The family as a whole

i) Roles

Problematic drinking can change the roles played by family members in relation to one another and the outside world. As a family member develops a drink problem, the old division of labour may break down. The problem drinker may cease to perform his or her previous functions as a breadwinner or in relation to the support and supervision of children, household chores or recreational activities. These functions are therefore either not performed or performed by another, often the spouse. However, a particular pattern that has been observed is that a child, particularly the eldest child, may be forced to adopt adult roles and responsibilities, for example, in doing the housework, or acting as a surrogate mother or father. He or she may also be forced to assume a kind of emotional responsibility for the family.

ii) Routines

The problem drinker's behaviour is likely to become unpredictable and disruptive, impairing the family's capacity to plan activities in advance or to stick to familiar routines. It may become impossible to be sure whether the problem drinker will return home at the proper time, or appear at school to collect the children, or, what state he or she will be in, in the presence of the child's friends. Uncertainty and anxiety are therefore constant features of life in a problem drinking family,

iii) Rituals

Family gatherings such as a Christmas or birthdays, designed to celebrate and integrate the family, may be particularly subject to disruption, either because of the absence of the problem drinker, or, perhaps much worse, their presence. This problem is encapsulated in a comment made by one of the children of problem drinking parents interviewed by Margaret Cork in one of the first studies of the subject 'The Forgotten Children' - "Dad spoiled every Christmas I can remember because he smashed the tree."

iv) Social life

This has two aspects: activities within the family and the family's relationship to the outside world. Activities, particularly recreational activities within the family are likely to be restricted as the drinker becomes unwilling or unable to participate, or the other family members themselves choose to avoid activities out of fear of the behaviour of the drinker.

The unpredictable, disruptive and often drunken behaviour of the drinker is likely to be regarded by family members as acutely embarrassing and shameful. The tendency is to keep the problem a secret from the outside world. Divulging the nature of the problem to others may be regarded as an act of betrayal or disloyalty. This makes it difficult or impossible to invite others into the family home, or, given the norms of hospitality, to accept invitations from others. The family tends to become increasingly socially isolated. Activities and relationships outside the home may come to be severely restricted. Where family members do still engage in activities and relationships outside the home, these are likely to be kept rigidly segregated from life at home.

In either case, family members may be unable to explain to others the real reasons for what is happening. A particular feature of this inability is that family members, often the spouse, are put in the position of having to tell lies in order to prevent the truth becoming apparent. For example, it may be the spouse who has to make the excuses for her partner's repeated absences from work. In this way the spouse may unwittingly protect her partner from the consequences of his own behaviour. Many commentators have referred to this tendency to collusion and cover-up and the way in which it may serve to perpetuate the drinking.

v) Finances

Money spent on alcohol is not available for other purposes. An alcohol problem may impair or destroy the drinker's capacity to earn a livelihood. Reduced earnings or unemployment are not infrequent consequences of drinking problems and these, naturally, affect the other members of the family and can have all sorts of repercussions. Holidays may have to be forgotten; it may become impossible for children to be sent on school trips; the rent may not be paid.

Vi) Communications

Communications within the family can be disrupted both by what is said and what is not said. In the early stages, the drinker may refuse to talk about the problems, and the spouse may also be reluctant verbally to confront his or her partner or discuss it with the children. In a Danish study(1), children said they could remember their parent's alcohol problems from when they were as young as 4-5 years old, usually several years before the problem was discussed by and between their parents.

Alternatively, or at a later stage, alcohol and drinking may come to dominate the conversation as well as the rest of the life of the family. Communication between the spouses may also be alcohol dominated. Even where the drinking itself is not addressed directly, there are likely to be conversations, often turning into arguments and recriminations, about the consequences of the drinking.

Given the way in which alcohol problems can affect the dynamics of the family, it is hardly surprising that the international research evidence is consistent in regard to the adverse impact on individual members of the family.

