CRAFFT Screening Test

Last updated
CRAFFT Screening Test
LOINC 71942-7

The CRAFFT [1] is a short clinical assessment tool designed to screen for substance-related risks and problems in adolescents. CRAFFT stands for the key words of the 6 items in the second section of the assessment - Car, Relax, Alone, Forget, Friends, Trouble. As of 2020, updated versions of the CRAFFT known as the "CRAFFT 2.1" and "CRAFFT 2.1+N" have been released.

Contents

The older version of the questionnaire contains 9 items in total, answered in a "yes" or "no" format. The first three items (Part A) evaluate alcohol and drug use over the past year and the other six (Part B) ask about situations in which the respondent used drugs or alcohol and any consequences of the usage. The CRAFFT 2.1 screening tool begins with past-12-month frequency items (Part A), rather than the previous "yes/no" question for any use over the past year, and the other six (Part B) questions remain the same.

The CRAFFT can function as a self-report questionnaire or an interview to be administered by a clinician. [2] Both employ a skip pattern: those whose Part A score is "0" (no use) answer the Car question only of Part B, while those who report any use in Part A also answer all six Part B CRAFFT questions. Each "yes" answer is scored as "1" point and a CRAFFT total score of two or higher identifies "high risk" for a substance use disorder and warrants further assessment.

Development and history

The CRAFFT Screening Test was developed by John R Knight, MD and colleagues at the Center for Adolescent Behavioral Health Research (CABHRe), formerly known as the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children's Hospital. [3] Their goal was to develop a screening tool that - like the CAGE questionnaire used for adults - was brief and easy to administer and score. [4] Unlike the CAGE, the CRAFFT was designed to be developmentally appropriate for adolescents and screen conjointly for both alcohol and drug use. Because motor vehicle crashes are a leading cause of death among adolescents, and often associated with alcohol and drug use, the CRAFFT includes a risk item to evaluate whether an adolescent has ever ridden in a car driven by someone (including themselves) who was under the influence of alcohol or other drugs. [5] It has been established as valid and reliable for identifying youth who need further assessment and therapeutic intervention [6] The CRAFFT was originally designed to screen adolescents at high risk of substance use disorders in primary medical care offices. However, the necessity for a universal 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. [7] 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 and widely implemented.[ citation needed ]

CRAFFT 2.1

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 2.1 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, CABHRe recommends that clinicians transition to using version 2.1. [8]

The CRAFFT 2.1 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). [1] 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. [2]

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 2.1 begins with past-12-month frequency items; i.e., "During the past 12 months, on how many days did you … [drink/use substance name]?"[ citation needed ]

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. [1] [3]

The CRAFFT 2.1 has been translated into the following languages: Albanian, Arabic, Burmese, Simplified Chinese, Traditional Chinese, Cape Verdean Creole, Haitian Creole, Dutch, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Laotian, Lithuanian, Nepali, Portuguese (Brazil), Portuguese (Portugal), Romanian, Russian, Somali, Spanish (Latin Am), Spanish (Spain), Swahili, Telugu, Turkish, Twi, and Vietnamese. [9]

CRAFFT 2.1+N

The CRAFFT 2.1+N expands upon the content from the CRAFFT 2.1 with the inclusion of the Hooked On Nicotine Checklist (HONC), which is a 10-item questionnaire that screens for dependence on tobacco and nicotine. [10] If a teen indicates use of a vaping device containing nicotine and/or flavors or any tobacco products within the frequency questions, they are prompted to answer the HONC questions as well. [11] A positive response to one or more of the items calls for further assessment regarding a serious problem with nicotine. [10]

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. [4] 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. [6] It is supported by many studies as a reliable and valid assessment of substance use and misuse in adolescents [7] [12] [13] and is considered an effective tool for assessing whether further assessment is warranted. [7] [14] [9] It has been well-validated against criterion standard psychological tests and structured psychiatric diagnostic interviews. [15] [16] [17] It has been recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents. [9] Findings suggest that pediatricians should regularly screen for substance use disorders in adolescents using the CRAFFT. [18]

