One out of every 4 children in the United States is living

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1 Parental Alcohol Problems: Parents Preferences for Screening and Intervention in the Pediatric Office Setting Celeste R. Wilson, MD, Lon Sherritt, MPH, and John R. Knight, MD ABSTRACT Objective: To assess parents preferences for parental alcohol screening and intervention during pediatric office visits for their children. Design: Descriptive pilot study. Setting: Pediatric primary care clinic in a large urban tertiary care hospital. Participants: Parents or other caregivers bringing their children for medical care during 2 weeks in July/August Measurements: Participants completed a 31-item anonymous questionnaire containing demographic items, 2 alcohol screening tests (TWEAK and AUDIT), and forced-choice response items designed to assess preferences for who should perform alcohol screening, acceptance of screening, and desired interventions if the screening were positive. Results: 189 (71%) of 265 eligible parents/caregivers agreed to participate. 185 questionnaires were returned and analyzed. 12% screened positive on the TWEAK, 8% screened positive on the AUDIT, and 13% screened positive on either test. 93% of those who screened negative said they would welcome or not mind being screened for alcohol use versus 90% of those who screened positive; this difference was not significant (P = 0.66). 61% of parents/ caregivers preferred to be screened by the pediatrician, 16% by a questionnaire, 6% by a nurse or nurse practitioner, and 7% did not want to be asked about their alcohol use. If their screen were to suggest an alcohol problem, 52% preferred the pediatrician talk to them about their alcohol use and give them options for getting help. The least preferred intervention was to do nothing at all. Conclusion: 13% of parents screened positive for problem alcohol use. Most parents reported they would welcome or not mind being screened for alcohol problems as part of the routine pediatric office visit, and that the alcohol screening should be conducted by the pediatrician. If they were found to have an alcohol problem, the majority of parents would want the pediatrician to discuss their alcohol use with them and refer them for additional services. One out of every 4 children in the United States is living in a household with an adult who has an alcohol problem [1]. It is well known that parental alcohol problems can have a myriad of effects on a child s medical well-being and psychosocial development [2 4]. The problems of children of alcoholic parents are broad and variable in scope, spanning behavioral, mental health, cognitive, educational, and medical spheres [5,6]. In addition, children of alcoholic parents are at increased risk of being abused or neglected, witnessing domestic violence, and having an alcohol problem when they get older [7 10]. Despite the growing evidence regarding the beneficial effects of implementing an alcohol screening and brief intervention program in the primary care setting [11 13], research shows that pediatricians receive minimal formal training in the overall area of substance disorders [14,15]. Recognizing the important role that primary care providers can assume in the prevention, identification, and management of substance abuse, the American Academy of Pediatrics (AAP) advises that pediatricians be able to screen for and evaluate the nature and extent of substance use among patients and their families [16]. Moreover, the AAP recommends that pediatricians discuss with parents the effects that their attitudes and behaviors regarding alcohol can have on their children [17]. Within the area of tobacco use, strategies have been proposed for pediatricians to screen, intervene, and assist parents with smoking cessation [18 20]. However, the framework for approaching the issue of parental alcohol use is less developed. Potential barriers to screening include lack of time, poor reimbursement structure, and competing priorities for the (continued on page 152) From the Department of Medicine and Center for Adolescent Substance Abuse Research, Children s Hospital Boston, Boston, MA. 146 JCOM March 2006 Vol. 13, No. 3

