Cover Article

Helping children in families hurt by substance abuse

By Hoover Adger, Jr., MD, MPH, Richard Blondell, MD, Janice Cooney, PA-C, James Finch, MD, Antonnette Graham, RN, MSW, PhD, Donald Ian Macdonald, MD, Judie Pfeifer, Med, Paul Robinson, MD, Sis Wenger, and Mark Werner, MD

Pediatricians have an obligation to aid children and adolescents who are exposed to family alcohol or other drug abuse or dependence. Asking the right questions, showing empathy, and guiding patients and families to available resources are the keys to motivating change.

The reasons are compelling for intervening on behalf of the one in four children exposed to family alcohol and other drug abuse disorders. Not only are health-care costs higher for these children; youngsters in families that abuse drugs are at increased risk of abusing drugs themselves. Compared with others, children in families with alcohol — or drug-abusing adults are more apt to be abused, to exhibit depression and anxiety, and to score lower on measures of verbal ability. They are also more prone to be truant and drop out of school. For a fuller examination of how familial substance use disorders affect children, see "Important facts about children in families affected by a substance use disorder."

More than 28 million children under the age of 18 in the US are exposed to family alcohol abuse or alcohol dependence.¹ And this figure is magnified by a significant number of children who are affected by families impaired by other psychoactive drugs. Many of the children exposed to substance abuse (alcohol, tobacco, and other drugs) are also living in chaotic environments that lack consistency, stability, and emotional support. Some of these children will find support from meaningful adults and be resilient, and they will enter adulthood as productive individuals, but some will develop substance use problems of their own or suffer mental health or serious coping problems.

Pediatricians can have a major influence on families who misuse alcohol, tobacco, and other drugs because they have a long-standing relationship with the family and are in an excellent position to understand how its dynamics influence these behaviors. You can screen for abuse; offer interventions, support, information, and referrals; and provide anticipatory guidance for children at risk. Keep in mind, however, that as a clinician, you will usually be dealing with the child's perception of the problem, rather than with the parent's substance abuse.

Making a difference

Your goal is to identify children or adolescents who live in families with substance abuse problems. Then you need to help them understand that many other children share this problem and that they did not cause it or the resulting behaviors. You also want these children to know that their concern is valid and that help is available. The following steps will help you to achieve these goals.

Listen and ask questions. One study indicated that fewer than half of pediatricians asked about problems with alcohol when taking a family history.² Yet a family history of alcohol and other drug abuse is more likely than many aspects of history to affect a child's immediate and future health.³ It is especially important to obtain information about family alcohol and drug abuse as part of a routine history. Then, when you see or suspect any of the following, it is important to screen for alcohol or drug abuse in that family:

• family dysfunction

• behavior or emotional problems in a child

• school difficulties

• recurrent episodes of apparent accidental trauma, or recurrent or multiple vague somatic complaints made by the child or adolescent.

In many instances, family problems related to alcohol or drug use are subtle; identifying them requires a deliberate and skilled screening effort.

Many pediatricians never ask the single most important screening question: "Have you ever been concerned about someone in your family who is drinking alcohol or using drugs?" This question sets the groundwork for possible later discussion. It lets families and children know that you believe substance abuse is a health issue and are able and willing to assist them. The question also identifies families with problems and begins the process of intervention.

Ask this question of parent(s) or children who are either alone or together. If a grandparent, nanny, or anyone else brings the child to the visit, the question is still appropriate. Ask it at all health maintenance visits, including any initial or prenatal visit and when the differential diagnosis includes the possibility of a substance-related illness or injury. The question may be part of a written questionnaire or a verbal history taken by the pediatrician or a staff member. How the patient answers this question should determine what you do next, as shown in the algorithm.

In addition to asking the algorithm question, we recommend motivational interviewing, a technique that promotes behavioral change using an empathic, respectful, patient-centered manner.⁴ A growing body of research demonstrates the efficacy of motivational interviewing as a useful strategy for helping patients acquire healthy behaviors. Pediatricians will find that it also increases patient satisfaction and decreases professional frustration.

The active ingredients in promoting change have been summarized in the acronym FRAMES—Feedback, Responsibility, Advice, Menu, Empathy, Self-efficiency.⁵ You may find it easier to use an abbreviated form of FRAMES, referred to by the mnemonic TEAR: Teach, Express empathy, Advise action, Reach agreement (see "How to conduct a motivational interview" at the end of this article). FRAMES, and five other tools for change, are described in detail in "Tools for effecting change."

