Substance Abuse

Substance abuse has a substantial and reciprocal impact upon families. There are many definitions of substance abuse and dependence but two authoritative sources are the fourth edition of the Diagnostic and Statistical Manual (DSM-IV-TR) (American Psychiatric Association 1994), commonly used in the United States, and the tenth edition of the International Classification of Diseases (ICD-10) (World Health Organization 1992). The criteria for alcohol abuse in the DSM-IV-TR include drinking despite recurrent and significant adverse consequences due to alcohol use. A diagnosis of alcohol dependence emphasizes a set of psychological symptoms (e.g., craving); physiological signs (e.g., tolerance and withdrawal); and behavioral indicators (e.g., use of alcohol to relieve discomfort due to withdrawal). Unlike the DSM-IV-TR, the ICD-10 does not include a category alcohol abuse, but rather uses the term harmful use, created so that problems related to alcohol use would not be underreported. Harmful use implies use that causes physical or mental damage in the absence of dependence (National Institute on Alcohol Abuse and Alcoholism 1995).

One of the limitations of these classifications (particularly with the DSM-IV-TR) is the lack of attention to cultural variations in the diagnosis of substance abuse (Tang and Bigby 1996). Around the world, substance use and abuse take on different meaning and importance. For example, there are different cultural norms about the legal drinking age. The legal age for purchasing alcohol in many European countries is sixteen years (in Denmark it is fifteen) (Eurocare 2001). Among indigenous groups, alcohol and other drugs may be integrated parts of tribal and community existence (Charles et al. 1994) where conventional definitions of abuse and dependence may be not be held. The definitions of substance abuse used in this entry tend to reflect the conventions of the nonindigenous cultures of North America because most of the research cited tends to use the DSM in its various editions. However, to maximize a cross-cultural perspective, multicultural and international studies are also referenced.

The emphasis in this entry is on reporting the evidence base for understanding substance abuse and the family. Popular but evidence-limited notions of the cause, effect, or treatment of substance abuse will not be included.

Prevalence and Incidence

International data suggest widespread and serious substance use and abuse. Within the United States, the annual National Household Survey on Drug Abuse (NHSDA) collects data on substance use patterns and trends among the general population. According to the 2001 NHSDA, 6.3 percent (14 million) of the U.S. population reported current use of illicit drugs (i.e., used an illicit drug at least once during the thirty days before the interview) (Substance Abuse and Mental Health Services Administration 2001). Among major racial/ethnic groups, the current rates for illicit drug use were 6.4 percent each for whites and African Americans and 5.3 percent for Hispanics/Latinos. The rate was highest among American Indian/Alaska Natives (12.6%), with Asians reporting the lowest rate (2.7%). Almost half (46.6%, approximately 104 million) of the U.S. population reported current use of alcohol. Almost 6 percent of the population (5.6%, 12.6 million) were heavy drinkers, consuming five or more drinks on one occasion in five or more days during the thirty days prior to interview.

Although trends in the United States and in other developing countries indicate either flat or declining alcohol use, rates are rising in many developing countries and in Central and Eastern Europe (World Health Organization 2001). One source has noted that "dangerous patterns of heavy drinking exist in most countries" (World Health Organization 2001, p. 1). With respect to illicit drug use, estimates for 1999 indicate 3 percent (180 million people) of the world's population consumed illicit substances (United Nations Office for Drug Control and Crime Prevention 2001). The most commonly consumed substance was cannabis, used by 2.4 percent (144 million people) of the world's population.

Because of the widespread abuse of substances among the world's population, there are likely to be substantial family effects. The next section reviews some of these findings.

Effects of Substance Abuse on Families

The effects of substances on couple and family relationships are both direct and indirect—and substantial. Due to limitations of the research designs, many findings are correlational and not causal. Thus, although many effects are associated with substance use, it is sometimes unclear whether the substance use is the cause or the effect.

Financial effects on families. Substance abuse by family members can have a substantial negative effect on the financial viability of caregivers. Substance-abusing caregivers may spend money allocated for food or clothing for children. Substance abusers may divert money from rent or mortgages to buy substances. Noncustodial parents who abuse alcohol are less likely to provide financial support for their children (Dion et al. 1997). In Yemen and Somalia, users may spend as much on khat (a type of stimulant) as they spend on food (Abdul Ghani et al. 1987). Additionally, families are often unwitting accomplices to their relative's substance abuse as the substance use is often financed by immediate family members (Gearon et al. 2001).

