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Chapter 4 of TAP 11: Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination

Chapter 4-Screening and Assessment

Assessment is one of the five critical elements of effective substance abuse treatment. It is the first stage of intervention with persons who are chemically dependent. A comprehensive appraisal of the individual's alcohol or drug problem, and how it affects his or her health and functioning, is vital for selecting treatment resources that best meet his or her needs. Assessment includes a determination of many factors, including:

• the severity of the problem;
• possible influences that have perpetuated chemical use, culminating in addiction;
• related difficulties; and
• the individual's perceptions of and attitude toward treatment.

This chapter will provide information about the purpose of assessment, as well as screening and assessment processes, methods, and instruments.

The Center for Substance Abuse Treatment has developed additional documents related to assessment to which the reader may refer for more information. These include the following.

• Screening and Assessment of Alcohol and Other Drug (AOD) Abusers in the Criminal Justice System, a Treatment Improvement Protocol (TIP), containing the recommendations of a Consensus Panel chaired by James Inciardi, Ph.D.
• Screening and Assessment of Alcohol- and Other Drug (AOD)- Abusing Adolescents, TIP 3, by Tom McLellan, Ph.D., and Richard Dembo, Ph.D. (1992).
• Criminal Justice Treatment Planning Chart (Center for Substance Abuse Treatment, 1993a).
• Juvenile Justice Treatment Planning Chart (Center for Substance Abuse Treatment, 1993b).

The Purpose of Assessment

Screening, assessment, and diagnosis are important in the treatment of any illness. Consider two people who go to a doctor with pain in their left arm. A variety of medical problems could result in such pain, including cardiovascular disease, a broken bone, arthritis, an infected wound, or cancer of the bone marrow, among others. Each of these conditions would call for a different type of treatment, ranging from the possibility of taking aspirin and doing some exercises for mild arthritis to possible surgery for severe heart disease or aggressive chemotherapy for cancer. If the physician prescribed the same treatment for both patients, without assessing and diagnosing the problem carefully, the odds of the treatment being appropriate for the problem would be minimal.

Instead, the doctor will ask each patient questions about how and when the pain started, how intense it is, the exact location of the pain, and other physical symptoms. He or she also will examine each patient and may request some medical tests. It may be necessary to have a specialist conduct part of the medical evaluation because of his or her greater expertise in a particular field. For example, a radiologist might be consulted to read x-rays of the affected area. Before determining the treatment needed for each person, the physician will review and analyze all of the information gathered. Once a diagnosis has been made, the doctor may provide the treatment needed or may refer either or both of the patients to a specialist who is more knowledgeable about treatment of the specific problem. Often, the doctor will ask the patient to return for a follow-up visit so that the accuracy of the diagnosis and the effectiveness of the treatment can be evaluated.

If the prescribed treatment has not alleviated the pain, additional tests may be done to further assess the cause of the problem. If the treatment has resulted in improvement or recovery from the problem, the physician will document that the diagnosis was accurate and the treatment was effective. This information will be useful if the doctor sees the same patient again for a similar problem. If another patient presents with the same symptoms and, after assessment, the diagnosis is the same, it is likely that the same course of treatment will be used again. However, if another patient with pain in the arm is diagnosed differently, the treatment prescribed is likely to be very different from that for another patient with the same presenting problem.

The Purpose of Assessment for Substance Abuse

There are at least five objectives for conducting appropriate and comprehensive assessments of persons with substance abuse problems or chemical dependency (McLellan & Dembo, 1992):

1. Identify those who are experiencing problems related to substance abuse and/or have progressed to the stage of addiction.
2. Assess the full spectrum of problems for which treatment may be needed.
3. Plan appropriate interventions.
4. Involve appropriate family members or significant others, as needed, in the individual's treatment.
5. Evaluate the effectiveness of the interventions that are implemented.

Why Is Assessment Important?

The assessment of persons with alcohol or drug problems is very much like the diagnosis of other disorders. Assessment is one of the five critical elements of effective treatment, and it is the first stage of the treatment process.