Remember that change is difficult and takes time, and ambivalence is normal. Do not expect immediate results. The goal of motivational interviewing is not to have a patient "see the light" and initiate immediate change but to move from one stage of change to the next. For some children or parents, a health-care visit based on motivational interviewing is all that is needed to resolve the ambivalence and begin the process. Once such families are motivated, they are more likely to mobilize their resources and make changes. For other patients, motivational interviewing is the overture for more in-depth treatment. It opens the door for future necessary therapeutic work.

Educate patients and their families. Let them know about the biologic, psychological, behavioral, and social consequences of alcohol and drug exposure. The child needs to learn that he or she did not cause the substance abuse problem or disorder and that, though she cannot cure it, she can help take better care of herself and lead a healthier, happier life. Children as well as their parents need to understand that alcohol or drug dependence is a disease and that it can affect all members of the family. They need messages of caring and support.

Offer brief advice intervention. Such interventions—such as suggesting joining a self-help group like Alateen, seeking help from a student assistance counselor at school, and finding a safe and caring adult who will listen, understand, and can support them—also have the potential to mitigate the negative effects of life in a chaotic home environment and to improve outcomes. The pediatrician who never asks about, or who ignores the obvious signs of distress that come from living with, an alcoholic or drug-addicted parent and takes no action to comfort the child or adolescent often compounds the problem. Inaction reinforces the despair and hopelessness commonly found among those who live with substance use disorders. If no intervention is necessary because the family does not have a problem with alcohol or drug abuse, it is often useful to give anticipatory guidance by presenting short messages that can prevent future problems. Always leave the door open by reminding the child that there are many children living in the fear and isolation caused by addiction in the family, and by asking that the child let you know if he ever has a concern.

Guide families to available resources and specialists when needed. Available resources can provide information, support, or treatment. Ideally, you should have an idea of what level or kinds of support are needed and then direct the family appropriately. At a minimum, this may simply be access to more information, so that the individual or family can sort out for themselves what help they need. Most dramatically, emergent referrals may be necessary if you believe physical abuse is part of the family picture.

In addition, referral options for substance abuse treatment may be needed for the alcohol - or drug-dependent family member. Also, referrals for mental health treatment may be required for family members suffering from the emotional consequences (such as depression or anxiety) of living with a person who has substance use problems.

In addressing the needs of the family, you may want to explore what resources the family can identify for themselves, such as family members or other relatives or friends. Other possibilities are local self-help groups such as Al-Anon, Alateen, and Alcoholics Anonymous (AA); school resources (nurses, counselors, social workers, teachers); pastoral counseling or other supports available through churches, therapeutic relationships, and youth groups and youth workers. Last, in exploring possible referral options, consider the family's insurance status, ability to pay out of pocket, or limitations placed by managed care arrangements.

Office staff may wish to contact national resources for more information (see "Where to go for help nationally").

Encourage a family member who is seeking help for a drinking spouse or parent to participate in Al-Anon or Alateen or help him find a substance abuse treatment specialist.

Also keep in mind that each state has an agency responsible for alcohol and drug-related programs and resources. The names of these agencies, as well as where they are located within state government, vary widely from state to state. In some instances, the substance abuse agencies are combined with mental health services. Many states also have resource centers with helpful free materials. To locate your state's agency, look under "State Government" listings or contact the National Association of State Alcohol and Drug Abuse Directors at 807 17th Street NW, Suite 410, Washington, DC 20006, 800-662-4357, or www.nasadad.org.

The steps just described constitute what has been termed level I of "core competencies" for the care of children and adolescents in families affected by substance abuse.⁶ If, based on your interests or the specifics of your practice, you want proceed to level II or level III of these core competencies, see "Introduction to the core competencies."

Setting up your office for success

Establishing office procedures that support your efforts and reinforce asking about family substance use is an important part of helping children in families affected by substance abuse.

Educate the office staff and get their commitment. Discuss the algorithm question with all members of the office team to gain their understanding and support. Educate the staff about the family dynamics of substance use disorders. One way to explain the importance of screening patients using the algorithm question is to point out that when one member of the family has a substance abuse disorder, all members of the family can be affected. Also note that children often suffer in silence, and denial can prevent the unaffected parent from obtaining help. Indicate that no one in the family may understand that alcohol or another drug addiction is a disease and that treatment is available; alternatively, entertain the possibility that the family is too ashamed to ask for help.

Train all the health-care providers in your office to ask the algorithm screening question. Have them practice with each other. Clarify the process to be used, including staff responsibilities, and make certain that everyone knows where materials are located. Brainstorm roles, needs, and impediments to implementation of these procedures and find solutions. Designate one staff member responsible for establishing and maintaining the system. This person can be a receptionist, nurse assistant, nurse practitioner, physician assistant, or office manager. Meet with staff on a regular basis for the first six months to discuss problems and give feedback as the team implements these activities.

