Youth and Substance Use Toolkit 

Table of Contents

01 Welcome

02 What is a Co-occurring disorder?

2.1 Recovery Support Systems
2.2 Levels of Care for SUD Tx
2.3 Resources

03 Confidentiality and Treatment Involving Minors (Youth)

3.1 Confidentiality and Limits to Confidentiality
3.2 A Minor’s Right to Consent to Treatment
3.3 A Minor’s Right to Confidentiality in Treatment
3.4 Confidentiality of Substance Use Disorder Patient Records
3.5 Resources 

04 Care Coordination for Youth Serving Agencies

4.1 Coordinated Care Approaches for Addressing Substance Use Disorders
4.2 Los Angeles County's System of Care: A Model for Integrated Youth SUD Treatment
4.3 Resources

05 Promoting Engagement in Prosocial Activities

5.1 The Role of Prosocial Activities in Youth Recovery
5.2 Supporting Recovery and Reducing Relapse Through Engagement
5.3 Building Positive Peer Networks and Family Bonds
5.4 Addressing Mental Health Through Trauma-Informed and Expressive Activities
5.5 Embedding Youth in Supportive Environments for Long-Term Recovery
5.6 Ensuring Cultural Responsiveness in Prosocial Programming
5.7 Recommendations for Expanding Access and Impact
5.8 Resources

06 Recovery Support Systems and the Importance of Parental Involvement in SUD Treatment with Youth

6.1 Recovery Support System
6.2 Parental Involvement in SUD Treatment
6.3 Statistics as of 2024
6.4 Resources

07 What is Trauma Informed Care?

7.1 Defining Trauma-Informed Care (TIC)
7.2 SAMHSA’s Six Principles of TIC
7.3 The Urgency for TIC in California Youth & Substance Use
7.4 Co-Occurring Disorders and Integrated Care
7.5 Creating Trauma-Sensitive Environments
7.6 TIC for High-Risk and Marginalized Youth
7.7 Implementing TIC in Practice
7.8 TIC as a Path to Equity and Recovery
7.9 Resources

08 Youth Involved in the Juvenile Justice System

8.1 Early Identification and Trauma-Informed Care for Incarcerated Youth
8.2 Resources

09 Commercial Sexual Exploitation of Children and Human Trafficking

9.1 Understanding the Intersection of CSEC, Human Trafficking, and SUDs
9.2 The Link Between Exploitation Trauma and Substance Use
9.3 Addiction as a Tool of Control in Trafficking
9.4 Barriers to Treatment for Exploited Youth
9.5 Trauma-Informed, Integrated Treatment Approaches
9.6 Actionable Recommendations for Agencies
9.7 Resources

10 References

11 Credits

The field of co-occurring disorders and substance use treatment can be complex and overwhelming for many new professionals and paired with the added complexities of working with youth and adolescents in this field can make it even more challenging. This toolkit is designed to cover helpful resources along many categories that are specific to working with youth and substance use treatment services. Each section has additional resources at the end with links and websites where you can get additional information and resources on this topic. While this toolkit is extensive and covers a wide range of resources from legal and ethical issues to clinical resources and guidelines. This is by no means an exhaustive list of topics and resources. We hope that this will provide additional insight and information on what we feel were the most essential areas to have knowledge of for new providers and professionals hoping to provide comprehensive substance use disorder services for youth in our state.

This toolkit is part of the SPARK-T grant funded by DHCS. SPARK-T (previously referred to as the DHCS Technical Assistance Grant) is a vital initiative aimed at addressing the increasing need for Substance Use Disorder (SUD) treatment services across California. As the landscape of SUD treatment continues to evolve, small and mid-sized providers are particularly in need of training and capacity-building resources. This grant focuses on supporting these providers through various initiatives at the State and local County levels.

Key areas of focus include:

• Integration of Harm Reduction
• Incorporating harm reduction strategies into all SUD treatment services.
• Expanding Reach
• Aiming to serve the 95% of individuals who require SUD treatment.
• Lower Barrier Care
• Establishing accessible and inclusive care across the SUD system.
• Community-Affirming Practices
• Ensuring providers are equipped to deliver effective and compassionate care.

What is a Co-occurring disorder?

2.1 Recovery Support Systems

The term co-occurring disorder refers to the presence of both a mental health disorder and a substance use disorder in the same individual (NIDA, 2024).A commonly used synonym is dual diagnosis , which describes this same condition. These disorders are typically identified through comprehensive, multi-level assessments and diagnostic tools designed to capture the complexity of a client’s symptoms at a detailed, micro level (Mosel, 2025). When supporting individuals with co-occurring disorders, it is essential for therapists to implement an integrated treatment approach that simultaneously addresses both the mental health and substance use components (NIDA, 2024). A nuanced understanding of co-occurring disorders enables therapists to tailor treatment plans to best meet the unique needs of each client (Mosel, 2025). Additionally, treatment approaches should be adapted to consider the intersectionality of the client and their family, ensuring care that is inclusive, culturally responsive, and sensitive to diverse identities and experiences.

