Ken C. Winters, PhD, Tamara Fahnhorst, MPH, Andria Botzet, MA, Ali Nicholson, BS, and Randy Stinchfield, PhD
CHAPTER OUTLINE
■ ASSESSING ADOLESCENT SUBSTANCE USE
■ PRINCIPLES OF ASSESSMENT
■ DEVELOPMENTAL CONSIDERATIONS
■ SELF-REPORT: VALIDITY AND ALTERNATIVES
■ CLINICAL CONTENT
■ INSTRUMENTATION
■ SUMMARY
ASSESSING ADOLESCENT SUBSTANCE USE
Alcohol and other drug use behaviors by adolescents remain a critical health problem in America, despite regulations against underage use of legal and illicit drugs. From an epidemiologic standpoint, drug use by teenagers is relatively common. According to a recent nationwide survey, Monitoring the Future (1), 50% of 12th graders have used an illicit drug in their lifetime, and one-fourth (25%) reported use of an illicit drug within the prior month. Also, adolescent onset of drug use greatly increases the estimated risk for developing a substance use disorder (SUD) during adolescence and young adulthood (2), and drug use by teenagers can lead to a variety of other negative consequences, including social and health impairments. These impairments include school failure, risky sexual behavior (3–7), delinquency, incarceration, suicidality (8–10), motor vehicle injuries/ fatalities (11,12), possible damage to the brain’s memory region (13–16), and significant medical health care costs (17–20).
Thus, precise assessment of adolescent drug use is essential in gaining an accurate understanding of the nature and extent of adolescent drug use and possible intervention or treatment needs. This chapter discusses the following issues pertaining to assessment: principles of assessment, self-report, developmental issues, clinical content, assessment process, and instrumentation.
PRINCIPLES OF ASSESSMENT
We distinguish two types of assessment: screening and comprehensive assessment. Screening is the first step in identifying whether a youth may be involved with drugs; comprehensive assessment explores with more depth the extent and nature of the drug involvement, consequential problems, and treatment needs. Thus, a screening should not be used to make definitive judgments about whether or not the adolescent has an SUD (i.e., abuse or dependence), nor should be used as a basis to determine if treatment is needed. Rather, screening results should be used for determining the need for additional assessment. A comprehensive assessment provides a basis for determining if treatment is warranted and, if so, at what level, and for assisting in the development of a comprehensive treatment plan to address the youth’s needs. Despite uneven requirements by licensing and accreditation organizations, there is a national trend toward requiring adolescent drug treatment facilities to use at least one adolescent-specific and psychometrically sound assessment instrument as part of intake and treatment planning. Later in this chapter, we review nationally recognized screening and assessment tools.
Screening
When an adolescent is suspected of using drugs, the assessment process should begin with screening questions about recent drug use quantity and frequency (e.g., How often did you use drugs in the past 6 months?), the presence of adverse consequences of use (e.g., Has your drug use led to problems with your parents?), and situations in which drug use is common (e.g., Do you use drugs before or during school?).
Comprehensive Assessment
If the screening suggests a possible drug use problem, the assessor should conduct a more comprehensive assessment in order to determine details of drug use history, consequences of such use, whether the teenager meets criteria for an SUD, and what other behavioral and mental co-occurring problems may exist. This detailed assessment should include a detailed inquiry into the age of onset and progression of use for specific substances, circumstances, frequency and variability of use, and types of drugs used. The assessor should also inquire about the context of use, which should include the usual times and places of drug use, the attitudes and use patterns of the adolescent’s peers, and typical behavioral and social triggers and antecedents that are associated with drug use. The clinician should also ask about direct and indirect consequences of use in the domains of school, social, family, psychological functioning, and physical/medical problems. Finally, the assessor should evaluate the adolescent’s problem recognition and readiness for treatment. These questions may help determine the initial treatment goals.
The determination of an SUD requires that the assessor review the criteria for substance abuse and dependence for specific substances. Abuse criteria focus on negative social and personal consequences as a result of repetitive use; dependence criteria address symptoms associated with the continued use of drugs in the face of negative consequences and loss of control over use (see next section). The differential diagnosis of adolescent SUDs requires consideration that the symptoms of drug use are not due to premorbid or concurrent problems, such as conduct disorder (CD) or family issues. Given the frequent comorbidity of SUDs and other psychiatric disorders, it is important that the assessor comprehensively review in timeline fashion the past and present history of psychiatric symptoms. Such a timeline approach can help the assessor sort out the interrelationship between drug use and comorbid psychopathology (21).
DEVELOPMENTAL CONSIDERATIONS
Identifying Clinical Significance
It can be difficult to determine when adolescent drug use will have short-term and minimal health effects versus when the drug use may escalate to negative long-term repercussions. The high prevalence rate of drug use by teenagers gives some credence to the notion that drug involvement is a normative part of youth. Most often, adolescents use legal drugs (alcohol or tobacco) within a social context (1,22–24). These so-called gateway drugs are readily accessible to minors because of their cultural prominence, legality, and general availability. The majority of youth will not progress beyond the use of these gateway drugs (25), yet some will progress to use illicit drugs and to develop serious problems. For example, based on national data, it is estimated that about 11% of youth (12- to 18-year-olds) will use drugs to the point of meeting the current Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV-TR) criteria (26) for either a substance abuse or a substance dependence disorder (27).
