Journal Issue: Juvenile Justice Volume 18 Number 2 Fall 2008
Screening and Diagnostic Assessment for SUDs among Juvenile Offenders
Although the negative consequences of substance use (including an elevated risk for continued offending) suggest the utility of substance abuse treatment, not every adolescent who uses alcohol or drugs needs treatment. Attempting to treat all substance-using juvenile offenders would be both impractical and a waste of costly and much-needed resources.20 Rather, treatment is more appropriate for adolescents with clinical substance use disorders.21 Identifying juvenile offenders with such disorders requires screening and, then, for those who screen positive, more thorough diagnostic evaluations. These evaluations help determine how intensive treatment should be (for example, whether detoxification is necessary) and whether treatment should take place in the community or in a residential or secure setting. Current "best practices" for treating adolescent SUDs also require a diagnostic assessment to learn whether the juvenile suffers from common co-occurring disorders (see the article in this volume by Thomas Grisso for further discussion).22
Adolescents held in juvenile justice sys-tem facilities are commonly screened for substance use problems. Among facilities reporting data on screening in the Office of Juvenile Justice and Delinquency Prevention's (OJJDP) 2002 Juvenile Residential Facility Census, 61 percent (holding 67 percent of juvenile offenders) screened all of the youth, with the highest screening rates reported by reception and diagnostic centers and by long-term secure facilities.23 Between 6 and 22 percent of facilities reported no screening at all. But although the facilities commonly did some screening, they less commonly used standardized screening instruments; 55 percent of programs in the OJJDP Census data and 48 percent in another national sample used such instruments.24 Thus, it is unclear whether programs are screening effectively enough and early enough to be maximally useful. Sixty percent of facilities (holding 64 percent of offenders) that reported on screening in the 2002 OJJDP Census did their screening within the first week.25 But if youths can be screened even before they are admitted to the facilities, they may be able to enter diversion programs instead, which may allow them the opportunity for community treatment. One review has suggested that a lack of case management and initial intake evaluation has led diversion programs to be under-used.26
Even if standardized screening and diagnostic evaluation services can be promptly delivered, assessing adolescent substance use and substance use disorders poses multiple challenges. Most standardized measures and structured interviews rely on self-report data, which require youths not only to comprehend complex questions, but also to provide accu-rate and honest reports. Because substance use is illegal, adolescents may be unwilling to disclose their use. Indeed, one study of juvenile detainees found that at least half of adolescent cocaine users (as detected by bioassay) denied recently using cocaine; self-reports may thus be more accurate for past use than for current use.27 Several guidelines on drug abuse treatment recommend monitoring drug use through urinalysis or other objective methods.28 In the 2002 OJJDP data, 73 percent of facilities (holding 77 percent of adolescent offenders) reported conducting urinalysis and 37 percent reported random drug testing. But even biological analysis has its limits, and different analyses (for example, of urine, saliva, and hair) vary in terms of their expense, the time it takes to receive results, and the time window of use that is detectable. Thus, a combination of self-reports and biological measures is probably necessary to evaluate thoroughly the substance use disorders of young offenders.
Assessing substance use disorders (using standard American Psychiatric Association criteria) requires characterizing substance use–related social consequences, dependence symptoms, and the associated impairment. Current psychiatric practice is to diagnose adolescents using the same criteria as adults, although the developmental appropriateness of this practice has been questioned.29 Many adolescents have been labeled "diagnostic orphans" because they show symptoms of a disorder that fall just short of diagnostic thresholds, making treatment decisions difficult.30 Moreover, the current taxonomy distinguishes between substance abuse and substance dependence disorders. Substance dependence is presumed to be more severe than substance abuse and to require treatment. However, recent research suggests that some symptoms of dependence are less severe than those of abuse, making it difficult to base treatment decisions on the distinction between abuse and dependence diagnoses.31
Finally, diagnosing and assessing adolescent substance use disorders is particularly complicated for juvenile offenders. For example, being confined in a correctional facility can influence the likelihood that particular substance use–related negative consequences can occur (such as negative effects on romantic relationships). Thus, for youths in secure confinement, assessing only current symptoms (rather than past symptoms) may be misleading. Moreover, there is some evidence that juvenile offenders under-report their own substance use–related impairment and that they may not have the judgment and maturity to appraise accurately such impairment.32