Bad Mouthing, Bad habits & Bad, Bad Boys · Bad mouthing, bad habits and bad, bad boys set out to...

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1 Bad Mouthing, Bad habits & Bad, Bad Boys Bad Mouthing, Bad habits & Bad, Bad Boys An exploration of the relationship between dyslexia and drug dependence An exploration of the relationship between dyslexia and drug dependence P. R. Yates P. R. Yates

Transcript of Bad Mouthing, Bad habits & Bad, Bad Boys · Bad mouthing, bad habits and bad, bad boys set out to...

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Bad Mouthing, Bad habits &

Bad, Bad Boys

Bad Mouthing, Bad habits &

Bad, Bad Boys

An exploration of the relationship between dyslexia

and drug dependence

An exploration of the relationship between dyslexia

and drug dependence

P. R. YatesP. R. Yates

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BAD MOUTHING, BAD HABITS & BAD, BAD BOYS: AN EXPLORATION OF THE RELATIONSHIP BETWEEN DYSLEXIA

AND DRUG DEPENDENCE

P. R. Yates

Supervised by Susan Eley, Kirsten Stalker & Alison Bowes

Dissertation submitted 31st August 2006

MSc. In Applied Social Research Department of Applied Social Science

University of Stirling

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TABLE OF CONTENTS

ACKNOWLEDGEMENTS 4 ABSTRACT 5 CHAPTER ONE: INTRODUCTION 6

Making connections 6 Understanding connections 7 Research questions & structure 8

CHAPTER TWO: LITERATURE REVIEW 10 Introduction 10 Understanding addictive behaviours 11 The nature and extent of dyslexia 12 Evidence of possible association between the two issues 14 Summary 15

CHAPTER THREE: METHODOLOGY 17 Introduction 17 Methodological approach 17 Description of the research process 20 Limitations of the process 22

CHAPTER FOUR: THE QUANTITATIVE FINDINGS 24

Introduction§24 Results from the LADS dyslexia screening 25 Results from the MAP interviews 29 Correlations between the LADS and MAPS data 37 Summary 40

CHAPTER FIVE: THE QUALITATIVE FINDINGS 42 Introduction 42 Experiences of drugs 43 Experiences of school 46 Views on reading and drug use 47 Summary 49

CHAPTER SIX: CONCLUSIONS 50 Introduction. 50 Implications of the quantitative data 50 Implications of the qualitative findings 51 Some further thoughts on future research possibilities 51

REFERENCES 53

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APPENDICES 60 APPENDIX A: THE MAUDSLEY ADDICTION PROFILE 61 APPENDIX B: BRIEF INTERVIEW SCHEDULE 67 APPENDIX C: CONSENT FORM 70

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ACKNOWLEDGEMENTS

This study relied heavily upon the goodwill and enthusiasm of a number of drug treatment services, both in Scotland and England. I am grateful to them for their candour and their continuing interest in the work. I am grateful too, to Davie, Pete, Willie, Fraser and Rick, who gave up their time to help me pilot the various instruments. Their interest was inspiring and helped me to question much of what I had initially assumed. Susan Eley, supervised the early stages of this study and helped me to refine my aims, Kirsten Stalker provided invaluable advice on the ethics and implications of the work I was undertaking and Alison Bowes was supportive and encouraging during those final whirlwind days! And finally thank you to my son Christy for the “Dyslexia?” painting, a detail of which is used for the cover.

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ABSTRACT

Bad mouthing, bad habits and bad, bad boys set out to explore the apparent relationship between dyslexia and drug dependence. The intention was to verify various anecdotal sources which have suggested that the incidence of dyslexia is higher amongst drug users than the general population. The study sought too to assess whether there was any correlation between dyslexia and the severity of dependence and to explore drug users views and experiences. The findings generally support the anecdotal evidence. Dyslexia does appear to be more prevalent in this population and dyslexic drug users appear to have significantly more drug-related difficulties.

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CHAPTER ONE: INTRODUCTION “dyslexia – [noun] a disorder involving difficulty in learning to read or interpret words, letters, and other symbols. derivatives - dyslexic adjective & noun. origin - from Greek lexis ‘speech’ (apparently by confusion of Greek legein ‘to speak’ and Latin legere ‘to read’)”. (Oxford Dictionary of English, 2005). Making connections This study is a largely exploratory attempt to consider the relationship, if such a relationship exists, between dyslexia and drug dependence. Dyslexia is popularly considered to be a condition or disability, which mainly affects the individual’s ability to read and write. However, there is a considerable body of evidence indicating that dyslexia is far more than a problem of literacy. Dyslexics, particularly in adulthood, are more likely to exhibit poor capacity for memory-span tasks, issues of organisational incapacity and physical awkwardness (dyspraxia) with various coping strategies having been developed over the years, to neutralise difficulties with reading and writing. There is a considerable body of literature within the fields of education and psychology, which notes the high numbers of dyslexic adolescents with behavioural difficulties and offending behaviour (McGee et al., 1986; Thomson, 1994; Thomson & Hartley, 1980). However the addiction literature is virtually silent about this issue despite numerous studies noting high levels of reading difficulties. Ardila and Bateman (1995) included a question on dyslexia in a survey of 1,879 university students in Bogotá and found little difference in incidence between the students who indicated that they had used drugs and those who had not. However, this was one question in a lengthy questionnaire and it would seem likely anyway, that the number of dyslexics found within a sample of university students, would be atypical. Despite this apparent dearth of any empirical evidence, on-line dyslexia chat rooms and local dyslexia association newsletters regularly throw up tales of good boys (and occasionally girls) “gone wrong”. Addiction workers too, report, anecdotally, high levels of reading disability amongst their clientele. Like childhood sexual abuse in the late 1980s (Yates et al., 1990), it may be that dyslexia is yet another precursor of adult dependence, the relevance of which is, as yet unrecognised. In a recent on-line survey of addiction workers (Yates, 2004), 82% of respondents estimated that between a quarter and one half of their clientele had reading

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difficulties, with 89% indicating that they thought these difficulties were a barrier to recovery. One respondent noted:

“When I first heard about your survey, I asked around the rest of my team. I was amazed. Almost everyone had a bunch of punters with dyslexia. But we’d never talked about it. And I thought it was just me!”

Another respondent wrote:

“It’s part of the middle class ‘gentrification’ of the addiction business. The addiction world is full of grammar school kids now, who just expect their working class clients to be thick. So when they have trouble reading, that just confirms it!”

Numerous respondents made similar points. The study was extremely small and could hardly be viewed as statistically significant, but there does appear to be a groundswell of anecdotal experience, which would seem to suggest that there is a significant problem amongst addiction treatment populations. Understanding connections If this connection does exist, there are, of course a number of possible explanations for the phenomenon. It might be that in some way, dyslexia disposes individuals to seek intoxication. This would, in many ways, be consistent with the findings of Goodwin (1990) and others, who have put forward the argument for the existence of a genetic inheritance of addiction. It would resonate too, with the recollections of some dyslexic addicts who recall their first experience of intoxication as “coming home” or “I felt right for the first time in my life” (see Chapter Five). There certainly is good evidence to suggest that dyslexia is hereditable but, as with addiction, there continues to be a vigorous debate concerning the relative influence of genetics and socio-economic factors. Even were this not the case, there would remain the thorny question of why all dyslexics were not addicts and indeed, why all addicts were not dyslexics. An alternative hypothesis is that the experience of dyslexia in adolescence is so profoundly frustrating that resentful teenagers turn to drugs almost out of spite. On the surface, this is a rather attractive proposition, but in truth, it is founded upon a somewhat cosy, stereotypical view of dyslexia. There is a popular perception that within every dyslexic, there is an intellectual (or at least, artistic) giant striving to escape. This is a natural expression of our collective desire that things be fair. We want the world to compensate “victims” so that we can believe that we will be similarly compensated, and be able to live happily if the same misfortune happens to us.

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The fear we feel when we see such “victims” is eased by a belief that they have found a new source of joy and satisfaction in life – they are actually better off now and happier - and we would be too if the same tragedy befell us. It seems only fair that people confined to wheelchairs should have great comedic skills or be innate empathetic counsellors and the non-wheelchair society pounces upon every example as proof. Without these ‘proofs’ we would be forced to feel guilty that we had received the better bargain. Out of this naïve sense of fair-play comes the notion of the frustrated dyslexic genius. But the literature on dyslexia does not support this notion and would suggest rather, that dyslexics are liable to display the same range of abilities and creativities as the wider population. A third possible explanation of any connection is that the two conditions – dyslexia and dependence – are simply part of a constellation of problems that coincide for quite separate reasons. Wilkinson (1997) notes that:

"It's hard to tell the difference between maps of crime, ill-health, drug

addiction or low educational achievement. They all look like maps of poverty".

There is certainly a good deal of evidence that both addiction and dyslexia are strongly associated with poverty (Advisory Council on the Misuse of Drugs, 1998; Gilman 1998; Rutter and Yule, 1975). It is entirely conceivable that both issues are unrelated sequelae of deprivation. Interestingly, these three explanations of the issue are strikingly similar to those proposed as explanations for addictive behaviour. Uni-dimensional explanations almost invariably fall into either the biological, the psychological or the socio-cultural camps Research questions & structure This small study does not seek to address these extremely difficult questions. As a modest first step, the study seeks to establish whether dyslexia is, indeed, more prevalent amongst a drug-treatment seeking population than it is within the wider community. In addition, the study seeks to examine any correlation between levels of severity in dyslexia and dependence. Finally, the study offers an opportunity for a small sample of drug users to reflect upon their experiences and offer their thoughts as to whether there is any connection between the two issues and to what extent reading difficulties were an issue in their life prior to drugs and the impact upon their experience of the addiction treatment system.

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Chapter Two describes the background to the two issues and explains in more detail the possible connections between the two. In Chapter Three, the methodology employed is explained, any limitations to the study model are examined and modifications for subsequent similar studies are recommended. In Chapter Four the main quantitative findings are set out and these are compared to the available evidence regarding dyslexia and dependence within the wider community. Chapter Five considers the thoughts and feelings of interviewees regarding the links between the two issues and their implications for recovery. Chapter Six looks at the implications of these findings for an addiction treatment system based largely upon cognitive behavioural principles and suggests further areas of study, which might encourage greater understanding of the issues and engender a more effective approach to recovery management.

