CORK Bibliography: CRAFFT (Adolescent Screening Test

16 citations. 2003 to present

Prepared: September 2012

Burke PJ; O'Sullivan J; Vaughan BL. Adolescent substance use: Brief interventions by emergency care providers. (editorial). Pediatric Emergency Care 21(11): 770-776, 2005. (31 refs.)

Use of tobacco, alcohol and other drugs plays a major role in adolescent morbidity and mortality. When under the influence of alcohol or other drugs, adolescents are at increased risk for injuries, unprotected sex, or interpersonal violence. Alcohol and other drugs are major factors in adolescent deaths, contributing to motor vehicle crashes, homicides, and suicides. Adolescents tend to have shorter substance use histories therefore they often experience emergency/acute care health treatment resulting from Substance use related trauma and/or overdose. Substance use screening of adolescents who present to an Emergency Department (ED) is vitally important. The CRAFFT is a valid and reliable screening tool that was developed for use with adolescents. If an adolescent screens positive, then the next step is to determine their stage of use and readiness for change in preparation for doing a brief intervention. Helping patients to recognize the potential relation between their substance use and health related consequences, may motivate them to decrease their use for harm reduction. Motivational interviewing is an effective, evidence-based approach to helping people change their high risk behavior.

Chang G; Orav EJ; Jones JA; Buynitsky T; Gonzalez S; Wilkins-Haug L. Self-reported alcohol and drug use in pregnant young women: A pilot study of associated factors and identification. Journal of Addiction Medicine 5(3): 221-226, 2011. (19 refs.)

Objectives: This study describes the factors associated with self-reported substance use in pregnant young women attending a hospital clinic and evaluates 3 ways in its identification. Methods: A cross-sectional study of 30 pregnant young adults who responded to a mail survey containing the CRAFFT screening tool. All completed a diagnostic interview that included self-report information on their use of alcohol and drugs before and during pregnancy, the T-ACE screening tool, and the contexts in which they would be likely to use. Medical records were reviewed. Results: One-third of participants consumed alcohol, marijuana, or both while pregnant. Many had lifetime diagnoses of alcohol (23%) or cannabis (30%) use disorders, but only 1 met criteria for current diagnosis. Age, race, education, and children at home were not associated with either prenatal alcohol or cannabis use. Before pregnancy, alcohol drinking was associated with prenatal alcohol use (P = .02) and prenatal cannabis use (P = .06). Another trend of the before-pregnancy cannabis use being associated with prenatal cannabis use (P = .08) was observed. Most participants indicated little likelihood of substance use in convivial, intimate, or negative coping contexts while pregnant. However, participants with prenatal substance use had significantly higher convivial (P = .02) and intimate (P = .01) subscale scores of the Drinking Context Scale before pregnancy. Compared to the medical record and the T-ACE, the CRAFFT was best in identifying prenatal substance use (c-statistic = 0.9). Conclusions: The CRAFFT screening instrument and asking about the contexts during which alcohol might have been consumed before pregnancy are promising approaches in the identification of prenatal substance use.

Cook RL; Chung T; Kelly TM; Clark DB. Alcohol screening in young persons attending a sexually transmitted disease clinic: Comparison of AUDIT, CRAFFT, and CAGE instruments. Journal of General Internal Medicine 20(1): 1-6, 2005. (33 refs.)

OBJECTIVE: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance. DESIGN, PARTICIPANTS AND SETTING: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year. MEASUREMENTS: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID). RESULTS: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT. CONCLUSIONS: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.

Cummins LH; Chan KK; Burns KM; Blume AW; Larimer M; Marlatt GA. Validity of the CRAFFT in American-Indian and Alaska-native adolescents: Screening for drug and alcohol risk. Journal of Studies on Alcohol 64(5): 727-732, 2003. (36 refs.)

