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Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services
VIII. Adolescents (12–18 Years)
There is a substantial body of behavioral literature dealing with adolescents. Most commonly, adolescence is considered to begin within puberty
and continue through 18 or 19 years of age. Individual differences in the onset of puberty and full achievement of sexual maturity create a situation
in which biological adolescence for some individuals begins as early as 6 years of age and extends into the early 20s. For program planning and evaluation,
adolescence can be defined as extending from the 11th or 12th birthday to the 19th birthday. Research supports screening interviews for tobacco,
alcohol, and illicit drug use for all adolescents aged 12–18 years, and suggests screening for depression as a “targeted” service.
Adolescence is a period of rapid change and development that offers unique opportunities for interventions that could have substantial impact on
future health and quality of life. Addictions and lifelong habits related to tobacco, alcohol, illicit drugs, and high-risk behaviors frequently
are formed in adolescence. Most of the literature and most guidelines relating to these issues focus on the adolescent age group and address community,
social agency, and educational interventions. Since the vast majority of adolescents use relatively little medical care, screening of adolescents
in health care settings has not been a cornerstone of most adolescent-related preventive behavioral programming. Almost all preventive behavioral
programming is conducted in school and community settings, and occasionally in correctional settings (Schinke et al., 2002).
Depression and suicide are major concerns in adolescence. Unfortunately, the adult screening tests for depression are not as specific or sensitive
for adolescents. This means that there will be more false-positives and more false-negatives. Furthermore, no studies have examined treatment outcomes
for children or adolescents identified by primary care clinicians through screening (USPSTF, 2003). This lack of adolescentspecific, primary-care–specific
research makes it difficult to suggest screening of all adolescents for depression as a “general” service. Preventive behavioral services to adolescent
pregnant women are the same for adolescents and adults.
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996), the
following is suggested for male adolescents and nonpregnant female adolescents:
Organizations developing clinical recommendations recommend universal (interview) screening of adolescents for tobacco, alcohol, and illicit drug
use—with follow-up on positive findings to confirm the impression from screening and provide needed counseling and other services. These include
the American College of Physicians (American College of Physicians Health and Public Policy Committee, 1986), the American Academy of Family Practice,
the American Academy of Family Physicians (1994), the American Academy of Pediatrics (AAP, 1994), the American College of Obstetrics and Gynecology
(ACOG, 1993), the American Medical Association (AMA , 1994), and others (ADA, 1992; CTF on the Periodic Health Examination, 1994b; NIH, 1989, 1994);
American Academy of Otolaryngology—Head and Neck Surgery, 1992; Green, ed., 1994; USPSTF, 1996). Although available interventions are limited in
efficacy, these services appear to be of enough value to the adolescents reachable by these means to be recommended as universal services for all
adolescents being seen in all health care systems (USPSTF, 1996).
With the exception of adolescents who are
pregnant or suffering from a major chronic
disease, it is unlikely that health care systems
can anticipate a significant immediate
reduction in other health care costs that
result from providing behavioral screening
and follow-up services. The universality of
these guidelines for health care systems is
based on the perception that attitudes and
habits developed during adolescence will
have a lifetime impact on health risk profiles
and quality of life.
A. Tobacco
Tobacco screening and follow-up for adolescents is classified as “general” because of the addictive nature of tobacco products and because of the
severe harm tobacco products cause. This classification also takes into account the lack of substantial evidence to show the value of clinician interventions
in either preventing tobacco use or in getting adolescents to quit. These recommendations are not limited to cigarettes and cigars because a substantial
number of teens use snuff or chewing tobacco (DHHS, 1994).
There are two major reasons to address tobacco control in adolescents. The first and most significant reason is to prevent future illness and death.
Most smokers start during adolescence, and if someone does not begin to smoke until after the age of 21, it is very unlikely that smoking will become
a lifelong addiction (DHHS, 1988; Henningfield, Cohen, & Pickworth, 1994). The second and less important reason relates to immediate prevention of
physical deterioration and illness.
Tobacco-related interventions have proven effective enough in practice to be universally implemented. This is backed up by the fact that all major
health care organizations and authorities recommend routine clinician counseling of adults, pregnant women, parents, and adolescents to avoid or
discontinue smoking and use of smokeless tobacco (USPSTF, 1996; American College of Physicians Health and Public Policy Committee, 1986; American
Academy of Family Physicians, 1994; AAP, 1994, 1988; ACOG, 1993; Manley et al., 1991; AMA, 1993; American Dental Association [ADA], 1992; CTF on
the Periodic Health Examination, 1994b; NIH, 1989, 1994; AMA, 1994a; American Academy of Otolaryngology—Head and Neck Surgery, 1992; Green, ed.,
1994).
