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Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients

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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
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 cat-
egories determined by a concurrently administered sub-
stance-use problem scale and a structured psychiatric di-
agnostic 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 op-
erating characteristic curve, sensitivity, specificity, posi-
tive 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. Di-
agnostic classifications for substance use during the past
12months 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 prob-
lem (sensitivity, 0.76; specificity, 0.94; positive predic-
tive value, 0.83; and negative predictive value, 0.91), any
disorder (sensitivity, 0.80; specificity, 0.86; positive pre-
dictive value, 0.53; and negative predictive value, 0.96)
and dependence (sensitivity, 0.92; specificity, 0.80; posi-
tive 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 signifi-
cantly affected by age, sex, or race.
Conclusion: The CRAFFT test is a validmeans of screen-
ing adolescents for substance-related problems and dis-
orders, which may be common in some general clinic
populations.
Arch Pediatr Adolesc Med. 2002;156:607-614
S
UBSTANCE ABUSE is the num-
ber-one health problem in the
United States, with an esti-
mated annual cost of over
$414 billion.
1
It is linked to
more than 400000 preventable deaths each
year, and the treatment of associatedmedi-
cal problems places a huge burden on the
US health care system. Substance abuse af-
fects men and women of all races, ethnic
groups, and ages—including adoles-
cents. 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, andmore
than one fourth have used an illicit drug
other than marijuana.
3
Substance abuse has been linked to
both mental and physical health prob-
lems, making settings where adolescents
receivemedical care ideal places for screen-
ing and early intervention.
4-6
In recogni-
tion of this opportunity, the American
Medical Association’s Guidelines for Ado-
lescent Preventive Services recommend
that health care providers ask all adoles-
cent patients annually about their use of
alcohol and other drugs as part of rou-
tine care and further assess those who re-
port any use.
7
However, adherence to this
recommendation is low; less than one half
of physicians report screening all adoles-
cent patients for substance use, and less
than one fourth report screening for drink-
ing and driving.
8,9
The precise reasons that somany phy-
sicians fail to screen are unknown. How-
ever, barriers to screening for other pre-
ventable health risks include a belief that
the prevalence of the problem is low in the
physician’s own patient population, inad-
equate training, lack of time or personnel
ARTICLE
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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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 incorpo-
rated into their office routines.
The ideal instrument for screening adolescentsmust
bedevelopmentally appropriate, valid and reliable, andprac-
tical for use in busy medical offices. A number of screen-
ing devices are available for this purpose, including brief
questionnaires andorally administered tests.
14,15
Question-
naires are usually administered to patients in the waiting
room. To be practical, they must be designed to be com-
pleted by patientswithin the usualwaiting time, and scor-
ing proceduresmust be sufficiently streamlined so that re-
sults can be given to the physician before themedical visit
begins.Questionnairesmaybe targetedat substanceuse alone
or include this as just one part of a more comprehensive
adolescent screening. Questionnaires have certain limita-
tions.Theymay require staff time for administrationor scor-
ing. They may also pose a risk to adolescents’ confidenti-
ality, especiallywhenparents arepresent in thewaiting area.
Orally administered brief screens are usually tar-
geted 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 prac-
tical, they must be easy to administer, score, and remem-
ber. 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
How-
ever, studies among adolescents have not provided ad-
equate evidence of the CAGE test’s sensitivity or reliabil-
ity.
18,19
In addition, some of its items (eg, “Have you ever
had a drink first thing in themorning to steady your nerves
or get rid of a hangover [eye-opener]?”) are not develop-
mentally appropriate for adolescents.
One brief screening device, the CRAFFT test, was
developed specifically for use among adolescent medi-
cal patients.
20
Like CAGE,
16
CRAFFT is verbally admin-
istered, simple to score (each yes answer=1 point), and
PARTICIPANTS AND METHODS
DESIGN
This criterion standard study compared the CRAFFT score
with diagnostic classifications and screening categories de-
termined by a concurrently administered substance use/
abuse problem scale and a structured psychiatric diagnos-
tic interview.
