ASA8285 - SECTION 4: ASSESSING AND DIAGNOSING ADOLESCENT ALCOHOL AND OTHER DRUG USE
Difficulties of Assessing Adolescent Alcohol and Other Drug Use
Assessing substance abuse in adolescents is difficult because most adolescent AOD use does not fit the traditional adult-based models of abuse or dependence. The American Psychiatric Association’s DSM-IV (1994) has established criteria for alcohol and substance abuse and dependence.
1. Alcohol abuse and substance abuse are defined as a maladaptive pattern of use with one or more symptoms (failure to fulfill major role obligations, use in physically hazardous situations, recurrent substance related legal problems, and continued use despite social or interpersonal problems) within a 12 month period.
2. Alcohol dependence and substance dependence are defined as a maladaptive pattern of substance use leading to clinically significant distress as manifested by three or more symptoms (tolerance; withdrawal; increased use; inability to control use; large amount of time spent in obtaining and recovering from use; reduction in important social, occupational, or recreational activities; and continued use despite recurrent physical or psychological problems) within a 12 month period.
In the DSM-IV, the symptoms of abuse and dependence are treated as being mutually exclusive and there is an implied hierarchy with dependence being more serious. However, studies of adolescents do not generally support the conclusion that abuse symptoms always precede dependence (Chung, Colby, Barnett, Rohsenow, Spirito, & Monti, 2000). The research shows that between 10%-30% of adolescents evidence one or two of the dependence symptoms and none of the abuse symptoms, meaning they do not have the necessary symptoms for either diagnosis (Winters, 2001).
Additionally, there are several symptoms that are not typically experienced by adolescents including withdrawal symptoms and significant AOD-related medical problems and other criteria such as hazardous use (especially driving under influence) that tend to be evidenced only in older adolescents and adults (Martin & Winter, 1998).
The American Academy of Pediatrics (1996) recommends using a different standard in diagnosing adolescent AOD use. They advocate a developmental perspective seeing adolescent AOD use along a severity continuum from:
2. Experimental use (minimal use typically associated with recreational activities often limited to alcohol use)
3. Early abuse (more established use often involving more than one drug, greater frequency, and adverse consequences begin to emerge)
4. Abuse (regular and frequent use over an extended period and several adverse consequences emerge)
5. Dependence (continued regular use despite repeated severe consequences, signs of tolerance, and adjustment of activities to accommodate drug-seeking and drug use)
6. Recovery (return to abstinence)
This continuum differentiates between two types of abuse as separate from addiction. Both early abuse and abuse are characterized by degrees of frequent use and adverse consequences, whereas dependence includes signs of tolerance and adjustment of activities to accommodate drug-seeking and drug use. When these criteria are used, what is often found is a heterogeneous group of youth who use alcohol and other drugs (primarily marijuana) at varying levels and on irregular schedules, some of who may meet abuse criteria (but not necessarily with any temporal stability).
While care should be exercised in not applying inappropriate criteria in diagnosing and treating adolescent AOD use, there are circumstances where adolescent AOD use is especially problematic and may require immediate intervention including:
1. The use of some drugs (e.g. crack cocaine) is sufficiently dangerous that by itself, and in the absence of any other personal consequences or diagnostic symptoms, is a cause for intervention.
2. Making age distinctions is important in that any regular use in a child or very young adolescent (e.g., 12 or 13 years old or younger) may be a warning flag for further drug involvement so that these individuals should be referred for early intervention.
3. Prolonged use of intermediate quantities of drugs or acute ingestion of large quantities of drugs at any age is sufficiently risky for adolescents that such behavior probably justifies intervention.
4. Use in particularly inappropriate settings (e.g., prior to driving or during school hours) may be considered abuse even in the absence of the overtly negative consequences of such use and it makes no sense to delay intervention until the person advances to more serious consequences such as getting expelled from school, involved in an automobile accident, or arrested.
5. In the event that an ambiguous pattern of risky substance use exists, intervention is warranted when the individual has experienced significant negative social or psychological effects of use.
6. Most controversial is the situation in which AOD use and consequences are absent, but several AOD use risk factors are present such as a family history of AOD addiction, drug involvement by older siblings, presence of conduct disorder or ADHD, or other risk markers and whether education or intervention is justified based just on their criteria.
