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Familial risk factors favoring drug addiction onset.

Drug addiction represents a global health and social challenge faced by the modern world, with ongoing problems for all parties involved; this is true especially for the members of the addict's family, who often have to admit their inability to cope in an efficient manner. The ever-growing prevalence of opiate drug abuse has eventually led to crises in modern society and traditional family ways; it has jeopardised fundamental social virtues and values and led to a rise in criminal behavior. Therefore, drug addiction issue should be viewed as a multidisciplinary phenomenon whose causes are to be sought in the interplay between biopsychological, familial and social factors, and in the interplay between risk and protective factors (UNODC 2009; NIDA 2003). Nevertheless, a family can't be viewed as an isolated entity, but rather as an integral part of the broader community, so that a family and society are in constant interaction that strongly affects not only individual behavioral patterns, but the society as a whole (Georgas 2006). It has been well recognised that, aside from familial risk factors, addiction onset can also be influenced by other cultural-social factors, personality features and genetic predispositions working together (NIDA 2003). While discussing the fundamental functions of the family, the American sociologist Talcott Parsons has mentioned primary and secondary socialisation, the former defined as going on within the familial frame during an early childhood, and the latter as taking place outside family boundaries and developing as a result of social influences stemming from peers, school and immediate surroundings (Georgas 2006). Familial sociopathology in terms of alcohol abuse, domestic violence and especially child molestation and neglect have adverse effects on the child's healthy psychological development and are frequently seen as the primary cause of psychological issues and risky behaviors, including addiction (Bry et al. 1998; Haddad, Barocas & Hollenbeck 1991). Studies devoted to addicts' families, carried out in Philadelphia, have demonstrated that the nature of chronic heroin addiction may be explained by family structure and intrafamilial relations (Stanton et al. 1978). In several of their studies, Stanton and colleagues have described the male addict prototype characterized by a highly involved and considerate, overprotective mother, indulgent when it comes to the addicted child or even favoring that child over the others. The father of the male addict, on the other hand, is pictured as separated, uninvolved, weak or distant, or aggressive and brutal, many among them being alcoholics as well.

Peak incidence for addiction occurs in adolescence although other forms of addiction may manifest later in life (NIDA 1999; Nikolic, Klein & Vidovic 1990). NIDA studies have pointed towards poor parental surveillance and parent-children conflicts as strong predictors of drug addiction onset (NIDA 1999). Studies have also found that in retrospect addicts very often viewed their mothers as more functional than their fathers in terms of involvement, responsibility and attachment (NIDA 1999. According to numerous theories, an inadequate fulfilment of the parental role, the lack of parental surveillance included, can eventually result in deviant behavior onset (Stattin & Kerr 2000; NIDA 1999). One study concerned with the relation between bad parenting and delinquency (often associated with drug consumption) revealed the delinquents to have markedly poorer communication with their parents, to lack trust in them, and to be much less bonded to them as compared to nondelinquents (Stattin & Kerr 2000).

Parental alcohol abuse, especially that of the father, can be responsible for children's issues such as behavior problems, delinquency, toxicomania, school issues or school quitting, and issues of a psychological nature like sleep disorders, anxiety and depression (Vitaro, Tremblay & Zoccolillo 1999; Haddad, Barocas & Hollenbeck 1991). Numerous studies have shown that poor interparental relations adversely impact child's psychological development, since marital conflicts are linked to a child's incapacity for social adjustment and his/her harsh upbringing regimen, later on closely related to risky behavior patterns including addictive substance consumption (Goddman & Brand 2009; Haine et al. 2008; Feric ?lehan 2004; Vuksic Mihaljevic & Grubesa 2004; NIDA 2003; Stanton et al. 1978). Given the hypotheses quoted above, drug addiction may certainly be analysed from the familial dynamics standpoint, as well as from the standpoint of family structure and intrafamilial relations (NIDA 1999; Stanton et al. 1978).

In line with the foregoing, this study primarily aimed at investigating the familial risk factors favoring drug addiction onset, taking into account developmental, interaction and social aspects, so as to ultimately be able to determine the existence of certain specific familial characteristics and a profile of family relations typical of drug addicts that might be shed light on as risky familial environments causing some children to be more prone to drug addiction.

DEVELOPMENTAL THEORIES ADDRESSING ADDICTION ONSET

The most renowned developmental theories addressing drug addiction onset are psychoanalytical theories that view the family as the key factor responsible for personality shaping. These theories have pointed towards several familial factors considered of importance not only for the onset of addiction, but other psychological disorders as well. Among these factors, those indicated as the most important are early separation from the parents, unfavourable perception of the father figure or his absence from the family, and conflicting, cold and distant relations with the parents (Oslen 2004; Nikolic, Klein & Vidovic 1990).

The family, defined as a core community primarily responsible for the upbringing of its offspring and expected to show continuous care for children's psychophysical development, may be considered essential for personality shaping and viewed as a primary social group playing a crucial role in the upbringing and socialisation of future generations (Janson 2007). In its efforts to fulfil this role, a family gets to witness and deal with various emotional relations and interactions, the dyadic relation between the mother and the child being the fundamental one (Rudan 1995). According to the psychoanalytical theory, child psychological development runs through psychosexual developmental stages (oral, anal, oedipal, latency, and adolescent stages). Should the first three stages run smoothly, i.e. free of major frustrations and traumas, and under favourable circumstances, the latency and adolescent stages are likely to be far less painful (Nikolic, Klein & Vidovic 1990). These theories have also suggested the importance of parental presence in early childhood, since separation from the parents can be the origin of anxiety and infinite psychological trauma. Early separations from the parents affect the quality of relations with the object of affection (the parent/the parents) and may profile the entire course of the child's further psychological development. Traumatic experiences witnessed in early childhood may compromise ego development (Rudan 1995; Klein 1992); separation from the parents definitely falls into the category of such experiences, since it can induce an overdue defence mechanism utilisation, personality splitting and projection. Premature separation from the parents may cause stress and psychological trauma that become a source of anxiety, which, in turn, may trigger drug consumption so as to bring "relief" and "alleviate" psychological symptoms arising due to traumas and stresses witnessed in the early childhood. Psychoanalysts are of the opinion that the quality of upbringing and well-balanced relations with both parents are a prerequisite for a healthy and normal development of a child (Nikolic 1991). Relations with the parents, built in early childhood, mirror the relations established in the adolescence. Close emotional relations with the parents are largely conditioned by emotional relations established in the first three developmental stages, and close emotional relations (intimacy) with the parents, established in early childhood, act as a protective factor hindering drug addiction onset during adolescence (Nikolic, Klein & Vidovic 1990; Goddman & Brand 2009).

