Strengthening Partnerships in School‐Based Substance Use Prevention and Intervention for Adolescents

ABSTRACT

Background

Adolescent substance use remains a significant concern for student health, well‐being, and academic outcomes, yet fewer than 4% of youth who need treatment receive it. Schools are a critical, but underutilized setting, for adolescent substance use prevention and intervention. While Multi‐Tiered Systems of Support (MTSS) provide a useful framework, meaningful engagement of youth, families, schools, and communities is crucial for effective and equitable systems.

Contributions to Theory

This paper asserts that youth‐family‐school‐community partnerships should serve as the core foundation of effective school‐based substance use programming. Drawing on Ecological System Theory and bridging school mental health and substance use literature, this paper proposes a framework that centers partnership, equity, and engagement within MTSS.

Implications for School Health Policy, Practice and Equity

School policy should prioritize funding and infrastructure that promotes genuine youth, family, school, and community collaboration, including telehealth options, flexible scheduling, and hiring school‐based mental health staff. These efforts can help to improve equitable access to multi‐tiered school substance use services for youth and families.

Conclusions

Partnerships among youth, families, schools, and communities should be central to school‐based substance use programming to support the development of effective and equitable school mental health systems.

1. Introduction

The 2023 National Survey on Drug Use and Health found that 2.2 million youth aged 12–17 (8.5% of the population) meet criteria for substance use disorder [1]. According to the 2023 Youth Risk Behavior Surveillance System (YRBSS), 22% of high school students drink alcohol and 28% have used marijuana [2]. More recent data from the Monitoring the Future Survey (2024) state that substance use rates declined during the COVID‐19 pandemic and have remained stable for cannabis and alcohol use for youth [3]. In 2024, alcohol use over the past 12 months was reported at 12.9% for eighth graders, 26.1% for 10th graders, and 41.7% for 12th graders; cannabis use was 7.2% for eighth graders, 15.9% for 10th graders, and 25.8% for 12th graders [1]. While rates of substance use have decreased, in recent years, data continue to underscore the need for prevention and intervention for adolescents at risk for or already engaging in problematic substance use.

The DSM‐5‐TR defines substance use disorders as a problematic pattern of substance use causing significant levels of impairment in at least two areas over a 12‐month period [4]. When working with adolescents, the threshold for problematic substance use is considerably lower, particularly due to the impact that substance use can have on healthy development [5]. Treatment should be provided to adolescents who exhibit functional impairment due to their substance use, including impacts on school, work, relationships, and impaired judgment or decision‐making. Addressing adolescent substance use is key in preventing a wide range of long‐term consequences, including but not limited to adult substance use disorder, health problems, criminal involvement, school failure, and death [5]. Many adolescents who receive mental health treatments also have comorbid substance misuse concerns, including 25% with depression, 27% of teens who have attempted suicide, and 15%–52% of those with PTSD [6, 7]. Comorbidity rates of major depressive disorder among adolescents with substance use disorders have increased significantly over time from 13% in 2011 to 26% in 2019 [8]. Furthermore, significant gender and racial disparities exist in comorbidities of substance and mood disorders among adolescents, including higher rates for girls and White youth compared to boys and adolescents of Black, Asian, Native Hawaiian, and Pacific Islander descents [8]. Substance use has been found to be related to several academic variables, including lower grades and skipping school [9]. Additionally, high school students who abstained from all substance use were found to have greater academic self‐efficacy and academic engagement than students who used substances in the past year [9].

Although treating adolescent substance misuse is critical, less than 4% of adolescents who need treatment actually receive care, with minoritized youth being even less likely to receive care [1, 10]. In addition to stigma and minimization of substance use concerns as typical adolescent behavior [10], barriers such as transportation to a treatment center, inconvenient clinic hours, high cost of treatment, and lack of culturally responsive care can prevent many adolescents from receiving care [11, 12]. Despite its prevalence and serious consequences, substance use remains underexplored as a relevant health disparity in school settings compared to other mental health concerns in the past. This gap persists for several reasons, including concerns around student privacy, stigma that discourages acknowledgement of substance use issues in schools, and competing priorities for school health initiatives, which can be seen in part as evidenced by its lack of inclusion in the original special issue of the Journal of School Health on “Healthier Students Are Better Learners” [13, 14]. Schools can reduce some of these obstacles and play a pivotal role in expanding access to substance use services, particularly when youth, families, schools, and communities engage in this work as genuine partnerships [15].

