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 Consensus Panel recommends that everyone who works with youth in a community use the same screening instruments. One way to accomplish this would be for schools, child welfare agencies, human service agencies, and juvenile justice systems to establish an areawide coordinating committee for adolescent screening and assessment. The committee could review and select reliable, standardized screening and assessment tools so that all agencies serving the local adolescents and their families will use the same standardized measures. The committee could also establish consistent referral criteria and a communitywide definition of "high risk" for substance use disorders.

The Consensus Panel also recommends a communitywide interagency mechanism for coordination of screening, management of information systems, and training of screeners and other relevant professionals. Any such mechanism would have to conform to confidentiality regulations.

It is also advisable, if possible, for local communities to collect their own norms on the standardized instruments. It is important for local agencies to keep databases on local drug testing results for the particular purposes of needs assessment. This information can also be shared with other community facilities, but only if any information identifying the client is stripped.

Screeners must be especially careful when stating and storing information. To avoid labeling, they should report facts only, not opinions, and give only the information that is necessary to meet the client's treatment needs.

Assessment

The comprehensive assessment, which is based on initial screening results, has several purposes:

1. To accurately identify those youth who need treatment
2. 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)
3. To permit the evaluator to learn more about the nature, correlates, and consequences of the youth's substance-using behavior
4. 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)
5. 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
6. To identify specific strengths of the adolescent (e.g., coping skills) that can be used in developing an appropriate treatment plan
7. 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
   • 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.

It is critical to form a therapeutic alliance with the family to the fullest extent possible and to involve the family in the assessment process. If there is evidence that the adolescent is being abused at home, the family should still be questioned about the adolescent's substance use. Providers must, however, report child abuse (see Chapter 4).

The use of well-designed questionnaires and interviews can yield an accurate, realistic understanding of the teenager and the problems she is experiencing. Assessment instruments must have both validity and reliability.

Of great importance to the user is the author's description of how the instrument is to be administered, scored, and interpreted. Specific statements should include

• The purpose or aim of the test
• For whom the test is and is not appropriate
• Whether the test can be administered in a group or only on an individual basis
• Whether it can be self-administered or if it must be given by an examiner
• Whether training is required for the assessor and, if so, what kind, how much, and how and where it can be obtained
• Where the test can be obtained and what it costs

Once selected, the tests should be administered and scored in the manner recommended by the authors; no substitutions should be made for any test items and no items should be eliminated or modified. For structured interviews, the interview format and item wording should be strictly followed.

After the information from the different sources (interview, observation, specialized testing) has been assembled, the assessor writes a report of what he has learned about the adolescent in terms that can be understood by all concerned, including the adolescent. The report should deal with such issues as (1) the way the adolescent processes information most effectively and how this will affect treatment, (2) how the adolescent's past experiences will affect her reaction to certain treatment interventions, (3) specific treatment placement recommendations and justifications, and (4) counselor recommendations.

Assessment instruments should be selected on the basis of their purpose, content, administration, time required for completion, training needed by the assessor, how the instrument can be obtained, its cost, and persons to contact for further guidance. The two most important criteria in the evaluation of any measurement instrument are reliability and validity.

Legal Issues

Programs that specialize, in whole or in part, in providing treatment, counseling, and/or assessment and referral services for adolescents with substance use disorders must comply with the Federal confidentiality regulations (42 C.F.R. §2.12(e)).

Information that is protected by the Federal confidentiality regulations may always be disclosed after the adolescent has signed a proper consent form. (Parental consent must also be obtained in some States.) The regulations also permit disclosure without the adolescent's consent in situations such as medical emergencies, child abuse reports, program evaluations, and communications among staff.

Any disclosure made with written client consent must be accompanied by a written statement that the information disclosed is protected by Federal law and that the person receiving the information cannot make any further disclosure of such information unless permitted by the regulations (§2.32).

When a program that screens, assesses, or treats adolescents asks a school, doctor, or parent to verify information it has obtained from the adolescent, it is making a client-identifying disclosure that the adolescent has sought its services. The Federal regulations generally prohibit this kind of disclosure unless the adolescent consents.

