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Original Articles

Psychiatric Disorders in Children of Parents With Substance Dependence Disorder

Okasha, Tarek A. MD*; Ibrahim, Nesreen M. MD*; Naguib, Rehab M. MD*; Khalil, Kerolos B. BSc; Hashem, Reem E. MD*

Author Information
Addictive Disorders & Their Treatment: September 2021 - Volume 20 - Issue 3 - p 159-167
doi: 10.1097/ADT.0000000000000216
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Abstract

A child is fundamentally dependent on his or her parents, including efforts to achieve developmental tasks. Obstacles in achieving the tasks needed for child development can cause feelings of inferiority, aggressiveness, and failure to socialize, affecting their forthcoming life.1

Two aspects have significant influence on a child’s behavior, which are the family structure and relationship among the family members, which determine the parental control, supervision, and affective measures of the parent-child relationship, such as attachment and closeness, and these aspects are affected in drug-abuse parents.2

Recent evidence is a strong reminder that parental mental illness is an important adversity that critically affects the lifelong mental well-being in offspring.3

An increasing body of research suggests that adverse outcomes for children raised in families with parental substance-misuse emerge early in the child’s life and are related to the quality of the parent-child relationship that significantly impacts on the child’s developing neurological system.4

The epidemiological surveys estimated that the worldwide lifetime prevalence of mental disorders in the general population range from 12.0% to 47.4%.5 One of the major risk groups for developing mental health problems is the offspring of psychiatric patients.6

The essential feature of a substance use disorder (SUD) is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. SUD occurs in a broad range of severity, from mild to severe, with severity based on a number of symptoms criteria endorsed.7

Opiate dependence is a severe form of drug dependence characterized by early onset, chronic course, and high rates of psychiatric comorbidity. Thus, children of opiate addicts’ parents would be expected to be at risk for a variety of psychiatric disorders for which early diagnosis and treatment would be important.8

The sequelae of drug abuse do not only affect the subject but may also extend to include his family members; it was found that violence against children has become rampant, especially among the families of addicted parents. The chance of child abuse among the parents who were both addicted was 2.66 times more than the families where the father alone was addicted.9

In a study of children of SUD parents, it was found that 54% of children admitted to an inpatient psychiatric unit had preadmission histories of parental substance abuse.10 In another study of children who lived with drug abuse fathers, they were more likely to have a lifetime psychiatric diagnosis (ie, 53% vs. 10% in non–substance-abusing homes). Compared with children in the other group, children in drug abuse homes were more than twice as likely to exhibit clinical levels of behavioral symptoms.11

The published studies of psychiatric diagnosis by direct, structured interview in children of a mixed sample of opiate and cocaine addicts12 found rates of disorders higher than those of children in a community sample.13

Meanwhile, children of addicted parents exhibit depression, anxiety, and elevated rates of psychiatric and psychosocial disorder more frequently than do children from nonaddicted families.14,15

Families in which one or both parents use illicit drugs, particularly opiates and cocaine, are much more likely to be living in poverty, and, also, it is associated with criminal activities and places the parents at risk for arrest and imprisonment. Moreover, drug-abusing families have more problems in areas known to influence children’s adjustment, including poorer dyadic adjustment and higher levels of partner violence.16

Furthermore, compared with families in which neither parent was dependent on alcohol or illicit drugs, the offspring of parents with alcohol or other drug illicit dependence were at least 3 times more likely to experience externalizing disorders such as attention deficit hyperactive disorder.17

Hence, we conducted this research to examine the effect of parental SUD on their children and to raise the concern that SUD is not only a self-problem, but there are long-term consequences on the offspring as well.

AIM OF THE WORK

The aim of the study was to illustrate the psychiatric illness found in children and adolescents of substance-dependent parents and to explore the associations between the psychiatric diagnosis and the severity of drug addiction in their parents.

MATERIALS AND METHODS

A cross-sectional comparative study was conducted at the outpatient clinics and inpatient ward of Heliopolis Psychiatric Hospital. This hospital has an inpatient ward for SUDs patients and outpatient clinics for both psychiatric disorders and SUD. All procedures were reviewed and approved by the Ethical Committee of Ain Shams University. Informed written consent was obtained from the parents of both groups after they were explained about the study objectives, and the subject was assured about the confidentiality of the information; it was clearly explained that their children’s participation in the study or withdrawal at any time did not interfere with their treatment process.

