Early Childhood Education
Parental Substance Abuse
Adult behavior can have a profound effect on child development and behavior. Data from the Adverse Childhood Experiences Study (ACE) suggests strongly that children are affected in a variety of ways by exposure to such adult risk factors as mental illness, especially depression, alcohol and/or drug abuse, and domestic violence. These adult risk factors have been linked to their child’s behavior, including childhood depression and other child mental health concerns, risk-taking behavior impacting school and peer relations, and self-regulatory behavior problems. The probable co-morbidity of these adult risk factors suggests that children are likely to grow up in homes with multiple risk factors, for example, living with a depressed mother who uses drugs to self-medicate her painful affect or growing up in a family where alcohol use exacerbates an abusive relationship between the parents. The ACE data indicate a correlation rather than causation between adult risk factors and child behavior, providing evidence that each child’s genetic makeup, temperament, and environmental factors impact outcomes for individual children.
Children of parents who abuse substances are themselves at double jeopardy for becoming addicts; they may have a biological predisposition for use of substances, especially alcohol, and they are more at risk for experiencing physical and/or sexual abuse as young children. These two forces— the biological and the environmental—often predict a child’s risk for their own substance abuse as a way of dealing with the trauma of their early maltreatment. This vicious cycle of parental substance abuse increasing the risk for physical and/or sexual abuse in childhood creates generational patterns of addiction in families. Thus identifying and intervening early in the lives of children experiencing such a significant adult risk factor as substance abuse is critical to individual child development.
Addiction has been described as a chronic, progressive, and potentially fatal disease with characteristic signs and symptoms. Addiction does not reflect amoral behavior or a lack of willpower—it is a characteristic of the disease that most addicts cannot stop their substance use without treatment, regardless of their desire for sobriety. The hallmarks of addiction are a loss of control over substance use and continued use despite negative consequences. These three aspects of addiction—chronic use, loss of control, and use despite negative consequences define addiction and answer many of the questions posed by providers and early childhood professionals. Why did she continue to use during her pregnancy? Why did she spend the food money on drugs? Why are her children so angry and out of control now that she is out of detox?
Many adults use drugs and alcohol to mediate their own painful affect in the face of the guilt, shame, and/or rage in their lives. And their children feel powerless to protect their parent(s), shame about having to make excuses for their parent’s behavior, or anger at the lack of consistent care giving and nurturing that all children need. A significant proportion of adults engaged in substance abuse report having been sexually abused as children. To numb their own pain, these children begin to use drugs that then increase their shame and feelings of self-loathing and guilt. And so the cycle continues.
The Impact of Substance Use on Child Development
This cycle of substance abuse and trauma directly affects children’s daily lives. Children live with the unpredictability and chaos of parents who cycle through binges and crashes. They learn to take the emotional temperature of the house— who is using, who is sleeping in the house, who is angry. They live with the effects of their parents’ emotional numbing that leaves little energy left for nurturing and protecting children. They often feel isolated, alone, and confused by the inconsistent care from various caregivers who may frequent the house or from well-meaning relatives who often enable the parents’ drug use. They may experience several out of home placements while their parents struggle with their addictions. This recurring theme of emotional unavailability and abandonment is a potent one for children living with parents who abuse substances.
Children also live with family secrets of shame, guilt, and fear. People with addictions become preoccupied with getting and taking drugs to the exclusion of all other needs and responsibilities, including taking care of themselves and parenting their children. They don’t provide adequate food, they are unable to organize themselves to get children ready for child care, and they cannot help their children negotiate the daily events in their lives. While some children withdraw in the face of these negative experiences, others express their concerns with rage and aggression. They learn the don’ts: don’t trust adults, don’t talk about what’s going on at home, and don’t feel anything about their experiences. To cope with this pain and the unpredictability of their lives, many children themselves turn to drugs as a way of overcoming their sense of powerlessness, low self-esteem, and social failure. Adult children of alcoholics report missing out on childhood because they assumed the role of caring for their parents or younger siblings. Living with a parent who is addicted poses significant challenges to the development of trust, attachment, autonomy, and modulation of effect for children.
