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date: 23 June 2018

Screening Substance Use and Misuse Among Middle and High School Students

Abstract and Keywords

This article provides an overview of screening adolescents for substance use, misuse, and substance use disorders. It covers the practical and empirical considerations when working with youth around issues of drugs and alcohol. Four reliable and valid screening tools are discussed: Alcohol Use Disorders Identification Test (AUDIT), CRAFFT, Rutgers Alcohol Problem Index (RAPI), and Problem-Oriented Screening Instrument for Teenagers (POSIT). The tools and techniques are drawn from evidence-based theoretical frames and practices, including close attention to the recent adolescent (Screening, Brief Intervention, Referral, and Treatment (SBIRT) resources.

Keywords: Screening, adolescents, drugs/alcohol, substance use, Screening and Brief Intervention Referral to Treatment (SBIRT), evidence-based practices, Alcohol Use Disorders Identification Test (AUDIT), CRAFFT, Rutgers Alcohol Problem Index (RAPI), Problem-Oriented Screening Instrument for Teenagers (POSIT)

Introduction

Screening for substance use disorders can be challenging due to the fact that both youth and families are often guarded about drugs and alcohol due to stigma, legality, and fear of labeling (Brener, Billy, & Grady, 2003). It is important to gather as much information as possible before determining a plan for any individual, especially a child or adolescent who may be volatile and inconsistent in their quest for identity. If the clinician is doing the screening and intake as well as the counseling, it is recommended that the adolescent be interviewed first. Then the parents should be interviewed with the client present. This helps to build trust that is critical in establishing rapport, otherwise known as the therapeutic alliance.

It is best if one is aware of the barriers that researchers warn can impede effective screening of adolescents regarding substance use. The most commonly identified barriers include insufficient time, lack of training in how to manage a positive screen, need to triage competing problems, lack of referral and treatment resources, determined parents who would not leave the room for a confidential discussion, and unfamiliarity with screening tools (Van Hook et al., 2007). It is important to note that providers reported they had enough time to administer a short screen but often had insufficient time to manage a positive result. One can glean the following recommendations from these findings: (a) carve out as much time as possible for the complexities of assessing adolescents, especially about substance use; (b) assure parents that better outcomes are likely if you get a chance to meet with their child without them in the room; and (c) become familiar with screening tools such as the ones noted in this article, as well as referral and treatment resources in your area. In preparation for such screening, referral sources, if not compiled by your agency or setting, should be obtained from local recovery-oriented systems of care (ROSC) groups. ROSCs were created by the Substance Abuse and Mental Health Services Administration (SAMHSA), and national establishment of ROSCs has become a Center for Substance Abuse Treatment (CSAT) priority (Sheedy & Whitter, 2013).

This article discusses the substance use/abuse screening methods that social work professionals can easily utilize, particularly in school settings. A summary table of screening tools developed particularly for the adolescent population is presented. Somewhat detailed information follows about four evidence-based screening instruments, Alcohol Use Disorders Identification Test (AUDIT), CRAFFT, Problem-Oriented Screening Instrument for Teenagers (POSIT), and Rutgers Alcohol Problem Index (RAPI), which are considered most efficient at school settings. This information covers how to administer the instruments and how to interpret the results. Finally, a case example is provided to demonstrate the techniques described in the article.

Substance users need help to become aware of their problems, explore possibilities for motivation for change, and determine change possibilities regarding substances during each screening procedure (Winters, 2001a). Social work professionals should remember to utilize their most astute clinical techniques to make successful initial contacts with potential substance users and refer them to suitable intervention programs.

The Nature of the Problem

A hallmark of the transition from childhood to adolescence is the increase in risk-taking behaviors (Nargiso, Friend, & Florin, 2013; Schulenberg, Bryant, & O’Malley, 2004; Windle et al., 2008). Alcohol continues to be the most commonly used drug among youth. For example, 2012 data from the Monitoring the Future (MTF) survey indicates that 72% of 12th graders (nearly three out of four) have tried alcohol, and 39% of 8th graders have reported some alcohol use in their lifetime (Johnston, O’Malley, Bachman, & Schulenberg, 2014).

Of greater concern is the widespread occurrence of episodes of drunkenness and binge drinking. The rates of self-reported drunkenness in the past 30 days were 5%, 14%, and 25% for grades 8%, 10%, and 12%, respectively, and the prevalence rates of binge drinking (occasions of consuming five or more drinks in a row in the previous two weeks) were 8%, 16%, and 25% for the three grades, respectively. The most recent MTF study (Johnston et al., 2014) notes that in 1981 41% of 12th graders reported having five or more drinks in a row on at least one occasion in the two weeks prior to the survey; thus, the recent two percentage-point increase to 24% in 2012 still leaves it well below peak levels of the 1980s.

