Psychosocial Correlates in Adolescent Children
 of Alcoholics-Implications for Intervention
(A Study From India)


Selwyn Stanley, M.A (SW); Ph.D.
Lecturer, Faculty of Health & Social Work
 School of Psychosocial Studies, University of Plymouth; UK.
e-mail: selwyn.stanley@plymouth.ac.uk

C. Vanitha,  MSW
Psychiatric Social Worker
 National Institute of Mental Health and Neuro Sciences
Bangalore, INDIA.

Abstract
Introduction: There has been an increasing focus on children of alcoholics particularly in the West seeking to understand the impact of parental alcoholism on their psychosocial functioning. Indian literature from this perspective is scanty and there is a need for more comprehensive investigation particularly with adolescent children of alcoholics (COAs).  
Objectives: This comparative study investigated the manifestation of self-esteem and adjustment in a group of fifty adolescent children of alcoholics (COAs) and a matched reference group of adolescent children of non-alcoholics (nCOAs). MATERIAL & METHOD: The Self esteem Index (Mac Kinnon, 1981) and Adjustment Inventory (Srivatsa and Tiwari, 1972) were the instruments administered. An ex-post facto research design was used. Chi square, t-tests and Karl Pearson’s correlation coefficients were computed using SPSS for analysis.
Findings: The data revealed lower self-esteem and poor adjustment in all domains studied, in the adolescent COAs than the controls. These deficits can be attributed to the increased stress and vitiated alcohol complicated domestic environment of the COAs.  
Clinical Implications: This study makes a strong case for psychosocial intervention with COAs who are otherwise neglected in conventional de-addiction programmes in India.
Key Words: Adolescent Children of Alcoholics, Self-esteem, Adjustment.

Introduction
There is a vast body of literature both in India and the West devoted to understanding the marital dynamics involved in alcoholism and ascertaining the deleterious impact that alcoholism could have on the personality and functioning of the spouse. Traits such as neuroticism, higher anxiety levels, depression, low self-esteem and communication apprehension have been reported in wives of alcoholics and attributed to the intense stress and trauma experienced by her in the vitiated domestic environment that she lives in (e.g. Stanley, 2001; Kutty and Sharma, 1988; Rao and Kuruvilla, 1991). Higher levels of marital conflict and aggression have been also documented in couples with an alcoholic spouse when compared to marital relationships which were not complicated by alcohol (Stanley, 2006; Stanley & Anitha, 2007). Of late there has been an increasing focus on children of alcoholics seeking to understand the adverse impact of parental alcoholism on their growth and psychosocial functioning. Indian literature from this perspective is scanty and there is a need for more comprehensive investigation to explore the consequences of parental alcoholism particularly on adolescent children.

Adolescence has been globally accepted to be a period of turbulence and a significant developmental milestone. Parental alcoholism could further compound and create a not so conducive domestic environment significantly impacting the adjustment and personality of the adolescent as he tries to come to grips with this tumultuous phase in his developmental career.

There is strong evidence to suggest that family dysfunction during childhood can negatively influence later life experiences and adjustment (Werner and Broida, 1991). Drinking behavior may interrupt normal family tasks, cause conflict and demand adjustive and adaptive responses from family members who do not know how to appropriately respond. In brief, alcoholism creates a series of escalating crises in family structure and function, which may bring the family to a system crisis. As a result, the members may develop dysfunctional coping behaviors observes Ranganathan (2004). Marital conflict and a lack of coping mechanisms were more frequent in these families and children of alcoholic (COAs) fathers represent a group at risk for the early onset of psychiatric problems observe Furtado et al. (2002).

Roosa et al. (1990), report that COA status was related to higher levels of negative and lower levels of positive events. Hall and Webster (2002) found that adult COAs had more self-reported stress and more difficulty initiating the use of mediating factors in response to life events. More COAs than comparison offspring were experiencing serious problems in the areas of drinking, personality and psychopathology (Casas-Gil and Navarro-Guzman, 2002) and Harter (2000), notes that adult COAs appear at increased risk for a variety of negative outcomes, including substance abuse, antisocial or under-controlled behaviors, depressive symptoms and anxiety disorders.

Sher et al. (1991), found that COAs reported more alcohol and drug problems, had stronger alcohol expectancies, higher levels of behavioural under-control and neuroticism, and more psychiatric distress in relation to nCOAs. Bird and Canino (1991), also found that children of alcoholics when compared to those of non-alcoholics manifested higher levels of behavioural under control, more neuroticism and greater psychiatric distress. Hall et al. (1994), report that adult COAs had lower life satisfaction scores and significantly lower levels of locus of control than nCOAs. Their academic performance is relatively poor (Miller and Krop, 1985) and Casas-Gil and Navarro-Guzman (2002) have identified five variables on which performance by children of alcoholic parents was poorer: intelligence, repeating a grade, low academic performance, skipping school days, and dropping out of school.

