Journal of Addiction Medicine:
A Review of Guidelines on Home Drug Testing Web Sites for Parents
Washio, Yukiko PhD; Fairfax-Columbo, Jaymes BA; Ball, Emily BA; Cassey, Heather BA; Arria, Amelia M. PhD; Bresani, Elena MS; Curtis, Brenda L. PhD; Kirby, Kimberly C. PhD
From the Treatment Research Institute (YW, JFC, E Ball, E Bresani, BLC, KCK), Philadelphia, PA; Department of Psychology, Drexel University (JFC), Philadelphia, PA; Department of Psychological, Organizational, and Leadership Studies, Temple University (HC), Philadelphia, PA; Prevention Research Center, University of Maryland School of Public Health (AMA), College Park, MD.
Send correspondence and reprint requests to Yukiko Washio, PhD, Treatment Research Institute, 600 Public Ledger Building, 150 S. Independence Mall West, Philadelphia, PA 19106. E-mail: email@example.com
Supported by an NIH grant, 5P50DA027841.
The authors have no financial relationships relevant to this article to disclose.
The authors have no conflicts of interest to disclose.
Received October 25, 2013
Accepted March 08, 2014
Objectives: To update and extend prior work reviewing Web sites that discuss home drug testing for parents, and assess the quality of information that the Web sites provide, to assist them in deciding when and how to use home drug testing.
Methods: We conducted a worldwide Web search that identified 8 Web sites providing information for parents on home drug testing. We assessed the information on the sites using a checklist developed with field experts in adolescent substance abuse and psychosocial interventions that focus on urine testing.
Results: None of the Web sites covered all the items on the 24-item checklist, and only 3 covered at least half of the items (12, 14, and 21 items, respectively). The remaining 5 Web sites covered less than half of the checklist items. The mean number of items covered by the Web sites was 11.
Conclusions: Among the Web sites that we reviewed, few provided thorough information to parents regarding empirically supported strategies to effectively use drug testing to intervene on adolescent substance use. Furthermore, most Web sites did not provide thorough information regarding the risks and benefits to inform parents' decision to use home drug testing. Empirical evidence regarding efficacy, benefits, risks, and limitations of home drug testing is needed.
In 1997, the Food and Drug Administration approved the first home drug testing kit to be available without a prescription, and, within the following year, more than 200 products were approved for home drug testing. Since then, many for-profit companies have made these products commercially available for online purchase. In addition, concerned parents have developed their own Web sites providing information and advice in an effort to help other parents prevent or address their child's drug and alcohol use (Levy et al., 2004). Parents seek advice from a variety of sources, including the Internet, regarding adolescent substance use; however, information on these Web sites is not necessarily empirically supported (Schwartz et al., 2003; Levy et al., 2004). Given that the commercial industries that sell home drug testing products do not report their sales data, it is difficult to estimate the prevalence of home drug testing product purchased by parents (Moore and Haggerty, 2001). However, in 2011, more than 1.7 million adolescents between the ages of 12 and 17 years in the United States were estimated to have a substance use disorder with 1.1 million meeting criteria for dependence or abuse on illicit or prescription drugs, 900,000 for alcohol dependence or abuse, and 380,000 for both (U.S. Department of Health and Human Services, 2011), suggesting that there is a large potential market for the use of home drug testing products.
Parental monitoring has been associated with less use of alcohol and drugs (Clark et al., 2012; Kaynak et al., 2013). Although these studies defined “monitoring” as keeping track of children's friends, whereabouts, activities, and social plans, the potential for using home drug tests for more direct parental monitoring of substance use is apparent. However, empirical evidence specific to the benefits of parental monitoring through home drug testing has not been directly established, and health care professionals stress safety concerns, including the technical limitations of testing, failure to correctly administer and use testing kits, false-positive and false-negative test results, and inaccurate interpretations of the results (Moore and Haggerty, 2001; Casavant, 2002; Levy et al., 2004; Levy et al., 2006a, 2006b; Committee on Substance Abuse [American Academy of Pediatrics, AAP] et al., 2007; Davidson, 2009; Arcinegas-Rodriguez et al., 2011). In addition, health professionals have cautioned parents to be aware of potential unintended psychosocial and behavioral consequences from parent-administered home drug testing. These include increases in conflict and violence and other disruptions to the relationship between parents and their children because of violating the children's rights and trust (Levy et al., 2004; Committee on Substance Abuse [AAP] et al., 2007; Arcinegas-Rodriguez et al., 2011), children switching to heavy drinking and to new or synthetic drugs that might not be included in the home drug test panel or might be harder or impossible to detect by home drug testing (Heyman and Adger, 1996; Levy et al., 2004; Levy et al., 2006b; Committee on Substance Abuse [AAP] et al., 2007; Levy et al., 2007), increasing drug use right after home drug testing because children assume that parents will not test them again, parents' following unsubstantiated claims and advice, and delayed diagnosis and treatment of potentially serious substance use or psychiatric disorders (Heyman and Adger, 1996; Levy et al., 2004; Committee on Substance Abuse [AAP] et al., 2007). These concerns have led the American Academy of Pediatrics (Committee on Substance Abuse [AAP] et al., 2007) and other professional organizations to recommend against parental home drug testing without professional guidance and likely have contributed to adamant resistance to home drug testing among some professionals.
