• Abrupt changes in work or school attendance, quality of work, work output, grades, discipline.

• Unusual flare-ups or outbreaks of temper.

• Withdrawal from responsibility.

• General changes in overall attitude.

• Deterioration of physical appearance & grooming.

• Wearing of sunglasses at inappropriate times. 

• Continual wearing of long-sleeved garments particularly in hot weather or reluctance to wear short sleeved attire when appropriate.

• Association with known substance abusers. 

• Unusual borrowing of money from friends, co-workers or parents.

• Stealing small items from employer, home or school.

• Secretive behavior regarding actions & possessions; poorly concealed attempts to avoid attention & suspicion such as frequent trips to storage rooms, restroom, basement, etc.

Every day, more than 700,000 Americans are being treated for alcoholism. In addition, up to 1/2 of American men have problems that are caused by alcohol.

• blackouts
• arrests
• loss of friends
• assaults
• sexual harassment & so on.

Among frequent binge drinkers, 62% of the men & 49% of the women had driven after drinking.

One doesn't have to be an alcoholic, however, to have serious problems w/alcohol.

• 80% of drunk drivers in fatal accidents 

• 67% of persons arrested for drunk driving aren't alcoholics

One doesn't have to be poor to have an alcohol problem, among women over 55 who make more than $40,000 a year, 23% have an alcohol problem. Only 8% of women this age, who make less than $40,000 a year, have alcohol problems.

Alcoholism remains very resistive to treatment. Peele describes the effectiveness of treatment this way: Most American alcoholics don't seek treatment; most of those that do enter treatment don't respond to it favorably; most of those who complete treatment relapse later!

As mentioned above, there has been a heated controversy between:

• (a) "alcoholism is a disease" (AA groups) which supposedly can only be controlled by total abstinence 

• (b) "alcoholism is a learned behavior" which can, in less severe cases, be unlearned, controlled & done in moderation (Miller & Berg, 1995; Miller & Munoz, 1976; Miller, 1978; Marlatt & Parks, 1982; Vogler & Bartz, 1985; Peele & Brodsky, 1991; Peele, 1998).

Alcohol:

• 450,000 of Americans die of smoking each year.
• 100,000 Americans die of alcohol each year.
• During their lifetime 27% of the population will suffer from a substance abuse disorder.
• 25% of Americans die of substance abuse.
• 95% of untreated addicts die of their addiction.
• 50% of traffic deaths are alcohol related.
• 50% of homicides are alcohol related.
• 40% of assaults are alcohol related.
• About 1/2 of state prison inmates & 40% of federal prisoners incarcerated for committing violent crimes report they were under the influence of alcohol or drugs at the time of their offence.
• More than 18 million patients currently need alcohol treatment & only 25% get it.
• Costs of alcohol abuse was $185 billion in 1998
• Costs of drug abuse was $97.7 billion in 1992.
• For every dollar spent on addiction treatment $7.00 are saved in costs to society in healthcare & criminal activity.

As a rule of thumb, the longer & heavier your drug use, the more problems you’ll experience during withdrawal. But also, as we just noted, the abstinence syndrome varies according to the type of substance (or substances) you’ve been using.

Two Causes

Medical research shows 2 major causes of physical addiction. First, your cells adapt to the drug & second, your metabolism becomes more efficient.

Adaptation in the cells. To your cells, the drugs you’re using become a way of life. Every time you use a drug, your blood carries it to every cell in your body. Your cells adjust. They grow to expect these doses on schedule.

Your cells learn to cope w/various drugs by defending themselves against the drugs’ toxic effects. Cell walls harden to retain stability & reduce toxic damage. But as your cells get tough against drugs, gradually more & more can be consumed. Your tolerance increases.

In the long run, however, cell walls break down. At this point, your cells not only lose their ability to keep toxins out but also become unable to retain essential nutrients. Many of them stop functioning altogether or start functioning abnormally. That’s when your organs (heart, brain, liver, or lungs), which are nothing more than whole systems of cells, begin to fail.

The family can be conceptualized as a dynamic system that changes over time as membership changes, individuals change and develop, relationships change, and the family's context changes.

A family system is interpretable only when its many multiple components are understood - the multiple components include the individual family members, the relationships between them, the family's relationships with its ecological context, the family's history (multi-generational and experience of events), and the host of internal and external forces for developmental change. There are several concepts that are key to a systems perspective on families (Begun, 1996 provides a review):

The family as a system is more than the sum of its parts. Family systems are composed of interdependent members whose interactions, dynamics, rules, boundaries, and patterns each contribute to family behavior. Individual family members affect the system as a whole, and the system affects individual members-there is a considerable degree of "circularity of influence" involved (Minuchin, 1974).

Changes in any part of the system affect the entire system. When there are developmental or other changes in an individual family member, changes in the interaction patterns between individuals, new family members are added, or family members leave, the changes reverberate throughout the system.

