Introduction
A large and growing body of research indicates children living with a parent or parents who abuse psychoactive substances often manifest significant emotional, behavioral, and social problems. Moreover, it has long been recognized that interventions are needed to address the clinical needs of these children, not only to treat their current psychosocial difficulties, but also to help prevent the development of future emotional and behavioral problems that often emerge in these children during their adolescence and early adulthood. In many circumstances, the only access treatment professionals have to these children is through a substance-abusing parent entering treatment.

Is Parenting Behaviors Of Substance Abusers Important?
Empirical data support the view that:

• parental substance use has a negative impact on parenting behaviors displayed toward children.
• inadequate and punitive parenting practices play a critical role in the development and maintenance of child problems.

Reviews of parenting and substance abuse literatures (e.g., Mayes & Bornstein, 1997) mention the types of parenting practices that have been closely associated with the development of child problems, including:

• inconsistent discipline,
• irritable explosive discipline,
• low supervision and involvement,
• inflexible,
• rigid discipline, and
• poor nurturance.

 

Parents Who Receive Standard Treatment for Substance Abuse
Effects on Children
Given the increased risk of adverse outcomes for children of substance-abusing parents, one might expect considerable interest in the impact of parental substance abuse treatment on child outcomes. If we consider some of the factors that have been associated with the psychosocial adjustment of children whose parents enter substance abuse treatment, including substance use frequency, parental conflict, and partner violence, it is plausible that addiction treatment for a substance-abusing parent would have a positive effect on children living in his or her home.

There have been surprisingly few studies that have explored this particular topic area; however, those that are available support the idea that treating substance-abusing parents has positive effects on children:

• Our investigative team recently completed a study showing that a traditional, community-based 12-step facilitation treatment for substance-abusing men that did not include any family treatment resulted in reduced substance use, reduced partner conflict, and decreases in male-to-female physical aggression during a 1-year posttreatment follow-up period. These improvements are likely to have healthful effects on custodial children living with parents who receive substance abuse treatment.

• More directly on point, Moos, Finney, and Cronkite (1990) examined family adjustment after alcoholic patients received individual alcoholism treatment. They found 11- to 14-year-old boys in remitted alcoholic families and a control group of nonalcoholic families exhibited lower rates of emotional, physical, and serious psychological problems than children living in families in which the alcoholic parent relapsed. Furthermore, these investigations also demonstrated higher levels of functioning (e.g., family cohesion, expressiveness, and organization) and lower levels of parental disagreement and conflict for remitted alcoholic and nonalcoholic families than for families of relapsed alcoholics.

Behavioral Couples Therapy for Substance-Abusing Parents
Effects on Children
Kelley and Fals-Stewart, 2002 reported on two completed investigations that involved a parallel replication of the same study design with alcoholic and drug-dependent male patients who were also the custodial parents of one or more school-aged children (i.e., between the ages of 6 and 16 years). In these investigations, 64 married or cohabiting men with a primary drug dependence diagnosis and 71 married or cohabiting men with a primary alcohol dependence diagnosis were randomly assigned to one of three equally intensive outpatient treatments:

• Behavioral Couples Therapy (BCT), involving the substance-abusing patient and his partner;

• Treatment-As-Usual (TAU) for the substance-abusing partner only, or

• Couples-based Psychoeducational Attention Control Treatment (PACT); consisting of lectures to both partners on various topics related to drug abuse, including the etiology and epidemiology of drug abuse, effects of the drugs on the body and brain, and so forth.

Results in the year after treatment revealed that BCT produced a greater reduction of substance use for men in these couples and more gains in relationship adjustment than did TAU or PACT. BCT also improved psychosocial functioning of the couples’ children significantly more than did the individual-based treatment or the attention control treatment.

Thus, for children of both alcohol- and drug-abusing fathers, BCT improved children’s functioning more than did individual-based or couple psychoeducation. It is important to emphasize that the BCT intervention contained no session content directly related to parenting practices or problems with children, yet the positive effects of BCT for the couple appeared to influence children in these homes positively.

Parent Training
In the past 30 years, numerous studies have focused on the effects of parent training and there is an extensive body of literature to show that teaching parents to change their children’s behavior can be a highly effective intervention procedure. There are now dozens of parent training interventions, which share certain commonalities:

• the intervention is conducted primarily with the parents;

• there is a refocusing from a preoccupation with problem behavior to an emphasis on prosocial goals;

• the content of these programs typically includes instruction in the social learning principles underlying the parenting techniques (e.g., training in positive reinforcement procedures including praise and other forms of positive parent attention and token or point systems; training in extinction and mild punishment procedures such as ignoring, response cost, and time out in lieu of physical punishment; training in giving clear instructions or commands; and training in problem solving); and

• extensive use of didactic instruction, modeling, role playing, and structured homework exercises.

Thus, it can be seen that parent training specifically addresses some of the parenting practices thought to be problematic among substance users. Moreover, integration of couples therapy and parenting training is particularly appropriate, as there is evidence that including a couple component to enhance communication, problem-solving skills, and pleasant activities engaged in by spouses increased the effectiveness of parent training.

Parent Training Plus Substance Abuse Treatment
Strengthening Families Program
Perhaps the most widely known parenting program that has been integrated into substance abuse treatment is the Strengthening Families Program (e.g., SFP; Kumpfer & Alvarado, 1995), which is a family-skills treatment approach that includes both parents and children. In the original study, SFP was used to reduce vulnerability to drug abuse in children of substance-abusing parents. Kumpfer and DeMarsh (1985) reported that, for those families who received SFP, there were improvements in parenting behaviors and reductions in child substance abuse. Since that time, SFP has been employed in a number of different settings and has been shown to improve family functioning and reduce vulnerability to substance use (e.g., for a review, see Kumpfer & Alvarado, 1995).

Parent Skills Behavioral Couples Therapy. As noted earlier, participation in Behavioral Couples Therapy by substance-abusing parents results in improved emotional and behavioral adjustment of custodial children, even though parenting and child issues are not addressed as part of standard BCT. This raises the question, "Can we improve the effects of BCT on children if, as part of the intervention, we added therapeutic content to address parenting and child issues?" Preliminary findings from a small study suggest that the addition of parent skills training exercises to BCT (referred to as Parent Skill BCT, or PSBCT) results in higher levels of psychosocial adjustment among children compared to parents who receive standard BCT or other interventions. Members of the AFRG are presently completing a large-scale randomized clinical trial to further explore the effect of PSBCT on custodial children.

Representative Articles:

Kelley, M. L., & Fals-Stewart, W. (2002). Couples- versus individual-based therapy for alcoholism and drug abuse: Effects on children’s psychosocial functioning. Journal of Consulting and Clinical Psychology, 70, 417-427.

Fals-Stewart, W., Fincham, F. D., & Kelley, M. L. (2004). Substance-abusing parents’ attitudes toward allowing their children to participate in treatment: A comparison of mothers versus fathers. Journal of Family Psychology, 18, 666-671.