Adolescents: Screening and Assessment For Substance Use Disorders

A continuing education course for 8 ces

consisting of reading and taking a post-test on
Screening and Assessing Adolescents For Substance Use Disorders
Treatment Improvement Protocol (TIP) Series 31


Fulfills CA BBS mandatory substance abuse training and mandated prelicensure requirement

Adolescents differ from adults both physiologically and emotionally as they make the transition from child to adult. Although experimentation with substances is common with this population, substance abuse can seriously impair development, leaving an adolescent unprepared for the demands of adulthood. Therefore, it is important for a wide range of professionals who come into regular contact with adolescents to recognize the signs of substance use. This TIP focuses on the most current procedures and instruments for detecting substance abuse among adolescents, conducting comprehensive assessments, and beginning treatment planning.

Table of Contents

Chapter 1 provides an overview of the document.

Chapters 2 and 3 present appropriate strategies and guidelines for screening and assessment.

An explanation of legal issues concerning Federal and State confidentiality laws appears in Chapter 4.

Chapter 5 provides guidance for screening and assessing adolescents in juvenile justice settings.

Appendix B summarizes instruments to screen and assess adolescents for substance abuse and general functioning domains, many of them updated since 1993.

Appendix C excerpts a 1998 publication on drug testing juvenile detainees prepared under a grant from the Office of Juvenile Justice and Delinquency Prevention of the U.S. Department of Justice.

Substance Use Disorders And the Adolescent's Development

A person's entire life is shaped in late adolescence and early adulthood. Developmental tasks associated with this period include dating, marriage, child bearing and rearing, establishing a career, and building rewarding social connections. Younger adolescents are taking the first steps on this path by separating from their parents, developing a moral code, and aligning themselves with different segments of their community. Although some experimentation is normal, sustained use of substances will likely interfere with the demands and roles of adolescence and make it more difficult to negotiate the transitions from early adolescence to late adolescence to young adulthood. Because substance use changes the way people approach and experience interactions, the adolescent's psychological and social development are compromised, as is the formation of a strong self-identity.


The purposes of the TIP are several:

1. To provide general guidelines for evaluating, developing, and administering screenings and assessment instruments and processes for those who screen and assess young people for substance use disorders

2. To inform a wide range of people whose work brings them in contact with adolescents in problem situations (e.g., teachers, guidance counselors, school nurses, police probation officers, coaches, and family service workers) about the processes, methods, and tools available to screen for potential substance use problems in adolescents

3. To discuss strategies and accepted techniques that can be used by treatment personnel to detect related problems in the adolescent's life, including problems with family and peers, and psychiatric issues and to see that these problems are dealt with during the primary intervention for a substance use disorder To outline a screening and assessment system designed to identify those youths with potential substance use problems in various settings

4. Adolescents differ from adults physiologically and emotionally and are covered by different laws and social services. This revised TIP is designed to help juvenile justice, health and human service, and substance use disorder treatment personnel better identify, screen, and assess people 11 to 21 years old who may be experiencing substance-related problems.

The TIP details warning signs of substance use disorders among adolescents, when to screen, when to assess, what domains besides substance use to assess, and how to involve the family and other collaterals.

Also covered are the legal issues of screening and assessing teenagers, including confidentiality, duty to warn, and how to communicate with other agencies.

The TIP also includes a chapter specifically for those working in the juvenile justice system who want to improve their screening and assessment procedures.

Appendix A lists the citations referred to throughout this TIP and relevant to the instrument summaries.

Appendix B provides up-to-date summaries of instruments relevant for screening and comprehensively assessing substance-abusing adolescents.

Appendix C contains excerpts from "Drug Testing of Juvenile Detainees," a publication prepared by the American Correctional Association and the Institute for Behavior and Health, Inc., under a grant from the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice.


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Addicted Adolescents - Screening

Learning Objectives

Clinicians will be able to:

1. Recognize the 'red flags', for assessment, detection, and signs of adolescent substance abuse.

2. Apply techniques for identifying, screening, and assessing adolescents for substance abuse.

3. Describe techniques for treatment planning with addicted adolescents.

4. Discuss current procedures and instruments for detecting substance abuse among adolescents.

5. Conduct comprehensive assessments.

6. Demonstrate awareness of the legal and ethical legal issues concerning Federal and State confidentiality laws in the treatment of addicted adolescents.




