Analisis del tratamiento a las drogas en adolescentes NIDA.pdf

8/20/2019 Analisis del tratamiento a las drogas en adolescentes NIDA.pdf

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Adolescent

Drug Abuse:Analyses of

Treatment Research

U.S. DEPARMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • National Institutes of Health


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Adolescent Drug Abuse: Analyses of TreatmentResearch

Editors:

Elizabeth R. Rahdert, Ph.D.

Division of Clinical ResearchNational Institute on Drug Abuse

John Grabowski, Ph.D.Department of Psychiatry and Behavioral SciencesUniversity of Texas Health Science Center

NIDA Research Monograph 771988

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

5600 Fishers LaneRockville, Maryland 20857

For sale by the Superintendent of Documents, U.S. Government Printing officeWashington, DC 20402


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NIDA Research Monographs are prepared by the research divisions of theNational Institute on Drug Abuse and published by its Office of Science. Theprimary objective of the series is to provide critical reviews of research problemareas and techniques, the content of state-of-the-art conferences, andintegrative research reviews. Its dual publication emphasis is rapid and targeted

dissemination to the scientific and professional community.

Editorial Advisors

MARTIN W. ADLER, Ph.D.Temple University School of Medicine

Philadelphia, Pennsylvania

SYDNEY ARCHER, Ph.D.Rensselaer Polytechnic lnstitute

Troy, New York

RICHARD E. BELLEVILLE, Ph.D.NB Associates, Health Sciences

Rockville, Maryland

KARST J. BESTEMANAlcohol and Drug Problems Association

of North America

Washington, D.C.

GILBERT J. BOTVIN, Ph.D.Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph.D.The Johns Hopkins Unversity School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph.D.Washington University School of

Medicine

St Louis, Missouri

MARY L. JACOBSONNational Federation of Parents for

Drug-Free Youth

Omaha, Nebraska

REESE T. JONES, M.D.Langley Porter Neuropsychiatric lnstituteSan Francisco, California

DENISE KANDEL, Ph.D.College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER. M.D. Yale University School of Medicine

New Haven, Connecticut

RICHARD RUSSONew Jersey State Department of Health

Trenton, New Jersey

NIDA Research Monograph Series

CHARLES R. SCHUSTER, Ph.D.Director, NIDA

THEODORE M. PINKERT, M.D., J.D.Acting Associate Director for Science, NIDA

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857


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Adolescent Drug Abuse:

Analyses of TreatmentResearch


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ACKNOWLEDGMENT

This monograph is based upon papers presented at a technical reviewon analyses of research concerning treatment of adolescent drugabusers which took place on November 6 - 7, 1985, at Bethesda,Maryland. The review meeting was sponsored by the Office of Scienceand the Division of Clinical Research, National Institute on Drug

Abuse. At the time of the review, Dr. John Grabowski, coeditor ofthe monograph, was chief of the Treatment Research Branch, Divisionof Clinical Research. He is currently affiliated with theUniversity of Texas Health Science Center.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission fromthe copyright holders to reproduce certain previously publishedfigures and tables, as noted in the text. Further reproduction of

the copyrighted material is permitted only as part of a reprintingof the entire publication or chapter. For any other use, thecopyright holder's permission is required. All other material inthis volume except quoted passages from copyrighted sources is inthe public domain and may be used or reproduced without permissionfrom the Institute or the authors. Citation of the source isappreciated.

National Institute on Drug Abuse

NIH Publication No. 94-3712

Formerly DHHS Publication No. (ADM) 88-1523

Printed 1988 Reprinted 1994

NIDA Research Monographs are indexed in the Index Medicus. They areselectively included in the coverage of American Statistics IndexBiosciences Information Service, Chemical Abstracts, CurrentContents, Psychological Abstracts, and Psychopharmacology Abstracts.

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Contents

Treatment Services for Adolescent Drug Abusers:Introduction and Overview

Elizabeth R. Rahdert . . . . . . . . . . . . . . . . . . . . 1

Assessing Adolescents Who Abuse Chemicals: The ChemicalDependency Adolescent Assessment Project

Ken C. Winters and George Henley . . . . . . . . . . . . . . . 4

Substance Abuse in Adolescents: Diagnostic Issues Derived FromStudies of Attention Deficit Disorder With Hyperactivity

Jan Loney . . . . . . . . . . . . . . . . . . . . . . . . . 19

Empirical Guidelines for Optimal Client-Treatment Matching

Reid K. Hester and William R. Miller . . . . . . . . . .

Family-Based Approaches to Reducing Adolescent Substance Use:Theories, Techniques, and Findings

Brenna H. Bry . . . . . . . . . . . . . . . . .

Parent and Peer Factors Associated with Sampling in EarlyAdolesence: Implications for TreatmentThomas J. Dishion, Gerald R. Patterson, and John R. Reid . . . 69

Pharmacotherapy of Concomitant Psychiatric Disorders in

Adolescence: Substances Abusers

27

39

Barbara Geller . . . . . . . . . . . . . . . . . . . . . 94

Treatment Validity: An Approach to Evaluating the Quality ofAssessment

Steven C. Hayes . . . . . . . . . . . . . . . . . . . . .

Adolescent Drug Use: Suggestions for Future ResearchNorman A. Krasnegor . . . . . . . . . . . . . . . . .

List of NIDA Research Monographs . . . . . . . . . . .

113

128

135

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Treatment Services for Adolescent Drug Abusers:

Introduction and OverviewElizabeth R. Rahdert

The annual High School Senior Survey conducted by the University ofMichigan's Institute for Social Research reported that the numberof senior high school students who used cocaine, as well as mostother drugs, remained exceptionally high during 1985 (Johnston etal. 1986). And these estimates of late adolescent drug use would

be even greater had the high-risk, difficult-to-sample high schooldropouts been surveyed. Unfortunately, the 1987 results from theongoing study indicate only a modest improvement over the 1985figures (Johnston 1988). While the 1987 data suggest only aslight, albeit statistically significant, decline in the use ofcocaine, marijuana, stimulants, and sedatives, there appears to belittle to no change in the student use of inhalants, LSD, heroin,or other opiates. In addition, the most recent figures show that 4in every 10 students surveyed said they tried one or more illicitdrugs at least once during the last 12 months. And nearly 5percent of those questioned said that during the past month they

had used one or more illicit drugs on a daily basis, some of whichwere potentially toxic and highly addictive.

These patterns of exposure to one or more potent psychoactiveagents indicate that many teenagers are far past the experimentalphase of illicit drug use, and provide a basis for predicting thata clinically significant number will or already do suffer seriousphysical, mental, and/or social effects after a relatively shortperiod of abusing drugs. And this prediction, in turn, suggeststhat different types of therapeutic interventions will be necessaryto treat these more severely affected youth.

The first addiction facilities, designed to treat the adult malealcoholic, admitted only a small fraction of the older, addictedadolescents. Few of these programs made any adjustment toaccommodate even the most obvious developmental differences

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evident in young drug-dependent clients. In any case, as thenumbers of drug-involved teenagers from the middle and uppersocioeconomic levels rose, so too did the number of treatmentfacilities created solely to address the adolescents' age-relatedproblems. Often these newly established programs advertised abroad range of therapeutic services, including differentcombinations of and variations on drug education, family-basedtherapy, parent training, peer group counseling, indlvidualpsychotherapy, and/or social skills training, with psychiatricallyoriented facilities at times offering medication as a therapeuticoption. What each program appeared to share was the common beliefthat it was the appropriate place for any and all adolescentclients. Few referred to other available programs, on a timelybasis, those teenagers they should not or could not treat.

Such all-inclusive admission policies reflect the fact that there

often is insufficient staff time, budgetary support, or perhapseven administrative inclination, to critically self-evaluate eachservice alone and on an interactive basis, to determine which youngclients they could and could not effectively treat. So too thesepolicies indicate the paucity of scientific evidence to supportspecific optimal therapeutic combinations for treatingdiagnostically different types of chemically dependent youth. Thecurrent need for adolescent drug abuse treatment research isapparent. As with most clinical research, designing and conductingthe necessary controlled clinical studies represents a difficult,but challenging, task.

The contributors to this monograph have presented an overview ofadolescent treatment research with the dual aims of targeting thespecific difficulties associated with adolescent clinical studiesand providing a critical review of what has already been learnedabout each step in the treatment process: 1) the initial screeningof high risk teenage populations in order to single out theaffected youth; 2) the diagnostic procedure for identifyingspecific impaired or dysfunctional areas; 3) the selection of themost appropriate treatment facility and/or program for theindlvidual adolescent, with choice of treatment based on the

results of a diagnostic assessment; 4) the delivery of specifictypes of treatment such as family-based therapy or pharmacotherapy;and 5) the establishment of aftercare programs designed forschool-age youth. It is evident from each review that the field ofadolescent treatment research shares a significant number of designproblems common to any study involving human subjects. young orold. In addition, many practical issues are identified that appearunique to studies involving youth rather than adults.

