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Conducting screening and assessment

Many people in drug and alcohol services have some kind of cognitive impairment and spend their whole lives without a diagnosis. A diagnosis can be valuable, though for some people with complex needs a diagnosis can increase the barriers to the treatment and support they need.

Working towards a diagnosis

People with complex needs need a service - and individuals within that service - to commit to working with them even if they present with issues that are primary or secondary to their drug and alcohol treatment needs. A drug and alcohol worker does not have to be an expert in all areas of complex need to be able to provide treatment to a person presenting with complex needs issues. Although getting formal assessments and diagnoses can give you insight into particular kinds of behaviour, this is just one of many factors to consider. Formal assessments are costly, take time and are not always easy to access.

Looking at the whole story for a person with complex needs is the key to unlocking effective strategies to working with them. You can work effectively without a diagnosis by being aware of the potential signs of an underlying issue and adjusting your practice accordingly. In addition to working within a holistic framework, there are a range of brief screening questionnaires and assessment tools that can support you to support your clients effectively.

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Screening

Using screening tools to identify if a person has indicators of cognitive impairment, such as difficulties in memory, attention, planning and organising activities, can provide information that can be used to plan and adapt care and support services. Screening tools can also indicate whether further assessment would be beneficial.

However, health professionals who can provide further assessment, such as neuropsychologists, may be difficult to access and you should consider exactly how any further assessment information would be useful to inform a person's care and support. Regardless of whether further assessment occurs, the person will still need support for their drug and alcohol use, in addition to a range of health and social factors such as mental and physical health, accommodation, parenting and family and social relationships (Alberta FASD Cross-Ministry Committee 2009).

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Assessment

On entering a drug and alcohol treatment program, people should undergo an assessment interview and complete standardised assessment tools as appropriate. The fundamental purpose of this is to gather comprehensive information that can be used to build up an understanding of the person in order to develop an individualised care plan. The care plan should be reviewed at regular intervals to ensure it remains accurate and to monitor the person's progress towards identified goals.

Assessing cognitive, physical and emotional functioning is important for all clients, but is especially important when working with or identifying a person with complex needs. A functional assessment will provide detailed information on their practical skills and limitations and can inform the development of a personalised care plan.

When further information is needed to understand the deficits that may underlie the practical difficulties, referral for a neuropsychological assessment may be warranted. Neuropsychological and functional assessments are complementary: neuropsychosocial describes the underlying skills or deficits, and functional describes the practical effects of these. For example, a neuropsychological assessment may reveal a deficit in planning and a functional assessment may reveal that this deficit affects the person's ability to do their shopping or manage a budget.

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Expectations of assessment and delivering assessment results

Before starting the assessment, you need to have a clear understanding of what you, your service and your client expect of the process and the outcomes. This includes considering:

  • The assessment process and specific assessment tools used - e.g. explain to the client if you're following a standard process that all clients go through or if a specific assessment is being used because of their presenting issues
  • What the results of the assessment process may be and how you'll communicate the results to the client
  • The impact of the results for the client and for their treatment
  • The treatment or intervention options for the client following the assessment, including the criteria for accessing your drug and alcohol program, waiting lists and possible points of referral.
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Client history

The personal, social and cultural history of a person is also important to consider (Morrison 2007). The areas outlined in the following table should be considered when conducting an assessment.

Elements of personal, social and cultural history


Childhood

Early relationships

Losses and traumatic experiences (including abuse)

Educational experiences

Adult life

Current living situation

Sexual and relationship life and difficulties

Employment and financial support

Legal involvement

Family history

Family breakdown and/or separation experiences

Family and cultural history that may contribute to experiences of intergenerational trauma

Family history of mental health and drug and alcohol issues


Considerations of culturally specific events and experiences should inform assessment practices, such as the effects of intergenerational trauma on Indigenous people or the trauma associated with migrants, refugees and humanitarian entrants.

Consider cultural diversity and the stigma that may be associated with drug and alcohol issues, mental health issues and disability from different cultural perspectives. Additionally, when using standardised screening and assessment tools, ensure they're culturally sensitive and appropriate.

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Masking impairment

Some clients will not disclose that they have an intellectual disability or low literacy skills and may try to hide the effects of their disability. This behaviour is often due to the stigma associated with having an intellectual disability, and the person may have experienced in the past that masking their disability will increase their chances of accessing a service.

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The retraumatising effects of screening and assessment

For some people, assessment will require sharing personal information that is emotionally distressing to recount. Additionally, many people will have tried to access multiple services in the past and have been through many different assessment processes. If the experience and outcomes of these assessment processes are largely negative for them, the process of assessment may produce feelings of stress and anxiety.

Therefore, it is important to make sure the person feels that the environment is safe and supportive and that you remain calm, open and approachable (MHCC 2010). Workers conducting assessments should receive education and support on methods to sensitively address these issues and support a person who becomes distressed during the assessment process.

It can be difficult to gain access to previous assessment records for a client (such as previous psychological assessments), and barriers such as cost and time can impact on a person seeking drug and alcohol treatment. Consider how information contained in past assessment records or a criminal record will be used to inform current treatment and care planning and whether obtaining this information is necessary. There may be alternative ways to find out the information you need when assessing a person for a service without obtaining their previous records.

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Validity and reliability of standardised screening and assessment tools

Most standardised drug and alcohol assessment tools have not been validated for use with people with an intellectual disability. Measures may also rely on retrospective memory, so the reliability of a person's recall may be an issue (Mendel & Hipkins 2002).

In relation to screening tools for cognitive impairment, the target group that many tools were designed for is older people with dementia, so they may not be suitable for use in drug and alcohol settings.

If you have concerns or questions about the validity and/or reliability of screening tool you would like to use in your service, talk to a specialist. Brain Injury Association NSW will be able to help you link to an appropriate specialist. Call BIA NSW on (02) 3868 5261 or free call 1800 802 840.

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Find out more

Resources for culturally appropriate screening and assessment include:

For information on considering a client's criminal record see the No Bars website.

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