hello, i'm ivette torres, and welcome to another edition of the road to recovery. today we'll be talking about prevention and early intervention in behavioral health, promising practices. joining us in our panel today are kristen brennan, executive director, fairfax partnership for youth, fairfax, virginia; dr. richard brown, professor of family medicine, school of medicine and public health, university of wisconsin, madison, wisconsin; gail ritchie, public health analyst, center for mental health services, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland; dr. pierluigi mancini, ceo, clinic for education, treatment,

prevention, and addiction, inc., norcross, georgia. pierluigi, between 2002 and 2011, the total number of adolescents that received prevention messages through the media went from 83.2 percent in 2002 and 75.1 percent on 2011. are we reaching enough young people with prevention messages? well, i think the question is how are we trying to reach the youth with prevention messages? i think that the development of technology today has given us an opportunity that we haven't quite caught up with. traditionally, we have public service announcements, we have school activities, but today, we have facebook. we have texting. we have an ability to find new ways that

we haven't quite exploded yet. so, the media we have to look at from a broader perspective, not just the broadcast media but everything that the youth are using today? that's correct. and i think that what we're doing is, we also need to measure, or find a way to measure, how it is that we are reaching them through these new media. absolutely. and kristen, you know, the same figures hold true for the school-based youth. it went from in 2002, from 78.8 percent of all youth that were in school receiving-adolescents, to be specific-that were receiving messages through their school-based environment, to 74.5 percent in 2011. what do you think happened? i know that for our programs in northern virginia, we do survey our youth annually, starting in 6th grade and going through 12th grade. and so, that has enabled us to learn a lot about

exactly what's going on. we ask them about all kinds of behaviors and practices. so, it gives us more information than we used to have. and what information are you getting? we're learning which trends are improving, which ones are not, things- such as? such as suicidality, the number of youth who have considered or attempted suicide, bullying behaviors, the numbers of youth who have either reported that they have bullied or been bullied in the past year. and every year we are tweaking those surveys to get more information, listening to the partners as they say, you know, "i think we need to ask kids about this so we can get better information." so we're getting more information, and that enables us to tailor our prevention practices a little more. and gail, in terms of the mental health issues with youth, particularly in light of the current incidents, what kind of messages should we be sending?

and are the ones that we're sending now being effective? well, there are a variety of messages that we can send out. i'd like to use our grand program, that is taking the good behavior game, which is an evidence-based practice, to 21 elementary schools across the country. what the literature tells us is that two major risk factors, early aggressive and disruptive behavior by elementary school boys in particular, lead them to be at risk for a variety of outcomes, both mental health problems as well as substance abuse problems. so, by going early into a young child's life, we can begin to put them on the developmental track that works, and this seems to be working across the country. and richard, this all assumes that the best way is through messaging, yes, but once the youth is affected in some way,

they really do have to be assessed. what does that mean to be assessed? well, it's really important that we look at youth who are having problems in any sphere of life because this is often such a web of risks that are interrelated. but it's also important that we recognize that everybody in this age group is at risk, so we really ought to be screening children on a regular basis, and this can happen- all children? all children, absolutely. so, this can happen in medical settings, but it can also happen in schools, it can also happen through other youth-serving organizations. and what is the definition of screening? what should a parent be knowledgeable about in terms of screening? what does that entail? yeah, it's real important that parents be knowledgeable because often parents hesitate a bit because this does involve asking kids some pretty personal questions. and parents hesitate, you know, "is this going to be in the record?" "might this haunt my child in the future?" but in reality, it's real important we be asking kids questions about tobacco use, substance use,

various symptoms of mental health disorders, so that we can identify issues early and head big problems off. and this is from the parents' perspective. pierluigi, what happens, what should the parents and friends of those youth also be cognizant and on the lookout for? well, i think parents need to be in the lookout for any change of behavior, any change of friends, any change of attitudes. friends need to be cognizant about those changes for several reasons. you know, we are learning more and more. we used to think that the parent was the most important voice in that children's life. today we're finding out it's all their siblings and friends that are the most important voices. so as parents, we also have to keep an eye on who are my children's friends, and as for those who are positive friendships, to make sure that we continue to

support those positive friendships. but we do need to look at changing behavior, change of clothing, change of attitudes, and also some isolation and some of the other negative type of behaviors that we're pretty much learning that it leads to some unhealthy symptoms. and gail, you know, you mentioned the whole notion of the youth that are affected by some mental health problems that also go to addiction. for youth 12 to 17 who experience depression in the past year-and this is 2011's data-they were two times as likely to take the first drink or use drugs as other youth in that cohort. talk to me a little bit about that. you know, this reminds me: we can approach it two ways. one way is to look at the issue of early intervention, or intervening early in the course of the illness. so you want to try to find people that are beginning to

experience depression at the point of being a diagnosable problem. and what do youth act like if they were beginning to experience depression? well, oftentimes they withdraw, their behavior is not like it was before, they're less social, they might report that they can't sleep or they sleep too much, they have less of an appetite or more of an appetite. these are important things to look for. and sometimes it's the opposite. sometimes kids will actually be depressed but actually more agitated and acting out more. that's right. i'd like to also add a point about prevention here. dr. gray-clarke from kaiser permanente, a number of years ago, did a wonderful study. he knew that mothers within the health organization who got depressed put their kids at risk, so he then developed and studied-and we have the good, randomized control trial that lead us in this-that he developed an evidence-based practice for youth whose parents were depressed who are not yet depressed yet.

