6 Working With Adolescents
Substance use disorders (SUDs) affect the entire family. They can interfere with a parent’s ability to be a caretaker and bond with a child, while also disrupting family health and well-being. Traditional SUD treatment focuses on the individual, despite evidence that parents and children are most effectively served through a family-centered treatment approach.
In 2019, parental alcohol or drug abuse factored into the removal of nearly 40% of all children who entered out-of-home (OOH) care. Adolescents made up 22.6%.’ Youth who enter foster care between the ages of 13 and 17 are more likely to exit the child welfare system through emancipation rather than family reunification; that number increases for older youths.2 Child welfare workers indicate a much higher prevalence of parental substance use than reported in their caseloads. This is primarily due to the variation in the national data since states and counties differ in how they use screening tools and track substance use as a factor in child welfare cases. Research shows a significant relationship between child maltreatment and adolescent delinquency, including developmental pathways to substance abuse,3 4 5 Children affected by child abuse or neglect have a 59% greater likelihood of arrest as a juvenile, a 28% greater likelihood of arrest at as an adult, and a 30% greater likelihood of committing a violent crime.•
Adolescence is a time period with specific health and developmental needs. A successful transition from childhood to adulthood can be difficult even under the best circumstances. For youth in foster care, the trauma associated with removal, combined with a lack of guidance and support tailored to this stage of development, can further complicate the transition.
Professionals often overlook adolescent needs when addressing the family system since generalized services are geared toward two populations: adults and children ages O – 18. However, it is a critical time when the potential for SUDs and/or mental health concerns emerge. Consideration of each adolescent development domain supports a tailored approach for service delivery-effectively meeting the needs of this population and their families.
Youth need nurturing support to navigate the developmental milestones of adolescence. By focusing on development, protective factors, fostering healthy relationships and resilience, providing opportunities, and enhancing youth strengths, professionals can help these young adults reach full potential. The Center for the Study of Social Policy (CSSP) publications, Youth Thrive: Promoting Youth Resilience and Youth Resilience: Protective and Promotive Factors, suggest questions to ask youth; offer steps professionals can take to foster resilience, social connections, cognitive and social-emotional development; identify concrete supports in times of need; and provide activities to assist those working directly with youth.
DEFINING ADOLESCENCE
Adolescence is the transition period from childhood to adulthood, including physical and psychological changes beginning around puberty and extending to age 25.7 While the World Health Organization (WHO) acknowledges that age is a convenient way to define adolescence, it is just one characteristic. Age is often a more appropriate method to assess and compare biological changes, which are universal, than social transitions, which can depend more on cultural environment.
The practical definition of adolescence varies widely. For example, the Department of Health and Human Services (HHS)/Office of Population Affairs (OPA) notes adolescence beginning as early as age 8.” WHO suggests this stage starts at 10,9 while the Centers for Disease Control and Prevention (CDC) lists the age as 12.10
WORKING WITH ADOLESCENTS: PRACTICE TIPS AND RESOURCE GUIDE
NCSACW defines adolescence as ages 12-18. This correlates with the Substance Abuse and Mental Health Services Administration’s (SAMHSA) definition,” the National Institute on Drug Abuse’s (NIDA) Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide,12 and SAMHSA’s Treatment Episode Data Set.13
Late adolescence or young adulthood is another critical life stage as individuals move toward independence-assuming responsibility for their own care and well-being, while also creating adult identities.14 Like adolescence, the exact definition of “young adulthood” remains imprecise. This stage includes psychosocial transitions such as gradual independence from family, as well as changes to residence, employment, education, finances, romance, and parenting status15-none of which are uniformly accomplished by a specific age. These factors also largely depend on culture.1• SAMHSA defines young adults as ages 18-25.11
Transitional age youth as defined in the U.S. Department of Education’s Foster Care Transition Toolkit includes all youth transitioning out the child welfare system. This can be as early as age 18 or as late as 23 in some states.18
States, through the John H. Chafee Foster Care Program for Successful Transition to Adulthood (the Chafee program), can provide financial, housing, employment, education, and other support services to prepare youth for the transition from foster care to living on their own. The program is available to youth who have experienced foster care at age 14 or older. The Family First Prevention Services Act (FFPSA) made amendments to the Chafee program in 2018 which permits states and Tribes to provide the program up to age 23 under certain circumstances.
THE 5 C’s OF POSITIVE YOUTH DEVELOPMENT
The adolescent years are full of potential. While it is vital to encourage teens to avoid risky behaviors, it’s also important to cultivate their positive qualities. Positive youth development views teens as having a lot to offer, while promoting the idea that adults can make a significant and positive difference in their lives by helping foster competence, confidence, connections, character, and caring.2°
ASSET DEFINITION HOW TO FOSTER IT
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•
Perception that one has • Provide services that support training and practice in abilities and skills • specific skills, either academic or hands-on
••
Internal sense of ••
self-efficacy and positive ••
self-worth •
Provide opportunities for adolescents to experience success when trying something new
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•
Positive bonds with people and institutions
•
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Help to foster and encourage relationships between
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youth and peers, teachers, parents and families of
• origin, and families of choice
•
A sense of right and wrong ••
(morality), integrity, and • respect for standards of •
Provide opportunities to practice increasing self-control and development of spirituality
correct behavior ••
••
|
A sense of sympathy and • empathy for others •
•
Care for young people
Adapted from The Teen Years Explained: A Guide to Healthy Adolescent Development by Clea McNeely, MA, DrPH and Jayne Blanchard
No single individual or agency can provide all the assistance young people need to thrive. It’s crucial that communities come together to support adolescents with complex needs. Special adolescent populations include minority youth; children of parents with SUDs or other substance use issues; transitional aged youth; pregnant and parenting teens; youth with mental health needs and high Adverse Childhood Experiences (ACEs) scores; youth involved with both child welfare and juvenile justice (also known as crossover youth); young people in recovery; and Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) youth.
