Proposal for Residential Addiction Treatment Programs for Youth

May 7, 2007

WORKING GROUP MEMBERS:

· Ellie Barrington, Parent Representative

· Mike Beauchesne, Dave Smith Youth Treatment Centre

· Rolland Choquette, Maison Fraternité

· Mariette Chrétien, Roberts Smart Centre

· John Helferty, Roberts Smart Centre

· Robert Laviolette, Maison Fraternité

· Joan Leadbeater-Graham, Rideauwood Addiction and Family Services

· Dr. Robert Milin, Children’s Hospital of Eastern Ontario and Royal Ottawa Health Care Group

· Melody Paruboczy, Dave Smith Youth Treatment Centre, Chair

· Pauline Sawyer, Alwood Treatment Centre

· Paul Welsh, Rideauwood Addiction and Family Services

· Julie Lemieux, Roberts Smart Centre

· Louise Logue, Ottawa Police Services

ADDITIONAL STAKEHOLDERS/CONSULTANTS:

· Glenn Barnes, Addiction Services of Eastern Ontario

· Alfred Cormier, Centre for Addiction and Mental Health

· Dr. Simon Davidson, Children’s Hospital of Eastern Ontario

· Yvon Lemire, Addiction and Problem Gambling Services of Ottawa

· Cam Macleod, Roberts Smart Centre

· Lance Migwans, Wabano

· Dan Paré, Youth Services Bureau

· Ron Parker, Addiction Referral Services Renfrew County

· Bruce Ransom, Wabano

· Mike Souillier, Royal Ottawa Health Care Group, Early Intervention Program

· Nancy B. MacNider, St.Mary’s Home

This proposal, developed by the Youth Residential Addiction Treatment Working Group (the Working Group), has been based upon the overview for youth residential addiction treatment completed by the Youth Cluster of the Champlain Addiction Coordinating Body (CACB). The CACB identified youth residential addiction treatment as one of their top three priorities to the Ministry of Health and Long Term Care (MOHLTC) on July 15, 2004. Youth residential addiction treatment has also been identified as a treatment priority in Ottawa’s Integrated Drugs and Addiction Strategy.

Currently in Ottawa, there are five programs specializing in youth substance use treatment, none of which have a residential component. Lack of residential treatment for youth is a national concern and has been cited as priority issues in Toronto and Vancouver’s Drug Strategies. It is commonly accepted that residential treatment should be available for youth and be viewed as an important part of a well-developed continuum of services in order to adequately serve youth with substance use problems. The nearest available residential treatment facility for Ottawa’s Anglophone youth under the age of 16 is located in Thunder Bay (an approximately 19-hour drive away and equivalent to driving from Ottawa to the tip of Florida). In 2005, 80% of admissions to the Thunder Bay facility were from outside their region with 17% of admissions being from the Ottawa area. There are no residential treatment programs for Francophone girls under the age of 18 in Ontario. The nearest residential treatment facility for Ottawa’s Francophone boys 15 years and over is in Opasatika, near Hurst (a 16 hour drive from Ottawa). Lack of residential addiction treatment compels outpatient programs to maintain clients who need residential treatment, in less intensive services. This is detrimental to those clients requiring residential treatment and also to the clients requiring outpatient services.

Alwood Treatment Centre, a 14-bed residential treatment program in Carleton Place for youth 16 to 22 years of age, has the capacity to admit only 60 of the 125 referrals it receives each year, and receives 1,300 calls each year, (5 calls per weekday) requesting residential services for youth under 16 years of age. Furthermore, Alwood is the sole long-term (4-6 months) residential addiction treatment facility in the entire province of Ontario for this age group, and has an average minimum wait time of 3 to 4 months. Some clients on the waiting list drop out because of such delays. It is anticipated that the Youth Residential Addiction Treatment Programs would receive over 300 referrals per year from local agencies alone. Such lack of access and excessive wait times are unacceptable for this vulnerable at-risk population and lead to serious consequences in the areas of health, education and corrections. These adverse consequences are felt by youth, families and communities. For every $1 spent on addiction treatment today, at least $5.60 will be saved in future associated costs (Report of the Provincial Auditor for Ontario, 1999).