PARTICIPANTS AND SETTING
The 538 study participants were 14- to 18-year-old pa-
tients coming for routine medical care to the Adolescent/
Young Adult Medical Practice at Children’s Hospital Bos-
ton, Boston, Mass, betweenMarch 15, 1999, and September
14, 2000. This practice serves both inner-city and subur-
ban youth from a wide range of social strata, racial groups,
and ethnic backgrounds. During the study recruitment pe-
riod, 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 sched-
uled patients before a clinic session and placed a recruit-
ment 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 practi-
tioner) invited eligible patients to participate in the study.
The provider completed the recruitment form, which in-
cluded demographic information, the provider’s impres-
sion 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 whowere deemed by the pro-
vider 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 pur-
pose of the study was to assess the value of screening ques-
tions 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 pro-
vider 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 mer-
chandise 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. De-
veloped by the National Institute on Drug Abuse (Bethesda,
Md), the POSIT was previously shown to be reliable among
adolescentmedical patients and a Substance Use/Abuse Scale
score of 2 or higher indicates increased risk.
24,25
The sec-
ond criterion standard was the Adolescent Diagnostic In-
terview (ADI),
26
a 30- to 90-minute structured diagnostic
interview, which yields alcohol- and drug-related diag-
noses (ie, abuse and dependence), according to the Diag-
nostic and Statistical Manual of Mental Disorders, Fourth Edi-
tion (DSM-IV).
27
The ADI has been well validated among
adolescents, and it can be administered by an appropri-
ately trained research assistant.
28,29
We used a structured
ADI training protocol for this study. All research assis-
tants read the ADImanual, watchedmodel interviews, prac-
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easy to remember. Its name is a mnemonic of the first
letters of key words in the test’s 6 questions. (Figure 1)
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 appro-
priate for teenagers. A pilot study among adolescent pa-
tients 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.
RESULTS
STUDY SAMPLE
During the 18-month recruitment period, providers in-
vited 711 adolescent patients to participate in the study.
We excluded a total of 41 patients (5.8%) because of cog-
nitive impairment (n=27), insufficient fluency in En-
glish (n=9), severe hearing impairment (n=2), an-
orexia nervosa (n=2), and psychosis (n=1). Of the 670
Have you ever ridden in a car driven by someone (including
yourself) who was “high” or had been using alcohol or drugs?
Do you ever use alcohol or drugs to relax, feel better about
yourself, or fit in?
Do you ever use alcohol or drugs while you are by yourself, alone?
Do you ever forget things you did while using alcohol or drugs?
Do your family or friends ever tell you that you should cut down on
your drinking or drug use?
Have you ever gotten into trouble while you were using alcohol or
drugs?
C
R
A
F
F
T
Figure 1. The CRAFFT questions.
ticed on volunteers, and were videotaped conducting prac-
tice 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, con-
ducted 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 (Mi-
crosoft, Redmond,Wash), which included automatic range
and logic checks and an entry-tracking log. We compared
the dual-entry files to identify discrepancies and recon-
ciled them by checking the original data source. The study
data manager then imported the cleaned dataset into Sta-
tistical Product and Service Solutions (SPSS) software (SPSS
Inc, Chicago, Ill) for analysis.
DATA ANALYSIS
Participants were divided into 5 mutually exclusive diag-
nostic groups based on their pattern of alcohol and other
drug use within the previous 12 months: (1) “no use” in-
cluded 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 whomet cor-
responding diagnostic criteria on the ADI interview for ei-
ther an alcohol- or drug-related disorder. Each ADI was
scored twice, first by a research assistant using the stan-
dard written instructions and then by computer using an
SPSS syntax algorithm developed by the instrument’s au-
thor.
26
In cases where the diagnoses were unclear, the prin-
cipal investigator (J.R.K.) and the study addiction psychia-
trist (G.C.) separately reviewed the entire ADI, discussed
any differences, and recorded the agreed-upon final diag-
noses. They were blinded to participants’ CRAFFT scores
while conducting these reviews.
