Alcohol Dependence Scale (ADS)

1. Abstract

The Alcohol Dependence Scale (ADS) is an authoritative, 25-item clinical and diagnostic instrument developed by Harvey A. Skinner and John L. Horn in 1984, originating from the empirical research conducted at the Addiction Research Foundation in Toronto, Canada. Specifically designed to provide a quantitative assessment of the severity of alcohol dependence syndrome, the scale operationalizes the conceptual framework introduced by Griffith Edwards and Milton M. Gross (1976) for the World Health Organization (WHO). The instrument evaluates symptoms occurring across the preceding 12 months, capturing cardinal behavioral, physiological, and cognitive manifestations of alcohol addiction, including psychomotor withdrawal manifestations, impaired control over drinking, awareness of compulsive drinking, alcohol-induced withdrawal seizures, delirium tremens, and tolerance. Scored across polytomous, trichotomous, and dichotomous response formats, total scores range from 0 to 47. Extensively validated across psychiatric, addiction treatment, forensic, and primary care settings, the ADS exhibits robust internal consistency (Cronbach’s alpha typically ranging from .85 to .94) and high test-retest reliability (.92). Confirmatory and exploratory factor analyses consistently substantiate either a hierarchically unified unidimensional construct of core physiological dependence or a four-factor secondary structure comprising Loss of Behavioral Control, Psychomotor and Autonomic Withdrawal Symptoms, Obsessive-Compulsive Drinking Style, and Severe Neuropsychiatric/Perceptual Symptoms. The ADS demonstrates exceptional concurrent, predictive, and discriminant validity, demonstrating strong correlations with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for severe Alcohol Use Disorder (AUD), liver biomarker elevations, protracted detoxification requirements, and relapse vulnerability. This paper provides an exhaustive psychometric, theoretical, and clinical review of the instrument.

2. Keywords

Alcohol Dependence Scale, ADS, alcohol dependence syndrome, addiction psychometrics, alcohol withdrawal, impaired control, Harvey Skinner, psychometric validation, severity assessment, substance use disorder

3. Authors

The primary architects and psychometric investigators of the Alcohol Dependence Scale are:

• Harvey A. Skinner, Ph.D., C.Psych., FCAHS: Professor Emeritus and Founding Dean of the Faculty of Health at York University; formerly Professor and Chair of the Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Ontario, Canada; Senior Scientist at the Addiction Research Foundation (ARF, now the Centre for Addiction and Mental Health [CAMH]), Toronto, Ontario, Canada.
• John L. Horn, Ph.D.: Renowned psychometrician and cognitive psychologist; formerly Professor of Psychology at the University of Denver and the University of Southern California; pioneer in structural measurement models, multivariate behavioral research, and the Cattell-Horn-Carroll theory of cognitive capabilities.
• Barry A. Allen, Ph.D.: Research Associate and co-investigator at the Addiction Research Foundation, Toronto, Ontario, Canada, collaborating on early epidemiological and psychometric validation protocols of the Alcohol Dependence Syndrome.

Institutional Origin and Correspondence Contact:
Department of Public Health Sciences, Faculty of Medicine, University of Toronto, 12 Queen’s Park Crescent West, Toronto, Ontario, M5S 1A8, Canada. Documentation and administrative oversight have historically been maintained through the Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, ON M5S 2S1, Canada.

4. Purpose

The primary purpose of the Alcohol Dependence Scale (ADS) is to deliver a reliable, psychometrically sound, and dimensional measure of the severity of alcohol dependence in individuals who consume alcohol. Unlike broad screening instruments such as the Alcohol Use Disorders Identification Test (AUDIT) or the Michigan Alcoholism Screening Test (MAST)—which are calibrated to identify the binary presence or absence of hazardous drinking, social complications, or general alcohol-related harm—the ADS is specifically engineered for clinical populations where problematic drinking has already been established. Its focus is the precise quantification of the biological and behavioral core of dependence along a continuous spectrum.

The clinical and research necessity for the ADS arose from the recognition that alcoholism is not an all-or-nothing, categorical entity, but rather a graduated, multidimensional psychobiological syndrome. Precise quantification of this continuum is clinically essential because the degree of dependence dictates diagnostic stratification, medical detoxification management, pharmacotherapeutic interventions (e.g., naltrexone, acamprosate, disulfiram), and long-term treatment planning. In the absence of an empirical metric of severity, clinicians risk either undertreating severely dependent patients—exposing them to life-threatening withdrawal states such as status epilepticus or delirium tremens—or overtreating mildly dependent problem drinkers with unnecessary, restrictive inpatient programs.

