Screening categories were "any problem" ie, problem use, abuse, or dependence , "any disorder" ie, abuse or dependence , and "dependence. Diagnostic classifications for substance use during the past 12 months were no use Validity was not significantly affected by age, sex, or race. Substance abuse affects men and women of all races, ethnic groups, and ages—including adolescents. Recent studies show that half of high school students are current drinkers, one third binge drink, and one fourth smoke marijuana. Substance abuse has been linked to both mental and physical health problems, making settings where adolescents receive medical care ideal places for screening and early intervention.
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Screening categories were "any problem" ie, problem use, abuse, or dependence , "any disorder" ie, abuse or dependence , and "dependence. Diagnostic classifications for substance use during the past 12 months were no use Validity was not significantly affected by age, sex, or race. Substance abuse affects men and women of all races, ethnic groups, and ages—including adolescents.
Recent studies show that half of high school students are current drinkers, one third binge drink, and one fourth smoke marijuana. Substance abuse has been linked to both mental and physical health problems, making settings where adolescents receive medical care ideal places for screening and early intervention.
The precise reasons that so many physicians fail to screen are unknown. However, barriers to screening for other preventable health risks include a belief that the prevalence of the problem is low in the physician's own patient population, inadequate training, lack of time or personnel to perform the screening, and perceived lack of effective treatments. The ideal instrument for screening adolescents must be developmentally appropriate, valid and reliable, and practical for use in busy medical offices.
A number of screening devices are available for this purpose, including brief questionnaires and orally administered tests. To be practical, they must be designed to be completed by patients within the usual waiting time, and scoring procedures must be sufficiently streamlined so that results can be given to the physician before the medical visit begins. Questionnaires may be targeted at substance use alone or include this as just one part of a more comprehensive adolescent screening.
Questionnaires have certain limitations. They may require staff time for administration or scoring. They may also pose a risk to adolescents' confidentiality, especially when parents are present in the waiting area. Orally administered brief screens are usually targeted at substance abuse alone and can be administered by the physician as part of the general health interview or while performing the physical examination.
To be practical, they must be easy to administer, score, and remember. Simple yes or no questions that lend themselves to mnemonic acronyms are ideal. The CAGE questions, which are widely used in medical settings, are a good example of this type of brief screen. Its name is a mnemonic of the first letters of key words in the test's 6 questions. Figure 1. A pilot study among adolescent patients who had used alcohol and other drugs found that CRAFFT had promising concurrent validity compared with a more lengthy scale.
This practice serves both inner-city and suburban youth from a wide range of social strata, racial groups, and ethnic backgrounds. A research assistant reviewed the birth dates of all scheduled patients before a clinic session and placed a recruitment reminder form on the cover of the chart of each age-eligible patient. At the conclusion of the medical visit, the primary care provider ie, physician or nurse practitioner invited eligible patients to participate in the study.
The provider completed the recruitment form, which included demographic information, the provider's impression of the patient's level of alcohol and other drug use, and the patient's response to the invitation to participate. We informed providers at the beginning of the study and periodically reminded them that their patient need not ever have used alcohol or other drugs to participate. We excluded patients who were unable to read and understand English and those who were deemed by the provider to have acute medical or psychiatric problems that precluded participation in research.
A research assistant explained the study procedures to interested patients and obtained signed assent. The Children's Hospital Boston Committee on Clinical Investigation institutional review board waived the requirement for parental consent in accordance with current guidelines for adolescent health research. The research assistant told participants that the purpose of the study was to assess the value of screening questions on use of alcohol and other drugs and that we would keep their answers confidential.
However, if we identified a serious problem, we would notify their primary care provider so that he or she could arrange appropriate care, which could include involving their parents.
All research assistants read the ADI manual, watched model interviews, practiced on volunteers, and were videotaped conducting practice interviews.
