
The Brantford/Brant Network was established based on shared interests in learning more about the needs of youth
presenting at local services. At the time that the network was taking root, there was also discussion about the
alignment of this project with other initiatives, such as Working Together for Kids Mental Health that was intended
to roll out in the area in the near future. Participating in the OYSP would well position the community to be prepared
for engaging in that initiative, laying the groundwork for enhanced on-going partnerships and collaboration. See the
local reports described above for details of the process in each community as well as Appendix B for implementation
summaries and Appendix E for a process summary. See Appendix F for the overall project timeline.
Partners
The Brantford/Brant Network includes representation from three community-based service sectors including the
addiction, mental health, and justice sectors (see Appendix A for agency descriptions). All four agencies participated
in all four project activities, which included: Capacity Building, Network Development, Screening Implementation,
and Data Collection. Please refer to Appendix B for a description of key project activities and Appendix C for
description of the respective agency participation.
Roles
CAMH Project Leads:
•
Provide resources and support meetings for youth-serving agencies to support all aspects
of project participation;
•
Provide training to staff in identifying and addressing substance use and/or CD concerns in
youth, implementing the GAIN SS and the data collection protocol;
•
Provide all necessary screening and project-related materials;
•
Provide templates and support for developing response, resource and referral guides
customised for the community;
•
Obtain ethics approval through CAMH and support each agency to comply with their ethics
approval processes.
CAMH Network Coordinator:
•
Identify local organizations, representing a minimum of two sectors to participate in the
project;
•
Vet prospective participating agencies for suitability;
•
Act as a liaison between project leads and participating agencies during the term of
the project;
•
Ensure participating agencies are covered by an up-to-date license for use of the GAIN SS
•
Identify and facilitate agency leads to obtain local REB approval for the project;
•
Support training provided by the project leads and facilitate provision of consultation as
needed throughout the project;
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CAMH Network Coordinator (continued):
•
Facilitate pre and post service provider surveys of staff attitudes, knowledge and practices to
all agency staff involved in the project;
•
Facilitate data collection by the participating agencies.
Participating Agencies:
•
Obtain license from Chestnut Health Systems Inc. or ensure up-to-date license for use
of the GAIN SS;
•
Comply with the agreed upon protocol by obtaining participant and parental consents as
required, administering GAIN SS and submitting the data to the project leads for data entry and
analysis;
•
Ensure staff participation in project-related training;
•
Maintain and store original data from participants as per REB policies and in accordance with legal requirements;
•
Ensure that as many eligible youth as possible have the opportunity to be included in the
project and that the rates of eligibility and consent are tracked.
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(See Appendix D for Project Timeline)
Prior to initiating project activities, agreements were signed between all participating agencies and CAMH.
A collaborative process was used throughout the project to develop joint goals, materials and processes as well as
research questions and data analyses. Once the agency level training was completed and data collection was underway,
the CAMH project team communicated with the participating agencies to maintain engagement, momentum, and
compliance with the project protocol, problem-solve issues and facilitate collaboration in the joint data analysis
process.
11. March 2012 – July 2012 – Networking:
(a) Identified interested agencies
(b) Established cross-sectoral networks
22. August 2012 – December 2012 – Agreements and REB:
(a) Developed an agreement between CAMH and each participating agency
(b) Secured all required REB approvals
33. November 29 and November 30 2012 – Capacity building
(a) Capacity building across sites was delivered using the package developed
by the project leads
(b) Project leads administered service provider consents and the Service
Provider Survey at the beginning of the training day
(c) Each Agency identified a lead to act as a “point person” for communication
with the CAMH network coordinator, including receiving and distributing
project packages to the participating service providers in their respective agencies
(d) Additional teleconference capacity building sessions were provided to train
staff who could not attend the in-person sessions in the administration of the
measures and the project protocol
44. January 2013 – Project launch:
(a) Distributed project packages (i.e. project instruction sheets, consent forms,
GAIN SS, background Information forms, tracking sheets)
55. January 2013 – September 2013 – Project actively underway:
(a) Service providers obtained consent from youth and parents as requird,
seeking service at their agencies, administered the GAIN SS and Background
Information Form
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(b) Anonymous copies of the completed measures and tracking sheets were
submitted to the CAMH network coordinator on a monthly basis, and
delivered to CAMH project leads at months 1, 3 and 6
(c) Consultation was provided as needed by the network coordinator and/or
project coordinator/project leads
(d) Staff feedback forms were collected on completion of the data collection
66.October 29, 2013 – Preliminary data analysis meeting:
Discussed:
(a) Data analysis questions
(b) Preliminary findings
(c) Fit with expectations and experiences of the community
(d) Lessons learned, including staff feedback on utility and feasibility of
administering the GAIN SS to youth in their agencies
(e) Feedback from network coordinator and agency leads
(f) Potential recommendations based on findings
(g) Report dissemination plan
Materials
Service Provider Project Package
Service Provider Consent Form
The consent form described the project, confidentiality and plans for data management. Service providers’ initials
only were required to ensure anonymity.
The Service Provider Survey is a self-report questionnaire that combines measures of service providers’: 1) servicerelated knowledge, attitudes and practices regarding youth substance use, mental health, co-occurring disorders, and
screening; 2) perceptions of co-occurring disorders-informed practices; 3) estimates of current use of CD-informed
practices; and 4) experiences with inter-agency referrals and collaboration.
Project Flow Chart (See Appendix E)
A step-by-step project flow chart was developed for use by all service providers to facilitate consistency across providers.
Referral Resource Guide
Customised templates listing local resources for consultation and referrals for follow-up on endorsement of concerns
on the GAIN SS were provided to each participating service provider.
Project Tracking Sheet
Tracking sheets were used to document rates of youth eligibility for project participation, consent/non-consent,
participation/reasons for non-participation, and data collection completion and submission for each youth seeking
service in each agency.
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Feedback Survey
The feedback survey was designed to gather information from participating service providers regarding their
perceptions of the feasibility and utility of administering the GAIN SS to youth in their setting and about the impact
of the screening process on their practices.
Youth Project Package
Youth Consent Form
The consent form described the project, confidentiality and plans for data management. Only youth initials were
required to ensure anonymity.
Parental Consent Form
The consent form described the project, confidentiality and plans for data management. Parental consent was
required in addition to youth consent in agencies where it was mandatory to obtain parental consent for youth under
16 years of age to seek services. Only parent’s initials were given to ensure anonymity.
Background Information Form
The Background Information Form is a one-page questionnaire used to gather demographic information about
the participating youth. The questions seek information about the determinants of health frequently cited in
the literature as associated with youth substance use and mental health concerns including age, sex, education,
employment, income support, housing, legal involvement, ethno-racial identification, and language diversity.
GAIN SS (CAMH Version)
The GAIN SS is a brief screening tool validated for use with individuals aged 10 years and older to quickly identify
those who may be experiencing difficulties in one or more of four dimensions: 1) internal mental distress (e.g.,
depression, anxiety); 2) behavioural complexity (externalizing behaviours e.g., ADHD); 3) substance use problems;
and 4) crime and violence (Denis, Chan, & Funk, 2006). The tool was developed by Chestnut Health Systems and
copyrighted in 2005. Chestnut Health Systems permitted CAMH’s Child, Youth and Family Program to modify the
GAIN SS in 2006, by adding seven items (not part of the original validation) at the end to screen for: eating-related
issues, trauma-related distress, disordered thinking and gambling, gaming and internet misuse concerns.
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Findings
19
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Background Information about Youth
Who participated?