What is most timely is the emphasis placed on the need to reliablyand cost efficiently examine the positive as well as negative

effects of therapeutic programs already in operation.Concurrently, more creative effort should be channeled towarddeveloping new and innovative techniques to meet the treatmentneeds so apparent in the results of our national adolescent surveys.

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REFERENCES

Johnston, L.D.; O'Malley, P.M.; and Backman, J.G. Drug Use AmongHigh School Students, College Students, and Other Young Adults;

National Trends Through 1985. DHHS Pub. No. (ADM) 86-1450.Washington, DC: Supt. of Docs., U.S. Govt Print Off., 1986.

Johnston, L.D. "Quantitative and Qualitative Changes in CocaineUse Among American High School Seniors, College Students, and YoungAdults." Paper presented at the NIDA Technical Review on TheEpidemiology of Cocaine Use and Abuse, Rockville, MD, 1988.

AUTHOR

Elizabeth R. Rahdert, Ph.D.Treatment Research BranchDivision of Clinical ResearchNational Institute on Drug Abuse5600 Fishers LaneRockville, Maryland 20857

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Assessing Adolescents Who Abuse Chemicals: The ChemicalDependency Adolescent

Assessment ProjectKen C. Winters and George Henly

INTRODUCTION

There are opportunities and challenges in the treatment of adoles-cent chemical dependency. Survey data continue to indicate thatAmerican teenagers are using alcohol and drugs at an uncomfortablyhigh rate (Johnston et al. 1984). More adolescents are beingserved by a greater number of chemical dependency treatment pro-grams than at any time before. At the same time, society as awhole is both becoming more interested in chemical abuse problems

and their treatment and calling for more accountability by thoseservice providers.

Increased awareness of the problem has affected identification andtreatment of adolescent chemical dependency. Those who abuse al-cohol or drugs are being identified at earlier stages of involve-ment by a wide range of professionals and agencies, which includeschool teachers and administrators, officials in the juvenile jus-tice system, and a wide array of therapists and counselors withvarying degrees of clinical training. Earlier detection by di-verse professionals may be a positive step for the adolescent user

and the family. There exists the potential that abusers can beidentified before severe problems develop, and identification mayoccur in settings that may encourage the individual to seek help.Yet this trend, in some respects, poses a strain on the treatmentfield. Increasingly, service providers are being asked to makeobjective decisions about diagnosis, need for treatment, and re-ferral for adolescents whose problem configurations are eitherdifferent or less well developed than those of adolescents treatedin the past.

CHALLENGE FOR ADOLESCENT ASSESSMENT

The traditional concepts of the nature of chemical dependency arelargely based on an adult model. When considering the case ofwhat Jellinek (1960) would classify as a gamma alcoholic (e.g., a45-year-old individual with a long history of problems resultingfrom excessive use of alcohol), it does not require a great deal

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of sophistication to make a diagnosis of chemical dependency.There is not likely to be much disagreement among professionalsabout this diagnosis. Similarly, when an adolescent presents manyof the hallmark symptoms of adult chemical dependency, it is un-likely that assigning a diagnosis of chemical dependency to this

individual would prove controversial.

Professionals may become increasingly uncomfortable, however,about making diagnostic and treatment decisions as adolescentclients bear less and less resemblance to chemically dependentadults. They may be reluctant to tell those adolescents that theyhave a chronic, progressive disease for which lifelong abstinenceis the only treatment route.

Much of this discomfort in assessing and diagnosing the problemsof adolescents in the early stages of involvement with chemicals

is warranted. Studies of general population samples indicatethat, as in the past, substantial proportions of adolescent chemi-cal abusers mature out of their problem use patterns without expo-sure to formal intervention or treatment. A recent study inMadison, WI, found that only about half of a sample of adolescentsidentified as alcohol abusers could still be so classified whenassessed 6 months later (Moberg 1983). Data from more extendedlongitudinal research also indicate the transitory nature of ado-lescent chemical misuse (Jessor 1982). Although it is not knownwhether remitted abusers will resume a pattern of misuse later inlife, data from the existing followup studies are provocative.

Another outcome of the increasing detection and treatment of youthchemical abuse is that insurers and other third-party paymentorganizations are facing mounting costs. Their reaction has beento require treatment organizations to further document and betterjustify the need for treatment. Consequently, and appropriately.treatment programs must develop assessment procedures that aremore objective and reliable. They are also confronted with thesituation of making diagnostic decisions based on criteria oftenformulated by those outside the field.

These strains on the assessment process are further compounded bythe growing attractiveness of chemical dependency treatment andthe reduced diagnostic stigma attached to the chemical dependencylabel. Adolescents or their parents may seek a diagnosis ofchemical dependency in situations where chemical abuse may not bethe primary difficulty. Parents would prefer to believe thattheir child is chemically dependent, rather than mentally dis-turbed, delinquent, or living in a chaotic family. The problemconfigurations of such clients may be so complex that it is diffi-cult to pinpoint the central target problem or problems. The need

to sort out target problems and make appropriate referral deci-sions will increase as adolescent chemical dependency treatmentfacilities become the programs of first resort rather than of lastresort.


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The development of increasingly diverse treatment programs alongthe health care continuum increases the demands made upon assess-ment procedures. The luxury rarely exists today of simply decid-ing whether or not the adolescent's problems are sufficientlysevere to warrant placement in the one and only available treat-

ment facility. Assessment procedures must become increasinglydetailed and multifaceted, if they are to permit matching theclient to an optimal treatment plan, as the trend moves towarddeveloping a variety of treatment levels and modalities from whichto choose.

The developments and issues described above pose major challengesfor adolescent assessment. Four of these challenges are identi-fied below.

First, there is a need for increased objectivity of client assess-

ment. At the present time, assessment practices in the field relyheavily on clinical judgment. In a recent survey of adolescentchemical dependency programs (Owen and Nyberg 1983), the majorityof respondents indicated that their assessment procedures are in-formal and typically based on in-house and relatively idiosyn-cratic questionnaires. As a result, it is problematic whendifferent programs wish to communicate about the nature of theirrespective clientele, or when researchers hope to utilize assess-ment information from a variety of facilities for research pur-poses. This state of affairs is not necessarily the result of thetreatment community's unwillingness to use clinically useful and

standardized assessment tools. The reality is that such tools donot exist.

Second, there must be meaningful differentiation of adolescentsacross levels or stages of chemical involvement. Adolescents maydiffer not only in terms of the severity and consequences of theirchemical use, but in the pattern of that use and in the configura-tion of factors that may play a role in leading to, or maintainingchemical misuse. One central question is whether one can validlydifferentiate short-term users or experimenters vs. those abuserswhose problems will endure. Extant data do not allow such dis-criminations of these two groups based on initial involvement withdrugs.

Another key issue is whether it is possible to differentiateadolescents in terms of the configuration of their chemicalinvolvement. This configural perspective is similar to themultiple-syndrome notion of adult alcoholism (Wanberg and Horn1983) and may prove to be a more appropriate framework from whichto view adolescent chemical involvement than simply distinguishingabusers along the severity dimension.

Third, there exists a need to identify and differentiate problemsaccompanying chemical abuse. The ability to assess not only theseverity of the chemical use problem itself, but also the extentof other problems that may complicate or be disguised by chemicalabuse, is a high priority.

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Finally, there must be differential assignment of client toappropriate treatment level and modality. As the diversity oftreatment services increases, the basis for choosing among themfor each available client becomes more complicated. There may besome clients for whom no appropriate treatment currently exists,while for others, decisions of formal treatment vs. education,residential vs. outpatient treatment, or extended care vs. supportgroup, are the relevant questions.

Clearly the issues surrounding the assessment of adolescent chemi-cal involvement are complex and controversial. In 1982, theChemical Dependency Adolescent Assessment Project was begun to ad-dress some of these issues. The 5-year project is unique in thatit is being completed collaboratively by a consortium of 16 estab-lished chemical dependency organizations in Minnesota. Fundingfor the project comes from the Northwest Area Foundation. The

Saint Paul Foundation and the Amherst H. Wilder Foundation areadministering the grant on behalf of the consortium. The remain-der of this report provides a brief summary of the relevantassessment literature on adolescent chemical involvement and dis-cusses the current status of research activities by the AdolescentAssessment Project.

BRIEF OVERVIEW OF PERTINENT LITERATURE

With the exception of two brief screening instruments, theAdolescent Alcohol Involvement Scale (AAIS) (Mayer and Filstead

1979) and the Youth Diagnostic Screening Test (YDST) (Alibrandi1978), no psychometrically developed or validated paper-and-pencilinstruments for use with adolescent chemical dependency popula-tions have been reported in the professional literature. The AAIShas been validated, to some degree, against independent clinicaldiagnosis and, in general, has undergone more research scrutinythan the YDST (Moberg 1983; Riley and Klockars 1984). Neverthe-less, the apparent value of the AAIS and YDST is limited to ini-tial screening applications. While they may permit generalevaluation of the extent or severity of the adolescent's problem,they do not provide for discrimination between different problemtypes or configurations.

