A COMPARISON OF ALCOHOL SCREENING INSTRUMENTS AMONG UNDER-AGED DRINKERS TREATED IN EMERGENCY DEPARTMENTS

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1 Alcohol & Alcoholism Vol. 37, No. 5, pp , 2002 A COMPARISON OF ALCOHOL SCREENING INSTRUMENTS AMONG UNDER-AGED DRINKERS TREATED IN EMERGENCY DEPARTMENTS THOMAS M. KELLY 1 *, JOHN E. DONOVAN 1, JANET M. KINNANE 1,2 nd DAVID M. C. D. TAYLOR 3 1 University of Pittsburgh School of Medicine, Pittsburgh, 2 Children s Hospitl of Pittsburgh, Pittsburgh, PA, USA nd 3 Royl Melbourne Hospitl, Victori, Austrli (Received 19 September 2001; in revised form 1 Februry 2002; ccepted 17 Februry 2002) Abstrct Aims: Few studies hve exmined the dequcy of dult-vlidted lcohol screening mesures when used with dolescents nd young dults. A totl of 103 subjects (55 mles, 48 femles) prticipted in study of lcohol use mong under-ged drinkers conducted in two emergency deprtments. Methods: Prticipnts completed three brief screening instruments for problemtic lcohol use: the Alcohol Use Disorders Identifiction Test (AUDIT); modified version of the TWEAK; nd the CAGE. Results nd Conclusions: Missing dt on the TWEAK, lower internl consistency for the TWEAK nd CAGE, nd the better bility of the AUDIT to differentite problem drinkers from non-problem drinkers, suggest tht the AUDIT performs best in screening for problemtic lcohol use mong under-ged drinkers treted in emergency deprtments. INTRODUCTION Adolescents who use lcohol re t incresed risk for ccidentl nd intentionl injury (Clrk et l., 1997; Spin et l., 1997; Kelly et l., 2001) nd illness (Hnsell nd White, 1991; Arri et l., 1995). However, the pssge of time reduces the impct tht drinking-relted injury hs in motivting ptients to seek or ccept help (Nilssen et l., 1994). Emergency deprtments (ED) re importnt settings for the erly identifiction of dolescents who misuse lcohol, becuse injured dolescents with problemtic drinking often present there first. There is evidence tht referrl for tretment for some lcohol-relted problems t the time of n ED visit my improve the rte of referrl cceptnce nd tretment follow-through (Spirito et l., 1994). Substnce-use screening instruments specificlly designed for dolescents re vilble (Leccese nd Wldron, 1994; Blum, 1997), but re generlly too long nd time-consuming to be prcticl in the hectic environment of hospitl ED. Shorter scles hve been developed for dolescents, but there is scnt reserch on such instruments mong dolescents who report rnge of lcohol involvements. Knight et l. (1999) developed 6-item screening instrument (the CRAFFT) for problemtic drug nd/or lcohol use by extrcting items from severl other, lengthier dolescent self-report instruments. These investigtors found tht the instrument possessed dequte internl consistency. Bstiens et l. (2000) recently reported on 5-item instrument, the RAFFT, nd found it to possess good sensitivity nd specificity for dignosing substnce use disorders mong dolescents seen in n emergency room or mbultory cre centre. However, selection bis ws operting in both of these studies, s mny of the subjects hd pprent symptoms of substnce misuse or hd been referred for tretment of substnce misuse pthology. In contrst to these instruments developed for dolescents, there is vriety of mesures designed to screen for problemtic lcohol use in dults tht re reltively short, cn be used *Author to whom correspondence should be ddressed t: Western Psychitric Institute nd Clinic, 3811 O Hr St, Pittsburgh, PA 15213, USA. in EDs, nd hve estblished relibility nd vlidity. It seems resonble to investigte the potentil of these instruments for the erly detection of problemtic lcohol use mong dolescents t high risk for injury nd illness. There re only few reports on the utility of existing dult-vlidted lcohol screening instruments for use with dolescents in EDs. Shope et l. (1997) used the CAGE in n ED study of 263 injured dolescents (men ge 16.9 yers), nd found tht CAGE scores correlted positively with ge, lcohol misuse (negtive consequences of drinking), nd overll lcohol involvement. However, this study did not involve comprison of the CAGE with other lcohol screening mesures. Chung et l. (2000) described n ED study of dolescents yers old tht compred the sme three screening instruments for problemtic lcohol use tht re used in the current study: (1) the Alcohol Use Disorders Identifiction Test (AUDIT, Sunders et l., 1993); (2) the TWEAK (Russell, 1994); (3) the CAGE (Ewing, 1984). Chung et l. (2000) used DSM-IV (Americn Psychitric Assocition, 1994)-defined lcohol use disorders s the criterion mesure, nd found tht the AUDIT performed best in predicting problemtic lcohol use, the TWEAK performed stisfctorily t cut-off score of 2, nd the CAGE ws reltively inefficient in its sensitivity nd specificity for lcohol