Norm-referenced assessment

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 An important aspect of using a norm-referenced assessment is the degree to which the norming group is representative of the target population to be assessed. Analyze available reviews for the Substance Abuse Subtle Screening Inventory (SASSI-3) in the Mental Measurements Yearbook, which can be found on the Week 3: Norm-Referenced AssessmentLinks to an external site. reading list. Provide a brief evaluation of the appropriateness of using SASSI-3 with young adult clients presenting problem drinking on a college campus. Incorporate one scholarly peer-reviewed article 

Substance Abuse Subtle Screening Inventory–3

Review of the Substance Abuse Subtle Screening Inventory-3 by EPHREM FERNANDEZ, Associate Professor of Clinical Psychology, Southern Methodist University, Dallas, TX:

DESCRIPTION. The Substance Abuse Subtle Screening Inventory-3 (SASSI-3) is a psychometric instrument that is designed to make inferences about substance dependence disorder. On one side, it has 14 face valid items that are quite obvious in their relationship to substance dependence; these are further divided into items related to alcohol and items related to other drugs. The other side consists of 67 items that are supposed to be indirect or nonmanifest in their relationship to substance dependence. The face valid items are to be rated on a 4-point scale of frequency, and the other items are in a true-false format. Responses can be made with reference to any one of four time frames: entire life, past 6 months, 6 months before, or 6 months since. The test is usually completed within 15 minutes and objectively scored within a minute or 2. Computerized versions are available, and so are optical scanning versions as well as an audiotaped version for those with reading difficulties.

Nine subscales are embedded in this instrument: Face Valid Alcohol, Face Valid Other Drugs, Symptoms, Obvious Attributes, Subtle Attributes, Defensiveness, Supplemental Addiction Measure, Family vs. Controls, and Correctional. In addition, there is a scale to detect random responding.

Scores are interpreted with reference to a decision rule stipulating cutoffs for each subscale. Exceeding any rule leads to an inference of high probability substance dependence disorder. Only if scores are below the cutoff on all rules is an inference of low probability made. The scores can be plotted on a profile graph. Further interpretation of individual subscale scores is possible, though (as the authors caution) such interpretations do not rest on empirical research and are best viewed as hypotheses and ideas for assessment.

DEVELOPMENT. This is a third edition of the adult form of the SASSI originally developed by Miller (1985). An adolescent SASSI was developed in 1990, and a Spanish version emerged in 1996. The SASSI-3 was developed out of data from a sample of 2,015 respondents, most of whom were in addiction treatment facilities, general psychiatric hospitals including a dual diagnosis center, a vocational rehabilitation program, and a sex offender treatment program. A subset of 839 cases had DSM diagnoses in addition to SASSI scores, and this was randomly divided into roughly equal numbers of those diagnosed with substance use disorder and those diagnosed without it. Data from the first of these subsamples were used to formulate decision rules on SASSI scoring, and these were cross-validated in the second subsample. There were no significant differences between these two subsamples in terms of age, years of education, or other demographic variables.

TECHNICAL. Psychometric studies of the SASSI have been accumulating although many have been on the adolescent version and other previous versions of the instrument. Many of the studies also remain in the form of unpublished dissertations.

Teslak (2000) found that SASSI-3 scores correlated with scores on similar screening measures such as the Michigan Alcoholism Screening Test (MAST) and the Drug Abuse Screening Test (DAST). However, the SASSI-3 was no more accurate than either of its counterparts and did not show incremental utility. Pearson (2000) found that the SASSI-3 predicted psychiatric substance use disorder. However, the concordance rate of the SASSI-3 with psychiatric substance use disorder was .69 for true positive rate and .82 for true negative rate, and these figures are considerably lower than previously observed. Arenth, Bogner, Corrigan, and Schmidt (2001) found lower accuracy, sensitivity, and specificity for the SASSI-3 in patients with traumatic brain injury than for a sample of disabled persons in a vocational rehabilitation program. Furthermore, they found that blood alcohol level at the time of injury had higher specificity when compared to SASSI-3 test classifications. More encouraging psychometric findings have been reported by Lazowski, Miller, Boye, and Miller (1998). Working on the development sample described earlier, these authors found a 95% concordance between SASSI-3 inferences and clinical diagnoses of substance dependence. The test had a sensitivity of 96% and a specificity of 93%. Its retest reliability in a sample of 40 respondents assessed 2 weeks apart was in the range of .92 to 1.00. The authors also noted that as compared to those who were test negative on the SASSI-3, those classified as test positive had higher mean scores on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Addiction Acknowledgment Scale, the MMPI-2 Addiction Potential Scale, the MacAndrew Alcoholism Scale-Revised, the Michigan Alcohol Screening Test, the Millon Clinical Multiaxial Inventory-II (MCMI-II) Alcohol Dependence Scale, and the MCMI-II Drug Dependence Scale. However, the absence of correlation coefficients in this context makes it difficult to conclude about the concurrent validity between the SASSI-3 and these other instruments.