Levy et al. (2004) recommended against home drug testing by parents after conducting a worldwide Web search in 2001 to closely examine the contents of Web sites that specifically advertised drug testing products to parents. The study identified 8 Web sites that sold home drug testing kits and had a specific section for parents. All of them listed multiple reasons why parents should perform home drug testing, for example, to support children in resisting peer pressure and give parents the evidence of their children's substance use. Content covered by the reviewed Web sites included educational materials for interested readers, information on the role of parents in preventing adolescent substance use, news stories related to adolescent substance use, recommendations for developing a family drug and alcohol policy such as repeated random testing, obtaining a child's assent before performing a test, and what to do if their child admits to drug or alcohol use. Of the 8 Web sites, 5 included direct links to other Web sites for substance abuse–related support groups and government and nonprofit organizations. None of the Web sites provided detailed instructions for collecting a valid specimen according to the protocol recommended by National Institutes on Drug Abuse (2009); 3 recommended confirmatory testing for positive urine tests conducted by parents; 1 provided technical assistance for testing urine samples; and 4 suggested that parents seek professional help if their child tested positive for drugs. Although some of the drug-related information presented on these Web sites might be useful, Levy et al. (2004) concluded that parents would be better served by referral to professionals for an assessment of their child's suspected substance use.
Although there have been no well-controlled trials evaluating home drug testing conducted independently by parents, providing rewards and consequences contingent on biochemical drug testing results, confirmed by professional testing laboratories, has often been successfully implemented in clinical research (Griffith et al., 2000; Lussier et al., 2006; Dutra et al., 2008) and shows very good efficacy in treating outpatients with substance use disorders (Castells et al., 2009). This approach has also been efficacious and safe when combined with parent training to monitor their children's substance misuse and provide contingent rewards and consequences (Donohue et al., 2009; Stanger et al., 2009). The parent training in this study has included weekly in-person counseling sessions for 3 to 4 months, covering topics on identifying and labeling adolescent behavior, developing contingency plans, and building limit-setting, monitoring, and relationship skills (Stanger et al., 2009).
Taking procedural information from empirically supported urine-monitoring interventions implemented by professionals and parents, we conducted a Web site review examining the comprehensiveness of the information provided for parents to (1) do home drug testing using procedures similar to those that have empirical support, (2) evaluate risks and benefits of the procedure, and (3) take appropriate precautions to reduce risks. Our purpose was not only to examine the extent to which Web sites provided this information for parents 10 years after the review by Levy et al. (2004), but also to extensively examine psychosocial contents of reviewed Web sites with an empirically based checklist.
Checklist Items for Web Site Review
We developed an initial checklist on the basis of the biological testing section of a National Institute on Drug Abuse (2009) drug use screening manual, manuals of empirically supported contingency management and parental training interventions that focus on urine monitoring, and literature describing clinicians' concerns regarding home drug testing by parents (Heyman and Adger, 1996; Moore and Haggerty, 2001; Casavant, 2002; Levy et al., 2004; Levy et al., 2006a, 2006b; Committee on Substance Abuse [AAP] et al., 2007; Levy et al., 2007; Arcinegas-Rodriguez et al., 2011). We then requested feedback on the checklist from a panel of 5 external experts (the “Acknowledgments” section) that included 2 of the authors of the earlier review (Levy et al., 2004) and other established scientists and clinicians in the field of substance abuse covering, pediatrics, adolescent medicine, and adolescent psychosocial substance abuse treatment. On the basis of their comments, we elaborated on the existing content and added 4 more checklist items. The final checklist (Table 1) contained a total of 24 items in 3 categories as follows: assessing appropriateness for home drug testing and preparing for it (eg, who is appropriate to test or be tested, potential for positive and negative effects, and how to introduce the testing); how to conduct home drug testing (eg, how to initiate a test, verify that the urine is their child's, interpret results, and deliver consequences); and provision of additional information and resources (eg, technical support, counseling support, and treatment options). The revised checklist was again circulated and received final agreement from the field experts.
