1

WHAT'S INSIDE

Preventing, Identifying, and 

Treating Substance Use Among 

Youth in Foster Care

BULLETINS FOR PROFESSIONALS | OCTOBER 2020

Supporting treatment and prevention for 

youth in foster care

Prevalence of substance use among youth in 

foster care

Youth in foster care often face multiple 

challenges that place them at increased risk 

of using substances, making it imperative 

that caseworkers understand how to prevent 

substance use, identify possible usage, and, 

if needed, support youth in their treatment 

and recovery. This work, however, cannot be 

undertaken by the child welfare field alone. It 

requires close collaboration with substance 

use treatment providers, families, the 

community, and others.

This bulletin provides child welfare 

professionals with information about the 

extent and effects of substance use among 

youth in foster care, ways to identify substance 

use, how to support youth in care who 

currently use or are at high risk for using 

substances, and strategies for prevention. 

It also addresses why and how you can 

collaborate with professionals in other fields.

Understanding the causes and impacts of 

substance use disorders

Identifying substance use among youth in 

foster care

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Collaboration to support youth

Conclusion

Additional resources

References
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PREVALENCE OF SUBSTANCE USE 

AMONG YOUTH IN FOSTER CARE

Because of their history of maltreatment, 

stressful home circumstances, and other 

trauma, youth in foster care are at significant 

risk for using substances (Substance Abuse 

and Mental Health Services Administration 

[SAMHSA], 2011). Studies show that youth in 

foster care use substances, including alcohol, 

marijuana, or other drugs, at rates similar to 

(Braciszewski & Stout, 2012; Greeno et al., 

2019; Kim et al., 2017) or higher than (Siegel 

et al., 2016) their peers who had not been in 

foster care. Furthermore, youth in foster care 

appear to begin substance use at an earlier 

age than their peers who had not been in 

foster care, which places them at a higher 

risk for developing a substance use disorder 

(SUD) (Braciszewski & Stout, 2012). According 

to data from the National Youth in Transition 

Database, 27 percent of 17-year-olds in foster 

care had been referred for substance use 

treatment (Administration for Children and 

Families, 2020).

The high risk of substance use also continues 

as they exit care, with youth formerly in foster 

care having higher lifetime use rates than their 

peers who were never in foster care (Greeno 

et al., 2019; Braciszewski & Stout, 2012). 

Additionally, the diagnostic rates for SUDs are 

much higher among youth in or formerly in 

foster care (Braciszewski & Stout, 2012). 

UNDERSTANDING THE CAUSES 

AND IMPACTS OF SUBSTANCE 

USE DISORDERS 

Repeated instances of substance use can 

lead to changes in the brain that cause SUDs 

(National Institute on Drug Abuse [NIDA], 

2018b). This section describes the effects of 

substance use on the brain, including how it 

can lead to an SUD, and risk and protective 

factors related to youth substance use. 

SUBSTANCE USE DISORDERS

The term "substance use disorders" covers 

a range of issues related to substance use 

or misuse. Clinical diagnosis of an SUD can 

be made by trained professionals using the 

criteria outlined in the fifth edition of the 

Diagnostic and Statistical Manual of Mental 

Disorders (DSM-5). This diagnosis is different 

than those in previous editions of the DSM. 

In the DSM-5, SUD, which is measured 

on a continuum from mild to severe, is a 

combination of the DSM-IV categories of 

substance abuse and substance dependence 

(American Psychiatric Association, 2013). 

Although many people use the term 

"addiction" when referring to an individual's 

SUD diagnosis or situation, addiction is not 

a formal diagnosis in the DSM-5. However, 

some individuals or groups, such as NIDA, use 

the terms synonymously (NIDA, 2018a). 

SUDs are greatly influenced by brain 

chemistry. The human brain is wired to make 

decisions and actions (e.g., eating, exercise) 

based on rewards. This reward system is 

driven by the chemical dopamine, which 

is released during pleasurable activities. 

