The International Journal of the Addictions, 14(7), 919-931, 1979
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Children of Heroin Addicts Barbara M. Herjanic, M.D. Victor Hugo Barredo, M.D. Washington University School of Medicine St. Louis, Missouri 631 10
Marijan Herjanic, M.D. Carlos J. Tomelieri, M.D. Washington University School of Medicine; Malcolm Bliss Mental Health Center St. Louis. Missouri 63 7 04
Abstract
Fourteen Black, male, opiate addicts, their wives, and their children were studied intensively using psychiatric interviews and psychological tests. Their 32 children were compared to 37 pediatric clinic children. The children raised in a home where father is an opiate addict function cognitively less well than their father, and the teenagers show earlier and stronger antisocial trends than pediatric clinic peers. On the other hand, there is a surprising absence of other psychopathology that one might expect, taking into consideration the deviant environment from which they come. A stable family unit is the single most important factor for the healthy growth and development of the child. Numerous studies had established 919 Copyright @ 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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the vulnerability of children related to family disturbance and particularly to mental illness and various dyssocial forms of behavior in the parents (Garmezy, 1974). With the known disastrous effects of drug addiction on the addict as well as on society, it is surprising how little attention has been paid to the development of children of drug addicts. The aim of our study was to describe a group of families in which the father was identified as an opiate addict and to determine if there were any characteristics or special problems in the children’s development which might be related to the father’s addiction.
METHOD Selection of Subjects
We attempted to locate men with a definite diagnosis of opiate addiction who were willing to participate in the study. The criteria for the diagnosis of opiate addiction were: (1) history of abuse of one or a combination of narcotic drugs (heroin, morphine, meperidine, methadone, etc.) during 1 year preceding the interview, and (2) history of withdrawal as shown by two or more of the following symptoms occurring within 18 hours of discontinuation of opiates and lasting more than 24 hours: insomnia, sweating or flushing, runny nose, chills, stomach cramps, diarrhea, muscle pain, nausea, gooseflesh, twitching. To be eligible, they had to be married with children in the age range of 6 to 17 and with wife and children who were also willing to participate in the investigation. Each parent signed informed consent for his or her own participation, and the mother signed consent for the children. Each family was reimbursed $20 plus $5/child for their participation in the study and, whenever necessary, transportation was provided from home to the place of the interview and back. If the family was very large, no more than six children were included in the study. Evaluation of Parents
The addict and his wife were interviewed individually using a systematic psychiatric interview and were given a battery of psychological tests (Peabody Picture Vocabulary Test, Porteus-Mazes, Structured and Scaled Interview to Assess Maladjustment, California Personality Inventory, Sensation Seeking Scale, and Means-Ends Problem Solving Scale). The diagnosis of all adult subjects was made from the structured psychiatric
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interview, using diagnostic criteria described by Feighner et al. (1972) by one psychiatrist (M .H.).
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Evaluation of Children
Once the diagnosis of drug addiction had been established in the father, the children were interviewed individually using a systematic structured psychiatric interview. In addition, each child was given a Peabody Picture Vocabulary Test, the Porteus-Maze Test, Wide-Range Achievement Test (reading), Means-Ends Problem Solving Scale, and Piers-Harris Children’s Self-concept Scale. The mother was given a developmental questionnaire about each child and was also asked about the same symptoms and behaviors contained in the structured psychiatric interview of the child. With the mother’s permission, a report was also requested from school. Diagnosis of the child was made by a child psychiatrist (B.M.H.) from the structured psychiatric interview of the child, interview with the mother about the child, and Peabody Picture Vocabulary Test using the diagnostic criteria described by Rutter et al. (1970) and the symptom checklist cutoff points developed by Herjanic and Campbell (1977). Comparison Group
For purposes of comparing data obtained from the child psychiatric interviews, children from a pediatric outpatient clinic were interviewed using the same structured psychiatric interview. The mothers were interviewed using the same developmental and family history questionnaire. The pediatric children were not given psychological tests nor was a report requested from school. Only one child from each family was interviewed, but the mother was questioned about all children between ages 6 and 17.
RESULTS At the beginning of the study it was our intention to investigate four groups of equal sizes; drug addicts, drug abusers, Black and White subjects. Our efforts were not successful. All abusers of nonnarcotic drugs, as well as most opiate addicts we were able to reach, were young single men with no children. Finally, we found two Black opiate addicts who qualified for the study and, through them, were able to reach the rest of
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the subjects. Fourteen Black families with 32 children were included in the study. The Parents
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Diagnosis
Thirteen fathers had a diagnosis of addiction to heroin. One father had a diagnosis of drug abuse, heroin. He had used heroin intravenously for more than 3 years every weekend, beginning Friday evening, three to four shots per day, the last shot not later than Sunday evening. He denied ever having enough withdrawal symptoms to qualify for the diagnosis of addiction. In three subjects the secondary diagnosis of alcoholism could be made and sociopathy in one. The question of sociopathy in patients with the diagnosis of drug addiction is a difficult one. We refrained from making the diagnosis unless it could be established clearly prior to the onset of drug addiction. If one disregards these considerations and examines the symptoms only, out of 14 fathers, seven qualify for a definite diagnosis of sociopathy and three for probable (Feighner et al., 1972). Five of the 14 mothers qualified for a psychiatric diagnosis, three drug abuse, marijuana; one drug abuse, amphetamine; and one drug abuse, hallucinogenic drugs. None had a secondary diagnosis and none qualified for a diagnosis of sociopathy. None were addicted to heroin. In general, the psychiatric disturbance of mothers was mild. Duration of addiction for fathers showed a mean of 5.5 years; 12 continued their drug use at the time of the interview; one had been in a methadone treatment program for 13 years prior to the interview, and one had decreased the amount of heroin he was taking, on his own, during the 8 months prior to the interview to the point that he did not have any withdrawal symptoms between injections, which were not more frequent than twice a week. Five mothers who qualified for a diagnosis of drug abuse had a duration of illness of 5 years; three of them continued to use the drug up to the time of the interview. All had discontinued the use of drugs during pregnancies.
