Objective. This article was designed to give pediatricians a basic knowledge of the needs of children who live in families with alcoholism. It briefly presents issues involved in the identification and screening of such individuals and provides primary attention to a variety of preventive and treatment strategies that have been used with school children of alcoholics (COAs), along with evidence of their effectiveness.
Methodology. A literature search including both published and unpublished descriptions and evaluations of interventions with COAs.
Results. The scope and nature of the problems of growing up in an alcoholic home are presented. The risk and protective factors associated with this population have been used as a foundation for preventive and treatment interventions. The most common modality of prevention and intervention programs is the short-term small group format. Programs for COAs should include the basic components of information, problem- and emotion-focused coping skills, and social and emotional support. Physicians are in a unique position to identify and provide basic services and referrals for COAs. School settings are the most common intervention sites, but family and broad-based community programs also have shown promise in alcohol and other drug prevention.
Conclusions. Several COA interventions have demonstrated positive results with respect to a variety of measures including knowledge of program content, social support, coping skills, and emotional functioning. Rigorous studies are needed to understand better the complex ways children deal with parental alcoholism. A need remains for empirically sound evaluations and for the delineation of research findings.
SCOPE OF THE PROBLEM
The exact number of children of alcoholics (COAs) in the general population is unknown. A recent estimate is that there are 26.8 million COAs in the United States. Of these, >11 million are younger than age 18.1 Our understanding of the effects of parental alcoholism on children continues to grow. Originally, many believed young COAs to be relatively unaffected by parental alcoholism because of their immaturity.2 Later, researchers seemed to have the opinion that all children experienced negative outcomes. More recently, researchers have begun to delineate the wide variety of outcomes experienced by COAs.3 Researchers are continuing to study the effects of parental alcoholism on children to understand the processes that determine these outcomes.
Often COAs deal with parental alcoholism and its consequent effects for many years. Research indicates that COAs are at greater risk for a host of behavioral and emotional problems, including developing an addiction. In fact, 13% to 25% of all COAs are likely to become alcoholic themselves.4
Many variables play a role in how, or whether, children will be affected by parental alcoholism. Although there is a strong genetic component to alcoholism, other psychosocial factors influence transmission, because not all COAs become alcoholic. It is clear that genetic and environmental variables contribute individually and interactively to produce a variety of outcomes for COAs. Therefore, prevention and intervention should focus on those moderating and mediating variables that impact the psychosocial factors influencing transmission.
Prevention researchers often take a public health model in approaching the primary prevention of emotional problems. According to Albee,5 to prevent something, we must first identify or describe what it is we wish to prevent. Then the causative forces that lead to the undesirable state or process must be identified and removed. Another strategy is to strengthen the individual to resist the causative agent. Specifically, Albee suggests a competency model, which is presented below:Albee's model suggests that building competence through increasing coping skills will reduce the incidence of psycopathology. Research on COAs indicates that this equation holds for the risk status of COAs. It has been observed that all the factors in the denominator of the model can be modified through intervention.6 Thus, appropriate goals for primary prevention for COAs would include the reduction of stress and the development of self-esteem, social competence, and a strong social support system.
CHOOSING GOALS FOR PREVENTION AND INTERVENTION
Recent research has concluded that despite risk, many COAs are remarkably well-adjusted.3,,7,8 However, work in the area of developmental psychopathology suggests that adjustment to stressful environments is more complicated than understood previously. For example, Luthar9 found that although some children living in highly stressful environments appeared to be coping well, they in fact had high rates of internalizing problems, such as depression and anxiety. Rather than accepting a stereotypical view of COAs,10 professionals involved in both research and service delivery should work toward understanding the unique and complex patterns of adjustment to parental alcoholism.
In an effort to understand how COAs cope, researchers have looked at mediating variables (those factors that explain the relationship between parental alcoholism and children's coping) and moderating variables (those factors that change the strength of the causal associations). These factors can be conceptualized along a number of dimensions. Some factors are intrapsychic (eg, self-awareness) and primarily involve processes within the individual, whereas other factors (eg, social support) are interpersonal and involve processes among persons. From another dimension, some factors (eg, intelligence or temperament) tend to be primarily genetic, whereas others (coping strategies) are shaped primarily through experience. Identification of these variables is important because they provide potential targets for intervention.
Researchers have identified three types of factors that have been found to influence the stress-adjustment relationship in children. These include: individual-level factors (eg, activity level, reflectiveness, cognitive skills, and positive responsiveness to others); family milieu factors (eg, families marked by warmth, cohesion, and the presence of a caring adult); and environmental factors (eg, presence of some external support from a teacher, neighbor, parent of peers, or even an institutional structure such as a school or church).11–13(For a more complete review, see Johnson and Leff in this issue.)
The majority of research regarding factors that influence COA status and outcomes has concentrated on individual variables related to the temperament and personality of the child. In an effort to frame the linkages among variables that influence COA outcomes, Emshoff6 presented a hypothetic developmental approach for examining the impact of parental drinking on child adjustment.
