Treating Paternal Alcoholism With Learning Sobriety ... - CiteSeerX

Journal of Family Psychology 2007, Vol. 21, No. 3, 435– 444

Copyright 2007 by the American Psychological Association 0893-3200/07/$12.00 DOI: 10.1037/0893-3200.21.3.435

Treating Paternal Alcoholism With Learning Sobriety Together: Effects on Adolescents Versus Preadolescents Michelle L. Kelley

William Fals-Stewart

Old Dominion University

RTI International

The purpose of this study was to determine whether Learning Sobriety Together, a treatment for substance abuse that combines behavioral couples therapy and individual counseling, had comparable secondary benefits on the internalizing and externalizing behaviors of adolescent versus preadolescent siblings living in homes with their alcoholic fathers (N ⫽ 131) and their non-substance-abusing mothers. During a 17-month assessment period, the association between parents’ functioning (i.e., fathers’ drinking as determined by percentage of days abstinent and parents’ dyadic adjustment) and children’s adjustment (as rated by mothers, fathers, and children’s teachers) was stronger for preadolescents than for their adolescent siblings, particularly in terms of children’s externalizing behaviors. Interventions that reduce paternal drinking and improve couple functioning may serve as an important preventative intervention for preadolescents in these homes, whereas adolescents may need more intensive interventions to address internalizing and externalizing symptoms. Keywords: children of alcoholics, internalizing and externalizing behavior, couples therapy

greater overall symptomatology than children from the demographically matched comparison sample, but they improved significantly following their fathers’ treatment. Children of stably remitted fathers were similar to the comparison sample and had fewer adjustment problems than children of relapsed fathers, even after accounting for children’s baseline adjustment. Similarly, Moos, Finney, and Cronkite (1990) found that, as compared with boys in homes in which an alcoholic parent relapsed, 11- to 14-yearold boys in remitted alcoholic families and a control group of nonalcoholic families exhibited lower rates of emotional, physical, and psychological problems. Compared with families of relapsed alcoholics, remitted and nonalcoholic families also demonstrated higher levels of family cohesion, expressiveness, and organization. Given the latter finding, these investigators speculated that family-involved treatments for alcoholism, designed to affect such family-level factors, may have a greater effect on children than individual-based interventions. Kelley and Fals-Stewart (2002) provided some support for this hypothesis. Their findings revealed that children whose parents received Learning Sobriety Together (LST),1 a family-involved intervention for substance abuse that includes behavioral couples therapy (BCT) for parents plus individual counseling but does not address child or parenting issues, showed greater improvement in psychosocial functioning at posttreatment and during 12-month follow-up compared with

It is estimated that 20%– 40% of adults entering treatment for alcoholism or drug abuse are raising one or more children (e.g., Pilowsky et al., 2001; Stanger et al., 1999). Moreover, it is widely acknowledged that children who live in homes with alcoholic or drug-abusing parents exhibit elevated levels of internalizing and externalizing problems compared with children whose parents do not abuse psychoactive substances (e.g., Christensen & Bilenberg, 2000). Unfortunately, most parents entering treatment for substance abuse are reluctant to allow their children to receive services, whether in the context of family-involved interventions offered by the treatment program or in another setting (Fals-Stewart, Kelley, Fincham, & Golden, 2004). However, available evidence has suggested that treatment for parental substance abuse has positive secondary effects on children. Andreas, O’Farrell, and Fals-Stewart (2006) found that children living with alcoholic fathers exhibited

Michelle L. Kelley, Department of Psychology, Old Dominion University; William Fals-Stewart, Addiction and Family Research Group, RIT International, Research Triangle Park, North Carolina. This project was supported, in part, by National Institute on Drug Abuse Grants R01DA12189, R01DA014402, R01DA014402-SUPL, R01DA015937, R01DA016236, R01DA016235-SUPL, and R21 DA018304-01 and by National Institute on Alcohol Abuse and Alcoholism Grant R21AA013690. We thank Antonio Morgan-Lopez, who assisted with several aspects of the data analysis, and Cathy G. Cooke for their comments on earlier versions of this article. Correspondence concerning this article should be addressed to Michelle L. Kelley, Department of Psychology (MGB 250), Old Dominion University, Norfolk, VA 23529-0267. E-mail: [email protected]

1

Previously, Learning Sobriety Together was referred to as behavioral couples therapy. Because BCT does not denote the multiple treatment components (e.g., conjoint treatment, individual counseling, group therapy), LST was adopted.

