- Email: [email protected]
Measuring problem drinking in first time offenders Development and validation of the College Alcohol Problem Scale (CAPS)
Journal of Substance AbuseTreatment, Vol. 14, No. 4, pp. 383-387, 1997 Copyright © 1997 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/97 $17.00 + .00
PII S0740-5472(97)00033-0
ELSEVIER
BRIEF REPORT
Measuring Problem Drinking in First Time Offenders Development and Validation of the College Alcohol Problem Scale (CAPS)
THOMAS O'HARE Boston College, Graduate School of Social Work, McGuinn Hall, Chestnut Hill, MA
Abstract-Research on college drinking continues to justify serious concerns for the psychological, social, and physical well-being of young persons who abuse alcohol. However, despite considerable interest and research in this regard, there are few valid, reliable and clinically useful brief screening instruments available to measure youthful drinking problems. The current study of 315 college students cited their first time for breaking university drinking rules describes the development and validation of the College Alcohol Problem Scale (CAPS)for measuring different psychosocial dimensions of problem drinking in college students. Two related but distinct factors emerged defining Socio-Emotional and Community Problems. These two factors explained almost two thirds of the variance, and showed very good internal reliabilities. MANOVA analysis demonstrated concurrent validity for the CAPS with both a measure of heavy drinking derived from the QFI and a modified version of the MAST. Implications for using the CAPS for identifying potential drinking problems in young persons are emphasized. © 1997 Elsevier Science Inc.
Keywords-college students;instruments;screening;drinkingproblems; problem scales.
INTRODUCTION
psychosocial mechanisms that potentiate continued abuse include expectancies of the reinforcing socioemotional effects of alcohol (Brown, Goldman, Inn, & Anderson, 1980; Brown, Christensen, & Goldman, 1987; O'Hare, 1990b), and tension reduction or stress dampening effects (Sher, 1987). Research on the situational aspects of consumption (i.e., with whom, where, when, under what circumstances) have revealed college drinking as a primarily social affair with most heavy drinking done in peer groups (Harford & Grant, 1987), when partying in large social gatherings (O'Hare, 1990a; Wechsler & McFadden, 1979) mostly on weekends (Kraft, 1979). Any attempt to measure youthful problem drinking requires this multidimensional perspective. Despite a substantial amount of research on college drinking, there are relatively few brief, valid, and reliable alcohol problem scales for young persons in the substance abuse literature (Leccesse & Waldron, 1994). Sev-
Alcohol abuse and related problems in young people continue to demand considerable attention and concern in the research literature. These problems are substantial among young persons in the general population (Williams & Debakey, 1992), as well as high school and college (Johnston, O'Malley, & Bachman, 1996; Wechsler, Davenport, Dowdall, Moeykens, & Costillow, 1994). These negative consequences include psychological (e.g., depression, suicide, anxiety), interpersonal (e.g., fights, unplanned sex) and community (e.g., driving under the influence) problems (Engs, 1977; Wechsler & McFadden, 1979; O'Hare, 1990a; Wechsler et al. 1994). Interacting
Reprint requests should be addressed to Thomas O'Hare, Boston College, Graduate School of Social Work, McGuinn Hall, Chestnut Hill, MA 02167-3807.
Received August 5, 1996; Accepted January 16, 1997.
383
384
T. 0 'Hare
eral different strategies have been applied to measure problem drinking, specifically in college students, but most have serious drawbacks. The CAGE, for example, a four-item screening device for detecting problem drinking or dependence (Mayfield, McLeod, & Hall, 1974), has been employed often in college drinking investigations. However, considerable research has demonstrated that it does not provide a sensitive measure of problem drinking for college students, especially for women (Heck & Williams, 1995; O'Hare & Tran, 1996). Drinking in the morning to steady nerves (i.e., "eye opener"), dichotomous criteria, and the fact that the CAGE queries lifetime use rather than more recent problems may not make this instrument particularly relevant to the situational and temporal variability that is typical of youthful drinking. Perhaps the most common approach to determining the extent of drinking-related problems among college students has been self-reported estimations of negative consequences attributed to drinking (O'Hare, 1990a; Wechsler et al., 1994). While this approach may have some research utility, evidence of factorial validity or scale reliabilities are typically not provided, and these data do not offer any validated taxonomy for categorizing different dimensions of problem drinking. Another instrument that does address a range of psychosocial consequences, the RAPI (White & Lebouvie, 1989), was shown to correlate with various measures of abuse, but demonstrated a relatively weak factor structure. Lastly, other more comprehensive substance abuse assessment instruments are available, but often require a lengthy structured interview, which is not practical where routine brief screens are needed. Given the high prevalence of abusive drinking on college campuses, brief, valid, and reliable self-report screening devices are needed so that practitioners who work, for example, in student health services or counseling environments can quickly evaluate and refer problem drinking students for further substance abuse assessment and intervention. The purpose of the current article is to, first, describe the development and initial validation of the College Alcohol Problem Scale (CAPS) with students cited for first offenses in a large public university in southern New England. Exploratory factor analysis was employed to sort out underlying psychosocial dimensions covering an array of drinking problems noted in the introduction. Secondly, MANOVA analysis was used to test initial criterion validity of the CAPS subscales with the Quantity-Frequency Index (QFI) and the 9-item Malmo modification of the MAST (Kristenson & Trell, 1982). Lastly, the clinical utility of this brief scale for use with college students will be discussed. METHOD Sample and Procedure Three hundred and fifteen undergraduate students at the University of Rhode Island completed the anonymous
