The American Academy of Pediatrics Committee on Adolescence amply pointed out (in 1983) the ever increasing role of the pediatrician in substance abuse counseling.1 The Committee's position statement indicated that "Pediatricians hold a valuable and responsible position with teenagers who come under their care with drug abuse," and "The use and abuse of psychoactive substances have become common, even among young adolescents, and the pediatrician must be prepared to address this issue as part of routine health care."1 Despite lack of familiarity with some of the important issues related to substance use and abuse, the pediatrician is often sought for advice by parents, educational institutions, and community agencies.
The pediatrician has five major areas of responsibility with respect to the issue of substance use and abuse in the care of patients. The pediatrician should have some familiarity with the nature and extent of childhood and adolescent drug use, possess the skills to determine the risk of abuse, be able to address the issue as part of routine health care, have knowledge of counseling and community referral resources, and take some responsibility in educating pediatrie patients about the issue. Some awareness of public policy issues being discussed in the practitioner's local community is desirable.
Adolescent chemical dependence has become a discrete diagnosis and is characterized as a progressive disorder, accompanied by loss of control over alcohol and other drugs, resulting in clinically identifiable consequences that interfere with normal adolescent and family development.2·3 Even if one accepts the premise of genetic predisposition to alcoholism and chemical dependence, most practitioners in the field support the utility of childhood prevention and early identification as being important in alleviating those factors that produce the serious problems accomanying the drug and alcohol abuse seen in adolescents and adults.4 Many factors that promote drug abuse in the pediatrie age group can be successfully manipulated to improve outcome and reduce drug and alcohol abuse. The pediatrician is in a key position to provide an objective assessment and aid children and families to gain access to treatment resources. In addition, parents and children alike have many misconceptions and much misinformation regarding the physical and emotional effects of specific drugs, and the practitioner should not underestimate his role to educate, especially as the child is introduced to drugs and alcohol increasingly in his or her environment.
A practical approach to office assessment of substance-using behavior is offered here. As with other adolescent health issues, the general approach will require interacting with the patient on an individual basis, maintaining a degree of confidentiality, and providing the child with directed advice in a way that shows interest and concern. In most cases, there are techniques for involving parents or other important family members in the discussion and disposition of these cases; these approaches will be outlined.
The specific approach to be used is modeled after cognitive, affective, and behavioral drug and alcohol educational programs. We have learned, in such programs, that providing information purely on a cognitive level rarely ever changes behavior and that impacting values, attitudes, and specific behaviors and skills offers more promise in changing drug use.5 Likewise, as practitioners we need to do more than collect information as a data base with respect to the patient's drug use habits. Equally as important is the assessment of each patient in the affective and behavioral domain. Having an understanding of the young person's attitudes and values with respect to drug use, his or her parents' values, and a clear idea of the child's specific drug and alcohol-related behaviors provides a more comprehensive picture and a clearer indication of future risk for substance abuse. This history- taking approach with patients may be applied in the coutse of doing a substance abuse assessment or may be incorporated as part of routine health care for patients seen for other medical concerns.
EXTENT AND NATURE OF ADOLESCENT DRUG USE
The pattern of drug use and abuse in the pediatrie age population has changed a great deal in the past several decades. For some drugs like marijuana, the "epidemic" of drug use talked about in the 1970s has seen a shift to a more endemic use.6 Young people today have incorporated the use of alcohol and marijuana into their normal social development to such an extent that problem behavior has become somewhat less visible and more difficult to affect.6 In addition, in more recent times alcohol and drug use during adolescence has been perceived as normative behavior, part of normal social and developmental changes seen during adolescence, not necessarily a problem or predictive of adult problem use. 7 Several of the other important temporal changes in drug use patterns among children and adolescents have included a shift to polydrug use and abuse as opposed to exclusive alcohol abuse; an increase in the number of adolescents identified as truly chemically dependent; and the introduction of a wider variety of drugs that promote multiple chemical dependencies.8 In addition, there has been an absolute increase in the number of young female adolescents with excessive drug and alcohol use, and it is not unusual to find young adolescent girls diagnosed with alcoholism involved in treatment or attending meetings of Alcoholics Anonymous.9 Even though we place a great deal more emphasis on prevention of drug and alcohol abuse with younger and younger children, we should remember that the highest use-rates of virtually every category of drug are among 18- to 25-yearolds. Physicians seeing older adolescents who are leaving high school to go to college or into the workplace should be aware of this fact and should discuss the issue with their older adolescent patients at any appropriate opportunity.
DETERMINING THE RISK FOR SUBSTANCE ABUSE
Childhood and adolescent drug use and abuse should be viewed on a continuum that begins with abstinence and progresses to chemical dependence. Recent research has estimated that 10% to 15% of adolescents under 18 years of age have definable problem use of alcohol and other drugs, approximately the same number are habitual users, and from 1% to 5% of adolescents are diagnosed as chemically dependent-8 At the other end of the spectrum is the child who has little or no experience with alcohol or other drugs prior to 18 years of age, comprising 10% to 15% of the adolescent population. The remainder of the adolescent population "experiment" with various drugs at some time during their adolescence and adjust their use in non-problem ways as they grow older. There are identifiable indicators of risk that tend to predict which adolescents will move along the continuum toward problem use.
With a background of early drug use, a number of other identifiable family and social factors tend to promote drug abuse. These include excessive use of alcohol by one or both parents or a strong family history of alcoholism, early peer choices relevant to drug use and deviant behavior, and an increased availability of alcohol and drugs in the child's home environment. In addition, there are some drug-independent variables which, as a group, may be important to identify. These factors include significant parental conflict that produces guilt and anxiety in. the child, early childhood alienation from family and community structure evidenced by poor academic performance or attendance, abandonment of outside recreational activities or a decrease in family-centered activities, and, in the older child, runaway behavior. 10 Parental personality traits that may be predictive are characterized by an inconsistent and impulsive parenting style or exposing the child to negative child-rearing practices such as verbal, .physical, and/or sexual abuse. For some reason, the first-bom in large families is at somewhat greater risk for developing substance abuse problems during adolescence and adulthood.11 No single background factor has a great deal of predictive value, although many chemically dependent youth grow up in families with these characteristics or live these experiences.
Defining problem drug use in children and adolescents is based on several factors. Traditionally, problem use has been identified based primarily on quantity and frequency of use.12 The young patient who drinks heavily on weekends, who functions well for long periods of time academically, and maintains welladjusted interpersonal relationships with family and friends rarely presents with significant problems. Assessing the extent of drug use is, however, an important part of the data base (Checklist 1). Defining problem use depends upon identifying a number of negative consequences in the child's life that can be related to drug use. In addition, the physician should search for any evidence of physical or psychological dependence. Clinical signs and symptoms of physical dependence in the pediatrie age drug abuser are distinctly unusual. Often, withdrawal symptoms and signs in young abusers, if they exist, are minimal and reflect the more sporadic use and the shorter history of dependence on drugs characteristic of the age group. The history of psychological dependence requires the identification of drug-seeking behavior and the degree to which the child has incorporated drug use into his or her daily activities. The child who uses drugs often during the day, has a history of solitary use, or has discovered a variety of ways of obtaining drugs or alcohol is at greater risk.
Identifying negative consequences of drug use in this population can be accomplished by using a questionnaire or a directed interview with the adolescent patient. The areas important to cover in this part of the history are summarized in Checklist 2. To identify negative consequences, major areas of the child's life should be inventoried. Any physical complications of drug use such as amnesic episodes (black-outs), accidents or injuries under the influence of drugs, and withdrawal symptoms should be elicited. A history of the patient's school performance and attendance in the previous 12 months should be obtained, along with an outline of his or her extracurricular and leisure activities. Often, children who are evidencing problem drug use have abandoned many of their previous athletic interests and other wholesome leisure activities. Questioning about legal difficulties and interaction with juvenile authorities or the police is important. If the youth concedes legal difficulties, questioning the youth regarding the relationship of the offense to drug and alcohol use becomes important, Problem users often experience considerable conflict with parents over their drug and alcohol use and their parents are often critical of their choices of friends. In addition, the child may have been in some disagreement with peers over their drug-taking behavior and experience some loss of friendship. If the adolescent has been involved in a relationship with a boyfriend or a girlfriend, difficulties in these relationships should be explored.
Taken as a whole, the data base should include quantity and frequency of use, some assessment regarding physical and psychological dependence, identification of negative consequences of use, and some assessment of family and cultural background prior to defining the degree of problems associated with the child's drug use.
In addition, a complete physical examination should be carried out even though drug-specific findings may be minimal. A general lack of conditioning is often evident, as well as some nutritional and weight difficulties and occasional evidence of unattended chronic medical problems. Carrying out the examination also gives the practitioner the opportunity to discuss the child's general state of health and to reflect on the potential deleterious effects of drug abuse.
ADDRESSING THE ISSUE AS PART OF ROUTINE HEALTH CARE
Questions about drug and alcohol use attitudes and knowledge should be incorporated routinely with every general medical visit for older children and adolescents. Every child over 10 years of age has some knowledge and has formed some values related to drugs and alcohol. The cognitive, affective, and behavioral model is used and integrated as part of the review of systems and such information is elicited individually with the patient.
The Cognitive Component
The pediatrician should obtain a clear history from the patient with respect to the degree of drug knowledge and experience, when the child was first introduced to alcohol or other drugs, and by whom they were introduced. Questions regarding the source of knowledge about drugs and alcohol should be elicited. This history can be obtained as a separate part of the history-gathering process or as part of the review of systems. In the context of asking questions about respiratory symptoms, for example, questions about cigarette use and other drug experiences can be asked.