The assessment process includes gathering information from a variety of sources. These sources may include the patient's own statements, previous records, and significant others. When the information is collected, it is reviewed and evaluated by a trained professional. The information and the treatment professional's interpretation of it are then used to develop plans for treatment.

A variety of instruments have been developed as tools for the assessment process. There is a list of some currently available assessment instruments at the end of this chapter. Assessment instruments should be evaluated for validity (Do they measure what they say they measure?) and reliability (Do they consistently provide the same results?). When assessment instruments are used, it is important to ascertain that research has been conducted to determine their validity and reliability on populations similar to those on whom the instrument will be used. For example, an instrument might be a valid and reliable assessment tool for white adult males, but it may not necessarily be useful for assessing adolescent females.

Without a comprehensive assessment, there is a risk of treating the wrong set of problems or failing to provide any intervention for some problems. The general disorder of chemical addiction is very global. An assessment that delineates causative influences, types of substances abused, and related health, social, and behavioral factors is necessary for appropriate patient-treatment matching. The treatment of an adolescent who has an alcohol problem is markedly different from the treatment of an adult addicted to opiate drugs.

Each person with a substance abuse problem is likely to have a unique constellation of symptoms and factors. Several areas must be included in a comprehensive assessment, including:

• physical development and medical problems (including both general health conditions and possible infectious diseases such as HIV, tuberculosis, hepatitis, and sexually transmitted diseases);
• history of drug use and any prior treatment received;
• psychosocial problems (either precipitating chemical use or resulting from the abuse of drugs or alcohol), such as family- and peer relationships, school or vocational difficulties, and legal and financial problems;
• psychiatric disorders; and
• current socioeconomic status and eligibility for various programs.

Who Should Be Assessed?

Substance abuse is not a selective illness; it is found among all segments of the population. People of either gender, from all age cohorts, racial and ethnic groups, and socioeconomic strata, are subject to the destructive impact of alcohol and other drug abuse and addiction. Thus, the identification of those who have a substance abuse disorder requires attentiveness and sensitivity to the range of complex indicators that might signal the need for assessment and possible treatment. There are many clues that can alert health professionals, educators, employers, family members, criminal and juvenile justice system personnel, and others that the use of alcohol or other drugs is a problem for an individual. For example:

• a physician might become suspicious of frequent injuries, liver damage, weight changes, certain diseases, and a variety of other physical symptoms for which one explanation could be substance abuse;
• a teacher or employer might be alerted by changes in performance or attendance at school or on the job;
• family members, significant others, and peers might become concerned over changes in mood, friendship patterns, and relationships; or
• criminal and juvenile justice personnel might infer associations between substance use and criminal or delinquent behavior such as income-generating crimes (e.g., thefts, prostitution), violent crimes, and drug-related crimes (e.g., possession, sales of controlled substances).

When these or other problems become apparent it is vital that the person be evaluated and referred for appropriate treatment, if needed. A thorough assessment for substance abuse is important because it can identify not only chemical dependency, but other medical, psychosocial, or psychiatric problems that may underlie the symptoms. Even if problems are not caused by substance abuse, it is just as vital that the person receives other appropriate interventions, such as primary health care or human services.

A Comprehensive Assessment Process

A comprehensive assessment consists of five consecutive stages as depicted in Figure 4-A (McLellan & Dembo, 1992; Tarter, Ott & Mezzich, 1991). Each part of this process will be discussed briefly in the following sections.

Recognition of Risk Factors

There is often a precipitating event that brings alcohol or drug-involved persons to the attention of those concerned about them. An automobile accident or DUI arrest, being fired from a job, an arrest for shoplifting, or a head injury from a fall might all result from the effects of alcohol or other drugs. On the other hand, the indicators of problem drinking or drug abuse might be pieced together over time. For example, a teacher might notice a steady decline in a student's grades and school attendance or an employer might notice changes in productivity. A parent or spouse might notice that an individual's habits, grooming, and disposition have changed, and there may be increasing tensions and difficulties in the person's relationships.

These signs often are consistent with substance abuse. All too often, however, no action is taken until the disease has progressed to the point of full addiction which is irreversible, but treatable. Declining social functioning and increasing involvement with the criminal or juvenile justice system are typical indicators of substance abuse. The consequences to the person's health and personal functioning can be devastating. As pointed out in Chapter 1, it is estimated that approximately 6.5 million Americans are addicted to chemicals, but only about 300,000 persons are receiving treatment (Primm, 1992).

