Addiction (1994) 89, 167-174

RESEARCH REPORT

The measurement of alcohol dependence and

impaired control in community samples

TIM STOCKWELL,' THIAGARAJAN SITHARTHAN, 2

DAVID McGRATH 2 & ERNIE LANG'
'National Centre for Research into the Prevention of Drug Abuse, Curtin University of
Technology, Perth, Western Australia 6001 & ;Centre for Drug and Alcohol Studies, Royal
Prince Alfred Hospital, Sydney, New South Wales 2050, Australia

Abstract
The concept of the Alcohol Dependence Syndrome has been influential in the field of alcohol studies in the
1980s. The Severity of Alcohol Dependence Questionnaire (SADQ} is one of a generation of alcohol problem
scales developed to measure degree of dependence rather than presence or absence of 'alcoholism'. This paper
describes the development of a form of the SADQ for community samples of drinkers (SADQ-C) and its
relationship to a brief scale designed to measure impaired control over drinking. In a sample of 52 problem
drinkers, SADQ and SADQ-C correlated almost perfectly (r = 0.98). In a larger sample of 197 attenders
at a controlled drinking clinic, Principal Components Analysis revealed one major factor accounting for
71.7% of the total variance. High internal reliability was indicated with a Cronbach's Alpha of 0.98.
Application of this instrument in a random survey of Western Australian households is then described. it was
necessary to remove items relating to 'reinstatement of dependence' for this sample. A single major factor was
identified by principal components analysis, accounting for 69.1% of the total variance. In both the clinic and
the community samples SADQ-C scores correlated highly with Impairment of Control scores. The findings are
interpreted as supporting the view that there is a single dimension of alcohol dependence upon which all
persons who drink alcohol with any regularity may be located.

Introduction presence or absence of 'alcoholism' (Davidson,

The concept of the Alcohol Dependence Syn-
drome (ADS) has had a tremendous influence on
the field of alcohol studies. First proposed by
Edwards & Gross (1976), it was soon adopted by the
World Health Organization as one of a range of
alcohol-related disabilities (1977). It has
spawned innumerable studies designed to test its
central tenets (Edwards, 1986) and also a new
Correspondence to Dr Tim Stockwell, National Centre for
Research into the Prevention of Drug Abuse, Curtin University of
Technology, Perth, Western Australia 6001, Australia.
generation of instruments to measure 'severity of
alcohol dependence' as opposed to the mere
1987). Most notably the terminology of the syndrome
concept, if not its entire substance, has usurped the
term 'alcoholism' in major international systems for
the classification of diseases. A clear consensus has
emerged in the treatment and research community
regarding the utility of the concept of a continuum of
dependence and its relationship to the possibility of
a problem drinker achieving a pattern of moderate
drinking (Stockwell, 1988).