Intervention
The primary care physician or nurse may inquire about the use of tobacco products at every visit, counsel not to initiate tobacco use, and reinforce
this message at every visit. A primary focus of adolescent tobaccorelated programming (as opposed to pregnant women and adults) is the initiation
of tobacco use.
Review of Literature
A more substantial review of the tobacco and health literature is presented in the discussion of tobacco in the Adults (19 Years and Older) section
of this report.
Evidence Base for Intervention
According to the 1996 Second Edition of the
U.S. Preventive Services Task Force’s Guide to
Clinical Preventive Services (USPSTF, 1996)—
The scope of this report does not permit an examination of each study of the health effects of smoking or the nature of the risk relationship
(e.g., relative risk, dose-response relationship) between smoking and each disease. Detailed reviews of this extensive literature have been published
elsewhere (CDC, 1990, 1993a; DHHS, 1986, 1989; U.S. Environmental Protection Agency [EPA], 1992; National Cancer Institute [NCI], 1993). A number
of consistent findings from this body of evidence are well established. First, tobacco is one of the most potent of human carcinogens, causing
an estimated 148,000 deaths among smokers annually due to smokingrelated cancers (CDC, 1993a). The majority of all cancers of the lung, trachea,
bronchus, larynx, pharynx, oral cavity, and esophagus are attributable to the use of smoked or smokeless tobacco (DHHS, 1986, 1989). Smoking also
accounts for a significant, but smaller proportion of cancers of the pancreas (CDC, 1990; Howe, Jain, Burch et al., 1991; Bueno de Mesquita, Miasonneuve,
Moerman, et al., 1991), kidney (DHHS, 1989), bladder (CDC, 1990; Hartge, Silverman, Schairer et al., 1993), and cervix (CDC, 1990; Coker, Rosenberg,
McCann, et al., 1992; Sood, 1991; Gram, Austin, & Stalsberg, 1992); … 100,000 deaths from coronary heart disease … [and] 85,000 deaths from pulmonary
diseases … . Children and adolescents who are active smokers have an increased prevalence and severity of respiratory symptoms and illnesses, decreased
physical fitness, and potential retardation of lung growth (DHHS, 1994)… the nicotine in tobacco is an addictive drug … initiation of tobacco use
at an early age is associated with more severe addiction as an adult.
There is a large body of evidence from prospective cohort and casecontrolled studies showing that many of these health risks can be reduced by
smoking cessation (CDC, 1990).
There have been no published trials that have adequately evaluated interventions by clinicians in preventing tobacco use initiation. Since the
mid-1970s, however, more than 90 controlled trials of schoolbased tobacco use prevention interventions have been published (DHHS, 1994). School-based
programs reduce the incidence (Hansen, Johnson, Flay, et al. 1988; Abernathy & Bertrand, 1992) and prevalence (Elder, Wildey, de Moor, et al.,
1993; Botvin, Dusenbury, Tortu, et al., 1990) of tobacco use in adolescents at 2 to 4 years follow-up. However, longer follow-up has shown little
long-term benefit … suggesting that program effects need to be reinforced (Flay, Koepke, Thomson, et al., 1989; Murray, Pirie, Luepker, et al.,
1989). All major health care organizations and authorities recommend routine clinician counseling of adults, pregnant women, parents, and adolescents
to avoid or discontinue smoking and use of smokeless tobacco (USPSTF, 1996; American College of Physicians Health and Public Policy Committee,
1986; AAFP, 1994; AAP, 1994, 1988; ACOG, 1993; Manley, et al., 1991; AMA, 1993; ADA, 1992; CTF on the Periodic Health Examination, 1994b; NIH,
1989, 1994; AMA, 1994a; American Academy of Otolaryngology—Head and Neck Surgery, 1992; Green, ed., 1994).
This literature search failed to yield significant new literature on the topics noted above since publication of the Guide. The problem is
not negative literature, but an absence of literature on clinician interventions for adolescents.
