Journal of Studies on Alcohol, Vol. 51, No. 1, 1990

Alcohol Abuse and Its Psychosocial Correlates in Sons

of Alcoholicsas Young Men and in the GeneralPopulation of Young Men in Prague LUD•K KUBI(•KA,JI•I KO•EN•' •o

ZDEN•K ROTH*

PsychiatricResearchInstitute, 181 03 Praha 8, Czechoslovakia

ABSTRACT. A sampleof 107 sonsof alcoholicsaged22-33 is comparedto a representative sampleof 1,274Praguemenof the sameagerangewithrespectto alcoholabuseandits psychosocial

comparedsamples,father's low education,discontinuedfamily socialization and undisciplined behavior in childhood were antecedents of abuseregisteredat or beforeage22. Self-reported

antecedentsand correlates. Data sourceswere cumulative records of alcohol abuse in health care files and interviews. The estimated relative risk of alcohol abuse for sonsof alcoholics versusother men

abusein the 6 monthsbeforeinterviewhad similarpsychosocial correlatesin both samples(heavilydrinking friends,a positiveattitude to heavydrinking,etc.). In both samplesabout40ø70 beganto drink regularlyat 17 or earlier.However,earlystartof drinkingled very frequentlyto early registeredabusein sonsof alcoholicswhereas no suchcontingencywasobservedin the generalmale population. (J. Stud. Alcohol 51: 49-58, 1990)

isabout3.5 with bothregistrationandself-reportcriteriaif a broad definitionof abuseisadopted.If, however,seriousregisteredabuse and/or medicaltreatmentof alcoholismat or before age 22 is the criterion of abuse,the estimatedrelative risk is about 10. In both

HISARTICLE attempts, first,toevaluate therisk of alcohol abuse in sons of alcoholics aged 22-33

yearson the basisof comparabledata derivedfrom the generalmale populationof the sameage. The second objectiveis to comparesonsof alcoholicsto the generalmale populationwith respectto psychosocial

ble to use as data sourcethe complete documentation on alcohol abuse in the files of the city's health care

antecedentsand correlatesof alcohol abuse. All included

men were residents of Prague, a city of over one million

population,data werecollectedon a representative sample of over 1,000 young men. At the same time an opportunity emergedto collect analogousdata on a smaller sampleof young men whose father or mother were registeredas alcoholicsby the health care system in Prague.For both samplesof youngmen it waspossi-

system(no privatehealthcareexistsin Czechoslovakia).

inhabitants.

As both health care files and interviews were data

By its design this study belongsto the category of studies of populations at high risk for alcoholism, recentlyreviewedby Schuckit(1985). Resultsof the first wave of a longitudinal investigationare presented.As the inherent assetsand liabilities of this type of study were analyzedby Schuckit,they will not be enumerated here. The most apparent weaknessof our study is, of course,its inability to separatethe geneticand environmental factorsof alcoholabuse.Why, then, add another studyto the existingoneswhen methodologically much strongerinvestigationsof the role of the geneticfactor in alcoholismhave beenpublished,especiallythe studies on adopteesby Goodwin et al. (1973), Cloninger et

sourcesit was possibleto compare results obtained using two very different operational definitions of alcohol abuse, one relying on health care records,the other on self-reports.In addition, broad and narrow definitionsof abusewere possible.It was expectedthat by comparingresultsobtainedusing different definitions of abuse the influence of the definition of abuse on the estimate of relative risk for sons of alcoholics could be made more clear. Another reason for con-

ducting the study was the question of whether psychosocial variablesare relatedto alcoholabusedifferentlyin sonsof alcoholicsas comparedto general population. It was hoped that answersto this question might throw some light on the role of psychosocial factors in the genesisof alcohol abusein sons

al. (1981) and Cadoret et al. (1985)? This study is presented for the following reasons: In a larger epidemiologicalstudy of alcohol use in the Prague

of alcoholics. The current discussion of the environmen-

tal versusgeneticfactorsin alcoholism(Fillmore, 1988; Peele, 1986) seemsto indicatethe need for additional empirical information.

*Dr. Roth is with the Instituteof Hygieneand Epidemiology,Prague, Czechoslovakia.

49

50

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A recurrent theme in the literature on alcoholism is the association between alcohol abuse and antisocial

behavior,' well documented in several studies (e.g., Cadoret et al., 1985, 1987; Virkkunen, 1979). An association was also found between antisocial personality diagnosis and early onset of all stagesof alcohol dependencein a sampleof alcoholicinpatients(Stabenau, 1984). Schuckit(1984) observedearlier and more severe alcohol-relatedand antisocialproblemsamong primary alcoholicswith any alcoholic parent than among those without an alcoholicparent. Conduct disordersand impulsivity during childhood and adolescence have repeatedly been identified in longitudinal studies as predictors of adult alcohol abuse (McCord and McCord, 1962; Robins et al., 1962; Vaillant, 1983). However, separate etiologic factors (both genetic and environmental)of alcohol abuseand antisocialpersonality have been claimed as the resultsof severalstudies (e.g., Vaillant, 1983; Cadoret et al., 1985, 1987). Considering this allegedly distinct etiology of the two disorders, how should their indubitable association be