It is anticipated that this outline would form the basis for discussions in the further development of these programs. The development of the Residential Addiction Treatment Programs will also follow service models, which include but are not limited to, those contained in Health Canada’s Best Practices for Youth and Substance Abuse, and be consistent with Setting the Course and other evidence-based practices.

As indicated, it is the intention of the Working Group that there would be two separate programs, one for English youth and one for Francophone youth and that this outline would form the basis of both of these programs. It is our strong recommendation that Maison Fraternité be the lead agency for the Francophone component of this project as this will ensure that Francophones will have access to an all-francophone institution for the treatment of addictions, in the same manner as they have access to Francophone schools, hospitals, “caisses populaires”, etc.

The potential needs of the Aboriginal population have not been fully incorporated into this proposal. It is not known at this time if culturally specific components may be adequately incorporated into the proposed programs to meet the needs of this population. Steps have been taken to include appropriate representation from this cultural group and their input will be incorporated into this document on a going forward basis.

Highlights of the ideal youth residential addiction treatment programs are:

1. Have an addiction specific focus

2. Include the following components:

1 x 16 bed program for English males;

1 x 16 bed program for English females;

1 x 8 bed program for Francophone males;

1 x 8 bed program for Francophone females.

There will be 12 treatment beds and 4 stabilization beds within each 16-bed unit and 6 treatment beds and 2 stabilization beds within each 8-bed unit.

3. Have an academic component - ideally with access to academic credits by entering into partnerships with local School Boards.

4. Treatment approaches will include evidence-based practices such as Motivational Enhancement Therapy, Cognitive Behavioural Therapy and Family System Intervention in a systemic approach within an addiction context, tailored to the individuals risk and need levels.

5. Provide and/or facilitate access to essential parent/family services specifically for adolescent substance abuse.

6. Actively involve parents/caregivers throughout the treatment process as appropriate.

7. While in the program abstinence will be required and will be emphasized in Continuing Care.

8. Integrate relapse prevention throughout the program.

9. Ensure continuity and service coordination with community based addiction treatment providers and other mental health services and auxiliary programs.

10. Be located within the Ottawa region where there is access to appropriate social, cultural and spiritual resources for youth.

11. Be located in an area that poses minimal risks to safety, runaways, treatment effectiveness and relapse as well as negative influence of drug using peers.

12. Have a non-institutional appearance and feel and be youth-appropriate.

13. Be fully accessible for persons with physical disabilities.

14. Be fully inclusive of GLBTQ, and visible minorities.

15. Services will be client centered and sensitive to the individual needs of all clients.

16. While withdrawal management/detoxification services are not compatible in a residential

youth addiction treatment facility, a period of stabilization and preparation is integral to an

effective treatment program.

17. The youth addiction treatment sector will continue to build a seamless continuum of care for both youth and their families

18. The program must have the capacity to effectively assess and manage clients with concurrent

disorders, consistent with mild to moderate mental health issues.

Success will be achieved when youth have timely access to critical intensive residential addiction treatment through a seamless continuum of care.

Supporting data can be found in:

1. Champlain District Health Council, Integrated Addiction Services Plan for the Champlain District, Technical Report, December 1999

2. Youth Managers Group Report – Recommendations on Residential Adolescent Substance Abuse Treatment, July 24, 1997

3. Ministry of Health Residential Working Group Phase 2 Report – A Strategy for Residential Addiction Treatment in Ontario, MOH March 2000

4. Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems, Health Canada, Canada's Drug Strategy Division, 2001

Structured addiction treatment programming will occur during day, evening and weekend shifts with qualified staff able to cover the programming demands of each shift. Weekend programming will remain structured but will be less intensive than weekday programs.

Treatment approaches that include a wide range of therapeutic modalities appropriate to youth addiction treatment, and are consistent with evidence-based and best practices, will be utilized. There will be an emphasis on reintegration to appropriate continuing care services for the teen and their family.

Outcome and follow-up evaluative research will be an integral part of the design in order to assess program effectiveness. Evaluation research data will be used to support quality and program service delivery and to add to the literature on evidence-based practices.