The CRAFFT has been translated into many languages, including Albanian, Arabic, Burmese, Simplified Chinese, Traditional Chinese, Cape Verdean Creole, Haitian Creole, Dutch, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Laotian, Lithuanian, Nepali, Portuguese (Brazil), Portuguese (Portugal), Romanian, Russian, Somali, Spanish (Latin Am), Spanish (Spain), Swahili, Telugu, Turkish, Twi, and Vietnamese. [9] Studies attest to its validity and reliability across cultures. [19] [20] [21] [22] [23] [ excessive citations ]

See also

Related Research Articles

<span class="mw-page-title-main">Substance abuse</span> Harmful use of drugs

Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods that are harmful to the individual or others. It is a form of substance-related disorder. Differing definitions of drug abuse are used in public health, medical, and criminal justice contexts. In some cases, criminal or anti-social behavior occurs when the person is under the influence of a drug, and long-term personality changes in individuals may also occur. In addition to possible physical, social, and psychological harm, the use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.

<span class="mw-page-title-main">Alcohol dependence</span> Medical condition

Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol.

The Alcohol Use Disorders Identification Test (AUDIT) is a ten-item questionnaire approved by the World Health Organization to screen patients for hazardous (risky) and harmful alcohol consumption. It was developed from a WHO multi-country collaborative study, the items being selected for the AUDIT being the best performing of approximately 150 items including in the original survey. It is widely used as a summary measure of alcohol use and related problems. It has application in primary health care, medical clinics, and hospital units and performs well in these settings. Using different cut-off points, it can also screen for Alcohol Use Disorder (DSM-5) and Alcohol Dependence. Guidelines for the use of the AUDIT have been published by WHO and are available in several languages. It has become a widely used instrument and has been translated into approximately fifty languages.

The Denver Developmental Screening Test (DDST) was introduced in 1967 to identify young children, up to age six, with developmental problems. A revised version, Denver II, was released in 1992 to provide needed improvements. These screening tests provide information about a range of ages during which normally developing children acquire certain abilities and skills. By comparing a child’s development to the developmental age ranges in this tool, it allows providers to identify young children with developmental problems so that they can be referred for help.

The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems. The questionnaire takes less than one minute to administer, and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism. The CAGE questionnaire does not have a specific intended population, and is meant to find those who drink excessively and need treatment. The CAGE questionnaire is reliable and valid; however, it is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE questionnaire have been frequently implemented for such a purpose.

A depression rating scale is a psychometric instrument (tool), usually a questionnaire whose wording has been validated with experimental evidence, having descriptive words and phrases that indicate the severity of depression for a time period. When used, an observer may make judgements and rate a person at a specified scale level with respect to identified characteristics. Rather than being used to diagnose depression, a depression rating scale may be used to assign a score to a person's behaviour where that score may be used to determine whether that person should be evaluated more thoroughly for a depressive disorder diagnosis. Several rating scales are used for this purpose.

The Severity of Alcohol Dependence Questionnaire is a 20 item clinical screening tool designed to measure the presence and level of alcohol dependence.

<span class="mw-page-title-main">Substance use disorder</span> Continual use of drugs (including alcohol) despite detrimental consequences

Substance use disorder (SUD) is the persistent use of drugs despite the substantial harm and adverse consequences to one's own self and others, as a result of their use. In perspective, the effects of the wrong use of substances that are capable of causing harm to the user or others, have been extensively described in different studies using a variety of terms such as substance use problems, problematic drugs or alcohol use, and substance use disorder.The National Institute of Mental Health (NIMH) states that "Substance use disorder (SUD) is a treatable mental disorder that affects a person's brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications. Symptoms can be moderate to severe, with addiction being the most severe form of SUD".Substance use disorders (SUD) are considered to be a serious mental illness that fluctuates with the age that symptoms first start appearing in an individual, the time during which it exists and the type of substance that is used. It is not uncommon for those who have SUD to also have other mental health disorders. Substance use disorders are characterized by an array of mental/emotional, physical, and behavioral problems such as chronic guilt; an inability to reduce or stop consuming the substance(s) despite repeated attempts; operating vehicles while intoxicated; and physiological withdrawal symptoms. Drug classes that are commonly involved in SUD include: alcohol (alcoholism); cannabis; opioids; stimulants such as nicotine (including tobacco), cocaine and amphetamines; benzodiazepines; barbiturates; and other substances.

