Children of Alcoholics

Are They Vulnerable or Resilient?

Alcohol consumption is rampant in most parts of the world, and in India, exact estimates are not available of the consumption rate due to the varied sociocultural practices and laws which govern various states. However, some data have revealed that the country's annual per capita spirit consumption had doubled to 5.7 L as compared to the annual global average alcohol consumption which was 6.4 L per person older than 15 in 2016.[¹] India is a diverse nation with cultural variations among ethnic, religious, and linguistic groups, and there are major differences between the urban and rural areas. One cannot accurately characterize the drinking patterns of all Indian ethnic and cultural groups based on the findings from just one of these groups. Indian attitudes to drinking include both permissive and abstinent features, especially when different population groups are considered.

The estimates in India would definitely be higher, though data from the Southeast Asian continent is lacking. The National Mental Health Survey of India 2015–2016 found the prevalence of alcohol use disorders to be 9% in adult men.[²³] In India, as there is nearly one-third revenue generated from sale of alcohol, the legislation for prohibiting its use is not in place as the government does not want to be aware of the harm caused by its consumption on family and the society together. Alcohol prohibition is dependent on each state's policy; hence, the alcohol legislation, state excise rates, organization of the production, and sale of alcohol are under full control of each state due to the revenue generated.[⁴] Due to these pitfalls, research on children of alcoholics (COAs) is lacking in India and has also taken a backseat in most of the western countries.

WHY ARE CHILDREN OF ALCOHOLICS VULNERABLE?

COAs have been under scrutiny for decades, especially in the sixties and seventies when most of the researches were generated. Researchers tried to study the lasting effects of the parental alcohol consumption on the development of the child as well as his lifespan.[⁵⁶⁷⁸] COAs have suffered from a nonconductive environment which was characterized by:

• Disturbed parent–parent relationship
• Parent–child relationship
• Deviant and faulty parental role modeling
• Lack of social and family support
• Varied psychopathology in parents.

Although researchers could identify several variables to understand the nature and extent of the problems faced by the COAs, there were difficulties faced in making valid generalizations as alcohol consumers were not a homogenous group.[⁵] Furthermore, the alcohol consumers had other substance comorbidities as well as psychiatric disorders.[⁶] Most of the researches carried out had methodological difficulties which could not solely attribute the impact of only alcohol on children and family.

PSYCHOPATHOLOGY IN CHILDREN OF ALCOHOLICS

Several researchers had noted a variety of emotional and behavioral problems in COAs.[⁵⁶⁷⁸⁹] However, due to the heterogeneity of alcohol dependence, it was very difficult for researchers to attribute a specific characteristic of parental alcoholism to COA. It was studied that the comorbid psychopathology in the parent with alcohol dependence was important to predict the psychopathological outcomes in relatives. Parental characteristics above and beyond alcoholism were important determinants of features observed in the alcoholics' offspring. Many researchers did try to study differences between COA and non-COAs to see if there was a genetic vulnerability and the reasons why the two differ.[⁶⁹¹⁰] Previous researchers also evaluated whether the problems seen in COAs were similar or different, as seen in children whose parents had other illnesses? There have been a few longitudinal studies done in COAs to track their entire development period and factors such as parental conflicts and the severity of the drinking and its effect on the child.[⁷¹⁰]

The various emotional and behavioral problems faced by COAs include the following:

• Internalizing symptoms
• Externalizing symptoms
• Fear and worry about their parent
• Academic difficulties
• Low self-esteem
• Abuse: Emotional, physical, verbal, and economic
• Socially inadequate
• Interpersonal problems and lower relationship satisfaction
• Poor job and work satisfaction in later life.

A variety of internalizing symptoms such as anxiety and depression in COAs have been studied by several researchers. These children may grow up to have fears not only for themselves but also worry about their parent with alcohol dependence. They often fear that the parent would get sick or die of substance use. Another important finding was that child maltreatment which could include physical/verbal abuse, inadequate parenting, repeated fights in front of the child, emotional abuse/neglect, depriving the child of a secure home, education, and a conducive environment for development often led to an increased risk for an alcohol use disorder and substance-related problems in COAs as compared to non-COAs. In fact, there are two theories postulated as to why child maltreatment leads to substance use disorders. An early onset of substance use disorders is attributed to an externalizing pathway where the child has temperamental issues, conduct traits, maladaptive parenting practices, etc., The other cause is the internalizing pathway which is characterized by stress and negative affect regulation and substances being used as a method of coping or self-medication.[¹¹¹²]

The externalizing symptoms include rule breaking, defiance, aggression, inattention, and impulsivity. Most of the COAs do satisfy the criteria for childhood disorders such as attention deficit hyperactivity disorder (ADHD), conduct disorders, and oppositional defiant disorder. Furthermore, there is high comorbidity between ADHD and conduct disorders due to which it is difficult to specify the exact psychopathology in these children. It has also been hypothesized that externalizing psychopathology is often associated with parental antisocial personality disorder and several family stressors.[^51314151617] Some researchers have focused on the association between externalizing disorders in children and its contribution to parental alcoholism-reverse causation.[¹⁸] However, there have been few studies which have included diagnoses of both parents and children using standardized diagnostic criteria with a prospective follow-up to gauge the range of problems in COAs. COAs with both parents having alcohol dependence are more likely to show greater externalizing behaviors due to a higher genetic load, increased stress, and dysfunction at home, due to the absence of a protective nonaffected parent.[¹⁹]

