ARTICLE

A New Brief Screen for Adolescent Substance Abuse

John R. Knight, MD; Lydia A. Shrier, MD, MPH; Terrill D. Bravender, MD;
Michelle Farrell; Joni Vander Bilt, MPH; Howard J. Shaffer, PhD

Objective: To develop a brief alcohol and other drug
(AOD) screening test for adolescents.
Methods: A 9-item test was constructed by combining and
modifying items from several AOD assessments, and ad-
ministered concurrently with the Personal Involvement
With Chemicals Scale (PICS), the criterion standard.
Setting: A hospital-based adolescent clinic.
Subjects: Fourteen- to 18-year-old patients consecu-
tively arriving for routine medical care who were known
to have used AOD.
Measures: Internal consistency of the 9 items was cal-
culated using the Cronbach a. The relationship be-
tween the brief screen and PICS raw score was deter-
mined by stepwise linear regression analysis. The PICS
T score has been shown to correctly classify substance
abuse treatment need as no treatment (T,35), brief of-
fice intervention (T = 35-40), outpatient or short-term
treatment (T = 41-54), and inpatient or long-term treat-
ment (T$55). Sensitivity and specificity rates for pre-
dicting a PICS T score of 55 or higher were calculated
from 2 3 2 tables.
Results: Ninety-nine adolescents were tested (70.7% fe-
male, 36.4% black, 32.3% white, 19.2% Hispanic, mean
age, 16.3 years). The 9 items had good internal consis-
tency (Cronbach a = .79). Stepwise linear regression analy-
sis identified 6 items whose total combined score was
highly correlated with PICS (Pearson r = 0.84, P,.01).
This model correctly classified 86% of subjects accord-
ing to the PICS criteria. Two or more yes answers had a
sensitivity of 92.3% and specificity of 82.1% for inten-
sive AOD treatment need. The 6 items were arranged into
a mnemonic (CRAFFT).
Conclusions: Further research must confirm the test’s
psychometric properties in a general clinic population.
However, CRAFFT seems promising as a brief AOD
screening test.
Arch Pediatr Adolesc Med. 1999;153:591-596

of death among young people, and a sig-

Editor’s Note: There appears to be nothing cheesy about CRAFFT nificant proportion are directly related to
as a brief AOD test. Now to get it tested in a large population. the use of alcohol.5,6
Catherine D. DeAngelis, MD According to the American Medical
Association’s Guidelines for Adolescent Pre-
ventive Services (GAPS)7 and the Mater-

From the Divisions of General
Pediatrics (Dr Knight) and
Adolescent and Young Adult
Medicine (Drs Shrier and
Bravender), Children’s
Hospital, and Division on
Addictions, Harvard Medical
School (Drs Knight and Shaffer
and Ms Vander Bilt), Boston,
Mass; and Colby College and
Harvard BASE Project,
Waterville, Me (Ms Farrell).
S
UBSTANCE USE and abuse has
been considered the num-
ber 1 health problem in the
United States.1 Recent epide-
miological data indicate drug
use by students in grades 8 through 12 has
risen significantly since 1990, and adoles-
cents are beginning to drink at younger
ages.2,3 Thirty-two percent of high school
students binge drink ($5 drinks in a row)
and 15.4% drive after drinking.4 Even more
alarming, 38.8% of surveyed students in
grades 9 through 12 reported riding in a
car with a driver who had been drink-
ing.4 This is particularly concerning as mo-
tor vehicle crashes are the leading cause
nal and Child Health Bureau’s Bright
Futures: Guidelines for Health Supervision
of Infants, Children, and Adolescents,8 ev-
ery adolescent should be screened for use
of alcohol or other drugs (AOD) as part
of routine health care. A policy statement
recently published by the American Acad-
emy of Pediatrics Committee on Sub-
stance Abuse states that pediatricians
should be “able to evaluate the nature and
extent of . . . alcohol and other drug use
among their patients . . . and make an as-
sessment as to whether additional coun-
seling or referral may be needed.”9 How-
ever, surveys of practicing pediatricians
indicate that fewer than half actually per-

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 SUBJECTS, MATERIALS,
AND METHODS
TEST DEVELOPMENT
A 9-item screening test was constructed by taking indi-
vidual questions from the RAFFT, DAP, and POSIT
(Table 1). Specific items were chosen because they had
been found to be sensitive and specific in prior validation
studies, and/or because they were deemed to be clinically
relevant and important. Questions were modified to in-
clude the word “drugs” as well as the word “alcohol,” and
most were qualified by “Have you (or do you) ever. . .”.
