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Drug And Alcohol Screening

Consumption of alcohol and other psychoactive drugs by youth and adults commonly is associated with problems and maladjustment in multiple spheres of functioning. The Drug Use Screening Inventory (DUSI) was developed in response to the long-recognized need by practitioners for a brief, efficient, and informative screening assessment of problems within these multiple spheres (Tarter 1990). Multidemnsional screening affords practitioners the oppotunity to gather information efficiently from a large number of individuals simultaneously. As such, it is distinguishable from comprehensive assessment, which is typically an individualized evaluation tailored to the client's needs.

The Drug Use Screening Inventory identifies youth and adults who are suspected to be involved problematically with alcohol or other psychoactive drugs. The instrument also is useful for identifying in an objective manner the areas of disturbance and their severity. It was designed specifically to quantify and rank the indicators of severity of alcohol and other drug use in conjunction with physical and mental health status and psychosocial adjustment to family, work, and school. The resulting profile of problem severity across these multiple dimensions enables the practitioner to identify the client's treatment needs and to plan treatment strategies sequentially. Importantly, because the DUSI's administration time is brief and because the DUSI yields information in multiple spheres, it is ideally suited for monitoring client change during treatment and followup.

This article briefly reviews the rationale underlying the development of the DUSI and describes the scoring and interpretation procedures. A case summary illustrates the application of information obtained from the DUSI to prevention or treatment intervention. It should be emphasized that the DUSI is intended for practical application ihn situations where evaluation of multiple spheres of functioning is required, for example, when decisions about the most appropriate treatment modality have to be made or when there is a need to monitor change during the course of the prevention or treatment intervention.

CONCEPTUAL FRAMEWORK FOR

SCREENING AND ASSESSMENT

A multistage screening and assessment process is, arguably, the most cost-efficient strategy for the comprehensive evaluation of the severity of alcohol and other drug use and associated problems (Tarter et a. 1991).

The first stage is devoted to screening for specific problems, the second stage to intensive, comprehensive evaluation, and the third stage of formulation of a personalized treatment plan. The DUSI does screen for specific problems and, under certain circumstances, may serve as the only instrument required, depending on the findings obtained. For example, if little or no disturbance is detected on the DUSI, subsequent evaluation may not be needed.

Stage 1

The first stage of the screening and assessment process--employing the Drug Use Screening Inventory--consists of a multidimensional screening of severity of the client's disturbance in 10 domains: Substance Use; Behavior Patterns; Health Status; Psychiatric Disorder; Social Competency; Family System; School Performance/Adjustment; Work Adjustment; Peer Relationships; and Leisure/Recreation (Figure 1).

The DUSI provides two types of information essential for planning and implementing treatment. First, it indicates the extent to which disturbances other than alcohol and other drug abuse are present, and possibly contributing to this abuse. Second, it allows for a quick determination as to whether the substance abuse is indeed the most severe problem among the 10 domains.

Stage 2

The second stage in the screening and assessment process-intensive, comprehensive evaluation--is based on the findings obtained from the Drug Use Screening Inventory. Because comprehsive evaluation is a labor-intensive task, the DUSI was designed to maximize efficiency by identifying the domains of disturbance that require a thorough diagnostic assessment. Toward this end, specialized diagnostic assessment instruments appropriate for evaluating each of the 10 above-mentioned domains extend and elaborate upon the findings obtained from the DUSI to fully map the pattern and severity of disturbance. (See Tarter 1990 for the specialized tests that correspond to the DUSI's domains.) For example, whereas the DUSI detects and quantifies the severity of psychiatric disorder, order, or a disorder in any of the other nine domains, the comprehensive diagnostic evaluation should fully delineate the disorder. The DUSI thus serves as a guide and framework for defining the assessment objectives in the diagnostic evaluation.

Stage 3

The third stage in the screening and assessment process--formulating a treatment plan tailored to the particular needs of the client--considers the type and severity of disorders identified in the first and second stages. Within the 10 domains evaluated, treatment resources can thus be allocated according to severity of the problems identified. As will be discussed more fully below, the DUSI enables the relative severity of problems across the 10 domains to be ranked. Such ranking clarifies treatment priorities for each client, and allows a treatment plan to be developed to address individual problems.

CHARACTERISTICS OF THE DRUG

USE SCREENING INVENTORY

Content

The Drug Use Screening Inventory yields information about problems that can be treated through clinical intervention or behavioral intevention, changing the behaviors that promote maladjustment, health problems, or alcohol and other

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drug use. Although certain aspects of a client's substance use behavior (legal problems, for example) are of concern to practitioners, such information does not bear directly on determining the specific type of treatment that is best suited to the client's needs. Hence, the DUSI is not designed to capture information about all facets of a client but, rather, is most suitable for accruing information that is useful for treatment planning.

The Drug Use Screening Inventory consists of 140 yes/no items organized into 10 domains (see sidebar).