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children whose parents participated in individual-based treatment or in a control group. Unfortunately, none of these investigations examined whether parents’ substance abuse treatment had different effects on children at different developmental stages, even though some evidence suggests that developmental stage might moderate this effect. For example, Moss, Clark, and Kirisci (1997) showed that children whose fathers’ alcohol disorder remitted before age 6 were comparable to control children, whereas children whose fathers’ alcoholism persisted beyond age 6 exhibited significantly more internalizing and externalizing symptoms than did control children. This may be due in part to the effects of differential exposure. More specifically, adolescents residing with a substance-abusing parent have spent more years in homes often characterized by low emotional support (e.g., Miller, Maguin, & Downs, 1997) and relationship stress and partner violence (e.g., Fals-Stewart, Kashdan, O’Farrell, & Birchler, 2002) than have their preadolescent counterparts. Prolonged exposure to this type of corrosive family environment may result in emotional and behavioral problems that become, over time, more crystallized and more resistant to change (see Kazdin, 2002). A competing hypothesis, however, is that rather than the child’s developmental stage being a possible moderator of whether the child benefits from the parent’s treatment for substance abuse, severity of the child’s symptoms at pretreatment may moderate any possible secondary benefits the child may accrue from reductions in parent drinking and changes in the family environment. Although researchers have not examined whether the severity of children’s symptoms is associated with changes that occur in response to parent treatment for substance abuse, children with more severe emotional and behavioral problems are more resistant to change in response to their own treatment (e.g., Dadds et al., 1999; Ferdinand, Visser, & Hoogerheide, 2004). Because they have lived in these homes longer, adolescents may tend to have more severe problems than preadolescents; consequently, it may be severity level, not developmental stage per se, that is associated with resistance to change. Clearly, any effort to explore the moderating effect of developmental stage and parents’ reductions in drinking and changes in the family environment should control for symptom severity to examine the possibility that children’s adjustment when the parent enters treatment, rather than developmental stage, may be the key factor that is associated with changes in children’s functioning associated with parent treatment for substance abuse. Comparing preadolescent and adolescent children from homes with substance-abusing parents presents unique challenges; families with younger children are likely to be different from those of older children in important ways. Although assessing families of preadolescent and adolescent children along theoretically and empirically important dimensions and analytically adjusting for differences is a common approach, it is not possible to know if all important variables have been assessed and controlled. Because the effects of the family on the adjustment of adolescent versus preadolescent children are theoretically central to under-

standing how substance abuse treatment may influence children’s functioning, the approach to controlling for differences in family environment is a particularly critical issue. The primary focus of the present study was whether possible change in children’s internalizing and externalizing behavior associated with reductions in parental drinking and changes in dyadic functioning would be moderated by developmental stage and children’s baseline functioning. Our primary hypothesis was that these relationships would be stronger for preadolescents than for adolescents. As a secondary hypothesis, we examined whether baseline functioning would moderate the association between parent drinking and couples’ dyadic functioning, such that children who exhibited fewer symptoms at baseline would show greater benefit from reductions in parental drinking and positive changes in the family environments. To control for familylevel effects, we used a participant pool consisting of parents with both custodial preadolescent and adolescent children.2

Method Participants Heterosexual couples in which men were entering abstinence-oriented outpatient treatment for alcohol misuse (N ⫽ 131) participated in this study. To be included, men had to (a) meet abuse or dependence criteria for alcohol according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., or DSM–IV; American Psychiatric Association, 1994); (b) have medical clearance to engage in abstinence-oriented outpatient treatment; and (c) refrain from participation in additional services, except for selfhelp meetings, unless recommended by their primary therapist. Couples were excluded if women had met DSM–IV criteria for a substance use disorder in the past 6 months or if either partner met DSM–IV criteria for an organic mental disorder. In addition, couples had to have one preadolescent (i.e., between 8 and 12 years) and one adolescent (i.e., between 13 and 16 years) living in their households. All children had to be the biological child of both parents. For couples who had more than one custodial preadolescent child or more than one adolescent child, one preadolescent and one adolescent were selected randomly for inclusion. The background characteristics of participants are shown in Table 1. 2

Our previous work has investigated differences in the functioning of children residing with an alcohol- versus a drug-abusing father (Fals-Stewart, Kelley, Fincham, Golden, & Logsdon, 2004), family and parent variables that predict a global assessment of children’s psychosocial functioning (Fals-Stewart, Kelley, Cooke, & Golden, 2003), and mothers’ reports of changes in school-age children’s functioning on a brief screening instrument as related to different types of treatment for paternal substance abuse (Kelley & Fals-Stewart, 2002). Data on the present families have not appeared elsewhere.