use disorders mong the dolescents. Chung et l. (2000) excluded lcohol-positive dolescents nd focused on the criterion vlidity of the instruments. Our method includes investigtion of internl consistency nd construct vlidity nd includes lcohol-positive dolescents. As result, we re ble to compre lcohol-positive with lcoholnegtive dolescents nd to ssess the criterion vlidity of the screening instruments using stndrd tht ws not vilble in the Chung et l. (2000) investigtion. The AUDIT ws developed by the World Helth Orgniztion s mesure of lcohol consumption, lcohol dependence, nd lcohol-relted problems. The TWEAK (Russell, 1994) ws developed to ssess potentilly hzrdous drinking ptterns mong women nd hs demonstrted relibility nd vlidity in these smples. The CAGE (Ewing, 1984) focuses on behviours consistent with lcohol dependence. The objectives of the present study were to determine the relibility (internl consistency) nd vlidity of these instruments in this Medicl Council on Alcohol

2 ALCOHOL SCREENING INSTRUMENTS 445 smple, nd to determine which of these instruments worked best in screening dolescents for problemtic lcohol use in n ED. SUBJECTS AND METHODS Procedure This protocol ws pproved by the Institutionl Review Bord of the University of Pittsburgh, Pittsburgh, Pennsylvni, USA. Dedicted reserch technicins stffed two regionl Level-1 hospitl EDs (one ws peditric ED) t vrious times between 18:00 nd 02:00 or between 21:00 nd 06:00. Inclusion criteri for the study consisted of: (1) ged yers (inclusive); (2) Glsgow Com Score = 15 (Jennet nd Bond, 1975), i.e. no serious hed injury; (3) ptient ccompnied by prent or legl gurdin (if ged <18 yers); (4) ble to red nd complete self-report questionnire. Ptients whom the medicl stff considered to be too seriously ill or too criticlly injured to pproch were excluded. Medicl stff members informed the reserch technicins of ptients meeting the bove criteri. Prents or gurdins of those ged <18 yers were pproched first, nd the reserch project ws explined. Prents were told tht they would not be informed of the study findings for their dolescent child. If they gve written consent for their child to prticipte, the dolescent ws then pproched to obtin his/her written, informed ssent. Following enrolment, n lcohol brethlyser test ws dministered using the Alco-Sensor III intoximeter (Intoximeters Inc., St Louis, MO, USA) to determine if the dolescent hd been drinking within severl hours of rrivl t the ED. The medicl stff were not informed of ny results nd there ws no entry of this reserch dt item into the medicl record. Following dministrtion of the brethlyser test, 29-item self-report questionnire ws dministered in privte to the dolescent. Although the questionnire is in self-report formt, the reserch technicin remined with the subject to nswer ny questions or clrify issues relted to completing the questionnire. The lcohol screening items from the AUDIT, the TWEAK nd the CAGE re embedded in the questionnire. Prticipnts were given $10 gift certificte for their prticiption. Smple A totl of 554 ptients between the ges of 12 nd 20 yers were screened for eligibility. The totl smple included 298 mles nd 253 femles (dt on gender is missing for three ptients who were screened for eligibility but not enrolled in the study). A totl of 416 ptients (75%) were screened t the peditric ED, nd 138 (25%) were screened t the generl hospitl ED; 359 ptients could be pproched ccording to protocol guidelines (195 ptients were under the ge of consent nd hd no prent with them or were too ill or injured to pproch); 282 (78.5%) ptients greed to prticipte. No sttisticlly significnt ge, gender or rcil differences were found between those who prticipted nd those who refused to prticipte. One cse ws missing from this nlysis (n = 358). Of the 282 prticipnts, 170 (60.3%) indicted tht they never drnk lcohol nd nine (3.2%) provided inconsistent responses regrding their lcohol use. In ll, 103 prticipnts (36.5%) indicted tht they used lcohol, i.e. more thn sip or tste on one occsion, nd properly completed the lcohol screening questionnire. These 103 lcohol-using prticipnts (48 femles, 55 mles) re the focus of this report. There were 82 Cucsins (79.5%), 15 Africn-Americns (14.5%), five Asin-Americns (5%), nd one Hispnic-Americn (1%) in the smple. The men ± SD ge of the smple ws 17.5 ± 2.1 yers (rnge ). Dt nlyticl procedures The scle properties of the three lcohol screening mesures were determined through the use of the Relibilities procedure in SPSS 8.0. This procedure ws used to clculte Cronbch α estimtes of the inter-item relibilities of the scles (Cronbch, 1951). The procedure lso computed item mens nd SD, scle men nd SD, correltion mtrix mong the items, n verge inter-item correltion, the correltion between ech item nd corrected item-totl