Accurately diagnosing substance use disorder among adolescents
Adolescence is a pivotal developmental growth period. Although the World Mental Health assessment called the “Composite International Diagnostic Interview Substance Abuse Module” (CIDI-SAM) was developed for adults, it is commonly used with adolescents. Thus, it may not accurately or reliably identify adolescents with substance use disorders. This study compared this module to diagnoses made by experienced clinicians.
Alcohol and other drug use among adolescents can be particularly harmful given adolescence is such a critical developmental period in the human life course. Substance use can disrupt healthy biological, emotional, and social development. Many adolescents engage in some form of substance use, and, for some, substance use is associated with life-altering consequences, such as delayed workforce entry, academic problems, later substance use and other psychiatric disorders, and injury or death.
Clinicians need reliable and valid assessment tools to identify adolescents with a substance use disorder and then to deliver appropriate treatments. Public health and policy experts also rely on valid measures of substance use disorders to understand trends of substance use disorder and develop relevant policies.
The World Health Organization developed a comprehensive survey tool to obtain valid information across 28 countries about the prevalence and correlates of mental health disorders, unmet need for treatment, treatment adequacy, and the societal burden of mental disorders. The survey included a substance use disorder module to specifically evaluate substance use. The substance use module is often used as the standard in research and practice to diagnosis substance use disorders. However, the module has not been validated with adolescents. How well the assessment compares to trained clinical experts in diagnosing substance use disorder among adolescents is unknown. Thus, researchers in this study aimed to compare diagnoses between this substance use module and clinical experts. Studies like these can also help us understand how accurate clinicians are in their real-world diagnostic assessments of substance use disorder for youth.
HOW WAS THIS STUDY CONDUCTED?
This cross-sectional study recruited adolescents from one outpatient substance use disorder clinic between July 2020 and February 2022. All adolescents aged 12-17 years were invited to participate in a study exploring the properties of substance use screening tools for adolescents. Among the 280 eligible participants, 38 adolescents chose to participate and completed the study. About two-thirds of participants (26, 68%) identified as male, and the average age was 16. About three-quarters (29, 76%) identified as White, and 32 (84%) identified as non-Hispanic. Participating adolescents were primarily from a home with two or more caregivers (31, 82%), with 27 (71%) homes having a caregiver with a college education or higher. Many (17, 45%) adolescents self-reported a history of being diagnosed with, or receiving medication for, attention deficit disorder/addition deficit hyperactivity disorder, and one-quarter screened positive for depression based on the PHQ-2 (10, 26%), and one-quarter also screened positive for generalized anxiety disorder based on the GAD-2 (9, 24%).
The 38 adolescents were given the web-based, World Mental Health Composite International Diagnostic Interview Substance Abuse Module (referred to in this summary simply as “module”) by a trained research assistant. They then underwent a 60-minute pediatric addiction medicine telehealth evaluation. The evaluating clinician was not made aware of the module results.
The evaluation was guided by a template that included open-ended prompts asking why the adolescent was seeking evaluation, what they hoped to gain, and what they liked/disliked about substance use. The guide also included a list of the substance use disorder criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. The 11 criteria for substance use disorders were assessed separately for alcohol, cannabis, and tobacco use disorders. Results from the module and clinician evaluations were then compared. In this study, a clinician’s diagnosis was assumed to be accurate and the “gold standard”. The module’s ability to correctly identify positive cases of substance use disorder (sensitivity) and differentiate, or correctly fail to identify, non-disordered substance use (specificity) was assessed using a technique called area under the curve, which generates a single statistic ranging from 0-1 that captures how well a test performs. The closer a test is to 1, the more valid an indicator it is for that construct; substance use disorder diagnosis, in this case.
WHAT DID THIS STUDY FIND?
The module and clinicians were often aligned, especially with alcohol use disorder and tobacco use disorder
Among the 38 participants, clinicians diagnosed 9 (24%), 31 (82%), and 23 (61%) with alcohol use, cannabis use, and tobacco use disorders respectively. In contrast, the module identified 11 (29%), 30 (79%), and 22 (58%) with alcohol, cannabis, and tobacco use disorders. Proportions between the groups (clinician vs. module determined diagnosis) were not meaningfully different. However, the same individuals were not necessarily diagnosed by both the module and the clinician. There were 6 (16%), 26 (68%), and 18 (47%) that were identified with alcohol, cannabis, and tobacco use disorders by both clinicians and the module.
