Children of Persons with alcohol dependence syndrome: Risks and Resilience, theories and interventions
Abstract
Children of parents with alcohol dependence syndrome (ADS) are vulnerable to develop various psychosocial problems and carry them into their later life. They are at-risk group to develop alcohol and other drug use related complications in their life. Some studies reported that despite adversities in their life some children who have resilience grew into competent adults. These factors significantly influence the overall development of any given person. Current paper shed light on theories, vulnerability, resilience, and available intervention packages related to children of parents with ADS.
Introduction
Alcohol consumption has been identified as a major risk factor for various health, social and economic problems of communities. It is measured as fifth leading global risks for burden of disease by disability-adjusted life years (DALYs) 1. It is estimated that 20–30% of medical health problems, road traffic accidents, homicide and other deliberate injuries are due to alcohol use. About 4% of the global disease burden across the world was due to alcohol 2.
India is the country where alcohol is traditionally prohibited and considered to be a 'dry' culture, however use of alcohol in some form always present in the country. Prevalence of alcohol consumption in India was reported to be 20-30%, and 10% among them were dependents 3-5. Recently, National Family Health Survey 6 reported prevalence of 29% and 1% alcohol use among male and female population respectively.
Children of persons with alcohol dependence syndrome (ADS) are a target risk group, as they have a predisposition to substance use and other psychiatric disorders, physical and psychological parental abuse, medical problems, cognitive deficits and school failure 7-10. Family is a primary social unit of the society; most of our behaviours are shaped by considerable influence of its members 11. A study from India found that 57% of college students who were using alcohol had family history of alcohol dependence 12. Substance problems run in the families through several pathways such as genetic 13,14, behavioural and cognitive processes 15,16, and problematic family environment 17.
Risk or Vulnerability
Risk factors are those characteristics thought to present in a group of people, usually children, with a higher probability of an undesirable outcome18. Adolescent children are taking more risks with their health, their lives, and their future than ever before,19 willingness to take risks and high levels of sensation seeking positively correlated with higher levels of alcohol and other drug use 20. Studies conducted with children of parents with ADS found that children are at-risk to develop alcohol and other drug use related complications due to both high genetic and environment factors 21,22. Parental approval of alcohol use as perceived by children increased the probability of high risk drinking among children 23.
Children of parents with ADS have found to be more vulnerable to mental health disorders and, general and specific health problems 24. Children grown up in this environment experienced family conflict 25, negative life events 26 and, low family cohesion and poor family organization 27. Family and personal strengths of people living in these families found to be inadequate 28. Parents with ADS reported to have poor parenting skills, poor self regulation and behaviour problems, which negatively influence the development of social competencies in their children 29. Children of parents with ADS showed greater difficulties in neuro-developmental aspects 30 and behaviour problems 28,31,32. Children of parents with drug use displayed higher rates externalizing and internalizing behaviours, such as attention deficit hyperactivity disorder, conduct and oppositional defiant disorders, impulsivity and delinquency, depression and anxiety 33-36,30,17 .
Resilience
During the end of 20th century, researchers’ perspective has begun to change. Longitudinal studies which have followed individuals from infancy to adulthood have revealed that only a minority might develop emotional and behavioural problem even after they are exposed to multiple stressors. Their findings directed researchers to consider the phenomenon of resilience, which is dynamic in nature and brings positive adaptation even in the context of adverse life situations 37. Benard 38 attributed resilience as social competence in order to elicit positive responses and have positive relationships with others, problem solving skills, having self control and resourcefulness in seeking help from others, autonomy in terms of having ability to sense own identify and to act independently, and a sense of purpose in life and clear idea about their future.
The Kauai Longitudinal Study39-41 explored the impact of bio-psycho-social risk factors and protective factors on children at-risk in their developmental course. The study identified three clusters protective factors (a) Protective factors within the individual- resilient children acquired positive characteristics such as activeness, affectionate, cuddly, good-natured, and easy to deal with, agreeable, cheerful, friendly, responsive, sociable, practical problem-solving skills, sense of pride, altruistic, self-confidence and realistic future plans. (b) Protective factors in the family- presence of at least one competent and trustworthy person in the family such as grandparents, older siblings, aunts, and uncles. The religious beliefs of families were also provided some stability and meaning in their lives. (c) Protective factors in the community- resilient children received emotional support and help during crisis situation from the elders and peer in their community. This study found that one-third of the high risk children become competent adults due to hard work they invested, loved well by others, played well and expected well.
