Validity of Brief Screening Instrument for AdolescentTobacco Alcohol and Drug Use

WHATrsquoS KNOWN ON THIS SUBJECT The widely disseminatedNational Institute on Alcohol Abuse and Alcoholism screening toolfor adolescent alcohol use was developed based on epidemiologicdata It has not been validated in a clinical sample and does notscreen for tobacco or drug use

WHAT THIS STUDY ADDS This study found that a measure thatexpanded the National Institute on Alcohol Abuse and Alcoholismadolescent alcohol use tool to include tobacco and drugs wassensitive and specific for identifying substance use disorders ina pediatric clinic patient population

abstractBACKGROUND AND OBJECTIVE The National Institute on Alcohol Abuseand Alcoholism developed an alcohol screening instrument for youthbased on epidemiologic data This study examines the concurrent val-idity of this instrument expanded to include tobacco and drugs amongpediatric patients as well as the acceptability of its self-administrationon an iPad

METHODS Five hundred and twenty-five patients (545 female 928African American) aged 12 to 17 completed the Brief Screener forTobacco Alcohol and other Drugs (BSTAD) via interviewer-administrationor self-administration using an iPad Diagnostic and Statistical ManualFifth Edition substance use disorders (SUDs) were identified usinga modified Composite International Diagnostic Interview-2 SubstanceAbuse Module Receiver operating characteristic curves sensitivitiesand specificities were obtained to determine optimal cut points on theBSTAD in relation to SUDs

RESULTS One hundred fifty-nine (303) adolescents reported past-year use of $1 substances on the BSTAD 113 (215) used alcohol84 (160) used marijuana and 50 (95) used tobacco Optimal cutpoints for past-year frequency of use items on the BSTAD to identifySUDs were $6 days of tobacco use (sensitivity = 095 specificity =097) $2 days of alcohol use (sensitivity = 096 specificity = 085)and $2 days of marijuana use (sensitivity = 080 specificity = 093)iPad self-administration was preferred over interviewer administration(z = 58 P 001)

CONCLUSIONS The BSTAD is a promising screening tool for identifyingproblematic tobacco alcohol and marijuana use in pediatric settingsEven low frequency of substance use among adolescents may indicateneed for intervention Pediatrics 2014133819ndash826

AUTHORS Sharon M Kelly PhDa Jan Gryczynski PhDa

Shannon Gwin Mitchell PhDa Arethusa Kirk MDb Kevin EOrsquoGrady PhDc and Robert P Schwartz MDa

aFriends Research Institute Baltimore Maryland bTotal HealthCare Baltimore Maryland and cDepartment of PsychologyUniversity of Maryland College Park Maryland

KEY WORDSadolescent substance use substance abuse screen DSM-5substance use disorder

ABBREVIATIONSATODmdashalcohol tobacco and other drugsAUCmdasharea under the curveBSTADmdashBrief Screener for Tobacco Alcohol and other DrugsCIDI-2 SAMmdashComposite International Diagnostic Interview-2Substance Abuse ModuleDSM-5mdashDiagnostic and Statistical Manual Fifth EditionIRBmdashinstitutional review boardNIAAAmdashNational Institute on Alcohol Abuse and AlcoholismRAmdashresearch assistantROCmdashreceiver operating characteristicSUDmdashsubstance use disorder

Dr Kelly assisted in the conceptualization and design of thestudy analyzed the data drafted the initial manuscript andreviewed the manuscript Dr Gryczynski assisted in theconceptualization and design of the study designed the datacollection instruments assisted with the design of the iPadprogram assisted with data analysis and reviewed andcritically revised the manuscript Dr Mitchell assisted in theconceptualization of the study and reviewed and edited themanuscript Dr Kirk assisted in the conceptualization of thestudy supervised on-site study activities and reviewed andedited the manuscript Dr OrsquoGrady conceptualized and designedthe study supervised data analysis and reviewed and criticallyrevised the manuscript Dr Schwartz assisted in theconceptualization and design of the study and reviewed andedited the manuscript and all authors approved the finalmanuscript as submitted

The National Institute on Drug Abuse did not play a role in thestudy design in the collection analysis and interpretation ofdata in the writing of this report or in the decision to submitthe manuscript for publication

wwwpediatricsorgcgidoi101542peds2013-2346

doi101542peds2013-2346

Accepted for publication Jan 30 2014

Address correspondence to Sharon M Kelly PhD FriendsResearch Institute 1040 Park Ave Suite 103 Baltimore MD 21201E-mail skellyfriendsresearchorg

(Continued on last page)

PEDIATRICS Volume 133 Number 5 May 2014 819

ARTICLE

by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

Substance use among US adolescentsremains highly prevalent In 2012 past-month use of alcohol tobacco andother drugs (ATOD) was 129 86and95 respectively for youth 12 to 17years of age1 Adolescent ATOD use isassociated with mental2ndash4 and physi-cal5 health problems poor schoolperformance67 violence89 juvenilejustice system involvement10 and in-creased risk of developing an addictivedisorder in adulthood1112

Primary care visits present an oppor-tunity to identify and intervene withsubstance-using youth because mostyouth in the United States access thehealth care system13 and preventingsubstance abuse among adolescents isa national public health priority (wwwhealthypeoplegov) Despite recom-mendations by the World Health Orga-nization14 and American Academy ofPediatrics15ndash17 that all adolescents re-ceive screening for ATOD use most ado-lescent medicine providers do not followthese best practice guidelines18ndash21

Existing instruments for screeningadolescentsrsquo ATOD use have notablelimitations The CRAFFT a brief screen-ing instrument recommended by theAmerican Academy of Pediatrics17 hasa number of strengths including itsbrevity and good psychometric proper-ties22ndash24 but it does not screen for to-bacco use provide information onfrequency of use or discriminate be-tween drug and alcohol use Similarlythe Alcohol Use Disorders IdentificationTest25 does not screen for tobacco ordrug use The 17-item substance-usescale of the Problem Oriented Screen-ing Instrument for Teenagers26 may betoo lengthy for routine use in a busypediatric practice24

To assist pediatricians in identifyingadolescents at risk for alcohol-relatedproblems the National Institute on Al-cohol Abuse and Alcoholism (NIAAA) de-veloped a brief screening instrument27

that asks patients about their frequency

of drinking in the past year and that oftheir friends The questions and clinicalcut points against alcohol use dis-orders were established based onnational epidemiologic survey data28

NIAAArsquos screening instrument has beenwidely disseminated to practitionersacross the United States However it hasyet to be validated in a clinical sample27

The current study provides the firstevaluation of the NIAAA instrument andits extension to tobacco and drug useamong pediatric patients This studyseeks to (1) examine the concurrentvalidity of the self-report frequency ofuse item in NIAAArsquos instrument that hasbeen expanded to include drug andtobacco use against measures withknown psychometric properties (2)determine the utility of the expandedinstrument as a brief assessmentmeasure for tobacco alcohol and druguse and (3) examine the acceptabilityof its self-administration on an iPad

METHODS

Participants

The study was conducted at 3 sites ofa federally qualified health center inBaltimore Maryland Adolescents await-ing primary care appointments wereenrolled from June 2012 through Febru-ary 2013 Inclusion criteria were (1) 12 to17 years of age and (2) willingness toprovide informed assent The study wasapproved by Friends Research Institutersquosinstitutional review board (IRB) To pro-tect participantsrsquo confidentiality no id-entifying information was collected anda waiver of the requirement of writtenassent was obtained from the IRB Awaiver of parental consent was also ap-proved by the IRB in accordance with theOffice of Human Research Protectionregulations (under 45 CFR 46116[d])

Brief Screener for TobaccoAlcohol and Other Drugs (BSTAD)

For the development of the BSTAD theNIAAA instrument was expanded to in-

clude questions about tobacco anddruguse andalso the frequency of ATODuse during the past 30 90 and 365 days(see Fig 1) Screening questions in-quiring about any use in the past yearwere first asked for the 3 substance-use domains (tobacco alcohol anddrugs) following NIAAArsquos convention inwhich 12- to 14-year-olds were askedthe questions about friendsrsquo use firstas a less-threatening way to approachthe topic of substance use followed bypersonal use questions with the orderreversed for adolescents ages 15 to 17(and 14-year-olds who were in highschool) Participants who endorsedpersonal use in any domain wereasked additional questions to gaugefrequency of use during the past 30 90and 365 days

Measures

In addition to the BSTAD the followingmeasures were administered

Modified Composite InternationalDiagnostic Interview

Items from the Composite InternationalDiagnostic Interviewmdash2 SubstanceAbuse Module (CIDI-2 SAM)29ndash31 an in-strument used to assess SUDs wereused as the criterion measure foridentifying SUD as defined by the Di-agnostic and Statistical Manual FifthEdition (DSM-5)32 The CIDI-2 SAM con-tains an item on craving which is in-cluded as a symptom inmeeting criteriafor an SUD under DSM-5 Questionscorresponding to the DSM-5 criteriawere asked for tobacco alcohol and 9categories of drugs in which the ado-lescent reported past-year use Consis-tent with DSM-5 diagnostic thresholdsparticipants were classified as havingan SUD if they reported 2 or more of 11criteria for a given substance

Usability and Acceptability

Participants were asked to rate theiragreement (on a Likert-type scale of

820 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

1 = strongly disagree to 5 = stronglyagree) with a series of items gaugingtheir comfort with the screening ques-tions and the administration formatExamples of questions included ldquoThesequestions were easy to understandrdquo ldquoI

was comfortable answering thesequestions about my alcohol tobaccoand drug userdquo ldquoI was able to re-member the number of days I usedalcohol tobacco or drugs in the pastyearrdquo and ldquoI would prefer to answer

these questions myself on an iPad in-stead of having a person ask merdquo

Procedures

Adolescents in the appropriate agerange were identified by clinic staff

FIGURE 1The BSTAD Note consistent with the NIAAA instrument if respondent is aged 12 to 14 friends questions are asked first if aged 15 to 17 (or 14-year-olds in highschool) personal-use questions are asked first

