Empathetic Curiosity: Better Engaging Youth With Substance Use Disorder

CLINICAL CONVERSATIONS

With the announcement of the updated set of guidelines from The American Society of Addiction Medicine (ASAM) Criteria, The Adolescents and Transition-Aged Youth volume, Psychiatric Times sat down with our Child and Adolescent Section Editor, Stephen Mateka, DO, to gauge what these new dedicated treatment standards and admission criteria for youth with substance use disorder (SUD)^1-3 mean for the practice of child and adolescent psychiatry.

Psychiatric Times: To start, the ASAM has announced a new set of guidelines that establish dedicated treatment standards and admission criteria for youth with substance use disorder. What do you believe these guidelines will bring to the table for practicing mental health clinicians? Do you think it will change current standards of care?

Stephen Mateka, DO: It is a great question. I think that first and foremost, it is going to offer clear guidance that is specific to this age group. We know that prior to this rollout, the ASAM guidelines had guidance for adolescents baked into those for adults, and these updated guidelines are going to offer very specific approaches to meet the needs of youth that are either under the age of 15 or transitioning from ages 16 to 25.

I would like to believe these changes will allow us to meet the current standards for this patient population. In fact, these guidelines are more reflective of meeting the unique needs of youth, as opposed to setting a whole new standard. It is only appropriate that we are treating youth developmentally and focusing on prevention techniques when possible. What really came through with these guidelines was the increased emphasis on secondary prevention, or when you already have a degree of a concern, but then you intervene in effort to prevent further escalation and decompensation.

PT: Previously, standards of care for adolescents with SUD were lumped in with those for adults. Why is it so critical for us to differentiate the standards for youth? What do you see as the biggest differences between treating adults and adolescents?

Mateka: As we know, 80% of SUDs start in youth, and the entire reasoning for these guidelines was to try to have better outcomes. It is common sense to make sure that you have the specific needs of youth being parsed out from those of adults. Additionally, SUD does not happen in a vacuum. It is not in isolation, where you just get exposed to a substance, and the next thing you know, you are addicted. There are many other factors at play, and we know that the adolescent brain is mostly all gas, no breaks—so they are already struggling with an underdeveloped frontal lobe that would allow them to make better decisions. Then getting exposed to the level of dopamine that comes with illicit substances completely primes the brain for a hijacking of their reward and pleasure system, and thus future behavior. Keeping that in mind, that we are dealing with a very vulnerable brain, it would then make sense that the efforts need to be focused much more preventatively, when compared to an adult. At age 25, the frontal lobe has been fully developed, so then those interventional services are not working with as much neuroplasticity. To me, this is really about the opportunity to change a trajectory of a child that is exposed to substances early in life.

Substances are rarely being used solely for the sake of the brief euphoria that they may bring. For us as clinicians, it is about asking the why: What need is being met? That usually involves co-occurring mental illness, or at the very least mental health struggles. When we talk to individuals that are using substances, one of their main reasons for use is the transient reprieve from the stresses or worries of their life. So obviously, if someone felt more confident and capable to address those concerns in a way that was healthy, it would make the need for substance use obsolete.

Lastly, we hear so often “it takes a village.” A systematic approach to help meet a youth's needs when it comes to substance use just makes sense. The new ASAM guidelines are now filtered through a holistic lens, that encourages activation of the system around the youth to make sure that they are wrapped in support. Support is the primary protective factor against decompensation when it comes to mental health and the primary predictive factor when it comes to resilience. It becomes a bit of a no brainer that this would be the strategy, and I am just thrilled that children and adolescents are getting the focus they so sorely deserve.

PT: What do you see as the biggest challenges in addressing substance use disorders in adolescents and transition aged youth?

Mateka: This is not just unique to adolescents or youth that are using substances, but really when it comes to mental health in general—even medicine in general—it is identifying what is the ideal and what is the reality, and then closing that gap. To me, it is going to be the actualization of sustainable systems, where you have clear protocols and algorithms, that ensure the right stakeholders are incorporated. For example, let’s we are going to mobilize the supports in the community: with school, with spiritual care, with the pediatrician, and with the mental health provider. That sounds fantastic. That is absolutely the ideal. But how is that actually going to be executed? How will you be able to get that many different entities on the same page with clear expectations and a shared vision? Furthermore, substance use is much more prevalent where there is a lack of mental health treatment, and that needs to be acknowledged and addressed. We are talking about our most vulnerable populations that need access to care the most. So there really needs to be a concrete plan in place of how this actually gets executed.