Related to the "problem severity" instruments is the group ofadolescent survey instruments. The Youth Experience Questionnaire(Dunnette et al. 1980), the Research Triangle Institute's Study ofAdolescent Drinking Behavior and Attitudes (Rachal et al. 1980).and the Institute of Social Research's Annual High School SeniorSurvey Questionnaire (Johnston et al. 1981) are three importantexamples of surveys of nonclinical adolescent populations. Thesesurvey questionnaires typically evaluate use prevalence, extent of

consumption, reasons for use, use patterns, and effects and conse-quences of use.

Development of instruments for adult chemical-abusing populationshas received, by far, greater attention. These instruments canoffer models from which to work in developing similar instruments

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for adolescents. The Michigan Alcoholism Screening Test (MAST)(Selzer 1971), the MacAndrew Scale from the Minnesota MultiphasicPersonality Inventory (MMPI) (MacAndrew 1965). the AlcoholDependence Scale (Skinner and Allen 1982), the CAGE Questionnaire(Mayfield et al. 1974), and the Drug Abuse Screening Test (Skinner1982) represent popular screening instruments for adults withsubstance use problems. Their value is limited, as in the AAIS,because of their focus on a single, general problem severitydimension. These questionnaires may be contrasted with theAlcohol Use Inventory (AUI) (Wanberg et al. 1977). a sophisticatedand well-researched instrument that assesses multiple dimensionsof alcohol involvement. Skinner's (1981) factor analysis of theAUI suggests four factors or alcoholism "syndromes" tapped by theAUI: alcohol dependence, perceived benefits from drinking, mari-tal discord, and polydrug use. These findings support a multiplesyndrome conception of alcohol abuse in adults.

In the domain of diagnostic structured interviews, there now existseveral interview protocols for adolescents (or children) thataddress DSM-III criteria for mental disorders, including those forsubstance use disorder diagnoses. Four prominent interview sched-ules include the Diagnostic Interview Schedule for Children andAdolescents (Reich et al. 1982), the Kiddie Schedule for AffectiveDisorders and Schizophrenia (Chambers et al., in press), theNational Institute of Mental Health Diagnostic Interview Schedulefor Children (Costello et al. 1984), and the Child AssessmentSchedule (Hodges et al. 1982). While these interviews have under-

gone evaluations for interrater agreement and have been validatedagainst external criteria, there are no published reports of thevalidity of their substance use disorder diagnosis sectionsagainst independent clinical diagnoses.

In addition to the focus on problem severity and diagnostic clas-sifications, existing personality inventories and research instru-ments have been used to explore the role of psychosocial variablesin adolescent chemical use. These studies have included measuresof deviance, sensation seeking, aggression, alienation, impulsiv-ity, self-esteem, locus of control, family cohesion, religiosity.

and peer attitudes (to list only a few). While many of thesevariables have consistently discriminated samples of adolescentchemical abusers from samples of nonabusers, the strength of theobserved relationships has generally been modest. Since itappears that none of these variables constitutes a necessary orsufficient basis for the development of adolescent chemical abuseor dependence, it may be more appropriate to consider them as riskfactors that may play a role in predisposing adolescent experimen-tation with chemicals or perpetuating chemical use once it isinitiated.

It is also important to note that the aforementioned psychosocialvariables are often associated with a broad range of problem be-haviors, including delinquency and sexual promiscuity (Jessor andJessor 1977; Rathus et al. 1980). Given the nonspecificity ofpsychosocial risk factors for adolescent chemical abuse, there is

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little validity in targeting high-risk individuals on the basis ofthese variables alone. Psychosocial measures may, however, havevalue in identifying subgroups of chemical abusers who have dif-ferent treatment needs or prognoses. There is an increasing bodyof research concerned with the identification of personality sub-types among adult alcoholics, and some common threads have emerged

across those studies (Costello 1981).

DEVELOPMENT OF A NEW ASSESSMENT BATTERY

In view of the limitations of existing tools to assess adolescentchemical involvement, the Chemical Dependency Adolescent Assess-ment Project began the process of developing a new standardizedassessment battery.

The first year of the project was spent reviewing pertinent liter-ature, consulting experts, and talking with direct service provid-

ers. A dominant theme that emerged was the complexity of theproblem configurations that characterize this clinical population.Adolescents were viewed as differing in multiple (perhaps config-ural) ways, not only in terms of chemical use problem severity.The convergence of anecdotal clinical reports and the emergingviewpoint in the adult literature of multiple alcoholism syndromesor types (Jellinek 1960; Morey et al. 1984) led the project tobase its model for instrument construction on a multidimensionalfooting.

A three-ring model has guided the project's efforts in instrumentdevelopment (figure 1). The first ring, which occupies the centerof the model, is the problem severity domain. It involves thesigns, symptoms, consequences, patterns, etc., of chemical abuseand dependency. The project instrument developed to assess thisdomain is the paper-and-pencil questionnaire entitled "PersonalExperience With Chemicals Scales" (PECS).

The cluster of variables forming the second ring in the modelrefers to the so-called risk factors of substance use. Thesepredisposing and perpetuating factors include genetic, sociodemo-

graphic, intra- and interpersonal , and environmental variables.The second paper-and-pencil questionnaire that was developed, thePersonal Experience Scales (PES), addresses a subset of thesevariables.

The third ring of the model includes variables associated with thediagnostic classification of psychoactive substance use disordersand attends primarily to factors associated with DSM-III-R cri-teria. We have developed a highly structured interview schedule,the Adolescent Diagnostic Interview-Revised (ADI-R), to addressthe third ring. Although the applicability of DSM-III-R sub-

stance use disorder diagnostic criteria to adolescents has beenquestioned, it may be expected that DSM-III-R interview scheduleswill be used to a greater degree as programs are forced to justifyand document their diagnostic decisions.

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FIGURE 1. A model to guide initial instrument construction

Since tne PECS and PES have received the most attention to date,the remaining discussion will focus on these two questionnaires.Due to limitations of space, only a brief overview of the develop-ment of these instruments will be presented. A more detailedreport on the development of the battery can be obtained by con-tacting the authors.

Preliminary Instrument Construction

Three steps were involved in constructing the item pools for thePECS and PES: (1) items were culled from existing measures andorganized into content categories; (2) ratings of the clinicalimportance of each content area were obtained from service provid-ers; (3) new items were written to represent each content areathat was rated important. Additional items were added to assessdefensiveness (items adapted from the Marlowe-Crowne Social Desir-ability Scale) (Crowne and Marlowe 1960) and invalid responding.The resulting preliminary versions of the two instruments wereeach about 250 items in length. In order to facilitate adminis-tration during the research phase, each instrument was dividedinto two subsets having similar item content and style, so thatthe instruments could be conveniently completed in two separate

sittings.

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Administration Procedures

In order to remain within project timelines, the PECS and PES wereadministered to independent samples at different times. Consent-ing adolescent clients at participating Minnesota chemical depend-ency evaluation and treatment programs were administered the PECS

or PES questionnaires during their first week of program contact.The order of administration of the instrument subtests was random-ized, so that the effects of item order and respondent fatiguemight be counterbalanced. The majority of clients completed bothsubtests for an instrument in a single sitting. The instrumentswere administered by staff members at the participating programs.

Subjects

Participants were consenting adolescents, ages 12 to 18, receivingchemical dependency evaluation or treatment at 16 Minnesota sitesbetween March 1984 and May 1985. The participating programs in-cluded both hospital and free-standing units that provided eitherevaluation or treatment services on either a residential or out-patient basis. Twelve of the sixteen sites are located in theMinneapolis-St. Paul metropolitan area; the remaining sites are inrural locations. Approximately 1,100 of the 1,600 clients identi-fied as eligible to participate in the study completed either thePECS or PES questionnaire. Comparisons of participants and non-participants during the PECS and PES administration phase failedto detect statistically significant differences on either demo-

graphic (sex, age, race, prior treatment history) or psychological(MMPI scale scores) variables. Sample characteristics are summa-rized in table 1. The majority of the sample is male, white, andbetween the ages of 15 and 17.

Scale Analyses

Rational and empirical strategies were employed in the developmentof the revised PECS. First, items were assigned a priori toscales and then reassigned or deleted based on their own-scale andother-scale correlations, so that scale reliability and independ-

ence could be maximized using the rational approach. Second, avariety of factor and cluster-analytic procedures were employed todefine empirically the PECS. Scales that emerged consistentlyacross these procedures were then evaluated for clinical utilityand interpretability. Most of the empirical scales were conceptu-ally similar to the rational scales; hence, the empirical scalesformed the basis for the selection of the final set of PECS. Asmall number of rational scales were retained because their clini-cal utility was judged to be important. Rational scale construc-tion procedures formed the primary basis for the development ofthe revised PES. In the analyses for both instruments, scale

characteristics were derived and optimized on a development sampleand then tested on a separate, replication sample.

