Abstract
All health care professionals with clinical responsibility for the care of children and adolescents must be able to recognize, as early as possible, associated health problems or concerns in children of substance-abusing parents, and to be able to assist these children and families in seeking treatment and promoting health. Health care providers can have a tremendous influence on families of substance-abusing parents because of their understanding of family dynamics and their close long-standing relationship with the family. Information about family alcohol and other drug use should be obtained as part of routine history-taking and when there are indications of family dysfunction, child behavior or emotional problems, school difficulties, and recurring episodes of apparent accidental trauma, and in the setting of recurrent or multiple vague somatic complaints by the child or adolescent. In many instances, family problems with alcohol or drug use are not blatant; rather, their identification requires a deliberate and skilled screening effort.
Combining the principles of anticipatory guidance, screening, and early identification, with the acknowledgment that families should be included in the process, leads to a clear conclusion that screening for children affected by parental substance abuse must occur at all ages across infancy, childhood, and adolescence. Health care providers need to be trained in the identification and management of children and youth exposed to parental addiction. Such training must begin during undergraduate education in the health professions and be reinforced by role-modeling among health professions faculty as well as practicing providers.
To effectively address the issue of parental problems with alcohol and other drugs (AOD), health care providers need to be trained in the identification and management of children and youth exposed to parental addiction. Alcoholism and other substance abuse is widespread in our society. In a recent study, 38% of Americans stated they had a family member with alcoholism.1 Because of its high prevalence and lack of socioeconomic boundaries, child health care providers should expect to encounter families with alcoholism and other drug abuse daily. A review of the literature reveals the wide range of important morbidity experienced by the children of substance-abusing families. In utero exposure to AOD can have devastating consequences on the developing fetus. Children and adolescents are at increased risk of physical and sexual abuse. School children manifest more psychosomatic illnesses; emotional, anxiety, and conduct disorders; and school problems including hyperactivity. Several recent studies suggest strongly that children of women who are problem drinkers have an increased risk of experiencing serious, unintentional injuries, and that children exposed to two parents with alcohol problems are at even greater risk.2 Studies of the link between parental substance abuse and child maltreatment suggest that substance abuse is present in at least half of families known to the public child welfare system.3
If these families and children are identified early, some of the associated morbidity may be avoided. Child and adolescent health care providers can have a tremendous influence on families of substance-abusing parents because of their understanding of family dynamics and their close long-standing relationship with the family. Information about family alcohol and other drug use should be obtained as part of routine history-taking and when there are indications of family dysfunction, child behavior or emotional problems, school difficulties, and recurring episodes of apparent accidental trauma, and in the setting of recurrent or multiple vague somatic complaints by the child or adolescent. In many instances, family problems with alcohol or drug use are not blatant; rather, their identification requires a deliberate and skilled screening effort.
A recent study indicated that fewer than half of pediatricians ask about problems with alcohol when taking a family history.4More family medicine practitioners than pediatricians asked about problems with alcohol, suggesting that training and practice orientation may be important. The likelihood of asking about problems with alcohol did not appear to be influenced by the pediatrician's self-report of knowledge about alcoholism but rather by whether the pediatrician had a personal family history of problems with alcohol.4 In a similar study focusing on recognition of family substance abuse among hospitalized children, attending physicians identified only 5% of families determined subsequently to have alcoholic parents.5 Thirty-three percent of pediatric faculty reported feeling little or no responsibility for substance-abuse referrals of patients' family members.5In contrast, Graham and colleagues found that patients wanted their physicians to ask about family alcohol problems and felt that the physician could help them and the abusing family member deal with their problems.6
A family history of alcohol and other drug abuse is more likely than many other aspects of history to affect a child's immediate and future health. A thorough understanding of family members' use of AOD is as important as a history for hypertension, cancer, or diabetes mellitus. In addition, family problems with alcohol or other drugs can jeopardize a parent's ability to carry out necessary therapeutic regimens for their child.
This background paper will discuss conceptual approaches to interviewing children, youth, and families; methods for screening and identifying families at high risk for substance-abuse problems; family issues in substance abuse; and approaches to early intervention in the primary care setting with children and families affected by substance abuse. The purpose of this discussion is to establish a clinical framework for child and adolescent health care that obviates the need to address family substance abuse and, therefore, clarifies the specific educational and training needs put forth by this initiative.
SCREENING VERSUS ASSESSMENT
The primary task of initial screening is to identify families with alcohol or other drug use problems that put their children and youth at risk for having physical or mental health complications. Screening questions identify those individuals most likely to have a problem related to alcohol or other drug use. Information gathered should help to decide whether there is a need for additional assessment by either the primary care provider or a consultant. It is helpful to keep in mind that screening is an important and time-efficient first step to identifying the probable existence of a problem, but that it differs from assessment and establishing a final diagnosis. Assessment is a more lengthy and structured process designed to determine the extent of the problem, explore comorbidities, and assist in treatment planning for the entire family.
Screening must occur at three different levels. The first is screening the child or adolescent for their own physical or mental health problems that may be associated with substance-abuse problems among family members. As the child grows older, there is an increasingly important opportunity to establish diagnostic concerns and related treatment plans that can be implemented with the child or adolescent directly. Many older children and adolescents can be assessed fully by the primary care provider without need for referral.
The second screening concern relates to identifying other family members at high risk for substance-abuse problems. It is likely that family members who appear to be at high risk for substance-abuse problems will need referral for more detailed assessment by substance-abuse professionals. Screening for, and intervening with, other family members affected by the family situation are necessary endeavors to maximize the health of the child. Third, as adolescents grows older, it is increasingly important to identify their own alcohol and other drug use problems, because children from homes with addiction problems are at higher risk for developing their own problems with AOD.
Although the ability to do an in-depth assessment and make an actual diagnosis may be beyond the time limitations and skills of many practitioners, all child and adolescent health care providers are responsible for screening and initial management or referral. The difficulty encountered sometime in obtaining accurate social and psychological histories and behavioral self-reports related to alcohol use by family members should not deter the physician from including such histories and interviews in routine office procedures.