<span class="mw-page-title-main">Addiction</span> Disorder resulting in compulsive behaviours

Addiction is a neuropsychological disorder characterized by a persistent and intense urge to use a drug or engage in a behavior that produces natural reward, despite substantial harm and other negative consequences. Repetitive drug use often alters brain function in ways that perpetuate craving, and weakens self-control. This phenomenon – drugs reshaping brain function – has led to an understanding of addiction as a brain disorder with a complex variety of psychosocial as well as neurobiological factors that are implicated in addiction's development.

The Patient Health Questionnaire (PHQ) is a multiple-choice self-report inventory that is used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform disorders. It is the self-report version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool developed in the mid-1990s by Pfizer Inc. The length of the original assessment limited its feasibility; consequently, a shorter version, consisting of 11 multi-part questions - the Patient Health Questionnaire was developed and validated.

The Hypomania Checklist (HCL-32) is a questionnaire developed by Dr. Jules Angst to identify hypomanic features in patients with major depressive disorder in order to help recognize bipolar II disorder and other bipolar spectrum disorders when people seek help in primary care and other general medical settings. It asks about 32 behaviors and mental states that are either aspects of hypomania or features associated with mood disorders. It uses short phrases and simple language, making it easy to read. The University of Zurich holds the copyright, and the HCL-32 is available for use at no charge. More recent work has focused on validating translations and testing whether shorter versions still perform well enough to be helpful clinically. Recent meta-analyses find that it is one of the most accurate assessments available for detecting hypomania, doing better than other options at recognizing bipolar II disorder.

The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder. It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5–10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old. The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.

The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9–17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues. There is also a 10-item short form. The measure assesses the child's mood and behavior symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children's bipolar symptoms. The CMRS also can differentiate cases of pediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.

The Modified Checklist for Autism in Toddlers (M-CHAT) is a psychological questionnaire that evaluates risk for autism spectrum disorder in children ages 16–30 months. The 20-question test is filled out by the parent, and a follow-up portion is available for children who are classified as medium- to high-risk for autism spectrum disorder. Children who score in the medium to high-risk zone may not necessarily meet criteria for a diagnosis. The checklist is designed so that primary care physicians can interpret it immediately and easily. The M-CHAT has shown fairly good reliability and validity in assessing child autism symptoms in recent studies.

John R. Knight is an Associate Professor of Pediatrics at Harvard Medical School (HMS) and the Associate Director for Medical Education at the HMS Division on Addictions. In 1999, he founded the Center for Adolescent Substance Abuse Research (CeASAR) and its companion outpatient clinic, the Adolescent Substance Abuse Program (ASAP). CeASAR and ASAP were the first programs of their kind to be located at a children’s hospital. He is best known as the clinical scientist who developed and validated the CRAFFT substance abuse screen for adolescents. In 2008 he was named the inaugural incumbent of the Boston Children’s Hospital Endowed Chair in Developmental Medicine

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is a semi-structured interview aimed at early diagnosis of affective disorders such as depression, bipolar disorder, and anxiety disorder. There are different versions of the test that have use different versions of diagnostic criteria, cover somewhat different diagnoses and use different rating scales for the items. All versions are structured to include interviews with both the child and the parents or guardians, and all use a combination of screening questions and more comprehensive modules to balance interview length and thoroughness.

