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Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 31.)

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Screening and Assessing Adolescents for Substance Use Disorders.

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Chapter 1-- Introduction

Since the 1960s, the rate of substance use by adolescents has waxed and waned: It is currently on the rise. In the early to mid-1990s, the percentage of 8th graders who reported using illicit drugs (that is, drugs illegal for Americans of all ages) within the past year almost doubled, from 11.3 percent in 1991 to 21.4 percent in 1995 (National Institute on Drug Abuse [NIDA], 1996). Drug use by high school students also has risen steadily since 1992; 33 percent of 10th graders and 39 percent of 12th graders reported the use of an illicit drug within the last 12 months (NIDA, 1996).

The frequency of the problem may mask its seriousness: Substance use can disrupt the young person's ability to adequately meet developmental tasks (Baumrind and Moselle, 1985; Newcomb and Bentler, 1989) and impair identity development, a central theme of adolescence. Sustained drug use will likely interfere with the demands and roles of late adolescence and early adulthood, including reaching achievement in dating, marriage, bearing and raising children, establishing a career, and building personally rewarding social connections (Havighurst, 1972). Thus, it stands to reason that the substance-using youth will find it more difficult to negotiate the demands of transition from early adolescence to late adolescence to young adulthood. An adolescent who has not attained development is likely to enter his 20s woefully unprepared for the demands of adult life (Baumrind and Moselle, 1985).

Some of the costs are emotional: Any substance use tends to interfere with a youth's ability to cope with feelings that are a necessary component of his developmental tasks. For example, instead of saying "I feel depressed" or "I feel anxious," an adolescent who is masking her emotions might say "I feel like a beer" or "I feel like a joint" and never know she is having a typical emotion. A great deal is at stake intellectually as well. Abstract thinking, propositional logic (the ability to form hypotheses and consider possible solutions), and metacognition (the ability to think about the thought process itself) are essential abilities that develop during the adolescent years--abilities blunted by alcohol and drug use.

To be treated, the problem must be found. Treatment providers, school nurses, pediatricians, and others who come in contact with teenagers need reliable and valid assessment instruments and procedures to

  • Identify potential substance users
  • Assess the full spectrum of treatment problems
  • Plan appropriate interventions
  • Involve the youth's family, as defined below, in all aspects of intervention
  • Evaluate the effectiveness of the interventions that are actually used
  • Assess substance use problems in the context of the youth's overall development

Screening and assessment are not neutral or passive procedures. Used intelligently, they can provide vital information, thus contributing to effective care. Used in a careless or unprofessional manner, there is the potential for significant harm to the very individuals who need help.

In the discussions that follow, adolescents' rights to privacy and confidentiality and the needs of parents to stay informed about their child's health are emphasized repeatedly to underscore the need for professional and sensitive handling of information on adolescents at each step of the assessment process.

Program staff must understand the impact that culture, race, and gender can have on screening and assessment. Multiethnic and multicultural programs are essential in today's society. People involved in the assessment process must be aware of how their own culture and ethnic background and their life experiences affect the assessment process. Also, before using screening and assessment tools, the assessor should review the instrument's user's manual to ensure that the instrument has been validated on adolescents with a wide range of demographic characteristics. Furthermore, when assessing youth with unique backgrounds, it is recommended that the assessor review the instrument's content so that possible gaps in content coverage can be addressed with supplemental information (e.g., most tests will not provide measures that accommodate an adolescent with a physical disability). Similarly, some screening instruments and procedures are normed for older adolescents, not for children from 11 to 14 years old.

Terms Used in This TIP

The adolescent. This volume uses the broadest possible definition of an adolescent--namely, an individual 11 to 21 years of age. This definition captures the great majority of the physical changes associated with adolescence and the maturing of a child into an adult. The emotional and behavioral transitional stages that have traditionally been associated with the teenage years (e.g., dating to marriage, sexual experimentation to childbearing and parenting, dependent to independent living, and school to work) have changed. In today's society, the adolescent's actual age or physical stage of development does not always correspond with the emotional or behavioral situations of his life. It is no longer unusual to see sexually active 11- to 13-year-olds, 15- to 17-year-olds living independently from their parents, 14- to 18-year-olds responsible for a family, or conversely, 25-year-olds living with their parents.

The diversity of physical, emotional, and behavioral stages among adolescents makes substance use disorder screening, assessment, and treatment planning for this group of individuals especially challenging. The discussions in this TIP assume that adolescents of different ages may have very similar types of problems and treatment needs; on the other hand, adolescents of the same age may be at very different stages of development.

It is obvious that alcohol use in a 13-year-old has much more significance and demands a more aggressive intervention than the same amount or frequency of alcohol use in a 19-year-old. Similarly, the types and quality of relationships that an adolescent experiences with family, school, work, and peers will vary significantly.

The family. The family is a key element in all aspects of screening, assessing, and treating adolescents for substance use disorders (Liddle and Dakof, 1995). However, before assessors involve families in the assessment process, they must reconsider the traditional definition of family (that is, a mother, father, and children all living together). Traditional definitions of family are no longer applicable for many members of society. For example, a family may consist of other relatives and adults who may be helping to raise the child (see Figure 1-1). An expanded definition of family may help the assessor identify individuals who can support the screening and assessment process, and assist the young person as well.

