The Relationship Between Mental Health and Substance Abuse Among Adolescents

Appendix C

NHSDA Questionnaire Items Used

APPENDIX C: NHSDA Questionnaire Items Used

DEMOGRAPHIC CHARACTERISTICS

Recorded Sex

What is your date of birth?

SUBSTANCE USE

1. Cigarettes

How long has it been since you last smoked a cigarette?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

I have never smoked a cigarette in my life

Think specifically about the past 30 days -- that is, from your 30-day reference data up to and including today. During the past 30 days, on how many days did you smoke a cigarette?

I smoked at least a puff or two from a cigarette on ______ day(s)

If None, mark one box for best answer:

I have smoked cigarettes but not during the past 30 days

I have never smoked a cigarette in my life

2. Alcohol

How long has it been since you last drank an alcoholic beverage?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

I have never drunk an alcoholic beverage in my life

During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? By "occasion," we mean at the same time or within a couple of hours of each other.

During the past 12 months, when you drank alcoholic beverages, on how many days did you get very high or drunk?

More than 300 days (which would be every day or almost every day)

At least 201 but no more than 300 days (that is about 5 to 6 days a week)

At least 101 but no more than 200 days (or about 3 to 4 days a week)

At least 51 but no more than 100 days (1 to 2 days a week)

At least 25 but no more than 50 days (3 to 4 days a month)

At least 12 but no more than 24 days (1 to 2 days a month)

At t least 6 but no more than 11 days (less than 1 day a month)

At least 3 but no more than 5 days in the past 12 months

At least 1 but no more than 2 days in the past 12 months

You drank an alcoholic beverage in the past 12 months, but

you never got very high or drunk

You have drunk alcoholic beverages, but not during the past 12 months

You have never drunk an alcoholic beverage in your life

3. Marijuana

How long has it been since you last used marijuana or hashish?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

You have never used marijuana or hashish in your life

4. Cocaine

Have you ever, even once, used any form of cocaine?

How long has it been since you last used any form of cocaine?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

You have never used cocaine in your life

5. Crack

Have you ever, even once, used "crack?"

How long has it been since you first used "crack?"

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

You have never used "crack" in your life

6. Heroin

Have you ever, even once, used heroin?

7. Hallucinogens

Please mark one box beside each hallucinogen to indicate whether you have ever used hallucinogen, even once?

LSD ("acid")

PCP ("angel dust," phencyclidine)

Peyote

Mescaline

Psilocybin ("mushrooms")

"Ecstasy" (MDMA)

Have you ever used a hallucinogen whose name you don't know?

Have you ever used any other hallucinogens besides the ones listed above?

How long has it been since you last used LSD, PCP, or any other hallucinogen?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

You have never used any hallucinogen in your life

8. Inhalants

Please mark one box beside each inhalant to indicate whether you have ever used any of the following kind of inhalant, even once, for kicks or to get high?

Amyl nitrite, "poppers," locker room odorizers, or "rush"

Correction fluid, degreaser, or cleaning fluid

Gasoline or lighter fluid

Glue, shoe polish, or toluene

Halothane, ether, or other anesthetics

Lacquer thinner or other paint solvents

Lighter gases (butane, propane)

Nitrous oxide or "whippets"

Spray paints?

Other aerosol sprays

Any inhalant whose name you don't know

Any other inhalants for kicks or to get high besides the ones listed above

How long has it been since you last used any inhalant for kicks or to get high?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

You have never used any inhalant in your life

9. Psychotherapeutics

As you read the following list of prescription pain killers, please mark one box beside each pain killer to indicate whether you have ever used that pain killer when it was not prescribed for you, or that you took only for the experience or feeling it caused. Again, we are interested in all kinds of prescription pain killers, in pill or non-pill form.

Codeine

Darvon

Demerol

Dilaudid

Methadone

Morphine

Percodan

Talwin

Tylenol with codeine

Have you ever used a pain killer whose name you don't know that was not prescribed for you, or that you took only for the experience or feeling it caused?