2.2 Levels of Care for SUD Tx

Substance use disorder treatment is offered across a continuum of care levels, each designed to meet clients’ varying needs based on the severity of their condition. Outpatient treatment provides flexible, part-time therapy that allows individuals to maintain daily  responsibilities while receiving care. Intensive outpatient programs (IOP) and partial hospitalization programs (PHP) offer more structured support with several hours of treatment per day, multiple days a week. Residential or inpatient treatment involves 24-hour care in a structured environment, ideal for individuals needing intensive support and supervision. At the highest level, medical detoxification is provided in specialized facilities to manage withdrawal symptoms safely under medical supervision. These levels of care can be stepped up or down based on an individual’s progress and clinical needs.

2.3 Resources

Treatment Considerations for Youth and Young Adults with Serious Emotional Disturbance and Serious Mental Illness and Co-Occurring Substance Use: https://www.samhsa.gov/resource/ebp/treatment-considerations-youth-young-adults-serious-emotional-disturbances-serious

Co-Occurring Disorders in the Adolescent Population – video:

This 90-minute presentation will provide in-depth information surrounding adolescent co-occurring disorders, including the presence and interaction of mental illness and substance use disorders. Attendees will be able to recognize signs of these conditions and behavioral presentation. You will learn about the circular impact that mental health and substance abuse have on each other and treatment approaches to treat these conditions. Time will be spent reviewing a case study to apply your learning from this presentation to a real case.

https://attcnetwork.org/products_and_resources/co-occurring-disorders-in-the-adolescent-population/

03 Confidentiality and Treatment Involving Minors (Youth)

3.1 Confidentiality and Limits to Confidentiality

According to the California Association of Marriage and Family Therapists (CAMFT), confidentiality is a foundational principle in therapeutic settings, referring to the understanding that information shared between a therapist and client remains private. However, there are specific circumstances in which a therapist is legally and ethically required to break confidentiality. As outlined by Caldwell (2024), there are five primary exceptions: disclosures of child abuse, elder abuse, dependent adult abuse, and situations in which the client poses a serious threat of harm to themselves or others. In these instances, therapists act as “mandated reporters,” meaning they are legally obligated to report such concerns to the appropriate authorities within a designated timeframe.

3.2  A Minor’s Right to Consent to Treatment

Minors have specific rights in mental health treatment that grant them a degree of autonomy in making decisions about their care. In California, a minor may consent to their own treatment without parental involvement if certain criteria are met. According to Caldwell (2024), the minor must be at least 12 years old and deemed “mature enough to participate in treatment,” a determination made by the treating therapist. When a minor consents to treatment  independently, they are solely responsible for the cost of services and for managing access to their treatment records.

However, there are important limitations regarding a minor’s ability to access their own records, and these considerations should be clearly reviewed and discussed with the treatment provider.

3.3 A Minor’s Right to Confidentiality in Treatment

Regardless of whether treatment consent is given by a parent, caregiver, or the minor themselves, the individual who provides consent typically holds the legal right to request access to the minor’s treatment records, including assessment forms, progress notes, and treatment plans (Caldwell, 2024). This raises valid concerns about a minor’s confidentiality, especially in cases where treatment has been consented to by a parent or guardian. Topics such as substance use can be deeply sensitive, often accompanied by feelings of shame or guilt, making it essential for youth to have a therapeutic space where they feel safe to speak openly about their experiences. Therapists must carefully assess family dynamics, the appropriateness of disclosing sensitive treatment information, and whether the specific information being requested is truly in the best interest of the client (Garcia, 2025).

3.4 Confidentiality of Substance Use Disorder Patient Records

42 CFR Part 2 is a federal regulation that provides strict confidentiality protections for individuals receiving substance use disorder treatment. It prohibits the disclosure of identifying information related to a person’s substance use disorder treatment without their written consent, except in specific circumstances like medical emergencies or court orders. The goal is to reduce stigma and encourage people to seek care without fear of legal or social consequences. These protections go beyond standard healthcare privacy laws like HIPAA (Health and Human Services 2024).

3.5 Resources

National Center for Youth Law –Minor Consent and Confidentiality
https://youthlaw.org/sites/default/files/2024-10/NCYLMinorConsentCompendium2024-California.pdf

Resource page for implementing AB 665 (Minor Consent for Mental Health Care)
https://www.cacfs.org/news/faq-minor-consent-mental-health-care-implementing-Assembly-bill-665

AB 665 – Consent to Mental Health Treatment 

Allows children on Medi-Cal, age 12 and older, the right to consent to mental health care on their own.
https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240AB665

AB 866 - Juveniles: care and treatment

Authorizes a dependent child of the juvenile court who is 16 years of age or older to consent to receive medications for opioid use disorder from a licensed narcotic treatment program as replacement narcotic therapy without the consent of their legal guardian.
https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB866

04- Care Coordination for Youth Serving Agencies

4.1 Coordinated Care Approaches for Addressing Substance Use Disorders

Substance use disorders (SUDs) are often co-occurring with other physical and/or mental health disorders, as well as environmental and social stressors (SAMHSA, 2020). The complexities that are often involved with SUDs are best addressed through a coordination of care between a team of specialists such as mental health providers, health care providers, juvenile justice workers, and social service providers, working along with the family in a holistic approach to address the many contributing factors involved in SUDs (Hogue et al., 2018). In order to coordinate care between agencies and resource providers, it is recommended to follow guidelines developed and provided by expert departments in the field such as the Department of Health Care Service’s California Advancing and Innovating Medi-Cal (CalAIM) (DHCS, 2022), Children and Youth Behavioral Health Initiative (CYBHI) (DHCS, 2021), and Los Angeles County Department of Public Health’s Substance Abuse and Prevention Control (SAPC) (SAPC, 2023).

