Adolescent behavioral health problems are on the rise worldwide, particularly for impulse control disorders (ICDs) including substance abuse, delinquency, obesity, and HIV/sexually transmitted diseases (STDs) for genetic and environmental reasons. Contributing to these developmental issues are children growing up in families of substance abusing, depressed, highly stressed, and dysfunctional parents. Even simple things such as the diminishing number of family meals eaten together has been found to have a negative impact on adolescent’s risk for substance use and negative youth development.fn1
Substance abuse has been a concern for many years, but recently there have been alarming rates of increasing adolescent tobacco, alcohol, and drug use worldwide, particularly in girls and women. In many developed countries, adolescent legal and illegal substance use has been rising for the past 5 years. along with concerns about youth risky consumption patterns in Europe and the United States. In the United States, 2014 resulted in nonsignificant decreases in adolescent substance use mostly because of a decrease in marijuana use. The biggest recent increase in substance use in adolescents has been in the use of party drugs—prescription drugs, binging on alcohol, and prescription drug misuse and e-cigarettes. The use of e-cigarettes is now higher than use of regular cigarettes, the use of which has decreased since 1992. Of course, teen alcohol misuse and accidents is the major cause of teen mortality. Traditional gender differences have narrowed in the United States and most countries. Girls have higher rates of tobacco and alcohol use in the 8th grade; however, by 10th grade, boys generally catch up.
The misuse of alcohol and other drugs has a significant impact on the global health and economy as well as the well-being of children and families. It is estimated that around 48% of adults worldwide use alcohol and 4.5% use illicit drugs, although only about 15% misuse alcohol and drugs. The greater the consumption of alcohol, the greater the harm done. It is of interest that Europeans have the highest amount of yearly alcohol consumption in the world: 2.5 times that of the world average. Despite lower overall consumption levels in Northern European countries compared with Southern European countries, where drinking small amounts of wine with meals is common, when Northern Europeans in Nordic counties drink they display more detrimental patterns of excessive use. Alcohol and other drug misuse has a wide impact on all strata of society, not just in terms of illness and disease, but also related to violence and crime rates, workplace injuries and performance, and family stability and relationship breakdown. The cost of addictions in the United States is very high and is estimated at about $2000 per person in economic costs related to lost revenue, taxes, treatment costs, criminal justice costs, fires, accidents, and other related costs.
Prevalence of Children of Substance Abusers
Substance misuse by adults does great harm to both themselves and society in general. Their children are impacted as well, often negatively, because many adult substance abusers are also parents. Substance abuse is a family disease because the addict affects those who live around him or her. Parental substance abuse is a public health concern due to its high prevalence and relationship to many negative child developmental and health outcomes. Although about 10.5% of US children currently live with a parent who had a diagnosed alcohol use disorder, about 25% of US children (19 million) have been exposed to parental alcoholism at some point while growing up and about 12.7%, or 9.2 million, have been exposed to parental drug abuse. These children might have been damaged by alcohol or drug exposure in utero or impacted by a chaotic and nonsupportive family environment.
Children’s Feelings and Beliefs About Parents’ Substance Misuse
Recent studies have reported on the child’s perspective toward their alcohol or drug-using parents. These studies demonstrate three common themes: family role reversal with the child taking on some parental duties, keeping the family secret with a strong “Do Not Tell” message from parents, and various coping and resilience strategies such as finding supportive people outside the family, use of humor, and having goals in life. These themes demonstrate the need for new approaches and interventions to support the development of children living in families where drug use is a problem. Children can feel confused and insecure when they do not understand their parents’ erratic behavior and mood, which can be significantly impacted by the effect of alcohol or other drugs. Parents are often like Dr. Jekyll and Mr. Hyde—two different personalities. They tend to be more loving and humorous when using moderately, but can be anxious, paranoid, and use excessive punishment when in withdrawal from their drugs. Of course, the impact on the personality of the parent depends on the drug of choice and other mental health problems. Excessive use of stimulants can make parents more agitated and dangerous to children, whereas heroin or depressant users tend to just get sleepy and groggy. Many children take on the parents’ role for their younger siblings due to the incapacitating effects of some drugs.
Differences Between Children of Alcoholics and Children of Other Drug Abusers
There are many different combinations of substances that can be abused and patterns of parental chemical dependence that influence the lives of the children growing up in alcoholic or chemically addicted families. First, the behavior surrounding the drug of choice differs. Unlike alcohol, the possession of heroin or cocaine is illegal, as is marijuana in most states. Children exposed to parents who abuse illegal drugs are also exposed to an aspect of life that children of alcoholics are not; using illegal drugs means that it is a criminal offense. The children who know about their parents’ drug use must be involved in a shroud of secrecy, giving rise to a home environment that is veiled in fear, lest the authorities find out about what their parents do. Unlike alcohol, which can be consumed openly and without fear of legal reprisal (barring certain restrictions), illicit drug use/abuse requires great secrecy. For this reason, the child of an addicted parent must contend with the secretive illegal drug activity of their parent both at home and in the community. Second, unlike children of alcoholics, the AIDS epidemic directly confronts the children of addicted parents, especially if the parents are intravenous drug users. Loss of significant others due to AIDS-related illness may become more pronounced in the lives of these children. Addicted parents may have AIDS (or be HIV positive); friends of their parents may have AIDS, or babies in the community may be HIV positive. Third, the type of chemical dependence influences the type of childhood home environment, especially if the addicted parent abuses heroin or is involved with an insidious addiction to crack. Parents involved with deviant activities may invite adult friends into the home who are also involved with similar activities. The presence of adult antisocial role models is a strong possibility for children living with addicted parents. Home environment is a critically important variable in shaping cognitive skills, academic achievement, and psychosocial adjustment. Deviant home environments are the source of many childhood behavioral problems. Finally, the effect of the drug on the parents’ behavior is profound. Methamphetamine addicts act one way, and heroin addicts another. This affects the parental role and parental behavior profoundly.