explained?Schuckit (1973) enumeratesthree etiologic possibilities:First, sociopathsabuse alcohol as but one symptom of their antisocial personality; second, alcoholics manifest sociopathic symptoms as a consequence of primary alcohol dependence; and third, a common

factor

leads to both

alcoholism

and socio-

pathy. On the basis of his 33-year follow-up study of 456 men, Valllant (1983) concludedthat Schuckit'sfirst two possibilitiesare right but that the third one probably is not. He observes that "once one disorder developedthe other often followed" (p. 317), the two disorders having, however, different premorbid etiologies. He also concludesthat most alcoholics are not premorbidlyantisocial.Cloninger's(1987a) explanation is •ased on his distinction of two types of alcoholism. The more frequent Type 1 is characterized by late onset of alcoholism (after 25) and minimal criminality of the abuserand his biologicalparents.The less frequent Type 2 (having a predominantly genetic etiology) is characterizedby early onset of abuse in both the abuser and his father and by criminality of both son and father. Cloninger theorizes that the two types of alcoholism are based on opposite positionson his three postulated(geneticallydetermined)dimensions of personality (Cloninger, 1987a, 1987b). It follows from Cloninger's theory that Type 2 alone is responsible for the association between alcohol abuse and anti-

socialbehavior. As Cloninger postulatesthe samebasic personality structure for Type 2 alcoholism and sociopathy, it is not clear whether he makes any distinction between

the two

disorders.

An attempt will be made in our article to bring additional empirical information to the above mentioned researchtheme by an evaluation of the significanceof•

ALCOHOL/JANUARY

1990

conductdisordersduring childhood and adolescencefor adult alcohol abuse in sons of alcholics as compared to the general male population. Method

Subjects The names of 107 sons of alcoholics were taken from

the files of the Prague city's Center for Youth at Risk for Alcoholism.

This center was established in 1967 to

offer preventivecare for children of parentstreated or registeredfor alcohol-related problems. All names of men born 1950-1961 residing in Prague in 1983, with a biologicalparent treated or registeredfor alcoholism, were selected from the Center's files. For any single family only one son was included on a random basis. The age distribution of the sample differs markedly from the age distribution of the Prague male population of the respectiveage range, older subjectsbeing underrepresented.This is becausethe Center gradually expanded its activities. Due attention to the different age distribution in the compared samplesis given in data analysis. In 97 cases, the father was treated or registered for alcoholism; in 8 cases,the mother; and in 2 casesboth biological parents had seriousalcoholrelated problems. In the majority of casesthe parent was treated for alcoholismas an inpatient. On the basis of available

documentation

it is estimated that in at

least 90ø7oof the sample either father or mother would meet the DSM-III (American Psychiatric Association, 1980) or ICD-9 (World Health Organization, 1977) criteria for the diagnosis of alcohol dependence. The sample of 1,274 men, 22-33 years old, representative of the general population of this age in Prague, was constructedas a two-stageprobability samplebased on electoral

lists.

Evidence of alcohol abuse in health care files All information

available in health care files concern-

ing alcohol abuse was collected for the sample of sons of alcoholics (SA sample) as well as for the general population sample (GP sample). It is necessaryto explain at this juncture that all medical care in the country has been provided by the state for almost 40 years. Documentation concerning alcohol abuse is centrally filed in outpatient centers for persons with problems related to alcohol and drugs. The files of all 13 Prague centers were searchedwith regard to every subject in the study. In addition, a search was conducted in the files of the Prague detoxication station (established 1951) and in the files of the city's two inpatient wards for alcoholics. It should, of course, be clear that many casesof alcohol abuse exist that are not registeredby the health care system.

KUBI(2KA, KOZEN• AND ROTH Interview data and paper-and-pencil questionnaire

A structuredinterview schedulewas developedas a part of the larger epidemiologicalstudy of alcohol use. The interview consistsof about 100 standard questions, some of them with precodedanswers,someopen-ended. In additionto a detailedexaminationof the respondent's use of alcoholic beverages,questionsare included concerning interviewees' developmental, demographic, social and psychologicalcharacteristicshypothetically related to alcohol use. Each interviewed

man was also

askedto fill in a paper-and-pencilquestionnairedesigned by the senior author for the assessmentof attitudes toward alcohol use. (The particular variablesconsidered in this article are listed in Tables 5 and 6.) A team of 29 trained

interviewers

visited the inter-

vieweesin their homes (or occasionallyat workplace). The responserate was 72% for the SA sample and 85% for the GP sample. Usable interview data were obtained on 77 sons of alcoholics and on 1,075 randomly selectedPrague men. The interviews were made during the winter months of 1983-84 using a double-blind procedure. Results

Alcohol abuse registered by the health care system As statedearlier, the age distributionof the SA sample differs markedly from the age distribution of the GP sample. (The age range of 22-33 years is identical in both samples.) Therefore, comparative results on

alcoholabuse,shownin Table1, are givenin three separate age categories. In view of the small N (11) in the oldest SA subsample, the percentagesfound in the respectivecolumn are of minimal informative value. It should be realized in interpreting Table 1 that cumulative life-long registration of alcohol abuse is considered. If, for example, a 30-year-old man was once treated at the Prague detoxication station when he was 18 he still belonged in the "any registration for alcohol abuse" category.

