Adolescent Alcohol Involvement Research Articles

Differential genetic associations between dimensions of eating disorders and alcohol involvement in late adolescent twins.

Twin studies have demonstrated shared genetic and environmental effects between eating disorders and alcohol involvement in adults and middle adolescents. However, fewer studies have focused on late adolescents or investigated a wide range of eating disorder dimensions and alcohol involvement subscales in both sexes. We examined genetic and environmental correlations among three eating disorder dimensions and two alcohol involvement subscale scores in late adolescent twins using bivariate twin models. Participants were 3568 female and 2526 male same-sex twins aged 18 years old from the Child and Adolescent Twin Study in Sweden. The Eating Disorder Inventory-2 (EDI) assessed the drive for thinness, bulimia, and body dissatisfaction. Alcohol involvement was assessed with the Alcohol Use Disorder Identification Test consumption (AUDIT-C) and problem (AUDIT-P) subscales. Only phenotypic and twin correlations in female twins met our threshold for twin modeling. The proportion of total variance for each trait accounted for by additive genetic factors ranged from 0.50 to 0.64 in female twins, with the rest explained by nonshared environmental factors and measurement error. Shared environmental factors played a minimal role in the variance of each trait. The strongest genetic correlation (ra ) emerged between EDI bulimia and AUDIT-P (ra = 0.46, 95% confidence interval: 0.37, 0.55), indicating that the proportion of genetic variance of one trait that was shared with the other trait was 0.21. Nonshared environmental correlations between eating disorder dimensions and alcohol involvement ranged from 0.03 to 0.13. We observed distinct patterns of genetic and environmental effects for co-occurring eating disorder dimensions and alcohol involvement in female vs. male twins, supporting sex-specific treatment strategies for late adolescents with comorbid eating disorders and alcohol use disorder. Our findings emphasize the importance of assessing family history of multiple eating disorder dimensions while treating late adolescents with problematic alcohol use, and vice versa, to improve detection and treatment.

The relationship of lifetime substance-use disorder with family functioning, childhood victimisation, and depression, among juvenile offenders in Malaysia

IntroductionAdolescent substance use is a multifactorial social issue that leads to detrimental outcomes. The aim of this study is to understand the association of a lifetime history of substance abuse or dependence with family functioning, childhood victimisation, and depression, among adolescent male inmates in a juvenile detention centre in Malaysia. MethodsThis study was cross-sectional involving 230 inmates and was conducted in a juvenile detention centre in Malaysia. The mean age of the participants was 16.65 years, with the highest percentage from the Malay ethnicity (87.8% where n = 202). The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), Adolescent Alcohol and Drug Involvement Scale (AADIS), Family Adaptability and Cohesion Evaluation Scale (FACES) IV and Juvenile Victimization Questionnaire Second Revision (JVQ-R2) were used as instruments. ResultsThe prevalence of a lifetime history of substance abuse and substance dependence is 72.6% and 58.3%, respectively. A lifetime history of substance abuse and dependence had a significant association with age, race, religion, and peer/sibling victimisation. Further analysis reveals that an increase in age can be a predictor of both lifetime history of substance abuse and dependence while peer/sibling victimisation may predict lifetime history of substance abuse. There was no significant association of lifetime substance-use disorder with family functioning and depression in the juvenile offenders. ConclusionsAdolescents exposed to peer/sibling victimisation might be at a higher risk of developing a substance-use disorder. At-risk groups need to be identified, assessed, and have intervention early to prevent adverse outcomes.

Limited Evidence of Associations Between Executive Functioning and Alcohol Involvement In UK Adolescents.

