Assessment of Substance Abuse among Teenagers: Review of Instruments Commonly Used in Healthcare and Research
Bivin J.B.1, Riaz KM2
1Staff Nurse Gr II, Mental Health Centre, Thiruvananthapuram, KL-695005
2Assistant Professor, Government College of Nursing, Thrissur, KL-680596, INDIA
*Corresponding Author Email: bivin.jb@gmail.com, riazmarakkar@gmail.com
ABSTRACT:
Effective and structured appraisal of substance abuse among teenagers is crucial for clinical research, planning of therapeutic and preventive measures, and provision of referral services. Despite advances in methodology and instrumentation, the assessment of adolescent substance abuse remains a complex clinical and practical process. It requires the careful and skillful application of measures across a wide range of service systems and providers such as school and clinical settings. In this article authors discuss the commonly used formalized assessment instruments for substance abuse among teenagers. There are plenty of substance abuse related assessment tools are available in the western literature. However, no published studies from India reported any standardized instruments on substance abuse among adolescents. This warrants a need for developing culturally sensitive measures on substance abuse among adolescents in India considering the extensive problem of substance abuse among teen population.
KEYWORDS: Substance Abuse, Adolescents, assessment.
INTRODUCTION:
Substance use disorders among teenagers are a major public health problem facing in India as many other countries globally.1The Global Youth Tobacco Survey2 in 2006 showed that 3.8% of students smoke and 11.9% currently used smokeless tobacco. Tobacco as a gateway to other drugs of abuse has been the topic of a symposium.3 A study4 of 300 street child laborers in slums of Surat in 1993 showed that 135 (45%) used substances. The substances used were smoking tobacco, followed by chewable tobacco, snuff, cannabis and opioids. Injecting drug use5 is also becoming apparent among street children as are inhalants.6 A study in the Andaman7 shows that onset of regular use of alcohol in late childhood and early adolescence is associated with the highest rates of consumption in adult life, compared to later onset of drinking.
Substance abuse intrudes children’s normal development and places them at higher risk for physical, emotional and mental health problems.8Adolescent drug abuse is associated with mental and physical5 health problems, poor school performance, violence, juvenile justice system involvement, and increased risk of developing an addictive disorder in adulthood.9 When confronted with an adolescent suspected of or acknowledged to have a substance abuse problem, it is important to integrate the assessment process with treatment decisions.10 The initial phase involves efficient identification of substance use and related problems, psychiatric co morbidity, and psychosocial maladjustment.11 This can be achieved by the use of screening instruments as a brief first step for the valuation of drug use before moving, if necessary, to the second step of comprehensive assessment of problem severity once it becomes clear that the adolescent may meet criteria for a substance use disorder.12The result of this assessment is a diagnostic conclusion that identifies the adolescent treatment needs. Despite advances in methodology and instrumentation, the assessment of adolescent drug and alcohol involvement remains an intricate clinical and practical process.13, 14 it requires the careful and skillful execution of procedures across a wide range of service systems and providers. Plentiful reviews illustrate the need for suitable adolescent assessment; argue for application of standardized measures, and overview a variety of adolescent- based tools.15 subsequently, for this review, we have carried out a systematic web-based review of the available instruments for assessing substance abuse among teenagers and adolescents. The instruments included in this paper are based on the previously published reviews16-19 and publications available in the internet. Authors conducted a detailed search using the instrument name in the Google for its recent revisions and any updates in psychometric properties available in the literature. The evaluation tools are organized into three broad categories: screening instruments, mid-range assessment instruments and comprehensive assessment instruments as done in the previously published review papers.16 Though the distinctions are somewhat arbitrary, they are made based on amount of time needed to administer and how many of the basic areas necessary for treatment are actually measured.
