Frequently Asked Questions About the CRAFFT Validation Study

  1. How was the study conducted?
    We asked the CRAFFT questions of 538 teens ages 14-18 who were patients at the Adolescent/Young Adult Medical Practice at Children's Hospital Boston. The practice serves both inner city and suburban youth from diverse social, racial and ethnic backgrounds. All participants were given a lengthy, structured confidential psychiatric diagnostic interview to determine who met criteria for an alcohol- or drug-related diagnosis of abuse and dependence. We analyzed the results of the diagnostic interviews to determine the prevalence of substance abuse and dependence. We compared the score from the CRAFFT screen with the results of the diagnostic interview to determine the accuracy of the CRAFFT tool.
  2. How do you know the teens were telling the truth?
    We have a high degree of confidence in the truthfulness of the adolescents' answers because we told them that we would keep their responses confidential. Prior studies have also demonstrated that self-reporting compares very favorably with other methods of substance use detection, such as laboratory tests. It's also important to consider that if our participants were underreporting their use, then the entire situation is even worse than our research shows.
  3. How did you arrive at the questions?
    As with most health care research, our work built on the work of many others and our own prior studies. We previously conducted a study at this same clinic for the purpose of developing a brief screening test. We first reviewed all previous research on this issue. We drew questions from other screens and questionnaires, and combined and modified the most promising questions to come up with a preliminary test. We included the word "ever" in all questions to make them more sensitive, and make sure that each asked about both alcohol and drug use. Initially, we came up with 9 questions and, through a pilot study, identified these 6 as the best. We are currently conducting analyses to see if we can make the test even shorter, but we must be careful that we don't sacrifice critical accuracy in the process.
  4. How can such simple questions be a valid tool for diagnosing such as complex issue as substance abuse?
    This is the whole science of screening. The idea is that it is possible to use a quick test to identify a high risk group. The purpose of CRAFFT is just to identify which teens require more time for comprehensive evaluation such as a diagnostic interview.
  5. How do you know when you have a "normal" teen who does a little experimentation versus one with serious problems?
    When clinicians actually administer the CRAFFT test, we recommend that they follow up every "yes" answer with "Can you tell me a little bit more about that?" If they hear that an incident happened only once, three years ago, then it may not be cause for great concern. However, if the substance abuse activity or problem occurred several times during the past year, then the situation warrants additional follow-up.
  6. Who should administer the test? Does it have to be a physician or can it be any medical professional such as a school social worker?
    No, it doesn't have to be a physician, but it should be a health care professional who is in a position to respect the teen's confidentiality and can refer the teen to appropriate resources for follow-up if needed. The reason it makes the most sense for physicians or other primary care providers to conduct the screening is that we want it to become part of every teen's routine healthcare.
  7. Can parents administer the test to get an idea whether a problem could exist?
    No, we don't recommend that parents ask these questions of their own children because of the high likelihood of dishonest responses. If parents are concerned about their teen, they should take their child to a healthcare professional to have the screening performed. They can, however, use the questions in the test to get an idea of the types of problems they should be looking for in their own teen.
  8. How should a parent go about getting their child's physician to screen for substance abuse?
    All physicians should be screening teens for high-risk behaviors, including substance use, as part of routine care. But it's fine for parents to mention to their child's physician that, "I strongly support your screening my child for alcohol or drugs and other risks". It's also important to keep in mind that parents should leave the room during at least part of their teen's exam to afford an opportunity for discussion of confidential information between the physician and the child.
  9. If teen substance abuse is a widely recognized problem, then why don't physicians do more to diagnose it?
    Up until now, physicians who see adolescent patients have been hampered by a lack of practical and accurate tools like the CRAFFT. And that's the point of our study. Physicians may also be discouraged by a general lack of treatment resources for teen substance abuse. We're committed to continuing research in this area so we can give them guidance as to exactly what they should do when they have a positive finding on the screening test.