AimsDeficits in motor inhibitory control and working memory have been hypothesized to be both a cause and consequence of heavy alcohol use. Adolescence is a critical developmental stage for inhibitory control and working memory, and it is also a stage when individuals are most likely to initiate alcohol use. This study aimed to examine whether inhibitory control and working memory would predict alcohol use and involvement in a group of UK adolescents.MethodsWe recruited 220 (N = 178, female) adolescents, aged between 16 and 18, from eight higher education settings in the Merseyside region of the UK. Alcohol use was examined using the Timeline Follow-Back and involvement (and related problems) using the Adolescent Alcohol Involvement Scale. A reward-based inhibitory control task (Go/No-Go) was used to examine the inhibition and reward sensitivity, and a self-ordered pointing task was used to measure working memory.ResultsMultiple regression demonstrated that neither inhibitory control (b = 0.02 (95% confidence interval (CI): −0.21, 0.24)) nor working memory (b = −0.12 (95% CI: −0.30, 0.07)) were significant predictors of alcohol use (units consumed). Inhibitory control (b = 0.61 (95% CI: 0.12, 1.09), specifically, in the no reward condition and school deprivation (b = 0.67 (95% CI: 0.06, 1.28) significantly predicted alcohol-related problems.ConclusionsOur findings demonstrated limited evidence that deficits in specific mechanisms of executive functioning (i.e. motor inhibition and working memory) were associated with alcohol-related problems in UK adolescents. This study adds to an increasing body of literature suggesting weak or non-existent links between inhibitory control, working memory and alcohol use.

A study of Substance Abuse and Quality of Life among Street Children in District Etawah

Background: The research series on street children are carried out in major cities by neglecting the rapidly developing small cities experiencing widespread urbanization. Unfortunately, there is lack of research-based evidences in field of mental health status and quality of life of street children. Aim & Objective: The study aimed to study the pattern of substance abuse & their correlates among street children and to assess the ‘quality of life’ among street children. Material & Methods: A sample of 145 street children of 13-18 years were enrolled by purposive sampling from January 2017 - June 2018 in Market places, Railway station, Bus depot etc. Subjects were searched at known hotspots in Etawah, and further sample was covered using snowball sampling. Information was gathered using predesigned and pre-structured questionnaire, along with WHOQOLBREF and Adolescent Alcohol and Drug Involvement Scale questionnaire. Results: Average Quality of life was tested using t test and ANOVA. Most of the street children 55% were aged between 13-15 years, 65 % had attended school for at least one year. Quality of life showed higher Physical health. Street living children had less psychological health score (30.3±7.1). Prevalence of drug abuse was 54%, while tobacco, alcohol, marijuana, inhalants, were the drugs consumed. Conclusion: Psychological health was more affected. Tobacco & alcohol were the common drugs consumed.

Prevalence and factors influencing behavioral problems among adolescents in selected high schools of Bhubaneswar: A survey in Odisha

Background: Adolescent health and well-being are important for the health of future generation. Adolescence is a period of complex amalgamation of emotional, physical and social development leading to functional independence of the individual. It is also a period when behavioral problems could adversely impact the mental health. Timely identification and utilization of support system could lead better adjustment and less emotional and behavioral problems in adolescents. The objective of the present study was to identify the prevalence and the factors influencing behavioral problems among adolescents.
 Materials and methods: Behavioral problems such as depression, substance abuse, suicidal tendency and conduct disorder were surveyed in schools. A total of 300 adolescents (150 boys and 150 girls) responded to the survey questions. Beck’s depression inventory, adolescent alcohol and drug involvement scale, suicidal behavioral questionnaire revised were used to examine depression, substance abuse and suicidal tendency respectively. Self structured questionnaire were used to evaluate conduct disorder and the factors influencing behavioral problems. The self designed tools were validated by seven multi disciplinary experts from pediatric, nursing, psychology and psychiatrics.
 Results: Prevalence of various conditions is reported, depression was reported by 36%, drug abuse is 16%, conduct disorder was observed in 45% and 27% risk of suicide. Age, class and gender have a strong association with behavioral problems. In this study it has shown that females are more affected by behavioral problems than males and more problems are reported in higher class’s students. Attitude of mother has a strong impact on behavior of an adolescent. Overall, the current study highlights the prevalence and the factors that impact behavioral conditions in adolescents.
 Conclusion: It concludes that behavioral problems among adolescents are common. They are often under recognized. Identification and recognition through proper assessment is needed to give them right referral.

Patterns of drug abuse in Upper Egypt: cause or result of violence?