Objective: Native-American adolescents are reported to be at high risk for drug and alcohol use and related negative consequences. A brief screening instrument that is culturally and developmentally appropriate can aid clinicians who work with Native youth in determining whether more extensive assessment of substance use is necessary The CRAFFT has been shown to be a valid and reliable screen among general adolescent outpatient clinic samples. Method: Data were collected as part of the Journeys of the Circle project, a collaborative effort between the Seattle Indian Health Board (SIHB) and the University of Washington's Addictive Behaviors Research Center. Psychometric properties of the CRAFFT were examined in 70 American-Indian and Alaska-Native youths ages 13 to 19 recruited from public schools and SIHBs outpatient clinics. Results: The CRAFFT demonstrated good internal consistency (alpha = 0.81). A score of 2 or higher on the CRAFFT was found to be optimal for capturing youths with high alcohol-related problems (sensitivity, 0.95; specificity, 0.86), frequent alcohol use (sensitivity, 1.00; specificity, 0.72) and frequent marijuana use (sensitivity, 1.00; specificity, 0.75). A cut-point of 3 was appropriate for identifying adolescents with frequent other drug use (sensitivity, 0.86; specificity, 0.76). Conclusions: The CRAFFT may be a valid instrument for identifying Native youths at risk for alcohol and other drug problems. This brief screen can be effective in helping providers determine the need for further assessment and treatment or prevention services for Native-American adolescents.

Falck RS; Nahhas RW; Li LN; Carlson RG. Surveying teens in school to assess the prevalence of problematic drug use. Journal of School Health 82(5): 217-224, 2012. (34 refs.)

Background: Illicit drug use by school-aged teens can adversely affect their health and academic achievement. This study used a survey administered in schools to assess the prevalence of problematic drug use among teenagers in a Midwestern community. Methods: Self-report data were collected from 11th- and 12th-grade students (N = 3974) in 16 school districts in the Dayton, Ohio, area. Students responded to a drug use survey that also included CRAFFT, a brief substance abuse screening instrument. Binomial and zero-inflated Poisson regressions were used to examine the association between CRAFFT scores and drug use practices, including abstinence. RESULTS: More than one third of students had CRAFFT scores suggestive of problematic use. Of these, 14.1% had scores suggesting drug dependence. Although alcohol, marijuana, and tobacco were the drugs most commonly used, an array of other drugs including opioids, benzodiazepines, stimulants, hallucinogens, and dextromethorphan were also commonly used. Higher CRAFFT scores were associated with a greater number of drugs used (p < .0001). Proportionately more 12th graders than 11th graders had CRAFFT scores indicating problems (p < .0001). Among 12th graders, boys were more likely than girls to have CRAFFT scores indicating dependence (p = .01). Conclusions: The results suggest that problematic drug use among high school students is more prevalent than has been recognized previously. CRAFFT can be used easily to assess the prevalence of problematic drug use among teenagers in school settings. CRAFFT results can also inform prevention and intervention activities, particularly if the CRAFFT instrument is paired with a drug use survey.

Kelly TM; Donovan JE; Chung T; Bukstein OG; Cornelius JR. Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C, CRAFFT, RAPS4-QF, FAST, RUFT-Cut, and DSM-IV 2-Item Scale. Addictive Behaviors 34(8): 668-674, 2009. (46 refs.)

Background: This study compared six of the briefest screening instruments for detecting DSM-IV-defined Alcohol Use Disorder (AUD) among older adolescents treated in Emergency Departments (ED). Methods: The AUDIT-C, the RAPS4-QF, the FAST, the CRAFFT, the RUFT-Cut, and 2-Items from the Diagnostic and Statistical Manual IV of the American Psychiatric Association [American Psychiatric Association (1994). Diagnostic and Statistical Manual of Psychiatric Disorders, (1994) (DSM-IV). 4th ed. Washington D.C.: American Psychiatric Association] criteria for AUD (heretofore referred to as the DSM-IV 2-Item Scale) were evaluated against the criterion of a current DSM-IV diagnosis of either alcohol abuse or dependence. The instruments were administered to 181 alcohol-using older adolescents (57% males; age range 18-20 years) in an ED and compared using Receiver Operator Characteristic (ROC) analyses against the criterion of a current DSM-IV diagnosis of alcohol abuse or dependence. Results: Of these instruments, the DSM-IV 2-Item Scale performed best for identifying AUD (88% sensitivity and 90% specificity), followed by the FAST and the AUDIT-C. Conclusions: Two items from the DSM-IV criteria for AUD performed best for identifying ED-treated older adolescents with alcohol use disorders. The FAST and AUDIT-C performed well, but are longer and more difficult to score in the hectic environment of the Emergency Department.

Kelly TM; Donovan JE; Chung T; Cook RL; Delbridge TR. Alcohol use disorders among emergency department-treated older adolescents: A new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF. Alcoholism: Clinical and Experimental Research 28(5): 746-753, 2004. (43 refs.)

