Second in a Series of Five Conversations With Noted Addiction Specialist

Click here to listen to the audio.

By Dennis Miller, BHC Senior Writer

Addiction is often described as a family disease, and with good reason. On any number of levels — genetic, behavioral, psychological, cultural and environmental — a person’s family history and dynamics are strong determinants of his or her risk of later addiction. But is this risk level written into our genetic code and therefore predetermined and unchangeable? Or are there in fact strategies that families and behavioral professionals can follow to significantly reduce that risk?

Noted addiction expert Ralph E. Tarter, Ph.D., of eCenter Research says that in fact there are many powerful strategies and parenting behaviors that can sharply reduce a child’s risk of becoming a substance abuser later in life, no matter what may be encoded into their genes. “There are a number of important, simple things that parents can do in everyday situations to lower the risk, especially where one of the parents is addicted,” Dr. Tarter says. “Number one, reduce the perception that drug use, alcohol and tobacco included, is associated with pleasure by allowing the children to observe their parents engaged in those behaviors. And number two, have parents exercise the requirement in their children that they must have routine behaviors that socialize them into being responsible, normative kids.”

These insights are just a few of Dr. Tarter’s evidence-based observations on the role of family dynamics both as a cause for addiction and a potent force for preventing it. Dr. Tarter is the Director of the NIDA-funded Center for Education and Drug Abuse Research (CEDAR), and a Professor of Pharmaceutical Sciences at the University of Pittsburgh School of Pharmacy. He has published 11 books, more than 200 peer-reviewed articles, and 71 book chapters. Dr. Tarter is currently researching the biobehavioral risk factors which underlie the risk for substance use disorders within a developmental perspective.

Today on Behavioral Health Central, we bring you the second in a series of five talks with this noted addiction expert. In the months to come, we’ll continue our series of conversations with Dr. Tarter, and explore topics such as targeting treatment intervention with an objective evaluation, what clinicians need to know to do an effective intake evaluation, and maximizing the benefits of treatment for addiction. The series promises to be a highly illuminating set of talks that will be key importance to all behavioral health professionals involved in the prevention and treatment of addiction.

To listen to today’s interview on the role of the family in addiction risk, click on the audio icon above. Or, continue reading for a complete, edited, written transcript.

 BHC: Why is addiction frequently referred to as a “family disease?”

RT: Well, a family is by definition a set of individuals who are in a close relationship. When we talk about addiction, we’re talking of a group of individuals who have a relationship that is biologically based, to a large extent by their genetic makeup, between parents and children. And we also have relationships that are not going to be genetically based, but nonetheless close, such as children who are living in adoptive homes or in second marriages or reconstituted families.

So when we talk about addiction in the context of a family, what we do know is that the single best predictor of whether or not an individual is going to develop an addiction is whether or not there’s a history of addiction in other family members. So for example if the father has addiction, a son has somewhere in the order of about 25- to 40-percent risk of also becoming addicted — even if that son is reared away or adopted out of that family. So genetic factors clearly play an important role in the transmission of addiction from one generation to the next, and it goes from both the father having an addiction and the mother having an addiction and what the genes are that are being contributed to the children.

In addition to the genetic aspects, of course, a family consists of children living in a certain type of environment where the parents or one parent may be actively using alcohol or other drugs, or the parents are creating or in the unfortunate situation of endorsing a type of an environment whereby the child is put into a high-risk situation. So the family nature of the disease stems from both the genetic contribution from parents to children, as well as the influence of older siblings on younger siblings, and the general environmental circumstances of the child.

When they’re all put together — and they are generally going to be closely related to each other, the genetic factors and the environment factors — we see a strong degree of intergenerational transmissibility of risk that is familial based. So to that extent, addiction is considered a family disease, because we often see it going from generation to generation to generation along familial lines. It’s not to say, of course, that everybody in the family is going to have the disorder; it only goes to speak to the issue that some individuals are going to be at much higher risk. And some of those individuals, depending upon how they’re made up constitutionally, are going to succumb to the disorder given the fact that they have this genetic and environmental predisposition.

