Adolescents between 10 and 19 years of age, are at a pivotal stage of health development marked by curiosity, experimentation, self-discovery; this period of development is often when many young individuals have their initial experiences with alcohol and other drugs (AOD).1-3
The connection between AOD use and adolescent mental health is complex and associated with the distinct vulnerabilities and difficulties; half of all lifetime lifelong mental health conditions beginning during this age group.3, 4 For some adolescents, AOD use can serve as a method of self-exploration, or a way to assert their independence as they formulate their own identity and to seeking social acceptance with peer influences and pressures. However, these behaviours come with inherent risks.5, 6.
The relationship between AOD use and mental health is bidirectional and associated with vulnerabilities and/or internalising or externalising behaviours. This is further complicated by the impact of adverse childhood experiences (ACE) and the presence of complex developmental trauma.5,7-9
Adolescents who have experienced ACE and/or trauma may be more likely to use substances as a coping mechanism, potentially leading to a pattern of harmful use.3,10
Equally, adolescents with mental health conditions may in turn use AOD as a form of self-medication as a self-soothing strategy or escapism, which can further complicate their mental health status, to manage their vulnerabilities or trauma.3,11 ACE and trauma increase the risk of mental health conditions developing and substance use can exacerbate existing mental health issues or trigger the onset of conditions such as post-traumatic stress disorder (PTSD) anxiety, depression or psychosis. This can lead to a vicious cycle, where AOD use worsens mental health symptoms, which in turn increases substance use and/or addiction.4,10-12
A ‘therapeutic use of self’ approach is an essential part of adolescent mental health work, as it is important to have a sense of awareness of one’s own wellness to be able to connect with others in a therapeutic relationship.13,14 Therapeutic relationships can impact the quality of the healthcare; therefore, it is important nurses adopt a holistic and trauma-informed care approach that considers developmental issues and mental health when caring for an adolescent.3,15-17 When adolescent substance use becomes problematic, the nurse should use validated developmental screening and assessment tools to assist with engagement, selecting the most appropriate mental health and AOD care and interventions necessary for the adolescent; these can include psychoeducation and/or counselling referral and follow ups.5,18-22 These age-appropriate tools can assist nurses to understand the complexities experienced by an adolescent to better support them in navigating this critical period in their lives (see Appendix).
Appendix
The table below lists some commonly used developmental mental health and AOD tools that nurses can consider within the adolescent period. It’s important to remember that these tools are not in isolation and should be used as part of a comprehensive assessment and require clinical nursing and organisation judgement and decision-making processes as part of choice and use in any clinical setting.15
References
1 World Health Organization (WHO). Adolescent Health: Adolescent health in the South-East Asia Region. World Health Organization Regional Office for South-East Asia, New Delhi, India. 2024. Available from: https://www.who.int/southeastasia/health-topics/adolescent-health
2 Luyten P, Malcorps S, Fonagy P. Adolescent brain development and the development of mentalizing. In Mentalization-Based Treatment for Adolescents: A Practical Treatment Guide(1st ed.). Routledge. 2021 May. p. 25-40. doi.10.4324/9780429323928
3 Blakemore SJ. Adolescence and mental health. The Lancet (British Edition). 2019 May; 393 (10185): 2030–2031. doi.10.1016/S0140-6736(19)31013-X
4 Wilson R & Riley S. Mental Health of Children and Young People. In Mental health: a person-centred approach (Third edition.). Cambridge University Press. 2022. p. 379-398.
