Parental alcoholism and associated risk factors

Wandekoken, Kallen Dettmann; Vicente, Creuza Rachel; Siqueira, Marluce Miguel de

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SMAD. Revista eletrônica saúde mental álcool e drogas

On-line version ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.7 no.3 Ribeirão Preto Dec. 2011

ORIGINAL ARTICLE

Parental alcoholism and associated risk factors

Alcoholismo parental y factores de riesgo asociados

Kallen Dettmann Wandekoken^I; Creuza Rachel Vicente^II; Marluce Miguel de Siqueira^III

^IRN, Master's student in Public Health, Universidade Federal do Espírito Santo, ES, Brazil. E-mail: kallendw@gmail.com
^IIDentist, Master's student in Public Health, Universidade Federal do Espírito Santo, ES, Brazil. E-mail: tchussa@gmail.com
^IIIRN, Ph.D. in Physiological Sciences, Associate Professor, Departamento de Enfermagem, Universidade Federal do Espírito Santo, ES, Brazil. E-mail: marluce.@ccs.ufes.br

Correspondence

ABSTRACT

The abusive use of alcohol at an early age becomes a predisposing factor for health, social and economic problems; thus, this research sought to identify risk conditions related to children and adolescents exposed to parental alcoholism. A systematic review was conducted, using the descriptors "alcoholism, risk factors and children", of papers published between 2005 and 2009 in Lilacs, Medline, Scielo and Adolec databases. Problems were found related to alcohol use by children; in relation to behavior and/or in relation to children's emotional factors, implying the need to discuss the issue in order to contribute to the formulation of public policies aimed at this population.

Descriptors: Alcoholism; Risk Factors; Father-Child Relations.

RESUMEN

El uso indebido de alcohol de forma precoz actúa como un factor predisponente para problemas de salud, sociales y económicos: delante de eso, la finalidad de esta investigación fue identificar condiciones de riesgo relacionadas a los niños y adolescentes expuestos al alcoholismo parental. Fue llevada a cabo una revisión sistemática, mediante los descriptores "alcoholismo, factores de riesgo y hijos", de artículos publicados entre 2005 y 2009, en las bases de datos Lilacs, Medline, Scielo y Adolec. Fueron verificados problemas respecto al uso de alcohol por los hijos; respecto al comportamiento y/o respecto a los factores emocionales de los hijos, implicando la necesidad de discusión del tema, con vistas a contribuir a la formulación de políticas públicas destinadas a esta población.

Descriptores: Alcoholismo; Factores de Riesgo; Relaciones Padre-Hijo.

Introduction

The World Health Organization (WHO) appoints alcohol as the most consumed psychoactive substance in the world and the preferred drug among children and adolescents, even when considering socioeconomic and cultural differences among countries⁽¹⁾.

Improper alcohol use in an early stage turns into a predisposing factors for health, social and economic problems. In addition, consumption before the age of 16 years enhances the risk of abusive drinking in adult age for men and women⁽²⁾.

Studies⁽³⁾ show that problematic alcohol use among adolescents is associated with a range of developmental impairments, due to characteristics like the challenge of rules, certainty of omnipotence, besides neurochemical issues related with brain maturing.

In that sense, it is interesting to highlight the study Violence, Drugs and AIDS in Schools, which Unesco researchers developed in 14 Brazilian cities. In that study, it is reported that alcohol is the most consumed drugs in schools, involving about 2.5 million students. Besides, about 10% of all students declared regular drinking⁽⁴⁾.

Thus, alcohol consumption is observed at an increasingly young age, enhancing school, biological, psychological, social and spiritual harm in children and adolescents. In addition, they get more frequently involved in situations of violence, aggressions, traffic accidents, chemical addiction, among others.

Alcohol use during adolescence exposes individuals to higher risks of chemical addiction in adult age and represents one of the main predictors of alcohol use in this phase of life⁽³⁾. Hence, the earlier experimentation starts, the worse the consequences and the greater the risk of developing alcohol abuse and dependence.

Another study⁽⁵⁾ also found that young people's contact with alcohol happens at an increasingly young age. The study involved 11.8 thousand adolescents from 96 private schools. It was observed that 37% had their first contact before the age of 13, and that more than 60% consumed in their own home. This evidences the influence of family on alcohol consumption, as a consequence of genetic factors or permissiveness and parents' example.