TABrE 1. Percentagesof men registeredfor alcohol abuse by the Praguehealthcare systemin the sonsof alcoholicssample(SA) and in the generalmale population of Prague sample(GP) Age 22-25 SA

GP

Age 26-29 SA

GP

Age 30-33 SA

GP

Any registration for alcohol abuse

18.3

medical treatment treatment

6.9

38.9

9.7

36.4

12.7

ated are classified

as "medical

treatment

of alcohol

dependence."The diagnosisof alcohol dependence(303 of ICD-9) or alcoholism (303 of ICD-8) was nearly always stated by the physicianin chargebefore medical treatment was initiated. However, the health care files do not always include enough details to consider the justification of the diagnosis. The category name "medical treatmentof alcoholdependence"is usedhere to imply that the included caseswere regardedby the health care personnel as very serious and in need of

disulfiram treatment in addition to psychological methods. By using the term alcohol dependencewe do not intend to take any theoretical position. Inasmuch as the small Ns in the SA subsamplesof Table 1 allow such comparisons, it seemsthat for the youngest age group of alcoholics' sons the risk of alcohol abuse(comparativeto general male population) increases with narrowing definition of abuse. The relative risk of the most serious form of abuse leading to medical treatment seems to be highest for the youngest age group of alcoholics' sons. Table 2 givesestimatedpercentages of registeredmen among sonsof alcoholicsand in the generalmale population for the whole age range of 22 to 33 years. Again, increasinglynarrow definition of registeredabuse is employed. The figures in Table 2 are based on sample data adjusted with respect to the samples' deviations from the population age distribution(taken from census results). These adjustments were especiallyimportant with regard to the data derived from the SA sample where the age distribution markedly differed from the

TABLE2. Estimated percentagesof 22 to 33-year-old men registered for alcohol abuseamong sonsof alcoholicsand in the general male populationof Prague(basedon sampledata adjustedto censusage distribution) Sons of

General

male

Relative

alcoholics population riska +_SE Any registration for alcohol

abuse

medical Medical

13.3

2.5

22.5

5.9

13.3 60

0.4 276

16.7 36

3.3 390

18.2

6.4

9.1 11

2.6 608

of

alcohol dependence N in subsample

In Tables 1 to 3 the "any registration for alcohol abuse" category also includescasesof "serious abuse" and casesof "medical treatmentof alcohol dependence." Seriousabuseis defined as repeated stays at the detoxication station or reports of frequent intoxications by relatives (or self-reports of the same) to the health center. All cases in which outpatient or inpatient medical treatment of alcohol-relatedproblemswas initi-

32.8

10.2

3.6 +_ 0.5

18.4

5.3

4.0 _+ 0.8

12.7 107

2.3 1,274

7.2 _+ 1.0

Serious abuse and/or

Serious abuse and/or Medical

51

treatment

treatment

of

alcohol dependence Sample size

aFor sons of alcoholics relative to sons of nonalcoholics, see the

appendix.

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JOURNAL OF STUDIES ON ALCOHOL/JANUARY

population age distribution. Table 2 also includes estimated relative risks of variously defined alcohol abuse for sons of alcoholics compared to sons of nonalcoholics. As there were undoubtedly some sons of alcoholics in the general population sample, the relative risks were computed using a formula that assumed that there were 5ø7o of sons of alcoholics

in

the Prague population of 22 to 33-year old men. This rather conservative assumption is based on some available data. (See the appendix for computation formulas.) In Table 2 the increase of relative risk with narrow-

ing definition of abuse is clearly observed. The estimated relative risk is about 7 with regard to the most serious form of abuse leading to medical treatment.

The health care files contain cumulative

information

on life-long alcohol abuse. It was therefore possible to compare the SA sample to the GP sample with respect to registered adolescent and early adult abuse. Table 3 summarizesdata on registration for alcohol abuse at or before age 22 (the age of the youngest membersof both samplesat the time of data collection). As there were no differences in early abuse with regard to year of birth (i.e., no cohort effects) the samples are directly comparable despite their differing age distributions in 1983. The relative risk of registered abuse at or before age 22 was computed by the formula given in the appendix. One observesin Table 3 a sharp increase of estimated relative risk for sons of alcoholics as one moves from the broad to the narrow

definition of early alcohol abuse. With regard to the medically treated alcohol dependenceat or before age 22, the estimatedrelativerisk attainsthe very high value of about 17. This figure should, however, be viewed with considerable

