An analysis of stressors and co-morbid mental health problems that contribute to youths' paths to...

An Analysis of Stressors and Co-Morbid Mental Health Problems That Contribute to Youths' Paths to Substance-Specific Services Sharon D. Johnson, PhD Arlene Stiffman, PhD Eric Hadley-Ives, MSW Diane Elze, PhD

Abstract

Substance-specific services are tailored to address the inappropriate use of chemicals such as alcohol and marijuana. Unfortunately, few teens ever access such need-based services. This article explores the paths to substance-~pecific service use in a sample of urban adolescents who are public service sector users: a direct path from substance misuse and an indirect path from general mental health service use. Results indicate that even though a significant percentage of youths frequently consume substances and display negative use-related behaviors, few actually received substance-specific services. Contributors to the substance misuse path included youths' family substance dependence and environmental stressors. Contributors to the mental health services path were comorbid depression and substance misuse.

Introduction

Substance-specific services have a primary objective of addressing the inappropriate consumption of alcohol or drugs. The need for such services among youths is apparent in the rates of substance use within the population, Adolescent substance use is so prevalent in the United States it could be considered a normal yet potentially problematic milestone in youth d e v e l o p m e n t / A m o n g the adolescent population, alcohol use is commonplace. As many as 80% of a national sample of youths reported having consumed more than a few sips of alcohol by the end of their high school years. 2

Although not as frequent, the use of illicit substances also is prominent among youths. Ap- proximately 55% of youths in the aforementioned national sample had experimented with some type of illicit substance (marijuana being the most prevalent) by the time they had finished high school. 2

Address correspondence to Sharon D. Johnson, PhD, Assistant Professor, Department of Social Work, University of Missouri-St. Louis, 8001 Natural Bridge Road, St, Louis, MO 63121-4499; e-mail: [email protected].

Arlene Stiffman, PhD, is Professor of Social Work, Center for Mental Health Services and Research, Washington University. Eric Hadley-Ires, MSW, is Research Associate, Center for Mental Health Services and Research, Washington University. Diane Elze, PhD, is Assistant Professor of Social Work, Center for Mental Health Services and Research, Washington

University.

Journal of Behavioral Health Services & Research, 2001, 28(4), 412-426. © 2001 National Council for Community Behavioral Healthcare.

412 The Journal of Behavioral Health Services & Research 28:4 November 2001

Though some evidence indicates that experimentation with substances, particularly marijuana, does not pose many adverse consequences for the typical youth, 3 one could argue that any type of use by youths is misuse. This is especially true when experimentation leads to frequent use that is accompanied by irrational behaviors. Behaviors such as driving while intoxicated and going to school while high put youths at risk for problems such as injury, arrest, or school suspension. Though these outward social behaviors are relatively frequent, few studies have examined them. <5 Instead studies have opted to examine behaviors, such as delinquency, that are known to coexist as a part of a problem behavior syndrome. 6-9 Frequent use may indicate that youths have entered a "gateway" to serious abuse or dependence. Once youths have entered this stage, the consequences may be numerous. These youths are at higher risk for later psychological and behavioral problems including depression and suicidal thoughts and attempts, 1° risky sexual behaviors, 11 increased delinquent and criminal behavior, 1°, 12 and violent behavior 13

The increased vulnerability of some youths to the negative consequences of initial substance use can be attributed in part to their exposure to negative social factors. Although other aspects including personality are important, 14 previously existing social conditions increase the risk that experimental use will lead to a general pattern of use and other negative outcomes. The social risk factors include prior association with substance using or tolerating peers 9,15-17; parental influences 18' 19; and negative neighborhood, school, and community environments. 2°,21 From a theoretical perspective, theories such as social learning support the contention that entities that present role models for substance use are the most critical of these social factors. 22 Though peer influence was once thought to be substantial, recent research 23'24 indicates that it is not as significant as once perceived. However, familial use and dependence continue to maintain predictive association with adolescent substance use. Whereas peer influences can have a societal impact, research 23 indicates that parental substance use can have a genetic as well as a societal influence on substance use. Drug use by family members increases youths' alcohol use, and factors such as maternal alcohol problems are associated with youths' severe drug misuse. 4'20

With the prevalence of use being so great among youthful populations, it is imperative that services be available to address this behavior when it evolves beyond experimentation. Thus, to prevent abuse and dependence once experimental use progresses into regular use, youths should have access to services that are specifically tailored to address the problems that consequently arise with continued use. Adolescent help-seeking can be a two-stage process that involves identification of the need for help and the process of actually obtaining help. 25 For some substance users, one barrier to obtaining help for their problem is not recognizing that the problem exists. 26 This may be especially true for youthful populations as evidence 27 indicates that the rate of professional help-seeking in youths who abuse substances is low. However, there is additional evidence 28 that indicates that specialized mental health care or substance-specific care may be most effective in addressing substance use problems.

