3. - ERICPhysician Patient Relationship; *Physicians; *Substance Abuse; Units of Study. ABSTRACT....

29
DOCUMENT RESUME ED 300 694 CG 021 189 AUTHOR Siegal, Harvey A.; Fahey, Patrick J. TITLE Recognition and Diagnosis. Adolescent Alcoholism: Recognizing, Intervening, and Treating Series No. 3. INSTITUTION Ohio State Univ., Columbus. Dept. of Family Medicine. SPONS AGENCY Health Resources and Services Administration (DHHS/PHS), Rockville, MD. Bureau of Health Professions. PUB DATE 87 CONTRACT 240-83-0094 NOTE 30p.; For other guides in this series, see CG 021 187-193. AVAILABLE FROM Department of Family Medicine, The Ohio State University, Columbus, OH 43210 ($5.00 each, set of seven, $25.00; audiocassette of series, $15.00; set of four videotapes keyed to guides, 17165.00 half-inch tape, $225.00 three-quarter inch tape; all orders prepaid). PUB TYPE Guides - Classroom Use - Materials (For Learner) (051) -- Reports - General (140) EDRS PRICE MFO1 Plus Postage. PC Not Available from EDRS. DESCRIPTORS *Adolescents; *Alcoholism; *Clinical Diagnosis; Physician Patient Relationship; *Physicians; *Substance Abuse; Units of Study ABSTRACT This document is one of seven publications contained in a series of materials for physicians on recognizing, intervening with, and treating adolescent alcoholism. The goals of this unit of study are to provide an overview of the problem of of teenage alcoholism and substance abuse and to facilitate the diagnosis of adolescent alcoholism. The information provided is designed to help the physician develop a greater understanding of the progression of alcoholism and substance abuse and a sensitivity to the manifestations of teenage alcoholism and substance abuse seen in clinical ptactice. This unit of study will enable the physician to: (1) describe the model of alcohol and other substance abuse as a progression of events usually moving from experimentation to dysfunction; (2) differentiate behavioral and psychological patterns or traits associated with each level of the progression; (3) describe behavior patterns which would likely be exhibited by an adolescent harmfully involved with alcohol; (4) describe the use of medical interviewing techniques in the attainment of a substance abuse history; (5) list risk factors relevant to substance abuse and describe how physical examination and laboratory tests are used as part of the evaluation; (6) synthesize data to make an accurate diagnosis and an assessment of substance abuse; and (7) assess personal skills as related to a patient's level of substance involvement to determine appropriateness of providing care, consulting, or referring. (NB)

Transcript of 3. - ERICPhysician Patient Relationship; *Physicians; *Substance Abuse; Units of Study. ABSTRACT....

Page 1: 3. - ERICPhysician Patient Relationship; *Physicians; *Substance Abuse; Units of Study. ABSTRACT. This document is one of seven publications contained in a series of materials for

DOCUMENT RESUME

ED 300 694 CG 021 189

AUTHOR Siegal, Harvey A.; Fahey, Patrick J.TITLE Recognition and Diagnosis. Adolescent Alcoholism:

Recognizing, Intervening, and Treating Series No.3.

INSTITUTION Ohio State Univ., Columbus. Dept. of FamilyMedicine.

SPONS AGENCY Health Resources and Services Administration

(DHHS/PHS), Rockville, MD. Bureau of HealthProfessions.

PUB DATE 87CONTRACT 240-83-0094NOTE 30p.; For other guides in this series, see CG 021

187-193.AVAILABLE FROM Department of Family Medicine, The Ohio State

University, Columbus, OH 43210 ($5.00 each, set ofseven, $25.00; audiocassette of series, $15.00; setof four videotapes keyed to guides, 17165.00 half-inchtape, $225.00 three-quarter inch tape; all ordersprepaid).

PUB TYPE Guides - Classroom Use - Materials (For Learner)(051) -- Reports - General (140)

EDRS PRICE MFO1 Plus Postage. PC Not Available from EDRS.DESCRIPTORS *Adolescents; *Alcoholism; *Clinical Diagnosis;

Physician Patient Relationship; *Physicians;*Substance Abuse; Units of Study

ABSTRACT

This document is one of seven publications containedin a series of materials for physicians on recognizing, interveningwith, and treating adolescent alcoholism. The goals of this unit ofstudy are to provide an overview of the problem of of teenagealcoholism and substance abuse and to facilitate the diagnosis ofadolescent alcoholism. The information provided is designed to helpthe physician develop a greater understanding of the progression ofalcoholism and substance abuse and a sensitivity to themanifestations of teenage alcoholism and substance abuse seen inclinical ptactice. This unit of study will enable the physician to:(1) describe the model of alcohol and other substance abuse as aprogression of events usually moving from experimentation todysfunction; (2) differentiate behavioral and psychological patternsor traits associated with each level of the progression; (3) describebehavior patterns which would likely be exhibited by an adolescentharmfully involved with alcohol; (4) describe the use of medicalinterviewing techniques in the attainment of a substance abusehistory; (5) list risk factors relevant to substance abuse anddescribe how physical examination and laboratory tests are used aspart of the evaluation; (6) synthesize data to make an accuratediagnosis and an assessment of substance abuse; and (7) assesspersonal skills as related to a patient's level of substanceinvolvement to determine appropriateness of providing care,consulting, or referring. (NB)

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-

_Adolescent AlebhpiiStritRecogrii4fig, Intervening, , aiid:Treating-

(The titles and thaterialslisted beloware contained in this series:).

Available.Materials :-

Written Audio. Video

1. Adolescents andSiihstan(e Abuse:An-O.Verview *

2. The Physician's Role in Prevention. *

3. keetiOitieni,dild:Diagriesis.

4. Inteivention.ivith the DependentAdolescent

5. The 'Physiciati'sRole.in -Referraland Treatment

6. Alcohol anct0ther Cheinicals

'Facility Guide (regaiding.medical-edtication, residency-training, .ancLcontinunig medicaLeducation)-.

aepariment of Family. MedicineCollege of Medicine The Ohio State University456 WeSt Tenth Avenue - Columbus, Ohio 43210

3

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Adolescent Alcoholism:Recognizing, Intervening, and Treating

3 Recognition and Diagnosis

Harvey A. Siegal, Ph.D.Professor and DirectorSubstance Abuse Intervention ProgramsDepartment of Medicine in SocietyWright State University)ayton, Ohio

Patrick J. Fahey, M.D.Assistant Professor and DirectorPredoctoral SectionDepartment of Family MedicineThe Ohio State UniversityColumbus, Ohio

Project EditorLawrence L. Gabel, Ph.D.

Content EditorsPatrick J. Fahey, M.D.Jep Hostetler, Ph.D.John S. Monk, Ph.D.

Contract Number: 240-83-0094

U.S. Department of Health and Human ServicesPublic Health ServiceHealth Resources and Services AdministrationBureau of Health ProfessionsDivision of Medicine

Project Officer: Margaret A. Wilson, Ph.D.

4

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Acknowledg- Project Staffments Lawrence L. Gabel, Ph.D. - Project Director, Associate Professor and Director, Graduate

Education and Research Section, Department ofFamily Medicine, The Ohio State University,Columbus, Ohio

Joan S. Rehner - Project Assistant, Secretary, Graduate Education and Research Section,Department of Family Medicine, The Ohio State University, Columbus, Ohio

Mark E. Clasen, M.D., Ph.D. - Family Medicine Coordinator (10/83-3/85), Clinical AssistantProfessor, Department of Family Medicine, The Ohio State University, Columbus, Ohio

Patrick J. Fahey, M.D. - Family Medicine Coordinator (3/85-9/86), Assistant Professor andDirector, Predoctoral Education Section, Department of Family Medicine, The Ohio StateUniversity, Columbus, Ohio

Jep Hostetler, Ph.D. - Alcoholism Coordinator, Associate Professor, Department of PreventiveMedicine, The Ohio State University, Columbus, Ohio

Robert E. Potts, Ph.D. - Education Coordinator, Associate Director, Biomedical Communica-tions, The Ohio State University, Columbus, Ohio

John S. Monk, Ph.D. - Evaluation Coordinator, Assistant Professor and Coordinator, Researchand Evaluation, Graduate Education and Research Section, Department of Family Medicine,The Ohio State University, Columbus, Ohio

Editorial ConsultantChester E. Ball, M.A., Assistant Professor Emeritus, The Ohio State University, Columbus,Ohio

Technical AssistantsAnnette M. Battafarano, IvI.A., Graduate Research Associate,Graduate Education and ReseatchSection, Department of Family Medi.-!ne, The Ohio State University, Columbus, Ohio

Eden V. Wells, B.A., Medical Student Research Associate, Graduate Education and ResearchSection, Department of Family Medicine, The Ohio State University, Columbus, Ohio

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Criteria/Assessment CommitteeSamuel A. Wenger, CAC, Ph.D., Counseling Psychologist, Columbus, Ohio

Charles L. Whitfield, M.D., Medical Director, The Resource Group; Clinical AssociateProfessor of Medicine and Family Medicine; Clinical Assistant Professor of Psychiatry, Univer-sity of Maryland School of Medicine, Baltimore, Maryland

Michael R. Liepman, M.D., Assistant Professor of Psychiatry and Human Behavior, BrownUniversity, Providence, Rhode Island

Joseph V. Fisher, M.D., Professor Emeritus, Departments of Family Medicine and Psychiatryand Behavioral Science, Medical University of South Carolina, Charleston, South Carolina

Beryl R. Fruth, M.D., Family Physician, Columbus, Ohio

Mary L. Budzak, M.D., Family Practice Resident, Department of Family Medicine, The OhioState University, Columbus, Ohio

Curtis L. Janeczek, M.D., Columbus, Ohio

A special note of appreciation is extended to persons in family practice residencyprograms anduniversities throughout Ohio for reviewing the materials and to faculty and residents of theCentral Ohio Affiliated Family Practice Residency Programs where the materials were piloted.

Grant Hospital, Columbus, OhioRiverside Methodist Hospital, Columbus, OhioUniversity Hospital, Columbus, OhioMt. Carmel Hospital, Columbus, Ohio

Composition, Camera Work, Reproduction, and Binding: Lesher Printers, Fremont, Ohio

Library of Congress Catalog Card Number: 86-051058

Copyright @ 1987 by the Department of Family Medicine, The Ohio State University. All rightsreserved.

