TREATING TEENS

I. Screening Instruments

Several adolescent substance abuse screening tests are available. These tools are useful because they can briefly estimate the severity of a youth's problem. Given their preliminary nature, screening measures typically call for conservative scoring decisions. For example, terms such as "probable substance abuser" or "needs a comprehensive assessment" are often used to describe an individual's test score. A screening tool's full value is appreciated when it is used to determine whether a more complete assessment should be conducted.

Adolescent Alcohol Involvement Scales (AAIS)
The AAIS is a 14-item self-report (Mayer & Filstead, 1979) scale that looks at the type of alcohol abuse and how often it occurs. Questions on the AAIS address topics such as, the last drinking episode, reasons for the initial drinking behavior, the situation in which the drinking occurred, short and long-term effects of drinking, the adolescent's perception about drinking, and the ways in which others perceive his/her drinking. The severity of the adolescent's alcohol abuse is determined by their overall score, which can range anywhere between 0 and 79. The major scales include non-user/normal, misuser, and abuser/dependent. The test scores are related to a substance abuse diagnosis as well as ratings from other sources. These other sources include independent clinical assessments and the adolescent's parents, as well as the consistency for each individual- ranging from .55 in a clinical sample to .76 in a general sample (Moberg, 1983). The norms for both of these samples are available in the 13-19 year-old range.

Adolescent Drinking Index (ADI)
The ADI (Harrell & Wirtz, 1989) is a 24-item self-administered test that examines adolescent drinking. It does so by measuring psychological, physical, and social symptoms as well as loss of control. This test is written at a fifth grade reading level. The results of this test provide a single score as well as two subscale scores. The subscale scores include, self-medicating drinking and rebellious drinking. These two scales are intended as research scales. The reliability of the ADI is good. Results are shown to be consistent and accurate (coefficient alpha, .93-.95) in measuring the severity of adolescent drinking problems. Studies show a moderate correlation with alcohol consumption as well as significant differences between groups with different levels of alcohol problem severity. In addition, there was a hit rate of 82% in classification accuracy of the ADI (Harrell & Wirtz, 1989). This means that 82% of the time, when a drinking problem was identified using this scale, the test was accurate in classifying the drinking as a problem and the test accurately determined the level of severity of the drinking problem.

Adolescent Drug Involvement Scale (ADIS)
Moberg and Hahn (1991) modified the AAIS (described above) to address drug use problem severity. The ADIS is a 13-item questionnaire written at an eighth grade reading level. This scale correlates (.72) with drug use frequency and (.75) with independent rating by clinical staff. When matched up with the frequency of drug use and the ratings that clinical staff gave, the scale correlates with their findings, therefore providing evidence of the validity of this test.

Client Substance Index (CSI)
This 113-item test (Moore, 1983) is based on Jellinek's 28 symptoms of drug dependence. Scores on the CSI reflect the degree of drug dependence, ranging from no problem, to misuse of substances, to chemical dependency. CSI scores have been shown to discriminate normal from drug treatment samples (Moore, 1983).

Client Substance Index-Short (CSI-S)
The CSI-S (Thomas, 1990) was developed and evaluated as part of a larger Substance Abuse Screening Protocol through the National Center for Juvenile Justice. This tool is a 15-item, yes/no self-report instrument that was adapted from Moore's (1983) multi-scale Client Substance Index. The objective of this brief screen is to identify juveniles within the court system who are in need of additional drug abuse assessment. When tested again and again, the results are comparable (coefficient alpha =.84-.87). The test also has the ability to discriminate groups defined according to the severity of their criminal offense (Thomas, 1990).

Drug and Alcohol Problem (DAP) Quick Screen
This 30-item screening questionnaire has a yes/no/uncertain response format. The DAP was tested in a pediatric setting (Schwartz & Wirtz, 1990), in which the authors report that about 15% of the respondents said yes to 6 or more items. From this, they determine the cut-off score for "problem" drug use to be inclusive of 6 or more responses of yes to the items on the scale. The items contribute to the score, however the validity and reliability of this test are not available.

Drug Use Screening Inventory-Revised (DUSI-R)
The DUSI-R is a 159-item instrument that documents the level of involvement with a range of drugs. It also describes the severity of consequences related to such involvement. The scale provides scores on 10 problem density subscales. Some of these subscales are: substance use, behavior problems, and psychiatric disorder. In addition to these 10 subscales, there is one lie scale. This is used for reliability purposes to ensure honesty in the respondents or identify inconsistencies within the responses. Domain scores were related to DSM-III-R substance use disorder criteria in a sample of adolescent substance abusers (Tarter, Laird, Bukstein, & Kaminer, 1992). An additional psychometric report provides norms and evidence of scale sensitivity (Kirisci, Mezzich, & Tarter, 1995).