Subjects of the study were divided into 2 groups of children: group A comprised 25 children of either parents diagnosed with substance dependence disorder, who were seeking advice in the inpatient and outpatient clinics for SUDs at Heliopolis Psychiatric Hospital. Inclusion criteria were age 6 to 18 years old and having at least 1 parent diagnosed as suffering from substance dependence disorder by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-4th edition (SCID I).

We targeted the eldest child among his siblings, as they show better understanding and cooperation while doing the assessment; moreover, they would have spent more time subjected to their parent’s drug abuse problem.

They were excluded if there was evidence of a past history of psychiatric disorder; those previously known to have learning disability, those with the presence of any comorbid psychiatric condition diagnosed by SCID I in their participating parent, and those refusing to give consent were excluded as well.

Group B comprised 25 children, closely matching group A children in terms of their age, sex, and educational level, who were chosen after their parents were screened by the General health questionnaire as free of any psychiatric diagnosis and matching group A parents. They were recruited from among the employees working at Heliopolis Psychiatric Hospital.

Study Procedures and Tools

Substance dependence parents (group A) were subjected to the following (and they are):

The SCID I scale18 was used to diagnose substance dependence and to exclude other psychiatric disorders. The Arabic research version was used.19 Thereafter, we applied the Addiction Severity Index (ASI) scale20 to assess the treatment problems found in individuals with SUDs. The Arabic version was used.21

Parents in group B were subjected to what follows:

Assessment using the General Health Questionnaire (GHQ)22 before being enrolled to ensure their eligibility to be included in the study after being screened as normal. The Arabic version was used.23

Children in both groups were subjected to what follows:

All children of both groups were examined using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI KID) scale: International Neuropsychiatric Interview for Kids and Adolescents.24 The Arabic version was used.25

Statistical Analysis

All recorded data were analyzed using the appropriate version of Package for Social Sciences (SPSS) for Microsoft windows software package. Version 20 was used. Statistically significant findings were determined by a 2-tailed P-value <0.05. The χ2-test was used to compare group A participants and group B participants.

RESULTS

Sociodemographic Data

The age of children in group A ranged from 6 to 18 years with mean age (10.52±3.4), while in group B it ranged from 6 to 17 years with mean age (12.12±1.4), with similar sex differences between both groups, as the number of male individuals were 17 and 18 in group A and B, respectively.

Comparison Between Children in Both Groups With Regard to the MINI KID Scale

Results of the MINI KID showed that psychiatric diagnosis was significantly higher in group A than in group B (P=0.002), as 80% of group A met the criteria of diagnosis.

The main significant differences were in the following disorders received by group A: major depressive disorder, dysthymia, panic disorder (in whole life), agoraphobia, and separation anxiety disorder with P-value of 0.018, 0.042, 0.021, 0.037, and 0.004, respectively, as shown in Table 1.

