CAPE BRETON REGION, NOVA SCOTIA

Cape Breton Region, Nova Scotia

© 2013 CAMH

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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 M6J 1H4

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 Can


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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 the Cape Breton Region, Nova Scotia,

one of the ten participating communities across Canada. Sincere thanks are due to the Cape Breton

network lead, Samantha Hodder, who advocated for Cape Breton to participate in this project, as well

as to the network coordinator, Brandy MacNeill, who spearheaded the project and worked tirelessly 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 agency protocols to integrate consistent

administration of a screening tool and dedicate staff time to participate in the project; and 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: Cape Breton Region

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

Cape Breton District Health Authority:

Addictions Services:

o Community Based Services

o Health Promotion and Prevention

o Inpatient Withdrawal Management

o Opiate Recovery Program

Brandy MacNeill

Barry McNeil

Samantha Hodder

Priscilla McIntyre

Sharon MacKenzie

Mental Health Services:

o Adult Mental Health

o Child and Adolescent Mental Health

o Emergency Crisis and Community

o Inpatient Mental Health

Youth Health Centre

Karen Shea

Julie MacDonald

Linda Parris

Corinna Simon

Mary Beth Leblanc

Cape Breton Victoria Regional School Board Cathy Viva


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Department of Justice, Community Corrections Brad Furey

Family Service of Eastern Nova Scotia Bridget Revell & Mary-Jo Church

Department of Community Services, Child Welfare John Janega & David Tunney

Network Leads

Cape Breton District Health Authority (CBDHA)

Samantha Hodder, Network Lead

Brandy MacNeill, Network Coordinator

Project Team: Centre for Addiction and Mental Health (CAMH)

Project Leads

Joanna Henderson

Gloria Chaim

Project Coordinators

Eleanor Liu

Megan Anne Tasker

Administrative Support

Stephanie Schultz

Research Analysts

Andra Ragusila

Dave Summers

Carly Clifton

Vivian Zhang

GAIN SS License

Chestnut Health Systems – Copyright holder for all Global Appraisal of Individual Needs instruments,

including Global Appraisal of Individual Needs - Short Screener (GAIN SS)


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Table of Contents

List of Figures 7

National Youth Screening Project 9

Overview 9

Context 9

Objectives 12

National Youth Screening Project: Cape Breton Region 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 46

Concurrent Substance Use and Mental Health Concerns 47

Service Provider Survey 54

Feasibility and Utility of the GAIN SS 55

Summary of Findings 57

Discussion 58

Recommendations 60

Appendix A: Cape Breton Region Network Member Agency Descriptions 65

Appendix B: Key Project Activity Descriptions 69

Appendix C: Agency Project Activity Participation 70

Appendix D: Project Timeline 71

Appendix E: Project Flow Chart 72

Appendix F: References 73


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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 Sex Category 44

Figure 19: Recent Suicide Concerns by Age and Sex Categories 45

Figure 20: Rates of Recent Additional Concerns by Sex Categories 46

Figure 21: Rates of Endorsement of Concurrent Disorders 47

Figure 22: Rates of Endorsement of Concurrent Disorders by

Service Sector and Sex 49

Figure 23: Rates of Endorsement of Concurrent Disorders by Age and Sex 50

Figure 24: Rates of Endorsement of Concurrent Disorders by

Legal System Involvement 51

Figure 25: Complexity of Needs 52

Figure 26: Service Provider Perceptions of GAIN SS Utility and Feasibility 55


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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 inter-agency

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

initiatives. 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 et al., 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: Cape Breton Region, Nova Scotia

Summary

The Cape Breton Network was the first of ten networks to launch the National Youth Screening

Project. Discussion about collaboration began in June 2010, followed by several meetings throughout

the summer and fall, resulting in five agencies committing to participate in the project. All necessary

Research Ethics Board (REB) submissions were approved and agreements were signed by March

2011.

Over a staggered six month period, commencing in April 2011, a cross-sectoral group of five youth-

serving agencies in and around Sydney, Nova Scotia undertook this collaborative project to

administer the GAIN SS and a demographic information form to youth aged 12 to 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 Cape Breton District Health Authority (CBDHA) expressed interest in participating in the

National Youth Screening Project 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. In

collaboration with CBDHA, a cross-sectoral network of five local agencies that serve youth was

formed and CBDHA took on the role of “Lead Agency”. Similar to the pilot screening projects

described above, 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 January 2011, CBDHA formally agreed to lead and coordinate a local collaborative network to

implement the GAIN SS1 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 Sydney, Nova Scotia, January 18-19, 2011. Service providers

attended from all five 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 March and April, four of the agencies launched the six-month data

collection phase. Two agencies were unable to participate in the data collection activity of the project.

The Department of Community Services - Child Welfare and the Cape Breton Victoria Regional

School Board participated only in capacity building and network development due to staff turnover.