The frequencies of demographic variables and partici-
pants’ diagnostic classifications were computed, and �
2
tests
were performed to determine whether proportions of demo-
graphic characteristics (ie, sex, age, and race/ethnicity) or pro-
vider impressions of alcohol or drug involvement differed be-
tween 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 me-
dian to preserve adequate cell size for analyses.We also trans-
formed the provider impression variables (ie, no use, occa-
sional use, problem use, abuse, dependence, and no
impression) into trichotomous variables (ie, no use/
occasional use, problem use/abuse/dependence, and no im-
pression) 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 as-
sess 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 be-
tween 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 specific-
ity) 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 cor-
rectly by CRAFFT), specificity (ie, probability that a true nega-
tive would be identified correctly by CRAFFT), positive pre-
dictive value (ie, probability that a CRAFFT-positive
participant was identified correctly), and negative predic-
tive value (ie, probability that a CRAFFT-negative partici-
pant was identified correctly) and used the bootstrap tech-
nique to estimate 95% confidence intervals.
30-32
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eligible patients, 538 (80.3%) agreed to participate. Rea-
sons most commonly cited for refusing included not
enough time (n=74), not interested (n=44), or camewith
a parent (n=8). The group of refusers did not differ sig-
nificantly 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 in-
cluded a significantly greater proportion of females (68.4%
vs 59.4%; P�.001).
DIAGNOSTIC CLASSIFICATIONS
Frequencies of participants’ demographic characteris-
tics and substance-related diagnostic classifications dur-
ing 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 dur-
ing the past year, and more than one fourth had experi-
enced 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, meth-
ylphenidate 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 re-
lated to cannabis use, and 2 were related to use of 3,4-
methylenedioxymethamphetamine (MDMAor “ecstasy”).
Participants with both abuse and dependence diagnoses
(eg, cannabis abuse and alcohol dependence) were clas-
sified as having dependence. Almost 10% of partici-
pants were classified with abuse and almost 7% with de-
pendence.
CRAFFT CHARACTERISTICS
The CRAFFT standardized item � was .68 and did not
increase with deletion of any item (range, .61-.65). Fre-
quencies 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 scoremedian was 1 (range,
0-6), and its distribution was highly skewed.
The CRAFFT score was strongly correlated with di-
agnostic classification (Spearman �=0.72; P�.001). For
diagnostic groups, the CRAFFTmedian scores (with in-
terquartile ranges) were no use, 0 (0-0); occasional use,
1 (0-1); problem use, 2 (1-3); abuse, 2 (1-3); and depen-
dence, 4 (2-5). The CRAFFT score discriminated ad-
equately among all groups (ie, mean ranks differed sig-
nificantly from each other and from all other groups)
except for problem use and abuse (Tamhane T2; P=.95).
Receiver operating characteristic curves are pre-
sented in Figure 2. These curves plot sensitivity against
1−specificity so that the curve area is an overall mea-
sure of a test’s accuracy. A receiver operating character-
istic area of 1 (upper-left corner of the graph) theoreti-
cally 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 re-
ceiver 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 predic-
tive values of a CRAFFT score of 2 or higher for identi-
fying each of the 3 screening categories are presented in
Table 2. Criterion validity did not differ significantly
by sex, age, or race/ethnicity.
COMMENT
This study provides good supportive evidence for the va-
lidity of the CRAFFT test as a substance abuse screen-
ing device for use among a general population of ado-
Table 1. Frequencies of Alcohol and Other Drug Diagnostic Classifications by Sex and Age in 538 Adolescent Patients*
Patient Characteristic
No. of
Patients
Diagnosis
No Use Occasional Use Problem Use Abuse Dependence
Total 538 267 (49.6) 127 (23.6) 57 (10.6) 51 (9.5) 36 (6.7)
Sex
Male 170 102 (60.0) 28 (16.5) 15 (8.8) 13 (7.6) 12 (7.1)
Female 368 165 (44.8) 99 (26.9) 42 (11.4) 38 (10.3) 24 (6.5)
Age, y
14 103 75 (72.8) 19 (18.4) 3 (2.9) 5 (4.9) 1 (1.0)
15 85 46 (54.1) 21 (24.7) 8 (9.4) 4 (4.7) 6 (7.1)
16 121 60 (49.6) 23 (19.0) 19 (15.7) 13 (10.7) 6 (5.0)
17 127 51 (40.2) 41 (32.3) 12 (9.4) 14 (11.0) 9 (7.1)
18 102 35 (34.3) 23 (22.5) 15 (14.7) 15 (14.7) 14 (13.7)
*Data given as number (percentage) of subjects unless otherwise indicated.
