Substance Misuse Screening
SCOPE OF THIS CHAPTERThis chapter concerns the support and guidance to be provided to looked after young people who may be involved in, or at risk of, using and misusing alcohol and/or drugs.
1. Introduction and Overview
In 1999 the Government established a set of objectives for Children's Social Services. One of these is 'to ensure that children looked after gain maximum life chance benefits from educational opportunities, health care and social care'.
Substance misuse and associated problems harm children and young people's welfare and prevent them from achieving their full potential. Drug use among young people aged 10 - 24 years is higher than it is for the rest of the population and, within this group, young people who belong to one or more of the 'vulnerable groups' report the highest rates of all.
- Those whose family members misuse substances;
- Those with behavioural, mental health or social problems;
- Those excluded from school and truants;
- Young offenders;
- Looked After children;
- Those who are homeless;
- Those who are being exploited;
- Those from some black and minority ethnic groups.
Children and young people who are in care are four times more likely than their peers to smoke and misuse alcohol and drugs. Addressing the early onset of substance misuse, along with any underlying causes, can prevent problems escalating. Early use of these substances is a recognised risk factor for problem drug use in later life.
The Offending, Crime and Justice Survey (OCJS) survey, which looks in detail at drug use and young people, found that whilst young people in vulnerable groups account for less than one third of their sample (28%) they represented nearly two thirds (61%) of the reported Class A drug users in the past year (Becker J and Roe S 2005).
The Children Looked After data submitted annually to government includes information on children and young people aged 11 to 18 who are, or have been, in care to build a local and national picture
- The number of children looked after for at least 12 months who were identified as having a substance misuse problem during the year;
- The number of those who received an intervention for their substance misuse problem during the year;
- The number who were offered an intervention but refused it.
2. Support for Looked After Children
All children and young people need clear and unambiguous information about all aspects of substance misuse to enable them to make informed decisions about their lives, which may include advice and support on resisting peer pressure. It is important for all those working with looked after children to highlight any drug or alcohol issue or need and take the appropriate steps to ensure those needs are met.
Royal College of Psychiatrists guidance on Practice Standards for Young People with Substance Misuse Problems (2012) seeks to support the identification of young people not seeking treatment but who may be at risk of substance misuse problems. In the first instance, identification simply involves talking to young people about substance misuse.
This should, wherever possible, take place in an environment in which the young person is comfortable and is not a 'one-off' but a more gradual process, though more urgent action may be required where there are safeguarding concerns. It may be helpful to have age appropriate information and literature on drugs and alcohol and specialist treatment services to hand, see Suggested Resources for advice.
Through discussion, it will be helpful to establish the following:
- A young person's knowledge of drugs, alcohol or solvents;
- If they take drugs, alcohol or solvents and, if so, how often and in what context;
- If there are any immediate/urgent risks related to substance use;
- If substance use is part of troubling behaviour - or unusual behaviour for that age group - in relation to their substance misuse;
- Whether there are any safeguarding issues.
Information on substances and heir use/ misuse should be provided to all Looked After Children through age-appropriate information and discussion.This active engagement with children of all ages also supports the identification of those children who feel affected by substance misuse in their close family or by members of their household.
3. Assessing Need and Providing Support
It is vital that all Children Looked After with substance misuse needs are identified early through their health assessment, statutory reviews and care planning processes and receive support and appropriate interventions as a result. The identification of these needs should be an ongoing consideration.
In Cambridgeshire substance misuse 'screening' forms part of the Initial and Review Health Assessments for Children Looked After which are undertaken by Specialist Nurses and Paediatricians. Initial Health Assessments are first undertaken within 20 working days of a young person becoming Looked After. Thereafter, Review Health Assessments take place annually, though the identification of needs relating to substance misuse should be an ongoing process and not reliant on a 'one-off' assessment.
Any recommendations from the Health Assessment should be incorporated into the child's Placement Plan/ Information Record and be monitored through Looked After Reviews.
The person undertaking the screening may not have expert knowledge of alcohol and drugs but should have an awareness of basic information and where to find it (see Appendix 1: Sources of Information). If in doubt about the level of need that a young person has, or how best to respond to them, advice, information and guidance should be sought from the local drug or alcohol agency.
Substance misuse issues for children, young people and their families are also part of both the Early Help Assessment and Single Assessment (social care) frameworks. Ensuring practitioners are aware of the impact and wider implications of drug and alcohol issues can prompt earlier, more effective intervention.
Generally, this 'screening' can form part of a wider conversation with a child or young person. The CRAFFT Tool (see Section 5, The CRAFFT Screening Tool) can help provide structure to the discussion.