Admission Criteria

Clients accessing the residential addiction treatment program will require a stabilization period of between 3 days to 2 weeks prior to their full participation within the residential program.

· Age 13 to 17 (flexibly applied to meet individual client needs)

· Assessed to be at moderate to severe substance abuse/dependency

· Ontario resident

· Speaks English or French

· Basic reading and writing skills

· Eight mandatory MOHLTC Addiction Assessment Tools completed

· Is not better suited to less intensive level of addiction treatment in accordance with the MOHLTC’s Admission and Discharge Criteria

· Acknowledgement of a substance abuse problem

· Open to making personal and lifestyle changes

· Agree to abstinence during treatment

· Agree to attend long term treatment*

· Must be in at least the “Preparation” Stage of Change

· Have a level of stability to allow participation in the program

· Does not pose a threat to physical or emotional safety of clients/staff/self

· Is agreeable to be involved in all aspects of the program

· Agree to respect and support fellow clients in their treatment process

· Current charges or court dates cannot interfere with the treatment program – charges must be either dealt with before treatment or remanded post treatment

· Must complete a screening process

* Clients will not be admitted to or retained in the program involuntarily.

It is understood that many potential clients will have co-occurring mild to moderate mental health issues. It is important that they are sufficiently stable either through medication or other treatment prior to their admission to the program.

Academic Component

1. 4 classrooms (one English male, one English female, one Francophone male, one Francophone female)

2. A ratio of 6 students to 1 teacher will be recommended (The partnership and collaboration of local School Boards/Ministry of Education will be required ie Section 23 classroom)

3. Anglophone classes - maximum of 24 youth requiring 4 teachers

4. Francophone classes – maximum of 12 students requiring 2 teachers

5. The school component will be available 12 months of the year

6. Clinical support for the classroom will be crucial to deal with crises, etc.

7. Volunteer tutors from the community will be relied upon to provide support to the classroom

8. Space within the classroom will require dividers, cubicles for students, some separated work stations with a larger area to come together, 1 –2 areas within the classroom that are more private, and computer stations

9. Individual Learning Courses (ILC) will be utilized

10. Individual Education Plans (IEP) will be developed for each student

11. Physical and health education will be included in the curriculum

12. Art, music, and drama would also be part of the school curriculum

Staffing

Staffing will be based on two 16-bed units for the Anglophone facility and two 8-bed units for the Francophone facility.

It is essential that qualified clinical staff have substantial, relevant, experience in the delivery of addiction specific treatment with youth.

Staff Salaries and Benefits

Please see attached staffing documents for the English and Francophone Youth Residential Treatment Programs, which outline the FTE, salary and benefit requirements. It must be noted that the salaries listed are for 2006. Cost of living adjustments will be required in conjunction with the opening of the Programs.

Other Program Costs

Psychiatric sessional fees must be calculated and included in the final cost.

A rough estimate for the annual rent utilities and supplies costs, such as: heating, hydro, communication systems, maintenance materials, municipal taxes, insurance (liability and property), capital reserve fund, staff training and food would be approximately $200,000 per unit. Operating costs will vary by location.

Total annual operating costs for the Anglophone male and female youth residential addiction treatment programs including the academic component: $3,156,650.

Total annual operating costs for Francophone Youth Residential Treatment Programs including the academic component: $1,759,225.

Setting

The recommended location for the Youth Residential Addiction Treatment Programs would be a rural setting within an easy commuting proximity to the urban area. The Programs should be located far enough outside of the urban area to provide a disincentive to runaways, contact with gang members and pimps and access to drugs, etc. A green space barrier between the treatment setting and any built up areas should provide this natural safety barrier to the clientele while still allowing access to parents and family members, staff members as well as providing access to cultural, recreational and medical facilities.