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CHAPTER TWO: LITERATURE REVIEW Introduction This chapter provides a brief summary of the background to our understanding of both addiction and dyslexia. The chapter represents the synthesis of a comprehensive literature search undertaken specifically for this study. The following search terms were used (both individually and in various combinations) 1: • dyslexia • dyspraxia • specific learning disability • specific learning disabilities • reading problems • writing problems • illiteracy • illiterate • low education • theories of dependence • theories of addiction • genetic inheritance • biological theories • disease model • characterological model • behavioural model • socio-cultural model • biopsychosocial model • addictive gene • dyslexic gene The following databases were searched: Alcohol Concern On-line Library; Alcohol Studies (Rutgers) Database; British Educational Index; Drug Misuse in Scotland (ISD) Publications Database; Drugscope On-line Library; DrugText; Executive Summaries On-line; Fagibliotek om rus; Ingenta; Lindesmith Center; Medline; National Drug Strategy Unit (Australia) On-line Library; NHS Scotland e-Library; NIDA Database; PsycInfo; Rapid Assessment and Response Archive; Robin Room Archive; Science Direct; Schaffer Library of Drug Policy; Scottish Addiction Studies On-line Library; Social Science Information Gateway; Web of Science; and the WHO Substance Misuse Database.

1 The list of terms provided here is not exhaustive. A number of other terms were used in various combinations and specific search terms were used to locate “grey” publications by known agencies or individuals.

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In addition, the following journals were searched: Addiction; Addictive Behaviours; Alcohol; Alcohol Research and Health; American Journal of Drug and Alcohol Abuse; Annals of Dyslexia; British Journal of Educational Psychology; British Journal of Psychology; Drug and Alcohol Dependence; Drug and Alcohol Review; Drugs Prevention, Education and Policy; Druglink; Dyslexia; Dyslexia Online Journal; Dyslexia Review; European Addiction Research; International Journal of Drug Policy; Journal of Drug Issues; Journal of Learning Disabilities; Journal of Research in Reading; Journal of Substance Abuse; and Findings. The search was restricted to full text articles in English published between 1950 and 20052. Over 300 articles and other publications (monographs, short works, book chapters etc.) were examined. Understanding addictive behaviours Throughout the late 19th Century and the first half of the 20th Century, addiction (or alcoholism or, earlier, inebriety) was generally considered to be a mysterious and normally, incurable disease (Baumohl and Room, 1987; Levine, 1979). Whilst early versions of this disease model laid the blame squarely on intoxicating liquor and provided the scientific basis for the establishment of prohibition in numerous developed countries in the early part of the 20th Century (Yates and McIvor, 2003), later, more sophisticated models were predicated upon the idea of an allergic reaction – possibly hereditary – amongst some (but not all) consumers (Levine, 1979; Peele and Alexander, 1985). It was this dispositional disease model which lay at the heart of the Alcoholics Anonymous movement from it’s inception in 1935 in Akron Ohio (Rawlings and Yates, 2001; Roizen, 1991). The theory was at its most influential in the 1960s when, heavily promoted by Jellinek (1960) and others, it was adopted by the World Health Organisation and the American Medical Association (Levine, 1979; Room, 1983). Later developments in the promotion of the disease model of addiction have tended to concentrate on the existence of an elusive “addictive gene”. Family studies (Tennant 1976; Smart and Fejer 1972; Annis 1974), twin studies and work with adoptive children of addicted parents (Schuckit et al. 1972; Goodwin 1976; Bohman 1977; Goodwin, 1979) have indicated that there may be some inheritance of the pre-disposition to intoxicating substances. In addition, some studies have suggested the possibility of neurological change in the brain function of pre-disposed consumers of intoxicants (Davis and Walsh 1970; Doust 1974). Some theorists have subsequently refined their position, arguing that such genetic components form only a part of the equation within a broader, multi-dimensional understanding (Goodwin, 1990). It was in the following decade that scientific study of the addiction phenomena began to challenge this, and other, less influential uni-dimensional explanations. The work 2 A number of specific publications were included which lay outside these parameters where their inclusion was felt to provide an important historical perspective.

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of Zinberg in particular, brought together aspects of the disease model with characterological (Khantzian, 1985; Wurmser, 1984; Leeds and Morgenstern, 1996) and behaviourist (Ellis, 1993; Morgan, 1996) models, into a multi-dimensional biopsychosocial theory of dependent behaviour (Donovan, 1988; Peele and Alexander, 1985; Zinberg, 1984). The biopsychosocial theory of addiction argued that a simple, single trigger for dependent behaviour did not exist (Peele and Alexander, 1985) and that instead, such behaviours were the result of a complex interaction between the chemical/biological experience; the personality of the individual; and the socio-cultural backcloth to the events over time (drug, set and setting) (Zinberg, 1984). For all its complexity, the model was readily adopted by practitioners and used as the basis of most assessment, diagnosis and treatment planning (Yates, 1984; Yates, 1988). This, more complex approach to understanding addiction, has been the bedrock of most practice developments over the past three decades, although recent changes in the field, largely as a result of the increased political profile of drug misuse and an apparent preoccupation amongst policy-makers with the drugs-crime axis, have resulted in the predominance of substitute prescribing interventions (methadone maintenance) effectively predicated upon the earlier disease model (Stimson, 2000; Yates et al., 2006). The nature and extent of dyslexia Dyslexia is by no means a recent phenomenon. As early as the end of the 19th Century (Morgan, 1896) and the beginning of the 20th Century (Brunner, 1905; Hinshelwood, 1917), scientists were noting the peculiarities of “congenital word-blindness”, where children who appeared otherwise intellectually capable, struggled with the basics of reading and writing. But it was in the 1970s and 1980s that the major advances were recorded. Up until that time, definitions of dyslexia were hardly difficult to find, but rarely scientifically specific. In 1968, the World Federation of Neurology (WFN) agreed that dyslexia was:

“... a disorder manifested by difficulty in learning to read despite conventional instruction, adequate intelligence and socio-cultural opportunity. It is dependent upon fundamental cognitive difficulties, which are frequently of constitutional origin.”

(cited in: Critchley, 1970)

No attempt, apparently, was made by the WFN to explain what was meant by “conventional instruction”, socio-cultural opportunity” or “constitutional origin”. A decade later, Wheeler and Watkins (1978) noted over a dozen definitions of dyslexia, almost all of which focused upon written language skills. Most were so-called ‘discrepancy’ theories concentrating upon the difference between the individual’s intellectual capacity and their actual performance in reading and writing (Thomson, 1990).

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The problem with such definitions, is that they are largely unable to distinguish between dyslexics and others with poor reading and writing ability and that they generally fail to define the characteristics of adult dyslexics who have often developed extremely complex coping mechanisms to compensate for their difficulties (McLoughlin, Fitzgibbon and Young, 1994). Dyslexia is more accurately defined as a problem with short-term memory (Miles, 1983) and the processing of information (Chasty, 1985; Vellutino, 1987). The distinction between the function and operative construction of short- and long-term memory was first proposed by James (1890), but subsequent work has added considerable complexity. Baddeley (1986) suggested that the short-term (or working) memory consisted of a dominant system (the central executive) and two complementary sub-systems which he called the sketch pad and the articulatory loop. It is this latter sub-system which is thought to govern both sequential tasking and phonological processing (McLoughlin, Fitzgibbon and Young, 1994). Gathercole and Baddeley (1990) have speculated that, in dyslexic individuals, the loop of the articulatory loop, is simply too short for adequate information storage and retrieval. McLoughlin, Fitzgibbon and Young (1994) have further developed this memory-based conception of dyslexia, listing the common characteristics as: late reading age, speed naming deficit, poor paired-associate learning, poor capacity for memory span tasks, low capacity for mental arithmetic, poor ability for sequential learning (multiplication tables, calendar months etc.), poor learning capacity and continued poor spelling and handwriting. Farnham-Diggory (1978) considered a number of American studies and estimated prevalence to be 2 – 25%. However, many of these studies were of learning disabilities generally and McLoughlin et al (1994) suggest a more realistic estimate of 4%. In Scotland, Clark (1970) measured incidence in Dunbartonshire and reported a figure of 5%. Both Snowling (2000) and Thomson (1990) agree that the wide variation in estimates are largely the result of differences in definition and methodology; particularly the choice of cut-off point in terms of age. McLoughlin et al (1994) argue that dyslexia in the adult population exhibits quite different symptoms or behaviours to those seen in the school-age populations studied in the majority of research initiatives. Adult dyslexics are likely to have developed a range of coping mechanisms to resolve issues of reading and writing (Patton and Polloway, 1992), although the issues of organisational capacity and physical awkwardness (dyspraxia) may remain unresolved. As with addiction, the issue appears to affect significantly more males than females. Rutter and Yule (1975), in a large UK-based study, found a ratio of 3.3:1 males to females. Critchley (1970) found a ratio of 4:1 whilst Naidoo (1972) calculated the ration to be 5:1. Again, Snowling (2000) and Thomson (1990) both argue that the discrepancies may lie in the methodology and point particularly to the earlier maturation of young girls.