questionnaires between January 1995 and May 1996 as part of an adjudication process for having been cited by campus authorities (campus police or dormitory resident assistants) for violating university rules concerning underaged drinking. Participants are described by the following demographics: gender [female (39.7%)/male (60.3%); age (M = 18.8, SD = .96, range = 18-26); year in school (freshman (67.0%), sophomore (23.5%), junior (8.3%), senior (1.3%)]. Residence status included: (living on campus (93.7%), living off campus/independent (3.5%), living off campus/with parents (1.6%), other (1.3%). About one fifth (22.5%) were members of a fraternity or sorority, all but one student (99.7%) designated their sexual orientation as heterosexual. The majority (90.8%) were White, with Native Americans, Asian/Pacific Islanders, Blacks, Latinos and "others" comparably distributed over the remaining 9.2%. Family income was identified as poor (1.6%), lower middle class (4.1%), middle class (51.7%), upper middle class (38.1%) and wealthy (3.5%) with 1% not reporting. Students completed the anonymous questionnaire when they reported to the Office of Student Life to pay a required fine. It was emphasized that the staff did not assume that the respondent had a substance abuse problem, but that the purpose of the project was to (according to instructions) "get an accurate picture of the range of experiences [relevant to substance use] among the students referred to us." The questionnaire included demographics, several measures of alcohol consumption and drug use, and questions about drinking situations and alcoholrelated problems. Instructions were generally self-explanatory, but office staff consisting of trained counselors and graduate students in related fields were available to answer questions. Staff reported a very high level of compliance and comfort with the process, and students appeared to complete the questionnaire generally in about 5 to 10 minutes. The decision to make the questionnaire anonymous was based on research evidence supporting the increased validity and reliability of self-report when confidentiality (in this case, reinforced by anonymity) is assured (Babor, Stevens, & Marlatt, 1987; Sobell, Toneatto, & Sogbell, 1994). After completing this one-time survey questionnaire, students were given a completed copy, and brief guidelines for interpreting some of the answers (e.g., a cut off score for "heavy drinking"). Students were invited to call the Office of Student Life for further consultation if they had any questions or concerns, specifically, about their substance use. The instrument and procedures for administering it were approved by the university human subjects review committee. Instrument The author constructed an initial item pool based on a range of standardized and unstandardized instruments used in prominent college drinking studies over the last 20 years (e.g., Engs, 1977; Wechsler & McFadden, 1979;
Measuring Problem Drinking in First Time Offenders
385
O'Hare, 1990a; Wechsler et al. 1994). Example items include psychophysiological (hangovers, memory loss), emotional (nervousness, depression), interpersonal (fights, arguments, unplanned sex), and community problems (drove under the influence, engaged in activities related to illegal drugs, problems with the law). After the item pool was reviewed by the author (an experienced mental health and substance abuse clinician), the Director of Student Life, and two masters level counselors (one a social worker) experienced with youthful substance use, the instrument was also piloted with several students to clarify ambiguities and reduce any redundancy. After this editing process, the initial item pool was reduced to 20. Students completing the instrument were asked to rate each problem on a 6-point scale ranging from ["severe" (5), "moderate" (3), "mild" (1), "no problem" (0)] after reading the following statement: "Rate the general level of difficulty you had over the past year with any of the items below that resulted from drinking too much alcohol". (The 10 items included in the final scale appear as they do in Table 1.) To test concurrent validity, heavy drinking and alcohol abuse were measured with the Quantity-Frequency Index (QFI) (with heavy drinking equal to five or more drinks at one sitting at least once per week) (Straus & Bacon, 1953; O'Hare, 1991) and the 9-item Malmo modification (Kristenson & Trell, 1982) of the Michigan Alcoholism Screening Test. The QFI has a substantial record of validity and reliability across treatment and nontreatment populations (Babor et al., 1987; Redman Sanson-Fisher, Wilkinson, Fahy, & Gibberd, 1987) including college students (O'Hare, 1991). The modified MAST (using a cut-off score of 2) has also been shown to be a sensitive tool for detecting problem drinking in university students (Nystrom, Perasalo, & Salaspuro, 1993). TABLE 1 Factor Loadings for Two CAPS Subscales (N = 315)
Item Socio-Emotional Feeling sad, blue, or depressed Nervous, irritability Family problems related to your drinking Badly affected friendship or relationship Hurt another person emotional/ physically Caused you to feel bad about yourself Community Problems Nausea, vomiting, or feeling tired/ hungover Spent too much money on alcohol or drugs Drove under the influence Problems with the law/school administration
Factor Loadings 0.68 O.74 0.79
0.33 0.30 0.22
0.79
0.13
0.70
0.35
0.76
0.32
0.19
0. 74
0.29
0.80
0.32 0.22
0.69 O.72
RESULTS
Factor Analysis The 20 items were submitted to principal components analysis with varimax rotation. Items with factor loadings below .60 or those loading ambiguously were eliminated, resulting in the retaining of two factors with eigenvalues exceeding 1.0. These two factors accounted for 62.9% of the variance, and are labeled as follows (with eigenvalues and percent of explained variance): Socio-Emotional Problems (5.2, 51.7%) and Community Problems (1.1, 11.2%). These two factors were composed of six and four items, respectively. Eigenvalues dropped below 1.0 after a two-factor solution resulting in the best achievable balance of theoretical parsimony and maximum variance explained (Comrey, 1988). The final factor solution appears in Table 1.
Internal Consistency Ratings Standardized Chronbach's alphas were calculated for the two subscales: Socio-Emotional Problems (.88) and Community Problems (.79).
Subscale Statistics Subscale means and standard deviations were calculated based on simple summation of all the respective items, and are as follows: Socio-Emotional (M = 2.9, SD = 4.5) and Community (M = 4.7, SD = 4.4). Pearson correlation between the two subscales was moderate (r --.63, p < .01 ).
