Screening and
Assessing Adolescents for Substance Use Disorders
Chapter 5 -- Screening and Assessment of Adolescents in Juvenile Justice Settings
It is estimated that up to 250,000 adolescents who enter the juvenile justice system (JJS) in the United States each year have a diagnosable substance use disorder. The percentage of juveniles with such disorders, among groups of delinquents that were studied, ranged from 19 percent to 67 percent (Dembo et al., 1993b, 1990b; Dembo and Associates, 1990).
The screening and assessment of adolescents, especially in the JJS setting, is a complex task. A growing body of literature indicates that adolescents entering the JJS have multiple problems in addition to substance use (Dembo et al., 1993b), which the evaluator must be alert to, including
- Physical or sexual abuse
- Psychological and emotional problems
- Poor performance in school
- Family difficulties, which may include mental health problems, parental neglect, foster care placement, involvement in criminal activity, and a history of substance use by family members, including current use, with or without the adolescent present
- Gang-related violence and involvement with drug sales, as well as other antisocial characteristics (e.g., vandalism)
- Living in neighborhoods where economic hardship, lack of employment opportunities, inadequate housing, and other factors related to poverty and low income have led to communitywide despair and hopelessness among adults as well as youth (Botvin et al., 1997; Schinke et al., 1997; Brinson, 1995; Davis et al., 1996; Dubrow and Garbarino, 1989; Duncan, 1996)
These interrelated problems have usually developed over several years, and may not have been detected during previous contacts of the youth with social service agency staff, school counselors, or law enforcement personnel. As a result, problems are often quite severe by the time an adolescent enters the JJS. The scope and severity of these psychosocial problems place juvenile offenders at significant risk for return to substance use and for further delinquent behavior. The depth of the problems produces unique challenges for staff providing screening and assessment in the juvenile justice system. Thus, a primary goal of substance use screening and assessment among juvenile offenders is to prevent their further involvement in the JJS.
The JJS traditionally has maintained an episodic interest in these individuals. The typical focus has been on the behaviors and activities that immediately preceded the adolescent's current involvement in the system, without an examination of the history of psychosocial problems contributing to his substance use and delinquent behavior. Individual monitoring of adolescents entering the juvenile justice system frequently ends at the completion of supervision. No further tracking is provided to make sure the adolescent receives services that might help to remedy key problem areas. These service and monitoring gaps are associated with severe lack of funding in the JJS. Fortunately, recent trends suggest that funding shortages may not be as acute as they were in the past. Juvenile drug courts are becoming more accepted in the JJS; they provide an opportune environment to address many needs of substance-using delinquent adolescents. Also, youth charged with minor offenses are being processed with diversion programs. Such programs optimize the opportunity to intervene early and prevent continued delinquency and drug abuse. Diversion programs are well-suited to screening for substance use disorders and referring to the appropriate community agency for followup assessment and treatment. For more information on diversion programs, refer to TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (CSAT, 1995b).
An excellent example of the diversion model is the Juvenile Assessment Center (JAC) in Hillsborough County, Florida (Dembo et al., 1993b). The core components of the JAC include a detailed screening of several problem areas followed by an indepth assessment where indicated, a determination of the level and type of services needed for each problem area that was identified, and an assignment to a case manager to ensure appropriate referrals to community service providers.
Screening and assessment activities within the JJS must be (1) provided at the earliest possible point in the youth's contact with the JJS in order to identify adolescents who are at risk for further involvement in substance use and serious delinquent behavior; (2) repeated at different stages in the system (intake, preadjudication, and postadjudication) to detect changes over time in the pattern of substance use, related problem behaviors, and the need for services; and (3) be multimodal and comprehensive so that several methods and sources are used to measure the range of the young person's physical, emotional, and environmental circumstances. When conducting screenings and assessments to determine patterns of use, programs should be aware of the youth's confinement status prior to testing. Periods of preassessment incarceration, (e.g., pretrial detention), may skew results of recent use surveys. An assessment taken soon after incarceration, when access to substances is limited, may provide inaccurate information about the adolescent's abstinence or use, potentially resulting in a false negative.
In general, the depth of the screening or assessment provided at a given point in the JJS should be determined by (1) the type of dispositional decision being considered (e.g., conditional release or commitment) and (2) the likelihood of further involvement in the juvenile justice system. A high priority should be established for screening and assessment with adolescents who are unlikely to be referred further within the JJS, in order to identify immediate needs for community services outside the system.
Screening and Assessment Protocols
The following discussion reviews general principles pertaining to screening and assessment protocols implemented in juvenile justice settings. The purpose of the various types of screening and assessment are presented, as well as important content areas to be probed. (The reader will find summaries of screening and assessment tools in Appendix B.)
