The development of the comprehensive addiction severity index for adolescents (CASI-A)

Journal

of Substance

Abuse

Treatment,

Vol. 12. No. 3, pp. 181-193, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0740-5472/95 $9.50 + .OO

Pergamon

ARTICLE

The Development of the Comprehensive Addiction Severity Index for Adolescents (CASI-A) An Interview KATHLEEN

for Assessing Multiple

MEYERS, *University

Problems

of Adolescents

A. THOMAS MCLELLAN, PhD,* JUDITH AND HELEN M. PETTINATI, PhDJf

MS,*

L. JAEGER,

B&t

of Pennsylvania/VA Center for Studies of Addiction, Philadelphia, Pennsylvania; iCarrier Foundation, Research Division, Belle Mead, New Jersey

The ComprehensiveAddiction Severity Index for Adolescents(CASI-A) is a 4.5to 90-minutecomprehensive,semi-structuredclinical interviewfor evaluatingadolescents whopresent for treatment at variousprovider agencies.CASI-A modulesand their individual items wereselected and revisedbasedon theory, clinical wisdom,and adolescentexperiencesobtained during pilot interviews andfocus groups. The CASI-A assesses known risk factors, concomitant symptomatology, and consequences of adolescentalcohol/drug usewithin sevenprimary areasof functioning: educationstatus, alcohol/drug use,family relationships,peer relationships,legalstatus, psychiatric distress,and useof free time, The CASI-A is not a diagnosticor screeninginstrument, but rather a clinical assessment tool that obtainsclinically pertinent information designedto guide treatmentplanning and to evaluatetreatmentoutcome. The CASI-A’s designmakesit suitablefor administrationin a variety of settings,for repeatadministrationat posttreatmentfollow-up evaluations, andfor assessment of virtually all adolescents in treatment regardlessof their admission problem. Overall, the CASI-A hasencouragingbut preliminary evidenceof validity and internal consistency.information collectedsoon after admissionduring administrationof the CASI-A by nonclinical interviewerscorrespondedquite well with that obtained over the courseof the adolescent’streatment stay b.v the entire treatment team. Reiisionsto the instrumentare being madein thoseareaswherecorrespondencebetweeninformation on the CASI-A and that extractedfrom clinical recordsdroppedbelow 75%, or in thoseearly subscales,wherealphacoefficients dropped beloM’.6. As a resultqf the encouragingresultsreported in thispaper, weare beginningadditional psychometrictesting, refining the proposedscoringsystem,and developinga computerizeddata entry, scoring, and report system. Abstract-

Keywords-adolescents;

assessment;

substance

abuse;

instrument

development.

INTRODUCTION Portions of this work were supported by the Carrier Foundation Research Division and the Treatment Evaluation Center Grant of the Center for Studies on Addiction, University of Pennsylvania/VA Medical Center. Earlier portions of this work were presented at the 1989 annual meeting of the College on Drug Dependence, Colorado, and the 1991 annual meeting of the American Psychiatric Association, New Orleans. Requests for reprints should be addressed to Kathleen Meyer\. Treatment Research Institute , 2W Market Street, One Commerce Square, Philadelphia, PA 19103. The CASI-A can be obtained by callins 1~800-238-2433

Received

October

19. 1993; .4cccpted

Januar!

17. 199.5.

OR EXPERIMENTATION characterizes normal adolescent development Over the years, the typography of such behavior has changed to include healthcompromising risky behaviors, which underlie many of the current morbidities of youth. Consequently, there is national interest in those risk behaviors with associatednegative sequelae,particularly drug and alcohol use. Also, there is great demand for effective RISK-TAKING

182

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treatment services to handle increasing numbers of youth with drug and alcohol use who present before diverse provider agencies (Bailey, 1989; Newcomb & Bentler, 1989; Rahdert & Grabowski, 1988). As such, the ability of service providers to deliver appropriate, cost-effective treatment hinges upon the availability of a comprehensive picture of individual patient needs. Furthermore, the ability to evaluate service delivery is contingent on the ability of the evaluator to measure relevant aspects of the patient and to target aspects of treatment in a reliable, valid, sensitive, and consistent manner. In fact, the methods and instruments that are employed in clinical assessment and treatment evaluation studies are the foundation of our knowledge about patient needs and treatment effects. Consequently, in an era of cost-containment, managed care, accountability, and service demand, and at a time when there is a paucity of information on adolescent treatment efficacy, an objective, clinically useful measure of patient status that could inform clinical decisions, uncover additional areas for intervention, monitor change, and provide a mechanism to conduct treatment evaluation studies would be most important and useful. In Part I of this paper, we review important issues in the assessment of adolescents. In Part II we describe the development of a new adolescent assessment instrument. Finally, in Part III we present preliminary validity and internal consistency data on this new instrument. PART I. ISSUES IN ADOLESCENT ASSESSMENT Areas of Assessment

It is well documented that alcohol/drug abuse coincides with problems in many other functional areas, although cause and effect are often difficult to distinguish. Typically, alcohol/drug abuse is but one facet in a myriad of difficulties a young person may be experiencing (Anglin, 1987; Bailey, 1989; Blum, 1987; Semlitz & Gold, 1986). At the same time, given widespread experimentation with alcohol and drugs among adolescents in general, the mere use of alcohol and drugs is not always indicative of serious pathology (Newcomb & Bentler, 1989). Consideration of the nature and scope of behavior in diverse nonsubstance areas can help to distinguish those adolescents who are in need of treatment from those who are not. If a thorough treatment plan is to be developed for those requiring treatment, a thorough and comprehensive assessment at the start of treatment is necessary. Consequently, instruments that assess multidimensional areas of functioning are particularly useful for an adequate appraisal of an adolescent’s need for treatment services.