BHC: Dr. Tarter, we hear a lot about children of alcoholics and other addicts of being at high risk for addiction. What can be done to lower their risk?

RT: There are a number of important, simple things that parents can do in everyday situations to lower the risk, especially where one of the parents is addicted — whether the mother or the father is addicted. And the most important thing to bear in mind is that addiction generally emanates and comes from two types of factors:

One is the effects that drugs have on the individual that produce a degree of sensitivity to these drugs and that causes them to want to keep using them. So, in that circumstance, where the child is exposed to a family in which the parents are using drugs, deriving what they see as a benefit and pleasure from using drugs, that of course increases the probability that the children themselves would want to use these kinds of substances. So an important factor here is that parents who use substances — even legal ones; alcohol and tobacco for example — when they are showing that there’s a high degree of pleasure in their own consumption, they are conveying messages to their children.

The second big factor that leads children into substance use rather early in life is when the children don’t consolidate internally the norms and the values of the traditions of society. And as a result these are the children who are likely to break the norms or violate the social norms in society. So what the parents can do to prevent this from happening is to inculcate through the child-rearing practices — specifically, have the child acquire responsible behaviors as early as possible.

The child should be contributing to the household — cleaning, lawn-mowing, taking out the garbage — whatever the tasks are, the child should learn the basic values and principles associated with normative behavior. And accordingly they will internalize these normative responsible behaviors in their life so that as they transition into adolescence they will have established within them the traditional values. And when an offer of a drug that is illegal comes before them (as it often will and indeed inevitably will at some point), they are then in a position of having their foundation established to have normative behavior and thus reject the drug.

So, the two things the parents can do: Number one, reduce the perception that drug use, alcohol and tobacco included, is associated with pleasure by having the children observe their parents engaged in those behaviors. And number two, the parents exercise the requirement in their children that they must have routine behaviors that socialize them into being responsible, normative kids, and accordingly, that will carry them through into adolescence.

BHC: Are there certain types of parenting styles that can increase the risk of addiction in children?

RT: Yes, and we have very strong evidence going back many years that, first of all, neglect as a parenting style — indifference from the child, not being engaged in the child’s educational development and recreational activities — is crucial. So we know that neglect is a very, very dangerous factor, and it becomes especially problematic from the mother’s standpoint if she does not bond — affectionately bond — with the child so the child is disconnected emotionally beginning early in life, in infancy, from the mother. We also know that the other side of severe parenting problems relates to maltreatment — children who are physically abused and not given the opportunities to have normal social and emotional development.

And in both of these situations, alcohol, tobacco and other types of drugs become basically a form of relieving the stress that’s associated with severe parental neglect or maltreatment. At a more subtle level, there are certain parenting styles that seem to be associated with increased risk in kids. We know from research published that fathers — because fathers tend to be more physical — who exercise physical punishment as a discipline style seem to increase the risk for substance use and addiction in children, the reason being that punishment received by the child is perceived and interpreted as legitimizing aggressive behavior. Because that’s what it is — the infliction of injury on the child is, in fact, aggressive, even though it is perceived by the parent as a discipline style. That then puts that child into accepting aggressivity — internalized aggressivity — as a form of acceptable behavior, especially from the father.

On the mother’s side, a parenting style that inculcates guilt and shame impacts on the child in a negative way because that lowers self-esteem and it lowers one’s confidence in oneself. So, apart from neglect and maltreatment, there are the more subtle aspects of parenting in which guilt coming from the mother (because that’s often a maternal strategy) and punishment coming from the father (because that’s typically more often a father type of discipline) are associated with increased risk of substance use in adolescence, and addiction later on.

BHC: Dr. Tarter, do children impact on the severity of addiction and drug use in their parents?