Capital Costs (TBD)

1. Approximately $220 per sq ft construction cost

2. Minimum of 5 acres of land per unit

2. 16 beds per unit – single occupancy

3. Approximately 12,000 sq. ft. per unit

Anglophone Residential Treatment Centre for Youth (13-17)

Staff Positions – Salary & Benefits (20%)

Position	Qualifications	FTE’s English Male 12 beds + 4 Stab	FTE’s English Female 12 Beds +4 Stab	Salary	Benefits	Total Salary & Benefits	Total FTE’s	Total Salary & Benefits x FTE’s
Executive Director	Masters Level	1.0		100,000	20,000	120,000	1.0	120,000
Program Director / Clinical Manager	Masters Level	1.0		85,000	17,000	102,000	1.0	102,000
Counsellor – Family Therapist	Masters Level	1.0		60,000	12,000	72,000	1.0	72,000
Counsellor – Therapist	Masters in Clinical / BSW, Addiction Certification	8.4	8.4	60,000	12,000	72,000	16.8	1,209,600
Counsellor – Intake	Masters in Clinical / BSW, Addiction Certification	1.0		60,000	12,000	72,000	1.0	72,000
Counsellor – Aftercare	Masters in Clinical / BSW, Addiction Certification	1.0		60,000	12,000	72,000	1.0	72,000
Overnight Workers	CYW	2.8	2.8	40,000	8,000	48,000	5.6	268,800
Occupational Therapist		.5		70,000	14,000	84,000	.5	42,000
Recreologist		.5		60,000	12,000	72,000	.5	36,000
Accountant	CGA	1.0		80,000	16,000	96,000	1.0	96,000
Office/ Operations Manager	Business Administration	1.0		70,000	14,000	84,000	1.0	84,000
Administrative Support		1.0		45,000	9,000	54,000	1.0	54,000
Cook/Nutritionist	Nutritionist	1.0		50,000	10,000	60,000	1.0	60,000
Cook Assistant		1.0		40,000	8,000	48,000	1.0	48,000
Maintenance/Grounds		1.0		40,000	8,000	48,000	1.0	48,000
Evaluation/ Outcome		.66		68,500	13,700	82,200	.66	54,250
Mental Health Nurse	BScN, BSW, Addiction Certification	1.0		80,000	16,000	96,000	1.0	96,000
Total Salaries/Benefits								2,534,650

Note: Psychiatric sessional fees will be required

Academic Program

* It is anticipated that the staff for the academic program will be provided fully or in part by local school boards or the Ministry of Education

Position	FTE’s	Salary	Benefits	Total Salary & Benefits	Total FTE’s	Total Salary & Benefits X FTE’s
Teacher	2.0	60,000	12,000	72,000	2.0	120,000
Educational Assistant	3.0	35,000	7,000	42,000	3.0	102,000
Total Salaries/Benefits						222,000

Clinical & Academic Staffing Components Total

$2,756,650

Francophone Residential Treatment Centre for Youth (13-17)

Staff Positions - Salary & Benefits (20%)

(In conjunction with existing staff at Maison Fraternité)

Position	Qualifications	FTE’s Francophone Male / Female 12 beds + 4 Stab	Salary	Benefits	Total Salary & Benefits	Total FTE’s	Total Salary & Benefits x FTE’s
Executive Director	Masters Level (Shared with MF)	0.5	100,000	20,000	120,000	0.5	60,000
Program Director / Clinical Manager	Masters Level	1.0	85,000	17,000	102,000	1.0	102,000
Counsellor - Family Therapist	Masters Level	1.0	60,000	12,000	72,000	1.0	72,000
Counsellor - Therapist	Masters in Clinical / BSW, Addiction Qualification	8.6	60,000	12,000	72,000	2.0	619,200
Counsellor - Intake	Masters in Clinical / BSW, Addiction Qualification	0.5	60,000	12,000	72,000	0.5	36,000
Counsellor - Aftercare	Masters in Clinical / BSW, Addiction Qualification	0.5	60,000	12,000	72,000	0.5	36,000
Overnight Workers	CYW	2.8	40,000	8,000	48,000	2.8	134,400
Accounting Clerk		0.5	60,000	12,000	72,000	0.5	36,000
Office / Operations Manager	Business Administration	1.0	70,000	14,000	84,000	1.0	84,000
Administrative Support		1.0	45,000	9,000	54,000	1.0	54,000
Cook/Nutritionist	Nutritionist	1.0	50,000	10,000	60,000	1.0	60,000
Maintenance/Grounds		1.0	40,000	8,000	48,000	1.0	48,000
Evaluation/ Outcome		.33	68,500	13,700	82,200	.33	27,125
Mental Health Nurse	BScN, BSW, Addiction Qualification	0.5	80,000	16,000	96,000	0.5	48,000
Total Salaries/Benefits							1,416,725

