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Journal of Social Work Practice in the Addictions
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Young Children of Parents with Substance Use
Disorders (SUD): A Review of the Literature and
Implications for Social Work Practice
Neta Peleg-Oren PhD
a
& Meir Teichman PhD
b
a
Community-Based Intervention Research Group (CBIR-G), Florida International University,
11200 South West 8th Street, MARC 310, Miami, FL, 33199
b
Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, 69978, Israel E-mail:
Published online: 12 Oct 2008.
To cite this article: Neta Peleg-Oren PhD & Meir Teichman PhD (2006): Young Children of Parents with Substance Use Disorders
(SUD): A Review of the Literature and Implications for Social Work Practice, Journal of Social Work Practice in the Addictions,
6:1-2, 49-61
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Young Children of Parents
with Substance Use Disorders (SUD):
A Review of the Literature and Implications
for Social Work Practice
Neta Peleg-Oren
Meir Teichman
SUMMARY. This article reviews the scientific literature that focuses
on school-age children of parents with substance use disorder (SUD).
The review examined the subjects, instruments, and results of 10
scientific studies published from 1985 to the present (2005). Gener-
ally, school-age children of parents with SUD demonstrated a variety
of emotional, cognitive, behavioral, and social problems. Specifically,
(a) children of drug users (CODs) were at higher risk than children of
alcoholics (COAs) for psychopathology and functional impairments,
and (b) Children of parents diagnosed as having SUDs (particularly al-
cohol), along with anti-social personality disorder (ASPD) showed
more negative psychosocial outcomes than children whose parents did
Neta Peleg-Oren, PhD, is Research Associate, Community-Based Intervention Re
-
search Group (CBIR-G), Florida International University, 11200 South West 8th Street,
MARC 310, Miami, FL 33199.
Meir Teichman, PhD, is Professor, Bob Shapell School of Social Work, Tel-Aviv
University, Tel-Aviv 69978, Israel (E-mail: teichma@post.tau.acc.il).
[Haworth co-indexing entry note]: “Young Children of Parents with Substance Use Disorders (SUD): A Review
of the Literature and Implications for Social Work Practice.” Peleg-Oren, Neta, and Meir Teichman. Co-published si
-
multaneously in Journal of Social Work Practice in the Addictions (The Haworth Press, Inc.) Vol. 6, No. 1/2, 2006,
pp. 49-61; and: Impact of Substance Abuse on Children and Families: Research and Practice Implications (ed:
Shulamith Lala Ashenberg Straussner, and Christine Huff Fewell) The Haworth Press, Inc., 2006, pp. 49-61. Single
or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-
HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: docdelivery@haworthpress.com].
Available online at http://www.haworthpress.com/web/JSWPA
© 2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J160v06n01_03 49
Downloaded by [Tel Aviv University] at 09:54 30 April 2013
not have ASPD. Recommendations for future research and implica
-
tions for social work practice are discussed.
[Article copies available for a
fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad
-
dress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.
com> © 2006 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Children of alcoholics, children of drug users, school-age
children
INTRODUCTION
Growing with parents with SUD (Substance Use Disorders) has a con
-
siderable impact on the development of young children. During the last
decade, the potentially negative impact of parental substance use has in-
creasingly become of great concern to social policy decision-makers and
practitioners alike (Barnard & McKeganey, 2004; Chassin, Carle, Nissim-
Sabat, & Kumpfer, 2004; Jones, 2004; Teichman, 2001).
The present review examined relevant findings from scientific stud-
ies that focused on school-age children whose parents use alcohol and
other illicit drugs. These studies were scientifically designed with ap-
propriate control groups, and used reliable and valid instruments. The
studies’ focal points were the children’s mental health, risks and/or pro-
tective factors, and psychosocial outcomes and consequences.
