Working with young people using substances

Why ‘young people’?

• Health and social care practitioners all have a role in prevention and early detection of problematic use of alcohol or other substances.

• This is true for adults and young people, but young people are by their nature more vulnerable and therefore more in need of support.

Range of interventions

Our role may be in:

– Prevention of problematic use – recognising risk factors, supporting preventative factors.

– Early detection of problematic use – defining what is and is not ‘problematic’ use.

– Delivering harm reduction, safeguarding and treatment pathways.

Prevention: recognising risk factors• As we have seen in the earlier material, the family itself can be either

a risk factor or a protective factor for later substance misuse. • Risk factors for problematic substance use are likely to be:

– Parental condoning of drug and alcohol use.

– School truanting and exclusion.

– Being in the wrong ‘crowd’ – gangs or older siblings.

– Easy access – living where substances are easily available.

– Genetic vulnerability.

Prevention: recognising risk factors (cont.)So, preventative factors tend to be the opposite:

– Parental supervision and access to support.

– Achieving at school and having aspirations.

– Cultural values against substance use.

– Poor access to substances.

– Genetic strengths and self esteem.

Prevention: recognising risk factors

• Identifying vulnerable young people is a first step in prevention.

• This may involve working with the young person themselves and strengthening their resilience in avoiding substances.

• Working with the family and strengthening the protective factors.

• Working with schools and others to give needed support.

Case study: Paul• Paul is 14. He lives in a pub with his mother and her partner. His

father was diagnosed with bi-polar disorder and killed himself when Paul was 5 years old.

• Paul’s school are very concerned about his recent behaviour. Usually a good pupil, his attendance has dropped, he has been found smoking cannabis on school premises and appears moody.

• The school nurse assessed Paul by using a bio-psycho-social model. – He was not eating or sleeping well – he was helping himself to

alcohol at home in order to sleep– He was depressed and concerned about his father – he

thought he would go the same way.– His mother was very busy, worried about money and difficult to

talk to.

Case study: Paul – interventions

The school nurse liaised with CAMHS for a mental health assessment.

• CAMHS worked with Paul and his mother to explore Paul’s father’s history. There was a need for Paul to learn about his father and gain support from his mother.

• His mother and Paul together stopped his use of alcohol in the home.

• The school nurse and head teacher arranged further support for Paul in school in recognition of his depression. They also used greater vigilance in school re cannabis use.

Case study: PaulThis case shows many elements of young people’s risk of substance misuse.

• At a vulnerable developmental stage, Paul had a mental health issue and was inclined to self medicate.

• • He had ready access to substances.

• Paul lacked parental supervision and support.

• He may have been genetically vulnerable to mental ill health.

Early detection of problem use: assessing (Crome et al 2004)

• The aim in non-specialist substance use assessment is to determine if there is problematic use and, if so, in what context is it happening. A bio-psychosocial approach will help cover the context of the use.

• It is hard to tell sometimes if use is ‘problematic’ or not.

• We need to exercise judgement about substance use regarding stage of maturity, type of use and to differentiate between ‘experimenting’ and problematic use.

• For over 15s, this can be more of a challenge than for younger people.

Other indicators of possible ‘problematic’ use (CCQ, 2012; NICE 2010)

Using ‘dangerous’ drugs such as opiates, cocaine, or using heavily (i.e. daily) or hazardously are clearly obvious signs of ‘problematic’ use.

The College Centre for Quality Improvement and NICE suggest the following ‘at risk’ situations for substance use for young people aged over 15:

– Being homeless.– Involvement in anti-social behaviour or crime.– Frequently drunk or under the influence of drugs at school or in public

places.– Repeatedly presenting with minor injuries or taking risks.– Frequently attending genito-urinary clinics or for emergency

contraception.– Self harm.– Being in the care system or involved with safeguarding agencies.

Brief screening – case study: Andrew• Andrew, 16 years old, is brought to A&E by his 19 year old brother. Andrew

appears very drunk and is behaving wildly. His brother took him to a night club and they both had a lot to drink. The brother reports they’ve used nothing else.

• Andrew’s blood alcohol level is three times over the legal driving limit, but his behaviour calms down during the 3 hours they are at A&E. He finally goes to sleep in a chair.

• On questioning, the brother reports it is his birthday and he wanted his brother to join his party. He didn’t realise Andrew was drinking that much. He is worried because his parents will ‘kill me’. Andrew has never been that drunk before.

• They live together with their parents and younger sister (aged 13). Andrew is supposed to be taking his GCSEs next week. The brother has an apprenticeship in an engineering firm.

• We can perform a brief assessment using a mental checklist of risks and protective factors and our knowledge of what is an ‘at risk’ context:

Brief screening – case study: AndrewRisk factors Evidence

Parental condoning and lack of supervision

Parents seem disapproving

School truanting and exclusion None. GCSEs coming up.

Aspirations Family appear to be aspirational:Brother’s career, Andrew’s studies

Being in the ‘wrong crowd’ Older brother and brother’s friends

Easy access Yes. Brother facilitates access

Genetic vulnerability None apparent

Homelessness, anti-social behaviour or crime

No history

Brief screening – case study: AndrewWhat do you think - ‘problematic use’ or experimental use?

– It is likely that this is a ‘learning curve’ for both brothers. There are few risks or signs of prior problematic use or vulnerability on this evidence.

– We might want to know more about the frequency of this behaviour, but it appears to be a ‘one off’.

See the next case study and complete your own brief screening.