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TABLE 1. Sample characteristics

DemographicVariables

PECS (n=646*) PES (n=458*)

n Percent n Percent

Sex

MaleFemale

377 60.4 265 61.6247 39.6 165 38.4

Age

12131415

161718

19+

Race

White 578 92.3 378Black 10 1.6 28American Indian 26 4.2 9Other 12 1.9 12

Prior Primary Treatment

NoYes

53278140

164151493

463 75.3 335 78.5152 24.7 92 21.5

0.8 25.1 2212.5 5222.5 107

26.4 11524.3 937.9 220.5 3

0.4

5.312.525.7

27.622.45.30.7

88.56.62.12.8

*Totals do not add to indicated n due to unavailable or missing data. N's referto development and replication samples.

Results

Titles and definitions of the resulting scales of the PECS and PESare presented in table 2. Scale reliabilities, based on the rep-lication samples, are reported in table 3. The revised PECS have113 items that permit the scoring of five Basic Scales, fiveClinical Scales, and three Validity Indices. The Basic Scalesaccount for the majority of reliable instrument variance. TheClinical Scales, whose items are largely redundant with the Per-sonal Involvement Scale, restructure the information from thatsingle scale in a way that may be interesting to clinicians,Estimates of internal consistency reliability for the revised PECSrange from .80 to .97. The 147 items of the revised PES are orga-nized into eight Personal Adjustment Scales, four Family and PeerEnvironment Scales, and two Validity Indices. In addition, fourbrief problem screens are scored. Internal consistency reliabil-ity estimates for the 12 substantive scales range from .74 to .90.

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TABLE 2. The revised scalesof the Personal Experience WithChemicals Scales (PECS) and the Personal ExperienceScales (PES)

PERSONAL EXPERIENCE WITH CHEMICALS SCALES

Clinical Scales

1 .

2.

3.

4.

5.

Personal Involment (29 items) - High scores on this scale suggest frequentuse at times and in settings that are inappropriate for drug use; use for psychological benefit or self-medication; and restructur ing activi t ies tobetter allow use (preoccupation). Low scores on this scale suggest relatlve-ly infrequent use associated with social settings. This set of items formsthe key scale to assess general problem severity.

Effects From Use (10 items) - The items of this set concern the immediatepsychological, physiological, and behavioral consequences of chemical use.

Social Benefits Use (8 items) - This scale reflects use associated with

increased social confidence and social acceptance.

Personal Consequences (11 items) - Items in this set focus on difficultieswi th f r iends, parents, school , and var ious other socia l inst i tu t ions that area result of the use of chemicals.

Social-Rereational Use (8 items) - Items from this scale are associated withthe use of chemicals for fun in social situations.

Basic Scales

6. Transsituational Use (9 items) - This set represents use in a variety of sett ings, part icular ly ones that are inappropriate for drug use (e.g..school).

7. Psychological benefits Use (7 items) - Items in this set suggest the use of chemicals to reduce negative emotional states and to enhance pleasure.

8 . Preoccupation (8 items) - This scale represents overinvolvement with chemicaluse, for example, by preplanning future use, restructur ing activi t ies tobetter allow private or social use, and rumination about use.

9. Loss of Control (9 items) - This set of items is associated with both theinability to abstain from chemical use and the inability to moderate use onoccasions when chemicals are available.

10. Polydrug Use (8 items) - The items defining this scale are all indicators of use of drugs other than alcohol.

Validity Indices

11.

12.

13.

Infrequent Responses (7 items) - These items, having very Iow rates of endorsement, may be associated with “faking bad,” lnattention, or randomresponding.

Defensiveness (15 items) - The basis for this set of items was the 33-itemMarlowe-Crowne Social Desirability scale, a frequently used measure of defensiveness. The Items were modified slightly to make them appropriate for an adolescent-population.

Pattern Misfit - Respondents with unusual pattern response on the PersonalInvolvement Scale can be statistically identified; an unusual pattern can beindicative of inattentive or random responding, or may represent actual, but

atypical, chemical use patterns.

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TABLE 2. (Continued)

PERSONAL EXPERIENCE SCALES

PersonaI Adjustment Scales

1.

2.

3.

4.

5.

6.

7.

8.

PersonaI Adequacy (10 items) - This scale reflects general self-esteem andself-regard, personal satisfaction, and feelings of competence.

Psychological Disturbance (10 items) - Items from this scale are associatedwith psychological problems and distress, such as difficulties with mood,thinking, and physical concerns.

Social Integration (6 items) - This scale represents social competence,feelings of belonging to a social group, and degree of mistrust in one'ssoc ia l I i f e .

Self-control (12 items) - These items focus on tendency to act out, todisplay anger and aggressiveness, and to defy authority.

Conventional Volumes (11 items) - The items in this set concern acceptance of tradit ional bel iefs about r ight and wrong.

Deviant Behavior (10 items) - High scores on this scale suggest involvementin unlawful or delinquent behavlor.

Future Goal Orientatiom (11 items) - This scale represents planning for andthinking about one’s future plans, goals, and expectations.

Spirituality (7 items) - High scores on this scale suggest belief inspir i tual I i fe and use of prayer.

Family and Peer Environment Scales

9. Peer Chemical Environment (8 items) - The items defining this scale indicateinvolvement with chemicals by one’s peers.

10. Sibling Chemical Use (4 ltems) - This set represents chemical use by brotherso r s i s t e r s .

11. Family Pathology (14 Items) - Items from this scale are associated withfamily problems of chemical dependency, physical or sexual abuse, and severefamily dysfunction.

12. Family Estrangement (13 items) - This scale ref lects lack of fami ly so l idar-Ity and closeness and the presence of a parent-child conflict.

Screens for Other Problems

These scales provide brief screens for the following problem areas:

13. Parent/Sibling Chemical Dependancy

14. Physical Abuse

15. Sexual Abuse

16. Eating Disorder

Validity Indices

17. Infrequent Responses (11 items) - These items have very low rates of endorse-ment and may refIect “faking bad ," inattention, or random responding.

18. Defensiveness (12 Items) - This set of items is based on the Marlowe-CrownSocial Desirability Scale and adapted for use with an adolescent population.

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TABLE 3. Coefficient alpha reliability estimates for the PECSand PES

Scale Coefficient Alpha

PECS

Personal Involvement .96Effects From Use .87Social Benefits Use .89Personal Consequences .84Social-Recreational Use .88Transsituational Use .91Psychological Benefits Use .93Preoccupation .92Loss of Control .87Polydrug Use .79

PES

Personal AdequacyPsychological DisturbanceSocial IntegrationSelf-ControlConventional ValuesDeviant BehaviorFuture Goal Orientation

SpiritualityPeer Chemical EnvironmentSibling Chemical Use'Family PathologyFamily Estrangement

.86

.80

.74

.84

.81

.80

.81

.90

.85

.87

.76

.88

Future Work

A series of more complete standardization and validation studies

were initiated in November 1985 to permit development of repre-sentative norms (both for treatment and nonclinical populations)and to further evaluate the battery's validity.

3 Validity evalua-

tions will include examining relationships of instrument scales toconcurrent measures and indicators (e.g., well-established person-ality measures, diagnoses, family history variables, and parentalreport) and to subsequent events (e.g., evaluation and treatmentoutcome). Time will not permit us to conduct an extensive outcomestudy to evaluate the instruments' ability to predict long-termtreatment outcome; however, initial validation efforts willexamine other important treatment variables, such as referral

decisions, treatment, compliance, and treatment aftercare recom-mendations.

This assessment battery is expected to be ready for distributionby June 1987. The package is expected to include a single

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paper-and-pencil inventory that represents the combined items fromthe PECS and PES, a brief screening test derived from the generalproblem severity dimension found in the PECS, a structured diag-nostic interview that addresses DSM-III-R criteria for psycho-active substance use disorders, and a user's manual.

CONCLUSIONS

The assessment package is intended to serve as an adjunct to clin-ical assessment. No assessment tool can address all the factorsthat need to be considered in making clinical decisions. Rather,the intent is to assist the clinician by providing informationthat is of known reliability and validity and that can be refer-enced with regard to the larger population of adolescents havingproblems related to chemical use. Sound assessment tools can alsoprovide a more solid foundation for future research. As profes-sionals find that adult models of chemical dependency are unwork-able when applied to an adolescent population, the search for newmodels will intensify. The implementation of a standardizedassessment package can lead to the establishment of a data basefrom which to launch that search.

FOOTNOTES

1.

2.

3.

The ADI-R contains the following sections: sociodemographicinformation, alcohol use, cannabis use, other drug use,psychosocial stressors, level of functioning, and a screen for

mental disorders. Currently, the interview is being evaluatedfor interrater agreement and content validity.

Conservative decision rules were established for the rejectionof questionnaires whose responses were of doubtful validity,due to high scores on the invalidity or defensiveness scale.

The revised versions of the PECS and PES were evaluated pre-liminarily against some available external criteria. High vs.low PECS scores were differentiated on the MMPI (number ofelevated scales), on clinical diagnoses (abuse vs. depend-

ence), and on the basis of inpatient vs. outpatient treatmentsetting. A similar contrasted group analysis of the PES indi-cated a strong relationship between deviant PES scores andscale elevations on the MMPI.

