Dehcho Region, Northwest Territories

Home , Dehcho Region, Northwest Territories

For more information, please contact:

Joanna Henderson, PhD Gloria Chaim, MSW Child, Youth and Family Services Clinician Scientist Deputy Clinical Director Centre for Addiction and Mental Health [email protected] [email protected] 80 Workman Way, Toronto, ON M6J1H4

Production of this report has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

Acknowledgments

The National Youth Screening Project Team would like to acknowledge the commitment, dedication and hard work of the many people representing services in the Dehcho Region, one of ten participating communities across Canada. Sincere thanks are due to Kathy Tsetso, Chief Executive Officer, Dehcho Health and Social Services Authority (DHSSA) and Marlene Villebrun, Mental Health Specialist, Department of Health and Social Services, Government of the Northwest Territories for their interest and support that made the Dehcho Region project possible. We would like to express our deep appreciation to Justin Dalton, Youth Treatment Project Coordinator, DHSSA, the Dehcho Region lead, for his vision, commitment and efforts to introduce the project and generate and sustain local and regional interest; to the agency leads who were prepared to commit to participate in a cross-sectoral collaboration, explore ways to integrate consistent administration of a screening tool and dedicate staff time to participate in the project; to front-line service providers who were willing to take the time to explore new practices, and to work on engaging 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 Agency: Dehcho Region, Northwest Territories The following agencies participated in one or more of the four key project activities: Network Development1, Capacity Building, Screening Implementation and Data Collection (Refer to Appendix A for agency descriptions and Appendix B for key project activity descriptions)

Partner Agency/Services Agency Leads Dehcho Health and Social Services Authority Connie McNab Fort Liard Health Carolyn Wilkes Fort Liard Social Services Fort Providence Health Fort Providence Social Services Fort Simpson Health Fort Simpson Social Services Health Cabins o Nahanni Butte o Trout Lake o Wrigley

1 For the Decho site, “Network Development” refers to working across departments and services within DHSSA, as well as collaboratively with other service providers as available, in some communities.

Dehcho Region, Northwest Territories

Local Lead: Dehcho Region, Northwest Territories

Justin Dalton

Project Team: Centre for Addiction and Mental Health

Project Leads Joanna Henderson Gloria Chaim

Project Coordinator

Megan Anne Tasker

Administrative Support Stephanie Schultz

Research Analysts Andra Ragusila Dave Summers Carly Clifton 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)

5 Dehcho Region, Northwest Territories

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Table of Contents

National Youth Screening Project 9

Overview 9 Context 9 Objectives 12

National Youth Screening Project: Dehcho Region, Northwest Territories 13

Summary 13 Development 13 Partners 14 Roles 14 Implementation Process 15 Materials 16 Findings 19

Discussion 22

Recommendations 25 Appendix A: Dehcho Region, Northwest Territories Network Member Agency Descriptions 29

Appendix B: Key Project Activity Descriptions 30 Appendix C: Agency Project Activity Participation 31 Appendix D: Project Timeline 32

Appendix E: Project Flow Chart 33 Appendix F: Background Information about the GAIN SS 34

Appendix G: References 35

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National Youth Screening Project

Overview The National Youth Screening Project (NYSP), Enhancing Youth-Focused, Evidence-Informed Treatment Practices through Cross-Sectoral Collaboration, was funded under Health Canada’s Drug Treatment Funding Program (DTFP) to work collaboratively with youth-serving agencies in seven communities across Canada to implement a common screening tool for youth substance use and mental health concerns. Each network was to include a range of agencies representing three or more sectors, including substance use, mental health, justice, child welfare, education, housing, outreach and primary health care. Each of the agencies was to participate in one or more of four key project activities: Capacity Building, Network Development, Screening Implementation and Data Collection (see Appendix B). Through this process, the project would have the opportunity to examine rates of co-occurring substance use and mental health concerns (frequently referred to as concurrent or co- occurring disorders (CD)) in different service sectors, across the adolescent and emerging adulthood age spectrum, and to examine the extent to which rates of CD are consistent with service provider expectations. As well, the project aimed to explore service provider perceptions of interagency referrals, perceived interagency collaboration and youth CD attitudes, knowledge, and practices at different time points in the project.