TABLE 1 - Comparison Between Children in Both Groups W Regard to the Diagnosis Using the MINI KID Scale
Groups [N (%)]
Group A Group B Total χ2 P
Major depressive disorder
 Meet criteria 5 (20.00) 0 5 (10.00) 5.556 0.018*
 Does not meet criteria 20 (80.00) 25 (100.00) 45 (90.00)
Suicidality
 Meet criteria 4 (16.00) 3 (12.00) 7 (14.00) 0.166 0.684
 Does not meet criteria 21 (84.00) 22 (88.00) 43 (86.00)
Suicidality risk
 Low 4 (100.00) 3 (100.00) 7 (100.00) x x
Dysthymia
 Meet criteria 6 (24.00) 1 (4.00) 7 (14.00) 4.153 0.042*
 Does not meet criteria 19 (76.00) 24 (96.00) 43 (86.00)
Hypomanic episode (current)
 Meet criteria 1 (4.00) 0 1 (2.00) 1.020 0.312
 Does not meet criteria 24 (96.00) 25 (100.00) 49 (98.00)
Hypomanic episode (past)
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
Panic disorder (current)
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
Panic disorder (lifetime)
 Meet criteria 7 (28.00) 1 (4.00) 8 (16.00) 5.357 0.021*
 Does not meet criteria 18 (72.00) 24 (96.00) 42 (84.00)
Agoraphobia
 Meet criteria 0 3 (12.00) 3 (6.00) 4.351 0.037*
 Does not meet criteria 25 (100.00) 22 (88.00) 47 (94.00)
Separation anxiety disorder
 Meet criteria 7 (28.00) 0 7 (14.00) 8.140 0.004*
 Does not meet criteria 18 (72.00) 25 (100.00) 43 (86.00)
Social phobia (social anxiety disorder)
 Meet criteria 2 (8.00) 0 2 (4.00) 2.083 0.149
 Does not meet criteria 23 (92.00) 25 (100.00) 48 (96.00)
Specific phobia
 Meet criteria 4 (16.00) 1 (4.00) 5 (10.00) 2.000 0.157
 Does not meet criteria 21 (84.00) 24 (96.00) 45 (90.00)
Obsessive compulsive disorder
 Meet criteria 0 1 (4.00) 1 (2.00) 1.020 0.312
 Does not meet criteria 25 (100.00) 24 (96.00) 49 (98.00)
Posttraumatic stress disorder
 Meet criteria 2 (8.00) 0 2 (4.00) 2.083 0.149
 Does not meet criteria 23 (92.00) 25 (100.00) 48 (96.00)
Alcohol use and dependence
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
Substance use and dependence
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
Tic disorder
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
ADHD
 Meet criteria 0 1 (4.00) 1 (2.00) 1.020 0.312
 Does not meet criteria 25 (100.00) 24 (96.00) 49 (98.00)
Conduct disorder
 Meet criteria 4 (16.00) 3 (12.00) 7 (14.00) 0.166 0.684
 Does not meet criteria 21 (84.00) 22 (88.00) 43 (86.00)
Oppositional defiant disorder
 Meet criteria 4 (16.00) 2 (8.00) 6 (12.00) 0.758 0.384
 Does not meet criteria 21 (84.00) 23 (92.00) 44 (88.00)
Psychotic disorders (current)
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
Psychotic disorders (lifetime)
 Meet criteria 0 2 (8.00) 2 (4.00) 2.083 0.149
 Does not meet criteria 25 (100.00) 23 (92.00) 48 (96.00)
Generalized anxiety disorder
 Meet criteria 5 (20.00) 1 (4.00) 6 (12.00) 3.030 0.082
 Does not meet criteria 20 (80.00) 24 (96.00) 44 (88.00)
Anorexia nervosa
 Meet criteria 3 (12.00) 0 3 (6.00) 3.191 0.074
 Does not meet criteria 22 (88.00) 25 (100.00) 47 (94.00)
Adjustment disorder
 Does not meet criteria 25 (100.00) 25 (100.00) 50 (100.00) x x
*Significant statistical difference.
ADHD indicates attention deficiency hyperactive disorder; MINI KID, Mini-International Neuropsychiatric Interview for Children and Adolescents; x, both groups are free of this disorders so no significant difference between them.

Results of ASI Scale in Fathers of Group A

We used the ASI scale to gain more information about areas of the parent’s life that may contribute to their substance-abuse problems. We found that with regard to the medical aspect, most parents (60%) had mild degree of severity. Turning to the employment aspect, the majority of parents (64%) had moderate degree of severity.

Looking to the alcohol and drug aspect, 72% of parents had moderate degree of severity. Their drug problem affected their family aspect in a moderate number of parents (56%) by severe degree. It caused psychiatric problems in 72% of the parents with mild degree of severity. Fortunately, most parents (72%) have no legal problems, as shown in Table 2.

TABLE 2 - Addiction Severity Index Scale in Parents of Group A
No Problem [N (%)] Mild [N (%)] Moderate [N (%)] Severe [N (%)] Extreme [N (%)]
Medical 2 (8.00) 15 (60.00) 5 (20.00) 2 (8.00) 1 (4.00)
Employment 1 (4.00) 4 (16.00) 16 (64.00) 4 (16.00) 0
Alcohol and drug 1 (4.00) 3 (12.00) 18 (72.00) 1 (4.00) 2 (8.00)
Legal 18 (72.00) 3 (12.00) 1 (4.00) 2 (8.00) 1 (4.00)
Family 0 1 (4.00) 10 (40.00) 14 (56.00) 0
Psychiatric status 1 (4.00) 18 (72.00) 3 (12.00) 3 (12.00) 0

Relation Between Addiction Severity and MINI KID Scale in Group A

Trying to find a relation between addiction severity and results of the MINI KID scale in group A, we found that only the employment aspect of ASI was significant, with P-value 0.025. This denotes that the unemployment of the substance abuse parent is a contributing factor to their children’s psychiatric illness, as shown in Table 3.

