Our spring issue of News and Reports is focused on adolescent substance dependence. The profile interpretation is of an adolescent SASSI; our FAQs column presents questions that we are most frequently asked about the adolescent SASSI. We have also included a sample of the type of report that The SASSI Institute prepares for school entities that provide us with normative adolescent data.
Our interest in adolescents flows naturally from our mission. We provide an assessment tool that promotes early identification and treatment of substance dependent individuals for the purpose of promoting recovery. Don't get us wrong. If the SASSI plays some part in getting a chronic alcoholic and drug addict with damaged health, deteriorated family relationships, and legal, financial, and career problems associated with substance use into a path of recovery, we are delighted. But if we can help you identify a person before the trip down this painful progression goes very far, we are even more pleased. With the age of onset of substance abuse problems getting lower over the past 20 years, "early" intervention often must occur in adolescence.
It has always been hard to identify, intervene and treat adolescents. Even when there are adolescent treatment facilities, somehow many teens who need services for substance-related disorders do not receive them. As counselors and caring adults, it grieves us to think of large numbers of 10-, 11-, and 12-year-olds using alcohol and other drugs. It is painful to see teens not only experiencing the direct consequences of their substance disorder progression, but also failing to succeed with the normal developmental challenges and skill development. The SASSI Institute wishes to support all efforts to provide assessment, intervention and treatment for those who may be in the early stages of the disorder so that the personal, financial, and social costs of addictions will be minimized.
As you may be aware, The SASSI Institute is in the process of updating and improving the Adolescent SASSI. Many people have volunteered to help us collect data, and we are in the process of contacting those people so that we can begin analyzing and developing an updated version. Hopefully together we can help those in the "springtime" of their lives to fully experience the delight and joyful renewal that is Spring.
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Sample Reports for Schools
On a number of occasions, The SASSI Institute has worked with school systems to help estimate the prevalence of substance dependence among the students. Typically, we provide the SASSIs, and the students take them anonymously. The completed SASSIs are returned to us for analysis and preparation of a report for the school officials. We have offered this service in the past because it is in keeping with our overall mission to reduce the negative impact of substance abuse and because it provides us with normative data. We would also consider providing this service in large employment settings.
The following is an illustration of the type of report that can be developed from a large sample of normative data.
Report
for
ANYTOWN JR-SR HIGH SCHOOL
March, 1999
Five hundred students completed the adolescent version of the Substance Abuse Subtle Screening Inventory (SASSI). Seventy were eliminated due to missing items or evidence that the student did not respond to the instrument in a meaningful manner (e.g., random responding, alternating true and false). Of the remaining 430 valid SASSIs, 80 or 19% were test positive, indicating a high probability of substance dependence. That figure can be used as an estimate of the prevalence of substance dependence in the sample of students who provided valid SASSI profiles. However, it is important to bear in mind that the SASSI is a screening tool, not a diagnostic instrument. Also, the results could be skewed because of the possibility that either a high or low percent of substance dependent students did not produce a valid profile. Therefore, it is not appropriate to conclude with absolute certainty that 19% of the students are substance dependent.
The impact of gender, grade level and ethnicity on SASSI classification results was examined. Analyses indicated significant gender differences. Twenty-four percent of the male students and 14% of the female students were test positive on the SASSI. In accord with expectations, the likelihood of being test positive on the SASSI increased with grade level -- 11% of junior high students were test positive on the SASSI, in comparison to 23% of high school students. Ethnicity was not shown to have an impact on the likelihood of being test positive on the SASSI.
