Parental Alcohol Screening in Pediatric Practices Celeste R. Wilson, Sion Kim Harris, Lon Sherritt, Nohelani Lawrence, Deborah Glotzer, Judith S. Shaw and John R. Knight Pediatrics 2008;122;e1022 DOI: 10.1542/peds.2008-1183
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/122/5/e1022.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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ARTICLE
Parental Alcohol Screening in Pediatric Practices Celeste R. Wilson, MDa,b, Sion Kim Harris, PhDa,b, Lon Sherritt, MPHa, Nohelani Lawrence, BSa, Deborah Glotzer, MDb,c, Judith S. Shaw, EdD, MPH, RNd, John R. Knight, MDa,b a
Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts; bDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts; cCambridge Health Alliance, Cambridge, Massachusetts; dDepartment of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
The authors have indicated they have no financial relationships relevant to this article to disclose.
What’s Known on This Subject
What This Study Adds
The AAP supports the pediatrician’s role in addressing family health issues and attitudes on alcohol use during the health care visit.
This study provides insight into parents’ preferences for parental alcohol screening and intervention during the pediatric health care visit, particularly for the subgroup of parents who have a positive alcohol screen result.
ABSTRACT OBJECTIVES. Pediatricians are in an ideal position to screen parents of their patients for alcohol use. The objective of this study was to assess parents’ preferences regarding screening and intervention for parental alcohol use during pediatric office visits for their children.
www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1183 doi:10.1542/peds.2008-1183
METHODS. A descriptive multicenter study that used 3 pediatric primary care clinic sites
(rural, urban, suburban) was conducted between June 2004 and December 2006. Participants were a convenience sample of consecutively recruited parents who brought children for medical care. Parents completed an anonymous questionnaire that contained demographics; 2 alcohol-screening tests (TWEAK and Alcohol Use Disorders Identification Test); and items that assessed preferences for who should perform alcohol-screening, acceptance of screening, and preferred interventions if the screening result was positive. RESULTS. A total of 929 of 1028 eligible parents agreed to participate, and 879 of 929
Key Words alcohol-related disorders, substance abuse detection, parent-child relationship, primary care, physician-patient/parent communication Abbreviations AAP—American Academy of Pediatrics AUDIT—Alcohol Use Disorders Identification Test Accepted for publication Jul 10, 2008 Address correspondence to Celeste R. Wilson,
completed surveys that yielded sufficient data for analysis. Most participants were MD, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mail: mothers. A total of 101 of 879 parents screened positive on either the TWEAK or the
[email protected] Alcohol Use Disorders Identification Test. Parents with a negative alcohol screen PEDIATRICS (ISSN Numbers: Print, 0031-4005; (alcohol-negative) were more likely than parents with a positive alcohol screen Online, 1098-4275). Copyright © 2008 by the American Academy of Pediatrics (alcohol-positive) to report that they would agree to being asked about their alcohol use. There were no significant differences in preferences within alcohol-positive and alcohol-negative groups for screening by the pediatrician or computer-based questionnaire. Most preferred interventions for the alcohol-positive group were for the pediatrician to initiate additional discussion about drinking and its effect on their child, give educational materials about alcoholism, and refer for evaluation and treatment. Alcohol-positive men were more accepting than alcohol-positive women of having no intervention. CONCLUSIONS. A majority of parents would agree to being screened for alcohol problems in the pediatric office. Regardless of their alcohol screen status, parents are accepting of being screened by the pediatrician, a computerbased questionnaire, or a paper-and-pencil survey. Parents who screen positive prefer that the pediatrician discuss the problem further with them and present options for referral. Pediatrics 2008;122:e1022–e1029
I
N 2001, ⬎6 million children in the United States were living with a parent who had an alcohol or other substance
