23. Specialist alcohol interventions and support for children and young people
Source: gov.uk (2025-11-28)

How to provide specialist alcohol interventions and support for children and young people. This includes assessment, care planning, multi-agency co-ordination, working with parents, safeguarding and the transition arrangements needed for young people moving to adult services.

23.1 Main points

Specialist alcohol interventions and the competencies for working effectively with children and young people are different to those for adults.

Children and young people’s alcohol use does not happen in isolation. Their problem alcohol use generally exists in a complex interdependence of mental health, social and educational problems and can be associated with experience of abuse, neglect or exploitation.

Practitioners working in services for children and young people aged 17 and under should be trained so they can:
- routinely identify children and young people at risk from alcohol and drug use
- offer brief information and advice where appropriate
- refer children and young people with problem alcohol and drug use to specialist alcohol services for assessment
Specialist alcohol and drug treatment services for children and young people should be child and young people centred, non-stigmatising and easily accessible.

Specialist alcohol treatment services working with children and young people should be fully integrated and aligned with schools and local services for children and young people at risk of poor outcomes. Specialist alcohol interventions and support fit into a wider context of safeguarding children and young people from harm and promoting their wellbeing.

All specialist alcohol and drug treatment services for children and young people must have child safeguarding policies and procedures in place and a child safeguarding lead. They must make sure all staff are trained in child safeguarding and know how to work in line with safeguarding procedures.

The legal framework for getting informed consent to treat children and young people is different to the framework for adults. Staff in specialist alcohol and drug treatment services should have a thorough understanding of capacity, competence and consent issues when working with children and young people aged 17 and under (such as the role of parental consent).

Alcohol and drug treatment practitioners should undertake comprehensive assessment alongside specialists from other involved services and make new referrals to relevant services.

Alcohol and drug treatment practitioners should work with children and young people to develop and review individualised care plans. And they should work in partnership with parents wherever possible.

Care plans for children and young people should address the child or young person’s problem alcohol use and their wider needs. This will usually involve working in partnership with other services.

For children with the most complex needs, including mental health problems or child protection concerns, there should be an integrated multi-agency approach across services. This includes having a named lead professional, such as a specialist mental health clinician or a child social worker. Alcohol and drug treatment practitioners should contribute to the multi-agency plan.

If a young person is moving from the children and young people’s alcohol and drug treatment service to an adult service, there should be a transitional plan in place well before they are due to move. The plan should set out how the transition will be managed and how the young person’s ongoing support needs will be met.

Alcohol and drug treatment practitioners should be able to engage and work effectively with children and young people of different ages.

Keyworkers should offer structured support. Structured support involves using specific psychosocial interventions which are common to evidence-based psychological treatments for alcohol and drug use. These common factors include:
- a strong therapeutic alliance
- structure and goal direction
- interventions to develop alternative rewards and activities to alcohol use
- engagement with supportive family and social networks and peer relationships
- building self-efficacy and coping skills
The evidence shows that age-appropriate cognitive behavioural and multi-component family therapies delivered by practitioners trained in these approaches can help children and young people to reduce alcohol use and related harms.

Although alcohol dependence is rare in children and young people aged 17 and under, medically assisted withdrawal must be available when they are diagnosed with alcohol dependence. There should be an agreed local pathway for age-appropriate inpatient medically assisted withdrawal for children and young people.

Medically assisted withdrawal is only one component of a child or young person’s care plan. Specialist staff should deliver the intervention along with relevant psychological therapies and mental health interventions within a clinical governance framework. If a child or young person is alcohol dependent, child safeguarding services should be involved.

Practitioners delivering interventions to children and young people should:
- be trained and have the skills required for the specific intervention they offer
- have access to ongoing supervision from an appropriately qualified professional
23.2 Overview

This chapter provides evidence-based guidance on prevention and specialist alcohol interventions for children and young people aged 17 and under.

The overall proportion of children drinking alcohol has been declining over the last decade. However, of the children and young people that do drink alcohol, a small number drink heavily. Children and young people’s alcohol use varies, but more typically involves experimenting or binge drinking. A small number of children and young people experience alcohol dependence.

Children and young people’s alcohol use does not happen in isolation. Children and young people’s problem alcohol use generally exists within a complex interdependence of mental health, social and educational problems and can be associated with experience of abuse, neglect or exploitation.

Guidance on the consumption of alcohol by children and young people (https://www.gov.uk/government/publications/alcohol-consumption-by-children-and-young-people) from the chief medical officer for England in 2009 recommended that an alcohol-free childhood is the healthiest and best option. However, if children drink alcohol, it should not be until at least the age of 15 years. If 15 to 17 year olds do consume alcohol:
- they should do so infrequently and certainly on no more than one day a week
- they should never exceed recommended adult daily limits
- it should always be with the guidance of a parent or carer or in a supervised environment
Alcohol and drug treatment services for children and young people should ensure the support and specialist alcohol interventions they offer to children and young people aged 17 and under is focused on their needs, is age-appropriate and offered in spaces that are separate from adult treatment.

Some specialist children and young people’s alcohol treatment services are commissioned for young adults up to the age of 25 as part of transitional arrangements to adult services.

Children and young people’s services that provide support for young adults up to the age of 25 should offer support and interventions appropriate to their age and developmental stage. Thy should also put in place transition arrangements to adult services for young adults who have ongoing support needs.

Adult alcohol treatment services need to provide targeted, age-appropriate interventions and support for young adults between 18 and 25 years old.

Children and young people with problem alcohol use may also have problem drug use. In this chapter we refer at times to drug use but we do not provide guidance on specialist drug interventions. Guidance on specialist drug interventions can be found in Drug misuse and dependence: UK guidelines on clinical management (https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management).

23.3 Vulnerabilities, protective factors, alcohol related risks and harms in children and young people

This section describes:
- vulnerabilities that increase the risk of children and young people developing problem alcohol use
- factors that can protect children and young people from developing risky behaviours including problem alcohol use
- alcohol related risks and harms for children and young people with problem alcohol use
The relationship between vulnerabilities and alcohol related harms can be complex and work in both directions. For example, children and young people might drink problematically to try and manage mental health problems or traumatic experiences. Problem alcohol use can also make mental health problems more severe or leave a child or young person more vulnerable to exploitation.

23.3.1 Vulnerabilities

As young people journey from childhood to adulthood, they go through a period of rapid developmental change. This is associated with a desire to experiment with adult behaviours, and with an increase in impulsive and risky behaviour. Some vulnerable children begin to drink before adolescence. Generally, the earlier children and young people drink, particularly heavily, the greater their risk of developing problem alcohol use and greater harm in later years (Bonomo and others, 2004; DeWit and others, 2000; Kuntsche and Gmel, 2013; Hingson and others, 2006).

Some vulnerabilities increase the likelihood of children and young people using alcohol, drugs or tobacco and developing problems with them.

Vulnerabilities include:
- experiencing abuse, neglect or exploitation
- being in care or a care leaver
- being affected by parent or carer issues including problem alcohol or drug use and mental health
- being affected by domestic abuse
- not being in education, or poor school attendance and engagement
- growing up in poverty or a marginalised community
- having a mental health problem, including an emotional or behavioural disorder
- having particular neurodevelopmental conditions such as attention deficit hyperactivity disorder (ADHD) or fetal alcohol spectrum disorder (FASD)
- having special educational needs
- being part of social norms and environments that encourage alcohol use
- involvement in anti-social behaviour or offending
- early sexual activity
23.3.2 Protective factors

Generally, the more risk factors a child or young person has, the more likely they are to use alcohol (or drugs). However, there is evidence that even when children have several vulnerabilities, there are some factors that can protect them from developing risky behaviours, including problem alcohol use. Keeping children and young people safe involves reducing and managing risks and also strengthening protective factors. Protective factors include strengths and skills that the child or young person has or can develop, as well as support from family, school and community.

The United Nations Office on Drugs and Crime (UNODC) and World Health Organization (WHO) International Standards on Drug Use Prevention (second updated edition) (https://www.unodc.org/unodc/en/prevention/prevention-standards.html) summarises important protective factors that help make young people less vulnerable to alcohol and drug use and other risky behaviours. These include:
- resilient mental and emotional health
- strong attachment to caring and effective parents
- strong attachment to supportive schools and communities
- personal and social competence
Other research (Velleman and Templeton, 2018) identifies additional protective factors including:
- a trusting relationship with a significant caring adult
- the child or young person’s own temperament
- engagement with school and community activities
- positive peer relationships
- swift resolution to parents’ problems
23.3.3 Alcohol related harms and risks to children and young people

Alcohol intoxication and problem alcohol use can have wide ranging health, social, educational and offending consequences for children and young people.

Physical and mental health alcohol related harms to children and young people

There is evidence that children and young people may be more vulnerable than adults to the negative effects of alcohol, particularly if they have a pattern of binge drinking (McCambridge and others, 2011). Children and young people are particularly vulnerable to alcohol related physical and mental health problems. Children and young people’s problem alcohol use is a significant public health concern.

There are differences between boys and girls that affect their risk of binge drinking. There is evidence that girls are more vulnerable than boys to binge drinking in response to stress caused by trauma. Girls are also more likely to have anxiety and depressive disorders. In contrast, among boys it is conduct disorder that is associated with binge drinking (Foster and others, 2014; Kilpatrick and others, 2003).

Alcohol use may be particularly harmful to children and young people’s developing brains. Alcohol use is associated with poorer cognitive functioning that can lead to educational and social problems (Toumbourou and Catalano, 2005; Lees and others, 2020).

Alcohol use is also associated with a range of mental health and neurodevelopmental conditions, particularly ADHD and behavioural difficulties in adolescence that leads to them being excluded from schools (Costello and others, 2000). If children and young people do not remain in education, it can affect their future opportunities. It also keeps them away from systems that can protect them from a range of risks and harms they might be experiencing.

Alcohol use is a risk factor for drug taking and is associated with an increased prevalence of smoking. Some children and young people experience problems with alcohol, drugs and smoking.

Alcohol related risks

Drinking alcohol can affect decision making, physical co-ordination, mood and impulse control. Intoxication and problem alcohol use, often combined with other risk factors (see section 23.3.1), can make it more likely that children and young people develop risky behaviours including:
- other substance use (which can increase harmful impact of both alcohol and drugs, including a risk of overdose)
- self-harm, including suicide
- accidents
- alcohol poisoning (which can be fatal)
- violence including domestic abuse
- risky sexual behaviours
Intoxication and problem alcohol use can increase vulnerability of children and young people to exploitation from adults or other young people who seek to harm them. They can be at increased risk of:
- exploitation, including criminal or sexual exploitation or modern slavery
- being a victim of violence, including sexual violence
- domestic abuse in their relationships
There is guidance on domestic abuse in young people’s relationships in section 22.5 in chapter 22 on people experiencing or perpetrating domestic abuse.