167
168 Tim Stockwell et al.
A major application of measures of alcohol
dependence is for screening out severely depen-
dent drinkers from controlled drinking and early
intervention programs (e.g., Ruzek, 1987). How-
ever, the utility of the various dependence scales
available has not been systematically evaluated
for general population rather than specialized
clinic samples. In an excellent review of alcohol
dependence scales, Davidson (1986) notes three
which have been widely used and have demon-
strated reliability and validity—the Alcohol
Dependence Scale (Skinner & Horn, 1984), the
Se verity of A lcohol Depe nde nce Data , or
SADD, (Raistrick, Dunbar & Davidson, 1981)
and the Severity of Alcohol Dependence Ques-
tionnaire, or SADQ (Stockwell et al., 1979).
While these are highly correlated with each
other, Davidson suggests that in many cases the
SADD covers the most elements of the ADS and
is more likely to be sensitive at the 'mild to
moderate' range of dependence. He notes, how-
ever, that the SADQ is the most widely used and
has the most evidence of reliability and validity
but suggests that its coverage of the ADS core
elements is limited to physical withdraws] signs
and drinking for the relief of these. Elsewhere it
has also been suggested (Stockwell & Saunders,
1990) tha t the SA DQ fa ils to a tte mpt the
measurement of what Edwards et al. (1977, p.
17) describe as 'a leading symptom' of the syn-
drome, namely, 'an impaired control over intake
of the drug ethyl alcohol'.
In the present study, the application of an
amended version of the SADQ with drinkers in
the mild to moderate range of dependence is
explored. Subjects were drawn both from a general
population sample and from attenders of a
controlled drinking clinic. The original form of
the SADQ is unsuitable for administration to
general population samples of drinkers because it
asks respondents to focus on 'a recent period of
heavy drinking' which, of course, they may not
ha ve ha d. I t is impor ta nt to note tha t the
amended SADQ contained all the original items
and no new ones; the introductory wording and
the stems for each question were the only
changes made. The relationship of SADQ scores
to impairment of control over drinking was also
explored in both of these samples.
Another impetus for the present study is the
surprising lack of data from general population
samples regarding degree of dependence and
individual signs of dependence. Such data can
be used to test whether some of the characteris-
tics of the ADS as it has been described in
clinical populations also apply for a less select
group of drinkers. The advent of a household
survey into drinking behaviour, drinking settings
and the consequence s of dr inking (Land e t
at., 1993) was used as an opportunity to correct
this knowledge deficit, and also to examine
the coherence of the ADS concept in a non-
clinical sample of drinkers. To our knowledge
this has only been attempted previously using
criteria for alcohol dependence
(Gaetano, 1991; Muthen, Grant & Hasin, 1993)
which, in our view, are based on fundamentally
different ideas about the nature of alcohol
dependence than in the original formulation of
the ADS.
Methods
Questionnaire development
The SADQ requires respondents to select one
of four frequency responses to each of 20
items regarding 'a recent period of heavy drink-
ing'. These responses are scored from 0 to 3
resulting in a maximum possible total score of
60. Scores greater than 30 have been found to
correspond to Edwards' own ratings of 'severe
alcohol dependence' (Stockwell et al., 1979).
Sub-sections of the instrument cover physical
withdrawal (PHYS), affective withdrawal (AFF),
drinking for the relief of withdrawal (RELIEF),
the experience of 'craving', typical daily alcohol
consumption (CONS) and reinstatement of
these symptoms after a period of abstinence
(REINST).
The following changes were introduced to the
wording of the original SADQ in order to render
it suitable for completion by general population
samples:
(a) the introductory statement was
considerably simplified to: "Please
answer all of the following questions
about your drinking by placing a tick
in the appropriate box";
(b) the first response option was
changed from `almost never' to 'never
or almost never' since some
respondents refuse to endorse the
former, e.g., if they have never had a
morning drink;
(c) respondents were asked to
focus on the last three months rather
than 'a recent period of heavy drinking';
 Measurement of alcohol dependence 169
(d) the by the first two
first 12 items authors on the basis of
began with their experience with
the stem 'The assisting drinkers to
day after overcome problems
drinking with impaired control.
alcohol ...'; Exactly the same
(e) the response format was
last four used as for the SADQ-
items (the C. Five items survived
'reinstatement the piloting procedures:
' section)
were (1) Af
introduced as ter having
follows: just two or
"Imagine the three drinks I
following felt like
situation: having a few
(i) Yo more.
u have hardly (2) Aft
drunk any er having two
alcohol for a or three drinks
few weeks; I could stop
(ii) Yo drinking if I
u then drink had other
very heavily things to do.
for two days. (3) W
How would you hen I started
feel the morning drinking
after those two alcohol I
days of heavy found it hard
drinking?". to stop until
I was fairly
drunk.
These revisions were (4) W
developed and piloted hen I went
with 20 attenders of drinking I
the controlled planned to
drinking clinic of have at least
Royal Prince Alfred six drinks.
Hospital, Sydney and (5) W
also samples of 20 and hen I went
then 50 householders in drinking I
Perth, Western planned to
Australia until the have no more
questionnaire was than two or
found to be free of three drinks.
ambiguity. This format
is henceforth referred
to as the "SADQC" Items 2 and 5 were
(the "C" denoting worded so as to denote
'community' samples). positive control and
A similar process was therefore served as a test
employed for testing the of whether respondents
intelligibility of six were using a response
'Impairment of set (e.g., unthinkingly
Control' items devised endorsing 'nearly
always' throughout).
Henceforth these five scales was 0.98 (p <
items will be 0.0001).
collectively referred to
as the ICQ.