The overall objective of the NYSP was to enhance service provider CD capacity, increase early intervention opportunities and improve pathways to treatment for youth aged 12-24 years with substance use concerns and CD. This was done through building sustainable stakeholder collaborations and providing CD-related capacity development opportunities.

Context

Background Youth with CDs 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 should be a routine part of client care in adults (Rush et al., 2009). However, effective

Dehcho Region, Northwest Territories 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 adhered to in projects such as these. 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 identification of useful adult tools and practices (Health Canada, 2002; Centre for Addiction and Mental Health, 2006).

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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 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).

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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, Chaim, & Henderson, 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

Dehcho Region, Northwest Territories

National Youth Screening Project: Dehcho Region, Northwest Territories

Summary Discussion about the Dehcho Region collaboration began in January 2011, followed by several meetings over the next year, resulting in the Dehcho Health and Social Services Authority (DHSSA) agreeing to have its services across 6 communities participate in the project. All necessary Research Ethics Board (REB) submissions were approved, a research license was obtained and agreements were signed by June 2012.

Over a staggered six month period, commencing in June 2012, a cross-sectoral group of youth- serving providers based in the Dehcho Region undertook this collaborative project to administer the GAIN SS and a demographic information form to youth aged 12-24 years seeking service at their services. 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. Due to a small sample size, general findings about the background and service needs of youth who participated in this study will be presented to ensure confidentiality of the participants.

Development In 2011, the Dehcho Health and Social Services Authority expressed interest in participating in the National Youth Screening Project in response to broad national dissemination of information about the project following the funding announcement. The DHSSA was interested in the project to build capacity to identify and address the complex needs of the youth who access its services as well as to have the opportunity to document the needs of youth seeking service in its respective services and communities. Information about the project was provided to all of the Chiefs and Mayors of all the involved Nations and Hamlets for review, feedback and approval to obtain endorsement of the project. In addition, all necessary research ethics approvals were obtained and a research license was issued by the Aurora Research Institute.

In March 2012, the DHSSA agreed to collaborate in the NYSP to implement the GAIN SS1 with youth seeking service at the participating services across the region. The project leads attended a project

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

Dehcho Region, Northwest Territories development meeting and held three one-day training workshops for service providers in Fort Simpson, Fort Liard, and Fort Providence, March 19, 20 and 22, 2012 respectively. Service providers attended from all the participating services across the region. In June 2012, the six-month data collection phase was launched. The Dehcho Region Project was established based on shared interests and concerns, including interest in the opportunity to work together in a research-community collaboration. The group was also interested and committed to ensuring that knowledge gained through this collaborative effort be shared locally, provincially and nationally.

Partners The Dehcho Region Project included representation from the social, health and outreach service sectors (see Appendix A for agency descriptions). Three of the seven services participated in all four key activities of the project, which include: Network Development2, Capacity Building, 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; 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, CAMH and the Stanton Territorial Health Authority; Obtain Northwest Territories Scientific Research License from the Aurora Research Institute.

Lead Agency: Dehcho Health and Social Services Authority Identify local organizations and services, representing a minimum of 3 sectors to participate in the project; Act as a liaison between CAMH and DHSSA services during the term of the project;

2 For the Decho site, “Network Development” refers to working across departments and services within DHSSA, as well as collaboratively with other service providers as available, in some communities. 14

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Facilitate and obtain local REB approval for the project; Obtain licenses from Chestnut Health Systems Inc. for use of the GAIN SS; Support training provided by the project leads and facilitate provision of consultation as needed throughout the project; Facilitate data collection by the participating services.

Participating Services: 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, a two party agreement was signed between CAMH and the Dehcho Health and Social Services Authority. The agreement described the project, roles, responsibilities, activities and commitments, as well as the data collection protocol. This agreement was developed and signed by CAMH and DHSSA, on behalf of its services in the Dehcho Region.

