|Year : 2016 | Volume
| Issue : 1 | Page : 17-22
The impact of parental alcohol dependence on the development and behavior outcome of children in a tertiary care hospital
Jasmeet Sidhu, Era Dutta, Nilesh M Naphade, Jyoti V Shetty
Department of Psychiatry, Bharati Hospital, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
|Date of Web Publication||22-Dec-2015|
Room 4, Department of Psychiatry, Bharati Hospital, Bharati Vidyapeeth Deemed University, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Parents play a pivotal role in upbringing a child and shaping their future. However, children of alcoholics (COAs) suffer due to their parent's dependence pattern. The various domains affected encompass cognitive, behavioural, psychological, emotional and social spheres. This study was designed to assess the impact of alcohol dependence in the parent on the development and behavior of their children, so that further steps could be taken to minimize the negative influences. Aims: To study the impact of parental alcohol dependence on the development and behaviour outcome of children in various domains, alongwith the effect of the family environment. Materials and Methods: The study was a cross-sectional observational study conducted at a tertiary care teaching hospital on 25 children between 6 and 18 years of age, whose atleast one parent was diagnosed as alcohol dependant. The other parent was assessed using a general health questionnaire-28. Child behaviour checklist and family evaluation scale (FES) were then applied. Statistical Analysis Used: The analysis was done according the manuals provided with the respective scales to calculate the score. Results: Both male and female COAs had high externalizing and internalizing scores. The girls have higher internalizing scores while the boys of such parents have higher externalizing scores. The FES showed dysfunction in all the three dimensions, namely the relationship, personal growth and the system maintenance. Conclusions: Our study corroborates the findings of the studies done in the past on COAs. The COAs face various affective, anxiety, somatic, attention deficit/hyperactivity, oppositional defiant conduct problems.
Keywords: Child behaviour checklist, children of alcoholics, externalizing, internalizing
|How to cite this article:|
Sidhu J, Dutta E, Naphade NM, Shetty JV. The impact of parental alcohol dependence on the development and behavior outcome of children in a tertiary care hospital. Med J DY Patil Univ 2016;9:17-22
| Introduction|| |
"Children are like clay. They are molded by those who surround them. Their environment shapes them and they adapt. They are the reflection of those that have created them."
- Ancient proverb
Strong evidence has concluded that family dysfunction during the childhood can negatively influence later life experiences and adjustment.  Children whose parents (or parental caregiver) use alcohol in such a way that it causes problems in their life are often referred to as children of alcoholics (COAs). 
Children of alcohol/substance abusers may be the victims of physical and emotional abuse and neglect. As a result, these youngsters may suffer from various anxiety and affective disorders. These children are not only frightened for their own wellbeing - They also harbor real concern that their parent may get sick or die as a result of the alcohol abuse. 
Children of parents with a lifetime diagnosis of alcoholism show varying levels of exposure to their parent's alcohol-related symptoms. At one extreme, some children may limit their social life, because they fear someone may find out the truth about the substance abusing parent. On the other hand, some children may use friends as buffers, relying on their leadership skills to take on key positions in school and extracurricular activities. These young people are often among the most difficult to identify as COAs because their achievements masks them and appear so "well-adjusted." 
Many COAs who rely on "adaptive distancing," a technique in which the child separates from the "centrifugal pull" of family problems in order to maintain pursuits and seek fulfillment in life, at times may fare better. Hence, not every family is affected identically. 
A considerable amount of research has examined the impact of parental alcohol misuse on children's development. The research reveals that COAs suffer from a range of maladaptive outcomes spanning almost all areas of development, including the cognitive, behavioural, psychological, emotional and social domains. ,
COAs are particularly themselves at high risk for substance use as well as other problems such as learning disability, hyperactivity, psychomotor delays, somatic symptoms and emotional problems. The highest risk for developing alcoholism exists for individuals who start using alcohol as adolescents, have a high family loading for alcohol problems and display a cluster of behavior traits described as disinhibited, under controlled or impulsive, which are usually evident in childhood and persist into adulthood. , There have been attempts to study various aspects of children of people with alcohol dependence from India and some published literature is available that looks at various domains in the same sample. 
Since the role of the family is very important, the overall functioning of the family has been gauged using various scales. Family environment scale (FES)  is one such scale, which has been widely used in various studies in India as well as abroad. The child behaviour checklist (CBCL)  is an important tool used to measure children's behaviour and development.
This study is an attempt to examine the areas of dysfunction with a specific focus on family, in COAs in the Indian context so that early identification and intervention can be planned. 