INTERVIEWING CHILDREN, YOUTH, AND FAMILIES
Over the past 20 years, there has been an increasing level of interest in, and appreciation for, the complexity of communication skills needed to establish effective physician–patient/family relationships. Recent efforts to organize concepts and knowledge about medical interviewing have established useful models for the medical interview.7 One particularly useful model for child and adolescent health care views the medical interview as having three central functions: 1) to collect information regarding a potential problem; 2) to respond to the patient and family's emotions; and 3) to educate the family and influence behavior.8 These functions are highly germane to the identification and intervention of children living with substance-abusing parents, because all three functions may need to occur simultaneously and are necessary to promote the well-being of these children adequately.
Collecting Information
To collect information about potential parental substance abuse, health care providers will need to 1) screen for and identify the family alcohol or drug problem; 2) understand the child's response to his/her perceived situation; 3) monitor changes in the child's behavior or health condition; and 4) provide themselves with a knowledge base regarding the child and family sufficient to develop and implement a treatment plan. Children should be encouraged to tell their story in their own words. This may require the physician to help create or facilitate the child's narration, to organize the flow of the interview, to use appropriate open- and closed-ended questions to clarify and summarize information, to show support and reassurance, and to monitor nonverbal cues.7 Health care providers will need to acquire the knowledge base of psychosocial and family issues that contribute to the child or adolescent's health condition. In addition, they may need to understand and respond to the patient and the family unit.
Many children of substance-abusing parents display particular illness behaviors, that is, they develop a particular way of responding to their perceived overall situation. It is well established that children and youth, based on individual and cultural differences, respond in different ways to similar biomedical and psychosocial conditions. Without an understanding of the psychologic and social underpinnings of illness behavior, the clinician may fail to collect all the relevant information related to the child's health problems.
Establishing Rapport
The second function of the pediatric interview involves the communication of interest, respect, support, and empathy between the clinician and the parent and between the clinician and the child or adolescent, with the goal of forming a relationship with the family.7,,8 By recognizing and responding to the child and family's emotional responses, the provider can ensure the child or family's willingness to provide information and can ensure relief of the child's physical or psychologic distress. Attending to a patient or family's emotions is essential for effective communication and treatment planning with any emotionally complex issue, particularly one as potentially controversial as parental substance abuse. The clinician needs to hear the patient's (or the family's) story with all its associated emotional distress. The emotions may range from fear to sadness, anger, or shame. A patient or family member verbalizing these feelings in the presence of someone who can tolerate them and not be frightened is, in itself, therapeutic. The nonusing parent may be as confused and frightened about the problem as the child. The open communication of fear and anxiety has been found to be related to satisfaction and compliance.9 The empathic clinician, by understanding the patient's situation, can decrease the child and family's anxiety, thereby increasing their trust, with associated willingness to offer more complete information and follow through with treatment recommendations.
Education and Behavior Change
Dealing with parental substance abuse requires education of the family and behavior change not only by the young patient, but by all family members as well. The third function of the medical encounter must build on the successes of the first two functions. Care must be taken to ensure the child and family's understanding of the nature of addiction, its influence on family function and individual family members, and its role in undermining a child's health. The physician likely will need to negotiate additional assessment or treatment of family members as well as a specific treatment plan for the child's physical and mental conditions. Emphasis may need to be placed on the child and family's coping styles and simple first-pass efforts at lifestyle change. This will require understanding and working with the social and psychologic consequences of the parental substance abuse.
These three functions often are interdependent. For example, an effective therapeutic relationship enables the child and family to share with the clinician important medical and personal information, thereby improving the chances of determining the nature of the problem correctly.
BARRIERS TO ADDRESSING FAMILY SUBSTANCE ABUSE
The underrecognition of substance abuse among parents and families and the failure to provide targeted services to the children of substance-abusing parents are deeply ingrained in our history and attitudes.10 A diagnosis of substance abuse is still associated with shame and rejection and therefore is avoided by children, families, and health care providers. Barriers to intervention with substance-abusing families include unfamiliarity with effective methods for detection, assessment, and early intervention with families; time constraints; lack of financial incentives; lack of adequate training in the essential knowledge and skills; and lack of support from other professionals. Although health professions training in communication skills, family systems theory, behavioral interventions, etc, is improving, many clinicians still express the concern that they lack the essential knowledge and skills in this area. Furthermore, many physicians still believe that asking such questions may be perceived as too intrusive and would alienate families. Unless the physician can demonstrate a nonjudgmental attitude, a genuine willingness to help, and a feeling of hopefulness, only the most blatant chronic and late-stage cases will be detected.
Pediatricians commonly note a lack of adequate skills for interviewing families and adolescents, providing effective interventions for behavioral health problems, and for handling denial by family members. The most common reason cited by health care professionals for not discussing sensitive topics such as parental substance abuse is a lack of time. Having a clear sense of the goals, methods, and structure of a screening interview may relieve the sense of time constraint. Involving office nurses or health educators in an office-wide screening program or using parental written questionnaires that include substance-abuse screening questions also may be useful.
The attitudes and beliefs of the health care professional also can be a barrier. Some providers feel that alcohol and other drug abuse should be handled by mental health or addiction treatment professionals rather than by primary care providers, or they have stereotypes about the so called typical family member who has substance-abuse problems, or they do not perceive their role as extending to the child's family.
Many health care professionals avoid looking for behavioral or substance-abuse problems because they are uncertain as to how to handle the problem once uncovered. Similarly, they rationalize that there is no way to help the family anyway, particularly with only two or three visits. Some health care professionals have attempted to address substance abuse or other family problems in the past and experienced discomfort, anger, or resentment toward them and, as a result, are reluctant to try again.