It should also be mentioned that, despite the clear consequences presented above, this consumption paradoxically is still fought and valued, depending on the angle: for the media and peers, consumption is enhanced. For the law and public health problems, it is fought. And amidst this context is an individual whose personality is under construction, navigating between opposite tides⁽³⁾.

Thus, various Brazilian and international studies have analyzed the association between psychological and sociocultural factors and students' greater drugs use, identifying that variables like gender, age, work, loss of family structure and absence of religion are associated with this reality⁽⁶⁾.

In that sense, considering the influence of several factors, like biopsychosocial and spiritual aspects, it is relevant to analyze that they originate in the family environment, mainly parental influences. The fact is that the family environment and the way members interact can contribute to the risk of problems observed in children of alcoholics⁽⁷⁾.

Thus, various researchers have focused on children of alcoholics, due to their increased risk of witnessing negative events in the family environment during their development^(8-9).

In view of the above, the intent was to review studies on the theme children of alcoholics, in the attempt to identify risk and vulnerability conditions related to children and young people exposed to parental alcoholism.

Material and Methods

The systematic literature review was developed based on an electronic search, in April 2010, using the databases MEDLINE, LILACS, SciELO and Adolec, with the following descriptors: alcoholism, risk factors and children.

The inclusion criteria were: papers on "parental alcoholism as a risk factor for problems in children and/or adolescents", published between January 2005 and December 2009, in English and Portuguese, and papers whose sample included children and/or adolescents with alcoholic parents. The exclusion criteria were: studies that did not investigate the review theme and did not comply with the established inclusion criteria.

In the first phase, the intent was to identify studies on the theme and whether they complied with the above criteria. In principle, 81 papers were selected. In the second phase, the studies were analyzed and distributed per theme area. After applying the inclusion and exclusion criteria, 18 articles were selected, as most articles in the search did not focus on the theme and were excluded. In case of disagreement among the reviewers about the analysis criteria, the paper was specifically discussed until a final consensus was reached, based on the criteria adopted in this study.

Results and Discussion

The results will be presented in view of the main categories appointed in the studies under analysis during the systematic review.

It is important to observe that interest in research on the relation between substance use and parental styles has increased since the mid-1990's⁽¹⁰⁾.

The 18 studies in the final sample were distributed according to the year of publication, as follows: no publication in 2005, one in 2006⁽¹¹⁾, four in 2007^(12-16), eight in 2008^(17-24) and four in 2009^(25-28).

The countries where most studies in the described theme area were developed were the United States with 11 papers^{(13-14;19-20,22,24-26,28)} and Corea^(23,27) with two; other papers were developed in Denmark⁽¹⁵⁾, China⁽¹⁸⁾, Spain⁽¹⁷⁾, Germany⁽¹⁶⁾ and The Netherlands⁽²¹⁾, each with one publication. As for the study design, longitudinal^{(11,15,20-22,24-25)}, case-control^(18,26) and cross-sectional^(12,19-20) designs predominated. Concerning the methodological approach, one 21-year study stands out, through intergenerational assessment⁽¹⁴⁾ (three generations), and studies that only assessed maternal alcoholism^(21,26). Sample sizes strongly varied, from 28 participants⁽²⁰⁾ to 2,073⁽¹⁸⁾ adolescents and/or children.

After a detailed review of the 18 papers' contents, these were divided in three distinct categories that grouped common themes to present the results.

The results appoint parental (maternal or paternal) alcoholism as an important risk factor for the development of problems related to alcohol beverage during adolescence^{(11-12,15,20)}. Family influence plays a stronger role in the development of alcoholism than in remission or recovery after dependence⁽¹⁵⁾.

In one study⁽¹²⁾, male gender and parents' divorce were identified as risk factors associated with alcohol use. In addition, this study, with 1,269 male participants (mean age 20.1 years) appointed the average start age of alcohol use as 15.7 years, and of alcohol dependence as 19.1 years, in line with other studies that affirm that alcohol use starts at an increasingly young age, as well as the development of chemical dependence.

The results also indicate that parental psychopathology, the family's socioeconomic status and instability in the residential neighborhood are important risk factors for the development of substance use, disorder and other psychopathologies in children of alcoholic parents⁽²⁸⁾.

