sbirt in schools · 2020-02-10 · sbirt in schools: introduction training 2/10/2020 11 crafft-ii:...

SBIRT in Schools: Introduction Training 2/10/2020

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SBIRT in SchoolsIdentifying and Addressing Substance Use

SBIRT in Schools Project

Massachusetts Department of Public Health (MDPH)School Health Unit • Provides school health service systems development and

technical assistance to public school districts and nonpublic schools

Bureau of Substance Addiction Services (BSAS)• Oversees the statewide system of services for those affected

by substance addiction

MASBIRT Training & Technical Assistance (MASBIRT TTA)

• Funded by BSAS to integrate SBIRT into diverse settings, and promote individual clinician SBIRT skills and competencies

School Health Institute for Education and Leadership Development (SHIELD)

• Provides training for school nurses according to DESE requirements


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Learning Objectives

At the conclusion of this activity participants will be able to:

1. Define SBIRT and its implementation in schools

2. Describe prevalence and risks of adolescent substance use

3. Apply a validated screening tool

4. Examine Motivational Interviewing strategies

5. Apply the Brief Negotiated Interview (BNI) tool

6. Determine when to make a referral

How to Claim Credit

***IMPORTANT***

• Register online ahead and complete online portion

• Check in today

• Attend the entire program

• Await email with link to complete evaluation


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Welcome and Recap from Online Training

What is SBIRT:

• A low-intensity, low-cost public health approach to

identify and address harms related to adolescent

substance use

Welcome and Recap from Online Training

In SBIRT, brief interventions are used to

1. to reinforce healthy behaviors,

2. to raise awareness of potential harms, and

3. to build motivation towards risk reduction

The Law:• 2016 STEP Act

Anything Else Stand Out?


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Part I: Prevalence and Risks of Adolescent Substance Use

Adolescent Past Month Alcohol Use in US

Source: Adolescents Aged 12-17. SAMHSA. Center for Behavioral Health Statistics and Quality, NSDUH. 2016 and 2017.

MA = 12.7%


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Adolescent Past Month Marijuana Use in US

Source: Adolescents Aged 12-17. SAMHSA. Center for Behavioral Health Statistics and Quality, NSDUH. 2016 and 2017.

MA = 8.9%

What are Some Risks of Teen Substance Use?


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Why SBIRT?

• Encourages open conversations with students about alcohol and other drug use.

• Aimed at prevention and early identification.

• Helps to establish relationships with trusted adults in school.

• Culture shift regarding substance use.

Part II: The SBIRT Process


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S

SCREENING

Universal screen to

identify unhealthy

substance use

What does SBIRT Stand For?

BI

BRIEF

INTERVENTION

Brief intervention to

address substance

use behaviors

RT

REFERRAL TO

TREATMENT

Referral for further

services as needed

Screening

S

SCREENING

Universal screen to

identify unhealthy

substance use

BI

BRIEF

INTERVENTION


address substance

use behaviors

RT

REFERRAL TO

TREATMENT


services as needed


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Why Screen Universally?

How Can We Help Students be Forthcoming?

• Introduce screening and inform universal

• Discuss confidentiality

• Define substances

• Ask permission!


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Introduction to SBIRT Screening

Introduce Screening

I am going to ask a few health screening questions about alcohol and other drug use that we are

asking all students in your grade.

Discuss confidentiality

There is no written record of this screening that includes information that specifically identifies you. Anything you tell me will be kept as confidential as possible. One reason why this information would not be kept confidential is if something you say indicates that there is an immediate risk to your safety or someone else’s safety. Additionally, you, your parent, or your guardian, could request the information we discussed today. In any case, we would figure out next steps for support together. Do you understand?

Define substances

By alcohol we mean beer, wine, wine coolers, or liquor. By drugs we mean anything that one might use for the feeling it causes including: marijuana, heroin, prescription drugs like OxyContin, etc.

Ask permission

Is it okay to ask you these questions?

CRAFFT-II: Beginning the Conversation

• Short alcohol and other drug screening and clinical assessment tool.

• Designed to identify substance-related risks and problems in adolescents 12-21.

• Developed and validated by John Knight, MD and colleagues at Boston Children’s Hospital in 1990’s - has gone through several versions.

• Employs a skip pattern for ease of use.

• CRAFFT-II available in 15+ languages.

Knight, J. R., Shrier, L. A., Bravender, T. D., Farrell, M., Bilt, J. V., & Shaffer, H. J. (1999). A New Brief Screen for Adolescent Substance Abuse. Archives of Pediatrics & Adolescent Medicine,153(6).


