What Are the CRAFFT Questions?

Patient Presentation
A 14-year-old male came to clinic for a health supervision visit and sports physical. The adolescent admitted to trying some cigarettes and some beer in the past few months at a friend’s house. The friend’s older brother had provided them to the younger teens during a sleep over. He stated that he “didn’t like them” and wasn’t going to be trying them again anytime soon. The teenager said that family members had an occasional beer during a social event or watching sports, but that he had never seen anyone drunk or driving while intoxicated. The past medical history showed a previous ankle injury from basketball. The family history was positive for depression in a maternal grandmother, but negative for substance abuse.

The pertinent physical exam showed a healthy male with normal vital signs and growth parameters. His examination was normal including his ankle. The diagnosis of a healthy male who had recently experimented with tobacco and alcohol was made. The physician talked with the adolescent and encouraged him to not use any substances. He also encouraged him to never drive or get into a car with anyone who had used a substance. The physician recommended having a safety plan with several telephone numbers of trusted adults who could give him a safe ride home if needed. The patient’s clinical course over the next several years found that he did try smokeless tobacco, and had a part of a beer with his family on very special social occasions.

Discussion
As tweens and teenagers continue to develop toward adulthood, they begin to engage in adult behaviors and take on the risks of those behaviors. Adolescent interviews are often guided using the acronyms HEADSS or SSHADESS to help elicit the adolescent’s strengths, weaknesses, behaviors and potential risks. HEADSS stands for home, education, activities, drugs/depression, suicide and sexuality. SSHADESS is slightly more expansive and stands for strengths, school, home, activities, drugs/substance abuse, emotion/depression, sexuality and safety.

“…[A]lcohol use is often the first risk behavior in which adolescents engage…” so screening for alcohol use is an important part of the adolescent interview. Deaths in the adolescent age range are usually because of accidents, homicide or suicide (about 70%), and alcohol often plays a role in these incidents. For example, in car accidents over 35% of them directly involved alcohol and an additional 20-25% were related to alcohol or another substance drug use, or riding in a car with a drunk driver. “All together, substance use accounts for almost 60% of accidental deaths among teens.”

Having time for parents to talk with their teenagers on a regular basis has been shown to decrease alcohol and tobacco use. For example, having a family dinner 3-7 times/week decreases the risk by about half. Alcohol is often taken from the adolescent’s home either being given it by family member or just taking it. Experts recommend that if alcohol is in the home that it is locked up. “The average length of time between the onset of teen substance use and a parent knowing is 2-2.5 years,” so experts recommend that if parents have a suspicion, then it is very likely that the adolescent already has a substance abuse problem.

Signs and symptoms of substance abuse include:

  • “Loss of interest in activities
  • Inconsistent school performance
  • Changes in dress and grooming
  • New friends that parents don’t like
  • Changes in eating and sleeping patterns
  • Alcohol, smoke, or chemical odors
  • Obvious intoxication or dizziness
  • Sudden mood changes and bizarre behavior
  • Frequent arguments or violent actions
  • Runaway and delinquent behavior
  • Suicide attempts”

Learning Point
An Adolescent SBIRT (screening for substance abuse, brief intervention and/or referral to treatment) algorithm recommended by the American Academy of Pediatrics.

Opening questions
Ask the adolescent to honestly answer the following questions:

During the past 12 months did you:
1. Drink any alcohol (more than a few sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high? (this includes illegal, prescription or over the counter drugs and things that you sniff or “huff”)

CRAFFT questions
As the adolescent 1 or more of these questions:
C = Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R = Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?
A = Do you ever use alcohol or drugs while you are by yourself or ALONE?
F = Do you ever FORGET things you did while using alcohol or drugs?
F = Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T = Have you ever gotten into TROUBLE while you were using alcohol or drugs?

If no to all opening questions, ask CAR question.

    If no to all questions, the health care provider should praise and encourage the adolescent.
    If yes to the CAR question, the health care provider should talk with the adolescent about risks of driving or riding in cars with someone who has been using substances and helping the adolescent to develop a safety plan for this possibility. A sample “Contract for Life” can be found at the Students Against Destructive Decisions website here.

If yes to any of the opening questions, ask all the CRAFFT questions (each yes to a question is one point).

    If CRAFFT score 0-1, give brief advice to stop using the substance.
    If CRAFFT score >2, then the adolescent is at high risk for having a substance abuse problem. A full psychosocial interview is needed to develop a plan for advising the adolescent and possible referral for treatment, along with the considerations of timing and confidentiality.