CHARACTERISTICS OF DRUG ADDICT FAMILIES Our subjects were young. The mean age of fathers was 29 years and of mothers, 27 years. All subjects were legally married. For most of them,
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this was the only marriage. The mean number of children per family was 3.5. Mean PPVT IQ of fathers was 96; of mothers, 84. Most fathers (8) had dropped out of high school. Two had graduated from high school and three had some college. Mother’s schooling was similar. Six fathers and six mothers were employed regularly (regular employment meant that a subject had worked for more than 1/2 of the time since the age 16). In two families, both spouses were regularly employed. Two subjects were college students supported by stipends from the Vocational Rehabilitation Program. Seven families received Aid to Dependent Children. On the Otis, Dudley, Duncan scale (Reiss et al., 1961) which measures the socioeconomic class of the family, using the usual occupation of the father on the scale of 1 to 100, the mean score of the addict families was 27 (range 1 to 45). Twelve fathers admitted that proceeds from criminal activities were the sole support for maintaining their habit. Indeed, all fathers had more than one arrest and 10 had been sentenced to prison. Only three mothers had one arrest; none had been in prison. Patterns of Drug Abuse
Fathers
Nine fathers started using heroin before age 21. All had used alcohol and marijuana prior to that time, and many abused amphetamines and barbiturates prior to becoming addicted to heroin. None of the subjects had a steady supply of heroin. Each had his own pattern of alternate drug use when his heroin supply ran out, usually either alcohol or barbiturates. Thirteen said that they preferred heroin to any other drug and would use it exclusively if they could purchase it whenever they needed it. One subject said that he preferred cocaine but used heroin because cocaine was rarely available. One-half of the subjects had participated at one time in a treatment program for addicts. Mothers
Practically all mothers tried, at one time or another, both alcohol and marijuana. Only one had tried heroin. It was interesting to note the attitude of wives toward the addiction of the husbands. All of them were aware of the addiction and all were disturbed by it. One-half were actively trying to persuade their husbands
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to seek help. One subject on methadone and one who decreased the amount of heroin did so at the insistence of their wives. All wives were able to recognize immediately the highs and lows in their spouses, and all of them developed their own ways of handling the situation. With few exceptions, wives refused to participate in the husband’s habit and were not willing to procure the drugs for them or help with narcotics’ paraphernalia. Most demanded that husbands “not bring those things home” and refused to keep the drug supplies at home. Children
There were 32 children in the 14 families of opiate addicts; 25 in the age group 6 to 11 years and 7 in the age group 12 to 17 years. The oldest child was 14 years old. There were 15 boys and 17 girls. All children were cared for consistently by their natural mothers. Fathers’ absences from home were brief, more frequent for those with older children, and usually the result of incarceration. Children reported that the main disciplinarian at home was more frequently father than mother. Six children were afraid of their parents; three of mothers and three of fathers. There was no evidence of physical abuse. The Comparison Group
The comparison group of pediatric children came from 37 different families (Table 1). There were 22 children in the 6 to 11 year age group and Table 1 Comparison of Diagnosis Children of addicts Diagnosis Normal Neurotic disorder Conduct disorder Adaptation reaction Borderline or mildly retarded Other Undiagnosed
6-11 years ( N = 25) 40%(10)
-
12-17 years ( N = 7)
-
4% (1)
14% (1) 43 % (3) -
44% (11)
43% (3)
8% (2) 4% (1)
-
Comparison group 6-11 years (N= 22)
12-17 years ( N = 15)
5 5 % (12) 5 % (1)
46% (7) 7 % (1)
-
9% (2) 13 % (3) 18% (4)
-
7 % (1) 20% (3) 13 % (2) 7 % (1)
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15 in the 12 to 17 year age group; 21 were boys and 16 were girls. All were Black from a similar urban lower socioeconomic environment as the children of the addicts. The mean number of children per family was 3.3 and only 13 (35%) lived in intact two-parent homes. Although no systematic psychiatric evaluation of the parents of pediatric children was performed, the mother was asked a number of questions about her own and her hushand’s adjustment. None of the parents were addicted to drugs. However, five (14%) of the children came from homes where one or both parents were under psychiatric care. In addition, four fathers had problems due to excessive drinking. Five of the pediatric children had a birth defect, as compared to one of the drug children. Chronic illness, including allergies, affected three and five of each group, respectively. A child was considered to be “normal” if the diagnostic interviews and psychological tests revealed no evidence of behavioral or emotional disturbance or slowness in mental development which, at this time in the child’s life, was interfering with the course of his development. These children had too few symptoms in any area to meet the diagnostic criteria for a psychiatric disorder and were felt to function within the normal range of variation. Thirty-one percent of the children of addicts were considered normal, all were within the younger age group; wheras 61% of the pediatric group were judged to be normal, and these were almost evenly divided between the younger and older age groups. The authors acknowledge that the diagnosis of mental retardation is a tentative one, based upon the scores of PPVT and Porteus-Mazes and upon a history of being in special education, or being held back in school, and upon the clinical diagnostic interview. Forty-four percent of the children of addicts and 14%of pediatric children showed evidence of being slow in mental development, but had insufficient symptoms to meet the criteria for any other psychiatric diagnosis. Of the total group, all were considered to fall within the borderline range except for four who showed definite evidence of mild mental retardation, three in the addict group and one in the pediatric teenage group. The two groups of children were compared on the basis of the same psychiatric interview. The questions contained in the interview can be divided into several areas, five of which are illustrated in Table 2. Each area contains about 10 questions and, depending on the number of positive answers, the child is rated as having no problems, mild, moderate, or severe problems in this area (Herjanic and Campbell, 1977). Learning problems were most frequent and about equally distributed in
