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. Author manuscript; available in PMC: 2021 Mar 15.
Published in final edited form as: J Soc Work Pract Addict. 2020 Jul 16;20(3):222–229. doi: 10.1080/1533256X.2020.1793069

Using the NIAAA Brief Alcohol Screener in Social Work Practice for Selected Prevention Targeting Youth

JONATHAN G TUBMAN 1, ALAN MECA 2, SETH J SCHWARTZ 3, TIMOTHY REGAN 4
PMCID: PMC7959007  NIHMSID: NIHMS1610842  PMID: 33727895

Abstract

This article discusses the use of brief screeners in social work practice to identity adolescents in need of selected interventions for alcohol and other drug use problems. Brief screeners can increase access to alcohol or other drug intervention services and promote the diffusion of evidence-based interventions to underserved communities when integrated in Screening, Brief Intervention and Referral to Treatment (SBIRT) initiatives. The two-item NIAAA Brief Alcohol Use Screener is discussed as a developmentally-tailored assessment tool that can be integrated into SBIRT in social work practice to improve detection of early-stage alcohol problems among adolescents who lack routine access to preventative health care. The use of brief, empirically-supported alcohol screeners in trainings for social work students and new professionals can enhance their preparation and competence to offer child and adolescent clients appropriate selected intervention options to reduce harms associated with underage alcohol use.

Keywords: Adolescents, alcohol screener, assessment, selected prevention, social work practice

Underage alcohol use continues to be a major threat to public health among adolescents and emerging adults in the United States (Ryan, Kokotailo, & the AAP Committee on Substance Use and Prevention, 2019). While national surveys such as Monitoring the Future (e.g., Miech et al., 2019) show recent trends of decreases in 30-day prevalence rates for underage alcohol use and drunkenness, rates in 2018 for binge alcohol use during the past two weeks (i.e., 5 or more standard drinks in a row) remain unacceptably high among 8th (3.7%), 10th (8.7%) and 12th (13.8%) grade students. Heavy episodic alcohol use by adolescents, alone or in combination with other substances, is a significant risk factor for multiple forms of preventable morbidity or mortality, in addition to accelerated development of alcohol and other substance use disorders (Patrick & Schulenberg, 2014). The American Academic of Pediatrics (AAP) released a recent policy statement that highlighted the negative impacts of underage alcohol use, including effects on the neurobiology and neuroplasticity of the developing brain, the emergence of psychiatric disorders, suicide attempts, unintended sexual activity, as well as accidental injuries and deaths. Among other recommendations, the policy statement called for early and consistent alcohol screening among children and adolescents to improve specific health outcomes (Quigley and the Committee on Substance Use and Prevention, 2019).

The use of alcohol screening to identify adults manifesting serious alcohol use problems and alcohol use disorders (AUDs) and refer them to treatment has a decades long history associated with the twin goals of (a) reducing the public health impact of AUDs and (b) expanding the population of adults participating in alcohol treatment at national and global levels (Institute of Medicine, 1990; Saunders & Aasland, 1987). The evolution of alcohol screening into a more comprehensive and integrated paradigm, i.e., Screening, Brief Intervention and Referral to Treatment (SBIRT), is based in part on the development of valid and reliable assessment tools for detecting cases of AUDs and the rigorous evaluation of cost-effective brief interventions for alcohol use problems and disorders (Agerwala & McCance-Katz, 2012; Babor & Robaina, 2016; Babor et al., 2007). Progress in the development of these scientific and clinical service delivery activities align well with the Institute of Medicine (IOM) prevention framework (Springer & Phillips, 2007) for the dissemination of effective, evidence-based practices to reduce the negative consequences of alcohol and other substance use disorders. In the present practice-related brief report, we discuss the integration of valid, reliable and developmentally-tailored brief alcohol screeners into SBIRT training initiatives in schools of social work to enhance social workers’ training and practice regarding selected alcohol prevention strategies, specifically targeting groups of vulnerable adolescents (Babor, Robaina, Noel, & Ritson, 2016).