Personal Experience Screening Questionnaire (PESQ)
The PESQ (Winters, 1992) is a brief 40-item screening instrument that consists of a scale that measures the severity of the drinking problem (coefficient alpha, .91-.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 test is estimated to have an accuracy rate of 87% in predicting the need for further drug abuse assessment (Winters, 1992).

Problem Oriented Screening Instrument for Teenagers (POSIT)
This 139-item self-administered yes/no instrument is part of the Adolescent Assessment and Referral System developed by the National Institute on Drug Abuse (Rahdert, 1991). It addresses 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. The need for further assessment has been determined by cut scores that have been established rationally, or confirmed with documented proof providing procedures (Latimer, Winters, & Stinchfield, 1997). Convergent and discriminating data for the POSIT have been reported by several investigators (Dembo, Schmeidler, Borden, Chin Sue, & Manning, 1997; McLaney et al., 1994).

Rutgers Alcohol Problem Index (RAPI)
The RAPI (White & Labouvie, 1989) is a 23-item questionnaire that focuses on the consequences of alcohol use in regards to family life, social relations, psychological functioning, delinquency, physical problems and neuropsychological functioning. The RAPI, when used as a screening device among heavy alcohol users, was found to correlate highly with the DSM-III-R requirements for substance use disorders (.75-.95) and when used on a large general population sample, the RAPI was found to have high internal consistency (.92) (White & Labouvie, 1989).

Substance Abuse Subtle Screening Inventory (SASSI)
Miller's (1985) 81-item adolescent version of the SASSI shows scores for several scales. Those scales are: face valid alcohol, face valid other drug, obvious attributes, subtle attributes, and defensiveness. The validity of this test is proven by its high correlation with the MMPI cut scores for chemical dependency and the SASSI's high correspondence with diagnosis of substance use disorder at intake (Risberg, Stevens, & Graybill, 1995).

II. Comprehensive Assessment Instruments
The field also consists of several comprehensive assessment instruments. These measures provide a detailed assessment of the multiple problems and strengths of the adolescent. Such information is important in helping to determine if the adolescent has clinical-level problems and to construct a treatment plan. Thre types of comprehensive assessments are reviewed: interviews that include an assessment of substance use disorders, interviews that primarily focus on psychosocial functioning, and multi-scale questionnaires.


Substance Use Disorder Interviews

Adolescent Diagnostic Interview (ADI)
The ADI (Winters & Henly, 1993) tests for symptoms associated with psychoactive substance use disorders (descriptions can be found in the DSM-III-R and DSM-IV). This instrument follows a structured interview format and it also measures information related to demographics as well as social class. It takes a look at the substance use consumption history, and the way a person functions in society in relation to mental health. Evidence for the interview's interrater agreement, test-retest reliability, the test's relationships to alternative measures of problem severity, and its agreement with independent diagnoses have been reported (Winters & Henly, 1993; Winters, Stinchfield, Fulkerson & Henly, 1993).

Customary Drinking and Drug Use Record (CDDR)
The CDDR (Brown, Meyers, Lippke, Tapert, Stewart & Vik, 1998) is a research-focused, structured interview that measures alcohol and other drug use consumption for both recent (prior 3 months) and lifetime periods. The interview tests DSM-III and DSM-IV substance dependence symptoms (including a detailed assessment of withdrawal symptoms) and several types of consequences of alcohol and other drug involvement. Psychometric studies provide evidence that the CDDR is reliable over time and across interviewers (average one-week test-retest coefficients for all major content domains is .91), discriminates community youths from substance-abusing youths, and converges with alternate measures (Brown et al., 1998).

Substance Use Disorders Diagnostic Schedule (SUDDS)
This instrument is a diagnostic checklist that is specific to DSM-III-R criteria (Hoffmann & Harrison, 1989). It should be used cautiously among adolescents. This is because several of the items are not appropriate for young people's experiences and the content coverage is pretty weak when it comes to school consequences and peer use issues. The SUDDS is accompanied by other measures that assist in determining the level of client treatment care based on client placement criteria from the American Society of Addiction Medicine (Level of Care Index, Mee-Lee & Hoffmann, 1992a and Recovery Attitude and Treatment Evaluator, Mee-Lee & Hoffmann, 1992b). The SUDDS current and lifetime ratings have been shown to be pretty even with independent clinical diagnoses in an adult sample (overall agreement, 71%-100%) (Davis, Hoffmann, & Luehr, 1992), although there have been no psychometric evaluations of the interview with adolescents.