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, Dehcho Health and Social Services Authority, was involved with the project throughout each stage of the project from initiation to completion. Once the service level training was completed and data collection was underway, the Local Lead, along with the project team at CAMH, was involved in communicating with the participating services to maintain engagement, momentum, and compliance with the project protocol, problem-solving of issues arising and collaborating in the joint data analysis process.

Implementation Process

1. January, 2011 – November, 2011 – Networking: a. Identified services b. Established interest in the project

2. October, 2011 – March 2012 – Agreements and REB: a. Developed 2-party agreement between CAMH and Dehcho Health and Social

Dehcho Region, Northwest Territories

Services Authority b. Secured ethics approval from the Stanton Territorial Health Authority Research Ethics Board c. Applied for Northwest Territories Scientific Research License

3. March, 2012 – Capacity building a. Capacity building across communities was delivered using the package developed by the project leads and reviewed by local officials

4. June, 2012 – Project launch: a. Local lead distributed project packages i.e. project instruction sheets, consent forms, GAIN SS, Background Information forms, tracking sheets

5. June, 2012 – December 2012 – Project actively underway: a. Service providers obtained consent from youth seeking service at their agencies, administered the GAIN SS and Background Information Form b. Anonymous copies of the completed measures and tracking sheets were submitted to the Local Lead on a monthly basis, and delivered to CAMH c. Consultation was provided as needed by the Local Lead and/or project coordinator/project leads

6. March, 2013 – April, 2013 – Preliminary report development process: a. Preliminary findings shared with Lead agency and local community leaders b. Report feedback through Local Lead c. Report shared with community leaders for feedback and apporved d. Stakeholder feedback incorporated into report

Materials

Service Provider Project Package Project Flow Chart (See Appendix E)

A step-by-step project flow chart was developed for use by all service providers to facilitate consistency across providers.

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.

Dehcho Region, Northwest Territories

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.

Youth Project Package Youth Consent Form

The consent form described the project, confidentiality and plans for data management. Youth initials only were required to ensure anonymity.

Parental Consent Form

The consent form described the project, confidentiality and plans for data management. Parental consent was required in addition to youth consent only where parental consent was required to obtain services for youth under 16 years of age. Parent’s initials only were required to ensure anonymity.

Background Information Form

The Background Information Form is a one-page questionnaire used to gather demographic information about the participating youth. The questions seek information about the determinants of health frequently cited in the literature as associated with youth substance use and mental health concerns including age, sex, education, employment, income support, housing, legal involvement, ethno-racial identification, and language diversity.

GAIN SS (CAMH Version)

The GAIN SS is a brief screening tool validated for use with individuals aged 10 years and older to quickly identify those who may be experiencing difficulties in one or more of four dimensions: 1) internal mental distress (e.g., depression, anxiety); 2) behavioural complexity (externalizing behaviours e.g., ADHD); 3) substance use problems; and 4) crime and violence (Denis, Chan, & Funk, 2006). The tool was developed by Chestnut Health Systems and copyrighted in 2005. Chestnut Health Systems permitted CAMH: Child, Youth and Family Program to modify the GAIN SS in 2006, by adding seven items (not part of the original validation) at the end to screen for: eating-related issues, trauma-related distress, disordered thinking and gambling, gaming and internet misuse concerns.

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Findings, Discussion and Recommendations

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Findings

Due the small number of youth in the sample (N < 12), only general findings will be presented to protect the confidentiality of participants. These findings should be interpreted with caution. Information gathered from participating youth, will however, be included in the National report.

Youth presenting for services in Fort Simpson, Fort Providence and Fort Liard contributed information to this report.

Youth from across the age range (12 to 24 years) participated.

Male and female youth participated.

The majority of participants identified their ethnicity as Aboriginal and reported English to be their first language.

The majority of participating youth screened positive for significant mental health concerns (internalizing or externalizing concerns) using the GAIN SS. (Please see Appendix F for background information about the GAIN SS).