TABLE 3 - Relation Between Type of Substance (in Parents of Group A) and Psychiatric Disorders in Their Children With MINI KID Scale
MINI KID Scale [N (%)]
Type of Substance Meet Criteria Does Not Meet Criteria Total χ2 P
Polysubstance 14 (70.00) 3 (60.00) 17 (68.00)
Heroin 1 (5.00) 0 1 (4.00)
Tramadol 4 (20.00) 1 (20.00) 5 (20.00) 1.434 0.698
Tow substance 1 (5.00) 1 (20.00) 2 (8.00)
Total 20 (100.00) 5 (100.00) 25 (100.00)
MINI KID indicates Mini-International Neuropsychiatric Interview for Children and Adolescents.

However, with regard to the family aspect of addiction severity, despite 60% of children meeting the criteria for having disorder, their parent showed “severe” degree of severity in their family aspect in ASI. No significance was found.

Relation Between Type of Substance (in Parents of Group A) and Psychiatric Disorders in Their Children

No significant relationship was found between the type of substance abused by the parents and the diagnosed psychiatric disorders in their children (P=0.698). Yet, 70% of parents whose children met the criteria of at least 1 disorder in MINI KID scale were abusing polysubstance. As regards 20% of parents abusing Tramadol, their children met criteria of at least 1 disorder in the MINI KID scale, as shown in Table 4.

TABLE 4 - Shows Relation Between Addiction Severity and Result of MINI KID Scale in Group A
MINI KID Scale [N (%)]
Meet Criteria Does Not Meet Criteria Total χ2 P
Medical
 No problem 1 (5.00) 1 (20.00) 2 (8.00) 2.917 0.572
 Mild 13 (65.00) 2 (40.00) 15 (60.00)
 Moderate 4 (20.00) 1 (20.00) 5 (20.00)
 Severe 1 (5.00) 1 (20.00) 2 (8.00)
 Extreme 1 (5.00) 0 1 (4.00)
Employment
 No problem 1 (5.00) 0 1 (4.00) 9.375 0.025*
 Mild 1 (5.00) 3 (60.00) 4 (16.00)
 Moderate 14 (70.00) 2 (40.00) 16 (64.00)
 Severe 4 (20.00) 0 4 (16.00)
Alcohol and drug
 No problem 1 (5.00) 0 1 (4.00) 5.208 0.267
 Mild 1 (5.00) 2 (40.00) 3 (12.00)
 Moderate 15 (75.00) 3 (60.00) 18 (72.00)
 Severe 1 (5.00) 0 1 (4.00)
 Extreme 2 (10.00) 0 2 (8.00)
Legal
 No problem 14 (70.00) 4 (80.00) 18 (72.00) 1.389 0.846
 Mild 2 (10.00) 1 (20.00) 3 (12.00)
 Moderate 1 (5.00) 0 1 (4.00)
 Severe 2 (10.00) 0 2 (8.00)
 Extreme 1 (5.00) 0 1 (4.00)
Family
 Mild 0 1 (20.00) 1 (4.00) 4.286 0.117
 Moderate 8 (40.00) 2 (40.00) 10 (40.00)
 Severe 12 (60.00) 2 (40.00) 14 (56.00)
Psychiatric status
 No problem 1 (5.00) 0 1 (4.00) 1.389 0.708
 Mild 14 (70.00) 4 (80.00) 18 (72.00)
 Moderate 3 (15.00) 0 3 (12.00)
 Severe 2 (10.00) 1 (20.00) 3 (12.00)
*Significant statistical difference.
MINI KID indicates Mini-International Neuropsychiatric Interview for Children and Adolescents.