The students were also asked to report the frequency of their current alcohol and/or drug usage. Of the 420 students who provided that information, 60% indicated that they never use. Of the remaining 40% of students who reported substance use, 25% reported using at least once a month and 15% reported that they used less frequently than once a month (see Table 1 for more specific frequency-of-use percentages). Findings also indicated consistency between SASSI results and self-reported frequency of substance use. Specifically, a higher percentage of test positive cases was found in the group of students who reported using one or more times per month (55% test positive cases) than in the group who reported using less than once a month or not at all (5% test positive cases). Male students reported more frequent usage than females, which is again consistent with the SASSI classification results indicating higher percentage of test positive results for males than for females. Further, 34% of the males reported using one or more times per month, in comparison to 18% of the females. The data also showed a steady increase in reported usage with increasing grade level. About 10% of junior high students reported using at least once a month, and 80% of them report never using. By contrast, 35% of high school students reported monthly usage, and 50% reported never using. It may be of importance to note that there is a large increase in reported usage between the 7th and 8th grades -- monthly usage increased from 6% to 16%. There is also a large increase in reported usage during the senior year. Forty-five percent of 12th graders reported monthly usage, compared to 34% of sophomores and juniors. As was the case in regard to SASSI results, ethnicity was not found to be related to frequency of current alcohol and drug usage.
| Table 1 |
| Self-reported Frequency of Substance Use |
| Frequency |
Number of cases |
Percent of sample |
| More than twice per week |
25 |
6 |
| About twice per week |
17 |
4 |
|
| About once per week |
21 |
5 |
| One to three times per month |
42 |
10 |
| Less than once a month |
63 |
15 |
| Never Use |
252 |
60 |
| Total |
420 |
100 |
It is interesting to note the extent to which the students acknowledged substance abuse. The SASSI includes face valid or obvious scales, as well as subtle scales. High scores on the face valid scales reflect acknowledged substance abuse. The average scores on the Face Valid Alcohol (FVA) and Face Valid Other Drug (FVOD) scales for all students in the present sample (FVA M = 3, FVOD M = 3) were very close to the average scores in a normative adolescent sample (see the Adolescent SASSI profile sheet).
However, the mean scores on the face valid scales of the students who were test positive on the SASSI (FVA M = 11, FVOD M = 12) were above the 98th percentile in the normative sample. Among the students who were test positive on the SASSI, 65% were test positive on the basis of the face valid scales, indicating that they were willing and able to acknowledge their substance abuse. Also, 60% of the students who were test positive on the SASSI, and therefore presumably substance dependent, acknowledged using at least once a week. Thus, it appears that, in the context of the anonymity of the testing program, many of the students who are abusing substances were able and willing to acknowledge relevant behavior.
The SASSI includes six scales that can be used to develop hypotheses regarding some adjustment, as well as addictions problems (FVA, FVOD, OAT, SAT, DEF, and COR). For purposes of the present report, average scores were computed on each of the scales for all students combined and for those students who were test positive on the SASSI. For the entire sample, all six of the scale scores were within the normal range. Students who were test positive on the SASSI showed elevations on the Subtle Attributes (SAT) scale and the Correctional (COR) scale, in addition to the elevations on FVA and FVOD noted earlier. The elevated SAT score (M = 4.7, SD = 2.8) suggests that the students who are test positive on the SASSI do not have adequate insight and awareness regarding the nature of their substance abuse and the impact it has on their lives. The elevated COR score (M = 7.9, SD = 2.4) suggests that the students who are test positive on the SASSI may be relatively likely to act out and present discipline problems.
It may also be of interest to note that the mean Defensiveness (DEF) scale score for the test-positive students is in the normal range (M = 5.9, SD = 3.3). As indicated above, the substance-abusing students were willing to acknowledge their substance abuse in this study. Therefore, it is not surprising that the mean Defensiveness score for test-positive students is not elevated. However, it is often the case that people who acknowledge substance abuse on the SASSI and have high scores on the COR scale also have exceptionally low DEF scores. Low DEF scores are associated with tendencies to endorse negative self-statements and are suggestive of problems with low self-esteem and depressed affect. That is not the case in the present sample. The available evidence on the SASSI suggests that the students who are reporting substance abuse are not showing apparent problems with self-esteem and depressed affect. That may be of some importance because if students who are abusing substances are not showing some of the common emotional problems, it may be difficult for teachers and counselors to identify them for early intervention.
