Read the following articles from the National Association for Children of Alcoholics (www.nacoa.org/). You will find these articles located under module notes: The Counselor and the COA; Silenced into

DAAC 1319: Intro to AOD

Module Four Notes

Module Four

Family Issues in Addiction

Family Systems

Another Chance: Hope and Health for the Alcoholic Family describes the devastation that substance abusing families face. In studying families you must first begin by understanding systems. The four principles of systems include:

1. Systems have a definite structure to them.

2. The whole is greater than the sum of the parts.

3. Changes in one piece in the system affect all of the other pieces in the system (but not necessarily the same way).

4. Systems always try to return to their original state.

The family is basically a system and these principles apply to it, as they do to other systems. In understanding families it is important to understand the four broad functions that rules perform within the family system:

1. To establish attitudes, expectations, values, and goals for the family.

2. To determine who will hold the power and authority, how it will be used, and how members are expected to respond to them.

3. To anticipate how the family will deal with change - it itself as a unit, in its members, and in the outside world.

4. To dictate how members may communicate with one another and what they may communicate about.

Families, like other systems are held together by its rules and patterns of responding. Rules in families are rarely written, but none the less understood and are passed along to new family members by words and actions. In a substance abusing family the most commonly known rules are those of: don’t talk; don’t feel; and don’t trust. These rules are reinforced not only by the substance abusers action but by the action of other family members.

Family structure today is different than it was thirty years ago, when the traditional family (mom, dad and children) was more the norm. Today’s nuclear family may consist of only one parent with children, or be a blended family with children from previous marriages. In addition, the need even in traditional families for mom to work has created a phenomenon of latchkey children; children whose parents are not available before or after work, leaving children home alone for extended periods of time.

In dysfunctional substance abusing families there are six primary roles that family members play. These roles respond to not only the family’s need but to some degree the needs of the individual members. Role-playing and the adoption of a particular role is not limited to substance abusing families, in fact they occur in all troubled families and even occasionally in healthy families in times of stress. In substance abusing families these roles tend to be more rigid. The six primary roles are:

1. Dependent

2. Enabler

3. Hero child

4. Scapegoat child

5. Lost child

6. Mascot child

Each role has distinct characteristics and reasons for existing. The DEPENDENT person is motivated by feelings of shame. They are identified by symptoms of drug use and abuse. For the individual the payoff is the relief of pain, for the family there is no payoff. The ENABLER is motivated by feelings of anger. On the outside this person appears capable and strong but on the inside they feel: tired, resentful, worried, suffering from low self-esteem, obsessed with the substance abusers behaviors, feelings of helplessness, are at greater risk of developing a physical illness than the spouse of a non-substance abuser, and are greater at risk of being depressed and becoming chemically dependent. They are identified by symptoms of powerlessness. For the individual the payoff is feelings of importance, for the family the payoff is someone acting in a position of responsibility. These two roles are usually filled by adults. When there is only one adult in the family, the hero child may take on the role of the enabler.

The HERO CHILD is motivated by feelings of inadequacy and guilt. The identifying symptom for them is over achievement. They tend to be outstanding students and don’t get into trouble; they help around the house and take care of the other children. The hero child is often the first born. The payoff for the individual is positive attention and they give the family a sense of self-worth. The hero child knows something is wrong and feels obligated to “fix” it and tries to fix the problem between parents by achieving something that will make them proud and forget the problem. Unfortunately each achievement is only a temporary cure, the hero tries compulsively harder for the next curing achievement and when they are not able to fix the problem they feel like a failure, guilty and not good enough to fix everything. Beneath the “perfect” facade, the hero is also angry, they have tried hard, but no one really appreciates the effort. They get tired of trying, but leave the family in an acceptable way: joins the military; goes off to college, gets married, takes a job in a distant city. Hero’s' are perfectionists and without help may become: workaholics, abusers of prescription medications and the next generation of enablers.