The majority of participating youth screened positive for substance use concerns, using the GAIN SS.

Approximately half of participating youth had both mental health and substance use concerns, using the GAIN SS.

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Discussion

Youth Needs The findings of this project in the Dehcho Region must be interpreted with caution given that they represent a small number of youth (<12) from only three communities out of six that participated in the project. However, it is notable that the majority of participants endorsed significant mental health or substance use concerns and approximately half endorsed both mental health and substance use concerns. These findings are consistent with findings in other communities and suggest that efforts to identify a suitable screening tool that can be implemented across the territory and to improve capacity to address substance use, mental health and co-occurring substance use and mental health problems are warranted. The literature, findings in other participating communities, and concerns identified across the age range in this sample, indicate the importance of continuing to provide or enhancing developmentally-informed and responsive services. In addition, given that the majority of participating youth identified their ethnicity as Aboriginal, identifying and developing tools and processes that are culturally sensitive and relevant is important.

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, leadership was required to implement the project through identifying, engaging and supporting service providers across the Dehcho Region. The Youth Treatment Project Coordinator, DHSSA, who had learned about the National Youth Screening Project (NYSP) through participation in national events, including the DTFP Coordination Meeting hosted by the Canadian Centre on Substance Abuse in January 2011, brought the project forward in the Dehcho Region as an opportunity to leverage the Northwest Territories DTFP funded Youth Treatment Project that was initiated in a similar timeframe. The NYSP project team was invited to present a proposal outlining options for participation in the NYSP and with the support of the Chief Executive Officer, Dehcho Health and Social Services Authority and the Mental Health Specialist, Department of Health and Social Services, Government of the Northwest Territories, a decision was made for the DHSSA to enter into a collaborative agreement with CAMH for participation in the national project. Local research ethics approval was granted by the Stanton Territorial Health Authority, in addition to the ethics approval from Health Canada and CAMH. Detailed information about the project including its objectives, protocol, and ethics approvals was shared with all the Chiefs and Mayors of all the Nations and Hamlets that could potentially participate in the Dehcho Region to seek their permission to carry out the project. Once that was confirmed, a Northwest Territories Scientific Research License was granted by the Aurora Research Institute prior to the project launch. The sustained leadership and

Dehcho Region, Northwest Territories hard work of the Dehcho Region Lead resulted in the Region’s active engagement in the project. Seven services representing three service sectors, social services, health services and outreach participated. The sectors were represented through a range of services administered by DHSSA in six communities across the region. Service providers from all the sectors participated in the initial network development and capacity building activities. Three of the services in one of the sectors participated in all aspects of the project, resulting in youth from three of the communities participating in the project (See Appendix C).

Providing a capacity building event in three locations (Fort Simpson, Fort Liard and Fort Providence), and 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, supported by the local lead. This helped to ensure that all aspects of the protocol were clearly and consistently communicated. The agency decided to send staff who would participate in the full project as well as staff who might use the screening tool with populations that were not part of this project (e.g., adults older than 24 years), and staff who would not be administering the screener, given their service role. In addition, service providers from other local community services were welcomed to join the training events. As such, the capacity building component of the project had a broader reach than initially anticipated. In addition, the local lead has continued to be involved in supporting a process in the NWT to identify a screening tool to be implemented across the NWT.

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. Although the number of participating youth was very small, agreement of youth to participate in the research component of the project along with completing the screener, is encouraging with respect to the feasibility of such initiatives and the potential of projects such as this to learn more about youth needs.

The final report was developed through an interactive process between the Project Leads, the Local Lead and community stakeholders, including the Mayors and Chiefs. Drafts of the report were shared, feedback was sought, findings were discussed and recommendations were jointly developed with participating stakeholders.

Limitations The findings of this project are limited by factors related to the screening tool, the extent and type of engagement of the participating service providers and the small number of participating youth. 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. In addition, the GAIN SS has not been validated with Aboriginal youth in the Canadian context. Since the

Dehcho Region, Northwest Territories majority of participating youth identified their ethnicity as Aboriginal, the findings should be interpreted with caution as the extent to which the tool is valid and reliable with this group is not known. Service providers engaged with the project to differing extents which may have impacted the findings in unknown ways. Lastly, the small number of participating youth limits what can be reported about youth needs from the perspective of confidentiality, as well as generalizability.