Note: M.F. = Maison Fraternité

Psychiatric sessional fees will be required

Academic Program

* It is anticipated that the staff for the academic program will be provided fully or in part by local school boards or the Ministry of Education

Position	FTE’s	Salary	Benefits	Total Salary & Benefits	Total FTE’s	Total Salary & Benefits X FTE’s
Teacher	1.25	60,000	12,000	72,000	1.25	90,000
Educational Assistant	1.25	35,000	7,000	42,000	1.25	52,500
Total Salaries/Benefits						142,500

Clinical & Academic Staffing Components Total

$1,559,225

APPENDIX 1

YOUTH RESIDENTIAL ADDICTION TREATMENT

REFERENCES

American Academy of Child and Adolescent Psychiatry (2001) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia. J Am Acad Child Adolesc Psychiatry, 40:7supplement, 4S-23S.

American Academy of Child and Adolescent Psychiatry (2005) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders. J Am Acad Child Adolesc Psychiatry, 44:6, 609-621.

Brown, SA, D’Amico, EJ, McCarthy, DM, Tapert, SF. (2001) Four-year outcomes from adolescent alcohol and drug treatment. J Studies on Alcohol, 62, 381-388.

Currie, JC. Best Practice Treatment and Rehabilitation for Youth with Substance Use Problems. Health Canada, Ottawa, Ontario, 2001.

Deas, D, Thomas, SE. (2001) An overview of controlled studies of adolescent substance abuse treatment. Am J Addictions, 10, 178-189.

Elliott, L, Irr, L, Watson, L, Jackson, A. (2005) Secondary Prevention Interventions for Young Drug Users: A systematic review of the evidence. Adolescence, 40:157, 1-22.

Gilvarry, E. (2000) Substance Abuse in Young People. J Child Psychol Psychiat, 41:1, 55-80.

Hser, Y, Grella, CE, Hubbard, RL, Hsieh, S, Fletcher, BW, Brown, BS, Anglin MD. (2001) An evaluation of drug treatments for adolescents in 4 US cities. Arch Gen Psychiatry, 58, 689-695.

Martin, K. (2002) Adolescent treatment programs reduce drug abuse, produce other improvements. NIDA Notes, 17. Available at www.nida.nih.gov/NIDA_Notes.

Mee-Lee, D. (Editor) Adolescent Patient Placement Criteria. In, ASAM PPC-2R, ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised. American Society of Addiction Medicine, Inc. Maryland: Chevy Chase, pp177-278, 2001.

Rowe, CL, Liddle, HA, Greenbaum, PE, Henderson, CE. (2004) Impact of psychiatric comorbidity on treatment of adolescent drug abusers. J Substance Abuse Treatment, 26, 129-140.

Shane, PA, Jasiukaitus, P, Green, RS. (2003) Treatment Outcomes among Adolescents with Substance Abuse Problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402.

Winters, K. (Revision Consensus Panel Chair) Treatment of Adolescents with Substance Use Disorders. Treatment Improvement Protocol (TIP) Series. Volume 32. US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Heath Services Administration, Centre of Substance Abuse Treatment, 1999.

APPENDIX 2

ADDITIONAL REFERENCES

1. Ontario’s Ministry of Health recently was ordered to pay $150,000 to the family of a drug-addicted teen who had to seek treatment in the United States due to the lack of residential treatment facilities in Canada. According to experts and addiction services personnel, there are 300-400 teens between the ages of 13 and 17 in Ontario each year who require residential treatment services. (National Post, 21 December 2001) (Note: At least 8 families received similar reimbursement in 2003)

2. Health Canada. Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems. 2001.

8.1.3 Structural and Program-Related Barriers (page 19)

· There is a specific lack of residential treatment available to those youth who need an intensive and highly structured environment.

