st. john’s, newfoundland -...

ST. JOHN’S, NEWFOUNDLAND

St. John’s, Newfoundland

© 2013 CAMH 3


For more information, please contact:

Joanna Henderson, Ph.D.

Clinician Scientist

[email protected]

Gloria Chaim, MSW

Deputy Clinical Director

[email protected]

Child, Youth and Family Services

Centre for Addiction and Mental Health

80 Workman Way, Toronto, ON M6J1H4

Production of this report has been made possible through a financial contribution from Health Canada.

The views expressed herein do not necessarily represent the views of Health Canada


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Acknowledgments

The National Youth Screening Project Team would like to acknowledge the commitment, dedication

and hard work of the many people representing agencies in St. John’s, Newfoundland, one of ten

participating communities across Canada. Sincere thanks are due to Renee Ryan, former Addictions

Consultant, Department of Health and Community Services, Newfoundland and Labrador and Kim

Baldwin, Regional Director of Mental Health and Addiction Services, Eastern Health, both of whom

supported the project and brought it to the attention and encouraged participation of Choices for

Youth and Eastern Health respectively. Appreciation goes to Sheldon Pollett, Executive Director,

Choices for Youth, for initiating development of the youth screening network in St. John’s,

volunteering his agency to take on the “Lead Agency” role and making it possible for Cheryl Mallard to

take on the role of network lead. Sincere appreciation is also due to Cheryl 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 for project purposes. We would also like to thank Health Canada for their commitment to

capacity building, data collection and knowledge exchange, demonstrated by providing the funding

support that made this project and dissemination of the findings possible.

National Youth Screening Project Partner Agencies: St. John’s, Newfoundland

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 Choices for Youth Community Youth Network

o Rogers Break Thru Project o Springboard GED o Street Outreach o Youth at Promise

Kerri Collins Ellie Jones

Eastern Health o Janeway Family Centre o Central Intake o Bridges Program o Complex Case Management o Family Services Counsellors o Youth Services / Youth Corrections o Rowan Centre

Susan McLeod and Deanne Costello


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o Community Mental Health Counsellors o Youth Outreach Counsellors

Stella Burry Community Services o Naomi Centre

Jennifer Corrigan

Network Lead

Cheryl Mallard, Choices for Youth

Network Coordinator

Heather Quinlan

Project Team: Centre for Addiction and Mental Health

Project Leads

Joanna Henderson

Gloria Chaim

Project Coordinator

Megan Anne Tasker

Administrative Support

Stephanie Schultz

Research Analysts

Andra Ragusila

Dave Summers

Carly Clifton

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)


Table of Contents

List of Figures 7

National Youth Screening Project 9

Overview 9

Context 9

Objectives 12

National Youth Screening Project: St. John's, Newfoundland 13

Summary 13

Development 13

Partners 14

Roles 14

Implementation Process 15

Materials 17

Findings 21

Background Information about Youth 23

Clinical Needs of Youth Based on the GAIN SS 36

Other Clinical Needs 45

Concurrent Substance Use and Mental Health Concerns 46

Service Provider Survey 53

Feasibility and Utility of the GAIN SS 54

Summary of Findings 56

Discussion 57

Recommendations 59

Appendix A: St. John's, Newfoundland Network Member Agency Descriptions 63

Appendix B: Key Project Activity Descriptions 65

Appendix C: Agency Project Activity Participation 66

Appendix D: Project Timeline 67

Appendix E: Project Flow Chart 68

Appendix F: References 69


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List of Figures

Figure 1: Age Distribution of Participants 24

Figure 2: Age Distribution by Service Sector 25

Figure 3: Sex Distribution of Participants 26

Figure 4: Sex Distribution of Participants by Service Sector 27

Figure 5: Service History by Service Sector 28

Figure 6: Ethnicity Distribution of Participating Youth 29

Figure 7: Current Living Arrangements 30

Figure 8: Current Living Arrangements by Sex 31

Figure 9: Current Living Arrangements by Age Categories 32

Figure 10: Current Living Arrangements by Service Sector 33

Figure 11: Number of Concerns Endorsed by GAIN SS Domain 37

Figure 12: Recent Clinical Needs Using Moderate Threshold by Service Sector 38

Figure 13: Recent Clinical Needs Using High Threshold by Service Sector 39

Figure 14: Recent Internalizing Concerns by Age and Sex Categories 40

Figure 15: Recent Externalizing Concerns by Age and Sex Categories 41

Figure 16: Recent Substance Use Concerns by Age and Sex Categories 42

Figure 17: Recent Crime and Violence Concerns by Age and Sex Categories 43

Figure 18: Recent Suicide Concerns by Age and Sex Categories 44

Figure 19: Rates of Recent Additional Concerns by Sex Categories 45

Figure 20: Rates of Endorsement of Concurrent Disorders 46

Figure 21: Rates of Endorsement of Concurrent Disorders by Service

Sector and Sex 48

Figure 22: Rates of Endorsement of Concurrent Disorders by Age and Sex 49

Figure 23: Rates of Endorsement of Concurrent Disorders by Legal

System Involvement 50

Figure 24: Complexity of Needs 51

Figure 25: Service Provider Perceptions of GAIN SS Utility and Feasibility 54


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National Youth Screening Project

Overview

The National Youth Screening Project (NYSP), Enhancing Youth-Focused, Evidence-Informed

Treatment Practices through Cross-Sectoral Collaboration, was funded under Health Canada’s Drug

Treatment Funding Program (DTFP) to work collaboratively with youth-serving agencies in seven

communities across Canada to implement a common screening tool for youth substance use and

mental health concerns. Each network was to include a range of agencies representing three or more

sectors, including substance use, mental health, justice, child welfare, education, housing, outreach

and primary health care. Each of the agencies was to participate in one or more of four key project

activities: Capacity Building, Network Development, Screening Implementation and Data Collection

(see Appendix B). Through this process, the project would have 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, and to examine the extent to which rates of CD are consistent with service provider

expectations. As well, the project aimed to explore service provider perceptions of interagency

referrals, perceived interagency collaboration and youth CD attitudes, knowledge, and practices at

different time points in the project.

