Screening for Underage Drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Alcohol Use Disorder in Rural Primary Care Practice


      To examine the National Institute on Alcohol Abuse and Alcoholism Youth Guide alcohol frequency screening thresholds when applied to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnostic criteria, and to describe alcohol use patterns and alcohol use disorder (AUD) characteristics in rural youth from primary care settings.

      Study design

      Adolescents (n = 1193; ages 12 through 20 years) visiting their primary care practitioner for outpatient visits in six rural primary care clinics were assessed prior to their practitioner visit. A tablet computer collected youth self-report of past-year frequency and quantity of alcohol use and DSM-5 AUD symptoms. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined.


      For early adolescents (ages 12 through 14 years), 1.9% met DSM-5 criteria for past-year AUD and ≥3 days with alcohol use in the past year yielded a screen for DSM-5 with optimal psychometric properties (sensitivity: 89%; specificity: 95%; PPV: 37%; NPV: 100%). For middle adolescents (ages 15 through 17 years), 9.5% met DSM-5 AUD criteria, and ≥3 past year drinking days showed optimal screening results (sensitivity: 91%; specificity: 89%; PPV: 50%; NPV: 99%). For late adolescents (ages 18 through 20 years), 10.0% met DSM-5 AUD criteria, and ≥12 past year drinking days showed optimal screening results (sensitivity: 92%; specificity: 75%; PPV: 31%; NPV: 99%). The age stratified National Institute on Alcohol Abuse and Alcoholism frequency thresholds also produced effective results.


      In rural primary care clinics, 10% of youth over age 14 years had a past-year DSM-5 AUD. These at-risk adolescents can be identified with a single question on alcohol use frequency.