Heavy Drinking and Problem Drinking Over half (55.6%) of these students are heavy drinkers based on their self-report with the QFI, and 71.4% scored positively on the modified MAST using a cut-off score of 2.
Concurrent Validity Full factorial MANOVA analysis was employed to test the concurrent validity of the CAPS against heavy and problem drinking. The QFI and the modified MAST were both used as independent variables with the two CAPS subscales (Socio-Emotional and Community problems) used as dependent variables. QFI responses were coded heavy drinking/non-heavy drinking, and a positive score (2 or more) on the MAST indicated problem drinking. It was expected that student reports of heavy and problem drinking would vary directly with Socio-Emotional and Community Problems. Gender was also added to a subsequent analysis to test for possible interaction effects by gender. A positive MAST score produced a significant main
386
T. 0 'Hare
effect for the two dependent CAPS subscales (Wilks lambda = .94, F = 9.61 (2/309), p < .01). When the two subscales were considered individually in univariate analysis of variance (df = 1,310) Socio-Emotional (F = 8.67, p < .01) and Community Problems (F = 18.96, p < .01) both showed significant differences by Mast score. Heavy drinking as measured with the QFI also resulted in a significant main effect on the two dependent problem subscales (Wilks lambda = .94, F = 10.22 (2/ 309), p < .01). When the two subscales were considered individually in univariate analysis of variance (df = 1,310) Socio-Emotional (F = 6.84, p < .01) and Community Problem Drinking (F = 20.51, p < .01) both showed significant differences with the QFI. Cell means and standard deviations can be reviewed in Table 2. There were no interaction effects between the MAST and the QFI, and no main or interaction effects with gender when it was included in the MANOVA analysis. DISCUSSION This investigation of college students adjudicated for the first time because of breaking university drinking rules provides initial support for the factorial validity, concurrent validity and internal consistency of the CAPS. Two well-defined subscales accounted for over 60% of the variance, correlated moderately, and varied directly with recognized measures of heavy (QFI) and problem drinking (modified MAST). The scale also showed very good internal consistency ratings.
Clinical Implications The current emphasis, however, is on the clinical utility of this brief instrument. An item analysis of the Socio-
TABLE 2 Means and Standard Deviations of Two CAPS Subscales with the QFI Measure of Heavy Drinking and MmMAST from SPSS-X MANOVA Output (N = 314) Independent Variables
Socio-Emotional Problems QFI Non-heavy drinkers Negative MAST (<2) Positive MAST (I>2) QFI Heavy drinkers Negative MAST Positive MAST Total sample Community Problems QFI Non-heavy drinkers Negative MAST (<2) Positive MAST (~>2) QFI Heavy drinkers Negative MAST Positive MAST Total sample
M
SD
N
1.03 1.65
2.7 2.5
70 69
1.45 4.45 2.88
2.0 5.4 4.5
20 155 314
1.81 3.20
2.2 3.2
70 69
3.30 6.77 4.66
3.0 4.6 4.4
20 155 314
Emotional Problem drinking factor reveals a concentration of negative drinking consequences including depression, anxiety and troubles with family, friends, and intimate relationships. The findings that these problems increase with alcohol consumption and problem drinking should not be surprising. Young men and women often have strong expectations that alcohol consumption will enhance social relationships (Brown, et al., 1987), but often underestimate the potential for problems which can occur even when they appear to be enjoying themselves (Carey 1993, 1995). The second factor, Community Problems, correlates moderately with Socio-Emotional Problems, but is a qualitatively different set of negative consequences, which include acute physiological effects of drunkenness (e.g., vomiting, hangovers, memory loss) along with illegal, antisocial, and potentially dangerous activities (e.g., driving under the influence, problems with the law). Unlike socio-emotional problems, these are consequences that seem to attract more public concern due to associated criminal activities such as vandalism, drunk driving, and involvement with illegal drugs, signaling, perhaps more serious involvement with substances in the long run (Chen& Randel, 1995). Overall mean scores for both the Socio-Emotional and Community subscales were low for those 155 respondents who were rated as both heavy (QFI) and problem (modified MAST) drinkers. Given that all items are rated 0-5, the potential range for the Socio-Emotional subscale is 0-30. As seen in Table 2, those first offenders had a mean score of 4.45. These same respondents also showed a mean score of 6.77 on a possible range of 0-20 on the Community subscale. Since college students are prone to underestimate the potential negative aspects of drinking (O'Hare & Tran, 1996; Wechsler et al., 1994), practitioners who work with them should be alert to potentially serious problems even when respondents indicate only a mild concern about the Socio-Emotional or Community consequences of their own drinking. For practitioners using the CAPS for initial screening purposes, even low self-reported ratings on individual items should be used as an impetus for more extensive clinical assessment. Given the high rates of alcohol abuse in young persons, routine substance abuse screening is necessary in any prevention or clinical setting. Skillful interviewing with reasonable assurances of confidentiality will often result in accurate self-report of substance use (Sobell, Toneatto, & Sobell, 1994) despite, perhaps, an underestimation of the seriousness of potential consequences. The individual items on the CAPS can serve as a starting point for discussion of specific problem areas related to drinking. Indications that a student has a greater problem in the Socio-Emotional or Community domain may serve as a basis for not only extensive differential assessment, but differential treatment planning as well. Psychotherapeutic or coping skills strategies may be emphasized for a student mainly reporting Socio-Emotional distress re-
Measuring Problem Drinking in First Time Offenders
