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Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients
John R. Knight, MD;
Lon Sherritt, MPH;
Lydia A. Shrier, MD, MPH;
Sion Kim Harris, PhD;
Grace Chang, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:607-614.
ABSTRACT
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Objective To determine the accuracy of the CRAFFT substance abuse screening test.
Design Criterion standard validation study comparing the score on the 6-item
CRAFFT test with screening categories determined by a concurrently administered
substance-use problem scale and a structured psychiatric diagnostic interview.
Screening categories were "any problem" (ie, problem use, abuse, or dependence),
"any disorder" (ie, abuse or dependence), and "dependence."
Setting A large, hospital-based adolescent clinic.
Participants Patients aged 14 to 18 years arriving for routine health care.
Main Outcome Measures The CRAFFT receiver operating characteristic curve, sensitivity, specificity,
positive predictive value, and negative predictive value.
Results Of the 538 participants, 68.4% were female, and 75.8% were from racial
and ethnic minority groups. Diagnostic classifications for substance use during
the past 12 months were no use (49.6%), occasional use (23.6%), problem use
(10.6%), abuse (9.5%), and dependence (6.7%). Classifications were strongly
correlated with the CRAFFT score (Spearman  , 0.72; P<.001). A CRAFFT score of 2 or higher was optimal for identifying
any problem (sensitivity, 0.76; specificity, 0.94; positive predictive value,
0.83; and negative predictive value, 0.91), any disorder (sensitivity, 0.80;
specificity, 0.86; positive predictive value, 0.53; and negative predictive
value, 0.96) and dependence (sensitivity, 0.92; specificity, 0.80; positive
predictive value, 0.25; and negative predictive value 0.99). Approximately
one fourth of participants had a CRAFFT score of 2 or higher. Validity was
not significantly affected by age, sex, or race.
Conclusion The CRAFFT test is a valid means of screening adolescents for substance-related
problems and disorders, which may be common in some general clinic populations.
INTRODUCTION
SUBSTANCE ABUSE is the number-one health problem in the United States,
with an estimated annual cost of over $414 billion.1
It is linked to more than 400 000 preventable deaths each year, and the
treatment of associated medical problems places a huge burden on the US health
care system. Substance abuse affects men and women of all races, ethnic groups,
and ages—including adolescents. Recent studies show that half of high
school students are current drinkers, one third binge drink, and one fourth
smoke marijuana.2 By their senior year in high
school, more than one half of students have used an illicit drug at least
once, and more than one fourth have used an illicit drug other than marijuana.3
Substance abuse has been linked to both mental and physical health problems,
making settings where adolescents receive medical care ideal places for screening
and early intervention.4-6
In recognition of this opportunity, the American Medical Association's Guidelines
for Adolescent Preventive Services recommend that health care providers ask
all adolescent patients annually about their use of alcohol and other drugs
as part of routine care and further assess those who report any use.7 However, adherence to this recommendation is low;
less than one half of physicians report screening all adolescent patients
for substance use, and less than one fourth report screening for drinking
and driving.8-9
The precise reasons that so many physicians fail to screen are unknown.
However, barriers to screening for other preventable health risks include
a belief that the prevalence of the problem is low in the physician's own
patient population, inadequate training, lack of time or personnel to perform
the screening, and perceived lack of effective treatments.10-13
Physicians may also lack familiarity with simple screening methods that can
be easily incorporated into their office routines.
The ideal instrument for screening adolescents must be developmentally
appropriate, valid and reliable, and practical for use in busy medical offices.
A number of screening devices are available for this purpose, including brief
questionnaires and orally administered tests.14-15
Questionnaires are usually administered to patients in the waiting room. To
be practical, they must be designed to be completed by patients within the
usual waiting time, and scoring procedures must be sufficiently streamlined
so that results can be given to the physician before the medical visit begins.
Questionnaires may be targeted at substance use alone or include this as just
one part of a more comprehensive adolescent screening. Questionnaires have
certain limitations. They may require staff time for administration or scoring.
They may also pose a risk to adolescents' confidentiality, especially when
parents are present in the waiting area.