Higher Risk for Addictions
Research suggests that children of addicted parents are at 2–9 times greater risk of becoming substance abusers as adolescents or adults depending on genetic risk, despite the positive and adaptive behavioral outcomes of many of these children. Among adolescents, children of substance abusers misuse substances more than children whose parents are not substance abusers and escalate their use more steeply. As young adults they are more likely to be diagnosed with alcohol and drug abuse/dependence. The risk for later substance misuse depends on their degree of risk factors compared with protective factors including risk factors associated with the extent of their family history of alcoholism, which includes whether one or both parents are abusers and the addiction severity, the type of alcoholism that runs in the family, and the extent of their parents’ antisocial behavior, health, and mental health problems. Gender differences also exist; for example, girls have increased vulnerability to the negative impact on later drug use from family environmental risks, which are high in families with substance-abusing parents.
Living with a parent who abuses alcohol or other drugs can have severe effects on every aspect of a child’s life, including social acceptance, mental and physical health, and school performance. Most studies find that children of substance abusers have elevated rates of psychological symptoms. Beyond risk for addictive behaviors, children of substance abusers are also at higher risk for developing emotional, behavioral, academic, criminal, and other social problems, particularly if both parents are substance abusers, have type II alcoholism, or genetic risks such as short alleles of the serotonin transporter (5- HTTLPR ) gene, and there is high stress and conflict in the family. They tend to be lower on protective factors and higher on risk factors, thereby increasing their risk for depression, anxiety, suicide, eating disorders, chemical dependency, teen pregnancy, and HIV.
They tend to have heightened levels of conduct problems in preschool and elementary school and delinquency in adolescence, particularly if their parents also show antisocial behaviour. Children of substance abusers also demonstrate elevations in impulsivity and activity level as well as behavioral disinhibition, leading some researchers to view them as behaviorally undercontrolled. Children of alcoholics have been found in a longitudinal study to age 23 years to employ more of a cognitive coping style and less of a decision-making coping style than children of nonalcoholic parents. Similarly, children of two parents with substance use disorders tend to use aggression as a major coping style, compared with children of only one or no parents with substance abuse disorders, who use a more problem-solving, decision-making style of coping. Earlier studies described children of substance abusers as higher in “difficult temperament,” meaning a relatively stable trait, likely genetically linked, that led to increased emotional and behavioral liability and difficulty with behavioral control. Parental alcoholism has also been linked to anxiety and depression in children, and West and Prinz have noted that children of alcoholics had higher levels of anxiety and depression than did controls in 10 of 11 published studies. Longitudinal studies up to three decades, found that children of alcoholics consistently reported greater risk for stressors in the family domain of 11 life areas. In addition, they report repeated and more severe stressors into adulthood in their family.
In addition, children of substance abusers show lower academic achievement than do children whose parents are not substance abusers, even in comparison with depressed children or children of divorce, and they have poorer cognitive functioning in the preschool years than do children whose parents are not substance abusers. Casas-Gil and Navarro-Guzman have identified five variables in which school performance by children of alcoholics was poorer: intelligence, repeating a grade, low academic performance, skipping school days, and dropping out of school. Sons of male alcoholics who have many alcoholic relatives across generations have been reported to show deficits in verbal and abstract reasoning and verbal learning. For this subgroup, Pihl and associates suggested that cognitive deficits may be caused by heritable dysfunctions of the prefrontal cortex and limbic systems. However, cognitive impairments may also stem from fetal alcohol exposure, high stress levels in pregnant mothers or a lack of environmental stimulation or conversely a chaotic home environment. Studies find that in the absence of family stress and conflict, the academic performance of boys who are children of alcoholics is similar to that of boys who are not until high school. As more thoroughly explained below, high family stress and elevated cortisol levels has been found to be related to triggering the phenotypic expression of genetic risks according to Brody and associates. Hence, for both environmental and genetic reasons, children of alcoholics living with high family conflict would likely have more trouble with their academic performance.
Family, adoption, and twin studies support the heritability of addictions, which is estimated to contribute to about 40%–60% of the overall risk. This heritable influence appears not to be substance specific. For instance, children of alcoholics today are also becoming abusers of illegal and prescription drugs. Children in families with many early onset alcoholics (beginning use before 15 years of age) are at highest risk for later substance abuse or addiction because this is an indicator of type II alcoholism. Type II alcoholism is the highly heritable type of alcoholism that appears to have a heavy genetic loading as compared with type I alcoholism, which is more environmentally caused. Research suggests that about 60% of the variance in risk for an alcohol use disorder is related to genetic factors and the remaining 40% is due to environmental factors in this type of alcoholism in males. However, twin and adoption studies suggest that girls are not at such a high risk. In females, only about 40% of the variance in risk for an alcohol use disorder is related to genetic factors and the remaining 60% is due to environmental factors. However, this risk increases if both biological parents are alcoholics from type II alcoholism families. Luthar and associates found that similar adverse circumstances are present for children whose parents abuse illegal drugs. They concluded, however, that maternal drug abuse per se is not as damaging to children’s resilience as maternal stress, depression, and anxiety disorders.
Which Genes Are Involved?
