Abstract

Psychological distress does not develop in isolation; this phenomenon is affected by a multitude of inter and intrapersonal factors, one of which is parental behaviors and parenting practices. Current research aimed to study the relationship between parental practices and psychological health of children of alcoholics. For this purpose, a demographic form, General Health Questionnaire, and Egna Minnen Betraffende Uppfostran were used. The sample was adult children of alcoholics between the age range of 18 to 25 (M=21.40, SD=2.36) and included both males (n=166) and females (n=158) selected through purposive sampling technique. The minimum level of education was matric (16.7 percent), and the highest educational level was masters (13.6 percent). Maternal rejection was found to be the strongest predictor for both psychological distress risk and intensity, whereas maternal overprotectiveness and emotional warmth were negative predictors of distress risk and intensity. Father's emotional warmth was a strong predictor of psychological distress intensity, and overprotectiveness was a strong predictor of psychological distress risk.  Findings were discussed in the context of previous research.

Key Words

Mental Health, Parental Practices, Adult Children of Alcoholics

Introduction

Alcoholism is a disease that transcends socio-economic barriers (Suneel & Siddique, 2020), time, and culture (Rehm, 2011). Maladaptive drinking patterns affect decision-making (Vergés et al., 2018) in such a way that professional and family life are negatively impacted (Rehm, 2011). 

In the Islamic Republic of Pakistan, alcohol is prohibited; however, the production, sale, and consumption is allowed for the non-Muslim contingent upon procuring a license from the Government of Pakistan (Kaplow, 2018). Regardless of its availability for the minority group, possession and consumption of alcohol are considered unacceptable and inappropriate morally and culturally, leading to a dearth of research into rates of misuse, as well as problems stemming from it. In one of the few surveys of alcohol use in Pakistan, doctors at a tertiary care hospital in Abbottabad reported that every 10th patient they treated in the OPD had an issue related to alcohol (i.e., 63% of all referrals; Subhan et al., 2020). Despite this statistical fact, training in identifying and treating alcohol-related disorders is missing from the medical school curriculum, leading to these conditions being highly stigmatized (Imran et al., 2010). 

Moreover, according to Haverfield and Theiss (2015), it has been observed that children of alcoholics avoid openly discussing consumption or alcoholism, with female children being more guarded. Moreover, female children have a harder time disclosing alcohol-related information. In Pakistan's collectivistic culture, the family unit holds great importance (Merkin, 2016). While in the West, children of alcoholics have the option of moving out of the family house and essentially end most contact with their parents (Haverfield, 2016), this is not an option for Pakistani children. A study by Lodhi et al. (2020) showed that about 50% of the sample of over 2000 participants between the ages of 18 to 31 lived in a joint family system with their parents and siblings.

In addition to the stigmatization and shame of alcohol use, the culture and family are based on a patriarchal value system in Pakistan, giving the father the role of the head patriarch who makes all the decisions for the family unit. A father's word is perceived as the 'final,' without children having the liberty to comment or object (Habiba et al., 2016). A study by Chee and Ullah, 2019 demonstrated this paradigm very clearly. They studied communication within Pakistani immigrant families living in Hong Kong. They found that communication between the patriarchal father figure and his family was one way. The father communicated his decisions without any input or feedback. Therefore, a Pakistani family's dynamics largely revolve around and controlled by the father figure or a male member as the head of the family. This becomes not only challenging but also pernicious for a family where a father is using alcohol to excess and making all the decisions without any check or balance. His decision-making ability might be compromised, which could thus be stressful for a child who has to live with their decision. Furthermore, this becomes increasingly difficult for the families in Pakistan when the primary caregiver or provider is afflicted with this disease (Habiba et al., 2016). 

There is a host of literature available from around the world that focuses on the effects of an alcoholic father or mother on children.  For decades Western researchers and clinicians have carefully and critically observed and empirically studied the relationship between parental alcoholism and its impact on children. Their findings have repeatedly suggested that the spouse and the children of alcoholics are vulnerable psychologically and emotionally (Beattie, 1987, 1989; Subby, 1987, 1989). Similar findings have emerged from Eastern countries (Ali, & Munaf, 2006; Dass et al., 2020; Hebbani et al., 2018; Omkarappa & Rentala, 2019; Sawant, 2020; Sumathi, 2018; Wong et al., 2018).