Parental alcoholism has been associated with several biologic outcomes in children, such as increased rates of hyperactivity or attention deficit disorder.14 Although a causal link has yet to be established,15 adverse biologic outcomes may set the stage for later behaviors such as discipline problems in school or delinquency, both of which predict future substance abuse.3,,14,16,17 Children who experience behavior problems in school are less likely to perform well on cognitive tasks. In general, COAs do less well on academic measures; have higher rates of school absenteeism; and are more likely to leave school, be retained, or be referred to the school psychologist than are non-COAs.3,,1418–20
Consequently, poor school performance acts to isolate COAs from their peers.21 Unfortunately, COAs already are at a disadvantage socially because of limited access to appropriate role models. These processes contribute to COAs' overall lower sense of social support, another variable related to substance abuse.22 Therefore, COAs must face problems with less social support and limited coping strategies, which may lead to lowered self-esteem, a variable that is negatively related to stress.23 Lower self-esteem, along with lowered internal locus of control, and emotional, psychiatric, and adjustment disorders are likely contributors to depression.14 It should not be surprising that COAs have a higher than normal incidence of alcoholism and other substance abuse.3,,4,14
The relationships outlined in Emshoff's model are not hypothesized to represent linear relationships. Because of the interrelatedness of these pathways, the connections between these variables are likely to be complex. In short, biologic influences are linked with lowered cognitive abilities that, in turn, influence interpersonal skills and behavior.
The family environment is the primary influence on children, especially COAs. Family socialization has been described as the link between the individual (psychologic and biologic) and the larger culture (sociodemographic and structural factors). The young person learns social behavior, including drinking behavior, during the ongoing socialization process with parents, older siblings, and peers.24
For example, McCord25 found that father–son transmission of alcoholism was more likely when the mother held the alcoholic father in high esteem. Wolin and colleagues found that ritual-deprived families heighten their children's vulnerability to alcoholism by permitting personal hardships to damage identity-building elements in their life, whereas children from ritual-protected families were less vulnerable to repeating the parent's alcoholism.26 Other family process variables that reduce the incidence of adverse outcomes include low conflict and violence, good communication patterns, and cohesion.27 More recently, Robinson and Rhoden28 have examined the effects of alcoholism on four essential family tasks: creating an identity, setting boundaries, providing for physical needs, and managing the family's emotional climate.
Although there has been much less research regarding environmental influences that affect COA adjustment, some contextual variables have been found to mediate the relationship between parental alcoholism and adjustment. For example, stressful life events may mediate the relationship between family alcoholism and mental health status of COAs.29 Additionally, social support from peers or caring adults can be either helpful in the coping process or reduce the need for coping.12,,13,30 Furthermore, a good relationship with the nonalcoholic parent has been suggested as a factor that protects the child from the negative effects of parental alcoholism,27,,31,32 although more recent research failed to support this hypothesis. There are many more environmental influences that might buffer children from the negative effects of parental alcoholism such as the school or the church. Unfortunately, these settings have yet to be researched adequately.13
PREVENTION AND INTERVENTION MODELS
In response to these individual and environmental risk factors, several types of programs have been developed for COAs. “Universal prevention” programs are designed for the general population. “Selective prevention” programs are those designed specifically for identified or self-identified COAs. “Indicated prevention programs” are designed for children with addicted parents who also have specific emotional or behavioral problems. In this article, we make a general distinction between “prevention” and “intervention” programs. Prevention programs target children not because of their own behavior, but because of the behavior of an adult caregiver. Intervention programs usually target children who already are exhibiting some symptomatology themselves. Most of the COA programs discussed in this article include both prevention and intervention to some degree, although each may have a primary focus of one or the other. It would not be incorrect to label all these programs as “preventive interventions.”
Windles and Searles33 outlined the prevention objectives of The National Council on Alcoholism. Using a public health model, the organization has defined primary prevention as preventing a problem before it starts. Therefore, the objective of prevention programs for COAs is to deter the development of drinking problems by targeting risk factors associated with drinking problems or other dysfunctional behaviors. The focus of the prevention effort might be general, as in broad-based community prevention programs, or specific to particular high-risk groups.
Two primary prevention models were proposed. First, the distribution of consumption model is aimed at the societal control over the availability of alcohol. This involves raising the drinking age, increasing the price of alcohol, and limiting sale hours, as well as other strategies. The second model is the sociocultural model, which focuses on education and enhancement of individuals' competencies through information, values' clarification, and skills-building techniques. These types of prevention programs can be community-wide; through media campaigns; or targeted at schools, recreational activities, or physicians' offices.34
Broad-based programs target all COAs, whether or not they are identified. The National Structured Evaluation (NSE)35study examined virtually every type of prevention activity, excluding treatment. Included in the evaluation were environmental change programs designed to change the community environment without intervening directly with individuals at risk for alcohol and other drug problems. The NSE found that examples of environmental approaches included some of the most effective programs and had the most consistent record of effectiveness across all types of outcomes.
