Adapting a Substance Abuse Screening Instrument SASSIVRASL for persons who are Deaf

1
Adapting a Substance Abuse Screening Instrument
(SASSI-VR-ASL) for persons who are Deaf

• Debra Guthmann, Ed. D.

2
Introduction

• Substance Abuse Screening/Assessments
• To date there is no formal substance abuse
  assessment/screening instrument specifically
  normed to use with the Deaf population.
• Statistics on the prevalence of substance abuse
  in the Deaf community assumes the occurrence is
  parallel to the hearing majority however valid
  estimates are limited.
• Numerous factors can be attributed to this lack
  of data.
• Barriers include the inaccessibility of
  screening assessments.

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Alcohol ScreeningTo Detect Dependent Drinkers -
CAGE

• Have people Annoyed you by criticizing your
  drinking?
• Have you ever felt bad or Guilty about your
  drinking?
• Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hangover? (Eye opener)
• Have you ever felt that you should Cut down on
  your drinking?

4
Additional Screening QuestionsRAFFT (Cherpital)

• Relax- Use to relax?
• Alone- Use alone?
• Family- Use with family?
• Friends- Use with friends?
• Trouble- Had any problems related to alcohol use?

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Additional Screening Questions Used to Predict
Risk

• Family History
• Has anyone in your family, such as your parents
  or siblings, had any problems with alcohol?
• Do you think they drink too much?
• Did their drinking affect you when you were
  growing up?

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Additional Screening Questions Used to Predict
Risk

• Age at first drink?
• Age first time you became drunk?
• How many times did you drink in high school?
• How many times a week did you drink alcohol in
  high school?

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Self Administered Pencil and Paper Questionnaire

• Alcohol Use Disorder Inventory Test (AUDIT) (10
  questions)
• 3 quantity/frequency questions
• 3 CAGE questions
• 4 consequence (blackouts, injuries, DUI,
  physician advice)

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Alcohol Use Disorders Identification Test (AUDIT)

• The following questions are about the past
  year. (Score)
• 1. How often do you have a drink containing
  alcohol?
• q Never (0) q Monthly or
  less (1) q 2 to 4 times a month (2)
  q 2 to 3 times a week (3) q 4 or more
  times a week (4)
• __________________________________________________
  __________________________________
• 2. How many drinks containing alcohol do you have
  on a typical day when you are drinking?
• q None (0) q 1 or 2 (1) q 3 or 4
  (2)
• q 5 or 6 (3) q 7 to 9 (4) q 10 or more (5)
• __________________________________________________
  __________________________________
• 3. How often do you have six or more drinks on
  one occasion?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)

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Alcohol Use Disorders Identification Test (AUDIT)

• 4. How often during the last year have you found
  that you were unable to stop drinking once you
  had started?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)
• __________________________________________________
  _______________
• 5. How often during the last year have you failed
  to do what was normally expected from you because
  of drinking?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)
• __________________________________________________
  _________________________
• 6. How often during the last year have you needed
  a first drink in the morning to get yourself
  going after a heavy drinking session?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)

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Alcohol Use Disorders Identification Test (AUDIT)

• 7. How often during the last year have you had a
  feeling of guilt or remorse after drinking?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)
• __________________________________________________
  _________
• 8. How often during the last year have you been
  unable to remember what happened the night before
  because you had been drinking?
• q Never (0) q Less than monthly (1) q
  Monthly (2)
• q Weekly (3) q Daily or almost daily (4)
• __________________________________________________
  ___________
• 9. Have you or someone else been injured as the
  result of your drinking?
• q No (0) q Yes, but not in the last year
  (2) q Yes, during the last year (4)

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Alcohol Use Disorders Identification Test (AUDIT)

• __________________________________________________
  ____________
• 10. Has a relative, friend, or a doctor or other
  health worker been concerned about your drinking
  or suggested you cut down?
• q No (0) q Yes, but not in the last year
  (2) q Yes, during the last year (4)
• A score of 8 or more is suggestive of high-risk
  drinking. People who score positive on the AUDIT
  should be assessed for potential alcohol-related
  problems.
• Babor TF, de la Fuente JR, Saunders J, Grant M.
  AUDIT The Alcohol Use Disorders Identification
  Tests Guidelines for use in Primary Health Care.
  Geneva, Switzerland World Health Organization,
  1992.