SCREENING INSTRUMENTS:
Substance Abuse Screening Instrument (SASI):
The SASI is a 15-item questionnaire with 3 forms, based on items taken from the Client Substance Index (CSI).20 It yields a single score, which, with cut-offs, categorizes the respondent's severity of substance involvement. SASI is in its early stages of development.16
Personal Experience Screening Questionnaire (PESQ): 21
PESQ is a 40-item questionnaire designed to identify those who need comprehensive evaluation from among unselected (e.g. school-based) samples of teenagers. It yields a single score which if above cutoff identifies the need for evaluation, and includes items on drug use frequency and psychosocial problems.22 The validation study of the PESQ found that an empirically derived cutoff score yielded an overall agreement rate of positives and negatives of 87% in predicting independently derived judgments by clinicians of the client’s need for further drug abuse assessment.”23
CRAFFT Screener:24
· C: Have you ever ridden in a car driven by someone (including yourself) who was “high” or using alcohol or drugs (AOD)?
· R: Do you use AOD to relax, change your mood, feel better about yourself, or fit in?
· A: Do you ever use AOD while you are by yourself, alone?
· F: Has any friend, family member, or other person ever thought you had a problem with AOD?
· F: Do you ever forget (or regret) things you did while using?
· T: Have you ever got into trouble while using AOD, or done something you would not normally do (break the law, rules, or curfew; engage in risky behavior to you or others)?
Based on a study in a large hospital-based adolescent clinic, together with pediatric settings, scores from the CRAFFT were found to be well prognoses the presence of a substance abuse or addiction diagnosis. When evaluated in a general pediatric setting, a cut off score of ≥2 correctly classified in 86% of cases whether the youth did or did not have a current substance abuse or dependence disorder.25
Adolescent Drinking Index (ADI):
The ADI consists of 24-items with two types of multiple-choice response formats. It is suitable as a non-clinical sample screen (e.g. classroom), but is primarily intended to screen for alcohol abuse in teenagers referred for psychological, emotional or behavioral problems.26 It yields a single scale score with cutoffs, as well as 2 subscale scores which are intended as research scales. Internal consistency coefficients across adolescent samples are uniformly high, exceeding .90. The cutoff score has an 82% accuracy rate, and the ADI correlates .60 to .63 with the Michigan Alcoholism Screening Test (MAST).27
Drug and Alcohol Problem Quick Screen (DAP Quick Screen):
This 30-item screening questionnaire, written at the sixth grade reading level, has a yes/no/uncertain response format. DAP-QS Assesses substance use relationships with parents and parents' use of alcohol, tobacco, and other substances. The DAP was tested in a pediatric setting, in which the authors report that about 15% of the respondents said yes to 6 or more items. From this, they decided the cut-off score for "problem" drug use to be inclusive of 6 or more responses of yes to the items on the scale.28 the items contribute to the score, though the validity and reliability of this test are not available.
Adolescent Drug Involvement Scale (ADIS):
The ADIS is a 13-item multiple response questionnaire that is modified from Adolescent Alcohol Involvement Scale (AAIS).29-30 Responses to each item are weighted, leading to a single score. All items measures the aspects of drug use. A final item asks for use frequency estimates of various types of drugs. It measures drug involvement in a continuum, ranging from no use to severe dependence. This measurement is in public domain and the validity details can be obtained elsewhere.31
Rutgers Alcohol Problem Index (RAPI): 32
The RAPI consists of 23 items associated with problem drinking. The adolescent is asked to indicate "how often each event has happened while they were drinking or as a result of drinking", responding on a 5-point likert-scale. It was developed on an unselected community sample, so may be appropriate for school-based screening. It yields a single measure and no use estimates. RAPI has a reliability of 0.92 and a 3-year stability coefficient of 0.40. The advantages of this short, self-administered screening tool are its ease of administration and its standardization, which make it possible to compare problem drinking scores across groups.33
Cannabis Abuse Screening Test (CAST):
This six-item scale screens for different aspects of harmful cannabis use by assessing the frequency of the following events throughout an individual's lifetime (never, rarely, sometimes, quite often, and often): seemingly non-recreational use (smoking alone or before midday), memory disorders, being encouraged to reduce or stop using cannabis, unsuccessful attempts to quit, and problems linked to cannabis consumption.34 The CAST appears to be one-dimensional and have high internal consistency (Cronbach's alpha =0.81). Among cannabis users who are low alcohol consumers, CAST presents very high sensitivity and specificity compared with the POSIT. The CAST seems to be an efficient tool in order to screen for cannabis use disorders among teenagers and young adults.35
