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Drug And Alcohol Course

INTRODUCTION

Epidemiological data strongly suggest many children are raised in homes in which one or both parents abuse alcohol or other drugs. For example, nearly 30% of female and 18% of male adult problem drug users live with children (1). It is estimated that nearly 8 million children live in homes with an alcoholic parent (2) and between 6 and 12 million children live in homes in which at least one parent has used an illicit psychoactive substance during the previous year (1,3). In a recent study of substance-dependent men and women entering treatment, 20% of these adults lived with and parented a child (4).

Over the last century, an extensive literature has evolved that examines the functioning of children of alcoholics, who are collectively referred to as COAs (5,6). In general, most investigations have concluded that COAs are at elevated risk for negative outcomes compared with children of nonalcoholic parents. More specifically, compared with children of nonalcoholics, both internalizing (e.g., anxiety and depression) and externalizing (e.g., conduct disorder and aggression) behavior are more common among COAs (7-9). Children who live with an alcohol-dependent parent also are more likely to have diagnosable childhood psychological disorders than do those who live with nonsubstance-abusing parents (3,10-14).

It has been implicitly assumed that children of substance abusers, who are often referred to as COSAs, were similar to COAs in many areas of functioning (15), even though rigorous comparisons between the groups have not been conducted. Unfortunately, the literature on COSAs is far less developed than the COA literature; however, those investigations that have been completed suggest that COSAs have significant emotional and behavioral problems. For example, in their seminal study, Sowder and Burr (16) reported many of the children of heroin-dependent mothers in outpatient treatment experienced emotional and school-related difficulties. Parental drug use has also been associated with negative child behavior on standardized child-rating scales (17,18). In particular, children of parents who enter treatment for drug dependence have higher incidence of internalizing and externalizing problems than children matched for demographic backgrounds in the general population (4,19). Sixty-six percent of the children of cocaine- and opiate-addicted mothers had at least one major psychiatric diagnosis by 12 years of age (20). Gabel and Shindledecker (21) found that 54% of a sample of children admitted to an inpatient psychiatric unit had preadmission histories of parental substance abuse. Similarly, Wilens and colleagues (9) reported that 59% of opioid-dependent parents exhibited a psychopathological condition versus 41% of children of alcohol-abusing parents. Once COSAs enter adolescence, Wilens and colleagues (18) observed that difficulties noted in the home environment extended to peer interactions and increased likelihood of delinquency.

Although both COAs and COSAs often experience emotional and behavioral difficulties, it is plausible that differences in psychosocial functioning would evolve in large part because of differences in the family and social environments created by alcoholic versus drug-abusing (DA) parents. For instance, Hogan (22) has persuasively argued that substantial differences exist in the home environments of children with parents who abuse alcohol versus illegal drugs. Families in which a parent abuses illegal drugs, particularly opiates and cocaine, are more likely to be living in poverty, whereas alcohol abusers are more likely to be living across a range of socioeconomic contexts (21). Because secrecy and stigma pervade the use of illegal drugs, greater social support is available for individuals who abuse alcohol than for substance abusers and their families. In addition, illegal drug use is associated with criminal activities and places the parent at risk for arrests and imprisonment and grave health risks. Although many drug-dependent individuals also abuse alcohol, children who live in homes with a parent who abuses illegal drugs may be expected to experience additional disruptive familial influences.

Moreover, the psychological and social adjustment of parents who abuse drugs are likely to be different from those who abuse alcohol. Miller (23) noted that, in comparison with alcohol-dependent patients, those who primarily abuse drugs other than alcohol are more impaired across a range of psychological and social indicators of functioning (21). Moreover, substance-abusers and their partners are more likely than nonsubstance-abusing adults to have psychiatric disorders such as depression and antisocial personality disorder (24). In addition, greater psychological stress has been reported among DA men and their partners than among demographically matched families of alcohol-dependent men and their partners (25). It is important that parents' psychological distress (26-28) and psychiatric disorders (29,30) often have a deleterious impact on their children's adjustment.

Although these converging lines of evidence suggest children from families in which a parent abuses drugs may have poorer psychosocial adjustment than children with an alcohol-dependent parent, such a comparison has not yet appeared in the literature. Thus, the purpose of the present investigation was to examine the psychosocial functioning of children from DA families (i.e., homes in which the father primarily abuses drugs other than alcohol) compared with children from alcohol-abusing (AA) families (i.e., homes in which fathers abuse alcohol). Specifically, it was hypothesized that children from DA families would have lower levels of psychosocial functioning than would children from AA families. We also sought to determine the relationship between fathers' substance use severity across multiple domains of functioning and children's adjustment.