Background: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents.Methods: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis.Results: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%).Conclusions: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.

Kelly TM; Donovan JE; Chung T; Bukstein OG; Cornelius JR. Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C, CRAFFT, RAPS4-QF, FAST, RUFT-Cut, and DSM-IV 2-Item Scale. Addictive Behaviors 34(8): 668-674, 2009. (46 refs.)

Knight JR; Harris SK; Sherritt L; Van Hook S; Lawrence N; Brooks T et al. Adolescents' preference for substance abuse screening in primary care practice. Substance Abuse 28(4): 107-117, 2007

OBJECTIVE: To assess adolescents' preferences for substance abuse screening in primary medical care settings. DESIGN/METHODS: Twelve- to 18-year-old patients (N = 2133) arriving for routine care at a network of primary care sites completed an interview that included demographic items, the CRAFFT screen, and a questionnaire assessing preferences for screening method (paper questionnaire, computer, oral interview by nurse or doctor). A subgroup (n = 222) completed the CRAFFT directly on the computer. RESULTS: Across the entire sample, paper was the screening administration method most preferred (mean rank (MR) = 2.92, 95%CI 2.87-2.96) vs. computer (MR = 2.38, 2.33-2.43), nurse (MR = 2.43, 2.39-2.47), and doctor (MR = 2.30, 2.25-2.35). Among the participants who received the screening on the computer, however, computer (MR = 3.08, 95%CI 2.42-2.52) was statistically tied with paper (MR = 2.88, 2.75-3.02) and both were ranked significantly higher than nurse (MR = 2.06, 1.94-2.17) and doctor (MR = 1.98, 1.82-2.14). The findings were similar for participants' reports of being "very likely" to be honest when answering substance abuse screening questions. CONCLUSIONS: Adolescents should ideally be screened for substance abuse using paper or computer questionnaires.

Knight JR; Sherritt L; Harris SK; Gates EC; Chang G. Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcoholism: Clinical and Experimental Research 27(1): 67-73, 2003. (48 refs.)

Background: Adolescents should be screened for alcohol misuse as part of routine care. The objective of this study was to compare the criterion validity of the Alcohol Use Disorders Identification Test (AUDIT), the Problem Oriented Screening Instrument for Teenagers substance use/abuse scale (POSIT), and the CAGE and CRAFFT questions among adolescents. Methods: Fourteen- to 18-year-old patients arriving for routine healthcare at a large, hospital-based adolescent clinic completed the four screens and the criterion standard Adolescent Diagnostic Interview, which yields DSM-IV diagnoses of alcohol abuse and dependence. Receiver operating characteristic (ROC) curves were plotted to determine optimal cut-points. Areas under the ROC curves of the four screens were compared, and sensitivities and specificities were calculated. Results: Participants' past 12-month alcohol diagnostic classifications were as follows: no use (58.6%), nonproblem use (13.0%), problem use (20.8%), abuse (5.4%), and dependence (2.2%). Optimal cut-points associated with problem use or higher were 2 for AUDIT, I for POSIT, 1 for CAGE, and 1 for CRAFFT. ROC curve area of the CAGE was significantly lower compared with areas of all other screens. Sensitivities (95% confidence intervals) were AUDIT 0.88 (0.83-0.93), POSIT 0.84 (0.79-0.90), CAGE 0.37 (0.29-0.44), and CRAFFT 0.92 (0.88- 0.96); specificities were AUDIT 0.81 (0.77-0.85), POSIT 0.89 (0.86-0.92), CAGE 0.96 (0.94-0.98), and CRAFFT 0.64 (0.59- 0.69). Conclusions: The AUDIT, POSIT, and CRAFFT have acceptable sensitivity for identifying alcohol problems or disorders in this age group. The CAGE is not recommended for use among adolescents.

Levy S; Sherritt L; Harris SK; Gates EC; Holder DW; Kulig JW et al. Test-retest reliability of adolescents' self-report of substance use. Alcoholism: Clinical and Experimental Research 28(8): 1236-1241, 2004. (26 refs.)

