Journal of Mental Health and Human Behaviour

: 2016  |  Volume : 21  |  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

Correspondence Address:
Shivanand Kattimani
Department of Psychiatry, JIPMER, Puducherry - 605 006


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.

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;21:112-116

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 2023 Feb 3 ];21:112-116
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Full Text


Alcohol dependence is a complex and heterogeneous disorder with both genetic and environmental determinants. [1] The studies have found that parental alcohol use disorder is associated with an increased risk of alcohol dependence in offspring. [2],[3] Impulsivity is defined as a predisposition toward rapid, unplanned reactions to internal or external stimuli without due regard to the negative consequences. [4] 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 [5],[6],[7] and is also associated with the development of dependence in individuals who have started drinking. [8] 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. [7],[9] Research suggests that this association is mediated by a shared genetic factor [7],[10],[11] and is more specific to those with a family history of alcoholism. [11],[12] Research in India has been consistent with these findings, though studies have been few and hampered by small sample sizes and methodological limitations. [4],[9]

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. [13],[14] Such behaviors are more frequent in the children of alcoholic fathers, [15] and this has been demonstrated in Indian studies as well. [16],[17] The relationship of externalizing behaviors to impulsivity is complex, though research suggests that they may share common genetic and neurobiological mechanisms. [18],[19]

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. [20] The presence of ADHD was evaluated as per Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) criteria [21] 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 [22] 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. [23] 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 [24] has been used in Indian children by earlier researchers. [25] 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. [26]

The CBCL is used to assess a wide variety of behaviors and emotions in children aged 6-18 years. [27] 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.


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}

[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}


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 [7],[10],[15],[28] and Indian studies. [9],[12],[16],[17] However, internalizing symptoms were not more commonly seen, which is in contrast to certain other research findings [29] but consistent with a recent large twin study which found a conclusive association for externalizing, but not internalizing problems in the children of alcoholics. [30] 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. [31],[32]

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; [33],[34] our results are in keeping with earlier research which has identified a specific association between nonplanning and alcohol dependence. [34],[35] This association between nonplanning impulsivity and alcohol dependence appears to be more specific for early-onset alcoholism. [36]

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. [12],[37] In turn, such deficits may reflect a common genetic diathesis, and linkage of both impulsivity and alcoholism to genes in the GABA, [11] dopamine, [18] and serotonin [38] 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. [39] 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. [17] 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 [40] and adults later diagnosed with alcohol dependence. [41] 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. [42] 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. [43] Sixth, although self-report has been shown to correlate significantly with certain aspects of alcoholism in adults, [26] 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. [44]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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