Substance use and mental health disorders can create significant family, social, and health problems. However, they are preventable and treatable. Regular screenings can help identify substance use and mental health disorders early and help families access community resources quickly. This resource will help Head Start staff learn more about screening tools available to identify substance use disorders. It includes important considerations for choosing a screening tool and guidance for conversations with families.
The Importance of Screening
Head Start and Early Head Start programs use developmental and sensory screening to identify children’s health and developmental concerns early. Identifying concerns early allows staff to refer children for further evaluation.
Much like developmental and sensory screenings for children, screening tools are also available to help identify substance use and mental health disorders in adolescents and adults. Identifying these disorders early can help prevent and reduce the impact of substance use disorders in families.
The Benefits of Screening
Substance use and mental health disorders are common and can create significant family, social, and health problems. However, they are preventable and treatable. Regular screenings can help identify substance use and mental health disorders early and help families access community resources – including appropriate, evidence-based care – more quickly. Early identification can improve health and relationships as well as help provide safe and nurturing environments.
Before adopting screening practices for substance use disorders in your program, consider the following questions.
- Which screening tool works for your population? Is the screening tool available in the languages of families in your program? How long does the screening take to administer? Is the screening self-administered or staff-administered?
- Who will conduct the screening? What supports, training, and experience do staff need to conduct the screening?
- Who will provide reflective supervision of staff who will be conducting the screening?
- How will you ensure the process respects informed consent, health literacy, privacy, and confidentiality?
- Who will support screening implementation and follow-up?
- What will you do if there is a positive screening?
- Who will assist in making referrals and follow-up?
- How can you best use your mental health consultant to support screening implementation?
Follow these tips if you choose to screen families for substance use disorders in your program.
- Start the conversation in a reassuring and compassionate matter.
- Consider language such as, “Can I ask you about drug or alcohol use? This information can help us provide you with useful resources,” or “This information can help us to support you to have a healthy pregnancy.”
- Emphasize your commitment to supporting a healthy pregnancy and parenting experiences.
- Provide families with information about the confidentiality of their responses.
- If the screening tool identifies a risk of a possible substance use disorder, it is important to:
- Remain nonjudgmental.
- Be clear with family members that you know they want to be as healthy as possible for themselves and their children and they can reduce risks to their health by getting support and treatment.
- Help families access medical insurance and determine eligibility for local treatment options.
- Discuss possible treatment resource referrals. Ensure that you are familiar with treatment services in your area and provide an updated resource list or directory.
Consider the following resources that may support you in your conversations with families. These short videos and the Motivational Interview Viewers Guide provide examples of how to use Motivational Interviewing strategies in everyday conversations between Head Start and Early Head Start staff and families.
Sample Screening Tools
These screening tools are in the public domain and recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA).
The 4P’s screening tool can be used to begin conversations with a parent about drug and alcohol use. Ask questions tactfully and respectfully. First, ask the parent these four questions:
- Have you ever used drugs or alcohol during this pregnancy?
- Did either of your parents ever have a problem with alcohol or drugs?
- Does your partner have a problem with alcohol or drugs?
- Have you ever had a problem with alcohol or drugs in the past?
Then, evaluate the responses. An answer of “yes” to one or more questions should trigger further questioning or referral to additional assessments and resources.
The CAGE and CAGE Adapted to Include Drug Use (CAGE-AID) is one screening tool medical professionals use often to identify individuals likely to have substance use disorders. Administering the CAGE takes less than one minute, requires no training, and can be in written form or performed verbally. The CAGE includes these questions:
- Have you ever felt you should cut down on your drinking or drug use?
- Have people annoyed you by criticizing your drinking or drug use?
- Have you ever felt bad or guilty about your drinking or drug use?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
Asking just two questions can detect alcohol or other drug problems in nearly eight out of 10 young and middle-aged adults. These questions are easily integrated into other services such as mental health consultation.
Ask a parent these two questions:
- In the last year, have you ever drunk or used drugs more than you meant to?
- Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
One yes or more indicates a need for a more in-depth assessment.
The T-ACE Screening Tool for Alcohol was specifically developed for use with pregnant women. T-ACE stands for Tolerance, Annoyance, Cut-Down, and Eye-Opener. Ask these four questions:
- Tolerance: How many drinks does it take to make you high?
- Annoyance: Have people annoyed you by criticizing your drinking?
- Cut-Down: Have you ever felt like you ought to cut down on your drinking?
- Eye-Opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Scoring: For the first question, any woman who answers more than two drinks is scored 2 points. Each “yes” to the other three questions scores 1 point. A score of 2 or more is considered a positive screen, and the woman should be referred for further assessment.
Sokol, R. J., Martier, S. S., & Ager, J. W. (1989). The T-ACE questions: practical prenatal detection of risk-drinking. American journal of obstetrics and gynecology, 160(4), 863–870. https://doi.org/10.1016/0002-9378(89)90302-5
Unlike screening tools designed to detect risks related to use, the RAPS-4 QF attempts to identify patients who meet diagnostic criteria for alcohol dependence. Ask these questions:
- Remorse: During the last year have you had a feeling of guilt or remorse after drinking?
- Amnesia: During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
- Perform: During the last year have you failed to do what was normally expected from you because of drinking?
- Starter: Do you sometimes take a drink when you first get up in the morning?
- Quantity: During the last year have you had five or more drinks on at least one occasion?
- Frequency: During the last year did you drink as often as once a month?
The TWEAK is a five-item screen that detects high-risk drinking during pregnancy. Independent researchers have evaluated the TWEAK against other screens. Although the TWEAK tends to perform relatively well, other brief screens have been found to have superior sensitivity.
TWEAK(C) stands for Tolerance, Worried, Eye-Opener, Amnesia, Cut Down. Ask these questions:
- Tolerance: How many drinks can you “hold”?
- Worried: Have close friends or relatives worried or complained about your drinking in the past year?
- Eye-Opener: Do you sometimes take a drink in the morning when you first get up?
- Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
- (K) Cut Down: Do you sometimes feel the need to cut down on your drinking?
- Screening, Brief Intervention, and Referral to Treatment for Substance Use
- Intervening Early: Substance Use Disorders During Pregnancy.
We hope this information and the sample screening tools that SAMHSA recommends will be helpful to your programs. Please share this information with your Policy Council, your board, staff, and others.
National Centers:Health, Behavioral Health, and Safety
Last Updated: March 25, 2021