Behavioral and Emotional Problems Among Children of Drug Abusers
Approximately 20% of adults in treatment for drug dependence live with and parent children ages 2 to 18 (Stanger et al., 1999). Several studies have shown that children living with parents in treatment for drug dependence have higher rates of internalizing and externalizing problems than do demographically matched children in the general population (Nunes et al., 1998b; Stanger et al., 1999; Wilens et al., 1995). In addition, children living with drug-dependent parents are more likely to experience socioeconomic disadvantages and report higher stress levels and more social isolation than comparison groups of children of nonabusing parents(Kumpfer and DeMarsh, 1986).
To determine whether children of drug abusers had higher rates of problems than comparison groups did, our initial study compared children of drug abusers with children referred for mental health services and children not referred for mental health services in the past 12 months (Stanger et al., 1999). Children living with parents who were receiving treatment for cocaine or opiate dependence showed more problems than children of similar age, gender, ethnicity and social class in the general population. The problems included internalizing, externalizing, and school and social problems. The children of drug abusers were at higher risk for these problems relative to nonreferred children, but showed significantly fewer problems than children who were referred for mental health services.
A significant percentage of children of drug abusers also showed clinical deviance, with a similar pattern of group differences for males and females from ages 2 through 18. For example, a total of 42% of children of drug abusers, compared to 27% of nonreferred children and 80% of referred children, scored in the clinical range on 1 syndrome or scale on the Child Behavior Checklist (CBCL) (Achenbach and Rescorla, 2001; Stanger et al., 1999). Of the eight syndromes scored for the CBCL, children of drug abusers showed the highest rate of deviance (18.6%) on the syndrome assessing rule-breaking behavior, compared to 6% of nonreferred youth (Stanger et al., 1999). Our results were highly similar to those of several other investigators (Moss et al., 1994; Nunes et al., 1998b; Wilens et al., 1995)
How Does Parental Substance Use Increase Risk to Children?
Although not all children living with drug-dependent parents experience behavioral/emotional problems, it is important to understand factors within families with a drug-dependent parent that increase or decrease the risk to children. Research on families with a substance-abusing parent has shown that psychopathology among the parents is an important risk factor for children's problems (Dierker et al., 1999; Luthar et al., 1998). We hypothesize that parental substance abuse and psychopathology exert much of their influence on children's behavior by disrupting parenting. This hypothesis is consistent with the stage model of the development of antisocial behavior articulated by Patterson and colleagues (1992). This model suggested that problems such as parental substance use, psychopathology and social disadvantage lead to early parent-child interaction problems, especially the use of ineffective discipline. These parenting problems lead directly to externalizing problems in early childhood. At later ages, children's externalizing problems predict other poor outcomes such as academic problems, rejection by nondeviant peers, association with deviant peers, low self-esteem, depressed mood, antisocial attitudes, delinquency and substance use.
Prior research has also shown that substance-dependent parents are at risk for parenting problems. For example, heroin-dependent mothers express more doubts about their parenting adequacy and their ability to control their children than do matched control mothers (Colten, 1982). Similarly, drug-abusing families reported having poorer family management techniques than control families did (Kumpfer and DeMarsh, 1986). In addition, parenting problems are important predictors of outcomes for children in substance-dependent families (Dobkin et al., 1997; Tarter et al., 1993).
Our research with drug-abusing families tests the hypothesis that parental substance use and psychopathology lead to problems among children living in the home by raising the risk for parenting problems. To test this hypothesis, we asked parents receiving treatment for cocaine-, opiate-, alcohol- or marijuana-dependence to participate in an assessment study. From November 1992 through January 2002, 271 patients receiving substance-abuse treatment entered the study. The parent participants were 60% female and 39% male.
In our earlier research on predictors of outcomes among children of substance abusers, we found that family conflict and parental psychopathology are important predictors for children of substance-dependent parents (Stanger et al., 2002). Our most recent analyses have tested whether parent and family problems among drug-dependent parents raise the risk to children by disrupting parenting (Kamon, 2003). These results help to explain how parental substance abuse leads to children's externalizing problems. We found that substance-abusing parents with more severe substance abuse and psychopathology tend to have more family problems. Parent and family problems are likely to co-occur, but either one alone can lead to disruptions in parenting. When parenting problems are present, children are highly likely to show conduct problems. In our study, parenting problems accounted for 49% of the variance in children's conduct problems among substance-abusing families. Other studies with general population samples have also shown that parenting problems mediate relations between parental substance-use and children's problems (Blackson et al., 1996; El-Sheikh and Flanagan, 2001).
