DSM-IV alcohol abuse and dependence criteria characteristics for recent onset adolescent drinkers
Introduction
Alcohol use disorders (AUDs) are a serious public health issue, often developing during adolescence (Young et al., 2002). Identifying adolescents at risk for AUD is a necessary step to reduce this problem. One of the most commonly used measures for diagnosing AUD is the DSM-IV. Traditionally, alcohol abuse and dependence are scored by the number of criteria endorsed with either a binary indicator of AUD presence or absence or a proportion score based on number of endorsed symptoms. The binary method ignores the full continuum of AUD severity that is thought to characterize alcohol dependence (Edwards and Gross, 1976). A proportion score assesses AUD severity in terms of taking into account the exact number of symptoms, yet both traditional scoring methods consider only the number of criteria endorsed, not the pattern. Consequently, it is assumed that all criteria equally contribute to the severity of AUD, and that measurement properties of the criteria are invariant across all characteristics of the individual. Finally, because DSM-IV AUD criteria were not designed specifically for adolescents, it remains unclear how the psychometric properties of these criteria vary for adolescents who have recently begun drinking and who are likely to have wide range of drinking exposure (Chung and Martin, 2005, Chung et al., 2005, Deas et al., 2000).
A number of studies have evaluated the psychometric properties of DSM-IV AUD criteria. Generally, these criteria discriminate well between levels of an underlying AUD construct, and have high probabilities of endorsement across a wide range of AUD severity. For example, among adults, the criteria “using a larger amount or over a longer period than intended” and “unsuccessful efforts to cut down” have been found to be more likely to be endorsed at low severity and the criteria “withdrawal,” “tolerance” and “activities given up or reduced” more likely to be endorsed at high AUD severity (Saha et al., 2007, Saha et al., 2006). Other IRT studies on DSM-IV criteria in adolescent drinkers have revealed low severity and/or poor discrimination for “tolerance,” “using larger amounts or over a longer period than intended” and “unsuccessful efforts to cut down” (Beseler et al., 2010, Harford et al., 2009, Hasin et al., 2003, Gelhorn et al., 2008, Martin et al., 2006). Only one study has investigated DSM-IV AUD psychometric properties in recent onset drinkers, finding that these properties differed as a function of time since onset of drinking in mostly young adults and adolescents who reported drinking in the past year and drinking onset within two years (McBride and Cheng, 2011). The psychometric properties of DSM-IV criteria have also been shown to vary as a function of age and gender (Harford et al., 2009).
Despite the fact that recent onset drinkers may have a wide range of drinking exposure, there have been no studies to date examining how the psychometric properties of DSM-IV AUD criteria differ as a function of drinking frequency. AUD symptoms are conventionally thought to emerge after prolonged and frequent exposure to alcohol (Anthony et al., 2005, Wagner and Anthony, 2002), but more recent studies have shown that symptoms can emerge within the first year of alcohol use (Lee et al., 2011, McBride and Cheng, 2011) and can predict future alcohol dependence (Behrendt et al., 2008, McBride and Cheng, 2011). Given that young recent onset drinkers are likely to drink considerably less frequently than older established drinkers on whom the DSM-IV criteria have been developed, it is important to determine whether the psychometric properties of these criteria are consistent, particularly for infrequent drinkers.
If psychometric characteristics of AUD criteria differ as a function of frequency of alcohol use, the AUD construct assessed by the same DSM-IV criteria may have a different meaning for adolescent drinkers depending on how frequently they drink. This can lead to problems in construct measurement, as well as interpretation, if potential differences in the meaning of the construct are not considered. If not considered when scoring an AUD severity construct, observed individual differences on these criteria related to drinking frequency are confounded with differences in the psychometric properties of the criteria.
The present study seeks to replicate existing studies by examining the likelihood of endorsement and discriminatory properties of DSM-IV AUD criteria, and extend this work by investigating whether criteria properties vary according to drinking frequency in a younger (aged 12–21), nationally representative population of 9356 recent onset (within the past year) and current (drank within the past 30 days) drinkers drawn from seven consecutive years of the National Survey on Drug Use and Health (NSDUH; 2002–2008).
We used item response theory (IRT) analysis to achieve these aims. Psychometric properties of criteria can differ in: (1) severity (the value of the latent AUD construct at which the probability of item endorsement is 50%) and (2) discrimination (how well an item differentiates between participants with different levels of latent AUD). IRT analysis helps to identify possible limitations when applying DSM-IV AUD criteria to adolescents and provide guidelines for refining the DSM-IV criteria to be better suited for adolescents. IRT evaluates how well each criterion performs on a latent AUD construct and how informative each criterion is over the continuum of that construct (Gelhorn et al., 2008, Martin et al., 2006).
Section snippets
Participants
The sample consisted of N = 9356 individuals aged 12–21 who reported (1) drinking in the past month and (2) their first exposure to alcohol within the past year. The NSDUH utilized multistage area probability methods to select a representative sample of the non-institutionalized U.S. population age 12 or older. Persons living in households, military personnel living off bases, and residents of non-institutional group quarters including college dormitories, group homes, civilians on military
Results
IRT results showed that severity and discrimination parameters for all but two criteria were invariant across drinking frequency groups after controlling for age, gender, ethnicity, and drinking quantity. The criteria “tolerance” and “time spent” had lower severity and did not discriminate as well for more frequent drinkers. The final multiple group IRT model was one in which all criteria slopes and thresholds were constrained to be equal between the two groups of drinkers, except for the two
Discussion
This study evaluated how DSM-IV alcohol abuse and dependence criteria measured an underlying AUD construct and whether individual criteria function differently based on the level of past month drinking frequency among recent-onset adolescent drinkers. A few major findings emerged. First, the majority of the criteria, with the exception of “tolerance” and “time spent,” showed good discrimination and were invariant in terms of both discrimination and severity across levels of drinking frequency,
Role of funding source
Data analysis and interpretation, manuscript preparation, review and approval were supported by grants R01 DA022313-01A2, R01 DA022313-02S1, R21DA024260, (Dierker), R21DA029834-01A1 (Rose) from the National Institute on Drug Abuse, and P50 DA010075 awarded to Penn State University and an Investigator Award from the McManus Charitable Trust (Dierker). We acknowledge The National Household Survey of Drug Use and Health (NHSDUH) funded by The Substance Abuse and Mental Health Services
Contributors
Jennifer Rose planned the core analyses, conducted all the analyses for the revised manuscript, wrote the revised manuscript, and provided revisions to earlier drafts of this paper. Chien-Ti Lee conducted analyses for the original paper, and wrote the majority of the original paper. Arielle Selya assisted with literature searches and revisions of the earlier drafts of this paper. Lisa Dierker designed the study in conjunction with Jennifer Rose, and provided revisions of this paper. All authors
Conflict of interest
None declared.
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