Select appropriate materials to make available in the office. You can provide educational materials in a variety of ways. Select magazines, self-help pamphlets, and posters appropriate for the waiting room and examining rooms.

• Select magazines about health or periodicals that do not carry advertisements for alcohol or tobacco.

• Use videotapes to provide educational material for children and families while they are waiting in the reception area for an appointment; these materials could include substance use disorder prevention programs or self-directed assessment programs.

• Post a list of community-based prevention and treatment activities (which may be available from a community agency) on a bulletin board in the waiting room; a list of self-help group meetings (AA, Al-Anon, Alateen) may also be helpful to patients or family members who are looking for help but may be too ashamed or afraid to ask directly.

• Collect materials and make them available to families These can be ordered free or at low cost from The National Clearinghouse for Alcohol and Drug Information (800-729-6686 or at www.health.org).

• Make certain that you have a system for ordering and replacing materials so they are always available when needed.

Develop a referral system.The designated staff person in charge of the office system can identify substance use disorder specialists and resources available for referral for children or their parents. To make referrals, you may want to identify counselors in your community or who might be willing to come to your office on a regular basis to conduct assessments and provide referral information.

Forms for making referrals and information on ordering materials are provided under, respectively, "Tool 4: Local resources worksheet" and "Tool 5: Available from The National Association of Children of Alcoholics," both in "Tools for effecting change."

Develop a reminder system. Such a system should have provisions for labeling the medical records of patients who have expressed concern about substance-abusing family members or have completed screening procedures. It also should remind the pediatrician about previous interventions. This system can identify at-risk substance abusers or families at each visit and indicate who merits long-term follow-up. Computerized medical records may greatly facilitate development of a reminder system for screening patients or following up on family worries. A manual tickler file system can also be used to record each contact. For example, the reminder can indicate when to ask the algorithm question again or to follow up on what the child told you in the previous contact. It can also remind you to screen the child for his own substance abuse or talk to or screen other family members. ("Tool 3: Screening and brief intervention information," in "Tools for effecting change," provides two brief screening instruments: CRAFFT for adolescents, and CAGE-AID, which has been modified to include questions about drugs, and discusses how to employ brief advice intervention and anticipatory guidance after administering these or other screening instruments.)

A final word

Asking appropriate questions during the routine history identifies children and adolescents who live in a family affected by a substance use problem. Expressing care and concern can provide comfort and hope to the child or adolescent who suffers the fallout from another person's alcohol or drug problem. By being attentive, you may also be able to initiate a series of events that eventually leads the person who has a substance abuse problem to sobriety, recovery, and repair of family dysfunction.

DR. ADGER is associate professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, Md.

DR. BLONDELL is associate professor of family medicine, The State University of New York, Buffalo.

MS. COONEY is on the staff of the department of surgery at the University of Wisconsin—Madison School of Medicine.

DR. FINCH is medical director of addiction medicine services at Durham County Mental Health, Durham, N.C.

DR. GRAHAM is professor of family medicine at Case Western Reserve University School of Medicine, Cleveland, Ohio.

DR. MACDONALD is chief executive officer of The Somerled Foundation and chair of the National Association for Children of Alcoholics.

DR. ROBINSON is director of the pediatric residency program and associate chair for education at the University of Missouri Hospitals and Clinics, Columbia, Mo.

MS. WENGER is executive director of the National Association for Children of Alcoholics.

This article is based on a kit that was developed with support from the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention and the National Association for Children of Alcoholics. The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

REFERENCES

1. Grant BF: Estimates of US children exposed to alcohol abuse and dependence in the family.

Am J Public Health

2000;90:112

2. Greer SW, Baucher H, Zuckerman B: Pediatrician's knowledge and practices regarding parental use of alcohol. Am J Dis Child 1990;144:1234

3. Duggan AK, Adger H, Macdonald EM: Detection of alcoholism in hospitalized children and their families. Am J Dis Child 1991;145:613

4. Miller WR, Rollnick S, Conforti K: Motivational Interviewing: Preparing People for Change (ed 2). New York, NY, Guilford Press, 2002

5. Miller W, Sovereign R: The check-up: A model for early intervention in addictive behaviors, in Loberg T, Miller W, Nathan P, et al (eds): Addictive Behaviors: Prevention and Early Intervention. Amsterdam, The Netherlands, Swets & Zeitlinger, 1989, pp 219-231

6. Adger H Jr, Macdonald DI, Wenger S: Core competencies for involvement of health care providers in the care of children and adolescents in families affected by substance abuse. Pediatrics 1999;103(5pt2):1083

How to conduct a motivational interview

Here is an example of how you can use the motivational interviewing technique called TEAR to help a young teenager who has begun to get into fights in school and whose father has an alcohol problem.