Domain I: Substance Use. The first part of this domain quantifies psychoactive drug-use patterns across 10 drug classes and identifies those drugs that the client prefers and, therefore, that are most likely to beproblematic. The second part consists of 15 questions that characterize severity of alcohol or other psychoactive drug use according to the degree to which they are integral to the client's life, cause adverse consequences, and reflect severity of dependence.

Domain II: Behavior Pattern. This 20-item scale evaluates behavioral maladjustment, anger expression, social isolation, acting out, and self-control.

Domain III: Health Status. This 10-item scale evaluates recent and current history of accidents, injuries, and disease.

Domain IV: Psychiatric Disorder. This 20-item scale screens for the presence of psychiatric disturbance most commonly found to be associated with alcohol or other drug use, particularly anxiety, depression, antisocial behavior, and psychotic symptoms.

Domain V: Social Competence. This 14-item scale evaluates the skills associated with everyday social interaction. In particular, assertiveness and refusal skills are documented.

Domain VI: Family System. This 14-item scale measures family dysfunction, conflict, and parental supervision in the home.

Domain VII: School Performance/Adjustment. This 20-item scale measures academic performance and adjustment to school.

Domain VIII: Work Adjustment. This 10-item scale measures work competency

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and motivation, with emphasis on the degree to which alcohol or other drug use interferes with employment adjustment.

Domain IX: Peer Relationships. This 14-item scale documents the peer group with respect to gang behavior, antisocial propensities, peer involvement with alcohol and other drugs, and size of the client's social network.

Domain X: Leisure/Recreation. This 12-item scale evaluates whether the client uses free time constructively or in a way that is not goal directed or satisfying.

ADMINISTRATION OF THE DRUG

USE SCREENING INVENTORY

The Drug Use Screening Inventory can be administered in several ways: to an individual, to a group, in a paper and pencil format, or on a personal computer.

The adolescent or adult client can read the 149-item questionnaire and write the responses on the pages. After the client has answered the questions, the examiner manually tabulates the scores for each of the 10 scales and also obtains the overall problem density index (discussed below).

For expediency, or when the DUSI is administered to a group, the clients place their responses on a special answer sheet. The scoring and profiling of the results are performed by an optical scanner.

The DUSI can be administered individually on a personal computer and the results profiled automatically. The questions appear one at a time on the video screen, and the client answers by pressing one of two keyboard buttons. The advantage of this format is that a client's record can be stored permanently. Furthermore, changes during treatment or followup can be charted automatically during the course of repeated assessments.

An important benefit of the computer format is that the data are incorporated into an expanding database. Accordingly, characteristics of the client population with respect to such program variables as dropouts and treatment failures can be described and analyzed easily.

All forms of the DUSI just described take about 20 minutes to complete. To the extent possible, the items comprising the DUSI are free of cultural or ethnic bias, and only a fifth-grade reading level is required to comprehend the questions.

SCORING

The Drug Use Screening Inventory provides information about the severity of problems in each of the 10 domains. Severity, or, more precisely, problem density, is determined by three scores.

First, the absolute problem density score indicates severity of disturbance according to the percentage of items endorsed in each of the 10 domains. For each domain, the problem density score ranges from 0 percent ot 100 percent. These scores provide the basis for determining whether treatment is warranted in one or more of the domains. It is important to note that no arbitrary threshold score is advocated for determing appropriateness for treatment; this is the the responsibility of the treatment provider. Determination of treatment needs should be based on the results of the DUSI in conunction with other relevant information available.

Second, the overall problem index score, like the absolute problem density score, gauges problem density, or severity. The overall score is derived from the total number of positive responses in each domain (raw score) averaged across all domains. This score reflects general severity of disturbance, recognizing that the 10 domains are to some degree interrelated. Also, the score determines the intensity of treatment, such as inpatient or outpatient, that suits the client's overall condition.

Third, the relative problem density score describes problem density, or severity, in each domain and demonstrates how the 10 domains are distributed with respect to their severity. The score is derived by adding the absolute problem density scores and dividing this total into the score for each domain. The resulting scores add up to 100 percent and reflect the relative severity of problems across the 10 domains. This computation reveals the unique distribution of problem severity within the client in the 10 domains cited. (For a more detailed discussion of scoring procedures, see Tarter 1990.)

INTERPRETATION OF THE DRUG

USE SCREENING INVENTORY

The following case summary illustrates the practical utility of the DUSI in screening for severity of alcohol and other drug abuse and related problems:

S.B. is a 17-year-old white female who was referred by the court for treatment after being arrested for driving under the influence of alcohol. This arrest was her first contact with legal authorities, and she had no prior history of treatment for either alcohol abuse or psychiatric disorder. She is in the 11th grade and earns mostly average grades. She lives with her mother, stepfather, and two younger siblings.