Education and coordination are very important for this stage of the assessment process. Health care providers, mental health professionals, educators, employers, criminal and juvenile justice personnel, and many others must know how to recognize factors that may be associated with substance abuse. It is also important that they conduct, or refer the person for, an initial screening to determine whether or not alcohol or drug use is a likely cause of the problems noticed.

Throughout the assessment and treatment process, coordination, collaboration, and communication among all responsible individuals and organizations is vital. At the State level, planners, legislators, funding sources, and other factions must recognize and underscore the importance of comprehensive assessments. This can be done by mandating that assessments be conducted and providing sufficient resources to accomplish this goal. State level decision makers also may provide guidelines related to appropriate assessment processes, techniques and instruments.

Community coordination is also critical. Agencies and professionals representing health and mental health care, education, the courts, and many other interests need to evaluate the problem of substance abuse in the community and the resources available for intervening. If not already in place, the services and funding needed to provide comprehensive assessments should be developed. The return on such an investment can be extremely valuable in both human and economic terms. Comprehensive assessment will facilitate more appropriate patient-treatment matching, more efficient use of scarce treatment resources, and more positive treatment outcomes. It is also important that agencies and professionals have open communication, are aware of the services available, and understand how to make referrals for assessment services.

Within agencies, such as hospitals, school systems, and the like, coordination of assessment and other substance abuse services is also important. For example, many persons are treated in hospitals for illnesses or injuries related to alcohol or drug abuse, but they never receive a comprehensive substance abuse assessment or needed treatment. Ways of coordinating services to en-sure that all personnel are alert to risk factors and follow through with appropriate screening and referrals for assessment should be developed.

Initial Screening

Screening refers to brief procedures used to determine the presence of a problem, substantiate that there is reason for concern, or identify the need for further evaluation. Screening may occur in several community and correc-tional settings. Private physicians, public health clinics, hospitals, mental health programs, and educational programs are among those that might screen individuals for substance abuse. Within the criminal and juvenile justice systems, screening should occur throughout the individual's contact. It should begin upon entry into the system and continue until release. This may include screening at points such as diversion, detention, pretrial, presentencing, sentencing, probation, incarceration, parole or aftercare, and revocation hearings. Both the Criminal Justice Treatment Planning Chart (Center for Substance Abuse Treatment [CSAT], 1993a) and the Juvenile Justice Treatment Planning Chart (CSAT, 1993b) indicate multiple points throughout each system at which screening and assessment for substance abuse should be conducted.

Screening Interviews and Instruments

Interview techniques and screening instruments may be designed to attempt to get alcohol-or drug-involved persons to reveal information about their substance abuse. These self-reports can be helpful in determining whether there is a need for further assessment and intervention. Screening interviews and instruments may be developed by a given agency, or they may be obtained from other sources providing them as a service or for profit.

Screening interviews might include a few brief questions asked during intake procedures that query the individual about the use of alcohol or other drugs. Screening instruments include brief tests (usually self-administered) that individuals take to provide information about their abuse of substances. In both cases, the alcohol- or drug-involved person is asked to give a self-report of his or her substance abuse.

Denial is a common facet of substance abuse disorders, as individuals (and often other significant persons in their lives) tend to minimize both the nature and the amount of their drug or alcohol use. Often, persons in denial actually convince them-selves that substance abuse is not a serious problem, though objective indicators suggest serious consequences (American Academy of Pediatrics, 1988; Miller, 1991). Persons who are drug-involved are more likely to be truthful about their use in settings they perceive as nonthreatening. Thus, reports from persons in treatment often are more credible than those from individuals in the criminal justice system. Assurance of confidentiality is an important factor that enhances self-reporting, while potential of prosecution and other sanctions is likely to diminish disclosures. While screening interviews and instruments may not give a true picture of drug and alcohol use in all cases, there are some persons who will be truthful. Coupled with other screening methods, such as chemical tests, these measures help distinguish users from nonusers (Nurco, Hanlon & Kinlock, 1990).