Social Work Practice and the Dissemination of SBIRT to Underserved Populations

The use of SBIRT with adults is an empirically-supported intervention strategy for addressing substance use disorders. However, evidence supporting the efficacy of SBIRT among adolescents is more mixed and has been the focus of advocacy among prevention specialists for additional research and expanded service provision (McCarty, Levy, & Harris, 2019). Direct social work practice to underserved adolescents is an appropriate domain for prioritizing the continued expansion of SBIRT to address clients’ alcohol and other drug use problems, in light of the prominent historical roles played by social workers to deliver substance use treatment services to disadvantaged populations (Galvani, 2015). In addition, social work education, as preparation for direct practice, is a critical point in professional development to integrate evidence-based innovations to ensure competence in practice skills among service providers and provide effective services for addressing clients’ alcohol and other drug use problems (Wells, Kristman-Valente, Peavy, & Jackson, 2013).

The majority of adolescents and young adults who need empirically-supported substance use interventions and treatments cannot access these services due to a range of individual (beliefs about treatment providers, co-occurring disorders), provider-related (implicit bias, training quality) or structural barriers (service availability or organization) (Priester et al., 2016). To address these long-term service gaps, early intervention strategies have been promoted, including the SBIRT paradigm (Bray, Del Boca, McRee, Hayashi, & Babor, 2017). This strategy for diffusing substance use interventions into underserved communities (e.g., via brief motivational interventions) has been implemented in a variety of settings with documented effectiveness and sustainability (Ogden, Vinjamuri, & Kahn, 2016). Front-line service providers, including social workers, play key roles in successful SBIRT implementations and increasingly, SBIRT training is a component of social work education (e.g., Carlson et al., 2017; Putney, O’Brien, Collin, & Levine, 2017).

Training in SBIRT is fundamentally about learning to engage clients to screen for a modifiable behavior and collaborating with them to construct action plans to mitigate potential harm (APHA, 2008; CDC, 2014). Engagement begins with establishing rapport, framing the screening exercise, as well as delivering screener items in ways that promote easy conversation. After delivering the screener questions, client engagement is promoted through intentional, motivational elements in the conversation (e.g., praise for not engaging in risk behaviors, tailored feedback and brief advice, motivational interviewing exercises). Flexible delivery formats and tailored content for screener items may increase clients’ access to treatment services through improved client disclosure and subsequent connection of clients to appropriate intervention or treatment options.

Reducing barriers to SBIRT implementation is one strategy for enhancing diffusion of brief alcohol or drug use interventions into underserved communities (Babor, Del Boca, & Bray, 2017). In primary health care settings, multiple barriers to SBIRT (e.g., lack of time, specific training or dedicated resources) may hamper effective implementation (Van Hook et al., 2007). To reach clients who cannot obtain preventative health care or who do not trust health care systems, social workers implement SBIRT in alternate venues (schools, community organizations) or in a wide range of student field placements (Senreich, Ogden, & Greenberg, 2017). In addition, use of very brief, valid and reliable screeners can facilitate the implementation of SBIRT in social work training or practice by reducing interviewing burden to new professionals and clients alike (e.g., McNeeley et al., 2015). Tailored, developmentally-appropriate brief alcohol screeners are a training and practice innovation in that they promote SBIRT diffusion, improve assessment of early-stage alcohol or other drug use problems among youth compared to other widely used screeners that capture more severe alcohol or drug use problems (e.g., the CRAFFT, AUDIT, CAGE or MAST) and can be used to more efficiently choose appropriate selected intervention options for clients.

The NIAAA Brief Alcohol Use Screener: Item Delivery and Assessment of Alcohol Risk

Many existing brief alcohol use screeners reliably identify adult clients manifesting alcohol dependence symptoms. To address a lack of brief screeners for underage alcohol use and early-stage alcohol use problems, the National Institute of Alcohol Abuse and Alcoholism (NIAAA) and the American Academy of Pediatrics (AAP) developed a brief, two-item screener to assess alcohol use among children and adolescents and their peers (NIAAA, 2011). The NIAAA Brief Alcohol Use Screener was developed using national survey data and prospective longitudinal studies tracking both normative transitions in alcohol use and the development of AUDs. Some advantages for social work training and practice of this brief screener include: evidence-based development; tailored content for children and adolescents ages 9 to 18 years; and age-appropriate item delivery, response formats and criteria for client alcohol risk classification.