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Table 2 Comparison of Drug Addict and Pediatric Children on Moderate and Severe Ratings of Disturbance
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Children of addicts
Comparison group
Area of comparison
6-11 years ( N = 25)
12-17 years ( N = 7)
6-11 years (N = 22)
12-17 years ( N = 15)
Problems at home Problems with peers Learning problems Behavior problems, school Alcohol and drug use
16% (4) 16% (4) 28 % (7)
71 % ( 5 ) 43 % (3) 43 % (3)
27 % (6) 23% ( 5 ) 32% (7)
33 % ( 5 ) 1 3 % (2) 47 % (7)
8 % (2) -
71 % ( 5 ) 29% (2)
-
18% (4)
13% (2) 7 % (1)
all groups. The younger pediatric children reported more behavior problems at school than the subjects of the same age. With the exception of this area, there were no differences between the two groups of younger children. The teenage children of the addicts showed a higher degree of disturbance. All seven received a psychiatric diagnosis. Considerably more of them showed more problems at home, with peers, and behavior problems at school than the pediatric teenagers. On the whole, surprisingly few children showed any acting out behavior. One 14 year-old boy boasted of his sexual activity with several partners, had been expelled from school, had repeated the sixth grade, and had serious problems at home. Two sisters 12 and 13 years old, experimented with alcohol and marijuana and had many somatic complaints. These three were diagnosed as having behavior disorders. All children were asked the question, “Has anything been happening at home lately that you were upset about?” Only one child expressed concern about her father’s behavior, and he was an alcoholic in addition to being an addict. Another child from a family which moved at least 11 times was upset over marital discord between her parents. On the whole, the children were unaware or unconcerned about the father’s drug usage, did not mention it spontaneously, nor as a reply to the above question. Children were not questioned specifically about their parents. Psychological Tests
The psychological test battery was designed to screen for intellectual
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functioning, reading level, visual-motor problems, self-esteem, and problem-solving capacity. We are not unmindful of the controversy about the validity of tests which measure intellectual performance when applied to Black populations. We cannot compare, therefore, our results to the standards arrived at among White children. However, a comparison to their own parents is a fair and valid test (Table 3). On the Peabody Picture Vocabulary Test (PPVT), fathers had scored significantly higher than mothers ( t = 2.47) or children ( t = 3.95). The performance levels as shown by the Porteus-Maze Test were in the same direction; however, the difference was not statistically significant. Mothers and children performed at approximately the same level. Younger children performed slightly better than older children; however, the differences were not statistically significant. An analysis of the distribution of children with a psychiatric diagnosis showed that they tended to cluster in families. If we exclude the families with one child only, there are three families with 10 children, all of whom are borderline or retarded in mental development. There are three families with seven children all of whom are normal. An additional two families with nine children show one normal child, five with psychiatric diagnosis, and three borderline in mental development. The IQ of the parents of borderline children was lower (fathers 85, mothers 74) than the parents of normal children (fathers 99, mothers 90). There were no other differences between the two sets of parents in regard to secondary diagnosis of the father, diagnosis of the mother, or employment of father or mother. The results of other psychological tests on parents were not analyzed at this time. The IQ of the parents with three borderline children and three psychiatrically disturbed children is the same as that of borderline parents, while the family with two children with psychiatric diagnosis and one
Table 3 Intellectual Functioning
Fathers Mothers Children
Peabody Picture Vocabulary Test Mean
Porteus-Mazes Mean
96 84 80
118 105 I08
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Table 4 Piers-Harris Scale Results
General score Behavior Intellectual and school status Physical appearance and attributes Anxiety Popularity Happiness and satisfaction
Borderline (n = 14)
Psychiatric diagnosis (n = 8)
Normal (n = 10)
53.2 13.7
56.4 14.9
64.3 15.7
11.7
12.1
15.3
7.5 7.4 7.5 6.6
7.5 7.6 7.5 7
8.8 8.4 8.9 8
normal child was mentioned previously. This is the father who prefers cocaine to heroin and the two children are the two girls with conduct disorder. The IQ of the parents is higher than in any other group. The results of the Piers-Harris Children’s Self-concept Scale correlate well with psychiatric diagnosis. Not only the general score, but also all six factors point in the same direction, the “borderline” group receiving the lowest and “normal” group the highest scores. Table 4 shows a comparison of the raw scores. It is interesting to note that the scores of children with a psychiatric diagnosis lie in between, but usually closer, to the “borderline” group. As expected, all scores of adolescents were significantly lower than those of younger children. We have received responses from the teachers on only 11 of the 32 children, six under 12 years old and five over 12 years old. They showed a considerable amount of learning difficulty, tended to confirm our overall evaluation, and did not contribute any new or unexpected information.
DISCUSSION A search of medical literature has not revealed any systematic studies of the offspring of male drug addicts or of children living at home with one or more addicted parents. The paucity of literature in this area may be related to factors associated with the addiction itself. Addicts are less likely to marry (O’Donnell, 1969) and have been shown to have sexual problems which would prevent many of them from producing offspring during periods of addiction or methadone treatment (Mintz et al., 1974).