Fetal exposure to alcohol and other drugs. There is considerable evidence for the effects of maternal substance use on the development of the fetus. Specifically, childhood developmental problems have been associated with maternal substance use. For example, prenatal alcohol exposure can lead to mental retardation, behavioral and neurological problems that may lead to poor academic performance, and legal and employment problems in youth and adulthood (National Institute on Alcohol Abuse and Alcoholism 2000). However, researchers do not know how much alcohol produces adverse fetal consequences. Thus, experts recommend that pregnant women should not consume alcohol (National Institute on Alcohol Abuse and Alcoholism 2000).

Early family environment. In addition to the direct effects of substances on the unborn child, the early social environment of children with substance-abusing parents adds potential risks. A high percentage of children in contact with the child welfare system have substance-abusing parents ( Jones-Harden 1998). Reviews have consistently documented the association between parental substance abuse and poor parenting skills ( Jones-Harden 1998). The type of child maltreatment often associated with these cases includes physical, medical, and emotional neglect (Hawley et al. 1995; Jones-Harden 1998). Research in Israel documented the ill effects of severe environmental deprivation when both parents are heroin-addicted and noted that the early home environment has a greater influence than in-utero exposure on developmental outcomes, as long as there is no significant neurological damage (Ornoy et al. 1996). Other research has found that a positive postnatal caregiving environment can attenuate some of the negative effects of prenatal exposure to substances ( Jones-Harden 1998; McNichol and Tash 2001).

Child and adolescent problems. Children with family histories of substance abuse differ from children without such histories in higher levels of aggression, delinquency, sensation-seeking, hyperactivity, impulsivity, negative affectivity (Dore et al. 1996; Giancola and Parker 2001), anxiety, and lower levels of differentiation of self (Maynard 1997). Family history of alcohol dependence, through a moderating influence of adolescent drug dependence, has predicted poor adolescent neuropsychological functioning (i.e., language and attention functioning) (Tapert and Brown 2000). On the other hand, youth without family histories of alcohol dependence seemed to be protected from poorer neuropsychological functioning (Tapert and Brown 2000).

Relational distress, partner and family violence. A nationwide study of married and cohabiting couples found that partners tend to share similar drinking patterns and when there are differences in the amounts of alcohol consumed, couples tend to have serious relationship problems including alcohol-related arguments and physical violence (Leadley, Clark, and Caetano 2000). Alcohol frequently plays a role in intimate partner violence. National surveys in the United States have reported that 30 to 40 percent of men and 27 to 34 percent of women who perpetrated partner violence were drinking at the time (Caetano, Schafer, and Cunradi 2001). The study also revealed that alcohol-related problems were related to partner violence among African Americans and whites, but not among Hispanics/Latinos.

In sum, there appear to be substantial effects of substance abuse on family and couple relationships. The next section reviews the evidence for factors that contribute to or protect from the risk for substance abuse.

Family Factors Contributing to Risk and Resiliency

Substance abuse is the result of a complex interaction of individual, family, peer, community, and societal factors (United Nations Office for Drug Control and Crime Prevention 2000). A consistent global finding is that substance abuse runs in families. A family history of drug abuse and dependence substantially increases the risk for such problems among members (Madianos et al. 1995; Wester-meyer and Neider 1994; Wu et al. 1996). The same pattern occurs with alcohol abuse and dependence (Curran et al. 1999; Jauhar and Watson 1995). Although genetics plays a substantial role in both alcohol (Bierut, Dinwiddie, and Regleiter 1998) and drug dependence (Tsuang et al. 1996), the family environment plays a role in both promoting and protecting from substance abuse and dependence. This section reviews some of these factors. Due to the limitations of the research designs, many of these findings are correlational and not causal.

Child physical and sexual abuse. Although much of the research is limited in design (e.g., retrospective designs, clinical samples), childhood abuse appears to be a risk factor for substance abuse. Women who were physically or sexually abused as children are at risk for alcohol abuse as adults (Langeland and Hartgers 1998; Rice et al. 2001) but the evidence for males is contradictory (e.g., contrast Galaif et al. 2001 and Langeland and Hartgers 1998). Childhood sexual abuse may also increase the risk for adolescent drug abuse among females ( Jarvis, Copeland, and Walton 1998). Tracey Jarvis and colleagues speculated that the use of drugs might be an effort to self-medicate the emotional pain associated with the abuse.