The dysfunctional family environment created due to the presence of parental alcoholism has been the focus of several investigations. A recent study by Kelley et al. (2007), reveals that adult children of alcoholics reported more parentification, instrumental caregiving, emotional caregiving, and past unfairness in their families of origin as compared to children of alcoholics. Williams and Corrigan (1992), comment that growing up in a household with alcoholic parents is more likely to produce emotional disorders, increases the child’s risk of health problems, physical abuse and neglect. The single most potent risk factor is their parent's substance-abusing behaviour and this can place children of substance abusers at biologic, psychological, and environmental risk (Johnson and Leff, 1999). Menees and Segrin (2000) observe that COAs are characterised as an at risk population because of the dysfunctional family environment that disrupts their psychosocial development. They often lack guidance and positive role modelling and live in an atmosphere of stress and family conflict. Obot and Anthony (2004), found evidence to favour the hypothesis that adolescent children living with an alcohol dependent parent have more delinquency problems than other adolescents. Mylant et al. (2002) found that adolescent COAs scored significantly lower on all psychosocial factors of family/personal strengths and school bonding and significantly higher on all factors of at-risk temperament, feelings, thoughts, and behaviours than non-COAs and that they were at risk for depression, suicide, eating disorders, chemical dependency, and teen pregnancy.

Hart et al. (2003) interpreted their results as providing partial and preliminary support for the contention that living in an alcoholic environment during childhood and adolescence plays a role in the manifestation of serious medical problems in adulthood. Findings from a longitudinal study by Andreas & O’Farrell (2007) show that fathers’ heavy drinking patterns and children’s psychosocial problems appear to be closely related to one another over time, waxing and waning in meaningful patterns, such that children’s adjustment was improved during times of parental alleviated drinking and was worsened during times of parental exacerbated drinking. Their results thus add additional support to the hypotheses of causal linkages between problematic parental and problematic child functioning.

It is well established that children of problem drinkers have an increased risk of developing mental health problems, not only during childhood but also when they grow up into adolescents and adults observe Cuijpers et al (2006). Children of alcoholic fathers are at high risk for psychopathology and gender-related differences also seem to exist contend Furtado et al. (2006). Depression and anxiety are recurring themes in the literature on COAs (e.g. Callan and Jackson, 1986; Williams and Corrigan, 1992; Steinhausen, 1995; Kelley, 1996; Deborah,1997) However, Reich et al. (1993), report that though children of alcoholics exhibit high rates of psychopathology and may be at risk specifically for oppositional and conduct disorders, they may be not so for depression. Behavioral problems in adolescence have been shown to be associated with the presence of a positive family history of alcoholism and negative parenting practices (Barnow et al., 2004). Jacob and Windle (2000) are of the view that risks for COAs might relate specifically to parental alcoholism and its impact on offspring development and not to the combined effects of various parental psychopathologies and/or extreme forms of family instability. Exposure to marital conflict is associated with children’s adjustment problems, including internalization and externalization (Cummings et al., 2000) and the results of Keller et al. (2005) indicate that problem drinking may harm children through its association with marital and parenting difficulties.

However, there is a contention within the alcoholism literature pertaining to children of alcoholics that holds that they manifest no significant differences in terms of psychopathology or other behavioural and personality deficits when compared to children of non-alcoholics. Segrin and Menees (1996), opine that children may exhibit undisturbed psychosocial functioning despite having an alcoholic parent and found no differences between adult children of alcoholic’s   and controls. Baker and Stephenson (1995), suggest that parental alcoholism does not necessarily result in personality differences in adult children. Morey (1999), found that COAs and nCOAs demonstrate no significant differences on measures of social support and shame while Reich et al. (1993), report few differences between children of alcoholics and controls with respect to self-esteem and achievement tests. Harter (2000) observes that there is little empirical support for "adult COA syndromes" described in the clinical literature since the reported outcomes in them are neither uniformly observed nor are specific to them. He contends that co-morbid parental pathology, childhood abuse, family dysfunction, and other childhood stressors may contribute to or produce similar outcomes.

The brief review of the literature in the field reveals that while a lot of investigations have been carried out with adult children of alcoholics, those with a specific focus on adolescent children are not many. Further there is a dearth of exploration carried out on this issue in the Indian socio-cultural context. This investigation was carried out against this background primarily from the stress perspective associated with co-dependency, which hypothesizes that the heightened stress of living in an alcohol complicated family environment could have adverse consequences on the personality traits of adolescent children and manifest deficits in their psychosocial functioning.

