Validity of Brief Alcohol Screening Tests Among Adolescents: A Comparison of the AUDIT, POSIT, CAGE, and CRAFFT John R. Knight, Lon Sherritt, Sion Kim Harris, Elizabeth C. Gates, and Grace Chang Background: Adolescents should be screened for alcohol misuse as part of routine care. The objective of this study was to compare the criterion validity of the Alcohol Use Disorders Identification Test (AUDIT), the Problem Oriented Screening Instrument for Teenagers substance use/abuse scale (POSIT), and the CAGE and CRAFFT questions among adolescents. Methods: Fourteen- to 18-year-old patients arriving for routine healthcare at a large, hospital-based adolescent clinic completed the four screens and the criterion standard Adolescent Diagnostic Interview, which yields DSM-IV diagnoses of alcohol abuse and dependence. Receiver operating characteristic (ROC) curves were plotted to determine optimal cut-points. Areas under the ROC curves of the four screens were compared, and sensitivities and specificities were calculated. Results: Participants��� past 12-month alcohol diagnostic classifications were as follows: no use (58.6%), nonproblem use (13.0%), problem use (20.8%), abuse (5.4%), and dependence (2.2%). Optimal cut-points associated with problem use or higher were 2 for AUDIT, 1 for POSIT, 1 for CAGE, and 1 for CRAFFT. ROC curve area of the CAGE was significantly lower compared with areas of all other screens. Sensitivities (95% confidence intervals) were AUDIT 0.88 (0.83���0.93), POSIT 0.84 (0.79���0.90), CAGE 0.37 (0.29��� 0.44), and CRAFFT 0.92 (0.88-0.96) specificities were AUDIT 0.81 (0.77���0.85), POSIT 0.89 (0.86���0.92), CAGE 0.96 (0.94���0.98), and CRAFFT 0.64 (0.59���0.69). Conclusions: The AUDIT, POSIT, and CRAFFT have acceptable sensitivity for identifying alcohol problems or disorders in this age group. The CAGE is not recommended for use among adolescents. Key Words: Substance-Related Disorders, Alcoholism, Substance Abuse Detection, Sensitivity and Specificity, Adolescence. MISUSE OF ALCOHOL is one of our nation���s greatest health problems with an estimated annual cost of more than $185 billion (Wagenaar et al., 2000) and more than 100,000 alcohol-related deaths each year (National Institute on Alcohol Abuse and Alcoholism, 2001). Heavy drinking adversely affects all ages, including adolescents, and is associated with both serious short- and long-term consequences. Greater than 35% of fatal motor vehicle crashes involving drivers ages 15 to 20 years old are related to alcohol use, and almost 25% involve a legally intoxicated driver (Centers for Disease Control, 1999). Adolescent drinking is linked to other serious health risk behaviors such as early sexual activity, truancy, violence, and weapon carrying (Kokotailo, 1995). Heavy drinking also interferes with normal adolescent cognitive, emotional, and social development and is linked to psychiatric disorders and delinquency (Hicks et al., 1993). Those who begin drinking before age 15 are four times as likely to develop alcohol dependence and more than twice as likely to develop alco- hol abuse compared with peers who delay drinking until age 21 (Grant, 1997 Robis and Przybeck, 1985). Primary care physicians and other healthcare providers can play an important role in preventing the harm associ- ated with alcohol misuse by recognizing problems early and providing appropriate intervention. A number of published guidelines emphasize the importance of routine alcohol screening of adolescents, including the American Medical Association���s Guidelines for Adolescent Preventive Ser- vices (Elster and Kuznets, 1994), the Bright Futures Guide- lines (Green, 1994), and the American Academy of Pedi- From the Department of Pediatrics (JRK, SKH), Division on Addictions (JRK, LS, SKH), and Department of Psychiatry (GC), Harvard Medical School, Boston Center for Adolescent Substance Abuse Research (JRK, LS, SKH, ECG, GC), Division of General Pediatrics (JRK, LS, ECG), and Division of Adolescent/Young Adult Medicine (JRK, SKH), Children���s Hos- pital, Boston and Department of Psychiatry (GC), Brigham and Women���s Hospital, Boston. Received for publication April 15, 2002 accepted October 24, 2002. Supported by Grant R01 AA12165 from NIAAA and The Substance Abuse and Mental Health Services Administration, and Grant 036126 from The Robert Wood Johnson Foundation. Other support was provided by Grant 5T20MC000-11-06 (JK) and Grant 5T71MC 00009-10 (LS, SH) from the Maternal and Child Health Bureau and by grant K24 AA00289 (GC) from NIAAA. Reprint requests: John R. Knight, MD, Center for Adolescent Substance Abuse Research, Children���s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 Fax: 617-267-9397 Email: john.knight@tch.harvard.edu. Copyright �� 2003 by the Research Society on Alcoholism. DOI: 10.1097/01.ALC.0000046598.59317.3A 0145-6008/03/2701-0067$03.00/0 ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH Vol. 27, No. 1 January 2003 Alcohol Clin Exp Res, Vol 27, No 1, 2003: pp 67���73 67

