Appendix C Screening and Assessment Instruments

	About this book
	SAMHSA/CSAT Treatment Improvement Protocols
	24. TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
	Executive Summary and Recommendations
	Chapter 1Substance Abuse and Primary Care
	Chapter 2Screening for Substance Use Disorders
	Chapter 3Brief Intervention
	Chapter 4Assessment
	Chapter 5Specialized Substance Abuse Treatment Programs
	Chapter 6Implementation and Recommendation Summary
	Appendix APharmacotherapy
	Appendix BLegal and Ethical Issues
	Appendix CScreening and Assessment Instruments
	Appendix DSubstance Abuse Resources for the Primary Care Setting
	Appendix FResource Panel
	Appendix GField Reviewers
	Tables and Figures*
	Appendix E -- Bibliography

Appendix C

Screening and Assessment Instruments

This appendix includes

In addition, ordering information for some of these and other tools appears at the end of the appendix.

The Alcohol Use Disorders Identification Test (AUDIT)

The following guidelines, questions, and scoring instructions are excerpted from Babor, T.F.; de la Fuente, J.R.; Saunders, J.; and Grant, M. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva: World Health Organization, 1992.

How To Use AUDIT

Screening with AUDIT can be conducted in a variety of primary care settings by persons who have different kinds of training and professional backgrounds. The core AUDIT is designed to be used as a brief structured interview or self-report survey that can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. When presented in this context by a concerned and interested interviewer, few patients will be offended by the questions. The experience of the WHO collaborating investigators (Saunders and Aasland, 1987) indicated that AUDIT questions were answered accurately regardless of cultural background, age, or gender. In fact, many patients who drank heavily were pleased to find that a health worker was interested in their use of alcohol and the problems associated with it.

In some patients, the AUDIT questions may not be answered accurately because they refer specifically to alcohol use and problems. Some patients may be reluctant to confront their alcohol use or to admit that it is causing them harm. Individuals who feel threatened by revealing this information to a health worker, who are intoxicated at the time of the interview, or who have certain kinds of mental impairment may give inaccurate responses. Patients tend to answer most accurately when

The interviewer is friendly and nonthreatening
The purpose of the questions is clearly related to a diagnosis of their health status
The patient is alcohol- and drug-free at the time of the screening
The information is considered confidential
The questions are easy to understand

Health workers should try to establish these conditions before AUDIT is given. When these conditions are not present, the Clinical Screening Instrument following the AUDIT questionnaire may be more useful. Alternatively, health workers may also use AUDIT to guide an interview with a concerned friend, spouse, or family member. In some settings (such as waiting rooms), AUDIT may be administered as a self-report questionnaire, with instructions for the patient to discuss the meaning of the results with the primary care worker. . . In addition to these general considerations, the following interviewing techniques should be used:

Try to interview patients under the best possible circumstances. For patients requiring emergency treatment or who are severely impaired, it is best to wait until their condition has stabilized and they have become accustomed to the health setting where the interview is to take place.
Look for signs of alcohol or drug intoxication. Patients who have alcohol on their breath or who appear intoxicated may be unreliable respondents. Consider conducting the interview at a later time. If this is not possible, make note of these findings on the patient's record.
If AUDIT is embedded, as recommended, in a longer health interview, then a transitional statement will be needed when the AUDIT questions are asked. The best way to introduce the AUDIT questions is to give the patient a general idea of the content of the questions, the purpose for asking them, and the need for accurate answers. The following is an illustrative introduction: "Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Because alcohol use can affect many areas of health (and may interfere with certain medications), it is important for us to know how much you usually drink and whether you have experienced any problems with your drinking. Please try to be as honest and as accurate as you can be." This statement should be followed by a description of the types of alcoholic beverages typically consumed in the population to which the patient belongs (e.g., "By alcoholic beverages we mean your use of wine, beer, vodka, sherry, etc.") If necessary, include a description of beverages that may not be considered alcoholic, e.g., cider, low alcohol beer, etc. . . .
It is important to read the questions as written and in the order indicated. By following the exact wording, better comparability will be obtained between your results and those obtained by other interviewers.
Most of the questions in AUDIT are phrased in terms of "how often" symptoms occur. It is useful to offer the patient several examples of the response categories (for example, "Never," "Several times a month," "Daily") to suggest how he might answer. When he has responded, it is useful to probe during the initial questions to be sure that the patient has selected the most accurate response (for example, "You say you drink several times a week. Is this just on weekends or do you drink more or less every day?"). If responses are ambiguous or evasive, continue asking for clarification by repeating the question and the response options, asking the patient to choose the best one. At times, answers are difficult to record because the patient may not drink on a regular basis. For example, if the patient was drinking intensively for the month prior to an accident, but not before or since, then it will be difficult to characterize the "typical" drinking sought by the question. In these cases it is best to record the amount of drinking and related symptoms for the heaviest drinking period of the past year, making note of the fact that this may be atypical or transitory for that individual.