2 (continued from page 146) pediatric clinic visit. Lack of knowledge in managing the parent with problem alcohol use and fear of a parent s negative response to questions regarding their alcohol use have also been cited by pediatricians as barriers to parental alcohol screening in the pediatric office setting [21]. However, whether parents actually exhibit negative responses to being screened for alcohol problems has not been fully supported by the literature. In fact, 1 prior study found that 17% of mothers bringing their children to the pediatrician screened positive for alcohol problems and more than 85% reported that they would welcome or not mind being asked about their alcohol use by their child s health care provider [22]. Similarly, another study found that parents feel that providers should ask about alcohol/drug use in the household [23]. Although researchers have identified parent substance use as an area of care that needs to be explored to improve the preventive and developmental services for young children [24], a MEDLINE search revealed no studies that have assessed parents preferences for how the alcohol screening should be conducted in the pediatric office setting and parents desired interventions should the screen be positive. The objectives of this study were (1) to determine the prevalence of parents/ caretakers screening positive for alcohol use as measured by 2 self-administered assessments (ie, TWEAK [25] and AUDIT [26,27]); (2) to determine parents /caretakers level of receptiveness to being asked about alcohol, cigarettes, depression, and home violence by their child s pediatrician; (3) to determine by what means parents/caretakers would most prefer being asked about alcohol use in the pediatric office setting; and (4) to determine what intervention(s), if any, parents/ caretakers would consider appropriate if they should screen positive for alcohol problems when bringing their child for routine pediatric care. Methods This was a descriptive pilot study conducted during 2 weeks in July/August Participants were parents/caregivers, age 18 years or older, bringing their children for routine medical care to a hospital-based pediatric primary care clinic. We excluded those who were unable to read or understand English (n = 15) or who presented with a medically unstable child (n = 0). Assessment Battery Our measure was a 31-item questionnaire containing demographic items, 2 validated alcohol screening tests, and forcedchoice response items assessing screening preferences. Demographic items included questions on age, ethnicity, marital status, highest grade completed, number of children living in the household, and age of the youngest child in the household. We used 2 alcohol screening tests in parallel to increase the sensitivity of problem alcohol use detection. The TWEAK [25] is a 5-item self-administered scale that has been validated among women. TWEAK is an acronym for the questions contained in the scale related to: Tolerance, Worried, Eyeopener, Amnesia, K(Cut) down. A 7-point scale is used to score the test. For the tolerance question, participants received 2 points if they reported being able to hold 6 or more drinks. A positive response to the worry question received 2 points, and a positive response to the last 3 questions received 1 point each. A total score of 2 or more was considered concerning for problem drinking. AUDIT [26,27] (Alcohol Use Disorders Identification Test) is a 10-item selfadministered screening questionnaire. It contains 3 scales that assess amount and frequency of drinking (3 questions), alcohol dependence (3 questions), and problems caused by alcohol (4 questions). The total score can range from 0 to 40. Acutscore of 8 or greater was used as indication of hazardous or harmful alcohol consumption. Both the TWEAK and AUDIT have been shown to be good alcohol screening tests for identifying past year alcohol abuse or dependence in both black and white women [28]. The sensitivity and specificity of the TWEAK has slight variability depending on ethnicity. That is, in black women, the TWEAK has a sensitivity/specificity of 80% and 94% compared with its psychometric values for white women, 71% and 90%, respectively [29 31]. Using a cut-score of 8 or greater, the AUDIT has been found to have good specificity among black and white women, 97% and 93%, respectively; however, the sensitivity values of 63% (black) and 59% (white) are notably lower [29 31]. Participants were asked to indicate their most and least preferred intervention (eg, no intervention, contact family member, contact their physician, give educational materials, referral information of treatment centers, pediatrician talk to me about my alcohol use) should it be determined they have an alcohol problem. They were also asked to indicate their feelings (eg, welcome, not mind at all, mildly annoyed, very annoyed) [22] if asked about alcohol use, depression, home violence, and cigarette use. Participants were also asked to indicate the person or method by which they would most prefer being questioned about their alcohol use (eg, pediatrician, nurse practitioner, nurse, medical assistant, office screening questionnaire using paper/pencil, anonymous interactive computer-based questionnaire, don t want to be asked about alcohol use). The total time required to complete the entire assessment battery was approximately 10 minutes. Procedure A research assistant invited parents to participate while they were waiting for the clinician to see their child. Parents/ caregivers completed the questionnaire, which did not include any identifying information, and placed it in the clinic 152 JCOM March 2006 Vol. 13, No. 3

