Validity of a brief screening instrument-CRAFFT in a multiethnic Asian population

Improving alcohol and substance use screening in school-age children: translation, adaptation and psychometric evaluation of the CRAFFT tool for Lumasaaba, Uganda

BACKGROUND

Children at risk of substance use disorders (SUD) should be detected using brief structured tools for early intervention. This study sought to translate and adapt the Car, Relax, Alone, Forget, Family/Friends, Trouble (CRAFFT) tool to determine its diagnostic accuracy, and the optimum cut-point to identify substance use disorders (SUD) risk in Ugandan children aged 6 to 13 years.

METHODS

This was a sequential mixed-methods study conducted in two phases. In the first qualitative phase, in Kampala and Mbale, the clinician-administered CRAFFT tool version 2.1 was translated into the local Lumasaaba dialect and culturally adapted through focus group discussions (FGDs) and in-depth interviews, in collaboration with the tool's authors. Expert reviews and translations by bilingual experts provided insights on linguistic comprehensibility and cultural appropriateness, while pilot testing with the target population evaluated the tool's preliminary effectiveness. In the second phase, the CRAFFT tool, adapted to Lumasaaba, was quantitatively validated against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) for diagnosing SUD in Mbale district, through a survey. Participants, chosen randomly from schools stratified according to ownership, location, and school size, were assessed for the tool's reliability and validity, including comparisons to the MINI KID as the Gold Standard for diagnosing SUD. Data were analyzed using STATA-15. Receiver-operating-characteristic analysis was performed to determine the sensitivity, specificity, and criterion validity of the CRAFFT with the MINI-KID.

RESULTS

Of the 470 children enrolled, 2.1% (n = 10) had missing data on key variables, leaving 460 for analysis. The median age and interquartile range (IQR) was 11 (9-12) years and 56.6% were girls. A total of 116 (25.2%) children had consumed alcohol in the last twelve-month period and 7 (1.5%) had used other substances. The mean CRAFFT score for all the children (n = 460) was 0.32 (SD 0.95). The prevalence of any alcohol use disorder (2 or more positive answers on the MINI KID) in the last 12 months was 7.2% (n = 32). The Lumasaaba version of the CRAFFT tool demonstrated good internal consistency (Cronbach's α = 0.86) and inter-item correlation (Spearman correlation coefficient of 0.84 (p < 0.001). At a cut-off score of 1.00, the CRAFFT had optimal sensitivity (91%) and specificity (92%) (Area Under the Curve (AUC) 0.91; 95% CI 0.86-0.97) to screen for SUD. A total of 62 (13.5%) had CRAFFT scores of > 1.

CONCLUSION

The Lumasaaba version of the CRAFFT tool has sufficient sensitivity and specificity to identify school-age children at risk of SUD.

Sensitivity and specificity of the CRAFFT to identify heavy cannabis use: Evidence from a large statewide adolescent sample

BACKGROUND AND AIM

Screening adolescents at risk for cannabis use disorders is critical. The CRAFFT is a screening tool designed to address both alcohol and drug use among youth. Current study tests the psychometric properties of the CRAFFT and attempts to modify one of the screening items to compare the efficiency.

DESIGN

We examined the ideal cut-off point of the CRAFFT for identifying persons with heavy cannabis use and compared the utility of the original and revised CRAFFT.

PARTICIPANTS

Sample (N = 132,555) averaged 16.19 (±1.21) years of age; 51.0% were female, 59.7% were White, 15.2% were Latino/Latina, and 6.7% were African-American. Majority resided in non-rural area and 34.5% were receiving free or reduced lunch at school.

MEASUREMENTS

Heavy cannabis use was defined as using cannabis 10 or more times in the past 30 days. Sensitivity, specificity, the area under the receiver operating characteristic curve, and Youden value were analyzed to determine the ideal cut-off point.

FINDINGS

Maximum overall predictive accuracy was at a cutoff score of 2 or higher when using the original CRAFFT questions. At a cutoff score of 2, sensitivity was 82.0%, specificity was 83.7%, with an AUC of 0.880. On the contrary, when an alternative CAR question was used, maximum predictive accuracy was at a cutoff score of 1 or higher when predicting heavy cannabis use. At a cutoff score of 1, sensitivity was 92.7%, specificity was 75.5%, with an AUC of 0.900.