Record answers carefully, using the comments section of the interview brochure to explain any special circumstances, additional information, or clinical inferences. Often patients will provide the interviewer with useful comments about their drinking that can be valuable in the interpretation of the total AUDIT score. . . .

The AUDIT Questionnaire



The AUDIT Questionnaire


Circle the number that comes closest to the patient's answer. 1. How often do you have a drink containing alcohol?
(0) Never	(1) Monthly or less	(2) Two to four times a month	(3)Two to three times a week	(4)Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
(0) 1 or 2	(1) 3 or 4	(2 5 or 6	(3) 7 to 9	(4)10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)FDaily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No	(2) Yes, but not in the last year	(4)Yes, during the last year
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
(0) No	(2) Yes, but not in the last year	(4)Yes, during the last year

Procedure for scoring AUDIT

Questions 1-8 are scored 0, 1, 2, 3, or 4. Questions 9 and 10 are scored 0, 2, or 4 only. The response is as follows:

AUDIT "Clinical" Questions and Procedure

Trauma history

1. Have you injured your head since your 18th birthday?

(3) Yes

(0) No

2. Have you broken any bones since your 18th birthday?

(3) Yes

(0) No



Clinical examination


Conjunctival injections
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
Abnormal skin vascularization
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
Hand tremor
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
Tongue tremor
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
Hepatomegaly
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
GGT Values*	Lower normal	(0-30 IU/1)=(0)
	Upper normal	(30-50 IU/1)=(1)
	Abnormal	(50 IU/1)=(3)

Scoring and Interpretation of AUDIT

As indicated by the AUDIT questions, each item is scored by checking the response category that comes closest to the patient's answer.

On the basis of evidence from the validation study (Saunders et al., in press), two cutoff points are suggested, depending on the purpose of the screening program or the nature of the research project. A score of 8 or more produces the highest sensitivity, while a score of 10 or more results in higher specificity. In general, high scores on the first three items in the absence of elevated scores on the remaining items suggest hazardous alcohol use. Elevated scores on items 4 through 6 imply the presence or emergence of alcohol dependence. High scores on the remaining items suggest harmful alcohol use. As discussed in the following section on diagnosis, each of these areas of alcohol-related problems implies different types of management.

The Clinical Screening Instrument is considered to be elevated when the total score is 5 or greater. Here, too, the examiner should give careful consideration to the different meanings attributed to alcohol-related trauma, physical signs, and the elevated liver enzyme. It should be noted that false positives can occur when the individual is accident prone, uses drugs (such as barbiturates) that induce GGT, or has hand tremor because of nervousness, neurological disorder, or nicotine dependence.

References

Saunders, J.B., and Aasland, O.G. WHO Collaborative Project on the Identification and Treatment of Persons with Harmful Alcohol Consumption. Report on Phase I: Development of a Screening Instrument. Geneva: World Health Organization, 1987.

Saunders, J.B.; Aasland, O.G.; Babor, T.F.; de la Fuente, J.R.; and Grant, M. WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Development of the screening instrument "AUDIT." British Journal of Addictions, in press.

Michigan Alcoholism Screening Test (MAST)



