Drug and Alcohol Dependence 103 (2009) 155158

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Drug and Alcohol Dependence

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Short communication

The Alcohol Use Disorders Identication Test (AUDIT) as a screening instrument

for adolescents
c , Mara Elena Alvarado b , Oscar Arteaga b
Rodrigo Santis a, , Mara Luisa Garmendia b , Gonzalo Acuna
a

Department of Psychiatry, Faculty of Medicine, Ponticia Universidad Catlica de Chile, Av. Camino El Alba 12351, Las Condes, Santiago, Postal Code: 7620002, Chile
School of Public Health, Faculty of Medicine, Universidad de Chile, Av. Independencia 939, Independencia, Santiago, Postal Code: 8380453, Chile
c
Addiction Unit, Clnica Santa Sofa, Av. Isabel La Catlica 4388, Las Condes, Santiago, Postal Code: 7550465, Chile
b

a r t i c l e

i n f o

Article history:
Received 7 September 2008
Received in revised form 24 January 2009
Accepted 26 January 2009
Available online 6 May 2009
Keywords:
AUDIT
Alcohol use disorders
Adolescents

a b s t r a c t
Background: The Alcohol Use Disorders Identication Test (AUDIT) is an international screening instrument extensively employed in adult target groups. However, there is scarce information on screening
with the AUDIT in adolescent populations. The purpose of this study was to determine the cut-off point
for hazardous, harmful, and dependent alcohol use through the validation of the AUDIT in a Chilean
adolescent sample.
Methods: The original English version of the AUDIT was translated into Spanish, using the procedure
recommended by the World Health Organization. The text was then back-translated and sent to one of
the original authors (Thomas Babor), who approved the translation. Students attending public schools
in Santiago, Chile, self-administered the AUDIT, and those older than 15 years completed the Composite
International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), which served as a gold standard.
Between 1 and 4 weeks after the CIDI-SAM, participants answered a second AUDIT.
Results: A total of 42 female and 53 male adolescents (mean age: 15.9 [SD = 1.2]) completed the AUDIT,
with a mean score of 4.3. Reliability according to Cronbachs alpha was 0.83. Testretest correlation
was also satisfactory (intra-class correlation 0.81 [95% CI 0.730.87]). Analysis of the receiver operating
characteristic (ROC) curve yielded cut-off points for hazardous, harmful, and dependent alcohol use of 3,
5, and 7 points, respectively.
Conclusions: The Chilean version of the AUDIT is a valid and reliable tool for identifying adolescents with
hazardous, harmful, and dependent alcohol use. The suggested cut-off points make screening with the
AUDIT more accurate for adolescent populations.
2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Alcohol consumption by adolescents has shown a marked
increase over the last 30 years in the majority of countries (World
Health Organization, 1980, 2001, 2007). Consumption at early ages
and frequent inebriation characterize an emerging pattern of use
(Deas et al., 2000; World Health Organization, 2001). Individuals who start to consume alcohol at an early age have a higher
risk of the following: future development of alcohol dependency
(Grant and Dawson, 1997); unintentional alcohol-related injuries
(Hingson et al., 2000); early age of alcohol abuse (Hawkins et al.,
1997); illicit drug use (Grunbaum et al., 2004); and tobacco use
(Shiffman and Balabanis, 1995). Therefore, children and adolescents
who consume alcohol are thought to constitute a risk group (World
Health Organization, 2004) that should be actively screened to facil-

