Screening and
Assessing Adolescents for Substance Use Disorders
Chapter 2 -- Preliminary Screening of Adolescents
The Consensus Panel recommends that all adolescents who exhibit signs of substance use receive appropriate, valid, and sensitive screening. Health service providers, juvenile justice workers, educators, and other professionals who work with adolescents at risk should be able to screen and refer for further assessment.
When screening turns up "red flags" that indicate that the adolescent may have a substance use disorder, the youth should be referred for a comprehensive assessment (Winters, 1994). For adolescents at high risk for substance use disorders, a negative screening result should be followed up with a re-evaluation, perhaps after 6 months. In recognition of the importance of early detection and intervention, it is appropriate to be inclusive when screening youth for substance use problems. The goal of screening is to identify accurately youth who will benefit from a full and complete assessment, at which time a determination of a substance use disorder can be made and recommendations for intervention developed.
Of course, just because an adolescent shows warning signs of substance use, this does not confirm that he has a problem severe enough to warrant a formal diagnosis or referral to intensive drug treatment. Some adolescents' substance involvement is temporary (Newcomb and Bentler, 1989), and most young substance users do not develop serious problems as they get older (Shedler and Block, 1990). Thus, professionals conducting screenings for substance use disorders must also be sensitive to the potential danger of stigmatizing the youth with a label of a substance abuse or substance dependence diagnosis or as having a "disease."
Screening
Screening determines the need for a comprehensive assessment; it does not establish definitive information about diagnosis and possible treatment needs. The process should take no longer than 30 minutes and ideally will be shorter. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the hallmarks of a screening program are (1) its ability to be administered in about 10--15 minutes and (2) its broad applicability across diverse populations (SAMHSA, 1994). A screen should be simple enough that a wide range of health professionals can administer it. It should focus on the adolescent's substance use severity (primarily consumption patterns) and a core group of associated factors such as legal problems, mental health status, educational functioning, and living situation. The client's awareness of her problem, her thoughts on it, and her motivation for changing her behavior should also be solicited.
During a 30-minute screening, there may be enough time to gather information from both the adolescent and a parent or guardian and to administer a brief standardized screening questionnaire to supplement the interview. A 10- to 15-minute screening process would involve the adolescent and one method of data collection (either brief questionnaire or structured interview). The shorter screening procedure may be the only feasible strategy in facilities that must process large numbers of at-risk youth and where staff is overburdened with other tasks. Some believe that behavioral histories obtained using interactive computer software are more accurate than those done by interview or written survey, but other experts debate this (Turner et al., 1998).
Who Should Screen
Community organizations (e.g., schools, health care delivery systems, the judiciary, vocational rehabilitation, religious organizations) and individuals associated with adolescents at risk must be able to screen and detect substance use. Thus many health and judicial professionals should have screening expertise, including school counselors, street youth workers, probation officers, and pediatricians.
Who Should Be Screened
Obviously, juvenile justice systems should screen all adolescents at the time of arrest or detention. "Status offenders" do not go through these processes, but they should also be screened. Adolescent offenders clearly form an at-risk population, and the base rate of substance use is sufficiently high among them to justify universal screening (Dembo et al., 1993a). Given the high correlation between psychological difficulty and substance use disorders, all teens receiving mental health assessment should also be systematically screened. Within other service delivery systems, runaway youth (e.g., at shelters), teens entering the child welfare system, teens who dropped out of school (e.g., in vocational/job corps programs), and other high risk populations (e.g., special education students) should also be screened.
Adolescents who present with substantial behavioral changes or emergency medical services for trauma, or who suddenly begin experiencing medical problems such as accidents, injury, or gastrointestinal disturbance should also be screened. In addition, schools should screen youth who show increased oppositional behavior, significant changes in grade point average, and a great number of unexcused school absences.
Components of the Screening Process
Naturally, an appropriate screening procedure must consider several variables pertaining to the client, such as age, ethnicity, culture, gender, sexual orientation, socioeconomic status, and literacy level. Before using standardized interviews and questionnaires, it is incumbent on the assessor to review the instrument manual to gauge how sensitive it is to differences in adolescents' backgrounds. For example, many instruments will have different norms for boys and girls and for younger and older children. Collecting normative data for representative populations of different cultural groups can confuse the assessment of substance use disorders among individuals across cultural groups. If the norm for a particular group is high substance use, high substance use will "score" as normal when compared with a standardization sample made up exclusively of members of that group. What is important is that the content of the test is appropriate for clients from a variety of backgrounds and cultural experiences. Responses to potentially culture-insensitive items should be reviewed with the individual for clarification.
There are three primary components to preliminary screening: (1) content domains, (2) screening methods, and (3) information sources.
Content
The screening procedure focuses on empirically verified "red flags," or indicators of serious substance-related problems among adolescents (Rahdert, 1991). The indicators tend to fall into two broad categories: those that indicate substance use problem severity and those that are psychosocial factors. While more research is needed to validate red flags of adolescent substance use disorders, a growing body of empirical literature identifies salient markers. Figure 2-1 provides a list of such markers prepared by the Panel. There is no definitive rule as to how many uncovered red flags dictate a referral for a comprehensive assessment. Many screening questionnaires provide empirically validated cut scores to assist with this decision. Nevertheless, any time there are several red flags or a few that appear to be meaningful, it is advisable to refer the adolescent for a comprehensive assessment.