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lescent clinic patients. The CRAFFT test has acceptable
sensitivity and specificity for identifying all screening cat-
egories and among all demographic subgroups. The sen-
sitivity and specificity found in this study for the depen-
dence 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 screen-
ing 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 increas-
ing severity of diagnostic classification. Therefore, its dis-
criminant 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. Al-
though an � of .70 or higher is generally considered de-
A B C
1.00
0.75
0.50
0.25
0.00 0.25 0.50 0.75 1.00
Score Sensitivity Specificity
1 0.96 0.74
2
*
0.76 0.94
3 0.47 0.98
4 0.26 1.00
5 0.10 1.00
6 0.01 1.00
Score Sensitivity Specificity
1 0.98 0.66
2
*
0.80 0.86
3 0.58 0.94
4 0.36 0.98
5 0.16 1.00
6 0.02 1.00
Score Sensitivity Specificity
1 1.00 0.51
2
*
0.92 0.80
3 0.72 0.90
4 0.58 0.97
5 0.03 1.00
6 0.00 1.00
S
e
n
s
i
t
i
v
i
t
y
1.00
0.75
0.50
0.25
0.00 0.25 0.50 0.75 1.00
1–Specificity
1.00
0.75
0.50
0.25
0.00 0.25 0.50 0.75 1.00
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).
Table 2. Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV)
for Patients With CRAFFT Scores of 2 or Higher*
Patient
Characteristic
Sensitivity
(95% CI)
Specificity
(95% CI)
PPV
(95% CI)
NPV
(95% CI)
Any Problem (Problem Use, Abuse, or Dependence)
Overall 0.76 (0.68-0.83) 0.94 (0.92-0.96) 0.83 (0.76-0.89) 0.91 (0.88-0.94)
Male 0.78 (0.64-0.91) 0.94 (0.89-0.98) 0.79 (0.66-0.92) 0.93 (0.88-0.98)
Female 0.75 (0.66-0.83) 0.94 (0.91-0.97) 0.84 (0.76-0.91) 0.91 (0.87-0.94)
Younger† 0.68 (0.54-0.81) 0.96 (0.93-0.98) 0.79 (0.66-0.91) 0.93 (0.89-0.96)
Older‡ 0.80 (0.71-0.88) 0.92 (0.88-0.96) 0.84 (0.76-0.92) 0.89 (0.85-0.94)
Any Diagnosis (Abuse or Dependence)
Overall 0.80 (0.72-0.89) 0.86 (0.83-0.89) 0.53 (0.44-0.61) 0.96 (0.94-0.98)
Male 0.92 (0.80-1.00) 0.89 (0.83-0.94) 0.59 (0.41-0.74) 0.98 (0.96-1.00)
Female 0.76 (0.66-0.86) 0.85 (0.81-0.89) 0.51 (0.40-0.60) 0.95 (0.92-0.97)
Younger† 0.70 (0.53-0.87) 0.90 (0.86-0.94) 0.44 (0.28-0.59) 0.96 (0.94-0.99)
Older‡ 0.85 (0.75-0.94) 0.82 (0.76-0.87) 0.57 (0.47-0.67) 0.95 (0.91-0.98)
Dependence
Overall 0.92 (0.82-1.00) 0.80 (0.77-0.83) 0.25 (0.18-0.33) 0.99 (0.98-1.00)
Male 0.92 (0.73-1.00) 0.82 (0.76-0.88) 0.28 (0.14-0.43) 0.99 (0.98-1.00)
Female 0.92 (0.78-1.00) 0.79 (0.75-0.83) 0.24 (0.15-0.32) 0.99 (0.98-1.00)
Younger† 0.92 (0.75-1.00) 0.88 (0.84-0.91) 0.28 (0.15-0.41) 1.00 (0.99-1.00)
Older‡ 0.91 (0.77-1.00) 0.72 (0.67-0.78) 0.24 (0.15-0.33) 0.99 (0.97-1.00)
*CI indicates confidence interval.