The Cape Breton Region 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 Cape Breton Region Network includes representation from the addictions, child welfare,

education, family services, health (i.e Youth Health Centres), 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;

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;

1Chestnut Health Systems granted a license to CBDHA to use the GAIN SS (CAMH Version) and gave permission to CBDHA to include all the participating agencies in the network in its licensing agreement.


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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: CBDHA

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 the CBDHA, the network lead agency.

2. A three-party agreement between CAMH, CBDHA 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. These agreements were developed and signed by five of the agencies.

Two of the agencies, Department of Community Services - Child Welfare and Cape Breton Victoria

Regional School Board were unable to participate in all four of key activities of the project, however,

both participated in the Capacity Building and Network Development activities, and Cape Breton

Victoria Regional School Board also participated in Screening Implementation in its schools.

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, CBDHA, 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 and problem-solving of issues

arising.

Implementation Process

1. May - November, 2010 – Networking:

a. Identified interested agencies

b. Established cross-sectoral network

2. September 2010 - March 2011 – Agreements and REB:

a. Developed 2-party agreement between CAMH and CBDHA

b. Developed 3-party agreement between CAMH, CBDHA and all

participating agencies

3. January 18 – 19, 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 the 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. April 2011 – Project launch:

a. Distributed project packages i.e. Project Instruction Sheets, Consent

forms, GAIN SS, Background Information forms, Tracking Sheets

5. April – September 2011 – 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

6. February 22, 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 agencyleads

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.


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Project Flow Chart (See Appendix E)

A step-by-step one page project flow chart was developed for use by all service providers to facilitate

consistency across providers.

Instructions for GAIN SS Use

A step-by-step one page protocol 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.


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GAIN SS (CAMH Version)

The GAIN SS is a brief screening tool validated for use with individuals aged 10 years and older to

quickly identify those who may be experiencing difficulties in one or more of four dimensions: 1)

internal mental distress (e.g., depression, anxiety); 2) behavioural complexity (externalizing

behaviours e.g., ADHD); 3) substance use problems; and 4) crime and violence (Denis, Chan & Funk,

2006). The tool was developed by Chestnut Health Systems and copyrighted in 2005. Chestnut

Health Systems permitted CAMH’s Child, Youth and Family Program to modify the GAIN SS in 2006,

by adding seven items (not part of the original validation) at the end to screen for: eating-related

issues, trauma-related distress, disordered thinking and gambling, gaming and internet misuse

concerns.


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21

Findings


22


23

Background Information about Youth

Who participated?

In total, 483 youth participated:

188 (39%) from addictions sector

21 (4%) from family services sector

150 (31%) from health sector2

19 (4%) from justice sector

105 (22%) from mental health 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 604 youth presented for service to

the participating programs and agencies over the course of the six-month project timeframe. Of these

youth 90% were eligible for the project (n = 544). Reasons for ineligibility included the GAIN SS had

already been administered (39%), immediate mental health concerns (e.g., psychosis) (33%),

cognitive limitations (23%), and the youth were not yet clients of the agency (5%). In addition, for 21

cases information was not provided. Of the youth who were eligible to participate in the project, 530

(97%) were approached for participation. Reasons for youth not being approached included clinician-

based reasons (judgment, forgot) (56%), no forms were available (19%), youth was unavailable (e.g.,

left, no show) (13%), and lack of time (13%). Of the youth who were approached, 86% completed the

GAIN SS. Based on the tracking sheets, 14% of youth who were asked to complete the GAIN SS

refused. Of the youth who completed the GAIN SS, 95% consented to have a copy used for the

purposes of this project. Overall then, based on these tracking sheet numbers, 79% of eligible youth

contributed screeners for this report. Some of the youth who did not contribute refused to participate

(17%), either through refusing to complete the GAIN SS (14%) or through declining to provide consent

(3%), while others were not approached (3%).

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

that approximately 89% of eligible youth were captured on tracking sheets.

2 In Cape Breton, the ‘health sector’ was represented by Youth Health Centres.


24

What are the demographics of the youth who participated?

AGE

FIGURE 1: AGE DISTRIBUTION OF PARTICIPANTS

The participating youth ranged in age from 12 to 24 years with an average age of 16.6 years and a

median age of 16.0 years. In Figure 1, the ages of participating youth are presented using age

categories commonly used in service provision. As can be seen, more youth were in the 12-15 years

age range than other age categories.

42%

35%

21%

2%

12-15 years old

16-18 years old

19-24 years old

Missing


25

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

family services and justice sectors were more likely to be in the older age group (19 to 24 years),

whereas at least half of participating youth presenting to the addictions and health sectors were 12 to

15 years old.

50%

10%

53%

6%

27%

32%

19%

45%

22%

36%

18%

71%

2%

72%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Addictions FamilyServices

Health Justice MentalHealth

Pro

po

rtio

n o

f Y

ou

th

Sector

19-25years

16-18years

12-15years


26

Sex

FIGURE 3: SEX DISTRIBUTION OF PARTICIPANTS

There are significantly more female youth than male youth in the group who participated in the project

(p <.05). Almost two-thirds of participating youth were female (62%), while 36% were male, 0.4%

identified as trans, and 1.7% 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.

