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

 Youth Substance Abuse in Iceland:

prevention and treatment 

Bragi Guðbrandsson

Director

Gov. Agency for Child Protection

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

©ICSRA 2004

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

28

11

6 6 7 7 84 4 4 5

26

333235

42

1414151619

23

13111112

15

17

0

5

10

15

20

25

30

35

40

45

50

1998 1999 2000 2001 2002 2003

%

Have become drunk the past 30 daysSmoke dailyHave tried hashishHashish more than 3 timesHave tried amphetamin

©ICSRA 2004

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

1 1 2 3 3 3 4 4 4 5 6 6 7 7 7 811 11

1820 21 22

2528

32

0

5

10

15

20

25

30

35

Port

ugal

Ukr

aine

Cyp

rus

Fran

ce

Gre

ece

Tur

key

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Hun

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Lith

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USA

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Nor

way

Swed

en

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and

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e Is

l.

U.K

.

Finl

and

Den

mar

k

%

©ICSRA 2004

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

2

4 45 5 5

6 67 7 7 7 7

89

1112

14 14

17

0

2

4

6

8

10

12

14

16

18

Port

ugal

Nor

way

Hun

gary

Tur

key

(Ist

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Lat

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Finl

and

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and

U.K

.

%

©ICSRA 2004

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

1,8 0,07,1 4,0

16,9 17,0

54,5 52,0

77,572,5

0

10

20

30

40

50

60

70

80

90

100

Boys Girls

%

Almost noneFewSomeManyAlmost all

©ICSRA 2004

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

60,856,0

28,3 28,6

10,915,4

0

10

20

30

40

50

60

70

80

90

100

Boys Girls

%

Almost never/rarelySometimesOften/almost always

©ICSRA 2004

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

43,4

67,7

28,7

15,5

34,6

9,910,0

24,5

7,5

0

10

20

30

40

50

60

70

80

90

100

Daily smoking Intoxication past 30 days Have used hashish

%

Unsupervised leisure activities

Organized youth work

Sports

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

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.

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

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

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”

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

The Organization of Child ProtectionThe Organization of Child ProtectionServices in IcelandServices in Iceland

Ministry of Social Affairs

Government Agency ForChild Protection

Child ProtectionAppeal

Committee

STATEState Treatment

Center for AdolescentsResidentialTreatment

Homes

Child Protection Committees

Departments of Social Services

LocalAuthorities

General SocialServices

LOCALAUTHORITIES

Cooperationschool, health care authorities, police

a.o.

Children’s house (Barnahus)

Children’s house (Barnahus)

The JudicialSystem

The JudicialSystem

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

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)

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

Young substance abusers: institutional treatment

Child Protection Services

Diagnostic Center for YouthDiagnostic Center for Youth

Acute placement

1-2 weeks

Assessment

2-4 weeks

Treatment

2-4 weeks

Police

Treatment Facilities

Prison Authorities

Discharge

1. Home(aftercare)

Long-termtreatment

facilities(specialized)

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

“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

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

0

10

20

30

40

50

60

70

80

90

1995 1996 1997 1998 1999 2000 2001 2002

Budg

et (%

)

"Contracted out"

Operated by the state

Transforming public into private operation

0

20

40

60

80

100

120

140

160

180

200

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

%

Exposed costs Budgetary appropriation=100

Matching costs to the Budget

93%

58%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Post reorganization 2002 Prior to reorganization 1994

The effect of reorganization on capacity utilization

5,5

7,6

4,4

5,5

0

1

2

3

4

5

6

7

8

Full capacity utilization Real capacityutilization

M.k

r. Before reorganisation

After reorganisation

Contracting out and cost efficiency

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