The situation has become even more problematic by the introduction of zero-tolerance policies, drug-testing programs, and locker searchers in the schools. These supposedly serve as deterrent and detective mechanisms and almost always have predetermined consequences. Zero-tolerance policies, introduced in 1994 to address weapons in schools, with Elementary and Secondary Education Act (ESEA) funding contingent on their enactment (Martin, 2000), quickly expanded to include a wide range of disciplinary issues such as drug use. As of 2001, 88% of schools across this country had zero tolerance policies for drugs, 87% for alcohol, and 79% for tobacco (CASA, 2001; ERIC, 2001), with most states treating minor or major incidents identically (e.g., in Maine, the policy was enforced for a high school girl who brought Tylenol to school for menstrual cramps [Rosenbaum, 2003]; in Georgia, an asthmatic child was barred by local school policy for carrying his asthma inhaler and died after a severe asthmatic attack while boarding a school bus [Reuters Health, 2002]). Rarely is an assessment and treatment referral a consequence. Instead, infractions are typically handled only by punitive measures such as suspension or expulsion, or referral to an alternative school (CASA, 2001; ERIC, 2001).

Drug testing of public school students who participate in athletics or other extracurricular activities has been introduced to deter use among the larger student body. It seems paradoxical that youth who display those protective factors shown in research studies to reduce the likelihood and severity of substance use among youth (e.g., extracurricular activities, school bonding; Hawkins, Catalano, & Miller, 1992) would be targeted for drug testing. However, parents want to be sure that their children attend drug-free schools and school systems are regularly chided by parents and community groups to “get tough on drugs,” not only while students are in school but also when they are participating in school-related activities after school or on the weekends.

In a large, multiyear national study, research ers from the University of Michigan's Institute for Social Research concluded that drug testing of public school students (conducted in approximately 19% of all U.S. secondary schools) did not deter use (Yamaguchi, Johnston, & O'Malley, 2003). At each of three grade levels (i.e., 8, 10, 12), there were identical prevalence and frequency rates of drug use over the 12 months prior to the examination in the schools with and without drug-testing programs. These data are critical in that the Supreme Court's split decision upholding the constitutionality of drug testing in schools was highly influenced by the notion that drug testing among public school students is a deterrent to use. Hence, the debate over a student's right to privacy and unreasonable and suspicionless searches continues.

Not only has school-based drug testing not been found to deter use, Chaloupka and Laixuthai (2002) found that it can result in an increase in alcohol use. Aware that alcohol is almost impossible to detect after 1 day (as are cocaine and heroin), students decreased their use of marijuana but increased their use of alcohol (Chaloupka & Laixuthai, 2002; Zeese, 2002). Consequently, there is concern that school-based drug testing could pose a number of unintended effects vis-a-vis switching to more dangerous forms of drugs to avoid detection. Finally, and again paradoxically, teens in schools that had drug-testing programs tended to view drugs as less risky and believed that drug testing must have been initiated because more students were using drugs, beliefs that have been consistently shown to lead to increases in using behaviors.

The second tier of the services system (i.e., agencies that focus on a specific problem area) often fares no better with respect to identification of the adolescent who uses, abuses, or is dependent upon substances. Since adolescent substance use disorders (SUD) are clinically complex, typically compromising numerous life domains (behavioral, mood, family, legal), it is not surprising that substance-abusing adolescents are prevalent in many different service systems. In one of the first studies to date, Aarons and colleagues (2001) found that 62% of youth in the juvenile justice system, 41% of youth in the mental health system, 24% of youth in the special-education system, and 19% of youth in

the child welfare system met criteria for a SUD. In each of these systems, adolescents had been assessed for some other disorder, illness, or problem behavior and were receiving some form of system-specific services (e.g., mental health services if in the mental health system, educational services if in the special education system). It is noteworthy that despite the high prevalence rates of SUD in these settings, most cases of SUD were not identified by staff in these systems. One must wonder whether and to what extent the unidentified SUD may have compromised the accuracy of the assessments for the targeted problems and the effects of the services that were provided.