Summary and Conclusions: The present data indicate that there may be a high rate of substance abuse in the population. The problem is more significant among male than female students. It also appears to increase with grade level, with major increases occurring between the 7th and 8th grades and between the 11th and 12th grades. The students were able and willing to acknowledge substance abuse in this study, although they may not have adequate insight into the manner in which the problem may pervade their lives. Given the high rate of substance abuse, the high level of acknowledgment, and the lack of evidence of problems with self-esteem and depressed affect among substance-abusing students, one speculative hypothesis is that these students are able to find cultural acceptance for their substance use.
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CLINICAL INTERPRETATION: SASSI Reveals Clinical Facets of Addicted High School Students
by Wayne Renn
For the clinical interpretation in this issue of News & Reports, the case presented is actually based on a composite of scores rather than a specific client. Each of the scale scores is the mean score for the group of students who tested positive on the SASSI in the sample report that was described earlier. However, for our purposes here, we will present the results as that of Jim, a 17-year-old male student who attends Anytown High School. You might think of Jim's SASSI scores as being typical of a student in this school who is likely to have a substance dependence problem.
As we begin to look at the results of Jim's SASSI, its important to first check for any evidence on the profile that he may have responded in a random or non-meaningful fashion or that he may have deliberately minimized or concealed problems. Since the RAP score of 1 is within normal limits, it would suggest that Jim seemed to have understood the SASSI items and responded in a meaningful way. Also, the DEF score of 6 suggests there is no evidence that Jim intentionally misrepresented or under-reported the degree to which he may be experiencing problems in his life. As we will see later, an average DEF score does not rule out the possibility that Jim may have little or no awareness of certain behavioral problems which, consequently, he is unable to acknowledge on the SASSI.
Based on Decision Rule 1 (FVOD=12) and Decision Rule 2 (SAT=5, over T score of 70), the SASSI results indicate that Jim has a high probability of having a substance dependence disorder. Not only is Jim's acknowledged use of other drugs significantly similar to that of substance dependent teenagers (FVOD=12), but he also is highly similar to addicted adolescents whether or not they were responding in a straightforward manner (SAT=5).
It's worthwhile to note that Jim reports experiencing some negative consequences, loss of control and perhaps social functioning problems with alcohol (FVA=11) as well as with a drug or drugs other than alcohol. Given that his acknowledged use is well beyond what the average teenager reports, it's unlikely that his FVA and FVOD scores are simply reflecting non-problematic social or recreational use.
Jim's demonstrated awareness of some of the problems he experiences while using may be offset by his inability to understand the impact this use has on other areas of his life (SAT=5). Consequently, from his perspective there really is no serious problem that he can't handle. His lack of insight regarding the nature of his substance misuse, the role it plays in helping him to cope with life, and the way it is affecting his psychological and emotional well-being would be typical of clients with elevated SAT scores and relatively average OAT scores (OAT=13). In fact, it's most likely that Jim will be surprised by the SASSI results since average OAT scores usually reflect an individual who sees himself being very different from substance dependent people. Common reactions you might expect range from "It's no big deal, I'm not using more than any of my friends" to "How can I be addicted? It's not like I'm shooting up or laying in a gutter somewhere." Although the responses may differ, the important point to remember is that they stem from Jim's lack of self-awareness and poor insight, not his deliberate attempts to conceal the truth from you. He is also likely to be relatively skilled at presenting himself as well adjusted and "on top of his game" despite any evidence you may have to the contrary.
Jim's responses show some similarity to adolescents who act out and are at risk for disciplinary problems (COR=8). Scores in this range often are associated with clients who tend to socialize with peer groups that are higher risk for norm violations, including the illegal consumption of alcohol and other drugs. It's likely that Jim's risk-taking behavior will ultimately lead to some involvement with school officials or the juvenile criminal justice system. The substance dependence problems further exacerbate his poor behavior management in that he is less able to control his actions when using. Likewise, his tendencies to live by his own standards and rules and act out certainly makes it more likely that he will continue to use illegal substances without appropriate intervention and treatment.