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 821 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

A research assistant (RA) approachedadolescents (and parents if present) inthe waiting area before their medicalvisit and asked if theywould like to hearabout the study After their appoint-ment the RA obtained informed assentinaprivate roomusingan IRB-approvedinformation sheet after which parentswere asked to return to the waitingarea and study measures were ad-ministered to participants

Participants first completed the BSTADwhich was administered by the RA forthe first half of the study sample (n =262) and self-administered using atouchscreen tablet (iPad) for the sec-ond half (n = 263) For adolescentsusing the iPad the RA was available toprovide assistance with reading and toresolve technical problems For allparticipants the RA subsequently ad-ministered the usabilityacceptabilityquestions followed by the modifiedCIDI-2 SAM items and 3 other measuresnot reported on in the current studyParticipants received a $20 Subway giftcard for participation

Statistical Analysis

The analysis focused on adolescentsrsquouse of alcohol tobacco and marijuanaonly because use of other substanceswas rare in this sample To be consis-tent with DSM-5 diagnoses which arebased on symptoms occurring over thepast year data analysis focused onfrequency of substance use in the pastyear Peer substance use was not ex-amined in the current study

Receiver operating characteristic (ROC)analyses were used to establish cutpoints for number of days of use oftobacco alcohol and marijuanaagainst the ldquogold standardrdquo of DSM-5SUD for each substance ROC curvesplot the sensitivity of a test against 1minus the testrsquos specificity creatinga useful visual depiction of a testrsquosperformance across the range ofpossible cut points

Optimal cut points in relation to DSM-5criteria for each substance wereestablished by visual inspection of theROC curves and examination of areasunder thecurve (AUC) sensitivities andspecificities Additionally participantsrsquousabilityacceptability ratings were com-pared for the subsample that self-administered the screening on theiPad with the subsample that completedthe interviewer-administered screeningusing the Mann-Whitney U test

RESULTS

Sample Characteristics

Of 584 adolescents approached by re-search staff 54 (92) refused partic-ipation The target sample of 525participants was reached by enrolling530 participants who completed thestudy because data from5participantswere not transmitted to the Web-baseddata system due to technical problemsThe sample of 525 adolescents was545 female and 928 African Amer-ican (see Table 1) Regarding age509 was aged 12 to 14 years and491 was aged 15 to 17 years

Cross-Check for Consistency inResponding

A cross-check of the data was con-ducted to compare 30- 90- and 365-dayresponses for each substance for eachindividual case Four cases (076 oftotal sample) were found to haveminorinconsistencies in responses (3 werecompleted on iPad 1 completed by in-terviewer)

Substance Use

Of 525 participants 159 (303) re-ported use of$1 substances (alcoholtobacco other drugs) during the pastyear on the BSTAD with 113 (215)adolescents reporting alcohol use 84(160) reporting marijuana use and50 (95) reporting tobacco use Six-teen (30) participants reported us-ing $1 illicit drugs other than

marijuana in the past year 9 (17)reported misuse of prescription opioids7 (13) reported misuse of over-the-counter medications and 2 (04)reported misuse of prescription seda-tives Use of cocainecrack amphet-amines and misuse of prescriptionstimulants was reported by 1 partici-pant each (02) No participantsreported using heroin hallucinogens orinhalants during the past year

Evaluation of Concurrent Validity

Table 2 shows the number () of par-ticipants meeting or exceeding theestablished cut point for each sub-stance as determined by examinationof the ROC curves (see Fig 2 for thesmoothed ROC curves and their re-spective confidence bands) as well asthe AUC sensitivity specificity and 95confidence intervals in relation to DSM-5 SUD for each substance at the iden-tified cut points

Tobacco

ROCanalysisshowedthat theoptimalcutpoint for tobacco use on the BSTAD in

TABLE 1 Participant Characteristics

Variable Total Sample (N = 525)

n ()GenderMale 239 (455)Female 286 (545)

RaceAfrican American 487 (928)White 4 (08)Other race 34 (65)

Age group12ndash14 y old 267 (509)15ndash17 y old 258 (491)

School enrollment statusa

Middle school 196 (373)High school 315 (600)Not enrolledother 13 (25)

Mode of BSTADadministrationInterviewer 262 (499)iPad 263 (501)

Substance use past yTobacco 50 (95)Alcohol 113 (215)Marijuana 84 (160)

a Data missing for 1 participant

822 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

relation to DSM-5 SUD was $6 days inthe past year The AUC for tobacco usewas 096 Its sensitivity was 095 in-dicating that using a frequency of usecut point of $6 days in the past yearcorrectly identified 95 of adolescentswho met DSM-5 criteria Specificity was097 for tobacco use indicating that atthis cut point the single frequency of useitem correctly identified 97 of adoles-cents who did not meet DSM-5 criteria

Alcohol

ROC analysis showed the optimal cutpoint on the BSTAD for frequency ofalcohol use in identifying DSM-5 alcoholuse disorder to be$2 days of use in thepast year AUC and sensitivity valueswere 090 and 096 respectively and itsspecificity was 085

Marijuana

Similar to alcohol use ROC analysisshowed the optimal cut point for fre-

quency of marijuana use on the BSTADto be $2 days of use in the past yearAUC and sensitivity values were 087and 080 respectively and specificitywas 093

BSTAD Usability by Mode ofAdministration (Interviewer vsiPad)

There were no significant differencesbased on mode of administration incomprehension comfort ability to re-call past-year frequency of use orwillingness toanswersimilarquestionsduring a future medical visit based onreported level of agreement with thefollowing statements (all statementsare shown in Table 3) ldquoThese questionswere easy to understandrdquo ldquoI wascomfortable answering these ques-tions about my alcohol tobacco anddrug userdquo ldquoI was able to remember thenumber of days I used alcohol tobaccoor drugs in the past yearrdquo and ldquoI would

be willing to answer questions likethese at my doctorrsquos office every yearrdquorespectively (all Ps 05) For the itemthat pertains to answering questionsin the doctorrsquos office findings shouldbe interpreted cautiously becauseparticipants may have perceived thatitem as assessing whether they wouldanswer questions as part of a confi-dential research study versus assess-ing whether they would sharesubstance use information with theirproviders

Participants in each subsample basedon mode of administration were askedif they would have preferred to answerquestions using the other mode andiPad self-administration showed anadvantage as the preferred mode (z =58 P 001) Only 209 of partic-ipants who completed the screening onthe iPad agreed or strongly agreed thatthey would have preferred that an in-terviewer had asked the questions

TABLE 2 ROC AUC Sensitivity and Specificity for the Past-Year Frequency of Use Items on the BSTAD in Relation to DSM-5 SUD (N = 525)

Cut Point on BSTADa MetExceeded Cut Point n () Met DSM-5 Criteria for SUD n () AUC Sensitivity (95 CI) Specificity (95 CI)

Tobacco $6 d 37 (70) 21 (40) 096 095 (081ndash100) 097 (095ndash098)Alcohol $2 d 98 (187) 24 (45) 090 096 (083ndash100) 085 (082ndash088)Marijuana $2 d 77 (147) 56 (107) 087 080 (069ndash089) 093 (091ndash095)

DSM-5 SUD requiresmeeting$2 of 11 possible criteria Sensitivity refers to the proportion of adolescents meeting DSM-5 criteria for SUD who were identified as meeting or exceeding the cutpoint on the BSTAD Specificity refers to the proportion of adolescents not meeting DSM-5 criteria for SUD who were identified as falling below the cut point on the BSTAD CI = confidenceintervala For past-year use

FIGURE 2ROC curves and confidence interval bands for tobacco alcohol and marijuana for past-year use frequency of use items on the BSTAD in relation to DSM-5 SUD(N = 525)

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 823 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

Conversely among those who com-pleted the screening with the in-terviewer 423 agreed or stronglyagreed that they would have preferredto self-administer the screening onan iPad

DISCUSSION

The NIAAArsquos adolescent alcohol screen-ing tool was empirically developedfrom epidemiologic data28 and hasbeen widely disseminated The currentstudy is the first to examine the per-formance of the self-reported fre-quency of use item from this tool ina pediatric patient sample and the firstformal extension of this tool to includedrug and tobacco use

This study furthers the effort to developand test asimple brief screen to rapidlytriage pediatric patients by risk levelSingle-item substance use screenershave been tested and recommended foradult primary care populations andhave been found to have low cut pointsin terms of number of days of use in thepast year33 Because onset of substanceuse typically occurs during the ado-lescent years patients in this agegroup are a critical target for screen-ing and intervention The overall per-formance metrics for the frequency ofuse items (including AUC sensitivityspecificity) compared with the goldstandard of meeting DSM-5 criteria for

tobacco alcohol and marijuana SUDwere favorable

Clinicians need a substance usescreening measure that is brief reli-able and practical24 The past-yearfrequency of use items on the BSTADconstitute a common question for to-bacco alcohol and drugs This ques-tion generally offers high sensitivityand specificity and meets the need forbrevity and reliability for each of the 3substances most commonly used byadolescents There is no need to scorethe instrument and it is simple to re-call the cutoffs for these 3 substancesBecause many adolescent treatmentproviders may find it important toscreen for any use of tobacco or othersubstances (not just their use dis-orders) it should be noted that thisinformation is also provided by theBSTAD