Some of the effects have been translated into behaviors such as controlling, provoking, caretaking, having poor communication, and low self-esteem (Beattie, 1987, 1989; Subby, 1987, 1989). Similar findings have been reported by Indian researchers that a substantial number of children of alcoholic parents lack social skills and satisfaction in relationships and have interpersonal issues and low self-esteem (Sawant, 2020). 

It has been contended that children of alcoholics can have emotional problems at a young age and observable during adolescence. According to one study, high school students who were children of alcoholics reported higher levels of depression and anxiety than a control group (Omkarappa & Rentala, 2019). Moreover, research demonstrates a significant relationship between father’s alcoholism and the propensity of developing a conduct disorder (Dass et al., 2020). A study on Indian college-going students who were children of alcoholics revealed that almost all the adult children of alcoholics who participated in that study reported stress levels above the cut-off point as measured on DASS-21, and over 50% of them reported depression (Hebbani et al., 2018). 

According to a study done on a similar population, Ali and Munaf (2006) reported that children of substance abusers had significantly more paranoia and hypomania than the children of parents who were not substance abusers. Furthermore, female children were reported to have developed anti-social personality disorder at a much higher rate than male children (Dass et al., 2020). Others contend that male children reported depressive symptoms, and female children were more likely to report symptoms of anxiety (Hebbani et al., 2018). Other researchers have also reported similar findings regarding gender differences in psychopathology in the children of alcoholics (Hebbani et al., 2018). It has also been observed that many children of alcoholics are gravitated towards drinking and develop alcohol-related problems or even alcoholism in adulthood (Wong et al., 2018).  

While psychological distress is commonly observed and reported in the children of alcoholic parents, there are also instances of children who, despite having an alcoholic parent, do not face emotional and psychological issues. Sawant (2020) calls this resilience and explores how there are children who do well in life and relationships despite having an alcoholic parent. Similarly, Wong et al., 2018 reported that children of alcoholics who had a better sleep and reported lower levels of tiredness also had higher resilience and did not develop behavioral and emotional problems as compared to others who had reported tiredness and bad sleep patterns. 

It is important to note that children are not the only ones impacted by a father's alcoholism; research suggests that the wives of alcoholics also suffer emotional problems (Sumathi, 2018). A study on an Indian population showed that in comparison to wives of non-alcoholics, wives of alcoholics had a significantly higher instance of depression (Sumanthi, 2018). This further jeopardizes the environment in the household and leads to further stress and strain for children. 

According to attachment theory, mental health is strongly impacted by the relationship of the child with his or her parents or primary caregivers (Bowlby, 1982, 1969; Bowlby, 1973; Ainsworth, 1985). Parental practices, in particular, play an important role in shaping an individual's mental health, as shown by Saleem et al. (2015). These researchers used the Egna Minnen Betraffende Uppfostran (EMBU) with an adolescent Pakistani population, and the results demonstrated that parental rejection was related to mental health problems, while parental warmth played a protective role in mental health (Saleem et al., 2015). 

For a population of children with an alcoholic father, divergent results might appear as some literature indicates that fathers with alcohol misuse have neglectful parental relationships from their own childhood (Icick et al., 2013). During treatment and rehabilitation, fathers with substance abuse problems self-reported that their children have been let down by them and their abuse-related behaviors.  Consequently, it scarred their relationship with the children (Caponnetto et al., 2020). Conversely, adolescent children of alcoholics also reported similar feelings. They reported distress and pressure at making adult decisions at a young age and to be at guard from embarrassing or even detrimental situations (Bickelhaupt et al., 2019). It is important to highlight, however, that even a father with an alcohol problem might be attentive to their children, according to Dube et al. (as cited in Shank et al., 2019).  

According to Pasternak and Schier (2012), many children assume the role of a caretaker and provide for the alcoholic to make the family more functional. This kind of role reversal is also termed as parentification in clinical and research related to alcoholism the alcoholic. This phenomenon is commonly called 'Parentification,' that families with alcoholic parents report often. Parentification is a role reversal between the parent and child, wherein the child takes care of the parent. Children of alcoholics reported higher instances of parentification and perceived it to be unfair (Pasternak & Schier, 2012). 