METHOD

Participants

Participants were 102 heterosexual couples in which the father was entering treatment for alcohol abuse (n = 51) or for abuse of another psychoactive substance (n = 51). Couples were recruited at one of two outpatient clinics in the northeastern Unite States as part of a larger study of the effects of couples-based treatments for substance use on individuals and their families.

Inclusion criteria for the present investigation were as follows: men had to 1) be between 20 and 60 years old; 2) be married for at least 1 year or living with a significant other in a stable common-law relationship for at least 2 years; 3) meet abuse or dependence criteria for at least one psychoactive substance use disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (31); 4) have as their primary drug of abuse a psychoactive substance other than alcohol for inclusion in the DA family group or have alcohol as their primary drug of abuse for inclusion in the AA family group; (a) and 5) have medical clearance to engage in abstinence-oriented outpatient treatment. Couples also were excluded if the father met current DSM-IV criteria for an organic mental disorder, schizophrenia, delusional (paranoid), or other psychotic disorder. Men with these disorders were not recruited for participation and were referred to other treatment programs.

Couples were recruited for the study if they met the above criteria and were living with at least one school-age child (defined as between 5 and 16 years of age) for whom one or both parents were the legal guardians. This age range was used because it is the age range for which the children's psychosocial adjustment measure (see below) was psychometrically evaluated. For families with more than one child in the age range surveyed, the data from one randomly selected child (i.e., the target child) were used in all statistical analyses that follow. This procedure was followed to guard against the violation of statistical assumptions regarding independent observations. In addition, couples were excluded 1) if mothers reported that they met current or lifetime abuse or dependence criteria on alcohol or other drugs or 2) if mothers or fathers reported that the mothers used illicit drugs or engaged in hazardous drinking during pregnancy with their 5 to 16-year-old children.

To obtain samples of AA and DA families who were comparable on sociodemographic and background characteristics, participants from the AA families were matched to the DA families on the following variables: 1) parents' age, 2) parents' education, 3) number of children in the target age range, 4) fathers' and mothers' race; and 5) family income. Alcohol-abusing families were considered matched to target DA families if 1) parents' average age was [+ or -] 3 years of the parents from the target DA family; 2) parents" average education was [+ or -] 1 year of the parents from the DA family; 3) the family had an equal number of children in the target age range; 4) fathers' or mothers' race matched exactly; and 5) family income was [+ or -] $50.00 weekly of the target DA family income.

The matching was effective. No significant differences were found between parents or children from the DA and NA families on the matching variables. As expected, the proportion of fathers meeting DSM-IV diagnostic criteria for alcohol dependence or dependence on another psychoactive substance differed between the groups. Of course, this difference is due to the operational definition used to classify fathers into AA and DA families. Demographic information on the AA and DA families is shown in Table 1.

Measures

Pediatric Symptom Checklist (PSC)

The PSC is a 35-item questionnaire that lists a broad range of emotional and behavioral items that assess parents' impressions of their children's psychosocial functioning (32). Sample items include "Is irritable, angry," "Teases others," "Blames others for his or her troubles." "Feels sad, unhappy," and "Worries a lot." Items are scored "never," "sometimes," or "often." An overall score is obtained by assigning a 0, 1, or 2, respectively, to each item and summing the total number of points. For children ages 6 through 16, a score greater than or equal to 28, and for children ages 4 through 5, a score greater than or equal to 24, has been empirically established as clinical cutoff scores (33). In addition to calculating the child's overall score, children were classified as being in the impaired or unimpaired range depending on whether their PSC score was 28 or more (for ages 6 to 16) or 24 or more (for ages 4 to 5).

The validity of the PSC has been demonstrated in more than 100 studies that have been published in pediatric, psychiatry, psychology, and education journals. The sensitivity and specificity of the PSC appears comparable with the Children's Global Assessment Scale and the Child Behavior Checklist (34-36). Test-retest reliability of the PSC was reported at r = 0.86 between two administrations approximately 4 weeks apart (37).