BackgroundDrug abuse and violence both are dangerous phenomena in all countries. The relation between drug abuse and violence is obscure, and what comes first is the question. This study clarifies the changes in drug abuse patterns in Upper Egypt and the association between drug abuse and different types of violence.MethodThree hundred patients seeking medical advice in Mental Health Hospital participated in this study. After obtaining their informed written consent, they underwent urine analysis to determine the abused drug and filled up a questionnaire to determine the type of violence. In this study, the patients were asked to fill out two types of scales: Adolescent Alcohol and Drug Involvement Scale (AADIS) and the Modified Overt Aggression Scale (MOAS).ResultsPatterns of drug abuse have been changed in Upper Egypt since the appearance of tramadol. The age of onset of abuse was 17.5 ± 5.5 years old. The age of 21–30 years old is the age of adult which is mostly affected. Most of the patients use combination of tramadol and others like alcohol, cannabis, other opioids, but 25% use tramadol alone. The type of violence changes from one drug abuse to another; auto-aggression was found in cannabis, while aggression towards objects and others was found in tramadol, inhalants, and other opioids.ConclusionDrug abuse is a direct cause that increases the violence in the community. Types and degree of violence differ according to the drug abuse type.

A prospective study of alcohol involvement and the dual-systems model of adolescent risk-taking during late adolescence and emerging adulthood.

To estimate interactions and unique effects of behavioral approach and behavioral control on alcohol involvement hypothesized by dual-systems models, during adolescence and emerging adulthood. In a longitudinal study, behavioral approach and behavioral control were examined in relation to alcohol involvement, cross-sectionally and prospectively. A total of 846 general population twins born in Colorado, USA were assessed twice (mean=17.3 and 22.8years; female=51.4%; white=91.8%). Behavioral approach was measured by self-report questionnaires of sensation-seeking and subjective effects of alcohol. Behavioral control was measured by self-reported lack of planning and nine executive functioning (EF) tasks. Interviewers administered semi-structured clinical interviews to assess alcohol use and disorder (AUD). None of 36 interaction effects was statistically significant (β=-0.16-0.14, P>0.06), suggesting that dual systems are additively related to alcohol involvement. In multiple regression models, behavioral approach and behavioral control explained independent variance in alcohol use quantity (β=0.09-0.33, P<0.04) and frequency (β=-0.11-0.29, P<0.03) at both waves. During adolescence, only subjective effects (β=0.27-0.28, P<0.001) explained independent variance in AUD. Moreover, measures of the same construct explained independent variance in alcohol involvement: for behavioral control, lack of planning and EF were associated with alcohol frequency in adolescence (β=-0.11-0.25, P<0.02) and AUD in emerging adulthood (β=-0.09-0.16, P<0.03). For the behavioral approach, subjective effects were associated with all measures at both waves (β=0.20-0.33, P<0.01) and sensation-seeking was associated with all measures in emerging adulthood (β=0.09-0.11, P<0.04). In prospective models, adolescent alcohol involvement was associated with later lack of planning (β=0.12-0.18, P<0.03) and lack of planning in adolescence was associated with later alcohol involvement (β=0.12-0.14, P<0.02). Both the behavioral approach and behavioral control components of dual-systems models explain alcohol involvement during adolescence and adulthood, and different measures of the same system assess separate risk processes. The relations between alcohol involvement and the dual systems appear to be bidirectional.

A straightforward approach for coping with unreliability of person means when parsing within-person and between-person effects in longitudinal studies

Longitudinal studies enable researchers to distinguish within-person (i.e., time-varying) from between-person (i.e., time invariant) effects by using the person mean to model between-person effects and person-mean centering to model within-person effects using multilevel models (MLM). However, with some exceptions, the person mean tends to be based on a relatively small number of observations available for each participant in longitudinal studies. Unreliability inherent in person means generated with few observations results in downwardly biased between-person and cross-level interaction effect estimates. This manuscript considers a simple, easy-to-implement, post-hoc bias adjustment to correct for attenuation of between-person effects caused by unreliability of the person mean. This correction can be applied directly to estimates obtained from MLM. We illustrate this method using data from a panel study predicting adolescent alcohol involvement from perceived parental monitoring, where parental monitoring was disaggregated into within-person (i.e., person-mean-centered) and between-person (i.e., person-mean) components. We then describe results of a small simulation study that evaluated the performance of the post-hoc adjustment under data conditions that mirrored those of the empirical example. Results suggested that, under a condition in which parameter bias is known to be problematic (i.e., moderate ICCX, small n, presence of a compositional effect), it is preferable to use the bias-adjusted MLM estimates over the unadjusted MLM estimates for between-person and cross-level interaction effects.

