The Chinese version of the Addiction Severity Index (ASI-C): Reliability, validity, and responsiveness in Chinese patients with alcohol dependence

Alcohol 46 (2012) 777e781

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The Chinese version of the Addiction Severity Index (ASI-C): Reliability, validity, and responsiveness in Chinese patients with alcohol dependence Zhen Sun a, Hanhui Chen b, Zhonghua Su c, Xuhui Zhou d, Sheng Zhang e, Wei Hao a, Ruiling Zhang a, * a

The Second Affiliated Hospital of Xinxiang Medical University, Jianshe Road East, Xinxiang 453000, China The Affiliated Hospital Shanghai Mental Health Center of Shanghai Jiaotong University, Shanghai 200030, China c The Second Affiliated Hospital of Jining Medical College, Jining 272051, China d Hunan Brain Hospital, Changsha 410007, China e Wuhan Mental Health Center, Wuhan 430022, China b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 13 February 2012 Received in revised form 26 August 2012 Accepted 26 August 2012

We evaluated the reliability, validity, and responsiveness of the Chinese version of the 5th edition Addiction Severity Index (ASI-C-5) in Chinese male alcohol-dependent inpatients. Three hundred and fifty-four inpatients with alcohol dependence from five regions of China were interviewed in person by five trained interviewers using the ASI-C-5. Responses were then analyzed for internal consistency reliability, discriminant validity, criterion validity, and responsiveness. Forty subjects were reinterviewed 7 days later to assess testeretest reliability. The ASI-C-5 had good internal consistency, with an overall standardized Cronbach’s alpha of 0.79. The Cronbach’s alpha values for internal consistency of domain CSs ranged from 0.48 to 0.95, and were above 0.60 for six domains. The 7 day testeretest reliability was acceptable as evidenced by high Pearson correlation coefficients (0.75e0.92, p < 0.01) for 6 of 7 domain CSs. Correlation coefficients between the seven domain CSs ranged from 0.007 to 0.390 (p < 0.05 or 0.01 two-sided), indicating strong discriminant validity. The correlation coefficient between the alcohol dependence composite score of ASI-C-5 and the Alcohol Use Disorders Identification Test (AUDIT) was 0.69 (p < 0.01), indicating good criterion validity. The frequency of extreme scores was low, except for significant floor effects in the “Drugs” and “Legal Status” domains. Collectively, these findings suggest that the ASI-C-5 exhibited strong reliability, validity, and responsiveness in Chinese male alcohol-dependent inpatients. Ó 2012 Elsevier Inc. All rights reserved.

Keywords: Addiction severity index Chinese version Reliability and validity Responsiveness Alcohol dependence

Introduction Alcohol dependence (chronic alcoholism) is characterized by the harmful physical, social, family, employment, and legal consequences of alcohol abuse, a pattern of compulsive alcohol consumption, and physiological and psychological dependence on alcohol. The incidence of chronic alcoholism in China had increased from 0.08% in the 1980s to 3.7% in 2003 and is still rising (Hao, Chen, & Su, 2005). There are a variety of treatment approaches for chronic alcoholism, including behavioral modification, support groups, and pharmacological treatments, each with unique goals for the patient. Evaluating the effectiveness of an addiction treatment should consider not only whether a patient stops drinking, but also if treatment improves physical health, mental health, and social behavior. At present, many treatment approaches used in China aim * Corresponding author. Tel.: þ86 373 3373798; fax: þ86 373 3374082. E-mail address: [email protected] (R. Zhang). 0741-8329/$ e see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.alcohol.2012.08.005

for abstinence from alcohol or improve physical symptoms, and ignore the negative effects caused by long-term intake of high doses of alcohol on a patient’s mental health, quality of life, work activities, and social communication. Patients continue to drink after alcohol withdrawal programs for many different reasons, including poor psychiatric status and family/social relations. Therefore, a comprehensive and individually customized treatment program is the ideal. Nonetheless, a comprehensive and standardized instrument for measuring outcome is still required; however, there has not been find this instrument to this day in china. The Addiction Severity Index (ASI) is semi-structured interviews for research on alcohol and substance abuse (McLellan et al., 1992, 1980). Originally developed by Thomas McLellan and his associates at the Center for Studies of Addiction in Philadelphia (McLellan et al., 1992), this multidimensional instrument assesses an individual’s self-reported problems in seven domains: (1) physical health, (2) employment and support, (3) alcohol use, (4) drugs use, (5) legal status, (6) family/social relations, and (7) psychiatric status. Items in each of these seven domains address current (within the past 30 days) and