Alcohol, marital problems, and domestic violence (2)

Not all member states are able to provide figures on these subjects. In Ireland, the national marriage guidance service (Accord), says that 11% of clients identified alcohol abuse as the primary presenting problem (1997). However, figures available from the Cork Counselling Service show a much higher level of up to 25% (1994-1996). In the United Kingdom it is estimated that persistent alcohol problems double the risk of divorce/separation and it has been stated that 1 in 3 divorce petitions cite excessive drinking by a partner as a contributory factor. However, this latter claim is of doubtful reliability.

As far as domestic violence is concerned, in France it is stated that alcohol is a determining factor in many social problems, ranging from job problems to criminal behaviour (violent attacks, rape, child abuse and marital violence)(3) but statistical information appears to be lacking. In Ireland 17.5% of men attending Cork Domestic violence treatment programme stated that they had been treated for alcohol or drug abuse. Figures from the Netherlands show that in 30% of cases of violence against wives or partners, the assailant is drunk at the time of assault. There are, in that country, around 15,000 drunken assaults on wives or partners each year. In Portugal, 16% of cases of violence against women are alcohol or drug related (the majority being associated with alcohol).

The 1996 British Crime Survey found the following in relation to domestic violence:

Problems for individual family members

a) The non-drinking spouse

The spouse has to cope with the bewildering unpredictability and frequent unpleasantness of life with a problem drinker. The more serious an alcohol problem, the less able a person is likely to be to perform competently, or at all, the various roles and responsibilities of a spouse and parent.

More than one third of problem drinkers receiving treatment cite marital conflict as one of the main problems caused by drinking. In the UK, the divorce rate is twice as high in marriages complicated by alcohol problems as in those without alcohol problems. (4) Marital conflict may take a violent form, and there is much evidence to show that domestic violence and alcohol are often associated. While problem drinking is neither a necessary nor a sufficient cause of domestic violence, high proportions of perpetrators of domestic violence are either problem drinkers or under the influence of alcohol at the time of the assault. Equally, high proportions of victims of violence are also under the influence of alcohol at the time of the assault.

There also appears to be an association between problematic drinking and child abuse, including incest. The connection between child abuse and alcohol abuse "may take the form of alcohol abuse in parents or alcohol intoxication at the time of the abuse incident."

An American review (5) concludes that alcohol consistently "emerges as a significant predictor of marital violence." Alcoholic women have been found to be significantly more likely to have experienced negative verbal conflict with spouses than were non-alcoholic women. They were also significantly more likely to have experienced a range of moderate and severe physical violence.

Studies have shown a significant association between battering incidents and alcohol abuse. Further, a dual problem with alcohol and other drugs is even more likely to be associated with the more severe battering incidents than is alcohol abuse by itself.

The spouse may be affected by relationship difficulties not only with his or her partner but also with the children. Most obviously, as the drink problem comes to dominate the lives of everyone in the family, the non-drinking parent may simply have less time and emotional as well as material resources to devote to the children. The non-drinking parent may have to assume the whole responsibility for disciplining the children, and it may well be the non-drinking parent who has to give the children the bad news that, for example, they cannot invite friends to the house or that there is no money for them this week. It is reported that, ironically and poignantly, children, especially perhaps young children, who cannot see behind the surface, may at times resent and blame the non-drinking parent as much or more than the drinking parent. (6)

The non-drinking parent is thus likely to experience an acute conflict of interests and loyalties between her partner and her children and to feel guilty for neglecting someone whichever course she takes. It is also reported that spouses, perhaps especially women, may blame themselves for their partner's drinking problem believing that they are in some way its cause.

"My husband always told me if I were a better wife, more loving, sexually responsive and less demanding, he wouldn't need to drink so much. I spent years trying to be that better wife, but his drinking didn't change." (7)

A note on co-dependency.

Much of the self help literature written for the spouses of problem drinkers is focused around the concept of "co-dependency". Until relatively recently co-dependency was a term used in the addiction field to describe the "enabling" behaviour of the partners of problem drinkers. The term "enabling" refers to all of the many ways in which spouses compensate for or cover up the destructive behaviour of their drinking partners, possibly facilitating continued drinking.

