Running head: SYSTEMATIC ERROR IN THE DETECTION Systematic Error in the Detection of Serious Mental Illness in the Signing Deaf Suzannah Jackson1, Louise Munro2, & Nerina Caltabiano3 1Psychology, James Cook University, 2QUT Faculty of Health, Queensland University of Technology, & 3 Department of Psychology, College of Healthcare Sciences, James Cook University Contact details: 1 [email protected]: ORCID iD: 0000-0002-7989-2077 2 [email protected]; ORCID iD: 0000-0001-8737-4360 3 [email protected]: ORCID iD: 0000-0002-3625-8236 _________________________________________________________________________ Abstract A limitation of existing sign language translations of clinical assessments of serious mental illness (SMI) is the presence of systematic error against the language preferences of signing Deaf people. The error occurs in the presentation of responses that invariably occur in written language format, rather than in a signed language, a contravention of international translation guidelines. The present study aims to modernise the field of Deafness and Mental Health using a web-based interface to improve the valid and reliable detection of SMI in signing Deaf people. In this study, the psychometric properties of an Australian Sign Language (Auslan) translation of both versions of the Kessler Psychological Scales of Distress (K10 and K6), were examined. The scales were translated according to World Health Organisation World Mental Health Survey protocols featuring graphics interchange format (GIF) technology as the response modality, then administered to 30 signing Deaf participants. Results of internal consistency showed that the K10-Auslan and K6-Auslan have acceptable reliability as measures of SMI in SYSTEMATIC ERROR 2 Australian Deaf people. The present study resolves the issue of systematic error in the detection of SMI in the signing Deaf, by introducing a translated clinical scale with the technological capacity to support sign language as the response modality. Keywords: Deafness and Mental Health, Sign Language Test Translation, Australian Sign Language, Kessler Psychological Scale of Distress, Graphics Interchange Format, Sign Language Technology SYSTEMATIC ERROR 3 Systematic Error in the Detection of Serious Mental Illness in the Signing Deaf In Australia, there are currently no linguistically and culturally appropriate assessment tools that can measure serious mental illness (SMI) in signing Deaf people. As a result, inequality in access to appropriate mental health assessment, treatment and evidence-based intervention, places Deaf people at higher risk of developing mental disorders. Epidemiological research conducted internationally shows an increased prevalence of psychiatric illnesses in Deaf adult populations compared to hearing people (Brigman et al., 2000; de Graaf & Bijl, 2002; Fellinger et al., 2005; Ridgeway, 1997). However, the body of research comprises studies that contain a design flaw, where the presentation of responses is displayed in written language format i.e. English, rather than a signed language, which is a contravention of international translation guidelines (Harkness et al., 2008). Moreover, the research includes comparisons of Deaf results against hearing norms, which is problematic given the disparate communication modalities, sensory and sociocultural experiences that exist between the two groups. Deafness is heterogeneous with individuals differentiated by factors such as degree of loss, type of loss, age of onset, communicate mode and cultural identification. The prevalence of deafness worldwide is estimated to be at approximately 15-26%, with the highest rates found in low-income countries (Fellinger, Holzinger, & Pollard, 2012). Deaf communities generally comprise individuals who are pre-lingual deaf, experience severe to profound loss and communicate via a signed language. Signing Deaf people represent roughly seven per 10000 people worldwide and are the focus of the current report. The Australian Deaf Community Members of the Australian Deaf community generally identify as Culturally Deaf and regard Australian Sign Language (Auslan) as their preferred mode of communication. Auslan is SYSTEMATIC ERROR 4 the primary language of some 6500 Deaf community members and is officially recognised by the federal government as a community language (Johnston, 2004). Deaf people have varying degrees of fluency in both Auslan and English, but primarily use Auslan as their native or preferred language (Deaf Australia, 2013). According to peak advocacy body Deaf Australia, the community is an organised network of citizens with many represented on executive boards of finance, health, advocacy, arts, sporting and social organisations at national and international