Overview of Substances

Substances, for the purpose of this chapter, include any psychoactive compounds or chemicals that change states of consciousness, alter mood or perception, and have the potential to cause social and health problems (McLellan, 2017). Substances are found in everyday consumer goods such as over the counter drugs, sodas, and chocolate; some have legal permissions for use (e.g., caffeine, prescriptions when used as directed such as opioids, benzodiazepines, or stimulants), others are deemed illegal (e.g., heroin, methamphetamine), and others are illegal for adolescents (e.g., alcohol prior to age 21 in the US, nicotine prior to age 18 in most US states). All of this being said, there is a difference between the physical effects of the substance and the social norms related to the use of the substance.

Seven classes of substances categorize the substance based upon their pharmacological and behavior effects: nicotine (e.g., tobacco products); alcohol; cannabinoids (e.g., cannabis); opioids; depressants (e.g., benzodiazepines); stimulants (e.g., cocaine and amphetamine), and hallucinogens (e.g., ecstasy, LSD) (McLellan, 2017). When discussing pharmacological effects, these are how the substances affect neurotransmission in the central nervous system (University of Minnesota [UM], 2015). As outlined in our psychopharmacology chapter, neurotransmitters can be modulated to either excite or inhibit the neural synapse; this will affect how the nervous system operates. Frequent use of external substances can create changes in how someone’s nervous system operates; in a way, the body has to rely on these substances.

Increased use of substances can lead to what is known as tolerance, and that is defined as the increase of the dose of substance needed to produce the same desired effect (UM, 2015). Think of this example: for someone who has consistently consumed three alcoholic beverages a day, they may need to consume more than three drinks to get a “buzzed” feeling. As tolerance increases, a person may be reliant or dependent on the substance. Signs of dependence emerge when a substance is not consumed, for instance irritability or cravings or fatigue. When these symptoms emerge, it can be a sign of withdrawal. Lastly, with continued use because of increased tolerance and dependence, a person may develop an addiction to the substance. For regular coffee drinkers, consider if you ever tried to cut back on your coffee consumption; it can be painful, and it may seem like you need coffee to function.

It can be easy to downplay the effects substances have, often because of social and cultural standards and expectations. For the coffee drinker, there is a coffee culture; it can be something social, a norm of the workplace, and funny to talk about when “you haven’t had your coffee yet.” And there are other substances that may appear less dangerous, for instance, when cannabis is compared to opioids. This may be part of the logic that Roger uses when he says, “It’s natural.” What is more concerning for his case is that while he thinks he is consuming safe amounts of cannabis (UM, 2015), his executive functioning is not able to look for potential complications over time. The teenage brain, prone to taking risks, may gravitate to substance use, and substance use can further lead to risk-taking or unforeseen problems. Let’s turn our attention now to substance use as it pertains to adolescents.

Overview of Adolescent Substance Use

An adolescent undergoes significant biological and psychological changes, which is dovetailed with the developmentally common increase in experimenting with risk-taking behavior (Becker & Fisher, 2018; Hernandez et al., 2015; Steinberg 2007). Experimentation with drugs and alcohol during adolescence is no exception, and the Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th Graders, 10th Graders, and 12th Graders showed the following rates of illicit drug use from 2017 to 2020 (Johnston et al., 2021).

The last year use of illicit drugs follows a pattern of increases for 8th and 10th graders, and a slight decrease for 12th graders, and the last year use of alcohol use follows a similar pattern. Past year rates for vaping increased for all grades from 2017 to 2020, reflecting the popularity of vaping products like nicotine, THC cartridges, and flavored cartridges (Bell & Keane, 2014). Despite leveling out in 2020, vaping rates have had striking increases across all age groups. Decreasing rates of opiate use, including heroin and prescription opiates in the midst of the ongoing opioid epidemic, are promising. Opioid death rates still account for a majority of drug overdose related deaths in youth (CDC, 2020). Data collection during 2020 was incomplete due to the COVID-19 pandemic.

Prevalence of Substance Use Disorders

Alcohol, nicotine, and cannabis are the most commonly used substances by adolescents Among those aged 12 to17, 9.4% (~2.3 million youth) drank alcohol in the past month, 13.2% (~3.3 million youth) used cannabis in the past year, and 2.3% (~572,000 youth) smoked cigarettes in the past month (SAMHSA, 2020). For youth ages 12 to17, the rate of illicit substance use (17.2%, or 4.3 million youth) has remained somewhat the same since 2015 (SAMHSA, 2020). A review of substance-use disorders in teens range from 4.0 to 8.9%, with a lifetime prevalence of 11.4% (CDC, 2020a; Swendsen et al., 2012). Alcohol use disorders (AUD) have a 3 to 6% prevalence, and prevalence rates drastically climb at the age of 17, with rates of 15.1% compared to younger groups at 1.3% (CDC, 2020a; Swendsen et al., 2012). Substance use disorders (SUD) often co-occur with other conditions, with an average comorbidity of 60 to 80% (Hersh et al., 2014; Swendsen et al., 2012).

Substance Use Disorders in Adolescents

Adolescent experimentation with substances is developmentally appropriate; as will be discussed in the clinical features section, substance use disorders emerge because of patterns of problematic use. Biological factors for SUDs encompass the genetic heritability (see Hussong et al., 2011) and parental drug/alcohol use and intrauterine exposure to drugs/alcohol can create biological vulnerabilities (CDC, 2020b). The neurophysiological changes in adolescence manifest at different ages of adolescents, with timing of puberty and its stages having an influence on substance use (Patton et al., 2004). Psychological vulnerabilities include personality traits like externalizing problems like impulsivity and novelty seeking (see Wiers et al., 2012) and internalizing problems like negative affectivity, and most developmentally apparent, pubertal change.

Social factors stand out as highly influential on adolescent substance use. In Becker and Curry’s (2014) review of adolescents and peer patterns of substance use and SUDs, they highlight socialization (the adoption of peer behaviors and peer selection, the desire to affiliate with like-minded individuals) as theories that describe social factors leading to SUDs. Drug use is in part the result of socialization, and the National Institute on Drug Abuse (2014) reports that deviant peer groups and limited prosocial outlets can lead to SUD. Families, specifically parenting, can influence the development of adolescent substance use, considering the role of parental behaviors like monitoring and supervision (Tobler & Komro, 2010), involvement in their child’s activities (Ryan et al., 2010), inconsistent or permissive parenting practices (CDC, 2020b), and parental beliefs like disapproval of substance use (Mrug & McCay, 2013). Other social and environmental factors include exposure to negative life events like trauma (Swedo et al., 2020).