  10. What should a physician do if he or she has a patient who has two or more "yes" answers?
    Physicians can do one of two things. They can take the time to talk to the teen further, get a more complete picture of the exact level of alcohol and drug involvement, and then decide what kind of intervention is required. On the other hand, if their time is limited, they can refer the teen to another medical care provider for a more thorough interview.
  11. If a provider finds that a teen has a severe substance related problem do they need to alert the parents, and if so, doesn't this breach the teen's rights to confidentiality?
    We recommend telling teens that the information they give us will be kept confidential, unless we find there is a danger to their life or health, or to someone else. In that case, we will have to let others know. When a teen is
    found to have a serious problem, such as alcohol or drug dependence, and needs treatment, parents must be informed. We always tell the teen first that their parents must be brought in, and discuss with the teen exactly how this will be done. There is almost never a need to provide parents with detailed information about use, which is what teens fear most often. Rather, we tell parents that we have identified a serious problem, and that we all need to work together to find the best treatment.
  12. How does a medical professional learn to apply the CRAFFT tool?
    Any provider can ask the questions. The biggest challenge lies in how to effectively follow-up on positive responses. During the next phase of our work, will plan to produce a training video on this topic. It will be posted on the CeASAR website, www.ceasar-boston.org.
  13. Since this study was done on city clinic patients, why do you believe the findings apply to the general population of teens in the US?
    The participants in our study were drawn from both the city and the suburbs, and they represented a mix of ages, genders, and race and ethnic backgrounds. We found the accuracy of the tool was not significantly affected by any of these factors.
  14. Did the findings on substance-related problems compare with what you expected?
    We weren't exactly sure what to expect. In a previous study, we found that up to a third of our patients screened positive for some kind of drug and alcohol risk. However, the CRAFFT Validation Study was the first to include a diagnostic interview as part of the assessment in a primary care clinic. The finding that 17% of our routine patients had a diagnosis of either abuse or dependence was higher than we expected.
  15. What kinds of mental health disorders were discovered?
    We're talking specifically about substance use disorders as defined by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or the so-called DSM-IV. Abuse is a mental disorder defined by repeated problems associated with use of a substance. Such problems include interference with school, family, peer relationships, and health problems among others. Dependence is an even more severe disorder, defined by preoccupation with alcohol and drug use, development of tolerance to the substance, withdrawal symptoms if use is stopped, and serious impairment with ordinary life. In our study, we found adolescents who were dependent on alcohol, cannabis, and MDMA or Ecstasy.
  16. Why is the drinking and driving question in the study when a "yes" answer doesn't necessarily mean the teens themselves have taken alcohol or drugs?
    This question may be the most important of all because it screens for the greatest public health problem. Motor vehicle deaths are the leading cause of death among teens and they don't have to be at the wheel to die. A "yes" answer to this question can lead to a number of recommendations to the teen. One option available to them is to sign a Contract for Life, which is a document available through the Students Against Destructive Decisions website. (www.saddonline.com.) The Contract for Life is an agreement made between parents and teens where the teen agrees to call parents for a ride, rather than to drive home after drinking or to accept a ride from someone else who has been drinking. Parents agree to pick up their kid up any time of the day or night with no recriminations as a result. Of course, in some cases, teens answer "yes" to this question because their parents are guilty of drinking and driving with their teens in the car. This can be a very complicated issue that warrants further action by the provider.
  17. Will you be doing anything to get the CRAFFT tool out to physicians so that they can use it?
    We have been working on that. We will continue to distribute pocket cards with the CRAFFT questions at no cost to recipients. The CRAFFT screening tool is also included in a policy statement issued by American Academy of Pediatrics, and has been part of a national case-based training curriculum for Pediatric residents on the Bright Futures guidelines.
  18. You mentioned that you will be conducting further research? Can you tell us what that will involve?
    With funding from the Robert Wood Johnson Foundation, we're studying the implementation of CRAFFT screening in a number of different sites including adolescent clinics, pediatric practices, school based health centers, and private offices. We're trying to help providers follow-up effectively when they get positive answers from the screening and create intervention strategies that are proven effective in helping adolescents.