Since the completion of the human genome project, there has been considerable interest in the identification of genes involved in this complex disease. Research has identified many genes that contain allelic variants associated with heritable phenotypes or characteristics that enhance vulnerability to addiction. More than 1500 genes have been implicated in research to increase vulnerability to addiction. However, a meta-analysis of these studies by a Chinese research team found that only five gene pathways were involved in the four major types of drug dependency from a total of 18 statistically significant molecular pathways for single types of addiction. These five pathways may underlie shared rewarding and addictive processes—that is, neuroactive ligand-signaling interaction, long-term potentiation, and the mitogen-activated protein kinase signaling pathway linked to memory and learning, and two new ones: (1) the gonadotrophin-releasing hormone signaling pathway involved in gonadotrophin secretion, and (2) stress-induced drug seeking and gap junction. They connected the five pathways into one common hypothetical molecular network for addictions. Although there are many genes involved in substance use disorder, researchers have found that the most genetically at-risk adolescents are those with one or two short alleles of the 5- HTTLPR serotonin transporter gene. They are more likely to become substance abusers, depressed, or delinquent, with lower behavioral and emotional control. This genetic risk is not rare and is found in 40% of whites and 60% of Asians and Native Americans, making them at higher risk for substance use disorders, depression, anxiety, and behaviors disorders. The 7-repeat dopamine gene has also been linked to increase substance abuse.
Epigenetic studies of the interaction of genes and environment have found that reducing stress in genetically at-risk individuals through positive parenting can dramatically reduce the phenotypic expression of genetic vulnerability in mice and children by 50%. According to Uhl and associates, “The overlapping genetic vulnerability for developing dependence on a variety of addictive substances suggests large roles for ‘higher order’ pharmacogenomics in addiction molecular genetics.” Discovering the pharmacogenomics of addiction is likely to have broad implications for neurotherapeutics.
Genetic factors have been shown to influence deviant peer selection. However, there is also support for interactions between genetic risk and peer influences. For example, Harden et al. found that adolescents who were genetically at risk for alcohol and tobacco use were also the most vulnerable to influences from their closest friends. Park et al. found that carriers of the dopamine receptor D4 long allele were more prone to alcohol dependency related to the influence of their heavy drinking sorority and fraternity friends.
Characteristics or Phenotypes of Children of Alcoholics That Increase Their Risk
Because the specific genes for addiction are only now beginning to be discovered, research has focused on identification of the phenotypes or disorders these children could inherit that increase their rates of substance abuse. Actually, genotypes do not always translate directly into phenotypes; hence, predicting later substance abuse is enhanced by monitoring the behaviors of high-risk children with many relatives who began alcohol or drug use before the age of 15 years of age.
These phenotypes or characteristics of children of substance abusers with type II alcoholism with genetic risks include higher rates of neuropsychological and limbic system deficits that include either: (1) behavioral and emotional self-regulation problems or (2) reduced executive functioning. Research suggests that these two cognitive deficits are primary factors leading to reduced resilience and increase risk for addiction.
Children of substance abusers have been reported to be genetically vulnerable to two major syndromes: (1) the overstressed youth syndrome (e.g., poor emotional regulation, difficult temperament, autonomic hyperreactivity, and rapid brain waves) and (2) prefrontal cognitive deficits in verbal and abstract reasoning and verbal learning. These cognitive deficits reduce their ability to understand that their parents’ erratic behaviors are caused by drugs and not by the child’s own behaviors. Schuckit found that alcohol smooths out the overactive autonomic nervous system stress response in children of alcoholics so that they report feeling normal for the first time in their lives. Alcohol and drugs also increase essential neurotransmitters such as dopamine, serotonin, and noradrenalin, which reduce their depression and anxiety. Hence, children of alcoholics are likely self-medicating their overreaction to stressors and depression/anxiety with alcohol and drugs. Unfortunately, the consequences of substance abuse frequently leads to increased negative consequences and more stress.
Fetal Alcohol and Drug Exposure
Of interest is that exposure to toxins like alcohol, tobacco, and other drugs in utero, appears to lead to similar neurodevelopmental deficits (e.g., prefrontal cognitive deficits and poor emotional regulation) as the genetic risks listed above. Unfortunately substance abuse by girls has been increasing dramatically since 1992; hence, young women are attracting attention as more enter drug treatment and are mothers. They become addicted more quickly and for different reasons. They appear to be influenced more by pressures to use or by observing the use of substances by friends, peers, and family members.
The economic cost of fetal alcohol syndrome and fetal alcohol effect (FAS and FAE) is very high. Popova et al. estimated that the lifetime economic costs of just one baby born with FAS in 2002 was estimated at $2 million. Chasnoff’s research suggests that the damage to the brain is mostly in the last 3 months when the brain is developing rapidly. Hence, if a pregnant woman stops substance use in the last trimester, much of the brain damage can be prevented. If not, children with FAS generally have significantly reduced general intelligence, executive functioning, language-based memory, and functional communication skills, which can result in more aggression and behavioral disorders. Unfortunately, more than 80% are not diagnosed appropriately when adopted or put into foster care, so they are not getting the services they need.
Adolescent Drinking and Brain Development
The adolescent brain is still maturing until about 25 years. Hence high levels of drinking or drug use in adolescence can lead to brain neurotoxicity and affect cognitive development, particularly in the higher cognitive executive functioning in the prefrontal cortex. The prefrontal cortex is involved in working memory, voluntary motor behavior, impulse control, rule learning, spatial learning, planning, and decision-making (Spear and White and Swartzwelder ). The new brain science suggests that youth who drink regularly may be delayed in brain development and not be connecting the dots about consequences that would possibly reduce their drinking in risky situations such as drinking and driving.
Two important neurotransmitter systems that undergo substantial changes during adolescence and are affected by alcohol consumption are dopamine and γ-aminobutyric acid (GABA). This damage to neurotransmitters and brain development can also affect increased depression and anxiety, and social and educational achievement. The ability to form new memories under the influence of alcohol is reduced, particularly in younger adolescents. A study of college students found that students with a history of binge drinking performed worse on memory tasks after consuming alcohol than did students without such a history. Adolescents were more disrupted by ethanol in trace conditioning than adults, and adults were more disrupted by ethanol in context fear conditioning than adolescents. Adolescent rats with prenatal exposure to alcohol are more impacted in fear conditioning studies than those without prenatal exposure, because of damage to hippocampal anatomy.