4.2 Los Angeles County's System of Care: A Model for Integrated Youth SUD Treatment

An example of how coordination of care may be implemented effectively is the approach taken by the Los Angeles County Department of Public Health’s Substance Abuse and Prevention Control (SAPC)’s System of Care approach (SAPC, 2023). The System of Care approach integrates SUD treatment with mental health, primary care, education, child welfare, juvenile justice, and community-based services (SAPC, 2023). The goal is to provide seamless, equitable, and culturally responsive care that promotes early intervention, treatment, and recovery (SAMHSA, 2014). Among the varying initiatives to help treat youth-related SUDs, several principles have been identified in effective coordination of care such as youth- and family- centered care, integrated services, cultural responsiveness, trauma- informed approaches, and a focus on early intervention and recovery (DHCS, 2021; CDPH, 2021)

Each initiative has developed an implementation strategy for coordination which include concepts such as:

• Building collaborative teams including youth, families, SUD clinicians, mental health providers, school staff, and representatives from child welfare or juvenile justice (Hogue et al., 2018). These teams should hold regular collaboration meetings to ensure congruence of treatment and address barriers to treatment that arise (SAMHSA, 2014). 
• Leverage state and/or county networks to access funding, training, and any electronic coordination tools such as LA County SAPC’s Sage electronic health record (EHR) system (SAPC, 2023). Additionally, agencies should identify and/or establish referral pathways to state- and county-funded programs such as outpatient, intensive outpatient, and residential treatment programs, and medication-assisted treatment (MAT) services (DHCS, 2022; SAPC, 2023).
• Integrate with school-based systems such as school-based health centers (SBHCs) and Student Behavioral Health Incentive Program (SBHIP) to deliver comprehensive SUD screening tools like the Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening model (DHCS, 2023; SAMHSA, 2020). Integrate with social systems to coordinate with juvenile justice and child welfare systems to support justice-involved or foster care youth, integrating SUD treatment into diversion or reentry plans (Hogue et al., 2018; CDPH, 2023).
• Ensure crisis and recovery access by providing youth with crisis hotline information (#988/988california.org) and Medi-Cal Crisis Services for immediate intervention, including overdose response with naloxone (DHCS, 2021). Coordination teams can facilitate recovery support through peer-led groups, recovery coaching, and recovery housing (located on SAMHSA website) (SAMHSA, 2020).
• Navigate legal and confidentiality issues by complying with 42 CFR Part 2 and California’s confidentiality laws, using data-sharing agreements to protect privacy while enabling coordination (SAMHSA, 2014). Teams should understand Family Code Section 6929, allowing youth aged 12 and older to consent to SUD treatment in certain cases (California Family Code, 2023).
• Monitor outcomes by evaluating coordination success using metrics like reduced substance use, engagement in treatment, and school retention (DHCS, 2021). Use tools like the Child and Adolescent Needs and Strengths (CANS) assessment to monitor progress (DHCS, 2021). Secure funding by sourcing multiple funding options available, such as funding from Medi-Cal, BHSA, Proposition 64 (Cannabis Revenue Fund), and federal grants (e.g., SAMHSA’s State Opioid Response) to sustain SUD services CDPH, 2023; SAMHSA, 2020). Additionally, teams are encouraged to work with policymakers to expand Medi-Cal reimbursement for youth SUD services, including prevention and recovery support, as recommended by the National Academy for State Health Policy (NASHP, 2022).

4.3 Resources

Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders- State and Community Profiles: https://library.samhsa.gov/product/intensive-care-coordination-children-and-youth-complex-mental-and-substance-use-disorders

Adolescent Substance Use Disorder Best Practices: https://www.dhcs.ca.gov/Documents/CSD_CMHCS/Adol%20Best%20Practices%20Guide/AdolBestPracGuideOCTOBER2020.pdf

05 Promoting Engagement in Prosocial Activities 

5.1 The Role of Prosocial Activities in Youth Recovery 

Prosocial activities—structured, positive, community-oriented engagements such as sports, arts, volunteering, peer mentorship, or cultural programs— enhance treatment outcomes by fostering social connection, resilience, and healthy coping mechanisms. This approach aligns with California’s Youth System of Care frameworks, including California Advancing and Innovating Medi-Cal (CalAIM), Children and Youth Behavioral Health Initiative (CYBHI), and Behavioral Health Services Act (BHSA), ensuring equitable and effective care across urban, rural, and underserved regions.

