CRAFFT: Adolescent Substance Use Screening Tool

Foundational Context

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.

What the Assessment Measures

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?

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

Interpretation Guidelines

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. At this threshold, sensitivity is ~76% and specificity is ~94% for DSM-defined alcohol use disorder.

Administration Considerations

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.

Psychometric Properties

• Reliability: Good internal consistency (α = 0.68–0.80).
• Validity: Sensitivity ~76%, specificity ~94% for DSM alcohol use disorder at cutoff ≥2.
• Populations: Validated for ages 12–21 in primary care, emergency departments, and school health settings.

Limitations

• 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.

References

Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607-614.