Patient Presentation
A 14-year-old male came to clinic for a health supervision visit and sports physical. The adolescent admitted to trying some cigarettes and some beer in the past few months at a friend’s house. The friend’s older brother had provided them to the younger teens during a sleep over. He stated that he “didn’t like them” and wasn’t going to be trying them again anytime soon. The teenager said that family members had an occasional beer during a social event or watching sports, but that he had never seen anyone drunk or driving while intoxicated. The past medical history showed a previous ankle injury from basketball. The family history was positive for depression in a maternal grandmother, but negative for substance abuse.
The pertinent physical exam showed a healthy male with normal vital signs and growth parameters. His examination was normal including his ankle. The diagnosis of a healthy male who had recently experimented with tobacco and alcohol was made. The physician talked with the adolescent and encouraged him to not use any substances. He also encouraged him to never drive or get into a car with anyone who had used a substance. The physician recommended having a safety plan with several telephone numbers of trusted adults who could give him a safe ride home if needed. The patient’s clinical course over the next several years found that he did try smokeless tobacco, and had a part of a beer with his family on very special social occasions.
Discussion
As tweens and teenagers continue to develop toward adulthood, they begin to engage in adult behaviors and take on the risks of those behaviors. Adolescent interviews are often guided using the acronyms HEADSS or SSHADESS to help elicit the adolescent’s strengths, weaknesses, behaviors and potential risks. HEADSS stands for home, education, activities, drugs/depression, suicide and sexuality. SSHADESS is slightly more expansive and stands for strengths, school, home, activities, drugs/substance abuse, emotion/depression, sexuality and safety.
“…[A]lcohol use is often the first risk behavior in which adolescents engage…” so screening for alcohol use is an important part of the adolescent interview. Deaths in the adolescent age range are usually because of accidents, homicide or suicide (about 70%), and alcohol often plays a role in these incidents. For example, in car accidents over 35% of them directly involved alcohol and an additional 20-25% were related to alcohol or another substance drug use, or riding in a car with a drunk driver. “All together, substance use accounts for almost 60% of accidental deaths among teens.”
Having time for parents to talk with their teenagers on a regular basis has been shown to decrease alcohol and tobacco use. For example, having a family dinner 3-7 times/week decreases the risk by about half. Alcohol is often taken from the adolescent’s home either being given it by family member or just taking it. Experts recommend that if alcohol is in the home that it is locked up. “The average length of time between the onset of teen substance use and a parent knowing is 2-2.5 years,” so experts recommend that if parents have a suspicion, then it is very likely that the adolescent already has a substance abuse problem.
Signs and symptoms of substance abuse include:
- “Loss of interest in activities
- Inconsistent school performance
- Changes in dress and grooming
- New friends that parents don’t like
- Changes in eating and sleeping patterns
- Alcohol, smoke, or chemical odors
- Obvious intoxication or dizziness
- Sudden mood changes and bizarre behavior
- Frequent arguments or violent actions
- Runaway and delinquent behavior
- Suicide attempts”
Learning Point
An Adolescent SBIRT (screening for substance abuse, brief intervention and/or referral to treatment) algorithm recommended by the American Academy of Pediatrics.
Opening questions
Ask the adolescent to honestly answer the following questions:
During the past 12 months did you:
1. Drink any alcohol (more than a few sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high? (this includes illegal, prescription or over the counter drugs and things that you sniff or “huff”)
CRAFFT questions
As the adolescent 1 or more of these questions:
C = Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R = Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?
A = Do you ever use alcohol or drugs while you are by yourself or ALONE?
F = Do you ever FORGET things you did while using alcohol or drugs?
F = Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T = Have you ever gotten into TROUBLE while you were using alcohol or drugs?
If no to all opening questions, ask CAR question.
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If no to all questions, the health care provider should praise and encourage the adolescent.
If yes to the CAR question, the health care provider should talk with the adolescent about risks of driving or riding in cars with someone who has been using substances and helping the adolescent to develop a safety plan for this possibility. A sample “Contract for Life” can be found at the Students Against Destructive Decisions website here.
If yes to any of the opening questions, ask all the CRAFFT questions (each yes to a question is one point).
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If CRAFFT score 0-1, give brief advice to stop using the substance.
If CRAFFT score >2, then the adolescent is at high risk for having a substance abuse problem. A full psychosocial interview is needed to develop a plan for advising the adolescent and possible referral for treatment, along with the considerations of timing and confidentiality.
A full outline can be found at in the American Academy of Pediatrics Policy Statement below in the To Learn More section
Questions for Further Discussion
1. How common is alcohol use and abuse by tweens and teenagers?
2. What resources are available in the local area for substance abuse treatment?
3. What is the difference between experimentation, limited use, problematic use, abuse and addiction of substances?
Related Cases
- Disease: Alcohol | Alcoholism | Underage Drinking
- Symptom/Presentation: Behavior Problems | Health Maintenance and Disease Prevention
- Specialty: Adolescent Medicine | Psychiatry and Psychology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Alcohol, Alcoholism, and Underage Drinking.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Children’s Hospital Boston, Center for Adolescent Substance Abuse Research. Clinician Information. Available from the Internet at Clinician Information (rev. 4/10/12, cited 2009).
Children’s Hospital Boston, Center for Adolescent Substance Abuse Research. Teen Safe. Available from the Internet at http://www.teen-safe.org/about (rev. 4/10/12, cited 2010).
Committee on Substance Abuse, Levy SJ, Kokotailo PK. Substance use screening, brief intervention, and referral to treatment for pediatricians.Pediatrics. 2011 Nov;128(5):e1330-40.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 