Trust and attachment. The role of parental attachment figures is to provide consistency, security, and limits for children while helping them develop internalized, integrated constructs for the self in relation to others. But children who are struggling with issues of trust rising from their sense of abandonment, loss, inconsistency, and lack of appropriate boundaries within their families create disordered models for attachment. They either connect indiscriminately to anyone who will pay attention to them (“any warm body will do”) or they reject all attempts by adults to nurture and set limits for them. Without experiencing a deep-felt sense of trust within a primary relationship, they internalize a model of mistrust that makes it difficult to connect to other adults who might support them such as teachers or foster parents.
Autonomy and self-esteem. Parents struggling with their own addictions are often unable to help their children successfully resolve such salient issues of family development as attachment, autonomy, individuation, and eventual independence. They place unreasonable demands on their children, leaving them with feelings of self-doubt and failure. The children believe that if they were only good/smart/pretty enough, everything would be better. The family secrets they carry make it hard for them to connect to other caregiving adults outside the family, worrying that their secrets might be betrayed, or worse, that they themselves are part of the secret. They struggle to be autonomous, but worry about balancing their own self-care with their caregiving responsibilities to their parents and younger siblings. They have very low self-esteem, and, as with most self-fulfilling prophecies, act out against or withdraw from the very people who might help them—their teachers, counselors, pediatricians.
Modulation of affect. Although adults use substances to break down their inhibitions or to feel better about themselves, the main effect of continued alcohol or drug use is to numb feelings, leaving people unable to identify their feelings or to match their feelings to appropriate social situations such as frightening or sad events. As parents, they have an extremely difficult time identifying or labeling emotions for their children, modeling appropriate feeling states, or helping their children deal with emotions in a socially acceptable way. Thus children of addicts are often emotionally volatile and labile, unable to modulate their own feelings of sadness, anger, or fear. Their ability to maintain their attention, focus on the tasks at hand, and follow rules can be challenged by their internal disorganization, arousal states, and such environmental influences as excess noise and the movement of other children, or emotionally laden sounds such as police sirens.
Prenatal exposure. Much is still unknown about the effects of prenatal cocaine exposure. Research on prenatal marijuana and tobacco exposure suggests that, even if no drug effects are found between the ages of six months and six years, the increasing cognitive demands and social expectations of school or puberty may unmask a series of risks from exposure not previously identified. Cumulative environmental risk and protective factors may also exacerbate or moderate negative cognitive and behavioral outcomes as children mature. Among children aged six years or younger, there is no convincing evidence that prenatal cocaine exposure is associated with developmental toxic effects that are different in severity, scope, or kind from the sequelae of multiple other risk factors. Many findings once thought to be specific effects of in utero cocaine exposure are correlated with other factors, including prenatal exposure to tobacco, marijuana, or alcohol, and the quality of the child’s environment.
Long-term studies using sophisticated assessment techniques indicate that prenatally exposed children may have subtle but significant impairments in their ability to regulate emotions and focus and sustain attention on a task. These neurobehavioral deficits may place these children on a developmental pathway that leads to poor school performance and other adverse consequences over time. Thus the impact of addiction on children might best be understood as an environmental effect, focusing more attention on inadequate/poor parenting, poverty, institutional racism, stress, community violence, and a chaotic, disorganized life style. These factors alone, independent of drug exposure, can lead to poor developmental outcomes for young children. And when these developmental outcomes are confounded by prenatal substance exposure, children are at much higher risk for experiencing the double jeopardy of substance exposure and poverty. Prenatal exposure may impact their ability to modulate their affect; the chaotic postnatal environment then exacerbates that inability by neglecting to provide kids with appropriate boundaries, predictable routines, or the comfort of familiar adults.
Breaking the Cycle: Interventions
Parental substance abuse intensifies the already well-recognized environmental hazards of poverty, violence, homelessness, depression, inadequate or abusive parenting, and multiple short-term foster placements. The best way to help children is not only to address their particular behavior or developmental problems but also to intervene to change the environmental influences that negatively affect the child. In other words, the best way to help a child is to help the parent recover. Supporting the development of a young child living with a substance- abusing parent requires a two-generational model of care by considering adult risk behavior as a critical component in addressing the development and behavior of children.