CONCLUSIONS

The results provide evidence that the CRAFFT is a promising brief diagnostic instrument for heavy cannabis use among youth. Modification to Car item may have potential in reducing disparities in sensitivity among different racial ethnic groups, as well as those who with low socioeconomic status.

Predictive Validity of the CRAFFT for Substance Use Disorder

BACKGROUND

The utility of CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) in identifying current and future problematic substance use and substance use disorders (SUDs) in pediatric emergency department (PED) patients is unknown. We conducted a secondary analysis of a study in 16 PEDs to determine the concurrent and predictive validity of CRAFFT with respect to SUD.

METHODS

At baseline, 4753 participants aged 12 to 17 years completed an assessment battery (CRAFFT and other measures of alcohol, drug use, and risk behaviors). A subsample was readministered the battery at 1-, 2-, and 3-year follow-up to investigate future SUDs.

RESULTS

Of 2175 participants assigned to follow-up, 1493 (68.6%) completed 1-year, 1451 (66.7%) completed 2-year, and 1265 (58.1%) completed the 3-year follow-up. A baseline CRAFFT value of ≥2 was significantly associated with problematic substance use or mild or moderate to severe SUD diagnosis on the Diagnostic Interview Schedule for Children at baseline (P < .001). The results persisted after 1, 2, and 3 years (P < .001). The best combined sensitivity and specificity was achieved with a baseline CRAFFT value of ≥1 as a cutoff for predicting problematic substance use and a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of mild SUD at 1, 2, and 3 years. The baseline CRAFFT score that best predicted a moderate to severe SUD at 1 year was ≥2; but at 2 and 3 years, the cutoff score was ≥1.

CONCLUSIONS

CRAFFT has good concurrent validity for problematic substance use and SUD in PED patients and is useful in predicting SUDs at up to 3 years follow-up but with limited sensitivity.

[Evaluation of the Brazilian version of the CRAFFT/CESARE scale for screening drug use by adolescents]

The scope of this article is to present the Brazilian version of the CRAFFT scale for screening drug use among adolescents and to assess its comprehensibility. It is a descriptive and quantitative study, which evaluated the applicability of the Brazilian version of the CRAFFT scale through a convenience sample of adolescents aged 14-21 enrolled at two technical schools. Three main aspects were evaluated: difficulty in understanding the scale; the validity of the translated scale comparing a subsample (28,8%) that also filled out the CEBRID questionnaire; and the percentage of adolescents who scored positive on the CRAFFT/CESARE using the pre-established cutoff point. The kappa coefficient was applied to establish correspondence between questionnaires and the ROC curve was used to evaluate the psychometric differences within different cutoffs. The CRAFFT/CESARE scale was applied in 2005 students, of which 1882 are within the defined age bracket. Only 2.2% of adolescents had difficulty in understanding the questions. The specificity of the CRAFFT/CESARE scale was 73.3%, and sensitivity was 87.1%. The concordance degree (Kappa) was considered good (0.461). The CRAFFT/CESARE scored positive in 36.2% of the adolescents.

Anxiety Symptoms and Coping Motives: Examining a Potential Path to Substance Use-Related Problems in Adolescents With Psychopathic Traits

BACKGROUND

Although the relation between impulsive-irresponsible psychopathic traits and substance use is well-documented, the path to developing substance use problems is less understood in adolescents with these characteristics.

OBJECTIVES

To examine the associations between psychopathy, anxiety, and substance use motives and a mechanism by which anxiety and alcohol and marijuana coping motives mediate the relation between psychopathic traits and substance use-related problems.

METHODS

A sample of 185 at-risk adolescent males from a residential military-style program reporting past alcohol or marijuana use (M age = 16.74) participated in the study.

RESULTS

Impulsive-Irresponsible psychopathic traits were uniquely and incrementally predictive of alcohol and marijuana use-related problems and anxiety. Anxiety and coping motives appeared to partially explain the association between impulsivity-irresponsibility and substance use-related problems.

CONCLUSIONS/IMPORTANCE

Findings suggest that youth expressing impulsive-irresponsible psychopathic traits may engage in problematic substance use at least partly as a function of heightened anxiety and a subsequent desire to alleviate distress by using alcohol or marijuana to cope.