Objectives

Material and Methodology
Sample and Selection Procedure
Study Group
The study group consisted of 50 respondents whose fathers were receiving de-addiction treatment at a private psychiatric hospital in Tiruchirappalli, India. Only adolescents between the age group of 13 and 18 years and who were residents of Tiruchirappalli were included in the sample. Their father was registered for in-patient treatment after being diagnosed by the psychiatrist according to ICD-10.

Children of relapsed or recovering alcoholics visiting the de-addiction centre for follow-up services were excluded.

Reference Group
50 nCOAs were identified from the schools of the study group respondents through their teachers. A child was included in the reference group only if the father did not have a known drinking habit and if the father scored less than seven (indicating non-alcoholic status) on the AUDIT (Alcohol Use Disorders Identification Test; Babor et al., 1983) and if the child had no known history of psychiatric illness. The two groups of respondents thus identified were comparable and matched on the following variables (Table I):

TABLE    I
AGE, BIRTH ORDER & FAMILY INCOME OF THE RESPONDENTS

     
The choice of same school respondents as the COAs also ensured a near homogenous socio-economic profile for both groups. Their socio-demographic profile is presented in Table No. II and the chi-square values indicate that the difference between the two groups is not significant and that they are also comparable on the variables tabulated.

TABLE  II
SOCIO DEMOGRAPHIC BACKGROUND OF RESPONDENTS

Figures in parantheses are percentages
*n=50, **p > 0.05


Research Design
This is a comparative study based on the presumption that the effect if any, of living with an alcoholic (study group) or non-alcoholic (reference group) father would have already manifested itself on both groups of respondents. The groups being matched on key socio-demographic variables, the study is only an attempt to determine and compare the levels of self-esteem, and adjustment manifested in these children at the point of data collection. This quasi-experimental study thus uses an ex-post facto research design.

Tools of Data Collection

1. Self Esteem Index (SEI, Mac Kinnon, 1981) assesses an individual’s perception of himself – his potential, worth and competence. It is a twenty-five item five point scale with responses ranging from “strongly agree” to “strongly disagree” and has been widely used for research in India in a variety of settings.

2. Adjustment Inventory (Srivatsa and Tiwari, 1972)
Adjustment inventory is an 80 item, two point scale with yes or no responses and measures four dimensions of adjustment namely:
Home adjustment, Educational adjustment, Emotional and Social adjustment.

3. Self Prepared Interview Schedule to elicit information pertaining to socio-demographic background and father’s drinking.

Results
Perception of Father's Drinking
Forty per cent of the COAs reported daily drinking by their father while forty two per cent said it was on alternate days, the remaining were not sure of the frequency of drinking.

Regarding the duration of drinking, forty per cent said it was up to three years with the remaining respondents mentioning that it was between three and ten years.

With regard to the behaviour of the father when intoxicated, fifty four per cent said that he became more silent than usual, twenty six per cent said that he became boisterous and shouted at others while the remaining twenty per cent expressed that he scolds and beats up the family members.              

TABLE  III
MEAN SCORE PROFILE OF RESPONDENTS ON SUBJECT DIMENSIONS
_________________________________________________________
                                                           CHILDREN OF                             STATISTICAL* *
        S.No.   DIMENSIONS          -------------------------------------  SIGNIFICANCE

                                                   Alcoholics *           Non-alcoholiCS *  

1. SELF-ESTEEM        MEAN        81.10                    97.26             t =11.41
                                 SD              6.60                    7.53              p <0.01
2.  OVERALL ADJUSTMENT
                                MEAN       119.88                   138.28            t =12.21
                                SD               8.66                      6.21            p <0.01
a.  HOME ADJUSTMENT
                                MEAN        29.36                    35.26              t = 10.29
                                SD             3.38                       2.24                p <0.01
b. EDUCATION
                                MEAN        17.36                    19.66               t =4.95
                                SD              1.66                      2.83              p <0.01
c. EMOTIONAL ADJUSTMENT
                               MEAN         32.08                     36.08               t = 7.85
                              SD               2.33                       2.74               p <0.01
d. SOCIAL ADJUSTMENT
                              MEAN          40.94                     47.38              t = 8.70

                              SD                4.07                      3.29               p <0.01

                                                                                          *n = 50;      ** df = 98



Self Esteem
Data presented in Table No. III show that the two groups of respondents manifest a high statistically significant difference on the scores of this dimension with the children of alcoholics obtaining a lower mean score indicative of poorer self esteem than children of the reference group.
 
Further it was seen in this study that the self-esteem scores did not show any significant correlations with the age of the child (r = 0.15, p > 0.05) or his birth order (r = 0.15, p > 0.05). However a negative correlation was obtained between the self-esteem scores and the number of siblings of the respondent child (r= - 0.30, p <0.01).