Additionally, there is the payment model. It cannot be ignored. We certainly wish that it was not part of the conversation, but we would be naive or ignorant not to include it. We need to ensure that families are able to not just access the services they need for their child, but afford them as well.

PT: How should clinicians be talking with their patients about substance use? What are the most important things to address? How can your peers start that conversation? I imagine it could be difficult.

Mateka: Absolutely, though I will also say, that is our job. Our job is to have difficult conversations, and that should not be something that deters us, but in fact, something that informs us of how important it is. How do you optimize your messaging to ensure it resonates with the person in front of you? If you give youth an opportunity to follow a script, answer generic questions, or give answers that are “supposed to be the right answer,” they are going to give them. I believe empathetic curiosity is at the heart of creating a safe space and developing the therapeutic alliance. It makes the youth in front of you say, “I feel like this person is actually listening to me, is actually interested in what I have to say, and is going to talk specifically to me and not at me like I am just a task or a note to be written.” The amount of times that I tell patients, “I don't blame you one bit…” I do not blame them for the way that they think, feel, or the choices that they make, because kids and teenagers are just trying to do their best to figure out the world. And if they find a problem gets solved, they are not considering the unintended consequences or the sequelae of that solution. They are just concretely saying, “Oh, that worked in that vacuum, and so I am going to try that again.” So if you are being judgmental, dismissive, or invalidating around substance use, then you have already lost, in my opinion. They are just trying to get their needs met. If you have an honest conversation of, “How is that strategy working out for you? Do you like the results and outcomes you're getting? And if you do not, then that means we have to do something differently, and it's my job to be able to guide you to that.” That is something that I hear a lot from the patients I work with. They will tell me, “I don't know how to do it. I don't know what I'm supposed to do.” Tell them that is not their job. Their job is to decide whether or not it matters enough to put in consistent effort. That is why clinicians have to go through so much schooling and training, so that we can offer the roadmap and guide our patients along the way.

PT: Is there anything else you'd like to specifically share with your peers about these new guidelines?

Mateka: If there would be one thing I would want my colleagues to further take away from these new ASAM guidelines, it is what they represent. They represent how care for youth really is meant to be, which is meeting them where they are, with their specific developmental needs, and a focus on primary and secondary prevention. It is really easy to appreciate improvement when it is in reaction to a problem. For example, if someone is struggling with addiction, and you are able to get them the support they need. They are no longer using substances; It is concrete. It tells the brain we have achieved something. But preventative measures are much harder for the brain to appreciate because they are abstract. It is in the future, and our brains have biases towards what is immediate and what is concrete.

If preventative efforts are really successful, you are going to have the absence of decompensation, the absence of suffering, and that is hard to wrap your head around sometimes. My hope is that my colleagues appreciate that ASAM has really hit the nail on the head of how to approach treating youth, not just with SUD, but with any type of mental health struggles. We must meet them where they are. We will approach them comprehensively and holistically, and we will try to prevent a debilitating trajectory. All we want is for these kids to have better outcomes, to live the healthy lives, and to achieve the goals and dreams that they have for themselves. That is the real work.

Dr Mateka is the child and adolescent section editor for Psychiatric Times.

References

1. New standards for adolescent substance use disorder care announced. News release. March 25, 2026. Accessed March 26, 2026. https://www.hazeldenbettyford.org/press-release/asam-youth-criteria

2. The ASAM Criteria, Fourth Edition Adolescents and Transition-Aged Youth Volume. ASAM. Accessed March 26, 2026. https://www.asam.org/asam-criteria/adolescent-volume

3. Kuntz L. ASAM announces new standards for adolescent substance use disorder care. Psychiatric Times. March 26, 2026. https://www.psychiatrictimes.com/view/asam-announces-new-standards-for-adolescent-substance-use-disorder-care