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Contents

Figures

PageIntroduction

1

Goal1

Objectives1

Recognition: The Progression Hypothesis 2Introduction 2The Progression Hypothesis 2A Summary of the Typology 4Behavioral Attributes 5Psychological and Psychosocial Attributes of User Groups 5Assessment and Therapeutic Assignment 6

The Family and Chemical Dependency:Its Impact Upon the Diagnostic Proccss 6

Introduction 6Experimentation: Initial Concern in the Family 6Committed/Harmful Involvement: The Family Responds 7

The Physician as Diagnostician 8Introduction 8Obtaining a History: Patient and Family System.., 9The Chemical Dependency Assessment: Methodology and Technology 9

Interview Technology 10The Adolescent: Opening the Interview 10Family Members: Technology of the Assessment Interview 12Medical History 13Physical Examination 14Construction of Assessment Datf, Base 15Synthesizing the Assessment Data 16Assessment 17Assessment and Compliance: The Physician's Limits 19Diagnostic Testing 20Terminating the Interview 20

Summary 21Evaluation 22References 23Resources for Physicians 23Resources for Patients and/or Pami lies 23

3-1. Progression Hypothesis 3

3-2. Discontinuity Between Affect and Behavior 73-3. Assessment Schematic 153-4. Assessment Dimensions 173-5. Problem Assessment - Intervention Level Matrix 18

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Introduction

Goal

Objectives

In the 19th century, the famous pathologist-physician, Sir William Osler, describedsyphilis as the "Great Pretender." Osler recognized how the signs andsymptoms of thisdisease, at each of its stages, could readily mimic those of other conditions. Because thedisease was so common at that time and so difficult :o control the physician waswise to consider syphilis as the actual cause of the disease which a patient was presenting.Today, alcoholism and, in a larger sense, chemical dependency might be seen in the sameway. While every physician is familiar with the end-stage ramifications of chronicalcoholism, which may entail impairment of virtually every organ system, the signs andsymptoms of many psychological and psychiatric abnormalities are mimicked by theeffects of the abuse of alcohol and other mood-altering chemicals. Depression, anxiety,paranoia, and the like are frequently misdiagnosed when the actual cause is, in fact, theabuse of psychoactive chemicals.

The primary care physician assessing adolescent patients is unlikely to see many of thempresenting end-stage physical ramifications. Instead, the consequences will be morelikely to present in the psychological and social domains. The intent of this unit of studyis to increase your awareness of these domains and to heighten your willing. 'ss toexplore the possibility of alcohol and drug abuse among your patients. This discussionwill provide physicians with an overview that can help in the recognition of the abuse ofthese substances in both the adolescent and his or her family. The models to be presented

of the development and progression of use/abuse and of family functioning arecertainly not exhaustive. Extensive literature on causation, development, and familydysfunction related to these conditions exists and is referen.:ed in other units of study ofthis series. Here we provide a schematic whichmay help you recognize these conditionsas they present in your patients.The unit of study recognizes that the primary care physician may not be the healthprofessional who will actually manage the case and provide the alcohol or drugabuse-specific treatment once these conditions have been identified. Instead, the intent isto offer physicians information and skills which will help them obtain a valid andreliable history and will facilitate an appropriate assessment of a chemical-relatedproblem.

The goal of this unit of study is to provide an overview of the problem of teenage alco-holism and substance abuse and to facilitate the diagnosis of this threat to health andwell-being. In reaching this goal, the physician will develop both a greater understand-ing of the progression of alcoholism and substance abuse and a sensitivity to the mani-festations of teenage alcoholism and substance abuse seen in clinical practice.

Upon completion of this unit of study, you will be I >le to:1. Describe the model of alcohol and other substance abuse as a progression of events

usually moving from experimentation to dysfunction.2. Differentiate behavioral and psychological patterns or traits associated with each

level of the progression.

3. Describe behavior patterns which would likely be exhibited by an adolescent harm-fully involved with alcohol.

4. Describe the use of medical interviewing techniques in the attainment ofa substanceabuse history.

S. List risk factors relevant to substance abuse and describe how physical examinationand laboratory tests are employed as part of the evaluation.

6. Synthesize data to make an accurate diagnosis and an assessment of substance abuse.7. Assess personal skills as related to a patient's level of substance involvement to

determine appropriateness of providing care, consulting, or referring.

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2Adolescent Alcoholism

Recognition: The ProgressionHypothesis

IThe progression hypothesis of substanceabuse lists several categories of usersand defines behavioral attributes andpsychological features within eachcategory.

IntroductionAn effective model of substance abuse should, at the

very least, make it possible to distinguish differentcategories of users. It also must describe how a user's"career" begins and ultimately where it can terminate.The Progression Hypothesis provides such a model.'Originally developed by Chambers in the early 1970's tocategorize epidemiological findings, Dr. Siegal, firstauthor of this unit of study, has used it extensively inclinical work with adolescent substance abusers. Themodel provides definable categories of users, distin-guishes between the categories with specific behavioralattributes, and provides some insight into differences inpsychological and social functioning between the cate-gories. This model assists the physician in evaluatingadolescent patients by

referencing where they are in their drinking orsubstance use career;logically sequencing intervention activities;avoiding the nonproductive, false dichtomy about"good" versus "bad" drugs;visualizing drug use in dynamic rather than staticterms; andfocusing the patient's and the family's attention onthe actual consequences of use.

Among adolescents, it is nonproductive to distinguishalcohol from other mood-altering drugs. Unquestion-ably, alcohol has greater availability and use than doother substances, and the ramifications of alcohol abuseamong the teenage and young adult group especiallyin the area of automobile-related fatalities is likely tobe more profound. However, the dynamics of use andprogression are similar. Also, the sole abuse of any singleagent tends to be rare in a sophisticated user. The scarypoint about the adolescent patient is that this progres-sion may be extremely rapid less than a year.

The Progression Hypothesis

The Progression Hypothesis is represented in Figure

3-1. It initially distinguishes between users and non-users; that is, those who abuse psychoactive drugs andthose who do not. The latter category, although psy-chologically and sociologically interesting, will not bereviewed here. Instead, attention will be focused uponthe significantly larger category of "users." Each of thegroups within the model is briefly described below.

Experimenters

IThe first category of use is theexperimenter who is doing, in mostsituations, what is a normal activity ofadolescence.

Experimentation is a nor:nal form of human activity.Most people exhibit a willingness to experiment withnew things in their environment in their life-long questfor satisfaction and fulfillment. Stated much moredirectly, we desire to "try" new foods, styles, andactivities. Among the things that are experimented withis how the mind categorizes, organizes, and experiencesthe data being brought to it by its externally andinternally focused senses. This has been referred to as the"state-of-consciousness."

This function can be manipulated in numerous ways.Altered states can be achieved by strenuous physicalactivity; for example, the "runner's high," fasting,hyperventilation or hypoventilation, medication, sleepdeprivation, pain, and ingesting psycho-active chemicals.Some writers have even suggested that mankind possessesan 'nnate drive to periodically alter the state-of-consciousness. Anthropologic and developmental datahave been offered to support the "inborn drive" hy-pothesis.1They claim a culture has yet to be discovered inwhich its members do not have some method of alteringconsciousness. Even very young children will alterperceptions through behavior, such as spinning tobecome dizzy.

As a culture, we accept the periodic alteration ofstate-of-consciousness as desirable. While there is cer-tainly some ambivalence, our culture endorses themoderate use of alcohol as one means to do so. In fact,experimentation with alcoholic beverages is consideredone of the milestones of adolescent life. However,experimentation is seldom a single event. Instead, it is a"testing" or "sifting" process by which people evaluatethe effects of use (whether they "like" the feelings) and

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Recognition and Diagnosis 3

Figure 3-1. Progression Hypothesis

LEVELS OF USE

Experimenters

Social Users

BEHAVIORAL ATTRIBUTES

Users

Imitative Behavior

Peer-Initiated

Recreational

PSYCHO-SOCIALCHARACTERISTICS

Self-Reliance

Self-Confidence

Self-Control

Goal-Oriented

Satisfaction withCurrent and Future Roles

Committed/HarmfullyInvolved Users

Dysfunctional Users

SeekersAdaptive Behavior

Self-Sustained

Self-Medication

DepressionAnxiety

Alienation

Role Frustration

Low Tolerance for Stress and Tension

High-Risk Taker

External Stimulus Seeker

Poor Reality Testing

determine how such effects "fit" with those from otheractivities and relationships.

Social and Recreational Use

IThe next category ofuse is the socialand recreational use of alcohol; thislevel of use does not usually interferewith the individual's daily activity.

During experimentation, people try to determine notonly whether they like the results but also if theconsequences are either too unpleasant or too painful. Ifboth decisions are positive, then progression to the nextstage or category in the model designated as "Socialand/or Recreational Use" may ensue.

Social and recreational use does not interfere in anykind of significant or consistent way with any if theuser's other responsibilities or roles. The use, when

observed or known to others, typically does not engenderstrong negative sanctions; it is considered "appropriate"for the individual's current position. Moreover, the pat-terns in which use is organized place the user at low riskfor problems.

Some explanation is necessary at this point. It shouldbe clearly understood that use by adolescents is not beingsanctioned. Instead, the intent is to categorize usagepatterns by their consequences or risk. While few wouldquestion the capacity of most adults to drink socially andrecreationally, the activity is clearly more difficult tosupport for adolescents. If drinking or drug use mayinterfere with an adolescent's acquisition and mastery ofsocial or psychological skills, then it is no longer simplysocial or recreational. Furthermore, what is seen asnonproblematic for one age group may certainly be foranother. An 18- or 19 -year -ofd's weekend drinkingcannot be considered in the same light as that of a14-year-old. The problems are as much in the percep-tions of the behavior by others as in the behavior itself.As such, it is essential that use by an adolescent is viewedin this larger context.

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Adolescent Alcoholism

Harmfully Involved/Committed Users

IThe next user category is the harmfullyinvolved/committed user; this type ofuser has impairment in major life areas.

A heavy line separates the first two categories of themodel from the latter two. While experimental andsocial use are defined as "normal," the latter two are seenas pathological. Expe.....iental and social/recreationaluse presents only a small risk for problems. This is netto imply that such use will not cause difficulties; butshould they occur, users quickly alter usage patterns oravoid them entirely.