Adolescents seem less sensitive than adults to other effects of drinking, such as impairment of motor coordination, sedation, and susceptibility to seizures during withdrawal. A study by Slawecki et al. found that during adolescence an acute alcohol dose significantly altered several electroencephalography (EEG) variables in the hippocampus and other brain regions of the control animals, but not in animals that had been exposed to alcohol during adolescence. Hence, it appears they can develop a tolerance to some alcohol effects. Some positron emission tomography (PET) studies suggest that the brain’s recovery from dopamine depletion from substance use disorders (particularly cocaine and methamphetamine) can take up to 2 years, but luckily it can recover.
Diversity of Outcomes in Children of Substance Abusers
Although having a substance-abusing parent affects many aspects of a child’s life, the degree of impact on children of substance abusers varies considerably. Although they are at higher risk, many children of substance abusers manifest few detectable or diagnosed developmental and psychological problems and do not develop substance use disorders. The great difference in later substance use disorder rates among children of substance abusers appears related to the number of inherited phenotype risks from type II alcoholism family history and the number of type I alcoholism environmentally caused risks. In addition, girls appear to have less genetic risk than boys, but girls have slightly higher sensitivity to family environmental risks.
The impact of parental addiction on children of substance abusers varies with degree of severity, developmental timing, and length of parental substance misuse. For example, children of active alcoholics have greater psychological distress than children of parents in recovery, particularly if the parent’s abuse ended early in the child’s development before 6 years of age. A longitudinal study by Andreas and O’Farrell suggested that periods of fathers’ heavier drinking patterns lead to increased children’s psychosocial problems. O’Farrell and Feehan found that remission after alcoholism treatment was associated with reduced family stressors, domestic violence and conflict, separation, and divorce, as well as improvement in family cohesion and caring. In addition, children were less affected by parental substance abuse if their parents had no other mental disorders.
Environmental Impacts: Global Negative Impact of Childhood Adverse Experiences on Children of Substance Abusers
There has been considerable interest recently in the negative impact of early childhood adverse experiences on children’s neurodevelopment and health outcomes leading to increased health care costs. Parental drug abuse and alcoholism has been found, in a decade-long study by the Centers for Disease Control and Prevention (CDC) of health management organization members, to be associated with multiple adverse early childhood circumstances. This same research group found that parental alcoholism and multiple childhood adverse experiences increased the risk for later adult alcoholism. However, multiple childhood adverse experiences increased the risk two- to fourfold for later self-reported alcoholism, heavy drinking, and marrying an alcoholic, even without parental alcoholism. In this retrospective self-report study of over 8500 individuals, those who grew up with both an alcohol-abusing mother and father had the highest likelihood of childhood adverse experiences. The mean number of childhood adverse experiences for persons with no parental alcohol abuse was only 1.4, compared with about twice as many for those with an alcohol-abusing father only (2.6) or mother only (3.2). Having both parents abusing alcohol increased the risk of childhood adverse experiences almost threefold for a mean of 3.8 childhood adverse experiences. Of interest is the lack of protection from adverse experiences in the family if the mother was an alcohol abuser.
Similar adverse circumstances are present for children whose parents abuse illegal drugs. These childhood adverse experiences can include exposure to frequent stressful and traumatic experiences such as abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing family violence and criminal behavior, parental divorce and separation, and parental incarceration. Hence, parental substance abuse or a family history of early onset alcoholism or drug abuse is a potent risk factor for later addiction in children.
Family Environmental Risk and Protective Factors
A growing number of family risk factors and fewer protective factors contribute to the higher rates of substance use in youth today. Worldwide, parents are spending less time parenting and supporting their children. Few parents in the United States still have a meal each day with their children, although two-thirds of children in other countries still have the main meal with their parents. However, fewer children than that talk with their parents on a regular basis. Living with drug-addicted caretakers, who spend about half as much time with their children as the average parents spend, increases children’s stress levels.
Other research suggests that positive family functioning and parenting that reduces children’s stress and cortisol levels can reduce by half genetic predispositions to a number of behavioral health disorders (substance abuse, depression, anxiety, thrill seeking, delinquency, and HIV status). The negative impact of parental drinking on children’s self-worth was mediated by family cohesion and supportive relationships, while good communication and problem-solving skills were associated with more effective parenting despite parental alcohol abuse. Having a mother who is an addict or two parents who are addicted increases the risk for later developmental problems. Without extended family protection and family or agency support, many children of substance abusers live in disruptive family environments. These environments are frequently characterized by family conflict, disorganization, or disrupted family rituals (meals together, bedtime rituals, holidays, and so on). The environment contributes to an already elevated sense of anxiety and stress in the children.
In families in which alcohol or other drugs are being abused, behavior is frequently unpredictable and communication is unclear. Family life is characterized by chaos and unpredictability. Behavior can range from loving to withdrawn to crazy. Structure and rules may be either nonexistent or inconsistent. Adult children of alcoholics report more parentification, instrumental caregiving, emotional caregiving, and past unfairness in their families of origin.
The SEM tested Social Ecology Model of Substance Abuse Vulnerability found that three factors (family cohesion, supervision and monitoring, and communication) in the family pathway were the most preventive of substance use. Unfortunately, addicted parents often fail to monitor their children’s behavior. The risk for substance use associated with early pubertal maturation was found to be increased by lax parental supervision (for girls) and a family history of substance use, psychiatric problems, or crime (for boys ).
Not every family is affected identically. Research has shown that families that maintain certain rituals, such as holiday traditions or a Friday night pizza and movie, can help mediate the chaos of addiction. Sober parents who are able to provide stability, support, and nurturing also help to minimize confusion and strengthen children. Sometimes family life is less damaging because children rely on adaptive distancing, a technique in which the child separates from the centrifugal pull of family problems in order to maintain pursuits and seek fulfillment in life, school, and friendships.