	0. Do you enjoy a drink now and then?	YES	NO
(2)	1. *Do you feel you are a normal drinker? (By normal we mean you drink less than or as much as most other people)	YES	NO
(2)	2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?	YES	NO
(1)	3. Does your wife, husband, a parent, or other near relative ever worry or complain abut your drinking?	YES	NO
(2)	4. *Can you stop drinking without a struggle after one or two drinks?	YES	NO
(1)	5. Do you ever feel guilty about your drinking?	YES	NO
(2)	6. *Do friends or relatives think you are a normal drinker?	YES	NO
(2)	7. *Are you able to stop drinking when you want to?	YES	NO
(5)	8. Have you ever attended a meeting of Alcoholics Anonymous (AA)?	YES	NO
(1)	9. Have you gotten into physical fights when drinking?	YES	NO
(2)	10. Has your drinking ever created problems between you and your wife, husband, a parent, or other relative?	YES	NO
(2)	11. Has your wife, husband (or other family member) ever gone to anyone for help about your drinking?	YES	NO
(2)	12. Have you ever lost friends because of your drinking?	YES	NO
(2)	13. Have you ever gotten into trouble at work or school because of drinking?	YES	NO
(2)	14. Have you ever lost a job because of drinking?	YES	NO
(2)	15. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?	YES	NO
(1)	16. Do you drink before noon fairly often?	YES	NO
(2)	17. Have you ever been told you have liver trouble? Cirrhosis?	YES	NO
(2)	18. **After heavy drinking have you ever had Delirium Tremens (DTs) or severe shaking or heard voices or seen things that really weren't there?	YES	NO
(5)	19. Have you ever gone to anyone for help about your drinking?	YES	NO
(5)	20. Have you ever been in a hospital because of drinking?	YES	NO
(2)	21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem that resulted in hospitalization?	YES	NO
(2)	22. Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problem where drinking was part of the problem?	YES	NO
(2)	23. ***Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? If YES, how many times? _______	YES	NO
(2)	24. Have you ever been arrested, or taken into custody, even for a few hours, because of other drunk behavior? If YES, how many times?______	YES	NO
Alcoholic Response is negative 5 points for each Delirium Tremens *2 points for each arrest SCORING SYSTEM: In general, five points or more would place the subject in alcoholic category. Four points would be suggestive of alcoholism, and three points or fewer would indicate the subject is not alcoholic.Source: Selzer, M.L. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry* 127:1653-1658, 1971.

Short Michigan Alcoholism Screening Test (SMAST)



PATIENT NAME: ________________________________
DATE OF BIRTH: _______________________________
DATE OF ADMINISTRATION: ______________________________
1. Do you feel you are a normal drinker? (By normal we mean you drink less than or as much as most other people)	YES	NO
2. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?	YES	NO
3. Do you ever feel guilty about your drinking?	YES	NO
4. Do friends or relatives think you are a normal drinker?	YES	NO
5. Are you able to stop drinking when you want to?	YES	NO
6. Have you ever attended a meeting of Alcoholics Anonymous?	YES	NO
7. Has drinking ever created problems between you and your wife, husband, a parent, or other near relative?	YES	NO
8. Have you ever gotten into trouble at work or school because of drinking?	YES	NO
9. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?	YES	NO
10. Have you ever gone to anyone for help about your drinking? If YES: was this other than Alcoholics Anonymous or a hospital? (If YES, code as YES; if NO, code as NO)	YES	NO
11. Have you ever been in a hospital because of drinking? If YES: Was this for (a) detox; (b) alcoholism treatment; (c) alcohol-related injuries or medical problems, e.g., cirrhosis or physical injury incurred while under the influence of alcohol (car accident, fight, etc.)?	YES	NO
12. Have you ever been arrested for drunken driving, driving while intoxicated, or driving under the influence of alcoholic beverages?	YES	NO
13. Have you ever been arrested, even for a few hours, because of other drunken behavior?	YES	NO

Michigan Alcoholism Screening Test

Geriatric Version (MAST-G)



1. After drinking have you ever noticed an increase in your heart rate or beating in your chest?	YES	NO
2. When talking with others, do you ever underestimate how much you actually drink?	YES	NO
3. Does alcohol make you sleepy so that you often fall asleep in your chair?	YES	NO
4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?	YES	NO
5. Does having a few drinks help decrease your shakiness or tremors?	YES	NO
6. Does alcohol sometimes make it hard for you to remember parts of the day or night?	YES	NO
7. Do you have rules for yourself that you won't drink before a certain time of the day?	YES	NO
8. Have you lost interest in hobbies or activities you used to enjoy?	YES	NO
9. When you wake up in the morning, do you ever have trouble remembering part of the night before?	YES	NO
10. Does having a drink help you sleep?	YES	NO
11. Do you hide your alcohol bottles from family members?	YES	NO
12. After a social gathering, have you ever felt embarrassed because you drank too much?	YES	NO
13. Have you ever been concerned that drinking might be harmful to your health?	YES	NO
14. Do you like to end an evening with a night cap?	YES	NO
15. Did you find your drinking increased after someone close to you died?	YES	NO
16. In general, would you prefer to have a few drinks at home rather than go out to social events?	YES	NO
17. Are you drinking more now than in the past?	YES	NO
18. Do you usually take a drink to relax or calm your nerves?	YES	NO
19. Do you drink to take your mind off your problems?	YES	NO
20. Have you ever increased your drinking after experiencing a loss in your life?	YES	NO
21. Do you sometimes drive when you have had too much to drink?	YES	NO
22. Has a doctor or nurse ever said they were worried or concerned about your drinking?	YES	NO
23. Have you ever made rules to manage your drinking?	YES	NO
24. When you feel lonely does having a drink help?	YES	NO

Problem Oriented Screening Instrument for Teenagers (POSIT)

Developed for the Adolescent Assessment/Referral System

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public respondent burden for this collection of information is estimated to average 25 minutes per response, including time for reviewing instructions and completing the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection of information, including suggestions for reducing this burden, to: Public Health Service Reports Clearance Officer, Attn: PRA, Hubert H. Humphrey Building, Room 721B, 200 Independence Avenue, S.W., Washington, DC 20201; and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20803.

Problem Oriented Screening Instrument for Teenagers (POSIT)

The purpose of these questions is to help us choose the best way to help you. So, please try to answer the questions honestly.

Please answer all the questions. If a question does not fit you exactly, pick the answer that is most true.

You may see the same or similar questions more than once. Please just answer each question as it comes up.

Please put an "X" through your answer.

If you do not understand a word, please ask for help.

You may begin.



1. Do you have so much energy you don't know what to do with it?	YES	NO
2. Do you brag?	YES	NO
3. Do you get into trouble because you use drugs or alcohol at school?	YES	NO
4. Do your friends get bored at parties when there is no alcohol served?	YES	NO
5. Is it hard for you to ask for help from others?	YES	NO
6. Has there been adult supervision at the parties you have gone to recently?	YES	NO
7. Do your parents or guardians argue a lot?	YES	NO
8. Do you usually think about how your actions will affect others?	YES	NO
9. Have you recently either lost or gained more than 10 pounds?	YES	NO
10. Have you ever had sex with someone who shot up drugs?	YES	NO
11. Do you often feel tired?	YES	NO
12. Have you had trouble with stomach pain or nausea?	YES	NO
13. Do you get easily frightened?	YES	NO
14. Have any of your best friends dated regularly during the past year?	YES	NO
15. Have you dated regularly in the past year?	YES	NO
16. Do you have a skill, craft, trade, or work experience?	YES	NO
17. Are most of your friends older than you?	YES	NO
18. Do you have less energy than you think you should?	YES	NO
19. Do you get frustrated easily?	YES	NO
20. Do you threaten to hurt people?	YES	NO
21. Do you feel alone most of the time?	YES	NO
22. Do you sleep either too much or too little?	YES	NO
23. Do you swear or use dirty language?	YES	NO
24. Are you a good listener?	YES	NO
25. Do your parents or guardians approve of your friends?	YES	NO
26. Have you lied to anyone in the past week?	YES	NO
27. Do your parents or guardians refuse to talk to you when they are mad at you?	YES	NO
28. Do you rush into things without thinking about what could happen?	YES	NO
29. Did you have a paying job last summer?	YES	NO
30. Is your free time spent just hanging out with friends?	YES	NO
31. Have you accidentally hurt yourself or someone else while high on alcohol or drugs?	YES	NO
32. Have you had any accidents or injuries that still bother you?	YES	NO
33. Are you a good speller?	YES	NO
34. Do you have friends who damage or destroy things on purpose?	YES	NO
35. Have the whites of your eyes ever turned yellow?	YES	NO
36. Do your parents or guardians usually know where you are and what you are doing?	YES	NO
37. Do you miss out on activities because you spend too much money on drugs or alcohol?	YES	NO
38. Do people pick on you because of the way you look?	YES	NO
39. Do you know how to get a job if you want one?	YES	NO
40. Do your parents or guardians and you do lots of things together?	YES	NO
41. Do you get As and Bs in some classes and fail others?	YES	NO
42. Do you feel nervous most of the time?	YES	NO
43. Have you stolen things?	YES	NO
44. Have you ever been told you are hyperactive?	YES	NO
45. Do you ever feel you are addicted to alcohol or drugs?	YES	NO
46. Are you a good reader?	YES	NO
47. Do you have a hobby you are really interested in?	YES	NO
48. Do you plan to get a diploma (or already have one)?	YES	NO
49. Have you been frequently absent or late to work?	YES	NO
50. Do you feel people are against you?	YES	NO
51. Do you participate in team sports which have regular practices?	YES	NO
52. Have you ever read a book cover to cover for your own enjoyment?	YES	NO
53. Do you have chores that you must regularly do at home?	YES	NO
54. Do your friends bring drugs to parties?	YES	NO
55. Do you get into fights a lot?	YES	NO
56. Do you have a hot temper?	YES	NO
57. Do your parents or guardians pay attention when you talk with them?	YES	NO
58. Have you started using more drugs or alcohol to get the effect you want?	YES	NO
59. Do your parents or guardians have rules about what you can and cannot do?	YES	NO
60. Do people tell you that you are careless?	YES	NO
61. Are you stubborn?	YES	NO
62. Do any of your best friends go out on school nights without permission from their parents or guardians?	YES	NO
63. Have you ever had or do you now have a job?	YES	NO
64. Do you have trouble getting your mind off things?	YES	NO