Sub-systems are embedded throughout the larger family system. Some of the most common sub-systems are the couple sub-system, parent-child sub-system, and sibling sub-system; family systems might also include:

• grandparent-grandchild
• step-parent and child
• half-siblings
• ex-partners 
• other extended family sub-systems

Family sub-systems do not operate independently of the whole system. Their character and nature are shaped by the overall culture of the family system. Family behavior may be enacted through sub-systems rather than the system as a whole. Interactions at the level of the sub-system may impact other family members and sub-systems, as well-both directly and indirectly.

Families exist within a larger social environment context. Families are nested in, are shaped by, and interact with other social systems that affect and are affected by family system processes. Thus, the family system is subject to events that occur within the:

• neighborhood
• community
• health care
• school
• workplace
• service delivery
• societal
• economic
• historical
• cultural systems

Social workers often rely on eco-maps in order to diagram and assess the nature of a family's complex interactions with its environmental context (Hartman, 1978).

Families are multi-generational. Family systems are influenced by their histories, as well as by an awareness of their futures. Families may have 4 or more generations that are currently relevant at one time, and family members are affected by inherited qualities across generations, as well. Social workers often utilize genograms to map the intergenerational and family history influences on family systems (Hartman, 1978).

Another characteristic of family systems approaches is an awareness of the fact that change in family systems is stressful and causes tension in the family. This applies to any change, positive or negative (e.g., death or other loss of a member, marriages, births, adoption, geographic moves, change in social status), because change requires families to dedicate resources and energy to adapt and adjust to their new circumstances.

Family systems are sometimes described by therapists as being very difficult to redirect and resistant to change - once systems have achieved a level of stability or homeostasis, they apply concerted efforts to maintain their hard-earned balance.

In fact, warnings have been offered about intervening to change an individual's alcohol abuse without adequately responding to the potentially destabilizing effect of an individual's recovery on the family system-the individual's drinking may represent a family system's homeostatic solution to otherwise distressed relationships (Steinglass, Davis, & Berenson, 1977; Orford, 1975).

The areas and points of family functioning where difficulties are likely to appear during an individual's long-term recovery from alcoholism include:

• Challenges in family role adjustment as the previously alcoholic individual attempts to regain significant roles abandoned through drinking (e.g., involvement in family decision making, authority, sex, intimacy, and other reciprocal exchanges);
• Difficulties in parent-child relationships, especially around behavior management and communication involving adolescent children;
• Developmental changes of family members, family life cycle transition, or situational change events experienced by the family system-e.g., launching children, job loss, adult developmental changes of either partner (Zweben & Perlman, 1983).

In sum, it is vitally important to take into consideration an individual's family (and other social contexts) when exploring the development, maintenance, or treatment of alcohol use disorders. The family system is an important client context, in part because it is one of the interpersonal situations in which the problems occur (Jacob & Leonard, 1988; McCrady & Epstein, 1995).

In some cases, the social context of family relationships may be a factor that becomes compelling for the maintenance of the alcohol problems (Shoham, Rohrbaugh, Stickle, & Jacob, 1998)-the specific nature of family interactions may foster the continuation of problematic drinking.

One central finding within the large body of research concerning the etiology of alcohol use disorders is that there exist multiple pathways to these outcomes (Cloninger, Sigvardsson, & Bohman, 1996). Clearly, there are complexly interacting contributions from genetics and other physiological forces, as well as influences from environmental contexts, including family, peer, workplace, neighborhood/community, and media. Alcohol use disorders are multiply determined (Hesselbrock, Hesselbrock, & Epstein, 1999).

Family Genetic Influences

Research indicates that genetic factors may contribute to the development of alcoholism, and family pedigree is the context for this particular source. Family pedigree studies that compare individuals with and without diagnosable alcohol dependency typically show an increase in the lifetime prevalence among biological relatives. The increase in risk for first-degree relatives (brother/sister and parent/child) developing alcohol dependency ranges from four to seven times the risk within the general population (Merikangas, 1990).

Adoption studies have compared children born of an alcoholic parent (usually the father) and reared by nonalcoholic adoptive parents with adopted children born of nonalcoholic parents. In U.S. and Scandinavian studies, the adopted infants of an alcoholic parent developed alcoholism as adults at higher rates than did their counterparts (Cloninger, Bohman, & Sigvardsson, 1981).

It is important to note that, while genetic factors are implicated in the development of alcohol use disorders, the findings also indicate that the genetic factors are not deterministic (Kendler, 1995; Slutske, et al., 1998; Cadoret, et al., 1995). In other words, genetic factors interact with other biological and environmental context factors to produce the observed outcomes.

