5.2 Screening Purpose and Instrument Selection
Key Takeaways
- Screening detects possible problems and the need for further assessment; assessment is the deeper, ongoing process that informs diagnosis and treatment planning.
- Know the standardized instruments and their cutoffs: CAGE (4 items, +2), AUDIT (10 items, +8), DAST-10 (+3 some/+6 substantial), MAST (25 items, +5), CRAFFT (adolescents, +2).
- The ASI is a structured assessment interview across seven life domains; the SASSI uses subtle items to detect minimized or denied use.
- SBIRT (Screening, Brief Intervention, Referral to Treatment) is the public-health model that organizes how a positive screen leads to action.
Screening Versus Assessment
These two words are tested as a distinction. Screening is brief, often a few questions, and answers one yes/no-style question: is a substance-use, mental-health, trauma, medical, or safety concern likely enough to justify a closer look? A positive screen is a signal, not a diagnosis. Assessment is the broader, ongoing, in-depth process that gathers history, severity, strengths, and functioning to support a DSM-5-TR diagnosis, level-of-care placement, and treatment planning. A screen can be administered in minutes by minimally trained staff; a full assessment is a clinical activity requiring training and scope.
A positive screen is a reason to ask more, assess risk, consider collateral information with proper authorization, and document findings. A negative screen can also be incomplete if the client is intoxicated, frightened, cognitively impaired, satisfying a mandate, or simply not asked about the relevant substance.
The Standardized Instruments and Their Cutoffs
The ADC exam can name specific tools. Memorize what each screens for and the published cutoff, while remembering that a score alone never makes a diagnosis.
| Instrument | Items / Format | Screens For | Positive Cutoff |
|---|---|---|---|
| CAGE | 4 yes/no (Cut down, Annoyed, Guilty, Eye-opener) | Lifetime alcohol problems | 2 or more "yes" |
| AUDIT (WHO) | 10 items, 0-40 | Hazardous/harmful alcohol use | 8+ hazardous; 15+ likely dependence |
| AUDIT-C | First 3 AUDIT consumption items | Heavy drinking | ~4 men / 3 women |
| MAST | 25 yes/no items | Alcohol-use problems/dependence | 5+ probable; 4 suggestive |
| DAST-10 | 10 yes/no (drugs, not alcohol) | Drug-use problems | 1-2 low; 3-5 moderate; 6+ substantial |
| CRAFFT | 6 items (Car, Relax, Alone, Forget, Friends, Trouble) | Adolescent substance risk | 2 or more "yes" |
| SASSI | Face-valid + subtle scales | Likely SUD, including minimized use | Decision rules, not one cutoff |
| ASI | Structured interview, 7 domains | Severity/treatment needs (assessment) | 0-9 severity ratings per domain |
Key memory hooks: CAGE and CRAFFT both flag at a score of 2; CRAFFT is the adolescent counterpart, designed brief like CAGE but with six items (and a screening prefix asking about past-year use of alcohol, cannabis, and other substances). AUDIT is the WHO 10-item alcohol tool flagging hazardous drinking at 8. DAST mirrors the MAST format but targets drugs other than alcohol.
The Addiction Severity Index (ASI), developed by McLellan in 1981, is a 45-60 minute semi-structured assessment interview rating severity 0-9 across seven domains: medical, employment/support, alcohol, drug, legal, family/social, and psychiatric. The SASSI (Substance Abuse Subtle Screening Inventory, by Glenn Miller) uses indirect items so it can flag clients who deny or minimize use on face-valid questions.
SBIRT: From Screen to Action
SBIRT (Screening, Brief Intervention, and Referral to Treatment) is the SAMHSA-endorsed, evidence-based public-health model the exam expects you to recognize. It links a screen to the right next step in three parts:
- Screening quickly assesses severity and identifies the appropriate level of response (often AUDIT/AUDIT-C, DAST, or a single-item screen).
- Brief Intervention is one or more short (typically 5-15 minute) motivational conversations that raise insight and motivation, used for low-to-moderate risk. A common structure is FRAMES: Feedback on personal risk, emphasis on personal Responsibility for change, clear Advice to change, a Menu of options, Empathy, and support for Self-efficacy.
- Referral to Treatment connects higher-risk or likely-dependent clients to specialty assessment and care, ideally as a warm handoff.
SBIRT is widely delivered in primary care, emergency departments, schools, and community settings. On the exam, a low-risk drinker who screens positive usually warrants brief intervention, while a client showing dependence, withdrawal, or high-risk patterns warrants referral to treatment. Brief intervention is not the same as brief treatment: brief intervention is a one-to-several-session motivational conversation for risky-but-not-dependent use, whereas brief treatment is a short structured course of therapy for clients with a diagnosable disorder. Mixing these up is a classic distractor.
Instrument Selection and Ethical Use
Selection begins with the referral question. A detox intake, outpatient admission, probation referral, school concern, and primary-care warm handoff each need different depth. The counselor weighs age, culture, language, literacy, disability, intoxication, privacy, urgency, and whether the setting can respond to a positive result. The counselor uses only tools they are trained to administer, explains why a tool is used, scores it per agency policy, and avoids using a screen outside its intended purpose.
Common Exam Traps
- Picking the most famous tool regardless of the client. If the stem describes limited English proficiency, cognitive impairment, acute intoxication, or severe distress, the better answer adapts the process, arranges qualified interpretation, defers nonurgent screening, or completes a safety assessment first.
- Using an adult tool for an adolescent. A teen usually warrants the CRAFFT rather than the CAGE or MAST.
- Treating a score as a diagnosis. Integrate scores with interview data, observation, records, toxicology, and collateral information; document what the tool suggests and what follow-up is planned. Watch for stems with "initial screen," "possible indication," or "best next step," which point toward cautious interpretation.
On the CAGE and CRAFFT questionnaires, how many positive responses typically indicate the need for further assessment?
Which instrument is a structured interview that rates severity from 0 to 9 across seven life domains and is best classified as an assessment rather than a brief screen?
In the SBIRT model, what is the appropriate next step for a client whose screen suggests low-to-moderate risk rather than dependence?