disorder, and nearly 10% of these children were ⱕ5 years of age.1 In 2-parent households, fathers were twice as likely as mothers to have an alcohol or other substance use disorder.1 Children of alcoholics are at increased risk for a variety of medical, behavioral, educational, cognitive, and mental health problems.2–6 Not only are they more likely to witness domestic violence, but they also have a greater chance of becoming victims of all forms of child maltreatment, including neglect, physical abuse, and sexual abuse. Although some parents with a drinking problem may be able to provide the basic physical necessities for their children, their alcohol consumption often renders them emotionally unavailable, leaving the child in a mental vortex of self-blame, unpredictability, emptiness, and despair.7 Moreover, children of alcoholics are 3 to 4 times more likely to have their own alcohol problems in later years,6,8–12 perpetuating the vicious cycle for the next generation. To interrupt this cycle and thereby improve the health of children, it is critical to identify and provide a pathway to assessment/treatment for parents with unhealthy patterns of alcohol consumption. e1022
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Because parents rarely present with obvious intoxication or smell of alcohol on the breath when bringing children for primary care, the parent with problem alcohol use may be easily missed. To enhance identification of unhealthy alcohol use and reduce negative consequences, a growing body of literature supports the incorporation of alcohol screening and brief intervention in the primary care setting.13–16 Pediatricians, with their commitment to child health, frequent interactions with parents, and close relationships with both children and families, have a unique opportunity to screen parents for alcohol use and refer them for additional assessment and treatment. Previous studies are shown that parents are willing to be screened for alcohol and other substance problems in the pediatric office setting.17–20 In updated care guidelines, the American Academy of Pediatrics (AAP) acknowledges the role of the pediatric health care professional in the prevention, identification, and management of substance abuse by recommending that pediatricians “screen for and evaluate the nature and extent of substance use among patients and their families.”21 The AAP recognizes the child health care visit as “an ideal opportunity to explore the family history and attitudes regarding alcohol use and discuss with parents the effects of positive and negative role modeling on their children”22; however, studies show that pediatricians’ identification of parental alcoholism is poor.19,23,24 Furthermore, little is known about the proportion of parents who will screen positive for an alcohol problem (“alcohol-positive”), whether their attitudes differ from those who screen negative (“alcohol-negative”), and their preferences for screening methods and interventions. The study objectives were to (1) estimate the proportion of problem alcohol users among parents who bring their children for routine pediatric care, (2) assess parents’ attitudes about being screened for alcohol problems by their child’s pediatrician, comparing alcohol-positive and alcohol-negative parents, and (3) assess alcohol-positive parents’ preferences for alcohol intervention. METHODS This was a prospective, observational, multicenter study conducted between June 2004 and December 2006. Study Sites There were 3 recruitment sites: an urban clinic, a suburban clinic, and a rural clinic. The urban site was a hospital-based pediatric ambulatory clinic in Cambridge, Massachusetts, that serves a diverse racial/ethnic and socioeconomic status population and has ⬃14 000 patient visits per year. The suburban site was a private pediatric practice in Milton, Massachusetts, that serves a largely white, middle class population and has ⬎20 000 patient visits per year. The rural site was a pediatric ambulatory and continuity clinic located in Burlington, Vermont, that serves primarily white, lower socioeconomic status families and has ⬃12 000 patient visits per year.