HIV/AIDS risk behaviors
Current public health concerns require that screenings for substance use disorders place a high priority on the issue of substance use as a contributor to risky sexual activity and to other HIV/AIDS risk behaviors (Leigh and Stall, 1993). According to the Youth Risk Behavior Survey, in 1995 over half of students in grades 9-12 had already engaged in sexual intercourse. Almost one-fifth reported that they had more than four sex partners, and only half of all sexually active high schoolers reported using a condom the last time they had intercourse. Drug use also appears to encourage risky sexual behavior: One-fourth of the sexually active students said they used substances the last time they had intercourse (Centers for Disease Control and Prevention, 1998; Jainchill et al., in press).
This issue highlights the importance that workers dealing with youth receive adequate training on HIV/AIDS prevention, education, and referral. Because confidentiality is essential in this area, agencies and service providers should have clear policies and procedures for recording, providing, and disclosing information on HIV counseling and testing. State laws vary concerning the confidentiality rights of youth and the right of parents to know about the HIV status of their child. Thus, it is important that local policies and procedures be consistent with State regulations. If a program receives funds from Federal sources, it may have to consider Federal laws as well.
Screening methods
Interviews and questionnaires
A model screening instrument is short, simple, and appropriate to the youth's age. The instrument should give the "big picture" of the youth's situation, not a lot of specific, detailed information. However, the instrument should be of sufficient scope to cover the "red flag" areas of substance use disorders and psychosocial functioning noted above. The tool should not require sophisticated knowledge in test administration or interpretation; it must have high utility for a broad range of professionals and paraprofessionals.
The most commonly used screening method is the interview. Not only is a screening interview an efficient means to gathering information on the essential red flags, it also offers an opportunity to observe the client's nonverbal behaviors and to gauge his verbal skills.
When structured screening interviews are used, it is important that the interviewer follow the administration structure provided in the interview booklet. Unstructured interviews pose special administration problems that contribute to measurement error. The Panel strongly recommends that structured or semistructured interviews be used in this field. Interviews should not be performed with parents present.
When using paper-and-pencil questionnaires, administration procedures should have the client read aloud the instructions that accompany the test to ensure that the client understands what is expected of him and to judge whether the client's reading ability is appropriate for the testing situation.
The Consensus Panel and Revision Panel reviewed available screening instruments for adolescent substance use (see Appendix B). Many of these screening instruments can be administered in 15 minutes and require only a few more minutes to score. Others ("mid-range screeners" such as Dembo's Prototype Screening/Triage Form) are quite lengthy and will require more administration, training, and scoring time (Dembo et al., 1990a). Furthermore, the group of screening tools varies considerably in how many red flags each tool covers. The Problem-Oriented Screening Instrument for Teenagers (POSIT), recently developed by the National Institute on Drug Abuse (NIDA) (Rahdert, 1991), covers 10 domains, while others are quite narrow in scope. Naturally, choosing a screening tool requires other considerations, including cost (some are not public domain) and its long-range value for agencies wanting to develop clinical databases. The reader is encouraged to contact the authors of instruments to obtain additional information about their applicability and utility.
Drug monitoring
Laboratory methods to monitor substance use can be conducted in the preliminary screening to supplement information gathered through screening tools and additional sources. Drug testing is an important addition to most screens and assessments; it is particularly useful at intake to juvenile assessment centers, other juvenile detention facilities, and crisis stabilization units. Drug monitoring should be conducted at an appropriate point during screening and in a manner consistent with accepted standards and guidelines. NIDA-certified laboratories are generally available in most communities and are equipped to provide agencies with the necessary training in collecting urine and blood samples.
Drug testing should always be conducted with the knowledge and consent of the adolescent. Surreptitious testing (e.g., asking for a sample for "medical" reasons and then testing it for drugs) is never advisable. Assessors should always report the results of testing to a youth and discuss their implications. Drawbacks to drug testing include the fact that lab tests yield a narrow range of information. Severity of use and the consequences of that use cannot be obtained from testing for the presence of drugs in urine and blood. Since adolescents may adulterate or replace their urine sample, collection should probably be observed. Appendix C provides additional information about laboratory testing procedures.
Other sources of information
Although it is a luxury in most screening situations, supplemental and corroborative information is useful during a screening evaluation. In most instances, obtaining it will involve interviewing a knowledgeable parent or guardian. Other logical sources at this level may be other family members, or the youth's caseworker, probation officer, or teacher. Getting information from other sources helps the assessor guard against developing an incorrect picture based solely on the young person's self-report. There is evidence that knowledgeable parents generally provide valid information about their child's "externalizing" problems, such as conduct problems, delinquency, and attention deficits, while they provide less valid and corroborating information with respect to the child's "internalizing" concerns, such as mood distress and self-view (Ivens and Rehm, 1988). Parents also can report on signs of use such as paper bags with inhalable substances in them, beer cans in a car, or drug-seeking behaviors such as stealing money from family members. Clinical wisdom suggests that parents' knowledge of their child's substance use is probably based on observation of its consequences (e.g., physical effects of intoxication).