Teach

"Billy, you know it is OK to be concerned about a parent or another person's alcohol or drug use. One of the most important initial things we can do is help you to learn more about how alcohol and drug abuse affect the individual involved such as your Dad, as well as how it affects you and others who live in the same house and care about him."

Express empathy

"Billy, I'm concerned about what we just talked about and how it is making you feel. I'd like to help you so that you can feel better and resume getting the good grades that you used to get in school."

Advise action

"Billy, I think it would be helpful for you to learn about alcohol and drug abuse and how it can affect everyone in the family. You can talk to a counselor at your school or attend meetings of a group called Alateen to learn about the disease of alcoholism and learn healthy ways to deal with anger."

Reach agreement

"Billy, I'm glad you are willing to agree to talk with your school counselor to learn more about alcohol and drug abuse and to explore attending an Alateen meeting. I think this is great, and I know you can be successful at dealing better with this problem if you try this."

Where to go for help nationally

Al-Anon

Supports spouses and other relatives and friends of alcoholics. Al-Anon Family Group Headquarters can assist in finding a local affiliate. 1600 Corporate Landing Pkwy., Virginia Beach, VA 23462; 888-425-2666 (help line, 800-344-2666); www.al-anon.org

Alateen

Part of Al-Anon; supports young people whose lives have been affected by the alcoholism of a family member or friend; for information, contact Al-Anon (above); www.alateen.org

Alcoholics Anonymous

Oldest of organizations designed to help alcoholics help themselves. The AA General Service Office can help locate a nearby affiliate. PO Box 459, Grand Central Station, New York, NY 10163; 212-870-3400; www.alcoholics-anonymous.org

The Center for Substance Abuse Prevention (CSAP)/Substance Abuse and Mental Health Services Administration (SAMHSA)

Provides national leadership in the federal effort to prevent alcohol, tobacco, and illicit drug problems. CSAP, One Choke Cherry Rd., Rockwall II, 9th Floor, Rockville, MD 20857; www.prevention.samhsa.gov

Narcotics Anonymous

International, community-based association of recovering drug addicts. NA World Service Office, PO Box 9999, Van Nuys, CA 91409; 818-773-9999; www.na.org

The National Association for Children of Alcoholics

Membership organization and clearinghouse for information and support materials for children of alcoholics and for those in a position to assist them. NACoA, 11426 Rockville Pike, Suite 100, Rockville, MD 20852; 301-468-0985 or 888-55-4COAS; www.nacoa.org

The National Student Assistance Association

Represents interests of student assistance professionals across the United States. NSAA, 4200 Wisconsin Ave. NW, Suite 106-118, Washington, DC 20016; 800-257- 6310; www.nasap.org

The National Clearinghouse for Alcohol and Drug Information

Supplies relevant materials covering the gamut of alcohol- and drug-related issues. NCADI, PO Box 2345, Rockville, MD 20852; 800-729-6686;www.health.org (for youth: www.health.org/kidsarea)

The National Council on Alcoholism and Drug Dependence

Through local affiliates, provides information about treatment opportunities and, sometimes, counseling of alcoholics and their families. NCADD, 20 Exchange Place, Suite 2902, New York, NY 10005; 212-269-7797; www.ncadd.org

The National Institute on Alcohol Abuse and Alcoholism

Supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. NIAAA, 5635 Fishers Lane, MSC 9304, Bethesda, MD 20892-9304; 301-443-3860; www.niaaa.nih.gov

The National Institute on Drug Abuse

Supports and conducts research and ensures the effective dissemination and use of the results of research to significantly improve drug abuse and addiction prevention, treatment, and policy. NIDA, Room 5213, 6001 Executive Blvd., Bethesda, MD 20892-9561; 301-443-1124; www.nida.nih.gov

Important facts about children in families affected by a substance use disorder

• Approximately one in four children younger than 18 years in the United States is exposed to alcohol abuse or alcohol dependence¹

• Children of alcoholics (COAs) experience higher health care costs than children from non-alcoholic families; total health care costs are 32% greater for COAs; and COAs are admitted to the hospital 24% more often, stay 29% longer, and have 39% higher inpatient hospital costs²

• Family modeling of drug using behavior and permissive parental attitudes toward children's drug use are family influences related specifically to an increased risk of alcohol and other drug abuse by the children³

• Children living with an active alcoholic score lower on measures of family cohesion, intellectual achievement, recreation and independence; these children usually experience higher of conflict within levels the family and are hampered by their inability to grow developmentally in healthy ways⁴

• Strong scientific evidence indicates that substance use disorders have a strong genetic component and tend to cluster in certain families; as many as 25% of COAs will become alcoholics themselves⁵