Developmental psychology literature indicates that early stages of life
are fundamental to normal formation of personality, “ego identity,” and
secure attachment style. During this period of life children acquire their
necessary social, and coping skills (Miller, 1993). These emotional,
cognitive, social, and behavioral developmental processes take place in
school, among peers, as well as in the family. Successful experiences pro
-
vide the child with feelings of competence and mastery, whereas failure
brings a sense of inadequacy and inferiority, low self esteem, and, in
some cases, intergenerational transmission of substance abuse and other
psychopathology (King & Chassin, 2004; Menuchin, 1987; Rodney &
Mupier, 1999; Rydelius, 1997). Thus, for normal development, the child
needs a safe and stable environment; a warm family that provides accep
-
tance, trust, sense of autonomy, and security (Straussner, Weinstein, &
Hernandez, 1979; Teichman & Kefir, 2000; Teichman & Teichman,
1990). A family, as we view it, is not just a sum of its individual members
(mother, father, children, etc.), characteristics, and patterns of behavior,
50 IMPACT OF SUBSTANCE ABUSE ON CHILDREN AND FAMILIES
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but a system that in which all members interact and affect each other (e.g.,
von Bertalanffy, 1968). Consequently, a dysfunctional parent may dis
-
rupt the ability of the family, as a whole, to provide the child, who is the
most vulnerable member of the family, with the necessary resources to
meet his or her needs (Teichman, Glaubman, & Garner, 1993). Further
-
more, having a substance-abusing parent often results in the development
of certain defense mechanisms and symptoms by children and adoles
-
cents (King & Chassin, 2004; Straussner et al., 1979). Despite the
long-acknowledged importance of childhood developmental period in
understanding the effects of parental substance use, only during the last
decade has it been a focus of substantial systematic study. Prior to recent
years, much of the work in this area stemmed from clinical observations
and retrospective studies of adult children-of-parents with alcohol or drug
abuse (ACOA/Ds). Moreover, due to nature of the subject-matter, few of
the field studies were based on comparisons with a proper control group.
Sher (1991) and other reviewers have noted a need for increased attention
to lifespan developmental factors in considering the effects of parental
substance use. Since an outcome at any particular time of assessment may
differ depending on the current developmental level of the child, as well
on many other factors (Seilhamer & Jacob, 1990; Sher, 1991; Windle &
Searles, 1990), research on the psychosocial adjustment of children and
adolescents in substance-abusing families cannot be automatically gener-
alized (Harter, 2000).
The aim of this paper is to review scientifically sound published stud-
ies on children of parents with alcohol or illicit drug abuse (COA/Ds) that
focus on the developmental period of childhood. We selected only studies
in which the researchers investigated the psychosocial outcomes as mea
-
sured by self-reports of the children. We assume that it is the child’s own
perception of her or his family at a given moment in life, rather than retro
-
spective recollections of childhood experiences, that presents the most re
-
liable picture of the impact of parental substance abuse on the child’s
development. Relying on memories and early recollections could raise
doubts that parental substance use constitutes the dominant factor in the
children’s distress.
METHOD
This review is based on published studies abstracted in the following
databases: PsychLit, Social Work Abstracts, Eric, and Medline. These
four major databases were used in order to obtain the maximum number
Neta Peleg-Oren and Meir Teichman 51
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of referred publications in the field. In the present review, COA/Ds are
defined as children (boys and girls) who have one or both parents that
are addicted to alcohol or drugs and diagnosed as having SUD accord
-
ing to DSM-III or DSM-IV or any other reliable screening tests like:
DIS (Diagnostic Interview Schedule), ICD-10, or MAST (Michigan Al
-
coholism Screening Test). “Childhood” in this review refers to elemen
-
tary school-age children. We did not include adolescence period because
even though adolescents are still living with their families, the physical
and psychological changes that they are facing sometimes may influ
-
ence their lives more than being children of parents with SUD. The re
-
view examines the target subjects, the instruments, and the results in
each study.
RESULTS AND DISCUSSION
After using combinations of the terms “offspring/children of alcohol-
ics,” “offspring/children of drug abuse/use,” “COAs, CODs, COA/Ds,”
“parental alcohol/drug abuse,” “childhood,” “school-age,” we found
only ten (10) papers published from 1985 up to the present (2005). As
shown in Table 1, most of the studies investigated children of alcoholics
(COAs). Children of parents with drug use disorders (CODs) were in-
vestigated only in comparison to COAs. Only two of the studies were
longitudinal.