correltion. The Correltion procedure of SPSS 8.0 ws used to clculte Person correltions mong AUDIT, TWEAK nd CAGE summtive scles scores. Student s t-test ws used for group comprisons on the instruments. The ssumption of homogeneity of men differences ws not met for some tests. For these tests, the t-sttistic nd degrees of freedom pproprite for n ssumption of unequl vrince re reported. RESULTS Scle properties of the lcohol screening mesures AUDIT. Tble 1 presents the frequency distributions on the ten AUDIT items. Items with the highest level of response re those ssessing frequency (no. 1), typicl quntity per occsion (no. 2), nd frequency of high-volume drinking (no. 3). Items ssessing the experience of problems due to drinking re much less frequently endorsed in this young smple. Relibility for the AUDIT ws high (stndrdized α = 0.88). The corrected item-totl correltions (Tble 1) indicte tht the lcohol intke items contribute most strongly to the totl AUDIT scores. Items relting to lcohol dependence nd consequences contribute more modestly. The men score for the AUDIT is 7.74 ± This is high for this reltively young smple, s the generlly ccepted cut-off for optiml sensitivity/specificity of lcohol use disorders is score of 8 (Conigrve et l., 1995). Tble 2 presents the correltions mong the ten AUDIT items. The verge inter-item correltion mong these items ws The strongest correltions were mong the lcohol intke items (nos. 1, 2 nd 3). Some noteworthy reltionships between intke, dependence nd problems included modertely strong correltion between item 3, binge drinking, nd item 5, filing to do wht is expected (r = 0.61). Item 4, being unble to stop drinking, nd item 8, being unble to remember, re similrly correlted (r = 0.58). Item 10, others concerned, correlted 0.65 with item 6, needing n eyeopener. TWEAK. Tble 3 presents the frequency distributions for the TWEAK scle. Consistent with the development of the instrument (Russell, 1994), the need to cut down item nd the eye-opener item tht re contined in the CAGE were included to construct the TWEAK scle. In order to void redundnt concepts, the items mesuring mnesi nd others worried (concerned), s stted in the AUDIT, were used in

3 446 T. M. KELLY et l. Tble 1. Item distributions, mens nd corrected item-totl correltions for the AUDIT scle Score (n) Item-totl No. Item Men ± SD correltion b 1. How often do you hve drink of lcohol? ± How mny drinks contining lcohol do you hve on ± typicl dy when you re drinking? 3. How often do you hve six or more drinks on one occsion? ± How often during the lst yer did you find tht you were ± unble to stop drinking once you hd strted? 5. How often during the lst yer did you fil to do ± wht you were expected to do becuse of drinking? 6. How often during the lst yer did you need drink in the ± morning fter hevy drinking session to get yourself going? 7. How often during the lst yer did you feel guilty or ± remorseful fter drinking? 8. How often during the lst yer were you unble to remember ± wht hppened the night before becuse of drinking? 9. Hve you or someone else been injured s result of your drinking? ± Hs reltive or friend, or doctor or other helth cre worker been ± concerned bout your drinking or suggested you cut down? Totl scle score 7.74 ± 7.14 Mens bsed on scoring continuum of 0 4 for items 1 nd 3 8; 0 = never, 1 = monthly or less; 2 = monthly; 3 = weekly; 4 = dily or lmost dily. Item 2: 0 = 1 2 drinks; 1 = 3 4 drinks; 2 = 5 6 drinks; 3 = 7 9 drinks; 4 = 10 or more drinks. Items 9 nd 10 bsed on scoring 0 = never; 2 = yes, but not in the lst yer; 4 = yes, in the lst yer. Totl scle scores rnge from 1 to 40. b Corrected for the presence of ech item. Tble 2. Inter-item correltions for the AUDIT scle Items AUDIT 1 AUDIT AUDIT AUDIT AUDIT AUDIT AUDIT AUDIT AUDIT AUDIT All coefficients re sttisticlly significnt t P 0.05 (two-tiled test). Tble 3. Item distributions, mens nd corrected item-totl correltions for the TWEAK scle Score (n) Item-totl Item Men ± SD correltion 1. How mny drinks cn you hold without flling sleep or pssing out? (Tolernce) b ± Hs reltive or friend, or doctor or other helth worker been concerned ± bout your drinking or suggested you cut down? (Worried) c 3. Do you ever need drink first thing in the morning to get going? (Eye-opener) d ± How often during the lst yer were you unble to remember wht hppened ± the night before becuse of drinking? (Amnesi) c 5. Hve you ever felt the need to cut down on your drinking? (Kut-down) d ± Totl scle score 2.74 ± 1.7 Mens bsed on scoring 0 for <6 drinks or 2 for 6 on item 1; 0 for no or 2 for yes to item 2; 0 1 for items 3 nd 5. All zeros on item 4 were scored 0, ll others were scored 1. Totl scle scores rnge from 0 to 7. b Thirty-three prticipnts did not respond to this item. c AUDIT item. d CAGE item.

