|Year : 2020 | Volume
| Issue : 2 | Page : 190-195
Prevalence of psychiatric morbidities among children of alcohol-dependent patients – A hospital-based cross-sectional study
Harsh Avinash Thappa, Arun Selvaraj, Vinoth Krishna Dass
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
|Date of Submission||02-Jul-2020|
|Date of Decision||04-Aug-2020|
|Date of Acceptance||25-Aug-2020|
|Date of Web Publication||25-Nov-2020|
Dr. Vinoth Krishna Dass
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Madagadipet - 605 107, Puducherry
Source of Support: None, Conflict of Interest: None
Background: Children of alcoholics (COAs), particularly experience life uniquely in the families of alcoholic parents. They are more likely than others to suffer from various physical, emotional, and mental health problems. Aims: The aim of this study is to estimate the prevalence of psychiatric morbidity among the children of alcohol-dependent patients attending our tertiary health care center, and further determine the association between clinical-sociodemographic background and psychiatric morbidities among these children. Methods: It was a cross-sectional study consisting of 100 COAs. Data collections tools used were: Pro forma for sociodemographic details, the Kiddie – Schedule for Affective Disorders and Schizophrenia for school-aged children (6–18 years) Present and Lifetime version (K-SADS PL), Learning Disability Checklist and Wechsler's Intelligence Scale for Children. The data were entered using statistical software Epi-Info (version 22.214.171.124) software package, analyzed using the SPSS software version 24.0. Results: About 60% of COAs assessed had the presence of psychiatric morbidity, with anxiety spectrum and depressive disorders being the most commonly associated diagnosis. It was noted that female gender had a positive association with anxiety spectrum disorders. Further, a history of child abuse had a positive association with evidence of psychiatric morbidity in these children. In addition, family history of antisocial personality traits had a significant association with conduct disorder in COAs. Conclusions: To conclude, psychiatric morbidities were identified in about 60% of children whose fathers were alcohol dependent. These COA's commonly manifested with two major psychiatric morbidities, namely anxiety and depression. Nearly 1/10th of these children were noted to have substance use as well.
Keywords: Child abuse, children of alcoholics, conduct disorder, psychiatric morbidity
|How to cite this article:|
Thappa HA, Selvaraj A, Dass VK. Prevalence of psychiatric morbidities among children of alcohol-dependent patients – A hospital-based cross-sectional study. Ann Indian Psychiatry 2020;4:190-5
|How to cite this URL:|
Thappa HA, Selvaraj A, Dass VK. Prevalence of psychiatric morbidities among children of alcohol-dependent patients – A hospital-based cross-sectional study. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Sep 27];4:190-5. Available from: https://www.anip.co.in/text.asp?2020/4/2/190/301437
| Introduction|| |
Alcoholism is a global health issue. The WHO estimations reveal around 208 million people with affected around the world, about 4.1% of the population above 15 years of age. Alcoholism affects not only the individual, but the functioning of his whole family and the environment around him. Living with an alcoholic can be constantly stressful, affecting each individual distinctively. Children of alcoholics (COAs), particularly experience life uniquely in such families. Hence, COA may be unable to nurture in developmentally healthy ways. COAs are more likely than others to suffer from various physical, emotional, and mental health problems. Furthermore, they are likely to have problems in school and may land up in alcohol abuse and use of other substances as well. Life in an alcoholic family is typically characterized by guilt, fear, pain, stress, and insecurities. However, these children seldom seek help from others, even in adulthood, thus enabling alcoholism to become a family secret. Greater effort should thus be taken from the medical and social service systems to recognize this susceptible group and provide early interventions to them.
Growing up in an alcoholic family does not essentially mean that the child will develop problems. There are youngsters who show little or no signs of difficulty and are also successful as adults. Even so, a family history of alcoholism serves as a substantial risk factor in these individuals. There is well-established evidence suggesting the familial transmission of alcoholism from parents to their off-springs. Density of alcohol problems in biological relatives is often linked to externalizing behaviors that are the important risk factors for alcohol problems in children from such families. Externalizing characteristics can be defined as a range of disruptive childhood behaviors. Furthermore, these children indubitably suffer from the internalizing disorders such as depression and anxiety. There are numerous other risk factors that can lead to such morbidities in COA's, both genetic and environmental. All in all, one can safely presume that alcohol dependence in fathers is associated with a predilection to diverse symptomatology in children from varied cultures and socioeconomic backgrounds. The aim of this current study was to estimate the prevalence of psychiatric morbidity among children of alcohol-dependent patients attending our tertiary health care center and to determine the association between clinical sociodemographic background and psychiatric morbidities among children of alcohol-dependent patients.