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Table 1 Sociodemographic Characteristics for Parents and Children Characteristic

M

SD

N

Parents Fathers’ age 43.6 5.3 Mothers’ age 42.3 5.4 Fathers’ education (years) 14.3 1.9 Mothers’ education (years) 14.9 1.7 Years married or cohabiting 16.2 4.6 Weekly family income (U.S. $) 594.5 204.7 Male and female partners’ racial or ethnic composition (fathers/mothers) Caucasian 90/94 African American 30/27 Hispanic 6/5 Native American 2/4 Other 3/1 Fathers’ years problematic alcohol use 13.9 5.4 Alcohol dependence 111 Alcohol abuse 20 Adolescents Age Grade Boys

14.5 9.7

0.6 1.0 70

Preadolescents Age Grade Boys

10.2 4.9

1.3 1.4 69

Measures Children’s adjustment. The Child Behavior Checklist (CBCL; Achenbach, 1991a) is a widely used 120-item questionnaire for parents of 4- to 18-year-old children and yields two broadband scores: Internalizing and Externalizing. Test–retest, internal consistency, and interrater reliability are good. T scores for the Internalizing and Externalizing subscales, corrected for child age and gender, were used as the analyses. The Teacher Report Form (TRF; Achenbach, 1991b), which assesses the child’s behavior in the school setting, was completed by the child’s primary teacher. The TRF generates age- and gender-corrected Internalizing and Externalizing subscale T scores. The TRF has good internal consistency, with low to moderate agreement with parent ratings. Teachers completed the TRF at the same intervals as parents; however, because children were not rated during the summer months, some teacher data were missing. Although the child’s primary teacher (or homeroom teacher for older children) completed the assessments, children changed grades over time and, as such, teacher’s scores reflect more than one teacher’s report.3 Substance use. The Timeline Followback Interview (Sobell & Sobell, 1996) is a calendar interview designed to gather retrospective estimates of an individual’s daily drinking and other drug use over a specified target interval. The substance use index derived from the Timeline Followback Interview was percentage of days abstinent (PDA), which

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was operationally defined as the percentage of days in the measurement interval in which fathers reported no drinking. After treatment completion and at 90-day intervals thereafter for 12 months, men provided information about their alcohol use reporting. To ascertain diagnoses, partners were interviewed with substance use modules of the Structured Clinical Interview for DSM–IV (First, Spitzer, Gibbon, & Williams, 1995). Relationship adjustment. The Dyadic Adjustment Scale (DAS; Spanier, 1976) is a 32-item self-report measure of relationship satisfaction with acceptable reliability and validity. Scores range from 0 to 151; higher scores indicate higher levels of adjustment. Couples’ DAS scores were highly correlated (r ⫽ .70, p ⬍ .001); couples’ average DAS scores at each assessment are used in the analyses that follow.

Procedure Men and their partners were asked to participate in an interview to determine eligibility for LST. During a 9-year period, 1,041 male patients met inclusion criteria for participation in LST; of these, 801 patients and their partners participated. Of these, 166 couples had at least one adolescent and preadolescent living in the home; 131 agreed to complete CBCLs regarding these children and allowed the children’s teachers to complete TRFs. Compared with other couples entering the treatment program, the partners of couples with adolescent and preadolescent children were significantly older and the couples had longer relationships (all ps ⬍ .05). All other comparisons on sociodemographic characteristics were not significant. Parents participated in LST as part of general clinical care provided by the treatment program (which typically included individual and group counseling, along with other psychosocial services, provided in an outpatient setting during a planned 3- to 6-month duration). Information regarding parents’ and children’s functioning was collected as part of an overall evaluation of program services. LST treatment overview. During the first 4 weeks after admission, men took part in the orientation phase of the program, during which background and medical information was collected. They also began counseling sessions with their individual counselor (once weekly). During the following 12-week LST primary treatment phase, couples attended one weekly BCT session, and men attended one individual counseling session each week. For the final 4 weeks, or the discharge phase, all men were scheduled to attend one weekly 60-min session with their individual therapist. The 12 weekly couple therapy sessions were used to (a) help male partners remain abstinent from alcohol and other 3

Because the teachers’ evaluations were obtained over a 17month period, children changed grades and homeroom teachers over the course of the study. The analyses were also run as cross-classified multilevel models (Goldstein, 2003) because children were not fully nested within a single teacher. The pattern of findings was the same as those reported and is available on request.