Fagerstrom Test for Nicotine Dependence (FTND):
The Fagerstrom Test for Nicotine Dependence36 contains six items that evaluate the quantity of cigarette consumption, the compulsion to use, and dependence. It is useful as a screen for nicotine dependence and as a severity rating that can be used for treatment planning and prognostic judgments. The brevity and easy scoring of the FTND make it an efficient way to obtain clinically meaningful information. It can also be incorporated into general health and lifestyle screening questionnaires in clinical and nonclinical settings. A modified version37 of this instrument is available by including a modified set of adult symptoms for teenagers to address graded levels of smoking behaviour, avoidance of the physiological effects of nicotine deprivation, and perceived difficulty refraining when prevented from smoking. The FTND is sometimes also called the FTCD (Fagerstrom Test for Cigarette Dependence). The FTND has good test–retest reliability, convergent validity, and discriminate validity. Internal consistency was better for the FTND than for the FTQ.38
RAFFT Screener:
The RAFFT is a five-question instrument developed for screening adolescent substance use disorders (SUD).39,40 In a recent study,41 the RAFFT performed well in teenagers with SUD, in an acute psychiatric setting, with sensitivity and specificity of 89% and 69% with two positive answers. The questions of the RAFFT (relax, alone, friends, family, trouble), appear to tap into common themes related to adolescent substance use, such as peer pressure, self-esteem, anxiety, and exposure to friends and family members who are using drugs or alcohol.
RUFT-Cut:
The RUFT-Cut is a 5-item screening instrument based on selected items from the AUDIT42 (2 items), CRAFFT24 (2 items), and CAGE43 (1 item), that shows promise in helping emergency department personnel quickly identify older teenagers who are in need of intervention or further evaluation. The RUFT-Cut questions are:
· Riding with an intoxicated driver
· being Unable to stop drinking
· Family, friends, health care worker showing concern
· getting into Trouble while drinking
· Feeling the need to Cut-down.
Two items use a 5-point scale and the other three uses a 0-1 scale. The RUFT-Cut was most efficient at a cut-score of 3 in the original study.44 The RUFT-Cut performed as well as the full scale AUDIT (sensitivity = 82%, specificity = 78 %), and performed significantly better than the CAGE for identifying AUD and non-AUD participants.45
Substance Abuse Subtle Screening Inventory (SASSI):
The SASSI46 is a brief self-report, easily administered psychological screening measure that is available in separate versions for adults (SASSI-3) and teenagers (SASSI-2). The SASSI includes both face valid and subtle items that have no apparent relationship to substance use. The subtle items are included to identify some individuals with alcohol and other drug problems who are unwilling or unable to acknowledge substance misuse or symptoms associated with it. This instrument is especially helpful in inpatient and outpatient settings, including criminal justice, employee assistance, educational, mental health, medical, and vocational. The SASSI for adults consists of 93 items; for teenagers, 100. Each test is available in pencil-and-paper self-administered, computer self-administered and optical scanning version, or via web-based administration. It takes approximately 10-15 minutes to administer and can be administered by support staff. Reliability studies have been done using test-retest measures. Validity studies have also been done, using measures of criterion (predictive, concurrent, "post-dictive").47
Drug Abuse Screening Test (DAST):
The Drug Abuse Screening Test (DAST) 48 was designed to provide a brief instrument for clinical screening and treatment evaluation research. The 28 self-report items tap various consequences that are combined in a total DAST score to yield a quantitative index of problems related to drug misuse. A modified version on DAST for its usage in adolescent population is available in the literature.49 The DAST-A demonstrated good internal consistency, high test-retest reliability, unidimensional factor structure, and good concurrent validity. DAST-A scores of greater than 6 yielded sensitivity, specificity, and positive predictive powers of 78.6%, 84.5%, and 82.3%, respectively, in differentiating adolescent psychiatric in patients with and without drug-related disorders.50
MID-RANGE ASSESSMENT INSTRUMENTS:
Client Substance Index (CSI):