Assessing Co-morbid Psychiatric and Social Problems
Substance abuse problems rarely occur in isolation. Issues related to school performance, family and peer functioning, psychiatric and psychological status, physical health, and delinquency are widely cited as factors that can predispose, precipitate, or perpetuate the use of AOD by adolescents. The term “dual diagnosis” or “co-morbid” describes the co-existence of a mental disorder with an AOD use problem.
Psychiatric disorders in childhood can cause an increased risk for the development of AOD abuse for adolescents. The research generally shows that co-morbidity rates for adolescents are similar as those for adults and are the norm among adolescents with AOD use problems (White, White, & Dennis, 2004). However, the disturbing fact is that more than 7 out of 10 adolescents who suffer from mental health problems are receiving no services for their problems (Dryfoos, 1997).
The most prevalent psychiatric co-morbidity in adolescents with AOD abuse is conduct disorder - with rates of 50% to almost 80% - and mood disorders - with rates of 24% to 50% for depressive disorders and 7% to 40% for anxiety (Zeitlin, 1999). Although attention-deficit, hyperactivity disorder (ADHD) is commonly reported in substance using and abusing adolescents, the observed association in most cases is likely due to the high level of co-morbidity between conduct disorder and ADHD.
Adolescents with AOD abuse also show high rates of psychotic disorders (particularly schizophrenia or bipolar mood disorder) and personality disorders (particularly cluster B which includes narcissistic and borderline personality disorders). Adolescents with AOD abuse also have high rates of learning disabilities.
The relationship between the adolescent AOD use and psychiatric disorders can occur in a number of different ways including:
1. Psychiatric symptoms or disorders developing as a consequence of substance use or abuse
2. Psychiatric disorders altering the course of substance use or abuse
3. Substance abuse altering the course of psychiatric disorders
4. Psychopathology, both in the individuals and their families, as a risk factor for the development of substance abuse
5. Substance abuse and psychopathology originating from a common vulnerability (from co-morbidity and adolescent substance abuse (Bukstein, 2001).
In about 75% of the cases, the onset of psychopathology precedes the development of AOD abuse (Kaminer, 2004).
Assessment Procedures and Instruments
Therefore, a thorough assessment is required in order to ensure an appropriate treatment plan to meet the needs of the adolescents with AOD use problems, as well as dually diagnosed adolescents (Kaminer, 2004; Tarter, 1990). A thorough assessment and treatment planning should include:
- Patterns of alcohol and other substance use
- Behavior patterns (i.e., running away, violence, self-destructive behavior)
- Health status and any medical problems
- Presence of psychiatric disorders
- Social skills
- The family system
- School adjustment
- Peer relationships
- Work history and relationships
- Leisure/recreational interests
- Problems with legal authorities
Assessment can be improved by obtaining collateral information from parents, school officials, and other independent sources (Winters, Latimer, & Stinchfield, 1999).
It is best to use standardized assessment instruments with demonstrated reliability and validity (Farrow, Smith, & Hurst, 1993). The most commonly used instruments available to measure adolescent AOD use are:
1. Personal Experience Short Questionnaire (PESQ)
2. Adolescent Drinking Index (ADI)
3. Adolescent Drug Involvement Scale (ADIS)
4. Client Substance Index (CSI)
5. Personal Experience Inventory (PEI)
6. Adolescent Diagnostic Interview (ADI)
7. Drug Use Screening Inventory—Revised (DUSI-R)
8. Problem Oriented Screening Instrument for Teenagers (POSIT)
9. Adolescent Drug Abuse Diagnosis (ADAD)
10. Customary Drinking and Drug Use Record (CDDR)
11. Teen-Addiction Severity Index (T-ASI)
The most commonly used diagnostic instruments for youth psychopathology are:
1. Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS)
2. Diagnostic Interview Schedule for Children (DISC)
The Institute of Medicine’s report on the Adolescent Assessment/Referral System developed by the National Institute on Drug Abuse recommends a three-phase assessment process. The initial screening phase involves identification of health disorders, psychiatric problems, and psychosocial maladjustment.
Based on this first phase, a minority of adolescents are required to go through a second phase, which includes an extensive assessment necessary for initiating integrated, problem-focused, and comprehensive treatment. This assessment provides a diagnostic summary which identifies the adolescent’s treatment needs within specific life domains, such as AOD use, psychiatric status, physical health status, school adjustment, vocational status, family function, peer relationships, leisure and recreational activity, and legal situation. The third phase involves the preparation and implementation of an integrative treatment plan (Kaminer, 2004).