Child welfare agencies should seek opportunities to work with substance use treatment providers, educators, mental health professionals, juvenile justice professionals, court staff, and others serving youth in foster care.21 This helps ensure an adolescent-focused framework that supports the complex needs of all involved. The Interagency Working Group on Youth Programs (Working Group) has developed a strategic plan, Pathways for Youth: Draft Strategic Plan for Federal Collaboration, as a first step. The plan helps partners address their common goals for youth; elevate strong models of youth programs, policies, and other supports; and articulate areas for future collaborative work with and for youth.
ADOLESCENT POPULATIONS
Many adolescent subpopulations, with either a personal or family history of using substances, present with different needs—especially youth with history in the child welfare system and transitional aged youth. Serving adolescents effectively means understanding potential youth at risk, youth currently misusing and abusing substances, and those in recovery. Staff can identify this subpopulation along the SUD continuum of prevention, intervention and treatment, and recovery supports.
•Youth of parents with SUDs
• High ACEs scores
• Mental health concerns
• Pregnant and parenting
• Minority youth
• LGBTQ youth
• Crossover youth
• Transitional age youth
• Foster age youth
• Youth diagnosed with SUD
• Young people in recovery
• Recovery supports
Youth with a history of family dysfunction, especially in the above groups, may be estranged from their family of origin (birth families) resulting in the creation of a “family of choice.” Families of choice are people selected by an individual to support their personal journey for recovery; they’re not limited to biological or legal definitions. Professionals should explore the definition of family for each youth and incorporate their chosen family as an opportunity for engagement.
Families are the most critical setting for child development. Risk factors such as poverty, single parenthood, dysfunction, abuse or trauma, parental mental illness, parental substance use, and family discord or illness negatively affect both the family unit and a child’s life outcome in general.22 Adverse experiences (e.g., parental substance use, domestic violence, poverty), which often push youth into the at risk category, influence childhood maltreatment and trauma—linked to physical, psychological, and behavioral consequences later in life.23
“Youth at risk” is a general term for a range of circumstances that place young people at greater vulnerability for problem behaviors such as substance abuse, school failure, juvenile delinquency, and mental health disorders.24 Individual factors include development of an SUD; high Adverse Childhood Experiences (ACEs) scores; mental health concerns; and youth who experiment with substances placing them at risk for developing an SUD (especially in the presence of other risk factors). Minority and LGBTQ youth populations may also be at a greater risk.
Crossover youth, transitional age youth, youth diagnosed with an SUD, and foster age youth are special populations that may require more services.
ADOLESCENT DEVELOPMENT IS NOT “ONE SIZE FITS ALL”
Adolescence is the transition period from childhood to adulthood. It includes physical and brain changes that may begin as early as age 8 and extend until age 25.25 The brain’s frontal lobes—especially the prefrontal cortex, which governs reasoning, decision-making, judgment, and impulse control—are the last parts to reach full development.26 This would explain typical teenage behaviors such as volatile emotions, risk-taking and boundary-testing, exploration and assertion of personal identity, navigation of peer relationships, and transition to independence.
“Plasticity” is the brain’s ability to change and adapt as a result of experiences which becomes stronger and more efficient throughout adolescence. The adaptive plasticity of adolescence marks this period of development as a window of opportunity for change through whichever mechanisms of resilience, recovery, and development are possible.27, 28
The timing of physical and cognitive changes varies throughout adolescence. Early adolescence differs greatly from later adolescence, which in turn looks much different than young adulthood. Professionals can maximize this opportunity for positive change by starting with developmentally appropriate support at the onset of puberty, rather than waiting until concerns begin to emerge later in adolescence.
Child welfare agencies should consider developmental science when making decisions about transitional aged youth and the tasks associated with transitioning to adulthood. An earlier start for these important services can ensure teens have the necessary resources, relationships, and opportunities to thrive. Considering the family histories of many of these youth, transitional and independent living services should include educational information on the effects of substance use on families. The Screening, Brief Intervention, and Referral to Treatment (SBIRT) is appropriate for youth who may be using substances and/or formally diagnosed with an SUD.
PARENTS/CAREGIVERS CONTINUE TO PLAY A KEY ROLE IN ADOLESCENT DEVELOPMENT
Youth develop in the context of relationships, and our actions in that relationship affect how their brains get rewired throughout development.29 The parent-child relationship helps teach kids and teens how to handle and respond to other relationships. Difficulties with attachment can stem from early experiences of abrupt or repeated separation from a parent/caregiver, or frequent changes in caregivers early in life (e.g., incarceration, SUD, frequent inpatient treatment episodes or hospitalizations, deployments, foster care, adoption, and/or deportation). Difficulties with attachment can last for years and continue to affect adolescents and young adults.30 Without identification and intervention, these difficulties can trigger a heightened lifelong risk for developing mental illnesses and SUDs, along with behavioral, social, and academic problems.31
Explore youths’ motivation to change. Fear of change and/or failure is too often mistaken as lack of motivation. Labels can contribute to this in the form of learned helplessness. It’s often necessary for professionals to hold these youths’ hands at first and to “check in” to ensure the youths feel safe.32
Parental education and family engagement remain the centerpiece of service components in a child welfare case plan for adolescents and young adults. For some at risk youth, parent education and family engagement can include individuals the youth views as family (such as extended family members and adult mentors, rather than traditional family relationships). Connections to siblings can serve as a protective factor; children who have positive relationships with siblings are less likely to exhibit internalizing behaviors (i.e., anxiety or depression, often directed inward or “kept inside”) after experiencing a traumatic event.33
If LGBTQ youth experience family rejection, child welfare agencies can collaborate with LGBTQ-affirming community service providers to address rejecting behaviors, while helping families and youth in foster care work toward reunification.