These modifications provided consistency among items and
enhanced the sensitivity of the screen.
SUBJECTS
The test was administered to a sample of patients consecu-
tively arriving for routine medical care at an adolescent clinic.
Patients aged 14 to 18 years who had a history of AOD use
were invited to participate by their primary care provider. Pa-
tients who could not speak English or who were judged to
be medically unstable or in crisis (eg, in need of a pregnancy
test) were not asked to participate. No data were collected
on subjects who were excluded or refused participation. Cli-
nicians, however, made an effort to include adolescents whose
current AOD use was thought to be significant, as the goal
of the study was to develop a brief test that could determine
which patients need referral to specialty treatment.
SETTING
The study was conducted in the Adolescent and Young Adult
Medical Practice at Children’s Hospital, Boston, Mass. Chil-
dren’s Hospital is a large tertiary care teaching hospital. The
form such a screening.10 The reasons for this low level of
compliance are unknown. Pediatricians may lack suffi-
cient training or be reluctant to initiate screening for a prob-
lem that they believe is both difficult to treat and time-
consuming to assess. Development of a brief and effective
method for AOD screening, assessment, and interven-
tion may therefore substantially improve practices among
pediatricians. The first step in formalizing a clinical man-
agement strategy must be the development of a practical
screening tool.
Several brief screening tests have been developed for
use among adults. In recent years, the Alcohol Use Dis-
orders Identification Test (AUDIT) has become widely
known and used.11-13 The AUDIT is a 10-item question-
naire that has been found to be sensitive and specific for
predicting current hazardous use of alcohol and, to a
slightly lesser extent, lifetime diagnosis of alcohol de-
pendence.13 Among adolescents, however, AUDIT lacks
sufficient sensitivity to make its use practical.14
The CAGE questions have also achieved wide-
spread use.15 This instrument’s name is a mnemonic of
the following 4 yes/no questions: “Have you ever felt that
you should cut down on your drinking?” “Have people
annoyed you by criticizing your drinking?” “Have you ever
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adolescent practice has more than 11 000 patients and more
than 4000 visits each year. It serves youth from both inner-
city and suburban communities.
DATA COLLECTION
A research assistant verbally administered the 9-item screen
and asked each subject to complete the PICS from the Per-
sonal Experience Inventory (PEI).23 The PEI has been well
validated, and the PICS T score has been shown to cor-
rectly classify substance abuse treament need as follows:
no treatment (T,35), brief office intervention (T = 35-
40), outpatient/short-term treatment (T = 41-54), and in-
patient/long-term treatment (T$55).24 The PICS scale was
used as the criterion standard in this study. The sample was
randomized for order of test administration (9-item screen
and then PICS vs PICS and then 9-item screen) and strati-
fied for sex. Subjects were offered a free movie pass or fast-
food voucher for their participation. Based on the Guide-
lines for Adolescent Health Research, 25 the Children’s
Hospital investigational review board waived parental con-
sent for this study.