5.2 Supporting Recovery and Reducing Relapse Through Engagement 

Prosocial activities promote recovery and reduce relapse rates, enhance social connectedness, address co-occuring mental health issues, and support long term recovery. Engaging in these types of activities helps promote recovery and reduce relapse rates by offering meaningful alternatives to substances through positive reinforcement, structuring individual’s times, and cultivating skill development. Engaging in rewarding activities like team sports, music, or community service activates the brain’s reward system, decreasing reliance on substances for pleasure (Volkow et al., 2016). This supports California’s strengths-based recovery model, as emphasized in CYBHI’s focus on early intervention (DHCS, 2021). Prosocial activities fill unstructured time, a key risk factor for substance use, by providing routine and purpose (SAMHSA, 2020). For example, attending an afterschool program or engaging in an organized sports program reduces idle time when youth might experiment with substances, a strategy supported by Proposition 64 funding for prevention programs. Engaging in prosocial activities help youth to develop coping skills, self-efficacy, and emotional regulation through activities like art therapy or outdoor recreation, which are critical for sustained recovery (Kelly et al., 2017). These align with BHSA’s emphasis on building resilience in high-risk populations, such as foster care or justice-involved youth (CDPH, 2023).

5.3 Building Positive Peer Networks and Family Bonds

Group activities, such as peer-led recovery groups, cultural clubs, or community service, help to promote peer support by creating positive peer networks, replacing substance-using social circles (Bassuk et al., 2016). Service teams can coordinate with already existing peer support programs developed by larger agency initiatives, such as CYBHI, when local agency resources are limited. Participation in school clubs, sports teams, or tribal youth programs builds a sense of community, reducing alienation—a key factor in substance use (Hogue et al., 2018). It is important to note that many schools have taken a zero tolerance to substance use on campus which may limit a youth’s ability to participate in organize school activities. A new piece of legislation AB2711 was signed in to law by Governor Newsom on January 1, 2025. This bills goal takes on the important task of shifting how school should respond to the substance use crisis among our youth and should start to have a significant impact across California. See  resources page for implementation guide. This fostering of a sense of belonging has been shown to be critical for California’s diverse populations, including Native American, Latinx, and LGBTQ+ youth, as supported by the California Reducing Disparities Project (CDPH, 2021). Additionally, prosocial activities enhance social connectedness through family engagement. Activities involving families, such as family volunteer days or cultural events, strengthen family bonds, a protective factor against SUDs. CalAIM’s family-centered approach encourages family involvement in care planning (DHCS, 2022).

5.4 Addressing Mental Health Through Trauma-Informed and Expressive Activities

Many youths with SUDs have co-occurring mental health disorders such as trauma and stress related disorders, mood disorders, and anxiety disorders. The California School-Based Health Alliance advocates for trauma-informed activities in school settings (CSHA, 2022). Activities like yoga, expressive arts, or equine therapy, often integrated into California’s community-based programs, reduce trauma-related symptoms by promoting mindfulness and emotional regulation (van der Kolk, 2014). Successes experienced in prosocial activities, such as winning a game or completing a community project, boost self-esteem, countering low self-worth tied to mental health challenges (Csikszentmihalyi, 1990). This aligns with BHSA’s focus on resilience- building for high-risk youth. Physical activities like sports, dance, or outdoor recreation reduce stress and improve mood through endorphin release, supporting mental health recovery (Ratey & Hagerman, 2008). Service teams can access these types of activities through School-Based Health Centers (SBHCs), which are funded by Student Behavioral Health Incentive Program (SBHIP) (DHCS, 2023).

5.5 Embedding Youth in Supportive Environments for Long- Term Recovery 

Prosocial activities help promote long-term recovery by embedding youth in supportive environments. Participation in community-based activities, such as volunteering, faith-based groups, or cultural programs, fosters long-term social integration, reducing recidivism to substance use (White & Kelly, 2011). Service teams in rural and tribal communities can utilize resources provided by CYBHI community-driven programs. Skill transfer gained through supportive environments such as leadership, teamwork, and communication skills translate to academic and vocational success, supporting recovery (Durlak et al., 2010). CalAIM’s Enhanced Care Management (ECM) incorporates these skills into care plans for youth with complex needs. Furthermore, California’s Youth Opioid Response (YOR) and  Medication-Assisted Treatment Expansion Project integrate prosocial activities into recovery support, such as peer-led groups and recreational programs, to promote sustained sobriety (DHCS, 2021).

5.6 Ensuring Cultural Responsiveness in Prosocial Programming

Service teams should be mindful that prosocial activities must be culturally responsive to serve California’s diverse youth. Incorporating activities that reflect cultural identities, such as Native American drumming circles, Latinx dance programs, or African American mentorship groups, help to enhance engagement (CDPH, 2021). BHSA includes mandates for culturally responsive services for underserved populations. Offer inclusive activities (e.g., pride-focused art groups) to support LGBTQ+ youth, who face higher SUD risks, aligning with CYBHI’s equity focus. Partnering with community- based organizations, utilizing Behavioral Health Continuum Infrastructure Program (BHCIP) funding for program expansion can help ensure activities are accessible in rural, tribal, and low-income communities.

