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Screening Measures for Problems in the Family
One technique to maximize the usefulness of responses to screening questions is to apply them to all members of the household. This can be done while interviewing an older child or adolescent, or with one family member when talking about others. For example, "Has anyone in your household or your family ever neglected their usual responsibilities when drinking or taking drugs?" "Have you ever felt someone in your household or family should cut down on their drinking or drug taking?" "Do you ever wish someone in your family didn’t drink so much?... Who is that?"
The CAGE questionnaire is a four-item alcohol screening instrument with demonstrated relevance for primary care in clinical, educational, and research settings. The CAGE asks whether the respondent has ever "needed to Cut down on their drinking; felt Annoyed by complaints about their drinking; felt Guilty about their drinking; or, had an Eye-opener first thing in the morning." The Family CAGE is a modified version of the commonly used CAGE questionnaire that simply broadens the standard CAGE items to include "anyone in your family". One can use the Family CAGE questions to provide a proxy report regarding another individual such as a parent or an older sibling. For example, if the patient is a 12-year-old who currently is not using alcohol or other drugs, but is concerned about a parent’s use of alcohol, the health care professional could screen for concerns about the parent’s alcohol use by asking the CAGE questions to the child in the following manner: "Do you think your mother needs to cut down on her alcohol use? Does your mother get annoyed at comments about her drinking? Does your mother ever act guilty about her drinking? Does your mother ever take a drink early in the morning as an eye-opener?" One or more positive answers to the Family CAGE can be considered a positive screen and needs additional assessment. The Family CAGE is intended to screen for alcohol problems in families, not to diagnose family alcoholism. A positive finding on the Family CAGE implies a greater relative risk for alcoholism in the family and should be followed by a more thorough diagnostic assessment.
Screening for the impact of Family Substance Abuse
The Family Drinking Survey also addresses how family members have been affected by a family member’s alcoholism. It is adapted from the CAST, the Howard Family Questionnaire, and the Family Alcohol Quiz from Al-Anon and is suitable for use with adolescent patients or nonusing parents. It addresses the effects of family alcoholism on the patient’s emotions, physical health, interpersonal relationships, and daily functioning. When patients or their parents have positive responses to the CAST or Family Drinking Survey, they are beginning to reveal the impact of the substance abuse on the family and on themselves. As the evidence of family dysfunction becomes more apparent, the health care provider should have more concern about the impact of the substance abuse. As the family becomes more submissive to the impact of the substance abuse, they more clearly distinguish themselves as an "alcoholic or drug abuse family."
An important consideration of children, youth, and parents is the confidentiality of the information gathered. Although many family members are eager to facilitate help for the alcoholic family member, others are more reluctant. If the presenting patient or nonusing parent is reluctant to share his/her concerns, the therapist can encourage individual counseling.
Screening Measures for Older Adolescents or Adult Family Members
A general psychosocial assessment of an adolescent’s functioning is the most important component of a screening interview for alcohol misuse or abuse. Begin with a discussion of general topical areas, including home and family relationships, school performance and attendance, peer relationships, recreational and leisure activities, vocational aspirations and employment, self-perception, and legal difficulties. The information gathered helps to determine whether alcohol or other drug use is a cause of behavioral dysfunction and the degree of patient impairment. It is often useful to ask about alcohol or other drug use directly, for example, "Tell me about your use of alcohol," or "When did you last drink alcohol?" If they do not use alcohol, explore their reasons for nonuse and affirm their decision. If they have used alcohol, ask whether they have ever been concerned about their use. If so, what is the nature of their concern, have they had periods of nonuse or cutting down, is there evidence of loss of control by breaking promises or rules, and is there evidence of the adolescent rationing their use? If the teen has never been concerned about his/her use, inquire whether anyone else has ever expressed concern about his/her use of alcohol. What was the nature of that concern and what was the patient’s attitude toward it? Is there evidence of remorse or guilt for behavior while using or obtaining alcohol?
The four-item CAGE questionnaire discussed above has proven useful in screening for alcohol problems both with adolescents and with adults. Although a positive response to the CAGE questions is not diagnostic of alcoholism, answering yes to two or more questions is highly suspicious and warrants additional evaluation. A variant of the CAGE suggested for use in pregnant women, called the T-ACE, substitutes tolerance for the question on guilt while including questions on annoyance, cuffing down, and eye-openers. For example, "How many drinks does it take to make you feel high?" An answer of more than two drinks is considered positive.