23.4 Prevention

This section is about prevention, including universal alcohol education and screening and brief intervention. Prevention for children and young people includes interventions aimed at:
- avoiding or delaying the start of alcohol use by children and young people
- children or people who have already started drinking in a risky way, to reduce the risk of this developing into harmful or dependent use
Prevention interventions should be commissioned and be available in every local area.

23.4 .1 Universal alcohol education

All children and young people should be given information and advice about sexual heath, mental health and drugs and alcohol to support their resilience. These issues are inter-related and advice should address them in an integrated way and not as separate issues.

Schools have a role to play in delivering interventions that prevent and reduce alcohol use among children and young people. The National Institute for Health and Care Excellence (NICE) guideline Alcohol interventions in secondary and further education (https://www.nice.org.uk/guidance/NG135) (NG135) recommends that schools should adopt a whole-school approach to alcohol education that includes universal and targeted interventions. As well as classroom-based curriculum activities and pastoral support, NICE encourages schools to provide preventative and educational activities involving parents, carers, families and communities. Schools should also develop strong connections and clear referral pathways with the children and young people’s specialist alcohol and drug treatment service for the most vulnerable pupils who need assessment and further support.

Specialist alcohol and drug treatment services do not need to be involved in planning or providing classroom-based alcohol education. But they may have a role in training school staff and should develop referral pathways with their local schools. They could also offer targeted interventions for groups or individual children and young people who may be at increased risk of developing problem alcohol use.

See section 23.15 for resources to support schools in teaching about alcohol and drug use.

23.4.2 Screening children and young people to identify risk of alcohol and drug use

Practitioners working with children and young people aged 17 and under should be trained to routinely undertake screening to identify children and young people at risk of alcohol and drug use and related harms.

There is guidance on identification and brief interventions in chapter 3.

Practitioners need to obtain consent from the child or young person or their parent or carer, as appropriate. There is guidance on competence and consent in section 23.6.

Practitioners should:
- know how to explain the screening in an age-appropriate way
- know how to respond non- judgementally and supportively and provide information to a child or young person who is drinking at harmful levels
- be sensitive to a child or young person’s beliefs and culture
- know when and how to refer a child or young person for a targeted prevention intervention or specialist comprehensive assessment
- know when and how to refer the child or young person to safeguarding services and other services to meet any other urgent needs
Practitioners need to work with all other services involved in the child or young person’s care.

23.4.3 Screening tools

The NICE guideline Alcohol-use disorders: prevention (https://www.nice.org.uk/Guidance/PH24) (PH24) endorses several validated screening tools. The alcohol use disorders identification test for consumption (AUDIT-C) is the most commonly used tool. You can find guidance on alcohol screening tools in section 3.3 in chapter 3 on identification and brief interventions.

A study of screening 10 to 17 year olds in emergency departments (Coulton and others, 2018) found that AUDIT-C is more effective than the alcohol use disorders identification test (AUDIT) in screening adolescents for:
- at-risk alcohol use
- heavy episodic alcohol use
- alcohol abuse (harmful drinking)
AUDIT (which can be completed after AUDIT-C) is more effective than AUDIT-C for identifying alcohol dependence.

The thresholds for levels of risk when using AUDIT-C with a child or young person are different to the thresholds used for adults. When screening children and young people between 10 and 17 years old, an AUDIT-C score of 3 or more identifies high risk drinking. Young people who score 5 or more should be offered a comprehensive assessment to assess alcohol and drug use (Coulton and others, 2018) and their wider needs (see section 23.8.4).

Research among 14 to 17 years olds in hospital emergency departments found no benefits to delivering brief interventions over screening alone (Deluca and others, 2020). Screening alone potentially raises awareness of high-risk drinking and may be enough to start behaviour change (McCambridge and Day, 2008). However, where screening identifies a child or young person with problem alcohol use, staff should talk to them about their alcohol use and (with consent) refer them to a specialist service.

23.4.4 Focusing on children and young people at risk of developing problem alcohol use

Services should focus screening on groups of children and young people at increased risk of developing problematic forms of alcohol or drug use. Section 23.3.1 describes these groups of children and young people.

Services attended by children and young people who are at increased risk of problem drinking include:
- pupil referral units
- youth offending services
- children’s social care services
- child and adolescent mental health services (CAMHS) and other mental health services
- GPs
- community and voluntary sector services for children and young people
Commissioners need to work with their contracted services to make sure there are comprehensive local arrangements across these services. This is to make sure children and young people who do not attend school, or who are excluded, are offered screening for problem alcohol and drug use, supported by appropriate referral and prevention interventions. An interactive approach is important when talking with children and young people about alcohol use.

23.5 Specialist alcohol and drug treatment services for children and young people

Commissioners, service providers and practitioners all play an important role in making sure that specialist alcohol and drug treatment services for children and young people are safe and welcoming.

Services should provide evidence-based specialist interventions for children and young people’s problem alcohol use, and care planned support for their wider needs. This will often involve working closely with other services for children and young people.

23.5.1 Age-appropriate services

Services working with children and young people should be age-appropriate and reflect that there are differences not only between adults and children, but also between children of different ages.

Children and young people’s specialist services work with 10 to 17 year olds. Some children and young people’s services continue to work with 18 to 24 year olds as a transitional arrangement. There is guidance on managing transitions in section 23.10.

Adult services work with young adults aged 18 to 24 and need to ensure services are age-appropriate and adequately targeted to their needs.

Service providers should always ensure shared spaces, including drop-ins, waiting rooms, and group work sessions, are age-appropriate and safe. Contact between young people using the service, particularly between different age groups or those with differing needs, should be risk assessed. If young adults aged 18 and over are using the service as part of transitional arrangements, the service should ensure they do not negatively affect the safety and age-appropriateness of the service for children and young people aged 17 and under. Services should consider separate locations or spaces for young adults.

23.5.2 Services centred on children and young people’s needs

Specialist alcohol treatment for children and young people is different to adult treatment. Specialist services need to be centred on the needs of children and young people and take into account:
- age and maturity
- developmental needs
- safeguarding duties
- issues of consent, competence and confidentiality (and the legal framework for this)
- patterns of problem alcohol (and drug) use and associated harms
- appropriate partnership working with parents or carers
The principles of quality governance apply to all alcohol and drug treatment services. But there are specific considerations and actions for services for children and young people aged 17 and under, including child safeguarding duties. These need to be incorporated into service policies and quality governance arrangements. You can find more information on quality governance in section 2.4 in chapter 2 on the principles of care.

A child safeguarding lead should contribute to designing and reviewing quality governance arrangements for children and young people’s services.

23.5.3 Co-production or consultation with children and young people

Children and young people’s voices should be at the heart of the care and support they receive.

Commissioners and service providers should actively support children and young people with lived and living experience of problem alcohol use to contribute to local needs assessment. These children and young people should also contribute to designing, implementing, monitoring and evaluating specialist children and young people’s alcohol treatment services.

Safeguarding processes should include children and young people’s involvement in co-production and consultation about services.

23.5.4 Integrating with schools and other services for children and young people

Specialist alcohol treatment services working with children and young people should be fully integrated and aligned with schools and local services for children and young people at risk of poor outcomes. Specialist alcohol interventions and support fit into a wider context of safeguarding children and young people from harm and promoting their welfare.

There should be clear and comprehensive referral pathways and agreements that confirm joint working arrangements to address the multiple vulnerabilities and complex needs children and young people experience. Services should have policies and agreements that set out information-sharing arrangements with other children and young people’ services, including children’s social care, education and mental health services, and also with parents and carers.

The Department for Education has published information sharing advice for safeguarding practitioners (https://www.gov.uk/government/publications/safeguarding-practitioners-information-sharing-advice) in England that may also be useful across the UK.

Services for children and young people at risk of poor outcomes including problem alcohol use include:
- schools and pupil referral units
- children’s social care services
- CAMHS and other mental health services
- youth offending services
- community and voluntary sector services for children and young people
23.5.5 Safeguarding

Children and young people’s services for children and young people have a vital role to play in contributing to safeguarding children and young people and promoting their welfare.

Services must have child safeguarding policies and procedures in line with national legislation and statutory guidance and local protocols. These should be agreed locally with children’s social care. There is information on national child safeguarding legislation in annex 1.

Each service must have a child safeguarding lead and all staff should be trained in child safeguarding and know how to follow organisational procedures.

Staff should know how and when to make child safeguarding referrals and share information appropriately.

Services must also have adult safeguarding policies and procedures and an adult safeguarding lead, in line with national legislation and statutory guidance. There is information on national legislation and guidance for adult safeguarding in annex 1.

Staff should be trained in adult safeguarding and know how and when to make adult safeguarding referrals for young adults or parents or carers.

23.5.6 The role of specialist alcohol and drug treatment service providers and commissioners

Commissioners and service providers should ensure that services:
- are non-stigmatising
- provide age-appropriate treatment in line with evidence-based guidance
- have staff that are competent to provide the interventions they offer and are supported and supervised to do so
- operate within local safeguarding frameworks for assessing children and young people’s needs
- have strong referral pathways and working relationships with other children and young people’s services, supported by active strategic partnerships
- are safe, accessible, welcoming and engaging for children and young people who should be able to self-refer
- are promoted in ways that will reach and feel relevant to children and young people
- target children and young people from groups at risk of problem alcohol use
take account of diversity among children and young people including:
- age
- sex
- gender identity
- sexual orientation
- race and ethnicity
- religion
- disability
- socioeconomic position
- offer interventions in private settings at a service base and also at other organisations or places where children and young people feel safe and comfortable
- offer flexible appointments to fit with children and young people’s school or college timetables, or appropriate other commitments
- provide age-appropriate service information in child and young person-friendly formats and media
- have a clinical care pathway in place for the small number of children and young people requiring a pharmacological intervention
23.5.7 Relevant clinical guidance and standards

The Royal College of Psychiatrists’ College Centre for Quality Improvement Practice standards for young people with substance misuse problems (https://www.drugsandalcohol.ie/17885/) sets out criteria for:
- comprehensive assessment
- integrated care planning
- delivering interventions
- transferring care after completing treatment
Services should also follow NICE guideline Transition from children’s to adults’ services for young people using health or social care services (https://www.nice.org.uk/guidance/ng43) (NG43).

The Royal College of Paediatrics and Child Health’s Healthcare standards for children and young people in secure settings (https://www.rcpch.ac.uk/resources/healthcare-standards-children-young-people-secure-settings) has guidance on meeting the needs of young people with problem alcohol or substance use in secure settings in England.

23.5.8 Monitoring

Services should monitor the extent to which staff routinely follow locally agreed thresholds to identify children and young people at risk.