Overcoming many of these barriers requires continuing education in the necessary knowledge, skills, and attitudes outlined in the accompanying guidelines. Such education must begin during undergraduate training in the health professions and should be reinforced by role-modeling among health professions faculty as well as by practicing providers. A recent study found that resident physicians record more information about alcohol and drug use if their faculty preceptors have themselves received training about addiction.11 In many respects, a shift in the cultural paradigm of health care must occur that enhances the value and importance of behavioral and family health within child and adolescent health care. The leadership of professional societies and government agencies that help to establish best practice guidelines also must give credibility and priority to this paradigm shift. The old concept that nothing can be done for a substance-abusing parent until s/he hits bottom has been replaced by successful techniques for earlier intervention. The idea that attainment of abstinence by the parent is sufficient to reverse the family's problems and the notion that nothing can be done to help the child as long as the parent continues to drink or use drugs are two common misconceptions that health care providers need to avoid.10
A DEVELOPMENTAL LIFESPAN PERSPECTIVE ON SCREENING
Anticipatory guidance throughout the lifespan of childhood and adolescence is a well-established principle of child health care. From the prenatal visit through each of the regularly scheduled health maintenance visits that occur from birth to 18 years of age, there are well-established tenets of health education, screening for health morbidities, and anticipatory guidance. These visits represent at least 20 opportunities for screening, early identification, and intervention for children living in families affected by substance abuse. The recent development of the American Medical Association's Guidelines for Adolescent Preventive Services not only recommends annual health maintenance visits for adolescents, but also includes three family assessment and counseling visits during the adolescent period.12 This recognition and emphasis on the role families play in a patient's health are laudable, particularly with its emphasis on parenting issues and family communication and conflict, and its open recognition of the role of family problems in adolescents' health. Combining the principles of anticipatory guidance, screening, and early identification with the acknowledgment that families should be included in the process leads to a clear conclusion that screening for children affected by parental substance abuse must occur at all ages in infancy, childhood, and adolescence.
The National Cancer Institute's Program for Preventing Tobacco Use During Childhood and Adolescence already has established this precedent.13 In this program, it is recognized that child health providers can screen, identify, educate, and intervene with children and families at all stages. Child health care providers are in a unique position to intervene in the early stages of parental substance abuse through identification of effects on their children because of the frequency of contact they have with most families throughout childhood and by taking advantage of the long-term relationships they have.
Discussions related to substance-abuse and related problems should begin with the prenatal visit by focusing on the responsibility of parents, parental lifestyle, and effects of parental alcohol and other drug use on the fetus, infant, child, and adolescent. Parents serve as important role models for their children. Attitudes and beliefs regarding alcohol, tobacco, and other drugs (ATOD) develop early in life. Parents need to be aware that their attitudes and beliefs can strongly influence and play a major role in shaping their child's behavior. Hence, it is important for the health care professional to explore the attitude of the family toward ATOD use and to provide basic education, screening, and early intervention services that are appropriate to the age and development of the child and the family situation.
If inquiries about parental substance abuse are incorporated into the family history portion of a clinical interview, they may seem less out of place to all involved. If one prefaces one's questions with phrases such as, “Now I'm going to ask you about diseases that can run in families or have an effect on children's health,” it may seem more natural and less intrusive to families.
Prenatal Visits
The earliest and perhaps the best time to bring up the subject of parental ATOD use is at a prenatal visit, especially if both parents attend. Concern for the unborn child's health should be the focus. It may be less threatening to first ask whether there have been alcohol or other substance-abuse problems in the parents' families. Questions about AOD can be coupled with questions about nutrition and smoking as part of a standard routine.
During pregnancy, parents are naturally concerned about the health of the fetus. Hence, it is worthwhile framing questions in two different contexts—the family history and the health of the fetus. Questioning may start addressing the use of over-the-counter medications, then prescription medications, then smoking, then alcohol and, finally, other drugs. An example of useful lead-ins is “Many parents seem to be confused about whether it is safe to drink alcohol during pregnancy. What is your understanding?” Questions also can be extended to the father.
Infancy and Early Childhood
During infancy and early childhood, the target of screening efforts continues to be the parents. Young adult parents are less likely to visit their own physician than are older adults. Health care professionals may be the only physician many parents of young children visit professionally. As a result, this group of parents can be more difficult to reach with health prevention messages and early interventions. Yet early childhood is a critical time in child development, because the effects of parental substance abuse can be profoundly harmful.
A good way to begin an interview with a parent may be by asking “How are things going for you?” When verbal or nonverbal responses indicate depression, fatigue, unhappiness, or other emotional or interpersonal discomforts, it may be useful to pursue the underlying causes such as personal or spousal substance abuse. For example, “People handle stress in different ways. Some people exercise, some sleep, some people eat more, others smoke cigarettes or use alcohol or other drugs. How are you handling it?”
The objective during infancy and early childhood is to reduce the amount and frequency of ATOD use occurring in the family to which the young child is exposed. Child health care providers should learn about the alcohol and other drug use habits of all parents of infants and young children. This can be done in the context of a global family health assessment and must build on established rapport and basic interviewing skills. Emphasis should be placed on how substance abuse can affect parenting decisions, exacerbate stress and marital problems in the home, create a potentially unsafe home environment, and model drug use behaviors for children. The use of established substance-abuse screening tools such as the CAGE (see definition below) and Alcohol Use Disorders Inventory (AUDIT) may be helpful (Fig 1).14–17 If parents already have made a change in their alcohol or other drug use habits, this should be positively reinforced. At a minimum, screening young adult parents for substance abuse raises an important issue, gives feedback to the parents, and establishes the willingness of the provider to discuss the issue at a later time if needed.
School Children
When children are asked from whom they learn most about health, the second most frequent response, after mothers, is their physician. To children, physicians are seen as powerful medical experts as well as role models for appropriate health behavior. It is important for the physician to reinforce nonuse of ATOD to counterbalance factors from within the family or environment that serve to support their use.
This developmental period provides the framework of knowledge and attitudes that will aid children when they are faced with more proximal pressure to use alcohol or other drugs. Parents should be encouraged to examine their own beliefs and practices concerning ATOD use. Children whose parents drink alcohol are more likely to do so than are children whose parents do not.18,,19 Children from families where alcoholism and/or drug abuse are present are particularly at risk for the development of substance-abuse problems. Children of alcoholics are four to five times more likely to develop alcohol dependence than are other children. Parents should be asked directly about their use of ATOD.
Anticipatory guidance about alcohol and other drug use should begin early in childhood when family standards and values are being assimilated. Well-child visits during the early school years provide many opportunities to discuss alcohol and other drug use with children and their parents together. Health care professionals can initiate or enhance the dialogue between children and their parents by asking if alcohol and other drug use is being discussed in school and at home, inquiring about the specifics of what is being taught, and assessing whether the child understands the messages being delivered. It is important to ask whether alcohol or drug use is discussed among friends, whether alcohol or other drugs are present in the child's environment, about their perceptions of why some people use AOD, and whether or not such use is harmful. This attention to common parenting and child behavior problems is valuable in preventing later problems.