Children of parents with ADS having individual factors such as self esteem, regular exercise and better school bonding 42-45, family factors such as family cohesion, adaptability and child-mother attachment, and community factors such as social trust, social responsibility and religiosity were found to have lower levels of behavioural problems 46-48.
Theories
Social Learning Theory: It is based on the work of Albert Bandura49. Children learn to behave through both instruction as well as observation. Consequences of their actions and the responses of people reinforce and modify children behaviours. Children learn to behave, then, through observation and social interaction, rather than just through verbal instruction. He also stressed that self-efficacy, defined as confidence in one’s abilities to perform appropriate behaviours, is important to learning and maintaining behaviours, especially in the face of social pressure to behave differently. It influenced on life skill and social skill programs development.
Problem–Behaviour Theory: Developed by Jessor50, it believes that children behaviours (including risk behaviours) are the product of complex interactions between people and their environment. This theory is concerned with the relationships among three interrelated psychosocial variables (personality system, perceived environmental system, and behavioural system). The personality system includes “values, expectations, beliefs, attitudes, and orientations toward self and society.” The perceived environmental system concerns perceptions of friends’ and parents’ attitudes toward behaviours. And, similar to Bandura, the behavioural system is usually described as a certain set of socially unacceptable behaviours (the use of alcohol, tobacco, and other drugs, sexual behaviour by persons below a certain age, delinquency, etc.). Each psychosocial system contains variables that act as instigators or controls on problem behaviour.
Social Influence Theory: It recognizes that children and adolescents will come under pressure to engage in risk behaviours (tobacco, alcohol). Social pressures include “peer”, “parents’ model”, “media”. Social influence programs anticipate these pressures and equip children with skills to resist them in prior to they are exposed.
Cognitive Problem Solving Theory: This competence building model of primary prevention theorizes that teaching interpersonal cognitive problem solving skills to children during childhood mitigate and prevent behavioural problems.
Resilience and Risk Theory: This theory argues that there are internal and external factors that protect against the social stressors or risks of poverty, anxiety, or abuse. If a child has strong protective factors, he/she can resist the unhealthy behaviours that often result from these stressors or risks. Resilience and risk theory provides an important part of a foundation for a life skills approach.
Screening tools
Identification of these children requires active screening using either the Children of Alcoholics Screening Test (CAST) 51,52 or adapting the CAGE 53 questionnaire.
• Do you think your mom/dad needs to cut down on their alcohol use?
• Does your mom/dad get annoyed at comments from other people about their drinking?
• Does your mom/dad ever feel guilty about their drinking?
• Does your mom/dad ever take a drink early in the morning as an eye-opener?
Intervention Programmes
Several programs have been developed to assist children of parents with alcohol dependence syndrome. In general a program may focus primarily on either prevention or intervention, but majority of the programs focus on both elements. Primary prevention focuses on children at-risk due to their genetic vulnerability or environmental factors or both. Secondary prevention targets children who are already having behavioural problems which predict later alcohol and other drug use. Finally, tertiary prevention is to help children who are already having alcohol and other drug use related problems and to decrease the associated complications. Some other primary prevention models such as curbing the availability, increasing the legal age of drinking, increasing the price of alcohol beverages and decreasing the selling hours are also helps systematically to reduce alcohol usage of a given country.
Alateen is an example of a community based self-help program for children of parents with alcohol dependence syndrome based on the 12-Step approach of Alcoholic Anonymous. Al-teen generally meets in public settings, such as churches or community centres.
Schools and colleges are logical settings for school based interventions because of children availability. There are some specific programs exclusively for children of parents with alcohol dependence syndrome. A School Based Support Group intervention conducted for children of parents with ADS resulted in improved knowledge, coping strategies and better social integration for female children54.
