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FAMILY PREDICTORS OF DRUG ABUSE

Family factors that predict drug use may be put into three interrelated categories: structural, historical, and interpersonal. The structural factors pertain to family composition, such as single- or two-parent families, the number of children, sibling spacing, and gender composition. Family historical factors specifically refer to intergenerational patterns, such as the extent and influence of drug usage in the family of origin. Finally, interpersonal factors relate to interpersonal dynamics in the family, such as those reflected in the quality of marital relationships or the quality of parent-and-child or sibling relationships.

Family Structural Factors.

Three structural factors—parental composition, family size, and birth order—are the most often included variables referred to in drug and family research. Although these factors seem to contribute to the etiology of drug abuse, one needs to look at the findings more critically to try to evaluate the extent of their influence.

The literature on drug abuse is replete with findings that suggest that, compared with traditional nuclear families, disorganized, especially single-parent families are more vulnerable environments for children. These families are associated with an earlier onset and greater degree of drug and alcohol abuse. Information regarding the role of family size and birth order, however, is currently insufficient. According to the data, there are very limited indications that an only child is the least at risk, whereas families with seven or more children are at greater risk for drug abuse. However, there seem to be fewer cases of drug abuse involving first-born children compared with the number of cases involving subsequent, especially last-born, children (Barnes, 1990; Glynn, 1984).

Stanton (1985), Hawkins et al. (1987), and Wells and Rankin (1991) have argued that family structural factors do not contribute much to our understanding of drug-abuse behavior. More important risks for children, they suggest, lie in family processes and the quality of family environments.

Divorce, for example, may be a healthy way of ending a hostile marital relationship. The separation of parents may only be the culmination of hostile relationships, painful negotiations, and the draining of family resources prior to the family breakup. Sessa and Steinberg (1991) argue that the most important impact of divorce on children is how much it disturbs the children's developmental tasks—for example, their autonomy. Most children experience relatively brief adjustment problems following a divorce, but continued development of the adjustment process depends on many more factors, such as the age of the children, the gender, the custodial parent, and the quality of life in the home after the divorce.

Different forms of families may possess varied abilities to exercise certain parenting practices, like monitoring and supervision. Dishion, Patterson, and Reid (1988) found interesting linkages between living in a single-parent family, poor parental monitoring, and greater adolescent involvement with drug-abusing peers. In a supportive family relationship, however, parental composition is not a predictor of adolescent drug use.

Variations in family size may impose certain restrictions and may afford opportunities for the utilization of family resources, such as parental support and finances. Birth order seems to expose each child to different opportunities for social learning (e.g., in regard to role models) and different behavioral expectations, depending on one's family traditions. It is therefore important to look at family processes and the quality of family environments as well as at the family structure.

Family History Factors.

Some well-established evidence indicates that drug use by any member of the family is related to drug use by other family members. In couple relationships, the initiation of a female partner into illicit drug use and her progression toward drug dependency are related to patterns of drug use in the male partner, whereas illicit drug use by the male partner is more independent of spousal drug use (Weiner, Wallen, & Zankowski, 1990).

Parental and sibling drug use have consistently been found to be associated with ADOLESCENT drug-abusing behavior (Hawkins et al., 1986). The transmission of the problem behavior, however, is perceived differently by different scholars. Although there is an increasing fascination with GENETIC explanations, more research is needed to validate genetic assumptions (e.g., Cadoret, 1990; Searles, 1990, 1991). In their view of the literature, Hawkins et al. (1986) concluded that the evidence from behavioral genetic research was limited to male ALCOHOLISM and the lack of convergent evidence from adoption, twin, and biological response studies. Similar criticism has been presented by Searles (1990, 1991), who also argued that only 20 percent of children of alcoholics become alcoholics and that half of all alcoholics do not have a family history of alcoholism. Research on the family clustering of OPIATE and ALCOHOL abusers indicates that a genetic explanation is inadequate when it is considered that the community or environment affects the choice of the substance of dependence.

A systemic (family) approach presents more compelling explanations. Research focusing on the role of parental attitudes and values has revealed a high congruence between parents' and adolescents' perceptions of the use and abuse of drugs (Barnes, 1990). When parents use drugs such as CIGARETTES and alcohol, it indicates to the children that such use is expected (or at least allowed) in the family.

Heavy drug use in the family, especially by parents, also disrupts functional properties of the family system (e.g., care and support, problem solving, etc.), and this, in turn, provides a conducive environment for drug use and abuse by other members of subsequent generations (Steinglass et al., 1987). Dishion and Loeber (1985) argued that parental drug use diminishes parental ability to exert effective monitoring and supervision, thus allowing children to mingle with peers who abuse drugs frequently. Clinical observation also suggests that parental drug use blocks effective communication, alters modes of interpersonal relations, and is associated with all kinds of child abuse (Barnes, 1990; Leonard & Jacob, 1988).