In total, 206 youth participated:
• 138 (67%) from the mental health sector
• 57 (28%) from the addictions sector
• 11 (5%) from the justice sector
How representative is the sample of youth who participated in the project?
Service providers were asked to use tracking sheets to record each youth eligible to participate. Information collected
on the tracking sheets included sex, age, consent response, and any comments on why individual youth may not have
been approached or refused to consent. All participating agencies used this approach to track participation rates.
According to the tracking sheets provided by the service providers from the four participating agencies, 323 youth
within the age range of this project presented for service to the participating programs and agencies over the course of
the six-month project timeframe. Of these youth, 87% were eligible for the project (n=282). Reasons for ineligibility
included being younger than 12 or older than 24 years old (5%), youth was not a client (39%), it was the last session,
and/or end of service (2%), immediate mental health concerns (7%).
In addition, for 19 cases (46%), no information about eligibility/ineligibility was provided. Of the youth who were
eligible to participate in the project, 228 (81%) were approached for participation. Reasons for youth not being
approached included clinician based reasons (e.g. judgment, forgot) (3%), there was no time (2%), no appropriate
forms (1%), or the youth was not available (51%). Of the youth who were approached, 90% completed the GAIN SS.
Based on the tracking sheets, 10% of youth asked to complete the GAIN SS refused. Of the youth who completed the
GAIN SS, 99.5% consented to have a copy used for this project.
Please note: Based on the number of completed consents and screeners we received from agencies who provided
tracking sheets, almost 100% of eligible youth (99.5%) were accurately captured on tracking sheets.
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What are the demographic characteristics of the youth
who participated?
How old were participating youth?
Figure 1: Age Distribution of Participants
37%
17%
12-15 years old
16-18 years old
19-24 years old
46%
The participating youth ranged in age from 12 to 24 years with an average age of 16 years and a median age of 16
years. In Figure 1, the ages of participating youth are presented using age categories commonly used in service
provision. As can be seen, the largest group of participating youth was 12 to 15 years old (46%).
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Figure 2: Age Distribution by Service Sector
100%
1%
9%
90%
80%
70%
40%
58%
46%
60%
19-24 years old
50%
16-18 years old
40%
30%
28%
20%
10%
0%
59%
12-15 years old
46%
14%
Addictions
Justice
Mental Health
Sector
When youth are grouped by sector, it can be seen that youth from the addictions sector were more likely to be in
the older age group (19 to 24 years), whereas the majority of participating youth presenting to the other sectors
were either in the 12 to 15 age category or the 16 to 18 age category likely due to the age mandates of some of the
participating agencies.
23
How many participants identified as male, female, trans or other?
Figure 3: Sex Distribution of Participants
1%
Male
55%
44%
Female
Missing
The majority of participants in this project were female (55%). Three participants did not answer this question.
No participants identified as trans or other.
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Figure 4: Sex Distribution by Service Sector
100%
90%
33%
80%
70%
68%
64%
60%
Male
50%
Female
40%
67%
30%
20%
32%
36%
10%
0%
Addictions
Justice
Mental Health
Sector
Comparing the sectors revealed that the mental health sector had a greater proportion of female participants relative
to the addictions and justice sectors.
25
How long had youth been receiving service prior to project participation?
Figure 5: Service History by Service Sector
100%
2%
2%
90%
80%
10%
19%
30%
70%
60%
10%
86%
30%
50%
40%
42%
20%
10%
0%
11%
10%
Addictions
Justice
2-12 Months
ago
In the past
month
50%
30%
More than a
year ago
Today
Mental Health
Sector
The majority of youth participating in the project endorsed beginning services within the past month (78%). Among
these youth, 31% completed the GAIN SS on their first day of service (not shown). As can be seen, there was a fair
amount of variability between sectors. For example, a large portion of the youth from the mental health sector
(42%) completed the screener the day of their first visit while the rate of same day participation was only around
10% for the addictions and justice sectors.
26
What ethnicities did youth report?
Figure 6: Ethnicity Distribution of Participating Youth
2%
4%
4%
2%
8%
Aboriginal
Black
White
Other
Don’t Know
79%
Missing
The most commonly endorsed ethnicity across all youth was White/European (79%) followed by Aboriginal (8%) and
Black (2%). Four percent of the ethnicities reported were identified by small numbers of youth and grouped together
under ‘Other’ (Chinese, Latin American, South Asian, West Asian, and ‘Other’) and 4% of responses indicated
“Don’t know”. Three percent of participating youth endorsed more than one ethnicity. Two percent of youth did not
complete this question.
Birth Country and First Language
The majority of participating youth reported being born in Canada (96%) while 1% reported being born outside of
Canada and 3% did not answer the question. Those born outside of Canada reported having been in Canada for 14
to 15 years. The majority of participating youth also reported that English was their first language (92%), while 1
participant (1%) reported a different first language and 7% did not respond.
27
What living arrangements did youth report?
Figure 7: Living Arrangements
11%
10%
3%
1%
1%
Parental / Family Home
Own / With Friends
Other Family / Relative
Supportive Housing
Unstable
74%
Missing
The largest group of participating youth (74%) reported that they were living with parents, while 11% reported living
on their own or with friends, 10% reported living with other family members, 3% reported living in supportive housing
(e.g. “group home”, “treatment facility”), and 1% reported that they were living in unstable housing (e.g. “shelter”, “on
street”, “couch surfing”).
28
Figure 8: Living Arrangements by Sex Categories
100%
90%
9%
80%
14%
1%
3%
1%
3%
10%
7%
Unstable
70%
Supportive Housing
60%
Other Family / Relative
50%
40%
79%
Own / With Friends
72%
30%
20%
10%
0%
Male
Female
Sex
Examination of sex differences in living arrangements revealed that the living arrangements of male and female
youth did not differ significantly.
29
Figure 9: Living Arrangements by Age Categories
100%
90%
1%
1%
5%
8%
4%
80%
3%
6%
15%
5%
Unstable
40%
70%
60%
50%
40%
83%
Supportive
Housing
Other
Family / Relative
77%
30%
51%
20%
Own / With Friends
10%
0%
12 to 15
16 to 18
19 to 24
Age
As can be seen in Figure 9, youth in the oldest age group were more likely to report living on their own or with
friends than the younger age categories. Youth in the younger age categories were more likely to report living in the
parental/family home.
30
Figure 10: Living Arrangements by Service Sector
100%
90%
5%
11%
2%
9%
18%
4%
80%
70%
1%
2%
Unstable
30%
Supportive Housing
60%
Other Family/Relative
50%
40%
30%
84%
82%
Own / With Friends
53%
Parental/Family Home
20%
10%
0%
Addictions
Justice
Mental Health
Sector
Youth presenting to the addictions sector for service have a more varied distribution of living arrangements than
other sectors. Youth presenting to the addictions sector were also more likely to live on their own or with friends
compared to youth from the other sectors. The majority of youth presenting to all three sectors reported living in the
parental home, with larger proportions in the justice and mental health sectors.
31
How many youth reported legal involvement?
The majority of participating youth reported never having any legal involvement (67%), while the remaining youth
reported legal involvement in the past 12 months (23%), more than a year ago (5%), or did not answer the question (5%).
How are participating youth doing in terms of education, employment and income?
Overall 73% of participating youth identified as students. Of those who did not identify as students, 36% indicated
that they were unemployed, 22% indicated part-time employment, 15% indicated full-time employment, 9%
indicated volunteering, and 2% each indicated involvement in an apprenticeship program and self-employment (not
exclusive categories).