36%

62%

0.4% 1.7%

Male

Female

Trans

Missing


27

FIGURE 4: SEX DISTRIBUTION OF PARTICIPANTS BY SERVICE SECTOR

Comparing the five sectors revealed that the male to female ratio differs between sectors. Health

services had a greater proportion of female participants than other sectors (85% female) whereas the

male to female ratio did not differ as significantly across the remaining sectors.

49% 43%

15%

61%

40%

51% 57%

85%

39%

60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AddictionsSector

FamilyServices


Pro

po

rtio

n o

f Y

ou

th

Sector

Female

Male


28

Service History

FIGURE 5: SERVICE HISTORY BY SERVICE SECTOR

Most youth (76%) participating in the project had been involved with the participating service for less

than one month, although there was a fair amount of variability across sectors. For example, the

majority of youth from the mental health and health sectors completed the GAIN SS on their first visit

(71% for mental health service sector and 75% for health service sector), while the majority of youth

who did the questionnaire in the addictions sector had been involved with their respective services for

one month or less (69%) and in the family services and justice sectors, the majority of youth had been

involved for more than two months (52% family services, and 58% for justice).

19% 14%

75%

26%

71%

50%

33%

17%

16%

8% 21%

33%

6%

21%

14%

10% 19%

2%

37%

7%

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

2-12MonthsagoIn the pastmonth

Today


29

Ethnicity

FIGURE 6: ETHINICTY DISTRIBUTION OF PARTICIPATING YOUTH

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

ethnicity across all youth was White/European (83%), followed by Aboriginal (6%), ‘Don’t know’ (6%),

Black (4%) and ‘Other’ (1%). Other reported ethnicities included youth identifying as Filipino, Arab,

and ‘Other’. Four percent of youth (n = 18) did not complete this question.

Birth Country and First Language

The majority of participating youth reported being born in Canada (96%) while 1% reported being born

outside of Canada and 3% did not answer the question. Those born outside of Canada reported

having been in Canada three to 18 years. The majority of participating youth also reported that

English was their first language (96%), while 2% reported a different first language and 2% left it

blank. Of those who indicated that their first language was not English, the majority (2%) reported that

Mi’kmaq was their first language.

6% 4%

83%

1% 6%

Aboriginal

Black

White/European

Other

Don't know


30

Living Arrangements

FIGURE 7: CURRENT LIVING ARRANGEMENTS

Most participating youth (78%) reported that they were living with parents, while 8% were living on

their own or with friends, 7% were living with other family members, 1% reported living in supportive

housing (e.g. “group home”, “treatment facility”) and 2% reported living in unstable housing (e.g.

“shelter”, “on street”, “couch surfing”).

78%

8%

7%

1% 2% 4% Parental/Family Home

Own/With Friends

Other Family/Relative

Supportive Housing

Unstable

Missing


31

FIGURE 8: CURRENT LIVING ARRANGEMENTS BY SEX

Examination of sex differences in living arrangements revealed that male youth were more likely to

report living in unstable and supportive housing than female youth, while female youth were more

likely to report living in the parental/family home. Male and female youth were equally likely to report

living in their own apartment or with friends.

75% 84%

8%

9% 10% 6% 3% 1% 4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Pro

po

rtio

n o

f Y

ou

th

Sex

Unstable

Supportive Housing

OtherFamily/Relative

Own/With Friends

Parental/FamilyHome


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.

91% 87% 49%

33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12-15 16-18 19-24

Pro

po

rtio

n o

f Y

ou

th

Age

SupportiveHousing


Own/WithFriends

Parental/FamilyHome


33

FIGURE 10: CURRENT LIVING ARRANGEMENTS BY SERVICE SECTOR

As would be expected given their age, older youth presenting for service to the family services sector

reported a wider variety of housing arrangements than youth presenting for service to other sectors.

83%

40%

88%

72% 77%

5%

35%

3%

17% 15%

6%

15%

8% 11% 8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


HealthServices

Justice MentalHealth

Pro

po

rtio

n o

f Y

ou

th

Sector

Unstable

SupportiveHousing


Own/WithFriends

Parental/FamilyHome


34

Legal Involvement

The majority of participating youth reported never having any legal involvement (67%), while the

remaining youth reported legal involvement in the past 12 months (18%), more than a year ago

(11%), or did not answer the question (4%).

Education, Employment and Income

Overall just over half of participating youth identified as students. Of those who did not identify as

students, 47% indicated that they were unemployed, 25% indicated part-time employment, 10%

indicated that they were engaged in volunteer activities, and 8% indicated they had full-time

employment.

Age was related to educational, employment and income status. For youth aged over 18 years (n =

101), they indicated that their employment situations were as follows: unemployed (48%), working

part-time (22%), attending school (18%), working full-time (14%) or volunteering (6%) (not mutually

exclusive). In contrast youth aged 18 years or younger (n = 372) indicated that they were students

(62%), unemployed (23%), working part-time (18%), volunteering (12%) and working full-time (1%).

