|Year : 2016 | Volume
| Issue : 2 | Page : 112-116
Externalizing behavior and impulsivity in the children of alcoholics: A case-control study
Ayyanar Sugaparaneetharan1, Shivanand Kattimani1, Ravi Philip Rajkumar1, Siddharth Sarkar2, Subramanian Mahadevan3
1 Department of Psychiatry, JIPMER, Puducherry, India
2 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
3 Department of Pediatrics, JIPMER, Puducherry, India
|Date of Web Publication||4-Nov-2016|
Department of Psychiatry, JIPMER, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Context: Reduced behavioural inhibition, characterized by impulsivity and disruptive behaviour disorders, has been identified as a developmental precursor of alcoholism with a considerable genetic component. Aims: The present study aimed to assess whether children of fathers with alcohol dependence have high impulsivity and externalizing behaviours. Setting and Design: Observational case-control study, done in a tertiary care teaching hospital of Southern India. Materials and Methods: The present case-control study recruited 50 children aged 7 to 14 years of fathers with alcohol dependence and 50 age- and gender-matched children of fathers without alcohol dependence. The two groups were compared using the DSM-IV-TR criteria for ADHD, the Barratt Impulsivity Scale (BIS) and the Child Behaviour Checklist (CBCL). Statistical Analysis Used: Descriptive statistics used to summarise the study findings. Cases and controls were compared on BIS and CBCL scores using a general linear model (GLM). All analyses were two tailed and test P value <0.05 was considered significant. Results: The children of fathers with alcohol dependence were more likely to meet criteria for ADHD (30% versus 10%, χ2 = 6.250, P = 0.012). After controlling for age and gender, impulsivity scores on the BIS tended to be higher in the cases (F = 2.410, P = 0.055) than controls, mainly in the non-planning domains (F = 3.650, P = 0.008). Similarly, externalizing behaviours on CBCL were more common in the cases than controls (F = 2.817, P = 0.029). Conclusions: Children of fathers with alcohol dependence had greater impulsivity and externalizing behaviours. This may represent a behavioural phenotype as well as a potential target for early intervention.
Keywords: ADHD, alcohol dependence, children, endophenotype, impulsivity
|How to cite this article:|
Sugaparaneetharan A, Kattimani S, Rajkumar RP, Sarkar S, Mahadevan S. Externalizing behavior and impulsivity in the children of alcoholics: A case-control study. J Mental Health Hum Behav 2016;21:112-6
|How to cite this URL:|
Sugaparaneetharan A, Kattimani S, Rajkumar RP, Sarkar S, Mahadevan S. Externalizing behavior and impulsivity in the children of alcoholics: A case-control study. J Mental Health Hum Behav [serial online] 2016 [cited 2021 May 13];21:112-6. Available from: https://www.jmhhb.org/text.asp?2016/21/2/112/193430
| Introduction|| |
Alcohol dependence is a complex and heterogeneous disorder with both genetic and environmental determinants.  The studies have found that parental alcohol use disorder is associated with an increased risk of alcohol dependence in offspring. , Impulsivity is defined as a predisposition toward rapid, unplanned reactions to internal or external stimuli without due regard to the negative consequences.  This behavioral phenotype is associated with several psychiatric disorders, particularly mood and substance use disorders. Specifically, impulsivity has been found to predict early onset drinking and alcohol use disorder in adolescence and adulthood ,, and is also associated with the development of dependence in individuals who have started drinking.  Childhood disorders associated with prominent impulsivity, such as attention deficit hyperactivity disorder (ADHD), increase the risk for the later development of alcohol dependence, and such patients tend to have an early onset of dependence. , Research suggests that this association is mediated by a shared genetic factor ,, and is more specific to those with a family history of alcoholism. , Research in India has been consistent with these findings, though studies have been few and hampered by small sample sizes and methodological limitations. ,
Apart from impulsivity, other externalizing behaviors - such as oppositional behavior, rule-breaking, and aggression - have also been associated with alcohol dependence, particularly early-onset, family history-positive alcoholism. , Such behaviors are more frequent in the children of alcoholic fathers,  and this has been demonstrated in Indian studies as well. , The relationship of externalizing behaviors to impulsivity is complex, though research suggests that they may share common genetic and neurobiological mechanisms. ,
In summary, impulsiveness and externalizing behaviors are risk factors for alcoholism, particularly early-onset alcohol dependence and both occur at high frequencies in the children of alcoholic fathers. To assess the relationship between these two factors, which has not yet been attempted in the Indian context, this study was conducted to compare the levels of impulsivity and externalizing behaviors - and the correlations between them - in children with or without a paternal history of alcohol dependence.
| Subjects and Methods|| |
This case-control study was conducted at the de-addiction clinic of a tertiary care hospital center in Southern India. The center caters to substance users from Puducherry and nearby areas and the majority of patients present with alcohol abuse or dependence. Most patients are brought for treatment by their families. Treatment is provided in the form of detoxification and relapse prevention as well as supportive group therapy for wives and other relatives. The study was carried out between September 2010 and July 2012.
