The CRAFFT Screening Tool
The CRAFFT is a behavioral health screening tool for use with children ages 12-18 and is recommended by the American Academy of Pediatrics' Committee on Substance Abuse with adolescents. It consists of a series of 6 questions developed to screen adolescents for high risk alcohol and other drug use disorders simultaneously. It is a short, effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted.
The Center for Adolescent Substance Abuse Research (CeASAR) is pleased to present the CRAFFT 2.0, an updated version of the CRAFFT adolescent substance use screening protocol.
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 2.0 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, we recommend that you transition to using version 2.0 in your clinical practice.
How do I use Version 2.0?
Similar to the original CRAFFT, the CRAFFT 2.0 is validated for use with adolescents aged 12-18 years old.
1. Begin by asking the questions regarding the patient’s past-12-month substance use.
The CRAFFT 2.0 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) (Harris et al., 2015). 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 (Couper et al., 2012).
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 2.0 now begins with past-12-month frequency items; i.e., “During the past 12 months, on how many days did you … [drink/use substance name]?”
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 (Harris et al., 2015; Harris et al., 2016). These data support the rationale to change the opening questions in the CRAFFT 2.0.
2. The actual CRAFFT screening questions remain the same in version 2.0.
If the patient answered “0” to all the opening “frequency of use” questions, ask the CAR question only. If the patient provided an answer >”0” to any of the “frequency of use” questions, ask the full set of six CRAFFT questions. Two or more “yes” answers to any of the CRAFFT questions indicates an elevated risk for a substance use disorder (SUD), and a need for further assessment. Further assessment should include the Talking Points for brief counseling described below, and may include a follow-up appointment with you, and/or referral to treatment.
3. Communication of risk – DSM-5 Criteria for a Substance Use Disorder
Similar to the original CRAFFT screening tool, the first step is to tell adolescents their CRAFFT “score” and to show where that score falls on the bar chart at the top of 2nd side of the CRAFFT card or Clinician-administered CRAFFT Interview. This chart shows data from a recent study testing the CRAFFT screener’s validity in identifying adolescents meeting DSM-5 criteria for a SUD (Mitchell et al., 2014). The bar chart shows the percentage of adolescents meeting criteria for a DSM-5 SUD by CRAFFT score. Using these percentages on the bar chart, the clinician should discuss with the adolescent their likelihood of having a potential problem with substance use based on their CRAFFT score.
4. Revised clinician Talking Points – the “5 Rs” of brief counseling
The next step is to have a brief motivational enhancement discussion with the adolescent using the recommended Talking Points for brief counseling. These talking points incorporate the latest science on the developing brain and substance use harms, and promote the use of strategies informed by Motivational Enhancement Therapy (MET). MET is a counseling approach based on cognitive and social psychology principles that helps patients recognize and discuss discrepancies between their substance use and personal values and goals. The clinician focuses on eliciting self-motivational statements from patients and encourages them to identify factors to support behavior change (Miller et al., 1992).
From this foundation we developed the “5 Rs” of brief counseling:
not to use
elicit self-motivational statements