Canadian Task Force on Preventive Health Care

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

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".

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.

Source Document
McNamee JE and Offord DR Children of alcoholics. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 470-85.