Corresponding author. Tel.: +56 2 754 8872; fax: +56 2 754 8879.
E-mail address: rsantis@med.puc.cl (R. Santis).
0376-8716/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.drugalcdep.2009.01.017

itate early intervention (Jernigan, 2001; World Health Organization,

2007).
The Project on Identication and Management of AlcoholRelated Problems has developed an international screening tool,
the Alcohol Use Disorders Identication Test (AUDIT) (Saunders et
al., 1993), and evaluated early interventions for groups with high
risk alcohol consumption (Babor and Grant, 1992; World Health
Organization, 2006). A World Health Organization Expert Committee recently recommended the implementation of screening
and brief intervention programs in national and regional healthcare systems, to reduce alcohol-related problems (World Health
Organization, 2007).
The AUDIT is used as a screening method in primary care and
other settings, with various target groups (Babor et al., 2001). Clinical research using the AUDIT has been carried out primarily in
developed countries and focused on adult risk groups (Babor et
al., 2001). It has been suggested that screening with the AUDIT be
expanded to include additional groups at risk of alcohol-related
problems, such as adolescents (Babor et al., 2001). For this, the

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R. Santis et al. / Drug and Alcohol Dependence 103 (2009) 155158

AUDIT should be evaluated with specic regard to its validity and

reliability in this group. Given that the AUDIT was designed as a
screening tool for international use, its authors have emphasized
the need to address its cultural appropriateness and cross-national
applicability (Babor et al., 2001).
The Seventh National Study on Drugs in School Population of
Chile showed a 38% prevalence of last-month alcohol use (Chilean
National Counsel for Narcotics Control, 2008). In the 2006 General Population Survey on Substance Use, 17.7% of adolescents who
drank alcohol in the previous month met the criteria of alcohol abuse according to the DSM-IV (Chilean National Counsel for
Narcotics Control, 2006). Thus, in Chile there is a large group of
adolescents who would benet from proper screening and intervention.
The available versions of the AUDIT in Spanish (Rubio et al., 1998;
Saunders et al., 1993) have linguistic usage that is uncommon in
Chile. The purpose of this study was to determine the cut-off points
for hazardous, harmful, and dependent alcohol use through the validation of a new Spanish version the AUDIT in a Chilean adolescent
sample.
2. Methods
The study protocol and the Informed Consent Form were approved by the Ethical
Committee of University of Chile.
2.1. Adaptation process
Both versions of the AUDIT that are available in Spanish (Rubio et al., 1998;
Saunders et al., 1993) were analyzed by a panel of Chilean experts, revealing important differences in language usage (rare use of some words, and misinterpretation
of the Spanish translation of previous year). Thus, there was a decision to create a
new version of the AUDIT in Chilean Spanish translated from the original version in
English. This validation of the AUDIT adhered strictly to the translation guidelines
of the World Health Organization (Babor et al., 2001; World Health Organization,
2005).
The initial versions were translated by two independent bilingual psychiatrists.
Consensus building by the research team generated a single version. Later, an expert
committee examined the text and decided on a nal Chilean version using the Delphi
method (Rowe and Wright, 1999). Three rounds were needed to reach a consensus.
Finally, the text was back-translated and sent to one of the original authors (Thomas
Babor), who approved its format and contents.
2.2. Sampling
The number of participants required in the sample population was calculated
based on a 15% prevalence of last-month alcohol use and 5% prevalence of lastmonth alcohol dependence (Chilean National Counsel for Narcotics Control, 2003).
Considering a population of 640 students attending two public schools in north
Santiago, Chile, an expected effect size of 1.6 and a target condence level of 95%,
the sample size was set at 77 participants. Students were recruited by a simple
random sampling.
2.3. Procedures
The AUDIT was self-administered by 95 students. Of these students 58 were older
than 15 years of age, and were therefore able to answer the Composite International
Diagnostic Interview-Substance Abuse Module (CIDI-SAM) as a gold standard. The
CIDI is a standardized interview developed by the WHO (Robins et al., 1988) and
validated in Chile (Vielma et al., 1992). It has been recommended by the WHO as a
gold standard for validating the AUDIT (Babor et al., 2001). However, the CIDI can be
administered only to persons older than 15 years. This instrument was administered
by an independent physician qualied as a CIDI administrator, who was blinded to
the AUDIT score. After 14 weeks, subjects were asked to answer a second AUDIT.
Since hazardous consumption is not a clinical diagnosis obtained by the CIDISAM, the threshold used to distinguish persons with low-risk levels of consumption
from those with higher-risk levels of consumption was based on the WHO recommendation: no more than 20 g of alcohol per day, 5 days a week, recommending two
non-drinking days (WHO, 2000; Babor et al., 2001). A standard drink was dened
as equivalent volumes containing an average of 13 g of ethanol, according to international standards (Babor et al., 2001).
2.4. Statistical analysis
Internal consistency was estimated using Cronbachs alpha, and testretest reliability was calculated through the intra-class correlation coefcient, both in the