Applicability of SUD Criteria
The applicability to adolescents of the DSM-IV-TR and the proposed DSM-5 criteria for SUDs has been met with reservation for several reasons, which include the following: the distinction of the abuse and the dependence criterion as applied to adolescents is not well supported by research; some criteria have limited utility among adolescents (e.g., an important criterion for dependence, tolerance, has low diagnostic specificity among adolescents given that this symptom can take extended lengths of time to develop); and the meaning of symptoms for adolescents who are relatively inexperienced with the effects of drugs may lead to higher rates of false-positive endorsements (e.g., “drinking more than intended” may be endorsed more frequently among teenagers because of poor judgment) (28,29). The proposed DSM-5 offers some improvement with respect to adolescents; for example, the distinction between abuse and dependence is eliminated. But other developmental adjustments were not made to accommodate the application of the revised criteria to adolescents (28,29).
Neurobiology
Recent research has indicated that the adolescent brain does not fully develop until early adulthood (30). In some regions of the brain, particularly the prefrontal cortex region, which is associated with judgment (resisting impulses and other executive functioning), nearly 50% of the neurons are “pruned” and are undergoing transformation during adolescence. Because of this immaturity, there is speculation that the developing adolescent brain may be highly vulnerable to the effects of drug use. Studies with laboratory animals have provided evidence that adolescent rats differ significantly from adults in their receptivity to the effects of alcohol (e.g., decreased sensitivity to the acute unpleasant effects of alcohol, increased sensitivity to the social disinhibitory effects of alcohol) (31,31a,31b). If we generalize these findings from animal research, the implication is that adolescents may be less capable of moderating their alcohol intake as compared to adults.
Studies with laboratory animals and humans also provide evidence that exposure to drugs during adolescence may influence memory and learning. After rats were chronically exposed to alcohol during adolescence, they exhibited greater cognitive difficulties than rats that were exposed to the same amount of alcohol in adulthood (32,33). From the human studies, Tapert and Schweinsburg (13) reported that adolescents with a history of heavy alcohol use had a smaller hippocampus (region of brain responsible for creating memories) compared to a matched control sample (on average, 10% smaller volume in the alcohol use group). Because pre–alcohol use brain functioning was not measured, we cannot draw any causal conclusions from this study. However, a more recent study with a prospective design confirms that heavy alcohol use during adolescence may deleteriously affect memory (34). Also, other studies have found negative impacts of cannabis on the developing brain (15,35), including its possible role in a decline in IQ (36), and the negative impacts of combined alcohol and cannabis use as well (14,16).
These findings have implication for assessment. Memory-and learning-impaired youth may produce compromised self-report, and performance scores on learning and attention tasks may be significantly affected by prior drug use. To minimize these effects, it is advisable to use assessment strategies that include memory aids, for example, timeline follow-back procedure (37), and to confirm the adolescent’s report with archival records and other sources.
Other Factors
Other developmental issues are relevant with respect to assessing adolescent drug use. Clinical studies have revealed both gender differences and similarities with regard to possible psychosocial determinants of drug use. Opland et al. (38) found that girls tend to utilize drug use as a coping mechanism for stress, whereas boys tend to use drugs for the pleasurable effects. Also, delays in social and emotional functioning (39), diminished respect toward authority, and tendencies to be egocentric (40) and to minimize negative consequences (41) may contribute to inaccurate reporting of personal drug use behaviors and to poor motivation to change (42,43).
SELF-REPORT: VALIDITY AND ALTERNATIVES
The utilization of self-report is a hallmark of a clinical assessment. Convenience, comprehensiveness, low cost, ease of administration, and the perception that the individual is the most knowledgeable reporter have encouraged the use of this method. Self-report approaches or formats include self-administered questionnaire (SAQ), interview, timeline follow-back (TLFB) (37), and computer-assisted interview (CAI). SAQs and interviews are the primary approaches used by clinicians. SAQs are completed independently by an individual and traditionally via a paper-and-pencil format. An interview (varying in degree of structure) is completed by a trained individual and often yields specific diagnostic data related to SUDs and coexisting psychiatric diagnoses. Lesser used strategies include the TLFB and CAI. The TLFB is a calendar-based tool that compiles a history of drug use over a specified time. TLFB method uses specific dates and events (e.g., birthdays, holidays, vacations) to enhance interviewee recollection to elicit a detailed pattern of recent drug use. The CAI method has been recently used with drug-abusing adolescent populations (44). With this method, the respondent completes an interview independently on a computer as the questions are delivered audibly via headphones. This approach may promote a greater sense of privacy while responding to potentially sensitive questions. Research on the concordance of SAQ, interview, TLFB, and CAI formats in clinical and epidemiologic samples is not conclusive, although the data suggest that, for the most part, the various formats yield similar levels of disclosure (45–48).
