Substance Use Screening Among Youth in Foster Care

There are >390 000 children in foster care (ie, in the custody of a county or state children's services agency and placed with temporary caregivers, including licensed foster caregivers, approved kinship caregivers, or in congregate or independent living situations with staff serving as caregivers) in the United States.1 Children in foster care face many health challenges compared with the general population, including increased rates of substance use and substance use disorders.2 Standardized screening, through Screening, Brief Intervention, and Referral to Treatment (SBIRT), is an evidence-based approach that assesses current substance use and provides the appropriate level of treatment.3 For standardized screening to be effective, substance use disclosure is critical. Adolescents report preferring self-administered (paper, digital) substance use screeners and response patterns suggest adolescents disclose substance use reliably.4 Electronic health record advances have made tablet-based screening efficient and cost-effective. However, before accepting tablet-based standardized substance use screening as a standard of care among youth in foster care, it is important to describe the validity of standardized substance use screening in a foster care clinic and factors associated with patterns of responding.With child welfare and institutional review board approval, we collected data from youth aged 10 to 20 years who were in foster care between February 2022 and March 2023 and seen for a mandated health examination in the foster care clinic at a pediatric medical center in the Midwest United States (for enrollment characteristics, see Supplemental Table 3). Standardized screening for substance use was initially completed with the CRAFFT 2.1 Questionnaire,5 which assesses for use of alcohol, cannabis, and "anything else to get high" within the past 12 months. On September 21, 2022, the screening tool was updated to the CRAFFT2.1+N questionnaire (parts A and B6), which adds an additional question asking about vaping and tobacco use. The screening was delivered on a tablet with results automatically imported into the electronic health record. Health care providers reviewed screening results with patients during the confidential portion of their examination, in which participants sometimes disclosed substance use not reported on the CRAFFT. Providers referred all patients who endorsed past-year substance use (on the CRAFFT screen or in the provider interview) to a trained interventionist who provided brief intervention ± referral to treatment. Youth who consented to enroll in longitudinal data collection were asked additional questions about substance use in the past 30 days. Confidentiality was maintained when desired by patients unless the risk to harm of self or others necessitated disclosure to child welfare partners (ie, with referrals to treatment; Supplemental Fig 1).During our study period, 373 youth completed CRAFFT substance use screening; if multiple screenings were completed, the first screening occurrence was used in analyses. Initially, 93 CRAFFT screens were positive. Among the 280 negative CRAFFT substance use screens, 34 (12.1%) endorsed substance use during the confidential interview with health care providers, resulting in an overall sample total of 127 (34.0%) youth who endorsed substance use (Table 1). Youth who denied substance use on screeners and endorsed use with providers were, on average, 2 years older and were more likely to live in independent living placements when compared with youth who did not change responses (Table 2). Rates of past 30-day alcohol, cannabis, and nicotine use reported to the interventionist for youth who did and did not revise their responses during the confidential interview did not significantly differ.A total of 242 youth completed the screen using the original CRAFFT2.1, with a 31.0% overall positivity rate for all substances. Cannabis was the most endorsed substance within the previous 12 months (n = 78, 20.9%). The screening positivity rate slightly increased, to 39.7% across 131 youth, with the implementation of the CRAFFT2.1+N. Among the youth who completed the screen after the nicotine question was added, 20 (15.3%) reported at least 1 day of nicotine use in the previous 12 months. Eighty percent of youth who endorsed nicotine use also endorsed use of another substance.This study demonstrates that standardized tablet-based substance use screening is valuable but not thorough for youth in foster care. In the current study, youth endorsed past-year substance use (39.7%) at a higher rate than the general population (21.6% report substance use in the past year7). The majority of youth had a reliable self-administered substance use screen; however, 12% had a false-negative substance use screen, despite screening specifically for nicotine in addition to other substances. This is a missed opportunity for substance use disorder prevention and harm reduction.8 False-negative screens in this study may result from concerns regarding confidentiality, literacy challenges, social desirability, or technology issues with tablet-based administration, which may be particularly relevant for youth in independent living placements. Furthermore, without the specific nicotine question on the CRAFFT screen, many youth using nicotine might have received intervention for other substance use, but likely would have failed to receive further assessment and intervention for nicotine use, a risk factor for many long-term health conditions. Limitations of this study include a lack of objective corroboration for substance use (eg, laboratory testing) and missing youth perspectives on barriers to successful screening. Although standardized tablet-based substance use screening clearly has value to detect substance use among youth in foster care, findings suggest that providers should follow up with negative screens to confirm results and identify opportunities for additional targeted intervention. Further research is needed to understand the best modalities of screening to improve detection and, ultimately, provide optimal intervention to prevent or reduce substance use.