global sample. Criterion validity was calculated measuring sensitivity, specicity,

predictive values, and area under the receiver operating characteristic (ROC) curve
in the sample of 58 participants who responded the CIDI-SAM. All the statistical
analyses were performed using STATA 10.0 (StataCorp LP, College Station, TX, USA).

3. Results
The sample was composed of 42 female and 53 male participants. Their mean age was 15.9 years (95% CI: 15.716.2). The mean
AUDIT score was 4.4 (95% CI: 3.35.5). Internal consistency showed
a Cronbachs alpha of 0.83 (95% CI: 0.780.82). Testretest reliability showed an intra-class correlation coefcient of 0.81 (95% CI:
0.730.87).
According to the World Health Organization criteria, 34.7% (95%
CI: 23.645.7%) of the sample reported hazardous drinking. In the
CIDI-SAM administration, 27.9% (95% CI: 13.941.9%) and 25.6%
(95% CI: 12.039.2%) of the participants were classied as engaging
in harmful drinking and having alcohol dependence, respectively.
Psychometric performance of AUDIT against CIDI-SAM is summarized in Table 1. The area under the curve (ROC) was 0.90 (95% CI:
0.840.97) for hazardous use, 0.78 (95% CI: 0.640.93) for harmful
consumption, and 0.76 (95% CI 0.600.92) for alcohol dependence.
In relation to hazardous consumption, the cut-off point with
the best sensitivity/specicity balance was a score of 3 (sensitivity 96.2%; specicity 63.3%; correctly classied 74.7%). With respect
to harmful consumption, the cut-off point with the best sensitivity/specicity balance was a score of 5 (sensitivity 75%; specicity
64.5%; correctly classied 67.4%). With respect to dependence, the
cut-off point with the best sensibility/specicity balance was 7
points (sensitivity 63.6%; specicity 75%; correctly classied 72.1%).
4. Discussion
According to this study, the Chilean version of the AUDIT is a
reliable and valid tool for identifying adolescents engaged in hazardous, harmful, and dependent alcohol use. Internal consistency,
testretest reliability, sensitivity, and specicity were satisfactory.
Reinert and Allen (2002), after reviewing studies that used the
AUDIT, pointed out the scarcity of research done on this test in
adolescent populations. Several studies used the cut-off scores recommended for adult populations to screen for alcohol use disorders
amongst adolescents (Harnett et al., 1999; Thom et al., 1999). The
AUDIT performance has been studied in some adolescent samples, particularly college students (Aertgeerts et al., 2000), but
they represent an older and more homogenous group (i.e., subjects beginning their university years, with a mean age of 18 years),
and the study did not explore hazardous drinking. To the best of
our knowledge, the only study that validated the AUDIT against the
DSM-IV criteria for an alcohol use disorder in a sample of similar
age as our sample (1319 years) was done by Chung et al. (2000).
They reported that the best sensitivity/specicity balance was at a
cut-off score of 4 points, similar to our ndings and lower than the
cut-off for adult samples (Reinert and Allen, 2002).
In relation to the differences between adolescents and adults,
the lower cut-off scores and the tight gap between different alcohol use disorders in adolescents might be related to a greater
neurobiological vulnerability in this stage of development, during which the inhibitory control of the prefrontal cortex is not
completely developed (Yurgelun-Todd, 2007). The differences with
adults might also be related to a different response to the acute
effects of alcohol. Animal research has shown that adolescents are
less sensitive to alcohols effects that may serve as cues to limit
intake, and they are more sensitive to effects on social facilitation (Spear and Varlinskaya, 2005). In recent years, developmental
frameworks have emerged (Masten et al., 2008) to guide research
and interventions in adolescents.