Parenting Interventions for Substance-Abusing Parents
In screening families for inclusion in this study, we found that a minority (20% to 25%) of adults in substance-abuse treatment lived with and parented children (Stanger et al., 1999). Most parents were willing to complete a standardized rating form about their children, and 40% reported significant problems in their children. Clinicians who treat parenting drug abusers should assume that a significant percentage of their clients' children have behavioral and/or emotional problems and that parents are willing to report those problems on standardized instruments.
Parenting disruptions appear to be common among substance-abusing parents, and because they are highly predictive of children's problems, our current research focus is on parenting interventions for substance-abusing parents. Parent management training is the most effective approach to the treatment of childhood conduct problems (Conduct Problems Prevention Research Group, 1999; Irvine et al., 1999; Jouriles et al., 2001; Martinez and Forgatch, 2001).
In our work with substance-abusing parents, we selected the Incredible Years parenting curriculum (Webster-Stratton, 1998, 1990). This social-learning-based curriculum focuses on teaching parenting skills to promote positive child behaviors and to reduce inappropriate child behaviors among children ages 3 to 10 years old. Topics are presented using videotape examples reviewed in two-hour group sessions. Videotape vignettes for each topic are shown each week, with the tape stopped for discussion after each vignette. Parents role-play skills in the group, taking turns portraying children and parents. We have also used other parent-training programs that have empirical support when working with individual families or families with older children (Dishion and Andrews, 1995; Forehand and Long, 1996; Patterson and Forgatch, 1987).
Our Incredible Years group participants have included opiate-, cocaine-, marijuana- and/or alcohol-dependent women and their male partners, most of whom were also substance-dependent. Many participants had received substance abuse treatment in the past or were in concurrent substance abuse or mental health treatment. Most mothers and approximately half the fathers scored in the clinical range on a standardized measure of symptoms of depression, and most children met DSM criteria for one or more disorders.
We do not exclude active substance users from the group. We feel that parents who are actively using might benefit from the parenting intervention, just as active substance abusers who are depressed can benefit from treatment for depression, even if they are not abstinent (Nunes et al., 1998a). We provide substance-abuse treatment referrals to parents who are actively using drugs or alcohol and who are not engaged in treatment elsewhere. We follow up regularly with parents to assist them in setting up and keeping appointments. We feel this practice most closely reflects community practices, in that parents requesting help with their children generally are not screened for substance use and are not denied such services if they have personal problems such as psychopathology. In order to reach the most children at risk, we offer all interested parents help with parenting.
During the first group meeting, we establish ground rules, and parents have included the rule that attending group under the influence of drugs or alcohol is not acceptable. To the best of our knowledge, all parents have followed that rule. However, we suspect that failure to attend group meetings has, at times, been related to substance use. When parents miss a group meeting for any reason, we call them that evening to schedule a make-up session. We discuss the reason for missing group and make referrals or request permission to contact their current treatment provider if we are concerned that they are using drugs or alcohol or having other problems (e.g., depression).
In our pilot work using the Incredible Years curriculum, we provide parents with incentives for attending sessions, completing their assignments to practice skills at home, and monitoring of their children's behavior and their parenting daily. The incentives are vouchers, which can be traded in for goods and services purchased by research staff. For example, parents have used purchased gift certificates for local recreational activities and small toys to be used as rewards for the children in their home behavioral chart program.
Many other researchers have supplemented behavioral treatment programs with similar voucher programs (Bickel et al., 1997; Budney et al., 2000; Higgins et al., 2000). In addition to directly targeting drug abstinence, contingency management procedures have been used to increase participation in assigned, pro-social, non-drug-related activities outside of therapy sessions (Petry and Martin, 2002; Petry et al., 2000). Participation in these activities was, in turn, highly correlated with drug abstinence, suggesting that improving compliance with treatment can improve outcomes. For this reason, we are using an incentive system to target attendance and compliance with parent training. We hypothesize that incentives will improve outcomes for this challenging population.
Dr. Stanger's research on children of substance abusers and parent-training interventions is funded by the National Institute on Drug Abuse.
Dr. Stanger is research associate professor of psychiatry and psychology at the University of Vermont.
Achenbach TM, Rescorla LA (2001), Manual for ASEBA School-Age Forms and Profiles. Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families.
Bickel WK, Amass L, Higgins ST et al. (1997), Effects of adding a behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 65(5):803-810.
Blackson TC, Tarter RE, Mezzich AC (1996), Interaction between childhood temperament and parental discipline practices on behavioral adjustment in preadolescent sons of substance abuse and normal fathers. Am J Drug Alcohol Abuse 22(3):335-348.
Budney AJ, Higgins ST, Radonovich KJ et al. (2000), Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol 68(6):1051-1061.
Colten ME (1982), Attitudes, experiences, and self-perceptions of heroin addicted mothers. Journal of Social Issues 38(2):77-92.