Substance use is not without consequences to adolescents, which can alter developmental trajectories. Sexual behavior can be influenced by substance use, with literature reviews (Becker & Fisher, 2018) highlighting substance use in adolescence increasing the likelihood of sexual intercourse, earlier sexual debut, and high-risk sexual activities like unprotected sex and sex with multiple partners. Such factors can increase the likelihood of teen pregnancy and increase the risk for sexually transmitted infections (Yan et al., 2007). Adolescent substance use can affect academic performance, ranging from less severe consequences like falling grades to more dire consequences like dropping out (Becker & Fisher, 2018). Lastly, adolescent substance use has been linked to delinquency (Tripodi & Bender, 2011). Substance use can be a gateway into the juvenile justice system as a result of high-risk behaviors, or it can prolong involvement with the system as substance use monitoring is typically part of court related supervision.

Developmental Systems Considerations for Substance Use Disorders in Youth

With Roger, adolescents will typically downplay their use, but they may not realize the impact it has. Even though he wasn’t planning on attending college, his use was interfering with planning for his future. We would need more information about his socialization patterns. How was cannabis introduced? Was there a family history of cannabis or other substance use? The developmental aspects of our guiding theory would urge us to stress the adolescent brain here, too; adolescence is a time of seeking autonomy, pushing boundaries, and engaging in risk taking behavior. The adolescent may developmentally be prone to substance use, and their frontal lobe is still developing; frequent substance use could hamper this frontal lobe development, the part of the brain responsible for executive functioning (Winter & Arria, 2011).

Experiences Across Racial and Ethnicity. Mennis and Stahler (2016) indicate that treatment rates in general for adolescents are low, and in particular, Black and Hispanic youth experience the lowest treatment rate across racial and ethnic groups. These disparities can vary depending on the primary substance of choice of the adolescent, but the disparity of treatment rates is observed across all substances for Black youth. Mennis and Stahler (2016) identified that there are acute disparities in treatment completion rates for Black adolescents who use alcohol and methamphetamine. For Hispanic youth who use heroin, treatment completion rates are particularly low compared to White youth. The lack of access, engagement, and completion of care elevates the need for culturally responsive clinical practices, and research indicates that culturally responsive treatments for substance use youth treatment are associated with significant reductions in post-treatment substance use (Steinka-Fry et al., 2017).

More problematic than the disparity of treatment rates is the fact that minority youth have more substance use related problems despite having less use. In the context of the juvenile justice system where there is disproportionate minority contact to be with, drug abuse violations for youth, on the whole, have decreased over 50% for both White and Black youth from 2007 to 2019 (Office of Juvenile Justice and Delinquency Prevention [OJJDP], 2019), and the rate for Black youth in 2019 has been at its lowest since 1980 (OJJDP, 2019). Despite this radical decrease, drug abuse arrests are still higher for Black youth than any other same-age racial group (OJJDP, 2019).

Experiences of LGBTQ+ Youth. In a national sample of sexual and gender minority adolescents, more than half reported alcohol use in their lifetime, and one-fourth reported cannabis use (Watson et al., 2020). These researchers found adolescents assigned male at birth had higher substance use prevalence compared with adolescents assigned female at birth, and greater risk was identified for transgender adolescents in comparison to cisgender adolescents (Watson et al., 2020). Generally speaking, sexual and gender minority adolescents disproportionately report problematic substance use compared to cisgender peers (Watson et al., 2020). It can be assumed that substance use can be a coping skill used when faced with stress related to discrimination, fear of the consequences of disclosing sexual or gender identity. Indeed, a recent meta-analysis found that the strongest risk factors for sexual minority youth are largely driven by marginalization and minority stress: victimization, lack of social support, psychological stress, negative disclosure reactions, and housing status (Goldbach et al., 2014). It is therefore important to consider the different psychological and social systems at play as a driver of substance use.

Assessment of Substance Use Disorders in Youth

Substance use disorders are characterized by a pattern of use of the substance that results in significant impairment or distress (American Psychiatric Association, 2013). Criteria span problems such as taking larger than intended doses of the substance, desires to cut down often accompanied by unsuccessful attempts, spending a significant amount of time acquiring or using substances, intense cravings or desires for use, social impairment, risky use of the substance, and what is known as pharmacological criteria, which includes tolerance of the substance’s effects and withdrawal symptoms (American Psychiatric Association, 2013).

The fifth edition of the Diagnostic and Statistical Manual (DSM-5) brought changes to the way SUDs were diagnosed. Substances were separated into distinct use disorders: alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other/unknown substances. Severity levels include mild (2-3 symptoms present), moderate (4-5 symptoms present), or severe (6 or more symptoms present).

Becker and Fisher (2018) highlight that these diagnostic criteria do not appropriately reflect the developmental characteristics of adolescence. They note the criteria related to physiological changes as troublesome, citing Winters and colleagues’ (2011) critique of the definitions of tolerance, withdrawal, and craving; in summary, the move from experimenting from regular use may not indicate tolerance, craving during adolescence is not well understood, and withdrawal may be rare because of the time needed to become physically dependent on the substance. The social difficulties and risk domains of the diagnosis may be based in developmental norms (i.e., navigating the pressures of their developing social world and the normative behavior of risk taking itself). Becker and Fisher (2018) offer a more in-depth discussion of these and other diagnostic criteria issues.

State of the Art Assessment Tools

Screening to Brief Intervention (S2BI; Levy et al., 2014) asks respondents to indicate how many times he or she has used eight different substances. Screening is meant to identify levels of risk for a disease or condition. Screening is critical, especially with adolescent substance use because of the nature of experimentation versus problematic use. Youth that experiment do not necessarily need outpatient counseling, or, when parents find out about their child’s use, residential treatment. Screening in general should follow with systematic clinical decision-making.

The S2BI specifically uses a stem question and forced response options to understand the past year use of tobacco, alcohol, and marijuana, as well as five other substances commonly used by adolescents. If a youth endorses use of tobacco, alcohol, or marijuana, the clinician should then ask about youth use of prescription drugs, illegal drugs, inhalants, or synthetic drugs. If a youth denies use, the clinician should use positive reinforcement of that behavior.