The cutoffs in the current study of 2 daysfor either alcohol or marijuana and 6days for tobacco use in the past yearsupport the frequency of use screeningquestionas a reliable rapid and simplestrategy for pediatricians to triagepatients into low-risk and higher-riskgroups However it is important tonote that although the measure may bean excellent screening tool the low cutpoints limit the ability of frequency ofuse on its own to act as a nuancedmeasure of the degree of problem

severity For patients who screen pos-itive on the BSTAD for any of thesesubstances further inquiry regardingproblems associated with use shouldbe pursued as is the case with anyscreening measure Minimally for allpatients screening positive a briefdiscussionintervention by the practi-tioner is warranted

Brief screening tools that offer the flexi-bilityofpatient-orprovider-administrationprovide flexibility in pediatric practicesand permit patient choice In the cur-rent study self-administration of theBSTAD on an iPad was feasible andwell received by participants Self-administration would benefit a busypediatric practice because data couldpotentially be entered directly intothe electronic medical record and im-mediately reviewed by the providerAnother potential advantage of self-administration is that there is someevidence that thisapproachyieldsmoreaccurate and reliable responses fromadolescents compared with adminis-tration by an interviewer for sensitivetopics3435

Rates of substance use in the past yearreported by participants were 95 forcigarettes or tobacco products 215for alcohol and 160 for marijuanaThese rates differ somewhat from na-tional rates for 12- to 17-year-olds in2012 which were 152 263 and135 for past-year use of tobacco al-cohol and marijuana respectively1

However substance use prevalence inour largely African American sample ismore in line with national data for Af-rican American adolescentsrsquo rates ofpast year tobacco (97) alcohol(208) and marijuana (135) useRates of illicit substance use other thanmarijuana were found to be low in thissample which is generally consistentwith rates found in national data Anotable exception is that rates of pre-scription drug misuse are higher na-tionally than what was found in our

TABLE 3 Usability and Acceptability Items (N = 525)

Item Strongly agree or agree

These questions were easy to understand 996I was comfortable answering these questions about my alcohol tobacco anddrug use

939

I was able to remember the number of days I used alcohol tobacco or drugsin the past year (n = 159)a

610

I would be willing to answer questions like these at my doctorrsquos office everyyear

898

The iPad touch screen was easy to use (n = 263)b 996I would prefer that a person ask me these questions in the doctorrsquos officeinstead of answering them myself on the iPad (n = 263)b

209

I would prefer to answer these questions myself on an iPad instead of havinga person ask me (n = 262)c

423

a Only participants who reported alcohol tobacco or drug use in the past year are included in percentageb Only participants who self-administered BSTAD questions on iPad are included in this percentagec Only participants who were asked BSTAD questions by interviewer are included in this percentage

824 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

sample1 Thus a degree of caution iswarranted when generalizing our find-ings to other groups of adolescents

The recently releasedDSM-5 criteria forSUD collapses 2 separate disordersfrom DSM-IV (labeled substance abuseand substance dependence) into a sin-gle category of SUD The use of the newDSM-5 criteria can be considereda strength of the study although theCIDI-2 has not been formally validatedagainst theDSM-5However theCIDIhasbeen validated for the DSM-IV36ndash38

which includes all of the same criteriain the DSM-5 with 2 exceptions (acraving criterion was added to theDSM-5 and the legal problem criterionfrom the DSM-IV was eliminated for theDSM-5) A limitation of the study is thatit was conducted in a single city witha largely African American populationFurther replication in other localitieswith diverse patient populations iswarranted Although it would havebeen useful to determine whether op-timal cut points differed by gender or

age group the prevalence of DSM-5SUDs in these subsamples was toolow to permit such analysis Examiningcut points for these subsamplesshould be a focus of future researchAdditionally data from all assessmentsadministered in this study were self-report and therefore substance usemay have been underreported Futurestudies should include the collection ofbiological samples to test for thepresence of substances that can serveas validity information beyond self-report although their relatively briefwindow limits their utility in thatregard Finally the administration order(self- vs interviewer-administered)was not randomized nor was the or-der of administration of the instru-ments

CONCLUSIONS

This study provides promising evidencesupporting the validity and utility ofusing past-year frequency of use asa quick and accurate screen for ado-

lescentsrsquo problematic tobacco alcoholand drug use Given the associationbetween substance use and depres-sion suicide violence fatal car acci-dents academic problems and thedevelopment of SUDs2681239 and thepotential effectiveness of brief inter-ventions and treatment of substance-involved adolescents4041 it is ofconsiderable importance that pedia-tricians family physicians and otherhealth care providers screen ado-lescents for substance use The use ofthe BSTAD or similar instruments canbe an important step in identifyingsubstance use and successfully in-tervening in the lives of adolescentpatients

ACKNOWLEDGMENTSTheauthorsthankDrGeethaSubramaniamfor her guidance and themedical staffand patients at Total Health Carefor their assistance We also thankKyra Walls for helping to prepare themanuscript

REFERENCES

1 Substance Abuse and Mental Health Ser-vices Administration Results from the 2012National Survey on Drug Use and HealthSummary of National Findings NSDUH Se-ries H-46 HHS Publication No (SMA) 13-4795 Rockville MD Substance Abuse andMental Health Services Administration2013

2 Kaminer Y Bukstein OG eds AdolescentSubstance Abuse Psychiatric Comorbidityand High-Risk Behaviors New York NYRoutledgeTaylor amp Francis 2008

3 Patton GC Coffey C Carlin JB DegenhardtL Lynskey M Hall W Cannabis use andmental health in young people cohortstudy BMJ 2002325(7374)1195ndash1198

4 Shrier LA Harris SK Kurland M Knight JRSubstance use problems and associatedpsychiatric symptoms among adolescentsin primary care Pediatrics 2003111(6 pt1) Available at wwwpediatricsorgcgicontentfull1116e699

5 Kokotailo P Physical health problems as-sociated with adolescent substance abuseNIDA Res Monogr 1995156112ndash129

6 Cox RG Zhang L Johnson WD Bender DRAcademic performance and substance usefindings from a state survey of public highschool students J Sch Health 200777(3)109ndash115

7 Martins SS Alexandre PK The associationof ecstasy use and academic achievementamong adolescents in two US nationalsurveys Addict Behav 200934(1)9ndash16

8 Eaton DK Kann L Kinchen S et al Youthrisk behavior surveillancemdashUnited States2005 J Sch Health 200676(7)353ndash372

9 Walton MA Cunningham RM Goldstein ALet al Rates and correlates of violentbehaviors among adolescents treated in anurban emergency department J AdolescHealth 200945(1)77ndash83

10 Tripodi SJ Springer DW Corcoran KDeterminants of substance abuse amongincarcerated adolescents implications forbrief treatment and crisis interventionBrief Treat Crisis Interv 2007734ndash39

11 Grant JD Scherrer JF Lynskey MT et al Ad-olescent alcohol use is a risk factor for adultalcohol and drug dependence evidence from

a twin design Psychol Med 200636(1)109ndash118

12 Hingson RW Heeren T Winter MR Age atdrinking onset and alcohol dependenceage at onset duration and severity ArchPediatr Adolesc Med 2006160(7)739ndash746

13 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2011 NationalCenter for Health Statistics Vital HealthStatistics 201210(254)1ndash80

14 World Health Organization CommonwealthMedical Association Trust UNICEF Orienta-tion Programme on Adolescent Health forHealth Care Providers Geneva SwitzerlandWorld Health Organization 2006

15 American Academy of Pediatrics Commit-tee on Substance Abuse Alcohol use andabuse a pediatric concern Pediatrics2001108(1)185ndash189

16 Kulig JW American Academy of PediatricsCommittee on Substance Abuse Tobaccoalcohol and other drugs the role of thepediatrician in prevention identification

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 825 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

A research assistant (RA) approachedadolescents (and parents if present) inthe waiting area before their medicalvisit and asked if theywould like to hearabout the study After their appoint-ment the RA obtained informed assentinaprivate roomusingan IRB-approvedinformation sheet after which parentswere asked to return to the waitingarea and study measures were ad-ministered to participants

Participants first completed the BSTADwhich was administered by the RA forthe first half of the study sample (n =262) and self-administered using atouchscreen tablet (iPad) for the sec-ond half (n = 263) For adolescentsusing the iPad the RA was available toprovide assistance with reading and toresolve technical problems For allparticipants the RA subsequently ad-ministered the usabilityacceptabilityquestions followed by the modifiedCIDI-2 SAM items and 3 other measuresnot reported on in the current studyParticipants received a $20 Subway giftcard for participation

Statistical Analysis

The analysis focused on adolescentsrsquouse of alcohol tobacco and marijuanaonly because use of other substanceswas rare in this sample To be consis-tent with DSM-5 diagnoses which arebased on symptoms occurring over thepast year data analysis focused onfrequency of substance use in the pastyear Peer substance use was not ex-amined in the current study

Receiver operating characteristic (ROC)analyses were used to establish cutpoints for number of days of use oftobacco alcohol and marijuanaagainst the ldquogold standardrdquo of DSM-5SUD for each substance ROC curvesplot the sensitivity of a test against 1minus the testrsquos specificity creatinga useful visual depiction of a testrsquosperformance across the range ofpossible cut points

Optimal cut points in relation to DSM-5criteria for each substance wereestablished by visual inspection of theROC curves and examination of areasunder thecurve (AUC) sensitivities andspecificities Additionally participantsrsquousabilityacceptability ratings were com-pared for the subsample that self-administered the screening on theiPad with the subsample that completedthe interviewer-administered screeningusing the Mann-Whitney U test

