Introduction

The use and abuse of alcohol and other mind-altering drugs is a worldwide phenomenon, and its political, legal, socioeconomic, health, mental health, and familial impact is felt widely. The United Nations(UN) has estimated that between 167 and 315 million individuals aged 15 to 64, representing 3.6–6.9% of the world’s adult population, used an illicit substance in 2010 (UN Office on Drugs and Crime, 2013). Moreover, the use of licit or legal substances, such as tobacco and alcohol, is much more prevalent and deadly. The use of tobacco is considered to be “one of the biggest public health threats the world has ever faced, killing nearly six million people a year. More than five million of those deaths are the result of direct tobacco use while more than 600,000 are the result of nonsmokers being exposed to second-hand smoke” (World Health Organization (WHO), 2013). The use of alcohol is considered the world’s third largest risk factor for disease burden and is associated with numerous social and interpersonal problems; over 2.5 million deaths each year are attributed to alcohol-related problems (WHO, 2011). Although the exact number worldwide is unknown, many of the abusers of alcohol and other drugs are parents of young children and adolescents.

While keeping in mind the global context and multidimensions of problems related to alcohol and other drug abuse, this chapter will focus on the impact of parents’ abuse of selective substances, such as alcohol, heroin and other opiates, cocaine and methamphetamines, tobacco, and marijuana, on their children. It will provide a summary of several theoretical perspectives, an overview of the dynamics of families with substance-abusing parents (SAPs), the impact on their children at different ages, and the most effective treatment approaches for children and parents. A brief discussion of the implications for service providers and policymakers will be offered.

Impact of substance abuse on the family

Although there is no commonly accepted international terminology in relation to problematic use of different psychoactive substances, the authors will use the term “substance abuse” as a catchall term for alcohol and other drug use-related problems, while the term “substance-use disorder” will be used as a diagnostic category (American Psychiatric Association, 2013). These terms refer to continued use of a substance by a parent despite experiencing a variety of psychosocial problems with various degrees of severity. The extensive use of some substances, such as opiates or alcohol, leads to physical dependence, or addiction, which means that the user cannot wait very long between doses without experiencing craving and symptoms of physical withdrawal, and, in most cases, requires detoxification under medical supervision. The use of other psychoactive substances, particularly cocaine, methamphetamine, or tobacco, while leading to severe psychological dependence, may not require formal medical detoxification.

In addition, the legal status of a substance has a differential impact on parents and their children. For example, alcohol (as well as other sedatives and hypnotics, such as sleeping pills and tranquilizers, opioid pain medications, and tobacco) can be legally obtained in most countries. Consequently, the lifestyles and ethnic backgrounds of individuals using these substances vary widely, reflecting the population at large. Moreover, addiction to alcohol develops slowly and thus the insidious impact of alcohol abuse is most commonly seen after adult independence has been achieved and the individual is likely to marry and become a parent. Although the effects of alcohol abuse by a parent vary considerably from family to family, common patterns may include “communication problems, conflict, chaos and unpredictability, inconsistent messages to children, breakdown in rituals and traditional family rules and boundaries and emotional, physical and sexual abuse” (Straussner, 2011, p. 5).

Unlike alcohol, the use of nonprescription opiates is illegal, and many of its users grew up in dysfunctional and often physically abusive families with parents and even grandparents who abused alcohol or opiates. Since opiates tend to be highly addictive, individuals tend to become affected at a younger age, often before completing their education and functioning as self-supporting adults. Consequently, they may have difficulties in forming or maintaining a stable family of procreation of their own and remain connected to their dysfunctional families of origin.

Given that the time and effort necessary to obtain drugs and to pay for them are considerable, the lifestyle associated with opiate addiction is highly unstructured and generally characterized by poverty and illegal activities. In most countries, opiate abusers are likely to be members of minority or disenfranchised, low-income groups, or may be characterized as having antisocial personality. A series of live-in partners, prostitution, and incarceration is fairly common with a severe negative impact on family life. In many parts of the world, intravenous opiate users and their partners are infected with HIV/AIDS and other sexually transmitted diseases, as well as exposed to various systemic infections including hepatitis C, tuberculosis, endocarditis and other heart infections, and pneumonia. Parental use of stimulants such as methamphetamines and cocaine (including crack) can also lead to various medical complications including sudden death and severe financial and legal repercussions, as well as negative psychological effects, such as increased paranoia and suicidal ideation, all of which wreak havoc on family life (Straussner, 2011).