Family attitudes and practices about substance abuse. Although peer influences are important in explaining substance use among youth (Lane et al. 2001), family attitudes and practices are also significant. Among Hispanic/Latino youth in particular, parents have been more influential than peers (Coombs, Paulson, and Richardson 1991). Family members' attitudes about and use of substances influence youth substance use. For example, an analysis of the 1997 household survey on substance use found that youth ages twelve to seventeen who perceived that their parents would be "very upset" with marijuana, cigarettes, and binge drinking reported the lowest prevalence of use of these substances in the past year (Lane et al. 2001). Similarly, the protective influence of strong family sanctions against alcohol use reduced the use of that substance among girls in Hungary (Swaim, Nemeth, and Oetting 1995). The level of influence seems to extend to siblings. In one household study in Canada, older sibling drug use, more than parental drug use, was the dominant influence of substance use among youth (Boyle et al. 2001).

Problematic family and partner relations. Family and partner conflict tends to increase risk for substance abuse. The national household survey in the United States found that adolescents who argued with their parents at least several times a week were more likely to have used marijuana in the past year than those who argued with their parents only once a week to once a month (Lane et al. 2001). Internationally, family conflict and lower perceived family caring increases the risk for adolescent substance abuse (Al-Umran, Mahgoub, and Qurashi 1993; Nappo, Galduroz, and Noto 1996; Swaim, Nemeth, and Oetting 1995).

Marital and family conflict appear to increase risk for alcoholism among women in Zagreb (Breitenfeld et al. 1998). Over three-quarters of 100 males admitted for alcohol abuse in Scotland ascribed their marital breakdown or family neglect to their drinking ( Jauhar and Watson 1995).

Family structure. Studies of family structure around the world have found that youth who live with both biological parents are significantly less likely to use substances, or to report problems with their use, than those who do not live with both parents (Challier et al. 2000; Johnson, Hoffman, and Gerstein 1996). However, family structure alone does not appear to explain substance abuse. The characteristics of these family structures offer some clues. For example, boys who are in care of their mothers and whose fathers are drug abusers are at increased risk for drug abuse but this is due to the genetic transmission of risk and lack of resources for effective parenting for single mothers (Tarter et al. 2001). Studies in Brazil and Saudi Arabia have noted that the quality of family relationships was more important than structure in explaining substance use (Al-Umran, Mahgoub, and Qurashi 1993; Carvalho et al. 1995).

Disruptions in the family life cycle seem to characterize these single-parent households. An unstable family environment (i.e., father absence, one or both parents who had immigrated, or death of parents) was associated with substance abuse among a nationwide sample of youth in Greece (Madianos et al. 1995). White non-Hispanics/Latinos and African Americans in changed families (e.g., those that changed from two parents to single parents during the study) had the highest rates of substance initiation (Gil, Vega, and Biafora 1998). Moreover, deteriorating family environments were stronger influences of drug initiation among Hispanic/Latino immigrants than nonimmigrants to the United States. Among African Americans, family structure and environment had the weakest effect on substance use and African-American youth in the care of their mothers or other adult family members, had the lowest proportion of drug onset (Gil, Vega, and Biafora 1998).

Thus, family structure along with characteristics of these families seems to account for substance abuse. More research is needed on the quality of the relationships within these family structures and on the time-order of the onset of substance use among youth with different family structures ( Johnson, Hoffman, and Gerstein 1996).

Protective family factors that mitigate risk for substance abuse. Although they may place members at risk of substance abuse, family factors may also be protective. As noted above, two-parent households appear protective. High levels of perceived support from family members seems to protect against youth alcohol use (Foxcroft and Lowe 1991) and drug use among Hispanics/Latinos (Frauenglass et al. 1997) and African Americans (Sullivan and Farrell 1999). Researchers have found that effective family relationships (e.g., family involvement and communication, proactive family management, or attachment to family) protect against adolescent substance abuse across racial and cultural groups (Carvalho et al. 1995; Stronski et al. 2000; Williams et al. 1999). Further, the positive effects of family support during adolescence seem long lasting. Greater family support and bonding during adolescence has predicted less problem alcohol use in adulthood (Galaif et al. 2001).