Similarly, the most commonly reported income sources for youth over 18 were as follows: welfare

(43%), employment (27%), no income (14%), employment insurance (12%), and parents/spouse

(11%), while youth aged 18 years and younger reported their income sources to be parents/spouse

(47%), no income (25%), employment (12%), family benefits (6%), and welfare (2%).

For youth over 18 years, educational attainment was also examined revealing a broad range of

educational achievements, including 4% of youth participants reporting grade 8 completion as their

highest educational achievement, 40% indicating grades 9-11 as their highest achievement, 4%

reporting achievement of high school completion without diploma, 27% indicating completion of high

school with diploma, 14% completing some non-university post-secondary education and 10%

completing some university studies.


35

How do the demographics of male and female youth compare?

TABLE 1: DEMOGRAPHIC COMPARISON OF MALE AND FEMALE PARTICIPANTS

Male Female

Average Age 17.6 15.9*

White / European 85% 81%

Born in Canada 99% 98%

English First Language 98% 98%

Unstable Housing 4% 0.3%*

Legal Involvement 45% 20%*

*p<.05

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

revealed that the male youth who participated were older, were more likely to have had legal

involvement and were more likely to report unstable housing than female youth who participated.


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 et al., 2006).

Depending on the service setting, use of each threshold may be more appropriate. For example, in

settings where the rates of clinically significant mental health and substance use problems are

expected to be low (e.g. primary care), use of the moderate threshold may be most appropriate. In

settings where individuals are seeking service for mental health and substance use concerns, use of

the high threshold may be more informative.

For this project, a modified version of the GAIN SS was used (GAIN SS CAMH 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 half 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 approximately half of the 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 30% of participating youth reported 3 or more recent indications of

problematic substance use. In the area of crime and violence, 13% of youth reported 3 or more

crime/violence concerns.

15% 15%

46% 43%

5%

28% 36%

26% 44%

8%

58% 49%

28%

13%

87%

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. As expected, youth presenting for

service to the health service sector had lower rates of overall endorsement across domains (not

shown). Using the threshold of 1 endorsement (see page 36 for explanation of thresholds) to identify

youth who screen positive, more than three quarters of youth, regardless of sector, screened positive

for internalizing concerns. Similarly, more than three quarters of youth across sectors except those

from the mental health sector screened positive for externalizing concerns. In the mental health

sector, over half of youth screened positive for externalizing concerns. Within the substance use and

crime and violence domains, rates of endorsement ranged from 40%-78% across sectors.

83%

90%

58%

67%

100%

81%

43%

57%

76% 79%

49%

40%

98%

89%

53%

64%

89%

61%

78% 72%

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

Addictions

FamilyServices

HealthServices

Justice

Mental Health


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, with the exception of health sector where a lower but still concerning rate of

42% of youth reported high severity internalizing concerns.

Youth presenting for service to the family services and mental health sectors had particularly high

rates of endorsement with over 80% indicating that they had been experiencing 3 or more

internalizing symptoms in the past year. Within the externalizing domain, a third to half of youth

across sectors reported experiencing high severity externalizing difficulties.

In the substance use domain, youth in the justice sector had the highest rates of endorsement of

problematic substance use with just over half of participating youth indicating experiencing 3 or more

symptoms of problematic substance use in the past year. Though lower, a substantial proportion

(24%-36%) of youth presenting for service to addictions, family services, and mental health sectors

also indicated experiencing 3 or more symptoms of problematic substance use in the past year.

Although rates of endorsement were substantially lower in the area of crime and violence than other

domains, 1 in 5 youth presenting to the addictions sector still endorsed 3 or more crime and violence

problems.

52% 56%

36%

21%

81%

33%

24%

5%

42% 39%

13% 5%

61%

39%

56%

17%

83%

54%

31%

12%

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

Addictions

FamilyServices

HealthServices

Justice

MentalHealth


40

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

FIGURE 14: RECENT INTERNALIZING CONCERNS BY AGE AND SEX CATEGORIES

Older youth (19-24 years) were more likely to endorse internalizing concerns than younger youth.

There were no differences between male and female participants.

46% 39%

86%

54% 53%

82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12-15 years old 16-18 years old 19-24 years old

Pro

po

rtio

n o

f Y

ou

th

GAIN SS Domain

Male

Female


41

FIGURE 15: RECENT EXTERNALIZING CONCERNS BY AGE AND SEX CATEGORIES

As shown in Figure 15, male youth aged 12 to 15 were more likely to endorse externalizing concerns

than male or female youth in any other category.

68%

43%

52% 45% 47% 46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


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 aged 19 to 24 were more likely to endorse problematic substance use concerns than

same aged female youth. Older youth were also more likely to endorse substance use concerns than

younger youth.

21% 26%

67%

13%

25%

43%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


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 youth than female youth,

especially male youth in the oldest age category.