4 ALCOHOL SCREENING INSTRUMENTS 447 this version of the TWEAK. The scores on this scle re lower compred to the AUDIT due to the 0 1, 0 2 scling nd becuse most items mesure problems relted to very hevy drinking or lcohol dependence, e.g. tolernce, needing n eye-opener, nd blcking out. Only two respondents endorsed needing n eye-opener first thing in the morning (item 3). The men score on the TWEAK scle ws 2.74, which reflects firly high level of lcohol problems on this 7-point scle. The performnce of this scle ws compromised by the tolernce question, becuse 32% of these dolescent/young dult drinkers did not know how to respond to this item. Correltions mong the TWEAK items (Tble 4) were much lower thn those mong the AUDIT items (Tble 2), nd the verge inter-item correltion of 0.17 ws much lower. The strongest correltions were between the others worried item nd the prticipnt s own concern for needing to cut-down (r = 0.43, P < 0.01), nd between needing n eye-opener nd the others worried item (r = 0.36, P < 0.01). Relibility bsed on internl consistency is low for the TWEAK scle (stndrdized item α = 0.50), suggesting tht the items re not mesuring single underlying construct. If the tolernce item is removed, internl consistency increses modertely (stndrdized item α = 0.62). This is still low but pproches the rnge displyed by the CAGE (results below). According to the corrected item-totl correltions (Tble 3), item 1 (Tolernce) nd item 4 (Amnesi) contribute very little to individul differences on the TWEAK scle. The other items contribute more, but still disply only modest item-totl correltions (rnge = ). CAGE. Tble 5 displys the CAGE items, their frequency distributions, nd item-totl correltions. The verge correltion mong the CAGE items ws 0.35, much higher thn tht found for the TWEAK, but lower thn found for the AUDIT. The item ssessing need to cut down Tble 4. Inter-item correltions for TWEAK TWEAK 1 TWEAK TWEAK * TWEAK TWEAK * n = 70, but 33 cses were excluded due to missing dt on Item 1 (Tolernce). *P < 0.05 (two-tiled test). correlted t 0.50 (P < 0.01) with nnoynce t criticism, 0.46 (P < 0.01) with feeling guilty bout your drinking, nd 0.21 (P < 0.05) with the eye-opener question. Annoynce correlted t 0.24 (P < 0.05) with guilt nd 0.43 (P < 0.01) with eye opener ; nd guilt nd eye-opener correlted t 0.23 (P < 0.05). The estimte of internl consistency for the 4-item CAGE ws α = 0.66, which is stisfctory for such short scle. The men ± SD score on the CAGE ws just 0.71 ± 1.03, reflecting the reltive lck of lcohol problems s ssessed by the CAGE in this young smple. Concurrent vlidity of the screening mesures Concurrent vlidity of the instruments ws ssessed by correltions mong the totl scle scores. The AUDIT nd TWEAK correlted t 0.83, the AUDIT nd CAGE correlted t 0.43, nd the TWEAK nd CAGE correlted t All three correltions were sttisticlly significnt (P < 0.001, two-tiled test). Construct vlidity using known group differences on lcohol use We investigted the construct vlidity of the instruments by compring younger nd older prticipnts, mles nd femles, nd ethnic groups on the screening instruments. Epidemiologicl studies showed tht older dolescents re generlly more involved in problem drinking thn younger dolescents (Brnes nd Welte, 1986; Centers for Disese Control nd Prevention, 1996), tht Cucsin dolescents re generlly more involved in problem drinking thn Africn-Americn dolescents (Rchl et l., 1982; SAMHSA, 1997) nd tht mle dolescents re more involved in problem drinking thn femle dolescents (Jessor, 1987; Windle, 1996). Construct vlidity of these instruments for ssessing problemtic lcohol use mong dolescents would be supported to the extent tht these sme known group differences re found on