atrics��� Guidelines for Health Supervision III (American Academy of Pediatrics, 1997). Although all guidelines rec- ommend an annual screening for alcohol and drugs, they do not provide details on how it should be performed. Screening is a procedure generally applied to populations and is intended to identify individuals at risk for a disease. Assessment is a procedure generally applied to individuals who have screened positive and is intended to confirm the presence of the disease and measure its severity. The ideal tool for screening adolescents should be developmentally appropriate, valid, reliable, and practical for use in busy medical offices (Knight, 2001). Some alcohol screening tests can be administered by the clinician as part of the general health interview or while performing the physical examination. To be practical, these must be brief and easy to score and remember. Simple yes/no questions that lend themselves to oral administration and mnemonic acronyms are ideal. Questionnaires, by way of comparison, are usu- ally administered to patients in the waiting room. To be practical, these must be capable of self-completion within the usual wait time, and scoring procedures must be suffi- ciently streamlined so that minimal staff training and time are required and results can be given to the clinician before the start of the medical visit. A number of brief screening instruments meet these criteria, including the four selected for this study. The Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992) was developed by the World Health Organization as a screening tool for hazardous alcohol consumption (Saunders et al., 1993). The AUDIT���s 10 multiple-choice response items require approximately 2 min for administration and another 3 min for scoring. Standard instructions state that a total score of eight or more indicates a strong likelihood of harmful alcohol con- sumption (Allen and Columbus, 1995). The AUDIT has been shown to be a valid means of identifying current hazardous use of alcohol among adults and college students (Allen et al., 1997 Fleming et al., 1991 Miles et al., 2001), and one study found the AUDIT to have good sensitivity and specificity for identifying alcohol disorders among 13- to 19-year-old emergency ward patients (Chung et al., 2000). However, another study found the AUDIT to be less practical for use among adolescents seen in a primary care setting (Foster et al., 1997). The Problem Oriented Screening Instrument for Teen- agers (POSIT) is a multiple-problem screening tool devel- oped by the National Institute on Drug Abuse specifically for adolescents aged 12 through 19 (Rahdert, 1991). The POSIT includes a total of 139 yes/no questions divided into 10 scales, one of which is the 17-item substance use/abuse scale (Allen and Columbus, 1995). A score of one or higher on this scale is considered a ���red flag��� for substance-related problems (Rahdert, 1991). The POSIT has been shown to have good reliability and validity among adolescents, in- cluding those seen in primary care medical settings (Dembo et al., 1996 Knight et al., 2001 McLaney et al., 1994). Although these two questionnaires have advantages, ad- ministration in the waiting room may pose a risk to ado- lescents��� confidentiality (Foster et al., 1997 McLaney et al., 1994). An alternative is an orally administered screen that physicians can administer during the course of the medical visit, after parents have left the room. The CAGE questions are a good example of this type of brief screen (Ewing, 1984). Originally developed for screening adults, the CAGE has become popular among medical clinicians (Mayfield et al., 1974). Its four yes/no questions are weighted equally (each yes answer 1), and a total score of two or greater is considered clinically significant (Allen and Columbus, 1995). The CAGE has been well validated among adults and may be particularly suited to identifying patients with alcohol dependence (Bush et al., 1987 Magruder-Habib et al., 1993 Soder- strom et al., 1997). However, the CAGE has been found to perform less well among females, college students, and adolescent medical patients (Aertgeerts et al., 2000 Chung et al., 2000 Knight et al., 2000 O���Hare and Tran, 1997). The CRAFFT shares many of the CAGE���s advantages but was designed specifically to be developmentally appro- priate for adolescents (Knight et al., 1999). CRAFFT is an acronym of the first letters of key words in the test���s six questions: ���Have 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 alcohol 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? Have you ever gotten into TROUBLE while you were using alcohol or drugs?��� Like the POSIT, CRAFFT screens for use of both alco- hol and drugs. A previous study concluded that the CRAFFT has adequate sensitivity and specificity for iden- tifying adolescents with substance-related problems (Knight et al., 2002). The purpose of the current study was to compare the criterion validity of the AUDIT, POSIT, CAGE, and CRAFFT in identifying alcohol-related pathol- ogy in an adolescent medical clinic population. METHODS This criterion standard study was conducted between March 15, 1999, and September 14, 2000, at the Adolescent/Young Adult Medical Practice of Children���s Hospital Boston. This clinic serves both inner city and suburban youth from a wide range of social strata, racial groups, and ethnic backgrounds. Primary care providers, including staff physicians and fellows specializing in adolescent medicine, pediatric residents, and nurse practitioners, served almost 5000 patients through both routine well care and urgent care visits during the study recruitment period. The study sample was drawn from all 14- to 18-year-old patients arriving for routine care. Before clinic sessions began, the birth dates of all scheduled patients were reviewed and a study recruitment form was placed on the chart cover of each age-eligible patient. The form included items that recorded demographic information, the provider���s impression of the 68 KNIGHT ET AL.