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CRAFFT-II ToolCRAFFT-II Part A: Ask These Questions to Everyone

CRAFFT-II Part B: Employ Skip Pattern


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CRAFFT-II: Scoring

• Each yes response to the CRAFFT questions scores 1 point.

• The higher the score, the higher the likelihood of a need for further assessment and/or referral.

• Scores should not take the place of clinical judgment.

CRAFFT-II: Practice

• Break into pairs.

• Practice screening your partner with the CRAFFT-II screening tool.

• Be sure to introduce the screening and then read the questions exactly as worded.

• Swap when prompted by the trainer.


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Part III: Motivational Interviewing

Group Reflection

• Take some time to think about a difficult change that you had to make in your life.

• How much time did it take for you to move from considering that change to actually taking action?


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Motivation to change is not linear

Change is a Process

We can have an influence on motivation!

Communication Exercise

1. Break into pairs.

2. One person will be the Speaker and one person will be the Helper.

3. Follow instructions on handout for Exercise 1.

4. When prompted by the trainer, continue to Exercise 2.


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Practitioner Style Influences Motivation

InquisitiveCuriousGenuine

AcceptingInterested

CollaborativeEmphasizes Choice

Draws Out Student’s View

Draws Premature ConclusionsCoerces

PressuresRushesPanicsJudges

PrescribesConfronts

LabelsFixes

Over AdvisesUninterested in Student’s

Perspective

When people can voice their own reasons for change, they are more likely

to make the change.

Take Home Message


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Ambivalence Precedes Change

Ambivalence is a normal, not pathological. Change happens by resolving ambivalence.

Evocation

Acceptance Partnership

Compassion

Spirit of Motivational Interviewing

These 4 principles are the basis of all MI conversations.They are the essence of MI.


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Components of Compassion

• Belief and commitment to act in student’s best interest.

• Genuine curiosity.

• Compassion vs empathy?

Components of Acceptance

Absolute Worth

• Each student will grow if given optimal conditions.

Accurate Empathy

• See the world through their eyes.

Autonomy

• Honoring and respecting each student’s choice.

Affirmation

• Seek and acknowledge the student’s strengths and efforts.


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Components of Partnership

• Foster and encourage power sharing.

• Keep the student’s expertise, perspectives, and input central in conversation.

Components of Evocation

• Unique to MI – working to draw out from the student rather than impose.

• Underlying belief is that they already have the skills and tools and knowledge to make changes.

• How can we draw that out and build on what they have?


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It’s Not About the Nail

Tips to Help Decrease Pushback

Don’t try to convince them

they have a problem.

Ask them about how they see

their substance use

(the things they like and like

less).


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The Pros & Cons Can Help Resolve Ambivalence

Ask for the one side:What are some of the things that you like about smoking?

I like how it makes me feel more creative. It’s fun to hang out and laugh with my friends.

Ask for the other side:What are some of the things that you like less about smoking?

It can be expensive if people just smoke your stuff and don’t chip in. Sometimes I feel a little foggy the next day.

The Pros & Cons Can Help Resolve Ambivalence

Then reflect back both responses in a double-sided reflection:

So, on the one hand smoking can be a fun social thing for you, and at the same time you get a little annoyed about the expense and the aftereffect it causes when you wake up in the morning.


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Don’t warn them of the

consequences of not changing

• Ask them what they know about the risks

• Elicit, Provide, Elicit

Use the MI Sandwich When Giving Information

Elicit:• What do you know about some of the risks of using alcohol?• Would it be okay if I share some additional information with you?

Provide:• One thing we know is that drinking can impact stability and

coordination and potentially lead to an injury.

Elicit:• What do you think about that?


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Don’t try to persuade them to think what

you think.

Reflect their perspective,

especially their pro-change thoughts!

Reflections Can Help Demonstrate Empathy

Reflections are statements that:

• Hold up a mirror to the conversation.

• Used to convey understanding and hypothesize about further meaning behind the words the person is saying.

• An active process where the practitioner decides what to reflect or ignore, what to emphasize, preferentially reflects change talk.


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Think of an Iceberg….

SIMPLE REFLECTIONS

(Restate or slightly rephrase)

COMPLEX REFLECTIONS

(An educated guess at what the speaker means by what they said)

Reflective Listening Example

I had one issue at school, but it’s really not that big of a deal. All of my friends smoke too.

One time you had some trouble related to smoking.

If it had been a bigger deal you might feel differently about it.

Simple

Complex


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Reflective Listening Example

I’ve tried to cut back on my own before, but nothing is going to work for me. I just can’t stop drinking.

You’ve tried to drink less in the past.