• A relationship between parental alcoholism and child abuse is indicated in a large percentage of child abuse cases⁶

• COAs exhibit symptoms of depression and anxiety more than children from nonalcoholic families⁷

• COAs score lower on measures of verbal ability than children from nonalcoholic families; are more likely to be truant, drop out of school, repeat grades and be referred to a school counselor; and have greater difficulty with abstraction and conceptual reasoning⁷

REFERENCES

1. Grant BF: Estimates of US children exposed to alcohol abuse and dependence in the family. Amer J Public Health 2000;90:112

2. Children of Alcoholics Foundation: Children of Alcoholics in the Medical System: Hidden Problems and Hidden Costs. New York, N.Y., 1988

3. Hawkins JD, Catalano RF, Miller JY: Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention.

Psychol Bull 1992;112:64

4. Filstead W, McElfresh O, Anderson C: Comparing the family environment of alcoholic and normal families. J Alcohol Drug Educ 1981;26:24

5. Johnson S, Leonard KE, Jacob T: Drinking, drinking styles and drug use in children of alcoholics, depressives and controls. J Stud Alcohol 1989;50:427

6. Widom CS: Child abuse and alcohol use. Research monograph 24: Alcohol and Interpersonal Violence: Fostering Multidisciplinary Perspectives. Rockville, MD, National Institute on Alcohol Abuse and Alcoholism, 1993

7. Johnson J, Rolf JE: Cognitive functioning in children from alcoholic and non-alcoholic families. Br J Addict 1988;83:849

Tools for effecting change

TOOL 1

FRAMES¹

Feedback

Providing patients with personal information regarding health status

"Billy, it is okay to be concerned about a parent or another person's alcohol or drug use. One of the most important initial things we can do is help you to learn more about how alcohol and drug use affect the individual involved as well as others who may live in the same house and care about that person."

Responsibility

Emphasizing the patient's freedom of choice and personal responsibility for change

"Billy, you need to know that you can't be responsible for changing other people's behavior, but you are in charge of your behavior."

Advice

Clearly recommending the need for change, conveyed in a supportive and concerned manner, rather than authoritatively

"Billy, I think it would be helpful for you to learn about alcohol and drug use and how it can affect everyone in the family. This will also help you learn other ways to deal with your frustration and anger."

Menu

Providing a variety of options for change

"Billy, you can talk to the counselor at school or attend a group called Alateen in order to learn about the disease of alcoholism and learn other ways to deal with anger."

Empathy

Style of helping based on reflective listening, warmth, genuineness, and respect

"Billy, I'm concerned about what we just talked about and how it is making you feel. I'd like to help you so that you can feel better and resume getting the good grades that you used to get in school."

Self-efficiency

Reinforcing the patients' expectations that they can change

"Billy, I am sure that if you make up your mind to learn about new ways to deal with your anger, you will be very successful in doing so."

TOOL 2

Basic principles and rationale for motivational enhancement

The basic principles and rationale for motivational enhancement begins with the assumption that the responsibility and capability for change lie within the patient and/or involved family member. The clinician's task is to create a set of conditions that will enhance the patient and/or involved family member's own motivation for and commitment to change. Your job is to mobilize their own inner resources as well as those inherent in their natural helping relationships. Miller and Rollnick² have described five basic motivational principles underlying such an approach that can be used to lead patients or involved family members in initiating and complying with behavior change efforts.

Express empathy

The clinician's role is to communicate great respect for the patient/family. He should be a blend of support person and knowledgeable consultant for the benefit of the patient. The patient/families' freedom of choice and direction and responsibility for change are respected. It is important to communicate to the child or adolescent that another person's drinking or drug use is not her fault and that she cannot be responsible for changing it. Supportive persuasion is gentle, subtle, and always assumes that change is up to the patient/family. The major role of the clinician is to listen rather than tell. The power of such gentle, non-aggressive persuasion is widely recognized in clinical writings. Reflective listening is a key to motivational interviewing. It communicates an acceptance of where patients are, while also supporting them in the process of change.

Develop discrepancy

People are motivated to change occurs when they perceive a discrepancy between where they are and where they want to be. The motivational enhancement approach seeks to enhance and focus attention on such discrepancies with regard to the drinking or drug use behavior. In certain cases, it may be necessary to first develop such discrepancy by raising the patient/families' awareness of the personal consequences for family members of the alcohol or other drug use.

Avoid argumentation

The motivational enhancement style explicitly avoids direct argumentation, which tends to evoke resistance. No attempt should be made to have the patient admit or accept a diagnostic label. The clinician does not seek to prove or convince by force or argument. Instead, the clinician assists the patient/family in accurately seeing the consequence of the drinking or drug use. When used properly, the patient/family, and not the clinician, voices the argument for change.