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Michigan Alcohol Screening Test (MAST)

• Structured interview instrument consisting of 25
  questions
• Administered rapidly
• Devised to provide a consistent, quantifiable
  instrument for the detection of alcoholism.
• The Brief Michigan Alcohol Screening Test (BMAST)
  
• Shortened version of the MAST
• 9 questions
• Administered as a paper and pencil test or read
  out loud to the individual
• Individual simply is required to respond with
  either yes or no to a series of questions
  designed to be significantly neutral I
• Individuals reluctant to identify themselves as
  dependent or abusing alcohol may reveal their
  affliction (Fuller et al, 1994)
• A score of five or more is considered compatible
  with substance abuse.

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Michigan Alcohol Screening Test (MAST)Please
answer YES or NO to the following questions. (You
may substitute the words drug use in place of
drinking)

• 1. Do you feel you are a normal drinker?
  ("normal" - drink as much or less than
• most other people)
• 2. Have you ever awakened the morning after some
  drinking the night before and found that you
  could not
• remember a part of the evening?
• 3. Does any near relative or close friend ever
  worry or complain about your drinking?
• 4. Can you stop drinking without difficulty after
  one or two drinks?
• 5. Do you ever feel guilty about your drinking?
• 6. Have you ever attended a meeting of Alcoholics
  Anonymous (AA)?
• 7. Have you ever gotten into physical fights when
  drinking?
• 8. Has drinking ever created problems between you
  and a near relative or close friend?
• 9. Has any family member or close friend gone to
  anyone for help about your drinking?
• 10. Have you ever lost friends because of your
  drinking?

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Michigan Alcohol Screening Test (MAST)Please
answer YES or NO to the following questions. (You
may substitute the words drug use in place of
drinking.)

• 12. Have you ever lost a job because of drinking?
• 13. Have you ever neglected your obligations,
  your family, or your work for two or more days in
  a row
• because you were drinking?
• 14. Do you drink before noon fairly often?
• 15. Have you ever been told you have liver
  trouble such as cirrhosis?
• 16. After heavy drinking have you ever had
  delirium tremens (D.T.'s), severe shaking, visual
  or auditory
• (hearing) hallucinations?
• 17. Have you ever gone to anyone for help about
  your drinking?
• 18. Have you ever been hospitalized because of
  drinking?
• 19. Has your drinking ever resulted in your being
  hospitalized in a psychiatric ward?
• 20. Have you ever gone to any doctor, social
  worker, clergyman or mental health clinic for
  help with any
• emotional problem in which drinking was part of
  the problem?

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Michigan Alcohol Screening Test (MAST)Scoring

• Score one point if you answered the following1.
  No2. Yes3. Yes4. No5. Yes6. Yes7 through
  22 Yes
• Add up the scores and compare to the following
  score card0 - 2 No apparent problem3 - 5 Early
  or middle problem drinker6 or more Problem
  drinker

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Adapting a Substance Abuse Screening Instrument
(SASSI-VR-ASL) for persons who are Deaf

• The Research and Training Center on Disability
  and Vocational Rehabilitation at Wright State
  University is adapting the SASSI for consumers of
  VR with approximately 1,000 consumers in three
  states.
• Due to issues related to readability, wording,
  regional signs, instrument length, it was
  determined that the SASSI-VR may not be effective
  with many Deaf individuals.
• Additional funding was requested and received
  from The National Institute on Disability and
  Rehabilitation Research (NIDRR) to develop the
  SASSI-VR-ASL.