REFERENCES

Alibrandi, T. Young Alcoholics. Minneapolis, MN: Comp CarePublications, 1978.

Chambers, W.J.; Puig-Antich, J.; Hirsch, M.; Paez, P.; Ambrosini,P.J.; Tabrizi, M.A.; and Davies, M. The assessment of affective

disorders in children and adolescents by semi-structured inter-view: Test-retest reliability of the K-SADS-P. Arch GenPsychiatry, in press.

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Costello, R.M. Alcoholism and the alcoholic personality. In:Meyer, R.E.; Babor, T.F.; Glueck, B.C.; Jaffe, J.H.; O'Brien,J.E.; and Stabenau, J.R., eds. Evaluation of the Alcoholic:Implications for Research, Theory, and Treatment. NationalInstitute on Alcohol Abuse Alcoholism Research Monograph No.

5. DHHS Pub. No. 81-1033. Washington, DC: Supt. of DOCS.,U.S. Govt. Print. Off., 1981.

Costello, A.J.; Edelbrock, C.S.; Dulcan, M.K.; Kalas, R.; andKlaric, S.H. Report on the NIMH Diagnostic Interview Schedulefor Children (DIS-C). National Institute of Mental Health.Washington, DC: Supt. of DOCS., U.S. Govt. Print. Off., 1984.

Crowne, D.P., and Marlowe, D. A new scale of social desirabilityindependent of psychopathology. J Consult Clin Psychol 24:349-354. 1960.

Dunnette, M.D.; Peterson, N.G.; Houston, J.S.; Rosse, R.L.;Bosshardt, M.J.; and Lammlein, S.E. Causes and Consequences

Adolescent Drug Experiences. Final report prepared underContract No. ROI DA 01343 for the National Institute on DrugAbuse. Minneapolis, MN: Personnel Decisions ResearchInstitute, 1980.

Hodges, K.K.; Kline, J.; Stern, L.; Cytryn, L.; and McKnew, D.The development of a child assessment interview for research

of

andclinical use. J Abnorm Child Psychol 10:173-189, 1982.

Jellinek, E.M. The Disease Concept of Alcoholism. Highland Park,NJ: Hillhouse Press, 1960

Jessor, R. Adolescent problem drinking: Psychosocial aspects and

developmental outcomes. In: Towle, L.H., ed.Proceedings:

NIAAA-WHO Collaborating Center Designation Meeting and AlcoholResearch Seminar Public Health Service. DHHS Pub.No.(ADM)85-1370. Washington, DC: Supt. of DOCS., U.S. Govt. Print.Off., 1982. pp.-104-143.

Jessor, R., and Jessor, S.L. Problem Behavior and PsychosocialDevelopment: A Longitudinal Study of Youth. New York:Academic Press, 1977.

Johnston, L.D.; Bachman, J.G.; and O'Malley, P.M. Highlights FromDrugs and American High School Students 1975-1983. NationalInstitute on Drug Abuse.- Pub. No. (ADM)83-1317.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1983.MacAndrew, C. The differentiation of male alcoholic outpatientsfrom nonalcoholic psychiatric patients by means of the MMPI. JStud Alcohol 26:238-246, 1965.Mayer, J., and Filstead, W.J. The Adolescent Alcohol InvolvementScale: An instrument for measuring adolescent use and misuse ofalcohol. J Stud Alcohol 40:291-300, 1979.

Mayfield, D.; McLeod, and Hall, P. The CAGE Questionnaire:Validation of a new alcoholism screening instrument. Am JPsychiatry 131:1121-1123, 1974.

Moberg, D.P. Identifying adolescents with alcohol problems: A

field test of the Adolescent Alcohol Involvement Scale. J StudAlcohol 44:701-722, 1983.

Morey, L.C.; Skinner, H.A.; and Blashfield, R.K. A typology ofalcohol abusers: Correlates and implications. J Abnorm Psychol93(4):408-417, 1984.

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Owen, P.L., and Nyberg, L.R. Assessing alcohol and drug problemsamong adolescents: Current practices.1983.

J Drug Educ 13:249-254,

Rachal, J.V.; Guess, L.L.; Hubbard, R.L.; Maisto, S.A.; Cavanaugh,E.R.; Waddell, R.; and Benrud, C.H. Adolescent DrinkingBehavior. Research Triangle Park, NC: Research TriangleInstitute, 1980.

Rathus, S.A.; Fox, J.A.; and Ortins, J.B. MacAndrew Scale as ameasure of substance abuse and delinquency among adolescents. JStud Alcohol 36:579-583, 1980.

Reich, W.; Herjanic, B.; Welner, Z.; and Gandhy. P.R. Developmentof a structured psychiatric interview for children: Agreementon diagnosis comparing child and parent interviews. J AbnormChild Psychol 10:325-336, 1982.

Riley,K., and Klockars, A.J. A critical examination of the

Adolescent Alcohol Involvement Scale. J Stud Alcohol 45:184-187, 1984.Selzer, M.L. The Michigan Alcoholism Screening Test: The quest

for a new diagnostic instrument. Am J Psychiatry 127:1653-1658,1971.

Skinner, H.A. Primary syndromes of alcohol abuse: Their measure-ment and correlates. Br J Addict 76:63-76, 1981.

Skinner, H.A. The Drug Abuse Screening Test. Addict Behav 7:363-371, 1982.

Skinner, H.A., and Allen, B.A. Alcohol dependence syndrome:Measurement and validation. J Abnorm Psychol 91:199-209, 1982.

Wanberg, K.W., and Horn, J.L. Assessment of alcohol use withmultidimensional concepts and measures. Am Psychol 38:1055-1069, 1983.

Wanberg, K.W.; Horn, J.L.; and Foster, F.M. A differentialassessment model for alcoholism: The scales of the Alcohol UseInventory, J Stud Alcohol 38:403-409, 1977.

ACKNOWLEDMENTS

Major funding for the Chemical Dependency Adolescent AssessmentProject was provided by a grant from the Northwest Area Founda-

tion; additional funding and project administration were providedby The Saint Paul Foundation and the Amherst H. Wilder Foundation.All correspondence should be addressed to Ken Winters, AdolescentAssessment Project, 1295 Bandana Boulevard North, Suite 210,St. Paul, MN 55108.

AUTHORS

Ken C. Winters, Ph.D.Project Director

George Henly. Ph.D.Associate Director

Adolescent Assessment Project1295 Bandana Boulevard North, Suite 210St. Paul, MN 55108

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Substance Abuse in Adolescents:

Diagnostic Issues Derived FromStudies of Attention DeficitDisorder With HyperactivityJan Loney

INTRODUCTION

The accumulated literature on the treatment of substance abuse inadolescents with a history of DSM-III diagnosed Attention DeficitDisorder with Hyperactivity or an associated Oppositional Disorderor Conduct Disorder is extremely limited. In part, this is due tocomplicated diagnostic questions which continue to command theattention of many investigators, and controversies surrounding thetreatment of hyperactivity and attention deficit disorders. Thisis especially true for children prescribed central nervous system

(CNS) stimulant medication.

The absence of an empirically based literature does not mean, how-ever, that existing studies of these childhood psychiatric dis-orders have no value for clinicians concerned with the treatmentof substance abuse among troubled adolescents. On the contrary,over the past decade, a great deal of information about the diag-nosis, prognosis, and treatment of attentional, oppositional, andconduct disorders has been gathered. Certainly this knowledgewill benefit clinicians in making assessment and interventiondecisions for drug-abusing adolescents.

The earliest research to be carried out focused on prognosis(e.g., Weiss et al. 1971) and treatment (e.g., Werry and Aman1975) and will be presented first. A discussion of the implica-tions of several recent studies of diagnosis (e.g., Milich et al.1982) will follow. A more detailed analysis of these and otherstudies concerning substance abuse and childhood hyperactivity isoffered in Kramer and Loney (1982).

Although distinctions have been made between the terms "childhoodhyperactivity" and "attention deficit disorder," they will be used

as synonyms in this discussion, referring to a population ofhyperactive children who have been studied under these and relatedterminologies (e.g., minimal brain dysfunction, hyperkineticsyndrome). Similarly, the terms "childhood aggression,"

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"oppositional disorder," and "conduct disorder" will be treated asif they were essentially synonymous.

INFORMATION ABOUT PROGNOSIS

Early investigators tended to believe that childhood hyperactivitywas a form of "maturational delay," and, therefore, the associatedsymptoms could be expected to disappear around the time of adoles-cence. However, carefully designed prospective studies found inmany hyperactive children a "continual display" of problems withinattention and motor restlessness extending into the adolescentand young adulthood years, and in several systematic followupstudies, a substantial minority of hyperactive children showedwhat could be called "eventual decay," in that after 18 years ofage they were assigned adult psychiatric diagnoses, the most com-mon being Antisocial Personality Disorder. Results from a recent

comprehensive outcome study of 100 children diagnosed as hyper-active (Gittelman et al. 1985) could be interpreted in terms of"maturational delay" (52 percent of previously diagnosed hyper-active boys showed no psychiatric disorder at 16 to 23 years),"continual display" (40 percent still displaying signs of anattentional disorder), and "eventual decay" (27 percent having anantisocial or conduct disorder at followup).

