Evidence-based screening, brief intervention and referral to treatment for substance-using adolescents with delinquent-type behaviours

Abstract

Background: Both substance use and delinquent-type behaviours are prevalent among adolescents in Cape Town, South Africa. However, early interventions in developed countries for adolescents with similar problems are not available in many low and middle income countries, including South Africa. This is a concern as providing evidence-based interventions that address these dual behavioural problems may prevent their progression. There is thus a need for identifying and understanding the kinds of interventions that would be able to address both of these problems Aim: The aim of this thesis is to identify an evidence-based intervention for reducing adolescent substance use and delinquent-type behaviours and adapt it for use among adolescents in Cape Town, South Africa. Method: This study comprised six parts. Study I utilised a longitudinal data set to examine the association between substance use and delinquent-type behaviours, as well as the trajectory of these behaviours among school-going adolescents in Cape Town. As one needs to know how to identify adolescents who would benefit from such an intervention, Study II identified suitable screening tools for identifying these adolescents. While screening tools are generally brief instruments to identify problems with substance use, assessment instruments for those adolescents who screen positive would more comprehensively assist in the further evaluation of their problem behaviours, as well as measure other risk factors for substance use and delinquent-type behaviour. Study III therefore tested and adapted assessment tools for those adolescents who screen positive for substance use and delinquent-type behaviour. The next step was to identify a suitable evidence-based brief intervention that addressed substance use and delinquent-type behaviours in an integrated manner. Study IV consisted of a systematic review and meta-analysis to identify such an intervention. As only studies from developed countries were included in the review, the final two studies concentrated on adapting the intervention identified in Study IV with service providers and adolescents in focus groups 6. Study V consisted of a cultural adaptation which tested the ecological validity of the identified brief intervention in Cape Town communities. Study VI was a content adaptation that modified the brief intervention for adolescents in this context, and to include a focus on delinquent-type behaviours. Results: The final result is a screening, brief intervention and referral to treatment (SBIRT) package that is ready to be tested for efficacy on substance use and delinquent type behavioural outcomes. Each study contributes to the different components that make up this package. The results from the longitudinal study indicated that while substance use is not predictive of delinquent-type behaviours, these two behaviours co-occur at different stages of adolescence. In addition, adolescents that smoked and were delinquent were at significantly higher risk of engaging in later delinquent-type behaviour. This suggests that it would be efficient to address the two risk behaviours simultaneously using an integrated intervention. The GAIN-SS was identified as an easy-to-use and psychometrically sound short screener for identifying adolescents with both problems who may benefit from a brief intervention. The comprehensive assessment tool developed for use if an adolescent screens positive and may therefore be eligible for such a brief intervention, measured the following core domains: substance use, delinquency, parenting practices, peer substance use and readiness to change. These were modified based on both adolescent participants’ and experts’ recommendations. Following assessment, Teen Intervene was identified as the brief intervention which was the most effective in reducing early adolescent substance use and consequences related to substance use. While this promising intervention addresses substance use and behavioural outcomes broadly, it did not do so in an integrated and comprehensive manner. Teen Intervene was also only tested in one population, and the results of the qualitative studies (V and VI) were therefore helpful in the adaptation of the intervention. Qualitative work found that the context that adolescents in the study have been exposed to within their home setting, school and community, as well as their relationships with people within these settings, influence their engagement in risk behaviours. Therefore ensuring ecological validity is important when modifying the identified intervention for use in Cape Town. The intervention was expanded to include a focus on delinquent-type behaviours and a handbook was developed for adolescents that contained information from the, skills-building exercises, as well as goal setting from the original intervention for the individual adolescent. Recommendations for the implementation of this intervention showed that the types of recruitment strategies in place may affect the uptake of services, and organisational factors (organisational readiness, staff issues, available resources) may affect the delivery of intervention services. Such issues should be taken into account before implementation takes place. Conclusion: This thesis is one of the first to investigate the relationship between substance use and delinquent-type behaviours in a developing country setting. It describes the identification of an SBIRT package for substance use and delinquent type behaviours among adolescents, and how these were adapted to develop an integrated intervention that addresses both of these problems. This adapted intervention may provide an option of tailor-made services for adolescents in disadvantaged communities in Cape Town, where adolescents are often affected by a host of social problems but where a lack of resources are available to address these problems. The contextual and content-based adaptation processes highlighted the importance of working with adolescents directly to ensure that the intervention adequately addressed the local context as well as the specific issues that they face, at their level of understanding. The engagement of service providers, who may be trained to deliver this integrated intervention package, was also important to address possible challenges that could occur while delivering the intervention. The next steps in the process would be to implement the adapted version of the intervention to iron out some of the potential implementation issues that were alluded to above, and ultimately to assess its efficacy in addressing the very real social conditions described in Chapter 1.