For adolescents other than pregnant women, the evidence base for the recommended interventions (clinician counseling to prevent tobacco use or to
encourage cessation of tobacco) is weak, but the health-status cost of becoming addicted to tobacco products or continuing an established addiction
is so extreme, that programming of even minimal effectiveness is considered standard practice.
Program Implementation Issues
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996), certain
strategies can increase the effectiveness of counseling to end tobacco use (NIH, 1986, 1989, 1994; AMA, 1994a; AAFP, 1987; Kenford, Fiore, Jorenby,
1994):
- Direct, face-to-face advice and suggestions
- Reinforcement
- Office reminders to the physician
- Self-help materials
- Community programs for additional help in quitting
- Drug therapy (nicotine patch or gum and related products)
Data To Be Tracked For Surveillance, Member Selection, Feasibility Assessment, and Program Evaluation
Data To Be Gathered
Refer to Appendix D, Procedures for Implementation and Evaluation of Preventive Services, and the sections on tobacco use in pregnant women and adults.
B. Alcohol
Alcohol screening and follow-up for adolescents are classified as “general” because of the severe immediate harm caused by alcohol use by adolescents,
including auto accidents and problems in school. This classification was established in the face of no substantial evidence base from randomized
controlled trials to show the value of clinician interventions in either preventing alcohol use or getting adolescents to quit.
Intervention
The primary care physician or nurse may choose to inquire as to use of alcohol at every visit, counsel abstention or moderation, and reinforce this
message at every visit.
Service-Related Issues Specific to Alcohol and Adolescents
- As with tobacco and illicit drugs, practitioners seeing adolescents may choose to address the topic of alcohol, urge abstinence or no more than
very moderate use, and explore whether there is a problem in need of additional discussion.
- High-quality, validated screening questionnaires that are brief enough to be practica in primary care settings are available for screening adolescents
and adults for problem drinking. Adults may be periodically screened for problem drinking or alcohol dependence. In most primary care settings,
the two-question, two-item conjoint screen (TICS) or fourquestion CAGE (Chan, 1994) or CUGE (Cut down/Under the influence driving/Guilty/Eye opener)
(Aertgeerts et al., 2000) screening instruments may be most useful. In emergency room and psychiatric inpatient settings, the CAGE (four yes/no
questions), Audit (10 multiple-choice questions), or Michigan Alcoholism Screening Test (MAST) (Selzer, 1971) (25 questions) may be considered.
These are all described below. In community health centers and facilitybased primary care outpatient settings with provision for nurses or social
workers to conduct initial patient settings, use of the 10-question Adult Use Disorders Identification Test (AUDIT) instrument may be very helpful.
- Special studies may be needed to identify whether the health care system has a high enough incidence of car crashes, injuries, homicides, or
suicides within any segment of its adolescent population to warrant partnering with appropriate community agencies to address possibly severe alcohol-related
problems.
Review of Literature
A more substantial review of the alcohol and health literature can be found in the section on Adults (19 Years and Older) in this report. The adult
alcohol discussion includes the most important alcohol screening questionnaires. Literature specific to use of alcohol during pregnancy is presented
in the section called Pregnant Women.
Evidence Base for Intervention
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—
… Use of alcohol by adolescents and young adults has declined over the past decade but remains a serious problem (NIDA, 1993). Among 12–17 year-olds
surveyed in 1993, 18 percent had used alcohol in the last month, and 35 percent in the last year (SAMHSA, 1994). In a separate 1993 survey, 45
percent and 33 percent, respectively, of male and female 12th graders reported binge drinking (five or more drinks on one occasion) within the
previous month (CDC, 1995b). The leading causes of death in adolescents and young adults—motor vehicle and other unintentional injuries, homicides,
and suicides—are each associated with alcohol or other drug intoxication in approximately half of the cases. Driving under the influence of alcohol
is more than twice as common in adolescents than in adults (CDC, 1987). Binge drinking is especially prevalent among college students: half of
all men and roughly one third of all women report heavy drinking within the previous 2 weeks (NIDA, 1993; Wechsler, Davenport, Dowdall, et al.,
1994). Most binge drinkers report numerous alcoholrelated problems, including problems with school work, unplanned or unsafe sex, and trouble with
police (Wechsler et al., 1994).
The American Academy of Pediatrics (AAP), AMA Guidelines for Adolescent Preventive Services (GAPS), the Bright Futures Guidelines, and the American
Academy of Family Physicians (AAFP) all recommend careful discussion with all adolescents regarding alcohol use and regular advice to abstain from
alcohol (American Academy of Pediatrics Committee on Adolescence, 1995; AMA, 1994b; Green, ed., 1994; AAFP, 1994).
Program Implementation Issues From the Published Literature
In a 2002 review of alcohol-problem related screening questionnaires (NIAAA, 2002), the National Institute on Alcohol Abuse and Alcoholism (NIAAA)
stated: “The Alcohol Use Disorders Identification Test (AUDIT) is relatively free of gender and cultural bias (Cherpitel, 1999; Reinert & Allen,
2002; Volk, Steinbauer, Cantor, & Holtzer, 1997). In addition, it shows promise for screening adolescents and older people—populations in which standard
screening instruments produce inconsistent results (Steinbauer, Canton, Holzer, & Volk, 1998; Reinert & Allen, 2002; Clay, 1997; Chung, Colby, Barnett,
et al., 2000; Chung, Colby, Barnett, & Monti, 2002). The major disadvantage of AUDIT is its length (10 questions) and relative complexity (multiple
choice); clinicians require training to score and interpret the test results (Allen & Columbus, 1995).” According to the 1996 Second Edition of the
U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—
Laboratory tests generally are insensitive and nonspecific for problem drinking in both adolescents and adults. Numerous studies demonstrate that
clinicians frequently are unaware of problem drinking by their patients (USPSTF, 1996; NIAAA, 1993). Early detection and intervention may alleviate
ongoing medical and social problems due to drinking and reduce future risks from alcohol abuse.
A 1990 Institute of Medicine (IOM) report concluded that specific recommendations for the treatment of alcohol problems in young persons were
impossible, due to disagreement over what constitutes a drinking problem in adolescents, the wide variety of interventions employed, and the absence
of any rigorous evaluation of different treatments (IOM, 1990). Recent reviews of school-based programs found that most effects were inconsistent,
small, and short-lived; programs that sought to develop social skills to resist drug use seem to be more effective than programs that emphasize
factual knowledge (Ennett, Tobler, Ringwalt, et al., 1994; Hansen, 1992).
All the data available regarding the efficacy of clinical interventions at the time of the 1996 report are from studies in adults, not adolescents.
The studies needed to document the efficacy of such interventions in adolescents simply have not been done, leaving us with a situation where we
either ignore alcohol problems in adolescents or extrapolate the results from adults to adolescents until such time as the needed studies can be
conducted, peer-reviewed, and published. As noted above, AMA, AAP, and AAFP all have opted to recommend intervention in adolescents despite the
lack of adolescent-specific studies.
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—
Typical of the results for nondependent drinkers, a metaanalysis of six brief intervention trials (5–15 minutes of clinical counseling) showed
an average reduction in alcohol consumption of 24 percent, comparing cases to controls. Although self-reported consumption may be subject to bias,
reported changes in drinking correlated with measures of GTT [glucose tolerance test] and blood pressure in most studies (Babor & Grant, eds.,
1992). It is important to note that this and most other such studies suffered from important methodological limitations.
For adults with alcohol-dependence, completing either inpatient treatment or 12 weeks of outpatient treatment, some studies have shown approximately
60 percent long-term abstinence rates. These data are difficult to interpret, however, because of inadequate control groups, insufficient or selective
follow-up, and selection bias due to the characteristics of patients who successfully complete voluntary treatment programs (IOM, 1989; Thurstin,
Alfano, & Sherer, 1986; Emrick, 1987). Since spontaneous remission occurs in as many as 30 percent of alcoholics (Smart, 1975/76; Saunders & Kershaw,
1979), reduced consumption may be inappropriately attributed to treatment. Successful treatment is likely to represent a complex interaction of
patient motivation, treatment characteristics, and the post-treatment environment (family support, stress, etc.) (IOM, 1990; NIAAA, 1993). The
IOM review concluded that treatment of other life problems (e.g., with antidepressant medication, family or marital therapy, stress management)
and [counsel with] empathetic therapists were [factors] likely to improve treatment outcomes (IOM, 1989).
Data To Be Gathered
Refer to Appendix D. There are no specific supplemental data needs relative to alcohol and adolescents.