The NIAAA Brief Alcohol Use Screener consists of two items, asking about adolescents’ alcohol use and peers’ alcohol use during the last year. The items are summarized by developmental level in Table 1. The wording and the delivery of the items varies by the developmental level of child or adolescent respondents. For example, the items delivered to elementary school students ask respondents if they (a) have any friends who drank alcohol during the past year or (b) ever had more than a few sips of beer, wine, or any drink containing alcohol. In contrast, high school students are asked during the past year (a) on how many days they had more than a few sips of beer, wine, or any drink containing alcohol and (b) how many drinks their friends usually drink on a drinking occasion. Elementary and middle school students are asked items about peers’ alcohol use first to facilitate an easy transition to a discussion of their own alcohol use behaviors.

Table 1.

Items of NIAAA Brief Alcohol Use Screener by Developmental Level of Respondents

Developmental Level Screener Item 1 Screener Item 2
Elementary School (ages 9–11) Do you have any friends who drank beer, wine or any drink containing alcohol in the past year? How about you – have you ever had more than a few sips of beer, wine or any drink containing alcohol?
Middle School (ages 12–14) Do you have any friends who drank beer, wine or any drink containing alcohol in the past year? How about you – in the past year, on how many days have you had more than a few sips of beer, wine or any drink containing alcohol?
High School (ages 15–18) In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol? If your friends drink, how many drinks do they usually drink on an occasion?
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Note. Additional information about the items and their delivery can be found in NIAAA (2011).

Adolescents’ levels of peer alcohol use are categorized as either “No Peer Risk” (i.e., no alcohol-using friends) or “Heightened Concern” (i.e., one or more alcohol-using friends). Adolescents’ levels of self-reported alcohol use are categorized into one of four levels: No Risk, Low Risk, Moderate Risk, or High Risk, based on an adolescent’s age and alcohol use frequency. For respondents ages 11 and under, any alcohol use is defined as high risk. For respondents between ages 12 and 15, a report of 6 or more alcohol use days in the past year is defined as high risk, and 1 to 5 use days is defined as moderate risk. For respondents ages 16 or 17, 1 to 5 alcohol use days is defined as low risk. Moderate risk is defined as 6 to 11 alcohol use days for age 16 or 6 to 23 alcohol use days for age 17. Alcohol risk criteria (i.e., cut-offs for numbers of alcohol use days at different ages) are provided (on p. 10) in the User’s Guide for the NIAAA Brief Alcohol Use Screener (NIAAA, 2011).

The NIAAA Brief Alcohol Use Screener: Empirical Support

Although the NIAAA Brief Alcohol Use Screener was developed several years ago, only recently have the reliability and validity of the cut-points of this screening tool for alcohol use problems and AUDs been verified empirically (e.g., Parast, Meredith, Stein, Shadel & D’Amico, 2018). In addition, a large multi-site evaluation of the screener with adolescents recruited from 16 pediatric emergency departments found that moderate or high alcohol risk classifications showed the highest combined sensitivity and specificity for assignment of an AUD diagnosis (Spirito et al., 2016). Longitudinal analyses of the same study support the predictive validity of the screener for the identification of adolescents at risk for future development of AUDs (Linakis et al., 2019). This brief, developmentally-informed screener for underage alcohol use is an excellent tool for the identification of adolescents with current AUDs or at high risk for developing AUDs, and its positive implementation features facilitate screening for unhealthy alcohol use by social work students and new social work professionals (US Preventative Services Task Force, 2018).

Our own school-based study documented the screener’s ability to detect adolescents at greater risk for early-stage alcohol use problems (e.g., greater numbers of drinking days, higher numbers of drinks per drinking day, greater number of days drunk) in a predominantly minority sample of middle and high school students (Meca et al., 2017). Additional validation analyses documented that screener scores generalized to a range of other developmentally normative problem behaviors among adolescents, including externalizing behaviors and health risk behaviors. For example, higher Self Alcohol Risk scores (i.e., client past-year drinking days) were significantly associated with measures of rule-breaking behavior, overt aggressive behavior and attributions of the legitimacy of aggressive behavior. In addition, Peer Alcohol Risk scores (i.e., the client has friends who drink) were significantly associated with scores for aggressive behavior, rule-breaking behavior and experiences of being bullied (Tubman, Meca, Schwartz & Egbert, 2018). With regard to health risk behaviors, Self Alcohol Risk scores were significantly associated with riding with an impaired driver, cigarette use, marijuana use and unplanned sex. Peer Alcohol Risk scores were significantly associated with riding with an impaired driver, cigarette use, marijuana use, unplanned sex and unprotected intercourse (Tubman et al., 2019). These findings highlight the usefulness of the NIAAA Brief Alcohol Use Screener for social work training and practice, in that adolescents who screen positive for higher alcohol risk are also significantly more likely to report multiple problem behaviors that may be addressed via additional assessment and intervention services.