The resentment and feelings of unfairness in such a parent-child relationship can lead to feelings of animosity even in adulthood for the child. Adult children also expressed feelings of frustration and disdain towards their alcoholic parent, reporting the parent to be selfish and expressing a preference of reduced to no-contact with them (Järvinen, 2013).

Apart from a child’s relationship with their parents, the relationship the parents have with each other also acts as a contributing factor to the child’s mental health. Children who witness domestic discord between parents, especially when physical violence is involved, report more depression, problems with sleeping, and aggression later in life (Asfour et al., 2019). It has been amply demonstrated that there is a strong positive relationship between alcoholism and family violence (Nacimento et al., et al., 2019).

However, the nonalcoholic parent acts as a mitigating factor to reduce stress and strain in the children and helps them to find some semblance of a healthy relationship. The overall childhood experience and effects of alcoholism are significantly reduced in children who had a functional nonalcoholic parent. Children with one functional parent who was able to take care of financial and social responsibilities of the child were observed to be better adjusted emotionally in adulthood (G?sior, 2014). 

There is a dearth of research in Pakistan on subjects related to alcohol use, which makes for an uncertain representation of the situation in the country related to alcoholism. The objective of the current study was to determine which parental practices are most detrimental and which are most protective for the mental health of adult children of alcoholic fathers. The results will help to understand the needs of this neglected population.

Objectives

• To explore the association between practices of fathers and mothers and psychological distress in children.

• To study the association between practices of fathers and mothers and severity of psychological distress in children.

• To assess the impact of practices of fathers and mothers on psychological distress and its severity in children.

Method

The present study was based on a correlational research design and used purposive sampling technique to select 330 participants. The sample was collected from private drug rehabilitation centers of Lahore and Islamabad. Participants in the present study were adults in the age range of 18 to 25 with a mean age of 21.4 (SD = 2.36) years, and both genders were almost equally represented (male=166, female=158). The minimum level of education was matric (tenth grade) 54 (16.7%), whereas the other participants had done intermediate (twelfth grade) 121 (37.3 %), graduation 105 (32.4 %), and masters 44 (13.6 %).

Inclusion Criteria - Participants in the present study were children of fathers admitted in a rehabilitation center for the second time for the treatment of alcoholism. The family system was nuclear with at least 3 siblings, including the participant. The minimum level of education was matric. 

Measures

In this study, three instruments were used, including the demographic profile, General Health Questionnaire, and Egna Minnen Betraffende Uppfostran.




General Health Questionnaire-30 (GHQ-30) 

was a self-report measure used to assess the mental health of children of alcoholic fathers. This tool could be used to screen and to assess the severity of any psychiatric disorders such as depression, anxiety, and somatic complaints. GHQ was used both to assess the risk of developing psychiatric disorders and to assess the severity of any existing psychiatric disorder. The internal consistency of both screening and severity was .88 and .85, respectively (Goldberg & Williams, 1988).







Egna Minnen Betraffende Uppfostran –A

Urdu version of Egna Minnen Betraffende Uppfostran (EMBU) was used to assess the perception of the children of both the parent’s rearing behaviors. EMBU was a Swedish acronym that, when translated into English, means "My Memories of Upbringing." This questionnaire was originally designed and developed in Sweden in (1980). EMBU follows a 4 point Likert-type scale ranging from “never” to “always.” It had four sub-scales: rejecting, emotional warmth, overprotective, and favoring. The present study assessed the perception towards both father and mother rearing behaviors through 27 items. The internal consistency of the scale for both father and mother together in the present study was .83; for father and mother dimension was .77 and .86, respectively.




Procedure

The rehabilitation centers were approached by setting an appointment and then meeting in person. The aim and objectives of the present study were explained to the authorities at the rehabilitation. They were assured of the confidentiality and anonymity of the participants. They were also assured that the testing for the research would not interrupt the daily schedule of the center. 

The researcher introduced himself/herself to the participants, and the aim of the research was shared. The participants were clearly told about the choice they had to participate, and it was absolutely voluntary. The verbal consent was taken because signing a document raised anxiety in the participants. They were reassured of the confidentiality. Moreover, they were told that it would take 40 minutes to complete the questionnaires. They were also told that there were no right or wrong answers. They just had to mark the one they thought was applicable to them. 