Some factors relate to vulnerability and risk, others are protective or resilience factors. Genetics can explain an individual's vulnerability to alcohol use disorders, while environment and other biological factors contribute to their emergence or expression.

In recent years, tremendous progress has been made in uncovering the specific biological mechanisms involved in these observed results. Clearly there is no specific gene or chromosomal "address" that determines who will and who will not develop alcohol use disorders.

However, there is increasing evidence concerning the neurotransmitter activity and brain sensitivity that predispose and protect for these disorders. For example, some children of alcoholic parents demonstrate different physiological responses to the effects of alcohol when compared to other individuals.

Children of alcoholics may have greater sensitivity to the stress-dampening effects of alcohol than do other individuals (Pihl & Peterson, 1995), as well as less sensitivity to the intoxicating effects of alcohol (Schukit & Smith, 1996). A lack of sensitivity to alcohol's intoxicating effects and increased sensitivity to anxiety-reduction effects of alcohol are associated with greater risk of developing alcohol dependence (Schukit & Smith, 1996), and these features are more apparent among children with alcoholic parent than among individuals with no family history of alcoholism (Molina, Chasin, & Curran, 1994).

These physiological mechanisms appear to have a high degree of heritability, at least according to these studies of adult offspring of alcoholic parents.

Family Context Influences

If genetics actually predestined an individual to develop alcohol use disorders, then each alcoholic individual would have first order relatives with the problem, and almost all adopted individuals born of an alcoholic parent would develop the problem-regardless of family rearing environment. Since this is not the case, the genetic factors must interact with other biological and environmental context factors to determine the outcome-both in terms of risk and protective factors.

"Individuals reared with an alcohol-abusing parent are at risk for developing alcohol problems due both the genetic factors and to faulty role modeling" (O'Farrell, 1995). Genetics explain an increased vulnerability to alcohol use disorders; family environment contributes to and mediates their emergence or expression (O'Farrell & Fals-Stewart, 1999).

For example, alcoholic parents may be more likely to give birth to children with difficult temperaments, which in turn may become a risk factor for substance problems later in life. The impact of temperament on developmental outcomes is not a genetic phenomenon as much as it is a function of a constitutional factor that interacts strongly with social environment contexts (such as parenting environment) to shape an individual's developmental course.

Cadoret et al. (1995) reported a higher occurrence of substance abuse among the offspring of alcoholic fathers compared to other individuals, and attributed part of the effect to the increased likelihood of early conduct problems among these offspring.

It is important to note that the very same parenting factors that appear to be linked to adolescent alcohol abuse (e.g., low levels of parental emotional support and a lack of control and monitoring of child behavior) are also linked to a host of other adolescent problem behaviors, such as smoking and early sexual activity (Jacob & Leonard, 1994).

Non-substance abusing adolescent children of parents with alcohol use disorders are more likely than others to experience negative emotionality, aggression, stress reaction, alienation, and low well-being (Elkins, McGue, Malone, & Iacono, 2004). Chassin et al. (1996) observed greater emotional reactivity among adolescent children of alcoholic parents than among other adolescents. "Hyperreactivity" to stress may contribute to the emergence of future alcohol use disorders as these individuals attempt to modify their experiences of stress.

Family contexts may provide exposure to key antecedents and consequences for alcohol abuse. For example, many alcohol-abusing individuals cite family arguments, poor family communication, inadequate family problem solving, and nagging at home as antecedents of a drinking episode (O'Farrell & Fals-Stewart, 1999).

Family members may also serve to intentionally or inadvertently reinforce or punish the drinking, providing consequences that increase or decrease the likelihood of future drinking episodes.

There also exists research evidence that parenting and other family functioning factors may influence the development of alcohol problems during adolescence or early adulthood. For example, in families with an alcoholic parent, children and adolescents may find that they have easy access to alcohol.

It is interesting to note that among preschool aged children, the ability to accurately identify alcoholic beverages simply by smell is directly related to the amount of alcohol consumed by the parents (Noll, Zucker, & Greenberg, 1990). This evidence indicates that an individual's socialization about alcohol begins with the family of origin, and begins at a very young age.

Even very young children (aged 3-6 years) begin to formulate expectancies concerning the effects of alcohol, at an age when their primary socialization agents are family members (Zucker, et al., 1995), and expectancies may help to predict later drinking choices (Kushner, et al., 1995).

Furthermore, alcoholic parents may present older children and adolescents with a set of norms that tolerate heavy drinking, as well as an absence of parental monitoring for drinking and other potentially harmful behaviors (Dawson, 2000; Rose, 1998; Waldron & Selsnick, 1998).

Alcohol Use Disorder Influences on Family

Drinking and family functioning are linked (Roberts & Linney, 2000), although the relationship may be causal, reciprocal, iterative, or incidental to other causes.