Finally, in addition to adverse circumstances within the family, parental alcoholism is also associated with elevated levels of more general negative uncontrollable life events. In particular, because alcoholics are likely to have less education and lower income, children of alcoholics may have fewer economic resources available to them. Consistent with their lowered socioeconomic status, children of alcoholics are more likely to report that a parent was fired from a job and that their families have financial problems. Although little is known about the exposure of children of alcoholics to adverse neighborhood or school environments, their lowered socioeconomic status raises the possibility that their broader social environments may also be less than ideal.
Substance Abuse Impact on Parenting
An important, yet poorly understood, feature of drug overuse is the potential impact on parenting capacity and child health outcomes. It is known that parents who are substance users become more aggressive and/or abusive toward their child when under the influence of drugs. 184 It is estimated that 40%–80% of child maltreatment reports concern families with substance abuse issues. Parents who use alcohol and drugs tend to be poor role models for their children, often exposing them to drug use and illegal behaviors, which may increase the risk of the children being recruited into drug use as they get older. Thus parents who use alcohol or drugs have greater risk of influencing children’s developmental outcomes negatively.
Although not all children are negatively impacted by their parents’ use of alcohol or drugs, the task of raising a child is undoubtedly made more difficult when a parent is regularly affected by alcohol or drug use. Despite federal funding and Medicaid funding for mothers’ and children’s residential or outpatient treatment facilities, there are still not enough treatment facilities that accept children; when they do, therapeutic programming for the children is frequently neglected. Unfortunately, there is a common notion among many substance abuse treatment programs that the parent should focus on his or her own recovery; the children are kept separated from the treatment process. This ignores the fact that the children also need preventive or therapeutic services and that improving parenting significantly reduces the parent’s guilt and depression and potentially reduces their relapse.
Child Abuse Potential
The comprehensive national survey conducted by the National Center on Child Abuse and Neglect found that 80% of surveyed states reported that parental substance abuse and poverty are the two major problems among child protective caseloads. Children of substance-abusing parents are three times more likely to be abused and 4 times more likely to be neglected than children from families where parents do not abuse alcohol and/or other drugs. Other national studies also support these findings; between 40% and 80% of all child maltreatment cases involve parental misuse of alcohol or drugs.
Compared with nonaddicted parents, addicted parents tend to neglect their children, spend about half as much time with them, and use more of a punitive and authoritarian parenting style with higher levels of corporal punishment. However, these children are more often neglected rather than emotionally or physically abused. Suomi’s research with peer-raised monkeys suggests that neglect may be more devastating to children’s brain and social/emotional development than physical punishment because neglected children feel unprotected by parents. Their levels of stress and anxiety are increased, resulting in insecurity, lack of parental bonding, and stronger peer cluster bonding; in turn, exploratory behaviors are reduced. Exploratory behaviors are needed in the development of self-control and executive functioning, but since they are reduced in stressful and anxiety-producing environments, the developmental process is perturbed.
The less-than-optimal parenting and family environments that children of alcoholics experience extend beyond the relationship between the alcoholic parent and the child. Even in infancy, deficits in mother-infant attachment have been found in families with problem-drinking fathers. Moreover, parental alcoholism is associated with higher levels of parent-adolescent conflict. Parental alcoholism is also associated with higher levels of exposure to family conflict and violence, although parents are not necessarily the perpetrators of the violence.
Genetic Vulnerability to Harsh Parenting in Children of Alcoholics Linked to Anger, Stress, Depression, and Negative Health Outcomes
The impact of family stress and conflict on children of alcoholics and their later drinking is complicated by genetic mediators and later environmental moderators. High levels of life stress overall is linked in adolescents to greater likelihood of alcohol use and to escalation in the quantity and frequency of their use over time. However, there is less empirical support for negative affect as the mediator between stress and alcohol use in adolescents than in adults. Over time, children who receive harsh parenting develop a heightened state of vigilance for signs of anger and tend to respond with anger when they perceive anger toward themselves. This negative affect leading to drinking is true only for some youths and in some contexts. Anger in adolescence related to harsh parenting is associated with poorer health (e.g., autoimmune disorders, higher stress or cortisol levels, and so on) but only in youth with a genetic sensitivity to negative affect related to one or two short alleles of the serotonin transporter gene ( 5-HTTLPR ). Like the CDC’s Adverse Childhood Experiences Study (ACES) results, other studies found that adults reared in harsher home environments evince higher blood pressure, worse metabolic profiles, greater inflammatory activity, and higher levels of depressive symptoms than adults reared in less harsh households. Hence, non-nurturing parenting leads to higher health care costs.
Resilience and Protective Factors in Children of Substance Abusers
Resilience has been defined as the achievement of competence or positive developmental outcomes under conditions that are adverse or that challenge adaptation. The Resilience Framework suggests that the development of resilience in high-risk children, such as children of substance abusers, is a complex transactional process between the child, his or her parents or caretakers, and their environment.
Not enough research has been conducted to understand these resilience processes. In contrast to the substantial literature on the relationship between parental alcoholism and children’s psychological problems, studies have generally failed to examine the development of resilience and competent performance or positive outcomes in children of alcoholics, although some relevant work has been done on the absence of negative outcomes. Generally, these studies have sought to specify factors that protect children of alcoholics from the negative outcomes associated with parental alcoholism. For example, Werner followed children of alcoholics from birth to age 18 and reported that those who did not develop serious problems had experienced fewer negative stress events, had more cuddly and affectionate infant temperaments, and had higher self-esteem and better communication skills. In a 32-year longitudinal study, Werner and Johnson found that one caring adult in the child’s life is a significant protective factor resulting in better adult adjustment and behavioral health.