17% 19% 27%

7% 11%

7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


44

FIGURE 18: RECENT SUICIDE CONCERNS BY SEX CATEGORY

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, 12% of participating

youth indicated that they had thought about suicide in the past month, with an additional 12%

reporting having thought about suicide in the past 2 to 12 months and 10% more who have thought

about it more than one year ago. Sixty-seven percent of youth indicated they had never thought about

suicide.

67% 67%

12% 9%

12% 12%

10% 13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Pro

po

rtio

n o

f Y

ou

th

Sex

Past month

2 to 12months ago

1+ years ago

Never


45

FIGURE 19: RECENT SUICIDE CONCERNS BY AGE AND SEX CATEGORIES

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

aged 19 to 24 were more likely to endorse suicide concerns than younger male youth. Also, in the 16-

18 age group, female youth were more likely to report recent thoughts of suicide than same aged

male youth.

18% 13%

34%

24% 25% 28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


46

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 20: RATES OF RECENT ADDITIONAL CONCERNS BY SEX CATEGORIES

Across male and female youth, 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 to

endorse eating concerns and traumatic distress compared to male youth.

8% 12%

39% 34%

15%

25%

4%

29% 28%

50%

34%

15% 17%

1% 0%

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

100%

Pro

po

rtio

n o

f Y

ou

th

Additional Concerns

Male

Female


47

Concurrent Substance Use and Mental Health Concerns

This project used the GAIN SS to identify youth who are likely to have concurrent disorders (i.e., co-

occurring substance use and mental health concerns). Youth who endorsed at least three recent

concerns in the substance use domain as well as at least three recent concerns in either the

internalizing or externalizing domain were identified as endorsing a concurrent disorder.

How many youth endorsed both substance use and mental health concerns?

FIGURE 21: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS

SUD

EXT

6%

17% 10%

19%

3%

16%

26% Did not screen positive for INT, EXT,

or SUD

3%

INT


48

Overall, 44% of youth screened positive for more than one area of concern, and 25% of participating

youth screened positive for possible concurrent (substance and mental health) disorders (i.e.

excluding the 26% who did not screen positive for internalizing, externalizing, or substance use

disorders). As can be seen in the Figure 21, 16% of all participating youth screened positive for co-

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

internalizing and substance use concerns, and 3% indicated concurrent externalizing and substance

use concerns. When we examined just those youth who screened positive we found that 88%

screened positive for internalizing concerns and problematic substance use, 76% screened positive

for externalizing concerns and problematic substance use, and 64% screened positive for both

internalizing and externalizing concerns, as well as significant substance use concerns.


49

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

FIGURE 22: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS BY SERVICE SECTOR AND SEX

Female youth from the justice sector were more likely to endorse concurrent disorders than male

youth and female youth in other service sectors. Almost three quarters of female youth in youth justice

screened positive for concurrent disorders. The lowest rates of concurrent disorders were found in

youth presenting to the health service sector.

42%

22%

5%

30% 34%

22% 25%

11%

71%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


HealthServices

Justice MentalHealth

Pro

po

rtio

n o

f Y

ou

th

Sector

Male

Female


50

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

Age and Sex

FIGURE 23: RATES OF ENDORSEMENT OF CONCURRENT DISORDERS BY AGE AND SEX

Youth 19 to 24, particularly male youth in this age category, were more likely to endorse concurrent

concerns than other groups.

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. Youth who live outside of the

parental/family home were more likely to endorse concurrent disorders than youth living in the

parental/family home (37% vs. 21%) (not shown).

19% 19%

67%

11%

23%

43%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f Y

ou

th

Age

Male

Female


51

Legal Involvement

FIGURE 24: 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 (46%) than youth who reported no previous involvement

with the legal system (16%) and indeed, more than half of youth (54%) who screened positive for

concurrent disorders reported previous legal involvement. Male youth who reported legal involvement

were more likely to endorse concurrent disorders than female youth who reported legal involvement.

Educational Status

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

18% of students endorsed concurrent substance use and mental health concerns, almost a third

(32%) of non-students screened positive for concurrent disorders.

55%

45%

80%

20%

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


52

Which factors are most important in understanding the Concurrent Disorder needs of youth presenting for service in Cape Breton Region?

Given that a number of factors were found to be related to endorsing both problematic substance use

and mental health concerns, and that a number of these factors were related to each other (e.g., age

and living arrangements), we examined all of these factors together in one model to understand which

factor(s) are most important in understanding who screens positive for concurrent disorders. The

factors included in this analysis were age, sex, service sector, living arrangements, legal involvement

and educational status. When all of these factors were considered together age, service sector, and

legal involvement were shown to be most important in understanding which youth are more likely to

endorse both substance use and mental health concerns. More specifically, older youth, particularly

youth aged 19 to 24 were more likely to endorse both substance use and mental health concerns. In

addition, even when we controlled for differences associated with age and the other factors, youth

who presented to the health services sector were significantly less likely to endorse mental health and

substance use concerns. Lastly, even after controlling for the impact of other factors like age and sex,

youth who had legal involvement were more likely to endorse concurrent concerns.