Results of the studies published since 1985 are consistent with the
conclusions of previous reviews that found that school-age children of
parents with SUD are at increased risk for negative outcomes in a num
-
ber of dimensions: emotional, cognitive, behavioral, and social prob
-
lems. Stress in families with substance use places the children at an
increased risk for problems in their emotional development, including a
relatively high level of depressive symptoms and anxiety, low self-es
-
teem, guilt feelings, and loneliness (Reich, Earls, Frankel, & Shayka,
1993). Other studies suggested problems in cognitive development. Ac
-
cording to Puttler et al. (1998), COAs had lower levels of intellectual
functioning than non-COAs. Serious behavioral problems were found
by Reich, Earls, Frankel, and Shayka (1993) and Kuperman, Schlosser,
Lidral, and Reich (1999). Presumably, in such families, there are neither
clear standards of behavior, nor limits or clear expectations. Parenting
style is inconsistent: the same behavior of the child may be rewarded in
one situation and be disciplined on another occasion. This may explain
the findings of several studies that children of parents with SUD mani
-
52 IMPACT OF SUBSTANCE ABUSE ON CHILDREN AND FAMILIES
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TABLE 1. Summary of Published Studies on COAD
Researchers Subjects Instruments Results
Christozov &
Toteva, 1989
(Longitudinal study)
220 COA
110 non-COA
Aged 4-14
Developed questionnaires: 1. evaluated the
child’s mental status, attitudes towards the
alcoholic father and the family, 2. evaluation
of the alcoholic father
1. COA exhibited psychological problems
such as fear, anxiety, low self-esteem,
emotional deprivation, and aggressiveness
compared to non-COA;
2. At follow-up COA demonstrated anti-social
behavior.
Rubio-Stipec, Bird,
Canino, Bravo, &
Algria, 1991
Second stage–386
children of alcoholic
parents and control
group)
Aged 4-16
DIS for the adult, CBCL, Clinical evaluation
of the child, Scale adapted from the
Coddington Life-Event Scale, Family
APGAR Questionnaire, Developed question-
naire for marital harmony, a measure of the
physical status of the child, DISC, C-GAS.
1. Parental alcoholism in addition to creating
an adverse family environment had an
effect on the relative risk for maladjustment
in the offspring;
2. The effects of parental alcoholism in children
may not be different from the consequences
of parental mental health.
Reich, Earls,
Frankel, & Shayka,
1993
125 COA
158 control group
Aged 6-18
For parents: HELPER, DICA-P, HEIC-P,
CBCL. For Children: DICA, HEIC, PPVT,
WRAT, CSEI. Also CBCL for teachers
COA exhibit high rate of psychopathology and
may be at risk especially for oppositional and
conduct disorder (CD) but not for depression.
Puttler, Zucker,
Fitzgerald, &
Bingham, 1998
44 children of
antisocial alcoholic
families, 94 children
of non-antisocial
alcoholic families, 74
childrenincontrol
group
Aged 3-8
For parents: family demographic
questionnaire, SMAST, DIS, DDHQ, ASB,
LAPS, CBCL. For children: WISC-R,
Stanford-Binet, WRAT-R
1. COA had poorer functioning than control
group;
2. Children from antisocial alcoholic families
had greater problems than children from
non-anitsocial alcoholic families;
3. Boys had higher behavioral problems than
girls in behavioral problems;
4. COA had lower levels of intellectual
functioning than non-COA
53
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TABLE 1 (continued)
Researchers Subjects Instruments Results
Kuperman, Schlosser,
Lidral, & Reich, 1999
266 COA
79 COA and anti-
social behavior,
118 non-COA
Average age 12
C-SSAGA 1. Parental alcoholism was associated with
increased risks for ADHD, CD, and
overanxious disorders;
2. Parental alcoholism plus ASPD was
associated with increased risk for
oppositional defiant disorder.
Moss, Baron, Hardie, &
Vanyukov, 2001
70 COAD and Anti-
Social Personality
Disorder (ASPD)
268 COAD without
ASPD
301 non-COAD/ASPD
SCID; K-SADS (Schizophrenia); SCID-II COAD+ASPD showed more major
depression, conduct disorder, ADHD,
oppositional defiant disorder, separation
anxiety disorder, and higher internalizing
and externalizing behavior problems
compared to other groups
Peleg-Oren, 2001 72 COAD
76 non-COAD
Aged 8-11
For parent: family socio-demographic
questionnaire, ASFS.