The SASSI-3 is portrayed as a test of substance dependence disorder, but how this differs from other substance-related disorders is left unclear. This is compounded by the authors’ references to terms such as substance use, substance abuse, and substance misuse. In an appendix to the user’s guide, it is stated that the SASSI-3 can be used to flag for further evaluation of substance abuse disorder. This is misleading in that it suggests that substance dependence is a mild precursor of substance abuse when (as defined by DSM) the latter is not associated with tolerance, withdrawal, or compulsive use. Also, by way of definition, it would be useful to clarify the substances that are embodied in this category of disorders. In DSM, this extends beyond the illicit drugs (that seem to be the focus of the SASSI-3) to medications, toxins, and even items of household consumption. DSM diagnoses of substance dependence also come with specifiers such as with or without tolerance, and different types of remission. In the absence of such specifiers, a SASSI-3 diagnosis is of limited clinical utility.

An even more serious handicap of the SASSI-3 is that it permits only a dichotomous interpretation of high versus low probability of substance dependence. There are more than 80 items and nine decision rules; have the authors perhaps undersold the instrument by ignoring the possibility that the number of decision rules satisfied might be related to the confidence level in diagnosing a substance dependence disorder? At least, if statements about medium probability of the disorder were possible, the instrument would be more clinically useful.

At a more minor level, some items in the SASSI-3 are phrased in common lingo (e.g., Item 8 on the FVOD: “Gotten really stoned or wiped out on drugs [more than just high]”). Other items use technical jargon that may not be fathomed (e.g., Item 9 on the FVA: “Had the effects of drinking recur after not drinking for a while [e.g., flashbacks, hallucinations, etc.]”). It is hard to see the purpose of a question about “weekly family take home income.”

COMMENTARY. The SASSI-3 is laudable in its attempt to assess substance dependence regardless of participants’ acknowledgment or denial. It does so by using a number of subtle items that may be indirectly associated with substance use. It is also convenient to administer, quick to score, and readily interpreted. However, the interpretations can only take the form of high or low likelihood of the disorder in question. This does not add much to a DSM diagnosis of substance dependence, and it also fails to shed light on the many qualifiers of such a diagnosis. No doubt, elaboration and illumination of the disorder is possible with further research in this area. Further research is also needed to quantify the psychometric features of the SASSI-3. Especially needed are factor analytic studies of the kind done on its predecessors, the SASSI-2 and the SASSI. There is reason to believe that such factorial validity as demonstrated for its predecessors will prevail in the case of the SASSI-3.

SUMMARY. As with many instruments that are driven exclusively by empirical data, the SASSI-3 is methodologically commendable but conceptually less impressive. This limits its clinical potential too. Yet, the test is widely used. With further research and revision, it can be expected to fill a significant void in the field of assessment of substance use disorders.

REVIEWER’S REFERENCES

Arenth, P. M., Bogner, J. A., Corrigan, J. D., & Schmidt, L. (2001). The utility of the Substance Abuse Subtle Screening Inventory-3 for use with individuals with brain injury. Brain Injury, 15, 499-510.

Lazowski, L. E., Miller, F. G., Boye, M. W., & Miller, G. A. (1998). Efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) in identifying substance dependence disorders in clinical settings. Journal of Personality Assessment, 71, 114-128.

Miller, G. A. (1985). The Substance Abuse Subtle Screening Inventory (SASSI): Adult SASSI-2 manual supplement. Spencer, IN: Spencer Evening World.

Pearson, B. S. (2000). Validation of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) with the adult chronically mentally ill population. Dissertation Abstracts International: Section B: The Sciences and Engineering, 60 (12-B): 6418.

Teslak, A. G. (2000). The utility of the CAGE, MAST, DAST, and SASSI-3 in assessing substance use/misuse in a psychiatric population. Dissertation Abstracts International: Section B: The Sciences and Engineering, 61 (5-B): 2814.

Review of the Substance Abuse Subtle Screening Inventory-3 by DAVID J. PITTENGER, Head and Associate Professor, Department of Psychology, The University of Tennessee at Chattanooga, Chattanooga, TN:

Like the proverbial better mousetrap, many clinicians and counselors will beat a path to the developer of a better indicator of substance abuse. An inexpensive instrument that readily identifies the presence of substance abuse is of considerable value for those working in a variety of venues including colleges and universities, where some students evidence the early stages of substance dependence; medical settings, where substance abuse compromises the health and treatment of the patient; and psychological treatment facilities where patients may exhibit psychiatric problems that mask significant substance abuse problems. The publishers of the third edition of the Substance Abuse Subtle Screening Inventory (SASSI-3) assure us that they have produced the better substance abuse index.