RT: That’s an excellent question, because just as we were talking a minute ago about how parents can influence children, children can also influence and do influence their parents. And you get then a loop where the parents influence the kids and the kids influence the parents and based upon the reaction of the parents and the children, it creates a cycle of mutual influence, and very often, that can spiral out of control.

We have some information from laboratory studies indicating that children, for example, who have difficult behavioral patterns — kids for example who tend to be hyperactive, oppositional, angry, aggressive — they often will induce in the parents a tendency toward avoidance, or induce anger and punishment in the parent. And many of the parents will be induced into a state of stress by their child, which could lead to an increased tendency on the parent’s part to drink. So all of these things feed back into the overall risks of the kids.

Now we have to be very careful here not to blame the children for these problems, but rather to understand that parents and children mutually influence each other and mutually cause reactions in each other that could, at the end of it all, both increase problems in the parents as well as increase problems in the children. And the problems that increase in the parents relate to the parents being driven away or separating from the bonding from the child or becoming more punitive towards the child. And then, in the parents’ reactions to the children, we see the kids then receiving less effective kinds of discipline and less emotional commitment and supervision from the parents.

So it’s important to recognize, then, in both treatment and prevention, how parents and kids are impacting on each other. And indeed how specific siblings are doing that in the family as well.

BHC: When should behavioral health clinicians or even primary care physicians consider intervention for children of alcoholics and addicts?

RT: If we were living in an ideal world where we had the resources, we would begin to start monitoring the parents at the time of pregnancy. Because we know that certain health behaviors in the parents — for example, substance-using parents, smoking included — lowers the age at which kids will end up smoking. So if your mother smokes during her pregnancy, kids will end up smoking, and start smoking younger or using other drugs at a younger age. And we also know they are at a greater risk for developing substance use and addiction as well.

Part of this has to do of course with the exposure to these compounds during pregnancy in utero and the effects of these compounds or drugs on the biological and brain development of the children. That’s a critical factor. But in addition to the health-promotion perspective — treating parents in the obstetrics and gynecologic practice — we also should begin in the infancy level with pediatricians. Because children who are at high risk are going to be showing some temperamental difficulties early on. They’re going to be more colicky, fussy, irritable-type children. They’re going to be harder for the parent often to form an attachment with, because the children themselves seem to be more emotionally active, don’t fall into an easy sleep/waking cycle or feeding cycle, and that makes parenting very hard.

So pediatricians early on need to be aware of the fact that children are going to be different in the amount of parenting that they’re going to require. And parents need to know that some children are going to need more investment on their part than other children. Some kids are just easy to raise; some kids are harder to raise. For sure, by late childhood, say around age ten or eleven, if the child has established behavioral patterns that point to an inability to self-regulate their behavior — what I mean by that is the inability to restrain impulses, the inability to sustain activity or concentration, the inability to listen to authority, maladjustment in school becoming a behavior problem or even beginning truancy activities — we’re now looking at a child who is at high risk.

Because when a child having these behavioral characteristics — often qualifying for diagnosis of attention/deficit disorder or conduct disorder or oppositional disorder — when a child is showing these characteristics early in life, as they transition into adolescence and going through the whole pubertal development phase, that set of characteristics becomes worse and becomes exacerbated, because those kids are leaving the parental sphere of influence and authority and are moving into a friendship or peer sphere of influence and authority. And that puts them at very high risk for getting into trouble at a very young age, including substance use.

So, ideally, interventions and risk should be monitored through childhood and for sure by the time we see the beginnings of the transitions of adolescence. If we see these behavior problems of poor self-regulation in the child, that’s a crucial time when intervention should clearly be considered. And it’s at that point where we can clearly and accurately measure the risk in children. An instrument that’s out there is the Drug Use Screening Inventory, which measures the areas of risk, ranging from psychiatric, family, friends, behaviors, school and so on. So we know what the areas of risk are and using a simple method of quantifying risk in this fashion, we can see what the components are that might be contributing to the child’s risk so we know what interventions need to be applied, and we could also then quantify or measure that magnitude of risk.