Participants Participants were parents/caregivers (hereinafter referred to as “parents”) who were ⱖ18 years of age bringing children for routine medical care. A total of 1130 parents were invited to participate in the study. Parents were excluded when they were unable to read/understand English (n ⫽ 102). Of the remaining 1028 parents who were eligible to participate, 929 (90%) agreed (310 [87%] of 356 at urban sites; 315 [95%] of 330 at suburban sites; 304 [89%] of 342 at rural sites), and of those, 879 (95%) questionnaires yielded sufficient data for analysis. Of the 24 participants who opted to return the questionnaire by mail, 8 (33%) actually did so. Recruitment A combined convenience and consecutive sampling approach was used. That is, parents were recruited in the clinic sessions on the basis of the research assistant’s availability (convenience sample); however, when the research assistant was present, she consecutively recruited parents (consecutive sample) in an effort to obtain a representative sample. On arrival at the clinic, parents were invited to participate in the study. Parents who were eligible and agreed were given an information sheet explaining the study purpose and procedures, as well as the study questionnaire. Questionnaires that were completed in clinic were returned anonymously in a sealed envelope; parents who chose to return questionnaires by mail were given a stamped envelope. All participants received educational materials on alcohol use and a $5 merchandise gift certificate. Participants’ willingness to complete and return questionnaires signified their informed consent. This protocol was approved by institutional review boards that govern each of the 3 respective sites. Questionnaire The questionnaire was developed by revising an assessment instrument that was used in a previous study17 and was pilot tested with a small group of nonparticipating parents. Changes suggested by the pilot were made to ensure clarity of the questionnaire before use in the study. The final questionnaire contained 40 items that included demographics; 2 brief alcohol-screening tests (TWEAK25 and Alcohol Use Disorders Identification Test [AUDIT]26,27); and questions that were designed to assess parents’ preferences for who should perform the alcohol screening, acceptance of the screening, and preferred interventions if the screening was positive (Table 1). The questionnaire also included items that were not specifically related to parental alcohol use, which will be reported elsewhere. Alcohol Screening Two well-validated screening devices, the TWEAK and the AUDIT, were self-administered as part of the study questionnaire. The 5-item TWEAK is scored using a 7-point scale and contains questions relating to drinking tolerance (T), others being worried about one’s drinking (W), using a drink as an eye-opener (E), others being PEDIATRICS Volume 122, Number 5, November 2008
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TABLE 1 Questionnaire Items That Assessed Parents’ Alcohol-Screening Preferences Questionnaire Item How would you feel if during your child’s well visit, your child’s doctor or nurse practitioner asked you about your use of alcohol? How comfortable would you feel about being asked about your alcohol use by each of the following people or methods?a My child’s nurse practitioner My child’s nurse My child’s pediatrician Medical assistant at my child’s doctor’s office Questionnaire for me to complete on computer without having to identify myself Questionnaire for me to complete on paper and then reviewed by my child’s doctor How likely are you to give completely honest answers about your alcohol use when asked in each of these ways?a My child’s nurse practitioner My child’s nurse My child’s pediatrician Medical assistant at my child’s doctor’s office Questionnaire for me to complete on computer without having to identify myself Questionnaire for me to complete on paper and then reviewed by my child’s doctor Imagine that your child’s doctor or nurse practitioner found that you had a drinking problem. Please indicate how you would feel about each of the following ways they could respond.a Contact a member of my family Contact my physician to inform him of the problem Schedule an appointment for me with my physician Schedule an appointment for me with a therapist/social worker Give me education materials about alcoholism Give me telephone numbers of centers where I can go for additional evaluation/ treatment Talk to me about my drinking, discuss how it may affect me and my child, and give me options for getting help How would you feel if your child’s doctor or nurse practitioner found out that you had a drinking problem and did not address it in any way? a Designated
