(p. 126) Early Origins of Alcohol Use and Abuse: Mental Representations, Relationships, and the Challenge of Assessing the Risk–Resilience Continuum Very Early in the Life of the Child
Alcoholism is the most common form of substance dependence disorder in the United States, affecting approximately 17 million adults. Approximately one in four children in the United States has been exposed to alcohol abuse/alcohol dependence at some point in his/her life before reaching 18 years of age (Grant, 2000), resulting in an estimated 15 to 19.9 million children of alcoholics (COAs) (Eigen & Rowden, 1996). Prospective longitudinal studies, beginning when children of alcoholics are infants and preschoolers, suggest that it is no longer adequate to view adolescent drinking onset as the baseline for understanding the etiological risk for problem drinking. For example, nearly 10 percent of fourth graders, 16 percent of fifth graders, and 29 percent of sixth graders report having had more than just a sip of alcohol (Donovan, 2007), and by eighth grade (early adolescence), slightly more than 19 percent report having been drunk at least once in their lifetime.
Prospective longitudinal studies suggest that risk for problem drinking shows itself even in infancy and early childhood and unfolds in a cascade of interplay between biological and experiential factors (Zucker & Gomberg, 1986; Zucker, 2006; Eiden, Leonard, Hoyle, & Chavez, 2004), particularly in families where co-occurring psychopathology exacerbates the negative impact of parental alcoholism. In this chapter, we focus on evidence pointing to early dysregulatory functioning of COAs reared in high-risk environments consisting of paternal alcoholism. We highlight evidence suggesting that children as young as preschool age have mental representations of alcohol use that include sensory and perceptual sensitivities, cognitive/cultural rules for use, and expectancies about self-use, and are exposed to affective relationship disturbances within the family. We propose that these early expectancies for alcohol use, emergent from parent–child relationships in the earliest years, can be linked to various developmental processes that organize mental representations of self, others, and self–other relationships, as well as to the synergistically developing neurobiological stress management and behavioral self-regulation systems. In addition, we also point (p. 127) to the role that temperament, dyadic relationships, and the child’s expanding social network can play in structuring internal resilience that may enable some children to ward off the negative effects of being reared in an environment surrounded by parental alcoholism, comorbid psychopathology, and conflictual relationship dynamics. Finally, we offer some comments concerning the difficulties of conducting research with high-risk families where there is parental substance abuse, comorbid psychopathology, high interpersonal conflict, and family disorganization.
Children of Alcoholics
It is beyond the scope of this chapter to summarize all the research in what is now a substantive prospective literature on children being reared in families with alcoholic parents (Eiden, Edwards, & Leonard, 2006; Fitzgerald, Puttler, Refior, & Zucker, 2007; Zucker, Donovan, Masten, Mattson, & Moss, 2009). Our goal is to (a) identify major challenges faced by COAs in early childhood (birth to 5 years of age), (b) show how these challenges are related to literature involving older COAs, and (c) comment on early childhood factors that are predictive of both risk and protection from alcohol abuse and related problem behaviors. After describing the context in which many COAs are reared and summarizing known behavioral and neurobiological outcomes that have been identified as arising as early as infancy and early childhood, we propose that children’s mental representations about alcohol use, including their beliefs, expectations (Zucker et al., 2009), and internalization of family codes and values (Sameroff, 1995) shift them toward the risk side of the risk–resilience continuum for subsequent problem drinking and comorbid psychopathology.
Factors in Early Childhood Predicting Risk for Alcohol Problem Behavior
Past research has consistently shown that COAs are more likely than non-COAs to develop psychopathology and substance-related problems (Sher, 1991; Windle & Searles, 1990). Many COAs are exposed to risk factors early in life that predispose them to becoming canalized into pathways leading to high risk for psychological and substance-use disorders (Fitzgerald & Zucker, 2005). Among those at highest risk, these pathways are infused with regulatory problems, relationship problems, and environmental stress, all of which are components of the early etiology for alcohol use disorders.
Self-regulation has been defined as “the exercise of control over oneself, especially with regard to bringing the self into line with preferred standards” (Vohs & Baumeister, 2004, p. 2). It refers to the capacity to regulate one’s behaviors, attention, and emotions (McCabe, Cunnington, & Brooks-Gunn, 2004). COAs are at (p. 128) risk for a number of problems related to the dysregulation of behavioral, cognitive, and physiological processes. As early as the preschool years, COAs, especially boys, are more likely to have externalizing problems than non-COAs (Fitzgerald, Puttler, Mun, & Zucker, 2000; Puttler, Zucker, Fitzgerald, & Bingham, 1998; Zucker, Heitzeg, & Nigg, 2011). COAs also have more internalizing problems than non-COAs, although the differences related to internalizing problems become more prominent during adolescence and young adulthood (Sher, 1991; Zucker, Chermack, & Curran, 2000).
Two- and three-year-old COAs are more likely than non-COAs to be impulsive and to have a difficult temperament and negative mood states (Eiden, Edwards, & Leonard, 2002; Eiden, Leonard, & Morrisey, 2001; Fitzgerald, Sullivan, Zucker, et al., 1993). They also appear to have a shorter attention span, higher externalizing behavior, and hyperactivity (Alterman & Tarter, 1986; Loukas, Fitzgerald, Zucker, & von Eye, 2001) than non-COAs. Moreover, early problem behaviors are often identifiable as precursors of conduct disorder, aggressiveness, and delinquency in childhood (Pihl & Peterson, 1991) and adolescence (Mayzer, Fitzgerald, & Zucker, 2009).
Sleep Patterns as Indicators of Dysregulation
In addition to behavioral and attention problems, there is preliminary evidence to suggest that young COAs have problems regulating basic physiological processes such as sleep. During infancy and early childhood, the amount of time that children sleep ranges from 18 hours for newborns (National Sleep Foundation, 2011) to 12 hours for preschoolers (Iglowstein, Jenni, Molinari, & Largo, 2003). Sleep plays an important restorative function for human beings at all age levels (Sheldon, 2005). Evidence suggests that COAs exhibit a deficit in the neural circuitry responsible for protecting sleep (Tarokh & Carskadon, 2009). Disturbances in sleep appear to have negative impacts on the child’s mental, emotional, and physical stability (Goldstein, Bridge, & Brent, 2008; Wong, Brower, & Zucker, 2009; Wong, Brower, Nigg, & Zucker, 2010). Therefore, it seems plausible that various aspects of sleep can provide an indication of the extent to which very young children are stressed by exposure to family conflict, parent emotional and/or physical abuse, or parental psychopathology.