In more recent times, "co-dependency" has been defined as a "pattern of painful dependence on compulsive behaviours and on approval from others in an attempt to find safety, self worth and identity".(8) More enthusiastic adherents have described co-dependency as a primary disease, present in every member of an addictive family, often worse than the disease itself, with its own physical manifestations. It is viewed as a treatable diagnostic entity.(9) Although men can theoretically be co-dependent, the literature refers almost exclusively to women.

Although it is clear that many people have been helped by their involvement in the co-dependency movement by finding ways to understand how they get pulled into a set of behaviours and become part of a destructive system, the concept itself raises broader social questions and needs to be critically evaluated. According to some, the concept of co-dependency, although seductive, may be dangerous. (10)

In her paper, "A Critical Analysis of the Concept of Co-dependency"(11), Anderson raises the following criticisms of the co-dependency movement:

• Its tendency to conceptualise interpersonal behaviours as addictions, thus trivialising the truly addictive behaviours associated with chemical dependency. (12)
• The failure of the co-dependency movement to differentiate between severe pathologies and relatively minor problems and to acknowledge the many resources and coping strategies of families coping with problems of addiction. (13)
• The pathologising of behaviours strongly associated with female qualities such as excessive caretaking of others and putting the needs of others first in order to protect relationships.
  
• The failure to recognise spouse's behaviour as a culturally conditioned response of an over functioning person in relation to an under functioning person.

Anderson quotes Wetzel's(14) summary of the themes shared by most successful women's programmes. These include consciousness raising regarding gender roles; addressing the right of every woman to live without domination, to be treated with respect, and to be paid equitably for her work; restructuring the family such that home maintenance and child care are shared with men on an equal basis; teaching women that both personal development and social action are essential for positive change in their lives; and teaching women how to analyse and develop policies and legislation, always beginning with the personal and generalising to the global, so that the connection becomes clear.

The results

The spouse of the problem drinker is therefore under severe psychological strain, and it is not surprising that the psychological problems reported for the spouses include anxiety, depression and low self-esteem. The indications are that spouses of problem drinkers are themselves heavy users of health and social services, and may be prescribed, and perhaps get into difficulties with medications such as tranquillisers. It is reported that some spouses themselves get into difficulty with alcohol, perhaps through using alcohol to cope with stress or as a result of the misguided strategy of drinking with the partner in the hope of exercising some control over his or her consumption. Where the non-drinking partner is employed, his or her own work performance or attendance may suffer as a result of the difficulties experienced at home.

Excluding cases in which the drinker dies, there are essentially three possible outcomes to the relationship: the partner continues drinking problematically and the spouse continues to live with the partner and the problem; the partner ceases to drink problematically; or the relationship ends. The outcome will depend not only on factors of individual personality and circumstance but also on cultural and social factors. For example, it has been reported that men married to problem drinking wives are more likely to seek a divorce than women married to problem drinking husbands. This pattern may be changing as it becomes easier for women to find employment and to live independently following divorce. Similarly, alcohol-impaired marriages may be more likely to survive in countries where neither the legal system nor social mores facilitate easy divorce.

b) Children

In a few jurisdictions, the association between problem drinking and bad parenting is regarded as so strong that evidence of a parental alcohol problem is assumed to be evidence of child neglect. The New York Family Court Act states:

'...proof that a person repeatedly misuses a drug or drugs or alcoholic beverages...shall be prima facie evidence that a child of or who is the legal responsibility of such person is a neglected child except....when such person is voluntarily and regularly participating in a recognised rehabilitative programme.'

Alcohol problems vary in nature, severity and persistence. Moreover, how badly a child is affected by parental problems is likely to depend, amongst other factors, on the child's age at the time they develop. The child under five is particularly vulnerable to diminished physical care whereas the older child may be more vulnerable to psychological damage. This is not to say, of course, that the younger child does not suffer psychological damage, merely that its situation does not allow it to detach from the abusive parent in the way an older child can do by simply leaving the family home.