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psychoactive drugs by reviewing and reinforcing compliance with a verbal contract negotiated by the partners during the first two conjoint sessions; (b) teach more effective communication skills, such as active listening and expressing feelings directly; and (c) increase positive behavioral exchanges between partners by encouraging them to acknowledge pleasing behaviors and engage in shared recreational activities. All sessions were conducted in accordance with a detailed therapy manual (Fals-Stewart, O’Farrell, Birchler, & Gorman, 2004). In the remaining 20 sessions, fathers participated in individual counseling sessions for alcoholism (Mercer & Woody, 1999). The underlying philosophy of the individual sessions, which is consistent with that of Alcoholics Anonymous, was that alcoholism is a complex biopsychosocial disease that is often chronic and debilitating. Of note is that neither the couples-based nor the individual sessions addressed parenting skills, parent– child interactions, or child behavior. Baseline and posttreatment follow-up data collection. During a 17-month period (i.e., on entering the study, at treatment discharge, and every 3 months thereafter for 1 year), mothers, fathers, and children’s teachers were interviewed. For family members, interviews were typically conducted at the alcoholism treatment programs; if families were unable or refused to come to the clinics, interviews were conducted over the telephone. Fathers were queried about their drinking, and both partners completed self-report questionnaires pertaining to dyadic adjustment. In addition, parents completed the measures of preadolescent and adolescent behavior separately. Homeroom teachers were contacted and asked to complete assessments of the target children on the same interview schedule as the parents.

Statistical Analysis General analytic framework. To account for dependencies in the data set due to nesting (e.g., child pairs were nested within their respective families), models were estimated using multilevel regression (MLR). For longitudinal designs, MLR allows for estimation of growth trajectories and identification of key correlates of change, which may be static (e.g., preadolescent vs. adolescent child) or timevarying (e.g., fathers’ frequency of drinking over time, couples’ dyadic adjustment). For the primary analyses, CBCL, PDA, and DAS scores at pretreatment were included

as indicator variables; posttreatment scores (i.e., those derived from assessments conducted at the end of treatment and at 3-, 6-, 9-, and 12-month posttreatment follow-ups) were included as outcome variables. The analyses presented are linear models; these fit the data better than quadratic, cubic, and other polynomial models. The focus of the study was whether possible change in children’s internalizing and externalizing behavior associated with reductions in parental drinking and changes in dyadic functioning would be moderated by developmental stage and children’s baseline functioning. Therefore, using a generalization of the formula from Xu (2003), the amount of variance explained was calculated for each rater for each of the significant hypothesized effects (i.e., Developmental Stage ⫻ PDA and Developmental Stage ⫻ DAS). For each model, Type I error rate was controlled using Bonferroni adjusted alphas. Separate Bonferroni correction factors were used for planned tests and unplanned tests when both types appeared in a given model (e.g., significant interaction effects were hypothesized for the models of children’s adjustment; the unplanned tests of main effects in the models were evaluated using one Bonferroni correction, and the planned tests of the interactions were evaluated using a different correction). Treating planned and unplanned tests differently, in terms of alpha corrections, is advocated by many authors, and use of Bonferroni adjustments for both types of tests is often recommended because of the power and flexibility of the method (Darlington, 1990). Handling missing data. Twenty six couples (20%) had at least one missing observation during the scheduled assessments; of these, 11 couples (8%) dropped out during the follow-up and did not provide data thereafter. In addition, 89 children (34%) had one or more teacher ratings missing. Procedures for data imputation in multilevel models (see Goldstein, 2003) were used to address missing data, which create a single complete data set and account for the uncertainty in true values of the missing data by including a correction factor when fixed and random parameters are estimated.

Results Fathers’ Drinking and Parents’ Relationship Adjustment Paternal PDA and couple DAS scores are located in Table 2. Pairwise comparisons were conducted between

Table 2 Observed Drinking and Relationship Adjustment Outcomes Pretreatment Measure PDA Couples’ DAS

M 38.3 79.3

SD 25.1 17.6

End of treatment M

SD a

92.2 107.3a

19.1 15.9

3 month M

SD a

86.3 101.3

22.4 15.8

6 month M

SD a

82.3 98.3a

24.1 16.1

9 month M

SD a

77.3 94.3a

26.4 22.3

12 month M

SD a

72.6 92.1a

27.4 24.7

Note. PDA ⫽ percentage of days abstinent; Couples’ DAS ⫽ mean Dyadic Adjustment Scale scores of male and female partners. a Indicates significant difference between individual posttreatment scores and pretreatment scores (p ⬍ .01; Bonferroni-corrected alpha of .05/5).