Roll with resistance

Motivational enhancement strategies do not meet resistance head on, but rather "roll with" the momentum, with a goal of shifting patient/family perceptions in the process. Ambivalence is viewed as normal, not pathologic, and is explored openly. Solutions are usually evoked from the patient/ family rather than provided by the clinician.

Support self-efficacy

People who are persuaded that they have a serious problem will still not move toward change unless there is hope for change. Self-efficacy is a critical determinant of behavior change. Self-efficacy is, in essence, the belief that one can perform a particular behavior or accomplish a particular task (such as going to a self-help group). In everyday language, this might be called hope or optimism. If one has little hope that things can change, there is little reason to face the problem. The clinician can be a cheerleader and play an important role by providing the patient/family with hope and optimism.

TOOL 3

Screening and brief intervention information

Choosing screening questions

Choose interviewing or screening methods to identify substance users. A combination of self-administered questions and a direct practitioner interview presents the best screening strategy. The most important aspect in setting up a screening procedure is to make it simple and consistent with other screening activities that occur in the clinician's practice. Questions that focus on alcohol and drug consumption and/or concerns are recommended. The questions should be short and easy to ask or administer. The alcohol/drug questions could be included in an overall health-screening instrument for the practice or clinic. There are recommended screening questions for adolescents as well as adults. A few brief screening instruments follow.^3-5

Examples of brief substance abuse screening instruments

CRAFFT for adolescents

C Have you ever ridden in a Car driven by someone who has recently used drugs or alcohol?

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 (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?

Score: Two or more "Yes" answers indicate a problem for follow-up.

CAGE-AID (The CAGE questions adapted to include drugs)

C Have you felt you ought to Cut down on your drinking or drug use?

A Have people Annoyed you by criticizing your drinking and drug use?

G Have you felt bad or Guilty about your drinking or drug use?

E Have you ever had a drink or used drugs first thing in the morning (Eye-opener) to steady your nerves, or get rid of a hangover, or get the day started?

Score: One or more "Yes" answers indicate a positive screen and the need for further assessment and follow up.

Practice brief advice intervention or anticipatory guidance

After the patient has been questioned or screened, the health care practitioner will want to give feedback to the patient. Although giving this brief feedback or advice is not difficult, health care practitioners are often uncomfortable discussing reductions in substance use. Health care practitioners are encouraged to practice the techniques presented in this guide with a colleague or staff member. It often helps to role-play asking questions and giving brief advice techniques in a controlled setting. Health care practitioners may want to attend workshops at national continuing education programs that teach how to use this technique. If no brief intervention advice is necessary for a child or family because there is not yet a problem with alcohol or drug use, it is often useful to give anticipatory guidance by presenting short messages that can prevent future problems. Also, always leave the door open by asking that the child let the health care practitioner know if ever there is a concern.

TOOL 4

Local resources worksheet

This should be filled out by a designated office staff person and made available to clinicians.

Local support groups

Phone numbers to identify contacts or meeting times for:

• Al-Anon _______________________________________________

• Alateen ________________________________________________

• AA (Alcoholics Anonymous) _______________________________

• NA (Narcotics Anonymous) ________________________________

Community mental health services for families and children

It may be necessary to call and identify resources best suited for families or children dealing with alcohol related issues. These may include classes, groups or therapists available for individual or family counseling. Clarify if resources are available regardless of ability to pay and how to access services.

Agency ________________________

Address _______________________

Phone ________________________

Contact person _________________

Notes on access or financial issues

__________________________________

__________________________________

Substance abuse treatment centers

For most patients insured by managed care organizations, treatment options available either for the alcoholic or the family members of the alcoholic will be dictated by the particular policy, and the patient may need to explore this himself. However, it may be useful to have identified a program that has services targeted directly to family members and to identify at least one well-regarded treatment program for potential referral for evaluation and treatment of patients with substance use disorders.

Program specifically for family members

Address _________________________

Phone __________________________

Contact person ___________________

Notes on access or financial issues

________________________________

________________________________

Program specifically for persons with substance abuse problem

Address _________________________

Phone __________________________

Contact person ___________________

Notes on access or financial issues

________________________________

________________________________

Individual mental health therapists

Not all mental health therapists are experienced or interested in working with children or families with substance use disorders. It may be necessary to question colleagues, call contacts within substance abuse treatment centers or have the patient check with her managed care referral systems. Ask about billing or insurance limitations.

Therapist __________________________

Phone ___________________________

Address ___________________________

Notes on expertise, payment

_________________________________

_________________________________

Shelters for emergent referral

Clarify conditions for admission, limitations (e.g., are children allowed? what ages?), and payment requirements, if any.