The hypothalamic-pituitary-adrenal axis system (HPA axis; McEwen & Wingfield, 2003; Ganzel, Morris, & Wethington, 2010) plays a key role in regulating emotions and is known to be negatively affected by both acute (Dickerson & Kemeny, 2004) and chronic stress, causing an imbalance in the individual’s ability to self-regulate stress and increasing the allostatic load (McEwen & Stellar, 1993). Allostatic load refers to the physiological consequences of stress exposure; and posits that persistent exposure to high stress has a negative effect on the individual’s ability to self-regulate.
The HPA axis in the neuroendocrine system helps individuals cope with stress. In response to stress, the human body quickly increases the production of corticotrophin-releasing hormone, adrenal corticotrophin, and cortisol (McEwen, 1998). When stress is terminated, the neuroendocrine system stops producing (p. 129) these hormones, and the hormones in the body quickly return to pre-stress levels (Dai, Thavundayil, Santella, & Gianoulakis, 2007). Among alcoholics, the question is the extent to which these stress regulatory systems no longer function to restore balance (Adinoff, Iranmanesh, Veldhuis, & Fisher, 1998). The developmental question concerns how early in the life cycle the homeostatic HPA-axis regulatory system becomes disorganized and what factors solidify or modify its functional status over the life course (Dickerson & Kemeny, 2004; Zucker et al., 2009).
Chronic stress, which is often present in alcoholic families, is likely to lead to chronic arousal of the HPA-axis among some COAs. Past research has shown a dysfunction of the HPA-axis in adult sons of alcoholics prior to the development of alcohol dependence (Gianoulakis, Thavundayil, & Brown & Dai, 2005; Dai et al., 2007). In addition to exposure to chronic stress, genetic differences in HPA-axis response to stress may interact with environmental triggers (Waltman, McCaul, & Wand, 1994; Dai, Thavundayil, & Gianoulakis, 2002; Zimmerman, Spring, Koller, Holsboer, & Soyka, 2004), predisposing COAs to stress-management dysfunction and increasing their vulnerability for the development of psychological and substance-related problems.
Everhart and Emde (2006) draw attention to a variety of stressors during infancy and early childhood that increase allostatic load and therefore increase the likelihood of dysregulation. Examples of dysregulation include problems controlling one’s behavior (externalizing behaviors), retreat from social interactions (internalizing behavior), or problems with endogeneous or internal biorhythms such as sleep–wake cycles. For example, in prospective studies using sleep measures based on parental ratings, investigators have found no differences in the prevalence of sleep problems among three- to five-year-old COAs compared with non-COAs (Wong, Brower, Fitzgerald, & Zucker, 2004; Wong, Brower, & Zucker, 2009; Wong, Brower, Nigg, & Zucker, 2010). However, studies using actigraphy (assessment of body movements during sleep) and polysomnography (multi-measure assessment of biophysiological activities during sleep) indicate that COAs between the ages of eight and 12 show different patterns of sleep and different physiological activity during sleep compared to non-COAs (Conroy, Hairston, Heitzeg, Gower, & Zucker, 2009; Tarokh & Carskadon, 2009). One study comparing actigraphy and sleep diary data between the two groups showed that eight- to 12-year-old COAs slept less and took longer to fall asleep than did non-COAs (Conroy et al., 2009). Sleep diaries on the same children indicated that COAs not only took longer to fall asleep, they also had lower “sleep efficiency” (a measure of the time sleeping divided by time in bed) than non-COA children.
Another study compared sleep electroencephalograms (EEG) of children nine to 10 years old with or without a parental history of alcohol abuse or dependence (Tarokh & Carskadon, 2009). Sleep researchers distinguish between two types of sleep, that with rapid eye movement (REM) activity (most often associated with dreaming), and that without rapid eye movements. Non-rapid eye movement sleep has various levels of depth, marked by different patterns (theta and delta waves) of electrical activity as measured by an electroencephalogram (EEG). Often, one observes bursts of activity, called spindles, in these recordings of brain waves. Tarokh and Caraskadon (2009) found that there were no signs of sleep disruption in sleep (p. 130) stages in nine- to 10-year-old children whose parents had no history of alcohol abuse or dependence. However, children with parents who had alcohol abuse histories had lower non-rapid eye movement (NREM) brain delta wave activity than comparison children, a finding that is consistent with other sleep studies comparing adult alcohol-dependent and abstinent alcoholics with non-alcoholics (Gillin, Smith, Irwin, & Kripke, 1990; Irwin, Miller, Gillin, Demodena, & Ehlers, 2000). The reduced delta wave activity among children with alcohol abusing parents may reflect a failure of the neurobiological structures responsible for protecting sleep. Children with alcohol abusing parents also exhibited less activity in the spindle range than comparison children. Some researchers have suggested that spindles play a role in protecting sleep by blocking the flow of sensory information from the thalamus to the cortex (De Gennaro & Ferrara, 2003; Yamadori, 1971) and therefore keeping the sleeper in deeper stages of sleep and maximizing the restorative aspects of sleep, such as the release of growth hormone.
Marital conflict and rates of interpersonal violence are high in many alcoholic families (Fitzgerald & Eiden, 2007; Floyd, Cranford, Daugherty, Fitzgerald, & Zucker, 2006; Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009; Stanley, 2008), and contribute to allostatic load in the form of persistent parent–child relationship difficulties. In one study, higher paternal alcohol consumption at 12 months of child’s age predicted negative parental behavior at 24 months (e.g., high negative affect, low warmth, and low sensitivity). Negative parental behavior in turn predicted high negative affect and low responsiveness in COAs. Another study showed that low parental warmth in the toddler years predicted low internalization of rules of conduct and poor effortful control among COAs in the preschool years (Eiden, Edwards, & Leonard, 2004, 2006).