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There is, however, general agreement that the symptomatology described by the term dyslexia cannot be accounted for in terms of intellectual ability (Snowling, 2000) and that the issue appears to have a strong genetic component (Thomson, 1990). Numerous studies (Ingram, Mason and Blackburn, 1970; Yule and Rutter, 1976; Decker and De Fries, 1980; Liu et al, 2004) attest to the high frequencies of reading difficulties and other aspects of the dyslexia syndrome amongst the families of dyslexics. As with addiction, however, these studies rarely do more than suggest some genetic factor and they generally fail to distinguish adequately between these impacts and those which are a product of the familial environment (Thomson, 1990). Evidence of possible association between the two issues The relatively high occurrence amongst adolescent dyslexics of both behavioural difficulties (McGee et al., 1986) and anti-social behaviour and offending (including drink or drug related offending), is extensively documented in the dyslexia and learning disabilities literature (Thomson, 1994; Thomson & Hartley, 1980). However, the addiction literature, whilst occasionally noting high levels of illiteracy in study samples (Ardila & Bateman, 1995; Daramola and Grange, 1971; Paxon, 1995; Sqeiff, 1976) of drug/alcohol misusing individuals, offers little by way of an examination of the causes of these levels of illiteracy. An on-line search of the Drugscope Library, the most extensive specialist collection in Western Europe, found eight studies using the keywords “literacy” and “illiteracy” but only one (Ardila and Bateman, 1995) using the keyword “dyslexia”. It seems possible, given the apparent discrepancy between these two sets of literature, that dyslexia, as a contributory factor to behavioural difficulties leading to drug or alcohol misuse and as a potential barrier to successful treatment for drug dependence, might have been overlooked by specialist services providing treatment or other responses to problems of misuse. Indeed, this would not be entirely surprising, since numerous studies (Thomson, 1990; Owen et al., 1971) have suggested that current prevalence rates, largely drawn from referrals within the education system, significantly underestimate the numbers of both very young and adolescent dyslexics despite strenuous efforts in UK education to identify such problems. Two articles – an interview with offender-turned-probation officer, Bob Turney (Peer, 2001) and the letters and writings of convicted murderer, Julian Cox (2001) – graphically illustrate the way in which the frustration, depression and low self-esteem associated with dyslexia might lead to offending and how the confusion and disorganisation might further compound the situation. An association between dyslexia and crime generally has been noted for many years (Critchley and Critchley, 1978). Svensson, Lundberg and Jacobson (2001) reported incidence of such problems at higher levels than the general population amongst young offenders in Sweden. In one recent study, Kirk and Reid (2001) examined a sample of inmates of a Scottish prison and found that 50% were dyslexic to some extent with some 12%

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severely so. This is clearly significantly higher than the incidence reported for the wider community and, although Kirk and Reid make no specific mention of drug or alcohol misuse, Her Majesty’s Chief Inspector of Prisons report for the period during which the research was undertaken, notes that “80% of admissions are found to have taken illegal substances at the point of entry.” (Fairweather, 2001). As with addiction, studies on dyslexia have consistently reported that personality and socio-economic circumstance (Zinberg’s set and setting) may interact with the biological/genetic component to affect the severity of the phenomenon. Indeed, it is possible that these aspects are so significant in some individuals, that dyslexia is almost impossible to identify (McLoughlin, Fitzgibbon and Young, 1994). Gerber, Ginsberg and Reiff (1992), in a study of adult dyslexics who have achieved success despite their impediment, identified a series of factors they felt crucial to the success of their study sample. Curiously, the list of factors – motivation, being goal-oriented, reframing (recognising their problems and acting to overcome them), persistence, readiness to utilise support – bear a remarkable resemblance to the qualities noted in studies of recovered or stabilised addicts (Peele and Alexander, 1985; Zinberg, 1984) which have contributed to their successful abstinence. Conversely, Riddick et al (1999) noted significantly lower self-esteem indicators and higher levels of feelings of anxiety and inferiority amongst a group of dyslexic students when compared to a control group. Similarly, situation or environment over time, can have a significant impact upon severity. In Rutter and Yule’s study of UK schoolchildren (1975), prevalence was almost twice as high in Inner London (6%) as it was in the Isle of Wight (3.5%). Molfese and Molfese (2002) argue that there is now compelling evidence to show the importance of home environment in mediating the dyslexic experience. Samuelsson and Lundberg (1996) identify poor home environment and unsupportive schooling as major factors in the development of the dyslexic child and the extent that the issue dominates their future lives; issues which are consistently noted in assessments of drug and alcohol misusers presenting for treatment (Peele and Alexander, 1985; Dorn and South, 1985). Summary Both addiction and dyslexia appear to have a strong biological/genetic basis, which is significantly impacted upon by individual personality and socio-economic issues. Both appear to be recorded at high levels amongst offender populations. Whilst none of these similarities amounts to a compelling argument for a link between dyslexia and addiction, there would appear to be sufficient parallels to justify further examination of the issues involved. Moreover, if there are indeed higher than anticipated numbers of dyslexic individuals amongst drug and alcohol treatment populations, this would have serious implications for treatment delivery. In the last decade, addiction treatment agencies have increasingly turned to cognitive-behavioural therapeutic techniques as the central plank in their response agenda

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(Wilson and Yates, 2001). However, these techniques necessarily assume a certain level of literacy and cognitive function. If a significant proportion of the treatment population is experiencing serious deficits in precisely these areas, then much of the work done with these individuals may be of limited value.

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CHAPTER THREE: METHODOLOGY Introduction The purpose of this small study was to address four inter-related questions:

• to establish whether dyslexia is more prevalent amongst a drug-treatment seeking population than it is within the wider community.

• to examine any correlation between levels of severity in dyslexia and

dependence.

• to record the views of dyslexic drug users in treatment, with regard to the connection – if any - between the two issues

• to record the experiences of dyslexic drug users in treatment as to extent to

which reading difficulties affected their early lives and impact now, upon their experience of the addiction treatment system.

Clearly, these questions, by their very nature required quite different approaches in order to gather the appropriate data. Consequently, a research strategy was devised which incorporated both quantitative and qualitative methods within a coherent and logical structure. This Chapter describes the process and explains the rationale for the chosen approach. Methodological approach From the outset, it was recognised that this study was likely to impact upon both the individuals tested and upon those organisations which provided access to the study sample. Dyslexia is popularly associated with illiteracy (with all the negative connotations which that term encompasses) and a positive diagnosis clearly has the potential to be upsetting for some individuals tested. Moreover, positive diagnoses could call into question some of the treatment approaches currently employed by the participating organisations. The ultimate aim of the study was to explore a possible difficulty which might be experienced by many seeking drug or alcohol treatment, to consider how this might impact upon their treatment experience and to suggest ways in which treatment modalities might be adjusted to accommodate the particular difficulties encountered. Thus, the intention was to produce data which might, ultimately, improve the treatment services offered.

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Three main instruments were used in this study in order to collect the necessary data. The level and severity of dyslexia was tested through the use of a computerised adaptive test called LADS (Lucid Adult Dyslexia Screening). The nature and extent of the dependent behaviour was tested using the Maudsley Addiction Profile (MAP). Finally, a small sub-sample of ten individuals were subsequently interviewed using a short interview schedule specifically designed for this study. LADS (Lucid Adult Dyslexia Screening) - LADS is a computerised test designed to screen for dyslexia in individuals over 16 years of age. The test was developed as a result of a five-year longitudinal study of early identification of dyslexia undertaken by staff at the Department of Psychology, University of Hull (Singleton, Thomas and Horne, 2000). This resulted in a computerised test for children called CoPS (Cognitive Profiling System), which was subsequently accredited by the Qualifications and Curriculum Authority for use as entry-level assessment for primary school pupils and is now used in over 3,500 primary schools in England and Wales. LADS, which was developed as an adult version of this initial screening programme, is widely used in further and higher education and in adult learning centres. Research has indicated that computerised assessments are less stressful (and potentially therefore, more accurate) than conventional tests administered by professionals perceived to be in positions of authority (Singleton, 2001). Moreover, since the test is self administered, individual respondents can undertake screening in private. The LADS test consists of four sub-tests, three of which are dyslexia-sensitive, whilst the fourth, a test measuring non-verbal matrix reasoning, is used as a measure of intellectual capacity against which the other sub-tests may be evaluated. Not only does this measure of reasoning ability allow assessors to distinguish between those whose performance in the other tests is low as a result of limited vocabulary or low intelligence and those for whom the discrepancy is due to dyslexia, it also provides an indication of the appropriate level of intervention in the case of positive test results (Singleton, 2001). The remaining three sub-tests measure time-sensitive recognition of words and non-words (lexical decoding), time-sensitive construction of non-words from syllables (lexical encoding and phonological capacity) and reverse-order digit span (working memory test) respectively. The test is adaptive, with the software adjusting output according to a continual rolling measure of sub-test ability against intellectual capacity. The Maudsley Addiction Profile (MAP) – MAP is designed as a brief, interviewer administered questionnaire for dependence assessment, treatment outcome and general research application (Marsden et al., 1998). The questionnaire was originally designed as a response to a UK-wide call for standardised models of outcome measuring in the addictions field (Task Force to Review Services for Drug Misusers

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1996) and was subsequently refined for use as the core instrument in the major study National Treatment Outcome Research Study (NTORS) (Gossop, Marsden, Stewart and Kidd, 2003). The MAP, like a number of other similar treatment-oriented substance-misuse screening instruments, measures problems in four domains recognised within the treatment literature to impact upon successful intervention outcome: substance use, health risk behaviour, physical and psychological health and personal/social functioning. The substance use section of the MAP records both frequency and intensity of the use of a range of commonly used/misused substances over a recall period of 30 days. The recall period is a compromise between the commonly used 7 days which often fails to adequately record episodic or intermittent (binge) misuse and longer periods of 6 months or a year which pose problems of accuracy in respondent recall. Frequency is recorded over the 30 day period with the use of “prompt cards” whilst intensity is assessed through verbatim reports of typical daily consumption. In scoring the MAP, these verbatim reports are converted into standardised units. Route of administration is recorded as oral, intranasal, inhalation and injection. The health risk behaviour domain records frequency of injection, together with self-reported evidence of sharing of injecting equipment (including paraphernalia such as spoons, filters etc.). In addition, respondents are asked to recall frequency of unprotected sexual activity within the 30 day recall period, together with an estimate of number of sexual partners. The physical health domain comprises a series of questions adapted from Darke et al.’s more extensive Opiate Treatment Index (1991, 1992). Each symptom is recorded on a five-point Likert-type scale measuring frequency during the recall period. Psychological health is similarly recorded using questions derived from the anxiety and depression sub-scales of the British Symptom Inventory (BSI) (Derogatis, 1975). Finally, the personal/social functioning domain examines client activity within the 30-day recall period in respect of relationship conflict, employment and criminal activity. The level of conflict with sexual partners, relatives and friends is measured in a similar way to the relevant domain in the Addiction Severity Index (McLellan et al., 1992) except that in the MAP, respondents are also asked to recollect frequency of contact. Employment and criminal activity is similarly measured in terms of frequency and intensity with respondents questioned about a series of crimes commonly associated with substance misuse. Completed MAPs can be scored in each domain to provide an overall level of dependence measure which is comparable across treatment populations and primary drug types (both alcohol and drug misusers) (see Appendix A).