Hyperactive Children and Risk of Adolescent Substance Abuse

In theory, there are numerous grounds for expecting that hyper-

active children might be predisposed to experimentation with il-legal substances such as marijuana. Studies of the distinguishingfeatures of hyperactive children emphasize a host of behavioraland emotional characteristics which are known or thought to berelated to illegal drug use: impulsivity, low self-esteem, non-compliance with authority, poor school performance, and suscepti-bility to peer pressure. Conversely, studies of the precursors ofsubstance abuse among normal children have identified a set ofpredisposing factors which are known to describe the typicalhyperactive child.

Attempts to examine adolescent substance use among hyperactivechildren have produced numerous methodological problems. Many ofthe followup studies had been nonblind, had relatively few sub-jects, included no control groups, and sustained considerablesubject attrition. Most of these investigations involved samplesof hyperactive subjects averaging 14 years of age and ranging fromas young as 9 to as old as 23 years of age. It is difficult togeneralize from these samples, as they represent children at dis-parate developmental stages with respect to exposure to illegaldrugs. Few of the subjects in these studies are old enough to

have developed a pattern of serious abuse, and many of the young-est had not yet been exposed to the full range of drugs with abusepotential. For these reasons, most research into substance useamong hyperactive children and adolescents had been limited tosubjects' use of marijuana and/or alcohol.

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Few studies have investigated hyperactive children's attitudes orintentions toward drug use. Fewer still have attempted to deline-ate the steps leading from the use of one type of drug to another.The relative paucity of this kind of information makes a compre-hensive theory associating adolescent substance abuse with hyper-activity and attention deficit disorders difficult to articulate.An exception has been the work of Hechtman et al. (1984), whopresented a series of pioneering studies which described substanceuse among groups of Canadian hyperactive children. The develop-mental focus permitted Hechtman et al. to contrast early substanceuse with more recent use. Hyperactive youngsters were not report-ed to differ from controls in their recent use of most illegalsubstances. However, control subjects were reported to use hallu-cinogens more frequently.

Developmental data can also help bring basic information about

initiation of substance use into clearer focus. For example, inone of Loney's studies (unpublished), 33 of 95 adolescent hyper-active boys said that they had tried marijuana. However, only 70of the boys knew someone who used marijuana, and only 50 of the 95reported actually having the opportunity to smoke it. Thus, the36 percent of the total sample who had tried the substance repre-sented two-thirds of those having the opportunity. Sixty percentof the 33 hyperactive boys who had "ever tried" marijuana had usedit some time during the month of the followup interview. Of the20 boys who continued to use it, 8 escalated to "frequent" use(defined as use of the drug on at least 15 days during the current

month). Only at the point of escalation did the hyperactive boystend to differ from their classmate controls; fewer controls usedmarijuana frequently during the month of the followup interview.

Differential Risk for Hyperactive Subgroups

It has long been known that hyperactive children are a heterogene-ous population, both at the time of initial psychiatric referraland in terms of response to treatment. Thus, a recurring questionconcerns identifying those characteristics or antecedent activi-ties that will predict which hyperactive child will develop drug-

related problems. Fortunately, studies that have asked theseprediction questions represent the more controlled and least am-biguous research. This is true in part because the questions ofproper diagnosis and appropriate control groups were not ofcentral importance.

Loney et al. (1981a; Loney et al. 1981b) have systematicallyfollowed approximately 300 hyperactive boys and controls intoadolescence (ages 12 to 18) and young adulthood (ages 21 to 23),using an extensive battery of tests and interviews to obtaininformation from the boys and their parents and teachers. All the

hyperactive boys were originally referred to a major medical cen-ter for outpatient psychiatric evaluation, and all were treatedwith either psychostimulant medication or with behaviorally ori-ented parent and teacher counseling. The results of these studiesindicate that among so-called hyperactive children, those who were

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more aggressive, oppositional, and conduct disordered eventuallyhad problems with illegal drug use. In contrast, hyperactivechildren who did not show signs of aggressivity at referralappeared more at risk for academic problems.

INFORMATION ABOUT TREATMENT

This discussion will be confined to studies of treatment withstimulant medications because of their presumed association withlater substance use.

There is no question that the majority of hyperactive childrenrespond with behavioral improvement after treatment with stimulantmedication such as methylphenidate. Numerous well-controlledwithin- and between-group studies have established their short-term efficacy. Unfortunately the studies that focus on the long-term consequences of the medication are rife with problems and,

therefore, difficult to interpret. Many compare medicated hyper-active children with unmedicated nonhyperactive children, such asbrothers and classmates, making it impossible to differentiate thesigns of a hyperactive disorder from the short-term effects of thestimulant medication. However, it is impossible to assign hyper-active children randomly to either long-term medication or non-treatment conditions.

Results from the earliest studies of the long-term stimulanteffects were discouraging because investigators expected the drug-induced behavioral improvements, in evidence during childhood, to

affect performance through adolescence even if a child was nolonger on the medication. Instead, there appeared to be no long-term drug effects on adolescent behavior (Weiss et al. 1975).However, later studies suggested that the effects, while minimal,were positive. For example, Loney, Kramer, and Kosier (Loney etal. 1981a) found that, at 5-year followup, hyperactive boys whohad been medicated for an average of 2 years were rated by theirmothers as having fewer problems with motor coordination and self-esteem than the unmedicated boys. However, when teachers ratedboth medicated and unmedicated hyperactives, no difference wasfound between groups in these or any other behaviors. In addi-tion, stimulant medication was unrelated to adolescent performanceon intelligence and achievement tests.

Childhood Drug Treatment and Risk of Substance Abuse inAdolescence

Early concern about the long-term effects of treating hyperactivechildren with a stimulant drug stemmed from the fear that suchtreatment would lead to later use of illegal drugs. This fearresulted from several coexisting factors: (1) Public sensitivity

to the increasing use of illegal drugs among youth, and (2) anexpectation that at maturity hyperactive children might becomedependent on stimulant medication in the same way as nonhyper-active adolescents. In the absence of data, public concern about

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stimulant medication acting to precipitate later drug abuse washard to allay.

Clinical reports verify that many hyperactive children disliketaking their stimulant medication because of its side effects,because their peers tease them about being on "speed," or because

they dislike taking any kind of pills. Many adolescents refuse totake their prescribed medication. Therefore, clinicians oftenhave difficulty maintaining their patients on a stimulant regimen,and many consider it improbable that drug abuse will emerge.

In an adolescent followup study of medicated and unmedicatedhyperactive boys, Loney et al. (1981a) found no differences be-tween groups in self-reported delinquencies such as stealing,property damage, and car accidents, although the unmedicated boysreported significantly more instances of drunk driving. Simi-larly, the medicated and unmedicated boys did not differ in the

seriousness of their overall involvement with legal authorities,although the unmedicated boys reported significantly more seriouspolice involvement for substance-related offenses. In a furtherstudy of the same sample, Kramer et al. (1981) found few differ-ences between medicated and unmedicated hyperactive boys in atti-tudes toward and experimentation with various illegal substances,but the trend was toward a higher use among the unmedicated hyper-active boys. Results from these studies suggest that if earlytreatment with stimulants can decrease the irritability andimpulsivity of hyperactive children and raise their frustrationtolerance and self-esteem, those effects might even decrease theprobability of ultimate drug abuse. This is a hypothesis thatneeds to be tested.

INFORMATION ABOUT DIAGNOSIS

Over the decades that childhood hyperactivity has been studied,questions regarding proper assessment and diagnosis have been fre-quent and frustrating. While early investigators focused theirattention on whether drug treatment was safe and effective, theunderlying disorder was little understood. It was acknowledged

that any given group of children selected for study was hetero-geneous in that the subjects varied from one another, and eachbehaved differently across different situations and from one timeto the next. Thus, the diagnostic issues surrounding attentiondeficit disorders with hyperactivity were increasingly addressed.

Initial diagnostic studies directed attention to aggressive behav-iors that had been identified as important predictors of treatmentsuccess. It became clear that many hyperactive children were alsoaggressive. For example, in a group of clinic-referred boys whomet criteria for hyperactivity on the widely used Conners teacher

rating scale, 65 percent were classified as both hyperactive andaggressive, whereas only 17 percent were exclusively hyperactive(Loney and Milich 1982).

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In contrast, unpublished data from a large metropolitan clinicyielded very different findings. Only 25 percent of the referredhyperactive boys received a mixed diagnosis. In addition, only 17percent of the hyperactive students from an elementary school sam-ple could be described as mixed hyperactive-aggressive children(Loney and Milich 1982). These findings have major diagnostic and

prognostic implications.

