Test Review: Global Appraisal of Individual Needs–Short Screener (GAIN-SS)

Purpose and Nature of the Test

The Global Appraisal of Individual Needs–Short Screener (GAIN-SS) is one of a family of instruments that range from screening or quick assessments to a full biopsychosocial and monitoring tool. The 23-item screener takes approximately 5 to 10 min to administer. The GAIN-SS was developed to quickly identify individuals as having one or more behavioral health disorders when administered the full version of the GAIN (Dennis, Feeney, Stevens, & Bedoya, 2008). It has 23 items that include measurement of internal mental distress disorders (i.e., somatic symptoms, depression, anxiety, trauma, homicidal/suicidal ideation), externalizing disorders (i.e., inattentiveness disorders, hyperactivity-impulsivity, conduct disorders), substance-related problems (i.e., substance issues, substance abuse, substance dependence), and crime/violence (i.e., general conflict, drug-related crimes, property-related crimes, interpersonal crime). Once a behavioral health disorder is identified, further assessment may be needed to make appropriate referrals for additional support.

In addition to the GAIN-SS, clinicians have a variety of assessment instruments to draw from. The GAIN Quick Assessment identifies individuals who will need feedback, brief intervention, or referral for more specialized assessment or treatment. The GAIN Initial Assessment (Clinical Core and Full Version) assists a clinician in diagnosing psychiatric disabilities and in the development of treatment plans. The full version of the GAIN (designated as GAIN-I) was created in 1993 as a collective effort between clinicians, researchers, and policy makers to create a comprehensive and standardized biopsychosocial assessment tool that would move beyond research to meet the treatment needs of adolescents and adults in a wide range of settings. Dr. Michael Dennis, senior research psychologist and director of the GAIN Coordinating Center, led this project with the goal of providing the GAIN assessment tool for a variety of populations in numerous settings including outpatient programs, intensive outpatient programs’ short- and long-term residential centers, welfare programs, and primary care programs (Chestnut Health Systems, 2015).

The authors of the GAIN created this assessment instrument in the 1990s due to the reluctance of substance abuse treatment programs and mental health agencies to assess for mental health or addiction-related disorders because there were no effective treatments available at the time. Currently, more substance abuse treatment programs pursue diagnosing co-occurring disorders and require effective instruments for screening, assessment, and planning purposes, which has led to the development of the GAIN-SS. Sacks (2008) suggested that the GAIN-SS and GAIN-I are commonly used in treatment centers for substance use disorders.

Previous versions of the GAIN-SS had items measuring behavioral health disorders using closed-ended questions with no opportunity for elaboration. For example, Question 1 asks an individual, “During the past 12 months, have you had significant problems . . . (a) with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?” (Dennis, Feeney, & Titus, 2013, p. 31). Individuals could respond by either indicating yes or no. The frequency of yes responses within each subscreener were computed, which resulted in participants being placed in the low (unlikely to have a diagnosis), moderate (a possible diagnosis; the client is likely to benefit from a brief assessment), or high (high probability of a diagnosis; the client is likely to need more formal assessment and intervention, either directly or through referral) categories (Sprong, Upton, & Pappas, 2012). The new version of the GAIN-SS (v.3) has incorporated a mechanism that measures the severity of these symptoms within a specific time frame, including past month, 2 to 3 months, 4 to 12 months, 1+ year, never. The newer version can be used in many settings (e.g., employee assistant programs) and be used as a method to measure periodic behavioral health change over time (Dennis et al., 2008).

GAIN-SS licensing cost is US$100 per agency. This cost includes unlimited use of paper assessment (provided in a PDF document to be printed by the agency) for up to 5 years. Chestnut Health Systems also offers a web application where the GAIN-SS can be administered to an unlimited amount of clients per account. Those who purchase this licensing agreement are able to gather data from the four subscreeners, Internalizing Disorder, Externalizing Discord, Substance Disorder, and Crime/Violence, and print summary and narrative reports that help with score interpretations and will assist in making recommendations for further assessment if needed. GAIN-SS online training is available for clinicians who want to receive formal training (self-paced course) and costs US$150 for 3 months of access or US$500 for 12 months of access to all clinicians. However, the authors suggest that reviewing the administration and scoring manual is sufficient, and no training or certification is needed as it relates to the GAIN-SS. There are no user qualifications provided to individuals who want to administer the GAIN-SS. If a clinician wanted to use a more advanced assessment (GAIN-brief assessment or GAIN-I), they would need specialized training and state licensure.