DESCRIPTION AND DEVELOPMENT. The SASSI, which was first published in 1988, is an empirically derived inventory designed to indicate the risk of substance dependence using items that are less likely to elicit suspicion and untruthful answers. Myerholtz & Rosenberg (1998) reported that the SASSI is an extremely popular instrument and used in a variety of treatment facilities as well as other settings (e.g., schools and employee assistant programs).

According to the SASSI-3 manual, the goal of the revision was to increase the ability of the SASSI to discriminate between those who are or are not substance dependent. The current version of the instrument contains most of the items used in the previous edition of the inventory and is appropriate for adults (age 18 and older). The publisher also produces an adolescent (ages 12-18) version of the SASSI.

The SASSI-3 consists of two parts that are printed on separate sides of a single paper form. The first part of the instrument represents the subtle portion of the inventory and contains 67 true-false statements. The vast majority (57) of the statements make no overt reference to drug and alcohol use, and appear to be easily understood by most adults. Twenty of these items were taken from the Psychological Screening Inventory (Lanyon, 1970).

Manual scoring consists of an easy-to-use transparent scoring template for the eight subscales of the first portion of the instrument. Alternatives include a computer version of the instrument and answer forms that may be machine scored. The publisher also offers an audiotape of the SASSI-3 for clients with reading problems. Scoring the first portion of the instrument yields one validity scale, five clinical scales, and two ancillary scales.

The Random Answer Pattern (RAP) is a measure of validity. It indicates whether the client answered randomly or had difficulty understanding the items.

There are three clinical scales that measure the presence of symptoms of substance abuse. The Symptoms (SYM) scale is a new scale that assesses the presence of behavioral, emotional, and social correlates of substance abuse. The Obvious Attributes (OAT) scale is an index of the social effects substance abuse (e.g., legal problems). According to the user’s guide, persons diagnosed with substance abuse are likely to endorse this item when answering honestly. The Subtle Attributes (SAT) scale complements the OAT scale as it consists of statements endorsed by substance dependent patients attempting to hide their dependence as well as those who answered honestly.

The Defensiveness (DEF) scale assesses willful attempts to deny substance dependence as well as a personality trait or reaction to stressful personal circumstances. The Supplemental Addiction Measure (SAM) scale purports to differentiate between defensive clients hiding substance abuse and other defensive individuals.

The Family vs. Controls (FAM) scale identifies individuals who may live with or have a significant relationship with a substance abuser. This scale is not used in determining substance dependence, but may be used to assess the needs of those close to a substance dependent person. Similarly, the Correctional (COR) is not a clinical measure as it serves as an indication of abusers who have had a record of legal/criminal entanglements.

The second portion of the instrument consists of 12 questions that identify the extent of alcohol use and 14 questions that identify the extent of other drug use. Clients may be instructed to answer the questions within the time frame of their entire life, during the past 6 months, or 6 months before or after a critical event. Although the instrument offers these options, the manual warns that the 6-month time frames may increase the proportion of false positives. Consequently the manual encourages users to use the entire lifetime unless circumstances dictate otherwise. The scale for these questions is a Likert scale ranging from 0 (never) to 4 (repeatedly).

There are separate normative data for male and females. Interpreting the results begins by plotting each subscale score on a graph that creates a client profile and then completing a checklist for nine “decision rules.” Each rule determines whether the client scored at or above a critical score for one or a combination of the scales. A positive response to any one of the rules is evidence of a high probability of substance dependence. An extensive user’s guide, which is separate from the manual, provides detailed accounts of different profiles that may emerge and their clinical significance.

TECHNICAL. The promotional material and manual for the SASSI-3 make extensive reference to the predictive validity of scores from the instrument. Specifically, the claim is that the SASSI-3 has a 94% correspondence rate with clinical assessments of substance abuse. Independent research examining the utility of the SASSI-3 also suggests that the instrument is an extremely useful tool (Horrigan & Piazza, 1999; Horrigan & Katz, 2000; Horrigan, Schroeder, & Schaffer, 2000) that should be used during the initial screening for substance abuse. Although these results are encouraging, they need to be interpreted with due caution. Striking features of the manual are the data and statistical information that are not reported. Those familiar with the Standards for Educational and Psychological Testing (AERA, APA, & NCME, 1999) will be disappointed by the notable absence of information that would allow one to make a more informed decision regarding the utility of the instrument.