Youths face several issues in their use of any type of mental health service. The primary issue for youths who misuse substances is the availability of services that are substance specific. The problem of availability can be the result of geographic constraints such as youths living in rural areas where services are limited, if available at all. 29 Service accessibility also influences youths' utilization of mental health services. 3° Accessibility creates a twofold problem. From a systems perspective, lack of accessibility means that service providers have not made a significant effort to avail their services to youths. In addition, the cost of services may hinder those youths who are not able to pay for services and are not eligible to receive some form of subsidy to cover the expense of treatment. 29 From the youths' perspective, they may access services only when they have to exert little effort to get the service. In many instances, youths who have previously had contact with a provider are more likely to receive care than youths with no prior contact. 31 Thus, a youth using substances who has no existing point of contact for services may be reluc- tant to seek out substance-specific services when a problem develops. When an existing point of

Youths" Paths to Substance-Specific Services JOHNSON et aL 413

contact is available, another significant issue in service utilization is that of the appropriate assessment of problem substance use. Practitioners are often faced with a lack of standardized measures specific to adolescents and may not understand the addiction process among the population as it is often complicated by other issues of adolescence. 32 Additional barriers to mental health treatment include factors such as the stigma attached to service receipt and family and other influential adults. Family and other influential adults can determine whether or not youths seek help for their problem behaviors. These individuals can serve as either barriers or facilitators of service receipt. 33

Several issues have to be addressed in order to increase the use of substance-specific services among youths. The most essential is having such services available to youths. Second to availability is the concern that those youths who are in need of services specific to their substance use may not be ready to receive such services. That is, youths may not cooperate with attempts to provide services to address their needs, especially if these youths have not recognized that a problem exists. Even with recognition of a problem, youths may not be willing or able to receive available services. In addition to the traditional barriers, youths who are in need of substance-specific services may be hindered by the accompaniment of more obvious behavioral or mental health problems. The psychological consequences of substance use may cause youths to seek mental health services that are specific to other co-morbid mental health problems such as depression. Problems that are commonly seen with substance use such as conduct disorde~ 3 may complicate or overshadow the assessment of inappropriate substance use. Thus, youths may receive services specific to the behavior rather than for substance use.

This article explores paths that may lead youths to receive services specific to their substance misuse. These paths are examined in light of youths' environmental stressors and co-morbid mental health problems that may serve as precursors to each path. The above literature highlights issues that may influence youths' use of substances and how this usage may exacerbate other mental health problems. In essence, the literature reveals two viable paths that may result in youths accessing and potentially utilizing substance-specific services. The first path may occur if the frequency of use and the behaviors that youths display consequent to their substance use are immediately identified as substance related and direct access to substance-specific services is obtained. The second path may occur when a youth is referred to services from a provider who is seeing the youth because of a mental health symptom or because the behaviors resulting from substance use were not immediately identified as substance related.

Figure 1 illustrates the associations hypothesized to lead to substance-specific service use. The model was constructed beginning with societal factors that were known to increase the likelihood of substance misuse. These factors included neighborhood, school, violence exposures, and peer influence---combined to represent negative environment--and familial substance use dependence. Theoretical and empirical evidence link each of these factors to increased levels of substance use frequency and subsequent behaviors. The literature indicates that substance use often exists in conjunction with other mental health problems, particularly depression and conduct disorder. Additional literature indicates that such problems are intensified by the presence of substance use. Since misuse can be viewed as a more advanced stage of use, it was perceived that depression symptoms and conduct disorder symptoms would be increased by substance misuse; thus the model sought to test whether or not this was the case.

Both environmental and familial factors were thought to have a direct influence on each of the coexisting mental health problems. Barriers were another construct that required attention within the model. Since some barriers such as stigma and youths' self-help beliefs are often based on the perceptions of youths, factors that could alter the thought processes of youths were assessed as predictors of barriers. These factors included substance misuse and depression. It was believed that barriers to help-seeking would have a negative influence across time on both general and substance- specific service use.