One benefit of such broad-based primary prevention is that it avoids labeling because all children are targeted for intervention. A more tailored application of this approach is classroom guidance on alcoholism and the effects of alcoholism on the family. Targeting all children in the normal classroom setting precludes the need for screening and consent and provides a valuable service to all children. However, denial may keep the COA from absorbing all the information.
Primary prevention models are now shifting to an emphasis on correcting misperceived social norms about drug use and expectations about drug use consequences. Social norms and related social influences are significant predictors of adolescent drug use and significant mediators of primary prevention programs.36 This represents a systems level approach in that a decrease in social norms and acceptance of drug use through prevention might have radiating positive effects on all youth, not just those participating in the program.37
Selection of prevention and intervention content should be guided by scientific knowledge about the risk and protective factors associated with all three levels of variables. Hawkins and colleagues38 provide a comprehensive review of the research, including individual, interpersonal, and contextual factors that contribute to the risk of substance abuse among adolescents and young adults. Researchers in this area recognize that the presence of multiple risk factors increases the risk for substance abuse.7
However, not all COAs require intervention or even treatment. At the same time, some COAs will need treatment beyond what can be provided through prevention and intervention programs. In that case, more intensive treatment is needed to deal with specific problems such as substance abuse or depression. For most COAs, education and support given in a primary prevention program as outlined here will provide sufficient help.
The design of prevention programs is a complicated but necessary process. For example, the influence of the child's developmental stage must be considered during program design. Elementary school children do not always have realistic perceptions of relationships and causal links and thus often feel responsible for the drinking parent. The middle school years are the period in which many children begin drinking alcohol and using other drugs. For this reason, experts agree that prevention should be focused on the preteen years.6 Older adolescents often experience both self-esteem and mental health problems. A consideration of these developmental issues is necessary to obtain desired program outcomes.
Another area that is often ignored when designing prevention and intervention programs is the influence of the child's cultural and ethnic background. Recent research suggests that not all children respond to stress in the same manner. Barrera and associates39 found that Hispanic adolescents were more resilient than their white counterparts. But whether this finding reflects a true group difference or measurement error is unclear. For example, other researchers have suggested that measures of stressful life events may not reflect adequately the lives of minority, primarily poor populations of youth.40 Experts in the field of substance abuse suggest that culturally appropriate interventions are more effective than are generic prevention interventions,41,,42 and results from recent evaluations seem to support this finding.
Whatever the age or background of the child, the importance of peer influence and mutual support43 makes group intervention the logical means of intervention with COAs. Group treatment has been highly recommended by many experts in the field6,,44because it reduces feelings of isolation, shame, and guilt.43 As an additional benefit, there is some empiric evidence that group interventions allow participants both to receive and to give support.45 Typically, these groups are for COAs only, or for others concerned about a loved one's drinking. Occasionally, programs provide groups for the entire family or concurrent parent and child groups.
Program content is often based in social learning theory and emphasizes role-playing, modeling, practice of resistance skills, and feedback. Significant effects on the reduction in use of cigarettes, alcohol, and marijuana have been found in general prevention programs.46–48 Recently, Roosa and co-workers49 tested the effects of protective factors such as social support and coping skills with a sample of COAs. Other programs emphasize environmental influences while integrating with other health and prevention programs. Community-based programs use multiple channels for delivery, based on the rationale that the more youths are exposed to consistent prevention strategies, the less likely they are to use substances.37
Although each intervention program is unique in some way, there are several intervention strategies that are relatively common across programs. These strategies include information, training in skill development, focus on social support and socioemotional needs of children, and emphasis on alternatives to substance use. These strategies have been developed for prevention efforts with diverse populations, but are applied (and sometimes adapted or customized) to groups of COAs.
It is common for COAs to have misunderstandings about alcoholism. Most programs provide some amount of information regarding alcohol and alcoholism to reduce misconceptions and to provide an accurate basis for education throughout the intervention. O'Rourke50outlined 10 topics often included in education programs. The disease model is promoted most commonly as a means of understanding the behavior of the alcoholic parent. Terms such as tolerance, blackouts, and withdrawal usually are presented during the education phase. Understanding these concepts helps the child reduce self-blame and guilt about parental drinking.
COA risk status is a common component of the information/education phase of intervention. It is important that COAs understand their risk for a variety of psychosocial problems, especially alcoholism. COAs should not be made to feel that they will definitely become an alcoholic if they drink, but COAs who are aware of their risk status drink significantly less (in frequency and quantity) than do COAs who are unaware of their risk status.51 Finally, misconceptions that COAs have in terms of the positive effects of drinking on cognitive and social performance should be addressed.52,,53
Promotion of specific competencies is often the focus of COA prevention and intervention. Focus on competency is an alternative to the more popular deficit model of prevention. For COAs, competencies can be viewed as protective factors that help children cope with stress, thereby reducing their risk status.
Some programs teach appropriate emotion-focused and problem-focused coping skills.7 Emotion-focused coping involves a modification of emotional distress without changing the source of the distress. It is an indirect process by which the child seeks social support or uses strategies, such as distancing or reframing the negative aspects of the situation, to emphasize the positive. Because COAs do not have control of parental drinking, it is an important coping skill. Children can be taught to look for external support, such as another family member or a friend's parent.