Where appropriate, services should record and monitor:
- how often these locally agreed risk thresholds are used as a prompt for further action
- the number of children and young people identified as being at risk of harm from their alcohol use
- the number of children and young people identified as needing a comprehensive assessment and treatment interventions
23.5.9 The role of practitioners

Practitioners in children and young people’s treatment services should:
- work with children and young people based on an understanding of their individual age related and developmental needs
- engage and form a trusting therapeutic alliance with children and young people of different ages
- understand how trauma affects children and young people and use a trauma-informed approach to working with them
- understand child safeguarding and act on safeguarding concerns in line with national statutory guidance and organisational procedures
- work with a strengths-based approach (see section 2.2.7 in chapter 2 on principles of care) and therapeutic optimism
- work in partnership with parents or carers wherever possible and appropriate
- work with a child or young person, their parent or carer (where appropriate) and other relevant services to comprehensively assess the child or young person’s needs and develop an individualised care plan and risk management (safety) plan
- consider protected characteristics including gender and gender identity differences and the impact of inequality in developing the care plan
- deliver evidence-based structured support and specialist interventions including targeted prevention, harm reduction, psychosocial interventions or pharmacological interventions
- co-ordinate the child or young person’s care within the service and routinely work with other agencies and professionals including children and young people’s mental health and child safeguarding services in the best interests of the child or young person
- contribute to multi-agency care plans and conferences such as child protection conferences
- be able to assess the competence of the child or young person to give consent for the appropriate interventions (competence)
- be able to assess capacity to make the decision in question (see glossary) for 16 to 17 year olds where they have any concerns
- understand parental responsibility, as defined by UK legislation in the Children Act 1989 (https://www.legislation.gov.uk/ukpga/1989/41/contents) for England and Wales, or the Children (Scotland) Act 1995 (https://www.legislation.gov.uk/ukpga/1995/36/contents), or the Children (Northern Ireland) Order 1995 (https://www.legislation.gov.uk/nisi/1995/755/contents)
23.6 Confidentiality and consent to treatment

Decisions about sharing confidential information and consent to treatment in children and young people’s services are different from adult services.

23.6.1 Confidentiality and consent in children and young people’s services

Practitioners should make confidentiality and consent policies clear to children and young people, and their parents or carers, when they first access the service. They should provide age-appropriate information that makes it clear that children and young people are entitled to confidentiality. They should also make clear any limitations to confidentiality due to safeguarding and managing risk.

Practitioners should let children and young people know who holds information about them, and when and how it can be shared.

Services should make sure all staff are trained and competent to act in line with their policies on confidentiality and consent.

All practitioners should understand the importance of confidentiality for children and young people. They should also know how and when it is appropriate to share information and with whom.

23.6.2 Competence to consent to treatment

Practitioners must obtain informed consent for a child or young person to begin treatment. The legal position on consent and refusal of treatment by children and young people aged 17 and under is different to that for adults. Practitioners should get voluntary consent from the child or young person, or the person with parental responsibility (as legally defined) as appropriate, before starting any intervention. They should make sure the child or young person and the parent or carer with parental responsibility has information about the service and interventions they are offering, including any risks and benefits.

Across the UK, there is no specific age when a child becomes competent to consent to treatment apart from Scotland where the Age of Legal Capacity (Scotland) Act 1991 draws the line between childhood and adulthood at a young person’s 16th birthday. Usually, competence to consent to their own treatment will depend on the maturity of the child and the seriousness and complexity of the treatment being proposed.

In England, Wales and Northern Ireland, where the young person is assessed as competent to give their consent to treatment, this is known as ‘Gillick competence’. Generally, young people aged 16 to 17 fall under the Mental Capacity Act and accordingly must be presumed to have capacity to consent to their own treatment. However, in very rare cases, the courts have overridden a young person’s refusal of treatment even when they had capacity to make that decision.

Children under 16 are not necessarily considered legally competent to give consent to treatment. Practitioners need to assess Gillick competence if the child wants to go ahead with treatment without their parents’ or carers’ knowledge or consent. It would be very unusual for a child under 13 years old to be offered treatment without first getting parental consent.

In Scotland, the Age of Legal Capacity (Scotland) Act requires the medical practitioner attending a child under the age of 16 years to consider whether the child is capable of understanding the nature and possible consequences of the procedure or treatment. If the child is assessed as capable, the practitioner must seek the consent of the child rather than of the parent. In practical terms, practitioners should look for signs that the child can consent on this basis from when the child is about 12 years old.

It is important that all staff working with children and young people in specialist alcohol treatment services are trained and competent to assess a child or young person’s competence or capacity to understand all aspects of the proposed treatment intervention. This includes training to ensure understanding of the legal framework for obtaining valid consent. There is information about competence to consent in the resources section at the end of this chapter. Practitioners should also be trained and competent to understand the legal concept of parental responsibility and how it applies to their work. There is information on parental responsibility in the resources section at the end of this chapter.

Even when a child or young person is assessed as competent, it is good practice to involve their parent of carer in the decision-making process wherever possible, but only if the child consents to their information being shared. Practitioners should ask the child or young person their views, wishes and feelings so that they are involved in, understand and agree decisions about their treatment, regardless of their competence. Practitioners should always record the outcome of the assessment of competence to consent in the case notes.

23.7 Working in partnership with parents

Practitioners should work in partnership with parents and carers where this is possible. Some children and young people will not want their parent or carer involved in their support or treatment, but many will be happy for them to be involved.

The way in which parents or carers are involved in a child or young person’s treatment will be based on:
- individual assessment
- the wishes of the child or young person
- their competence or capacity to consent to treatment
If the child or young person under 16 years is assessed as not competent, or a 16 to 17 year old is assessed as lacking capacity to give consent for treatment, the person with parental responsibility needs to give consent for treatment.

If the child or young person consents for the parent or carer to be involved in their treatment, the assessor or keyworker should agree with the child or young person what their involvement will be.

Involvement can include:
- contributing information and views to assessment, care planning and care plan reviews
supporting the child or young person to meet their care plan goals which can include:
- encouragement
- rewards for achievements
- practical actions like helping the child or young person take part in a supportive activity
- taking part in a treatment intervention such as family therapy
- sharing information if there are concerns about the safety or welfare of the child or young person
The service should have a confidentiality policy that sets out how staff will work with parents and carers while respecting the confidentiality of the child or young person.

When a parent or carer is involved with a child and young person’s treatment, the practitioner should create opportunities for the parent and child or young person to discuss the situation together as well as ensuring the child or young person can discuss their concerns and give their perspective alone.

If the child or young person is competent to give consent to treatment and they do not want their parent or carer to be involved, the service should offer them the opportunity to attend on their own, with a trusted friend or a support person if they wish. This should be made clear in the service information.

Involving parents or carers and providing them with support and information on alcohol and other substances can help them to:
- understand the child or young person’s problem alcohol use and how it is linked with their other needs
- support the child or young person to work towards their goals to stop or reduce their alcohol use
- contribute to promoting safety and managing risk for the child or young person
- manage stresses related to the child or young person’s alcohol use
- support the child or young person to remain engaged with the service
- support the child or young person to work on other issues such as school engagement or involvement in anti-social or offending behaviour
- improve communication between the parent or carer and the child and young person and strengthen family relationships
Discussions with parents or carers can help to identify their own support needs.

For example, these can include:
- their own problem alcohol or drug use
- mental health problems
- physical health problems
- conflict between parents or carers
- domestic abuse
- social needs, including housing and financial problems
The practitioner should offer referral to services that can offer support for the parent or carer’s needs. If the parent or carer is able to access support, this could also help to strengthen their parenting capacity and family functioning.

23.8 Assessment and engagement

There is guidance on assessment in chapter 4 on assessment and treatment and recovery planning. Much of chapter 4 is relevant to children and young people as well as adults and you should read chapter 4 for more guidance. This section summarises additional considerations when assessing children and young people.

23.8.1 Assessment and engagement: main points

Services should provide straightforward access to assessment which should start as soon as possible after referral.

Assessment should involve the assessor and the child or young person working together to reach a shared understanding of their alcohol use and their wider needs, strengths and goals. Where appropriate, a parent or carer should also contribute.

As children and young people with problem alcohol use have complex needs, assessment should involve other relevant children and young people’s services including mental health services and children’s social care where appropriate.

Services should use validated assessment tools to support assessment, but these should not take the place of a structured clinical interview with the child or young person.

Practitioners should actively try to engage the child or young person in an age-appropriate way from first contact and throughout the assessment process.

23.8.2 Referral and initial contact

The referral process for the service should be straightforward and accessible for children and young people. Services should actively reach out through organisations and social media most commonly used by children and young people to provide accessible information about how children and young people can refer themselves to the service and what help the service can offer. They should also provide information on the service website and circulate information to relevant services so parents or carers and professionals can refer a child or young person.

It is vital that children and young people are safe and feel comfortable accessing the service. Staff should consider whether access is safe and convenient for the child or young person. If the child or young person, or the professional supporting them, have any concerns, the service should offer a choice of location that is safer or has better transport links. This is so they can access the service independently, where appropriate. The service should also fit appointments around the child or young person’s schooling and other activities that are important for them.

If the child or young person has been referred by a professional, the assessor should ask for relevant information about the child or young person from that professional (who should gain the child or young person’s consent, or their parent or carer’s consent). This will help the assessor to have a better understanding of the child or young person’s needs. It can also help to reduce the number of times that they are asked about difficult areas of their life by professionals when they are new to a service.

Staff should consider children and young people’s preferences about the appointment. This includes who they prefer to be seen by, whether they can bring a friend, parent or carer and how many people will be present. Staff should work with the child or young person to manage their expectations and provide open and honest explanations if their preferences cannot be granted.

Staff should also ask a child or young person, or their parent, carer or support worker, if they need any reasonable adjustments for a disability or a mental health problem. The service should then make these adjustments.

Staff can encourage children and young people to attend the service by providing welcoming introductory communication before their first appointment. Providing clear age-appropriate information about the assessment process and confidentiality can also help. Friendly reminders about appointments (digitally if appropriate) can also encourage attendance. If the child or young person misses the appointment, non-judgemental follow-up with another appointment offer might make it easier for them to attend and can help them stay engaged. Staff should always communicate information in an age-appropriate way avoiding clinical language and in accessible formats considering:
- language
- literacy
- sensory disability
- cognitive disability
- neurodiversity
- digital literacy and access
Interpreters (including sign language) who are not known to the child or their family should be available to make sure there is equal access to assessment.

Initial contact is very important to help the child or young person feel welcome and to help them to begin their engagement with the service at this early stage.

23.8.3 First appointment

Staff who greet children and young people should do this with professionalism and a non-stigmatising, warm approach. It is vital that all staff, including reception staff and volunteers, treat children and young people with respect. Where children and young people are accompanied by a parent or carer, staff should also make them welcome.