Socioeconomic Status and Adolescent Alcohol Involvement: Evidence for a Gene–Environment Interaction

Adolescence is an optimal developmental stage for examining the interplay of environmental factors and the genetic risk for alcohol involvement. The current study aimed to examine how socioeconomic status might interact with genetic risk for alcohol involvement among adolescents. A total of 839 same-sex adolescent twin pairs (509 monozygotic and 330 dizygotic) from the 1962 National Merit Twin Study completed a questionnaire containing items assessing alcohol involvement. Twins were approximately 17 years old at the time of participation. Parents provided reports of family income and educational attainment. Models were fit examining parental education and family income as moderators of genetic and environmental influences on alcohol use. There was evidence for moderation of genetic and environmental influences on alcohol involvement by family income. For twins with the lowest levels of family income, genetic and shared environmental influences accounted for 50% and 26% of the variance in alcohol involvement, respectively, compared with 2% and 67% of the variance among those at the highest level of income. These findings suggest that etiological influences on alcohol involvement vary as a function of an adolescent's socioeconomic status.

Demographic Moderation of the Prediction of Adolescent Alcohol Involvement Trajectories.

Several school- and family-based preventive interventions target and effectively reduce adolescent alcohol misuse. However, whether demographic groups achieve equal success with these interventions is unclear. In particular, most interventions target younger adolescents, and program effectiveness tends to be measured with majority White samples; subgroup analyses are rarely reported. We analyze longitudinal data from a sample of N = 6189 adolescents (40% Black, 60% White; 50% female) in 6th through 12th grade to quantify the degree to which age, race, and gender moderate the associations between seven well-known risk and protective factors (RPFs) that serve as common intervention targets. The RPFs that we study are drawn from social learning theory, problem behavior theory, and social control theory, including individual factors (positive alcohol expectancies and deviant behavior), family context (perceived parental involvement, perceived parent alcohol use, and access to alcohol), and peer context (descriptive and injunctive norms). Multilevel growth models allow us to conduct the demographic subgroup moderation analysis. Results suggest that these well-studied RPFs explain alcohol involvement to varying degrees, but they explain substantially more variation in alcohol involvement by White adolescents compared with Black adolescents. We find differential patterns of significance and of leading predictors of alcohol involvement as a function of age, race, and gender and the interactions thereof. These results indicate that the prevention field needs to better understand the RPFs affecting minority and high school youth in order to provide a stronger basis for alcohol prevention efforts.

Associations between childhood ADHD, gender, and adolescent alcohol and marijuana involvement: A causally informative design

BackgroundWe report whether the etiology underlying associations of childhood ADHD with adolescent alcohol and marijuana involvement is consistent with causal relationships or shared predispositions, and whether it differs by gender. MethodsIn three population-based twin samples (N = 3762; 64% monozygotic), including one oversampling females with ADHD, regressions were conducted with childhood inattentive or hyperactive-impulsive symptoms predicting alcohol and marijuana outcomes by age 17. To determine whether ADHD effects were consistent with causality, twin difference analyses divided effects into those shared between twins in the pair and those differing within pairs. ResultsAdolescents with more severe childhood ADHD were more likely to initiate alcohol and marijuana use earlier, escalate to frequent or heavy use, and develop symptoms. While risks were similar across genders, females with more hyperactivity-impulsivity had higher alcohol consumption and progressed further toward daily marijuana use than did males. Monozygotic twins with more severe ADHD than their co-twins did not differ significantly on alcohol or marijuana outcomes, however, suggesting a non-causal relationship. When co-occurring use of other substances and conduct/oppositional defiant disorders were considered, hyperactivity-impulsivity remained significantly associated with both substances, as did inattention with marijuana, but not alcohol. ConclusionsChildhood ADHD predicts when alcohol and marijuana use are initiated and how quickly use escalates. Shared familial environment and genetics, rather than causal influences, primarily account for these associations. Stronger relationships between hyperactivity-impulsivity and heavy drinking/frequent marijuana use among adolescent females than males, as well as the greater salience of inattention for marijuana, merit further investigation.

The Prospective Association Between Internalizing Symptoms and Adolescent Alcohol Involvement and the Moderating Role of Age and Externalizing Symptoms.

