Adolescents Substance Abuse Screening Program: experience with Czech adaptation of the CRAFFT Screening Test
21.3.2009 Ladislav Csémy, John Knight, Olga Starostová, Lon Sherritt, Pavel Kabíček, Shari Van Hook
Adolescents Substance Abuse Screening Program: experience with Czech adaptation of the CRAFFT Screening Test
Ladislav Csémy1, John Knight2, Olga Starostová1, Lon Sherritt2, Pavel Kabíček3, Shari Van Hook2
1 CEPROS – Centre For Anti-drug Services And Public Health
2 CeASAR - Center for Adolescent Substance Abuse Research, Harvard Medical School
3 Clinic of children and adolescents medicine, 1.LF UK a VFN; Subdepartment of adolescents medicine IPVZ
Introduction
Excessive alcohol and drug abuse by adolescents in the Czech Republic is a problem with serious social and health consequences. According to results of the ESPAD Study (Csémy et al., 2006), more than 40% sixteen-year-old adolescents have some experience with illegal drugs (most frequently hemp drugs) and frequent drinking of excessive alcohol doses are stated by almost 25% of the representative sample.
Prevention aimed mainly at illegal drugs is developing and also the number of well conceived programmes is growing, however, the effects are still far behind expectations. Absolute majority of prevention programmes was oriented at school-based youth and was realized in school environment. Only recently this has extended to addressing general practitioners for children and youth as a group with significant potential in the area of prevention. The role of GPs in prevention of problems with alcohol and drugs was comprehensively worked out by John Knight, pediatrician and professor at Harvard University (2001). Results of his research which lasted several years show the unique position of a paediatrician for children and youth regarding a timely identification of problems and providing brief advice or intervention. That can be effective because it is realized based on a relationship between the doctor and the adolescent. Expert authority is connected with trust and partnership in this relation which facilitates the acceptance of the doctor’s recommendations by the adolescent.
A significant contribution to methodology of timely prevention came in the form of producing and publishing the Drug Prevention Manual in practice of PLDD by CEPROS in 2006 (see Starostová et al., 2007) which also contains then unvalidated CRAFFT Screening Test. Simultaneously, a research project called A Brief Screen for Adolescent Substance Abuse Reduction, conducted in American – Czech cooperation of two research NGOs, CeASAR and CEPROS, verifies the CRAFFT Screening Test, the screening tool itself, and subsequent intervention by PLDD in Czech conditions. The first phase of the project realized so far consisted of testing the Czech adapted version of the CRAFFT Screening Test (Knight et al, 1999), which is used to identify individuals with increase risk of alcohol and other drugs abuse. It is a six-item instrument with individual questions stated in Tables 1 and 2. The goal of this statement is to acquaint GPs of children and adolescents with the results of the first project phase where we verified the characteristics of the CRAFFT Screening Test and established a limit where a patient can be considered a risk patient.
Methods
Collection of data The verification of the Czech adapted version of the CRAFFT Screening Test took place in the framework of the Brief Screen for Adolescent Substance Abuse Reduction Project in February to March 2007. The data was collected in ten Prague GP surgeries for children and adolescents.
Set The analyses are based on answers of 151 adolescents (74 boys). Average age of the set was 15,1 years (s.o. 1,9), in the age between 11,4 years and 19 years. Due to the fact that invitations for prevention checkups go to children aged 13, 15 and 17 years of age, these age groups were also considered in processing the results. The observed set sample showed good consistency with distribution of adolescents in Prague regarding the type of school (basic school 48 %, lyceum 17 %, secondary school 9 %, vocational secondary school with leaving certificate 18 % and apprentice school 8 %).
Research Instrument The persons questioned were asked to answer six questions from the CRAFFT questionnaire. The CRAFFT questionnaire was complemented by Adolescents Diagnose Interview (ADI) (Winters, 1993) adapted in Czech for the purposes of validating the CRAFFT Screening Test.
Results
The Czech adaptation of the CRAFFT Screening Test had a satisfactory reliability. The coefficient of internal consistency (Cronbach α) was at 0,72.
Table 1 summarizes the distribution of answers on individual CRAFFT items according to gender. Most frequent positive answers were registered in item 2 which monitors drinking alcohol or using a drug to relax (42 % positive answers). Relatively frequent positive answers also appeared in item 4 (amnesia under the influence of a substance - 22 % positive answers) and in item 1 and 3 (19,9 % respectively 18,5 %). There were no statistically significant differences between girls and boys by any of the items.
Table 2 shows percentages of positive answers according to age groups. Progression of positive answers occurring with age is obvious and also understandable. If a modal age of first experience with alcohol is lower that 13 years and with marijuana lower than 15 years, then it is not surprising that 17-year-olds already show frequent symptoms signalising substance abuse risk.
