Assessing Substance Abuse Problems with Deaf and Hard of Hearing Students

Debra Guthmann, Ed.D., and co-authored by Katherine A. Sandberg, B.A., C.C.D.C.R.

Debra S. Guthmann, M.A., Ed.D is director of the Division of Pupil Personnel Services at the California School for the Deaf in Fremont, CA, and the former director and current project director for a long-term training grant at the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Dr. Guthmann has developed materials and provided outreach and training activities nationally and internationally regarding various aspects of substance abuse with Deaf and hard of hearing individuals.

Katherine A. Sandberg, B.S., C.C.D.C.R. is program manager of the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Ms. Sandberg was also involved in the development of a specialized version of the Drug Abuse Resistance Education (D.A.R.E.) Curriculum and has provided material development, outreach and training activities in the area of substance abuse with Deaf and hard of hearing individuals nationally.

School counselors who provide services to Deaf and hard of hearing students may encounter situations that could be related to the young person's use of alcohol and/or other drugs. Locating an agency that can provide an appropriate chemical dependency assessment for a Deaf or hard of hearing person is difficult since there are no formalized assessment tools normed or specifically designed to use with Deaf and hard of hearing individuals. Additionally, most assessors are unfamiliar with how to work with Deaf and hard of hearing people, less likely to be fluent in American Sign Language and unaware of appropriate treatment options. The purpose of this article is to provide an overview of chemical dependency, assessment issues and considerations unique to this population. A chemical dependency assessment tool developed by the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals is described as well as a case study of a young man that will assist with the application of the assessment process.

School counselors and other professionals who provide services to deaf and hard of hearing students should be aware of the potential problems of alcohol and other drug abuse.

It is estimated that 9.6 percent of men and 3.2 percent of women in the United States will become alcohol dependent at some time in their lives(Grant, 1992); many more men and women will exhibit drinking behavior that can be classified as alcohol abuse. According to the 1992 National Household Survey on Drug Abuse, more than 74 million Americans have used alcohol/drugs and this use can interfere with daily living, relationships, and the health of the user. Addiction to alcohol and or other drugs is found in every class and group of people in the United States including Deaf and hard of hearing people. How does one know if someone is an alcoholic and or drug addict? Can a teenager be addicted? If someone only drinks on the weekend are they an alcoholic? It is imperative that professionals who work with Deaf and hard of hearing individuals be familiar with how to identify the basic signs and symptoms of alcohol and drug abuse. This article will provide a basic overview of chemical dependency, symptoms of substance abuse and a case study outlining assessment issues.

An important place to begin is by understanding what is meant by the term chemical dependency. Chemical dependency can be defined as the continued use of mood altering chemicals, despite suffering harmful consequences and marked by the inability to stop using. It is a primary love relationship with alcohol or another drug that systematically changes the way a person thinks, feels and behaves. For a person who is dependent, using alcohol/drugs becomes more important than interpersonal relationships, performance at school or work, physical health, planning for the future, or anything else. When drinking and/or using drugs are causing problems in a person’s life and the individual continues to drink or use in spite of the problems, then that person has a problem with drugs and alcohol.

There is substantial evidence that chemical dependency can be accurately described as a disease. In fact, "The American Medical Association, American Psychiatric Association, American Public Health Association, American Hospital Association of Social Workers, World Health Organization, and the American College of Physicians have now each and all officially pronounced alcoholism as a disease (Valiant, 1983). In April of 1987, the American Medical Society on Alcoholism and other Drug Dependencies ( whose membership includes over 2,000 M.D.’s certified as specialists in chemical dependency) officially declared that what is true for alcoholism is also true for addiction to other drugs (Schaefer, 1996).

Chemical Dependency is a primary disease meaning that it is not just a symptom of some other underlying physical or emotional disorder. Instead, it causes many such disorders. This means that many other problems a chemically dependent person may have - such as physical illness, disturbed family relationships, depression, unresolved grief issues and trouble at school or on the job - cannot be treated effectively until the person stops using chemicals. The dependency must be treated first.

Chemical Dependency is a progressive disease and once a person enters the addiction process, the disease follows a predicable progressive course of symptoms. Left untreated, it always gets worse. The progression typically starts with a person using chemicals with few consequences and moves to the use of chemicals with more serious consequences. Typically, the addictive process happens more quickly with young people who begin using alcohol and other drugs.