Cultural diversity can influence understanding of and reception to supportive services and family engagement. Immigrant and culturally diverse families often come to an understanding of their child’s needs while simultaneously interacting with an unfamiliar health care system and its practitioners. Supporting the family’s culture and traditions may also contribute to the parents’ engagement with interventions and services. With permission, working with cultural, community or religious organizations can be a source of support and collaboration.
ADOLESCENTS ARE BIOLOGICALLY MORE VULNERABLE TO THE NEGATIVE EFFECTS OF SUBSTANCE USE
Adolescence generally means increased exposure to peer pressure, risky behaviors, and substances with abuse potential. Substance use in teens can affect healthy brain development and long-term functioning associated with memory, attention, impulse control, and the ability to experience reward. It can also delay executive functioning such as judgment and meeting goals, while contributing to difficulties with emotion regulation, and increasing the probability of substance dependence and addiction later in life.34 Many youth in foster care come from families with histories of SUDs, placing the adolescent at risk as well. For adolescents involved in child welfare, disrupted brain development, as a result of maltreatment, can cause impairments to the brain’s executive functions: working memory, self-control, and cognitive flexibility (i.e., the ability to look at things and situations from different perspectives)—all contributing to a heightened vulnerability for youth at risk from the effects of substance use.35 It is important to understand the propensity of developing an SUD.
Substances, at first, may alleviate emotional pain for adolescents dealing with trauma, mental illness, family dysfunction, grief, and many other common experiences for those with either a history in child welfare, or labeled “at risk”. Youth at risk may experiment with substances and/or misuse prescribed or over- the-counter substances without carrying the clinical diagnosis of an SUD. For teenagers struggling with substance use and traumatic stress, the negative effects and consequences of one disorder compound the problems of the other. There is a strong connection between traumatic stress and substance use that has implications for children and families, whether the user is an adolescent or a parent.36
Child welfare, court, and SUD treatment professionals should establish joint policies and procedures for sharing information regarding assessment results to ensure a seamless transition to treatment services. The point at which family members are referred from one system to another (such as from child welfare to SUD treatment) is critical in setitng the stage for whether they engage and remain in services.
Some people have a genetic predisposition for developing mental disorders and SUDs; they may be at greater risk based on factors such as growing up in a home affected by a family member’s mental health or history of substance use.37, 38 Providing adolescents with insight on their family dynamics, family health history, and predisposition for diseases— including mental health diagnoses and SUDs—is an important component of prevention and individualized treatment planning.
Family-based approaches to treatment highlight the need to engage the family. For some at risk youth, family-centered treatment includes those the child views as family—such as extended family members, older siblings, and adult mentors—rather than traditional family relationships. Professionals should work to preserve connections and continuity by engaging parents, other connected relatives, and fictive kin with whom they have existing relationships. This can ensure frequent and meaningful family time experiences for children and their parents, as well as siblings placed separately.39
UNTREATED MENTAL HEALTH CONCERNS MAY PLACE YOUTH AT RISK
Half of all mental health problems begin by the age of 14.40 When left untreated, adolescent mental health conditions can lead to serious, even life-threatening consequences which extend to adulthood, impairing both physical and mental health, while limiting opportunities to lead fulfilling lives. Mental illness follows no single pattern. Some adolescents suffer a one-time, prolonged episode, while others experience problems episodically. Early intervention and treatment for these issues can help decrease the negative effects.
SUDs and mental health problems frequently co-occur, with national surveys showing that approximately half of all individuals experiencing one will also experience the other (NIDA, 2020).41 Symptoms of an SUD can be similar to those of a mental health disorder, and vice versa (Child Mind Institute & Center on Addiction, 2019).21, 42 Additionally, the disorders may have developed at the same time, or one disorder may have contributed to the other. For example, a youth may self-medicate to reduce overwhelming feelings of anxiety—or facilitate their avoidance of intense emotions—following a traumatic experience and/or episodes of post-traumatic stress disorder (PTSD). Since selecting the proper treatment depends on a correct diagnosis, referring youth who exhibit symptoms is critical.”
Any concerns that professionals, child welfare workers, and family members have about an adolescent’s mental health need prompt attention. Consulting a healthcare provider or mental health professional is vital. Take any comments about suicide or wishing to die seriously, especially those coming from children and teens.
Strong cultural identity is tied to lower rates of depression, anxiety, isolation, and other mental health challenges and contributes to mental health resilience, higher levels of social well-being, and improved coping skills, among other benefits.44 Assist youth in the exploration of their cultural identity by asking about practices and norms that are important to them and supporting access to cultural activities and community members. Think about cultural identity as a piece of well-being like housing, education, and safety when thinking about unmet needs and systemic change.44
- SAMHSA’s TIP 59: Improving Cultural Competence helps professional care providers and administrators understand the role of culture in the delivery of mental health and substance use services. It describes cultural competence and discusses racial, ethnic, and cultural considerations.
- The Office of Minority Health offers free and accredited e-learning programs to improve cultural competency along with information on The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards), framework and toolkit to guide organizations’ efforts in evaluating their implementation of the CLAS standards.