Evaluating multiple areas is also critical to treatment outcome evaluation. In the adult treatment literature, treatment outcome has long been considered multidimensional, including not only reduction in alcohol and drug use, but also psychosocial functioning. In fact, components of psychosocial functioning have often been more associated with posttreatment outcome than the severity of alcohol/drug use and these components constitute useful patient-to-treatment matching criteria (McLellan, Woody, Luborsky, O’Brien, & Druley, 1983; Gottheil, McLellan, & Druley, 1981). Method

of Assessment

Client responses and behavior, interviewer style, and assessment format have impact on the assessment process. During initial evaluations, adolescents typically provide only brief and vague answers and rarely report problematic behaviors spontaneously (Blotcky, 1984). In these instances, an interactive interview can be advantageous (Fleming, Leventhal, Glynn, & Ershley, 1989; Hirschi, Hindelang, & Weis, 1980; Prout & Chizik, 1988). The type of interactive interview is also important. When compared to free-form interviewing, the use of semi-structured instruments during the interview process has been shown to increase the number of clinical observations, improve the quality and reliability of diagnoses, and provide a more comprehensive clinical evaluation (Heltzer, 1981). Conversely, the method of questioning afforded by self- or computer-administered questionnaires (although generally useful in large scale studies) can be problematic when relied upon for clinical assessment with adolescent subgroups such as adjudicated adolescents (Hirschi, Hindelang, & Weis, 1980; Prout & Chizik, 1988), and when inattention, lack of motivation, disinterest, or reading difficulties exist (McLellan et al., 1992). These are situations that often occur during initial, generally unwanted evaluations with adolescents. The lack of opportunity for rapport building during questionnaire administration can further hamper honest reporting under these circumstances (Weber, Miracle, & Skehan, 1994). Thus, for the purpose of treatment planning, clinical interviews are an essential part of the assessment process. If paper/pencil measures are used during clinical assessment, these should be supplemented with structured or semi-structured interviews. The Status of Adolescent

Assessment

Within the past 6 years a number of improvements in the area of adolescent drug and alcohol assessment have occurred. Historically confined to screening instruments of alcohol/drug use (Alibrandi, 1978; Moberg, 1983), survey questionnaires of drug/alcohol use among high-school samples (Johnson, O’Malley, &

CASI-A

Backman, 1987), measures of unidimensional constructs (Chambers et al., 1985) and structured diagnostic interviews for deriving DSM-III-R diagnoses (see Gutterman, O’Brien, & Young, 1987), there have been recent attempts to develop standardized methods and instruments to assessthe full clinical spectrum of problems presented by alcohol/drug abusing adolescents (see Tarter, 1990, and Winters, 1990, for a review of available instruments). Most known are the Personal Experience Inventory (PEI) (Henley & Winters, 1988), the Adolescent Assessment Referral System - POSIT (Rahdert, 1991), the Teen Addiction Severity Index (Teen ASI) (Kaminer, Buckstein, &Tarter, 1991), and the Adolescent Drug Abuse Diagnosis (ADAD) (Friedman & Utada, 1989). Our Response. In response to the need for an adolescent assessment instrument, we decided to develop a semi-structured, interactive interview. The focus of the interview is to assess multiple areas of functioning so that problems do not remain uncovered as a result of lack of self-disclosure by the adolescent and/or failure to adequately explore areas by the interviewer. In 1988, we began developing the Comprehensive Addiction Severity Index for Adolescents (CASI-A), an interactive, multidimensional, semi-structured interview for assessment of adolescent alcohol/drug use and psychosocial problems. We stress that the CASI-A is nor a screening instrument but is rather a comprehensive assessment instrument for evaluating the multidimensional nature of problems experienced by those adolescents who present for treatment at various provider agencies. PART II. OVERVIEW OF THE CASI-A’S DEVELOPMENT PROCESS Background Work on the CASI-A

Initial Initial development of the CASI-A began in 1988 at the Carrier Foundation, a private, nonprofit psychiatric hospital in a suburban area, and involved three stages. Stage 1. Selection of an Adult Instrument for Modification. In the first stage of the development process, a thorough review of available instruments was conducted in an attempt to find a reliable and valid adult assessment instrument that met the aforementioned criteria (i.e., multidimensional, semi-structured, interview-driven). Of the available instruments, the Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, & O’Brien, 1980) was selected to serve as a model for the adolescent assessment instrument. Why An instrument Modeled After the ASI? The AS1 is a standardized, well-validated, clinical research in-

183

terview designed to assess problem severity in areas often associated with alcohol/drug use in adults. It is one of the most comprehensive, yet practical-toadminister assessment instruments for adult addiction and psychosocial severity, and has proven to be useful in clinical evaluation and treatment planning, treatment outcome assessment, and treatment response prediction (McLellan et al., 1980; McLellan et al., 1983; McLellan et al., 1985). Given its effective utility in the treatment and research field of adult addiction and given that it met the basic format being sought (i.e., interviewer-driven, semistructured, multidimensional), using the ASI as an assessment model in terms of method of questioning and question-type appeared reasonable. We believed initially (and confirmed this during our early pilot work), that a direct translation of the AS1 would not meet the needs for an adolescentspecific assessment tool. However, adapting available adult instruments for younger populations has proven successful in the past as evidenced in the Kiddie SADS (Chambers, Puig-Antich, & Tabrizi, 1978) and the Children’s Depression Inventory (Kovacs & Beck, 1977). Consequently, we believed if thorough developmental and adolescent-specific work were performed on the ASI, it could provide a framework for an adolescent assessment tool. Stage 2. Initial Revision of Assessment Areas and Item Pool. Initial revisions to the AS1 were based upon information regarding known risk factors, concomitant symptomatology, and consequences of adolescent alcohol and drug abuse. Initial assessment areas were selected on the basis of areas known to be affected by or known to put an adolescent at risk for alcohol/drug abuse. Initial content was selected on the basis of salient items within each area of functioning. These preliminary assessment areas with corresponding items were compared to the assessment areas and items of the ASI. Areas and items of overlap with the AS1 were retained in the CAN-A; items pertinent to adolescents were added and items from the AS1 that were inappropriate to this population were deleted. This draft instrument was then reviewed with social workers and certified drug and alcohol counselors (all were specialists in adolescent treatment delivery) for content and face validity. Additional revisions were made as necessary. Stage 3. Refinement of Assessment Areas, Item Pool, and Scoring System. In an effect to maximize the applicability of the instrument to adolescents and to begin field testing of the instrument, 67 pilot interviews were conducted and 17 focus group meetings were held with adolescents who had drug and alcohol problems and adolescents who had mental health problems, all of whom participated in varying services provided by