Excerpt: Introduction

The purpose of screening is to identify adolescents who need a more comprehensive assessment for substance use disorders. It does so by uncovering "red flags," or indicators of serious substance-related problems among adolescents. As such, it covers the general areas in a client's life that pertain to substance use without making an involved diagnosis. The Consensus Panel recommends that all adolescents who exhibit signs of substance use receive appropriate, valid, and sensitive screening.

Selection of screening and assessment instruments for use with adolescents should be guided by several factors:
(1) reliability and validity of the tool,
(2) its appropriateness to an adolescent population,
(3) the type of settings in which the instrument was developed, and
(4) the intended purpose of the instrument.

The Panel recommends that screening and assessment cover multiple domains pertaining to the individual and his environment, and that the process involve more than one method and source. Important features of screening and assessment instruments include High test-retest reliability

Evidence of convergent validity (i.e., the instrument is strongly correlated with other instruments that purport to measure similar constructs) ¨ Demonstrated ability to predict relevant criteria, such as school performance, performance in treatment, and substance use relapse

Availability of normative data for representative samples based on, for example, age, race, gender, and different types of settings (e.g., school, detention center, and drug clinic)

The ability to measure meaningful behavioral and attitude changes over time

When assessing family members, certain principles should be kept in mind: Adolescents may define family in nontraditional ways. Treatment providers should allow adolescents to identify and acknowledge the people they would describe as "family," even though they may not live with the adolescent.

The law and society may define family in ways that differ from the actual experiences of substance-abusing youth. ¨ Cultural and ethnic differences in family structures should be respected.

Although an adolescent may be initially identified as having a substance use disorder, she may be a victim of family discord. The treatment provider should be aware that the core problem may reside outside the adolescent and that the young person's problems are a symptom of this environmental distress.

Screening Health service providers, juvenile justice workers, educators, and other professionals who work with adolescents at risk should be able to screen and refer for further assessment. Community organizations (e.g., schools, health care delivery systems, the judiciary, vocational rehabilitation, religious organizations) and individuals associated with adolescents at risk must be also able to screen and detect possible substance use. Thus, many health and judicial professionals should have screening expertise, including school counselors, street youth workers, probation officers, and pediatricians. For adolescents at high risk for a substance use disorder, a negative screening result should be followed up with a re-evaluation, perhaps after 6 months.

Juvenile justice systems should screen all adolescents at the time of arrest or detention, including "status offenders" who are not normally screened. Given the high correlation between psychological difficulty and substance use disorders, all teens receiving mental health assessment should also be systematically screened.

Within other service delivery systems, runaway youth (e.g., at shelters), teens entering the child welfare system, teens who dropped out of school (e.g., in vocational/job corps programs), and other high-risk populations (e.g., special education students) should also be screened.

Adolescents who present with substantial behavioral changes or emergency medical services for trauma, or who suddenly begin experiencing medical problems such as accidents, injury, or gastrointestinal disturbance should also be screened. In addition, schools should screen youth who show increased oppositional behavior, significant changes in grade point average, and a great number of unexcused school absences.

Because of the close connection between substance use and HIV, workers dealing with youth should receive adequate training on HIV/AIDS prevention, education, and referral, including confidentiality issues. The screening process should last no more than 30 minutes--ideally, 10--15 minutes--and the instrument should be simple enough that a wide range of health professionals can administer it. It should focus on the adolescent's substance use severity (primarily consumption patterns) and a core group of associated factors such as legal problems, mental health status, educational functioning, and living situation. The content of the test must be appropriate for clients from a variety of background and cultural experiences, and for clients of differing age and experience.

The Panel strongly recommends that structured or semistructured interviews be used in this field, since unstructured interviews pose special administrative problems that contribute to measurement error. Interviews should not be performed with parents present. When using paper-and-pencil questionnaires, the screener should have the client read aloud the instructions that accompany the test to ensure that the client understands what is expected of her and to judge whether the client's reading ability is appropriate for the testing situation. There is no definitive rule as to how many uncovered red flags indicate a need for a comprehensive assessment.

Many screening questionnaires provide empirically validated cut scores to assist with this decision. Nevertheless, any time there are several red flags or a few that appear to be meaningful, the screener should refer the adolescent for a comprehensive assessment. Drug monitoring is a useful adjunct to screening and should be conducted at an appropriate point during screening and in a manner consistent with accepted standards and guidelines. Laboratories certified by the National Institute on Drug Abuse are available in most communities and are equipped to provide agencies with the necessary training in collecting urine and blood samples. Drug testing should always be conducted with the knowledge and consent of the adolescent. Testers should always report the results of testing to a youth and discuss their implications. If time permits, the person conducting the screening should also get information from another source such as parents, family members, or case workers to get a more complete picture. It is wise to collect the information when the youth is not present in the interview room and to tell the parents that what they say may be shared with the adolescent in the summary of the screening.