2. Internal consistency
of the SADQ-C and
1. Concurrent Validly of ICQ in a clinic sample
the SADQ-C with SADQ Method. A larger
Method. A sample of 'clinic sample' was
52 attenders of the drawn from 197
Royal Prince Alfred individuals attending
Hospital clinic for the Royal Prince Alfred
controlled drinkers Hospital's alcohol
completed the SADQ treatment programme.
and SADQ-C at least Following a
one week apart in order psychosocial and
to check the com- medical assessment,
parability of the two clients of this
questionnaires. The programme enrol in
questionnaires were a programme aimed
completed in a either at total
balanced order. Pearson abstinence or
correlation coefficients controlled drinking.
were calculated for each Clients are generally
pair of equivalent items self-referrals or
and also for the total referred by health
scores. The intention professionals and other
was to adapt the SADQ government and non-
so that it asked government agencies.
exactly the same The mean age of the
questions as before, clinic sample was
though with wording 38.9 years (SD = 9.7,
appropriate for drinkers range 21 to 63 years).
regardless of whether The internal
they were attending for consistency of both the
treatment. ICQ and SADQC was
examined by
calculating
Results. Scores on
Cronbach's Alpha
equivalent items for
reliability coefficients
the SADQ and SADQ-
for each scale. Prin-
C were highly
cipal Components
correlated with each
Analysis (PCA)
other and with total
w a s conducted in
scores for both scales.
order to test whether,
Of the inter-item
as in previous studies
correlations, 11 were
of clinical populations
in excess of 0,90, 18
(Stockwell et al.,
were 0.70 or higher
1979), one main factor
and only two were
corresponding to a
lower than 0.60. The
single dimension of
latter were the lowest
dependence severity
and highest quantity-
would be
frequency items (r =
disc over e d. I nte r -
0.54 and 0.58,
sec tion cor re la tion
respectively). The
coefficients were also
Pearson coefficient of
calculated for the five
correlation between
subsections of the
total scores on the two
SADQ-C and the
total ICQ score.