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

FIGURE 25: COMPLEXITY OF NEEDS

57%

35%

8%

71%

26%

3%

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


53

In order to understand how many participants experience multiple areas of concern we also examined

the following social determinants of health, along with mental health and substance use concerns: 1)

housing (unstable or supportive), 2) education/occupation (under 18 and not a student or 18 and older

and not a student and not employed), 3) legal involvement (past or current legal involvement), 4)

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

problems (high severity). Notably, 34% of participants reported having 3 or more factors and 5% of

participants reported experiencing 5 or more of the 6 factors. These findings highlight the complexity

of the needs of the individuals who are presenting for service and participated in this project.


54

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 Cape Breton Region (n = 120) completed the service provider survey prior to

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

(n = 39) 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 Cape Breton Region service providers are presented following.

Service provider comments about administering the GAIN SS:

“I liked that the tool was brief but still covered a range of behavioral issues. Also

it is effective in that it helps link the individual to the appropriate service,

regardless of their entry point.”

“Concern reflecting on screening tool being (for) the purposes of research

probably resulted in lack of participation by service providers in the data

collection phase”

“GAIN-SS was a great addition to services’ intake systems and youth were willing

to complete the screening tool.”


55

Feasibility and Utility of the GAIN SS

FIGURE 26: 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 many also reporting a perceived disruption from its use. Notably, those service

providers who perceived the training to be more helpful used the GAIN SS more often in their service

delivery. In addition, those service providers who reported using the GAIN SS with a greater

proportion of their youth clients reported the measure to provide more useful information, to impact

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

service providers who used the GAIN SS with a smaller proportion of their youth clients.

84%

32%

78%

68% 72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Usefulinformation atleast some of

the time

Not disruptive Impactedservice at least

some of thetime

Facilitatereferral at leastsome of time

Recommenduse at leastsome of the

time

End

ors

emen

t R

ate

GAIN SS Utility and Feasibility


56

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

practices

Agency context, service provider role and mandate impacted perception of

feasibility and utility, disruption and clinical benefit of administering the GAIN SS:

“If use of the GAIN could have been disruptive, I didn't use it. Rarely did any

additional information result from the completed GAIN”

“Easy to administer - very useful screening tool”

“The GAIN-SS has been an asset to the work I do with youth. It is a great tool to

facilitate dialogue with youth as well as direct referrals.”

“I found it very helpful - great segue into resources available; over time youth

more open to referral.”

“I have found this tool useful in getting a sense of where our youth are at in their

lives and also in assisting us in providing the best and most relevant service to

them”

“I found it to be a good tool for screening of concurrent disorders in the youth

population and it helped me to generate further discussions related to their

responses.”


57

Summary of Findings

Approximately 79% of eligible youth presenting to participating services and agencies contributed to

this report.

95% of youth who completed the GAIN SS gave consent for it to be included in this report.

Youth presenting for services from addictions, family services, health, justice and mental health

service sectors contributed information to this report.

Youth from the whole age range (12-24 years) participated, with differences in age being apparent

across service sectors.

The majority of participants were female, and the health sector had significantly more female

participants than other sectors.

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

Canada and having English as their first language.

Male youth, older youth and youth presenting for service to the family services sector endorsed a

wider variety of current living arrangements and were less like to live in the parental/family home.

Almost half of male youth and one fifth of female youth 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.

Almost one quarter of participating youth reported significant suicide-related concerns in the past

year.

Almost half of participating youth (44%) screened positive for more than one disorder and 25% 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 age, sex, service sector, living

arrangements, legal involvement, and student status. Of these the most important appear to be age,

legal involvement and service sector. Younger youth, youth presenting for service to health

services, and those without previous legal involvement were less likely to endorse concurrent

mental health and substance use concerns.

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

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

with service provider perceptions of the capacity building activities and their use of the GAIN SS.

Those service providers who found the training more helpful and those who used the tool with more

of their youth clients, found the GAIN SS more useful and perceived it to impact service and

facilitate referrals more frequently.


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Discussion Youth Needs

The findings of this project in Cape Breton Region, Nova Scotia 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, 16 to 18 year old girls were more likely to

report suicide-related concerns than boys, but in the older age category males and females did not

differ significantly, with older male youth experiencing significantly more suicide-related concerns than

younger male youth. Also, the health sector saw a greater proportion of female youth than other

sectors and the justice sector had more male youth than other sectors.

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 the Cape Breton

Region, the interest, support, and enthusiasm of the network lead and ultimately the sustained hard

work of the network coordinator resulted in Cape Breton being the first community to launch and

complete the project. They exceeded their initial agreement to enlist partners representing three

service sectors; rather, enlisting seven (addictions, mental health, health, youth justice, family service,

child welfare and education). Service providers from all seven sectors participated in the network

development and capacity building activities. Ultimately, due to administrative challenges including

staff turnover, agencies representing five sectors, excluding child welfare and education, participated

in all the project activities (See Appendix C).