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Substance Abuse Subtle Screening Inventory (SASSI)

• Original version
• 75 item, self-report instrument used to identify
  people with alcohol and/or drug problems
• Design
• 46 General statements true/false format
• 12 Alcohol and 17 Drug questions required the
  respondent to indicate how often never, one or
  more times, repeatedly, they had experienced
  listed situations during the past 12 months.

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)General

• Mark YES or NO for each question.
• 1. Most people make some mistakes in their life.
• 2. I have never been in trouble with the police.
• 3. I was always well behaved in school.
• 4. My troubles are not all my fault.
• 5. I have not lived the way I should.
• 6. I do not like to sit and daydream.
• 7. No one has ever criticized or punished me.
• 8. Sometimes I have a hard time sitting still.
• 9. At times I feel worn out for no special
  reason.
• 10. Sometimes Ive had days, weeks or months when
  I couldnt get much done because I just wasnt up
  to it.
• 11. I am very respectful of people who are in
  charge of running things.
• 12. I like to obey the law.
• 13. I have been tempted to leave home for good.
• 14. I often feel that strangers look at me as if
  they dont like me.
• 15. Some criminals are so clever that I hope they
  get away with what they have done.
• 16. I have sometimes drunk too much.
• 17. Much of my life is boring.

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)

• 18. Sometimes I wish I could control myself
  better.
• 19. I believe that people sometimes get confused.
• 20. I break more laws than many people.
• 21. If some friends and I were in trouble
  together, I would rather take the whole blame
  than tell on them.
• 22. I think there is something wrong with my
  memory.
• 23. I have never broken a serious law.
• 24. Nearly everyone enjoys being picked on and
  made fun of.
• 25. There have been times when I have done things
  I couldnt remember later.
• 26. I know who is to blame for most of my
  troubles.
• 27. I have used too much alcohol or pot or used
  too often.
• 28. I guess I know some people with pretty bad
  reputations.
• 29. Most people will laugh at a joke now and
  then.
• 30. I have hardly ever been punished.
• 31. I smoke cigarettes regularly.
• 32. At times I have been so full of energy that I
  felt I didnt need to sleep for days at a time.
• 33. I often spend time thinking about people who
  have done me wrong

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)

• 34. I have sometimes sat around when I should
  have been working.
• 35. I take all my responsibilities seriously.
• 36. I have neglected obligations to family or
  work because of my drinking or using drugs.
• 37. I have had a drink first thing in the morning
  to steady my nerves or get rid of a hangover.
• 38. While I was a teenager, I began drinking or
  using other drugs regularly.
• 39. My father was/is a heavy drinker or drug
  user.
• 40. When I drink or use drugs I tend to get into
  trouble.
• 41. My drinking or other drug use causes problems
  between my family and me.
• 42. I do most of my drinking or drug use away
  from home.
• 43. My doctors have not prescribed enough
  medication to get the relief I need.
• 44. At least once a week I use some
  over-the-counter medicines for stomach acid or
  digestion problems.
• 45. I have never felt sad over anything.
• 46. I have periods where I drink or use drugs a
  lot and then dont use at all for a while.

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)ALCOHOL

• For each question mark 5 or more times, 1-4 times
  or never.
• 1. In the past 12 months, I had drinks with
  lunch.
• 2. In the past 12 months, I took a drink(s) to
  help express my feelings or ideas.
• 3. In the past 12 months, I took a drink(s) to
  help me feel less tired or to give me energy to
  keep going.
• 4. In the past 12 months, I had more to drink
  than I intended to.
• 5. In the past 12 months, I experienced physical
  problems after drinking. (such as, nausea,
  seeing/hearing problems, dizziness, etc.)
• 6. In the past 12 months, I got into trouble on
  the job, in school, or at home because of
  drinking.
• 7. In the past 12 months, I became depressed
  after I sobered up.
• 8. In the past 12 months, I argued with my
  family or friends because of my drinking.
• 9. In the past 12 months, I had the effects of
  drinking happen again after I didnt drink for a
  while. (For example, flashbacks, seeing things
  that werent really there, etc.)
• 10. In the past 12 months, I had problems in
  relationships because of my
• drinking. (For example, loss of friends,
  separations, divorce, etc.)
• 11. In the past 12 months, I became nervous or
  had the shakes after I sobered up.
• 12. In the past 12 months, I tried to commit
  suicide while I was drunk.