Age was related to educational, employment and income status. Youth aged 18 years and older (n=42), indicated that
their employment situations were as follows: unemployed (36%), attending school (24%), working part-time (12%),
and working full-time (17%) (not mutually exclusive). In contrast, youth aged 17 years or younger (n=164) indicated
that they were students (86%), unemployed (13%), working part-time (12%), and working full-time (1%). Similarly,
the most commonly reported income sources for youth aged 18 and older were as follows: employment (33%), no
income (17%), welfare (12%), parents/spouse (12%), and employment insurance (12%), while youth 17 years and
younger reported their income sources to be parents/spouse (52%), no income (43%), and employment (10%).
For youth aged 18 years and older who were not in school, educational attainment was also examined and revealed
a broad range of educational achievements, including 13% of youth participants reporting grade 10 completion or
less as their highest educational achievement, 22% indicating grade 11 as their highest achievement, 34% indicating
completion of high school with diploma, and 28% completing some non-university post-secondary education.
32
How do the demographic characteristics of male and female youth compare?
Table 1: Demographic Comparison of Male and Female Participants
Male
Female
Average Age
17.0
15.9*
Born in Canada
99%
99%
English First Language
100%
99%
Unstable Housing
1%
1%
Legal Involvement
40%
21%*
*p<0.5
Examination of potential differences in background characteristics between male and female youth revealed that
male participants were significantly older than female participants. They also differed significantly in their histories
of legal involvement, with male youth reporting significantly higher rates of previous legal involvement.
33
Clinical Needs of Youth Based on the GAIN SS
The GAIN SS is a well-validated and reliable screener for mental health and substance use concerns in youth and adults.
It has four 5-item subscreeners embedded within the overall measure to screen across four domains: Internalizing
(INT) disorders (e.g., mood, anxiety disorders), Externalizing (EXT) disorders (e.g., attention deficit/hyperactivity
disorder), Substance Use disorders, and engagement in Crime/Violence (CV). In order to fully understand the findings
presented in this report, it is important to understand the scoring decisions that informed the analyses. The GAIN
SS has been shown to have excellent sensitivity and specificity. These rates change, however, depending on how the
GAIN SS is scored and analyzed.
Within each subscreener using a moderate threshold of at least one recent (2-12 months ago) or current (past month)
concern has excellent sensitivity (94-98%) for identifying youth who will meet diagnostic criteria for disorder, but
lower (71-76%) specificity, i.e. lower accuracy in ruling out youth who will not meet diagnostic criteria for disorder.
Using a high threshold of three or more recent or current concerns within one domain improves the specificity to 96100%, but results in decreases in sensitivity (49-68%). Using a threshold of three or more current or recent concerns
endorsed across all domains (total) will identify 91% of youth who will meet diagnostic criteria for a disorder and will
rule out 90% of youth who will not have a disorder (Dennis et al., 2006).
Depending on the service setting, use of each threshold may be more appropriate. For example, in settings where the
rates of clinically significant mental health and substance use problems are expected to be low (e.g. primary care),
use of the moderate threshold may be most appropriate. In settings where individuals are seeking service for mental
health and substance use concerns, use of the high threshold may be more informative.
For this project, a modified version of the GAIN SS was used (GAIN SS CAMH Version) which includes 7 additional
items following the original subscreeners. These additional items provide information about eating behaviour,
thinking-related issues, traumatic distress, and gambling, gaming and internet overuse. Sensitivity and specificity
data for these items are not yet available and these items are not scored.
34
How many youth endorsed concerns on the GAIN SS?
Figure 11: Number of Concerns Endorsed by GAIN SS Domain
100%
10%
90%
35%
80%
57%
70%
60%
80%
45%
3+ Recent Concerns
20%
50%
96%
1-2 Recent Concerns
40%
No Recent Concerns
30%
37%
20%
10%
0%
44%
46%
14%
7%
6%
INT
EXT
3%
1%
SUB
CV
Total
GAIN SS Domain
As can be seen in Figure 11, 80% participating youth endorsed three or more recent internalizing concerns, suggesting
that with a full diagnostic assessment they may meet criteria for a diagnosis in the internalizing domain (e.g. mood
disorder, anxiety disorder, etc.). In the externalizing domain, more than half of youth endorsed three or more recent
externalizing concerns.
Endorsement of three or more concerns on the substance disorder subscreener was less common, but nevertheless,
over one-third of participating youth reported three or more recent indications of problematic substance use. In
the area of crime and violence, 10% of youth reported three or more crime/violence concerns. Overall, 96% of
participating youth endorsed three or more issues across the four subscales, suggesting that almost all participating
youth would receive a diagnosis with a full diagnostic assessment.
35
How do the needs of youth differ across sectors?
Figure 12: Clinical Needs using Moderate Threshold (1+ Endorsements) by Service Sector
100%
90%
80%
97%
97%
88% 90%
86%
82%
86%
80%
80%
70%
63%
Addictions
60%
49%
50%
Justice
41%
40%
Mental Health
30%
20%
10%
0%
INT
EXT
SUB
CV
Gain SS Domain
In Figure 12, the needs of youth by service sector are presented. Using the threshold of one endorsement to identify
youth who screen positive, more than 80% of youth regardless of sector screened positive for internalizing concerns.
Similarly, more than 85% of youth across sectors screened positive for externalizing concerns.
There were notable differences in rates of concerns for each domain of clinical needs, between youth in the mental
health sector and youth in the other two sectors. Specifically, youth from the mental health sector reported higher
levels of internalizing and externalizing concerns and lower levels of substance use and crime and violence concerns
in comparison to the youth from justice and addictions sectors.
36
Figure 13: Clinical Needs using High Threshold (3+ Endorsements) by Service Sector
100%
90%
86%
80%
70%
74%
73%
65%
Addictions
60% 60%
60%
50%
50%
50%
Justice
40%
40%
Mental Health
30%
18%
20%
14%
10%
0%
6%
INT
EXT
SUB
CV
Gain SS Domain
Using a threshold of three or more recent or current concerns within one domain improves the specificity (i.e. fewer
false positives) of the GAIN SS screener and allows identification of youth with higher severity of needs.
As can be seen in Figure 13, the majority of youth presenting to services across sectors have high internalizing
concerns. Significant difference in rates of internalizing concerns did exist among the sectors, with youth from the
mental health sector reporting the highest rate (86%). In addition, at least half of the youth across sectors reported
experiencing high levels of externalizing difficulties yet these rates did not differ significantly across sectors.
In the substance use domain, almost 75% of youth from the addictions sector endorsed experiencing three or more
symptoms of problematic substance use in the past year, while half of youth presenting to the justice sector had more than
three endorsements. The mental health sector saw the lowest proportion of youth endorsing problematic substance use. The
difference among the three sectors was statistically significant.
In the area of crime and violence, rates of endorsement were substantially lower than other domains, although over
40% of youth from the justice sector endorsed three or more crime and violence problems, which was significantly
higher than the rates of endorsement in the other two sectors.
37
Who endorsed internalizing mental health concerns (e.g., depression, anxiety)?
Figure 14: Internalizing Concerns by Age and Sex Categories
100%
90%
90%
83%
80%
70%
89%
69%
64%
60%
Male
50%
44%
40%
Female
30%
20%
10%
0%
12 to 15
16 to 18
19 to 24
Age
Overall female youth were significantly more likely than male youth to endorse internalizing concerns (female 86%
vs. male 72%; not shown), particularly in the 12 to 15 age category. In addition, younger youth were significantly
more likely to endorse internalizing concerns than older youth.
38
Who endorsed externalizing mental health concerns (e.g., impulsivity)?
Figure 15: Externalizing Concerns by Age and Sex Categories
100%
90%
80%
70%
60%
67%
63%
60%
60%
Male
50%
40%
40%
Female
30%
20%
11%
10%
0%
12 to 15
16 to 18
19 to 24
Age
As shown in Figure 15, younger youth overall were significantly more likely to screen positive for externalizing
behaviour problems than older youth. Although more male youth in the 19 to 24 age category were more likely
to identify externalizing concerns than female youth, the difference is not statistically significant, likely due to
small sample sizes.
39
Who endorsed problematic substance use?
Figure 16: Substance Use Concerns by Age and Sex Categories
100%
90%
80%
72%
70%
60%
Male
47%
50%
40%
30%
20%
31%
33%
30%
Female
21%
10%
0%
12 to 15
16 to 18
19 to 24
Age
Overall, males (48%) were significantly more likely to endorse substance use concerns than female youth (26%)
(not shown) particularly among youth aged 19 to 24. Over 20% of male and female youth in all age categories
endorsed recent substance use concerns. Additionally, older youth were significantly more likely to report
substance use problems than younger youth.
40
Who endorsed difficulties with crime and violence?
Figure 17: Crime and Violence Concerns by Age and Sex Categories
100%
90%
80%
70%
60%
Male
50%
40%
Female
30%
20%
10%
0%
23%
16%
14%
5%
12 to 15
2%
0%
16 to 18
19 to 24
Age
Male youth (18%) generally were more likely to screen positive for crime and violence concerns than female
youth (4%) (not shown), particularly in the 16 to 18 age category. There was no significant difference in crime and
violence concerns across the age categories.
41
How many youth endorsed suicide-related concerns?
Figure 18: Suicide Concerns by Age and Sex Categories
100%
90%
80%
70%
62%
60%
62%
Male
50%
47%
40%
30%
Female
36%
26%
20%
10%
0%
0%
12 to 15
16 to 18
19 to 24
Age
Given the clinical importance of suicide-related concerns, the single item related to suicide-related thinking and
behaviour from the internalizing subscreener was examined. Overall, 48% of participating youth indicated that they
had thought about suicide in the past year, including 28% of youth who indicated suicide-related concerns in the
past month.
When we examined these rates by sector we found relatively consistent rates across sectors ranging from 33% in the
addictions sector to 54% in the mental health sector. An additional 13% of youth reported suicide-related concerns
more than 12 months ago. Thirty-nine percent of youth indicated they had never thought about suicide. When we
examined rates of endorsement by sex and age category (Figure 18), it was revealed that in the 12 to 15 age group,
female youth were significantly more likely than male youth to endorse suicide concerns, while in the 19 to 24 age
group, male youth were significantly more likely to endorse suicide-related concerns than female youth.
42
How many youth endorsed additional areas of concern, like trauma-related distress?
As part of the process of meeting the needs of service sector stakeholders, and with the permission of Chestnut
Health Systems, the copyright holders of the GAIN SS, we added 7 items to the end of the GAIN SS. The items that
were added were not part of the original GAIN SS nor the validation study (Dennis et al., 2006), and as a result
their reliability, validity, and utility are unknown. Nevertheless, it was identified by stakeholders that it would be
important to ask about other areas of concern expected to be important for the youth participants so that these
areas could be explored further if youth indicated any concerns. The items were from the areas of eating concerns (2
items), traumatic stress (1 item), disordered thinking concerns (2 items), gambling concerns (1 item) and gaming/
internet concerns (1 item).
Figure 19: Additional Concerns by Sex Categories
46%
46%
48%
55%
55%
42%
24%
6%
23% 21%
15%
8%
1% 1%
Male
Additional Concerns
Female
The distressing memories/dreams (trauma-related distress) item and thoughts of persecution were the most
commonly endorsed additional items and were endorsed by about half of all youth (not shown). Youth were least
likely to endorse concerns about gambling. Female youth were significantly more likely than male youth to endorse
eating-related concerns including missed meals/threw up and binge eating.
43
Figure 20: Additional Concerns by Age Categories
58%
49%
30% 32%
31%
51% 52%
44%
34%
35%
28%
19%
12%
21%
18%
19%
12%
9%
1%
0%
3%
12 to 15
16 to 18
Additional Concerns
19 to 24
When the additional concerns were examined by age groups, it can be observed that across all items other than
gambling, youth aged 16 to 18 were more likely to report the concerns whereas youth aged 19 to 24 were least
likely to report the concerns. The level of binge eating concern was significantly higher for youth aged 18 years and
younger compared to youth aged 19 to 24.
44
Concurrent Substance Use and Mental Health Concerns
This project used the GAIN SS to identify youth who are likely to have concurrent disorders (i.e., co-occurring
substance use and mental health concerns). Youth who endorsed at least three recent concerns in the substance use
domain as well as at least three recent concerns in either the internalizing or externalizing domain were identified
as endorsing a concurrent disorder.
How many youth endorsed both substance use and mental health concerns?
Figure 21: Concurrent Disorders
2%
2%
8%
23%
5%
28%
22%
10% did not screen positive for internalizing or externalizing
mental health concerns, nor problematic substance use
45
Overall, 61% of youth screened positive for more than one area of concern, and 33% of participating youth screened
positive for possible concurrent (substance and mental health) disorders.
As can be seen in the Figure 21, 23% of all participating youth screened positive for co-occurring internalizing,
externalizing and substance use, 8% endorsed concurrent internalizing and substance use concerns, and 2% endorsed
concurrent externalizing and substance use concerns.
46
Who was more likely to endorse Concurrent Disorders?
Did rates of Concurrent Disorders differ for male and female youth or for younger and older youth?
Figure 22: Concurrent Disorders by Sex
100%
90%
80%
70%
60%
50%
43%
40%
30%
25%
20%
10%
0%
Male
Female
Sex
Significantly more males (43%) screened positive for concurrent disorders than females (25%).
47
Figure 23: Concurrent Disorders by Age
100%
90%
80%
70%
60%
53%
50%
40%
30%
34%
25%
20%
10%
0%
12 to 15
16 to 18
19 to 24
Age
The difference in rates of endorsement for concurrent disorders was statistically significant, with higher rates of
endorsement associated with older age.
48
Figure 24: Concurrent Disorders by Age and Sex Categories
100%
90%
80%
70%
64%
60%
Male
50%
40%
40%
30%
20%
31%
Female
30%
22%
21%
10%
0%
12 to 15
16 to 18
19 to 24
Age
It can be observed in Figure 24 that males were more likely to screen positive for co-occurring mental health and
substance use concerns than female youth in each age group, but this is particularly evident within the oldest age
group.
49
How did the rates of Concurrent Disorder endorsement compare across service sectors?
Figure 25: Concurrent Disorders by Service Sector and Sex Categories
100%
90%
80%
70%
60%
68%
61%
Male
57%
50%
40%
Female
33%
30%
20% 18%
20%
10%
0%
Addictions
Justice
Mental Health
Sector
Figure 25 shows that youth in the addictions sector reported the highest rate of concurrent disorders and those in the
mental health sector reported the lowest rate of concurrent disorders. This is true for both male and female youth. Rates
of concurrent disorders were not significantly different between males and females within each sector.
50
Living Arrangements
For the purposes of the following analyses living arrangements were reduced to two categories: 1) parental/family
home, and 2) living outside of the parental/family home.
Figure 26: Concurrent Disorders by Living Arrangement
100%
90%
80%
70%
60%
50%
46%
40%
30%
29%
20%
10%
0%
Parent/family home
Not in parent/family home
Living Arrangement
Rates of endorsement of concurrent disorders differed significantly between youth who live outside of the parental/family
home (46%) and youth living in the parental/family home (29%) particularly for male youth. The rates of concurrent
disorder endorsement however did not differ between male and female youth within each living arrangement group.