The growing legalization of marijuana is likely to lead to increased use among some individuals (Palamar et al., 2014). While little is known about the impact of parental marijuana use on family life, it is known that marijuana-abusing individuals appear to be more inner-focused and less socially interactive, making them less physically and emotionally available to their families (Straussner, 2011).

Given these dynamics, familiarity with the pharmacological actions of different substances of abuse: their impact on individuals, families, and communities: and the kinds of medical and psychosocial interventions that are needed should be required for anyone trying to help the children of SAPs. Moreover, it is important to keep in mind that many women, whether or not they have a substance-abuse problem themselves, tend to remain in relationships with substance-dependent men. On the other hand, men, in general, tend to leave women who have a substance-abuse problem, leaving the women with limited financial and emotional resources that make it difficult to care for themselves, much less their children.

Theoretical frameworks for understanding substance-abuse problems

Substance abuse is a complex, multifaceted issue that continues to invite controversy as to whether it is a disease, a mental health problem, or a behavior that can be controlled by the individual. This controversy underlies many of the conflicting policies and treatments for both legal and illegal drugs. It also leads to the confusion and shame that both SAPs and their children feel in attempting to understand the out-of-control behaviors that are frequently manifested. Research studies have not identified a single etiological factor that accounts for why some individuals abuse and become addicted to a substance and others do not. Among the most frequently cited factors are genetic and neurobiological differences, psychodynamic factors, severe psychological stress and trauma, and social and environmental dynamics.

There is ample evidence from longitudinal, prospective family and twin studies that there is family heritability for developing the more severe forms of substance-use disorders, and these factors have now been shown to apply not only to alcoholism but also to severe problems with opiates, cannabis, and, to a lesser extent, cocaine (Merinkangas and McClair, 2012). Neurobiological research has increased our understanding of addictive disorders as a “disease of the brain” (Volkow et al., 2011); once an individual’s brain has been repeatedly exposed to drugs, neurological adaptations cause sensitization, so that over time the brain produces an augmented reaction to the drug. The cues associated with the use of the substances, including the social and psychological contexts, take over the thinking processes of the individual, resulting in compulsive behavior that is automatic and thus outside conscious thought (Litrell, 2010). In addition to the biological aspects, the environmental availability and cultural views of the use of a substance influence the risk of becoming addicted.

A psychodynamic perspective proposed by Khantzian (2003) views substance abuse as an adaptation to coping with developmental deficits in one’s ability to regulate emotions and self-esteem and to cope with painful feelings. Khantzian’s self-medication hypothesis proposes that the psychopharmacological effect of specific drugs is sought by individuals to deal with the particular deficits in their emotional self-regulation. For example, he has observed that the use of opiates helps to mute intense anger and rage in those who have suffered psychological abuse and narcissistic injuries. Stimulants are often helpful for people who have depression as well as attention-deficit hyperactivity disorder (ADHD), while drugs with sedative effects, like alcohol and benzodiazepines, have appeal for those who are tense and anxious and those who are highly self-critical (Khantzian, 2003).

More recently, modern attachment theory has augmented Khantzian’s self-medication hypothesis by focusing on the processes that may lead to developmental deficits in emotion regulation, which are seen as stemming from early relational trauma and unattuned responsiveness from the child’s caregivers, resulting in insecure attachment (Schore and Schore, 2008). Insecure attachment predisposes the individual to be vulnerable to – at risk of – using substances as a way of dealing with painful feelings and anxieties about interpersonal closeness. The resulting substance abuse can thus be both the cause and the consequence of addiction, whereby the individual develops an unhealthy attachment to substances as a means of filling a deficit in interpersonal relationships (Flores, 2004).

A conceptual framework focusing on clinical intervention with those with insecure attachment has been proposed by Fonagy and his colleagues (2002). These researchers examine the ways in which ability to mentalize develops in the context of early attachment relationships and its importance in enabling people to regulate their emotions. “Mentalization” refers to parents’ ability to understand what their child is thinking and to reflect the child’s inner world. There is increasing evidence that such mentalizing contributes to attachment security. The abuse of a substance is seen as a way to avoid mentalizing by parents in order not to think about their own traumas. In addition, the dysregulated behaviors often demonstrated by a substance-abusing parent, as well as by the non-substance-abusing parent who is preoccupied with one, may result in parents’ inability to accurately mentalize about their child’s inner world (Fewell, 2010).