The consequences of substance use are serious, costly, and extensive. Most substances have immediate physiological influences. They interfere with correct perception and rational judgment (McWhirter, McWhirter, McWhirter, & McWhirter, 2004). There is some evidence for intervening at the elementary level but equal effectiveness when implementing in middle schools (Marsiglia, Kulis, Yabiku, Nieri, & Coleman, 2011). It is well established that adolescents are more likely to be involved in risk-taking behaviors under the influence of substance(s). Not surprisingly, substance use often leads to fatal accidents and crime. Alcohol consumption, for instance, is a major cause of death among youth via motor vehicle accidents, homicides, suicides, and drowning (DHHS, 2000). Furthermore, heavy drinking and smoking often contribute to various diseases: cancer, heart disease, many liver-related diseases (DHHS, 2000), and sexually transmitted diseases, including HIV/AIDS (CDC, 2004). The economic costs of substance misuse in the United States were estimated to be $167 and $110 billion, respectively, in 1995 (DHHS, 2000). Substance use has particularly detrimental impacts on the mental health of adolescents. Newcomb and Bentler (1989) found that serious drug users are vulnerable to experience loneliness, depression, and suicide ideations. Youth often get into the vicious cycle of feeling uncomfortable, using substances to feel better, and then, ultimately, feeling more uncomfortable. Moreover, substance use hinders youth from accomplishing important developmental tasks, performing expected duties, and building healthy relationships with others. Previous studies have consistently indicated that substance use is significantly associated with poor educational outcomes and academic failure (Jeynes, 2002; National Commission on Drug-Free Schools, 1990), physical fights and criminal behavior (Kellam, Prinz, & Sheley, 2000), substance abuse, violence, suicidal thoughts, competence (Burrows-Sanchez, Lopez, & Slagle, 2008; Gunter & Bakken, 2010), aggression, delinquency (Lynne-Landsman, Graber, Nichols, & Botvin, 2011), gender and the justice system (Tarter, Kirisci, Mezzich, & Patton, 2011), and inadequate positive social connection (Havighurst, 1972). Also, distinctions are being made among adolescents from urban and rural communities (Lynne-Landsman et al., 2011; Dunn, Goodrow, Givens, & Austin, 2008) as well as the examination of substance use behavior and suicide indicators among rural middle school students (Dunn et al., 2008).

How Is Screening Different From Assessment and Diagnosis?

Before examining specific screening methods and procedures, it is necessary to understand the differences between screening, assessment, and diagnosis of substance use/misuse. The primary purpose of screening is to identify potential substance users who need a thorough assessment (Winters, 2001a). On the other hand, comprehensive assessment aims to verify substance use/abuse of an adolescent and reveal other relevant problems and service needs (Winters, 2001b). Diagnosis is carried out based on the most comprehensive measures or highly structured criteria such as those presented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Diagnosis is considered a more decisive conclusion compared to assessment. While assessment refers to “the process of gathering information,” diagnosis is defined as the “the conclusion that is reached on the basis of the assessment” (Fisher & Harrison, 2004, p. 84).

A comprehensive substance use/abuse assessment or diagnosis is best conducted by alcohol, tobacco, and other drug (commonly referred to as ATOD) specialists in general, and those involved in the intervention plan or treatment service in particular. Thus, it is recommended for social work professionals to provide screening services only, unless they have adequate training and qualification for substance use assessment and diagnosis (Fisher & Harrison, 2004). There have been significant advances in the science of understanding adolescent brain development and substance use disorders as brain disease. The science of drug testing has also advanced over the years, and parents and schools are more often considering random drug testing to support positive student decision making and not just for punitive purpose (Russell, Jennings, & Classey, 2005). Another major shift in the field is from a medical model, problem-focused stance to a strengths-based model. For example, instead of focusing on diagnosis, scare tactics, and problem identification, school clinicians work to create honest dialogues with students, noting decisional balance as a factor and promoting healthy lifestyles and choices. In line with this is a movement toward educating about recovery as well as substance abuse and addiction (Hutchinson, Ashcraft, & Anthony, 2006; Salm, Sevigny, Mulholland, & Greenberg, 2011).

Early Screening and Intervention

Although the detrimental consequences of adolescent substance use are immense, appropriate screening, referral, and treatment can significantly reduce the harmful effects (Winters, Latimer, & Stinchfield, 1999). Early intervention is considered especially desirable in terms of effectiveness and efficiency. The Consensus Panel for the Center for Substance Abuse Treatment (CSAT) recommends that all adolescents showing any sign of substance use be properly screened (Winters, 2001a). Thus, professionals who work with at-risk youth must have screening resources and expertise so that the adolescents can receive more comprehensive assessment and intervention services (Winters, 2001a). Since adolescents spend a large amount of time at school, the role of school mental health professionals in identifying youth with potential substance use disorders at earlier stages and providing them with intervention opportunities cannot be overemphasized.

Theoretical Foundations

Stage of Readiness to Change

One approach to addressing screening for youth substance use, misuse, and disorders is utilizing the stage of change model. The stage of change model has become an influential perspective in the area of substance abuse (Becan, Knight, Crawley, Joe, & Flynn, 2015). Most of the early research on stage of change and substances has been done on smoking, which has established that stage of change is absolutely related to current smoking patterns, with individuals in the preparation stage smoking fewer cigarettes, reporting less dependence, and making more quit attempts. Individuals at later stages of change also express more self-efficacy to abstain, and stage of change has been found to predict success at follow-up (Prochaska, DiClemente, & Norcross, 1992). Pallonen (1998) broadened the model to adolescents, finding that adolescents and adults were remarkably similar in the transtheoretical measures, and, except for the processes of change, both groups exhibited similar behavior at different stages of the smoking cessation process. The research also found that adolescent smokers were generally less prepared to quit than adults were. Stage of change was related to quit attempts, although adolescents used behavioral methods, as well as cognitive-experiential processes, in the transition from contemplation to preparation.

Historically, professionals believed intervention was possible with adolescent substance misusers only if they had sufficient awareness and willingness to consider and pursue abstinence. However, with the stage of change model predomination in the field, interventions have fortunately shifted toward targeting “where the client is” and working with the adolescent at whatever stage of readiness he or she presents (i.e., precontemplation, contemplation, preparation, and action) (Prochaska & DiClemente, 2005).

Response to Intervention (RTI) Framework

Academic and behavioral difficulties in the school setting often go hand in hand with middle school and high school student drug and alcohol use and misuse. It is important that school educators, administrators, counselors, and stakeholders consider the nexus of academic performance and substance behaviors for a holistic and complete picture of the students’ risk, protective factors, areas of concern, and action plans. For effective and successful intervention and prevention strategies with regard to drugs and alcohol, one can utilize the response to intervention (RTI) model (Sprague, Cook, Browning-Wright, & Sadler, 2008), which provides guidance for proper screening and assessment to examine students’ substance abuse risk, evidence of early warning signs, and relevance in public education with respect to evaluations and referrals. Once youth are assessed for their need for universal, selected, or indicated services, the proper services and resources can be sought, as illustrated in Figure 1 (Sprague & Walker, 2004–2005).