Orally administered brief screens are usually targeted at substance
abuse alone and can be administered by the physician as part of the general
health interview or while performing the physical examination. To be practical,
they must be easy to administer, score, and remember. Simple yes or no questions
that lend themselves to mnemonic acronyms are ideal. The CAGE questions, which
are widely used in medical settings, are a good example of this type of brief
screen.16 The CAGE test has been shown to have
good validity among adult medical patients.17
However, studies among adolescents have not provided adequate evidence of
the CAGE test's sensitivity or reliability.18-19
In addition, some of its items (eg, "Have you ever had a drink first thing
in the morning to steady your nerves or get rid of a hangover [eye-opener]?")
are not developmentally appropriate for adolescents.
One brief screening device, the CRAFFT test, was developed specifically
for use among adolescent medical patients.20
Like CAGE,16 CRAFFT is verbally administered,
simple to score (each yes answer = 1 point), and easy to remember. Its name
is a mnemonic of the first letters of key words in the test's 6 questions.
(Figure 1)
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Figure 1. The CRAFFT questions.
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In contrast to the CAGE test, however, the CRAFFT test screens for other
drugs as well as for alcohol, and its questions were designed to be developmentally
appropriate for teenagers. A pilot study among adolescent patients who had
used alcohol and other drugs found that CRAFFT had promising concurrent validity
compared with a more lengthy scale.20 The purpose
of the current study was to determine the criterion validity of the CRAFFT
test among a larger, more general population of adolescent medical patients,
including those who had used alcohol and other drugs and those who had not.
PARTICIPANTS AND METHODS
DESIGN
This criterion standard study compared the CRAFFT score with diagnostic
classifications and screening categories determined by a concurrently administered
substance use/abuse problem scale and a structured psychiatric diagnostic
interview.
PARTICIPANTS AND SETTING
The 538 study participants were 14- to 18-year-old patients coming for
routine medical care to the Adolescent/Young Adult Medical Practice at Children's
Hospital Boston, Boston, Mass, between March 15, 1999, and September 14, 2000.
This practice serves both inner-city and suburban youth from a wide range
of social strata, racial groups, and ethnic backgrounds. During the study
recruitment period, the practice provided care to 4995 patients aged 10 to
24 years through both routine well-care and urgent-care visits; 2986 (60%)
of these patients were aged 14 to 18 years.
RECRUITMENT PROCEDURES
A research assistant reviewed the birth dates of all scheduled patients
before a clinic session and placed a recruitment reminder form on the cover
of the chart of each age-eligible patient. At the conclusion of the medical
visit, the primary care provider (ie, physician or nurse practitioner) invited
eligible patients to participate in the study. The provider completed the
recruitment form, which included demographic information, the provider's impression
of the patient's level of alcohol and other drug use, and the patient's response
to the invitation to participate. We informed providers at the beginning of
the study and periodically reminded them that their patient need not ever
have used alcohol or other drugs to participate.
We excluded patients who were unable to read and understand English
and those who were deemed by the provider to have acute medical or psychiatric
problems that precluded participation in research. A research assistant explained
the study procedures to interested patients and obtained signed assent. The
Children's Hospital Boston Committee on Clinical Investigation (institutional
review board) waived the requirement for parental consent in accordance with
current guidelines for adolescent health research.21-22
The research assistant told participants that the purpose of the study
was to assess the value of screening questions on use of alcohol and other
drugs and that we would keep their answers confidential. However, if we identified
a serious problem, we would notify their primary care provider so that he
or she could arrange appropriate care, which could include involving their
parents. After completing the assessment battery, each participant received
a $25 merchandise certificate as compensation for his or her time.
MEASUREMENTS
The assessment battery included the 6-item CRAFFT test and 2 criterion
standards. The first criterion standard was the 17-item Substance Use/Abuse
Scale from the Problem Oriented Screening Instrument for Teenagers (POSIT),23 which assesses substance-related problems and risks.
