Children of alcoholics: implications for professional school counseling.
Alcohol abuse affects the entire family, yet only recently has attention focused on the needs of children with parents or guardians who abuse alcohol and/or other drugs. Professional school counselors (PSCs) must be prepared to identify and address the needs of these students. Parental alcohol abuse presents serious academic, emotional, physical, and social problems to families, schools, and society at large. Alcohol-abusing parents generally are ineffective in meeting their children's educational, developmental, social, and emotional needs (Robinson & Rhoden, 1998). Therefore, early prevention and intervention efforts are essential in these students' lives. For the purposes of this article, the term children of alcoholics (COAs) will encompass children living in families where parental or guardian alcohol abuse, dependence, and/or addiction is present.
The problem of parental alcohol abuse is pervasive in the United States. An estimated 9,700,000 children (or 15% of the 66 million children) 17 years of age or younger are living with an adult diagnosed with alcohol abuse or dependence in the past year. Additionally, findings from a national longitudinal alcohol epidemiologic survey suggest that 1 in 4 children younger than 18 years of age in the United States are exposed to alcohol abuse or dependence in their family (Grant, 2000). Families abusing alcohol are often closed systems; family members are not encouraged to build relationships outside of the immediate family, and the "family secret" of alcohol abuse is hidden from other individuals in the community (Edwards, 2003). Therefore, these statistics on the prevalence of COAs are probably conservative. Consequently, based on these national statistics and the occurrence of underreporting, an average PSC caseload of 477 students (U.S. Department of Education, 2003) may have approximately 120 students who have been or will be exposed to alcohol abuse or dependence in their family.
Further complicating the issues of COAs is that many alcohol-abusing parents have coexisting psychiatric disorders. To describe the condition of a person having both a psychiatric disorder and a chemical dependency, the terms dual disorder, dual diagnosis, comorbidity, and co-occurring disorders often are used. Research findings suggest that an estimated 50% of substance abusers have at least one mental illness (Brooner, King, Kidorf, Schmidt, & Bigelow, 1997; Halikas, Crosby, Pearson, Nugent, & Carlson, 1994). Often individuals with dual disorders are experiencing tremendous psychological pain, which is apparent in their much higher rates of suicide and suicide attempts than the general population. Consequently, caretakers with comorbidity are generally less able to meet the emotional, educational, and social needs of their children.
Alcohol abuse is a multigenerational issue, in which this biopsychosocial disorder often is passed from one generation to the next. This is evident in the research in which COAs have been found to be 4 times more likely than non-COAs to develop alcohol abuse or dependence (Brook et al., 2003; National Association for Children of Alcoholics [NACOA], 1998). Parental alcohol abuse often presents potentially long-term behavioral, social, and psychological problems for these children including depression, anxiety, and conduct disorders, as well as the development of rigid and inflexible coping skills (Bosworth & Burke, 1994; Fals-Stewart, Kelley, Cooke, & Golden, 2003). The trauma the children experience while growing up often results in relationship problems and developmental disabilities (Fields, 2004). Sadly, only a small portion of these young people receive any type of professional counseling services.
Paradoxically, according to the American School Counselor Association (ASCA, 1997), the core goal of professional school counseling programs is to provide "all students with life success skills" (p.1). Furthermore, the ASCA (2004b) position statement At-Risk Students advocates that PSCs employ prevention and consultation strategies while being proactive leaders in the identification of "at-risk" students. However, research on COAs highlights the inconsistency between the advocated PSC objectives and the services these students actually are receiving. This article provides PSCs with information on COAs and, more specifically, an introduction to alcohol abuse as a family illness, a description of the possible effects of family alcohol abuse on children, potential indicators of COAs, and suggestions that PSCs may implement to support COAs and their families.
ALCOHOL ABUSE AS A FAMILY ILLNESS
Families are systems in which each family member's behaviors, or lack thereof, influence every other family member in some way. Thus, parental alcohol abuse not only affects the abusing individual, but also the entire family. This compensatory change in other family members often is referred to as circular causality or circularity. Within circularity, one family member's maladaptive behavior (i.e., alcohol abuse) contributes to the dysfunctionality of the entire system (Lambie & Rokutani, 2002).