A survey conducted in the UK[²⁰] in children of parents with mental disorders, the COAs, whose parents had mental disorders too, and the COAs whose parents did not have any mental disorders to find the specificity of the problem in this group of individuals revealed:

• COAs experienced significant discord and violence in their home lives than the other two groups
• There were no significant differences seen in COAs whose parents had or did not have mental disorders. They suffered more than children of parents with mental disorders
• The COAs were more likely to experiment alcohol and drug abuse than the other groups with a greater risk in boys
• The COAs were significantly less likely to seek help and support to deal with their problems than children of parents with mental disorders as alcoholism has multiple and interacting factors at the familial, societal, and community levels. The family often tries to keep as a secret the problem of parental alcoholism, becomes isolated, and lacks social support, and children often blame or condemn themselves for the situation.

Indian research in COAs is cross sectional and has corroborated western findings.[²¹²²²³] Narang et al. in their study in male COAs found disturbances in the areas of conduct disorders, anxiety, and physical illness with emotional problems compared to the children of nonalcoholic parents. They found lower self-esteem and poor adjustment in all spheres studied in the COAs than in the controls.[²⁴] Omkarappa and Rentala found that mean scores of anxiety, depression, separation anxiety, social phobia, obsessive-compulsive problems, and physical injury were high in COAs compared with non-COAs.[¹⁴]

Thappa et al. in their study found a high prevalence of psychiatric morbidity in 60% of COAs with anxiety spectrum disorders in 18%, depressive disorders in 14% along with alcohol, nicotine and cannabis use disorders in 10%,11% and 6% of COAs, respectively.[²⁵]

WHAT MAKES CHILDREN OF ALCOHOLICS RESILIENT?

It has been seen that despite having an alcoholic parent, many COAs do not develop alcohol use disorders or any substance-related problems or may not experience anxiety or depressive symptoms and usually have a high work and relationship satisfaction. Hence, even if the child has gone through faulty parenting, an abusive environment, these COAs do not develop any psychopathology. What makes these children different? Why are they resilient? Several researchers have proposed certain protective factors for COAs.[²⁶] It is, therefore, important to have an understanding of the same because these children show positive adaptation in spite of the adversity. This is called “resilience” which is a dynamic process helping the child to cope and break the genetic vulnerability.

Several researchers noted that certain child characteristics such as older age, high self-esteem, high self-regulation, high academic and cognitive abilities, IQ, the ability to sustain attention, the ability to process negative emotional stimuli effectively, having an affectionate temperament or flexible and optimistic temperament, an internal locus of control, and increased positive affect act as protective factors for COAs.[²⁷²⁸²⁹]

Similarly, there are parental factors which also help in resilience building. These include secure attachment, a positive parent–child relationship, positive and consistent parenting high family cohesion, adaptability and interaction and trustworthy family members, an accepting mother, a mother's who is high in the controlling parenting style and a father's who is low in the controlling parenting style, social support, extracurricular activities, and later positive interpersonal relationships.[²⁷]

As per some studies, COAs are affected differently as each family does not react identically. COAs may suffer in their social life as they would be ashamed about their alcoholic parent and hence deter from bringing friends home, etc., However, some COAs may use friends as buffers to escape from the situation at home. They use their skills to take key positions in school and extracurricular activities and hence appear “well adjusted.” This is known as adaptive distancing where the child separates from the “centrifugal pull” of family problems in order to maintain pursuits and seek fulfillment in life and thus fares better.[³⁰] Furthermore, it has been seen that the COAs who were followed up over 5 years and used primary control coping strategies such as planning and social support and secondary coping strategies such as acceptance of stressful life events and religion had the lowest alcohol consumption.[³¹]

Heitzeg et al. in their functional magnetic resonance imaging studies of brain activity of COAs found that different brain regions might contribute to whether COAs would be resilient or vulnerable to the development of alcohol use disorders. Adolescents with alcoholic parents who exhibited low problem drinking behavior showed an increased activation of the orbital frontal gyrus and left insula in response to negative affective stimuli compared to those who exhibited problem drinking behavior.[²⁸] Wong et al. postulated that there was a relationship between childhood sleep parameters (i.e., rhythmicity and an absence of trouble sleeping) and adolescent behavioral control which adds to resilience and impacts substance use outcome among COAs.[³²]

CAN INTERVENTION HELP?

In India, we do not have the awareness for the impact on COAs and the necessary intervention programs for the same. Ideally, prevention being better than cure, it would be important to identify the children at risk due to genetic or environmental factors. Primary prevention focuses on these COAs who do not have any symptoms but are at risk. Secondary prevention involves intervention in those COAs who have developed alcohol use disorder. Tertiary prevention is to prevent a further deterioration in their behavior and the complications of alcohol use disorder.

Many developed countries have a school-based support group system where the team is sensitized to the issues of COAs. There may be community-based self-help programs like Alateen for the COAs which is based on the 12-step approach of Alcoholics Anonymous. However, in developing and low-income countries, it does not come as a priority. Orientation toward mental health is sadly lacking in our governmental policies, and the administrators are not at all aware of the impact of substance use on the family.

Research which is longitudinally oriented toward identification, treatment, and prevention is the need of the day as it will give the statistics for the government to take notice. Till then, it is the responsibility of every health-care provider to take cognizance of the implications of alcohol use disorder and its ill effects whether psychological, medical, and environmental and ask the same of their patients and their families.