Executive Function Deficits in AOFAD

One of the initial studies in this area is by Wiers et al8 has examined the effect of multigenerational alcoholism vis-à-vis childhood attention-deficit hyperactivity disorder and conduct disorder on the executive functions in 76 boys aged 7 to 11 years. The study found that parental alcohol use predicted selective attention deficits, which further mediated the executive functions. Subsequent studies consistently showed that executive functions are impaired in the children of fathers with alcohol-use disorders. For instance, a survey by Grekin et al9 examined the association between parental alcohol use and the child's executive functioning in 816 adolescents (414 boys and 402 girls) whose mean age was 15 years 2 months (standard deviation [SD] 3.48 months). The children were assessed with Stroop Color Word Test and Wisconsin Card Sorting Test. Results indicate that the study group had significant impairments in executive functions attributable to paternal alcohol dependence. However, the impairments in executive function were evident only on the Stroop test. Similar data on the executive functions in children have been published from the developing countries as well. For example, a study from India10 has examined the behavioral and cognitive problems among the children of fathers with and without alcohol dependence. The study used Malin's Intelligence Scale for Indian Children (MISIC) and Trail Making Test to assess the cognitive functions. The study revealed that the children of fathers with alcohol dependence have significant difficulties with frontal lobe functions, including deficits in executive functions. Although there is limited evidence, subsequent studies have found that executive functioning deficits seem to continue into the adulthood of AOFAD.11 Given the lack of literature from the developing countries, it is essential to study the nature of executive deficits in AOFADs more extensively.

Behavioral and Emotional Problems in AOFAD

A systematic review by West and Prinz12 which focused on the studies published between 1975 and 1985 revealed diverse psychopathology, vulnerability to inevitable psychosocial adversities and dysfunctional family interactions in children of fathers with alcohol dependence. Subsequent studies have also supported that parental alcoholism is associated with a heightened incidence of psychopathology, behavioral disturbances, and occupational impairments in children. For instance, Barnow et al13 examined the role of family loading of alcohol use in externalizing symptoms among 7 to 18 years old children. The results reveal a significantly positive correlation between children's attention and delinquent behavior and the number of first or second-degree relatives with alcohol-use disorders. The correlation was significant even after controlling for antisocial personality disorder and drug dependence in the parents. Thus, there is considerable evidence to suggest that executive functioning deficits besides family stress were strongly associated with various behavioral and emotional problems, including child delinquency in the context of parental alcohol-use disorders.9

A community-based longitudinal study by Keller et al14 yielded results similar to the previous studies. Keller et al followed up families with a child in kindergarten (n = 235) at two time-points. They found a direct effect of parental alcohol problems on both internalizing and externalizing problems in children through the mediation of destructive marital conflict and indirect effects of paternal drinking. Studies from developing countries have reported similar findings. A study from India revealed lower self-esteem and poor adjustment in AOFADs (n = 50) when compared with the matched, reference controls, though the stress and vitiated domestic environment were attributed for the same.15 Another study from India indicated that the children of alcohol-dependent parents have significant externalizing and internalizing problems, with girls having more problems than boys. However, the family environment is reportedly adverse for both boys and girls.16 Another study from India17 examined psychopathology and neuropsychological characteristics of 50 children with a paternal history of alcohol dependence compared with 50 children without such history. The study found that those with a paternal history have significant problems in both domains. The study did not elaborate on the nature of psychopathology in the study group. However, a potential limitation of this study is that it used Child Behavior Checklist as the single measure of psychopathology sans any clinical interviews and MISIC as a measure of neuropsychological status even though it is not a robust measure. A study from an inpatient facility of a tertiary health care center in central India examined psychopathology in children of alcohol-dependent parents (n = 50) and no-alcohol-dependent parents in the age range of 4 to 14 years.18 The results indicate that the children of parents with alcohol dependence had marked levels of depression and anxiety but no significant issues related to behavioral problems, conduct disorder, psychotic symptoms, physical illness, emotional problems, and somatization. Another study from India also revealed that the children of parents with alcohol dependence experience a higher rate of anxiety, depression, and low self-esteem than children of non-alcoholic parents.19 Similar trends were noted from other developing countries. For instance, a study from Morocco indicates that AOFADs show significantly high levels of psychological distress, especially symptoms of somatization, hostility, and anxiety.20 Overall these findings suggest that the children and adolescent offspring of parents with alcohol dependence can have significant levels of both internalizing and externalizing problems.10 13 16 21 22 23 24 A few studies have noted that the behavior problems varied with the gender of the children, with externalizing problems more in boys and internalizing problems more in girls.6 20 But there is also evidence to suggest that gender is an essential factor only at certain age levels, particularly during pre-adolescence.25 26

In summary, a few studies have identified the importance of executive dysfunction in psychopathology in children of alcohol-dependent parents.2 8 Moreover, the nature of psychopathology can vary with a child's gender and family variables. However, prior Indian literature on executive function impairment among the offspring of alcohol-dependent fathers has been sparse and sporadic. Furthermore, previous studies have involved a narrower age range or have only assessed specific elements of executive functioning.

Participants

The sample consisted of two groups of adolescents aged 10 to 19 years. The age range was decided as per the World Health Organization.27 Group one included 39 AOFADs with the International Classification of Diseases -10 diagnosis of alcohol dependence in fathers. Group two had 45 adolescents without a history of alcohol dependence in fathers (hereafter, control group). The exclusion criteria included low body mass index (BMI), history of seizures, head injury, unconsciousness, and any major health problems in the last 2 years were. A few participants were recruited from schools (n = 53, 63%) and the community (n = 13, 16%) through the snowballing method. A few AOFADs were recruited by purposive sampling when their fathers came to the study center for mental health services for alcohol use (n = 18, 21%). Because of the differences in the sampling technique used, the control group cannot be expected to be exactly equal to AOFADs. For more detail, see Table 1 that presented the sociodemogrpahic characteristics of both groups.