Implications for Social Work Education and Practice

The NIAAA Brief Alcohol Use Screener was developed to promote universal alcohol screening in pediatricians’ offices across the United States. This is an inadequate single-focus strategy for addressing persistent minority health disparities, since children from disenfranchised minority groups are less likely to access routine preventive healthcare or to have access to high quality alcohol or other drug intervention or treatment services. Therefore, it is critical that social work students and new social work professionals be trained to adopt and use evidence-based, developmentally-informed screening tools to identify accurately youth reporting early-stage alcohol problems, because they are at elevated risk for a host of maladaptive outcomes including AUDs, premature school separation, police contact and health risk behaviors. Links between underage alcohol use and multiple negative developmental outcomes provide a strong rationale for adoption of the NIAAA Brief Alcohol Use Screener, alone or embedded in broader psychosocial assessments, to provide training opportunities for social work students to probe for additional alcohol-related problems and consider the most appropriate selected intervention options available.

The integration of brief, valid and reliable, developmentally-tailored alcohol screeners into social work training efforts for evidence-based, selected intervention strategies can achieve important goals including: improved assessment of early-stage alcohol problems; more efficient program implementation; and expanded access to SBIRT for at-risk youth. In addition, this social work training innovation is congruent with the core values of social workers. Specifically, the integration of developmentally-tailored assessment tools like the NIAAA Brief Alcohol Use Screener into SBIRT efforts supports the principles of service by more accurately assessing child and adolescent clients manifesting early-stage alcohol use problems and social justice by expanding access to SBIRT among vulnerable, underserved youth. The developmentally-informed tailoring of the two items of this screener will allow the diffusion of this assessment tool to marginalized adolescent populations, the early detection of underage alcohol use and potential reduction of negative consequences (e.g., unintentional accidents, arrest). These are tangible social and public health benefits.

Social work students and new professionals using this screener will be better prepared to intervene with child and adolescent clients reporting underage alcohol use, regardless of setting. First, using the NIAAA Brief Alcohol Use Screener allows social workers to use two simple questions to classify adolescents at Lower, Moderate, or Highest risk for alcohol use problems. Next, social workers, regardless of setting, can provide an appropriate, guided brief intervention depending on the clients’ Alcohol Risk classification including: brief advice or written health recommendations (Lower risk), motivational interviewing (Moderate risk), or motivational interviewing plus referral for structured, targeted intervention (Higher risk; NIAAA, 2011). Using this two-step triage strategy empowers social work professionals to feel prepared to offer to child and adolescent clients an appropriate evidence-based selected intervention option to reduce possible harms associated with underage alcohol use. Broader implementation of this screener in SBIRT training protocols in social work education could expand the numbers of underserved youth receiving treatment for substance use problems and reduce existing disparities in health and other developmental outcomes.

The NIAAA Brief Alcohol Use Screener provides guidance and resources for clinical and counseling professionals for the use of the two-item screener in practice settings. Therefore, this very brief, validated screener for underage alcohol use includes accessible materials that can be integrated in existing substance use disorder coursework in MSW training programs (Belfiore, Blinka, BrintzenhofeSzoc, & Shields, 2017; Gotham, Knopf-Amelung, Krom, Stilen, & Kohnle, 2015). This tool has substantial promise for improving the health of adolescents at high risk for multiple negative developmental outcomes and it is a valuable resource in both social work education and the practice of current social work professionals. Social workers play important roles in identifying youth who may be at risk for AUDs and negative developmental outcomes. Implementing the NIAAA Brief Alcohol Use Screener in training protocols provides an additional evidence-based tool for selected intervention that allows social workers to feel prepared and confident in their ability to address short- and long-term harms among child and adolescent clients displaying signs of alcohol use problems.

Contributor Information

JONATHAN G. TUBMAN, Department of Psychology, American University, Washington, DC, USA.

ALAN MECA, Department of Psychology, Old Dominion University, Norfolk, VA, USA.

SETH J. SCHWARTZ, Department of Public Health Sciences, University of Miami, Miami, FL, USA.

TIMOTHY REGAN, Department of Psychological & Brain Sciences, Texas A&M University, College Station, TX, USA.

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