Adjustment Profile
The data in table III reveals that COAs have obtained lower mean scores on overall adjustment as well as all its component sub-dimensions (Home Education, Emotional and Social adjustment) than the respondents of the reference group and that the difference between them is statistically significant.

Self Esteem and Adjustment
The self-esteem scores showed a highly significant positive correlation with the overall adjustment score (r= 0.68, p<0.01) and also with all its component sub-dimensions namely, home adjustment (r= 0.65, p<0.01), education (r= 0.42, p<0.01) as well as emotional (r= 0.59, p< 0.001) and social adjustment (r= 0.52, p<0.01). It is significant to observe that all the correlations are positive in nature. Though a cause-effect relationship cannot be read into this finding, each dimension studied can be expected to directly influence the other.
 
Discussion
The low self-esteem scores obtained by the study group respondents according to Mac Kinnon (1981), indicates feelings of unhappiness with oneself and feelings of not being competent. It reflects a sense of alienation and feelings of meaninglessness and failure.

Cole et al. (1980), observe that emotional maturity manifests in high self-esteem and enhances one’s interpersonal ability. Thus the low self-esteem seen in COAs is indicative of poor emotional maturity and may diminish their interpersonal competence. This perhaps is reflected in the poor adjustment scores obtained by the COAs across several domains seen in this study.

The findings of this study do not agree with that of Churchill et al. (1990), who found no significant relationship between parental alcoholism and self-esteem of their children. In contrast, the results are congruent with that of Morey (1999), who reports that self-esteem ratings for COAs were significantly lower in comparison to ratings for nCOAs. Domenico and Windle (1993) also observe that ACOAs reported higher levels of depression and lower levels of self-esteem. In a recent study Hussong and Chassin (2004), found that children of alcoholics showed a statistically significant difference in their emotional and behavioural aspects such as shyness, insecurity and low self-esteem. Williams and Corrigan (1992), observe that growing up in a household with alcoholic parents is likely to produce low self- esteem and Harter (2000) has also reported low self esteem in ACOAs. Drucker and Greco-Vigorito  (2002) observe that five separate factors related to Negative Self-concept, Acting-out. Somatic/Disturbed Symptoms, Mood, and Hopelessness and that depressive symptoms displayed by children of substance abusers are related to self-concept and externalization.

The finding of poor adjustment across all domains studied in COAs is consistent with the literature on this issue. Harter (2000), reports that COAs faced difficulties in family relationships, and experienced generalized distress and maladjustment. Hall and Webster (2002) found that ACOA had more symptoms of personal dysfunction than the control group while Casas-Gil and Navarro-Guzman (2002) report that more COAs than comparison offspring were experiencing serious problems in the areas of educational and social functioning. Sher et al. (1991) observe that COAs also evidenced lower academic achievement and less verbal ability than nCOAs. Lower quality of life scores in children of alcoholics has been reported in another study by Oravecz (2002).

Haugland (2003), also reports that children of alcohol abusing fathers were found to have more adjustment problems compared to a general population sample. His findings further suggested that child adjustment in families with paternal alcohol abuse is the result of an accumulation of risk factors rather than the effects of the paternal alcohol abuse alone. Both general environmental risk factors (psychological problems in the fathers, family climate, family health and conflicts) and environmental factors related to the parental alcohol abuse (severity of the alcohol abuse, the child's level of exposure to the alcohol abuse, changes in routines and rituals due to drinking) were related to child adjustment. Adult children of alcoholics have reported more parentification, instrumental caregiving, emotional caregiving, and past unfairness in their families of origin as determined by Kelly et al. (2006). Thus the alcohol complicated domestic environment of the COAs could account for the deficits in self esteem and adjustment seen in them in this study and these findings are in consonance with the bulk of the western literature on these issues.

Implications for Psychosocial Intervention
The findings of this study have definite implications for intervention in de-addiction settings. It highlights the fact that any effective de-addiction programme must acknowledge the ‘need’ of adolescent children to overcome and deal with various deficits in their psychosocial functioning. The involvement of children in most de-addiction programmes in India is often peripheral if not totally non-existent. De-addiction counsellors tend to concentrate more on the alcoholic in enabling him overcome his psychological problems and in preparing him to lead a life without alcohol. While the spouse is frequently involved for marital therapy, conflict resolution and antabuse compliance, the therapeutic needs of children trapped in such families are most often ignored.                       

It is therefore important that the therapeutic needs of these children are addressed through individual psychotherapy and other supportive therapies by providing an opportunity for ventilation of feelings and integrating elements that will boost their self esteem and promote their psychosocial adjustment in deficient areas. Normal difficulties and dilemmas associated with adolescence in general could be worked through in these sessions besides focusing on issues pertaining to parental alcoholism. A study from Korea reports that stress management program helps children of alcoholics by enhancing self-esteem, providing information about alcohol, and improving emotional and problem focused coping abilities, eventually enhancing their mental health (Yang and Lee, 2005). Hence stress management techniques and relaxation modalities could be an important component of working with COAs.