RESULTS

Sample Characteristics

Of 584 adolescents approached by re-search staff 54 (92) refused partic-ipation The target sample of 525participants was reached by enrolling530 participants who completed thestudy because data from5participantswere not transmitted to the Web-baseddata system due to technical problemsThe sample of 525 adolescents was545 female and 928 African Amer-ican (see Table 1) Regarding age509 was aged 12 to 14 years and491 was aged 15 to 17 years

Cross-Check for Consistency inResponding

A cross-check of the data was con-ducted to compare 30- 90- and 365-dayresponses for each substance for eachindividual case Four cases (076 oftotal sample) were found to haveminorinconsistencies in responses (3 werecompleted on iPad 1 completed by in-terviewer)

Substance Use

Of 525 participants 159 (303) re-ported use of$1 substances (alcoholtobacco other drugs) during the pastyear on the BSTAD with 113 (215)adolescents reporting alcohol use 84(160) reporting marijuana use and50 (95) reporting tobacco use Six-teen (30) participants reported us-ing $1 illicit drugs other than

marijuana in the past year 9 (17)reported misuse of prescription opioids7 (13) reported misuse of over-the-counter medications and 2 (04)reported misuse of prescription seda-tives Use of cocainecrack amphet-amines and misuse of prescriptionstimulants was reported by 1 partici-pant each (02) No participantsreported using heroin hallucinogens orinhalants during the past year

Evaluation of Concurrent Validity

Table 2 shows the number () of par-ticipants meeting or exceeding theestablished cut point for each sub-stance as determined by examinationof the ROC curves (see Fig 2 for thesmoothed ROC curves and their re-spective confidence bands) as well asthe AUC sensitivity specificity and 95confidence intervals in relation to DSM-5 SUD for each substance at the iden-tified cut points

Tobacco

ROCanalysisshowedthat theoptimalcutpoint for tobacco use on the BSTAD in

TABLE 1 Participant Characteristics

Variable Total Sample (N = 525)

n ()GenderMale 239 (455)Female 286 (545)

RaceAfrican American 487 (928)White 4 (08)Other race 34 (65)

Age group12ndash14 y old 267 (509)15ndash17 y old 258 (491)

School enrollment statusa

Middle school 196 (373)High school 315 (600)Not enrolledother 13 (25)

Mode of BSTADadministrationInterviewer 262 (499)iPad 263 (501)

Substance use past yTobacco 50 (95)Alcohol 113 (215)Marijuana 84 (160)

a Data missing for 1 participant

822 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

relation to DSM-5 SUD was $6 days inthe past year The AUC for tobacco usewas 096 Its sensitivity was 095 in-dicating that using a frequency of usecut point of $6 days in the past yearcorrectly identified 95 of adolescentswho met DSM-5 criteria Specificity was097 for tobacco use indicating that atthis cut point the single frequency of useitem correctly identified 97 of adoles-cents who did not meet DSM-5 criteria

Alcohol

ROC analysis showed the optimal cutpoint on the BSTAD for frequency ofalcohol use in identifying DSM-5 alcoholuse disorder to be$2 days of use in thepast year AUC and sensitivity valueswere 090 and 096 respectively and itsspecificity was 085

Marijuana

Similar to alcohol use ROC analysisshowed the optimal cut point for fre-

quency of marijuana use on the BSTADto be $2 days of use in the past yearAUC and sensitivity values were 087and 080 respectively and specificitywas 093

BSTAD Usability by Mode ofAdministration (Interviewer vsiPad)

There were no significant differencesbased on mode of administration incomprehension comfort ability to re-call past-year frequency of use orwillingness toanswersimilarquestionsduring a future medical visit based onreported level of agreement with thefollowing statements (all statementsare shown in Table 3) ldquoThese questionswere easy to understandrdquo ldquoI wascomfortable answering these ques-tions about my alcohol tobacco anddrug userdquo ldquoI was able to remember thenumber of days I used alcohol tobaccoor drugs in the past yearrdquo and ldquoI would

be willing to answer questions likethese at my doctorrsquos office every yearrdquorespectively (all Ps 05) For the itemthat pertains to answering questionsin the doctorrsquos office findings shouldbe interpreted cautiously becauseparticipants may have perceived thatitem as assessing whether they wouldanswer questions as part of a confi-dential research study versus assess-ing whether they would sharesubstance use information with theirproviders

Participants in each subsample basedon mode of administration were askedif they would have preferred to answerquestions using the other mode andiPad self-administration showed anadvantage as the preferred mode (z =58 P 001) Only 209 of partic-ipants who completed the screening onthe iPad agreed or strongly agreed thatthey would have preferred that an in-terviewer had asked the questions

TABLE 2 ROC AUC Sensitivity and Specificity for the Past-Year Frequency of Use Items on the BSTAD in Relation to DSM-5 SUD (N = 525)

Cut Point on BSTADa MetExceeded Cut Point n () Met DSM-5 Criteria for SUD n () AUC Sensitivity (95 CI) Specificity (95 CI)

Tobacco $6 d 37 (70) 21 (40) 096 095 (081ndash100) 097 (095ndash098)Alcohol $2 d 98 (187) 24 (45) 090 096 (083ndash100) 085 (082ndash088)Marijuana $2 d 77 (147) 56 (107) 087 080 (069ndash089) 093 (091ndash095)

DSM-5 SUD requiresmeeting$2 of 11 possible criteria Sensitivity refers to the proportion of adolescents meeting DSM-5 criteria for SUD who were identified as meeting or exceeding the cutpoint on the BSTAD Specificity refers to the proportion of adolescents not meeting DSM-5 criteria for SUD who were identified as falling below the cut point on the BSTAD CI = confidenceintervala For past-year use

FIGURE 2ROC curves and confidence interval bands for tobacco alcohol and marijuana for past-year use frequency of use items on the BSTAD in relation to DSM-5 SUD(N = 525)

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 823 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

Conversely among those who com-pleted the screening with the in-terviewer 423 agreed or stronglyagreed that they would have preferredto self-administer the screening onan iPad

DISCUSSION

The NIAAArsquos adolescent alcohol screen-ing tool was empirically developedfrom epidemiologic data28 and hasbeen widely disseminated The currentstudy is the first to examine the per-formance of the self-reported fre-quency of use item from this tool ina pediatric patient sample and the firstformal extension of this tool to includedrug and tobacco use

This study furthers the effort to developand test asimple brief screen to rapidlytriage pediatric patients by risk levelSingle-item substance use screenershave been tested and recommended foradult primary care populations andhave been found to have low cut pointsin terms of number of days of use in thepast year33 Because onset of substanceuse typically occurs during the ado-lescent years patients in this agegroup are a critical target for screen-ing and intervention The overall per-formance metrics for the frequency ofuse items (including AUC sensitivityspecificity) compared with the goldstandard of meeting DSM-5 criteria for

tobacco alcohol and marijuana SUDwere favorable

Clinicians need a substance usescreening measure that is brief reli-able and practical24 The past-yearfrequency of use items on the BSTADconstitute a common question for to-bacco alcohol and drugs This ques-tion generally offers high sensitivityand specificity and meets the need forbrevity and reliability for each of the 3substances most commonly used byadolescents There is no need to scorethe instrument and it is simple to re-call the cutoffs for these 3 substancesBecause many adolescent treatmentproviders may find it important toscreen for any use of tobacco or othersubstances (not just their use dis-orders) it should be noted that thisinformation is also provided by theBSTAD

The cutoffs in the current study of 2 daysfor either alcohol or marijuana and 6days for tobacco use in the past yearsupport the frequency of use screeningquestionas a reliable rapid and simplestrategy for pediatricians to triagepatients into low-risk and higher-riskgroups However it is important tonote that although the measure may bean excellent screening tool the low cutpoints limit the ability of frequency ofuse on its own to act as a nuancedmeasure of the degree of problem

severity For patients who screen pos-itive on the BSTAD for any of thesesubstances further inquiry regardingproblems associated with use shouldbe pursued as is the case with anyscreening measure Minimally for allpatients screening positive a briefdiscussionintervention by the practi-tioner is warranted

Brief screening tools that offer the flexi-bilityofpatient-orprovider-administrationprovide flexibility in pediatric practicesand permit patient choice In the cur-rent study self-administration of theBSTAD on an iPad was feasible andwell received by participants Self-administration would benefit a busypediatric practice because data couldpotentially be entered directly intothe electronic medical record and im-mediately reviewed by the providerAnother potential advantage of self-administration is that there is someevidence that thisapproachyieldsmoreaccurate and reliable responses fromadolescents compared with adminis-tration by an interviewer for sensitivetopics3435

Rates of substance use in the past yearreported by participants were 95 forcigarettes or tobacco products 215for alcohol and 160 for marijuanaThese rates differ somewhat from na-tional rates for 12- to 17-year-olds in2012 which were 152 263 and135 for past-year use of tobacco al-cohol and marijuana respectively1

However substance use prevalence inour largely African American sample ismore in line with national data for Af-rican American adolescentsrsquo rates ofpast year tobacco (97) alcohol(208) and marijuana (135) useRates of illicit substance use other thanmarijuana were found to be low in thissample which is generally consistentwith rates found in national data Anotable exception is that rates of pre-scription drug misuse are higher na-tionally than what was found in our

TABLE 3 Usability and Acceptability Items (N = 525)

Item Strongly agree or agree

These questions were easy to understand 996I was comfortable answering these questions about my alcohol tobacco anddrug use

939

I was able to remember the number of days I used alcohol tobacco or drugsin the past year (n = 159)a

610

I would be willing to answer questions like these at my doctorrsquos office everyyear

898

The iPad touch screen was easy to use (n = 263)b 996I would prefer that a person ask me these questions in the doctorrsquos officeinstead of answering them myself on the iPad (n = 263)b