The SCAPEGOAT CHILD is motivated by feelings of hurt, and is identified by acts of delinquency. These children receive attention but it is negative attention for their bad behaviors. They take the focus in the family away from the dependent person. These children often grow up with an even higher risk for developing addictions. The two family roles of hero and scapegoat children are the two roles most likely to be switched. In large families were there are four or more children it is not unusual for each of the four children roles to be played out. The scapegoat is usually the second child. Since the hero has the family’s positive attention, this child seeks what is left; negative attention - the child’s role is to take the attention away from the family’s trouble. The scapegoat usually seeks acceptance from peers who are also having trouble with their parents, they frequently become involved in alcohol, drug abuse, vandalism, and sexual promiscuity which leads to trouble with school authorities and the police.

The LOST CHILD is motivated by feelings of loneliness. They are easily identified by their shyness. The payoff for the individual is escape into a fantasy world, where they don’t have to deal with all the dysfunctional issues of the family. They offer the family a sense of relief since they present no major problems; they just blend into their surroundings. The lost child is often the third or a middle child. This child’s role is to cause no trouble for the family. They receive little positive or negative attention from the family. Their needs are not attended to, they receive no praise for achievements, and they receive no reassurance about their fears. In order to survive they create a fantasy world where things are as they would like them to be. They have little interpersonal experience, and become more and more isolated. Without treatment, the lost child looks toward leading a lonely life sometimes seeking relief in alcohol, drugs, and over the counter medication.

The MASCOT CHILD is motivated by feelings of fear. These children are identified by their clowning around and hyperactivity. They receive attention by these actions and offer the family some fun. They often carry this immaturity with them into their adulthood. The mascot child is often the youngest. They sense that something is wrong in the family but receives reassurance from other family members that nothing is wrong - this discrepancy between one’s perception and the reassurance of others causes a continual conflict that leads to anxiety and feelings of “going crazy”. They feel less frightened when others give them attention. They develop behaviors to draw attention to themselves; these behaviors are often clowning around or being cute. The attention they receive for these behaviors reinforces them to continue to do them. The compulsive need for attention is often misunderstood as hyperactivity or paranoia.

Formal intervention is the creation or use of a crisis involving the alcoholic that is so emotionally painful that they will stop denying that alcohol /drugs are a problem before they lose everything. The book discusses how an effective intervention for the substance abuser involves a number of factors. Interventions can work if: it is prepared for carefully under the guidance of a trained professional; it is conducted in a loving, hones, and non-hostile manner; there is a treatment system in place that will accept the substance abuser; and the family is committed to recovery and will continue treatment for themselves regardless of the outcome of the intervention. To conduct an intervention the following things must take place: someone in the family must reach out for help; a list is made of the important people in the substance abusers life who have seen the chemically induced behavior or the consequences; a decision is made as to who will participate in the intervention; each member is briefed on how the intervention is to work; and the intervention is rehearsed as part of the preparation. During the intervention each family member reads a list they have prepared. The substance abuser is confronted with the reality of their drug use and the effects it is having on each member in very concrete way. The substance abuser is given the chance to go to treatment immediately. Interventions are most effective when work supervisors are involved. In some cases going to treatment may be a condition for continued employment.

In understanding substance abuse and its impact of the family; it is important to understand the roles that people in dysfunctional substance abusing families play; the function of rules, and the principles of systems. Families are a complicated group in society today, complicated even more when one or more family members are substance abusers.

Disrupted Activities

Research has shown that the impact of addiction on the family system is often directly related to the disruption of family activities. These activities fall into three broad categories: family celebrations, family traditions, and patterned routines. In families where one or more members are addicted the following disruptions are often found:

Family celebrations and traditions such as holidays, birthdays, and anniversaries are inconsistently observed and when observed there are often major disturbances caused by the addict.
Routine patterns that govern daily life such as dinner time, homework time, curfew, chores and bedtime are often arbitrary or nonexistent. This lack of pattern may result in a lack of monitoring or supervision of children in the family. Rules and the consequences for breaking them may be inconsistent. This may lead to inconsistent or excessively severe discipline of the children.
Family routines and the behavior of members change depending on whether a family member is using or not using AOD at the time.

Common Characteristics of Addicted Families

When family members become organized around the dependent person and family activities are disrupted, families may develop certain characteristics such as:

Communication between family members may become rigid, with strict rules about unmentionable subjects.
Children may take on a parental role with other family members.
Alcohol or other drugs may be used by other family members to handle stress or solve problems.
Family members may feel comfortable only during a crisis and may create crisis in order to establish emotional closeness.
Family members may lack clear behavioral expectations of other members.
Parents may have low expectations for children’s success.
Privacy may not be valued or respected.
There may be a strong sense of loyalty between family members.

Children of Substance Abusers

Children of alcoholics (COAs) face special problems as a result of living in a home disrupted by alcohol problems. An estimated 6.6 million children under the age of 18 live in households with at least one alcoholic parent. For our purposes we will use COA to address children growing up in families where any psychoactive substances are being abused, not just alcohol.

What are characteristics of the typical COA? A mistake often made by prevention practitioners is to cluster all COAs into rigid behavioral categories. However, each child's personality and reaction to parental alcohol dependence is unique. One child may fail classes, while another may escape stress by studying for perfect grades. Some rebel, while others are overly compliant. In addition, factors at home such as marital conflict or severity of parental drinking, can influence acting‑out behaviors.

While certain tendencies are found more commonly in COAs, they can also describe children raised in other types of dysfunctional families. Young COAs may exhibit more symptoms of depression and anxiety, including crying, bed-wetting, social isolation, fear of school, or nightmares. Older youths may isolate themselves for long periods of time, claiming they have "no one to talk to." COAs may have difficulty relating to teachers, other students, and school. Teenagers may be perfectionists, hoarders, excessively self‑conscious, or prone to phobias. They often believe that they are failures, even if they do well academically.

Most COAs do not develop serious problems coping with life. One study found that 59 percent of COAs had not developed serious coping problems by age 18. Researchers have found that maintaining consistency around important family activities such as vacations, mealtimes, or holidays, are protective factors for some families with parental alcoholism. Children can also have

some protection if the active alcoholic is confronted and seeks help, if family rituals or traditions are maintained, if consistent significant others are around, and if there is moderate to high religious observance.

Although there is a genetic component to vulnerability for alcohol dependence, COA issues are not related primarily to alcohol use and problems, but instead to social and psychological dysfunction that may result from growing up in an alcoholic home. Most COAs do not develop alcohol problems. In research samples, two‑thirds of alcoholics did not have one or more alcoholic parents. Still, COAs are two to four times more likely to develop alcohol problems than others. That they are at higher than average risk of developing problems merits the attention of prevention practitioners.

It is not always possible to identify COAs and provide intervention services. If the parent is receiving treatment, preventive services, such as mentoring, can be provided for the child. Prevention activities can include information on alcoholism and resources so that older COAs can seek out assistance through schools or community agencies.

Children of substance abusers (COSAs) are often put in parenting situations with younger siblings and need help in learning just to be a child.
COSAs will often blame themselves before they will blame their parents.
COSAs often think they are responsible for their parents’ substance abuse.
Lying is often common for all members of the family. COSAs may need help in learning that it is ok to tell the truth.
COSAs often don’t feel they have a right to their feelings because their parents denied or minimized feelings.
COSAs may look for approval by being compulsively helpful and may need help in understanding they have value all on their own.
COSAs have been verbally abused. It is highly likely they have been neglected and physically and/or sexually abused; touching of any kind may be threatening.
Expressions of strong feelings such as love may have occurred only during periods of parental AOD use; children, especially adolescents, may seek expressions of feeling through the use of chemicals.

Resiliency in Children of Substance Abusers

The following factors can help build resiliency in children of substance abusers:

a relationship with a caring adult role model
self-esteem and internal locus of control
a sense of purpose and future
a sense of one’s own identity and the ability to act independently and exert some control over one’s environment
problem solving skills and the ability to plan
a sense of humor and the ability to play
a conscience and the ability to sacrifice for others
the ability to adapt to new situations
social competence and the ability to recruit and attach to adults or parent surrogates in positive ways

Child abuse

Children growing up in substance abusing families are often victims of child abuse. The four main types of child abuse include: physical abuse, neglect, sexual abuse and emotional abuse. In 2000, three million reports of child abuse were made in the United States. Of these, 62% were screened in and 38% were screened out. Screened-in referrals alleging that a child was being abused or neglected were investigated to determine whether the allegations could be substantiated. Thirty-two percent of those investigated resulted in a finding of maltreatment or risk of maltreatment. Approximately 879,000 children were found to be victims of child abuse. Child fatalities numbered over 1,200 for the year 2000. That works out to a rate of 1.71 children per 100,000; the highest of all industrial nations. Our youngest children are at greater risk with 44% of child fatalities being younger than one year old. Eight-five percent of child fatalities were younger than 6 years old.

Physical Abuse is characterized by the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking or otherwise harming a child. The statistics on physical child abuse are alarming. It is estimated hundreds of thousands of children are physically abused each year by a parent or close relative. Thousands die. For those who survive, the emotional trauma remains long after the external bruises have healed.

Children who have been abused may display:

a poor self-image
sexual acting‑out
inability to trust or love others
aggressive, disruptive, and sometimes illegal behavior
anger and rage
self‑destructive behavior
self‑injury
suicidal thoughts
passive or withdrawn behavior
anxiety and fears
school problems or failure
feelings of sadness or other symptoms of depression
flashbacks, nightmares
drug abuse
alcohol abuse

Often the severe emotional damage to abused children does not surface until adolescence or later when many abused children become abusing parents. An adult who was abused as a child often has trouble establishing intimate personal relationships. These men and women may have trouble with physical closeness, touching, intimacy, and trust as adults. They are also at higher risk for anxiety, depression, substance abuse, medical illness, and problems at school or work.

Child Neglect is characterized by failure to provide for the child’s basic needs. Neglect can be physical, educational, or emotional.

Physical neglect includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. Educational neglect includes the allowance of chronic truancy, failure to enroll a child of mandatory school age in school, and failure to attend to a special educational need. Emotional neglect includes such actions as marked inattention to the child’s needs for affection, refusal of or failure to provide needed

psychological care, spouse abuse in the child’s presence, and permission of drug or alcohol use by the child. The assessment of child neglect requires consideration of cultural values and standards of care as well as recognition that the failure to provide the necessities of life may be related to poverty.

Child sexual abuse has been reported up to 80,000 times a year, but the number of unreported instances is far greater, because the children are afraid to tell anyone what has happened, and the legal procedure for validating an episode is difficult.

Sexual abuse includes fondling a child’s genitals, intercourse, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. Many experts believe that sexual abuse is the most under‑reported form of child maltreatment because of the secrecy or "conspiracy of silence" that so often characterizes these cases.

Child sexual abuse can take place within the family, by a parent, step‑parent, sibling or other relative; or outside the home, for example, by a friend, neighbor, child care person, teacher, or stranger. When sexual abuse has occurred, a child can develop a variety of distressing feelings, thoughts and behaviors.

No child is psychologically prepared to cope with repeated sexual stimulation. Even a two‑ or three‑year‑old, who cannot know the sexual activity is "wrong," will develop problems resulting from the inability to cope with the over‑stimulation and emotional deceit.

The child of five or older who knows and cares for the abuser becomes trapped between affection or loyalty for the person, and the sense that the sexual activities are terribly wrong. If the child tries to break away from the sexual relationship, the abuser may threaten the child with violence or loss of love. When sexual abuse occurs within the family, the child may fear the anger, jealousy or shame of other family members, or be afraid the family will break up if the secret is told.

A child who is the victim of prolonged sexual abuse usually develops low self‑esteem, a feeling of worthlessness and an abnormal or distorted view of sex. The child may become withdrawn and mistrustful of adults, and can become suicidal. Personality disorders, such as Dissociative Identity Disorder (Multiple Personality Disorder), have been linked to sexual abuse.

Some children who have been sexually abused have difficulty relating to others except on sexual terms. Some sexually abused children become child abusers or prostitutes, or have other serious problems when they reach adulthood. Often there are no obvious physical signs of child sexual abuse. Some signs can only be detected on physical exam by a physician.

Sexually abused children may develop the following:

unusual interest in or avoidance of all things of a sexual nature
sleep problems or nightmares
depression or withdrawal from friends or family
seductiveness
statements that their bodies are dirty or damaged, or fear that there is
something wrong with them in the genital area
eating disorders
self‑injury
refusal to go to school
delinquency
conduct problems
secretiveness
running away
aspects of sexual molestation in drawings, games, fantasies
unusual aggressiveness
suicidal behavior

Emotional Abuse (psychological/verbal abuse/mental injury) includes acts or omissions by the parents or other caregivers that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders. In some cases of emotional abuse, the acts of parents or other caregivers alone, without any harm evident in the child’s behavior or condition, are sufficient to warrant child protective services (CPS) intervention. For example, the parents/caregivers may use extreme or bizarre forms of punishment, such as confinement of a child in a dark closet. Less severe acts, such as habitual scapegoating, belittling, or rejecting treatment, are often difficult to prove and, therefore, CPS may not be able to intervene without evidence of harm to the child.

Although any of the forms of child maltreatment may be found separately, they often occur in combination. Emotional abuse is almost always present when other forms are identified.

Adult Children of Addicts as Parents

Adult children of addicts (ACOAs) often have painful memories associated with disrupted family holidays and traditions. These painful memories may get in the way of their forming healthy traditions and relationships in their adult families:

ACOAs often have no concept of what normal is, they see normal as “perfect” and will often become perfectionist parents.
ACOAs often have no frame of reference for setting appropriate boundaries and therefore are unable to set appropriate limits for their children.
ACOAs often find it difficult to play because they have only seen out-of-control adults who were drinking or using drugs. They fear that spontaneity will lead to chaos.
ACOAs will often be hypervigilant parent who smother their children with concern or fear.
ACOAs have often been inappropriately touched as children and may be ambivalent about showing physical affection.
ACOAs have difficulty with grieving because of the many unresolved losses in their lives and may have problems being emotionally available to their children’s sadness.
ACOAs may have been parental children and may expect their children to take care of them as they took care of their parents.
ACOAs may minimize their children’s feelings because was their experience as children.
ACOAs are often heavily invested in their work because that is a source of self-esteem.
ACOAs may feel incompetent as parents.
ACOAs may harbor deep seated feelings of shame for their parents and have overwhelming feelings of failure for recreating the addiction cycle if they use drugs.
ACOAs may associate the ability to express emotion with drinking or being out of control and may not know healthy ways to express strong feelings without fear.

Recovery and Reorganization of the Whole Family

In viewing the problem of addiction as a family illness, the term enabler is used to describe the behavior, attitudes, and feelings of family members who help to maintain or foster the addict’s AOD use. The word codependent has also been used to describe family members whose lives develop in reaction to and center on that of the AOD-involved individual. The codependent person becomes preoccupied with the addicts behavior, may place their well-being before his or her own, and may be able to derive self-esteem only to the extent that they can care for the addict. In working with families it is important to remember:

a period of disillusionment comes when everything is not the way everyone had hoped
sobriety does not bring immediate relief, because role expectations may not be fulfilled
the family has to look at problems that have developed in relation to the drug addiction and things that are not related and may not change
everyone in the family will have to change their expectations of each other, roles will shift
the addicts involvement in a 12 step program may be resented by family members as taking away from family time
the non-drinking partner may leave the addict because of a perceived loss of control due to role change.

Additional Resources

Resources of Interest:

Children of Alcoholics: Important Facts @ www.health.org/pubs/coa/impfacts.htm
National Association for Children of Alcoholics Articles About COAs and ACOAs @