The Adolescent Substance Abuse Subtle Screening Inventory-A2 (SASSI-A2)

The Adolescent Substance Abuse Subtle Screening Inventory-A2 (SASSI-A2) is a self-report questionnaire designed to screen adolescents ages 12–18 for substance use disorders (SUDs). The SASSI-A2 is a clinical instrument that attempts to overcome the obstacle of adolescent duplicity and denial by using questions with obvious face validity for substance use, as well as questions with less obvious (subtle) clinical contexts. The inventory includes 72 true/false items assessing:

• Substance misuse symptoms
• Family and social environment risks
• Attitudes and beliefs regarding alcohol and drug use
• Subtle items designed to identify individuals with substance use problems

The SASSI-A2 also includes 28 four-choice Likert-type items assessing the frequency, extent, and nature of substance abuse. Six additional items assess current and past substance use, school information, and legal involvement, but are not used in scoring.

The SASSI-A2 has several administration and interpretation formats, including:

• Paper-and-pencil
• Computer-based
• Optical scanning
• Online

A 4.4 reading level is required. There is an audio administration version for examinees with low reading levels. The instrument allows clinicians to designate one of four time periods relative to substance use.

Scoring for the paper-and-pencil version is done with a gender-based profile document and a scoring template. Twelve scales are obtained through the scoring format to determine:

• Similarity to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, DSM-5) substance use disorder criteria
• Abuse severity level
• Environmental factors associated with substance use disorders
• Similarity to individuals with a history of legal violations

The profile converts scores to standard scores with separate gender-based norms. Nine decision rules are applied to scale scores to determine:

• The high probability or low probability of a substance use disorder
• Severity

Development

The Adolescent SASSI was originally developed in 1990. In 1998, a research edition of the SASSI-A2 was initiated that included original Adolescent SASSI items and 45 new items. The final form, published in 2001, included 40 items from the original Adolescent SASSI and 32 of the experimental items. Data were obtained from 2,326 adolescents ages 12–18 enrolled in 48 treatment and correctional programs, including:

• Addictions treatment centers
• Inpatient psychiatric hospitals
• Outpatient behavioral health facilities
• Juvenile corrections programs
• Five school systems

The assumption guiding the SASSI-A2 is that respondents either manifest or do not manifest similarity to diagnostic criteria associated with substance-related and substance-induced disorders listed in the DSM-IV-TR. Supplemental materials promote the use of the SASSI-A2 with updated DSM-5 criteria.

Technical Information

Development of the SASSI-A2 was based on a sample size of 1,470 adolescents ages 12–18. This sample was diverse in terms of:

• Gender
• Ethnic classification
• Age
• Employment status
• Existence or nonexistence of substance use/dependence disorder
• Clinical setting
• Residential circumstances
• Prior involvement with legal systems

A subset of this sample (N = 1,244) was divided into development (n = 621) and cross-validation (n = 623) samples to develop and cross-validate decision rules. A normative sample of 856 adolescents drawn from school and community youth program settings was also used.

Using a sample of 70 adolescents and a 2-week interval, test-retest correlation coefficients for the nine scales used in determining high or low probability of substance use disorder ranged from .81 to .92. The overall coefficient was .89.

Internal consistency (alpha) coefficients (N = 2,145) ranged from .63 to .95, with an overall alpha coefficient on the nine scales of .75. Internal consistency is not a major consideration in the SASSI-A2’s reliability because the scale was not intended to measure a unitary construct.

Validity evidence is reported in terms of concurrent validity. The scale is based upon the premise that instrument results match clinical substance use disorder diagnoses. Combining development and cross-validation sample data, the overall accuracy rate in positively identifying individuals with and without SUD was 94%. The SASSI-A2 does not predict future substance use problems.

Other validity evidence includes:

• Sensitivity
• Specificity
• Positive and negative predictive power

For the combined sample data, a 95% sensitivity rate was reported in identifying respondents with an SUD who tested positive on the SASSI-A2. The instrument had an 89% specificity rate. It had a 98% positive predictive power rate. The negative predictive power rate was 75%.

Data suggest that accuracy is not significantly influenced by demographic and overall functional level and adjustment factors.

Commentary

The SASSI-A2 is a structured assessment for use with adolescent substance users. The most utility would be demonstrated in work with adolescents in treatment, service, or correctional settings who are diagnosed with or suspected of having SUDs. Use as a screening measure with general adolescent populations in school or community settings may be limited. Incorporating the SASSI-A2 with a comprehensive clinical or biopsychosocial interview would likely attain the maximum clinical utility.

Other limitations include:

• Lack of information about the geographical locations of test development samples
• The need for a more ethnically diverse nonclinical normative sample

Further delineation of norms, clinical, and validation data is needed for African American, biracial, and multiracial youth.

The SASSI-A2 is an appropriate instrument to supplement a comprehensive clinical or substance abuse–related interview or biopsychosocial assessment. It helps clinical personnel establish the similarity of adolescents to those diagnosed with SUDs. At this time, the instrument has limited utility as a general screening measure for adolescents within the general population or in nonclinical or noncorrectional settings.

More work is needed to:

• Expand ethnic representation within nonclinical normative groups
• Further delineate internal consistency reliability
• Expand instrument validation

Additional research is needed to substantiate the SASSI-A2’s applicability to DSM-5 diagnostic changes.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.

Lazowski, L. E., & Miller, G. A. (2013). The adolescent SASSI-A2 updated user’s guide. The SASSI Institute.

Miller, F. G., & Lazowski, L. E. (2001). The adolescent SASSI-A2 manual. The SASSI Institute.

Perera-Diltz, D. M., & Perry, J. C. (2011). Screening for adolescent substance-related disorders using the SASSI-A2: Implications for nonreporting youth. Journal of Addictions & Offender Counseling, 31, 66–79.