Drug addiction onset is closely linked to adolescence. By definition, adolescence is the time of crisis in the life of virtually all individuals; however, children coming of age under unfavourable conditions compromising their emotional development are far more endangered. Psychoanalysts have taken the position that adolescence can be best described as the period characterised by a number of psychological phenomena and issues that an adolescent needs to resolve. One of the major issues to be resolved is the oedipal conflict; its final resolution should be followed by the assumption and the embracing of sex roles. Major task number two, pending resolution, is social affirmation in the local milieu and the assumption of social roles. From where the psychoanalysts stand, definite fulfilment of these tasks and ultimate resolution of these conflicts depend on relations established in the primary childhood (Rudan 1995). Furthermore, since one has to prove and promote himself/herself within the local community, the role of peer groups, and their influence on values an adolescent chooses to adopt and observe, is of the utmost importance; therefore, such peer groups may often be directly involved in drug addiction onset. In light of the foregoing, it is highly likely that a certain number of adolescents, whose early psychological development was rich in difficulties and frustrations, would try to resolve an otherwise normal adolescent crisis by virtue of drug consumption.

INTERACTION THEORIES--FAMILIAL RELATIONS AND FAMILY STRUCTURE AS

FACTORS IMPLICATED IN ADDICTION ONSET

Symbolic-interaction theories addressing the role of a family have acknowledged the importance of communication between family members not only for the proper family functioning, but for its survival as well. Marriages and families are essentially built of individuals having a long-term mutual interaction (relations), the latter being dependent on the roles assumed by an individual family member at a given point (Plunkett 2011: Jankovic 1994). Interaction theory greatly resembles conflict theory, which states that a conflict represents the foundation of each and every social relation, familial relations included, such conflict stemming from a desire to assume as powerful familial role as possible in order to protect one's interests (Janson 2007; Farrington & Chertok 1993). This conflict arises on the grounds of controversial wishes and desires of two or more groups, or on the grounds of a limited supply of the objects concurrently targeted by various individuals or groups. This theory argues that such conflict represents the basic ingredient of not only the social life of an individual, but the development and progress of the society on the whole (Farrington & Chertok 1993). Studies of the birth families of addicts by Stanton and colleagues (1978) showed that the causes and nature of chronic heroin addiction may be explained by analysis of familial relations, i.e. the analysis of familial interactions and family structure. These studies attempted to find out the differences between families dealing with addiction and families dealing with similar issues. The comparison revealed some phenomena seen across addicts' families to be very similar to those encountered among other disorderly and dysfunctional families and/or families dealing with issues of other nature. In addition, it was found that the family of an addict has distinctive features and specificities. For instance, such families are characterized by high substance (in particular alcohol) addiction prevalence rates seen across generations, as well as by a frequent predisposition to other forms of addiction, for instance pathological gambling disorder. Of note, other studies carried out within 1975-1979 timeframe yielded similar results, even though it should be pointed out that the focus of the later studies devoted to this problem had mostly been shifted from familial factors, in particular familial relations favoring drug addiction onset (Coleman & Stanton 1978; Harbin & Maziar 1975).

Numerous later studies have demonstrated that the consumption of drugs and other addictive substances can be associated with familial surroundings characterised by an insufficiency or lack of parental support and by little parental knowledge about the persons their adolescent is associating with. NIDA studies have revealed poor parental surveillance and parent-child conflicts to be strong predictors of drug addiction onset (NIDA 1999). This research has suggested the importance of a strong emotional relationship with the parents and parental support as protective factors hindering drug abuse. As opposed to that, parental addiction, parent-child conflicts, a local milieu favoring drug abuse, and positive peer group attitudes towards drug consumption are risk factors facilitating drug addiction onset. According to numerous theories, inadequate parental practices, the lack of parental surveillance included, can ultimately lead to deviant behavior onset (Stattin & Kerr 2000). These theories support the thesis that adequate parental surveillance is capable of preventing deviant behavior including addiction. A study that dug deeper into the association between poor parental practices and delinquency showed that delinquents have a far poorer communication with their parents as compared to non-delinquents; they have little faith in, and loose bonds with, their parents (Cernkovich & Giordano 1987). The results of the research study "The System of Values Observed by the Young Ones and Social Changes Witnessed in Croatia" carried out by the Institute for Social Research in Zagreb, Croatia on the sample of 17,000 young individuals aged 15 to 29 recruited throughout Croatia showed that young drug and alcohol addicts express their dissatisfaction with the quality of their parents' marital life and come from structurally impaired families far more often than their counterparts (Bouillet 2004). In addition, these young addicts were of the opinion that their family is of virtually no relevance for their attitudes and beliefs. In conclusion, numerous studies have shown that the consumption of drugs and other addictive substances can be related to familial surroundings characterised by a poor parental support and little parental knowledge about the persons their adolescent is associating with. An overview of studies dealing with maladjusted behavior came to the conclusion that relationships with parents play a key role in drug addiction prevention, largely due to opened channels of an intrafamilial communication (Tokic 2008; Berger & Sather 2007). A number of other studies also have stressed the importance of favorable interfamilial communication and close emotional relations between parents and their offspring in the prevention of behavioral disorders including addiction (Feric ?lehan 2004; NIDA 2003; Glavak, Kuterovac Jagodic & Sakoman 2003; Kerr et al. 2003; NIDA 1999). Favorable and supportive intrafamilial communication allows family members to express their needs, and creates a democratic environment full of trust and warmth in which closer and more cordial relations between the parents and their children can be established more easily. In creating such an environment, the roles of parents and adolescents are equally important; parents, on one hand, should be warm and supportive and have faith in their child/children, while children, on the other hand, should be willing to establish open and sincere communication with their parents and have faith in them, too (Kerr et al. 2003).