In clinical practice, the ADS serves multiple critical functions:

• Stratification of Treatment Intensity: Total scores correspond directly to the patient placement criteria developed by the American Society of Addiction Medicine (ASAM). Patients scoring in lower quartiles (scores 1–13) typically benefit from outpatient brief interventions, motivational interviewing, and moderation-oriented counseling, whereas individuals in the upper quartiles (scores 22–30 and 31–47) mandate rigorous inpatient or intensive outpatient medical detoxification followed by an unequivocal goal of total abstinence.
• Anticipation of Medical Complications: By explicitly assessing physiological neuroadaptation, psychomotor shaking, autonomic hyperactivity (tachycardia, diaphoresis), sensory misperceptions, and withdrawal-induced seizures, the ADS provides clinical staff with immediate predictive indicators for complicated withdrawal syndromes requiring aggressive benzodiazepine-tapering regimens.
• Cognitive and Relapse Risk Profiling: Elevated scores on items evaluating blackouts, prolonged post-drinking cognitive clouding, and compulsive behavioral reinstatement signify severe central nervous system neurotoxicity and heightened vulnerability to immediate post-discharge relapse.
• Outcome Evaluation in Clinical Trials: In addiction research, the ADS functions as a gold-standard baseline covariate and primary or secondary outcome measure. It allows clinical trialists to control for baseline dependence severity when evaluating novel neuropharmacological agents and psychotherapeutic modalities.

5. Psychological Construct

The construct measured by the ADS is the Alcohol Dependence Syndrome, conceptualized as a distinct psychobiological cluster of cognitive, behavioral, and physiological phenomena wherein the consumption of alcohol assumes a markedly higher priority for a given individual than other behaviors that once had greater value. The scale delineates this overarching construct into several intercorrelated, highly specific clinical dimensions:

Loss of Behavioral Control and Compulsive Drinking

This dimension reflects the progressive impairment in the individual’s executive ability to regulate drinking behavior. It encompasses the phenomenon of “loss of control” following the initiation of drinking, characterized by an inability to reliably limit consumption to moderate levels, gulping beverages rapidly to accelerate intoxication, drinking continuously throughout the day, and repeated, unsuccessful efforts to cut down or cease drinking altogether. Neurobiologically, this represents frontostriatal dysfunction and dysregulated mesolimbic dopamine signaling, wherein cue-induced alcohol craving overrides prefrontal inhibitory control mechanisms.

Psychomotor and Autonomic Neuroadaptation

Repeated, chronic exposure to high doses of ethanol produces profound compensatory adaptations within central neurotransmitter circuits, notably downregulation of inhibitory gamma-aminobutyric acid (GABA_A) receptors and upregulation of excitatory N-methyl-D-aspartate (NMDA) glutamate receptors. When blood alcohol concentrations decline during sobering up, the unmasked hyperglutamatergic state generates severe psychomotor agitation and autonomic outflow. The ADS operationalizes this dimension via items measuring internal and peripheral tremulousness (“the shakes”), sudden diaphoresis, hyperhidrosis, autonomic tachycardia, gastrointestinal emesis, and psychomotor ataxia (stumbling, staggering, and weaving).

Severe Neuropsychiatric and Perceptual Manifestations

At the extreme end of the dependence spectrum lies gross neuropsychiatric breakdown during withdrawal and intoxication. This subconstruct includes transient and sustained perceptual distortions, such as formication (the vivid, terrifying sensation of tactile hallucinations, such as insects crawling under the skin), elementary or complex auditory hallucinations, visual hallucinations, panic attacks rooted in the terrifying anticipation of alcohol deprivation, and full-blown delirium tremens (DTs). It also captures alcohol-induced epileptiform activity (withdrawal seizures or fits) resulting from acute neuronal hyperexcitability.

Cognitive Impairment and Memory Disturbances

Chronic ethanol neurotoxicity and acute episodic neurochemical disruptions yield substantial cognitive pathology. This dimension is measured through the frequency and duration of anterograde amnesic episodes (blackouts), ranging from brief memory lacunae of less than an hour to catastrophic multi-day dissociative memory losses, as well as prolonged post-drinking cognitive clouding (“fuzzy or unclear thinking”) extending over multiple days.

