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Module 10 I - Disabilities and Alcohol Use Disorders

PARTICIPANT HANDOUT

Introduction

The Americans with Disabilities Act has increased the responsibility of alcoholism treatment programs to accommodate individuals with disabilities, but many individuals with a disability do not get needed alcoholism treatment (de Miranda, 1999; DiNitto & Webb, 1998; Moore, 1998; National Association on Alcohol, Drugs and Disability, 1999; Wolkstein, 2002). Social workers and others in the helping professions generally receive little education about disabilities, and even less about individuals with co-occurring disabilities and alcohol problems. Health care professionals also have their own experiences, beliefs and attitudes about alcohol problems that may inhibit recognition and referral to treatment. Social workers often need to employ advocacy skills at all systems levels to acquire alcoholism treatment for individuals with co-occurring disabilities (de Miranda, 1999). When an individual with a disability does not do well in alcoholism treatment, insufficient accommodation may be the root cause (Moore, 1998).

Examples are a good way to increase the understanding of alcohol use disorders and co-occurring disabilities. Thus, this module discusses alcohol problems in conjunction with intellectual or cognitive disabilities (mental retardation and traumatic brain injury) and physical disabilities (spinal cord injury, deafness/other hearing difficulties, and blindness/ other visual impairment). These disability areas have received the most attention in the alcoholism literature. (Conditions of mental illness that may be disabling are addressed in another module.)

Learning Objectives

This module provides information on alcohol use disorders as they relate to individuals with disabilities. By the end of this module, social work learners should be able to:

A. Describe the relationship between alcohol use disorders and co-occurring disabilities.
B. Recognize ways to improve treatment of alcohol use disorders for individuals with co-occurring disabilities.

Background


A chart of percent with Disability by Age. <5=1%, 6-14=8%, 15-21=6%, 22-24=22%, 45-54=15%, 55-64=15%, 65-79=22%, 80+=11%

In 1997, an estimated 53 million Americans had a disability, including 33 million whose disabilities were severe (McNeil, 2002). No agreed upon, universal typology of disabilities exists, however the category of severe disability usually includes conditions that prevent an individual from adequately performing at least some tasks or activities required for daily living. Smart (2001) describes other ways to discuss disabilities. One is in terms of four broad categories:

  • physical disabilities that include sensory, mobility, and health disorders (e.g., stroke, cerebral palsy, spinal cord injury, Parkinson's disease, post-polio syndrome, diabetes, AIDS, children born after exposure to certain teratogenic agents, etc.);
  • intellectual disabilities (e.g., mental retardation, Down syndrome, or autism);
  • cognitive disabilities (e.g., learning disabilities and traumatic brain injury);
  • psychiatric disabilities (e.g., mental illness or substance use disorders).

Another categorizing framework involves onset. For example, congenital, lifelong disability (e.g., those manifested in the prenatal, perinatal, or neonatal period) can be compared to disability that is acquired at a later stage of development due to accident, illness, injury, or gradually/developmentally manifested disorders. Onset also includes the factors of acute (sudden) or gradual appearance of the disabling condition. Onset is important for adjustment because it involves elements of plasticity and adaptability, time for adapting, scope of functions affected, access to support and resources, anticipatory socialization opportunities, and expectations.

In addition to the domain of the disability and the nature of its onset, an individual's response to disability is also affected by environmental factors such as responses of significant others and cultural/societal responses to disability. Individuals with disabilities may be overprotected and restricted from normal life experiences, or denied employment and opportunities for social interaction. In some countries, individuals with disabilities are respected and integrated into society, while those in other countries are stigmatized, denigrated, victimized, and ostracized.

Smart (2001) notes that, "it is not disability itself, but the meaning that the individual ascribes to the disability that will determine the response to the disability," and this construction may change over time (p. 229).

"…It is not disability itself, but the meaning that the individual ascribes to the disability that will determine the response to the disability…"

Smart (2001, p. 229)

Some responses are more positive or adaptive than others. For example, an individual who acquires a disability may proceed to develop new interests, learn new skills, and become active in disability rights/advocacy movements. Or, an individual who is responding to loss, anger, grief, guilt, frustration, low self-esteem, or physical pain due to a disability may find that alcohol provides initial or temporary solace or relief. Although drinking might remit following a period of adjustment to an acquired disability, an alcohol use disorder is a problem in its own right, and requires primary treatment.

Almost any disability can co-occur with an alcohol use disorder. Whether or not there is a direct relationship between the two, alcohol problems impair an individual's response to a disability. A pre-existing alcohol use disorder can hinder an appropriate response to the disability, and an alcohol use disorder that develops after a disability can impede the development of skills necessary to adjust to the disability, and can cause previously acquired skills to deteriorate (Koch, Nelipovich, & Sneed, 2002).

Alcohol and Intellectual Disabilities

Approximately 2-3% of the population meets criteria for mental retardation (Burgard, Donohue, Azrin, & Teichner, 2000; Westermeyer, Kemp, & Nugent, 1996), now referred to as an intellectual disability (Asch, 2001). The American Psychiatric Association (2000) levels of intellectual functioning are described in the box to the right and illustrated in the graph below. Many individuals with mild or moderate intellectual disabilities live within the general community, thereby having ready access to alcohol. However, evidence suggests that they are less likely to use alcohol than the general population (DiNitto & Webb, 1998).

APA Levels of Intellectual Disability:
- Mild (IQ of 50-55 to approximately 70)
- Moderate (IQ of 35-40 to 50-55)
- Severe (IQ of 20-25 to 35-40)
- Profound (IQ below 20 or 25)


A chart of IQ ranges

The sparse literature on intellectual disability and alcohol problems suggests that a person with intellectual disabilities drinks to "fit in" with the rest of the world (Selan, 1981). Unfortunately, these individuals are also easily influenced and vulnerable to exploitation (Pack, Wallander, & Browne, 1998; Sobsey, 1994). They can benefit from instruction on how to avoid alcohol problems. For example, those who take psychotropic, anticonvulsant (antiseizure), or other medications need appropriate instruction on the contraindications of using them with alcohol and other drugs-as well as instruction on how to distinguish between medications prescribed by a doctor and other substances (Christian & Poling, 1997).