Welcome; not mind at all; mildly annoyed; very annoyed Completely comfortable; mostly comfortable; somewhat comfortable; not at all comfortable
Definitely likely; probably likely; somewhat likely; not at all likely
I would welcome it; I would not mind at all; I would be mildly annoyed; I would be very annoyed
I would welcome it; I would not mind at all; I would be mildly annoyed; I would be very annoyed
response set was listed for each of the choices given.
annoyed by one’s drinking (A), and having felt the need to cut down on one’s drinking (K). The 10-item AUDIT yields a score from 0 to 40 and contains 3 subscales related to amount and frequency of drinking, alcohol dependence, and problems caused by alcohol use. In an emergency department population with harmful drinking, a TWEAK score of ⱖ2 had sensitivity and specificity of 89% and 87% and 98% and 54% for women and men, respectively.28 Increasing the cut point to 3 resulted in a decrease in sensitivity (74% for women and 94% for men), but an increase in specificity (93% for women and 75% for men).28 An AUDIT score of 8 had sensitivity and specificity of 62% and 97% for women and 93% and 77% for men, respectively.28 Whereas decreasing the cut point to 7 resulted in an increase in sensitivity and slight decrease in specificity for women (76% and 95%, respectively), there was a minimal increase in sensitivity and noticeable decrease in specificity for men (94% and 72%, respectively).28 To achieve the best balance of sensitivity and specificity for this study, we used different cut points that were based on gender. A positive TWEAK screen was defined as a score of ⱖ2 for women and ⱖ3 for men. A positive AUDIT screen was defined as a score of ⱖ6 for women and ⱖ8 for men. Participants were defined to be alcohol-positive when they screened positive on either the TWEAK or the AUDIT. e1024
Response Set
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Screening Preferences The questionnaire included a series of items that assessed parents’ preferences for the alcohol screening (eg, How would you feel if during your child’s well visit, your child’s doctor or nurse practitioner asked you about your use of alcohol? How comfortable would you feel about being asked about your alcohol use by each of the following people or methods?). Most of the items had a 4-option forced-choice response format to record the degree of agreement or acceptance. Data Analysis All data were entered twice into a Microsoft Access 97 (Redmond, WA) database. Any discrepancies were resolved by examination of the original data source. Response frequencies were computed for each survey item using SPSS 12.0 (Chicago, IL). Differences in demographic and alcohol screen–positive proportions by clinic site were assessed in Stata 9.2 (College Station, TX). Differences in demographic proportions by site were tested using Fisher’s exact test. Participants’ responses to being screened were analyzed with adjustments for the 3-site sampling design in SUDAAN 9.0 (Durham, NC). Site was the nest variable and participant was the primary sampling unit in a sampling with replacement design. Multivariable analysis, using generalized estimating equations, was conducted to assess potential
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TABLE 2 Demographics Based on Recruitment Site Demographics
Age 18–29 y 30–39 y ⱖ40 y Gender Female Male Relationship to child Mother Father Other family member Race/ethnicity White Black Asian Hispanic/Spanish/Latino Other Education Less than high school High school/some college College graduate Marital status Married, living with spouse Single, living with partner Not living with spouse or partner Reason for visit Well visit Follow-up Urgent care Other Alcohol screen results TWEAK-positiveb AUDIT-positivec Alcohol-positived
Overall (N ⫽ 879), n (%)
Site Suburban (n ⫽ 299), n (%)
Urban (n ⫽ 284), n (%)
Rural (n ⫽ 296), n (%)
162 (19.8) 343 (41.9) 313 (38.3)
19 (6.9) 136 (49.6) 119 (43.4)
53 (20.8) 103 (40.4) 99 (38.8)
90 (31.1) 104 (36.0) 95 (32.9)
729 (82.9) 150 (17.1)
250 (83.6) 49 (16.4)
225 (79.2) 59 (20.8)
254 (85.8) 42 (14.2)
714 (81.2) 150 (17.1) 15 (1.7)
249 (83.3) 49 (16.4) 1 (0.3)
221 (77.8) 59 (20.8) 4 (1.4)
244 (82.4) 42 (14.2) 10 (3.4)
.010
672 (81.3) 59 (7.1) 30 (3.6) 25 (3.0) 41 (5.0)
270 (95.7) 3 (1.1) 6 (2.1) 0 (0.0) 3 (1.1)
141 (55.5) 49 (19.3) 17 (6.7) 23 (9.1) 24 (9.4)
261 (89.7) 7 (2.4) 7 (2.4) 2 (0.7) 14 (4.8)
⬍.001
35 (4.1) 328 (38.9) 481 (57.0)
0 (0.0) 57 (19.9) 229 (80.1)