You’ve tried to quit drinking in the past and it hasn’t worked. You’re wondering what else you might do.

Simple

Complex


Don’t tell them they should

change.

Ask them how ready they are to

change.


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Use Rulers to Build Motivation

1. On a scale of 1-10 how important is it for you to avoid drinking and driving?

2. Why did you choose that number and not a lower number?


Don’t argue with them about the

benefits of change.

Use open questions to evoke their

thoughts about change.

Don’t tell them how they should

change.


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Open-Ended Questions to Evoke Information

• Tell me a little about how marijuana fits into your life? What does a typical week look like for you?

• If you decided to make a change in your use, what would that look like?

• How would you know if it was time to consider making a change?

Open vs. Closed Questions

• Do you think smoking could be affecting your grades?Walk me through how you usually go about your homework? How does smoking fit into that?

• Have you thought about cutting back? How might you go about reducing some of the risks you mentioned?


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Don’t point out their struggle.

Point out their strengths!

Affirmations Can Help Boost Confidence

Statements that acknowledge personal strengths or behaviors that help move in the direction of change.

• Genuine.• Specific.• Congruent with the conversation.• Highlight strengths or values of that particular person.

• Used to help build student confidence.

“You are a loyal person. Your friendships are important to you.”

• Avoid positive judgment or cheerleading.


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Affirmation vs. Positive Judgment

• You know how to speak up for what you need.

• Well done, that was a good decision!

• It looks to me like that was a hard choice to make and I really admire how you stuck with it.

• I am so proud of you.

• Great job!

• You’ve put a lot of thought into what your next step will be.

• I am impressed with how much you have accomplished here.

Rating MI Fidelity: Thumbs Up or Down?

Smoking weed helps me focus and be more creative.

I’m worried your not thinking this through. Smoking is risky and will only make things

worse for you.


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“Eventually I think I’ll get some help, I just don’t want to do it right now. I have so much else going on,

and no one really gets that.”

“I think it’s really important that you do

this as soon as possible. Let’s just call together now so you can get it over with.

I like drinking with my friends

sometimes. It helps me relax. I just don’t want my parents to

find out.

On the one hand drinking helps you

relax and at the same time you’re worried

that your parents will find out and get

upset.

Rating MI Fidelilty: Thumbs Up or Down?


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My boyfriend wants me to take Percocet

with him. I don’t want to, but I don’t

know how to say no. What do you think I

should do?

I have some ideas that might be helpful, but

first I’d like to hear what your thoughts

are.

Meet People Where They Dream

• People want to be their best self.

• People already have what they need to be that best self.

• Our job is to help draw it out by evoking them to talk about their reasons for change in an atmosphere of acceptance and compassion.


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Know Your Why

Part IV: The Brief Intervention


31

S

SCREENING

Universal screen to

identify unhealthy

substance use

Brief Intervention

BI

BRIEF

INTERVENTION


address substance

use behaviors

RT

REFERRAL TO

TREATMENT


services as needed

The Key to SBIRT: Brief Intervention

• Brief

• Non-confrontational

• Guided conversation

• Uses Motivational Interviewing (MI) principles & strategies to enhance motivation to change use of alcohol and other drugs


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Two Types of Brief Intervention

Negative screens: use REACT • Reinforce the student’s decision not to use

• Explore any safety concerns

Positive screens: use the BNI• Enhance student’s motivation to change risky behaviors and

consider healthier decisions (e.g. cutting back, quitting, or seeking counseling/support)

REACT (Negative Screens)

• Reinforce healthy decisions.

• Educate about risks.

• Anticipate Challenges of Tomorrow


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REACT: Reinforce

• Reinforce & Elicit reasons to not drink or use drugs

• “You’ve made the decision to not use alcohol or other drugs. Tell me how you made that decision?”

• [Reflect their reasons].

REACT: Educate with the MI Sandwich

Educate, if student is open, about risks:

Elicit: • What do you know about how alcohol and other drugs affect teens? • Is it okay if I share some additional information with you?

Provide:• One thing we know is that driving under the influence of alcohol or

other drugs can impair perception and reaction time, and sometimes leads to accidents.

Elicit: • What do you make of that?


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Explore any safety concerns:• “Tell me more about the time when you got a ride home

from your friend who had been smoking.”• “What were your feelings about that situation?”• “What conversations have you had with family about this?”

Ask open questions about the future:• “What situations might make it difficult for you to continue

to not use alcohol or other drugs? • “What could you do in those instances?”• “What advice would you give to a friend?”