Interpersonal Factors.

There are at least two broad dimensions of interpersonal dynamics in the family—support and control—and one facilitating dimension—communication (Barber, 1992; Rollins & Thomas, 1979). The support dimension refers to the positive affective experience associated with relationships, such as acceptance, encouragement, security, and love. The control dimension pertains to the extent to which children's behavior is restricted by the caregiver(s), and this ranges from establishing rules and discipline to varieties of physical coercion (e.g., hitting and yelling). Familial support is regarded as the most robust variable in the prevention of all kinds of delinquent behaviors in children and adolescents (Baumrind, 1991; Gecas & Seff, 1990). Different aspects of support have recently been identified, such as general support, physical affection, companionship, and sustained contact (Gecas & Seff, 1990), all of which are negatively associated with socially unacceptable behaviors. Coombs and Landsverk (1988), for example, found consistent evidence that maintaining a rewarding parent-child relationship deters substance abuse during childhood and adolescence (see also reviews by Glynn, 1984; Hawkins et al., 1986). Parental praise and encouragement, involvement and attachment or perceived closeness, trust, and help with personal problems are all characteristics of the families of abstainers, whereas parental rejection, conflicts, manipulative relations, and overinvolvement are related to the earlier onset and continued use of drugs (Baumrind, 1991; Hawkins et al., 1986).

The control dimension is more complex than the support dimension, since one needs to differentiate between types of control. Baumrind (1987, 1991), for example, distinguished between authoritative and authoritarian controls. The first is characterized by a combination of warmth, supervision, and opportunity for negotiation; this type of control is associated with positive outcomes. In her study of drug-abusing adolescents, Baumrind found that authoritative control characterized the families of abstainers and soft experimental drug users. Authoritarian control, on the other hand, is based on force, threats, and physical punishment; this is the type of control that characterized the families of dependent drug users. Other studies have revealed that sexual abuse and physical abuse are prevalent in the families of drug abusers.

It has been especially well documented that families with inconsistent or no clearly defined rules also have adolescents who abuse drugs (see Baumrind, 1987; Coombs & Landsverk, 1988; Hawkins et al., 1986; Volk et al., 1989). The constantly changing rules in some families jeopardize parental ability to monitor and supervise children and make it difficult for the children to adapt to family expectations.

In order to function within these two dimensions, families must rely on their communication mechanism. To give support or exert control over others, it is necessary to communicate one's intents. Watzlawick, Beavin, & Jackson (1967) believe that when people communicate, the communication also defines their relationships with other persons. They also believe that to be able to define the relationship, those who communicate should be able to understand each other's perceptions regarding what they talk about and regarding their relationship. In a family where drug use is prevalent, communication is heavily loaded with interpersonal misperception and exchanges of negative affect. Studies also indicate that communication in these families is frequently blocked either by the use of drugs or feelings of not being understood (Hawkins et al., 1986; Jurich et al., 1985; Piercy et al., 1991).

The Family and Other Systems.

The peer group and school are two other systems to be considered when the adolescent member of the family who is involved in drug abuse. These systems intervene with their own parenting practices, because they provide much of the environment for learning VALUES, attitudes, and norms as far as expected behaviors are concerned (behaviors that may or may not be expected by the adolescent's family).

It is well known that most new drug users are introduced to drugs by peers and that peers help maintain patterns of use, including greater dependent use. To assess the influence of peers, one should assess the following indicators (Agnew, 1991): (1) time spent with peers, (2) the degree of attachment to peers, and (3) the extent of peer delinquency or drug use.

Although researchers find consistent evidence of the relationship between school DROPOUTS, low performance and underachievement in school, and drug abuse, it is not known when school factors become developmentally salient as possible predictors of drug abuse (Hawkins et al., 1986). Some research indicates that a low grade-point average and dropping out of school are strongly associated with children's involvement with drug-abusing peers. It is clear, on the other hand, that parental involvement in children's schoolwork and activities reduces the changes of a child being seriously involved in drug use.

Hawkins et al. (1987) documented limited evidence with regard to the association of drug use and the social isolation of the family. The 1990 NATIONAL HOUSEHOLD SURVEY indicated that drug users were concentrated within underprivileged families of lower social economic status and within communities of color.

IMPLICATIONS FOR PREVENTION

In the last ten years, those responsible for drug-PREVENTION efforts have discovered that (1) the most effective programs are multilevel programs; (2) it is most cost-effective to target youth aged twelve and younger; (3) the family is the most influential context within which to set programs, especially with drug users who are younger and female; and (4) LIFE-SKILL programs rather than knowledge-oriented programs are most effective in preventing drug abuse.