Developed by the National Institute on Drug Abuse (Bethesda, Md), the POSIT
was previously shown to be reliable among adolescent medical patients and
a Substance Use/Abuse Scale score of 2 or higher indicates increased risk.24-25 The second criterion standard was
the Adolescent Diagnostic Interview (ADI),26
a 30- to 90-minute structured diagnostic interview, which yields alcohol-
and drug-related diagnoses (ie, abuse and dependence), according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV).27
The ADI has been well validated among adolescents, and it can be administered
by an appropriately trained research assistant.28-29
We used a structured ADI training protocol for this study. All research assistants
read the ADI manual, watched model interviews, practiced on volunteers, and
were videotaped conducting practice interviews. Study investigators and the
ADI's author reviewed all videotapes to ensure initial competence, and the
trained research assistants periodically observed and rated each other to
ensure adherence.
A research assistant verbally administered the CRAFFT questions and
recorded participants' responses, conducted the ADI interview, and monitored
participants' completion of the paper/pencil version of the POSIT scale. All
data were entered twice into a specially designed data management program
based on Access 97 software (Microsoft, Redmond, Wash), which included automatic
range and logic checks and an entry-tracking log. We compared the dual-entry
files to identify discrepancies and reconciled them by checking the original
data source. The study data manager then imported the cleaned dataset into
Statistical Product and Service Solutions (SPSS) software (SPSS Inc, Chicago,
Ill) for analysis.
DATA ANALYSIS
Participants were divided into 5 mutually exclusive diagnostic groups
based on their pattern of alcohol and other drug use within the previous 12
months: (1) "no use" included participants who reported no use of alcohol
or other drugs; (2) "occasional use" included those who reported any use but
had a POSIT score less than 2 and did not have an ADI diagnosis; (3) "problem
use" included those with a POSIT score of 2 or higher but no ADI diagnosis;
and (4) "abuse" and (5) "dependence" included those who met corresponding
diagnostic criteria on the ADI interview for either an alcohol- or drug-related
disorder. Each ADI was scored twice, first by a research assistant using the
standard written instructions and then by computer using an SPSS syntax algorithm
developed by the instrument's author.26 In
cases where the diagnoses were unclear, the principal investigator (J.R.K.)
and the study addiction psychiatrist (G.C.) separately reviewed the entire
ADI, discussed any differences, and recorded the agreed-upon final diagnoses.
They were blinded to participants' CRAFFT scores while conducting these reviews.
The frequencies of demographic variables and participants' diagnostic
classifications were computed, and  2 tests were performed
to determine whether proportions of demographic characteristics (ie, sex,
age, and race/ethnicity) or provider impressions of alcohol or drug involvement
differed between the study sample and the group of refusers. We transformed
participant age into a dichotomous variable (ie, younger youth and older youth)
based on the sample median to preserve adequate cell size for analyses. We
also transformed the provider impression variables (ie, no use, occasional
use, problem use, abuse, dependence, and no impression) into trichotomous
variables (ie, no use/occasional use, problem use/abuse/dependence, and no
impression) because abuse and dependence impressions were uncommon and cell
sizes were not adequate for analysis.
We assessed the internal consistency of the CRAFFT test using the standardized 
coefficient. We computed the frequencies and distributions of the CRAFFT score
and the diagnostic classifications and measured their associations using the
nonparametric Spearman coefficient. To assess the ability of the CRAFFT
test to discriminate among diagnostic classification groups, we first converted
CRAFFT scores to ranks, then used 1-way analysis of variance and a post-hoc
comparison test to compare mean ranks between pairs of groups. Due to heteroscedasticity,
we used the Tamhane T2 post hoc comparison test (based on a t test) that did not assume equal variance.
We plotted receiver operating characteristic curves to determine the
optimal cut point for the CRAFFT test (ie, total score with the highest product
of sensitivity and specificity) for identifying 3 screening categories: any
problem (ie, problem use, abuse, or dependence), any diagnosis (ie, abuse
or dependence), or dependence. We calculated sensitivity (ie, probability
that a true positive would be identified correctly by CRAFFT), specificity
(ie, probability that a true negative would be identified correctly by CRAFFT),
positive predictive value (ie, probability that a CRAFFT-positive participant
was identified correctly), and negative predictive value (ie, probability
that a CRAFFT-negative participant was identified correctly) and used the
bootstrap technique to estimate 95% confidence intervals.30-32
RESULTS
STUDY SAMPLE
During the 18-month recruitment period, providers invited 711 adolescent
patients to participate in the study. We excluded a total of 41 patients (5.8%)
because of cognitive impairment (n = 27), insufficient fluency in English
(n = 9), severe hearing impairment (n = 2), anorexia nervosa (n = 2), and
psychosis (n = 1). Of the 670 eligible patients, 538 (80.3%) agreed to participate.