65. Have you ever threatened anyone with a weapon?	YES	NO
66. Do you have a way to get to a job?	YES	NO
67. Do you ever leave a party because there is no alcohol or drugs?	YES	NO
68. Do your parents or guardians know what you really think or feel?	YES	NO
69. Do you often act on the spur of the moment?	YES	NO
70. Do you usually exercise for a half hour or more at least once a week?	YES	NO
71. Do you have a constant desire for alcohol or drugs?	YES	NO
72. Is it easy to learn new things?	YES	NO
73. Do you have trouble with your breathing or with coughing?	YES	NO
74. Do people your own age like and respect you?	YES	NO
75. Does your mind wander a lot?	YES	NO
76. Do you hear things no one else around you hears?	YES	NO
77. Do you have trouble concentrating?	YES	NO
78. Do you have a valid driver's license?	YES	NO
79. Have you ever had a paying job that lasted at least 1 month?	YES	NO
80. Do you and your parents or guardians have frequent arguments which involve yelling and screaming?	YES	NO
81. Have you had a car accident while high on alcohol or drugs?	YES	NO
82. Do you forget things you did while drinking or using drugs?	YES	NO
83. During the past month have you driven a car while you were drunk or high?	YES	NO
84. Are you louder than other kids?	YES	NO
85. Are most of your friends younger than you are?	YES	NO
86. Have you ever intentionally damaged someone else's property?	YES	NO
87. Have you ever stopped working at a job because you just didn't care?	YES	NO
88. Do your parents or guardians like talking with you and being with you?	YES	NO
89. Have you ever spent the night away from home when your parents didn't know where you were?	YES	NO
90. Have any of your best friends participated in team sports which require regular practices?	YES	NO
91. Are you suspicious of other people?	YES	NO
92. Are you already too busy with school and other adult supervised activities to be interested in a job?	YES	NO
93. Have you cut school at least 5 days in the past year?	YES	NO
94. Are you usually pleased with how well you do in activities with your friends?	YES	NO
95. Does alcohol or drug use cause your moods to change quickly like from happy to sad or vice versa?	YES	NO
96. Do you feel sad most of the time?	YES	NO
97. Do you miss school or arrive late for school because of your alcohol or drug use?	YES	NO
98. Is it important to you now to get or keep a satisfactory job?	YES	NO
99. Do your family or friends ever tell you that you should cut down on your drinking or drug use?	YES	NO
100. Do you have serious arguments with friends or family members because of your drinking or drug use?	YES	NO
101. Do you tease others a lot?	YES	NO
102. Do you have trouble sleeping?	YES	NO
103. Do you have trouble with written work?	YES	NO
104. Does your alcohol or drug use ever make you do something you would not normally do-like breaking rules, missing curfew, breaking the law, or having sex with someone?	YES	NO
105. Do you feel you lose control and get into fights?	YES	NO
106. Have you ever been fired from a job?	YES	NO
107. During the past month, have you skipped school?	YES	NO
108. Do you have trouble getting along with any of your friends because of your alcohol or drug use?	YES	NO
109. Do you have a hard time following directions?	YES	NO
110. Are you good at talking your way out of trouble?	YES	NO
111. Do you have friends who have hit or threatened to hit someone without any real reason?	YES	NO
112. Do you ever feel you can't control your alcohol and drug use?	YES	NO
113. Do you have a good memory?	YES	NO
114. Do your parents or guardians have a pretty good idea of your interests?	YES	NO
115. Do your parents or guardians usually agree about how to handle you?	YES	NO
116. Do you have a hard time planning and organizing?	YES	NO
117. Do you have trouble with math?	YES	NO
118. Do your friends cut school a lot?	YES	NO
119. Do you worry a lot?	YES	NO
120. Do you find it difficult to complete class projects or work tasks?	YES	NO
121. Does school sometimes make you feel stupid?	YES	NO
122. Are you able to make friends easily in a new group?	YES	NO
123. Do you often feel like you want to cry?	YES	NO
124. Are you afraid to be around people?	YES	NO
125. Do you have friends who have stolen things?	YES	NO
126. Do you want to be a member of any organized group, team, or club?	YES	NO
127. Does one of your parents or guardians have a steady job?	YES	NO
128. Do you think it's a bad idea to trust other people?	YES	NO
129. Do you enjoy doing things with other people your own age?	YES	NO
130. Do you feel you study longer than your classmates and still get poorer grades?	YES	NO
131. Have you ever failed a grade in school?	YES	NO
132. Do you go out for fun on school nights without your parents' or guardians' permission?	YES	NO
133. Is school hard for you?	YES	NO
134. Do you have an idea about the type of job or career that you want to have?	YES	NO
135. On a typical day, do you watch more than 2 hours of TV?	YES	NO
136. Are you restless and can't sit still?	YES	NO
137. Do you have trouble finding the right words to express what you are thinking?	YES	NO
138. Do you scream a lot?	YES	NO
139. Have you ever had sexual intercourse without using a condom?	YES	NO