The module performed the worst with cannabis use disorder
The module was able to identify alcohol use and tobacco use disorders moderately well, with area under the curve values of about 0.75, suggesting the module correctly classifies adolescents about 75% of the time. Values between 0.7–0.8 are considered acceptable, while values of 0.8–0.9 are considered excellent. In contrast, the module was not able to discriminate cannabis use disorder as well based on an area under the curve value of 0.6. Values between 0.5–0.6 are considered nondiscriminatory.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
In this study, adolescents completed the World Mental Health Composite International Diagnostic Interview Substance Abuse Module, a commonly used measure to identify individuals with a substance use disorder, and were also evaluated by a clinician for alcohol, cannabis, and tobacco use disorders. While overall numbers of cases diagnosed by clinicians versus a module were similar (see figure above), the rate of agreement for a given individual depended on the type of substance use being assessed. The module performed moderately well for alcohol and tobacco use disorders but poorly for cannabis use disorder. This means that the module may not appropriately identify adolescents with and without cannabis use disorder. Adolescents are at a unique stage of development, and substance use disorders may present differently. Adolescents may also perceive the diagnostic criteria differently. For example, they may not recognize patterns of their behavior or appropriately attribute consequences to their substance use.
Cannabis use and the disorder criteria may be particularly nuanced for adolescents due to their developmental stage. Appropriately understanding substance use disorder criteria, especially cannabis use disorder, for adolescents likely requires additional research.
Previous studies highlighted how cannabis use among youth can be harmful and yet is increasing nationally. For example, cannabis use among youth is linked to worse learning, attention, and executive functioning. Cannabis use disorder is also uniquely associated with suicidal behaviors among youth. Recreational cannabis legalization for adults has also been found to increase the likelihood of youth cannabis use. The results from this study suggest that a commonly used measure functions poorly in identifying those with and without cannabis use disorder. Further evaluation is needed to understand the nuance of cannabis use disorder among adolescents and how to screen for it.
Individuals’ first experiences with substance use often occur during adolescence. Use can escalate from experimentation to use associated with a range of immediate and prolonged consequences (e.g., worse academic grades, delayed workforce entry). Identifying adolescents with a substance use disorder early is important to connect those individuals with the appropriate services (intensive outpatients, residential treatment, etc.) as well as craft public health responses to substance use. Many adolescents also use multiple substances, so distinguishing between alcohol, cannabis, and tobacco use disorders can further help target treatment. The findings from this study further highlight the need to expand research into developmentally appropriate screening and diagnostic tools.
The adolescents screened were all presenting to an outpatient clinic, which likely increases the probability of a positive substance use disorder. Thus, the results here may underestimate the differences between the module and clinicians among the general population of adolescents not presenting to outpatient clinics.
The small sample size prevents analyses assessing differences within demographic (e.g., gender, race) groups. The small sample size also reduces the precision of parameter estimates.
BOTTOM LINE
In this cross-sectional study of a small number of adolescents in outpatient substance use disorder treatment who underwent both a structured diagnostic screening and clinician interview, this adult-based screening tool aligned adequately with clinician diagnoses for alcohol and tobacco but not cannabis use disorder. The results for cannabis use disorder had the biggest discrepancy between the screener and clinician. Although substance use disorder screeners are commonly used, they are not a replacement for an evaluation by a trained clinician. Future research is needed to tease apart the nuances of substance use disorder among adolescents and how to measure it.
For individuals and families seeking recovery: This study showed that a common adult-based screener for substance use disorders did not perform as well as a trained clinician in identifying substance use disorder, particularly cannabis use disorder, among adolescents when compared to an evaluation done by a trained clinician. If you or a loved one are considering an evaluation for substance use disorder, it may be best to seek an evaluation by a trained clinician.