caution

as its standard

error is also

quite high. (The 5ø7oconfidential interval lies between 3.8 and 30.8.) The objection may be made that relative risk is not

an adequatemeasureof the strengthof the relationship between parental alcoholism and son's alcohol abuse. For pure mathematicalreasonsthe value of the estimated relative risk should increase with narrowing definition of abuse. Two measures of association--not

sensitive to changes in marginal distributions--were therefore applied to data summarizedin Tables 2 and 3, namely Yule's Q and the odds ratio. For Table 2 the three Q valuesexpressing the strengthof association between parental alcoholismand son's alcohol abuse are .62, .60 and .72, the oddsratios being 4.3, 4.0 and 6.2, respectively,if one proceedsfrom the broad to the narrow definition of abuse. For Table 3 the Q values are .57, .77 and .82 and the odds ratios are 3.7, 7.8 and 10.1. With one exception it may be again observedthat the strengthof associationincreaseswith

1990

TABLE3. Percentageof men registeredfor alcohol abuseat or before age 22 in the sons of alcoholics sample and in the general male population of Prague sample Sons of

General

male

alcoholics population

Relative

riska+ SE

Any registration for alcohol

abuse

15.9

4.9

3.6 + 0.7

9.3

1.3

11.3 + 2.9

7.5 107

0.8 1,274

17.3+ 6.7

Serious abuse and/or medical Medical

treatment

treatment

of

alcohol dependence Sample size

aFor sons of alcoholics relative to sons of nonalcoholics, see the appendix.

narrowing definition of abuseand that the association is generally stronger for early registeredabuse. The two compared samplesalso differed in attained educational level, there being a lower percent of better educated men in the SA sample. Data on education were, of course,only availablefor thosewho cooperated at the interviews. There were 30ø7omen with completed secondary(or higher) education in the SA sample as distinct from 53ø7oin the GP sample. The practice of some authors to compare sons of alcoholics to other men matched with respectto educational level was not regardedas sound by the presentauthors. The objection is that a failure to attain higher education by sons of alcoholicsmight sometimesbe one of the sequelae of adolescentand early adult alcohol abuse. It seems to us that a better justified procedurefrom a methodological point of view would be to take parents' education into

account.

The distribution

of father's

and

mother's educational level in the SA and GP samples

were therefore compared insofar as the necessaryinformation

was available from interviews. Four educa-

tional levels were distinguished. The distribution of father's educational level is somewhat less advantageous

in the SA sample. The difference falls, however, short of statistical significanceas revealed by a X: value of 7.25 (.05 < p < .10 for 3 df). As for mother's education, the differenceis far from beingstatisticallysignificant (X: = 2.71, df = 3). On the basisof theseresults the conclusionwas made that differences in parents' educational level might have only a negligible effect on the observed differences in alcohol abuse between

the two compared samples of young men.

Self-reported alcohol abuse

Resultspresentedin this sectionare basedexclusively on interview data. Complete data concerningalcohol abuse were obtained from 77 sons of alcoholics and

from 1,074 membersof the generalpopulationsample. Whereasin the caseof registeredalcoholabusecumulative life-long evidence was considered, the findings

KUBI(•KA, KO:ZEN• AND ROTH TABLE4. Percentagedistribution of self-reportedfrequencyof consuming six or more drinksat a session (90 g ethanolor more) in the sampleof 22 to 33-year-old sonsof alcoholics (N = 77) and in the sampleof the generalpopulationof Praguemen aged22-33 (N = 1,074)

53

comparedto sonsof nonalcoholics,computedby the formula in the appendix,equals3.5 + 0.51. If we compare the percentages of men who said that they abstained in the past 6 months becauseof previous alcohol-related problems we arrive at 6.5% and 0.1%

male

in the SA and GP samples,respectively. Again, with

alcoholics a

population

narrowing definition of abuse the relative risk for sons of alcoholics markedly rises.

9.1

1.1

26.0

33.0

24.7 16.9

35.1 21.3

Sons of

Abstained from alcohol in the last 6 months Never had six drinks in the last

6 months

Six or more drinks occasionally Six or more drinks 1-2 times monthly

General

Psychosocial characteristics associated with registered

Six or more drinks once a week or

more often

23.4

9.5

ax: = 44.97, 4 df, p < .001, for sonsof alcoholicscomparedto general population sample.

concerningself-reportedalcohol abuse are limited to the last 6 months of each interviewee's life. Answers

to three interview questionsare analyzedhere. The main informationis basedon answersto the question asking for the frequencyof sessionswith six or more drinks consumed. It must be added that a Czech drink