209

I would prefer to answer these questions myself on an iPad instead of havinga person ask me (n = 262)c

423

a Only participants who reported alcohol tobacco or drug use in the past year are included in percentageb Only participants who self-administered BSTAD questions on iPad are included in this percentagec Only participants who were asked BSTAD questions by interviewer are included in this percentage

824 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

sample1 Thus a degree of caution iswarranted when generalizing our find-ings to other groups of adolescents

The recently releasedDSM-5 criteria forSUD collapses 2 separate disordersfrom DSM-IV (labeled substance abuseand substance dependence) into a sin-gle category of SUD The use of the newDSM-5 criteria can be considereda strength of the study although theCIDI-2 has not been formally validatedagainst theDSM-5However theCIDIhasbeen validated for the DSM-IV36ndash38

which includes all of the same criteriain the DSM-5 with 2 exceptions (acraving criterion was added to theDSM-5 and the legal problem criterionfrom the DSM-IV was eliminated for theDSM-5) A limitation of the study is thatit was conducted in a single city witha largely African American populationFurther replication in other localitieswith diverse patient populations iswarranted Although it would havebeen useful to determine whether op-timal cut points differed by gender or

age group the prevalence of DSM-5SUDs in these subsamples was toolow to permit such analysis Examiningcut points for these subsamplesshould be a focus of future researchAdditionally data from all assessmentsadministered in this study were self-report and therefore substance usemay have been underreported Futurestudies should include the collection ofbiological samples to test for thepresence of substances that can serveas validity information beyond self-report although their relatively briefwindow limits their utility in thatregard Finally the administration order(self- vs interviewer-administered)was not randomized nor was the or-der of administration of the instru-ments

CONCLUSIONS

This study provides promising evidencesupporting the validity and utility ofusing past-year frequency of use asa quick and accurate screen for ado-

lescentsrsquo problematic tobacco alcoholand drug use Given the associationbetween substance use and depres-sion suicide violence fatal car acci-dents academic problems and thedevelopment of SUDs2681239 and thepotential effectiveness of brief inter-ventions and treatment of substance-involved adolescents4041 it is ofconsiderable importance that pedia-tricians family physicians and otherhealth care providers screen ado-lescents for substance use The use ofthe BSTAD or similar instruments canbe an important step in identifyingsubstance use and successfully in-tervening in the lives of adolescentpatients

ACKNOWLEDGMENTSTheauthorsthankDrGeethaSubramaniamfor her guidance and themedical staffand patients at Total Health Carefor their assistance We also thankKyra Walls for helping to prepare themanuscript

REFERENCES

1 Substance Abuse and Mental Health Ser-vices Administration Results from the 2012National Survey on Drug Use and HealthSummary of National Findings NSDUH Se-ries H-46 HHS Publication No (SMA) 13-4795 Rockville MD Substance Abuse andMental Health Services Administration2013

2 Kaminer Y Bukstein OG eds AdolescentSubstance Abuse Psychiatric Comorbidityand High-Risk Behaviors New York NYRoutledgeTaylor amp Francis 2008

3 Patton GC Coffey C Carlin JB DegenhardtL Lynskey M Hall W Cannabis use andmental health in young people cohortstudy BMJ 2002325(7374)1195ndash1198

4 Shrier LA Harris SK Kurland M Knight JRSubstance use problems and associatedpsychiatric symptoms among adolescentsin primary care Pediatrics 2003111(6 pt1) Available at wwwpediatricsorgcgicontentfull1116e699

5 Kokotailo P Physical health problems as-sociated with adolescent substance abuseNIDA Res Monogr 1995156112ndash129

6 Cox RG Zhang L Johnson WD Bender DRAcademic performance and substance usefindings from a state survey of public highschool students J Sch Health 200777(3)109ndash115

7 Martins SS Alexandre PK The associationof ecstasy use and academic achievementamong adolescents in two US nationalsurveys Addict Behav 200934(1)9ndash16

8 Eaton DK Kann L Kinchen S et al Youthrisk behavior surveillancemdashUnited States2005 J Sch Health 200676(7)353ndash372

9 Walton MA Cunningham RM Goldstein ALet al Rates and correlates of violentbehaviors among adolescents treated in anurban emergency department J AdolescHealth 200945(1)77ndash83

10 Tripodi SJ Springer DW Corcoran KDeterminants of substance abuse amongincarcerated adolescents implications forbrief treatment and crisis interventionBrief Treat Crisis Interv 2007734ndash39

11 Grant JD Scherrer JF Lynskey MT et al Ad-olescent alcohol use is a risk factor for adultalcohol and drug dependence evidence from

a twin design Psychol Med 200636(1)109ndash118

12 Hingson RW Heeren T Winter MR Age atdrinking onset and alcohol dependenceage at onset duration and severity ArchPediatr Adolesc Med 2006160(7)739ndash746

13 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2011 NationalCenter for Health Statistics Vital HealthStatistics 201210(254)1ndash80

14 World Health Organization CommonwealthMedical Association Trust UNICEF Orienta-tion Programme on Adolescent Health forHealth Care Providers Geneva SwitzerlandWorld Health Organization 2006

15 American Academy of Pediatrics Commit-tee on Substance Abuse Alcohol use andabuse a pediatric concern Pediatrics2001108(1)185ndash189

16 Kulig JW American Academy of PediatricsCommittee on Substance Abuse Tobaccoalcohol and other drugs the role of thepediatrician in prevention identification

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 825 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

relation to DSM-5 SUD was $6 days inthe past year The AUC for tobacco usewas 096 Its sensitivity was 095 in-dicating that using a frequency of usecut point of $6 days in the past yearcorrectly identified 95 of adolescentswho met DSM-5 criteria Specificity was097 for tobacco use indicating that atthis cut point the single frequency of useitem correctly identified 97 of adoles-cents who did not meet DSM-5 criteria

Alcohol

ROC analysis showed the optimal cutpoint on the BSTAD for frequency ofalcohol use in identifying DSM-5 alcoholuse disorder to be$2 days of use in thepast year AUC and sensitivity valueswere 090 and 096 respectively and itsspecificity was 085

Marijuana

Similar to alcohol use ROC analysisshowed the optimal cut point for fre-

quency of marijuana use on the BSTADto be $2 days of use in the past yearAUC and sensitivity values were 087and 080 respectively and specificitywas 093

BSTAD Usability by Mode ofAdministration (Interviewer vsiPad)

There were no significant differencesbased on mode of administration incomprehension comfort ability to re-call past-year frequency of use orwillingness toanswersimilarquestionsduring a future medical visit based onreported level of agreement with thefollowing statements (all statementsare shown in Table 3) ldquoThese questionswere easy to understandrdquo ldquoI wascomfortable answering these ques-tions about my alcohol tobacco anddrug userdquo ldquoI was able to remember thenumber of days I used alcohol tobaccoor drugs in the past yearrdquo and ldquoI would

be willing to answer questions likethese at my doctorrsquos office every yearrdquorespectively (all Ps 05) For the itemthat pertains to answering questionsin the doctorrsquos office findings shouldbe interpreted cautiously becauseparticipants may have perceived thatitem as assessing whether they wouldanswer questions as part of a confi-dential research study versus assess-ing whether they would sharesubstance use information with theirproviders

Participants in each subsample basedon mode of administration were askedif they would have preferred to answerquestions using the other mode andiPad self-administration showed anadvantage as the preferred mode (z =58 P 001) Only 209 of partic-ipants who completed the screening onthe iPad agreed or strongly agreed thatthey would have preferred that an in-terviewer had asked the questions

TABLE 2 ROC AUC Sensitivity and Specificity for the Past-Year Frequency of Use Items on the BSTAD in Relation to DSM-5 SUD (N = 525)

Cut Point on BSTADa MetExceeded Cut Point n () Met DSM-5 Criteria for SUD n () AUC Sensitivity (95 CI) Specificity (95 CI)

Tobacco $6 d 37 (70) 21 (40) 096 095 (081ndash100) 097 (095ndash098)Alcohol $2 d 98 (187) 24 (45) 090 096 (083ndash100) 085 (082ndash088)Marijuana $2 d 77 (147) 56 (107) 087 080 (069ndash089) 093 (091ndash095)

DSM-5 SUD requiresmeeting$2 of 11 possible criteria Sensitivity refers to the proportion of adolescents meeting DSM-5 criteria for SUD who were identified as meeting or exceeding the cutpoint on the BSTAD Specificity refers to the proportion of adolescents not meeting DSM-5 criteria for SUD who were identified as falling below the cut point on the BSTAD CI = confidenceintervala For past-year use

FIGURE 2ROC curves and confidence interval bands for tobacco alcohol and marijuana for past-year use frequency of use items on the BSTAD in relation to DSM-5 SUD(N = 525)

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 823 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

Conversely among those who com-pleted the screening with the in-terviewer 423 agreed or stronglyagreed that they would have preferredto self-administer the screening onan iPad

DISCUSSION

The NIAAArsquos adolescent alcohol screen-ing tool was empirically developedfrom epidemiologic data28 and hasbeen widely disseminated The currentstudy is the first to examine the per-formance of the self-reported fre-quency of use item from this tool ina pediatric patient sample and the firstformal extension of this tool to includedrug and tobacco use