Addiction Severity Index (ASI)

The ASI is a 45- to 60-minute structured interview that measures the lifetime and recent (past 30 days) severity of problems in seven areas of functioning: alcohol, drug, employment, family-social, legal, medical, and psychiatric (38). Composite scores were calculated for each area assessed; these were based on weighted combinations of individual items that provide reliable, valid, and sensitive measures of problem severity, in the seven areas noted, for the 30 days prior to the interview. Composite scores range from 0.0 to 1.0, with higher scores indicating greater impairment (39).

Procedure

Participants entering either the alcoholism or drug abuse treatment program were interviewed as part of their intake protocol. During this intake interview, the ASI was administered to the male patients. Female partners of men entering the alcohol or drug treatment programs completed the PSC for each child in the age range living in the home. Participants were not paid for their participation.

RESULTS

Children's Psychosocial Functioning

Children from the DA families had significantly higher scores on the PSC (M = 25.1; SD = 19.7) than children from the AA families (M = 14.4; SD = 10.6), t (100) = 3.86; p < 0.001. In addition, a significantly greater proportion of children from DA homes had clinical levels of psychosocial impairment (n = 23; 45%) compared with children living with alcohol-dependent fathers (n = 5, 10%), [chi square] = 15.95 (1), p < 0.001.

Addiction Severity of Fathers in the DA and AA Families

The ASI subscale composite scores for fathers from the DA and AA families are located in Table 2. Pairwise comparisons revealed that fathers in the DA families had significantly higher subscale scores on five of the seven subscales (i.e., Drug, Legal, Medical, Employment, and Family); fathers in the AA families had significantly higher subscale scores on one subscale (i.e., Alcohol).

Mediation Analysis

We sought to determine if fathers' ASI subscale scores mediated the relationship between family type (DA and AA) and children's psychosocial adjustment. To demonstrate that one or more of these variables is a mediator, the following four conditions must be met (40): 1) family type (i.e., DA or AA) must be associated with children's psychosocial adjustment, 2) family type must be associated with the mediator, 3) the mediator must be associated with children's PSC score when controlling for family type in the model, and 4) the relationship between family type and children's PSC score must be meaningfully reduced when controlling for the mediator. If conditions 1, 2, and 3 are met, but the relationship in condition 4 remains significantly different from zero when the mediator is included in the model, this indicates the variable meets the criteria for partial mediation. If all four conditions are met and the relationship in condition 4 is no longer significantly different from zero, the variable meets criteria for full mediation.

As shown in Table 3, conditions for partial mediation were met for five ASI variables: Drug, Legal, Medical, Employment, and Family. None of the ASI subscales met the conditions for full mediation.

DISCUSSION

This study compared the psychosocial functioning of children living in homes with fathers who primarily abuse drugs other than alcohol with children of alcohol--abusing fathers. As hypothesized, children living with DA fathers exhibited a greater number of behaviors indicative of psychosocial distress. An examination of PSC item endorsements indicated children from DA families experienced a wide range of symptoms, which included irritability, fighting, teasing, fearing new situations, anger, and worrying. It is important, based on their mothers' reports, 45% of children with DA fathers exhibited behavior defined as clinically significant.

Although many factors may contribute to increased distress for children living with DA fathers, similar to the work by Miller (23), we found that illegal drug abuse resulted in more severe social consequences than alcohol abuse. Specifically, scores on the ASI Drug, Legal, Medical, Employment, and Family subscales were substantially higher for DA men than for AA men.

Previous research has shown that more severe drug use is associated with illegal activities such as theft and less likelihood of full- or part-time employment (41). For men in the present study, illegal drug use was associated with greater legal difficulty and more employment problems. Illegal drug abuse appears to result in difficulty meeting the demands of full-time employment (e.g., greater unemployment, more job changes, and more absenteeism) and in many cases may deprive children of the family's main source of income. Low family income and financial problems have established negative effects on children (42,43). Noteworthy is the finding by Gillham and colleagues (44) who found a more consistent relationship between paternal unemployment and child abuse and neglect than maternal unemployment and child mistreatment. For children living with DA men, job instability appears to be an associated problem that has significant implications for children's psychosocial functioning.

It is also possible that the child's mother, who was not substance-dependent at the time of the study, may have had little ability to shield the child from the deleterious and far-reaching effects of illegal substance abuse. In fact, illegal drug use resulted in greater family-related problems. Both chaotic family life and less adequate parenting are known to compromise child functioning (28).