The following should inform the discussion:
- It is important not to make judgmental statements to young people about their alcohol/drug use;
- Remain calm and supportive even when hearing something concerning;
- Paraphrase what the young person says to confirm they have been understood;
- It is advisable to listen more than talk;
- The young person may ask questions about drugs/alcohol generally so it is important to be prepared to respond.
4. Confidentiality and Information Sharing
Confidentiality and information sharing should be discussed with all young people before any discussion takes place with others. As a general rule, the consequences of the identification of substance misuse should be clearly explained to the young person. This should include informing them about the information you can provide and about any service to which you may want to refer them.
If a child or young person is to be encouraged to approach a service for help, they need to know that their information will not be passed on without their knowledge or consent.All young people should be encouraged to talk about their substance misuse with their parents, where this is appropriate, and with their carers, as they play an important role in supporting and protecting the young person. Young people who do not want to tell their parents or carers should not have their confidentiality breached unless there is a safeguarding concern, in which case they should be supported to understand this.
5. The CRAFFT Screening Tool
The LAC Health Assessments will, as and when appropriate, utilise the CRAFFT Screening Tool.
Possible outcomes from assessment
No further action required. Child or young person not using substances or has no unmet needs related to substance misuse identified.
Further screening conversation to provide brief advice and information. Further conversation would include supplementary questions to enable staff to enquire about:
- Whether a young person has used substances;
- The type used and how it was taken (in what context);
- How frequently taken (including first and most recent time);
- Presence of any other risks or concerns (e.g. mental health concerns, safeguarding, use within family, sexual vulnerability);
- Young person's view of use and impact on their lives (problems at home, school, with relationships);
- Their willingness to access a further assessment or help.
Personalised feedback given to child or young person on their current substance use choices might use a motivational interviewing approach, with further education offered on the effects of alcohol and drugs.
Discussion should include current use, risks, harm reduction advice, referral and treatment options, in primary and specialist care, between the professional and the treatment service. Agreement on helpful actions that the professional could undertake/ offer and advice and support the treatment service can offer to the professional.
Referral to local young people's treatment service, with the young person's agreement.
Young person already engaging with the local young people's treatment service. Any relevant information shared with the treatment service with the young person's permission. A request for a report on the young person's needs and progress to be shared with professionals could be requested with the young person's permission. Any recommendations/actions arising from the Health Assessment and/or use of the CRAAFT tool should be incorporated into the child's Placement Plan/ Information Record and be monitored through Looked After Reviews.
If a Young Person refuses support
Where a young person is in need of an intervention but is unwilling to access it directly the specialist substance misuse services can usually be contacted on a 'what if?' or anonymous basis for advice, information and support.A young person may not have the motivation to address their substance misuse at this stage and cannot be forced. In this case, the priority is to provide information to ensure they are informed of the risks and how to minimise any harm caused by their substance misuse. Those supporting them should monitor the situation and seek opportunities to motivate the young person to change. Advice should be sought from the LAC Nurse and specialist services for advice on how to engage with the young person.
Substance use screening undertaken during Health Assessments is documented by health professionals in the assessment paperwork and the CRAFFT forms are attached to this. A sample of Health Assessments are quality assured by the Designated Doctor and Nurse for Looked After Children.Confidentiality issues and sharing is discussed with young people at the beginning of assessments. Prior written consent to assessments is obtained from those with parental responsibility for young people aged under16 years and those over16 years will be asked for their written consent at assessments.
Appendix 1: Sources of information
Alcohol and Drugs
Alcohol and drugs include all legal, prescribed and over the counter medication as well as illegal substances and solvents/volatile substances. It does not include tobacco
Cambridgeshire Child and Adolescent Substance Use Service
Self-referrals and professional can contact CASUS by:
Referrals should be sent to CASUS by:
Inclusion are the commissioned adult (Over 18) alcohol and treatment service in Cambridgeshire. Referrals can be made directly by:
Telephone: 0300 555 0101 (local rate)
Other sources of information and support include:
Frank - National drugs website (www.talktofrank.com/)
Text: 82111 or Telephone: 0300 123 6600
KOOTH - Free safe and anonymous online support for young people.
Youthoria - Information for 11-19 year olds in Cambridgeshire.
www.keep-your-head.com - Information on mental health and wellbeing for children and young people across Cambridgeshire and Peterborough.
CHUMS - Mental Health and Emotional Well-being Service for Children and Young People - CHUMS provides therapeutic support in a variety of ways.
Smoking - CamQUIT Under 18 / Over 18