C. Illicit Drugs
Programming to control use of illicit drugs by adolescents is classified as “general” because of the severe immediate harm caused by drug use by
adolescents—including auto accidents and problems in school. A number of studies demonstrate the efficacy of clinical interventions in reducing or
eliminating drug use among symptomatic adolescents. Although community interventions have demonstrated value in preventing adolescent drug use, there
is no substantial evidence that stand-alone clinical interventions can prevent drug experimentation and use. There is no substantial evidence base
to show the value of clinician interventions in getting asymptomatic adolescent drug users to quit. In each instance, the needed adolescentspecific
studies have not been done. Given these circumstances, the severe harm caused by drugs in adolescents, and the difficulty in ascertaining which adolescents
are using illicit drugs (because many parents do not know and many adolescents are unlikely to be forthright on this issue with adult authority figures),
the most prudent course appears to be brief universal screening of adolescents for drug use (by interview at each primary care visit), with follow-up
as appropriate.
Intervention
The primary care physician or nurse may wish to inquire as to the use of illicit drugs at every visit, counsel abstention, and reinforce this message
at every visit. Service-related issues specific to illicit drugs and adolescents are as follows:
- To approach discussion of use of illicit drugs in a nonjudgmental manner, clinicians should consider establishing a trusting relationship with
patients and properly respect their concerns about the confidentiality of disclosed information. This would mean that physicians and other clinicians
would need to spend much more time with their adolescent patients so they can get to know each other and begin to establish the trusting relationships
needed. Although common sense suggests these steps to be taken to enhance the ability of health care delivery systems to deal with alcohol and
related issues in adolescent populations, we know of no randomized controlled trials that demonstrate their efficacy. Here, again, the needed studies
have not been done.
- Clinician inquiry as to use of illicit drugs at every visit with clinician counseling at every visit not to initiate use of illicit drugs.
- Health care systems may wish to consider the need to develop and maintain special training programming to educate and assist clinicians in establishing
relationships with adolescents and in communicating with them about illicit drugs and related topics.
- Health care systems may wish to consider the need for reimbursement and payment systems that will enable clinicians to spend the time required
to establish and maintain the desired trusting relationships with adolescents. Such reimbursement mechanisms would eliminate current financial
disincentives to longer clinic visits.
Review of Literature
Evidence Base for Intervention
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—
In a national household survey in 1993, 14 percent of adults ages 18–25 years and 3 percent of those over 35 reported using illicit drugs within
the last month (SAMHSA, 1994).
Among high school seniors in 1994, 22 percent reported using an illicit drug in the past month: marijuana (19 percent), stimulants (4 percent),
inhalants (3 percent), and hallucinogens (3 percent) were more common than cocaine (1.5 percent) or heroin (0.3 percent) (NIDA, 1994b). Abuse of
inhalants is a leading drug problem in younger adolescents (NIDA, 1994b) and can cause asphyxiation or neurologic damage with chronic abuse (Sharp,
1992). Abuse of anabolic steroids in adolescent boys and young men can cause psychiatric symptoms and has been associated with hepatitis, endocrine,
and cardiovascular problems.
Drug use is more common among men, unemployed adults who have not completed high school, and urban residents. The overall prevalence of drug use
does not differ greatly among White, African American, and Hispanic/Latino populations, but patterns of drug use may differ (NIDA, 1994a). Adverse
effects of drug use are greatest in heavy users and those dependent on drugs, but some can occur from even occasional drug use. Cocaine can produce
acute cardiovascular complications (e.g., arrhythmias, myocardial infarction, cerebral hemorrhage, and seizures), nasal and sinus disease, and
respiratory problems (when smoked) (Perper & Van Thiel, 1992; Warner, 1993). Dependence on cocaine produces diminished motivation, psychomotor
retardation, irregular sleep patterns, and other symptoms of depression (Gold, Washton, & Dackis, 1985). “Crack,” a popular and cheaper smokeable
form of cocaine, is also highly addictive. Mortality among injection drug users (IDUs) is high from overdose, suicide, violence, and medical complications
from injecting contaminated materials (e.g., human immunodeficiency virus [HIV]) infection, hepatitis, bacterial endocarditis, chronic glomerulonephritis,
and pulmonary emboli); in some cities, up to 40 percent of IDUs are infected with HIV (National Center for Infectious Diseases, 1993). Although
the extent of adverse effects of marijuana use is controversial, chronic use may be associated with respiratory complications or amotivational
syndrome (Schwartz, 1987; Jones, 1984). In a 1991 survey, 8 percent of cocaine users and 21 percent of marijuana users reported daily use for 2
weeks or more (Keer, Colliver, & Kopstein, 1994).
