Due Tomorrow on 02/04/16 by 8:00 PM. No exceptions please.. Any questions please ask Ty.
Screening tools are not designed to make diagnoses. They can give evidence that a problem exists. However, there is no guarantee that one screening tool or even one assessment or type of data will yield the necessary data to inform the addictions professional about a potential treatment plan and next steps. This is why addictions professionals may have to seek multiple (also known as multimodal) data sources from which to elicit sufficient data on an individual.
In this Discussion, you will consider what you might do in a hypothetical situation in which a client’s scores on a screening tool are insufficient for the purposes of interpretation.
To prepare:
Review the article “Screening for Alcohol Problems: What Makes a Test Effective?” (See attachment)
Review the data collected for the diagnostic summary for Jane Roberts (pseudonym “Patty”) in Chemical Dependency Counseling: A Practical Guide, Appendix 6 (pp. 262–263) (See below for Jane Roberts diagnostic case summary)
Jane Roberts case summary
Jane is single and a beautician. Father died when she was young. She was raised by an emotionally distant alcoholic mother. She felt abandoned all her life which led to her drinking starting in her teenage years. She strived for affection and attention from other men which led to addiction to sex. Was confused between sex and love. She has men who were abusive, which led to her not having assertive skills to the point where she had trouble for asking what she wanted and problems expressing how she feels. Her alcohol started increasing, which led to her take valium to sleep. Therefore, addiction to valium increased to double the dosage. She has no social system except for her boyfriend of 2 months. The psychological testing showed she is emotionally unstable and manipulative. She breaks the rules of society to get her own way. She is suffering from mild depressive symptoms, along with daily anxiety.
Jane Roberts problems are as follows:
- Extended withdrawal from alcohol and valium, as evidence by autonomic arousal and elevated vital signs.
- Inability to maintain sobriety outside a structured program of recovery, as evidenced by client having tried to quit using chemicals many times unsuccessfully.
- Anemia, as evidenced by chronic history of low red blood cell counts.
- Upper respiratory infection, as evidenced by sore throat and rhinitis.
- Fear of rejection and abandonment, as evidenced by client feeling abandoned by both her mother and her father now clinging to relationships even when abusive.
- Poor relationship skills, as evidenced by client not sharing the truth about how she feels or asking for what she wants, leaving her unable to establish and maintain intimate relationships.
- Dishonesty, as evidenced by client chronically lying about her chemical use history.
- Poor assertiveness skills, as evidenced by client allowing other people to make important decisions for her, inhibiting her from developing a self-directed program of recovery.
Review the introduction scenario featuring Terrence. Terrence is faced with a client, Angela, who is presenting several problems (See below)
Your written assignment is to response to the following questions below regarding Terrence:
Consider the following scenario:
Terrence is considering next steps for a client, Angela, who has come for therapy at the family counseling center where he works. When Angela scheduled her appointment on the telephone, she had described her concerns with marital difficulties, insomnia, and depression. During her first session, however, Terrence noticed that Angela had a very nervous demeanor, picked at her skin constantly, and had a rasping cough. When Terrence asked Angela about her employment, she admitted that she had lost her job and that her husband was angry about it. She said she was afraid her husband was on the brink of becoming abusive. Terrence is not sure what to do first. He suspects Angela might have a substance addiction, but clearly she has several interlocking problems, and many are urgent.
What sources of data might Terrence collect in order to understand the client’s problems? Explain why you chose each source. Finally, provide a rationale for the number of sources you recommend.
References
Stewart, S. H., & Connors, G. J. (2004–2005). Screening for alcohol problems: What makes a test effective? Alcohol Research & Health, 28(1), 5–16. (See attachment)
Screening for Alcohol Problems
What Makes a Test Effective?
Scott H. Stewart, M.D., and Gerard J. Connors, Ph.D.
Screening tests are useful in a variety of settings and contexts, but not all disorders are amenable to screening. Alcohol use disorders (AUDs) and other drinking problems are a major cause of morbidity and mortality and are prevalent in the population; effective treatments are available, and patient outcome can be improved by early detection and intervention. Therefore, the use of screening tests to identify people with or at risk for AUDs can be beneficial. The characteristics of screening tests that influence their usefulness in clinical settings include their validity, sensitivity, and specificity. Appropriately conducted screening tests can help clinicians better predict the probability that individual patients do or do not have a given disorder. This is accomplished by qualitatively or quantitatively estimating variables such as positive and negative predictive values of screening in a population, and by determining the probability that a given person has a certain disorder based on his or her screening results. KEY WORDS: AOD (alcohol and other drug) use screening method; identification and screening for AODD (alcohol and other drug disorders); risk assessment; specificity of measurement; sensitivity of measurement; predictive validity; Alcohol Use Disorders Identification Test (AUDIT)
T he term “screening” refers to the confirm whether or not they have the application of a test to members disorder. When a screening test indicates SCOTT H. STEWART, M.D., is an assistant of a population (e.g., all patients that a patient may have an AUD or professor in the Department of Medicine,
in a physician’s practice) to estimate their other drinking problem, the clinician School of Medicine and Biomedical probability of having a specific disorder, might initiate a brief intervention and Sciences at the State University of New such as an alcohol use disorder (AUD) arrange for clinical followup, which York at Buffalo, Buffalo, New York. (i.e., alcohol abuse or alcohol depen- would include a more extensive diag dence). (For a definition of AUDs and nostic evaluation (Babor and Higgins- GERARD J. CONNORS, PH.D., is director other alcohol-related diagnoses, see the Biddle 2001). and a senior research scientist at the sidebar “Definitions of Alcohol-Related Regardless of the context in which Research Institute on Addictions, State Disorders.”) Screening is not the same screening tests are administered and University of New York at Buffalo, as diagnostic testing, which serves to the subsequent responses, it is impor- Buffalo, New York. establish a definite diagnosis of a disor- tant to have an appreciation of the der; screening is used to identify people strengths and limitations of screening Dr. Stewart gratefully acknowledges career who are likely to have the disorder. These tests. Accordingly, the main purpose of development support from the National people are often advised to undergo more this article is to review the characteris- Institute on Alcohol Abuse and Alcoholism detailed diagnostic testing to definitively tics of screening tests that influence (NIAAA) through grant K23–AA–014188.