For treatment professionals and treatment systems: The commonly used substance use disorder screener, World Mental Health Composite International Diagnostic Interview Substance Abuse module, may not be appropriate for adolescents. Findings from this study found that the module performed moderately well for alcohol and tobacco use disorder compared to a trained clinician. However, the module performed poorly for diagnosing cannabis use disorder among adolescents. Treatment professionals and systems should consider identifying a trained clinician to evaluate adolescents for substance use disorders when an adolescent shows signs of substance use, especially cannabis use.
For scientists: The World Mental Health Composite International Diagnostic Interview Substance Abuse module performed moderately well for diagnosing alcohol and tobacco use disorders among adolescents when compared to a clinician. However, the module performed less well when diagnosing cannabis use disorder among this population. Previous research suggests adolescence is a unique life stage, and substance use during this phase is associated with consequences that may be different from those of adults. Thus, the findings from this study suggest that diagnostic screenings may also require unique elements for adolescents. However, more work is needed to validate and replicate these findings through larger and more diverse sample sizes. Additional qualitative work, such as cognitive interviews, related to substance use disorder criteria for adolescents may reveal unique insights in disordered substance use among this population. In future studies, researchers may also investigate how an adolescent’s context impacts substance use disorder presentations and screening.
For policy makers: Adolescent substance use and substance use disorder are major public health concerns. This study found that a commonly used substance use disorder screener did not perform well compared to evaluations done by trained clinicians, especially for cannabis use disorder. These findings suggest that adolescents likely need developmentally appropriate screeners for substance use disorder. Policy makers should consider the underestimation of cannabis use disorder among adolescents in the general population as well as possible funding opportunities developmentally-sensitive diagnostic instruments for youth.
Alcohol and other drug use among adolescents can be particularly harmful given adolescence is such a critical developmental period in the human life course. Substance use can disrupt healthy biological, emotional, and social development. Many adolescents engage in some form of substance use, and, for some, substance use is associated with life-altering consequences, such as delayed workforce entry, academic problems, later substance use and other psychiatric disorders, and injury or death.
Clinicians need reliable and valid assessment tools to identify adolescents with a substance use disorder and then to deliver appropriate treatments. Public health and policy experts also rely on valid measures of substance use disorders to understand trends of substance use disorder and develop relevant policies.
The World Health Organization developed a comprehensive survey tool to obtain valid information across 28 countries about the prevalence and correlates of mental health disorders, unmet need for treatment, treatment adequacy, and the societal burden of mental disorders. The survey included a substance use disorder module to specifically evaluate substance use. The substance use module is often used as the standard in research and practice to diagnosis substance use disorders. However, the module has not been validated with adolescents. How well the assessment compares to trained clinical experts in diagnosing substance use disorder among adolescents is unknown. Thus, researchers in this study aimed to compare diagnoses between this substance use module and clinical experts. Studies like these can also help us understand how accurate clinicians are in their real-world diagnostic assessments of substance use disorder for youth.
HOW WAS THIS STUDY CONDUCTED?
This cross-sectional study recruited adolescents from one outpatient substance use disorder clinic between July 2020 and February 2022. All adolescents aged 12-17 years were invited to participate in a study exploring the properties of substance use screening tools for adolescents. Among the 280 eligible participants, 38 adolescents chose to participate and completed the study. About two-thirds of participants (26, 68%) identified as male, and the average age was 16. About three-quarters (29, 76%) identified as White, and 32 (84%) identified as non-Hispanic. Participating adolescents were primarily from a home with two or more caregivers (31, 82%), with 27 (71%) homes having a caregiver with a college education or higher. Many (17, 45%) adolescents self-reported a history of being diagnosed with, or receiving medication for, attention deficit disorder/addition deficit hyperactivity disorder, and one-quarter screened positive for depression based on the PHQ-2 (10, 26%), and one-quarter also screened positive for generalized anxiety disorder based on the GAD-2 (9, 24%).
The 38 adolescents were given the web-based, World Mental Health Composite International Diagnostic Interview Substance Abuse Module (referred to in this summary simply as “module”) by a trained research assistant. They then underwent a 60-minute pediatric addiction medicine telehealth evaluation. The evaluating clinician was not made aware of the module results.