lated to substance abuse. For the young person reporting Community problems, treatment may need to incorporate contingency management strategies as well. Once problems are identified, clinicians should emphasize the development and maintenance of a good working relationship in order to further monitor drinking patterns as well as negotiate treatment goals for reducing the consequences of excessive drinking (Marlatt & Tapert, 1993; Miller & Rollnick, 1991). At that point, the CAPS can be used as a self-monitoring tool to assist students in staying on track with their treatment process. Limitations of the Study Generalizations to other college samples should be made cautiously. This sample of young persons cited for their first campus alcohol offense generally appears to be disproportionately heavy drinkers compared to other college populations (O'Hare, 1990a; Wechsler & McFadden, 1979) in which heavy drinking rates (employing a similar QFI criteria of "five or mo~e" drinks at one sitting) have varied around 20%. Future investigations should employ the CAPS with a more diverse array of youthful populations, and use other measures to evaluate further its concurrent and predictive validity. REFERENCES Babor, T.F., Stephens, R.S., & Marlatt, G.A. (1987). Verbal report methods in clinical research on alcoholism: response bias and its minimization, Journal of Studies on Alcohol, 48, 410--424. Brown, S.A., Goldman, M.S., Inn, A., & Anderson, L.R. (1980). Expectations of reinforcement from alcohol: their domain and relation to drinking patterns. Journal of Consulting and Clinical Psychology 48, 419~26. Brown, S.A., Christiansen, B.A., & Goldman, M.S. (1987). The Alcohol Expectancy Questionnaire: An instrument for the assessment of adolescent and adult alcohol expectancies. Journal of Studies on Alcohol, 48, 483-491. Carey, K.B. (1995) Heavy drinking contexts and indeces of problem drinking among college students. Journal of Studies on Alcohol, 56, 287-292. Carey, K.B. (1993). Situational determinants of heavy drinking among college students. Journal of Counseling Psychology, 40, 217-220. Chen, K., & Kandel, D. (1995). The natural history of drug use from adolescents to the mid-thirties in a general population sample. American Journal of Public Health, 85, 41-47. Engs, R.C. (1977). Drinking patterns and drinking problems of college students. Journal of Studies on Alcohol, 38, 2144-2156. Harford, T., & Grant, B,F. (1987). Psychosocial factors in adolescent drinking contexts. Journal t~f Studies on Alcohol, 48, 551-557. Heck, E.J., & Williams, M.D. (1995). Using the CAGE to screen for drinking-related problems in college students. Journal t~fStudies on Alcohol, 56, 282-286. Johnston, L.D., O'Malley, P.M., & Bachman, J.G. (1995). National survey results on drug use .from the monitoring the future study,
387 1975-1994. Volume II: College students and young adults. Rockville, MD: USDHHS. Kraft, D.P. (1979). Alcohol education programming at the University of Massachusetts, Amherst, and evaluation of results to date. Paper presented at the American Psychological Association Convention, San Francisco, CA. Kristenson, H., & Trell, E. (1982). Indicators of alcohol consumption: Comparisons between a questionnaire (MmMAST), interviews and serum gamma-glutamyl transferase (GGT) in a health survey of middle-aged males. British Journal of Ad_diction, 77, 297-304. Leccese. M., & Waldron, H.B. (1994). Assessing adolescent substance use: a critique of current measurement instruments. Journal of Substance Abuse Treatment, 11,553-563. Marlatt, G.A., & Tapert, S.F. (1993). Harm reduction: Reducing the risks of addictive behaviors. In J.S. Baer, G.A. Marlatt, & R.J. McMahon (Eds.), Addictive behaviors across the litespan (pp. 243273). New York: Sage. Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism screening test. American Journal of Psychiatry, 131, 1121-1123. Miller, W.R., & Rollnick, S. (1991). Dealing with resistance. In W.R. Miller & S. Rollnick (Eds.), Motivational Interviewing: preparing people for changes (pp. 100-112). New York: Gui!tbrd Press. Nystrom, M., Perasalo, J., & Salaspuro, M. (1993). Screening for heavy drinking and alcohol-related problems in young university students: the CAGE, the MmMAST and the Trauma Score Questionnaires. Journal of Studies on Alcohol, 54, 528-533. O'Hare, T, (1990a). Drinking in college: Consumption patterns, problems, sex differences and legal drinking age. Journal ~?fStudies on Alcohol, 51,536-541. O'Hare, T. (1990b). Alcohol expectancies and social anxiety in male and female undergraduates. Addictive Behaviors, 15, 561-566. O'Hare, T. (1991). Measuring alcohol consumption: A comparison of the retrospective diary and the quantity frequency methods in a college drinking survey. Journal of Studies on Alcohol, 52, 500-502. O'Hare, T., & Tran, T.V. (1996) Predicting problem drinking in college students: Gender differences and the CAGE questionnaire. Addictive Behaviors, 22, 13-21. Redman, S.. Sanson-Fisher, R.W., Wilkinson, C., Fahey, P.P., & Gibberd, R.W. (1987). Agreement between two measures of alcohol consumption. Journal of Studies on Alcohol, 48, 104-108. Sher, K. (1987). Stress dampening response. In H. Blane& K. Leonard (Eds.), Psychological theories of drinking and alcoholism, (pp, 227-271) New York: Guilford Press. Sobell, L.C., Toneatto, T., & Sobell, M.B. (1994). Behavioral assessment and treatment planning for alcohol, tobacco and other drug problems: Current status with an emphasis on clinical applications. Behavior Therupy, 25, 533-580. Straus, R., & Bacon, S.D. (1953). Drinking in college. New Haven, CT: Yale University Press. Wechsler, H., & McFadden, M. (1979). Drinking among college students in New England: Extent, social correlates, and consequences of alcohol use, Journal of Studies on Alcohol, 40, 969-996. Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Costillow, S. (1994). Health and behavioral consequences of binge drinking in college. JAMA, 272, 1672-1677. White, H.R., & Lebouvie, E.W. (1989). Towards the assessment of adolescent problem drinking. Journal of Studies on Alcohol, 50, 30-37. Williams, G.D., & Debakey, S.F. (1992). Changes in levels of alcohol consumption: United States, 1983-1988. British Journal of Addictions, 87,643-648.