5.7 Recommendations for Expanding Access and Impact

Recommendations for increasing engagement in prosocial activities would be to collaborate with local organizations (e.g., Boys & Girls Clubs, tribal councils, arts councils) to provide access to sports, arts, volunteering, or cultural activities, as supported by CYBHI’s community partnership initiatives. Include prosocial activities (e.g., group therapy outings, peer mentorship, community service) into outpatient ,intensive outpatient, or residential programs, aligning with CalAIM’s holistic care model. Work with SBHCs and schools to offer after-school SBHCs and schools to offer after-school programs or clubs, using SBHIP funding to support implementation (DHCS, 2023). Encourage clinicians to get educated on facilitating trauma-informed, culturally responsive activities, promote attendance to trainings from the California Institute for Behavioral Health Solutions or county behavioral health departments. Involve families in activities (e.g., family recreation days, cultural events) and conduct outreach in high-risk areas, as emphasized by BHSA’s community engagement requirements. Track engagement in prosocial activities and correlate with treatment outcomes (e.g., reduced substance use, improved school attendance) using standardized tools like Child and Adolescent Needs and Strengths (CANS), as required by CYBHI. Pool funding from Medi-Cal, Proposition 64, BHSA, and federal grants (e.g., SAMHSA’s State Opioid Response) to sustain programs. Consult county behavioral health departments for technical assistance.

5.8 Resources

Elevate Youth California 

A statewide program addressing substance use disorder by investing in the youth leadership and civic engagement for youth of color and 2S/LGBTQ+ youth ages 12 to 26 living in communities disproportionately impacted by the war on drugs.

https://elevateyouthca.org/

Implementation Guide

Practical tips and best practices to help schools adopt a public health framework.

https://shorturl.at/6unWp

Know Your Rights for Youth 

A quick-reference tool empowering youth with information about their rights under AB 2711.

https://shorturl.at/QR6dT

06 Recovery Support Systems and the Importance of Parental Involvement in SUD Treatment with Youth

6.1 Recovery Support System

Treatment for substance use disorders often involves the therapist working collaboratively with the client to define what recovery personally means to them and identifying the support they need to sustain it (DHCS, 2020). A key part of the recovery process includes building on the client’s existing strengths and helping them establish a reliable support network. Recovery support systems may include peer support groups such as Alcoholics Anonymous (AA), Alateen, or group therapy, as well as guidance from mentors, recovery coaches, or sponsors (DHCS, 2020).

6.2 Parental Involvement in SUD Treatment 

Research consistently shows that family involvement can significantly enhance the effectiveness of treatment for individuals with substance use disorders (Hogue et al., 2022). The family’s role in recovery is not only supportive but can serve as a crucial protective factor during the vulnerable stages of early sobriety. As clients begin to navigate the complexities of recovery, families can provide stability, emotional support, and accountability. Their presence offers an additional layer of safety and structure that helps reinforce therapeutic gains made during treatment. Effective family involvement may include establishing consistent routines, setting and maintaining healthy boundaries, adopting new communication strategies, and working to dismantle long-standing dysfunctional patterns within the family system. By engaging in these practices, families can create a more supportive and recovery-friendly environment. Ultimately, when families are actively involved and equipped with the right tools, they become a safe, nurturing foundation for their loved one, helping to buffer against relapse and promote long-term healing. To engage parents in therapy for their child with a substance use disorder, it's important to approach them with empathy and without judgment, emphasizing that their involvement is a vital part of the healing process. Helping parents understand substance use as a coping strategy that often stems from underlying trauma or emotional pain can reduce blame and foster compassion. Using trauma-informed language and creating a safe, supportive environment encourages parents to become active partners in their child’s recovery journey.

6.3 Statistics as of 2024

Research consistently shows that family involvement can significantly enhance the effectiveness of treatment for individuals with substance use disorders (Hogue et al., 2022). The family’s role in recovery is not only supportive but can serve as a crucial protective factor during the vulnerable stages of early sobriety. As clients begin to navigate the complexities of recovery, families can provide stability, emotional support, and accountability. Their presence offers an additional layer of safety and structure that helps reinforce therapeutic gains made during treatment.  Effective family involvement may include establishing consistent routines, setting and maintaining healthy boundaries, adopting new communication strategies, and working to dismantle long-standing dysfunctional patterns within the family system. By engaging in these practices, families can create a more supportive and recovery-friendly environment. Ultimately, when families are actively involved and equipped with the right tools, they become a safe, nurturing foundation for their loved one, helping to buffer against relapse and promote long-term healing.

6.4 Resources

Family Involvement in Treatment and Recovery for substance Use Disorders among Transition-Age Youth: https://pmc.ncbi.nlm.nih.gov/articles/PMC8380649/

UW Addictions Drug & Alcohol Institute: Family Involvement Toolkit

Provides Information and Resources for family involvement in substance use treatment and recovery https://adai.uw.edu/retentiontoolkit/family.htm

07 What is Trauma Informed Care?

7.1 Defining Trauma- Informed Care (TIC)

The National Institute of Mental Health describes Trauma-informed care (TIC) as the critical framework for delivering mental health and related services, particularly for individuals who have experienced trauma. TIC recognizes the widespread prevalence of trauma, its profound impact on mental and physical health, and the need to create safe, supportive environments to promote healing and recovery. Trauma-informed care is an approach that assumes individuals accessing services may have a history of trauma and integrates this understanding into all aspects of care delivery. Trauma—resulting from experiences such as abuse, neglect, violence, loss, or systemic stressors like racism—can lead to lasting psychological, emotional, and physiological effects, including post-traumatic stress disorder (PTSD), anxiety, depression, and substance use disorders (van der Kolk, 2014; SAMHSA, 2014). TIC shifts the focus from “What’s wrong with you?” to “What has happened to you?” fostering environments that avoid re-traumatization and support recovery.

