Street youth in substance abuse treatment: characteristics and treatment compliance.

Smart, Reginald G. ; Ogborne, Alan C.

INTRODUCTION

Researchers in countries such as Australia (Wales, 1991); Canada (Radford, King, & Warren, 1989; Smart & Adlaf, 1991) and the United States (Robertson, Koegel, & Ferguson, 1989) recently studied street youth and found that they have substantial alcohol and drug problems as well as psychiatric and social problems. Indeed, a new wave of street youth is appearing in many parts of the world. Unlike many of the counterculture or hippie youth of the 1960s and 1970s who left home to establish new lifestyles and values, few young people are abandoning home for these reasons. Most seem to leave because of conflicts with parents and school, sexual or physical abuse, or alcohol and drug abuse by parents (Smart, Adlaf, Walsh, & Zdanowicz, 1992; Radford et al., 1989; Young, Godfrey, Matthews, & Adams, 1983).

Given their large number of emotional and drug abuse problems it is reasonable to expect that many street youth will require drug abuse treatment. This is a report on the first study of street youth in treatment for alcohol or drug abuse.

The current wave of street youth includes many with serious psychiatric as well as substance abuse problems. Fischer (1989) recently reviewed studies on the prevalence of mental health problems among the homeless. Although estimates vary from one study to another, the rate seems to be about 40% for both alcohol and drug problems and mental illness. More recently, Robertson et al. studied 93 homeless youth in Hollywood, California and found that almost half were alcohol or drug abusers according to DSM III criteria. Radford et al.'s (1989) study of street youth in ten Canadian cities found that daily drug use was prevalent. About 24% were using marihuana daily, 4% cocaine, 2% solvents, and 9% alcohol, but no problem measure was used. Also, Smart and Adlaf (1991) studied 145 street youth in Toronto. They found that 9% drank alcohol daily. In addition, daily use of cannabis, cocaine, and crack were also high (16%, 6%, and 6%, respectively). Almost half reported current alcohol problems at a clinically significant level, and 24% reported a high level of drug problems. However, only 15% had ever received treatment for alcohol problems and 24% for drug problems. Little is known about street youth in treatment and we have been unable to find any study which deals with the problem. Because street youth have so many social and psychiatric problems, they should be difficult to treat. This report describes a study of 847 youth seen at a variety of treatment centers in Ontario. Comparisons were made between street youth and conventional youth on social and demographic characteristics, alcohol and drug abuse histories, and treatment outcomes.

METHODS AND MATERIALS

The data for this paper were derived from 11 Ontario substance abuse treatment programs participating in an ongoing monitoring study involving 20 such programs. Programs contributing data for the present analysis had, at the time of writing, each completed assessment on at least 30 cases aged 24 or under. Included were three specialized addiction assessment/referral services (Ogborne & Rush, 1990), a 28-day residential program serving people 16 or older, an early-intervention program geared to school referrals, and five youth-oriented outpatient counselling services. These programs are clearly varied, and some are also unique within the province. They were included in the study for a variety of reasons and are not necessarily representative of other Ontario programs.

The analysis focused on 847 cases between the ages of 12 and 24 for whom reasonably complete intake profiles were currently available. These cases represent 69% of all youth seen at least once in the program concerned. Most of the other cases dropped out before assessments were completed. However, in a few cases, assessments were ongoing at the time the programs last submitted data for analysis. These also are excluded from most analyses. (Programs computerize their own data and periodically submit data disks for review and analysis by the project team.)

The assessment instrument was designed especially for the study and featured a detailed substance use section and questions concerning a range of psychosocial issues. The assessment profile is completed by program staff, and the forms were designed to serve both clinical and program monitoring purposes. Thus the items were all clinically relevant and the data collection form has spaces for clinical notes. One objective of the overall study was to enhance the assessment function within the participating programs, and the completeness of the assessment profile was one of the criteria used to determine if this objective was achieved.

Identifying Street Youth

For the present report, cases were considered to be street youth if, at the time of assessment, they had no fixed address or reported that they had been without one at some time in the previous six months. Cases were also considered to be street youth if they had two or more of the following characteristics: (1) they had dropped out of school before grade 12; (2) they reported having slept on the streets at some time during the past six months; (3) they reported eating at mission shelters in the previous six months; (4) they reported using a food bank in the previous six months; (5) they reported that scarce resources caused them to go without food for a whole day at some time in the previous six months. If data were not sufficient to classify cases as street youths or non-street youths, they were excluded from the analysis.

