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Adolescent Substance Use Screening Instruments: 10-Year Critical Review of the Research Literature
Over ten million teenagers in the United States admit in a national survey that they drink alcohol, although it is illegal under the age of 21 in all states. In some studies, nearly one-quarter of school-age children both smoked cigarettes and drank alcohol. Over four thousand adolescents every day try marijuana for the first time. The dangers of use, abuse and dependency on each of these substances have been established. When we also consider that these three substances are considered gateway drugs, that is, drugs whose use is likely to lead to experimentation with "hard" drugs, the potential problem of such widespread use is even more severe. Additionally, use of these substances is known to co-occur with a number of other psychiatric conditions as well as health issues such as the incidence of sexually-transmitted diseases, unwanted pregnancies and fetal alcohol syndrome babies.
Given the magnitude of the issue, it is essential that clinics, schools, juvenile detention centers and medical clinics have screening instruments at hand that quickly and accurately evaluate potential or present abuse or dependency conditions in the populations they serve. This paper is intended to serve as a listing of the most up-to-date instruments available, a brief description of the applicability of each, and a review of the critical literature that evaluates their respective reliability and validity.
Adolescent Substance Use Screening Instruments: 10-Year Critical Review of the Research Literature
The Adolescent Alcohol and Other Drug
AAOD) Problem: An Overview
The History of AAOD
Consequences of AAOD
Constellation of Symptoms Making
Co-Occurring Psychiatric Illnesses
AAOD Epidemiological Research
Screening for AAOD Use: Its
Relevance to the Problem
Other Risk Factors in AAOD Use
Use of DSM Criteria in Identification
Of AAOD Use
Factors to be Considered in Self-Reported Data
Critical Review of Selected Instruments
Appendix One: Chart
This paper attempts to define the criteria that make a screening instrument for AAOD use valuable, and to set out in a clear and well-researched method which instruments, developed or adapted to be in general use over the period of the last ten years, most closely fit these standards.
The Adolescent Alcohol and Other Drug (AAOD) Problem: An Overview
According to 1998 figures, the most recent to be available, there were 10.4 million teenagers between the ages of 12 and 20 in the United States who drink alcohol, although drinking under the age of 21 is illegal in every state. Nearly half of these, 5.1 million, reported that they were binge drinkers, and two million were heavy drinkers. (SAMHSA, 1999) Two years earlier, nearly 200,000 had received treatment for substance abuse. (SAMHSA, TEDS, 1992-1997)
On the average, boys first experiment with alcohol at age 11, and girls at age 13. The National Institute of Alcohol Abuse and Alcoholism has determined that the onset of drinking prior to age 15 creates four times the likelihood of alcohol dependence, compared to waiting until the age of 21. (Grant, 1998) The chance of a teen becoming alcohol-dependent diminishes by 14% for every year after 15 that drinking is delayed. (Grant, 1998) Eighty percent of adults receiving treatment for alcohol problems report becoming intoxicated in their teens. (SAMHSA, TEDS, 1992-1997)
DSM criteria may or may not be totally applicable to teen drinking problems, with many experts believing that a substantial number of children are "diagnostic orphans" overlooked by its adult standards. Nonetheless, school surveys estimate that between 4 and 20% of teenagers in school either have or have had alcohol abuse or dependence that meets DSM criteria. (Martin and Winters, 1998)
Concurrent use of alcohol and tobacco stood at 22% of students between grades 7 and 12 in New York State. (Hoffman et al., 2001) The 1999 Michigan Youth Risk Behavior Survey reported that 34% of the respondents had smoked during the previous month and half of them considered themselves regular smokers. Eighty percent of adult smokers begin before the age of 18. (YRBS, 2001)
On average in 1998, over 4,000 adolescents per day were using marijuana for the first time. Twelve-year-old children use inhalants more than any other illegal drug. (Burgoon, 2002) A study of injection drug users with a median age of 22 reported that 48% of them have previously experienced at least one, and a median of two, overdoses, from injecting speedballs (heroin/cocaine mixtures). Sixty-five percent had not sought medical attention at the time of their last overdose. (Ochoa et al., 2001)
From these figures, it is clear that the AAOD use in present-day American is extremely high.