But clearly, intervention needs to be considered by the time the child is entering into adolescence if we see behavioral problems indicative of emotional dysregulation or poor behavioral self-regulation, poor impulse control and poor attentional capacities reflected in maladjustment in school, or peers or friends who parents may not approve of. That’s where the red flags are really starting to pop up in a very serious way.

BHC: Beyond the higher risk of addiction later in life, what other sorts of psychological damage can be afflicted on children of active alcoholics and addicts?

RT: The factors that we have learned in the last decade include the degree to which the risk for addiction aggregates with risk for a variety of other negative outcomes in childhood and in adulthood. So in addition to the risk for addiction, what we see is risk associated with under-employment, under-education, tremendously increased risk for unplanned pregnancy, and risk for sexually-transmitted diseases including HIV infection. We see that when a child transitions from late childhood into adolescence that if the self-regulatory capacities have not been established and the child has an opportunity to affiliate with friends who do not comply or closely adhere to the norms and laws of society and the cultural norms, then that child is at risk for engaging in a number of risky behaviors that all congregate with each other.

That in turn increases the likelihood of delinquency, including criminal activity. And it should be noted that adolescence is a time in life when, more so than any other time in life, kids receive interventions for addiction in the criminal justice system. They also become at risk for depression and anxiety disorders, including post-traumatic stress disorder, so it’s absolutely important to not think about addiction as existing in isolation from a complex set of social outcomes that could be very negative, and legal outcomes that can be negative, as well as psychiatric outcomes.

Associated with that, of course, and embedded in all of that, is risk for adverse health outcomes through infections, for example, or traumatic injury through car accidents when kids are drinking. They’re already at high risk without drinking because of their higher impulsivity, but drinking, of course, just exacerbates that, and mortalities on the highways and roads are well known. So, traumatic injury becomes a major issue and infectious disease becomes another issue that we have to think about in terms of health outcomes.

And one — which is not thought of very often but really is one that has tremendous long-term consequences as well — is oral/dental diseases. Yellowing teeth, missing teeth, bad breath, periodontal disease — a whole set of outcomes are associated with one’s self-neglect just because of the poor self-regulation and involvement with alcohol and drugs and other risky behaviors. And poor oral dental health becomes quite important in all of this because it impacts on your potential for good social adjustment, such as interpersonal relationships between individuals in terms of intimacy. It impacts on your employability — people who have bad teeth or missing front teeth are less attractive and less desirable to hire. And it all has disease implications because there’s some indication now showing that chronic periodontal disease and other associated gum diseases in early life have long-term impact later in life, including higher risk for autoimmune diseases, cardiovascular disease and diabetes. So, oral dental disease becomes very, very important, recognizing that many of the drugs that people are taking — nicotine through tobacco, alcohol, we know that amphetamines, for example, increase oral dental diseases — these are often not given a lot of consideration but they have tremendous negative social impacts and health impacts as well.

So, yes, the long answer to a very specific question here is that we are not looking at addiction in isolation from everything else. Addiction is usually aggregating with a variety of other negative outcomes.

BHC: Dr. Tarter, does the gender of the parent or children bear on risk and intervention strategy?

RT: It definitely bears on risk. We know from the evidence that a father conveys greater risk for the disorder than a mother who has addiction. It seems to be in the literature now and fairly well documented. And not only the magnitude of the risk but the pattern of the risk. So the mother seems to convey the risk through more depression and anxiety-related symptoms — more the emotionality type symptoms — whereas the father seems to communicate the risk to what we call externalizing or acting-out symptoms which lead to more antisociality.

So, when you look at them both together, the emotionality and the anxiety and the externalizing impulsivity, they all add up to what we call dysregulation — poor psychological self-regulation. So, indeed, what’s coming down from each parent needs to be considered in terms of the parent relationship to the child.