For the purpose of this study, cases consisted of 50 children aged 7-14 years of age whose biological fathers fulfilled the ICD-10 DCR criteria for current alcohol dependence but were abstinent for the past 1 month. Recruitment was carried out as follows: Patients with alcohol dependence following up at the de-addiction clinic were screened. Those individuals with children in the age group 7-14 years were informed about the study, and those who agreed to participate were enrolled. In case, a patient had more than one child in that age group; he was asked to bring his eldest child. Fifty age- and gender-matched children aged 7-14 years, recruited from the children of hospital staff and their relatives without a history of alcohol dependence, formed the control group. Children suffering from an active medical or neurological disorder, those previously diagnosed as having psychiatric illness or receiving psychotropic medication, those with developmental delay, and those with a family history of psychiatric disorder were excluded from the study. None of the cases' mothers had a history of alcohol use. This age range was chosen to represent the pediatric population as per the guidelines of the institute's child psychiatry services, which cater to children up to the age of 14, and at the same time to recruit children who could provide valid information on self-rated impulsivity. The study was approved by the Institute's Ethics Committee. All participants were recruited after obtaining assent from them and written informed consent from their parents.
A brief interview was conducted to collect details regarding the present or past psychiatric illness in the children, family history of psychiatric illness, and substance dependence in first-degree family members using ICD-10 DCR.  The presence of ADHD was evaluated as per Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) criteria  of ADHD. Impulsivity in children was assessed using Barratt's Impulsivity Scale (BIS). Behavioral problems in children were assessed using the Child Behavior Checklist (CBCL). The information was gathered in a single session by one of the authors.
The BIS  is a self-report questionnaire designed to assess the personality and behavioral construct of impulsiveness. The current version of the BIS is composed of 30 items describing common impulsive or nonimpulsive behaviors and preferences. The structure of the instrument allows for the assessment of six first-order factors (attention, motor, self-control, cognitive complexity, perseverance, and cognitive instability) and three second-order factors, i.e., attentional impulsiveness (attention and cognitive instability), motor impulsiveness (motor and perseverance), nonplanning impulsiveness (self-control and cognitive complexity). These factors have been consistently identified in patient populations, including children, across cultures.  A total score is obtained by summing the first or second-order factors. Items are scored on a 4 point scale from rarely/never, occasionally, often, and always/almost always. Some of the items are reverse scored. Total scores can range from 30 to 120, and higher scores reflect greater impulsivity. A validated adolescent version of the scale  has been used in Indian children by earlier researchers.  In case a child in our study had difficulties in understanding a particular question, assistance was given by the investigator through conversational interviewing. We used self-reported impulsivity in our study as it appears to be more strongly correlated with alcohol-related behaviors than other measures of impulsiveness. 
The CBCL is used to assess a wide variety of behaviors and emotions in children aged 6-18 years.  The CBCL is a behavior checklist that can be filled by parent and primary care taker under the guidance of the interviewer. It contains a total of 113 questions. The questions are grouped into 8 categories, or subscales, which focus on different aspects of behavior and include social withdrawal, somatic complaints, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. Items are rated on a 3-point scale based on the frequency of occurrence. Higher scores on the CBCL indicate greater behavioral disturbance.
Statistical analysis was done using SPSS version 17.0 (SPSS Inc. Chicago, Ill, USA). Descriptive statistics in the form of frequencies and mean with standard deviation were used to summarize the study findings. Cases and controls were compared on BIS and CBCL scores using a general linear model (GLM). GLM was used to adjust for the possible confounding effects of age and gender in the two groups. The partial η2 was used as a measure of effect size. All analyses were two-tailed, and a P < 0.05 was considered statistically significant.