The S2BI is highly sensitive and can discriminate risk-categories, and a youth’s response on it can correlate closely with the likelihood of a SUD (Levy & Williams, 2016). Youth with frequency responses of “once or twice” correlates with no SUD and this should be followed up with brief advice and medical home follow-up (Levy & Williams, 2016). A response of “monthly” correlates with mild or moderate SUD which should illicit a motivation intervention from the clinician that focuses on assessing for problems, advising to quit, and making a plan. Lastly, responses of “weekly or more” correlates with a severe SUD, and this should follow the previous motivational intervention and add a referral to treatment. The motivation intervention can follow the items on the CRAFFT, an evidence-based screening and brief intervention tool for problems related to substance and alcohol use of youth ages 12-21 (Knight et al., 1999).

The CRAFFT has been widely implemented in a variety of settings, from medical to community settings (Knight et al., 1999), and it also has validity for adolescents with varying socioeconomic and racial/ethnic backgrounds (Knight et al., 1999) The main ideas of the questions contribute to the acronym CRAFFT: operating a CAR while high, use of substance to RELAX or fit in, use while ALONE, FORGETTING things while using, if FAMILY/FRIENDS tell them to cut down on use, and getting into TROUBLE (Knight et al., 1999). Ask each question on the CRAFFT, and positive responses can indicate opportunity for brief intervention. For instance, if a youth is using substances alone, inquire about social networks- is this an issue with social skills? Or ask about other clinical hunches like depressive withdrawal- is there some behavior activation needed if there is the presence of depressive symptoms? The CRAFFT also has a brief intervention script that reviews the “5 Rs” for brief counseling: reviewing the results, recommending not to use, riding/driving risk counseling, response eliciting of self-motivational statements, and reinforcing self-efficacy (Knight et al., 1999).The CRAFFT also provides a scoring guide with score ranges about the probability of a DSM-5 substance use disorder.

Other Helpful Measures

The S2BI and the CRAFFT are considered to be the most state of the art screening and assessment tools, so the following discussion will touch on alternative options and contextualize the use of instruments in a structured interview. There are a variety of well-validated and reliable assessments available for assessing substance use problems in adolescents. Depending on your referral question and purpose of assessment, you can choose between self-report screenings, structured interviews around problems and consequences of use, or structured and semi-structured diagnostic interviews. Consult the National Institute on Drug Abuse site to see what fits your particular setting.

With other screening options, the Michigan Drug Abuse Screening Test (DAST) has 10, 20, and 28-item versions and has high reliability and validity in a variety of settings with adolescents (Yudko et al., 2007). The DAST does not differentiate between substances and so may be helpful for youth with polysubstance use who may have family conflict related to one substance but legal issues or impairment at school related to other substances. Screenings should be followed up with more in-depth assessment.

Structured interviews that assess a variety of substance use problems and consequences, as well as motivation for treatment and reasons for cutting down, including the Global Assessment of Individual Needs (GAIN; Dennis et al., 2003; Titus et al., 2013), which takes approximately 1.5 to 2 hours to administer. The GAIN also assesses internalizing and externalizing problems, and common psychosocial problems that accompany substance use (e.g., school problems, legal problems), so could be used in your routine practice as part of a multi-dimensional assessment. The GAIN – Short Screener (Dennis et al., 2006) takes about 30-45 minutes to administer. Clinicians could choose to only administer the substance use section, which would take considerably less time. The GAIN-I, GAIN-Q3, and GAIN-SS are all freely available from Chestnut Health Systems.

Diagnostic interviews (interviews conducted by the clinician to diagnose a substance use disorder) include the Teen Addiction Severity Index (T-ASI). The T-ASI is a structured clinical interview that can be used to assess substance use severity, past treatments, years of use, and common risk behaviors (e.g., IV drug use; Kaminer et al., 1991). The T-ASI also assesses functioning in other psychosocial domains, including family, peer/social relationships, justice involvement, employment/school/training, and psychological distress. The T-ASI does not include a diagnostic checklist and so may require more clinical judgment or an additional tool to make a formal diagnosis. The T-ASI takes approximately 30 to 45 minutes to administer.

The Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (K-SADS-PL) is a semi-structured interview that includes both adolescent and parent-report sections. The semi-structured nature of the K-SADS gives the clinician more flexibility in phrasing than a structured interview but also requires more clinical judgment. The K-SADS-PL is freely available from Kennedy Krieger Institute and also includes a computerized version with automatic scoring. Instruments like the GAIN and K-SADS-PL do require additional training in their administration and interpretation of scores to make diagnostic decisions. Training materials and online training are available for the K-SADS and GAIN on their websites. The T-ASI does not require specific training; however, the T-ASI should be administered by a person trained in clinical interviewing techniques, such as a social worker.

Intervention with Substance Use Disorders

The combination of the S2BI and the CRAFFT constitute a scalable way to implement brief intervention that is tied to the level of risk. For youth that require treatment and long-term care, there are various approaches to take. Common components of treatment such as advancing motivation, developing skills for harm reduction or abstinence, reorganization peer networks to include prosocial peers, with most interventions being sourced from motivational interviewing approaches, CBT, and contingency management (Fisher et al., 2018; Gray & Squeglia, 2018; Hogue et al., 2018; Jhanjee, 2014; Waldron & Turner, 2008). Hogue and colleagues’ (2018) update of the evidence base for adolescent substance use treatment identify five approaches that are deemed Well-Established: ecological family-based treatment (FBT-E), group cognitive-behavioral therapy (CBT-G), individual CBT (CBT-I), motivational enhancement therapy/CBT (MET/CBT), and MET/CBT + FBT-B.

Hogue and colleagues’ review (2018) review highlights the inconsistent performance of motivational interviewing as a stand-alone, brief intervention (Hogue et al., 2018), although it is worth noting that motivational approaches can be used in combination with other treatment modalities like CBT. The systematic review that Dr. Becker mentioned in her interview that compared to treatment as usual, motivational interviewing reduces alcohol use, heavy alcohol use, and overall substance-related problems, but not cannabis use (Steele et al., 2020). In general, there are few effective treatments of cannabis use and cannabis use disorder among adolescents.

Motivational technique center on motivational interviewing (MI), which is a treatment model that is brief, lasting usually between 1-2 sessions (Fisher et al., 2018). This intervention is not focused on “curing” the substance use, rather its meant to target the intrinsic motivation of the adolescent to change. Clinicians explore the youth’s ambivalence to change in hopes to build motivation, and in motivational enhancement models, the motivational interviewing session will have provider offers non-confrontational, normative feedback in client feedback sessions (Fisher et al., 2018).