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Nichtern (1973) and Fanshel (1975) in two separate studies reported on children of addicted mothers in residential placement outside of the natural family setting. Most children had left their natural homes below 3 years of age and, in addition to mother’s addiction, suffered from many other disadvantages: broken homes, unknown father, neglect, abandonment, and physical abuse. While Nichtern had found a whole range of problems from developmental lags and learning problems to excessive anxiety, poor socialization, and withdrawal, Fanshel reported that “the adjustment of children as measured over time appeared no less problematic than that of children who were separated from their families because of other factors in their life situations” (page 61 1). Our findings show that children raised in the home where father is an opiate abuser function cognitively less well than their fathers, and the teenagers show earlier and stronger antisocial trends than their pediatric clinic peers. We have not, however, been able to pinpoint with such a small group of subjects either specific antecedents of possible drug abuse or problems in the children which could be specifically related to the factor of drug addiction in their fathers apart from a multitude of problems related to their total environment. We were beset by many of the problems one faces in trying to do a family study. Our observations were necessarily from the outside, and were related to the kind of data we could collect from each individual member. Anthony and Koupernik (1970) pointed out some of the difficulties and hazards in this process of trying to do family studies. We really had no measure for the circular exchanges that invariably play a large part in the intrafamilial dynamics and certainly affect the growing up process of these children (Ackerman et al., 1970). Our findings suggest several areas for future research. First of all, the finding that the children of drug addicts function cognitively less well than their parents is potentially one of grave importance, indicating the need for careful investigation of the parents and children of these families by using a complete battery of psychoeducational tests. If the findings for which we have, at the present, no good explanation prove to be consistent, then the implications for the care and treatment of these families are highly significant. The adolescent children in this study showed the problems (school difficulties, early sex, and early use of alcohol and marijuana) reported to precede serious abuse (Halikas et al., 1976). They must, therefore, be considered to be vulnerable to a life of drug addiction themselves. Controlled longitudinal studies of the children of heroin addicts are
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needed to tease out the variables which may distinguish these children in adolescence from those of alcoholic parents or those of nonaddicted parents who live in the same neighborhoods. Such longitudinal studies are also essential in trying to determine any possible genetic effects related to having a parent with the problem of addiction. Even with the limitations which this study presents, there are some implications relative to drug treatment programs now in effect. At the present time, drug addicts surface in our society either at police headquarters or at treatment centers. When the addict appears first because of legal difficulties, his children are in a sense victims of the crime or crimes which the father has committed. The arm of the law itself may reach no further than the father; however, those concerned with the families of victims of crime could well turn their attention to the children of fathers who are incarcerated because of drug problems. The mother and children most certainly need to be referred for more than the welfare check. As shown by our study, the children very likely are having special problems in school for which guidance is needed, and the adolescents may already be showing acting out behavior which is possibly an antecedent to a life of drug and other problems. Addicts who appear first at a treatment facility on a voluntary basis may be appearing there for the first time because of concerns about their family. T o our knowledge, little attention has been paid to the children in the family while treatment is being administered to the addicted parent. This study confirms the special risks involved in being a child in the family of an addict. If preventive measures are going to be instituted to lessen the vulnerability of these youngsters to enable them to develop without resorting to drug addiction themselves, then treatment policies need to be expanded to include the whole family. This implies that persons specializing in family problems and in child development would be included on the staff of such centers. As more attention is paid to the families of the addicts who appear for treatment, more families will be located for further research to find the answers to some of the many questions which remain unanswered in respect to the children of heroin addicts. ACKNOWLEDGMENTS
This study was supported in part by Grants DA 4RG008 and MH 05938.
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REFERENCES ACKERMAN, N.W., PAPP, P., and PROSKY, P. Childhood disorders and interlocking pathology in family relationships. In The Child in His Family, Vol. 1 (E. J. Anthony and C. Koupernik, eds.) New York: Wiley-Interscience, 1970, pp. 241-266. ANTHONY, E.J., and KOUPERNIK, C. Preface. In The Child in His Family, Vol. 1 . New York: Wiley-Interscience, 1970. FANSHEL, D. Parental failure and consequences for children. Am. J. Public Health 65: 604-612, 1975. FEIGHNER, J.P., ROBINS, E., GUZE, S.B., WOODRUFF, R.A., Jr., WINOKUR, G., and MUNOZ, R. Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26: 57-63, 1972. GARMEZY, N. Conceptual models and research methods. Part I. Children at risk. Schizophrenia Bull. 8: 14-90, Spring 1974. HALIKAS, J.A., DARVISH, H.S., and RIMMER, J.D. The black addict: A new look at a current population. Presented at the Third National Drug Abuse Conference, New York City, March 1976. HERJANIC, B., and CAMPBELL, W. Differentiating psychiatrically disturbed children on the basis of a structured interview. J. Abnorm. Child Psychol. 5 : 127-134, 1977. MINTZ, J., O’HARE, K., O’BRIEN, P., and GOLDSCHMIDT, J. Sexual problems of heroin addicts Arch. Gen. Psychiatry 31: 700-703, 1974. NICHTERN, S. The children of drug users. J . Am. Acad. Child. Psychiatry 12: 24-31, 1973. O’DONNELL, J.A. Narcotic Addicts in Kentucky (Public Health Service Publication No. 1881). 1969. REISS, A.J., Jr., DUNCAN, O.D., HATT, P.K., and NORTH, C.C. Occupations and Social Status. New York: Free Press, 1961. RUTTER, M., TIZARD, J., and WHITMORE, K. Education, Health and Behavior. London: Longman, 1970.