Have you ever used any other pain killer beside the ones listed above, that was not prescribed for you, or that you took only for the experience or feeling it caused?

As you read the following list of prescription tranquilizers, please mark one box beside each tranquilizer to indicate whether you have ever used that tranquilizer when it was not prescribed for you, or that you took only for the experience or feeling it caused. Again, we are interested in all kinds of prescription tranquilizers, in pill or non-pill form.

Atarax

Ativan

Diazepam

Librium

Tranxene

Valium

Xanax

Have you ever used a tranquilizer whose name you don't know that was not prescribed for you, or that you took only for the experience or feeling it caused?

Have you ever used any other tranquilizer besides the ones listed above, that was not prescribed for you, or that you took only for the experience or feeling it caused?

As you read the following list of prescription stimulants, please mark one box beside each stimulant to indicate whether you have ever used that when it was not prescribed for you, or that you took only for the experience or feeling caused. Again, we are interested in all kinds of prescription stimulants, in non-pill form.

Benzedrine

Biphetamine

Dexamyl

Dexerdrine

Fastin

Ionamin

Methamphetamine

Methedrine

Preludin

Have you ever used a stimulant whose name you don't know

that was not prescribed for you, or that you took

only for the experience or feeling it caused?

Have you ever used any other stimulant besides the ones listed above, that was not prescribed for you or that you took only for the experience for feeling it caused?

As you read the following list of prescription sedatives, please mark one box beside each sedative to indicate whether you have ever used that sedative when it was not prescribed for you, or that you took only for the experience or feeling it caused. Again, we are interested in all kinds of prescription sedatives, in pill or non-pill form.

Dalmane

Halcion

Methaqualone (including Sopor and Quaalude)

Nembutal

Phenobarbital

Placidyl

Seconal

Tuinal

Have you ever used a sedative whose name you don't know that was not prescribed for you, or that you took only for the experience or feeling it caused?

Have you ever used any other sedative besides the ones listed above, that was not prescribed for you, or that you took only for the experience/feeling it caused?

INJECTION DRUG USE

Have you ever, even once, used a needle to inject a drug that was not prescribed for you, or that you took only for the experience or feeling it caused?

PROBLEMS CAUSED BY DRUG USE (Beginning in 1995)

As you read the following list of types of drugs, please mark one box beside each type of drug to indicate whether...

1. You have used that type of drug during the past 12 months.

2. You had a period of a month or more during the past 12 months when you spent a great deal of time getting the drug, using the drug, or getting over its effects .

3. You have used that kind of drug much more often or in larger amounts than you intended to during the past 12 months.

4. You have built up a tolerance for the drug so that the same amount of the drug had less effect than before during the past 12 months.

5. Your use of that drug has often kept you from working, going to school, taking care of children, or engaging in recreational activities during the past 12 months.

6. Your use of the drug has caused you to have any emotional or psychological problems-- such as feeling uninterested in things, feeling depressed, feeling suspicions of people, feeling paranoid, or having strange ideas during the past 12 months.

7. Your use of that drug has caused you any health problems--such as liver disease, stomach disease, pancreatitis, feet tingling, numbness, memory problems, as accidental overdose, a persistent cough, a seizure or fit, hepatitis, or abscesses during the past 12 months.

8. During the past 12 months, you have wanted or tried to stop or cut down on your use of that drug but found that you couldn't.

a. Cigarettes

b. Alcohol

c. Marijuana or hashish

d. Cocaine (including "crack")

e. Heroin

f. Hallucinogens, such as LSD, "acid," PCP, "Ecstasy," psilocybin (mushrooms), mescaline, peyote

g. Inhalants, such as amyl nitrite, "poppers," nitrous oxide, gasoline or lighter fluids glue, spray paints, correction fluids

h. Pain killers, such as codeine, Tylenol with codeine, Darvon, Percodan, Demerol, methadone, opiates