The Affective Component
Assessing the child's attitudes toward alcohol and drug use and the child's perception of his parent's values related to this issue may be important predictors of future use.7 Questions about what drugs are used, and how often, should be followed with questions about the child's attitudes in general toward drug and alcohol use and some assessment of which drugs the patient would likely experiment with, which ones he would not, and why. Even among heavy drug users, adolescents will "draw the line" and not be willing to use certain categories of substances. Exploring any differences between the child's attitudes toward drugtaking and the parent's value system may be quite revealing. In addition, the child may not have an accurate perception of parents' attitudes because of a lack of meaningful communication about the subject.
For those children and young adolescents who have little or no personal experience with alcohol or drugs, insight into the child's attitudes and value systems that allow him to resist use allows the physician to judge the child's degree of immunity to peer pressure. The physician should be cautioned, however, that the course of adolescent development is a highly dynamic one, and values and attitudes may change dramatically from year to year with any individual young patient. The same values and attitudes toward drug-taking behavior elicited in one visit may be different at a visit one year later. Attitudes and values should continue to be assessed as the child gains exposure to more social experiences and peer pressure.
The Behavioral Component
Children of all ages have varying degrees of verbal and behavioral skills to resist experiences with which they are not comfortable. The physician should assess the ease with which the patient is able to discuss drugtaking behavior, attitudes and values, and the extent of the child's communication skills - specifically, refusal skills in dealing with the peer and social pressures to use drugs. Investigating the behavioral component with the pediatrie patient may take the form of suggesting hypothetical situations wherein the child might feel obligated to use drugs, asking the child to generate verbal responses to avoid trouble. Children with built-in resistance to drug-taking have usually developed helpful skills at a young age to resist drug use situations they feel to be unwise or dangerous. The physician should feel free to offer decision-making alternatives if the young patient appears unsure how to handle risky situations.
In summary, the use of a cognitive, affective, and behavioral approach to assessment as part of the standard health care routine gives a clear picture of the patient's drug use experience, attitudes, and skills to deal with the issue. When applied in context as part of the routine medical history, each of the components described can be assessed in relatively short order. Practitioners are urged to apply these concepts in taking a history from older pediatrie patients and to vary their approach to fit their own style of communication with adolescent patients.
REFERRING THE PROBLEM PATIENT
Few pediatricians will possess the skills, the experience, or the time to treat children and adolescents with significant problem drug use or chemical dependence. Communities vary a great deal with respect to the quantity and quality of drug and alcohol treatment facilities for adolescents. The approaches to treating adolescent chemical dependence vary greatly, and there are as many philosophies of treatment as there are treatment agencies and practitioners. Individual psychotherapy with the adolescent has proven to be the least effective, with the exception of those adolescents with significant identifiable affective disorders, especially depression. 13 In most cases, group and family therapy approaches are indicated. The pediatrician should be aware of several outpatient and inpatient adolescent treatment programs available to their patients, the agency's treatment philosophy, to what degree they use group and family interventions, and the financial arrangements necessary for acceptance into treatment. Many communities also have youthserving agencies that offer a variety of less restrictive outpatient treatment approaches. A resource list of these agencies should be available to the pediatrician. For those youth identified as having alcoholic or drug addicted patients, many communities have support groups for children of alcoholics, such as an ALATEEN organization. The physician should insist on patient follow-up during or after treatment as indicated. The physician should be willing to follow up patients medically after they enter treatment elsewhere in the community to provide medical monitoring of disulfiram (Antabuse) therapy or drug detoxification, although this is rarely necessary or indicated with this population. If the physician is going to monitor the adolescent and require drug and alcohol abstinence, the use of disulfiram may be indicated as well as investigating drug intake using currently available urinalysis techniques. The physician is cautioned not to prescribe disulfiram unless the patient has shown some degree of abstinence without it, understands the Antabuse-alcohol reaction, and is well motivated not to use alcohol. Because most adolescent drug abusers are polydrug users, disulfiram has limited utility.
In conclusion, the pediatrician has an important role and is often asked to deal with the drug using behavior of young patients. Familiarity with the adolescent drug use issue is indicated, keeping in mind that drug use patterns and drugs used change over time. Pediatricians should gain some skills in assessing drug use behavior, attitudes, and knowledge as part of providing routine health care. Attaining proficiency in determining the risk of substance abuse is useful. In addition, pediatricians treating these young patients should be familiar with community resources for assessment and treatment of those patients identified as having problem behavior. Lastly, physicians should continue to follow their patients through the treatment process and should periodically reassess adolescents who are not currently evidencing problem behavior, as the physician is in the best position to act as educator, to be an advocate, and to provide family support for change.
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