them. Age differences. To test for ge differences on the lcohol screening mesures, dolescents in the smple were divided into two groups t the men ge of 17.5 yers. There were 51 prticipnts in the younger group nd 52 in the older group. The groups differed in the expected direction on the TWEAK (younger group men = 2.23 ± 1.5 vs older group men = 3.10 ± 1.8; t = 2.1, df = 68, P < 0.04) nd on the AUDIT (younger group men = 5.02 ± 4.9 vs older group men = ± 8.0; t = 4.0, df = 82.7, P < 0.001). The groups did not differ significntly on the CAGE (younger group men = 0.60 ± 0.85 vs older group men = 0.84 ± 1.17; t = 1.2, df = 90, P = 0.22). Tble 5. Item distributions, mens nd corrected item-totl correltions for the CAGE scle Score (n) Item 0 1 Men ± SD Item-totl correltion 1. Hve you ever felt the need to cut down on your drinking? (Cut down) ± Hve you felt nnoyed by criticism of your drinking? (Annoyed) ± Do you ever feel guilty bout your drinking? (Guilty) ± Do you ever need drink first thing in the morning to get going? (Eye-opener) ± Totl scle score 0.72 ± 1.03 Mens bsed on scoring 0 for no responses; 1 for yes responses to ll items. Totl scle scores rnge from 0 to 4.

5 448 T. M. KELLY et l. Gender differences. Mles nd femles did not differ on the AUDIT or the CAGE. They did differ significntly only on the TWEAK (mle men = 3.9 ± 1.5 vs femle men = 2.1 ± 1.8; t = 2.8, df = 67, P < 0.009). Ethnic/rcil differences. Cucsin dolescents (n = 82) were compred to Africn Americn dolescents (n = 15) on ech screening mesure (other dolescents were not included). The two rcil groups differed significntly only on the AUDIT, with Cucsin dolescents scoring higher thn Africn- Americn dolescents (Cucsin men = 8.56 ± 7.6 versus Africn-Americn men = 5.07 ± 3.9; t = 2.7, df = 37, P < 0.02). Criterion vlidity Hzrdous drinking. In order to ssess potentilly hzrdous drinking, the prticipnts were ssigned to groups bsed on whether they drnk six or more drinks on one occsion less thn once month versus more frequently. Bohn et l. (1995) used similr binge drinking criterion with dults, nd defined hzrdous drinking s drinking more thn six drinks on one occsion weekly or more often. Given the younger ge nd greter inexperience with lcohol mong dolescents, it seemed resonble to set the criterion here t monthly or more often. Bsed on the specified criterion, there were 73 nonhzrdous drinkers nd 30 hzrdous drinkers in the AUDIT nd CAGE nlyses, nd 42 non-hzrdous drinkers nd 28 hzrdous drinkers in the TWEAK nlysis. All three screening instruments significntly discriminted between potentilly hzrdous drinkers nd non-hzrdous drinkers (AUDIT, men for hzrdous drinkers = 15.9 ± 7.3 vs 4.3 ± 3.2 for non-hzrdous drinkers, t = 8.4, df = 33.8, P < 0.001; TWEAK, men for hzrdous drinkers = 3.93 ± 1.5 vs 1.93 ± 1.3 for non-hzrdous drinkers, t = 5.8, df = 68, P < 0.001; CAGE, men for hzrdous drinkers = 1.1 ± 1.3 vs 0.56 ± 0.85 for non-hzrdous drinkers, t = 2.1, df = 39.6, P < 0.05). The criterion for hzrdous drinking is lso the third AUDIT item nd my hve inflted differences on this scle. Therefore, we removed this item nd computed 9-item AUDIT score to compre the groups. Hzrdous drinkers were still higher on the AUDIT: men = 14.3 ± 6.4 vs 3.8 ± 2.8 for non-hzrdous drinkers (t = 8.7, df = 33.8, P < 0.001). Alcohol use prior to presenttion in the ED. Eleven prticipnts (11%) scored positively on the lcohol brethlyser test. The lcohol brethlyser score (BrAC) represents criterion for problemtic lcohol use tht is externl to the scores the prticipnts received on the screening instruments. The brethlyser-positive prticipnts were compred to the brethlyser-negtive prticipnts on the screening instruments, nd were found to differ significntly only