The overall objective of the NYSP was to enhance service provider CD capacity, increase early

intervention opportunities and improve pathways to treatment for youth aged 12-24 years with

substance use concerns and CD. This was done through building sustainable stakeholder

collaborations and providing CD-related capacity development opportunities.

Context

Background

Youth with CD experience difficulties in many areas of functioning, resulting in vulnerability to

increased risk-taking behaviour, poor academic/vocational performance, increased suicide risk, and

adverse health effects, including increased risk for substance dependency and psychiatric disorders

continuing into adulthood (Rush, Castel, & Desmond, 2009). Unfortunately, effective, developmentally-

informed interventions have yet to be established. From a public health perspective there is a

desperate need to develop integrated models of service delivery across the continuum of care to

improve outcomes and reduce the high individual and societal costs associated with CDs (Rush et al.,

2009). Evidence suggests that universal screening for mental health and/or substance use disorders


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should be a routine part of client care in adults (Rush et al., 2009). However, effective and efficient

screening, assessment and treatment approaches, especially for youth, are only beginning to emerge.

At the same time, concerns about co-occurring substance use and mental health issues in youth have

been identified in services across sectors including child welfare, youth justice, mental health,

addictions, education, health care, housing and other social service agencies (Chaim & Henderson,

2009). There is a strong rationale for effective, consistent screening in youth service delivery settings

(Rush et al., 2009).

In Canada, there have traditionally been separate service delivery systems for health, mental health,

substance use treatment and social services rather than integrated or collaborative models of service

delivery. With recent calls to develop integrated models of service delivery in Canada (Health Canada,

2002), some agencies are beginning to offer integrated CD services, although little information is

available about types and accessibility of these services. Emerging evidence suggests that cross-

discipline collaborations may have particular benefits for improving access and meeting youth and

family needs (McElheran, Eaton, Rupcich, Basinger, & Johnson, 2004; Murphy, Rosenheck,

Berkowitz, & Marans, 2005). There are many barriers, however, to cross-discipline approaches,

especially if the disciplines involved differ substantially in organizational culture, philosophy, values

and practices (Oliver & Dykeman, 2003; Robillard, Gallito-Zaparaniuk, Kimberly, Kennedy, Hammett,

& Braithwaite, 2003). It has been argued that these barriers can be addressed through

communication, relationship-building, joint educational opportunities and practice-based initiatives,

although the specific impacts of these strategies have not been established (McElheran et al., 2004;

Murphy et al., 2005; Oliver & Dykeman, 2003; Henderson, MacKay, & Peterson-Badali, 2010).

Although it is well known that youth presenting for service often have multiple co-occurring needs, the

fragmented system is generally not set up to address them. There are many challenges including

stigma, lack of resources, lack of knowledge and lack of attention to youth-specific needs, as well as a

frequent lack of collaboration and limited integration. The work of the Canadian Mental Health

Commission (2006) and the National Treatment Strategy Working Group (2008) highlighted these

issues and provided some fundamental principles to be considered and followed in planning new

initatives. Themes and recommendations identified across these documents including “every door is

the right door,” the need to improve access, the importance of attending to population specific needs,

the need to collaborate within and across sectors, the importance of generating solid data to inform

investments and making knowledge exchange a priority, have informed this project as well as our

previous collaborative screening network projects ( GAIN Collaborating Network, 2009; Concurrent

Disorders Support Services Screening Project, 2011).

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


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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.)

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 Program (CYFP) 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, 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 in

the Toronto-based Mental Health and Addiction Youth Network (MAYN) in replicating the project

within their own agencies. In 2008, 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


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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).

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, 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 participating in a national youth screening project.

In 2010, while awaiting acceptance of their DTFP proposal, 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 et al., 2011).

The National Youth Screening Project: Enhancing Youth-Focused, Evidence-Informed Treatment

Practices through Cross-Sectoral Collaboration was granted DTFP funding in 2010.

Objectives

Promote, facilitate and evaluate implementation of evidence-based screening procedures and tools

in cross-sectoral youth-serving agencies

Establish network protocols for referral and intervention to improve pathways to care for youth

Promote and facilitate collaboration and knowledge exchange amongst service providers through

the establishment of local cross-sectoral networks of youth-serving agencies

Increase use of reliable and valid tools across agencies and sectors

Evaluate and compare youth service needs across jurisdictions

Evaluate and compare pre-post service provider capacity re: evidence-based practices for youth

substance use with or without co-occurring mental health concerns

Promote a standardised screening protocol for youth concurrent disorders


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National Youth Screening Project: St. John’s, Newfoundland

Summary

Discussion about the St. John’s, Newfoundland Network collaboration began in June 2010, followed

by several meetings throughout the summer and fall, resulting in four agencies committing to

participate in the project. All necessary Research Ethics Board (REB) submissions were approved

and agreements were signed by December 2011.

Over a staggered six month period, commencing in January 2011, a cross-sectoral group of four

youth-serving agencies in and around St. John’s, Newfoundland undertook this collaborative project to

administer the GAIN SS and a demographic information form to youth aged 12 – 24 years seeking

service at their agencies. Service providers participated in training about youth substance abuse and

CD, with an emphasis on evidence-based screening practices, clinical use of the GAIN SS and

implementation of the project protocol. 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 2010, the Department of Health and Community Services, Mental Health and Addictions Division,

Newfoundland and Labrador expressed interest in development of a National Youth Screening Project

network in St. John’s in response to broad national dissemination of information about the project prior

to the submission of the proposal as well as following the funding announcement. Choices for Youth

expressed interest in developing and leading a cross-sectoral network ultimately comprised of four

local agencies that serve youth. Similar to the pilot screening projects described previously, the

agencies expressed interest in participating in a project to build capacity to identify and address the

complex needs of the youth who access their services as well as in having the opportunity to

document the needs of youth seeking service in their respective agencies, sectors and community.


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In September 2011, Choices for Youth formally agreed to take on the role of “Lead Agency” and

coordinate a local collaborative network to implement the GAIN SS[1] with youth seeking service at the

participating agencies. The project team held a one-day training workshop for service providers,

repeated on two consecutive days to allow for all agency staff to be trained, in St. John’s,

Newfoundland April 4-5, 2011. Service providers attended from all four participating agencies. Prior

to the training, the service providers were surveyed regarding their attitudes, knowledge and practices

related to youth substance use, mental health and co-occurring concerns. In January, all four

agencies launched the six-month data collection phase. Four of the Eastern Health programs

participated in all project activities. Five were unable to participate in the data collection activity. The

Complex Case Management program participated in capacity building and network development. The

Central Intake, Family Services Counsellors, Youth Services / Youth Corrections, and Youth Outreach

Counsellors participated in all project activities other than data collection, including GAIN SS

implementation.