1.1. The Role of Schools in Adolescent Substance Use Supports

Youth spend a significant percentage of their time in the school setting, making it an ideal setting for addressing mental health concerns in an accessible and acceptable way [11]. Comprehensive school mental health systems (CSMHSs) utilize an interdisciplinary approach to addressing student mental health concerns from prevention to more intensive treatment approaches, building on a public health framework to take a preventative approach to mental health concerns known as Multi‐Tiered Systems of Support (MTSS) [16]. Using MTSS allows for a continuum of mental health services with all students receiving school‐wide prevention initiatives (Tier 1), a smaller proportion of students (approximately 15%) who are at risk for mental health concerns receiving more targeted interventions (Tier 2), and those students with the most intense needs (top 5%) receiving individualized intervention supports (Tier 3) [12].

While CSMHSs serve a wide range of mental health concerns [12, 16], they have historically been underutilized in addressing adolescent substance use [15]. Some models for addressing substance use in schools using an MTSS framework have been proposed, which include specific substance use oriented programming across all three tiers based on the Substance Abuse and Mental Health Services Administration's (SAMHSA) recommendations for addressing adolescent substance use [17]. In these models, Tier 1 interventions provide universal, school‐wide prevention, including screening for and addressing individual risk factors for substance use disorders through social–emotional curricula and the development of positive emotional regulation skills [18], using peer education programs in which trained students serve as positive role models in substance use prevention efforts [19] and social norms campaigns, which display positive and accurate messaging of students' use and perceptions of substance use [20]. Tier 2 supports are used with students who have been identified as at‐risk for a substance use disorder and involves supports which are more intensive than universal prevention in Tier 1 but still maintain a preventative approach. Examples of Tier 2 small group interventions for substance use include brief motivational interviewing and skill‐building groups enhancing coping skills and teaching effective decision‐making skills, or the use of Check‐in/Check‐out, an intervention where a student is paired with a trusted adult in the school to discuss the student's performance on specific behavioral and learning goals at the beginning and end of the school day, to address risk factors for substance use [17, 21]. Tier 3 supports are designed for students who require individualized intensive services including those at imminent risk for or diagnosed with a substance use disorder. Example Tier 3 services include one‐on‐one school‐based counseling with a school‐employed mental health provider or a community behavioral health provider, collaboration with offsite outpatient treatment providers, and wrap‐around supports [12]. Embedding substance use prevention and intervention programming within a tiered framework as opposed to referring out for substance use concerns allows schools to provide more comprehensive and responsive behavioral health care, while increasing access to substance use supports in a real‐world setting.

Although MTSS frameworks for substance use treatment exist [17], there remains a need to identify the factors that enhance their effectiveness and support their broader implementation, given the prevalence of adolescent substance use. This paper will expand existing frameworks by emphasizing how youth, family, school, and community partnerships are a core component of both CSMHS and the adolescent substance use treatment literature and therefore must be central to school‐based efforts to address substance use.

2. Theoretical Foundations of Partnerships in School‐Based Substance Use Programming

Youth, family, school, and community collaboration and partnerships are consistently considered to be important parts of CSMHSs [22, 23]. From an Ecological Systems Theory perspective, individuals are shaped from the interconnected environments in which we live [24], and thus it is important to integrate mental health supports across these interconnected settings of school, community, and home. While several models for these partnerships exist, core considerations include a strengths‐based approach that fosters trust and empowerment across systems and supports the sustainable development of capacity over time [22]. Youth, family, school, and community partnerships are associated with various student outcomes, including academic achievement and social–emotional functioning [25]. In addition to youth, family, school, and community partnerships, the inclusion of youth voice has gained increasing attention in the school mental health literature, with evidence suggesting that youth engagement strengthens CSMHSs [26]. Meaningful partnerships with youth, such as peer‐led mental health education programs and youth leadership programs, have been found to be effective ways to promote culturally responsive, effective, and equitable engagement, as it provides students with the opportunity to share their insights throughout intervention development and implementation [27, 28, 29]. Specifically, this section will explore these partnerships through the lens of schools as the central hub through which these partnerships operate.