K. Meyers et al.

184 the Carrier Foundation (e.g., specialized day school, inpatient treatment). Adolescents were told at the outset of one-to-one pilot interviews that, in addition to our interest in their answers, we were equally interested in their opinion of the questions themselves. In this way, we used these adolescents as consultants in the interview, asking them to think about important issues that we failed to ask and what questions made them uncomfortable (e.g., reporting on the occurrence of illegal behavior of a family member). We paid special attention to the form of each question and enlisted their assistance in re-wording questions that were difficult to understand. Adolescents were also asked if there was anything that they felt was irrelevant or in their opinion could be omitted. In other words, the adolescent provided feedback on item representativeness, item wording, and item difficulty. This process occurred at the end of each CASI-A module. After discussion of each CASI-A module, interviewers completed forms that delineated the above issues from the adolescent’s perspective as well as CASI-A sections the interviewer had particular difficulty with, specific questions the interviewer had difficulty explaining, and adolescent answers that were difficult to code. The procedures for focus group meetings were slightly different. Adolescents were approached individually and told that there were issues that we felt may be important to them but which we were having difficulty understanding and explaining (e.g., family problems). They were asked if they would be willing to share their ideas on certain topics in a group setting. Seventeen focus groups of 5 to 7 adolescents each were facilitated by one of two masters level school psychologists. During focus groups, adolescents were encouraged to generate items for assessment within the area being discussed at a particular meeting (e.g., What does it mean to say that you are having “serious problems in getting along with” your family?). The overall goal of the groups was to have adolescents assist in operationalizing certain constructs and wording certain items. Biweekly meetings were held with research and clinical staff to review the information from both interview and group formats and to make subsequent refinements to the instrument. On the basis of this work, the CASI-A developed into its first testable form (described below).

CASZ-A Basic Description. The CASI-A is a 45 to 90-minute semi-structured interview (available from the first author). The length of the interview is heavily dependent upon the level of the adolescent’s alcohol and drug involvement. Like the ASI, the CASI-A assesses symptoms in areas of adjustment which contribute to or result from addiction. Most of the ASI’s problem areas (referred to as modules in the CASI-A) were reorganized to afford better applicability to the

adolescent population, The modules were designed to be independent from one another. Questions within each module assess all aspects of a particular area of functioning, rather than concentrating solely on whether those symptoms and behaviors are solely alcohol and drug related.

Form of Questions. During

Stage 3 of the development process, it became apparent that youth found it difficult to make subjective decisions on general categorical questions (e.g., whether there were significant periods of time during which they had “serious problems” with their family). A series of objective, focused, and concrete questions (e.g., “Have you or any other family member gotten so angry that furniture was destroyed, objects were thrown, or doors or walls were punched?“) were subsequently incorporated within each module. During our early pilot work, it became apparent that adolescents were having difficulty estimating the frequency of symptoms and behaviors in number of days experienced over the past month (e.g., “How many days in the past month did you feel that your parents/guardians were unavailable to you?“), as well as in estimating “lifetime” information (e.g., “How many years have you felt down, sad, or “bummed out?“). They were, however, quite competent in expressing whether something had occurred as well as in generating the age at which behaviors/symptoms began to occur consistently. Consequently, each CASIA question is formatted to identify whether problem symptoms occurred in the year and the month prior to the interview. In addition, subjects are asked the age at which various symptoms and behaviors first occurred on a regular basis. This “age-of-onset” is used not only to differentiate long-standing from recent problems, but also to allow interviewers to begin to characterize (on an individual level) potential precursors and consequences of alcohol/drug use. These time parameters (past month, past year, age first) are used as a proxy for problem stability and severity as well as lifetime information. Since the age of onset questions are primarily answered in terms of grade (e.g., I started drinking in 8th grade), grade-to-age conversion tables are included for a quick transposition of these answers. In addition to objective questions, subjective ratings by the youth are also included within each module. Within the ASI, a Patient’s Rating Scale permits the adult to communicate the extent to which she or he has been troubled or bothered by problems within each problem area. Although this basic format has been maintained in the CASI-A, several modifications were necessary to increase the fluidity of the interview. During Stage 3 of the developmental process, it became apparent that adolescents were not acknowledging the presence of problems despite their own reports of sig-

CA%-A

nificant symptoms and problem behaviors. Consequently, prior to determining the level of concern and importance of treatment for each area, the CASI-A initially assesses whether the adolescent acknowledges the presenceof problems and then assesses subjective ratings of discomfort (i.e., the extent to which she or he is troubled or bothered by problems in a particular area) and importance of treatment. Unlike the ASI, interviewer severity ratings are not included in the CASI-A. We experienced much difficulty in obtaining any degree of reliability on interviewer severity ratings during early pilot work. We found that they were heavily influenced by the perspective and background of the interviewer. Consequently, we decided to deleteinterviewer severity ratings and include only whether the interviewer feels that any adolescent misrepresentation occurs. It should be noted that the most recent work with the ASI (McLellan et al., 1992)suggeststhat the importance of severity ratings has been overemphasized, and that more attention should be focused on individual AS1 items and AS1 composite scores. CASZ-A Modules. The Medical problem area of the AS1 was not retained in the CASI-A. During stage 3 it became apparent that assessmentof anything other than gross anomalies would be beyond the scope of the CASI-A: responsesindicating medical problems were extremely rare. Consequently, the CASI-A identifies the date of the last physical examination for all youth and the last gynecological examination for female youth so that a referral for a full medical examination can be initiated when clinically indicated. It should be noted that health-oriented questions (e.g., sexually transmitted diseases)are included in other areas of the CASI-A. Like the Medical problem area, the Employment/ Social Support problem area did not easily translate to meet the needs of adolescents. Consequently, the Employment/Social Support Problem Area of the AS1 was divided into two CASI-A modules: Education and Use of Free Time. The Education Module assesses the presence of academic, attendance, disciplinary, and motivation/attitude problems. For those not in school, questionspertaining to lack of attendance are included. The Use of Free Time Module includes an Employment and Leisure Subsection. The Employment Subsection assesses work schedule, job relevance to career aspirations, and potential for job interference. Questions that addressthe degree of self-sufficiency are included for those who have dropped out of school. The Leisure Subsection assessesthe degree to which the youth has previously participated in appropriate leisure activities. This information can be used by clinical staff to ascertain whether the youth must learn to restructure free time to replace alcohol and drug use. Given the high prevalence of multiple substanceuse

