This study investigates factors that influence the conversations that child and adolescent psychiatrists have with their patients about substance use. The goal of the study is to gain a better understanding of salient psychological and communication constructs in this context using social cognitive theory as a guide. The study consisted of a national online survey of child and adolescent psychiatrists (n = 170) focused on understanding factors that affect self-efficacy and communication competence related to discussing substance use with adolescent patients. Results show that communication apprehension has a strong negative association with perceptions of self-efficacy. Results also show that past positive experiences have a stronger association with self-efficacy than past negative experiences. Results related to communication competence were mixed, with self-efficacy not being significantly related to communication competence; which could indicate potential issues with measurement. Communication competence was found to be related to overall perceptions of training, as well as past positive experiences discussing substance use. These results have implications related to the design and implementation of training interventions for child and adolescent psychiatrists to improve their level of comfort in discussing substance use with their patients.