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157

Table 1
The performance of the recommended cut-off scores on the AUDIT against hazardous use, harmful use and alcohol dependence diagnoses.
Cut-off

Sensitivity % (95% CI)

Specicity % (95% CI)

PPV % (95% CI)

NPV % (95% CI)

Hazardous use (n = 95)

2
100.0 (84.0100.0)
3
96.2 (78.499.8)
4
84.6 (64.295.0)
5
80.8 (60.092.7)

59.2 (44.372.7)
63.3 (48.376.2)
69.4 (54.481.3)
77.6 (63.087.8)

56.5 (41.270.8)
58.1 (42.272.6)
59.5 (42.274.8)
65.6 (46.880.8)

100.0 (85.4100.0)
96.9 (82.099.8)
89.5 (74.396.6)
88.4 (74.195.6)

Harmful use (n = 58)

4
75.0 (42.893.3)
5
75.0 (42.893.3)
6
66.7 (35.488.7)

58.1 (39.374.9)
64.5 (45.480.2)
74.2 (55.187.5)

40.9 (21.563.3)
45.0 (23.868.0)
50.0 (25.574.5)

85.7 (62.696.2)
87.0 (65.396.6)
85.2 (65.495.1)

Dependence (n = 58)
5
72.7 (39.392.7)
6
63.6 (31.687.6)
7
63.6 (31.687.6)

62.5 (43.878.3)
71.9 (53.085.6)
75.0 (56.287.9)

40.0 (20.065.6)
43.8 (20.869.4)
46.7 (22.372.6)

87.0 (65.696.6)
85.2 (65.495.1)
85.7 (64.495.3)

PPV, positive predictive value; NPV, negative predictive value.

This study has some limitations. First, CIDI-SAM is a gold standard valid for individuals more than 15 years of age. However, it
was considered worthwhile to include younger adolescents in this
study due to the observed prevalence of alcohol use in this group
(Chilean National Counsel for Narcotics Control, 2008). Second, the
sample size did not allow for the assessment of gender differences
in the AUDIT performance. This needs to be addressed in future
research. Third, positive predictive values were low and negative
predictive values were high for the three categories explored. However, in this respect the present study is not different from other
studies that validated the AUDIT against clinical diagnoses (Reinert
and Allen, 2002). Clinically, a misclassication due to false positives might be considered less serious than a misclassication due
to false negatives.
The Chilean version of the AUDIT constitutes an adequate
screening instrument aimed at early recognition of alcohol use
disorders in adolescents. Besides screening in school populations,
the AUDIT might be useful in other settings such as primary care,
emergency services, juvenile mental health services, and juvenile
justice. Additionally, the AUDIT could be included in household or
school-based epidemiological surveys to estimate alcohol use disorders in adolescents. We encourage the research community to
gather information on the psychometric properties of the AUDIT in
adolescent populations in other countries, to appropriately compare epidemiological and clinical ndings at early stages of alcohol
use.
Role of funding source
Funding for this study was provided by FONIS Grant
SA05I20078; FONIS had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the
report; or in the decision to submit the paper for publication.
Contributors

Authors Santis, Garmendia, Acuna,

Alvarado and Arteaga
designed the study and wrote the protocol. Authors Santis and
managed the literature searches and summaries of previAcuna
ous related work. Authors Garmendia and Alvarado undertook the
wrote
statistical analysis, and authors Santis, Garmendia and Acuna
the rst draft of the manuscript. All authors contributed to and have
approved the nal manuscript.
Conict of interest
All authors declare that they have no conicts of interest.

Acknowledgements
This project was funded by FONIS (Grant SA05I20078). We
would like to thank Professor Thomas Babor for his assistance in
the adaptation process of the AUDIT.
We are very grateful to Professor Thomas Babor for his collaboration in the back translation of the Chilean version of the AUDIT.
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