REACT: Anticipate Challenges of Tomorrow

The Brief Negotiated Interview (Positive Screens)

1. Build Rapport

2. Explore Pros & Cons

3. Provide Feedback/Information

4. Use Readiness Ruler

5. Negotiate Action Plan / Thank client

Developed by BNI-ART Institute,@ BU.edu and The Yale Brief Negotiated Interview Manual. D’Onofrio, et al. New Haven CT: Yale Univ. School of Med. 2005


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Things to Note about the BNI

• Follows a scripted approach

• BNI is the skeleton, but you bring it to life

• Not always linear; might need to adapt process as situation unfolds

• While ideal, it might not be possible to complete each step at every encounter

Step 1: Build Rapport

• Thank you for answering these questions. I’m wondering if I can learn a little bit more about you. What is a typical day like for you? What are some important things in your life right now?

• How does your use of [X] fit in?

OR

• Can you tell me a little more about your past or current drinking or drug use?


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Step 2: Explore Pros and Cons

• What do you like about using [X]? What else?

• What do you like less or regret about using [X]? What else?

• You mentioned [issues from CRAFFT] can you tell me more about that?

• So on the one hand [PROS] and on the other hand [CONS].

Step 3: Provide Feedback

• What do you know about the risks of using [X]?

• Is it okay if I share some additional information with you? [Provide 1-2 salient facts].

• What do you think about that?


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Provide Feedback: Alcohol Use

• Your brain is still developing and alcohol can impact many of those connections that aren’t quite finalized.

Mental

• Most high school students in Massachusetts don’t currently drink alcohol (~69%)*.

Social

• Alcohol use can increase your risk of injuries that may require a visit to the emergency room.

Physical

*Massachusetts, High School Youth Risk Behavior Survey, 2017

Provide Feedback: Marijuana

• Your brain is still developing and marijuana can impact memory and learning.

Mental

• Most high school students in Massachusetts don’t currently use marijuana (~76%)*.

Social

• Marijuana can affect coordination and increase risk of injuries that may require a visit to the emergency room.

Physical

*Massachusetts, High School Youth Risk Behavior Survey, 2017


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Step 4: Use Readiness Ruler

• Given what we have talked about, on a scale of 1-10 how ready are you to make any changes in your use?

• Why did you pick that number and not a lower number?

OR

• What would need to happen for you to consider making a change?

• [Reflect back reasons for change].

Step 5: Negotiate Action Plan

• If you decided to make a change, what would that look like?

• [Offer suggestions or referral if appropriate using-Elicit Provide-Elicit]

• How confident are you that you could make this change on a scale of 1-10?

• Why not a lower number?

• What could help you get to a higher number?

• [Summarize plan]. Is it okay if we check in about this to see how things are going?

• Thank you for speaking with me today!


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Part V: Providing Education on Risks

Brain Development

• Brain development continues into a person’s twenties.

• Alcohol and drugs can affect this development and contribute to a range of problems later in life.


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Age at First Drink

% w

ith

Alc

oh

olD

iso

rder

Source: Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence. Arch Pediatr Adolesc Med. 2006;160:739-746.

Alcohol

About 1 in 4 Americans who begin drinking before age 18, will develop a SUD in adulthood.

4745

38

32

28

1517

119

0

5

10

15

20

25

30

35

40

45

50

<13 14 15 16 17 18 19 20 21+

Age at First Use and Later Risk

Drinking and Driving

If your BAC was 0.08 (legally impaired), it would take about 5.33 hours for the alcohol to be eliminated from your body.


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What is a Drink?

Risks of Marijuana Use

• Mixing marijuana and alcohol can increase risk of alcohol poisoning

• Mode of use – dabbing, smoking, edibles• Inconsistent potency• Delayed onset of effects

• Regular use can lead to decreased levels of testosterone

• Over time use can lead to increased anxiety and depression symptoms


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Risks of Mixing

Using more than one substance at a time is common.

Combining two drugs can change or increase their effects, making them dangerous.

Risk of Embarrassment, Injury, Violence


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Educational Materials on MASBIRT TTA Website

Part VI: Putting It All Together


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Practice a BNI!