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Methods

Design

The Youth Services Project, funded by the National Institute of Mental Health, is a longitudinal study examining adolescents' mental health needs and use of mental health services. The youths included in the study are from St. Louis and have used services from the health, juvenile justice, and child welfare or education sectors. These service sectors were all in a position to screen youths for mental health problems and to either provide some mental health services or refer them to services elsewhere. Interviewers recruited youths in waiting rooms of service agencies and through letters and posters requesting volunteers for a study of the mental health needs of teens. Trained professional interviewers obtained informed consent from all subjects and their guardians before administering the instrument. Over 95 % of the youths who were approached agreed to participate. The youths completed a structured interview concerning demographics; social and academic behaviors; mental health; service use; and family, social, and community environments. Youths were provided a monetary incentive at each time period for completing an interview.

Sample

During the first wave of data collection, 792 youths were included in the project. The youths were all between 14 and 17 years of age, with a mean age of 15.3 years. The sample was 57% female and 43% male. Eighty-six percent of the sample was black, 13% white, and 1% other. The racial composition of the sanaple is not representative of the racial demographics of St. Louis; however, it is representative of adolescent public sector users, based on demographic tallies of such users. 34 Socioeconomic status was determined by the occupation of the parent who had provided the most financial support to the family within the last 6 monthsY Accordingly, 77% were from lower socioeconomic status (SES) families, with 15% being welfare recipients. Fifty-three percent of the adolescents lived in single-parent, female-headed households.

Following a 2-year interim period, 85% (n = 675) of the original sample were tracked and re- interviewed. Numerous tracking strategies were implemented to address expected life changes that would influence tracking efforts. 36 Of particular concern for this study were the youths who had aged out of the juvenile justice, child welfare, and/or public education systems, as perhaps these youths were no longer participants in structured programs to monitor their behaviors or refer them to needed services. The data for this article are based on those youths interviewed at both time 1 and time 2. The sociodemographic characteristics of the re-interviewed sample did not differ significantly from that of the initial sample.

Measures

Substance misuse

A measure of substance misuse was derived from the Diagnostic Interview Schedule for Children- Revised (DISC-R). 37 To measure frequency of use at time 1, respondents were asked on how many occasions they used alcohol or marijuana in the 6 months before the interview. Responses ranged from never to 40 or more occasions. Behaviors and symptoms consequent to substance use at time 1 included going to school or work with a hangover, going to school or work while high, using drugs while at school, forgetting what happened while drunk, driving or doing dangerous things while high, drinking when you had decided not to, doing drugs when you had decided not to, drinking more than you thought you would, and taking more drugs than you thought you would.


Comorbid mental health problems

To assess the impact of co-morbid mental health problems, various symptoms of depression and conduct disorder (DISC-R) were examined. The items for depression assess suicidal thoughts as well as physical and mental manifestations of depression including eating and sleeping difficulties and hopelessness. Eighteen items measured at time 1 were included in the construct. The items for conduct disorder assess violent and delinquent behavior including whether or not the youth had engaged in robbery, burglary, fighting, cruelty, or vandalism.

Environmental stressors

The social risk factors included exposure to traumatic events, family dysfunction, and the negative characteristics of youths' neighborhoods, schools, and peers. Each of these measures was based on time 1 data.

A measure of exposure to traumatic events was modified from the posttraumatic stress section of the DISC-R. 38 Respondents were asked if they had experienced any of a list of extremely frightening or upsetting events that interfered with their life (causing someone's death or injury, being attacked or beaten, narrowly escaping serious danger, seeing a person killed, knowing someone who was beaten or killed, personally being threatened with harm).

Information about community environment consisted of youths' ratings of their neighborhood and school problems. 39,4° Neighborhood problems included shootings, murders, abandoned buildings, neighbors on welfare, prostitution, drug dealing, and homeless individuals. School problems included drug dealing, shootings or knifings, damaged equipment, and high levels of anger or stress.

The negative behaviors of peers were measured by asking respondents how many of their peers were not in school and did not have a job, drank alcohol or did drugs at least one time per week, were in trouble with the police, had children, and belonged to gangs.

Family dependence

Family dependence was measured by youths' response to whether or not either of their biologic parents or their full brothers or sisters had a drinking or drug problem. This construct was measured as a dichotomous variable.