The St. John’s, Newfoundland Network was established based on shared interests and concerns,

including interest in the opportunity to work together in a research-community collaboration.

Furthermore, the network members expressed a desire to lay the groundwork for on-going

partnerships and collaboration through their participation in the NYSP. The network was interested

and committed to ensuring that knowledge gained through this collaborative effort be shared locally,

provincially and nationally.

Partners

The St. John’s, Newfoundland Network includes representation from the addictions, family services,

housing, outreach & support, justice and mental health sectors, with both hospital and community-

based agencies and services included (see Appendix A for agency descriptions). Two thirds of the

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

National Project Team:

Provide resources for and support meetings of youth-serving agencies to support all aspects of

project participation;

[1]

Chestnut Health Systems granted a license to Choices for Youth to use the GAIN SS (CAMH Version) and gave permission to Choices for Youth to include all the participating agencies in the network in its licensing agreement.


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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 each community;

Obtain ethics approval through Health Canada and CAMH and support each agency to comply with

their ethics approval processes.

Lead Agency: Choices for Youth

Identify local organizations, representing a minimum of 3 sectors to participate in the project as a

participating agency;

Vet prospective participating agencies for suitability;

Act as a liaison between CAMH and participating agencies during the term of the project;

Identify and facilitate agency leads to obtain local REB approval for the project;

Obtain licenses from Chestnut Health Systems Inc. for use of the GAIN SS for participating

agencies;

Support training provided by the project leads and facilitate provision of consultation as needed

throughout the project;

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:

Comply with the agreed upon protocol by obtaining participant and parental consents, administering

GAIN SS and submitting the data to the lead agency for review;

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.

Implementation Process

(See Appendix D for Project Timeline)

Prior to initiating project activities, two separate agreements were signed:

1. A two-party agreement between CAMH and Choices for Youth, the network lead agency.

2. A three-party agreement between CAMH, Choices for Youth and each of the respective

participating agencies.


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Each agreement described the project, roles, responsibilities, activities and commitments, as well as

the data collection protocol. Five of the programs in Eastern Health were unable to participate in all 4

of the key activities of the project; however, the Complex Case Management program participated in

the Capacity Building and Network Development activities, and Central Intake, Family Services

Counsellors, Youth Services / Youth Corrections, and Youth Outreach Counsellors programs also

participated in Screening Implementation.

A collaborative process was used throughout the project to develop joint goals, materials and

processes as well as research questions and data analyses. The lead agency, Choices for Youth, was

involved with the project throughout each stage of the project from initiation to completion. Once the

agency level training was completed and data collection was underway, the lead agency, along with

the project team at CAMH, was involved in communicating with the participating agencies to maintain

engagement, momentum, and compliance with the project protocol, problem-solving of issues arising

and collaborating in the joint data analysis process.

Implementation Process

1. May - November, 2010–Networking:

a. Identified interested agencies

b. Established cross-sectoral network

2. September,2010 - December 2011–Agreements and REB:

a. Developed 2-party agreement between CAMH and Choices for Youth

b. Developed 3-party agreement between CAMH, Choices for Youth and all

participating agencies

c. Secured all required REB approvals

3. April 4-5, 2011 – 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 training day

c. Each Agency identified a lead to act as a “point person” for communication with

the Network Lead, including receiving and distributing project packages to the

participating service providers in their respective agencies

4. January 2012 – Project launch:

a. Distributed project packages i.e. project instruction sheets, consent forms, GAIN

SS, Background Information forms, tracking sheets

5. January – July 2012 – Project actively underway:

a. Service providers obtained consent from youth seeking service at their


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agencies, administered the GAIN SS and Background Information Form

b. Anonymous copies of the completed measures and tracking sheets were

submitted to the network coordinator on a monthly basis, and delivered to

CAMH at month 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

e. 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

6. October 4th. 2012 – 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 provided on utility and feasibility of

administering the GAIN SS to youth in their agencies

e. Feedback from network 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.

Service Provider Survey

The Service Provider Survey is a self-report questionnaire that combines measures of service

providers’ 1) service-related 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)


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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 to

endorsement of concerns on the GAIN SS were provided to each participating service provider.

GAIN SS 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.

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. Youth initials

only 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 only where parental consent was required to obtain

services for youth under 16 years of age. Parent’s initials only were required 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, &


19

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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21

Findings


22


23

Background Information about Youth

Who participated?

In total, 107 youth participated:

63 (59%) from housing, outreach, and support sector

44 (41%) from treatment 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 136 youth 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 = 118). Reasons for ineligibility included the GAIN SS had

already been administered (14%), immediate mental health concerns (e.g., psychosis) (43%), and

cognitive limitations (43%). In addition, for 11 cases information was not provided. Of the youth who

were eligible to participate in the project, 111 (94%) were approached for participation. Reasons for

youth not being approached included clinician-based reasons (e.g., judgment) (57%), youth was

unavailable (e.g., left, no show) (14%), and parent unavailable to provide required consent (29%). Of

the youth who were approached, 95% completed the GAIN SS. Based on the tracking sheets, 5% of

youth who were asked to complete the GAIN SS refused. Of the youth who completed the GAIN SS,

100% consented to have a copy used for the purposes of this project. Overall then, based on these

tracking sheet numbers, 90% of eligible youth contributed screeners for this report.

Please note: Based on the number of completed consents and screeners we received, we estimate

that approximately 99% of eligible youth were captured on tracking sheets.


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What are the demographics of the youth who participated?

AGE

FIGURE 1: AGE DISTRIBUTION OF PARTICIPANTS

The participating youth ranged in age from 14 to 24 years with an average age of 18.2 years and a

median age of 17.0 years. In Figure 1, the ages of participating youth are presented using age

categories commonly used in service provision. As can be seen, participating youth were evenly

distributed across age categories.