For children: CRPBI, FACESIII (only
cohesion), ASCQ, EDS
1. No significant differences were found
between the two groups in family
cohesion, parenting styles, and
psychosocial adjustment;
2. Insecure-avoidant attachment style was
more prevalent among COAD than
among non-COAD.
Wilens, Biederman,
Bredin, Hahesy, Abrantes
et al., 2002
22 COA
22 COD (opiod
dependence)
139 control group
Aged 6-18
SCID; KSADS-E (epidemic version–
childhood disorders); Wide Range
Achievement Test–WRAT; WISC-R;
Social Adjustment Inventory–SAICA;
Moos FES.
1. The COD (opioid dependence) had more
psychopathology and functional
impairment that the COA;
2. COAD were of lower SES, had
significantly more difficulties in
academic, social, and family functioning,
and higher rates of psychopathology
than non-COAD.
54
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Kelley & Fals-Stewart,
2004
COD
COA or non-SA
fathers
Aged 8-12
For children: K-SADS-PL.
For parents: SCID, TLFB, PSC.
COD were more likely to have a lifetime
psychiatric diagnosis;
COD were more than twice as likely to
exhibit clinical levels of behavioral
symptoms.
Werner & Johnson, 2004
(Longitudinal study)
65 COA–aged 2 at
beginning phase over
30 years
Aged 1,2,10–Observation by social workers
and nurses;
Grade 4-5–Behavior evaluation by
teachers.
Grade 8,10,12–Scholastic Aptitude &
Achievement tests.
Age 10–Parents’ interview
Aged 18–Child’s interview
Age 18,31,31–Rotter LCS, perceived
stress and support questionnaires
Age 31, 32–EAS
Score on California Psychological
Inventory & Nowicki.
Information from Court and Dept. of Mental
Health
COA who became competent adults relied
on significantly larger numbers of sources of
support in their childhood.
55
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fested problem behaviors as early as pre-school age (Kuperman et al.,
1999; Puttler, Zucker, Fitzgerald, & Bingham, 1998). Furthermore, par
-
ents who had anti-social or conduct disorder diagnosis in addition to
SUD further affected their children. Indeed, children of parents with
SUD and anti-social personality disorder (ASPD) had even greater
problems than offspring of non-ASPD alcoholic families (Moss, Baron,
Hardie, & Vanyukov, 2001; Puttler et al., 1998). Two studies that
compared the psychopathology of COAs to CODs indicate that CODs
exhibited more psychological problems such as fear, anxiety, low self-
esteem, emotional deprivation, and aggressiveness than COAs or
non-COAs (Kelley & Fals-Stewart, 2004; Wilens, Biederman, Bredin,
Hahesy, Abrantes et al., 2002).
Either as a result of these problems, or as an independent issue, sev
-
eral studies pointed out setbacks in the COAs’ social development:
These children were frequently described as reticent and reserved and
their social life limited (Christov & Toteva, 1989; Rubio-Stipec, Bird,
Canino, Bravo, & Algria, 1991). According to these studies, shame and
secrecy were the main reasons for the social isolation.
However, contrary to these findings, Peleg-Oren (2001) did not find
differences between children of addicted fathers and their matched con-
trols. Peleg-Oren investigated children, 8 to 11 years old, whose fathers
were diagnosed as having SUD. They were matched with same gen-
der/age children attending the same school and residing in the same
neighborhood. Their self reports of their parents’ parenting styles and
family cohesion were compared as well as their psychosocial adjust-
ment. Contrary to previously reviewed studies, no significant differ-
ences were found between the COA/Ds and non-COA/Ds in family
cohesion, parenting styles, psychosocial adjustment, and emotional dis
-
tress.
Finally, longitudinal studies provide us with knowledge about the
long-term effects of growing up with parents with SUD; to what extent
such an experience is perceived as a traumatic one, and how such expe
-
riences affect the course of development from childhood to adoles
-
cence, and, thereafter, to adulthood. Only two longitudinal studies are
reported. These studies provided support to the commonly accepted as
-
sumption that parental SUD entails life-long developmental negative
repercussions for those children. Children of COA/Ds experienced so
-
cial-emotional difficulties and problems as early as infancy due to dys
-
functional life experiences with parents with SUD. However, Werner
and Johnson (2004), whose longitudinal study followed children of al
-
coholics from the age of 2 years for over a 30-year period, challenged
56 IMPACT OF SUBSTANCE ABUSE ON CHILDREN AND FAMILIES
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these sweeping conclusions. They reported that the availability of sup
-
port systems significantly affected the development of the children into
adulthood. Availability of support systems within the extended family
or in the community may have a positive influence on the child’s ability
to cope effectively with the trauma of growing up in such families. Fac
-
tors such as strong extended family support and the maintenance of
family routines were important mediating factors on the potential for
positive outcomes for the child (Barnard, 2003; Barnard & McKeganey,
2004).