Perception o f barriers to help-seeking

At their time 1 interviews, youths were asked if any of the following were a concern when they needed help or would be a concern if they needed help: (1) paying for the help/treatment, (2) wondering what other people might think, (3) believing that the services might not help, (4) feeling it was/is too difficult to get help, (5) being unsure where to go or if you were going to the right person or place to get help, (6) believing that the problem would go away or you could solve it yourself, and (7) feeling that the kinds of help gotten in the past were not good.

Service use

At time 1, youths were asked if they had spoken about their alcohol or &'ug use within the last 6 months to anyone at a health clinic, school, social service or child welfare agency, legal system entity, church or community center, or mental health service center. To measure substance-specific service use (time 2), the respondents were asked about their use of services within the last 6 months and since their last interview. Youths were asked if, within the last 6 months, they had spoken to a professional in any of five service sectors concerning their alcohol or drug use; or, in the 2 years since their last interview, they had received treatment at an alcohol/drug clinic or treatment unit.

Youths' Paths to Substance-Specific Services JOHNSON et al. 417

To measure general mental health service use (time 2), respondents were asked if, since their time 1 interview, they had spoken to anyone at a school, child welfare agency, juvenile or adult court, health care clinic, or mental health service center. Youths were asked if they had spoken to these individuals about their worries, behaviors, family problems, or feelings. In addition, youths were asked if they had received help from an inpatient service center, a school-based service, or an outpatient service for any mental health-related problem. Substance use was excluded from this response.

Analysis Structural equation modeling was used to examine paths to substance-specific service use. The

analyses were performed using the CALIS statistical program. 41 The overall model fit was determined by examining chi-square data as well as comparative fit index (CFI), non-normed fit index (NNFI), and adjusted goodness-of-fit index (AGFI) information. The resulting model consisted of both latent and manifest variables. Latent variables are hypothetical constructs that are based on factor scores; manifest variables are directly observed constructs in which the actual scores obtained are utilized. 42 The latent constructs were the result of iterated principal component factor analysis examining how well the items fit together in explaining the concept of interest. Only those items loading at .40 or better were retained in each latent construct (see the appendix). Substance use frequency and the behaviors and symptoms of use were conceptualized as one construct--substance misuse. Separate factors were generated for depression symptoms, conduct disorder symptoms, barriers to help-seeking, negative school characteristics, negative neighborhood characteristics, negative peer influence, and traumatic exposures. The school, neighborhood, peer, and traumatic exposure constructs loaded well on one factor that was retained as negative environment. Factor analysis revealed that only five barriers to help- seeking met the criteria for inclusion in the construct; thus only five were retained for the structural model. The manifest variables consisted of the measurements actually obtained for the measure, 42 as items did not meet the statistical properties for latent development. The three manifest variables were family dependence, general mental health service use, and substance-specific service use.

Results As indicated in Table 1, those youths who interviewed at both time 1 and time 2 were mostly

female and African American. These youths ranged in age from 13 to 18 years, with the majority being age 15 or 16 when they were interviewed at time 1. The SES of this select sample indicates that the majority of the youth (77%) resided in households where the primary income ranged from welfare to low-paying service labor.

Substance use/misuse

The sample reported high rates of substance use during time 1. Fifty-two percent (n = 353) of the youths reported that they had used substances within the last 6 months. Forty-eight percent (n = 327) of the youths drank alcohol, and 29% (n = 195) reported marijuana use. Twenty-five percent (n = 169) had used both substances. Of those youths who used alcohol, 38% (n = 123) drank on more than six occasions in the last 6 months. Of those youths who used marijuana, 53% (n = 104) had done so on six or more occasions in the last 6 months. The most frequent substance use behaviors were drinking more than they thought they would (n = 80) and going to school or work while high (n = 78).

Service use

Of those youths reporting time 1 substance use (n = 353), 16% (n = 55) had received substance- specific services prior to their time 1 interview. Prior to their time 2 interview, 15% (n = 54) of


Table 1 Select demographics and substance use reports for youths interviewed at both time t and time 2

Substance use Total (%)* at time 1 (%)t

Sample 675 (100) 353 (52) Gender

Males 271 (40) 156 (49) Females 404 (60) 197 (49)

Race African Americans 584 (87) 299 (51) European Americans 83 (12) 52 (63) Others 8 (1) 2 (25)

Age groupings 13-14 196 (29) 79 (40) 15-16 347 (51) 198 (57) 17-18 132 (20) 76 (58)

*Percentages are based on n = 675 t Percentages are based on each subgroup total

time 1 substance users received substance-specific services. Only 6% (n = 20) of these youths received services prior to both interviews. Time 2 general mental health service use, which excluded substance-related services, was utilized by 46% (n = 164) of time 1 substance users.