Two illustrations will help make the "normal" vs."pathological" distinction clear. First, let us consideradults. Many adults drink alcohol, and it gives most nodifficulty. Also, most adults drive automobiles. How-ever, should adults ever put the two together (that is,drink alcohol and drive), they arc at risk for a DWI(Driving While Intoxicated) citation, or worse, a seriousautomobile crash. Either tends to be a very unpleasant,embarrassing, and ultimately expensive experience. Formost people to whom it happens, the attendant difficul-ties arc enough to convince t:iem not to do it again.Because of the severe consequences and their recognitionof their own vulnerability, they arc unlikely to placethemselves in jeopardy again.

A similar scenario can be offered for an adolescentwho sustains a disciplinary proceeding at school becauseof a violation of school rules pertaining to alcohol ordrug use. The fact of the discovery and the impact of thesanctions imposed, coupled with the understanding thathe did get caught, are enough to engender a behavioralchange. Experimenters and social and recreational usersare not willing to continually jeopardize importantactivities. Others, however, do not alter their problem-atic behaviors because they arc either committed to alifestyle for which this substanceuse is necessary, or, theyarc harmfully involved, meaning they do not have theability, without external assistance, to effect anypermanent change in their use, even if they want to.

Those placed in the Committed/Harmfully Involvedcategory arc likely experiencing impairments in some oftheir major life areas, such as

family,;chool (or employment),social relationships,self-concept and self-esteem,

psychological functioning, and/orhealth.

Problems consistently will appear first in the familyrealm and then surface at school or with the law. It isbehavioral problems that are usually noticed. The mostfrequent will be extreme mood swings, combativeness,isolation, apathy, and radical changes in appearance andpeer group associations. Because adolescence representssuch a period of change and turmoil, it is unlikely thatsuch changes will be initially attributed to eitherdrinking or drug use. The recognition of the relationshipbetween behavioral problems and the use often comesonly with intervention.

Persons in this third category arc still integrated intothe major societal institutions. While they are alienatedand the family is operating under considerable stress,"normal" function is still possible. School or job per-formance is impaired, but the abusers remain involved inthese activities and continue to claim their importancewhile disclaiming their satisfaction with them.

Without intervention, persons who arc harmfully in-volved arc likely to sec their substance use as entirelyunder control, as causing no real problems, and any diffi-culties that they may be experiencing arc caused by others

teachers, parents, meddlesome friends committedto persecuting them.

Dysfunctional Abusers

The final stage is the dysfunctionalabuser; life has been disastrouslyaffected by alcohol use. Unfortunately,this may result from a rapid progressionin adolescence.

Those in the final or "dysfunctional abusers"categorypresent as individuals with substance-abuse-causedproblems so overwhelming that thesupports provided byfamily and occupation or school have been removed. Thefamily has disintegrated or has disinherited them, theyhave been expelled from school; they cannot hold asteady job. Each area of life has been disastrouslyaffected by substance abuse. They have, in effect,expended all of their social and material resources.

A Summary of the TypologyThe Progression Hypothesis presents a comprehensive

way to view alcoho: and drug use with a population.

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Recognition and Diagnosis

While virtually everyone begins as a "nonuser," many, ifnot most, will at leasr experiment with alcohisl, andmany others will experiment with additional psycho-active drugs. Fortunately, most remain at the experi-mental and social/recreational level, and only a few, forreasons not clearly understood, will become harmfullyinvolved or worse.

The Progression Hypothc.is is especially useful to thephysician because it encourages a consideration of theramificative.s ter consequences of use on function. Untilfunctional impairment (that is, repeated disruption ofone or several of the eight major life areas) has beendocumented, then the issues surrounding use patterns canbe seen primarily in terms of vulnerability or risk. In thiscase, intervention is more difficult than when harmfulinvolvement can be established.

Behavioral Attributes

IThe first two categories of users arecharacterized by alcohol use which ispeer-initiated, imitative, recreationalbehavior.

For purposes of assessment, additional distinctionsbetween the "normal" and "pathological" should bemade. The second column in Figure 3-1 portrays thebehavioral attributes of those in the experimental andsocial/re( eational groups; they are designated as"Users." Those in the harmfully involved and dysfunc-tional categories are described as "Seekers." "Users"report that alcohol does something to them. They reportenjoying the taste, the conviviality surrounding con-sumption, and the alter& perceptions that are beingexperienced. Use constitutes imitative behavior be-havit . that is peer-initiated and peer - sustained. It isrecreational, and it occurs in such a way that neitherdevelopmental tasks nor role cupectations arc consistent-ly impaired.

7-4 The z'wo categories ("seekers') aref:aracterized by alcohol use which is'-initiated, adaptive, and a self-Wading behavib.-,

"Seekers" report that alcohol does something forthem. The effects provide them with something that they

12

pecceive as lacking. For example, problem drinkersreport that, when they drink, they feel more powerful,more in control of themselves and their environment,more poteut, and more attractive. Alcohol and othersubstance abuse is the "Seeker's" way of adaptingin an environment that is perceived as unpleasant orhostile. It is a direct way to avoid the painful tasks ofmaturation such as learning how to cope with feelings ofrejection, uncertainty, and insecurity.

Because the effects are so predictable, the abuse isself-reinforcing, and the behavior is self-sustained.Without a:cohol, the harmfully involved adolescentperceives little consistency in how he will be mated bypeers, family, and others; little control or satisfaction isexpected. Alcohol, Ivawever, consistently offers thedesired effect.

The who are harmfully involved have learned thatthey edit chemically cope with the painful feelings ofdepression, anxiety, and stress. They arc, in effect,medicating themselves.

Psychological 2: :d PsychosocialAttributes of User Groups

!Psychological attributes ofexperimenters and social users includeself-reliance, self-confidence, goalorientation, and role satisfaction.

The third column in Figure 3-1 portrays the significantdifferences in the psychological characteristics of thosewho are harmfully involved and those who are not. Thedebate about whether substance abuse is the "cause" orthe "result" of these dysfunctional conditions is non-productive. From a patient management perspective, allnonmedical use must be terminated before any effectivetreatment can be initiated.

For those who are not harmfully invcinied, standardpsychometric instruments provide nonremarkable re-sults. Perhaps one of the most sensitive indicators is the"orientation to present or future roles." The perceptionthat you will likely have is that young people who aree :ntially sa4sfied with where the/ seem to be going arcthe least probi,matic.

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6 Adolescent Alcoholism

!Psychological features of the last twocategories include alienation, rolefrustration, anxiety, depression, poorreality testing, and risk-taking activity.

Conversely, thc,e who are harmfully involved showlittle direction or satisfaction. The picture they presentemphasizes alienation, depression, and anxiety. Look foracting-out behavior such as combativeness inyoung men and sexual difficulties most likely promis-cuity in girls. Change and lack of definition arehandled poorly since stress and environmental tensionare not tolerated well. Because they have created anelaborate psychological defensive system to protect theirusage, it is unlikely that they will be able to understandthe concern that others are exhibiting about their situ-ations. This concern will typically be seen in negativeterms.

Assessment and Therapeutic Assignment

!Assessment of where in the progressionthe teenager is allows better formulationof a treatment plan. The final twocategories of users need formaltreatment.

The physician's task is two-fold here: (1) determiningwhere in the progression the patient currently is, and(2) recommending the most appropriate service.

The task confronting the physician in assessing thesubstance-abusing patient is to determine where thepatient is in the progression. Having doneso, it becomespossible to determine an appropriate level of service. Forthose adolescents who are not committed/harmfullyinvolved, yet still demonstrating some vulnerability,prevention activities and education are appropriate. Forthose who are committed/harmfully involved and thedysfunctional users, formal treatment is necessary. Fac-tors relevant to determining the choice of treat.nentmodality such as residential versus outpatient treat-ment would include the findings of medical assess-ments, motivation toward treatment, drinking patterns,and availabilir of resources. Treatment alternatives andmodalities for alcohol abusers are discussed at length in asubsequent unit of study of this series.

The Family and Chemical Dependency:Its Impact Upon the Diagnostic Process

IntroductionIf chemical dependency mimics and compounds dys-

functional signs and symptoms found within the indi-vidual, the mimicry and confusion are even greater whenapplied to a family system. If one member of the familyis chemically dependent, the entire family will beaffected.

The purpose of this discussion is not to present anexhaustive description of the family confronted bydependency or abuse by one of its members; instead, it isto help sensitize the physician to the signs and symptomsindicative of these conditions as they manifest themselvesin the family system. In a real sense, it is assumed that thedegree of familial dysfunction is likely related to theextent and severity of the problems of its individualmembers.

Seen in systems terms, the family is an entity whichattempts to maintain its equilibrium or balance. As such,it alters its configuration in response to behavioralchanges by its members. We must remember that theperiod of adolescence is one of the most difficult andstressful for both the young person and the family. Themajor developmental tasks involving the constructionand testing of a s,:parate identity along with the need todisengage from the family are well underway. At best,adolescent behavior will be inconsistent; more realis-tically, inconsistent and periodically problematic. Thephysician making any kind of behavioral assess.nentmust move beyond reports of discrete incidents andsearch for emerging patterns which may indicate alcohol-ism or drug abuse.

Experimentation: Initial Concernin the Family

IThe physician can serve as a resourcefor the teenager and family in theexperimentation stage while always

g being watchful for "something wrong."

In the family confronted for the first time with drug oralcohol experimentation by a teenager, there is uncer-tainty about the meaning of the behavior. Generally,parents are more concerned about experimentation withdrugs other than alcohol simply because they have had

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WNW

Recognition and Diagnosis 7

less direct experience with them. Moreover, social normssurrounding experimentation with alcohol are betterknown, and parents may look back to their own experi-ences to define the incident.

It also is important to maintain some perspectiveabout age and development. What is at :eptable for a19-year-old may not be acceptable for a 1S-year-old.While experimentation may occur at any age, very earlyexperimentation may be indicative of a problem. If yousense that something is not quite right when consideredin light of your understanding of the adolescent and thefamily, you should accept the perception as a vitalcomponent in your assessment process.