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Table 3 Observed Mothers’, Fathers’, and Teachers’ Internalizing and Externalizing T Scores of Preadolescent and Adolescent Children Rater and developmental stage

Pretreatment M

SD

End of treatment M

SD

3 month M

SD

6 month

9 month

12 month

M

SD

M

SD

M

SD

Internalizing Mother Preadolescent Adolescent Father Preadolescent Adolescent Teacher Preadolescent Adolescent

59.16 64.90

8.99 8.04

49.34 59.11

11.24 9.38

50.34 58.13

9.61 10.26

52.47 59.21

11.34 9.31

55.14 58.36

9.69 10.03

54.61 59.24

10.38 9.69

56.72 60.87

9.93 10.81

49.43 54.63

10.64 8.01

51.62 56.34

11.36 9.31

51.89 56.93

10.61 9.48

52.81 57.56

10.24 10.86

53.84 57.19

9.46 10.12

53.88 58.61

11.24 9.17

49.13 52.64

9.64 10.02

50.21 53.12

10.21 8.99

52.84 54.02

11.20 10.14

52.43 54.12

9.64 10.71

52.86 55.12

10.26 9.49

Externalizing Mother Preadolescent Adolescent Father Preadolescent Adolescent Teacher Preadolescent Adolescent

62.14 64.04

9.38 10.62

53.18 56.21

10.35 11.07

53.46 57.28

11.04 8.95

54.27 58.21

9.69 10.56

55.48 59.94

10.32 10.78

56.27 61.04

10.45 9.38

60.21 63.94

10.44 11.86

52.74 54.99

9.49 11.21

51.61 55.07

10.74 11.56

53.67 58.61

11.78 12.43

54.04 59.00

9.75 10.61

53.71 59.49

10.24 16.61

59.28 62.44

9.96 10.48

52.84 58.49

10.29 9.89

53.03 58.11

9.78 10.24

53.99 59.61

10.68 11.08

54.87 60.22

9.04 10.47

53.81 59.47

10.59 8.89

pretreatment PDA and DAS scores and subsequent scores (i.e., end of treatment and 3-, 6-, 9-, and 12-month followup) to determine whether there were improvements (i.e., for both PDA and DAS, higher scores indicate improvement) in adjustment compared with baseline functioning. In comparison to pretreatment levels, fathers’ PDA and couples’ DAS scores were significantly higher at all subsequent assessment periods. Thus, fathers and parents manifested higher levels of functioning compared with baseline. We also examined changes in functioning over time. Using a standard Wald test and pretreatment PDA as a covariate, the coefficient for the linear effect of time in the multilevel model examining fathers’ PDA (B ⫽ ⫺4.21, SE ⫽ 1.66), was significant (z ⫽ ⫺2.53, p ⬍ .01). For couple DAS scores (with the pretreatment DAS as a covariate), the coefficient for time (B ⫽ 3.30, SE ⫽ 1.54) in the MLR model was also significant (z ⫽ ⫺2.14, p ⬍ .05). Thus, for PDA and DAS, for the fathers and the couples, respectively, there was some erosion of the positive effects of treatment (i.e., reduction in PDA and DAS) during the posttreatment period (i.e., 3-, 6-, 9-, and 12-month followups).

Mothers’ ratings. Analysis of mothers’ reports of children’s posttreatment internalizing and externalizing behaviors (i.e., CBCL Internalizing and Externalizing T scores) yielded the same pattern of results. As hypothesized, we found a significant interaction between stage of development and PDA and stage of development and DAS (i.e., Developmental Stage ⫻ PDA and Developmental Stage ⫻ DAS parameters were significant). In both instances, the significant interaction revealed that the association between CBCL scores and these indicators (i.e., PDA and DAS) was significantly different as a function of stage of child’s development (preadolescent vs. adolescent). For mothers’ Internalizing scores, the Developmental Stage ⫻ PDA pseudo-R2 was .11 and the Developmental Stage ⫻ DAS pseudo-R2 was .13. For mothers’ Externalizing scores, the Developmental Stage ⫻ PDA pseudo-R2 was .08 and the Developmental Stage ⫻ DAS pseudo-R2 was .08. Conversely, the interaction terms between pretreatment score and PDA and pretreatment score and DAS were not significant. The nature of the Developmental Stage ⫻ PDA and Developmental Stage ⫻ DAS interactions predicting the

Children’s Adjustment Parents’ and teachers’ ratings of children’s Internalizing and Externalizing T scores from the CBCL and the TRF, respectively, are located in Table 3. The parameter estimates from the MLR models predicting mothers’ and fathers’ CBCL Internalizing and Externalizing T scores and teachers’ TRF scores appear in Table 4.4

4

The multilevel regression models were also conducted with CBCL raw scores. Because CBCL raw scores do not correct for child gender, we included child gender in the raw score models. The models predicting CBCL raw scores revealed no significant main effect or interactions for child gender and are available on request.