So, the genetic aspect is very clear. More internalizing disorders from the mother coming down, more externalizing behavior problems coming down from the father. There’s also, of course, a gender interaction effect. A father-daughter relationship is different from a father-son relationship and that also needs to be considered, because the father-son relationship is going to generally be one where the relationship is going to be more blunt, more openly direct. In dealing with daughters, on the other hand, and given the nature of the makeup of the differences of males and females, girls are much more sensitive to loyalty, interpersonal niceties and etiquette. So the style of communication to a daughter has to be much more subtle, much more — I don’t want to necessarily say gentle, but much more tuned into the interpersonal sensitivity of a parent to a daughter, more than a parent to a son, just because the nature of communication and the quality of the relationships are going to be different in terms of how boys and girls respond to these communications.

BHC: One final question, Dr. Tarter. What’s the one single most important thing that parent’s can do to minimize risk for substance abuse in their children?

RT: The most important thing that can be done is to raise a child with the idea in mind that the values and attitudes align largely with societal norms around issues pertaining to compliance with the law. That is probably the most important thing. To know the difference ultimately between what is right and what is wrong in the context of law.

And towards that goal, if we have a barrier established in children that says, “Even though I don’t agree with the law, I’m not going to cross over that barrier. I’m going to conform with the law,” then we now have a way in which we’re able to have children not engage in the use of illegal drugs. Regardless of what we think about their safety and their consequences, the fact of the matter is, if we agree that we are going to conform to the law and the person believes that, they’ll stay within the confines of the law.

So the single most important thing that a parent can do is to inculcate that norm. I’m not saying that the law is going to be right or wrong; I’m just saying that if that’s the law, then we want to protect our children and ensure their success in life by not having them get involved in the criminal justice system and being able to have a productive life. That’s what we want to do. I’m not justifying the law, and I’m really just trying to promote the success of our children. So to have them comply within the law, what is required is that the child acquire the strong sense and capability of self-regulation.

I believe from our research at the Center for Education and Drug Abuse Research here in Pittsburgh, where we have been tracking about 2,000 kids now for almost 20 years, that the ones that do well are the ones in which the parents have, through ordinary daily activity, allowed the kids to learn how to think strategically, and to think about the consequences of their behavior. I often call this telescopic thinking, that in their mind’s eye they can put up a telescope and say, “If I do this, then these are the consequences that may occur from doing this.”

And by having telescopic thinking and knowing that the consequences may not be good, such as dropping out of school or being truant from school or using a drug or shoplifting or whatever the activity is, if they have in their mind’s eye the capacity to put up the telescope and use this to regulate their own behavior, those are the people in life who generally turn out much better than those who can not envision and conceptualize the future.

So I would encourage parents to practice with their kids, whether it’s around the dinner table or in idle discussion or in simple teachable moments, to say to the child, “If you want to do this, what do you think are the consequences?” Think about the consequences. Talk them out verbally, and then after a while the child doesn’t have to talk them out verbally — they become internalized simply in the form of thought. But to train the person to have what we call “consequential thinking,” that’s the most important thing. What would happen if you were to cross the street or run across the street on a red light? What possible things could happen? What do you think is going to happen if you keep eating sugar candy? What do you think is going to happen if you continue to eat junk food? What do you think is going to happen?

Get the kids to think consequentially and after a while this telescope of long-term consequence becomes an automatic response. So, that’s the most important thing that parents can do with their children, in my opinion.

BHC: Dr. Tarter, I really appreciate you taking the time to talk with us today, and we look forward to part III of our interview series next month, which will be on, “How to Target Treatment Intervention to an Objective Evaluation.” Thank you for speaking with us today.

RT: Great! Thank you. The pleasure is all mine. I look forward to it.

Comments (0)

Subscribe to this comment's feed