Paternal alcoholism has been associated with elevated rates of father–son conflict. Loukas et al. (2001) found that both family conflict and father–son conflict partially accounted for the relationship between father’s antisocial behavior and his three- to eight-year-old son’s externalizing problems. Evidence supports the conclusion that the poor quality of parent–child interactions in alcoholic families has a negative impact on children’s behavior. Whipple, Fitzgerald, and Zucker (1995) found that during parent-directed play and clean-up, alcoholic fathers were less able to keep their preschool age sons on task than were non-alcoholic fathers. Alcoholic fathers and their sons also were less able to interpret each other’s nonverbal cues and less likely to respond to each other appropriately. These fathers were less skillful at facilitating compliance in their children. As a result, more time was required to complete clean-up and children showed increasing levels of negative affect toward their fathers.
Another study also reported non-compliant behavior among the preschool-age sons of alcoholic fathers during clean-up sessions after free play (Eiden et al., 2001). When compared to sons of non-alcoholic fathers, sons of alcoholic fathers showed higher rates of non-compliance. When both parents were alcoholic, higher rates of noncompliance were found among boys and lower rates were found among (p. 131) girls. Moreover, there was little mutual affect between the girls and their parents. These findings suggest that in response to insensitive parental attempts to achieve compliance, girls were more likely to comply and withdraw from their parents, whereas boys were more likely to engage in aggressive and oppositional behavior.
Environmental stress is associated with heavy drinking and alcoholism (Dawson, Grant, & Ruan, 2005; Linsky, Straus, & Colby, 1985; King, Bernardy, & Hauner, 2003) and contributes to family and individual allostatic stress and the inability to maintain normative regulatory processes. Alcoholics are more likely than others to have trouble in job-related, financial, and legal matters, and they are more likely to have lower socio-economic status (Fitzgerald & Zucker, 1995). These adjunctive influences to family and person dynamics combine to expose alcoholics to persistent stress (Fitzgerald, Zucker, & Yang, 1995). As might be expected, these adult stress experiences also have an impact on stress within the family. Across several longitudinal studies, alcoholic parents systematically reported more family stressors than did non-alcoholics. Many of these events were related to family crises, such as eviction, job loss, being cut off from welfare, and being in financial trouble (Hussong, Bauer, Huang, et al., 2008). All of these experiences not only engender acute crises, but to the extent that they exist over time, they also lead to a sense of chaos and unpredictability of the environment and of the future, factors that have been linked to high levels of cortisol production (Dickerson & Kemeny, 2004).
Even though COAs are exposed to multiple risk factors and are therefore vulnerable to the development of multiple problems, there is considerable heterogeneity in developmental outcomes, suggesting that some COAs are more resilient than others (Wong, Zucker, Puttler, & Fitzgerald, 1999; Zucker, Wong, Puttler, & Fitzgerald, 2003). Compared to the vast literature on risk factors for alcohol problem behavior, research on protective factors is scarce. Nevertheless, there are some indications that protective factors are embedded in the child’s temperament, mother–child relationships in early development, and in sibling relationships later in childhood and adolescence.
Resilient COAs appear to have more easy-going temperaments than do non-resilient COAs. One longitudinal study found that resilient COAs were more “cuddly and affectionate” during the first year of life than non-resilient COAs (Werner, 1986). By grade 12, the resilient COAs in the same study appeared to show more self-control, more caring toward others, and more tolerance of individual differences. Another study found that, over a longitudinal time frame of three to 14 years, vulnerable COAs, defined by individual and family risk, were more reactive and had a shorter attention span than children from a low-risk background (Zucker (p. 132) et al., 2003). Reactivity is a core component of temperament and is related to the individual’s stress management system, thus providing, at the least, a connection to allostatic processes (Rothbart, Derryberry, & Posner, 1994; Strelau, 1998).
Secure Mother–Child Attachment
A core tenet of the interdisciplinary field of infant mental health is that early relationships matter. For COAs, studies of relationship dynamics during the early years are consistent with the infant mental health dictum. A secure relationship with the non-alcoholic parent (mother) appears to moderate the relationship between father’s alcoholism and externalizing problems in COAs (Edwards, Eiden, & Leonard, 2006). COAs who had a secure mother–infant attachment at 12 months had significantly fewer externalizing problems at 24 months and 36 months of age compared with COAs with insecure attachment. The same pattern of findings was reported for internalizing problems at 36 months of age. Another study also reported similar findings among COAs under the age of six (Kittmer, 2005). The extant literature on social-emotional development provides ample evidence to support the contention that the quality of the mother–infant relationship provides a powerful moderating influence on development of the HPA-axis stress regulating system (Fonagy, Luyten, & Strathearn, 2011a,b).
It is important to note that children may develop secure relationship with caregivers other than their mothers. Such relationships also appear to be associated with good outcomes. One longitudinal study of children of alcoholics showed that children who received a great deal of attention and affection from their primary caregivers had better developmental outcomes, regardless of who their primary caregivers were (Werner, 1986; Werner & Johnson, 2000).
Very little research is available on how sibling relationships may be related to positive outcomes in young COAs. Existing research on adolescents shows that siblings influence each other’s behavior, including their drinking and drug use (Trim, Leuthe, & Chassin, 2006). Support from siblings was positively related to adolescent COA’s (mean age = 12.7 years) self-esteem and negatively related to father ratings of externalizing problems (Barrera, Chassin, & Rogosch, 1993). In contrast, conflict with siblings was positively related to self-report and maternal ratings of externalizing problems. In retrospective reports, resilient adult COAs reported that they had strong relationships with their siblings in childhood (Kittmer, 2005).
Enjoyment of School and Achievement Scores
COAs who are resilient are more likely to enjoy school, regardless of whether they do well academically (Werner & Johnson, 2000). Resilient COAs appear to have higher achievement scores than non-resilient COAs. One study found that there were significant differences on a measure of educational progress between resilient COAs and non-resilient COAs (Werner, 1986). Another study reported (p. 133) that resilient COAs had higher scores on a measure of math, reading, and spelling than non-resilient COAs (Zucker, Wong, Puttler, & Fitzgerald, 2003). There is also some evidence showing that resilient COAs have a stronger achievement orientation than non-resilient COAs (Werner, 1986).
COAs are at greater risk for alcohol abuse and alcohol-related problems than children without an alcoholic parent. Although some of the risk may be transmitted genetically, there also is strong evidence for significant interactions between adverse environments and vulnerable neurobiological risk, underlying the contemporary understanding of the interplay between genetic and experiential organizers of behavior (Sun & Zhao, 2010). Moreover, a considerable body of work indicates that the familial and other environmental adversity is evident during early childhood and contributes to heightened difficulties with stress management as evidenced by the early appearance of behavior problems. This is especially the case when the father is the alcoholic.