The overall validity and reliability of the self-report method for assessing adolescent drug use and related problems are still debated in the literature. Stinchfield (49) found that adolescents attending a treatment program for drug dependence generally reported notably more past drug use and consequences compared to disclosures at the start of intervention. In other studies, underreporting occurred more frequently with less socially acceptable drugs, such as cocaine or opiates, compared to marijuana (50–53). Improved bioassay techniques (e.g., radioimmunoassays followed by confirmatory GC/MS) are being used to corroborate adolescent self-report of drug use (54–57). Williams and Nowatzki (58) reported that some adolescents disclosed drug use in an interview though the urinalysis conducted immediately after the interview showed a negative finding. Some of this discrepancy was accounted for by limitations in the urinalysis “detection window” for different drugs and because of individuals’ varying metabolic rates, but the authors hypothesized that deliberate fabrication, poor memory, and boastfulness may have also been contributing factors (50). These findings are not surprising given the circumstances under which an adolescent assessment may be conducted. Defiance, fear, and apprehension can influence the results of an assessment. In addition, youth may see the assessment as an opportunity to “cry for help” and exaggerate their responses. Despite possible limitations, the validity of self-report for adolescent drug use has been supported by several lines of evidence: Only a small percentage of youth endorse improbable questions; adolescent self-reports agree with corroborating sources of information, such as archival records and, for the most part, urinalyses; and the base rate of elevations on “faking-good” and “faking-bad” scales is relatively low (59–64).
Alternatives to Self-Report
Drug Testing
Four biologic-based tests (urine, hair, saliva, and sweat) are currently used to detect drugs in the body (54,55,63). The main aspect that distinguishes these specimens is the period or window of time for which the drug can be detected. In addition, cost, access, tampering vulnerability, invasiveness, and reliability/validity are other factors that differentiate these biologic sampling procedures. Urinalysis is the most commonly used procedure to detect drug use and validate self-report (224,225). The window of detection varies considerably for illicit drugs; the detection period for alcohol with a standard urine test is only about 8 hours. Tampering can be minimized by directly visualizing the collection of the urine or using the federal protocol. Hair analysis has become more commonly used to detect exposure to drugs over a longer period than afforded by urine testing (54), but several variables (e.g., chemical processing; differences in hair structure, growth, porosity, and hygiene; exposure to drugs in the air, e.g., marijuana smoke) have been shown to affect the concentrations of drugs in the hair (65). The testing of saliva and sweat to detect drug exposure is still being refined; their advantages include a noninvasive collection process and the detection of very recent drug use (12 to 24 hours). Newer biomarkers for alcohol (e.g., ethyl glucuronide and phosphatidylethanol) hold promise of detecting alcohol for longer periods (days) compared to standard procedures (66).
Clinical Observation
In addition to self-report and biologic tests, direct observation by the assessor for behavioral and psychological indicators of drug use can be an objective and useful supplement to the assessment process. A simple checklist of items, such as the presence of needle marks, unsteady gate, slurred or incoherent speech, or shaking of hands or twitching of eyelids can indicate problematic use. A 14-item checklist of observable signs that may indicate a drug problem is contained in the Simple Screening Instrument for Alcohol and Other Drug Abuse (67), and the Clinical Opiate Withdrawal Scale (COWS) consists of 11 items that measure withdrawal from opiates (e.g., sweating, pupil size) (www.naabt.org).
Reports from Others
Although parent report is relatively valid in the identification of many mental health problems such as attention deficit hyperactivity disorder (ADHD) and conduct problems, it is unlikely that parents can provide detailed reports about the types, frequency, and quantity of drug use by their son or daughter (62,63). Collecting information from peers may prove to be a valuable resource especially if the peers are not currently using drugs or are in recovery, although it is very difficult to get peers to participate in the assessment of a friend.
CLINICAL CONTENT
Substance Use Disorder
Drug use that goes beyond experimentation and progresses into problematic involvement is formally delineated by various classification systems, with the primary systems including the DSM-IV-TR (26) and the International Classification of Diseases, 10th rev. (68).
In the DSM-IV-TR diagnostic system, the problem-level drug use is separated into categories of abuse or dependence. Abuse symptoms pertain to drug use that increases risk for or results in negative health and social consequences, such as role impairment, physically hazardous use, recurrent substance-related legal problems, and social and interpersonal difficulties resulting from drug use. Abuse symptoms are meant to characterize predependent symptoms; accordingly, an individual must meet at least one of the abuse criteria within the prior 12 months, without obtaining a dependence diagnosis, to receive an abuse diagnosis.
DSM-based dependence, on the other hand, requires the positive endorsement of at least three of seven symptoms, all of which reflect psychological and physiologic features. Psychological characteristics refer to continued and compulsive drug use in the face of negative consequences, such as the continuation of drug use despite recognition of drug-induced depression or quitting important social or occupational activities because of drug use. Symptoms indicating physiologic dependence refer to tolerance (i.e., the need for increased amounts to achieve intoxication) and withdrawal (i.e., the development of symptoms such as nausea, anxiety, increased pulse rate, or insomnia from the cessation of heavy or prolonged drug use). In the DSM-IV-TR, substance abuse and substance dependence criteria are the same for all substances, and the diagnoses of abuse and dependence are hierarchically arranged (i.e., a dependence diagnosis precludes an abuse diagnosis).