Results. Cronbach's
Alpha was 0.97 for
the SADQ-C. When
the five ICQ items
were added a
coefficient of 0.98 was
obtained. A single factor
accounted for a large
percentage (71.7%)
and all
170 Tim Stockwell et al.
Table 1. Pearsall correlation coefficients for SADQ-C score, ICQ total score and SADQ-C
subscales for the clinical sample (n = 197)
SADQ-C PHYS
PHYS 0.93
AFF 0.88
0.79
RELIEF 0.94
0.86
CONS 0.86
0.78
REINST 0.93
0.83
ICQ 0.90
0.79
individual questionnaire items loaded
significantly on this factor. The next largest
factor only accounted for 6.8% of the variance
and had significant loadings from three of the
affective withdrawal items. When Factor Analysis
was performed upon pooled SADQ-C and ICQ
items, again a major factor corresponding to
'alcohol dependence' accounted for most of the
variance (68.7%). Table 1 shows that the five sub-
scales of the SADQ-C were highly inter-correlated
with each other and also the total ICQ score.
3. Prevalence of dependence signs in the community
sample
Method. A general population sample was
drawn from a random household survey of 1272
persons aged 16 and over residing in the Perth
metropolitan area, Western Australia. Full de -
t a i l s o f p r o c e d u r e s ha v e b e e n de s c r i be d
elsewhere (Lang et al., 1993). Only persons who
reported having drunk at least one drink in the
past three months were asked to complete the
SADQ-C and ICQ-a total of 944 'drinkers'.
Data weighted by sex and number of persons
resident in the respondent's household were
used for the purposes of reporting the frequency
with which the signs of dependence covered by
the two scales were experienced by a representative
community sample of persons who had had at
least one drink of alcohol in the previous three
months.
Results. Table 2 documents percentages of
drinkers from both the clinical and general
population samples who endorsed SADQ-C
items positively. A surprising number of the gen-
eral population drinkers reported experiencing
physical withdrawal symptoms-13.4% reported
morning sweating and 9.3% morning shakes.
The frequency of the 'affective' withdrawal item
`the day after drinking alcohol, I dreaded waking
AFF RELIEF CONS REINST
0.81
0.70 0.78
0.79 0.85 0.76
0.68 0.79 0.77 0.83
up in the morning' (17.9%) may reflect the
experience of 'hangovers'. The high frequency
with which the general population drinkers
endorse the first three 'reinstatement' items sug-
gests that these hypothetical questions only
tapped the extent to which most respondents
believed they would experience these symptoms
after two 'very heavy' drinking days. Far fewer
believed they would be 'craving for a drink' the
morning after such a binge (19.2%). ICQ items
were frequently endorsed positively by the gen-
eral population sample of drinkers. The items
which best discriminated them from the clinic
sample were whether they found it 'hard to stop'
after having two or three drinks (19.0°/0 versus
92.4%) and whether they ever planned to have at
least six drinks on a single occasion (28.3%
versus 94.9%). When reinstatement items were
not completed in the original SADQ it was
recommended that the total remaining score
was pro-rated (Stockwell et al., 1983). Using
weighted data to provide a representative com-
munity sample, the full breakdown of pro-rated
SADQ-C responses comprised 58% zero scores,
38% scoring 1-10, 3% 11-20 and only 1%
between 21 and 30.
4. Internal consistency and structure of the SADQC
and ICQ in a community sample
Method. A sub-sample of 330 persons from the
community sample was used for the following
analyses whose average daily consumption was
equal to or greater than one drink. Dependence
signs were so rare in persons who drank less
than this that to have included them would
have skewed the frequency distribution beyond
 Measurement of alcohol dependence 171

Table 2. Percentages of drinkers in both clinic and general

population samples report-
ing dependence signs at least 'sometimes' or 'slightly' in past
3 months
Clinic
sample
(94)

Populati
on
sample
(%)
SADQ-C item (ti =
197) (n =
944, weighted)
Physical withdrawal ("The day after drinking alc
Woke up sweaty

75.1
Hands shake in a.m..

72.1
Dread waking Body shakes in a.m.
50.3
Fear of people 64.0
Edge of despair 64.0
Frightened 59.9
Withdrawal relief ("The day after drinking alcohol
Liked a.m. drink 60.4
Gulped first few 36.5
Rid a.m. shakes 59.4
Strong craving 64.5

Consumption ("During past 3 months

drank more than ...:")
7 + drinks/day
15 + drinks/day
30 + drinks/day
60 + drinks/day

Reinstatement ("Morning after 2 very h

Start to sweat 8
Hands shake 7
Body shake 5
Crave a drink 8

tolerable limits for general population

parametric analysis. sample, so exploratory
Internal consistency factor analysis was used
was examined by to examine the internal
calculating split-half structure of the two
reliability coefficients and scales. As in the
also by calculating validation of the
correlations between original SADQ, the
the ICQ and the five quantity-frequency
SADQ-C sub-scales. scale was omitted from
This was the first time both the PCAs and
the questionnaire had tests of internal
been administered to a consistency since the
four items collectively further PCA was
form a scale and should conducted without the
not be examined reinstatement items.
individually. This resulted in a first
factor