Barriers to help-seeking

The most frequent barrier to help-seeking reported by the sample was the belief that the problem would go away or they could solve the problem on their own. This was the case for 58% (n ----- 391) of the total sample of which 55% (n = 217) were time 1 substance users. In terms of access to services, 43% (n = 151) of time 1 substance users reported that they were not sure where or whom to go to for help, and 27% (n = 94) reported it was too difficult to get help. Perception of the quality of services also was a barrier reported frequently by the youths. Of time 1 substance users, 41% (n = 143) believed services would not be beneficial. Twenty-seven percent of the substance users reported that previous help received was not good. What others might think was a concern for 36% of the substance users, while only 20% of the group reported the inability to pay for help or treatment as a barrier.

Model testing

Results (Figure 2) revealed that the hypothesized model provided a good fit to the data (X: = 11.18, d f = 10, p = .34). Other fit indices also confirmed the appropriateness of the model to the data (AGFI = .98, CFq = .998, and NNFI = .996).

Not surprising was the fact that substance-specific service use at time 2 was associated with time 2 mental health service use (.37). The second hypothesized path from time 1 substance misuse to substance-specific service use was not as strong but significant (.14). Most surprising was the positive relationship between time 2 substance-specific services and time 1 perceptions of barriers to treatment (.08). Together the three significant paths accounted for 19% of the explained variance in substance-specific service use.

Youths' Paths to Substance-Specific Services JOHNSON et al. 419

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Time 1 predictors of time 2 general mental health service use only explained 9% of the variance in the construct. Substance misuse (. 16) and depression (.15) had similar paths to general mental health service use although the construct excluded substance-related services. Youth whose co-morbid mental health problems manifested as depression were more likely to receive mental health services following their time 1 interview than youths with co-morbid conduct disorder (nonsignificant path). Youths' perception of barriers to help-seeking did not influence their use of general mental health services across time.

Time 1 barriers were associated with youths' symptoms of depression (.38). Depression alone accounted for 14% of the variance in these barriers. The model explained a small portion of the variance in depression (16%). Family substance dependence (.23) and negative environment (.27) predicted youths' symptoms of depression. Surprisingly, depression was not associated with youths' substance misuse. Substance misuse (.40) was, however, significantly associated with conduct disorder; along with negative environment (.32), it accounted for 40% of the variance in conduct disorder. Predictors of substance misuse included negative environment (.53) and family substance use dependence (.09). These time 1 predictors explained 31% of the variance in substance misuse. There also was a mild but significant correlation between negative environment and family substance use dependence (. 19).

Discussion

Given the prevalence rates of substance use in national samples, the relatively high occurrence of use reported by this sample was not surprising. What is surprising, however, is that this seemingly high-risk sample did not exceed the rates of use reported in national samples. Notwithstanding, it would appear that a significant portion of these youths have entered a "gateway" to substance abuse or dependence as indicated by their frequency of use and their reported use-related symptoms and behaviors. Though more than half of the youths using substances had spoken to a provider of services for some reason, only a small percentage had specifically discussed their issues of substance use with a provider. The results suggest that even though the sample consisted of public service sector users, few youths were utilizing substance-specific services. This finding suggests that youths' use of substances may not be recognized as a problem and addressed by providers; further, youths themselves may not recognize their symptoms and behaviors as indicators of a problem. Indeed, many of the youths noted that if they believed the problem would go away or if they thought they could solve the problem themselves, this would serve as a potential barrier to seeking help. In addition, the accessibility of services in terms of not knowing where to seek help and the difficulty of seeking help also presented as potential barriers to these youths' help-seeking behaviors. It also is important to note that the youth participants in this study were recruited from service sectors that were in a position to screen youths for mental health problems and to either provide some mental health service or refer to services elsewhere. The relative lack of substance-specific service use compared with the need for services may be an indication that the service sectors were neither prepared to provide such services nor to assess and refer youths to such services. 29'43

It was believed that two paths to substance-specific services were feasible and the model supported both paths. The stronger path from mental health service indicates that youths are more likely to receive substance-specific services while they are receiving some other form of mental health service. The association between general mental health service use and substance-specific service use indicates that though some youths may only receive non-substance-related services for their problem behavior, these providers may subsequently refer the youths for more specialized care. The mild path from substance misuse to substance-specific service use may be the result of across time relationships. Substance-specific service use among time 2 substance users may be greater. Because the paths from misuse to both types of services were similar, there is some indication that behaviors associated with substance use are just as likely to be addressed based on their manifestation rather than their cause.