Self-Administered Alcoholic Screening Test (SAAST)



1.	+	Do you enjoy a drink now and then? (If you never drink alcoholic beverages, and have no previous experience with drinking, do not continue with questionnaire.)		YES	NO
2.	-	Do you feel you are a normal drinker? (That is, drink no more than average).		YES	NO
3.	+	Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?		YES	NO
4.	+	Do close relatives ever worry or complain about your drinking?		YES	NO
5.	-	Can you stop drinking without a struggle after one or two drinks?		YES	NO
6.	+	Do you ever feel guilty about your drinking?		YES	NO
7.	-	Do friends or relatives think you are a normal drinker?		YES	NO
8.	-	Are you always able to stop drinking when you want to?		YES	NO
9.	+	Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your drinking?		YES	NO
10.	+	Have you gotten into physical fights when drinking?		YES	NO
11.	+	Has drinking ever created problems between you and your wife, husband, parent, or near relative?		YES	NO
12.	-	Has your wife, husband, or other family members ever gone to anyone for help about your drinking?		YES	NO
13.	+	Have you ever lost friendships because of your drinking?		YES	NO
14.	+	Have you ever gotten into trouble at work because of your drinking?		YES	NO
15.	+	Have you ever lost a job because of drinking?		YES	NO
16.	+	Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?		YES	NO
17.	+	Do you ever drink in the morning?		YES	NO
18.	+	Have you ever felt the need to cut down on your drinking?		YES	NO
19.	+	Have there been times in your adult life when you have found it necessary to completely avoid alcohol?		YES	NO
20.	+	Have you ever been told you have liver trouble? Cirrhosis?		YES	NO
21.	+	Have you ever had delirium tremens (DTs)?		YES	NO
22.	+	Have you ever had severe shaking, heard voices, or seen things that weren't there after heavy drinking?		YES	NO
23.	+	Have you ever gone to anyone for help about your drinking?		YES	NO
24.	+	Have you ever been in a hospital because of drinking?		YES	NO
25.	+	Have you ever been told by a doctor to stop drinking?		YES	NO
26.	+	Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?		YES	NO
27.	+	Was drinking part of the problem that resulted in the hospitalization?		YES	NO
28.	+	Have you ever been a patient at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problem?		YES	NO
29.	+	Have you ever been arrested, even for a few hours, because of drunken behavior (not driving)? How many times?		YES	NO
30.	+	Have you ever been arrested, even for a few hours, because of driving while intoxicated? How many times?		YES	NO
31-34. Have any of the following relatives ever had problems with alcohol?
31.	+	A.	Parents	YES	NO
32.	+	B.	Brothers or Sisters	YES	NO
33.	+	C.	Husband or Wife	YES	NO
34.	+	D.	Children	YES	NO

Note: The + sign indicates alcoholic responses.