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Recommendations

The following recommendations were developed based on the information gathered from the small number of participating youth (<12) and discussion of the project process and findings with project stakeholders:

Although based on a small sample of youth (<12), continued capacity building regarding mental health, substance use and concurrent disorders is warranted given that the participants endorsed significant mental health and/or substance use concerns.

Consideration should be given to exploring the feasibility of gathering similar information as was gathered through this project in the other participating services across communities, to increase understanding about the concerns of youth presenting for service.

Given the majority of participating youth identified their ethnicity as Aboriginal, further examination to ensure cultural sensitivity and relevance of tools and interventions is warranted.

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 this screening tool, or another culturally appropriate tool, at subsequent points in the service delivery process for the purposes of monitoring within treatment progress and post-treatment outcomes.

Further study is also recommended to examine the relative impacts of training, agency policy, protocols, monitoring, supervision and administrative support on implementation of new practices, such as the implementation of a consistent screening tool and process, as was examined in this project.

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Appendices

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Appendix A: Dehcho Region, Northwest Territories Network Member Agency Description

Dehcho Health and Social Services Authority One of eight Government of Northwest Territories Health and Social Services Authority regions, the Dehcho (Slavey for ‘big river’) occupies the southwest corner of the territory, bordering the Yukon to the west, Great Slave Lake to the east, and the provinces of BC and Alberta to the south. The 3,409 residents of the Dehcho are spread across nine communities – including the Hay River Reserve – ranging from 55 in Kakisa to 1,283 in the regional administrative centre of Fort Simpson. Sitting at the confluence of the Mackenzie and Liard Rivers, 375 kilometres southwest of Yellowknife, Fort Simpson is accessible by road along the Mackenzie and Liard Highways – and by air from Whitehorse or Yellowknife. The communities of Trout Lake and Nahanni Butte are accessible by winter road only or fly-in. Three-quarters (75%) of the Dehcho’s residents are Aboriginal. The Dehcho First Nation represents the Dene and Métis people of the territory and consists of twelve member nations. More than one third (36%) of the region’s population is 24 years of age or younger. The Dehcho HSSA provides health and social services to residents each of the nine communities under its administrative responsibility. Generally, a greater range of services and greater staff specialization is offered in the 3 larger (‘hub’) communities of the region – Fort Simpson (the regional administrative centre), Fort Providence, and Fort Liard. Service providers from these communities deliver services to the outlying (‘satellite’) communities in their geographic catchment. Fort Simpson, Fort Providence and Fort Liard each has a Health Centre that offers a greater range of services relative to the Health Cabins of the satellite communities. Fort Simpson’s Health Centre offers the greatest range of services, and is also the base for physicians who provide services to the Dehcho. There is a locally based general practitioner (GP) position as well as specialists who come for regularly scheduled visits. Each of the Community Health Nurses (CHNs) has an assigned area of specialty (e.g., chronic disease) and provides support to applicable specialists. Each of the CHNs working out of the three health centres also has an assigned community to which they travel 3 days per month. The GP travels to the same community on the third day to see triaged patients.

Social Services are provided to residents of the hub and satellite communities in a similar manner. Both social workers (SWs) and Mental Health and Addiction Counselors (MHACs) provide services in the larger communities out of the Social Services offices, and in other settings as applicable (e.g., schools). SWs and MHACs travel to outlying smaller communities on an as-needed (rather than scheduled) basis. There are four Community Wellness Worker (CWW) positions in the region; these provide basic MHA support and deliver education and prevention programs. (See DHSSA website).

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Appendix B: Key Project Activity Descriptions

Network Development1 Service providers that participated in the Network Development activity played a role in building collaborative relationships, starting with preliminary discussions regarding project participation. These service providers participated in project specific meetings and training, and collaborated with the local lead and project team to carry out the project.