33%

34%

33% 12-16 years old

17-19 years old

20-24 years old


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FIGURE 2: AGE DISTRIBUTION BY SERVICE SECTOR

When youth are grouped by sector (see Figure 2), it can be seen that youth who participated in the

housing, outreach, and support sector were more likely to be in the older age group (20 to 24 years),

whereas the majority of participating youth presenting to the treatment sector were12 to 16 years old.

8%

70%

37%

30% 56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Housing, Outreach, & Support Treatment

Pro

po

tio

n o

f Y

ou

th

Sector

20-24years

17-19years

12-16years


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Sex

FIGURE 3: SEX DISTRIBUTION OF PARTICIPANTS

This project had 51 male participants, 54 female participants, and one participant who identified as

trans. The difference in the number of male and female participants was not significant. There was

also one individual who did not provide this information. In order to protect the privacy of participants,

only those who identified as male or female are included in subsequent analyses related to sex.

48%

50%

1% 1%

Male

Female

Trans

Missing


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FIGURE 4: SEX DISTRIBUTION OF PARTICIPANTS BY SERVICE SECTOR

Comparing the two sectors reveals that the male to female ratio does not differ between sectors.

51% 45%

49% 55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Sector

Female

Male


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Service History

FIGURE 5: SERVICE HISTORY BY SERVICE SECTOR

More youth participating in the project endorsed being involved with the participating service for more

than a year (37%) than any other option. There was a fair amount of variability between sectors. For

example, more youth from the treatment sector completed the GAIN SS on their first visit or in their

first month (46%) of being with the service than youth from the housing, outreach, and support sector

(22%).

7%

23% 15%

23% 31%

31%

47%

23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Sector

More thana year ago

2-12Monthsago

In the pastmonth

Today


29

Ethnicity

FIGURE 6: ETHNICITY DISTRIBUTION OF PARTICIPATING YOUTH

Seven percent of participating youth endorsed more than one ethnicity. The most commonly endorsed

ethnicity across all youth was White/European (85%), followed by Aboriginal (9%), ‘Don’t know’ (3%),

‘Other’ (2%), and Black (1%). Five percent of youth (n = 5) did not complete this question.

Birth Country and First Language

The majority of participating youth reported being born in Canada (96%) while 2% reported being born

outside of Canada and 2% did not answer the question. Those born outside of Canada reported

having been in Canada two and 15 years respectively. The majority of participating youth also

reported that English was their first language (95%), while 2% reported a different first language and

3% left it blank. One individual indicated Inuktitut as their first language; no other languages were

reported for non-English first language.

9% 1%

85%

2%

3%

Aboriginal

Black

White / Europe

Other

Don't know


30

Living Arrangements

FIGURE 7: CURRENT LIVING ARRANGEMENTS

The largest group of participating youth (45%) reported that they were living with parents, while 27%

reported living in unstable housing (e.g. “shelter”, “on street”, “couch surfing”), 11% were living on

their own or with friends, 8% reported living in supportive housing (e.g. “group home”, “treatment

facility”) and 4% were living with other family members.

45%

11% 4%

8%

27%

1%

4%

Parental/Family Home

Own/With Friends

Other Family/Relative

Supportive Housing

Unstable

Other

Missing


31

FIGURE 8: CURRENT LIVING ARRANGEMENTS BY SEX

Examination of sex differences in living arrangements revealed that the living arrangements of male

and female youth did not differ significantly.

46% 45%

10% 13%

6% 2%

10% 8%

25%

32% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Pro

po

rtio

n o

f Y

ou

th

Sex

Other

Unstable

Supportive Housing


Own/With Friends



32

FIGURE 9: CURRENT LIVING ARRANGEMENTS BY AGE CATEGORIES

As can be seen in Figure 9, older youth reported a wider range of housing arrangements as would be

expected given their developmental stage.

78%

44%

15%

12%

24%

8%

3%

8%

6%

12%

6%

36%

46%

3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age (years)

Other

Unstable

Supportive housing

Other family/relative

Own/with friends

Parental/family home


33

FIGURE 10: CURRENT LIVING ARRANGEMENTS BY SERVICE SECTOR

As would be expected given the services provided by the housing, outreach, and support sector, there

is more variability in living arrangement than in the treatment sector which predominantly serves youth

who live in parental/family homes.

17%

86% 3%

5%

8%

9%

49%

2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Sector

Other

Unstable

Supportive Housing


Own/With Friends



34

Legal Involvement

The majority of participating youth reported never having any legal involvement (54%), while the

remaining youth reported legal involvement in the past 12 months (27%), more than a year ago

(14%), or did not answer the question (5%).

Education, Employment and Income

Overall 37% of participating youth identified as students. Of those who did not identify as students,

79% indicated that they were unemployed, 11% indicated part-time employment, 5% indicated they

had full-time employment, 3% indicated involvement in an apprenticeship program, and 2% indicated

self-employment.

Age was related to educational, employment and income status. Youth aged 18 years and older (n =

53), indicated that their employment situations were as follows: unemployed (75%), attending school

(12%), working part-time (10%), working full-time (6%), and in an apprenticeship program (4%), (not

mutually exclusive). In contrast youth aged 17 years or younger (n = 54) indicated that they were

students (63%), unemployed (33%), working part-time (9%), volunteering (4%), and in an

apprenticeship program (2%). Similarly, the most commonly reported income sources for youth aged

18 and older were as follows: welfare (62%), no income (17%), employment (9%), family benefits

(4%) parents/spouse (4%), and disability (4%) while youth 17 years and younger reported their

income sources to be parents/spouse (22%), no income (39%), Choices for Youth/CYFS (15%);

family benefits (9%), welfare (9%), and employment (7%).

For youth aged 18 years and older, educational attainment was also examined revealing a broad

range of educational achievements, including 10% of youth participants reporting grade 8 completion

or less as their highest educational achievement, 65% indicating grades 9-11 as their highest

achievement, 8% reporting achievement of high school completion without diploma, 14% indicating

completion of high school with diploma, 2% obtaining a trade or vocational certificate, and 2%

completing some non-university post-secondary education.


35

How do the demographics of males and females compare?

