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By Dr. Ken C. Winters
Director
Center for Adolescent Substance Abuse
University of Minnesota
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. Screening measures typically call for conservative scoring decisions. For example, terms such as "probable substance abuser" or "needs a comprehensive assessment" may be used to identify an individual's use. This is done in order to avoid the mistake of claiming that there is no substance use problem when in fact there is one. A screening tool's full value is appreciated when it is used to determine whether a more complete assessment is necessary and to decide upon the treatment needs of the individual.
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).
Diagnostic Interview for Children and Adolescents (DICA)
The DICA (Herjanic & Campbell, 1977; Reich, Herjanic, Welner, & Gandhy,
1982) is a 416-item interview that asks DSM-IV specific questions. Psychometric
evidence specific to substance use disorders has not been published on the DICA,
but some of the other sections have been evaluated for their reliability and
validity (Welner, Reich, Herjanic, Jung, & Amado, 1987).
Diagnostic Interview Schedule for Children (DISC-C)
This instrument has undergone several adaptations (e.g., Costello, Edelbrock,
& Costello, 1985; Shaffer, Schwab-Stone, Fisher, et al., 1993), and now
features a DSM-IV version (Shaffer, Fisher, & Dulcan, 1996). There are
separate forms of the interview for the parent and the child. As part of a
larger study focusing on several diagnoses, Fisher and colleagues (1993) found
the DISC-C to be highly sensitive in correctly identifying youth who had
received a hospital diagnosis of any substance use disorder (n=8). Both
interview forms had a sensitivity of 75%. For the one parent-child disagreement
case, the parent indicated that they did not know any details about their
child's substance use. Also, the DISC-C is associated with moderate test-retest
stability for substance use disorders (Kappa = .46) (Roberts, Solovitz, Chen,
& Casat, 1996), meaning that after testing and retesting, the same results
were found.
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).
Kiddie SADS (K-SADS)
This semi-structured interview is organized around Research Diagnostic Criteria
and adapted for young clients of the Schedule for Affective Disorders and
Schizophrenia (SADS) (Endicott & Spitzer, 1978). The data (which comes from
several sources) is then integrated into the most appropriate diagnosis. The
alcohol and drug questions are contained in the lifetime version of the
interview (K-SADS-E-5) (Orvaschel, 1995). The newest version incorporates
changes from the results from a test-retest reliability study (Puig-Antich &
Ryan, 1986). However, no psychometric data on the substance use disorder section
have been reported.
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).
Structured Clinical Interview for the DSM (SCID)
The SCID features a guided decision-free structure, in which interviewers
present questions word for word. Specific operational (technical) definitions
and severity criteria are presented for each symptom. Interviewers rate each
symptom as absent, subclinical, or clinically present. The SCID is widely used
to assess substance use disorders among adults, and has shown reliability in
field trials (e.g., Williams, Gibbon, First, et al., 1992). Martin and
colleagues (1995) modified the DSM-III-R version of the SCID (Spitzer, Williams,
& Gibbon, 1987) to assess DSM-IV substance-use disorders among adolescents.
Symptoms and diagnoses showed good validity, and preliminary analyses suggested
moderate to good reliability for this interview (Martin et al., 1995).
II. 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.
III. Several interviews for adolescents are adaptations of a well-known adult tool, the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O'Brien, 1980).
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).
IV. Paper and Pencil 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).
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