Conduct Problems Prevention Research Group (1999), Initial impact of the Fast Track Prevention trial for conduct problems: I. The high-risk sample. J Consult Clin Psychol 67(5):631-647.
Dierker LC, Merikangas KR, Szatmari P (1999), Influence of parental concordance for psychiatric disorders on psychopathology in offspring. J Am Acad Child Adolesc Psychiatry 38(3):280-288.
Dishion TJ, Andrews DW (1995), Preventing escalation in problem behaviors with high-risk young adolescents: Immediate and 1-year outcomes. J Consult Clin Psychol 63(4):538-548.
Dobkin PL, Tremblay RE, Sacchitelle C (1997), Predicting boys' early-onset substance abuse from father's alcoholism, son's disruptiveness, and mother's parenting behavior. J Consult Clin Psychol 65(1):86-92.
El-Sheikh, M, Flanagan E (2001), Parental problem drinking and children's adjustment: Family conflict and parental depression as mediators and moderators of risk. J Abnorm Child Psychol 29(5):417-432.
Forehand R, Long N (1996), Parenting the Strong-Willed Child. Chicago: Contemporary Books.
Higgins ST, Wong CJ, Badger GJ et al. (2000), Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol 68(1):64-72.
Irvine AB, Biglan A, Smolkowski K et al. (1999), The effectiveness of a parenting skills program for parents of middle school students in small communities. J Consult Clin Psychol 67(6):811-825.
Jouriles EN, McDonald R, Spiller LNWD et al. (2001), Reducing conduct problems among children of battered women. J Consult Clin Psychol 69(5):774-785.
Kamon J (2003), Predictors of overt and covert externalizing behaviors among children of drug dependent parents. Unpublished doctoral dissertation. Vt.: University of Vermont.
Kumpfer KL, DeMarsh J (1986), Family environmental and genetic influences on children's future chemical dependency. Journal of Children in a Contemporary Society 49-91.
Luthar SS, Cushing G, Merikangas KR, Rounsaville BJ (1998), Multiple jeopardy: risk and protective factors among addicted mothers' offspring. Dev Psychopathol 10(1):117-136.
Martinez CR, Forgatch MS (2001), Preventing problems with boys' noncompliance: effects of a parent training intervention for divorcing mothers. J Consult Clin Psychol 69(3):416-428.
Moss HB, Majurnder PP, Vanyukov MM (1994), Familial resemblance or psychoactive substance use disorders: behavioral profile of high risk boys. Addict Behav 19(2):199-208.
Nunes EV, Quitkin FM, Donovan SJ et al. (1998a), Imipramine treatment of opiate-dependent patients with depressive disorders: A placebo-controlled trial. Arch Gen Psychiatry 55(2):153-160.
Nunes EV, Weissman MM, Goldstein RB et al. (1998b), Psychopathology in children of parents with opiate dependence and/or major depression. J Am Acad Child Adolesc Psychiatry 37(11):1142-1151.
Patterson GR, Forgatch MS (1987), Parents and Adolescents Living Together, Part 1: The Basics. Eugene, Ore.: Castalia.
Patterson GR, Reid JB, Dishion TJ (1992), Antisocial Boys. Vol. 4. Eugene, Ore.: Castalia.
Petry NM, Martin, B (2002), Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. J Consult Clin Psychol 70(2):398-405.
Petry NM, Martin B, Cooney JL, Kranzler HR (2000), Give them prizes, and they will come: Contingency management for treatment of alcohol dependence. J Consult Clin Psychol 68(2):250-257.
Stanger C, Higgins ST, Bickel WK et al. (1999), Behavioral and emotional problems among children of cocaine- and opiate-dependent parents. J Am Acad Child Adolesc Psychiatry 38(4):421-428.
Stanger C, Kamon J, Dumenci LHS et al. (2002), Predictors of internalizing and externalizing problems among children of cocaine and opiate dependent parents. Drug Alcohol Depend 66(2):199-212.
Tarter RE, Blackson TC, Martin C et al. (1993), Characteristics and correlates of child discipline practices in substance abuse and normal families. American Journal on Addictions 2(1):18-25.
Webster-Stratton C (1998), Preventing conduct problems in Head Start children: strengthening parenting competencies. J Counsult Clin Psychol 66(5):715-730.
Webster-Stratton C (1990), Enhancing the effectiveness of self-administered videotape parent training for families with conduct-problem children. J Abnorm Child Psychol 18(5):479-492.
Wilens TE, Biederman J, Kiely K et al. (1995), Pilot study of behavioral and emotional disturbances in the high-risk children of parents with opioid dependence. J Am Acad Child Adolesc Psychiatry 34(6):779-785.