3 ORIGINAL RESEARCH drop box. Those parents/caregivers who were unable to complete the questionnaire during the course of the clinic visit were given the option of returning it by mail. A parent s/caregiver s willingness to complete the questionnaire served as informed consent for their participation. All parents/caregivers received educational materials and a merchandise certificate as a token of appreciation for their participation. This protocol was approved by the Children s Hospital Committee on Clinical Investigations. Data Analysis All data were entered twice into Microsoft Access 97 (Redmond, WA). The dual files were compared to identify entry errors, and discrepancies were reconciled by checking the original data source. The cleaned dataset was then imported into SPSS 10.0 (Chicago, IL) for analysis. Frequencies and comparative statistics were computed. As mentioned, participants who scored 8 or more on the AUDIT and/or 2 or more on the TWEAK were considered to have a positive alcohol screen. Results Of 265 eligible parents, 189 (71%) agreed to participate, and 185 completed questionnaires were analyzed. Four participants did not complete the questionnaire and were eliminated from the analysis. Participants mean age was 32 ± 10 years. For the purpose of analysis, age was dichotomized at the mean yielding 2 age categories: younger (age < 32 years) and older (age 32 years). The sample included a large proportion of individuals from racial/ethnic minority groups (83.2%). There was a minority of white non-hispanic participants (13.5%). Participants ranged in education level, with over half having at least some level of college training. Married participants comprised a relatively small proportion (40%) of the sample. More than 90% of participants were a parent to the child they were bringing for the clinic appointment. The majority of participants were mothers (75.7%). However, other caregivers (4.3%) including grandparents, aunts, uncles, and a nurse were also represented. Approximately 75% of participants had a child younger than 6 years of age living in their home. Table 1 presents the demographic characteristics of participants based on their alcohol screening category. Of the 185 questionnaires, 176 yielded sufficient data to allow adequate scoring of either the TWEAK or AUDIT. Thus, 9 questionnaires were excluded from alcohol risk comparisons due to incomplete responses to the alcohol screening test items. Twenty-three participants screened positive on either the TWEAK or AUDIT and will be referred to hereinafter as alcohol-positive. Of the 176 questionnaires, 164 participants completed all of the TWEAK items and 167 completed all of the AUDIT items. Twenty (12.2%) participants screened positive on the TWEAK and 13 (7.8%) screened positive on the AUDIT. There were no substantial differences Table 1. Demographic Characteristics for Alcohol Screening Category Alcohol- Alcohol- Overall* Positive Negative P Characteristic N = 185 N = 23 N = 153 Value n (%) Overall 23/ /176 (13.1) (86.9) Age Younger (< 32 yr) 92 (49.7) 11 (47.8) 76 (49.7) Older ( 32 yr) 90 (48.6) 10 (43.5) 76 (49.7) Race/ethnicity Black 97 (52.4) 11 (47.8) 84 (54.9) White 25 (13.5) 2 (8.7)0 22 (14.4) Hispanic 37 (20.0) 4 (17.4) 31 (20.3) 0.11 Asian 5 (2.7) 0 5 (3.3) Other 15 (8.1)0 5 (21.7) 8 (5.2) Education Less than high 13 (7.0) 3 (13.0) 9 (5.9) school High school 063 (34.1) 14 (60.9) 43 (28.1)0 graduate Some college 053 (28.6) 03 (13.0) 48 (31.4) College graduate 035 (18.9) 1 (4.3) 34 (22.2)0 Beyond college 13 (7.0) 1 (4.3) 15 (9.8)00 Other 03 (1.6) 0 3 (2.0)0 Marital status Single 091 (49.2) 15 (65.2)0 71 (46.4)0 Married 074 (40.0) 04 (17.4)0 67 (43.8)0 Separated 05 (2.7) 01 (4.3)00 4 (2.6) Divorced 11 (5.9) 02 (8.7)00 8 (5.2)0 Widowed 02 (1.1) 0 2 (1.3)0 Relationship to child Mother 140 (75.7)0 11 (47.8)0 121 (79.1)0 Father 31 (16.8) 9 (39.1) 22 (14.4) Other 8 (4.3) 0 9 (5.9) Not indicated 3 (1.6) 3 (13.0) 1 (0.7) Age of youngest child at home < 2 yr 98 (53.0) 13 (56.5) 81 (52.9) 3 6 yr 40 (21.6) 03 (13.0) 35 (22.9) > 6 yr 41 (22.2) 04 (17.4) 34 (22.2) No children at 4 (2.2) 2 (8.7) 2 (1.3) home *Columns may not sum to expected N due to missing or invalid data. Participants were considered alcohol-positive if they had a TWEAK score of 2 and/or an AUDIT score of 8. P value for alcohol-positive versus alcohol-negative. Vol. 13, No. 3 March 2006 JCOM 153