If you feel that the adolescent's 'se is actually at theexperimental or social/recreational level, you can serveas an information resource for your patient and thefamily. Take care not to become enmeshed in familystrife about freedom, choice of friends, etc., because ifyou seem to be taking sides, your credibility as a source ofinformation and assistance will be compromised. We donot mean to imply that the physician should never take astand; such would be irresponsible. Be aware that in theirattempt to resolve conflict and strife, family memberswill look to persons outside of the system to validatetheir opinions and wishes. However, offering pronounce-ments a" vhat is acceptable behavior for a teenager inthe contc of, that family is not likely to be productivefor the physician in the long run. Be definitive about thepresence of stress and tension, then focus on issues such asvulnerability and that behavior can have real conse-ouences. It is through education and counseling servicesthat families will reach an understanding of acceptablebehavior.

Committed /Harmful Involvement:The Family Responds

IWith harmful involvement, youth mayhave inner emotions disguised by outersigns of charm, hostility, or helpless-ness. The family often has poorcommunication and hides the problem.

If the abuser is harmfully involved with drugs, he iseither unwilling or unable to recognize the extent ofinvolvement and likewise to appreciate the severity of theproblems being experienced. Therefore it is unlikely that

he willwill attempt to effect a consistent change in eitherpersotoi behavior or in treatment of other familymembers. In these states, there is a discontinuity betweenaffect and observable output-behavior. Some writershave characterized this as a "two-layered ring" (Figure3-2). In this conceptualization, the inner feelings arethose of anger, guilt; shame, fear, and a very low self-image or self- esteem. Conversely, the externally observ-able behaviors vary between anger, hostility, aggressive-ness, charm, intimidation, helplessness, and grandiosity.

To appreciate the dynamics of substance abusers'behaviors, one must understand that chemically de-pendent persons need to protect their abilities to con-tinue drinking or using drugs. In the case of harmfulinvolvement, it is the relationship with mood-alteringdrugs that has become the most important aspect in theirlives. The perceived positive relationship is reinforcedeach time they experience the anticipated effects of thedrug(s) since they are more predictable and viewed asmore consistently pleasurable than the interaction withfamily members and others.

Figure 3-2. Discontinuity BetweenAffect and Behavior

GRANDIOSITY

OVERTBEHAVIORS

I

ANGER e(-->

HELPLESSNESS

E---> INTIMIDATION

EMOTIONS

FearShameGuilty

UncertaintyPoor SelfImagePoor SelfEsteem

HOSTILITY

1AGGRESSION

CHARM

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8 Adolescent Alcoholism

Thus, in the family system in which an adolescentmember is chemically dependent, one typically will findthe following:

Poor CommunicationInteraction in the family isonly at the most superficial levels. It is characterizedby an unwillingness or inability to meaningfullyconfront and resolve any family-related issues(View/Discuss Video VIIa).

IntimidationRecognition or acknowledgement ofdrug or alcohol involvement evokes a response by theteenager of overt hostility and anger. The behavioralresponse is so immediate and so full of much threatthat it discourages family members from approach-ing any subject regardless of how tangentialrelated to use.

Purposeful Hiding and ObscurationAny directmention of use or signs suggesting it are carefullyobscured by elaborate schemes. Passivity and non-communication provide complementary vehicles forthe adolescent in his desire to control interventionsby family members.

While these behavioral characteristics are describedseparately, experientially they are inseparable. Withoutconsciously trying, families in which a member is harm-fully involved engage, in what is typically referred to as"a conspiracy of silence." Through it they avoid the riskof disrupting the family system's equilibrium. Thismechanism is responsible for the "denial-of-problem"by family members when intervention is first attemptedby others external to the system (View/Discuss Video I).The harmfully involved individual also has defensemechanisms, just as does the family; these are discussedin Unit of Study 4, Intervention with the DependentAdolescent, along with management suggestions forsome of these specific familial issues.

The family equilibrium is sustained by the behaviorand interactional patterns presented here. The familysystem is now functioning at a level structured toaccommodate the behavioral changes which have oc-curred in its impaired member. The equilibrium dis-courages changes by family members who fear evengreater disruption and uncertainty in their lives. Besidesthe usual reticence that many people have in revealingwhat they feel to be shameful or unpleasant information,the fear of even greater changes occurring in their livesnow encourages these family members to withholdinformation from the physician (View/Discuss VideoIX).

The Physician as Diagnostician

Introduction

The physician's role in the diagnosticprocess is described and outlined earlyto the involved family, as well as whatrole will be played when treatment isbegun.

The physician usually becomes aware of substanceabuse problems in one of the family's members whensome disruption occurs within a major life area. In thecase of the adolescent member, these problems canpresent as brushes with the law, behavioral or academicproblems in school, automobile accidents, the discoveryof drugs, drunken incidents at home, an overdose, orradical changes in behavior. Often, another familymember brings the matter to the physician's attention, orthe physician may first be presented with the patient,such as in an overdose situation. The task of thephysician is to evaluate the extent and severity of theadolescent's use and problems by obtaining data fromfamily members, the patient, and other available sources.These data will help with the assessment of the problem.

Initial sections below will consider the diagnosticprocess as it relates to individuals and families. Finalsections will describe the assessment process itself. Inobtaining information, the physician instantly runs intothe confidentiality issue. While this is discussed more inUnit of Study 4, Intervention with the DependentAdolescent, the physician should advise all concernedthat information is confidential, unless the physicianfears harm to the teenager or others.

Many physicians are reluctant to pursue the diagnosisof alcoholism because of their inabilities to providetreatment of the diagnosed condition. They recognize thedifficulties involved iu providing direct substance abusetreatment, the need for special resources (such as therapygroups), and their own time constraints. It is essentialthat the physician define for himself or herself and thefamily the goals for the diagnostic and assessmentprocess. Unless the physician is prepared to actuallyprovide treatment, then it needs to be very clear with thefamily and the adolescent that assessment is being doneto (1) identify or diagnose a problem, its extent, and itsseverity; and (2) make a recommendation for the servicethat will be provided elsewhere. It is necessary that thefamily be assured that there will not be simply a "hand-

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Recognition and Diagnosis

off" to some nameless program or agency. Instead, thephysician will maintain involvement with the family'shealth care and will take a special interest in monitoringtEe progress of the adolescent patient and the family asthey receive the recommended service. For the family, thephysician can reinforce professional interest by stating inadvance that alcohol and drug abuse are medicalproblems about which there is much to be concerned.The actual treatment and referral process is fullydiscussed in Unit of Study 5, The Physician's Role inReferral and Treatment.

Obtaining a History: Patientand Family System

IThe physician obtains data individuallyfrom as many pertinent family membersas possible and from the patient. Agroup meeting without the teenager maybe worthwhile. Beware of denial!

After establishing the goals and objectives of thediagnostic process, the physician should describe to theperson who has brought attention to the matter what isto happen next. This will involve interviewing each ofthe family members individually, including the identifiedpatient. The physician should schedule sufficient timewith each person involved to assure enough time toobtain the necessary data. If appropriate, the physicianmay conclude by speaking to the parent(s) regardingassessment of the problem (View/Discuss Video VIIb).Should intervention be the recommendation, the processis fully described in Unit of Study 4, Intervention withthe Dependent Adolescent (View/Discuss Video VITO.

In the evaluation of the identified patient, there maybe between one and four "parents" involved. This refersto the situation of the "blended family" in which thenatural parents have divorced and married others, withthe adolescent having contact with both families. Often,valid data can be obtained from all involved parties.Siblings, natural or adopted, can provide invaluabledata, and attempts should be made to solicit their input.A group meeting of family members, teacher, and a bestfriend may be quite helpful (View/Discuss Video V).While it would be idLal to hope to interview all con-cerned parties, as in any clinical situation, we ultimatelyhave to use what is available. This may mean that theonly data available will be from the identified patientand a single parent.

The Chemical Dependency Assessment:Methodology and Technology

'Other sources of information includeschool records and information frontprior counselors or even the legalsystem.

The goals and objectives of the substance abuseassessment are in actuality not dissimilar from that ofany medical or health-oriented assessment. The inter-viewer needs to be able to

1. facilitate the patient's telling his own story,2. collect sufficient data to make a valid and reliable

assessment,3. organize the data in some sort of coherent fashion,4. draw appropriate conclusions from the data, and5. formulate and present a plan of action to the

patient and family.

As in other therapeutic interviews, if the process iseffective, the patient will achieve greater insight intocurrent conditions and himself.

In the area of substance abuse, however, the patient(and perhaps the family as well) often has a stake inobscuring from the physician, or anyone else likely toimpact upon the current situation, as much data as hepossibly can. Therefore, from the time the initial contactis made requesting that the physician assess an adolescentpatient's current drinking and/or drug situation, it isnecessary to begin the data collection process by request-ing sources of data not usually sought.

Typically, the request for an assessment of an adoles-cent occurs after a crisis has occurred the adolescentpresents at school intoxicated, drugs or alcohol are foundin his possession in school, there has been an encounterwith the police, or some crisis occurred in the home.Upon this initial contact, the physician should requestinformation and documentation relevant to the adoles-cent's current situation. This would include, but not belimited to,

reports obtainable from the teenager's school,statements and records from any therapists orcounselors that the adolescent has consultedwith in the last 18 to 24 months, andany contact with juvenile justice authorities,such as information available through probationofficers.

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10 Adolescent Alcoholism

We would counsel that the physician request theparents or guardians of the adolescent to obtain theinformation (and reports) from the sources listed above.The welter of privacy and confidentiality legislationmakes it extremely difficult for a third party evenwith seemingly appropriate releases to obtain infor-mation about another. The physician who attempts towade through these systems may become stymied; havethe parent or guardian directly request these materialsand have them conveyed to you before the actualassessment.

While the information provided by these sources willnot substitute for a comprehensive personal history, theycan be useful in corroborating the .eports offered by theadolescent and his family. These data, if available,provide a valuable point of triangulation for anypersonal history data offered. Contradictions betweensuch external records and self or family reports provide avaluable data source in making an assessment.

Another adjunct to the assessment process can be theuse of drugs/toxicological urine screens. Regardless ofthe findings of the screen, which if positive for any agentsshould be included in the database, there may be somepsychological advantage obtained by it. At the very least,the use of such a procedure is reflective of the "scientific"aspects of health care; laboratory testing fits with thepatient's perception of the methods of diagnosis. Morespecifically, since the adolescent patient seldom knowswhat urine testing can effectively reveal, having provideda sample and then having the results of it known to thephysician places the physician at some psychologicaladvantage in obtaining a drug history. Knowing that thephysician has "scientifically produced" data available,the teenager may be more willing to be open about hisusage pattern.