The evaluation was guided by a template that included open-ended prompts asking why the adolescent was seeking evaluation, what they hoped to gain, and what they liked/disliked about substance use. The guide also included a list of the substance use disorder criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. The 11 criteria for substance use disorders were assessed separately for alcohol, cannabis, and tobacco use disorders. Results from the module and clinician evaluations were then compared. In this study, a clinician’s diagnosis was assumed to be accurate and the “gold standard”. The module’s ability to correctly identify positive cases of substance use disorder (sensitivity) and differentiate, or correctly fail to identify, non-disordered substance use (specificity) was assessed using a technique called area under the curve, which generates a single statistic ranging from 0-1 that captures how well a test performs. The closer a test is to 1, the more valid an indicator it is for that construct; substance use disorder diagnosis, in this case.
WHAT DID THIS STUDY FIND?
The module and clinicians were often aligned, especially with alcohol use disorder and tobacco use disorder
Among the 38 participants, clinicians diagnosed 9 (24%), 31 (82%), and 23 (61%) with alcohol use, cannabis use, and tobacco use disorders respectively. In contrast, the module identified 11 (29%), 30 (79%), and 22 (58%) with alcohol, cannabis, and tobacco use disorders. Proportions between the groups (clinician vs. module determined diagnosis) were not meaningfully different. However, the same individuals were not necessarily diagnosed by both the module and the clinician. There were 6 (16%), 26 (68%), and 18 (47%) that were identified with alcohol, cannabis, and tobacco use disorders by both clinicians and the module.
The module performed the worst with cannabis use disorder
The module was able to identify alcohol use and tobacco use disorders moderately well, with area under the curve values of about 0.75, suggesting the module correctly classifies adolescents about 75% of the time. Values between 0.7–0.8 are considered acceptable, while values of 0.8–0.9 are considered excellent. In contrast, the module was not able to discriminate cannabis use disorder as well based on an area under the curve value of 0.6. Values between 0.5–0.6 are considered nondiscriminatory.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
In this study, adolescents completed the World Mental Health Composite International Diagnostic Interview Substance Abuse Module, a commonly used measure to identify individuals with a substance use disorder, and were also evaluated by a clinician for alcohol, cannabis, and tobacco use disorders. While overall numbers of cases diagnosed by clinicians versus a module were similar (see figure above), the rate of agreement for a given individual depended on the type of substance use being assessed. The module performed moderately well for alcohol and tobacco use disorders but poorly for cannabis use disorder. This means that the module may not appropriately identify adolescents with and without cannabis use disorder. Adolescents are at a unique stage of development, and substance use disorders may present differently. Adolescents may also perceive the diagnostic criteria differently. For example, they may not recognize patterns of their behavior or appropriately attribute consequences to their substance use.
Cannabis use and the disorder criteria may be particularly nuanced for adolescents due to their developmental stage. Appropriately understanding substance use disorder criteria, especially cannabis use disorder, for adolescents likely requires additional research.
Previous studies highlighted how cannabis use among youth can be harmful and yet is increasing nationally. For example, cannabis use among youth is linked to worse learning, attention, and executive functioning. Cannabis use disorder is also uniquely associated with suicidal behaviors among youth. Recreational cannabis legalization for adults has also been found to increase the likelihood of youth cannabis use. The results from this study suggest that a commonly used measure functions poorly in identifying those with and without cannabis use disorder. Further evaluation is needed to understand the nuance of cannabis use disorder among adolescents and how to screen for it.
Individuals’ first experiences with substance use often occur during adolescence. Use can escalate from experimentation to use associated with a range of immediate and prolonged consequences (e.g., worse academic grades, delayed workforce entry). Identifying adolescents with a substance use disorder early is important to connect those individuals with the appropriate services (intensive outpatients, residential treatment, etc.) as well as craft public health responses to substance use. Many adolescents also use multiple substances, so distinguishing between alcohol, cannabis, and tobacco use disorders can further help target treatment. The findings from this study further highlight the need to expand research into developmentally appropriate screening and diagnostic tools.