The indirect medical and social consequences of drug use are equally important: criminal activities related to illicit drugs take a tremendous
toll in many communities. Use of injection drugs and crack are major factors in the spread of HIV infection (CDC, 1994; Edlin, Irwin, Faruque,
et al., 1994)… . Drugs play a role in many homicides, suicides, and motor vehicle injuries… . Nearly half of all users of cocaine or marijuana
reported having driven a car shortly after using drugs (Schwartz, 1987; Keer et al., 1994).
Early intervention has the potential to avert some of the serious consequences of drug abuse, including injuries, legal problems, and medical
complications. Although various treatments have been proven effective in persons with drug dependence, they have largely been studies in patients
who have already developed medical, social, or legal problems due to their drug use. There is much less evidence that systematic screening and
earlier intervention is effective in improving clinical outcomes among asymptomatic persons, who may be less motivated to undergo treatment than
more severely impaired drug users. Here, again, the needed studies have not been done.
Treatment of adolescent substance use disorders has been recently reviewed for nearly 1,500 primary middle-class adolescents aged 12–19 years
who entered inpatient or residential treatment programs (Bergmann, Smith, & Hoffman, 1995). Compared to use before treatment, there was a significant
reduction in regular drug use (weekly or more) 1 year after treatment (85 percent versus 29 percent), and 50 percent of teens had been abstinent
for 6 months. Increasing parental participation in treatment was associated with greater levels of abstinence.
High school primary prevention programs that emphasize “life skills” have reduced tobacco or alcohol use over the short term (1 year) (Botvin
& Botvin, 1992), but long-term effects on illicit drug use have not been well studied. In a 6-year randomized trial among 3,597 high school students,
a prevention curriculum delivered in grades 7–9 significantly reduced smoking and alcohol use, but not marijuana use, in high school seniors; a
subgroup of students who received a more complete intervention were less likely to use marijuana regularly (5 percent versus 9 percent) (Botvin,
Baker, Dusenbury, et al., 1995).
The American Medical Association (AMA, 1988) and the American Academy of Family Physicians (AAFP, 1994) advise physicians to include an in-depth
history of substance use disorder as part of a complete health examination for all patients. The … AAFP (1994), AMA Guidelines for Adolescent Preventive
Services (GAPS) (AMA, 1994b), Bright Futures recommendations (Green, ed., 1994), and American Academy of Pediatrics (AAP, 1989; AAP Committee on
Substance Abuse, 1993) suggest that clinicians discuss the dangers of drug use with all children and adolescents and include questions about substance
use disorder as part of routine adolescent visits.
The AMA and most other medical organizations endorse urine testing (for drugs) when there is reasonable suspicion of substance use disorder, but
none of these groups recommends routine drug screening in the absence of clinical indications.
Program Implementation Issues From the Literature
According to the 1996 Second Edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—
The diagnostic standard for drug abuse and dependence is the careful diagnostic interview (APA, 1994)… .
There are few data to determine whether the use of standardized screening questionnaires can increase the detection of potential drug problems
among patients. Brief alcohol screening instruments such as the CAGE or MAST can be modified to assess the consequences of drug use in a standardized
manner (Trachtenberg & Fleming, 1994; Skinner, 1982), but these instruments have not been compared with routine history of clinician assessment.
Questionnaires to identify adolescents at increased risk for drug use have not been validated in prospective studies (Schwartz & Wirtz, 1990).
Other instruments, such as the Addiction Severity Index (McLellan et al., 1980), are useful for evaluating treatment needs but are too long for
screening.
Toxicological tests can provide objective evidence of drug use… . Sensitivity of these tests generally is above 99 percent compared with reference
standards (Armbruster, Schwartzoff, Hubster, et al., 1993); sensitivity for detecting drug use in individuals, however, depends directly on timing
of drug use and the urinary excretion of drug metabolites. Marijuana may be detected for up to 14 days after repeated use, but evidence of cocaine,
opiates, amphetamines, and barbiturates is present for only 2 to 4 days after use. Various techniques may be employed by drug users who wish to
avoid detection that further reduces the sensitivity of urine testing: water loading, diuretic use, ingestion of interfering substances, or adulterating
urine samples. Most importantly, toxicologic tests do not distinguish between occasional users and individuals who are dependent on or otherwise
impaired by drug use.
False-positive results from urine drug screening are possible due to crossreaction with other medications or naturally occurring compounds in
foods (ElSohly & ElSohly, 1990). To prevent falsely implicating persons as users of illicit drugs, screen-positive samples are usually confirmed
with more specific (and expensive) techniques, such as gas chromatography-mass spectroscopy (GC-MS). These procedures reduce, but do not eliminate,
the possibility of false-positive results due to crossreactions, contamination, or mislabeled specimens. Proficiency testing of nearly 1,500 urine
specimens sent to 31 U.S. laboratories produced no falsepositive results and three percent false-negative results (Frings, Bataglia, & White, 1989).
A similar study of 120 clinical laboratories in the U.K. demonstrated higher error rates (4 percent false-positive, 8 percent false-negative),
largely due to laboratories that did not use confirmatory tests (Burnett, Lader, & Richens, 1990).
Drug testing is frequently performed without informed consent in the clinical setting on the grounds that it is a diagnostic test intended to
improve the care of the patient. Because of the significance of a positive drug screen for the patient, however, the rights of patients to autonomy
and privacy have important implications for screening of asymptomatic persons (Merrick, 1993). If confidentiality is not ensured, test results
may affect a patient’s employment, insurance coverage, or personal relationships (Rosenstock, 1987). Testing during pregnancy is especially problematic,
because State law may require physicians to report evidence of potential harmful drug or alcohol use in pregnant patients.
Data To Be Gathered
See Appendix D. Because optimal two-way communication with adolescents, especially regarding use of illicit drugs, requires
longer clinic visits, health care systems may wish to establish some means by which they can track time spent by primary care staff and time spent
by those specializing in adolescent health in clinic visits.
D. Depression
Depression in adolescents presents risk of suicide, risks relative to substance use disorder, inhibition of development of scholastic and emotional
skills, and for those with a chronic illness (such as asthma, diabetes, or even severe obesity), risk of nonadherence to prescribed regimens of care.
The incidence of documented suicides by adolescents and young adults has dramatically increased in recent decades, with 5,000 youths committing
suicide each year and perhaps as many as 500,000–1,000,000 making an attempt (Greydanus, 1986; USPSTF, 1996).
In 2002, the U.S. Preventive Services Task Force issued the recommendation that all adults should be screened for depression in health care settings,
but concluded that evidence was insufficient to extend this recommendation to children and adolescents because of the limited number and quality
of available studies specific to children and adolescents (USPSTF, 2002b, 2003; Pignone et al., 2002). The problem here is that few adolescent-specific
studies have been done, and none has been done in primary care settings (USPSTF, 2003). The studies that have been done in other settings suggest
that available screening procedures are less reliable in adolescents than adults, but that treatment is comparable in efficacy.
A discussion of the adult literature and screening procedures that may be considered are both presented in the discussion about depression in the
section of this report called Adults (19 Years and Older).
The available literature on depression in adolescents clearly shows an increase in risk and severity of depression among children and adolescents
with a depressed parent, as well as adolescents who have economic, social, and educational vulnerabilities. As a matter of practicality, it will
probably be easier for primary care practitioners to directly screen the adolescent for depression with a brief screening instrument than it would
be to explore whether or not one or both parents might be depressed and explore possible sociodemographic risk factors. Preventive interventions
aimed at such children, when they are showing “subsyndromal” depressive symptoms can be very effective in preventing future episodes of major depression
(Clarke et al., 2001).
Depression and suicide are major concerns in adolescence. Unfortunately, the adult screening tests for depression, although fairly good, are not
as specific or sensitive for adolescents. This means that there will be more false-positives and more falsenegatives. Furthermore, no studies have
examined treatment outcomes for children or adolescents identified by primary care clinicians through screening (USPSTF, 2003). This lack of adolescent-specific,
primarycare –specific research creates a situation where screening of all adolescents for depression cannot be suggested as a “general” service.
It may be advisable to screen adolescents for depression as a “targeted” service. The case for screening of preadolescent children is much less clear;
it may be advisable to alert clinicians to signs and symptoms of depression in such children rather than having them apply universal screening.