Despite controversy concerning the interdependence of hyper-activity and aggression, there is evidence that each of thesecharacteristics should be measured as independent dimensions.Each may have different childhood antecedents and differentadolescent and adult consequences (Loney et al. 1981b). For cli-nicians interested in the treatment of illegal and norm-violatingbehaviors such as substance abuse, it is important to note thatthese behaviors appear to be more closely related to childhoodaggression, conduct problems, and oppositional behavior than they

are to childhood overactivity, short attention span, and cognitiveimpulsivity.

As clinical investigators become more sensitive to the diagnosticissues, fewer include aggression in their definition of hyper-activity. However, the lack of discriminant validity of the meas-ures of hyperactivity and aggression suggests that hyperactivityand aggression may be two separate problems (Loney et al. 1978).two intertwined problems (Prinz et al. 1981), or indistinguishablefacets of the same problem--a Conduct Disorder (Quay 1979). Mostscales used to measure these two constructs have been moderately

to highly intercorrelated. However, when the behavioral observa-tion data were substituted for teacher rating-scale data, correla-tions between hyperactivity and aggression were markedly reduced(Loney and Milich 1982).

Meanwhile, what appears to be a relationship between childhoodhyperactivity and adolescent substance abuse may actually be thepreviously well-documented relationship between childhood aggres-sion and substance abuse. Most of the rating scales and struc-tured interviews used to assign scores on hyperactivity factors orto diagnose children with attentional disorders contain items

which tap factors related to aggressive behavior as well as motoractivity and ability to concentrate. Therefore, the selected sam-ples of hyperactive children often include aggressive/oppositionalas well as exclusively hyperactive children. Obviously, data onthe drug use of these samples cannot be interpreted with clarityand confidence.

Attempts have been made to obtain more homogenous samples by ex-cluding children with DSM-III diagnosed conduct disorders. Thismethod is likely to remove the oldest and most antisocial chil-dren, but an unknown number of oppositional and/or aggressivechildren will remain in the group. Since these children are knownto be at risk for drug abuse, their presence will confound theresults. Other frequently used methods to identify hyperactiveadolescents may actually increase the heterogeneity. When parent

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input is added to the results from teacher questionnaires whichgather data on children in structured, attention-demanding situ-ations, diagnostic heterogeneity is often increased.

Diagnostic procedures that use several methods of assessment orhigh cut-off scores to select the most severely dysfunctional

children will probably increase the proportion of mixed hyper-active-aggressive children in their samples. Results from thosestudies might have less generalizability to populations of purehyperactive children. But these limitations will persist untilvalid measures of attentional, conduct, and oppositional disordersare available.

At present an empirical foundation is in the process of being built. Meanwhile, critically important questions will remain inunderstanding the relationship between attentional deficit and

adolescent substance abuse disorders.

REFERENCES

Diagnostic and Statistical Manual of Mental Disorders. 3rdedition Washington, DC: American Psychiatric Association.

1980.Gittelman, R.; Mannuzza, S.; Shenker, R.; and Bonagura, N. Hyper-active boys almost grown up: I. Psychiatric status. Arch GenPsychiatry 42:937-947, 1985.

Hechtman, L.; Weiss, G.; and Perlman, T. Hyperactives as young

adults: Past and current substance abuse and antisocialbehavior. Am J Orthopsychiatry 54:415-425, 1984.

Kramer, J., and Loney, J. Childhood hyperactivity and substanceuse: A review of the literature. In: Gadow, K.D., and Bialer,I., eds. Advances in Learning and Behavioral Disabilities.Vol. I. Greenwich, CT: JAI Press, 1982.

Kramer, J.; Loney, J.; and Whaley-Klahn, M.A. The role of pre-scribed medication in hyperactive youths' substance abuse.Poster presented at the annual meeting of the AmericanPsychological Association, Los Angeles, 1981.

Loney, J., and Milich, R. Hyperactivity, inattention, and aggres-

sion in clinical practice. In: Wolraich, M., and Routh, D.K.,eds. Advances in Developmental and Behavioral Pediatrics.Vol.3 Greenwich,CT: JAI Press 1982.

Loney, J.; Langhorne; J.E., Jr.; and Paternite, C.E. An empiricalbasis for subgrouping the hyperkinetic/minimal brain dysfunctionsyndrome. J Abnorm Psychol 87:431-441, 1978.

Loney, J.; Kramer, J.; and Kosier, T. Medicated versus unmedi-cated hyperactive adolescents: Academic, delinquent, and symp-tomological outcome. Poster presented at the annual meeting ofthe American Psychological Association, Los Angeles, 1981a.

Loney, J.; Kramer, J.; and Milich, R.S. The hyperactive childgrows up: Predictors of symptoms, delinquency, and achievementat follow-up. In: Gadow, K., and Loney, J., eds. PsychosocialAspects of Drug Treatment for Hyperactivity. Boulder, CO:Westview Press, 1981b.

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Milich, R.; Loney, J.; and Landau, S. The independent dimensionsof hyperactivity and aggression: A validation with playroomobservation data. J Abnorm Psychol 91:183-198, 1982.

Prinz, R.J.; Connor, P.A.; and Wilson, C.C. Hyperactive andaggressive behaviors in childhood: Intertwined dimensions.J Abnorm Psychol 9:191-202, 1981.

Quay, H.C. Classification. In: Quay, H.C., and Werry, J.S.,eds.York: Wiley, 1979.

Psychopathological Disorders of Childhood. 2nd ed. New

Weiss, G.; Minde, K.; Werry, J.S.; Douglas, V.; and Nemeth, E.Studies on the hyperactive child VIII: Five-year follow-up.Arch Gen Psychiatry 24:409-414, 1971.

Weiss, G.; Kruger, E.; Danielson, U.; and Elman, M. Effects oflong-term treatment of hyperactive children with methylphenf-date. Can Med Assoc J 112:159-165. 1975.

Werry, J.S., and Aman, M.G. Methylphenidate and haloperidol inchildren: Effects on attention, memory, and activity. Arch GenPsychiatry 32:790-795, 1975.

AUTHOR

Jan Loney, Ph.D.ProfessorDepartment of Psychiatry and

Behavioral ScienceSouth Campus, Putnam HallState University of New York

at Stony BrookStony Brook, NY 11794-8790

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Empirical Guidelines for Optimal

Client-Treatment MatchingReid K. Hester and William R. Miller

INTRODUCTION

In the last 10 years, interest in treating adolescent substanceabuse appears to have increased dramatically. A great deal moretreatment is now being provided to this population, frequentlyutilizing intervention strategies which have been extrapolatedfrom those used to treat adults. Unfortunately, our understandingof which interventions are most beneficial for which adult clientsis in its infancy. The purpose of this paper is to develop guide-lines for matching adolescent clients to treatments, based on the

current substance abuse treatment literature. An underlyingassumption in developing such guidelines is the following hypoth-esis: Adolescents who are appropriately matched to treatment willshow outcomes superior to those who are unmatched or mismatched.This hypothesis predicts an interaction between client variablesand treatment outcome even in the absence of main treatmenteffects. Figure 1 shows how client characteristics could interactwith treatment outcome to produce a potentially confusing pictureof the effects of treatment.

Education, which significantly interacts with treatments A and B,

has been labelled the predictive variable. In study 1, for cli-ents with low educational levels treatment B has a better outcomethan A. In study 3 the opposite is true, while in study 2 thereis no significant difference. Averaging all educational levelsresults in no main effect of treatment, thereby leading to theerroneous conclusion that the treatments are equivalent. In fact,however, there is a significant interaction between education lev-els and treatments, and for certain clients there is a substantialdifference in effectiveness between the alternative interventions.

Matching a client's needs to specific treatments has validity and

is routinely done in medicine. Although widely discussed, thisnotion has seldom been applied in the area of alcohol and drugabuse treatment. It is a notion which is just beginning to devel-op in the area of adolescent substance abuse treatment, and there

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FIGURE 1. A hypothetical cl ient-by-treatment interaction

are few data which can be used to develop guidelines. The reasonsfor this are several. First is the common and, we believe, mis-taken assumption of uniformity of drug or alcohol abuse. Alcohol-ism, in particular, has been thought to have a common etiology andtherefore one method of treatment. A second factor discouragingindividualization of intervention has been the historic tendencyfor treatment professionals and programs to adhere to a single,often dogmatic view of etiology and proper remediation. To besure, there are rival and alternative approaches to intervention,but each particular program has tended to embrace and manifest aspecific strategy, be it education, group confrontation, drug sub-stitution, therapeutic community, Alcoholics Anonymous or Narcot-ics Anonymous, or training in alternatives to drug use. As a

consequence of these factors, assumption of uniformity and adher-ence to a particular philosophy of intervention, treatment, andprevention programs have often offered a very narrow range ofalternative strategies necessarily constraining the potential forindividualizing intervention.

We will review the adolescent data first, then the adult litera-ture, to determine potentially fruitful areas of investigation.Next, we will present recommendations for the development ofpotentially promising approaches and procedures to evaluate clienttreatment interactions. Of necessity, much of what will be pre-

sented is extrapolated from the adult alcohol and drug abusetreatment literature. Although there may be significant differ-ences in treatment interventions which are appropriate for adoles-cents, how to match a client with optimal treatment is still anempirical question. The adult treatment literature has valuable

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information which can be used efficiently and effectively todevelop and evaluate adolescent client treatment interactions.