51
Are youth who have had legal involvement more or less likely to endorse Concurrent Disorders?
For the purposes of the following analyses, legal involvement was reduced to two categories: 1) no legal involvement
and 2) previous legal involvement.
Figure 27: Concurrent Disorders by Legal System Involvement
100%
90%
80%
70%
60%
50%
45%
40%
30%
28%
20%
10%
0%
No legal involvement
Previous legal involvement
Legal Involvement
Figure 27 showed that youth with a history of previous legal involvement (45%) were significantly more likely to screen
positive for concurrent disorders than youth without a history of legal involvement (28%).
52
Figure 28: Concurrent Disorders by Legal System Involvement and Sex
100%
90%
80%
70%
60%
56%
Male
50%
40%
30%
Female
33%
29%
25%
20%
10%
0%
No legal involvement
Previous legal involvement
Legal Involvement
Among youth with previous legal involvement, male youth (56%) were significantly more likely to endorse concurrent
disorders than female youth. However among youth without legal involvement, males and females did not differ
significantly in their rates of concurrent disorders.
53
Educational Status
Figure 29: Concurrent Disorders by Student Status
100%
90%
80%
70%
60%
50%
44%
40%
30%
29%
20%
10%
0%
Student
Non-student
Education Status
When comparing youth who identified as students to those who did not, it was revealed that 29% of students and
44% of non-students endorsed concurrent substance use and mental health concerns, which is statistically significant,
suggesting that educational status was related to screening positive for concurrent disorders.
54
Figure 30: Concurrent Disorders by Student Status and Sex
100%
90%
80%
70%
63%
60%
Male
50%
40%
30%
Female
33%
26%
21%
20%
10%
0%
Student
Non-student
Education Status
Male youth who did not identify as students were more likely to screen positive for concurrent disorders when compared
with youth who identified as students as well as female youth who did not identify as students.
55
How many participants endorsed multiple areas of concern in their lives?
Figure 31: Complexity of Needs
100%
90%
80%
70%
60%
57%
63%
Male
50%
38%
40%
Female
35%
30%
20%
6%
10%
0%
2%
0-2
3-4
5-6
Number of Significant Needs
In order to understand how many participants experience multiple areas of concern we also examined the following
social determinants of health, along with mental health and substance use concerns: 1) housing (unstable or supportive),
2) education/occupation (under 18 and not a student or 18 and older and not a student and not employed), 3) legal
involvement (past or current legal involvement), 4) internalizing concerns (high severity), 5) externalizing concerns
(high severity), and 6) substance use problems (high severity). Overall, 40% of participants reported having 3 or more
concerns with 4% experiencing 5 or more concerns (not shown). Results did not differ significantly between male and
female youth. These findings highlight the complexity of the needs of the individuals who presented for service and
participated in this project.
56
This project included a survey about service providers’ attitudes, knowledge, and practices regarding youth substance use, mental health, and concurrent disorders. Questions about interagency collaboration and interagency
referral practices were also included in the survey. In addition, the project included a feedback survey that gathered
information regarding the feasibility, utility, and impact of using the GAIN SS.
Service providers in the Haldimand-Norfolk and Brant Region (n=66) completed the service provider survey prior
to participating in the project’s capacity building training events and then again with the feedback survey (n=41)
approximately seven to nine months after training took place.1 Detailed results for the service provider survey from
all the participating regions can be found in the Ontario Youth Screening Project final report. The results from the
feedback survey of Haldimand-Norfolk and Brant Region service providers are presented as follows.
(1)
Service provider surveys were collected from both Haldimand and Norfolk and Brantford and Brant County together and as a result, the
responses from the two communities have been analyzed together.
57
Utility and Feasibility of the GAIN SS
Figure 32: Service Provider Perceptions of GAIN SS Utility and Feasibility
100%
90%
92%
81%
80%
76%
70%
60%
50%
46%
40%
30%
22%
20%
10%
0%
Useful information
at least some of
the time
Not at all
disruptive
Impacted service
at least some of
the time
Facilitated referral Recommended
at least some of use at least some
the time
of the time
GAIN SS Utility and Feasibility
Service providers who provided feedback reported that generally the GAIN SS was useful and impacted service
decisions. The majority of service providers recommended continued use of the GAIN SS despite some also reporting
a perceived disruption from its use. Fifty-three percent reported that being part of this network project has facilitated
inter-agency communication and/or relationships.
58
Service provider comments about the feasibility and utility of the GAIN SS in their practices
“The staff have found the GAIN SS tool helpful in their work and identifying needs of
youth.”
“Really positive experience and youth did not mind being screening for things that may
have been missed.”
“Some staff expressed confusion around consent For example, although completing
the GAIN SS is confidential requiring only the student’s consent, if they screen positive
and are referred for further help they would then require their parent’s consent to access
those additional services.”
“Time is already tight and many of the staff felt that they just did not have the time that it
would take to complete and then address the outcome of the survey.”
“Staff felt that there is a definitely lack of capacity to deal with students who screen
positive and that they don’t have the resources to support these kids. They are not
mental health experts and there is a lack of mental health services in Brantford.
Their primary choices are St. Leonard’s or the General Hospital and these are not
sufficient or effective ways to deal with some of the issues that they see. Therefore, there
is a feeling of helplessness around screening: if a student screens positive, this merely
opens up the question: Where do we go from here? And the options are few and often
not ideal.”
“Students often come to discuss another issue (e.g., sexual health) and asking them to
complete the GAIN SS doesn’t ‘fit’ into the conversation/reason for visit.”
“Although partners such as school board, child/youth/social workers, and Health
Schools Team Nurses came together for the initial workshop/training, there was no
further communication and this proved to be a barrier for numerous staff.”
59
“Staff felt excited after the training but then disappointed at having to wait almost 6
months before the OK was received from the school board. By this point, continuity had
been lost and many felt they had to re-train themselves regarding implementation.”
“With respect to completing the survey, students struggled with the definition of
“significant” and often needed clarification around what this actually means.”
“Social workers working in school need to become part of this process as well or it
creates a feeling of tension. For example, if a nurse screens a student as positive, the
next step is often for them to become involved with the school’s child/youth worker
or social services. However, if these services are not in the loop and not involved with
the GAIN SS, this creates a disconnect and a lack of continuity of services as far as
the student is concerned. Staff felt that future projects need to involve community and
school partners, including the school board, more closely.”
60
Summary of Findings
• Ninety
percent of eligible youth presenting to participating services and agencies contributed to
this report.
• Almost
100% of youth (99.5%) who completed the GAIN SS gave consent for it to be included in this report.
•
Youth presenting for services from the addictions, mental health, and justice sectors contributed
information to this report.
•
Differences between the age categories were apparent across the service sectors. Youth in the
addictions sector were more likely to be in the older age category (19-24 years) and the majority
of youth presenting to the other sectors (mental health and justice) were in the 12 to 15 and 16 to
18 age categories.
•
The project had slightly more female than male participants (55% vs. 44%).
•
The majority of participants identified their ethnicity as White/European, reported being born in
Canada and having English as their first language.
•
Older youth and youth presenting to the addictions sector were less likely to live in the
parental/family home.
•
Male participants were significantly older than female participants. Additionally, male youth
reported significantly higher rates of current and previous legal involvement as compared to
female youth (40% vs. 21%).
•
More than half of participating youth screened positive for internalizing and externalizing mental
health concerns and over one-third of youth screened positive for problematic substance use.