Youths' Paths to Substance-Specific Sen, ices JOHNSON et aL 421

The need for coordination of general and specific types of mental health services for youths has traditionally presented as a challenge to the f ie ld . 44 Coordination of general and substance-specific services is critical if all the issues related to substance use are to be addressed with youths. Though the path to mental health services from misuse behaviors was significant, practitioners may fail to recognize that such behaviors are the result of a substance use problem. Because of the presenting nature of the behavior, these practitioners may instead refer youths to other services to address the problems. For instance, if a youth goes to school while high, this possibly impairs his or her academic abilities and thus the outcome (academics) is addressed rather than the precursor (substance use). Depending on the nature of the behavior, youths may have their problems addressed within other sectors (ie, juvenile justice), which may not refer the youths to additional services.

Previous research had provided indication that substance misuse often exists in conjunction with conduct disorder and depression. There also was some indication that the use of substances increases the intensity of both of these mental health problems. This study found that although the disorders may exist at the same time, substance misuse does have a significant association with the display of conduct disorder symptoms. The same was not true for the association with depression. A separate model not presented here assessed whether or not the associations among the three mental health problems would change if conduct disorder and depression predicted misuse. The results indicated that the path from depression symptoms to substance misuse was not significant. The lack of association between substance misuse and depression could be a result of the symptoms of depression evaluated. Conduct disorder symptoms had a similar path to misuse as misuse had with conduct disorder (.39 compared with .40). This suggests that the symptoms of conduct disorder and substance misuse are so closely related that they feed off each other rather than one being a function of the other.

The misuse of substances was just as significant to conduct disorder as was environmental influences such as exposure to traumatic events, neighborhood and school conditions, and the influence of peers. These environmental factors also played a significant role in substance misuse. When youths experience traumatic events and perceive that their neighborhoods and schools are negative and that their peers display negative behaviors, they are more likely to act out behaviors, which may con- jointly involve their increased use of substances. Some controversy still exists as to whether or not social factors such as family and peers affect the misuse of substances. Research 17,23 indicates that these factors are more important in explaining substance use but not necessarily misuse. This study found that environmental stressors and family dependence do influence the misuse of substances. Although the role of family dependence in misuse was not as strong as suspected, it had a strong relationship to youths' symptoms of depression. This suggests that the modeling of substance use by family members is more internalized than externalized by the youths.

Limitations

The study possessed weaknesses that impact the interpretation and generalizability of the results. The sample was taken from an urban area and may not represent all adolescents, especially those who reside in non-urban areas. The data were based on the youths' self-report of behaviors with no cross- validation of these behaviors. This may create some bias in the results reported. Another concern was how the construct of misuse was defined. Certain behaviors that appeared to "represent" misuse were selected. Even though there is no known universal definition, the measure did have good reliability. There were some measures included in the study whose reliability fell within the .64 to .67 range. Although this is a minimally acceptable range, 4z these moderate estimations may have some impact on the interpretability of the results. This issue was addressed to some extent by utilizing previously standardized items within the constructs. Also, it is recognized that barriers to help-seeking are critical factors for consideration in service utilization. The construct used in the structural model contained the items that were less frequently reported by the sample. This creates a problem in the feasibility of the barriers construct to project the impact of the construct on service use adequately.


In addition, there is recognition that the availability of substance-specific services is a substantial barrier. However, data limitations prevented the assessment of this construct within the model.

Implications for Behavioral Health Services

Despite any limitations, the findings have clear implications. Many youths have entered the gateway to substance abuse as they have gone beyond simple experimentation with substances to the display of negative behaviors as a result of substance use. It is possible that society in general underestimates the harm that can result from experimentation, especially when it considers usage a normal youthful behavior. Efforts should be made to increase awareness of the potential for detrimental outcomes when youth experimentation is not taken seriously. Another area of concern is that many of these youths are not talking about substance-related problems with practitioners within service settings. Youths may fear that discussing their problems and behaviors associated with substance use may result in punitive rather than therapeutic measures. Thus, practitioners at all levels should provide safe environments in which youths feel comfortable discussing the issues of substance use. In addition, youths may be internalizing the influence of family dependence. Youths should be encouraged to discuss these issues and find productive ways to vent the frustrations associated with viewing this type of behavior within the family unit.