Several studies have focused on positive family environment factors and have discovered a few protective factors or processes. Wolin and colleagues found that alcoholic families who maintained consistent rituals (e.g., vacations, birthday celebrations) had children who were less likely to develop alcohol problems. Similarly, children of alcoholics whose families had higher levels of organization were less likely to initiate illegal drug use.
Higher levels of family cohesion and support have also been shown to enhance outcomes for children of alcoholics. Farrell et al. found that children of alcoholics showed high levels of adolescent deviance and distress when family cohesion was low, but that these effects were reduced when family cohesion was higher. Similarly, Barrera and associates found that children of alcoholics in low-conflict families resembled children whose parents were not alcoholics, whereas children of alcoholics who experienced high levels of family conflict showed elevated levels of psychological distress. The notion that family cohesion and support are associated with better outcomes among children of alcoholics is consistent with the finding of Moos and Billings that families in which paternal alcoholism had remitted after treatment had both higher levels of family cohesion and lower levels of psychological distress among their children. These data suggest that parental recovery may promote resilience for children of alcoholics, perhaps because the family environment also recovers. However, because these findings are from a sample of fathers who received alcohol treatment, they may not generalize to untreated families.
Research has also suggested that parental supervision is an important protective factor for children of alcoholics. Curran and Chassin found that consistent discipline and monitoring of their adolescents’ behavior by mothers were associated with better outcomes among both children of alcoholics and children whose parents were not alcoholics. However, consistency of discipline includes monitoring and positive reinforcement and should not be taken as synonymous with punishment, which has been associated with poorer outcomes among children of alcoholics.
Finally, some data point to the importance of extrafamilial influences. Ohannessian and Hesselbrock found that children of alcoholics with high levels of support from friends closely resembled children whose parents were not alcoholics, whereas children of alcoholics with less peer support consumed more alcohol and had more alcohol-related problems. Thus a supportive relationship with someone outside of the family may be protective. Moreover, Jordan and Chassin found that adolescent children of alcoholics who had greater involvement in positive activities outside the home were less likely to develop a substance use disorder in young adulthood. In the case of parental alcoholism, where adverse circumstances exist within the family environment, extrafamilial influences may be particularly important.
A significant protective factor to build the resiliency of children is to bolster social support networks and to increase autonomy and sense of safety. For children growing up in an unpredictable environment with parental substance abuse, improving resilience and enhancing protective factors is valuable. It seems clear that educational health care interventions presented in a supportive social environment are a useful and effective strategy for improving outcomes and enhancing health behaviors.
In summary, although little research has focused specifically on positive outcomes and competent performance among children of alcoholics, some work has been done to identify factors that predict lower levels of negative outcomes. These studies suggest that parental support and control, and family environments that are characterized by stability, cohesion, organization, and preservation of routines and rituals are associated with better outcomes. These critical family protective processes (e.g., family attachment, parental supervision and monitoring, and organization and communication) were found to be the most important protective factors of later substance use in a major cross-site study of 8500 high-risk youth funded by the Center for Substance Abuse Prevention. In addition, high levels of friend support and involvement in positive activities outside the home reduce negative outcomes for children of alcoholics. Finally, it has been suggested that parental recovery from alcoholism is itself protective.
Prevention Programs Specifically for Children of Alcoholics
Most of the evidence-based programs for children from substance-affected homes identified and reviewed in the Broning and associates (2010) meta-analysis were school-based, while two were family-based and one was community-based. Most programs lasted between 8 and 14 weeks, with weekly sessions of approximately 90 minutes. Group sizes were not always reported and usually ranged from 8 to 12 children. Program content did vary, but common themes for most of the programs emerged, such as coping with emotions, problem solving, education on drugs and addiction, peer resistance, communication skills, and ways to be safe in family relations. Didactics usually included theory and practical exercises, discussion, role-play, and video material in some case.
School-Based Primary Prevention Programs
Very few prevention programs have been developed specifically for children of alcoholics. Most prevention programs specifically for children of alcoholics are limited to school-based education programs that are relatively short in duration and conducted with small groups of students who self-identify as children of alcohol or drug abusers. Although there may be many such school-based programs for children of alcoholics, according to Price and Emshoff, very few of them are even described in the prevention literature and even fewer have outcome evaluations. Because of the positive research results for behavioral training models, programs for children of alcoholics are including more social competency skills training. In one of the few research-based models, Roosa and colleagues found positive changes in knowledge, social support, and emotion-focused coping behavior in their 8-week, school-based program for children of alcoholics. Emshoff’s Students Together And Resourceful program teaches students social competency skills, and provides accurate information about alcoholism and its effects on the family. Participants reported more friends and stronger social relations, increased sense of control, and improved self-concept with less depression.
Family-Focused Prevention Programs for Children of Alcoholics and Substance Abusers
Several prevention programs for children of alcoholics and substance abusers that include a family-strengthening approach to increasing resiliency through family skills training have been developed and tested in federally funded prevention research—namely, the Strengthening Families Program and Focus on Families. Positive results have been found for the 14-session Strengthening Families Program in improving social competencies and family relationships and in reducing later tobacco, alcohol, and drug use in children of addicted parents in treatment. Moreover, this program has been culturally adapted and evaluated in separate 5-year federal phase-in designs for rural and urban African American, Latino, Asian and Pacific Islander, and Native American families.
A very similar family skills training program, designed also specifically for children of alcoholics, is the 16-session Celebrating Families Program. It was tested in a quasi-experimental pilot study against a strengthening family program (SFP) and found to have as good parenting and family outcomes, but not as good child behavioral health outcomes. It is currently being tested in several federal Administration for Children and Families (ACF) grants along with SFP, but outcome results are not yet analyzed. However, the providers and families do not seem to like the program as much and one state stopped implementation in favor of continuing SFP (Brook, February 2016, personal communication). Celebrating Families is much more based on Alcoholics Anonymous (AA) practices and philosophy, so possibly if parents are still in denial, they will reject Celebrating Families. In addition, the children’s behaviors got worse, which resulted in a higher number of parents dropping from the program in the comparative evaluation.