In the assessment phase, one can determine the risk status of a family by looking at the intergenerational history of drug usage, reported child abuse, the children's academic performance, the degree of parental involvement in schools, and the characteristics of the community in which the family lives (e.g., population density, extent of economic and social deprivation, rates of criminal activity and drug abuse behavior).

In the program development phase, one may well consider issues embedded in (1) individual and family development (Baumrind, 1991; Steinglass et al., 1987), (2) culture and gender (Weiner et al., 1990), and (3) health and economy, both of which affect the individual and the family (Bush & Iannotti, 1987; Conger et al., 1991). One could also determine how these issues are interconnected in order to come up with the best possible program for specific populations.

In the implementation phase, matching of staff and target group and the ways in which the programs are delivered may affect the outcomes. It may be wise to staff prevention programs delivered in cultures other than the mainstream culture with personnel of similar backgrounds or with those who have an adequate knowledge of that specific culture. Positive and nonthreatening approaches that combine both information and life-skill building are most effective. Parental or significant-other involvement with involvement by the school give programs the most credibility to youth.

FAMILY TREATMENT

As described earlier, dysfunctional family life is one potential contributor to the development of drug addictions in family members. The reciprocal nature of addictions and disorganized families, however, is evident in that not only may dysfunctional families produce addictive behaviors in their members, but these addictions, in turn, may affect the quality of family life, thus negatively impacting the behavior of family members and devitalizing or fracturing family relationships. The most demoralizing aspect of this reciprocity is that drug addictions are often passed from earlier generations to later generations, unless this pattern can be ended by successful treatment or intervention.

Until the mid-1980s, very few drug treatment programs directly utilized spouses, parents, or other family members in their treatment of the identified patient. After that time, family therapy became the treatment of choice for most drug abusers, especially in the area of alcoholism treatment. A growing body of research findings has shown that family-centered drug interventions are very effective in getting family members off drugs and keeping them off (Lewis & McAvoy, 1984).

There is evidence, for example, that family groups given systemic family interventions have a higher treatment success rate—that is, decreased drug dependence and less recidivism (Stanton & Todd, 1982). In contrast, if adolescents are treated individually and their family system has not changed, they often return home to resume the same roles and behaviors that had earlier fostered their addictive behaviors.

The inclusion of other family members in an adolescent's drug treatment does add to the complexity of the treatment. Yet this addition often gives a family therapist greater leverage for sustained and successful drug treatment (Lewis & McAvoy, 1984), because of the drug abuser's wish to maintain family love and relationships. Strengthening family relationships may therefore help to reduce or eliminate an individual's addictive behaviors.

Some of the better known interventions currently used in the field of alcoholism treatment are treatments based on family systems. For instance, research has revealed that the spouses of alcoholics often play roles that support their spouse's addiction (through co-dependency). Changes in the spouse's behavior and roles, however, can also contribute to the effective treatment of the spouse's alcoholism (Steinglass et al., 1987).

Systemic family treatment has also been widely utilized in the treatment of adolescents' drug abuse, according to the successful research conducted by Stanton and Todd (1982) with adult heroin addicts. In this programmatic research, one of the best controlled studies of family therapy, the researchers found a significant decrease in the heroin usage of young adults when family-focused therapy was employed.

A longitudinal study of 136 adolescents (Lewis et al., 1991) also documents the relative effectiveness of a family therapy program as compared to a family education program and treatment-as-usual (i.e., individual counseling). In this study, the two brief family-based drug interventions together reduced the drug use of nearly one-half (46%) of the adolescents who received them. This success is thought to be due primarily to the fact that both of these outpatient interventions focused on the systemic treatment of entire family groups. In contrast, the family therapy intervention seemed to have been more effective in significantly reducing adolescent drug use for a greater percentage of the adolescents (54.6% compared with 37.5%). Thus family-based interventions (especially family therapy) can be potent and viable drug-treatment programs.

The best drug treatment, however, may be a combined treatment (Lewis, 1989), in which individual treatment focuses on the teaching of social skills and strategies for coping with stress, whereas the emphasis of the family treatment component is on increasing the nurturance and parenting skills of other family members. It is at the intersection of these two approaches that much of the current creativity seems to be taking place. Even though their focus and methods may differ, it is good for these two arenas of inquiry to become better known to each other, since each has a wealth of understanding to contribute to the other.

(SEE ALSO: Adjunctive Drug Taking; Codependence; Conduct Disorder and Drug Use; Conduct Disorder in Children; Ethnic Issues and Cultural Relevance in Treatment; Ethnicity and Drugs; Poverty and Drug Use; Treatment Types; Vulnerability As Cause of Substance Abuse)

R. A. LEWIS

M.S. IRWANTO