10 (3.8) 125 (47.1) 129 (49.0)
25 (8.5) 147 (49.8) 123 (41.7)
⬍.001
595 (70.7) 95 (11.3) 151 (18.0)
256 (89.5) 9 (3.1) 21 (7.3)
166 (63.8) 31 (11.9) 63 (24.2)
173 (58.6) 55 (18.6) 67 (22.7)
⬍.001
307 (35.1) 99 (11.3) 440 (50.3) 28 (3.2)
117 (39.1) 20 (6.7) 156 (52.2) 6 (2.0)
128 (45.9) 35 (12.5) 101 (36.2) 15 (5.4)
62 (20.9) 44 (14.9) 183 (61.8) 7 (2.4)
63 (7.2) 54 (6.2) 101 (11.5)
25 (8.4) 24 (8.1) 41 (13.7)
19 (6.9) 12 (4.2) 28 (9.9)
19 (6.5) 18 (6.1) 32 (10.8)
Pa
⬍.001
.110
⬍.001
.640 .160 .320
a Fisher’s
exact test for difference in proportion by site. positive is defined by a score of ⱖ2 for women andⱖ3 for men. c AUDIT positive is defined by a score of ⱖ6 for women and ⱖ8 for men. d Alcohol-positive is defined by screening positive on either the TWEAK or AUDIT. b TWEAK
confounding of bivariate associations by demographic variables. Model variable selection was accomplished using backward stepwise regression with variable entry and exit criteria of P ⬎ .20 for the change in maximum likelihood criteria.29 Multivariable analysis did not identify confounding by any demographic factors for the relationship between alcohol-screening status and likelihood of being definitely honest or being completely comfortable with screening administration method. Consequently, prevalence of responses and adjusted Wald 2 P values for the difference in proportions for alcohol-positive and alcohol-negative respondents are reported. RESULTS Overall, participants were mostly women (82.9%), the child’s mother (81.2%), white (81.3%), college graduates (57.0%), and married (70.7%) and had a mean age of 37 ⫾ 8.5 years (Table 2). Approximately half of the
participants had come to the clinic for a “sick visit/urgent care” appointment for their child. There was great variability across the sites in race, ethnicity, and socioeconomic status. Of the 3 sites, the urban site had a significantly higher proportion of participants identifying themselves as black (19.3%), whereas the suburban site had the largest proportion of college graduates (80.1%) and 2-parent/partner families (92.6%); however, there was no significant difference in the proportion of positive alcohol screen results across the 3 sites. Alcohol Problem Screening Approximately 1 in 9 parents (n ⫽ 101; 11.5%) screened positive on either the TWEAK or the AUDIT and are hereinafter referred to as “alcohol-positive.” A total of 778 participants were negative on both alcohol screens, hereinafter referred to as “alcohol-negative.” The alcohol-positive and alcohol-negative groups did not differ significantly with regard to gender, age, race/ethnicity, clinic site, marPEDIATRICS Volume 122, Number 5, November 2008
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73
Pediatriciana
52
Negative screen Positive screen
71
Computera
68
59
Nurse practitionera
54
44
20
40
83 65 78
Medical assistanta
26 0
84 64
Nursea
32
Medical assistanta
86 70
Nurse practitionera
34
Nursea
88 76
Paper/pencila
48
60
80
% completely comfortable
Negative screen Positive screen
76
Computera
54
Paper/pencila
89
Pediatriciana
55 0
20
40
60
80
100
% definitely honest
FIGURE 1 Likelihood of being completely comfortable when screened according to various personnel/methods on the basis of alcohol screen results. a P ⬍ .001.
FIGURE 2 Likelihood of being definitely honest when screened according to various personnel/ methods on the basis of alcohol screen results. a P ⱕ .002.
ital status, education level, pregnancy, parity, children’s age, or current receipt of counseling; however, those who were alcohol-positive were more likely to have ever had counseling (12.2% vs 5.4%; P ⫽ .01).
computer questionnaire compared with screening by a medical assistant. When compared with their male counterparts, more women reported being completely comfortable or definitely honest when screened by any of the various methods. In addition, the 2 gender groups differed in how alcohol screen status affected reports of comfort level and honesty. Among women, alcohol-negative and alcohol-positive participants differed significantly in comfort level and likelihood of being honest across all screening methods. For example, 50.0% of alcohol-positive mothers compared with 74.6% of alcohol-negative mothers reported being completely comfortable with screening by a pediatrician (P ⬍ .001). In contrast, among men, there were no significant differences between the alcohol-positive and alcohol-negative groups for either comfort level or honesty.