Because an adequate assessment cannot be done in justa few minutes, the physician should schedule interviewswith the adolescent for blocks of at least 45 minutesduration for the assessment. It is useful at this initialcontact for the physician to explain that the assessmentmay take more than one interview; these should bescheduled at that time. If the assessment is completedduring the first block, then other time blocks -- sched-uled several days later can be freed for other work.

To review, the assessment begins with an interviewwith the adolescent and all of the family members (andrelevant others accompanying him). This introductorysession, generally lasting five to ten minutes, outlines thephysician's goals and objectives for the assessment and

the expectations of the family and adolescent. Then,beginning with the adolescent, each member of thefamily is interviewed separately.

Interview TechnologyIt is important to emphasize again that the chemical

dependency assessment intsaview is not dissimilar to anyother health or medical interview. The physician needs tofacilitate the patient's (and family's) telling of the story,to help focus them on the process so that relevant data areprovided, and to terminate the process when sufficientdata have been obtained. Perhaps even more so in thissituation than in others, the physician needs to create anatmosphere which encourages rapport and disclosure. Heor she needs to be exquisitely aware of the negativevariables that impinge on this atmosphere and makeevery effort to overcome them. Factors which encouragethe patient's perception of the physician's empathy andacceptance, as well as the perception of privacy (bothpsychologic and actual) need to be encouraged.

The Adolescent: Opening the Interview

Your teenage patient will likely behostile; allow the patient to present hisown history, using open-endedquestions.

Typically, the adolescent presents in a hostile ordefensive posture. He is present at the assessment becauseof a crisis involving drinking or drug use or the suspicionthereof (View/Discuss Video X). He is angry with hisparents and other authority figures in his life, and readilyidentifies the physician as aligned with them. Seldom,however, will he verbalize these feelings. Any attemptsby the physician to mollify these feelings generally areunsuccessful. Also, the time constraints imposed by theassessment itself mitigate against any kind of construc-tive confrontation with the adolescent's feelings. In-stead, it is more productive to acknowledge the patient'sfeelings, and affirm his right to own them. Using such aposture, it is possible to "agree-to-disagree" about howthe world works and still proceed with the task at hand.

Immediately inquiring about drug usage or drinking isnonproductive. It readily confirms the adolescent'spreconception about the nature of the assessment and canmake him even more defensive. However, by againacknowledging that the visit has been provoked by a

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Recognition and Diagnosis 11

crisis or at least a disruption in the teenager's lifeand that the situation involved has at least two sides, andso far all that has been heard is the one offered by parentsor some other authority figure, it makes it possible toinvite him to tell his side of the story and to describe fromhis own perspective the events that led up to the crisis(View/Discuss Video III). This provides the youngperson with the opportunity to begin telling his ownstory.

The description of the specific event lends itself readilyto lines of inquiry allowing the teenager to describe howhis family has reacted to the incident, and the reaction ofothers including peers around him to what hashappened.

Early in the interview process, make it clear that youare interested only in him and that if you ask questionsabout friends, it is for clarification and that you do notwant identifying information such as last name and thelike. Open-ended questions are much, much moreproductive than closed-ended questions. At each point,ask for clarification and specification., and, most im-portantly, request behavioral examples.

Data need to describe changes that have occurred inthe adolescent's life that may relate to his drinking ordrug usage. Since this is such a rapid period of change indevelopment, intervals of three to six months areappropriate milestone marks. Again, it is essential thatbehavioral examples are obtainc.. This is where theperspective on the young person's situation will beobtained.

To provide the understanding of thepatient's relationship with alcohol, havethe teenager discuss his changing usepatterns during initial experimentation:when use occurred, who was present,how he felt, and what it did for him.

As you begin taking the drinking and drug history donot separate it from other aspects of the adolescent's life.For example, ask him to describe his initial experimenta-tion with alcohol: when it occurred, who was there, howhe felt about it, and what it did for him. Proceed toqueries about more recent events and any changes inconsumption patterns or tolerance. Ask for his feelingsabout drinking, how he feels when he drinks, and whathe thinks his drinking seems to do for him. These data

i$

will provide a picture of the adolescent's relationshipwith alcohol (and other drugs).

For example., some health professionals find it com-fortable to lead into the questions after inquiring aboutthe smoking history. A typical dialogue may be:

Physician: "Do you smoke cigarettes or other to-bacco?'

Patient: "I guess you could say I do."

Physician: "How many packs a day?"

Patient: "Somewhere around two."

Physician: "Do you use snuff or other smokelesstobacco?"

Patient: "Only when I play softball, then I grab acan of snuff."

Physician: "How do you use alcohol?" (Notice thedifference in asking this question as op-posed to, "How much do you drin(c?")

Patient: "I never touch the stuff!"or

"I don't drink."Or

"I quit six months ago."Or

"A couple of beers a night."Or

"As much as I can afford."

A helpful question to ask yourself is, "Does drinkinginterfere recurringly with any aspect of this person'slife?" If the cumulative answer is yes, the physician hassome evidence that this teenager is at least harmfullyinvolved with alcohol.

It is also important to determine the scurce of theyoung person's alcohol or drugs, not to report it to theauthorities, but rather to determine his usage pattern.For example, the teenager who can buy his own mari-juana is further advanced in his usage pattern than theyoung person who only smokes it when provided by afriend.

IBe sure to ask the teenager about hisfamily's substance use.

It is vital to ask the youngster to describe hisperceptions of parental and other family members'drinking (and/or drug use). Encourage him to compare

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12 Adolescent Alcoholism

and contrast his own use to that of the family's. Here toodo not forget to get behavioral examples outlining hisdescriptions.

Family Members: Technology of the AssessmentInterview

IFamily members should be asked aboutspecific incidents and the impact ofthese incidents upon the family. Identifychanges in behavior that have recentlyoccurred.

Structurally, the assessment interview for familymembers is not dissimilar to that of the identifiedpatient's. It begins with inquiry at the most general leveland gradually narrows to obtaining (more) specific data,finally focusing on those areas necessary to inform thediagnostic process.

For family members, begin by asking them to onceagain recount their impressions of the specific incident(or incidents) which motivated the assessment. Afterthey provide their understanding of "the facts" of theincident, they should relate their impressions of theteenager's school and social or peer situation.

Each respondent should be asked to describe theimpact of the incident(s) or perceived problems whichthe teenager has experienced on the family's functioning.These accounts can provide a rich source of data aboutthe adolescent's role in the family, the family's level offunctioning, and the kinds of support that the family canmobilize to resolve the crisis.

Having dealt with the specific incident(s) and using achronologically structured approach, data are elicitedabout the teenager for the preceding 12 to 24 months,focusing on perceived changes in school performance,leisure activities, interests, peer associations, behaviorwithin the family, and any other areas that the familydeems important. Encourage the parent(s) to providedatawith as many behavioral examples as possibleon general behavior and do not restrict the report to onlythose areas that are concluded to be problematic ordrug-related.

IDo not hesitate to obtain data aboutdrug and alcohol use by allpersons.

Data about the parent's own drinking and drug use

should be obtained. This line of questioning is initiatedwhen you believe that rapport is greatest; the inquiryshould be grounded within larger behavioral patterns,such as dietary habits, sociability, recreation, and thelike.

The evaluation should include drinking and drug usedata on each family member. Do not be satisfied withcursory labels such as "social drinker" or "a few beers."Instead, ask specifically about drinking patterns and,most importantly, the ramifications of drinking :n themajor life areas. These are sensitive areas, so questionsmust be posed in neutral, nonjudgemental ways.

In the assessment of familial risk factors, inquireabout the presence or history of alcoholor drug problemsin the identified patient's blood relatives within the threegenerations of the nuclear family. If any "problem" isindicated, then ask the family member to describe it ingreater detail.

From the perspective of their current situation, somefamily members will not wish to "rock the boat." Whilethey are not happy with what may be occurring withinthe family, the prospect of additional turmoil or changeis greeted with much anxiety. Obtaining information toprovide a valid assessment in a brief period of time willchallenge the physician. The challenge, however, is wellworth it (View/Discuss Video IX).

Data collection necessarily begins at the first momentof contact wit'l the patient and the family. The physicianshould carefully note how members of the family relateto each other. Subtle information from family memberswill suggest much about the family's pattern of com-munication. Easier, more open communication amongfamily members suggests that the family is functioningata fairly healthy level. An example of a family notfunctioning at a healthy level is one in which thephysician astutely may recognize that a woman's recentbout of back pain is secondary to problems with herteenage son. Knowledgeable physicians are attuned tothe health problems of other members of the family.Stress has been correlated with the onset of organicillness.

The physician needs to facilitate the patient's tellingthe entire story. Use of open-ended questions to ac-complish this is demonstrated in several of the videoscenarios. However, it is unlikely that the patient will beable to or willing to provide all of the necessary datahimself. Conversely, information about what is occur-ring in the family as reported by the parent(s) may also behighly selective and biased. Therefore, the physician

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Recognition and Diagnosis 13

needs to obtain the rerspective of as many of the variousindividuals as possible to complete the assessment. Thisincludes a behavioral inventory being obtained to deter-mine the degree of drug involvement. Remember in theprocess that the history of progressive changes usuallyprovides a better guide to appropriate therapy than theactual drug-use history.3 Each member should describenot only his or her impression of the identified patient'scurrent situation, but also his or her role .n thefunctioning of the family. Discrepancies become indi-cators of problematic areas within family functioningand are vital data in making the assessment.

The model recommended to obtain diagnostic infor-mation from teenagers reflects the problem-orientedframework. This model may be used for a patientbrought to your attention as having an alcohol abuseproblem or in screening for abuse in the routine officecare of our youth. This will include critical aspects in themedical history, physical examination, assessment, andcare plan (SOAP system: subjective data, objective data,assessment, plan).

Medical History

!Routine family history should includepresence or absence of alcoholism.There is very strong evidence for thegenetic component of this illness.