Westermeyer et al. (1996) found no differences in psychological, family, interpersonal, job, or legal problems among patients with and without an intellectual disability admitted to chemical dependency treatment. However, those with an intellectual disability were overrepresented in the program compared to their numbers in the general population, despite a later onset of alcohol and other drug use and shorter duration of related problems. This may be because even small amounts of alcohol can compromise the already impaired functioning of an individual with an intellectual disability (Westermeyer et al., 1996). This low threshold should be considered when screening for alcohol problems among individuals who have intellectual disabilities, although remarkably few programs for people with intellectual disabilities conduct such screening.

McGillicuddy and Blane (1999) designed two substance abuse prevention programs for adults with intellectual disabilities. One focused on assertiveness skills, the other on normative behaviors and role models. Both interventions resulted in increased knowledge and skills, but not improved attitudes or reduced substance use. This may be related, in part, to the specific nature of intellectual disabilities-individuals with mental retardation do not generalize well between training and real-life situations.

Intervention may not alter drinking behavior in this population if cognitive limitations and social skill needs are not appropriately accommodated

Alcoholism treatment programs that served clients with intellectual disabilities used longer treatment periods; more supportive, directive, and behavioral techniques; less confrontation; more individual and less group treatment; more alcohol education and simplification and repetition of concepts; more concrete goals over shorter time frames; close work with family members; and more patience (Campbell, Essex, & Held, 1994; Krishef & DiNitto, 1981). The Association for the Help of Retarded Children in New York City provides one of the few programs specifically for individuals with intellectual disabilities who have alcohol or other drug problems. An earlier program, the Maine Approach (1984), offered a comprehensive model for assisting people with co-occurring intellectual disabilities and alcohol problems. It recommended behavioral techniques, contracting, 12-step programs for those capable of participation, and included sponsors who were willing to work closely with the client. Wenc (1980/1981) emphasized that 12-step groups provide these individuals with much-needed socialization opportunities (that did not involve alcohol situations) and encouraged care providers to accompany clients to these groups rather than simply referring them.

Westermeyer et al. (1996) suggest that cognitively-based relapse prevention and 12-step groups may not be effective with this population. They recommend residential placement in facilities familiar with the unique needs of individuals with intellectual disabilities, involvement of family members and significant others, supervision, day and evening programs with specialized groups for people with mental retardation, and rewards for maintaining abstinence. Paxon (1995) recommends relapse prevention strategies that include self-regulatory training which helps clients monitor their behavior and anticipate its effects, and skills training which assists clients to develop proficiencies related to specific tasks. Alcoholism treatment providers are encouraged to offer support groups specifically for individuals with intellectual disabilities.

Spinal Cord Injuries

Spinal cord injury (SCI) to the back or neck often causes paralysis. Paraplegia is spinal cord damage that results in loss of feeling or inability to use the lower body or legs. Tetraplegia (formerly called quadriplegia) is spinal cord damage that results in loss of feeling or inability to use the lower body/legs, and all or part of the arms or upper body (Medical Rehabilitation Research and Training Center, 1996). An estimated 183,000 to 230,000 individuals in the United States have spinal cord injuries (National Spinal Cord Injury Statistical Association, 2001). Fifty-five percent were injured between the ages of 16 and 30, and 82% are male. The most common causes of SCI are motor vehicle accidents (39%); violence, primarily from gunshot wounds (25%); and falls (22%). Intoxication has been implicated in 39% to 50% of SCIs, and substantial numbers of these individuals had pre-existing alcohol use disorders (Bombardier & Rimmele, 1998; Heinemann & Hawkins, 1995).

Crises like the experience of an SCI are prime opportunities for alcohol intervention. Professionals are often reluctant to address alcohol use, but Bombardier and Rimmele (1998) found considerable willingness to discuss drinking and motivation to change among SCI patients who had pre-injury alcohol problems. In a sample of 121 individuals with SCI, Heinemann, Schmidt, and Semik (1994) reported that the percent of heavy drinkers decreased from 55 percent to 20 percent during the 12 months after injury. However, treatment providers are concerned about increased drinking over time (Babor, 1993; Heinemann & Hawkins, 1995). Frequent or persistent pain may increase patients' risk for self-medicating with alcohol (Radnitz & Tirch, 1995). But alcohol abuse can result in physical problems such as increased dependence on catheterization (O'Donnell et al., 1981/1982), bladder infections (Moore, 1998), serious medication interactions (Moore & Ford, 1991), and pneumonia or other life-threatening illnesses (Yarkony, 1993). Psychosocial problems may also ensue, such as depression, decreased life satisfaction (Young et al., 1995), and neglect of activities necessary to achieve full functional potential (O'Donnell et al., 1981/1982).

Spinal Cord Injuries
- Affect 183,000-230,000 people
- Intoxication is involved in 39-50% of injuries (pre-existing alcohol use disorders)
- People with brain injuries or spinal cord injuries, or mental illness may have AODA rates as high as 50% compared to 10% in the general population
- Drinking may decline during the first year
- Alcohol increases the risk of physical & mental complicating conditions
- Alcohol interferes with function and adjustment

Following hospitalization, individuals with SCI usually participate in inpatient rehabilitation. Patients may be reluctant to leave the SCI rehabilitation setting due to fears of independent living (Anderson, 1980/1981) and concerns that successful rehabilitation may lead to loss of Social Security or other benefits (DiNitto & Webb, 1998). Those with alcohol problems can benefit from programs that integrate SCI rehabilitation with alcoholism treatment, but such programs are rare.