This study furthers the effort to developand test asimple brief screen to rapidlytriage pediatric patients by risk levelSingle-item substance use screenershave been tested and recommended foradult primary care populations andhave been found to have low cut pointsin terms of number of days of use in thepast year33 Because onset of substanceuse typically occurs during the ado-lescent years patients in this agegroup are a critical target for screen-ing and intervention The overall per-formance metrics for the frequency ofuse items (including AUC sensitivityspecificity) compared with the goldstandard of meeting DSM-5 criteria for

tobacco alcohol and marijuana SUDwere favorable

Clinicians need a substance usescreening measure that is brief reli-able and practical24 The past-yearfrequency of use items on the BSTADconstitute a common question for to-bacco alcohol and drugs This ques-tion generally offers high sensitivityand specificity and meets the need forbrevity and reliability for each of the 3substances most commonly used byadolescents There is no need to scorethe instrument and it is simple to re-call the cutoffs for these 3 substancesBecause many adolescent treatmentproviders may find it important toscreen for any use of tobacco or othersubstances (not just their use dis-orders) it should be noted that thisinformation is also provided by theBSTAD

The cutoffs in the current study of 2 daysfor either alcohol or marijuana and 6days for tobacco use in the past yearsupport the frequency of use screeningquestionas a reliable rapid and simplestrategy for pediatricians to triagepatients into low-risk and higher-riskgroups However it is important tonote that although the measure may bean excellent screening tool the low cutpoints limit the ability of frequency ofuse on its own to act as a nuancedmeasure of the degree of problem

severity For patients who screen pos-itive on the BSTAD for any of thesesubstances further inquiry regardingproblems associated with use shouldbe pursued as is the case with anyscreening measure Minimally for allpatients screening positive a briefdiscussionintervention by the practi-tioner is warranted

Brief screening tools that offer the flexi-bilityofpatient-orprovider-administrationprovide flexibility in pediatric practicesand permit patient choice In the cur-rent study self-administration of theBSTAD on an iPad was feasible andwell received by participants Self-administration would benefit a busypediatric practice because data couldpotentially be entered directly intothe electronic medical record and im-mediately reviewed by the providerAnother potential advantage of self-administration is that there is someevidence that thisapproachyieldsmoreaccurate and reliable responses fromadolescents compared with adminis-tration by an interviewer for sensitivetopics3435

Rates of substance use in the past yearreported by participants were 95 forcigarettes or tobacco products 215for alcohol and 160 for marijuanaThese rates differ somewhat from na-tional rates for 12- to 17-year-olds in2012 which were 152 263 and135 for past-year use of tobacco al-cohol and marijuana respectively1

However substance use prevalence inour largely African American sample ismore in line with national data for Af-rican American adolescentsrsquo rates ofpast year tobacco (97) alcohol(208) and marijuana (135) useRates of illicit substance use other thanmarijuana were found to be low in thissample which is generally consistentwith rates found in national data Anotable exception is that rates of pre-scription drug misuse are higher na-tionally than what was found in our

TABLE 3 Usability and Acceptability Items (N = 525)

Item Strongly agree or agree

These questions were easy to understand 996I was comfortable answering these questions about my alcohol tobacco anddrug use

939

I was able to remember the number of days I used alcohol tobacco or drugsin the past year (n = 159)a

610

I would be willing to answer questions like these at my doctorrsquos office everyyear

898

The iPad touch screen was easy to use (n = 263)b 996I would prefer that a person ask me these questions in the doctorrsquos officeinstead of answering them myself on the iPad (n = 263)b

209

I would prefer to answer these questions myself on an iPad instead of havinga person ask me (n = 262)c

423

a Only participants who reported alcohol tobacco or drug use in the past year are included in percentageb Only participants who self-administered BSTAD questions on iPad are included in this percentagec Only participants who were asked BSTAD questions by interviewer are included in this percentage

824 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

sample1 Thus a degree of caution iswarranted when generalizing our find-ings to other groups of adolescents

The recently releasedDSM-5 criteria forSUD collapses 2 separate disordersfrom DSM-IV (labeled substance abuseand substance dependence) into a sin-gle category of SUD The use of the newDSM-5 criteria can be considereda strength of the study although theCIDI-2 has not been formally validatedagainst theDSM-5However theCIDIhasbeen validated for the DSM-IV36ndash38

which includes all of the same criteriain the DSM-5 with 2 exceptions (acraving criterion was added to theDSM-5 and the legal problem criterionfrom the DSM-IV was eliminated for theDSM-5) A limitation of the study is thatit was conducted in a single city witha largely African American populationFurther replication in other localitieswith diverse patient populations iswarranted Although it would havebeen useful to determine whether op-timal cut points differed by gender or

age group the prevalence of DSM-5SUDs in these subsamples was toolow to permit such analysis Examiningcut points for these subsamplesshould be a focus of future researchAdditionally data from all assessmentsadministered in this study were self-report and therefore substance usemay have been underreported Futurestudies should include the collection ofbiological samples to test for thepresence of substances that can serveas validity information beyond self-report although their relatively briefwindow limits their utility in thatregard Finally the administration order(self- vs interviewer-administered)was not randomized nor was the or-der of administration of the instru-ments

CONCLUSIONS

This study provides promising evidencesupporting the validity and utility ofusing past-year frequency of use asa quick and accurate screen for ado-

lescentsrsquo problematic tobacco alcoholand drug use Given the associationbetween substance use and depres-sion suicide violence fatal car acci-dents academic problems and thedevelopment of SUDs2681239 and thepotential effectiveness of brief inter-ventions and treatment of substance-involved adolescents4041 it is ofconsiderable importance that pedia-tricians family physicians and otherhealth care providers screen ado-lescents for substance use The use ofthe BSTAD or similar instruments canbe an important step in identifyingsubstance use and successfully in-tervening in the lives of adolescentpatients

ACKNOWLEDGMENTSTheauthorsthankDrGeethaSubramaniamfor her guidance and themedical staffand patients at Total Health Carefor their assistance We also thankKyra Walls for helping to prepare themanuscript

REFERENCES

1 Substance Abuse and Mental Health Ser-vices Administration Results from the 2012National Survey on Drug Use and HealthSummary of National Findings NSDUH Se-ries H-46 HHS Publication No (SMA) 13-4795 Rockville MD Substance Abuse andMental Health Services Administration2013

2 Kaminer Y Bukstein OG eds AdolescentSubstance Abuse Psychiatric Comorbidityand High-Risk Behaviors New York NYRoutledgeTaylor amp Francis 2008

3 Patton GC Coffey C Carlin JB DegenhardtL Lynskey M Hall W Cannabis use andmental health in young people cohortstudy BMJ 2002325(7374)1195ndash1198

4 Shrier LA Harris SK Kurland M Knight JRSubstance use problems and associatedpsychiatric symptoms among adolescentsin primary care Pediatrics 2003111(6 pt1) Available at wwwpediatricsorgcgicontentfull1116e699

5 Kokotailo P Physical health problems as-sociated with adolescent substance abuseNIDA Res Monogr 1995156112ndash129

6 Cox RG Zhang L Johnson WD Bender DRAcademic performance and substance usefindings from a state survey of public highschool students J Sch Health 200777(3)109ndash115

7 Martins SS Alexandre PK The associationof ecstasy use and academic achievementamong adolescents in two US nationalsurveys Addict Behav 200934(1)9ndash16

8 Eaton DK Kann L Kinchen S et al Youthrisk behavior surveillancemdashUnited States2005 J Sch Health 200676(7)353ndash372

9 Walton MA Cunningham RM Goldstein ALet al Rates and correlates of violentbehaviors among adolescents treated in anurban emergency department J AdolescHealth 200945(1)77ndash83

10 Tripodi SJ Springer DW Corcoran KDeterminants of substance abuse amongincarcerated adolescents implications forbrief treatment and crisis interventionBrief Treat Crisis Interv 2007734ndash39

11 Grant JD Scherrer JF Lynskey MT et al Ad-olescent alcohol use is a risk factor for adultalcohol and drug dependence evidence from

a twin design Psychol Med 200636(1)109ndash118

12 Hingson RW Heeren T Winter MR Age atdrinking onset and alcohol dependenceage at onset duration and severity ArchPediatr Adolesc Med 2006160(7)739ndash746

13 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2011 NationalCenter for Health Statistics Vital HealthStatistics 201210(254)1ndash80

14 World Health Organization CommonwealthMedical Association Trust UNICEF Orienta-tion Programme on Adolescent Health forHealth Care Providers Geneva SwitzerlandWorld Health Organization 2006

15 American Academy of Pediatrics Commit-tee on Substance Abuse Alcohol use andabuse a pediatric concern Pediatrics2001108(1)185ndash189

16 Kulig JW American Academy of PediatricsCommittee on Substance Abuse Tobaccoalcohol and other drugs the role of thepediatrician in prevention identification

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 825 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

Conversely among those who com-pleted the screening with the in-terviewer 423 agreed or stronglyagreed that they would have preferredto self-administer the screening onan iPad

DISCUSSION

The NIAAArsquos adolescent alcohol screen-ing tool was empirically developedfrom epidemiologic data28 and hasbeen widely disseminated The currentstudy is the first to examine the per-formance of the self-reported fre-quency of use item from this tool ina pediatric patient sample and the firstformal extension of this tool to includedrug and tobacco use

This study furthers the effort to developand test asimple brief screen to rapidlytriage pediatric patients by risk levelSingle-item substance use screenershave been tested and recommended foradult primary care populations andhave been found to have low cut pointsin terms of number of days of use in thepast year33 Because onset of substanceuse typically occurs during the ado-lescent years patients in this agegroup are a critical target for screen-ing and intervention The overall per-formance metrics for the frequency ofuse items (including AUC sensitivityspecificity) compared with the goldstandard of meeting DSM-5 criteria for

tobacco alcohol and marijuana SUDwere favorable

Clinicians need a substance usescreening measure that is brief reli-able and practical24 The past-yearfrequency of use items on the BSTADconstitute a common question for to-bacco alcohol and drugs This ques-tion generally offers high sensitivityand specificity and meets the need forbrevity and reliability for each of the 3substances most commonly used byadolescents There is no need to scorethe instrument and it is simple to re-call the cutoffs for these 3 substancesBecause many adolescent treatmentproviders may find it important toscreen for any use of tobacco or othersubstances (not just their use dis-orders) it should be noted that thisinformation is also provided by theBSTAD