The wating room and the room where the assessment takes place should be age-appropriate. The information displayed should show that it is a children and young people centred service.

Assessment should include a focus on engagement. The assessment appointment is often the first face-to-face contact the child or young person has with the service and it is an opportunity to begin building a therapeutic alliance.

To help the child or young person engage in treatment, the assessor should use a warm, empathic and non-judgmental approach and integrate the principles of motivational interventions into the assessment process (see section 5.5.6 on motivational interventions in chapter 5 on psychosocial interventions).

Since many children and young people with problem alcohol use experience trauma, staff should use a trauma-informed approach. Services should make sure staff are trained, supervised and supported to use a trauma-informed approach applied to children and young people. There is guidance on trauma informed practice in section 2.2.8 in chapter 2 on principles of care.

The assessment should take the form of a structured clinical interview (a conversation aimed at assessing the child or young person’s treatment needs). The assessor will need to record information in a structured way, but a ‘checklist’ approach to assessment is not a good way to engage a child or young person.

It is very important to show an interest and listen to the child or young person’s concerns, views, interests and hopes. If they are accompanied by their parent or carer, the assessor should also involve the parent or carer in the process and ask them for their views at appropriate points.

23.8.4 Initial assessment

This section sets out how to carry out an initial assessment with a child or young person during the first meeting. The assessor can then carry out a more comprehensive assessment, involving other clinicians over the following meetings.

Assessing protective factors and any immediate risks

It is important to ask about the child or young person’s alcohol use and identify any immediate risks to the child or young person but wherever possible, the initial assessment should focus on the child or young person’s strengths, interests, positive activities and supportive networks as well.

Assessors will need training and therapeutic competencies to ask the assessment questions and to respond sensitively to the answers.

At the first appointment the assessor should briefly assess the child or young person, focusing on:
- the duration, pattern and severity of their alcohol use
- the duration, pattern and severity of their other drug use
- their mental health and physical health problems
- their family situation
- any urgent treatment needs, including the potential need for assisted withdrawal
- any urgent social needs such as housing
- any immediate risks to the child or young person
- any immediate risks to others
- their strengths and other protective factors
- their ideas about the help they might need
Assessors should record if the child or young person:
- is in contact with other services
- has been prescribed any medication
- has any health needs, such as allergies
Assessing alcohol use

The assessor should make an initial assessment of the child or young person’s alcohol use. They should use a screening tool such as AUDIT-C, but this should support a conversation about the child or young person’s alcohol use, not replace it.

The thresholds for levels of risk when using AUDIT-C with a child or young person are different to thresholds used for adults. When screening children and young people between 10 and 17 years old, an AUDIT-C score of 3 or more identifies high risk (harmful) drinking.

The assessor should ask the child or young person about:
- their alcohol use (approximate number of units and pattern) over the last 1 to 4 weeks
- what age their drinking began and how long they have experienced problem alcohol use
- any symptoms of dependence (withdrawal symptoms or withdrawal complications)
Alcohol dependence among children and young people is rare but can happen. If the initial assessment suggests the child or young person may be alcohol dependent, based on whether the assessor has the appropriate competence, they should carry out or arrange an assessment of the child or young person’s need for medically assisted withdrawal. Any doctors, nurses or pharmacists responsible for assessing and managing medically assisted alcohol withdrawal should be competent to diagnose and assess alcohol dependence and withdrawal symptoms in children and young people.

The assessor can also begin to explore with the child or young person how their experiences within their families and networks, including their friends and peer groups, interplay with their alcohol use.

Assessing urgent needs and risks

In the initial assessment, the assessor should aim to identify any immediate risks to the child or young person or to others. Areas to consider as part of the initial risk assessment are listed below in section 23.8.6 on risk assessment.

Assessing strengths and protective factors

It is helpful for the assessor to ask the child or young person about:
- supportive parents, carers or family members, safe adults in their broader network and supportive friends
- their strengths
- their interests
- their identity
- their culture
- any supportive groups or activities they take part in
- their hopes and aspirations
- their views on what changes they want to make to their alcohol use or in related areas of their life
Actions at the end of initial assessment

At the end of the initial assessment, the assessor, the child or young person and parent or carer should agree a simple plan about what will happen next.

The assessor should explain in an age-appropriate way what a comprehensive assessment involves and obtain consent from the child or young person or their parent or carer as appropriate to go ahead with this.

With consent, they should agree a date for the next appointment.

The assessor and the child or young person can also agree some actions, based on the readiness of the child or young person, that they can take towards changing their alcohol use before the next session. For example, they could record their alcohol use in a drink diary either on paper or digitally.

The assessor should begin to discuss with the parent or carer how to understand:
- their child or young person’s alcohol use
- their broader needs
- how they can best support their child
The assessor should provide the child or young person with age-appropriate information about:
- the nature of problem alcohol use and drug use
- available support and specialist alcohol interventions
- harm reduction information and advice (see information on harm reduction interventions in section 23.8.6)
If the child or young person is (or has recently been) in contact with other services, the assessor should ask for consent to contact those services so they can contribute to the assessment.

The assessor should also ask for consent from the child or young person or the parent or carer (as appropriate) to make referrals to other relevant specialist services so they can contribute to a comprehensive assessment. Depending on the child or young person and the urgency of need, this referral can be done at the end of the initial assessment or can wait until the next appointment.

Sharing information and consent

If the initial assessment or comprehensive assessment (see section 23.8.5) identifies any urgent needs or risks, including safeguarding concerns, the assessor should agree any actions they can take to manage the risks with the child or young person and their parent or carer. The assessor should get consent from the child or young person or their parent or carer to share information with relevant services.

If the child or young person or parent does not give consent, and the assessor thinks they need to share information without consent because of a safeguarding concern or to manage risk they should follow relevant national and organisational safeguarding procedures and organisational risk management procedures.

This will usually involve consulting their child safeguarding lead or a senior member of the clinical team.

The assessor should explain openly their reasons for sharing information without consent and what information will be shared and with whom. They should listen to the child or young person’s and the parent or carer’s concerns and explain they believe that sharing information is in the child’s best interests.

The assessor should clearly document any decision to disclose information without consent, setting out:
- the reasons for disclosure
- details of who agreed the decision
- details of what needs to change before full confidentiality will be reinstated
You can find details of relevant child safeguarding legislation and statutory guidance in annex 1.

23.8.5 Multidisciplinary comprehensive assessment

This section sets out elements of a comprehensive assessment which practitioners can carry out over several sessions.

A multidisciplinary approach to comprehensive assessment

All children and young people with problem alcohol use should be offered a comprehensive assessment of their needs. Comprehensive assessment builds on the initial assessment.

For the assessment to be comprehensive it needs to be undertaken by a team of specialists who have the competence to assess the child or young person’s wider developmental, mental health and safeguarding needs. This will involve working with specialists from other children and young people’s services.

This might include working with:
- CAMHS and other mental health support services
- GPs
- children’s social care
- youth justice services
- schools, pupil referral units and education support services
- services for children with special educational needs or disabilities
- community and third sector services for children, young people and families
The role of the assessor in the alcohol and drug treatment service is to assess the child or young person’s problem alcohol use and related needs, which would include awareness of their mental health needs, and to co-ordinate information and assessments of their wider needs by other relevant specialists.

Many children with problem alcohol use also have a mental health problem. Services should ensure that a child or young person coming for support and treatment for problem alcohol use should have access to a specialist mental health clinician for children and young people. This clinician can carry out a comprehensive assessment of their needs if their problem alcohol use is associated with physical, psychological, educational and social problems and/or comorbid problem drug use. A child or young person being assessed in a mental health service should also have their alcohol and drug use assessed.

Alcohol and drug treatment services should make sure that specialist alcohol and drug practitioners responsible for alcohol assessments for children and young people are trained, supported and supervised to do this. This includes competencies in multidisciplinary and multi-agency working.

Aims for the comprehensive assessment

The aim of comprehensive assessment is to gather and consider information, so the assessor, the child or young person, the parent or carer (where appropriate) and professionals from relevant services can agree a personalised care plan and a risk management (safety) plan.

The assessor should explain the process of the comprehensive assessment to the child or young person and their parent or carer where appropriate. The child or young person should be at the centre and fully involved in this assessment process.

Comprehensive assessment process

A comprehensive assessment can take some time to do, but support and specialist alcohol interventions can begin before the comprehensive assessment is complete. The practitioner should make sure any immediate needs and risks are addressed.

The assessment is the beginning of an ongoing conversation with the child and young person about their alcohol use. The assessor’s approach to this should be based on the principles of motivational interviewing. A confrontational approach is not effective or helpful. There is guidance on motivational interviewing in section 5.5.6 in chapter 5 on psychosocial interventions.

Through the assessment process, the assessor can help the child or young person consider their alcohol use and any changes they might want to make. Based on the readiness of the child or young person, the assessor can encourage them to monitor their own alcohol use and be curious about triggers for drinking and things that help them to avoid drinking or avoid drinking heavily.

Assessment tools

Assessors should carry out the assessment as a structured clinical conversation.

Validated clinical tools, such as the Teen Addiction Severity Index (T-ASI) (https://www.euda.europa.eu/drugs-library/teen-addiction-severity-index_en), can support this conversation but should not replace it. Assessment is a continuing process and the assessor should not attempt to cover all the areas below in one meeting. Children and young people, particularly those who have experienced trauma, often need time to develop trust in a new relationship with a practitioner and may need help to reflect on aspects of their lives for their needs to be identified.

Practitioners can get information from the child, young person, parents and carers and other professionals. Sometimes it is helpful to corroborate information gained from one source with another.

The assessment should review:
- alcohol use - patterns, frequency, how much they consume (see section 23.8.3 above initial assessment)
- any signs of alcohol dependence
- drug use - patterns, frequency, how much they consume
- any signs of drug dependence
- mental health including self-harm and suicidal thoughts, intentions or past suicide attempts
- neurodevelopmental conditions including autism, ADHD and FASD
- physical health problems
- sexual health and pregnancy
- family relationships and environment
- any parental issues including alcohol or drug use, mental health, domestic abuse
- developmental and cognitive needs, school attendance and engagement
- special educational needs
- physical disabilities and learning disabilities
- peer relationships, social functioning and community networks
- partner relationships
- past history of abuse of trauma (adverse childhood experiences)
- current risks and safeguarding concerns including abuse, neglect and exploitation (see section 23.8.6 on risk assessment)
- protective factors including supportive adults and peers and coping strategies
- aspirations, readiness to change and belief in ability to change
There is guidance on comprehensive assessment in chapter 4 on assessment and treatment and recovery planning and much of this guidance can be adapted for children and young people.

Professionals and services involved in a child or young person’s care should share relevant information to support high quality care in line with multi-agency information sharing agreements.