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Figure 1-1: Family Members. Family can include Biological or adoptive parents, grandparents, aunts, uncles Brothers and sisters (including half-siblings) Current foster parent(s) Former foster parent(s) Other children placed in current or previous (more...)

As assessors seek to define the family, they should bear certain principles in mind:

  • The law and society may define family in ways that differ from the actual experiences of substance-using youth.
  • Adolescents may define family in nontraditional ways. Treatment providers should allow adolescents to identify and acknowledge the people they would describe as "family," even though they may not live with the adolescent. For example, family members may include the extended family, foster parents, or an adult who is close to the youth.

Whether its make-up is traditional or not, the family's function continues to be much as it has always been: to meet family members' physical, emotional, financial, spiritual, and cultural needs. Another characteristic of a family is a sense of duty and obligation, so family members provide for needs that range from food and shelter and emotional support, to helping the youth develop values and cultural traditions. Such nurturing is essential to a child's development, and the multiplicity of family types should not prevent treatment staff from understanding and addressing failures in family roles.

The importance of family involvement throughout the assessment process is discussed in this volume. Assessors should receive training in theories and concerns about "family systems" (Szapocznik et al., 1988). It should be kept in mind, however, that despite the importance of family involvement in assessing troubled youth, agencies are often frustrated by the lack of available resources needed to adequately include the family in the process. In addition, abused adolescents should be protected from abusing parents. So although family involvement in screening and assessment, as well as in treatment, is usually highly recommended, it is not always feasible.

Substance abuse. What is meant by substance abuse? A vast amount of literature discusses the problem severity continuum of "using" drugs and the abusive and dependent problems that arise from excessive substance use (American Psychiatric Association, 1994). However, these distinctions often do not consider the special case of adolescents (Martin et al., 1995; Winters et al., in press). The term abuse is often used to refer to any use by adolescents because any use of substances is illegal. In addition, given the rapid physiological changes that occur during adolescence, some experts argue that use of any substance contributes to the "abuse" of a developing body and personality.

In this volume, however, we emphasize the more traditional definitions of abuse and its related concept of dependence. That is, abuse is defined as use of psychoactive substances that increases risk of harmful and hazardous consequences; dependence is defined as a pattern of compulsive seeking and using of substances despite the presence of severe personal and negative consequences. Thus, the Revision Panel, like its predecessor, focused on the identification and referral of adolescents who are showing either substance abuse or dependence characteristics as defined by criteria in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (APA, 1994) criteria and for whom health care or social service resources are warranted.

In addition, the Panel recognizes the importance of new advances in conceptualizing adolescent substance involvement that are more developmentally germane to young people. An excellent example of recent progress along these lines is the Diagnostic and Statistical Manual for Primary Care, which views adolescent substance use disorders along a continuum of severity, which extends from experimentation with drug use through problematic use to disorders of abuse and dependence (American Academy of Pediatrics, 1996).

Screening and assessment. Screening and assessment constitute a two-step process to determine the existence and extent of a substance use problem. Screening is a process that identifies people at risk for the "disease" or disorder (National Institute on Alcohol Abuse and Alcoholism, 1990). As such, screening refers to a brief procedure used to determine the probability of the presence of a problem, substantiate that there is a reason for concern, or identify the need for further evaluation. In a general population, screening for substance abuse and dependency would focus on determining the presence or absence of the disorder, whereas for a population already identified at risk, the screening process would be concerned with measuring the severity of the problem and determining need for a comprehensive assessment.

Comprehensive assessment determines the nature and complexity of the individual's problems. There are at least five objectives for conducting appropriate and comprehensive assessments of persons with substance abuse or dependence problems (Substance Abuse and Mental Health Services Administration, 1994):

  1. To identify those who are experiencing problems related to substance abuse and/or have progressed to the stage of dependence
  2. To assess the full spectrum of problems for which treatment may be needed
  3. To plan appropriate interventions
  4. To involve appropriate family members or significant others, as needed, in the individual's treatment
  5. To evaluate the effectiveness of interventions implemented

It is beyond the scope of this TIP to address the evaluation of treatment effectiveness. This domain includes assessing treatment process (e.g., treatment involvement) and posttreatment functioning. Interested readers are directed to TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (Center for Substance Abuse Treatment [CSAT], 1995), for more information about this topic.

Intervention. The term intervention refers to a spectrum of responses to reduce or ameliorate the problem behaviors under consideration. Among the least intrusive but often effective interventions are conversations between an adolescent and a concerned parent, teacher, physician, or friend. More formalized interventions include prevention programs (aimed at preventing drug use onset), early intervention programs (aimed at intervening before the substance use becomes problematic), and intensive treatment programs (typically directed at stopping current use and maintaining abstinence).

Perhaps the most common interventions are treatment efforts that may take place in outpatient, partial hospital, or residential settings (including correctional facilities). "Partial hospitalization" is a term used to refer to the provision of daytime care with clients returning home overnight. Treatment options are discussed fully in the TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT, 1999).