Drug Recognition Techniques

Drug recognition techniques are a systematic and standardized evaluation process to detect observable signs and symptoms of drug use. These include, among others, indicators such as dilated or constricted pupils, abnormal eye movements, elevated or lowered vital signs, muscle rigidity, and observation of behavioral indicators of drug use, such as speech, affect, and appearance. All the areas evaluated in these procedures are observable physical reactions to specific types of drugs. The three key elements in the drug recognition process are:

• verifying that the person's physical responses deviate from normal;
• ruling out a non-drug-related cause of the deviation; and
• using diagnostic procedures to determine the category or combination of drugs that is likely to cause the impairment.

These techniques originally were developed by the Los Angeles Police Department as a result of frequent encounters with impaired drivers. However, when tested for blood alcohol levels, these motorists did not have high enough concentrations of alcohol to result in the impairments the officers observed. In response to this problem, drug recognition techniques were developed to help officers identify drug-impaired drivers. Subsequently, personnel at the Orange County, California, Probation Department applied drug recognition techniques to their clients and have used their findings to expand the period for detecting drug use. The techniques are based on documented medical findings about the effects of alcohol and various drugs of abuse on the body. (See American Psychiatric Association, 1987; Ellenhorn & Barceloux, 1988; Giannini & Slaby, 1989; Gilman & Goodman, 1985; Grinspoon & Bakalar, 1990; Julien, 1992; O'Brien & Cohen, 1984; Schuckit, 1989.)

Drug recognition techniques can be very useful in identifying persons who are under the influence of alcohol or illegal substances or who have used drugs recently. They may be used appropriately at many points of contact with individuals. Based on evaluations conducted in several settings, trained personnel are capable of accurately detecting current or recent drug use with these techniques with high degrees of accuracy.

Drug recognition techniques are cost-effective. Although initial staff training can be costly, the techniques require only a few pieces of equipment and few continuing costs. They provide immediate information about current or recent drug use, and they are minimally intrusive. They rely on observations of body parts and functions that are visible to anyone at any time, rather than the collection of body fluids and the observation of bodily functions that are considered private. The techniques also are systematic and standardized, and they collect information about several observable signs and symptoms that are reliable indicators of drug use.

With drug recognition techniques, categories of drugs can be detected, but specific drugs cannot be determined. For example, it is possible to conclude that someone has used a central nervous system (CNS) stimulant, but it would not be possible to decide whether it was cocaine or amphetamines. Not all drugs are equally detectable with these techniques. Some categories of drugs cause pro-nounced physical symptoms while others provide few observable clues. Chemical testing is needed to determine more specific information about the types of drugs used. This is especially true when an individual is abusing more than one drug. If the person denies use, or if court actions or sanctions are to be taken, toxicological evidence may be necessary. However, drug recognition techniques are a good screening device before chemical testing. Sometimes, when confronted by the findings of a drug recognition expert, individuals may acknowledge their drug use and cooperate with the treatment process more readily. The techniques also can be used to rule out the presence of certain categories of drugs, thereby reducing the costs of testing for all possible substances.

Chemical Testing

Chemical testing is the most accurate method of determining current or recent drug use. Chemical testing can delineate the specific drug or drugs being used, but it cannot replace the assessment process to diagnose the addictive disorder. Many addicted persons use more than one mood-altering substance. It is especially common for alcohol to be used in combination with other drugs. Proper determination of the specific drugs being used is crucial in the patient-treatment matching process. The abuse of differing substances often requires varied treatment approaches. When multiple substances are being abused, it is important to combine appropriate treatment modalities and components.

Scientific methods of chemical testing include:

• breath analysis;
• saliva tests;
• urinalysis;
• blood analysis; and
• hair analysis.

Additional methods are being developed and investigated, such as the analysis of perspiration.

Currently breath analysis, saliva tests, and urinalysis are the most practical, accurate, and cost-effective methods of chemical testing available, especially for the criminal justice system and many community agencies. Blood analysis is sometimes used in medical settings, but is much more costly. Breath analysis and saliva tests are used to detect alcohol consumption, while urinalysis is employed to detect other drugs of abuse.