In some cases, family members feel resentment toward the individual with a disability, feel guilty about their resentment, and do too much to "help" (O'Donnell et al, 1981/1982; Perez & Pilsecker, 1994). Providing a drink to the individual with SCI may temporarily alleviate family members' guilt, avoid angry exchanges, or may be seen as promoting normalcy (O'Donnell et al,1980/ 1981; Radnitz & Tirch, 1995). Involving family members in treatment can help avoid their "enabling" of the problem drinking.

Following a return to the community, individuals with SCI may attend outpatient alcoholism treatment programs and 12-step or other self-help meetings. They may also benefit from group sessions specifically for people with physical disabilities that address lifestyle changes and other specific disability-related concerns (Schaschl & Straw, 1989). Treatment providers should help the individual to develop new and satisfying interests, address erroneous expectancies about alcohol's positive affects (e.g., improved mood and social and sexual functioning), and focus on the development of skills for coping with the increase in life stressors following an injury (Alston, 1994; Heinemann et al., 1994; Woll, Schmidt, & Heinemann, 1993; Young et al., 1995).

Alcoholism treatment programs must allow individuals with SCI the time necessary to engage in activities of daily living and self-care routines. Accessible transportation should be provided to treatment and self-help meetings when needed, and parking, buildings, and restrooms must be made accessible. True accessibility means that an individual can independently gain access, and does not require the assistance of others. For example, ramps should not be too steep, doors can be independently operated, flooring materials are not too plush, and sufficient space is available for passage and turning around.

Traumatic Brain Injury

According to the Brain Injury Association of America, "traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial adjustment". The National Center for Injury Prevention and Control (1999) provides the following information on traumatic brain injury (TBI) : An estimated 1.5 million Americans sustain TBI each year. In 1999, approximately 5.3 million adults and children were living with a permanent TBI, and males are twice as likely as females to experience TBI. Motor vehicle crashes are the leading cause of hospitalization for TBI; violence, especially suicidal behavior and assaults with firearms, is the leading cause of death due to TBI; and falls are the leading cause of TBI among older people.

Traumatic Brain Injury
- Affects 1.5 million people each year
- 5.3 million live with permanent traumatic brain injury
- 33-50% of injuries involved alcohol at .10 or higher
- Males are twice as likely to experience TBI
- Major causes include motor vehicle crashes, violence using firearms, and falls


Reviews indicate that 33% to 50% of those with TBI had a blood alcohol level (BAL) greater than .10 (the level at which DWI arrests are made in many states) at the time of injury, and 50% to 66% may have histories of alcohol and other drug problems (Corrigan, 1995; Corrigan, Bogner, & Lamb-Hart, 1999). Individuals with TBI generally limit drinking following injury, but drinking may increase over time (Corrigan, Rust, & Lamb-Hart, 1995; Kreutzer, Witol, Sander et al, 1996).

TBI results in a variety of symptoms of varying severity including memory loss, trouble concentrating, difficulty performing more than one task at a time, difficulty keeping up with conversation, seizures, vision problems, speech impairments, headaches, increased anxiety, depression and/or mood swings, altered personality characteristics, impulsive behavior, and difficulty appreciating how one's behavior impacts on others (Brain Injury Association, 2002). Peers or others who do not understand the effects of TBI may avoid interacting with the individual. If the individual is unable to engage in previous work or other activities, negative emotional responses to the brain injury may increase. Family members may become overprotective and boredom for the individual often ensues, increasing the likelihood of drinking (Kaitz, 1991; Sparadeo, Strauss, & Barth, 1990). The Brain Injury Association recommends that individuals with TBI not drink for a number of reasons (Strauss, 2001):

  • alcohol impairs cognitive functioning
  • drinking increases the risk of another brain injury
  • medications such as benzodiazepines to control muscle spasms, or Dilantin to prevent seizures may slow already impaired thought processes and consuming alcohol aggravates the situation (Sparadeo, 2001); and,
  • caregiving relationships suffer if an individual with TBI abuses alcohol (Gardner, 2002).

Social work and health care professionals should routinely screen patients with TBI for alcohol and other drug problems (Bombardier & Davis, 2001; Frye, 2001). They should allow adequate time to conduct assessments, give clients breaks during the interview if needed, and be sensitive should a client's attention wane or evidence of restlessness occur (Moore, 1998). Social workers should be sure that they select assessment strategies that are valid and reliable for use with persons who have impaired cognitive processes. Since accurate assessments may be influenced by memory impairments (Jones, 1989), Kreutzer and colleagues (1990, 1996) recommend using multiple assessment methods including interviews, questionnaires, reviews of client records, and home-based interviews with clients and family members. Collateral sources of data may be important, but clients should be interviewed alone so that their answers are not unduly influenced (Moore, 1998).

What alcoholism treatment providers may call "denial" or "lack of motivation" may be impaired cause-and-effect reasoning due to TBI. A non-confrontational intake interview (Moore, 1998) using motivational interviewing principles (Miller & Rollnick, 1991) can facilitate recognition of the need for alcoholism treatment. The Ohio Valley Center for Brain Injury Prevention and Rehabilitation (n.d.) recommends that practitioners determine a person's unique learning and communication styles, assist the individual to compensate for the different learning style, and offer the individual direct feedback. Accommodations may include allowing clients to take breaks during group sessions, providing concrete examples, reframing abstract concepts, conducting individual and group treatment in rooms free of visual and auditory distractions, and focusing on clients' strengths. Behavioral rather than insight oriented approaches are also recommended (Jones, 1989; Miller, 1994). Utilizing pictures to convey concepts, role-playing, and memory aides like personal notes or taping sessions for review have also proven useful (Moore, 1998; DePompei & Corrigan, 2001; Sparadeo, 2001).

Deafness and Other Hearing Difficulties

Approximately 21 million people (8.6%) in the United States aged three or older are deaf or hard of hearing, with men 1.5 times more likely than women to be affected (Ries, 1994). The most common causes of hearing loss are childhood or pregnancy related illnesses (e.g., rubella/German measles), injury, noise exposure, heredity, and aging (National Association of the Deaf, n.d.). Rather than having a disability, many Deaf people see themselves as members of a distinct cultural group with its own "language, experiences and values" (Guthmann & Sandberg, n.d. a). Those whose hearing loss occurs early in life often relate more closely to Deaf culture than those who became deaf post-lingually-after having developed speech and language abilities (Smart, 2001; Steinberg, 1991).