Screening Substance Use and Misuse Among Middle and High School StudentsClick to view larger

Figure 1. The response to intervention (RTI) model

This RTI model also notes the value of screening with consideration of the person in their environment or context. Research supports the importance of culturally appropriate prevention and intervention approaches for youth (Holleran Steiker, Goldbach, Hopson, & Powell, 2011). When screening, it is critical to consider cultural aspects, including age appropriateness, linguistic differences, comprehensive and critical thinking abilities, spirituality, and client ethnicity. Attention should be given to strengths and the biopsychosocial-spiritual aspects of the individual/family (Graybeal, 2001), as these realms have all been shown to be relevant to substance abuse behaviors and choices. School workers are also advised to consider the age and developmental stage of students who are being screened or assisted.

SBIRT (Screening, Brief Intervention, and Referral to Treatment)

To recognize warning signs early, there is a recent trend toward integrating alcohol and drug screening and education in primary care settings. A federally funded screening program, including brief interventions and referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the SAMHSA in a wide variety of medical settings. SBIRT is defined as “a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk” (Babor et al., 2007, p. 7). The limited evidence from SBIRT outcome research with adolescents suggests that brief interventions may be effective with youth, but several gaps in the literature were identified (Mitchell, Gryczynski, O’Grady, & Schwartz, 2013). This evidence-based method has been used in emergency rooms, but findings are still not definitive as to whether the motivational interviewing brief intervention techniques using motivational interviewing (MI) were effective with young adults. In fact, according to Mitchell et al. (2013), there have been six large random-assignment studies of adolescent patients (age range 12 to 21) in urban U.S. emergency departments (EDs). None of these found significant group differences in reducing drinking or binge drinking at any of their follow-up interviews at 3, 6, or 12 months for groups assigned to MI-based brief interventions compared to assessment only (Bernstein et al., 2010; Maio et al., 2005; Spirito et al., 2011; Walton et al., 2010).

There were few adolescent substance use screenings conducted in primary care clinics, schools, and other community settings, and none addressed referral to treatment. Thus, there is a need for additional research to fill these gaps in the evidence base. It is theoretically sound that pediatricians provide early, relationship-based assessment for substances along with other health oriented areas including healthy sexual behavior choices (e.g., teen pregnancy prevention, HPV vaccines, etc.). However, in the Annals of Internal Medicine, Patenode et al. (2014, p. 612) reviewed all recent research and found that the body of evidence was small and included mostly adolescents without substance use problems. They conclude that “evidence is inadequate on the benefits of primary care–relevant behavioral interventions in reducing self-reported illicit and pharmaceutical drug use among adolescents.” However, it is clear that more research is needed in this area.

The Council on Social Work Education (CSWE) is presently partnering with the Hilton Adolescent SBIRT Project and Learning Collaborative, creating resources and modules to educate practitioners in the most effective ways to utilize SBIRT techniques with adolescents, and the online modules will be available in 2016 for social workers (see http://sbirt.webs.com/). To learn more and see some of the role plays, case studies, tools, simulations, and other resources, see http://www.sbirteducation.com/.

Who Needs to Be Screened?

As substance use is quite prevalent among American youth, and many of them are diverge from the stereotypes of ATOD users, school social workers and school counselors need to be always aware that the possibility of a substance use problem exists when they are providing any kind of service to students. Ideally, screenings for substance use/abuse would be done universally with all students. However, given limited resources and inadequate numbers of school mental health professionals, it would be more desirable to focus on screening students at risk for substance use/abuse or showing some indication of possible substance use.

An effective way to identify potential substance users for screening is to utilize a multidisciplinary team including classroom teachers. Because classroom teachers spend much time with students and have many opportunities to observe student behaviors directly, they can make a significant contribution to problem identification (Gonet, 1994). School social workers and drug counselors can encourage participation of teachers in case identification procedures and enhance the quality of information reported by the teachers, using a form specially designed to easily detect substance use among students.

In addition to middle and high school settings, the National Institute on Health recommends that substance screening be conducted in the following health and community settings as well: schools, primary care, emergency departments, prenatal care, criminal justice system, and collegiate populations (Bonnie, Stroud, & Breiner, 2015).

Setting the Stage for Effective Screening

At the beginning of the screening process, it is very important to spell out the policy of confidentiality and the limits or exceptions to it. Many adolescent clients (and some of the younger ones) may arrive at the screening interview without their parents. Still, collateral data should be obtained if possible. Screening the whole family together provides important information, protects the counselor legally, and can be therapeutic if done with compassion, care, and consistency. It is important to assess techniques and directions on a case-by-case basis. For example, if the youth has been physically or sexually abused, and the clinician is aware of it, the parents (if they are the perpetrators) should not be interviewed in the standard fashion. Having the parents present may even put the child at risk. In other cases, as with runaway or homeless youth, identified parents are not always available. There are exceptions such as runaway and/or homeless youth for who identified parents are not always available. In such cases, in fact, it can put the child at risk if parents are involved. When counseling with an adolescent in the presence of his or her parents, clinicians should make it clear that whatever the client says in individual counseling will be held strictly confidential unless his or her health, safety, or security is at risk. During this same meeting, counselors should advise the parents, in front of the client, that the parents’ verbalizations will be held confidential as well.