Practical Applications

The GAIN-SS administration and scoring manual provides instructions for administering, scoring, and guidance on how to interpret the results (Dennis et al., 2013). Materials are provided to assist in training staff to administer and score the screening instrument. Web-based systems and ongoing support services are available to provide answers and assist the individuals administering the GAIN-SS. The GAIN-SS can be administered verbally for clients who have difficulty reading and are available in English and Spanish. The GAIN-SS v.3 also includes personalized anchors to address confusion with client’s perception, or misperception, of the time period covered by questions. These anchors are based on making the questions more time-specific using a script and calendar (Dennis et al., 2008).

The GAIN-SS was developed to serve in semi-structured interviews and allows some flexibility to explain and clarify items and collect verbatim responses from the client. The GAIN-SS allows the administrator to read the items at an appropriate tempo, repeat misunderstood items, and use neutral probes when needed. The manual states that those administering the exam should (a) get to know the GAIN, (b) be aware of participant inattentiveness, (c) be humane, (d) avoid being confrontational, and (e) be culturally sensitive (Dennis et al., 2013).

The GAIN-SS manual provides easy to use instructions for scoring the screening device. The scoring section is fairly easy to follow as the manual provides guidance on how to score the questions within each category and what specific scores indicate. However, an actual completed example within the manual would have been helpful. Scoring requires the client to identify a time for a behavior that is denoted by 4 (past month), 3 (2 or 3 months ago), 2 (4–12 months ago), 1 (1 + years ago), or 0 (never). These scores can then be used to gather data for a scoring template that identifies behavior that is focused on activity in the past month, past year, and during a lifetime. Correspondingly, the authors maintain that the past month can be used as a measure of change, the past year counts as a screen for current disorder, and the lifetime measure as a way to measure remission. Scores on each subscale are combined to provide a total score for each subcategory (i.e., internal disorder, external disorder, substance-related problems, and crime/violence). If a client has indicated never to questions within a subsection, they would be categorized in the low category (unlikely to have a diagnosis or need services). If a client has received a score of 1 to 2 for past year symptoms, they would be categorized in the moderate category (possible diagnosis and need for services: a brief assessment and brief intervention would be beneficial). Finally, if a client has a score of 3 or above, they would be in the high category (high probabilities of diagnosis and need for services: client will need a formal assessment and intervention). The GAIN-SS manual states that over half of individuals who receive a moderate score and almost all of those with a high score on the total disorder screener will end up with a diagnosis when administered the full version of the GAIN. However, it should be noted that the GAIN-SS should not be used as a diagnostic tool but rather as a tool to identify individuals who need further assessment.

In the Interpretation section of the manual, there is a discussion on the meaning of the scores of the four subscreeners to assist with determining what types of behavioral health services might be required. In addition, there are interpretations as a measure of change to help with predicting risk for relapse and interpretation for quality assurance and program planning to assist with policy creation and program planning (Dennis et al., 2008). These are all useful ways to apply the results of the GAIN-SS including practical applications for various populations, such as people with substance addiction who are attempting to gain employment, and it was determined to be an appropriate and inexpensive screening instrument of alcohol and drugs in community rehabilitation programs (Sprong et al., 2012).

Technical Aspects

The GAIN-SS has undergone several revisions since its original publication and has incorporated a time frame to identify severity of the identified problems in the past month and the likelihood for relapse potential. As aforementioned, the GAIN-SS quickly assesses four potential behavioral health-related problems, including internal disorders, external disorders, substance-related problems, and crime/violence. The GAIN-SS psychometric properties were analyzed for 27,703 individuals, with 21,082 individuals classified as adolescents (12–17 years of age) and 6,621 individuals classified as adults (18+ years of age or older). Racial demographic information was provided and revealed 16% identifying as African American/Black (n = 4,356), 37% identifying as Caucasian/White (n = 10,283), 30% identifying as Hispanic (n = 8,247), 14% identifying as mixed (n = 3,928), and 3% identifying as Other (n = 874).

Statistical analysis displayed high internal consistency of the screener (α = .96), high correlation with the 123-item GAIN-I (r = .84 to .94), and “sensitivity (90% or more) for identifying people with a disorder and for correctly ruling out people who did not (92% or more)” (Dennis et al., 2008, p. 2). A confirmatory factor analysis revealed high consistency of the GAIN-SS with the full GAIN model. The confirmatory fit index was “slightly less accurate for the GAIN-SS [.87] and the full GAIN [.92], and slightly more precise in terms of the root mean square error of approximation (RMSEA) for the GAIN-SS [.05] and the full GAIN [.06]” (Dennis et al., 2008, p. 2).

