1. Effective Utilization of the SIF for TEAP Specialists Diane A. Tennies, Ph.D., LADC Lead Regional TEAP Health Specialist November 1, 2012

2. Learning Objectives After this presentation, participants will be able to: Describe the concept of a risk assessment and the rational for including a standardized risk assessment instrument (CRAFFT) within the SIF. Accurately score the CRAFFT. Describe the clinical ramifications of a positive screen on the CRAFFT. Develop ways to incorporate individualized assessment and brief interventions into the TEAP program.

3. Survey 1.) How often do you review the SIF? 2.) How confident are you that you score the CRAFFT accurately? 3.) What percentage of students obtain a positive screen on the CRAFFT? 4.) What percentage of students who have a positive on the CRAFFT ALSO test positive on the entrance drug screen?

4. Survey Continued 5.) What percentage of students who have a positive screen on the CRAFFT are NOT students you were aware were at high risk for substance use? 6.) How have the changes to the SIF changed your assessment process in terms of identifying high risk students?

5. Social Intake Form We are focused ONLY on the TEAP section today In April the updated SIF was released with many changes: No more Frequency, Intensity, and Duration (FID) of substance use Also TEAP’s now review the data Why?? The answer has its origins in the purpose of the SIF. Why does JC collect this information during the first 48 hours?

6. The Answer RISK ASSESSMENT Purpose of the SIF is to determine which students are ‘at risk’ due to their behavior. So in-depth collection of sensitive data such frequency, intensity and duration of drug use is done by those with the clinical expertise (TEAP Specialists) when it is deemed clinically necessary. So instead of FID – it was replaced with an Actuarial Risk Assessment Measure

7. A What?? Actuarial Risk Assessment compares an individual to what is known about the population group they come from with regards to certain variables, such as substance abuse. Everyone is familiar with the model as it impacts us all – in ways such as health and life insurance rates. Actuarial measures attach specific statistical weighting to different variables to assess the risk based on what is known about a certain population

8. Well, sort of like this…

9. CRAFFT CRAFFT is an actuarial risk assessment. CRAFFT is a pneumonic for the 6 questions (Car, Relax, Alone, Forget, Friends/Family and Trouble). This better predicts which students warrant more of the TEAP’s time and focus over asking FID questions.

10. Advantages of the CRAFFT The CRAFFT is a MassHealth-approved behavioral health screening tool and recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents/young adults. Developed by modifying questions from longer screens (i.e., qualify with “ever”; screen for drugs as well as alcohol), combining similar questions, and then assessing concurrent validity to identify the best questions for identifying adolescents who need substance abuse intervention/treatment. The sensitivity of the CRAFFT is similar to the longer AUDIT and POSIT tests’, and much greater than the CAGE (which is not recommended for use with adolescents). The CRAFFT works equally well for alcohol and drugs, for males and females, and for youth from diverse race/ethnicity backgrounds.

11. CRAFFT Have you ever ridden in a C ar driven by someone (including yourself) who was high or had been using alcohol or drugs? ** Do you ever use alcohol or drugs to R elax, feel better about yourself, or fit in? Do you ever use alcohol or drugs while you are by yourself A lone? Do you ever F orget things you did while using alcohol or drugs? Do your F amily or F riends ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into T rouble while you were using alcohol or drugs?

12. Scoring of the SIF Research indicates that a “yes” to two of the questions signals a problem needing further evaluation and a score of 4 or more “should raise suspicion of substance dependence” (Knight et al., 2002): SUMMARIZE: Determining which students at risk for not completing JC and developing a substance abuse problem. Then do further assessment. Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607– 14.

13. Why the ‘Car” question? Have you ever ridden in a C ar driven by someone (including yourself) who was high or had been using alcohol or drugs? This screens for the greatest public health problem – Motor Vehicle deaths are the leading cause of death among this age group (don’t have to be behind the wheel to die).

14. Here is how the new updated Social Intake Form will appear: Note the use of footnotes to clarify scoring

17. Questions 10 and 11 NOT PART OF CRAFFT. Included to provide you with more clinical information 10. Affected Others and need for support 11. Tobacco Use = referral to TUPP

18. What Happens Next? Counselors administer the SIF but it is the TEAP specialist’s job to follow up on the answers to the questions. The easy part is administering it – harder part is effective follow up. TEAP Specialist review and sign within one week of student arriving on center (yes, each one needs to reviewed, scored and signed). The ‘negative’ SIF’s = no further response needed The ‘positive’ SIF’s = now what?

19. Implications of Positive CRAFFT

20. Implications of a Positive CRAFFT Okay really what is next? Review the SHR** What might you find? What are you looking for? Consistency of response, for instance. Meet with the student – assess and motivate Follow up every ‘yes’ question to gather more data to assess level of risk and need for intervention. Possible question would be, “Can you tell me more about that?”

21. Motivate?

22. Motivational Interviewing Motivational interviewing (or “Change Talk”) techniques are helpful at this juncture to highlight ambivalence Change Talk is meant to be self- motivating dialogue. Change is facilitated by communicating in a way that elicits the person’s own reasons for and advantages of change. A full presentation of motivational interviewing techniques that are used in brief interventions is beyond the scope of this webinar - review Motivational Interviewing by W.R. Miller and S. Rollnick.

23. Okay, a Few Basics of MI Motivational Interviewing focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitate change. The method differs from more “coercive” or externally-driven methods for motivating change as it does not impose change (that may be inconsistent with the person's own values, beliefs or wishes); but rather supports change in a manner congruent with the person's own values and concerns. The most recent definition of Motivational Interviewing (2009) is: “... a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”

24. Your Turn Examples of successful MI?

25. Further Assessment Further assessment may also be required. SASSI-3/SAASI-A2 AUDIT/MAST/DAST More clinical records

26. Then what? Other Options: MSWR Involvement in TEAP Mandatory or voluntary?

27. What if they say ‘No’ to further assistance? What then? Check back in with them Use more MI Encourage other levels of involvement, such as recreation

28. Revisit Learning Objectives Describe the concept of a risk assessment and the rational for including a standardized risk assessment instrument (CRAFFT) within the SIF. Accurately score the CRAFFT. Describe the clinical ramifications of a positive screen on the CRAFFT. Develop ways to incorporate individualized assessment and brief interventions into the TEAP program.

29. Wrapping Up