All systems, including families, work to maintain homeostasis and equilibrium, or balance (Nichols & Schwartz, 2003). That is, when one family member introduces a new element (i.e., alcohol abuse) into the family, the other members will compensate or change to sustain the previous equilibrium within the system (Edwards, 1998; Fields, 2004). This preservation of homeostasis, functional or dysfunctional, supersedes the needs of any individual and potentially leads to developmental delays in the family members (Brown & Lewis, 1999; Lambie & Rokutani, 2002). Thus family members, including children, will make unhealthy modifications to preserve family equilibrium in the presence of alcohol abuse.
Additionally, families develop rules, norms, communication patterns, boundaries, and roles that are established implicitly and/or explicitly to support homeostasis. An example of a common family rule and norm of an alcohol-abusing family is the "family secret." The family secret is established so members of the family will not openly discuss the family's dysfunctionality (e.g., alcohol abuse, child abuse, and spousal abuse). In time, maintaining the secret may become a dominating force within the family. Block (1981, as cited in Fields, 2004) referred to the alcohol-abusing family secret as encompassing the three significant rules for COAs, which are, "Don't talk. Don't trust. Don't feel" (p. 152). In order to support secret keeping, families with alcohol abuse problems tend to be closed systems with rigid boundaries (Edwards, 1998). Their norms and roles become ingrained, not allowing other systems such as schools, other families, and health care agencies to intervene or influence the family system.
Families in which alcohol abuse is present tend to have other common themes. Members of these systems often adapt by employing three strategies: (a) avoid the alcohol abuser and take care of oneself; (b) become a caregiver and work to control and support the dysfunctional system; and (c) accept the dysfunctionality and work to maintain the family's facade (family secret) (Kinney, 2003). These coping approaches are utilized to survive in an alcohol-abusing family and often develop into generalizable family roles.
ROLES IN ALCOHOL-ABUSING FAMILIES
Shame is a powerful feeling that is commonly shared among COAs. That is, the family dysfunction of an alcohol-abusing family is often shamed-based. Its members develop a belief that they are bad and worthless people (Fields, 2004). In order to cope with these strong negative feelings, COAs have been described as developing roles that are "rigid patterns of behavior from childhood--that were adopted to survive emotionally in a family rendered dysfunctional by alcoholism" (Alford, 1998, p. 250). Examples of those adopted roles were introduced by Wegscheider-Cruse (1981, 1985) and are seen as influencing the way one makes meaning of his or her world, often distorting one's perspectives throughout life. These roles are generalizations and have not been validated by empirical research (van Wormer & Davis, 2003); therefore, they should not be used to label individuals. The following are five examples of possible COA roles and are labeled in terms of the person's coping mechanisms, which a PSC may observe:
1. Chief enabler/family manages This family member is the person the alcohol abuser relies on most. The chief enabler protects the alcohol abuser from the possible consequences of his or her behavior and denies any dysfunctionality within the system. Often the chief enabler attempts to control, rationalize, minimize, and take responsibility for the family's problems. He or she is frequently the alcohol abuser's partner.
2. Family hero. These family members work extremely hard to make the family appear healthy and functional. They tend to be the firstborn, achievement orientated, responsible, perfectionistic, parentified, and model students. Frequently, school personnel find these students to be delightful and school leaders. Their need to achieve is not intrinsic, but rather an attempt at maintaining the family's facade of being functional. Often these students are "people pleasers" and seek others' approval.
3. Family scapegoat. These COAs are the opposite of the heroes as they work to divert attention away from the parental alcohol abuse (the real issue) by acting out. They often are blamed for any problems and tend to be labeled the "identified client" in counseling, acting as the symptom bearer for the family's dysfunction. These students often are labeled rebels and troublemakers who are angry and acting out. School personnel may contribute a great deal of time and energy to working with these students in an attempt to "fix" the problem. However, while the family and other systems are focusing on the scapegoat, the underlying parental alcohol abuse goes unnoticed.
4. Lost child. The lost child adapts to the system's chaos by removing himself or herself and hiding, requiring the least amount of energy from caregivers. These COAs often identify with the other family members' pain, wanting to reduce it and possibly take it from them. They tend to deny their feelings and needs, internalizing their pain, which can put them at high risk for self-injurious behavior and suicide. Additionally, these students have deficits in social skills because they have learned to adapt by removing themselves from situations and are frequently seen as loners who are shy and sensitive. Often these students are overlooked in school and family settings because they are not experiencing disciplinary problems and blend into the crowd.