For example, when you eat something 

delicious, your body may release dopamine, 

which makes you feel good. Your brain then 

associates eating this food, regardless of 

whether it is healthy for you or not, with 

pleasure and encourages you to eat it again. 

When someone takes a drug, it can cause a 

rush of dopamine to be released. The amount 

of dopamine released is often much higher 

than that of other rewards, which creates 
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the "high" of taking drugs (NIDA, 2014). This 

can cause the person to seek out the drug to 

replicate the high. As the drug use continues, 

the brain may not achieve the same high, 

and so larger amounts of the drug may be 

required to trigger the reward system. Rather 

than an SUD being a character flaw, as it 

has historically and even presently been 

portrayed, it is a chemical response in the 

brain that can direct an individual's behaviors. 

For more detailed definitions and descriptions 

related to substance use, refer to NIDA's The 

Science of Drug Use and Addiction: The Basics. 

IMPACT OF SUBSTANCE USE ON YOUTH

Substance use can have myriad effects on 

an individual's health and can lead to other 

negative outcomes due to changes in behavior 

and decision-making. Short-term health 

effects of substance use include changes 

in appetite, wakefulness, heart rate, blood 

pressure, and mood as well as heart attacks, 

stroke, psychosis, overdose, or even death 

(NIDA, 2017). Long-term health effects of 

substance use include heart or lung disease, 

cancer, mental illness, hepatitis, and other 

health problems. Other effects of substance 

use include increased impulsivity and poor 

judgement, troubled relationships, risky 

sexual behaviors, early pregnancy, difficulty 

obtaining housing and employment, stress, 

and criminality as well as decreased education 

levels and memory (NIDA, 2017, 2018b; Kim et 

al., 2017).

RISK AND PROTECTIVE FACTORS FOR 

YOUTH SUBSTANCE USE

Although anyone who uses drugs is at risk 

of developing an SUD or even becoming 

addicted, not everyone does. Just as there is 

no single risk factor for child maltreatment, 

there is no single risk factor for an SUD. 

Factors affecting an individual's likelihood for 

developing an SUD include biology or genetics 

(e.g., presence of a mental health issue) and 

their environment (e.g., peer pressure, family 

circumstances, exposure to stress) (NIDA, 

2018b). This includes experiencing adverse 

childhood experiences, which can lead to 

substance use among youth, including earlier 

initiation of use (Duke, 2018). 

Although not an exhaustive list, the following 

are risk factors for substance use by youth in 

the general population (Centers for Disease 

Control and Prevention [CDC], 2019):

 Family history of substance use, including 

parental substance use

 Positive parental attitudes toward 

substance use

 Limited parental supervision

 Family rejection of sexual orientation or 

gender identity

 Association with peers who use substances 

or have a history of delinquent behaviors

 Lack of connection to school

 Low academic performance

 Childhood sexual abuse

 Mental health challenges

Additionally, exposure to any potentially 

traumatic event as a child—including 

experiencing or witnessing maltreatment or 

other interpersonal violence, having a serious 

accident or illness, and others—can increase 

the risk an adolescent will use substances 

(Carliner et al., 2016). 
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Unfortunately, many of the same 

circumstances that are risk factors for youth 

substance use are the same circumstances 

faced by youth in or at risk of entering foster 

care (Brook et al., 2015). Of particular note is 

that youth who have been maltreated, when 

compared to their nonmaltreated peers, are 

more likely to use substances earlier, use 

more types of substances, and have more 

severe usage (Gabrielli et al., 2016). 

Additionally, adolescents' brains are wired 

for engaging in risk-taking behaviors and 

new experiences, and using substances may 

fulfill that drive in an unhealthy way (NIDA, 

2014). Furthermore, the adolescent brain is 

still maturing and is malleable, including in 

areas responsible for evaluating situations, 

making decisions, and regulating emotions 

and impulses. 