RESULTS

The available data were sufficient to permit 847 cases to be classified as street youth or non-street youth using the criteria noted. There were, however, large differences between programs involved with respect to the percentage of cases with insufficient data (range 7%-77%). This largely reflects differences in program procedures concerning the timing of the assessments. Thus, one outpatient program had very few unclassifiable cases (5%) because assessments were started at the first face-to-face contact. However, in most other outpatient programs, assessments were not started until the second, third, or later appointment, by which time many cases had dropped out. In some programs individual staff members also held strong convictions concerning assessment, and chose not to start the assessment interview until clients were judged to be ready.

Compared with those unable to be classified due to insufficient data, classified cases were more likely to be female (39% vs. 30%; p [is less than] .01), slightly, though significantly older (mean age 18.9 years vs. 183 years; p [is less than] .01), more likely to be referred by schools (23% vs. 13%; p [is less than] .01), and less likely to have been referred from the criminal justice system (13% vs. 22%; p [is less than] .01). These differences were not consistent across programs and, for the most part, program-specific differences between classified and unclassified cases were neither statistically significant nor in a uniform direction. An exception concerned the ratio of unclassified versus unclassified cases referred from the criminal justice system. This ratio was greater than 1 to 7 of the 11 programs, and the differences in proportions referred by the criminal justice system between classified and unclassified cases were statistically significant for three of these programs.

Of the 847 cases retained for analysis, 261 (31%) were classified as street youth and the rest as non-street youth. Tables 1 and 2 compare these two groups with respect to a wide range of other variables and in Table 2 the groups are also compared with a sample of street youth in Toronto (Smart & Adlaf, 1991). These tables show that, for the current sample, there were many statistically significant differences between those classified as street youth and non-street youth with respect to the other variables considered. In all cases these differences showed the street youth to have more problems than did the non-street youth. Street youth were more likely to be unemployed, on welfare, school drop-outs, on probation, recently incarcerated, estranged from their families, physically and sexually abused, depressed, and of low self-esteem. Further, the street youth were more likely to report that they had eating problems, were hyperactive, and had attempted suicide. Street youth reported using a wider range of drugs and more frequent use of drugs other than cannabis. Concern about drugs and alcohol was more prevalent among the street youth who also were more likely to describe themselves as both "alcoholic" and "drug addicted." Street youths were also more likely to report previous residential treatment for substance abuse and to have been in a detoxification center.

TABLE 1
Selected Characteristics of Street Youth and Others(a)

 Street Youth Others
 (N = 261) (N = 586)
Street Characteristics:

No fixed address or in temporary 40.6% 0%
shelter at referral

In past 6 months:

No place to stay 60% 0%
Slept on streets 37% 2%
Ate at mission 22% 0%
Used a foodbank 24% 1%
No food for a day 51% 5%

Employment status at assessment

Working F/T or P/T 12% 17%
Student 27% 60%
Unemployed 50% 20%(*)
Other 11% 4%

Currently on welfare 33% 10%(*)

Drug/alcohol problems

Considers self an alcoholic 47% 23%(*)
Considers self a drug addict 49% 27%(*)
Considers self both an alcoholic 31% 10%(*)
and drug addict

Main drug causing problems(b)

Cannabis 13% 15%
Hallucinogens 11% 6%
Cocaine/crack 25% 14%
Benzodiazepines 0 1%(*)
Amphetamines .2% .2%
Inhalants 1% 1%
Narcotics .4% 1.2%
Alcohol 26% 27%
Number of different types of drugs 3.9 2.5(*)
ever used

Legal situation

On probation/parole/bail
or awaiting trial 48% 36%(*)
Been in correctional establishment
in past 6 months 30% 16%(*)

Ever received help from:

Residential program 24% 9%(*)
Outpatient program 10% 7%
Detox. centre 16% 4%(*)
Counsellor/therapist in other
setting 23% 14%(*)
Any of the above 45% 26%(*)

Family/Social Relationships

Lives with both parents 18% 44%(*)
Does not see either parent more
than 1/month 40% 27%(*)
Not currently involved in a
relationship 61% 67%
Ever run away from home(c) 66% 36%(*)
Ever kicked out by parents(c) 62% 22%(*)
Ever taken by CAS(c) 31% 10%(*)
Considers most friends drink or
use drugs heavily 40% 21%(*)

Referral process

Family involved 24% 36%(*)
School/employer involved 7% 30%(*)
Correctional system involved 10% 15%(*)
Any third party involved 78% 85%(*)