TABLE 1: DEMOGRAPHIC COMPARISON OF MALE AND FEMALE PARTICIPANTS

Male Female

Average Age 18.3 18.2

White / European

Aboriginal

88%

6%

82%

14%

Born in Canada 98% 98%

English First Language 100% 96%

Unstable Housing 25% 32%

Legal Involvement 58% 31%*

*p<.05

Examination of potential differences in background characteristics between male and female youth

revealed that they only differed significantly in their histories of legal involvement, with male youth

reporting significantly higher rates of current and previous legal involvement.


36

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 (SUB), 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 96-100%, 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, Chan, & Funk, 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 Modified Version)

which includes 7 additional items following the original subscreeners. These additional items provide

information about eating behavior, 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.


37

FIGURE 11: NUMBER OF CONCERNS ENDORSED BY GAIN SS DOMAIN

As can be seen in Figure 11, more than two thirds of participating youth endorsed 3 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.). Similarly, in the

externalizing domain more than half of youth endorsed 3 or more recent externalizing concerns.

Endorsement of 3 or more concerns on the substance disorder subscreener was less common, but

nevertheless, almost half of participating youth reported 3 or more recent indications of problematic

substance use. In the area of crime and violence, almost a quarter of youth reported 3 or more

crime/violence concerns. Overall, 94% of participating youth endorsed 3 or more issues across the 4

subscales, suggesting that most participating youth would receive a diagnosis with a full diagnostic

assessment.

7% 12%

30% 36% 24%

29%

21%

42%

6%

69% 59%

49%

22%

94%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

INT EXT SUB CV Total

Pro

po

rtio

n o

f Y

ou

th

GAIN SS Domain

3+ recentconcerns

1-2 recentconcerns

No recentconcerns


38

How do the needs of youth differ across sectors?

FIGURE 12: RECENT CLINICAL NEEDS USING MODERATE THRESHOLD (1+ ENDORSEMENTS) BY SERVICE SECTOR

In Figure 12, the needs of youth by service sector are presented. Using the threshold of 1

endorsement to identify youth who screen positive, more than 90% of youth regardless of sector,

screened positive for internalizing concerns. Similarly, more than 80% of youth across sectors

screened positive for externalizing concerns. Within the substance use and crime and violence

domains, rates of endorsement ranged from 59%-77% across sectors. Youth presenting to the

treatment sector were more likely to screen positive for externalizing difficulties than youth presenting

to housing, outreach and support, while youth presenting to housing, outreach and support were more

likely than youth presenting to the treatment sector to screen positive for substance use problems.

92%

84% 77%

68%

96% 95%

59% 59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

INT EXT SUB CV

Pro

po

rtio

n o

f Y

ou

th

GAIN SS Domain

Housing,Outreach,and Support

Treatment


39

FIGURE 13: RECENT CLINICAL NEEDS USING HIGH THRESHOLD (3+ ENDORSEMENTS) BY SERVICE SECTOR

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 for service across sectors have high

internalizing concerns. In addition, over 80% of youth presenting to the treatment sector reported

experiencing high severity externalizing difficulties.

In the substance use domain, approximately half of youth endorsed experiencing 3 or more symptoms

of problematic substance use in the past year.

In the area of crime and violence, rates of endorsement were substantially lower than other domains,

although approximately one quarter of youth endorsed 3 or more crime and violence problems.

67%

44% 52%

18%

73%

81%

46%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

INT EXT SUB CV

Pro

po

rtio

n o

f Y

ou

th

GAIN SS Domain

Housing,Outreach, andSupport

Treatment


40

How do the needs of youth differ across age and sex categories?

FIGURE 14: RECENT INTERNALIZING CONCERNS BY AGE AND SEX CATEGORIES

Overall, female youth were more likely to endorse internalizing concerns than male youth, although as

can be seen in Figure 14 this is true for younger youth only. In the older age group male and female

youth did not differ in their rates of endorsement.

48% 50%

67%

93% 91%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


41

FIGURE 15: RECENT EXTERNALIZING CONCERNS BY AGE AND SEX CATEGORIES

As shown in Figure 15, younger youth were more likely to endorse externalizing concerns than older

youth.

86%

45% 53%

80%

59%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


42

FIGURE 16: RECENT SUBSTANCE USE CONCERNS BY AGE AND SEX CATEGORIES

Male youth overall were more likely to endorse problematic substance use concerns than female

youth.

62%

45%

67%

47%

35%

44%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


43

FIGURE 17: RECENT CRIME AND VIOLENCE CONCERNS BY AGE AND SEX CATEGORIES

Crime and violence problems were more commonly endorsed by male than female youth, especially

male youth in the oldest age category.

38%

27% 28% 27%

13%

0% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


44

FIGURE 18: RECENT SUICIDE CONCERNS BY AGE AND SEX CATEGORIES

Given the clinical importance of suicide-related concerns, the single item related to suicide-related

thinking and behavior from the internalizing subscreener was examined. Overall, 15% of participating

youth indicated that they had thought about suicide in the past month, with an additional 19%

reporting having thought about suicide in the past 2 to 12 months and 25% reporting concerns more

than 12 months ago. Forty-one percent of youth indicated they had never thought about suicide.

When we examined rates of endorsement by sex and age category it was revealed that female youth

were more likely than male youth to endorse suicide concerns, especially in the younger age

categories.

14% 9%

22%

67%

48%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


45

Other Clinical Needs

How many youth endorsed additional areas of concern?

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: RATES OF RECENT ADDITIONAL CONCERNS BY SEX CATEGORIES

As can be seen, the distressing memories/dreams (traumatic distress) item was endorsed by

approximately half of youth and was the most commonly endorsed additional item. Youth were least

likely to endorse concerns about gambling. Female youth were significantly more likely than male

youth to endorse eating concerns and thoughts of persecution, while male youth were more likely than

female youth to endorse videogame overuse.

0%10%20%30%40%50%60%70%80%90%

100%

Pro

po

rtio

n o

f Y

ou

th

Additional Concerns

Male

Female


46

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 20: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS

INT

SUD

14%

6% 5%

5%

6%

34%

15% Did not screen positive for INT, EXT, or SUD

13%

EXT


47

Overall, 59% of youth screened positive for more than one area of concern, and 45% of participating

youth screened positive for possible concurrent (substance and mental health) disorders. As can be

seen in the Figure 20, 34% of all participating youth screened positive for co-occurring internalizing,

externalizing and substance use concerns, 6% endorsed concurrent internalizing and substance use

concerns, and 5% indicated concurrent externalizing and substance use concerns.


