PART I: Addiction in the deaf community
Recovery from alcohol and drug addiction involves the acceptance of abilities and limitations, as well as the initiation of cognitive and behavioral changes. For those with substance abuse problems who are deaf, it may imply an acceptance of deafness in addition to the acceptance of the addiction.

It is imperative that the drugs and alcohol be removed as soon as possible and abstinence maintained because it is impossible to deal with the emotional and mental health issues of a client who is still using. Motivating addicted persons to give up their drugs of choice is not easy - and for those who are deaf - it becomes even more of a challenge. In the using community, drugs know no boundaries; one does not need to share a language to buy a bottle or "cop some dope" so linguistic barriers are irrelevant. In recovery, however, feelings emerge that need to be addressed. Although there are isolated cases of success, most deaf individuals with substance abuse problems resent being sent to therapy sessions and recovery meetings where they are unable to understand what is being said and cannot share what they are feeling. Resentment added at this early stage of recovery further complicates the effectiveness of treatment. Thus the issue of deafness, and more importantly communication, needs to be addressed as early in the recovery process as possible.

Treating the deaf
Normal language development occurs in pragmatic and social contexts beginning in the home. Children who are profoundly deaf typically do not share the language and culture used in the home since approximately 90 percent are born into hearing families (Easterbrooks & Baker, 2002; Humphrey & Alcorn, 1995). The average deaf adult (because a spoken language is not assimilated at an early age) reads at about the fourth grade level (LaSasso& Mobley, 1997). This makes even reading and writing a difficult and cumbersome task. There are numerous deaf adults who have not developed recognized or sophisticated levels of communication due to the mixed linguistic cultures during the formative years of language development (Christensen & Delgado, 1993). In addition, there are as many variations in language use among the deaf as there are accents, dialects, and languages among the hearing.
Many deaf adults use American Sign Language (ASL), as opposed to signed or spoken English, as their preferred mode of communication since it depends on vision (a strength) and not audition (a weakness). ASL users pose a unique problem to hearing therapists because the language is not comparable to English. ASL users may appear to lack intelligence or social appropriateness because not only is their language different, but so are their social norms. Based on language issues only, this group is the easiest to treat when the linguistic and cultural barrier is bridged because these individuals have developed thought and language and are often able to express themselves effectively. The ability of the client to communicate effectively significantly impacts the therapeutic process.

Breaking the sound barrier
Many of those with substance abuse issues who are deaf can assimilate into the therapeutic community effectively when a qualified interpreter participates in the recovery process. A professionally trained interpreter can be a great asset, and when integrated successfully, communication transpires normally between the therapist, all clients, deaf and hearing, and significant others. The most effective interpreter is one who has been invisible during the interpreted session, yet all the members of the interaction had an equal "voice" (Humphrey and Alcorn, 1995).

Qualified interpreters adhere to an ethical code of conduct which, in part, requires that an interpreter refrain from interpreting in situations when not adequately trained to meet the needs of the assignment. Family members, for example, should not be used as interpreters. A professional interpreter from outside the family allows the client to communicate fluently and deal confidentially with any contributing factors that may arise from unresolved family issues.

Working with an interpreter
If it has been determined that the services of an interpreter are needed and a qualified interpreter has been procured, the clinician and interpreter should meet prior to the initial session to clarify roles and responsibilities. The interpreter is responsible for sharing linguistic information just as the clinician is responsible for the therapeutic process. Here are a few suggestions:
- Never leave the interpreter alone with the client.
-Know that the interpreter will convey all information so avoid private conversations in his/her presence.
- Expect a slight delay in response time to allow for linguistic conversions.
-Do not expect a word-for-word translation.
-Talk directly to the client, not the interpreter.

Legal requirements
"Deafness" is categorized legally as a disability and is covered under laws protecting special populations. Individuals who are deaf fall within the purview of a "disability" and are guaranteed, by law, equal access to services available to persons without hearing loss. Equal access for the person with a substance abuse problem who is deaf generally means access to communication and may mean hiring an interpreter.

Being restored to sanity
Members of linguistic minorities present unique challenges to therapists who treat addictions, but education and awareness continues to improve the quality of care that is provided. Today there are treatment options and recovery programs that offer solutions to millions of people with substance abuse problems all over the world, in different languages, in different cultures - solutions that significantly improve the quality of life for many. Awareness of the linguistic and cultural diversity of the substance abuser who is deaf may help to restore an individual to sanity - a life that might otherwise be lost to the depths of hopelessness and despair caused by addiction.

Eugene N. Crone, PhD, CAP, MAC, NCAC II, ICADC, has worked in association with the owners of the National Deaf Academy since September 1995 as Director of Addiction Services. As a recovery specialist, Dr. Crone has earned the prestigious "Mel Schulstad Professional of the Year AwardÓ from NAADAC in 1997 and "The Professional of the Year Award" for outstanding work in the field of addiction presented by the Florida Chapter of NAADAC in 1996. He was nominated for the "National Jefferson Award for Outstanding Community Service" and is currently celebrating his twenty-fifth year in the field of Addiction.