The limited studies available suggest that substance abuse occurs at comparable rates among Deaf and hearing samples (Lipton & Goldstein, 1997). However, the true extent of alcohol use disorders among Deaf persons is difficult to determine because researchers and practitioners generally do not accommodate their communication styles for adequate assessment, and Deaf individuals may not be comfortable talking about alcohol and other drug abuse (Steitler & Rubin, 2001). As an already stigmatized group, Deaf communities strive to present a positive image, and this may contribute to a reluctance in acknowledging the existence of alcohol problems (Guthmann & Blozis, 2001). Media campaigns and school-based preventive curricula are generally not captioned or otherwise accessible to Deaf individuals, thus contributing to inadequate knowledge about alcohol and other drug problems (Guthmann & Blozis, 2001).

American Sign Language

American Sign Language - The box depicts the English Alphabet in American Sign Language hand signs

The communication styles of people who are deaf and hard of hearing vary. Individuals who have difficulty hearing may be able to use amplification devices that allow them to interact directly with hearing people.

Image of Hello - Signed  English

Many Deaf people use American Sign Language or ASL (ASL syntax differs from spoken English) or a variant of ASL such as Signed English (which utilizes English syntax). Others use Oralism, which combines Speechreading (lip reading) and English speech (Lipton & Goldstein, 1997). Still others use regional ASL dialects, personally developed "home signs," and finger spelling (Steinberg, 1991). Many deaf individuals are conversant in more than one modality (Lipton & Goldstein, 1997). Computer Assisted Realtime Transcription (CART) offers another communication option, as do computerized "talking boards."

Accommodating the client's preferred communication styles is of utmost importance, but there are few alcoholism treatment programs specifically for individuals who are deaf or hard of hearing. Since most treatment programs do not have staff fluent in the communication modes of people who are deaf, interpreters must be employed. To protect confidentiality, interpreters should be professionals rather than family members or friends. Staff should receive in-service education on how to work effectively with interpreters and clients.

No standardized tools are available for assessing alcohol problems among individuals who are deaf, leaving treatment providers to develop their own methods (Guthmann & Sandberg, n.d. b). Individuals who became deaf before acquiring language skills may not read English well because of the difference in ASL syntax and because reading is generally taught phonologically (Lipton & Goldstein, 1997). Thus, written assessment and treatment materials should be geared to the client's reading level, or alternative means should be employed, such as visual aids, experiential activities (e.g., role plays) and drawings (Guthmann, n.d. c; Guthmann & Blozis, 2001; Steitler & Rubin, 2001). Alcoholics Anonymous and the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals offer helpful visual materials for recovery.

The literature on the treatment of alcohol and other drug use disorders for people who are deaf or hard of hearing often focuses on service barriers and gaps, such as the lack of accessible treatment programs and self-help groups, a paucity of interested/skilled service providers, and difficulty finding recovering role modes (Guthmann & Blozis, 2001; Steitler & Rubin, 2001). Since Deaf people often have histories involving insensitive treatment by service providers, social work professionals must take the time to interact with the Deaf community to gain its confidence. Closer alliances are needed to identify available resources and form collaborations to develop new resources.

Blindness and Visual Impairments

Braille uses 6-8 raised dots in patterns to represent letters and numbers

.Braille uses 6-8 raised dots in patterns to represent letters and numbers.

Approximately 10 million Americans are blind or have significant visual impairments, including 1.3 million who meet the legal definition of blindness (American Foundation for the Blind, 2001). The major causes of blindness and vision impairment are macular degeneration, cataract, diabetic retinopathy, and glaucoma (National Eye Institute and Prevent Blindness America, 2002). There has been little study of substance use disorders among individuals who are blind or visually impaired, and no good estimates of the extent of the problem exist.

Definitions
  • Legal blindness as defined by law:
    - central vidual acuity of 20/200 in the better eye with the best possible correction
    - a visual field of 20 degrees or less
  • Functional limitation:
    - central visual acuity of 20/200 in the better eye with the best possible correction
    - a visual field of 20 degrees or less
  • Non-severe limitation
    - difficulty seeing words and letters
  • Servere limitation
    - unable to see words and letters

Moore (1998) provides suggestions for professionals assisting an individual who has a visual impairment. Learn about the onset (congenital, childhood, or adult), cause (disease, accident), and extent of the vision loss (some useable vision, referred to as low vision, or no vision). Obtain information about mobility, communication aide, and level of independence in activities of daily living. Work with the client and professionals who specialize in visual impairments to determine appropriate accommodations, such as lighting, writing technologies, and use of tape recorders or other communication devices. Orient the client to the surroundings and give clear instructions that do not rely on visual cues. Always ask individuals if assistance with mobility is needed or desired; do not automatically make such assumptions.

When conducting group education and treatment sessions, practitioners should always provide auditory cues. Verbalize content written on white boards or flip charts and address group members by name. Social work professionals should also work with local service providers to acquire large print and audiotaped materials. For those who read Braille, this is another option for providing materials. There are also many possibilities for using computer technology with voice capability. Recovery materials for individuals with visual impairments can be purchased from Alcoholics Anonymous. Professionals can also make contacts with AA and other self-help group members who can take newcomers to meetings, introduce them to other members, and orient them to the facility.

Concluding Remarks

Social workers play an important role in helping clients with disabilities and co-occurring alcohol use disorders by providing encouragement, hope, and services. Because alcoholism treatment services for individuals with disabilities are scarce, social workers must be creative and persistent when helping clients access the services they need. Rehabilitation specialists, consumer groups, and organizations that provide information and support to individuals with disabilities have valuable information and resources that social workers can use to develop better services for individuals who have an alcohol use disorder and co-occurring disabilities. More collaboration among professionals in the fields of alcoholism and disabilities and individuals with disabilities is needed.