Reasons most commonly cited for refusing included not enough time (n = 74),
not interested (n = 44), or came with a parent (n = 8). The group of refusers
did not differ significantly from the study sample in age, sex, race/ethnicity,
or provider impressions of alcohol use, other drug use, or any substance use.
The study sample was also similar to the entire group of 14- to 18-year-old
clinic patients in distribution by age and race/ethnicity but included a significantly
greater proportion of females (68.4% vs 59.4%; P<.001).
DIAGNOSTIC CLASSIFICATIONS
Frequencies of participants' demographic characteristics and substance-related
diagnostic classifications during the previous 12 months are presented in Table 1. Participants were almost equally
distributed across years of age; 68.4% were female, 50.6% were black non-Hispanic,
24.2% were white non-Hispanic, 18.8% were Hispanic, and 6.5% were Asian/other.
Approximately one half of participants had used alcohol or other drugs during
the past year, and more than one fourth had experienced alcohol- or drug-related
problems. There were a total of 59 abuse diagnoses; 16 were for alcohol alone,
30 for other drugs alone, and 13 for both alcohol and other drugs. Of the
43 drug abuse diagnoses, 36 were related to cannabis, 5 to stimulants (including
caffeine pills, methylphenidate hydrochloride, and amphetamines), and 2 to
both cannabis and stimulants. There were a total of 36 dependence diagnoses;
7 were for alcohol alone, 24 for other drugs alone, and 5 for both alcohol
and other drugs. Of the 29 drug dependence diagnoses, 27 were related to cannabis
use, and 2 were related to use of 3,4-methylenedioxymethamphetamine (MDMA
or "ecstasy"). Participants with both abuse and dependence diagnoses (eg,
cannabis abuse and alcohol dependence) were classified as having dependence.
Almost 10% of participants were classified with abuse and almost 7% with dependence.
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Table 1. Frequencies of Alcohol and Other Drug Diagnostic Classifications
by Sex and Age in 538 Adolescent Patients*
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CRAFFT CHARACTERISTICS
The CRAFFT standardized item was .68 and did not increase with
deletion of any item (range, .61-.65). Frequencies of positive responses to
individual CRAFFT items (Figure 1)
were "ridden in a car," 42.6%; "use to relax," 15.6%; "use alone," 10.8%;
"forget things you did," 12.3%; "friends tell you to cut down," 8.4%; and
"gotten into trouble," 10.6%. The CRAFFT score median was 1 (range, 0-6),
and its distribution was highly skewed.
The CRAFFT score was strongly correlated with diagnostic classification
(Spearman = 0.72; P<.001). For diagnostic
groups, the CRAFFT median scores (with interquartile ranges) were no use,
0 (0-0); occasional use, 1 (0-1); problem use, 2 (1-3); abuse, 2 (1-3); and
dependence, 4 (2-5). The CRAFFT score discriminated adequately among all groups
(ie, mean ranks differed significantly from each other and from all other
groups) except for problem use and abuse (Tamhane T2; P = .95).