Chemical Dependency is a chronic disease. This means that there is no cure for this condition. In this respect, chemical dependency is similar to diabetes, another chronic disease. In both cases, an individual can have a healthy, happy, and productive life as long as he or she accepts the need for a program of recovery. For the chemically dependent person, this means no use of mood-altering chemicals and other changes in one’s lifestyle. Chemical dependency is a lifelong disease with effective treatment, but no cure. This makes it particularly challenging to work with young chemically dependent deaf or hard of hearing people who often feel hopeless when thinking of a lifetime of abstinence.

Chemical Dependency is a fatal disease. A chemically dependent person ultimately dies prematurely if he or she continues to use alcohol or other drugs. According to Schaefer (1996), the average lifespan of an alcoholic is 10 to 12 years shorter than that of a non alcoholic. He also states that alcoholics are 10 times more likely than non-alcoholics to die from fires, 5 to 13 times more likely to die from falls and 6 to 15 times more likely to commit suicide.

The four characteristics of chemical dependency just described( primary, progressive, chronic and fatal) can be discouraging for both the addicted person and others who want to help. But, chemical dependency can be treated and arrested. Schaefer (1996), indicates that seven out of ten chemically dependent persons who accept treatment and use the knowledge and tools they are given there find sobriety.

Addiction develops over a period of time. Usually, people begin to drink or use other drugs to have a good time. Many young people report that they begin using mood altering chemicals in response to peer pressure or to fit in better. Some people also state they began using to "run away from" problems in their live. Regardless of the reason for beginning to use, the pattern of addiction consists of four different stages which include: Use, Misuses, Abuse and Dependency. 1.) Stage One - Use - A person uses alcohol and or other drugs in a way that does not cause problems in everyday life, for their family, for their friends or for society(community); 2.) Stage Two - Misuse - A person uses alcohol or other drugs and the alcohol and/or other drugs causes problems for them. These problems can happen at home, school or work and can involve the family, friends and/or the police; 3.) Stage Three - Abuse - A person thinks or feels that he/she needs the alcohol and/or other drugs to feel good, to go to work or school, to solve problems, to socialize with friends, etc.; 4.) Stage Four - Dependency(Addiction) - A person needs to use alcohol and/or other drugs, just to feel normal. These individuals have many problems but don’t see them. These individuals cannot stop their use of alcohol and/or other drugs without some level of intervention.

The criteria used to diagnose chemical dependency may include several or all of the following items: continued use despite negative consequences, pathological use, loss of control, use to extreme intoxication, blackouts, increased tolerance, preoccupation with use, polydrug use, intoxication throughout the day, repeated attempts to quit/control use, binge use, solitary use, failure to meet obligations due to use, use to medicate feelings, unplanned use, protecting supply, changing friends, willingness to take increasing risk, morning use or tremors.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is widely used to "provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study and treat people with various mental disorders" (DSM-IV, 1994, p. xxvii). There is an entire section dealing with substance-related disorders which presents diagnostic options for various substances and for abuse or dependence. The DSM-IV criteria for alcohol dependence include a maladaptive pattern of alcohol use; increased tolerance; characteristic withdrawal symptoms; inability to cut down or stop; giving up or reducing social occupational or recreational activities because of drinking; time spent focused on drinking or obtaining alcohol; and continued drinking despite physical or psychological problems caused by the use of alcohol. Diagnosis or assessment of a substance abuse problem may happen in a variety of settings including a medical setting, a substance abuse treatment program, a funding agency or a mental health services provider.

The purposes of chemical dependency assessment are to evaluate an individual's strengths, problems, needs and develop a treatment plan (CSAT-ASAM, 1995). While assessment has always been an important aspect of appropriately serving clients, the burgeoning of managed care systems, with conservative approaches to placing people in treatment, make accurate assessment even more crucial.