SOCIOLOGICAL THEORIES--SOCIAL FACTORS AND FAMILIAL SOCIOPATHOLOGY AS RISK FACTORS FAVORING ADDICTION ONSET

When discussing a family, it should be borne in mind that neither any given family nor any given person can be profiled independent of the entire social context. A family can be described as an ever-changing structure whose functioning, as well as the pathology potentially witnessed in the later stages, depend on a number of social determinants such as familial financial standing, cultural and religious values, level of education, migrations, and social isolation or adaptability, as well as on various larger-scale events witnessed by the local community--war operations, economic crises and criminal offences being the most striking among them (Georgas 2006; Cudina-Obradovic & Obradovic 2002; NIDA 1999). The onset of addiction, which nowadays poses as a global problem, also depends on a number of psychological and sociological factors whose interplay eventually triggers an individual drug addiction onset (Klarin 2002; Kusevic 1987). It has been well established that drug addiction onset can be closely linked to adolescence--an age in which young people face numerous, extremely dynamic and intense changes. It is not uncommon for certain young age groups to express their rebellion against the culture dominating their local communities by following novel trends in music, culture and leisure time spending. By doing so, they also rebel against parental authority as the primary factor responsible for their socialisation. One of the most prominent social factors responsible for drug addiction onset is the ever-growing drug availability (Perasovic 2000). Clearly, should a drug be hard to obtain, it will be sought by individuals prone to antisocial behavior and rejection of all social values, as well as by individuals coming from turbulent or dubious familial and social environments. Nonetheless, ever-growing drug availability increases the chances for consumption by young people across all social strata regardless of presence of risk factors. The social deviation theory views drug addiction as a phenomenon typical of social environments in which drugs are easy to obtain, as well as a phenomenon typical of criminal milieus and environments prone to accept deviant behavior in general (Hill 1980). Therefore, drug abuse issue witnessed across young population can not be resolved by virtue of separate interventions, but rather by virtue of targeted interventions aiming at three psychosocial impact factors: behavior, personality and surroundings, familial one in particular (Milkman & Wanberg 2005).

Under the influence of social developments, a family may witness changes during which traditional patterns of its functioning are gradually perishing and new, modern attitudes and family and marital values are substituted. The proportion of employed women is constantly rising, while, at the same time, the traditional institution of marriage steadily loses its relevance, so that the number of people determined to establish informal, extramarital relations is growing by the day; in turn, attitudes towards family and children are undergoing changes as well (Cudina-Obradovic & Obradovic 2002). The traditional family featuring a stable group of characters is gradually decreasing, while an ever-growing number of young people tend to embrace different trends more attuned to their generation. In addition, influenced by various global trends, younger generations gradually establish their own values, substantially different not only from those observed by adults but from those socially favorable and/or acceptable as well (Williams 2003). Lack of public awareness together with the lack of high-quality, well-organised preventative and therapeutic programmes, in particular those that are family-oriented, are factors in the constant increase in the number of addicts seen in certain societies.

THE CURRENT STUDY

A number of studies and theories (NIDA 2003, 1999) have attempted to define familial features that pose risk factors for drug abuse, as well as those acting as protective factors. The most important protective familial factors reported by the majority of these studies were close relations between parents and their children, positive disciplinary measures exercised within the family, continuous parental surveillance, inclusion of children in the decision-making processes, healthy communication between parents and children and their mutual trust, inclusion of parents into their children's lives (familiarity with children's friends and habits), strong and affirmative family ties, and conventional parental attitudes towards drug consumption (NIDA 2003). The main familial risk factors reported by these studies are lack of close emotional parents-children relations, chaotic familial environments (especially those featured by parental alcoholism or abuse of other psychoactive substances), loose bonds between parents and children, and lack of parental care, as well as familial attitudes advocating drug consumption (NIDA 2003; Williams 2003). The research in this field of expertise has also shown that drug addiction should be viewed as a multidisciplinary phenomenon influenced not only by familial, but also by other cultural-social factors, personal characteristics and genetic predisposition which together can lead to drug addiction onset (NIDA 1999).

Nevertheless, in order to uncover and elucidate its causal background and aetiology, drug addiction can be analysed from the viewpoint of family dynamics, familial structure and familial interrelations. Should one take this path of consideration, three main aspects are to be taken into account:

1. The developmental aspect, implying an analysis based on psychosocial developmental stages;

2. The interaction aspect, implying an analysis based on family dynamics and the quality of family relations; and

3. The social aspect, implying an analysis based on social dynamics capable of affecting the family and pushing it towards familial sociopathology.

In line with the foregoing, the main goals of this study were to identify possible differences between addicts' and non-addicts' families in terms of developmental, interaction and social factors, so as to be able to ultimately identify familial risk factors favoring drug addiction onset.

To that effect, developmental, interaction and social features of drug addicts' families and major characteristics of addicts' psychological development starting from the earliest childhood up to adolescence have been studied along with those descriptive of nonaddicts, so as to be able to identify the differences between the two. The three main features studied in this regard were:

* Developmental features: separation from the parents early in life (i.e. prior to the age of seven), parental divorce or death of one of the parents during the subject's childhood and adolescence, self-perception of one parent as more attentive and more caring, psychological trauma and stressful events in childhood and adolescence, lack of parental surveillance and support;

* Interaction features: emotional relations with the parents established in childhood and existent at the present moment, relations with the siblings, interparental relations, distribution of power within the family, communication with the parents, and support given by the family;

* Sociological features: family migrations taking place in the subject's childhood and adolescence, familial sociopathology such as harassment and domestic violence, alcohol abusing and mentally challenged parents, religious beliefs and attitudes, criminal offences committed by family members, etc.

