Building resilience in children of alcoholics.

The legacy of parental alcoholism cuts deep. Nearly 6.2 million children in the United States younger than 18 years old live with at least one parent who is currently dependent on alcohol, according to estimates from the 1996 National Household Survey on Drug Abuse (NHSDA, now known as the National Survey on Drug Use and Health). The number increases exponentially when it is broadened to include those children living with adults who have abused or been dependent on alcohol some time in their lives.

Research has long established that having an alcoholic parent increases a child's risk for multiple negative behavioral and developmental outcomes. That increased risk is conveyed through social, emotional, environmental, and biologic pathways. In particular, many studies have focused on the rates of alcohol and drug use and abuse among children of alcoholics, and most have similarly concluded that this population is significantly more vulnerable to substance abuse problems than their peers from non-alcoholic families.

Data from a national epidemiologic survey out of Johns Hopkins University, Baltimore, for example, show that children of a parent with active alcohol dependence initiated use of alcohol, cigarettes, and marijuana earlier and at higher age-specific rates than children who did not have an alcohol-dependent parent.

Using NHSDA information collected from 1995 to 1997, the investigators identified a sample of 2,888 parent-child pairs, which included 114 children of alcohol-dependent parents and 2,774 children whose interviewed parent was not dependent on alcohol. The odds ratios for past-year tobacco, alcohol, and marijuana use for the children with alcoholic parents were 3.2, 1.6, and 2.9, respectively.

The differences in substance use between the two groups started to emerge as early as age 9 years, and the additional risk was sustained at least through age 17 years, the authors wrote. By 17 years, 73% the children of alcoholic parents had smoked cigarettes, 70% had begun drinking alcohol, and 41% had smoked marijuana, compared with 44%, 57%, and 26%, respectively, of the children from nonalcoholic homes (Drug Alcohol. Depend. 2001;65:1-8).

In addition to an increased risk for substance use in this population, there also appears to be a greater likelihood of an accelerated trajectory from onset of drinking and drug use to problem substance use, a recent study by Andrea Hussong, Ph.D., of the University of North Carolina, Chapel Hill, and her colleagues shows. Using longitudinal data from a community-based sample, the investigators conducted survival analyses and determined that children of alcoholics progressed more quickly from initial adolescent alcohol use to the onset of disorder than matched controls, even after controlling for externalizing symptoms and heavier drinking patterns at initiation. A similar "telescoping" risk was observed for drug disorders (J. Abnorm. Psychol. 2008;117:63-78).

With respect to illicit drug use, adolescent children of alcoholics who use drugs are more likely to continue doing so during their transition to young adulthood than their peers from non-alcoholic families. In a study that tracked and monitored the drug use habits of 545 adolescent children of alcoholics and demographically matched children of nonalcoholic parents for 15 years, David B. Flora, Ph.D., of the University of North Carolina at Chapel Hill, and his colleagues determined that the control group significantly decreased their drug use during this time, consistent with national data, while the children of alcoholics did not.

The findings show that "[children of alcoholics] do not typically follow the normative trend by which individuals are expected to mature out of drug use before age 30," the authors wrote (Psychol. Addict. Behav. 2005;19:352-62).

The investigators also looked at the impact of marriage on drug use trajectories in young adult children of alcoholics and determined that "marriage mediated but did not moderate the relations between parental alcoholism and the rate of change in drug use during the transition into young adulthood and the level of drug use at ages 25 to 30."

Although marriage predicted the amount of drug use in men 25-30 years old--about 94% of married men either remained abstinent from drugs or decreased their drug use--the children of alcoholics in this study were less likely to be married and thus not only had smaller decreases in drug use between 25 and 30, they had higher levels of drug use overall, according to the authors.

In addition to a proclivity for alcohol and drug use and abuse, children of alcoholics are at increased risk for other negative outcomes, including conduct problems, aggression, depression, and anxiety, according to the Substance Abuse and Mental Health Services Administration (SAMSHA).

But not all children of alcoholics succumb to the potential negative consequences. In fact, studies suggest that, despite the odds, a large proportion of children of alcoholics do not develop serious problems.

In an often-cited longitudinal study of children of alcoholics born on the Hawaiian island of Kauai, psychologist Emmy Werner, Ph.D., of the University of California, Davis, reported on 49 children of alcoholic parents who were raised in chronic poverty from birth to 18 years. Although 41% of the study participants had developed coping problems by age 18, 59% appeared to cope well and had not developed serious problems. Among the shared characteristics of the "resilient" children were adequate communication skills, average intelligence, a desire to achieve, and the ability to get positive attention from other people (J. Stud. Alcohol. 1986;47:34-40).

A later report on the same cohort showed that study participants who effectively coped with the trauma of growing up with an alcoholic parent and became competent adults by age 32 had relied on more sources of support in their childhood than did those offspring of alcoholics with coping, problems (Subst. Use Misuse 2004;39:699-720).

In a separate 3-year study of 267 adolescents, including 127 children of alcoholics, self-awareness, a perceived control over one's environment, and the possession of cognitive coping skills were all identified as having a buffering effect against potential negative consequences associated with having an alcoholic parent (J. Stud. Alcohol 1997;58:272-9).

Although resilience in children of alcoholics is still not fully understood--a recent study by the University of Michigan, Ann Arbor, that has identified differences in neural activation mechanisms between vulnerable and resilient children of alcoholic parents adds a new dimension to the research in this arena (Alcohol Clin. Exp. Res. 2008;32:414-26)--the available evidence suggests that building resilience is a critical intervention goal.

For example, in a school-based prevention intervention called Students Together and Resourceful (STAR)--identified as a model program by SAMSHA--children of alcoholics gain self-efficacy through education about alcoholism and its effects on the family as well as group exercises that allow participants to recognize and express their feelings and to practice problem-solving, stress-management, and alcohol-refusal skills. In randomized trials comparing outcomes of children of alcoholics who did and did not participate in the intervention, participants attained improved self-concept as well as decreases in depression (Pediatrics 1999;103:1112-21).

Certain elements of the STAR program should be universal to all interventions for this population, according to lead author James Emshoff, Ph.D., professor of psychology at Georgia State University, Atlanta. These include "skill building in the areas of coping and social competence, social support, an outlet for the safe expression of feelings, and healthy alternative activities."

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at [e-mail].