Salience and Primacy of Alcohol Consumption

The behavioral narrowing of the individual’s daily repertoire is indexed by items measuring constant, intrusive obsessional thoughts regarding alcohol, carrying bottles or concealing alcohol in close physical proximity at all times, and rapid reinstatement of heavy drinking patterns following intervals of voluntary or involuntary abstinence.

6. Theoretical Framework

The conceptual foundation of the Alcohol Dependence Scale is rooted in the seminal work of British psychiatrist Griffith Edwards and American physician Milton M. Gross, who in 1976 formulated the Alcohol Dependence Syndrome construct under the auspices of a World Health Organization scientific group. Prior to the Edwards and Gross formulation, conceptualizations of alcoholism were fragmented, conflating moral failure, societal harm, non-specific psychological vulnerability, and heterogeneous medical end-organ pathologies (such as hepatic cirrhosis or pancreatitis) into an ill-defined diagnostic category.

Edwards and Gross revolutionized the field by proposing a clear, theoretical demarcation between two distinct entities:

1. The Alcohol Dependence Syndrome: An intrinsic, psychobiological, and behavioral syndrome characterized by an interrelated cluster of physiological and behavioral symptoms directly resulting from chronic, neuroadaptive alcohol consumption.
2. Alcohol-Related Disabilities: The secondary, extrinsic medical, psychological, psychiatric, occupational, familial, and legal consequences that arise as complications of heavy drinking.

Edwards and Gross postulated seven core, interrelated elements that constitute the dependence syndrome:

• Narrowing of the drinking repertoire: The drinking schedule becomes stereotypical, rigid, and disconnected from conventional environmental cues or social occasions.
• Salience of drink-seeking behavior: Maintaining alcohol intake takes priority over personal health, employment, family, and former values.
• Increased tolerance to alcohol: The requirement for markedly increased amounts of alcohol to achieve the desired psychological effect.
• Repeated withdrawal symptoms: The emergence of tremulousness, sweating, autonomic instability, and perceptual distortions upon cessation or reduction of drinking.
• Relief or avoidance of withdrawal symptoms: Drinking specifically to dispel or prevent withdrawal phenomena (e.g., morning drinking).
• Subjective awareness of a compulsion to drink: The internal psychological urge to drink, often characterized by a perceived loss of control.
• Reinstatement after abstinence: The rapid recurrence of the full physiological and behavioral dependence syndrome within days or weeks following a relapse after an extended period of abstinence.

In 1982 and 1984, Harvey A. Skinner and John L. Horn translated this conceptual model into an empirical psychometric instrument. Drawing from an initial pool of over 100 items derived from the Alcohol Use Inventory (AUI), Skinner and Horn isolated the 25 items that most directly, cleanly, and reliably operationalized the Edwards-Gross clinical features. The resulting ADS provided the scientific bridge that shifted psychiatric taxonomy away from dichotomous notions of alcoholism toward the continuous, dimensional framework ultimately adopted by the American Psychiatric Association in the DSM-III, DSM-IV, and DSM-5 (under Alcohol Use Disorder), as well as the International Classification of Diseases (ICD-10 and ICD-11).

7. Validity

The psychometric validity of the Alcohol Dependence Scale has been scrutinized and confirmed across dozens of clinical trials, forensic evaluations, and epidemiological studies involving tens of thousands of participants globally.

Construct and Structural Validity

Construct validity was established during the seminal psychometric derivation studies conducted by Skinner and Allen (1982). Administering the ADS alongside comprehensive medical, psychiatric, and cognitive assessment batteries, the researchers demonstrated that ADS scores loaded heavily on an overarching physiological dependence dimension. The construct reflects an orderly progression: individuals endorsement patterns conform to a Guttman-like simplex pattern, where mild psychological reliance and hangovers appear at low levels of the trait, whereas autonomic withdrawal, seizures, and delirium tremens emerge exclusively at high latent trait levels.

Convergent and Criterion Validity

The ADS exhibits profound convergent validity with other standardized addiction assessment measures and diagnostic systems:

• Diagnostic Congruence: ADS scores show high sensitivity and specificity in discriminating DSM-III, DSM-IV, and DSM-5 criteria for moderate to severe Alcohol Use Disorder. In clinical calibration studies, a cut-off score of 9 or greater yielded an area under the receiver operating characteristic curve (AUC) exceeding .88 for current psychiatric diagnoses of alcohol dependence.
• Correlation with Biological Markers: Significant positive correlations have been repeatedly documented between elevated ADS scores and hepatic biomarkers of chronic heavy ethanol consumption, including gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and mean corpuscular volume (MCV).
• Concordance with Structured Interviews: The ADS correlates strongly (r = .72 to .84) with interview-based instruments, including the Addiction Severity Index (ASI) Alcohol Composite Score and the Composite International Diagnostic Interview (CIDI).