A special set of interventions occurs within the juvenile justice system (JJS) and includes arrests, probation, and detention. A primary purpose of these interventions is to interrupt the course of illegal and antisocial behaviors, many of which are associated with substance use. Ideally, detention incorporates a treatment protocol to facilitate rehabilitation.

Because of the special circumstances surrounding JJS interventions and the large number of adolescents identified and processed within that system, this volume includes a description of tools that were developed and validated for use with juvenile justice adolescents; Chapter 5 is devoted to the discussion of JJS assessment procedures for substance use disorders.

Assessment Model

It is useful to understand the coverage of this TIP by considering a multiple assessment model (see Chapter 3). The three components of the model--content, methods, and sources--each pertain to specific evaluation goals. The content domain refers to the important clinical variables of adolescent substance use and related problems. For the most part, evaluation of adolescent substance use disorders should address four primary factors: substance use disorder severity, predisposing and perpetuating risk factors, coexisting psychiatric disorders, and response distortions, such as faking good and faking bad tendencies. This perspective assumes that substance use disorders are usually accompanied by other problems in an adolescent's life, such as school performance, peer and family adjustment, medical problems, and crime (Jessor and Jessor, 1977).

The second component of the model refers to the methods used to measure the content. Naturally, there are numerous ways to gain information about substance use. This TIP emphasizes available instruments using the method of self-report questionnaires and interviews. However, direct observation and laboratory testing are also relevant assessment methods to consider.

Finally, several information sources may be relevant when evaluating an individual's substance use disorder. In addition to the client, other informants include parents, teachers, peers, employers, and significant others. (Of course, collateral sources cannot be contacted for information without the adolescent's written consent.) Written reports and records from schools, previous treatment experiences, and juvenile courts also contain information that may be relevant to the adolescent's substance use problems. The Consensus Panel agrees with the conventional wisdom that assessors must use multiple sources in conjunction with a client report because relying on any one source may lead to an underestimate or overestimate of the problem (Weissman et al., 1987). Nevertheless, it is important that the diverse information collected across sources is coherently incorporated into a diagnostic picture. Failure to do so may result in a treatment referral that is irrelevant for the client. Also, assessors need to evaluate the relative validity of the information from different sources and should not assume that the client's self-report is necessarily less valid than other information sources. While there is clearly some evidence to the contrary (e.g., Stinchfield, 1997), several instruments have documented the validity of adolescent self-report of drug involvement (see Winters, 1994).

Figure 1-2 summarizes the application of the three-component assessment model at the screening and comprehensive assessment levels. This application recognizes that the screening evaluation will focus primarily on substance use disorder severity and target a few key psychosocial variables (e.g., psychiatric status). Furthermore, screening should be limited to a short questionnaire and a brief interview and may rely solely on the client and parent as sources of information. However, a comprehensive assessment is intended to address substance use problem severity in great depth, as well as adequately cover the wide range of multiple problems that accompany these problems. This process should employ multiple methods and multiple sources.

Figure 1-2: Screening and Assessment.

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Figure 1-2: Screening and Assessment.

Selection of Screening And Assessment Instruments

Selection of screening and assessment instruments intended for use with adolescents must be guided by several factors: (1) evidence for reliability and validity, (2) the adolescent population(s) for which the instrument was developed and normed, (3) the type of settings in which the instrument was developed, and (4) the intended purpose of the instrument.

Important features of screening and assessment instruments include

  • High test-retest reliability: Are there similar results when the test is given again to the same youth after a brief interval (for instance, 1 week)?
  • Evidence of convergent validity with other instruments attempting to measure the same construct: Is there a strong relationship between the results obtained from this instrument and the results obtained from other instruments designed to look at the same kind of problem (e.g., substance use disorder severity)?
  • Demonstrated ability to measure outcomes that correspond to criterion or standard for comparison: Has the test proven over time that it has helped to predict specific behaviors (e.g., performance in treatment) or clinical decisions (e.g., diagnostic decisions) in the same or similar populations?
  • Availability of normative data for representative groups defined by age, race, gender, and type of settings: Has research shown evidence of a test's reliability and validity among different populations of young people (e.g., boys, girls) and in different kinds of settings (e.g., school, treatment programs)?
  • Sensitivity of the instrument to measure meaningful behavioral changes over time: Is there evidence that the tool reliably measures the changes in a young person's behavior and related thinking?

In addition to the above criteria, it is important to consider these features: The instrument should be relatively easy to administer and not burdensome in length; a detailed user's manual and appropriate scoring materials need to be available; and the cost of the materials for administering and scoring the instrument should not be excessive. See Chapter 3 for more on evaluating instruments.

Substance use disorders invariably ripple out into other areas of a person's life, and this is especially true with young people who are developing emotionally, intellectually, and physically. Although this volume focuses on assessing the individual youth's problems as a foundation for treatment, programs involved with adolescent substance use disorders should also be a part of efforts to address the fundamental community and societal problems that contribute to adolescents' substance use disorders.

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