The adolescents screened were all presenting to an outpatient clinic, which likely increases the probability of a positive substance use disorder. Thus, the results here may underestimate the differences between the module and clinicians among the general population of adolescents not presenting to outpatient clinics.
The small sample size prevents analyses assessing differences within demographic (e.g., gender, race) groups. The small sample size also reduces the precision of parameter estimates.
BOTTOM LINE
In this cross-sectional study of a small number of adolescents in outpatient substance use disorder treatment who underwent both a structured diagnostic screening and clinician interview, this adult-based screening tool aligned adequately with clinician diagnoses for alcohol and tobacco but not cannabis use disorder. The results for cannabis use disorder had the biggest discrepancy between the screener and clinician. Although substance use disorder screeners are commonly used, they are not a replacement for an evaluation by a trained clinician. Future research is needed to tease apart the nuances of substance use disorder among adolescents and how to measure it.
For individuals and families seeking recovery: This study showed that a common adult-based screener for substance use disorders did not perform as well as a trained clinician in identifying substance use disorder, particularly cannabis use disorder, among adolescents when compared to an evaluation done by a trained clinician. If you or a loved one are considering an evaluation for substance use disorder, it may be best to seek an evaluation by a trained clinician.
For treatment professionals and treatment systems: The commonly used substance use disorder screener, World Mental Health Composite International Diagnostic Interview Substance Abuse module, may not be appropriate for adolescents. Findings from this study found that the module performed moderately well for alcohol and tobacco use disorder compared to a trained clinician. However, the module performed poorly for diagnosing cannabis use disorder among adolescents. Treatment professionals and systems should consider identifying a trained clinician to evaluate adolescents for substance use disorders when an adolescent shows signs of substance use, especially cannabis use.
For scientists: The World Mental Health Composite International Diagnostic Interview Substance Abuse module performed moderately well for diagnosing alcohol and tobacco use disorders among adolescents when compared to a clinician. However, the module performed less well when diagnosing cannabis use disorder among this population. Previous research suggests adolescence is a unique life stage, and substance use during this phase is associated with consequences that may be different from those of adults. Thus, the findings from this study suggest that diagnostic screenings may also require unique elements for adolescents. However, more work is needed to validate and replicate these findings through larger and more diverse sample sizes. Additional qualitative work, such as cognitive interviews, related to substance use disorder criteria for adolescents may reveal unique insights in disordered substance use among this population. In future studies, researchers may also investigate how an adolescent’s context impacts substance use disorder presentations and screening.
For policy makers: Adolescent substance use and substance use disorder are major public health concerns. This study found that a commonly used substance use disorder screener did not perform well compared to evaluations done by trained clinicians, especially for cannabis use disorder. These findings suggest that adolescents likely need developmentally appropriate screeners for substance use disorder. Policy makers should consider the underestimation of cannabis use disorder among adolescents in the general population as well as possible funding opportunities developmentally-sensitive diagnostic instruments for youth.
Alcohol and other drug use among adolescents can be particularly harmful given adolescence is such a critical developmental period in the human life course. Substance use can disrupt healthy biological, emotional, and social development. Many adolescents engage in some form of substance use, and, for some, substance use is associated with life-altering consequences, such as delayed workforce entry, academic problems, later substance use and other psychiatric disorders, and injury or death.
Clinicians need reliable and valid assessment tools to identify adolescents with a substance use disorder and then to deliver appropriate treatments. Public health and policy experts also rely on valid measures of substance use disorders to understand trends of substance use disorder and develop relevant policies.
The World Health Organization developed a comprehensive survey tool to obtain valid information across 28 countries about the prevalence and correlates of mental health disorders, unmet need for treatment, treatment adequacy, and the societal burden of mental disorders. The survey included a substance use disorder module to specifically evaluate substance use. The substance use module is often used as the standard in research and practice to diagnosis substance use disorders. However, the module has not been validated with adolescents. How well the assessment compares to trained clinical experts in diagnosing substance use disorder among adolescents is unknown. Thus, researchers in this study aimed to compare diagnoses between this substance use module and clinical experts. Studies like these can also help us understand how accurate clinicians are in their real-world diagnostic assessments of substance use disorder for youth.