Web Site Selection
The authors employed comprehensive Web search strategies described by Levy et al. (2004) and Schmidt and Ernst (2004), selecting the most commonly used search engines (Google, Yahoo, and Bing) and a meta-search engine (WebCrawler) to yield the maximum number of commonly visited Web sites. We used 4 search terms (“parent,” “drug test,” “home,” and “kit”) connected by the Boolean operator (“AND”).
We reviewed the first 50 Web sites returned by each search engine. Focusing on the first 50 Web sites replicates the method from prior work by Levy et al. (2004) and is a frequently used approach that restricts the review to sites most likely accessed, given that 90% of search engine users do not look at search results beyond the first page (Freeman and Chapman, 2012). For our review, we included Web sites that (1) were returned in at least 2 search engines, (2) discussed home drug testing products whether or not they were directly available for sale on that Web site, and (3) addressed parents as potential consumers. Web sites met the second criterion if a Web site introduced home drug testing products, whether by nonprofit Web sites developed by concerned parents or by for-profit Web sites that offered products. Web sites met the third criterion if they included words or phrases such as “parent,” “your child,” “your teen,” and “your kid.” We excluded Web sites that advertised products that required sending test samples to a laboratory for analysis and did not allow parents to determine the results at home (eg, hair samples). The Web sites were reviewed online and printed in their entirety between June and July 2012. Each site was reviewed independently by 2 of the authors (JF-C and EB) to determine whether the site met the inclusion/exclusion criteria. Discrepancies in decision of which Web site to include or exclude between the 2 authors were discussed with 2 investigators (YW and KCK) and resolved by reviewing the inclusion and exclusion criteria, then coming to an agreement on whether to include or exclude a Web site for review. Examples include determining whether the page was directed toward parents and excluding Web sites with only an option of hair sample testing. The decisions were then incorporated to clarify inclusion and exclusion criteria as needed.
Evaluation of the Selected Web Sites
Each site was also reviewed independently by the same 2 authors by using the checklist to evaluate the type of information given to parents. Both authors checked correspondence between the content in each Web site and checklist items to code the type of information provided. We did not include information listed in blogs associated with the Web sites because the information in the blog was not provided by the Web site owner but by the readers.
The authors compared their checklists with each other. When the authors did not agree on the part corresponding to a checklist item within a Web site or when only 1 of them identified or did not identify a part corresponding to a checklist item, the Web site was reviewed by 2 investigators (YW and KCK), and the discrepancies were discussed and resolved. These decisions were then used to clarify criteria for the checklist items. The evaluation was replicated in August 2012 by another author (HC), who was not involved in the initial evaluation to again verify results and look for any updates on these Web sites. No significant changes in the content of the Web sites were noted.
Sixty of the 200 Web sites across 4 search engines introduced home drug-testing products. Of the 60 Web sites, 8 came up in more than 2 search engines and listed information specifically targeting parents. Although the search returned the same number of Web sites as Levy et al. (2004), none of the Web sites address (ie, uniform resource locators [URL]) overlapped with the previous review. Three of the Web sites from Levy et al. (2004) had been terminated, 4 did not appear within the first 50 Web sites returned in our search, and 1 did not meet our inclusion criterion (ie, hair testing by professional laboratories).
We found that none of the Web sites covered all the items on the checklist, and only 3 covered at least half the number of items on the checklist (Table 1, 12, 14, and 21 items, respectively; Fig. 1). The remaining 5 Web sites covered less than half of the checklist items, with the number of items covered ranging from 6 to 10 items. Overall, the mean number of items covered across all 8 Web sites was 11.
The total number of Web sites that covered each checklist item is presented in Table 1 (“last column”). Eight items were covered by more than half the reviewed Web sites (ie, on 5 or more Web sites). It is worth noting that the checklist items “states potential benefits of home drug testing for their child” and “cautions parents on the conceptual and technical limitations of drug screening kits” were covered by all the reviewed Web sites. Although all the Web sites included cautions, the amount of information provided in each Web site varied.
We found that the number of Web sites discussing home drug testing for parents and meeting our inclusion criteria was low (N = 8) and had not increased in number relative to the earlier review a decade ago (Levy et al., 2004). Unfortunately, as was the case a decade ago, most of the Web sites lacked content consistent with professional guidelines, and evidence-based procedures considered important by relevant field experts. As such, most Web sites did not provide parents with enough information to allow them to be well-informed in considering if and when to use home drug testing or how to use it to achieve optimal benefits. Not all safety concerns emphasized by substance use professionals (described in the introductory paragraphs of this article) were addressed by the reviewed Web sites, especially regarding (1) potential increase in disruptions to the relationship between parents and their children because of violating the children's rights and trust (Levy et al., 2004; Committee on Substance Abuse [AAP] et al., 2007; Arcinegas-Rodriguez et al., 2011; Table 1, checklist items 1, 2, 7, 10, and 17), (2) children switching to heavy drinking and to new or synthetic drugs that might not be included in the home drug test panel or might be harder or impossible to detect by home drug testing (Heyman and Adger, 1996; Levy et al., 2004; Levy et al., 2006b; Committee on Substance Abuse [AAP] et al., 2007; Levy et al., 2007; Table 1, checklist items 3 and 5), (3) increasing drug use right after home drug testing because children assume that parents will not test them again, and (4) failure to make adequate treatment referral (Heyman and Adger, 1996; Levy et al., 2004; Committee on Substance Abuse [AAP] et al., 2007; Table 1, checklist items 22, 23, and 24).