48

How similar were rates of Concurrent Disorder endorsement across service sectors?

FIGURE 21: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS BY SERVICE SECTOR AND SEX

Overall, 45% of youth across sectors screened positive for concurrent disorders, with the rates

between sectors being equivalent. There was also a trend for male youth to be more likely to screen

positive for concurrent disorders than female youth across service sectors.

52% 58%

39% 35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n

of

Yo

uth

Sector

Male

Female


49

What factors are related to endorsing both mental health and substance use concerns?

Age and Sex

FIGURE 22: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS BY AGE AND SEX

Overall 54% of male youth and 37% of female youth endorsed co-occurring mental health and

problematic substance use. When rates of endorsement were examined by age categories, 50% of

the youngest age group, 35% of the middle age group, and 50% of the oldest age group screened

positive for concurrent disorders. There was a trend for male youth to be slightly more likely to

endorse concurrent disorders than female youth, but no significant age differences.

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. Rates of endorsement of

concurrent disorders, however, did not differ significantly between youth who live outside of the

parental/family home (50%) and youth living in the parental/family home (41%).

57%

36%

61%

40% 35%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 to 16 17 to 19 20 to 24

Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


50

Legal Involvement

FIGURE 23: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS BY LEGAL SYSTEM INVOLVEMENT

For the purposes of the following analyses, legal involvement was reduced to two categories: 1) no

legal involvement and 2) previous legal involvement. Youth who reported past legal involvement were

more likely to endorse concurrent disorders (59%) than youth who reported no previous involvement

with the legal system (34%). This was especially true for female youth. In addition, more than half of

youth (58%) who screened positive for concurrent disorders reported previous legal involvement.

Educational Status

When we compared youth who identified as students to those who did not, it was revealed that 44%

of students and 45% of non-students endorsed concurrent substance use and mental health

concerns, indicating that educational status was not related screening positive for concurrent

disorders.

45%

57%

28%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No legal involvement Previous legal involvement

Pro

po

rtio

n o

f Y

ou

th

Legal Involvement

Male

Female


51

Which factors are most important in understanding the Concurrent Disorder needs of youth presenting for service in St. John’s, Newfoundland?

Given that both sex and legal involvement were found to be related to endorsing both problematic

substance use and mental health concerns, and that these factors are related to each other, we

examined these factors together in one analysis to understand which factor(s) are most important in

understanding who screens positive for concurrent disorders. When sex and legal involvement were

examined together, legal involvement was shown to be most important in understanding which youth

are more likely to endorse both substance use and mental health concerns. More specifically, youth

with legal involvement were more likely to endorse both substance use and mental health concerns,

even after the effects of sex were taken into consideration.

How many participants endorsed multiple areas of concern in their lives?

FIGURE 24: COMPLEXITY OF 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)

28%

52%

20%

44% 41%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-2 3-4 5-6

Pro

po

rtio

n o

f Y

ou

th

Number of Significant Needs

Male

Female


52

internalizing concerns (high severity), 5) externalizing concerns (high severity), and 6) substance use

problems (high severity). Overall, 62% of participants reported having 3 or more factors and almost a

fifth (17%) of participants reported experiencing 5 or more of the 6 factors. Results did not differ for

male and female youth. These findings highlight the complexity of the needs of the individuals who

are presenting for service and participated in this project.


53

Service Provider Survey

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 St. John’s, Newfoundland Region (n = 53) completed the service provider

survey prior to participating in the project’s capacity building training event and then again with the

feedback survey (n = 19) approximately one year after training took place. Detailed results for the

service provider survey can be found in the National Youth Screening Project national report. The

results from the feedback survey of St. John’s, Newfoundland service providers are presented

following.


54

Feasibility and Utility of the GAIN SS

FIGURE 25: SERVICE PROVIDER PERCEPTIONS OF GAIN SS UTILITY AND FEASIBILITY

Service providers who provided feedback reported that generally the GAIN SS was useful, impacted

treatment decisions, and facilitated referrals. The majority of service providers recommended using

the GAIN SS despite some also reporting a perceived disruption from its use. Notably, those service

providers who perceived the training to be more helpful reported the measure to impact service and

recommendations more frequently and to facilitate the referral process more often than service

providers who rated the training as less helpful.

87%

47%

87% 80%

93%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Usefulinformation

at least someof the time

Notdisruptive

Impactedservice at

least some ofthe time

Facilitatereferral at

least some oftime

Recommenduse at leastsome of the

time

End

ors

em

en

t R

ate

GAIN SS Utility and Feasibility


55

Service provider comments about the feasibility and utility of the GAIN SS in their

practices

“We are more attentive to making sure mental health is immediately addressed as

well as substance abuse.”

“I found this instrument difficult to administer and inappropriate to administer in a first

session.”

“It is a co-occurring screener which we don’t have currently which can be used easily

and effectively.”

“It has resulted in some additional partnership among network members who are

now delivering some programs together to at-risk youth.”

“Choices for Youth is a partner in the National Youth Screening Project. The use of

GAIN-SS was an appropriate fit for the work of our Outreach and Youth Engagement

program, and in particular, 3 key program areas also being funded by DTFP.

Addictions Community Support (focused on engaging youth with addictions issues

and connecting them to appropriate supports and service by building meaningful

relationships with them); Jumpstart (a pre-employment program for youth facing

many employment barriers including addictions); and Momma Moments (a group for

our young moms who are also experiencing isolation and multiple other barriers

while offering a supportive environment for young parents to seek appropriate

support i.e. Mental Health and Addictions).

“Through use of GAIN-SS, we have established a screening and assessment

process that allows us to develop individual support plans for the youth we are

working with. For some youth, it has helped identify issues they may be struggling

with that were difficult to disclose or discuss, or at times were unaware of the root of

their struggles. Completion of the GAIN-SS often results in starting conversations

about concerns youth had and supports they really needed.”


56

Summary of Findings

Approximately 90% of eligible youth presenting to participating services and agencies contributed to

this report.

100% of youth who completed the GAIN SS gave consent for it to be included in this report.

Youth presenting for services from addictions, mental health, and outreach, housing and support

service sectors contributed information to this report.