METHODS

Throughout 2008 and 2009, an investigation was carried out involving an addict group and a control group not addicted to drugs, alcohol and other addictive substances. The study was anonymous, and made use of a 67-variable questionnaire as the main metric tool. The addict group was comprised of a total of 146 drug addicts; there were 92 men, 51 women and three individuals who neglected to state their gender who were aged 18 to 46 (most of them being 23 to 28 (the average age M = 28.18 SD = 5.070). At the time, the subjects were undergoing residential treatment either on the premises of the Psychiatric Hospital Vrapce or on the premises of the Clinical Hospital "Sisters of Mercy" established in Zagreb. The control group was comprised of a total of 134 individuals; there were 88 men, 45 women and one individual who neglected to state his/her gender who were aged 17 to 44, most of them being 22 to 27 (the average age M = 27.13; SD = 5.224). The main criterion observed in selecting the control group was to recruit roughly the same number of nonaddicted examinees and to standardise them for their sociodemographic features such as age, sex, educational background, place of birth and place of residence; these efforts eventually yielded a control group fully matching the addict group as regards sex ([chi square] = 0.132; df = 1; p > 0.05), age (t = 1.678; df = 268; p > 0.05), magnitude of the place of birth (t = 0.111; df = 265; p > 0.05), and magnitude of the place of residence (t = 1.758; df = 263; p > 0.05). However, it should be noted that the educational background seen across the controls is generally higher than that seen across the addict group ([chi square] = 44.275; df = 4; p < 0.01). The reason for pointing this out is that some studies have indicated that school failure and poor academic achievements yield "normality" in not more than 6.5% of cases; in these cases, antisocial behavior, personality disorders, organic symptoms, etc. are far more common (Nikolic 1993). Taking this into account, as well as given that early drug addiction onset (at the age of 13, 14, or 15) and not intellectual or some other deficits represent the most probable cause of poor education in the addict group, control group subjects having a somewhat higher level of education but otherwise matching the addict group were not excluded from the study. The control group was comprised of employees of the Psychiatric Hospital Vrapce and the CHC "Sisters of Mercy," as well as persons affiliated with the State Administration and Public Services, unemployed persons and students.

The members of both groups filled out the questionnaire independently, i.e. without any assistance and in the absence of researchers. The researchers or medical staff of the hospitals in reference distributed the questionnaire among the addicts, explained to them the purpose of the study, and pointed out that all the answers would be kept anonymous, but that they should be honest and straightforward. The questionnaire was given solely to addicts whose acute therapy had been completed. With the questionnaire, the addicts were provided with the cover letter containing an explanation of the study purpose and a request for as honest answers as was possible. Participation in the study and questionnaire fulfilment were voluntary; the addicts reluctant to comply were not forced to do so. The questionnaire was anonymous, without personal data like name, date of birth (only year) etc.) and participants were informed orally and in the written form about all relevant features of study such as aims, methods and means of using data . Approval was obtained from the Board of Ethics of University of Medicine in Zagreb for implementation of this study and the Boards of Ethics of Hospital Vrapce and Clinical Hospital Sister of Mercy.

The researchers had also personally delivered the questionnaire to the control subjects, together with the explanatory cover letter describing the purpose and the goal of the study and requesting as honest answers as was possible. None of the subjects received his/her questionnaire by email.

The variables addressed by the questionnaire were mostly qualitative in their nature and referred to the familial sociodemographic status, the features of the subject's early development, the family structure and the dynamics of its intrarelations, as well as to the familial sociopathology witnessed throughout the subject's childhood and adolescence. For each variable addressed by the questionnaire, several categories were offered as answers; in addition, the category "other" was provided as well, offering the respondents the chance to give a descriptive answer/an answer different from those offered on the menu. The collected data were entered into the computer database making use of the SPSS Statistics software. The questions answered in the descriptive manner ("open category answers") were analysed by the researchers, so as to boil them down to two or three categories (positive, negative and neutral). Within the framework of this study, differences in sociodemographic, developmental and interaction familial features and familial sociopathology for the addicted and the control groups were studied that included the following: parents' marital status, educational background of the father, educational background of the mother, the number of family members, severe illnesses that the participant had recovered from by the age of three, separation from the mother up until the age of three, separation from the parents (until the age of seven), emotional relations with the father during childhood, emotional relations with the mother during childhood, perception of a more attentive and more focused parental care, communication with the father during childhood and adolescence, communication with the mother during childhood and adolescence, clarity of the messages conveyed by the parents during the upbringing process, harmony between the parents and the siblings, free exchange of standpoints and opinions among family members, parental support, parental surveillance, decision-making process related to tangible assets and other issues, interparental relations, parental divorce or death of one of the parents, indication of the parent the respondent continued to live with following his/her parents' divorce or/and death of one of them, parental alcoholism and mental disorders, harassment and domestic violence witnessed, religious beliefs and attitudes, and felonies committed by family members.

Data were analysed using descriptive and parametric statistics. Variables descriptive of the two mutually comparable study groups were correlated to each other. In order to validate the interrelations, a nonparametric statistical method (x2 test), deemed significant at the level of significance of p < 0.05 or, with more substantial differences, at the level of significance of p < 0.01, was used, together with correlation analysis. The statistical analysis made use of the SPSS-Statistics software.

RESULTS

Familial Sociodemographic Features

The results showed no statistically significant differences between sociodemographic profiles of the addicts' and the control subjects' immediate families. Across both study groups, the subjects mostly came from three- to five-member families (72%) and were mostly firstborns (39% in the addicted versus 49% in the control group) who assessed their family standing as good on a five-point scale (66% in the addicted versus 62% in the control group). The addicts and the controls did, however, statistically significantly differ in their parents' marital status (32% of addicts coming from incomplete families that faced either parental divorce or death of one of the parents versus 21% of such cases in the control group) (p < 0.05) (see Table 1).