The comprehensive assessment, which is based on initial screening results, has several purposes: To accurately identify those youth who need treatment

1. To further evaluate if a substance use disorder exists, and if so, to determine its severity including whether a substance use disorder exists based on formal criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders-IV)

2. To permit the evaluator to learn more about the nature, correlates, and consequences of the youth's substance-using behavior

3. To ensure that additional related problems not flagged in the screening process are identified (e.g., problems in medical status, psychological status, nutrition, social functioning, family relations, educational performance, delinquent behavior)

4. To examine the extent to which the youth's family (as defined in the introduction to this volume) can be involved not only in comprehensive assessment, but also in possible subsequent interventions

5. To identify specific strengths of the adolescent (e.g., coping skills) that can be used in developing an appropriate treatment plan

6. To develop a written report that Identifies the severity of the substance use disorder, identifies factors that contribute to or are related to the substance use disorder , identifies a corrective plan of action to address these problem areas, details an interim plan to ensure that the treatment plan is implemented and monitored to its conclusion

7.Makes recommendations for referral to agencies or services , Describes how resources and services of multiple agencies can best be coordinated and integrated. In addition, the assessment begins a process of responding creatively to the youth's denial and resistance and can be seen as an initial phase of the youth's treatment experience.

The assessor should be a well-trained professional experienced with adolescent substance use issues, such as a psychologist or mental health professional, school counselor, social worker, or substance abuse counselor. One individual should take the lead in the assessment process, especially with respect to gathering, summarizing, and interpreting the assessment data. An assessor not licensed to make mental health diagnoses should refer an adolescent in apparent need of a formal mental health workup to an appropriate professional. The assessment should be conducted in an office or other site where the adolescent can feel comfortable, private, and secure.

To arrive at an accurate picture of the adolescent's problems, the following domains should be assessed:

Strengths or resiliency factors, including self-esteem, family, religiosity, other community supports, coping skills, and motivation for treatment.

History of use of substances, including over-the-counter and prescription drugs (including Ritalin), tobacco, caffeine, and alcohol. The history notes age of first use, frequency, length, pattern of use, and mode of ingestion, as well as treatment history.

Medical health history and physical examination (noting, for example, previous illnesses, infectious diseases, medical trauma, pregnancies, and sexually transmitted diseases). An adolescent's HIV risk behavior status (e.g., does he inject drugs or practice unsafe sex?) should be assessed as well. A full sexual history, including sexual abuse and sexual orientation, should be taken.

Developmental issues, including influences of traumatic events, such as physical or sexual abuse and other threats to safety (e.g., pressure from gang members to participate in drug trafficking).

Mental health history, with a focus on depression, suicidal ideation or attempts, attention deficit disorders, oppositional defiance and conduct disorders, and anxiety disorders, as well as details about prior evaluation and treatment for mental health problems. Also assess the disability status of the individual young person.

Family history, including the parents' and/or guardians' history of substance use, mental and physical health problems, chronic illnesses, incarceration or illegal activity, child management concerns, and the family's cultural, racial, and socioeconomic background and degree of acculturation. The description of the home environment should note substandard housing, homelessness, proportion of time the young person spends in shelters or on the streets, and any pattern of running away from home. Issues regarding the youth's history of child abuse or neglect, involvement with the child welfare agency, and foster care placements are also key considerations. The family's strengths should also be noted as they will be important in intervention efforts.

School history, including academic performance and behavior, learning-related problems, extracurricular activities, and attendance problems. Has the child been assessed with a learning disability, or perhaps received special education services at some time in his educational career?

Vocational history, including paid and volunteer work.

Peer relationships, interpersonal skills, gang involvement, and neighborhood environment.

Juvenile justice involvement and delinquency, including types and incidence of behavior and attitudes toward that behavior.

Social service agency program involvement, child welfare involvement (number and duration of foster home placements), and residential treatment.

Leisure activities, including recreational activities, hobbies, interests, and any aspirations associated with them.


This course consists of reading and taking a post-test on:

Treatment Improvement Protocol (TIP) Series 31
Ken C. Winters, Ph.D. Revision Consensus Panel Chair

Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 99-3282

All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.


Cost of the 8 unit course is $88

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