These results begin to elucidate differences between children living with DA and AA men, as well as factors that may in part account for within-group differences among children with drug-dependent fathers. However, additional investigations are needed to identify children who are most vulnerable to the deleterious effects of paternal drug abuse. It is important to note that critical work is being done to examine the pathways between mothers' substance abuse and child outcomes (45). Luthar and colleagues (20) have shown that both parenting behaviors and sociodemographic variables influence child outcomes for children living with drug-dependent mothers. However, missing from the literature is a comprehensive picture of the lives of children living with substance-dependent fathers and the specific mechanisms by which drug use leads to negative child outcomes. In addition, we know very little about the variables that may serve as protective factors for children in these homes. In addition, the dynamics of two-parent homes in which the father is drug-dependent are substantially different from those of children living in single-parent homes with substance-dependent mothers. For instance, many children of DA mothers are "farmed out" to other relatives (46) or placed in out-of-home care (47). In contrast, children in our sample appear to have spent many years in homes with substance-dependent fathers. In short, we cannot assume identical developmental trajectories for children living with drug-dependent fathers versus drug-dependent mothers. It is important to note that the vast majority of investigations of COSAs have focused on infants and young children of DA mothers. Clearly, the present results suggest that examining children living with drug-dependent fathers is worthy of further study.

Because illegal drug use has effects beyond the individual, there are clear implications for social policy and for mental health professionals. Clinicians working with fathers who enter treatment for drug abuse should assume that many of the children in these homes may be experiencing significant emotional or behavioral difficulty. It may be necessary to screen children for the presence of psychosocial disorders (e.g., anxiety disorder and conduct disorder) or behaviors that may be antecedents for later problems (e.g., aggression and school problems).

In addition, several studies have shown that family-based interventions for substance abuse are more effective than individual-based treatments for drug abuse (48). For instance, Behavioral Couples Therapy (BCT), which emphasizes ways to reduce drug use and to improve dyadic functioning, is more effective than individual treatment for reducing days of drug use, increasing periods of abstinence, decreasing drug arrests, reducing partner violence, and increasing relationship satisfaction (49,50). Kelley and Fals-Stewart (51) found that couples-based treatment for men entering treatment for drug or alcohol abuse improved children's psychosocial functioning over individual-based treatment or a psychosocial attention control treatment. At present, however, many men do not want their children involved in their treatment (52). Clearly, offering a wide range of treatment options, and possibly offering individual treatment for children, may be important for families in which a DA father is living with dependent children.

The present study has several methodological limitations. Although the sample size of the substance abuse groups was relatively large in comparison with much of the previous research, future research would benefit from larger samples and from carefully matched comparison groups of children from nonsubstance-abusing families and families of men with other psychiatric disorders. An additional limitation of the present study is that men in both the alcohol and drug conditions were entering treatment for substance abuse. We do not know the degree to which data from children in these families may generalize to that of children with substance-dependent fathers who are not seeking treatment. Furthermore, the majority of children were between 8 and 13 years of age; however, some children as young as 5 and as old as 16 were included in the sample. Thus, not all children were in the same stage of development, which may introduce significant heterogeneity to our findings. Post hoc analyses, however, revealed that children's age was not associated with mothers' reports of children's behavioral symptomology.

Our findings also are limited by the reporting of children's psychosocial functioning by mothers only. Although cognitive distortion may be possible, we believe that mothers were able to provide reasonable ratings on a standardized measure of child behavior. Nevertheless, future research should attempt to obtain reports by other knowledgeable adults such as teachers and perhaps children themselves. Our results are also limited by the use of a global screening instrument for children's behavioral symptomology. Clearly, additional research is needed, which assesses child functioning using more detailed measures, as well as assesses child adjustment across a broad range of domains. Although mothers did not report drug use or any significant alcohol use during pregnancy or in recent months, we cannot be assured that maternal drug or alcohol abuse did not occur.

Although there are a number of methodological limitations, there are a number of strengths that should be noted. The present research used widely utilized instruments with demonstrated reliability and validity. The sample size was relatively large comparison with much of the previous research on the psychosocial functioning of children living in homes with alcohol or other drug abuse. Samples also were matched on important sociodemographic variables.

CONCLUSIONS

Globally, our findings demonstrate that children living with fathers entering treatment for substance abuse primarily other than alcohol appear to exhibit significantly more psychosocial distress than do children of alcohol-dependent men. Moreover, a significant percentage of children living with drug-dependent fathers exhibit behavior that is indicative of psychosocial impairment, as well as the types of behaviors that are generally considered to be antecedents of adolescent and adult problems (53). For children of DA but not AA men, the severity of the fathers' addiction was closely related to children's distress. These findings call for additional research to identify factors associated with the risk and resiliency of children living with DA fathers and suggest that additional resources are needed for children in these homes.