(whichis mostfrequentlyhalf a liter of beer)contains approximately15 gramsof ethanol.(Beeris servedin glasses containing half a liter, distilledspiritsin glasses containing0.05 L. One liter of wine is equal to six drinks.)If in reply to a precedingquestiona man said that he had not beendrinkingin the last 6 months, he was asked to give his reasonsfor abstinence. Table 4 distinguishedfive categoriesof answersto the above question. As the distribution has no relation

to age in any of the two samples,the differentage distributionin the SA and GP samples is disregarded in comparative resultsconcerning self-reported abuse. Thereis a statistically highlysignificant differencebetween' the SA and GP sampleswith regardto the distribution acrosscategoriesof Table 4. If men who admitted consuming six or more drinks at least once a week are

labeledasabusers, oneobserves thatalmostone-quarter of alcoholics'sonsare abuserswhereasonly one-tenth of the generalmalepopulationfallsinto thiscategory. The other categoryshowinga major differenceis ab-

stainers.There are 9% abstainersamong sons of alcoholics ascompared to 1% abstainers in the general populationsample.Of the sevenabstaining menin the SA samplefive admitted that previousalcohol abuse led them to abstainwhereasonly oneof the twelveabstainersin the GP campie gave that reason for ab-

abuse

The following self-reported characteristicsof the in-

terviewedmen were given attentionin the analyses: father'slow educational level(withoutcompleted secondary education),discontinuityin family socialization (not broughtup by both own parents),undisciplined behavior in childhood (as reflected in poor school marksfor conduct),earlystart of regulardrinking(at leastoncea weeksince17 yearsor earlier),adolescent delinquency(leadingto policeor court interventions) and subject'slow educationallevel(withoutcompleted secondary education).The first four characteristics may be conceivedas possibleantecedentsof alcohol abuse whereasthe last two have an equivocalstatusbecause

adolescent delinquency and low educationallevelmay be held as possibleantecedents as well as sequelaeof adolescentand early adult alcohol abuse. As for the

alcohol abuse variable, any registrationfor alcohol abuse at or before age 22 was considered.Two 2 x 2 (Characteristicx Abuse) contingencytables were analyzedwith respectto each characteristic,one based on SA sampledata, the other on GP sampledata. The strengthand statisticalsignificanceof the respective associations were evaluatedseparatelyfor SA and GP data. In addition, a composite2 x 2 x 2 (Characteristic x Abuse x Population)table was analyzedwith respect to each characteristic to test the statistical

significanceof a possiblethird-order interaction. The

log-linear model was applied to this purpose. A statisticallysignificantthird-order effect means that the associationbetweena given characteristicand abuseis not the samein sonsof alcoholicsas in the general male population. The resultsof the abovementionedanalysesare summarizedin Table 5. Two statisticallysignificantthirdorder interactions are observed. The first concerns father's low educational level which is associated with

early registeredalcohol abusein both sonsof alcoholics

and generalmale population,the associationbeing

staining.If onecombines intoa singlecategory previous

significantlystrongerin the caseof sonsof alcoholics.

and present self-reportedabuse, there are 30% self-

The otherthird-orderinteractionrelatesto earlybeginning of regulardrinking.Among sonsof alcoholicsthe early startersare much more frequentlyregisteredas abusersat or before age 22 than the late starters,the

reportedalcoholabusersin the SA samplecompared to 10% abusersin the GP sample.The estimatedrelative risk (+ SE) of alcoholabusefor sonsof alcoholics

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TtmLE 5. Psychosocialcharacteristics associatedwith alcohol abuseregisteredat or before age 22 in sons of alcoholics(N = 77) and in the general male population of Prague (N = 1,075)

Sons of alcoholics Father's

low education

Discontinued family socialization Undisciplined as child Regular drinker since age 17 Adolescent delinquency Low educational

level

General population

Yule'sQ

pa

Yule'sQ

1.00

.004

.46

t•

Third-order interaction

pC

.004

.030 Ns

.77

.035

.49

< .001

.67

.021

.61

< .001

Ns

.77

.006

.13

Ns

.023

.75

.011

.68

< .001

Ns

1.00

.014

.76

< .001

Ns

aFisher'sexact one-sidedprobability.

bTwo-sided x: with Yates'correction. cSignificanceof the Characteristic x Abuse x Sample interaction in the log-linear analysis.

respectivefiguresbeing 27.3% and 4.6%. No such contingency is observedin the GP sample, the percentage of early registered abusersbeing 5.4% in the case of early startersand 4.2% among late starters. It should be added that the percentageof subjectswho began to drink regularly since 17 or earlier is about the same in the two compared samples (42.9% in the SA sample and 40.0% in the GP sample). The remaining four characteristicslisted in Table 5 (i.e., discontinued family socialization, undisciplined behavioras child, adolescentdelinquency,and subject's low educationallevel are about equally strongly associated with early registered alcohol abuse in both samples. The association is strongest with regard to young men's educational level; early registration for alcohol abusebeing limited to men with low educational level in the SA sampleand almost so in the GP sample. Let it be added that of the first four dichotomous