Prior to obtaining the drug-taking history, as outlinedlater, the physician should be tailoring questions in theroutine medical history to include alcohol-related issues.Specific examples include:

1. In the family history, add alcoholism when askingstandard questions, such as "Are there any diseasestl-,t run in your family such as diabetes, cancer,alcoholism, or heart disease?" This is quite rea-sonable knowing that alcohol can be a familialproblem and knowing how great a risk teenagersreally are for substance abuse. Familial aspects ofalcoholism were discussed at length in the first twounits of study of this series, but a brief review ofthe importance of genetic factors is worthwhile.

Numerous studies, including twin studies, havedemonstrated the strong genetic predisposition ofsome individuals toward the disease of alco-holism.' One of the most convincing effortsconducted by Goodwin et al. showed a fourfoldgreater concordance between adoptees and their

20

biological parents versus their adopted parents!5An impressive 1985 review on genetic factors byMarc Schuckit, M.D., is strongly recommendedfor review.' His report includes a summary ofstudies of those individuals that physicians shouldsingle out for special attention, such as the youngmales with a close alcoholic family member. Thephysician uncovers this special risk by a goodfamily history. Schuckit notes that this groupappears to have less intense responses to modestdoses of alcohol; the resulting theory suggests thatthe high-risk individual is less able to judge whenhe is getting closer to being intoxicated and is lesslikely to stop before actual intoxication occurs.

2. In a review of systems or past medical history, youmight specifically ask (if not already part of yourroutine) ques is about hepatitis, -vithdrawalexperiences, and depression. Specific indicators ofpossible alcohol abuse include recurrent trauma,recurrent severe colds, and mood disorders.

3. It is quite important in reviewing medicationswith your young patients to determine if there ismedicine misuse, intentional or not. Also, poten-tial interactions with alcohol and common drugslike antihistamines, analgesics (i.e., propoxy-phene), or certain anticonvulsants should be keptin mind.

4. The physician should never forget that tobacco isalso an addictive drug. Ask about smokingcigarettes. Do something if smoking occurs.Smokeless tobacco use is now epidemic, andspecific inquiry about its use is warranted.

Clinical situations such as overdose orautomobile accidents are "red flags" forthe physician. Presence of the major riskfactorsheredity, stress, poor supportsystems, and availability of alcoholshould signal the physician to pursue thediagnosis.

Certain other illnesses in the medical history will be"red flags" that should force you to explore a drughistory later on. Some examples may include an overdosesituation, a hospitalization for trauma resulting from anauto accidentespecially a single-car accidentor anew onset of a seizure disorder when the work-up wasnegative. Trauma secondary to fighting should also besuspect.

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14Adolescent Alcoholism

Of even greater importance in determining howaggressive the physician should be in pursuing thepossibility of alcohol abuse is the presence of risk factors.The four key risk factors for alcoholics are

heredity,availability of alcohol and other drugs,peer and /or support system influences, andstress, both external and developmental.4

The presence of risk factors is a strong signal to thephysician to pursue the possibility.

Of course, you should be wary of diseases or condi-tions in which any alcohol use should be avoided. Theseinclude seizure disorders, diabetes, and pregnancy. Besure to ask if the patient has ever been cautioned aboutnot drinking, given special health circumstances. Ifdrinking continues in spite of a previous warning, then bevery suspicious of a problem and pursue this line ofquestioning.

At this point in the interview, a natural step is toinquire about drug use, either past or present. Again, atfirst, tangential questions are more useful than directones. Since some teenagers are sophisticated with alcoholand since virtually all who have difficulties with alcoholuse other drugs, it is often helpful to approach the subjectby inquiring about prescription drugs, with phrases suchas: "Has a doctor ever prescribed a pain pill, sleeping pill,or tranquilizer for you?" This type of question may setthe stage for more openness by the patient. Thenquestions posed in generalities about peer activitiesrelevant to drug use become an easy way to broach thepatient's own use. Here too, be sure to approach theissues with a chronological perspective. Be :speciallysensitive to changes in the patient's usage pattern.

Drug-use history-taking can be learned with a mini-mum of practice. Objective data can and must beobtained to solidify the assessment of alcohol- or drug-abuse problems. Certain specific questions you may wishto incorporate in your history might depend upon thedefinitions you choose; these will be further discussedunder Assessment.

Phsycial Examination

IThe physical examination of adolescentswho abuse alcohol is usually normal.But it is still important, especially theneurological and the mental statusaspects.

A teenager usually does not have the -lassie signs ofalcohol abuse as observed in a patient with cirrhosis whohas a markedly enlarged liver, ascites, and j lundice.Earlier signs of alcoholism, though uncommon inteenagers, may include mild tachycardia, unexplainedscars, or borderline hypertension.' On most occasions,you will probably find an unremarkable young patient infront of you. Thus, most of our emphasis in this unit ofstudy has been on behavioral history. It is definitely notnormal to observe alcohol on someone's breath, needletracks, a tremor, or constricted pupils. Icteric scleraeobviously merit your concern; but do not forget that yourpatient may instead have infectious hepatitis. Suchfindings deserve further careful evaluation by the phy-sician. Signs of depression, such as psychomotor retar-dation or loss of interest in normal activities, should beexplored and evaluated.

Other aspects of the physical examination should bementioned. Abnormal lung fields detected on examina-tion (or a history of recurrent bronchitis) should raisesuspicion of cigarer' amoking or marijuana use.

Occasion:Illy, a teenager will be patently intoxicatedor appear to be under the influence of alcohol or drugs.This state needs little elaboration; intoxication shouldbe noted if present, and a chemical screen including ablood alcohol level should be ordered. Ataxia may implyconcomite-n: hydrocarbon abuse if it is prominent. Otheraspects of the neurological evaluation are also quiteimportant, even more so if the patient has been activelydrinking. Be careful not to blame neurological change onethanol automatically; perhaps head trauma has causedcentral nervous system bleeding. Certainly nystagmus,ophthalmoplegias, and peripheral neuropathies need tobe looked for; although finding them is uncommon, thisdoes not release the physician from the search.

A mental status examination is quite important.Unfortunately, this aspect of a physical examinationoften gets forgotten after the required psychiatry rota-tion. Has there been a change in the youth's judgement?How about remote and recent memory? Have you notedappearance, behavior, orientation, and emotional tone?Evaluation of suicide risk and thought content obses-sions, phobias, delusions, ambivalence is essential for aproper medical evaluation. Indeed, this aspect of theexamination is more likely to demonstrate abnormalitiesthan others. Consider simply the nationwide concernabout teenage suicide. To repeat a critical pointthegeneral rule for teenage alcohol abusers is that thephysical examination is unremarkable. However, do notbe fooled!

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Recognition and DiagnosisitV1111111"7...k1111110111111111MS

15

Construction of Assessment Data Base

IThe physician needs to consider ciliafrom all soul ces.

Figure 3-3 presents a schematic of the assessmentprocess. It outlines the larger categories of data to beobtained from the identified patient and then tri-angulated through with data from other sources su, h asfamily and school. These categories of data are thencombined by the physician to assess the patient's positionon the progression continuum and/or his vulnerability tocontinued or additional problems.

Factors such as the resources which the adolescent andthe family can mobilize for the resolution of these

problems, the adolescent's level of insight and maturity,and the extent of motivation to effect change need to beconsidered. These are important in the construction ofthe plan of action and referral to the specific agency/program for the recommended service.

At a minimum, the physician needs data in each of theboxes (areas) represented in the schematic. The absenceof any will seriously compromise the assessment effort.Therefore, we will discuss these in some greater detailbelow.

Central to the assessment process itself must be a focuson the ramifications or consequences cf drinking anddrug use on specific life-area functions. These include (1)family relationships, (2) social relationships, (3) psy-chological functioning, (4) self-concept or definition, (5)

Figure 3-3. Assessment Schematic

Life-Areaimpairment

DrinkingPattern

sen

DrugUPatter

ProblemAssessment

RiskFactors

PsychologicalSituation

MedicalFindings

ResourcesAvailable forMobilization

Referral forSpecific Service

Maturity,Insight

Motivation

22

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Adolescent Alcoholism

health, (6) school or occupational functioning, (7) legalinvolvement/problems, and (8) financial problems.

Alcohol or drug "abuse" is seen as use of agents in sucha way that it causes consistent problems in any of themajor life-areas. Chemical dependence as a aiagnosisshould be seriously considered when the adolescentpersists in his pattern of tr,! despite the interventions offamily, school, or social control agencies. A person is saidto be "dependent" when there is evidence to suggest thathe is either unable or unwilling to modify his drug- oralcohol-using behavior patterns in the face of unpleasantor even painful consequences. Dependency can also beattributed when the use of alcohol or drugs constitutesthe major coping mechanism. Dependency is alsodocumentable by a marked increase in tolerance to theeffects of alcohol or other drugs or the onset ofwithdrawal symptomsor distress upon cessation of theiruse.

Returning to the progression model offered in apreceding section, dependency, in an adolescent, appearsto equate reasonably well with the categories of "harm-ful involvement." These definitions are consonant withthe diagnostic categories offered in DSMIII:305.OX/303.9X. However, when dealing with teenagers, specificdrug use or drinking patterns can provide a moreuseful perspective than with adults. In the adolescent,any kind of daily use should be considered a strongindicator of harmful involvement and should raise thesuspicion of dependence. The usage pattern itself isperhaps one of the best indicators of vulnerability forsubsequent problemsthe heavier or more frequent theuse, the greater the vulnerability.

Other sigr.s and symptoms need to be seriouslyconsidered. These would include, but not be limited to:blackouts, repeated use of chemicals to cope withunpleasant or painful feelings, previous unsuccessfulattempts at control, "binges" of intoxication, andsolitary use at something other than the most experi-mental levels (View/Discuss Video X). The psycho-logical variables usually considered include depression,role frustration, anxiety, inappropriate or acting-outbehavior, or any other difficulties to which a patientmight respond through self-medication. It is also essen-tial to assess the suicide risk of the adolescent. If there isindication of a strong riskeither consistent ideation,prior attempts, or planningthen immediate hospitali-zation and psychiatric examination/observation need tobe recommended.

Synthesizing the Assessment Data

!After synthesizing the clinicalassessment, formulation of anappropriate plan of care follows.