Psychosocial Functioning Interviews

Adolescent Drug Abuse Diagnosis (ADAD)
The ADAD is a 150-item structured interview that looks at the following content areas: medical status, drug and alcohol use, legal status, family background and problems, school/employment, social activities and peer relations, and psychological status. The interviewer uses a 10-point scale to rate the patient's need for additional treatment in each content area. These severity ratings translate to a problem severity dimension (no problem, slight, moderate, considerable, and extreme problem). The drug use section includes a detailed drug use list and how often the use occurs, and a brief set of items that looks at specific areas of drug involvement (e.g., polydrug use, attempts at abstinence, withdrawal symptoms, use in school). Psychometric studies on the ADAD, using a broad sample of clinic-referred adolescents, provide favorable evidence for its reliability and validity (Frideman & Utada, 1989). A shorter form (83 items) of the ADAD intended for treatment outcome evaluation is also available.

Adolescent Problem Severity Index (APSI)
The APSI was developed by Metzger and colleagues (Metzger, Kushner, & McLellan, 1991) of the University of Pennsylvania/VA Medical Center. The APSI provides a general information section that addresses the reason for the assessment and the referral source, as well as the adolescent's understanding of the reason for the interview. Additional sections of the APSI include drug/alcohol use, family relationships, education/work, legal, medical, psycho/social adjustment, and personal relationships. Some concurrent validity for the alcohol/drug section has been empirically demonstrated (Metzger et al., 1991) and predictive validity evaluations are underway.

Comprehensive Addiction Severity Index for Adolescents (CASI-A)
The CASI-A is a structured interview developed by Meyers (1991). It covers several areas, including the following: 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 many major topics, there is space provided for the interviewer's comments, severity ratings, and ratings of the quality of the interviewee's answers. An interesting feature of this interview is that it incorporates results from a urine drug screen and observations from the interviewer. Psychometric studies on the CASI-A are being conducted by the author.

Teen Severity Index (T-ASI)
Another adolescent version of the ASI was adapted by Kaminer, Bukstein & Tarter (1991). The T-ASI 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 thought to be less relevant to adolescent drug abusers. Patient and interviewer severity ratings are rated on a 5-point scale for each of the content areas. Preliminary data indicate adequate interrater agreement and initial validity data (Kaminer, Wagner, Plummer, & Seifer, 1993).

Multi-Scale Questionnaires

Adolescent Chemical Health Inventory (ACHI)
The ACHI (Renovek, 1988) consists of 128 items that address use problem severity and several psychosocial factors. Some of the psychosocial scales measure family closeness, depression, alienation, family support, family chemical use and physical and sexual abuse. The ACHI additionally screens for defensiveness. The test is self-administered through use of a personal computer. Validity data collected for the ACHI indicate that the instrument is able to differentiate between adolescent drug abusers and non-abusers.

Adolescent Self-Assessment Profile (ASAP)
This self-administered, 225-item, multi-scale inventory (Wanberg, 1992) was developed on the basis of many variable research studies by Wanberg and colleagues. The instrument provides an in-depth assessment of drug involvement, including how often drug use occurs, the consequences and benefits of drug use, as well as the major risk factors associated with such involvement (e.g., deviance, peer influence). Supplemental scales, which 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 "normal" groups are provided in the manual.

Chemical Dependency Assessment Profile (CDAP)
This 232-item self-report questionnaire assess 11 dimensions of drug use, including expectations of use (e.g., drugs reduce tension), physiological symptoms, the amount used and how often the use occurs, and attitude toward treatment. A computer-generated report is provided. Limited normative data are available thus far on only 86 subjects (Harrell, Honaker & Davis, 1991).

Hilson Adolescent Profile (HAP)
The HAP consists of 310 true-false items that cover 16 scales, two 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 (Inwald, Brobst, & Morissey, 1986).

Juvenile Automated Substance Abuse Evaluation (JASAE)
The JASAE (ADE Inc. 1987) is a computer-assisted, 108-item (T/F) instrument that is based on a similar adult measure, the SALCE. The JASAE produces a 5 category score, ranging from no use to drug abuse (including a suggested DSM-IV classification), accompanied by a summary of drug use history. The instrument also includes a measure of life stress and a scale for test-taking attitude. The JASAE has been shown to discriminate clinical groups from nonclinical groups.

Personal Experience Inventory (PEI)
The PEI is a 276-item, multi-scale questionnaire that measures chemical involvement problem severity (10 scales), psychosocial risk (or protective) factors (12 scales), and the tendency for subjects to distort responses (5 scales). 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 clinical information. Extensive normative and psychometric data (including test-re-test reliability and convergent and predictive validity) are available (Winters & Henly, 1989; Winters, Stinchfiled & Henly, 1996).