These tests can accurately reveal drugs in the system, but the time frame for detection is limited. Alcohol is eliminated from the body within a few hours of ingestion. Other drugs remain in the system longer, but detection limits can range from a few hours to about 30 days. Thus, chemical testing is dependable for identifying frequent users, but less frequent users of some drugs may test negative despite continuing use. Urinalysis cannot determine when drugs were actually ingested, nor can the level of intoxication be identified, as it can be with breath analysis for alcohol. It addition to identifying drug use, chemical testing can be a useful monitoring device and therapeutic agent in treatment when used with other interventions. As addiction is a chronic relapsing condition, chemical testing is a therapeutic tool to help prevent relapse.

Chemical testing is a highly reliable method of determining alcohol or drug use, but it also is a more intrusive process–especially urinalysis. To prevent adulteration of urine samples, the collection of specimens should be observed.

Selection of urinalysis methodologies also is important. For initial tests, immunoassays are generally used. All immunoassay tests operate in basically the same way, but differ from one manufacturer to another in the chemical "tag" used to identify the drug.

Specimens for testing may be sent to laboratories for analysis; however, reliable products are available for on-site testing in agencies. Whether using laboratory or on-site testing, agencies need to have well-defined chemical testing policies that delineate procedures, including the following areas:

• specimen collection;
• chain of custody (e.g., handling, documentation, storage, transportation);
• cutoff levels for initial and confirmation tests;
• scheduling of tests and selection of persons to be tested;
• quality assurance and quality control;
• safety procedures;
• interventions/treatment referrals; and
• other applications of findings, such as legal actions.

Gas chromatography/mass spectrometry (GC/MS) is considered the "gold standard" in urinalysis. It is highly accurate and is the only method of urinalysis that reliably produces quantitative results. It is frequently used as a confirmation method if initial immunoassay tests produce positive results.

Technological Innovations

A second development, called the Telemetered Drug Use Detection system, is evaluating the feasibility of a drug detection device worn on the wrist. Through analysis of perspiration, the device could detect drug use and send results to a central control station. This technology combines position identification (similar to electronic monitoring), chemical and biological processes, and microcommunications and signaling. It is a noninvasive method of chemical testing for drug use (Jackson, 1992).

Other Sources of Information

The screening processes already described in this section are those which attempt to obtain information directly from the person believed to be using drugs or alcohol. It also may be important to collect data from other sources during the screening process. Among others, this may include obtaining facts from family members, teachers, and employers; reviewing available records (e.g., health, psychosocial, legal); and considering the observations made by professionals.

Advantages and Disadvantages of Screening Methods

Drug recognition techniques and chemical testing methods can provide reliable information on current or recent drug use. However, self-reports through interviews and tests are the only screening devices that will provide information about alcohol and drug use over time. The accuracy of self-reports relies upon the motivation of the individual to disclose drug use. Chemical testing is the most expensive of the three methods but provides the most scientifically valid information. Chemical testing also is the most intrusive of the three methods, requiring observed specimen collection procedures to ensure accurate results.

Key Issues in Screening for Alcohol and Drug Involvement

There are several considerations in selecting screening methods and instruments and conducting screening procedures. These should be deliberated carefully by those who will be endorsing or conducting screenings. Table 4-A provides a summary of key areas (McLellan & Dembo, 1992).

Screening should detect specific indicators of substance abuse, such as health factors, educational or job-related problems, relationship difficulties, or financial and legal consequences of substance abuse. If screening procedures indicate that substance abuse or dependency is probable, the person should be referred for a more comprehensive assessment.

Comprehensive Assessment

Screening is useful in differentiating persons who are alcohol-or drug-involved from those who are abstainers or whose use is limited and is not creating any problems for them. Assessment, on the other hand, indicates a process to determine the nature and complexity of the individual's spectrum of drug abuse and related problems (McLellan & Dembo, 1992). A comprehensive assessment uses extensive procedures that evaluate the severity of the substance abuse problem, elicit information about cofactors, and assist in developing treatment and follow-up recommendations. In addition to assessing substance abuse per se, a comprehensive assessment will probe related problem areas, such as (McLellan & Dembo, 1992; Tarter, Ott & Mezzich, 1991):

• medical status and problems (including both general health conditions and infectious diseases such as HIV, tuberculosis, hepatitis, and sexually transmitted diseases);
• psychological status and possible psychiatric disorders;
• social functioning; family and peer relations;
• educational and job performance;
• criminal or delinquent behaviors and legal problems; and
• socioeconomic status and problems.