23.8.6 Risk assessment

Assessing risks and protective factors

Assessing risk is an important part of any assessment. Risk assessment should inform the content of the care plan and should consider risks to the child or young person and any risks they might pose to others. Multiple risk factors can mean that the overall risk to the child or young person is higher.

When assessing risks to children and young people, service assessment frameworks and practitioners can draw on the assessment framework set out in Appendix 4: triangle chart for the assessment of children in need and their families (https://www.londonsafeguardingchildrenprocedures.co.uk/appendix_4.html) of the ‘London Safeguarding Children Procedures’.

Although it is important to identify risks, it is also important to identify protective factors and to talk with the child or young person about these. It is important that the child or young person is supported to feel they have agency and can make choices and access support to reduce risks.

Multi-agency approach

For some children and young people, there is already a multi-agency plan in place such as a safeguarding plan led by children’s social care or a risk management (safety) plan led by a child and adolescent mental health specialist. The multi-agency plan should inform the alcohol and drug treatment service risk management plan. And the alcohol and drug treatment practitioner should also contribute to the multi-agency plan and to a multi-agency approach to managing risk.

Risks to consider in a risk assessment

Risks to consider in a risk assessment for a child or young person include:
- abuse, neglect and exploitation (consider any risks related to parenting or family environment and also the wider social context they are in)
- domestic abuse within their family or within their own partner relationships (as a victim or a perpetrator)
- mental health related risks, including signs of severe mental illness (psychosis or bipolar disorder)
- self-harm and suicide risks
- any physical health risks
- if they are not in education or have poor school attendance
- if they are a victim or a perpetrator of violence
- their association with peer networks that increase risk of exploitation or offending
- homelessness
- online harms
- harmful gambling
- gaming addiction
Alcohol related risks to consider in a risk assessment for a child or young person include:
- high risks to health due to the quantity of alcohol use, including the risk of alcohol poisoning and risks to liver health or cognitive development
- risks associated with alcohol dependence in a child or young person such as withdrawal and withdrawal complications and longer-term health risks, and their need to fund alcohol use
high risks related to intoxication including:
- accidents
- being at risk or being a victim of violence (including sexual violence)
- alcohol (and drug) use and intoxication in risky contexts such as association with adults or other young people who seek to harm them including criminal or sexual exploitation
- increased risk of being drawn into offending behaviour
Risks related to other substances to consider in a risk assessment for a child or young person include:
- increased risk of harm and of overdose if they are using both alcohol and other substances
- nicotine and smoking health related risks
high risks to health and safety related to their use of other substances (illicit drugs, prescription or over the counter medication, complementary health medicines) including:
- dose
- which substances and route of administration
- risk of substances being mislabelled or mis-sold
You can find guidance on assessing drug related risks in Drug misuse and dependence: UK guidelines on clinical management (https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management).

You can find details of relevant child safeguarding legislation and statutory guidance in annex 1.

Harm reduction information and advice

The assessment is an opportunity for the assessor to give the child or young person harm reduction information and advice based on their individual needs, as well as more general health and wellbeing information and advice. Based on the individual needs of the child or young person, the assessor should provide age-appropriate harm reduction information and advice. This can include:
- information and advice about intoxication and related risks
- information and advice about alcohol poisoning
- information and advice about concurrent alcohol use and prescribed medications or illicit drug use
- information on alcohol and health risks
If a child or young person is alcohol dependent, the assessor should give them information and advice:
- to help them not stop or reduce drinking suddenly
- about tolerance and the risks of reduced tolerance after a period of abstinence or low risk drinking
You can find harm reduction information in chapter 8 on harm reduction.

They should also provide details of information resources on alcohol and drugs for children and young people, such as FRANK (https://www.talktofrank.com/).

23.9 Care planning

This section is about care planning. Section 23.11 provides guidance on selecting care packages and interventions.

23.9.1 Developing a care plan

The assessor should summarise the findings of the assessment in a broad written care plan. If the assessor does not continue to work with the child or young person, they will hand the care plan over to the keyworker or a clinician who will further develop the plan with the child or young person.

The keyworker is a single named practitioner who:
- meets regularly with the child or young person in treatment
- co-ordinates their care planning within the service
- leads on working with other services involved in their care
- provides structured support (see section 23.13.3 below)
The child or young person should have an active role in developing the care plan and their views and wishes should be considered. It is important that the child or young person feels they have choices about plans for their support and interventions. The parent or carer (where appropriate) and other relevant professionals should also contribute to developing the plan.

Every child or young person’s care plan should:
- be based on and tailored to meet their individual needs
- summarise the findings of the assessment
- describe their agreed initial goals and preferred outcomes
- describe how their needs will be met, including the interventions the alcohol and drug treatment service will offer
- be multidisciplinary and outline arrangements agreed with other services and agencies to meet their wider needs, including any mental health needs
- include pharmacological interventions if these are assessed as needed
- have a named keyworker responsible for co-ordinating their care in the alcohol and drug treatment service and communicating with other services
- have one named lead professional responsible for co-ordinating care across all relevant agencies, where several services are providing care
- include names and contact details of other professionals and services involved
23.9.2 Risk management (safety planning)

The risk assessment is the basis for risk management (safety planning). Risk assessment (safety) plans will build on the initial assessment and are likely to be expanded following the comprehensive assessment and adjusted throughout the child or young person’s treatment.

A risk management (safety) plan is usually a separate plan to the care plan, but agreed actions in the risk management plan should normally inform the care plan. It should be clearly accessible to relevant staff in the child or young person’s records.

The keyworker in the alcohol and drug treatment service who is responsible for co-ordinating risk management (safety) planning should be competent to do so. The multidisciplinary team (MDT) or wider clinical team should have clinical oversight of risk management.

Where risks are high, there is likely to be a multi-agency safety plan, for example a safeguarding plan led by a social worker, or a multi-agency risk management (safety) plan led by a children and young people’s mental health professional (see section 23.9.3).

A risk assessment and risk management (safety) plan should be based on the child or young person’s individual needs and how to support their immediate and longer-term safety.

Wherever possible, the child or young person should be involved in the process of developing their individual risk management (safety) plan by agreeing to goals and any actions they can take to manage risks. However, there may be safeguarding or other high risks that practitioners will have a duty to act on, even if the child or young person does not agree with the plan. In this case, the practitioner should explain to the child or young person the actions they are taking and why.

Risk management (safety) plans should clearly identify the:
- actions to manage the risks and who will take them
- people and factors that can help in managing risk and increasing safety
- actions the child or young person can take themselves to reduce risk and increase safety
The risks to a child or young person can constantly change, so practitioners will need to regularly review their risk assessments and risk management (safety) plans. Changes in any of the risk areas (such as alcohol and drug use, physical health, mental health or social factors) may affect the level of risk in another area. For example, increased risk related to a child or young person’s mental health might increase their overall safeguarding risk, even where their alcohol use has not changed.

A sole keyworker might not be able to see the interaction of risk across all areas, so it is important that the service provides supervision and involvement of the MDT or senior clinician in reviews. Keyworkers will need to amend the identified risk management actions if risks or related factors change, or actions to reduce risks and increase safety have not been effective.

Services need organisational procedures for escalating and managing immediate risks. Keyworkers should have access to advice and supervision from the named child safeguarding lead and relevant members of the MDT or wider clinical team.

All staff in children and young people’s services should be trained to respond to safeguarding risks and understand organisational safeguarding procedures, including when and how to make a child safeguarding referral.

It is important that organisational risk management processes should include processes for following up a child or young person with complex needs where there are risks to their safety or health if they disengage from treatment.

23.9.3 Multi-agency care planning including risk management (safety) planning

When a child or young person has complex needs and several services are providing care, professionals from different services will need to make sure everyone has clear expectations about their role and that care is well co-ordinated. They will need to agree who is the lead professional responsible for co-ordinating the person’s care across services. This might be the keyworker from the alcohol and drug treatment service. But where risks are high, a professional from another service will normally be the lead professional. For example, a social worker or a mental health professional for children and young people.

All services involved should have information-sharing arrangements and should share information at reviews and in between reviews if there are relevant changes in the child or young person’s situation, or any risks.

Services will need to work together and with the child or young person to integrate care plans and risk management (safety) plans so there are no contradictions. Where there is a co-ordinated multi-agency plan such as a safeguarding plan led by a social worker, the key worker (or where appropriate, the specialist clinician) from the alcohol and drug treatment service will contribute to the multi-agency plan. They will also contribute to multi-agency case conferences, such as child protection conferences or mental health care planning reviews.

Professionals from involved services will need to co-ordinate timetabling of appointments to make it possible for the child or young person to attend them all and not feel overwhelmed.

23.9.4 The care planning process

The care plan is an active document that is adjusted over time. It is the basis for the care planning process which takes place throughout treatment and support.

Goals and goal setting

Practitioners should approach goal setting and reviewing based on the principles and techniques of motivational interventions, which can strengthen engagement.

As well as the keyworker and the child or young person setting goals for the child or young person’s alcohol use and other substance use, care planning will involve them setting wider goals for other areas of the child or young person’s life.

Each child or young person’s care plan should be based on their individual needs, but goals for the plan and for specific interventions commonly include:
- reducing or stopping alcohol use
- reducing or stopping any drug use
- improving their protective factors
- supporting positive decision-making
- enhancing their understanding of actions and consequences
- improving their educational engagement and social functioning
- improving their mental health and wellbeing
- increasing the support they are receiving for any neurodiverse needs or disabilities
- encouraging positive relationships with safe and supportive adults and peers who do not have problem or drug alcohol use or engage in risky behaviours
- involving parents and carers where appropriate and strengthening family relationships
The risk management (safety) plan will identify goals to reduce and manage risks to the child or young person and any risks they might pose to others.

Duration of treatment

The needs of children and young people who engage with alcohol and drug treatment services are very varied, so the duration of support and interventions offered by the service will also vary. Practitioners should always base the duration of an intervention on individual need and not on a standard length of time. Arbitrary time limits on interventions are not helpful and may make poor outcomes more likely.

Although keyworkers should avoid arbitrary or premature decisions about the length of the treatment episode, practitioners should still agree clear and ambitious care plan goals with the child or young person. This includes planned timescales for action and regular reviews.

Reviewing the care plan

The keyworker should regularly review the care plan with the child or young person, and where appropriate with the parent or carer, and adjust it where necessary. This gives the child or young person (and their parents or carer) a chance to consider whether the interventions are helping, and to monitor progress against agreed goals. The child or young person should have an active role in reviewing and adjusting the care plan and their parent or carer, and other relevant professionals, should contribute to the process where appropriate.

Support after leaving the service

An important part of care planning is preparing the child or young person for when the time comes for them to leave the service.