Anecdotally, we noted that information was often presented in an unsystematic way, making it difficult for parents to determine when they had reviewed all the important information regarding home drug testing. For example, information was frequently provided on different pages within the Web site, with no central location summarizing the information or providing links to the other pages. The only exception was Web site H, which listed information relevant to the checklist items in 1 parent-related Web page. Future Web sites should present information in a more systematic and visible manner.
Parents are potentially major consumers of home drug testing products and should be provided with professionally informed guidelines, such as those listed in the checklist, to maximize the potential benefits of home drug testing. The information should also indicate when and why parents should seek additional professional support for home drug testing and the type of potential support to seek and expect. Extrapolating from empirically supported adolescent treatments, the professional support ideally would at least provide parents with support in communication skills, dealing with drug-positive urine tests, and praising or providing other rewards for drug-negative tests (cf Brooks et al., 2012; Kirby et al., 1999; Moos, 2007; Waldron and Turner, 2008; Stanger et al., 2009). Because research suggests that new intervention skills are less likely to be acquired from information alone than when coaching and feedback from a skilled professional are involved (cf Miller et al., 2004; Manuel et al., 2012), parents' skills in home drug testing most likely improve under the guidance of behavioral health professionals, and information on Web sites should be seen as supplemental to these sources. However, parents should understand that this type of ideal training is not widely available and that few professionals have experiences assisting with home drug testing. As such, they may be more likely to find a professional who will work with them but insist on laboratory testing. Furthermore, parents should be prepared to encounter professionals that strongly advise against home testing or laboratory testing. In fact, in addition to expressing concerns about safety, the American Academy of Pediatrics (Committee on Substance Abuse [AAP] et al., 2007) states that more empirical research is promptly needed to examine benefits, risks, and limitations of home drug testing. Lack of empirical evidence might also be one of the leading contributors to lack of knowledge, training, and, thus, practice regarding drug testing not only for parents but also for medical professionals. Finally, empirical evidence regarding well-defined protocols may also help medical professionals make proper referrals to behavioral and mental health professionals upon identifying drug-positive results, instead of dealing with the positive results in their office (Levy et al., 2006a, 2006b).
We used the same search terms and procedures that Levy et al. (2004) used for the purposes of updating and expanding their review and for exploring the extent to which Web site information may have changed over the past decade. Future reviews might expand or revise the search terms and ranges to capture a wider variety of Web sites discussing home drug testing.
We suggest that Web sites could be improved by including more information derived from biological testing guidelines, manuals of empirically supported contingency management and parental training interventions that focus on urine monitoring, and literature describing clinicians' concerns regarding home drug testing by parents. This information could better assist parents to more effectively consider when and how to use home drug testing. Empirical research directly examining efficacy, benefits, risks, and limitations in home drug testing is needed to better inform the development of professionally approved guidelines for using home drug testing products. Guidelines, then, could be provided by Web sites in a systematic and reader-friendly manner. In addition to including instructions and recommendations for parents, Web sites ideally would also include a list of professionals and other resources available to directly help parents use the products effectively and avoid potentially harmful consequences.
We thank Drs Kathleen Myers, Catherine Stanger, Sharon Levy, John Knight, and Mark J. Fishman for reviewing this manuscript and providing feedback regarding the checklist examining Web page content.
The author contributions are given as follows: Yukiko Washio conceptualized and designed the study, carried out the review, drafted the initial manuscript, and approved the final manuscript as submitted; Jaymes Fairfax-Columbo helped review the literature, develop the checklist, and review and evaluate the Web sites; Emily Ball helped develop the checklist and review and evaluate the Web sites; Heather Cassey helped review the literature and provided a secondary evaluation of the Web sites; Amelia M. Arria assisted in reconceptualizing and revising the manuscript; Elena Bresani helped develop the checklist and revise the manuscript; Brenda Curtis helped reconceptualize and revise the manuscript; and Kimberly C. Kirby participated in conceptualizing and designing the study, finalizing the checklist and evaluation procedures, and in revising the manuscript.
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adolescents; home drug testing parents; substance abuse; substance dependence
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