Protective factors can help prevent youth 

from using substances or help them cope if 

substance use has already begun. For youth, 

examples of protective factors for substance 

use include social, emotional, behavioral, 

cognitive, and ethical competence; selfefficacy; parent or family engagement; 

spirituality; resiliency; family support and 

stability; parental disapproval of substance 

use; parental supervision; and connectedness 

to school and community or faith-based 

groups (Office of the Surgeon General, 2016; 

SAMHSA, 2011; CDC, 2019). For additional 

information about protective factors, 

read Child Welfare Information Gateway's 

Protective Factors Approaches in Child Welfare.

Co-Occurrence of Substance Use 

Disorders and Mental Health 

Problems

SUDs and mental health problems 

frequently co-occur, with national surveys 

showing that approximately half of all 

individuals experiencing one will also 

experience the other (NIDA, 2020). 

Symptoms of an SUD can be similar to 

those of a mental health disorder, and 

vice versa (Child Mind Institute & Center 

on Addiction, 2019). Additionally, the 

disorders may have developed at the 

same time, or one disorder may have 

contributed to the other. For example, 

a youth may self-medicate to reduce 

their overwhelming feelings of anxiety. 

Since selecting the proper treatment is 

dependent on a correct diagnosis, it is 

critical to refer youth exhibiting symptoms 

of either disorder for a comprehensive 

assessment with a trained professional. 

For additional information, refer to 

Common Comorbidities With Substance 

Use Disorders Research Report by NIDA 

and Substance Use + Mental Health in 

Teens and Young Adults: Your Guide 

to Recognizing and Addressing CoOccurring Disorders by the Child Mind 

Institute and the Center on Addiction.
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IDENTIFYING SUBSTANCE USE 

AMONG YOUTH IN FOSTER CARE

Due to their close contact with youth and 

their families and intimate knowledge of their 

histories, child welfare caseworkers can play 

a key role in identifying youth in foster care 

who may be using substances. By identifying 

these youth as soon as possible after they 

come into contact with the child welfare 

system, caseworkers can help them access 

services and supports that can assist them 

in ending the use and stemming the possible 

short- and long-term effects.

Two key components of identification are 

screening and assessment. Screening for 

a possible SUD is a way to determine if a 

problem may be present, while assessments 

are more comprehensive and allow a 

professional to determine more conclusively 

if a problem is present and develop a plan 

to address it. Even if a screen identifies the 

possibility of a substance use issue, that does 

not mean the youth has been diagnosed as 

such. An assessment by a trained professional 

is required to make that diagnosis. Screening 

and assessments may be conducted as part of 

regular practice, or they may be used when 

others notice signs of possible substance use. 

(See the "Signs of Substance Use in Youth" box 

in this section for more information.) Since 

conducting assessments requires a level of 

experience and training beyond that of most 

caseworkers, this section focuses on the 

basics of conducting substance use screening. 

The American Academy of Child and 

Adolescent Psychiatry and the Child Welfare 

League of America (2003) recommend that 

all children be screened for substance use, 

as well as mental health needs, within 24 

hours of being placed in out-of-home care. 

Agencies also may want to screen or assess 

youth whose families have child welfare 

involvement but have not been removed from 

care (SAMHSA, 2011). Additional screening 

should also be provided on a regular basis, 

particularly after significant transitions 

and when there is a change in the youth's 

psychosocial functioning, as usage could 

begin or worsen during a youth's involvement 

with the child welfare system. 

The Role of Peers in Substance Use

Peer relationships play a key role in 

decision-making and behaviors among 

youth. Peer approval of substance use 

can increase the risk for substance use, 

but conversely, peer disapproval can 

decrease that risk (Mason et al., 2014). A 

large study of youth in foster care found 

that they considered characteristics of 

their peer group to be the strongest risk 

and protective factor for substance use 

(Brook et al., 2015). Family factors are still 

important to youth substance use, but 

agencies and professionals should keep 

in mind the importance of peer influence 

as they develop prevention and treatment 

programs.
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Caseworkers will need to determine who 

will provide the information for the screen: 

the youth or a parent or other caregiver. 