characteristics listedin Table 5--which may be regarded as possible antecedentsof early alcohol abuse--only father's low educational level is more frequent in the SA sample (62.7%) than in the GP sample (47.9%). This small difference doesnot explain the large difference in the percentageof registeredabusersin the SA and GP samples: In the log-linear analysis of the respective2 x 2 x 2 table, the partial associationbetween registeredalcohol abuseand sampletype is highly significant statistically(p = .002) with the effect of father's educationallevelbeing controlled.As for young men's own education, 70.1% of the SA sample and 47.1% of the GP samplewere without completed secondary education.This differencein educationis highly significantstatistically(p < .001) but even so doesnot fully explain the large difference in the proportion of early registeredabusersamong SA and GP men: The partial associationbetweenabuseand sampletype (subjects' educationallevelbeingcontrolled)is still statistically significant (p = .019). Among the less educated sons of alcoholics 20.4ø7owere early registered abusersbut only 8.5ø7oGP sample members with low education

were registered.No SA samplemember with completed secondary education and only 1.3070GP sample men with completed secondary education were early registered abusers. As already mentioned, low educational level may be both causeand consequence of early alcohol

abuse.

It is observed that childhood conduct disorders, as reflected in bad school marks for conduct, are substantially correlated with early registered alcohol abuse in

both sons of alcoholics and general population men. (The respectivevalues of Yule's Q are .67 and .61.) Only a slightly larger percentage of the SA sample reported bad school marks for conduct, the respective figuresbeing 40.3O7o (SA) and 33.4O7o (GP). This small and statistically nonsignificant difference contributes next to nothing to the explanation of the large differencein early registeredabusebetweenthe two samples, the partial associationbetweenparental alcoholismand son's abuse being highly significant statistically (p = .0035) with the effect of childhood conductdisorders controlled.

Self-reported delinquencyin adolescence(before age 19) is even more strongly associatedwith early registered alcohol abusein both samples,the Qs being .75 (SA) and .68 (GP). An almost equal percentageof the SA and the GP sample members reported juvenile delinquency, 15.9070and 16.6%, respectively, which means that the much higher percentageof early registered alcohol abusersamong sons of alcoholicscannot be explained by a greater percentageof early antisocial individuals in the SA sample. It follows that with the effect of juvenile delinquency controlled, the partial associationbetweenearly registeredabuseand parental alcoholismis highly significantstatistically(p -- .0012). The associationsof psychosocialcharacteristicswith a narrowly defined early registeredabuse(i.e., serious abuse or medical treatment at or before age 22) are of about the same strength as the associationsfound with regard to any early registration. This result was obtained for both studied samples.

KUBI(•KA, KO•EN• AND ROTH

55

TAa•.E 6. Psychosocialcharacteristicsassociatedwith self-reported alcohol abuse in sons of alcoholics sample (N = 77) and in the general male population of Prague sample (N = 1,074) Sons of alcoholics

Yule'sQ Discontinued family socialization Undisciplined as child Regular drinker since age 17 Adolescent delinquency Low

educational

Third-order interaction

Yule'sQ

pO

.44

•s

.27

.046

- .03

•s

.41

< .001

.082

.51

.084

.37

< .001

•s

.62

.026

.44

< .001

•s

•s

.43

< .001

•s

- .02

level

General population

pa

pc •s

Single or divorced Heavily drinking friends Member of a stable group of drinkers

.43

.058

.25

< .017

•s

.93

< .001

.76

< .001

•s

.88

< .001

.64

< .001

•s

Positive

attitude

.84

< .001

.52

< .001

.087

Tolerant

norm of how much is too much

.66

.006

.59

< .001

•s

to intoxication

aFisher's exact one-sided probability.

t'Two-sided X2 with Yates'correction. CSignificanceof the Characteristic x Abuse x Sample interaction in the log-linear analysis.

Characteristics associated with self-reported abuse Psychosocialcharacteristicsshowing statistically significant associationswith self-reported alcohol abuse are summarized

in Table

6. Those men who admitted

to having consumedsix or more drinks (90 g of ethanol or more) at least once weekly in the last 6 months were classifiedas self-reported alcohol abusers.With regard to the first six characteristicsthe abstaining former abuserswere classifiedas abusers,but in analysesconcerning the last four characteristicsall abstainers were excluded.

Discontinuedfamily socialization,undisciplinedchildhood behavior, early start of regular drinking and adolescent delinquency must have preceded adult alcohol abuseand may therefore be regardedas possible antecedentsof adult abuse. The remaining six variables listed in Table 6 are best regarded as psychosocialcorrelates

of adult

abuse. One observesthat young men's own education showsno relationto self-reportedabusein the SA sample and a weak one in the GP sample, the third-order interaction being not significant. It is worth noting that childhood conduct disorders are unrelated to self-reported adult alcohol abuse in the SA sample and only slightly correlated with selfreported abusein the GP sample, the Qs being -.03 (SA) and .41 (GP). The associationsbetween selfreported adolescentdelinquencyand self-reported adult abuse are more marked; the Qs are .62 (SA) and .44 (GP). The partial association between parental alcoholism and son's self-reported abuse remains statistically highly significant with the effects of conduct disordersduring childhood and juvenile delinquency controlled (p < .0001).

abuse.