DATA ANALYSIS
The research assistant entered all data into the Statistical
Program for the Social Sciences (SPSS Inc, Chicago, Ill) for
Microsoft Windows 7.5. Demographic frequencies, means,
and SDs were determined. A t test was performed for or-
der of test administration. The PICS T scores were calcu-
lated for purposes of standardization. Correlations were ana-
lyzed with Pearson r statistics and internal consistency
reliability was assessed using Cronbach a. A stepwise lin-
ear regression analysis was performed using the PICS raw
score as the independent variable. Sensitivity, specificity,
and positive and negative predictive values were calcu-
lated from frequency tables.
felt bad or guilty about your drinking?” “Have you ever
had a drink first thing in the morning to steady your nerves
or get rid of a hangover (eye opener)?” The CAGE ques-
tions have several advantages that undoubtedly account
for its popularity among clinicians. It is brief, verbally
administered, easy to remember, and easy to score (each
yes answer = 1). The CAGE questions have been shown
to have high sensitivity and specificity in medical set-
tings, with a score of 2 or greater indicating a high prob-
ability of an alcohol-related diagnosis.16 It has not been
validated among adolescents, however, and some items
(eg, the “eye opener” question) are not developmentally
appropriate for teenagers.
Several screening questionnaires have been de-
signed specifically for use with adolescents. Most re-
cently, the Problem-Oriented Screening Instrument for
Teenagers (POSIT) has received considerable atten-
tion.17 It is a 139-item self-administered yes/no question-
naire that was developed by the National Institute on Drug
Abuse as part of the Adolescent Assessment/Referral Sys-
tem, a comprehensive battery that is designed to screen,
assess, and guide treatment decisions. The POSIT ques-
tionnaire comes in both English and Spanish versions,
and a computer-based CD-ROM version is presently un-
 dergoing beta testing. The POSIT contains 10 scales: sub-
stance use/abuse, physical health status, mental health
status, peer relations, family relations, educational sta-
tus, vocational status, social skills, leisure and recre-
ation, and aggressive behavior/delinquency. The POSIT
questionnaire has been validated among adolescents aged
12 through 19 years in multiple settings from schools to
juvenile correctional systems, and has been found to have
good internal consistency and test-retest reliability among
adolescents in an outpatient medical clinic.18 The POSIT
may be an ideal way to screen patients in clinical set-
tings that are dedicated to adolescent medicine, but the
20-minute completion time makes it less practical for use
by general pediatricians or family practitioners. A brief,
verbally administered test like CAGE would likely gain
wider acceptance in these settings.
Another questionnaire, the Drug and Alcohol Prob-
lem (DAP) Quickscreen, consists of 30 yes/no items and
was developed for use among adolescents in primary care
medical offices.19 Like POSIT, questions were worded to
inquire about use of both alcohol and other drugs. In a
validation study, Schwartz and Wirtz20 found that 4 DAP
items accounted for 70% of the variation between high-
risk and low-risk users: “Do you use tobacco products
(cigarettes, snuff, etc)?” “Have you ever had an in-
school or out-of-school suspension for any reason?” “Do
you sometimes ride in a car driven by someone (includ-
ing yourself) who is high or who appears to have had too
much to drink?” “Has anyone (friend, parent, teacher or
counselor) ever told you that they believe that you may
have a drinking or drug problem?” These 4 items, how-
ever, have not been tested independently from the par-
ent instrument.
The closest CAGE equivalent for adolescents is the
RAFFT test, developed specifically as a brief screen for
teenagers as part of the Brown University Project ADEPT
manual.21 Like the CAGE test, RAFFT is a mnemonic
based on individual items: “Do you drink to relax, feel
better about yourself, or to fit in?” “Do you ever drink
alcohol while you are by yourself (alone)?” “Do any of
your closest friends drink?” “Does a close family mem-
ber have a problem with drinking?” “Have you ever got-
ten into trouble from drinking?” The RAFFT test has sev-
eral advantages. All of its items are developmentally
appropriate for adolescents. Each question calls for a
yes/no response, making it easy to score. The RAFFT test
is brief and easy to remember. However, RAFFT also has
some limitations. It was intended as a clinical “prompt”
for trainees, rather than a validated screening device. Clini-
cal interpretation is therefore difficult. There is prelimi-
nary evidence of RAFFT’s validity, but no studies of its
psychometric properties have yet been published.22 In
addition, the wording of the RAFFT questions does not
include drugs, limiting their sensitivity for identifying
misuse of psychoactive substances other than alcohol.
