15.13 Young people and substance misuse

Substance misuse should be routinely explored within assessments of need and risk.

All substances, including alcohol, carry potential risks if mis-used. There is no safe limit for children and young people using alcohol and all substance use carries risks. 

It is important for those working with children and young people to recognise that substance use in itself may not be problematic but to understand the factors contributing to making it so.

For the purposes of this guidance problematic use is looked at in terms of frequency, patterns of use, method of use, amounts used, social, emotional and physical effects and any other wider issues of vulnerability and risk.

Not all problematic use will need to be considered in terms of child protection processes but for some young people their problematic substance use, and related issues, will need to be considered as an issue of actual or potential Significant Harm.

In terms of the recognition of problematic substance use, the following common indicators should be considered:

• Daily use
• Daily use more than once a day
• Missing overnight or returning home late
• Excessive mood swings, which seem to follow periods of use
• Marked deterioration in a young person's mental wellbeing
• Frequent tensions and complaints of money/property being taken without permission
• School absenteeism and/or exclusion from school in relation to substance use
• A sudden drop in educational attainment
• Risky methods of use such as using alone, or in rare circumstances, injecting
• Marked deterioration in physical health, with no clear explanation
• Frequent contact with criminal justice system in relation to substance misuse
• Frequent attendance at the A & E department
• Rapid weight loss / gain
• Sleeplessness
• Drug debt
• Giving up activities previously enjoyed by the young person.

As with all general risk factors it is important to appreciate that there can be other reasons underlying the difficulties and careful assessment is needed.

Particular attention also needs to be given to vulnerable young people who are known to fall into groups where substance misuse is likely to be more prevalent. These are:

• Young people whose parents and carers have used problematically (Young people with parents addicted to drugs are at much higher risk of being exploited)
• Homeless and insecurely housed young people
• Young people in or leaving care 
• Young people excluded or truanting from school
• Young people involved in exploitation; see also 8.39 Criminal and sexual exploitation including serious organised crime and gangs | Sussex Child Protection and Safeguarding Procedures Manual
• Young people with early developmental trauma
• Young people with neurodevelopmental conditions (often undiagnosed)
• Disabled young people
• Other minority groups such as young people who identify as lesbian, gay, bi-sexual or transgender
• Young people experiencing mental health difficulties
• Children not in stable accommodation/between local authorities/sofa-surfing.

There are a number of questions that can be asked when considering the need for a referral to Children's Social Care as a child in need of protection:

• Is the identified substance use unusual for a person of this age?
  • It is important to note that the normalisation of cannabis use by young people means that the risks of exploitation are often overlooked and local intelligence suggests that cannabis appears to be the gateway drug to exploitation in many but not all cases.
• Is the child/young person withholding information about the extent of their substance use?
• Does the young person have a mature understanding of the level and type of their substance use?
• Is the substance misuse life-threatening or seriously detrimental to the child/young person's physical or mental health?
• Is the substance misuse becoming increasingly chaotic or dangerous?
• Does the young person have complex problems that may put them at risk of suffering significant harm as a direct or indirect result of misusing substances?
• Is the substance use leading to or indicative of crime or exploitation by others? see also 8.39 Criminal and sexual exploitation including serious organised crime and gangs | Sussex Child Protection and Safeguarding Procedures Manual
• Does the young person appear to be running up drug debts to dealers?
• If the young person is a parent, how does the substance use or misuse impact parenting capacity?

If the young person has a combination of these factors in their problematic substance use then careful assessment using the four parameters outlined in the assessment section should be undertaken. It is important that professionals understand how to access their local specialist young people's substance use team to make use of their specialist knowledge and skills.

If it is felt that that the young person's substance use has or is likely to become a child protection issue, the general processes laid out in this guidance with regard to referring to Children's Social Care must be followed - see Making a Referrals Procedure. If workers are not sure of the need for referral, consultation should always occur with Children's Services and outcomes recorded. 

Any agency concerned that the young person's drug/alcohol use is a child protection matter must also refer to the young persons' substance misuse service as well as Children's Services. Direct work with the young person by a substance use team will require the consent of the young person first.

Workers in universal and targeted services should consult with the local young people's substance use services in deciding whether a young person's substance use is an issue of Significant Harm or escalating risk.  Where there are actual or potential issues of Significant Harm relating to a young person's substance use this liaison and consultation must take place.

Certain vulnerable groups such as children of substance misusing parents for whom there may be a concern around whether or not they are using substances should always be referred to specialist services for joint assessment purposes, assuming they consent. 

The duty of confidentiality owed a young person under 16 is the same as that owed to any other person, but the right to confidentiality is not absolute.

Where there is a child protection risk (including within a contextual safeguarding context) associated with the young person's substance use this outweighs the young person's right to privacy - see Information Sharing and Confidentiality. In these circumstances professionals should act in accordance with the Making a Referral Procedure.

A young person should be encouraged to accept a referral to specialist young people’s substance use services. Such services will consider how and what information about the young person's substance misuse is shared with other agencies, e.g. the young person's school. The young person should be helped to understand how, why and when the information will be shared. 

In cases of potential Significant Harm relating to a young person's substance use consideration will need to be given to the involvement of parents and carers, if they do not already know about or recognise the young person's substance use as an issue of Significant Harm.

In relation to substance use the case law (Fraser Guidelines) suggests that young people using substances problematically may be less able to give informed consent.

The 'Four Parameters' guidance below sets out a framework for identifying when a young person's substance use may be actually or potentially a child protection issue.

The age and maturity of the child or young person

The younger the child, the more problematic it is to guarantee or maintain confidentiality. Given the problems of establishing competence, and therefore capacity to consent, young people under the age of 13 are unlikely to be offered confidential treatment for substance use, and should have parental consent and/or involvement unless this puts them at further risk. It is possible that failure to inform parents/carers that a young person is misusing drugs could lead to a possible negligence action if the service failed to take sufficient action to protect the child from harm as a result of that drug misuse.

The degree of seriousness of drug misuse

The more serious the drug (or substance) misuse, the more likely it is that disclosure of confidential information to other agencies will have to be considered.  In deciding whether to disclose, the service must take into account the patterns and levels of drug taking, the risks of morbidity, mortality and health risks, and other risks such as involvement in crime and other behaviour linked with the substance misuse. The supply source of the young person's drugs may also be important, particularly if he/she is at risk of exploitation or coercion.

Whether harm or risk is continuing or increasing:

Harm from drug-taking needs to be assessed with consideration of past, present and potential future behaviour. If there is a clear risk to the child or young person arising from present behaviour, or evidence of an escalation of risk to an unacceptable level, it is important that the service takes steps to ensure the future safety of the child or young person.

General context in which drug taking is set:

Where the child or young person has multiple problems, it is likely that they may be more at risk of misuse, having fewer protective factors available to them. Services must assess the child's full circumstances and determine whether to disclose confidential information against the child's wishes.

Drug debt entrapment

Children and young people who are being exploited by organised crime networks or county lines gangs can often run up drug debts as a form of trapping the child or young person into exploitation. If children or young people are in debt and it is unclear where it has come from this is very much a clear indicator of potential exploitation and needs to be referred to Children’s Services. In these circumstances professionals should act in accordance with the Making a Referral Procedure