As predicted by self-medication theories that drinking is motivated by a desire to ameliorate emotional distress, some studies find internalizing symptoms (e.g., anxiety, depression) increase risk of adolescent drinking; however, such a risk effect has not been supported consistently. Our prior work examined externalizing symptoms as a potential moderator of the association between internalizing symptoms and adolescent alcohol use to explain some of the inconsistencies in the literature. We found that internalizing symptoms were protective against early adolescent alcohol use particularly for youth elevated on externalizing symptoms (a 2-way interaction). Our sample has now been followed for several additional assessments that extend into young adulthood, and the current study tests whether the protective effect of internalizing symptoms may change as youth age into young adulthood, and whether this age-moderating effect varied across different clusters of internalizing symptoms (social anxiety, generalized anxiety, and depression). Internalizing symptoms were hypothesized to shift from a protective factor to a risk factor with age, particularly for youth elevated on externalizing symptoms. A community sample of 387 adolescents was followed for 9 annual assessments (mean age=12.1years at the first assessment and 55% female). Multilevel cross-lagged 2-part zero-inflated Poisson models were used to test hypotheses. The most robust moderating effects were for levels of alcohol use, such that the protective effect of all internalizing symptom clusters was most evident in the context of moderate to high levels of externalizing problems. A risk effect of internalizing symptoms was evident at low levels of externalizing symptoms. With age, the risk and protective effects of internalizing symptoms were evident at less extreme levels of externalizing behavior. With respect to alcohol-related problems, findings did not support age moderation for generalized anxiety or depression, but it was supported for social anxiety. Findings highlight the importance of considering the role of emotional distress from a developmental perspective and in the context of externalizing behavior problems.

Time perspective and alcohol-use indicators in France and the United Kingdom: results across adolescents, university students, and treatment outpatients

While some research has reported a significant relationship between time perspective and alcohol use, that research has differed considerably in terms of how both variables are operationalized.The present study aimed to investigate this relationship by operationalizing time perspective in three ways, using raw scale scores, using temporal clusters, and using the Deviation from a Balanced Time Perspective approach. Additionally, age-appropriate measures of alcohol-related behavior were used, and alcohol scale scores were assessed as both an ordinal and a categorical measure. Data gathered in adolescents and university students in the United Kingdom were re-analyzed, and new data from a French university sample and a French Treatment Outpatient sample were analyzed. Overall, results using the Alcohol Use Disorders Identification Test revealed a very modest relationship between scores on this measure and the various time perspective approaches. Results using the Adolescent Alcohol Involvement Scale suggested a stronger relationship between scores on this measure and the time perspective approaches. The results are discussed in the context of the extant literature, and methodological concerns specific to the use of the Zimbardo Time Perspective Inventory are discussed.

Commentary on Rossow et al. (2016): Early days yet in the cycle from peer to parent drinking as influences on adolescent alcohol involvement.

Commentary on Rossow et al. (2016): Early days yet in the cycle from peer to parent drinking as influences on adolescent alcohol involvement.

Brief Interventions for Adolescents

Public health concerns regarding adolescent alcohol and other drug involvement emphasize the need for continuing research to develop and evaluate preventive interventions for use in a variety of settings. This focus includes research on brief interventions. This short commentary piece provides an overview of the brief intervention literature and highlights future directions.

INVOLVEMENT OF ADOLESCENTS FROM NORTHERN PORTUGAL WITH ALCOHOL

ABSTRACT Objective: to analyze the relationship between sociodemographic variables and involvement of adolescents with alcohol. Method: a cross-sectional descriptive and correlational study, with a quantitative approach, was conducted with a sample of 378 students who attended regular high school in the city of Chaves, in Northern Portugal. A questionnaire that included the Adolescent Alcohol Involvement Scale was used as data collection instrument. Results: most students were female (60.8%), aged between 17 and 18 years (53.2%), and fit in the category "Regular drinker without problems" (79.9%). Male adolescents were more commonly involved with alcohol (p=0.010). Conclusion: involvement with alcohol seems to be in an intermediate level, associated with gender, age group, level of schooling, and religious practice. These results justify the development of community interventions, with the aim of preventing alcohol consumption.

Should Parents Allow Their Adolescent Children to Drink at Home? Family Factors as Predictors of Alcohol Involvement Trajectories Over 15 Years.