Classroom Exercises

  1. Create a local community resource guide for persons with disabilities who have alcohol (or alcohol and other drug) problems. Include agencies and programs that focus on serving people who have alcohol and other drug problems, those that focus on serving individuals who have a disability, and those, if any, which provide integrated services for individuals who have a disability and an alcohol or other drug problem. Agencies that serve individuals who have a disability may include:
    a) The local offices of the state vocational rehabilitation agency, the state agency for individuals who are blind or visually impaired, and the state agency for individuals who are deaf or hard of hearing;
    b) Independent Living Centers (ILCs);
    c) One Stop Centers;
    d) The Arc;
    e) other community-based agencies for individuals with disabilities.
    Visit these agencies or programs, ask staff about their policies and services for people with disabilities who have an alcohol or other drug problem, and compile this information into a notebook. The class may wish to offer copies to interested agencies and organizations.
  2. Divide learners into working groups to learn more about different disabilities. Ask them to utilize web sites and other resources pertaining to each disability to obtain information about aspects of the disability such as causes, prevalence, treatment, impact on family, medications frequently prescribed during the course of treatment, and co-occurrence with alcohol and other drug use disorders. Have each group report to the class about significant information they learned.
  3. Attend Alcoholics Anonymous, Narcotics Anonymous, other 12-step groups, Secular Organizations for Sobriety, and other self-help group meetings for people who have alcohol or other drug problems in your community. Note architectural, social, and communication barriers that prevent individuals with disabilities from attending or participating. Discuss the changes in accessibility, content, format, etc. needed to make the group inclusive to individuals who have a disability. In addition, after researching resources in your community, attend one or more open 12-step or other self-help group meetings for people who have a disability and a co-occurring alcohol or other drug use disorder, if any exist, and have a class discussion about these experiences. Compare and contrast experiences from the meetings for individuals who have a disability with the other meetings attended.
  4. Invite a panel of individuals who have experienced alcohol and other drug use disorders and co-occurring disabilities to talk to your class about their views of the relationship between their co-occurring disabilities and the factors that have been most helpful in their recovery. Also consider including family members on the panel to gain their perspective. Contacting local agencies that assist persons with disabilities and advocacy groups for individuals with disabilities as well as alcohol and other drug treatment programs and self-help groups may identify individuals interested in talking to the class.
  5. Invite practitioners who treat people with alcohol and other drug use disorders and co-occurring disabilities to discuss:
    a) the challenges and rewards they experience in working with clients,
    b) the services and approaches they feel are most useful to help clients, and
    c) the changes they would like to see in policies and services that would facilitate recovery from alcohol and other drug disorders.
  6. Invite an expert on the Americans with Disabilities Act (ADA) to discuss what is required (and not required) of alcoholism and drug treatment programs when serving people who have alcohol use disorders and co-occurring disabilities. Also ask them to address employment protections for those with alcohol use disorders and the impact of disability policy on individuals who have disabilities.
  7. Invite vocational rehabilitation counselors and other staff from the local office of the state vocational rehabilitation agency to talk about their work with individuals who have disabilities, the skills that are needed to work with an individual who has a disability, and how they assess for alcohol and other drug use disorders in their consumers.
  8. Review the history of disability legislation. [A good timeline for this is found in Wolkstein, E. (Ed.). (2002). Second national conference on substance abuse and coexisting disabilities: Facilitating employment for a hidden population. Available: http://www.med.wright.edu/citar/sardi/rrtc_conference.html]. Have a speaker address how disability legislation has changed and the impact of current legislation, such as the Social Security Disability Insurance (SSDI) program, the Supplemental Security Income (SSI) Program, the Workforce Investment Act (WIA), the Ticket to Work and Work Incentives Improvement Act (TWWIIA), and other important legislation.

References

Albrecht, G. L., Seelman, K. D., & Bury, M. (Eds.) (2001). Handbook of disability studies. Thousand Oaks, CA: Sage Publications.

Alston, R. J. (1994). Sensation seeking as a psychological trait of drug abuse among persons with spinal cord injury. Rehabilitation Counseling Bulletin, 38(2), 154-163.

American Foundation for the Blind. (2001). Statistics and sources for professionals. Available: http://www.afb.org/info_document_view.asp?documentid=1367

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th ed., text revision (DSM-IV-TR™). Washington, D.C.: APA.

Anderson, P. (1980/81). Alcoholism and the spinal cord disabled: A model program. Alcohol Health & Research World 5(2), 37-41.

Asch, A. (2001). Intellectual disabilities-Quo vadis? In G. L., Albrecht, K. D. Seelman, & M. Bury (Eds.), Handbook of disability studies (pp. 267-296). Thousand Oaks, CA: Sage Publications.

Association for the Help of Retarded Children. New York, NY. Available at: http://www.ahrcnyc.org/

Babor, T. F. (1993). Substance use disorders and persons with physical disabilities: Nature, diagnosis, and clinical subtypes. In A. W. Heinemann (Ed.), Substance abuse and physical disability (pp. 43-61). New York: Haworth Press.

Bombardier, C., & Davis, C. (2001). Screening for alcohol problems among persons with TBI. Brain Injury Source, 5(4), 16-19.

Bombardier, C. H., & Rimmele, C. T. (1998). Alcohol use and readiness to change after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 79(9), 1110-1115.

Boros, A. (1989). Facing the challenge. Alcohol Health and Research World, 13(2), 101-103.

Brain Injury Association of America. (2002). The costs and causes of traumatic brain injury.

Burgard, J. F., Donohue, B., Azrin, N. H., & Teichner, G. (2000). Prevalence and treatment of substance abuse in the mentally retarded population: An empirical review. Journal of Psychoactive Drugs, 32(3), 293-298.

Campbell, J. A., Essex, E. L., & Held, G. (1994). Issues in chemical dependency treatment and aftercare for people with learning differences. Health & Social Work, 19(1), 63-70.