and so it's a preventive intervention, it's a cognitive behavioral format, and i think it's very encouraging. and kristen, how does the school system then, you can certainly do your surveys, but what do you do when you do begin to see a pattern of behavior within a student, and how do you capture that, and how do you approach that student? well, it's of the utmost important that the school personnel are working together. we have school social workers, counselors, and psychologists, and in some cases we also have a substance abuse support person from our csb, the community services board. and they are working together and communicating on the youth who've come to their attention and then strategizing on how they can best support that youth. now, of course, the school systems, they are limited in what they can offer in treatment. so, where programs like ours, as a nonprofit agency, come in is to make families and the community aware of

what resources are there for them, so that they can seek effective treatment for youth. and going back to something gail was saying earlier, you were talking about how early aggressive behavior is a key thing to be aware of for young children, and we're really, at our organization, trying to bring attention to the fact that we want to start paying attention at that point, and bringing effective treatment and therapies to youth at that point, rather than waiting until later when there's a crisis that occurs. you know, the other issue that you mentioned, that you tried to get them treatment. well, we know for a fact that only about, i would say, 10.8 percent of the people who really need treatment of the 20.6 million that are affected-and this is the entire population, 12 and older, that have a problem. so, how do you begin to weed out with those families

to try and get them help? there's actually a program, a national campaign, called the 1 in 5 campaign, which states that one in five youth have an issue, and of those five, one of them gets treatment. that's sort of the rule of thumb that we go by. so, there are a lot of different things that we try to do in our community because we're aware that nationwide, it's a problem with resources, providing access to effective treatment is a huge problem across the country. so, when we come back, i want to continue with that train of thought because i think that will be very helpful for our audience. we'll be right back. [music] we want everybody in the community to understand

signs and symptoms of mental illness and of addiction, or even just an emerging problem, so that individuals can know when either themselves, their family members, or a neighbor, or friend is having difficulties and they may need to reach out for help. so, increasingly, we're trying to help people understand what addiction is about, what mental illness is about, what mental health conditions are about, and what substance abuse is about, so that we can identify these signs and symptoms sooner, and so that neighbors can help neighbors in reaching out and getting the help that they need. what samhsa is doing with regard to facilitating the integration of the assessment of mental and behavioral health problems in the primary care settings-our major initiative is the screening, brief-intervention, and referral to treatment initiative, which lodges the screening in the primary care setting. so as part of the primary care team, what the mental health

counselor or the substance abuse counselor would be doing is asking questions about alcohol and drugs and also dealing with mental health issues. recovery benefits everyone. substance use and mental disorders can be treated. it all starts day one. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. so kristen, do you want to continue telling us exactly how you helped those parents try and seek help? yeah, one of the things that we've been doing over about the last year is a community education program. i had the opportunity to go and speak to all of the about 500 counselors in our public school system (we have one of the largest public school systems in the country) and give them information on helping

youth not only to access the services that are available but some information about self-care. so, we do a lot of community education around the importance of sleep and nutrition and exercise and things like that, so that youth who don't have access or who aren't ready to access treatment have some strategies that they can pursue on their own. but i've also done that program for parent groups, for ptas, and we're actually going to be having a tv show coming up in the next couple of months on our local government channel where we'll be talking about a lot of those kinds of topics, also. we do advocacy around the community. we work with our local government and the school system because, like i said, we're a not-for-profit, so we are not linked directly to the government or the school system. we're kind of working in between, with the community-based organizations. and gail, does that parallel some of techniques and approaches that you do in some of your programs?

yes. it reminded me of the concept that we use in a couple of our programs which is-for prevention in particular-we know that, mental health professionals, for example, most of prevention will not be done by the mental health community, but it will be done by people in the social settings where children are. so, in the program, which we're moving-the good behavior game-to elementary schools, is a prime example of how teachers are preventionists. and i think that's also another way to look at the problem of early intervention, trying to find kids who are just becoming ill with mental health or substance abuse problems. we know that if we can train those that are in the social sphere where children are to know more about these issues, then that's a way to get them to treatment. you know, i really wanted to mention when we had our prevention program, we started it in the middle school, and we moved it down to the elementary school.