· Programs often have lengthy waiting lists, which discourage timely treatment.

· High costs (e.g. transportation) may limit access to treatment.”

We have an epidemic in our province but less than 20 (funded) residential beds.

8.2.5 Aboriginal Youth (page 23)

Elements of cultural appropriateness were identified by some respondents. Elements include:

· Appropriate language;

· Inclusion of a spiritual component (beliefs and practices) in treatment;

· Aboriginal staffing;

· Culturally appropriate outreach;

· Connection of Aboriginal youth to Aboriginal social service systems and support.

10.1.4 Outreach to Families (page 31)

There was broad consensus among key experts on the importance of actively involving the family in treatment. The engagement of even one family member (a sibling or one parent) is considered critical. It is recognized that families have diverse needs (for therapy, education or support), which programs need to address. Sometimes early work with parents is the entry point for youth treatment.

10.1.6 Needs of Specialized Groups (page 32)

Street-involved youth/Aboriginal youth require, above all, a safe and secure treatment environment.
Aboriginal youth require programs, which incorporate traditional beliefs and practices from the Aboriginal community. There is a need for a component of treatment, which addresses spiritual needs, practices and beliefs.

12.3 Treatment Approaches : Literature Review (page 42-43)

Catalano et al. (1990 -1991) review of treatment outcome research associated the following elements with treatment success:

· The availability of special services which support the development of client skills (education, training, relaxation, sexual education and recreation);

· The availability of active recreational activities and skill-based recreational opportunities;

· Participation of parents or a parental figure in treatment (if parents can contribute constructively);

· Availability of family therapy, behavioural family therapy and combined structural/behavioural approaches.

Stanton and Shadish (as cited in Weinberg et al., 1998) supported the superiority of family therapy (as opposed to family psychoeducation or support groups) for youth in treatment. Joanning et al. (1992) noted the effectiveness of structural-strategic family therapy (SSFT), which involves all family members, whether or not they are involved in treatment. Other integrated models (multi-dimensional family therapy) have also demonstrated treatment success.

13.2 Treatment Structure, Duration and Intensity: Literature Review (page 46)

The argument that residential treatment must be retained as the mainstay of intervention for substance dependence for adolescents or adults is unconvincing. However, there is a good case to be made for the use of residential facilities for the client who is homeless, or for whom the usual environment is so conducive to substance use that a form of residential care is appropriate. (Spooner et al. 1996:6 - 9)

15.3 Wider Scope of Treatment Availability (page 48)

Key experts also noted that there was a lack of certain types of treatment resources and options for youth, making success difficult to achieve. Specific gaps were noted in the following areas:

· A lack of residential treatment, especially regionally based resources;

· Specific treatment for youth with fetal alcohol syndrome/fetal alcohol effects (FAS/FAE);

· Easy and timely access to treatment;

· Treatment for gay and lesbian youth;

· Gender-specific treatment.

APPENDIX 3

ARGUMENTS SUPPORTING THE ESTABLISHMENT

OF TWO SEPARATE YOUTH RESIDENTIAL TREATMENT FACILITIES:

ONE FOR ANGLOPHONE YOUTH AND ONE FOR FRANCOPHONE YOUTH

« More than half a million Francophones live in Ontario, the largest group of French-speaking people outside Quebec. They need access to services in French, particularly residential treatment services, and accurate information on the services available across the province. »

« To meet the addiction needs of Francophones in Ontario, addiction agencies in the parts of the province designated for French language services will work together to improve the level, distribution and quality of French language addiction treatment services. »

« These districts will work with the Francophone community and service providers to ensure that Francophones have access to:

- a full range of community-based services

- residential treatment services in French

- a continuum of bilingual services. »

(Ontario Substance Abuse Bureau, Setting the Course, A Framework for Integrating Addiction Treatment Services in Ontario, January 1999, 35 pages, pages 31-32)

« Recommendation 25: The Residential Working Group recommends that :

- An additional five restricted residential services for youth be developed, bringing the total capacity to six services. OSAB should request the Youth Managers Group to identify the specific number of beds required for such centres.