Problem-focused coping involves strategies to change or to manage the problem situation. This might include specific survival skills such as how to live within an alcoholic home and how to handle situations such as driving with a drunk parent and explaining parental behavior to friends. Other skills include information about decision-making, problem-solving, communication, and peer-resistance skills. Children can be taught how to use both emotion-focused and problem-focused techniques in conjunction to manage their stress. Of course, an important part of successful interventions is the provision of opportunities to practice these newly acquired skills.
Social Support and Socioemotional Issues
Four areas of functioning are often identified as important aspects of personal–social competence and coping for COAs and therefore are important areas for intervention: self-esteem, self-efficacy, the ability to establish and maintain intimate relationships, and the development of effective strategies for expressing feelings and solving problems.7Personal–social competencies can influence the level of adaptation despite physical vulnerability and lack of control over stressors.5,,54,55
Social support is a natural result of group participation. Sharing common reactions and coping mechanisms builds group cohesion. Many participants learn for the first time that they are not alone in dealing with parental alcoholism.
A focus on socioemotional issues such as depression, anger, guilt, and mistrust is important, whether within the context of therapy or within the context of prevention. Many COAs cope quite well; others appear to cope well but do not. For the child who merely appears to be functioning well, problems in these areas may not be readily apparent. The denial of these children serves a protective function requiring group facilitators to exercise patience and sensitivity. Extra support is needed as children adapt to their changing awareness about parental drinking.
Self-esteem often is a direct or indirect goal of COA interventions. COAs often use a perfectionist focus as a means of acquiring self-esteem. Self-esteem based on perfection obviously is unattainable, thus setting the child up for failure. Learning alternative ways to feel good about oneself is an important focus of interventions. The more the COAs understand the disease process, acquire healthier means of coping, and are supported by others who share the same experience, the better they will feel about themselves.
Group leaders should be knowledgeable about COA issues. For example, they should be cognizant that COAs may have problems with interpersonal boundaries, a characteristic common in alcoholic families. Leaders should be especially sensitive to feelings of abandonment children may experience when the group terminates.
Alternative activities provide opportunities for COAs to participate in activities that exclude alcohol, tobacco and other drugs. Healthy alternative activities (eg, sports activities, peer leadership training institutes, experiential programs such as Outward Bound) can help build a sense of self-efficacy, increase self-esteem, provide a positive peer group, and increase life skills such as problem-solving and communication. Programs may be focused exclusively on alternative activities or may include them as part of a comprehensive prevention program.
SETTINGS FOR PREVENTION AND INTERVENTION
Prevention and intervention efforts should address risk and protective factors for substance abuse across the various levels that we have reviewed. The options for where the actual prevention or intervention program occurs are also varied. Ideally, prevention and intervention will be most effective when multiple risk and protective factors are addressed within the multiple settings in which children live. For example, physicians that care for children and their families represent the first line of defense. Additionally, the school is an obvious point for all levels of prevention. Parents, as the primary educators of children, can participate actively in prevention efforts. Finally, community settings, although often overlooked, may provide creative means of reaching greater numbers of at-risk children.
The Role of Primary Care Physicians
Although not often thought of as a setting for prevention, primary care physicians have the unique opportunity to prevent problems through education and to provide early intervention when necessary. Adger56 outlined recently the role of the primary care physician in the identification, prevention, and intervention of substance-abuse problems in children. The Committee on Substance Abuse of the American Academy of Pediatrics recommends that pediatricians include information about substance abuse in their anticipatory guidance to all children and adolescents. Physicians should possess the knowledge to recognize risk factors, identify the signs and symptoms of substance abuse, evaluate the extent of alcohol use, and offer appropriate counseling and referral when necessary. The Guidelines for Adolescent Preventive Services established by the American Medical Association recommends both primary (eg, patient education and anticipatory guidance) and secondary (eg, early intervention) preventative strategies to reduce adolescent substance use. The Guidelines for Adolescent Preventive Services also recommends that physicians routinely ascertain their patients' risk factors including a family history of alcoholism and conduct screenings for all school children and adolescents. These screenings should begin during prenatal visits and continue with developmentally appropriate information as the child and family mature.
Physicians have additional help providing services to their young patients. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents57 was initiated in 1990 by the Maternal Child Health Bureau of the Health Resources and Services Administration and the Medicaid Bureau of the Health Care Financing Administration. These guidelines were developed in response to the economic, social, and demographic causes of morbidity and mortality among this country's children. The project takes a comprehensive view of health, emphasizing physical well-being, mental health, cognitive development, and social efficacy. A central goal of the program is to involve health professionals, families, and educators in a comprehensive prevention effort that recognizes the contextual forces impacting children.58 The guidelines provide an important and previously missing link in prevention efforts for children, that of integrating health services with education and human services.