Center for Substance Abuse Treatment. (1995). The role and current status of patient placement criteria in the treatment of substance use disorders. Treatment Improvement Protocol (TIP) Series 13. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration. DHHS Publication No. (SMA) 95-3021.

Christian, L., & Poling, A. (1997). Drug abuse in persons with mental retardation: A review. American Journal on Mental Retardation, 102(2), 126-136.

Corrigan, J. D. (1995). Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 76(4), 302-309.

Corrigan, J. D., Bogner, J. A., & Lamb-Hart, G. L. (1999). Substance abuse and brain injury. In M. Rosenthal, E. R. Griffith, J. D. Miller, & J. Kreutzer (Eds.) Rehabilitation of the adult and child with traumatic brain injury, 3rd ed,(pp.556-71). Philadelphia: FA Davis.

Corrigan, J. D., Rust, E., & Lamb-Hart, G. L. (1995). The nature and extent of substance abuse problems in persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 10(3), 29-46.

de Miranda, J. (1999, May/June). Treatment services offer limited access for people with disabilities. The Counselor, 24-25.

DePompei, R., & Corrigan, J. D. (2001). Double trouble: Substance abuse and traumatic brain injury in youth. Brain Injury Source, 5(4), 32-34.

DiNitto, D. M. & Webb, D. (1998). Compounding the problem: Substance abuse and other disabilities. In C. A. McNeece & D. M. DiNitto. Chemical dependency: A systems approach, 2nd ed., (pp. 347-390). Boston: Allyn and Bacon.

Frye, D. (2001). Screening for substance abuse as part of the neuropsychological assessment. Brain Injury Source, 5(4), 20-22.

Gardner, W. (2002). The impact of behavior problems on caregivers after traumatic brain injury. Brain Injury Source, 6(1), 40-44.

Guthmann, D., & Blozis, S. A. (2001). Unique issues faced by deaf individuals entering substance abuse treatment and following discharge. American Annals of the Deaf, 146(3), 294-304.

Guthmann, D. S., & Sandberg, K. A. (n.d.. a). Access to treatment services for deaf and hard of hearing individuals. Minneapolis, MN: The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Available: http://www.mncddeaf.org/articles/access_ad.htm

Guthmann, D., & Sandberg, K. A. (n.d. b) Assessing substance abuse problems with deaf and hard of hearing students. Minneapolis, MN: The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Available: http://www.mncddeaf.org/articles/students_ad.htm

Guthmann, D., & Sandberg, K. A. (n.d. c) Providing substance abuse treatment to deaf and hard of hearing clients. Minneapolis, MN: The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Available: http://www.mncddeaf.org/articles/treatment_ad.htm

Heinemann, A. W., & Hawkins, D. (1995). Substance abuse and medical complications following spinal cord injury. Rehabilitation Psychology, 40(2), 125-140.

Heinemann, A. W., Schmidt, M. F., & Semik, P. (1994). Drinking patterns, drinking expectancies, and coping after spinal cord injury. Rehabilitation Counseling Bulletin, 38(2), 134-153.

Helwig, A. A., & Holicky, R. (1994). Substance abuse in persons with disabilities: Treatment considerations. Journal of Counseling and Development, 72(2), 227-233.

Hubbard, J. R. & Martin, P. R. (Eds.). (2001). Substance abuse in the mentally and physically disabled. New York: Marcel Dekker.

Jones, G. A. (1989). Alcohol abuse and traumatic brain injury. Alcohol Health & Research World, 13(2), 104-109.

Kaitz, S. (1991). Integrated treatment: Safety net for survival. Headlines (Summer), 11-16.

Koch, S., Nelipovich, M., & Sneed, Z. (2002). Alcohol and other drug abuse as coexisting disabilities: Considerations for counselors serving individuals who are blind or visually impaired. Re:View, 33(4), 151-159.

Kreutzer, J. S., Doherty, K. R., Harris, J. A., & Zasler, N. D. (1990). Alcohol use among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 5(3), 9-20.

Kreutzer, J. S., Witol, A. D., Sander, A. M., Cifu, D. X., Marwitz, J. H., & Delmonico, R. (1996). A prospective longitudinal muticenter analysis of alcohol use patterns among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 11(5), 58-69.

Krishef, C. H., & DiNitto, D. M. (1981). Alcohol abuse among mentally retarded individuals. Mental Retardation, 19(4), 151-155.

Lipton, D. S., & Goldstein, M. F. (1997). Measuring substance abuse among the deaf. Journal of Drug Issues, 27(4), 733-754.

The Maine approach: A treatment model for the intellectually limited substance abuser. (1984). Augusta and Waterville, ME: The Maine Department of Mental Health and Mental Retardation and The Kennebec Valley Regional Health Agency.

McGillicuddy, N. B., & Blane, H. T. (1999). Substance use in individuals with mental retardation. Addictive Behaviors, 24(6), 869-878.

McNeil, J. (2002). Americans with disabilities: 1997. Household Economic Studies, Current Population Reports P70-73. Washington, DC: U.S. Census Bureau. Available: http://www.census.gov/hhes/www/disable/sipp/disab97/asc97.html

Miller, N. S. (1994). Alcohol and drug disorders. In S. C. Yudofsky, R. E. Hales, & J. M. Silver (Eds.), Neuropsychiatry of traumatic brain injury (pp. 471-498). Washington, DC: American Psychiatric Press.

Miller, W. R., & Rollnick, S. (Eds.) (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Moore, D. (1998). Substance use disorder treatment for people with physical and cognitive disabilities. Treatment Improvement Protocol (TIP) Series 29. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration. DHHS Publication Number (SMA) 98-3249.