Community-Based Prevention Programs for Children of Alcoholics
There are very few community-based programs for children of alcoholics, but one popular one is Alateen. This self-help support program for children of alcoholics is implemented in the community through Alcoholics Anonymous. This program provides a safe environment in which children can share their feelings, experiences, and tips for surviving their parents’ addictions and negative behaviors. The Cambridge and Somerville Program for Alcoholism Rehabilitation program offered junior-high-age children of alcoholics or children whose parents were not alcoholics a range of after-school services at schools or in community settings. DiCicco et al. found that mixing children of alcoholics and children whose parents were not alcoholics in alcohol education groups, compared with groups specifically for children of alcoholics, resulted in reduced drinking among children of alcoholics and reductions in the intention to drink in the future. Moreover, because of stigmatization issues, recruitment of children of alcoholics was easier for the basic education group than for the group that was specifically for children of alcoholics. These results suggest that prevention programs not specifically for children of alcoholics may be a valuable option for recruiting and delivering services to children of addicted or substance-abusing parents.
Family-Based Prevention and Treatment
Developmental theories support the critical role of families in child raising and suggest that supportive families are key to raising healthy children and preventing later adolescent problems. Our consumer-oriented, fast-paced society appears to have forgotten this important role for parents. Longitudinal research suggests that parents substantially impact their teens’ health behaviors. Although peer influence is a major reason that adolescents initiate negative behaviors, a positive family environment (e.g., family bonding, parental supervision, and communication of prosocial family values) protects youth from engaging in unhealthy behaviors, such as substance abuse, delinquency, and early or unprotected sex. These protective family factors have even a stronger influence on girls.
What can be done to reduce unacceptably high levels of harmful behaviors in adolescents? Evidence-based family intervention approaches that have been found to be effective include : (1) behavioral parent training (primarily cognitive/behavioral parent training); (2) family skills training (including parent training, children’s skills training, and family practice time together); (3) family therapy (structural, functional, or behavioral family therapy), and (4) in-home family support. The most recent review identified 35 family interventions. Information on these specific family interventions including program descriptions, websites, and contact information can be found at www.strengtheningfamilies.org .
Only 7 family interventions of these 35 programs met the highest level of evidence of effectiveness, or Exemplary I, which required a minimum of two randomized controlled trials with positive results implemented by at least two independent research teams with different populations. These Exemplary I family programs included: Helping the Noncompliant Child, The Incredible Years, the Strengthening Families Program, Functional Family Therapy, Multisystemic Family Therapy, Preparing for the Drug Free Years, and Treatment Foster Care. A subsequent review of family interventions for substance abuse prevention for the United Nations Office of Drugs and Crime (2010) identified one other Exemplary I program—Triple P. Many of these best of the best family evidence-based interventions are described in an edited book by Van Ryzin and associates.
Seven programs were classified into the Exemplary II Level because they had at least one randomized controlled trial with positive prevention results. The other programs were classified primarily into the Model Level because they had only quasi-experimental research results. Some Promising Level programs were added to the list because they were programs that were based on existing proven programs, but did not yet have outcome results. Since the last expert review in 1999, additional randomized controlled trials have been conducted on existing and new family interventions; hence, this list is not complete.
The senior author developed a website for the United Nations Office of Drugs and Crime with program descriptions and contact information of all the best parenting and family programs in the world for dissemination to developing countries. So far, at least 50 high level evidence-based programs were identified from over 500 programs nominated by different governments and literature searches. A protocol for culturally adapting evidence-based family strengthening interventions has already been published from this United Nations Expert Group’s work.
Family-Focused Interventions for Children of Parents With Substance Use Disorders
Although a number of effective family-based approaches to substance abuse prevention have been found through expert reviews of the literature, only a few were designed specifically for children of substance abusers and only two have been tested in randomized controlled trials—The Strengthening Families Program and Focus on Families.
The Strengthening Families Program was designed by Kumpfer and colleagues in 1982 and tested specifically for children of substance abusers in outpatient methadone maintenance and mental health drug treatment centers in a National Institute on Drug Abuse randomized controlled trial testing the three different components compared to treatment as usual. The resulting Strengthening Families Program includes three 14-week sessions in parent training, children’s social skills, and family relationship enhancement, followed by booster sessions every 6 months. Specific program results included improved parenting skills, confidence, and parenting efficacy, which led to a reduction in children’s overt and covert aggression, hyperactivity, depression, conduct disorders, and improved social competencies. Family relationships (organization, cohesion, communication, conflict) were significantly improved. Decreases in substance use in both the parents and older children were also revealed. Moreover, this program has been culturally adapted and evaluated by independent researchers for rural and urban African American, Latino, Asian and Pacific Islander, and Native American families with positive program outcomes including a 40% improvement in recruitment and retention for culturally tailored programs. In a National Institute on Alcoholism and Alcohol Abuse (NIAAA) randomized controlled trial (RCT) with children of alcohol abusers in Canada and the United States, positive results were found for behavioral and social outcomes in the children of alcoholics. Other RCTs have reported positive program results for different age-adaptations of SFP (SFP 0-3, 3-5, 6-11, 12-16 years) in elementary school-aged rural children, junior high school rural children, and inner-city 7- to 11-year-olds.