Screening and Assessment at Key Points
Procedures need to be developed to ensure that the results of screening and assessment follow the adolescent through successive stages of the JJS. Figure 5-1 is a matrix that describes the purpose of each of the five types of screening or assessment: preliminary screening, risk assessment, drug testing/urinalysis, psychosocial assessment, and comprehensive assessment. For each type, the matrix indicates the domains that the screening or assessment is designed to probe. Again, the adolescent must sign a consent form prior to the assessment process so that her rights to privacy, issues of mandatory reporting of abuse, disclosure of information, and duty to warn are clarified (see Chapter 4).
Whenever possible, results of preadjudication screening and assessment should include a checklist or other means to identify a juvenile's relevant problem areas. Results should also define specific services needed and alternative types of services available in the community to assist judges, probation officers, and others working with the juvenile to develop a disposition plan. Those screening and assessment instruments that assist in this process by readily identifying problem areas and levels of problem severity should be selected. Consultation should be provided to the juvenile court in interpreting results from various assessment protocols that are reviewed at the time of disposition.
It may be useful for juvenile justice and clinical staff from community social service agencies to collaborate in developing procedures for triage and referral. Staff from community agencies should be encouraged to "reach in" to detention and other secure facilities to assist in developing and implementing individualized aftercare plans for juvenile offenders. For example, community agency staff, acting in a case management model, can be particularly useful in clarifying admission criteria for various community treatment programs and can help to secure family involvement in aftercare services and link juveniles to a range of other services. Likewise, JJS staff should also be encouraged to "reach out" to facilitate adequate community involvement.
Juvenile justice agencies should develop procedures to guide referral decisions for substance use disorder assessment, mental health assessment, and other relevant community services. Decision rules guiding referrals for further assessment should include the development of threshold criteria (e.g., behavioral markers and test scores) for referral and should reflect:
- The severity of the problem
- The capabilities of community agencies to provide comprehensive assessment or related services
- Available resources for community assessment services
In recognition of the importance of early detection and intervention, rules for deciding how to interpret the results of initial screening should be designed to be overinclusive in identifying adolescents who may have substance use disorders. It is better to identify more adolescents as having substance use disorders than to be overly cautious and miss some. Rules for deciding how to interpret the results of psychosocial assessment may be more conservative in consideration of the limited resources available for providing further comprehensive assessment.
In some areas, screening and assessment units have been successfully implemented in detention centers to identify adolescents with substance use disorders and mental health problems. The detention setting offers a good opportunity to identify adolescents at high risk for further delinquent behavior and substance use. Resources permitting, the period of juvenile detention can be used constructively to provide initial screening, risk assessment, psychosocial assessment, or more comprehensive assessment.
Preliminary steps in developing a screening and assessment unit within detention centers include meetings with community agencies to review the goals of the unit and an updated review of available referral services. Community service providers can also be invited to visit the detention facility. Preliminary meetings with external agencies can be designed to develop a community referral network for substance-involved juveniles. In addition, negotiations may need to take place within various levels of the bureaucracies that oversee the detention center to persuade authorities that a screening and assessment unit for substance use disorders is needed, perhaps entailing the allocation of additional resources. (Such lobbying may be formal or informal in nature, to include meetings and reports documenting the need.) Community service providers may be enlisted to support such efforts as well.
Centralized intake and referral units in the community provide an alternative to specialized screening and assessment units developed in detention centers as a setting for early identification of high-risk adolescents in the JJS. Within a centralized intake unit, comprehensive information is compiled regarding the adolescent's mental health, substance use, medical, educational, and other social service needs. Centralized intake units rely on collaboration among law enforcement and social service agencies to conduct evaluations of youth and to make referrals for community services. Any sharing of substance use information, however, must comply with Federal confidentiality regulations.
Implementing Screening and Assessment Protocols
All juveniles entering a juvenile justice facility should receive an initial screening, risk assessment, and followup assessment, as indicated. Figure 5-2 provides juvenile justice protocols for implementing screening and assessment. Initial screening should be conducted within 24 hours of entry to the agency or facility. Screening and assessment activities may need to be completed over the course of several days for juveniles who are intoxicated, show symptoms of mental illness, are experiencing significant stress related to arrest or incarceration, or are not honestly disclosing information during an initial interview. Self-administered instruments should be designed to reflect the reading level and cultural background of the juvenile population. Alternative screening and assessment measures should be developed to accommodate the needs of juveniles with limited reading skills or with physical disabilities.
As discussed in Chapter 1, data should be collected from different sources; besides self-report, these sources include (with the adolescent's consent) knowledgeable parent(s)/guardians, other individuals who may be familiar with the juvenile, and laboratory tests (see Appendix C for further discussion on laboratory testing).
Results of screening and assessment should describe the various sources of the information obtained and should indicate how the different sources of information contributed to findings and recommendations. The use of screening and assessment instruments should be supplemented by individual interviews. Individual interviews are particularly important in clarifying responses and gathering additional information related to suicidal behavior, recent substance use, and mental health symptoms. Screening, assessment, and interviews should be conducted in a private room where the youth feels safe and comfortable. The use of holding cells to conduct screening and assessment is not recommended.