on the AUDIT (BrAC positive men ± SD: 15.6 ± 9.6 versus BrAC negtive: 6.8 ± 6.2; t = 2.96, df = 11.04, P < 0.02; two cses were missing from this nlysis, n = 101). DISCUSSION The findings in this study indicte tht lcohol screening instruments previously vlidted with dults vry in their performnce with n older dolescent smple. The primry objective of this study ws to determine the utility of the instruments s ssessments for problemtic lcohol use in dolescents treted in EDs. In this study, the AUDIT displyed high internl consistency nd demonstrted vlidity for differentiting lcohol users long known group lines: Cucsins scored higher on the AUDIT thn Africn-Americns, nd older dolescents scored higher thn younger dolescents. The AUDIT lso discriminted between hzrdous nd non-hzrdous drinking nd ws the only screening instrument in this study tht differentited lcohol-positive versus lcohol-negtive dolescents bsed on brethlyser redings in the ED. Utilizing the sme screening instruments, Chung et l. (2000) lso found tht the AUDIT performed best in screening for problemtic lcohol use mong dolescents treted in n emergency deprtment. These investigtors used DSMdefined lcohol use disorders s the criterion mesure for ssessing the performnce of these instruments. However, Chung et l. (2000) studied only lcohol-negtive dolescents. Our method included screening for lcohol use t the time of the prticipnt s presenttion t the emergency deprtment s n dditionl criterion for problemtic lcohol use. Our findings on this criterion contribute dditionl evidence tht the AUDIT performs best s screening instrument mong dolescents seen in emergency deprtments. The TWEAK ws too low on internl consistency to be considered n dequte mesure of problemtic lcohol use in the current smple. However, if the tolernce item is removed, internl consistency for the TWEAK increses to n α = Chung et l. (2000) pointed out tht tolernce is quite vrible nd it is, therefore, difficult to develop definition of tolernce tht is pproprite for both dults nd dolescents. These investigtors concluded tht n item tht ssesses high-volume drinking, e.g. frequency of drinking five or more drinks, my be preferble in this popultion to one tht ssesses tolernce. The TWEAK ws, however, the only instrument tht differentited mle nd femle drinkers, with mles scoring higher. Interestingly, the highest degree of vrince between the genders on the TWEAK ws on item 1, the tolernce item. Sixty-five per cent of the mles who responded to this item indicted tht they cn hold six or more drinks without pssing out, wheres only 39% of the femles gve this response. However, mny dolescents responded tht they did not hve enough experience with lcohol to know how to nswer the tolernce item. Thus, the tolernce item my work well in discriminting between the genders, but only mong those prticipnts who know how to nswer it. The CAGE did not perform well s screening mesure for problemtic lcohol use in our dolescent/young dult smple. This finding is consistent with tht by Chung et l. (2000). Heck nd Willims (1995) similrly found the CAGE to be poor predictor of problem drinking in college students. They suggested tht its emphsis on items indictive of lcohol dependence my hve been responsible for its poor performnce in their reltively young college smple. Fleming et l. (1991), on the other hnd, found tht the AUDIT hd good internl consistency (α = 0.80) mong college students, nd tht it correctly clssified 78% of those dignosed with lcohol misuse by DSM-III criteri. These investigtors suggested tht the AUDIT hs dvntges over the CAGE, becuse it ssesses frequency of use nd quntity nd frequency of binge drinking long continuum, which is n dvntge for the erly detection of drinking problems.