As the practitioner and the child or young person regularly review progress towards care plan goals, the appropriate duration for the end of support from the service will become clear. The practitioner and the child or young person can then agree a date for ending the treatment episode and allocate enough time to plan for this, as well as making sure support is in place for them after they leave the service.

It is important that the end date leaves time and space to prepare the child or young person for the end of their involvement with the service. For some children and young people, this will involve a transition to another service for children and young people or to an adult service. For others, it may be an end to support from professional services at that time. People can be at increased risk of relapse at transition or ending points without appropriate preparation and support, so careful preparation is important. Section 23.10 provides guidance on transitions.

The keyworker and the child or young person, and where appropriate the parent or carer, should agree a support plan for after they leave the service. This can include:
- their goals as they leave the service
- supportive activities they will be taking part in
- supportive adults and supportive friends
- details of any ongoing or new professional support from other services
Even if a child or young person has reduced or stopped their alcohol use and achieved positive outcomes in other areas of their life, they may still need help for problem alcohol use and related risks in the future. Services need to agree contingency plans to manage their return to harmful alcohol use and associated risks. This can include actions they can take and who they will contact if they begin to use alcohol problematically again.

The practitioner should make it clear to the child or young person that they can contact the service for support again and how they can do this. The practitioner should encourage them to contact the service as soon as they are having problems, or if they feel at risk of returning to problematic alcohol use.

The practitioner should decide on appropriate follow up appointments, based on individual assessment and supported by the multidisciplinary team. These appointments are to check in with the child or young person and see how they are managing, and these can be weeks or months after they leave the alcohol and drug treatment service. Any appointments like this will depend on their individual situation and whether they will be involved with other services when they leave.

23.10 Transition to adult services

All young people in alcohol treatment who will be transferring to an adult service should have a transitional care plan agreed well before their 18th birthday, so there is time to prepare them for transition. Practitioners should involve the young person, and where appropriate their parent or carer. Transitional plans should meet the NICE quality standard Transition from children’s to adult services (https://www.nice.org.uk/guidance/qs140).

If the young person is involved in more than one service, the lead professional should co-ordinate their transitional care plan across all services. Transition to different services, such as youth offending teams, CAMHS and statutory children’s services, occur at different ages or developmental stages. These different arrangements should be detailed in the transitional care plan, so everybody is clear about which agencies are involved, what they are offering and when the support is due to end.

If the young person is moving to an adult alcohol and drug treatment service, the alcohol treatment practitioner, supported by the multidisciplinary team, should prepare the young person. This includes working with the adult service and the young person to make sure there is continuous age-appropriate support for the young person.

The children and young people’s alcohol treatment service, the adult alcohol and drug treatment service and the young person should develop a plan. This should be a stepped approach, as follows.
- Share information about the young person’s needs to support the referral to the adult service.
- Introduce the young person to the adult keyworker and arrange several joint appointments involving the young person and both services.
- Where appropriate, introduce the young person’s parents or carers to the new service and discuss their role in their young person’s care.
- The children and young people’s service should develop a new care plan with the adult service and the young person.
- Both services should make sure that the young person’s wider needs are addressed in the care plan. Include details of other children and young people’s services involved, what support they are offering and when this support is due to end. Include details of any other adult service that the young person is moving to and what they will offer.
- Set a review date that the young person, the specialist young person’s worker and the new adult services worker will attend.
You should provide services based on a child or young person’s need, not just based on their age. If a children and young people’s service can meet the needs of a person aged 18 or over better than an adult service, without putting other young people who use the service at risk, then this would be the most appropriate placement. So, commissioners should allow services to be flexible when considering transitional arrangements to make sure that any transfer of an 18 year old into adult alcohol treatment services is in the young person’s best interests.

Some children and young people’s services continue to work with 18 to 24 year olds on transitional arrangements until professionals working with them assess that it’s appropriate for them to transfer to an adult service. Also, some young adults aged 18 to 24, assessed as having needs which would make starting treatment in an adult service inappropriate, can start treatment in a child or young person’s service and then transfer to an adult service once professionals assess this as appropriate, as a part of transitional arrangements.

Adult services should provide tailored services and interventions for the needs of young adults, including ensuring there is a safe and appropriate environment for them to receive their support.

23.11 Selecting care packages and interventions

23.11.1 Deciding which interventions to offer

The keyworker and multidisciplinary team should decide which interventions the service will offer based on the child or young person’s individual needs. This involves considering the severity of their problem alcohol use and the complexity of their wider needs.

In general, the duration and intensity of interventions, and the extent to which other services are involved, is likely to increase with the severity of problem alcohol use or complexity of co-occurring needs (such as mental and physical health problems, educational, social and safeguarding needs).

For most children and young people with problem alcohol use, the interventions the alcohol and drug treatment service offers will be psychosocial interventions. The service should offer all children and young people structured support (see section 23.13.3) delivered by a named keyworker.

23.11.2 Children and young people with complex needs

Where children and young people have needs in several areas and their protective factors are not strong, they are likely to benefit from:
- a more intensive intervention that might include ongoing structured support
- psychological treatment (see section 23.13.4) from a specialist member of the multidisciplinary team
- care planned interventions from other relevant services
Children and young people with the most complex needs, including children with severe mental health or neurodevelopmental conditions or high safeguarding needs, are likely to need a multi-agency package of care led by a specialist professional, such as a specialist mental health clinician or a social worker. The interventions from the children and young peoples’ alcohol and drug treatment service will contribute to this wider multi-agency plan.

23.11.3 Inpatient and residential treatment

It is rare for children and young people to be alcohol dependent but if they are, they will need a more intense specialist alcohol intervention that integrates a pharmacological intervention (medically assisted withdrawal) with psychosocial interventions. Inpatient medically assisted withdrawal in an age-appropriate setting is recommended for children 10 to 17 years old.

Most children and young people should receive support and specialist psychosocial interventions in the community. There is little evidence that residential units and therapeutic communities are effective for young people with problem alcohol use.

A minority of children and young people may be attending residential units. It is likely that those attending residential units will have significant alcohol and drug problems with multiple comorbidities, including conduct disorders. They may also be involved in the criminal justice system and might have been referred by the courts or children’s social care. So, these units need to have a skilled multidisciplinary team creating a safe environment in which children and young people can feel secure and engage in multicomponent programmes for both alcohol and other co-occurring mental and physical health conditions.

23.11.4 Information about services

Keyworkers should be familiar with the range of treatment and support options the service offers and be able to provide accurate information on each of these in a way that the child or young person can understand. Information should be verbal and written or in another format such as video.

23.12 Managing co-occurring alcohol and mental health and neurodevelopmental conditions

An example of a care package for a child or young person with complex needs is how the alcohol and drug treatment practitioner and mental health services work together to manage co-occurring alcohol and mental health conditions or neurodevelopmental conditions.

Occasional alcohol use, persistent use and dependence can all cause or make worse mental health problems and some neurodevelopmental conditions, such as ADHD, and interfere with treatments. Co-occurring mental health and neurodevelopmental conditions and alcohol problems are common among people in children and young people’s mental health services and alcohol and drug services.

It is vital that all children and young people with significant alcohol and drug problems receive a comprehensive assessment of their mental health and any neurodevelopmental conditions.

Mental health treatment and treatment for some neurodevelopmental conditions will often involve paediatric services and child and adolescent mental health services. There needs to be active communication and co-ordination between these services and children and young people’s alcohol and drug treatment services.

Any treatment for comorbid conditions should be underpinned by carefully co-ordinated care that addresses a young person’s personal, family, health and social care needs. Practitioners need to take particular care of children and young people who have alcohol or drug problems and suicidal thoughts. This is because treatment can be challenging and requires a carefully monitored integrated approach between the mental health service provider and the children and young people’s alcohol and drug treatment service.

The treatments for comorbid mental health conditions will vary but require:
- more intensive case management
- careful monitoring and co-ordination
- continuity of care
- proactive engagement
- continued training and supervision of all staff
For children and young people with more significant mental health disorders, there needs to be:
- engagement by all professionals involved (including CAMHS clinicians and alcohol and drug treatment services)
- a good working relationship between these professionals
- a named mental health practitioner leading on the child or young person’s care
- co-ordinated delivery of multiple psychosocial interventions, alongside pharmacological treatments for mental ill-health, where these have been assessed as clinically appropriate
- multidisciplinary and multi-agency care plans with regular reviews
23.13 Specialist psychosocial interventions

23.13.1 Evidence base

The evidence base for specific psychosocial interventions for problem alcohol use among children and young people aged 17 and under is limited. Recommendations are often made using research from adult, young adult and university student populations and are often based on research from outside the UK.

As with psychosocial interventions for other conditions, meta-analyses have shown that substance use treatment programmes help children and young people to reduce alcohol and drug use, although there is less information on longer term outcomes (Dennis, 2004; Tanner-Smith and others, 2016).

The evidence is inconclusive on recommending one type of intervention above another (Godley and others, 2004). But research suggests that delivering an intervention based on a clear theoretical model is more likely to make a positive difference to outcomes and engagement than offering a less structured intervention.

Some psychotherapeutic factors have been found to be common in effective treatment for all conditions and across all age groups (Peterson, 2019). These common factors are closely related and include:
- a strong therapeutic alliance
- empathy
- warmth and authenticity
- a formulation of the child or young person’s problem and how to treat it that is understood and agreed between them and the practitioner
Section 23.13.3 provides guidance on structured support that is based on common factors in effective treatment for problem alcohol and drug use.

23.13.2 Delivering specialist psychosocial interventions

Psychosocial interventions for problem alcohol use in children and young people consist of structured support and formal psychological treatments.

Structured support is generally delivered in community alcohol treatment services by a keyworker who is the named practitioner in the service with an ongoing relationship with the child and young person.

Formal psychological treatments recommended for children and young people are generally provided by a specialist member of the MDT according to individual need, alongside a keyworker who provides structured support.

Alcohol and drug workers in their keyworking role can deliver structured support. Services should provide training and regular clinical supervision to practitioners who provide structured support to children and young people, which should be underpinned by a quality governance framework.

23.13.3 Structured support

Structured support involves using specific psychosocial interventions which are common to evidence-based psychological treatments for alcohol and drug use (Moos, 2007; Manuel and others, 2011). These common factors (or change mechanisms) include:
- a strong therapeutic alliance
- structure and goal direction
- interventions to develop alternative rewards and activities to alcohol use
- engagement with supportive family and social networks and peer relationships
- building self-efficacy and coping skills
Using these common factors to frame the use of specific psychosocial interventions is a pragmatic and flexible approach to providing treatment and support. These psychosocial interventions can be described as ‘evidence-based practices’ to highlight the distinction from a comprehensive formal psychological treatment approach (Manuel and others, 2011).

Keyworkers should adapt structured support to a child or young person’s individual needs based on individual assessment.