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life-time status and functioning. The design of the ASI offers a number of advantages. It covers various dimensions of functioning, provides an estimate of problem severity on each of these dimensions, and is a standardized tool for clinical evaluation that has enhanced the quality of therapy and research. Since the 1980s, the ASI had become one of the most commonly used instruments for the assessment of the severity of drug (Gerevich, Bacskai, Ko, & Rozsa, 2005). Also, the application of the ASI to alcohol-dependent individuals has been verified in several countries (Daeppen et al., 1996; DeJong, Willems, Schippers, & Hendriks, 1995; McLellan et al., 1985, 1992 and Scheurich et al., 2000). The instrument has been translated into over 20 languages and adapted for use in many cultural contexts (Gerevich et al., 2005; Hendriks, Kaplan, van Limbeek, & Geerlings, 1989; Krenz et al., 2004; Luo, Wu, & Wei, 2010 and Scheurich et al., 2000). The ASI has nearly achieved both reliability and validity, although some problems still exist (Mäkelä, 2004). The Chinese version (ASI-C) has been applied to patients with a history of drug abuse, and its reliability, validity, and responsiveness confirmed (Liang et al., 2008; Luo et al., 2007a, 2007b and Zhao, Li, & Hao, 2004). However, the ASI-C has not yet been applied to patients with a history of alcohol dependence, so its reliability, validity, and responsiveness for this patient population are unknown.

From December 2010 through May 2011, 354 participants were recruited from one hospital-based withdrawal program in each of five regions of China: Henan (n ¼ 154), Shanghai (n ¼ 50), Hunan (n ¼ 50), Hubei (n ¼ 50), and Shandong (n ¼ 50). All met the following eligibility criteria established by the Northern Ireland Alcohol Case Control Study (NIACCS) and adapted to the Chinese context: (1) 18 years or older, (2) male, (3) all 4 grand-parents Han Chinese, (4) a diagnosis of alcohol dependence by DSM-IV, (5) alcohol dependence not considered secondary to bipolar illness or drug abuse (patients do not drink heavily only to help them withdraw from other drugs or when other drugs are not available), and (6) residence in mandatory withdrawal inpatient program for no more than 30 days. Each subject provided signed informed consent before the study. Two participants were subsequently excluded from the final analysis because of incomplete information.

during the 30 days prior to interview (which refer to behaviors during the 30 days prior to admission in our present study). Severity ratings are primarily used as clinical estimates of problem severity. The majority of studies using the AS1 have used CSs as measures of client change from pre-treatment to post-treatment (McLellan et al., 1992). In addition, CSs offer distinct statistical advantages, such as greater reliability and statistical power for measuring changes in addiction severity (McLellan et al., 1992). This study focused on the evaluation of the ASI-C-5 using CSs as the principle indices. Composite scores were calculated by a weighted formula designed to provide equal contributions from each item, which was essentially the same formula to calculate composition scores in the original English version of the ASI. Scores varied from 0 to 1, with a higher score indicating greater problem severity. A total of 354 male inpatients with a history of alcohol dependence were interviewed by face-to-face. The interview was based on the ASI-C-5 questionnaire and individually administered by two Ph.D. students and three Masters Students who completed a 1-day training program that reviewed the ASI manual through discussions and practice sessions. The severity of each of the seven domains was assessed individually and independently using the SRs and CSs. Among these 354 inpatients, they were informed of the purpose of the study, and we asked whether they would be willing to receive the second retest in 7 days. For those who would be willing to participant in testeretest measurements, forty were randomly selected and the same interviewer used a similar set of questions. No special instructions were given to the participants at the second interview. There were two reasons why the 7-day interval was selected. First, a 1-week interval reduces the influence of subject memory on previous answers while still permitting accurate recall of the events that occurred 30 days prior to admission (with limited subjective change in interpretation of results). Second, a similar time interval was used in other studies examining the testeretest reliability of other ASI versions (Drake, McHugo, & Biesanz, 1995 and Joyner, Wright, & Devine, 1996). The Alcohol Use Disorders Identification Test (AUDIT), a simple ten-question test developed by the World Health Organization to determine if a person’s alcohol consumption may be harmful, was used to estimate the criterion validity of ASI-C-5. Each client answered 10 questions related to frequency of various symptoms. The AUDIT was used as external reference for the alcohol scale of the ASI-C-5, and they were used at the same period of one day as ASI-C-5.

