Summary by Ken C. Winters, PhD, Tamara A. Fahnhorst, MPH, Andria Marie Botzet, MA, Ali Elizabeth Nicholson, BS, Randy Stinchfield, PhD, and Walker Krepps, BA
104
Based on “Principles of Addiction Medicine” Chapter by Ken C. Winters, PhD, Tamara A. Fahnhorst, MPH, Andria Marie Botzet, MA, Ali Elizabeth Nicholson, BS, and Randy Stinchfield, PhD
ASSESSING ADOLESCENT SUBSTANCE USE
Adolescent onset of drug use greatly increases the estimated risk for developing a substance use disorder (SUD) and can lead to a variety of other negative consequences, including school failure, risky sexual behavior, delinquency, incarceration, suicidality, motor vehicle injuries/fatalities, possible damage to the brain’s memory region, and significant medical health care costs. Precise assessment of adolescent drug use is essential to gain an accurate understanding of the nature and extent of adolescent drug use and to inform possible intervention or treatment needs.
PRINCIPLES OF ASSESSMENT
Screening is the first step in identifying whether a youth may be involved with drugs. Screening results should be used to determine the need for a comprehensive assessment. The comprehensive assessment is used to explore the extent and nature of the drug involvement, consequential problems, and treatment needs. Despite uneven requirements by licensing and accreditation organizations, a national trend requires adolescent drug treatment facilities to use at least one adolescent-specific and psychometrically sound assessment as part of intake and treatment planning.
Screening
For adolescents, the assessment process should begin with screening questions pertaining to 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.
Comprehensive Assessment
If the screening suggests a possible drug use problem, a more comprehensive assessment can determine details of drug use history, consequences, whether criteria is met for an SUD, and what other behavioral and mental co-occurring problems may exist. This 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 explore context of use, use patterns of peers, and triggers associated with drug use. The clinician should also ask about consequences of use in the domains of school, social, family, psychological functioning, and physical/medical problems. Finally, the adolescent’s problem recognition and readiness for treatment should be evaluated to help determine treatment goals.
DEVELOPMENTAL CONSIDERATIONS
Identifying Clinical Significance
Most often, adolescents use legal drugs (alcohol or tobacco) within a social context. Although the majority of youth will not progress beyond the recreational use of these drugs, about 11% of youth will use illicit drugs to the point of meeting a clinical definition of an SUD.
SUD Criteria
In DSM-5, drug use problem severity is no longer separated into categories of abuse or dependence. Rather, a range of 11 symptoms that reflect harmful and hazardous use, negative consequences of use, continued and compulsive drug use in the face of negative consequences, and physiologic signs of tolerance and withdrawal are combined into a single SUD category. The elimination of the abuse and dependence categories in the DSM-5 has mainly been favored by professionals because the distinction between abuse and dependence criteria, especially as applied to adolescents, is not well supported by research. Furthermore, the meaning of some symptoms for adolescents, who are relatively inexperienced with the effects of drugs, may lead to higher rates of false-positive endorsements.
Neurobiology
The adolescent brain, particularly the prefrontal cortex region, does not fully develop until early adulthood. Because of this immaturity, the developing adolescent brain may be highly vulnerable to the effects of drug use.
SELF-REPORT: VALIDITY AND ALTERNATIVES
Self-report is a hallmark of clinical assessment for its convenience, comprehensiveness, low cost, and the perception that the individual is the most knowledgeable reporter. Self-report formats include self-administered questionnaire (SAQ), interview, timeline follow-back (TLFB), and computer-assisted interview (CAI). SAQs and interviews are the primary approaches used by clinicians. Research on the concordance of SAQ, interview, TLFB, and CAI formats suggests that, for the most part, the various formats yield similar levels of disclosure.
Though commonly used, the overall validity and reliability of the self-report method for assessing adolescent drug use and related problems is still debated. Underreporting of the quantity and type of drug use on self-report measures by adolescents can occur. In response, improved bioassay techniques are available to corroborate adolescent self-report of drug use. Youth may also see the self-report 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.
Alternatives to Self-Report
Drug Testing
Urinalysis, hair analysis, saliva testing, and sweat testing are all used to detect exposure to drugs. Newer biomarkers for alcohol, for example, ethyl glucuronide and phosphatidylethanol, hold promise of detecting alcohol for longer periods (days) compared to standard procedures.
Clinical Observation
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. The Clinical Opiate Withdrawal Scale consists of 11 items that measure withdrawal from opiates (e.g., sweating, pupil size).
Reports from Others
Information from peers may be a valuable resource especially if the peers are not currently using drugs or are in recovery. It is less likely that parents can provide detailed reports about the types, frequency, and quantity of drug use by their child.
CLINICAL CONTENT
Course of SUDs
Understanding the course of adolescent SUDs provides a vital perspective in our understanding of the etiology and prognosis of SUDs. Multiple studies support the notion that there may be distinct paths for experimental use compared to SUD. 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, greater readiness to change, and fewer conduct problems or other co-occurring psychopathology. Factors influencing better outcomes during treatment include a longer length of treatment and family involvement in treatment. Posttreatment predictors of better outcome include participation in aftercare, low levels of peer substance use, ability to use coping skills, and continued commitment to abstain.
Psychosocial Factors
Psychosocial dimensions provide beneficial information and should be included in the assessment protocol. These factors include interpersonal relationships, school and employment, history of criminal justice involvement and delinquency, recreational activities, and sexual behavior. Lesbian, gay, and bisexual teens have been shown to be at higher risk than their heterosexual peers.