Mental Representations, Expectancies, and Alcoholism Etiology
Overwhelming evidence supports the conclusion that behavioral and neurobiological dysregulation very early in the life course are part of the etiological pathway toward alcohol problem behaviors (Zucker et al., 2009). Such behaviors may become manifest as early as the preschool years. Advances in brain science and understanding of hormone regulatory systems have opened new approaches for understanding the individual’s mental representations of events and for exploring how such representations formed early in the life course affect decision processes later in development. Of particular interest to the etiology of alcoholism are the experiential triggers that may evoke specific expectancies at critical decision points guiding the individual towards decisions to engage in risky behavior. In the study of risk development in childhood, there is considerable literature on alcohol expectancies, but little attention has been paid to the mental representations that children of alcoholics form concerning parental drinking and problem behaviors. Of particular interest is how such representations may be mediated by neurobiological structures that were organized in relation to the child’s experiential world, including the inner world of self-development as well as the relational world of self–other interaction. One area of potential research concerns the extent to which mental representations of experience are homologous to the structure-function organization of the prefrontal cortex and HPA axis, each of which plays a critical role in self-regulation.
Over twenty years ago, we presented evidence that many COAs have mental representations of alcoholic beverages as substances, and that COA’s “ability to recognize and name these substances, to recognize the cultural rules of their use, and to formulate expectancies about the cognitive and behavioral effects of use can occur well before adolescence” (Zucker & Fitzgerald, 1991; (p. 134) Zucker, Kincaid, Fitzgerald, & Bingham, 1995). We noted that mental representations or schemas about alcohol use have their origins during the preschool years, and that schemas include aspects of context, motivation, emotion, and normative characteristics of use (Zucker et al., 1995).
Investigators asked a community sample of preschool- to kindergarten-age children to engage in a series of tasks designed to determine whether they could discriminate and identify a variety of substances by their smell (Noll, Zucker, & Greenberg, 1990). The smell task included alcoholic beverages and a variety of non-alcoholic substances that were likely to be familiar to the children (Play-Doh, apple juice, popcorn, etc.). Children were first asked to identify a smell through recall; a subsequent trial used a photograph of the substances as a prompt to recognition memory. After the identification task, children were then asked to provide information about who used the substance, whether the child liked the substance, and if the child expected to use it in the future.
Noll and his colleagues found that older children did better on the recall and recognition tasks than younger children, and that prompting improved their ability to recognize the smells. Children were better able to identify familial substances than they were alcohol or tobacco. The children who correctly identified the alcoholic beverages also attributed their use to adults, not to children. Of specific interest was the finding that success at odor identification was related to heavier parental drinking (especially by fathers) and to parental use of alcohol for purposes of escape. Thus, in a community sample of very young children, there was a connection between parental alcohol use and young children’s sensory and perceptual representations about alcoholic beverages.
Mental representations refer to the encoding of experience into memory. Such encoding comes from self-reflections about experience (sensory and perceptual identification of objects in the individual’s experiential world), and from the self–other relationship experiences about events (parental labeling of objects, descriptions of events, comments about others). In infancy and early childhood, the construction of mental representations occurs in a relationship context, in which significant others interpret internal feeling states (“You are certainly a very happy baby today!” “Your father is a drunk and doesn’t care about us!”), and shape the child’s intersubjective world of shared meaning (Trevarthen, 1980).
In a high-risk population-based sample, three- to six-year-old children were shown 10 photographs of beverages (5 non-alcoholic and 5 alcoholic) in a random order, and were asked to identify each of the beverages, first by recall (“What is this?”) and then by recognition (“Show me the milk bottle!”) (Zucker et al., 1995). Ten drawings of adults and/or children in various contexts were presented, and the children were asked to name the beverage that each person in each drawing was drinking. The vast majority of the sample correctly identified at least one alcoholic beverage, including three-year-olds. COAs were seven times more likely to be able to identify at least one alcohol beverage. Kindergarten-age children attributed more alcoholic beverage use to drinkers, especially male drinkers.
Overall, children in the study attributed alcohol beverage use to adult males more than to adult females, and considerably more than to children. Fathers’ (p. 135) consumption, reported separately by the fathers, was correlated with their sons’ attributions of adult male consumption, and mothers’ reported consumption (not fathers’) predicted their children’s attributions of alcohol use to adult women. These findings suggest that, by age five, children reared in high-risk alcoholic families have schemas that include sensory, perceptual, and expected use dimensions of alcoholic beverages that are more organized than those of children reared in non-alcoholic families. This led Zucker et al. (1995, p. 1016) to conclude that the “presence of such schemas, nested in an environment that sustains their development and encourages the development of non-alcohol-specific risks, is the breeding ground within which the most severe alcohol problems are likely to emerge and then crystallize.”
However, the cognitive and sensory-perceptual components of an emergent schema are only part of the story. Missing are the social-emotional components, the affective load that underlies problem behavior and, we contend, completes the nesting structures that can cascade children of alcoholics into early onset smoking, drinking, sexual, and antisocial behavior.
Mental Representations, Familial Alcoholism, and Co-Occurring Psychopathology
Mentalization refers to the ability to recognize mental states in oneself and in others, including the ability to reflect on one’s own thoughts, emotions, wishes, desires, and needs as well as those of others. It is a mother’s inference that her infant is thinking and feeling (“You sure love little teddy bear and he makes you so happy!”). It also is an ability that gradually organizes in infancy and early childhood with respect to children’s ability to disconnect their feelings from their behavior. For example, parents and preschool teachers spend considerable time helping their children understand that they can feel angry, but must learn not to express angry feelings in self-destructive or other-destructive behaviors.
Mental representations involve the encoding of events into autobiographical narratives about self, others, and self–other relationships. Autobiographical memory for events develops during the second and third postnatal years, roughly at the same time that children develop “a knowledge structure whose features serve to organize memories of experiences that happened to ‘me’” (Howe & Courage, 1997, p. 499). As events merge over the life course, autobiographical memories become part of one’s “autobiographical reasoning” (Habemas & Bluck, 2000) and merge into a coherent narrative that is organized from familial and cultural experiences (Atran, Medin, & Ross, 2005).