Self-Report Screening Instruments for Adolescents

Although there are various approaches available, self-report screening instruments are commonly used to identify ATOD problem among adolescents (Martin & Winters, 1998). Using standardized instruments has some advantages: such methods reduce potential bias and are less likely to threaten students than other methods (Winters, 2001a); and it makes mental health professionals more likely to be perceived as trustworthy (Orenstein, Davis, & Wolfe, 1995). If school mental health professionals plan to use self-report screening instruments, the biggest challenge is selecting the best instrument in a given situation. Fortunately, many screening instruments for the adolescent population have been developed in recent years, and now there is a wide range of appropriate instruments. Since the characteristics of the instruments are very diverse, school mental health professions are advised to check the qualities, cost, and required conditions of the instruments thoroughly before choosing one. The POSIT and RAPI are especially recommended for school mental health professionals considering low cost, copyright, easy access, and psychometric traits of the instruments. Thus, these instruments are presented as exemplars along with AUDIT and CRAFFT, a behavioral health screening test whose acronym stands for Car, Relax, Alone, Forget, Friends, Trouble.

AUDIT

Brief Description

The AUDIT is an international screening instrument extensively employed in adult target groups. However, it is often used for screening in adolescent populations (see Figure 2).

Screening Substance Use and Misuse Among Middle and High School StudentsClick to view larger

Figure 2. AUDIT

Developed by the World Health Organization (WHO) in 1982, AUDIT is a simple way to screen and identify individuals at risk of alcohol problems (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). AUDIT was developed and evaluated over a period of two decades, and it has been found to provide an accurate measure of risk across gender, age, and cultures. As the first screening test designed specifically for use in primary care settings, AUDIT has the following advantages:

  • Cross-national standardization: AUDIT was validated on primary healthcare patients in six countries. It is the only screening test specifically designed for international use.

  • Identifies hazardous and harmful alcohol use, as well as possible dependence.

  • Brief, rapid, and flexible.

  • Designed for primary healthcare workers.

  • Consistent with ICD-10 definitions of alcohol dependence and harmful alcohol use.

  • Focuses on recent alcohol use.

Format and Administration

This 10-question, brief screening instrument can be administered with a client verbally by a clinician or self-administered on paper. The AUDIT focuses on drinking patterns and alcohol-related behaviors.

Scoring and Interpretation

Each of the answers to the question are attributed a certain number of points (see AUDIT screening instrument attached). Add up the points associated with answers. A total score of 8 or more indicates harmful drinking behavior, which warrants further assessment and intervention. Research supports use of AUDIT for adolescents ages 14 to 18, with cut points of 2 for identifying any alcohol problem use and 3 for alcohol abuse or dependence (Knight, Sherritt, Harris, Gates, & Chang, 2003).

Research Findings and Psychometric Properties

A sample of adolescents and young adults (N = 103, 55 males), ranging in age from 12 to 20.9 years (mean [SD] age = 17.5 [2.1]), completed AUDIT. Confirmatory factor analyses were conducted using LISREL 8.20 software to test the one-factor, two-factor, and three-factor solutions for AUDIT reported in the literature. Findings support those of others who have reported that AUDIT assesses a consumption factor and an alcohol-related problems factor among primary care patients at risk for problematic drinking behavior (Kelly & Donovan, 2001). Another study examined the utility of the AUDIT as a screening measure for identifying young adolescents in an urban emergency departments (EDs) (Fairlie, Sindelar, Eaton & Spirito, 2006). Adolescents (13–17 years old) who presented to the ED were screened; 859 adolescents who denied alcohol use prior to their ED visit were administered AUDIT. Of the 500 younger adolescents (13–15 years old), approximately 4% (n = 22) were classified as AUDIT-positive using a cut-score of 4 or greater. Of the 359 older adolescents (16–17 years old), almost 19% (n=67) were classified as AUDIT-positive. The ability of shorter versions of AUDIT to identify AUDIT-positive adolescents (as classified by the 10-item AUDIT using a cut-score of 4 or greater) was also explored. Since the adolescents in the current study were not alcohol-positive at the time of the ED visit, they would likely have been missed by biochemical alcohol screening alone. Screening procedures that employ AUDIT may be most efficient when adapted for the specific adolescent age group (younger versus older), thus identifying the highest number of adolescents who should be targeted for intervention.

In another study, a total of 42 female and 53 male adolescents (mean age: 15.9 [SD=1.2]) completed AUDIT, with a mean score of 4.3. Reliability according to Cronbach’s alpha was 0.83. Test-retest correlation was also satisfactory (intraclass correlation 0.81 [95% CI 0.73–0.87]). Analysis of the receiver operating characteristic (ROC) curve yielded cutoff points for hazardous, harmful, and dependent alcohol use of 3, 5, and 7 points, respectively.

AUDIT is a valid and reliable tool for identifying adolescents with hazardous, harmful, and dependent alcohol use. Lowering the recommended adult cut-scores on the shorter versions of AUDIT appears necessary to identify adolescents who may benefit from intervention or referral (Knight et al., 2003). The suggested cutoff points make screening with AUDIT more accurate for adolescent populations.

Application of the Instrument

This screening tool is specifically designed to assess alcohol use and misuse. AUDIT identifies not just profoundly harmful drinkers but also hazardous drinkers who have not yet reached that level of harm. As drinkers at an earlier stage may respond better to interventions aimed at reducing their consumption, AUDIT is preferable to other alcohol screens in clinical practice.

CRAFFT

Brief Description

CRAFFT (see Table 1) is a well-supported behavioral health screening tool for use with children under the age of 21 and is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents. It was developed by modifying promising questions from longer screens and has a conservative outcome, being that responses qualify with “ever.” CRAFFT screens for drugs as well as alcohol. It was designed by researchers who combined similar questions on longer assessment tools and then determined the concurrent validity to identify the best questions for identifying adolescents who need substance use disorder treatment (Knight et al., 1999).

Table 1. CRAFFT

During the past 12 months, did you:

1. Drink any alcohol (more than a few sips)?

2. Smoke any marijuana?

3. Use anything else to get high?

(“Anything else” includes illegal drugs, over-the-counter and prescription drugs, inhalants, etc.)

C Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

A Do you ever use alcohol or drugs while you are by yourself, ALONE?

F Do you ever FORGET things you did while using alcohol or drugs?

