Concrete steps for screening, detection and treatment of adolescent substance use

Despite advances in technology and availability, one of the best ways for parents and health care providers to prevent or help stop adolescent substance use is still an old-fashioned conversation, according to a new Viewpoint published in the November issue of The Lancet Child & Adolescent Health. The piece, written by a team of University of Rhode Island trainees under Prochaska Endowed Professor Sarah Feldstein Ewing, stresses that relying on detection through informal observation­ -; as parents and providers have commonly done with alcohol and tobacco use­­ -; is quickly becoming a thing of the past. The paper provides health care professionals and parents concrete steps for screening, detection and intervention.

The past decade has seen a global surge in adolescent use of e-cigarettes/vaping, cannabis, and prescription opioids not-taken-as-prescribed. This surge has been aided, in some cases, by entirely new methods of substance use and delivery-; such as cannabis edibles and vaping -; as well as youths' lower perceptions of harm, and/or greater accessibility. These substances have "invisible symptoms" to adults and, in turn, can be much harder-to-detect by parents, caregivers, and health care providers.

"What is so different today than in past generations is that parents and providers could really rely on what we traditionally think of as obvious signs to tell if kids were using. Did they come home smelling like cigarettes or cannabis? Is there alcohol on their breath? Are they slurring their speech?" said Feldstein Ewing. "While some of these things still work, where we run into trouble today is that, more and more, the substances that kids are using are just not as easy to spot. And, the signs are not as conspicuous as they once were."

This is especially concerning when it comes to the still-developing adolescent brain. While the ways in which these substances affect the brain are under ongoing investigation, there is evidence to suggest that their use during adolescence may adversely affect long-term neural and behavioral development. Also, because their use can be hard to identify by adults, youth may be more likely to transition from experimentation to heavier, hazardous use in a manner that is often undetected by providers or caregivers until there is a substantial impact on school, work, or their personal or family relationships.

In addition to her position as a professor of psychology within URI's College of Health Sciences, Feldstein Ewing is a child/adolescent clinician with over two decades experience working in adolescent substance use prevention and treatment.

Families would come to me for treatment for youth engaged in heavy substance use and say, 'I didn't even know my kid was using.' Parents are having a hard time and now that many states are making cannabis legal for recreational use, I think parents and providers are really feeling at a loss to navigate this."

Sarah Feldstein Ewing, Professor of Psychology, URI's College of Health Sciences

The Viewpoint is primarily geared toward adolescent health care providers who are in a unique position to assist in detection as well as facilitating access to treatment services, due to their recurring appointments with young people. But, says Feldstein Ewing, parents and caregivers may also find the recommendations helpful. Opening the lines of communication with young people can provide adolescents a platform in which to discuss current life concerns, including substance use. One straightforward way that parents or caregivers can do this, she says, is by increasing the frequency of family dinners.

"It's definitely hard today -; families are busy with work, school, sports and other activities. But the point is, if that can be a place where you are seeing and connecting with your kids every day, it will be easier to notice small changes in behavior or other patterns. It doesn't even have to be a dinner, it can also take the form of drives or walks – if you provide a forum to talk about 'regular stuff' it will be easier for them and for you to bring these things up."

Provider use of well-validated substance use screening tools, specific for adolescents, is recommended as part of the framework -; as is active listening and the use of open-ended questions. Providers may also be able to communicate things that parents can't, such as the risks and potential longer-term effects associated with such substances. By the same token, adolescents may be more likely to open up to providers in the patient-provider context. Parents and providers may find that asking about peer use can provide helpful insights while being perceived as less intrusive to young people.

"The most important part of all this is that this is new territory -; and that's OK. The things we have done historically no longer translate well for these new forms of substances, so we need to readjust. Providers and parents often do not feel comfortable discussing topics like substance use because they are not sure what to do if teens say, 'Yes , we are using'," said Feldstein Ewing. "But when it comes down to it, even though we often think about teens as spending most of their time with their friends, parents still have the biggest influence on their teen's behavior. So knowing where they are, who they are hanging out with, and being open to having these sometimes scary conversations on a consistent basis is important. And, providers have a critical role to play in supporting kids and families."

Feldstein Ewing is Director of URI's Adolescent Neuroscience Center for Health Resilience, which focuses on adolescent translational approaches, increasing understanding of the links between basic biological mechanisms -; like the brain ­­-; and effective treatments for reducing adolescent health risk behaviors. Several of Feldstein Ewing's trainees contributed to the piece, including lead author, Genevieve Dash, M.S., at the University of Missouri; as well as Karen Hudson, M.C.R., at URI; and her URI graduate students Emily Kenyon, Emily Carter, and Diana Ho.