Another study⁽¹¹⁾ compared personality differences between young people living in environments with parental alcoholism and those coming from non-alcoholic environments, by monitoring levels of neuroticism (anxiety, depression, guilt, shyness, bad mood and drama) and psychoticism (aggressiveness, egocentrism, impulsiveness and antisocial behavior) of individuals in both groups, showing higher levels of neuroticism and psychoticism among participants who lived with parental alcoholism.

This study also identified that, even when they start the adult phase, individuals who lived in alcoholic environments maintained high levels of behavioral and emotional deviations⁽¹¹⁾. Likewise, other authors mentioned that individuals with bi-parental alcoholism presented a greater probability of adverse childhood experiences^(18).

In the same sense, a research⁽¹³⁾ examined the social competency trajectories among the children of alcohol and non-alcoholic parents between 6 and 15 years of age, observing no differences for male children, but lesser social competency at the age of 6 years among female children, indicating that children of alcoholic parents may experience lesser social competency in childhood.

An interesting finding in one of the studies analyzed shows that mothers with alcoholic partners present less tenderness and less maternal warmth during playful interactions with their children, as a predictor of lesser social competency in childhood^(13).

These results raise the possibility that stress, associated with the fact of having an alcoholic partner, may entail excessive effects for maternal interaction with the child, interfering in the maternal love and support capacity ^(13).

Also, about behavior, another study⁽¹⁶⁾ aimed to determine whether children of alcoholic parents display more behavioral problems that children of non-alcoholic parents, and also aimed to determine the influence of a paternal antisocial personality disorders (PAPD) in this context. It was suggested in that study that children of alcoholic parents present higher risks for the development of behavioral and attention problems only when parental alcoholism is associated with PAPD.

Another result, found in a Danish longitudinal study⁽¹⁵⁾ on alcoholism, which aimed to determine predictors of adult male alcoholism, appoints the influence of pre-morbid behaviors consistent with childhood conduct disorder (CD) and attention deficit/hyperactivity disorder (ADHD) on the development of alcohol consumption. Similarly, higher ADHD and suicide rates were found in individuals with maternal alcoholism than in controls^(26).

In line with the above data, one research⁽¹⁷⁾ identified probability levels of subclinical symptoms twice as high and of a definitive diagnosis of any mental disorder four times as high among children of alcoholics. The study more specifically mentions significantly higher risks for attention deficit/hyperactivity disorder, depression, phobias, enuresis and ticks. Besides, they obtained worse results on all cognitive tests used and their risk of low school performance levels were nine times higher than among control participants⁽¹⁷⁾.

Other studies^(19,22) showed that parental drinking was directly associated with children's externalization and internalization behaviors. Resilience may serve as a protection factor against parental alcoholism, but its magnitude is small. Departing from the same viewpoint, some authors^(23,25) mention the high risk that children will experience some kind of psychopathology in childhood or adolescence, mainly externalization disorders, besides increased chances of depressive disorders, which are higher in adolescents.

In that sense, one study⁽²⁰⁾ aimed to assess the affective circuit and risk of alcoholism during late adolescence, in view of differences between the frontostriatal responses of vulnerable and resilient children of alcoholic parents. In conclusion, more externalized behaviors were found in the vulnerable group, which is related with pre-frontal dorsomedial activation. This appoints a consistent pattern in the activation of the suppression of affective response, perhaps resulting in inability to develop emotional stimuli over time. This did not happen in the resilient group.

Other authors⁽²⁴⁾ also identified that children of alcoholic parents were also more prone to the experience of repetitive stressors and their stressor rate more severely in adult age.

It is interesting to highlight one study⁽²¹⁾ that differs from the above, in which significant relations were highlighted between family relation and alcohol use. The authors show that, except for the specific behavioral control of alcohol, the problem of alcoholic parents does not structurally affect the family at all time. And, in addition, more alcohol-related problems do not result in lesser behavioral control, less general support or further permissiveness.

Some authors⁽²¹⁾ believe that these differences may be related with methodological issues, as that study does not discuss the diagnosis of alcohol dependence, but all cases of drinking problems, which may reflect the situation of the population in general. Another explanation is related to the hypothesis that the parental part who does not use alcohol tends to protect the children from stressing situations related to the partner's alcoholism.

Similarly, other authors⁽²⁷⁾ have shown that adolescents who received less parental support were more prone to attending to substance abuse criteria, as well as adolescents with peer influence. Adolescents with high levels of parental support, on the other hand, were not influenced by alcoholism, concluding that a positive relation between parents and children will mitigate the negative effects of an alcoholic father on the risk of substance abuse^.

The fact is that, in the study⁽²¹⁾ in question, it is also mentioned that the results do not imply that drinking problems do not affect personal or functional cognition, but suggest that the parents are able to regulate their behavioral problems concerning their children and parental practices. They indicate that parents with greater alcohol-related problems are not more permissive than parents without these problems.

The results also appoint that higher levels of behavioral control, support, rules and alcohol use control by parents result in less alcohol consumption in most young adolescents. When parents are more permissive towards alcohol use, the adolescents display higher usage levels. Support and control of alcohol use, however, are associated with less alcohol use in younger adolescents, of up to four years⁽²¹⁾.

It seems that parents exert influence during the initial phase of alcohol use, which happens more or less at the age of 14 years, but they are no longer that important once the drinking habit has been established⁽²¹⁾.

It is suggested that genetic factors become more important during adolescence, while the role of environmental factors decreases. In addition, during adolescence, paternal factors become less important, while the influence of friends increases and strongly affects alcohol use^(21,25). Thus, the influence of social support on the risk of substance abuse depends on the source of support - parents or peers⁽²⁸⁾.

It is also highlighted that specifically maternal alcohol use is directly associated with alcohol use by older adolescents. This finding is important, as most of the previous studies that focused on alcoholism or drinking problems ignored women⁽²¹⁾.

Another study⁽¹⁴⁾ analyzed during the systematic review should be highlighted due to the different methodological approach. A 21-year research aimed to test intergenerational transmission models of substance use. Three generations were assessed: G1-grandparents, G2-parents and G3-children. It was hypothesized that alcohol use in G2 was associated with lack of discipline and poor inhibitory control of G1 on G2. Substance use in G2 at the end of adolescence, then, was associated with substance use by the children in G3. And, in the conclusion, variations are observed in terms of the substance: for alcohol use, only crossed associations among the generations were found. For illegal drugs on the other hand, both poor inhibitory control and poor discipline influenced intergenerational use.

Conclusion

Based on the results found in this study, it was observed that strategies that only consider children and/or adolescents may not be effective. Approaches are needed that take into account family influence when devising preventive actions related to psychoactive substance use.

In line with the papers analyzed, parental alcoholism can be a risk factor and cause problems related to alcohol use by the children: related to behavior and/or related to emotional factors in the children.

Therefore, bonds between parents and children should be strengthened and more positive attitudes of support and dialogue should be encouraged, with a view to enhancing family socialization, which can produce more effective results, as the papers showed. In that sense, it is important for parents to pay attention to their children's daily development, contributing to the education and value formation process.

Thus, in this research, attempts were made to understand the problems deriving from parental alcoholism for the children, in a psychosocial approach of psychoactive substance use and abuse. Hence, the understanding of these issues can contribute to the development of health policies that benefit children and adolescents, seeking to promote healthy life and actions to prevent improper alcohol use. In addition, it can contribute to the scientific development of professionals who work in this area every day.

References

1. Vieira DL, Ribeiro M, Romano M, Laranjeira MM. Álcool e adolescentes: estudo para implementar políticas Municipais. Rev Saúde Pública. 2007;41(3): 396-403.

2. Laranjeira R, Hinkly D. Evaluation of alcohol outlet density and its relation with violence. Rev Saúde Pública. 2002;36(4):455-61.

3. Pechanscky F, Szobot CM, Scivoletto S. Uso de álcool entre adolescentes: conceitos, características epidemiológicas e fatores etiopatogênicos. Rev Bras Psiquiatr. 2004;26(supl. 1):14-7.

4. Abramovay M. Violência, Drogas e Aids nas Escolas. Brasília: Unesco; 2002.

5. Bouer J. Álcool na infância: 37% dos jovens bebem antes dos 13 anos. Associação Brasileira de Estudos de Álcool e outras Drogas, out. 2009;[acesso 13 jan 2010]; Disponível em: http://www.abead.com.br/midia/exibMidia/?midia=5018.

6. Soldera M, Dalgalarrondo P, Côrrea HR Filho, Silva CAM. Uso de drogas psicotrópicas por estudantes: prevalência e fatores sociais associados. Rev Saúde Pública. 2004;38(2):277-83.

7. National Institute on Alcohol Abuse And Alcoholism. Children of Alcoholics: Are They Different? Alcohol Alert. July 1990; [acesso 13 jan 2010]; 9(288). Disponível em: http://pubs.niaaa.nih.gov/publications/aa09.htm.

8. Jacob T, Johnson S. Parenting Influences on the Development of Alcohol Abuse and Dependence. Alcohol Res Health. 1997;21(3):204-9.

9. Moss RH, Billings AG. Children of alcoholics during the recovery process: Alcoholic and matched control families. Addict Behav. 1982;7:155-63.

10. Paiva FS, Ronzani TM. Estilos parentais e consumo de drogas entre adolescentes: revisão sistemática. Psicol Estud. 2009;14(1):177-83.

11. Larkins JM, Sher KJ. Family history of alcoholism and the stability of personality in young adulthood. Psychol Addict Behav. 2006;20(4):471-7.

12. Sartor CE, Lynskey MT, Heath AC, Jacob T, True W. The role of childhood risk factors in initiation of alcohol use and progression to alcohol dependence. Addiction. 2007 Feb;102(2):216-25.

13. Eiden RD, Edwards EP, Leonard KE. A conceptual model for the development of externalizing behavior problems among kindergarten children of alcoholic families: role of parenting and children's self-regulation. Dev Psychol. 2007 Sep;43(5):1187-201.

14. Pears K, Capaldi DM, Owen LD. Substance use risk across three generations: the roles of parent discipline practices and inhibitory control. Psychol Addict Behav. 2007;21(3):373-86.

15. Knop J, Penick EC, Nickel EJ, Mednick SA, Jensen P, Manzardo AM, et al. Paternal alcoholism predicts the occurrence but not the remission of alcoholic drinking: a 40-year follow-up. Acta Psychiatr Scand. 2007;116(5):386-93.

16. Barnow S, Ulrich I, Grabe HJ, Freyberger HJ, Spitzer C. The influence of parental drinking behaviour and antisocial personality disorder on adolescent behavioural problems: results of the Greifswalder Family Study. Alcohol. 2007;42(6):623-8.

17. Diaz R, Gual A, Garcia M, Arnau J, Pascual F, Cañuelo B, et al. Children of alcoholics in Spain: from risk to pathology. Results from the ALFIL program. Soc Psychiatry Psychiatr Epidemiol. 2008;43(1):1-10.

18. Xiao Q, Dong MX, Yao J, Li WX, Ye DQ. Parental alcoholism, adverse childhood experiences, and later risk of personal alcohol abuse among Chinese medical students. Biomed Environ Sci. 2008;21(5):411-9.

19. Hussong AM, Flora DB, Curran PJ, Chassin LA, Zucker RA. Defining risk heterogeneity for internalizing symptoms among children of alcoholic parents. Dev Psychopathol. 2008;20(1):165-93.

20. Heitzeg MM, Nigg JT, Yau WY, Zubieta JK, Zucker RA. Affective circuitry and risk for alcoholism in late adolescence: differences in frontostriatal responses between vulnerable and resilient children of alcoholic parents. Alcohol Clin Exp Res. 2008;32(3):414-26.

21. Van der Zwaluw CS, Scholte RH, Vermulst AA, Buitelaar JK, Verkes RJ, Engels RC. Parental problem drinking, parenting, and adolescent alcohol use. J Behav Med. 2008;31(3):189-200.

22. Lee HH, Cranford JA. Does resilience moderate the associations between parental problem drinking and adolescents' internalizing and externalizing behaviors? A study of Korean adolescents. Drug Alcohol Depend. 2008;96(3):213-21.

23. Hill SY, Shen S, Lowers L, Locke-Wellman J, Matthews AG, McDermott M. Psychopathology in offspring from multiplex alcohol dependence families with and without parental alcohol dependence: a prospective study during childhood and adolescence. Psychiatry Res. 2008;160(2):155-66.

24. Hussong AM, Bauer DJ, Huang W, Chassin L, Sher KJ, Zucker RA. Characterizing the life stressors of children of alcoholic parents. J Fam Psychol. 2008;22(6):819-32.

25. Marmorstein NR, Iacono WG, McGue M. Alcohol and illicit drug dependence among parents: associations with offspring externalizing disorders. Psychol Med. 2009;39(1):149-55.

26. Cottencin O, Nandrino JL, Karila L, Mezerette C, Danel T. A case-comparison study of executive functions in alcohol-dependent adults with maternal history of alcoholism. Eur Psychiatry. 2009;24(3):195-200.

27. Park S, Kim H, Kim H. Relationships between parental alcohol abuse and social support, peer substance abuse risk and social support, and substance abuse risk among South Korean adolescents. Adolescence. 2009;44(173):87-99.

28. Buu A, Dipiazza C, Wang J, Puttler LI, Fitzgerald HE, Zucker RA. Parent, family, and neighborhood effects on the development of child substance use and other psychopathology from preschool to the start of adulthood. J Stud Alcohol Drugs. 2009;70(4):489-98.

Correspondence:
Kallen Dettmann Wandekoken
Universidade Federal do Espírito Santo
Centro de Estudos e Pesquisas sobre o Álcool e outras Drogas
Av. Marechal Campos, 1468
Bairro: Maruípe
CEP: 29040-090, Vitória, ES, Brasil
E-mail: kallendw@gmail.com

Received: Aug. 16^th 2010
Accepted: Jan. 5^th 2012

1. Vieira DL, Ribeiro M, Romano M, Laranjeira MM. Álcool e adolescentes: estudo para implementar políticas Municipais. Rev Saúde Pública. 2007;41(3): 396-403. [ Links ]

2. Laranjeira R, Hinkly D. Evaluation of alcohol outlet density and its relation with violence. Rev Saúde Pública. 2002;36(4):455-61. [ Links ]

3. Pechanscky F, Szobot CM, Scivoletto S. Uso de álcool entre adolescentes: conceitos, características epidemiológicas e fatores etiopatogênicos. Rev Bras Psiquiatr. 2004;26(supl. 1):14-7. [ Links ]

4. Abramovay M. Violência, Drogas e Aids nas Escolas. Brasília: Unesco; 2002. [ Links ]

6. Soldera M, Dalgalarrondo P, Côrrea HR Filho, Silva CAM. Uso de drogas psicotrópicas por estudantes: prevalência e fatores sociais associados. Rev Saúde Pública. 2004;38(2):277-83. [ Links ]

8. Jacob T, Johnson S. Parenting Influences on the Development of Alcohol Abuse and Dependence. Alcohol Res Health. 1997;21(3):204-9. [ Links ]

9. Moss RH, Billings AG. Children of alcoholics during the recovery process: Alcoholic and matched control families. Addict Behav. 1982;7:155-63. [ Links ]

10. Paiva FS, Ronzani TM. Estilos parentais e consumo de drogas entre adolescentes: revisão sistemática. Psicol Estud. 2009;14(1):177-83. [ Links ]

11. Larkins JM, Sher KJ. Family history of alcoholism and the stability of personality in young adulthood. Psychol Addict Behav. 2006;20(4):471-7. [ Links ]

12. Sartor CE, Lynskey MT, Heath AC, Jacob T, True W. The role of childhood risk factors in initiation of alcohol use and progression to alcohol dependence. Addiction. 2007 Feb;102(2):216-25. [ Links ]

14. Pears K, Capaldi DM, Owen LD. Substance use risk across three generations: the roles of parent discipline practices and inhibitory control. Psychol Addict Behav. 2007;21(3):373-86. [ Links ]

19. Hussong AM, Flora DB, Curran PJ, Chassin LA, Zucker RA. Defining risk heterogeneity for internalizing symptoms among children of alcoholic parents. Dev Psychopathol. 2008;20(1):165-93. [ Links ]

21. Van der Zwaluw CS, Scholte RH, Vermulst AA, Buitelaar JK, Verkes RJ, Engels RC. Parental problem drinking, parenting, and adolescent alcohol use. J Behav Med. 2008;31(3):189-200. [ Links ]

24. Hussong AM, Bauer DJ, Huang W, Chassin L, Sher KJ, Zucker RA. Characterizing the life stressors of children of alcoholic parents. J Fam Psychol. 2008;22(6):819-32. [ Links ]

25. Marmorstein NR, Iacono WG, McGue M. Alcohol and illicit drug dependence among parents: associations with offspring externalizing disorders. Psychol Med. 2009;39(1):149-55. [ Links ]