When assessing the extent of an individual’s chemical use the quantity of chemicals used should not be the sole basis for a diagnosis. The quality of use also provides helpful indicators of dependency. The development of increased tolerance or the presence of withdrawal symptoms are considered indicators of dependence. The concept of loss of control is also recognized as significant in assessing chemical dependency. The individual who uses more than planned or violates his/her own limits for use may be experiencing a loss of control. As previously mentioned, another factor considered to indicate dependency is the continued use of mood altering chemicals despite knowledge of negative consequences. Individuals who seek to resolve their problems through the use of alcohol and other drugs end up with even more problems because of their use.

For diagnostic purposes, many agencies that work with Deaf and hearing individuals will develop their own assessment protocols, which seek to eliminate the communication barriers inherent in diagnostic tools developed for use with hearing people. Agencies may also modify existing tools or protocols to accommodate the communication and cultural features of the deaf person. The following elements, consistent with the biopsychosocial perspective, should be included in an assessment: medical examination, alcohol and drug use history, psychosocial evaluation, psychiatric evaluation (where warranted), review of socioeconomic factors, review of eligibility for public health, welfare, employment and educational assistance programs" (CSAT, 1995, p. 66).

One way of assessing the impact alcohol and other drugs have on a person's life is to consider the consequences of that use in various life areas. These life areas may include school/employment, family, social physical, legal, spiritual, financial and the impact that substance abuse has had on each area. Generally, the primary difference in assessing Deaf and hard of hearing individuals as compared to the assessment of hearing people relates to communication issues. Unfortunately, there are currently no formalized assessment tools specifically designed for use with Deaf persons. Many agencies that serve hearing people will attempt to use standardized assessment tools such as the M.A.S.T. (Michigan Alcohol Screening Tool) to assess a Deaf person. This kind of assessment is inappropriate to use with many Deaf clients because of the vocabulary and language level of the instrument. Programs serving Deaf people have also developed their own systems or modified existing instruments normed on hearing people. Perhaps more crucial than the assessment tool or form is the manner in which the assessment interview is conducted. It is crucial that the interviewer take into account the possibility of lack of knowledge of terminology and other communication and cultural factors. The process typically incorporates a structured interview model focusing on major life areas. The following are some of the consequences commonly seen in the respective life areas:

Physical

frequent, unexplained illness

sudden weight loss or gain

injuries (from fight, accidents)

generally unhealthy appearance

unusual sinus or dental problems

memory loss (blackouts), hangovers

Family

fights, disagreements (about use)

neglect of responsibilities

failure to attend family functions

lack of trust

separation/divorce

loss of custody of children

Legal

DWI or DUI charges

probation violations

restraining orders

legal fines

court appearances

Financial

overdue bills

banking problems

borrowing/stealing money

owing money to others

gambling activity

unexplained sources of income

Work/School

unexplained absences

pattern of absences/tardiness

inconsistent/declining performance

under the influence of chemicals

problems with teachers/students

discipline in job/school

Social

isolation, lack of friends

changing friends

socialization centered on use

friends are older or younger

broken relationships

These signs can help to detect a problem with the use of alcohol or other drugs. One or even a few of these symptoms alone is probably not significant but in combination, they can point to difficulties. Changes in these life areas that are not attributable to other causes may be significant factors when considering whether or not a person has alcohol or other drug use problem. These life areas help those attempting to assess for potential alcohol or other drug use problems a more complete picture of how chemical use has impacted the individual's life as a whole.

It is important to reiterate that just because an individual meets some of the above criteria does not necessarily mean that the person is chemically dependent. An example of this would be a case where a Deaf high school student was coming to school late on a daily basis. Staff had also noticed that the student's grades were dropping and he was not as motivated in school. If you look at the above criteria, this kind of behavior might be an indication of potential alcohol and or drug use. In this example, as it turned out, the teenage boy's father was working nights and they had gotten a new big screen television with pay for view movies and other cable options. The student was staying up all night watching television and was not able to wake up on time to go to school or to complete his homework. Once the family was able to resolve the issue of no television access at night, the student's attendance at school and grades improved. This points out the importance of using the above information as a guide, but collateral information becomes critical when attempting to determine the need for chemical dependency treatment or other interventions.