Alcohol Screen Acceptance The great majority (89%) of parents, regardless of their alcohol screen status, reported that they would welcome or not mind being asked about their drinking during the course of the pediatric office visit; however, a significantly greater proportion of alcohol-negative parents (91%) compared with alcohol-positive parents (77%) reported they would welcome or not mind alcohol screening (P ⬍ .001). Women (90.4%) were more accepting of being screened than men (84.5%; P ⫽ .04). Comfort With Screening Methods and Likelihood of Honest Response Alcohol-negative parents showed greater comfort with screening than alcohol-positive parents across all methods (all P ⬍ .001), even after adjustment for demographic characteristics (Fig 1). Of the 6 screening methods, parents in both groups felt most comfortable with screening by a pediatrician, computer-based questionnaire, or paper-pencil questionnaire. Among alcoholpositive parents, the proportion who endorsed completely comfortable was higher (P ⬍ .05) for computer questionnaire than for nurse practitioner and nurse. Responses about honesty followed a similar pattern; that is, the percentage of parents who reported being definitely honest were highest for screening by the pediatrician, by computer-based questionnaire, and by paper-pencil questionnaire (Fig 2). In adjusted analyses, alcohol-negative parents were more likely to report being definitely honest than alcohol-positive parents across all screening methods. Among alcohol-positive parents, the proportion who endorsed being definitely honest was higher (P ⬍ .05) for screening by a pediatrician and for e1026
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Acceptance of Interventions Among Alcohol-Positive Parents Overall, regardless of gender, most participants reported that, should they be found to have an alcohol problem, they would welcome or not mind the pediatrician’s talking to them about it (82%), giving them telephone numbers of treatment/assessment centers (74%), and educational materials about alcoholism (73%; Fig 3) Compared with alcohol-positive women, however, alcohol-positive men were more accepting of having no intervention (57% vs 26%; P ⫽ .02). DISCUSSION In this study, ⬃1 in 9 parents who brought their children for routine pediatric care had a positive alcohol screen, and the vast majority of parents were accepting of being screened for alcohol problems as part of the routine pediatric office visit. Alcohol-positive parents seemed equally accepting of being screened by the pediatrician, a computer-based questionnaire, or a paper-pencil survey. Moreover, with regard to interventions, alcohol-positive parents overwhelmingly preferred the pediatrician
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Pediatrician talk to me
84 75
Female Male
79
Telephone Nos.a
55
Educational materialsa
78 55 48
Notify MD
29
Notify family member
40 36
Schedule MD appointment
33 29 33
Refer to social worker
20 26
Do nothinga 0
20
57 40
60
80
100
% welcome/not mind FIGURE 3 Acceptance of interventions for alcohol screen-positive according to gender. a P ⱕ .05.
initiating additional discussion about their drinking and its effects on their child, giving them educational materials about alcoholism, and referring them for evaluation and treatment. These findings are consistent with results from our previous work17 and studies by others regarding the prevalence of parental alcohol problems and parents’ acceptance of being screened for alcohol problems18; however, prevalence of alcohol problems is determined by where one chooses to set the score cut point for a given alcohol screen. For this study, we used differential cut point scores on the basis of gender as informed by relevant studies in the literature,28,30–32 understanding that little has been published on the psychometric properties for our population of interest. Thus, our determination of the cut point scores was an extrapolation and best estimate. This study provides insight into the preferences and attitudes of the subgroup of parents with a positive alcohol screen. It is not surprising that alcohol-negative parents generally seem to welcome or not mind being screened for alcohol problems. Of greater importance is that ⬎75% of alcohol-positive parents were also accepting of alcohol screening. This finding should reassure pediatricians, because fear of a negative response to questioning has been cited as a potential barrier to alcohol screening.33 Alcohol-positive parents selected pediatrician, computer-based questionnaire, and paper-pencil questionnaire as their top 3 screening methods. The compelling endorsement of the pediatrician over other medical staff would suggest that there is a component to the parent– pediatrician dyad that makes this relationship unique and sets the pediatrician apart from other office staff. Parents may view parental alcohol screening as one of a multitude of topics that fall within the pediatrician’s purview. Parents also expressed a greater likelihood of being honest when screened by the pediatrician, computer-based questionnaire, or paper-pencil question-