This brief view of the literature highlights the importance of studying
risk and protective factors in the life of a child growing with parents
with SUD. Garbarino (1999) defined resilience as the ability to bounce
back from crisis and overcome stress and injury, and as a mean of devel
-
oping a positive sense of self. Dawe, Harnett, Staiger, and Dadds (2000)
pointed out that the likelihood of developing psychosocial problems is
not determined by one single risk factor (like parental SUD), but by in-
teractions among risk and protective factors over time. Protective fac-
tors enable the child’s healthy growth and development. Teit and
Huizinga (2002) summarized this in stating that: “Many studies have
found that numerous high-risk individuals defy unfavorable outcomes.”
LIMITATIONS OF THE STUDY
The limitations of this review must be considered. Even though the
studies used reliable instruments, it was very hard to directly compare
the studies due to the incompatibility of the instruments. In addition,
this review included only English and Hebrew language studies pub
-
lished over two decades, and included only papers in journals abstracted
in the previously discussed databases. Scientific studies published in
other languages and/or not abstracted in those databases might be of
great importance in terms of culture diversity.
IMPLICATIONS FOR SOCIAL WORK PRACTICE
Findings from the present review can be used to improve decision
making about intervention. First, although COA/Ds are at high-risk for
negative psychosocial consequence, it is a heterogeneous population with
diverse developmental needs. Evaluation of the needs and resources of
the family and the children is vital in order to plan and implement effec
-
Neta Peleg-Oren and Meir Teichman 57
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tive and appropriate interventions for the children and for the family. Sec
-
ondly, due to the obstacles to effectively implementing interventions in
real-world social work practice settings with potentially limited resources,
social workers must take into consideration two significant issues: (a) In
most cases, CODs (opioid) are at higher risk than COAs (alcohol) for
psychopathology and functional impairments; (b) Parental SUD (particu
-
larly alcohol) in addition to anti-social personality disorder is associated
with more negative psychosocial outcomes to the child than parental sub
-
stance use without ASPD. Hence, we recommend that:
•
High-risk CODs should have priority in assessment and interven
-
tionthanCOAs;
•
There is an urgent need to identify COAs from families where anti
-
social behavior is evident due to the intergenerational transmission
of the disorder, and to develop early intervention programs that ad-
dress their needs;
• Comprehensive intervention programs should consider both the
family and the children, as well as members of the extended family,
who may provide support for the child and for the non-addicted
spouse (e.g., Aviram & Spitz, 2003; Barnard & McKeganey, 2004;
Csiernik, 2002).
School-age children of parents with SUD are rarely the direct focus
of intervention. This stems from the assumption that children will indi-
rectly benefit from the assistance offered to their parents (Miller, 2003).
Nevertheless, during the last decade several experimental interventions
with children of parents with SUD have been designed and imple-
mented (i.e., Peleg-Oren, 2002a). Group intervention is one of the
remedial tools that are appropriate to the developmental stage of ele
-
mentary school-age children. At this stage peer-group becomes impor
-
tant to them. The group can provide a support and an arena where social
skills are developed; the group offers the child the possibility of belong
-
ing and of sharing their burden with other children suffering from simi
-
lar dysfunctional family situations (Peleg-Oren, 2002b).
CONCLUSION
More research is needed to examine the risk and protective factors as
-
sociated with the intergenerational transmission of substance use. In
particular, future research should look closely at critical points in time
58 IMPACT OF SUBSTANCE ABUSE ON CHILDREN AND FAMILIES
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in the developmental process identifying the trajectory of functional im
-
pairments and substance use among children of parents with SUD.
Given that these children are at high risk to develop SUD and other
mental health problems as adolescents and adults, the development of
innovative intervention programs for the children should be the main
concern.
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