PII S0740-5472(97)00033-0
ELSEVIER
BRIEF REPORT
Measuring Problem Drinking in First Time Offenders Development and Validation of the College Alcohol Problem Scale (CAPS)
THOMAS O'HARE Boston College, Graduate School of Social Work, McGuinn Hall, Chestnut Hill, MA
Abstract-Research on college drinking continues to justify serious concerns for the psychological, social, and physical well-being of young persons who abuse alcohol. However, despite considerable interest and research in this regard, there are few valid, reliable and clinically useful brief screening instruments available to measure youthful drinking problems. The current study of 315 college students cited their first time for breaking university drinking rules describes the development and validation of the College Alcohol Problem Scale (CAPS)for measuring different psychosocial dimensions of problem drinking in college students. Two related but distinct factors emerged defining Socio-Emotional and Community Problems. These two factors explained almost two thirds of the variance, and showed very good internal reliabilities. MANOVA analysis demonstrated concurrent validity for the CAPS with both a measure of heavy drinking derived from the QFI and a modified version of the MAST. Implications for using the CAPS for identifying potential drinking problems in young persons are emphasized. © 1997 Elsevier Science Inc.
Keywords-college students;instruments;screening;drinkingproblems; problem scales.
INTRODUCTION
psychosocial mechanisms that potentiate continued abuse include expectancies of the reinforcing socioemotional effects of alcohol (Brown, Goldman, Inn, & Anderson, 1980; Brown, Christensen, & Goldman, 1987; O'Hare, 1990b), and tension reduction or stress dampening effects (Sher, 1987). Research on the situational aspects of consumption (i.e., with whom, where, when, under what circumstances) have revealed college drinking as a primarily social affair with most heavy drinking done in peer groups (Harford & Grant, 1987), when partying in large social gatherings (O'Hare, 1990a; Wechsler & McFadden, 1979) mostly on weekends (Kraft, 1979). Any attempt to measure youthful problem drinking requires this multidimensional perspective. Despite a substantial amount of research on college drinking, there are relatively few brief, valid, and reliable alcohol problem scales for young persons in the substance abuse literature (Leccesse & Waldron, 1994). Sev-
Alcohol abuse and related problems in young people continue to demand considerable attention and concern in the research literature. These problems are substantial among young persons in the general population (Williams & Debakey, 1992), as well as high school and college (Johnston, O'Malley, & Bachman, 1996; Wechsler, Davenport, Dowdall, Moeykens, & Costillow, 1994). These negative consequences include psychological (e.g., depression, suicide, anxiety), interpersonal (e.g., fights, unplanned sex) and community (e.g., driving under the influence) problems (Engs, 1977; Wechsler & McFadden, 1979; O'Hare, 1990a; Wechsler et al. 1994). Interacting
Reprint requests should be addressed to Thomas O'Hare, Boston College, Graduate School of Social Work, McGuinn Hall, Chestnut Hill, MA 02167-3807.
Received August 5, 1996; Accepted January 16, 1997.
383
384
T. 0 'Hare
eral different strategies have been applied to measure problem drinking, specifically in college students, but most have serious drawbacks. The CAGE, for example, a four-item screening device for detecting problem drinking or dependence (Mayfield, McLeod, & Hall, 1974), has been employed often in college drinking investigations. However, considerable research has demonstrated that it does not provide a sensitive measure of problem drinking for college students, especially for women (Heck & Williams, 1995; O'Hare & Tran, 1996). Drinking in the morning to steady nerves (i.e., "eye opener"), dichotomous criteria, and the fact that the CAGE queries lifetime use rather than more recent problems may not make this instrument particularly relevant to the situational and temporal variability that is typical of youthful drinking. Perhaps the most common approach to determining the extent of drinking-related problems among college students has been self-reported estimations of negative consequences attributed to drinking (O'Hare, 1990a; Wechsler et al., 1994). While this approach may have some research utility, evidence of factorial validity or scale reliabilities are typically not provided, and these data do not offer any validated taxonomy for categorizing different dimensions of problem drinking. Another instrument that does address a range of psychosocial consequences, the RAPI (White & Lebouvie, 1989), was shown to correlate with various measures of abuse, but demonstrated a relatively weak factor structure. Lastly, other more comprehensive substance abuse assessment instruments are available, but often require a lengthy structured interview, which is not practical where routine brief screens are needed. Given the high prevalence of abusive drinking on college campuses, brief, valid, and reliable self-report screening devices are needed so that practitioners who work, for example, in student health services or counseling environments can quickly evaluate and refer problem drinking students for further substance abuse assessment and intervention. The purpose of the current article is to, first, describe the development and initial validation of the College Alcohol Problem Scale (CAPS) with students cited for first offenses in a large public university in southern New England. Exploratory factor analysis was employed to sort out underlying psychosocial dimensions covering an array of drinking problems noted in the introduction. Secondly, MANOVA analysis was used to test initial criterion validity of the CAPS subscales with the Quantity-Frequency Index (QFI) and the 9-item Malmo modification of the MAST (Kristenson & Trell, 1982). Lastly, the clinical utility of this brief scale for use with college students will be discussed. METHOD Sample and Procedure Three hundred and fifteen undergraduate students at the University of Rhode Island completed the anonymous
