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Substance Abuse

ISSN: 0889-7077 (Print) 1547-0164 (Online) Journal homepage: http://www.tandfonline.com/loi/wsub20

Psychometric Characteristics of the Teen AddictionSeverity Index-Two (T-ASI-2)

Benjamin B. Brodey MD , Darcy McMullin PhD , Yifrah Kaminer MD, MBA ,Ken C. Winters PhD , Edward Mosshart MA , Craig S. Rosen PhD & Inger S.Brodey PhD

To cite this article: Benjamin B. Brodey MD , Darcy McMullin PhD , Yifrah Kaminer MD, MBA ,Ken C. Winters PhD , Edward Mosshart MA , Craig S. Rosen PhD & Inger S. Brodey PhD (2008)Psychometric Characteristics of the Teen Addiction Severity Index-Two (T-ASI-2), SubstanceAbuse, 29:2, 19-32, DOI: 10.1080/08897070802092942

To link to this article: http://dx.doi.org/10.1080/08897070802092942

Published online: 17 Oct 2008.

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Psychometric Characteristicsof the Teen Addiction Severity Index-Two (T-ASI-2)

Benjamin B. Brodey, MDDarcy McMullin, PhD

Yifrah Kaminer, MD, MBAKen C. Winters, PhD

Edward Mosshart, MACraig S. Rosen, PhDInger S. Brodey, PhD

ABSTRACT. The Teen Addiction Severity Index-Two (T-ASI-2) was developed as an extensionof the T-ASI to assess the severity of substance abuse and related problems among adolescents(N = 371) 12-19 years of age. The T-ASI-2 consists of 18 domains that assess current use of alco-hol, tobacco, marijuana, and other drugs, as well as mental health service utilization, treatment sat-isfaction, school difficulties, social functioning with family members and peers, substance use byfamily members and peers, depression, anxiety, attention deficit, hyperactivity, defiant and riskybehaviors, and readiness for change. Results show that all domains have adequate to excellent in-ternal consistency (.54 to .88, median .80). New domains assessing psychological factors stronglycorrelated with gold standard assessments in the respective areas. The T-ASI-2 was designed tobe a user friendly, cost-effective, viable assessment of substance use behavior and related factors.

KEYWORDS. Teen addiction, substance abuse, T-ASI-2

Lifetimeprevalenceof adolescent substanceuse has gradually declined since 1999; how-ever, a considerable number of adolescents stillreport having tried both licit and illicit drugs

(1). Results from the 2006 Monitoring the Fu-ture study reveal that 41% of 8th graders reporthaving ever tried alcohol and 21% report hav-ing ever tried an illicit drug. Older adolescents

Benjamin B. Brodey and Darcy McMullin are affiliated with TeleSage, Inc., P.O. Box 750, Chapel Hill, NC27514.

Yifrah Kaminer is affiliated with the Alcohol Research Center, the University of Connecticut Health Center,Farmington, CT 06030-2103.

Ken C. Winters is affiliated with the University of Minnesota, Department of Psychiatry.Edward Mosshart is affiliated with Sundown M. Ranch.Craig S. Rosen is affiliated with the Stanford University, Department of Psychiatry and Behavioral Sciences.Inger S. Brodey is affiliated with the University of North Carolina at Chapel Hill, Department of English and

Comparative Literature.Address correspondence to: Benjamin B. Brodey, MD, at the above address (E-mail: bb@telesage.com).The authors would like to thank Sundown M. Ranch and DayBreak for their participation.This research was funded by a NIH grant # 5R44 DA015566-03.

Substance Abuse, Vol. 29(2) 2008Available online at http://suba.haworthpress.com

© 2008 by The Haworth Press. All rights reserved.doi:10.1 19080/08897070802092942

doi:10.1080/08897070802092942 [Article copies available for a fee from The Haworth Docu-ment Delivery Service: 1-800-HAWORTH. E-mailaddress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2008 by The Haworth Press. All rights reserved.]

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report significantly higher rates of lifetime use;73%of12thgradershave triedalcoholand48%have tried an illicit drug. Out of all the illicitdrugs, marijuana is the one most prevalentlyused by adolescents, and it is also perceived asthe most readily available (1).

