Pediatric Case Studies
A 14-yr-old male patient presents to your clinic complaining of sore throat and cough. He has been feeling ill for about 1 week, and has had no fever, nasal congestion, or runny nose. He says he feels tired and his mom states that he hasn't been getting out of bed to go to school for the past few days.
He is a previously healthy young man without any significant medical history. Physical examination is remarkable only for a mildly erythematous throat without petechiae.
Lungs are clear, and the rest of his exam is normal. Vital signs are also within normal limits.
A rapid strep screen is negative and you diagnose him with a viral syndrome and recommend symptomatic relief.
The patient and his mother return the next week as he is still complaining of a sore throat. Mom seems most concerned that he is much less active than he usually is and that he has been truant from school.
You question him about how he is feeling, and he tells you that his "mom just won't get off [my] back." With further questioning, it is revealed that he has had a marked change in his performance at school and that he no longer plays on the soccer team.
At that point, you ask the patient if he would like to talk to you without his mom present (with her permission, of course).
When you are able to talk alone, he confides that he has been smoking pot at least once every day for the past month or so. He doesn't think that this is a "big deal" and states that "everyone he knows does it too."
Questions For Health Care Professionals
- A. How would you approach the patient (either cooperative or resistant)?
- B. What data do you need to collect or what initial screening should be done?
- C. What other medications/drugs/alcohol is the patient using?
- D. What internal/external obstacles and biases might the patient/parent face?
- E. What internal/external obstacles and biases might the physician face?
- F. What do you do now?
- G. How does the physician make a referral?
- H. When and how should the physician follow up with the patient?
(The goal is to develop a positive, non-judgemental rapport with the patient.)
- Use your rapport. You can best help a patient if they see you as ally rather than a threat. Try not to be accusatory or derogatory in your discussion.
- Use a neutral, matter of fact, tone of voice
- Acknowledge it may be difficult for the patient to share this information.
- Don't be judgmental in your attitude toward the patient or the parent. The more of a nonjudgmental stance you portray, the more likely the patient is to reveal information.
- Display compassion and concern.
- Phrase your questions appropriately. For example, ask, "Tell me about your alcohol use," instead of "Do you drink?" And "What kinds of drugs do you use?" instead of "Do you use drugs?" (Avoid the term "illegal drugs".)
- Don't be afraid to explore the issue. Ask what his knowledge about marijuana and other substances is. Ask if he knows about the risks and side effects of these substances. Phrasing the questions without judgment is very important. It may be helpful to say, "Would you like to know about the side effects that these substances have on your body?"
- Ensure confidentiality but explain that his mother needs to be told about his marijuana use. Help him develop a strategy to tell her himself.
- If patient is resistant, acknowledge that it is difficult and uncomfortable and explain that you believe this is a health issue and is part of your over all approach to patients. Continue to gently ask questions.
- Allow any resistance, pre-contemplation, and minimization to be okay. Avoid any power struggles. At this time it is unnecessary for the patient to admit that he has a problem.
- Be redundant. If your questions are not being completely answered ask again. Be Patient.
- This patient is engaging in high-risk behavior, and it is having negative consequences in his life. It is also likely affecting his health.
- According to the DSM IV, an addiction is defined by the biopsychosocial consequences of use, not just frequency and amount. Administer the AUDIT or ask the following questions:
- When did you first start smoking pot? How often? How much?
- Have you tried to cut back before? What happened?
- Does it take you more pot to feel intoxicated than it used to?
- Have you ever had periods where you don't recall what you did while you were smoking?
- Have you ever had to smoke first thing in the morning in order to calm your nerves?
- Has anybody ever told you that they think you smoke too much?
- Have you ever been in treatment for alcohol or drug abuse?
- Have you ever had any alcohol or drug-related arrests?
- Have you ever missed work, school, or family responsibilities because you were too high or hung over?
- Do you find that you are depressed after an episode of smoking?
- Do you have arguments with people in your life regarding your behavior while you are high?
- Would you consider cutting down your marijuana intake?
- Who else in the patient's life uses alcohol or other substances?
- The parent/parents need to be involved in this process. Help your patient understand that his mom needs to be told about his substance use so that you may begin to work through this together. Explain that you would prefer that he tell her himself, but if he refuses, you must tell her.
