Case Seven: Treating Children of Alcoholics


Tom is a 16 year old who comes to you for a physical because he wants to try out for the soccer team. When you ask about stress in his life, he notes that he parents are always fighting, and this upsets him.

He believes that they fight more when they have been drinking, and he believes that his father is the heavier drinker of the two, but he cannot quantify either parent's use.

Questions For Health Care Professionals

A. How would you approach the patient (either cooperative or resistant)?
(The goal is to develop a positive, non-judgemental rapport with the patient?)

  1. Use your rapport.

  2. Don't be afraid to explore the issue.

  3. Display compassion and concern.

  4. Ensure confidentiality

  5. Use a neutral, matter of fact, tone of voice

  6. Acknowledge it may be difficult for the patient to share this information.

  7. Be nonjudgmental. The more nonjudgmental you are the more likely the patient is to reveal information.

  8. Be redundant. If your questions are not being completely answered ask again.

  9. Phrase the question appropriately. For example, ask, "Tell me about your parent's alcohol use," instead of "Do they drink?" And "What kinds of drugs do they use?" instead of "Do they use drugs?" (Avoid the term "illegal drugs".)

B. What data do you need to collect or what initial screening should be done?  (The goal is to gather relevant history and barrier information.)

  1. This patient is at least in a difficult situation and at most in a dangerous situation.

  2. Assess the environmental risks as well as how the patient is coping with his situation.

  • a. How often do your parents drink?

  • b. When you say "your parents always fight," how often does this occur? How long has this been happening?

  • c. Is there any physical or verbal abuse in the home? (keep in mind that the patient may define physical and verbal abuse very differently, therefore assess carefully)

  • d. What do you do when they fight?

  • e. Do you ever feel frightened or unsafe in the home?

  • f. Tell me about your alcohol use. What kinds of drugs do you use?

  • g. Do you know if your parents have ever been in treatment for drug or alcohol use?

  • h. Do you ever miss school or other activities because of your parents' fighting?

  • i. Are you seeing a counselor? Would you be willing to see a counselor?

  • j. Do you talk to any of your peers about this?

If the person becomes resistant or uncooperative try to reassure the patient that you are gathering this information to provide the best care for his health. If the patient remains resistant then ask them what they would like to do, ask them if you could ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient being in the pre-contemplation stage of change. 

C. What other medications/drugs is the patient using?

  1. Review the patient's medication. Be alert to a history of physical injuries, that given this new information, may be attributed to violence in the home.

  2. Ask specifically about "pills." Such as "Do you ever take any kind of pills?" and "Do you ever take anyone else's pills?" (Note: It is important to ask specifically about pills, as many people do not consider pills to be drugs of abuse.)

  3. Review history of illegal drug use. If currently using illegal drugs, ask questions as noted in section B. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your drug use." Or ask specifically about certain drugs such as "tell me about your marijuana use.")

D. What is the pattern of patient's medication/drug use?

(The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)

E. What internal/external obstacles and biases might the patient face?

(The goal is to determine how receptive/resistant the client will be to a discussion regarding his/her drug use. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient.)

If it is believed that she has an addiction:

  1. Fear of getting into trouble with his parents.

  2. Fear of getting his parents into trouble.

  3. Embarrassment and shame

  4. Fear of rejection by friends or culture

  5. The patient's belief that this is normal

  6. Lack of insurance for treatment

  7. Transportation

  8. Fear of legal ramifications if they feel they are divulging sensitive information

F. What internal/external obstacles and biases might the physician face?

  1. Wanting to avoid the dilemma of confronting the parents

  2. Belief that addiction is a moral issue and not a medical issue

  3. Lack of treatment availability (affordability, waiting-lists, services not available in community)

  4. Physician's discomfort with addressing substance abuse issues

  5. Physician uses his or her own parenting style as a barometer of what is a normal/healthy family.

  6. Time constraints

  7. Physician's family history causes countertransference (misperceptions based on personal experiences).

G. What do you do now?

(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)

  1. Discuss evidence for concern (patient's reported distress, concerning results of physical examination)

  2. Display compassion

  3. Provide reassurance that there is help available

  4. Ask the patient whether he would like you to talk with his parents (depending on the severity of the situation, the physician may decide to speak with the parents, regardless of the patient's wishes, however, keep in mind the patient's safety may be at risk should his parents become angry with him)

  5. Assess the need for a referral to DCFS

  6. Address the stigma associated with having parents who may be alcoholics

  7. Because the patient has reported stress due to the situation, at the very least, he could be encouraged to see his school counselor. Ask him if he would be willing to do this.

H. How does the physician make a referral? 

If it is clear that there is concern regarding the patient's home environment and his ability to cope with the resulting stress, a referral should be made.

  1. Explore possibilities for counseling. Keep in mind that most referral to a therapist will need the parents' cooperation. However, any child can make an appointment with his school counselor without parental consent.

I. When and how should the physician follow up with the patient?

This provides the physician with the opportunity to coordinate with other services provides to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)

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