| Results|| |
Fifty children were recruited in each group. The mean age in both groups was 11.52 years (±2.03 years). Fifteen (30%) of the cases and 5 (10%) of the controls had a DSM-IV-TR diagnosis of ADHD, the difference being statistically significant (χ2 = 6.250, P = 0.012). The scores on the BIS and CBCL in both the groups are shown in [Table 1]. GLM was used to compare the cases and controls as there were interaction effects of gender and age. From the table, it can be surmised that after controlling for age and gender, there was a trend level difference in the BIS total score between the cases and controls (P = 0.055). When individual domains of impulsivity were considered, nonplanning domain scores were significantly higher in the children of alcoholics (P = 0.008). Through the overall CBCL scores did not differ significantly between the cases and controls (P = 0.151), cases scored significantly higher than controls on the externalizing symptoms subscale (P = 0.029).
|Table 1: Scores on impulsivity and scores on various child behavioral domains |
Click here to view
[Table 2] shows the correlation analysis between BIS scores and CBCL total scores, externalizing symptoms and internalizing symptoms in cases and controls. Impulsivity, as measured by the BIS, was strongly and significantly correlated with the total scores on CBCL and externalizing symptoms on CBCL (P < 0.001 for the comparisons) in both groups. However, the BIS impulsivity scores were not significantly correlated with the CBCL internalizing symptoms score.
|Table 2: Correlation between child behavior scores and impulsivity scores |
Click here to view
| Discussion|| |
In our study, externalizing behaviors and ADHD were more commonly present in the children of parents with alcohol dependence. This is consistent with both international research ,,, and Indian studies. ,,, However, internalizing symptoms were not more commonly seen, which is in contrast to certain other research findings  but consistent with a recent large twin study which found a conclusive association for externalizing, but not internalizing problems in the children of alcoholics.  This may reflect variations in study samples and methodology, or the effect of confounding factors such as paternal comorbidity, maternal mental health, and the child's gender. ,
Although total impulsivity was not significantly elevated in children of alcoholics after correction for confounding factors, these children scored significantly higher on the nonplanning domain of the BIS. Impulsivity is a multidimensional construct, and different dimensions of impulsivity may be more specifically correlated with specific alcohol-related variables; , our results are in keeping with earlier research which has identified a specific association between nonplanning and alcohol dependence. , This association between nonplanning impulsivity and alcohol dependence appears to be more specific for early-onset alcoholism. 
The origin of impulsive and externalizing behaviors in these children is multifactorial. They may reflect underlying deficits in cognitive functions, particularly those related to the frontal lobes such as planning and delaying responses. , In turn, such deficits may reflect a common genetic diathesis, and linkage of both impulsivity and alcoholism to genes in the GABA,  dopamine,  and serotonin  pathways has been documented. The association of these features with serotonergic dysregulation is supported by a study which found lower blood serotonin levels in children of alcoholics who scored high on a measure of behavioral problems.  On the other hand, psychosocial explanations must also be considered. Impulsive and disruptive behaviors may be an adaptive consequence of living and surviving in a family where at least one of the family members has alcohol dependence, as impulsive behavior in children is more common in families with significant interpersonal conflict.  Furthermore, there is evidence that exposure to adversity early in life, such as childhood abuse, can cause cognitive deficits and increase impulsivity both in the children of alcoholic parents  and adults later diagnosed with alcohol dependence.  A prospective study of young children of alcoholics found that a variety of other factors, including maternal warmth and parental depression, were associated with impaired self-regulation in the children of alcoholics, and that this, in turn, predicted externalizing behaviors at the age of 3.  These results illustrate that impulsivity and externalizing behaviors in these children cannot be ascribed to a single cause, and probably result from gene/environment interactions.
Some limitations of this study should be kept in mind while interpreting the findings. First, the study was conducted in a hospital setting; hence, generalization to other settings should be done with caution. Second, English language versions of the structured scales were used as a validated Tamil version was not available. Third, interviewer bias could not be fully eliminated due to the study design. Fourth, structured diagnostic instruments were not used to rule out the presence of other psychiatric disorders. Fifth, we did not examine any objective behavioral, biological or genetic correlates of impulsivity, which have been demonstrated in earlier studies of adolescents.  Sixth, although self-report has been shown to correlate significantly with certain aspects of alcoholism in adults,  we do not know if the same is true in children. And finally, we did not attempt to correct for other factors, such as maternal mental health or other childhood adversities, which could have mediated the association between a family history of alcoholism and these behaviors.
Despite these limitations, this study adds to the limited Indian literature on early childhood markers and risk factors for alcoholism in high-risk children. Impulsivity, particularly in the nonplanning domain, is associated with a family history of alcoholism, though this association is moderated by age and gender. Externalizing behavior is also significantly elevated in these children, and there is a significant correlation between the two, underlining their putative common origins. In keeping with this, protective factors such as secure attachment of the child to his mother can protect a child from externalizing behaviors even when there is a family history of alcoholism. Screening children of patients attending a de-addiction clinic for these behaviors may help to identify those at risk and to offer early intervention to children with undiagnosed ADHD or other externalizing disorders. Further research should focus on examining the longitudinal strength of this association, its biological and psychosocial determinants, and the role factors such as maternal care which may attenuate such behaviors and lead to better outcomes. 