Screening in Primary Care: What Is the Best Way to Identify At-Risk Youth for Substance Use?

BACKGROUND

It is important to improve primary care providers' capability to identify youth at risk for alcohol and other drug use. To our knowledge, this is the first study to use Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria to compare screeners for youth for both alcohol and marijuana, given that these are the most frequently used substances by this age group.

METHODS

We compared the psychometric performance of 4 screeners: the National Institute on Alcohol Abuse and Alcoholism Screening Guide (NIAAA SG), the Alcohol Use Disorders Identification Test, the Car-Relax-Alone-Forget-Family and Friends-Trouble (CRAFFT) screener, and the Personal Experience Screening Questionnaire Problem Severity Scale (PESQ-PS) in identifying alcohol and marijuana use outcomes. Youth age 12 through 18 (N = 1573; 27% black, 51% Hispanic) were screened with the NIAAA SG, followed by a Web survey that included the other screeners and outcomes.

RESULTS

Sensitivity for alcohol outcomes indicated that the NIAAA SG (0.87) did not perform as well as the CRAFFT (0.97) or PESQ-PS (0.97) screeners but performed better than the Alcohol Use Disorders Identification Test (0.70). The pattern for sensitivity across screeners for marijuana outcomes was similar.

CONCLUSIONS

An important tradeoff in primary care settings is precision versus practicality. Because of brevity and focus on frequency of drinking, the NIAAA SG offers ease of administration and is good at identifying youth with probably problematic drinking levels. The PESQ-PS and the CRAFFT correctly identify more at-risk youth for alcohol and marijuana than the NIAAA SG. Future work is needed to elucidate how to efficiently and accurately identify at-risk youth in the primary care setting, including determining the best cutoff points to use to increase sensitivity.

Psychometric properties of the German version of the CRAFFT

INTRODUCTION

The CRAFFT questionnaire is a widely utilized measure of problematic alcohol and drug use. The brief screening instrument has been translated into multiple languages, and some studies regarding its psychometric properties have been published. However, investigations on the factorial validity of the CRAFFT in a clinical sample are not available yet and empirical findings on the psychometric properties of the German version of the CRAFFT are very limited.

METHODS

Data were collected in a German sample of 316 adolescent patients treated in emergency departments following alcohol intoxication. Problematic alcohol use was assessed using the German version of the CRAFFT. Data concerning frequency and quantity of alcohol consumption were collected. A confirmatory factor analysis using the 6 items of the CRAFFT modelled as categorical indicators of a single latent factor using a robust weighted least squares estimator was conducted. We also calculated a reliability coefficient and correlations between the CRAFFT and external criteria of alcohol use.

RESULTS

The unidimensional model showed excellent global goodness-of-fit (χ(2)=9.76, df=8, χ(2)/df=1.22, RMSEA=0.027, CFI=0.983, TLI=0.976) and satisfying local parameters (standardized factor loadings between 0.37 and 0.69). We observed a poor reliability coefficient of 0.525. A positive association with alcohol use indicated construct validity of the German CRAFFT.

DISCUSSION

Concerning its factorial and construct validity the German version of the CRAFFT is a promising instrument for measuring problematic alcohol use in clinical adolescent populations, but the reliability has definitely to be investigated again in further studies.

Reliability of the GAIN-SS, CRAFTT and PESQ screening instruments for substance use among South African adolescents

Introduction

Screening for adolescent substance use can assist with the early identification of substance-related problems and guide the provision of appropriate services. As such, psychometrically sound screening tools are needed. The aim of this study was to compare the reliability of the CRAFFT, Global Appraisal of Individual Needs-Short Screener (GAIN-SS) substance use subscale and Personal Experience Screening Questionnaire (PESQ) among adolescents from disadvantaged communities in Cape Town, South Africa.

Methods

Adolescents aged 12–19 years (n = 231) completed the three screeners at two points in time.

Results

Findings show that all three of the screeners had adequate internal consistency (Cronbach α ≥ 0.8). Test-retest reliability was similar for all three screeners, with intraclass correlation coefficient values slightly higher for the PESQ (0.82, 95% CI: 0.77–0.86) than for the GAIN-SS substance use subscale (0.79, 95% CI: 0.73–0.84) and CRAFFT (0.76; 95% CI: 0.66–0.83). Kappa values indicated that the GAIN-SS substance use subscale and CRAFFT had moderate levels of agreement, while the PESQ had substantial levels of agreement for identifying those who had moderate or higher substance use risks at Time 1 and Time 2.