- The National Center for Cultural Competence at Georgetown University offers resources, self-assessments and learning opportunities to increase the capacity of health care and mental health care programs to design, implement, and evaluate culturally and linguistically competent service delivery systems to address growing diversity, persistent disparities, and to promote health and mental health equity.
THE CO-OCCURRENCE OF TRAUMA EXISTS IN ADOLESCENTS TOO
Trauma exposure is pervasive among children and adolescents. Epidemiological data indicate that nearly two-thirds of U.S. children will experience a traumatic event before their 18th birthday” When children face abuse and neglect, their brain develops behaviors to survive the high stress and remain alert; eventually, those behaviors alter the brain.45 Even with healthy development, changes in brain chemistry and structure during adolescence create behaviors that might feel unfamiliar or challenging. But teens with prior trauma must adjust to those typical changes in addition to coping with the developmental effects of past experiences. Long after a child establishes safety and coping mechanisms to survive, the traumatic experiences remain, and can contribute to difficulties in development, interactions, and behavioral traumatic adaptations”
Adolescents with a history of trauma typically continue to face ongoing rejection, abandonment, and violence. This makes it increasingly more difficult for them to cope, gain stability, and establish meaningful connections since unresolved trauma can trigger mental illness, substance use, and other risk-taking behaviors. Family responses to LGBTQ youth who express gender and sexual identity may vary. Although some families may show support and acceptance, others could respond in a way that might traumatize youth.47
Professionals working with individuals and families that include adolescents should re-examine practice and policies to ensure that youth receive no further trauma through their involvement in services and systems. Ideally, teens can find a path to recovery and family wellness through individualized support that differs from generalized services for children.
Professionals should approach adolescents with a commitment to providing services that are welcoming, compassionate, and genuine, while seeking to understand how youth experience engagement in social services systems. Understanding and empathy can better support youth who are struggling and displaying difficult, disrespectful, and defiant behaviors. Understanding the Links Between Adolescent Trauma and Substance Abuse, A Toolkit for Providers offers primers for substance abuse and mental health providers as well as information on treatment recommendations.
When working with an adolescent with trauma, providers need a solid background in trauma informed care. SAMHSA’s Concept of Trauma and Guidance for a Trauma Informed Approach provides a framework for becoming a trauma informed organization, system, or service sector.
Expect teens to test you. Adolescents naturally desire independence. Sometimes this transition from childhood to adulthood manifests as rebellious and disrespectful behavior, leading to great conflict with parents or other supports in their life.32,46
For high risk youth and/or youth involved in child welfare, given their life experiences, they have the right to be skeptical and suspicious. They won’t easily risk being hurt again and want to know whether the social worker will abandon them or follow through. Professionals must avoid reinforcing those beliefs and the idea that adults can’t be trusted.32
HEALTHY SEXUAL DEVELOPMENT INVOLVES MORE THAN SEXUAL BEHAVIOR
Healthy sexual development is not simply a matter of having sex; it also involves a young person’s ability to manage intimate and reproductive behavior responsibly—without guilt, fear, or shame.48 It’s the combination of physical sexual maturation known as puberty, age-appropriate sexual behaviors, the formation of a positive sexual identity, and a sense of sexual well-being.49 Expressions of sexual behavior and identity differ among youth. This may be especially challenging for LGBTQ teens. Perhaps feeling worlds apart from their heterosexual peers, family, or members of their community, they need support throughout adolescence more than ever. In addition, sexual and other stages of development may be different for sexual minority teens.
According to a study from the Child Welfare League of America, “rejection from families of origin, foster families, caseworkers, and others places LGBTQ youth at a greater risk for negative life outcomes, including increased chances of physical and mental health challenges, lower self-esteem, illegal drug use, HIV and STDs, and depression and suicide.”50 The 2018 National Survey on Drug Use and Health (NSDUH) suggests that substance use patterns reported by sexual minority adults (individuals who describe themselves as lesbian, gay, or bisexual) are higher compared to those reported by heterosexual adults. LGBTQ individuals often enter treatment with more severe SUDs.51
Sexual minorities with SUDs are more likely to have additional mental health disorders.52 For example, gay and bisexual men, as well as lesbian and bisexual women, report greater odds of frequent mental distress and depression than their heterosexual counterparts.53 Transgender children and adolescents have higher levels of depression, suicidality, self-harm, and eating disorders than their non-transgender counterparts. Nearly one-third of LGBTQ youth had attempted suicide at least once in the prior year compared to 6% of heterosexual youth.54
Supportive services should include access to confidential, culturally sensitive, and nonjudgmental counseling and healthcare providers familiar with the full spectrum of sexual behaviors and gender identities. The American Psychological Association’s pamphlet Answers to Your Questions for a Better Understanding of Sexual Orientation and Homosexuality is designed to provide accurate information for those who want to better understand sexual orientation and the impact of prejudice and discrimination on those who identify as lesbian, gay, or bisexual.
Developing trust is key to serving the adolescent population. Explain to them what is and is not confidential information. Providing the parameters at the start, and discussing together how to relay certain information to parents, will help to establish trust. Practitioners must stay informed on confidentiality issues. Confidential Care forAdolescents in the U.S. Health Care System provides information on federal and state protections and challenges for providers.