Receiver operating characteristic curves are presented in Figure 2. These curves plot sensitivity against 1 - specificity
so that the curve area is an overall measure of a test's accuracy. A receiver
operating characteristic area of 1 (upper-left corner of the graph) theoretically
indicates that the test is always correct, and an area of 0.5 (a diagonal
line bisecting the plot area) indicates that the accuracy is no better than
chance alone. The receiver operating characteristic areas for CRAFFT were
high for all screening categories (any problem = 0.92; any diagnosis = 0.90;
and dependence = 0.93). A CRAFFT score of 2 or higher was associated with
the maximal product of sensitivity and specificity, which is also the cut
point closest to the upper-left corner of the graph. This is one way of identifying
a screening test's optimal cut point, although it does not take into account
the test's cost/benefit ratio.33 The CRAFFT
optimal cut point was 2 for all 3 screening categories. One hundred thirty-two
(25%) of 538 participants had a CRAFFT score of 2 or higher. Sensitivity,
specificity, and positive and negative predictive values of a CRAFFT score
of 2 or higher for identifying each of the 3 screening categories are presented
in Table 2. Criterion validity
did not differ significantly by sex, age, or race/ethnicity.
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Figure 2. The CRAFFT test receiver operating
characteristic curves for any problem (ie, alcohol or other drug problem use,
abuse, or dependence) (A), any diagnosis (ie, abuse or dependence) (B), and
a dependence diagnosis (C). Asterisk indicates the optimal cut point (ie,
the maximum product of sensitivity and specificity).
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Table 2. Sensitivity, Specificity, Positive Predictive Value (PPV),
and Negative Predictive Value (NPV) for Patients With CRAFFT Scores of 2 or
Higher*
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COMMENT
This study provides good supportive evidence for the validity of the
CRAFFT test as a substance abuse screening device for use among a general
population of adolescent clinic patients. The CRAFFT test has acceptable sensitivity
and specificity for identifying all screening categories and among all demographic
subgroups. The sensitivity and specificity found in this study for the dependence
category were close to those reported in the previous pilot study (0.92 and
0.82, respectively) for identifying the need for inpatient treatment, a similar
condition, even though the pilot study was conducted in a much-higher-risk
sample.20 The CRAFFT test is designed to be
a screening tool, so its result is either positive or negative, and a positive
result indicates a need for further assessment. However, the CRAFFT score
is correlated with increasing severity of diagnostic classification. Therefore,
its discriminant properties can help clinicians estimate not only the presence
but also the magnitude of risk of substance-related problems. For example,
a score of 4 or higher should raise suspicion of substance dependence.
The standardized of .68 indicates that CRAFFT has an acceptable
degree of internal consistency. Although an of .70 or higher is generally
considered desirable, is partly a function of scale length, and the
CRAFFT test has only 6 items.34 It is interesting
that the did not increase with the deletion of any item, despite the
fact that the car question differs from all other items in the scale. This
question is designed to screen for risk of alcohol-related car crashes. Although
important, this risk is not necessarily related to having an alcohol- or drug-related
disorder. Some adolescents may answer this question affirmatively based on
having ridden in a car with an intoxicated family member, rather than driving
after drinking or riding with an intoxicated peer. Nonetheless, almost 43%
of the study participants answered "yes" to this question, and providers need
effective strategies to deal with this risk.
We have provided detailed information on the characteristics of CRAFFT
in Figure 2 and Table 2. Providers can therefore determine the optimal score cut
point for the screening category they most wish to target and how best to
interpret a positive screen in their own patient populations. Overall, we
recommend using a score of 2 or higher as indicating a need for further assessment.
A clinic provider can be reasonably reassured when CRAFFT is negative but
should assess his or her patient further when the test is positive. However,
the relative risk of a false-positive test (eg, additional interview) is low
compared with that of a false-negative (ie, missed diagnosis and opportunity
for early intervention). Some providers may therefore choose to further assess
those adolescents whose score is only 1.
The sensitivity and specificity (0.80 and 0.86, respectively) found
in this study for CRAFFT in identifying any disorder compare quite favorably
with those found by Bastiaens et al35 for the
substantively different RAFFT test (0.89 and 0.69, respectively) and by Chung
et al18 for modified versions of the CAGE16 (0.67 and 0.82, respectively), TWEAK36
(0.84 and 0.80, respectively), and AUDIT37
(0.97 and 0.75, respectively). The CRAFFT test presents some clear advantages
over these other brief screening tests. First, the CRAFFT is the only screening
test that includes an item on drinking and driving (or riding with an intoxicated
driver). Alcohol-associated motor vehicle accidents are a leading cause of
death among adolescents,38 and a question regarding
this risk should be a part of routine screening.