Background: Adolescent substance abuse is a serious problem for which effective interventions are needed. To conduct trials of new therapies, investigators need reliable means of identifying potential participants and of measuring outcomes. The objective of this study was to determine the 1-week test-retest reliability of the CRAFFT screening test and of the timeline follow-back (TLFB) calendar method for measuring alcohol, cannabis, and other drug use. Methods: Ninety-three 12- to 18-year-old patients presenting for routine medical care to three urban adolescent clinics were administered the CRAFFT screen in both lifetime and past-year versions and a 90-day TLFB. Both measures were completed on the day of the clinic visit and again 1 week later. We computed K coefficients and the intraclass correlation coefficient (ICC) for the CRAFFT and computed the ICC separately for TLFB self-reports of alcohol and cannabis. Results: For the CRAFFT, kappa for individual items ranged from 0.31 to 0.86, and the ICC was 0.93 (95% confidence interval, 0.90-0.95). However, the total score of the lifetime CRAFFT at time 2 was significantly lower than at time 1; there was no difference in time 1 and time 2 total scores for the past-year version. The ICCs for past-90-days TLFB variables were as follows: drinking days, 0.92; drinks per occasion, 0.87; cannabis days, 0.83; and joints per occasion, 0.76. Past-30-day and past-60-day intervals compared favorably to past-90-day intervals. Conclusions: The CRAFFT screen is a reliable means of screening adolescents for substance abuse, although we recommend using the past-year version. The TLFB is a reliable method of quantifying adolescents' alcohol and cannabis use at intervals of 30, 60, or 90 days.

Kelly TM; Donovan JE; Chung T; Bukstein OG; Cornelius JR. Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C, CRAFFT, RAPS4-QF, FAST, RUFT-Cut, and DSM-IV 2-Item Scale. Addictive Behaviors 34(8): 668-674, 2009. (46 refs.)

McCabe SE; West BT; Teter CJ; Cranford JA; Ross-Durow PL; Boyd CJ. Adolescent nonmedical users of prescription opioids: Brief screening and substance use disorders. Addictive Behaviors 37(5): 651-656, 2012. (38 refs.)

Objectives: The objectives of this study are to examine the associations among a positive score on the CRAFFT (a substance use brief screening test for adolescents) and demographic characteristics, diversion sources, routes of administration, substance use behaviors and motivations associated with the use of prescription opioids without a legal prescription. Methods: In 2009-2010, a sample of 2744 middle and high school students from two Midwestern school districts in the United States self-administered a Web-based survey. Results: Approximately 5.6% (n = 148) of respondents reported past-year nonmedical use of prescription opioids (NMUPO). Of those reporting NMUPO, approximately 35.1% (n = 52) screened positive for substance use disorders based on the CRAFFT. Multiple logistic regression analyses indicated that the odds of buying prescription opioids, obtaining opioids from multiple diversion sources, administering opioids intranasally, and using opioids to get high were greater for nonmedical users with a positive CRAFFT screen as compared to NMUPO with a negative CRAFFT screen. NMUPO with a positive screen was motivated primarily for recreational purposes, while NMUPO with a negative screen was motivated almost exclusively by pain relief. Conclusions: The CRAFFT brief screening test for adolescents can be used to identify a subgroup of NMUPO at the highest risk for a substance use disorder as well as a subgroup of NMUPO who would benefit from appropriate pain management.

Moreno MA; Briner LR; Williams A; Brockman L; Walker L; Christakis DA. A content analysis of displayed alcohol references on a social networking web site. Journal of Adolescent Health 47(2): 168-175, 2010. (40 refs.)

Purpose: Exposure to alcohol use in media is associated with adolescent alcohol use. Adolescents frequently display alcohol references on Internet media, such as social networking web sites. The purpose of this study was to conduct a theoretically based content analysis of older adolescents' displayed alcohol references on a social networking web site. Methods: We evaluated 400 randomly selected public MySpace profiles of self-reported 17- to 20-year-olds from zip codes, representing urban, suburban, and rural communities in one Washington county. Content was evaluated for alcohol references, suggesting: (1) explicit versus figurative alcohol use, (2) alcohol-related motivations, associations, and consequences, including references that met CRAFFT problem drinking criteria. We compared profiles from four target zip codes for prevalence and frequency of alcohol display. Results: Of 400 profiles, 225 (56.3%) contained 341 references to alcohol. Profile owners who displayed alcohol references were mostly male (54.2%) and white (70.7%). The most frequent reference category was explicit use (49.3%); the most commonly displayed alcohol use motivation was peer pressure (4.7%). Few references met CRAFFT problem drinking criteria (3.2%). There were no differences in prevalence or frequency of alcohol display among the four sociodemographic communities. Conclusions: Despite alcohol use being illegal and potentially stigmatizing in this population, explicit alcohol use is frequently referenced on adolescents' MySpace profiles across several sociodemographic communities. Motivations, associations, and consequences regarding alcohol use referenced on MySpace appear consistent with previous studies of adolescent alcohol use. These references may be a potent source of influence on adolescents, particularly given that they are created and displayed by peers.