Once drug use begins to have noticeablynegative effects on adolescents, they may endup referred into treatment by parents, schoolworkers, or the medical, mental health or juve-nile justice systems. Admission rates to adoles-cent treatment programs have been on the rise:from 1994 to 2004, there was a 43% increase inadmissions to state-regulated programs, mostlybecause of an increase in the number of adoles-cents seeking treatment for marijuana abuseand an increase in the number of adolescentsbeingreferred to treatment throughthecriminaljustice system (2). However, even after com-pleting treatment, many of these adolescentsstill struggle with substance use. A review ofthe literatureshows thatonaverageonly38%ofadolescents remain abstinent 6 months post-treatment, and 32% are abstinent at 12 months(3). Therefore, it is necessary to incorporateinto a treatment plan the ability to track clients’progress after treatment so that another inter-vention can occur if the client returns to a detri-mental pattern of substance use. In order to ac-complish this, a reliable and valid measure thattracks changes in adolescents’ substance useover time is needed.

SUBSTANCE USE ASSESSMENTS

A recent review of issues relating to the as-sessment of adolescent substance abuse stressesthe importance of meaningful assessment of awide rangeof variables (4). Toaid in theassess-ment of these variables, self-reports can be abeneficial tool. Self-report of substance useamong adolescents is generally valid and de-tects more use than laboratory tests, (5) and pa-rental/collateral reports (6,7), the latter ofwhich are low to moderately accurate com-pared to self-report or drug urinalysis. The In-stituteofMedicinerecommends theuseofbriefscreening instruments as an essential first stepfor assessing drug use; measures for the assess-ment of severity should follow once a positivescreen is elicited.

One such comprehensive instrument is theAddiction-Severity Index (ASI; 8), which isconsidered the gold standard instrument forassessing multiple domains of functioningamong substance-using adults (9). The ASI is asemi-structured interview that takes an averageof 50 minutes to complete when administeredby a trainedclinician (10). In addition to assess-ing drug and alcohol use, the ASI includes do-mains that assess medical status, employmentstatus, legal status, family history, family andsocial relationships, and psychiatric status.

The ASI was developed and validated amongadults; however, due to the developmental pro-cesses during adolescence and the psycho-social role of substance use in their lives, ado-lescent drug users have different drug-usepatterns (e.g., binge drinking, polysubstanceuse), trajectories (i.e., they still have notreached the peak of drug abuse) and relatedproblems (e.g., school, family, peer-social) ascompared toadults (11). As a resultof thesedif-ferences, in the late 1980s, Kaminer and col-leagues modified the ASI into the Teen-Addic-tionSeverity Index (T-ASI) to assess substanceuse among teens (12). Like its adult counter-part, the T-ASI is a semi-structured interview.The language of the T-ASI was simplified sothat adolescents with a 5th grade reading levelcould understand and respond to the questions.Basedon theclinicalconsensusofKaminerandcolleagues,certaindomainsof theASIwerenotincluded in the T-ASI while other domainsdeemed more relevant to adolescents wereadded to the T-ASI. For example, the medicaldomain from the ASI was dropped because ad-olescents tend to have fewer health problemsthanadults, and twoadditionaldomains, schoolstatus and social-peer relationships, wereadded to the T-ASI, resulting in a total of sevendomains (12,13).

As they previously done with the ASI (14),Brodey and colleagues revised the wording ofthe T-ASI to make it suitable for a self-reportversion (T-ASI-SR) via the Internet or auto-mated telephone (15), allowing for comparableassessments, but with less use of the clinician’stime than the previous semi-structured inter-view format. While developing and validatingthe T-ASI-SR, psychometric concerns aroseabout the instrument. For example, internalconsistency of all the domains was less than .70

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for the clinician-administered version, and lessthan .70 on four of the six domains in for theself-report versions (internet and telephone ad-ministered). Three domains, peer, school, andlegal status, had reliabilities at or less than .50across all three types of administration. More-over, the psychological composite did notadequately assess some mental health concernsrelevant to teens, such as delinquent behaviorand attention deficit disorder.