      AUD (Alcohol use disorder), CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition), FN (False negative), FP (False positive), NIAAA (National Institute on Alcohol Abuse and Alcoholism), NPV (Negative predictive value), PCP (Primary care practitioner), PPV (Positive predictive value), TN (True negative), TP (True positive)
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        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Results from the 2013 National Survey on Drug Use and Health: Summary of national findings.
        (NSDUH Series H-48. HHS Publication No. (SMA) 14-4863) Substance Abuse and Mental Health Services Administration, Rockville, MD2014
        • Miech R.A.
        • Johnston L.D.
        • O'Malley P.M.
        • Bachman J.G.
        • Schulenberg J.E.
        Monitoring the Future: National survey results on drug use, 1975-2014. Volume I: Secondary school students.
        Institute for Social Research, the University of Michigan, Ann Arbor2015
        • Department of Health and Human Services
        The Surgeon General's Call to Action To Prevent and Reduce Underage Drinking.
        Department of Health and Human Services, Office of the Surgeon General, 2007 (Accessed October 1, 2009)
        • Levy S.J.
        • Kokotailo P.K.
        • Committee on Substance Abuse
        Substance use screening, brief intervention, and referral to treatment for pediatricians.
        Pediatrics. 2011; 128: e1330-e1340
        • National Institute on Alcohol Abuse and Alcoholism
        Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide.
        (NIH publication 11-7805) National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD2011
        • Fairbrother G.
        • Scheinmann R.
        • Osthimer B.
        • Dutton M.J.
        • Newell K.A.
        • Fuld J.
        • et al.
        Factors that influence adolescent reports of counseling by physicians on risky behavior.
        J Adolesc Health. 2005; 37: 467-476
        • Gordon A.J.
        • Ettaro L.
        • Rodriguez K.L.
        • Mocik J.
        • Clark D.B.
        Provider, patient, and family perspectives of adolescent alcohol use and treatment in rural settings.
        J Rural Health. 2011; 27: 81-90
        • Millstein S.G.
        • Marcell A.V.
        Screening and counseling for adolescent alcohol use among primary care physicians in the United States.
        Pediatrics. 2003; 111: 114-122
        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        The NSDUH Report: Underage drinking in rural areas.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2004 (Accessed February 3, 2015)
        • Clark D.B.
        • Gordon A.J.
        • Ettaro L.E.
        • Owens J.M.
        • Moss H.B.
        Screening and brief interventions with underage drinkers.
        Mayo Clin Proc. 2010; 85: 380-391
        • Knight J.R.
        • Sherritt L.
        • Shrier L.A.
        • Harris S.K.
        • Chang G.
        Validity of the CRAFFT substance abuse screening test among general adolescent clinic patients.
        Arch Pediatr Adolesc Med. 2002; 156: 607-614
        • Cook R.L.
        • Chung T.
        • Kelly T.M.
        • Clark D.B.
        Alcohol screening in young persons attending a sexually transmitted disease clinic: comparisons of AUDIT, CRAFFT, and CAGE instruments.
        J Gen Intern Med. 2005; 20: 1-6
        • Levy S.
        • Weiss R.
        • Sherritt L.
        • Ziemnik R.
        • Spalding A.
        • Van Hook S.
        • et al.
        An electronic screen for triaging adolescent substance use by risk levels.
        JAMA Pediatr. 2014; 168: 822-828
        • Clark D.B.
        • Chung T.
        • Martin C.S.
        Alcohol use frequency as a screen for alcohol use disorders in adolescents.
        Int J Adolesc Med Health. 2006; 18: 183-189
        • Chung T.
        • Smith G.T.
        • Donovan J.E.
        • Windle M.
        • Faden V.B.
        • Chen C.M.
        • et al.
        Drinking frequency as a brief screen for adolescent alcohol problems.
        Pediatrics. 2012; 129: 1-8
        • Knight J.R.
        • Harris S.K.
        • Sherritt L.
        • Van Hook S.
        • Lawrence N.
        • Brooks T.
        • et al.
        Adolescents' preferences for substance abuse screening in primary care practice.
        Subst Abus. 2007; 28: 107-117
        • Gregor M.A.
        • Shope J.T.
        • Blow F.C.
        • Maio R.F.
        • Weber J.E.
        • Nypaver M.M.
        Feasibility of using an interactive laptop program in the emergency department to prevent alcohol misuse among adolescents.
        Ann Emerg Med. 2003; 42: 276-284
        • Maio R.F.
        • Shope J.T.
        • Blow F.C.
        • Gregor M.A.
        • Zakrajsek J.S.
        • Weber J.E.
        • et al.
        A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents.
        Ann Emerg Med. 2005; 45: 420-429
        • Donovan J.E.
        Estimated blood alcohol concentrations for child and adolescent drinking and their implications for screening instruments.
        Pediatrics. 2009; 123: e975-e981
        • Casper R.
        • Penne M.
        Assessment of the computer-assisted instrument.
        (DHHS Publication 03-3768)in: Gfroerer J. Eyerman J. Chromy J. Redesigning an Ongoing National Household Survey: Methodological Issues. SAMHSA, Office of Applied Statistics, Rockville, MD2002
        • Harford T.C.
        • Grant B.F.
        • Yi H.Y.
        • Chen C.M.
        Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: Results from the 2001 National Household Survey on Drug Abuse.
        Alcohol Clin Exp Res. 2005; 29: 810-828
        • Winters K.C.
        • Lee C.S.
        Likelihood of developing an alcohol and cannabis use disorder during youth: Association with recent use and age.
        Drug Alcohol Depend. 2008; 92: 239-247
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        5th ed. American Psychiatric Association, Washington, DC2013
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        4th ed. American Psychiatric Association, Washington, DC1994
        • Grimes D.A.
        • Schultz K.F.
        Uses and abuses of screening tests.
        Lancet. 2002; 359: 881-884
        • Chung T.
        • Martin C.S.
        What were they thinking? Adolescents' interpretations of DSM-IV alcohol dependence symptom queries and implications for diagnostic validity.
        Drug Alcohol Depend. 2005; 80: 191-200
        • Chung T.
        • Colby S.M.
        • O'Leary T.A.
        • Barnett N.P.
        • Monti P.M.
        Screening for cannabis use disorders in an adolescent emergency department sample.
        Drug Alcohol Depend. 2003; 70: 177-186
        • Clark D.B.
        • Moss H.B.
        Providing alcohol-related screening and brief interventions to adolescents through health care systems: obstacles and solutions.
        PLoS Med. 2010; 7: 1-4