| Methods|| |
It was a cross-sectional study conducted in the department of psychiatry, a tertiary care centre in Puducherry of 18 months' duration. The study participants were 100 children of patients who attended psychiatry outpatient department and/or inpatients admitted in Psychiatry ward for alcohol cessation. The inclusion criteria were as follows: (1) Patients diagnosed with alcohol dependence syndrome (ADS) according to ICD-10 DCR guidelines, with at least 5 years of duration of illness. (2) Children of patients with ADS who met the above criteria aged between 6 and 18 years. (3) Patients with ADS who gave consent. The following were excluded: (1) Patients with other substance abuse or dependence; (2) Children of alcohol-dependent patients aged between 6 and 18 years with medical or surgical comorbidities; and (3) Mothers with known psychiatric illness. Sample size was calculated using the prevalence rate of a particular morbidity (conduct disorder) occurring in children of alcohol-dependent fathers from previous studies using the formula 4PQ/D2, where-in P (Prevalence) was taken as 10.9 and D (absolute precision) as 6%. Consecutive alcohol-dependent patients who attended the psychiatry outpatient department and inpatients admitted in the psychiatry ward for de-addiction along with their children aged 6–18 years, who met the inclusion and exclusion criteria mentioned above were recruited for the study.
Data collection procedure
Alcohol-dependent patients who visited our outpatient department and inpatients admitted in our ward for alcohol cessation treatment diagnosed on the basis of ICD–10 DCR guidelines were chosen. All information regarding the research project was given to them to read or was read to them. Consent was obtained from these patients and/or sources who could be used as the accessible sources of information. These patients, their spouses and children were then called to the hospital for an interview on a date convenient for the family. The children were called to the hospital for the study only on holidays/after school hours. Initial socio demographic details were obtained from them followed by the complaints from parents, complaints received from school, and then screening questionnaires namely the Kiddie – Schedule for Affective Disorders and Schizophrenia for school-aged children (6–18 years) Present and Lifetime version (K-SADS PL) and learning disabilities checklist were applied. K-SADS PL - The K-SADS-PL November 2016 combines both dimensional and categorical assessment methods to detect the current and prior episodes of psychopathology in children and adolescents in accordance to DSM-5 criteria. After an unstructured introductory interview, screen interview is initiated which surveys the primary symptoms of the different diagnoses assessed. Specific enquiries and scoring criteria are provided to evaluate each symptom. The bulk of the items is scored using a 0–3 point rating scale, where 0 indicates no information is available, 1 suggests that the symptom is not present; 2 specifies subthreshold levels of symptomatology, and scores of 3 signify threshold criteria. The remaining items are graded on a 0–2 point rating scale on which 0 suggests no information, 1 infers the symptom is not present, and 2 indicate the symptom is present. When deciding if a symptom meets threshold versus subthreshold level criteria, it is imperative to assess the severity, frequency, and duration of the symptom, along with impairment from the symptom. To achieve a threshold score of 3, the youngster must meet or surpass the threshold scoring criteria. The whole interview takes about 30–45 min in total, screening various disorders listed.
Learning disability checklist
Devised by the National Center for Learning disabilities, it is used to assess evidence of specific learning disorder in children, aged from preschool to high school and adult. It has various domains such as social/emotional, attention, gross and fine motor skills, language, reading and written language.
Furthermore, the psychologist assessed those children chosen for the study for their Intelligence and the presence of intellectual disability if necessary and grade its severity using Wechsler's Intelligence Scale for Children (WISC). The Institute Ethics Committee approval was taken before initiating the study.
The data were entered using statistical software Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America (USA) software package, analyzed using the SPSS version 24.0 (SPSS Inc., Chicago, Illinois, USA). Categorical independent variables were analyzed by using the Chi-square test and continuous variables using the unpaired t-test. To assess the associations between dependent and independent variables, Fisher's exact test was applied. P < 0.05 was considered as statistically significant.
| Results|| |
A total of 100 children, belonging to 65 alcoholic fathers enrolled and consented for the study. Thirty-eight fathers taken for the study had one child, whereas 19 fathers had 2 children and 8 had 3 children between the age groups as mentioned in the inclusion criteria. The children were assessed using K-SADS PL screening tool, intelligence tests, and learning disability checklist to look for evidence of any psychiatric morbidity in them.
