Screening of Adolescents for Substance Use Disorders

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Screening of Adolescents for Substance Use
Disorders

• Scott Reiner, M.S., C.S.A.C., C.A.C., C.C.S.
• 2006 Virginia Summer Institute
• for Addiction Studies

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Percentage of U.S. High School Students Reporting
Lifetime Illicit Drug Use, 1991 to 2005
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Treatment Stages and the Problem Severity
Continuum
Problem Severity
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Training Objectives

• Gain knowledge about signs and symptoms of
  substance use problems in adolescents
• Learn about different methods to gathering
  information and making decisions about the
  presence of substance use problems in adolescents
• Understand the strengths and weakness of
  different approaches to screening
• Gain exposure to several validated screening
  tools that might be used in their work settings

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Signs of AdolescentSubstance Misuse
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Risk and Protective Factors
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Developing Screening Questions
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• Screening and assessment constitute a two-step
  process to determine the existence and extent of
  a substance use problem.

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Preliminary Screening

• A preliminary screening is conducted when an
  individual is suspected of having problems that
  may be related to involvement with alcohol and
  other drugs

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Screening

• The aim is to determine the probability of the
  presence of a problem, substantiate that there is
  reason for concern, or identify the need for
  further evaluation or comprehensive assessment
  not to establish definitive information about
  diagnosis and possible treatment needs

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Screening

• The process should be relatively short and simple
  and within the expertise of a wide-range of
  professionals
• Should take no longer than 30 minutes
• Has broad applicability across diverse
  populations
• Can be completed by community organizations and
  individuals associated with adolescents at risk

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Screening Basics

• Focus on substance use severity and a core group
  of associated factors.
• It does not establish definitive information
  about diagnosis and possible treatment needs.
• When screening turns up red flags, the youth
  should be referred for a comprehensive assessment.

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What Should You Screen For?

• In a general population, screening for substance
  abuse and dependency would focus on determining
  the presence or absence of the disorder.
• For a population already identified at risk, the
  screening process would be concerned with
  measuring the severity of the problem and
  determining need for a comprehensive assessment.

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Who Should Be Screened?

• All adolescents involved in the juvenile justice
  system
• Adolescents receiving mental health assessment
• Runaway youth
• Youth entering the child welfare system
• Youth who have dropped out of school
• Adolescents with sudden onset of behavioral
  changes or medical problems
• Youth with significant changes in school
  behavior, attendance or performance

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The Consensus Panel recommends that all
adolescents who exhibit signs of substance use
receive appropriate, valid, and sensitive
screening.
TIP 31, page 9.
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Components of the Screening Process

• There are three primary components to preliminary
  screening
• (1) Content domains
• (2) Screening methods
• (3) Information sources

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Screening Content Domains

• Empirically verified red flags including
• Indicators of substance use problem presence and
  severity
• Other psychosocial factors
• 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.

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Indicators for Assessment

• Substance Use Disorder-Related
• Use of substances during childhood or early
  teenage years
• Substance use before or during school
• Peer involvement in substance use
• Daily use of one or more substances

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Indicators for Assessment

• Psychosocial
• Physical or sexual abuse
• Parental substance abuse (including driving under
  the influence/driving while intoxicated)
• Sudden downturns in school performance or
  attendance
• Peer involvement in serious crime
• Marked change in physical health
• Involvement in serious delinquency or crimes
• HIV high-risk activities (e.g., intravenous drug
  use, sex with intravenous drug user)
• Indicators of serious psychological problems
  (e.g., suicidal ideation, severe depression)

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Screening Methods

• Standardized interview or questionnaires
• Red Flag indicators
• Chemical testing (urine, breath, saliva)
• Informed observation
• Other sources of information

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Screening Methods

• Interviews and questionnaires
• A model screening instrument is short, simple,
  and appropriate to the youths age.
• It is strongly recommended that structured or
  semi-structured interviews be used.

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Screening Methods

• Biological/toxicological monitoring
• Laboratory methods to monitor substance use can
  be conducted in the preliminary screening to
  supplement information gathered through screening
  tools and additional sources.

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Screening Methods

• Other Information Sources
• Parents and other family members
• Caseworker, teacher, probation officer
• Getting information from other sources helps the
  screener guard against developing an incorrect
  picture based solely on the young persons
  self-report

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Screening Cautions

• The presence of warning signs of substance use
  does not confirm that a youth has a problem
  severe enough to warrant a formal diagnosis or
  referral to intensive drug treatment.
• Professionals conducting screenings for substance
  use disorders must 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.

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Screening Cautions

• Use of procedures sensitive to differences in
  adolescents backgrounds (e.g., age, ethnicity,
  culture, gender, sexual orientation,
  socio-economic status, literacy)

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Standardized Adolescent Screening Instruments

• CRAFFT
• Problem Oriented Screening Instrument for
  Teenagers (POSIT)
• Substance Abuse Subtle Screening Inventory
  (SASSI-A2)

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Advantages of Standardized Instruments

• Eliminate most subjective bias
• Promote consistency
• Have established reliability and validity
• Can help compare the client to other people
• Can be used as a periodic indicator of
  change/progress

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Selecting Screening Tools

• Reliability
• Relative freedom of a measure from error
• Consistency over time (test-retest)
• Consistency over raters (inter-rater)
• Validity
• Extent to which the instrument measures what it
  is intended to measure
• Content (face validity)
• Criterion validity

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The CRAFFT Questions

• C - Have you ever ridden in a CAR driven by
  someone (including yourself) who was "high" or
  had been using alcohol or drugs?
• R - Do you ever use alcohol or drugs to RELAX,
  feel better about yourself, or fit in?
• A - Do you ever use alcohol/drugs while you are
  by yourself, ALONE?
• F - Do your family or FRIENDS ever tell you that
  you should cut down on your drinking or drug use?
• F - Do you ever FORGET things you did while using
  alcohol or drugs?
• T - Have you gotten into TROUBLE while you were
  using alcohol or drugs?

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CRAFFT

• Less than 2 yes answers
• unlikely to need referral
• 2 or more yes answers
• 80 chance of having a serious problem
• 50 chance of a DSM-IV SUD
• 25 chance of alcohol or drug dependence

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Problem Oriented Screening
Instrument for Teenagers (POSIT)

• Substance use abuse
• Physical health
• Mental health
• Family relations
• Peer relations

• Educational status (i.e., learning
  disabilities/disorders)
• Vocational status
• Social skills
• Leisure/recreation
• Aggressive behavior/ delinquency

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Problem Oriented Screening
Instrument for Teenagers (POSIT)

• Includes both cut-off scores for problems in each
  domain, as well as individual red-flag items

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Substance Abuse Subtle Screening Inventory
(SASSI-A2)

• Frequency items direct measure of AOD
  involvement
• Symptom-related scales
• Risk items family social environment
• Attitude items beliefs about substance use
• Subtle items characteristics found in youth
  with AOD problems even if they dont acknowledge
  substance misuse

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SASSI A2

• 94 accuracy in correctly classifying adolescents
  as having or not having a substance use disorder
• Can identify youth with substance use problems in
  the absence of self-reported use or consequences

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The Evaluation Process
From CSAT TIP 31
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Developing a Screening Procedure

• Define and describe the setting
• Which youth will be identified for screening and
  how?
• What screening procedures will be used?
• Who will administer the screening procedure?
• Describe potential barriers, training needs,
  other considerations