but the important component for us, because we started mental health promotion at the same time that we did substance abuse prevention, and our key component was the parents. we needed to have a very strong parental component because we work with immigrant parents, we work with latino parents, and there was a great disconnect from what the children were learning and doing to what the parents thought they needed to be learning and doing. and what we found out is the children were our partners in helping educate the parents about mental health promotion and substance abuse prevention. but you also work with the parents? correct. yeah. you train the parents because you had a very, very unique situation there for a while where you had a lot of suicides in your community. correct. and besides being the silent epidemic in latino families, it became a very difficult topic. so we did engage the parents, and today actually,

our suicide prevention program has grown, where we're now also training latino youth to be suicide peer mentors at the schools, and that program is also beginning to develop and give us some excellent results. richard, speaking about screening, i know that you're working with physicians at the university of wisconsin and medical school. and how, what, does the program entail in terms of getting them to understand what they need to do in their everyday practice? and actually, we're working with not just physicians, but clinical settings throughout the entire state of wisconsin. and one lesson that we learned early on is that the current staff, the physicians, the nurses, they just don't have time to do yet one more thing. so, we've actually found that we can make the most progress if we help them expand their healthgate, health care teams, and everybody has a role. so, the receptionist will ask the team to fill out

a questionnaire when they arrive at the clinic. the medical assistant who checks vital signs will notice if there's a risky response or not. and then for those who have risky responses, there's a full-time, well-trained, well-supported, dedicated health educator who is trained in motivational interviewing and other techniques so they can really connect with that teen and explore with them what are the pros and cons of their behaviors. are they fearful of any risks? are they already starting to have some issues in their lives that they wish would change? and those are the kind of techniques that certainly physicians and nurses could learn, but again, they just don't have that amount of time to spend with the kids. if we could add somebody to the health care team, who's really well-trained and focused on delivering just this behavior, we can do much better. but under the model of screening and brief intervention, is this sort of, does it follow that model? because under that model, people are taught almost to do

what you're saying but there are many settings who may not be able to add on additional staff to be able to do this, and they train, i know that samhsa, csat has trained quite a number of people in being able to adjust their approach in order to provide that brief intervention. yeah, and actually samhsa has supported both models, one model where the current staff, often the physician, actually delivers the service, another model where we expand the health care team. and what we find is when we can expand the health care team, we more consistently deliver more evidence-based services of longer duration to kids. but for settings where the health care team cannot be expanded, then we certainly want to take advantage of the opportunity to train physicians and nurses. and especially in rural areas, where maybe if they expanded the team, there wouldn't be enough people to serve, they even have to be even more flexible, and

maybe people are serving multiple roles in the process. and gail, what are some of the screening tools-and pierluigi-what are some of the screening tools that parents need to be aware of for screening for mental health issues? well, there are some basic tools i think that the primary care physician uses, and i think maybe you can help me on this question. rich, can you help me on that? sure. and yeah, i don't know if i would envision parents using these tools, but it certainly- but being aware of them- yeah, it certainly helps to be aware and understand that this is a good thing for their kids to get, but the tools that we use in practice are maybe an initial question or two, and we don't actually want to start with alcohol and drugs because that's a little jarring for kids. they're on their toes when they're asked initially about that, so maybe we'll start with something maybe a little easier like diet or exercise or sleep, and then we'll ask about tobacco, and then we'll get into alcohol and drugs. maybe we'll preface the questions on their drinking and drug use with questions about whether they know any friends who are drinking or using.

and then a very helpful questionnaire to use for alcohol and drugs is called the crafft, c-r-a-f-f-t, and each of those letters stands for a question. and then for depression, the phq-2 can be a good initial screener, and the phq-9 is more of a more complete, yet still brief, assessment instrument. and it's very easy: just ask the questions, add up the scores, and give an indication what level of risk or problem someone might have. we can never use these tools to make a firm diagnosis, but at least they're a good indication. and actually, if a parent is concerned, they can find these tools online. and if they have a good, trusting relationship with their young one, maybe they can ask. but if they're not sure they're the best person, chances are they're not, and may be good to let somebody in a clinical setting handle it. and in our agency, we have a hybrid agency, where we have a prevention branch and a direct clinical services branch. in both branches, we use the gain, and for prevention, we started adapting the gain short screener.

and this gives us a real quick picture: is this youth heading towards a path that we can help them avoid? for the treatment, we have a more thorough gain that gives us a lot of information about the youth, about all types of behaviors, that we can use to help diagnose and to help develop a treatment plan for that youth. what are some of the questions that the short gain has, for example? well, the short gain will ask you about have you ever used alcohol? how many times in the past 30 days have you ever used tobacco? how have you handled a certain episode where you felt angry? so, it starts dealing with managing emotions, which is one of the key areas that we work in our prevention program. and then it can go further. it can be modified, but it can go further into sexual behavior, into other emotions, and so on.