Youth aged 14 to 24 years participated, with differences in age being apparent across service

sectors.

Participants were evenly split between male and female participants.

The majority of participants identified their ethnicity as white/European, reported being born in

Canada and having English as their first language.

As would be expected older youth and youth presenting for service to the outreach, housing and

support services sector endorsed a wider variety of current living arrangements and were less likely

to live in the parental/family home.

Over half of male youth (58%) and almost a third of female youth (31%) indicated that they had

experienced legal involvement.

The majority of participating youth screened positive for significant internalizing or externalizing

mental health concerns and/or problematic substance use. Moreover, substantial numbers of youth

from each sector endorsed significant difficulties.

Age and sex are related to rates of endorsement across domains.

Over one third (34%) of participating youth reported significant suicide-related concerns in the past

year and more than half reported suicide-related concerns in their lifetimes (59%).

More than half of participating youth (59%) screened positive for more than one disorder and 45% of

youth 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 youth participating in the project include sex and legal involvement. Of these the

most important appear to be legal involvement, especially female youth with legal involvement.

Complexity of the needs of the participating youth was evident in the high number (62%) reporting 3

or more concerns out of 6 that include social determinants of health along with mental health and

substance use.

The majority of service providers reported that they found the GAIN SS provided useful information,

impacted service delivery and facilitated referrals. Higher ratings in some areas were associated

with service provider perceptions of the capacity building activities.


57

Discussion

Youth Needs

The findings of this project in St. John’s, Newfoundland suggest that many youth presenting for

service, regardless of which sector they present to, are experiencing significant substance use and/or

mental health concerns. Moreover, almost half of participating youth endorsed significant concerns in

more than one domain, and one quarter of youth screened positive for co-occurring substance and

mental health concerns. These findings suggest that recent efforts to improve capacity to address co-

occurring substance use and mental health problem 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. For example, girls in the youngest age categories were

more likely to report suicide-related concerns than boys, but in the older age category male and

female youth did not differ significantly. Also, female youth with legal involvement were much more

likely to have screened positive for concurrent disorders than female youth without legal involvement.

These, and other findings from the project, have implications for service delivery, both in terms of

thinking about issues such as access, but also in terms of what services might be most applicable at

different ages and for male and female youth. Unfortunately the number of youth who identify as trans

who participated was too small to allow for meaningful analyses. Future projects should aim to better

understand the needs of this often overlooked group of 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, local leadership was required to build a network through

identifying, engaging and supporting partners from various youth service sectors. In Newfoundland,

the efforts of representatives from the Department of Health and Community Services, Newfoundland

and Labrador and Mental Health and Addiction Services, Eastern Health, who had learned about the

project through their involvement in national committees, including the Federal Provincial Territorial

(FPT) Committee, to identify local leadership and interested agencies in St. John’s facilitated

community engagement in the project. The enthusiasm and sustained hard work of the Choices for

Youth lead resulted in the St. John’s, Newfoundland service community’s active engagement in the

project. They exceeded their initial agreement to enlist partners representing four service sectors;

rather, enlisting six (addictions, mental health, family services, health, outreach, housing and support

and youth justice). It should be noted that the sectors were represented in the broad spectrum of


58

programming available across four agencies. Service providers from all six sectors participated in the

network development and capacity building activities. Ultimately all of the sectors were represented in

all aspects of the project, however not all of the participating programs engaged in the data collection

component of the project (See Appendix C).

Providing more than one capacity building event, including teleconference 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.

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 St. John’s indicate that 100% 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 learn more about youth needs.

Following completion of data collection the project team learned that GAIN SS administration was

continuing in at least one agency 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.

Limitations

The findings of this project are limited by factors related to the screening tool as well as extent and

type of engagement of the participating service providers. The screening tool 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.


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Recommendations

Gender-informed and gender-specific services should be considered to ensure that links to all

necessary services are available to both male and female youth given that, although they are

equally likely to present for services across agencies, it is important to ensure that the services that

are delivered are designed to address the different types of difficulties male and female youth

experience. For example, male youth were more likely to endorse substance use and crime and

violence related concerns than female youth, the latter in the oldest age category; female youth

were more likely than male youth to endorse internalizing and suicide concerns, especially in the

younger age categories and male youth were more likely than female youth to endorse co-occurring

mental health and problematic substance use. Further research is needed to address the needs of

youth who identify as trans or other youth who do not identify as solely male or female.

Developmentally informed and responsive services are indicated in order to meet the needs of

transitionally aged youth (19 to 24 years), especially those who are seeking and/or receiving

services in the adult service sector.

Continued capacity building regarding concurrent disorders across sectors is warranted given that

the majority of participants endorsed significant concerns in two or more domains. It is notable that

youth presenting to housing, outreach and support were more likely to screen positive for substance

use problems. 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 regarding interventions to address substance

use and concurrent disorders.

Building capacity for trauma-informed care across sectors is also suggested, given that half the

youth endorsed concerns related to traumatic distress.

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 female 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 gender informed and specific approaches across sectors, including the

justice sector.

Given the high rate of endorsement of concurrent concerns across the participating sectors, to

increase opportunities for early identification, consideration should be given 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 other highly accessible settings such

as educational settings.


60

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.

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.


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Appendices


62


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Appendix A: St. John’s, Newfoundland Network Member Agency Descriptions

Choices For Youth – Choices is a non-profit, charitable, community-based agency that provides

housing and lifestyle development supports to youth in the St. John’s metro area. Choices for Youth’s

main focus is to provide young people with adequate, stable, and age-appropriate support systems

during a transition period in their lives. Part of what guides Choices for Youth’s programming is the

operating principles. Based on an empowerment philosophy, they strive to develop programming that

meets the needs of young people, promotes flexibility and innovative responses, and be designed and

evaluated in partnership with them. This includes: helping youth access financial support to stabilize

their immediate situation, mediate family issues and issues with landlords, counseling youth through

day-to-day issues and conflict resolution, providing youth with referrals for services such as drug

treatment or healthcare services, attending appointments with youth for treatment or healthcare

services and supporting their efforts to make healthier life choices, helping young people find stable,

safe housing, providing youth with basic necessities, providing emergency shelter to young men (and

referrals for shelter to young women), assisting young people obtain proper I.D. to access financial

support and healthcare services, create and encourage employment and educational opportunities

that work for youth. Another key aspect to helping youth is building a solid relationship of trust and

empowering them to make healthy life choices. At Choices, this involves employing a “Harm

Reduction” philosophy where youth are met and accepted regardless of what choices they are

currently making. Staff at Choices create a supportive, safe environment where youth can increasingly

become more involved and build trusting relationships, gradually making changes when they are

ready.