CBT has been shown to be efficacious (Hogue et al., 2018), and it also can be adapted for cultural considerations (Hogue et al., 2018). In fact, CBT for substance use has a better impact on youth substance use treatment outcomes when it is delivered through the lens of the culture of the youth (Hogue et al., 2018). In general, CBT approaches will consider the thoughts about use, consider the triggers for use, and the impact of feelings on substance use and include skills to help reduce relapse (Hogue et al., 2018). The Adolescent Community Reinforcement Approach (A-CRA; Meyers et al., 2011) is one such CBT intervention that has been shown to be efficacious. A-CRA uses operant condition techniques to understand and change the rewards that adolescents typically experience with substance use and replace these rewards with those from non-substance use activities, such as the rewards associated with being on a sports team, joining a club, or learning a new skill. First, a functional analysis of substance use is conducted, in which the antecedents and consequences of substance use are explored, as well as rewards and punishments associated with use. Then a period of time of abstinence is chosen (e.g., one month), not an agreement or declaration of lifetime abstinence, in an effort to move adolescents toward abstinence and practice skills needed to achieve more long-term abstinence. The therapist and adolescent plan for this period of abstinence followed by skills training and relapse prevention. Parent communication and monitoring is also included in A-CRA in two parent-only sessions and two parent-adolescent sessions. A-CRA is one of the only interventions shown to reduce cannabis use problems in adolescents (Dennis et al., 2004).

Family Therapy

Treatment should consider the many systems of a child’s life, which largely center around the family (Gray & Squeglia, 2018). Protocols such as functional family therapy, brief strategic family therapy, and multisystemic family therapy have shown to be superior to control groups (National Institute on Drug Abuse, 2014). Even beyond these specific family-based interventions, adolescent interventions for substance use that include parent/caregiver involvement tend to be superior to ones that do not (i.e., that include only individual, or group therapy focused on the adolescent alone; Waldron & Turner, 2008; Tanner-Smith et al., 2014).

Multicomponent Interventions

Multicomponent Interventions are treatment packages that combine more than one approach; three of five well-established or probably efficacious combinations include contingency management (Hogue et al., 2018). Contingency management tends to be used in SUD treatment settings, and, as Dr. Becker mentioned, is highly efficacious in adults. It has not been evaluated as a stand-alone intervention in adolescents. It is an approach that uses operant behavioral principles and awards; incentives are given to youth for either attendance or treatment compliance goals (Gray & Squeglia, 2018). Rewards vary based on the type of system with both vouchers and prize-based models. As an example of the prize-based model, if 500 slips of paper or tokens are placed in a large jar or fishbowl, 250 may include positive comments (e.g., “Good job!”), 209 small ($1), 40 large ($20), and 1 jumbo prize ($100). Prizes worth roughly these amounts or vouchers in these amounts would be given if chosen, and only for a specific behavior, such as attendance in individual or group therapy, or submitting a negative urine drug screen that day. Drug screens need not be negative for all drugs, and often contingency management reinforces only negative cocaine or opioid screens (Stanger & Budney, 2010). Increasing chances of earning prizes in conjunction with continuous or repeated positive treatment behaviors (e.g., earning 2 draws from the fishbowl for 2 consecutive visits or 2 consecutive negative urine screens) is also associated with improved abstinence outcomes. Contingency management can be a helpful strategy to improve attendance and retention in treatment (Stanger & Budney, 2010; 2019).

Screening, Brief Intervention, And Referral to Treatment. SBIRT has been discussed at length across this chapter. It is an approach done frequently in primary care, in which population-based screening occurs to identify youth who are at-risk and provide an appropriate dosage of intervention (Knight et al., 1999). Typically, youth screened fall into three categories: those not at-risk (no intervention), moderate-risk (brief intervention like psychoeducation), or high-risk (psychoeducation and referral for ongoing care). This is a great way to align provider resources with patient needs. SBIRT related interventions show good improvements over control groups (Winters et al., 2014). There is also a mobile app version that can guide clinicians through the SBIRT steps, including administering screening tools and guiding treatment decisions (Curtis et al., 2019). This app is freely available for Apple and Android phones and includes decision points to help guide clinicians in screening, intervention, and choosing treatment referral options.

Referral for Medication Management. It is important to understand that adolescents may be interested in medication for substance use disorders and may experience substance use problems severe enough to warrant medication. Medications can help manage cravings and withdrawal symptoms, thereby decreasing use and increasing likelihood of abstinence or lower levels of use. There are several medications that are effective for adolescents with opioid use disorders (Camenga et al., 2019) and growing evidence for medications for alcohol use disorders (Clark, 2012). Referral to treatment may therefore include both psychosocial treatment and medication management.

If you find that you need to refer an adolescent for specialized substance use treatment, the National Institute of Alcohol Abuse and Alcoholism (NIAAA) has designed a Treatment Navigator, which is an online tool to identify signs of high-quality treatment for alcohol use disorder in the community, directories of alcohol use treatment providers, psychoeducation on treatments that work for alcohol use problems, and guidance on how to choose a treatment. However, the Treatment Navigator does not currently include adolescent-specific treatments in its directories but is likely expanding to adolescent treatment in the coming years. Currently, families and clinicians can search for treatments by the Family Resource Center or Partnership for Drug-Free Kids (both available on the NIAAA website). The Substance Abuse and Mental Health Services Administration also has a behavioral health (which includes substance use services) treatment search engine (available on SAMHSA’s website).Treatment providers can be searched by geographic location and include psychosocial treatments as well as buprenorphine and methadone prescribers, two medications that help reduce opioid use. Though treatments are not specified by age, many times facilities have the word children or families in the title of the facility. Given the relationship between substance use in families, both the NIAAA and SAMHSA treatment locators may be especially helpful when referring parents/caregivers or other adult family members for their own substance use treatment. If you are interested in more specialized training in effective treatments for substance use problems, there are trainings, webinars, toolkits, and apps available from the Addiction Technology Transfer Centers, available on their search engine. There are 10 region-specific Addiction Technology Transfer Centers, as well as a specialty center for Native and Hispanic/Latinx populations, which are all funded by SAMHSA.

