THE RELATIONSHIP BETWEEN THE FAMILY DENSITY OF ALCOHOLISM AND EXTERNALIZING SYMPTOMS AMONG 146 CHILDREN

Sven Barnow, Marc Schuckit,*, Tom L. Smith, Ulrich Preuss and George Danko

UCSD Department of Psychiatry (116A), VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA

Received 16 November 2001; in revised form 19 January 2002; accepted 8 February 2002


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Aims: To evaluate the prevalence of externalizing symptoms, such as attention problems, aggression and delinquency in the offspring of alcoholics. Methods: A total of 146 children were divided into three groups with no (group 1, n = 28), one or two (group 2, n = 103) and three or more (group 3, n = 15) first- or second-degree relatives with an alcohol use disorder. Results and Conclusions: The group comparisons revealed that the children of group 3 had significantly higher values for the Child Behavior Checklist scales of attention and delinquent behavioural problems. The results remained significant after controlling for some additional factors such as antisocial personality disorder and drug dependence in the parents.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Children of alcoholics have been reported to have an elevated risk for externalizing symptoms, including attention problems, aggression and delinquency (Martin and Sher, 1994Go; Giancola et al., 1996Go; Jacob, 1999Go), and conduct (CD) or antisocial personality disorders (ASPD) (Bukstein, 1989Go; Sher, 1991bGo; Stowell and Estroff, 1992Go; Hesselbrock and Hesselbrock, 1992Go, 1994Go; Alterman et al., 1998Go). Longitudinal research suggests that these behavioural problems are robust predictors of future alcohol and other substance use disorders (Clark et al., 1999Go). However, not all studies agree that externalizing measures relate to the presence or absence of a family history of alcoholism (FH+), including earlier data published from this series of subjects (Schuckit et al., 2000Go).

The disagreement might come from several issues. First, there are multiple causes of externalizing symptoms, including brain damage (Cohen et al., 1989Go; Kandel and Mednick, 1991Go), cognitive deficits (Moffitt, 1990Go, 1993Go), and a stressful family environment (Kumpfer and Turner, 1990Go; Steinberg, 1990Go; Barber, 1996Go; Pettit, 1997Go). However, few studies control for one predicting factor while studying another. Second, some studies did not control for the family histories (FH) of ASPD and drug dependence, each of which has been reported to be related to both externalizing symptoms and the risk for alcohol-related problems (Hesselbrock, 1985Go; Helzer and Pryzbeck, 1988Go; Hesselbrock and Hesselbrock, 1992Go; Kessler et al., 1997Go; Deater-Deckard et al., 1998Go). Third, many investigations, including our own earlier report, considered the FH of alcoholism as being present or absent, with few incorporating a more sophisticated measure, such as the density of alcoholic relatives (Windle, 1996Go; Schuckit et al., 2000Go). Fourth, some of the disagreement might reflect methodological issues, such as the use of cross-sectional versus longitudinal data, or might relate to the quality of the measures used (Sher, 1991aGo). Finally, in interpreting the literature, it is important to state clearly what is being predicted. Thus, aggression might have different predictors than delinquent behaviour or attention problems, and these domains might relate differently to use, alcohol problems or an alcohol use disorder.

This paper presents data from an ongoing longitudinal study where several factors that might impact on the relationship between externalizing symptoms and a FH of alcoholism are controlled. The families have been intensively studied over 15 years through personal interviews with both mothers and fathers of the subjects (Schuckit and Smith, 2000Go, 2001aGo). These data are used to ask the question of whether, once some additional variables are controlled, the degree of family loading of alcoholism relates to externalizing symptoms, such as attention problems, and delinquent or aggressive behaviour in the offspring.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Subjects and general procedures
Data reported here were generated from multiple sources available on 146 offspring aged 7–18 years from an ongoing prospective study (Schuckit and Smith, 2001bGo). The original subjects, the fathers of these offspring, had volunteered for participation in an evaluation of drinking, but not yet alcohol-dependent, sons of alcoholic fathers and controls, and who entered the investigation between 1978 and 1988 at ~20 years old. The fathers were evaluated with personal structured interviews similar to the Structured Clinical Interview for DSM-III-R (SCID) (Spitzer et al., 1992Go), and participated in a protocol in which their intensities of response to alcohol were determined (Schuckit, 1998Go; Schuckit and Smith, 2000Go, 2001aGo).