A common problem encountered when assessing Deaf students involves the use of chemical dependency language not familiar to the individual. For example, a typical question may deal with the experience of a "blackout" which is a significant diagnostic feature of chemical dependency. (Blackout refers to a period of time in which the person is awake and functioning but after which there is no recollection of some or all of the events.) In assessing a Deaf client, the interviewer may need to explain the phenomenon in addition to (or instead of) using the term "blackout". The interviewer who fails to explain concepts or vocabulary that may be unfamiliar risks compromising the validity of the assessment. Many students will not ask for an explanation or clarification of terminology, but instead may respond to the question without understanding it completely. Another common problem area is related to the use of an interpreter for an assessor who is not able to communicate directly with the Deaf client. The addition of a third party will most likely change the dynamics and possibly the validity of the interview session if the interpreter is not fully qualified. The limited availability of such interpreters is also a factor that continues to be a problem throughout the United Sates. There are very few interpreter training programs that focus on the specialized substance abuse vocabulary necessary when assessing Deaf individuals.

Knowing and recognizing potential signs of chemical abuse is an important step in helping individuals who may be experiencing problems. A significant aspect of chemical dependency is the denial exhibited by the individual requiring some kind of intervention. In the absence of outside feedback, many people are able to rationalize, minimize and in others ways deny the problem. Chemical use becomes such an integral part of one's life that a person is unable to see the negative effects or to attribute them to the use of the alcohol or other drugs. While accusations about chemical use may lead to even stronger denial, sharing of genuine concerns can be an effective technique to help someone realize how their use is having a negative impact. The use of "I" statements and naming specific concerns or behaviors can be helpful. For example, a counselor might say, " I notice you have been missing a lot of classes.", or "I notice your grades are dropping in several classes." "I care about you and am concerned that you might need some help." Such communication is less likely to raise the person's defenses and lets them know that someone cares about them.

The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals(MCDPDHHI) has developed an assessment tool that is useful in recording the information, once the interview with the client has been completed (Appendix A). When talking with a client, it is essential to maintain eye contact and to elicit information from the person in a non-judgmental manner. The manner in which questions are asked can determine the effectiveness of the interview.

To assist in the application of the assessment process, a case study is presented below followed by the completion of an assessment questionnaire on Tim.

Presenting Problem: Tim has been asked to see his school counselor by one of his teachers. This teacher and several others have noticed that Tim’s attendance has been inconsistent and that his performance in his classes has slipped. He has stopped participating in athletics, which used to be very important to him. He seems to be alone much of the time and is rarely seen with his old group of friends.

Background: Tim is the only deaf child of hearing parents. He has two siblings, a younger sister and an older brother. It appears that Tim’s hearing loss has been present since birth and is of unknown etiology. Tim’s parents divorced when he was 8 years old. Tim continued to live with his siblings and his mother after the divorce. Tim’s father does not sign at all; Tim’s mother and brother have limited sign skills. Tim’s sister signs well and seems to have a close relationship with him. Tim rarely sees his father. Tim depends on American Sign Language as his primary means of communication. Lately, Tim and his mother have argued frequently, usually about Tim’s failure to come home on time. Tim’s mother is concerned because he seems different in some way.

School: Tim started school in a pre-school program in his home town. He also attended elementary school there with an interpreter for several hours each day. Tim was successful academically during his elementary school years and was involved with activities with his hearing peers. In the 7th grade, Tim transferred to the School for the Deaf. Initially, Tim participated in both school and extracurricular activities. He was successful in the classroom and in various sports. Over the past year and a half, teachers, dorm supervisors and coaches began noticing changes in Tim. He began to have attendance problems, sometimes coming back to school late from weekends home, sometimes skipping a class or two during the day. His grades began to decline and he dropped out of football, basketball and finally baseball. Tim does not spend much time with his old friends at the Deaf School, and in fact, is alone at school much of the time. Staff have seen him off campus with a group of hearing kids occasionally. At this time, he is in danger of failing two of his classes. At a recent conference held with Tim, his mother, the principal and his counselor, Tim admitted that he has been using marijuana and drinking beer on a regular basis at home and has no desire to continue attending the deaf school. Tim doesn’t think he has a problem with his use and has no desire to stop at this time.

Social: As mentioned above, Tim’s group of friends has changed in the past year and a half. The group of hearing people he has been seen with appear to be several years older than Tim. Some of these hearing friends have been kicked out of their high schools and attend an alternative school. Tim has mentioned to several people that he wants to leave the school for the Deaf so he can attend the alternative school with his friends. Several of Tim’s former friends at the school have commented to staff that Tim has changed and that they don’t have much contact with him any more. A few weeks ago, Tim was involved in a fight in the school cafeteria and staff were unable to get a clear explanation of the reason for the fight.