Putting It All Together

As we saw with Roger, he was screened by his primary care team using the SBIRT approach. Parents must be supported in this process, as youth who minimize the impact of their use on their life or downplay the severity of their use will likely not want to engage in treatment. Parent management training skills may be helpful for parents, considering how to reward and incentivize the youth to engage in treatment. Roger was ultimately referred to an outpatient program. The clinician there wanted to include the family in the treatment process. Roger’s parents recognized what could motivate him as a reward; he would soon express an interest in driving, and he loved playing video games. They set a reinforcement schedule: if Roger completed treatment, the parents would help with Roger obtaining a learner’s permit. To shape behavior, the parents developed a teen points system. Attending treatment allowed Roger more time on his gaming system. While this approach seems to be appeasing the youth, the parents held the belief that decreased substance use was more preferred than not providing the reward schedule. So, what could happen if Roger’s substance use seems to require longer-term treatment? What if the parents are on board with and follow through on the plan, but Roger still has problematic substance use?

Motivational Enhancement and Cognitive Behavioral approaches could be helpful in this case. A few key aspects of treatment would be teaching Roger problem-solving skills, affective management, communication skills, and relapse prevention, as well as ways Roger’s parents can reinforce and reward the use of these skills. It would be helpful to evaluate for a co-occurring disorder, but let’s say that that isn’t the case for Roger. As Dr. Becker mentions in her interview, highlighting ambivalence is a key part of motivational interviewing, and problem-solving skills can help Roger engage in the creative process of generating and evaluating options regarding his use. Even after learning these skills, in the midst of his peers, Roger may need help with assertiveness in communicating his own needs and preferences. Relapse prevention focuses on the triggers for use and would help Roger identify his personal triggers for use and match appropriate skills for such triggers (e.g., self-talk, distraction, and engaging social supports). For worksheets and supports in this consider the linked resource from Webb and colleagues (2007).

Clinical Dialogues: Substance Use Disorders in Youth with Dr. Sara Becker, PhD

Sean E. Snyder, LCSW: Over the course of this dialogue, Dr. Becker will be discussing engagement, assessment, and intervention in the world of adolescent substance use. To start, I am thinking about engagement with our population and in those initial meetings, I tend to see that the youth from the beginning will minimize their use, or they’re like, “You know this isn’t a big deal. I don’t know why the adults are overreacting.” As a clinician, we know substance use can be serious because of its potential to be harmful, but we don’t want our righting reflex to come out and alienate the child, right? How do you approach joining with adolescent clients that have a history of substance use?

Sara Becker, PhD: With adolescents who have a history of substance use, the first thing to keep in mind is that the primary pathway to treatment is typically through the justice system, and then the secondary path to treatment is usually that the kid is sent to treatment by an authority figure because they got in trouble with their parents or their school. The vast majority of kids presenting for a treatment for adolescent substance use will be mandated or coerced in some way. They were either mandated through the justice system or are being coerced to go by their family or school, so it’s important to recognize that most teens who present will have very low motivation to be there.

Because of that, the predominant and most effective approach for engaging teens is to use motivation enhancement techniques. Specifically, brief techniques that fall under the umbrella of motivational interviewing are most recommended, with the idea that you really try to highlight the teen’s ambivalence about cutting down their substance use and try to join with them and recognize that. A phrase we use is “roll with the resistance;” it means that you reflect with the teen what you’re hearing and validate the advantages they get from substance use, as well as the disadvantages. And again, try to highlight areas of discrepancy and ambivalence related to their use to try to promote them to build internal or intrinsic motivation to change.

Snyder: In that approach, you hold up both the pros and the cons and not push the teen towards one side. And depending on what programs the child is referred to, there can be a difference between the abstinence approach versus the harm reduction approach. How much does that philosophy of care influence how you engage with a youth?

Becker: Yes, abstinence-only approaches tend to not be favored, as more harm reduction or use reduction approaches tend to be more developmentally appropriate. It’s important to consider child development because developmentally, some level of experimentation with substances is normal for kids. It’s normal for kids to experiment at some level, and so coming at teens at a young age and requiring that they’d be abstinent as a condition of treatment is really what teens are expecting when they present to treatment. They’re expecting to be confronted and they’re expecting to be given a “just say no” approach. The approaches that tend to be most effective with this age group really try to disengage their expectation of “just say no” by teaching them skills to cut down and helping them build the motivation to cut down. These approaches are typically more in line with a harm reduction approach than an abstinence-only approach.

Snyder: With adolescents specifically, autonomy is their developmental task. They want to be autonomous, and we as providers have to consider autonomy and what that means with different ecological systems, such as the justice system, the school system, and the family system. In the clinician’s office, direct systems work comes from directly working with parents. How do you balance adolescent need for autonomy and parental expectations for treatment? How do you hold up those two parts of the family system?

Becker: There are a couple of ways that we could think about this question. One is that one of the evidence-based principles for working with adolescents who have a history of substance use is to involve the family. The treatment approaches that involve parents and other family members tend to be more effective than those that are adolescent-only approaches, and that’s been shown in multiple meta-analyses and systematic reviews, including several that I’ve been part of. These reviews show that involving the family is an effective evidence-based principle. Having the parent and teen in the same room and using family approaches to understand the role that the teen’s substance use plays in the family system is an approach that tends to be effective.

A colleague of mine, Aaron Hogue, is trying to distill in lay language and lay terms for providers out in the field, what exactly should you do with a family of a teen that has used substances. He and his team have watched over 300 hours of family therapy sessions of different family therapy models to code them and try to distill what exactly you should do. Readers, stay tuned for that, because it can tell you what specific ingredients of family therapy work. I can say multi-system family therapy works, multidimensional family therapy works, and family behavioral therapy works, but what we don’t have a good handle on is the core ingredients of those approaches, what makes them work.

The other way that I would answer your question is when you meet with the teen individually, and you’re using a motivational building approach, there’s an acronym called OARS that is the key principles of motivational interviewing: using your Open-ended questions, Affirmations, Reflections, and Summary statements. You can highlight the tension about the adolescent’s enjoyment of substances and then the consequences they’re experiencing at home, the pressures they’re experiencing from parents. When I train, I spend a lot of time on reflection statements and I talk a lot about double-barreled reflections. I will actually highlight that tension that you were just talking about and say, “On the one hand, it sounds like you really enjoy smoking cannabis with your friends and it helps you to relax it reduces your anxiety, on the other hand, your parents are really on your case and your parents are telling you absolutely cannot use it all. How can we reconcile that? What kind of plan do you want to make before you leave today?” The goal is to acknowledge those tensions.