With the exception of the Buffalo and Michigan longitudinal studies (see Fitzgerald & Eiden, 2008), discussion of relationship disorders (Zeanah et al., 1999) in connection with mental representations and very early life course narratives does not appear in the alcoholism literature. Other researchers, however, have repeatedly demonstrated that early relationship disorders and traumatic events influence the narratives that children construct over time (Conway & Pleydell-Pearce, 2000). For example, three- to five-year-old children who are exposed to repeated parental use of aggression in response to frustration themselves have high levels (p. 136) of aggression, externalizing, and antisocial behavior (Muller, Fitzgerald, Sullivan, & Zucker, 1994).
Mental representations of events are also linked to the neurobiological responses triggered by stressful and traumatic experiences in infancy and early childhood. Stress responses increase glucosteroid release, which has a negative effect on the hippocampus and medial temporal lobe networks (Markowitsch, Thiel, Kessler, von Stockhausen, & Heiss, 1997) that affect memory and stress regulation. The hippocampus and related limbic structures of the medial temporal lobe mature relatively early in postnatal life and are involved in the development of explicit memory (Nelson, 1995), a component of memory that reaches its near-adult level by the preschool years. Thus, damage to the hippocampus and the neural networks it is associated with would have direct effects on impulse control and self-regulation of behavior. In their studies of borderline personality disorder and the attachment system, Fonagy et al. (2011a, 2011b) stress the connections between behavioral indicators of emotion dysregulation, impulsivity, and disturbed interpersonal functioning, and the dopaminergic and oxytocinergic systems, both of which play key roles in the regulation of emotional and social behavior.
In the early-childhood literature, emphasis on mental representations has been twofold; development of mental representations of attachment objects in children (the initial love objects in the child’s life) (Bowlby, 1969; Spitz, 1965), and the influence of such representations on one’s parenting abilities (Fraiberg, Adelson, & Shapiro, 1975). The representations of adults who have unresolved conflicts with their parents subsequently affect their parenting abilities. Thus, memory for familiar events during early development (mother–infant or father–infant relationships) is related to the development of a working model of self and relationships that is hypothesized to carry over into adulthood and to be evoked when the adult is placed in the parenting context. Bűrgin (2011) refers to representations as “intrapsychic entities” that symbolize meaning to external events, and posits that they are evoked from self–other interactions and are unconsciously activated during subsequent interpersonal interactions. Stern (1985) describes the progression of self, beginning with self–other differentiation, moving to intersubjective relatedness, and ending with a sense of self coming into being, a sort of existential affirmation that “I am!” Fraiberg et al. (1975) used the “ghosts in the nursery” metaphor in an effort to capture the mother’s intrapsychic entities created by her own rearing that interfere with her ability to form nurturing relationships with her baby. Some evidence suggests that similar “ghosts” may exist for fathers as well (Fuller, Chermack, Cruise, et al., 2003; Grossman & Fremmer-Bombik, 1994, Shears, Robinson, & Emde, 2002).
An explicit assumption of attachment theory (Lyons-Ruth, 1996) is that memory for familiar events (mother–infant interactions) is related to the development of a working model of self as well as a working model for relationships (Verschuren, Marcven, & Schoefs, 1996). The bulk of this literature suggests that children as young as three years of age already have working models or schemas about familiar events. Autobiographical memories are only partially based on experience, however, because they are constructed from experience and are influenced by exposure to others’ constructions of experience, particularly those (p. 137) of parents (Schneider & Bjorklund, 1998). Mothers who elaborate their stories and challenge their toddlers with high rates of memory questions tend to have toddlers with richer autobiographical memories (Harley & Reese, 1999). Toddlers who were developmentally more advanced in self recognition also tended to have richer autobiographical memories of shared events. “Therefore, to understand the relations among the attachment system and the hidden traumas that produce dysregulation of the HPA axis during the first year, it is necessary to elucidate how attachment processes during the first year are embedded within a matrix of intersubjective communications” (Schuder & Lyons-Ruth, 2004, p. 90).
Infancy and early childhood provide numerous occasions for children to model sex-role behavior and to construct their initial working models of what it is to be a father, mother, spouse, or parent. These mental representations incorporate adult behavior and interpersonal dynamics, including such behaviors as drinking and smoking, and such dynamics as marital conflict. Children remember events that are consistent with gender role stereotypes better than those that are inconsistent, and, remarkably, when events are not consistent with these stereotypes, preschool-age children distort the information to make it consistent (Davidson, 1996). “Like father, like son” is driven as much by the son’s identification processes as it is by the father’s modeled behavior.
When considered in the context of a broader developmental literature, therefore, alcohol expectancies of preschool age children are complex organizational structures. Moreover, they are unique to the individual child’s experiences, the autobiographical structures of mind (Schneider & Bjorklund, 1998). The question is, do these early mental structures strengthen over the elementary-school years so that when children transition to adolescence, the mental models or expectancies related to alcohol and interpersonal relationships play a regulatory role in decisions about drinking, smoking, sexual activity, or other risky behaviors? Evidence from longitudinal studies of externalizing behavior suggests that an affirmative answer to this question is a reasonable hypothesis. According to Lorber and Egeland (2009, p. 912), “Infancy is characterized by rapid development of emotion regulatory capacity, patterns of relating to others, and internal representations of relationships; each is surmised to be important to the development of externalizing problems. Maladaptive infancy parenting may negatively impact these capacities and behaviors during a period in which they are thought to be highly sensitive to environmental input, thus setting the stage for the development of persistent externalizing psychopathology.”
Studies of the early years of life that are related to the development of memory for events provide some support for the hypothesis that early mental representations play a critical role in subsequent decision processes. Figure 7.1 captures this process in the context of children exposed to high levels of parental psychopathology and marital conflict. As the self and self–other systems organize during the first three postnatal years, children consolidate expectancies and create and co-create (through parenting and other relationships) mental representations about the self and interpersonal relationships and consciously or unconsciously evoke representations as their social and affective networks expand and they become increasingly independent actors in constructing their own life narratives. As the (p. 138) (p. 139) children move through childhood and into adolescence, various experiences will maintain, enhance, facilitate, or dampen cumulative risk. What seems increasingly clear is that movement along the risk–resilience continuum apropos of the etiology of alcohol problem behavior and associated co-active psychopathology is driven in part by the mental representations about drinking and interpersonal relationships that have their origins in infancy and early childhood.