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Light JM, Irvine KM, Kjerulf L. Estimating genetic and environmental effects of alcohol use and dependence from a national survey: A "quasi-adoption" study. J Stud Alcohol 1996;57:507-20.
Lieb R, Merikangas KR, Höfler M, Pfister H, Isensee B, Wittchen HU. Parental alcohol use disorders and alcohol use and disorders in offspring: A community study. Psychol Med 2002;32:63-78.
McGue M. A behavioral-genetic perspective on children of alcoholics. Alcohol Health Res World 1997;21:210-7.
Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. Psychiatric aspects of impulsivity. Am J Psychiatry 2001;158:1783-93.
Verdejo-García A, Lawrence AJ, Clark L. Impulsivity as a vulnerability marker for substance-use disorders: Review of findings from high-risk research, problem gamblers and genetic association studies. Neurosci Biobehav Rev 2008;32:777-810.
Ivanov I, Schulz KP, London ED, Newcorn JH. Inhibitory control deficits in childhood and risk for substance use disorders: A review. Am J Drug Alcohol Abuse 2008;34:239-58.
Chang Z, Lichtenstein P, Larsson H. The effects of childhood ADHD symptoms on early-onset substance use: A Swedish twin study. J Abnorm Child Psychol 2012;40:425-35.
Rubio G, Jiménez M, Rodríguez-Jiménez R, Martínez I, Avila C, Ferre F, et al.
The role of behavioral impulsivity in the development of alcohol dependence: A 4-year follow-up study. Alcohol Clin Exp Res 2008;32:1681-7.
Sringeri SK, Rajkumar RP, Muralidharan K, Chandrashekar CR, Benegal V. The association between attention-deficit/hyperactivity disorder and early-onset alcohol dependence: A retrospective study. Indian J Psychiatry 2008;50:262-5.
Edwards AC, Kendler KS. Twin study of the relationship between adolescent attention-deficit/hyperactivity disorder and adult alcohol dependence. J Stud Alcohol Drugs 2012;73:185-94.
Villafuerte S, Strumba V, Stoltenberg SF, Zucker RA, Burmeister M. Impulsiveness mediates the association between GABRA2 SNPs and lifetime alcohol problems. Genes Brain Behav 2013;12:525-31.
Silva MC, Benegal V, Devi M, Mukundan CR. Cognitive deficits in children of alcoholics: At risk before the first sip! Indian J Psychiatry 2007;49:182-8.
King SM, Iacono WG, McGue M. Childhood externalizing and internalizing psychopathology in the prediction of early substance use. Addiction 2004;99:1548-59.
Englund MM, Egeland B, Oliva EM, Collins WA. Childhood and adolescent predictors of heavy drinking and alcohol use disorders in early adulthood: A longitudinal developmental analysis. Addiction 2008;103 Suppl 1:23-35.
Barnow S, Schuckit M, Smith TL, Preuss U, Danko G. The relationship between the family density of alcoholism and externalizing symptoms among 146 children. Alcohol Alcohol 2002;37:383-7.
Narang RL, Gupta R, Mishra BP, Mahajan R. Temperamental characteristics and psychopathology among children of alcoholics. Indian J Psychiatry 1997;39:226-31.
Raman V, Prasad S, Appaya MP. Children of men with alcohol dependence: Psychopathology, neurodevelopment and family environment. Indian J Psychiatry 2010;52:360-6.
Esposito-Smythers C, Spirito A, Rizzo C, McGeary JE, Knopik VS. Associations of the DRD2 TaqIA polymorphism with impulsivity and substance use: Preliminary results from a clinical sample of adolescents. Pharmacol Biochem Behav 2009;93:306-12.
Tarter RE, Kirisci L, Mezzich A, Cornelius JR, Pajer K, Vanyukov M, et al.
Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. Am J Psychiatry 2003;160:1078-85.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1993.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR ®
. Washington, DC: American Psychiatric Publishing; 2000.
Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol 1995;51:768-74.
Chahin N, Cosi S, Lorenzo-Seva U, Vigil-Colet A. Stability of the factor structure of Barrat′s Impulsivity Scales for children across cultures: A comparison of Spain and Colombia. Psicothema 2010;22:983-9.