Legal: Tim has had no legal problems at school. He has been picked up for curfew violations three times in the last 6 months when he has been at home. No charges were filed.

Financial: Tim’s mother provides him with spending money. He occasionally asks her for additional money but it is unclear to staff how Tim spends his money. Tim’s friends notice that he seems to have a lot of money with him at times.

Family: Staff members at the school have talked to Tim’s mother about his grades and his lack of participation in other school activities. Tim’s mom has tried talking to him about these issues but both quickly become frustrated about the communication problems. Tim’s mother is concerned but feels she has little influence over him at this time. They have had a couple of nasty arguments and Tim is sometimes gone all night when he is home from school. His mother is unsure who he is with when he is out.

Physical: Staff have noticed that Tim’s appearance has changed lately. He use to be clean cut and conscientious about his appearance. Recently, he wears very baggy clothes, has bags under his eyes and wears a stocking cap pulled down over his head and face. Tim has had more frequent illnesses lately. Teachers at the school report that he occasionally appears to be hung over. Tim reported to a dorm supervisor that once, he had gone to a party over the weekend and woke up at a friend’s house the next morning and couldn’t remember how he got there.

The assessment questionnaire that the MCDPDHHI developed, can be used when meeting with a Deaf or hard of hearing client that may have a drug and/or alcohol problem. It is important to remember that this form should only be used as a guide. When interviewing a Deaf or hard of hearing person, eye contact is critical to the assessment process. It is essential for the interviewer to become familiar with the assessment questionnaire so that the person is not looking down at the form and completing it while talking with the client. While the intake or interview with the client is in process, write down notes that can be later transferred to the assessment form.

Referred by: _School Counselor_________ Agency: _School for the Deaf_____ Phone: 555-3333

Reason for Referral: _______problems in school ________________________________________

Communication Preference: _________________Sign language______________________________

Family Incidence of Hearing Loss? YES / NO If yes, identify members: __Family is hearing_________

Family Incidence of alcohol/drug problems? YES If yes, identify members: ____Unknown__________

Other background information: __________Parents divorced when Tim was 8 years old_________

Admissions for Detox: Place __None reported______________ Dates __________________

Place __None reported____________ Inpatient / Outpatient Dates ___________________

Place __________________________ Inpatient / Outpatient Dates ___________________

_____ Suicidal thoughts/behavior ____ Anger problems ____ Depression _____ Use to medicate emotional pain

Identify chemicals used. For each chemical, identity age of first use & present pattern of use.

Use information: ______________________________________________________________________________________________

___________________________________________________________________________________________________________

____ TOLERANCE need for increase amounts of substance to achieve intoxication or markedly diminished effect with continued use of the same amount.

____ WITHDRAWAL characteristic syndrome or same or closely related substance taken to relieve or avoid withdrawal symptoms.

____ TIME spent in activities necessary to obtain substance or recover from its use.

__x__ SOCIAL, OCCUPATIONAL , RECREATIONAL activities given up or reduced because of use.

____ CONTINUED use despite knowledge of physical or psychological problems caused or exacerbated by the use.

The information presented in this article and Tim's case helps to illustrate key concepts of the assessment of substance abuse problems. Those key concepts include the following:

For person's who are Deaf or hard of hearing, like Tim, the principles of addiction and assessment are the same as they are for hearing people. The process, however, must take into account the communication factors mentioned above including lack of familiarity with vocabulary, lack of assessors who are skilled communicators with Deaf and hard of hearing individuals and a lack of qualified interpreters able to facilitate communication for a valid assessment.

The process of recovery begins by discovering the problem. Only through appropriate and accurate assessments can Deaf and hard of hearing people get the help they need to recover from alcohol and other drug addiction.