Wolin and Wolin59 caution that pediatricians should not regard COAs as a homogenous group with uniform genetic vulnerability. Nor should they accept a clearly defined profile of psychopathology for all COAs. Pediatricians are encouraged to view COAs as having a myriad both of strengths and of weaknesses. The “damage model” tends to overlook strengths but is attractive because of its reliance on deficits and technical terms for identifying pathology.59The investigators encourage pediatricians to use the “challenge model” by encouraging youths to explore creative endeavors, participate in mentoring programs, extracurricular activities, and community activities.59 A pediatrician can become a supportive adult outside the family to provide guidance, encouragement, empathy, and resilience.
In general, group settings, usually within schools, appear to be the primary mode of program delivery. The school is a logical place for intervention because it is the environment in which large numbers of children are available for long periods of time, and it is the setting in which problems relating to parental alcoholism will be most consistently discernible.43
Furthermore, prevention programs within schools ease access to needed information and services. Children, particularly COAs, have limited access to out-of-school programs, especially when transportation is difficult. Children likely may resist attending programs in mental health centers because of the negative stigma or embarrassment.
Finally, an additional benefit is that the school is part of a network of community agencies and can serve as a focal point for the mobilization of prevention and intervention services with regard to specific COA issues. Since 1986, when the Drug Free Schools and Communities Act was signed into law, schools have been the primary agency involved in alcohol prevention. This legislation provides financial resources to reinforce and coordinate the efforts of schools and to provide education and intervention in the areas of alcohol and drug abuse. Unfortunately, although it is recognized that educational settings are logical sites for prevention and intervention efforts, few school-based programs designed specifically for COAs have been described in the literature.43 Several programs that have been discussed in the literature are reviewed here.
Student Assistance Programs
Modeled after employee assistance programs, student assistance programs (SAPs) are comprehensive prevention programs that attempt to provide prevention and early intervention services for high-risk youth. As such, SAPs typically focus on COAs as one high-risk group. SAPs can be found at the elementary, middle, and high school levels. They vary as to problem focus, staffing, programming, and evaluation techniques. Generally, they are designed for prevention and early intervention of high-risk behaviors, especially substance abuse.60 There are several models, but usually masters level counselors are placed in schools or at local centers. They provide individual and group interventions for students with family, school, peer, alcohol, drug, or other personal problems. Typically, the SAP has a core team that includes key members of a school's staff.61 Students may self-refer to the program or they may be referred by school personnel or parents.
Anderson2 described the structure and focus of SAPs as including three core components. First, the SAP has a structure and process of identifying students who are abusing substances or who are at risk. Second, there is a community component that provides professional resources for prevention and intervention when necessary. Finally, there is an aftercare component to reintegrate students returning from treatment.
As SAPs have developed, staff have become better trained and more adept at identifying and referring students. Support for SAPs has developed at both the district and state levels. In Minnesota, for example, SAPs have been legislatively mandated for all schools. Since 1988, SAPs have been moving toward professionalism with the establishment of professional organizations, journals, and increasing emphasis on evaluation.62
Stress Management and Alcohol Awareness Program
The stress management and alcohol awareness program (SMAAP) is an 8-week, school-based preventative intervention designed specifically for COAs.49 The framework is a person-centered, competency-building intervention that uses various psychoeducational techniques to strengthen children's competence. These include the enhancement of self-esteem, provision of alcohol-related information, and emotion and problem-focused coping strategies.
A noteworthy feature of the SMAAP was that children self-selected into the program. The recruitment strategy was developed by Emshoff and Moeti63 and refined by Gensheimer and colleagues.64 The process includes showing a film depicting experiences of COAs to all students in the targeted grades, holding an informational follow-up meeting to discuss the film and explain the program, and finally extending an invitation to all children who are interested in participating.
A recent revision of SMAAP65 added practice with coping skills and updated information that reflects recent information concerning misconceptions COAs often have about the effects of alcohol use on cognitive ability and social competence.52,,53 The revised curriculum included the use of a “personal trainer” who met weekly with the participants to help them develop personal skills, build self-worth, and reinforce coping skills outside of school.65 Using the recruitment procedure described previously, children with parental permission were randomly assigned to undergo the program immediately or to one of two delayed-treatment control groups.
Results demonstrated that children who participated in SMAAP were more likely than were controls to report increased knowledge, social-support, and emotion-focused coping behavior. Outcome findings were strongest for program knowledge. The positive changes in reports of coping were similar to the pilot66 in that the intervention improved children's report of coping, although the effect sizes were small. There was some support for increased problem-solving and social competence ratings by teachers, although teachers were not blind to who participated in the intervention at any given time. The results also showed an overall significant increase in the expected reduction of tension resulting from alcohol consumption. This unintended negative side effect is an important one to be clarified in future prevention research as more positive alcohol-related expectancies have been related to greater alcohol use by adolescents.53,,67 There were no differences between groups that underwent and those that did not undergo the personal trainer component.