DISCUSSION

Factors related to the home environment, particularly the effects of paternal care and addiction, have a strong association with all types of child maltreatment. Among the most negative consequences of alcoholism and drug addiction are the psychosocial effects of parental substance abuse on their children. In comparison with children raised by parents who do not misuse alcohol or any substance, children who live with a substance abuse parent exhibit elevated symptom levels for both internalizing (eg, sadness and worrying) and externalizing (eg, aggression) syndromes.26

The current study examined whether children of parents with SUDs were at greater risk for developing psychiatric problems compared with those whose parents did not have SUDs. Our sample consisted of 2 groups of children. Group A consisted of 25 children whose parents were diagnosed with substance abuse disorder according to Diagnostic and Statistical Manual of Mental Disorders-4th edition research criteria, and group B consisted of 25 children whose parents were mentally free.

In our study, we used the MINI KID scale to compare between children in both groups, and we found that the risk of having psychiatric disorder in children of group A increased when their parent was a substance abuser. As 80% of children in the case group met criteria to have at least 1 psychiatric disorder, in the control group (group B) only 36% of the children had psychiatric disorder.

This was in agreement with Fals-Stewart and colleagues who examined lifetime psychiatric disorders and current emotional and behavioral problems of 8 to 12-year-old children living with drug-abusing fathers compared with children living in demographically matched homes with alcohol-abusing or non–substance-abusing fathers. Substance-abusing fathers were recruited from an outpatient treatment program like our study. Children living with drug-abusing fathers were more likely to experience a lifetime psychiatric disorder and more negative behaviors compared with children living with an alcohol-abusing father or non–substance-abusing parents. He found that children who lived with drug-abusing fathers were more likely to have a lifetime psychiatric diagnosis (ie, 53% vs. 25% in alcohol-abusing homes and 10% in non–substance-abusing homes).27

Our results are in line with the study of Ranta and Raitsalo, who found that children of mothers with substance abuse more often had disorders of psychological development as well as behavioral and emotional disorders than other children.28,29

In addition, we found that there was a significant difference between the 2 groups where children with substance-abusing parents suffer more from major depression, dysthymia, whole life panic disorder, agoraphobia, and separation anxiety disorder of children.

Similarly, Bountress and Chassinin30 found that children of parents with a current SUD were at higher risk for externalizing and internalizing problems, compared with those whose parents had not been diagnosed.

Moreover, Johnson and colleagues who studied 72 male and female children (35 children of substance abusers and 37 children of parents who were not substance abusers) aged 8 to 14 years. They found that children of substance abusers compared with children of parents who were not substance abusers were at significant disadvantage on measures of depression and trait anxiety.31

In contrast, Gabel and Shindledecker32 found that there was no significant difference between boys with substance-abusing parents and boys without substance-abusing parents on the severe aggressive/destructive behavior variable, attention deficit disorder, or depressive disorder diagnoses considered separately.

Furthermore, their results matched our results in finding no significant difference between boys with substance abuse parents and boys without substance abuse parents on the conduct disorder.32

Surprisingly, on studying the relation between the ASI measured in parents and the psychiatric disorders in their children, we did not find any significant difference, except in the employment aspect of ASI. Although there is a clinical effect of other aspects such as the “family aspect,” and these effects should be taken in consideration, these effects did not make a statistical difference. This was in agreement with Raitasalo et al33 in their recent large longitudinal study reporting that parental alcohol abuse, regardless of severity, is associated with an increased risk of mental and behavioral disorders in children.

CONCLUSIONS

This study shows the detrimental effects of SUD when it comes in a child-bearing parent.

Our study found that the prevalence of psychiatric disorders in children increases when their parents had SUD when compared with their counterparts.

Moreover, we found that the variation of the severity of parent addiction does not always affect the risk to have psychiatric disorders in their children. Hence, having any drug abuse even of mild degree can affect the child’s well-being, indicating the importance of tackling and treating this problem in those parents and the importance of supporting and helping their children to sustain a healthy mental life.

Limitations

A lot of SUD parents did not accept to include their children in our study out of stigma of SUD. Only parents who suspected that their child had any psychiatric disorder accepted to be recruited in our study.

The current study is limited by small sample size. Furthermore, being a hospital-based study and not a community-based study may affect generalization of results.

ACKNOWLEDGMENTS

The authors thank the parents of both groups and all the children who were motivated to volunteer in the research to enrich the scientific knowledge and improve the clinical practices.

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Keywords:

substance use disorders; children of SUD parents; psychiatric disorders in children

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