Study investigators and the ADI's author reviewed all videotapes to ensure initial competence, and the trained research assistants periodically observed and rated each other to ensure adherence. All data were entered twice into a specially designed data management program based on Access 97 software Microsoft, Redmond, Wash , which included automatic range and logic checks and an entry-tracking log.
We compared the dual-entry files to identify discrepancies and reconciled them by checking the original data source. Participants were divided into 5 mutually exclusive diagnostic groups based on their pattern of alcohol and other drug use within the previous 12 months: 1 "no use" included participants who reported no use of alcohol or other drugs; 2 "occasional use" included those who reported any use but had a POSIT score less than 2 and did not have an ADI diagnosis; 3 "problem use" included those with a POSIT score of 2 or higher but no ADI diagnosis; and 4 "abuse" and 5 "dependence" included those who met corresponding diagnostic criteria on the ADI interview for either an alcohol- or drug-related disorder.
Each ADI was scored twice, first by a research assistant using the standard written instructions and then by computer using an SPSS syntax algorithm developed by the instrument's author. We transformed participant age into a dichotomous variable ie, younger youth and older youth based on the sample median to preserve adequate cell size for analyses. To assess the ability of the CRAFFT test to discriminate among diagnostic classification groups, we first converted CRAFFT scores to ranks, then used 1-way analysis of variance and a post-hoc comparison test to compare mean ranks between pairs of groups.
Due to heteroscedasticity, we used the Tamhane T2 post hoc comparison test based on a t test that did not assume equal variance. We plotted receiver operating characteristic curves to determine the optimal cut point for the CRAFFT test ie, total score with the highest product of sensitivity and specificity for identifying 3 screening categories: any problem ie, problem use, abuse, or dependence , any diagnosis ie, abuse or dependence , or dependence.
During the month recruitment period, providers invited adolescent patients to participate in the study. We excluded a total of 41 patients 5. Of the eligible patients, Frequencies of participants' demographic characteristics and substance-related diagnostic classifications during the previous 12 months are presented in Table 1.
Participants were almost equally distributed across years of age; Approximately one half of participants had used alcohol or other drugs during the past year, and more than one fourth had experienced alcohol- or drug-related problems. There were a total of 59 abuse diagnoses; 16 were for alcohol alone, 30 for other drugs alone, and 13 for both alcohol and other drugs. Of the 43 drug abuse diagnoses, 36 were related to cannabis, 5 to stimulants including caffeine pills, methylphenidate hydrochloride, and amphetamines , and 2 to both cannabis and stimulants.
There were a total of 36 dependence diagnoses; 7 were for alcohol alone, 24 for other drugs alone, and 5 for both alcohol and other drugs. Of the 29 drug dependence diagnoses, 27 were related to cannabis use, and 2 were related to use of 3,4-methylenedioxymethamphetamine MDMA or "ecstasy". Participants with both abuse and dependence diagnoses eg, cannabis abuse and alcohol dependence were classified as having dependence.
For diagnostic groups, the CRAFFT median scores with interquartile ranges were no use, 0 ; occasional use, 1 ; problem use, 2 ; abuse, 2 ; and dependence, 4 Receiver operating characteristic curves are presented in Figure 2. A receiver operating characteristic area of 1 upper-left corner of the graph theoretically indicates that the test is always correct, and an area of 0.
A CRAFFT score of 2 or higher was associated with the maximal product of sensitivity and specificity, which is also the cut point closest to the upper-left corner of the graph. Sensitivity, specificity, and positive and negative predictive values of a CRAFFT score of 2 or higher for identifying each of the 3 screening categories are presented in Table 2. The CRAFFT test receiver operating characteristic curves for any problem ie, alcohol or other drug problem use, abuse, or dependence A , any diagnosis ie, abuse or dependence B , and a dependence diagnosis C.