The objective of our study was to develop and
validate an AOD screening test for adolescents that is
brief, reliable, and practical for use in pediatric office
practice. The test should be simple to administer and
score. Individual items should be developmentally
appropriate, worded to include both alcohol and other
drugs, and elicit a yes/no response. The screen should
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Table 1. Screening Test (9-Item) and Sources of Questions*
Parent
No. Question Instrument†
1 Have you ever ridden in a car driven by someone DAP
(including yourself) who was high or had been
using alcohol or drugs?
2 Do you ever use alcohol or drugs to relax, RAFFT,
feel better about yourself, or fit in? POSIT
3 Do you ever use alcohol or drugs while you RAFFT
are by yourself (alone)?
4 Has anyone (parent, teacher, friend) ever thought DAP
you had a problem with alcohol or drugs?
5 Do you ever forget things you did while using POSIT
alcohol or drugs?
6 Have you ever gotten into trouble while you were RAFFT
using alcohol or drugs?
7 Does alcohol or drug use cause your moods POSIT
to change quickly, from happy to sad
or vice versa?
8 Do your family or friends ever tell you that you POSIT
should cut down on your drinking or drug use?
9 Does your alcohol or drug use ever make you do POSIT
something that you would not normally do—
like breaking rules, missing curfew, breaking
the law, or having sex with someone?
*Questions 1, 2, 3, 5, 6, and 8 are included in the current study model
(CRAFFT).
†DAP indicates Drug and Alcohol Problem Quickscreen19; RAFFT, a
mnemonic device for a brief alcohol and other drug screen developed as part
of Project ADEPT 21; and POSIT, Problem-Oriented Screening Instrument for
Teenagers.17
allow pediatricians to quickly and accurately discrimi-
nate patients requiring intensive AOD treatment from
those amenable to office intervention or brief counsel-
ing. Lastly, like CAGE and RAFFT, the test should have
a mnemonic that makes it easy to remember.
RESULTS
The final study sample included 99 adolescents (70.7%
female, 36.4% black, 32.3% white, 19.2% Hispanic). The
mean age of subjects was 16.3 ± 1.4 years and mean grade
level was 10.2 ± 1.4. All questions on the 9-item screen
were equally weighted (each yes answer = 1) and the test
was constructed so that all items were scored in the same
direction (yes answer indicates high risk for AOD prob-
lem). The mean score was 2.1 ± 2.3. The screen had good
internal consistency (Cronbach a = .79), and a values did
not change substantially with deletion of any item.
Six subjects who completed the 9-item screen did
not complete the PICS and were excluded from subse-
quent analysis. The PICS raw score mean for the entire
sample was 45.9 ± 16.1 (range, 29-91) and the standard-
ized T score range was 39.5 to 78.1 (mean = 50, SD = 10).
Neither test score was affected by the order of adminis-
tration (PICS first, t = −1.37, P = .17; 9-item screen first,
t = −0.83, P = .41).
The scores of the 9-item screen and PICS were highly
correlated (r = 0.82, P,.001). The results of the step-
wise linear regression analysis are shown in Table 2.