Moore, D. (2002). Plenary 1: Prerequisite for change: Identifying the problem. In E. Wolkstein (Ed.), Second national conference on substance abuse and coexisting disabilities proceedings: Facilitating employment for a hidden population (pp. 21-24). Dayton, OH: Rehabilitation Research and Training Center, Wright State University School of Medicine, Department of Community Health. Available: http://www.med.wright.edu/citar/sardi/rrtc_conference.html

Moore, D., & Ford, J. A. (1991). Prevention of substance abuse among persons with disabilities: A demonstration model. Prevention Forum, 11(2), 1-3, 7-10.

Moore, D. & Li, L. (1994). Alcohol use and drinking-related consequences among consumers of disability services. Rehabilitation Counseling Bulletin, 38(2), 124-132.

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Perez, M., & Pilsecker, C. (1994). Group psychotherapy with spinal cord injured substance abusers. Paraplegia, 32(3), 188-192.

Radnitz, C. L., & Tirch, D. (1995). Substance misuse in individuals with spinal cord injury. The International Journal of the Addictions, 30(9), 1117-1140.

Ries, P. W. (1994). Prevalence and characteristics of persons with hearing trouble: United States, 1990-91. Data from the National Health Survey, Series 10, no. 188. Hyattsville, MD: National Center for Health Statistics, Vital Health Statistics. Available: http://www.cdc.gov/nchs/data/series/sr_10/sr10_188.pdf

Rothman, J. C. (2003). Social work practice across disability. New York: Allyn & Bacon.

Schaschl, S., & Straw, D. (1989). Results of a model intervention program for physically impaired persons. Alcohol Health & Research World, 13(2), 150-153.

Selan, B. H. (1981). The psychological consequences of alcohol use or abuse by retarded persons. Paper presented at the 105th Annual Meeting of the American Association on Mental Deficiency, Detroit, MI.

Smart, J. (2001). Disability, society, and the individual. Gaithersburg, MD: Aspen Publishers.

Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent acceptance? Baltimore: Paul H. Brookes Publishing Company.

Sparadeo, F. R. (2001). Treating substance abuse in individuals with TBI: The lessons of experience. Brain Injury Source, 5(4), 24-27, 42-45.

Sparadeo, F. R., Strauss, D., & Barth, J. T. (1990). The incidence, impact, and treatment of substance abuse in head trauma rehabilitation. Journal of Head Trauma Rehabilitation, 5(3), 1-8.

Steinberg, A. (1991). Issues in providing mental health services to hearing-impaired persons. Hospital and Community Psychiatry, 42(4), 380-389.

Steitler K., & Rubin, J. L. (2001). Deafness and chemical dependency: A paper. Rochester, NY: Rochester Institute of Technology, Substance and Alcohol Intervention Services for the Deaf. Available: http://www.rit.edu/~257www/tips/paper.htm

Strauss, D. (2001). An overview of substance abuse and brain injury. Brain Injury Source, 5(4), 8-11, 40-41.

Wenc, F. (1980/81). The developmentally disabled substance abuser. Alcohol Health and Research World, 5(2), 42-45.

Westermeyer, J., Kemp, K., & Nugent, S. (1996). Substance disorder among persons with mild mental retardation: A comparative study. The American Journal on Addictions, 5(1), 23-31.

Wolkstein, E. (Ed.). (2002). Second national conference on substance abuse and coexisting disabilities: Facilitating employment for a hidden population. Available: http://www.med.wright.edu/citar/sardi/rrtc_conference.html

Woll, P., Schmidt, M. F., & Heinemann, A. W. (1993). Alcohol and other drug abuse prevention for people with traumatic brain and spinal cord injuries. Chicago, IL: Rehabilitation Institute of Chicago, Midwest Regional Head Injury Center for Rehabilitation and Prevention.

Yarkony, G. M. (1993). Medical complications in rehabilitation. In A. W. Heinemann (Ed.), Substance abuse and physical disability (pp. 93-105). New York: Haworth Press.

Young, M. E., Rintala, D. H., Rossi, C. D., Hart, K. A., & Fuhrer, M. J. (1995). Alcohol and marijuana use in a community-based sample of persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 76(6), 525-532.

Definitions of disability vary by study. See McNeil (2002) for definitions of disability and severe disability used in this report and by the U.S. Census Bureau. Definitional issues are also discussed in Albrecht, Seelman, & Bury (2001).

Annotated Bibliography/Additional Teaching Resources

Printed documents

Albrecht, G. L., Seelman, K. D., & Bury, M. (Eds.). (2001). Handbook of disability studies. Thousand Oaks, CA: Sage Publications. This 852-page volume is an interdisciplinary look at the field of disability studies. It addresses many of the political and advocacy perspectives on disability as well as policy responses to disability. It aids in understanding historical and current responses to disability from different viewpoints.

Hubbard, J. R. & Martin, P. R. (Eds.). (2001). Substance abuse in the mentally and physically disabled. New York: Marcel Dekker. This book contains chapters on substance abuse in individuals with physical and mental disabilities including cardiovascular disease, HIV, chronic pain disorders, neurological disorders, and head injuries.

The NAADD report: The newsletter on alcohol, drugs, and disability. Available from National Association on Alcohol, Drugs and Disability, Inc., 2165 Bunker Hill Drive, San Mateo, CA 94402-3801, 650-578-8047, e-mail: Solanda@sbcglobal.net. This is the nation's only periodical specifically focused on alcohol, drugs, and disability. It features first person accounts, new resources, promising programs, and news items.

National Center for Dissemination of Disability Research & Rehabilitation Research and the Research & Training Center on Community Integration of Individuals with Traumatic Brain Injury. (2002). Guide to traumatic brain injury resources. Available: http://www.ncddr.org/du/products/tbiguide/index.html This guide is designed for those who work with individuals with traumatic brain injury. It includes information about books and book chapters, journals, training manuals, and other resources.

National Center for Dissemination of Disability Research & Rehabilitation Research and the Training Center on Drugs and Disability. (2001). Guide to substance abuse and disability resources. Available: http://www.ncddr.org/du/products/saguide/index.html . This downloadable document contains references for books and book chapters, fact sheets, conference papers and proceedings, journal articles, newsletters and articles, project reports, training manuals, and audio and videotapes on substance abuse and disability. This document is a good place to start for people with little knowledge about substance abuse and people with disabilities.