5. Family mascot. The principal function of this role is to redirect attention away from the family's alcohol abuse and pain through the mascot's humor, charm, foolishness, and self-deprecation. These students often are the center of attention (i.e., class clown), while in their family they work to alleviate others' pain by making them laugh. These students often are compassionate and possess strong aptitudes, and they may be leaders in a school's drama and music departments. (Alford, 1998; Fields, 2004; Pitman, 1990; Robinson & Rhoden, 1998; Sciarra, 2004; van Wormer & Davis, 2003; Wegscheider-Cruse, 1981, 1985)
The family roles described above offer a useful framework for understanding some family dynamics and functionality. However, these roles are generalizations and should not be used to simply label or stereotype individuals. These family roles are not exclusive; therefore, families not having alcohol abuse-related issues may fit into this model (Alford, 1998; van Wormer & Davis, 2003). Additionally, family members may have qualities from more than one role. Nevertheless, these COA roles provide a useful perspective on families with alcohol abuse for PSCs.
POSSIBLE EFFECTS OF FAMILY ALCOHOL ABUSE ON CHILDREN
The potential consequences of family alcohol abuse on a child's development can be profound. Alcohol abuse disrupts families, and each member may be affected differently. Children raised in alcohol-abusing families have different life experiences than children raised in non-alcohol-abusing families (NACOA, 1998). COAs grow up in an environment of conflict, tension, instability, and uncertainty. It is important for PSCs to understand the potential consequences on children raised in such a family climate. The possible effects on COAs are organized by type--psychological, academic, and social--and listed below.
Many COAs tend to blame themselves for their caretaker's alcohol abuse and their family's dysfunctionality. Some of these young people believe that if they were "better" and earned all A's, their parent's alcohol abuse would cease. This may lead to feelings of guilt and shame because of their inability to "fix" their family. Therefore, these students may have low self-esteem and feelings of worthlessness (Arman, 2000; Bosworth & Burke, 1994; Fields, 2004; Kinney, 2003).
Fear is a common feeling among COAs. Fears include the fear of losing control, fear of feeling, and fear of conflict. Family life is unpredictable and frequently aggressive and violent. Additionally, physical and sexual abuse is significantly more prevalent in alcohol-abusing families (Bosworth & Burke, 2001). As a result, COAs may suffer from post-traumatic stress disorder and experience sleep disturbance, nightmares, anxiety, and depression, which may manifest in crying, bed wetting, and isolationism (Kinney, 2003). Furthermore, COAs are 4 times more likely to develop a substance abuse problem than are non-COAs. Recent research also has linked attention deficit hyperactivity disorder to parental alcohol abuse (Bosworth & Burke; Hoggard & Christenberry, 1994; Kinney; Meeks, Heit, & Page, 1995; NACOA, 1998; Sheridan & Green, 1993).
The family climate that a COA is raised in is often controlling, which reinforces family members' feelings of powerlessness. As a result, COAs tend to feel that they have an external locus of control where they are unable to affect external events. Therefore, they see themselves as being controlled by external forces with little ability to cause change. Additionally, this external focus is related to lower levels of self-identity and self-awareness (Sheridan & Green, 1993).
The potential consequences of parental alcohol abuse on a student's educational development may be significant, and all school personnel should appreciate this. COAs are more likely to have learning disabilities, be truant and delinquent, repeat more grades, and drop out of school. Additionally, many of these students exhibit lower academic achievement and more cognitive deficits with lower intelligence quotient scores and lower arithmetic, reading, and verbal scores than their peers. COAs also tend to think concretely, even into adulthood (not abstractly). Furthermore, the chaotic home environment of COAs may make it difficult for these students to complete their homework and receive necessary rest, reducing their ability to concentrate in school (Arman, 2000; Fields, 2004; Hoggard & Christenberry, 1994; Kinney, 2003; NACOA, 1998).
