Core Competencies for Involvement of Health Care Providers in the Care of Children and Adolescents in Families Affected by Substance Abuse

A relationship between parental substance abuse and subsequent alcohol problems in their children has been documented extensively. Children of alcoholics (COAs) are considered to be at high risk because there is a greater likelihood that they will develop alcoholism compared with a randomly selected child from the same community. COAs and children of other drug-abusing parents are especially vulnerable to the risk for maladaptive behavior because they have combinations of many risk factors present in their lives. The single most potent risk factor is their parent’s substanceabusing behavior. This single risk factor can place children of substance abusers at biologic, psychologic, and environmental risk. Since the turn of the century, many reports have described the deleterious influence of parental alcoholism on their children. A series of studies measured mortality, physiology, and general health in the offspring of alcoholic parents and concluded that when mothers stopped drinking during gestation, their children were healthier. Today, research on COAs can be classified into studies of fetal alcohol syndrome, the transmission of alcoholism, psychobiologic markers of vulnerability, and psychosocial characteristics. Each of these studies hypothesizes that differences between COAs and children of nonalcoholics influence maladaptive behaviors later in life, such as academic failure or alcoholism. This research supports the belief that COAs are at risk for a variety of problems that may include behavioral, psychologic, cognitive, or neuropsychologic deficits. The vast literature on COAs far outweighs the literature on children of other drug abusers. Relatively little is known about children of heroin addicts, cocaine abusers, or polydrug abusers. Nonetheless, many researchers suggest that the children of addicted parents are at greater risk for later dysfunctional behaviors and that they, too, deserve significant attention to prevent intergenerational transmission of drug abuse. Most research on children of other drug abusers examines fetal exposure to maternal drug abuse. The overview of the research on children of substance abusers points toward the need for better, longitudinal research in this area. Most studies on COAs or other drug abusers are not longitudinal; they examine behavior at one point in time. Given the studies reviewed in this article, it is unclear whether we see true deficits or developmental delay. Longitudinal studies will allow us to predict when early disorders and behavioral deviations will be transient or when they will be precursors to more severe types of maladaptive behavior. Longitudinal research also will enable us to explain specific childhood outcomes. Differences in outcome could be studied simultaneously to understand whether antecedents discovered for one are specific to it or are general antecedents leading to a broad variety of outcomes. Pediatrics 1999; 103:1085–1099; development; research; children of alcoholics; genetic; psychosocial. ABBREVIATIONS. COA, children of alcoholics; FAS, fetal alcohol syndrome; EEG, electroencephalography; MZ, monozygotic; DZ, dizygotic; ERP, event-related potential; DRD2, D2 dopamine receptor (gene); MM, methadone-maintained; FHP, Family History Positive; FHN, Family History Negative; HVA, homovanillic acid; DBH, dopamine-b-hydroxylase. Addiction to alcohol and other drugs is a serious problem in the United States. Approximately 10% of American adults and 3% of adolescents in the United States are addicted to alcohol or other drugs.1 As a society, we should be concerned about the rates of alcohol and drug use among our adolescent population. Determining why one adolescent is more vulnerable than another to drug use has been an area of research spanning the past 2 decades. Reviews of the literature on risk factors associated with drug and alcohol abuse in children or adolescents implicate many factors, such as childhood personality, hyperactivity, antisocial traits, stress, and interpersonal risk factors including low academic performance and commitment and associations with substance-using peers.2–5 A relationship between parental substance abuse and subsequent alcohol problems in their children has been documented extensively,6–9 although some have found that parental substance abuse is not directly related to their children’s substance-using behavior.10 Several researchers have found that teenagers are more likely to drink and use drugs if their parents drink and/or use drugs.11–13 Kandel and associates13 found that 82% of drinking families raise youth that also drink, and that 72% of families who abstain raise youth who also abstain. Annis11 found that a same-sex, same-use pattern seems to exist. Mothers and daughters have similar patterns of substance abuse (mostly tranquilizers and painkillers), and fathers and sons share their choice in drugs (usually alcohol and cigarettes). Coombs and Dickson12 found that the substance abuse behavior of both the mother and the father influenced their children’s substance abuse behavior. Mothers and fathers of substance-abusing youth tended to drink and to use other drugs more often and more heavily. Chassin and Barrera14 explored substance use among adolescents over a 3-year period in 246 adolescent children of alcoholics (COAs) and 208 children of nonalcoholics. They noted important developmental differences in the use of alcohol and drugs among COAs. Older adolescent COAs showed steep escalations in drug use. Younger COAs showed escalations in alcohol and other drug use if their fathers had From the *Department of Psychiatry, Division of Alcohol and Drug Abuse, University of Maryland, Baltimore, Maryland; and the ‡Department of Psychiatry, Division of Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, Maryland. Received for publication Jan 4, 1999; accepted Jan 5, 1999. Address correspondence to Jeannette L. Johnson, PhD, Department of Psychiatry, Division of Alcohol and Drug Abuse, University of Maryland, 630 W Fayette St, Room 1-135A, Baltimore, MD 21201-1691. E-mail: jjohnson@