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Children of Heroin Addicts Barbara M. Herjanic, M.D. Victor Hugo Barredo, M.D. Washington University School of Medicine St. Louis, Missouri 631 10
Marijan Herjanic, M.D. Carlos J. Tomelieri, M.D. Washington University School of Medicine; Malcolm Bliss Mental Health Center St. Louis. Missouri 63 7 04
Abstract
Fourteen Black, male, opiate addicts, their wives, and their children were studied intensively using psychiatric interviews and psychological tests. Their 32 children were compared to 37 pediatric clinic children. The children raised in a home where father is an opiate addict function cognitively less well than their father, and the teenagers show earlier and stronger antisocial trends than pediatric clinic peers. On the other hand, there is a surprising absence of other psychopathology that one might expect, taking into consideration the deviant environment from which they come. A stable family unit is the single most important factor for the healthy growth and development of the child. Numerous studies had established 919 Copyright @ 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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the vulnerability of children related to family disturbance and particularly to mental illness and various dyssocial forms of behavior in the parents (Garmezy, 1974). With the known disastrous effects of drug addiction on the addict as well as on society, it is surprising how little attention has been paid to the development of children of drug addicts. The aim of our study was to describe a group of families in which the father was identified as an opiate addict and to determine if there were any characteristics or special problems in the children’s development which might be related to the father’s addiction.
METHOD Selection of Subjects
We attempted to locate men with a definite diagnosis of opiate addiction who were willing to participate in the study. The criteria for the diagnosis of opiate addiction were: (1) history of abuse of one or a combination of narcotic drugs (heroin, morphine, meperidine, methadone, etc.) during 1 year preceding the interview, and (2) history of withdrawal as shown by two or more of the following symptoms occurring within 18 hours of discontinuation of opiates and lasting more than 24 hours: insomnia, sweating or flushing, runny nose, chills, stomach cramps, diarrhea, muscle pain, nausea, gooseflesh, twitching. To be eligible, they had to be married with children in the age range of 6 to 17 and with wife and children who were also willing to participate in the investigation. Each parent signed informed consent for his or her own participation, and the mother signed consent for the children. Each family was reimbursed $20 plus $5/child for their participation in the study and, whenever necessary, transportation was provided from home to the place of the interview and back. If the family was very large, no more than six children were included in the study. Evaluation of Parents
The addict and his wife were interviewed individually using a systematic psychiatric interview and were given a battery of psychological tests (Peabody Picture Vocabulary Test, Porteus-Mazes, Structured and Scaled Interview to Assess Maladjustment, California Personality Inventory, Sensation Seeking Scale, and Means-Ends Problem Solving Scale). The diagnosis of all adult subjects was made from the structured psychiatric
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interview, using diagnostic criteria described by Feighner et al. (1972) by one psychiatrist (M .H.).
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Evaluation of Children
Once the diagnosis of drug addiction had been established in the father, the children were interviewed individually using a systematic structured psychiatric interview. In addition, each child was given a Peabody Picture Vocabulary Test, the Porteus-Maze Test, Wide-Range Achievement Test (reading), Means-Ends Problem Solving Scale, and Piers-Harris Children’s Self-concept Scale. The mother was given a developmental questionnaire about each child and was also asked about the same symptoms and behaviors contained in the structured psychiatric interview of the child. With the mother’s permission, a report was also requested from school. Diagnosis of the child was made by a child psychiatrist (B.M.H.) from the structured psychiatric interview of the child, interview with the mother about the child, and Peabody Picture Vocabulary Test using the diagnostic criteria described by Rutter et al. (1970) and the symptom checklist cutoff points developed by Herjanic and Campbell (1977). Comparison Group
For purposes of comparing data obtained from the child psychiatric interviews, children from a pediatric outpatient clinic were interviewed using the same structured psychiatric interview. The mothers were interviewed using the same developmental and family history questionnaire. The pediatric children were not given psychological tests nor was a report requested from school. Only one child from each family was interviewed, but the mother was questioned about all children between ages 6 and 17.
RESULTS At the beginning of the study it was our intention to investigate four groups of equal sizes; drug addicts, drug abusers, Black and White subjects. Our efforts were not successful. All abusers of nonnarcotic drugs, as well as most opiate addicts we were able to reach, were young single men with no children. Finally, we found two Black opiate addicts who qualified for the study and, through them, were able to reach the rest of
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the subjects. Fourteen Black families with 32 children were included in the study. The Parents
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Diagnosis
Thirteen fathers had a diagnosis of addiction to heroin. One father had a diagnosis of drug abuse, heroin. He had used heroin intravenously for more than 3 years every weekend, beginning Friday evening, three to four shots per day, the last shot not later than Sunday evening. He denied ever having enough withdrawal symptoms to qualify for the diagnosis of addiction. In three subjects the secondary diagnosis of alcoholism could be made and sociopathy in one. The question of sociopathy in patients with the diagnosis of drug addiction is a difficult one. We refrained from making the diagnosis unless it could be established clearly prior to the onset of drug addiction. If one disregards these considerations and examines the symptoms only, out of 14 fathers, seven qualify for a definite diagnosis of sociopathy and three for probable (Feighner et al., 1972). Five of the 14 mothers qualified for a psychiatric diagnosis, three drug abuse, marijuana; one drug abuse, amphetamine; and one drug abuse, hallucinogenic drugs. None had a secondary diagnosis and none qualified for a diagnosis of sociopathy. None were addicted to heroin. In general, the psychiatric disturbance of mothers was mild. Duration of addiction for fathers showed a mean of 5.5 years; 12 continued their drug use at the time of the interview; one had been in a methadone treatment program for 13 years prior to the interview, and one had decreased the amount of heroin he was taking, on his own, during the 8 months prior to the interview to the point that he did not have any withdrawal symptoms between injections, which were not more frequent than twice a week. Five mothers who qualified for a diagnosis of drug abuse had a duration of illness of 5 years; three of them continued to use the drug up to the time of the interview. All had discontinued the use of drugs during pregnancies.