Snyder: Yes, practitioners have these great micro skills, and we just have to remind ourselves to use them because they go such a long way. Something separate but also fundamental to clinician training is trauma-informed care as a basic mindset. So let’s say a clinician takes a trauma-informed approach; they recognize the person they are seeing has been exposed to trauma and note that the client has substance use challenges. Almost immediately, the clinician is thinking about maladaptive coping for managing PTSD or anxiety. What do you make of that? Is that the case, that substance use is largely maladaptive coping?

Becker: I think that’s an impression that a lot of behavioral health folks have, that substance use almost always is maladaptive coping, and I would say that’s not necessarily the case. There are a lot of teens that just use substances because they enjoy it, because they’re bored. Both things are true. We have teens that certainly are using it because they have underlying mental health challenges, like trauma or anxiety or even ADHD. ADHD is actually the most common co-occurring disorder with substance use in adolescents.

And so, certainly, I would say, the first step in assessment is understanding a teen’s level of substance use, and the predominant screening tools are frequency-based to really get a sense of the level of concern that you should have about the substances in particular. If after assessing you are concerned about a teen’s substance use, I would say, as with all good clinical practice, you would want to do a more multidimensional assessment and understand more factors. Are we concerned about anxiety? Are we concerned about depression? Are we concerned about traumatic stress, attention issues? And we always need to ask about suicide. I think any good assessment of adolescents needs to understand suicide risk as well.

But usually, the first step in screening is just very brief, frequency-based questions to understand whether this is a kid that’s experimenting once or twice, or this is really something that is raising a red flag for us. Or this teen is at risk of using on a regular basis.

Snyder: Yes, we are formulating from the beginning to get those contextual factors, and you’ve made me think, too, as a clinician, sometimes our assumption goes right to thinking of maladaptive coping because that’s something I as a clinician can treat. Maladaptive coping feels like a low-hanging fruit in a treatment context, when really, as you mentioned, substance use can sometimes be enjoyable; it can just be like other things that teens enjoy. I appreciate you doing a little boundary spanning here for the conversation.

Back to contexts, one of the big things to consider is peer groups. I feel as a clinician, I have no control over the kids that my clients hang out with and other social factors like that. I’m wondering, maybe clinicians frame substance use as maladaptive coping because it gives some locus of control for the clinician, like “I can actually treat that!”

Becker: Part of why family-based therapy models are so effective is that parental monitoring and parental communication around norms and expectations around substance use are huge risk/resilience factors. Kids whose parents are more able to monitor on a daily basis and are aware of the kids their child is hanging out with, those kids tend to be at lower risk of substance use. Parents that have very strong communication about norms in the house and expectations around substance use also tend to be a protective factor for youth. That’s one of the reasons that family approaches, we believe, are more effective, because you’re teaching the parents skills to be able to monitor the teen more effectively.

Snyder: Yes, it’s situating the presenting problem amongst a constellation of factors; it’s not just this one kind of clinical transaction that goes on.

Becker: You’re exactly right; about half to two-thirds of adolescents with a substance use disorder will have at least one co-occurring mental health problem. So, it is very common. Yet, even in those kids with multiple problems, when you do your functional analysis, it isn’t always the mental health problem that is why they’re using substances. Sometimes they’re using because they’re bored or because it’s fun, and they enjoy hanging out with friends.

Snyder: A key takeaway here, too, in practice, is that sometimes individual therapy feels a lot easier for clinicians, and it’s hard to make that conceptual leap into family therapy. It just feels different because clinicians have to deal with a lot of things in the room. So maybe for the clinician that has difficulty with running family sessions, they can still have a family therapy mindset in doing individual work

Becker: Absolutely, and that’s something my team has done, layering in separate parent sessions to an adolescent one-on-one intervention, and I think sometimes that can be a helpful interim step for providers out in the community, if they’re not quite ready or comfortable with doing family therapy. Just meeting with the parent one-on-one and giving the parents some psychoeducation about how to monitor and to know how to communicate with their teen can be a very effective adjunct to an intervention.

Snyder: Really meet them where you feel most component—sage advice! Now, before moving on to more formal assessment questions, are there any other kinds of takeaways for clinicians about engagement with this population?

Becker: There’s been some cool work in the field about how we engage parents and families. I think that’s a separate set of skills. It speaks to your point that some clinicians are comfortable engaging adolescents, comfortable using motivation building approaches but really struggle to get the parent involved. Two of the most well-supported family pre-treatment engagement strategies are Structural–Strategic Systems Engagement (SSSE) and Community Reinforcement and Family Training (CRAFT).

Snyder: With assessment, you hinted at this when at the beginning of treatment, you’re just really trying to understand the level of risk, frequencies, onset of use, determining experimentation versus pervasive patterns of use frequency. It can be a lot to think about with assessment. So, screening to the rescue! One of the screeners that I’ve found helpful in practice is the CRAFFT, the screening and brief intervention tool. Does your team use that? What are your thoughts with the CRAFFT?

Becker: Yes, so the CRAFFT is excellent as an evidence-based screening tool. I believe that evidence is most strong with youth 14 to 18. Members of the team that developed the CRAFFT based at Boston Children’s Hospital actually now recommend a different screening tool, called the S2BI which I use extensively. The CRAFFT Version 1.0 used a “Yes-No” question format for the first three screening questions, like “Have you ever used alcohol? Have you ever used cannabis? Have you ever used other drugs?” Not surprisingly with adolescents, those types of yes-no questions lead to a lot of false reporting.

With teens, if you ask them a yes-no question, they are more likely to say no. To address this, CRAFFT Version 2.0, which is what is out now, uses frequency-based questions, which are shown to yield more honest and accurate responses because they normalize use. The questions ask questions like, “Over the past year, on how many days would you estimate that you have used cannabis alcohol and other drugs?” But estimating the number of days out of 365 is hard for teens to do.

The gold standard screening tool that is now recommended by the American Academy of Pediatrics was developed by members of the same team and is used very extensively in statewide rollouts in Massachusetts. The tool is called S2BI, which stands for Screening to Brief Intervention. It’s seven items, and each item asks, “Over the past year, how often have you used [a specific substance]?” and the choices are never, once or twice, monthly, or weekly. It’s a little bit easier for teens to answer. Basically, it starts with three gateway questions, which are alcohol, cannabis, and tobacco/nicotine products, because those are the ones that are shown to catch the largest number of kids, and then, if teens answer yes to any of those, you ask an additional set of questions about other high-risk drugs of use, such as prescription and synthetic drugs. If a teen screens as positive on S2BI, then they would get the CRAFFT, because the CRAFFT items are problem-based items that can help you assess the level of severity. Each letter of CRAFFT represents a type of problem with teens: riding in the car while under the influence or using friends to relax. And you go through each letter.