Vol. 28, No. 1, 2004/2005 5
exist, as defined in two disease classification systems—
pattern of alcohol use leading to clinically significant
criteria for alcohol dependence in the past.
Alcohol dependence is defined as a
time in the same 12-month period:
of the same amount of alcohol.
symptoms.
longer period than was intended.
Alcohol dependence may include physiological
classified as being without physiological dependence.
is defined as a pattern of alcohol use that is causing damage
A variety of terms are used in the scientific literature to describe alcohol use disorders (AUDs) and other condi tions characterized by excessive alcohol consumption. AUDs are disorders for which specific diagnostic criteria
the Diagnostic and Statistical Manual of Mental Disorders (DSM), devised by the American Psychiatric Association (APA), and the International Classification of Diseases (ICD), by the World Health Organization (WHO).
DSM Criteria
The most recent version of the DSM, the DSM–IV–TR (APA 2000), includes two AUDs, alcohol abuse and alcohol dependence, which have the following diagnostic criteria:
Alcohol Abuse. Alcohol abuse is defined as a maladaptive
impairment or distress, as manifested by the occurrence of one (or more) of the following within a 12-month period:
• Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household).
• Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol).
• Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct).
• Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about intoxication, physical fights).
In addition, the patient must have never met the
Alcohol Dependence. maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by the occurrence of three (or more) of the following at any
• Tolerance, as defined by either of the following:
– A need for increased amounts of alcohol to achieve intoxication or the desired effect.
– Markedly diminished effect with continued use
• Withdrawal, as manifested by either of the following:
– The characteristic withdrawal syndrome.
– Use of alcohol to relieve or avoid withdrawal
• Drinking alcohol often in larger amounts or over a
• A persistent desire or unsuccessful efforts to cut down or control alcohol use.
• A great deal of time spent in activities necessary to obtain alcohol, use it, or recover from its effects.
• Giving up or reducing important social, occupa tional, or recreational activities because of alcohol use.
• Continued alcohol use despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
dependence if there is evidence of tolerance or withdrawal. If neither of these is present, alcohol dependence is
ICD Criteria
The most recent version of the ICD, ICD–10 (World Health Organization 1993), distinguishes between harm ful use and alcohol dependence syndrome. Harmful use
to health. The damage may be physical (e.g., hepatitis following long-term alcohol use) or mental (e.g., depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social
Definitions of Alcohol-Related Disorders
Alcohol Research & Health 6
Screening for Alcohol Problems
harmful use.
within a 12-month period:
alcohol.
longer period than intended.
drawal symptoms.
effect.
use of the same amount of alcohol.
harm.
ICD–10.
These terms can differ in their meanings and generally
American Psychiatric Association (APA). Diagnostic and Statistical Manual Washington, DC: APA,
2000.
World Health Organization (WHO). International Statistical Classification Geneva,
Switzerland: WHO, 1993.
consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of
The ICD criteria for alcohol dependence syndrome are very similar to those for alcohol dependence in the DSM–IV–TR. They specify that three or more of the following manifestations should have occurred together for at least 1 month or, if persisting for periods of less than 1 month, should have occurred together repeatedly
• A strong desire or sense of compulsion to consume
• Impaired capacity to control drinking in terms of its onset, termination, or levels of use, as evidenced by either of the following:
– Alcohol often taken in larger amounts or over a
– A persistent desire or unsuccessful efforts to reduce or control alcohol use.
• A physiological withdrawal state when alcohol is reduced or ceased, as evidenced by either of the following:
– The characteristic withdrawal syndrome for alcohol.
– Use of the same (or closely related) substance with the intention of relieving or avoiding with
• Evidence of tolerance to the effects of alcohol, such that one of the following occurs:
– A need for significantly increased amounts of alcohol to achieve intoxication or the desired
– A markedly diminished effect with continued
• Preoccupation with alcohol, as manifested by one of the following:
– Giving up or reducing important alternative pleasures or interests because of drinking.