Brief screening – case study: Jane• Jane is 16 and lives in a hostel for care leavers. She was

put in care at age 12 because her mother was an “alcoholic” and couldn’t cope.

• Jane recently gave up the course at a local college because she became pregnant. She had a miscarriage at 20 weeks and now attends the local Connexions to plan for another course.

• She has been arrested twice for being drunk and disorderly with friends at weekends.

• She turns up at the ante-natal services she used to attend to see her midwife because she thinks she might be pregnant again.

Brief screening – case study: Janecomplete your own screen!

Risk factors Risk level

Parental condoning and lack of supervisionSchool truanting and exclusion

Aspirations

Being in the ‘wrong crowd’

Easy access

Genetic vulnerability

Homelessness, anti-social behaviour or crime

Brief screening – case study: Jane

• Jane ticks many of the boxes for being at risk of problematic substance use.

• She is a ‘care leaver’ and so a vulnerable young person.

• She has no supervision except for a social worker.

• She is possibly engaging in risky sex and getting drunk regularly with friends who don’t look after her.

• She may have been drinking while in the early stages of pregnancy so her baby is also at risk (see ‘specific issues in pregnancy’ for more on this).

• A positive is that she seems to be seeking help and willing to go back to college.

Brief assessment (NICE, 2008; CCQ, 2012)

All staff working with children and young people should be able to identify those at risk and know when further assessment or referral is required.

Any brief assessment should include:

– What is taken (and how).

– How often.

– In what context.

We could do this for Andrew:

What is taken alcohol - bingeing

How often once

In what context his brother’s birthday

Actions following a ‘positive’ screen for over 15s (CCQ, 2012)

• A brief assessment is recommended where there are clear concerns.

• This involves simply asking more questions about: what they use, how often, in what context. The practitioner can then decide the next step:

• Next step options: – Carry out a comprehensive assessment if able.– Referral to more specialist services.– Deliver brief interventions (advice and information).

Actions following a ‘positive’ screen for over 15s (CCQ, 2012)

• A person over 16 has the right to choose or refuse assessment or treatment like any adult.

• That does not mean that brief intervention should not attempt to engage the young person in help seeking, gaining further support or obtaining more information.

• See the resource ‘Brief intervention and harm reduction’ for more on this.

• We must exercise a duty of care for young people under 15. • Recommendations for this age range are:

– Offer a comprehensive assessment for health, education and social care needs. This should include mental health and family needs.

– It should also involve the family where appropriate. – This is likely to be done by specialist services or trained

practitioners.

Communicating with young peopleFor practitioners who are not experienced in working with children and young people, it is worth noting that young people’s communication needs are often very different to adults’ communication styles.

‘People should listen to us more. They never do. They always do what they want anyway’

(Young person in DfES, 2006:13).

Recommended approaches to communication (Ridley et al, 2009)

Recommended approaches include:

– Spend time getting to know the person.

– Be proactive - ask direct questions.

– Support any written material with verbal or practical explanation.

– Create an atmosphere which encourages disclosure – share stories, give examples, make suggestions.

– Watch Caroline Ridley, Senior Lecturer at Manchester Metropolitan University, give for tips on talking about substances to young people .

Case study: Josie

Read the following case study: Josie. Then look back at the recommendations.

– What do you think is happening here?

– Which recommendations apply?

Case study: Josie (Ridley et al 2009)

• At a hospital assessment, a 15 year old girl attended with her father. When asked ‘ever smoked, drunk alcohol, used drugs’ the girl answered ‘no’.

• When the father went to get a coffee, the questions were asked again with the explanation that they needed to know because of risk during surgery.The girl answered the questions truthfully without her father hearing about her smoking and drinking.

• The practitioner has asked direct questions.

• The practitioner has taken advantage of the right context for obtaining truthful disclosure.

• We can see that the practitioner was also giving information by explaining why the answers were needed.

Gillick competences (Wheeler, 2006)

There is a list of abilities a child under 16 may demonstrate to be deemed competent to make informed and independent decisions about their health and treatment.

The child can:

• Understand the reasons for and nature of any treatment offered.

• Understand principal benefits and risks.

• Understand the consequences of refusal.

• Make a choice free from coercion or pressure.

Gillick competences (cont.) (Wheeler, 2006)

• The Gillick competences apply to substance misuse assessment for young people under 16.

• Practitioners can assess and advise if they consider the young person demonstrates the 4 principles of competency.

• The practitioner does not require parental consent.

• This has particular implications where family involvement may compromise an assessment, as we have seen in Josie’s case example.

• See the case studies attached to this resource for more examples.

References• Crome I Ghodse H Gilvarry E & McArdle P (2004) Young People and

Substance Misuse. London, Gaskell. • Deptartment for Education & Skills (2006) Youth Matters: next steps. London,

DfES. • Galvani S (2012) Supporting People with Alcohol and Drug Problems.  Bristol:

Policy Press• College Centre for Quality Improvement (CCQ) (2012) Practice Standards for

young people with substance misuse problems. London, CCQ. • NICE (2008) Drug Misuse: Psychosocial Interventions. National Institute of

Clinical Excellence Clinical Guidance 51. • NICE (2010) Alcohol-use disorders: preventing harmful drinking. National

Institute of Clinical Excellence Public Health Guidance 24. • Ridley C Helsby V & Crew K (2009) Communicating with children and young

people and their families. In Webb (Ed), Nursing: communication skills in practice. Oxford, Oxford University Press.

• Wheeler R (2006) Gillick or Fraser? A plea for consistency over competence in children. BMJ, 332, 807.