In recording events leading up to the most recent offense, staff conducting screening and assessment interviews should note the social context of delinquent behavior, including substance use, peer involvement, and relevant psychosocial stressors. Similarly, the juvenile's perceptions of reasons for initiating and continuing to use substances should be elicited. Interviews should also note the juvenile's perceptions and attitudes about (1) the screening or assessment process, (2) the interviewer, (3) the juvenile justice setting in which the interview is conducted, and (4) the accuracy of information provided by the youth or by the interviewer regarding the youth.
The interviewer should evaluate the adolescent's reading level (if necessary) and other factors that may influence the quality of screening and assessment results (for example, effects of immediate intoxication, mental health symptoms, and motivation).
Juvenile justice staffing patterns should be developed to reflect the flow of referrals for screening or assessment. Assignment of juvenile justice staff exclusively to screening and assessment activities encourages burnout and tends to restrict the diversity of the work experience and involvement in other aspects of the juvenile justice program. Juvenile justice staff members are also frequently overburdened with large numbers of daily screenings and assessments. Thus, if resources are available, screening and assessment services perhaps should be contracted out to community-based organizations.
Evaluation and Quality Management Monitoring
Screening and assessment often provide an important contribution to program evaluation activities. For example, this information is useful in describing characteristics of juvenile populations served at various stages of the system, emerging trends in drug use, HIV risk behaviors, and physical or sexual abuse. The information may assist in the following activities:
- Documenting the need for additional community services for juvenile offenders
- Identifying existing screening and assessment instruments that need modification
- Evaluating changes over time in mental health status, substance use, or other areas of functioning
- Identifying signals or situations that can help to predict disciplinary incidents within juvenile facilities or trigger relapse or recidivism following release from juvenile custody
- Supporting the need for ongoing screening and assessment activities within juvenile settings
- Identifying breakdowns in multiagency service coordination
When conducting an outcome evaluation that assesses an adolescent's behavior after he completes treatment, programs should be aware of the problems posed under the Federal confidentiality regulations. For a discussion of the issues and a more complete explanation of the requirements of __2.52 and 2.53, 42 C.F.R., Part 2, see TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (CSAT, 1995a).
Screening and assessment information may also contribute to reports developed for facility or agency administrators describing patterns of juvenile admissions, severity of substance use or other problems, and services needs. Both criterion-based tests (in which the instrument measures an established criterion, like a diagnosis) and norm-based tests (in which a normal range of responses for youth in various settings has been identified) are useful in assisting evaluation efforts.
All juvenile justice facilities and programs must develop policies and procedures for responding to critical issues that may arise during a screening or assessment interview. These issues include reported physical or sexual abuse, suicide threats, HIV status, aggressive behavior, and symptoms of acute intoxication or withdrawal. Staff should be trained in methods of responding to these issues and in documenting responses.
Quality management activities should include examination of the accuracy and comprehensiveness of screening and assessment records, methods used to obtain information, staff responses to critical issues identified during screening and assessment, and the use of screening and assessment information in developing referral decisions. Whenever possible, screening and assessment interviews should be periodically observed by someone within the program and followed with a debriefing so that ratings and referral decisions can be compared and reviewed.
Staff Training
All juvenile justice staff providing screening or assessment services should be trained in the following areas:
- Cultural sensitivity and competence
- Legal and ethical issues
- Administration, scoring, and interpretation of instruments
- Determination of reading abilities
- Interviewing techniques
- Report writing
- Interpersonal communication
- Counseling techniques
- Management of critical incidents
- Working collaboratively with the treatment community
Staff should also receive training in implementing policies and procedures related to screening and assessment. Juvenile justice staff assigned to administer screening and assessment protocols should observe interviews conducted by other staff and should have regular opportunities to debrief following difficult screenings or assessment interviews and to discuss problems encountered in the use of various test instruments.
Staff conducting screening or assessment at intake to the juvenile justice system should be trained to recognize causes and symptoms of stress and to develop an awareness of the potential impact of stress on test and interview results. Staff should also be alerted to the potential for overestimating the need for intensive treatment services based on results of an initial interview without the addition of collateral supporting information. Program procedures and training efforts should be designed to encourage staff to postpone more comprehensive screening or assessment if evidence of significant stress or acute intoxication or withdrawal is observed. Staff should also receive training on issues surrounding adolescents in juvenile justice facilities and HIV infection.
Juvenile justice staff should receive training in maintaining the confidentiality of screening and assessment information and in guidelines for reporting information. All staff involved in screening and assessment should understand the key issues related to informed consent, which include mandatory reporting of child abuse or neglect, disclosure of information to parents or guardians, courts, attorneys, or other agencies, and duty to warn. Staff may need training in issues related to the duty to warn, in order to effectively respond to situations involving a juvenile's threat to harm a potential victim (see Chapter 4).
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 99-3282
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