As both the ASI and T-ASI are widely usedin substance abuse settings for assessment pur-poses, these instruments are very useful in de-veloping treatment plans and protocols. TheASI and ASI-SR have exhibited adequatepsychometric properties, but the T-ASI-SR hasnot been as sound. Consequently, the currentstudy revised the T-ASI-SR to achieve betterpsychometric characteristics and broader cov-erage of psychological functioning.

METHOD

Participants

Three hundred seventy-one adolescents be-tween the ages of 12 and 19 were recruited fromfour substance abuse clinics (three outpatientand one inpatient) in the northwest U.S. Fifty-seven percent of participants were male, 88.4%were non-Hispanic, 76.5% were White, and81.7% were inpatients. The average age of par-ticipants was 15.96 (SD = 1.21) years.

Materials

Participants completed a battery of assess-ments, including the revised self-report versionof the T-ASI (T-ASI-2). The T-ASI-2 reflectsmany changes to the T-ASI-SR. The revisionconsists of 18 domains as compared to the 7 do-mains of the T-ASI-SR. Several existing do-mains were divided into multiple ones in orderto improve construct validity and internal con-sistency. For example, on the TASI-SR therewas one family domain and one peer domain.The revised version now contains two domainsfor both family and peers, one assessing rela-tionships and the other assessing substance useof the referenced group. The psychiatric statusdomain was also divided into multiple domains

reflecting psychological problems commonlyexperienced by teens. Additionally, new do-mains exist for depression, anxiety, attentiondeficit, hyperactivity, defiant behavior, andrisky behavior. The TASI-SR-R consists ofquestions that assess both lifetime substanceuse and current use; however, the current studyfocuses only on questions concerning currentuse because they are most sensitive to change,and therefore most applicable to trackingprogress over time.

Participants also completed three gold stan-dard assessments, the Beck Anxiety Inventory(BAI; 16), the Conners-Wells’ Adolescent Self-Report Scales (CASS; 17), and the ReynoldsAdolescent Depression Scale 2nd edition(RADS; 18). These were included to assess thevalidity of some of the new domains (anxiety;defiant behavior, attention deficit, hyperactiv-ity; and depression, respectively) that had notbeen included in the original T-ASI. The BAI isa reliable instrument that discriminates anxietyfrom depression (the correlation between theBAI and Beck Depression Inventory is .48).The CASS has four subscales; conduct prob-lems, inattention, hyperactivity, and an ADHDindex. Internal consistency reliabilities rangefrom .75 to .85 and 6 to 8 week test-retestreliabilities range from .72-.87. Divergent va-lidityof theCASS subscaleshasbeenshown bythefact thatadolescentsdiagnosedwithADHDscore higher than adolescents with emotionalproblems on all of the subscales. The RADS as-sesses dysphoric mood, anhedonia, negativeself-evaluation, and somatic complaints, andexhibits excellent reliability (r = .94 among aclinical sample).

Procedure

All incoming clients completed the T-ASI-2as part of standard intake practice. Clients wereasked if they wanted to participate in a studythat would assess their progress at four addi-tional time points in the year following treat-ment. Those who consented (approximately90%) were paid $15 after completing theT-ASI-2 at intake (the follow-up component ofthe study will be reported elsewhere). Partici-pants completed the survey on a touchscreencomputer, and data were sent via secured

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Internet connections to TeleSage where theywere stored and analyzed.

RESULTS

Over half of the sample reported using to-bacco(76.5%),marijuana(65.2%),andalcohol(63.4%) at least once in the past 30 days. Otherdrugs that were assessed received moderate en-dorsement of use in the past 30 days; opiates(28%),cocaine(25.3%),over thecountermedi-cations (21.6%), methamphetamines (19.4%),amphetamines (15.1%), MDMA (14.6%), andhallucinogens (11.9%). Less than 10% of thesample reported using the remaining drugs atleast once in the past 30 days; sedatives (9.7%),inhalants (9.2%), Ritalin (5.9%), GHB (1.3%),ketamine (0.8%), and rohypnol (0%).