Second, the CRAFFT test screens for both alcohol and other drug problems,
whereas the CAGE, TWEAK, and AUDIT tests screen for alcohol problems alone.
Drug use is highly prevalent among adolescents,2
and most providers would likely prefer a single test that can screen for all
psychoactive substances simultaneously. Third, the CRAFFT test is simpler
to administer and score than either the TWEAK or AUDIT tests. The TWEAK items
are weighted, and AUDIT was not designed for oral administration. Although
written questionnaires may present an advantage in efficiency when patients
complete them in the waiting area, they are limited by risks to confidentiality.
One study reported that adolescent medical patients were frequently dishonest
when answering providers' questions about substance use because parents were
present.39 Providers can ask the CRAFFT questions
during the course of the adolescent's physical examination, after parents
have left the room. However, some adolescents may be reluctant to discuss
their alcohol and other drug use with the pediatrician, even when parents
are not present.
Few comparable validation studies have been conducted in general adolescent
clinic settings, and none of these included both a risk assessment (ie, the
POSIT scale) and a psychiatric diagnostic interview (ie, the ADI).18-20,24, 35
Our unique approach to validation of the CRAFFT test allows us to report on
the estimated prevalence and range of substance-related disorders among patients
in a general adolescent clinic. More than one half of patients in our clinic
had used alcohol or other drugs during the past year, and more than one fourth
had experienced serious substance-related problems. Almost 1 in 6 (16.3%)
had a substance-related diagnosis of abuse or dependence as defined by the DSM-IV.
These findings have serious implications for adolescent health care.
They unquestionably reinforce the importance of the existing Guidelines for
Adolescent Preventive Services recommendations for universal substance abuse
screening. These findings also suggest a need for additional time and personnel
to further assess the substantial numbers of adolescents who will screen positive
when universal screening is implemented. Positive screens should be followed
by a more complete substance use history, taken by either a physician or some
other trained health care professional. Unfortunately, recent changes in the
health care system have already placed pressure on providers to see more patients
quickly. If universal screening is to improve, health care systems must find
ways to provide the additional resources needed for assessment of substance-using
adolescents.
These findings also suggest a need to increase the capacity of systems
and communities to provide substance abuse treatment for adolescents. In clinic
settings such as ours, one fourth of patients need at least a brief intervention,
and one sixth likely need referral to a treatment specialist. Current resources
are not adequate to meet this need. In our own metropolitan area, adolescents
needing substance abuse treatment are most often referred to adult programs
because so few adolescent-only programs exist. Adult programs rarely accept
younger adolescents, and they are not designed to respond to the unique developmental
needs of younger or older adolescents. New approaches, such as office-based
interventions, must be developed to adequately meet the need for treatment.
There are limitations to the generalizability of our findings regarding
diagnostic classifications. This study was conducted in a single urban hospital-based
adolescent clinic. Prevalence rates among adolescent patients seen in other
clinics, family practices, or general pediatric practices may be different.
However, Chung et al18 found a similar rate
(18%) of alcohol disorders in an adolescent emergency department sample, and
one large study estimated the rate of current alcohol dependence for the 18
years and older US population at large to be 4.4%, with higher rates among
the young.40
This study relied on adolescents' self-report. The extent to which some
participants may have underreported and others overreported their use of substances
is unknown. However, self-report of alcohol and other drug use has been shown
to be generally reliable and compares favorably with other methods of substance
use detection.41-42 The 18-month
study recruitment period included 2 summers. Adolescents may use alcohol and
other drugs at higher rates when not in school, and recall bias may have resulted
in higher reports of past 12-month use by participants recruited during the
summer months.
The findings on prevalence may be further limited, in that the study
sample, although generally reflective of the clinic population at large, was
not selected randomly. Participants were consecutively recruited in approximately
half of the 12 clinic sessions conducted each week. We instructed providers
to invite all 14- to 18-year-old patients to participate, not only those who
had used alcohol or other drugs. However, we cannot assess to what degree
they followed this instruction; provider selection bias, resulting in higher
than actual prevalence estimates for disorders, remains a possibility. By
contrast, healthier and less-affected patients may have been more likely to
agree to participate in the study, resulting in self-selection bias and lower
than actual estimates of prevalence. Future studies on prevalence should address
these limitations and include a larger and more diverse group of clinic settings.