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)Other Drugs

• For each question mark 5 or more times, 1-4 times
  or never.
• The word misuse means taking medicine in
  larger amounts than prescribed, longer than
  prescribed, or using someone elses medicines.
  Drugs include things like pot, cocaine, meth,
  heroin, etc.
• 1. In the past 12 months, I misused medicines or
  took drugs to improve my thinking or feeling.
• 2. In the past 12 months, I misused medicines or
  took drugs to feel better about a problem.
• 3. In the past 12 months, I misused medicines or
  took drugs to become more aware of my senses.
  For example, sight, hearing, touch, etc.
• 4. In the past 12 months, I misused medicines or
  took drugs to improve my enjoyment of sex.
• 5. In the past 12 months, I misused medicines or
  took drugs to help me forget bad feelings I have
  about myself.
• 6. In the past 12 months, I misused medicines
  or took drugs to forget school, work, or family
  pressures.
• 7. In the past 12 months, I got into trouble
  with the law because of drugs.
• 8. In the past 12 months, I got really stoned
  or wiped out on drugs - more than just high.

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Substance Abuse Subtle Screening Inventory
Vocational Rehabilitation (SASSI VR)

• 9. In the past 12 months, I tried to talk a
  doctor into giving me a prescription drug. (For
  example, tranquilizers, pain killers, pills to
  calm my nerves, etc.)
• 10. In the past 12 months, I spent my spare time
  in drug-related activities. (For example,
  talking about drugs, buying, selling, taking,
  etc.)
• 11. In the past 12 months, I drank alcohol and
  took medicines or drugs at the same time.
• 12. In the past 12 months, I kept taking medicine
  or used drugs in order to avoid pain or
  withdrawal.
• 13. In the past 12 months, I have felt that
  misuse of medicines or drug use has kept me from
  getting what I want out of life.
• 14. In the past 12 months, I took a higher dose
  or different medicines than my doctor prescribed
  in order to get the relief I need.
• 15. In the past 12 months, I used other peoples
  medication.
• 16. In the past 12 months, my doctor denied my
  request for medication I needed.
• 17. In the past 12 months, I was accepted into a
  treatment program due to misuse of medicines or
  drug use.

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Substance Abuse Subtle Screening Inventory
(SASSI) Description of the subscales

• Symptoms (SYM) reflecting symptoms of AOD use
  (e.g. I have sometimes drunk too much).
• Obvious Attributes (OAT) measure the clients
  openness or willingness to admit symptoms or
  problems related to substance abuse. Those
  people with elevated scores may be able to
  recognize their resentments, feelings of
  self-pity, impulsivity and low frustration
  tolerance.
• Subtle Attributes (SAT) An elevated SAT may
  indicate that the client is sincerely deluded
  or unaware of the says in which AOD have impacted
  his or her life. The client may also lack
  insight.

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Substance Abuse Subtle Screening Inventory
(SASSI) Description of the subscales

• Defensiveness (DEF) A high score on this
  subscale may reflect a test taking defensiveness
  or a deliberate attempt to manipulate the test.
  Therefore, a high score may be an attempt by a
  client to conceal a substance use disorder. Low
  scores may indicate feelings of worthlessness or
  difficulty in accepting positive feedback.
• Supplemental Addiction Measure (SAM) used in
  conjunction with the DEF scale to differentiate
  the defensive responses of clients with a high
  probability of a substance dependence disorder
  from those clients with a low probability of such
  a disorder.
• Family versus Controls (FAM)) identify clients
  who are members of a substance-abusing family
  system.