Reproduced with permission from Swenson and Morse. Mayo Clinic Proceedings 50:204-208, 1975.

Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

This scale is not copyrighted and may be used freely.



CIWA-Ar


Patient:__________________________ Date: ________________ Time: _______________.(24 hour clock, midnight = 00:00)
Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______
NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting	TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
TREMOR -- Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient's arms extended 5 6 7 severe, even with arms not extended	AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
PAROXYSMAL SWEATS -- Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats	VISUAL DISTURBANCES -- Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
ANXIETY -- Ask "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions	HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe
AGITATION -- Observation. 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about	ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person
	Total CIWA-Ar Score ______ Rater's Initials ______ Maximum Possible Score 67

Ordering Information for Selected Assessment Instruments

Addiction Severity Index (ASI)

The Addiction Severity Index (ASI) is a multidimensional, 161-item structured interview that takes approximately 45 minutes to complete and score.

A copy of the fifth edition of the ASI form and administration manual are available at no charge by writing the developer:

Thomas McLellan, Ph.D.

Department of Psychiatry

University of Pennsylvania

Philadelphia, PA 19104

(215) 823-6095

Free copies of the National Institute on Drug Abuse (NIDA) ASI technology transfer package can be obtained by calling the National Clearinghouse for Alcohol and Drug Information (NCADI) at (800) 729-6686 and asking for package BKD 122.

Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI) is a 21-item, paper and pencil self-report depression rating scale that requires about 15 minutes to complete.

The manual and 25 record forms cost $41 and may be ordered from:

The Psychological Corporation

555 Academic Court

San Antonio, TX 78204

(800) 228-0752

Beck Hopelessness Scale

The Beck Hopelessness Scale (BHS) is a 20-item self-administered questionnaire that takes 10 minutes to complete. Developed by the author of the Beck Depression Inventory, the BHS may be ordered from:

Aaron Beck, Ph.D.

Center for Cognitive Therapy

University of Pennsylvania

Suite 519

133 South 36th Street

Philadelphia, PA 19104

Mini-Mental State (MMS)

The 11-question Mini-Mental State (MMS) is frequently used by mental health clinicians in evaluating patients. It can also be used by nonmental health clinicians with minimal training.

The MMS may be ordered from:

Marshal F. Folstein, M.D.

Department of Psychiatry

New England Medical Center

750 Washington Street

Boston, MA 02111

(617) 350-8442

(617) 956-5772 FAX

Problem Oriented Screening Instrument for Teenagers (POSIT)

The POSIT is reproduced in this appendix. The 139-item POSIT instrument can be self-administered via paper and pencil, computer, or audiotape; or it can be administered as a structured interview.

The POSIT has no copyright and may be ordered along with its scoring templates at no cost by contacting:

Adolescent Assessment Referral System Manual *(DHHS publication no. ADM 91-1735)

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, MD 20847-2345

(800) 729-6686

Recovery Attitude and Treatment Evaluator:

Clinical Evaluation (RAATE-CE) Questionnaire I (RAATE-QI)

The RAATE-CE and RAATE-QI are assessment of severity tools designed for compatibility with the ASAM Patient Placement Criteria. The RAATE-CE is a 35-item structured interview that requires approximately 20 to 30 minutes. The RAATE-QI is a 94-item self-report that takes patients about 30 to 45 minutes to complete.

These tools may be ordered from:

New Standards, Inc.

1080 Montreal Avenue

Suite 300

St. Paul, MN 55116

(800) 755-6299

(612) 690-1303 FAX

Self-Administered Alcoholic Screening Test (SAAST)

The 37-item SAAST is derived from the MAST and is reproduced in this appendix. This test can be administered by an interviewer or self-administered via paper and pencil or computer.

The SAAST may be ordered from:

Mayo Foundation for Medical Education and Research

200 First Street, S.W.

Rochester, MN 55905