Responses to all questions used in the calcu-lation of composite scores were transformedinto z scores. This was done for two reasons:(1) some questions that assess the same domainhave different response options and transform-ing them to a common metric allows for com-posites tobemade,and(2)manyquestionshavehighly skewed distributions (e.g., number ofdays in the past 30 that you used opiates). Next,exploratory principal-axis factor analyses withvarimax rotation were conducted on all Likert-type domains to construct validity. Single fac-tor solutions were appropriate for all domains.Items that loaded above .40 were combined anddividedby the totalnumberofquestions for thatdomain to calculate the composite score. Inter-nal consistency reliability was then calculatedfor each domain using Cronbach’s alpha. Fordomains that lost itemsduetothefactoranalysisresults, Cronbach’s alphas are reported for bothpre- and post-reduction composites.

Table 1 shows the number of items on theT-ASI-2 that assess current endorsement of thedomains. Also included in the table are theitems that were used to calculate the compositefor each domain. A difference in these twonumbers resulted for several reasons. First,some of the items included on the survey arescreening items (e.g., “Have you used alcoholin the past 30 days?”), and thus are not includedin composite; other items were excluded fromthe composite based on the results of the factor

analyses. For instance, one of the seven itemsassessing family functioning loaded at .02, andthus was excluded from the final analyses.Inter-item correlations were examined for col-linearity among items remaining within a do-main. Correlations greater than .90 can distortresults models due to the redundancy of itemcontent; therefore, this value was used as acut-off. Results show that within a domain, notwo items correlated higher than .75; therefore,no items were deleted based on this analysis.All items included in the analyses are presentedin the Appendix.

Internal consistency reliability for each ofthe domains as well as for the gold standard in-struments included in the study are also re-ported in Table 1. Reliabilities are high (α >.70), for all of the T-ASI-2 domains, except thetobacco use and risk behavior domains. Relia-bilities for the created domains of defiant be-havior, attention deficit, and hyperactivitywere comparable to those of the CASSsubdomains. Additionally, reliabilities of theBAI and our anxiety domain are similar (.95and .88, respectively), but ours achieves this re-liability more efficiently with 57% (12) feweritems. Similarly, although the RADS has ahigher reliability than our depression domain(.94 versus .85), both are high, and our domainhas 75% (23) fewer items than the RADS.

Table 2 shows the correlations among all ofthe T-ASI-2 domains, several of which are par-ticularly noteworthy. First, all of the substanceuse domains–tobacco, alcohol, marijuana, andother drugs–were significantly correlated withone another and with peer substance use. Sec-ond, all of the psychological variables–depres-sion, anxiety, attention deficit, hyperactivity,risky behavior, and defiant behavior–were allsignificantly correlated with each other (withthe exception of the correlation between riskybehavior and depression). Moreover, all sub-stance use domains were significantly corre-lated with school difficulties, defiant behavior,and peer substance use. Alcohol, marijuana,andotherdruguseweresignificantlycorrelatedwith attention deficit. Other drug use signifi-cantly correlated with all psychological domains(e.g.,depression,anxiety)unlike tobacco,alco-hol, and marijuana use.

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Convergent validity of particular domainswas also examined by correlating them withgold standard instruments. Table 3 shows thecorrelations between the depression, anxiety,defiant behavior, attention deficit, and hyper-activitydomainsof theT-ASI-2and theRADS,BAI, and subscales of the CASS. All domainsstrongly correlated with the gold standard mea-sures of the respective domains (e.g., our de-pressiondomainand theRADScorrelatedatr=

.85, our anxiety domain and the BAI correlatedat r = .75, and our attention deficit measure cor-related with the inattention subscale of theCASS at r = .67) indicating convergent validityof the domains. Furthermore, although all do-mains significantly correlated with all goldstandard instruments, the strongest correlationwas between the domain and the respective in-strument or subscale (e.g., hyperactivity corre-lated strongest with the hyperactivity subscales

Brodey et al. 23

TABLE 1. Reliabilties of the Domains of the T-ASI-2

aReliability for Other Drug Use was calculated with all drugs reported by at least 10% of participants.bNumbers in parentheses are Cronbach’s alpha for the domain prior to item deletion.D

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of the CASS). The exception is the anxiety do-main, which correlated strongly with both theBAI and the RADS. However, it must be notedthat depression and anxiety are often highlycorrelatedwithoneanother; infact, in thisstudythe BAI and RADS correlated at .70.