- Once the parent is informed, assess their level of knowledge about substance use and also try to ascertain what their attitude is toward marijuana use. Is there a history of substance use/abuse in the family? Again, explore the issue with the parent as you did with the patient. It may be helpful to talk to them individually as well as together.
- If either the patient or parent becomes resistant or uncooperative try to reassure them that you are gathering this information to provide the best care for his health. If they remain resistant then ask them what they would like to do, ask them if you could ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient/parent being in the pre-contemplation stage of change.
- Ask specifically about "pills." Such as "Do you ever take any kind of pills?" and "Do you ever take anyone else's pills?" (Note: It is important to ask specifically about pills, as many people do not consider pills to be drugs of abuse.)
- Ask about alcohol consumption, including what type of alcohol, amount consumed, and frequency.
- Review history of other illegal drug use. If currently using other illegal drugs, ask questions as noted in section B. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your drug use." Or ask specifically about certain drugs such as "tell me about your marijuana use.")
(The goal is to determine how receptive/resistant the patient and parent will be to a discussion regarding his drug use. The physician needs to be aware of the internal/external stigma and biases that the patient and parent face. The physician will need this information to determine how best to approach the patient.)
- Fear of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an addict
- Embarrassment and shame
- Fear of rejection by friends or culture
- The patient's belief that his smoking marijuana is not problematic
- The parents' belief that his smoking marijuana is not problematic
- Lack of insurance for treatment
- Residing with a substance user/abuser
- Fear of legal ramifications if they feel they are divulging sensitive information
- Society's stigma and blame
- Belief that addiction is a moral issue and not a medical issue
- Lack of treatment availability (affordability, waiting-lists, services not available in community)
- Physician's discomfort with addressing substance abuse issues
- Physician uses his or her own pattern of drinking/substance use as a barometer of what is alcohol misuse. (Physician may be drinking as much without significant clinical impairment.)
- Time constraints
- Physician's family history causes countertransference (misperceptions based on personal experiences).
F. What do you do now?
(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)
- Discuss evidence for concern (school failure, relationship problems with parent, physical symptoms from smoking)
- Display compassion (Remember that addiction is a life threatening disease thus show the same sensitivity as you would for identifying any other life-threatening illness, such as cancer.)
- Provide reassurance that it is treatable
- Ask the patient and parent how they feel about your concerns
- Address the stigma associated with having an addiction by reassuring the patient and parent that this is a medical illness and not a question of moral character
- Assuming that the patient is not in need of treatment, physician can initiate discussion of a plan for reduction or elimination of smoking marijuana. This might include exercise, finding new friends who are not users, dealing directly with stress producing problems, as well as a specific strategy for reducing or eliminating smoking.
G. How does the physician make a referral?
If it is clear that there is significant clinical impairment in the patient's biopsychosocial functioning as a result of his marijuana use. The patient should be referred to a substance abuse treatment provider for further evaluation and treatment.
If the patient is receptive:
- If the patient does not have insurance that covers substance abuse treatment, or does not have the ability to pay for treatment, or if the physician has no knowledge of substance abuse treatment agencies, refer to SL County Division of Substance Abuse at 468-2009 or refer directly to Interim Group Services.
- Ideally physicians should begin to develop relationships with substance abuse treating agencies and can refer to a specific agency for treatment. However, the physician should encourage the patient to call his insurance company to determine what services are covered.
- Regardless of the specific referral, the physician should list the name of the agency and the phone number on a prescription blank and give to the patient.
If the patient is not receptive:
- If the patient and/or parent remain resistant then ask them what they would like to do, give them the referral on a prescription, and encourage them to consider following through with the referral.
- Ask the patient and parent if you can ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient being in pre-contemplation stage of change.
H. When and how should the physician follow up with the patient?
(This provides the physician with the opportunity to coordinate with other services provides to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)
If there was a referral:
- Physician should provide referral information to the treating agency regarding concerns and respond to any requests for information from the treating agency.
- Physician should ask the patient/parent if they followed up with their referral and discuss resulting actions. Reinforce and encourage continued participation in treatment.
- In case of severe addiction, physician should coordinate directly with treating agency.
If there was no referral:
- Discuss patient's progress toward reducing or eliminating marijuana usage. Ask specifically about activities or strategies that the patient used to accomplish that goal. Congratulate successes.
- If patient is making no progress and appears to be struggling in this area, then provide referral as noted above.