International Journal of Psychosocial Rehabilitation
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.
C. Vanitha, MSW
Psychiatric Social Worker
National Institute of Mental Health and Neuro Sciences
Stanley S., Vanitha C. (2008). Psychosocial
Correlates in Adolescent Children of Alcoholics-
Implications for Intervention.
International Journal of Psychosocial
Rehabilitation. 12 (2), 67-80
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).
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.
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
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
- To study and compare the self-esteem and adjustment in adolescent
children of alcoholics (COAs) and those of non-alcoholics (nCOAs).
- To bring out the association if any between socio-demographic
factors and the subject dimensions studied.
- To study the relationship if any among the subject dimensions.
- To discuss implications for therapeutic intervention with
adolescent COAs and their families in the light of the results obtained.
Material and Methodology
Sample and Selection Procedure
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.
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):
AGE, BIRTH ORDER & FAMILY INCOME OF THE
t = 0.78
P > 0.05
P > 0.05
P > 0.05
* df = 98
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
DEMOGRAPHIC BACKGROUND OF RESPONDENTS
Figures in parantheses are percentages
*n=50, **p > 0.05
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
3. Self Prepared Interview Schedule to elicit information pertaining to
socio-demographic background and father’s drinking.
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
SCORE PROFILE OF RESPONDENTS ON SUBJECT DIMENSIONS
Alcoholics * Non-alcoholiCS
138.28 t =12.21
*n = 50; **
df = 98
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
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).
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
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 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
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
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
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
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
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.
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
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