Measurements

Statistical analyses

The ASI-C-5 was translated from the fifth edition of the English version by two translators and revised by editors specializing in addiction research (McLellan et al., 1992). The scale was then translated back into the original language and compared to the English version by native English-speaking editors. Only minimal, necessary changes were made to adapt the items to Chinese linguistic and sociocultural factors such as diction or expression style, criminal categories, and compliance with legal regulations. The ASI provides two summary scores, severity ratings (SRs) and composite scores (CSs). For SRs, the interviewer uses a 10-point scale for each area to rate the patient’s need for further treatment. This assessment relies on the patient’s symptoms at the time of interview and the patient’s own subjective evaluation. The interviewer has to decide how much additional treatment the patient needs in each area. Each composite score is the sum of answers to several questions within a domain of the ASI-C. Composite scores are not rating scales, but mathematically derived scores from 55 items selected as indicators of the severity of specific problems. The items in each domain measure behaviors

The internal consistency of overall ASI and each ASI domain was examined using Cronbach’s alpha value, with a value of 0.6 or higher considered acceptable (Gerevich et al., 2005). The testeretest reliability, discriminant and criterion validity of CSs were examined by calculating the Pearson’s productemoment correlation coefficient. Responsiveness was assessed by ceiling/ floor effects. A p value less than 0.05 was considered to be statistically significant.

Methods Patient sample and data collection

Results Demographic characteristics Three hundred and fifty-four inpatients were recruited for this study from five regions of China but all were Han ethnic males. Two participants were excluded in the final analysis for unreliable answers (i.e., patient inability to understand the questions), for a final sample size of 352. The average age of participants was 43.9 years (SD ¼ 8.9) with an average of 10 years (SD ¼ 3.2) of formal

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education. In total, 71.6% were married, 16.8% divorced, 5.7% single, 2.0% remarried, and 1.4% widowed. The average length of alcohol dependence was 9.8 years (SD ¼ 7.4). Only seven patients (2.1%) had abused other drugs (Table 1). The subjects in the retest group were matched to the whole population for average age (41.5 years), length of formal education (9.7 years), and length of alcohol addiction (8.9 years) (all p > 0.05). Internal consistency of CSs In each problem area, several items were selected as indicators of problem severity and the intercorrelations between these items and the severity ratings were determined (McLellan et al., 1980). In the majority of cases, the scores on items probing the different problem areas showed a substantial degree of correlation with the severity assessments. In most cases, individual items were significantly correlated with the CSs. The standardized Cronbach’s alpha was calculated to estimate the internal consistency of the ASI-C-5 because different scales have attached a different weight to each item (Alterman, Brown, Zaballero, & McKay, 1994). The overall standardized Cronbach’s alpha was of 0.79, which is acceptable according to Nunnally’s recommendation (Nunnally & Bernstein, 1994), indicating that the domains with Cronbach’s alpha of 0.6 or more could be used in the ASI-C-5. Cronbach’s alpha for each domain ranged from 0.48 to 0.95 (Table 2), with the lowest value in the domain of “Employment” and the highest in the domain of “Legal Status”. With the exception of “Employment”, each scale satisfied Nunnally’s recommendation. In addition, eight items of the “Drugs” section, three items of the “Legal status” section (“Awaiting charges, trial last 30 days” “Dealing and other illegal money-making activities last 30 days.” “Illegal income last 30 days”) and one item of the “Family/Social Relations” section (Days had serious conflicts with your family in last 30 days) were deleted because of lack of response, which was only for the calculation of Cronbach’s alpha. However, these items were retained in the calculation of the composite scores.