Domestic violence shelter ____________

Address __________________________

Phone ___________________________

Notes ___________________________

Homeless shelter ______________

Address __________________________

Phone ___________________________

Notes ___________________________

School resources

Counselor/social worker _____________

Address __________________________

Phone ____________________________

Notes ____________________________

_________________________________

Nurse________________________

Address __________________________

Phone ____________________________

Notes ____________________________

_________________________________

Student assistance program _________

Address _________________________

Phone __________________________

Notes __________________________

Other resources _______________

Address __________________________

Phone ____________________________

Notes ____________________________

_________________________________

TOOL 5

Available from The National Association for Children of Alcoholics (NACoA)

"You're Not Alone"

A nine minute video speaking directly to children and youth, provides information about alcoholism, being safe, finding adults who can help, and about groups as a place to find support. The video is designed for the classroom, for church youth groups, and for youth in community settings. A discussion guide comes with each video ($39.00).

"Kit for Kids"

Written specifically for children and youth, this eight-page booklet includes factual information about alcoholism and being a child of an alcoholic, practical do's and don'ts, phone numbers to call for help, and a list of books for further information ($1.00).

"Kit for Parents"

Written for parents in families where there is alcoholism, this 14-page booklet offers facts about alcoholism, how to provide support to their children and help for themselves and their spouses, practical do's and don'ts, and a list or resources for further information ($2.00).

Children of Alcoholics: Selected Readings

NACoA's 2000 (volume 11) publication of articles by leading authorities, both researchers and clinicians, covers a broad array of useful and reliable information with each author contributing a chapter ($14.95).

Free posters and brochures

Developed by the White House Office of National Drug Control Policy, Center for Substance Abuse Treatment, and NACoA. These materials focus on encouraging young people living with addiction to talk with supportive adults:

• The brochure "You Can Help" is a guide for caring adults working with young people experiencing addiction in the family.

• The brochure "It's Not Your Fault" give youth the message that alcoholism is not their fault and suggest that they find a safe person to talk to.

• The posters "Think Again" and "Home After School" also give youth the message that alcoholism is not their fault and suggest that they find a safe person to talk to.

For more information and to order any of the materials, contact NACoA. Mailing address: 11426 Rockville Pike, Suite 100, Rockville, MD 20852; fax, (301) 468-0987; telephone, 888-55-4COAS (2627); e-mail, nacoa@nacoa.org; Web site, www.nacoa.org.

TOOL 6

About the National Clearinghouse for Alcohol and Drug Information (NCADI)

What is it?

NCADI is part of the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services

What resources does NCADI offer?

NCADI offers a broad range of information and prevention materials suitable for parents and children that could be used for handouts in your office. Materials include pamphlets, booklets, fact sheets, videos, research monographs and posters.

The NCADI web site includes an extensive catalogue, updated regularly, as well as materials for children and adults in both English and Spanish that can be downloaded directly.

How do I contact NCADI?

National Clearinghouse for Alcohol and Drug Information of SAMHSA
P.O. Box 2345
Rockville, MD 20847-2345
Fax: 301-468-6433
800-729-6686
1-800-487-4889 (TTD)
www.health.org

REFERENCES

1. Adger H. Jr, Macdonald DI, Wenger S: Core competencies for involvement of health care providers in the care of children and adolescents in families affected by substance abuse. Pediatrics 1999;103(5pt2):1083

2. Miller WR, Rollnick S, Conforti K: Motivational Interviewing: Preparing People for Change (ed 2). New York, NY: Guilford Press, 2002

3. Knight JR, Shrier LA, Bravender TD, et al: A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153:591

4. Brown, RL, Rounds LA: Conjoint screening questionnaires for alcohol and drug abuse. Wis Med J 995;94:135

5. Frank SH, Graham A, Zyzanski S J, et al: Use of the family CAGE in screening for family problems in primary care. Arch Fam Med 1992;1:209

Introduction to the core competencies

Using preventive interventions with adolescents and their families has become increasingly more important. These interventions strengthen families and maximize opportunities for health care providers to enhance the health and welfare of children. The Core Competencies for Involvement of Health Care Providers in the Care of Children and Adolescents in Families Affected by Substance Abuse is a statement that articulates three distinct levels of care.¹ The Core Competencies attempts to recognize and account for individual differences among health care providers. It specifically calls for a minimal role for all primary care providers but provides enough flexibility to choose their role and degree or level of involvement. Further, it recognizes a central tenet that, while health care providers must be responsible for identifying the problem, they are not expected to solve, manage, or treat the problem all by themselves.