After the participants had filled the forms, they were checked for the missing values; if the participant was still there, he/she was told that they had missed item/s and would they like to fill them. If the participants had gone, then those forms were discarded. The data were then entered in the software Statistical Package of Social Sciences for descriptive and inferential statistics. 

In order to assess the impact of parental practices on psychological distress severity and psychological distress screening, two simple multiple regressions were computed with EMBU subscales as the independent variables and GHQ Severity and Screening respectively as the dependent variables. IBM Statistical Program for the Social Sciences Subscription was used to compute the statistical analyses. 

Results

Descriptive statistics for the study variables are displayed in Table 1.




 

Table 1. Descriptive Statistics of the Study Variables

Variable	Range	M (SD)
EMBU
Father OP	6-23	11.07 (3.85)
Father EW	9-31	9.87 (1.74)
Father R	6-24	14.72 (5.87)
Mother OP	6-18	10.86 (2.80)
Mother EW	9-36	28.23 (4.89)
Mother R	6-23	9.36 (3.68)
Q
Severity	10-54	36.21 (11.50)
Screening	1-24	10.90 (5.71)

Note. EMBU = Egna Minnen Betriifende Upfostron; OP = Overprotective; EW = Emotional Warmth; R = Rejecting. GHQ = General Health Questionnaire.

 




In order to assess the impact of parental practices on psychological distress severity and psychological distress screening, two simple multiple regressions were computed with EMBU subscales as the independent variables and GHQ Severity and Screening respectively as the dependent variables. Assumptions of linearity and homoscedasticity of residuals were met. There was an absence of outliers, multicollinearity, and singularity (see Table 2). Three scales of the EMBU were transformed to improve normality (Father Overprotectiveness – Sqrt; Father Emotional Warmth – Inverse; and Father Rejection – Log10).




 

Table 2. Correlations between GHQ Subscales and the Subscales of the EMBU

Variable	F OP	F EW	F R	M OP	EM EW	M R
GHQ Severity	.418**	.271**	.619**	.221**	-.574**	.517**
GHQ Screening	.460**	.277**	.623**	.159**	-.612**	.447**

Note. GHQ Severity = General Health Questionnaire Severity; GHQ Screening = General Health Questionnaire Screening; F = Father; M = Mother; OP = Overprotectiveness; EW = Emotional Warmth; R = Rejection.

 




A simple multiple regression was carried out with the six subscales of the EMBU as independent variables and psychological distress severity as the independent variable (GHQ Severity).  The results of this analysis were significant [F (6, 317) = 83.484, p < .001, R² = .612] with an adjusted R² value of .605, indicating that almost two-thirds of the variance in psychological distress severity is predicted by perceived parental practices.

Though all six independent variables contributed to the variance in psychological distress severity, the strongest predictors were maternal rejection (b = .641), mother emotional warmth (b = -.404), and mother overprotectiveness (b = -.329). Only father emotional warmth (b = .220) was a significant predictor of psychological distress severity among the EMBU father subscales. 

A simple multiple regression was carried out with the six subscales of the EMBU as independent variables and psychological distress screening as the independent variable (GHQ Severity).  The results of this analysis were significant [F (6, 317) = 91.782, p < .001, R² = .635] with an adjusted R² value of .628, indicating that almost two-thirds of the variance in psychological distress risk is predicted by perceived parental practices.

Though all six independent variables contributed to the variance in psychological distress screening, the strongest predictors were maternal rejection (b = .512), mother overprotectiveness (b = -.446), and mother emotional warmth (b = -.442). Only father overprotectiveness (b = .278) was a significant predictor of psychological distress screening among the EMBU father subscales.  

Discussion

Alcoholism is a problem reported across the globe and is associated with an array of social, psychological and financial problems (Dass et al., 2020). Islamic Law of Pakistan forbade consumption of alcohol by Muslim citizens; only non Muslim groups are allowed to consume and sell alcohol under special license. However, Muslim individuals can also easily procure and consume it using illegal means. Alcoholism badly impacts the lives of the family members of the patient (Sawant, 2020) and the situation becomes even more bleak when the head of the family is involved in alcoholic abuse in a patriarchal society such as Pakistan's. 