In combining the data elements provided by thecategories depicted in Figure 3-3, the physician isattempting to distinguish a pattern of abuse fromdependency. This determination hinges upon (1) thelevel and extent of life-area impairment, (2) previousattempts to deal with these problems and modify usagepatterns, (3) the drinking pattern and situation, (4) thedrug use pattern and situation, and (5) the risk factors.

Figures 3-4 and 3-5 present some initial attempts atthe construction of a diagnostic matrix. In Figure 3-4, arough quantification and weighting of impairment andrisk factors have been suggested. This matrix starts at themost benign level and proceeds to the most profound.TLe scale suggested should be seen as qualitative and away of differentially combining the physician s judge-ments with the available data. The matrix suggestsdifferent levels of intervention as they relate to thevarious levels of problem assessment and vulnerability.

The' index recognizes that there is a differentialprogression or development of drug problems. Under-stand that when risk factors are to be included, noteveryone "starts at the same place" and that such amatrix formation makes it possible to encompass realis-tically diffe-ent substance-abuse career paths. For ex-ample, the young person who is currently at the"experimental level" of use, yet is "high at the risk-far- level" and whose psychological situation isproblematic, is certainly in need of intervention andtreatment. This matrix makes such a multifactorialdecision possible.

Figure 3-5 is a more descriptive (narrative) presenta-tion of the same concept. The use of such a matrix allowsthe physician to visualize the data base of the assessmentas process. Naturally, the physician confronted with apatient, the patient's family, and their unique situationwill necessarily have to provide his or her own weightingof the discrete assessment elements.

For both the identified patient and the family, use theoutline provided by the assessment schematic. It readilyprovides a summary of the areascomparable to areview of systems in a medical assessmentnecessary toa valid and reliable assessment. Other information

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Recognition and Diagnosis 17

Figure 3-4. Assessment Dimensions

Usage Life-Area Risk Factors Psychological Situation

1+ 1+ 1+ 1+2+ 1+ 2-3 22 2 4-5 23-4 3 2-3 3-43-4 4-5 4-5 3-4S S S S

One to Five Rating Scale:OneSuggests little or no difficultyFiveSuggests the greatest level of importance, difficulty, or risk.

Use

The values arc summed horizontally. This would suggest the following treatment/intervention matrix:

Intervention

Education and supportare appropriate

Numerical Summation

4-8

9-13

Problem

AssessmentLifestyleConcerns

Moderate problem

14 or more Severe problem or greatvulnerability

Formal treatment program isappropriate

Residential treatment is appropriate

subjective, objective, archivalare triangulated witheach other and the central data source. Possible contra-dictions and discordances are noted and should beseen asmarkers calling for additional exploration.

Assessment

Be cautious in actually charting thediagnosis of alcoholism. Ascertain theprimary problems and secondary ones.Your diagnosis may depend on yourdefinition.

When putting together your medical assessment of theproblem(s) at hand for your teenage patients, you mustkeep in mind the possibility of substance abuse as anunderlying cause. This problem should not always be adiagnosis of exclusion. However, you must also be waryof routinely including substance abuse as a possiblemajor factor in a patient's medical chart since yourrecords may be referenced at some point for purposessuch as life insurance or a job. One cannot overestimatethe need for the great care with which your thoughts arc

placed into someone's medical chart in the phase ofcarewhen diagnoses are uncertain. A reasonable example ofcareful charting of a medical assessment in the problem-oriented medical record can be as follows: "Based uponthe history and the physical examination which demon-strated thyromegaly, John's tremors seem most likelyrelated to hyperthyroidism. But should his thyroidstudies prove to be normal, other alternative diagnosesmight include severe anxiety, a metabolic disorder,substance abuse, or withdrawal." It is not fair to yourpatient to make a brief, hurried note that can come backto haunt him, such as: "Tremor, new onset. R/o drugabuse, R/o hyperthyrodism, R/o anxiety." In any case,be sure to include behavioral examples or even quotesfrom patient and family. Thc,e will not only be the mostuseful in your ongoing management of the case, but willalso be the most defensible should your opinion bechallenged.

The physician must be careful as to the primarydiagnosis. In some cases, imreased alcohol intake may bea symptom of an underlying depression. The latterproblem responds to different treatment plans, withpharmacotherapy probably being able to make a greatercontribution in management. While experts contend

?4

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18Adolescent Alcoholism

Figure 3-5. Problem AssessmentIntervention Level Matrix

Assessment DimensionsClinical Assessment/Numerical Determination Intervention

Usage patternLife Area ImpairmentRisk FactorsPsychological Situation

ExperimentalMinimalMinimalGood

Education, Social, andPsychological Support

Usage PatternLife Area ImpairmentRiskFactorsPsychological Situation

Social/RecreationalMinimalModerateAdequate

Education, Social, andPsychological SupportCareful Monitoring of Case

Usage PatternLife Area ImpairmentRisk FactorsPsychological Situation

Usage PatternLife Area ImpairmentRisk FactorsPsychological Situation

Social/RecreationalMinimalHighProblematic

CommittedModerateModerateAdequate

Formal Outpatient Program

Formal Outpatient Program

Usage PatternLife Area ImpairmentRisk FactorsPsychological Situation

CommittedSevereHighProblematic

Inpatient/Residential

Usage PatternLife Area ImpairmentRisk FactorsPsychological Situation

DysfunctionalSevereHighProblematic

Inpatient/Residential

that the alcohol issue still needs to be addressed prior totackling other problems, your willingness to prescribemedications will be influenced by thepatient's drinkingor drug-use situation, or both problems may be equallyimportant. Either Tway, a logical plan of care dependsupon your clinical assessment of the patient's prob-lem(s), interrelated or not.

The actual assessment or presumptive medical diag-nosis as it relates to alcohol is best made in terms ofwhere the patient fits onto the progression scale of thedisease process, keeping in mind that there is more thanone path of this progression. Actually diagnosing alco-holism requires that the individual be at least at theharmfully involved phase of the scale. In making yourdiagnosis, it may be useful to review several definitionsrelating to alcohol abuse. You can choose which works

best for you and your patients.

1. World Health Jrganization: Alcoholism is achronic behavioral disorder manifested by re-peated drinking of alcoholic beverages in excess ofdietary and social uses of the community and to anextent that it interferes with the drinker's health,social, or economic function.°

2. Psychiatric profession: One of the "substance usedisorders", diagnostic criteria for alcohol abuseinclude a pattern of pathological abuse, impair-ment of social or job functioning due to alcoholuse, and duration of disturbance for at least onemonth; alcohol dependence implies either a pat-tern of abuse or impairment, plus tolerance orwithdrawal phenomena.

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1151,

Rec-Ignition and Diagnosis!On

19

3. The Chafetz definition: Alcoholism is a chronicbehavioral disorder that manifests itself in anundue preoccupation with alcohol, in its use to thedetriment of physical and mental health, in a lossof self-control, and in a self-destructive attituded ng with personal relationships and litesialations.8

It is very important to remember t:.,at these definitionsare offcrcd for adults. However, they still May somekinds of functional of behavioral impairments thatyou will be looking for in your history-taking relative toadolescents. The exact diagnostic label it less importantthan the frank documentation of consistently occurringdifficulties.

Assessment and Compliance: The Physician'sLimits

ICompliance with proposed treatmentdepends on available resources. Formalintervention may be necessary for manyadolescent patients.

In additon to documenting the presence of problems,their etiology, and an appropriate treatment strategy, theassessment must explore the kinds of resources that thepatient and the family can mobilize for the resolution oftheir problems. Like other conditions, compliance orfollow-through with the recommended treatment isoften the most problematic part of the process.

Compliance is particularly problematic with sub-stance abuse services. If a family member is chemicallydependent, the family has likely reconstituted its pat-terns of interaction to accommodate, or at least notchallenge, the affected individual. The first crisis maysimply not have the power to shake these patterns andmove the troubled member and family into treatment. Astrategy for a more effective intervention !s presented inthc next unit of study, Interve: t:on with the DependentAdolescent. The abuser tends to stubbutnly cling to thebelief that use is really nonproblematic and that thedifficulties experienced relate entirely to the misguidedefforts of others. He is entirely oblivious to his increasingvulnerability. These beliefs can be particularly tenaciousamong adolescents since the role demands made uponthem are minimal. They are sincerely surprised when

they arc the ones who are in trouble.

From the parents' perspective, the only psychologicaldefense to a worsening home situation is denial. Whilethey can describe changes in their teenager's behavior,they arc usually unwilling or unable to make theconnection between drug usc and these aanges. Thcy arefrankly frustrated that all attempts at control throughreason, discipline, and perhaps even counseling have beenunsuccessful. _for change to occur, the connectionbetween use and problems needs to be recognized. Sincethe connection can only be made by the person himself,the physician's role is structured around providingperspective, information, and guidance. The patient andfamily should at least hear about the process of chemicaldependency progression, the patient's place on it, and thelikelihood that the problems which are occurring willnot resolve themselves.

Because education is a key element of treatment, thephysician should describe for the patient s...nd the familythe entire continuum of substance abuse arid attendamproblems. Using language that is nontechnical andneutral, the physician will locate the patient akng thiscontinuum, based upon the available dat a. The physicianwill frankly admit that no 1)ne has a "crystal ball"capable of predicting the future; however, given theknowledge about the progression of the condition,additional and even worse problems an be anticipated.The physician will thcn describe what he believes has tobe done or may defer recommendation for footaltreatment to an intervention meeting if he fee's that thisis appropriate. The assessment will end ffering aspecific recommendation for treatment and t's,e nem=information to the patient and family about how toobtain it, or arrangements are made for a formalintervention.

The unwillingness of the patient and the family toAccept specific findings and to follow the recommenda-tion reflects their unwillingness o* inability to accuratelysec their current situation. It may very well be that boththe troubled member and the family need to experienceeven more difficulty related to the drinking to convincethem that the conclusions that have been drawn aboutthe problems and the solutions are indeed proper ones.Therefore, even though recommendations at times arcrejected, the physician should waintain an open, accept-ing posture toward the patient and the family, with theexpectation that he or she will br successful in directingthem into treatment some time in the future.

0/.

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20 Adolescent Alcoholism

Diagnostic Test' g

Although a CBC or diver enzyme- maybe abnormal, most blood tests arenormal in teenage alcohol abusers.Blood alcohol level (BAL) may behelpful in certain specific situations.