59

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), as well as 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 findings in Cape Breton from this project indicate that most 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, through the project coordinator, the project team learned that

GAIN SS administration was continuing in some agencies beyond the six month project data

collection phase. Some agencies and services (e.g. CBDHA Addictions and Mental Health services),

were planning to implement policies and protocols to establish on-going consistent implementation of

the GAIN SS in their services. As well, some of the agencies that didn’t participate in the formal data

collection portion of the project, nonetheless, had implemented the GAIN SS in their agencies. This

highlights the importance of considering unanticipated consequences and suggests that an initiative

such as this project may have the potential to significantly impact agency policy and protocol.

Limitations

The findings of this project are limited by a few important factors. The system to capture the extent to

which the sample is representative of youth typically presenting to the participating services (service

provider completed tracking sheets) has limitations and the data indicate that some tracking sheets

were not completed, although the extent of the problem is not clear. As a result, the relevance of the

findings to youth who did not participate is not clear. Secondly, 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. Lastly, different service

providers and services engaged with the project to differing extents which may have impacted the

findings in unknown ways.


60

Recommendations

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

necessary services are available where male and female youth are more likely to present for service

and to ensure that once accessed, the services that are delivered are designed to address the

different types of difficulties male and female youth experience. 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

almost half of participants endorsed significant concerns in two or more domains. 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 concurrent disorders.

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

approximately half of 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. 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.

The impact of social determinants of health on the manner and type of services available to youth

should continue to be explored. For example, youth who had living arrangements outside the

parental/family home had higher rates of screening positive for co-occurring substance use and

mental health concerns, but this finding did not hold up when the relationship between older age and

the increased likelihood of concurrent concerns was taken into account. Nevertheless, since this

project only included a relatively small sample of youth with non-family home living arrangements, it

may be the case that with a larger sample of youth with non-family living arrangements more would be

learned and important service needs unique to this group would be identified.

Implementation of consistent screening in sectors such as health where youth have the lowest rates

of screening positive for problematic substance use and mental health concerns provides an excellent

opportunity for early identification and intervention, while not using expensive specialized resources.

Consideration should be given to gathering similar information as was gathered through this project in


61

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.

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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63

Appendices


64


65

Appendix A: Cape Breton Network Member Agency Descriptions

Cape Breton District Health Authority: Addiction Services

Addiction Services provides comprehensive prevention, education and treatment services to

individuals, families and communities affected by substance abuse and/or gambling.

Community Based Services:

Community Based Services provides a comprehensive range of assessment, intervention,

consultation and treatment services. Referrals may be made by family members, professionals,

members of self-help groups or may be self-referrals. Programs offered through CBS include Adult

Counselling, Adolescent Counselling, Women's Services, Problem Gambling Counselling, and

Addiction Day Program.

Health Promotion & Prevention Services: Adolescent Services:

The CBDHA Addictions Adolescent team offers health promotion and addiction prevention for teens.

The team offers individual early intervention counselling with Adolescent Outreach Workers and three

youth group programs on a regular basis throughout the year. Any youth 13 – 18 years of age is

eligible to connect with an adolescent outreach worker who is present both in schools and in the

community.

Inpatient Withdrawal Management Unit:

Inpatient Withdrawal Management (or IWMU) is an 18 bed unit located at the Cape Breton Regional

Hospital. The inpatient unit manages the acute phase of withdrawal in a safe, therapeutic

environment.

Opiate Recovery Program:

The Opiate Recovery Program provides methadone maintenance treatment in a community setting. It

is one component of a comprehensive prevention and treatment strategy to help those struggling with

opiate dependence and related harms. The Opiate Recovery Program offers: Medical evaluation and

ongoing assessment; daily dosing of methadone at a community retail pharmacy; random drug

screening; methadone education and support groups; short and long term outpatient counselling and

ongoing assessment; referrals, collaboration and assistance navigating additional healthcare needs

and social supports.


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Cape Breton District Health Authority: Mental Health Services

Mental Health Services is a district-wide program that offers a broad range of general and specialized

inpatient, outpatient and community-based mental health services to residents of all ages across the

continuum of care.

Adult Mental Health:

Adult Outpatient Mental Health Services serves a population within the following mental disorders:

Major Mental Disorders, Neurodevelopment Disorders, Adjustment Disorders, and Personality

Disorders, and it works with communities to provide appropriate, compassionate and integrated

emergency outpatient mental health services. The MHS services focus on quality of life through

prevention, early identification and intervention, treatment, support, consultation, community

partnerships, education and research. Referrals are accepted from any source, including self

referrals. The intake nurse screens all intakes to ensure appropriateness of the referral based on the

target population and the catchment area of the particular clinic.

Child and Adolescent Services:

Child and Adolescent Services is an outpatient service involving a multidisciplinary team approach

including psychology, psychiatry, social work and in-home behavioural interventionists. The service

provides assessment and treatment for children up to age 19 and their families, for a wide range of

mental health disorders. The service includes the Intensive Community-Based Treatment Team, the

N.S. Initiative for Sexually Aggressive Youth and the Autism Intervention Program as well as part-time

clinical services in North Sydney, Glace Bay, Baddeck and Neil's Harbour.