The rates of endorsement were significantly different across sectors for internalizing and substance
use concerns but not for externalizing concerns. Youth in the mental health sector presented with
a higher rate of internalizing concerns and lower rate of substance use concerns than youth in the
addictions and justice sectors.
•
Age and sex are related to rates of endorsement across domains. Female youth were significantly
more likely to endorse internalizing concerns and less likely to endorse substance use and crime and
violence related concerns than male youth. Youth aged 19 to 24 were significantly less likely to
report mental health concerns and were more likely to report substance use concerns than youth in
the younger age categories.
•
Forty-eight percent of participating youth reported significant suicide-related concerns in the past
year. While females were more likely than males to report suicide-related concerns in the youngest
age group (12-15 years old), males were more likely than females to report such concerns in the
oldest age group (19-24 years old).
•
Trauma-related distress and thoughts of persecution were endorsed by approximately half of the
youth overall. Female youth were significantly more likely than male youth to endorse eating-related
concerns.
61
•
More than half of the participating youth (60%) screened positive for more than one disorder
and one-third of participating youth (33%) screened positive for co-occurring mental health and
substance use concerns.
•
Factors found to be significantly related to experiencing co-occurring mental health and substance
use concerns for participating youth included age, sex, living arrangements, educational status,
and legal involvement. Older male youth were significantly more likely to endorse a concurrent
disorder than female youth. As well, participants who did not live with their parents/in the family
home were more likely to endorse a concurrent disorder than youth who lived in the parental/
family home. This relationship was especially true among male youth. Youth with a history of legal
involvement were more likely to endorse concurrent disorders than those without such history, most
notably among male participants. Being male and not identifying as a student was related to a
higher endorsement of concurrent disorders than being a student or female.
•
Forty percent of participating youth reported three or more concerns out of six that included social
determinants of health along with mental health and substance use concerns. This indicates that
close to half of participating youth have complex needs.
•
The majority of service providers reported that they found the GAIN SS provided useful information,
impacted service delivery and facilitated referrals. 53% of service providers reported that being part
of this network project has facilitated inter-agency communication and/or relationships.
62
Discussion
Youth Needs
The findings of this project in Brantford and Brant County suggest that many youth presenting for service, regardless
of which sector they present to, are experiencing significant substance use and/or mental health concerns. More than
half of participating youth endorsed significant concerns in more than one domain, and one-third of youth screened
positive for co-occurring substance and mental health concerns. Youth in the addictions sector reported the highest
rate of concurrent disorders (68% male and 61% female) when compared to the justice and mental health sectors.
These findings suggest that recent efforts to improve capacity to screen across sectors and to address co-occurring
substance use and mental health problems are warranted.
The findings of this report also support the need for gender-sensitive and developmentally-informed approaches
with youth. The concerns and needs of male and female youth differed, as did the needs and concerns of younger and
older youth. In terms of gender related needs, female youth were significantly more likely to endorse internalizing
concerns and less likely to endorse substance use and crime and violence-related concerns when compared to males
in the same age categories. Additionally female youth in the younger age category (12-15 years old) were more likely
to report suicide-related concerns than male youth. However male youth in the older age category (19-24) were more
likely to report suicide-related concerns than female youth. In terms of age related needs, endorsement of substance
use concerns, increased with age, being highest in the 19-24 age category, while youth in the younger age categories
were more likely to report mental health concerns. Additionally, the likelihood of screening positive for concurrent
disorders was associated with living arrangement (outside of the parental/family home), educational status (not
being in school), and history/current legal involvement particularly for male youth.
These, and other findings from the project, have implications for service delivery, including screening practices, in the
participating sectors, particularly when considering what services might be most applicable at different ages, and for
male and female youth.
Project and Implementation Processes
As described in this report there were several essential steps required to initiate, carry out and complete this project.
First and foremost, collaboration between community stakeholders was required to build a network through
identifying, engaging and supporting partners from various youth service sectors. In Brant County, teleconference
and face to face meetings were arranged with interested parties from area planning tables including the Student
Support Leadership Initiative (SSLI) group which spanned Haldimand, Norfolk and Brant Counties and the Brant
Children’s Services committee to explore interest in project participation and discuss project details and expectations
for involvement. As a result, four agencies in Brantford and Brant County committed to project involvement. The
enthusiasm and hard work of the project network coordinator resulted in the Brantford and Brant County service
community’s sustained and active engagement in the project. In this community, the project had representation
from three service sectors including addictions, mental health, and youth justice. Service providers from all three
sectors participated in the network development and capacity building activities. Ultimately all service sectors were
represented in the screening implementation and data collection activities of the project as well (See Appendix C).
Providing more than one capacity building event, including webinar training options for those who could not attend
the “live” events, provided greater opportunity for all agency staff to receive training directly from the project leads.
This helped to ensure that all aspects of the protocol were clearly and consistently communicated. Agencies decided to
send staff who would participate in the full project as well as staff who might use the screening tool with populations
that were not part of this project (e.g., adults older than 24 years), and staff who would not be administering the
screener, given their role in the agency but might receive youth who had been screened. As such, the capacity building
component of the project had a broader reach than initially anticipated. During the joint data analysis, feedback
63
indicated that a mechanism for regular, on-going contact amongst service providers, in addition to the process put in
place for agency leads, would be helpful following the initial capacity building events to enhance network-building,
referral capacity and knowledge of resources would be helpful. In addition it was recommended that efforts be made
to ensure receipt by all participating service providers of the local Referral Resource Guide.
Staff concerns about potential challenges in engaging youth in screening and research processes are a common
barrier to engaging service providers and community-based agencies in projects such as this one. The project findings
in Brantford and Brant County indicate that 90% of the youth who completed the screener, also agreed to participate
in the research component of the project. This is very encouraging with respect to the feasibility of such initiatives
and the potential of projects such as this to generate information about local youth needs.
Following completion of data collection, the project team learned that GAIN SS administration was continuing in a
couple of the agencies beyond the six month project data collection phase. This suggests that in some situations this
project has the potential to prompt sustained changes in practice. In addition, one of the agencies is also considering
using the GAIN SS during the intake process in place of a full assessment to help facilitate referrals.
Limitations
The findings of this project are limited by factors related to the screening tool as well as the extent and type of
engagement of the participating service providers and the number of male and female youth in each age group.
The GAIN SS is a high level screening tool intended to identify youth who would be likely to have a diagnosis with a
full assessment and who thus would benefit from assessment and service planning. As a result, it does not provide
detailed information about the areas of concern that are identified. Service providers and services engaged with the
project to differing extents which may have impacted the findings in unknown and/or ways that may not be obvious. 64
Recommendations
•
•
•
Gender-informed and gender-specific services should be considered to ensure that the services
delivered are designed to address the different types of difficulties male and female youth experience.
For example, female youth were more likely to endorse internalizing concerns and suicide-related
concerns, especially in the younger age categories; male youth were more likely to endorse substance
use and crime and violence (older age categories) related concerns than female youth. Additionally,
significantly more male youth screened positive for concurrent disorders than female youth across
age categories.
Developmentally-informed and responsive services are indicated in order to meet the needs of youth
as they move from early to later adolescence and into the transitional-aged youth group (19 to
24 years), especially those who are aging out of child and youth focused services and seeking and/
or receiving services in the adult service sector. The increase with age in rates of endorsement for
substance use and concurrent disorder concerns, in particular, is notable in this community.