Familial Developmental Features

When it comes to familial developmental features, the results showed statistically significant differences between the addicted and control groups. These differences were seen in a number of developmental aspects, as well as in a number of childhood and adolescent psychological developmental features. The variables differing between the addicted and the control groups were as follows:

* Separation from the parents prior to the age of seven: (27% in the addicted vs. 11% in the control group; p < 0.05 (p < 0.01, [chi square] = 11.377, Df = 1, p = 0.003)

* Parental divorce or death of one of the parents experienced in early childhood or adolescence (35% of the addicts compared to 21% of the controls, p < 0.01 (p < 0.05, [chi square] = 6.962, Df = 2, p = 0.031). When this occurred, the addicts were also much younger than their nonaddicted counterparts.

* Psychological trauma and stressful experience: (46% in the addict vs. 26% in the control group, p < 0.01 ([chi square] = 11.930, Df = 1, p = 0.001). Among the addicted subjects who claimed to have experienced a psychological trauma or stress, the greatest number (addicts 28%, controls 35%) reported exposure to war environment. The most striking difference in the type of the experienced trauma, seen between the addicted and the control groups, appears with physical or sexual harassment; as compared to the control subjects, the addicts were significantly more often physically or sexually abused (14 % of the addicts vs. 3 % of the controls; see Table 2).

* Parental surveillance: (p < 0.01); ([chi square] = 23.457, df = 11, p = 0.009) The addicts' parents had established a statistically poorer parental surveillance over their children so that both of the nonaddicts' parents were much more often fully informed about their children's whereabouts, friends and outings as compared to the addicts' parents. As compared to 38% of the controls, the parents of only 19% of addicts were familiar with their children's friends and hangouts during childhood and adolescence. In 30% of cases, the addicts' parents did not have a clue about their children's friends or outings, either because they showed no interest in the matter or because the study subjects deprived them from that information; for the sake of comparison, this was the case in only 13% of our control subjects (see Table 3).

* Parental support: ( p < 0.01); [chi square] = 23.457, df = 11, p = 0.009) The control group was given a much more substantial and a much more adequate parental support as compared to the addicted group. The members of the control group claimed to be adequately controlled and truly loved by their parents significantly more often (35% as compared to 13% of the addicts); reports about the conflicts with the parents were far rarer (4% of controls vs. 14% of the addicts), as was the choice of the category "other" offered in the questionnaire (2% of controls vs. 9% of the addicts). During childhood, adequate parental support was provided to 60% of addicted study participants (parental support and understanding, 47%; parental control and true love, 13%), as compared to 82% of the controls (see Table 4).

Familial Interaction Features

As regards familial interaction features, especially emotional relations and communication with the parents, the results showed striking differences between the addicted and control groups. Variables revealing the most profound differences between the two were as follows:

* Unfavourable emotional relationship with the parents, especially with the father, established throughout childhood and adolescence: When it comes to the variable that addresses the perception of emotional relations with the father established throughout childhood and adolescence, a statistically significant difference between the addicted and the control groups was noted (p < 0.05) ([chi square] = 15.142, df = 1, p = 0.010); the addicts more often described their relations with their fathers as negative, i.e. aggressive and harsh (12% vs. 4% of the control subjects) and cold and indifferent (11% vs. 9% of the control subjects). In addition, the addicted study participants more often picked "other" as an answer (14% vs. 7% of the controls), most commonly in order to describe the relationship that was ultimately classified as negative (the terms most often used to describe the relationship under this category were "distant", "far too harsh" or "nonexistent" due to the father's absence). Statistically significant differences between the addict and control groups (p < 0.01) were also found with the variables addressing the perception of relations with the mother established during childhood ([chi square] = 15.288, df = 5, p = 0.0009). As compared to the controls, the addicted study participants were far more prone to describe their relationship with their mothers as negative, that is to say either aggressive and harsh (7% vs. 2% of the controls) or cold and indifferent (4% vs. 0% of the controls) (see Table 5).

* An imbalanced emotional perception of parents during childhood and adolescence in favor of the mother was reported by the majority of the addicts; 87% of them perceived their mothers in a positive manner (and described them as tolerant and full of understanding, indulgent and soft, or harsh but full of love), while 63% reported a positive perception of the father figure ([chi square] = 4.457, df = 114, p < 0.01). The correlation between the negative relation with the father and that with the mother was low, but still significant (r = 0.21). In addition, the more negative the relationship was with father, the more negative the relationship was with the mother too. This imbalance was not seen in the control group; 80% of the control subjects had a positive relationship with their fathers, and 92% with their mothers (see Table 5).

* Uneven perception of parental attentiveness and care, and getting along with the parents at the present moment: As opposed to their nonaddicted counterparts, the majority of the addicts perceived their mothers as more attentive and more caring (60% versus 37% of the controls) ([chi square] = 17.274, df = 2, p = 0.000). Unlike nonaddicts (who mostly got on well with both parents), addicts continue to perceive their parents differently even as adults, so that they mostly got along better with their mothers (52% of the addicts versus 33% of the control group). p < 0.01 ([chi square] = 20.276, df = 2, p = 0.000) (see Tables 6 and 7).

* Negative communication with the father throughout childhood and adolescence: 62% of the addicts established a defensive or negative communication with their fathers, as compared to 24% of their control counterparts; p < 0.01 ([chi square] = 45.906, df = 6, p = 0.000). That is the most profound difference between the addicts and the controls. The relationship in for the addict group was most often described as defensive - criticising (32%), defensive - superior (18%), or defensive - negatively interpreted by participants (12%). As opposed to that, a defensive communication with the father was described by not more than 24% of the control subjects; this communication was most often described as defensive --superior (13%) or criticising, blaming and incomprehensible (8%), while only 3% of the control subjects described this communication as defensive negatively interpreted (see Table 8).