Predictive Validity

The predictive utility of the ADS is particularly robust across clinical longitudinal cohorts:

• Severity of Inpatient Withdrawal: Prospective studies demonstrate that baseline ADS scores reliably predict the severity of acute alcohol withdrawal, as measured by the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). High ADS scores (>22) are associated with a six-fold increase in the likelihood of requiring high-dose intravenous benzodiazepines or medical intensive care unit (ICU) admission.
• Post-Treatment Relapse: In longitudinal tracking of individuals completing residential treatment, baseline ADS scores independently predicted time-to-first-drink and number of drinking days at 6- and 12-month follow-ups, with severely dependent individuals experiencing significantly accelerated relapse rates compared to individuals in low-dependence quartiles.

Discriminant Validity

The scale effectively discriminates between pure alcohol dependence and general psychological distress or primary psychiatric disorders. ADS scores maintain low-to-moderate correlations with generalized measures of neuroticism, anxiety, and depression (e.g., Beck Depression Inventory, SCL-90-R), confirming that the instrument captures the specific biological-behavioral consequences of alcohol consumption rather than generic emotional dysphoria or somatic symptom reporting.

8. Reliability

The Alcohol Dependence Scale demonstrates exceptional reliability across multiple metrics, testing populations, and delivery formats.

Internal Consistency

Across heterogeneous samples—ranging from voluntary outpatient substance use clinics to court-mandated impaired driving offenders and acute inpatient detoxification units—the internal consistency of the ADS is uniformly high:

• Seminal Development Cohorts: Skinner and Allen (1982) reported a Cronbach’s alpha (α) of .92 in their primary clinical derivation sample of 225 treatment-seeking individuals.
• Cross-Validation Studies: Subsequent extensive investigations (e.g., Blankfield, 1989; Ross, Gavin, & Skinner, 1990; Doyle, Donovan, & Kivlahan, 2007 in the COMBINE study) demonstrated Cronbach’s alpha coefficients consistently ranging between .85 and .94, confirming strong item covariance and minimal measurement error.
• Item-Total Correlations: Corrected item-total correlation coefficients for the 25 items range from .35 to .74, with the highest values observed for items reflecting core withdrawal tremulousness, compulsive morning drinking, and loss of control.

Test-Retest Reliability

Temporal stability assessments have revealed remarkable reproducibility across stable intervals. When administered to non-withdrawing, abstinent clinical participants over a one- to two-week test-retest interval, the Pearson product-moment correlation coefficient was r = .92 (p < .001). Even across longer windows (up to 3 months) among individuals maintaining their drinking baseline without active intervention, stability coefficients remained elevated (r > .80).

Inter-Rater and Modality Invariance

The instrument retains equivalent psychometric integrity whether completed as a self-administered paper-and-pencil inventory, via computerized or mobile electronic health interfaces, or when administered as a structured clinical interview by a trained clinician or psychiatric nurse. Intraclass correlation coefficients (ICC) across administration modalities consistently exceed .90.

9. Factor Analysis

The structural dimensionality of the Alcohol Dependence Scale has been the subject of extensive psychometric investigation employing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Original Exploratory Factor Structures

In the foundational work by Skinner and Horn (1984), principal components analysis with varimax and promax rotations supported a primary general factor capturing overall physiological alcohol dependence, alongside four meaningful clinical sub-factors accounting for approximately 53% to 60% of total variance:

• Factor I: Loss of Behavioral Control: Dominated by items measuring inability to stop drinking after one or two drinks (Item 25), gulping drinks (Item 24), failing in attempts to cut down (Item 23), daytime drinking (Item 15), and drinking to intoxication or passing out (Item 1). Primary loadings range from .52 to .78.
• Factor II: Psychomotor and Autonomic Withdrawal Symptoms: Composed of items assessing physical shaking upon sobering up (Item 3), physical sickness/vomiting (Item 4), feverish sweating (Item 7), tachycardia/rapid heartbeat (Item 17), and motor incoordination/staggering (Item 6). Primary loadings range from .58 to .81.
• Factor III: Obsessive-Compulsive Drinking Salience: Characterized by panic regarding alcohol availability (Item 9), carrying or concealing a bottle (Item 11), constant intrusive cognitions about alcohol (Item 18), and rapid reinstatement of heavy consumption after abstinence (Item 12). Factor loadings range from .48 to .73.
• Factor IV: Severe Neuropsychiatric and Perceptual Manifestations: Dominated by delirium tremens (Item 5), visual hallucinations (Item 8), auditory hallucinations (Item 19), tactile hallucinations/formication (Item 21), weird/frightening sensations (Item 20), withdrawal convulsions/seizures (Item 14), and profound extended blackouts (Items 10, 22). Factor loadings range from .55 to .84.