Although research has shown that parents 

and caregivers tend to provide more accurate 

information than adolescents for substance 

use screening, the unique situations of youth 

in foster care present challenges to collecting 

information from parents or caregivers 

(SAMHSA, 2011). Parents may not be available 

or able to provide accurate information, 

perhaps due to their own substance use or 

wanting to give responses that may expedite 

reunification, and caregivers may not have 

had enough contact with the youth to 

differentiate their normal behaviors from 

behaviors that may indicate substance use. 

Screening can still be conducted with the 

parents, caregivers, or youth, but you should 

interpret the results with these issues in 

mind. If you believe the situation is high risk, 

you may want to send the youth directly to a 

qualified professional for assessment.

Caseworkers should only use scientifically 

validated screening instruments that are 

recommended for use by their agencies. 

Screening instruments are developed for 

particular populations, so you should make 

sure the screen is appropriate for the person 

being screened and the person taking the 

screen, if different. For example, the screen 

should be appropriate for person's age, 

language, culture, and reading level. 

You will also need to be aware of how the 

child's custody status affects who, if anyone, 

needs to provide consent for the screen (or 

assessment). If the youth is in the care of 

the State (i.e., has been removed from home 

and placed in out-of-home care), the agency 

will likely have decision-making authority 

about whether a youth should be screened or 

assessed. The results should be shared with 

the caregivers to help them better understand 

the youth's situation and needs, as allowed 

by State and Federal regulations regarding 

the disclosure of confidential substance use 

information. For youth still in their parents' 

custody, the parents may need to provide 

consent for the screenings or assessments, 

but the age at which youth can consent for 

those may vary by State.

Staff involved in screening should be trained 

about how to administer and interpret 

the results as well as what steps should 

be taken after the screening is completed 

(e.g., referring youth for services). When 

you administer a screen, it is crucial to 

read it to the informant exactly as written. 

Deviating from the wording at all can affect 

the informant's response and, therefore, the 

results. After the screen has been completed, 

caseworkers should seek the assistance of 

a substance use, medical, or other relevant 

professional to interpret the screen and 

determine what services or supports may 

be needed by the youth and their family 

(SAMHSA, 2011).

For additional information, refer to SAMHSA's 

Identifying Mental Health and Substance Use 

Problems of Children and Adolescents: A Guide 

for Child-Serving Organizations, which also 

features a section focused on child welfare 

settings. Chapter 2 features tables that 

provide detailed information about screening 

tools for youth substance use. Another 

useful resource is NIDA's Screening Tools for 

Adolescent Substance Use webpage.
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SUPPORTING TREATMENT AND 

PREVENTION FOR YOUTH IN 

FOSTER CARE

SUDs can be treated, but similarly to other 

chronic diseases such as diabetes or heart 

disease, there is not necessarily a cure (NIDA, 

2018b). This section describes the availability 

and usage of treatments by youth and 

describes some of the evidence-based and 

promising treatments designed specifically 

for them. It also describes strategies for 

preventing the use of substances by youth.

TREATMENT AVAILABILITY AND USAGE

According to the 2018 National Survey on 

Drug Use and Health, only 11 percent of youth 

ages 12 to 17 in the general population who 

needed substance use treatment received any 

treatment at a specialty facility (i.e., hospital 

[inpatient], drug or alcohol rehabilitation 

facility, or a mental health center) (SAMHSA, 

2019b). Of the youth in the general population 

who needed treatment but did not receive it 

at a specialty facility, nearly all (98 percent) 

did not perceive they had a need for 

treatment. Given that youth in foster care 

generally have less access to services and 

supports, this gap between service need and 

access may even be larger for them compared 

with the general population (Braciszewski, 

Tzilos Wernette, Moore, Tran, et al., 2018).

One critical barrier to obtaining treatment 

is the lack of facilities that offer programs 

tailored for youth. Results from the 2018 

National Survey of Substance Abuse 

Treatment Services (N-SSATS) found that only 

25 percent of facilities offered such programs 

(SAMHSA, 2019a), and the 2012 N-SSATS 

showed that only 48 percent of facilities even 

accepted youth clients (SAMHSA, 2014a). 