Peer Factors
Peer variables are one of the most prominent factors contributing to the onset and maintenance of drug use. Youth who associate with peers who use drugs are far more likely to use drugs than those who do not associate with drug-using peers.
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. Parental antisocial behavior history is also relevant in offspring SUD liability. There is converging evidence that the initiation of alcohol use in midadolescence is predominantly influenced by factors such as parental monitoring and father’s drinking level, rather than genetic factors. 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. Parenting factors are strongly associated with adolescent risk for drug involvement. There is evidence for 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.
Psychological Benefits
Many adolescents use drugs because these serve psychological need states including mood enhancement, stress reduction, and relief from boredom.
Co-Occurring Mental Health Disorders
Most adolescents who are involved with drugs have co-occurring behavioral or mental disorders, and their presence is a negative sign for recovery.
Coexisting Externalizing Disorders
Childhood aggression, rebelliousness, theft, and destructiveness, along with related externalizing disorders such as conduct disorder and oppositional defiant disorder, are common among youth with an SUD as well as among children who have a parent with a history of an SUD. Antisocial behaviors in late childhood, and the initiation of drug use in early adolescence, may predict later drug involvement. The exact relationship between externalizing behavior and SUDs is not yet known.
The relationship between ADHD and SUDs is equally complex. Some studies have found that individuals with a history of ADHD are more likely to develop substance use and substance-related problems. Other studies have not found similar relationships.
Coexisting Internalizing Disorders
Internalizing disorders such as anxiety disorders (i.e., PTSD) and mood disorders (i.e., major depression) may be another pathway associated with SUD. Adolescents with an SUD and children of parents with an SUD sometimes demonstrate increased rates of internalizing disorders and related symptoms. Another complicating feature is that data from adolescents with an SUD indicate that both conduct disorders and major depression may coexist in some individuals.
INSTRUMENTATION
Several summaries of adolescent screening and comprehensive assessments exist including two by the federal government, “Screening Assessment of Adolescents with a Substance Use Disorder” and “Screening and Assessing Youth for Drug Involvement,” as part of the National Institute on Alcohol Abuse and Alcoholism, 2nd edition, handbook, “Assessing Alcohol Problems: A Guide for Clinicians and Researchers” as well as journal articles and book chapters.
Alcohol Screens
Two screening tools focus exclusively on alcohol use. The Adolescent Drinking Inventory is a 24-item measure that examines adolescent problem drinking by measuring psychological symptoms, physical symptoms, social symptoms, and loss of control. The second measure is the 23-item Rutgers Alcohol Problem Index. This tool measures consequences of alcohol use pertaining to family life, social relations, psychological functioning, delinquency, physical problems, and neuropsychological functioning.
Screens for All Drugs
The 14-item Adolescent Alcohol and Drug Abuse Involvement Scale measures drug abuse problem severity. 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. The 40-item Personal Experience Screening Questionnaire consists of a problem severity scale, drug use history, select psychosocial problems, and response distortion tendencies (“faking good” and “faking bad”). The 81-item adolescent version of the Substance Abuse Subtle Screening Inventory (SASSI) yields scores for several scales, including face-valid alcohol, face-valid other drug, obvious attributes, subtle attributes, and defensiveness.
Screens for Nonalcohol Drugs
The Drug Abuse Screening Test for Adolescents was adapted from Skinner’s adult tool. This 27-item questionnaire is also associated with favorable reliability data and was found to be highly predictive of DSM-IV drug-related disorder when tested among adolescent psychiatric inpatients.
Multiproblem Screens
The 139-item Problem Oriented Screening Instrument for Teenagers 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. 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.
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.
Diagnostic Interviews
Diagnostic interviews, which focus on DSM-based criteria, address numerous psychiatric disorders, including SUDs. The Diagnostic Interview for Children and Adolescents (DICA) is a structured interview used widely among researchers and clinicians. Another useful instrument that has undergone several adaptations is the Diagnostic Interview Schedule for Children (DISC). Both the DICA and the DISC have parent and youth versions.
Problem-Focused Interviews
These tools measure several problem areas associated with adolescent drug involvement, but do not provide a means to obtain a formal diagnosis of an SUD.
Multiscale Questionnaires
Self-administered multiscale questionnaires such as the Adolescent Self-Assessment Profile and the Hilson Adolescent Profile typically measure both drug use problem severity and psychosocial risk factors, and detect response distortion tendencies.
KEY POINTS
1. Assessment of adolescent drug use is critical because youth have the highest incidence of drug users compared to older groups, and drug use during adolescence greatly increases the chance for an SUD.
2. Brain development during adolescence is incomplete, especially in the prefrontal cortex, which governs judgment. This and many other factors unique to adolescents demand assessments that are tailored to youth.
3. Many factors can influence adolescent drug use including the course of an SUD: psychosocial factors such as peers and family, psychological benefits, and co-occurring mental health conditions including externalizing and internalizing disorders.
Acknowledgments
Preparation of this chapter was supported in part by grants from the National Institute on Drug Abuse (DA017492, K02 DA015347, P50 DA027841) and the National Institute on Alcohol Abuse and Alcoholism (AA14866).
REVIEW QUESTIONS
1. True or false: One way that the acute physiologic effects of substance use impacts assessment is that some drugs contribute to poor memory.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
