CRAFFT: Adolescent Substance Use Screening Tool

What the CRAFFT measures

The CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) was developed by John R. Knight and colleagues at the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children's Hospital (2002). It is the most validated and widely recommended substance use screening tool for adolescents aged 12–21, endorsed by SAMHSA, the American Academy of Pediatrics (AAP), and NIDA.

The American Academy of Pediatrics (AAP) recommends annual substance use screening for all adolescents as part of preventive health visits. The most current version, CRAFFT 2.1, addresses evolving patterns including electronic cigarettes and prescription drug misuse.

The CRAFFT v2.1 assesses alcohol and drug use risk in adolescents across two stages:

Part A (initial screen): Three questions about alcohol, marijuana, and other substance use in the past 12 months.

• If the patient answers "No" to all three, only the "Car" question is required.
• If any Part A answer is "Yes," all six CRAFFT questions are administered.

Part B (CRAFFT acronym items):

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

How to administer the CRAFFT

1. Part A: Ask about past-12-month use of alcohol, marijuana, and other substances.
2. Part B: Administer the 6 CRAFFT questions. If Part A was negative, only the "Car" question is strictly required, though completing all 6 provides a full score.
3. Scoring: Sum all "Yes" responses from Part B.
4. Action: Deliver brief counselling based on the score range.

The CRAFFT can be self-administered or administered verbally by a clinician. Confidentiality should be clearly communicated to the adolescent regardless of format.

CRAFFT scoring and interpretation

Each item is scored Yes (1) or No (0). Total score: 0–6.

Score ranges:

• 0–1: Negative Screen. Low risk; brief positive feedback and anticipatory guidance recommended.
• 2–3: Positive Screen. High-risk use; brief motivational intervention and consider referral to substance use assessment.
• 4–6: High Risk. High probability of a substance use disorder; refer to detailed substance use evaluation and treatment.

Clinical threshold:

• ≥2 is the validated cutoff for identifying adolescents who may benefit from a full assessment or intervention (Knight et al., 2002; Mitchell et al., 2014). The 4–6 band reflects clinical convention rather than a separately validated threshold.

Psychometric properties

• Reliability: Good internal consistency (α = 0.68–0.80).
• Validity: In 538 adolescents aged 14–18 at a hospital-based clinic, CRAFFT scores correlated strongly with diagnostic classification (Spearman rho 0.72). At a cutoff of ≥2, sensitivity was 0.76 and specificity 0.94 for any problem (problem use, abuse or dependence), 0.80 and 0.86 for any disorder, and 0.92 and 0.80 for dependence. Validity was not significantly affected by age, sex, or race (Knight et al., 2002).
• DSM-5: In 525 primary care patients aged 12–17, the AUC was 0.93 for problem use and 0.97 for DSM-5 substance use disorder, and the cut-point of 2 remained optimal (Mitchell et al., 2014).
• Populations: Validated for ages 12–21 in primary care, emergency departments, and school health settings.

Limitations

• Screening, not diagnosis: a positive screen calls for a comprehensive clinical evaluation.
• Does not differentiate by substance type in the final score.
• Self-report is subject to social desirability effects; confidentiality is critical.
• Not designed for youth under age 12.