questionnaires between January 1995 and May 1996 as part of an adjudication process for having been cited by campus authorities (campus police or dormitory resident assistants) for violating university rules concerning underaged drinking. Participants are described by the following demographics: gender [female (39.7%)/male (60.3%); age (M = 18.8, SD = .96, range = 18-26); year in school (freshman (67.0%), sophomore (23.5%), junior (8.3%), senior (1.3%)]. Residence status included: (living on campus (93.7%), living off campus/independent (3.5%), living off campus/with parents (1.6%), other (1.3%). About one fifth (22.5%) were members of a fraternity or sorority, all but one student (99.7%) designated their sexual orientation as heterosexual. The majority (90.8%) were White, with Native Americans, Asian/Pacific Islanders, Blacks, Latinos and "others" comparably distributed over the remaining 9.2%. Family income was identified as poor (1.6%), lower middle class (4.1%), middle class (51.7%), upper middle class (38.1%) and wealthy (3.5%) with 1% not reporting. Students completed the anonymous questionnaire when they reported to the Office of Student Life to pay a required fine. It was emphasized that the staff did not assume that the respondent had a substance abuse problem, but that the purpose of the project was to (according to instructions) "get an accurate picture of the range of experiences [relevant to substance use] among the students referred to us." The questionnaire included demographics, several measures of alcohol consumption and drug use, and questions about drinking situations and alcoholrelated problems. Instructions were generally self-explanatory, but office staff consisting of trained counselors and graduate students in related fields were available to answer questions. Staff reported a very high level of compliance and comfort with the process, and students appeared to complete the questionnaire generally in about 5 to 10 minutes. The decision to make the questionnaire anonymous was based on research evidence supporting the increased validity and reliability of self-report when confidentiality (in this case, reinforced by anonymity) is assured (Babor, Stevens, & Marlatt, 1987; Sobell, Toneatto, & Sogbell, 1994). After completing this one-time survey questionnaire, students were given a completed copy, and brief guidelines for interpreting some of the answers (e.g., a cut off score for "heavy drinking"). Students were invited to call the Office of Student Life for further consultation if they had any questions or concerns, specifically, about their substance use. The instrument and procedures for administering it were approved by the university human subjects review committee. Instrument The author constructed an initial item pool based on a range of standardized and unstandardized instruments used in prominent college drinking studies over the last 20 years (e.g., Engs, 1977; Wechsler & McFadden, 1979;
Measuring Problem Drinking in First Time Offenders
385
O'Hare, 1990a; Wechsler et al. 1994). Example items include psychophysiological (hangovers, memory loss), emotional (nervousness, depression), interpersonal (fights, arguments, unplanned sex), and community problems (drove under the influence, engaged in activities related to illegal drugs, problems with the law). After the item pool was reviewed by the author (an experienced mental health and substance abuse clinician), the Director of Student Life, and two masters level counselors (one a social worker) experienced with youthful substance use, the instrument was also piloted with several students to clarify ambiguities and reduce any redundancy. After this editing process, the initial item pool was reduced to 20. Students completing the instrument were asked to rate each problem on a 6-point scale ranging from ["severe" (5), "moderate" (3), "mild" (1), "no problem" (0)] after reading the following statement: "Rate the general level of difficulty you had over the past year with any of the items below that resulted from drinking too much alcohol". (The 10 items included in the final scale appear as they do in Table 1.) To test concurrent validity, heavy drinking and alcohol abuse were measured with the Quantity-Frequency Index (QFI) (with heavy drinking equal to five or more drinks at one sitting at least once per week) (Straus & Bacon, 1953; O'Hare, 1991) and the 9-item Malmo modification (Kristenson & Trell, 1982) of the Michigan Alcoholism Screening Test. The QFI has a substantial record of validity and reliability across treatment and nontreatment populations (Babor et al., 1987; Redman Sanson-Fisher, Wilkinson, Fahy, & Gibberd, 1987) including college students (O'Hare, 1991). The modified MAST (using a cut-off score of 2) has also been shown to be a sensitive tool for detecting problem drinking in university students (Nystrom, Perasalo, & Salaspuro, 1993). TABLE 1 Factor Loadings for Two CAPS Subscales (N = 315)
Item Socio-Emotional Feeling sad, blue, or depressed Nervous, irritability Family problems related to your drinking Badly affected friendship or relationship Hurt another person emotional/ physically Caused you to feel bad about yourself Community Problems Nausea, vomiting, or feeling tired/ hungover Spent too much money on alcohol or drugs Drove under the influence Problems with the law/school administration
Factor Loadings 0.68 O.74 0.79
0.33 0.30 0.22
0.79
0.13
0.70
0.35
0.76
0.32
0.19
0. 74
0.29
0.80
0.32 0.22
0.69 O.72
RESULTS
Factor Analysis The 20 items were submitted to principal components analysis with varimax rotation. Items with factor loadings below .60 or those loading ambiguously were eliminated, resulting in the retaining of two factors with eigenvalues exceeding 1.0. These two factors accounted for 62.9% of the variance, and are labeled as follows (with eigenvalues and percent of explained variance): Socio-Emotional Problems (5.2, 51.7%) and Community Problems (1.1, 11.2%). These two factors were composed of six and four items, respectively. Eigenvalues dropped below 1.0 after a two-factor solution resulting in the best achievable balance of theoretical parsimony and maximum variance explained (Comrey, 1988). The final factor solution appears in Table 1.
Internal Consistency Ratings Standardized Chronbach's alphas were calculated for the two subscales: Socio-Emotional Problems (.88) and Community Problems (.79).
Subscale Statistics Subscale means and standard deviations were calculated based on simple summation of all the respective items, and are as follows: Socio-Emotional (M = 2.9, SD = 4.5) and Community (M = 4.7, SD = 4.4). Pearson correlation between the two subscales was moderate (r --.63, p < .01 ).
Heavy Drinking and Problem Drinking Over half (55.6%) of these students are heavy drinkers based on their self-report with the QFI, and 71.4% scored positively on the modified MAST using a cut-off score of 2.