Moore, D. (1998). Substance use disorder treatment for people with physical and cognitive disabilities. Treatment Improvement Protocol (TIP) Series 29. DHHS Publication No. (SMA) 98-3249. Rockville, MD: Substance Abuse and Mental Health Services Administration. This publication can be ordered from http://store.health.org/.
An abbreviated version can be viewed online at http://www.guideline.gov/VIEWS/summary.asp?guideline=1040&summary_type=brief_summary&view=brief_summary&sSearch_string= This comprehensive resource is for anyone interested in learning more about substance abuse and people with disabilities. It provides information about specific disabilities as well as general guidelines for assessment, treatment, and prevention of substance abuse in people with disabilities.

Rothman, J. C. (2003). Social work practice across disability. New York: Allyn & Bacon. This book is a good primer for social workers interested in improving their practice with individuals with disabilities. The chapters address topics such as theoretical frameworks, the Americans with Disabilities Act, disability and identity development, using client strengths, and social support networks.

Smart, J. (2001). Disability, society, and the individual. Gaithersburg, MD: Aspen Publishers. This book addresses many of the psychosocial aspects of disability, including definitions of disability, prejudice and discrimination, and societal and individual responses to disability. Although alcohol and other drug problems are mentioned only in passing, this volume contains important information for social workers and other social service professionals. It offers many resources, especially videos, first person accounts of disability, and class exercises.

Substance Abuse Resources & Disability Issues (SARDI). (1999). SARDI training manual. Dayton, OH: SARDI. (Third Printing, revised July,1999.) Additional information about this manual can be found at http://www.med.wright.edu/citar/sardi/products.html. This manual is intended for those interested in teaching about substance abuse and disabilities. The nine sections discuss an overview of substance abuse and disabilities, Americans with disabilities, substance abuse prevention, identification of substance abuse in persons with disabilities, interviewing skills, finding solutions, support groups, connection agencies, and resources.

Wolkstein, E. (Ed.). (2002). Second national conference on substance abuse and coexisting disabilities: Facilitating employment for a hidden population. Available: http://www.med.wright.edu/citar/sardi/rrtc_conference.html Copies in alternative formats are available from RRTC on Drugs and Disability, Wright State University, P. O. Box 927, Dayton, OH 45401-0927, phone: 937-259-1384. This document contains proceedings from one of the few conferences on substance abuse and disabilities. It provides an overview of the issues facing people with disabilities and alcohol or other drug use disorders; a timeline of the history of disability legislation; a glossary of acronyms of organizations that address disability, alcohol, and other drug use disorders, and related concerns; and an extensive list of web sites.

Web sites:

American Foundation for the Blind: http://www.afb.org/ This is a comprehensive web site for people with visual impairments. The web site can be adjusted for viewing by those with visual impairments.

The Arc: http://www.thearc.org/ This national organization's website provides a great deal of useful information for people with mental retardation and developmental disabilities, their families, and others wishing to learn more about these disabilities.

Brain Injury Association of America: http://www.biausa.org/ This web site has extensive information on brain injuries. The medical information is easy to understand and includes a description of what happens when the brain is injured. Resources include information on national and state resources, prevention, treatment, and rehabilitation.

The Disability Resources Monthly (DRM) Guide to Disability Resources on the Internet: http://www.disabilityresources.org/index.html. This is probably the most comprehensive listing of disability resources on the web. The site includes an extensive listing of statewide resources, an extensive list of links to other disability resources, and a great search engine to find information on a variety of topics affecting people with disabilities.

Disability Social History Project: http://www.disabilityhistory.org/ This site focuses on the history of disabilities and disability issues. It includes a timeline of dates relevant to people with disabilities, a list of famous people with disabilities, and links to other sites about disabilities.

The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals: http://www.mncddeaf.org/ This resource is for people with hearing impairments and substance use disorders and professionals. It contains many articles that can be downloaded and videos that can be purchased.

The National Association on Alcohol, Drugs and Disability Inc., (NAADD): www.naadd.org "The mission of NAADD is to create public awareness of issues related to alcoholism, drug addiction, and substance abuse faced by persons with other co-existing disabilities, and to provide a peer approach to enhance access to services, information, education and prevention through the collaborative efforts of interested individuals and organizations nationwide." This web site contains many resources for people interested in substance abuse among people with disabilities.

The National Association of the Deaf: http://www.nad.org/ The National Association of the Deaf is the largest and oldest organization for people who are deaf. It contains many resources and includes information about legal issues and state and national resources.

National Clearinghouse for Alcohol and Drug Information: Substance Abuse and Disabilities: Exploring the Relationship: http://www.health.org This web site is rich with information about people with alcohol and other drug problems and co-occurring disabilities. The site includes information about federal publications, links to information about different resources for individuals with disabilities and alcohol and other drug problems, and information about the cultural groups' responses to disability and alcohol and other drug problems.

National Spinal Cord Injury Association: http://www.spinalcord.org/ This comprehensive web site contains a variety of information about people with spinal cord injuries. The site includes links to state, federal, and other resources.

The Substance Abuse Resources & Disability Issues (SARDI) Program: http://www.med.wright.edu/citar/sardi/ This site contains many resources on substance abuse and people with disabilities.

Through the Looking Glass: http://www.lookingglass.org/ This nationally recognized center in Berkeley, California, is for families in which a parent, child, or grandparent has a disability. The web site is filled with information for families of those with disabilities, including an extensive listing of other web sites.

Video:

Cerebral Palsy of New Jersey. (n.d.). Silent Storm [video]. Trenton, NJ: Cerebral Palsy of New Jersey, 354 South Broad Street, Trenton, New Jersey, 08608. This ten-minute video explores substance abuse in individuals with disabilities and is a nice complement to other teaching materials. The video can be obtained for a small fee from Cerebral Palsy of New Jersey.

 

Updated: March 2005