Research Challenges Working with High-Risk Alcoholic Families
Problems associated with longitudinal studies appear in the literature frequently, beginning with introductory textbooks in psychology, where they are contrasted with cross-sectional approaches. However, some literature does exist to assist investigators who want to plan long-term and large-scale studies, particularly where there is interest in etiological pathways and the influence of risk factors as organizing constructs (Stouthamer-Loeber, van Kammen, & Loeber, 1992). Working with high-risk, substance abusing families presents a number of challenges for participants and researchers. For participants, the challenges are best understood in the context of daily life events related to addictive behavior, family conflict, parent–child relationships, and interaction with social agencies. For participants working with researchers, the challenge also is to be able to describe their lives and in so doing become more aware of them. This is often a challenging task when one’s life has been heavily burdened by trauma and stress. For researchers, the challenges encompass issues related to the ethical conduct of research, adherence to scientific rigor, scheduling data collection sessions, unpredictable participant behavior, staff selection, recruitment, training, and continuity.
Assembling evidence that risk aggregation for alcoholism begins at least as early as the preschool years, Zucker and his colleagues began a recruitment process that involved a search through 18,359 court files in order to recruit an alcoholic family sample, and 18,889 residences to recruit a community comparison sample (Zucker et al., 2000). This effort produced 159 court alcoholic families and 91 community families that met the recruitment criteria. Families recruited into the study were informed that researchers would have to report instances of suspected child abuse or personal harm. Because family dynamics within the high-risk court-recruited sample were fragile, it was imperative that we used a contact strategy that would build trust and compliance for the planned 30-year multiple contact, intense data-collection study. We found our trust builder when we hired an individual with a master’s degree in social work (MSW) as our field coordinator, whose responsibilities included conducting the recruitment interview and sustaining family contacts throughout the (now 26) years of the study. We note this explicitly to illustrate the critical importance that trust-building plays in sustaining relationships with high-risk families. Indeed, when focusing on individual and family relationship dynamics to understand etiology and the flow of risk over time, it is important to learn (p. 140) as much as possible about life course pathways that may or may not be tapped by standardized assessment tools. Many investigators use narratives to achieve this depth of understanding. In other instances, trust building may allow personal disclosure to occur naturally, but over time. For example, in one instance a mother informed the assessor that the target child’s father was not in fact his biological father. This revelation required us to code all data related to that family as suspect for biological-father parenthood.
Thus, maintaining a personal and consistent relationship with each family meant that family members were more willing to share intimate information about their personal and family life. In addition to our field coordinator, we also discovered it was essential to use clinically sophisticated data collectors, individuals who were at ease with blue-collar families, sometimes quite poor, and sometimes troubled by personal and family difficulties in addition to paternal alcoholism. Evidence that relationships matter was demonstrated by the fact that after five to ten years in the study, many participants included the Longitudinal Study staff among key social supports, whereas we were not listed in the initial assessment of social support networks.
Because initially all participants lived within 50 miles of Michigan State University most data collection took place on campus. This enabled us to include structured videotape observation sessions, as well as to have controlled settings in which to assess children and parents. As the study moved into the third data collection wave (child aged 9–12), many families had moved considerably further from campus, including out of state. Therefore, we began to shift toward home visits for data collection. Data collection from teachers has always been conducted by mailing research packets with return envelopes.
Home visits introduced new complications to the assessment process. On some occasions, when home visitors arrived for scheduled sessions, participants were intoxicated and therefore data collection could not take place. This required rescheduling and another round trip. When done at a distance (some participants now reside over a thousand miles from Michigan), rescheduling is done on the spot because the data collector is staying at a hotel in the area. Some homes are located in unsafe neighborhoods, and occasionally dogs are not people-friendly and dog bites can occur. In other instances, guns are plentiful and in very open display. Female data collectors sometimes may be in uncomfortable situations with male participants. We advise female data collectors about their appearance and how to gently but firmly deal with propositioning from adult male participants. We are always in need of more male assessors.
Assessors also need to be trained in how to deal appropriately, and legally, with events such as child abuse and anything that suggests that a participant may be suspect for self-harm. They also are trained to deal with family trauma resulting from death, illness, or separation/divorce. Such events can be especially difficult for young children.
(p. 141) Marital and Partner Conflict
Family conflict also presents challenges to assessors. When step-parents are involved, assessors need to be prepared to interact with jealous spouses who do not want “investigators hanging around,” or do not want their partner talking with female interviewers even on the telephone. Occasionally, we interact with family members who have become involved with fundamental religious sects whose religious leaders advise them not to share personal or family information with “outsiders.”
Maximizing Retention and Participant Mobility
From one perspective, all of our strategies for preparing data collectors are focused on assuring their safety and the quality of the data obtained. From another perspective, our strategies are to maximize retention, a constant challenge when working with high-risk families (Cotter, Burke, Loeber, & Navratil, 2002; Navratil, Green, Loeber, & Lahey, 1994). For a planned over-thirty-year study, paying attention to participant retention is essential. In addition to trust building and staff consistency, we use multiple family informants to track highly mobile families.
High mobility requires use of multiple strategies for tracking and locating families over long periods of time, stressing financial resources that otherwise could be invested in other aspects of the research project. Peripatetic residence and the inability to keep schedules and appointments negatively impact financial resources committed to data collection; the assessor may travel considerable distances to meet with families, only to return empty-handed. Life styles are also peripatetic, sometimes to avoid the law (e.g., child protective services being about to remove a child from the home), sometimes to get a new job, sometimes to avoid paying the rent.
Among very-low-income families, practices such as leaving forwarding addresses are less likely to be routine. We send cards for nearly every occasion possible, including birthdays and secular and religious holidays, and we send child and adult newsletters. All are sent with postal return codes so that we know within a relatively short time whether a family has moved. When that occurs, we kick in our family informant contacts to locate the participant family. We sometimes have hired private detectives to track families, and we collate visits in local areas for drop-ins, even if a particular family is not scheduled for assessment. The use of home data collections and phone assessments also provides information about family mobility and continued interest in the study. Without question, our decision to move from university-based to home-based data collection was critical to the continued success of the longitudinal aspects of the study.