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Short Interview Schedule - In order to record, in a systematic fashion, respondents’ views on on possible links between their drug use and their dyslexia, a short interview schedule was designed specifically for the study. The interview schedule asked a series of questions within the framework of three domain areas. Firstly, the schedule asked respondents for their personal recollections of the use of drugs, particularly early experiences of intoxication. In part, this area of questioning stems from the suggestion in some of the dyslexia literature (Davis, 1994) that dyslexic children learn at an early age to “self-trigger” disorientation in order to process information. This theory is regarded as somewhat contentious and it should be acknowledged that there is little support for it in the academic literature3. However, it is commonly accepted by many practitioners in the field and the descriptions offered of such episodes of disorientation bear a striking resemblance to drug or alcohol induced intoxication. Secondly, the schedule posed a series of questions regarding respondents’ childhood experiences, particularly within the education system. Questions were deliberately circumspect and did not explicitly mention dyslexia. Rather, they sought to establish evidence of experiences and incidents commonly associated with positive diagnosis. In addition, this set of questions allowed an exploration of problems which preceded problematic use of drugs, in order to refute any suggestion that the results of the LADS test were simply the result of neurological damage arising out of problematic alcohol or drugs consumption. Lastly, the schedule asked respondents for their views on whether problems with reading had any connection to their substance misuse and whether they were aware of any situations in which these problems had affected their experience of treatment (see Appendix B). Description of the research process The study comprised a series if interrelated stages4:

• Initial survey of drug treatment professionals’ views • Literature search (see Chapter Two) • Leaflet and interview schedule design • Piloting of the chosen instruments • Recruitment of the required sample • Collection of the data • Feedback to individuals and agencies

3 There is however, substantial evidence of significantly different brain-pattern activity in information processing in dyslexics and non-dyslexics (Geschwind and Galaburda, 1985; Springer and Deutsch, 1998; Best and Demb, 1999). 4 Although these stages were largely chronological, there was, inevitably, a significant amount of overlap. The literature search, for instance continued throughout the study period.

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• Data analysis • Report writing

The initial survey of the views of drug treatment professionals was reported upon in an earlier assignment for this course (Yates, 2004). The survey consisted of an on-line questionnaire exploring the views of drug treatment professionals as to their impressions regarding the prevalence of dyslexia amongst their caseloads and their impression of its relevance to the treatment process. This survey did not formally form a part of the current study but it was regarded as a crucial confirmation of the possibility that dyslexia is a significant factor in treatment populations and is briefly summarised elsewhere in this report (see Chapter Two). Given the sensitivity of the topic explored and the likelihood that some respondents might have reading difficulties, a great deal of care was taken in constructing both the consent form and the interview schedule. The consent form was written in simple everyday language and substantial sections took the form of comic-style cartoons. In part, this was in order to attract potential respondents through the use of humour but it was also envisaged that framing important sections of text in speech bubbles would improve readability for dyslexics (Garzia, 1993; Kavanaugh, Freese, Andrade and May, 2001; Andrade, Kavanagh and Baddeley, 1997). Neither the consent form nor the interview schedule specifically mention “dyslexia”, and both documents utilised a dyslexia-friendly font/point-size (Ariel/ p. 14). Both documents and the MAP were subsequently tested with a small group of drug users in the Fife area, for readability and comprehensibility. In the event, this pilot group (5 current drug treatment service users) became quite enthusiastic about the project and requested a further session where they could undertake the LADS dyslexia test also. No members of the pilot group were included within the final sample of 50 individuals. A range of drug treatment services were contacted to request access. Given Kirk and Reid’s (2003) recent study of dyslexic offenders in a Scottish custodial establishment, no agencies were approached where referral is overtly coercive, such as Drug Courts, Drug Treatment and Testing Order Projects etc. Thus, although some of the eventual sample were indeed attending court-mandated treatment, the majority were not and were therefore primarily a cohort of drug misusers rather than offenders. Both residential and non residential agencies were contacted and the final sample comprised 25 attenders of non-residential treatment services and 25 residents from two residential rehabilitation agencies. Both the residential agencies were “concept-based” therapeutic communities (see Yates et al., 2006) which were chosen since it was felt both that the high degree of structure in such establishments would contrast well with the looser regime in non-residential agencies and that problems of working memory in particular, might be better addressed in a situation where expectation and routine were continually reinforced.

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Fieldwork was completed in May and June 2006 with more interviews/tests being conducted than were actually required for the study (see Chapter Four). Follow-up meetings were arranged with key contacts in all participating agencies during which details of the results were provided in addition to leaflets on adult dyslexia provided by the British Dyslexia Association, information on local adult literacy and dyslexia services and drug treatment-specific advice on the management of dyslexic clients and possible adaptations of current treatment practice. Data was subsequently analysed by hand. Transcripts of interviews were also analysed manually. In two cases, responses were judged to be identifiable and the clients involved were re-contacted and permission sought to use specific quotations within the final report. In both cases, permission was given without hesitation. Limitations of the process There are a number of limitations to this study, not least the relatively small sample size. However, a good deal of effort went into ensuring that the sample was representative of the wider drug treatment population: with one notable exception. No female respondents were included within the final sample. The decision to exclude female substance misusers was taken at a relatively early stage in the study since both the drug treatment and the dyslexia literature estimate male to female ratios of between 4:1 and 3.3:1. It was therefore felt that within a sample of 50, the cumulative impact of these two ratios would be to fail to achieve statistical significance. There were, additionally, some minor difficulties in administering the MAP, which is normally intended for use at initial assessment and for outcome monitoring thereafter. In the majority of cases, respondents’ drug/alcohol use had been modified by their contact with their respective treatment service. This was particularly the case with the residential cohort, where almost all respondents were drug-free. Respondents were therefore asked to recall the 30-day period immediately prior to their current treatment episode. Clients who indicated either, that they had difficulty in recalling this period, or that they had been in treatment for 8 weeks or longer, were interviewed as normal but excluded from the final sample. In fact, most respondents claimed to have very good recollection of the recall period and this was particularly true of the residential cohort. With a small study of this nature, it was not possible - for reasons of cost and time - to recruit a control group of non-drug users. Results from the data were therefore compared to the wider population on the basis of a range of articles, which have consistently estimated the level of dyslexia at 4 – 5%. Finally, a great deal of thought was given to the issue of personal disclosure. Since the author of the study is a former drug addict with a long history of working within drug treatment and a clear diagnosis of severe dyslexia, it was recognised that this

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might impact upon the study in some way. On balance, it was felt that failure to disclose might be regarded by some respondents as dishonest and as a result, the author’s former drug using history was disclosed in the consent form and personal dyslexia status was disclosed “on request”. In practice, both issues surfaced with some regularity during fieldwork and the knowledge that the administrator of the tests/interviews had personal experience appeared to both interest and reassure respondents. However, it should be noted that the issue of substance misuse is now heavily researched and there is some evidence of treatment agencies becoming “research resistant”. It seems likely that access to clients on such a sensitive issue was – at least in some agencies – approved on the basis of the author’s history and reputation and therefore, potentially difficult to replicate with other personnel. Summary Every effort was made to ensure that the data collected was immediately relevant to the issues explored and that the study had a coherent and logical structure. Considerable thought also went into ensuring accessibility and usability of the instruments used and the recruited pilot group were consulted on a number of occasions regarding changes and modifications to the documents. Contact with the selected treatment agencies is ongoing and in some instances, individual sessions on the management of dyslexia have been undertaken.

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CHAPTER FOUR: THE QUANTITATIVE FINDINGS Introduction Singleton et al. (2004) warn that caution should be exercised in using the LADS computerised screening tool with vulnerable populations such as offenders and substance misusers, since a higher number of false positives is likely to occur. In part this is due to higher than normal levels of poor or disrupted schooling resulting in low levels of literacy. In addition, the authors warn that a history of long-term substance use may affect cognitive skills. For this reason, brief discussions were held prior to all tests and interviews, with keyworkers of targeted individuals and/or, in many cases, with the individuals themselves. Discussions covered schooling experiences, concerns about reading and writing and current reading and writing activity. Respondents reporting seriously disrupted schooling were tested and interviewed as normal, but were not included within the final sample. Similarly, respondents who were clearly intoxicated at the time of interview, or who reported being upon medication above certain daily limits, were not tested. Typically, this included a small number of respondents in non-residential treatment services receiving a prescription of methadone above 70 millilitres per day. This was not an issue with respondents in residential treatment settings, who were either drug or alcohol free or on low, detoxification levels of medication at the time of interview. Finally, one individual was of a minority ethnic background. He described himself as “Scottish Asian” and appeared to have no difficulty with English language. Indeed, he had been born in Scotland and regarded Urdu as “just the language I have to use at home”. He tested low for probability of dyslexia. Consent forms were coded numerically, with the same code used on both the LADS tests and the MAP questionnaire. In addition, a letter code was added to the consent form to indicate whether the individual was right or left-handed, since there appears to be some association between left-handedness and dyslexia (Tonneson et al., 1993). All respondents were asked before commencement of the test whether they wished their results to be communicated to the relevant keyworker. All but two agreed to this procedure. These two requested that they received their results individually. In both cases, a further appointment was agreed later in that same day, at which they were given a detailed appraisal of their results. The delay was felt to be appropriate since it was important for the administrator to be confident about the test results and to have a clear view of the implications and the appropriate action to be recommended in each case. In the event, one of the two was categorised as low probability of dyslexia and was advised that further action was deemed unnecessary. The remaining respondent was classified as borderline and was advised, following

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further scrutiny of the results, that there was only a low probability of dyslexia but that he might wish to consult with his keyworker about the possibility of further tests. Results from the LADS dyslexia screening All respondents included in the final sample of 50 individuals, completed all four sub-tests in the order presented. Tests were done individually, with the administrator providing detailed information and reassurance about the test and subsequently retiring once respondents were clear that he could be called back at any time should they encounter any problems. In the event, the vast majority had little difficulty navigating their way through the test and many appeared to enjoy the experience. On respondent remarked:

“This is no bother, eh? It’s a fucking sight easier than all they arcade games I play and I usually do them when I’m off my face, eh!”

Most respondents completed the test within approximately 20 minutes although the times varied since the software adapts both the nature of the questions and the number according to perceived ability. All respondents completed the test at a single sitting. The initial test on reasoning ability is the test against which the other three sub-tests are measured. In the event, a minority (28% n = 14) were found to be below average with no clients testing as low ability. Figure 1: Measured reasoning ability across the whole cohort (n = 50)

0

5

10

15

20

25

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35

Low Below Avg. Average Above Avg. High

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Nor was this broad picture significantly altered when non-residential and residential populations were compared. Once again, the majority in both cohorts tested as average and above. Figure 2: Measured reasoning ability across the residential (n = 25) and non- residential (n = 25) cohorts.