- Priority be given to restricted services for Aboriginal youth and Francophone youth, and a service in Toronto. The location of the Aboriginal and Francophone services should be based on further consultation.

- The principles which guide the distribution of restricted youth residential services should include:

- services should be spread across the province

- youth aged 12-17 who require residential services should be served in restricted services

- there should be one Francophone and one Aboriginal residential service for youth aged 12-17.

- Services exercise flexibility in serving clients in the transitional years of 16-19 to ensure positive movement of youth between age specific services. For instance, it may be more appropriate for an individual 16 years old to be served in a program for 18-24 year olds. Conversely, an individual who is 18 might be better served in a program for 12-17 years olds.

- There might be interministerial collaboration regarding financial support and services for youth.

- There be local collaboration between children’s mental health services, other children’s services, and addiction services to enhance the local response to youth with addiction problems.

(Residential Working Group, A Strategy for Residential Addiction Treatment in Ontario, Phase II Report, March 2000, 66 pages, pages 36-37)

« Services to Francophones, in most cases, should be delivered in French. In addition, culture is as important a consideration as language. »

(idem, page 42)

« Increasing the proportion of encounters within the health system where there is language congruence between provider and patient is often viewed as the ideal response. Many authors believe that providing an interpreter can never be as satsifactory as direct communication, no matter how skilled the interpreter. This results from the desire on the part of both parties for direct, unmediated communication, and the recognition that even the presence of another person in the encounter can affect rapport and the type of information shared. »

(Health Canada, Language Barriers in Access to Health Care, Ottawa, November 2001, 120 pages, page 3)

« The emphasis on cost containment within the health care system has increased demands for « evidence-based » decision making. Until recently, there was little research available on the effects of language barriers and language access services to guide policy and program development. Although research is still in the early stages of development, there have been several important studies conducted over the past few years. These studies have provided evidence that language barriers are associated with differences in service utilization, patient health outcomes, patient satisfaction, patient « compliance », participation in health research, protection of patient rights, and patient knowledge od diseases and conditions. The significance of these findings increases when links are made with related research (such as patient/provider communication and literacy in an official language). »

(idem, page 8)

« Patient satisfaction is the most recognized and widely used measure of effectiveness of provider-patient communication (Kaplan et al., 1989). It is also an outcome of care, and has been suggested as highly correlated with quality of care. One would expect that individuals who do not share a common language with their providers would be less satisfied with their care : most research on the topic confirms that this is indeed the case. »

(idem, page 75)

« Une langue est plus qu’un simple moyen de communication; elle fait partie intégrante de l’identité et de la culture du peuple qui la parle. C’est le moyen par lequel les individus se comprennent eux-mêmes et comprennent le milieu dans lequel ils vivent… L’importance des droits en matière linguistique est fondée sur le rôle essentiel que joue cette langue dans l’existence, le développement et la dignité de l’être humain. Le langage constitue le pont entre l’isolement et la collectivité… »

(Jugement Montfort, 7 décembre 2001)

TRANSLATION : « Language is not simply a communication tool; it is an essential part of the identity and the culture of the people who speak it. It’s the mean individuals use to understand themselves and the world they live into… The importance of linguistic rights is based on the essential role the language they speak has in their existence, their development and their dignity as human beings. Language is what enables a person to move from isolation to social life. »

« La possibilité de recevoir des soins de santé mentale et de toxicomanie en français fait toute la différence, selon les bénéficiaires. Il est primordial de comprendre et de se faire comprendre, et de se sentir à l’aise dans son milieu de vie. »

(Le Blanc Pierre, Étude sur les formes d’organisation des services de santé en français dans l’Est de l’Ontario, Réseau des services de santé en français de l’Est de l’Ontario, octobre 2003, page 33)

TRANSLATION : « Francophone clients say that being able to receive mental health or addiction services in French makes all the difference. It is vital to understand and to be understood, and to feel well at ease in its environment. »

« Tous les Franco-Ontariens et les Franco-Ontariennes ont droit à des services de santé en français de qualité égale et d’accès égal aux services de santé offerts à la majorité. »