Carol A. Goodman, MEd, CT, is currently completing doctoral studies in Curriculum and Instruction at Indiana University of Indiana in Pennsylvania and is the Program Coordinator of Education of the Deaf and Hard of Hearing at Kean University in Union, New Jersey. Originally from Florida, she is a nationally certified sign language interpreter with ten years of experience working in the field of mental health and addictions.

References
Christensen, K.M. & Delgado, G.D. (Eds.).(1993). Multi-cultural issues in deafness. Longman: White Plains, NY.
Easterbrooks, S.R. & Baker, S. (2002). Language learning in children who are deaf and hard of hearing: Multiple pathways. Allyn & Bacon: Boston.
Humphrey, J.H. & Alcorn, B.J. (1995). So you want to be an interpreter? An introduction to sign language interpreting (2nd ed.). H&H Pub.:Amarillo, TX.
LaSasso, C.J. & Mobley, R.T. (1997). National survey of reading instruction for deaf and hard-of-hearing students. U.S. Volta Review, 99(1), 31-59.

PART II: Treating Substance Abuse in People with Mental Retardation

Little information is directly available addressing issues related to substance misuse or abuse for people with mental retardation even though the literature emphasizes the need to facilitate community participation for this segment of the population. Importantly, epidemiological data indicate that 47 percent of Americans (approximately 104 million people), 12 years of age and older, drink; and six percent of these people (approximately 13 million) report heavy drinking defined as five drinks or more, for five days or more, within a 30-day period (U.S. Department of Health & Human Services, 2000). Notably, lower consumption rates do not correspond with fewer substance-related problems since alcohol and drug-related problems occur at a range of consumption levels varying in severity and frequency. Comprehensive data on the impact of substance use is not available for people with mental retardation and/or significant disabilities.

Extant research on substance use in the general population indicates consumption patterns meeting DSM-IV criteria for substance abuse or dependence are usually associated with poor functioning in numerous domains, such as, family, social, occupational, medical, and legal (McLellan et al., 1992). In addition, the literature indicates that sub-clinical consumption levels similarly contribute to significant negative consequences, such as illegal activity including school drop-out, juvenile delinquency, theft, larceny, physical and sexual abuse, domestic violence, violent crimes, vehicular homicide, and suicide. The mediating mechanisms related to these outcomes are still the foci of numerous investigations. However, most professionals would agree the disinhibitory effects of alcohol and/or other substances contribute to the demonstrated behavior problems associated with substance use.

The paucity of research
Parallel investigations focusing on substance use and misuse by people with mental retardation and/or other disabilities are not available. The available data suggest that people with mental retardation and/or other cognitive or psychiatric disabilities might be vulnerable to experiencing similar effects from substance use since problems with behavioral regulation often exist for these groups in general. Therefore, professionals working with people who have mental retardation, especially individuals within the high moderate to mild range of functioning who might have more exposure to social situations where substance use is an issue, may need to address substance use and misuse.

The paucity of research notwithstanding, the existing literature supports the need for professionals working with people who have mental retardation to address substance-related issues. Present research indicates people with mental retardation engage in substance use and misuse that is often associated with negative outcomes including legal, occupational, and residential difficulties. These data reveal that substance use is initiated as early as the fourth grade, which parallels the age of onset for youth without mental retardation who are at the highest risk for demonstrating clinical levels of substance-related problems throughout their lifetime (Grant & Dawson, 1997). Clearly, problems in this area appear to begin early and may exert a significant impact, partly because of the existing vulnerabilities of persons with cognitive limitations.
What the numbers say

The intermittent nature and methodological problems that characterize the existing research related to substance use in people with mental retardation preclude any analysis of consumption patterns that definitively signify problematic use in this population. However, the literature indicates that youth with mental retardation similar to their peers without mental retardation, appear to demonstrate patterns of poly-substance use that include all categories of legal and illegal substances without a specific preference for any substance category. In addition, there are not enough data systematically examining consumption patterns to know which consumption levels or patterns of use result in negative outcomes. The one available treatment study focusing on people with mental retardation indicates people with mental retardation can experience significant negative outcomes with as little as two alcoholic drinks per drinking episode. Importantly, this is well within the levels of consumption considered to be "normalÓ in people without mental retardation. These data suggest that existing screening methods may not be sensitive enough for people with mental retardation. Furthermore, standards for social acceptability of this level of consumption may also limit our efforts or concerns.