The general picture therefore, is of a relatively normal population in terms of intellectual capacity, although, it is noticeable that the numbers for above average and high are lower than might be expected in a more generalised population. Overall scores for dyslexia are provided by the system in a range which includes low, borderline, moderate and high probability of dyslexia. Singleton et al. (2004) estimate that the software has a high classification accuracy. Thus, where individuals are classified as low probability of dyslexia there is a 95% probability that they are not dyslexic. Similarly, for those within the classification high probability of dyslexia there is a 95% probability that they are dyslexic. For those within the moderate probability of dyslexia classification, this figure reduces to 90%. However, within the borderline category, the probability factor was found in validation tests to be as low as 25% (Singleton and Horne, 2001). In such cases, the test administrator is advised to look carefully at the individual sub-test scores and consider a further referral to an educational psychologist or similar.

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Low Below Avg. Average Above Avg. High

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Of the final sample of 50, 21 were classified as high probability, 0 were classified as moderate probability, 13 as borderline and 16 as low probability. Figure 3: Overall dyslexia test results across the whole cohort (n = 50)

Once again, this picture appeared relatively unaffected when the cohort was separated into its non-residential and residential components. Figure 4: Dyslexia test results across the residential (n = 25) and non- residential (n = 25) cohorts.

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The 13 borderline scores were examined individually, in light of the field notes taken on interview prior to commencement of the test. Given the low probability factor estimated for this classification by the developers of the test (Singleton and Horne, 2001), these were subsequently assumed, for the purposes of this study, to be non-dyslexic (although their borderline status was relayed back to the relevant keyworker with advice that further tests might be appropriate). The high probability scores were similarly examined. Of the 21 high probability scores, one respondent (from the non-residential sub-set) was noted to have disclosed that he was born into a travelling family where literacy was not highly regarded and where the family’s lifestyle had resulted in an extensively disrupted school career with long periods of non-attendance. On the basis of this information, coupled with some slight anomalies in the test results, the finding was adjudged to be unsound and this result was reclassified as borderline. This resulted in a slight readjustment of the overall results as shown in Figure 5: Figure 5: Readjusted dyslexia test results across the residential (n = 25) and non- residential (n = 25) cohorts.

Since the non-residential cohort was comprised of individuals who were effectively current drug users (albeit, largely moderated) and the residential cohort was almost exclusively composed of drug-free individuals5, this would appear to suggest that the findings are independent of the current nature of the individual respondent’s drug use

5 Only 5 members of this sub-group were in receipt of detoxifying doses and this was at levels adjudged to be of little significance in terms of cognition.

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and that what was being witnessed was indicative of an underlying difficulty rather than any effect resulting from intoxication. Moreover, the majority of those classified as high probability of dyslexia, in both sub-groups (62%), appear to be average or above in their reasoning capacity, suggesting that the high level of positive tests are unlikely to be due to other historical factors resulting in low literacy skills. Figure 6: Readjusted “High probability” classifications by reasoning ability scores (n = 20).

Overall, the readjusted score for prevalence of dyslexia was 40%. McLoughlin (1994) and Clarke (1970) estimate the prevalence within the general population at 4% and 5% respectively. Prevalence estimates within this range are now generally accepted (Snowling, 2000). Clearly, the levels of dyslexia noted in the current study are significantly higher than those found in the general population; even allowing for a small number of false positives/negatives. Singleton et al. (2001) report the rate of false positives in LADS screening, as 3.7%. False negatives, in the same series of tests were estimated to be 4.5%. Thus even allowing for these estimated error levels, prevalence of dyslexia in this sample remains far higher than would be found within the wider community. Results from the MAP interviews Of the 50 individuals assessed with the Maudsley Addiction Profile, the majority (94%) were using more than one substance. All were using at least one substance –

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overwhelmingly either heroin or alcohol – on a daily basis. The amounts consumed were generally very high. Daily (and even regular) users of alcohol were typically consuming between 8 and 60 units per day6. Heroin users were using between 0.5 and 3.5 grams per day, whilst those who noted that they were also smoking cannabis – and cannabis was generally described by this group as a secondary drug of choice – would typically smoke between 5 and 15 joints per day7. 72% were using one of the benzodiazapine drugs (usually either diazepam or nitrazepam) in addition to their primary drug of choice; typically between 50 and 150 milligrams per day. Those using either cocaine hydrochloride or crack cocaine (68%) were smoking, inhaling or in some cases, injecting, between 0.5 and 3.0 grams per day8. Many respondents were using methadone mixture either via prescription or purchased illicitly on the streets. No distinction was made in this study between prescribed and illicit medications since the intention was to understand overall consumption figures prior to the current treatment episode. 64% were using methadone in a variety of combinations. Almost all were using methadone mixture orally although two respondents were using physeptone (injectable methadone), which had been stolen from a pharmacy. Of the rest, around half were using prescribed methadone often “topped up” with illicit methadone. The remainder were purchasing blackmarket methadone to supplement their heroin supply. Only four respondents reported use of amphetamine and in all four cases, the reported usage was below five days in the 30-day recall period. As a result, amphetamine has not been individually recorded below.

6 The current UK Government recommended safe limits for adult males is 3 – 4 units per day to a maximum of 21 units per week. 7 The amount of cannabis in a single rolled cigarette (joint or spliff) is understandably subject to huge variation but each joint is likely to contain at least 0.5 grams. 8 A single rock of crack cocaine has been assumed to contain the equivalent of 0.5 grams

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Figure 7: Consumption of alcohol by units per day (n = 50).

Figure 8: Consumption of heroin by grams per day (n = 50).

Figure 9: Consumption of cannabis in joints per day (n = 50).

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6-7 jts. 8-9 jts. 10-11 jts. 12-13 jts. 14-15 jts.

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Figure 10: Consumption of benzodiazepines in milligrams per day (n = 50).

Figure 11: Consumption of cocaine (inc. crack cocaine) in grams per day (n = 50).

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Figure 12: Consumption of methadone (prescribed & illicit) in millilitres per day (n = 50).

Note: Those reporting use of below 40 mls. Per day were almost invariably reporting use of illicit methadone purchased in order to supplement a heroin habit. Although there was little or no discernable difference between the residential and the non-residential cohorts in terms of the types of drugs consumed and the frequencies of consumption, those interviewed in residential settings were significantly more likely to have been using by injection (80%) than those interviewed in non-residential agencies (36%). The residential cohort also reported a wider use of substances over the recall period. Figure 13: Total number of substances used in the residential (n = 25) and non- residential (n = 25) cohorts.

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Total number of drug use incidents is measured in MAP by calibrating the number of drugs used multiplied by the number of days used in each type. Thus an individual reporting that they had used heroin and diazepam on a daily basis over the 30-day recall period plus alcohol on every other day, would score 75 ([2 x 30] + [1 x 15] = 75). Since the MAP measures for 8 drugs identified as problematic with space to add a theoretically unlimited list of other drugs not identified, technically, there is no limit to the number of drugs/days which could be reported. However, in practice, the majority of other drugs reported within the other category, could successfully be assigned to one of the named drugs (thus both lofexidine and subutex were classified with methadone and ecstasy was classified as amphetamine). Moreover, those reporting use of cocaine, overwhelmingly used both cocaine hydrochloride powder and crack-cocaine (generally according to which version was available on that particular day) and these two were therefore elided in the final calculations. Thus, the overall range was judged to be from 0 – 240 (8 drug types x 30 possible days). This range was further sub-divided into moderate and high-risk consumption categories, with 120 drugs/days as the division point. 38 respondents (76%) were moderate risk (range: 26 – 120) and 12 (24%) were high risk (range: 122 – 219). Figure 14: Total number of MAP drugs/days in medium and high risk consumption categories (n = 50).

When separated into residential and non-residential categories, once again, those in residential treatment were more likely to be in the high-risk consumption category than their non-residential equivalents. Twice as many individuals in the residential cohort were high-risk consumers when compared to their counterparts. Moreover, the range within the high-risk category for the residential cohort was somewhat higher overall at 135 – 219 with an average score of 162. The non-residential cohort, by contrast, reported a range of 122 – 162 with an average score of 143.

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Figure 15: MAP drugs/days in medium and high-risk consumption categories by treatment type (n = 50). Medium-risk High-risk The disparity in drug consumption intensity, would appear to show that drug users presenting to residential treatment are likely to be more heavily dependent and living more chaotic lifestyles. This in itself is not entirely surprising since many local authorities have a policy of only referring for residential treatment when community-based options have failed. Health risk behaviour was relatively low across the whole cohort. Few had had more than one sexual partner within the 30-day period and 19 (36%) had had no sexual partner during that time. Of the 29 (58%) who had been injecting, 15 reported sharing injection equipment, with twice as many sharers in the residential cohort (10: 66%) as there were in the non-residential one (5: 33%). Both physical and psychological health is measured by the MAP in a ten-question matrix which allows overall scoring in a range from 0 – 40. As with drugs use incidence, these scores were divided evenly into moderate and high incidence of health problems. 20 respondents (40%) reported high incidence of health problems. Figure 16: MAP physical health indices in medium and high-risk incidence categories (n = 50).

Non-residential

Residential

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The physical health problems most commonly reported were stomach pains, tremors and joint pains: symptoms which might generally be expected amongst a sample of drug users the majority of whom were reliant upon an intermittent supply of tolerance-creating drugs with the consequent risk of regular experience of withdrawal symptoms. There was though, little discernable difference between the residential and non-residential cohorts in reporting incidence, with approximately half of the high-incidence reports coming from each sub-group. Figure 17: MAP physical health indices in medium and high-risk categories by treatment type (n = 50). Medium-incidence High-incidence With psychological health however, the picture looked significantly different. 35 respondents (70%) reported high incidence of psychological difficulties including panic attacks, depression and suicidal ideation. Figure 18: MAP psychological health indices in medium and high-risk incidence categories (n = 50).

There were significant differences too, between the two sub-groups. Of those reporting high incidence of psychological distress the majority (60%) were from the residential cohort.