(Savoie, Gérald R., La voie à suivre, Document préliminaire pour le groupe de travail franco-ontarien sur la transformation du système de santé de l’Ontario, 15 mars 2005, 19 pages, page 16)

TRANSLATION : « All Franco-Ontarians, both males and females, have the right to health services in French that are equal in quality and in accessibility than those offered to the majority. »

« The Francophones of Champlain are among the very first residents of this region. The community’s contribution in the evolution of health care has been significant and is on-going. Approximately 20 per cent of the Champlain region’s population is Francophone and at 206,000, they represent about 38 per cent of the province’s Francophone population. Many new Canadians who establish in Champlain and whose mother tongue is neither English nor French, claim French as their second language. Services to this population must be provided in a culturally sensitive manner and in French primarily. »

(Toward Transformation in Health, Creating an Integrated Health Service Plan in the Champlain Region, A Blueprint, November 2006, 37 pages, page 10

Appendix 4

Treatment Principles and Values:

Key Expert Perspectives

Principle	Key Expert Comments
1. Treatment planning and delivery should be highly individualized, client-centered and client-directed. Tools like the “Stages of Change” model and motivational interviewing support this approach.	· Go where, start where and respect where youth are at. · Treatment must be designed to meet individual treatment plans and to support residents to achieve goals.
2. While there is sometimes a struggle between the “harm reduction” and abstinence models, the harm reduction approach is most effective with and responsive to youth needs and the stage of life. Teaching youth to “keep themselves safe” is the “cornerstone” of this approach.	· Keep the kids as safe as possible in terms of harm reduction. · If they are going to use, teach them how they can use safely. · Most individuals mature out of addiction. Provider’s job is to ensure they come out of their addiction unharmed and intact.
3. Treatment should offer and be based on choice. A multi-dimensional, eclectic model is preferable to one which is based on an uni-dimensional treatment approach.	· Treatment providers must be cognizant of all approaches available – and move to one or another, if needed. · Offer a menu of opportunities.
4. Treatment should consider youths within a system – of family, peers, community and others (school teachers, counselors and correctional staff)	· Kids must be linked to all members of their community, for example, elders. · Listen very carefully to what the client says about the community and who they feel the workers in the community are that they respect.
5. The climate of treatment should be caring, respectful, safe and open.	· In our program, there is no issue that cannot be brought to the table. · Give them a sense of community, living in a safe place, offering unconditional love. · Respect and treat them like human beings.
6. Wherever feasible, families should play an important part in treatment. If there is no current “stable” family, a family of “significant” adults should be created.	· Family has to be involved, and if a youth has no family, you create one – a “family of choice.” People from the community are chosen by youth to be a family.
7. Treatment needs to consider the youths’ spiritual, mental, emotional and physical self needs.	· Must give these kids spiritual guidance. · Have them attend sweat lodge and sundance traditional ceremonies.
8. Programs should espouse the principle of “least intrusive treatment” as a first option (based on appropriate assessment and treatment matching).	· A mistake is to impose a heavy-handed, highly intensive program at the early stage.
9. Staff must respect and value youth in treatment, trusting in their basic motivation and value.	· Kids are okay, they may screw it up, but they’ll work it out. · Help youth create a “thicker” story of themselves – that they are valuable, will get a job. · Show other ways of looking at self.
10. Wherever possible, learning should be experiential and be conducted in a variety of venues.	· Use activity-based treatment (for example, martial arts and sports) in community, exploring their interests and pushing them further to develop their interests.
11. Treatment should focus on positives, not deficits in the youth’s life. The “Resiliency Model” is a useful approach.	· Focus on positives, not what needs fixing. Identify, focus and build on youth’s positive strengths. · Avoid deficit thinking – build on skills already there. · Do not label as an addict – doesn’t give room to grow.
12. Treatment should focus on the building of specific skills, which enhance self-esteem.	· A key objective is to enhance child’s competence in different aspects of his/her life that will help him/her become a good decision-maker. · Provide youth with a toolbox to help them understand what they need to do for self, how (they) can make responsible decisions re: setting goals and achieving them.

Canada’s Drug Strategy Division – Health Canada (2001)

“Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems.”