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Table 4 Multilevel Regression Parameter Estimates Predicting Internalizing and Externalizing Subscale Scores Internalizing subscale Rater and effect Mother Constant Time Developmental stage Pretreatment score DAS PDA Developmental Stage ⫻ PDA Pretreatment Score ⫻ PDA Developmental Stage ⫻ DAS Pretreatment Score ⫻ DAS Father Constant Time Developmental stage Pretreatment score DAS PDA Developmental Stage ⫻ PDA Pretreatment Score ⫻ PDA Developmental Stage ⫻ DAS Pretreatment Score ⫻ DAS Teacher Constant Time Developmental stage Pretreatment score DAS PDA Developmental Stage ⫻ PDA Pretreatment Score ⫻ PDA Developmental Stage ⫻ DAS Pretreatment Score ⫻ DAS

Externalizing subscale

Parameter

SE

Parameter

SE

48.67† 0.98† 4.92 0.19 ⫺0.07 ⫺0.12† 0.10* 0.02 0.07* ⫺0.01

8.93 0.32 2.00 0.01 0.04 0.04 0.03 0.07 0.02 0.06

51.67† ⫺1.12† 3.26 0.16† ⫺0.08† ⫺0.11† 0.09* 0.03 0.07* ⫺0.02

9.16 0.38 1.89 0.06 0.03 0.04 0.03 0.05 0.03 0.05

48.66† ⫺0.81 3.30 0.12† ⫺0.05 ⫺0.07 0.08 0.02 0.06 0.01

9.18 0.35 1.28 0.04 0.09 0.04 0.05 0.04 0.04 0.03

50.69† ⫺0.84 3.25† 0.17† ⫺0.96 ⫺0.14 0.11* 0.02 0.03* ⫺0.04

9.69 0.32 1.16 0.05 0.04 0.06 0.04 0.02 0.01 0.02

49.44† ⫺0.49 1.73 0.16 ⫺0.06 ⫺0.07 0.02 0.05 0.01 ⫺0.01

6.18 0.40 0.73 0.06 0.05 0.06 0.03 0.03 0.01 0.04

51.48† ⫺0.97 3.69† 1.11 ⫺0.07† ⫺0.12 0.13* 0.02 0.07* ⫺0.01

7.17 0.48 1.10 0.06 0.02 0.05 0.04 0.02 0.02 0.03

Note. Developmental stage ⫽ preadolescent (scored 0) and adolescent (scored 1); PDA ⫽ percentage of days abstinent; DAS ⫽ Dyadic Adjustment Scale. * p ⬍ .006 (Bonferroni corrected alpha of .05/8, with the correction factor of 8 being the number of a priori planned tests). † p ⬍ .004 (Bonferroni corrected alpha of .05/12, with the correction factor of 12 being the number of unplanned tests of constitutive, plus the constant, terms for the models of Internalizing and Externalizing T scores).

Internalizing and Externalizing T scores interactions are illustrated in Figure 1, suggesting a stronger association between PDA and CBCL scores and DAS and CBCL scores for preadolescents than for adolescents. This is supported by simple effects analyses. For Internalizing T scores, using data from adolescents only, the effects for PDA (B ⫽ ⫺0.05, SE ⫽ .05, ns) and DAS (B ⫽ ⫺0.02, SE ⫽ .03, ns) were not significant; however, using data from the preadolescents, effects for PDA (B ⫽ ⫺0.13, SE ⫽ .06, p ⬍ .05) and DAS (B ⫽ ⫺0.08, SE ⫽ .04, p ⬍ .05) were both significant. Similarly, for Externalizing T scores, using data from adolescents only, the effects for PDA (B ⫽ ⫺0.07, SE ⫽ .04, ns) and DAS (B ⫽ ⫺0.05, SE ⫽ .03, ns) were not significant. For preadolescents, effects for PDA (B ⫽ ⫺0.14, SE ⫽ .06, p ⬍ .01) and DAS (B ⫽ ⫺0.10, SE ⫽ .04, p ⬍ .01) were both significant. Fathers’ and teachers’ ratings. Using posttreatment fathers’ and teachers’ ratings of children’s externalizing behavior (i.e., CBCL Externalizing T scores) as response variables, the same pattern of results emerged as when we