There is evidence to indicate that children show a considerable improvement on various domains when their alcoholic fathers undergo treatment. Andreas et al. (2006), have found that before their fathers' treatment, COAs exhibited greater overall and clinical-level symptomatology than children from a demographically matched comparison sample, but they improved significantly following their fathers' treatment. An effective package to overcome alcoholism should go beyond routine pharmacotherapy and individual psychotherapy for patients. A wholistic intervention package must involve other therapeutic adjuncts such as family therapy, couples therapy for not only the spouse but also the COAs. O'Farrell and Fals-Stewart (2002), have advocated Behavioural Couples Therapy (BCT) since it has been found to reduce social costs and domestic violence and showed indirect benefits for the couple's children, and so BCT ought to be expanded to include family members other than spouses, particularly the COAs. O'Farrell and Feehan (1999), note that BCT with alcoholics and remission after individual alcoholism treatment have been associated with improved family functioning in a variety of domains, including reduced family stressors; improved marital adjustment; reduced domestic violence and verbal conflict; reduced risk of separation and divorce; improvement in important family processes related to cohesion, conflict and caring; and reduced emotional distress in spouses. These family factors have been linked with child mental health and psychosocial functioning in more general child developmental and psychopathology studies. Gains for COAs will hence accrue if they are involved in family therapy sessions. This will facilitate opening up of communication channels and resolution of conflicts within the family and thereby enhance the domestic and emotional adjustment of the children. Ranganathan, (2004), observes that it is imperative to involve family members in treatment and that family therapy ought to be specific, with attainable therapeutic goals.

Children of alcoholic fathers represent a group at risk and are deserving of more attention in prevention and early intervention (Furtado et al., 2002).  Erblich et al. (2001) contend that since COAs themselves are at particularly high risk for developing drinking problems, early intervention efforts among COAs need to be initiated. Some of the guidelines that they stress include emphasising the negative consequences of alcohol, developing in youth an increased sense of responsibility for their own success, helping them to identify their talents, motivating them to dedicate their lives to helping society rather than feeling their only purpose in life is to be consumers, providing realistic appraisals and feedback for youth rather than graciously building up their self-esteem, stressing multicultural competence in an ever-shrinking world, encouraging and valuing education and skills training, increasing cooperative solutions to problems rather than competitive or aggressive solutions, and increasing a sense of responsibility for others and caring for others (Kumpfer and Hopkins, 1993). An affectionate father-child bond has a protective effect observe Brook et al. (2003) and so an important focus during the course of family therapy is to strengthen the intimacy between the parent and child, particularly with the alcoholic father since it is likely that  these bonds are already exacerbated due to the so called “generation gap”.  It is also necessary to confront parents with the effects of their behaviour (intervention, therapy) to develop their possibilities to renovate their parenting functions, which is necessary for effective prevention observes Wojcieszek (2003).            

Nespor (2004) holds that prevention at the family level includes appropriate family monitoring and rules, moderate and consistent family discipline and family conflict resolution. Kumpfer et al. (2003), hold that since "substance abuse" is a "family disease" of lifestyle, effective family strengthening prevention programs should be included in all comprehensive substance abuse prevention activities. They advocate dissemination of five highly effective family strengthening approaches (e.g., behavioural parent training, family skills training, in-home family support, brief family therapy, and family education).

Currently, many COAs remain unidentified within schools and may not be receiving the counselling services that they deserve and require. The family dysfunctionality of such children places them at high risk for adverse academic, physiological, emotional, and social consequences observe Lambie and Sias, (2005). It then becomes an important task for the school counsellor to identify such children in distress and to provide them with supportive services besides intervention with families to the extent possible. Knowledge of fathers' alcohol use and its time of onset may be used to determine children who are at added risk of problematic alcohol use later in life and so special guidance, support and treatment can be targeted to these families observe Seljamo et al (2006). In the Indian scenario where the majority of schools do not have a professional counsellor, this important task needs to be addressed by teachers who are in a position to identify such children.

While groups such as ‘Alateen’ function for COAs in the West, such therapeutic self help groups for COAs in the Indian setting are woefully lacking and must be initiated. The common intervention foci for such groups should according to Emshoff and Anyan (1991), include information on alcohol and alcoholism, the dynamics of alcoholic families, common social and emotional reactions (e.g., embarrassment, loneliness, guilt, depression, anger), skill building (e.g., problem solving, communication, expression of feelings), coping strategies for living in an alcoholic home, and general social and emotional support. Kuhns (1997), observes that both group psychotherapy and self-help groups for COAs were effective in decreasing levels of depression while Kingree and Thompson (2000), found that participation in the mutual help group promoted perceived status benefits, which in turn led to reductions in depression and substance use. The need to strengthen the social support available to such children has been highlighted by Werner and Johnson (2004) who’s data showed that individuals who coped effectively with the trauma of growing up in an alcoholic family and who became competent adults relied on a significantly larger number of sources of support in their childhood and youth than did the offspring of alcoholics with coping problems.