When providing drug/alcohol programming to students the following components are essential to keep in mind; the cultural aspects of deafness, communication modalities, access to recovering deaf role models, access to deaf and/or interpreted AA/NA meetings and materials that are available in ASL on videotape or modified written English. Materials are also needed that focus on assisting students in developing assertiveness and social competencies, improving self-esteem and strategies for resisting negative peer pressure. Schools need to be proactive and ensure that counselors are able to identify potential chemical abuse problems. Each school should have some kind of prevention program in place and clear consequences if students violate the drug/alcohol policy. Some schools have set up peer advisor programs or sober social clubs which has helped to support students who are at risk. Schools should establish a drug/alcohol committee made up of parents, students, staff and community members to review existing policies and ensure that prevention services are provided to students. Policies should include clear consequences that are consistent. Some schools use community service as well as the suspension from athletics, student boards or other school activiites as consequences related to drug/ alcohol use. Training should be provided to instructional, clinical and residential staff regarding drug/alcohol issues and the related policies and procedures of the school.

The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals (MCDPDHHI) currently provides assessment, treatment and aftercare services to Deaf and hard of hearing persons. As a national model the program offers a staff of professionals trained and experienced in substance abuse and deafness. Unique materials and approaches developed and utilized by the Program help to provide individuals with the opportunity for a quality treatment experience.

The (MCDPDHHI) was established in 1989 to meet the chemical dependency treatment needs of Deaf and hard of hearing individuals in an environment that was able to meet the communication and cultural needs of this population. Initially designed with an adolescent focus, the Program expanded to serve persons aged sixteen years and above. In 1990, the Program was the recipient of a grant from the Center for Substance Abuse Treatment to serve as a model program for substance abuse treatment of Deaf and hard of hearing persons. The grant, initially funded for 3 years and later renewed for an additional 2 years, provided the development of an assessment tool, the program’s clinical approaches, specialized treatment materials, outreach and training services and dissemination of materials and information. In addition, the Program also received two grants from the Office of Special Education and Rehabilitation Services. One grant provided intensive four day professional Development Forums focused on training professionals who work with Deaf and hard of hearing clients who may be chemically dependent. The other grant provides a certificate in Chemical Dependency and Deafness through the University of Minnesota.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (fourth edition.). Washington, DC: Author.

Center for Substance Abuse Treatment. (1995). Treatment Improvement Protocol: The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders. Rockville, MD.: USDHHS.

Evans, K. and Sullivan, J., (1990). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser. The Guilford Press, New York.

Grant, B.F. (1992). DSM-IIIR and proposed DSM-IV alcohol abuse and dependence, United States 1988: A nosological comparison. Alcoholism: Clinical and Experimental Research 16(6): 1068-1077.

National Household Survey on Drug Abuse., (1992). National Institute on Drug Abuse, United States Department of Health and Human Services, Rockville, MD.

Schaefer, D., (1996). Choices & Consequences: What to do when a teenager uses alcohol/drugs. Johnson Institute, Minneapolis, Minnesota.

Vailant, G., (1983). The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery Cambridge, MA: Harvard University Press.

Referred by: ____________________ Agency: ________________ Phone: _______________

Reason for Referral: _________________________________________________________________

Marital Status: ______________ Living Arrangement:; _______________________________

School Status: ______________ Employment Status: ________________________________

Communication Preference: __________________________________________________________

Family Incidence of Hearing Loss? YES / NO If yes, identify members: _________________________

Family Incidence of alcohol/drug problems? YES / NO If yes, identify members: ________________

_________________________________________________________________________________

Other background information: _________________________________________________________

__________________________________________________________________________________

Place __________________________ Inpatient / Outpatient Dates ___________________

_____ Socialization around use _____ Negative reputation _____ Gambling _____ Friends older / younger

_____ Suicidal thoughts/behavior _____ Anger problems ____ Depression _____ Use to medicate emotional pain

Identify chemicals used. For each chemical, identity age of first use & present pattern of use.

_____ TOLERANCE need for increase amounts of substance to achieve intoxication or markedly diminished effect with continued use of the same amount.

_____ WITHDRAWAL characteristic syndrome or same or closely related substance taken to relieve or avoid withdrawal symptoms.

_____ TIME spent in activities necessary to obtain substance or recover from its use.

_____ SOCIAL, OCCUPATIONAL , RECREATIONAL activities given up or reduced because of use.

_____ CONTINUED use despite knowledge of physical or psychological problems caused or exacerbated by the use.