The present study examined familial risk and protective factors as moderators of parents allowing their adolescent children to drink at home on longitudinal alcohol involvement trajectories. A total of 772 community adolescents and their parents provided data beginning in 1989 and at four subsequent time points over 15 years; Black adolescents were intentionally oversampled (50% at baseline). Outcomes related to allowing adolescents to drink at home depended on family structure: Adolescents from intact families who were allowed to drink at home showed the lowest levels of alcohol use and problems over time, whereas those from nonintact families who were allowed to drink at home showed the highest levels of involvement. These results controlled for family history of alcohol problems, consistent parenting styles, and demographic characteristics. Results suggest that allowing adolescents to drink at home is neither inherently protective nor risky but depends on the family context. Implications for the development of adolescent alcohol involvement are discussed.

Progressive elaboration and cross-validation of a latent class typology of adolescent alcohol involvement in a national sample.

Most studies of adolescent drinking focus on single alcohol use behaviors (e.g., high-volume drinking, drunkenness) and ignore the patterning of adolescents' involvement across multiple alcohol behaviors. The present latent class analyses (LCAs) examined a procedure for empirically determining multiple cut points on the alcohol use behaviors in order to establish a typology of adolescent alcohol involvement. LCA was carried out on six alcohol use behavior indicators collected from 6,504 7th through 12th graders who participated in Wave I of the National Longitudinal Study of Adolescent Health (AddHealth). To move beyond dichotomous indicators, a "progressive elaboration" strategy was used, starting with six dichotomous indicators and then evaluating a series of models testing additional cut points on the ordinal indicators at progressively higher points for one indicator at a time. Analyses were performed on one random half-sample, and confirmatory LCAs were performed on the second random half-sample and in the Wave II data. The final model consisted of four latent classes (never or non-current drinkers, low-intake drinkers, non-problem drinkers, and problem drinkers). Confirmatory LCAs in the second random half-sample from Wave I and in Wave II support this four-class solution. The means on the four latent classes were also generally ordered on an array of measures reflecting psychosocial risk for problem behavior. These analyses suggest that there may be four different classes or types of alcohol involvement among adolescents, and, more importantly, they illustrate the utility of the progressive elaboration strategy for moving beyond dichotomous indicators in latent class models.

Sipping, drinking, and early adolescent alcohol consumption: a cautionary note.

Epidemiological studies report markedly varying rates of adolescent alcohol involvement. Despite being a common adolescent behavior, a potential cause of this variation is that consumption of sips is either not measured or not distinguished from consumption of whole beverages. Participants were 1,843 grade 7 adolescents recruited across 49 Australian secondary schools (M age=12.4, SD=0.5). Quantity and frequency of lifetime and past 6-month consumption were assessed, distinguishing between sipping and drinking. For comparison with international population surveys, quantity was reported as any consumption, sipping only, and drinking only. Combining sipping and drinking into a single category, lifetime consumption was reported by 67.3% of the present sample. Distinguishing lifetime consumption by sipping and drinking: only 7.8% of adolescents had consumed a whole beverage; the remaining 59.6% had only sipped. Consumption of whole beverages was mostly limited to 1 to 2 drinks (84.2% of drinkers). Sipping and drinking were also infrequent: 78.2% of sipping and 60.4% of drinking, occurred less than monthly. Heavy episodic consumption was uncommon (1.2% of the sample). When other population studies were inspected, a clear trend for higher drinking rates were found in those studies where sipping was counted as drinking and vice versa. Consumption of whole beverages appears infrequent in early adolescence, as sipping, but not drinking, was common in our sample. Comparing the present data with international population consumption measures highlights the need to more precisely measure and report adolescent consumption, particularly in relation to sipping.

The reliability and factorial validity of the Adolescent Alcohol Involvement Scale in a large sample in the United Kingdom

The assessment of adolescent drinking behavior is a complex task, complicated by variability in drinking patterns, the transitory and developmental nature of the behavior and the reliance (for large scale studies) on self-report questionnaires. The Adolescent Alcohol Involvement Scale (Mayer & Filstead, 1979) is a 14-item screening tool designed to help to identify alcohol misusers or more problematic drinkers. The present study utilized a large sample (n = 4066) adolescents from Northern Ireland. Results of Confirmatory Factor Analyses and reliability estimates revealed that the 14-items share sufficient common variance that scores can be considered to be reliable and that the 14 items can be scored to provide a composite alcohol use score.