As has been described, in the worst cases the world of the child of a problem drinking parent is likely to be bewildering, unpredictable and threatening.

The possible adverse effects of a problem drinking parent may be seen in relation to Erikson's concept of the importance of trust for the development of a healthy personality: the child must be able to trust the love of the adults who care for him, and he must also be able to trust in the fact that they will continue to be around in the future.(16)

The child may experience various forms of neglect and feel abandoned by both parents; it may fear that the drinking parent may die, or that the non-drinking parent may leave; it may have a restricted capacity to make or sustain friendships; to be the victim of verbal or physical aggression; to be a witness to conflicts, perhaps violent conflicts, between his or her parents, and may experience the break-up of the family.

"To the child, it can feel as if everyone in his or her world is full of anger, bitterness and pain, with no-one offering warmth, love or support."(17)

The child may be forced to take on adult roles and responsibilities and in this very real sense be deprived of their childhood. A particular feature that can arise is that the child, like the spouse, comes to believe that he or she may be to blame for the problems the family is experiencing.

The Results

Many studies have been carried out in numerous countries of the children of problem drinking parents. These show consistently that they are at increased risk of a range of problems during childhood.(19) These can be grouped under three main headings:

2. Anti-social behaviour: children of problem drinking parents are at raised risk of aggressive behaviour, delinquency, hyperactivity and other forms of conduct disorder.
   
   
4. Emotional problems: these include a wide range of psycho-somatic problems from asthma to bed wetting; negative attitudes to their parents and to themselves, with high levels of self-blame; withdrawal and depression.
   
   
6. School environment: the problems include learning difficulties, reading retardation; loss of concentration; generally poor school performance; behavioural problems such as aggression and truancy.

A Spanish study (20) shows a statistically significant impairment among children of alcoholics in many areas, including:

• anorexia and other eating disorders;
• body development;
• language and communication skills;
• nightmares, insomnia, and nocturnal restlessness;
• a higher rate of depressive symptoms;
• disturbed behaviour patterns;
• anxiety-related disorders and phobias;
• performance on the Weschler Intelligence Scale.

In the UK, a social worker with a children's telephone help line (21) has summarised what children of problem drinkers tell the counsellors about their experience:

• having to take responsibility for their parents
• feeling embarrassed and ashamed of their parents, not being able to take friends home
• problems at school
• being bullied
• being preoccupied, lack of concentration
• afraid of what they may find every time they return home
• witnessing arguments and fights
• feeling guilty and responsible for their parents' behaviour
• feeling hopeless, helpless, irritable, nervous, depressed, let down, disappointed, confused, lonely, anxious, angry and resentful.

It is sometimes suggested that in the problem drinking family, children may be affected differently, and come to play different roles, according to their birth order. In one theory, the first born child is the `hero' of the family (taking over adult roles and responsibilities); the second is the `scapegoat' or rebel (relationship problems, delinquency); the third is the invisible or 'lost' child (demands little from other family members, always takes a back seat) and the fourth is the `joker' (immature and demanding).(22) It is unclear, however, how well founded such typologies are.

Abuse and neglect

Parental alcohol consumption can have adverse effects on children even before they are born.

Foetal alcohol problems:

Foetal alcohol syndrome is defined in terms of the following:

• Foetal growth retardation

• Central nervous system involvement (neurological abnormalities, developmental delay, intellectual impairment, head circumference below the 3rd centile, brain malformation).

• Characteristic facial deformity

• Other, lesser abnormalities, affecting all systems in the body, have been described and are referred to as foetal alcohol effects.