Adolescents
Families continue to exert significant influence on adolescents and on the behaviors in which teenagers choose to engage. Early identification of families with substance-abuse problems is critically important to the prevention of substance abuse among adolescents themselves. Family issues to address include parent–child interactions and maladaptive family problem-solving, which often involve avoidance of issues and conflict.20,,21 Families with marital discord, financial strains, social isolation, and disrupted family rituals (such as meal times, holidays, and vacations) also increase an adolescent's risk of problem alcohol use.22 Adolescents are particularly at risk if parents are either excessively permissive or punitive or if parents offer little praise or seem persistently neglecting of the adolescent.
Clear parent-defined conduct norms are an important protective factor.19,,21,23 Adolescents least likely to use AOD are emotionally close to their parents, receive advice and guidance from their parents, have siblings who are intolerant of drug use, and are expected to comply with clear and reasonable conduct rules. The parents of nonusers typically provide praise and encouragement, engender feelings of trust, and are sensitive to their children's emotional needs.
Alcohol use should be included as a primary consideration in all behavioral, family, psychosocial, or related medical problems. The identification and assessment of high-risk behaviors and predisposing risk factors are key aspects in the early recognition of alcohol-related problems. As a routine part of the adolescent visit, there should be an assessment of risk by reviewing risk factors and behaviors with youth and their parents.
ESTABLISHED SCREENING MEASURES
There remains a dearth of rigorously designed research studies on screening and early intervention for children and youth from families affected by substance abuse. Considerably more research has been conducted and well-summarized elsewhere on methods for screening adolescents for their own alcohol and other drug abuse.24
Screening for alcohol or other drug-use problems within families and other caregivers must begin with a careful and detailed psychosocial history. Information about the structure, function, and interpersonal problems of families, parents, children, and adolescents provides a necessary background from which the need for additional screening efforts can be determined. Evidence of child behavior problems, early school failure, parenting difficulties, family conflict, or changes in the home environment are commonly present in families affected by substance abuse. The suggestions for screening discussed below are intended to provide examples and a framework for building on a baseline psychosocial history when additional screening is indicated for possible family substance abuse. Often additional screening will need to be conducted with a parent or family member directly. However, there also may be situations when a school child or adolescent should be interviewed alone to gather relevant information.
Despite potential advantages of early detection through family screening, reviews of existing screening instruments and research directions for substance-abuse screening have ignored this opportunity.25 Some screening measures can be used as proxy reports on another family member, whereas others are intended for direct use with suspect family members. Child and adolescent health care providers may need to develop additional comfort in asking substance-abuse screening questions directly to parents or other family members. Screens for alcohol abuse are better developed and used more widely than those for other forms of psychoactive substance use.
Screening Measures for Problems in the Family
Based on the nature of a presenting medical problem or as a result of problem areas in the psychosocial history, screening may involve asking the child or adolescent patient questions directly, and often alone, that are developmentally appropriate, and addressing their perceptions of problematic substance use in the family. By age 7 or 8, most children have developed accurate perceptions of the role of AOD in their parents' lives. The child can provide valuable information in response to simple questions such as, “Do you think that anyone in your family has a problem with alcohol or other drugs? Do you think that either your mother or father drinks alcohol too much? Have you seen either your mother or father use drugs?” Older children and adolescents should be asked if they are concerned about their parents or another family member for any reason.
One technique to maximize the usefulness of responses to screening questions is to apply them to all members of the household. This can be done while interviewing an older child or adolescent, or with one family member when talking about others. For example, “Has anyone in your household or your family ever neglected their usual responsibilities when drinking or taking drugs?” “Have you ever felt someone in your household or family should cut down on their drinking or drug taking?” “Do you ever wish someone in your family didn't drink so much?… Who is that?”
The CAGE questionnaire is a four-item alcohol screening instrument with demonstrated relevance for primary care in clinical, educational, and research settings (Fig 1).14–16 The CAGE asks whether the respondent has ever “needed to Cut down on their drinking; felt Annoyed by complaints about their drinking; feltGuilty about their drinking; or, had anEye-opener first thing in the morning.” The Family CAGE is a modified version of the commonly used CAGE questionnaire that simply broadens the standard CAGE items to include “anyone in your family” (Fig 2). One can use the Family CAGE questions to provide a proxy report regarding another individual such as a parent or an older sibling. For example, if the patient is a 12-year-old who currently is not using alcohol or other drugs, but is concerned about a parent's use of alcohol, the health care professional could screen for concerns about the parent's alcohol use by asking the CAGE questions to the child in the following manner: “Do you think your mother needs to cut down on her alcohol use? Does your mother get annoyed at comments about her drinking? Does your mother ever act guilty about her drinking? Does your mother ever take a drink early in the morning as an eye-opener?” One or more positive answers to the Family CAGE can be considered a positive screen and needs additional assessment. The Family CAGE is intended to screen for alcohol problems in families, not to diagnose family alcoholism. A positive finding on the Family CAGE implies a greater relative risk for alcoholism in the family and should be followed by a more thorough diagnostic assessment.
In a recent study, one positive response on the Family CAGE was more sensitive than asking about perceived family alcohol problems.26 In the same study, 48% of adult patients had a score of ≥2. The specificity of the Family CAGE for family alcohol problems was 96%, the positive predictive value 90%, the sensitivity 39%, and the negative predictive value 62%.26 The Family CAGE also correlates with family stress, family communication problems, marital dissatisfaction, and use of drugs other than alcohol. The ability to use the Family CAGE in this manner offers the potential for great flexibility for the pediatric encounter and allows for a comfortable way of collecting pertinent screening information about or from patients and parents. By substituting the words drug use for drinking, the Family CAGE also can be used to screen for problematic use of drugs other than alcohol. Additional research on the application of the Family CAGE is needed.
Screening for the Impact of Family Substance Abuse
A longer written screening tool that may be useful is the Children of Alcoholics Screening Test (CAST).27,,28 The CAST was developed as an assessment tool that could identify older children, adolescents, and adult children of alcoholics. This 30-item self-report questionnaire measures patients' attitudes, feelings, perceptions, and experiences related to their parents' drinking behavior, using a yes/no format. It may be useful when a written questionnaire is the preferred method with older children or adolescents.