Concurrent Validity Full factorial MANOVA analysis was employed to test the concurrent validity of the CAPS against heavy and problem drinking. The QFI and the modified MAST were both used as independent variables with the two CAPS subscales (Socio-Emotional and Community problems) used as dependent variables. QFI responses were coded heavy drinking/non-heavy drinking, and a positive score (2 or more) on the MAST indicated problem drinking. It was expected that student reports of heavy and problem drinking would vary directly with Socio-Emotional and Community Problems. Gender was also added to a subsequent analysis to test for possible interaction effects by gender. A positive MAST score produced a significant main
386
T. 0 'Hare
effect for the two dependent CAPS subscales (Wilks lambda = .94, F = 9.61 (2/309), p < .01). When the two subscales were considered individually in univariate analysis of variance (df = 1,310) Socio-Emotional (F = 8.67, p < .01) and Community Problems (F = 18.96, p < .01) both showed significant differences by Mast score. Heavy drinking as measured with the QFI also resulted in a significant main effect on the two dependent problem subscales (Wilks lambda = .94, F = 10.22 (2/ 309), p < .01). When the two subscales were considered individually in univariate analysis of variance (df = 1,310) Socio-Emotional (F = 6.84, p < .01) and Community Problem Drinking (F = 20.51, p < .01) both showed significant differences with the QFI. Cell means and standard deviations can be reviewed in Table 2. There were no interaction effects between the MAST and the QFI, and no main or interaction effects with gender when it was included in the MANOVA analysis. DISCUSSION This investigation of college students adjudicated for the first time because of breaking university drinking rules provides initial support for the factorial validity, concurrent validity and internal consistency of the CAPS. Two well-defined subscales accounted for over 60% of the variance, correlated moderately, and varied directly with recognized measures of heavy (QFI) and problem drinking (modified MAST). The scale also showed very good internal consistency ratings.
Clinical Implications The current emphasis, however, is on the clinical utility of this brief instrument. An item analysis of the Socio-
TABLE 2 Means and Standard Deviations of Two CAPS Subscales with the QFI Measure of Heavy Drinking and MmMAST from SPSS-X MANOVA Output (N = 314) Independent Variables
Socio-Emotional Problems QFI Non-heavy drinkers Negative MAST (<2) Positive MAST (I>2) QFI Heavy drinkers Negative MAST Positive MAST Total sample Community Problems QFI Non-heavy drinkers Negative MAST (<2) Positive MAST (~>2) QFI Heavy drinkers Negative MAST Positive MAST Total sample
M
SD
N
1.03 1.65
2.7 2.5
70 69
1.45 4.45 2.88
2.0 5.4 4.5
20 155 314
1.81 3.20
2.2 3.2
70 69
3.30 6.77 4.66
3.0 4.6 4.4
20 155 314
Emotional Problem drinking factor reveals a concentration of negative drinking consequences including depression, anxiety and troubles with family, friends, and intimate relationships. The findings that these problems increase with alcohol consumption and problem drinking should not be surprising. Young men and women often have strong expectations that alcohol consumption will enhance social relationships (Brown, et al., 1987), but often underestimate the potential for problems which can occur even when they appear to be enjoying themselves (Carey 1993, 1995). The second factor, Community Problems, correlates moderately with Socio-Emotional Problems, but is a qualitatively different set of negative consequences, which include acute physiological effects of drunkenness (e.g., vomiting, hangovers, memory loss) along with illegal, antisocial, and potentially dangerous activities (e.g., driving under the influence, problems with the law). Unlike socio-emotional problems, these are consequences that seem to attract more public concern due to associated criminal activities such as vandalism, drunk driving, and involvement with illegal drugs, signaling, perhaps more serious involvement with substances in the long run (Chen& Randel, 1995). Overall mean scores for both the Socio-Emotional and Community subscales were low for those 155 respondents who were rated as both heavy (QFI) and problem (modified MAST) drinkers. Given that all items are rated 0-5, the potential range for the Socio-Emotional subscale is 0-30. As seen in Table 2, those first offenders had a mean score of 4.45. These same respondents also showed a mean score of 6.77 on a possible range of 0-20 on the Community subscale. Since college students are prone to underestimate the potential negative aspects of drinking (O'Hare & Tran, 1996; Wechsler et al., 1994), practitioners who work with them should be alert to potentially serious problems even when respondents indicate only a mild concern about the Socio-Emotional or Community consequences of their own drinking. For practitioners using the CAPS for initial screening purposes, even low self-reported ratings on individual items should be used as an impetus for more extensive clinical assessment. Given the high rates of alcohol abuse in young persons, routine substance abuse screening is necessary in any prevention or clinical setting. Skillful interviewing with reasonable assurances of confidentiality will often result in accurate self-report of substance use (Sobell, Toneatto, & Sobell, 1994) despite, perhaps, an underestimation of the seriousness of potential consequences. The individual items on the CAPS can serve as a starting point for discussion of specific problem areas related to drinking. Indications that a student has a greater problem in the Socio-Emotional or Community domain may serve as a basis for not only extensive differential assessment, but differential treatment planning as well. Psychotherapeutic or coping skills strategies may be emphasized for a student mainly reporting Socio-Emotional distress re-
Measuring Problem Drinking in First Time Offenders