History of AAOD
Use of alcohol to excess is certainly not a new development, but a societal reality going back to earliest times. Intoxicating spirits have been used throughout the history of man for religious and celebratory purposes and for relaxation and pleasure, and there has always been the risk of improper use and addiction. However, only recently has the use and abuse of alcohol been perceived as a problem for children.
The Pilgrim Fathers were quick to adopt the habit of smoking tobacco. Oliver Wendell Holmes referred to opium as "God's own medicine." (Morgan, 1981) By the time of the Civil War, opium use was prevalent, not only under the care of a physician, but also as a recreational drug. Patent medicines, laced with opiates, were used by many religious and even puritanical persons as a mood enhancer and reliever of anxiety and pain.
However, the Temperance Movement began to agitate against alcoholism and related crime and social dislocation, and their efforts eventually led to Prohibition. By 1930, drugs were perceived as a separate problem to the extent that the Federal Bureau of Narcotics was formed to regulate their use.
The war in Vietnam was a crucial event in the American experience with drug abuse, as young servicemen came home hooked on heroine and heavily involved with marijuana. At the same time, the social revolution of the radical sixties emphasized freedom to do as one wished, Timothy Leary and others introduced the idea of the psychedelic experience, and music and entertainment glorified the use of a spectrum of drugs.
The advent of crack cocaine made hard drugs affordable to low-income people, especially young people, on an unprecedented scale. The drug cartels changed their distribution methods to reflect the lower price point and new market for crack. " 'There were no top three or four people [drug dealers],' says former DEA agent Bob Stutman. 'The organization was a twenty-year-old guy and three ten-year-old kids.' " (PBS Frontline: Drug Wars)
More single-parent families, families with both parents working, and larger class sizes with less latitude for teachers to administer discipline - all these factors contributed to a generation of children with more freedom to get into trouble.
The open admission by celebrities that they use recreational drugs sets an example for youth, and intimates that drug use is "cool." The use of, and addiction to, one of the current designer drugs, Vicodin, has been acknowledged by Brett Favre, Darryl Strawberry, Michael Jackson, Courtney Love, Chevy Chase, and Matthew Perry. The rapper Eminem has a Vicodin tattoo on his arm and refers to the drug in his lyrics. David Spade joked on a televised awards show that he found some Vicodin in his gift basket. (The Waismann Institute, 2001)
Finally, the so-called War on Drugs has been widely perceived as a war on youth and on various ethnicities and races. Various organizations have lobbied for the decriminalization of marijuana, if not for its legalization, and in fact, it is now legally used in some areas for medicinal purposes.
The Gateway Theory proposes that the more "respectable," legal, or relatively innocuous drugs serve as a preparatory step to the use of hard drugs. Thus, proponents of drug control are loath to see either the current legal drinking age lowered, or other possibly addictive drugs legalized.
The seriousness of the drug problem (including tobacco and alcohol use) among American youth is staggering, and cannot help but deeply concern those who deal with them, whether as parents, teachers, physicians, law enforcement/justice department personnel, or social service workers. The first step in treatment must be seen to be at least identifying the problem, and to that end, effective and accurate screening is crucial.
Consequences of AAOD
Late adolescence is recognized as a crucial time in the development of a young person, during which high-school education is typically completed and post-secondary options embarked upon. The negative effects of AAOD on scholastic accomplishment are well documented. Falling grades, lapses in school attendance, and discipline problems leading in some cases to expulsion are all common results of alcohol and drug use. At the very least, memory and cognitive impairment, accompanied by lack of attentiveness, are bound to impact the student's ability to achieve in class. In a study conducted in Quebec, Canada, which followed a group of 879 boys and 929 girls from kindergarten in 1986 and 1987 into adolescence ten years later, the researchers…[continue]
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