In families with substance-abusing parents, there may be influences that protect from abuse. Preliminary research has suggested that a factor that provides some protection for children in homes with substance-abusing parents is the availability of a stable, nurturing relative such as grandmothers or aunts ( Jones-Harden 1998). In research in Colombia, the adverse effects of parental substance abuse were buffered by effective parent-child rearing practices (Brook et al. 2001).

Protection extends beyond parents to siblings. One study reported that older brother abstinence from drugs, as well as strong attachment to parents, explained reduced drug use among younger brothers (Brook, Brook, and Whiteman 1999).

In sum, the risk and protective factors suggest that family relationships have a significant impact on substance abuse and dependence. However, the research is not sufficiently developed to indicate which or how much of these protective factors are necessary to reduce risk. There are variations across groups and in timing in their importance for preventing or reducing risk (Gil, Vega, and Biafora 1998). Further, the risk and protective factors at other levels, such as community or societal, may mitigate or attenuate risk.

Treatment for Substance Abuse

A common reason for seeking treatment for substance abuse is a problem with interpersonal relationships (Tucker and Gladsojo 1993). Given the evidence showing the influence of family and social relationships on substance abuse, cited above, treatment attempts to improve the quality of inter-personal relationships and to teach problem solving skills to couples and families with a substanceabusing member. Interactions between family members are important in the etiology and maintenance of substance use. Family interactions are interdependent and, over time, become patterns of behavior that the family maintains. Family interventions focus on identifying and changing the patterns that support the problematic substance use. Some family-based interventions also acknowledge that the family system is maintained in a broader context of peers, work, school, and neighborhood and attempt to engage elements from these systems in therapy. Although there are different models of family-based interventions, the common focus is on changing the patterns of interaction within the family (Robbins and Szapocznik 2001).

Reviews of the substance abuse treatment literature in the mid-1990s noted that modest benefits could be ascribed to family-based interventions (Edwards and Steinglass 1995; Liddle and Dakof 1995). The reviews concluded that although the research at that time indicated the promise of family-based interventions, there were not enough randomized clinical trials to warrant an endorsement of efficacy, defined as a high degree of confidence that the intervention reduced or eliminated substance abuse.

Treatment of alcohol abuse and alcohol dependency. Three interventions that effectively reduce alcohol abuse and dependency among adults are Behavioral Couples (or marital) Therapy (BCT), Behavioral Family Therapy (BFT), and the Community Reinforcement Approach (CRA). BCT is highly structured and guided by a treatment manual principally developed by Timothy O'Farrell, Barbara McCrady, and their colleagues (Fals-Stewart, Birchler, and O'Farrell 1996; McCrady 2000; O'Farrell, Van Hutton, and Murphy 1999). Early sessions focus on helping the couple to increase positive verbal exchanges and behaviors. Later sessions build skills at positive marital communication and problem solving. Sessions include review of disulfiram (an alcohol antagonist) contracts, homework assignments, and the client's drinking or urges to drink. Sessions continue with the introduction of new material, modeling of new skills by the therapist, and rehearsal of the skills by the couple. To complement the approach, a module of fifteen sessions is used to establish and maintain a relapse prevention plan that includes how to identify and manage warning signs of lapses.

BFT, an efficacious and promising intervention across groups and substances (Azrin et al. 1996; Edwards and Steinglass 1995; Stanton and Shadish 1997), is based on the assumption that behaviors are maintained by consequences. Change is unlikely to occur unless more rewarding consequences result from different behaviors. For example, parent skills training, a feature of BFT, teaches parents to increase reward for positive behaviors and ignore negative behaviors to produce change. A strategy often used is to improve communication between the parents and the adolescent.

CRA is an efficacious and comprehensive intervention that involves spouses, family members, and others in the drinker's social network to change the marital, familial, and social reinforcers that support the drinker's behavior (Kirby et al. 1999; Miller, Meyers, and Hiller Sturmhoefel 1999). Beginning with a functional analysis of the drinking behavior (i.e., a review of persons, places, and contexts that act as triggers for substance use behavior), significant others are trained to help the drinker to engage in treatment and to remove positive reinforcers during drinking episodes. Drink refusal skills, relaxation, control of drinking urges, and methods to deal with risky social situations are taught. Often disulfiram contracts are included.