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Table 2 Internal consistency of ASI-C-5 (n ¼ 352). Domains

Mean CS value

Number of items

Standardized Cronbach’s alpha

Physical health Employment Alcohol Drugs Legal status Family/social relations Psychiatric status

0.377 0.593 0.799 0.002 0.008 0.337 0.382

3 3 6 6 2 12 11

0.83 0.48 0.67 0.93 0.95 0.73 0.75

at two separate times. To examine the ASI-C-5 stability over time, the test was repeated 7 days after the first interview in 40 randomly selected inpatients. Naturally, there may be changes between the two interviews, but a few stable characteristics are to be expected. The testeretest reliability coefficients are presented in Table 3. Pearson’s productemoment correlation for CSs ranged from 0.75 to 0.92, indicating a moderate to high level of stability of ASI-C scores among inpatients with a history of alcohol dependence. However, since few subjects responded to the “drug use” and “legal status” domains (drug use in 4 cases, and legal status in 15 cases), the reliability measures for these two parametric values were not tested. Discriminant validity The designers of the ASI put much emphasis on the independence of the seven problem domains. Thus, considerable attention has been paid to the discriminant validity of the summary measures (domain CSs and SRs). To test whether the different ASI domains reflected distinct problem areas with minimal overlap, the correlations between CSs were evaluated (Table 4). These correlation coefficients were low, with the exception of the psychiatric status and the family/social relations domains (r ¼ 0.39, p < 0.01 twosided). Criterion validity of the CSs

Testeretest reliability Testeretest reliability measures the extent to which questions in an instrument yielded consistent responses from the same subject

Table 1 Characteristics of study subjects (n ¼ 352). Variables

Mean (SD) or n (%)

Age (mean SD yrs) Marital status (n, %) Married Remarried Single Divorced Widowed Other Years of education (mean SD yrs) Occupation (n, %) Farmer Worker Private business owner Official staff Retiree Unemployed Driver Other Length of alcohol addiction (mean SD yrs) Drug addiction (n, %) Yes No

43.9  8.9 252 (71.6) 7 (2.0) 20 (5.7) 59 (16.8) 5 (1.4) 9 (2.6) 10.0  3.2 60 (17.0) 107 (30.1) 50 (14.2) 64 (18.2) 19 (5.4) 35 (9.9) 13 (3.7) 5 (1.4) 9.8  7.4 7 (2.1) 45 (97.9)

Criterion validity refers to the extent to which a measurement correlates with an external measure of the phenomenon under study. The greater the extent of correlation, the better the criterion validity of the scale, with correlation coefficients from 0.4 to 0.8 thought to be acceptable. Indeed, the correlation between the alcohol use status as measured by the ASI-C-5 and AUDIT was 0.69 (p < 0.01), indicating significant criterion validity of ASI-C-5 in the alcohol use domain. Responsiveness Responsiveness is a critical characteristic for assessing the result of clinical intervention; it is defined as the ability to detect clinically relevant changes in patient condition (Beaton, 2000). The capacity of any metric to reflect changes can be assessed in terms of the Table 3 Testeretest reliability of CSs of ASI-C-5 (n ¼ 40). Domains

First mean

Second mean

Pearson

Physical health Employment Alcohol Legal status Family/social relations Psychiatric status

0.44 0.70 0.77 0.02 0.39 0.44

0.40 0.70 0.83 0.02 0.32 0.45

0.86* 0.86* 0.84* 0.92* 0.75* 0.89*

Note: *p < 0.01.