Programs may not communicate with the parents of an adolescent unless they get the adolescent's written consent. The Federal regulations contain an exception permitting a program director to communicate with an adolescent's parents without her consent when

1. The adolescent is applying for services
2. The program director believes that the adolescent, because of an extreme substance use disorder or a medical condition, does not have the capacity to decide rationally whether to consent to the notification of her guardians
3. The program director believes the disclosure is necessary to cope with a substantial threat to the life or well-being of the adolescent or someone else

Other exceptions to the Federal confidentiality rules prohibiting disclosure regarding adolescents seeking or receiving substance use disorder services are

• Information that does not reveal the client as having a substance use disorder
• Information ordered by the court after a hearing
• Medical emergencies
• Information regarding crimes on program premises or against program personnel
• Information shared with an outside agency that provides service
• Information discussed among people within the program
• Information disclosed to researchers, auditors, and evaluators with appropriate Institutional Review Board review and approval to ensure the protection of program participants

Juvenile Justice Settings

Many adolescents entering the juvenile justice system (JJS) have substance use disorders. Many also have experienced or are experiencing

• Physical or sexual abuse
• Psychological and emotional problems
• Poor performance in school
• Family difficulties, which may include mental health problems, parental neglect, foster care placement, family involvement in criminal activity, and a history of substance use disorders by other family members, including current use, with or without the adolescent present
• Gang-related violence and involvement with drug sales, as well as other antisocial characteristics (e.g., vandalism)
• Living in neighborhoods where economic hardship, lack of employment opportunities, inadequate housing, and other factors related to poverty and low income have led to communitywide despair and hopelessness among adults as well as youth

The depth of the problems calls for a more holistic approach to the juvenile offender rather than the typical focus on individual crime episodes. A primary goal of substance use screening and assessment among juvenile offenders is to prevent their further involvement in the JJS. Thus screening and assessment should be repeated at different stages in the system (intake, preadjudication, and postadjudication) to detect changes over time in the pattern of substance use, related problem behaviors, and the need for services.

All juveniles entering a juvenile justice facility should receive an initial screening, risk assessment, and followup assessment, as indicated. Initial screening should be conducted within 24 hours of entry to the agency or facility. Screening and assessment activities may need to be completed over the course of several days for juveniles who are intoxicated, show symptoms of mental illness, are experiencing significant stress related to arrest or incarceration, or are not honestly disclosing information during an initial interview. Alternative screening and assessment measures should be developed to accommodate the needs of juveniles with limited reading skills and with physical disabilities.

When conducting screenings and assessments to determine patterns of use, programs should be aware of the youth's confinement status prior to testing. Periods of preassessment incarceration (e.g., pretrial detention) may skew results of recent use surveys. In recognition of the importance of early detection and intervention, rules for deciding how to interpret the results of initial screening should be designed to be overinclusive in identifying adolescents who may have substance use problems. In other words, it is better to identify more adolescents as having substance use problems than to be overly cautious and miss some.

Screening, assessment, and interviews should be conducted in a private room where the teenager feels safe and comfortable. The use of holding cells to conduct screening and assessment is not recommended.

All juvenile justice staff providing screening or assessment services should be trained in the following areas:

• Cultural sensitivity and competence
• Legal and ethical issues
• Administration, scoring, and interpretation of instruments
• Determination of reading abilities
• Interviewing techniques
• Report writing
• Interpersonal communication
• Counseling techniques
• Management of critical incidents
• Working collaboratively with the treatment community

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.

To help teenagers who have substance use disorders, the problem must first be identified. The members of both Consensus Panels for this TIP believe that health professionals, educators, and others who come into regular contact with adolescents have the obligation to use appropriate, effective, and respectful means to identify potential substance use problems among adolescents. Screening and assessment procedures must be followed by sensitive, direct treatment and interventions as indicated by the test results. This TIP offers practical guidance to accomplish these goals, supported by the research and the extensive clinical experience of the two Consensus Panels.