PREDICTOR DATA

Adolescent literature

National studies (e.g., the Drug Abuse Reporting Program (DARP)and the Treatment Outcome Prospective Study (TOPS)) to date appearto have been designed to gather data on the overall outcome ofclients receiving treatment in the various settings. Only theDARP included an "intake only" comparison group of clients(Simpson and Sells 1982). Unfortunately, Simpson and Sells didnot find any data which might indicate an optimal client-treatmentsetting match. They did note, however, that the best predictorsof specific posttreatment outcomes were pretreatment measures of

functioning (e.g., pretreatment alcohol problems predicted heavierconsumption after treatment). Simpson and Sells also noted thatcontinued time in treatment, completion of treatment, and favor-able behavior during treatment were positive prognostic indicatorsof outcome.

The TOPS specifically evaluated treatment outcome for adolescents(Hubbard et al. 1985). Unfortunately, this study does not appearto have included any untreated control groups. Consequently, itis impossible to determine how much of the improvement in outcomemeasures after treatment may have been affected by confounding

factors.

Two studies of young drug abusers in Scandinavia have specifiedclient characteristics which influence outcome after treatment.Holsten (1980) found that 26 percent of the variance in outcome at1 to 6 years after treatment was associated with: (a) the youthnot being registered for criminality for the 12 months prior tothe first contact, (b) no alcohol problems at the time of thefirst contact, (c) being female, (d) being raised in a brokenhome, and (e) having a father who had no alcohol problems duringthe youth's childhood. Benson (1985) found that continued users

after treatment tended to: (a) deviate more from school careers,(b) be more truant if they were male, and (c) have one or morealcoholic parents if they were female. Low intensity of drug andsolvent abuse were positive prognostic factors.

Vaglum and Fossheim (1980) reported that adolescents' primary drugof abuse was associated with how favorably they responded to vari-ous forms of treatment. For users of psychedelic drugs the amountof family therapy, followed by individual psychotherapy, was moststrongly correlated with outcome, whereas confrontive milieu ther-apy was slightly negatively correlated with outcome. Conversely,for opiate and central nervous system (CNS) stimulant users, thedegree of confrontive milieu therapy was strongly correlated withoutcome, followed by family therapy and individual psychotherapy.

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Unfortunately, for the purposes of developing matching criteria,these studies, with the exception of that of Vaglum and Fossheim,were primarily concerned with the overall impact of substanceabuse treatment. Comparisons were between treatment settings, andit is impossible to determine what sort of specific interventions

were conducted within those settings. This lack of specificityseverely limits the utility of these data in developing matchingcriteria.

Adult Literature

If there are very few relevant data in the adolescent treatmentliterature, perhaps useful implications can be derived from theliterature describing adult treatment strategies. While there maybe substantial differences in the specific problems which adoles-cents and adults present, perhaps by examining the adult litera-

ture we may at least avoid reinventing the wheel (or the Edsel)and avoid some of the mistakes reported in the adult literature.We will examine the adult literature by client variables ratherthan by treatment interventions because the search for potentialmatching criteria is of foremost concern here.

Psychopathology. A recent National Institute on Drug Abuse (NIDA)report (1983) presented the results of two studies of clienttreatment interactions where the treatment populations were opiateaddicts. Both studies evaluated the effects of structured psycho-therapies in addition to the usual drug counseling of the clinic

programs. In one study, conducted in Philadelphia at the VA Medi-cal Center, clients with low levels of psychiatric symptoms had abetter outcome than those with higher levels of such symptoms.They also reported that the "high-severity clients assigned toadditional therapy groups showed more significant improvements,while those high-severity clients who received counseling aloneshowed progress only in reducing their drug use" (NIDA 1983,p. iv). In addition, depressed clients received substantial ben-efits from the additional therapy, while those with antisocialpersonality showed little improvement except in drug use. In con-trast with these results, the New Haven study in the NIDA report

did not find significant client treatment interactions. Thediscrepancies between the two studies were attributed to the dif-ferences in treatment populations and problems with the implemen-tation of the second study.

McLellan and his associates (McLellan et al. 1983), who conductedthe 1983 NIDA study in Philadelphia, also conducted a retrospec-tive and prospective study to develop a multivariate equationwhich optimally matched clients with treatments. In their initialstudy they found that measures of psychiatric symptomatology andsocial stability interacted with outcome in complex ways. Theinvestigators used this information, attempting to match clientsprospectively to various treatments. They found that clientsappropriately matched to treatment had a significantly better out-come than those who were unmatched or mismatched. Clients werenot randomly assigned to matched or unmatched conditions, however,

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and some of their statistical analyses may have overestimated theeffects of matching. Nevertheless, these two studies represent asignificant advance in client-treatment matching research.

Cognitive style. Cognitive style can be defined as "enduring

patterns of perception and information processing that the clientevidences in a broad range of situations" (Miller and Hester, inpress). McLachlan (1972; McLachlan 1974) found a strong inter-action between a client's conceptual level (CL) and the structurednature or directiveness of treatment. People with low CL tend todepend on authority and prefer simpler rules and constructs. Incontrast, high-CL individuals are more independent and more com-plex in their thought processes. McLachlan hypothesized thathigh-CL alcoholics would benefit more from a less structured andnondirective approach, while low-CL clients would show greaterbenefit from a more structured and directive approach. At 12- to

16-month followup (McLachlan 1974), clients matched during treat-ment and aftercare had a 71-percent recovery rate, whereas thosewho were mismatched in treatment and aftercare had a 38-percentrecovery rate. Recovery rates for clients only matched to treat-ment or to aftercare showed intermediate rates of recovery.Finally, although no main effects for treatment were found, therewas a strong interaction effect. McLachlan would have concludederroneously that directiveness of treatment has no effect onoutcome had he not investigated the effects of CL.

In a retrospective prediction of outcome, Thornton et al. (1977;

Thornton et al. 1981) found an interaction between developmentallevel (DL) and outcome. DL is a construct similar to CL. Atfollowup they found that high-DL clients were more likely to drinkmoderately when they did drink, whereas low-DL clients drank morefrequently and more heavily.

Finally, Karp et al. (1970) studied the relationship between fielddependence, a measure of cognitive style, and outcome. Foralcoholics, field independence predicted initiation of and contin-uation in psychotherapy. In contrast, dropouts from psychotherapyfor drug abuse were slightly more field independent. When theycombined interventions in analyses, field dependence failed topredict compliance in treatment.

Neuropsychological functioning. O'Leary et al. (1979) foundneuropsychological impairment to be negatively associated withoutcome for alcoholics. They did not find, however, that provid-ing cognitively impaired alcoholics with more or longer treatmentsignificantly improved outcome (Walker et al. 1983). This doesnot preclude the interesting possibility that clients with cogni-tive impairments might differentially benefit from different types

of interventions.

Self-esteem. Annis and Chan (1983) found a significant inter-action between self-esteem and a confrontational group therapyintervention. Alcoholic clients with high self-esteem benefited

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from the additional intervention; for those with low self-esteem,it was detrimental, and they fared better without it.

Social stability. Both Levinson (1977) and Smart (1978) foundmarried and employed alcohol abusers to be more likely to develop

moderate drinking outcomes, compared to less socially stableclients. Azrin et al. (1982) found that unmarried clients bene-fited differentially from a broad-spectrum community approach.Married clients, on the other hand, had comparable outcomes whenthey received either the comprehensive community program or disul-firam with a behavioral compliance program. Thus, clients withless social stability may need a more broadly based system ofinterventions.

Client choice. Satisfaction with treatment (Vannicelli 1978),compliance in treatment (Sanchez-Craig 1980), and outcome from

alcoholism treatment (Thornton et al. 1977) have been positivelyassociated with the amount of client choice in determining thegoal and nature of treatment. Kissin et al. (1971) randomlyassigned clients to receive up to three treatment choices.Abstinence rates at followup increased with the number of choicesoffered to the client.

Summary of Client Variables

The brief review provided above of interaction between adultclient variables and treatment suggests that there may be a number

of similar or identical variables which influence treatment out-come among adolescents. It would be grossly premature to recom-mend specific criteria for matching adolescents to treatment atthis time. However, a number of general principles can be extrap-olated from the data on adult matching. In a recent review of theadult literature in this area (Miller and Hester, in press), wecame to the following tentative conclusions:

The degree of differential benefit from a broad-spectrumintervention (such as the "alternatives" approach common indrug abuse intervention with adolescents) depends upon thedegree to which the individual manifests the life problem ordeficit for which the additional intervention is an effectivetreatment.

Clients show greater improvement when matched with a treatmentthat is congruent with their cognitive style relative to cli-ents who are unmatched or mismatched.

Clients who choose their treatment approach from among alterna-tives show greater acceptance of, compliance in,