There is no statisticallysignificantthird-order interaction,listed in Table 6 (two results are marginal). This meansthat the psychosocialantecedentsand correlates of self-reportedadult alcohol abuseare essentiallyidentical and of about the same strength in young sons of alcoholicsas in the generalyoung male population. This is (with two exceptions)reflected in the quite similar values of Yule's Q for the SA and GP samples. One should not be misled by comparing the p values in columns 2 and 4 of Table 6 as an association of the same

strength leads to a much smaller p value in the much larger GP sample. The last four characteristicsgiven attention in Table 6 are rather strongly associatedwith self-reported alcohol abuse in both SA and GP men. In both sampleshaving heavily drinking friends is the characteristicshowing the strongest association with self-reported abuse. Note that father's educational level is missing in Table 6 because it has no relation to self-reported

Discussion

With regard to the first objective of our study--the evaluation

of relative risk of alcohol abuse in sons of

alcoholics as young men--our findings clearly indicate that the value of relative risk depends on the definition of abuse. With a narrow definition of registered

abuse(medicallytreatedcases)the associationbetween parental alcoholism and son's abuse is much stronger than with a broad definition (any registration of alcohol-related problems). A similar though less convincing finding is obtained with self-reported abuse. The resultsalso show that early registered(at or before age 22) seriousabuseis more stronglyrelatedto parental alcoholism than serious abuse registered in later years of life. The findingssummarizedin the above paragraphwill most likely be interpretedas supportiveof the hypothesis of a genetic predispositionto alcohol abuse in many

56

JOURNAL OF STUDIES ON ALCOHOL/JANUARY

sons of alcoholics by those who are in favor of such a hypothesis. It may be remembered that in the well

known study of Goodwin et al. (1973), adopted-away sonsof alcoholicswere more likely to be alcoholic only if a narrow def'mitionof alcoholismin sonswas adopted. Cloninger's (1987a) distinction of two types of alcoholism should also be mentioned in connection with

our findings. Early onset (Type 2) alcoholismis especially strongly based on a geneticbackground of Type 2, according to Cloninger. Although in our study we did not differentiatebetweenforms of parental alcoholism, our findings seem to be in line with Cloninger's reasoning: Our casesof young men medically treated for alcoholism at the age of 22 or earlier would be classifiedas Type 2 by Cloninger. Our finding that this early onset alcoholismis especiallystrongly related to parental alcoholismmay be regarded as supportiveof Cloninger'stypology if we supposethat our early onset casesamongsonsof alcoholismhad a parentwith Type 2 alcoholism. This suppositioncannot, however, be verified.

The second objective of our study was to analyze how alcohol abuse is related to psychosocialvariables in sonsof alcoholics--comparativeto analogousresults concerningthe general male population. The overall result is quite clear: In sonsof alcoholics,abuseis related to psychosocialvariables in essentiallythe same way as in the general young male population. Any interpretationof this generalresult should considerthe rather heterogenousnature of our set of psychosocial variables. Childhood conduct disorders, for example, have probably both geneticand environmentaletiology. The majority of the consideredpsychosocialvariables may, however, be designatedas environmental(social). Consequently,the finding of equally strongcorrelations of

social

variables

with

alcohol

abuse

in

sons of

alcoholicsand the general male population is strongly supportiveof the role of social factors in the genesis of alcohol abuse, whether a genetic predispositionto abuse is present or not. Of the two exceptionsto the just mentioned overall result, one concerns the different sequelae of regular drinking during adolescence. Early start of regular drinking led in 27ø7oto early registration for alcohol abuse if the early starter had an alcoholic parent, whereas only 5ø7oregular adolescentdrinkers in the general male population became early registered abusers.One may speculatethat a geneticpredisposition to alcohol abuse makes a large number of alcoholics' sonsunable to avoid abusivedrinking once they begin to drink regularly as adolescents.However, an environmentalexplanationof this finding is also possible if we consider the role of the alcoholic

father

as

a model of abusivedrinking. This "bad example" factor was deniedby the findingsof Cloningeret al. (1981)

1990

but supported by the results of two other adoption studies (Cadoret et al., 1985, 1987). The other exceptionconcernsour finding that registered abuseand self-reported abusehave different patterns of relations to psychosocialvariables. Whereas registeredabuseis strongly related to young men's and their fathers' educational level (abuse being associated with low education), self-reported abuse shows only a very weak relation to young men's education and none to their fathers'

education.