5 Bailey S, Newton N, Perry Y, Grummitt L, Baams L, Barrett E. Trauma-informed prevention programmes for depression, anxiety, and substance use among young people: protocol for a mixed-methods systematic review. Systematic Reviews. 2023 Oct; 12 (1): 203–203. doi.10.1186/s13643-023-02365-4
6 Bartholomeusz C. Alcohol and other drug use in young people with mental health issues: applying the principles of integrated practice- Part 1: why are integrated interventions recommended? Headspace. National Youth Mental Health Foundation. 2021. Available from: https://headspace.org.au/assets/Reports/Integrated-Treatment-Evidence_Part-1.pdf
7 Kaiser S, Zimmet M, Fraser J, Liddle K, Roberts G. ‘Recognition of attachment difficulties and developmental trauma is the responsibility of all paediatricians’, Journal of Paediatrics and Child Health. 2018 Oct; 54 (10): 1110-1116. doi.10.1111/jpc.14154
8 McLaughlin KA, Weissman D, Bitrán D. Childhood Adversity and Neural Development: A Systematic Review. Annual Review of Developmental Psychology. 2019 Dec; 1 (1): 277-312. doi.org/10.1146/annurev-devpsych-121318-084950
9 McLean S. The effect of trauma on the brain development of children: Evidence-based principles for supporting the recovery of children in care. Australian Institute of Family Studies, Child Family Community Australia. Commonwealth of Australia. 2016 June. Available from: https://aifs.gov.au/resources/practice-guides/effect-trauma-brain-development-children
10 McCrory EJ, Gerin MI, Viding E. Annual Research Review: Childhood maltreatment, latent vulnerability and the shift to preventative psychiatry – the contribution of functional brain imaging. Journal of Child Psychology and Psychiatry. 2017 Mar; 58 (4): 338–357. doi.10.1111/jcpp.12713
11 Lewis SJ, Koenen KC, Ambler A, et al. Unravelling the contribution of complex trauma to psychopathology and cognitive deficits: a cohort study. British Journal of Psychiatry. 2021 Aug; 219 (2): 448- 455. doi:10.1192/bjp.2021.57
12 McCrory EJ, Mayes L. Understanding Addiction as a Developmental Disorder: An Argument for a Developmentally Informed Multilevel Approach. Current Addiction Reports. 2015 Oct; 2(4): 326–330. doi.10.1007/s40429-015-0079-2
13 Clarke A, Meredith PJ, Rose TA. Exploring mentalization, trust, communication quality, and alienation in adolescents. PloS One. 2020 June; 15(6): e0234662–e0234662. doi.10.1371/journal.pone.0234662
14 Sleater AM, Scheiner, J. ‘Impact of the therapist’s “use of self”’, European Journal of Counselling Psychology (Trier). 2020 Jan; 8 (1): 118–143. doi.10.5964/ejcop.v8i1.160
15 Barrett EL, Adams ZW, Kelly EV, et al. Service provider perspectives on treating adolescents with co-occurring PTSD and substance use: challenges and rewards. Advances in Dual Diagnosis. 2019 Oct; 12(4): 173–183. Doi.10.1108/ADD-07-2019-0005
16 Stavely H, Redlich C, Peipers A. Engaging young people and their families in youth mental health: strategies and tips for mental health workers. Orygen, Melbourne. 2018. Available from: https://www.orygen.org.au/About/Service-Development/Youth-Enhanced-Services-National-Programs/Primary-Health-Network-resources/ENGAGING-YOUNG-PEOPLE-AND-THEIR-FAMILIES-IN-YOUTH
17 Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884. Available from: https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf
18 McCarthy A. 2018. Evidence Summary – Brief psychological interventions for young people with common mental health conditions: Which brief intervention elements have been tested and work? Orygen, The National Centre of Excellence in Youth Mental Health. Available from: https://www.orygen.org.au/Training/Resources/General-resources/Evidence-summary/Brief-psychological-interventions-for-young-people
19 Parker AG, Hetrick SE, Jorm AF, et al. The effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: A factorial randomised controlled trial. Journal of Affective Disorders. 2016 May; 196: 200–209. doi.10.1016/j.jad.2016.02.043
20 Sarkhel S, Singh O, Arora M. Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation. Indian Journal of Psychiatry. 2020 Jan; 62(8): 319–323. doi.10.4103/psychiatry.IndianJPsychiatry_780_19
21 Orygen. Brief interventions in youth mental health toolkit. Melbourne: Orygen, The National Centre of Excellence in Youth Mental Health; 2022. Available from: https://www.orygen.org.au/Training/Resources/Brief-interventions/Toolkits/Orygen-Brief-Interventions-in-Youth-Mental-Health.aspx
22 World Health Organization. Guidelines on mental health promotive and preventive interventions for adolescents: helping adolescents thrive. Geneva: World Health Organization; 2020 Sept. Available from: https://www.who.int/publications/i/item/9789240011854
NB: From item 23 onwards are the commonly used developmental mental health and AOD tools references within the table
23 Smith GL, McGuinness TM. Adolescent Psychosocial Assessment: The HEEADSSS. Journal of Psychosocial Nursing and Mental Health Services. 2017 Apr; 55(5): 24–27. doi.10.3928/02793695-20170420-03
24 Goldenring JM, Rosen DS. Getting into adolescent heads: an essential update. Contemporary Pediatrics 2004 Jan; 21(1), 21(1): 64-90.