Students Together And Resourceful
Students Together And Resourceful is an intervention that is based from a community psychology orientation. One goal was to provide students with accurate information concerning alcohol, alcoholism, and family reactions to alcoholism to understand the etiology of alcoholism and to reduce self-blame. A secondary goal was to increase social competence and both the quantity and the quality of peer relations. Group exercises were designed to facilitate the identification, acceptance, and expression of feelings. A related goal was that of improving the social network of participants. Specific skills such as problem-solving, decision-making, stress management, and refusal skills were emphasized. In short, the intervention was designed to do what parents normally do: help children learn to live with themselves in their environments, establish good relationships, and make constructive decisions and follow them through.
A strength of this program was the use of a wait list control group that received the intervention at a later time. The analyses consisted of comparisons between the control and treatment groups over time, strengthening the argument that outcomes were a result of the intervention. Participants were successful in establishing stronger social relations, a sense of control, and improved self-concept. Participants reported increases in the number of friends, peer involvement, and perceived social support. Participants also reported decreased loneliness and depression.6
The Cambridge and Somerville Program for Alcoholism Rehabilitation (CASPAR) is a pioneer in the COA prevention field offering a range of prevention and intervention services. Classroom teachers and CASPAR staff conduct classes on alcohol and other drugs for primary through 12th grade students. The goal of this approach is to prevent the development of substance abuse and related problems in a general population of children. CASPAR also has programs for high-risk groups of youth at all grade levels. Groups are conducted by adult staff in school and community settings (eg, housing developments and recreation centers) and by trained peer leaders in after-school groups in junior high schools.68 Students then can either self-refer or be referred by parents, teachers, community agencies, other students, or CASPAR personnel.
Evaluation data have provided interesting findings. Students participated in either COA-specific groups or a basic education group. COAs in the basic alcohol education groups consistently reported that they learned useful information and indicated that they would drink differently and were drinking less as a result of participation than did non-COAs and children in the COA group. However, children in the alcoholic families group reported more positive learning experiences. Although COAs seemed to gain more from groups dealing directly with parental alcoholism, more children were willing to attend the basic education group where they could avoid self-identification as a COA and still were able to learn useful information.69,,70
Children of Drug Abusers and Alcoholics
Children of Drug Abusers and Alcoholics is an early intervention program for high-risk children 4 to 10 years of age who live with at least one parent (or guardian) addicted to alcohol and/or other drugs. The program consisted of two 12-week components, one for children and one for families. Children were involved in small group activities involving art and play therapy activities. One evening each week, children participated with their parent or guardian in a family interaction group in which the families participated in unstructured art and play therapy activities. Results demonstrated improved competence and behavior as measured by the Child Behavior Checklist. However, the evaluation results should be interpreted with caution because of the lack of a control group.71
Strengthening Families Program (SFP)
The SFP is a family intervention that has been shown to reduce risk factors; increase resilience; and decrease alcohol, tobacco, and drug use among elementary school children of substance abusers (COSA).72 The basic intervention consists of a parent training program and social skills training for the children, as well as a family relationship enhancement program. Typically, the program is conducted in churches, schools, or community centers in sessions of 2 or 3 hours.
Kumpfer and associates73 offer several suggestions for successful implementation of family-focused interventions. It is crucial that focus groups include members who are representative of the target population. Innovative recruitment strategies should include outreach to community agencies, schools, churches, housing authorities, and youth service agencies, among others, in a attempt to involve hard-to-reach families.
The SFP has been modified for a variety of cultural groups including rural and urban African American COSA, Hawaiian COSA, Hispanic COSA, and rural preteens.73 Evaluation studies showed that the basic program with minor cultural revisions was more effective than a substantially revised program. The investigators concluded that the core content of the program should not be deleted when making cultural revisions. As a result of positive outcomes of SPF replications, the National Institute on Drug Abuse has chosen the SFP as one of three model substance-abuse prevention programs for dissemination.
Community-based prevention programs may target other family members as well as members of the larger community. These programs operate from a model that recognizes that both the family and the community influence the child. Community-based programs are moving toward multiple channels of service delivery as a means of increasing “dosage.”37 Wherever the setting, ensuring confidentiality and minimizing the stigma of alcoholism and of COA status must be considered as important factors in designing prevention and intervention programs. Alateen is a self-help program that normally meets in various community settings such as churches or community centers. The Midwestern Prevention Program is a good example of a broad-based community prevention program using many modes of intervention strategies.
Alateen is a program for COAs based on the Alcoholics Anonymous 12-Step Program of Recovery. Very few evaluation data on the effectiveness of Alateen are available. Hughes74 found that Alateen participants had more positive scores on a mood state and self-esteem scale than did COAs who did not participate in Alateen. Peitler75 compared Alateen to group counseling and no treatment in sons of alcoholics 4 to 16 years of age. Group counseling had more positive effects than did Alateen in improving self-worth and reducing withdrawal and antisocial tendencies.