Some LGBTQ youth are more likely than their heterosexual peers to experience negative health and life outcomes. It is critical for service providers, supports, and family members of LGBTQ youth to have access to the resources they need to ensure LGBTQ youth receive support. Organizations can collaborate across systems (mental health, substance use treatment, homeless services, juvenile justice, courts, etc.) to ensure LGBTQ youth receive support through a coordinated system of care. Professionals can support transgender and gender non-conforming youth by asking about and using correct names and pronouns, protecting the right to express gender identity, providing access to needed mental and medical health services, and ensuring youth can safely access sex-segregated spaces (such as congregated care facilities and bathrooms).
- SAMHSA’s guide, A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children, offers resources to help practitioners in health and social service systems implement best practices to engage and help families and caregivers support their LGBT children.
- Advocates for Youth’s toolkit, Creating Safer Spaces, highlights challenges faced by LGBTQ youth, offers insight on how they thrive, and enhances awareness among healthcare staff, educators, and additional youth-serving professionals about the existing disparities in order to provide safer spaces.
- The Family Acceptance Project® offers training and resources on an evidence-based family model of wellness, prevention, and care to strengthen families, while promoting positive development and healthy futures for LGBTQ children and youth.
ADDRESSING DISPARITIES
Structural barriers to successful development such as poverty, unequal allocation of resources, racism, bias, and discrimination can create inequities that amplify the risks of negative outcomes for youth.55
Professionals must show awareness and sensitivity to cultural diversity, life situations, and other factors that shape a person’s identity.
There’s a need to recognize how barriers disproportionately hurt marginalized communities; thus, professionals must also promote the delivery of affordable, accessible, integrated, and coordinated adolescent services. Reducing disparities to achieve equity of services for all adolescents requires long-term, coordinated, interdisciplinary, and intersectional strategy, with adequate resources to study, implement, evaluate, and sustain the strategy.56
- The National Academies of Science, Engineering, and Medicine (NASEM)’s 2019 report, The Promise ofAdolescence: Realizing Opportunity for All Youth, explains some of the most serious disparities in outcomes for adolescents, as well as the sources of these outcomes (e.g., wealth and resource inequality, differences in the way institutions respond to adolescents from different backgrounds, prejudicial or discriminatory atittudes or behavior by adults or peers who interact with adolescents).
- Primer on How and What We Teach Youth about Racism and Xenophobia, developed by Dr. Deborah Rivas-Drake and Bernardette Pinetta at the University of Michigan, offers resources focused on how to teach anti-racism to young people. This document includes links to helpful articles, research papers, webinars, podcasts, and organizations, as well as a wide-ranging list of books on social justice for children, adolescents, and adults.
- The Center for the Developing Adolescent’s brief, How Developmental Science Can Help Us Address Inequities During Adolescence, highlights some of the key features of adolescent development to consider in any reimagining of the systems, policies, and programs serving young adults to help ensure equitable treatment and outcomes for all involved.
RESOURCES FOR PREVENTION
Positive Youth Development (PYO} 101 Online Courses is a series of short, interactive courses intended to introduce PYD to professionals, volunteers, and advocates. The series can be used independently or to supplement the training curriculum listed above.
The Think, Act, Grow (TAG} Playbook provides action steps for improving adolescent health outcomes and a game plan for engaging adolescents in promoting their health and healthy development.
Preventing Drug Use among Children and Adolescents identifies 16 key principles for prevention programs based on risk and protective factors, the type of program, and the delivery method. These principles, from the National Institute on Drug Abuse (NIDA), can help parents, educators, and community leaders think about, plan for, and deliver research-based prevention programs at the community level. The references following each principle are representative of current research.
Reframing Adolescent Substance Use and its Prevention: A Communications Playbook is a step-by-step guide to using evidence-based framing strategies to communicate about adolescent substance use.
Substance Misuse Prevention for Young Adults supports health care providers, systems, and communities seeking to prevent substance misuse among young adults. It describes relevant research findings, examines emerging and best practices, identifies knowledge gaps and implementation challenges, and offers useful resources.
Preventing, Identifying, and Treating Substance Use Among Youth in Foster Care provides child welfare professionals with information about the extent and effects of substance use among youth in foster care, ways to identify substance use, how to support youth in care who currently use or are at high risk for using, and strategies for prevention. It also addresses how to collaborate with professionals in other fields.
SPECIALIZED PROGRAMS FOR YOUTH AT RISK:
Across Ages is a mentoring initiative designed to increase the resiliency and protective factors of at risk middle school youths through a comprehensive intergenerational approach. The overall goal is substance use prevention. keepin’ it REAL (kiR) Middle School Program is a 10-week classroom-based universal substance use prevention program for youth ages 10-13. kiR is designed to reduce the risks of alcohol, tobacco, and other risky drug use as well as promote social and emotional competencies such as drug refusal efficacy. The weekly lessons are 45 minutes each using a “from kids, through kids, to kids” approach, kiR increases students’ confident communication skills, decision-making skill, resistance skill efficacy, emotional intelligence (e.g., empathy, perspective taking, self-control), and awareness of social support. Program examples, role-plays, and videos feature personal experiences of early adolescents. To help reinforce the messages from the 10 weekly lessons, there are 3 optional lessons on “how to make your own refuse, explain, avoid, and leave (kiR) videos.” Multicultural program videos address e-cig use, vaping, and use of prescription medication. There are three culturally grounded versions: Multicultural, Rural, and Spanish.
WORKING WITH ADOLESCENTS: PRACTICE TIPS AND RESOURCE GUIDE
The Importance of a Trauma-Informed Child Welfare System outlines the essential components and features examples from state and local programs that incorporate trauma-informed practice. After providing a brief overview of trauma and its effects, the brief explores trauma-informed practice and the importance of strengthening families and communities to help them heal. The brief also highlights the ability of cross-systems collaboration to create a trauma-informed child welfare system that improves child and family well-being.