A strong positive correlation was displayed for the subscales on the GAIN-SS and the scales on the GAIN-I (concurrent validity) for adolescents: Internal Mental Distress Scale (ID; r = .90), Externalizing Disorder Combined Scale (ED; r = .92), Substance Problem Scale (SP; r = .92), Crime and Violence Scale (CV; r = .89), and Total Disorder Scale (r = .93). A strong positive correlation was displayed for the subscales on the GAIN-SS and the scales on the full version for adults: ID (r = .92), ED (r = .93), SP (r = .96), CV (r = .88), Total Disorder Scale (r = .92). It is expected that if a person obtained a specific score on subcategories of the GAIN-SS, he or she should have similar scores on the GAIN-I (e.g., if a client was categorized as high on the SP for the SS, he or she should be in the high category of the full version).

The average nondiagonal correlations were provided to display the average correlations between the GAIN-SS and all of the unrelated subscales of the GAIN-I (discriminant validity). The correlational values for adolescents ranged from .41 to .50 (ID = .41, ED = .50, SP = .42, CV = .41). The correlational values for adults ranged from .36 to .53 (ID = .42, ED = .53, SP = .39, CV = .36). All of the nondiagonal correlations for both adolescents and adults fall outside of the 95% confidence interval for the diagonal correlations, therefore providing evidence that there is dissimilarity between constructs for adolescents and adults. It is expected that evidence is provided to demonstrate that constructs that should be unrelated (theoretically) are in fact unrelated.

Conclusion

The GAIN-SS is a quick and cost-effective method to screen for co-occurring and co-existing disabilities within a vocational rehabilitation context. The licensing costs include unlimited use of paper assessment up to 5 years in a scannable PDF format. In addition, training is available for administering and interpreting the GAIN-SS but it is not required.

Just one example of a significant barrier to vocational success that is accurately measured with the GAIN-SS screener is substance abuse problems. The Substance Abuse and Mental Health Services Administration [SAMHSA] (2015) found that 20.2 million individuals in the United States met the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) diagnostic criteria for substance abuse or dependence. Of those, 7.9 million had a co-occurring mental disorder (SAMHSA, 2015) and 12% of the population with disabilities experienced issues related to substance abuse (National Rehabilitation Information Center, 2011). Sprong and colleagues (2012) found that 18.40% were in the moderate to high categories (approximately 2 times greater than the general population). Not only did they analyze the consistency of the GAIN-SS, but they also surveyed vocational specialists who administered the screener to obtain information related to whether the screener would be appropriate for persons with disabilities. They evaluated areas related to comprehension of the items, frequency of questions of clients asking for clarification, methods to improve the instrument, and whether breaks were needed (note: may compromise the external validity of results if administration procedures are not followed). Vocational specialists working with a variety of disabilities indicated minimal issues with administration of the screener but did suggest that there was some confusion regarding the items for clients with cognitive-related disabilities. The reported average time of administration of the GAIN-SS is 5 to 10 min (Sprong et al., 2012).

There are no discussions of accommodations in the manual or possible ways to modify the assessment for those with visual, reading, or cognitive disabilities. However, as this can be clinician administered, the barriers could potentially be minimized for persons with visual disabilities or those who have difficulty reading. In addition, despite the potential difficulties for persons with cognitive-related disabilities, the GAIN-SS still may be beneficial in screening for a magnitude of other barriers that persons with disabilities may have, which will allow for immediate referral for further assessment, if needed.

In conclusion, utilizing the GAIN-SS to identifying the barriers through further assessment will help the vocational rehabilitation counselor to provide appropriate services so that identified barriers can be reduced. Carise, McLellan, Festinger, and Kleber (2005) suggested incorporating the screener into a preliminary survey to vocational rehabilitation services as success in these programs increases when a client’s barriers are identified and addressed prior to the services being provided. In terms of physical or psychological disabilities and co-existing substance use disorders (diagnosis classification and symptoms revised to substance-related disorders per the Diagnostic and Statistical Manual of Mental Disorders [5th ed.], DSM-5; American Psychiatric Association, 2013), employment has been identified to significantly predict substance abuse treatment completion (Melvin, Davis, & Koch, 2012) and therefore concurrent vocational rehabilitation services and substance abuse treatment should be considered.