Continued capacity building regarding concurrent disorders across sectors is warranted given that
more than half of participating youth endorsed significant concerns in more than one domain. It is
notable that rates of concurrent disorders between sectors were equivalent with the exception of
the mental health sector where rates were lower. This project aimed to improve early identification
and pathways to care through evidence-based practice in the form of screening using a standardized
tool. Subsequent projects should consider the importance of capacity building across sectors
regarding enhanced collaborative care, referral practices and interventions to access appropriate
services to address substance use and concurrent disorders.
Building capacity for trauma-informed care across sectors is also suggested, given that half of all
participating youth endorsed concerns related to traumatic distress. Consideration should be given
to gender-specific services addressing trauma, given the high endorsement of traumatic distress by
both male and female youth.
•
•
The finding that one of the strongest predictors of screening positive for concurrent disorders was
previous legal involvement highlights the importance of early screening and follow-up for youth
who come in contact with the justice sector, particularly male youth. Consideration of strategies
such as screening youth who have early police contact for emerging substance use and/or mental
health difficulties may identify opportunities for earlier intervention, rather than waiting for serious legal
problems and/or for serious substance use and/or mental health problems to develop. This reinforces
the need for developmentally and gender informed and specific approaches across sectors,
including the justice sector.
• Given the high rate of endorsement of suicide concerns, particularly amongst the younger female
youth, as well as the high rate of endorsement of concurrent concerns across the participating sectors,
efforts to ensure early identification of concerns are recommended across sectors. Consideration
should be given to extending consistent brief screening practices and to gathering similar information
as was gathered through this project in other health care settings such as community based primary
care and hospital emergency rooms and/or in settings accessible to youth such as educational
settings.
• While this project examined youth needs at one point in time in service delivery, consideration should
be given to the potential utility of repeating administration of the screening tool at subsequent points in
the service delivery process for the purposes of monitoring within treatment progress and post-treatment
outcomes.
65
•
Given the importance of being able to respond in an effective and timely manner to positive screening
results, it is recommended that all service providers contact agencies for the most up-to-date information
on services. In addition, it is recommended that the local Children’s Services Committee continue to
address referral capacity and knowledge of resources to enhance network-building, referral capacity
and knowledge of resources.
•Further study is also recommended to examine the relative impacts of training, agency policy,
protocols, monitoring, supervision and administrative support on implementation of new practices,
such as the implementation of a consistent screening tool and process, as was examined in this
project.
66
Appendices
67
68
Appendix A: Brantford and Brant County Network Member Agency Descriptions
Contact Brant
Contact Brant is a single point service access mechanism (intake and referral) for children and youth ages 0 - 18 with mental
health concerns or intellectual disabilities. Contact Brant is the first place to contact for information, questions, and access
to community resources and programs. Contact Brant helps navigate the many services available to children, youth and
their families, and triages, by completion of intake, assessments and referral, to the most appropriate community service.
Brant County Health Unit
The Brant County Health Unit is a community health agency located in Brantford, Ontario. It provides health services to
approximately 100,000 residents living within the City of Brantford and 25,000 residents living within the County of Brant,
which includes the towns of Paris, St. George, Oakland, Scotland, and Burford. The health unit’s activities are guided by
the Board of Health which is made up of elected officials and representatives from the community. A wide range of health
services are offered, most of which focus on promoting and protecting health and preventing disease, illness and injury. The
Health Unit is home to several different teams, including the Healthy Schools Team. This team is made up primarily of public
health nurses who work in elementary and secondary schools to provide health education and supports to children, youth,
and young adults.
Woodview Children’s Centre
Woodview offers a broad spectrum of services for children and youth facing mental health challenges and individuals of all
ages with Autism Spectrum Disorder. The program works in partnership with families who have an integral part to play in
the services that are provided. They work with schools and social service agencies to support individuals and families.
Programs involved in project:
Child and Family Counselling
Child and Family Counselling provides office-based counseling services for children and youth up to the age of 18 and
their families. Those presenting with acute mental health issues are seen on a priority basis.
Youth Justice:
This program provides counselling and support to youth who are experiencing social, emotional and/or behavioural
difficulties and have come into conflict with the law. Services may be office, home or community based. Support is
also provided to families.
69
St. Leonard’s Community Services, Addiction and Mental Health Services
Agency Vision
St. Leonard’s Community Services is a recognized centre of excellence for the provision of services to children,
youth, adults and families.
Agency Mission:
St. Leonard’s Community Services responds to needs by providing quality addiction, mental health, employment,
education, justice and residential programs that enable children, youth, adults and families to overcome challenges
through choices that result in positive change.
Agency Values and Beliefs:
As we discharge our mission in pursuit of our vision, we adhere to the following values and beliefs:
1. A commitment to excellence in client service.
2. Respect for the dignity and diversity of our clients, staff and community.
3. Support and recognition of our staff.
4. Collaboration and knowledge exchange.
5. Accountability to our funders, clients, partners and the community.
These values drive all of the agency’s programs, policies.
The Addiction Services of the Addiction and Mental Health Centre consist of a bio-psychosocial assessment,
development of a strength based service plan, family support and aftercare, which may include individual and/or
group counselling and referral to appropriate services such as residential treatment for individuals struggling with
drug, alcohol, gambling and/or concurrent disorders.
70
Appendix B: Key Project Activity Descriptions
Network Development
Member agencies that participated in the Network Development activity played a foundational role in building
a collaborative network, starting with preliminary discussions regarding project participation. These agencies
participated in several meetings with the project team, in addition to network specific meetings and training. The
agency leads and broader network membership also collaborated with the project team to carry out the project.
Capacity Building
Service providers and agency leads from interested agencies participated in a half-day evidence-based youth cooccurring disorders capacity building session and a half-day screening and intervention protocol training session.
During this session, where agencies had committed to full project participation and had obtained research ethics
approval, service providers also completed the Service Provider Survey. Some agencies that participated in the
Capacity Building activities were interested in participating in the full project but were not able to due to resource
or administrative challenges, such as difficulties completing legal and/or ethics processes in the required network
timeframe.
Screening Implementation
Member agencies that participated in the full project implemented the GAIN SS with youth seeking services at their
agencies. Some agencies chose to implement the GAIN SS with the youth seeking service for clinical purposes, but
did not participate in the full data collection component of the project (see below).
Data Collection
Member agencies that participated in the full project participated in a six month data collection period. During this
time, the GAIN SS and Background Information Form were administered to consenting youth seeking service at their
agencies and a copy was sent to the project team. The data was prepared by the project team and a local community
report was generated through a collaborative process between the project team and the participating agencies.
71
Appendix C: Agency Project Activity Participation
Project Activity
Sector
Agency Name
Addictions
Mental
Health
Justice
Network
Development
Capacity
Building
Screening
Implementation
Data
Collection
St.Leonard’s
Community Services,
Addtion Services
X
X
X
X
Brant County
Health Unit
X
X
X
X
Contact Brant
X
X
X
X
Woodview Children’s Centre:
Child & Family Counselling
X
X
X
X
Woodview
Children’s Centre:
Youth Justice
X
X
X
X
72
Appendix D: Project Timeline
Year 1
2011
OCT
DEC
Year 2
2012
JAN
MAR
APR
JUN
Year 3
2013
JUL
SEP
OCT
DEC
JAN
MAR
APR
JUN
2014
JUL
SEP
OCT
DEC
JAN
MAR
Networking:
Introduce project to
potential participating
agencies
Establish cross-sectoral
network: REB Approval
& Signing of MOU
Capacity
Building
Project launch
Project actively
underway
Preliminary findings
presented
Report to
stakeholders
Brantford and Brant County, Ontario Timeline
73
Ontario Youth Screening Project Timeline
Appendix E: Project Flow Chart
Ontario Youth Screening Project: Project Flow
New youth (aged 12-24)
presents for service
Youth info is recorded on
Tracking Form
Youth is given
Youth Package
Youth refuses to complete
package
Youth completes
questionnaires and consent
to share info is provided
Youth completes
questionnaires and does
not provide consent to
share info
Info is recorded on Tracking
Form and regular agency
service is delivered
Questionnaire: Info is
reviewed and used for
service planning, copy
of consent is provided to
youth/parent
Questionnaire: Info is
reviewed and used for
service planning
Original consent and
anonymous copy of
questionnaire package
is submitted to Project
Coordinator
Form and agency service is
delivered
Informed by screening info
74
Form and agency service is
delivered
Informed by screening info
Appendix F: References
Armstrong, T.D. & Costello, E.J. (2002). Community studies on adolescent substance use, abuse, or
dependence and psychiatric comorbidity. Journal of Consulting and Clinical Psychology, 70
(6), 1224–1239.