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Figure 19: MAP psychological health indices in medium and high-risk categories by treatment type (n = 50). Medium-incidence High-incidence In terms of both social conflict and criminal activity, scores ranged from 0 to 100 and 0 to 692 respectively. In neither domain were there significant differences between the two sub-groups. Those reporting low scores for social conflict often noted that they had no contact with partners, relatives and/or friends and therefore, limited opportunity for conflict of the kind described. A surprising number (10: 20%) reported that they had committed no crimes other than possession of controlled drugs9 during the recall period. Those who reported committing crimes on a daily basis (28: 56%) were generally shoplifting or dealing in drugs. Drug dealing accounted for some 92% of criminal activity in those committing more than 200 crimes in the recall period. In part this is because those actively involved in selling controlled drugs as part of their strategy to support their own individual habits, might typically commit between 20 and 50 such offences each day. Unemployment was the norm across the whole sample with only two reporting any days paid work in the recall period. Of those two, one had worked for 15 of the 30 days within the “black” economy, as a mini-cab driver whilst the other had worked for 2 days as a window-cleaner. Correlations between the LADS and MAPS data Poly-drug use is generally seen as a significant indicator of serious and continuing drug dependence (Marsden et al., 1998). Much, of course, depends also upon the frequency and intensity of use and upon the relative addictive or destructive potential of the drugs in question.

9 Throughout this study, the term “controlled drugs” relates specifically to those drugs listed within the Misuse of Drugs Act 1971. This terminology remains consistent regardless of whether the drugs in question were legally prescribed or obtain illicitly through diverse sources.

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Of the 22 individuals in the sample who reported using 5 or more drugs over the recall period, half were dyslexic. Those in the sample who had tested as having a high probability of dyslexia, were more likely to have used a greater array of substances; with 19 of the 20 using three or more different drugs. Figure 20: Total percentage of substances used in the dyslexic (n = 20) and non- dyslexic (n = 30) cohorts.

This picture remained consistent in the analysis of drugs/days consumption data. Those who had been tested as having a high probability of dyslexia, were more likely to be high-risk consumers (40%) than were their non-dyslexic counterparts (10%). Furthermore, the average MAP scores for the dyslexic respondents, within both the high-risk category (average score: 175.5) and the medium risk category (average score: 78.45) were significantly elevated. The corresponding scores for the non-dyslexic respondents (including the borderlines) were 154.0 and 66.81 respectively. Figure 21: % MAP drugs/days in medium and high-risk consumption categories by dyslexic (n = 20) and non-dyslexic (n = 30) respondents.

The dyslexic respondents were also more likely to have injected drugs during the recall period. Amongst dyslexic respondents, 75% (n = 15) reported injecting whilst only 43% (n = 13) of the non-dyslexics had done so.

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The average MAP scores for the incidence of physical health problems showed little or no discrepancy between the dyslexic and non-dyslexic cohorts, with the dyslexic sub-group scoring an average 16.13 for low incidence and 26.17 for high incidence. In the non-dyslexic sub-group, the corresponding scores were 12.5 for low incidence and 27.0 for high. However, the distribution across the two groups was strikingly different. In the non-dyslexic group, some 73% fell into the moderate risk category whilst the corresponding figure amongst the dyslexic sub-group was 40%. Figure 22: % MAP physical health indices in medium and high-risk categories by dyslexic (n = 20) and non-dyslexic (n = 30).

In the case of psychological problems, the differences between the two sub-groups were more obvious. Average MAP scores for low incidence of psychological problems were 14.83 for the non-dyslexic group and 16.67 for the dyslexics. Scores for high incidence were 27.39 for the non-dyslexic group and 32.88 for the dyslexics. Distribution was also quite different, with 60% of non-dyslexics being categorised as high incidence and a corresponding 85% for dyslexics. Figure 23: % MAP psychological health indices in medium and high-risk categories by dyslexic (n = 20) and non-dyslexic (n = 30).

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The MAP measure of social conflict includes conflict with regular partners, family members and friends (either in face-to-face conflicts and arguments or similar disputes by telephone) adjusted for the number of days of actual contact during the recall period. Analysis of these scores by dyslexic and non-dyslexic populations, shows that although the ranges are virtually identical at 0 – 96 for the dyslexics and 0 – 100 for the non-dyslexics there is a slight but significant difference between the average scores. On average, the dyslexic sub-group reports 45.25 conflict episodes whilst the non-dyslexics reported an average of 35.43. There was little discernable difference between the two sub-groups in terms of criminal activity with the dyslexics reporting an average of 122.5 crimes over the 30-day period whilst the non-dyslexics reported an average of 127.03. Summary Rice (2000) has argued that dyslexia research within offender populations should be treated with some caution, since many such studies do not, apparently, adjust adequately for false positives. Singleton et al. (2001) have further warned of the possibility of reduced cognitive ability resulting from long-term drug use; particularly where individuals are currently continuing to use substances. However, the data collected for this study was rigorously filtered in order to avoid the difficulties reported elsewhere. Firstly, no individuals who presented in an intoxicated state were tested. A number of individuals were tested and interviewed but eventually excluded from the final sample either because it was believed that their capacity to complete the LADS test might be influenced by poor or disrupted schooling resulting in a low literacy level, or because their length of time in treatment indicated that they might not be able to recall the pre-treatment episode period with sufficient clarity. As a result, a total of 74 tests were completed but 24 tests (and the corresponding MAP interviews) were excluded from the final sample. Where tests and interviews were completed but not utilized, feedback was provided as appropriate in exactly the same way as for the final sample. Secondly, all high probability and borderline results were scrutinized individually. As a result of this further analysis, one high probability test was judged to be unsafe and reclassified as borderline. In the light of the developers’ estimates of probability levels (Singleton et al., 2004), the resulting 14 borderline tests were classified as non-dyslexic. Whilst this undoubtedly resulted in some dyslexic individuals being included within the non-dyslexic category, it was felt that this was justifiable in order to ensure that the analysis discernable differences between the two sub-groups was based upon a dyslexic sample where their was a strong probability of dyslexia.

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Moreover, the relatively slight chance of a small number of dyslexics being erroneously classified as non-dyslexic, would tend to reduce rather than inflate any distinctions between the two sub-groups. This was a necessarily small, unfunded study in an area where there is no substantive body of literature against which to compare data outcomes. However, it does appear possible to draw some tentative conclusions from the quantitative data available. Firstly, there appears to be compelling evidence to suggest that the incidence of dyslexia within drug-treatment populations is considerably higher than within the general population. Secondly, there were clear differences between the residential and non-residential sub-groups which are likely to have resulted from current British drug policy which generally reserves the (apparently) more expensive option of residential rehabilitation for those individuals who have demonstrated an inability (often, after a significant number of failed treatment episodes in community settings) to cease or moderate their misuse of drugs without the highly structured and intensively supportive environment offered by residential treatment settings. Thirdly, dyslexic individuals within drug-treatment populations appear to be more likely than their non-dyslexic counterparts to use a more extensive range of substances and to use those substances with greater frequency and intensity. They are more likely too, to inject substances with all the inherent dangers associated with unsupervised, non-medical injecting practices. In addition, dyslexic drug users report higher levels of both physical and psychological health problems. This higher rate of difficulty (whether real or perceived) is particularly striking in terms of psychological health where reporting of feelings of worthlessness, depression and suicidal ideation are strongly associated with low self-esteem: a factor widely regarded as being fundamental to the success or failure of individual recovery (Zinberg, 1984; Peele and Alexander, 1985).

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CHAPTER FIVE: THE QUALITATIVE FINDINGS Introduction The quantitative data collected during the course of this study is useful in providing a snapshot of the likely incidence of dyslexia amongst a typical drug treatment population. It also offers an early opportunity to examine the ways in which dyslexic treatment-seekers might differ from their non-dyslexic counterparts. This in itself, is likely to have implications for drug treatment delivery and it was for this reason that the agencies chosen for data collection were broadly representative of the more commonly used treatment modalities in the United Kingdom. However, the data can shed little light upon the intrinsic nature of the relationship between dyslexia and drug dependence and the ways in which this issue might affect the individual’s experience of the treatment process. Moreover, there remains the issue of whether dyslexic-type symptoms might be drug-induced or part of an earlier array of social, environmental and/or biological sequelae, which might, individually or collectively, be predictive of later dependent behaviour. It was for these reasons that a small sub-group of individuals was selected for post-test interview, with 5 individuals selected from each of the two modalities: community-based, non-residential harm reduction programmes and residential therapeutic communities. This small group of 10 were all interviewed at length following their LADS test and MAP interview. In all cases, they were interviewed on the same day as their tests were administered and had been randomly selected from amongst those individuals deemed to be in the high probability category for dyslexia. At the time of the interview, none of the respondents were aware of the outcome of their LADS test, nor would any mention have been made to them regarding dyslexia. The consent leaflet, did not mention dyslexia at all and care was taken to ensure that dyslexia was not mentioned in the pre-test discussions. In practice, five individuals raised the issue of dyslexia independently, prior to the test. Generally this was in the context of disclosing that they had been tested for dyslexia as a child or that they did not believe that they were dyslexic. None of these five individuals was amongst the sub-group of 10 chosen for post-test interview. All ten interviewees were given a further opportunity to confirm their consent at the commencement of the interview and it was again stressed that anything they said would be treated in strict confidence and would not affect their treatment programme in any way. It was explained to them that the interviews would be tape-recorded but that only the researcher would hear the tapes and that these tapes (and any related transcripts), would be kept in secure conditions until the submission of the final report; at which point they would be destroyed. It was also explained to them what use would be made of the interview material and a commitment was given that any verbatim remarks would be anonymised or, where this was not possible, specific permission would be sought.

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As with the MAP and the LADS tests, interviews were conducted on an individual basis in private. Separate audio cassette tapes were used for each interview and labels were coded in the presence of the interviewee using the same coding system as had been used for the other documentation. Some 8.25 hours of tape were recorded and subsequently transcribed for analysis by hand. Interviews were semi-structured using a pre-prepared interview schedule (see Appendix B). However, given the exploratory nature of the study, it was felt appropriate to allow respondents to dictate the direction of the interview to some extent, whilst ensuring that the 25 core questions had been adequately covered. Experiences of drugs During the first part of the interview, respondents were asked to recall their physical feelings during their initial drug use. Specifically, they were asked to identify the drugs that they most enjoyed when they first used them. All of the interviewees intimated that their first experience with drugs was with smoking tobacco. Most (8: 80%) reported that they had started smoking before the age of twelve and all of the sample had continued to smoke. Alcohol was also ubiquitous and all 10 reported that they were regularly consuming alcohol to the point of intoxication by the age of 15 years (average age 14.15 yrs.). Most (7: 70%) claimed that one or both of their parents drank heavily and that they had, as children, regularly seen them drunk. One respondent said:

“My old man was always pished. He was aye coming hame an’ layin’ intae us, eh? Then he’d end up on the floor an’ I’d have tae help ma maw put him tae bed! I’d have been at the primary [Scottish primary school: 6 – 12 yrs.] then.”

