Screening and assessing adolescent substance use disorders in clinical populations (2008)

When faced in a clinical setting with an adolescent suspected of or known to have a substance abuse problem, it is important to integrate the assessment process with treatment decisions. The initial phase involves efficient identification of substance use and related problems, psychiatric comorbidity, and psychosocial maladjustment. This objective can be achieved by the use of screening instruments as a brief first step for the assessment 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 (SUD). The result of this assessment is a diagnostic summary that identifies the adolescent treatment needs. Finally, an integrative treatment plan is developed to target multidimensional areas of dysfunction, which includes psychiatric comorbidity, as well as potential problems in the school, family, peer, and legal domains. With 6.0% and 5.4% of youths ages 12 to 17 years classified as needing treatment for alcohol use and illicit drug use, respectively, and with substance use during adolescence appearing to lead to a much greater rate of a current SUD compared to rates if drug use occurs later in life, these are important public health issues.
Reports on performance of pediatricians who customarily see youths for periodic checkups and address their medical needs have not been encouraging. Less than half of the pediatricians surveyed reported screening adolescents for use of tobacco, alcohol, and other drugs, and less than one fourth acknowledged feeling comfortable conducting a comprehensive assessment or offering or making referral for treatment. The reasons for these troubling figures have been summarized as follows: insufficient time, lack of training to manage positive screens, need to triage competing medical problems, lack of treatment resources, unfamiliarity with screening tools, and tenacious parents (who may not readily leave the room).
There are no similar reports addressing how prepared child and adolescent psychiatrists (CAPs) are to follow the task at hand. Based on our own clinical and teaching experience, the quantity and quality of training devoted to the screening and assessment of youth substance use, abuse, and dependence in medical schools and psychiatric residency/fellowship training are often insufficient. Little, if any, training is given on how to screen and assess for substance involvement and related problems and on what tools are available to assist with this process. Therefore, the objectives of this column are, first, to introduce several established screeners and comprehensive assessments, and, second, to make recommendations as to standards of training and professional proficiency. [Extract]