The DUSI was administered as part of a core clinical assessment and was performed in the Pittsburgh Adolescent Alcohol Research Center, which is funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). S.B.'s most severe problems (see Table 1) revealed by the absolute problem density scores (those exceeding 50 percent on the respective scales) aggregate around substance use, psychiatric disorder, family and school adjustment, and leisure and recreation activities. It also is noteworthy that she positively endorsed (answered yes to) 50 percent of the DUSI questions.

Ranking the scores according to their relative problem density demonstrates that school adjustment (16.9 percent), family adjustment (16.6 percent), substance use (15.5 percent), psychiatric disorder (12.7 percent), and deficient leisure and recreation (12.7 percent) account for almost 75 percent of S.B.'s total problems.

S.B.'s profile of relative problem density scores identifies and ranks the relative severity of her problems (Figure 2). It is significant that her health status, behavior patterns, social skills, and work and peer relationships reflect little or no disturbance. Using this information as the basis for comprehensive diagnostic evaluation, the practitioner determined, by using another instrument, the Structured Clinical Interview for DSM-III-R (SCID), that S.B. qualified for a diagnosis of depression. Further exploration suggested her depression appeared to be due, in part, to longstanding conflict with and perceived rejection by her stepfather. Significantly, there was also a family history of depression on the maternal side of the family and alcoholism in the biological father.

The treatment team assigned to S.B.'s case discussed these findings and implemented a treatment plan with the foremost aim of ameliorating the depression. The treatment plan consisted of cognitive behavioral psychotherapy. in conjunction with family counseling.

The above case summary highlights ways in which the DUSI can provide objective, quantitative information that has direct bearing on treatment. As a screening tool, it provides the information necessary for matching treatment to the individual's needs.

VALIDITY AND RELIABILITY

Because the Drug Use Screening Inventory is a new instrument, the designers suggest that users not rely on its results alone when formulating a treatment plan or monitoring treatment progress and outcome until the validation studies are completed. Ongoing studies are examining the DUSI's association with other instruments and testing is predictive utility. At the very least, it is recommended that the DUSI results be reviewed in conjunction with other clinically relevant information whenever possible. Currently, the validity and reliability of the DUSI are being studied in two research centers at the University of Pittsburgh.

In the NIAAA-funded center, adolescents who abuse alcohol and other drugs are studied to elucidate the biomedical, psychiatric, neuropsychologic, psychosocial, nutritutional, and immunogenic aspects of early-age onset of alcohol problems. This research program affords clinicians the opportunity to validate the DUSI with respect to each of the 10 domains assessed.

In the center funded by the National Institute on Drug Abuse, high-risk youth between 10 and 12 years of age are tracked prospectively to determined the biobehavioral antecedents and natural history of drug abuse. Within this research program, the DUSI is being investigated for its applicability in detecting youth at high risk for alcohol and other drug abuse and for characterizing alcohol and other drug involvement within a developmental perspective.

To date, research has shown that the DUSI scores provide valid assessments of the psychiatric concomitants of alcohol and other drug use (Tarter et al. unpublished data 1991) and that problem density scores rae correlated with early childhood temperament characteristics (Tarter et al. 1990). The more severe the deviation is from normal for such temperament traits as behavioral activity level and emotionality, the more striking are the problem severity scores on the DUSI.

SUMMARY

This article has outlined a multistage screening and assessment strategy for known and suspected abusers of alcohol and other drugs. Their prognosis is enhanced when the problems are delineated and quantified so that specific, focused, and targeted treatment can be implemented. The Drug Use Screening Inventory not only guides the diagnostic process but also facilitates implementation of the treatment plan. Finally, it provides practitioners the opportunity to chart and quantify changes that occur during treatment or followup and to describe, within a multivariate framework, the characteristics of the client or patient population at each particular facility or agency.

REFERENCES

TARTER, R.E. Evaluation and treatment of adolescent substance abuse: A decision tree method. American Journal of Drug and Alcohol Abuse 16(1&2):1-46, 1990.

TARTER, R.E.; LAIRD, S.B.; KABENE, M.; BUKSTEIN, O.; AND KAMINER, Y. Drug abuse severity in adolescents is associated with magnitude of deviation in temperament traits. British Journal of Addiction 85(11):1501-1504, 1990.

TARTER, R.; OTT, P.; AND MEZZICH, A. Psychometric assessment. In: Frances, R., and Miller, S., eds. Clinical Textbook of Addictive Disorders, New York: Guilford, 1991. pp. 237-267.

RALPH E. TARTER, PH.D., is professor of psychiatry and neurology in the Department of Psychiatry, and education and training core director at the Pittsburgh Adolescent Alcohol Research Center, of the University of Pittsburgh School of Medicine. He also is director of the Center for Education and Drug Abuse Research, Pittsburgh, Pennsylvania.

ANDREA H. HEGEDUS, PH.D., is administrator of the Pittsburgh Adolescent Alcohol Research Center, Department of Psychiatry, University of Pittsburgh Medical School.

Research funds were provided by National Institute on Drug Abuse grant DA05605 and National Institute on Alcohol Abuse and Alcoholism grant AA08746.

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