CRAFFT Screening Test

The CRAFFT screening

This is a health tool that screens for substance abuse (drug and alcohol use) in adolescents with potential risk factors. It is based on the CRAFFT questionnaire, a screening method built and validated in the US by John R Knight, MD and colleagues at the Center for Adolescent Substance Abuse Research CeASAR.

The American Academy of Pediatrics' Committee on Substance Abuse has recommended it for periodic monitoring usage within adolescent populations.

The CRAFFT assessment is usually applied when there are concerns regarding an adolescent or young person’s substance abuse and in case the clinician had already discussed with the patient about such type of misuse. This aims to be the young person version for substance related high risk behaviors similar to what the CAGE or the FAST alcoholism questionnaire represents for adults.

Sometimes, before applying the six questions, the clinician will ask the subject whether they:

1. Drink any alcohol (more than a few sips)?

2. Smoke any marijuana or hashish?

3. Use anything else to get high?

In the clinical setting, in case the patient answers with "no" to any of the above three questions, the assessment is continued with just the first question. If the patient answers positive to any of the above, then the whole CRAFFT is applied.

These questions evaluate alcohol and drug use over the past year while the following six focus on the effects of usage. In case the patient denies any usage and the protocol with the car question is applied, the clinician then has to advise the young person in regards to the possible consequences of such risky behavior and monitor the case after a period of time for other risk factors.

In order to obtain reliable and truthful reactions from the subject, the clinician is advised to underline the confidential component of the assessment.

The main CRAFFT items from which the acronym arises, emphasize the main focus words in the questions: Car, Relax, Alone, Forget, Family and Trouble. These are answerable with “yes” or “no”:

1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?*

2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself Alone?

4. Do you ever Forget things you did while using alcohol or drugs?

5. Do your Family or friends ever tell you that you should cut down on your drinking or drug use?

6. Have you ever been in Trouble while you were using alcohol or drugs?

*This question is specifically designed because alcohol and drug related motor vehicle incidents are the main mortality cause among young persons.

The CRAFFT questions are often used in other assessment processes such as the CAF (Common Assessment Framework for parents, carers and children) or the ASSET method in order to distinguish which patients qualify under the clinical levels of substance use disorder.

The DSM-IV Diagnostic Criteria³ (Abbreviated) introduces guidance for the diagnosis of substance abuse and dependance and these are presented below.

Substance Abuse (1 or more of the following):

■ Use causes failure to fulfill obligations at work, school, or home;

■ Recurrent use in hazardous situations (e.g. driving);

■ Recurrent legal problems;

■ Continued use despite recurrent problems.

Substance Dependence (3 or more of the following):

■ Tolerance;

■ Withdrawal;

■ Substance taken in larger amount or over longer period of time than planned;

■ Unsuccessful efforts to cut down or quit;

■ Great deal of time spent to obtain substance or recover from effect;

■ Important activities given up because of substance;

■ Continued use despite harmful consequences.

CRAFFT score interpretation

CRAFFT scoring is an easy to administer test and there is no specific training required for those who administer it.

Each question is answered by either "yes" or "no".

The CRAFFT total score has a cut off for high risk and need of further assessment of 1 for under 14s and 2 or higher for 14-18 year olds.

The probability percentage of substance abuse increases with the CRAFFT score, results of 2 corresponding to approximately 55% while results of 6 corresponding to 100%.

This alcohol and drug use screening method has been validated subsequently against psychological and psychiatric methods. In time has proven high sensitivity and specificity while at the same time the test retest reliability has shown positive results in screening usage abuse and referring subjects for further care.

Drug misuse or dependence usually refers to the use of prescribed or over the counter drugs. There are certain classes of drugs included but not limited to: cannabis, cocaine, narcotics, opioids, solvents, tranquilizers, stimulants or hallucinogens.

Discovering early misuse or dependence can allow proper support to be offered, management of withdrawal symptoms if necessary and recovery therapy.

References

Original reference

Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153(6):591-6

Validation

Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156(6):607-14

Other references

American Psychiatric Association. Diagostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington DC, American Psychiatric Association, 2000

Dhalla S, Zumbo BD, Poole G. (2011) A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Curr Drug Abuse Rev; 4(1):57-64.