One feature of the DSM-based definition of SUDs (including the new DSM-5) is that none of the criteria directly refer to onset, quantity, and frequency variables. This is not to say that these variables are not important to assess. Indeed, consumption history does produce important information, particularly when data are compared with regularly updated norms of use.
Course of SUDs
The clinical course of youth with an SUD indicates the changes and expression of an SUD as well as the associated functioning over time (69). Understanding the course of adolescent SUDs provides a vital perspective in our understanding of the etiology and prognosis of SUDs. Multiple studies have examined developmental trajectories of adolescent drug use behaviors (42,70,71) and have found results that support the notion of separate experimental and SUD paths. Developmental trajectories have been characterized as developmentally limited or intermittent, as would be expected in an experimental case, as well as persistent or relatively continuous, suggestive of an SUD. One such trajectory by Lewinsohn et al. (41) found gender differences in alcohol use within a community sample; females had an earlier age of onset for an alcohol use disorder compared to males (14.6 vs. 16.1 years old, respectively), though males developed alcohol-related problems at a faster rate between the ages of 18 and 19 (41). The same sample provided evidence that the average duration of an alcohol use disorder was about 52 weeks for the community sample of adolescents (41).
Some variables have been found to predict the course of SUDs among adolescents in a drug treatment setting. Pretreatment characteristics that are associated with more favorable substance use outcomes include a lower substance use severity level at admission (72), greater readiness to change (73,74), and fewer conduct problems or other co-occurring psychopathology (75–77). Factors influencing better outcomes during treatment include a longer length of treatment (78,79) and family involvement in treatment (80,81). Posttreatment predictors of better outcome include participation in aftercare or continuing care (77,82–84), low levels of peer substance use (85,86), ability to use coping skills (87,88), and continued commitment to abstain (73,89). Of all these factors, the posttreatment predictors accounted for more variance in the teenagers’ outcomes at 1 year after treatment than did the pretreatment and during-treatment variables. However, it is important to recognize that predictors may change over time, just as the impact of the predictor on the course of SUD may change. For example, Latimer et al. (90) reported that sibling drug use was associated with more frequent drug use during the first 6 months posttreatment, but as time passed, peer drug use became a stronger predictor of SUD course than sibling drug use.
Psychosocial Factors
Measurement of the various psychosocial dimensions that are related to drug use behaviors provides beneficial information regarding the onset and maintenance factors of the drug use and aids in treatment planning. Dimensions that should be included in the assessment protocol include interpersonal relationships, school and employment, history of criminal justice involvement and delinquency, recreational activities, and sexual behavior. Sexual orientation should be included during the assessment as lesbian, gay, and bisexual teens have been shown to be at higher risk than their heterosexual peers (91,92). Also, religiosity and spirituality have been shown to be a protective factor for teens (93) and should be further explored during assessment (94,95); the Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS) is a psychometrically sound tool for this purpose (96). Because of their prominence in the treatment research literature, these two additional psychosocial factors merit further discussion—peer factors and family environment.
Peer Factors
Multiple research studies indicate that peer variables are one of the most prominent factors contributing to the onset and maintenance of drug use, although its effect is likely more pronounced for older than younger teenagers (97). Chilcoat and Breslau (98) found that youth who associate with peers who use drugs were six times as likely to use drugs as those who did not associate with drug-using peers. Similar findings were found by Farrell and Danish (99,100) and Winters et al. (101). A parallel finding by Guo et al. (102,103) revealed that adolescents involved with peers exhibiting antisocial behaviors were at a higher risk of initiating illicit drug use. Understanding the intricacies of peer relationships is complex. The nature of this association between drug use and peers could be due to pressure to use drugs from drug-using friends or to the increased likelihood that drug-using individuals seek out other drug-using peers. Peer influences may also impact the youth’s attitudes and expectancies regarding drug use as well as the youth’s access to drugs (104–108).
Family Factors
Family influences encompass several variables, including familial genetic risk and parenting practices. Children whose parents suffer from an SUD have been shown to be at increased risk for the development of an SUD (109,110). Also, other psychopathology in family members, particularly parental antisocial behavior history, is relevant in offspring SUD liability (111–116). Results from twin and family studies provide additional insight into the role of family genetics and home environment on youth drug use. There is converging evidence that the initiation of alcohol use in mid-adolescence is predominantly influenced by factors such as parental monitoring and the father’s drinking level, rather than genetic factors (117–121). However, after drinking is initiated, it appears the genetic factors increasingly influence the frequency of alcohol and other drug use, as well as the prevalence of SUDs (122–124). Of course, it is important to keep in mind that even in the face of a presumed SUD heritable liability, a normative developmental outcome is still more common among youth than a disordered course (14).