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Substance Abuse Subtle Screening Inventory
(SASSI) Description of the subscales

• Correctional (COR) measure of acting-out
  behavior. A high score matches the responses of
  individuals in correctional settings. If a
  person receives a high score, is not in a
  correctional setting, and is not classified as
  chemically dependent on the rest of the SASSI,
  the persons acting out may be attributed to
  causes other than alcohol or other drug abuse.
• Random Answering Pattern (RAP) a validity scale
  to detect random responding, reading or
  comprehension problems, faking, or other problems
  that would cause a client to give highly unusual
  responses. The items are statements to which
  nearly everyone would give the same response
  (e.g., People always do the right thing).
• Note As useful as the SASSI is, a self-report
  inventory should not be used in isolation from
  other assessment techniques, diagnosis should be
  made only by mental health providers with formal
  training and experience in the AOD field and
  should be based on a comprehensive assessment.

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SASSI-VR-ASL Modifications

• Translation into American Sign Language
• Follows a yes/no format (instead of True/False)
• A linguistics committee consisting of 5 Deaf
  individuals
• met multiple times to review SASSI questions item
  by item and come to agreement about how to
  interpret each equivalent.
• met in the studio for two sessions to create a
  CD-Rom ASL version of the SASSI modeled by a
  native Deaf signer.
• Directions for each section were signed.
• The concept of time, experiencing in the past 12
  months, was set as a marker
• The term Drugs was clarified to include
  Misuse of prescription drugs and Use of
  drugs
• Ambiguous terms were expanded (e.g. the shakes)
  
• The Producer edited the CD-Rom and created an
  interactive version to be used for the back
  translation process.

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Participants
AGE N 37 Ages ranged from 24 to 62 (mean of 43)
29
Participants
30
N37 REPORTING STATES/36 Unidentified/1

• ARIZONA (AZ)
• CALIFORNIA (CA)
• COLORADO (CO)
• GEORGIA (GA)
• ILLINOIS (IL)
• INDIANA (IN)
• IOWA (IA)
• KANSAS (KS)
• KOREA
• MARYLAND (MD)
• MASSACHUSETTS (MA)
• MINNESOTA (MN)
• NEW JERSEY (NJ)
• NEW YORK (NY)
• OHIO (OH)
• ONTARIO, CANADA
• OREGON (OR)

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Back Translation Procedure

• Individuals sought nationally for participation
  in the process to ensure that sign selections
  were not regional
• Participants were all Deaf or CODAs (Children of
  Deaf Adults).
• They were given a copy of the CD-Rom with
  directions to review and write down each question
  in English (conceptually).
• Subjects participated in the study blindly, they
  had not seen the original version of the
  instrument.
• Some participants received a 25.00 stipend for
  their participation
• Responses were collected and analyzed.

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Back Translation Findings

• 32 correctly completed responses were received.
• The length of the instrument, (75 Questions),
  required some people several hours to complete
• Results were analyzed by three raters
• Equivalency between the original and translated
  version was evaluated
• The author of the instrument at the SASSI
  Institute, and the Project Director from the RRTC
  at Wright State were also involved in this
  process comparing the data to their own studies
  used with VR (Vocational Rehabilitation)
  participants

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Back Translation Findings

• There are three sections to the SASSI
• General- most clearly understood
• Alcohol- confusion with the concept use in the
  past 12 months
• Drug- confusion with the concept use in the past
  12 months and Misuse of prescription drugs
• 5) Other misunderstandings and confusion
• Never vs. Ever
• Frequency of use (1-4 times/5 times or more)
• Description of Symptoms (e.g., flashbacks,
  hallucinations)
• Implication of judgment (disapproval)

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Revision of Translated Tool

• Recommendations were made for translations to be
  kept, revised or eliminated
• 42 Questions were kept including some revisions
• The Focus group met again to review the results
  from the back translation and made revisions
• A second CD-Rom with the revisions was made

35
Next steps

• Goal
• Reduce number of questions to 20-25 in order to
  shorten the length of the assessment
• Funding will be sought to do a large validation
  of the instrument for use within the Deaf
  community
• Future Recommendations
• Determine
• Regional influences
• Appropriateness for all language users

36
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