Community Youth Network (Thrive) – Thrive is an umbrella organization that works with the

community to address gaps in services, build community partnerships, increase awareness of existing

programs and services, and to conduct outreach to our most marginalized youth. The organization’s

vision statement is meeting youth where they are, helping youth go where they want to go, and

supporting youth to be who they want to be. The organization assists youth, primarily 12 -18 years,

who live in poverty and have limited access to mainstream programs and services. Thrive aims to

help youth to achieve their full potential and enhance the capacity of youth serving agencies.

Eastern Health:

Bridges Program – Is an outpatient mental health service for youth and their families who are

experiencing a serious, urgent mental illness/health problem or crisis. Bridges is a brief intervention/

outpatient mental health service. Bridges has an interdisciplinary team comprised of psychology,

social work, and occupational therapy. Assistance is available to young clients with problems such as

depression, suicidal and self-harm behaviors, eating disorders, sexuality concerns, mental illnesses


64

and family conflict. Key service areas are: individual therapy, family therapy, psychiatric consultation

and treatment, parent education and supportive counseling, post hospital follow-up to inpatient mental

health treatment, and referral to other agencies.

Community Mental Health Counselors - Community Mental Health counselors are located

throughout the region. They provide therapeutic counseling to individuals of all ages in the areas of

mental health and addictions. Counseling is provided on an individual, couple, or family basis, with

groups offered as needed and opportunity arises. The Mental Health Counselors are also available for

consultations, presentations, and provision of information to any local community/professional group,

or school, upon request.

Complex Case Management-A service designed to ensure that individuals with complex mental

illness receive appropriate and integrated level of care, treatment and support. This program provides

individual group and family therapy; or service coordination coupled with individual and family support;

consultation with psychiatry and other relevant services and community agencies, with possible

referral as appropriate.

Janeway Family Center - Is an outpatient mental health service offering a coordinated and

comprehensive service for children and youth facing a wide range of mental health issues including

emotional, social or behavioral challenges. Janeway Family Centre is comprised of six teams, each

consisting of social workers, psychologists and staff using a combination of individual, family or group

interventions and varied therapeutic approaches according to their area of expertise.

Rowan Center - The Rowan Centre is a day treatment program for adolescents between the ages of

12 and 18 whose involvement with substance use and/or gambling is having a negative impact on

their lives. Youth will move into less intensive follow up services upon completion of the day treatment

program.

Youth Outreach -This program provides effective outreach to youth ages 12-17. Youth Outreach

Workers provide services and support to youth in the community in partnership with community based

organizations. Youth outreach involves rapport building in an attempt to connect youth to community

programs, services and supports. Youth outreach activities include mental health promotion,

addictions/prevention, education and program/project delivery, as well as supportive counseling,

screening, referral and advocacy in relation to mental health and addictions concerns.

Stella Burry Community Services:

Naomi Centre - Naomi Centre is an emergency shelter and short-term residence for young women

between the ages of 16 -30 who are in need of safe, supportive and temporary housing. Young

women who are residents at Naomi Centre receive support that encourages making informed choices

and decisions, potentially leading to greater stability in regards to personal relationships, finances,

emotional well being and housing so she can return to her family or community. A social worker is

available to provide counseling and assistance to the young woman and her family if necessary. Staff

assist residents with educational and employment needs, life skills instruction and housing.


65

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 co-occurring 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.


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Appendix C: Agency Project Activity Participation

SECTOR Agency name

Project activity

Network Development

Capacity Building

GAIN SS Implementation

Data Collection

Addictions Eastern Health • Rowan Centre ● ● ● ●

Family services

Eastern Health • Family Services Counselors ● ●

Health services

Eastern Health • Central Intake ● ●

Housing, outreach &

support

Choices for Youth ● ● ● ● Community Youth Network ● ● ● ● Naomi Centre ● ● ● ● Eastern Health Youth Outreach Counselors ● ●

Justice Eastern Health • Services / Youth Corrections ● ●

Mental health

Eastern Health Complex Case Management ● ●

Eastern Health Bridges Program ● ● ● ● Eastern Health Janeway Family Centre ● ● ● ●

Eastern Health Central Intake ● ●

Eastern Health Community Mental Health Counselors ● ● ● ●


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Appendix D: Project Timeline

Year 1 Year 2 Year 3

2010 2011 2012 2013

Apr - Jun

July - Sept

Oct - Dec

Jan - Mar

Apr - Jun

July - Sept

Oct - Dec

Jan - Mar

Apr - Jun

July - Sept

Oct - Dec

Jan - Mar

Networking: Introduce project to

potential participating agencies

Establish cross-sectoral network:

REB Approval & Signing of MOU

Training for participating agencies

Project launch

Project actively underway

Preliminary findings presented

Report to stakeholders

Legend

St. John’s, Newfoundland Timeline

National Youth Screening Project Timeline


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Appendix E: Project Flow Chart


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Appendix F: References

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: Centre for Addiction and Mental Health.

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.

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.

Hillman, L., Chaim, G., & Henderson, J. (2011). Cross-sector collaboration in action: Findings from the

Concurrent Disorders Support Services Screening Project. Toronto, ON: Authors

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.

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.

National Treatment Strategy Working Group (2008). A systems approach to substance use in Canada:

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 and

social workers. AIDS Care, 15(5), 649-663.


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Reid, G.J., Evans, B., Brown, J.B., Cunningham, C.E., Lent, B., Neufeld, R., Vingilis, E., Zaric, G., &

Shanley, D. (2006). Help – I need somebody: The experiences of families seeking treatment for

children with psychosocial problems and the impact of delayed or deferred treatment. Ottawa, ON:

Canadian Health Services Research Foundation.

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?

Comparing the mental and addiction needs of adolescent clients across two CAMH programs.

Poster Presentation, Annual Convention of the Canadian Psychological Association, Ottawa, ON.

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