I85 among adolescents, two of the ASI’s Problem Areas (Alcohol and Drug) have been incorporated into one ALCOHOL/DRUG Module in the CASI-A. This module assesses the age of first and regular use, use patterns over the past year [(e.g., weekly, monthly), new addition to the CASI-A basedupon data reported in this paper], duration of use, the social environment of use, and reasonsfor use for individual alcohol/drug categories (e.g., hallucinogens). Additional questions are directed toward behavior while under the influence of alcohol/drugs, methods for obtaining alcohol/drugs, and treatment history. Unlike the ASI, cigarette use is also assessed. The Family/Social Support Problem Area of the AS1 was divided into two CASI-A modules: Peer Relationships and Family Relationships. The Peer Relationships Module assesses the adolescent’srelationships with his friends, the environment within which these relationships occur, composition of the peer group, and diverse issuesof sexual behavior. Within the Family Relationships module, interpersonal family dynamics, parenting behavior, family history of psychiatric, alcohol/drug, criminal problems, and physical and sexual abuse are evaluated. The General Information, Legal, and Psychiatric Modules remained similar to those in the ASI, although the information was adapted for applicability to the adolescent population. The General Information section obtains basic demographic-type information, results from urine drug screens, and questions regarding stressful life events. It is suggestedthat information specific to a treatment program or research study be incorporated within this module as needed. Like the ASI, the Legal Module of the CASI-A explores legal history. However, since some youth may have yet to come in contact with the legal system despite their behavior, the CASI-A assesses whether the youth has committed crimes regardlessof police recognition. Additional information on whether she or he has ever been questioned by the police, involved with the juvenile justice system for illegal behavior, and whether pending charges, a trial, or sentencing exists has only recently been included. The focus of the Psychiatric Module is the determination of the nature and extent of psychological symptomatology, which symptoms predate the onset of alcohol/drug use, and treatment and medication history. Like the ASI, the CASI-A concentrates on overt symptomatology although wording has been adapted to better describe symptomatology experienced by adolescents (e.g., felt hopeless, “bummed out”).

CAST-A Scoring. The current CASI-A scoring system was theoretically designed.Unlike the ASI, each CASIA module contains numerous subscalesbased on a rational-inductive structure in which CASI-A items were placed into respective categories basedon a theo-

186 retical framework. The following lists the subscales in each module, based on information obtained during the series of objective questions: Education-education severity, education needs, education denial; Alcohol/ drug-use severity, progression of use, use patterns, methods to obtain, consequences, treatment history, alcohol/drug needs, alcohol/drug denial; Free Timeemployment severity, leisure severity, free time needs, free time denial; Peer-peer interaction (severity), peer group composition, abusive sex, STD risk, pregnancy risk, peer needs, peer denial; Family-interaction (separate patient, family, and both patient and family severity scores), parenting behavior, family history, family needs, family denial; Legal-legal severity, legal needs, legal denial; Psychiatric-psychiatric severity, treatment history, psychiatric needs, psychiatric denial. Twenty-one subscales are theoretically defined and are based on the scoring systems described below. The most basic level of scoring within each subscale utilizes an additive procedure of the presence/absence of a behavior/symptom. Dichotomous variables within each theoretical subscale are summed, yielding the subscale’s total score. However, in an effort to give subscales more clinical relevance and subsequent utility, assessment time parameters (past month, past year, age first) are used as a proxy for problem recency, problem stability, and problem severity by superimposing continuous constructs upon the nominal categories. For example, for each individual item, scores range from 0 to 4 depending on when in the adolescent’s life the problem occurred. Using this system, individual item scores of module subscales are then summed, yielding the subscale’s score. Clinicians have suggested that this approach has clinical merit and utility, and we are currently testing the feasibility of this approach. Needs and denial subscale scores are based on a comparison of the patient’s subjective ratings of each problem relative to the objective information obtained about that problem in the module. They were conceptualized to provide an indication of the degree of correspondence between the youth’s actual problems and the youth’s ratings of such problems: in other words, to assess whether the adolescent has any insight into issues affecting his ability to function. Follow-up. At follow-up, CASI-A items of all modules except the Alcohol/Drug Module are identical, although the time parameters differ. For example, adolescents are asked separately about the past 30 days and the time period since last assessment contact. The Alcohol/Drug Module incorporates additional questions including participation in self-help groups and/or an aftercare program, length of time to episode of first use posttreatment, number of days completely abstinent, and consistently being in substance use situations or in the presence of other users with no abstention

K. Meyers et al. models. These additional items were used because they have been associated with relapse among youth (Brown, Vik, & Creamer, 1989). instruction Manual. To ensure that the reliability of assessment information is not compromised by inconsistent methods of administration or individual interpretation of instrument items, an instruction manual accompanies the CASI-A. The CASI-A manual describes the appropriate conditions for conducting the interview and provides detailed instruction for administration and scoring of individual items, thus allowing the interview to be administered in a uniform way. Item definitions are provided as well as conventional methods for eliciting complete and accurate information from individuals. This manual and the CASI-A are available at no charge from the first author. Interviewer QualiJications. Although there are no minimal educational requirements to perform a competent CASI-A interview, the interviewer should have considerable skill at developing early rapport, eliciting information, and probing and focusing sometimes diffuse narrative responses from adolescent participants. The potential interviewer must fully understand the intent of each question and be able to recognize when the adolescent misunderstands the question so that paraphrasing/rewording of the question can occur. As with the AS1 interviews, the interviewer is expected to be an active participant in the CASI-A interview. PART III.

