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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. A useful definition of early intervention would include services directed at 1) individuals or families whose use of ATOD (Alcohol, Tobacco, and Other Drugs) 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 therapist-delivered health education and counseling can lead to improvement in health status. 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. 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.
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, therapists 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. Review of the extensive literature on motivational enhancement is beyond the scope of this review, but there are several useful resources worthy of review.
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 therapist 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 therapist-family relationship rather than strengthen it. The therapist 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 therapist 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 therapist 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 therapist must realize that the family has three issues to confront. The first is for family members to acknowledge their denial, i.e., 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 therapist 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 therapist 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 therapist 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 therapist 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. AlAnon 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, therapists can refer family members for therapy to substance abuse 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.
- Werner, Mark J., Alain Joffe, and Antonette V. Graham; "Screening, Early Identification, and Office-based Intervention with Children and Youth Living in Substance-abusing Families"; Pediatrics; May99 Vol. 103 Issue5, p1099.
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