Following the initial evaluation, all 453 original subjects were located an average of ~10 years after their laboratory participation, and evaluated with face-to-face structured interviews, which recorded their changes in demography, as well as their alcohol, drug, and mental health problems during the interval, with complete data gathered on 450 individuals (99.3%) (Schuckit, 1998Go). The same men were evaluated again at ~15 years after the original study (98% of those eligible), at which time detailed data were also gathered regarding the spouses' personal and family histories of alcohol, drug, and mental health problems using an interview based on the SCID and similar to that originally used to evaluate the subjects (Schuckit and Smith, 2001bGo; M.Schuckit et al., submitted).

Methods
The 15-year follow-up time-point also gathered information from the spouses of all offspring. Among the 444 children, 151 were aged 7–18 years, including four with some missing data. One additional child had very high ratings in all Child Behavior Checklist (CBCL, Achenbach, 1991Go) scales (most >2 SD), and was therefore excluded from the current analysis, resulting in 146 subjects: 77 boys (mean age ± SD: 9.9 ± 2.56 years) and 69 girls (10.8 ± 3.01 years).

Externalizing type behaviour was assessed by means of the CBCL, using standardized T values of the narrowband scales for attention problems, aggressive behaviour and delinquency, as well as the broadband scale of behavioural problems, which included aggression and delinquency. Additionally, a symptom count was generated summarizing 42 items from the sections on attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and CD using the parent report version of Semi-Structured Assessment for the Genetics of Alcoholism for Children (C-SSAGA-P) (Kuperman et al., 2001Go). This SSAGA (Bucholz et al., 1994Go; Hesselbrock et al., 1999Go) was developed to facilitate parents' reports on children up to the age of 17 years. The SSAGA is based on the Schedule for Affective Disorders and Schizophrenia (SADS) and similar interviews, and gathers demographic information and the lifetime history of the use of alcohol, tobacco, and illicit substances (Bucholz et al., 1994Go; Hesselbrock et al., 1999Go), while reviewing periods of psychiatric disorders based on DSM-III-R and DSM-IV (American Psychiatric Association, 1987Go, 1994Go). Reliability for diagnoses, including alcohol dependence, other drug dependence and depression for the full SSAGA were good to excellent, with kappa values of >0.60 for most diagnoses (Bucholz et al., 1994Go).

Analysis of results
Prior analyses from this data set used 162 offspring aged up to their twenties who were divided into family history positive versus negative groups (Schuckit et al., 2000Go). The current study extends those evaluations by dividing offspring into three groups based on the number of parents or grandparents with alcohol abuse or dependence as established from personal interviews of the parents of these offspring. The original 151 possible subjects considered here did not include 11 individuals aged >18 years incorporated in the prior analysis (Schuckit et al., 2000Go). The current three groups included those children with no alcoholic parents or grandparents (group 1, n = 28), those with one or two such alcoholic relatives (group 2, n = 103), and those where three or more of the six potential relatives met criteria for an alcohol use disorder (group 3, n = 15). The relatively low number of children in group 1 reflects the fact that ~50% of the original subjects, the parents of the children, came from families with a positive history of alcoholism (Schuckit, 1998Go). Differences across the three groups overall were evaluated using a {chi}2-test for categorical data and analysis of variance (ANOVA) for continuous variables. When an overall significant group difference in the ANOVA was observed, the Tukey honestly significant differences post hoc test was carried out to compare pairs of the three groups.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The demographic characteristics of the three groups are presented toward the top of Table 1Go. While the groups were similar regarding age, gender, and years of education, the number of children in the family was lower in group 1, whereas fewer children in group 3 lived with their biological father. There was also a difference in fathers' religion, with more Catholics and fewer Protestants in group 3, and in mother's education, with higher values in group 1.


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Table 1. Demography, family histories and externalizing symptoms of the 146 children divided by density of alcohol use disorders in parents and grandparents
 
Considering externalizing symptoms, to corroborate our previous analysis, data were first analysed using two groups reflecting the presence or absence of a family history of alcoholism. While no significant differences on externalizing measures were observed, scores were generally higher for the family positive group (data not shown). The positive group was then divided based on the family density of alcohol abuse and dependence including mothers' and fathers' parents, yielding the three groups described above. When that was completed, two significant differences appeared, with higher values on attention problems and delinquent behaviour for offspring of group 3.