PRELIMINARY TESTING OF THE CASI-A

Once the CASI-A had evolved into a testable form, adolescents receiving drug/alcohol and/or mental health treatment at the Carrier Foundation were asked to participate in a preliminary examination of its validity. (Parents had previously signed consent forms permitting their adolescent’s participation in assessment research.) Adolescents were told that they would participate in an interview that would ask questions about many different areas in their life, would complete paper/pencil questionnaires unrelated to the CASI-A (e.g., prospects for smoking treatment), and would have their clinical charts reviewed upon discharge from the hospital. It should be noted that these adolescent subjects had not participated in earlier developmental work. The purpose of this phase in the CASI-A’S developmental process was to begin to examine validity and reliability issues. After informed consent was obtained from the adolescent, CASI-A and chart data were collected and subsequently compared to determine whether CASI-A information collected at admission by independent research assistants would be consistent with the subsequent clinical record collected in the usual way

CASZ-A

187

by trained professional staff. We also used CASI-A data to begin to explore internal consistency of proposed subscales. We reasoned that if this less costly, preliminary examination of validity and reliability looked promising, more formal reliability and validity work would be indicated. METHOD Subjects

After approximately three years of early developmental work, 103 adolescents were recruited to participate in preliminary testing on the CASI-A. Of these, 1 subject refused to participate and 2 subject interviews were terminated due to inconsistent responses. Subjects were adolescents receiving either psychiatric treatment, substance abuse treatment, or both types of treatment on a specialized adolescent unit of the Carrier Foundation, a private, nonprofit psychiatric hospital. Sixty-six percent of youth were on the Substance Abuse Treatment Track of the Unit; the remaining adolescents participated in some substance abuse-related treatment sessions given their drug use history. Subjects ranged in age from 12 to 18 years, with a mean age of 15.7 (SD = 1.4). Fifth-five percent of the sample was male and 89% Caucasian. Based on the attending psychiatrist’s discharge diagnoses, 71% of the sample were diagnosed with both a substance abuse/dependence diagnosis and another Axis I psychiatric diagnosis. According to CASI-A information, the average age of onset of psychiatric symptoms was 9.5 years (SD = 3.4). Ninety-eight percent of the youth had a history of psychiatric treatment; 24% also had a history of taking psychotropic medication. In terms of drug use demographics based on CASI-A information, all youth reported a history of drug/alcohol use: 77% used at least one substance (excluding cigarettes) in the past year. Subjects reported first trying drugs/alcohol at 10.4 (SD = 2.9) years of age on average which is approximately 5th grade. Excluding cigarettes, the average age of first drug/alcohol use rises to 11.3 (SD = 3.0) years. Subjects used drugs/ alcohol primarily with friends (73%) for the purpose of feeling better (64%). Forty-three percent had a history of blackouts, with 20% reporting a history of drug overdose. In terms of drug procurement, 10% of the sample engaged in sex for drugs or money, 2 1% dealt drugs, and 37% reported stealing. Twenty-eight percent of the subjects had at least one previous drug/ alcohol treatment attempt. Other CASI-A information revealed that almost all youth “hung out” with other drug/alcohol abusing adolescents (85%), and 75% reported that some of their friends had problems with the law. The majority of the youth (72%) were sexually experienced (i.e., they had engaged in anal or vaginal intercourse at least one

time), and 70% were sexually active (i.e., they had engaged in anal or vaginal intercourse in the past year). Not surprisingly, few of the sexually active youth reported condom use (31%), and 69% reported two or more past year sexual partners. Youth reported initiating sexual activity in approximately 8th grade (13.4 years; SD = 1.9). Thirteen youth had a history of a sexually transmitted disease (13Oro); six males reported having impregnated a female partner; three females reported having been pregnant. Validation Procedures

Assessment. Testing was typically performed over a l-week period. Day one included an explanation of the study and an overview of upcoming events. At that time, arrangements for subsequent testing sessions were made. The first assessment session was for the completion of paper-and-pencil questionnaires unrelated to the CASI-A [e.g., knowledge of issues related to Acquired Immune Deficiency Syndrome (AIDS)]. These one-to-one sessions were monitored by research staff to assure questionnaire completion, compliance, and accuracy. Once the paper-and-pencil questionnaires were completed, the second assessment session for administration of the CASI-A was scheduled. Prior to administering the CASI-A, issues of confidentiality were discussed and reemphasized throughout the interview. The research interviewer stressed that truthful answers were necessary and that the subject should refrain from making up an answer. The interviewer described the design of the interview, stressing the assessment areas, and explained the assessment time frames and the patient rating scale. During CASI-A administration, each new module was introduced separately, which enabled the subject to concentrate on each of the areas independently (e.g., “Now I am going to ask you some questions about school.“). If ambiguity or inconsistency in subject responses were noted, questions were reframed or subjects were made aware of the inconsistency and asked to explain. If the subject could not or would not reconcile an answer, the value was coded as missing. If a pattern of inconsistency emerged, the interview was terminated. (Two interviews were terminated for this reason.) Chart Review. To assess concurrent validity, a chart review form was designed to correspond to each CASIA module. To differentiate symptoms that were reported as not experienced by the adolescent from those that were simply not asked by the clinical team, reviewers coded whether the symptom was present, whether the absence of the symptom had been reported (e.g., John denies cocaine use), or whether no mention of the symptom was recorded. Staff who conducted the chart reviews were experienced with the charting pro-

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cedures, but were blind to information obtained on the CASI-A. Each chart review took approximately 2 hours to complete. Importantly, staff reviewing charts were also asked to record dinically important information that was not collected by the CASI-A. These items were later discussed at research staff meetings for possible inclusion in the next version of the CA%-A.

Analyses

Information about problem symptoms available from the CASI-A but not present in the chart could be due to inconsistent responding by the subjects or to the question not being asked by clinical staff. This latter possibility is a potential confound in percent agreement calculations. For this reason, we decided to treat the clinical chart as the “gold standard” and to determine whether issues, information, and problems that were recorded on the chart by the time of discharge had originally been identified by the CASI-A interview (See CASI-A column in Table 1). Of course this is not a

TABLE I Between Chart and CASI-A Information: Does the CASI-A Obtain Information Present in the Clinical Record?