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Table 4 Inter-correlation between CSs of ASI-C-5 (n ¼ 352). Domains

Physical health

Employment

Alcohol

Drug

Legal status

Family/social relations

Psychiatric status

Physical health Employment Alcohol Drugs Legal status Family/social relations Psychiatric status

1 0.013 0.279** 0.041 0.007 0.016 0.274**

1 0.045 0.036 0.028 0.169** 0.038

1 0.047 0.011 0.158** 0.329**

1 0.016 0.055 0.082

1 0.153** 0.127*

1 0.390**

1

Note: *p < 0.05 (two-sided), **p < 0.01 (two-sided).

proportion of respondents at the floor (very low scores: If scale content is deviating from the normal, measured results are tend to be very low scores, so the scale can’t distinguish differences.) or the ceiling (very high scores: If scale content is comparative generalization, measured results are tend to be very high scores, so the scale also can’t distinguish differences.) in each domain. A large proportion of respondents at either extreme will clearly limit the capacity of the test to register deterioration or improvement (Walters, Munro, & Brazier, 2001). Thus, responsiveness was calculated by determining ceiling/floor effects. To some degree, the smaller the proportions of worst score and best score, the stronger the response sensitivity of the scale (Wei et al., 2006). The proportions of worst score (0) and best score (1) for the seven domains of the ASI-C-5 (Table 5) were low, except the worst scores on the domains “Drugs” and “Legal Status”. Discussion The ASI is a comprehensive and effective scale for analyzing the total complex of problems found in the substance-abusing patient, and ideally is also able to differentiate patients on the basis of their individual treatment needs to facilitate more specific forms of intervention (McLellan et al., 1980). Our findings were generally consistent with many other studies examining different versions of the ASI (Hodgins & el-Guebaly, 1992; Krenz et al., 2004; and McLellan et al., 1992). Reliability The ASI-C-5 had good internal consistency, with an overall standardized Cronbach’s alpha of 0.79. For four domains of the ASIC-5 (physical health, alcohol use, family/social relations, psychiatric status) also had acceptable Cronbach’s alphas. In contrast, the “employment and support” domain had a very weak internal consistency, possibly due to the modification to the original items or poor linguistic or cultural adaptation. First of all, in the original ASI questionnaire, two of the key items in the domain of “employment and support” involved driving a car were modified into one item (Are your job opportunities limited because of the lack of transport?) in the ASI-C-5, and Cronbach’s alpha diminishes directly with the less number of items in the scale. In addition, transport does not have the same significance for employment in Table 5 Responsiveness of ASI-C-5 (n ¼ 352). Domains

The floor effect (%)

The ceiling effect (%)

Physical health Employment Alcohol Drugs Legal status Family/social relations Psychiatric status