Intervention with COAs must hence involve resolution of individualised issues pertaining to adolescence as well as parental alcoholism. Elements to enhance their self esteem and adjustment across various domains need to be consciously included besides involving them in family therapy sessions. Strengthening their social support systems, fortifying familial bonds besides facilitating their participation in self help groups comprising of other COAs, could go a long way in enhancing their mental health. These efforts must be concurrently initiated along with other therapeutic procedures that focus on the alcoholic per se.

Conclusion
This study has revealed that the majority of COAs manifest lower levels of self-esteem and a lesser degree of adjustment than nCOAs. The two groups of respondents were matched on key socio-demographic variables and the alcoholism of the father of the study group subjects was a major differentiating factor between the two. The author against this background is inclined to concur with the proponents of the stress perspective on co-dependents of alcoholics as the data of this study indicates that the stressful and vitiated domestic environment prevalent in alcohol complicated familial relationships is responsible for the low self-esteem and deficient adjustment seen in adolescent children of alcoholics. There is hence an imperative need for therapeutic intervention with this population. The need of the hour is to develop programmes for COAs with a strong focus on strengthening resilience in them and to inculcate desirable personality traits and enhance their psychosocial functioning through appropriate psychotherapeutic procedures. This study underscores the point that co-dependent adolescent children of alcoholics also merit therapeutic intervention owing to the various deficits in psychosocial functioning manifested in them.

References

Andreas, J.B. & O’Farrell, T.J.(2007). Longitudinal Associations Between Fathers’ Heavy Drinking Patterns and Children’s Psychosocial Adjustment, Journal of Abnormal Child Psychology, 35:1–16.

Andreas, J.B., O'Farrell, T.J. & Fals-Stewart, W. (2006). Does individual treatment    for alcoholic fathers benefit their children? A longitudinal assessment. Journal of Consulting and Clinical Psychology, 74(1):191-198.

Babor,T. F. , Funete, D.L., Saunders, J., & Grant, M. (1983). The Alcohol Use Disorders Identification Test, Geneva: WHO publication.
    
 Baker, D.E., & Stephenson, L. A. (1995). Personality characteristics of adult   children of alcoholics. Journal of Clinical Psychology, 51(5), 694-702.
       
Barnow, S., Lucht, M., Hamm, A., John, U. & Freyberger, H. J. (2004). The relation of a family history of alcoholism, obstetric complications and family environment to behavioral problems among 154 adolescents in Germany: results from the children of alcoholics study in Pomerania. European Journal of Addiction Research, 10(1):8-14.

Bird, S. & Canino, G. (1991). Children of alcoholic parents in the community. Journal of Studies on Alcohol, 52, 78-88.

 Brook, D.W., Brook, J. S., Rubenstone, E., Zhang, C., Singer, M. & Duke, M. R. (2003). Alcohol use in adolescents whose fathers abuse drugs. Journal of Addictive Diseases, 22(1), 11-34.

Casas-Gil, M.J. & Navarro-Guzman, J.I. (2002). School characteristics among children of alcoholic parents.  Psychological Reports, 90 (1), 341-348.

Callan, V.J & Jackson, D. (1986). Children of alcoholic fathers and recovered alcoholic fathers. Journal of Studies on Alcohol, 47 (2), 180-182.

Cole, C.L., Cole, A.I. & Dean, D.G. (1980). Emotional maturity and marital adjustment. Journal of Marriage and the Family, 42, 533-539.

Churchill, J.C., Broida, J.P. & Nicholson, N.L. (1990). Locus of control and self-esteem of adult children of alcoholics. Journal of Studies on Alcohol, 51(4), 373-376.     

Cuijpers, P., Steunenberg, B. & Van Straten, A. (2006). When children of problem drinkers grow old: Does the increased risk of mental disorders persist? Addictive Behaviors, 31(12), 2284-2291.

Cummings, E.M., Davies, P.T., & Campbell, S.B. (2000). Developmental psychopathology and family process: Theory, research and clinical implications. New York: Guilford.

Deborah, E. (1997). Intellectual, cognitive and academic performance among sons of alcoholics during early school years: differences related to subtypes of familial alcoholism. Alcoholism: Clinical and Experimental Research, 24 (97), 1020-1027.