The cutoffs in the current study of 2 daysfor either alcohol or marijuana and 6days for tobacco use in the past yearsupport the frequency of use screeningquestionas a reliable rapid and simplestrategy for pediatricians to triagepatients into low-risk and higher-riskgroups However it is important tonote that although the measure may bean excellent screening tool the low cutpoints limit the ability of frequency ofuse on its own to act as a nuancedmeasure of the degree of problem

severity For patients who screen pos-itive on the BSTAD for any of thesesubstances further inquiry regardingproblems associated with use shouldbe pursued as is the case with anyscreening measure Minimally for allpatients screening positive a briefdiscussionintervention by the practi-tioner is warranted

Brief screening tools that offer the flexi-bilityofpatient-orprovider-administrationprovide flexibility in pediatric practicesand permit patient choice In the cur-rent study self-administration of theBSTAD on an iPad was feasible andwell received by participants Self-administration would benefit a busypediatric practice because data couldpotentially be entered directly intothe electronic medical record and im-mediately reviewed by the providerAnother potential advantage of self-administration is that there is someevidence that thisapproachyieldsmoreaccurate and reliable responses fromadolescents compared with adminis-tration by an interviewer for sensitivetopics3435

Rates of substance use in the past yearreported by participants were 95 forcigarettes or tobacco products 215for alcohol and 160 for marijuanaThese rates differ somewhat from na-tional rates for 12- to 17-year-olds in2012 which were 152 263 and135 for past-year use of tobacco al-cohol and marijuana respectively1

However substance use prevalence inour largely African American sample ismore in line with national data for Af-rican American adolescentsrsquo rates ofpast year tobacco (97) alcohol(208) and marijuana (135) useRates of illicit substance use other thanmarijuana were found to be low in thissample which is generally consistentwith rates found in national data Anotable exception is that rates of pre-scription drug misuse are higher na-tionally than what was found in our

TABLE 3 Usability and Acceptability Items (N = 525)

Item Strongly agree or agree

These questions were easy to understand 996I was comfortable answering these questions about my alcohol tobacco anddrug use

939

I was able to remember the number of days I used alcohol tobacco or drugsin the past year (n = 159)a

610

I would be willing to answer questions like these at my doctorrsquos office everyyear

898

The iPad touch screen was easy to use (n = 263)b 996I would prefer that a person ask me these questions in the doctorrsquos officeinstead of answering them myself on the iPad (n = 263)b

209

I would prefer to answer these questions myself on an iPad instead of havinga person ask me (n = 262)c

423

a Only participants who reported alcohol tobacco or drug use in the past year are included in percentageb Only participants who self-administered BSTAD questions on iPad are included in this percentagec Only participants who were asked BSTAD questions by interviewer are included in this percentage

824 KELLY et al by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

sample1 Thus a degree of caution iswarranted when generalizing our find-ings to other groups of adolescents

The recently releasedDSM-5 criteria forSUD collapses 2 separate disordersfrom DSM-IV (labeled substance abuseand substance dependence) into a sin-gle category of SUD The use of the newDSM-5 criteria can be considereda strength of the study although theCIDI-2 has not been formally validatedagainst theDSM-5However theCIDIhasbeen validated for the DSM-IV36ndash38

which includes all of the same criteriain the DSM-5 with 2 exceptions (acraving criterion was added to theDSM-5 and the legal problem criterionfrom the DSM-IV was eliminated for theDSM-5) A limitation of the study is thatit was conducted in a single city witha largely African American populationFurther replication in other localitieswith diverse patient populations iswarranted Although it would havebeen useful to determine whether op-timal cut points differed by gender or

age group the prevalence of DSM-5SUDs in these subsamples was toolow to permit such analysis Examiningcut points for these subsamplesshould be a focus of future researchAdditionally data from all assessmentsadministered in this study were self-report and therefore substance usemay have been underreported Futurestudies should include the collection ofbiological samples to test for thepresence of substances that can serveas validity information beyond self-report although their relatively briefwindow limits their utility in thatregard Finally the administration order(self- vs interviewer-administered)was not randomized nor was the or-der of administration of the instru-ments

CONCLUSIONS

This study provides promising evidencesupporting the validity and utility ofusing past-year frequency of use asa quick and accurate screen for ado-

lescentsrsquo problematic tobacco alcoholand drug use Given the associationbetween substance use and depres-sion suicide violence fatal car acci-dents academic problems and thedevelopment of SUDs2681239 and thepotential effectiveness of brief inter-ventions and treatment of substance-involved adolescents4041 it is ofconsiderable importance that pedia-tricians family physicians and otherhealth care providers screen ado-lescents for substance use The use ofthe BSTAD or similar instruments canbe an important step in identifyingsubstance use and successfully in-tervening in the lives of adolescentpatients

ACKNOWLEDGMENTSTheauthorsthankDrGeethaSubramaniamfor her guidance and themedical staffand patients at Total Health Carefor their assistance We also thankKyra Walls for helping to prepare themanuscript

REFERENCES

1 Substance Abuse and Mental Health Ser-vices Administration Results from the 2012National Survey on Drug Use and HealthSummary of National Findings NSDUH Se-ries H-46 HHS Publication No (SMA) 13-4795 Rockville MD Substance Abuse andMental Health Services Administration2013

2 Kaminer Y Bukstein OG eds AdolescentSubstance Abuse Psychiatric Comorbidityand High-Risk Behaviors New York NYRoutledgeTaylor amp Francis 2008

3 Patton GC Coffey C Carlin JB DegenhardtL Lynskey M Hall W Cannabis use andmental health in young people cohortstudy BMJ 2002325(7374)1195ndash1198

4 Shrier LA Harris SK Kurland M Knight JRSubstance use problems and associatedpsychiatric symptoms among adolescentsin primary care Pediatrics 2003111(6 pt1) Available at wwwpediatricsorgcgicontentfull1116e699

5 Kokotailo P Physical health problems as-sociated with adolescent substance abuseNIDA Res Monogr 1995156112ndash129

6 Cox RG Zhang L Johnson WD Bender DRAcademic performance and substance usefindings from a state survey of public highschool students J Sch Health 200777(3)109ndash115

7 Martins SS Alexandre PK The associationof ecstasy use and academic achievementamong adolescents in two US nationalsurveys Addict Behav 200934(1)9ndash16

8 Eaton DK Kann L Kinchen S et al Youthrisk behavior surveillancemdashUnited States2005 J Sch Health 200676(7)353ndash372

9 Walton MA Cunningham RM Goldstein ALet al Rates and correlates of violentbehaviors among adolescents treated in anurban emergency department J AdolescHealth 200945(1)77ndash83

10 Tripodi SJ Springer DW Corcoran KDeterminants of substance abuse amongincarcerated adolescents implications forbrief treatment and crisis interventionBrief Treat Crisis Interv 2007734ndash39

11 Grant JD Scherrer JF Lynskey MT et al Ad-olescent alcohol use is a risk factor for adultalcohol and drug dependence evidence from

a twin design Psychol Med 200636(1)109ndash118

12 Hingson RW Heeren T Winter MR Age atdrinking onset and alcohol dependenceage at onset duration and severity ArchPediatr Adolesc Med 2006160(7)739ndash746

13 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2011 NationalCenter for Health Statistics Vital HealthStatistics 201210(254)1ndash80

14 World Health Organization CommonwealthMedical Association Trust UNICEF Orienta-tion Programme on Adolescent Health forHealth Care Providers Geneva SwitzerlandWorld Health Organization 2006

15 American Academy of Pediatrics Commit-tee on Substance Abuse Alcohol use andabuse a pediatric concern Pediatrics2001108(1)185ndash189

16 Kulig JW American Academy of PediatricsCommittee on Substance Abuse Tobaccoalcohol and other drugs the role of thepediatrician in prevention identification

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 825 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

sample1 Thus a degree of caution iswarranted when generalizing our find-ings to other groups of adolescents

The recently releasedDSM-5 criteria forSUD collapses 2 separate disordersfrom DSM-IV (labeled substance abuseand substance dependence) into a sin-gle category of SUD The use of the newDSM-5 criteria can be considereda strength of the study although theCIDI-2 has not been formally validatedagainst theDSM-5However theCIDIhasbeen validated for the DSM-IV36ndash38

which includes all of the same criteriain the DSM-5 with 2 exceptions (acraving criterion was added to theDSM-5 and the legal problem criterionfrom the DSM-IV was eliminated for theDSM-5) A limitation of the study is thatit was conducted in a single city witha largely African American populationFurther replication in other localitieswith diverse patient populations iswarranted Although it would havebeen useful to determine whether op-timal cut points differed by gender or

age group the prevalence of DSM-5SUDs in these subsamples was toolow to permit such analysis Examiningcut points for these subsamplesshould be a focus of future researchAdditionally data from all assessmentsadministered in this study were self-report and therefore substance usemay have been underreported Futurestudies should include the collection ofbiological samples to test for thepresence of substances that can serveas validity information beyond self-report although their relatively briefwindow limits their utility in thatregard Finally the administration order(self- vs interviewer-administered)was not randomized nor was the or-der of administration of the instru-ments