25 Cappelli M, Zemek R, Polihronis C, et al. The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool. Pediatric Emergency Care, 2020 Jan; 36(1):9–15. doi.10.1097/PEC.0000000000001180
26 Knowledge Institute on Child and Youth Mental and Addictions. The HEADS-ED (Over 6 years). Children’s Hospital of Eastern Ontario (CHEO) Research Institute. n.d. Available from: https://www.heads-ed.com/en/survey?survey_type=over6
27 Knowledge Institute on Child and Youth Mental and Addictions. The HEADS-ED (Under 6 years). Children’s Hospital of Eastern Ontario (CHEO) Research Institute. n.d. Available from: https://www.heads-ed.com/en/survey?survey_type=under6
28 Garofoli M. Adolescent Substance Abuse. Primary Care: Clinics in Office Practice. 2020 Jun; 47(2): 383–394. doi.10.1016/j.pop.2020.02.013
29 Källmén H, Berman AH, Jayaram-LindströmN, Hammarberg A, Elgán TH. Psychometric Properties of the AUDIT, AUDIT-C, CRAFFT and ASSIST-Y among Swedish Adolescents. European Addiction Research. 2019; 25(2): 68–77. doi.10.1159/000496741
30 Agley J, Gassman, RA, Jun M, Nowicke C, Samuel S. Statewide Administration of the CRAFFT Screening Tool: Highlighting the Spectrum of Substance Use. Substance Use & Misuse. 2015 Nov; 50(13): 1668–1677. doi.10.3109/10826084.2015.1027930
31 Knight JR, Sherritt L, Shrier LA, Kim Harris S, Chang G. Validity of the ‘crafft‘ substance abuse screening test among general adolescent clinic outpatients. Journal of Adolescent Health. 2002 Feb; 30(2): 97–97. doi./10.1016/S1054-139X(01)00355-X
32 Knight J. GET THE CRAFFT: CRAFFT 2.1. CRAFFT. Center for Adolescent Substance use and Addiction Research (CABHRe), Boston Children’s Hospital. USA 2020a. Available from https://crafft.org/wp-content/uploads/2021/07/CRAFFT_2.1_Clinician_2021-07-03.pdf
33 Knight J. GET THE CRAFFT: CRAFFT 2.1+N. CRAFFT Center for Adolescent Substance use and Addiction Research (CABHRe), Boston Children’s Hospital. USA. 2020b. Available from: https://crafft.org/wp-content/uploads/2021/07/CRAFFT_2.1N-HONC_Clinician_2021-07-03.pdf
34 Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Manual for use in primary care. World Health Organization. 2010 Jan. Available from: https://www.who.int/publications/i/item/978924159938-2
35 Metro North Mental Health – Alcohol and Drug Service (2020). Instructions for Clinicians: How to administer the ASSIST-Y and linked intervention to young people: Queensland Health Version. Queensland Health. 2020 Sept. Available from: https://insight.qld.edu.au/shop/how-to-administer-the-assist-y-and-linked-intervention-to-young-people
36 Drug and Alcohol Service South Australia (DASSA). ASSIST-Y Clinical Form 10-14 yo. SA Health. Government of South Australia. 2011a Oct. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/1e9bf2004011d95da239bb4826472d56/ASSIST-Y+10-14yo+questionnaire+24Oct2011-DASSA-June2013.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-1e9bf2004011d95da239bb4826472d56-nKKyvGf
37 Drug and Alcohol Service South Australia (DASSA). Instructions for Clinicians: How to administer the ASSIST-Y and linked intervention to young people aged 10-14 years. SA Health. Government of South Australia. 2011b Dec. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/93ee91804011ebae8194bb4826472d56/ASSIST-Y+10-14yo+instructions+for+clinicians+Dec+2011-DASSA-June2013+revised+March.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-93ee91804011ebae8194bb4826472d56-nKOJchb
38 Drug and Alcohol Service South Australia (DASSA). ASSIST-Y Clinic Form 15-17 yo. SA Health. Government of South Australia. 2011c Oct. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/3e8449004011dd95a92fbb4826472d56/ASSIST-Y+15-17yo+questionnaire+24Oct2011-DASSA-June2013.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-3e8449004011dd95a92fbb4826472d56-nKKyu68
