Additional Strains and Burdens on the Assessment Process
While the lack of rigorous, clinically oriented assessment tools is a major deficit for the adolescent chemical dependency field, certain public health and clinical factors are exerting additional strain on the assessment process. These added strains further burden the field's efforts to effectively and efficiently identify and treat teenagers who abuse chemicals. Five sources of strain are identified and briefly discussed: empirically based knowledge gaps, expanding need for services, popularity of the "chemical dependency" label, and developmental issues.
Progress toward an empirical understanding of the essential clinical features of adolescent chemical abuse and dependency has been slowed because of a lack of adolescent assessment research. Current scientific knowledge about the addiction process in adolescents pales in comparison to our understanding of the psychosocial predictors of drug use in school samples (e.g., Huba and Bentler 1982; Jessor, R. and Jessor, S. 1977; Kande1 1978). While this analogue research provides an important empirical foundation for increasing understanding about teenage drug addiction, there is a great need for studies of clinical adolescent populations. Three key assessment questions that appear to need research attention are briefly discussed below.
• Can adolescents be meaningfully differentiated in terms of problem severity? While adolescents are likely to differ importantly in terms of severity of their chemical use, the extent to which such differences can be measured reliably and validly requires further research (see Henly and Winters 1988; Winters in press). For example, is the distinction between chemical abuse and dependence disorders valid for teenagers? Are the essential symptoms of adolescent addiction similar to adult alcoholism? Are multidimensional models of adult alcoholism (e.g., Wanberg and Horn 1983) applicable to adolescents? This later issue is important in terms of instrumentation since unidimensional screening tools will not suffice in the study of possible multidimensional aspects of adolescent problem severity.
• What other problems accompany adolescent chemical involvement? The ability to assess the extent of other problems that may complicate or be disguised by chemical use, and which may require treatment in their own right, is a high priority. As will be discussed in more detail below, the current popularity of the "chemical dependency" label may encourage health professionals and parents to assign a diagnosis of chemical dependency when, in fact, the drug problem is incidental compared to the presence of other mental or behavioral problems. Moreover, those with chemical use problems may reveal coexistent clinical disorders that require treatment attention in their own right (e.g., Morrison and Smith 1987).
• Can the identification of distinct diagnostic subgroups lead to client-treatment "matches"? As the diversity of treatment services increases, the basis for choosing among them for each available client becomes more complicated. Primary chemical dependency treatment may not be appropriate for many clients suspected of drug problems. For some, a combination of chemical dependency and psychiatric treatment may be indicated. For others, deciding between residential or non-residential treatment is the relevant question. Information from detailed and standardized assessment tools have great potential to assist in this process.
Expanding Need for Services
Despite some leveling of frequency of drug use by high school seniors in recent years, survey data continue to indicate that American teenagers are using alcohol and drugs at a disturbingly high rate (e.g., Johnston et al. 1987). Estimates indicate that a significant proportion of alcohol or drug treatment admissions in this country are adolescents. Based on a recent report by the National Association of State Alcohol and Drug Abuse Directors (1986)( n1), approximately 14% of admissions for drug treatment in 1985 were adolescent admissions. This report also indicated that 41 states identified a need for improved drug treatment or prevention services or both for children and adolescents, with the most critical need being the expansion or establishment of youth residential drug treatment facilities. Moreover, a recent federal survey (National Institute on Alcohol Abuse and Alcoholism 1984) indicated that alcohol treatment programs are specializing in youth services at a much higher rate than for any other "special population" (e.g., elderly and women).
The increased need for, and expansion of, services will likely result in earlier identification of adolescent chemical abuse and dependence by service providers who are quite diverse in terms of training and experience (Beschner and Friedman 1985; Winters and Henly 1988). This group of service providers may include teachers, probation officers and school counselors. The early detection of "high risk" youth by diverse practitioners working in a variety of settings is encouraging. Drug-abusing teenagers can be identified before problems progress to chronic proportions and in settings that may encourage the individual to seek help sooner. However, this trend poses problems for assessment professionals. As adolescents enter the health care system at an earlier age, it becomes more difficult for assessors to make appropriate decisions about diagnosis and need for treatment. As professionals in the field diversify, diagnostic decisions among them are likely to become more variable. One clinician's definition of chemical dependency may be quite different than another's. Such a lack of standardized and widely accepted diagnostic criteria raises legitimate concerns about the validity of diagnostic decisions and the appropriateness of referral and treatment decisions.
Also related to this issue of increasing diversity of chemical dependency professionals is the surprising lack of formal training in alcoholism and substance abuse by approved clinical and counseling psychology programs (see Lubin et al. 1986).
Popularity of the "chemical dependency" label
As society's awareness and concern about adolescent substance abuse increases, and as adolescent treatment services expand, there maybe a tendency for the stigma associated with the chemical dependency label to diminish. A growing attractiveness of chemical dependency treatment may be apparent in situations where adolescents -- or their parents -- readily accept a diagnosis of chemical dependency, despite the fact that chemical use may not be the primary problem. Parents may prefer to accept such a diagnosis, rather than a diagnosis of mental illness or delinquency, or that the problem lies elsewhere (e.g., the family situation). For some, adolescent chemical dependency treatment facilities may be the program of first choice rather than of last resort. Unfortunately, this attitude may encourage chemical dependency counselors to prematurely label the individual as chemically dependent.
Adolescents, even in the most accommodating and stress-free setting, pose special problems for assessment. This may be related to lack of identity formation or immature cognitive development. A certain degree of maturity is probably needed if an individual is to honestly examine his/her behavior, and the resulting consequences of that behavior. Moreover, certain attitudes and behaviors often noted in adolescents, such as self-centeredness, propensity for taking risks, and the rejection of conventional values (Benson et al. 1984), are not likely to contribute to insight about the dangers of drug use. When adolescent clients are defiant and oppositional, the assessor is forced to rely on a subjective perspective of the client's problems and on the reports of others. However, both of these strategies are problematic. Subjective clinical judgement is prone to certain biases, such as context effects and unreliability in gathering information. When the assessor must rely heavily on the reports of others, the assessment process is weakened. Much of the important clinical information needed to comprehensively assess adolescent chemical abuse and dependency is only known by the client (see Winters, in press). Furthermore, studies have shown that parents tend to under-report problems and disorders in their children (e.g., Mueller and Cooper 1988; Weissman and Wickramaratne 1987).
These five sources of strain on the assessment process -- gaps in scientific knowledge, expanding need for intervention and treatment services, increased popularity of the "chemical dependency" label, concerns by watchdog groups and developmental issues -- combined with the lack of adequate assessment tools, create a difficult situation for the adolescent chemical dependency service provider. Improved assessment instrumentation would help address many of these problems by providing more valid detection of which individuals need which type of service. Also, the potential problem of defiant and low-insight adolescent clients can be partially addressed by using standardized instruments that include measures of defensiveness and that contain behaviorally oriented clinical scales which may not be as prone to denial effects. Finally, well-developed clinical instruments can provide a data base from which researchers can more systematically close important knowledge gaps.
- Winters, Ken; The Need for Improved Assessment of Adolescent Substance Involvement; Journal of Drug Issues, Summer 1990, Vol. 20, Issue 3.
Reflection Exercise #9
The preceding section contained information
about the need for improved assessment of adolescent substance involvement. Write
three case study examples regarding how you might use the content of this section
in your practice.
What five sources of strain on the assessment process create a difficult situation for the adolescent chemical dependency service provider? Record the letter of the correct answer