Results. Cronbach
Alpha coefficients were
0036 for the SADQ-C
alone and 0.87 when
combined with the
ICQ. As shown in
Table 3, apart from the
Reinstatement sub-
scale, the individual
sub-scales of the
SADQ-C were highly
correlated both with
each other and also
with total ICQ score (p
< 0.001 in each case).
Factor Analysis of the
SADQ-C identified a
main factor which
accounted for 50.8% of
the variance and the
second and third
largest 21.0% and
8.2%, respectively. All
SADQ-C items bar
each of the four
hypothetical
'reinstatement' items
loaded significantly on
the main factor. The
second factor
comprised only the
reinstatement items,
while the third factor
comprised the three
most severe physical
morning withdrawal
items plus the
'affective' withdrawal
item 'I dread waking
up in the morning'. Both
Varimax and Oblimin
rotations resulted in
these same factor
solutions. These results
are all consistent with
the above suggestion
that the reinstatement
items are responded to
in a hypothetical
manner by a
community sample and
are not a useful indi-
cation of dependence.
As a consequence, a
172 Tim Stockwell et al.
Table 3. Pearson correlation coefficients for ICQ total score and SADQ-C
subscales for the general population sample of drinkers (n = 944)
PHYS AFF
PHYS
AFF 0.49
RELIEF 0.46 0.42
CONS 0.45 0.43
REINST 0.07 - 0.02
ICQ 0.40 0.43
which accounted for as much as 69.1% of the
total variance and upon which all remaining
SADQ-C items loaded significantly.
Discussion
(0 Can the SADQ be modified for use with non-
clinic populations of drinkers?
The short answer to this question is 'Yes, but in
a shortened form'. The SADQ was modified for
use in general population samples of drinkers
whom it cannot be assumed either drink heavily
or experience any alcohol-related problems.
While the same items were used in the new
questionnaire (the SADQ-C), the introductory
statement and the stems used for each question
required adaptation for non-problem drinkers.
The wording of the SADQ-C was found to be
clear to samples of drinkers and problem
drinkers alike. When administered to a clinic
sample, total scores on the two scales were found
to be almost identical and correlated almost per-
fectly. The SADQ-C had very high internal
reliability when administered to a large general
population sample of drinkers in a random
household survey, and also to a group of 197
problem drinkers attending a clinic.
Despite being apparently identical instruments
when used with problem drinkers, the new
SADQ-C could not be used in its entirety as a
measure of severity of alcohol dependence in the
community sample. PCA and correlational
analyses indicated that a complete sub-scale, that
concerning the 'reinstatement' of dependence
signs after a period of abstinence, tapped a sep-
arate construct to that of dependence. The
remaining 12 items (excluding the Quantity-Fre-
quency sub-scale) did, however, load on a large
main factor corresponding to degree of alcohol
dependence. The large amount of variance ex-
plained by the main factor (72%) is consistent
RELIEF CONS REINST
0.45
0.0] - 0.10
0.45 0.54 - 0.08
with the analysis of the original SADQ which,
prior to 11 items which loaded less strongly on
the main factor being dropped, produced a main
factor accounting for 53% of the total variance
(Stockwell et al., 1979). It is noteworthy that
there were also problems with the 'reinstate-
ment' section in the original SADQ with some
respondents refusing to answer hypothetical
questions (Stockwell et al., 1983).
We suggest that a reduced 16 item SADQ-C
can be used in general population studies in
which a measure of severity of dependence is
required. In order to contrast scores with those
obtained by clinic samples, total SADQ-C score
can be pro-rated as in the original study (Stock-
well et al., 1979).
(ii) How does the SADQ-C measure of alcohol
dependence relate to impaired control over drinking?
The SADQ-C was found to be highly correlated
with a new scale designed to measure impaired
control, the ICQ. Individual ICQ items corre-
lated significantly with total SADQ-C with
Pearson coefficients ranging from 0.68 to 0.81.
T ot al IC Q sc or e c or r e la t e d hi gh ly an d
significantly with SADQ-C score, there being a
Pearson coefficient of 0.90.
Edwards (1978) lists 'impaired control' over
alcohol consumption as an indication of the
presence of one of the core elements of the ADS,
namely 'a subjective awareness of a compulsion
to drink'. At the time when the original SADQ
was devised it was thought that a paper and
pencil test would be unable to tap so subtle a
concept. Indeed, when developing a structured
interview designed to measure degree of alcohol
dependence, Chick (1980) reported difficulty in
 Measurement of alcohol dependence 173