Fossati A, Barratt ES, Acquarini E, Di Ceglie A. Psychometric properties of an adolescent version of the Barratt Impulsiveness Scale-11 for a sample of Italian high school students. Percept Mot Skills 2002;95:621-35.
Singh P, Solanki RK, Bhatnagar PS. BIS-11A-Hindi version: A preliminary study of impulsivity in rural and urban Indian adolescents. Indian J Psychiatry 2008;50:96-9.
Hamilton KR, Ansell EB, Reynolds B, Potenza MN, Sinha R. Self-reported impulsivity, but not behavioral choice or response impulsivity, partially mediates the effect of stress on drinking behavior. Stress 2013;16:3-15.
Loukas A, Fitzgerald HE, Zucker RA, von Eye A. Parental alcoholism and co-occurring antisocial behavior: Prospective relationships to externalizing behavior problems in their young sons. J Abnorm Child Psychol 2001;29:91-106.
Puttler LI, Zucker RA, Fitzgerald HE, Bingham CR. Behavioral outcomes among children of alcoholics during the early and middle childhood years: Familial subtype variations. Alcohol Clin Exp Res 1998;22:1962-72.
Waldron M, Martin NG, Heath AC. Parental alcoholism and offspring behavior problems: Findings in Australian children of twins. Twin Res Hum Genet 2009;12:433-40.
Hussong AM, Flora DB, Curran PJ, Chassin LA, Zucker RA. Defining risk heterogeneity for internalizing symptoms among children of alcoholic parents. Dev Psychopathol 2008;20:165-93.
Hussong AM, Cai L, Curran PJ, Flora DB, Chassin LA, Zucker RA. Disaggregating the distal, proximal, and time-varying effects of parent alcoholism on children′s internalizing symptoms. J Abnorm Child Psychol 2008;36:335-46.
Smith GT, Fischer S, Cyders MA, Annus AM, Spillane NS, McCarthy DM. On the validity and utility of discriminating among impulsivity-like traits. Assessment 2007;14:155-70.
Coskunpinar A, Dir AL, Cyders MA. Multidimensionality in impulsivity and alcohol use: A meta-analysis using the UPPS model of impulsivity. Alcohol Clin Exp Res 2013;37:1441-50.
Tomassini A, Struglia F, Spaziani D, Pacifico R, Stratta P, Rossi A. Decision making, impulsivity, and personality traits in alcohol-dependent subjects. Am J Addict 2012;21:263-7.
Dom G, D′haene P, Hulstijn W, Sabbe B. Impulsivity in abstinent early- and late-onset al
coholics: Differences in self-report measures and a discounting task. Addiction 2006;101:50-9.
Crews FT, Boettiger CA. Impulsivity, frontal lobes and risk for addiction. Pharmacol Biochem Behav 2009;93:237-47.
Jakubczyk A, Wrzosek M, Lukaszkiewicz J, Sadowska-Mazuryk J, Matsumoto H, Sliwerska E, et al.
The CC genotype in HTR2A T102C polymorphism is associated with behavioral impulsivity in alcohol-dependent patients. J Psychiatr Res 2012;46:44-9.
Twitchell GR, Hanna GL, Cook EH, Fitzgerald HE, Little KY, Zucker RA. Overt behavior problems and serotonergic function in middle childhood among male and female offspring of alcoholic fathers. Alcohol Clin Exp Res 1998;22:1340-8.
Lovallo WR, Farag NH, Sorocco KH, Acheson A, Cohoon AJ, Vincent AS. Early life adversity contributes to impaired cognition and impulsive behavior: Studies from the Oklahoma Family Health Patterns Project. Alcohol Clin Exp Res 2013;37:616-23.
Jakubczyk A, Klimkiewicz A, Mika K, Bugaj M, Konopa A, Podgórska A, et al.
Psychosocial predictors of impulsivity in alcohol-dependent patients. J Nerv Ment Dis 2013;201:43-7.
Eiden RD, Edwards EP, Leonard KE. A conceptual model for the development of externalizing behavior problems among kindergarten children of alcoholic families: Role of parenting and children′s self-regulation. Dev Psychol 2007;43:1187-201.
Schweinsburg AD, Paulus MP, Barlett VC, Killeen LA, Caldwell LC, Pulido C, et al.
An FMRI study of response inhibition in youths with a family history of alcoholism. Ann N Y Acad Sci 2004;1021:391-4.
Edwards EP, Eiden RD, Leonard KE. Behaviour problems in 18- to 36-month old children of alcoholic fathers: Secure mother-infant attachment as a protective factor. Dev Psychopathol 2006;18:395-407.
[Table 1], [Table 2]