Table 1. Sociodemographic characteristics with
alcohol-abusing (AA) and drug-abusing
with alcohol-abusing (AA) and drug-abusing (DA) fathers.

Variable                                 AA (N = 51)    DA (N = 51)

Mean (SD)
Fathers' age (yr)                         34.2 (9.1)      33.3 (8.9)
Mothers' age (yr)                         31.3 (8.2)      31.1 (7.6)
Fathers' education (yr)                   11.9 (1.2)      11.8 (1.8)
Mothers' education (yr)                   12.4 (1.3)      12.3 (2.2)
Length of relationship (yr)                5.9 (4.4)       5.7 (4.2)
Age of target child (yr)                   9.8 (0.0)       9.7 (3.9)
Weekly family income                    199.4 (91.3)    188.5 (90.0)
Number (%)
Couples who were legally married             41 (80)         29 (57)
Target children who were male                26 (51)         24 (47)
Fathers who met DSM-IV criteria for
Alcohol dependence                          51 (100)         22 (43)
Cocaine dependence                             0 (0)         26 (51)
Opiate dependence                              0 (0)         18 (35)
Cannabis dependence                            0 (0)          6 (12)
"Other"                                        0 (0)          9 (18)

Table 2. Means and standard deviations of addiction severity index
composite subscale scores for fathers from alcohol-abusing (AA) and
drug-abusing (DA) families.

Subscale        AA (n = 51)     DA (n = 51)     t (100)

Drug            0.08 (0.07)     0.35 (0.08)      17.81 ***
Alcohol         0.31 (0.11)     0.20 (0.06)     - 7.30 **
Legal           0.21 (0.16)     0.32 (0.12)       3.99 **
Medical         0.14 (0.12)     0.17 (0.11)       2.00 *
Employment      0.21 (0.11)     0.52 (0.18)       8.31 ***
Family          0.25 (0.10)     0.32 (0.11)       2.20 *
Psychiatric     0.25 (0.10)     0.29 (0.11)       0.28

* p < 0.05.

** p < 0.01.

*** p < 0.001

Table 3. Effects of potential mediating variables on the
relationship of family type with children's psychosocial
adjustment.

                              Relationship to children's
                               psychosocial adjustment

ASI subscale                   B          SE        t (99)

Drug                          1.10        0.17     6.43 **
Alcohol                       0.21        0.19     1.11
Legal                         0.26        0.10     2.53 *
Medical                       0.54        0.13     4.28 **
Employment                    0.23        0.08     2.79 *
Family                        0.54        0.13     4.15 **

                         Relationship of family type
                          with children's psychosocial
                         adjustment after controlling for
                        potential mediating variable

ASI subscale                  B           SE        t (99)

Drug                         20.30        5.34     3.80 **
Alcohol                     -13.08        3.89    -3.36 **
Legal                        -7.31        3.27    -2.23 *
Medical                      -7.97        2.93    -2.73 **
Employment                   -7.88        2.97    -2.66 **
Family                       -9.91        2.87    -3.45 **

Note: ASI = addiction severity index.

* p < 0.05.

** P < 0.01.

ACKNOWLEDGEMENTS

This research was supported in part by grants from the National Institute on Drug Abuse (R01DA12189 and R01DA14402) and the Alpha Foundation.

(a) An algorithm [from Ref. (54)] was used to determine male partner's primary drug of abuse, with decisions based on combinations of his self-report data, diagnostic information, prior treatment information, and frequency of use for each drug more than 90 days and 12 months before treatment. A dyad was classified as an alcoholic couple if the male partner's primary drug was alcohol. Conversely, dyads in which male partners primarily abused other psychoactive substances were classified as drug-abusing couples.

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Cathy G. Cooke, (1) Michelle L. Kelley, (1), * William Fals-Stewart, (2) and James Golden (2)

* Correspondence: Michelle L. Kelley, Department of Psychology, Old Dominion University, Norfolk, VA, USA; Fax: (757) 683-5987; E-mail: mkelley@odu.edu.

(1) Old Dominion University, Norfolk, Virginia, USA

(2) Research Institute on Addictions, University of Buffalo, The State University of New York, Buffalo, New York, USA

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