7.2 SAMHSA’s Six Principles of TIC

The Substance Abuse and Mental Health Services Administration (SAMHSA) has outlined six key principles of Trauma Informed Care. These principles guide organizations and providers in creating trauma-sensitive systems:

1. Safety: Ensure physical and emotional safety for clients and staff. This includes creating welcoming environments, clear communication, and predictable routines to reduce anxiety and fear (SAMHSA, 2014).
2. Trustworthiness and Transparency: Build trust through consistent, honest interactions and clear explanations of procedures. Transparency in decision-making helps clients feel secure and respected.
3. Peer Support: Promote connections with peers who have lived experience of trauma. Peer support fosters hope and mutual understanding, a focus of NIMH-funded research on recovery models (Bassuk et al., 2016).
4. Collaboration and Mutuality: Emphasize partnerships between providers and clients, ensuring clients have a voice in their care. This reduces power imbalances and empowers individuals.
5. Empowerment, Voice, and Choice: Prioritize client autonomy by offering choices in treatment and respecting their preferences. Empowerment helps counteract the helplessness often associated with trauma.
6. Cultural, Historical, and Gender Issues: Address cultural and systemic factors, such as racism, historical trauma, or gender-based violence, that influence trauma experiences. Services must be culturally responsive and inclusive (SAMHSA, 2014).

7.3 The Urgency for TIC in California 

SAMHSA’s data indicate that over 70% of individuals with SUDs have experienced trauma, such as childhood abuse, domestic violence, or community violence (SAMHSA, 2014). In California, populations like youth in foster care, justice-involved individuals, and communities facing systemic racism (e.g., Black, Latinx, and Native American populations) experience disproportionately high rates of trauma (Copeland et al., 2007). California’s diverse demographics, including large immigrant, LGBTQ+, and unhoused populations, face unique trauma risks, such as discrimination, forced displacement, or historical trauma, necessitating culturally responsive TIC (CDPH, 2021). Trauma significantly increases the risk of SUDs, depression, anxiety, post-traumatic stress disorder (PTSD), and co-occurring disorders.

SAMHSA’s research shows that trauma alters neurobiological stress responses, contributing to substance use as a coping mechanism (van der Kolk, 2014). In California, where opioid overdoses and mental health crises are rising, TIC addresses these root causes to improve treatment outcomes. Without TIC, standard interventions may re-traumatize clients through coercive practices, lack of safety, or cultural insensitivity, leading to treatment dropout and worsened symptoms (SAMHSA, 2014). TIC ensures services are inclusive for marginalized groups, supporting BHSA’s mandate to serve high-risk populations, including justice-involved youth and unhoused individuals (CDPH, 2023).

7.4 Co-Occurring Disorders and Integrated Care

California’s treatment agencies, serving individuals with SUDs and mental health conditions, face unique challenges that underscore the need for TIC. Many clients in California’s treatment agencies have co-occurring SUDs and mental health disorders, often rooted in trauma. TIC ensures integrated treatment, such as Integrated Dual Disorder Treatment (IDDT), which SAMHSA endorses for addressing both conditions simultaneously (SAMHSA, 2020). CalAIM’s Enhanced Care Management (ECM) supports this integration for complex cases (DHCS, 2022). Without TIC, interventions may fail to address trauma’s underlying role, leading to poor engagement and relapse

7.5 Creating Trauma- Sensitive Environments

Standard practices, such as confrontational approaches or lack of privacy, can re-traumatize clients, particularly youth or unhoused individuals. TIC minimizes harm by creating safe, non-coercive environments, a priority for California’s Certified Community Behavioral Health Clinics (CCBHCs) (DHCS, 2023). In high-stress settings like crisis intervention or residential treatment, TIC is essential to avoid triggering trauma responses (DHCS, 2021). TIC improves client engagement, retention, and recovery by fostering trust and empowerment. SAMHSA’s research shows TIC reduces dropout rates and improves symptoms of PTSD, SUDs, and depression (Hales et al., 2019). In California, where treatment agencies face high demand and workforce shortages, TIC enhances efficiency by creating supportive environments that reduce staff burnout and improve client-provider interactions.

7.6 TIC for High- Risk and Marginalized Youth

California’s youth, foster care, justice- involved, and unhoused populations face elevated trauma exposure. TIC is critical for these groups, as emphasized by BHSA’s focus on high- risk populations and CYBHI’s youth-specific initiatives (CDPH, 2023; DHCS, 2021). For example, Native American youth in rural areas or LGBTQ+ individuals in urban centers require culturally tailored TIC to address historical trauma or discrimination, aligning with SAMHSA’s cultural responsiveness principle.