Despite these limitations, this study provides strong supportive evidence
for the criterion validity of the CRAFFT test. The CRAFFT test offers pediatricians,
nurse-clinicians, family practitioners, internists, and other primary care
providers a practical means of quickly identifying adolescent patients who
need more comprehensive assessment or referral to substance abuse treatment
specialists.
| What This Study Adds
Guidelines for universal screening of adolescent patients for substance
use have been available for some time. However, little attention has been
given to the specifics of how this screening should be conducted. Many widely
used screening devices are either impractical for busy medical offices or
developmentally inappropriate for adolescents. Also unknown is the likely
outcome of universal screening, ie, what proportion of adolescent patients
have alcohol- and drug-related disorders.
This study demonstrates that the brief CRAFFT test has good validity
for identifying substance-related problems and disorders in adolescent medical
patients. The screen can be orally administered, and it has a convenient mnemonic,
based on key words in each of the 6 yes or no questions. Substance-related
problems and disorders were highly prevalent in the clinic we studied, affecting
more than 1 in 4 patients. Studies proposing new intervention strategies for
those who screen positive are urgently needed.
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AUTHOR INFORMATION
Accepted for publication March 4, 2002.
This study was supported by grant R01 AA12165 from the National Institute
on Alcohol Abuse and Alcoholism, Bethesda, Md, and the Substance Abuse and
Mental Health Services Administration, Rockville, Md, and grant 036126 from
the Robert Wood Johnson Foundation, Princeton, NJ. Other support was provided
by grants 5T20MC000-11-06 (Dr Knight) and 5T71MC 00009-10 (Drs Shrier and
Harris) from the Maternal and Child Health Bureau, Rockville, and grant K24
AA00289 (Dr Chang) from the National Institute on Alcohol Abuse and Alcoholism.
We thank Erin Gates, BA, Elizabeth Gates, BA, Sarah Rosenberg, BA, and
Allison Arneill, MA, for assistance in study implementation; the clinicians
and staff of the Adolescent/Young Adult Medical Practice at Children's Hospital
Boston for assistance in recruitment; Ken C. Winters, PhD, for consultation
on the study measurement battery; and S. Jean Emans, MD, for review of the
manuscript.
We have found that laminated pocket cards listing the 6 CRAFFT questions
are helpful for administering the screen in actual office practice. Readers
who would like a complimentary CRAFFT test pocket card may obtain one by contacting
the Center for Adolescent Substance Abuse Research, Children's Hospital Boston,
300 Longwood Ave, Boston, MA 02115; telephone: 617-355-5433; fax: 617-267-9397;
Web site: http://www.ceasar-boston.org.
Corresponding author and reprints: John R. Knight, MD, Center for
Adolescent Substance Abuse Research, Children's Hospital Boston, 300 Longwood
Ave, Boston, MA 02115 (e-mail: john.knight{at}tch.harvard.edu).
From the Departments of Pediatrics (Drs Knight, Shrier, and Harris)
and Psychiatry (Dr Chang) and the Division on Addictions (Dr Knight and Mr
Sherritt), Harvard Medical School, the Center for Adolescent Substance Abuse
Research (Drs Knight, Shrier, Harris, and Chang and Mr Sherritt) and the Divisions
of General Pediatrics (Dr Knight and Mr Sherritt) and Adolescent/Young Adult
Medicine (Drs Shrier and Harris), Children's Hospital Boston, and the Department
of Psychiatry, Brigham and Women's Hospital (Dr Chang; Boston, Mass).
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3. Johnston L, O'Malley P, Bachman J. Monitoring the Future: National Survey Results on
Drug Use, 1975-2000. Volume 1: Secondary School Students. Bethesda, Md: National Institute on Drug Abuse; 2001. Available at: http://www.monitoringthefuture.org/pubs/monographs/vol1_2000.pdf. Accessed
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