Researchers have recognized that children of alcoholics (COAs) are a high risk population-at elevated risk for alcoholism and other biological, psychological and social difficulties (Puttler et al., 1998). However, many individual COAs do not develop problems either as children or adults. A significant amount of research effort has been expended to differentiate what factors and patterns of development distinguish high-risk COAs (with problems) from resilient COAs (without problems). In this bulletin we will briefly discuss the behavioral problems associated with a young person having an high-risk COA status.

It has been proposed and reasonably substantiated that high-risk COAs live within a nexus of parental and family risk factors that aggregate in such a manner so as to increase the child's propensity toward behavioral problems (Ellis, Zucker & Fitzgerald, 1997). Behavior problems associated with high-risk COAs include externalizing problems with associated patterns of intellectual functioning, and internalizing problems.

Externalizing Problems
Externalizing problems include rule breaking behavior (e.g., breaks rules, lacks guilt, bad friends, lies, steals, swears, truant, uses drugs, etc.) and aggressive behaviors (e.g., argues a lot, defiant, mean, destroys things, explosive, has temper, loud, threatens, etc.), according to Achenbach-TRF, Child Behavior Checklist, 2001. Externalizing behaviors in COAs have been connected with an aggregation ("nesting") of co-occurring risk factors including impulse "under-control," negative affectivity-temperament and factors found in their alcoholic parent's "high lifetime levels of antisocial involvement" (Puttler et al., 1998). This aggregate of risk factors seems to express itself in a developing line of early patterns of rule breaking behavior, trouble making, and early negative peer involvement that morphs into involvement in a deviant peer network which reinforces the deviant behavior.

Internalizing Problems
Internalizing behavior problems associated with a high-risk COA status include anxious/depressed mood (e.g., cries a lot, numerous fears, nervous, worries, feels worthless, self-conscious, feels too guilty, etc), having a depressed mood and being withdrawn (e.g., enjoys little, shy, timid, sad, lacks energy, rather be alone, etc.) and having somatic complaints (e.g., feels dizzy, overtired, aches, headaches, nausea, eye problems, stomach problems, etc.) per Achenbach-TRF of CBCL, 2001.

Researchers, Hill et al., 1998, have pointed out that in contrast to the more pronounced and problematic externalizing behaviors associated with COA status, there is a sub-group of COAs who are temperamentally and behaviorally inhibited and seem vulnerable to a different, internalizing pathway that leads to addiction and other co-occurring psychopathologies (major depression, agoraphobia, anxiety disorders) in their youth and young adult years. A concurring cross-sectional study by Bygholm Christensen & Bilenberg (2000) comparing 103 Danish children of alcoholic fathers and mothers in treatment to non-COA controls found that COAs had twice as great a risk of displaying internalizing behavior in the clinical range (the same odds ratio as children of depressed parents); and that maternal alcoholism had a greater impact on daughters' internalizing symptoms, whereas paternal alcoholism had a greater internalizing impact on sons.

Hill and colleagues make an important practical point about these internalizing COAs. They assert that this COA subgroup of "behaviorally inhibited children are often viewed by parents and teachers as 'good' children because they are not as disruptive as children with externalizing behavior problems" (p. 416). Because their behavior does not press educators, they many times do not register a level of concern that warrants interventive action. It can be seen from Hill and colleagues work, that in terms of positive contribution to the class, to the curricular flow, and to educational outcomes, these children present a real need for intervention. They suggest that internalizing children may (1) have a harder time making friends with classroom peers, which (2) can reduce the buffering effects of friendship upon the negative impact of the parent's alcoholism, furthering feelings of alienation, (3) dampening the development of social skills, (4) leading to more disengagement from classroom participation, and (5) ultimately finding school less rewarding.

These investigators also suggest that the, "recognition by teachers that behaviorally inhibited children are at risk for a variety of problems may provide opportunities for intervention," and hypothesize that "school based programs that teach social skills to children identified as behaviorally inhibited could be effective in reducing psychiatric and substance abuse problems" (Hill et al., 1998, p. 416). It seems plausible that by using such skill-enhancing interventions, internalizing SI-children could have a more engaged school experience with the possibility of enhanced overall performance.

Readings

• Bygholm Christensen, H. and Bilenberg, N. (2000). Behavioural and emotional problems in children of alcoholic mothers and fathers. European Child & Adolescent Psychiatry 9:219-226.
• Ellis, D. A., Zucker, R. A., and Fitzgerald, H. E. (1997). The role of family influences in development and risk. NIAAA Alcohol Health & Research World 21(3): 218-226.
• El-Sheikh, M. and Flanagan, E. (2001). Parental problem drinking and children's adjustment: family conflict and parental depression as mediators and moderators of risk. Journal of Abnormal Child Psychology 29:5, 417-432.
• Hill, S. Y., Lowers, L., Locke, J., Snidman, N. and Kagan, J. (1999). Behavioral inhibition in children from families at high risk for developing alcoholism. Journal of the American Academy of Child and Adolescent Psychiatry 38:4, 410-417.
• Loukas, A., Fitzgerald, H. E., Zucker, R. A., and von Eye, A. (2001). Parental alcoholism and co-occurring antisocial behavior: prospective relationships to externalizing behavior problems in their young sons. Journal of Abnormal Child Psychology 29:2, 91-106.
• Malone, S. M., Iacono, W. G., and McGue, M. (2002). Drinks of the father: Father's maximum number of drinks consumed predicts externalizing disorders, substance use, and substance use disorders in preadolescent and adolescent offspring. Alcoholism: Clinical and Experimental Research 26:12, 1823-1832.
• Puttler, L. I., Zucker, R. A., Fitzgerald, H. E., and Bingham, C.R. (1998). Behavioral outcomes among children of alcoholics during the early and middle childhood years: familial subtype variations. Alcoholism: Clinical and Experimental Research 22:9, 1962-1972.
• Schuckit, M. A., Smith, T.L., Radziminski, S., Heyneman, E.K. (2000). Behavioral symptoms and psychiatric diagnoses among 162 children in nonalcoholic or alcoholic families. American Journal of Psychiatry, 157:11, 1881-1883.
• Twitchell, G.R., Hanna, G. L., Cook, E. H., Fitzgerald, H. E., Little, K. Y., and Zucker, R. A. (1998). Overt behavior problems and serotonergic function in middle childhood among male and female offspring of alcoholic fathers. Alcoholism: Clinical and Experimental Research 22:6, 1340-1348.
• Wall, T. L., Garcia-Andrade, C., Wong, V., Lau, P. and Ehlers, C.L. (2000). Parental history of alcoholism and problem behaviors in Native-American children and adolescents. Alcoholism: Clinical and Experimental Research 24:1, 30-34.
• Weinberg, N. Z. (1999). Commentary: Behavioral inhibition and developmental risk. Journal of the American Academy of Child and Adolescent Psychiatry 38:4, 417-419.