The nine-item Patient Health Questionnaire (PHQ-9) is a depressive symptom scale and diagnostic tool introduced in 2001 to screen adult patients in primary care settings. The instrument assesses for the presence and severity of depressive symptoms and a possible depressive disorder. The PHQ-9 is a component of the larger self-administered Patient Health Questionnaire (PHQ), but can be used as a stand-alone instrument. The PHQ is part of Pfizer's larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 takes less than three minutes to complete. It is scored by simply adding up the individual items' scores. Each of the nine items reflects a DSM-5 symptom of depression. Primary care providers can use the PHQ-9 to screen for possible depression in patients.

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a model that encourages mental health and substance use screenings as a routine preventive service in healthcare.

<span class="mw-page-title-main">Addiction severity index</span> Clinical assessment tool

The Addiction Severity Index (ASI) is used to assess the severity of patient's addiction and analyse the need of treatment which has been in use for more than 2 decades since its publication in 1992. It is used in a variety of settings such as clinics, mental health services in the US, the Indian Health Service and several European countries. One of its major applications is as a clinical assessment tool for clinicians to determine the severity of the addictions and the necessity for treatment through probing the patients' conditions in both health and social issues. 7 aspects including medical health, employment/ support status, drug and alcohol use, illegal activity and legal status, family and social relationships and psychiatric health were inquired.