6 ALCOHOL SCREENING INSTRUMENTS 449 Our ssessment of concurrent vlidity my hve been ffected by the use of some of the sme items for constructing the vrious scles. Notwithstnding this, the nlysis indicted tht ll the instruments were mesuring lcohol misuse, but the vrying sizes of the correltions suggest tht the instruments re not mesuring the sme underlying construct(s). The high correltion between the AUDIT nd the TWEAK my be relted to incresed vrince in the scores, due to their lrger scles (AUDIT rnge 1 40; TWEAK rnge 0 7). Furthermore, the AUDIT mesures lcohol intke nd the tolernce item on the TWEAK my be proxy for intke, since it is bsed on number of drinks. In contrst, the CAGE focuses on items relted to lcohol dependence nd this my explin its lower correltion with the other instruments. Cherpitel nd Clrk (1995) studied these instruments in n dult ED smple nd found tht significntly higher percentge of Africn-Americn mles scored positively on ll three mesures compred to Africn-Americn femles. The smll number of prticipnts who reported ny lcohol use in our study precluded testing for gender differences within the ethnic/rcil groups, but we did find tht Africn-Americns scored lower on the AUDIT. Consistent with our findings, Clements (1998) found tht only the AUDIT differentited between the rces in college smple, with Cucsins scoring higher thn Africn-Americns. Our findings re lso in line with recent epidemiologicl study (Grnt, 1997) tht reported lower rtes of lcohol misuse nd dependence mong Africn- Americns. The present findings should not be generlized beyond dolescents treted in EDs. Regionl vritions in lcohol use which ffect smples nd results hve been reported from one ED to nother in dult smples (Cherpitel nd Clrk, 1995). However, it is not cler tht geogrphic region impcts our findings, since Chung et l. (2000) reported similr findings in n ED-treted smple of dolescents from different region of the country. The fct tht the current smple ws primrily Cucsin requires us to be cutious in pplying our findings to Africn-Americn or other rce prticipnts. It is expected tht level of illness nd injury will ffect the smple in studies such s ours, nd we were unble to pproch s mny ptients t the dult ED due to serious illness or injury. It is possible tht more seriously ill or injured dolescent ptients re treted t dult fcilities. As result, the AUDIT, the TWEAK, nd the CAGE my perform differently from wht ws found in the current study, if used with criticlly injured dolescents. Limittions notwithstnding, we were ble to exmine the performnce of three widely used lcohol screening instruments in smple of ED-treted dolescents. The success of prevention nd tretment efforts relies on the erly identifiction of substnce use problems (Winters et l., 1993). This is popultion tht is t high risk for problemtic lcohol use nd setting in which dolescents re likely to present first for tretment of lcohol-relted illness or injury. Therefore, the potentil for erly detection of problemtic lcohol use mong ED-treted dolescents is gret nd this cn hve positive impct on prevention nd tretment efforts. Experienced investigtors hve lso noted tht the popultion under investigtion is n importnt considertion in choosing the pproprite instrument (Misto et l., 1995; Cherpitel, 1998). The higher internl consistency for the AUDIT, s compred to the TWEAK nd CAGE, s well s its more consistent performnce in differentiting lcohol-using dolescents long known group lines nd in discriminting between problemtic nd non-problemtic lcohol users, led us to conclude tht the AUDIT performs best s n lcohol screening instrument mong dolescents treted in EDs. The consistency of findings between our study nd others, especilly those from other EDs nd studies of smples close in ge to our subjects (e.g. college students) dds to the vlidity of our findings nd supports this conclusion. Acknowledgements The uthors wish to express their pprecition to Drs Duncn Clrk, Oscr Bukstein nd Kevin Lynch for their ssistnce in the preprtion of this mnuscript. This work ws supported by the Ntionl Institute on Alcohol Abuse nd Alcoholism (NIAAA) Grnt No. P50 AA08746 nd NIAAA Mentored Clinicl Scientist Development Awrd to the first uthor (Grnt No. K08-AA00280). REFERENCES Americn Psychitric Assocition (1994) Dignostic nd Sttisticl Mnul of Mentl Disorders, 4th edn. Americn Psychitric Assocition, Wshington, DC. Arri, A. M., Dohey, M. A., Mezzich, A. C., Bukstein, O. G. nd Vn Theil, D. H. (1995) Self-reported helth problems nd physicl symptomtology in dolescent lcohol busers. Journl of Adolescent Helth 16, Brnes, G. M. nd Welte, J. W. (1986) Adolescent lcohol buse: subgroup differences nd reltionships to other problem behviors. Journl of Adolescent Reserch 1, Bstiens L., Frncis, G. nd Lewis, K. (2000) The RAFFT s screening tool for dolescent substnce use disorders. Americn Journl of Addictions 9, Blum, R. (1997) Adolescent substnce use nd buse. Archives of Peditric nd Adolescent Medicine 151, Bohn, M. J., Bbor, T. F. nd Krnzler, H. R. (1995) The lcohol use disorders identifiction test (AUDIT): vlidtion of screening instrument for use in medicl settings. 