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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. 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. 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.
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 substanceabusing 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. More 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. 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. Thirty-three percent of pediatric faculty reported feeling little or no responsibility for substance-abuse referrals of patients' family members. In 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.
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.
Interviewing Children, Youth, and Families
Barriers to Addressing Family Substance Abuse
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. 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.
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