Level I of the Core Competencies

All primary health care providers with responsibility for the care of children and adolescents, regardless of their specific area of training or discipline should, at a minimum, have the knowledge and skills to practice at level I. This includes:

• basic understanding of the medical, psychiatric and behavioral symptoms of children and adolescents in families affected by substance use disorders

• familiarity with local resources

• routine screening for family history/current use of alcohol and other drugs

• determination of whether family resource needs and services are appropriate

• ability to express an appropriate level of concern and offer support and follow-up

The specific knowledge and skills indicated in level I of the Core Competencies are suggested as a baseline or minimal level of competence that all primary health care providers should strive to achieve. The role of the health-care provider is to initiate an inquiry about an important health problem for which the appropriate care could dramatically improve patients' well being. It is not the intention of the Core Competencies to burden the busy health care provider with attempting to solve complicated family and behavioral issues that have evolved over long periods of time.

From all health professionals with clinical responsibility for the care of children and adolescents, level I calls for the following:

• Be aware of the medical, psychiatric and behavioral syndromes and symptoms with which children and adolescents in families with substance abuse present

• Be aware of the potential benefit to both the child and the family of timely and early intervention

• Be familiar with community resources available for children and adolescents in families with substance abuse

• As part of the general health assessment of children and adolescents, health professionals need to include appropriate screening for family history/ current use of alcohol and other drugs

• Based on screening results, determine family resource needs and services currently being provided, so that an appropriate level of care and follow-up can be recommended

• Be able to communicate an appropriate level of concern, and offer information, support, and follow-up

Some want to do more

The statement of the Core Competencies recognizes that some practitioners will want to do more. For these individuals, different and more advanced knowledge and skills will be required. Most important, this is a decision that each provider will make on his or her own. Some will want to attain the additional knowledge and skills while most will be able to collaborate with and refer to those who have the skill and expertise to provide these more specialized services. The end result, however, is increased attention to an important problem and enhanced opportunities for validation, education, support and treatment for patients and families affected by substance use disorders. In short, the Core Competencies are a vehicle for helping us to brighten the future for children who may be struggling with one of the families' biggest and most burdensome secrets.

These competencies are presented as a specific guide to the core knowledge, attitudes and skills that are essential to meeting the needs of children and youth affected by substance abuse in families. There are over 28 million children of alcoholics in America; almost 11 million are under the age of 18 years. Countless other children are affected by substance-abusing parents, siblings or other caregivers. There is an association between child physical, emotional and sexual abuse and neglect, domestic violence and substance abuse in the family. All children have a right to be emotionally and physically safe. No child of an alcoholic or other substance-abusing parent should have to grow up in isolation and without support. Recognizing that no one is unaffected in families with substance abuse, health professionals should play a vital role in helping to optimize the health, well being, and development of children and adolescents from these families and should recognize, as early as possible, associated health problems or concerns. It is the hope of the National Association for Children of Alcoholics (NACoA) that organizations representing health care professionals will adopt these competencies or competencies modeled from them. Developed by a multi-disciplinary professional advisory group to NACoA, these competencies set forth three levels for professional involvement with children who grow up in homes where alcohol and other drugs. other drugs are a problem. All health care providers should aspire to level I. Resources and programs should be made available for the training of professionals who desire to achieve competency at levels II and III.

Level II of the Core Competencies

In addition to level I competencies, health-care providers accepting responsibility for prevention, assessment, intervention, and coordination of care of children and adolescents in families with substance abuse should:

• Apprise the child/family of the nature of alcohol and other drug abuse/dependence and its impact on all family members and strategies for achieving optimal health and recovery.

• Recognize and treat, or refer, all associated health problems.

• Evaluate resources–physical health, economic, interpersonal, and social–to the degree necessary to formulate an initial management plan.

• Determine the need for involving family members and significant other persons in the initial management plan.

• Develop a long-term management plan in consideration of the above standards and with the child or adolescent's participation.

Level III of the Core Competencies

In addition to levels I and II competencies, the health-care provider with additional training who accepts responsibility for long-term treatment of children and adolescents in families with substance abuse should:

• Acquire knowledge, by training or experience in the medical and behavioral treatment of children of families affected by substance abuse.

• Continually monitor the child/adolescent's health needs.

• Be knowledgeable about the proper use of consultations.

• Throughout the course of health- care treatment, continually monitor and treat, or refer to care any psychiatric or behavioral disturbances.

• Be available to the child or adolescent and the family, as needed, for ongoing care and support.

REFERENCE

1. Adger H Jr, Macdonald DI, Wenger S: Core Competencies for involvement of health care providers in the care of children and adolescents in families affected by substance abuse. Pediatrics 1999;103(5pt2):1083