Conclusion

The findings indicate that all of these short screeners seem to have acceptable reliability when used in this population. All of the three screeners are appropriately reliable when used with adolescents from disadvantaged communities in Cape Town, but the PESQ performed slightly better. Future studies should also include the assessment of validity of these screeners in this context.

The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs: a reevaluation and reexamination

BACKGROUND

The CRAFFT, previously validated against DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnostic criteria, is the most widely used screening instrument for alcohol and other substance misuse in adolescents. The present secondary analysis study sought to compare the CRAFFT with the new DSM-5 diagnostic criteria in order to assess the CRAFFT's psychometric properties and determine the optimal cut-point for identifying adolescents in need of further assessment.

METHODS

Participants were primary care patients aged 12-17 (N = 525) who were recruited while waiting for a medical appointment in an urban federally qualified health center in Baltimore, Maryland, USA. Participants were administered the CRAFFT and the Composite International Diagnostic Interview, second edition, modified to include the new DSM-5 craving item. The authors examined the performance of the CRAFFT in identifying any problem use (defined as 1 or more DSM-5 criteria) and any DSM-5 substance use disorder (2 or more DSM-5 criteria) for alcohol or drugs other than tobacco. The authors examined sensitivity, specificity, and receiver operating characteristic areas under the curve (AUC) to determine the optimal CRAFFT cut-point(s) for predicting any problem use and any DSM-5 substance use disorder (SUD).

RESULTS

Examining the CRAFFT as a continuous measure, AUC values were 0.93 for problem use or higher and 0.97 for DSM-5 SUD. Consistent with previously recommended cut-points for the CRAFFT, the cut-point of 2 performed optimally for identifying adolescents both exhibiting problem use of alcohol or drugs and meeting DSM-5 SUD criteria for alcohol or other drugs.

CONCLUSIONS

Despite changes in the DSM substance use diagnostic criteria, the CRAFFT continues to demonstrate excellent sensitivity and specificity at its established cut-point of 2. Additional studies examining the CRAFFT in light of the new DSM-5 diagnostic criteria with more diverse populations are warranted.

Comorbid physical and mental illnesses among pathological gamblers: Results from a population based study in Singapore

The aim of the current study was to examine the comorbidity of pathological gambling with other mental and physical disorders as well as to examine health related quality of life perceived by those with pathological gambling using data from a community survey in Singapore. All respondents were administered the South Oaks Gambling Screen to screen for pathological gambling. The diagnosis of mental disorders was established using the Composite International Diagnostic Interview; while chronic physical conditions were established using a checklist. The weighted lifetime prevalence of pathological gambling was 2.7%. After multiple logistic regression, age 18-34 years (OR=5.3, 95% CI=1.6-17.4), male gender (OR=7.8, CI=3.8-16.2), widowhood (OR=4.2, 95% CI=1.02-17.5), and those with pre-primary (OR=17.1, CI=4.9-59.1), primary (OR=5.3, CI=1.7-16.6), and secondary education (OR=6, CI=2.5-14.7) had significantly higher odds of having pathological gambling. Those of Malay (OR=0.1, 95% CI=0.07-0.2) and Indian ethnicity (OR=0.2, 95% CI=0.1-0.3) had significantly lower odds of having pathological gambling compared to those of Chinese ethnicity. Pathological gamblers had significantly higher odds of having comorbid mental and physical disorders than non-gamblers/non-problem gamblers. The significant association of comorbid mental and physical disorders among those with pathological gambling indicates a need to screen for these disorders and for their subsequent treatment.

Validity and reliability of the Turkish version of CRAFFT Substance Abuse Screening Test among adolescents

AIM

This study aimed to validate the CRAFFT diagnostic test, against the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, Axis 1-based diagnostic inventory in a Turkish population of adolescents.

METHOD

The 124 adolescents who were 15-18 years old were enrolled to this study. CRAFFT was self-administered. Interviews took approximately 30 minutes, including the DSM-IV diagnostic interview for alcohol/drug dependence.