This analysis identified a 6-item model (F = 34.017,
P,.001) whose total score was highly correlated with the
PICS score (r = 0.84, P,.001). The 6 items were “Have

Table 2. Stepwise Linear Regression Analysis
of the 9-Item Screening Test
Model Items* r R2 Adjusted R 2
Forget 0.584 0.341 0.333
Forget, car 0.713 0.508 0.497
Forget, car, relax 0.781 0.610 0.597
Forget, car, relax, trouble 0.810 0.657 0.641
Forget, car, relax, trouble, 0.824 0.680 0.661
alone
Forget, car, relax, trouble, 0.839 0.704 0.683
alone, friends
*See Table 1 for complete wording of screening questions.
you ever ridden in a car driven by someone (including
yourself) who was high or had been using alcohol or
drugs?” “Do you ever use alcohol or drugs to relax, feel
better about yourself, or fit in?” “Do you ever use alco-
hol or drugs while you are by yourself (alone)?” “Do you
ever forget things you did while using alcohol or drugs?”
“Do your family or friends ever tell you that you should
cut down on your drinking or drug use?” and “Have you
ever gotten into trouble while you were using alcohol or
drugs?”
The CRAFFT model accounted for 68% of the total
variance, and internal consistency was maintained (Cron-
bach a = .68).
Distribution of subjects by PICS treatment catego-
ries was no treatment, 0%; brief intervention, 22.5%; out-
patient/short-term treatment, 49.5%; and inpatient/long-
term treatment, 29%. The CRAFFT model correctly
classified 86% of subjects through discriminant analy-
sis. The highest severity category was chosen as that which
pediatricians most need to identify, and a PICS T score
of 55 or higher was therefore used as the “condition” for
calculations of sensitivity, specificity, positive predic-
tive value, and negative predictive value. The 6-item
CRAFFT model, with a cut-off score of 2 or more yes an-
swers, had a sensitivity of 92.3% (24/26) and specificity
of 82.1% (55/67) for long-term treatment need.
COMMENT
The psychometric properties of the CRAFFT questions
seem promising, and the test deserves further refine-
ment and validation. In this study, the CRAFFT score was
strongly correlated with the PICS score, and is an easier
test for pediatricians to administer. The test had good in-
ternal consistency, indicating that each item is clinically
useful for detecting problems with AOD. The sensitivity
and specificity rates were high among subjects who had
used AOD. Clinicians had thus prescreened their pa-
tients; ie, determined that they had at least some history
of AOD use. This is exactly how the test would be used
in clinical practice. According to current guidelines for
health supervision, every adolescent should routinely be
asked questions such as “Have you drunk alcohol in the
past month? How much? What is the most you ever had
to drink? Have you ever tried other drugs? How often
have you taken them in the past month?”8 These ques-
tions are an appropriate initial screen for AOD use. When
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answers are positive and concerning, the CRAFFT ques-
tions can assist in determining if the use is significant
enough to warrant referral to a mental health specialist.
Examination of adjusted R2 values in Table 2 sug-
SE
gest that the test likely could be shortened and im-
13.1024 proved. The 3-item model (forget, car, relax) accounted
11.3814
for almost 60% of the variance, the 4-item model (for-
10.1853
9.6145
get, car, relax, trouble) 64%, and the 5-item model (for-
9.3419 get, car, relax, trouble, alone) 66%. Thus, one might ar-
gue that adding the latter 2 or 3 questions adds relatively
9.0379 little explanatory value for purposes of statistical analy-
sis. While further testing and refinement of this screen
is needed, all 6 CRAFFT questions are clinically rel-
evant and additional questions and discussion should
follow any yes answer. Each will therefore be briefly
discussed.
“Have you ever ridden in a car driven by someone
(including yourself) who was high or had been using al-
cohol or drugs?” This may be the single most important
question to ask. As previously discussed, alcohol-
related motor vehicle crashes are a leading cause of death
for teenagers. In fact, those youth that answer yes to this
question need advice, assistance, and follow-up by the
primary care provider even if they do not use AOD them-
selves. If they have ridden home with an intoxicated peer,
for example, the pediatrician may work toward the de-
velopment of a “rescue plan.” This is a contract with par-
ents to provide a ride home whenever their son or daugh-
ter calls to request one, with no recriminations or
disciplinary action. A very different situation evolves, how-
ever, when the driver of the car in question is in fact the
parent. In this case, the pediatrician may need to be-
come involved in a parent intervention or, in extreme cir-
cumstances, file a report to child protection authorities.