Programs geared toward youth are crucial 

to positive treatment outcomes because 

the treatment needs of youth and adults 

are different. For example, youth tend to 

use different substances than adults (e.g., 

many more youth receive treatment for 

marijuana use than alcohol, but it is the 

opposite for adults), and youth are less likely 

to experience withdrawal symptoms (NIDA, 

Signs of Substance Use in Youth

The following are possible signs of a 

youth’s substance use and warrant adults 

in the child’s life taking steps to address 

any issues (NIDA, 2014):

 Changes in behavior for no apparent 

reason (e.g., withdrawal, frequent 

exhaustion or depression, hostility) 

 Changes in peer groups

 Carelessness with grooming

 Decreased academic performance

 Skipping classes 

 Loss of interest in preferred activities

 Adjustments in eating or sleeping 

habits

 Declining relationships with family and 

friends

The presence of these signs, however, is 

not proof that a youth is using substances, 

and they may also indicate other 

factors affecting the youth (e.g., normal 

developmental stages, mental health 

issues).
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2014). Additionally, some schools may offer 

substance use treatment services, as well as 

screening or prevention programs, for youth 

(Ladegard et al., 2017).

Even when programs may be available, youth 

in foster care still face barriers to receiving 

treatment. Compared to their peers not 

in foster care, youth in care are less likely 

to view substance use as harmful or have 

negative opinions of other substance users 

(Siegel et al., 2016). Additionally, youth in 

care also may fear the consequences of 

seeking help for substance use (e.g., being 

expelled from a program), have difficulty 

bonding or trusting individuals or institutions, 

and experience a lack of continuity or 

coordination of their care (Braciszewski, 

Tzilos Wernette, Moore, Tran, et al., 2018). 

They may also confront challenges common 

to all youth. Youth in general may have 

difficulty believing treatment is necessary 

or seeing their own behavior patterns or 

consequences (NIDA, 2014). They also may not 

know where to find help or fear the stigma of 

being labeled with a substance use problem. 

TREATMENT CONSIDERATIONS

When youth in foster care require treatment 

for an SUD, caseworkers can help ensure they 

receive treatment that meets their specific 

needs, which can help optimize outcomes. 

Caseworkers can help find service providers 

that have programs that focus on youth 

treatment in general, and they can also ensure 

providers are familiar with the specific needs 

of youth in foster care. They can also support 

youth during and after treatment. Since youth 

generally have less access to services after 

they transition out of care, it is important to 

ensure they receive services for any substance 

use issues before that occurs. 

NIDA (2014) provides guidance for treating 

SUDs in youth, including the following: 

 Treatment should be tailored to the unique 

needs of each youth and address their 

overall needs (e.g., physical health, housing, 

school, transportation).

 Behavioral therapies have been shown to 

be effective in treating youth SUDs. They 

can strengthen their motivation to change, 

offer incentives, build skills to resist or 

refuse substances, help the youth replace 

substance use with other activities, and 

promote positive relationships.

 Youth with SUDs also frequently have 

mental health conditions, and so it is 

critical that any co-occurring conditions 

are identified and treated as well. 

Adolescent Community 

Reinforcement Approach (A-CRA)

A-CRA is an intervention that seeks to 

support youth in recovery by increasing 

family, social, and educational/vocational 

reinforcement. Sessions are conducted 

with the youth alone, the caregiver alone, 

and the youth and caregiver together. The 

therapist reviews the youth’s needs and 

self-assessment and chooses from among 

17 A-CRA procedures that address areas 

such as coping skills, problem-solving, and 

social activities in order to help eliminate 

substance use. A-CRA is designated as 

being evidence supported or based by 

NIDA, the Alcohol & Drug Abuse Institute, 

and the California Evidence-Based 

Clearinghouse for Child Welfare. 
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 Since any use by youth is cause for concern, 

even youth without a diagnosed SUD may 

benefit from some type of intervention. 

 Youth should remain in treatment for 

an adequate period of time and receive 

appropriate follow-up care. (This is further 

addressed later in this section.)

 Although addiction medications have been 

shown to be effective and are commonly 

prescribed for adults, they are not generally 

approved for youth by the Food and Drug 

Administration.