Treatment Recommendations:
The results of the SASSI indicate that Jim is likely to have a substance dependence disorder that will require some form of addictions therapy. His treatment plan should include relatively intensive efforts designed to increase his awareness and insight regarding the nature of his substance dependence problems and the impact of these problems on other areas of his life. Joining Jim in a discussion of his responses on the Face Valid items may be one way to help him further explore specific behaviors and events in a way that leads him to a better understanding of his own addiction. Cognitively structured educational approaches may also facilitate increased awareness of the addictive process in general and how it specifically has been manifested in his life.
In light of Jim's inability to see himself as being similar to other addicted adolescents, a group process may be counter-indicated initially. However, once a solid therapeutic bond with a treatment provider has been established and he gains a better understanding of his addiction issues, both supportive and therapeutic group modalities may be more beneficial. In addition, affective and experiential techniques may be useful in helping Jim to become more aware of feelings and increase his ability to establish intimate, trusting relationships.
Given Jim's risk for acting out behavior, he most likely will need to have some level of supervision that is conducive to helping him manage his own behavior and make appropriate behavioral changes. Anger management and impulse control strategies may also be necessary to help Jim learn more effective ways of dealing with powerful and potentially destructive emotions. This work will be further enhanced by a treatment plan that supports a continued period of abstinence. Hence, random toxicological screening and a relatively high frequency of contacts may help increase the likelihood of a favorable outcome.
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FAQ's - Frequently Asked Questions regarding the Adolescent SASSI
Q - What is the appropriate age range for the Adolescent SASSI?
A - The normative data used in the development of the Adolescent SASSI included students ranging in age from 12 to 18 years old.
Q - Since the Adult SASSI-3 and the current Adolescent SASSI are both appropriate for 18-year-old clients, how do I decide which one to use?
A - We typically suggest that you consider at least two issues with regard to selecting the optimal form. First, the life circumstances and emotional development of the client may provide some direction as to which form to use. For example, the Adult SASSI-3 may be the better choice for an 18-year-old client in her first year of college working and living on her own away from home, relatively independent from parents. On the other hand, the adolescent form may be more suited for an 18-year-old who recently graduated from high school, still lives at home with his parents, and is unemployed and hanging out with his high school buddies.
Secondly, the adult and adolescent forms differ with regard to some of the scales. For example, the SYM and FAM scales only appear on the Adult SASSI-3. Therefore, the adult form may be the most appropriate in those cases where you want some measure of the person's ability or willingness to acknowledge the behaviors and experiences commonly thought to be associated with the causes of substance dependence (SYM). Likewise, the adult form would also be the best choice in those cases where it's important to measure the client's similarity to family members of substance dependent individuals (FAM). Conversely, if you want to know how the client's responses compare to other adolescents who are at high risk for acting out behavior (adolescent COR scale), the adolescent form is the better choice.
Q - What is the reading level of the Adolescent SASSI?
A - 5th grade.
Q - How do I know if the adolescent client really understood the questions?
A - The Random Answering Pattern (RAP) scale on the adolescent profile measures the degree to which the client responded to the items on the SASSI in a meaningful way. Generally speaking, scores of 0 or 1 indicate a normal pattern of response (i.e., the client took the time to read the item, understood what it was asking and responded accordingly). Scores of 2 or higher on the profile could indicate random or non-meaningful responding. In these cases, a relatively cautious approach regarding the meaning of the results is recommended until you can resolve the problem. Sometimes, reviewing the relevant RAP items with clients can be a useful way to gain important information about the nature of their answers.
Q - How should I administer the SASSI to teenagers who have literacy problems?
A - If you suspect that clients' reading skills may limit their ability to understand the Adolescent SASSI items, it is permissible to read the questionnaire to them. One effective method of administration is to have clients sit at a table with a copy of the questionnaire that they will be completing. From a different location in the room, the administrator can slowly read each of the items from a separate form as clients fill in responses on their own form. The SASSI Institute also distributes an audiotape that can be used for this type of administration. For additional information, please call 1-800-726-0526.
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