Understanding the Links Between Adolescent Trauma and Substance Abuse: A Toolkit for Providers focuses on the needs of youth with traumatic stress and substance abuse problems, while promoting evidence-based practices in clinical settings. This serves as a training guide for providers working with this population.
Youth Thrive: A Framework to Help Adolescents Overcome Trauma and Thrive examines how focusing on thriving complements the field’s growing move to become trauma-informed. Previous efforts to identify protective factors targeted the developmental needs of children up to age 6, aiming to help parents promote healthy development (Horton, 2003). Youth Thrive posits a research-informed framework for building protective and promotive factors for adolescents and young adults, ages 9-26, particularly the most vulnerable (Harper Browne, 2014).
Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents provides information on promoting healthy sexual development and sexuality.
YOUTH USING AND MISUSING: INTERVENTION AND TREATMENT
Navigating the treatment process can be overwhelming for anyone-especially an adolescent. To best serve them, a basic understanding of the treatment process helps relieve fears and anxiety. There are five steps to SUD treatment: 1) screening, 2) comprehensive assessment, 3) stabilization, 4) treatment, and 5) continuing care and recovery support.57
SBIRT is a comprehensive, integrated, public health approach to the delivery of an early intervention strategy focusing on substance use and motivation toward behavioral change for individuals with, or at the risk of developing, an SUD.58
- Improving Adolescent Health: Facilitating Change for Excellence in Youth Screening, Brief Intervention and Referral to Treatment {SB/RT) is a change package, or a practical guide, specific enough for clinicians to implement, test, and measure progress on an evidence-based set of changes, while general enough to use in multiple settings. Change packages are proven tools to promote practice transformation in primary care.
- Using SBIRTto Talk to Adolescents about Substance Use: A Four-Part Series introduces professionals to the SBIRT model as a way to learn from adolescents about their substance use, discuss what might motivate them to reduce or abstain (if needed), and execute a plan to do so.
Following the screening and assessment process for SUDs, an individualized treatment recommendation is made to place the adolescent in the proper level of care and develop their treatment plan. The American Society of Addiction Medicine’s (ASAM) Treatment Criteria for Addictive, Substance Related, and Co-Occurring Conditions is the most widely used and comprehensive set of guidelines for placement in a treatment setting. The ASAM Criteria is composed of six dimensions to assess an individual holistically, taking into account their biological, social, and psychological aspects:
DIMENSION 1 ••
••
|
DIMENSION 2 •
•
ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL: assessing an individual’s past and current experiences of substance use and withdrawal
BIOMEDICAL CONDITIONS AND COMPLICATIONS: assessing an individual’s health history and current physical condition
DIMENSION 3
•• EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS: assessing an
• individual’s thoughts, emotions, and mental health.
•
DIMENSION 4 •
••
READINESS TO CHANGE: assessing an individual’s interest and readiness for change
DIMENSION 5
DIMENSION 6
• RELAPSE, CONTINUES USE, OR CONTINUED PROBLEM POTENTIAL: assessing an individual’s
•• relationship with relapse, continued use, or problems with use.
•• RECOVERY/LIVING ENVIRONMENT: assess an individual’s recovery and living situation including
•• people, places, and things.
PG 10
UNDERSTANDING QUALITY TREATMENT
Understanding the treatment resources provided in your community is critical to developing comprehensive case or service plans for adolescents. As a referring practitioner, it’s essential to know the signs of quality treatment. SAMHSA provides an overview of the Five Signs of Quality Treatment, including accreditation, medication, evidence-based practices, families, and supports.
Child welfare, healthcare, and other community agencies and professionals who refer to treatment should know the quality SUD treatment available in their areas. Professionals can use the discussion questions in NCSACW’s Understanding Substance Use Disorder Treatment: A Resource Guide for Professionals Referring to Treatment to help frame conversations with SUD treatment agencies and begin to establish collaborative relationships.
Child welfare professionals can share information about policies, protocols, and practices with treatment agencies. Collaboration benefits parents, children, adolescents, and families. Building collaborative relationships with treatment agencies takes time but often results in better referrals to more effective services and ultimately better outcomes for families.
In addition to looking for quality SUD treatment agencies, professionals might also search for youth-friendly clinical services to help engage adolescents in SUD treatment. Read Teen Network’s Tip Sheet, Characteristics of Youth-Friendly Clinical Services, for more details.
RESOURCES FOR INTERVENTION AND TREATMENT
Principles ofAdolescent Substance Use Disorder Treatment: A Research-Based Guide provides scientifically tested, evidence-based approaches to the treatment of adolescent substance abuse.
SAMHSA’s TIP 31: Screening and Assessing Adolescents for Substance Use Disorders provides guidelines for screening and assessing teens for substance use issues.
NIDA has launched two brief Screening Tools for Adolescent Substance Use online that providers can use to assess SUD risks among adolescents aged 12-17. With the American Academy of Pediatrics (AAP) recommending universal screening in pediatric primary care setint gs, these tools help providers quickly and easily introduce brief, evidence-based screenings into their clinical practices.
AAP’s Motivational Interviewing Strategies to Facilitate Adolescent Behavior Change provides detailed strategies for increasing receptivity and decreasing resistance, guidance for behavior change plans, and worksheets for a motivational approach to counseling adolescents about health behavior change.