A recent study found that four criteria most frequently endorsed by those with alcohol problems are 1) blackouts, 2) objections by family members or close friends, 3) withdrawal symptoms when the abused substance is not immediately available, and 4) neglect of responsibiIities. From these general ideas developed the following brief questionnaire (the BONS) for use with adult alcoholics that also can be used while interviewing parents: 1) Have you ever been drunk enough that the next day you could not remember what you had said or done? 2) Have your family or friends told you they objected to your drinking? 3) Have you ever neglected some of your usual responsibilities when drinking? 4) Have you ever had the shakes after stopping or cutting down on your drinking, or the morning after drinking? A positive response to any of these four questions should be considered a positive screening for high risk for alcohol problems.
The AUDIT is a 10-question screening measure that is administered most easily in written form. It was developed by the World Health Organization specifically to be used in primary care settings and has been used extensively in an international intervention trial. The AUDIT incorporates questions about drinking quantity, frequency, and binge behavior, along with questions about consequences of drinking. Unlike the CAGE, it assesses alcohol use and problems over the last 12-month period.
Brief screening questionnaires such as the CAGE and AUDIT are most useful as an entry into meaningful direct discussion about alcohol use and the parent’s self-perception of their use. These clinical aids are not intended to be diagnostic instruments; rather, they facilitate gathering information, which can be used to complement the psychosocial history. Experienced interviewers will not simply ask each question within the CAGE or any other screening tool, but will use the areas targeted by these questions to briefly probe the critical issues behind alcohol or other drug use. For example, when a parent acknowledges a previous attempt to cut down on drinking, this provides an excellent opportunity to explore their self-perceptions of problems they themselves have noted as a result of drinking. When a parent admits to feelings of guilt because of behaviors while drinking, they have a palpable sense of the need for change and may feel motivated because of it. Questions such as those in the CAGE often allow the parent to define the direction of the interview in a useful manner. Familiarity with the general content of these screening measures can help the health care professional better understand the objectives of an alcohol use screening interview and, as a result, become a more sophisticated interviewer.
Another well-validated screening device is the Short Michigan Alcoholism Screening Test (SMAST). This screen is designed to be self-administered and includes 13 questions related to concerns of others about the respondent’s ability to carry out personal and social obligations. It does not, however, include questions about the physical effects of addiction. The SMAST can be given during an interview or as a written questionnaire to parents when an early suspicion of possible substance-abuse problems is developing.
There are several slightly longer written questionnaires that also have been found to be useful, including the Drug and Alcohol Problem Quick Screen, the Adolescent Alcohol Involvement Scale and the Personal Experience Screening Questionnaire. The Problem Oriented Screening Instrument for Teenagers is a 120-item questionnaire that serves as the screening battery for 10 functional areas influenced by adolescent alcohol or other drug use. It is linked to a more comprehensive evaluation process called the Adolescent Assessment and Referral System, which may be useful in clinical settings where adolescents undergo comprehensive assessment. The Drug Use Screening Inventory enables practitioners to screen and assess the multiple problems of adolescents who abuse AOD in a manner that guides treatment selection and evaluation.
In addition to asking traditional questions about the family such as who lives at home and what are the parents’ occupations encourages asking questions such as, "Who in the family has emotional difficulties?", "Who in the family does not get along well with each other?", "Why?", ‘Who is divorced or having marital problems?" The genogram is best used to ask questions about relationships, family conflicts and turmoil, who are the strong personalities in the family, who helps solve problems and who creates them, and histories of psychiatric illness or substance abuse. This process fills in many details that can be linked to the therapist’s knowledge of the patient’s primary family to help create a more complete understanding of the family context. It also will reveal genetic vulnerability.
- Werner, Mark J., Alain Joffe, and Antonette V. Graham; "Screening, Early Identification, and Office-based Intervention with Children and Youth Living in Substance-abusing Families"; Pediatrics; May99 Vol. 103 Issue5, p1099
Reflection Exercise #2