lated to substance abuse. For the young person reporting Community problems, treatment may need to incorporate contingency management strategies as well. Once problems are identified, clinicians should emphasize the development and maintenance of a good working relationship in order to further monitor drinking patterns as well as negotiate treatment goals for reducing the consequences of excessive drinking (Marlatt & Tapert, 1993; Miller & Rollnick, 1991). At that point, the CAPS can be used as a self-monitoring tool to assist students in staying on track with their treatment process. Limitations of the Study Generalizations to other college samples should be made cautiously. This sample of young persons cited for their first campus alcohol offense generally appears to be disproportionately heavy drinkers compared to other college populations (O'Hare, 1990a; Wechsler & McFadden, 1979) in which heavy drinking rates (employing a similar QFI criteria of "five or mo~e" drinks at one sitting) have varied around 20%. Future investigations should employ the CAPS with a more diverse array of youthful populations, and use other measures to evaluate further its concurrent and predictive validity. REFERENCES Babor, T.F., Stephens, R.S., & Marlatt, G.A. (1987). Verbal report methods in clinical research on alcoholism: response bias and its minimization, Journal of Studies on Alcohol, 48, 410--424. Brown, S.A., Goldman, M.S., Inn, A., & Anderson, L.R. (1980). Expectations of reinforcement from alcohol: their domain and relation to drinking patterns. Journal of Consulting and Clinical Psychology 48, 419~26. Brown, S.A., Christiansen, B.A., & Goldman, M.S. (1987). The Alcohol Expectancy Questionnaire: An instrument for the assessment of adolescent and adult alcohol expectancies. Journal of Studies on Alcohol, 48, 483-491. Carey, K.B. (1995) Heavy drinking contexts and indeces of problem drinking among college students. Journal of Studies on Alcohol, 56, 287-292. Carey, K.B. (1993). Situational determinants of heavy drinking among college students. Journal of Counseling Psychology, 40, 217-220. Chen, K., & Kandel, D. (1995). The natural history of drug use from adolescents to the mid-thirties in a general population sample. American Journal of Public Health, 85, 41-47. Engs, R.C. (1977). Drinking patterns and drinking problems of college students. Journal of Studies on Alcohol, 38, 2144-2156. Harford, T., & Grant, B,F. (1987). Psychosocial factors in adolescent drinking contexts. Journal t~f Studies on Alcohol, 48, 551-557. Heck, E.J., & Williams, M.D. (1995). Using the CAGE to screen for drinking-related problems in college students. Journal t~fStudies on Alcohol, 56, 282-286. Johnston, L.D., O'Malley, P.M., & Bachman, J.G. (1995). National survey results on drug use .from the monitoring the future study,
387 1975-1994. Volume II: College students and young adults. Rockville, MD: USDHHS. Kraft, D.P. (1979). Alcohol education programming at the University of Massachusetts, Amherst, and evaluation of results to date. Paper presented at the American Psychological Association Convention, San Francisco, CA. Kristenson, H., & Trell, E. (1982). Indicators of alcohol consumption: Comparisons between a questionnaire (MmMAST), interviews and serum gamma-glutamyl transferase (GGT) in a health survey of middle-aged males. British Journal of Ad_diction, 77, 297-304. Leccese. M., & Waldron, H.B. (1994). Assessing adolescent substance use: a critique of current measurement instruments. Journal of Substance Abuse Treatment, 11,553-563. Marlatt, G.A., & Tapert, S.F. (1993). Harm reduction: Reducing the risks of addictive behaviors. In J.S. Baer, G.A. Marlatt, & R.J. McMahon (Eds.), Addictive behaviors across the litespan (pp. 243273). New York: Sage. Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism screening test. American Journal of Psychiatry, 131, 1121-1123. Miller, W.R., & Rollnick, S. (1991). Dealing with resistance. In W.R. Miller & S. Rollnick (Eds.), Motivational Interviewing: preparing people for changes (pp. 100-112). New York: Gui!tbrd Press. Nystrom, M., Perasalo, J., & Salaspuro, M. (1993). Screening for heavy drinking and alcohol-related problems in young university students: the CAGE, the MmMAST and the Trauma Score Questionnaires. Journal of Studies on Alcohol, 54, 528-533. O'Hare, T, (1990a). Drinking in college: Consumption patterns, problems, sex differences and legal drinking age. Journal ~?fStudies on Alcohol, 51,536-541. O'Hare, T. (1990b). Alcohol expectancies and social anxiety in male and female undergraduates. Addictive Behaviors, 15, 561-566. O'Hare, T. (1991). Measuring alcohol consumption: A comparison of the retrospective diary and the quantity frequency methods in a college drinking survey. Journal of Studies on Alcohol, 52, 500-502. O'Hare, T., & Tran, T.V. (1996) Predicting problem drinking in college students: Gender differences and the CAGE questionnaire. Addictive Behaviors, 22, 13-21. Redman, S.. Sanson-Fisher, R.W., Wilkinson, C., Fahey, P.P., & Gibberd, R.W. (1987). Agreement between two measures of alcohol consumption. Journal of Studies on Alcohol, 48, 104-108. Sher, K. (1987). Stress dampening response. In H. Blane& K. Leonard (Eds.), Psychological theories of drinking and alcoholism, (pp, 227-271) New York: Guilford Press. Sobell, L.C., Toneatto, T., & Sobell, M.B. (1994). Behavioral assessment and treatment planning for alcohol, tobacco and other drug problems: Current status with an emphasis on clinical applications. Behavior Therupy, 25, 533-580. Straus, R., & Bacon, S.D. (1953). Drinking in college. New Haven, CT: Yale University Press. Wechsler, H., & McFadden, M. (1979). Drinking among college students in New England: Extent, social correlates, and consequences of alcohol use, Journal of Studies on Alcohol, 40, 969-996. Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Costillow, S. (1994). Health and behavioral consequences of binge drinking in college. JAMA, 272, 1672-1677. White, H.R., & Lebouvie, E.W. (1989). Towards the assessment of adolescent problem drinking. Journal of Studies on Alcohol, 50, 30-37. Williams, G.D., & Debakey, S.F. (1992). Changes in levels of alcohol consumption: United States, 1983-1988. British Journal of Addictions, 87,643-648.