naire compared with the other screening modalities. When considering possible implementation strategies, an alcohol screen administered by computer or paperpencil modalities are practical options. The screening tool could be incorporated into a preexisting health survey and completed by the parent before the clinical encounter. We also found a gender difference in parents’ comfort level for being screened. Alcohol-positive mothers were less comfortable being screened for alcohol use when compared with their alcohol-negative counterparts. This finding may be partly attributable to feelings of shame, embarrassment, and stigmatization associated with problematic alcohol use, as well as societal views that drinking is more acceptable in men than women; however, a direct link between the influence of gender and social desirability has not been found,34 specifically as it relates to substance abuse reporting.35 Despite this expressed discomfort, the majority of alcohol-positive mothers indicated that they would give an honest response during the screening process. Although we did not specifically address the issue of parents’ fear of losing custody as it relates to their comfort level or honesty with the alcohol screening, anecdotally, we do believe that parents may be reluctant to disclose the extent of their alcohol use because of such concern; however, we do not believe that this was an issue in this study because parents’ participation was completely anonymous. Although alcohol-positive parents suggested that they would be accepting of certain interventions, they clearly did not want pediatricians to notify their own doctor or family members or refer them to a social worker. Many parents may consider alcoholism as a “family secret” and feel reluctant to share the degree of their alcohol use with others.36–38 Parents’ desire to keep a positive alcohol screen between them and the pediatrician should be respected, except in unusual cases of child endangerment, because it protects the parents’ confidentiality. Last, fathers were more ambivalent than mothers about having the pediatrician provide an intervention for their drinking problem. Fathers’ indifference to having an intervention provided is actually an opportunity for pediatricians to intervene, because the most preferred screening method among fathers in our sample was having the pediatrician talk to them about their drinking; however, for this to be widely adopted, pediatricians will need more training in how to administer effective brief interventions. This study has several strengths, including its high participation rate. It is possible that parents who declined participation in the study were the ones with the most severe alcohol problems; however, if this is true, then our results represent an underestimation of the actual problem. The study sample was recruited directly from the population of interest, that is, parents presenting to pediatric ambulatory primary care clinics, and the sample size was large, particularly of the subgroup of parents with a positive alcohol screen. In addition, we used 2 well-validated alcohol-screening tests to increase the sensitivity for detecting parents with problem drinking. PEDIATRICS Volume 122, Number 5, November 2008
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There are also limitations. Despite our efforts to increase diversity, most of the sample was white, well educated, and English-speaking, which limits the generalizability of our findings. Future studies should plan to examine the comfort levels, attitudes, and perceptions among people with diverse ethnic backgrounds, because it would provide the opportunity to develop and implement culturally appropriate screening practices in the clinical setting. In addition, in the general population, alcohol use and associated alcohol problems tend to be markedly higher in men than women39; however, because the majority of our sample was female, the 11.5% of parents who were found to have a positive alcohol screen is likely an underestimation of the actual prevalence in families that consist of both male and female parents. Nonetheless, although there may be a bias, our results are a fair representation of parents bringing their children for care to a network of pediatric ambulatory clinics. Although parents endorsed pediatricians as the most preferred individual to conduct the alcohol screening, only 1 of the study sites used nurse practitioners as care providers. Thus, this finding could have been a reflection of parents’ lack of familiarity with the services provided by nurse practitioners. Although knowledge of their alcohol screen results may well have generated a different response to the screening preferences and intervention items, the alcohol-screening questions preceded the items about screening preferences and intervention; therefore, it is likely that parents had increased awareness of their level of alcohol use as a result of having just responded to the alcohol-screening questions. CONCLUSIONS Parents with problem alcohol use are accepting of alcohol screening in the pediatric office setting, as well as a variety of interventions, including referral for additional assessment and treatment. To treat their patients optimally, pediatricians must acknowledge the potential adverse effects of parental alcohol use on the patient and embrace the concept that parental alcohol use should be addressed with parents during the clinic visit. To provide such office-based intervention services, pediatricians will likely need additional clinic visit time, an adequate reimbursement structure, and organizational support. This study suggests that if pediatricians can implement a screening and intervention model, then there is already a population of parents who could surely benefit and may, indeed, be willing to take that first step. ACKNOWLEDGMENTS This study was supported by grant 051109 from the Robert Wood Johnson Foundation-Substance Abuse Policy Research Program. Dr Wilson was supported by a faculty fellowship grant from the Center of Excellence in Minority Health and Health Disparities at Harvard Medical School. We are grateful to Edith Munene, MA, Emily Kallock, LICSW, and Wendy S. Davis, MD, for assistance with study organization and implementation and Lori V. e1028
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PEDIATRICS Volume 122, Number 5, November 2008
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e1029
Parental Alcohol Screening in Pediatric Practices Celeste R. Wilson, Sion Kim Harris, Lon Sherritt, Nohelani Lawrence, Deborah Glotzer, Judith S. Shaw and John R. Knight Pediatrics 2008;122;e1022 DOI: 10.1542/peds.2008-1183 Updated Information & Services
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