Domenico, D. and Windle, M. (1993). Intrapersonal and interpersonal functioning among middle-aged female adult children of alcoholics. Journal of Consulting and Clinical Psychology, 61(4):659-666.
Drucker, P.M. and Greco-Vigorito, C. (2002). An exploratory factor analysis of children's depression inventory scores in young children of substance abusers. Psychological Reports, 91(1):131-41.

Emshoff, J.G., & Anyan, L. L. (1991). From prevention to treatment. Issues for school-aged children of alcoholics. Recent Developments in Alcohol, 9, 327- 346.

Erblich, J., Earleywine, M., & Erblich, B. (2001). Positive and negative associations with alcohol and familial risk for alcoholism. Psychological Addiction Behaviour,15(3),204-209.
 
Furtado, E. F., Laucht, M. & Schmidt, M. H. (2002). Psychiatric problems in children of alcoholic fathers. Journal for Child and Adolescent Psychiatry and Psychotherapy, 30(4), 241-250.

Furtado, E.F., Laucht, M. & Schmidt, M.H. (2006).  Gender-related pathways for behavior problems in the offspring of alcoholic fathers. Brazilian Journal of Medical and Biological Research, 39(5), 659-669.

Hall, C.W. & Webster, R.E. (2002). Traumatic symptomatology characteristics of adult children of alcoholics.  Journal of Drug Education, 32(3), 195-211.        

Hall, C.W., Bolen, L.M. & Webster, R.E. (1994). Adjustment issues with adult children of alcoholics. Journal of Clinical Psychology, 50(5), 786-92.

Hart, K. E., Fiissel, D. L. &  McAleer, M. (2003). Do Adult Offspring of Alcoholics Suffer from Poor Medical Health? A Three-Group Comparison Controlling for Self-Report Bias. Canadian Journal of Nursing Research, 35(1), 52-72.

Harter, S.L. (2000). Psychosocial adjustment of adult children of alcoholics: a review of the recent empirical literature. Clinical Psychological Review. 20(3), 311-337.
    
Haugland, B.S. (2003). Paternal alcohol abuse: relationship between child adjustment, parental characteristics, and family functioning. Child Psychiatry and Human Development, 34(2), 127-46.

Hussong, A. M. & Chassin, L. (2004). Stress and coping among children of alcoholic parents through the young adult transition. Development and Psychopathology, Special issue: Transition from Adolescence to Adulthood, 16(4), 985-1006.

Jacob, T. & Windle, M. (2000). Young adult children of alcoholic, depressed and nondistressed parents. Journal of Studies on Alcohol, 61(6), 836-844.
   
Johnson, J.L. &  Leff, M. (1999). Children of substance abusers: overview of research findings. Pediatrics, 103(52), 1085-1099.     
       
Keller,P.S., Cummings,E.M., &  Davies, P.T. (2005). The role of marital discord and parenting in relations between parental problem drinking and child adjustment,  Journal of Child Psychology and Psychiatry 46:9,  943–951.

Kelley, S. J. (1996). Do substance abusing mothers experience increased parenting stress? International Congress of the International Society for the Prevention of Child abuse and Neglect, Dublin.

Kelley, M.L., French, A., Bountress, K., Keefe, H.A., Schroeder, V., Steer, K., Fals-Stewart, W. & Gumienny, L. (2007). Parentification and family responsibility in the family of origin of adult children of alcoholics. Addictive Behavior, 32(4), 675-85.
       
Kingree, J.B. & Thompson, M. (2000). Mutual help groups, perceived status benefits, and well-being: a test with adult children of alcoholics with personal substance abuse problems. American Journal of Community Psychology, 28(3), 325-342.
         
Kuhns, M.L. (1997). Treatment outcomes with adult children of alcoholics: depression. Advanced Practice of Nursing Quarterly, 3(2), 64-69.
    
Kumpfer, K.L. & Hopkins, R. (1993). Recent advances in addictive disorders. Prevention: Current research and trends. Psychiatric Clinician of North America, 16(1),11-20.
    
Kumpfer, K. L., Alvarado, R. & Whiteside, H. O. (2003). Family-based interventions for substance use and misuse prevention. Substance Use & Misuse, 38(11-13), 1759-1787.  
    
Kutty, A.B. & Sharma, R.G. (1988). Comparative Study of Temperamental Differences in Wives of Alcoholics and Non-alcoholics. Journal of Clinical Psychology, 15(1), 92-94.
    
Lambie, D. M. & Sias, S. M. (2005). Children of Alcoholics: Implications for Professional School Counselling. Professional School Counselling, Special issue: Professional School Counselling in Urban Settings. Vol 8(3), 266-273.

Mac Kinnon, N. J.  (1981). Self-esteem Index. University of Guelph.
    
Menees, M. M. & Segrin, C. (2000). The specificity of disrupted processes in families of adult children of alcoholics. Alcohol and Alcoholism, 35(4), 361-367.
    