The present study was carried out to explore the impact of parental alcohol dependence on the development and behavior outcome of children in various domains, along with the effect of the family environment.
| Materials and Methods|| |
Study design and Participants
This was a cross-sectional observational study, which was carried out at a tertiary care teaching hospital on the indoor patients and their children, after seeking due consent and assent. The study received clearance from the Ethical Committee.
Twenty-five children aged between 6 and 18 years, having no known psychiatric illness were interviewed. Their parent was diagnosed as per the international classification of disease-10 as alcohol dependence syndrome. The other parent who was not alcohol dependent was assessed using a general health questionnaire (GHQ-28) scale. If the score of this parent was <24 on GHQ-28, the child was considered as a part of the study.
Children of parents having organic brain syndromes, mental retardation or any other psychiatric illness were excluded. However, a comorbid diagnosis of tobacco dependence was entertained.
Children with any physical/visual/auditory handicap; chronic medical illnesses like diabetes, asthma or chronic renal disease were not included as these were further confounding factors.
The assessments involving the parents, FES  and the CBCL  were administered.
The GHQ-28  is a symptom and well-being self-rating scale with the severity of symptoms compared to the habitual state of the person in question on a 4-point rating scale.
The CBCL  is a descriptive instrument designed to classify behavioral and emotional disorders of children aged 6 through 18 years. Each of the 113 items were scored on a three-step response scale: 0, not true; 1, sometimes true; and 2, often true. The test can be self-administered or administered by an interviewer. The two broad band groupings of behavioral problems assessed correspond to the internalizing and externalizing behavior. Adequate reliability and validity has been established. We applied the CBCL scale in three languages - English, Marathi and Hindi.
FES  assesses the social environments of families along three salient dimensions that is, relationship dimension (cohesion, expressiveness, and conflict), personal growth dimension (independence, achievement orientation, intellectual-cultural orientation, active recreational orientation and moral religious emphasis) and system maintenance dimension (organization and control).
The scores were calculated on the basis of responses of the subjects and their nonalcohol dependent parent. The manuals provided with the standard scales were used for calculating and interpreting the results.
| Results|| |
Our study group consisted of 25 children in the age group of 6-12 years, comprising of 14 (56%) boys and 11 (44%) girls. In the age 6-11 years age group there were 11 boys and 7 girls, while in the 12-18 years age group, there were 3 boys and 4 girls. As 100% of the alcohol dependent parents were fathers, GHQ-28 was applied on their respective wives and only those scoring <24 were made a part of this study.
Seventy-two percentage of the children were from lower socioeconomic status families, 20% were from middle while 8% were from higher socioeconomic group. 
Seven girls in the age group 6-11 years had an internalizing score of 68.1 (± 10.2) compared to a Normal T-Score of 50.1 (± 9.7). Four girls in the age group of 12-18 years had an internalizing score of 50.1 (± 8.1) compared to a Normal T-Score of 50.1 (± 9.7).
Amongst boys, in the age group 6-11 years the internalizing score of 58 (± 7.6) compared to a Normal T-Score of 50.2 (± 9.6), while in the age group of 12-18 years, score of 56.3 (± 9.3) compared to a Normal T-Score of 50.2 (± 9.6) were observed.
Seven girls in the age group 6-11 years had an externalizing score of 59.6 and a standard deviation (SD) of 9.6 compared to a Normal T-Score of 50.1 (SD ± 9.5). Four girls in the age group of 12-18 years had an externalizing score of 61 (SD ± 7.1) compared to a Normal T-Score of 50.1 (SD ± 9.5).
Eleven boys in the age group 6-11 years had an externalizing score of 65.2 (SD ± 8.7) compared to a Normal T-Score of 50 (SD ± 9.6), while boys in the age group of 12-18 years had an internalizing score of 61 (SD ± 9.2) compared to a Normal T-Score of 50.1 (SD ± 9.6).
The affective, anxiety, somatic, attention deficit hyperactivity disorder attention deficit hyperactivity disorder and conduct problems in both sexes have been tabulated [Table 1] [Table 2] [Table 3].
FES on the three dimensions showed the scores as depicted [Table 4] [Table 5] [Table 6].
| Discussion|| |
In the study, all the 25 subjects had their father as the alcohol dependent parent. Most studies examining outcomes for children of parents who misuse alcohol have not so far distinguished between paternal or maternal alcohol misuse.  This may be due to the fact that lesser women are likely to engage in alcohol misuse. Consequently, in studies where there are more males than females with alcohol dependence, there may be insufficient statistical power to detect the impact of maternal drinking. To our knowledge, till date, there hasn't been clear evidence that maternal alcohol misuse has a greater or lesser impact on children than paternal alcohol misuse. 