The new recommendation is to use the CRAFFT as a pivot point in a brief intervention, with the teen using a motivation-building approach. You would actually ask the CRAFFT and for each answer that they say yes to, you would say, “Tell me more about the last time that you drove in a car,” or “tell me about the last time that you used when you forgot what happened.” You would actually use those pivot points as part of a brief motivation-building intervention. In sum, absolutely you can still use the CRAFFT, but I would say that leading national organizations now advocate to use the S2BI, in part because the S2BI is more sensitive if you’re going to use a universal screening approach.

My biggest takeaway message for the screening of substance use is that universal approaches are the most widely recommended because clinical judgment about which teens need to be screened is imperfect. We can use broad-based universal screening because it reduces an adolescent’s sense of and resistance to being singled out. I would suggest using the S2BI and the CRAFFT Version 2.0 universally, then using those results to guide your decisions about what to do with the teen. This advice comes from my clinical research experience, in which I frequently use adolescent SBIRT.

Snyder: Oh, I love SBIRT! It’s something I’ve shared with my students, especially because as social workers, we will be in a variety of settings like pediatric primary care clinics, schools, or after-school programs. SBIRT can be done anywhere really, and it’s feasible to provide brief intervention. It can also be critical because there are difficulties with the referral to long-term treatment for a variety of problems related to provider availability and accessibility promotion challenges.

I think what’s great about the CRAFFT as a brief intervention tool is that you can really tailor it to the youth, where you can highlight if the challenge is related to social skills, is it something related to relaxation skills, or is it related to behavioral activation? Or if it’s that they’re bored, it can be a jump-off point for general motivational interviewing, or even brainstorming about alternatives. So you can really tailor the brief intervention to the client’s needs.

Becker: Yes, with the CRAFFT, it helps make good sense of why the teens use and what they get out of it. You can say, well, “It sounds like using helps you to relax, and at the same time, you’re getting into trouble. Help me to understand which of those is more important to you or how that tension is affecting you?” and you can get more detail.

Snyder: It really does help with making the link. Now, shifting gears to another assessment measure, I wanted to get a sense of an instrument that I’ve seen that your lab has used for some of its studies, the GAIN. Could you talk a little bit about what’s on the GAIN and what’s the utility of using it? I’m thinking about how that instrument could be applicable in certain settings.

Becker: There are a number of excellent validated tools out there, so people should use what makes sense for their context. That being said, the GAIN is something my team has found useful. The Global Appraisal of Individual Needs is one I’ve used for a long time, because in my first ever exposure to clinical research in 2003, the GAIN was the instrument being used across a SAMHSA national initiative. The GAIN is for both adolescents and adults, and it’s really a family of instruments. There are assessments of different lengths that you can use to assess substance use. There’s a very brief screener called the GAIN Short Screener, and there is a version called the GAIN Lite that you can use to get a handle on some of the teen’s biggest presenting concerns. Then there are versions called the GAIN Core, the GAIN Initial, and GAIN Monitoring, a 90-day follow-up version. It’s a family of comprehensive assessment tools developed by Michael Dennis and colleagues that has some really good psychometric data.

Snyder: What I like about GAIN is that it has specific substance use questions, whereas I’ve used the Strength and Difficulties Questionnaire, and substance use questions do appear on that inventory. It’s helpful to see an instrument that integrates substance use questions on it.

Becker: Yes, and there are others like that. For instance, the Teen Addiction Severity Index by Yifrah Kaimer and colleagues. There are a number of comprehensive adolescent assessment tools that are like one-stop shops.

Snyder: Thank you for all your wisdom and insight about engagement and assessment! In that, we talked about intervention with how it is a part of SBIRT, we talked about motivational enhancement family strategies as a way to guide engagement. Are there other intervention techniques or guiding principles with an intervention that you would recommend for clinicians?

Becker: Great question! To take the 10,000-foot view of the field, SBIRT tends to be an approach that’s recommended in settings where teens are present but aren’t necessarily presenting because they have a substance use concern. SBIRT is an excellent fit for school counseling centers, primary care, emergency departments, and other places where teens are being referred for either physical or mental health issues, and you want a quick assessment of whether you should also be concerned about substance use. If you are a clinician in one of these settings, you could use the S2BI or some of the tools we have discussed to get a sense of the adolescent’s level of substance use risk.

If you’re in a specialty substance use setting, you obviously wouldn’t need to do SBIRT; you could just do an assessment of the types of co-occurring problems that the adolescent might have. SBIRT is what we would call a prevention/early intervention model where you’re trying to assess as many teens as possible and then provide or refer to appropriate care those teens that need an indicated intervention because of documented substance use problems. Some teens will only need a brief motivation-building intervention while others will need referral to specialty treatment. For teens that need specialty care, that’s when we start looking at approaches like cognitive-behavioral therapy that help teens to learn skills to reduce their use and to prevent relapse, or approaches like family-based approaches, where you’re providing some sort of parenting education or support and potentially involving the teen and the parent sessions together.

Snyder: Something that I’ve seen especially in group settings or group programming is contingency management. Have you seen that being widely used?

Becker: Thank you for asking about that. Contingency management is another passion of mine! Contingency management is a highly effective intervention for reducing substance use in adults, and it has been studied less in adolescence, although in studies of it in adolescence, it looks to be highly effective. I recently did a major systematic review of the adolescent substance use literature, and it’s a little bit harder to tease apart because, for some reason, in adolescent literature, contingency management is rarely studied by itself. In the literature, you will see CBT combined with contingency management or contingency management with some family sessions. It’s harder for me to say as a standalone intervention that contingency management is highly effective for adolescents. It’s super clear that contingency management is an effective standalone intervention for adults, and it’s a little bit more difficult to tease that apart in the adolescent literature.

Contingency management is an intervention that provides patients with some sort of tangible reward or motivational incentive for meeting specific, well-defined treatment goals. There are a range of possible treatment targets. You might reward the teen for submitting negative urine screens, attending their sessions, remaining engaged in care, or other treatment goals that somehow you’re able to monitor consistently, like the teen attending school for an entire week. You can also train parents to use contingency management with their adolescents by setting goals or using a chart to track and reward the teen’s behavior.