Stress Management and Alcohol Awareness Program (SMAAP) is a competency-building intervention program developed by Roosa and colleagues55. It is a school based program conducted for children of parents with ADS for 8 weeks duration. The program emphasized on building self-esteem, providing alcohol related education, and teaching emotions and problem-focused coping strategies. Short et al56 evaluated the program and found that increased knowledge, social support, and emotion-focused coping behavior among participants compared to non participants. In addition, teachers reported increased problem solving and social competence among participants.
The Students Together And Resourceful (STAR) program is designed for the students by providing accurate information on alcohol use related complications, effects on the family and increase social competence. Group exercises are directed to help students recognize and express their feelings and to practice specific skills, such as problem-solving, decision making, stress management, and alcohol refusal skills. A randomized study conducted to compare the program with non participant children of parents with alcohol dependence syndrome. Results indicated that participants were successful in establishing stronger social relationships, a sense of control, and an improved self-concept. In addition, participants reported increases in the number of friends and in perceived social support 57.
The Strengthening Families Program58 (SFP) developed by Kumpfer and Marsh (1983) provides training for parents, children, and families. Sessions for parents focus on education about alcohol and other drugs, communication skills, and utilization of reinforcement and other techniques to guide children’s behaviour. The children’s social skills program includes sessions on feelings, anger management, problem-solving, communication, peer resistance, and alcohol and other drugs information. Typically the program is a fourteen session pacage conducted in churches or community centers, 2-3 hours in a week. In a randomized, controlled trial, the program was found to reduce risk factors, increase resilience (competence when under stress), and decrease alcohol and other drugs use among children of alcohol and other drugs abusers 59.
Children Having Opportunities in Courage, Esteem and Success60 (CHOICES). School based program for 3rd and 4th grade students. Program focused on coping strategies, emotions identity and family. Overall the program has 11 sessions, weekly 1 hour session with individuals and 30 minutes session with mentors. Horn and Kolba61 conducted a study and found improvement in self esteem, isolation, loneliness, coping strategies and knowledge on program content.
Teen Club Program62 is a two year program of 90 minutes meeting every week. It is a group program for female teenagers with drug involved families and lack of family and social support. Program focused on problem solving, health education, social behavior, home visits for crisis intervention.
Focus on Families Program is a 16 weeks intervention (biweekly 90 minutes’ sessions) for families with methodone treated parents, sessions with group of families combined with home based case management. Program focused on relapse prevention, stabilization and improvement of family management practices. Study indicated improvement in parenting skills, improvement in parent drug use, deviant peers and family management, and changes in children’s behavior or attitudes63.
Friends in Need Program64 emphasized teaching, strategies and skills for coping with aversive environment where they live. They found improvement in class room behaviours, self worth and reduced physical aggression for the intervention group.
Life Skills Interventions are considered to be the single most effective intervention for reducing risky behaviors among children. WHO advocated universal life skills education program for every school across the world. It has to be considered in the formal and non-formal education system65. Different people may react to the same drug in different ways on different occasions, and in the same person, drug reactions may vary on different occasions. Life Skills based education for drug use prevention addresses two factors with personal and interpersonal skills and through the decision making process, addresses drugs in a meaningful and socially relevant way. Given the broad definition of a drug, Life Skills based education for drug use prevention contributes to the primary goals of drug education for young people such as, to delay the onset of drug use; to stop harmful use; to increase their awareness of the consequences of drug use; and to enhance decision-making ability for healthier lifestyle choices. Giving importance to diversity, in some cultures and communities non-use may be a primary goal.
Conclusion
Research studies across the world suggest several appropriate levels of intervention and basic prevention program components. Basic information about harmful consequences of alcohol and other drug use need to be included in the school curricula. Research studies in recent past revealed that peer led education found to be effective in preventing and delaying initiation of alcohol and other drugs. Family intervention and parental training are other potential promising strategies which mental health professionals can employ them to strengthen parents and other significant ones in the family to develop better resilience and reduce risks among children. Comprehensive community programs which focus social norms with regard to substances are another important underutilized area. Preventive intervention programs should include the basic components of information and education, skill building in the areas of coping and social competence, social support, create environment for safe expression of feelings, and healthy activities.