Youth, family, school, and community partnerships are particularly critical in addressing substance use within school mental health systems, given the strong emphasis on family involvement in substance use treatment [23, 30]. Families play a central role in shaping adolescents' behaviors and attitudes towards substance use, with research demonstrating that parental modeling of healthy behaviors and adolescents' alignment with parental values serve as protective factors [31]. Therefore, it is not surprising that family involvement in substance use treatment is associated with improved engagement, attendance, and outcomes [21]. Research consistently shows that family‐based interventions are more effective for preventing and addressing adolescent substance use concerns compared to individual therapy or other modalities [32, 33]. Family engagement in mental health treatment is not only effective but also culturally congruent for many minoritized families, particularly those from collectivist cultures in which family interdependence is highly valued. For these youth and their families, family‐based approaches may be more culturally acceptable and empowering than traditional Western models that emphasize individual responsibility and autonomy [34, 35].

Common strategies for family involvement in substance use treatment include modeling healthy behavior, setting clear expectations about abstinence, and engaging in consistent parental monitoring of teens' activities and peer groups [36]. With family psychoeducation around problematic substance use, caregivers can help to engage teens in the identification of triggers and function of their substance use and problem‐solve strategies, and promote and reinforce positive, alternative activities and behaviors [37]. Additionally, therapy can improve parent–child communication and family relationships and processes, which in turn can serve as protective factors in the treatment process [38]. Caregiver involvement in treatment may also focus on preparing families to support their adolescent's readiness for treatment, such as learning how to suggest treatment options in a non‐confrontational manner and addressing common logistical or emotional barriers to care [39].

Community partnerships are also critical for meeting adolescent substance use support needs in schools. While schools can serve to decrease the barrier for behavioral and mental health services, collaboration with community partners can expand the range and intensity of services available to youth. More specifically, the level of care required at Tier 3 for youth with substance use disorders is often best provided by community‐based partners with specialized training and experience, as many school mental health professionals may lack formal training in substance use treatment and/or protected time to deliver these services. Therefore, collaboration, coordination, and integration of community‐based care into CSMHSs can help to improve access to mental health services and avoid duplication of services [40]. Additionally, community partnerships can promote culturally responsive care, build trust, and reduce stigma by fostering bidirectional communication between communities and providers, emphasizing strengths‐based approaches, and ensuring that interventions and outcomes are relevant to the broader community [41, 42].

Centering youth voice and collaborating as partners is also seen as an important part of adolescent substance use treatment. Involving youth as partners is critical as they can speak to the norms, attitudes, and behaviors about substance use among their peers based on their lived experience [43]. Given that peers play a significant role in shaping adolescent behaviors around substance use [44], centering their voice in efforts to prevent and treat substance use is critical. Youth partnerships for substance use allow for youth to be included in the decision‐making process, engaged in reciprocal communication, and builds relationships among the youth and the adult mental health professionals [43].

The school mental health and adolescent substance use literature both emphasize collaborative, multi‐system partnerships, reflecting a shared understanding of adolescent development. From an ecological systems perspective, the individual student is at the center of multiple contexts simultaneously, including their peers, family, school, and larger community. Addressing substance use in just one of these contexts ignores much of the student's world and thus is likely to be insufficient in practice [24]. When addressing substance use within a school mental health framework, partnerships across these systems should not be viewed as optional enhancements but as core mechanisms that enable effective intervention. By leveraging the unique contributions of each context, youth, family, school, and community partnerships support the delivery of effective and equitable care.

2.1. Efforts to Minimize Barriers to Partnerships in School Treatment of Adolescent Substance Use

Several barriers can deter consistent participation, despite the importance of youth, family, school, and community partnerships in promoting adolescent mental wellbeing and preventing substance use concerns. Regarding family involvement, one key developmental challenge is adolescents' growing need for autonomy. It is typical for youth to engage in identity exploration and risk‐taking behaviors during adolescence [45], which may lead to resistance in caregiver involvement. Concerns about confidentiality and privacy may also deter adolescents from consenting to family participation [46]. In schools, specifically, adolescents and their families may be hesitant to seek school‐based support due to concerns about how their shared mental health information could impact future academic and vocational opportunities. This may be especially relevant for school counselors, who provide academic support and letters of recommendation and often serve as a gateway to future opportunities, while also working in a dual role as mental health counselors [47]. Psychoeducation regarding confidentiality and privacy laws, such as HIPAA and FERPA, can help to mitigate such concerns.

