The Role of Primary Care Physicians

by Hoover Adger, Jr., MD, MPH


There are an estimated 28.6 million Americans who are children of alcoholics (COAs), nearly 11 million of them under the age of 20.

Many of these children are exposed to chaotic family environments which lack consistency, stability or emotional support. Many will go on to develop alcoholism, other drug problems, and/or other serious coping problems. Most will have seen their pediatrician, adolescent medicine or family practitioner multiple times along the way. These children should not have to suffer in silence and need to know that help is available.

Children and adolescents living in families where there is an alcohol or other drug abusing parent or other caretaker often develop unhealthy living patterns. They may not learn to trust themselves or others, how to handle uncomfortable feelings, or how to build positive relationships. Children and adolescents who lack these skills are at higher risk for school failure, depression, increased anxiety, as well as trouble with alcohol and other drugs.

Children of alcoholic and other drug abusing parents often come to the pediatrician, adolescent health or other primary care provider with recurring and vague symptoms, such as fatigue, abdominal pain, or musculoskeletal complaints, which may be indicative of psychosomatic illness. In addition, they may suffer from accidental injury, verbal abuse, physical abuse or sexual abuse associated with parental drinking or drug use. Poor communication, permissiveness, under-socialization, neglect and violence-all potentially devastating-are common in children who live in alcoholic families. Primary health practitioners can help reduce or prevent alcohol and other drug related impairment by providing education, identifying affected youth and families and by initiating early intervention.

Role of the Child/Adolescent
Health Practitioner

The Committee on Substance Abuse of the American Academy of Pediatrics recommends that pediatricians include substance abuse in their anticipatory guidance to all children and adolescents. The committee's guidelines reiterate that practitioners should possess the skills necessary to recognize risk factors and signs of substance abuse in their patients, and should be able to evaluate the nature and extent of alcohol use and to offer appropriate counseling or referral. The Guidelines for Adolescent Preventive Services (GAPS) established by the American Medical Association recommend both primary (e.g., patient education and anticipatory guidance) and secondary (e.g., early intervention) preventive strategies to reduce adolescents' use of alcohol and other drugs. These measures include screening of all children and adolescents and the utilization of brief counseling and referral as needed. GAPS also recommends that practitioners routinely ascertain their patients' risk factors (including a family history of alcoholism) in the medical history and conduct screening evaluations for all school-aged children and adolescents. Clearly, there is a need to extend these recommendations to include the identification of alcohol and other drug related problems in the family.

Discussions about prevention of alcohol abuse and related problems should begin with the prenatal visit by focusing on the responsibility of parents, parental lifestyle, and effects of parental alcohol use on the fetus, infant, child and adolescent. Parents serve as important role models for their children. Children's attitudes and beliefs regarding alcohol develop early in life, often by age 7 or 8. 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 provider to explore the attitude of the family toward alcohol use and provide basic education appropriate to the age and development of the child.

Anticipatory guidance about alcohol 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. Pediatricians and other primary care practitioners should routinely include an assessment of alcohol risk factors (including a family history of alcoholism) in the medical history.

Physicians can initiate or enhance the dialogue between children and their parents by asking if alcohol use is being discussed in school, inquiring about the specifics of what is being taught, and assessing if the child understands the messages that are being delivered. It is important to ask if alcohol use is discussed among friends, whether alcohol is present in the child's environment, about their perceptions of why some people use alcohol and whether or not alcohol use is harmful.

In addition to providing anticipatory guidance, the primary care provider can play an active role in general prevention programs directed at children and adolescents. Pediatricians, adolescent medicine specialists, family practitioners and others can act as important advocates for appropriate community and school-based prevention approaches and in educating patients and parents, ensuring that local programs are culturally relevant and appropriate for the various communities and populations they serve.

Routine Screening

All child/adolescent health practitioners should screen and perform an initial evaluation of their patient's use of alcohol and/or other drugs and determine indications for further assessment and intervention. They should also screen for alcohol and drug related problems in the family. A primary task of initial screening and evaluation is to determine if the use of alcohol and other mood altering substances is associated with identifiable consequences and if such use is causing behavioral impairment. Information gathered should help to decide if there is a need for further assessment or exploration of additional problems. Physicians need to keep in mind that screening is an important and time-efficient first step to identifying the existence of a problem, but that if a problem is identified, it does not mean that they have to "fix it." Help is available to assist them.

In addition to being useful for screening about an adolescent's alcohol use directly, one can use the questions to provide a proxy report regarding another person. They can be adapted for inquiry about alcohol use of a parent or other adult. For example, the CAGE questions could be used in the following manner with the child or adolescent who is not using alcohol or other drugs, but seems concerned about a parent's use of alcohol:

The ability to use the CAGE in this manner offers the potential for great flexibility for the pediatric/adolescent encounter and allows for a comfortable way of collecting pertinent screening information about or from patients and parents.

While routine screening for alcohol use may be a desirable goal, much will have to change before it becomes a reality. Physicians and other health professionals in training need to develop a sense of responsibility and optimism toward their patients' alcohol problems and confidence in their clinical skills related to caring for patients with these problems. Numerous studies show that physicians are uncomfortable with and report a need for additional training in screening and management of alcohol related problems. Hence, educational programs need to be available to help primary care practitioners develop the clinical skills to assess and manage patients with alcohol problems. At a minimum, curricular time should be devoted to alcohol related issues in medical schools, residency training programs and continuing medical education courses.

To this end, NACoA has embarked on an initiative to assist primary care practitioners who care for children and adolescents so that appropriate awareness of, and interventions directed at, protecting the physical and mental health of children and adolescents can become a routine part of their health care.

Conclusion

Primary care physicians encounter a significant number of children, adolescents, and families who are affected by alcoholism and other drug related problems. The challenge before health care providers is to identify individuals early in their involvement and to intervene in a timely and meaningful manner. An appreciation of the magnitude of the problem among youth and families and the role of the primary care practitioner in prevention, management, and treatment is vital.

Hoover Adger, Jr., MD, MPH, is Professor of Pediatrics and Associate Director of Adolescent Medicine at Johns Hopkins Hospital, Baltimore, MD. He is a current member of the NACoA Board of Directors and the immediate past Deputy Director in the federal government’s Office of National Drug Control Policy(ONDCP).

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