Among the most emotionally traumatic experiences for children are those in which their severe distress or fright is caused by their caregivers, since the very people on whom they depend for soothing are the cause of the distress. The Adverse Childhood Experiences (ACE) Study (Anda et al., 2006) has provided epidemiological evidence of the cumulative negative effects of childhood trauma. It demonstrated the correlation between childhood abuse, neglect, domestic violence, and parental substance abuse (PSA) and negative physical health throughout the life span. The study showed that as the number of adverse childhood experiences increased, so did the magnitude of severe health problems. Moreover, there was a strong relationship between early adverse experiences and substance use and abuse in later life, where the greater the number of adverse childhood experiences was highly correlated with early initiation of alcohol use or marriage to an alcoholic spouse (Anda et al., 2006). This lends strength to the argument for the transgenerational impact of parental trauma on their children.

Impact of prenatal substance abuse on neonates and infants

Studies show that biological, environmental, and systemic risk factors commence in pregnancy and are compounded by the postnatal caregiving environment (Tsantefski et al., 2014). While there are some indications that paternal substance use is detrimental to the fetus and neonate, research in this area remains limited (Kendel, 2013). On the other hand, there is a growing knowledge about the consequences of maternal substance abuse during pregnancy.

Substances used by the mother are transmitted to the fetus during pregnancy and may result in the birth of an addicted baby or, depending on the substance used and the timing, in permanent physiological and neurological damage (Azmitia, 2001). It is important to note that although substance use during pregnancy can be very destructive, for many women pregnancy and motherhood can function as a motivating factor in seeking treatment. Conversely, fear of losing custody of their children or lack of child-care resources are frequent treatment obstacles. The impact of fetal exposure to alcohol and other drugs is determined by many factors, including the gestational age of the fetus at exposure, the dosage and frequency of substance taken, the kinds of substances consumed simultaneously, and environmental factors (Nadel and Straussner, 2004).

One of the most destructive substances affecting the embryo is alcohol. Fetal alcohol syndrome (FAS) was first identified in the USA in the early 1970s (Jones and Smith, 1973). Subsequent research revealed a continuum of developmental outcomes ranging from subtle neurobehavioral effects to profound mental retardation and significant medical problems. This continuum of developmental outcomes has become known as fetal alcohol spectrum disorder (FASD) and is believed to affect approximately 2–5% of school-age children in the USA and some Western European countries (May et al., 2009). The manifestation of FASD can range from facial deformities to hyperactivity to central nervous system and information-processing problems; it is seen as one of the leading causes of mental retardation.

Although the more severe manifestations of FASD are generally associated with heavier drinking during pregnancy, not all heavy-drinking women give birth to a child with FAS, and milder manifestations of FASD may occur at drinking levels that range within most cultural norms. The fact that some mother–child dyads appear to be more vulnerable to alcohol’s effects than others suggests that both biological and environmental factors may play a role (Smith, 2011).

The use of illicit drugs, particularly opiates such as heroin, is also associated with prenatal and childbirth complications and adverse outcomes for infants and children. While some babies appear to suffer no ill effects from prenatal drug exposure, others may be premature or small for gestational age and have resulting complications such as respiratory problems. Some neonates suffer from drug withdrawal, known as neonatal abstinence syndrome, and have symptoms such as excessive crying and irritability; hypertonia (stiff muscles); tremors; sleep disturbances; and increased sensitivity to light, sound, and touch. As the child develops, other physiological effects may become evident, including developmental delays such as failure to thrive; cognitive deficits; and speech, language, and motor delays. Physical problems, such as asthma, may develop in connection with respiratory deficiencies. During the school years, learning disabilities and behavioral problems such as ADHD and conduct disorder may become evident (Azmitia, 2001; Nadel and Straussner, 2004).

Although there has been some research on the effects of cocaine, marijuana, and tobacco on neonates, it has been difficult to disentangle the unique effects of each substance, as polysubstance use and nutritional deficiencies are prevalent in the populations studied. Studies have documented that prenatal cocaine and methamphetamine use leads to an increased risk of perinatal death, placenta abruption, low birth weight, prematurity, and small gestational birth weight. Prenatal smoking also increases the chances of sudden infant death syndrome and orofacial clefts.