Family is generally the primary source of nurturance, attachment and socialization for individuals and effects of substance abuse problems on the family and individual family members merit special attention. Family members are likely to be affected differently by alcohol abuse but mostly observed to have experienced weakened attachment, unmet developmental needs, economic hardships, psychological distress, violence and an increased risk of developing substance use disorder in family members (Wlodarczyk et al.,2017). 

Therefore, the current study aimed to explore the relationship of father's alcohol abuse with parental practices and psychological distress of children. Present study revealed an interesting finding that parental rejection particularly from fathers had significant positive association with severity of psychological problems in children. This pattern of relationship between parental rejection and psychological disturbance of children in the present study is very much in line with other studies revealing compromised relationship between drug abusers and their children (Järvinen, 2013). The other aspect is the increased severity of psychological distress which is heavily supported by findings of many previous studies that reported high frequency of psychological disorders in children who face parental neglect from alcohol-abusing parents (Omkarappa & Rentala, 2019; Sawant, 2020; Tedgard et al., 2019; Wlodarczyk et al.,2017) and also by researches that identified higher severity of psychological disturbances in children who have weak emotional attachments with their drug-abusing parents (Bickelhaupt et al., 2019). Attachment theories posit that the quality of parent child attachment system strongly affect children’s health and functioning by providing basic nurturance, emotional support and coping against psychological distress and failure to these increases the risk of psychological disturbance. 

Parental temperament, behaviors, and practices play a pertinent role in shaping one's personality, and literature at large has demonstrated that parental alcoholism adversely impacts the children regardless of their age. Literature observed and reported that the children of parents having alcohol abuse problem have significantly higher incidence of depression and anxiety, low self-esteem, distress, relationship issues (Omkarappa, & Rentala, 2019; Sawant, 2020) and reported high incident of family violence (Nacimento et al., 2019). 

Previous research that reported more incidents of child neglect, higher levels of stress and family violence in alcohol-abusing families and identified these factors contributing strongly to psychological problems in children also supported the relationship between parental rejection and higher psychological distress in children as was also identified in present study (Wlodarczyk et al.,2017). Generally, children do not only rely on parents for their physical needs but also get emotional support from parents, and failure to provide for these needs are likely to make children more susceptible to psychological disturbances. Attachment with parents is used as the reference point for later behavioral patterns when parents fail to provide emotional security and fulfillment, children are likely to transfer this dissatisfaction to their relationships outside the home as well. In Pakistan, parents are generally considered to be the binding force for the family, and family structure is weakened in case parental figures face any physical or psychological health issue (Habiba et al., 2016). Father usually is the strongest figure playing a key role in family functioning in Pakistani patriarchal society and the whole family suffers if the strongest link is weakened or fail to fulfil his rule. If the male parental figure is engaged in alcohol it adversely affects all aspects of family functioning from increased financial pressure to security of the family members. Family members of such households reported to feel more vulnerable and unsafe and consequently are exposed to high risk of abuse and psychological problems. In substance-abusing families, all these problems are frequently observed and usually lead to psychological problems of family members, particularly children, as is evident in the present study as well (Wlodarczyk et al.,2017). 

Interestingly emotional warmth was found to be a strong predictor of incident rate and intensity of psychological distress among children in substance-abusing families. Mother's overprotectiveness turned out to be a strong negative predictor of psychological distress in the present study and is supported by literature identifying emotional warmth as an integral source of comfort and support for most individuals. Parents in substance-abusing families have shown clear deficiencies in fulfilling parental roles and thus increase the risk of psychological distress in children (Tedgard et al., 2019) which later on transformed into psychological disorders. On the other hand, literature also identified that secure attachments and positive parent child relationships in alcohol and drug-abusing families work as strong protective factors for children against psychological, behavioral and many social problems (Wlodarczyk et al.,2017). These findings directly support the findings of the current study which reports positive mother child attachment to be a predictor of lower psychological distress.

Conclusion

An unhealthy attachment system and parental neglect makes a child more vulnerable to stress and therefore more susceptible to having problems with depression, trauma, anxiety, and other mental illness and this risk increases manifold in alcohol-abusing families. Emotional warmth and protectiveness of parents may decrease the risk of psychological distress in children of alcohol abusing families.  

Implications

The present study will help in planning an intervention or counseling program for children of substance abusing parents. Moreover, to prevent such issues, the parents having alcoholism could be counseled. On a larger scale, an educational program could be made to help the society become aware of such issues.

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