Table 4. Percentages of drinkers in clinic and general

population samples endorsing at least 'some-
times' for Impaired Control items
Clinic sample
(a = 197)
Item
After 2/3 drinks felt like more 97.0
After 2/3 drinks could stop 66.0
Hard to stop till drunk 92.4
Planned at least 6 drinks 94.9
Planned no more than 2 or 3 drinks 63.5

operationalizing predictive power, e.g.

impaired control. in relation to
Since that time, determining the
Heather, Rollnick & possibility of attaining a
Winston (19133) re- controlled drinking
ported that a goal.
'subjective scale' of
perceived likelihood
of being able control
one's drinking was a (iii) Is alcohol
better predictor of a dependence a uni-
successful 'harm-free' dimensional construct?
drinking outcome than
was a more 'objective' The findings of this
one—the SADQ. In investigation provide
fact, many of the items strong support for the
in the subjective scale view that alcohol
concerned whether dependence is a uni-
control over drinking dimensional construct
had been successfully whether it is applied to
exerted in the recent just problem drinkers
past. It would appear or to the wider group of
that these questions do all people who drink
succeed in accessing alcohol with any
impaired control and so regularity. PCA yielded
the ICQ was developed large main factors
with this in mind. corresponding to alcohol
dependence in both the
It can be concluded study samples. The
that the original failure of the
SADQ does in fact 'Reinstatement' of
correlate closely with dependence items in the
impaired control over SADQ-C for the
drinking as measured community sample
by the ICQ---just as should not be
Heather et al. (1983) interpreted as
found that their 'subjec- indicating a lack of
tive' measure of alcohol coherence of the ADS
dependence correlated concept. The high
highly with SADQ frequency of positive
score. Future research responses to these
will need to examine items in the absence of
whether pooling the two positive responses to
scales results in greater
other depe nde nce Conclusions
items indicate s tha t
they only The findings of this
study indicate that the
measure beliefs about short form of the
a hypothetical SADQ-C provides a
situation rather than an valid and reliable
actual experience of measure of degree of
dependence being alcohol dependence in
reinstated. general community
The strong samples. The full
correlations between version of the SADQ-C
the measures used in can also be used with
this study of physical samples of heavy or
withdrawal signs, problem drinkers and
affective withdrawal, can be considered the
drinking for the relief equivalent of the
of withdrawal, typical original SADQ for
level of alcohol which considerable
consumption evidence of reliability
(undoubtedly a good and validity has been
surrogate measure of amassed. Unlike the
tolerance) and original, the SADQ-C
impaired control focuses on the last
over drinking three months rather
provide good evidence than a 'recent period of
for the coherence of heavy drinking'. It may,
the ADS concept. The therefore, be better
fact that these suited for use as a
correlations are even treatment outcome
stronger in the measure. Further
sample of problem research will test the
drinkers (and utility of the full
include also the SADQ-C with and
measure of without the
`Reinstatement') also
supports the
proposition that the
coherence of the
proposed 'syndrome'
increases with its
increasing severity
(Edwards, 1978). The
finding that
substantial numbers
of drinkers in a
community sample
reported morning
'sweats' (14%) and
'shakes' (9%) is
further support for the
view that there is a
continuum of alcohol
dependence along
which all people who
drink alcohol with
any regularity can be
located.
174 Tim Stockwell et aL
brief ICQ as a predictor of the ability of problem
drinkers to regain control over their drinking.
A c k no w l e d g e me n t s
We would like to acknowledge Geoff Sayer for
his assistance with some of the statistical analy-
ses. The Perth-based authors were supported by
funding from the National Campaign Against
Drug Abuse while conducting this work.
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