Parenting factors are strongly associated with adolescent risk for drug involvement, especially factors such as closeness or warmth and control or monitoring. These aspects of parenting reflect characteristics of affection, nurturance, and acceptance of the child by the parent, as well as characteristics of supervising the child’s activities and firmness in setting limits (125–128). Several researchers have found increased drug use among adolescents in families that lack closeness or affection, lack effective discipline, lack supervision, have excessive or weak parental control, and have inconsistent parenting (127–135).
Psychological Benefits
In spite of the detrimental effects incurred when using drugs, many adolescents use drugs because they serve psychological need states (136–138). Psychological advantages of adolescent drug use include mood enhancement, stress reduction, and relief from boredom (139–141). One study found that mood enhancement played a more central role in drug use among youth with an SUD, whereas these psychological benefits were not as important to youth who used drugs infrequently and did not have an SUD (142). Because psychological benefits play such an important role in the attraction and exacerbation of drug use among adolescents, intervention efforts must address these underlying factors.
Co-Occurring Mental Health Disorders
A very reliable finding in the clinical and epidemiologic literatures is that most adolescents who are involved with drugs have co-occurring psychological disorders (143–146) and that their presence is a negative sign for recovery (44,76,147,148). The most common types of comorbid psychiatric conditions include externalizing disorders (i.e., CD, oppositional defiant disorder, and ADHD) and internalizing disorders (i.e., depression and anxiety disorders— primarily posttraumatic stress disorder). We will discuss these disorders in more detail.
Coexisting Externalizing Disorders
Childhood aggression, rebelliousness, theft, and destructiveness, along with related externalizing disorders such as CD and oppositional defiant disorder, are common among youth with an SUD as well as among children of parents with an SUD (111–116). Prospective research reveals that antisocial behaviors in late childhood, and the initiation of drug use in early adolescence, predict later drug involvement (149–152). The exact relationship between externalizing behavior and SUDs is complex. Three theories have been proposed. One argues that because CD has been found to predate or contribute to the development of an SUD (153–155), the resulting poor behavioral inhibition or increased novelty seeking may lead to increased drug use. The second theory is that given that SUDs have been found to precede CD (143), factors that coincide with drug use, such as poor judgment and association with delinquent peers, may act as a catalyst for antisocial behavior and subsequent oppositional defiant disorder or CD. Finally, a third perspective is that CD and drug use may occur concurrently, for they may share common environmental and personal risk factors (e.g., socioeconomic status, family, low academic achievement, association with deviant peer group). In this light, these risk factors may act independently or synergistically to impact the severity of the substance use and antisocial behavior (143,156,157), and both CD and drug use would interact with each other over time to escalate the severity of the other set of symptoms (158).
The relationship between ADHD and SUDs is equally complex, despite the significant amounts of literature that have explored the association. Some studies have found that individuals with a history of ADHD, compared with controls, are more likely to develop substance use and substance-related problems (158–162). Other studies have not found similar relationships (163–165). There is also a large body of research that supports the view that the association of ADHD–drug use problems is mediated by CD (151,152,163,164,166–168). But this mediation hypothesis is not a universal finding (169,170). With regard to tobacco, a commonly cited gateway drug, ADHD has also been linked to its early initiation and increased use (161,162), and there are indications that this link holds even after controlling for CD (160,171,172).
Coexisting Internalizing Disorders
Internalizing disorders such as anxiety disorders (i.e., post-traumatic stress disorder) and mood disorders (i.e., major depression) may be another pathway associated with SUD (173–176). Children of SUD parents have been found to have increased rates of internalizing disorders and related symptoms (111–115). Among adolescents with an SUD, elevated rates of internalizing disorders and related symptoms have been reported, especially among females as compared with male adolescents with an SUD (177–180). Childhood major depression has been found to be more common with adolescent-onset than with adult-onset SUD (81). These associations do not, however, establish that a causal pathway exists between childhood internalizing disorders and later SUDs. Similar to the “chicken and egg” conundrum that exists with SUDs and externalizing disorders, the specific association between internalizing disorders and SUDs remains indistinct. Researchers have found that symptoms of anxiety and depression may be produced by alcohol or other substances (173,178,181), whereas others have demonstrated that an alcohol disorder may exacerbate symptoms of posttraumatic stress disorder (182–184).
Another complicating feature is that data from adolescents with an SUD indicate that both CDs and major depression may coexist in some individuals (185). Prospective longitudinal research that integrates findings for antisocial disorders with findings for internalizing disorders beginning in preadolescence and assesses the sequencing of these characteristics for specific developmental periods (i.e., early adolescence, middle adolescence) is needed to clarify these relationships (151).
Other psychiatric disturbances have also been shown to correlate with adolescent SUD, though at a lower rate. A number of individuals with eating disorders such as bulimia nervosa have been shown to also abuse substances or have an SUD (186,187). In addition, adverse life events including childhood maltreatment (i.e., physical abuse, sexual abuse, neglect) have also been found to be associated with the development of an SUD (186,188).