There are three basic steps in the assessment process (McLellan & Dembo, 1992):

1. Information
2. Data analysis
3. Treatment plan development

Each of these will be discussed in the following sections.

Information Gathering

There are three sources of information that can be helpful in conducting a comprehensive assessment:

1. Existing information
2. Individual and collateral interviews
3. Testing instruments

Investigation of existing information. Table 4-B contains several categories of information that may already be available about an individual. Confidentiality requirements, to protect the privacy of individuals, require the person to sign a release of information form before much of the information listed in Table 4-B can be requested.

Self-reports, interviews, and collateral contacts. Interviews with individuals are much more extensive than the self-reports that were described as a method for screening. The interview can reveal valuable information about the person, to complement other information and obtain an accurate evaluation of problems. An assessment interview also may be the foundation for a positive, trusting working relationship during future interventions.

As with screenings, collateral interviews involve gathering information from other persons who are, or have been, associated with the person being assessed. Collateral sources should be asked to provide descriptive information rather than to form judgments about the person. As with patient interviews, information received is not always accurate. Possible collateral sources include family members, peers, teachers, employers, and others who might have helpful information.

Information gathering may involve one professional obtaining information in all areas. However, when particular areas raise concern, an interviewer or case manager may request consultation from other professionals. For example, if an individual discloses that he or she is bothered by certain physical symptoms, and the assessor is not a physician, a referral should be made for a medical examination. Similarly, it might be necessary to obtain psychological or psychiatric evaluations if it is determined that in-depth assessments in these areas are needed and the person conducting the assessment is from a different discipline. A multi-disciplinary assessment team is recommended for obtaining the range of information needed for comprehensive assessment and treatment planning.

Interviews should be adapted to the age and culture of the patient. Cognitive abilities can affect the interview process; thus, the interviewer must be aware of the patient's cognitive ability level and try to structure the interview accordingly. Language may present another barrier in the assessment process. If the individual being assessed is not fluent in the same language as the interviewer, an experienced interpreter who is familiar with the patient's culture and the interview questions should be used (McLellan & Dembo, 1992).

Some of the information to be probed during interviews with the individual and collateral sources will include, but is not limited to, the following areas. Often, these overlap with information gathered from existing records.

Testing instruments. Testing instruments can include:

• standardized interviews,
• structured interviews; and/or
• self-administered tests.

These techniques have been developed to assess individuals in multiple areas (e.g., personality, aggressive tendencies, social skills, stress factors, risk for substance abuse, intellectual capacity). Most of the instruments have been formulated and standardized through a systematic research and validation process.

An advantage of using standardized instruments is that information regarding their reliability and validity may be available. If an instrument has high validity, it will accurately measure what it intends to measure. An instrument that has high reliability will produce stable results; the test's outcome will not be significantly influenced by fluctuating or extraneous factors (such as a person's mood or the time of day). The instrument should be normed, or validated, with a population similar to those with whom it will be used. For example, an instrument used with adolescents should be normed on other adolescents. An instrument to be used with criminal offenders should have been normed on other offender populations. However, even when the credibility of these tests has been proved, test outcomes may be affected by other factors, including:

• attempts by individuals using them to "slant" the outcome by deliberately answering questions incorrectly;
• ability of individuals to read and understand the test items;
• motivation of persons to take the test seriously; and
• cultural sensitivity of the test.

The assessment process is likely to be most helpful and informative when a variety of techniques are used. Testing instruments are a tool to guide decision-making efforts. As with all other techniques, the limitations of these tests must be realized. Staff members who are given the responsibility of administering and interpreting them should be fully trained.

