Nordic Ministerial meeting on Substance Abuse Isafjordur, 10-11th of August 2004

1. Nordic Ministerial meeting on Substance Abuse Isafjordur, 10-11th of August 2004 Youth Substance Abuse in Iceland: prevention and treatment Bragi Guðbrandsson Director Gov. Agency for Child Protection

2. Outline • Some research findings on substance abuse among Icelandic youth • Primary and secondary prevention: the role of the state, local government and NGO´s • Treatment services for youth in Iceland • Voluntary treatment: SÁÁ • Intervention by the CPS • “Gatekeeping” in treatment services • The benefits of “Contracting out” treatment services • Future orientations: home-based intervention

3. Trends in substance use among 10th grade students in Iceland from 1998-2003

4. Proportion of students in 10th grade who have become drunk 10 times or more during last 12 months (ESPAD 1995)

5. Proportion of students in 10th grade that have had accidents or injuries in relation to alcohol use (ESPAD 1995)

6. Proportion of students in 10th grade in 1997 that have become drunk in the last 30 days by how many of their friends use alcohol

7. Proportion of students in 10th grade that have become drunk the last 30 days by how often they spend time with their parents after school during weekdays

8. Daily smoking and drug use in three groups: Among those with the highest participation in unsupervised youth activities, in organized youth work and in sports

9. Primary prevention: The role of the Public Health Institute of Iceland • The PHI is a center for preventive work in various public health areas: accident prevention, dental health, nutrition, mental health, tobacco, alcohol and drug abuse • The Alcohol and Drug Abuse Council: aims at professionalism and continual search for knowledge, incl. assessment of preventive measures • Regular surveys on alcohol- and drug related problems, e.g. hospital admissions, criminal offences and drunken driving • Coordination and collaboration

10. Primary and Secondary prevention: The role of Local Governments • Wide range of services for youth, including supervised leisure activities and sports • Educational measures, campaigns (Drug free Iceland 2002) and other preventive activities, esp. in elementary schools • Intervention by the local Child Protection Services: family support and counselling, psychological and other therapeutical services, support persons for youths etc.

11. Prevention: The role of NGO´s • The Drug Free Youth, a parental organization • The Parent´s House: hotline services, parent support groups, aftercare counselling and group work for youth, programs for children of alcoholics etc. • SÁÁ: the mainstream treatment services for substance abuse in Iceland, operates a detoxification clinic, two outpatient units, two treatment clinics, three recovery houses and a social center

12. SÁÁ: Voluntary Treatment Services for Youth • an operation of a special detox division for young substance abusers • young substance abusers integrated into mainstream treatment services • based on the 12 step program with an emphasis on alcoholism as a progressive disease • substance abuse seen as a focal point – a primary concern • emphasis on growth of spiritual awareness and promotion of new and healthy lifestyles • voluntary intake based on the request of the youth him/herself • 120 to 130 adolescents submitted annually during the past years

13. Shortcomings of the 12 step voluntary treatment services for youth • lack of comprehensive diagnosis other than addiction (social/family assessment, ADHD/Attention deficit, depression, PTD etc.) • the applicability of the disease model to youth • “to hit bottom” – limited a fragmented history of abuse • the issue of “labelling” • the principle of abstinence – doomed to failure? • the vicious circle of treatment “drop-outs” and re-admissions • negative treatment outcomes: low risk youth and negative socialisation or “infectious effects”

14. Intervention by the Child Protection Services • The “honeymoon phase” and self destructive behaviour • The provisions of the Child Protection Act: - refer to specialised treatment for alcohol and drug abuse, serious behavioural problems and criminal offences - refer to the obligation of the CPS to take supportive measures before placement in institutions - intake or placement in institutional treatment is considered “last resort” - The Government Agency for Child Protection bears the responsibility of providing the appropriate treatment facilities

16. Child Protection and Treatment Services for Youth • reorganisation of the treatment services 1995 – 2000 • 5 state operated treatment facilities closed • A new diagnostic center established • Long-term treatment in “family settings” • Two basic principles: • “Gatekeeping” • “Contracting out” of long-term treatment

17. Gatekeeping • To ensure that services are provided only to those who meet specified eligibility criteria • To ration and make effective use of scarce resources • To focus on the youths needs and targeting services • Should raise thresholds for unnecessary or even harmful placement (low risk youth)

18. Application for institutional placement- “gatekeeping” All appropriate supportive measures have been unsuccessfully tried Child Protective Services apply for placement to the Government Agency for Child Protection. Application assessment (incl. advice from the Child Psychiatry Hospital) Government Agency for Child Protection decides on placement Applications based on a contract with the Prison Administr. General principles: 1. Respect for the child’s wishes 2. Partnership with family

19. Young substance abusers: institutional treatment Child Protection Services Diagnostic Center for Youth • Discharge • Home • (aftercare) Assessment 2-4 weeks Acute placement 1-2 weeks Treatment 2-4 weeks Police Treatment Facilities Prison Authorities Long-term treatment facilities(specialized)

20. Long-term treatment services • eight long-term treatment facilities with 60 beds • typical size is 6 youth living sharing their lives with the treatment provider • emphasis put on “emotional nourishment” • different target groups and variation in treatment goals • two facilities specialize in substance abuse • behaviouralistic and environmental approach • educational objectives and meaningful responsibilities • psychological- and family counselling

21. “Contracting out” treatment services • The overt goal: to improve quality of treatment, increase flexibility and improve cost efficiency • Quality is improved by clearer definition of standards and the separation of service and supervision • Flexibility is increased as it is easier to accommodate for demand for treatment that changes from one time to another • Cost control is more effective as a fixed price is negotiated, overhead costs are reduced and management more efficient

22. The Contractual Framework • Identifies treatment facilities and location • Defines treatment goals and “modules” • Identifies target group and number of youth • Number of staff, training and special qualification (incl. psychological services) • Defines the intake and discard process • Identifies established procedures like the rights of children in institution, confidentiality etc. • States the monitoring role of the GACP, reports and other information to be submitted • Defines financial remuneration, the duration of the contract and framework for revision/disagreements

23. Transforming public into private operation

24. Matching costs to the Budget

25. The effect of reorganization on capacity utilization

26. Contracting out and cost efficiency

27. Future orientations • The importance of research and evidence based interventions • Interventions/treatment can exacerbate risk factors, e.g. placing antisocial youth together in groups • Pathway plans and post-treatment care • Alternatives to institutional treatment • MST, a model of home-based service delivery • Implementing MST and PMT nationwide in Norway: a beautiful social experiment