The instability and unpredictability that COAs experience in their homes affect their relationships with others. These students may be embarrassed to have friends come to their home and may isolate themselves. The alcohol-abusing parent's inability to meet the child's emotional needs may lead to insecure attachment, influencing the COA's ability to trust others. Additionally, poor communication skills (e.g., family secrets) and difficulties with trust contribute to COAs having problems in intimate relationships (Bosworth & Burke, 1994; Fields, 2004; Hoggard & Christenberry, 1994; Kinney, 2003; NACOA, 1998).
POTENTIAL INDICATORS OF COAs
It is difficult to identify COAs. Sadly, little research has been conducted relating to COAs and professional school counseling services; however, it safe to presume that only a small percentage of these students do receive counseling services (Doweiko, 2002). One reason for this lack of identification is that students are unlikely to reveal their family secret of alcohol abuse. Moreover, as was evident in the presented COA family roles, these young people do not have a single profile; rather, they appear similar to other students and have a wide range of intellectual abilities, social skills, and coping skills (Knight, 1994). PSCs must be knowledgeable about COAs and work with their teachers to identify students' behavioral patterns. Although some COAs can be readily detected as troubled children because they offer hard-to-miss behavioral indicators such as anger, rebellion, and conduct disorders, others blend into the school landscape. The unseen COAs tend to be withdrawn and isolated, potentially affecting their healthy development.
Several behavioral signs may be helpful to PSCs in identifying COAs (Greenburg, 1999). It is important to note, however, that behavioral cues do not necessarily mean that a student is a COA. If PSCs observe potential indicators of COAs, they should communicate their perceptions to the student and receive clarification of their interpretations before proceeding. Nevertheless, having an understanding of COA symptomology is paramount in intervening as early as possible for the student's benefit.
The following behavioral cues of COAs are organized in relation to observable school issues. Some behavioral indicators of COAs may indicate other kinds of difficulties. Therefore, it is important for PSCs to obtain as much information as possible concerning their students to expend their case conceptualization, thus increasing their therapeutic effectiveness. The following are behavioral cues in identifying COAs in a school setting:
1. Absenteeism. A COA student's attendance may be erratic. Children may be frequently absent so they can stay home to take care of an alcohol-abusing parent.
2. Tardiness. These students often may be late to school because they have to take care of their siblings and the family. For example, they may have to prepare breakfast and get their siblings off to school before they can leave for school themselves.
3. Neglected physical appearance. A student may come to school looking disheveled and unkempt, or just inappropriately dressed, which may suggest neglect or abuse. Mondays often are considered "sloppy days."
4. Fluctuating academic performance. Sometimes the student's school performance varies from day to day and even throughout the day. There is little consistency in these young people's lives, and this may be evident in their inconsistent behavior and mood. These students may perform better in their morning classes, hut as the school day comes to an end their functioning may deteriorate as they become distressed about returning home.
5. Problems controlling mood and behavior. Some COAs are prone to emotional outbursts, temper tantrums, or other disruptive behavior, and others may demand extra attention by acting out or becoming the class clown.
6. Parental concerns. Parents may be difficult to reach and fail to keep meetings and conference appointments, and they may appear uninterested in their child's school performance. Additionally, parents may attend meetings and school functions under the influence of alcohol.
7. Physical symptoms. COAs may have psychosomatic responses; that is, their emotional pain is manifested in physical symptomology. Thus, these students may persistently complain about stomachaches, headaches, and other physical ailments without explainable causes.
8. Sad affect. These students are experiencing emotional pain. COAs may internalize this pain and appear to school personnel as being sad, depressed, and withdrawn.
9. School disciplinary problems. Some COAs internalize their pain, whereas others externalize. The externalizers tend to appear angry and often are involved in school disciplinary consequences for acting out, fighting, and being aggressive.
10. Peer cues. The COA student's peers may offer hints that there is a problem. They may come to the PSC or teacher and express concern about their friend and say that he or she is sad. Other students may tease the COA for his or her parent's alcohol abuse. (Bijur, Kurzon, Overpeck, & Scheidt, 1992; Children of Alcoholics Foundation, 2003; Fals-Stewart et al., 2003; Kohler & Collins, 1995; Sciarra, 2004) (Sec Edwards, 2003, for a list of possible behavior changes specific to adolescent alcohol and substance abuse)
By watching, listening, and interacting with students, PSCs and other school personnel can begin to identify COAs who might otherwise remain unnoticed. Some COAs may be willing to disclose their concerns about their parent's alcohol abuse or reveal such problems through their drawings, stories, and play (O'Rourke, 1992). However, it is important for PSCs to remember that identification should be made with great discretion, and clarification of one's perceptions is always necessary.