References

  1. 1 2 3 Harris, Sion K; et al. (2015). "Adolescent substance use screening in primary care: validity of computer self-administered vs. clinician-administered screening". Subst Abus. 1 (37 ed.): 197–203.
  2. 1 2 Couper, M.; et al. (2012). "The design of grids in web surveys". Soc. Sci. Comput. Rev. 3 (31 ed.): 322–345.
  3. 1 2 Harris SK, Sherritt L, Copelas S, Knight JR. Reliability and validity of past-12-month use frequency items as opening questions for the updated CRAFFT adolescent substance use screening system. International Network on Brief Interventions for Alcohol and Drugs Annual Meeting, 2016. Lausanne, Switzerland.
  4. 1 2 Dhalla, S; Zumbo, BD; Poole, G (March 2011), "A review of the psychometric properties of the CRAFFT instrument: 1999–2010.", Current Drug Abuse Reviews, 4 (1): 57–64, doi:10.2174/1874473711104010057, PMID   21466499
  5. Cunningham, Rebecca M.; Walton, Maureen A.; Carter, Patrick M. (2018-12-20). "The Major Causes of Death in Children and Adolescents in the United States". New England Journal of Medicine. 379 (25): 2468–2475. doi:10.1056/NEJMsr1804754. ISSN   0028-4793. PMC   6637963 . PMID   30575483.
  6. 1 2 Mitchell, SG; Kelly, SM; Gryczynski, J; Myers, CP; O'Grady, KE; Kirk, AS; Schwartz, RP (2014), "The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs: a reevaluation and reexamination.", Substance Abuse, 35 (4): 376–80, doi:10.1080/08897077.2014.936992, PMC   4268117 , PMID   25036144
  7. 1 2 3 Knight, John R; Sherritt, Lon; Harris, Sion Kim; Chang, Grace (June 2002), "Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients", Archives of Pediatrics & Adolescent Medicine , 156 (6): 607–614, doi:10.1001/archpedi.156.6.607, PMID   12038895
  8. "Use the CRAFFT – CRAFFT" . Retrieved 2021-11-16.
  9. 1 2 3 4 "Get the CRAFFT", The Center for Adolescent Behavioral Health Research (CABHRe), Children's Hospital Boston, 2021, retrieved 15 November 2021
  10. 1 2 WHEELER, K; FLETCHER, K; WELLMAN, R; DIFRANZA, J (2004). "Screening adolescents for nicotine dependence: The hooked on nicotine checklist". Journal of Adolescent Health. 35 (3): 225–230. doi:10.1016/s1054-139x(03)00531-7. ISSN   1054-139X. PMID   15313504.
  11. CRAFFT (28 October 2021). "CRAFFT 2.1 Provider Manual" (PDF). CRAFFT. Archived (PDF) from the original on 2021-11-16. Retrieved 22 November 2021.
  12. Knight, JR; Sherritt, L; Harris, SK; Gates, EC; Chang, G (January 2003), "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, doi:10.1111/j.1530-0277.2003.tb02723.x, PMID   12544008
  13. Dhalla, Shayesta; Zumbo, Bruno D.; Poole, Gary (2011-03-01). "A review of the psychometric properties of the CRAFFT instrument: 1999–2010". Current Drug Abuse Reviews. 4 (1): 57–64. doi:10.2174/1874473711104010057. ISSN   1874-4745. PMID   21466499.
  14. Neinstein, Lawrence S; Gordon, Catherine M; Katzman, Debra K; Rosen, David S; Woods, Elizabeth R, eds. (2008), "CRAFFT", Adolescent Health Care: A Practical Guide (5th ed.), Wolters Kluwer / Lippincott Williams & Wilkins, p. 950, ISBN   978-0-7817-9256-1 , retrieved 21 November 2010
  15. Knight, J. R.; Shrier, L. A.; Bravender, T. D.; Farrell, M.; Vander Bilt, J.; Shaffer, H. J. (1999-06-01). "A new brief screen for adolescent substance abuse". Archives of Pediatrics & Adolescent Medicine. 153 (6): 591–596. doi:10.1001/archpedi.153.6.591. ISSN   1072-4710. PMID   10357299.
  16. Knight, John R.; Sherritt, Lon; Shrier, Lydia A.; Harris, Sion Kim; Chang, Grace (2002-06-01). "Validity of the CRAFFT substance abuse screening test among adolescent clinic patients". Archives of Pediatrics & Adolescent Medicine. 156 (6): 607–614. doi:10.1001/archpedi.156.6.607. ISSN   1072-4710. PMID   12038895.
  17. Dhalla, Shayesta; Zumbo, Bruno D.; Poole, Gary (2011-03-01). "A review of the psychometric properties of the CRAFFT instrument: 1999–2010". Current Drug Abuse Reviews. 4 (1): 57–64. doi:10.2174/1874473711104010057. ISSN   1874-4745. PMID   21466499.
  18. Levy, SJ; Kokotailo, PK (November 2011). "Substance use screening, brief intervention, and referral to treatment for pediatricians". Pediatrics. 128 (5): e1330–40. doi:10.1542/peds.2011-1754. PMID   22042818.
  19. Kandemir, H; Aydemir, Ö; Ekinci, S; Selek, S; Kandemir, SB; Bayazit, H (2015). "Validity and reliability of the Turkish version of CRAFFT Substance Abuse Screening Test among adolescents". Neuropsychiatric Disease and Treatment. 11: 1505–9. doi: 10.2147/NDT.S82232 . PMC   4484694 . PMID   26150721.
  20. Subramaniam, M; Cheok, C; Verma, S; Wong, J; Chong, SA (December 2010). "Validity of a brief screening instrument-CRAFFT in a multiethnic Asian population". Addictive Behaviors. 35 (12): 1102–4. doi:10.1016/j.addbeh.2010.08.004. PMID   20805016.
  21. Bertini, MC; Busaniche, J; Baquero, F; Eymann, A; Krauss, M; Paz, M; Catsicaris, C (April 2015). "Transcultural adaptation and validation of the CRAFFT as a screening test for problematic alcohol and substance use, abuse and dependence in a group of Argentine adolescents". Archivos Argentinos de Pediatria. 113 (2): 114–8. doi: 10.5546/aap.2015.eng.114 . PMID   25727823.
  22. Cummins, LH; Chan, KK; Burns, KM; Blume, AW; Larimer, M; Marlatt, GA (September 2003). "Validity of the CRAFFT in American-Indian and Alaska-Native adolescents: screening for drug and alcohol risk". Journal of Studies on Alcohol. 64 (5): 727–32. doi:10.15288/jsa.2003.64.727. PMID   14572196.
  23. Cote-Menendez, M; Uribe-Isaza, MM; Prieto-Suárez, E (2013). "[Validation for Colombia of the CRAFFT substance abuse screening test in adolescents]". Revista de Salud Publica (Bogota, Colombia). 15 (2): 220–32. PMID   24892665.

Further reading