The Midwestern Prevention Project
The Midwestern Prevention Project is a comprehensive, multicomponent community trial for prevention of adolescent drug abuse. Although it is not a program that targets COAs specifically, we include it here as an example of a comprehensive prevention effort with solid evaluation findings. The program integrates demand and supply reduction strategies, resistance skill training programs, and local school and community policy efforts aimed at institutionalizing prevention programming and limiting youth access to drugs. The program is an example of a combination of both strategic primary prevention and a comprehensive prevention approach.
The intervention consists of five program components: a mass media campaign, school involvement, parent involvement, community organization, and health policy. The evaluation took place in two major metropolitan areas, with the school being the unit of analysis. Results demonstrated that adolescents in schools assigned to the intervention condition showed consistently lower prevalence rates of cigarette, alcohol, and marijuana use than did adolescents in schools assigned to the control condition. By the 4th year, 9th/10th graders in intervention schools showed less cocaine and crack use. Mediational analyses have shown a decrease in social acceptance of substance use and perceived norms about drug use36,,37 and that these changes have a significant mediational effect on subsequent drug use.
Our understanding of the factors that influence adjustment has grown tremendously over the last decade. We now understand that the patterns of adjustment are not as simple as once thought and that children may be affected in subtle ways. To be effective, prevention and intervention programs must be based on our knowledge of the mediating and moderating factors of the exposure-adjustment relationship.
Evaluation research with COAs indicates several basic prevention components that should be included in programs for COAs. These include information and education, skills-building in the areas of coping and social competence, social support and an outlet for the safe expression of feelings, and finally healthy alternative activities.
Furthermore, there are many settings where prevention and intervention with COAs can be conducted. Primary care physicians should be trained to screen, identify, and refer COAs to appropriate programs. Additionally, doctors can use their resources to advocate for policy changes that will help ensure the mental health of their young patients and their families. Programs in schools can be expanded to reach more young people through school-wide alcohol and drug education. Although not well-researched, parental and family training is a promising area that has been shown to reduce child and adolescent risk factors. Comprehensive community programs that target social norms regarding alcohol and other drugs is another promising, yet underutilized, resource.
Finally, future research should work to clarify the differences between COAs and children exposed to other forms of stress or family dysfunction. Above all, more stringent methods are needed to improve both program design and evaluation methods. Future research can further our understanding through the use of better sampling procedures, random assignment, control groups, appropriate sample sizes, use of developmentally and culturally appropriate instruments, and precise definitions of parental alcoholism. Another important area for future research concerns how different cultural and ethnic groups are impacted by parental alcoholism, how they should be recruited into programs, and which intervention components provide relevant information and skills to particular groups.
Emshoff and Anyan76 called for the use of an action research model that would frame an interactive relationship between research and intervention. As researchers continue to search for links among characteristics of COAs, their families, and ways to protect them from negative outcomes, this approach remains relevant. Longitudinal evaluations of programs will lead to improved programs and provide information to help researchers understand the length of program effects. Finally, the delineation of evaluation information is critical to improve services for COAs.
- COA =
- children of alcoholics •
- NSE =
- National Structured Evaluation •
- SAP =
- student assistance program •
- SMAAP =
- Stress Management and Alcohol Awareness Program •
- CASPAR =
- Cambridge and Somerville Program for Alcoholism Rehabilitation •
- SFP =
- Strengthening Families Program •
- COSA =
- children of substance abusers
- ↵National Association for Children of Alcoholics. Children of Alcoholics: Important Facts. Rockville, MD: National Clearinghouse for Alcohol Information; 1998
- ↵Anderson G. When Chemicals Come to School. Troy, MI: Performance Resource Press; 1987
- Albee G
- Emshoff JG
- ↵Nastasi BK, DeZolt DM. School Interventions for Children of Alcoholics. New York, NY: Guilford Press; 1994
- ↵Serrins DS, Edmundson EW, Laflin M. Implications for the alcohol/drug education specialist working with children of alcoholics: a review of the literature from 1988 to 1992. J Drug Educ. 1995;:25:171–190
- ↵Garmezy N. Stressors of childhood. In: Garmezy N, Rutter M, eds. Stress, Coping, and Development in Children. New York, NY: McGraw-Hill; 1983