HOW WAS THIS STUDY CONDUCTED?
This cross-sectional study recruited adolescents from one outpatient substance use disorder clinic between July 2020 and February 2022. All adolescents aged 12-17 years were invited to participate in a study exploring the properties of substance use screening tools for adolescents. Among the 280 eligible participants, 38 adolescents chose to participate and completed the study. About two-thirds of participants (26, 68%) identified as male, and the average age was 16. About three-quarters (29, 76%) identified as White, and 32 (84%) identified as non-Hispanic. Participating adolescents were primarily from a home with two or more caregivers (31, 82%), with 27 (71%) homes having a caregiver with a college education or higher. Many (17, 45%) adolescents self-reported a history of being diagnosed with, or receiving medication for, attention deficit disorder/addition deficit hyperactivity disorder, and one-quarter screened positive for depression based on the PHQ-2 (10, 26%), and one-quarter also screened positive for generalized anxiety disorder based on the GAD-2 (9, 24%).
The 38 adolescents were given the web-based, World Mental Health Composite International Diagnostic Interview Substance Abuse Module (referred to in this summary simply as “module”) by a trained research assistant. They then underwent a 60-minute pediatric addiction medicine telehealth evaluation. The evaluating clinician was not made aware of the module results.
The evaluation was guided by a template that included open-ended prompts asking why the adolescent was seeking evaluation, what they hoped to gain, and what they liked/disliked about substance use. The guide also included a list of the substance use disorder criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. The 11 criteria for substance use disorders were assessed separately for alcohol, cannabis, and tobacco use disorders. Results from the module and clinician evaluations were then compared. In this study, a clinician’s diagnosis was assumed to be accurate and the “gold standard”. The module’s ability to correctly identify positive cases of substance use disorder (sensitivity) and differentiate, or correctly fail to identify, non-disordered substance use (specificity) was assessed using a technique called area under the curve, which generates a single statistic ranging from 0-1 that captures how well a test performs. The closer a test is to 1, the more valid an indicator it is for that construct; substance use disorder diagnosis, in this case.
WHAT DID THIS STUDY FIND?
The module and clinicians were often aligned, especially with alcohol use disorder and tobacco use disorder
Among the 38 participants, clinicians diagnosed 9 (24%), 31 (82%), and 23 (61%) with alcohol use, cannabis use, and tobacco use disorders respectively. In contrast, the module identified 11 (29%), 30 (79%), and 22 (58%) with alcohol, cannabis, and tobacco use disorders. Proportions between the groups (clinician vs. module determined diagnosis) were not meaningfully different. However, the same individuals were not necessarily diagnosed by both the module and the clinician. There were 6 (16%), 26 (68%), and 18 (47%) that were identified with alcohol, cannabis, and tobacco use disorders by both clinicians and the module.
The module performed the worst with cannabis use disorder
The module was able to identify alcohol use and tobacco use disorders moderately well, with area under the curve values of about 0.75, suggesting the module correctly classifies adolescents about 75% of the time. Values between 0.7–0.8 are considered acceptable, while values of 0.8–0.9 are considered excellent. In contrast, the module was not able to discriminate cannabis use disorder as well based on an area under the curve value of 0.6. Values between 0.5–0.6 are considered nondiscriminatory.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
In this study, adolescents completed the World Mental Health Composite International Diagnostic Interview Substance Abuse Module, a commonly used measure to identify individuals with a substance use disorder, and were also evaluated by a clinician for alcohol, cannabis, and tobacco use disorders. While overall numbers of cases diagnosed by clinicians versus a module were similar (see figure above), the rate of agreement for a given individual depended on the type of substance use being assessed. The module performed moderately well for alcohol and tobacco use disorders but poorly for cannabis use disorder. This means that the module may not appropriately identify adolescents with and without cannabis use disorder. Adolescents are at a unique stage of development, and substance use disorders may present differently. Adolescents may also perceive the diagnostic criteria differently. For example, they may not recognize patterns of their behavior or appropriately attribute consequences to their substance use.
Cannabis use and the disorder criteria may be particularly nuanced for adolescents due to their developmental stage. Appropriately understanding substance use disorder criteria, especially cannabis use disorder, for adolescents likely requires additional research.