The CSI 51 is a structured interview in three sections: 19 items on type and frequency of substance use, 105 yes/no items, and 3 short answer questions. Besides yielding use frequency estimates of alcohol and several substances, it yields only one score on a single dimension ranging from "no problem," to "at- risk,"“misuse," "abuse,”, and "dependency."Measures: "no substance problem" to "substance dependency" The hypothetical dimension ranging from "no problem" to "dependency" is theoretically sound and very well developed in the CSI.20 Cut-off scores yield categorizations, which hold up well in comparison to judgments made by counselors after thorough evaluation. The CSI has the advantage of being integrated with several other instruments in a comprehensive case management system.45
Drug Use Screening Inventory-Revised (DUSI-R): 52
The DUSI-R measures severity of problems in 10 domains: (1) substance abuse, (2) psychiatric disorder, (3) behaviour problems, (4) school adjustment, (5) health status, (6) work adjustment, (7) peer relations, (8) social competency, (9) family adjustment, and (10) leisure/recreation. It documents drug and alcohol use, preferred substance, and substance with which users report the greatest problem. The DUSI-R also contains a "lie scale," used for reliability purposes to ensure honesty in the respondents or identify inconsistencies within the responses. The DUSI-R is available in three formats: pencil-and-paper self-administered; interview; and computer-based self-administered. The self-administered versions require at least a fifth-grade reading level. The DUSI-R has 159 items and takes approximately 20-40 minutes to administer. Reliability studies have been done on the DUSI-R using test-retest, split half, and internal consistency measures. Validity studies have also been done, using measures of content, criterion (predictive, concurrent, “post-dictive”), and constructs.53
Problem-Oriented Screening Instrument for Teenagers (POSIT):
The POSIT is a 139-item questionnaire with a yes/no response format. It is a refined version of the DUSI.54 It is designed to identify teenagers who may possibly have problems suggesting specific assessment. It yields measures on 10 areas-a combined chemical use measure and 9 measures of areas which may be problematic.
Measures:
1. Substance Use/Abuse
2. Physical Health
3. Mental Health
4. Family Relationships
5. Peer Relationships
6. Educational Status
7. Vocational Studies
8. Social Skills
9. Leisure/Recreation
10. Aggressive Behavior
The psychometric properties of the POSIT is well established in the literature.55, 56
Teen-Addiction Severity Index (T-ASI):
The T-ASI is a semi-structured interview requiring 30-45 minutes for administration. It yields 70 ratings in seven domains: chemical use, school status, employment/support status, family relations, peer/social relationships, legal status, and psychiatric status.57 It found to be good; inter-rater reliability has been R=.78.58
Assessment of Chemical Health Inventory (ACHI) - Adolescent version:
The ACHI contains 128 questions to which the teenager responds on a 5- point scale ranging from “strongly agree" to "strongly disagree". It has a paper-and-pencil format and a computer format for direct entry of responses by the respondent. Norming procedures appear to make it suitable for a wide range of settings, from un-referred school settings to treatment-program entry. It yields an overall score representing which is designed to place the teen within a continuum of alcohol and/or drug use-abuse dependency. It yields scores on 9 other dimensions associated with chemical misuse.16 Discriminate validity was found to be good (test accurately discriminated between teenagers diagnosed as substance abusers and those who were not). Analysis of variance indicated no age, sex, race, or religious differences significantly affecting the ACHI scores.17
Comprehensive Assessment Instruments:
Adolescent Diagnostic Interview (ADI):
The ADI systematically assesses psychoactive substance use disorders in 12- to 18-year-olds. Based on DSM-III-R criteria, this convenient structured interview also evaluates psychosocial stressors, school and interpersonal functioning, and cognitive impairment. In addition, it screens for specific problems commonly associated with substance abuse.59 The ADI is unique among the comprehensive batteries in that it yields a psychiatric diagnosis of psychoactive substance use disorder. The psychometric evaluation of ADI is mentioned elsewhere.60,61
Prevention Intervention Management System (PMES):
The PMES is a 150-item structured interview and questionnaire designed to evaluate teenagers already identified and in treatment for substance abuse.62 The first part, the Client Intake Form, yields qualitative information on demographics, family background, school and legal problems, and drug and alcohol use history .The second part is a 95-item questionnaire yielding several measures (Below table) in each of three main areas: family relations, peer activity, and self- esteem and satisfaction.