CHARACTERISTICS OF DRUG ADDICT FAMILIES Our subjects were young. The mean age of fathers was 29 years and of mothers, 27 years. All subjects were legally married. For most of them,
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this was the only marriage. The mean number of children per family was 3.5. Mean PPVT IQ of fathers was 96; of mothers, 84. Most fathers (8) had dropped out of high school. Two had graduated from high school and three had some college. Mother’s schooling was similar. Six fathers and six mothers were employed regularly (regular employment meant that a subject had worked for more than 1/2 of the time since the age 16). In two families, both spouses were regularly employed. Two subjects were college students supported by stipends from the Vocational Rehabilitation Program. Seven families received Aid to Dependent Children. On the Otis, Dudley, Duncan scale (Reiss et al., 1961) which measures the socioeconomic class of the family, using the usual occupation of the father on the scale of 1 to 100, the mean score of the addict families was 27 (range 1 to 45). Twelve fathers admitted that proceeds from criminal activities were the sole support for maintaining their habit. Indeed, all fathers had more than one arrest and 10 had been sentenced to prison. Only three mothers had one arrest; none had been in prison. Patterns of Drug Abuse
Fathers
Nine fathers started using heroin before age 21. All had used alcohol and marijuana prior to that time, and many abused amphetamines and barbiturates prior to becoming addicted to heroin. None of the subjects had a steady supply of heroin. Each had his own pattern of alternate drug use when his heroin supply ran out, usually either alcohol or barbiturates. Thirteen said that they preferred heroin to any other drug and would use it exclusively if they could purchase it whenever they needed it. One subject said that he preferred cocaine but used heroin because cocaine was rarely available. One-half of the subjects had participated at one time in a treatment program for addicts. Mothers
Practically all mothers tried, at one time or another, both alcohol and marijuana. Only one had tried heroin. It was interesting to note the attitude of wives toward the addiction of the husbands. All of them were aware of the addiction and all were disturbed by it. One-half were actively trying to persuade their husbands
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to seek help. One subject on methadone and one who decreased the amount of heroin did so at the insistence of their wives. All wives were able to recognize immediately the highs and lows in their spouses, and all of them developed their own ways of handling the situation. With few exceptions, wives refused to participate in the husband’s habit and were not willing to procure the drugs for them or help with narcotics’ paraphernalia. Most demanded that husbands “not bring those things home” and refused to keep the drug supplies at home. Children
There were 32 children in the 14 families of opiate addicts; 25 in the age group 6 to 11 years and 7 in the age group 12 to 17 years. The oldest child was 14 years old. There were 15 boys and 17 girls. All children were cared for consistently by their natural mothers. Fathers’ absences from home were brief, more frequent for those with older children, and usually the result of incarceration. Children reported that the main disciplinarian at home was more frequently father than mother. Six children were afraid of their parents; three of mothers and three of fathers. There was no evidence of physical abuse. The Comparison Group
The comparison group of pediatric children came from 37 different families (Table 1). There were 22 children in the 6 to 11 year age group and Table 1 Comparison of Diagnosis Children of addicts Diagnosis Normal Neurotic disorder Conduct disorder Adaptation reaction Borderline or mildly retarded Other Undiagnosed
6-11 years ( N = 25) 40%(10)
-
12-17 years ( N = 7)
-
4% (1)
14% (1) 43 % (3) -
44% (11)
43% (3)
8% (2) 4% (1)
-
Comparison group 6-11 years (N= 22)
12-17 years ( N = 15)
5 5 % (12) 5 % (1)
46% (7) 7 % (1)
-
9% (2) 13 % (3) 18% (4)
-
7 % (1) 20% (3) 13 % (2) 7 % (1)
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15 in the 12 to 17 year age group; 21 were boys and 16 were girls. All were Black from a similar urban lower socioeconomic environment as the children of the addicts. The mean number of children per family was 3.3 and only 13 (35%) lived in intact two-parent homes. Although no systematic psychiatric evaluation of the parents of pediatric children was performed, the mother was asked a number of questions about her own and her hushand’s adjustment. None of the parents were addicted to drugs. However, five (14%) of the children came from homes where one or both parents were under psychiatric care. In addition, four fathers had problems due to excessive drinking. Five of the pediatric children had a birth defect, as compared to one of the drug children. Chronic illness, including allergies, affected three and five of each group, respectively. A child was considered to be “normal” if the diagnostic interviews and psychological tests revealed no evidence of behavioral or emotional disturbance or slowness in mental development which, at this time in the child’s life, was interfering with the course of his development. These children had too few symptoms in any area to meet the diagnostic criteria for a psychiatric disorder and were felt to function within the normal range of variation. Thirty-one percent of the children of addicts were considered normal, all were within the younger age group; wheras 61% of the pediatric group were judged to be normal, and these were almost evenly divided between the younger and older age groups. The authors acknowledge that the diagnosis of mental retardation is a tentative one, based upon the scores of PPVT and Porteus-Mazes and upon a history of being in special education, or being held back in school, and upon the clinical diagnostic interview. Forty-four percent of the children of addicts and 14%of pediatric children showed evidence of being slow in mental development, but had insufficient symptoms to meet the criteria for any other psychiatric diagnosis. Of the total group, all were considered to fall within the borderline range except for four who showed definite evidence of mild mental retardation, three in the addict group and one in the pediatric teenage group. The two groups of children were compared on the basis of the same psychiatric interview. The questions contained in the interview can be divided into several areas, five of which are illustrated in Table 2. Each area contains about 10 questions and, depending on the number of positive answers, the child is rated as having no problems, mild, moderate, or severe problems in this area (Herjanic and Campbell, 1977). Learning problems were most frequent and about equally distributed in