The Family Drinking Survey also addresses how family members have been affected by a family member's alcoholism.29 It is adapted from the CAST, the Howard Family Questionnaire, and the Family Alcohol Quiz from Al-Anon and is suitable for use with adolescent patients or nonusing parents. It addresses the effects of family alcoholism on the patient's emotions, physical health, interpersonal relationships, and daily functioning. When patients or their parents have positive responses to the CAST or Family Drinking Survey, they are beginning to reveal the impact of the substance abuse on the family and on themselves. As the evidence of family dysfunction becomes more apparent, the health care provider should have more concern about the impact of the substance abuse. As the family becomes more submissive to the impact of the substance abuse, they more clearly distinguish themselves as an “alcoholic or drug abuse family.”
Many substance-abusing parents themselves are children of substance abusers. Inquiring about family histories of addiction while completing a three-generation genogram with parents can help them put their own substance abuse in an intergenerational context. This motivates some parents to seek treatment to prevent passing on this self-destructive behavior to their own children as their parents did to them. It also can sensitize parents to the emotional devastation they are causing their children by acknowledging their own childhood experiences.
An important consideration of children, youth, and parents is the confidentiality of the information gathered. Although many family members are eager to facilitate help for the alcoholic family member, others are more reluctant. If the presenting patient or nonusing parent is reluctant to share his/her concerns, the physician can encourage individual counseling.
Attendance at meetings of Al-Anon, Alateen, or Adult Children of Alcoholics groups are important for family members. Whether or not the family member affected obtains treatment, other family members may need to learn to care for themselves, and 12-step programs can be extremely supportive.
Screening Measures for Older Adolescents or Adult Family Members
The signs and symptoms of alcohol and other drug abuse in adolescents often are subtle. More telling than physical signs may be the indication of dysfunctional behaviors. A sudden lapse in school attendance, falling grades, or deterioration in other life areas may become more apparent as alcohol or other drug use escalates.30 Often problems with interpersonal relationships, family, school, or the law become more evident as use increases. Depressive symptoms such as weight loss, change in sleep habits and energy level, depressed mood or mood swings, and suicidal thoughts or attempts may be presenting symptoms of alcohol or other drug use.
A general psychosocial assessment of an adolescent's functioning is the most important component of a screening interview for alcohol misuse or abuse. Begin with a discussion of general topical areas, including home and family relationships, school performance and attendance, peer relationships, recreational and leisure activities, vocational aspirations and employment, self-perception, and legal difficulties. The information gathered helps to determine whether alcohol or other drug use is a cause of behavioral dysfunction and the degree of patient impairment.
It is often useful to ask about alcohol or other drug use directly, for example, “Tell me about your use of alcohol,” or “When did you last drink alcohol?” If they do not use alcohol, explore their reasons for nonuse and affirm their decision. If they have used alcohol, ask whether they have ever been concerned about their use. If so, what is the nature of their concern, have they had periods of nonuse or cutting down, is there evidence of loss of control by breaking promises or rules, and is there evidence of the adolescent rationing their use? If the teen has never been concerned about his/her use, inquire whether anyone else has ever expressed concern about his/her use of alcohol. What was the nature of that concern and what was the patient's attitude toward it? Is there evidence of remorse or guilt for behavior while using or obtaining alcohol?
McLellan and Dembo have reviewed screening and assessment measures recently for adolescent alcohol and other drug use.24Several established measures suitable for use both with adolescents and with adult family members are discussed below. Both adolescents and adult family members may need referral to professionals trained to conduct assessments.
The four-item CAGE questionnaire discussed above has proven useful in screening for alcohol problems both with adolescents and with adults.14–16 Although a positive response to the CAGE questions is not diagnostic of alcoholism, answering yes to two or more questions is highly suspicious and warrants additional evaluation. A variant of the CAGE suggested for use in pregnant women, called the T-ACE, substitutes tolerance for the question on guilt while including questions on annoyance, cutting down, and eye-openers.31For example, “How many drinks does it take to make you feel high?” An answer of more than two drinks is considered positive.
A recent study found that four criteria most frequently endorsed by those with alcohol problems are 1) blackouts, 2) objections by family members or close friends, 3) withdrawal symptoms when the abused substance is not immediately available, and 4) neglect of responsibilities.32 From these general ideas developed the following brief questionnaire (the BONS) for use with adult alcoholics that also can be used while interviewing parents: 1) Have you ever been drunk enough that the next day you could not remember what you had said or done? 2) Have your family or friends told you they objected to your drinking? 3) Have you ever neglected some of your usual responsibilities when drinking? 4) Have you ever had the shakes after stopping or cutting down on your drinking, or the morning after drinking? A positive response to any of these four questions should be considered a positive screening for high risk for alcohol problems.
The AUDIT is a 10-question screening measure that is administered most easily in written form.17 It was developed by the World Health Organization specifically to be used in primary care settings and has been used extensively in an international intervention trial. The AUDIT incorporates questions about drinking quantity, frequency, and binge behavior, along with questions about consequences of drinking. Unlike the CAGE, it assesses alcohol use and problems over the last 12-month period.
Brief screening questionnaires such as the CAGE and AUDIT are most useful as an entry into meaningful direct discussion about alcohol use and the parent's self-perception of their use. These clinical aids are not intended to be diagnostic instruments; rather, they facilitate gathering information, which can be used to complement the psychosocial history. Experienced interviewers will not simply ask each question within the CAGE or any other screening tool, but will use the areas targeted by these questions to briefly probe the critical issues behind alcohol or other drug use. For example, when a parent acknowledges a previous attempt to cut down on drinking, this provides an excellent opportunity to explore their self-perceptions of problems they themselves have noted as a result of drinking. When a parent admits to feelings of guilt because of behaviors while drinking, they have a palpable sense of the need for change and may feel motivated because of it. Questions such as those in the CAGE often allow the parent to define the direction of the interview in a useful manner. Familiarity with the general content of these screening measures can help the health care professional better understand the objectives of an alcohol use screening interview and, as a result, become a more sophisticated interviewer.
Another well-validated screening device is the Short Michigan Alcoholism Screening Test (SMAST).33 This screen is designed to be self-administered and includes 13 questions related to concerns of others about the respondent's ability to carry out personal and social obligations. It does not, however, include questions about the physical effects of addiction. The SMAST can be given during an interview or as a written questionnaire to parents when an early suspicion of possible substance-abuse problems is developing.