4 Table 2. Frequency and Percentage of Acceptance of Screening for Alcohol Use, Cigarette Use, Depression, and Home Violence and Subsequent Alcohol Screen Result Welcome/Not Mind* Alcohol- Alcohol- Overall* Positive Negative N = 185 N = 23 N = 153 P n (%) Alcohol use 142/155 18/20 123/ (91.6) (90.0) (92.5) Cigarette use 144/155 19/21 124/ (92.9) (90.5) (93.9) Depression 139/153 17/20 121/ (90.8) (85.0) (92.4) Home violence 140/153 18/19 121/ (91.5) (94.7) (91.7) *Columns may not sum to expected N due to missing or invalid data. Participants were considered alcohol-positive if they had a TWEAK score of 2 and/or an AUDIT score of 8. between those participants with a positive TWEAK versus AUDIT score across demographic categories. One hundred fifty-three participants had a negative alcohol screen and will be referred to as alcohol-negative. Compared with alcohol-negative participants, alcohol-positive participants were significantly less educated (Mann Whitney U test, P = 0.002) and significantly less likely to be the mother of the child they were bringing to clinic (alcohol-positive 48% versus alcohol-negative 79%; Fisher s exact test, P = 0.003). There was no significant difference between the 2 groups as to age, race/ethnicity, marital status, and age of the youngest child living in their home. Table 2 presents the distribution of participants acceptance of being screened in the pediatric office for alcohol use, cigarette use, depression, and home violence based on their alcohol screen result. Overall, more than 90% of participants reported that they would welcome or not mind being screened for alcohol use, cigarette use, depression, or home violence. There was no significant difference between alcohol-positive and alcohol-negative participants on any of these screening topics. Table 3 presents frequency and percentage of preferred person/method for alcohol screening by alcohol screening status. Overall, more than 60% of participants chose the pediatrician as the preferred person/ method by which they wanted to be screened. This finding was consistent regardless of the participant s alcohol screening category. Of the alcohol-positive participants, 4 (17.4%) indicated that they did not want to be asked about their alcohol use. Although this is a small number, when compared Table 3. Frequency and Percentage of Preferred Person/ Method for Alcohol Screening by Alcohol Screening Status Preferred Alcohol- Alcohol- Screening Overall* Positive Negative Method N = 160 N = 23 N = 137 P with the 7 alcohol-negative participants (5.1%) who chose the same response, the magnitude of the difference suggests a trend toward significance (Fisher s exact test, P = 0.06). Analysis of frequencies of most preferred interventions should the alcohol screen be positive revealed that, overall, the most highly endorsed intervention (51.6%) was for the pediatrician to talk to me about my drinking, discuss how it would affect me and my child, and give me options for getting help. Only one person wanted the provider to do nothing should the alcohol screen be positive. The responses did not differ significantly by alcohol screening category. Discussion n (%) Pediatrician 98 (61.3) 14 (60.9) 84 (61.3) 1.0 Office screening 14 (8.8)0 1 (4.3) 13 (9.5) questionnaire Anonymous 12 (7.5) 2 (8.7) 10 (7.3) 0.69 computer-based questionnaire Nurse practitioner 8 (5.0) 1 (4.3)0 7 (5.1) 1.0 Nurse 2 (1.3) 0 2 (1.5) 1.0 Medical assistant 2 (1.3) 0 2 (1.5) 1.0 Don t want to be 11 (6.9)0 4 (17.4) 7 (5.1) 0.06 asked about my alcohol use Other 13 (8.1) 1 (4.3) 12 (8.8) 1.0 *Overall, data were classified as missing or invalid for 25 of the participants. Participants were considered alcohol-positive if they had a TWEAK score of 2 and/or an AUDIT score of 8. Data were classified as missing or invalid for 25 of alcoholnegative participants resulting in 137 responses to this item that were interpretable. Responses included none, n/a, anyone. This study shows that the majority of parents/caretakers would welcome or not mind being screened for alcohol problems during the pediatric clinic visit. Parents indicated that they wanted the pediatrician to conduct the screening as opposed to another office personnel or screening method. This finding was not surprising, as the pediatrician already has an established relationship with the family and is in an ideal position to inquire about sensitive social factors which can ultimately influence a child s well-being. Such factors 154 JCOM March 2006 Vol. 13, No. 3