7.7 Implementing TIC in Practice 

SAMHSA provides practical guidance for California agencies to adopt TIC, ensuring alignment with state initiatives:

• Staff Training: Train all staff—clinicians, administrative personnel, and peer specialists—on trauma’s effects, TIC principles, and de-escalation techniques. Leverage training resources from the California Institute for Behavioral Health Solutions or BHSA’s workforce development programs (CDPH, 2023).
• Trauma-Sensitive Screening: Use validated tools like the Adverse Childhood Experiences (ACEs) questionnaire or PTSD Checklist (PCL-5) to identify trauma histories sensitively, with client consent. Integrate screening into SBIRT (Screening, Brief Intervention, and Referral to Treatment) protocols, supported by CYBHI (DHCS, 2021).
• Safe Environments: Design facilities with calming elements (e.g., soft lighting, private consultation rooms) and clear, predictable protocols. This is critical for agencies in rural areas or serving unhoused clients, supported by Behavioral Health Continuum Infrastructure Program (BHCIP) funding (CDPH, 2023).
• Trauma-Specific Interventions: Offer evidence-based treatments like Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Seeking Safety, which address trauma and SUDs concurrently. These align with CalAIM’s integrated care model (SAMHSA, 2020).
• Community Partnerships: Collaborate with schools, tribal organizations, and community-based groups to provide culturally responsive services, as emphasized by BHSA’s community engagement requirements.
• Continuous Evaluation: Use client and staff feedback to assess TIC implementation, ensuring fidelity to SAMHSA’s principles. Track outcomes (e.g., treatment retention, reduced symptoms) using tools like Child and Adolescent Needs and Strengths (CANS), required by CYBHI.

7.8 TIC as a Path to Equity and Recovery 

Research indicates an urgent need for trauma-informed care in California’s treatment agencies due to the high prevalence of trauma, its impact on SUDs and mental health, and the state’s diverse, vulnerable populations. By adopting TIC’s six principles—safety, trustworthiness, peer support, collaboration, empowerment, and cultural responsiveness—agencies can prevent re-traumatization, enhance treatment outcomes, and promote health equity. TIC aligns with California’s CalAIM, CYBHI, and BHSA initiatives, ensuring integrated, compassionate care.

7.9 Resources

Key Ingredients for Successful Trauma-Informed Care Implementation:

https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf

Trauma Informed Care web page: https://www.acesaware.org/ace-fundamentals/principles-of-trauma-informed-care/

Trauma Informed California

Trauma Informed California promotes trauma-informed practices within California’s social service sector through the creation of informative, research-based white papers and guides, the Unsafe Behaviors Inventory tool, and the Stop Trusted Advisor Abuse public advocacy campaign. Main web site: https://trauma-informed-california.org/

08 Youth Involved in the Juvenile Justice System 

8.1  Early Identification and Trauma-Informed Care for Incarcerated Youth

Youth involved in the juvenile justice system are at significantly higher risk for developing substance use disorders (Goldman & Wilson, 2023). Addressing these issues during incarceration is a critical intervention point and has been shown to reduce rates of recidivism (Goldman & Wilson, 2023). Implementing evidence-based screening tools and assessment methods both prior to and during incarceration can play a vital role in identifying substance use early, allowing for timely intervention and support that may improve long-term outcomes for justice-involved youth (Goldman & Wilson, 2023). According to the Child Crime Prevention & Safety Center youth involved in the justice system often enter with existing trauma, which can be further compounded during incarceration. In response, many juvenile detention centers have recently begun implementing care teams to provide mental health services and support to youth during their time in custody.

8.2 Resources

Screening and Assessment of Co-Occurring Disorders in the Justice System

This guide examines a wide range of evidence-based practices for screening and assessment of people in the justice system who have co-occurring mental and substance use disorders for developing and operating effective programs for justice-involved individuals who have CODs.

https://library.samhsa.gov/sites/default/files/pep19-screen-codjs.pdf

National Institute of Health 

Critical Issues for Youth Involved in the Juvenile Justice System: Innovations in Prevention, Intervention, and Policy: https://pmc.ncbi.nlm.nih.gov/articles/PMC6438718/

Juvenile Law Center

Juvenile Law Center engages in federal and state legislative reform, impact litigation, research, and public education to improve conditions for youth in prison and to reduce the harm of the child welfare and justice systems. Main web page: https://jlc.org/

Youth in the Justice System: An Overview:

47 minute video provided an overview of the history and hot topics in the juvenile justice system.

https://jlc.org/youth-justice-system-overview

Access our Youth Advocacy Toolkit:

A toolkit for starting a youth advocacy program. https://jlc.org/youth-advocacy#paragraph-820

09 Commercial Sexual Exploitation of Children and Human Trafficking

9.1 Understanding the Intersection of CSEC, Human Trafficking, and SUDs

Service teams need to be aware of the interconnection that exists between the commercial sexual exploitation of Children (CSEC), human trafficking, and youth with SUDs. These interconnected populations require specialized, trauma-informed approaches to treatment. CSEC refers to any sexual activity involving a minor (under 18) in exchange for something of value (e.g., money, shelter, drugs), including prostitution, pornography, or sex trafficking. It is inherently exploitative, as minors cannot consent to such activities (Greenbaum & Crawford-Jakubiak, 2015). Human trafficking involves the use of force, fraud, or coercion to exploit individuals for labor, services, or commercial sex. Sex trafficking of minors is a subset that overlaps with CSEC, as it involves minors exploited for commercial sex, regardless of coercion (U.S. Department of Justice, 2020). CSEC is often a form of human trafficking, specifically sex trafficking, when minors are exploited for commercial sex. All CSEC cases involving minors in the U.S. are considered human trafficking under federal law (Trafficking Victims Protection Act [TVPA], 2000), as minors cannot legally consent to commercial sex, implying inherent coercion or exploitation.