“Do you ever use alcohol or drugs to relax, feel bet-
ter about yourself, or fit in?” The intention of this ques-
tion is to determine if there is “use for effect.” A yes an-
swer may indicate that the teenager feels uneasy in social
situations and would be particularly susceptible to peer
pressure and high-risk behavior.26 With these youth, pe-
diatricians should discuss positive alternatives for so-
cializing (eg, school- or church-sponsored activities) and
offer brief counseling and support.
“Do you ever use alcohol or drugs while you are by
yourself (alone)?” The social context of AOD use is im-
portant. Most adolescents begin to use AOD with peers,
yet peer influence has little to do with continuation of
use.27,28 Using alone is a “red flag” behavior and may in-
dicate emerging addictive pathology and increasing so-
cial isolation.29 A positive response to this one question
may be in itself an indication for early referral to treat-
ment.
“Do you ever forget things you did while using
alcohol or drugs?” A yes answer to this question is
another indication of a serious problem. Episodes of am-
nesia usually indicate heavy alcohol use, heavy drug use,
or a combination of both. Anterograde amnesia (black-
out) is a particularly worrisome sign that may indicate
alcoholism.30 Pediatricians should always follow up a yes
answer with further questions regarding how long ago
this occurred, what the pattern of use was at the time,
and whether or not there have been recurrences. This is
594
 another symptom that indicates a likely need for prompt
referral to treatment.
“Do your family or friends ever tell you that you
should cut down on your drinking or drug use?” This is
a third-person version of the “cut down” question from
CAGE. Adolescents’ responses to questions about how
others view their behavior are often quite revealing. This
question also assists the clinician in determining who
might be a potential ally in intervention and treatment
for the patient. A yes answer should be followed with ques-
tions such as “Who was it that told you that? Why would
they think that? Do you think they still feel that way?
Why or why not?”
“Have you ever gotten into trouble while you were
using alcohol or drugs?” This question helps determine
problem severity. The Figure illustrates a theoretical
model for understanding the progression of AOD use
among adolescents that is based on the American Acad-
emy of Pediatrics DSM-PC Child and Adolescent Ver-
sion.31,32 According to this model, the “problem use” stage
is very important to identify in the medical office set-
ting. Negative consequences occur as a result of AOD use,
but control over use has not been completely lost. Youth
at this stage are often still amenable to brief interven-
tions. Pediatricians must remember, however, that
younger adolescents, whose cognitive abilities are still
emerging, may be developmentally unable to associate
their problems with AOD use. The question should there-
fore be broken down into several shorter ones: “Have you
gotten into any trouble since I last saw you? What hap-
pened? Were you using alcohol or other drugs at the time?
Have you ever considered that, if you hadn’t been using
alcohol or drugs, you might not have gotten into trouble?”
This sequence of questions can not only elicit valuable
information, but becomes the beginning of an interven-
tion. Such office interventions have been previously de-
scribed, but not yet formally studied in adoles-
cents.31,33-35
Determination of the CRAFFT’s validity must be an
ongoing and dynamic process. The purposes of our study
were to begin that process and to stimulate continuing
research. Given that the condition identified by the screen
is associated with significant morbidity and mortality, and
that the relative “cost” of a false-positive (ie, further as-
sessment) result is negligible compared with that of a false-
negative result, a model with high sensitivity and high
negative predictive value is desirable. The 6-item CRAFFT
model, with a cut-off score of 2 or more, is both sensi-
tive (92%) and specific (82%) for indicating intensive-
treatment need, and has adequate positive (67%) and
negative (97%) predictive value according to PICS cri-
teria. In other words, 92% of adolescents who need in-
tensive treatment will be identified by a CRAFFT score
of 2 or higher (sensitivity), and 97% of those with a lower
score do not need intensive treatment (negative predic-
tive value). Lowering the CRAFFT cut-off score to 1 would
increase sensitivity (100%), but decrease specificity
(58.2%). Consideration may also be given to use of a
model with fewer items. For example, a 4-item test with
cut-off score of 2 had a sensitivity of 81% and a speci-
ficity of 90%, and a positive predictive value of 75% and
negative predictive value of 92.3%.