used mothers’ CBCL Externalizing T scores. The Developmental Stage ⫻ PDA and Developmental Stage ⫻ DAS interaction terms were significant and in the same direction as we found when we modeled mothers’ reports of children’s externalizing behavior (i.e., CBCL Externalizing T scores). For fathers’ CBCL Externalizing T scores, the Developmental Stage ⫻ PDA pseudo-R2 was .09 and the Developmental Stage ⫻ DAS pseudo-R2 was .07. For teachers’ Externalizing T scores, the Developmental Stage ⫻ PDA pseudo-R2 was .10 and the Developmental Stage ⫻ DAS pseudo-R2 was .09. In addition, the Pretreatment Score ⫻ PDA and Pretreatment Score ⫻ DAS interaction terms were not significant. Isolating effects of PDA and DAS on Externalizing scores for adolescents versus preadolescents yielded the same pattern of results for both fathers and teachers as we found for mothers. For fathers’ ratings of adolescents’ externalizing behavior, the effects for PDA (B ⫽ ⫺0.06, SE ⫽ .04, ns) and DAS (B ⫽ ⫺0.04, SE ⫽ .03, ns) were not significant; for preadolescents, effects for PDA (B ⫽

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441

Figure 1. Associations between Child Behavior Checklist (CBCL) Internalizing and Externalizing T scores and percentage of days abstinent and couples’ Dyadic Adjustment Scale (DAS) scores for preadolescents (PreAdol) and adolescents (Adol).

⫺0.15, SE ⫽ .07, p ⬍ .01) and DAS (B ⫽ ⫺0.11, SE ⫽ .05, p ⬍ .01) were both significant. For teachers’ ratings of adolescents’ externalizing behavior, the effects for PDA (B ⫽ ⫺0.07, SE ⫽ .04, ns) and DAS (B ⫽ ⫺0.02, SE ⫽ .03, ns) were not significant; for preadolescents, effects for PDA (B ⫽ ⫺0.15, SE ⫽ .06, p ⬍ .01) and DAS (B ⫽ ⫺0.09, SE ⫽ .04, p ⬍ .01) were both significant. For CBCL Internalizing T scores, our primary hypothesis was not supported. More specifically, the Developmental Stage ⫻ PDA and Developmental Stage ⫻ DAS interaction terms were not significant. In addition, the Pretreatment Score ⫻ PDA and the Pretreatment Score ⫻

DAS interaction terms were also not significant in these models.5

Discussion Our primary hypothesis was partially supported. For externalizing behaviors, changes in mothers’, fathers’, and teachers’ ratings were moderated by developmental stage. 5 For the six models, we tested all multiplicative two-way and three-way interaction terms. The only interaction terms that were significant are those so noted in the text and in Table 4.

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Specifically, the effects of parents’ functioning (i.e., for both fathers’ drinking frequency and couples’ dyadic adjustment) on children’s adjustment were stronger for preadolescents than for adolescents, even after controlling for children’s baseline symptom severity. Follow-up analyses indicated changes in parents’ functioning were not significantly associated with adolescents’ adjustment during the posttreatment period; in contrast, these relationships were significant for preadolescent children. Teachers also reported the same pattern with respect to children’s externalizing behavior. This finding suggests that changes in the home environment (in terms of parent drinking or dyadic relationships) were related to the externalizing behavior of preadolescent children in an important out-of-home context (i.e., school). For internalizing behaviors, a stronger relationship between parents’ adjustment and preadolescent versus adolescent children’s functioning was only supported when modeling mothers’ reports. In that case, the pattern of findings was the same as we found for externalizing behaviors across all raters; namely, after controlling for children’s baseline symptom severity, the relationship between parents’ adjustment was stronger for preadolescents than for adolescents. For adolescents, the relationship between parents’ functioning and their adjustment was not significant, but these relationships were significant for preadolescents. Using father and teacher ratings, however, there was no difference in the relationship between parents’ adjustment and internalizing behaviors between adolescent versus preadolescent siblings. It appears that the internalizing and externalizing behaviors of adolescents are more resistant to change, at least from the effects of parents’ functioning, after alcoholism treatment. Among adolescents in our sample, adjustment was not related to paternal drinking behavior or relationship satisfaction. This result is not unexpected, given that, particularly for boys, disruptive and aggressive behaviors are progressively more stable from childhood through adolescence (see Broidy et al., 2003). Although gradually separating from one’s family is normative, adolescents’ problem behaviors are, in large part, maintained by peer group influences, often regardless of parental pressures (see Henggeler et al., 1986). It is important to recognize, however, that preadolescents are not passive recipients of the changes that occur in the family context. Rather, it appears that they are at a point developmentally where their behavior is more influenced by the familial environment than by their adolescent counterparts. Several reasons may account for discrepancies between mothers’ ratings of internalizing behaviors versus fathers’ and teachers’ ratings. Both boys and girls are more emotionally dependent on their mothers than their fathers (see Geuzaine, Debry, & Liesens, 2000). This difference may provide more opportunities for mothers to be aware of their children’s changing emotions. In addition, compared with their peers, adolescents with alcohol-dependent fathers report their relationships to their fathers as being less secure (Cavell, Jones, Runyan, Constantin-Page, & Velasquez, 1993). Children in these homes may be less trusting of and