†Younger patients were aged 14 years or older but younger than 16.7 years.
‡Older patients were aged 16.7 years or older but younger than 19 years.
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sirable, � 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 ques-
tion affirmatively based on having ridden in a car with
an intoxicated family member, rather than driving after
drinking or riding with an intoxicated peer. Nonethe-
less, 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 char-
acteristics of CRAFFT in Figure 2 and Table 2. Provid-
ers 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 pa-
tient populations. Overall, we recommend using a score
of 2 or higher as indicating a need for further assess-
ment. 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, re-
spectively) found in this study for CRAFFT in identify-
ing any disorder compare quite favorably with those found
by Bastiaens et al
35
for the substantively different RAFFT
test (0.89 and 0.69, respectively) and by Chung et al
18
for modified versions of the CAGE
16
(0.67 and 0.82, re-
spectively), TWEAK
36
(0.84 and 0.80, respectively), and
AUDIT
37
(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 rid-
ing with an intoxicated driver). Alcohol-associated mo-
tor 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 provid-
ers 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 ei-
ther the TWEAK or AUDIT tests. The TWEAK items are
weighted, and AUDIT was not designed for oral adminis-
tration. 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’ ques-
tions 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 reluc-
tant to discuss their alcohol and other drug use with the
pediatrician, even when parents are not present.
Few comparable validation studies have been con-
ducted 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 gen-
eral 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 ado-
lescent health care. They unquestionably reinforce the
importance of the existing Guidelines for Adolescent Pre-
ventive Services recommendations for universal sub-
stance abuse screening. These findings also suggest a need
for additional time and personnel to further assess the
substantial numbers of adolescents who will screen posi-
tive when universal screening is implemented. Positive
screens should be followed by a more complete sub-
stance use history, taken by either a physician or some
other trained health care professional. Unfortunately, re-
cent changes in the health care system have already placed
pressure on providers to seemore patients quickly. If uni-
versal 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 sub-
stance abuse treatment for adolescents. In clinic set-
tings 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 ad-
equate to meet this need. In our own metropolitan area,
adolescents needing substance abuse treatment are most
often referred to adult programs because so few adoles-
cent-only programs exist. Adult programs rarely accept
younger adolescents, and they are not designed to re-
spond to the unique developmental needs of younger or
older adolescents. New approaches, such as office-
based interventions, must be developed to adequatelymeet
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 adoles-
cent clinic. Prevalence rates among adolescent patients
seen in other clinics, family practices, or general pedi-
atric practices may be different. However, Chung et al
18
found a similar rate (18%) of alcohol disorders in an ado-
lescent 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 ex-
tent to which some participants may have underre-
ported 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 com-
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pares favorably with other methods of substance use de-
tection.
41,42
The 18-month study recruitment period in-
cluded 2 summers. Adolescentsmay 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 ran-
domly. Participants were consecutively recruited in ap-
proximately 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 preva-
lence estimates for disorders, remains a possibility. By
contrast, healthier and less-affected patientsmay 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 ad-
dress these limitations and include a larger andmore di-
verse 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 pri-
mary care providers a practical means of quickly iden-
tifying adolescent patients who needmore comprehensive
assessment or referral to substance abuse treatment spe-
cialists.
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 Har-
ris) from the Maternal and Child Health Bureau, Rock-
ville, and grant K24 AA00289 (Dr Chang) from the Na-
tional 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 Ado-
lescent/Young Adult Medical Practice at Children’s Hospi-
tal 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 compli-
mentary CRAFFT test pocket card may obtain one by con-
tacting the Center for Adolescent Substance Abuse Re-
search, Children’s Hospital Boston, 300 Longwood Ave,
Boston, MA 02115; telephone: 617-355-5433; fax: 617-267-
9397; Web site: www.ceasar-boston.org.
Corresponding author and reprints: John R. Knight, MD,
Center for Adolescent Substance Abuse Research, Chil-
dren’s Hospital Boston, 300 Longwood Ave, Boston, MA
02115 (e-mail: john.knight@tch.harvard.edu).
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