DISCUSSION

The current study’s aim was to develop a re-liable extension of the T-ASI-SR to assess sub-stance use among adolescents, and several sig-nificant results were obtained. First, all of the

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TABLE 2. Inter-Correlations of the T-ASI-2 Domains

aT – TobaccobA – AlcoholcM – MarijuanadOD – Other DrugseSU – Service UtilizationfTS – Treatment SatisfactiongS – SchoolhFF – Family FunctioningiFSU – Family Substance UsejPF – Peer FunctioningkPSU – Peer Substance UselD – DepressionmA – AnxietynAD – Attention DeficitoH – HyperactivitypDB – Defiant BehaviorqRB – Risky BehaviorrRC – Readiness for ChangesBold indicates p < .001tItalics indicates p < .01

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domains of the T-ASI-2 showed adequate togood internal consistency, except risky behav-ior. However, this domain is understandablylow because it assesses a comprehensive, verydiverse range of risky behaviors that are not ex-pected to appear in the same individual. For ex-ample, some of these behaviors (e.g., weap-ons-carrying and participating in street racing)show a gender-bias, whereas others (e.g., hav-ing sexual intercourse without a condom) donot. Second, the new domains created for theT-ASI-2 correlated highly with included goldstandard measures of anxiety, depression, defi-ant behavior, attention deficit, and hyperactiv-ity. The inclusion of these domains in an instru-ment of substance use assessment is desirableconsidering the high proportion of adoles-cents with substance use disorders and comor-bid psychiatric disorders (19). By administer-ing the T-ASI-2 to adolescents as they enter asubstance abuse treatment center, domains canbe identified that may need immediate treat-ment or re-assessment after a period of absti-nence. Finally, school difficulties, peer sub-

stance use, and defiant behavior were corre-lated with all substance use behaviors.

The T-ASI-2 adds an additional 11 domainsto the previous version, allowing for more spe-cificassessmentofsubstanceusebehaviorsandrelated domains. Although the added length tothe instrument may seem disadvantageous, inthe current study, the T-ASI-2 was adminis-tered via computer which allowed screeningquestions to branch participants out of morespecific follow-up questions if they did not ap-ply, thereby tailoring the length of the instru-ment to the particular participant.

The results of this study provide preliminarysupport for the T-ASI-2 as a reliable and validassessment tool for substance use and relatedbehaviors. Future analyses need to be con-ducted to examine test-retest reliability of thedomains, as well as more rigorous validationcomparsions with published instruments. TheT-ASI-2 offers many advantages over previousversions of the T-ASI in that self-administra-tion via the Internet or telephone is low-cost,fairly quick, and allows the adolescent to com-plete the survey from virtually anywhere, as

Brodey et al. 25

TABLE 3. Correlations Between T-ASI-2 Domains and Gold Standard Instrumentsa

aAll correlations significant at p < .001bD – DepressioncA – AnxietydAD – Attention DeficiteH – HyperactivityfDB – Defiant BehaviorgRADS – Reynolds Adolescent Depression ScalehBAI – Beck Anxiety InventoryiCON – Conduct Subscale of CASSjATT – Inattention Subscale of CASSkH_C – Hyperactivity Subscale of CASSlADHD – ADHA Index Subscale of CASS

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compared to paper administration. Thus, theT-ASI-2canbeused toassessadolescents’ sub-stance use and psychological progress aftertheyhave left treatment.Future researchshouldexamine the ability of T-ASI-2 domains to pre-dict substanceuse. Ifpredictiveability is found,these domains may be helpful in predicting andpreventing relapse over the long-term.

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15. Brodey BB, Rosen CS, Winters KC, Brodey IS,Sheetz BG, Steinfeld RR, Kaminer Y: Validation of theTeen-Addiction Severity Index (T-ASI) for Internet &automated telephone self-report administration. PsycholAddict Behav 2005; 19:54-61.

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APPENDIX

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28 SUBSTANCE ABUSE

APPENDIX (continued)

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30 SUBSTANCE ABUSE

APPENDIX (continued)

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32 SUBSTANCE ABUSE

APPENDIX (continued)

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