What is the recommended approach for a drug screen in a child at the request of parents?

Drug Screening in Children at Parents' Request

Drug testing of a child at a parent's request should involve obtaining the adolescent's assent and permission to share results, discussing the limitations of testing, and establishing an action plan for both positive and negative results before proceeding. 1

Initial Assessment Before Testing

• Before agreeing to drug testing, the pediatrician should:
  • Get a detailed description of parental concerns
  • Formulate a differential diagnosis for the behavioral changes
  • Determine if drug testing would be a helpful part of assessment
  • Discuss limitations of testing with parents (false positives/negatives, detection windows)
  • Establish a consensus on action plans for both positive and negative results 1

Approach to the Adolescent

• Discuss the concerns raised by parents with the adolescent
• Explain the recommendation for drug testing
• Obtain the adolescent's assent and permission to share results
• If the adolescent refuses consent to share results, do not share them with parents 1
• Explain to parents that their child has not consented to release if this occurs

Testing Considerations

• Urine drug screens are the most common testing method
• Ensure specimen integrity testing (creatinine) is included with each sample
• Be aware of detection windows for different substances
• Consider that many substances may not be detected on standard panels:
  • Synthetic cannabinoids are not detected on standard cannabinoid screens
  • Methylphenidate is not detected on routine amphetamine panels
  • Not all benzodiazepines are detected on standard benzodiazepine screens 1

Managing Test Results

Positive Results

• Review positive results first with the adolescent privately
• Ask for additional information that might explain results
• Consider both laboratory results and history before determining likelihood of substance use
• If the adolescent's report matches test results, discuss next steps (abstinence trial, ongoing testing, referral to counseling)
• If adolescent denies use despite positive results, present information to parents (if consent obtained) 1

Negative Results

• Can support history of no recent drug use and reassure parents
• Do not dismiss ongoing behavioral or mental health symptoms because of negative results
• Consider mental health evaluation if behavioral concerns persist
• Remember that a single negative result does not exclude possibility of drug use 1
• Consider potential for:
  • Substituted/adulterated/diluted samples
  • Use of substances not detected by test panel
  • Missed detection window

Home Drug Testing

• The American Academy of Pediatrics does not endorse home drug testing due to:
  • Complexity of testing
  • Potential for parents to misinterpret results
  • Limited evidence that home testing reduces drug use
  • Potential negative impact on parent-child relationship 1
• Professional evaluation is recommended whenever parents have substance use concerns

Common Pitfalls to Avoid

1. Breaching confidentiality: Only share results with parents if the adolescent has consented, unless there's acute risk of harm 1

2. Misinterpreting results: Drug tests can yield false-positives (e.g., fluoroquinolone antibiotics) and false-negatives (e.g., diluted samples, substances not on panel) 1

3. Relying solely on testing: Clinical decisions based on history and physical examination should not be discounted due to inability to obtain a drug test 1

4. Dismissing ongoing concerns with negative results: Consider mental health evaluation for persistent behavioral issues despite negative drug tests 1

5. Testing without a plan: Establish how results will be used before ordering tests 1

By following these guidelines, pediatricians can appropriately respond to parental requests for drug testing while maintaining the adolescent's trust and providing appropriate care for potential substance use issues.