Structured Abstract
Please note: In 2003, the CTF updated its Grades of
Recommendations to include an "I Recommendation" for situations where
insufficient evidence exists to allow a recommendation to be made.
(Formerly, these situations were captured under a "C
Recommendation".) This change is not retroactive, and all
"C Recommendations" made prior to 2003 have not been
reevaluated in light of the new "I" recommendation grade. For a
discussion of these recommendation grades, please link to the 2003 article in
the Canadian Medical Association Journal here.
Children of Alcoholics
Prepared by Jane E. McNamee, MA, and David R. Offord, MD, FRCPC, Department
of Psychiatry, McMaster University
These recommendations were finalized by the Task Force in April 1994
Contents
Objective
To make recommendations about routine screening to detect various morbidities
in non-complainant children (0 to 18 y) in Canada, who live with an alcoholic
or alcohol-abusing parent; and about preventive/treatment programs.
Burden
of Suffering
In the past, definitions of parental alcoholism have ranged from self-reported
family histories of heavy drinking or alcohol-dependency to parents who
were described as "problem drinkers", "recovering alcoholics", or "recovering-
diagnosed-alcoholics", or those who met the criteria systematically defining
alcohol abuse or dependence in later studies.
Although Canadian data is not available, it is estimated that 1 out
of every 8 children in the U.S. lives in an alcoholic home. Using
this ratio with 1991 Canadian population statistics for children aged 0-19
years, it can be estimated that close to one million children lived in
an alcoholic home in Canada in 1991. The implications of parental
alcoholism for children include increases in the risk of alcoholism, fetal
alcohol syndrome, child abuse or neglect, emotional problems, and maladjustment,
with the possibility of lower IQ scores. The risk of alcoholism among
biological sons and daughters of alcoholics has been found to be as high
as four times that of children of non-alcoholics.
Options
Screening tests include the Children of Alcoholics Screening Test (CAST),
and single item measures ("Do you consider that either of your parents
ever had a drinking problem?" and "Do you consider that either of your
parents may have, or may have had an alcohol abuse problem?"). The Children
of Alcoholics Life-Events Schedule (COALES) was described, but no evidence
was presented. Interventions include routine screening, anonymous
support groups (Al-Ateen and Al-Atot) and school-based programs.
Outcomes
Measures of intervention effectiveness were self esteem, behavioural changes
and school grades. Other outcomes included reliability and validity of
screening tests and characteristics of health care delivery (history-taking,
physician recognition rate of problem and effectiveness of recruitment
procedures).
Evidence
MEDLINE was searched from 1988 to October 1992 using the keywords "children
of alcoholics".
Recommendations were graded as:
|
A
|
Good evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
B
|
Fair evidence to support the recommendation that the condition
be specifically considered in a PHE. |
|
C
|
Poor evidence regarding inclusion or exclusion of the condition
in a PHE, but recommendations may be made on other grounds. |
|
D
|
Fair evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
|
E
|
Good evidence to support the recommendation that the condition
be specifically excluded from consideration in a PHE. |
Quality of evidence was rated according to 5 levels:
|
I
|
Evidence from at least 1 properly randomized controlled
trial (RCT). |
|
II-1
|
Evidence from well-designed controlled trials without randomization. |
|
II-2
|
Evidence from well-designed cohort or case-control analytic
studies, preferably from more than 1 centre or research group. |
|
II-3
|
Evidence from comparisons between times or places with
or without the intervention. Dramatic results in uncontrolled experiments
could also be included here. |
|
III
|
Opinions of respected authorities, based on clinical experience,
descriptive studies or reports of expert committees. |
Values
The 13-member Task Force of experts in family medicine, geriatric medicine,
pediatrics, psychiatry and epidemiology used an evidence-based method for
evaluating the effectiveness of preventive health care interventions. Recommendations
were not based on cost-effectiveness of options. Patient preferences were
not discussed.
Background papers providing critical appraisal of the evidence and tentative
recommendations prepared by the chapter author were pre-circulated to the
members. Evidence for this topic was presented and deliberated upon in
1- to 2-day meetings, 2 to 3 times per year from October 1993 to April
1994. Consensus was reached on final recommendations.
Benefits,
Harms, and Costs
The CAST measures children's feelings, attitudes and experiences about
parent drinking behaviour. High CAST scores are significantly associated
with low family cohesion and support, and high family conflict. In a cohort
study, 100% of children of clinically-diagnosed or self-reported alcoholics
were reliably identified. The false positive rate was 23% . Other cohort
studies report that the CAST discriminates in adolescent and psychiatric
populations.
No reliability or sensitivity data were reported for single-item screening
questions.
A descriptive study of alcoholism in families of hospitalized children
found that physicians had low recognition rates of substance abuse in families.
In another study, only 34% of physicians reported taking a family substance
abuse history on pediatric patients.
Most existing programs are directed at children of parents hospitalized
for alcoholism. Evaluation of interventions is hindered by a lack of comparability
of programs, populations and outcomes, and a lack of control for confounding.
Community-based support groups such as Al-Ateen, and Al-Atot are not
well studied because of requirements for participant anonymity. In a non-replicated
cohort study, adolescents attending Al-Ateen reported higher self-esteem
and better grades than those not attending groups. No behavioural differences
were noted.
Efficacy of curriculum- or school-based programs depends on both the
effectiveness of the intervention, and the participation of the target
population. A cohort study reported that recruitment procedures targeting
children of alcoholics in Grades 4 to 6 did attract children at risk. However,
reports of parental drinking were later found to have little validity.
Another study found that a self-recruitment process for a program targeted
at the same population was not effective. Results of a subsequent cohort
study suggested that recruitment may affected by the potential negative
effects of labelling and negative stereotyping.
Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence
[I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations
in support of individual recommendations are identified in the guideline
text.
-
There is insufficient evidence to include, in the PHE of children, routine
evaluation to identify those with family members who are alcoholics or
who are abusing alcohol [C, III].
However, for children thought to be at high risk, evaluation and support
should be provided .
-
There is fair evidence to include, in the PHE of children, screening with
the Children of Alcoholics Screening Test for the detection of risk [B,
II-2].
-
There is insufficient evidence to include, in the PHE of children, use
of 2 screening questions to detect risk [C,
III].
-
There is insufficient evidence to to include, in the PHE of children, screening
procedures for management purposes [C].
-
There is insufficient evidence to include, in the PHE of children, referral
to community-based groups (Al-Ateen, Al-Atot) [C,
II-2] or for or against referral to school-based
intervention programs [C,
II-2].
Validation
This report was externally peer-reviewed. The U.S. Preventive Services
Task Force, Institute of Medicine and the Alcohol Risk Assessment Intervention
Project of the College of Family Physicians of Canada have made recommendations
about screening to assess the drinking behaviour of pediatric patients.
No recommendations have been made regarding screening to identify children
with parents who abuse alcohol.
Sponsors
The Canadian Task Force on Preventive Health Care
developed this guideline with funding from Health Canada.
Selected
References
Source Document
Link to Full Text of this
review
Link to Summary Table of Recommendations of this review
Link to Selected References list of this review
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