* Negative communication with the mother: Even though the communication established between the addicts and their mothers during childhood and adolescence is far better than that with the fathers (70% had more positive communication with the mother, as opposed to 36% who had positive communication with the father), the control group members perceived their communication with their mothers as supportive and positive significantly more often than the members of the addicted group (94% of the controls vs. 70% of the addicts, p < 0.01). ([chi square] = 34.272, df = 6, p = 0.000) (see Table 8).

* Poor and conflicting interparental relationships featured by constant arguments and misunderstandings were reported by 15% of the addicts and 2% of the controls (p < 0.01) ([chi square] = 45.906, df = 6, p = 0.000) (see Table 9).

* Unequal distribution of powers in favor of the father or mother: For the addicts, final decisions were significantly more often taken either by their fathers or by their mothers and significantly more infrequently by both parents, as opposed to the controls, who reported that decisions were mostly made consensually by both parents. In the addict group, relevant decisions were taken by the father in 32% and by the mother in 25% of cases; in the control group, decisions were made by the father in 29%, and by the mother in 16% of cases. Decisions jointly made by the mother and the father were more often reported by the control subjects (51% of the controls vs. 35% of the addicts; p < 0.01) ([chi square] = 11.027, df = 1, p = 0.001) (see Table 10).

Familial Sociological Features

The results pertaining to the familial sociological features showed that the most profound difference between the addicts and the controls can be seen in familial sociopathology. As compared to the control group, the addicts' families most often had to deal with alcohol abuse and mental disorders (39% vs. 17% of controls), p < 0.01 ([chi square] = 15.847, df = 1, p = 0.000). It should be noted, however, that, with a few exceptions, the addicts predominantly had to deal with parental alcoholism or alcoholism in the immediate or broader family, while, in addition to the aforementioned, a substantial percentage of the controls had to deal with mentally-challenged parents as well (a mentally-challenged mother in 17% of the controls vs. 2% in the addicts, both mentally-challenged parents in 8% of the controls and 0% of the addicts, and the combination of an alcoholic father and a mentally-challenged mother in 4% of the controls and 2% of the addicts) (see Table 11; Table 12 lists those who fell into the "other" category (including one father, who should be in the first category). [chi square] As compared to the controls, the addicts were most often molested during childhood and adolescence (26% of the addicts vs. 11% of the controls; ([chi square] = 9.389, df = 1, p = 0.002), and were more often witnesses to domestic violence (29% of the addicts vs. 16% of the controls) ([chi square] = 6.937 df = 1, p = 0.008), while their family members were more often charged with criminal offences (14% in the addicted vs. 2% in the control arm; p < 0.1) ([chi square] = 12.796, df = 1, p = 0.000). During their childhood and adolescence, 49% of the addicted subjects moved at some point, as compared to 39.7% of their control counterparts, so that no statistically significant difference in this regard was revealed (p > 0.05). However, there was a statistically significant difference in their religious upbringing (p < 0.01), with a religious upbringing more often encountered among the controls (76% of the controls vs. 57% of the addicts) ([chi square] = 11.0027, df = 1, p = 0.01).

DISCUSSION

The results of this study demonstrate the burden imposed on the addicts' families by various familial risk factors capable of substantially influencing the onset of various psychological disorders (drug addiction included) to be statistically significantly heavier than that imposed on the families of the nonaddicts; the situation remained unchanged throughout the subjects' childhood and adolescence.

Starting from their early days, the addicts were statistically more often separated from one or both parents; according to psychoanalytical theories, this enhances their vulnerability and proneness to developing various psychological symptoms and disorders, drug addiction included (Oslen 2004; Nikolic 1991). Furthermore, the study uncovered the fact that addicts more often came from families characterised by poor interparental relations, along with parental divorce or death of one of or both parents experienced in the subjects' early childhood. In addition, psychological trauma or stress experienced during childhood and adolescence were significantly more frequently reported by the addicts as compared to the controls. It has been well recognised that unresolved psychological traumas experienced in childhood are capable of jeopardising ego development and hindering normal psychological functioning (Chilcoat & Breslau 1998; Nikolic, Klein & Vidovic 1990). This study also showed the emotional relations and communication with the parents established by the addicts throughout their childhood and adolescence to be much more negative as compared to the nonaddicts, the most pronounced difference appearing in the communication with the father, which was negative for most of the addicts. Furthermore, this study revealed another characteristic typical of addicts' families--a marked imbalance in emotional relations and communication with the parents, i.e. significantly more negative relationships and communication with the fathers as compared to those with the mothers, suggesting that the negative role played by the addict's father figure represents a key factor in drug addiction etiology and suggesting other possible studies in the etiology of other psychological disorders as well (Lamb & Tamis-Lemonda 2004). Namely, 37% of the addicts assessed their childhood relationships with their fathers as negative (aggressive and harsh, cold and indifferent, or "other"); on the other hand, the relationship established with the mother during childhood was seen as negative by not more than 12% of the addicts. Therefore, it is fair to say that negative communication and negative emotional relationships with the father established during childhood and adolescence can be risk factors favoring drug addiction onset. These data support the thesis brought forward by a number of studies that points towards the crucial role of the father figure and his presence in the family, especially in early developmental stages, as important not only for the subsequent normal development of a child, and later of an adolescent, but also for the establishment of a healthy and supportive familial environment and successful parenthood. The sensibility of the father and the degree of his involvement in the upbringing process substantially impact not just emotional, but also sensory-motor and linguistic development of a child (Tamis-Lemonda et al. 2004; NIDA1999; Bry et al. 1998). Our results also indicate that, when it comes to the addicted study population, a number of fathers failed to fulfill their roles; together with other negative factors, this may have led to poor social adaptation and drug addiction onset in their children. Therefore, further research into the importance of the father figure and its relevance for the healthy and normal child's development and the prevention of his/her risky behaviors, addiction included, is of extreme importance for preventative programs and addiction treatment planning.