A full outline can be found at in the American Academy of Pediatrics Policy Statement below in the To Learn More section

Questions for Further Discussion
1. How common is alcohol use and abuse by tweens and teenagers?
2. What resources are available in the local area for substance abuse treatment?
3. What is the difference between experimentation, limited use, problematic use, abuse and addiction of substances?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Alcohol, Alcoholism, and Underage Drinking.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Children’s Hospital Boston, Center for Adolescent Substance Abuse Research. Clinician Information. Available from the Internet at Clinician Information (rev. 4/10/12, cited 2009).

Children’s Hospital Boston, Center for Adolescent Substance Abuse Research. Teen Safe. Available from the Internet at http://www.teen-safe.org/about (rev. 4/10/12, cited 2010).

Committee on Substance Abuse, Levy SJ, Kokotailo PK. Substance use screening, brief intervention, and referral to treatment for pediatricians.Pediatrics. 2011 Nov;128(5):e1330-40.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Some Reasons for Using Orthotic Helmets for Positional Plagiocephaly?

    Patient Presentation
    A 6-month-old male came to clinic for his health supervision visit. He had previously been noted to have right occipital plagiocephaly and the parents had been instructed to change infant positions, increase “tummy-time” and to do stretching exercises of his neck. The family admitted some compliance with the treatment, and were now more concerned about his face as they felt he now was having some facial changes noting his right cheek seemed more prominent. He was otherwise well and developmentally appropriate currently sitting with minimal assistance, easily transferring objects, and saying vowels and consonant sounds. The past medical history showed that he was a first born male, full-term infant.

    The pertinent physical exam revealed an interactive infant with normal vital signs and growth parameters. His right occipital area had significant flattening and a slightly vertical peak when viewed from behind the infant. When viewed from above the head had a parallelogram appearance. He had ~8 mm anterior ear displacement. When measuring from the eyebrow to the contralateral occipital protuberance, there was a 10 mm difference between the two sides. There was no obvious ridging of the suture lines, and the anterior fontanelle was 1 cm open. The diagnosis of positional plagiocephaly was made. The infant was referred to a neurosurgeon for possible orthotic treatment with a helmet. The patient’s clinical course showed that the family did comply with the helmet use and after 4 months the infant had significant improvement with only mild posterior flattening and only slight anterior ear displacement still present.

    Discussion
    Plagiocephaly can occur at birth due to in utero or intrapartum problems (i.e. prematurity, multiple birth, breech positioning, oligohydramnios, forceps extraction, etc.), but positional plagiocephaly (PP) usually occurs after birth due to mechanical factors. These include positioning of the infants head such that little repositioning occurs (i.e. bottle feeding only on same side, placement in crib on same side, placement always on infant’s back with no prone placement, lying or sitting in crib, infant carrier or other similar object for prolonged time periods, etc.)

    Usually PP has a parallelogram skull shape when observed from above caused by flattening of the affected occiput and anterior displacement of the ipsilateral ear and facial structures. This is in contrast to true craniosynostosis (premature closure of the sutures) which is more trapezoidal with flattening of the occipital and frontal areas on the affected side. Although uncommon, lamboid craniosynostosis can also make a parallelogram shape as well.

    PP prevention includes infant placement in multiple positions (i.e. upright in arms, cradled in adult arms with head orientation alternating between arms, placement on back for sleep with head orientation alternating at different ends of the crib, prone positioning while awake and attended such as “tummy-time”, etc.) and prolonged placement in one position avoided such as car seats or infant swings. Most infants will have improvement in 2-3 months with repositioning and/or neck exercises. If not, then referral to a neurosurgeon or other similar team proficient in treatment should be considered. Skull radiographs and computed tomography of the head are not recommended, unless a neurosurgeon or other specialist has recommended them for possible surgical evaluation of craniosynostosis.

    Treatment for PP includes:

    • 1. Repositioning – education of parents to frequently change positions as noted above.
    • 2. Neck exercises – torticollis is often present. Neck exercises to increase range of motion can be reviewed here.
    • 3. Orthotic skull molding helmets

    Learning Point
    Skull molding helmets are often recommended for infants older than 6 months, if positioning and exercises have failed to give an adequate response and if the cranial diagonal distances are more than 1.0 cm different between sides (normal difference is 2-4 mm). As most primary care physicians do not have cranial calibers available in their office this measurement is difficult to obtain. One measurement which could be easier to obtain is the anterior superficial helical ear fold to the lateral canthus of the eye indicating anterior displacement of the structures. Normal is < 0.5 cm difference from one side to the other. Helmets have the best results when they are used early (4-6 months) and may have shorter times for results. Reasonable results can be found in infants 12 months.

    Questions for Further Discussion
    1. Why are families and providers concerned about positional plagiocephaly?
    2. How common is positional plagiocephaly?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Uncommon Infant and Newborn Problems and Head and Brain Malformations.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Graham JM Jr, Gomez M, Halberg A, Earl DL, Kreutzman JT, Cui J, Guo X.
    Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr. 2005 Feb;146(2):258-62.