Diagnostic testing for possible alcohol abuse mayinclude certain tests beyond the blood alcohol level(BAL). The CBC cart be a useful screening test bydemonstrating an elevated mean corpuscular volume(MCV). This may be more significant if liver enzymesare also elevated. The gamma glutamyl transferase is themost sensitive (though less specific) of the liver enzymes.Elevated SGPT (ALT) or SGOT (AST) would also besignificant. However, teenagers usually do not showthese abnormalities as frequently as do older drinkers.The physician must be cognizant of other etiologies ifliver enzymes are elevated, such as mononucleosis orhepatitis. Clearly the emergency situation demandscomplete blood and urine levels of the substances ofabuse.

A urine toxicology screen can be used in the diagnosticstudies, especially with "polypharmacy" as is often thecase with young people. Care must be used that you arecandid with your patient. Also keep in mind thatpatients are minors under the age 18, which may affectyour obtaining various tests and consent. The value ofcurrent blood tests and x-rays to evaluate organs knownto be damaged by alcohol such as the pancreas (amylase)and the brain seem to be of unproven value in the earlierstages of alcohol abuse unless there is a specific indica-tion. Although most substances are cleared from theyouthful body in short order, the urine toxicology screenmay well demonstrate cannabinoids seven to ten daysafter abuse has stopped and is Lhus a reasonable officescreen.3

The blood alcohol level can be tested and immediatelyread in the office or the emergency department using apocket-sized device such as the Alco-Sensor II.' If theBAL is more tf in 100 mg% (0.1 gram) without grossevidence of intoxication (such as slurred speech, anataxic gait, or over-relaxation of facial musculature) awell-developed tolerance to the effects of alcohol can beestablished. With these data available the physician canthen check the veracity of other self-reported data andchallenge them when appropriate. Also, if the BAL is 300mg% (0.3 gram) or more, regardless of symptoms or

Available from: Intoximeters, Inc., 1901 Locust St., St. Louis, MO 63103.

signs, it encourages the diagnosis of alcoholism,' becausethe 150 to 300 mg% BAL's in an awake person implythe presence of a high degree of pharmacologicaltolerance, which can be a major diagnostic criterion foralcoholism. Remember, that a negative or zero readingmeans nothing other than that there is no alcohol in theperson's body. If the person does appear intoxicated evenin the face of the data, be sure to order tests capable ofdetecting the presence of other mood-altering drugs.

The BAL should be treated as a corroboratory medicaltest that is useful in helping the physician or healthprofessional reach an accurate assessment or diagnosis.Thus, it is a test to be used only in a positive heipingcapacity. It should not be used in a negative or punitivecapacity, and it should be kept confidential, as any otherpart of the patient's medical record.

Since alcohol contributes to the death of nearly 5000teenagers a year on the highways, same additionalperspectives on BAL would be useful for your patienteducation activities. Most states use 100 mg /dl (0.10%)as the legal definition of driving-under-the-influence(DUI); but in 1986, the American Medical Associationwent "on record" as recommending that all states use0.05% BAL as the criterion for conviction of DUI.9 Thiswas based on a review of numerous scientific findingsthat for most people alcohol above this level causes adeterioration of driving skills. However, a review of theliterature demonstrates that young people are not onlyinexperienced drivers but are usually inexperienceddrinkers as well. Therefore, teenagers in fatal crashesshow even lower BALs than older drivers. Thus, there isno "safe" level. The JAMA reference in this paragraph isstrongly recommended. This message should be com-municated to all of your teenage patients.

Terminating the Interview

!Terminating the diagnostic process (theassessment) may involve both individualand group interviews.

The physician might consider three separate termina-tion interviews. For the adolescent, when you havecollected sufficient data or have exhausted your ability toobtain additional relevant data, present the adolescentwith a schematic of the major life-areas, including usagepatterns and risk factors. Invite him to summarize theinformation that he has provided about each and toassess his own level of impairment/difficulty/involve-

2'

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Recognition and Diagnosis 21

ment on each of these. Then present him with an outlineof the progression hypothesis and ask him to placehimself along the continuum on the basis of the data thathe has provided. Discuss his self-assessment within thecontext of the categories and perspectives; this becomes,he termination of the interview.

The same process can be used with the parents orfamily. Using the structure provided through theschematic, the respondent(s) are invited to summarizethe data that they have provided and their impressions ofwhere their youngster belongs on each of the dimensions.Having done so, offer an outline of the progressioncontinuum and ask them to place their teenager on it. Atthe same time, they should be encouraged to identify anintervention level (service level) which they believe mightreduce the level of vulnerability that their teenager iscurrently experiencing or which might address thespecific problems to which they have alluded. Yourdirect feedback constitutes the termination of the inter-view with the family.

The third termination session, which involves thefamily and the adolescent together, reviews your assess-ment of the identified patient's place on the progressioncontinuum and your recommendation for actual service.You then briefly but carefully summarize your impres-sions, distinguishing between data and interpretation.Value-laden words such as "addicted," "alcoholic," or"drug addict," should be avoided, using instead neutral,less inflammatory concepts such as "harmful involve-ment" and "dependence."

Since these findings have already been provided to theadolescent and the family, they can be very briefly

28

summarized in this third meeting. The assessmentconcludes with y ,,ar recommendation for interventionand, most importantly, what this serv;ce can provide forthe adolescent and the family. As noted earlier, if you feelin a given situation that the above process is notappropriate for a specific teenager because the familylacks control, the "standard intervention," which can bemore surprising to the teenager, can be used. This isdescribed in the next unit of study.

A Final NoteInterviewing, history-taking, and assessment are de-

veloped skills. While the process described above mayappear at first reading to he cumbersome, it is inactuality much like a medical assessment. Perfection andspeed come with practice. Like any other skill, there arefew immutable rules. Each physician identifies andperfects the techniques that work best for him or her.However, committing yourself to an explicit modelassures that the data you collect are comprehensive andcan lead to an action plan.

SummaryWe have reviewed the complex, behavioral factors in

the clevelopmen't and diagnosis of alcoholism. Thisbehavioral component is critical for physicians to mastersince teenagers do not usually show the end-stagefindings of alcoholism. Alcoholism can be approached asother diseases in a problem-oriented fashion. We havethus reviewed this illness in a subjective, objective,assessment, and plan-of-care approach. The key elementsare in the history, which the physician should attempt toobtain from as many concerned individuals as possible.

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22 Adolescent Alcoholism

Evaluation Four stages of substance abuse are outlined in this unit of study. These stages areexperimental use, social/recreational use, committcd/harmfully involved, and dysfunc-tional abuse. A distinction is made between the first two and second two use patterns,with emphasis being placed on the need to educate and guide those who areexperimenting and using socially or recreationally and the need to diagnose andintervene when a person crosses the line to the harmfully involved and abuser stages. Thekey word in this progression of stages is dysfunction. As a physician, it is essential thatyou recognize dysfunction as a potential symptom of alcoholism or substance abuse. Toassist you in this process, we ask that you fill out the following matrix which includes onone axis the six major areas in which dysfunction occurs. In each cell, place appropriatesymptoms or tests that would indicate dysfunction. After you have completed this table,share it and discuss it with colleagues and, if possible, one or more alcoholism andsubstance-abuse specialists.

Alcoholism and Substance Abuse Diagnostic Matrix

I II III IVArea in Which Sources of Specific Tests Symptoms or Possible Ex-Dysfunction Information Examining Test Results plantations forMay Occur Regarding Functional Indicating Symptoms or

Functional Status Dysfunctional Results OtherStatus Status Than Alcoholism

or Substance Abuse

Family

School/Work

SocialRelationships

Self-Conceptand

Self-Esteem

Psychologic7.;Function

PhysicalWell-Being

When you entertain the possible diagnosis of alcoholism or substance abuse, you may wish to till in the blank matrixspecifically for your patients. The presence of strong indicators of dysfunction in Column III of the matrix withoutacceptable alternative explanations in Column IV would be a strong indicator of alcoholism or substance abuse.

After you have used the matrix several times, discuss its application with your colleagues. Jf you feel its use issupported, include it as a regular portion of your diagnostic work-up for adolescent patients presenting with problemsassociated with potential alcoholism or substance abuse.

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Recognition and Diagnosis 23

References

Resources forPhysicians

Resources forPatients and/orFamilies

1. Grinspoon, L.: Marijuana Reconsidered. Cambridge, MA: Harvard University Press,1971, p. 235-2.52; 281-284.

2. Weil, A.: The Natural Mind. Boston, MA:Houghton Mifflin, 1972.

3. McDonald, DJ.: "Drug, Drinking, and Adolescence." American Journal of Diseasesof Children, 138(2):117-125, 1534.

4. Hess, J.W., Liepman, and Ruane, T.J. (eds.): Family Practice and PreventiveMedicine. New York: Human Sciences Press, Inc., 1983.

S. Goodwin, D.W., Schulsinger, F., Moller, N., Hermansen, L., Winokur, G., andGuze, S.: "Drinking Problems in Adopted and Non-adopted Sons of Alcoholics."Archives of General Psychiatry, 31:164-169; 1974.

6. Schuckit, M.A.: "Genetics and the Risk for Alcoholism." Journal of the AmericanMedical Association, 254(18): 2614-2617, 1985.

7. Liepman, M.R., Anderson, R.C., and Fisher, J.V.: Family Medicine CurriculumGuide to Substance Abuse. Kansas City, MO:Society of Teachers of FamilyMedicine, 1984, pp. 3-9.

8. Chaftez, M.E.: The Alcoholic Patient: Diagnosis and Management. New Jersey:Medical Economics Books, 1983, pp. 82-83.

9. Council on Scientific Affairs, American Medical Association: "Alcohol and theDriver." Journal of the American Medical Association, 255(4):522-527, 1986.

1. Chafetz, M.E.: The Alcoholic Patient: Diagnosis and Management. New Jer-sey:Medical Economics Books, 1983.

2. Liepman, M.R., Anderson, R.C., and Fisher, J.V.: Family Medicine CurriculumGuide to Substance Abuse. Kansas City, MO:Society of Teachers of FamilyMedicine, 1984.

Your community mental health center or local substance abuse treatment facilitieswill probably have pamphlets that are most appropriate for the problems and treatmentapproaches that exist in your particular setting.