Even when youths have "reasonable" access to services (service sector users), their utilization of services remains a concern. These results suggest that practitioners may not recognize youths' need for services that are specific to their substance use until their use is frequent and results in numerous behaviors and symptoms. Thus, it is important that practitioners both address youths' need and give referrals to substance-specific practitioners. Providers who are in gateway services should be trained to recognize substance behaviors and symptoms and make referrals before these behaviors progress to misuse. Providers should have access to developmentally appropriate assessment tools and be trained in the addiction process as it pertains to or is intertwined with adolescent development.

Although it may be advantageous for practitioners to refer to specialists, the additional effort of seeking services may mean that youths do not follow through and get substance-specific help. The mild paths from misuse to substance-specific service indicate that avenues for youths to receive such specialized services may be dependent on receipt of other general mental health service. It is up to practitioners to ensure that the referral process is not a tedious one in which youths become "consumed" in the system and become victims of ineffective coordination efforts. The process must be free of congestion, and it must eliminate any obstacle that may be a potential barrier to youths' service utilization. Practitioners also must recognize when youths' behaviors are rooted in the misuse of substances so that appropriate referrals to specialized services can be made. There also is concern that youths may not have direct access to substance-specific services. Very few youths are receiving services that could potentially help them eliminate these problems. Though this study did not assess the effectiveness of substance-specific services, it is believed that any additional services beyond the general mental health system are advantageous and should be utilized by youths once they enter the gateway to substance misuse.

A great deal of consideration Should be given to the real and perceived barriers that present as obstacles to help-seeking. A very real barrier for youths is the lack of available services to address youths' substance use needs. When services are available, youths need to have either a direct or a non-complicated indirect access to these services. Another obstacle for consideration may be youths thinking that they themselves can address the problem without seeking the help of others. Mental health professionals and other service providers to youths must work to educate youths about the positive aspects of help-seeking. Youths have to recognize that they are not necessarily in a position to provide an adequate assessment of their own problem situation. This is especially the case for adolescent substance users who may have, as a result of their substance use, distorted perceptions of the appropriateness of their behaviors or the seriousness of their situations.

Youths" Paths to Substance-Specific Services JOHNSON et aI. 423

A c k n o w l e d g m e n t

This research was supported by grant R24 MH50857-02 from the National Institute of Mental Health.

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Youths" Paths to Substance-Speci f ic Services J O H N S O N et al. 4 2 5

Appendix

Factor Loadings for Retained Items on Latent Constructs

Substance Misuse (Cronbach's ot = .86)

Often use more drugs than planned .70 Use drugs after deciding not to .57 Drink more than thought you would .60 Take drugs while at school .75 Forget what happens while drunk .56

Frequency of use Drink after deciding not to Go to school/work high Go to school/work hung over Ever drive/do dangerous things

Conduct Disorder S y m p t o m s (Cronbach's ot = .65)

Involved in serious physical fights .48 Robbed someone Used weapon in fight .49 Broken into house/car/building Been physically cruel .47 Broken something on purpose

Negative Env ironment

Negative school .54 Negative neighborhood .50

(Cronbach's a = .67)

Negative peer influence Exposures to violence

Depress ion S y m p t o m s

At times very sad At times nothing was fun Lack of appetite Less energy Blame self for things Feeling indecisive Felt hopeless Unable to concentrate Thoughts of suicide

.86

.51

.77

.58

.63

.47

.57

.59

.70

.60

(Cronbach's ot = .87)

.54 Trouble sleeping .50

.50 Less talkative .53

.41 Difficulty working .55

.46 More tired than usual .57

.63 Dislike self .57

.50 Often on the verge of crying .55

.60 Trouble paying attention .49

.49 Felt many things went wrong .62

.45 Thoughts of death .46

Barriers to Help-Seeking (Cronbach's ot = .64)

It was too difficult to get help Concerned with what others think Not sure where/whom to go to for help

.53

.44

.66

Worried about paying for help .49 Services before not helpful .46


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