F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

T Have you ever gotten into TROUBLE while you were using alcohol or drugs?

The sensitivity of CRAFFT is similar to the longer AUDIT and POSIT tests (Knight et al., 2003. CRAFFT works equally well for alcohol and drugs, for boys and girls, for younger and older adolescents, and for youth from diverse racial and ethnic backgrounds. It is proven to be much more accurate and effective than the historically utilized CAGE, which lacks validity with adolescents.

Format and Administration

CRAFFT is a mnemonic acronym comprised of the first letters of each of the critical questions. However, screening using CRAFFT begins by asking the adolescent to “Please answer these next questions honestly,” reminding him/her of your office confidentiality policy, and then by asking the following opening questions.

Scoring and Interpretation

If the adolescent answers “no” to all three opening questions, the provider only needs to ask the adolescent the first question—the CAR question. If the adolescent answers “yes” to any one or more of the three opening questions, the provider asks all six CRAFFT questions. Each “yes” response to the CRAFFT questions is scored 1 point. Adolescents who report no use of alcohol or drugs and have a CRAFFT score of 0 should receive genuine but not overly exaggerated praise and encouragement. Those who report any use of alcohol or drugs and have a CRAFFT score of 0 or 1 should be encouraged to stop and receive brief advice regarding the adverse health effects of substance use. A score of 2 or greater is a “positive” screen and indicates that the adolescent is at high-risk for having an alcohol or drug-related disorder and requires further assessment.

Research Findings and Psychometric Properties

CRAFFT has adequate psychometric properties for detecting alcohol and/or substance use disorders in adolescents. Researchers studying CRAFFT report 11 studies on validity and six studies on reliability (Dhalla, Zumbo, & Poole, 2011) with a variety of relevant populations. In general, CRAFFT was found to be a good screening instrument for gradations of alcohol and substance misuse, flagging mild, moderate, and severe substance use disorders. At optimal cut-points, the sensitivities of CRAFFT ranged from 0.61 to 1.00, and specificities ranged from 0.33 to 0.97. CRAFFT showed modest to adequate internal consistency values ranging from 0.65 to 0.86 and high test-retest reliability. More studies of the psychometric properties of CRAFFT need to be carried out to further assess and improve generalizability to other populations. Gender and ethnic differences also require further examination, as do versions that are adapted for different languages and cultures.

Application of the Instrument

CRAFFT is an excellent starting place for clinicians due to its brevity and validity with youth populations. However, the limited number of questions on CRAFFT may make it more difficult to measure varied and more specific risk factors and outcomes (Christie et al., 2007). Because it is simple, professionals can memorize the screening tool and work it into early sessions with youth and families to determine whether or not to refer the client to substance use assessment and intervention experts.

POSIT

Brief Description

POSIT (see Table 2) is one of the most widely used instruments for adolescent substance use/abuse. It was developed by the National Institute on Drug Abuse (NIDA) to identify potential problems and service needs of adolescents aged 12 to 19 years. It is one of the more extensive screening tools and therefore takes more time, but it yields more information than the simple CRAFFT inquiry tool. It is composed of 139 yes/no questions under the following 10 subscales: Substance Use and Abuse; Physical Health Status; Mental Health Status; Family Relations; Peer Relations; Educational Status; Vocational Status; Social Skills; Leisure and Recreation; and Aggressive Behavior and Delinquency.

Table 2. POSIT

The purpose of these questions is to help us choose the best way to help you, so please try to answer the questions honestly.

Please answer all the questions. If a question does not fit you exactly, pick the answer that is most true.

You may see the same or similar questions more than once. Please just answer each question as it comes up.

Please put an “X” through your answer.

If you do not understand a word, please ask for help.

You may begin.