Another respondent noted:

“My mam used to get stuck into the vodka most nights. She’d drink until she passed out and then she’d wet herself. Me big sister used to put carrier bags on the seat and cover them with an old towel so it didn’t soak the cushion. All the grown-ups I knew then was like that. I didn’t think there was owt odd about it.”

Of the 10 interviewees, 8 reported a vivid recall of their first experience of alcohol. In all of these reports, this first experimentation had continued to the point of intoxication:

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“That first time, me an’ my mate half-inched a bottle of Buckie [Buckfast Tonic Wine: 70 cl., ABV. 14.8% = 10.36 units] fae the Pakki shop. Necked the fuckin’ lot. My mate was sick but for me, it wis nae bother! I just thought, ‘Aye, brilliant! This is me feelin’ right.’ Ken what I mean? I ken it’s weird but I was oot mae face an’ I just felt normal like.”

“We lifted a bottle of Diamond White [Strong white cider: 3 ltr., ABV. 8.4% = 25.2 units] from ASDA. There were three of us but I drank most of it. After that, we teamed up wi’ some birds who’d got some Breezers [Bacardi Rum & Fruit Juice alcopop: 250 ml., ABV. 5% = 1.38 units] from somewhere. I reckon I did four of them an’ all. It was megga. I was flying an’ I felt like the king of the world.”

Most of those interviewed had similar tales of their early encounters with alcohol. All had had substantial quantities of alcohol on their first episode and continued to drink in this fashion throughout their teenage years. The early recruitment into tobacco and alcohol was echoed by their use of cannabis. Most (9: 90%), were regular cannabis smokers by the age of 14 years (average age 13.310), smoked heavily throughout their teens and had continued to do so up to (and including) the MAP recall period:

“I’ve always smoked dope. Pretty much as much as could get me hands on. Usually about ten or twelve joints a day. Big ones though. That would be what I’d do, whatever else I was into.”

However, they were generally dismissive of their use of cannabis, seeing it as something which underpinned and paralleled their use of other – for them – more serious addictions: “Dope’s no big deal – just background noise. Same as Vallies, really”. Of the 10 interviewees, 7 regarded heroin as their primary drug of choice, with 2 responding that alcohol was their main problem and 1 citing cocaine. All (including the 3 who did not regard heroin as their primary drug) had started using in their early to mid-teens and all had injected for most of their heroin-using careers:

“I was smoking it at first. You know, chasin’ like. Then on my fifteenth birthday me brother showed me how to jag – some birthday present that was! But he was right into it like. So was I after that. It was the rush. I couldn’t get enough of it! I used to jag vodka sometimes, just to get that feeling. Like your brain was explodin’.”

10 The earliest age for consumption of cannabis was 11 years in the case of one interviewee who had been inducted into cannabis smoking by an elder sister.

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“I had a real thing about injecting from the start. I had a psych once who told me it was sexual or something. And it was! For me it was better than sex! I used to be like a salesman for injecting. I’d even get off on it when I injected someone else!”

“Even with coke, I injected. Most of my pals used to smoke it or snort it. Fuck that! I wanted to see the blood in the barrel. Injecting coke like… it blows the top of yer head off, man!”

Even those interviewees who were completely drug-free at the time of interview, looked back upon their experience of heroin use with a certain amount of fondness. One interviewee remarked:

“Aye. I ken it fucked me up like eh? But I loved it tae bits at the time. See in them early years when I was just intae it? That was the first time I’d ever felt right.”

“They reckon meth’s the same thing. Bollocks. Doesn’t even come that close [interviewee makes a minimising gesture with index finger and thumb]. Meth just makes you feel fuzzy. There’s no buzz. Well, there probably isn’t supposed to be. But smack makes you feel safe like. You’re in a bubble an’ no fucker can touch you! Know what I mean? You can see everything but no fucker can touch you.”

With the exception of the interviewee who had become a cocaine addict and dealer in his mid-twenties, all of the sample had retained their allegiance to a primary drug of choice which they had first encountered, and selected as such, in their early to mid-teens. The two respondents who reported alcohol as their drug of choice argued that their use of heroin had been merely an opportunistic episode. From their perspective, they had been “messing about with it” because it had been popular at the time. Of the 10 interviewees, 7 reported varying frequencies of intoxicated experiences at school. One had started to use heroin whilst actually at school, but for the others, being intoxicated at school seemed to be one of the many milestones in their growing dependence. Indeed, most appeared to have recognised the potential for their drug or alcohol use to spiral out of control at an early stage. One interviewee said:

“I didn’t want to end up like me owd feller but it’s mebbe in the blood like. I’d buy stuff off of mates at school. Meaning it for night-time like. But I could never wait. Next thing, I’d be off on one.”

Another mapped out the attempts he had made to exercise a certain amount of control in the face of an increasing addiction:

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“At first it was like, ‘Aye this is magic but mebbe just fae the weekends.’ Then it was, ‘Well I’ll no use in the daytime.’ But I couldnae seem tae stop maesel. A’ my pals could, but I couldnae.”

Experiences of school A total of 5 (50%) of the interview sample were left-handed although no deliberate attempt was made to recruit such a high number. Interviewees were selected at random from those with positive LADS results and not from the consent forms where handedness was recorded. Two of the older left-handed respondents (both over 40 yrs.) remembered teachers attempting to correct this at school:

“I had one teacher. An old guy. He never used to say anything. Just

used to come up behind me, take the pen out of me hand and put it in the other. Once he slippered me for changing it back. Didn’t say anything about my left hand. He just said it was because I was ‘wilful’.”

These two and one other, could also remember being “told off” at home because of their left-handedness. One remembered his mother complaining about it at a parents’ night because, “nobody at home was left-handed so they must be teaching it at school”. Eight of the group had had nicknames whilst at school. Of these, four were largely irrelevant, being corruptions of real names. Thus, a “Robinson” was called “Robbo” and a “Hugh” was called “Wee Shug”. However, the other four names appeared to relate to their performance and behaviour at school. One was nicknamed “Smiffy” (“You know, the dozy one in the Bash Street Kids”). Another was called “Lurch” after a Frankenstein-like character in an American television series (“They just thought I was big and stupid, I suppose.”). Two remembered being called the “Absent-Minded Professor”. One remembered being called this both at home and at school. The other remarked:

“Fuck it! I’d forgot about that until you asked just now. Right, when I left school, I started as an apprentice for a sparks, so “Amp” seemed to fit and it stuck all through. But thinking about it, it started in primary with a teacher calling me Absent-Minded Professor. After a bit, she shortened it to A.M.P. It was always ‘A.M.P., hand out those bean bags while we all have your attention!’ or ‘Would you like to tell the class what you were thinking about A.M.P., it must have been really interesting!’ In the end everyone was using it – but not spelling it out like she did. Same when I went up to the big school”.

Only two of the group had enjoyed their school days. Most had struggled with lessons although four appear to have excelled at either art or gymnastics/sport. All of

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the 10 listed English as their least favourite subject and the one in which they struggled most. A number mentioned mathematics and two professed to having hated science. Four of the group had been referred to an educational psychologist and one of this four had subsequently been sent to a “special school” as a result of his disruptive behaviour. However, only one had been formally diagnosed as dyslexic. (In fact, of the whole sample, only three of the fifty had apparently been diagnosed as dyslexic and one of these had been as an adult whilst in prison11). Only the one interviewee who had been formally diagnosed at school, could recall receiving any additional support for their reading and/or writing problems. Seven respondents reported that they had had problems of some kind with reading or writing during school. These problems ranged from severe problems with both reading and writing to an acute inability to read at the expected speed:

“I was aye getting’ ribbed about me readin’. No that I couldnae read but a’ ma mates would hae read a hale book an’ I’d still be on page 4, ken?”

Only two of the group indicated that they enjoyed reading now. Of these, one had taught himself to read with the aid of a specialist tutor after having been diagnosed as dyslexic during a lengthy prison sentence. This respondent had a passion for history books and was currently reading Eric Newby’s A Short Walk in the Hindu Kush. The other respondent read mostly short stories in the science-fiction and fantasy genres although he remarked (with a certain amount of pride):

“But I’ve read Lord of the Rings three times! ‘Course it takes me ages and I get a cramp in me finger [interviewee makes a pointing gesture denoting the action of following words with his finger] but I’ve still read it!”

Views on reading and drug use Only two of the group did not feel they had a problem with reading and writing. One of these remarked:

“I had a problem when I were at school but it’s sorted now. I mean I don’t read or owt, but that’s cos I don’t like reading. And anyway, I’m too jumpy and I can’t concentrate on a book, really. I suppose that might be the coke like. Though I reckon I were allus like that!”

11 However, it should be noted that this information was gleaned from field notes taken during pre-test discussions. It could quite easily be the case that more were actually diagnosed and that this information was simply not disclosed during these discussions.

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Most could remember times when their day-dreaming or their weak memory had been remarked upon be teachers or peers. One had been referred on two occasions to a hearing specialist after a teacher had questioned whether he could actually hear properly:

“She tellt me maw I was mebbe deef or summat. I think she was just sick o’ me no doin’ what she tellt me an’ doin’ summat else. It wisnae badness. I’ve aye had this thing about no understandin’ what I’m tellt. So youse ask a couple times an’ then ye ken if ye ask again that’ll be you. Troublemaker. So you just do what you think was right. An’ it’s no.”

