What is the role of CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening in assessing substance abuse in adolescents and young adults?

CRAFFT Screening for Adolescent Substance Use Assessment

The CRAFFT screening tool is a highly validated, 6-question instrument specifically designed for adolescents aged 12-21 years that should be used annually in primary care and behavioral health settings to identify risky substance use, with a score of ≥2 indicating need for further assessment or intervention. 1

What is CRAFFT?

The CRAFFT is a brief screening tool consisting of 6 yes/no questions, with each affirmative answer scoring 1 point 1:

• C - Have you ever ridden in a Car driven by someone (including yourself) who was "high" or had been using drugs or alcohol? 1
• R - Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? 1
• A - Do you ever use alcohol or drugs while you are by yourself, Alone? 1
• F - Do you ever Forget things that you did while using alcohol or drugs? 1
• F - Does your Family or Friends ever tell you that you should cut down on your drinking or drug use? 1
• T - Have you ever gotten into Trouble while you were using alcohol or drugs? 1

Clinical Performance and Validation

The CRAFFT demonstrates strong psychometric properties with sensitivities ranging from 0.61-1.00 and specificities from 0.33-0.97 across diverse populations. 2 More specifically:

• For identifying "any problem" (problem use, abuse, or dependence): sensitivity 0.76, specificity 0.94, positive predictive value 0.83, negative predictive value 0.91 3
• For identifying "any disorder" (abuse or dependence): sensitivity 0.80, specificity 0.86 3
• For identifying dependence: sensitivity 0.92, specificity 0.80 3
• Internal consistency ranges from 0.64-0.86 with high test-retest reliability 2, 4
• Validity is not significantly affected by age, sex, or race 3

Recommended Use and Implementation

The American Academy of Pediatrics recommends the CRAFFT as the preferred screening tool for adolescents in pediatric settings. 1 Key implementation points include:

• Administration time: Takes less than 2 minutes to complete 1
• Delivery format: Can be administered as an interview, paper-based, or computer-based self-report 1
• Scoring threshold: A score of ≥2 is considered positive and warrants further assessment or brief intervention 1, 3
• Frequency: Should be administered annually for all adolescents 5

Updated Version: CRAFFT 2.1+N

The CRAFFT 2.1+N is the most current version that includes specific assessment of vaping, cannabis products (edibles, vaping, dabbing), and nicotine products (JUUL, Puff Bars, vape pens). 1, 5 This updated version:

• Assesses past-year use of electronic cigarettes, prescription opioids, and newer cannabis delivery methods 1
• Evaluates motivations for use, hazardous patterns, and negative consequences 1, 5
• Provides clearly demarcated clinical cutoffs signaling when further assessment or intervention is needed 1, 5
• Can be easily integrated into electronic health records 1

Clinical Context and Confidentiality

Confidentiality is essential for accurate adolescent screening responses. 1, 6, 7 Best practices include:

• Excuse parents/guardians from the room during substance use screening to validate the adolescent's developmental need for privacy 1, 6, 7
• Explain that information will remain confidential unless there is immediate risk of harm to self or others, as supported by federal and state privacy laws 1, 6, 7
• Consider integrating CRAFFT into broader psychosocial frameworks like HEEADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety) which strategically progresses from less threatening to more personal topics 1, 6, 7

Comparison with Other Screening Tools

While other validated tools exist for adolescent substance screening, the CRAFFT offers distinct advantages:

• S2BI: Queries frequency of use per substance but may require additional questions about specific vaping/cannabis products 1, 5
• BSTAD: High sensitivity/specificity but similarly may need supplementation for newer product types 1
• AUDIT-C: Validated for ages 12-19 but focuses primarily on alcohol quantity/frequency 1, 6, 5

The CRAFFT 2.1+N addresses these gaps by explicitly including contemporary substance delivery methods. 1, 5

Special Populations

The CRAFFT has been preliminarily validated beyond adolescents:

• Young pregnant women (ages 17-25): positive predictive value 90%, negative predictive value 80% using calendar-based recall 1
• Compared with diagnostic interview in pregnancy: positive predictive value 58%, negative predictive value 83% 1
• Adolescent psychiatric inpatients: elevated scores (≥2) correlated with substance use disorders at discharge (P<0.0001), positive urine screens for alcohol (P=0.0048) and marijuana (P<0.0001), and history of suicide attempts (P=0.005) 8

Common Pitfalls to Avoid

• Do not skip screening in the presence of parents - this significantly reduces disclosure accuracy 1, 6, 7
• Do not use outdated versions - the CRAFFT 2.1+N includes critical questions about vaping and newer product forms that older versions miss 1, 5
• Do not ignore positive screens - approximately 25% of general adolescent clinic populations score ≥2, indicating substantial prevalence of at-risk use 3
• Do not assume low risk based on demographics - validity is consistent across age, sex, and racial/ethnic groups 3

Clinical Action Based on Results

When CRAFFT score is ≥2:

• Conduct further assessment to determine severity (problem use vs. abuse vs. dependence) 3
• Consider brief intervention using motivational interviewing techniques 5
• Refer to specialty substance use treatment when indicated 1
• Consider urine drug screening as the gold standard for objective confirmation 5

When CRAFFT score is 0-1:

• Provide anticipatory guidance about delaying substance initiation until age 25 when brain development is complete 5
• Reassess annually 5