There are several slightly longer written questionnaires that also have been found to be useful, including the Drug and Alcohol Problem Quick Screen,34 the Adolescent Alcohol Involvement Scale,35 and the Personal Experience Screening Questionnaire.36 The Problem Oriented Screening Instrument for Teenagers is a 120-item questionnaire that serves as the screening battery for 10 functional areas influenced by adolescent alcohol or other drug use.37 It is linked to a more comprehensive evaluation process called the Adolescent Assessment and Referral System, which may be useful in clinical settings where adolescents undergo comprehensive assessment.38 The Drug Use Screening Inventory enables practitioners to screen and assess the multiple problems of adolescents who abuse AOD in a manner that guides treatment selection and evaluation.39
Family Mapping
The genogram, or family tree, is a versatile clinical tool that can help clinicians obtain family and social history. Often, when patients and their families see the constellations of family disease and problems highlighted on the family tree, they appear to take them more seriously, as if they realize their implications for the first time. The process of the physician and the patient/parent drawing the family tree together facilitates the physician–patient–family relationship. Asking about family information in a structured, matter-of-fact way helps the interviewer remain objective and reduces physician discomfort. The genogram also seems to foster honesty by lowering the patient or parent's resistance to talking about embarrassing or painful matters. Asking older children or parents about their family invites them to move into a rational thinking mode and encourages them to be less governed by the intense feelings that may be associated with the family.
In addition to asking traditional questions about the family such as who lives at home and what are the parents' occupations encourages asking questions such as, “Who in the family has emotional difficulties?”, “Who in the family does not get along well with each other?”, “Why?”, “Who is divorced or having marital problems?” The genogram is best used to ask questions about relationships, family conflicts and turmoil, who are the strong personalities in the family, who helps solve problems and who creates them, and histories of psychiatric illness or substance abuse. This process fills in many details that can be linked to the physician's knowledge of the patient's primary family to help create a more complete understanding of the family context. It also will reveal genetic vulnerability.
THE FAMILY FROM A SYSTEMS PERSPECTIVE
For the family to meet the basic needs of its members and society, it must 1) physically protect and sustain its members by providing shelter, safety, food, and clothing; 2) promote a sense of individuality or autonomy, so that each member can think and feel independently; 3) promote a sense of connectedness, so that each member meets emotional needs for affection and intimacy appropriately; 4) foster a sense of competence and self-worth, so that each member feels good about him/herself and contributes productively to society; and 5) encourage each member to develop a sense of right and wrong and conform to basic values and rules of society. It is useful to keep in mind that all families have strengths, some more than others. To help an individual, it is as important to identify the strengths of a family as it is to detect its weaknesses.
Children of substance-abusing parents often grow up in chaotic family environments that lack consistency, stability, and emotional support. Poor communication, permissiveness, undersocialization, and neglect are common and can be devastating. A basic understanding of family systems and the characteristics of healthy and substance-abusing families is essential to identifying and working with high-risk children and youth.40 Families affected by substance abuse frequently develop issues around boundaries, communication, problem-solving styles, and role assignments. Recognizing these family systems issues is an important aspect of working with children from all backgrounds.
Substance abuse, like other chronic illnesses, is progressive over an extended period, has periods of flare-ups and remissions, and can cause psychologic and physiologic disability. Both family and patient may go through stages of dealing with substance abuse similar to those of other chronic illnesses, including denial and disbelief; shock, anger, disorganization; loss; attempts to eliminate or escape the problem; and acceptance and recovery. Many of the patterns or coping mechanisms used by members of the substance-abusing family also are found in family members of patients with other chronic diseases. These patterns can vary in the amount of dysfunction and pain they cause the family. Although the economic burden of chemical dependency may be similar to that with other chronic illnesses, the stigma, shame, and guilt are greater. By comprehending the impact of substance abuse on a family, a physician can develop a model that will be useful in understanding family patterns in other chronic illnesses.
Families gradually adjust to the negative impact of substance abuse. Gradual changes occur in the family's coping styles and behaviors that eventually permit the disease to continue. These enabling behaviors add to the dysfunction in the family. The family must recognize their contribution to the disease process to facilitate treatment. It is easy to identify how alcoholic behavior affects the family, but the impact of enabling behavior on the substance abuser can be more difficult for the family to understand. Family members become enablers because they care about the family member affected and therefore protect him/her from the negative consequences of his/her illness. Paradoxically, the results of the caring and protecting can lead to delayed treatment and can be disastrous for the chemically dependent person.
Family Disease Model
As the substance abuse progresses, the family's actual life becomes divergent from the family's intended lifestyle. There is little congruence between what the family wants their life together to be and what it has actually become. Because the realization of the disparity is very painful, suppression of feelings and secretiveness is common. If family members begin to be concerned that substance abuse may be the cause of their problems, they develop strategies to preserve their intended integrity. A dysfunctional family system develops around the disease that is protected by defense mechanisms, isolation, rules, and roles. As the members slip deeper into these behaviors, reality becomes distorted and the pain of the family dysfunction is displaced away from the cause, the family disease of substance abuse.
Denial is the defense mechanism used most commonly. Its primary purpose is to maintain ego integrity in the abuser and family members. Denial may stem from ignorance of what chemical dependence is or may be motivated by wishful recall of previously happy times. The family denial can be stronger than that of the affected member and usually is related to the amount of stigmatization felt by the family members. Because of the power of the denial, the illness can progress notably, and physicians can feel frustrated in their attempts to confirm a suspected diagnosis with a family member. Because denial is below the level of awareness, family members do not acknowledge that denial is occurring. Once denial begins, it becomes automatic and progressive.
Minimization is the attempt to dilute the action of the substance abuser and lessen the impact on the family. For example, a wife may say that her spouse yells a lot but has never hit her, thus, she does not believe that he is a substance abuser.
Projection attributes the cause of the problem to another person or thing. A husband may cover for a wife's marijuana use by complaining that the children are behavior problems.
The isolation that develops around the family is both social and emotional. Because of the shame associated with substance abuse, family members do not share their painful experiences with anyone inside or outside of the family. The boundaries around families become rigid and impermeable, with a restricted flow of information passing into and out of the family. In such situations, normal needs may be gratified in abnormal ways. For example, the incidence of sexual abuse is reportedly high in substance-abusing families.41
Family Rules
As in any system, rules develop for self-regulation and order. In the chemically dependent family, the rules restrict behavior, limit creative problem-solving, and restrict autonomy. The emphasis is on following the rules and not on developing intimate, nurturing relationships. Although not overtly required, the following rules have been described clinically:
Don't talk—Even young children learn not to share painful observations. A mother with strong denial will not confirm her child's observation of Dad's out-of-control drinking behavior. When observations are not validated, family members stop making them and important issues are not discussed. The drinking is neither mentioned nor confirmed, and the family secret grows. Everyone knows it is there, but no one mentions its existence.