Intervention
Primary care practitioners can use their clinical judgment in deciding which adolescents to screen for depression, and the screening procedures that
should be used. The health care delivery system should assure that practitioners seeing large numbers of adolescents are familiar with the research
on this topic. All such practitioners should be alert to signs and symptoms of depression in both children and adolescents.
Review of Literature
A more substantial review of the literature on depression appears in the section of this report called Adults (19 Years and Older).
Evidence Base for Intervention
Depression is common among adolescents, with a point prevalence estimated at 3–8 percent (Clarke et al., 2001; Birmaher et al., 1996). By 18 years
of age, as many as 25 percent of adolescents have had at least one depressive episode (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993). Children
and adolescents with a depressed parent are up to six times more likely to develop depression than other children (Downey & Coyne, 1990; Beardslee,
Versage, & Gladstone, 1998).
Evidence now exists that psychosocial interventions may prevent depression (Beardslee et al., 1993; Clarke et al., 1995; Jaycox, Reivich, Gillham,
& Seligman, 1994). A frequently studied group consists of individuals who do not meet full DSM–IV criteria for an affective episode, but who report
significant “subsyndromal” depressive symptoms. Full-blown depression is more likely to develop in these individuals (Roberts, 1987; Horwath, Johnson,
Klerman, & Weissman, 1992; Weissman, Fendrich, Warner, & Wickramaratne, 1992). Such individuals have been the subject of several targeted prevention
interventions (Clarke et al., 1995; Jaycox et al., 1994).
Clarke et al. (2001) published such a study in a managed care population in Oregon. The Clarke team enrolled 45 cases and 49 controls, including
adolescent children showing “subsyndromal” depressive symptoms who had at least one depressed parent. Those offspring who met the diagnostic criteria
for full-blown depression were treated and studied separately. Those with no depressive symptoms were not subsequently followed up. Those offspring
with subdiagnostic levels of depressive symptoms insufficient for a diagnosis were invited to receive the experimental intervention, and adolescents
who chose to participate were randomly assigned to the experimental intervention versus the usualcare group. In this small but well-designed randomized
controlled trial, the intervention was a 15-session group cognitive therapy prevention program. In the year after intake, cases experienced 11 days
of depression, compared with 44 days for controls. Over a mean follow-up period of 15 months, 9.3 percent of the cases experienced one or more depressive
episodes, compared with 28.8 percent of the controls. Much but not all of this preventive benefit persisted through the 24-month follow-up, suggesting
a durable but fading level of protection.
A parallel study by the Clarke team, of children and adolescents who were already experiencing major depression at time of intake showed no net
benefit from the cognitive therapy intervention (Clarke et al., 2002).
In an earlier study (Clarke et al., 1995), the Clarke team tested 1,625 high school students with the CES-D (depression questionnaire) and then
conducted a randomized controlled trial of 150 students with “subsyndromal” depressive symptoms who agreed to participate in the study. After randomizing
them and providing the same 15-session cognitive therapy intervention, cases showed a 14.5 percent rate of depressive episodes over the next 12 months,
compared with 25.7 percent of the controls—a level of risk and benefit similar to the children of depressed parents noted above. This high school
study did not explore parental mental health conditions or other potential risk factors.
In a thought-provoking ecological study published in 2001, Podorefsky et al. (Podorefsky, McDonald-Dowdell, & Beardslee, 2001) interviewed low-income
families with parental depression and explored alliance-building as an intervention to reduce both parental and child depression. Sixteen families
participated in the study. Without exception, mothers described depression as a reaction to traumatic or chronic stressful conditions. The research
team felt that at least some of these families were living under conditions of overwhelming adversity. The intervention involved alliance-building
at the community level, as well as with caregivers and family. It focused on family resilience and immediate daily concerns—with promising preliminary
results. This study suggests, but does not prove, that for at least some families with depression under certain circumstances, assistance with dealing
with environmental causes of the depression might be of value— and might be within reach of agency social work staff and community partners.
The literature on the prevalence of depression in adults and the efficacy of screening and follow-up procedures is reviewed in the section of this
report on adult depression and will not be duplicated here.
Summary: Adolescents 12–18 Years
Research supports screening interviews for tobacco, alcohol, and illicit drug use for all adolescents aged 12–18 and suggests screening adolescents
for depression as a “targeted” service. The literature supporting screening adolescents for depression is less robust than its counterpart in adults
because the randomized, adolescent-specific studies have not been done.
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