INSTRUMENTATION
Significant advances have occurred since the mid-1980s in the development and evaluation of adolescent drug abuse assessment instruments (189,190). Most of these measures have been normed on adolescents. Some tools are designed to screen youth at risk for drug problems, whereas other measures provide extensive, diagnostically related information.
Several summaries of adolescent screening and comprehensive assessments exist, including two by the federal government, “Screening Assessment of Adolescents with a Substance Use Disorder” (191) and “Screening and Assessing Youth for Drug Involvement” (190), as part of the National Institute on Alcohol Abuse and Alcoholism, 2nd ed., handbook, “Assessing Alcohol Problems: A Guide for Clinicians and Researchers” (192), as well as journal articles (28,29,189) and book chapters (193). We provide our own syntheses of these various summaries. Inclusion in our overview was the requirement that the instrument was developed specifically for adolescents, its psychometric properties have been reported in a peer-reviewed publication, and user information is available in print (e.g., manual, scoring information), and the instrument’s author or publisher is accessible to answer user questions. The synthesis includes both screening and comprehensive instruments.
Screening Instruments
Clinicians and researchers working with adolescents have access to a wide range of screening instruments, most commonly self-report questionnaires, to describe the possible or probable presence of a drug problem (see Table 104-1 for a listing). We review four categories of screening tools: alcohol, all drugs (including alcohol), nonalcohol drugs, and multiscreens.
TABLE 104-1 SCREENING INSTRUMENTS
Alcohol Screens
There are two contemporary screening tools that focus exclusively on alcohol use. One is the Adolescent Drinking Inventory (ADI) (194). The ADI’s 24 items examine adolescent problem drinking by measuring psychological symptoms, physical symptoms, social symptoms, and loss of control. Written at a fifth grade reading level, it yields a single score with cutoffs as well as two research subscale scores (self-medicating drinking and rebellious drinking). The ADI yields high internal consistency reliability (coefficient alpha, 0.93 to 0.95) and has demonstrated validity in measuring the severity of adolescent drinking problems (e.g., it has revealed a very favorable hit rate of 82% in classification accuracy). The second measure in this group is the 23-item Rutgers Alcohol Problem Index (195). The Rutgers Alcohol Problem Index measures consequences of alcohol use pertaining to family life, social relations, psychological functioning, delinquency, physical problems, and neuropsychologic functioning. Based on a large general population sample, the Rutgers Alcohol Problem Index was found to have high internal consistency (0.92) and, among heavy alcohol users, a strong correlation with the DSM-III-R criteria for SUDs (0.75 to 0.95) (195).
Screens for All Drugs
Another group of screening tools is the relatively short measures that nonspecifically cover all drug categories, including alcohol. Examples of these measures are the Adolescent Alcohol and Drug Abuse Involvement Scale (196), CRAFFT (197,198), Personal Experience Screening Questionnaire (199), and the Substance Abuse Subtle Screening Inventory (SASSI) for adolescents (200). The 14-item Adolescent Alcohol and Drug Abuse Involvement Scale measures drug abuse problem severity scale; a range of reliability and validity evidence for this screen has been reported (196). The CRAFFT is a specialized six-item screen designed to be administered verbally during a primary care interview to address both alcohol and drug use. Its name is a mnemonic device to assist physicians to incorporate six questions during their primary care exams. Based on a study in a large hospital-based adolescent clinic, scores from the CRAFFT were found to be highly correlated with scores from several existing and valid measures, and a cutoff score of 2 has been found to be highly predictive of a drug problem (197,198). The 40-item Personal Experience Screening Questionnaire consists of a problem severity scale (coefficient alpha, 0.91 to 0.95), drug use history, select psychosocial problems, and response distortion tendencies (“faking good” and “faking bad”). Norms for normal, juvenile offender, and drug-abusing populations are available. The Personal Experience Screening Questionnaire is estimated to have an accuracy rate of 87% in predicting the need for further drug abuse assessment (199). The 81-item adolescent version of the SASSI yields scores for several scales, including face-valid alcohol, face-valid other drug, obvious attributes, subtle attributes, and defensiveness. Validity data indicate that SASSI scale scores are highly correlated with the Minnesota Multiphasic Personality Inventory (MMPI) scales and that its cut score for “chemical dependency” corresponds highly with intake diagnoses of SUDs (201). However, claims that the SASSI can accurately detect unreported drug use and related problems have not been empirically justified (243).
Screens for Nonalcohol Drugs
The third category of screening tools pertains to those that screen only nonalcohol drugs. Only one screen falls into this group, the Drug Abuse Screening Test for Adolescents (202), and was adapted from Skinner’s (203) adult tool, the Drug Abuse Screening Test. This 27-item questionnaire is associated with favorable reliability data and is highly predictive of a DSM-IV-TRdrug-related disorder when tested among adolescent psychiatric inpatients (211).
