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http://www.nacoa.org/pdfs/Ackerman.pdf

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Learn more about alcoholism and your marriage.....

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Learn more about alcoholism and your marriage.....

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667243/

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Alcohol use is often part of the fabric of marriage and family life, and although it is associated with certain positive effects, excessive drinking and alcohol disorders can exert a negative effect on the marital development and on the development of children in the context of the family. This review considers evidence that alcohol influences and is influenced by marital/family processes, including transitions into marriage and parenthood, marital satisfaction, marital violence, parenting, and child development. The review discusses the importance of antisocial behavior and the need to examine women's drinking, and the joint impact of men's and women's drinking on marital/family processes. The review highlights the lack of studies in certain key areas, including the link between discordant drinking and violence and marital satisfaction, the role of alcohol in child neglect, and the potential role of marital conflict as a mediator or moderator of the relationship between alcohol and child functioning.

Keywords: parental behavior, intimate partner violence, child development, family violence

Intimate partner violence: behaviors that involve physical aggression from one person to a partner in an intimate relationship, including less severe items such as pushing, grabbing, and shoving as well as more severe items such as hitting with a fist and beating up

Alcohol problems: social, legal, or interpersonal consequences that occur while drinking (e.g., arrested for DWI, violent behavior) or are attributed to acute or chronic consumption (e.g., lost friends due to drinking, damaged health)

Do Transitions into Marriage/Parenthood Impact Drinking?

The transition to marriage

The literature regarding changes in excessive drinking over marriage and parenthood transitions is more consistent. Alcohol consumption, particularly excessive drinking, declines over the transition to marriage ( Miller-Tutzauer et al. 1991), and this is not due to other transitions such as becoming a parent or completing one's education ( Bachman et al. 1997). This "marriage effect" is also observed before marriage among men and women who report being engaged to marry and appears to stabilize within two years after marriage. The strongest findings are observed in large general population studies of young adults that assess drinking annually or biannually.

Excessive or heavy drinking: a pattern of alcohol consumption that exceeds normative levels and is considered to be hazardous, in terms of either the total amount of consumption over an extended time period (i.e., average drinks per day over the last month) or the frequent consumption of large amounts at one time

Alcohol diagnosis or disorder: a maladaptive pattern of physical, behavioral, and experiential symptoms that are indicative of impairments in functioning and/or physical or psychological dependence. This term encompasses both alcohol abuse and alcohol dependence (or alcoholism) and is usually assessed with specific criteria or is assumed because the individual has presented for treatment for alcoholism

Very little research has addressed why the transition to marriage leads to reduced excessive drinking. The most systematic work in this regard is by Bachman et al. (2002), in an expansion of their earlier work. Using data from Monitoring the Future, a large, longitudinal study of youth, these investigators examined changes in religiosity, social-recreational activities, friends' alcohol use, and normative views of alcohol use and found evidence that all of these were impacted by marriage. Structural equation models suggested that reductions in binge drinking were completely mediated by decreased "evenings out" and increased "disapproval of occasional heavy drinking" for both men and women. The model was examined for the total quantity of alcohol consumed in the last 30 days, and the results were largely comparable.

Some research has examined factors that might qualify the relationship between the transition to marriage and drinking reductions. However, much of this evidence is equivocal. For example, studies have found the marriage effect only for women, only for men, or for both men and women ( Leonard & Rothbard 1999). Most of the research has focused on young adult participants, and few researchers have examined the marriage effect later in life. Bogart et al. (2005) found the marriage effect for marriages that occurred under 20 years old, and for marriages occurring in the 20s, which is developmentally normative. It is unclear whether marriage later in the 30s has the same protective effect. Some evidence suggests that the marriage effect may be stronger for European Americans in the United States than among African Americans ( Curran et al. 1998, Mudar et al. 2002).

Several studies have shown that marriage serves as a protective factor even among those with serious alcohol problems. Chilcoat & Breslau (1996) assessed approximately 1000 young adult members of a health maintenance organization at age 21-30 and reinterviewed them three and a half years later. Among single subjects with no initial alcohol problems, those who married were less likely (8.6%) to experience an alcohol symptom at follow-up than single subjects who remained single (15.7%). Among subjects who had an alcohol diagnosis at baseline, the remission rate was higher among those who married (76.5%) than among those who remained single (46%). Dawson et al. (2006) reported on participants who had a lifetime diagnosis of alcohol dependence. Controlling for sociodemographic factors, alcoholism severity, and other disorders, entry into a first marriage increased the likelihood of nonabstinent recovery, but did not increase the likelihood of abstinent recovery.

The transition to parenthood

Only a handful of studies have examined women's drinking from conception to the postnatal period. These studies have documented marked decreases in women's drinking from prepregnancy to pregnancy, and a marked increase in drinking from pregnancy to the postnatal period. Others have reported significant declines during pregnancy and a marked increase to or above prepregnancy levels by 8 to 12 months postpregnancy ( Fried et al. 1985, Homish 2004). Data from the Monitoring the Future project also indicate dramatic decreases in frequency of heavy drinking in the past two weeks, from baseline to pregnancy status for both men and women ( Bachman et al. 1997). Other mediating factors, such as living arrangements, employment status, and marital status, did not account for this dramatic decrease in alcohol consumption from prepregnancy to pregnancy for women, but did explain the decrease in heavy drinking for men. Thus, although there was some reduction in heavy drinking among men that was associated with having a pregnant spouse, this reduction was explained primarily by the general condition of being married rather than the pregnancy status of the spouse.

These data also indicate an association between being a parent and reductions in frequency of drinking and frequency of heavy drinking from prepregnancy among both men and women. This association was not explained by marital status for frequency of drinking, but was explained by marital status for frequency of heavy drinking. There were reductions in both alcohol variables for single mothers, but not for single fathers ( Bachman et al. 1997). Data from this study were obtained at two-year intervals over two decades. Thus, they describe general changes occurring over much longer periods, unlike the longitudinal data regarding increases in women's drinking after delivery described above.

Do Transitions Out of Marriage Impact Drinking?

Given that the transition into marriage is associated with reduced drinking, it is reasonable to hypothesize that the transition out of marriage would be associated with increased drinking. Cross-sectional studies indicate that divorced men and women are more likely to be excessive drinkers than are single men and women. However, as we discuss below, such an association could arise from excessive drinking playing a role in divorce. Consequently, longitudinal studies, particularly studies that can accurately place the temporal position of the divorce, are most informative. Two studies are particularly noteworthy. Bachman et al. (1997) found that the transition from marriage to divorce led to increases in the percentage of both men and women who were classified as heavy drinkers. Temple et al. (1991) conducted a meta-analysis of 12 longitudinal studies conducted in Europe, Canada, and the United States and reported that "for the younger age group, and for both sexes, not getting married and becoming unmarried are associated with increased typical quantity per occasion at follow-up" (p. 1279). These effects were homogeneous across all 12 studies. Moreover, it is not simply that individuals appear to drink more after divorce. They also appear to experience more alcohol-related problems ( Chilcoat & Breslau 1996, Horwitz et al. 1996). As with the reduction in excessive drinking in the transition into marriage, there are various explanations concerning the increase in drinking over the transition out of marriage. It is important to recognize that entirely different explanations may account for these symmetrical effects. Several important changes occur with divorce, such as the diminution of family responsibilities (depending on the presence of children and the custody arrangements) and the restructuring of the social network and patterns of socializing that could be responsible for the increased drinking. Unfortunately, as with the transition into marriage, little empirical work exists that attempts to address the processes underlying the divorce transition.

Despite the strong support for increased drinking after divorce, there is one interesting and somewhat discordant finding. Wilsnack et al. (1991) found that married women who were problem drinkers at an earlier assessment were at a reduced risk for alcohol problems at follow-up if they had separated or divorced between assessments. This suggests that divorce among problem-drinking women may reduce the risk of alcohol problems, possibly by removing them from a heavy-drinking or stress-inducing partner.

Assortative Mating

Assortative mating: nonrandom selection of intimate partner, usually viewed in terms of similarity or concordance with respect to some specific characteristic

Spousal Influence

The clearest evidence of spousal influence is observed among treatment studies in which alcoholics are more likely to return to drinking if their spouse is a drinker (e.g., Moos et al. 1990). In a more recent example, McAweeney et al. (2005) followed alcoholic men and their wives recruited from the community for nine years. One of the predictors of husband recovery was whether the wife had an alcoholic disorder at baseline. In addition, there was evidence that husband recovery had a salutary effect on the alcohol problems of the wife, indicative of reciprocal effects of husband and wife drinking on each other's recovery.

Few studies address the possibility of spousal-influenced drinking in community samples. In a sample of newlyweds, Leonard & Eiden (1999) found evidence in SEM analyses that husband drinking before marriage was longitudinally predictive of wife drinking in the first year of marriage, controlling for wife premarital drinking and husband drinking in the first year of marriage. In an independent sample of newlyweds, Leonard & Mudar (2004) replicated this association, but also found evidence that after the first year of marriage, wife's heavy drinking was longitudinally predictive of husband's heavy drinking. This study also examined factors that might promote spousal influence. We hypothesized that a husband's influence on his wife's drinking over the transition to marriage might reflect an interdependency process and a desire to maintain or consolidate their relationship. Our results suggested that husband-to-wife influence over the transition to marriage was stronger among women who were more highly dependent, reported fewer friends, and believed that alcohol had a positive impact on relationships. However, it is important to note that this effect was only observed over the marital transition, and was not observed from the first to the second year of marriage.

Intimate Partner Violence

Distal drinking patterns and intimate partner violence

Excessive alcohol consumption and alcohol problems are robust correlates of men's violence toward women. The relationship has been observed in case-control studies of partner homicides and injured women seen in an emergency room. The relationship has been observed in other health care settings including primary health care, family practice clinics, prenatal clinics, and rural health clinics. It has also been found in large random samples of the general population and in random samples focused on specific minority populations (see Leonard 2002 for review). In a meta-analysis of this literature, Lipsey et al. (1997) reported an effect size of 0.22 for the association of chronic alcohol use and intimate partner violence (IPV), suggesting that the risk of violence among moderate to heavy drinkers is twice that of nondrinkers and light drinkers. However, the risk may be even higher among the very heavy drinkers. Recently, O'Leary & Schumacher (2003) utilized two nationally representative data sets to examine the full range of drinking and to determine whether the relationship represented a linear or threshold effect. Although they found weak evidence of linearity, they concluded, "the difference between high or binge drinking and more moderate levels of drinking appears to be an important threshold with regard to IPV" (p. 1582).

In contrast to men's drinking, the relationship between women's drinking and IPV is less well-established. Given the association between women and men's drinking, studies that control for men's drinking are the most pertinent. Across community samples, several studies have failed to find a relationship between women's drinking and IPV controlling for men's drinking ( Kaufman Kantor & Asdigian 1997, Leonard & Senchak 1996), possibly because of the small number of very-heavy-drinking women, while other studies have found a relationship ( Kaufman Kantor & Straus 1989, Schafer et al. 2004). In the Schafer et al. study, approximately 1600 European American, African American, and Hispanic couples were interviewed in 1995 and again in 2000. For both European American and African American couples, men's alcohol problems were associated with male-to-female violence, and female alcohol problems were associated with female-to-male violence. Studies of clinical samples of alcoholic or violent women are strongly supportive of a relationship. Similar to the findings of Schafer et al. (2004), Stuart et al. (2006) studied men and women arrested for IPV and found that perpetrators' alcohol problems were associated with their frequency of IPV, and the partners' alcohol problems were associated with the frequency of their IPV toward the identified perpetrator, for both male and female perpetrators.

IPV: intimate partner violence

Although research addressing women's drinking has usually controlled for the effects of partner's drinking, two recent studies suggest that the configuration of couple's drinking patterns are important predictors of IPV. Quigley & Leonard (2000) found that husband and wife excessive drinking in the first year of marriage interacted to prospectively predict violence over the next two years. The interaction indicated that IPV was more likely for excessive-drinking husbands with light-drinking wives. Leadley et al. (2000) found that discrepant drinking patterns were associated with IPV after controlling for heavy drinking. It may be that excessive drinking is not as contentious when both partners are heavy drinkers in contrast to couples with discordant drinking patterns. It is also plausible that drinking together serves a positive relationship function for concordant heavy drinkers, but not for discordant couples. This is an issue to which we return below.

Alcohol use and IPV following treatment

A growing number of longitudinal analyses suggest that changes in drinking behavior after treatment are predictive of changes in violence. O'Farrell and colleagues have conducted the majority of research in this area focused on alcohol. In a key study, O'Farrell and associates (2004) observed that alcoholic men involved in a combined alcoholism and behavioral couples therapy (ABCT) program reduced their IPV from the year before to the two years after treatment and that this effect was apparent primarily among alcoholics in remission. In addition, these changes were observed for both male aggression and female aggression, and for verbal aggression, overall physical violence, and severe violence. Finally, the extent of involvement in ABCT predicted subsequent partner violence, with some evidence that this effect was mediated by improved relationship functioning and reduced problem drinking. Because these studies used treatments that included ABCT, the reduced violence may be the effect of reduced alcohol consumption in the context of acquiring behavioral relationship skills. However, subsequent research has clarified this issue. O'Farrell et al. (2003) and Stuart et al. (2003) found reductions in husband-to-wife violence among male alcoholics receiving only treatment for alcoholism, and posttreatment violence was associated with fewer days of abstinence. Interestingly, one recent study focused on men who were court referred for treatment for IPV. Jones & Gondolf (2001) assessed the frequency of drunkenness among 308 male batterers for several times over a one-year period. Controlling for severe psychopathology and a previous arrest for non-domestic violence, the frequency of drunkenness was associated with IPV recidivism, with increases observed among men who reported being drunk 2-3 times per month in the time period that the recidivism occurred.

ABCT: alcoholic behavioral couples therapy

Proximal alcohol use and IPV

Although the relationship between men's drinking and IPV is well established, there is controversy as to whether the relationship reflects a direct causal relationship or whether it is spurious or indirect. This controversy stems primarily from the difficulties in establishing causality in psychological research rather than from conflicting data. Three sources of data provide support for a causal hypothesis. The first is experimental studies of alcohol and laboratory aggression, a topic beyond the scope of this chapter. The other two sources are studies of alcohol and marital interactions and event-based studies.

Experimental designs are often considered the strongest for inferring causality. In the context of alcohol and IPV, the primary difficulty with such an experiment is the development of a dependent variable that reflects aggression but that is also ethically acceptable. Marital interaction studies focus on negative verbal behavior in the context of a marital conversation. Although negative verbal behavior is not physical aggression, research has shown that, independent of marital distress, couples who have engaged in IPV display greater negativity in marital interactions than couples who have not engaged in such violence (e.g., Leonard & Roberts 1998a). Moreover, verbal aggression is longitudinally predictive of experiencing and perpetrating subsequent IPV ( Schumacher & Leonard 2005). Several studies have examined the impact of alcohol on marital interactions. Leonard & Roberts (1998a) asked aggressive and nonaggressive husbands and their wives to discuss an important conflict, and then to discuss their most serious conflict after the husbands had received no alcohol, an active placebo, or an intoxicating dose of alcohol. Alcohol led to increased husband problem solving and increased husband and wife negativity relative to placebo and no alcohol. Aggressive and nonaggressive couples were equally influenced by alcohol. Similar studies have been conducted with alcoholics. Despite some inconsistent findings, these studies tend to support the hypothesis that alcohol increases negative interactions among alcoholics and their spouses, but not among control husbands and spouses ( Jacob & Krahn 1988). It is of interest that this increase in negativity may occur only among alcoholics with antisocial features ( Jacob et al. 2001). In an interesting extension of these studies, Haber & Jacob (1997) examined the influence of alcohol on the marital interactions of couples in which the husband, wife, or both were alcoholic. Alcohol was associated with lower negativity among couples in which only the wife was alcoholic, but higher negativity among couples in which both were alcoholic. In short, although there have been some discrepant findings, the administration of alcohol in the context of marital conflict appears to increase the expression of negative affect and behavior, even when both members of the couple are alcoholic.

One of the major advances in our understanding of acute alcohol consumption and IPV has been the use of event-based techniques. Two general approaches have been used. In a between-subjects approach, participants who have experienced an IPV event are compared with individuals who have experienced a less serious event (e.g., verbal aggression) controlling for stable dispositional variables (e.g., hostility) that differ between the participants and situational characteristics that differ between the events. In a within-subjects approach, an IPV event is compared with a less serious event collected from the same participant, with statistical controls for situational factors differing between the events. This approach can be extended to diary data that record the occurrence/nonoccurrence of IPV daily and link this to alcohol use on each day.

Event-based research has found that acute alcohol consumption is associated with both the occurrence and severity of IPV. The relationship has been found with between-subjects designs, within-subjects designs, and diary studies, and by men's reports, women's reports, and combined reports. It has been found in studies of community samples ( Leonard & Quigley 1999), criminal justice surveys ( Martin & Bachman 1997), and detailed studies of alcoholics and batterers in treatment ( Fals-Stewart 2003). Studies that have examined both men's and women's drinking found largely uniform support for a relationship between men's drinking and IPV, but reported equivocal findings with respect to women's drinking. Several specific findings are worth highlighting. The amount of alcohol consumed prior to the violence is often quite substantial. Murphy et al. (2005) reported the husband consumed 13-14 drinks prior to IPV but 8-10 prior to verbal aggression events. In addition, Fals-Stewart (2003) found that the violence was most likely to occur within four hours after drinking. Finally, the event-based approach has been utilized to examine moderators of the proximal association of men's drinking and IPV. Fals-Stewart et al. (2005) tested antisocial personality disorder (ASPD) as a potential moderator in the context of a multiple-thresholds model of IPV. Among clinical samples of men who had previously engaged in IPV, alcohol consumption was associated with the occurrence of nonsevere violence for men who did not meet criteria for ASPD. For men with ASPD, proximal alcohol use did not increase the likelihood of nonsevere violence, but it did increase the likelihood of severe violence.

Marital Satisfaction and Stability

Heavy drinking and alcoholism are widely accepted as causes of marital problems and dissolution. In early studies, husband's alcohol use was one of the common reasons given for the breakup of the marriage ( Levinger 1966). Similarly, among couples presenting for marital therapy, heavy drinking among the men is very common and is often a source of disagreements ( Halford & Osgarby 1993). In an extensive review of the literature, Marshal (2003) found that studies with sufficient variability in measures of alcohol consumption and sample sizes reported significant negative correlations between alcohol consumption and marital satisfaction. He also found considerable evidence that alcoholics in treatment and their spouses have lower levels of marital satisfaction than appropriate groups, and that the marital interaction of alcoholics and their spouses were also indicative of poor marital functioning. One recent study ( Floyd et al. 2006) found that hostile marital interactions were observed among couples with an antisocial alcoholic husband. Interestingly, positive interaction behaviors were highest among couples who were concordant for alcoholism (either both or neither had a diagnosis) and lowest among couples consisting of an alcoholic husband and a nonalcoholic wife.

It seems obvious that excessive drinking and alcoholism would have a detrimental impact on marital quality and, if unresolved, could result in marital separations and divorce. Although it seems implausible that there should be no causal influence, the nature and strength of that causal influence are not clear, nor is it clear whether there are any moderating factors. There are several key aspects to consider. First, as noted earlier, excessive drinking and alcohol disorders often co-occur with other disorders, such as antisocial personality and depression. For example, Whisman (1999) found that any mood, anxiety, or substance use disorder was associated with poor marital satisfaction for both women and men. However, after controlling for other disorders, neither alcohol nor drug use disorders were associated with marital satisfaction. Second, very few longitudinal studies have examined this issue, and the results are not entirely consistent. In a 1981 probability sample of women in which heavier drinkers were oversampled, wives' reports of husbands' drinking at baseline predicted wives' distrust and lack of support from husbands five years later ( Wilsnack & Wilsnack 1990). In contrast, in a sample of newlyweds, Leonard & Roberts (1998b) observed that decreases in marital quality over the first year of marriage were predicted by husbands' average daily alcohol consumption, husbands' problem drinking, and wives' problem drinking at the time of marriage. However, only wives' problem drinking remained a significant predictor after controlling for sociodemographic factors, personality factors, and perceived conflict behaviors. Recently, Kearns-Bodkin & Leonard (2005) used longitudinal growth curve analyses to examine the relationship between frequent excessive drinking and marital satisfaction over a three-year period. Contrary to our expectations, we did not observe any longitudinal influence of husband or wife heavy drinking on declines in marital satisfaction or vice versa. However, there were significant correlations between one partner's change in alcohol involvement and the spouse's change in marital quality; steeper declines in drinking were associated with less steep declines in partner's marital quality.

A final key aspect is that, similar to studies of IPV, very few studies actually assess both husband and wife alcohol use and consider the possibility that the combination of husband and wife drinking may predict relationship quality. Specifically, research suggests that discrepant drinking patterns are related to marital functioning. In a community sample of married couples, McLeod (1993) found that couples who were concordant on lifetime alcohol dependence reported more positive marriages in comparison with discordant couples. Mudar et al. (2001) observed that newlywed couples with concordant heavy drinking had marital satisfaction scores that were comparable to couples with concordant nonheavy drinking, and that both of these groups had higher marital satisfaction than did couples with discordant drinking patterns. Homish & Leonard (2007) have found that the discrepancy between husband and wife heavy drinking is longitudinally predictive of lower scores on marital satisfaction. Finally, Ostermann et al. (2005) have found that discrepant drinking was prospectively predictive of the probability of divorce. It may be that excessive drinking is not as contentious among couples in which both partners are heavy drinkers, in contrast to couples in which one partner is not a heavy drinker. It is also plausible that drinking together serves as a positive relationship event for concordant heavy drinkers but not for discordant couples.

Marital Satisfaction as an Influence on Drinking

Marital problems create stress, and some individuals might increase their drinking in response. However, there are few empirical studies of this issue. In community samples, only two studies have examined this. Whisman et al. (2006) examined almost 1700 married men and women without a current alcohol disorder. Over 12 months, baseline marital dissatisfaction predicted the occurrence of an alcohol disorder after controlling for lifetime alcohol disorders, although separate analyses by gender could not be conducted. Testa & Leonard (2001) studied IPV as a predictor of drinking among women. After controlling for sociodemographic variables, initial relationship satisfaction, and verbal aggression, wives who experienced IPV during the first year of marriage reported a greater frequency of heavy drinking episodes.

Treating the Marriages of Alcoholics

If couples with better marriages do better after alcoholism treatment, it seems reasonable to hypothesize that the efficacy of alcohol treatment could be enhanced by coupling it with marital therapy. Seminal work, conducted by O'Farrell et al. (1985) and McCrady et al. (1986), reported promising effects for adding ABCT to alcoholism treatment, with respect to both marital functioning and drinking outcomes. This work and subsequent research by these two teams demonstrated that ( a) the improvement was not simply due to including the spouse in the treatment context; ( b) the improvement was observed primarily in ABCT and not other marital therapies; ( c) the advantages of ABCT could be observed at two years after treatment, and ( d) ABCT had an overall positive cost/benefit ratio ( Epstein & McCrady 1998). Although less data are available for women's alcoholism, ABCT has been shown to be effective for both male and female alcoholics. More recently, this research has focused on two different issues: enhancing the long-term efficacy of ABCT for alcoholism and utilizing intimate relationships to foster and support treatment entry.

The efficacy of ABCT, like most therapies, dissipates with time. Moreover, couples with more severe marital problems, as well as more severe alcohol problems, are the most likely to relapse ( O'Farrell et al. 1992). Two studies have assessed the value of additional relapse prevention (RP) sessions following standard ABCT for alcoholism. McCrady et al. (2004) found that four RP sessions did not lead to better marital or drinking outcomes in contrast to standard ABCT or ABCT with linkage to Alcoholics Anonymous. In contrast, O'Farrell et al. (1998a) found that 15 additional RP sessions led to better marital outcomes for 18 months after RP. For couples with very low pretreatment marital satisfaction, the RP sessions led to more days of abstinence than did ABCT alone. One potential explanation for the different findings is that O'Farrell et al. had 15 RP sessions over a one-year period, whereas McCrady et al. only had four, with three of the four occurring within six months post treatment.

Recent work has also focused on helping family members behave and cope more effectively when an alcoholic family member will not seek treatment. Sisson & Azrin (1986) developed a treatment for the family members of alcoholics that focused on avoiding violence, reinforcing sobriety, not reinforcing drinking, and strengthening the alcoholic's motivation for treatment. Miller et al. (1999) further developed this community reinforcement treatment (CRT) and conducted a clinical trial in which significant others (e.g., wives, parents) were randomly assigned to one of three conditions: ( a) CRT; ( b) an alternative approach designed to facilitate involvement with Al-Anon; or ( c) the Johnson Institute Intervention, which was centered around a family/group confrontation of the alcoholic. All three approaches had a positive effect on the functioning of the significant others, but the CRT led more of the alcoholics to seek treatment than the other two approaches. Recently, Rychtarik & McGillicuddy (2005) evaluated two approaches for women with an alcoholic partner: a coping skills approach and an Al-Anon approach. This study found that involvement in either the Spouse Coping Intervention or the Al-Anon facilitation program led to improvements in spouse functioning and reductions in husband drinking. Of importance, a strong interaction was observed that suggested women who had experienced IPV had lower depression and had partners with fewer drinks per drinking day in the Spouse Coping Intervention relative to the Al-Anon facilitation program.

CRT: community reinforcement treatment

FAE: fetal alcohol effects

FASD: fetal alcohol spectrum disorders

Fetal alcohol syndrome (FAS): a developmental disability that includes central nervous system deficits, growth deficits, and a distinctive pattern of facial anomalies

Maternal Alcohol Use

Children of Alcoholics Literature

The relatively large literature on children of alcoholics focuses primarily on children of alcoholic fathers, and maternal alcohol problems, when present, are generally nested within fathers' alcohol problems. These studies range from infancy to adulthood and focus on a range of outcomes, including temperamental antecedents to alcohol problems, socialization experiences, behavior problems, substance use among peers, variables related to alcohol use such as expectancies, age of onset, smoking, and alcohol use, as well as problem drinking and transition to adulthood. Several models for increased vulnerability among children of alcoholics have been proposed, including the risk for substance abuse problems among children of alcoholics (see Sher 1991, Zucker 2006). Early research demonstrated associations between paternal alcoholism and externalizing and internalizing behavior problems ( Sher 1991) and the subsequent development of substance use, alcohol problems, and alcoholism (e.g., Jacob & Windle 2000). Theoretical discussions on children of alcoholics have suggested that one pathway to greater substance use problems is via the association between fathers' alcoholism and difficult temperament in infancy, to poor behavioral undercontrol and greater externalizing problems in early childhood, to conduct disorder in middle childhood, to higher antisocial behavior and substance abuse in adolescence and adulthood ( Tarter et al. 1999, Zucker 2006). These discussions have also emphasized the importance of gene × environment interactions or interactions of temperamental vulnerability and environmental risk in predicting child outcomes as a function of parental alcohol problems ( Jacob et al. 2003, Tarter et al. 1999, Zucker 2006). In this view, temperamental predispositions may be activated only in the presence of environmental stress. As noted in a recent review ( Zucker 2006), eight different longitudinal studies have provided consistent evidence that externalizing and internalizing problems are developmental precursors to substance use disorders in adolescence. However, longitudinal studies examining such pathways from conception or infancy have been few in number. Until recently, the majority of studies began in early adolescence with the goal of tracking substance use trajectories. The literature has also been plagued by treatment samples with generalizability issues, lack of consideration of comorbid risk factors, and lack of focus on process variables, although more recent longitudinal studies have used sophisticated methodologies to address these issues (see Zucker 2006).

Internalizing behavior problems: feelings of depression, sadness, anxiety, and social withdrawal

Externalizing behavior problems: a combination of physical aggression, acting out behaviors, oppositional or defiant behaviors, and engagement with illegal activities

Trajectories: the shape or nature of change in a given variable or construct over time

The few studies focusing on early childhood trajectories indicate that children of alcoholics, especially those with two parents with an alcohol problem, deviate from more normative trajectories for externalizing behavior problems. For instance, Edwards et al. (2006) reported that children of nonalcoholics followed a developmental trajectory of increasing aggressive behavior from 18 months to 3 years, a peak at age 3, and a sharp decline from age 3 to 4. However, children of two parents with an alcohol problem did not exhibit the normative decline from 3 to 4 years of age. In addition, cumulative family risk (other parental psychopathology, family conflict, and negative parenting) was predictive of higher aggression at 18 months of age, and trajectories varied by child gender. Similarly, Loukas et al. (2003) examined trajectories of disruptive behavior from preschool to early adolescence among sons of alcoholic and nonalcoholic parents. Although disruptive behavior declined from preschool to age 12, sons of alcoholic fathers were consistently higher in disruptive behavior than were sons of nonalcoholics and this association remained after controlling for maternal alcohol problems, family conflict, and child temperament. Finally, Hussong et al. (2005) reported that girls of alcoholic fathers had lower social competence at age 6 than girls of nonalcoholic fathers on both self-reports and teacher reports, but did not differ at age 15, primarily due to decreases in social competence among girls of nonalcoholic fathers. Thus, although the association between parents' alcohol problems and early risk outcomes such as behavior problems is more consistent and suggests deviations from normative trajectories beginning between 3 and 4 years of age, results regarding positive aspects of social development such as social competence are not as clear.

Although few longitudinal studies have focused on early childhood antecedents of the pathways to risk among children of alcoholics, several have examined trajectories of substance use beginning in early adolescence, as well as predictors and consequences of these trajectories. These studies have used sophisticated analytic frameworks to examine longitudinal changes in alcohol-related outcomes in adolescence, from adolescence to adulthood, and within adulthood (see Chassin et al. 2004). Despite considerable variability in age of participants and the dependent measures, results indicate three to four specific trajectories including an early-onset/heavy-use group, a moderate/experimental/developmentally limited group, and a low-risk/low-use group. Across these studies, a family history of alcohol problems is consistently linked to the early-onset/heavy-use trajectory. Individual difference variables such as negative emotionality and low self-regulation have also been predictive of the early-onset/heavy-use trajectory (e.g., Chassin et al. 2004). One persistent question is the role of comorbid parental psychopathology such as depression and antisociality in predicting substance abuse trajectories among children of alcoholics. Using a prospective design, Chassin et al. (1991) reported that parents' alcohol problems were uniquely predictive of adolescent alcohol involvement and internalizing problems, parents' antisocial behavior was uniquely predictive of drug use and externalizing problems, and parents' affective disorder was uniquely predictive of internalizing problems. Thus, the results regarding the association between fathers' alcoholism and risky trajectory for alcohol involvement are quite consistent and remain even after including comorbid risk factors in model testing.

Many studies have assessed parental alcohol problems at a single point and have failed to consider that alcohol problems tend to fluctuate, with periods of remission and relapse. Studies of variations in child outcomes with fluctuations in parents' alcohol problems over time are few in number. Moss et al. (1997) reported that children with fathers who recovered from substance use during the first six years of the child's life were no different from controls by adolescence. Similarly, Moos & Billings (1982) found children of recovered alcoholics to be similar to controls on both family environment and child outcomes, with the exception of child depression, whereas children of relapsed alcoholics had poorer family environment and emotional functioning. DeLucia et al. (2001) specifically tested the hypothesis that parental recovery from alcohol problems may be associated with improvements in parenting, leading to better child outcomes. Contrary to expectations, parenting and child outcomes did not change over time as a function of fathers' alcohol trajectories over a three-year period, and this result was consistent across reporters (father or child) and for multiple-outcome variables. In summary, the temporal associations between fathers' alcohol problems or alcohol consumption and parenting or child outcomes have not been studied extensively and have produced mixed results, with more recent studies specifically testing variations over time producing largely null results. Large longitudinal data sets using more recent advances in statistical analyses of parallel processes may be better able to answer this question.

Summary Points/Future Issues

1. Marital and family transitions exert an influence both with respect to excessive drinking and the development of alcohol disorders, although the effect is strongest close to the transition.

2. Excessive drinking and alcohol disorders adversely affect marital satisfaction and stability, although this impact is observed primarily among couples with discordant patterns of consumption.

3. A strong association exists between excessive alcohol consumption and the occurrence of intimate partner violence, and although there continues to be controversy over the causal status, the evidence is supportive of a contributing role of acute heavy consumption in the occurrence of violence.

4. By treating the marriage in conjunction with alcoholism, Alcoholic Behavioral Couples Treatment appears to lead to improved drinking outcomes and greater marital satisfaction and has a salutary effect on intimate partner violence.

5. The association between parents' alcohol problems and child maltreatment has been well documented, but these studies have methodological problems that do not allow for causal inferences. In particular, although child neglect is the most common form of maltreatment, problems of definition and measurement have been rampant. Recent advances in measurement of child neglect should allow for more sophisticated study designs, including designs that allow causal inferences.

6. Alcoholic parents are at higher risk for having children with behavior problems, and children's behavior problems may increase parental stress and lead to more drinking, but more research is needed to firmly document the link between parental stress and drinking.

7. A large number of studies have documented the effects of marital conflict on child functioning. Given the effects of alcohol on marriage, future studies should use longitudinal designs to examine the potential role of marital processes as mediators or moderators of the association between parents' alcohol problems and child outcomes.

8. The early developmental trajectories of children of alcoholics leading to risk or resilience are still unclear. Although behavioral undercontrol is cited as an early milestone signifying a trajectory of increasing risk, this construct is not well defined and is not a developmentally salient indicator of risk until the preschool years. Better understanding of neonatal and infancy predictors of behavioral undercontrol and more cohesive definition of this construct would facilitate longitudinal research attempting to understand developmental pathways to risk and resilience among children of alcoholics.

Preparation of this chapter was supported in part by National Institute on Alcohol Abuse and Alcoholism grants R37AA009922 to Kenneth Leonard and R01AA10042 to Rina Eiden.

Bachman JG, O'Malley PM, Schulenberg JE, Johnston LD, Bryant AL, Merline AC, editors. The Decline of Substance Use in Young Adulthood: Changes in Social Activities, Roles, and Beliefs. Mahwah, NJ: Erlbaum; 2002. p. 307.

Bachman JG, Wadsworth KN, O'Malley PM, Johnston LD, Schulenberg JD. Smoking, Drinking, and Drug Use in Young Adulthood: The Impacts of New Freedoms and New Responsibilities. Mahwah, NJ: Erlbaum; 1997. p. 241.
Largest, most extensive report on the longitudinal impact of young adult transitions, including engagement, marriage, parenthood, and divorce as well as other transitions that are not family specific.

Galanter M. Recent Developments in Alcoholism, Vol. 13: Alcohol and Violence: Epidemiology, Neurobiology, Psychology, Family Issues. New York: Plenum; 1997.

Homish GG, Leonard KE. The drinking partnership and marital satisfaction: the longitudinal influence of discrepant drinking. J Cons Clin Psychol. 2007 In press. [PMC free article]

Focuses on positive aspects of development using statistically sophisticated methodology and multimethod assessments to examine developmental trajectory of social competence among children of alcoholic and nonalcoholic parents.

Kaufman Kantor G, Asdigian N. When women are under the influence: Does drinking or drug use by women provoke beatings by men? 1997. pp. 315-36. See Galanter 1997.

Leonard KE. Alcohol and substance abuse in marital violence and child maltreatment. In: Wekerle C, Wall A, editors. The Violence and Addiction Equation: Theoretical and Clinical Issues in Substance Abuse and Relationship Violence. Philadelphia, PA: Brunner/Mazel; 2002. pp. 194-219.
Critiques studies of alcohol and child maltreatment with sections highlighting methodological issues, offers suggestions for future directions, and provides a detailed review and critique of studies of alcohol and marital violence.

Leonard KE, Roberts LJ. Marital aggression, quality and stability in the first year of marriage. In: Bradbury TN, editor. The Developmental Course of Marital Dysfunction. New York: Cambridge Univ. Press; 1998b. pp. 44-73.

Lipsey MW, Wilson DB, Cohen MA, Derzon JH. Is there a causal relationship between alcohol use and violence? A synthesis of evidence. 1997. pp. 245-82. See Galanter 1997.

Martin SH, Bachman R. The relationship of alcohol to injury in assault cases. 1997. pp. 41-56. See Galanter 1997.

Moos RH, Finney JW, Cronkite RC, editors. Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford Univ. Press; 1990.

Sher KJ, editor. Children of Alcoholics: A Critical Appraisal of Theory and Research. Chicago, IL: Univ. Chicago Press; 1991.

Wilsnack RW, Wilsnack SC. Marital drinking and the quality of marital relationships: patterns from a U.S. longitudinal study; Paper presented at 35th Int. Inst. Prev. Treat. Alcohol., Int. Counc. Alcohol Addict.; Berlin, Germany. 1990.

Windle M. Coexisting problems and alcoholic family risk among adolescents. In: Baker TF, Hesselbrock VM, Meyer RE, Shoemaker W, editors. Types of Alcoholics: Evidence from Clinical, Experimental, and Genetic Research. New York: NY: Acad. Sci.; 1994. pp. 157-64.

Zucker RA. Alcohol use and the alcohol use disorders: a developmental-biopsychosocial systems formulation covering the life course. In: Cicchetti D, Cohen D, editors. Developmental Psychopathology: Risk, Disorder, and Adaptation. New York: Wiley; 2006. pp. 620-56.
Thoroughly reviews literature on pathways to development of substance use disorders among children of alcoholics. Highlights importance of a systems approach that incorporates temperamental risk with environmental factors that foster the development of alcohol problems in this population.

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Marital and Family Processes in the Context of Alcohol Use and Alcohol Disorders

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Alcohol use is often part of the fabric of marriage and family life, and although it is associated with certain positive effects, excessive drinking and alcohol disorders can exert a negative effect on the marital development and on the development of ...

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Affects on Relationships? Get the Facts:

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Affects on Relationships? Get the Facts:

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https://www.drinkaware.co.uk/check-the-facts/effects-on-relationships

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Alcohol can form part of social occasions but can become an issue in relationships. Get advice to help ensure it doesn't affect yours.

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Southern Illinois Al-AnonAlateen Family Groups

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Southern Illinois Al-AnonAlateen Family Groups

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Southern Illinois Al-Anon and Alateen Family Groups consists of twelve Districts, each with individual groups with a single purpose: to help families and friends of Alcoholics.

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Do you need help? Does your family need help? Look at this information and find out some resources to help get your life back on track!!

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Who Are Al-Anon Members? Al-Anon members are people, just like you, who are worried about someone with a drinking problem. Family members have the opportunity to learn from the experiences of others who have faced similar problems. Read More Teens come together to

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