The sample used to create the norms for this version of the instrument were 848 patients drawn from addiction treatment centers, general psychiatric hospitals, dual diagnosis hospitals, vocational rehabilitation programs, and sex offender treatment programs. All participants had completed the SASSI-3 and had been independently evaluated for substance abuse using the criteria established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987; DSM-IV, American Psychiatric Association, 1994). There is no indication of the credentials of the persons rendering the diagnosis of substance abuse. Within the sample, 80% were diagnosed as substance dependent.

COMMENTARY. Although the reported accuracy rate of the SASSI-3 is high, the data should be interpreted with some caution. Using the test with populations for which there is a high proportion of substance abuse may inflate its criterion validity. Stated from a different perspective, using the instrument as a screening instrument for populations with a lower base rate of substance dependence (e.g., college students, employee assistance programs) may produce lower criterion validity estimates (Lilienfeld, Wood, & Garb, 2000). Using the data presented in the manual, I determined LB, an asymmetric measure of association, to be LB = .70. In other words, using the SASSI-3 reduces by 70% the error in predicting the criterion of substance dependence. Although this is an extremely high value, it may be substantially lower for different populations. Unfortunately, the manual provides no normative data for populations not directly associated with treatment for a psychopathology.

There are other notable absences in the supporting materials. As stated previously, the SASSI-3 contains several important clinical scales. Indeed, the user’s guide describes several examples of patients who represent different clinical symptom profiles. Unfortunately, there are no data to verify the appropriateness of making these distinctions among profile patterns. Similarly, there has been no attempt to confirm the factor structure of the instrument. Indeed, Gray (2001) was unable to confirm a factor model implied by the subscales.

There is also limited information regarding the temporal stability of the instrument. The manual reports high test-retest reliability for a 2-week interval with only 40 respondents who were part of the substance abuse treatment population. Myerholtz and Rosenberg (1997, 1998) reported much lower reliabilities for the binary diagnosis of substance dependence for the 2-week interval (phi = .68) and the 4-week interval (phi = .36), and that SASSI scores are susceptible to instructions for fake good or bad.

Finally, there are no data to indicate the utility of the SASSI-3 relative to other measures of substance abuse. Myerholtz and Rosenberg (1998) reported moderate to large coefficient Kappas between the SASSI and other indicators of substance abuse, some of which are in the public domain. Given the availability of a number of alternative screening instruments, one would hope to have data that illustrate the incremental validity of using the SASSI-3 at the exclusion of other instruments.

SUMMARY. The SASSI-3 may well serve as a quick and ready triage instrument for the presence of substance abuse. Users should not be sanguine in assuming the SASSI-3 is as accurate as its publisher claims. Consequently, one hopes that the publishers of the instrument will expand their analysis of the psychometric properties of the instrument.

REVIEWER’S REFERENCES

American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (1999). Standards for educational and psychological testing. Washington, DC: American Educational Research Association.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders: DSM-III-R. Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: Author

Gray, B. T. (2001). A factor analytic study of the Substance Abuse Subtle Screening Inventory (SASSI). Educational & Psychological Measurement, 61, 102-118.

Horrigan, T. J., & Katz, L. (2000). Ohio’s Bill 167 fails to increase prenatal referrals for substance abuse. Journal of Substance Abuse Treatment, 18, 283-286.

Horrigan, T. J., & Piazza, N. (1999). The Substance Abuse Subtle Screening Inventory minimizes the need for toxicology screening of prenatal patients-A post partum assessment. Journal of Substance Abuse Treatment, 17, 243-248.

Horrigan, T. J., Schroeder, A. V., & Schaffer, R. M. (2000). The triad of substance abuse, violence, and depression are interrelated in pregnancy-National survey findings. Journal of Substance Abuse Treatment, 18, 55-58.

Lanyon, R. I. (1970). Development and validation of a psychological screening inventory. Journal of Consulting & Clinical Psychology, 35, 24-37.

Lilienfeld, S. O., Wood, J. M., & Garb, H. N. (2000). The scientific status of projective techniques. Psychological Science in the Public Interest, 1, 27-67.

Myerholtz, L. E., & Rosenberg, H. (1997). Screening DUI offenders for alcohol problems: Psychometric assessment of the Substance Abuse Subtle Screening Inventory. Psychology of Addictive Behaviors, 11, 155-165.

Myerholtz, L., & Rosenberg, H. (1998). Screening college students for alcohol problems: Psychometric assessment of the SASSI-2. Journal of Studies on Alcohol, 59, 439-446.

Article Reference: Fernandez, E., & Pittenger, D. J. (2003). Substance Abuse Subtle Screening Inventory–3 (The). 
The Fifteenth Mental Measurements Yearbook.

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