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Table 2 Comparison of Drug Addict and Pediatric Children on Moderate and Severe Ratings of Disturbance
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Children of addicts
Comparison group
Area of comparison
6-11 years ( N = 25)
12-17 years ( N = 7)
6-11 years (N = 22)
12-17 years ( N = 15)
Problems at home Problems with peers Learning problems Behavior problems, school Alcohol and drug use
16% (4) 16% (4) 28 % (7)
71 % ( 5 ) 43 % (3) 43 % (3)
27 % (6) 23% ( 5 ) 32% (7)
33 % ( 5 ) 1 3 % (2) 47 % (7)
8 % (2) -
71 % ( 5 ) 29% (2)
-
18% (4)
13% (2) 7 % (1)
all groups. The younger pediatric children reported more behavior problems at school than the subjects of the same age. With the exception of this area, there were no differences between the two groups of younger children. The teenage children of the addicts showed a higher degree of disturbance. All seven received a psychiatric diagnosis. Considerably more of them showed more problems at home, with peers, and behavior problems at school than the pediatric teenagers. On the whole, surprisingly few children showed any acting out behavior. One 14 year-old boy boasted of his sexual activity with several partners, had been expelled from school, had repeated the sixth grade, and had serious problems at home. Two sisters 12 and 13 years old, experimented with alcohol and marijuana and had many somatic complaints. These three were diagnosed as having behavior disorders. All children were asked the question, “Has anything been happening at home lately that you were upset about?” Only one child expressed concern about her father’s behavior, and he was an alcoholic in addition to being an addict. Another child from a family which moved at least 11 times was upset over marital discord between her parents. On the whole, the children were unaware or unconcerned about the father’s drug usage, did not mention it spontaneously, nor as a reply to the above question. Children were not questioned specifically about their parents. Psychological Tests
The psychological test battery was designed to screen for intellectual
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functioning, reading level, visual-motor problems, self-esteem, and problem-solving capacity. We are not unmindful of the controversy about the validity of tests which measure intellectual performance when applied to Black populations. We cannot compare, therefore, our results to the standards arrived at among White children. However, a comparison to their own parents is a fair and valid test (Table 3). On the Peabody Picture Vocabulary Test (PPVT), fathers had scored significantly higher than mothers ( t = 2.47) or children ( t = 3.95). The performance levels as shown by the Porteus-Maze Test were in the same direction; however, the difference was not statistically significant. Mothers and children performed at approximately the same level. Younger children performed slightly better than older children; however, the differences were not statistically significant. An analysis of the distribution of children with a psychiatric diagnosis showed that they tended to cluster in families. If we exclude the families with one child only, there are three families with 10 children, all of whom are borderline or retarded in mental development. There are three families with seven children all of whom are normal. An additional two families with nine children show one normal child, five with psychiatric diagnosis, and three borderline in mental development. The IQ of the parents of borderline children was lower (fathers 85, mothers 74) than the parents of normal children (fathers 99, mothers 90). There were no other differences between the two sets of parents in regard to secondary diagnosis of the father, diagnosis of the mother, or employment of father or mother. The results of other psychological tests on parents were not analyzed at this time. The IQ of the parents with three borderline children and three psychiatrically disturbed children is the same as that of borderline parents, while the family with two children with psychiatric diagnosis and one
Table 3 Intellectual Functioning
Fathers Mothers Children
Peabody Picture Vocabulary Test Mean
Porteus-Mazes Mean
96 84 80
118 105 I08
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Table 4 Piers-Harris Scale Results
General score Behavior Intellectual and school status Physical appearance and attributes Anxiety Popularity Happiness and satisfaction
Borderline (n = 14)
Psychiatric diagnosis (n = 8)
Normal (n = 10)
53.2 13.7
56.4 14.9
64.3 15.7
11.7
12.1
15.3
7.5 7.4 7.5 6.6
7.5 7.6 7.5 7
8.8 8.4 8.9 8
normal child was mentioned previously. This is the father who prefers cocaine to heroin and the two children are the two girls with conduct disorder. The IQ of the parents is higher than in any other group. The results of the Piers-Harris Children’s Self-concept Scale correlate well with psychiatric diagnosis. Not only the general score, but also all six factors point in the same direction, the “borderline” group receiving the lowest and “normal” group the highest scores. Table 4 shows a comparison of the raw scores. It is interesting to note that the scores of children with a psychiatric diagnosis lie in between, but usually closer, to the “borderline” group. As expected, all scores of adolescents were significantly lower than those of younger children. We have received responses from the teachers on only 11 of the 32 children, six under 12 years old and five over 12 years old. They showed a considerable amount of learning difficulty, tended to confirm our overall evaluation, and did not contribute any new or unexpected information.
DISCUSSION A search of medical literature has not revealed any systematic studies of the offspring of male drug addicts or of children living at home with one or more addicted parents. The paucity of literature in this area may be related to factors associated with the addiction itself. Addicts are less likely to marry (O’Donnell, 1969) and have been shown to have sexual problems which would prevent many of them from producing offspring during periods of addiction or methadone treatment (Mintz et al., 1974).