It is unfortunate that those delivering health or social services as part of larger agencies or systems (e.g., hospital systems, mental health systems) rarely screen for alcohol and drug problems (Center for Substance Abuse Treatment [CSAT], 2000). There are several reasons for this. First, there has been little effort to train key personnel from these various systems (e.g., school nurses, probation officers, case workers) in the use of some of the proven substance abuse screening instruments (CSAT, 2000; NASADAD, 1998; SAMHSA, 1993). With respect to health-care practitioners, sizable portions of physicians feel ill equipped to discuss these topics with their adolescent patients (Karam-Hage, Nerenberg, & Brower, 2001). In a survey assessing medical residents' perception of substance abuse knowledge and assessment skills, only half felt that they were adequately prepared to identify, manage, or refer a substance-abusing adolescent (Siegal, Cole, & Eddy 2000; Steg, Mann, Schwartz, & Wise, 1992). Further, staffs from diverse service systems do not possess sufficient knowledge of disorders outside of their respective disciplines to adequately diagnose or comprehensively assess comorbid conditions (NASADAD, 1998, 1999). These problems are compounded by systems issues that dictate exclusion of each other's clients, confidentiality requirements that stifle collaboration, and the lack of bridges between systems of care that limit coordination of need- based services (NASADAD, 1998, 1999). These issues alone and in combination cause a number of multi-problem youth to fall through the cracks.

Second, and intimately connected to the first reason, is the lack of reimbursement for screening and early intervention activities. Few states currently reimburse adolescent screening efforts outside the specialty sector substance abuse treatment system and there are a number of payment restrictions for AOD screening and diagnostic assessments within primary care settings (Buck & Umland, 1997; Rivera, Tollefson, Tesh, & Gentilello, 2000; CSAT, 2001). Even if the services are reimbursed through insurance programs, roughly 4 million adolescents in this country are without any form of health insurance, with additional youth covered by plans that do not provide for preventive care or behavioral health treatments (Center for Adolescent Health and the Law, 2000). As in all other areas of health and social services, the only sure way of increasing the probability of clinically recommended practices is through reimbursement.

Third, the complex interrelationships between the parents' right to know about assessment and the legal protection of the adolescent's privacy and confidentiality can further complicate identification. Adolescents want their health issues to be kept private and want to receive certain services without their parents' or guardians' consent (Ford & English, 2002; Ford et al., 1997). Without these guarantees, adolescents will forego services (Ford, Bearman, & Moody, 1999; Klein, Wilson, McNulty, Kapphahn, & Collins, 1999) until their problems escalate to a point when they can no longer be ignored. Fortunately, as illustrated below, most states give youth the sole authority to consent to assessment and treatment for those conditions in which parental knowledge would curtail adolescent treatment seeking (e.g., STD testing, alcohol or drug use).

However, in some states that accept minor consent for services, (1) the physician has the discretion to notify the parent without the adolescent's consent (e.g., in Colorado, Oklahoma, and Louisiana [Colorado, 1995; Oklahoma, 1995; Louisiana, 1995]); and (2) parental involvement is required prior to the end of mental health or alcohol and drug treatment (Oregon; OAHHS, 2004). While statutes that give the adolescent the right to consent to treatment are vitally important, adolescents are not knowledgeable about what they can and cannot obtain without their parents' permission and there is movement to restore parental consent for all conditions (Boonstra & Nash, 2000; Cheng, Savageau et al., 1993; Ford et al., 1997; Marks, Malizio, Hoch, Brody, & Fisher, 1983). Mandated compliance with the Health Insurance Portability and Accountability Act (HIPPA) of 1996 may further complicate these issues. In section 164.502(g) of the Privacy Rule of December 2000, parents are generally able to access and control health information about their minor child. Consequently, they generally have access to all charts, medical records, etc., thereby affording them access to information their adolescent children may not want them to have. However, 164.502(g)(3)(ii) A&B states that if a state or other law permits a minor to obtain a particular health service without the consent of the parent, it is the minor and not the parent who has control over the information. If state or other applicable law is silent or unclear, service providers have the discretion to permit or prohibit parental access without interference from the Federal Privacy Rule.

Finally, critics of early identification argue that it unnecessarily widens the net for behavioral health services and stigmatizes at-risk youth or youth with low-level problem behav iors (Goldson, 2001; Kammer, Minor, & Wells, 1997). Although many in the substance abuse field advocate early identification so that brief interventions and/or referrals will result, the intended positive outcomes may not always occur. As indicated above, many and even most zero-tolerance programs are simply punitive, with no clear benefits for the substance-using adolescent who may wish to seek help. In contrast, if the same identification efforts were linked to programs of useful and desirable rehabilitative services, short-and long-term benefits to the substance-using adolescent could result. Thus, the philosophy of the setting and intent of identification (i.e., habilitative treatment or punitive expulsion or incarceration) can impact the outcome of the substance-using youth identified early. More research is needed to evaluate the effectiveness of various post–substance use identification strategies so that early identification and intervention programs can be based on empirical data rather than on individual or public opinion.