A statistically significant difference between the addicted and the control groups was established also in relation to the variable addressing their perception of the relationship with the mother established during childhood; the control group members perceived their mothers as tolerant and full of understanding far more often than the members of the addicted arm (44% of the controls vs. 32% of the addicts), and far less often saw them as aggressive and harsh (2% of the controls vs. 7% of the addicts). These results indicate that, in spite of the fact that the addicts perceive their relationship with the mother as far more positive than that with the father, the emotional relationship of the mother with the child during childhood was far more negative when the mothers of future addicts were compared to those of the control group members. This leads to the conclusion that the emotional relationship established with the parents plays the key role not only in drug addiction onset, but its prevention as well (Berger-Saether 2007). It is possible that, due to the unresolved emotional issues with the parents and due to the challenges faced during the early developmental stages, certain adolescents find it hard to define, and stick to, their own identities, and have trouble adjusting to the given circumstances; interlaced with other unfavorable psychosocial factors, this could lead to psychological issues, social maladjustment and behavioral deviations, and drug addiction onset. Our results also lead us to conclude that families of addicts are characterised by the lack of emotional closeness between the child and the parents; this is perceived as a risk factor for drug addiction onset by the present authors and many other researchers as well.

In addition, the study showed the addicts to be under significantly poorer parental surveillance as compared to the non addicts; the same goes for parental support. According to numerous studies carried out on both national and international scales, parental surveillance represents one of the major protective factors shielding from the drug addiction onset, and the lack of such a continuous parental surveillance represents a risk factor that favors drug addiction onset (NIDA 1999). Our results further corroborate that hypothesis; all of our addicted subjects' friends and outings were known to not more than 19% of their parents, as compared to 38% of the control subjects' parents. Furthermore, a statistically significant difference between the two study arms was revealed in the variable addressing the parental support provided throughout childhood and adolescence; the control group had far more often reported their parents to be controlling, but full of love (35% of the controls vs. 13% of the addicts), while parent-child conflicts were far rarer for them (4% of the controls vs. 14% of the addicts). In support of that, several international and national studies have shown parental acceptance and support to be closely linked with child's healthy psychosocial development (Haddad, Barocas & Hollenbeck 1991).

The results also showed that addicts and nonaddicts mutually differ when it comes to the distribution of power within the family. Addicts' families are typically featured by a more specific familial pattern and an uneven distribution of decisionmaking power within the family, either to the benefit of the father or to the benefit of the mother.

In addition, our study showed alcoholism, especially that of the father, to be significantly more frequent in the addicts' immediate and broader families. The same goes for felonies committed by family members, as well as for domestic abuse and violence. These results led us to conclude that familial sociopathology such as alcoholism, domestic violence, and especially child molesting and negligence, has an adverse impact on child's healthy psychological development and very often is a primary cause of risky behavior, drug addiction included (Etz, Robertson & Ashery 1998).

Also, the addicts were significantly less often brought up in religious homes--a fact that corroborates the hypothesis that religious beliefs represent a protective factor against the addiction onset (NIDA 2003, 1999).

We can conclude that family as the fundamental social construct has a significant impact on shaping of the child's personality, so that it represents not only a developmental frame, but the framework for the prevention of numerous psychological and behavioral disorders including drug addiction.

The results of this research have demonstrated the existence of familial risk factors favoring drug addiction onset, already disclosed by a number of national and international studies; from our standpoint, this is also the major scientific achievement and contribution of this study. Familial factors associated with the family structure and familial interrelations, as well as with familial sociopathology, make certain children and adolescent groups more prone to drug addiction as compared to their peers. The results led us to conclude that there exists a strong causal relationship between the onset of drug addiction in the later stages of life and the presence of familial risk factors throughout childhood and adolescence, such as: separation from the parent(s) early in life (prior to the age of seven), parental divorce or death of one of the parents, conflicting interparental relations, familial sociopathology such as alcoholism and parental addiction, criminal offences, abuse and domestic violence, lack of parental support and surveillance, lack of close emotional relationship with the parents and inadequate parent-child communication, a negative emotional relation and communication with the father, as well as a psychological trauma and stressful events experienced in the childhood and adolescence. Based on the outcome of our study, it can be concluded that, as compared to the controls, the families the addicts were born into are far more often witnesses to psychopathological events and psychosocial factors that, in combined effort, ultimately create a risky familial environment and therefore pose as familial risk factors favoring drug addiction onset.

One or all of these familial features make certain children and adolescents more vulnerable than their peers living under different circumstances, and put them in a higher risk of developing a variety of risky behavior patterns including drug addiction. Furthermore, the results suggest the important role of the father figure in terms of the emotional relations and communication established throughout childhood and adolescence in drug addiction onset.

In line with the foregoing, it is to be expected that the results of this study may aid in shaping the guidelines for further research into familial risk factors favoring drug addiction onset, as well as in shaping the guidelines for designing high-quality preventative programs oriented towards children and adolescents coming from risky familial environments. In addition, this study provides compelling evidence on the existence of a distinctive pattern of power distribution and emotional relations within the addicts' birth families; family-oriented drug addiction treatments that include withdrawal therapy, rehabilitation and resocialisation can be improved based on this knowledge.

Family-oriented drug addiction prevention represents a relatively unexplored area and a challenge that should be addressed in the years to come. The results of this study suggest that family-oriented addiction prevention should be initiated as early as possible, while the methods of approach should involve parents, children and adolescents. This study also demonstrated the need for further investigation into the cause-effect relationship between the risk and protective factors associated with individual drug addiction proneness.

Healthy psychosocial child development would benefit from early interventions oriented towards these risk factors and tailored so as to recruit the whole family. Furthermore, the results indicate the need for further research into familial relations and structures of the families addicts were born into, as well as the need for comprehensive therapeutic approach oriented towards not only an addict, but his/her family as a whole; the family clearly plays an essential role in drug addiction onset, but also in its prevention and treatment.