Standardized and Structured Interviews. The standardized interview differs from the structured interview in that it limits the interviewer to a prescribed style and list of questions. Using the standardized interview, the interviewer is restricted from freely probing beyond conflicting or superficial answers, sometimes considered a disadvantage of this technique. An advantage is that this interview may be more credible than the structured interview, an important consideration when results are used to support significant decisions (e.g., treatment referrals or legal actions).

Minimal training is usually required to administer standardized interviews. To administer structured interviews, interviewers must have knowledge and experience in working with similar populations, as well as expertise in interviewing. The goal of this interview is to obtain as much information as possible about the person. Therefore, the interviewer is expected to probe beyond superficial or conflicting answers. Structured interviews usually take more time to administer and interpret than standardized interviews.

Self-Administered Tests. Usually, less staff skill is required with self-administered tests than with structured or standardized interviews. On the other hand, these tests require some motivation and reading ability on the part of the individual being assessed. Many instruments are written at the fourth or fifth grade reading level. Moreover, self-administered tests are only credible if the person is willing to answer the questions honestly. However, written tests can be helpful for those who have difficulty speaking directly about themselves. These instruments provide an indirect and, for some, less threatening method of self-disclosing information. They also prevent interviewer bias and, like other standardized instruments, can be scored and quantified. Reliability and validity measures usually are available as well.

Data Analysis

Once information is gathered, it is interpreted for use in decision making. During this phase, professional service providers determine the severity of the person's alcohol or drug problem, possible contributing factors, and his or her readiness for intervention.

The professional conducting or managing the assessment process will use all of the collected data to arrive at an opinion about the individual's substance abuse problem. The question to be answered is: Do the data indicate that the person is addicted to or dependent on one or more chemicals, an abuser of chemicals, or not adversely affected by occasional use of drugs and/or alcohol? (Doweiko, 1990).

The analysis must encompass the range of problems, strengths and sources of support available to the person. It also should address factors that have contributed to or are related to alcohol and other drug abuse (McLellan & Dembo, 1992).

Treatment Plan Development

The findings from the assessment process and monitoring of treatment should be documented to enhance clinical case supervision. The data derived from the screening and assessment processes form the basis of a treatment plan. This plan must recognize the unique constellation of problems and other factors that have been identified for the individual. The treatment plan will recommend a course of action that attempts to address the patient's unique needs. Implementation of the plan will involve providing or referring the person to appropriate treatment programs and monitoring his or her progress. A single treatment modality or a combination of services may be needed. The treatment plan should be comprehensive, containing information about the following categories:

• the identified problems to be addressed;
• the goals and objectives of the treatment process (e.g., to help the individual abstain from use of drugs, to help the patient resolve underlying self-esteem problems, to help the person achieve full employment);
• the resources to be applied (i.e., treatment programs, funding, other services, etc.);
• the persons responsible for various actions (e.g., making referrals, attending treatment sessions, follow-up reports);
• the time frame within which certain activities should occur; and
• the expected benefits for the person who will participate in the treatment experience.

Appropriate Interventions

Based on the recommendations made in the treatment plan, appropriately matched treatment interventions should be provided to the drug-involved individual. This may include:

• preventive and primary medical care;
• testing for infectious diseases;
• random drug testing;
• pharmacotherapeutic interventions;
• group counseling interventions
• substance abuse counseling;
• life skills counseling;
• general
• health education;
• peer/support groups
• liaison services;
• social and athletic activities;
• alternative housing; and
• relapse prevention.

These may be provided on either an outpatient or an inpatient/residential basis depending on the needs of the person. More information on these interventions and services will be given in later chapters.

Evaluation of Process and Outcome

As with the example of the treatment of arm pain at the beginning of this chapter, the assessment and intervention process includes evaluation of the process and outcomes. Process evaluation indicates whether or not the appropriate procedures were used. Were the needed assessment procedures performed and did they result in a timely and appropriate treatment plan? Did the individual attend the treatment programs and services recommended in the treatment plan? Were the services that were promised delivered?