Capacity Building Service providers from DHSSA and from other 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. Some agencies and services that participated in the Capacity Building activities were interested in participating in the full project but were not able to due to resource or administrative challenges, such as difficulties completing legal and/or ethics processes in the required network timeframe.

Screening Implementation Member agencies that participated in the full project implemented the GAIN SS with youth seeking services at their agencies. Some agencies chose to implement the GAIN SS with the youth seeking service for clinical purposes, but did not participate in the full data collection component of the project (see below).

Data Collection Member agencies that participated in the full project participated in a six month data collection period. During this time, the GAIN SS and Background Information Form were administered to consenting youth seeking service at their agencies and a copy was sent to the project team. The data was prepared by the project team and a local community report was generated through a collaborative process between the project team and the participating agencies.

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Appendix C: Agency Project Activity Participation

Project activity

SECTOR Agency name Network Capacity Screening Data Development1 Building Implementation Collection

Social DHSSA Fort Liard Social ● ● ● ● Services Services

DHSSA Fort Providence ● ● ● ● Social Services

DHSSA Fort Simpson ● ● ● ● Social Services

Health DHSSA Fort Liard Health ● ● Services Services

DHSSA Fort Providence ● ● Health Services

DHSSA Fort Simpson ● ● Health Services

Outreach DHSSA Health Cabins Nahanni Butte ● ● Trout Lake Wrigley

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Appendix D: Project Timeline

Year 1 Year 2 Year 3 2010 2011 2012 2013

Apr - July - Oct - Jan - Apr - July - Oct - Jan - Apr - July - Oct - Jan - Jun Sept Dec Mar Jun Sept Dec Mar Jun Sept Dec 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

Dehcho Region, Northwest Territories Timeline Legend National Youth Screening Project Timeline

Dehcho Region, Northwest Territories

Appendix E: Project Flow Chart

Dehcho Region, Northwest Territories

Appendix F: Background Information about the GAIN SS

The GAIN SS is a well-validated and reliable screener for mental health and substance use concerns in youth and adults. It has four 5-item subscreeners embedded within the overall measure to screen across four domains: Internalizing (INT) disorders (e.g., mood, anxiety disorders), Externalizing (EXT) disorders (e.g., attention deficit/hyperactivity disorder), Substance Use disorders (SUB), and engagement in Crime/Violence (CV). In order to fully understand the findings presented in this report, it is important to understand the scoring decisions that informed the analyses. The GAIN SS has been shown to have excellent sensitivity and specificity. These rates change, however, depending on how the GAIN SS is scored and analyzed. Within each subscreener using a moderate threshold of at least one recent (2-12 months ago) or current (past month) concern has excellent sensitivity (94-98%) for identifying youth who will meet diagnostic criteria for disorder, but lower (71-76%) specificity, i.e. lower accuracy in ruling out youth who will not meet diagnostic criteria for disorder. Using a high threshold of three or more recent or current concerns within one domain improves the specificity to 96-100%, but results in decreases in sensitivity (49-68%). Using a threshold of three or more current or recent concerns endorsed across all domains (total) will identify 91% of youth who will meet diagnostic criteria for a disorder and will rule out 90% of youth who will not have a disorder (Dennis, Chan, & Funk, 2006).

Depending on the service setting, use of each threshold may be more appropriate. For example, in settings where the rates of clinically significant mental health and substance use problems are expected to be low (e.g. primary care), use of the moderate threshold may be most appropriate. In settings where individuals are seeking service for mental health and substance use concerns, use of the high threshold may be more informative.

For this project, a modified version of the GAIN SS was used (GAIN SS CAMH Modified Version) which includes 7 additional items following the original subscreeners. These additional items provide information about eating behavior, thinking-related issues, traumatic distress, and gambling, gaming and internet overuse. Sensitivity and specificity data for these items are not yet available and these items are not scored.

Dehcho Region, Northwest Territories

Appendix G: 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.

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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.