Nevitt JR; Lundak J; Galardi G. Profile of adolescent alcohol offenders in two rural midwestern counties. Psychological Reports 98(2): 379-384, 2006. (25 refs.)

Screening tools specifically developed for use with adolescents may be more sensitive predictors of relapse or recidivism than self-report inventories typically used to screen adults. 70 adolescents in a program for drunk drivers in two counties in southeastern Nebraska were given both the CRAFFT and the Alcohol Use Disorder Identification Test questionnaires during routine alcohol-dependency evaluations. The Michigan Alcoholism Screening Test was also given to 28 subjects selected at random. 11 boys and 6 girls did not successfully complete the program. Significant correlations obtained for AUDIT scores for both the CRAFFT (r(69) = .65, p < .01) and failure to complete diversion (r(69) = .23, p < .05). Subjects were grouped by age (18 and younger and over 18 years) and by sex. A 2 x 2 analysis of variance for scores on the AUDIT indicated significant main effects for both age (F-1,F-66 = 4.86, p < .05) and sex (F-1.66 = 5.96, p < .01). MAST and CRAFFT scores showed no age or sex differences. The AUDIT might be included in drug and alcohol assessments with similar samples of adolescents.

Subramaniam M; Cheok C; Verma S; Wong J; Chong SA. Validity of a brief screening instrument: CRAFFT in a multiethnic Asian population18. Addictive Behaviors 35(12): 1102-1104, 2010. (18 refs.)

Aim: To validate the CRAFFT screening test, against the DSM IV Axis 1-based diagnostic inventory in a population of adolescents and young adult males in Singapore. Methods: The 23,248 participants belonged to a cohort of males who had undergone a medical examination prior to enlistment for military service. This study took place between August 2004 and August 2005. Subjects underwent a two-stage assessment and were administered the CRAFFT questionnaire and the Composite International Diagnostic Interview (CIDI). Results: The mean age of the subjects was 19 years (range, 16 to 26 years). The CRAFFT showed moderately high levels of internal consistency (Cronbach's alpha=0.73). The optimum cutoff point for drug-related disorder either abuse or dependence and alcohol-related disorder either abuse or dependence criterions were found at CRAFFT score of 1 or higher. Conclusion: The CRAFFT test is a valid means of screening adolescents for substance-related disorders in a multiethnic population of adolescent and young adult males.

Bernard M; Bolognini M; Plancherel B; Chinet L; Laget J; Stephan P; Halfon O. French validity of two substance-use screening tests among adolescents: A comparison of the CRAFFT and DEP-ADO. Journal of Substance Use 10(6): 386-395, 2005. (30 refs.)

Aim: The objective of this study was to compare the criterion validity of the CRAFFT and DEPADO. Method: One hundred and sixty-three adolescents (80 from the general population and 83 regular substance users) completed the ADAD and the MINI questionnaires, as well as either the CRAFFT or the DEP-ADO in roughly equal proportions, between March 2002 and August 2003. Sensitivity and specificity were calculated. Results: Both questionnaires had high sensitivity but the DEP-ADO showed a better specificity than CRAFFT. A score equal or higher than 8 on the scale of DEP-ADO appeared to be an appropriate threshold for problems related to substance use. DEP-ADO had a sensitivity of 92.0% and a specificity of 80.6% with severity rating scores of ADAD (alcohol and drug areas combined). With the MINI diagnoses, DEP-ADO had a sensitivity of 95.1% and a specificity of 68.9%. Conclusion: DEP-ADO appears to have higher diagnostic utility for identifying substance use than CRAFFT in regard to sensitivity and specificity. However, the CRAFFT has the advantage of considering substance use over a lifetime period. Further studies should be targeting younger subjects and more diverse substance-use patterns.