Evidence of binge drinking
The investigations that do report patterns of substance use are limited in number, but address substance use in both youth and adults with mental retardation. These data do not consistently address patterns of consumption, however, there is evidence suggesting that both youth and adults with mental retardation engage in binge drinking, e.g., drink five or more drinks per drinking occasion. And when a control group of participants without mental retardation were included in the sample, the data revealed that people with mental retardation engage in binge drinking more frequently than people without mental retardation. However, because there are so few studies available, it is impossible to know whether people with mental retardation who engage in binge patterns of consumption are the only people with mental retardation who might be susceptible to developing substance-related difficulties. The clinical utility of these data becomes even more questionable when considered in the context of huge literature on problematic consumption patterns demonstrated by people without mental retardation. Specifically, the data indicate that although many people without mental retardation engage in binge drinking, especially during the college years, it is only a small percentage (approximately six percent) who develop clinical levels of lifetime, problem consumption patterns.

Models of risk
Overall, the current literature does little more than provide evidence of the problem. The differences in methodology and in the nature of the targeted information, as well as the number of research reports available, make it difficult to discern which consumption patterns will be indicative of problematic use as compared with patterns of social use for people with mental retardation. In a similar manner, there is not enough research related to substance use or misuse in people with mental retardation to identify with some degree of certainty, individual or environmental characteristics that are indicators of risk for substance misuse and abuse in people with mental retardation. Models of risk for early onset of substance misuse and abuse in people without mental retardation may not be relevant for people with mental retardation since the degree of risk associated with any factor is functionally related to the environmental/person response to that factor. That is, identified risk factors for people without mental retardation may be irrelevant for people with mental retardation since they might have different socializing experiences.

Research exploring characteristics of risk for substance misuse and abuse that are specific to people with mental retardation is unavailable. Despite the absence of available information specific to people with mental retardation, the available risk research related to persons without mental retardation provides some temporary guidelines for a meaningful discussion in this area. A review of the substance-related risk literatures for people without mental retardation and the research related to behavioral and emotional functioning in people with mental retardation suggests parallels exist in these literatures that warrant clinical consideration and further empirical investigation. Examination of the intersections between the two literatures indicates individual and environmental factors might contribute to substance-related problems in people with mental retardation, including: family history of substance abuse; prenatal exposure to alcohol; difficult temperament or high arousability; psychiatric disability; and association with deviant peer groups. Environmental characteristics include living in a low socioeconomic neighborhood. [For a more extensive review of the parallels in risk factors see Cocco & Harper, 2002 in references section]. Importantly, little information is available addressing the social implications of these risk factors for youth or adults with mental retardation.

Collectively, the available research on substance use in people with mental retardation and the parallels in the substance abuse risk literatures suggests the need for further research in this area. In the absence of research directly addressing substance use and other high-risk behaviors in people with mental retardation, professionals working with people who have mental retardation, especially those functioning within the mild to high moderate range, might want to proactively assess clients for the presence of risk factors. Such an assessment should occur at regular intervals that closely correspond to developmental transitions, such as transitioning to middle school, high school, first job, or other major psychosocial transitions, such as moving, divorce, or death of a significant person. Targeted areas for assessment should include family history of substance use, current use of alcohol or other substances by parents and other family members, and characteristics of the person with mental retardation including, temperament, social interaction skills, peer relationship problems, and involvement in structured community programs during non-school-related hours.

Assessing the consequences
Professionals working with adults who have mental retardation may want to determine whether their clients are engaging in substance use. In addition to directly assessing current use of a particular substance, it would be important to assess the consequences associated with substance use since it is not clear from the current literature what level of use represents the threshold for non-problematic use as compared to problematic use for persons with mental retardation. The available data suggests these levels vary at the individual level, and the lower levels for persons with mental retardation appear lower than the low threshold level for persons without mental retardation. Additional areas to assess that would be informative for ascertaining the effects of substance use for any particular individual include the situations and consequences associated with use.

To summarize, there is accumulating evidence that people with mental retardation do engage in substance use and misuse, although there is a pronounced absence of research addressing assessment, intervention, and treatment of substance use for people with mental retardation. Additionally, little information is available identifying the individual or environmental factors that contribute to risk for substance use in people with mental retardation. Since this information is unavailable, professionals working with individuals with mental retardation functioning within the high moderate to mild range, should assess areas demonstrated to contribute to problematic use in persons without mental retardation, specifically, family history of substance use, fetal alcohol syndrome, difficult temperament, psychiatric disability, poor social skills, and low SES environments. Lastly, professionals and others working with people who have mental retardation might want to compile a list of community resources and activities that will increase opportunities for community inclusion and simultaneously decrease opportunities to engage in substance use.

Dennis C. Harper, PhD, ABPP, is Professor of Pediatrics in the Department of Pediatrics/Division of Psychology in the College of Medicine, and Professor of Graduate Studies in Rehabilitation/ College of Education in the Center for Disabil-ities and Development, University of Iowa.

Karen M. Cocco, PhD, is Assistant Professor at The University of Iowa Graduate Programs in Rehabilitation/College of Education. She can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

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