Previous studies highlighted how cannabis use among youth can be harmful and yet is increasing nationally. For example, cannabis use among youth is linked to worse learning, attention, and executive functioning. Cannabis use disorder is also uniquely associated with suicidal behaviors among youth. Recreational cannabis legalization for adults has also been found to increase the likelihood of youth cannabis use. The results from this study suggest that a commonly used measure functions poorly in identifying those with and without cannabis use disorder. Further evaluation is needed to understand the nuance of cannabis use disorder among adolescents and how to screen for it.
Individuals’ first experiences with substance use often occur during adolescence. Use can escalate from experimentation to use associated with a range of immediate and prolonged consequences (e.g., worse academic grades, delayed workforce entry). Identifying adolescents with a substance use disorder early is important to connect those individuals with the appropriate services (intensive outpatients, residential treatment, etc.) as well as craft public health responses to substance use. Many adolescents also use multiple substances, so distinguishing between alcohol, cannabis, and tobacco use disorders can further help target treatment. The findings from this study further highlight the need to expand research into developmentally appropriate screening and diagnostic tools.
The adolescents screened were all presenting to an outpatient clinic, which likely increases the probability of a positive substance use disorder. Thus, the results here may underestimate the differences between the module and clinicians among the general population of adolescents not presenting to outpatient clinics.
The small sample size prevents analyses assessing differences within demographic (e.g., gender, race) groups. The small sample size also reduces the precision of parameter estimates.
BOTTOM LINE
In this cross-sectional study of a small number of adolescents in outpatient substance use disorder treatment who underwent both a structured diagnostic screening and clinician interview, this adult-based screening tool aligned adequately with clinician diagnoses for alcohol and tobacco but not cannabis use disorder. The results for cannabis use disorder had the biggest discrepancy between the screener and clinician. Although substance use disorder screeners are commonly used, they are not a replacement for an evaluation by a trained clinician. Future research is needed to tease apart the nuances of substance use disorder among adolescents and how to measure it.
For individuals and families seeking recovery: This study showed that a common adult-based screener for substance use disorders did not perform as well as a trained clinician in identifying substance use disorder, particularly cannabis use disorder, among adolescents when compared to an evaluation done by a trained clinician. If you or a loved one are considering an evaluation for substance use disorder, it may be best to seek an evaluation by a trained clinician.
For treatment professionals and treatment systems: The commonly used substance use disorder screener, World Mental Health Composite International Diagnostic Interview Substance Abuse module, may not be appropriate for adolescents. Findings from this study found that the module performed moderately well for alcohol and tobacco use disorder compared to a trained clinician. However, the module performed poorly for diagnosing cannabis use disorder among adolescents. Treatment professionals and systems should consider identifying a trained clinician to evaluate adolescents for substance use disorders when an adolescent shows signs of substance use, especially cannabis use.
For scientists: The World Mental Health Composite International Diagnostic Interview Substance Abuse module performed moderately well for diagnosing alcohol and tobacco use disorders among adolescents when compared to a clinician. However, the module performed less well when diagnosing cannabis use disorder among this population. Previous research suggests adolescence is a unique life stage, and substance use during this phase is associated with consequences that may be different from those of adults. Thus, the findings from this study suggest that diagnostic screenings may also require unique elements for adolescents. However, more work is needed to validate and replicate these findings through larger and more diverse sample sizes. Additional qualitative work, such as cognitive interviews, related to substance use disorder criteria for adolescents may reveal unique insights in disordered substance use among this population. In future studies, researchers may also investigate how an adolescent’s context impacts substance use disorder presentations and screening.
For policy makers: Adolescent substance use and substance use disorder are major public health concerns. This study found that a commonly used substance use disorder screener did not perform well compared to evaluations done by trained clinicians, especially for cannabis use disorder. These findings suggest that adolescents likely need developmentally appropriate screeners for substance use disorder. Policy makers should consider the underestimation of cannabis use disorder among adolescents in the general population as well as possible funding opportunities developmentally-sensitive diagnostic instruments for youth.