 Legal interventions and sanctions or family 

pressure may be an important factor 

in entering or completing treatment, 

especially given that youth with an SUD 

often do not see the need for treatment. In 

publicly funded substance use facilities, the 

juvenile justice system is the top referral 

source.

The University of Washington Alcohol and 

Drug Abuse Institute (2016) lists six treatment 

interventions for youth as being evidence 

based:

 Adolescent community reinforcement 

approach (see text box)

 Brief intervention/motivational 

interviewing

 Cognitive behavioral therapy

 Functional family therapy

 Motivational enhancement therapy and 

cognitive behavioral therapy

 Multidimensional family therapy

Culturally Appropriate Interventions

When referring youth to treatment, 

caseworkers should make sure the 

proposed treatment, as well as the 

provider itself, are culturally appropriate 

for that individual. Treatments that are 

tailored for a particular culture can help 

with client engagement and attendance 

and promote improved provider-client 

relationships (Gainsbury, 2016). For 

additional information about culturally 

appropriate substance use treatment, 

refer to the Georgetown University 

National Center for Cultural Competence, 

the University of Washington Alcohol and 

Drug Abuse Institute, and the National 

Network to Eliminate Disparities in 

Behavioral Health.
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RECOVERY SUPPORT

Relapse (i.e., resuming substance use after 

an attempt to stop) is common and does 

not mean the treatment is not or will not be 

successful (NIDA, 2014). Multiple rounds of 

treatment may be necessary, and additional 

supports will be necessary even after the 

treatment has been completed. During and 

after treatment, caseworkers should help 

monitor youth for continued substance use or 

potential triggers for use, such as high levels 

of stress or contacts with peers who have 

previously promoted substance use. They can 

also follow-up with other caring adults in the 

youth's life, such as their current caregivers, 

other family members, teachers, and coaches, 

to see if they have observed any risk factors 

and help determine how they can promote 

continued abstinence from substances. 

During a series of focus groups, youth 

reported the following five major reasons for 

relapse: feeling unable to cope with negative 

emotions without substances, stress relief, 

cognitive factors (e.g., poor motivation, urges 

to use substances, low confidence), social 

issues (e.g., peer pressure), and environmental 

issues (e.g., access or availability of 

substances) (Gonzales et al., 2012b). 

Access to recovery supports is a key factor to 

averting future substance use. Components 

of recovery support may include aftercare 

(e.g., support groups), relationships with peers 

and family, and substance-free activities 

(e.g., work, school, hobbies) (Acri et al., 2012). 

Although an SUD is a chronic disease, many 

youth do not view it that way (Gonzalez 

et al., 2012a). Rather, they view substance 

use as being about lifestyle or individual 

choice, something they can stop at any time, 

and not putting them at risk for negative 

outcomes. Therefore, caseworkers and others 

supporting youth in recovery may want to 

focus on strategies that mesh with youth 

views of substance use. For example, youth 

views about substance use and recovery do 

not necessarily align with 12-step programs, 

which are a commonly referred aftercare 

support (Gonzalez, 2012a). Rather, they may 

want to highlight activities that support 

lifestyle improvement (e.g., improved 

decision-making, employment, education, 

new positive activities). 

Treatment Resources

For a more complete review of treating 

SUDs in youth, including descriptions of 

evidence-based programs, refer to NIDA’s 

Principles of Adolescent Substance Use 

Disorder Treatment: A Research-Based 

Guide.

The following resources offer additional 

information about substance use 

treatment approaches for youth:

 Treating Youth Substance Use: 

Evidence Based Practices & Their 

Clinical Significance (University of 

Washington Alcohol and Drug Abuse 

Institute)

 Behavioral Health Treatment Services 

Locator (U.S. Department of Health 

and Human Services [HHS], SAMHSA)

 Program Search (Blueprints for Healthy 

Youth Development)
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PREVENTION

Although youth in foster care often have a 

host of risk factors for substance use, it can 

be prevented. Substance use prevention 

efforts can be applied at three levels, similar 

to maltreatment prevention interventions: 

universal interventions aimed at all members 

of a given population; selective efforts aimed 

at a subgroup at high-risk for substance 

use; and indicated interventions targeted to 

individuals already using substances but who 

have not developed an SUD (Office of the 

Surgeon General, 2016). Communities will 

need to determine the mix of strategies that 

works best for them. 