I. Tranquilizers, such as Valium, Xanax, Librium, Ativan, other antianxiety drugs

j. Stimulants, such as the methamphetamine, "speed," Dexedrine, Biphetamine, Benzedrine, "uppers," other amphetamines

k. Sedatives, such as methaqualone, Seconal, Tuinal, Placidyl, barbiturates, sleeping pills,"downers"

PROBLEMS CAUSED BY DRUG USE (1994)

As you read the following list of types of drugs, please mark one box beside each type of drug to indicate whether

1. You have used that type of drug during the past 12 months

2. You had a period of a month or more during the past 12 months when you spent a great deal of time getting the drug, using the drug, or getting over its effects

3. You have used that kind of drug much more often or in larger amounts than you intended to during the past 12 months

4. You have built up a tolerance for the drug so that the same amount of the drug had less effect than before during the past 12 months

5. You have often been under the effects or after-effects of that kind of drug in situations where your physical safety was threatened (such as driving a car or motorcycle, using heavy machinery, or swimming) during the past 12 months.

6. Your use of the drug has caused you to have problems with your family or friends, problems at works, school, or with the police, or any emotional or psychological problems during the past 12 months.

As you read the following list of types of drugs, please mark one box beside each type of drug:

If you wanted to cut down or stop using that drug in the past 12 months,

If you did not want to cut down or stop using that drug, or

If you did not use that drug in the past 12 months, AND

Whether you were able to cut down on or stop your use of that drug every time you wanted to during the past 12 months.

TREATMENT

Have you ever received treatment or counseling for your use of alcohol or any drug, not counting cigarettes?

How many times in the past 12 months have you received treatment or counseling for use of alcohol or any drug, not counting cigarettes?

As you read the following list of places where treatment for drug use is offered, please mark one box beside each type of treatment place to indicate whether you have received treatment for your use of other drugs not counting cigarettes or alcohol in that type of facility during the past 12 months.

A hospital overnight as an inpatient

A residential drug or alcohol rehabilitation facility (overnight)

A drug or alcohol rehabilitation facility as an outpatient

A mental health center or facility as an outpatient

An emergency room

A private doctor's office

A prison or jail

A self-help group

I received treatment in some other place

How long has it been since you last received treatment or counseling for your alcohol or drug use, not counting cigarettes?

Within the past 30 days

More than 30 days ago but within the past 12 months

More than 12 months ago but within the past 3 years

More than 3 years ago

Where did you receive treatment the last time you were treated for your alcohol or other drug use, not counting cigarettes?

A hospital overnight as an inpatient

A residential drug or alcohol rehabilitation facility (overnight)

A drug or alcohol rehabilitation facility as an outpatient

A mental health center or facility as an outpatient

An emergency room

A private doctor's office

A prison or jail

A self-help group

I received treatment in some other place

As you read the following list of drugs, please mark one box beside each type of drug to indicate whether you received treatment or counseling for your use of that kind of drug the last time you received treatment.

Alcohol

Marijuana or hashish

Cocaine or "crack"

Heroin

Hallucinogens

Inhalants

Prescription painkillers or analgesics

Prescription tranquilizers

Prescription stimulants

Prescription sedatives

I received treatment for use of some other drug(s)

What was the primary drug you received treatment for during the last time you were treatment?

PSYCHOLOGICAL FUNCTIONING

Below is a list of items that describe young people. Think about whether each item describes you now or within the past 6 months. Please mark the box next to the "1" if the item is not true of you. Mark the box next to the "2" if the item is somewhat or sometimes true of you. If the item is very true or often true of you, mark the box next to the"3'. Please mark only one box for each question.

Note: This answer sheet contains a list of questions about problems and experiences pertaining to youths. This scale was developed by Dr. Thomas Achenbach, and was used on the NHSDA with his permission. Due to copyright restrictions, the questions are not shown in this report.

This page was last updated on August 05, 2008.

SAMHSA, an agency in the Department of Health and Human Services, is the Federal Government's lead agency for improving the quality and availability of substance abuse prevention, addiction treatment, and mental health services in the United States.

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