36.9 0.6 0.0 98.9 95.7 28.7 12.5

2.6 29.0 0.3 0.0 0.0 0.0 0.0

China as in the United States. The reliability measures for the “drug use” and “legal status” CS’s were quite low, since there was very little reporting of drug use or crime indicators. It is not possible to get high scores on these coefficients with very low reporting. Thus, these two domains require further modification and validation. In addition, we are confident that the respondents felt comfortable in fully reporting illegal activities, and the low numbers did not reflect apprehension on the part of the respondents. The possible reasons that so few individuals reported drugs or crime are still unclear, but may be connected with Chinese alcohol drinking culture and legal system, which deserves further investigation. The testeretest reliability of the ASI-C-5 was similar to other versions (Mäkelä, 2004). The CS coefficients were higher than reported in some previous studies, however, greater agreement among the CSs would be expected because these scores are based on mathematical formulas and did not take into account the interviewer’s subjective interpretation. Overall, the testeretest reliability of the ASI-C-5 was acceptable. Good testeretest reliability was also reported for the original ASI in a study of alcoholdependent patients in French-speaking Switzerland, with 10-day testeretest reliability of the composite scores between 0.71 and 0.95 (Daeppen et al., 1996). Validity Criterion validity of the ASI-C-5 was supported by the significant correlation of the alcohol domain with the AUDIT score, in accord with similar studies on other versions (Liang et al., 2008 and Scheurich et al., 2000). A test exhibits good discriminant validity if it is highly correlated with a conceptually related standard measure and at the same time is poorly correlated with conceptually unrelated standard measures. Correlations between domains of the ASI were generally low, except for the “family/social relations” and the “psychiatric status” domains, which exhibited moderate correlation. Again, this finding is consistent with many other studies (Appleby, Dyson, Altman, & Luchins, 1997; Bilal, 1988; Hendriks et al., 1989; and Zanis, McLellan, Cnaan, & Randall, 1994). The moderately high correlation between these two domains may reflect self-selection, since the study sample consisted only of treatment-seeking addicts. Whether any two variables, for example the “family/social relations” and the “psychiatric status”, are positively related obviously depends on living circumstances. Totally speaking, our results indicate strong discriminant validity of ASI-C-5, with high internal consistency of CSs. Responsiveness Responsiveness is an important factor when selecting measures in rehabilitation, and the ASI-C-5 has good responsiveness in Chinese male alcohol-dependent inpatients. The exceptions were the domains “drugs use” and “legal status”, where the floor effects were significant, possibly because heavy alcohol use secondary to

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drug addiction was an excluding factor for enrollment and alcohol addicts experience fewer legal problems than drug addicts. Furthermore, some patients may misrepresent criminal problems. Nonetheless, the responsiveness of ASI-C has already been confirmed in methadone maintenance treatment clinics (Luo et al., 2007b). However, it is worthy of mentioning that responsiveness of items seems very closely linked to the population sampled. For examine, in contrast to many samples of individuals with alcohol dependence in the U.S., most of the individuals in our present study this sample had no drug problems. Thus, if an individual had no drug problems, a score of zero on the composite is just reality. In general, this criterion seemed much less important than the other data on reliability and validity. This was a pilot study evaluating the reliability, validity, and responsiveness of ASI-C-5 in patients with alcohol dependence and aimed to lay the foundation for further refinement of this assessment tool for use in China. One limitation of this study involves the “drugs use” and “legal status” domains. Nearly 98% of the interviewees had no previous drug dependence problems and 96% of the interviewees had not experienced legal problems within the last 30 days before admission, so the floor effect was significant. Another limitation is that a number of clients may have difficulties in recalling the relevant information due to alcohol-dependent amnesia or cognitive decline. An additional limitation is that the evaluation of criterion validity was limited to the alcohol dependence composite scores. Whether there is also significant criterion validity of ASI-C-5 in other drug use deserves further investigation. These limitations may have an impact on the evaluation of the reliability, validity, and responsiveness of the ASI-C-5. In addition, the sample size was relatively small, and there was no construct validity evaluation. Given these limitations, we still found that the ASI-C-5 has acceptable reliability, validity, and responsiveness. The scale was demonstrated to be a reliable and valid instrument for Chinese male alcohol-dependent inpatients and can be used for many clinical and research studies on alcoholism, such as studies assessing the relationship between addiction severity and problems revealed by the seven domain scores and studies comparing the effectiveness of different treatments. Acknowledgments This study was supported by National Key Basic Research and Development Program (NKBRDP) of China (2009CB522000), State Key Program of National Natural Science of China (81130020), National Nature Science Foundation (30971050), and Fund for Talents with Innovation in Medical Science and Technology of Henan Province (3052), Foundation of Henan Science Technology Committee (094200510005). References Alterman, A. I., Brown, L. S., Zaballero, A., & McKay, J. R. (1994). Interviewer severity ratings and composite scores of the ASI: a further look. Drug and Alcohol Dependence, 34, 201e209. Appleby, L., Dyson, V., Altman, E., & Luchins, D. J. (1997). Assessing substance use in multiproblem patients: reliability and validity of the Addiction Severity Index in

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