Originally, the study was located at one university. When it relocated to the University of Michigan and became a two-university site, new administrative issues surfaced. Because the universities are only about one hour’s driving distance apart, we scheduled project meetings at each site on alternate months. Modern (p. 142) forms of electronic communication also assist in keeping a sense of connectedness between the sites. Social gatherings for project staff also help build rapport and project spirit. One problem, however, carries a real administrative burden, and that concerns project oversight by two institutional review boards (IRBs). What is acceptable to one IRB may not be acceptable to the other. In our case, the project is reviewed by a Medical IRB at one site and by a Community IRB at another site. One IRB may request specific changes to a consent letter, whereas another IRB may find the requested changes problematic. While we have managed to negotiate the two IRBs, it frequently requires considerable administrative time to secure joint agreement. Having multiple sites also means more coordination and thus more work. For instance, managing two biweekly payrolls may mean that an administrator has to do payroll-related paperwork every week.
Aging of Participants, Researchers, Review Panels, and the Scientific Zeitgeist
Everyone in the study deals with all of the issues related to life-course changes. Our three-year-olds have moved through puberty, into adulthood, and in some instances into parenthood. Parents who originally were in their 20s to 40s are now 26 years older, as are the researchers who have been with the study from its inception. Compliant preschool- and elementary-age children become less compliant teenagers, and as assent forms turn to consent forms when participants reach age 18, we have discovered that earlier study involvement, primarily negotiated with the parents, is of no particular interest to a late adolescent or young adult who has other things on his or her mind than sitting down to fill out some forms and answer questions that require reflection. Family composition changes with step-parent and single parent configuration. Parents and teens become involved with the criminal justice system, with some serving prison time. The problems associated with reconnecting with teenagers are especially challenging, particularly with teens that drop out of school and leave home.
At a different level, there is a contact challenge to staff, because when a study like this is initiated, one typically has expertise with subject functioning and important/relevant variables within a specific developmental window. Long-term, as subjects become older, investigators need to educate themselves about development and functioning in order to keep the study current. In some ways, the study outgrows the investigators’ expertise. In addition, as study subjects grow older, they tend to become older than the young staff one typically hires for assessment. So the age differential can create rapport problems. Also, vis-à-vis engaging with families that are financially successful, study participants may no longer see the participation fees as worth the time required for data collection. We have used a sliding pay scale to attempt to deal with this issue.
An additional long-term challenge is to sustain funding for what has, over the years, been a very significant but also very expensive scientific undertaking. Even with five-year federal funding cycles, keeping a study alive over five federal funding cycles (our earliest period was supported by local and state resources) has always been a significant hurdle. Review panels have no interest in supporting and (p. 143) monitoring important risk variables for a very expensive scientific undertaking, just so that a decade or more later the study will (probably) be able to examine long-term predictors of adult disorder. If the study is to be sustained, one must uncover important intermediary questions. And even then, non-longitudinal researchers tend not to have patience for the large cost and long span of time involved in characterizing a long-term story.
Perhaps the biggest challenge of all is that the science changes while the study is being conducted. State-of-the-art measures in one decade are passé in the next. A focus on one domain of function, considered central to understanding the development of risk at one time point may be regarded as of secondary, or even of trivial importance at another. Only by sustaining a broad network of relationships with a multidisciplinary group of colleagues can these challenges be effectively met.
The Human Story
When one examines the descriptive statistics on families participating in the high risk for alcoholism prospective studies, it is clear that there are numerous environmental experiences that flood children in the highest-risk homes. In the Michigan Longitudinal Study, to date, five percent of parents have died, with 1.4 percent of the total having been suicides or probable suicides (an annual rate approximately 100 times higher than the national average), and another 1.0 percent of the deaths have involved accidents (most often vehicular) and drug overdoses.
Other indicators point to a kaleidoscope of negative imagery surrounding earlier life in the highest-risk families. Marital assortment (Thiessen & Gregg, 1980) is substantial for drinking, rule breaking, and inattention to social achievement. There are strong relationships between mothers’ and fathers’ age of first drunkenness, their level of delinquency, and their antisocial behavior in their own childhoods. There also is assortment on the level of education each parent has achieved. These experiences form the background history of the child-rearing environment. It is most negative among the families at highest risk for the evolution of early risk, and for the subsequent development of substance use disorder among the children (Zucker et al., 1996; Buu et al., 2009).
At the individual level, the life stories of these families is heartrending; parental conflict is the norm, and physical violence between parents is not uncommon; adults come and go because they have multiple, usually sequential relationships, but also multiple sexual partners. Unemployment is often present, either within the immediate family or among relatives, who then spend time just hanging around; children are shipped to a grandparent when a parent is incarcerated or sent to a detoxification center; learning difficulties and attentional problems for the children are not unusual, and although initial involvement in school is looked forward to, by late middle childhood, there is too much going on outside the school setting to allow a sustained focus. School performance deteriorates, or there are conflicts with the teacher. Peer involvement with friends is commonly with others coming from like kinds of families, and the peer network becomes the (p. 144) quasi-support group and home away from home. Early involvement with alcohol and cigarettes is frequent, and it is an easy jump to engage in such life-course decisions when access and use is so common among one’s friends. Often parents do not care. Sometimes they even offer the children alcohol or other drugs, thinking it is cute, or they are being friendly. Earlier sexual involvement often occurs, and teen pregnancies are more common. Among the offspring who have already had a child by age 20, the overwhelming majority come from families with an alcoholic parent.
Not all individuals nor all families have such a bleak picture. Some children, even within such disorganized homes, manage to stay disengaged from their parents and siblings. Sometimes they, for whatever reason, come to the conclusion that the substance involvement leads only downward, and they make a personal resolution to not use. Not uncommonly, a friend’s parents take an interest in the youngster, or a minister does, and the child responds to the interest and attention and begins to spend more and more time at the other family’s home. Significant involvement in church activity is sometimes an escape, and school performance is good. Functioning in young adulthood, to the extent we have information on this, suggests such a trajectory of disconnection can be maintained, including steady employment, sometimes pursuit of a college education, and advancement from minimum wage to supervisory/managerial jobs. At the same time, health problems (acid reflux, problems with weight control) and psychological indicators of distress, such as phobias, fears of public speaking, or bouts of depression, are often present. Unfortunately, wherever there has been this history of exposure to negative contexts and negative images, a residue of psychological or interpersonal scars shows itself, albeit playing a minor role in day-to-day functioning.