39 Drug and Alcohol Service South Australia (DASSA). Instructions for Clinicians: How to administer the ASSIST-Y and linked intervention to young people aged 15-17 years. SA Health. Government of South Australia. 2011d Dec. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/ea47f7004011ecb88359bb4826472d56/ASSIST-Y+15-17yo+instructions+for+clinicians+Dec+2011+revised+March+2017.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-ea47f7004011ecb88359bb4826472d56-nKOkuKu
40 McPhee I, Sheridan B, Horne A, Keenan S, Houston F. Look what’s coming over the hill: DAST-10 problem severity among non-treatment seeking young people. Drugs, Habits and Social Policy. 2022 Apr; 23(1): 22–35. doi.10.1108/DHS-07-2021-0034
41 Skinner HA. (1982). The drug abuse screening test. Addictive Behaviors. 1982 Jun;7(4): 363–371. doi.10.1016/0306-4603(82)90005-3
42 National Addictions Management Service (NAMS). Self-Assessment Tool – Tools for Adolescents. National Addictions Management Service. Singapore. 2024. Available from: https://www.nams.sg/helpseekers/drug-use/Pages/self-assessment-tool.aspx
43 Christie G, Marsh R, Sheridan J, et al. The Substances and Choices Scale (SACS) – the development and testing of a new alcohol and other drug screening and outcome measurement instrument for young people. Addiction (Abingdon, England). 2007 Aug; 102(9): 1390–1398. doi.10.1111/j.1360-0443.2007.01916.x
44 Metro North Mental Health – Alcohol and Drug Service. Substances and Choices Scale (SACS) – Screening Tool: Opt for Wellbeing. Insight: Centre for alcohol and other drugs training and workforce development and Dovetail: Supporting the youth alcohol and drug sector in Queensland. Queensland Health. 2024 Feb. Available from: https://insight.qld.edu.au/shop/substances-and-choices-scale-sacs-screening-tool
45 Whāraurau. Substance & Choices Scale and Brief intervention (SACS-ABC). National Centre for Infant, Child and Adolescent Mental Health (ICAMH) workforce development. University of Auckland. New Zealand. 2024 May. Available from: https://www.wharaurau.org.nz/all-resources/substance-choices-scale-and-brief-intervention-sacs-abc
46 Ross JA, Minegishi M, Brogna M, Subramaniam G, Levy S, Weitzman E. Identifying Adolescent Vaping With Screening to Brief Intervention and Brief Screener for Tobacco, Alcohol, and Drugs Screening Tools. Journal of Adolescent Health. 2024 May; 75(1) 196–199. doi.10.1016/j.jadohealth.2024.02.038
47 Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatrics. 2014 Sept;168(9): 822-828. doi.10.1001%2Fjamapediatrics.2014.774
48 National Institute on Drug Abuse (2019) Screening Tools for Adolescent Substance Use. U.S. Department of Health and Human Services. 2019 May. Available from: https://nida.nih.gov/nidamed-medical-health-professionals/screening-tools-resources/screening-tools-adolescent-substance-use
49 Reichenheim ME, Interlenghi GS, Ferreira MF, de Moraes CL. The Alcohol Use Disorders Identification Test (AUDIT) in Adolescents: Using a Model-Based Approach to Identify Patterns of Alcohol Misuse. Substance Use & Misuse. 2021 Aug; 56(13): 1915–1922. doi.10.1080/10826084.2021.1958859
50 Babor T, Higgins-Biddle J, Saunders J, Monteiro M. The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. Second edition. Department of Mental Health and Substance Dependence. World Health Organization. 2001 Nov. Available from: https://www.who.int/publications/i/item/WHO-MSD-MSB-01.6a
Authors:
Annabel Axford, RN/Midwife; Masters in Primary Health Care, Lecturer of Nursing, University of South Australia, Clinical and Health Sciences, Adelaide, South Australia
Paul Cooper, RN, Masters of Nursing (Mental Health), Lecturer in Nursing, University of South Australia, Clinical and Health Sciences, Adelaide, South Australia