Measures:
|
1. Family Relations |
2. Peer Activity |
3. Self-Esteem and Satisfaction |
|
Control Consistent Parenting Conflict Trust and Understanding Care and Support Affiliation |
Peer Activity Level Peer’s Legal Involvement |
Self-Esteem |
Inter-rater agreement of the PMES is good63 but in-depth validity estimation is lacking in the literature.
Personal Experiences Inventory (PEI):
It is a comprehensive instrument that covers all substances and related problems. PEI consists of two parts, the Chemical Involvement Problem Severity (CIPS) section and the Psychosocial (PS) section. It provides a list of critical items that suggests areas in need of immediate attention by the treatment provider and summarizes problems relevant for planning the level of treatment intervention.64
Measures:
|
Section I: Chemical Involvement Problem Severity |
Section II: Psychosocial Section |
|
Basic Scales |
Personal Adjustment Scales b. Psychological Disturbance |
It measures most of the relevant dimensions for drug and alcohol abuse treatment; it yields frequency of use but not quantity of use estimates for various types of substances. Reliability as reported is adequate, but the validity work on the numerous scales is uneven, though generally adequate for its intended use. It has been used in a variety of settings.65-67
Adolescent Drug Abuse Diagnosis (ADAD):
The ADAD is a 150-item semi structured interview suitable for making treatment planning decisions for teenagers identified as having a drug or alcohol problem. It yields composite scores on drug and alcohol use and on 6 other life areas.68 it provides structured ways of obtaining the interviewer's severity ratings in each of the composite areas, and a way of collecting uses frequency information. Psychometric properties of the ADAD are available in the western literature.69, 70
CONCLUSION:
Authors reviewed a few recent Indian studies reporting the prevalence of substance abuse among teenagers. Many reviewed articles were done among teenagers who were either admitted to a hospital71-73 or in community settings.74-78. All these studies adopted a survey method and do not describe about any structured screening instrument either they have devised and adopted. Survey method was adopted in studies which estimated the prevalence of substance abuse among street children in India.79-84 School-based prevalence studies also failed to explain the instruments used in their research in detail.77, 85-94 Screening instrument used in global studies by WHO was adopted in a few studies,85,86 while some other studies report peer-reviewed instruments used in their studies very vaguely77,80 This review warrants an immediate need for a culturally sensitive instrument measuring the substance related issues among teenagers in India. Assessing adolescent substance use is a multifaceted clinical and practical challenge faced by various health care professionals. Because problem identification, triage and referral, level-of-care decisions, treatment provision, and treatment outcome are predicated upon an adequate evaluation of the assets and liabilities the youth brings to an intervention setting, multidimensional, comprehensive assessment using standardized measures is necessary at various stages of the evaluation procedure incorporating the cultural elements to which the health care system serve.
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Received on 29.06.2016 Modified on 18.07.2016
Accepted on 28.08.2016 © A&V Publications all right reserved
Asian J. Nur. Edu. and Research.2017; 7(2): 248-254.
DOI: 10.5958/2349-2996.2017.00052.0