Recovery oriented care and support systems help people with SUDs and mental disorders successfully manage their conditions
long-term. Recovery is a process of change through which people improve their health and wellness while striving to reach their full potential. There are four major dimensions of recovery:
HEALTH—overcoming or managing one’s disease(s) or symptoms, and making informed, healthy choices that support physical and emotional well-being
HOME—having a stable and safe place to live
PURPOSE—conducting meaningful daily activities and having the independence, income, and resources to participate in society
COMMUNITY—having relationships and social networks that provide support, friendship, love, and hope 59
To reinforce gains made in treatment and improve their general quality of life, recovering adolescents may benefit from recovery support services, which include continuing care, mutual help groups (such as 12-step programs) and peer recovery support services. Such programs provide a community setitng where fellow recovering youth can share their experiences, provide mutual support, and promote a substance-free lifestyle.59
Twelve-step groups are guided by a set of fundamental principles including: 1) Willpower alone cannot achieve sustained sobriety, 2) Surrendering to the group conscience must replace self-centeredness, and 3) Long-term recovery involves a process of spiritual renewal.59
Some youth may have difficulty connecting with 12-step groups due to their religious undertones. If so, several alternatives provide secular relapse prevention tools such as Women For Sobriety, Self-Management and Recovery Training (SMART), Secular Organizations for Sobriety (SOS), LifeRing Secular Recovery, and Moderation Management.60
Peer recovery support services, such as recovery community centers, help individuals remain engaged in treatment (and/or the recovery process) by matching them with peer leaders who have direct experience with addiction and recovery. This can take place one-on-one or in groups. Depending on the needs of the adolescent, peer leaders may provide mentorship, coaching, and connect individuals to treatment, 12-step groups, or other resources. Peer leaders may also facilitate or lead community-building activities, helping recovering adolescents build alternative social networks and find drug- and alcohol-free social options.59
Research indicates that most individuals with an SUD need at least three months in treatment to significantly reduce or stop their drug use—and the best outcomes occur with longer durations.61 Recovery frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses can occur and should signal a need for treatment to be reinstated or adjusted.
Professionals working with youth in substance use and mental health recovery should view treatment completion as the beginning of a long-term process, and include strategies to engage them in both short- and long-term recovery supports specific to their needs.
RESOURCES FOR YOUTH IN RECOVERY
The Research and Training Center for Pathways to Positive Futures’ publication, Implementing the Peer Support Specialist Role for Youth, provides an example of how one locally initiated program has implemented the peer support specialist role for youth and young adults. The brief covers aspects of training, coaching, supervision, role definition, and financing—while describing challenges and solutions.
NCSACW’s The Use of Peers and Recovery Specialists in Child Welfare Settings examines how child welfare agencies and family court programs have integrated peers and recovery specialists into their service delivery to support families affected by SUDs. Also included is an overview of two models of support for families: peer support by persons who have experienced SUDs and child welfare involvement, and professional support from recovery specialists. The brief also offers advice to professionals applying peer or recovery specialist models in their communities.
Youth MOVE National offers resources on youth peer support, best practices, assessing youth voice, publications, and TA tools. There’s also a directory of over 60 chapters across the U.S. focusing on youth needs and community trends.
The National Technical Assistance Network for Children’s Behavioral Health (TA Network)’s publication, Providing Youth and Young Adult Peer Support Through Medicaid, offers guidance, key considerations, and examples of young adult peer support programs.
For additional resources on recovery supports tools and resources for young adults, visit Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS).
The Northwest Mental Health Technology Transfer Center Network’s (MHTTC) webinar, Supporting the Youth Peer Support Role Within Your Organization, provides an overview of the responsibilities and boundaries of the youth peer support role, while offering tips on how to support this role (and these employees) in your agency.
To best serve the adolescent population it is critical to pay close attention to youth engagement. Young people in foster care may miss out on opportunities for decision-making, community engagement, and leadership—sparking a sense of powerlessness and isolation.62 Encourage adolescents and families to become stakeholders in their lives. Adolescents will typically engage when youth and adults teach, contribute, and learn from each other. Including adolescents in their own life decisions fosters their development and progress toward autonomy.
Engagement helps youth gain skills like knowledge, self-esteem, and feelings of connectedness.63 Engagement occurs when young people take responsible actions to create positive change; it also has the potential to create change within their community.
Organizations focusing on youth engagement can improve their programs through feedback, gain community recognition, and attract potential funders.
PROGRAMS AND INTERVENTIONS FOR YOUTH IN RECOVERY
SMART Recovery TEENS is a free self-help program that offers a place where teens can get together to try to look
into and change behaviors that hurt themselves and others like smoking, drinking, fighting and using drugs.
SMART Recovery’s Young Adult Outreach Program offers
SMART Meeting Facilitators onsite group training or a convenient self-study online training option for adults dealing with addiction in an educational or support seittng such as a high school university, or recovery community organization.
Narcotics Anonymous (NA)- TEEN LINE provides a directory of local supports, training and outreach programs, access to a teen message board and teen talk cell phone application and toll-free phone and text line as well as educational resources specific to teens.
Seeking Safety (adolescent version) is a present-focused, coping skills therapy to help people attain safety from trauma and/or substance abuse. The treatment is available as a book, providing both client handouts and clinician guidelines. The treatment may be conducted in group or individual format for adolescents (both females, and males) in various seitnt gs (e.g., outpatient, inpatient, residential, home care, and schools). Seeking Safety consists of 25 topics that can be conducted in any order and number.
Teen Anon is a behavioral and spiritual program for teens 12-19 based on the 12-steps adapted from Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Al-Anon, Alateen and Nar-Anon.