Table 1 Percentages of positive answers on individual items of the CRAFFT Screening Test according to gender
|
|
Male |
Female |
Total |
|
|
1. C |
Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol or drugs? |
17,6 |
21,1 |
19,9 |
|
2. R |
Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? |
39,2 |
46,1 |
42,4 |
|
3. A |
Do you ever use alcohol or drugs while you are by yourself, alone? |
20,3 |
17,1 |
18,5 |
|
4. F |
Do you ever forget things you did while using alcohol or drugs? |
17,6 |
26,3 |
21,9 |
|
5. F |
Do your family or friends ever tell you that you should cut down on your drinking or drug use? |
13,5 |
13,2 |
13,2 |
|
6. T |
Have you ever gotten into trouble while you were using alcohol or drugs? |
10,8 |
6,6 |
8,6 |
Table 2 Percentages of positive answers on individual items of the CRAFFT Screening Test according to age categories
|
Age group |
13 |
15 |
17 |
|
|
1. C |
Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol or drugs? |
5,9 |
17 |
35,3 |
|
2. R |
Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? |
13,7 |
44,7 |
70,6 |
|
3. A |
Do you ever use alcohol or drugs while you are by yourself, alone? |
2,0 |
19,1 |
35,3 |
|
4. F |
Do you ever forget things you did while using alcohol or drugs? |
5,9 |
14,9 |
45,1 |
|
5. F |
Do your family or friends ever tell you that you should cut down on your drinking or drug use? |
2,0 |
17,0 |
21,6 |
|
6. T |
Have you ever gotten into trouble while you were using alcohol or drugs? |
0 |
8,5 |
17,6 |
Distribution of summary codes in CRAFFT is shown in diagram 1 where 42% respondents have 0 points and this part of the sample can be considered without risk in relation to alcohol or other substances. Further 27% stated only one positive answer and thus they also fall into the low-risk category. Two and more points were recorded by 30,4% of the sample. Two points are considered a recommended critical value indicating a need for brief advice or intervention, that is why this limit is highlighted in the diagram by a vertical line.
Diagram 2 clearly indicated that while 13-year-olds have only a marginal number of two and more points, more than half of 17-year-olds have reached this score.
Diagram 1 - Score distribution in CRAFFT Screening Test (total sample N = 151)
Diagram 2 - Score distribution in CRAFFT Screening Test depending on age
The Czech adaptation of the CRAFFT Screening Test had good sensitivity in the critical 2-point value (85 %) as well as specificity (83 %) and an adequate positive and negative predictive value (97 %, respectively 63 %), and in relation to ADI criteria led to a specific indication of 84,7 % cases. The critical value of 2 positive answers as a limit of risk behaviour by adolescents remained and it is identical with the critical value used in the USA.
Discussion and conclusions
Short screening methods for finding out problems with alcohol or other addictive substances are not really used much in the Czech Republic so far. Specific experience exists with the CAGE and AUDIT questionnaires which are used to identify adults drinking problems. Only AUDIT has been pilot-tested in the short intervention context provided by a GP. CRAFFT Screening Test is therefore the only screening tool used to identify problems with alcohol or drugs by adolescents and this pilot study verified its characteristics.
The Czech adaptation is very well comparable with results acquired by CRAFFT in the USA (Knight et al. 1999) in many parameters (specificity, sensitivity, reliability).
The pilot study contained 30,4% of respondents from the Czech sample who reached the critical score of 2 points. During the CRAFFT validation in the USA the same score was reached by 25% of the tested sample (Knight et al., 2002). A higher occurrence of persons in the risk zone in the Czech sample compared to the American one led to considerations whether it should not be appropriate to raise the critical value for Czech population from 2 to 3 points. However, a comparison with a criteria deduced from ADI confirmed that the test is optimally functional in a Czech environment at the critical value of 2 points. The fact that a higher percentage of our adolescents are in the risk zone can be explained by higher tolerance of the society towards alcohol and other addictive substances. Also, minimum age for alcohol is lower here (18 years compared to 21 in the USA) and the practical availability of alcohol to adolescents is incomparably higher. As far as young persons’ experience with drugs, the international ESPAD study (Csémy et al., 2006) suggest that Czech 16-year-olds have a comparable prevalence of experience with drugs like their Western-European and American counterparts.
Experience with the Czech version of the CRAFFT Screening Test confirm its applicability as a useful screening tool for establishing alcohol or substance abuse by adolescents. The project is continuing and testing the influence of brief intervention by adolescents’ GPs based on the CRAFFT Screening Test results and patient interviews according to the proposed methodology.
Acknowledgements
The authors wish to thank MUDr. Jitka Bělorová, MUDr. Karel Holub, MUDr. Jaroslava Chaloupková, MUDr. Věra Jedličková, MUDr Marie Kolářová, MUDr. Alena Mottlová, MUDr. Renáta Růžková, MUDr. Marie Schwarzová, MUDr. Leona Tylingrová, MUDr. Petra Vlková for their cooperation which was indispensable for the realization of the project.
Funding support: Screening and Brief Advise to Reduce Teen Substance Use / RO DA 018848/ NIDA RFA-DA-04-006 /
Literature
Csémy L, Lejčková P, Sadílek P. Evropská školní studie o alkoholu a jiných drogách (ESPAD). Výsledky průzkumu v České republice v roce 2003 . 1. vyd. Praha: Úřad vlády České republiky, 2006 .
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Knight JR, Sherritt L, Shrier LA, Harris SM, Chang G. Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients. Arch Pediatr Adolesc Med, 2002, 156:607-614.
Knight JR. The Role of the Primary Care Provider in Preventing and Treating Alcohol Problems in Adolescents. Amb Pediatr, 2001, 1:150-161.
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