Confirmatory Factor Analysis and Structural Modeling

Subsequent confirmatory studies (e.g., Allen, 1991; Martin, Jacob, & Earleywine, 1996; Kahler et al., 2003) tested whether the ADS is best conceptualized as a strictly unidimensional scale, a multi-factor uncorrelated model, or a higher-order hierarchical model.

CFA results have demonstrated that a second-order hierarchical model—in which the four specific lower-order factors load onto an overarching, singular general factor of Alcohol Dependence—exhibits superior fit across multiple indices:

• Comparative Fit Index (CFI) values routinely exceed .93 to .96.
• Tucker-Lewis Index (TLI) values fall between .92 and .95.
• Root Mean Square Error of Approximation (RMSEA) remains within the acceptable range (≤ .05 to .06; 90% CI [.045, .068]).
• Standardized Root Mean Square Residual (SRMR) ≤ .05.

These findings substantiate the clinical practice of using both the single, aggregate composite score (0–47) for overall diagnostic severity stratification and individualized subscale profiles for nuanced clinical intervention planning.

10. Instrument / Measurement Tool

• Instrument Name: Alcohol Dependence Scale (ADS)
• Original Authors: Harvey A. Skinner, Ph.D. and John L. Horn, Ph.D.
• Publication Year: 1982 (Journal of Abnormal Psychology); 1984 (User’s Guide published by the Addiction Research Foundation)
• Construct Assessed: Severity of the psychobiological alcohol dependence syndrome along a continuous continuum
• Target Population: Adolescents and adults (ages 16 and older) with suspected or confirmed history of alcohol consumption; psychiatric patients, medical inpatients, outpatients, forensic and impaired-driving populations
• Administration Format: Self-report paper-and-pencil questionnaire, clinician-administered structured interview, or computer/digital assessment
• Completion Time: Approximately 5 to 10 minutes
• Total Number of Items: 25 items
• Recall Window: Previous 12 months
• Item Response Formats and Scoring Logic:
  • Dichotomous Items (2 response choices): Items 2, 9, 15, 18, 24, and 25. Scored 0 (indicating absence of symptom) or 1 (indicating presence of symptom). Note that Item 25 is reverse-keyed (“Yes” = 0, “No” = 1).
  • Trichotomous Items (3 response choices): Items 1, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 17, 19, 20, 21, and 23. Scored 0, 1, or 2, reflecting increasing frequency or severity.
  • Polytomous Items (4 response choices): Items 10, 16, and 22. Scored 0, 1, 2, or 3, reflecting graduated progression of blackouts and post-intoxication cognitive clouding.
• Total Score Range: 0 to 47 points (calculated by summing the numerical scores across all 25 items).
• Standard Clinical Interpretation Bands & ASAM Placement Guide:
  • 0 points: No evidence of alcohol dependence reported. Does not rule out hazardous drinking or social alcohol problems. Validate self-report; provide general education/advice.
  • 1 to 13 points (1st Quartile): Low level of alcohol dependence. Symptoms are predominantly psychological rather than physiological. Suggested care: Brief intervention, outpatient motivational counseling, ASAM Level I care. Controlled/moderation drinking goals may be viable if no contraindications exist. (Note: A score of 9+ is highly indicative of meeting DSM criteria for alcohol abuse/dependence).
  • 14 to 21 points (2nd Quartile): Intermediate level of alcohol dependence. Definite psychological dependence; early emergence of physical tolerance and minor withdrawal symptoms. Suggested care: Structured outpatient addiction treatment (ASAM Level I or Level II). Abstinence-oriented goals strongly favored.
  • 22 to 30 points (3rd Quartile): Substantial level of alcohol dependence. Established physical neuroadaptation with marked withdrawal symptoms. Significant risk for medical, psychiatric, and social complications. Suggested care: Intensive outpatient or residential/inpatient treatment (ASAM Level II or Level III). Monitored medical detoxification is indicated; complete abstinence is the primary recommended treatment goal.
  • 31 to 47 points (4th Quartile): Severe level of alcohol dependence. Severe physical dependence with elevated probability of life-threatening withdrawal complications (delirium tremens, withdrawal convulsions), end-stage hepatic or neurological disease, and severe cognitive impairment. Suggested care: Immediate inpatient medical detoxification followed by long-term intensive residential rehabilitation (ASAM Level III or Level IV). Total lifelong abstinence is mandatory.