9.2  The Link Between Exploitation Trauma and Substance Use

CSEC and human trafficking are closely linked to SUDs in youth, creating a cycle of vulnerability and exploitation that treatment agencies must address. Youth who experience CSEC or trafficking often endure severe trauma, including physical abuse, sexual violence, and psychological manipulation. This trauma increases the risk of SUDs as a coping mechanism, with studies showing that 50–80% of trafficked youth have substance use issues (Lederer & Wetzel, 2014). Trauma-related disorders (e.g., PTSD, anxiety) are prevalent among CSEC survivors, further driving substance use to self-medicate (van der Kolk, 2014). California’s CYBHI emphasizes trauma-informed care for such youth (DHCS, 2021).

9.3 Addiction as a Tool of Control in Trafficking

Traffickers often use drugs to manipulate and control victims, fostering addiction to maintain compliance. Youth may be coerced into CSEC to obtain drugs or as payment for drug debts, perpetuating a cycle of addiction and exploitation (Farley et al., 2016). In California, where opioid and methamphetamine use among youth is a growing concern, traffickers exploit these addictions, particularly in vulnerable populations like foster care or unhoused youth (CDPH, 2023). Youth at risk for CSEC and trafficking, such as those in foster care, juvenile justice systems, or experiencing homelessness, are also at higher risk for SUDs due to systemic inequities, poverty, and lack of support. California’s BHSA prioritizes these high-risk groups for integrated services (CDPH, 2023). Marginalized populations (e.g., Black, Latinx, Native American, LGBTQ+ youth) face disproportionate risks of both trafficking and SUDs due to systemic racism, discrimination, and social exclusion, as noted in the California Reducing Disparities Project (CDPH, 2021).

9.4 Barriers to Treatment for Exploited Youth

It should be noted that CSEC and trafficking survivors often face stigma, fear of legal consequences, and mistrust of systems, which hinder engagement in SUD treatment. Trauma from exploitation can make traditional treatment settings feel unsafe, necessitating trauma-informed care (SAMHSA, 2014). Service teams should remain mindful of these barriers while developing treatment plans and consulting with other care providers.

9.5 Trauma-Informed, Integrated Treatment Approaches

The relationship between CSEC, human trafficking, and SUDs has significant implications for servicing agency’s approach to treating youth, such as the need to implement trauma informed care, screening for CSEC and trafficking, integrated treatment models, effective coordination of care, and cultural responsiveness. TIC is essential to create safe, non-re-traumatizing environments. Utilize trauma-sensitive screening tools promoted by CYBHI (e.g., Human Trafficking Screening Tool [HTST]) to identify CSEC/trafficking histories without triggering distress (DHCS, 2021). Address co-occurring SUDs, PTSD, and mental health disorders using evidence-based interventions like Seeking Safety or Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), which target trauma and substance use concurrently (Cohen et al., 2017). Collaborate with child welfare, juvenile justice, and anti-trafficking organizations (e.g., California Coalition Against Sexual Assault [CALCASA]) to provide wraparound services (CDPH, 2023). Tailor services to address the unique needs of marginalized groups, such as Native American or LGBTQ+ youth, who face heightened risks (CDPH, 2021).

9.6 Actionable Recommendations for Agencies

Recommendations for addressing CSEC and human trafficking in youth SUD treatment include educating all staff on CSEC, trafficking, and their links to SUDs, using resources from SAMHSA or the California Department of Social Services’ CSEC Program. Focus on TIC, trauma screening, and recognizing exploitation signs (e.g., branding tattoos, frequent runaway behavior). Integrate trauma-sensitive screening into intake processes, using tools like HTST or Adverse Childhood Experiences (ACEs) questionnaire, with client consent to avoid re-traumatization. Provide Seeking Safety, TF-CBT, or other trauma-focused therapies, ensuring access to Medication-Assisted Treatment (MAT) for SUDs, as supported by Youth Opioid Response (YOR) (DHCS, 2021). Establish relationships of understanding with anti-trafficking organizations, child welfare, and schools to coordinate care, aligning with CYBHI’s cross-system approach. Refer youth to specialized services like CSEC Model Programs in California. Design service spaces with calming elements (e.g., private rooms, soft lighting) and clear protocols to ensure safety, as emphasized by SAMHSA’s TIC framework. Incorporate peer specialists with lived experience and involve families in treatment to build trust, aligning with CalAIM’s family-centered model.

9.7 Resources

National Center for Youth Law –

CSEC Focus Area NCYL seeks to end the commercial sexual exploitation (CSE) of children and youth and support children, youth, families and caregivers affected by CSE experience safety

and healing so that they may achieve their goals. We work to research, identify, develop and implement policies and practices that achieve collective systems change.

Main web page: https://youthlaw.org/focus-areas/commercial-sexual-exploitation

CSEC Action Team https://youthlaw.org/csec-action-team-0

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11: Credits 

Written by:

Drew V Wilson, LMFT

Carla Cross, LMFT

Savannah Garcia, AMFT

Designed by:

Gracie Laramirez Alvarado