Logistical barriers, such as appointment times during working hours and transportation needs, are significant barriers to parental involvement in behavioral health treatment within the school setting [48, 49]. Increasing the availability of flexible scheduling and telehealth options has been shown to mitigate many of these access issues [38]. Telehealth services can improve logistical feasibility and help to decrease stigma in caregiver involvement in behavioral health services across settings [50]. It allows for more natural and less disruptive engagement, especially for nonresidential caregivers or those with limited availability [51]. Families may also be reluctant to engage in therapy for their child's substance use due to their own personal attitudes towards the adolescent's substance use and mental health treatment [52, 53]. Others may experience associative stigma, which is the fear of being blamed or judged for their child's struggles, or worry that participation in therapy implies poor parenting [53, 54]. To address these barriers, school‐based providers can foster trust and collaboration. This includes offering culturally responsive psychoeducation on the benefits of caregiver involvement, highlighting family strengths, normalizing the therapeutic process, and celebrating small successes. Establishing a nonjudgmental, partnership‐based approach can help caregivers feel valued rather than scrutinized, increasing the likelihood of sustained involvement in treatment.

3. Partnership‐Oriented Approaches to School‐Based Substance Use Prevention and Intervention

Building on existing CSMHS frameworks for addressing substance use, schools must take additional steps to integrate meaningful partnerships with youth, families, and communities across all tiers of MTSS. Although not exhaustive, Table 1 illustrates partnership‐oriented strategies that integrate evidence‐based programs (EBPs) successfully implemented in schools with youth and families, alongside equity and engagement considerations across the three MTSS tiers. This is distinct from other MTSS approaches for substance use prevention and interventions which currently exist [17], as it provides schools with guidance on how to thoughtfully integrate partnerships with youth, families, and communities into each tier of programming. It also highlights considerations for embedding equity across all tiers of MTSS. School communities will have unique student populations; therefore, there is no one‐size‐fits‐all model for all schools. In such, these strategies provide guidance on how equity and partnership considerations can strengthen MTSS frameworks for substance use programming in schools.

TABLE 1.

Partnership‐centered strategies for school‐based substance use prevention and intervention.

Tier	Program	Target group	Key features	Equity considerations	Required training or background	Partnership considerations
Tier 1	Screening, Brief Intervention, Referral to Treatment (SBIRT)	Adolescents	Universal and targeted screening, motivational interviewing, treatment referrals	Validated in diverse adolescent populations, can be delivered electronically, culturally sensitive	Health and mental health professionals (i.e., pediatricians, nurses, school & community mental health professionals, etc.)	Screening identifies students' needs to guide intervention. Family consent and input should be incorporated, with results shared appropriately. Referrals should be coordinated with community partners to support follow‐up care.
Tier 1	Botvin LifeSkills (LST)	Students (grades K‐12)	Personal self‐management skills, social skills, drug resistance skills	Culturally adapted for African‐American, Latinx, and Indigenous youth	Trained teachers and school staff, school & community mental health professionals, school prevention/MTSS specialists	Strong rapport between school staff and students improve implementation. Can be paired with Botvin Parent Program (see below) for increased family engagement.
Tier 1	Botvin Parent Program	Parents and caregivers of students in grades 6–9	Parent psychoeducation, skill‐building, positive parenting practices	Available in Spanish	Trained teachers and school staff, school & community mental health professionals, family navigators or specialists	Family‐based programming requires strong partnership between youth, family and school.
Tiers 1 and 2	Strengthening Families Program (SFP)	Students and families	Caregiver skills building, family bonding, youth skills training	Available in Spanish. Culturally adapted models for African American, Latinx, and Native American families.	Trained teachers, and school staff, school & community mental health professionals, family therapists, community prevention specialists	Joint programming for both youth and families, viewing family as core part of student's development. SFP can be delivered by community partners in schools.
Tiers 1 and 2	Strong African American Families (SAAF)	African American students and families	Strengths‐based family skill building, culturally sensitive SEL skills for students, strengths‐based caregiver skills, family bonding, communication and connection	Program materials reflect African American cultural experiences, language, and imagery.	Trained teachers and school staff, school & community mental health providers, community prevention specialists, family navigators or specialists certified in SAAF	Joint programming for both youth and families, viewing family as core part of student's development. SAAF can be delivered by culturally responsive community partners in schools.
Tier 3	Adolescent Community Reinforcement Approach (A‐CRA)	Adolescents	Functional analysis, caregiver involvement	Family participation. Implemented with White, Hispanic, African American and Biracial adolescents.	Licensed school & community mental health professionals (i.e., social workers, psychologists, etc.) with specialized training and certification in A‐CRA	Partnership with families and communities central to intervention, including family engagement in sessions. Working collaboratively with community providers to coordinate additional care needs.
Tier 3	Motivational Enhancement Therapy–Cognitive Behavioral Therapy 5 (MET/CBT5)	Adolescents	Motivational interviewing, CBT‐based coping skills	Feasibility of 5 session format in low‐resource or time‐limited settings, Strengths‐based, youth‐led goal setting	Licensed school & community mental health professionals (i.e., social workers, psychologists, etc.) with specialized training in MET and CBT modalities	Working collaboratively with community providers to coordinate additional care needs. Families should be involved in treatment, particularly with psychoeducation. Youth should be involved in determining their treatment goals.