DOI: 10.1080/02791072.2012.685408

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Jadranka Ivandic Zimic, Ph.D. (a) & Vlado Jukic, M.D., Ph.D. (b)

(a) Senior Adviser to the Government and to the Governmental Office of the General Programs & Strategies Department, Office for Combating Drug Abuse of the Government of the Republic of Croatia, Zagreb, Croatia.

(b) Head of the Hospital, Psychiatric Hospital Vrapce, Zagreb.

Please address correspondence to Jadranka Ivandic Zimic, Ph.D., Office for Combating Drug Abuse of the Government of the Republic of Croatia, Preobra?enska 4/II 10000 Zagreb, Croatia; phone: +385 1 48 78 130; fax: +385 1 48 78 120; email: jadranka.ivandic@ uredzadroge.hr
TABLE 1
Parents' Marital Status

                             Addicts   Controls

Together                       68%       79%

Parents Divorced               18%       12%

One Parent Deceased             4%        1%

Single-Parent Family:           8%        7%
  Self-Supporting Mother

Single-Parent Family:           2%        1%
  Self-Supporting Father

TABLE 2
Type of Trauma or Stress Experienced

                                  Addicts   Controls

Physical or Sexual Harassment       14%        3%

Exposure to War Environment         28%       35%

Fire or Natural Disaster             3%        9%

Great Suffering or Death of an      20%       21%
  Immediate Family Member

Parental Divorce                    17%       18%

Death of a Parent                   12%       12%

TABLE 3
Parental Surveillance

                                                   Addicts   Controls

Yes, Both of My Parents were Acquainted with my      19%       38%
Friends and Outings

Yes, Only my Mother was Acquainted with my            9%        6%
Friends and Outings

Yes, Only my Father was Acquainted with my            1%        1%
Friends and Outings

Yes, Both of My Parents were Acquainted with         35%       36%
Some of my Friends and Outings

No, Both of My Parents were Unacquainted with
  my Friends and Outings Since They Never             3%        3%
  Really Cared about Them

No, Both of My Parents were Unacquainted with
  my Friends and Outings Since I Never Bothered      27%       10%
  to Keep Them Posted

No, my Father was Unacquainted of my Friends
  and Outings Since He Never Really Cared            2%         4%
  about Them

No, my Mother was Unacquainted with my Friends
  and Outings Since She Never Really Cared           0%         1%
  about Them

No, My Father was Unacquainted with my Friends
  and Outings Since I Never Bothered to Keep         2%         1%
  him Posted

No, My Mother was Unacquainted with my Friends
  and Outings Since I Never Bothered to Keep         2%         0%
  her Posted

TABLE 4
Parental Support

                             Addicts   Controls

Support and Understanding      47%       47%

Emotional Coldness and          5%        1%
  Indifference

Harshness and Control           8%        7%

Control and Love               13%       35%

Indifference and Freedom        4%        5%

You were Continuously in       14%        4%
  Conflict

Other                           9%        2%

TABLE 5
Emotional Relationship with Father or Mother
Throughout Childhood and Adolescence

                              Father               Mother

                        Addicts   Controls   Addicts   Controls

Aggressive and            12%        4%         7%        2%
  Harsh

Indulgent and             20%       18%        37%       34%
  Gentle

Tolerant and Full of      19%       28%        32%       44%
  Understanding

Harsh (rigid or           24%       34%        18%       14%
  strict) but Loving

Cold and                  11%        9%         4%        0%
  Indifferent

Other                     14%        7%         1%        6%

TABLE 6

Perception of Parental Attention and Care Provided
throughout Childhood and Adolescence

               Addicts   Controls

Father            9%        8%
Mother           60%       37%
Both Parents     31%       55%

TABLE 7

With Which One of your Parents are you Getting
Along Better at the Present Moment

                                  Addicts   Controls

Father                              16%        7%
Mother                              52%       33%
Equally Well with Both Parents      33%       60%

TABLE 8

Communication with the Father or Mother
throughout Childhood and Adolescence

                     Father               Mother

               Addicts   Controls   Addicts   Controls

Supportive-      17%       24%        30%       30%
Favoring

Supportive-       6%       11%        27%       36%
Empathic

Supportive-      13%       40%        13%       28%
Positively
Interpreted

Defensive-       18%       13%        10%        0%
Superior

Defensive-       32%         8        16%        2%
Criticising

Defensive-       12%        3%        0%         2%
Negatively
Interpreted

TABLE 9 Interparental Relations

                           Addicts    Controls

Good--Full of                28%         24%
  Understanding and
  Mutual Support

Good, But with               40%         47%
  Occasional Arguments
  and Misunderstandings

Not So Good--They Were       12%         24%
  Often In Dispute

Other                         7%          3%

Poor--They Were              15%          2%
  Arguing All the Time

TABLE 10
Distribution of Power: Who was in Charge
of Decision Making

                             Addicts   Controls

Father                         32%       29%
Mother                         25%       16%
Mother and Father Jointly      35%       51%
Whole Family Together           8%        5%

TABLE 11

Alcohol Abusing and Mentally Challenged Family
Members

                                 Addicts   Controls

Alcohol Abuse by Father Only       63%       63%

Alcohol Abuse by Mother Only       7%         0%

Father--Alcohol Abuse,             2%         4%
  Mother--Mentally Challenged

Both Parents Mentally              0%         8%
  Challenged

Mentally Challenged Mother         2%        17%
  Only

Other                              26%        8%

TABLE 12
Addicts who Circled the Answer "Other" in
Response to the Item "Alcohol Abuse and Mental
Disorders - which of the Family Members"

Alcohol Abuse          Mental Disorders

Grandmother       3    Grandmother             1
Grandfather       7    Brother                 1
Father            1    Grandfather's sister    1
Uncle             1    Other                   0
Total            12    Total                   3
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Author:Zimic, Jadranka Ivandic; Jukic, Vlado
Publication:Journal of Psychoactive Drugs
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Date:Jun 1, 2012
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