    Lipira AB, Gordon S, Darvann TA, Hermann NV, Van Pelt AE, Naidoo SD, Govier D, Kane AA. Helmet versus active repositioning for plagiocephaly: a three-dimensional analysis. Pediatrics. 2010 Oct;126(4):e936-45.

    Kluba S, Kraut W, Reinert S, Krimmel M.
    What is the optimal time to start helmet therapy in positional plagiocephaly?
    Plast Reconstr Surg. 2011 Aug;128(2):492-8.

    Laughlin J, Luerssen TG, Dias MS; Committee on Practice and Ambulatory Medicine, Section on Neurological Surgery. Prevention and management of positional skull deformities in infants. Pediatrics. 2011 Dec;128(6):1236-41.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Wheezing?

    Patient Presentation
    An 18-year-old female came to the emergency room with cough and problems “catching her breath” for 2 days. Symptoms started with clear rhinitis 2 days ago and yesterday she had a fever to 100.8° with increased cough and thickness of the nasal secretions. The cough was productive but not different than her normal persistent cough due to immotile cilia syndrome that was diagnosed as a preschool child. She also complained of facial and teeth pain for the past 12 hours. The review of systems was otherwise negative. The pertinent physical exam showed a relatively well-appearing female with a coarse cough, but no increased work of breathing. Her respiratory rate was 20, her oxygen saturation was 98% on room air, and she was afebrile. HEENT showed boggy swollen nasal turbinates with thick, yellow-green secretions. She had facial tenderness over the frontal and maxillary sinuses. She had post-nasal drip and no specific tooth pain with palpation. Lungs had mild wheezing that resolved with coughing. The diagnosis of clinical sinusitis was made, and the patient was placed on antibiotics. She had a health maintenance examination set-up in 2 weeks and was to followup then.

    Discussion
    Wheezing is an adventitial breath sound caused by narrowing of the airway causing a musical, high-pitched, continuous sound. It occurs with expiration but as severity increases, it also occurs in inspiration. If caused by secretions then wheezing may disappear after a cough, and change in different parts of the lung fields. It is usually associated with intrathoracic processes (usually mid-trachea and below). Stridor is sometimes confused with wheezing but it occurs during inspiration and is usually caused by extrathoracic processes such as croup or vocal cord paralysis. An explanation of other adventitial breath sounds can be foundhere.

    Immotile cilia syndrome is an autosomal recessive disease with abnormal ciliary motion and impaired ciliary clearance of mucous. Patients may have cough and wheezing even if they do not have problems such as a pulmonary infection. Other common problems include otitis media, sinusitis and male infertility.

    Learning Point
    The differential diagnosis of wheezing includes:

    • Pulmonary (primarily)
      • Asthma
      • Bronchiolitis
      • Bronchiectesis
      • Bronchopulmonary dysplasia
      • Cystic fibrosis
      • Pneumonia
      • Tracheo-, bronchial obstruction
        • Bronchomalacia
        • Tracheomalacia
        • Tracheoesophageal fistula
        • Tracheal web
        • Tracheal stenosis
      • Tumor – internal, e.g. cystic adenomatoid malformation
      • Lobar emphysema
      • Pulmonary hemosiderosis
    • Pulmonary (secondarily)
      • Allergy
        • Anaphylaxis
        • Allergic rhinitis
      • Aspiration
        • Gastroesophageal reflux
        • Foreign body
        • Swallowing disorder
      • Smoke inhalation
      • Tobacco use
      • Tumor – external, e.g. mediastinal tumors
      • Drugs – salicylates, beta-blockers
    • Cardiovascular
      • Congenital heart disease
      • Pulmonary embolism
      • Vascular ring
    • Other
      • Alpha-1-antitrypsin deficiency
      • Immunologic
        • Immune deficiency
        • Immotile cilia syndrome
      • Infectious Disease
        • Croup
        • Epiglottitis
        • Mycosis
        • Parasites
        • Rhinitis
        • Sinusitis
        • Tuberculosis
      • Munchausen syndrome
      • Sarcoidosis

    Patients often present with a cough and on physical examination have wheezing, but one may be seen without the other. Their differential diagnoses also overlap. A differential diagnosis of cough can be found here.

    Questions for Further Discussion
    1. What are the criteria for the diagnosis of asthma?
    2. What is the epidemiology and natural history of immotile cilia syndrome?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Sinusitis, Breathing Problems and Lung Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:156-158.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:272-276.

    Sharma GD. Primary Ciliary Dyskinesia. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/1002319-overview#a0199 (rev. 3/27/2012, cited 4/2/12).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital