Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka.
Proforma For Registration Of Subjects For Dissertation
1. Name of the candidate and address:
Dr.Jasmine.G
Postgraduate
Department Of Psychiatry,
St. John’s Medical College Hospital
Sarjapur road, Bangalore -560034
2. Name of the Institution:
St. John’s Medical College Hospital
3. Course of Study and Subject:
MD – Psychiatry
4. Date of Admission to Course:
19.03.2009
5. Title Of The Topic:
Psychopathology in adolescent offspring’s of alcohol dependent patients. Does short term abstinence lead to change?
6. Brief resume of the intended work:
6.1 Need for the study:
There is a higher prevalence of emotional and behavioral problems in children whose parents use alcohol (1,2,3). Very few studies have evaluated the changes in psychopathology in children of alcohol dependent fathers when they remain abstinent. Studies from treatment samples are very few and have shown positive results (11, 13, 15). However Community studies have found less consistent support for children’s benefiting from the improvements in their parent’s drinking problems casting doubt on results from treatment sample studies (9,10). Also, previous studies in this area have important limitations like modest sample size, inadequate measures, and variation in strength and consistency of findings which reduces confidence in the results. This study is an opportunity to test whether excessive drinking in parents is a risk factor for child adjustment. Such a study can determine whether changes in a putative risk factor (i.e., parental excessive drinking) are linked with changes in child adjustment. There have been no prospective studies from India.
6.2 Review of Literature:
The prevalence of childhood behavioural problems is significantly high in children of alcoholic fathers as compared to non-alcoholic fathers (1,2,3).Various studies report that children of alcohol dependent parents exhibit elevated symptom levels for both internalizing (e.g., sadness and worrying) and externalizing (e.g., aggression) syndromes compared with children of non dependent parents (4). Previous studies suggest that characteristics of the family such as parental monitoring, parental discipline, family conflict and family rituals may mediate and/or moderate the relationship between parental alcoholism and offspring adjustment (5,6,7). However, Inter parental conflict has emerged as one of the primary component of marital difficulties which leads to behaviour problems in children (8). The question of association between the changes in problematic parental drinking and changes in children’s adjustment has received relatively little attention in past research. Few studies have showed improvement in above mentioned problems in Children when the fathers abstain from alcohol (11,12,14).
Moos et al studied children of 28 relapsed and 23 remitted alcoholic patients two years after the patients got treatment and compared with 59 matched controls. Compared with children of control families, Children of alcohol dependents whose fathers relapsed had greater problems. Emotional functioning among Children of alcohol dependents whose fathers remitted was comparable to that among control children. However this study used modest sample size and rudimentary measures (11 yes–no items) of child functioning. Also, child functioning was not assessed before treatment so whether child adjustment improved after parental alcoholism treatment is not known. Callan and Jackson showed improvement in problems when the parental alcohol use reduced (11, 12). This study had small sample, limited measurement, and select sample of Children from Alateen (13).
A study by Kelley and Fals-Stewart found limited improvements in child functioning after decreased substance use in parents after individual treatment and Couple based treatment. They divided the study group into two groups; children (between the ages of 8 and 12 years) and adolescents (between 13 and 16 years) Despite exhibiting non-clinical levels of externalizing symptoms at pre-treatment, children (8-12yrs) showed improvement in their externalizing behaviours from pre-treatment to follow-up. But found no improvement in adolescents (13-16 yrs) (14).
A recent prospective study by Andreas JB in 2006 showed improvement (after 12 wk therapy) when the fathers alcohol use reduced. They studied 125 children between age groups of 4-16 years. They used Paediatric symptom Checklist as their main tool to assess psychopathology in the children. First assessment was done when the fathers entered the treatment and the follow ups were done immediately after treatment and at 6 & 12 months after treatment. The Mean score reduced from 26.4% to 12.8 % (15).
In India Narang attempted to study the childhood psychopathology and temperamental characteristics among Children of alcohol alcoholics and found more disturbances in them (16). They used Childhood Psychopathology Measurement Schedule (CPMS) to assess Psychopathology and found that the children of alcoholics had significant conduct disorder, anxiety, physical illness with emotional problems and somatization symptoms compared to children of non alcoholic parents (16). Benegal et al showed higher prevalence of behavioural problems and cognitive deficits in these children (17). However there have been no prospective studies from India.
Objectives of the Study:
· To evaluate the effect of father’s alcohol abstinence on the psychopathology of their children.
· To study the influence of interparental conflict on childhood psychopathology.
Materials and Methods:
7.1 Source of Data:
Subjects will be selected from children of male inpatients admitted for alcohol deaddiction in SJMCH. Informed consent will be taken.
Inclusion criteria:
· Married Male patients qualifying for Alcohol dependence syndrome according to ICD10 and having adolescent in the age group of 11 to 16yrs
· Staying within 15 km radius and willing to come after 3 months for a follow up
Exclusion criteria
· Male subjects qualifying for other Axis 1 psychiatric diagnosis other than Nicotine dependence
· Fathers qualifying for Dissocial personality disorder.
· Children with seizures, mental retardation or any neurological disorders.
7.2 Method of Collection of Data:
· Duration of study: 1 year
· Sample size calculation:
o It was calculated from a study by Andreas et al where they had used paediatric symptom checklist. So, for a change of 4 units of symptoms in the study with 80% power and 0.5% alpha value, we would require a sample size of 115 families (15). With attrition rate of 20% during follow up, we would like to have a sample size of 140 subjects.
o If families have more than one adolescent then the eldest of them in the within the age group (inclusion criteria) would be taken up for the study.
· Study design: Prospective study.
Baseline data collection:
Fathers:
· Fathers will be assessed after the withdrawal period. Fathers scoring less than eight using CIWA-Ar (The revised Clinical Institute for Withdrawal Assessment) (18) will be recruited into the study.
· MINI-plus (Mini International Neuropsychiatric Interview) will be used to confirm alcohol dependence syndrome and to rule out other Axis 1 psychiatric disorders and antisocial personality disorder (19).
· Severity of alcohol dependence will be assessed using Severity of alcohol dependence Questionnaire ( SADQ )(20).
Mothers:
· MINI-plus will be used to evaluate for any psychiatric diagnosis in the mother.
· SDQ-Parent version would be used by them to assess the psychopathology in their children (21).
Adolescents:
· The Emotional and Behavioural problems will be assessed using Strengths and Difficulties Questionnaire (SDQ) - adolescent version (self report).
· Children’s Global Assessment Scale (CGAS) will be employed to assess global emotional and behavioural functioning (22)
Interparental conflict
It will be assessed using revised conflicts tactics scale (23,25)
Note: If SDQ reveals any significant emotional and behavioural problems, they will be referred to child psychiatrist for further management.
Second assessment: 3 months later
Fathers:
· Assessed for abstinence using Alcohol Abstinence Self-Efficacy Scale (AASE)(24).
· Severity of alcohol dependence will be reassessed using Severity of alcohol dependence Questionnaire ( SADQ ).
Mother
· SDQ – parent version- follow up questionnaire will be used.
Adolescent:
· SDQ- follow up questionnaire will be used.
· Children’s Global Assessment Scale will be employed again to assess their emotional and behavioural functioning.
Interparental conflict
It will be assessed using revised conflicts tactics scale
Statistical analysis
Descriptive statistics including mean, median and standard deviations will be generated. Paired sample t test will be used to compare absolute mean change of SDQ total scores. The influence of interparental conflict will be assessed using regression analysis.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals if so, please describe briefly-
7.4- Not applicable
8. List of references:
1. Reich W, Earls F, Frankel O, Shayka JJ. Psychopathology in children of alcoholics. J Amer Acad Child Adolesc Psychiat 1993:32:995-1002.
2. Loukas, A., Fitzgerald HE, Zucker RA, Von Eye A. Parental alcoholism and co-occurring antisocial behavior: Prospective relationships to externalizing behavior problems in their young sons. J Abnorm Child Psychol 2001: 29: 91-106.
3. Connolly GM, Casseell S, Stewart TJ, Silva PA, O’Brien MK. The effect of parents’ alcohol problems on children’s behaviour as reported by parents and by teachers. Addiction 1993:88:1383-1390.
4. Johnson JL, Leff M. Children of substance abusers Overview of research findings. American Academy of Pediatrics 1999:103:1085–1099.
5. Chassin L, Pillow DR, Curran PJ, Molina BSG, Barrera MJR. The relation of parental alcoholism to early adolescent substance use: A test of three mediating mechanisms. J Abnorm Psycho 1993:102: 3-19.
6. Sher KJ. Children of Alcoholics: A Critical Appraisal of Theory and Research, Chicago, IL: Univ. of Chicago Press: 1991.
7. Windle M, Tubman JG. Children of alcoholics. In: Silverman WK, Ollendick TH, editors. Developmental Issues in the Clinical Treatment of Children, Needham Heights, MA: Allyn & Bacon: 1999. p. 393-414.
8. Emery RE. Marriage, divorce, and children’s adjustment. 2nd ed.CA: Thousand Oaks: 1999.
9. Puttler LL, Wong MM, Fitzgerald HE, Zucker RA. When is there a COA effect? Family functioning as a function of parent alcoholism status. Alcoholism Clinical and Experimental Research 2004:28 Suppl 5: 23-34.
10. DeLucia C, Belz A, Chassin L. Do adolescent symptomatology and family environment vary over time with fluctuations in parental alcohol improvement? Developmental Psychology 2001:37: 207–216.
11. Moos RH, Billings AG. Children of alcoholics during the recovery process: Alcoholic and matched control families. Addictive Behaviors 1982:7:155-163.
12. Moos RH, Finney JW, Cronkite RC. Alcoholism treatment: Context, process, and outcome. New York: Oxford University: 1990.
13. Callan VJ, Jackson D. Children of Alcoholic fathers and recovered fathers: Personal & family functioning. Journal of studies on alcohol 1986:47:180-182.
14. Fals-Stewart W, Kelley ML, Fincham FD, Golden J, Logsdon T. Emotional and behavioral problems of children living with drug-abusing fathers: Comparison with children living with alcoholic fathers and nonsubstance-abusing fathers. J Fam Psychol 2004:18:319–330.
15. Andreas JB, O’Farrell TJ, Fals-Stewart W. Does individual treatment for alcoholic fathers benefit their children: A longitudinal assessment. J Consult Clin Psychol 2006:74:191–198.
16. Narang RL, Gupta R, Mishra BP, Mahajan R. Temperamental characteristics and psychopathology among children of alcoholics. Indian J Psychiat 1997:39 Suppl 3; 226-231.
17. Silva MC, Benegal V, Devi M, Mukundan CR. Cognitive deficits in Children of Alcoholics: At risk before the first sip! Indian J Psychiatry 2007:49:182-188.
18. Sullivan JT, Sykora K, Schneiderman J, Naranjo C, Sellers EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989:84:1353-1357.
19. Sheehan DV, Lecrubier Y, Harnett‐Sheehan K, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar G: The Mini International Neuropsychiatric Interview (M.I.N.I.): The Development and Validation of a Structured Diagnostic Psychiatric Interview. J Clin Psychiatry 1998:59 Suppl 20:22‐33.
20. Stockwell T, Murphy D. Hodgson R. The severity of alcohol dependence questionnaire: Its use, reliability and validity. British Journal of Addiction 1983:78 Suppl 2: 45-156.
21. Goodman R. The Strengths and Difficulties Questionnaire: A Research Note. Journal of Child Psychology and Psychiatry 1997:38:581-586.
22. Shaffer D, Gould MS, Brasic J et al. A Children’s Global Assessment Scale (CGAS). Arch Gen Psychiatry 1983:40:1228–1231.
23. Straus MA. The Conflict Tactics Scale and its critics: An evaluation and new data on validity and reliability. In: Straus MA, Gelles RJ, editor. Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Bmnswick, NJ: Transaction Publishing;1990. p. 49-73.
24. DiClemente CC, Carbonari JP, Montgomery RPG, Hughes SO. The Alcohol Abstinence Self-Efficacy Scale. Journal of Studies on Alcohol 1994:55:141-148.
25. Selwyn Stanley. Interpersonal Violence in Alcohol Complicated Marital Relationships. J Fam Viol 2008:23:767–776.
9. Signature of the candidate:
10. Remarks of the Guide:
11. Name and designation of
11.1 Guide: Dr. K. Srinivasan, MD, DPM
Professor
Department of Psychiatry
.
11.2 Signature
11.3Co guides: (1) Dr. M. V. Ashok, MD
Professor
Deparment of Psychiatry
(2) Dr. Johnson Pradeep MD
Lecturer
Department of Psychiatry.
11.4 Signature: (1)
(2)
11.5 Head of Department: Dr. R. B. Galgali, MD, DPM, DNB
Professor & HOD
Deparment of Psychiatry
11.6 Signature