- ↵Rutter M. Protective factors in children's responses to stress and disadvantage. In: Joffe JM, Albee GW, Kelly LD, eds. Readings in Primary Prevention of Psychopathology: Basic Concepts. Hanover, NH: University Press of New England; 1979
- Werner EE
- ↵Gross J, McCaul ME. A comparison of drug use and adjustment in urban adolescent children of substance abusers. Int J Addict. 1990–1991;25:495–511
- Johnson JL,
- Sher KJ,
- Rolf JE
- Marcus AM
- ↵Weintraub SA. Children with adolescents at risk for substance abuse and psychopathology. Int J Addict. 1990–1991:25:481–494
- ↵Kumpfer KL. Family-focused Prevention Interventions for Children of Alcoholics. Presented at the National Council on Alcoholism Annual Forum; Alcohol and the Family; 1986; San Francisco, CA
- ↵Ayers TS, Short JL, Beals J, Sandler IN, Roosa MW. Stress, Self-esteem, and Symptomatology in Children of Problem Drinking Parents. Presented at the Western Psychological Association Annual Conference; 1988; San Francisco, CA
- ↵Barnes GM. Impact of the family on adolescent drinking patterns. In: Johnson JL, Rolf JE, eds. When Children Change: Critical Perspectives on Children of Alcoholics. New York, NY: Guilford Press; 1990
- McCord J
- ↵Wolin SJ, Bennett LA, Jacobs JS. Assessing family rituals in alcoholic families. In: Imber-Black E, Roberts J, Whitney R, eds. Rituals in Families and Family Therapy. New York, NY: WW Norton & Company; 1988
- ↵Clair DJ, Genest M. Variables associated with the adjustment of children of alcoholics. In: Lotterhos JF, McGuire ME, eds. Nurse Care Planning on Alcoholism: A Resource Guide. Greenville, NC: East Carolina University, Alcoholism Training Program; 1987
- ↵Robinson BE, Rhoden JL. Working with Children of Alcoholics: The Practitioner's Handbook. Thousand Oaks, CA: Sage Publications; 1998
- ↵Beal J, Roosa MW, Sandler IN, Short JL, Gehring L. Social Support Among Children of Alcoholics. Presented at the American Psychological Association Convention; 1986; Washington, DC
- Rutter M
- ↵Windle J, Searles JS, eds. Children of Alcoholics: Critical Perspectives. New York, NY: Guilford Press; 1990
- ↵Williams CN. Prevention and treatment approaches for children of alcoholics. In: Windle J, Searles JS, eds. Children of Alcoholics: Critical Perspectives. New York, NY: Guilford Press; 1990
- ↵National Structured Evaluation (NSE). Third Report to Congress on Alcohol and Other Drug Abuse Prevention: The National Structured Evaluation. Washington, DC: US Dept of Health and Human Services; 1995
- ↵Pentz MA. Comparative effects of community-based drug abuse prevention. In: Baer JS, Marlatt GA, McMahon RJ, eds. Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues. Newbury Park, CA: Sage Publications; 1993
- ↵Gonzales NA, Gunnoe ML, Jackson KM, Samaniego RY. Validation of a multicultural events scale for urban adolescents: preliminary strategies for enhancing cross-ethnic and cross-language equivalence. Am J Community Psychol. In press
- ↵Botvin GJ. Drug abuse prevention in school settings. In: Botvin GJ, Schinke S, Orlandi MA, eds. Drug Abuse Prevention with Multiethnic Youth. Thousand Oaks, CA: Sage Publications; 1995
- ↵Moran J. Alcohol Abuse Among Urban Indian Adolescents. Presented at the National Institute on Alcohol Abuse and Alcoholism; 1996; Washington, DC
- Brown KA,
- Sunshine J
- Ellickson PL,
- Bell RM
- ↵Pentz MA. Social competence and self-efficacy as determinants of substance abuse in adolescence. In: Shiffman S, Wills TA, eds. Coping and Substance Abuse. Orlando, FL: Academic Press; 1985
- O'Rourke K
- Kumpfer KL
- ↵Nastasi BK. Groups for Prevention and Intervention With Children of Alcoholics. Boston, MA: Allyn & Bacon; 1998
- ↵Adger H. The Role of Primary Care Physicians. Rockville, MD: National Association for Children of Alcoholics; 1997; http://www.health.org/nacoa
- ↵Bright Futures. Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, VA: Health Resources and Services Administration, Center for Education in Maternal and Child Health; 1995. Brochure
- Palmer JH,
- Paisley PO
- ↵Emshoff JG, Moeti R. Preventive Intervention with Children of Alcoholics. Presented at the Southeastern Psychological Association Meeting; March 1986; Orlando, FL
- DiCicco L,
- Davis RB,
- Hogan J,
- MacLean A,
- Orenstein A
- ↵Springer JF, Phillips JL, Phillips L, Cannady LP, Kerst-Harris E. CODA: a creative therapy program for children in families affected by abuse of alcohol or other drugs. J Community Psychol. 1992; 55–74; OSAP Special Issue
- ↵Kumpfer KL, DeMarsh JP, Child W. Strengthening Families Program: Children's Skills Training Curriculum Manual, Parent Training Manual, Children's Skill Training Manual, and Family Skills Training Manual. Prevention Services to Children of Substance-abusing Parents; Salt Lake City, UT: Social Research Institute, Graduate School of Social Work, University of Utah; 1989
- ↵Kumpfer KL, Molgaard V, Spoth R. The strengthening families program for the prevention of delinquency and drug use. In: Peters RD, McCahon RJ, eds. Preventing Childhood Disorders: Substance Abuse and Delinquency. Newburg, CA: Sage Publications; 1996
- Peitler EJ
- ↵Emshoff JG, Anyan LL. From prevention to treatment: issues for school-aged children of alcoholics. In: Galanter M, ed. Recent Developments in Alcoholism: Children of Alcoholics. Vol 9. New York, NY: Plenum Press; 1989
- Copyright © 1999 American Academy of Pediatrics