LiveWell Teens offers free online support groups led by trained facilitators and educators to help teens better monitor and manage their moods, increase well-being, and reduce symptoms of mental illness.
Adolescent Community Reinforcement Approach (A-CRA) is a behavioral intervention that seeks to increase the family, social, and educational/vocational reinforcers of an adolescent to support recovery from substance abuse and dependence. The manual outlines an outpatient program that targets youth 12-25 years old with Diagnostic and Statistical Manual of Mental Disorders (DSM-5) cannabis, alcohol, and/or other substance use disorders. A-CRA also has been implemented in intensive outpatient and residential treatment seitnt gs.
MyClients+ includes Creative Teen Therapy Activities to help engage teens and build rapport.
Professionals who engage young people, and especially their caregivers, from diverse backgrounds, must learn the cultural values and expectations that guide social interaction, mental health and substance abuse treatment, and salient themes in their communities.
It essential to build a rapport with adolescents while setitng parameters and boundaries. Get to know your clients and talk about what’s important to them—all while providing a safe space. Authentic relationship building creates a positive environment to motivate change.
Be patient and allow trust to evolve naturally. High risk youths may not know how to develop healthy relationships, so this will take time. Many youths expect to fail and feel unworthy of help. Some may not develop the capacity to trust while they’re involved with child welfare, so getitng to the point where they know their supports won’t harm them is significant and allows for progress.32
Adolescents commonly resist support at the beginning of treatment. High risk youth have felt adults giving up on them, so they won’t expect the relationship with new providers to be different.32 Adolescents involved in child welfare have heightened resistance due to frequently changing supports; they also may distrust service providers due to family and parental separations. Motivational interviewing is an effective strategy to encourage change, identify how current behavior may be interfering with long term goals, and address any resistance—all while working together.
Allow the adolescent to take the lead in identifying whom they view as family—such as extended family members, older siblings and adult mentors—rather than traditional family relationships. Remain aware of family of choice for transitional age youth and LGBTQ youth as they may be estranged from their birth families (families of origin). Many young adults in treatment for a SUD do not have the option of having their family of origin (biological members) participate in their treatment. Providers are encouraged to include family services to client’s family of choice, as they are the “family” supporting the client in their recovery journey.
RESOURCES FOR ENGAGEMENT
Engaging, Empowering, and Utilizing Family and Youth Voice in All Aspects of the Child shows how family and youth voices are critical to a well-functioning child welfare system. It strongly encourages all public child welfare agencies, dependency courts, and Court Improvement Programs to ensure that these voices play a major role in child welfare program planning and improvement efforts.
Walking the Talk: A Toolkit for Engaging Youth in Mental Health provides an understanding of how youth engagement can directly benefit youth services and communities. It includes activities designed to engage youth such as team building, facilitation, hosting techniques, planning and evaluation. The toolkit also provides success stories.
Strategies for Authentic Integration of Family and Youth Voice in Child Welfare outlines key tasks in engaging families and youth at the system and agency levels, while offering child welfare managers tips, strategies, and stories from the field. Managers can use this tip sheet when engaging youth and families, considering policy to support engagement, or training staff. The tip sheet includes a matrix tool that focuses on the impact of the engagement along a continuum, from ineffective to effective.
Recruitment Strategies and Practices for Disconnected Youth explores emerging findings from a two-year study of the Urban Employment Demonstration Grants for Youth and Young Adults, funded by the U.S. Department of Labor (DOL), Chief Evaluation Office (CEO). In 2015 DOL’s Employment and Training Administration (ETA) awarded seven cities with two-year grants to develop projects addressing the workforce needs of disconnected youth and young adults (ages 16-29). The grants focused on communities experiencing high unemployment, crime, and poverty rates, along with low rates of high school graduation.
The Center for Nonprofits at the University of Wisconsin-Madison explores how Assets Coming Together (ACT) for Youth communities responded to the challenges of youth engagement. Staff presented lessons learned, identified strategies and outcomes at the community level in Strengthening Communities Through Youth Participation, and offered guidance on the Youth Participatory Evaluation (YPE) through which young people evaluated the programs, organizations, and systems designed to serve them.
Youth.gov offers the Youth Involvement and Engagement Assessment Tool as part of a continuous quality improvement. Organizations and community-based partnerships complete the assessment every six months.
Child Welfare Information Gateway (CWIG) developed the Family Engagement Inventory (FEI), a cross-disciplinary collection of information that can help professionals understand the differences and commonalities regarding family engagement, while improving collaboration and outcomes for families across child welfare, juvenile justice, behavioral health, education, and early childhood education.
LEARN MORE
- NCSACW has many TA resources including publications, webinars, and tools that child welfare workers, court professionals, and communities can use to better serve families affected by SUDs. These are available at: https://ncsacw.samhsa.gov.
- In crisis or life-threatening situations, call 911, contact the National Suicide Prevention Lifeline (a 24-hour toll-free hotline at 1-800-273-8255 (TALK)) or go to your nearest hospital emergency room. For more details and to identify treatment options in your area, visit SAMHSA’s treatment locator at https://www.samhsa.gov/find-treatment or call 1-800-662-4357 (HELP).
- The National Alliance on Mental Illness (NAMI) offers a six-week education program titled “NAMI Basics” for parents and family caregivers of children and teens experiencing symptoms of mental illness or who already have a diagnosis.
- Parent Encouragement Program’s parent education course for parents of adolescents, Thriving with Teens.
Email NCSACW at ncsacw@cffutures.org
WORKING WITH ADOLESCENTS: PRACTICE TIPS AND RESOURCE GUIDE
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