The variable, age of father (years) was normally distributed (Shapiro-Wilk test: P = 0.051). The mean age of father (years) was 42.13 (standard deviation [SD] ± 7.32) ranging between 27 and 62 years. The median (interquartile range [IQR]) age of father (years) was 42.00 (6.00).
Majority of the father's assessed had completed secondary education (34%), followed by high school education (25%). Sixteen percent of the fathers assessed were noted to be illiterates, whereas 12% had completed only primary education. About 9% and 4% of fathers had posthigh school degrees and had completed their postgraduation, respectively.
Seventy-one percent (71.0%) of the children assessed were Hindu by religion, whereas 20.0% and 9.0% of them were Muslim and Christians, respectively.
Forty-three of the children assessed belonged to a lower to upper lower background; 38 were from middle to lower middle class; 18 were from an upper middle class, while only 1 belonged to an upper background.
Relation to alcohol use
The variable, total duration of alcohol use (years) was normally distributed (Shapiro-Wilk test: P = 0.201). The mean (SD) of total duration of alcohol use (years) was 19.97 (7.09). The median (IQR) of total duration of alcohol use (years) was 20.00 (9.25). The total duration of alcohol use (years) ranged from 6 to 35 years.
The variable, average intake (units/week) was not normally distributed (Shapiro-Wilk test: P < 0.001). The mean (SD) of average intake (units/week) was 71.57 (28.97). The median (IQR) of average intake (units/week) was 64.00 (36.00). The average intake (units/week) ranged from 34 to 160 in both groups.
Clinical profile of fathers of children under study
Majority of the fathers (94%) had craving for alcohol, following abstinence. About 58% developed tolerance to alcohol that is required greater amounts of alcohol over time to feel similar pleasurable effects, noted earlier with lower doses. About half (54%) of the patients needed an eye-opener drink almost every day. Half (50%) the patients had experienced symptoms of simple withdrawal some time in their past/present. About 28% of the patients had history of at least 1 episode of withdrawal seizures in the past or present. About a quarter (27%) of the patients had experienced delirium tremens at least once after withdrawal from alcohol. With respect to physical complications due to long-term alcohol consumption, about half (51%) of the patients had gastric complications; less than a quarter (24%) patients had developed pancreatitis sometime in the past or present. About 42% of the patients had a history suggestive of liver disease. Twenty-nine percent of the patients had developed neurological complications. No more than 18% of the patients had cardiac complications due to long-term consumption of alcohol.
Children of alcoholic profile
The variable, age of children (years) was not normally distributed (Shapiro-Wilk test: P ≤ 0.001). The mean (SD) of age of children (years) was 12.76 (3.78). The median (IQR) of age of children (years) was 13.00 (6.00). The age of children (years) ranged from 6 to 18. Fifty-two of the children assessed were males, whereas 48 were females.
Sixty-five of the children were of birth order 1 followed by 27 with birth order 2 and 8 with birth order 3. History of child abuse was elicited in 32 children.
Sixty percent (60%) of the total children assessed and screened had psychiatric morbidity [Table 1]. Eighteen percent (18%) of the children had anxiety spectrum disorder. Among these, 4% of the children had generalized anxiety disorder, 4% of the children had agoraphobic symptoms, 4% had separation anxiety, while 3% of the children suffered from symptoms of panic disorder. Two percent of the children had specific phobia, whereas 2% of the children had social anxiety disorder. Two percent of the children had obsessive compulsive disorder.
|Table 1: Prevalence of psychiatric morbidity among the participants (n=100)|
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Fourteen percent (14%) of the children had depressive disorder. Eleven percent of the children had tobacco use disorder. Ten percent of the children had alcohol use disorder.
Educational status (Fisher's exact test χ2 = 4.780, P = 0.509) as well as socioeconomic status of fathers (Fisher's exact test χ2 = 0.742, P = 1.000) had no relationship to the occurrence of psychiatric morbidity amongst COAs.
The Box-and-Whisker plot depicted the distribution of total duration of alcohol use (years) in the 2 groups [Figure 1]. The middle horizontal line represents the median total duration of alcohol use (years), the upper and lower bounds of the box represent the 75th and the 25th centile of total duration of alcohol use (years) respectively, and the upper and lower extent of the whiskers represent the maximum and the minimum total duration of alcohol use (years) in each of the groups. There was no statistically significant difference between the groups in terms of total duration of alcohol use (years) (t = −0.419, P = 0.676).