Foetal alcohol syndrome is relatively rare with reported incidence of 1.7 per 1,000 and 3.3 per 1,000 live births in Sweden and France (23), respectively. It is reported that every year in Germany around 2000 children are born with foetal alcohol syndrome. (24)

The syndrome is not seen consistently in infants born to women who are heavy consumers of alcohol and occurs only in approximately one third of children born to women who drink about 2 gms per kilogram of body weight per day (equivalent to approximately 18 units of alcoholic drink per day). The differing susceptibility of foetuses to the syndrome is thought to be multifactorial and reflects the interplay of genetic factors, social deprivation, nutritional deficiencies, tobacco and other drug abuse, along with alcohol consumption.(23)

The incidence of foetal alcohol effects may be much higher than foetal alcohol syndrome. Some studies have suggested that children born to mothers who have on average as little as one to two drinks per day, or who may occasionally have up to five or more drinks at a time, are at increased risk for learning disabilities and other cognitive and behavioural problems. However, it is difficult to establish the frequency of a birth defect that is hard to identify at birth and may be confused with other health problems.(23)

Other child abuse (25)

Information is not available from every member state as to the relation between alcohol problems and child abuse, but, for those able to supply such figures, it would seem that it is not unusual for half the number of cases to involve alcohol. In the Netherlands, whilst 17% of child abuse cases had alcohol addiction as a contributory factor, between 30 and 50% of children registered with Boards of Child Protection had parents who were excessive drinkers. In Norway, it is believed that alcohol is involved in 60-70 per cent of cases of child abuse and neglect. In Lisbon and Porto in Portugal, 49% of incidents of physical or emotional abuse towards children involve alcohol, whilst estimates for Italy suggest a figure of 50%. 12.9% of children taken into care in Ireland - as opposed to all cases of child abuse - had parents who were assessed as addicted to alcohol or other drugs. A 1992 study in Spain showed that 30% of cases of child abuse or neglect met the criteria for parental alcohol abuse or dependence.

More detailed figures are available for the United Kingdom. In the period 1995-1997 the following numbers of children under 18 years (England/Wales and Northern Ireland) and under 16 years (Scotland) were placed on child protection registers as having been abused or neglected or at considerable risk of abuse/ neglect:

Table 2. UK: Children placed on child protection registers

A survey of case loads of child care social workers identified 28 per cent of cases in which alcohol was thought to be contributory factor. In child protection cases, the percentage of referrals involving alcohol ranged from 30 to 60 per cent.

Table 3. UK: Percentages of alcohol involved cases of child abuse.

Devon County Council in an analysis of needs and services carried out in 1996 identified 15% of all children and young people looked after away from home as having either alcohol problems themselves or as the children of adults with an alcohol problem. If the data outlined above are replicated throughout the U.K. a total of 30% of all registered abused and neglected children (a figure of approximately 11,500) could be suffering, at least in part, because of alcohol misuse. Since only 64% of children, on average, referred to a child protection case conference are actually registered the numbers severely abused and neglected are considerably higher.

Further confirmation of the problems experienced by children in families misusing alcohol comes from two major child care charities in the U.K. The National Society for the Prevention of Cruelty to Children, the largest charity working exclusively with abused and neglected children, analysed 2,234 calls received by their help line for a 4 month period to 31.12.97. This showed that 23% of child abuse or neglect calls involved the misuse of alcohol.

In a report published in November 1997 by 'Childline', a free national children's help line, 3,255 children who spoke about parental alcohol misuse were shown to have been counselled in a twelve month period from 1.4.95 to 31.3.96. This survey shows that alcohol misuse was an issue across almost the entire range of problems which children cited, including running away, violence in the home, physical abuse and poor family relationships.

Table 4. UK: Parental alcohol misuse and problems for children.

The cycle of abuse

There is considerable evidence in regard to the way in which abusive behaviour in one generation produces abusive behaviour in the next. An obvious example is the increased risk of problem drinking in children of problem drinkers. Physical, including sexual, abuse appears to follow a similar pattern. In particular, while alcohol abuse in a parent or other may be associated with child sexual abuse, there is also evidence that, especially among women, childhood sexual abuse is associated with problem drinking later in life.(26)

Variations in the experience of problems

Children of problem drinking parents are at raised risk of problems, but not all such children experience problems at the same level of severity. Some do not appear to experience any significant problems even while they are children, let alone as adults.