Contingency management tends to be effective with whatever treatment goal you select, and what you will find is that whatever you target is what you will get from the youth. So, if you target attendance, you will get improvements in attendance. If you target urine screens, you’ll get reductions in negative urine screens. Contingency management has been shown to have positive spillover effects, so when you target attendance, you tend to see some reduction in the level of substance use. But, the strongest effects are typically exactly what you target, so it’s important to choose your target carefully! Unfortunately, the biggest challenge with contingency management is that it’s just not available in the community. It’s very hard for a family interested in it to find it because very few practitioners in the field do it. In a national survey, only about 10% of clinicians say that they’ve used it, and very few know what it is.

But let me again take a broad view. The principles of contingency management are monitor behavior, track it, and then reward doing that behavior very consistently. Providers can do that, or providers can teach parents to do that. Principles of contingency management are definitely attractive to use with teens.

Snyder: Thank you for sharing the principles about it and highlighting that if you target that one thing, you’re going to get that one thing. Contingency management is not the catch-all, wonder intervention that’s going to cover everything.

Becker: You have to be very mindful that you’ll get the biggest effects on the one thing you target, and you’ll get it while you’re targeting it. There’s some data suggesting it’s sustainable, but the effects will generally be strongest while treatment is active. This may help to explain why when you look at the adolescent literature, you often see contingency management paired with something like CBT; you’re using contingency management to get a quick, accelerated start to treatment. When you want the teen to be able to cut down quickly, the CBT comes in to teach the kid relapse prevention skills. Developmentally at this age, I think there’s concern if you just reward them and then pull the rewards away; it might be a little bit harder for a teen to sustain their progress.

Snyder: So, we are nearing the end of the interview. There are two things that I wanted to go over; the first is related to health equity, and the second part is around things like dissemination and implementation, seeing that you have expertise there.

With health equity and thinking about the experiences of Black and Brown youth, and about sexual and gender minority youth, are there trends that you’re seeing with those groups?

Becker: Yes, there’s a lot I would love to say about this topic. In this field, in particular, there’s a lot of very concerning disparities when you actually look at national data. White kids tend to use substances more often than kids identifying as Black or African American, or kids identifying as Hispanic or Latinx. But what you tend to see is that kids who identify as racial or ethnic minorities, particularly Black and Latinx, have more substance-related consequences than White kids. There’s a disparity issue where, if you were to just look at the number of kids with substance use problems, we should be seeing mostly White kids in treatment, and we should be seeing mostly White kids in juvenile justice facilities, but we actually see the opposite. I’ve worked in a state juvenile justice facility, and I believe the data in our state juvenile justice facility was fairly indicative of the data nationally, where 90% of kids in the juvenile justice facility were admitted because of substance related “crimes.” It’s essentially the youth equivalent of incarceration; these kids were being held in a detention center where they were because of substance use, and the kids were predominantly Black and Latinx. And yet we know that in our communities, the kids using most tend to be White kids. I think this speaks to really concerning issues with the system itself; there is structural racism, such that Black kids get diverted to punitive places where they’re less likely to get treatment and white kids get diverted to residential treatment centers or places that are more treatment focused. So that’s a huge concern.

And then, you were talking about sexual minority youth as well, I have several wonderful colleagues (Lourah Kelly and Benjamin Shephard) that study this and will try to do their work justice. My understanding is that in both adolescent and adult populations, individuals identifying as asexual or gender minority have higher rates of substance use and higher rates of substance-related consequences than those that identify as heterosexual.

Snyder: Thank you for highlighting those disparities; naming the problem is the first step in solving the problem. And then, the last formal item for me is around dissemination and implementation. So that is a big note to end on, but I have to think about rolling out evidence-based practices for adolescent substance use. I know this could be a whole book in and of itself. At its core, how do we build momentum for these types of EBPs?

Becker: The research-to-practice gap for adolescent substance use is probably the biggest gap that we could think of. The Institute of Medicine has released several reports about how big the evidence-to-practice gap is in mental health and substance use fields. And their conclusion is the gaps are much bigger than in the physical health field. The Surgeon General’s report and several other follow-up reports talk about some of the unique challenges of the substance use field. We essentially have two problems; one is that parents and teens aren’t aware that treatment even exists for substance use. There’s a real knowledge gap. I’ve been on the side of having parents discover a bong in their kids room and call asking how they can get their teen into residential treatment. They just don’t know what to do; they don’t even know that outpatient therapy or counseling is even an approach that works for teens. And then the other piece is on the supply side, where there’s very few programs that deliver treatment for adolescent substance use. There’s even fewer that deliver what I would call effective treatment for adolescent substance use. There’s a huge gap in services out in the field.

Another reality that we have to face is that a lot of mental health providers will not treat kids with adolescent substance use and will take the kids out of treatment and say, “Get your substance use under control and come back when you are ready to work on mental health.” There are all sorts of problems, and there’s not a quick answer to how to address this; we could talk about this for days! But I do think we need to be promoting substance use treatment principles and effective intervention principles much further upstream in training programs. I’m of the view that even though substance use is common among adolescents, it’s a very high-risk behavior. I would like to see effective principles of screening and brief intervention, some of the things we’ve talked about, infused into the medical school curriculum. I’d love to see it infused into Ph.D. programs for clinical psychology. I’d like to see it infused in social work programs, because really anyone who works with adolescents should be aware of and screening for substance use; it’s such a common behavior and such a high-risk behavior.

The work that I think really needs to happen is that providers of all types need to be equipped to deal with this.

Snyder: That seems feasible to train folks because it is embedded into established training programs. Integrating substance use more into existing settings would be a huge positive step in the right direction. And thank you for sharing all your wonderful insights. I’ll leave you for final thoughts before we wrap up.

Becker: I would love to close by noting that substance use in this age group is normal yet probably not as pervasive as teens think. There’s this common trend where you see teens say “I use substances because every teen in my high school uses substances.” They don’t realize that it’s normal for a lot of teens to experiment but not normal for a lot of teens to use often. Those teens that use substances most often tend to be the ones at the greatest risk. If you are a clinician out in the community, you can start off by getting a sense of how frequently a teen is using, and if the teen is using more than monthly, that’s a teen that should be on your radar as possibly having some problems related to use. In sum, if you screen for substance use, you can help close this remarkable gap in treatment for youth.

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