Bijl, R.V. & Ravelli, A. (2000). Current and residual functional disability associated with psychopathology: Findings from the Netherlands Mental Health Survey and Incidence Study
(NEMESIS). Psychological Medicine, 30, 657-668.
Boak, A., Hamilton, H.A., Adlaf, E.M. & Mann, R.E. (2013). Drug use among Ontario students 1977-2013.
Ontario Student Drug Use and Health Survey. Toronto, ON: Centre for Addiction and Mental Health.
Centre for Addiction and Mental Health. (2006). Navigating screening options for concurrent
disorders. Toronto, ON: Author.
Chaim, G. & Henderson, J. (2009). Innovations in collaboration: Findings from the GAIN Collaborating
Network Project. Toronto, ON: Authors.
Clark, H.W., Power, A.K., Le Fauve, C.E. & Lopez, E.I. (2008). Policy and practice implications of
epidemiological surveys on co-occurring mental and substance use disorders. Journal of
Substance Abuse Treatment, 34 (1), 3-13.
Collishaw, S, Maughan, B, Goodman, R & Pickles, A (2004) Time trends in adolescent mental health.
Journal of Child Psychology and Psychiatry. 45(8):1350-62
Dennis, M.L., Chan, Y.F., & Funk, R.R. (2006). Development and validation of the GAIN Short Screener
(GSS) for internalizing, externalizing and substance use disorders and crime/violence problems
among adolescents and adults. American Journal on Addictions, 15, 80-91.
Elster, A.B. & Kuznets, N.J.(1994). AMA Guidelines for Adolescent Preventive Services (GAPS):
Recommendations and Rationale. Chicago, IL: American Medical Association.
Grisso, T., Vincent, G., & Seagrave, D. (Eds.). (2005). Mental health screening and assessment in
juvenile justice. New York: Guilford Press.Health Canada (2002). Best practices: Concurrent
mental health and substance use disorders. Ottawa, ON: Author.
Henderson, J., Chaim, G., & Rush, B. (2007). Knowledge, skills and tools: Addressing the mental health
and addiction needs of youth. Symposium presentation, Issues of Substance 2007 Conference,
Edmonton, AB.
Henderson, J., Chaim, G., & Goodman, I. (2009, August). Evaluating youth concurrent disorders across
youth-serving agencies in Toronto, Canada. Paper presentation, 117th Annual Convention of
the American Psychological Association, Toronto, ON.
Henderson, J., MacKay, S., & Peterson-Badali, M. (2010). Interdisciplinary knowledge translation:
Lessons learned from a mental health - fire service collaboration. American Journal of
Community Psychology, 46, 277-288.
Henderson, J. & Chaim, G. (2013). National youth screening project: Enhancing Youth-focused,
evidence-informed treatment practices through cross-sectoral collaboration. Toronto, ON: Authors.
75
Hillman, L., Chaim, G., & Henderson, J. (2011). Cross-sector collaboration in action: Findings from the
Concurrent Disorders Support Services Screening Project. Toronto, ON: Authors
Kessler, R.C., Chiu, W.T., Demler, O., Merikangas, K. R. & Walters, E.E. (2005). Prevalence, severity,
and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey
Replication (NCS-R). Archives of General Psychiatry, 62(6), 617-627
King, R. D., Gaines, L. S., Lambert, E. W., Summerfelt, W. T., & Bickman, L. (2000). The co-occurrence
of psychiatric and substance use diagnoses in adolescents at the Fort Bragg Demonstration
Project: Frequency, recognition, cost and outcomes. Journal of Behavioral Health Services and
Research, 27(4), 417-430
Lewinsohn P.M., Rohde P. & Seeley J.R. (1995). Adolescent psychopathology: III. The clinical
consequences of comorbidity. Journal of the American Academy of Child and Adolescent
Psychiatry. 34, 510–519.
McElheran, W., Eaton, P., Rupcich, C., Basinger, M., & Johnston, D. (2004). Shared mental health care:
The Calgary model. Families, Systems & Health. 22(4), 424–438.
Mental Health Commission of Canada. (2009). Toward recovery and well-being: A framework for a
mental health strategy for Canada.
Ministry of Children and Youth Services (2013). Ontario’s Policy Framework for Child and Youth
Mental Health. Retrieved from: http://www.children.gov.on.ca/htdocs/English/topics/
specialneeds/mentalhealth/shared_responsibility.aspx
Murphy, R. A., Rosenheck, R. A., Berkowitz, S. J., & Marans, S. R. (2005). Acute service delivery in a
police-mental health program for children exposed to violence and trauma. Psychiatric
Quarterly, 76(2), 107-201.
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Recommendations for a National Treatment Strategy. Ottawa, ON: National Framework for
Actions to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.
Oliver, C., & Dykeman, M. (2003). Challenges to HIV service provision: The commonalities for nurses
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C.E., Lent, B., Neufeld, R., Vingilis, E., Zaric, G., & Shanley, D. (2006). Help – I need somebody:
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Research Foundation.
Roberts, R.E., Roberts, C.Y. & Xing, Y. (2007) Comorbidity of substance use disorders and other
psychiatric disorders among adolescents: evidence from an epidemiologic survey. Drug and
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Robillard, A.G., Gallito-Zaparaniuk, P., Arriola, K. J., Kennedy, S., Hammett, T., & Braithwaite, R. L.
(2003). Partners and processes in HIV services for inmates and ex-offenders. Facilitating
collaboration and service delivery. Evaluation Review, 27, 535-562.
Rush, B., Castel, S., & Desmond, R. (2009). Screening for concurrent substance use and mental health
problems in youth. Toronto, ON: Centre for Addiction and Mental Health.
Skilling, T., Henderson, J., Root, C., Chaim, G., Bassarath, L., & Ballon, B., (2007). Who are our clients?
76
Comparing the mental and addiction needs of adolescent clients across two CAMH
programs. Poster Presentation, Annual Convention of the Canadian Psychological Association,
Ottawa, ON.
Urbanoski, K.A., Cairney, J., Bassani, D, & Rush, B. (2008). Perceived unmet need for mental health
care among Canadians with co-occurring addiction and mental disorders. Psychiatric
Services, 59 (3), 283-289.
Vida, R, Brownlie, E.B, Beitchman, J.H, Adlaf E.M,, et al. (2009). Emerging adult outcomes of
adolescent psychiatric and substance use disorders. Addictive Behaviors, 24, 800-805.
Waddell, C., McEwan, K., Cody, A. Shepherd, D. et al. (2005). A public health strategy to improve the
mental health of Canadian children. Canadian Journal of Psychiatry, 50 (4), 226-233.
77

Ontario Youth Screening Project Brantford and Brant County

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