SUGGESTIONS FOR PSCs TO ASSIST COAs AND THEIR FAMILIES
Schools offer a logical place to identify and assist COAs. One reason is that children consistently spend more time in school than anywhere else (Berk, 2002; NACOA, 1995). Secondly, parental alcohol abuse affects children's psychosocial development, likely retarding these students' ability to establish interpersonal relationships and be successful at school (Sher, 1997). Furthermore, earl), identification and intervention hold promise for preventing future substance abuse and reducing potentially long-lasting emotional, social, behavioral, and physical problems (Vail-Smith & Knight, 1995). The earlier that students are exposed to intervention services designed to provide emotional support and the development of coping skills, the greater the potential effectiveness of these services.
Public awareness has increased about the potential consequences of parental alcohol abuse on young people's healthy development and the need for earl), intervention. Currently, schools are being asked to play critical roles in assisting COAs (NACOA, 1995; Sciarra, 2004). PSCs are at the center of prevention and intervention strategies for COAs. Research suggests that PSCs are in an excellent position to assist these students, and they should be able to identify COAs. Additionally; according to the PSC research participants in Vail-Smith and Knight's (1995) study, it was believed that greater than 40% of PSCs' students were being reared by an alcoholic parent or guardian. Furthermore, nearly 97% of the PSCs surveyed agreed that it was important for PSCs to be able to provide counseling and referral services for COAs. Sadly, 95% of these surveyed PSCs felt inadequately informed about COAs (Vail-Smith & Knight). This high percentage of PSCs feeling they have an insufficient knowledge base relating to COAs reinforces the need for this article and for school counselor preparation programs to address the needs of this "at-risk" population of students.
This deficiency concerning COAs needs to be addressed. Suggestions that PSCs may implement to assist COAs and their families follow.
Increase Knowledge Concerning Substance Abuse and COAs
The Council for Accreditation of Counseling and Related Educational Programs (2001) standards for curriculum and clinical training do not specify course work in substance abuse in the professional school counseling curricula (Lambie & Rokutani, 2002). Yet, PSCs consistently work with students and their families concerning alcohol and substance abuse. Therefore, it is critical that practicing PSCs and those in training increase their personal awareness and knowledge of alcohol abuse and its impact on the family. Remaining ignorant about issues related to alcohol abuse reinforces family dysfunction itself and may be deemed unethical practice. ASCA's (2004a) Ethical Standards for School Counselors states that an ethical PSC "strives through personal initiative to maintain professional competence including technological literacy and to keep abreast of professional information. Professional and personal growth are ongoing throughout the counselor's career" (E.1.c).
A vital component of increasing understanding of COAs is to increase personal awareness. Examining personal beliefs, biases, and attitudes about alcohol and substance abuse is necessary for PSCs to work ethically and effectively with these students. Many PSCs may be themselves adult children of alcoholics. These helping professionals need awareness and acceptance of their own family history and its potential effect on their life and professional work (Fields, 2004; Greenburg, 1999; Kohler & Collins, 1995; Vail-Smith & Knight, 1995).
Educate Other Educators About COAs
With specialized training in interpersonal communications and child development, PSCs are an excellent resource to provide educational training to other school personnel concerning COAs. This training should incorporate components discussed in this article, including alcohol abuse as a family illness, the potential effects of family alcohol abuse on students, and possible indicators of COAs. Consultation can be integrated into the training, with the counselor offering consultation services to all school personnel as needed. If any school personnel think that a student is a COA and requires services, he or she should feel comfortable consulting with the PSC. It is important that school personnel work collaboratively, respect each other's expertise, and view their relationship as a partnership (Lambie & Rokutani, 2002).
Facilitate Classroom Guidance Relating to Alcohol Abuse and COAs
Just as school personnel need to learn information concerning alcohol and substance abuse and its potential effects on family members, the same is true for students. Introducing students to the prevalence of alcohol abuse and its possible effects in families may help to normalize some of the COAs' feelings and provide them the support needed to break their families' secrets and talk to a professional about the problem. Also, classroom guidance is an effective forum to teach students healthy coping skills and support the development of resilience, which may help to minimize the consequences of their families' dysfunctionality.