Research suggests (27) that some of the main factors influencing the likelihood of experiencing problems and thus the degree of negativity of the child's experience are:

• Violence: witnessing violence even when not its target greatly increases the child's risk of experiencing the kind of problems described above.

• Marital conflict: even non-violent marital conflict appears substantially to increase the likelihood of children experiencing severe problems.

• Separation, divorce and parent loss: this also appears to be another major factor affecting the negativity of the child's experience.

• Inconsistency and ambivalence in parenting: this is implicit in the above, and related to the unpredictability of life in a problem drinking household. Much research suggests that, especially in their earlier years, children have a strong need for structure, for things to be familiar, stable and thus predictable.

Problems in later life

The evidence is clear that the children of problem drinking parents can have very disturbed and unhappy times as children, though this is not inevitable. But do the emotional and other problems persist into later, adult life? In many cases they do. Evidence for this is provided by the United States, where there is a large social movement of adults who experienced parental alcoholism in their childhoods, and a formal association, Adult Children of Alcoholics (ACA). There are also helping services for children, one of the aims of which is to reduce the risk of problems continuing into later life. In the USA there is the National Association For Children of Alcoholics (NACoA).

Some children have significant problems that persist into later life and affect their lives as adults. However, the available evidence is limited and is primarily concerned with the question of whether children of problem drinkers themselves become problem drinkers, and with the persistence of clinically definable psychological or other problems.

The available evidence does not necessarily answer the question of whether adult children of problem drinking parents escape from their experience entirely unscathed. Careers may be damaged if achievements at school were less than they would have been had the parental alcohol problem not existed.

A UK study (28) found that a minority of children of problem drinkers had problems continuing into early adulthood. Compared with a control group of young adults from non-problem drinking families, they were more likely to have misused alcohol or other drugs themselves, and a proportion were found to have a more negative adult adjustment - to be more depressed, more anxious, to have relationship difficulties, to leave home early and, generally, to be more dissatisfied with their lives. A common finding is that some children of problem drinking parents find difficulties in later life in making and sustaining close, adult relationships.

In the UK study, the bad outcomes were more likely to occur in children both of whose parents had an alcohol problem, and if the problematic drinking occurred in the home rather than elsewhere.

However, the most significant finding was that the strongest predictor of psychological problems in early adulthood was not having a problem drinking parent, or even two problem drinking parents, but family disharmony. In families which managed to remain intact and relatively harmonious despite the alcohol problem (a small group), the children appeared to emerge largely undamaged. In contrast, children from disharmonious families were more likely to experience problems as young adults, whether it was alcohol or some other factor that was the cause of the disharmony.

Family disharmony as a cause of problems in later life

There is a large scientific literature on the effects on the children of parental divorce and separation. The evidence suggests that parental divorce has 'a moderate, long-term negative impact on adult mental health'. (29)

The impact on the health of children of divorced parents can be severe, with a higher risk of ill health from the time of parental separation until adult life: children under five when their parents divorce are especially vulnerable.(30) There is also evidence that children from divorced families grow up to show a higher risk of premature mortality across the life span. One study suggests that the higher mortality risk for men may be partially explained by the fact that men who have experienced parental divorce are more likely to have failed marriages, to be less educated, and to engage in fewer service activities. Women who experience parental divorce may smoke more and be more likely themselves to divorce, both of which predict higher mortality risk.(31)

A note on genetic factors

Alcohol problems tend to run in families and through the generations. First degree relatives of alcoholics are two to seven times more likely than the general population to develop problems with alcohol sometime in their lifetime (Merangas, cited in 9th Special Report 1997). Numerous investigations have attempted to discover why this should be. Clearly, one possible explanation is a form of 'social contagion' whereby problematic drinking is learned behaviour and, for a variety of reasons, children and others come to imitate the behaviour of the problem drinker.