Emergency Crisis Service:

Through the Emergency Crisis Program at the Cape Breton Regional Hospital, anyone whose life or

well being is at risk and who requires immediate care can receive emergency mental health services

24 hours a day, seven days a week.

Inpatient Mental Health Services:

This service consists of three units located at the Cape Breton Regional Hospital for patients generally over the age of 16 years.

Unit 1C: a short stay, eight-bed unit for patients with an expected length of stay of five to seven days.

It provides comprehensive assessment and stabilization for individuals in crisis who require 24-hour

supervision and care.

Unit 1B: a 22-bed unit for patients with an expected length of stay of one to six weeks, providing a

range of individual and group treatment approaches.

Unit 1D: a 16-bed unit with a rehabilitation focus for patients requiring longer stays to support their

recovery and eventual move back into the community.


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Cape Breton District Health Authority (CBDHA): Youth Health Centres

Youth Health Centre (YHC) provide youth with confidential access, coordination and referral to a

comprehensive range of services available in the community that address their health needs. These

centres provide health education, health promotion, information and referral, follow-up and support, as

well as some clinical services. Although youth health centres provide information on a wide range of

health issues, they are also a key source of sexual health information for youth. Some services

offered through the YHCs include STI testing, education, and support regarding healthy choices,

dating, relationships, bullying, and nutrition. Services are available to youth up to age 19.

Cape Breton Victoria Regional School Board

Cape Breton-Victoria Regional School Board is committed to providing the best educational programs

and services to our children and community. The School Board strives to build strong basic

educational skills and augment these attributes by challenging the most sophisticated learner. It is

noted for its diversity in all programs. Additionally, the board has developed “state of the art”

technology laboratories with a district-wide computer network system.

The Board covers a vast area, encompassing urban and rural settings in two municipalities-Cape

Breton Regional Municipality and Victoria County. CBVRSB provides educational services to over

18,000 students in more than 56 schools, as well as 185 adult learners in four Adult education

Centres. These educational services are provided using a significant commitment of resources. Our

board also has two Learning Centres (Excerpt taken from www.cbv.ns.ca).

Department of Community Services: Child Welfare

This Intake / Investigation Team is the entry point for the Department of Community Service Child

Welfare regarding concerns of child abuse and neglect under the Children and Family Services Act.

The team consists of admin workers, social workers and family support workers. The team determines

if it is ‘fit’ to act, the time needed to respond, and it creates an intervention plan and assigns a social

worker to the case. A case plan is developed in consultation with the parents (caregivers) to reduce

the risk of future harm to the children and to outline the basis of our involvement. In the vast majority

of cases the matters are rectified at the Intake level. More complex cases can be transferred to the

Open Protection Unit, or can lead to court ordered interventions to ensure the protection of the

children.

Department of Justice: Community Corrections

Department of Justice - Community Corrections provides supervision to the youth sentenced to court

ordered community dispositions from the ages of 12-17. Amongst this supervision is support by

referral to outside agencies to address the young person’s needs. Community Corrections also

provides youth with “Options to Anger”, “Girls Circle” and Voices (for female youth). These programs

are offered by staff when operationally possible.

http://www.cbv.ns.ca/


68

Family Services of Eastern Nova Scotia

Family Services of Eastern Nova Scotia provides professional counselling services on a wide range of

issues based on their mandate: To promote and strengthen families and individuals in the building of

a just and supportive society, and to preserve the sanctity of the family unit. Family Life programs are

also offered to groups with topics ranging from self-esteem, stress/anger management, parenting,

adolescent issues, and young children. The agency also serves as the provider of Marriage

Preparation Courses throughout the service area.


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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 youth seeking

service at their agencies and, with consent, 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

Screening Implementation

Data Collection

Addictions

Cape Breton District Health Authority • Community Based

Services • Health Promotion and

Prevention: Adolescent Services

• Inpatient Withdrawal Management Unit

• Opiate Recovery Program

● ● ● ●

Child welfare

Department of Community Services: Child Welfare

● ●

Education

Cape Breton Victoria Regional School Board

● ●

Family services

Family Services of Eastern Nova Scotia

● ● ● ●

Mental health

Cape Breton District Health Authority • Adult Mental Health • Child and Adolescent

Services • Emergency Crisis

Service • Inpatient Mental Health

Services

● ● ● ●

Health

Cape Breton District Health Authority • Youth Health Centres

● ● ● ●

Justice

Department of Justice: Community Corrections

● ● ● ●


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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

Cape Breton Region, Nova Scotia Timeline

National Youth Screening Project Timeline


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Appendix E: Project Flow Chart


73

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.


74

Oliver, C., & Dykeman, M. (2003). Challenges to HIV service provision: The commonalities for nurses and

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

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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