1. Do you have so much energy you don’t know what to do with it?

YES

NO

2. Do you brag?

YES

NO

3. Do you get into trouble because you use drugs or alcohol at school?

YES

NO

4. Do your friends get bored at parties when there is no alcohol served?

YES

NO

5. Is it hard for you to ask for help from others?

YES

NO

6. Has there been adult supervision at the parties you have gone to recently?

YES

NO

7. Do your parents or guardians argue a lot?

YES

NO

8. Do you usually think about how your actions will affect others?

YES

NO

9. Have you recently either lost or gained more than 10 pounds?

YES

NO

10. Have you ever had sex with someone who shot up drugs?

YES

NO

11. Do you often feel tired?

YES

NO

12. Have you had trouble with stomach pain or nausea?

YES

NO

13. Do you get easily frightened?

YES

NO

14. Have any of your best friends dated regularly during the past year?

YES

NO

15. Have you dated regularly in the past year?

YES

NO

16. Do you have a skill, craft, trade, or work experience?

YES

NO

17. Are most of your friends older than you?

YES

NO

18. Do you have less energy than you think you should?

YES

NO

19. Do you get frustrated easily?

YES

NO

20. Do you threaten to hurt people?

YES

NO

21. Do you feel alone most of the time?

YES

NO

22. Do you sleep either too much or too little?

YES

NO

23. Do you swear or use dirty language?

YES

NO

24. Are you a good listener?

YES

NO

25. Do your parents or guardians approve of your friends?

YES

NO

26. Have you lied to anyone in the past week?

YES

NO

27. Do your parents or guardians refuse to talk to you when they are mad at you?

YES

NO

28. Do you rush into things without thinking about what could happen?

YES

NO

29. Did you have a paying job last summer?

YES

NO

30. Is your free time spent just hanging out with friends?

YES

NO

31. Have you accidentally hurt yourself or someone else while high on alcohol or drugs?

YES

NO

32. Have you had any accidents or injuries that still bother you?

YES

NO

33. Are you a good speller?

YES

NO

34. Do you have friends who damage or destroy things on purpose?

YES

NO

35. Have the whites of your eyes ever turned yellow?

YES

NO

36. Do your parents or guardians usually know where you are and what you are doing?

YES

NO

37. Do you miss out on activities because you spend too much money on drugs or alcohol?

YES

NO

38. Do people pick on you because of the way you look?

YES

NO

39. Do you know how to get a job if you want one?

YES

NO

40. Do your parents or guardians and you do lots of things together?

YES

NO

41. Do you get As and Bs in some classes and fail others?

YES

NO

42. Do you feel nervous most of the time?

YES

NO

43. Have you stolen things?

YES

NO

44. Have you ever been told you are hyperactive?

YES

NO

45. Do you ever feel you are addicted to alcohol or drugs?

YES

NO

46. Are you a good reader?

YES

NO

47. Do you have a hobby you are really interested in?

YES

NO

48. Do you plan to get a diploma (or already have one)?

YES

NO

49. Have you been frequently absent or late to work?

YES

NO

50. Do you feel people are against you?

YES

NO

51. Do you participate in team sports which have regular practices?

YES

NO

52. Have you ever read a book cover to cover for your own enjoyment?

YES

NO

53. Do you have chores that you must regularly do at home?

YES

NO

54. Do your friends bring drugs to parties?

YES

NO

55. Do you get into fights a lot?

YES

NO

56. Do you have a hot temper?

YES

NO

57. Do your parents or guardians pay attention when you talk with them?

YES

NO

58. Have you started using more drugs or alcohol to get the effect you want?

YES

NO

59. Do your parents or guardians have rules about what you can and cannot do?

YES

NO

60. Do people tell you that you are careless?

YES

NO

61. Are you stubborn?

YES

NO

62. Do any of your best friends go out on school nights without permission from their parents or guardians?

YES

NO

63. Have you ever had or do you now have a job?

YES

NO

64. Do you have trouble getting your mind off things?

YES

NO

65. Have you ever threatened anyone with a weapon?

YES

NO

66. Do you have a way to get to a job?

YES

NO

67. Do you ever leave a party because there is no alcohol or drugs?

YES

NO

68. Do your parents or guardians know what you really think or feel?

YES

NO

69. Do you often act on the spur of the moment?

YES

NO

70. Do you usually exercise for a half hour or more at least once a week?

YES

NO

71. Do you have a constant desire for alcohol or drugs?

YES

NO

72. Is it easy to learn new things?

YES

NO

73. Do you have trouble with your breathing or with coughing?

YES

NO

74. Do people your own age like and respect you?

YES

NO

75. Does your mind wander a lot?

YES

NO

76. Do you hear things no one else around you hears?

YES

NO

77. Do you have trouble concentrating?

YES

NO

78. Do you have a valid driver’s license?

YES

NO

79. Have you ever had a paying job that lasted at least 1 month?

YES

NO

80. Do you and your parents or guardians have frequent arguments which involve yelling and screaming?

YES

NO

81. Have you had a car accident while high on alcohol or drugs?

YES

NO

82. Do you forget things you did while drinking or using drugs?

YES

NO

83. During the past month have you driven a car while you were drunk or high?

YES

NO

84. Are you louder than other kids?

YES

NO

85. Are most of your friends younger than you are?

YES

NO

86. Have you ever intentionally damaged someone else’s property?

YES

NO

87. Have you ever stopped working at a job because you just didn’t care?

YES

NO

88. Do your parents or guardians like talking with you and being with you?

YES

NO

89. Have you ever spent the night away from home when your parents didn’t know where you were?

YES

NO

90. Have any of your best friends participated in team sports which require regular practices?

YES

NO

91. Are you suspicious of other people?

YES

NO

92. Are you already too busy with school and other adult supervised activities to be interested in a job?

YES

NO

93. Have you cut school at least 5 days in the past year?

YES

NO

94. Are you usually pleased with how well you do in activities with your friends?

YES

NO

95. Does alcohol or drug use cause your moods to change quickly like from happy to sad or vice versa?

YES

NO

96. Do you feel sad most of the time?

YES

NO

97. Do you miss school or arrive late for school because of your alcohol or drug use?

YES

NO

98. Is it important to you now to get or keep a satisfactory job?

YES

NO

99. Do your family or friends ever tell you that you should cut down on your drinking or drug use?

YES

NO

100. Do you have serious arguments with friends or family members because of your drinking or drug use?

YES

NO

101. Do you tease others a lot?

YES

NO

102. Do you have trouble sleeping?

YES

NO

103. Do you have trouble with written work?

YES

NO

104. Does your alcohol or drug use ever make you do something you would not normally do like breaking rules, missing curfew, breaking the law, or having sex with someone?