5 ORIGINAL RESEARCH would include, but are not limited to, alcohol use, cigarette use, depression, and home violence. In situations when the alcohol screen is positive, parents/ caretakers would prefer that the pediatrician engage them in discussion about their alcohol use, its far-reaching ramifications, and treatment options. This alternative was preferred to contacting a family member, referring to a social worker, or giving educational materials. Our findings show that parents want the pediatrician to take an active role in both screening them for alcohol problems and intervening should a problem exist. However, pediatricians will likely need additional support and training if they are expected to provide this service. We found that 13% of parents/caretakers screened positive for alcohol problems. This figure is consistent with the national estimated prevalence of adults with alcohol problems [32]. Parents/caretakers with a positive alcohol screen had less college experience and were more likely to be male. More specifically, they were the father of the child they were bringing to the clinic visit. This finding has implications for screening practices. Given the increased likelihood that a father accompanying his child to the pediatric clinic visit will have an alcohol problem, careful consideration should perhaps be given to differential screening of this particular subgroup. Although pediatricians may be hesitant to screen parents for substance use because of their concerns about the parent becoming defensive or angry [21], the reality of these concerns was not confirmed in our study. Regardless of their alcohol screening category, parents reported that they would welcome or not mind being screened for their alcohol use. However, given the small sample size of participants with a positive alcohol screen, this finding has low power. Future studies should examine this question in larger samples of parents. Strengths of our study include that it was conducted in a busy pediatric primary care clinic and the broad racial/ ethnic diversity of the sample. The questionnaire was anonymous; therefore, parents/caregivers could be forthcoming with their responses. Respondents may have been less likely to have been completely truthful had their anonymity not been assured. Future studies are needed to address parents degree of willingness to be honest when screened by various personnel/methods. In addition, we used 2 alcohol screening tests in parallel to increase the sensitivity of detecting parents/caretakers with problem alcohol use, given that there is often a high degree of stigmatization surrounding one s use of substances. In practice, a clinician could easily ask the 5 questions contained in the TWEAK assessment. The longer 10-item AUDIT assessment would mostly likely be used as a self-administered screen. There are several study limitations. There were a small number of participants screening positive for alcohol problems. As a result, interpretation of the analysis on this subgroup must be considered preliminary. In addition, the scoring of the screening tests did not take into account potential physiologic differences between males and females. Future studies should consider using differential scoring based on gender. Parents were not informed of their alcohol screen results. Knowledge of their results may have changed their preferences for screening methods and intervention. It is possible that the hypothetical nature of some of the items may have rendered them meaningless to alcohol-negative respondents. Also, approximately 13.5% of respondents were found to have entries that were missing or invalid. We conclude that parents/caretakers welcome or do not mind being screened for alcohol problems in the pediatric office setting. They prefer the pediatrician conduct the screening as opposed to another person or method. If the screen is positive, they would want the pediatrician to discuss their drinking and refer them for additional services. Future studies are needed to explore what practice changes would be needed to facilitate the screening of parents in the pediatric office setting, whether pediatricians feel that this is their role, and whether they are receptive to assuming this responsibility. Acknowledgments: The authors thank Daniela Jodorkovsky, BA, and Sarah Rosenberg, BA, for their assistance with study implementation; and Joanne Cox, MD, and the clinicians and staff of the Children s Hospital Primary Care Center at Children s Hospital Boston for assistance with recruitment. Corresponding author: Celeste R. Wilson, MD, Children s Hospital Boston, 300 Longwood Ave., Boston, MA Funding/support: This project was supported by a grant from the Children s Hospital Boston Awards Committee of the Research Faculty Council and from grant R01 AA A1S1 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Other support (JK) provided by grant K07 AA from NIAAA and grant T21MC from the Maternal and Child Health Bureau. Financial disclosures: None. Author contributions: conception and design, CRW, LS, JRK; analysis and interpretation of data, CRW, LS, JRK; drafting of the article, CRW, JRK; critical revision of the article, CRW, LS, JRK; statistical expertise, LS; obtaining of funding, CRW, JRK; administrative or technical support, CRW, JRK; collection and assembly of data, CRW, LS. References 1. Grant BF. Estimates of US children exposed to alcohol abuse and dependence in the family. Am J Public Health 2000;90: Emshoff J, Price A. 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