Intervention approaches for young children with language delays, attachment disorders, regulatory concerns, attention disturbances, and motor problems have been well documented in the early intervention literature and are very effective for children impacted by parental substance abuse. But the challenge for providers is to understand the child’s behavior within the context of the family’s relationships and their ability to function. Providers must think carefully about the environment in which the child lives before deciding on an intervention approach. For children of addicted parents, their behavior may have much less to do with the early intervention or classroom environment than with the internal neurobehavioral mechanisms that control affect, attention, and arousal. Providers cannot plan strategies for a “disruptive” child without considering the family factors. Providers need training and ongoing supervision to be able to ask hard questions about family history and child-rearing practices in culturally sensitive ways. For example, providers might ask a parent “Who does your child remind you of? Do you think you (or his father) acted like this in preschool?” The answers to these questions provide significant insight into how the family sees the child, their expectations for her/his behavior, and issues that might be impacting the child at home.
The Role of Children in Their Parent’s Recovery
The birth of a baby can present substance abusing parents with a wide open window of opportunity. Children can be a powerful motivating force for parents to examine their behavior, to have the strength needed to enter treatment, to consider a different life for themselves and their family. A new baby can also precipitate a crisis that forces family members to confront the substance abusing parent. Family-focused interventions for addicted parents and their young children require a delicate balancing act in which providers must consider both the adult’s needs and those of the child. Treatment that focuses exclusively on the adult or the child ignores the power of the parent-child dyad and the advantages that can come from changing the family system.
The challenge in providing family-focused interventions is literally to get the parent’s attention and to develop a therapeutic relationship with them. The ability to form these alliances is based on the severity of the parent’s addiction, their level of denial, potential for relapse, and the presence of concomitant psychiatric concerns. These problems also interfere with the ability of the provider to model behavior, give information, and help the parents support their baby’s self-regulation, developmental skills, and emotional health. Yet, there are many advantages to family-focused interventions for parents struggling with addiction. At the onset of drug treatment, the parent-child relationship can sustain the parent through the difficult early detoxification and rehabilitation period. Providers can use the baby’s behavior as a vehicle to reach the parent and begin to establish a therapeutic relationship with her around her concerns for her child. Infants demonstrate a wealth of behaviors that indicate their feelings, their connection to the people around them, and their development. By smiling exclusively for her father or no longer crying when his mother picks him up, infants use these preferential signals to indicate to the parent how central he/she is to the child (“when he sees you, his whole face lights up”). Second, children provide a powerful basis for examining a parent’s life decisions and choices. Simply asking why a particular name was chosen for the baby gives enormous insight into the life experiences and family history. (“She’s named for my grandma who raised me after my mom left; he’s named for his father in prison”). As they talk about their children, parents narrate their own lives, offering providers a chance to empathize with traumatic events, to correct misconceptions, and to support the parent’s vision for the future.
And while children can be a significant source of pride and self-esteem for parents, they can also be triggers for anger, repressed memories, relapse, or depression. Teaching parents basic child development can help them understand that when their child cries for them when they leave, the child is not spoiled, but missing the person who is so central in his life—his parent. Issues of abandonment are often pivotal in the lives of addicts. By helping them to see their role in supporting their child’s growing independence, providers can help them to place new meaning on events in their own lives, on how they understand and interact with their children, and on how they respond to their own losses, anger, and pain. Finally, children offer addicted parents hope for a future in which they can attain sobriety and maintain their family; in other words, a better life for themselves and their children.
Further Readings: Brooks, C. S., B. Zuckerman, A. Bamforth, J. Cole, and M. Kaplan-Sanoff (1994). Clinical issues related substance-involved mothers and their infants. Infant Mental Health Journal 15(2), 202-217; Feletti, V., R. Anda, D. Nordenberg, D. F. Williamson, A. M. Spitz, V. Edwards, M. P. Koss, and J. S. (1998). The relationship of adult health status to childhood abuse and household Dysfunction. American Journal of Preventive Medicine 14, 245-258; Frank, D. A., M. Augustyn, W. Knight, T. Pell, and B. Zuckerman (2001). Growth, development, and behavior in early childhood following prenatal cocaine exposure: A systematic review. JAMA 285(12), 1613-1625; M. Kaplan-Sanoff, B. Zuckerman, and S. Parker (1991). Poverty and early childhood development: What do we know and what should we do? Infants and Young Children; Sameroff, A., R. Seifer, R. Barocas, M. Zax, and S. Greenspan (1987). Intelligence quotient scores for 4 year old children: Social environmental risk factors. Pediatrics 79, 343-350; Shonkoff, J., and D. Phillips (2000). Neurons to neighborhoods: The science of early child development. Washington, DC: National Academy of Sciences.