– Spending a great deal of time in activities necessary to obtain or consume alcohol, or to recover from its effects.
• Persistent alcohol use despite clear evidence of harmful consequences, as evidenced by continued use when the person is actually aware, or may be expected to be aware, of the nature and extent of
In addition to the diagnosis of alcohol dependence, the World Health Organization also uses the term “haz ardous use,” which describes a pattern of substance use that increases the risk of harmful consequences for the user. These may include not only physical and mental health consequences but also social consequences. In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance but do not meet the criteria for a current disorder in the drinker. However, the term is not a diagnostic term in the
Other Terms Used
In addition to these specific diagnostic terms, various other terms are used in the literature, such as problem drinking, at-risk drinking, and problematic drinking.
are defined in the context of the specific study.
—Scott H. Stewart and Gerard J. Connors
References
of Mental Disorders. Fourth Edition, Text Revision.
of Diseases and Related Health Problems. Tenth Revision.
Vol. 28, No. 1, 2004/2005 7
their usefulness in clinical settings. This includes their validity, sensitivity, and specificity. In addition, the article dis cusses methods to quantify the likeli hood that a patient with a given screen ing result actually has the disorder (i.e., the postscreen probability). A review of different screening tests, particularly those that can be used in specific settings or with special populations, is beyond the scope of this article. The accompa nying table summarizes the features of some of the most commonly used screening instruments. Additional screening tools and their characteristics have been reviewed by Connors and Volk (2003) and are described in the other articles in this issue and the companion issue of Alcohol Research & Health.
What Disorders Are Amenable to Screening?
Not all disorders are suitable for screening; in fact, for certain disorders, screening tests may not be helpful or desirable. The main goal of screening is to identify patients at risk for a given disorder or at early stages of the disorder, so that they can begin to receive effective treatment and avoid or ameliorate the morbidity and mortality associated with the disor der. Consequently, disorders should have the following characteristics to be considered suitable for screening:
• They should be a cause of substantial morbidity or mortality.
• Effective treatment should be available that leads to a measurable improvement in morbidity and mor tality compared with no treatment.
• Early treatment initiated after a positive screening result should lead to a better outcome than treatment which is initiated later in the disease process, when the disease has pro duced obvious symptoms that have led to a diagnosis. For example, in a general medical setting, patients should have better outcomes if an intervention is initiated after a
screening test, such as the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al. 2001), suggests a pattern of “harmful drinking” than if a diagnosis is made and intervention started after the patient already has devel oped a more severe condition, such as alcoholic liver disease.
• The disorder should be relatively common because, all else being equal, screening for prevalent disorders is more cost-effective than screening for rare disorders.
AUDs and other drinking problems generally fit these criteria. They are a major cause of morbidity and mortality (NIAAA 2000), are prevalent in the population (NIAAA 2003), and effective treatments are available (Saitz 2005). In addition, because AUDs may have an acute presentation (e.g., alcohol-related trauma or gastrointestinal bleeding) or
result in long-term adverse consequences (e.g., liver disease) patients benefit from early detection and intervention. Finally, many people with AUDs never are diagnosed correctly. The next sections therefore will explore the characteristics screening tests must possess in order to be useful and effective.
Characteristics of Screening Tests Affecting Their Usefulness
Screening tests are designed to be used with members of large populations who have no obvious signs of a particular disease or disorder. For detecting AUDs and other alcohol-related problems, screening may involve the use of biological markers (e.g., liver tests or measurement of a compound called carbohydrate- deficient transferrin) (see Allen et al. 2003) or self-report questionnaires (e.g., the AUDIT, CAGE, and others).
Common Alcohol Screening Instruments in Medical Settings*
Population to Number of Items Time to Administer Measure Be Screened (Subscales) (Minutes)
Alcohol Use Adults 10 (3) 2 Disorders Identification Test (AUDIT)
CAGE Adults and 4 <1 Questionnaire adolescents > 16 years
Michigan 25 8 Alcoholism adolescents Screening Test (MAST)
Self- Adults 35 (2) 5 Administered Alcoholism Screening Test (SAAST)
* Briefer versions of some of these screening instruments (e.g., the MAST and SAAST) also have been tested.
SOURCE: National Institute on Alcohol Abuse and Alcoholism (NIAAA). Assessing Alcohol Problems: A Guide for Clinicians and Researchers, 2d ed. NIH Pub. No. 03–3745. Washington, DC: U.S. Dept. of Health and Human Services, Public Health Service, 2003.
Adults and
Alcohol Research & Health 8
Screening for Alcohol Problems
Because screening large numbers of people comes at a cost, the screening test should be considered beneficial from the perspective of the society in which it is applied. This means that the test either saves more resources than it utilizes or that the benefits resulting from the screen are perceived to outweigh the cost. Cost-effectiveness is thus determined by factors such as the disease character istics discussed above, the direct costs of the screening test, the safety of the test, and the validity of the screening test. Validity refers to the screening test’s ability to distinguish those at greater risk for a disorder from those at lower risk. In the development of screening tests, validity is quantified by comparing screening results with a gold standard for diagnosis.
Validity and the Gold Standard