Results from NIDA-funded research show 

that programs involving families, schools, 

communities, and the media are effective for 

preventing substance use in youth (NIDA, 

2018b). Outreach and education are critical 

in these efforts, particularly when they 

demonstrate the harmful effects of substance 

use. Examples of evidence-based prevention 

programs that have shown positive results for 

decreasing substance use in youth include 

LifeSkills Training and Project Towards No 

Drug Abuse, two school-based programs, and 

Strengthening Families Program: For Parents 

and Youth 10–14, a family-focused program 

(Office of the Surgeon General, 2016). 

Not all evidence-based prevention programs 

have been tested for effectiveness on 

foster care populations, and agencies 

and communities may need to make 

adjustments to fit their needs. For example, 

many prevention programs take place in 

Mobile Interventions to Treat 

Substance Use

Mobile interventions have become more 

popular and shown promise in multiple 

fields, including treatment for physical 

and mental health problems (Braciszewski, 

Tzilos Wernette, Moore, Tran, et al., 2018). 

Advantages of mobile interventions 

include increasing the likelihood of 

honest responses, the prevalence of 

mobile devices among youth, and youth 

preferring computerized or paper forms 

to face-to-face interactions (Braciszewski, 

Tzilos Wernette, Moore, Tran, et al., 

2018; Pilowsky & Wu, 2013). iHelp 

(Interactive Healthy Lifestyle Preparation) 

is a mobile intervention designed for 

youth exiting foster care. It includes a 

computer-based intervention that utilizes 

motivational interviewing principles and 

is individualized based on user responses. 

Youth then receive daily text messages 

tailored to their readiness for change, 

with themes changing over time based on 

participants’ responses to poll questions. 

In a pilot study, iHelp showed positive 

scores for youth satisfaction, engagement, 

and retention and moderate effects on 

use of marijuana, which was the substance 

the pilot focused on (Braciszewski, Tzilos 

Wernette, Moore, Bock, et al., 2018).
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school and family settings, but given the 

transitional nature of the lives of many youth 

in foster care, this could pose a barrier 

to full participation. Additionally, many 

programs highlight parent training and 

family management, but for youth in foster 

care, family may represent increased risk 

for use (Brook et al., 2015). Youth in foster 

care are also less likely to talk with parents 

or guardians about substance use issues 

than those living with their biological or 

adoptive parents (SAMHSA, 2014b). Since 

parent or family engagement is a protective 

factor, though, programs that help develop 

the caregiver-youth relationship may be a 

valuable means of preventing substance use.

Prevention efforts can begin well before 

children reach adolescence. However, few 

substance use prevention programs for 

children under age 10 have been evaluated 

for their effect on usage, in part because that 

requires expensive long-term follow-up on 

use that may not begin until years or decades 

later (Office of the Surgeon General, 2016).

Agencies and communities will need to 

assess the needs of their children, youth, 

and families—as well as seek their input—

to determine the prevention strategy and 

programs that will best serve them. For 

additional information about best practices 

in substance use prevention, refer to chapter 

3 of Facing Addiction in America: The Surgeon 

General’s Report on Alcohol, Drugs, and Health

as well as NIDA's "Lessons From Prevention 

Research."

Preventing Substance Use in Foster 

Care by Improving the Caregiver 

Environment

KEEP SAFE is a prevention program 

designed to address problem behaviors, 

including substance use, in youth in 

foster care by improving the caregiving 

environment and improving the youthcaregiver relationship. Foster parents 

and kinship caregivers attend 16 weekly 

90-minute group support sessions in 

which they learn parenting techniques 

(e.g., positive reinforcement, increased 

supervision) and are given an opportunity 

to practice the acquired skills (Buchanan 

et al., 2019). A randomized controlled 

trial showed that youth in foster care 

participating in the program had 

significantly less substance use than those 

in the group receiving standard services 

(Kim et al., 2017). 
Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: info@childwelfare.gov | https://www.childwelfare.gov 13

COLLABORATION TO SUPPORT 

YOUTH 

To best prevent, identify, or treat substance 

use among youth in foster care, it is critical 

for the community to come together as one. 