Impact of PSA on school-aged children

School-aged children of SAPs can range from those known as “resilient children” who do very well in school and are rarely recognized as having any problems at home to those exhibiting severe emotional and behavioral problems. In a well-known longitudinal study, Werner and Johnson (2004) followed children of alcoholics for a 30-year period beginning at age 2. These researchers found that the availability of support systems within the extended family or in the community significantly affected the development of the children into adulthood. Strong extended-family support and the maintenance of family routines were the important mediating factors on the potential for positive outcomes for the child.

More recent studies have focused mainly on children with “externalizing behavior problems” (Eiden et al., 2007). Such children, particularly boys, not only exhibit attention deficits, hyperactivity, conduct disorders, and academic problems, but also cause difficulties for teachers and other students, at times leading them to become scapegoated by their peers. Consequently, not only do these children lack the basic supports at home, but they also may not obtain the support from peers and school personnel that could ameliorate some of the pain experienced by growing up with a SAP. Other children, most commonly girls, are more likely to exhibit what is currently termed internalizing behaviors and feelings, such as social withdrawal, low self-esteem, and feelings of loneliness. These behaviors and feelings can predispose these children to depression, suicidality, and addictions, which become more noticeable during adolescence.

Impact of PSA on adolescents

While less susceptible than younger children to being physically harmed by their parents, adolescents with SAPs are at high risk of suffering other negative consequences affecting their physical, emotional, and behavioral health. In fact, it has been argued that, compared with younger children, adolescent children of SAPs are at greater risk because, on average, they have had more prolonged exposure to PSA and its consequences (Fenster, 2011).

It is important to keep in mind the great variability between early, mid, and late adolescence, as well as the differences among adolescents. Generally, younger adolescents are more dependent on peers for a sense of identity, are more loyal to their family, and are much more concrete in their thinking. In contrast, older adolescents’ newly developing ability for abstract reasoning makes them better able to understand the impact of PSA and recovery from it on their own behavior. At times, the physical and psychological changes faced by adolescents may play a more critical role in their lives than that of being a child of a SAP. Therefore, understanding the developmental issues of adolescents is crucial to effective interventions. Specifically, it is important to remember that the prefrontal cortex of the adolescent brain is not fully developed, so these youth do not yet have a well-developed capacity to control emotions and make good judgments. Moreover, the hormonal changes during adolescence affect the amygdala (which controls emotions), causing emotions to be intensified. It is common for adolescents to experience everything as a crisis; have mood swings; be impulsive, self-absorbed, and overly sensitive; and not be able to plan or understand cause and effect (Corzolino, 2006).

In addition to their emotional instability, adolescent children of SAPs are likely to confront a constellation of stress factors within and outside their families. Pre-existing internalizing and externalizing problems become more evident during adolescence, placing these children at increased risk of emotional, familial, social, academic, and legal problems. Of particular concern is the increased risk of intergenerational transmission of substance-use problems during the adolescent years. Studies have shown that more than half of all children who were exposed to PSA disorders during adolescence developed their own substance-use disorders, compared with 15% of those who were not so exposed (Rothman et al., 2008).

Barriers to treatment

Children of all ages often experience feelings of guilt and shame about their parents’ substance abuse and may be reluctant to discuss it. Some perceive this abuse and impaired parenting as normal and therefore “not a problem.” Even when children recognize a parent’s alcohol or drug use as problematic, they may want to protect the parent, or be fearful of the negative consequences of sharing their “family secrets.”

Parents may also avoid seeking services due to the stigma and fear of the consequences, such as being judged and having their children taken away. Other barriers include drug-using lifestyles, relationship difficulties between parents, negative attitudes of professionals, concerns about confidentiality, and the cost of, and lack of confidence in, available treatments (Taylor et al., 2008).

Treatment approaches

Given these challenges to disclosure, it would seem best for clinicians to explore, in a respectful and nonjudgmental fashion, PSA and other adverse childhood events in every child or adolescent. Once PSA is recognized, appropriate help needs to be offered to both parents and children. Interventions and treatments range from the removal of children from SAPs and placement in foster care to individual and group treatment of children or their parents, as well as family-based treatment.

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