Correspondence

Module Alcohol/Drug Alcohol Use Marijuana Use Cocaine Use Other Drug Use illegal Methods To Obtain Neg. Consequences Education Academic Problems Disciplinary Problems Motivation Problems Family Intra-Family Conflict Family History of Pathology Incest Peers Deviant Peer Group Problems w/Peers Sexually Active Inconsistent Condom Use Psych Depressive Symptoms Suicide Attempts Anxiety Symptoms Impulsive Symptoms Paranoid Symptoms Self-Esteem Issues

-

-

Chart n

complete evaluation of concurrent validity, but we felt it was an important and logical first step. Results of these analyses would indicate whether the CASI-A was capable of obtaining, at admission by a trained technician, information that could later be obtained by the full treatment team during the entire course of treatment. Within each module, we also identified what percentage of information reported on the CASI-A (CASI-A column in Table 2) was addressed in the chart (Chart column in Table 2). Results of these analyses would indicate whether the CASI-A uncovered additional information that was unavailable clinically, most likely because certain types of questions were not systematically asked. To begin to preliminarily examine internal consistency of proposed past year subscales, past year CASI-A items were grouped into theoretical constructs. Cronbath’s Alpha statistic was used to determine how well the items combined into the proposed single dimension scales. Alpha’s of .6 or better were considered to indicate adequate internal consistency. If the proposed past year subscales had adequate internal consistency,

TABLE 2 Correspondence Between CASI-A and Chart information: Does the Clinical Record Contain Information Obtained by the CASI-A?

CASI-A n (96)

79 68 42 52 16 36

75 67 38 51 14 34

56 56 54

43 (77%) 47 (84%) 39 (72%)

58 55 10

56 (97%) 37 (67%) 0

52 40 25 9

51 30 24 7

(98%) (75%) (96%) (78%)

68 47 36 56 35 60

60 39 26 51 17 40

(88%) (83%) (72%) (91%) (49%) (67%)

(95?6) (98%) (90%) (98%) (87%) (94%)

Module Alcohol/Drug Alcohol Use Marijuana Use Cocaine Use Other Drug Use Illegal Methods To Obtain Neg. Consequence Education Academic Problems Disciplinary Problems Motivation Problems Family Intra-Family Conflict Family History of Pathology Incest Peers Deviant Peer Group Problems w/Peers Sexually Active Inconsistent Condom Use Psych Depressive Symptoms Suicide Attempts Anxiety Symptoms Impulsive Symptoms Paranoid Symptoms Self-Esteem Issues

CASI-A

Chart

n

n (%)

83 74 42 61 48 67

75 67 38 51 14 34

(89%) (90%) (90%) (84%) (29%) (51%)

70 71 61

43 (61%) 47 (66%) 39 (64%)

72 43 2

56 (78%) 37 (86%) 0

94 67 70 47

51 30 24 7

(54%) (45%) (34%) (15%)

78 47 70 74 28 69

60 39 26 51 17 40

(77%) (83%) (37%) (69%) (61%) (58%)

CASI-A

continued development be indicated.

189

of the scoring system would

Results

Preliminary Indication of Validity. As shown in Table 1, we found high rates of concordance between information extracted from clinical charts and that which was initially reported during the CASI-A interview. The substance abuse module had the overall highest agreements. For example, of the 100 adolescent charts reviewed, 79 of the charts documented past year alcohol use (Chart column in Table 1). Of those 79 adolescents, 75 (94%) reported alcohol use on the CASI-A (CASI-A column in Table 1). Sixty-seven youth (98%) reported marijuana use on the CASI-A out of the 68 youth for which it was documented in their clinical charts. The CASI-A was equally able to obtain information on cocaine use, other drug use, and consequences as a result of use, with agreement rates of 90%) 98%) and 94%, respectively. Notably, of the 15 positive admission drug screens, 14 or 93% of the youth reported drug use in the preceding 30 days. In terms of peer relationships, the CASI-A was able to elicit information on the type of peer group present in the adolescent’s life. Of the 52 charts that documented that the youth “hung out” with problem peers, 51 or 98% of the youth reported similar information on the CASI-A. Out of the 40 charts for which peer problems were documented, 30 of the youth (75%) reported peer problems. Of the 25 sexually active youth identified through their chart, 24 reported this on the CASI-A (96%). The information on intrafamily conflict was also concordant with the chart (56 CASI-A reports out of the 58 clinical records [97%]). But the CASI-A was less concordant in acquiring family history information: only 33 or 67% of the youth reported such out of the 55 youth for which a family history of pathology was documented in their clinical charts. None of the youth for whom sexual abuse was documented in the clinical record reported sexual abuse information on the CASI-A. The ability of the CASI-A to obtain information on depressive symptoms, suicide attempts, anxiety symptoms, and impulsive behavior was quite good, especially considering that the CASI-A reflected status around the time of admission only, while the discharge record accumulated information throughout treatment. Sixty adolescents reported depressive symptoms out of the 68 positive charts (88%); 39 adolescents reported suicide attempt(s) out of the 47 for which suicide was stated in the clinical record (83%), 26 adolescents reported anxiety symptoms out of the 36 positive charts (72010), and 51 (91 To) adolescents reported impulsive behavior on the CASI-A out of the 56 adolescents for whom impulsive behavior was later documented in the

clinical charts. The psychiatric symptoms within the CASI-A that did not correspond well with the clinical charts were paranoia (47%) and self esteem (67%). Table 2 looks at agreement in a different way. As stated previously, we calculated the percentage of information reported on the CASI-A (CASI-A column in Table 2) that was documented in the clinical chart (Chart column in Table 2). The CASI-A regularly obtained information that was not routinely collected during clinical assessment, even by the end of treatment. Within the substance use module, for example, of the 48 youth who reported engaging in prostitution, theft, or drug dealing for drug procurement, only 14 or 29% had this information in the charts. Of the 67 youth who reported experiencing consequences as a result of drug/alcohol use, 34 or 5 1% of the clinical records mentioned this issue. Importantly, we found more disclosures of drug use during the past month than positive drug screens at admission: only 14 or 23% of the subjects who reported past month use had a positive admission drug screen. Of the 70 CASI-As in which subjects reported being sexually active, only 24 or 34% of the charts documented sexual activity. Of the 47 CASI-As where no or irregular condom use was reported, only 7 or 15% of the charts addressed this issue. Five pieces of information were not assessed by the CASI-A but were consistently found in the charts of the patients: educational level and occupation of parents/guardians; number of siblings; “enabling” behavior of parents, e.g., one parent “covers for” the adolescent so that she or he does not get into trouble, especially by not informing the other parent about things that have happened; intentional self-mutilating behavior of the adolescent; various consequences of illegal behavior. It should be noted that legal information between the two sources of data was not compared due to almost complete divergence of the information collected on the CASI-A and that which was recorded in the clinical chart. Our resolution of this issue is described in the discussion section. Similarly, lack of chart information regarding free-time activities negated chart/CASI-A comparisons on this topic. Preliminary Indication of Internal Consistency. Table 3 highlights items by past year subscales and their internal consistency coefficients. The Alcohol/Drug subscales had the highest Cronback’s alpha coefficients. An alpha coefficient of .80 was achieved for the drug/ alcohol consequences subscale, which is the sum of yes responses to 5 consequences of continued alcohol/drug use. Use severity is composed of 8 drug categories answered in months of at least weekly use over the past year. This subscale yielded an alpha of .78. For drug procurement (yes to three illegal methods to obtain drugs/alcohol), a .58 coefficient was achieved. The ed-