Other data from our

larger study suggestthe following interpretationof this finding: Heavy drinkerswith low educationallevel (very frequentlysonsof lesseducatedfathers)are at a greater risk to be registeredas abusersthan heavily drinking wall educatedyoung men (mostly sonsof well educated fathers) becausethe drinking culturesof the two social strata differ. There is, for example, more fighting in ebriety in the drinking culture of the lesseducated. Fighting attracts the attention of the police and leads to registration for alcohol abuse by the health care system.Our finding that father's higher educationprotects the son from being registered as an abuser even more effectively if the father is an alcoholic adds emphasisto what already has been said: Registrationfor abuseis a socialeventthat proceedsdifferentlyin social strata distinguishedby educationallevel. It is likely that well educatedregisteredfathers are especiallystrongly motivatedto protect their heavily drinking sonsfrom also being registered as abusers because they feel stigmatized by their own registration. It seemsto us that there is nothing specificto Prague or Czechoslovakiain our finding that heavy drinking is more easily registered as abusive drinking in men with low education and in sons of less educated fathers.

If we are correct in assumingthat this prevails in most countries with some form of registration for alcohol abuse, then the result has implications for researchin geneticsof alcoholism. It would mean that in studies relying on registeredabuse the prevalenceof abuse would be selectivelyunderestimatedin socialstrata with highereducation.Consequently,estimatesof heritability of abuse would be higher in studiessampling mostly personswith low education--for whom the registration criterion of abuse is relatively valid--than in studies with a larger spectrumof educationallevelsamong the sampled subjects. Let us finally comment briefly on our results concerning the relations between adult alcohol abuse and conduct disorders during childhood and adolescence. Not surprisingly we found that these developmental disorders correlated with registered alcohol abuse in sonsof alcoholicsas well as in the generalmale population. It is somewhatsurprisingthat the percentagesof men reportingbad schoolmarks for conductand delinquency in adolescenceare not significantly higher in

KUBI(2KA,KO•EN• AND ROTH the sample of alcoholics'sons. Consequently,the much higherpercentages of registeredand self-reportedalcohol abusersin our sample of alcoholics' sons cannot be explained away by data available in this study on conduct disordersduring childhood and adolescence.The significance of this conclusion is, of course, lessened by the retrospectiveself-report character of our data on developmental disorders and perhaps also by the fact that a somewhat lower percentageof sons of alcoholics participated in the interviews than the percentage of the generalpopulation samplewho participated. Studiesof children of alcoholicsrepeatedlyfound them to be somewhatmore frequently characterizedas impulsive, maladjustedin school, etc., when compared with control children (Knop et al., 1985; Mat•j•ek, 1982). One aspectof our findings concerningthe relations between childhood

conduct disorders and adult alcohol

of the subsample.The variance of A is given by the formula

$• = E p• [mi (ni--mi)]/n ]. Theage-adjusted estimates of the proportion of abusersin the general male population G

(and4) werecomputed similarly. On the assumption that 5ø7oof the general male population of 22-33 year old men are sons of alcoholics, the estimate of relative risk of abuse for sons of alcoholics compared to sons of nonalcoholicsis

R -- .95A/(G -

associated with childhood

conduct disorders than self-

answer

we can offer.

Appendix Computationformulas used in the preparation of Tables 2 and 3

The age-adjustedestimatesof the proportion of abusers among sonsof alcoholicswere computed by the formula A

= • Pi (mi/ni) wherePi is the proportionof men in the respectiveage group of the Prague population of 22-33 year

old men,mi is the numberof abusers in the respective agedefinedsubsample of sonsof alcoholics, and ni is the size

.05A). The approximate variance of R is

s• = R2[s2•/A 2 + (s•+.05•s2•)/(G-.05s2•) - 2(.095s2• (G-.05A)],

and SEn equals the square root of this

expression.

Acknowledgments The authors thank Ms Marie Pintov•i and Ms Libuge Kmo•kov•i

for their indefatigable efforts in data collection. Dr. J. DuplinskSr helped with the constructionof the GP sample and in other ways. Thanks are Prochfizhov•i

abuse brings perhaps a bit of new information. We found registeredearly adult abuse to be more strongly reported abuse in later adulthood. Any interpretation of this result should take into account that very young adults almost always become registered as alcohol abusers in consequenceto disinhibited drunken compartment (fighting, etc.). It is not surprising that individuals who were undisciplinedschoolboysare especially prone to disinhibited behavior when intoxicated by alcohol as young adults. Sayingthis, we stand before the question discussedin the introductory section: Are these early registered abusers simply individuals with antisocial personalities, as Vaillant (1983) would likely have them, or do they belong to a specific category of disorders,perhapsthe Type 2 alcoholismof Cloninger (1987)? In trying to answerthis questionwe shouldconsider that whereasonly 9ø7oof undisciplinedschoolboys in the generalpopulation samplebecameearly registered abusers, 26ø7oof undisciplined schoolboys with an alcoholic parent were already registered as abusers at 22. Evidently, something in addition to a tendency to disinhibition is presentin the caseof sonsof alcoholics that transforms an unruly schoolboy into a fighting abuser of alcohol at 20. That this something is most probably both geneticand environmentalis the modest

57

extended to Ms Jffina Novotnfi for effective technical assistance.

and

Ms

Zdefika

Note

1. The authors are indebted to an anonymous reviewer for his suggestionthat they include a discussionof this theme in their article.

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