Young people aged 12 to 20 account for 11 percent of all alcohol consumed in the United States, and more than 90 percent of this consumption is binge drinking. The 12-17 age group accounts for nearly 30 percent of illicit drug use. Because 90 percent of those who develop a substance use disorder started using before the age of 18, Screening, Brief Intervention and Referral to Treatment (SBIRT) may be used strategically to identify risky use and provide early intervention services to prevent more severe consequences.
For this model to work, an open and honest conversation must occur between the young person and the SBIRT practitioner. But for a population that cannot legally consume alcohol and may be using illegal drugs, honest disclosure poses risks. Youth may fear that disclosing use, even to a professional, will mean their parents, schools or even legal authorities will be notified, and they will get into trouble.
“For SBIRT to be effective, it is important for clinicians and counselors to convey to youth that what they say is strictly confidential and stays between them and the provider,” said Brett Harris, DrPH, a clinical assistant professor at the University at Albany School of Public Health who has been working to implement SBIRT in various adult and youth settings for more than six years. “Confidentiality is a huge issue.”
Confidentiality generally means that any information disclosed between a minor and the SBIRT practitioner is not shared with any other outside parties (including parents), unless the minor is of harm to himself or others. This policy helps to build trust and increase the likelihood that a youth will disclose. Confidentiality laws and policies vary from state to state and from facility to facility, so understanding your setting’s specific policies is important.
School based health centers (SBHCs), for example, protect their patients under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which ensures that their parents and schools will not be notified of any care received or disclosure made in the center. These centers are run by outside medical entities and are independent of the school. The primary consent that parents provide for services is to initially authorize their child to enroll in the SBHCs for the year.
Though confidentiality is intact within the center, it can be jeopardized by insurance billing and outside referrals. For example, if a student receives a brief intervention and the SBHC submits for reimbursement, the child’s parents may receive notification from the insurance company. This issue becomes much larger when a child is referred to addiction treatment. Because of the costs involved (some or all of which may be covered by insurance), it is almost impossible for a minor to receive treatment services without his or her parents knowing about it.
Fortunately, it is quite rare for youth to be using at a level which indicates the need for a treatment referral. When further treatment is necessary, there are some settings which have the capacity to provide more intensive intervention or treatment services in-house. For example, in New York State SBHCs, staffed with medical and mental health professionals, 88 to 97 percent of providers report responsibility for substance use intervention and management. Another 40 percent report referring students in need of treatment to on-site mental health counselors. For the most part, conducting SBIRT with young patients in SBHCs enables those who demonstrate at-risk substance use to receive care that is easy to access and does not require parental involvement.
Although SBHCs are designed to value students’ confidentiality, juvenile justice and traditional school settings do not have the same built-in protections. Substance use could lengthen sentencing for juvenile delinquents or could result in expulsion from schools. Therefore, to create an open discussion about substance use, these settings must develop their own individual confidentiality policies that balance disciplinary policies with the need to address youth substance use. In these settings, the degree of confidentiality that young people receive varies.
Although confidentiality is essential for building trust and rapport between a minor and an SBIRT practitioner, Harris stresses that parental involvement is usually an important source of support for young people who need more intensive intervention services or addiction treatment. In fact, teens respond better to intervention and treatment when parents are involved.
When a young person presents with a substance use disorder in need of treatment, the SBIRT practitioner will often ask for the child’s permission to involve parents or offer to facilitate a discussion between the parent and child. Ensuring confidentiality can function as an initial way to build trust and understand a young person’s use, but having the support and involvement of parents can help maximize the effectiveness of intervention and result in the best outcomes.
Trust facilitates the effectiveness of SBIRT. Research tells us that people are often honest about substance use when asked, which is one reason why SBIRT may help promote behavior change. Each youth-service setting must consider how to eliminate both actual and perceived penalty for disclosure in order to promote honesty and achieve positive outcomes.
Danielle Noriega is a research analyst at NORC at the University of Chicago supporting the Adolescent SBIRT Project and a variety of other public health work. NORC is an independent research institution that delivers reliable data and rigorous analysis to guide critical programmatic, business and policy decisions.
Jessica Williams is the director of communication and health promotion at the Institute for Research, Education and Training in Addictions (IRETA) in Pittsburgh, Pennsylvania. IRETA is a federally designated training and technical assistance center to advance the use of SBIRT.