Previous psychological problems

Anorexia/bulimia 16% 8%(*)
Learning disability 22% 19%
Hyperactivity 46% 27%(*)

Worker assessment of main problem

Accommodation 32% 5%(*)
Marital/family 51% 52%
Education/Employment 47% 38%(*)
Financial 23% 12%(*)
Leisure 19% 18%
Legal 24% 19%
Mental health 18% 23%
Social isolation 14% 9%
Physical health 3% 4%
Physical abuse 5% 3%
Sexual abuse 10% 5%
Both alcohol and drugs 63% 39%(*)

Reported or suspected abuse

Physical assault by family
member 47% 29%(*)
Sexual assault by family 15% 9%(*)
member(d)
Sexual assault by non-family
member(d) 30% 17%(*)

a Cases with missing data for specific items were excluded when calculating
percentages for these items

* p [is less than] .01

b self assessed

c these questions asked only of cases under 19. Percentages based on number
asked each question

d included incest, inappropriate touching and sexual exposure
Table 2
Selected Characteristics of Street Youth and Others in Current Sample and
Street Youth in Toronto(a)

 Current Sample Street
 Youth in
 Toronto
 Street Youth Others
 (N = 261) (N = 586) (N = 145)

Percent male 60.5% 60.2% 68%

Age

[less than] 16 13% 27% 5%
16-18 34% 34% 41%
19-21 23% 18%(*) 42%(**)
22-24 30% 21% 12%
Mean 19.1% 17.9%(*) 19%

Grade left school

[less than] 9 16% 4% 12%
9-11 50% 21% 54%
12 + 7% 14% 12%
Currently enrolled 28% 61% 22%

Regarding alcohol use(b)

Concerned about drinking 69% 51%(*) 46%(**)
Ever drank in morning 56% 31%(*) 35%(**)
Bothered by others 67% 47%(*) 34%(**)
Felt bad or guilty(c) 59% 51% 31%(**)
At least one of the above 83% 71%(*) 65%(**)

Regarding drug use

Concerned about drugs 71% 57%(*) 45%(**)
Unable to stop when wants to 37% 27% 43%
Desire to use less 83% 78% 38%(**)
Drug-related arrests (past 6 months) 9% 8% 26%(**)
Shared needles 12% 3%(c) 27%

 Past 6 months Past year

Drugs use

Cannabis Ever 85% 73% 96%(**)
 5 + days/week 24% 19% -
 Daily - - 16%

Hallucinogens(d) Ever 70% 49% 82%
 5 + days/week 4% 1% -
 Daily - - 3%

Cocaine(e) Ever 68% 38% 73%
 5 + days/week 17% 7% -
 Daily - - 6%

Tranquillizers Ever 30% 17% 70%(**)
 5 + days/week 2% 2% -
 Daily - - 2%

Amphetamines Ever 31% 20% 33%
 5 + days/week 2% 1% -
 Daily - - 0%

Inhalants Ever 26% 10% 24%
 5 + days/week 2% 1% -
 Daily - - 0%

Narcotics(f) Ever 24% 15% 18%
 5 + days/week 2% 1% -
 Daily - - 0%

Depression

Felt sad 57% 38% 37%(**)
Felt depressed 60% 3% 30%(**)
Felt like crying 38% 24% 26%

Ever attempted suicide: 53% 30% 42%(**)

Self esteem

Feel good about self 50% 66%(*) 68%(**)
Feel person of worth 64% 81%(*) 86%(**)
Able to do things as well as 80% 83% 95%(**)
others

a Cases with missing data for specific items were excluded when calculating

* Differences between street youth and non street youth statistically
significant (p [is less than] .01)

** Differences between street in current and Toronto samples statistically
significant (p [is less than] .01)

b cage items

c adjusted for age

d refers to LSD for Toronto sample

e Includes each in current samples

f refers to heroin only in Toronto samples

When comparisons between the street youth in the current sample and those in the Toronto sample were possible, it was found that the current sample included a higher proportion of both younger ([less than]16) and older ([greater than]21) cases and a smaller proportion of cases who have ever used cannabis and tranqillizers. However, the street youth in treatment expressed more concern about their alcohol and drug use than did those in the Toronto sample, and presented themselves as being more depressed, having lower self-esteem, and more likely to report that they had attempted suicide.