No single individual or agency can provide the 

support youth need to thrive and avoid the 

inappropriate use of substances. Child welfare 

agencies should seek out opportunities to 

work with substance use treatment providers, 

educators, mental health professionals, 

juvenile justice professionals, court staff, 

and others who work with youth in foster 

care. By working together, they can develop 

a comprehensive and consistent message 

to support youth at risk of or already using 

substances. For example, agencies can 

institute an adolescent-focused framework 

to help all parties better agree on who the 

client is and what the goals are; develop 

joint accountability and outcomes that link 

the services together; establish data and 

information-sharing measures; and provide 

training for staff beyond child welfare, such 

as substance use treatment, education, and 

mental health (Traube, 2019). They can also 

work together to support youth in engaging 

in prosocial activities that may help reduce 

the risk of substance use. Additionally, 

agencies should work in partnership with 

parents and other caregivers as well as the 

youth themselves. They can provide valuable 

information about youths' needs and help 

shape programs. 

Use of Psychotropic Medications

Children in foster care are much more 

likely than children in the general 

population to use psychotropic 

medications, which are prescribed 

to address emotional and behavioral 

problems (Stambaugh et al., 2012). 

According to data from the National 

Survey of Child and Adolescent WellBeing II, between 27 and 47 percent 

of youth in foster care ages 11 to 17 

use psychotropic medications, with 

the rate increasing the longer the child 

has been in care (Fernandes-Alcantara 

et al., 2017). Even if a medication is 

prescribed for a youth, caseworkers 

should ensure that the medication is 

being used as prescribed, and it is best 

practice for agencies to have medical 

providers review prescribed medications 

to determine if they are still required or 

if the dosages or number prescribed are 

appropriate. Caseworkers should also see 

if nonmedication interventions, such as 

therapy, are available and appropriate for 

the youth. For additional information, refer 

to Information Gateway’s Understanding 

Psychotropic Medications web section as 

well as two Children’s Bureau publications: 

Making Healthy Choices: A Guide on 

Psychotropic Medications for Youth in 

Foster Care and Supporting Youth in 

Foster Care in Making Healthy Choices: 

A Guide for Caregivers and Caseworkers 

on Trauma, Treatment, and Psychotropic 

Medications.
Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: info@childwelfare.gov | https://www.childwelfare.gov 14

CONCLUSION

Youth in foster care are at a heightened 

risk for substance use. Since they may 

not recognize their own problems with 

substances, it is critical for adults in their 

lives, including child welfare professionals, 

to help them identify any substance use 

problems and seek assistance from treatment 

professionals. It is also incumbent upon the 

child welfare field to work with other systems 

touching the lives of these youth to develop 

and implement evidence-based prevention 

strategies.

ADDITIONAL RESOURCES

 Substance Use Disorders and Addictions 

Series (American Psychological Association)

 "Tutorials for Child Welfare Professionals"

(National Center on Substance Abuse and 

Child Welfare)

 Substance Use and Adolescent 

Development (HHS, Office of Population 

Affairs)

 Screening and Assessment Tools Chart

(HHS, NIH, NIDA)

 Facing Addiction in America: The Surgeon 

General’s Report on Alcohol, Drugs, and 

Health (HHS, Office of the Surgeon General)

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SUGGESTED CITATIONS:

Child Welfare Information Gateway. 

(2020). Preventing, identifying, and treating 

substance use among youth in foster care. U.S. 

Department of Health and Human Services, 

Administration for Children and Families, 

Children’s Bureau. 

This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information 

Gateway. This publication is available online at https://www.childwelfare.gov/pubs/bulletins-youthsud/.

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau