parental substance use impairment, parenting and substance use disorder risk

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Brief article Parental substance use impairment, parenting and substance use disorder risk Amelia M. Arria, (Ph.D.) a,b, , Amy A. Mericle, (Ph.D., MSW) a , Kathleen Meyers, (Ph.D.) a , Ken C. Winters, (Ph.D.) a,c a Treatment Research Institute, Philadelphia, PA 19106, USA b Center on Young Adult Health and Development, University of Maryland School of Public Health, Department of Family Science, College Park, MD 20740, USA c Department of Psychiatry, University of Minnesota, Minneapolis, MN 55454, USA Received 18 February 2011; received in revised form 12 August 2011; accepted 3 October 2011 Abstract Using data from a nationally representative sample, this study investigated substance use disorder (SUD) among respondents with ages 1554 years as a function of their parents' substance-related impairment and parents' treatment history. In addition, associations among maternal and paternal substance-related impairment, specific parenting behaviors, and risk for SUD in the proband were examined. As expected, parental substance-related impairment was associated with SUD. Paternal treatment history was associated with a decreased risk for SUD in the proband but did not appear to be associated with positive parenting practices. Results of post hoc analyses suggested that parenting behaviors might operate differently to influence SUD risk in children where parents are affected by substance use problems compared with nonaffected families. Future research is warranted to better understand the complex relationships among parental substance use, treatment, parenting behaviors, and SUD risk in offspring. Opportunities might exist within treatment settings to improve parenting skills. © 2012 Elsevier Inc. All rights reserved. Keywords: Parenting; Drug abuse; Family history; Substance use disorders; Parents 1. Introduction More than 8.3 million children younger than 18 years (11.9%) lived with at least one parent who was dependent on or abused alcohol or an illicit drug during the past year (SAMSHA, 2009). There is an extensive and reliable literature that has linked parental substance use disorder (SUD) to an increased risk in their children of SUD as adults (Orford & Velleman, 1990; Velleman & Orford, 1993a; Kendler, Davis, & Kessler, 1997; Merikangas et al., 1998), adolescent drug involvement (e.g., Clark & Winters, 2002; Rhee et al., 2003), and other negative outcomes, such as early conduct and behavioral problems and school failure (e.g., Luthar, Cushing, Merikangas, & Rounsaville, 1998). Research strongly supports that familial risk has both genetic and environmental components (Goldman & Bergen, 1998; Merikangas & Avenevoli, 2000). Family environments in which a parent has an SUD are often characterized as traumatic, chaotic, and unpredictable and can, in turn, have adverse consequences for children living in such families (Velleman & Orford, 1993b; Kumpfer & DeMarsh, 1986; Kumpfer & Bluth, 2004). Several studies have demonstrated that parents who are active users of alcohol and other drugs have impaired parenting skills that exacerbate the high-risk nature of the family environment (Dunn et al., 2002). For example, research has demonstrated that parental SUD is associated with decreased levels of monitoring and supervision (Latendresse et al., 2008; Chassin, Pillow, Curran, Molina, & Barrera, 1993; Dishion, Capaldi, & Yoerger, 1999), poorer quality of parentchild interactions (Johnson & Leff, 1999; Brook, Whiteman, Balka, & Cohen,1995; Brook, Brook, Arencibia-Mireles, Richter & Whiteman, 2001; Johnson, Cohen, Chen, Kasen, & Brook, 2006), parentchild conflict Journal of Substance Abuse Treatment 43 (2012) 114 122 Corresponding author. Tel.: +1 215 399 0980; fax: +1 215 399 0987. E-mail address: [email protected] (A.M. Arria). 0740-5472/11/$ see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2011.10.001

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Page 1: Parental substance use impairment, parenting and substance use disorder risk

Journal of Substance Abuse Treatment 43 (2012) 114–122

Brief article

Parental substance use impairment, parenting and substanceuse disorder risk

Amelia M. Arria, (Ph.D.) a, b,⁎, Amy A. Mericle, (Ph.D., MSW) a,Kathleen Meyers, (Ph.D.) a, Ken C. Winters, (Ph.D.) a, c

aTreatment Research Institute, Philadelphia, PA 19106, USAbCenter on Young Adult Health and Development, University of Maryland School of Public Health, Department of Family Science,

College Park, MD 20740, USAcDepartment of Psychiatry, University of Minnesota, Minneapolis, MN 55454, USA

Received 18 February 2011; received in revised form 12 August 2011; accepted 3 October 2011

Abstract

Using data from a nationally representative sample, this study investigated substance use disorder (SUD) among respondents with ages15–54 years as a function of their parents' substance-related impairment and parents' treatment history. In addition, associations amongmaternal and paternal substance-related impairment, specific parenting behaviors, and risk for SUD in the proband were examined. Asexpected, parental substance-related impairment was associated with SUD. Paternal treatment history was associated with a decreased risk forSUD in the proband but did not appear to be associated with positive parenting practices. Results of post hoc analyses suggested thatparenting behaviors might operate differently to influence SUD risk in children where parents are affected by substance use problemscompared with nonaffected families. Future research is warranted to better understand the complex relationships among parental substanceuse, treatment, parenting behaviors, and SUD risk in offspring. Opportunities might exist within treatment settings to improve parentingskills. © 2012 Elsevier Inc. All rights reserved.

Keywords: Parenting; Drug abuse; Family history; Substance use disorders; Parents

1. Introduction

More than 8.3 million children younger than 18 years(11.9%) lived with at least one parent who was dependent on orabused alcohol or an illicit drug during the past year (SAMSHA,2009). There is an extensive and reliable literature that haslinked parental substance use disorder (SUD) to an increasedrisk in their children of SUD as adults (Orford & Velleman,1990; Velleman & Orford, 1993a; Kendler, Davis, & Kessler,1997; Merikangas et al., 1998), adolescent drug involvement(e.g., Clark & Winters, 2002; Rhee et al., 2003), and othernegative outcomes, such as early conduct and behavioralproblems and school failure (e.g., Luthar, Cushing,Merikangas,& Rounsaville, 1998). Research strongly supports that familial

⁎ Corresponding author. Tel.: +1 215 399 0980; fax: +1 215 399 0987.E-mail address: [email protected] (A.M. Arria).

0740-5472/11/$ – see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.jsat.2011.10.001

risk has both genetic and environmental components (Goldman& Bergen, 1998; Merikangas & Avenevoli, 2000).

Family environments in which a parent has an SUD areoften characterized as traumatic, chaotic, and unpredictable andcan, in turn, have adverse consequences for children living insuch families (Velleman & Orford, 1993b; Kumpfer &DeMarsh, 1986; Kumpfer & Bluth, 2004). Several studieshave demonstrated that parents who are active users of alcoholand other drugs have impaired parenting skills that exacerbatethe high-risk nature of the family environment (Dunn et al.,2002). For example, research has demonstrated that parentalSUD is associated with decreased levels of monitoring andsupervision (Latendresse et al., 2008; Chassin, Pillow, Curran,Molina, & Barrera, 1993; Dishion, Capaldi, & Yoerger, 1999),poorer quality of parent–child interactions (Johnson & Leff,1999; Brook, Whiteman, Balka, & Cohen,1995; Brook, Brook,Arencibia-Mireles, Richter & Whiteman, 2001; Johnson,Cohen, Chen, Kasen, & Brook, 2006), parent–child conflict

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115A.M. Arria et al. / Journal of Substance Abuse Treatment 43 (2012) 114–122

(El-Sheikh & Flanagan, 2001), perception of less parentalwarmth (Barnow, Schuckit, Lucht, John, & Freyberger, 2002),and inconsistent discipline (Kandel, 1990; Tarter, Blackson,Martin, & Loeber, 1993).

Longitudinal studies have identified pathways by whichimpaired parent–child relations in families with substance-abusing parents are associated with adolescent adjustmentproblems. As an example, low levels of parentalmonitoring are linked to deviant peer affiliation, increaseddrug exposure opportunities, and later tobacco and otherdrug use (Brook, Pahl, & Ning, 2006). Moreover, there isevidence to suggest that the genetic risk may be partiallymanifested by difficult temperament characteristics (e.g.,sensation seeking, behavioral disinhibition), making par-enting even more challenging with these high-riskadolescents (Mezzich et al., 2007; Pears, Capaldi, &Owen, 2007).

In contrast to the wealth of knowledge regarding familyenvironments in which a parent has an SUD, few studies havefocused on whether parental treatment for or recovery fromdrug problemsmodifies the risk of their child later developingan SUD. Moos and Billings (1982) compared 51 children ofrelapsed and recovered alcohol-dependent patients withchildren from matched control families and found thatchildren of relapsed alcohol-dependent parents exhibitedmore symptoms of emotional disturbance than did controlchildren but that children of recovered alcohol-dependentparents were functioning as well as controls. In a similarstudy, Callan and Jackson (1986) found that children ofrecovered alcohol-dependent parents and matched controlsrated their families as happier and more trusting, cohesive,secure, and affectionate than children of families in whichfathers still drank alcohol.

More recent studies of children with parents in treatmenthave found similar results. In particular, in their study of 125children of alcohol-dependent fathers, Andreas, O'Farrell, &Fals-Stewart (2006) found that child adjustment improvedwhen fathers received treatment for alcoholism and thatfathers' recovery from alcoholism was associated withclinically significant reductions in child problems. Inaddition, Andreas and O'Farrell (2007) found that childrenwhose fathers remained mostly abstinent following theirtreatment showed lower levels of adjustment problemscompared with children whose fathers continued to drinkheavily following their treatment.

We could find only one study that failed to find abeneficial impact of parental recovery on child outcomes. Intheir study of 137 families with an alcohol-dependent fatherand 130 matched control families, DeLucia, Belz, andChassin (2001) found that children of recovered alcohol-dependent fathers exhibited more symptoms than didchildren of non-alcohol-dependent fathers, suggesting thatalthough paternal alcoholism has remitted in these families,children of recovered alcohol-dependent fathers mightremain on a general higher risk trajectory relative to childrenof non-alcohol-dependent fathers.

This small but growing body of empirical research canbenefit from more investigations regarding the nature ofthe association between parental SUD, parental treatmentand recovery, and risk for drug abuse later in life amongtheir children. This study analyzed data from the NationalComorbidity Survey (NCS; Kessler, McGonagle, Zhao, &Nelson, 1994) to explore the relationships betweenparental substance abuse history, parental substanceabuse treatment exposure, parenting behaviors, and therisk of developing an SUD. In the NCS, respondentsprovided information on themselves and behaviors of theirmothers and fathers separately, allowing examination ofthe association between maternal substance-related impair-ment and maternal parenting behaviors, as well asanalogous associations for fathers. The study had twoprimary purposes: (a) to evaluate the association betweenparental substance-related impairment and substance abusetreatment on parenting behaviors (b) to examine the extentto which the quality of the parent–child relationship,parenting behaviors, and parental impairment were associ-ated with the risk of SUD in the respondents.

2. Methods

2.1. Design of the NCS and analytic sample

The NCS (Kessler et al., 1994) was conducted from 1990to 1992 and collected data from a multistage area probabilitysample of civilians aged 15–54 years and living innoninstitutionalized settings in the United States. Morethan 8,000 respondents were surveyed, of whom 5,877completed a supplemental interview that covered topicsrelevant to this study, including parental history ofsubstance-related problems and treatment.

The analytic sample consisted of 5,632 respondents whocompleted Part 2 of the NCS interview and reported that theywere raised by either their biological mother or father. Theserespondents are henceforth referred to as probands todistinguish them from their parents. Missing data wereminimal; 86% of probands (n = 4,860) had complete dataacross the 25 variables. However, missing data were mostprevalent among variables pertaining to probands' naturalfathers (approximately 15% were not raised by their naturalfathers, which might have limited their ability to reportinformation pertaining their natural fathers).

2.2. Measures

2.2.1. Proband SUDSUD in the proband was operationalized as having

Diagnostic and Statistical Manual of Mental Disorders,Third Edition, Revised (DSM-III-R) criteria for eitherlifetime substance dependence or substance abuse. Wecollapsed across alcohol and other drugs because we wereinterested in the possible relationship between parenting

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116 A.M. Arria et al. / Journal of Substance Abuse Treatment 43 (2012) 114–122

behaviors and the severity of the addiction problem,regardless of the relation to alcohol or other drugs.

2.2.2. Parental substance-related problems andtreatment history

The NCS interview assessed the presence of problems(e.g., legal, health, marital or family, social, or employmentproblems) with alcohol, nonmedical use of prescriptiondrugs, and illicit drugs among the probands' natural fatherand/or mother. Probands with a parent with an alcohol orother drug problem were then asked whether that parent(separately for fathers and mothers) had “impairment” (e.g.,legal, health, family, social, or employment problems) as aresult of these problems. Probands were only asked if theirparent ever got professional treatment if they indicated boththat their parent had a history of abusing substances andexperienced “problems” or impairment associated with it.Unfortunately, there were no additional questions about thetype of treatment received and the length of time in treatment.

2.2.3. Quality of relationship with parents andparenting behaviors

Probands were asked to rate the quality of theirrelationship with their mother and father (separately)while growing up as either excellent, good, fair, or poor.A dichotomous variable was created that collapsedcategories into “excellent/good” or “fair/poor.” In addition,eight questions taken from the Parental Bonding Index(Parker, Tupling, & Brown, 1979) were asked regardingparenting behaviors for biological mothers and fathers(separately). Response options were as follows: a lot,some, a little, or not at all. These items were dichotomizedinto two categories: a lot/some and a little/not at all. In ourprimary analyses, we analyzed these nine items separately.In a post hoc analysis, to test the overall effect of“parenting,” a single score was created by summing acrossitems (Chronbach's α = .76 and .80 for maternal andpaternal parenting, respectively).

2.3. Statistical analyses

All estimates were weighted to reflect sampling proba-bilities for selection in the NCS study. Our analyses tookplace in several stages. First, we generated descriptivestatistics to describe the sample with respect to demographiccharacteristics, the prevalence of lifetime SUD among theprobands, and the prevalence of parental substance use,impairment, and treatment history.

Second, logistic regression models were developed toestimate the effect of maternal and paternal substance-relatedimpairment and treatment history on the likelihood oflifetime SUD in the proband. All regression modelscontrolled for gender (male), race (four categories withnon-Hispanic White as the comparison group), age (range =15–61 years), and years of formal education (range = 0–17).In addition to these covariates, models analyzing parenting

items and the likelihood of SUD in the proband alsocontrolled for age at first drink (range = 1–47 years).

Third, parenting items were compared between probandswho had parents with a history of substance-relatedimpairment with those without impairment. These analysesused weighted frequencies and were conducted separatelyfor maternal and paternal items. A series of nine logisticregression models tested the association between maternalimpairment and specific maternal parenting items, and nineadditional similar models were developed for paternal items.Next, the analyses were confined to probands whose parentsmet criteria for impairment, and a series of logistic regressionmodels were developed to test the association betweenreceiving treatment and the nine parenting items. Again,models were developed separately for mothers and fathers.

Lastly, logistic regression models were developed toexamine the association between each maternal parentingitem with SUD in the proband; another set of models wererun for paternal parenting items with SUD. Two post hocanalyses were conducted to examine the relative contribu-tions of parenting items and substance-related impairment inthe parent on risk for SUD among the probands. First, weexamined the association between parenting practices andrisk for SUD for probands with and without impairedmothers and fathers. Second, we evaluated a simultaneouslogistic regression model that included four key independentvariables: maternal impairment; paternal impairment, asummary parenting “score” for mothers, and the score forfathers. This model was run on the subsample of probandswho were raised by both their mother and their father andheld constant demographic characteristics.

Analyses were conducted in Stata Version 10 (StataCorp,2007) using survey commands that compute standard errorsusing first-order Taylor series linear approximation. Smallernumbers of mothers who received substance abuse treatmentprohibited the estimation of weighted standard errors in somemodels. However, to better understand the relationshipbetween maternal substance abuse treatment and probandSUD and the relationship between maternal substance abusetreatment and maternal parenting items, we ran these modelsunweighted. However, we also ran them weighted, treatingstrata with single sampling units as certainty units scaled onthe average variance from strata with multiple sampling units.

3. Results

3.1. Sample characteristics

Table 1 describes the characteristics of the sample. Mostof the sample were non-Hispanic White, with equal genderrepresentation. The sample was diverse with respect to ageand educational attainment. Most respondents (82.9%) wereraised by both biological parents, and 15.2% were raised bytheir biological mother only. Approximately one in six(17.4%) met DSM-IV-R criteria for lifetime dependence

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Table 1Sample characteristics (N = 5,632)

Demographics n %

Gender (% male) 2,821 50.2Race/ethnicityNon-Hispanic White 4,309 76.6Non-Hispanic Black 611 10.9Hispanic 506 9.0Other 197 3.5Age category15–24 years 1,402 24.925–34 years 1,725 30.735–44 years 1,553 27.645–54 years 944 16.8Educational level0–11 years 1,193 21.212 years 1,970 35.013–15 years 1,306 23.2≥16 years 1,154 20.5Childhood living arrangement (n = 5,631)Raised by biological mother only 854 15.2Raised by biological father only 109 1.9Raised by both biological mother and father 4,660 82.9Lifetime SUD in the probandAny alcohol abuse 532 9.4Any drug abuse 254 4.5Any alcohol or drug abuse only 704 12.5Any alcohol dependence 801 14.2Any drug dependence 416 7.4Any alcohol or drug dependence 977 17.4Any substance use (alcohol/drug) disorder (abuse/dependence) 1,506 26.8History of parental substance problemsAny maternal history of substance abuse problems (n = 5,588) 507 9.1Any paternal history of substance abuse problems (n = 5,334) 1,369 25.4Maternal and paternal history of substance abuse problems (n = 5,299) 225 4.2Maternal impairment from substance problems (n = 5,588) 343 6.1Paternal impairment from substance problems (n = 5,334) 1,052 19.5Maternal and paternal impairment from substance problems (n = 5,299) 133 2.5Maternal treatment for substance problems (n = 5,573) 107 1.9Paternal treatment for substance problems (n = 5,271) 250 4.7Maternal and paternal treatment for substance problems (n = 5,244) 9 0.2

Note. Unweighted sample sizes are indicated in parentheses. However, cell counts and percentages are weighted.

117A.M. Arria et al. / Journal of Substance Abuse Treatment 43 (2012) 114–122

upon alcohol and/or an illicit or prescription drug, and 26.8%met criteria for lifetime SUD.

One quarter (25.4%) of the sample had fathers who hadproblems with alcohol or drugs, and fewer (9.1%) hadmothers with such problems. Almost one in five (19.5%) offathers were “impaired” (i.e., had legal, health, marital orfamily, social or employment problems related to theirsubstance use) compared with 6.1% of mothers. Only 2.5%of the sample reported impairment in both parents. Very fewprobands reported that their parents received treatmentrelated to substance use impairment (i.e., 1.9% of mothersand 4.7% of fathers).

3.2. Parental impairment, treatment history, and proband'slifetime risk of SUD

Table 2 shows that maternal substance-related impair-ment was associated with SUD in the proband (odds ratio

[OR] = 2.19, p b .001). Similarly, paternal impairment wassignificantly associated with increased risk for SUD (OR =2.38, p b .001), as was having both maternal and paternalimpairment (OR = 3.17, p b .001).

Treatment for substance abuse problems in fathersreduced the risk of SUD in the proband (OR = 0.56, p =.010). Small sample sizes precluded similar weightedanalyses for mothers; however, unweighted and weightedanalyses treating single strata as scaled certainty unitsshowed that maternal treatment was not related to SUD inthe proband.

3.3. Parental substance-related impairment, treatmenthistory, and parenting

Table 3 presents descriptive data on the difference inreported parenting items based on the presence or absence ofa parent with substance-related impairment, along with the

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Table 2Associations between parental substance abuse, treatment history, and SUD in the probanda

Parental historya % SUD in proband OR (95% CI)b

Maternal historyNo maternal impairment from substance problems 25.6 2.19 (1.61–2.98)

p b .001Maternal impairment from substance problems 42.9No maternal treatment for substance problemsc 44.4 0.83

n/adMaternal treatment for substance problemsc 40.4Paternal historyNo paternal impairment from substance problems 22.6 2.38 (1.91–2.97)

p b .001Paternal impairment from substance problems 39.7No paternal treatment for substance problemsc 43.3 0.56 (0.36–0.87)

p = .010Paternal treatment for substance problemsc 29.4Maternal and paternal historye

No maternal and paternal impairment from substance problems 24.8 3.17 (1.90–5.30)p b .0001Maternal and paternal impairment for substance problems 51.7

a Estimates were weighted and based on available data among those raised by their “natural” mothers or fathers.b All models controlled for the proband's age, race, gender, and level of education.c Only probands whose mothers and fathers who were impaired by substance use were asked whether their parents received treatment.d Standard errors for models testing the association between maternal substance abuse treatment history could not be calculated due to sampling strata with a

single sampling unit; thus, confidence intervals and test statistics are not available (n/a). Models were also run weighted with scaled certainty units as well asunweighted and were not significant.

e Estimates were based on those raised by their natural mothers and fathers.

118 A.M. Arria et al. / Journal of Substance Abuse Treatment 43 (2012) 114–122

results of regression models that examine the associationbetween impairment and parenting items, holding constantdemographic characteristics. Maternal impairment signifi-cantly reduced the likelihood of all parenting items, with theexception of restrictiveness. With respect to fathers, all buttwo parenting items (overprotectiveness and babying) wereassociated with substance-related impairment.

Table 3Associations between parental substance-related impairment, treatment history, an

Parenting itemsa

Among all probands raised by biolog(n = 5,510)

Maternal substanceimpairment

ORbNo Yes

Positive relationship 86.6 57.7 0.24p b

High level of understanding 82.3 57.2 0.34p b

High level of confiding 75.2 49.8 0.38p b

High level of overprotectiveness 64.1 42.8 0.43p b

High level of babying 43.2 28.2 0.60p =

High level of effort 95.3 75.3 0.17p b

High level of restrictiveness 61.5 56.6 0.81p =

High level of strictness 75.6 62.0 0.54p b

High level of consistency 86.1 67.7 0.35p b

a Estimates were weighted (subsample sizes are indicated in parentheses).b All models controlled for proband's age, race/ethnicity, gender, and level of

No differences were observed when we comparedindividuals whose mothers or fathers received treatmentwith those who did not; therefore, the data are not presentedin tabular format. One exception was that maternal effort wasgreater in individuals who had mothers who receivedtreatment A weighted model with scaled certainly unitsindicated that probands raised by a mother with substance-

d parenting items

ical mothers Among all probands raised by biological fathers(n = 3,681)

(95%CI)

Paternal substanceimpairment

ORb (95%CI)No Yes

(0.17–0.33).001

82.5 53.7 0.27 (0.22–0.35)p b .001

(0.25–0.47).001

68.8 42.0 0.36 (0.28–0.45)p b .001

(0.28–0.52).001

58.9 34.7 0.40 (0.32–0.51)p b .001

(0.32–0.58).001

56.2 52.9 0.85 (0.67–1.08)p = .185

(0.44–0.83).002

32.0 29.1 0.84 (0.65–1.09)p = .207

(0.11–0.25).001

87.7 66.3 0.28 (0.22–0.36)p b .001

(0.59–1.11).195

57.3 50.7 0.75 (0.60–0.94)p = .016

(0.39–0.75).001

78.5 68.7 0.60 (0.47–0.76)p b .001

(0.25–0.49).001

84.4 70.6 0.47 (0.36–0.61)p b .001

education.

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Table 4Associations between maternal and paternal parenting items and lifetime SUD in the proband

Parenting items

Maternal Paternal

SUD in proband (%) OR (95%CI) SUD in proband (%) OR (95%CI)

Quality of relationship 0.57 (0.46–0.71)p b .001

0.61 (0.49–0.74)p b .001Fair/poor 36.0 34.0

Excellent/good 25.0 23.1Level of understanding 0.66 (0.54–0.80)

p b .0010.66 (0.54–0.79)p b .001Little/not at all 34.0 30.8

Some/a lot 24.9 22.7Level of confiding 0.71 (0.59–0.85)

p b .0010.68 (0.56–0.81)p b .001Little/none at all 32.9 29.5

Some/a lot 24.4 22.3Overprotectiveness 0.89 (0.75–1.05)

p = .1600.73 (0.61–0.88)p = .001Little/none at all 29.8 31.9

Some/a lot 24.8 20.6Level of babying 1.00 (0.84–1.19)

p = .9870.90 (0.73–1.11)p = .310Little/none at all 27.3 28.3

Some/a lot 25.8 19.7Level of effort 0.47 (0.34–0.66)

p b .0010.70 (0.55–0.89)p = .004Little/none at all 43.5 33.0

Some/a lot 25.5 24.2Restrictiveness 0.90 (0.76–1.07)

p = .2220.89 (0.74–1.06)p = .193Little/none at all 29.5 28.9

Some/a lot 24.8 23.2Strictness 0.81 (0.68–0.97)

p = .0220.90 (0.72–1.11)p = .304Little/none at all 32.0 28.6

Some/a lot 24.8 24.7Consistency 0.75 (0.60–0.93)

p = .0080.84 (0.66–1.06)p = .150Little/none at all 34.4 29.2

Some/a lot 25.2 24.8

Note. Estimates were weighted and based on available data among those probands who were raised by their biological mothers or fathers. All models controlledfor proband's age, race/ethnicity, gender, level of education, and age at first drink.

119A.M. Arria et al. / Journal of Substance Abuse Treatment 43 (2012) 114–122

related impairment who received treatment were more likelyto report that their mother put in a high level of effort raisingthem (OR = 2.26, p = .022).

3.4. Parenting items and risk of lifetime SUD

Table 4 presents the results of regression modelsdescribing the association between parenting items andlifetime risk of SUD in the proband, holding constantdemographic characteristics and age at first drink. Fourparenting items were related to SUD risk (regardless ofparent gender): having a good parent–child relationship, ahigh level of understanding, a high level of confiding, and ahigh level of effort. Interestingly, one additional maternalbehavior (consistency) and one additional paternal behavior(protectiveness) were found to be associated with asignificantly reduced risk of SUD.

Post hoc analyses were performed to examine whether theassociations between parenting items and risk of lifetime SUDdiffered based on parental impairment. These results indicatedthat parenting items appeared to play a less important role inpredicting SUD risk in the context of parental substance-related impairment. Because of the small number of motherswith impairment, we were unable to test weighted models ofthe effect of parenting. However, unweighted models did notfind that parenting items were related to SUD among probands

with impaired mothers. Only one result was significant whenmodels were run weighted treating stratum with singlesampling units as scaled certainty units; in this model, babyingincreased the risk for SUD among probands with impairedmothers. Similarly, although several paternal parenting itemswere associated with SUD risk among probands withnonimpaired fathers, none were significantly related to SUDrisk among probands with impaired fathers.

The second post hoc analysis tested the simultaneouseffects of maternal and paternal impairment on proband SUDin a model that also included maternal and paternal parentingitems and demographic characteristics among respondentsraised by both parents. Results revealed that althoughmaternal and paternal impairment retained statistical signif-icance, maternal and paternal parenting items did not. Takentogether, the results of the post hoc analyses suggest thatparenting behaviors might operate differently to influenceSUD risk in children in families affected by substance useproblems than in nonaffected families.

4. Discussion

A number of important findings emerged from this study.In this large general population sample, we demonstratedthat parental substance-related impairment was associated

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with a decreased likelihood of a number of positive parentingbehaviors as reported by probands. This finding confirmsprior work linking parental substance abuse with poordiscipline skills (use of coercive control, harsh discipline,and failure to follow through), limited or absent parentalmonitoring, ineffective control of children's behaviors,problems regulating aggression, lower levels of parentalinvolvement, and more negative parental behaviors (Keller,Cummings, & Davies, 2005; Smyth, Miller, Mudar, &Skiba, 2003; Pears et al., 2007).

We also found evidence that treatment among impairedfathers decreased lifetime SUD risk in probands but did notfind significant associations between treatment exposure andpositive parenting behaviors. Without knowing more detailsregarding the treatment received, we cannot conclude thattreatment in general does not improve parenting skills. Onthe contrary, the literature suggests the opposite. Indeed, intheir study of parent training for 170 women in residentialsubstance abuse treatment, Camp and Finkelstein (1997)found that women who received the training madeimprovements in self-esteem and made significant gains inparenting knowledge and attitudes. Similarly positive resultshave been demonstrated among heroin-addicted mothersparticipating in a relational psychotherapy mothers' group(Luthar & Suchman, 2000; Luthar, Suchman, & Altomare,2007). Furthermore, preliminary results of the partners inparenting (PIP; Bartholomew, Knight, Chatham, & Simpson,2002) intervention indicate that substance-abusing motherswho participated in PIP reported improved attitudes towardparenting strategies and reduced family conflict (Knight,Bartholomew, & Simpson, 2007). Importantly however,most of the parenting interventions for parents with SUD aregeared toward mothers with young children (generally lessthan 5 years of age). Developing and evaluating parentinginterventions for the full range of parents with SUD isindicated. Specifically, it would be important to test thefeasibility and effectiveness of implementing parentinginterventions within the context of substance abuse treatmentprograms. Demonstration projects implementing the Nurtur-ing Program for Families in Substance Abuse Treatment andRecovery, a group-based parenting program for familiesaffected by substance abuse (Camp & Finkelstein, 1997;Moore & Finkelstein, 2001), and pilot work described earlier(Luthar & Suchman, 2000; Luthar et al., 2007; Knight et al.,2007) suggest that it is feasible to do so and that suchinterventions can improve parenting outcomes. Moreover, avariety of evidence-based parent training curricula arecurrently available to reduce children's aggression andbehavior problems and increase social competence (e.g.,the Incredible Years, see Webster-Stratton & Reid, 2010, fordescription) and to reduce risks and enhance protectionagainst early substance use initiation in children and earlyadolescents (e.g., Preparing for the Drug Free Years, seeHawkins et al., 1988). However, research on the effective-ness of these interventions among substance-abusing parentsis lacking, as is research on the effectiveness of these

interventions when being delivered within the context ofsubstance abuse treatment. Treatment settings might beappropriate settings for parenting education, but the extent towhich treatment programs routinely offer such opportunitiesis unknown. In addition to examining the short- and long-term effects of these interventions on the children of parentsin treatment, these studies also need to examine the effects ofthese interventions on parents' recovery.

Our post hoc analyses indicated that protective effects ofparenting behaviors on SUD risk might be diminishedamong parents with substance-related impairment. Thesefindings underscore the complexity of the relationshipsamong parental SUD, parenting behaviors, and childoutcomes. Future research is warranted to understand theseassociations more fully. Specifically, it would be useful toknow whether specific parenting behaviors are moreimportant than others in mitigating the risk of SUD infamilies affected by substance abuse.

4.1. Limitations

A number of limitations of the study must be noted. First,our data are retrospective, limiting our ability to establishcausality between childhood exposure to parental substance-related impairment and adult SUD. Moreover, we cannotmake claims about the temporality of the associationbetween parental treatment and SUD in the offspringbecause details were not available regarding the timing oftreatment relative to the proband's SUD diagnosis. Inaddition, our findings are subject to recall bias. For olderindividuals in the study, the time between their responses andthe actual events was very long, for younger individuals, thetime lapse was shorter, but not insignificant. All of ourmodels controlled for proband age in the analysis to helpminimize this problem. Although proband age is a covariatein various analyses, a proportion of respondents had notpassed through the period of greatest SUD risk. Futurestudies with larger samples of older individuals with parentswith SUD are warranted. Generalizability of our findings islimited for three reasons: (a) the probands were a relativelyhomogenous White sample, most of whom were raised byboth parents and hence the findings might not generalize tosingle-parent households or other types of households; (b)although missing data were minimal, data were most likelyto be missing on variables pertaining to characteristics ofnatural fathers; and (c) these data were collected fromresearch, albeit from a landmark study, that was conducted inthe early 1990s. Because the number of mothers whoreceived treatment for their substance abuse problems wassmall, we could not thoroughly explore the influence oftreatment on maternal parenting behaviors. We were alsolimited by sample size to analyze the additive effects ofhaving more than one parent who had substance-relatedimpairment. These limitations withstanding, our study is oneof only a handful of studies that has examined whetherparental treatment for alcohol and drug problems modifies

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the risk of later developing an SUD and the associationbetween parental treatment and parenting behaviors, and it isthe only one that has examined these issues using a large,nationally representative data set.

4.2. Directions for future research

Although this article extends a small literature on therelationship between parental SUD, parenting behaviors,and SUD in probands, a number of questions remain. Forexample, does a positive relationship with and/or positiveparenting skills of the non-SUD parent moderate the effectof the SUD parent? Is the role of the SUD parent in thefamily important? For example, does the SUD status of theprimary caretaker mediate or moderate SUD risk and canthis be impacted by the parenting skills of the otherparent? Are there differential effects of these factors on thedevelopment of alcohol as opposed to drug disorders?What are the unique contributions of each parent's SUDamong respondents with impaired mothers and fathers?Examinations of these questions can help to inform thedevelopment of interventions for parents with SUD. Forexample, if the parenting skills of the non-SUD parent canmoderate the impact of the SUD parent, working with bothparents during the substance abuse treatment episodewould be important.

Expanding data elements in the various national databasesis also indicated. For example, data from the 2007 NationalSurvey of Substance Abuse Treatment Services (N-SSATS)indicate that 1,135,425 individuals were treated in the 13,648reporting facilities on the survey reference date (SubstanceAbuse and Mental Health Administration, 2008). Althoughthe N-SSATS survey provides a great deal of informationabout clients' characteristics and services provided insubstance abuse treatment programs, it does not capturedata on how many clients are parents nor does it assesswhether programs provide services that focus on parentingskills. Basic descriptive data are needed to help treatmentproviders understand the magnitude of the problem and togauge how their programming compares with that of othersacross the nation.

4.3. Summary and conclusions

Our study, using a large, nationally representative dataset, provides additional evidence for the link betweenparental substance abuse and risk for developing SUD inadulthood as well as for the deleterious effects ofsubstance abuse on parenting behaviors. This coupledwith the familial nature of addiction reinforces theimportance that substance abuse treatment providersconsider including parenting skills interventions duringtreatment. Patients who are parents represent a potentiallyimportant audience for prevention initiatives to mitigate theintergenerational transmission of SUD by modifyingparenting practices.

Acknowledgments

During the time of this work, Dr. Arria received fundingfrom the National Institute on Drug Abuse (P50-DA02784and R01-DA14845) and the Betty Ford Institute. Dr. Wintersreceived funding from the National Institute on Drug Abuse(P50-DA02784 and K02DA015347).

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