less likely to discuss their emotions with their fathers. Also, alcoholism may render the substance-abusing parent less aware of children’s less-apparent behavior. The discrepancy between findings with respect to mothers’ reports and teachers’ reports also mirrors previous studies (e.g., Glaser, Kronsnoble, & Forkner, 1997). The difference between mothers’ and teachers’ observations of children’s internalizing behavior is not surprising given differences between behaviors that are observable (i.e., externalizing) versus those that are directed toward one’s self (i.e., internalizing). Our competing hypothesis—that any associations between changes in children’s internalizing and externalizing behavior and reductions in drinking and changes in couples’ dyadic relationships would be moderated by the severity of children’s symptoms at pretreatment—was not supported. Specifically, the two-way Pretreatment ⫻ PDA and Pretreatment ⫻ DAS interaction terms were not significant in any of the models. Moreover, controlling for baseline severity of children’s symptoms did not attenuate the relationship between developmental stage and changes in parent and couple functioning. These results suggest that although the child’s behavioral symptoms at pretreatment may be associated with changes in children’s behavior, regardless of the severity of the child’s symptoms at pretreatment, associations between reductions in drinking and couples’ relationship satisfaction and children’s internalizing and externalizing behavior appear stronger for preadolescents than for adolescents. Our findings have important implications for treatment providers. Interventions designed to reduce paternal drinking and improve couple functioning may be viable preventative interventions for preadolescents in these homes and a way to benefit children without identifying or treating children directly. This is important because many parents entering substance abuse treatment are reluctant to allow their children to participate in treatment (Fals-Stewart, Kelley, et al., 2004). In contrast to younger children, even in families of remitted fathers adolescents who exhibit behavioral difficulties may need direct intervention to address problem behaviors. There are some limitations of the present investigation that should be highlighted. These findings may not generalize to families in which the female partner or both parents abuse alcohol. Also, families were recruited from outpatient treatment for alcoholism and may not reflect those who choose other forms of treatment (e.g., inpatient care). In addition, we did not examine whether continued participation of fathers in self-help groups such as Alcoholics Anonymous or other forms of treatment influenced child and family outcomes. Clearly, disentangling the benefits of family-based treatment from participation in other types of aftercare or treatment is important. In addition, future research should examine symptom counts or diagnoses as well as PDA as a method of determining alcohol severity. Although sampling families with adolescent and preadolescent children provided some level of control over familylevel variables, children are often treated differently even within the same home (e.g., Jacob, 1974). Also, because

COUPLES THERAPY FOR ALCOHOLISM

limited information was available on parents’ psychopathology, the effect of this factor was not examined. We also focused on the flow from parent to child; however, poor behavior on the part of children contributes to negative parental behavior (e.g., Arnold & O’Leary, 1995). We examined the effects of one type of treatment, LST, which is not widely used in community-based treatment programs (e.g., Fals-Stewart, Logsdon, & Birchler, 2004). Moreover, although providers followed a detailed treatment manual, treatment fidelity measures were not collected. Future research should address whether other treatments (e.g., individual treatment for alcoholism) show a similar pattern of findings. Also, children should complete information on internalizing symptoms themselves. Last, the present findings beg the question “Is there a dose–response relationship between amount of LST therapy received and improvements in children?” At present, what constitutes a therapeutic dose of LST is not known—that is, the amount of individual and conjoint sessions needed for participants to reach a “good-enough level” (Barkham et al., 2006). Once future studies determine what constitutes a therapeutic dose of LST, an important next step would be to explore the relationship between children’s adjustment and whether parents received a therapeutic dose. Nevertheless, the present study used a longitudinal design and multiple raters (i.e., mothers, fathers, and teachers). By comparing preadolescents and adolescents within these homes, we controlled for effects of treatment on parent and family functioning (e.g., declines in drug use, changes in dyadic functioning) and family characteristics (e.g., parent age, income) that may affect children’s outcomes. Given the prevalence of alcohol abuse in the United States, its serious and often long-term impact on children, and the barriers to treatment for many of these children, research on the secondary impact of substance abuse treatment is necessary. Compared with adolescent children, the internalizing and externalizing behavior of preadolescent children in these homes appears responsive to parents’ changes in drinking and dyadic functioning, which may improve in response to effective treatment.

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Received February 13, 2006 Revision received June 19, 2006 Accepted August 4, 2006

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