Two other interventions that show promise in reducing alcohol abuse and dependency are Functional Family Therapy (FFT) and Multi Systemic Family Therapy (MSFT). FFT is a manually guided intervention involving eight to thirty sessions spread over a three-month period (Stanton and Shadish 1997; Weinberg et al. 1998). The approach evolved from the need to serve at-risk adolescents and their families with few resources or who were difficult to treat. FFT has phases that consist of engagement and motivation, behavior change, and generalization. Each phase involves assessment and intervention. For example, in the engagement and motivation phase, assessment focuses on the level of negativity and blaming in family exchanges. The intervention in this phase would target the development of behaviors and communication that reduce negativity and blaming. Similarly, in the generalization phase, assessment identifies the range of situations to which the family can apply new behaviors. The objective of intervention in this phase would be to maximize the functional range of the family's new behavior(s).

MSFT views substance abuse as antisocial behavior that develops from a complex network of interconnected systems: the individual, the family, and extrafamilial factors such as peers, school, and neighborhood (Henggeler, Pickrel, and Brondino 1999; Schoenwald et al. 1996). The intervention is primarily targeted to adolescents. MSFT attempts to alter parenting skills and resources as well as improve the adolescent's coping skills. The intervention integrates strategic family therapy, structural family therapy, behavioral parent training, and cognitive-behavioral therapy. The home-based intervention is designed to reduce service barriers, increase family retention in treatment, allow for the provision of intensive therapy, and enhance treatment gains. MSFT is designed for approximately sixty hours of contact with the family, but family needs determine the frequency and duration of contact.

Treatment of drug abuse and drug dependency. Although some of the interventions described above are useful in treating drug abuse and dependency, Brief Strategic Family Therapy (BSFT), Multidimensional Family Therapy (MDFT) and the Matrix model (MM) are also promising. BSFT and MDFT target adolescent drug abuse. BSFT is a short-term, problem-focused intervention based partly on classical and operant conditioning (Stanton and Shadish 1997; Szapocznik and Williams 2000). Substance abuse is viewed as the result of problematic family interactions that are rewarding based on familiarity and habit. The focus of the intervention is on improving family interactions so that new behaviors are rewarded and replace the substance abuse by the family member. The techniques used in this process are joining (engaging and entering the family system), diagnosing (identifying the maladaptive interactions as well as the family strengths), and restructuring (transforming maladaptive family interactions). BSFT is delivered in twelve to fifteen sessions over three months. BFST was developed for application with inner city Hispanic/Latino and African-American families. Therapists are trained to assess and facilitate healthy family interactions based on the cultural norms of the family.

MDFT views the development of adolescent drug use as the result of individual, family, peer, and community influences (Liddle and Dakof 1995; Schmidt, Liddle, and Dakof 1996). Reducing unwanted behavior and increasing desirable behavior occurs in multiple ways and within different settings (e.g., in the home, school, and community). MDFT interventions typically include individual sessions held in parallel with family sessions. In the individual sessions, adolescents learn effective decision making, negotiation, and problem-solving skills. In the family sessions, parents identify their parenting style and learn positive developmentally appropriate skills to influence their child's behavior.

The MM recognizes the important influence of the family on the development, maintenance and consequences of drug abuse (Rawson et al. 1995; Shoptaw et al. 1994). The intervention includes family education groups to assist families in understanding the effects of the drug abuse of the member. The intervention requires therapists to use nonconfrontational methods to promote the individual's self-esteem, dignity, and self-worth. Sessions include early recovery skills groups, conjoint sessions, family education groups, twelve-step programs, relapse analysis, and social support groups.

Conclusion

Much progress has been made in understanding the relationship between substance abuse and the family. Family factors have an important role in explaining the onset, development, and amelioration of substance abuse. Encouraging gains have been made in treating couples and families with substance abuse problems. More research is needed involving diverse and international populations, but efficacious treatments are growing in type and number that bodes well for improving the lives of millions worldwide.

See also:Child Abuse: Physical Abuse and Neglect; Child Abuse: Sexual Abuse; Childhood, Stages of: Adolescence; Children of Alcoholics; Chronic Illness; Codependency; Conduct Disorder; Developmental Psychopathology; Family Rituals; Health and Families; Homeless Families; Juvenile Delinquency; Therapy: Couple Relationships

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MARK J. MACGOWAN

CHRISTOPHER P. RICE