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Journl of the Americn Acdemy of Child nd Adolescent Psychitry 36, Clements, R. (1998) A criticl evlution of severl lcohol screening instruments using the CIDI-SAM s criterion mesure. Alcoholism: Clinicl nd Experimentl Reserch 22, Conigrve, K. M., Hll, W. D. nd Sunders, J. B. (1995) The AUDIT questionnire: choosing cut-off score. Addiction 90, Cronbch, L. J. (1951) Coefficient lph nd the internl structure of tests. Psychometrik 16, Ewing, J. A. (1984) Detecting lcoholism the CAGE questionnire. Journl of the Americn Medicl Assocition 252,

7 450 T. M. KELLY et l. Fleming, M. F., Brry, K. L. nd McDonld, R. (1991) The Alcohol Use Disorders Identifiction Test (AUDIT) in college smple. Interntionl Journl of the Addictions 26, Grnt, B. (1997) Prevlence nd correltes of lcohol use nd DSM-IV lcohol dependence in the United Sttes: results of the Ntionl Longitudinl Alcohol Epidemiologic Survey. Journl of Studies on Alcohol 58, Hnsell, S. nd White, H. W. (1991) Adolescent drug use, psychologicl distress nd physicl symptoms. Journl of Helth nd Socil Behvior 32, Heck, E. J. nd Willims, M. D. (1995) Using the CAGE to screen for drinking-relted problems in college students. Journl of Studies on Alcohol 56, Jennet, B. nd Bond, M. (1975) Assessment of outcome fter severe brin dmge. Lncet i, Jessor, R. (1987) Problem-behviour theory, psychosocil development, nd dolescent problem drinking. British Journl of Addiction 82, Kelly, T. M., Donovn, J. E., Lynch, K. G. nd Clrk, D. B. (2001) Alcohol use disorders nd other risk fctors for dolescent suicidl idetion nd ttempts. Suicide nd Life-Thretening Behvior 31, Knight, J. R., Shrier, L. A., Brvender, T. D., Frrell, M., Vnder Bilt, J. nd Shffer, H. J. (1999) A new brief screen for dolescent substnce buse. Archives of Peditric nd Adolescent Medicine 153, Leccese, M. nd Wldron, H. B. (1994) Assessing dolescent substnce use: critique of current mesurement instruments. Journl of Substnce Abuse Tretment 11, Misto, S. A., Connors, G. J. nd Allen, J. P. (1995) Contrsting selfreport screens for lcohol problems: review. Alcoholism: Clinicl nd Experimentl Reserch 19, Nilssen, O., Ries, R. K., Rivr, F. P., Gurney, J. G. nd Jurkovich, G. J. (1994) The CAGE questionnire nd The Short Michign Alcohol Screening Test in trum ptients: comprison of their correltions with biologicl lcohol mrkers. Journl of Trum 36, Rchl, J. V., Guess, L. L., Hubbrd, R. L. nd Misto, S. A. (1982) Fcts for plnning no. 4: lcohol misuse by dolescents. Alcohol Helth nd Reserch World 6, Russell, M. (1994) New ssessment tools for risk drinking during pregnncy: T-ACE, TWEAK, nd others. Alcohol Helth nd Reserch World 18, SAMHSA (1997) Ntionl Household Survey on Drug Abuse Min Findings US Deprtment of Helth nd Humn Services, Rockville, MD. Sunders, J. B., Aslnd, O. G., Bbor, T. F., de l Fuente, J. R. nd Grnt, M. (1993) Development of the lcohol use disorders identifiction test (AUDIT): WHO collbortive project on erly detection of persons with hrmful lcohol consumption II. Addiction 88, Shope, J. T., Copelnd, L. A., Mle, R. F., Blow, F. C. nd Brockmnn, L. M. (1997) Correltes of lcohol involvement mong injured dolescents (bstrct). Alcoholism: Clinicl nd Experimentl Reserch 21 (Suppl. to no. 3), 29A. Spin, D. A., Boz, P. W., Dvidson, D. J., Miller, F. B., Crrillo, E. H. nd Richrdson, J. D. (1997) Risk-tking behviors mong dolescent trum ptients. Journl of Trum: Injury, Infection nd Criticl Cre 43, Spirito, A., Lewnder, W. J., Levy, S., Kurkjin, J. nd Fritz, G. (1994) Emergency deprtment ssessment of dolescent suicide ttempters: fctors relted to short-term follow-up outcome. Peditric Emergency Cre, 10, Windle, M. (1996) An lcohol involvement typology for dolescents: convergent vlidity nd longitudinl stbility. Journl of Studies on Alcohol 57, Winters, K. C., Stinchfield, R. D. nd Henly, G. A. (1993) Further vlidtion of new scles mesuring dolescent lcohol nd other drug buse. Journl of Studies on Alcohol 54,

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