levels. Yet in healthcare settings, the contemporary understanding of deafness continues to reflect an historic notion of a disability that requires amelioration. Sociomedical definitions posit deafness as a state of “abnormality”, contrasted against the duplicitously “normal” ability to hear and speak (Ferndale, Munro, & Watson, 2016). The definition was popularised in the 1800’s by proponents of the oralist approach, resulting in an international ban on the use of sign language in the education of Deaf children. The impact of sign language prohibition was so substantial that it reportedly triggered the sociolinguistic and cultural genocide of functioning Deaf communities at the time (Lane, 1993a; Ladd, 2003). The modern term ‘audism’ captures the ongoing process of structural subordination of Deaf communities, sign language and culture (Bauman, 2004). The implications at the individual level is a working assumption that a Deaf person’s happiness is dependent on acquiring fluency in the language of the dominant hearing culture. To this day, organisations that promote audism derive significant economic benefit and community support for oralist programs that discourage (and often ban) sign language. As a consequence, such programs divert resources away from the social, structural and environmental requirements of signing communities (Branson & Miller, 2002; Obasi, 2008). Hence Deaf people in need of SYSTEMATIC ERROR 5 medical support are systematically disadvantaged with respect to gaining full access to resources according to language preference. Deafness and Mental Health in Australia The Deafness and Mental Health Statewide Consultation Service in Queensland is the only psychiatric facility that caters to the cultural and linguistic diversity of Deaf people (The State of Queensland, 2016). The service was established in response to a 1998 report conducted by Dianne Briffa into Australian mental health service providers that found treating psychiatrists, therapists and psychologists were not providing access to the Deaf community effectively. Yet health professionals still believe that a lack of appropriate therapeutic tools in sign language, interpreters and availability of expertise prevents them from adequately assessing SMI in Deaf people (Ferndale, Watson, & Munro, 2016). Ensuring that services accommodate language preference increases access to healthcare information (Napier & Kidd, 2013), whereas failure to do so may impact a Deaf consumer’s understanding of a range of concepts including mental health, drug and alcohol dependence and sexual health (Terry, Le, & Nguyen, 2016). Recent evidence shows mental health systems that privilege hearingness influence Deaf people to internalise disempowerment (Ferndale, Watson, & Munro, 2016) and exacerbate the course and severity of SMI (Fellinger, Holzinger, & Pollard, 2012). The Epidemiology of Deafness and Mental Health Epidemiological studies conducted internationally report an increased prevalence of psychiatric illnesses in Deaf adult populations. Studies in Great Britain, New Zealand, Holland and Austria involving administration of signed language versions of the General Health Questionnaire (GHQ) found significantly higher scores in Deaf participants indicating the presence of psychiatric illness than hearing comparison groups (Brigman et al., 2000; de Graaf & SYSTEMATIC ERROR 6 Bijl, 2002; Fellinger et al., 2005; Ridgeway, 1997). More recently, a comprehensive review of the international literature on the mental health of Deaf people stated that there was ample evidence for higher rates of mental health problems in people who are Deaf than in hearing individuals (Fellinger, Holzinger, & Pollard, 2012). In Australia, Deaf adult epidemiological data is limited to one existing study that examined the psychometric properties of an Auslan version of the Outcome Rating Scale (ORS-Auslan; Munro & Rodwell, 2009). In the study, Deaf participants scored higher on the ORS-Auslan compared to hearing comparisons, yet rather than conclude that deafness is linked to increased prevalence of psychiatric illness, the authors instead implicated cultural factors to explain the disparity. For instance, they found that the clinical threshold for what was characterised an illness was lower in the Deaf group indicating that Deaf people may hold unique values and beliefs about mental illness. These diverse cultural norms might affect validity and reliability of routine psychometric instruments, like the hearing-normed ORS-Auslan, making them clinically over-sensitive to Deaf people. This finding prompted the authors to instead focus on within-group comparisons and to date, the ORS-Auslan is the only measure able to effectively distinguish between clinical and non-clinical