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Every pediatrician will face the issue of impaired parents and caregivers at some point in their career. A recent report offers some advice on handling those situations.
Confronting problems with drug and alcohol abuse isn’t an issue reserved for only those clinicians treating adults-it’s a common problem in pediatrics, too. A recent report in Pediatrics1 details the scope of the problem, as well as provides guidance for how to handle impaired caregivers in clinical practice.
Steven Bondi, JD, MD, assistant professor of Pediatrics at the University of Rochester, New York, and the lead author, says the goal of the paper was to highlight for pediatricians that this is a big issue in every population, and one they absolutely will face in their careers.
“This is a common problem. Alcohol and drug misuse is incredibly prevalent in our society,” Bondi says. “This is a problem that every pediatrician should expect to see during his or her career. Be ready.”
How big is the problem?
An estimated 8.7 million children in the United States2 live with a parent or caregiver who has a substance abuse disorder, according to estimates from the US Department of Health and Human Services. Most of these children-7.5 million-live with a parent who has an alcohol use disorder, and about 2 million have a parent with a drug abuse disorder. The impact of a caregiver’s drug or alcohol abuse on a child can be profound, and pediatricians play a pivotal role in helping to recognize and mediate these risks.
Pediatricians have many areas for concern when it comes to an impaired caregiver, primarily in assessing the safety of the environment for the child. There are ethical and legal considerations to assessing and reporting the impairment of caregivers, and there also is an impact to the physician-patient relationship and trust. First and foremost, clinicians should be prepared to act immediately in cases of immediate danger, such as a caregiver driving with a child when impaired. Confrontations within the medical practice can be difficult and should generally be avoided, according to the report, but in cases of impaired driving, a clinician is advised to first try and secure alternate transportation-such as calling a cab-and to contact law enforcement if needed.
When does the pediatrician have to act?
There are times when a pediatrician should not, and cannot, look away from these problems. Pediatricians are required to look out for the best interests of their patient, even if it causes problems for the caregiver. Pediatricians are subject to mandated reporting requirements and have a duty to act when safety is a concern.
“Social services reporting is mandated whenever there is a reasonable suspicion of abuse or neglect,” Bondi says. “The key phrase here is reasonable suspicion. That's a pretty low threshold in theory but can be challenging in practice. Fundamentally, the question to consider is whether the child is safe. It's really important to remember that in an acute situation-like the child is going to ride in a car with an impaired person-law enforcement should be contacted first because officers can respond immediately.”
Guidance for confronting the caregiver
The report includes a number of recommendations for pediatricians to use in dealing with impaired caregivers. The first is to conduct a safety audit of the practice, and to train staff on how to recognize and intervene as needed. Reporting any confrontation is another task that must be considered. In cases wherein confrontations or concerns about a caregiver’s impact on patient safety, a clinician’s duty to the patient overrides any considerations for confidentiality in regard to the parent or caregiver.
Even when a confrontation is required, Bondi says his hope is that pediatricians confront impaired caregivers as he hopes they would approach anyone-with kindness and respect.
“The conversation with an impaired caretaker may be quite difficult for the pediatrician, for the parent, and for the child,” Bondi says. “It's best to find a discreet but safe area where the conversation can be had. I think framing everything as concern for the child is a great way to get through to the caretaker.”
Another consideration is the fact that impaired caregivers may be unable or unwilling to give consent for medical treatment. The report suggests that nonurgent treatments be delayed until consent can be obtained, and that the pediatrician should be sure to document conversations and concerns in regard to delayed care.
Overall, Bondi says he hopes pediatricians realize how often they will face impaired caregivers and to be prepared for it.
“Encountering an impaired caregiver is something many pediatricians likely have never thought about. Having to react in the heat of the moment and not having previously considered this problem could result in a less than ideal interaction,” Bondi says. “It is my hope that at a minimum clinicians will read this report and tuck away the points that we raised. Thus, they won't be completely blindsided when it comes up. Of course, ideally practices would consider these issues thoroughly and train staff based on the issues we raise.”
1. Bondi, SA, Scibilia J; Committee on Medical Liability and Risk Management. Dealing with the caretaker whose judgment is impaired by alcohol or drugs: legal and ethical considerations. Pediatrics. 2019;144(6):e20193153. Available at https://pediatrics.aappublications.org/content/144/6/e20193153#ref-1. Accessed February 11, 2020.
2. Lipari RN, Van Horn SL. Children living with parents who have a substance use disorder. In: The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2013. Available at: https://www.ncbi.nlm.nih.gov/books/NBK464590/. Published August 24, 2017. Accessed February 11, 2020.