There is guidance on structured support in section 5.5 in chapter 5 on psychosocial interventions. This approach can be used for working with children and young people, but clinicians and keyworkers need to adapt it so it’s appropriate for their age and developmental stage. The sections below summarise considerations, based on the above common factors, when providing structured support for children and young people.

A strong therapeutic alliance

You should read about therapeutic alliance in section 5.5.1 in chapter 5 on psychosocial interventions. There is evidence that the therapeutic alliance is a major influence on therapeutic outcomes across all age groups (Peterson, 2019). Research shows that when working with young people, a strong therapeutic alliance with both the young person and parents promotes positive therapeutic outcomes (Murphy and Hutton, 2017). There is evidence for the positive role of the therapeutic alliance in some specialist substance misuse treatment interventions for young people (Shelef and others, 2005; Tetzlaff and others, 2005; Hogue and others, 2006).

Practitioners working with children and young people need capabilities in forming a therapeutic alliance with children and young people of different ages. Practitioners need to understand the child or young person’s developmental needs and how these affect the way they should interact with the child or young person to build a trusting relationship.

Many children and young people attending services have experienced trauma and the practitioner should use an age-appropriate trauma-informed approach.

Structure and goal direction

You should read about structure and goal direction in section 5.5.2 in chapter 5 on psychosocial interventions (/guidance/clinical-guidelines-for-alcohol-treatment/5-psychosocial-interventions#support-structure-and-goal-direction).

There is evidence (outlined in the UNODC and WHO ‘International Standards on Drug Use Prevention’) that children and young people benefit from a structured (but not rigid) approach.

It is important that the child or young person contributes to the development of their individualised care plan, including the goals that they agree on. A shared understanding between the keyworker and the child or young person of their difficulties and how they will make changes strengthens the therapeutic alliance and leads to positive outcomes.

Some children and young people experience a lack of structure, predictability and safety in their family or their daily life. So, a predictable structure and reliable support from an adult are important to promote a sense of emotional safety, trust and self-confidence. The individual care plan should encourage ambition and confidence in the child or young person’s ability to achieve change. See section 23.9 for guidance on care planning.

The keyworker should help the child or young person break down goals into achievable steps so they can have a sense of achievement as they make progress. This can help support their belief that they can make changes.

Interventions to develop alternative rewards and rewarding activities

You can read about rewards and rewarding activities in section 5.5.3 in chapter 5 on psychosocial interventions (/guidance/clinical-guidelines-for-alcohol-treatment/5-psychosocial-interventions#rewards-and-rewarding-activities). It provides guidance on supporting an adult to take part in rewarding and meaningful activities in the context of building recovery from long term problem alcohol use.

One significant difference when offering structured support to children and young people is that ‘recovery’ and ‘recovery-oriented activities’ are not usually applicable concepts to children and young people. This is because of their developmental stage (which will vary according to their age) and their different patterns of alcohol use. However, it is important to support children and young people to access meaningful and positive activities. Helping them engage in positive and rewarding activities is about helping them find alternatives to problem alcohol use, but it is also about supporting and promoting their age-appropriate development and strengthening protective factors across all areas of their life.

If a child or young person is not in education, there should be a multi-agency approach to care planning that will usually be led by child safeguarding services. Structured support offered by the keyworker in the alcohol and drug treatment service should contribute to the multi-agency approach, and support actions to help the child or young person get back into education. This is vital for their development and future opportunities and to reduce their vulnerability to harms, including exploitation.

It is also important to help the child or young person to identify activities they would like to take part in or develop and help them to access one or more of these activities. To help them access an appropriate activity, the keyworker should offer emotional support and encouragement. The keyworker should also help to find suitable activities, and where appropriate obtain consent from parents or carers and make practical arrangements so the child or young person can attend. Taking part in an activity they love or find rewarding can provide them with a sense of meaning, self-efficacy and hope. It can also be a way of meeting other children and young people with shared interests. There is evidence that being involved in positive activities and hobbies can be protective for children and young people with vulnerabilities (Velleman and Templeton, 2018).

Parents or carers being involved in the child or young person’s treatment can mean they are supported to attend activities and also receive rewards when they make progress towards their goals. Rewards can be in the form of praise or a treat, such as a family outing.

Family and social networks and peer relationships

You should read about social support and networks in section 5.5.4 in chapter 5 on psychosocial interventions (/guidance/clinical-guidelines-for-alcohol-treatment/5-psychosocial-interventions#social-support-and-recovery-oriented-networks). An essential part of structured support is helping people to establish or re-establish connections with people or groups who can provide useful support. Section 5.5.4 includes guidance on helping adults access mutual aid groups and recovery orientated social networks.

The concepts of recovery and recovery orientated networks are not usually applicable to children and young people (see previous section above) and adult mutual aid groups are not suitable for children and young people. However, supportive family and social networks are vital for children and young people’s development, wellbeing and safety.

The keyworker can help the child or young person map their family and social networks and identify adults and peers who are or could be supportive. Keyworkers should help children and young people strengthen existing supportive networks and develop new ones.

Helping children and young people develop supportive networks can include:
- access to interventions to strengthen their relationships with parents, carers and family members (see section 23.13.4)
- helping them access safe, age-appropriate, supportive youth, community or faith-based groups and activities that promote their wellbeing and development and provide an opportunity to make new friendships
- helping them take part in structured groups with peers at the service, including those who have made significant changes in their alcohol use and other areas in their life
- encouraging them to develop peer relationships in their daily lives that do not involve risky or anti-social behaviour
There is guidance in involving parents or carers in the child or young person’s care in section 23.7.

Where a child or young person is involved in relationships with adults or peers that put them at risk of significant harm, the keyworker must follow national guidance and organisational procedures for child safeguarding.

If peer relationships do not involve a safeguarding risk but involve other children or young people with problem alcohol or drug use or other risky behaviours, the keyworker can help the child or young person to review these relationships and the potential role of peer pressure in their problem alcohol use.

Self-efficacy and coping skills

You should read about interventions to promote self-efficacy and develop coping skills in section 5.5.5 in chapter 5 on psychosocial interventions (/guidance/clinical-guidelines-for-alcohol-treatment/5-psychosocial-interventions#self-efficacy-and-coping-skills).

Supporting a child or young person’s belief in their ability to make changes in their alcohol use and in other areas of their life is an essential element of structured support for children and young people whose self-confidence and self-esteem can often be very low. See the next section below for guidance on how keyworkers can use an approach based on motivational interventions to do this.

Keyworkers can also support children and young people to learn age-appropriate coping skills, as described in section 5.5.5 in chapter 5.

Learning skills to resist peer pressure to drink or take part in other risky behaviour is particularly relevant for children and young people. Children and young people often also benefit from learning skills to manage emotions and interpersonal difficulties.

Structured support and motivational interventions

You should read guidance on structured support and motivational interventions in section 5.5.6 in chapter 5 (/guidance/clinical-guidelines-for-alcohol-treatment/5-psychosocial-interventions#structured-support-and-motivational-interventions).

Motivational interviewing (MI) and motivational enhancement therapy (MET) principles are used extensively in children and young people’s treatment services, although the evidence is mainly from adults. There is some evidence to support using MI and MET to reduce problem alcohol use in young people (aged 13 to 15) (Kohler and Hoffman, 2015) and in combination with cognitive behavioural therapy to reduce cannabis use (Dennis and others, 2004). The general clinical consensus is that MI and MET techniques are important in engaging young people in treatment.

Structured support and preparing for treatment to end

An important part of structured support is helping the child or young person prepare for the end of their engagement with the alcohol treatment service and agreeing support after they leave. There is guidance on planning for endings and transitions in section 23.9.4 and 23.10, respectively.

23.13.4 Psychological treatments for young people

Psychological treatments that practitioners could consider for a child or young person’s care plan are set out below. These are recognised evidence-based structured interventions that can be offered by a competent practitioner. Practitioners delivering these interventions should:
- be trained in the approach
- have the skills required for the specific intervention offered
- have access to ongoing supervision from an appropriately qualified professional
If the assessment suggests that a child or young person would benefit from one of these interventions, the intervention should be offered alongside structured support and interventions to meet their wider needs.

Elements of these interventions may be integrated into structured support under the oversight of a practitioner trained in the approach and with supporting clinical supervision.

The practitioners can use MI alongside the psychological treatments described in section 23.13.4 as they can be helpful in building the therapeutic alliance and engagement with treatment (Miller and Rollnick, 2023).

Cognitive behavioural therapy

Services can offer cognitive behavioural therapy (CBT) for children and young people aged 10 to 17 years who have alcohol problems and have limited comorbidities (other mental or physical health conditions co-occurring with alcohol problems) and good social support. This is a time-limited, structured psychological intervention. It is recommended by NICE guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (https://www.nice.org.uk/guidance/cg115) (CG115).

CBT can be effective in reducing alcohol use as well as other related problems. You can find guidance on CBT in section 5.6.4 in chapter 5 on psychosocial interventions.

Practitioners should adapt the CBT programme to the child or young person’s developmental stage. The learning principles of CBT operate similarly for adults and children and young people. However, the behavioural targets of change, and how rewards for achievement are negotiated, will vary depending on the age and developmental level of the child or young person. For some children and young people, this may involve adding components to the programme to develop basic social and coping skills (Waldron and Kaminer, 2004).

Skills training

Skills training helps children and young people develop the knowledge, attitude and skills they need to cope with difficult life situations and to manage their emotions. These are important factors in supporting them to make healthy choices and to reduce harmful behaviours. This might include skills for resisting social pressure or dealing with feelings of exclusion. Learning new personal or social skills can be a component of CBT interventions, but skills training can also be offered as a standalone approach.

The NICE guideline Drug misuse prevention: targeted interventions (https://www.nice.org.uk/guidance/ng64) recommends skills training is offered to children and young people and to their parents and carers. Practitioners will need to consider whether to offer these training sessions to children and young people and their parents and carers together, or as separate sessions.

Multicomponent programmes including family support and family therapies

Multicomponent interventions combine 2 or more intervention approaches. The exact combination of components in a programme depends on the specific needs of the child or young person. The components of the intervention should be agreed in partnership with the child or young person, their family, the specialist alcohol and drug treatment service and any other services involved in their care.

NICE CG115 recommends multicomponent programmes based on various approaches to family therapy (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for children and young people with significant co-morbidities and limited social support.

These are all intensive programmes provided over an extended period, generally between 3 to 6 months, with family sessions and individual interventions for both the child or young person and their parents or carers. Delivering these interventions needs trained and experienced practitioners, strong supervisory structures, and small caseloads.

NICE CG115 provides more detail on how these therapies can be used to support children and young people, their parents and wider family to make changes that will help the child or young person with their problem alcohol use.