|Figure 1: Comparison of the two groups in terms of total duration of alcohol use (years) (n = 100)|
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The Box-and-Whisker plot below depicted the distribution of average intake of alcohol (units/week) in the two groups [Figure 2]. The middle horizontal line represents the median average intake (units/week), the upper and lower bounds of the box represent the 75th and the 25th centile of average intake (units/week), respectively, and the upper and lower extent of the whiskers represent the maximum and the minimum average intake (units/week) in each of the groups.
|Figure 2: Comparison of the two groups in terms of father's average intake (units/week) (n = 100)|
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The variable, average intake of alcohol (units/week) was not normally distributed in the two subgroups of the variable, “Any Psychiatric Morbidity.” Thus, nonparametric tests (Wilcoxon test) were used to make group comparisons. There was no significant difference between the groups in terms of average intake of alcohol (units/week) (W = 1119.500, P = 0.573).
Sex of the COAs had no relationship to the occurrence of psychiatric morbidity statistically (χ2 = 0.007, P = 0.935).
No relationship between gender of COAs and occurrence of depressive disorder (χ2 = 3.580, P = 0.058) and anxiety spectrum disorder (χ2 = 14.704, P ≤ 0.001) could be established statistically.
Female children had the larger proportion of anti-social personality disorders (ASPD) (33%) than male children (4%).
There was a strong statistical association between psychiatric morbidity and history of child abuse (χ2 = 26.662, P ≤ 0.001). Similarly, the occurrence of conduct disorder had a strong statistical relationship with a family history of ASPD (Fisher's exact test χ2 = 29.849, P ≤ 0.001).
| Discussion|| |
Alcohol misuse in underprivileged and deprived societies is particularly harmful as limited financial earnings of the family necessary for sustenance, health care, and schooling are diverted to alcohol. Alcoholism is a disease, involving and impacting every member of the family in a devastating manner in India. COAs are progenies who have grown up in families where either one or both parents are alcoholic. COAs are raised in an atmosphere having a lack of parental care and affection, which is crucial for their development. Alcoholic parents have been recognized for their defective parenting styles. Parenting should preferably be centered on discipline and distinct rules, whereas alcoholics base their parenting on their drinking status and moods. This results in inconsistent and erratic reactions from these parents, leaving children with a sense of uncertainty and danger., The fundamental school years, i.e., from 6 to 15 years or so, are acknowledged as the latency developmental period of children, but this phase does not apply to COAs, as they are persistently under strain which hampers their growth. COAs labor under direct physical, verbal, emotional, and sexual exploitation from their alcoholic parent. Parent–child role reversal has also been perceived in COAs, as they often have to carry the burden of the family. These children typically do everyday household duties, tend to their alcoholic parents and siblings, and even shield other family members when the alcoholic parent becomes drunk and offensive. The effects of these stressors are evidenced in their learning difficulties, conduct and behavioral problems, lack of focus, and deprived academic performance in COAs. In COAs, stress sensitivity can be witnessed through behavioral signs and symptoms. Stress due to the external milieu not only upsets the child's self-regulation, but also hinders development of a normal coping mechanism, which can be appreciated in later years, as these children cultivate more anxiety and depression than those with nonalcoholic parents.,,, Furthermore, the home atmosphere becomes resentful and communication among family members gets worse, which consecutively distresses the psychosocial growth of the children.
Raman et al. in their study of children of men with alcohol dependence in relation to psychopathology, neurodevelopment, and family environment tried to compare the nature and extent of behaviour and cognitive problems in children of men with and without alcohol dependence. Thirty-two children (17 in the study group and 15 controls) were evaluated for psychopathology, neurodevelopment, cognitive functioning, and family environment. Children in families where there is an alcohol-dependent father were found to be at increased risk for behavioral and emotional problems, cognitive deficits, and dysfunctional family environment. They concluded that children of males with alcohol dependence had higher externalizing than internalizing scores and have trouble with frontal lobe functions and neurodevelopmental tasks. In yet another explorative survey of COA fathers, assessed the problems faced by sixty children (10–14 years) of alcoholic fathers attending selected de-addiction centers in Mangalore, India, found 16.6% had severe, 61.7% moderate and 21.7% of them experienced mild degree of problems due to their father's alcoholism. Psychiatric morbidity in COA parents has been assessed and compared with that of nonalcoholic parents at a tertiary health center in Central India. This study found depression and anxiety to be substantial higher in COAs than in progenies of nonalcoholics. However, there were no differences for low intellect, behavioral and emotional problems, conduct disorder, psychosis, distinct symptoms, physical illness, and somatization between the two groups. In our study comprising of 100 COA's, psychiatric morbidity was found in 60% of children. The mean age of children assessed was about 13 years. Somehow children of male alcoholics were only included in this study by chance. It is at this age that the child enters puberty and personality alterations gradually begin to ensue. Furthermore, resources that exist in this age group are inadequate to efficiently cope up with these stressful circumstances, thus developing a defective coping mechanism.
Abnormal coping mechanisms that the child inculcates can bring about anxiety. In our study, about 18% of COA's assessed showed evidence of anxiety spectrum disorders; 4% each screened positive for generalized anxiety disorder, agoraphobia and separation anxiety, while 3% of these children suffered from panic disorder. Two percent (2%) each showed evidence of specific phobia, social anxiety disorder, and obsessive-compulsive disorder. Our study is in concordance with studies by Sher et al. and Hill et al. which also point to COAs having greater odds of developing general anxiety disorder, agoraphobia, and social phobia. The Epidemiologic Catchment Area Project data also suggest that COAs have higher 6-month prevalence of agoraphobia and simple phobia and also higher lifetime risk for simple phobia, generalized anxiety disorder, panic disorder, and agoraphobia. Furthermore, Omkarappa and Rentala in their study compared the rates of anxiety, depression, and self-esteem among 200 children comprising 100 children each of alcoholic and nonalcoholic parents and determined that there were substantial differences among COA and non-COA groups with respect to anxiety, depression, self-esteem, separation anxiety, social phobias, obsessive compulsive problems, and physical injury. This can be accredited to the fact that parental alcoholism can bring about family disruption and can result in volatile home environments, which can subject the child to anxiety-provoking conditions. Costello et al. studied all anxiety disorders in children and established that generalized anxiety disorder and social anxiety disorder were most rampant in children, as against panic disorder and obsessive compulsive disorder, which are rare before 12 years of age. Girls were observed to have higher levels of anxiety across all age ranges, reminiscent of adults. Similarly, our study showed female gender having larger proportion of anxiety spectrum disorders, at about 33%, in comparison to males (3.8%).
Another key outcome of our study was that depression among COAs which was the second most predominant disorder present, at about 14%. This finding is in concordance with studies by Chassin et al. and Anda et al. who established the risk of depression increasing as the number of reported adverse experiences increased due to parental alcohol abuse. Hinrichs et al. also noted that COAs have a propensity toward being submissive, avoidant, unhappy, and may dread rejection or desertion.
Growing up in an alcohol-abusing household considerably escalates the risk for the child to experience hostile circumstances such as domestic violence, abuse, and family dysfunction. Alcoholism in a family can diminish a mother's ability to care for her child as she is more involved with family problems; therefore, the child feels unloved and secluded.
COAs themselves are at high risk for substance abuse. The utmost risk for developing alcoholism subsists for those individuals who begin consuming alcohol as adolescents have a 71 high family burden of alcoholism or exhibit a cluster of behavior traits labeled as disinhibited, under controlled or impetuous, that are often apparent in childhood and continue into adulthood., Similarly, our study encountered COA's to have higher prevalence of nicotine use (11%) and alcohol use (10%), with up to 6% having used cannabis at some point in their life.
We did not find any significant associations when comparing education level of the father, socioeconomic status, total duration of alcohol use, and average intake of alcohol/week with the presence of a psychiatric morbidity in COA's. Our findings are in concordance with those by Sidhu et al. who also noted negligible evidence of a direct causal relationship between socioeconomic status, parental alcohol misuse, and negative consequences in children. Ellis et al. on the contrary found the rates of alcohol misuse to be expressively higher in families with lower socioeconomic status compared to those from higher socioeconomic status. Furthermore, gender of the child had no significant associations with the presence of psychiatric morbidity in general, and with depressive disorders as well. The purpose of studying the problems that parental alcohol abuse present for the children is to make the general public more aware of these problems and the damage that these could lead to, by affecting the children. The next logical step is to undertake multidisciplinary interventions, to mitigate the problems faced by COA's.
Ours was a hospital-based, cross-sectional study with no control group assessed separately. Somehow children of male alcoholics were only included in this study by chance.
| Conclusions|| |
To conclude, psychiatric morbidities were identified in about 60% of children whose fathers were alcohol dependent. These COA's commonly manifested with two major psychiatric morbidities, namely anxiety and depression. Nearly 1/10th of these children were noted to have substance use as well.
This study was approved by Institutional Ethics Committee with reference number SMVMCH-EC/DO/AL/12T3/2017 obtained on 11/11/2017.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I would like to acknowledge my late Professor and Head Dr. Rajgopalan Kumar for his immeasurable guidance and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]