K. Meyers et al.

I90 TABLE 3 Past Year Subscales by Items (With Alpha Coefficients)

Education (.67) Academic Difficulty Attendance Problems Disciplinary Problems Motivation Problems Use Severity (. 78) Months of: Alcohol Use Cannabis Use Cocaine Use Inhalant Use Hallucinogen Use Amphetamine Use Barbiturate Use Opioid Use Family Interaction (.67) Violence Toward Property Violence Toward Member Sexual Abuse Poor Communication Outside Intervention (e.g., child protection services) Peer Problems (.55) Difficulty Making Friends Difficulty Keeping Friends Difficulty Establishing Intimate Relationships Difficulty Maintaining Intimate Relationships Problems “Getting Along” With Peers Psychological Distress (.62) Restlessness Anxiety/Worry lmpulsivity Rebelliousness Hostility/Violence Depression Suicide Ideation/Attempts Hallucinations/Paranoia Drug/Alcohol Procurement (. 58) Sex-for-drugs/money Theft Drug Dealing Drug/Alcohol Consequences (.80) Continued Use Despite Dangerous Behavior Physical/Social/Psy Consequences Interference/Preoccupation Tolerance Family History (.48) Drug/Alcohol Problems/TX Psychiatric Problems/TX Illegal Behavior/Incarceration Peer Group Composition (.58) Peer Drug/Alcohol Use Peer Illegal Behavior

ucation (yes responsesto four problem areas), family interaction (yes responsesto 5 problem areas), and psychological distress (yes, responsesto 8 symptom categories of psychological distress) subscalesachieved alpha coefficients of .67, .63, and .62, respectively. lnternal consistency of the peer subscalesapproached our standard of .6, with peer problems (5 problem areas)

yielding an alpha coefficient of .55 and group composition (2 friend “types”) a coefficient of 58. Not surprisingly, given the difficulty observed in chart/ CASI-A comparisons, our family history measure yielded a coefficient of only .48. Subject Acceptance. Perhaps one of the most important indicators of the potential utility of an instrument is whether or not the interview will be accepted by its participants. To assesshow adolescentsfelt about the CASI-A, 51 youth of the 100youth were askedto complete a satisfaction questionnaire after the CASI-A interview designed to assesstheir opinions regarding participation in the interview. Ratings of interview ease and enjoyment were quite high. Overall, 88% of the adolescentsenjoyed participating in the CASI-A interview, 96% felt that they were able to get their ideas and feelings across, and 94% did not find questions in the interview difficult to answer. Ninety-two percent felt that the interview was comprehensive, and 98% felt comfortable answering even the most sensitive questions. The only question the adolescents expressed discomfort in answering was disclosing the occurrence/nonoccurrence of illegal behavior of family members. DISCUSSION Assessingalcohol/drug useand concomitant problems among adolescentsrequired significant departure from the widely used method for adult assessment,the ASI. Substantial revisions in AS1 content, assessmentparameters, and the scoring system were necessary to capture the unique characteristics of the adolescent population. CASI-A modules and their individual items were selectedand revised based on theory, clinical wisdom, and adolescent experiences and input. Hence, a comprehensive spectrum of adolescentspecific information is obtained in both module and item format. The CASI-A assesses known risk factors, concomitant symptomatology, and consequencesof adolescentdrug/alcohol usewithin sevenprimary areas of functioning: education status, alcohol/drug use, family relationships, peer relationships, legal status, psychiatric distress,and useof free time. The CASI-A is not a diagnostic nor screening instrument, but is rather a clinical assessmenttool that obtains clinically pertinent information designed to guide treatment planning and to evaluate treatment outcome. The CASI-A should be administered by trained interviewers; self-administration is inappropriate. The CASI-A’s design makes it suitable for administration in a variety of settings, for repeat administration at posttreatment follow-up evaluations, and for assessmentof virtually all adolescentsin treatment, regardless of their admission problem. Of course the CASI-A is only appropriate for those adolescentswho

CASI-A

would otherwise be considered for any other form of interview, and patients impaired by significant developmental disabilities or psychiatric disturbance (e.g., acute psychosis) are unsuited to this or any other treatment planning interview. Overall, the CASI-A has encouraging but preliminary evidence of validity and internal consistency. Information collected soon after admission during administration of the CASI-A by nonclinical interviewers corresponded quite well with the obtained over the course of the adolescent’s treatment stay by the entire treatment team. We have tried to build content and face validity into the subscales throughout the various stages of the CASI-A’s development. Continued development of these subscales is indicated, given that the past year subscales are moderately to highly internally consistent. As a result of the data reported here, revisions to the instrument are being made in those areas where correspondence between information on the CASI-A and that extracted from clinical records was less than 75%, or in those early subscales where alpha coefficients were less than .6. Additional clinical input as well as focus group meetings have been used to revise these areas of the CASI-A. For example, re-review of our anxiety symptom questions by clinical staff resulted in the rewording of these questions to include physical symptoms. Clinical staff believe that adolescents tend to experience physical symptomatology and should be better able to respond to these more concrete symptoms. Discussions continue regarding better ways to operationalize the concepts of paranoia and self-esteem. The failure by adolescents to disclose sexual abuse during our CASI-A interviews early in the treatment stay is not surprising, given our limited contact with the subject during this study. Clinical reports indicate that first-time disclosures typically occur as one nears discharge and are generally sparked by group therapy discussions in which other abused adolescents discuss their experiences. Thus, it is quite possible that the CASI-A will never be able to assessthis sensitive issue at intake for those who have not yet disclosed the abuse. We have, however, suggested ways to re-frame this sensitive question in the manual. It should be mentioned that a promising new instrument that deals exclusively with the assessment of abuse in substancedependent adolescents and has evidence for validity has been developed by Shanks, Krill-Smith, & Crowley (1993). An overview of the family history data suggested that some adolescents are unaware of substance use or psychopathology in their second degree relatives; this accounts for many of the discrepancies between subject reports and their clinical charts. However, a number of subjects also expressed discomfort at answering questions regarding the illegal behavior of family mem-