Multiproblem Screens
The final group of screening measures consists of two “multiscreen” instruments that examine several domains in addition to drug involvement. The 139-item Problem-Oriented Screening Instrument for Teenagers (204) is part of the Adolescent Assessment and Referral System developed by the National Institute on Drug Abuse. It tests for 10 functional adolescent problem areas: substance use, physical health, mental health, family relations, peer relationships, educational status, vocational status, social skills, leisure and recreation, and aggressive behavior/delinquency. Cut scores for determining the need for further assessment have been rationally established, and some have been confirmed with empirical procedures (205). Convergent and discriminant evidence for the Problem-Oriented Screening Instrument for Teenagers has been reported by several investigators (206,207). The Drug Use Screening Inventory— Revised is a 159-item instrument that describes drug use problem severity and related problems. It produces scores on 10 subscales as well as one lie scale. Domain scores were related to the DSM-III-R SUD criteria in a sample of adolescent substance abusers (208,209). An additional psychometric report provides norms and evidence of scale sensitivity (210).
Comprehensive Assessment Instruments
If an initial screening indicates the need for further assessment, clinicians and researchers can employ various diagnostic interviews, problem-focused interviews, and multiscale questionnaires (see Table 104-2for a listing). These instruments yield information that can more definitively assess the nature and severity of the drug involvement, typically assign an SUD diagnosis, and identify the psychosocial factors that may predispose, perpetuate, and maintain the drug involvement.
TABLE 104-2 COMPREHENSIVE ASSESSMENT INSTRUMENTS
Diagnostic Interviews
Diagnostic interviews that focus on the DSM-based criteria for SUDs include both general psychiatric interviews that address all psychiatric disorders, and SUD interviews that focus primarily on drug use and related domains of functioning. The majority of the diagnostic interviews are structured, that is, the format directs the interviewer to read verbatim a series of questions in a decision-tree format, and the answers to these questions are restricted to a few predefined alternatives. The respondent is assigned the principal responsibility of interpreting the question and deciding on a reply.
There are two well-researched psychiatric diagnostic interviews that address SUDs as well as the full range of child and adolescent psychiatric disorders. The Diagnostic Interview for Children and Adolescents (212) is a structured interview and is used widely among researchers and clinicians. Psychometric evidence specific to SUDs has not been published on the Diagnostic Interview for Children and Adolescents, but some of the other sections have been evaluated for reliability and validity (213). An instrument that has undergone several adaptations is the Diagnostic Interview Schedule for Children (DISC) (214). Its DSM-IV-TR version is the DISC—Revised (215–217). Separate forms of the interview exist for the child and the parent. As part of a larger study focusing on several diagnoses, Fisher et al. (218) found the DISC—Revised to be highly sensitive in correctly identifying youth who had received a hospital diagnosis of any SUD (n = 8). Both interview forms (parent and child) had a sensitivity of 75%. For the one parent– child disagreement case, the parent indicated that they did not know any details about their child’s substance use.
The second subgroup of diagnostic interviews primarily focuses on diagnostic criteria for SUDs. The ADI (219) assesses diagnostic symptoms associated with psychoactive SUDs. Other sections provide an assessment of substance use consumption history, psychosocial stressors, and level of functioning. Also, screens for several adolescent psychiatric disorders are provided. The authors have developed a DSM-IV-TR version of the ADI (ADI-R). Evidence that supports the interview’s psychometric properties has been reported (219–221). A second SUD-focused interview is the Customary Drinking and Drug Use Record (222). The Customary Drinking and Drug Use Record measures alcohol and other drug use consumption, DSM-IV-TR substance dependence symptoms (including a detailed assessment of withdrawal symptoms), and several types of consequences of drug involvement. There are both lifetime and prior 2-year versions of the Customary Drinking and Drug Use Record. Psychometric studies provide supporting evidence for this instrument’s reliability and validity (222). The third instrument in this subgroup is the Global Appraisal of Individual Needs (GAIN) (223). This semistructured interview covers recent and lifetime functioning in several areas, including substance use, legal and school functioning, and psychiatric symptoms. Very favorable reliability and validity data are associated with the GAIN, including data for the SUDs section when administered to a treatment-seeking adolescent population (224,225,242).
Problem-Focused Interviews
The second major group of comprehensive instruments— problem-focused interviews—measure several problem areas associated with adolescent drug involvement, but do not provide a means to obtain a formal diagnosis of an SUD. The interviews summarized here are adapted from the well-known adult tool, the Addiction Severity Index (226). Thus, these interviews assess drug use history and related consequences, as well as several functioning difficulties, often experienced by drug-abusing adolescents.
The Comprehensive Adolescent Severity Inventory (227) measures education, substance use, use of free time, leisure activities, peer relationships, family (including family history and intrafamilial abuse), psychiatric status, and legal history. At the end of several major topics, the space is provided for the assessor’s comments, severity ratings, and quality ratings of the respondent’s answers. An interesting feature of this interview is that it incorporates results from a urine drug screen and observations from the assessor. Psychometric studies on the Comprehensive Adolescent Severity Inventory support the instrument’s reliability and validity (227,228). The other Addiction Severity Index– adapted interview of note is the Teen Severity Index (229). The Teen Severity Index consists of seven content areas: chemical use, school status, employment–support status, family relationships, legal status, peer–social relationships, and psychiatric status. A medical status section was not included because it was deemed to be less relevant to adolescent drug abusers. Adolescent and interviewer severity ratings are elicited on a five-point scale for each of the content areas. Psychometric data indicate favorable interrater agreement and validity evidence (230,231). Kaminer et al. (232) has also developed a health service utilization tool that complements the Teen Severity Index, named the Teen Treatment Services Review. This interview examines the type and number of services that the youth received during the treatment episode.