Another possible explanation is that there is a genetic basis to problem drinking. While it is unlikely that genetic factors alone can explain the great variations in the prevalence of alcohol dependence from one country or society to another, or in the same society over time, the consensus of scientific opinion is that genetic factors do play a part. Studies of families, twins, adoption and genetic markers have shown that genetic factors are involved in relation to alcohol consumption (total amount and frequency); complications experienced (physical, social and psychological) and dependence. However, it is 'the balance between environmental and genetic factors that is important. It is not genetic factors on their own that make someone an alcoholic or problem drinker.'(32)

This is illustrated in a British study of young adults. A biological vulnerability from an alcohol dependent parent was neither sufficient nor necessary for the participants in this study to develop alcohol dependence as a young adult, although there was an increased risk. There also appeared to be strong protective effects of positive family relationships on the potential negative effects of a family history of alcoholism, a theme discussed further below. (33)

The findings of genetic research have two main implications for the subject of this report. Firstly, further progress may lead to improvements in the treatment of problem drinking and alcohol dependence. Secondly, genetic research and knowledge may help in relation to the prevention of problem drinking and dependence. Given that the biological offspring of problem drinking parents appear to be at increased risk of becoming problem drinkers themselves, then they are a group with special needs for educational or other interventions.

Protective factors and 'resilience'

It is already clear from the foregoing that there are some factors that serve to protect the psychological well being of children in adverse circumstances and which reduce the likelihood of their experiencing continuing problems in adulthood.(34) There are also factors that can protect the well being of the spouse of the drinker. It is of course important for these factors to be identified because they suggest measures that can be taken within families and by helping agencies to mitigate the worst effects of the alcohol problem.

In relation to the children, the most obvious protective factor is a cohesive relationship between the parents. If this can be maintained despite the alcohol problem, the children are at greatly reduced risk of suffering harm.

A second factor is cohesive family relationships. Even if a cohesive parental relationship is not maintained, the risk to children is reduced if family cohesion and activities are maintained. A particularly important factor appears to be that what are described above as family rituals are maintained, especially during the heaviest drinking years. Another factor is whether the family of origin of the non-drinking parent maintains family rituals at a high level.

A third element is the other (non-drinking) parent: if he or she is able to provide a stable, supportive environment, the risks of a negative outcome for the child(ren) are reduced.

A further important factor is suggested to be a cluster of psychological characteristics in spouses and children known as 'planning' or 'deliberateness'(35). Essentially, this is the opposite of an attitude of fatalistic helplessness. It includes the ability psychologically to distance oneself from adverse circumstances and to formulate coping strategies. It also encompasses the ability to think through situations and alternative possibilities, and to come to deliberate decisions about the best courses of action to take.

'Deliberateness' is evident in the pattern of 'selective disengagement and re-engagement' that some commentators have identified as a means of coping by children of problem drinking parents. Examples are a child's efforts to disengage from the disruptive elements of family life and to engage with others outside the family. At a later stage in the life cycle, deliberateness may be evident in the choices and decisions made by the now adult child of a problem drinking parent in relation to forming a family of his or her own, by consciously planning how to be the same or different from their family of origin.

It is suggested that the presence or absence of these factors help to explain why some alcohol impaired families are 'transmitters', that is, transmit the problems to the next generation, while in others the cycle is broken. They also help to explain why many children brought up in otherwise highly problematic family environments do not appear to suffer a lasting adverse impact. The optimistic finding here is that having to cope with adversity can strengthen people as well as damage them.

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2. Reported in Alcohol, Health and Society. WHO Paris 1995.
3. Unless otherwise stated,figures below provided by members of the working party.
4. Health in France 1994. French High Committee on Public Health 1996.
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6. NCADI. USA 1995
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20. Information provided by ABS.
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23. Royal College of Obstetricians & Gynaecologists: Guideline: Alcohol Consumption in Pregnancy. Nov 1996.
24. Information from DHS, Germany.
25. Information supplied from members of the working party.
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