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Nichtern (1973) and Fanshel (1975) in two separate studies reported on children of addicted mothers in residential placement outside of the natural family setting. Most children had left their natural homes below 3 years of age and, in addition to mother’s addiction, suffered from many other disadvantages: broken homes, unknown father, neglect, abandonment, and physical abuse. While Nichtern had found a whole range of problems from developmental lags and learning problems to excessive anxiety, poor socialization, and withdrawal, Fanshel reported that “the adjustment of children as measured over time appeared no less problematic than that of children who were separated from their families because of other factors in their life situations” (page 61 1). Our findings show that children raised in the home where father is an opiate abuser function cognitively less well than their fathers, and the teenagers show earlier and stronger antisocial trends than their pediatric clinic peers. We have not, however, been able to pinpoint with such a small group of subjects either specific antecedents of possible drug abuse or problems in the children which could be specifically related to the factor of drug addiction in their fathers apart from a multitude of problems related to their total environment. We were beset by many of the problems one faces in trying to do a family study. Our observations were necessarily from the outside, and were related to the kind of data we could collect from each individual member. Anthony and Koupernik (1970) pointed out some of the difficulties and hazards in this process of trying to do family studies. We really had no measure for the circular exchanges that invariably play a large part in the intrafamilial dynamics and certainly affect the growing up process of these children (Ackerman et al., 1970). Our findings suggest several areas for future research. First of all, the finding that the children of drug addicts function cognitively less well than their parents is potentially one of grave importance, indicating the need for careful investigation of the parents and children of these families by using a complete battery of psychoeducational tests. If the findings for which we have, at the present, no good explanation prove to be consistent, then the implications for the care and treatment of these families are highly significant. The adolescent children in this study showed the problems (school difficulties, early sex, and early use of alcohol and marijuana) reported to precede serious abuse (Halikas et al., 1976). They must, therefore, be considered to be vulnerable to a life of drug addiction themselves. Controlled longitudinal studies of the children of heroin addicts are
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needed to tease out the variables which may distinguish these children in adolescence from those of alcoholic parents or those of nonaddicted parents who live in the same neighborhoods. Such longitudinal studies are also essential in trying to determine any possible genetic effects related to having a parent with the problem of addiction. Even with the limitations which this study presents, there are some implications relative to drug treatment programs now in effect. At the present time, drug addicts surface in our society either at police headquarters or at treatment centers. When the addict appears first because of legal difficulties, his children are in a sense victims of the crime or crimes which the father has committed. The arm of the law itself may reach no further than the father; however, those concerned with the families of victims of crime could well turn their attention to the children of fathers who are incarcerated because of drug problems. The mother and children most certainly need to be referred for more than the welfare check. As shown by our study, the children very likely are having special problems in school for which guidance is needed, and the adolescents may already be showing acting out behavior which is possibly an antecedent to a life of drug and other problems. Addicts who appear first at a treatment facility on a voluntary basis may be appearing there for the first time because of concerns about their family. T o our knowledge, little attention has been paid to the children in the family while treatment is being administered to the addicted parent. This study confirms the special risks involved in being a child in the family of an addict. If preventive measures are going to be instituted to lessen the vulnerability of these youngsters to enable them to develop without resorting to drug addiction themselves, then treatment policies need to be expanded to include the whole family. This implies that persons specializing in family problems and in child development would be included on the staff of such centers. As more attention is paid to the families of the addicts who appear for treatment, more families will be located for further research to find the answers to some of the many questions which remain unanswered in respect to the children of heroin addicts. ACKNOWLEDGMENTS
This study was supported in part by Grants DA 4RG008 and MH 05938.
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REFERENCES ACKERMAN, N.W., PAPP, P., and PROSKY, P. Childhood disorders and interlocking pathology in family relationships. In The Child in His Family, Vol. 1 (E. J. Anthony and C. Koupernik, eds.) New York: Wiley-Interscience, 1970, pp. 241-266. ANTHONY, E.J., and KOUPERNIK, C. Preface. In The Child in His Family, Vol. 1 . New York: Wiley-Interscience, 1970. FANSHEL, D. Parental failure and consequences for children. Am. J. Public Health 65: 604-612, 1975. FEIGHNER, J.P., ROBINS, E., GUZE, S.B., WOODRUFF, R.A., Jr., WINOKUR, G., and MUNOZ, R. Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26: 57-63, 1972. GARMEZY, N. Conceptual models and research methods. Part I. Children at risk. Schizophrenia Bull. 8: 14-90, Spring 1974. HALIKAS, J.A., DARVISH, H.S., and RIMMER, J.D. The black addict: A new look at a current population. Presented at the Third National Drug Abuse Conference, New York City, March 1976. HERJANIC, B., and CAMPBELL, W. Differentiating psychiatrically disturbed children on the basis of a structured interview. J. Abnorm. Child Psychol. 5 : 127-134, 1977. MINTZ, J., O’HARE, K., O’BRIEN, P., and GOLDSCHMIDT, J. Sexual problems of heroin addicts Arch. Gen. Psychiatry 31: 700-703, 1974. NICHTERN, S. The children of drug users. J . Am. Acad. Child. Psychiatry 12: 24-31, 1973. O’DONNELL, J.A. Narcotic Addicts in Kentucky (Public Health Service Publication No. 1881). 1969. REISS, A.J., Jr., DUNCAN, O.D., HATT, P.K., and NORTH, C.C. Occupations and Social Status. New York: Free Press, 1961. RUTTER, M., TIZARD, J., and WHITMORE, K. Education, Health and Behavior. London: Longman, 1970.