Offer Counseling Groups for COAs
Group counseling has been found to be an effective intervention strategy for COAs (Arman, 2000; Sciarra, 2004). Counseling groups provide a safe forum for children to learn to identify and express feelings, to safely cope with family problems, to learn about alcohol abuse and its effects on the family, and to learn how to have fun (Substance Abuse and Mental Health Services Administration, 2003). These groups focus on interpersonal problem solving, interactive feedback, and other counseling support methods within a here-and-now framework. See Arman (2000) for a practical model for facilitating a COA group for PSCs.
Be Accessible and an Effective Listener
Students need to know who their PSC is before they will seek him or her out. PSCs need to get out of their offices and be visible and accessible to students. When students see PSCs interacting with other students, they are likely to see them as safe adults whom they may feel comfortable approaching.
Once the PSC is working with a COA, it is important to communicate understanding, acceptance, empathy, and compassion. The PSC should provide the student with a forum to process his or her feelings and thoughts without fear of repercussion. Often COAs feel isolated, ashamed, and responsible; therefore, it is important for the PSC to convey to these students that they are not alone, are not responsible for their parents' alcohol abuse and family dysfunctionality, and are not responsible for "fixing" or "controlling" the problem.
Provide Liaison and Referral Services to Other Agencies
PSCs are in a unique position to develop connections among families, community agencies, the school, and students through referring families to services and by functioning as a liaison. Often, COAs require mental health services that PSCs are not trained to provide and are too in-depth for the school environment. However, PSCs can initiate student referrals to other community agencies such as community mental health and substance abuse treatment centers. Research has found positive outcomes from school-community agency collaborative relationships (Hobbs & Collison, 1995). Connecting these students and their families with the needed resources and services may be achieved through providing liaison services. Common referrals available in most communities include self-help groups such as Al-Anon, which is open to family or friends of individuals with alcohol problems, or Alateen, which is available for teenagers of families with alcohol problems. Additionally, PSCs may want to be aware of community crisis intervention hot line numbers in case the family is prone to alcohol-or drug-related violence (Edwards, 1998).
Accept and Acknowledge Professional Competencies and Limitations
Because PSCs are not required to be competent in issues related to substance abuse, many PSCs do not have the necessary preparation to provide substance abuse counseling. Nevertheless, PSCs can continue to increase their professional competencies while providing referral and consultation services to students and their families. As part of PSCs' ongoing professional development (as required to maintain licensure), they should advocate for and attend inservice training activities relating to COAs and other substance abuse-related issues.
PSCs can play a key role in supporting, assisting, educating, and referring students affected by parental alcohol abuse. However, PSCs need a sound understanding of COAs and an awareness of their own attitudes, beliefs, and biases about alcohol and substance abuse. Without this knowledge and appreciation, PSCs are likely to simply perpetuate this familial and societal secret. A conscious effort is needed among professional school counseling associations, preparation programs, and practitioners to offer training to PSCs concerning COAs.
Additionally, schools as collaborative systems must work to support these students and their families. Early identification and intervention are essential for breaking the systemic homeostasis of this dysfunctionality, which often leads students to fail to achieve their potential and to develop feelings of guilt, shame, and worthlessness. In support of this collaborative school effort, PSCs need to provide in-service training to all school personnel concerning COAs. As is evident, parental alcohol abuse is a systemic dysfunction; therefore, it requires a systemic effort to support change (i.e., the entire school system and other community resources).
Remaining silent about COAs reinforces the dysfunctionality itself'. PSCs need to be proactive advocates and leaders in their schools and communities to support this unseen population of students. As with most multigenerational dysfunctions, it is difficult to stop all parental alcohol abuse. Nevertheless, through early identification, intervention, and support to COAs, the trauma these students experience may be lessened and their family's multigenerational pattern of alcohol abuse and dysfunctionality permanently disrupted.
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Glenn W. Lambie, Ph.D., is an assistant professor with the Counseling and School Psychology Program, School of Education, Chapman University, Orange, CA. E-mail: firstname.lastname@example.org
Shari M. Sias, Ph.D., is an assistant professor with the Department of Rehabilitation Studies, East Carolina University, Greenville, NC.