Although this continuity picture of incremental risk across childhood is the worst-case scenario, a more common, albeit also troubling, pattern of adaptation is more the norm. This is the pattern of moving into and out of damaged functioning and traumatic exposure to high stress at irregular intervals; that is, a period of time exists where a number of these negative experiences are occurring, which then subside. Thereafter, a period of time of irregular duration occurs, when problems are manageable and life appears to return to normal, and then another wave of difficulties shows up.
For staff who are involved in interviewing and other data collection, the burden of observing these life difficulties is a hard one to carry. Frequent discussions among staff, the proffering of referrals whenever requested, and urging attention and treatment for serious troubles that are mentioned only in passing or on a questionnaire (e.g., suicidal thoughts) all ease the burden a little, but not much, especially when such advice is ignored. (Child abuse is another matter entirely, and is reported when there are signs it is happening.) This work has sent an undercurrent message to all of us, repeatedly: it is that preventive intervention is essential for this population, and the blindness about its need, the lack of awareness about its early appearance, and the lack of funding for sustained and/or periodic intervention effort are roadblocks that are essential to remove.
(p. 145) Future Directions
If one includes the time when the early pilot work was being done for the Michigan Longitudinal Study, it has been in the field and under scientific stewardship for 30 years; if one counts the time since the formal start of the regular data collection, the duration is 25 years at this writing. Over that interval, a series of major collaborations have been developed that extend our scientific inquiry biologically deeper—by way of collaborations with neuroscientists (Heitzeg et al., 2008, 2010) and molecular geneticists (Villafuerte et al., 2011; Strumba et al., 2011), and environmentally broader—by way of extensive examination of the neighborhood context and its effects upon development for both generations of these families (Buu et al., 2007, 2009, 2010). These collaborations also have allowed us, by means of trajectory analysis, to characterize developmental variation and individual differences in a much more differentiated way (Shedden & Zucker, 2008; Jester, Nigg. et al., 2008; Jester, Puttler, et al., 2008) than we had at the study’s outset.
Currently, the project is integrated with, and participates in, five other National Institutes of Health (NIH) projects focused on:
(a) neuroimaging (functional magnetic resonance imaging, fMRI) of late adolescents and young adults;
(b) a parallel neuroimaging project examining the emergence of risk in children in middle childhood who have not yet begun alcohol or other drug use;
(c) the role of the dopaminergic system in addiction in young adults (examined via positron-emission tomography, PET);
(d) the role of sleep problems as a mediator of externalizing and internalizing risk prior to the onset of substance use;
(e) the genes mediating precursive behavioral risk;
(f) the components of neurocognitive risk that are precursive to alcohol use as well as those that develop as a result of heavy consumption.
Four other projects were previously funded to examine:
(a) the neurophysiological components of precursive risk for smoking;
(b) marital interactions as protectors or enhancers of problem alcohol use and relapse over time;
(c) the roles of stress and internalizing risk on drug abuse; and
(d) the relationship between sleep problems, alcohol/other drug abuse, and related comorbidity (e.g., suicidality) in adolescence and young adulthood.
Although NIH funding has ended for these latter projects, the integrative work with the core study continues.
This array of projects, assessing multiple levels of functioning simultaneously and also developmentally, has given us an extraordinarily broad playing field on which to explore relationships, both over time and across levels of analysis. It is not an accident that these collaborations have developed. They were a direct result of the initial nature of the study design, and also of the very carefully constructed, (p. 146) albeit very broad, measurement structure of the data collection. The availability of these multiple probes is of special relevance to the hypothesis we proposed at the beginning of the chapter; namely, that it is mental representations about self and social context (one component of which is representations about alcohol), along with the internalization of family codes and values, that shift the child toward the risk side of the risk–resilience continuum for subsequent problem drinking and comorbid psychopathology. This is a complex set of relationships to parse, because it involves relationships between conscious self-experience, presence of a set of environments or risky contexts, and some kind of internal processing that consolidates these interactions. Such processing does not all take place at a “conscious” level, but rather involves substructures of the brain that monitor feeling and action tendencies, suppress some, and allow others to be expressed. At the neural level, this is the core mechanical structure, but at the same time, the brain is assessing meaning and assimilating what the context is conveying about support, opposition, reward, punishment, etc. A number of recent project activities have focused on these issues (e.g., Heitzeg et al., 2008; Weiland et al., in press; McAweeney et al., 2005, Fuller et al., 2003).
This is not the place to go into that work in any detail, but it forms the backbone of what we will be pursuing in the years ahead. That work will involve an extensive examination of:
— Gene X environment interactions, focusing on candidate genes known individually to relate to risky behavior, but where the interactions with environment leading to elevated risk are only meagerly charted (see, for example, Caspi et al., 2002).
— Developing a detailed characterization of the social environment, including development of a differentiated vocabulary about what environmental “types” are relevant to specific classes of behavior (internalizing behaviors/externalizing behaviors, inhibition, cognitive complexity, achievement, etc.)
— Characterizing the dynamics of resilience developmentally from early life to early adulthood, with a special focus on stability and instability/discontinuity of this adaptation.
Much of this work will take advantage of the multiple levels of function we have characterized, but not all are biological. Understanding the reciprocal relationship, developmentally, between facilitating environment and individual behavior, over long spans of time is already one specific item on our agenda.
Children of alcoholics can be exposed to the full range of biological and experiential factors that organize, canalize, and structure life-course pathways. The heterogeneity of alcohol problem behavior indicates that there also are factors that contribute to resilience, although such factors are less well understood. Over the life course, many individuals slide from one side of the risk–resilience continuum to another in response to individual, familial, peer, and other influences. We (p. 147) suggest that mental representations about drinking and associated behaviors form as early as infancy and early childhood. Such representations influence expectancies and both decision and affective processes that are anchored in the neurobiology of executive and stress-regulatory systems that shift children of alcoholics toward the risk side of the risk–resilience continuum. These forces are particularly strong in families where parental addiction and comorbid psychopathology surround all facets of the child’s rearing environment. Conducting longitudinal research in such families challenges the personal and relational resources of family members, and simultaneously challenges researchers to maintain constant vigilance over the changing dynamics of life-course transitions among research participants and themselves.
Descriptions of individual and family functioning in this chapter are based on the Michigan Longitudinal Study interview accounts from multiple assessments of the same individuals over intervals as long as 25 years.
Preparation of this chapter was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (R37 AA07065) (RAZ). We also want to recognize the extraordinary contributions that Susan Refior and Leon Puttler have made to the Michigan Longitudinal Study over the past 27 years.
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