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Developmental
Variations Disorders
Abstinence
Dependency
Experimental (Tolerance,
Use Withdrawal)
Abuse
Regular
(Continued
(Social)
Use Problem
Use Despite
Harm)
Use
(Adverse
Consequences)
Problem
Stage
A developmental view of stages of adolescent alcohol and other drug use.
This study has several limitations. The sample size
is relatively small. Data were not collected on adoles-
cents who refused to participate or were excluded. In ad-
dition, while the demographic makeup of the study sample
was fairly typical for an urban hospital-based adoles-
cent practice, the mean PICS score (45.9) for the sub-
ject population was high. In a prior study, adolescents
meeting Diagnostic and Statistical Manual of Mental Dis-
orders, Revised Third Edition criteria for an AOD “abuse”
diagnosis had a PICS score mean of 40.1 and those meet-
ing criteria for a “dependency” diagnosis had a mean score
of 51.3.23 As the mean for our subjects falls between these
2 numbers, we conclude that our study population had
a high prevalence of alcohol- and drug-related pathol-
ogy. None of the subjects fell into the “no treatment” cat-
egory according to PICS treatment classification. The
sample, of course, was not selected at random. Study cli-
nicians were told that adolescents who had ever used AOD
could be included, but most invited only those adoles-
cents they felt were using AOD regularly.
Finally, as in all validation studies, our brief screen
can be no better than the instrument it was compared
against, and the PICS validation was performed in a dif-
ferent subject population (ie, an AOD specialty clinic).
Further studies of the CRAFFT questions are needed, in-
cluding predictive and differential validation against an
assessment battery that includes a standardized diagnos-
tic interview. It should be validated in different popula-
tions and settings. Further refinement of items is also
needed, and clinical utility should be investigated by elic-
iting feedback from both pediatric clinicians and ado-
lescent patients. Final decisions regarding a 4-item vs a
6-item model should be guided by blending data analy-
sis with clinical experience, theoretical considerations,
and practicality.
The CRAFFT questions show potential as a brief
AOD screening device. The test is easy to administer and
score, and its sensitivity and specificity rates are prom-
ising. Further research must confirm the test’s charac-
teristics before its use can be widely recommended. This
research should include testing in other populations and
clinical settings. Concurrent and predictive validity stud-
ies should be conducted against instruments that assess
both AOD use severity and diagnoses. Individual CRAFFT
items can likely be modified and improved. However,
 CRAFFT has the potential to assist clinicians in quickly
identifying youth who need referral to substance abuse
treatment programs.
Accepted for publication October 7, 1998.
This work was supported in part by grants MCJ259360
and MCJ-MA 259195 from the Maternal and Child Health
Bureau, Washington, DC, and grant DA09288-01 from the
National Institute on Drug Abuse, Washington, DC.
Presented at the Annual Meeting of the Ambulatory Pe-
diatric Association, New Orleans, La, May 3, 1998.
We thank Ken C. Winters, PhD; Elizabeth Rahdert,
PhD, for advice and assistance; Michelle Palacios for coor-
dination of the project; and S. Jean Emans, MD, and Eliza-
beth Goodman, MD, for reviewing the manuscript.
Reprints: John R. Knight, MD, Children’s Hospital.
300 Longwood Ave, Boston, MA 02115 (e-mail: knight_j
@a1.tch.harvard.edu).
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