 Miller, D. & Krop, J. (1985). The children of alcoholics screening test: relationship to sex, family environment and social adjustment in adolescents. Journal of Clinical Psychology, 45, 335-339.
    
Morey, C. K. (1999). Children of alcoholics: a school-based comparative study. Journal of Drug Education, 29(1), 63-75.
       
Mylant, M.L., Ide, B., Cuevas, E. & Meehan, M. (2002). Adolescent children of alcoholics: Vulnerable or resilient? Journal of the American Psychiatric Nurses Association, l 8(2), 57-64.

Nespor, K. (2004). New trends in the treatment and prevention of addictive disorders. Cas Lek Cesk, 143(4), 231-235.
       
Obot, I.S. & Anthony, J.C.(2004). Mental health problems in adolescent children of alcohol dependent parents:Epidemiologic research with a nationally representative sample.Journal of Child & Adolescent Substance Abuse, 13(4), 83-96.
       
O'Farrell, T. J. & Fals-Stewart, W. (2002). Behavioral couples and family therapy for substance abusers. Current Psychiatry Report, 4(5), 371-376.
    
O'Farrell, T.J. & Feehan, M. (1999). Alcoholism treatment and the family: do family and individual treatments for alcoholic adults have preventive effects for  children? Journal of Studies on Alcohol Supplement, 13,125-129.
               
Oravecz, R. (2002). Children of alcoholics. Horizons of Psychology, 11(3), 95-107.

 Rao, Sathyanarayana,T. S. & Kuruvilla, K. (1991). A Study on the Personality Characteristics of wives of Alcoholics,Indian Journal of Psychiatry, 33(3), 180-186.

Reich, W., Earls, F., Frankel, O. & Shayka, J. J. (1993). Psychopathology in children of alcoholics. Journal of American Academy of Child and Adolescent Psychiatry, 32(5), 995-1002.

Ranganathan, Shanthi. (2004). Families in Transition: Victims of Alcoholism and New Challenges Ahead. International Journal for the Advancement of Counselling, 26(4),399-405.

Roosa, M. W., Beals, J., Sandler, I. N. & Pillow, D. R. (1990). The role of risk and protective factors in predicting symptomatology in adolescent self-identified children of alcoholic parents. American Journal of Community Psychology, 18(5), 725-741.
          
Segrin, C. & Menees, M. M. (1996). The impact of coping styles and family communication on the social skills of children of alcoholics. Journal of Studies on Alcohol,57(1):29-33.

Seljamo, S., Aromaa, M., Koivusilta, L., Rautava, P., Sourander, A., Helenius, H.
et al. (2006). Alcohol use in families: A 15-year prospective follow-up study. Addiction, 101(7), 984-992.

Sher, K.J., Walitzer, K.S., Wood, P.K. & Brent, E.E. (1991). Characteristics of children of alcoholics: putative risk factors, substance use and abuse, and psychopathology. Journal of Abnormal Psychology, 100(4), 427-448.

Srivatsa, G. N. & Tiwari, G. (1972). Adjustment Inventory. Agra Psychological Research Cell Publication, India.

Stanley, S. (2001). Neuroticism and marital adjustment in wives of alcoholics. Indian Journal of Social Psychiatry, 17(1-4), 32-41.

Stanley, S. (2006). Marital adjustment & quality of life in couples with and without an alcoholic husband. Indian Journal of Psychological Medicine, 28(2), 18-32.

Stanley, S. & Anitha, P. (2007). Spousal conflict and adjustment in alcohol complicated marital relationships. In Perspectives on Family Empowerment, V.T.Samuel (ed).pub div. Mariann college kuttikanam, India.

Steinhausen, H. C. (1995). Psychopathology in the offspring of alcoholic parents. Journal of the American Association of Child Psychiatry, 23(4), 465-    471.

Werner, L. J. & Broida, J. P. (1991). Adult self-esteem and locus of control as a function of familial alcoholism and dysfunction. Journal of Studies on Alcohol, 52(3), 249-252.

Werner, E.E. & Johnson, J.L. (2004). The role of caring adults in the lives of children of alcoholics. Substance Use and Misuse, 39(5):699-720.

Williams, O. B. & Corrigan, P. W. (1992). The differential effects of  parental alcoholism and mental illness on their adult children. Journal of Clinical Psychology, 48, 406-416.    

Wojcieszek, K.A. (2003). Parents and children in families with alcohol problems--anthropologic and preventive study. Med Wieku Rozwoj. 7(1.2):65-74.

Yang, S.H. & Lee, P.S. (2005). The effects of a stress management program on mental health and the coping behavior for the children of alcoholics. Taehan Kanho Hakhoe Chi. 35(1):77-86.