Multiscale Questionnaires
The third group of comprehensive instruments consists of the self-administered multiscale questionnaires. These instruments range considerably in terms of length; some can be administered in less than 20 minutes, whereas others may take a full hour to administer. Yet, as a group, many of them share several characteristics: Measures of both drug use problem severity and psychosocial risk factors are provided; strategies are included for detecting response distortion tendencies; the scales are standardized to a clinical sample; and the option of computer administration and scoring is available. Four examples of instruments in this group are briefly summarized. The Adolescent Self-Assessment Profile was developed on the basis of a series of multivariate research studies by Wanberg (233). The 225-item instrument provides an in-depth assessment of drug involvement, including drug use frequency, drug use consequences and benefits, and major risk factors associated with such involvement (e.g., deviance, peer influence). Supplemental scales that are based on common factors found within the specific psychosocial and problem severity domains can be scored as well. Extensive reliability and validity data based on several normative groups are provided in the manual. The Hilson Adolescent Profile (234), a 310-item questionnaire (true/false), has 16 scales, 2 of which measure alcohol and drug use. The other content scales correspond to characteristics found in psychiatric diagnostic categories (e.g., antisocial behavior, depression) and psychosocial problems (e.g., home life conflicts). Normative data have been collected from clinical patients, juvenile offenders, and normal adolescents (234). Another true/false questionnaire is the 108-item Juvenile Automated Substance Abuse Evaluation. The Juvenile Automated Substance Abuse Evaluation (235) is a computer-assisted instrument that produces a 5-category score, ranging from no use to drug abuse (including a suggested DSM-IV-TR classification), as well as a summary of drug use history, measure of life stress, and a scale for test-taking attitude. The Juvenile Automated Substance Abuse Evaluation has been shown to discriminate clinical groups from nonclinical groups. The Personal Experience Inventory (236) consists of several scales that measure chemical involvement problem severity, psychosocial risk, and response distortion tendencies. Supplemental problem screens measure eating disorders, suicide potential, physical/sexual abuse, and parental history of drug abuse. The scoring program provides a computerized report that includes narratives and standardized scores for each scale, as well as other various clinical information. Normative and psychometric data are available (236,237).
SUMMARY
Drug use is prevalent among American teenagers. The 2011 Monitoring the Future study found that 63.5% of high school seniors had used alcohol in the past year and 36.4% had used marijuana. Nearly half had tried an illicit drug at least once in their lifetime. Even among eighth graders, 26.9% had already tried alcohol and 18.2% reported illicit drug use in their lifetime (1). Not only do youth have the highest prevalence of drug users within its age group compared with older age groups (1), drug use during adolescence greatly increases the likelihood of developing a later addiction (153,155), and the earlier one starts to use drugs during the teenage years, a greater risk is conferred for an early onset of an SUD (2). To further complicate the issue, adolescent drug use frequently co-occurs with psychological other behavioral disorders (25,238,239), making the assessment process even more complex. Finally, a large proportion of youth use drugs but do not necessarily meet criteria for an SUD, raising the need for accurate assessment tools. Fortunately, the field consists of multiple psychometrically sound screening, and comprehensive measures are available to assess not only the level of use but also patterns of use, accompanying drug use behaviors, SUDs, and comorbidity. The continued development of new and improved biologic assays is a welcomed accompaniment to methods of self-report.
Nonetheless, research is needed to fill important measurement gaps. For many instruments, there are no or little data on its psychometric properties for specialized subpopulations of youth (e.g., ethnic/racial groups, younger and older teenagers), and some measures have not been formally tested to determine their adequacy as a measure of change. A good measure of change should meet the condition that its standard error of measurement is sufficiently minimal to permit its use in detecting small to medium change over time (240,241). As we have already noted, it is unclear whether the distinction between substance abuse and dependence is diagnostically meaningful when applied to adolescents, and there is a need to improve our measurement of individual abuse and dependence criteria for youth given that some criteria appear to have questionable relevance when applied to young people (28). The newest diagnostic system, DSM-5, eliminates the distinction between abuse and dependence, which is a favorable change with respect to adolescents (244). A related unresolved area is the need for more precise identification of related psychosocial problems that may contribute to the onset and maintenance of drug involvement. Many existing tools assess psychosocial risk factors historically, which is not optimal for more precisely understanding which risk factors recently preceded the drug use or are current consequences of it.
ACKNOWLEDGMENT
The authors wish to acknowledge the National Institute on Drug Abuse (Dr. Winters, DA017492, K02 DA015347, and P50 DA027841) and the National Institute on Alcohol Abuse and Alcoholism (Dr. Winters, AA14866).
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