Compliance with Treatment

The 10 programs contributing data for the present analysis differed with respect to their methods, objectives, and expectations for clients. However, for the purposes of the overall study program, coordinators of nonresidential services agreed to record the total number of direct service hours provided to clients from intake to discharge, and coordinators of residential services agreed to record days in residence from intake to discharge. In addition, all coordinators agreed to record clients' circumstances of discharge.

Treatment compliance data for one residential program were difficult to interpret because it offered highly individualized services. The other residential program that contributed data had discharged 12 street youths and 15 non-street youths. There were no statistically significant differences between the days in residence or in the proportion of premature discharges (i.e., prior to program completion) for the two groups. However, discharge prior to program completion was common for both street youth (42%) and others (37%).

Three of the nonresidential services that contributed data had no discharged cases at the time of their last update. The others had each discharged from 2 to 28 cases, and collectively these programs had discharged 46 street youths and 115 non-street youths. As previously noted, these programs differed in their assessment procedures, and thus differed in the proportion and characteristics of cases with sufficient data for analysis. It would be desirable to consider the relationships between street youth characteristics and program compliance on a program by program basis. However, the number of discharged cases per program were too small to merit such analyses. Thus, only analyses involving all 6 nonresidential programs with discharged cases were considered.

For all cases discharged from nonresidential programs, the average number of hours of direct service provided were similar for street youth and others (3.1 vs. 3.5; [is greater than].30). However the street youth and the non-street youth were more likely to terminate their relationship with the program without telling the staff (47% vs. 19%; p [is less than] .01). (Other modes of termination included program completion, transfer to another program, mutual consent, and termination against advice.)

DISCUSSION

As expected, street youth in treatment were found to have a larger number of social and drug use problems than did non-street youth. Street youth were more likely to be unemployed, on welfare, and to have legal problems. They were also more likely to report being abused and to be currently estranged from their families. They had more psychological problems such as depression, low self-esteem, and hyperactivity. Not surprisingly, they used more alcohol and drugs than did non-street youth and were more likely to define themselves as addicted.

Street youth in the present sample shared many of the characteristics of those in community samples, but they tended to have more serious alcohol and drug problems and to have lower self-esteem and more depression. Clearly, street youth represent a serious challenge to the addiction treatment system.

Discharged street youth and non-street youth had similar lengths of stay and drop-out rates in one residential program, and similar amounts of outpatient treatment. However, discharged street youth were more likely to have dropped out of outpatient programs. Further, drop-out rates were high for both types of programs, and given their many problems, the average amount of time spent receiving outpatient services by both street youth and non-street youth seems very low (3 to 3.5 hours). As more data become available we will be able to determine if some outpatient services have a greater capacity to retain street youth than do others, and also explore differences in outcomes of street youth and others in residential or outpatient programs. At this stage, the number of cases per program are too small to warrant detailed analyses.

In general, the data suggest that for substance-abusing youth and especially those with street youth characteristics, many treatment episodes are brief and terminate prematurely according to program staff. Although brief treatments and unplanned terminations do not necessarily represent treatment failures, the frequency of such events suggests the need for more experimentation in the delivery of youth services. This could include planned brief interventions, the use of outreach workers to maintain contact with drop-outs, as well as the establishment of long-term supportive residences for youth while they use other community resources. Of course, long-term follow-up should be a feature of any attempts to evaluate these and other innovations.

REFERENCES

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Ogborne, A. C., & Rush, B. R. (1990). Specialized addictions assessment/referral services in Ontario: A review of their characteristics and roles in the addiction treatment system. British Journal of Addiction, 85, 197-204.

Radford, J. L., King, A. J. C., & Warren, W. K. (1989). Street youth and AIDS. Ottawa: Health and Welfare, Canada.

Robertson, M. J., Koegel, P., & Ferguson, L. (1989). Alcohol use and abuse among homeless adolescents in Hollywood. Contemporary Drug Problems, 16, 333-390.

Smart, R. G., & Adlaf, E. M. (1991). Substance use and problems among Toronto street youth. British Journal of Addiction, 86, 999-1010.

Smart, R. G., Adlaf, E. M., Walsh, G. M., & Zdanowicz, Y. (1992). Drifting and doing: Changes in drug use among Toronto street youth, 1990-1992. Toronto: Addiction Research Foundation.

Wales, S. (1991). Youth health: Street kids in an inner suburb of Melbourne. Australian Family Physician, 20, 1297-1302.

Young, R. L., Godfrey, W., Matthews, B., & Adams, G. R. (1983). Runaways: A review of negative consequences. Family Relations, April, 275-281.