YES

NO

105. Do you feel you lose control and get into fights?

YES

NO

106. Have you ever been fired from a job?

YES

NO

107. During the past month, have you skipped school?

YES

NO

108. Do you have trouble getting along with any of your friends because of your alcohol or drug use?

YES

NO

109. Do you have a hard time following directions?

YES

NO

110. Are you good at talking your way out of trouble?

YES

NO

111. Do you have friends who have hit or threatened to hit someone without any real reason?

YES

NO

112. Do you ever feel you can’t control your alcohol and drug use?

YES

NO

113. Do you have a good memory?

YES

NO

114. Do your parents or guardians have a pretty good idea of your interests?

YES

NO

115. Do your parents or guardians usually agree about how to handle you?

YES

NO

116. Do you have a hard time planning and organizing?

YES

NO

117. Do you have trouble with math?

YES

NO

118. Do your friends cut school a lot?

YES

NO

119. Do you worry a lot?

YES

NO

120. Do you find it difficult to complete class projects or work tasks?

YES

NO

121. Does school sometimes make you feel stupid?

YES

NO

122. Are you able to make friends easily in a new group?

YES

NO

123. Do you often feel like you want to cry?

YES

NO

124. Are you afraid to be around people?

YES

NO

125. Do you have friends who have stolen things?

YES

NO

126. Do you want to be a member of any organized group, team, or club?

YES

NO

127. Does one of your parents or guardians have a steady job?

YES

NO

128. Do you think it’s a bad idea to trust other people?

YES

NO

129. Do you enjoy doing things with other people your own age?

YES

NO

130. Do you feel you study longer than your classmates and still get poorer grades?

YES

NO

131. Have you ever failed a grade in school?

YES

NO

132. Do you go out for fun on school nights without your parents’ or guardians’ permission?

YES

NO

133. Is school hard for you?

YES

NO

134. Do you have an idea about the type of job or career that you want to have?

YES

NO

135. On a typical day, do you watch more than 2 hours of TV?

YES

NO

136. Are you restless and can’t sit still?

YES

NO

137. Do you have trouble finding the right words to express what you are thinking?

YES

NO

138. Do you scream a lot?

YES

NO

139. Have you ever had sexual intercourse without using a condom?

YES

NO

Format and Administration

The original POSIT is a paper-and-pencil questionnaire. Recently, a CD-ROM version became available. It can be self-administered or administered during an interview in a variety of settings including schools. No specific qualification is necessary for administration.

Scoring and Interpretation

POSIT can be scored and interpreted in two different ways, using either the original or the new scoring system. In the original scoring system, questions are classified as general, age-related, or red-flag items. While every point-earning answer to general items adds one risk score in each subscale, the answer to age-related items does only for the teenagers in a specified age range. Either any point earning in red-flag items or expert-based cutoff score in a subscale is interpreted as an indication for further assessment or service in the problem area. In the new scoring system, however, red-flag items are not taken into account, and the total score of each subscale is used to determine the level of risks in the area.

Research Findings and Psychometric Properties

The internal consistency of POSIT varies across the subscales and different studies. Some subscales, such as substance use/abuse, mental health, and aggressive behavior/delinquency exhibit high levels of internal consistency, while others such as leisure/recreation, vocational status, and physical health show lower levels of internal consistency than conventionally acceptable ranges. However, it should be noticed that the Cronbach’s alpha for the substance use/abuse subscale has been identified as high, ranging from 0.77 (Knight, Goodman, Pulerwitz, & DuRant, 2001) to 0.93 (Melchior, Rahdert, & Huba, 1994). Acceptable levels of test–retest reliability also have been reported (Dembo, Schmeidler, & Henly, 1996; McLaney & Boca, 1994). All the subscales of POSIT have successfully differentiated heavy substance users from nonusers, showing good concurrent differential validity (Melchior et al., 1994). In a study (McLaney & Boca, 1994) in which POSIT was compared with the Personal Experience Inventory (PEI), Diagnostic Interview for Children and Adolescents (DICA), and the Adolescent Diagnostic Interview (ADI), POSIT also showed both convergent and divergent validity.

Application of the Instrument

Based on prior empirical studies, POSIT is a recommended screening instrument especially for substance use/abuse problems among adolescents. One of the advantages of POSIT lies in its comprehensiveness. The screening results with POSIT can identify potential problems in various areas rather than assessing substance use problems only. Such comprehensiveness might help mental health professionals make better referrals for further assessment or necessary services based on various needs of the adolescents. Easy administration and cost effectiveness are also considerable benefits of POSIT. In addition, POSIT is in the public domain and can be easily obtained at no cost by contacting NIDA, the National Clearinghouse for Alcohol and Drug Information, or by visiting the website of the National Institute on Alcohol Abuse and Alcoholism.

RAPI

Brief Description

RAPI (see Table 3) is a simple, unidimensional screening tool for problem drinking. Its target populations are adolescents and young adults aged 12 to 21 years. The researchers at the Center of Alcohol Studies, Rutgers University, developed RAPI in 1989 to create an efficient and conceptually sound instrument to assess problem drinking among adolescents. This instrument has been validated on nonclinical as well as clinical samples.

Table 3. RAPI

None

1–2 Times

3–5 Times

More Than 5 Times

HOW MANY TIMES HAS THIS HAPPENED TO YOU WHILE YOU WERE DRINKING OR BECAUSE OF YOUR DRINKING DURING THE LAST YEAR?

0

1

2

3

Not able to do your homework or study for a test

0

1

2

3

Got into fights with other people (friends, relatives, strangers)

0

1

2

3

Missed out on other things because you spent too much money on alcohol

0

1

2

3

Went to work or school high or drunk

0

1

2

3

Caused shame or embarrassment to someone

0

1

2

3

Neglected your responsibilities

0

1

2

3

Relatives avoided you

0

1

2

3

Felt that you needed more alcohol than you used to in order to get the same effect

0

1

2

3

Tried to control your drinking (tried to drink only at certain times of the day or in certain places, that is, tried to change your pattern of drinking)

0

1

2

3

Had withdrawal symptoms, that is, felt sick because you stopped or cut down on drinking

0

1

2

3

Noticed a change in your responsibility

0

1

2

3

Felt that you had a problem with alcohol

0

1

2

3

Missed a day (or part of a day) of school or work

0

1

2

3

Wanted to stop drinking but couldn’t

0

1

2

3

Suddenly found yourself in a place that you could not remember getting to

0

1

2

3

Passed out or fainted suddenly

0

1

2

3

Had a fight, argument, or bad feeling with a friend

0

1

2

3

Had a fight, argument, or bad feeling with a family member

0

1

2

3

Kept drinking when you promised yourself not to

0

1

2

3

Felt you were going crazy

0

1

2

3

Had a bad time

0

1

2

3

Felt physically or psychologically dependent on alcohol

0

1

2

3

Was told by a friend, neighbor, or relative to stop or cut down drinking

Currently Available Mean Scores of RAPI

Clinical Sample

N

Mean

Nonclinical Sample

N

Mean

14–16 year old males

42

23.3

14–16 year old males

151

7.5

14–16 year old females

19

22.2

14–16 year old females

147

5.9

17–18 year old males

43

21.1

17–18 year old males

211

8.2

17–18 year old females

15

26.0

17–18 year old females

208

7.4

Different things happen to people while they are drinking ALCOHOL or because of ALCOHOL drinking. Several of these things are listed below. Indicate how many times each of these things happened to you WITHIN THE LAST YEAR.

