CRAFFT Screening Test

Development and history

The CRAFFT Screening Test was developed by John R Knight, MD and colleagues at the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children's Hospital. Their goal was to develop a screening tool that - like the CAGE questionnaire used for adults - was brief and easy to administer and score. Unlike the CAGE, the CRAFFT was designed to be developmentally appropriate for adolescents and screen conjointly for both alcohol and drug use. Because alcohol- and drug-related motor-vehicle crashes are the leading cause of death among adolescents, the CRAFFT includes a single risk item to evaluate this. It has been established as valid and reliable for identifying youth who need further assessment and therapeutic intervention The CRAFFT was originally designed to screen adolescents at high risk of substance use disorders in primary medical care offices. However, the necessity for an adolescent screening measure was made apparent by research findings suggesting that half of high school students drink, a third binge drink, and a fourth use marijuana. For drug use specifically, studies show that more than half of high school seniors have used an illegal drug of any kind and a fourth have used illegal drugs other than marijuana.^[7][8] In addition, more than two-thirds of high school seniors, half of sophomores, and a third of eighth graders have used alcohol in the past year.^[8] These findings also contributed to the identification of a need for a tool like the CRAFFT to be developed.

Version 2.0

This revised version of the CRAFFT screening tool incorporates changes that enhance the sensitivity of the system in terms of identifying adolescents with substance use, and presents new recommended clinician talking points, informed by the latest science and clinician feedback, to guide a brief discussion about substance use with adolescents. The CRAFFT 2.0 provides an updated and revised version of this well-validated and widely utilized adolescent substance use screening protocol. Although the previous version of the CRAFFT will still be available, CeASAR recommends that clinicians transition to using version 2.0.

The CRAFFT 2.0 screening tool begins with past-12-month frequency items, rather than the previous “yes/no” question for any use over the past year. A recent study examining these opening yes/no questions found that they had relatively low sensitivity in identifying youth with any past-12-month alcohol or marijuana use (62% and 72%, respectively). Research also has suggested that yes/no questions may contribute to lower sensitivity on certain measures by inhibiting disclosure of less socially desirable behaviors; i.e., they may be more prone to social desirability bias.

Alternatively, questions that ask “how many” or “how often” implicitly imply an expectation of the behavior, and may thus mitigate discomfort around disclosure. The instruction, “Say ‘0’ if none” follows each question to convey that non-use is also normative. The CRAFFT 2.0 now begins with past-12-month frequency items; i.e., “During the past 12 months, on how many days did you … [drink/use substance name]?”

This new set of frequency questions was tested in a recent study of 708 adolescent primary care patients ages 12–18 that found a sensitivity of 96% and specificity of 81% for detecting past-12-month use of any substance, suggesting better performance in identifying substance use compared to that of the “yes/no” questions found in the prior study. These data support the rationale to change the opening questions in the CRAFFT 2.0.

The CRAFFT 2.0 will be translated into the following languages: Chinese, Creole, French, German Hebrew, Japanese, Khmer, Korean, Laotian, Portuguese (Brazil and Portugal), Russian, Spanish (Spain and Latin America), Turkish, Ukrainian, and Vietnamese.

Psychometrics

Research has shown that CRAFFT has relatively high sensitivity and specificity, internal consistency, and test-retest reliability as a screener for alcohol and substance misuse. The CRAFFT questionnaire has been validated against the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and demonstrates good ability to distinguish between those with and without clinical levels of any DSM-5 substance use disorder. It is supported by many studies as a reliable and valid assessment of substance abuse in adolescents and is considered an effective tool for assessing whether further assessment is warranted. It has been well-validated against criterion standard psychological tests and structured psychiatric diagnostic interviews. It has been recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents. Findings suggest that pediatricians should regularly screen for substance abuse in adolescents using the CRAFFT.

The CRAFFT has been translated into many languages, including Mandarin, French, Haitian Creole, French, Hebrew, Japanese, Khmer, Laotian, Russian, Portuguese, Spanish, Turkish, and Vietnamese. Studies attest to its validity and reliability across cultures.