One 10-year study followed participants to the age of 22 years and found a two- to threefold reduction in lifetime diagnosis of anxiety, social phobia, depression, and personality disorders when compared with their no-treatment controls. Another 10-year follow-up study of genetically at-risk African American students completing a culturally adapted version of SFP 10-14, called Strengthening African American Families (SAAF) in RCT schools, found a 50% reduction in diagnosed substance abuse, depression, anxiety, thrill seeking, and HIV status. This human epigenetic study with humans replicated the finding with mice that nurturing parenting can dramatically reduce the phenotypic expression of substance abuse in children with risky genes.
Recently, a Cochrane Collaboration and World Health Organization meta-analysis of universal alcohol prevention programs in schools found that a 7-session Strengthening Families Program for 10- to 14-year-olds was twice as effective in reducing alcohol use as any other school-based intervention having at least 2 years of follow-up data. A cost-benefit analysis showed a return of $9.60 for every dollar spent by the school when they implemented the Strengthening Families Program for 10- to 14-year-olds. Because of these positive results, the Strengthening Families Program has been adopted for replication and evaluation in seven countries in Europe, including four that have 1–2 years of pre- to posttest outcome results—Spain, The Netherlands, Sweden, and the United Kingdom.
The second program, Focus on Families, was also developed for children of parents in methadone maintenance treatment. This program found reductions in relapse for the parents but no significant improvement in the children. Zucker and associates found positive results on children’s prosocial skills at a 6-month follow-up after the fathers or both parents participated in a 12-session behavioral parenting program tested with fathers arrested for drunk driving.
Two other programs have been designed for children of substance abusers and show promising preliminary nonexperimental research results—Celebrating Families and Nurturing Program for Families in Substance Abuse Treatment and Recovery . Designed to prevent child maltreatment in children of alcoholics, the 15-session Celebrating Families has been found to improve family reunification rates from 37% to 72% for children of alcoholics removed by child protective services as well as to reduce the number of days to reunification. Positive changes in knowledge, coping skills, decision-making, and feelings expression were also reported for the program. Using the same evaluation instruments as those used for the Strengthening Families Program, Celebrating Families reported similarly positive effects at posttest on several outcome measures: improving parenting skills, family organization, communication, and cohesion. The child outcomes were mixed, however, and only two positive child outcomes were reported (reduced depression and concentration problems). The study also reported a nonsignificant positive trend for social skills, and three negative iatrogenic effects, namely for overt and covert aggression and hyperactivity. A longitudinal study is necessary, as children of substance abusers have been observed to increase their negative acting-out behaviors when their parents enter treatment. Some suggest that these children act out because they feel safer to do so. Finally, research on 170 mothers participating in the Nurturing Program suggested improved parenting attitudes at posttest on the Adult-Adolescent Parenting Inventory and reduced relapse.
Prevention programs not specifically designed for children of substance abusers may also be effective if they have core content demonstrated to be effective in reducing mediating factors for later substance abuse in children of substance abusers. For example, Chassin and associates have discussed necessary core content for children of alcoholics that includes content that increases children’s alcohol and drug awareness, social competencies, awareness of feelings, emotional and behavioral control, and reducing depression. With the exception of Zucker’s intervention, most family-based programs for children of substance abusers are family skills training programs that typically include the parent training component and not children’s skills training or family skills training utilizing a standard dosage between 14 and 17 sessions. Shorter programs are not as effective in attaining behavioral changes in addicted families.
Reviews of prevention programs for children of alcoholics and substance abusers have expressed the need for additional research on etiology and effective prevention programming as available outcome studies are dated. Ethical and practical issues in designing, implementing, and evaluating programs for children of substance users are discussed in several publications. b
b References 39, 49, 72, 79, 87, 121, 146.
Core Content of Effective Family Programs
Effective family programs involve the whole family (rather than just the parents or children) in interactive, skills, or behavior change processes, rather than involving them in didactic educational lessons. The underlying psychological theories include behavioral psychology and/or family systems theory, which stress the importance of the engagement process and reducing barriers to attendance through relationship building; personal invitations; provision of meals, childcare, and transportation, and sometimes, paying families for their time. Most effective programs begin with sessions designed to improve positive feelings in the family through positive reframing or skills exercises stressing family strengths. Engagement in structured methods for communication and discipline techniques are also practiced once positive family feelings are increased. O’Farrell and Fals-Stewart have found that behavioral couples therapy reduces domestic violence, which indirectly benefits the couple’s children. Hence, behavioral couples therapy should be expanded to include children of substance abusers to improve outcomes. An affectionate parent-child bond has a protective effect on later drug use ; hence, therapeutic interventions that strengthen parent and child bonding are recommended, particularly when there is already stress from the generation gap or differential generational acculturation in immigrant families.
Kaminski and associates at the Centers for Disease Control and Prevention have analyzed the critical core components of evidence-based family intervention programs from 77 studies of programs for 0 to 7-year-olds. Because the presence of conduct disorders in early life often precedes later delinquent, aggressive, and risky behaviors in adolescence, they reasoned that effective parenting could reverse this trend. The core components of effective parenting and family interventions are: (1) the format should include practice time for the parents with their children in the sessions with the therapists or group leaders available for coaching; (2) during family sessions, parents should be taught to interact positively with children (such as showing enthusiasm and attention for good behavior and letting the child take the lead in play activities); (3) parenting content should include increasing attention and praise for positive children’s behaviors, children’s normal development to make expectations realistic for children’s behaviors, positive family communication including active listening and reducing criticism and sarcasm, and effective and consistent discipline including time-outs; (4) children’s content should include teaching children social skills for how to get along better with parents, peers, and teachers in a more respectful manner; and (5) home practice assignments should be assigned and encouraged to improve generalization of new behaviors at home. Additional reviews of the literature on effective family strengthening approaches have also supported these findings (Office of Juvenile Justice & Delinquency Prevention, Strengthening America’s Families Web site, www.strengtheningfamilies.org ; United Nations Office of Drugs and Crime Web site, www.unodc.org/unodc/en/prevention/index.html ).