Asterisk indicates the optimal cut point ie, the maximum product of sensitivity and specificity. This study provides good supportive evidence for the validity of the CRAFFT test as a substance abuse screening device for use among a general population of adolescent clinic patients. The CRAFFT test has acceptable sensitivity and specificity for identifying all screening categories and among all demographic subgroups. The sensitivity and specificity found in this study for the dependence category were close to those reported in the previous pilot study 0.
Therefore, its discriminant properties can help clinicians estimate not only the presence but also the magnitude of risk of substance-related problems. For example, a score of 4 or higher should raise suspicion of substance dependence. This question is designed to screen for risk of alcohol-related car crashes.
Although important, this risk is not necessarily related to having an alcohol- or drug-related disorder. Some adolescents may answer this question affirmatively based on having ridden in a car with an intoxicated family member, rather than driving after drinking or riding with an intoxicated peer.
Providers can therefore determine the optimal score cut point for the screening category they most wish to target and how best to interpret a positive screen in their own patient populations. Overall, we recommend using a score of 2 or higher as indicating a need for further assessment. A clinic provider can be reasonably reassured when CRAFFT is negative but should assess his or her patient further when the test is positive.
However, the relative risk of a false-positive test eg, additional interview is low compared with that of a false-negative ie, missed diagnosis and opportunity for early intervention.
Some providers may therefore choose to further assess those adolescents whose score is only 1. The sensitivity and specificity 0. First, the CRAFFT is the only screening test that includes an item on drinking and driving or riding with an intoxicated driver. Alcohol-associated motor vehicle accidents are a leading cause of death among adolescents, 38 and a question regarding this risk should be a part of routine screening.
Drug use is highly prevalent among adolescents, 2 and most providers would likely prefer a single test that can screen for all psychoactive substances simultaneously. Although written questionnaires may present an advantage in efficiency when patients complete them in the waiting area, they are limited by risks to confidentiality. One study reported that adolescent medical patients were frequently dishonest when answering providers' questions about substance use because parents were present.
However, some adolescents may be reluctant to discuss their alcohol and other drug use with the pediatrician, even when parents are not present. Few comparable validation studies have been conducted in general adolescent clinic settings, and none of these included both a risk assessment ie, the POSIT scale and a psychiatric diagnostic interview ie, the ADI.
More than one half of patients in our clinic had used alcohol or other drugs during the past year, and more than one fourth had experienced serious substance-related problems. Almost 1 in 6 These findings have serious implications for adolescent health care. They unquestionably reinforce the importance of the existing Guidelines for Adolescent Preventive Services recommendations for universal substance abuse screening. These findings also suggest a need for additional time and personnel to further assess the substantial numbers of adolescents who will screen positive when universal screening is implemented.
Positive screens should be followed by a more complete substance use history, taken by either a physician or some other trained health care professional. Unfortunately, recent changes in the health care system have already placed pressure on providers to see more patients quickly.
If universal screening is to improve, health care systems must find ways to provide the additional resources needed for assessment of substance-using adolescents. These findings also suggest a need to increase the capacity of systems and communities to provide substance abuse treatment for adolescents.
In clinic settings such as ours, one fourth of patients need at least a brief intervention, and one sixth likely need referral to a treatment specialist. Current resources are not adequate to meet this need. In our own metropolitan area, adolescents needing substance abuse treatment are most often referred to adult programs because so few adolescent-only programs exist.
Adult programs rarely accept younger adolescents, and they are not designed to respond to the unique developmental needs of younger or older adolescents. New approaches, such as office-based interventions, must be developed to adequately meet the need for treatment. There are limitations to the generalizability of our findings regarding diagnostic classifications.
This study was conducted in a single urban hospital-based adolescent clinic. Prevalence rates among adolescent patients seen in other clinics, family practices, or general pediatric practices may be different. This study relied on adolescents' self-report.
CRAFFT Screening Test
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. 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. 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.
CRAFFT Screening Test
Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients
Center of Excellence for Integrated Health Solutions
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