RESULTS

The mean age of subjects was 16.653 years (minimum: 15 years, maximum: 18 years). A score of 2 or higher in part B was found to be optimal for detecting youths with substance dependence problems (sensitivity: 0.82; specificity: 0.88) and it was sufficiently discriminative.

CONCLUSION

The CRAFFT is a valid and reliable instrument for identifying Turkish-speaking youths at risk for substance use disorders.

Psychometric properties and concurrent validity of the CRAFFT among Norwegian adolescents. Ung@hordaland, a population-based study

The aim of the study was to examine the psychometric properties of the CRAFFT-questionnaire, and its concurrent validity with self-reported measures of alcohol consumption and illicit drug use ever among Norwegian adolescents. This study employs data from the ung@hordaland survey (N=9680). The concurrent validity of the CRAFFT-questionnaire was examined both as a case-finder with different cut-offs, but also as an ordinal scale. The ordinal scale was constructed by counting the number of affirmative responses from 0 to 6. Current self-reported excessive alcohol consumption, frequent binge drinking and any illicit drug use ever were employed as concurrent validity measures. The internal reliability of CRAFFT was adequate, and there was a linear relationship between CRAFFT-score and excessive alcohol consumption, frequent binge drinking and illicit drug use ever for both genders. Overall, this study shows a good concurrent validity and adequate psychometric properties of the CRAFFT-questionnaire. There results indicate, however, that the use of CRAFFT as a case-finder needs further research, as a suitable cut-point was difficult to determine. The authors conclude that in a clinical setting one positive answer is enough to warrant further investigation, and for research purposes the use of the questionnaire as an ordinal scale or using a cut-point of 2 might be preferable.

Screening questionnaires for problem drinking in adolescents: performance of AUDIT, AUDIT-C, CRAFFT and POSIT

BACKGROUND/AIMS

Only rather few data on the validity of screening questionnaires to detect problem drinking in adolescents exist. The aim of this study was to compare the performance of the Alcohol Use Disorders Identification Test (AUDIT), its short form AUDIT-C, the Substance Module of the Problem Oriented Screening Instrument for Teenagers (POSIT), and CRAFFT (acronym for car, relax, alone, forget, family, and friends).

METHODS

The questionnaires were filled in by 9th and 10th graders from two comprehensive schools. All students received an interview using the alcohol section of the Composite International Diagnostic Interview. Alcohol abuse and alcohol dependence according to DSM-IV as well as episodic heavy drinking served as criteria to validate the screening instruments.

RESULTS

All 9th and 10th graders (n=225) of both schools participated. No significant differences were found for areas under the receiver operating characteristic curves ranging from 0.810 to 0.872. Cronbach's alpha was satisfactory (0.77-0.80) but poor for CRAFFT (0.64). Different cut-offs are discussed.

CONCLUSIONS

Considering validity as well as reliability, AUDIT, AUDIT-C and POSIT performed well; however, the POSIT is quite lengthy. AUDIT-C showed good psychometric properties and has clear advantages because of its brevity.

Alcohol, tobacco, marijuana and hallucinogen use in Samoan adolescents

INTRODUCTION AND AIMS

Adolescent substance use has increased with globalisation, and yet few data exist from lower- and middle-income countries and the Pacific Islands.This study examines the prevalence of three aspects of substance use over the past 30 days in Samoan adolescents: (i) use of alcohol, tobacco and other drugs; (ii) polysubstance use; and (iii) possible substance use problems.

DESIGN AND METHODS

A survey was administered to secondary school children (n = 879) between 12 and 19 years of age at a single school in Apia, the capital of Samoa, in August 2008.

RESULTS

There were important gender differences in substance use with boys reporting significantly higher rates of any use of each substance and polysubstance use. Boys were also three times more likely to report behaviours indicative of substance use problems. There were no significant differences in regular use of any substance with the exception of marijuana. Although the use of hallucinogens is prominent for boys and girls in the younger age group (12–15), consumption decreases with age. Boys showed substantial increases in any use of alcohol and marijuana and daily use of tobacco by age.There was also a significant increase in the number of boys reporting behaviours indicative of disordered use by age to 21% of 16- to 19-year-old boys.

DISCUSSION AND CONCLUSIONS

One of few studies on substance use in Samoa, the data provide a basis for setting priorities to address health risks posed by adolescent use and understanding the influence of rapid change.