Use the following code:

0 = None

1 = 1–2 times

2 = 3–5 times

3 = More than 5 times

Format and Administration

RAPI is composed of 23 items describing alcohol-related problems or symptoms. The original version of RAPI asks respondents how many times they experienced each problem during the last three years and provides five answer categories for each question: none, 1 to 2 times, 3 to 4 times, 6 to 10 times, and more than 10 times. A later version of RAPI asks respondents the same questions, but the time frame was reduced to the previous year for greater specificity. The number of answer categories was also reduced to four, ranging from “none” to “more than five times.” RAPI is a self-administered paper-and-pencil-type instrument, but it can be easily administered also in an interview format if preferable or necessary. No special training is required for administration.

Scoring and Interpretation

Scoring of RAPI is simple. If the number assigned to each answer category is added, it forms a total scale score. It should be noted, however, that the last two answer categories of the original version of RAPI need to be combined, and three need to be assigned. Therefore, the total scores of both the original and the later version of RAPI range from 0 to 69. The total score indicates the level of problem drinking. The necessity for further assessment can be made based on the norms available. According to the most recent data provided by the RAPI developers, the mean scores for clinical sample range from 21 to 26, while those for nonclinical sample range from 5.9 to 8.2, depending on gender and age. Specific information about RAPI mean score is exhibited in Table 3.

Research Findings and Psychometric Properties

The 23-item RAPI resulted from factor analyses conducted on a nonclinical sample of 1,308 adolescents. Its internal consistency measured was 0.92, and test–retest with a three-year period marked 0.40 (White & Labouvie, 1989). RAPI has showed high correlation levels with the Adolescent Alcohol Involvement Scale (AAIS), the Alcohol Dependence Scale (ADS), DSM-III, and DSM-III-R (greater than 0.70), indicating good convergent validity. In addition, RAPI can differentiate seriously problematic drinkers from less problematic drinkers in adolescence.

Application of the Instrument

As a screening instrument for adolescents, RAPI has several merits. First, it is efficient. Its administration and scoring procedures are simple and require only 15 minutes or less (10 minutes for administration and 3 to 5 minutes for scoring). It is in the public domain, and no cost is necessary. Second, RAPI has high utility. It can be used for nonclinical as well as clinical samples. Third, all the RAPI items are worded appropriately for teenage students and are easy to understand. Fourth, it can be used for various purposes. Based on RAPI scores, for example, service referral can be done properly, and the effectiveness of the intervention program for adolescent drinkers can be evaluated. Furthermore, according to the scale developers, it is possible to use RAPI to assess all types of substance use problems. The only thing necessary is to use proper words for the substance instead of “alcohol” or “drinking.” RAPI has also some limitations. Most notably, there is no clear cutoff point based on which adolescents with a drinking problem and adolescents without a problem can be classified. Another limitation is that RAPI measures only one problem area (e.g., alcohol use/abuse). Considering previous studies that have consistently found that substance use/abuse problems are complicated and related to many other areas, it would be more desirable to use RAPI with other instruments for more accurate screening or comprehensive assessment.

Conclusion

This article aims to provide awareness of the scope and repercussions of adolescent substance use, directions for choosing and utilizing a screening tool especially in school settings, and an example of a screening scenario. Tools including the teacher’s behavioral checklist, AUDIT, CRAFFT, POSIT, and RAPI are evidence-supported, reliable, simple instruments for gathering information that can help school mental health professionals determine if an adolescent needs more intensive substance-related referral and triage. It is important to note, however, that screening tools, no matter how comprehensive, cannot elicit definitive diagnoses and will not be likely to fully capture the nature of an adolescent’s relationship to substances. Because adolescents almost always hide their use due to fear, shame, and a desire to maintain the option to use substances, workers must be gentle, creative, and tenacious (Holleran Steiker, 2016). The critical data lie in the rapport built between worker and student. To do the effective work of drawing out the facts, building connection with the individual, and putting the pieces together, a worker can utilize motivational interviewing techniques described in other areas of this book (for information, trainings, and publications, see the MI website http://www.motivationalinterview.org).

It is important to remember that adolescent substance use/abuse can be profoundly injurious mentally, emotionally, socially, and physically. In fact, it can be potentially fatal and should not be minimized as a “passing phase.” Workers do best to err on the conservative side and, if concerns arise, to consult with and/or refer the student to a substance abuse expert.

Additional Resources

The Alcohol and Drug Abuse Institute at the University of Washington has an extensive substance use screening and assessment instruments database. They note that this resource is intended to help clinicians and researchers find instruments used for screening and assessment of substance use and substance use disorders. It should be noted that some instruments are in the public domain and can be freely downloaded from the Web; others can only be obtained from the copyright holder. This can be accessed with this link: http://lib.adai.washington.edu/instruments/.

Additionally, there are a number of online trainings approved by the National Institute of Health that can help enhance practitioners’ skills in this area. For example, youth alcohol screening training can be accessed at http://www.medscape.org/viewarticle/806556. Access to the CME course External Web Site Policy requires a username and password, which users can set up for free at https://login.medscape.com/login/sso/getlogin?ac=401.

Further Reading

Erickson, C. K. (2011). Addiction essentials: The go-to guide for clinicians and patients. New York: W. W. Norton & Company.Find this resource:

Leukefeld, C. G., Gullotta, T. P., & Staton-Tindall, M. (2009). Adolescent substance abuse: Evidence-based approaches to prevention and treatment. New York: Springer.Find this resource:

Naar-King, S., & Suarez, M. (2011). Motivational interviewing with adolescents and young adults. New York: Guilford Press.Find this resource:

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