The outcome evaluation will examine whether or not the individual benefitted from the assessment and the interventions. It will indicate whether or not the assessments were accurate in correctly defining the problem and matching the person with appropriate treatment resources. If so, and if the patient is cooperative, there should be indicators of improvement or recovery when follow-up evaluations are conducted. If not, it will be necessary to use the feedback information to initiate additional assessment procedures or change the treatment plan. Outcome evaluation also may indicate problems in service delivery. Chapter 10 will provide more information on program evaluation.

Process and outcome evaluation data also may provide documentation of service needs. Although assessments may indicate needs for specific services, often they do not exist in particular communities, they are not affordable for all persons who need them, or there is not sufficient room in programs for new referrals. These data are extremely important for community and State decision makers who must determine program priorities and funding resources.

Assessment Instruments

There are standardized testing instruments available to assess individuals in a variety of areas. When selecting these instruments, consideration should first be given to the areas to be assessed, and options should be limited to instruments that are designed to address those areas. The following factors should then be considered in reviewing the various instruments:

• ease of use;
• expertise and time required of staff to administer and score test;
• training required to administer and score the instrument, and whether or not such training is available;
• possibility of bias (cultural or in administration of the test);
• validity (Have studies proved that it accurately measures what it was intended to measure?);
• reliability (Have studies shown that if the test were repeated with the same person, the results would be the same?);
• credibility of test among members of the judiciary and treatment professionals;
• adaptation of test to management information system input and retrieval;
• whether the test has been normed with a population similar to the client group;
• availability of test in languages other than English;
• motivation level, verbal and reading skills required of persons to be assessed;
• propensity for test to be manipulated; and
• average cost per test.

Sources of Assessment Instruments

Proprietary instruments are developed and copyrighted by individuals or organizations. There is usually a cost for their use. Some instruments are developed by local agencies. They often are program-specific and may or may not be useful in other settings. Often they have not been validated to determine their accuracy. Many agencies are willing to share such instruments without a charge. Instruments developed by federal agencies are in the public domain and may be used without a fee. Validity and reliability studies for them are documented (National Task Force on Correctional Substance Abuse Strategies, 1991).

Brief information about several available assessment instruments (both interviews and self-administered) is included at the end of this chapter. The instruments included in this list do not represent an exhaustive exploration of such instruments, nor does incorporation in this list represent an endorsement of particular instruments. Rather these are offered as a compilation of those instruments located through literature review. Because the needs of various agencies and systems vary, service providers and decision makers should examine an array of instruments and select those best suited to their particular needs.

Conclusion

Assessment is the beginning of the treatment process. It is a critical element of treatment, for without comprehensive assessment, appropriate patient-treatment matching is not possible. Just as it would be inappropriate to treat arthritis with chemotherapy intended for cancer patients, it is similarly unsuitable to provide a drug-involved adolescent with treatment intended for an adult male alcoholic. Thus, scarce treatment resources may not be used wisely if patients are not assessed carefully before treatment plans are formulated. Comprehensive assessment improves the overall cost-effectiveness of providing treatment.

Assessment is important in the coordination of services, as well. Valuable information can be gained so that the most appropriate services for individuals are delivered at the community level. Aggregated information is also beneficial for State and local decision makers needing to determine priorities, set standards, and allocate funding according to the areas of greatest need.

In the next chapter more information will be provided about patient-treatment matching, an important outcome of assessment.

References

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Crist, D.A., & Milby, J.B. (1990). Psychometric and neuro-psychological assessment. In W.D. Lerner & M. A. Barr (Eds.), Handbook of hospital based substance abuse treatment. New York: Pergamon Press.

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Schaefer, P.J. (1992). Summaries of assessment instruments for identifying and diagnosing adolescent drug involvement. Lexington, KY: American Probation and Parole Association (unpublished).

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Endnotes

1. Portions of this section were adapted from Assessment Instruments and Techniques (Chapter 11) and Drug Recognition Techniques (Chapter 12) in Identifying and Intervening with Drug-Involved Youth, written by Ann H. Crowe and Pamela Schaefer, American Probation and Parole Association.

2. Information in this section was adapted from Assessment Instruments and Techniques (Chapter 11) in Identifying and Intervening with Drug-Involved Youth, written by Pamela Schaefer, American Probation and Parole Association.

Last Updated 11-7-02