• Get into pairs

• Practice going through a BNI

• Switch

Video: Brief Intervention


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Part VII: Referrals

S

SCREENING

Universal screen to

identify unhealthy

substance use

Referral to Treatment

BI

BRIEF

INTERVENTION


address substance

use behaviors

RT

REFERRAL TO

TREATMENT


services as needed


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Levels of Referral

4. Referral for immediate medical emergency OR as required by state law.

1. Follow-up conversation for assessment with Screener.

2. Follow-up conversation for assessment with another school professional.

3. Referral for assessment or services (can be in-school or out of school).

Adolescent Substance Use Treatment Services

Outpatient services (A-CRA)

Detox or stabilization units

Residential treatment

Recovery high schools

Medication-assisted treatment

School based intervention programs


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Outpatient Treatment

Adolescent Community Reinforcement Approach (A-CRA) is: Evidence based treatment developed by Chestnut Health

Systems For youth & young adults ages 12-24 Brief treatment Teaches coping skills Delivered in the community, clinics, schools or homes Includes family sessions Delivered by A-CRA trained and certified clinicians

Statewide Resources

Massachusetts Substance Use Helpline *Web based resources listing all substance use services for youth under the age of 25

www.helplinema.org

Call: 1-800-327-5050

Office of Youth & Young Adult Services at BSAS, MDPH*State office overseeing state funded and licensed substance use services for youth under the age of 25

Call: (617) 624-5111

Massachusetts Health Promotion Clearinghouse*Free printed materials on substance use prevention and treatment resources.

www.mass.gov/maclearinghouse

http://www.helplinema.org/

http://www.mass.gov/maclearinghouse


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Part VII: Planning for Implementation

De-identified data submitted within 90 days of screening completion

DPH Data Collection Tool


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Next Steps

• www.MASBIRT.org/schools

• Toolkit, checklist, and other helpful resources

Visit MASBIRT Website

• www.MAClearinghouse.com

• www.DrugFree.orgGather Materials

• Discuss and finalize implementation plan with your SBIRT teamFinalize

Implementation Plan

• Think about any other trainings you may want to sharpen your skills!

• Additional SBIRT trainings: Mastering SBIRT, Implementation Essentials, etc.

Consider Additional Trainings

Other Trainings

• MASBIRT TTA SBIRT in Schools: Implementation Essentials (3 hours) • For districts/individuals who have not implemented SBIRT previously• Reviews implementation planning, including challenges and potential solutions• Focused on those directly involved in SBIRT implementation• Some time for skills practice

• MASBIRT TTA SBIRT in Schools: Mastering SBIRT (3 hours)• For districts/individuals who have implemented SBIRT previously• Focus on clinical skill in delivering SBIRT, including the REACT model to reinforce healthy decisions

with students who screen negative for substance use, and the Brief Negotiated Interview for students who screen positive for substance use

• Further discussion about referrals, consent and confidentiality

• BSAS Supporting Schools: Strategies for Discussing Substance Use with Students (6 hours)• Reviews methods from the A-CRA model which can support school staff to intervene around a

student’s substance use with developmentally appropriate and evidence-based strategies• Includes demonstration and practice of a Functional Analysis of Substance Use Behavior,

Increasing Pro-Social Recreation, Drinking/Drug Refusal Skills, and Sobriety Sampling

http://www.masbirt.org/schools

http://www.maclearinghouse.com/

http://www.drugfree.org/


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Training & Technical Assistance Resources

• MASBIRT Training & Technical Assistance (MASBIRT TTA) • Phone: (617) 414-3749 • Email: [email protected]• Web: www.MASBIRT.org

• Massachusetts Department of Public Health, School Health Unit• Director of School Health: Karen Robitaille, MBA, MSN, RN, NCSN• Email: [email protected]• Web: https://www.mass.gov/orgs/school-health-services

• Massachusetts Department of Public Health, Bureau of Substance Addiction Services• Web: https://www.mass.gov/orgs/bureau-of-substance-addiction-services

• School Health Institute for Education and Leadership Development (SHIELD)• Web: http://sites.bu.edu/shield/

Regional School Nurse Consultant Contacts

Region Name Phone Email

BostonMary Jane O’Brien, PhD, RN, CPNP, NCSN

(617) 635-6788 [email protected]

CentralJanet Guertin-Moruzzi, BSN, RN, NCSN


MetrowestJill Connolly, MEd, BSN, RN, NCSN

(781) 848-4000 x7841 [email protected]

NortheastShanyn Toulouse, MEd, BSN, RN, NCSN


SoutheastAnn Linehan, DNP, MSN, RN


WestVeronica Webb Barrett, MSN, MA, RN, HNB-BC


mailto:[email protected]

http://www.masbirt.org/


https://www.mass.gov/orgs/school-health-services

https://www.mass.gov/orgs/bureau-of-substance-addiction-services

http://sites.bu.edu/shield/








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Wrap Up

• What is one thing you learned, realized or were surprised by today?

Thanks!

Any questions?

Please fill out electronic evaluations!

sbirt in schools · 2020-02-10 · sbirt in schools: introduction training 2/10/2020 11 crafft-ii:...

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