CONCLUSIONS

This study provides promising evidencesupporting the validity and utility ofusing past-year frequency of use asa quick and accurate screen for ado-

lescentsrsquo problematic tobacco alcoholand drug use Given the associationbetween substance use and depres-sion suicide violence fatal car acci-dents academic problems and thedevelopment of SUDs2681239 and thepotential effectiveness of brief inter-ventions and treatment of substance-involved adolescents4041 it is ofconsiderable importance that pedia-tricians family physicians and otherhealth care providers screen ado-lescents for substance use The use ofthe BSTAD or similar instruments canbe an important step in identifyingsubstance use and successfully in-tervening in the lives of adolescentpatients

ACKNOWLEDGMENTSTheauthorsthankDrGeethaSubramaniamfor her guidance and themedical staffand patients at Total Health Carefor their assistance We also thankKyra Walls for helping to prepare themanuscript

REFERENCES

1 Substance Abuse and Mental Health Ser-vices Administration Results from the 2012National Survey on Drug Use and HealthSummary of National Findings NSDUH Se-ries H-46 HHS Publication No (SMA) 13-4795 Rockville MD Substance Abuse andMental Health Services Administration2013

2 Kaminer Y Bukstein OG eds AdolescentSubstance Abuse Psychiatric Comorbidityand High-Risk Behaviors New York NYRoutledgeTaylor amp Francis 2008

3 Patton GC Coffey C Carlin JB DegenhardtL Lynskey M Hall W Cannabis use andmental health in young people cohortstudy BMJ 2002325(7374)1195ndash1198

4 Shrier LA Harris SK Kurland M Knight JRSubstance use problems and associatedpsychiatric symptoms among adolescentsin primary care Pediatrics 2003111(6 pt1) Available at wwwpediatricsorgcgicontentfull1116e699

5 Kokotailo P Physical health problems as-sociated with adolescent substance abuseNIDA Res Monogr 1995156112ndash129

6 Cox RG Zhang L Johnson WD Bender DRAcademic performance and substance usefindings from a state survey of public highschool students J Sch Health 200777(3)109ndash115

7 Martins SS Alexandre PK The associationof ecstasy use and academic achievementamong adolescents in two US nationalsurveys Addict Behav 200934(1)9ndash16

8 Eaton DK Kann L Kinchen S et al Youthrisk behavior surveillancemdashUnited States2005 J Sch Health 200676(7)353ndash372

9 Walton MA Cunningham RM Goldstein ALet al Rates and correlates of violentbehaviors among adolescents treated in anurban emergency department J AdolescHealth 200945(1)77ndash83

10 Tripodi SJ Springer DW Corcoran KDeterminants of substance abuse amongincarcerated adolescents implications forbrief treatment and crisis interventionBrief Treat Crisis Interv 2007734ndash39

11 Grant JD Scherrer JF Lynskey MT et al Ad-olescent alcohol use is a risk factor for adultalcohol and drug dependence evidence from

a twin design Psychol Med 200636(1)109ndash118

12 Hingson RW Heeren T Winter MR Age atdrinking onset and alcohol dependenceage at onset duration and severity ArchPediatr Adolesc Med 2006160(7)739ndash746

13 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2011 NationalCenter for Health Statistics Vital HealthStatistics 201210(254)1ndash80

14 World Health Organization CommonwealthMedical Association Trust UNICEF Orienta-tion Programme on Adolescent Health forHealth Care Providers Geneva SwitzerlandWorld Health Organization 2006

15 American Academy of Pediatrics Commit-tee on Substance Abuse Alcohol use andabuse a pediatric concern Pediatrics2001108(1)185ndash189

16 Kulig JW American Academy of PediatricsCommittee on Substance Abuse Tobaccoalcohol and other drugs the role of thepediatrician in prevention identification

ARTICLE

PEDIATRICS Volume 133 Number 5 May 2014 825 by guest on October 4 2018wwwaappublicationsorgnewsDownloaded from

and management of substance abuse Pe-diatrics 2005115(3)816ndash821

17 Levy SJ Kokotailo PK Committee on Sub-stance Abuse Substance use screeningbrief intervention and referral to treat-ment for pediatricians Pediatrics 2011128(5) Available at wwwpediatricsorgcgicontentfull1285e1330

18 Bethell C Klein J Peck C Assessing healthsystem provision of adolescent preventiveservices the Young Adult Health Care Sur-vey Med Care 200139(5)478ndash490

19 Fairbrother G Scheinmann R Osthimer Bet al Factors that influence adolescentreports of counseling by physicians on riskybehavior J Adolesc Health 200537(6)467ndash476

20 Hingson RW Zha W Iannotti RJ Simons-Morton B Physician advice to adolescentsabout drinking and other health behaviorsPediatrics 2013131(2)249ndash257

21 Millstein SG Marcell AV Screening andcounseling for adolescent alcohol useamong primary care physicians in theUnited States Pediatrics 2003111(1)114ndash122

22 Knight JR Sherritt L Harris SK Gates ECChang G Validity of brief alcohol screeningtests among adolescents a comparison ofthe AUDIT POSIT CAGE and CRAFFT AlcoholClin Exp Res 200327(1)67ndash73

23 Knight JR Sherritt L Shrier LA Harris SKChang G Validity of the CRAFFT substanceabuse screening test among adolescentclinic patients Arch Pediatr Adolesc Med2002156(6)607ndash614

24 Knight JR Shrier LA Bravender TD FarrellM Vander Bilt J Shaffer HJ A new briefscreen for adolescent substance abuseArch Pediatr Adolesc Med 1999153(6)591ndash596

25 Reinert DF Allen JP The alcohol use dis-orders identification test an update of re-

search findings Alcohol Clin Exp Res 200731(2)185ndash199

26 Rahdert ER The Adolescent AssessmentReferral System Manual (DHHS Publica-tion [ADM] 91-1735) Washington DC USDepartment of Health and Human Services1991

27 National Institute on Alcohol Abuse and Al-coholism Alcohol Screening and Brief In-tervention for Youth A Practitionerrsquos Guide(NIH Publication No 11-7805) Rockville MDNational Institutes of Health 2011

28 Chung T Smith GT Donovan JE et alDrinking frequency as a brief screen foradolescent alcohol problems Pediatrics2012129(2)205ndash212

29 Cottler LB Composite International Di-agnostic InterviewmdashSubstance AbuseModule (SAM) St Louis MO Department ofPsychiatry Washington University School ofMedicine 2000

30 Cottler LB Robins LN Helzer JE The re-liability of the CIDI-SAM a comprehensivesubstance abuse interview Br J Addict198984(7)801ndash814

31 Robins LN Wing J Wittchen HU et al TheComposite International Diagnostic In-terview An epidemiologic instrument suit-able for use in conjunction with differentdiagnostic systems and in different cul-tures Arch Gen Psychiatry 198845(12)1069ndash1077

32 American Psychiatric Association Di-agnostic and Statistical Manual of MentalDisorders 5th ed Washington DC Ameri-can Psychiatric Association 2013

33 Smith PC Schmidt SM Allensworth-DaviesD Saitz R A single-question screening testfor drug use in primary care Arch InternMed 2010170(13)1155ndash1160

34 Dolezal C Marhefka SL Santamaria EK LeuCS Brackis-Cott E Mellins CA A comparison

of audio computer-assisted self-interviewsto face-to-face interviews of sexual be-havior among perinatally HIV-exposedyouth Arch Sex Behav 201241(2)401ndash410

35 Turner CF Lessler JT Devore JW Effects ofmode of administration and wording onreporting of drug use In Turner CF LesslerJF Gfroerer JC eds Survey Measurementof Drug Use Methodological StudiesWashington DC Government Printing Of-fice 1992177ndash220

36 Compton WM Cottler LB Dorsey KB SpitznagelEL Mager DE Comparing assessments ofDSM-IV substance dependence disordersusing CIDI-SAM and SCAN Drug AlcoholDepend 199641(3)179ndash187

37 Cottler LB Grant BF Blaine J et al Con-cordance of DSM-IV alcohol and drug usedisorder criteria and diagnoses as mea-sured by AUDADIS-ADR CIDI and SCAN DrugAlcohol Depend 199747(3)195ndash205

38 Forman RF Svikis D Montoya ID Blaine JSelection of a substance use disorder di-agnostic instrument by the National DrugAbuse Treatment Clinical Trials Network JSubst Abuse Treat 200427(1)1ndash8

39 Centers for Disease Control and Prevention(CDC) Alcohol involvement in fatal motorvehicle crashesmdashUS 1997ndash1999 MMWRMorb Mortal Wkly Rep 199948(47)1086ndash1087

40 Mitchell SG Gryczynski J OrsquoGrady KESchwartz RP SBIRT for adolescent drug andalcohol use current status and futuredirections J Subst Abuse Treat 201344(5)463ndash472

41 Knight JR Harris SK Sherritt L et alPrevalence of positive substance abusescreen results among adolescent primarycare patients Arch Pediatr Adolesc Med2007161(11)1035ndash1041

(Continued from first page)

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE The authors have indicated they have no financial relationships relevant to this article to disclose

FUNDING All phases of this study were supported by National Institute on Drug Abuse grant R01 DA026003-03S1 Funded by the National Institutes of Health (NIH)

POTENTIAL CONFLICT OF INTEREST The authors have indicated they have no potential conflicts of interest to disclose

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OGrady and Robert P SchwartzSharon M Kelly Jan Gryczynski Shannon Gwin Mitchell Arethusa Kirk Kevin E

Drug UseValidity of Brief Screening Instrument for Adolescent Tobacco Alcohol and

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Referenceshttppediatricsaappublicationsorgcontent1335819BIBLThis article cites 32 articles 6 of which you can access for free at

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OGrady and Robert P SchwartzSharon M Kelly Jan Gryczynski Shannon Gwin Mitchell Arethusa Kirk Kevin E

Drug UseValidity of Brief Screening Instrument for Adolescent Tobacco Alcohol and

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