11. Permissions & Fee and Test Year

Publication History: The Alcohol Dependence Scale was developed during the late 1970s and early 1980s under the auspices of the Addiction Research Foundation (ARF) in Toronto, Ontario, Canada. The foundational psychometric validation paper was published in 1982 in the Journal of Abnormal Psychology (Skinner & Allen, 1982), and the definitive clinical manual and user guide were published in 1984 (Skinner & Horn, 1984).

Copyright and Ownership: Copyright © 1984 by the Addiction Research Foundation of Ontario (now merged into the Centre for Addiction and Mental Health [CAMH]). All proprietary, intellectual, and distribution rights are maintained under CAMH.

Permissions, Licensing, and Fees: The ADS was developed with public funding and has historically been placed in wide clinical and research circulation to advance the identification and treatment of substance use disorders. Academic researchers, non-profit institutions, and practicing clinicians are generally permitted to use the scale for non-commercial clinical assessment and empirical research without paying per-administration royalty fees, provided full bibliographic citation and copyright acknowledgment are attributed to Harvey A. Skinner and CAMH. However, incorporation of the instrument into commercial software platforms, electronic health record (EHR) systems for commercial resale, or sponsored industry clinical trials may require formal written licensing permission. Inquiries regarding permissions and official test manuals may be directed to:

Centre for Addiction and Mental Health (CAMH)
Publications and Intellectual Property Licensing
33 Russell Street, Toronto, Ontario, M5S 2S1, Canada
Website: https://www.camh.ca

12. References

• Edwards, G., & Gross, M. M. (1976). Alcohol dependence: Provisional description of a clinical syndrome. British Medical Journal, 1(6017), 1058–1061. https://doi.org/10.1136/bmj.1.6017.1058
• Skinner, H. A., & Allen, B. A. (1982). Alcohol dependence syndrome: Measurement and validation. Journal of Abnormal Psychology, 91(3), 199–209. https://doi.org/10.1037/0021-843X.91.3.199
• Skinner, H. A., & Horn, J. L. (1984). Alcohol Dependence Scale (ADS): User’s Guide. Addiction Research Foundation. Toronto, Canada.
• Horn, J. L., Skinner, H. A., Wanberg, K., & Foster, F. M. (1984). Alcohol Use Inventory (AUI): Manual. Psychological Assessment Resources (PAR). Odessa, FL.
• Blankfield, A. (1989). The Alcohol Dependence Scale (ADS): A validation study in an Australian clinical population. Drug and Alcohol Dependence, 23(2), 127–134. https://doi.org/10.1016/0376-8716(89)90018-9
• Ross, H. E., Gavin, D. R., & Skinner, H. A. (1990). Diagnostic validity of the MAST and the Alcohol Dependence Scale in the assessment of DSM-III alcohol disorders. Journal of Studies on Alcohol, 51(6), 506–513. https://doi.org/10.15288/jsa.1990.51.506
• Martin, C. S., Jacob, T., & Earleywine, M. (1996). Factor structure of the Alcohol Dependence Scale in a clinical sample. Alcoholism: Clinical and Experimental Research, 20(3), 519–523. https://doi.org/10.1111/j.1530-0277.1996.tb01085.x
• Kahler, C. W., Strong, D. R., Hayaki, J., Ramsey, S. E., & Brown, R. A. (2003). An item response analysis of the Alcohol Dependence Scale in a clinical sample. Journal of Studies on Alcohol, 64(1), 127–136. https://doi.org/10.15288/jsa.2003.64.127
• Doyle, S. R., Donovan, D. M., & Kivlahan, D. R. (2007). The COMBINE Study: Conceptual and empirical relationships among measures of alcohol consumption and dependence. Journal of Studies on Alcohol and Drugs, 68(4), 574–584. https://doi.org/10.15288/jsad.2007.68.574
• American Society of Addiction Medicine. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (3rd ed.). American Society of Addiction Medicine. Chevy Chase, MD.

13. Items of the Scale (Questionnaire)