It is important to note, however, that Table 1Go revealed that religion and having lived with the biological father differed significantly between groups. Thus, ANOVAs were used to evaluate the relationship of these two characteristics to the CBCL externalizing measures and the C-SSAGA-P symptom count, with no significant results. Furthermore, the possibility that the increase in externalizing values in group 3 might reflect a higher prevalence of having a relative with a probable or definite diagnosis of an ASPD and/or illicit drug abuse or dependence can be excluded, because there were no significant differences in the prevalence of these diagnoses among the three groups.

Considering gender differences, although the number of subjects was relatively small, we also re-evaluated all analyses separately for girls and boys, with results indicating similar patterns for the genders, with somewhat higher group differences in females. Finally, all analyses were re-calculated using the raw data of the CBCL measures instead of the age- and gender-standardized T values, with the same significant group differences observed.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The current study evaluated the pattern of externalizing symptoms in 146 children using data gathered from two separate measures. The offspring reported on here are part of an ongoing longitudinal study of well-characterized families with information gathered from personal interviews with the fathers and mothers of these subjects over the prior decades (Schuckit and Smith, 2000Go, 2001bGo). The analyses evaluated externalizing symptoms, such as attention problems, aggression and delinquency, in this population after controlling for strong family histories of ASPD or when fathers with drug dependence were excluded, and in the context of relatively highly educated and functional parents.

Consistent with our prior analyses based on the presence or absence of an alcoholic relative (Schuckit et al., 2000Go), the overall results revealed no significant differences in externalizing symptoms when offspring with alcohol misuse or dependence in their families were compared to those with no such histories. However, when families were broken down based on the number of parents and grandparents who were alcoholic, a different result appeared. While there were no differences between individuals with no family alcoholic member and those with one or two alcoholic relatives, higher externalizing scores for attention problems and delinquency were observed for those offspring with three or more such relatives. Thus, even after controlling for several important extraneous factors, such as ASPD and illicit drug dependence in relatives, these externalizing symptoms were found to relate to higher density alcoholic families.

Our research group and others have theorized that various genetically influenced characteristics are likely to be associated with an enhanced risk for alcoholism (Sher, 1991bGo; Zucker et al., 1995Go; Schuckit, 2000Go). Thus, some people might have an enhanced risk for substance use disorders in general related to very high levels of impulsivity and disinhibition as marked by the existence of ASPD in the family, and yet others might be at increased risk through a low level of response to alcohol, or independent psychiatric conditions, such as bipolar manic depressive disease and schizophrenia. The current results support the contention that, even after controlling for each of these characteristics, and even in the absence of frank ASPD, a greater density of alcoholism within the family might relate to higher rates of externalizing symptoms, such as attention problems and delinquency in the children. According to the reports by Babor et al. (1992) and Cloninger et al. (1996), families with a high density of alcoholism might carry a predisposition toward an earlier onset of more severe disorder and are more likely to be associated with multiple substance dependencies.

Future stages of the ongoing study will evaluate the relationship between the externalizing symptoms seen in the current children at an average age of ~10 years, and the subsequent pattern of substance use and related problems. Furthermore, we will have the opportunity of evaluating these externalizing symptoms as they impact on future aggression, delinquency, and the possible development of ASPD. Until those follow-ups are completed, it is important to remember that the current data support a cross-sectional relationship between high density alcoholism in the family and externalizing symptoms, but that the clinical implications of these relationships have not yet been established.

There are additional caveats. First, the children studied here were relatively young, and additional symptoms are likely to develop as these boys and girls reach adolescence. Second, the sample is relatively small, and the groups differed in the number of subjects, thus only group differences that reflect at least medium-sized effects could be reliably evaluated. However, we estimate that between 450 and 500 children in these families will reach an age of >=7 years over the next decade or so. Third, no personal interviews with children were carried out at the 15-year follow-up, although the ongoing 20-year follow-up incorporates a personal SSAGA and other evaluations for children aged >=13 years. It was not possible to gather details at this stage regarding the home environment and, thus, it is possible that, despite the generally high level of education for these parents, some of the attention and delinquency symptoms on the CBCL, as well as the diagnostic symptom count from the SSAGA, might have reflected relatively temporary environmental events, rather than a more prominent biological predisposition. Finally, our data did not allow us to investigate the different levels of exposure to parental problem drinking, and there were not enough subjects to allow for an adequate evaluation of males and females separately.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
This work was supported by NIAAA Grant 05526, the Veterans Affairs Research Service, and funds provided by the State of California for medical research on alcohol and substance abuse through the University of California, San Francisco.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed. Back


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 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
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