Child Psychiatry Consult

‘You’re not going to tell my parents about this are you?’


You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.1 The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.2

A counselor talks to a male teen SolStock/Getty Images
The adults making rules, regulations, and laws face dual ethical responsibilities: to allow autonomy and striving for independence, while providing guidance, supervision, and protection against harm.

Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.5

Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.

A teen girl talks to a doctor Steve Debenport/Getty Images
When facing decisions about whether to disclose information and include parents in decision-making, consider whether you have implicit bias based on social or political views that may impact your decision. This may include whether you feel a strong tendency to side with adolescents or with parents in family conflict and, if so, why. Both substance use and parental involvement in adolescent health can be polarizing topics, and good decisions more often are evidence based than ideology based. If time permits, consulting with a colleague can provide an opportunity to decrease the impact of implicit bias.

You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.

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