Don't feel—When painful experiences are not shared, feelings do not get words attached to them and they remain undefined. Comments such as “No, I wasn't scared,” “I never get angry,” and “Why should I cry, it wouldn't help” are frequent. The only feeling that usually gets displayed is anger. Instead of understanding that anger is a normal reaction to certain experiences, anger is often used explosively in chemically dependent families as a defense to prevent others from approaching the real problem.
Don't trust—Chemically dependent people often make promises and plans with the best of intentions of fulfilling them. Nonabusing family members add to the inconsistency in the environment by expecting behaviors that they realize the chemically dependent person cannot perform. For example, a father who always arrives home very late on pay day will be asked to bring ice cream for dessert. Subsequently, the disappointed children are angry at both Mom and Dad when dinner ends with no dessert and feel that both parents broke their promises.
Family Roles
Roles help maintain balance in the family system and provide another method for individuals to insulate themselves against the emotional pain of living in a chemically dependent family. There are two reasons why the physician must understand these roles. First, patients may describe themselves in these terms, and it is supportive for the patient when the physician understands. Second, and more important, when individuals use role-dominated behaviors, they do not develop to their full potential. If physicians understand the behaviors, albeit through stereotypic roles, they are in a better position to recognize the limitations in their patient's life, to diagnose the health problems related to maladaptive behaviors, and to assist the person in learning more functional conduct. Individuals who feel trapped in role-related behaviors may suffer from stress-related illness or may demonstrate behavioral manifestations of their emotional pain. Physicians who understand these behaviors and associated symptoms can be helpful in uncovering the underlying problem of substance abuse, in explaining to the family how they are being affected, and in helping the patient understand the ways that chemical abuse is affecting various members of the family.
Wegscheider has described one potentially useful model to conceptualize family roles in the alcoholic family.42 The so-called chief enabler protects the chemically dependent person from facing the consequences of his/her disease by assuming the alcoholic's responsibilities and by shielding his/her actions from others. They do not understand that they can not control the chemically dependent person's AOD use or other behaviors. Although enablers look responsible and capable, they can harbor a variety of negative feelings. Although they work hard to maintain stability, the situation can deteriorate. Frustration, anxiety, and stress-related symptoms are an understandable corollary of enabling behaviors.
The so-called family hero brings pride to the family by being successful at school or work. At home, the hero assumes the responsibilities that the enabling parent abdicates. By being overly involved in work or school, he/she can avoid dealing with the real problem at home and patterns of workaholism can develop. Although portraying the image of self-confidence and success, the hero may feel inadequate and experience the same stress-related symptoms as the enabler.
The so-called scapegoat diverts attention away from the chemically dependent person's behavior by acting out his/her anger. Because other family members sublimate their anger, the scapegoat has no role model for healthy expression of this normal feeling. They become at high risk for self-destructive behaviors and may be hospitalized with a variety of traumatic injuries. Although all the children are genetically vulnerable to alcoholism, this child is often considered the highest risk because of his/her association with risk-taking activities and peers. Although tough and defiant, the scapegoat is also in pain.
The so-called lost child withdraws from family and social activities to escape the problem. Family members feel that they do not need to worry about her/him because s/he is quiet and appears content. S/he leaves the family without departing physically by being involved with television, video games, or reading. This child does not bring attention to her/himself, but also does not learn to interact with peers. Many clinicians have noted that bulimia is common in chemically dependent families and feel this child is prone to satisfy his/her pain through eating.
The so-called family clown brings comic relief to the family. Often the youngest child, s/he tries to get attention by being cute or funny. With family reinforcement, his/her behavior continues to be immature and s/he may have difficulty learning in school.
Another approach for understanding the alcoholic family has been proposed by Steinglass and colleagues.43,,44 Through careful study, these research clinicians have found that families differ in their responses to the effects of alcoholism. They affirm that the family's priorities, rituals, behavioral styles, and use of energy and resources are altered by the presence of alcoholism. Most families are successful at maintaining their primary tasks and are not identified as problematic. In families in whom the alterations are the greatest, the disease is passed on to the next generation. When the family is able to resist the full effects of the disease, the children do not necessarily recreate an alcoholic family after their own marriages.
EARLY INTERVENTION WITH SUBSTANCE-ABUSING FAMILIES
Early intervention is a transitional component in the continuum of substance-abuse care, which is intended to fall somewhere between prevention and treatment, and can be distinguished in terms of target population and specific objectives.45 A useful definition of early intervention would include services directed at 1) individuals or families whose use of ATOD places them or other family members at an unacceptably high level of risk for negative consequences; 2) individuals whose use of ATOD has resulted in clinically significant dysfunctions or consequences for themselves or family members; and 3) individuals or families who exhibit specific problem behaviors hypothesized to be precursors to ATOD problems. In the case of children of substance-abusing parents, an early intervention for the parent and family also should be viewed as prevention for the child. In addition, interventions by primary care providers, which lead to changes in the family's functioning and overall health, can be seen to affect the entire family. Therefore, prevention, intervention, and treatment rapidly become indistinguishable and concurrent when working with substance-abusing families.
Early intervention services can be distinguished from prevention in that early intervention services target specific individuals rather than the general population. Target populations have been defined based on ATOD use per se, on use patterns suggestive of abuse, on the occurrence of use-related consequences for the family member or child, or on the presence of risk factors within the family known to be associated with high risk for substance abuse. Abuse might be defined by patterns of use that place users and their family members at unacceptably high levels of health risk. Use in inappropriate settings, such as before driving, may be indication for intervention, even before negative consequences have occurred. Using a consequence-based definition for problem drinking, it is not patterns of use that determine the need for early intervention. Rather it is the appearance of negative consequences, which should include health risks or poor outcomes for anyone in the family of a substance abuser. Some substances, such as crack cocaine, heroin, or methamphetamines, are sufficiently dangerous that any use is, in fact, cause for intervention.