Measures

Procedure

The study was approved by the Institute's Ethics Committee of the National Institute of Mental Health and Neurosciences (NIMHANS). Written informed assent from a child and consent from a parent were obtained if an adolescent was under 18 years of age. In the case of AOFADs recruited from the clinic, alcohol-use history in fathers was noted from the case file. Conversely, in the case of adolescents recruited from the schools and community, the history of alcohol dependence in the father was confirmed by interviewing the fathers and/or the mothers of the adolescents. Each adolescent who participated in the study was further interviewed individually to obtain socio-demographic information. The adolescent's BMI was assessed and interpreted as per the revised growth charts for Indian children.31 Information regarding the health of the adolescents was obtained from their mothers, and it was considered nil significant if the adolescent did not require a hospital visit in the last 2 years. BRIEF-P and SDQ were administered individually by a trained project staff by directly interviewing the mothers.

Statistical Analysis

The data were analyzed using Statistical Package for Social Sciences for Windows version 24. Group differences in executive function impairment (AOFADs and control group) were analyzed using the chi-square test and t-test/Mann–Whitney U. Spearman's and Pearson's correlation coefficients were computed to examine the associations among selected clinical variables, BRIEF scores, and SDQ scores. Analysis of covariance (ANCOVA) was done to determine the differences in the impairment of executive functions after controlling for income and education, as the two groups differed significantly on these two variables.

Correlation between BRIEF and SDQ Scores in AOFADs

The mean SDQ total difficulties score was 25.87 (SD 4.89; range = 13.0–35.0), and the mean GEC score was 59.07 (SD = 7.68; range = 45.0–77.0). The GEC score in the AOFADS (n = 39) positively correlated with SDQ's total difficulties score (r = 0.49, p < 0.01), as well two of the sub-domains, viz. emotional problems score (r = 0.48, p < 0.01) and hyperactivity score (r = 0.58, p < 0.01). The CRI (r = 0.53, p < 0.01) and BRI (r = 0.31, p < 0.05) positively correlated with the SDQ total difficulties score.

Nature of Executive Functioning Deficits

Children with the father having alcohol dependence were found to have maturational lag and executive function deficits.10 16 22 However, many studies, particularly those that focused on adults, have primarily described inhibition impairment.26 32 The current study reveals that AOFADs can have significant difficulties in various executive functions such as inhibiting impotent responses, poor self-monitoring, shifting focus to adaptive responses, emotional control, and overall organizational skills. Thus, the problems seem to encompass the core three dimensions of executive functions, viz., behavioral, emotional, and cognitive capacities and the problems seem to be clinically significant. These findings are similar to the emerging evidence noted in adults with alcohol dependence that impairment encompasses each subcomponent of executive functions.1

Nature of Emotional and Behavioral Problems

SDQ scores indicate that AOFADs experience significantly more emotional and behavioral problems than the control group. The issues ranged from emotional problems, conduct problems, and hyperactivity to interpersonal difficulties with peers. However, AOFADs did not differ from the control group in prosocial behaviors. These findings are supported by the existing literature that internalizing disorders,26 33 conduct disorders,10 33 34 peer problems,20 and low self-esteem19 are widely prevalent in AOFADs. The majority of the previous studies indicate that externalizing disorders are more common than internalizing disorders in children of alcohol-dependent parents.10 22 However, the current study suggests that both internalizing and externalizing problems are prevalent in AOFADs and they exist without any impairments in prosocial behaviors. In light of these findings, it is necessary to examine if the group differences were due to gender differences. A few studies that have examined gender differences have reported externalizing problems are found more among boys and internalizing problems are more among girls.6 16 However, the current study did not find any gender differences in behavioral and emotional problems as measured by SDQ. This finding corroborates with the study by Furtado et al35 that gender differences in psychopathology may not be evident in adolescents and older groups.

Father's Alcohol Dependence and Child's Executive Dysfunctions and Behavioral Pathology

The current study supports the previous studies that the mean number of years of alcohol dependence in fathers positively correlated with children's executive functional impairments and psychopathology.36 For instance, Grekin et al9 found that paternal alcohol-use disorders are associated with child executive functioning and family stress, which may lead to externalizing problems such as child delinquency. Insights into the link between executive functions and psychopathology also come from studies focusing on general physical conditions. For instance, a survey of adolescents with coronary heart diseases indicates that executive function problems can disrupt the application of critical adaptive coping skills, resulting in poor coping and more significant emotional distress.37

Some studies found that fathers' alcohol dependence and children's psychopathology are not consistent when other variables are factored.2 Conversely, a few studies indicate that the association is robust even after controlling for important variables such as children's age and gender.13 14 16 17 26 38 However, the current study reveals a strong association between executive functions and psychopathology in AOFADs even after controlling for family income and AOFADs' education. Therefore, this study suggests that executive dysfunctions and paternal alcohol dependence strongly correlated with both internalizing and externalizing problems in AOFADs. Interestingly, the AOFADs did not differ from their peers in interpersonal skills and prosocial behaviors. Thus, it indicates that AOFADs can have well-preserved interpersonal or social skills even in the backdrop of emotional and behavioral problems. These findings have an important implication for intervention—strengths coexist with behavioral disturbances and the former can be strengthened to the child's advantage.

There are specific limitations to this study. The adolescents' executive functions were reported by parents, while the emotional and behavioral problems were self-reported by the adolescents. Hence, reporting biases cannot be ruled out. More importantly, robust methods such as clinical interviews were not employed to understand the psychopathology in AOFADs. Parental psychopathology was not examined or controlled in the study.