yes. i'd like to add, to give a story. i think thinking about this issue as a public health problem might shed some light on it. dr. robert mcfarlane from maine medical school did a very interesting study, it was very enlightening. he wanted to try to reach late teens, early youth, early adults, who are at risk for a psychotic break. and so what he did, his catchment area was portland, maine. and he trained counselors and high school teachers- i think it might have been parents, not quite sure-but the idea is-i'm sure it was, actually-that if these folks began to know what are some of the signs, where most people would say, "oh, they're going to grow out of it," he would say, "please, send me your person if they're showing these signs." and it turned out to be a wonderful way of actually

lowering the rates of psychotic behavior on the part of the population as a whole in that area. and when we come back, i do want to get to, not only continue to learn more of what you're doing, gail, but also deal with the issues of the peer counselors that i want to go back to. we'll be right back. [music] for more information on national recovery month, to find out how to get involved, or to locate an event near you, visit the recovery month website at recoverymonth.gov. i felt broken. [shatter] i needed help from my addiction and depression, and help was there. i found support as i rebuilt my life, piece by piece. with the help of my family and recovery support community, i'm rebuilding my life. i'm through recovery. i am whole again. join the voices for recovery. it's worth it. for information on mental and substance use disorders,

including prevention and treatment referral, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music] yale has a long history of pioneering research in substance abuse, and we've been able to take that even further with sbirt research. sbirt-it's a funny sounding acronym, but it stands for screening, brief intervention, and referral to treatment. screening is very important because many, many folks out there who have substance issues never get any intervention. sbirt, by definition, is identifying those patients along the entire spectrum of use, from just risky use or hazardous use to those that are on the severe end of the spectrum and are dependent. sbirt will identify those patients, offer an intervention,

either to reduce the use or to refer to a specialty treatment program. the heart of sbirt is the b and i in the s-b-i-r-t. our version of the brief intervention is something called the brief negotiation interview. b and i is comprised of four steps: it's build rapport, give feedback, enhance motivation, and negotiate a plan for change. i was actually surprised. when i came in, i came in actually for a minor heart attack, so when i came in, i was kind of surprised when they came in and they were talking to me about it, you know? it was, the main thing about the drug problem is tryin' to admit to somebody, you know what i mean? there's no finger wagging, there's not a lot of facts and figures about what could happen to you, and it's not scaring you about your issues, it's a simple communication style that asks the patient to tell the practitioner the downsides of their problematic use, what they think is a problem with it. and not only that, but asking them to imagine

what things could be better in their lives were they to cut down or to stop altogether or to even go on to treatment. utilizing sbirt in clinical practice and training physicians to utilize sbirt in clinical practice allows us to identify patients who might not otherwise be ready to come forth to their doctors and tell them about it, and also be able to have a skill to talk to patients about how to reduce their alcohol or substance use, or get them to more specialized treatment. and i end up talking, telling some people in here that direct me to the right direction, to programs, outpatient programs, that were able to help me out. because the sbirt program is a very specific and practical skillset, we have a structure training program that helps residents, medical practitioners, nurses, pas, what have you, learn it so that they are able to bring it from the classroom into the ed. we've also created a virtual coach, and the virtual coach is the ability to do some of that training online.

the user of the program clicks through and picks what steps of the b and i to do with this patient. and, depending on the level of correctness of their choices, the patient responds in various ways. sbirt gives the practitioner a needed skill in order to screen and intervene. it's a skill like any other skill that they learn in medical school, and it has the potential to improve the health of the public. i wouldn't even be here, or it would take me a longer time. the earlier, the better. you know, i was able to catch it in a stage that-you know, i'm not a long time user, but i am a user, so it was able to help me balance myself out and get myself into the help that i needed. i see many patients at the end stage of their disease, not only from their alcohol and substance use longstanding, but also from the co-occurring illnesses, which can result as, from, substance use. and so it's become vital to me, not only as a clinician but also as an educator, to really promote prevention, to allow us to identify patients before they really have

reached these end-stage processes in their disease. and so, bringing these prevention techniques and early identification techniques to the residents, i feel, will only improve the health care of patients long term. so kristen, we had mentioned before the whole issue of peer-to-peer interventions. can you talk to us a little bit, and how does that work? there are a variety of ways that we can utilize the information, the expertise of peers to help each other. there's peer mentoring, there's peer mediation, there're a variety of different things that we can do. with peer mediation, we work with youth to help each other resolve conflict, which is a tremendously useful thing in this day and age because there are so many opportunities for youth to be in conflict, not just in person now, but digitally. we want to give them as many ways to resolve those conflicts as possible. what kind of things go on digitally today?