23.14 Pharmacological interventions for children and young people

23.14.1 Medically assisted withdrawal

Alcohol dependence in children and young people is rare. But a minority of children or young people can be dependent on alcohol. Medically assisted withdrawal is needed if a young person is assessed as physically dependent.

Before medically assisted withdrawal

Chapter 10 on pharmacological interventions provides guidance on prescribing for medically assisted withdrawal and chapter 11 provides guidance on community medically assisted withdrawal. This section notes specific considerations and adjustments for children and young people. Clinicians prescribing and managing medically assisted withdrawal should follow the guidance in chapter 10 alongside this section and they should also consult the British National Formulary for Children (https://bnfc.nice.org.uk/) (BNFC) because prescribing for children and young people is different to prescribing for adults.

Staff responsible for assessing and managing medically assisted withdrawal should be clinicians who are competent in:
- diagnosing and assessing alcohol dependence and withdrawal symptoms appropriate to the settings in which it is managed
- the use of drug regimens for children and young people
Before any treatment for dependence, it is important that a person’s clinical history has determined alcohol dependence. It is important that anxiety symptoms or an anxiety disorder are not confused with withdrawal symptoms and inappropriate treatment started.

Polydrug use is an important consideration. Clinicians will need to carefully assess the level of use and dependence on any substance, particularly if the child or young person is using alcohol and drugs (such as opiates and benzodiazepines) together.

There is guidance in section 10.6.1 in chapter 10 on pharmacological interventions about medically assisted withdrawal for people with co-occurring alcohol dependence and drug use or dependence.

The clinician and keyworker in the children and young people’s alcohol and drug treatment service should provide information about medically assisted withdrawal and what it will involve to the child or young person and to their parent or carer, including the risks and benefits for the child or young person. They should also inform other professionals involved in caring for and safeguarding the child or young person.

Involving the right people

Age-appropriate pharmacological interventions for problem alcohol or drug use need to involve specialist services and staff such as:
- paediatricians
- practitioners from the specialist alcohol and drug treatment service
- primary care
- CAMHS staff
- addiction psychiatrists
- nursing staff
If a child or young person needs medically assisted withdrawal, staff should involve children’s social care.

When a child or young person needs pharmacological management, it is good practice to involve their parents and carers, even if they have been assessed as competent to consent to their own treatment. Practitioners should do as much as they can to make sure parents or carers are involved.

Medically assisted withdrawal should be only one component of a child or young person’s care plan, and it should be integrated with psychosocial interventions. It should also be based on a comprehensive multi-agency assessment, including risk assessment.

Pathway to treatment

NICE CG115 provides guidance on delivering alcohol treatment to children and young people aged 10 years and older and includes a specific pathway for those aged 10 to 17 years old.

NICE recommends inpatient admission for medically assisted withdrawal. This should be in an age-appropriate setting with access to specialist alcohol treatment expertise. Children and young people should not be treated in an adult setting.

Any setting, such as a paediatric or CAMHS inpatient setting, that a child or young person is referred to should be registered with the national regulatory body.

There should be a clear local clinical pathway for children and young people who require inpatient medically assisted withdrawal. It should be agreed between commissioners, senior leaders of children and young people’s healthcare services, specialist alcohol and drug treatment services and child safeguarding services. These partners should also agree referral and discharge routes. Agreeing the clinical pathway can help reduce unnecessary delay and help to improve patient safety if there is a need for a child or young person to undergo inpatient medically assisted withdrawal.

Settings such as secure estates, residential services, acute or mental health hospitals need to ensure that treatments delivered by specialist alcohol treatment clinicians are available to manage withdrawal, if a child or young person staying there needs it.

Prescribing for children and young people

Clinicians prescribing and managing medically assisted withdrawal should follow the guidance in chapter 10 alongside this section. They should also consult the BNFC.

Many medications for alcohol dependence will be off-label for children and young people aged 17 and under.

There are situations when clinicians might decide that using unlicensed medicines or using medicines outside the terms of the licence (known as off-label use) is in the best interest of the patient, based on available evidence.

Prescribers should be aware of their responsibilities when prescribing unlicensed or off-label medications, outlined in the Medicines and Healthcare products Regulatory Agency guidance Off-label or unlicensed use of medicines: prescribers’ responsibilities (https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities#examples-of-off-lbel-use-of-medicines).

Children and young people respond differently to medications than adults and younger children respond differently than older children. So, clinicians need to show detailed care and attention when making prescribing decisions for children and young people.

For those children and young people who require medically assisted withdrawal, clinicians can use benzodiazepines (chlordiazepoxide or diazepam) with doses adjusted based on their:
- age
- height
- weight
- stage of development
Clinicians should consult the BNFC.

It is important that any child or young person offered medically assisted withdrawal is closely monitored by competent specialist staff. What this looks like in practice will be based on clinical judgement determined on a case by case basis, but prescribing should be regularly reviewed.

You can find more information on pharmacological interventions for children and young people in secure settings in the 2009 Department of Health Guidance for the pharmacological management of substance misuse among young people in secure environments (http://www.drugsandalcohol.ie/14428/).

23.14.2 Relapse prevention

There is limited evidence from trials investigating the efficacy or use of relapse prevention medications in young people. Also, relapse prevention medications are not licensed for use in people aged 17 and under because of the lack of evidence to guide their use and safety in younger people. There are some pilot placebo-controlled or open-label randomised control trials of acamprosate, naltrexone or disulfiram in young people (mainly 15 to 19 years old). But all the studies are based on small groups and their results should be interpreted very cautiously (Clark, 2012).

NICE CG115 recommends that after a careful review of the risks and benefits, specialist clinicians can consider offering acamprosate or oral naltrexone, along with CBT, to young people over 16 who have not benefited from or engaged with a multicomponent treatment programme.

23.15 Resources

23.15.1 Guidance on children and young people’s services

Establishing youth-friendly health and care services (https://www.gov.uk/government/publications/establishing-youth-friendly-health-and-care-services) sets out 8 standards and associated quality criteria for youth-friendly services that have been developed in partnership with young people.

Multi-agency practice principles for responding to child exploitation and extra-familial harm (https://tce.researchinpractice.org.uk/) is part of the Tackling Child Exploitation support programme, funded by the Department for Education and led by Research in Practice with the University of Bedfordshire and The Children’s Society. It developed a set of practice principles to inform local and national responses to child exploitation and extra-familial harm. These principles are also helpful for working with children with vulnerabilities in general.

Getting it right for every child (https://www.gov.scot/policies/girfec/) is a framework and shared language for promoting, supporting, and safeguarding the wellbeing of children and young people in Scotland. It includes principles and values for working with children and young people.

23.15.2 Resources for schools to teach about alcohol and drug use

The PSHE Association has developed drug education (https://pshe-association.org.uk/drugeducation), a resource to support schools to teach about alcohol and drug use, including drug education for children with special educational needs and disabilities (SEND) (https://pshe-association.org.uk/resource/drugs-alcohol-lessons-send). These resources help teachers to plan age-appropriate lessons and to feel confident about informing young people about the law, risks and consequences associated with alcohol use. This resource is for schools in England.

23.15.3 Legal, statutory and policy frameworks

Specialist alcohol treatment and the competencies for working effectively with young people are different to those for adults. The resources below provide information on the different legal, statutory and policy frameworks for working with children, young people and their families.

Child safeguarding

Child safeguarding legislation and statutory guidance applies to both children and young people’s services and adult services. You can find more information on the legislation and statutory guidance for each UK nation in annex 1.

Parental responsibility

All mothers and most fathers have legal rights and responsibilities as a parent. This is known as parental responsibility. You can find out more at Parental rights and responsibilities (https://www.gov.uk/parental-rights-responsibilities).

Parental responsibility is defined by UK legislation in the:
- Children Act 1989 (https://www.legislation.gov.uk/ukpga/1989/41/contents) for England and Wales (in section 3: meaning of “parental responsibility”)
- Children (Scotland) Act 1995 (https://www.legislation.gov.uk/ukpga/1995/36/contents)
- Children (Northern Ireland) Order 1995 (https://www.legislation.gov.uk/nisi/1995/755/contents)
Capacity to consent to treatment

The Care Quality Commission (CQC) has published a brief guide on capacity and competence to consent in under 18s (PDF, 80KB) (https://www.cqc.org.uk/sites/default/files/Brief_guide_Capacity_and_consent_in_under_18s%20v3.pdf), which summarises the policy position and details relevant guidance and legislation in England.

Age of Legal Capacity (Scotland) Act 1991 (Section 2(4)) (https://www.legislation.gov.uk/ukpga/1991/50/section/2) informs practitioner decisions about the capacity of a child under the age of 16 years to consent to their own treatment.

You can read more about Gillick competency and Fraser guidelines and making decisions about capacity to consent to treatment at the:
- NSPCC learning website’s Gillick competency and Fraser guidelines (https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines)
- CQC’s GP mythbuster: Gillick competency and Fraser guidelines (https://www.cqc.org.uk/guidance-providers/gps/gp-mythbuster-8-gillick-competency-fraser-guidelines)
- General Medical Council’s 0 to 18 years guidance (https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/0-18-years)
Confidentiality

Confidentiality: NHS code of practice (https://www.gov.uk/government/publications/confidentiality-nhs-code-of-practice) provides guidance to NHS and NHS-related organisations about patient information confidentiality issues. It also briefly outlines expectations and exceptions around confidentiality for children and young people.

23.16 References

Bonomo YA, Bowes G, Coffey C, Carlin JB and Patton GC. Teenage drinking and the onset of alcohol dependence: a cohort study over seven years (https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2004.00846.x). Addiction 2004: volume 99, issue 12, pages 1,520 to 1,528 (registration and subscription required for full article).

Clark D. Pharmacotherapy for adolescent alcohol use disorder (https://link.springer.com/article/10.2165/11634330-000000000-00000). CNS drugs 2012: volume 26, issue 7, pages 559 to 569 (registration and subscription required for full article).

Costello E, Armstrong T and Erkanli A. Report on the developmental epidemiology of comorbid psychiatric and substance use disorders (https://www.researchgate.net/publication/267421222_Report_on_the_Developmental_Epidemiology_of_Comorbid_Psychiatric_and_Substance_Use_Disorders). National Institute on Drug Abuse, 2000.

Coulton S, Alam F, Boniface S, Deluca P, Donoghue K, Gilvarry E, Kaner E, Lynch E, Maconochie I, McArdle P, McGovern R, Newbury-Birch D, Patton R, Phillips CJ, Phillips T, Rose H, Russell I, Strang J and Drummond C. Opportunistic screening for alcohol use problems in adolescents attending emergency departments: an evaluation of screening tools (https://academic.oup.com/jpubhealth/article/41/1/e53/4953708?login=false). Journal of Public Health 2018: volume 41, issue 1, pages e53 to e60.

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