After getting the teenager's consent, the assessor should also collect information about family life, including substance use behaviors and attitudes in the home, and whether physical, sexual, or emotional abuse is present. It is wise to collect the information when the youth is not present in the interview room and to tell the parents that what they say may be shared with the adolescent in the summary of the screening.
The Need for Community Coordination
At-risk behavior among youth is often viewed solely as a disciplinary problem rather than a signal that intervention is needed. Community-based training and community involvement in the screening process can go a long way toward enhancing effective community responses to substance-using adolescents. The Consensus Panel recommends that everyone who works with youth use the same instruments. One way to accomplish this would be for schools, child welfare agencies, human service agencies, and juvenile justice systems to establish an areawide coordinating committee for adolescent screening and assessment. The committee could review and select reliable, standardized screening and assessment tools from among the instruments presented in (Appendix B so that all agencies serving the local adolescents and their families will use the same standardized measures. The use of these measures can be refined from feedback gained from focus groups.
When substance use disorder treatment, mental health, and related service providers and other community agencies specifically designed to serve at-risk youth agree to use the same screening instruments and follow similar procedures, the community is most able to apply consistent referral criteria. This process can be facilitated by communities agreeing on definitions of "high-risk" behavior for their particular community and thresholds for referring young persons for additional comprehensive assessment and treatment. If possible, local communities should ascertain the instruments' reliability and validity for that community. It is also important for local agencies to maintain their own databases on local drug testing results for the particular purposes of need assessment. For example, it helps to have data on the frequencies of abuse of various drugs and to document what are the most prevalent problems that coexist with the substance use disorder.
Administrative considerations regarding preliminary screening include cost, ease of use, flexibility of use in different settings among different populations, analyses of screening data, and preparation of relevant reports. To address these considerations, agencies throughout the community or local area must coordinate their screening policies. A communitywide interagency mechanism should be put in place to coordinate and implement screening, management of information systems (MIS), and training of screeners and other relevant professionals. Any such mechanism would have to conform to confidentiality regulations (see below).
The establishment of an areawide coordinating body for screening and assessing adolescents for substance use disorders could greatly facilitate administrative effectiveness on all levels. Such centers can coordinate intake, screening, referral, and MIS activities. The Treatment Alternatives for Safe Communities (TASC) program offers one example of effective interagency collaboration. TASC programs have been successful in identifying a large number of offenders in need of substance use disorder services (Cook, 1992). The TASC evaluation conducted in 1976 stated that various programs had achieved success in identifying a large number of offenders who qualified for TASC services and that self-reports, urinalysis, and referrals from lawyers and judges seemed to increase client flow (Toborg et al., 1976). This type of structured case management between the criminal justice and treatment systems has facilitated the traditional goals of each system.
Funding for grassroots training and implementation is necessary to support communitywide collaboration. Training should take place within a particular agency, among different agencies, and areawide. These efforts will help to identify the service providers most likely to conduct preliminary screening (such as protective service and intake workers, guidance counselors, and nurses). Training should focus on the advantages and cautions when using standardized measures (e.g., advantage of reducing error associated with subjective judgment versus inherent limitation of tests to address the unique situation of an individual).
After client-identifying information has been stripped, screening results can be made available to a large repository that can track data through on-line computer and database systems. A number-identifying system is one way to share data and yet ensure confidentiality. MIS tracking based on compiled data can provide information critical to future planning. (Some communities will not have the resources to conduct these efforts.) Electronic case reporting and instrument scoring are easing the inevitable move to paperless recordkeeping and electronic data communication, and they provide aggregate data for population descriptions, internal accountability, and reports to funding and licensing agencies. In addition, aggregate case data can sometimes persuade funding and governmental agencies responsible for resource allocation that a serious need exists for expanded local resources for adolescents.
How information is stated and stored in the files is critical, especially in today's world of computerized recordkeeping. Computerization of records greatly complicates efforts to ensure security. Once a file is created, it can "follow" a client for the rest of her life. Wording can lead to misinterpretation, creating future problems. Labeling of the adolescent must be avoided. One way to avoid labeling is to report facts, not opinions, and only information that is necessary for meeting the client's treatment needs. (For a brief discussion of some of the issues computerization raises, see TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing [CSAT, 1996], pp. 52-53.)
Protocols developed by community agencies to govern screening and assessment must be clear about consent and patient notice, confidentiality and privacy, State and Federal regulations (including those regarding child abuse reporting), and duty-to-warn requirements. Programs must establish and follow guidelines on confidentiality and privacy, including policies for administrative procedures and training. In other words, confidentiality and privacy must be highlighted as priorities in every aspect of the program. Training must be provided so that protocols and instruments are clearly understood. Interviewers must remind clients in a clear, realistic, and understandable manner about their rights concerning informed consent and privacy. See (Chapter 4 for a more detailed discussion of confidentiality and other legal concerns.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 99-3282
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