This respondent had had two referrals to a hearing clinic. On the first occasion, no action was taken because his mother “was on a bender” and missed the appointment. On the second, an assessment was completed and no hearing problems were found. This resulted in a severe beating from the father for “wasting everybody’s time.” None of the individuals interviewed appeared to have ever considered a link between the problems they had experienced at school and their later addiction to drugs. A number noted that their parents had had addiction problems and suggested that their own difficulties were part of their inheritance. But this appeared to be little more than a half-understood regurgitation of the popular mythology on addiction in general and the addictive gene in particular. Most had used a number of treatment services prior to their current one. Their failure to engage with these previous treatments in any meaningful way seem to have been considered, by the professionals involved, to be a direct result of their lack of motivation. But from their perspective, it was the services that had failed them. One interviewee remarked:

“I’ve tried loads of places. And I really have tried. But it’s fucking hard. And I don’t think they know how hard it is. I was at one place where I was supposed to keep a diary of what I was using each day. But my writing is really shit and I didn’t want them to see it so I just kept telling them I’d forgot to bring it. In the end they said I was just taking the piss.”

Another respondent spoke of how he had had regular counselling at another project but that he had found it hard to take in all that was being said in the weekly one-hour sessions this involved:

“I wanted it to work, see. But I just couldn’t keep up really. I got loads of advice and it made sense at the time. But after I left, I could never remember what had been said. And the other problem was she used a lot of words I didn’t understand but I just thought that was me being thick.”

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The issue of remembering instructions and advice was a consistent factor in almost all of the 10 stories. One interviewee in a residential treatment unit said:

“I had a look at the Pull-up Book [a record book normally kept in most therapeutic communities, of formal reprimands administered for poor behaviour or failure to respond as required] the other day. I’ve had about twenty pull-ups in the last two weeks and almost everyone of them has been for forgetting something I was told to do.”

Summary At the outset, it was acknowledged that this study was, in part, limited by the necessarily small sample size. With the qualitative element of the study, this problem was further amplified. The sub-sample was extremely small and there was no control group. However, by randomly choosing 10 individuals who appeared to have significant dyslexic problems, it was possible to begin to explore the nature of these problems and how they related to the individual misuse of drugs or alcohol. Almost all of the interviewees provided information relating to their time at school which appeared to suggest that the dyslexia identified by the LADS test was a long-standing issue that predated the onset of drug dependence. All the interviewees related histories of addiction which appeared to have begun to be problematic at a very early stage. Eight of the ten described home circumstances which suggested that dependence was also an issue for one or both parents and, in some cases, for elder siblings. Snowling (2000) has suggested that the dislexic demographic may be skewed by the fact that it is very often through parental pressure that problems at school first come to light and a diagnosis is made. The home circumstances described within these 10 interviews were, for the most part, situations in which such attention to educational development would have been extremely improbable. Perhaps not surprisingly, interviewees were hesitant about the relationship between the problems they described and the drug dependence which had led them into treatment. Their personal experiences of treatment services, however, indicated that often it was difficulties with memory and organisational capacity as well as simple literacy which often undermined their recovery.

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CHAPTER SIX: CONCLUSIONS Introduction. The various limitations of this study have been acknowledged at numerous points within this report. Of particular concern, is the contention by Singleton et al (2004), Rice (2000) and others, that high prevalence of dyslexia within offender populations might be deceptive. Singleton et al. (2004) have also suggested that the incidence of false positives amongst drug user populations (especially continuing users) might be abnormally high as a result of cognitive damage from long-standing drug misuse. A great deal of care therefore has been taken in the preparation and implimentation of this research to minimise these possibilities. In particular, a very conservative approach was taken to the interpretation of the LADS results, with only those with high probability scores being assigned to the “dyslexic” category. Moreover, a series of interviews with individuals within this category were conducted to ascertain whether dyslexia-type problems might have preceded the onset of problematic drug use. Lastly, the final sample was equally divided between those who were drug-free at the time of the test and those who continued to use (albeit in a modifed way). No significant differences in dyslexia scores between these two groups were noted despite quite striking differences in drug history, health issues and social stability. Implications of the quantitative data The overall level of prevalence within the population surveyed was 40%. This is significantly higher than any accepted estimate for the incidence of dyslexia amongst the general population. Even accounting for a small number of possible false positives (and, incidentally, ignoring any false negatives) the differences between this population and the wider community look striking. In addition, there appears to be good reason to suspect that dyslexic drug users might exhibit more severe problems and engage in more challenging drug behaviours than their non-dyslexic counterparts. If these findings are replicated across drug treatment populations generally, then they could have significant implications for the delivery of such treatments. For the past decade, drug treatment methodology has largely been dominated by cognitive-behavioural approaches which rely heavily upon the individual’s cognitive capacity to analyse situations – particularly risky situations – and devise alternative non-risk strategies. Generally, these alternative strategies will have been developed and rehearsed with the assistance of the therapist and ‘stored’ for future use. It is not difficult to see how various elements of this process might prove extremely difficult for an adult dyslexic; particularly where written instructions and self-maintained ‘drug diaries’ are a crucial aspect of the approach.

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Some thought too, might need to be given to the form in which support is provided by most drug treatment services. Individuals attending these services are routinely offered weekly counselling and support sessions which would normally last for an hour. There is some evidence though, that adult dyslexics might benefit from the availability of shorter, more frequent sessions. In order to make such changes, drug services would need to routinely screen for dyslexia at the initial assessment stage in order to ascertain which clients might require additional support and/or modified services. However, a previous survey (Yates, 2004) suggested that few, if any, services test clients for dyslexia at any stage during the treatment process. Furthermore, there appears to be a significant resistance to further ‘complicating’ assessment systems; particularly within those agencies whose raison d’etre is the provision of low-threshold, non-threatening community services. Implications of the qualitative findings. The suggestion that dyslexic children self-trigger internal disorientation processes has received scant attention within the academic literature despite the widespread belief in the theory amongst many practitioners (Davis and Braun, 1997; Temple, 2002). In light of this theory, the reporting, by a number of interviewees within this study, that their experience of intoxication was of a feeling at once exhilerating and yet stangely familiar and comforting, is certainly worthy of further exploration. Respondents in this study described their experiences of intoxication as: “like coming home” and “the first time I’d ever felt right”. Their use of needles was described in similar terms with a general preoccupation amongst most respondents with the short-lived intense initial sensation usually experienced with intraveneous injection of psychoactive substances. Commonly called the ‘rush’, this sensation featured strongly when respondents were questioned about their injecting practices. Economic or social reasons (for injecting rather than smoking or inhaling) were never mentioned. Some further thoughts on future research possibilities This study has offered an opportunity to examine a relatively ‘untouched’ area of interest. In the course of the data-collection, a number of issues emerged which suggest a potential for further examination. In particular, there appears to be a clear indication that dyslexic drug users engage in a more chaotic drug using life style than their non-dyslexic counterparts. They consume more drugs, they are more likely to inject and they report more health problems. What is not clear is why this should be. The Maudsley Addiction Profile is a useful short screening tool which was chosen partly for its simplicity of use and

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the relatively short length of time taken to administer. However, exploring the reasons for these differences in behaviour would require a more sophisticated instrument such as the Addiction Severity Index. This would have implications for the cost of such a project and the rate at which interviews and tests could be completed. The relationship between left-handedness and dyslexia is an area of some contention. Tonnessen et al. (1993) and others have argued that there is strong evidence for this commonly held belief, but numerous authorities have questioned this standpoint (Snowling, 2000; Ellis et al., 2006). In this study, dextrality was noted but this was not done in any systematic way. Rather, handedness was simply noted by observing which hand subjects used to complete the consent form. Over the whole sample, 22% (n = 11) were noted as being lefthanded. This figure rose to 35% (n = 7) when only those tested as dyslexic were considered. However, even this higher figure remains a minority of those who tested positive and therefore severely limits its value as a predictor. Finally, the responses relating to experiences of intoxication were intriguing. Given the evidence already available of the genetic transference of both addiction (Goodwin, 1990) and dyslexia (Snowling, 2000) the possibility that dyslexic people might be genetically disposed to experience intoxication in a different way is a fascinating possibility and certainly worth considering further.

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APPENDICES

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APPENDIX A: THE MAUDSLEY ADDICTION PROFILE

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APPENDIX B: BRIEF INTERVIEW SCHEDULE

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Dyslexia & Dependence – Client Interview Schedule Preamble

• Explain who I am • Seek confirmation that I can tape the interview and explain that some tapes

will be transcribed • Explain that tapes will be kept in a locked filing cabinet and transcriptions

kept on a secure server and that they will be destroyed on completion of the study

• Explain that any quotations used in the final report will be anonymised and that, where I feel clients could be identified, I would seek specific permission.

• Explain that they are free to leave at any stage or to decline to answer any questions without this affecting their treatment plan or any forthcoming referrals, appointments etc.

Physical experiences of drugs 1. What drugs did you most enjoy when you first used them?

Do you remember why that was? 2. Do you remember any physical feelings that you particularly liked when you

were using these drugs? 3. Do you remember any physical feelings that you particularly disliked when

you were using these drugs? 4. Do you remember any times when you had these feelings before without

using drugs? 5. Did you ever use drugs while you were actually in school? What was that like? 6. Are the drugs you are looking for help with, the drugs that you have always liked best? If not, what drugs did you prefer and why aren’t you looking for help with

them?

Experiences of school 1. Are you left or right-handed? Do you remember this causing any discussion at school or at home?

2. Did you enjoy your time at school? 3. Did you have a nick-name when you were at school? What was it?

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4. Did you have a nick-name in your family? What was it? 5. What were you best at when you were at school? 6. What were you worst at when you were at school 7. Did you ever have any special tests when you were at school?

(prompt with:. hearing, sight, reading etc.) 8. Were you ever told that you had a problem as a result of these tests?

What were you told and who told you? 9. Did you ever get any special help when you were at school?

(prompt with:. Specials needs teacher, scribe, psychologist etc.) 10. Did you enjoy reading when you were at school? 11. Do you enjoy reading now? What is it you read? 12. What is it you like/dislike about reading? Views on reading and drug use 1. Do you feel that you have a problem with reading? 2. Do you think you have any other problems?

(prompt with:. organisational skills, day-dreaming, memory, clumsiness, hearing, etc.)

3. Have you ever tried to get help for these problems?

4. Have you ever thought that these problems might have something to do with your drug use? What makes you think that?

5. Do you think these problems have anything to do with the way you use drug services?

6. Do you think these problems make it harder or easier to get what you need

out of drug services? What makes you think that?

7. Can you think of any particular times in treatment when reading problems

might have been responsible for you being treated differently to other service users In what ways were you treated differently and why?

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APPENDIX C: CONSENT FORM

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