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6 TFAH • WBT • PaininTheNation.org School Climate Creating a positive and inclusive school climate can promote the healthy development of students and help them avoid risky behaviors. Research has demonstrated that when students believe adults and peers at school care about them, they are more likely to avoid unhealthy behaviors such as drug and alcohol misuse. 28 The MTSS model provides a concrete framework to improve school climate and contribute to student well-being and success. There are many variations of MTSS being implemented across the country. MTSS is defined as "the practice of providing high-quality instruction and interventions matched to student need, monitoring progress frequently to make decisions about changes in instruction or goals, and applying child response data to important educational decisions." 29 The model was originally designed for special education students but has grown in promise and practice as evidence mounts of its effectiveness in improving school climate and student success. To enhance both academic and behavioral outcomes, school leaders can implement Positive Behavioral Interventions and Supports (PBIS) models that rely on positive rather than punitive approaches to student misbehavior. Research indicates the PBIS approach contributes to reduced problem behavior, decreased bullying, less illegal substance use, and increased graduation rates. 30 According to a Washington State Institute for Public Policy cost-benefit analysis, for every dollar spent on PBIS, there is a return of $13.61 in societal benefits. 31 The PBIS approach provides a framework for school personnel to organize and deliver evidence-based practices at the school or district level. Screening On average, children spend about one- third of their time in school. 32 Thus, schools provide an excellent setting for proactively screening children for substance misuse and mental health risk factors. Screenings are a quick and low- cost method of reaching a wide number of children to identify risky behaviors and problems early and implement appropriate interventions. In addition, making these types of screenings routine could possibly help reduce the stigma associated with mental and behavioral health concerns, may help students feel cared for, and possibly normalize the use of systems for providing help and resources. An annual screening for substance misuse and suicidal thoughts are among the recommendations in the authoritative standards for care such as Guidelines for Adolescent Preventive Services and Bright Futures. 33 Schools can: l Screen students on a periodic basis using an age-appropriate questionnaire; l Intervene with students who present risk factors by providing feedback about unhealthy behaviors and educating them about the risks involved with substance misuse; l Refer for treatment students who need further assessment and services; l Provide onsite mental health in schools; and l Assist in the process to make treatment available where it doesn't exist, including establishing a referral system that helps link students to youth- friendly providers. Teachers and schools may need to document unmet needs and work to ensure accessibility. $13.61 ROI for every $1 invested in PBIS Screenings are a quick and low-cost method of reaching a wide number of children to identify risky behaviors and problems early and implement appropriate interventions.

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