191

bers. Perhaps they were also uncomfortable in answering questions regarding family members’ psychiatric and drug/alcohol problems. In addition to modifications based on agreement figures, we incorporated questions pertaining to the five areas in which data were consistently available in the clinical chart but not collected on the CASI-A: parent/guardian educational level; parent/guardian occupation; number of siblings; “enabling” behavior of parents; intentional self-mutilating behavior of the adolescent. Importantly, since the legal information collected by the CASI-A was not collected by clinical staff, and since that which was recorded by clinical staff was not collected by the CASI-A, we were unable to compare this module. In an effort to determine clinical appropriateness, we consulted various staff. In the test CASI-A, we concentrated heavily on the type of offense committed by the adolescent and less heavily upon the consequence of the offense. This, however, did not yield critical information from the perspective of clinical or juvenile justice staff. Hence, the revised CASI-A now includes the various outcomes of illegal behavior (e.g., questioned by police, appeared before a judge, charged/convicted of a crime, spent time in detention) and instructs the interviewer to record the offense(s) that resulted in each consequence in the Legal Module’s comment section. We also believed that there were other areas that needed revision based on ongoing use of the instrument, discussions with the interviewers, and discussions with the adolescents. For example, although we obtained a 75% agreement figure between the chart and CASI-A in regard to peer relationships, and the alpha coefficient approached .6, we believed that we could do better. Hence, we ran an additional three focused groups and revised the peer module to better operationalize peer relationships. We have also expanded sections in the family module based on additional clinical input. So as not to miss the very infrequent drug/ alcohol users (fewer than 10 times last year), to be able to identify the extremely heavy drug/alcohol users (e.g., more than once a day), and to make it easier for the adolescent to respond, we revised the way in which we assessed past year drug/alcohol use: rather than obtain the number of months a subject used drugs/ alcohol on at least a weekly basis, we now assess patterns of use (e.g., weekly, monthly). We anticipate differentiating the type of sexual behavior that the adolescent engages in (anal, vaginal, oral) as well as the frequency of condom use by sexual activity to better assess risk for infection with the human immunodeficiency virus (HIV). Our data also suggest that some potentially important information was not routinely collected by clinical staff (e.g., sexual behavior). We acknowledge the possibility that data obtained by the CASI-A but not found in clinical records may not have occurred at a

K. Meyers

I92

clinical threshold and therefore was not documented in the clinical record. We will explore this in future work. We should mention, however, that a review of this data suggested that information documented in clinical records varied by both those evaluating the adolescent as well as the presenting problem of the adolescent. This is quite typical during clinical assessment in which evaluations many times proceed along the theoretical orientation or approach of the clinician, leading to confirmation of early clinical impressions rather than generation of competing hypotheses or conflicting diagnoses. This can often result in a biased picture of a patient’s status, resulting in the omission of clinically relevant information that is outside the purview of the evaluator. It is for this reason that structured and semi-structured interviews are becoming increasingly more commonplace in many treatment facilities. Standardized assessment packages allow for the comprehensive collection of information by all staff on all patients, guaranteeing that assessment areas are not overlooked. Thus, we fell that the discrepancies between positive reports on the CASI-A and lack of discussion in the clinical record suggest the need for standardized assessment practices. Such practices also aid in program and/or system referral and better lend themselves to accountability, program evaluation, and client outcome assessment. In sum, the CASI-A has evolved over the past 6 years to a point where it has encouraging but still preliminary evidence of validity. Importantly, we examined concordance of the presence of problem behavior and symptoms. More in-depth analyses will be performed with a new adolescent sample. The CASI-A is a tool that collects clinically pertinent information in multiple areas of functioning, and is to be used as a comprehensive intake and posttreatment assessment instrument. The information elicited through administiation of the CASI-A should be sufficient to guide treatment planning activities and monitor posttreatment outcome. It was designed to assess all adolescents regardless of the system (e.g., mental health, drug/ alcohol, juvenile justice) to which they are referred. As a result of the encouraging results reported in this article, we are beginning psychometric testing (e.g., test-retest reliability, internal consistency, concurrent validity, predictive validity), refining the proposed scoring system, and developing a computerized data entry, scoring, and report system. We plan to eventually establish norms stratified by gender, race, age group, and treatment type. The CASI-A will continue to be evaluated for its reliability and validity, and revisions will be made as necessary. ACKNOWLEDGMENTS We wish to thank Stanley Birch, Jr., William Horn, Rosemary Dante, Pat Sargiotto, and other research

et al.

and administrative staff from the Carrier Foundation; Harvey Kushner, Biometrics and Computing, Philadelphia; David S. Metzger and David Zanis, Penn/VA Center for Studies of Addiction, for comments on the manuscript; Brian Marcy and Tom Richardson, Carrier Foundation, Maureen Burke, Penn/VA Center for Studies of Addiction, Joan KOSS, Hispanic Family Center, Arizona State Universit?, and Thomas Crowley, University of Colorado Health Sciences Center for their feedback throughout the use of the CASI-A; Craig Chioino, Hispanic Family Center, Arizona State University, for ongoing work on the automated data programs; and the adolescents who shared sometimes painful information about their lives. This article is dedicated to Kevin Meyers (February 7, 1964-June 7, 1994). REFERENCES Alibrandi, T. (1978). Young alcoho/ics. Minneapolis, MN: Comp Care Publications. Anglin, T.M. (1987). Interviewing guidelines for clinical evaluation of adolescent substance abuse. Pediatric Clinics of North Amer-

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