Use SBIRT approach to identify teens who need help for substance use
AAP Clinical Report
In a pair of reports, the Academy has reaffirmed its recommendation to incorporate
universal screening, brief intervention and referral to treatment (SBIRT) practices for adolescent substance use into routine health care.
A revised policy statement has been simplified from a 2011 statement, and a new clinical
report contains updated guidance, including screening tools and intervention procedures.
The policy and report from the Committee on Substance Abuse, both titled Substance Use Screening, Brief Intervention and Referral to Treatment, appear in the July issue of Pediatrics (see resources).
Need for screening
“Substance use is one of the most important modifiable behaviors adolescents engage
in, and as guardians of children’s health, it is critically important for us to keep
talking about this topic with them,” said Sharon J. Levy, M.D., M.P.H., FAAP, a lead
author of both document.
According to the clinical report, 28% of eighth-graders and more than 68% of 12th-graders
have tried alcohol. In addition, half of high school students reported ever using
illicit drugs, and 41% have tried smoking cigarettes.
Any amount or type of substance use increases the potential for risky behaviors. Half
of all adolescents visiting the emergency department for trauma-related injury test
positive for alcohol use compared to only 5% of adolescents seeking emergency care
for other reasons, according to the clinical report.
A survey of pediatricians found that approximately 50%-86% of respondents performed
routine adolescent substance use screening, but only a minority used validated screening
tools, and most relied on clinical impressions. A recent study found that only one-third
of adolescents excessively using alcohol were detected when pediatricians relied on
Validated screening tools featured in the clinical report ask questions about frequency
of use, which has been found to be effective at predicting risk of developing or having
a substance use disorder, Dr. Levy said.
Focus on healthy behaviors
Regardless of the screening results, brief intervention is important. The clinical
report describes “a type of screening outcome-responsive dialogue that focuses on
encouraging healthy choices and healthful behavior regarding identified risk activities
so that the risk behavior and effects are prevented, reduced or stopped.”
If a parent suspects a child is using illicit substances but the patient denies it,
speak to the patient alone and ask why he or she thinks the parent is concerned. Patients
who continue to deny use may have to be referred to a counselor who can obtain further
information, Dr. Levy said.
If patients are not an immediate risk to themselves or others, pediatricians may choose
to “accept” their answers and provide positive reinforcement similar to what is said
to patients who do not use substances, said Janet F. Williams, M.D., FAAP, co-author
of the reports.
“You can respond to them by telling them you are glad they are making healthy choices
and available if they ever have questions about using substances,” Dr. Williams said.
“Building their confidence and causing them to realize discrepancy in their actions
may prompt them to start questioning the safety of their choices, motivating them
to make healthier choices.”
Informing patients ahead of the screening that their responses will be kept confidential
may increase the likelihood that they will answer honestly.
Patients who report partaking in substance use once or twice in the past year should
be informed about potential negative health effects and encouraged to decrease use.
Substance use that is more frequent may be considered a substance use disorder, and
brief motivational intervention may be more effective at empowering patients to change
behavior than attempting to convince them to change.
Handling a severe disorder
When patients are found to be at immediate risk of harm and/or having a severe substance
use disorder, confidentiality may need to be broken. However, patients should be informed
of this decision before disclosing information to parents.
Adolescents may be more concerned about implicating their friends or revealing where
they obtained the substances than admitting to substance use. However, Dr. Williams
said pediatricians can reassure patients that they do not have to share details that
do not endanger them.
The clinical report includes a chart with the various levels of treatment care, including
outpatient and inpatient/residential care. Research reports that only 10% of adolescents
requiring treatment receive services. This can be attributed to patients who do not
believe they have a problem and either deny use during screening or do not recognize
the need for treatment. In addition, a lack of understanding about treatment may contribute
to the low number.
The big picture
“When speaking to pediatricians, we learned that they often think treatment referral
for a substance use disorder means sending a patient to rehab,” Dr. Levy said. “In
reality, only a very small proportion of the population with substance use disorders
Dr. Levy said she hopes the policy and clinical report help pediatricians to think
in broader terms about referring patients for community-based counseling to treat
underlying reasons that may have led them to start using substances in the first place.
In addition to practicing SBIRT, the policy statement recommends pediatricians advocate
for continued research and adequate payment for SBIRT-related issues, as well as parity
of access to mental health and substance use disorder treatment.