4. Implications for School Health Research

Researchers should prioritize collaboration with key partners when identifying effective school‐based interventions for student substance use concerns. Participatory Action Research (PAR) and Youth Participatory Action Research (YPAR) are research frameworks that center collaboration with youth, families, and community partners and are increasingly used in school settings [55]. YPAR and PAR involve participants as co‐researchers in a reflective process, allowing them to contribute their lived experience and expertise to inform more effective, equitable, and culturally responsive interventions [56]. Using PAR and YPAR to further examine EBPs for substance use in schools can strengthen implementation, identify barriers that limit effectiveness, and improve understanding of intervention outcomes [57]. This research will also help support cultural adaptations of and equitable access and outcomes for school‐based substance use prevention and intervention.

5. Implications for School Health Policy, Practice and Equity

It is essential that districts and states integrate substance‐use related policies in schools that center partnerships to better support student well‐being. As highlighted in Inseparable's School Mental Health Report Card, addressing substance use through school policy involves fostering a healthy school climate, promoting mental wellness, ensuring early intervention, strengthening connections to substance use services, building a skilled workforce, and securing sustainable funding [58]. Examples of substance use policies for schools that support the partnerships include providing professional development for teachers and school staff on the importance of partnerships in addressing substance use concerns, having connections to mental health and substance use care as an alternative to suspension, hiring dedicated school mental health professionals who can serve as liaisons between youth, family, school and the community, and integrating a range of substance use treatment supports (e.g., youth peer support specialists, individual, group, and family therapy) which have been vetted by relevant stakeholders into school‐based services. Flexible schedules, such as evening and weekend hours, and telehealth options are also key for increasing opportunities for caregiver participation in school‐based programming. Schools must also continue to address barriers that arise when implementing substance use prevention and intervention programming, including schools' limited resources, as well as parents' and students' fear of being labeled or concerns with confidentiality of information in the schools. The use of community partnerships can help to mitigate duplication of services and allow schools to hone in specific resources that are most important for them to provide. Finally, youth voice must be centered in the selection, adaptation, and implementation of school‐based programming, including multi‐tiered systems of support for substance use prevention and intervention. One way to accomplish this is by directly asking students, through qualitative methods, to describe which types of interventions they would be most likely to participate in and respond to, as well as what factors may increase or inhibit their engagement in those interventions [59]. Leveraging existing community resources as part of an asset‐based community partnership model can help schools with limited resources provide increasingly comprehensive services to their students [22]. Effective partnerships are inherently related to local community assets, culture, and needs. Therefore, partnerships will vary across school settings, which is an asset allowing tailored application of the partnership framework to match the distinct needs of the school community. For example, schools in urban areas with diverse student populations will likely have access to more culturally specific community‐based organizations to partner with for in referrals and family outreach, compared to schools in rural areas that rely more heavily on organizations with telehealth infrastructure. Regardless of local context, youth‐school‐community‐family partnerships play a key role in addressing the wide range of student needs and concerns, specifically in promoting substance use prevention and intervention towards better student wellness and academic engagement [9, 22].

6. Conclusion

School‐based substance use education, prevention, and treatment services are not currently being used to their maximum potential, given that despite the serious impact of substance use on adolescent functioning, many adolescents do not receive any support or services. School‐based substance use services that view partnerships between youth, families, schools, and communities as the foundation of school‐based substance use programming have the potential to significantly reduce the long‐term consequences of adolescent substance use. Centering these relationships across all tiers of programming and working to minimize barriers to partnership will help to build effective and equitable school‐based substance use programming.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. The research reported in this publication was funded by a Substance Abuse and Mental Health Services Administration (SAMHSA) State Opioid Response Grant, grant number H79TI087776 from the Maryland Behavioral Administration within the Maryland Department of Health.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.