Mental Health: Substance Use, Teens and You – You Don’t Know If You Don’t Ask

Substance use and substance use disorders (SUDs) are frequently underrecognized and associated with significant psychiatric, neurocognitive and social sequelae. According to a 2022 survey of 13-year-olds, 8% reported cannabis use, 17% nicotine use and 23% lifetime alcohol use. Worryingly, earlier initiation is associated with higher rates of psychiatric comorbidity and more rapid progression to SUD.¹ This article aims to emphasize the importance of substance use screening, resources for substance use assessments and prevention, as well as protective support for children and adolescents.

Pressures for Substance Use

Adolescents are particularly vulnerable due to ongoing neurodevelopment, including incomplete maturation of the prefrontal cortex, contributing to impaired executive functioning and increased risk-taking behaviors. Additionally, social influences play a significant role during adolescence, consistent with the stage of psychosocial development defined by psychologist Erik Erikson as “identity vs role confusion.” Individuals at this age are reaching out to peers as well as non-family models to help formulate their identity and ideals. This can work in both protective and non-protective ways. If a teen has friends who use substances, their risk of substance initiation increases 1.5- to 2-fold.²

Screening for Substance Use

Screening is indicated in high-risk populations. Adolescents may be hesitant to disclose substance use when asked directly, thereby requiring the incorporation of indirect conversational approaches to improve insight. An indirect way to gain understanding is asking what they like to do with their friends, and if their friends use substances.

High-risk population groups include^1,2:

• Youth in foster care (at a fivefold increased risk of SUD)
• Adolescents with co-occurring psychiatric disorders
• Adolescents who struggle with planning, goal setting or sustaining effort on important tasks
• Youth with high parent-child conflict
• Youth with parental history of substance use
• Adolescents with a history of school disciplinary actions or other rule-breaking behaviors
• Youth with a tendency toward risk-taking/novelty-seeking behavior or poor impulse control

The American Academy of Pediatrics (AAP) recommends universal screening for substance use using validated tools at all adolescent health supervision visits.³ The AAP website contains a list of validated screening measures for various SUDs. Successful screening depends on a patient-clinician relationship based on trust, confidentiality and promoting independence.²

Commonly used screening instruments^a

Abbreviations: BSTAD, Brief Screener for Tobacco, Alcohol and other Drugs; CRAFFT, Car, Relax, Alone, Friends/Family, Forget, Trouble; S2BI, Screening to Brief Intervention

^aInformation derived from Simon et al.⁴

For adolescents who screen positively, the model recommended by the AAP and Nelson et al. for secondary prevention (e.g., those who have tried substances) is the SBIRT, which stands for Screening, Brief Intervention and Referral to Treatment.^2,3 The AAP website contains helpful information for using this methodology. Nelson et al.’s article also discusses primary, secondary and tertiary prevention strategies for substance use.

Support for Children

Once youth screen positive, referral to evidence-based treatment is the next step. Protective factors play a critical role in prevention and recovery. In an analysis of cross-sectional survey data from 17 high schools, social support and school connectedness were related to lower odds of violence as well as substance use. Adolescent access to meaningful relationships, as well as evidence-based treatment, is vital for a holistic approach to addressing substance use.⁵

In conclusion, a multitude of pressures contribute to child and adolescent substance use. The risks over time only build and deteriorate physical, psychological and social functioning. As clinicians, we are obligated to be vigilant to this crisis and provide empathetic, evidence-based support to our patients.

References:

1. Green R, Wolf BJ, Chen A, et al. Predictors of substance use initiation by early adolescence. Am J Psychiatry. 2024;181(5):423-433. doi:10.1176/appi.ajp.20230882
2. Nelson LF, Weitzman ER, Levy S. Prevention of substance use disorders. Med Clin North Am. 2022;106(1):153-168. doi:10.1016/j.mcna.2021.08.005
3. Substance use screening. American Academy of Pediatrics. 2025. Accessed July 13, 2026. https://www.aap.org/en/patient-care/substance-use-and-prevention/substance-use-screening-brief-intervention-and-referral-to-treatment-sbirt/substance-use-screening/
4. Simon KM, Levy SJ, Bukstein OG. Adolescent substance use disorders. NEJM Evid. 2022;1(6):EVIDra2200051. doi:10.1056/evidra2200051
5. Szoko N, Joseph P, Hanner CD, et al. Protective factors against violence and substance use in adolescents: a latent class analysis. J Adolesc Health. 2026;78(5):774-782. doi:10.1016/j.jadohealth.2026.01.003