Majority of the subjects in our study belonged to the lower socioeconomic status (72%). This may be due to the fact that the bulk of the general strata of population to which the hospital caters to is of lower socioeconomic group. There is minimal evidence of a direct causal link between socioeconomic status, parental alcohol misuse and negative outcomes for children. Rates of alcohol misuse in one study were found to be significantly higher in families with lower socioeconomic status compared with those families from higher socioeconomic status.  The FES was not compared to the normal population matched with the study subjects as the study is not a comparative one, still it was found that all the three dimensions, namely the relationship dimension, personal growth dimension and the system maintenance dimension appeared to be affected. The least score in the relationship dimension were in the "conflict" subscale which may depict the amount of openly expressed anger, aggression and conflict among family member which could be most likely due to the constant quarrels within the family related to the alcohol abuse by the father. In the personal growth dimensions, lower scores were seen in independence and intellectual-cultural orientation subscales of which the independence subscale refers to the extent to which family members are assertive, self sufficient, and can make their own decisions. Intellectual-cultural orientation subscale refers to the degree of interest in political, social, intellectual and cultural activities. Hence, the low scores in this subscale could be attributed to the disturbed family structure and functioning due to paternal alcohol abuse but also due to the fact that these subjects belonged to lower socioeconomic status and their parents were not well educated. The consensus in the literature is that parental alcohol misuse brings disruption to the entire family functioning. In general, where there is parental alcohol misuse, families are more dysfunctional and hassled, perceive their environment to be less cohesive, lack routines and have lower levels of physical and verbal expression of positive feelings, leading to higher levels of unresolved conflict, fighting, blaming and arguing. ,, There have been similar findings concluded in an Indian study done by Babita Mahato et al. published in 2009, however, no FES was used in their study. 
Our study showed that the internalizing as well as the externalizing scores of the COAs are greater than the normal scores of the matched population on the CBCL. A large body of literature indicates links between family stress, conflict and child externalizing and internalizing behaviours which are similar to the findings in our study. ,, Many studies in our country , also used CBCL and had similar findings in the Indian setup.
A major difference noticed in our study was in the type of problems faced by the girls and boys. The girls had more internalizing problems as compared to boys who had more externalizing problems. Internalizing problems included anxious/depressed, withdrawn/depressed and somatic complaints. We suppose that one of the reasons for girls having more internalizing scores especially somatic complaints could be because the girls included in the study were in the age group 6-18, who usually have similar complaints during the initial few years of attaining menarche which is further supported by the higher scores in somatic problems in girls in the age group 12-18 as depicted in [Table 3] in the study. Boys on the other hand, had more externalizing problems, which included attention problems and aggressive behaviour. Studies done both in the West and in Indian set up have corroborated the findings in our study. ,,,,,,
The affective problems, anxiety problems, somatic problems, attention deficit/hyperactivity problems, oppositional defiant problems and conduct problems in the subjects were also studied. Scores were found to be on the higher side for most of these dimensions.
The purpose of studying the problems that parental alcohol abuse present for the children is to make the society more aware of these problems and the damage that these could lead to, by affecting the children. The next logical step is intervention - which needs to be a multidimensional approach that should include steps for the betterment of those already affected and preventive measures for the generations to come. There is a variety of views about how to provide services to the COAs. The types of problems to which children are vulnerable are varied, and therefore, so are the individual responses of children.
Research findings can be useful in directing the focus of practice. For example, boys whose parents misuse alcohol demonstrate higher levels of aggression, hyperactivity, and mental health problems and appear to fare far worse than girls.  Internalizing behaviours in girls occur as commonly and are as serious. An important aim of any intervention is to help children develop better coping strategies, such as more effective ways of responding to situations at home. Providing appropriate access to services, which can offer support, encouragement and opportunities to children who are suffering for no fault of theirs, is the least that we could do for the betterment of their future, thereby helping the society become a better place to live.
The sample size of our study was small and comprised of only the indoor patient population making extrapolation to the community scenario difficult.
| Conclusion|| |
The two important facts that have been appreciated by one and all since a very long time have been taken into account and amalgamated in our study, which are - The Ill effects of alcohol on not the individual but also on the family; and that children have very impressionable minds and they follow by example.
To conclude, our study corroborates the findings of the studies done in the past that children of alcohol dependent parents have higher internalising as well as externalizing scores. Also, the girls have higher internal sing scores while the boys of such parents have higher externalizing scores.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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