Behavioral medicine is the interdisciplinary field concerned with the application of behavioral principles and strategies to the modification of lifestyle patterns for the prevention of disease and enhancement of health. Studies have demonstrated that physician-delivered health education and counseling can lead to improvement in health status.46 Although the development of brief interventions is in a formative stage and many evaluations are not rigorous, the weight of evidence supports brief interventions as a promising method for reducing alcohol-related problems.25 There remains little research that specifically addresses the efficacy of brief interventions offered by child and adolescent health care providers to families affected by substance abuse.
Traditionally, physician training has emphasized a biomedical model, which is oriented toward diagnosis and treatment of diseases, rather than a systems model that embraces prevention and health promotion.47 Moreover, traditional medical training promotes a paternalistic and directive style, which is less likely to lead to change in patient or parental behavior than a collaborative and patient/family-centered style that involves the child and family in the process of change.
Babor notes the difficulty of introducing behavioral technologies into medical practice and suggests that new academic programs will be needed if brief interventions are to be widely used by health practitioners. To be able to provide effective brief interventions for AOD use problems, physicians require 1) knowledge of patient education and behavior change interventions; 2) interviewing and assessment skills to make accurate evaluations of risk for substance-abuse problems; and 3) health promotion skills to help children and their families reduce risk or maintain health behaviors. With insufficient knowledge and skills, health care providers may lack the confidence to intervene successfully. The primary impact of brief interventions is motivational, triggering a decision and commitment to change within an interpersonal context.48 Review of the extensive literature on motivational enhancement is beyond the scope of this review, but there are several useful resources worthy of review.48–53
It is important to recognize that the substance-abusing parent is a whole person with dreams, desires, and strengths, as well as difficulties. Genuine concern combined with clear feedback can be useful; for example, “I am concerned that your husband's alcohol use may be causing a problem for the family… or may be affecting your son's health.” The focus of the concern should be the parent's needs as well as those of the children and spouse, an approach that can be difficult to maintain. Statements such as, “Dealing with substance-abuse problems can be difficult. I want to be helpful to the whole family,” may be useful.
It is important for the physician to remember that a positive screen does not make a diagnosis. A diagnosis that is reached too hastily and without a complete and thorough assessment may sever the physician–family relationship rather than strengthen it. The physician should advocate additional exploration into the area, either with him/herself or with a specialist. For example, “I am concerned that you may have an alcohol use problem. In my opinion, we need to gather more information about this possibility. I would like you to see a specialist to help us determine if a problem with alcohol exists.” It is important for the physician to express his/her concern for the parent and child and the belief that substance abuse is not a moral weakness but a treatable disease. The physician also should play an important role in educating the family and child and can help the parent to explore the links between parental substance abuse and family dysfunction. Referral to other professionals or community resources, as well as personal follow-up, is a key component of office-based intervention.
To help the family members obtain treatment, the physician must realize that the family has three issues to confront. The first is for family members to acknowledge their denial, ie, to recognize that a family member has the disease of chemical dependency and needs treatment. By using the family in the process of diagnosis, the physician not only gathers important and persuasive information about the patient, but also helps the family members break through their own denial.
The second issue is for the family to understand the physical, psychological, social, and spiritual impact of the substance abuse and that each one may need help or treatment. If the nonsubstance-abusing family member has presented to the physician with physical symptoms or has discussed family disruption, this information can be suggested as an indication of how the family is being affected by the disease. Often individual and family therapy is indicated.
The third issue is for family members to realize that they did not cause the alcoholism, but that their behavior can contribute to the disease. The physician should assist the family members in understanding their behaviors that keep the chemically dependent individual from facing the consequences of his/her use. By examining their enabling behaviors, the physician can help family members learn healthier actions and, perhaps, motivate the substance-abusing person into treatment. Parents can be afforded the guidelines established by the National Institute on Alcohol Abuse and Alcoholism for nonrisky drinking, namely, two drinks daily, and no more than four on a single occasion for men; and no more than one drink daily for nonpregnant women. One drink is defined as 12 oz of beer, 4 oz of wine, or 1.5 oz of liquor.
Even if the chemically dependent person does not obtain treatment, the family can find relief from its pain. Often a 12-step program can be helpful. Al-Anon is recommended for spouses and other adults living with a chemically dependent person, and Alateen is recommended for older children and adolescents. Support groups also may be available through the child's school.
In addition to self-help groups, physicians can refer family members for therapy to counselors if the presenting problems warrant additional treatment. Because family members often do not recognize the extent to which they have been affected, it is important that the referral be made to a therapist who understands the impact of family substance abuse.
School children and adolescents living with substance-abusing parents need to hear that the family's problems are not their fault, that their parent has a disease that is beyond their control and for which they need help, that many other young children feel the same way they do and have had the same experiences, and that there is help available for them directly.
SUMMARY
Screening and early identification of children affected by parental substance abuse must occur at all ages across infancy, childhood, and adolescence. Health care providers need to be trained in the identification and management of children and youth exposed to parental addiction. Such training must begin during undergraduate education in the health professions and must be reinforced by role modeling among health professions faculty as well as among practicing providers. All health care professionals with clinical responsibility for the care of children and adolescents must be able to recognize as early as possible associated health problems or concerns in children of substance-abusing parents and must be able to assist these children and families in seeking treatment and promoting health.
- AOD =
- alcohol and other drugs •
- ATOD =
- alcohol, tobacco, and other drugs •
- AUDIT =
- Alcohol Use Disorders Inventory •
- CAST =
- Children of Alcoholics Screening Test •
- SMAST =
- Short Michigan Alcoholism Screening Test
REFERENCES
- Copyright © 1999 American Academy of Pediatrics
In this issue
Jump to section
- Article
- Abstract
- SCREENING VERSUS ASSESSMENT
- INTERVIEWING CHILDREN, YOUTH, AND FAMILIES
- BARRIERS TO ADDRESSING FAMILY SUBSTANCE ABUSE
- A DEVELOPMENTAL LIFESPAN PERSPECTIVE ON SCREENING
- ESTABLISHED SCREENING MEASURES
- THE FAMILY FROM A SYSTEMS PERSPECTIVE
- EARLY INTERVENTION WITH SUBSTANCE-ABUSING FAMILIES
- SUMMARY
- REFERENCES
- Figures & Data
- Info & Metrics
- Comments
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