There are several family problems that are likely to co-occur with an individual's alcohol abuse, including:

• intimate partner violence
• conflict and low relationship satisfaction
• economic and legal vulnerability
• child risks

Communication in family systems that involve members with substance problems may be characterized as highly critical, involving considerable amounts of nagging, judgments, blame, complaints, and guilt (Reilly, 1992).

Families of individuals with alcohol use disorders are often characterized by:

• conflict
• chaos
• communication problems
• unpredictability
• inconsistencies in messages to children
• breakdown in rituals and traditional family rules
• emotional and physical abuse (Connors, Donovan, & DiClemente, 2001)

Couples

Alcohol problems are common among couples that present for relationship/marital therapy (Halford & Osgarby, 1993), and marital problems are common among those who present for alcohol treatement (O'Farrell & Birchler, 1987). Alcohol abuse affects couples' relationships in a variety of negative ways, including:

• communication problems
• increased conflict
• nagging
• poor sexual relations
• domestic violence (Connors, Donovan, & DiClemente, 2001)

Individuals married to persons with alcohol use disorders have higher rates of psychological, stress-related medical problems, and greater use of medical care systems, than other individuals (Connors, Donovan, & DiClemente, 2001; Holder, 1998). There is great controversy over the concept of co-dependency in couples' alcohol-involved relationships.

On one hand, there exists some literature describing the characteristics of co-dependency. On the other hand, there are research studies indicating that these characteristics are present in the vast majority of the population (up to 95%), and that there is an absence of evidence supporting the validity of a "diagnosis" of co-dependency (Fisher & Harrison, 2000).

Parent-Child Relations

Parenting functions performed by individuals who are alcohol-impaired may be characterized as inconsistent, unpredictable, and lacking in clear rules and limits (Reilly, 1992). Children of alcoholic parents frequently experience chaotic parenting and poor quality home environments during significant developmental periods (Blanton et al., 1997; Jacob & Leonard, 1994; Zucker et al., 1996).

The children of alcoholic parents may be exposed to high levels of family conflict, as well (Moos & Billings, 1982; Webb & Baer, 1995). Parents with a history of substance abuse, compared to other parents, show lower constraint, control, harm avoidance and traditionalism in relation to their families (Elkins, McGue, Malone, & Iacono, 2004).

In some cases, disturbances in parent-child relationships are not only exhibited in the dyad involving an alcoholic parent, but also in the dyad involving the other parent. For example, Eiden and Leonard (1996) observed disturbances in the mother-infant attachments among dyads where the father was a heavy drinker.

There is clear documentation of the cognitive impairments associated with chronic, heavy alcohol consumption, and it is important to consider the ways in which these types of impairments might affect the quality and nature of childcare and child rearing (Sher, 1991). There does seem to be an association between parental alcohol/drug related problems and the development of parenting practices in the grown up children.

Among mothers, the effect on their parenting appears to be mediated by their own alcohol/drug problems; among fathers, the effect on their parenting appears to result from their own experiences of parental neglect in childhood, leading to a lack of parental warmth and more child neglect (Locke & Newcomb, 2004).

It is important to note that some of the parenting behaviors being described may be a response to behavioral problems among children, not only a cause of developmental problems. Children with difficult temperaments or conduct disorders present challenges that may contribute to poor parenting practices; if parental alcoholism is associated with these traits in offspring, it is not surprising that it is also associated with the observed differences in parenting (Gee & Cadoret, 1996).

Also suggestive of this mutual influence model is the observation that interactions between boys and their mothers were more similar than dissimilar among alcoholic and non-alcoholic families, as long as the non-disruptive children were the ones being compared (Dobkin, Charelbois, & Tremblay, 1997).

Children of Alcoholics

"Of an estimated 28 million Americans who are children of alcoholics, nearly 11 million are under the age of 18" (Adger, 2000, p. 235). The risk estimates of children of alcoholics (COAs) developing an alcohol use disorder vary from 4:1 to 9:1 (Russell, 1990). The variability in estimates is attributable to differences in study sampling, definitions and criteria, and assessment strategies.

For example, some COAs have a parent who is currently alcoholic, some have been exposed to a parent's alcoholism at some point in their lives, and still others have a parent (or parents) whose alcoholism predated their birth, but it may still have an impact on their development. Another way of looking at these individuals is to identify

(1) children of current alcoholics,

(2) children of parental period alcoholics, and

(3) children of lifetime alcoholics-a parent who was ever an alcoholic (Eigen & Rowden, 2000).

 

The distinction has important implications for epidemiological and assessment purposes.

In essence, children born to and living with a parent experiencing an alcohol use disorder are exposed to both biological and environmental forces that may contribute to developing alcohol problems themselves (Begun & Zweben, 1990).

In addition to being at higher risk for developing alcohol problems of their own, children of alcoholics have higher rates of other challenges than do children of non-alcohol impaired parents-even as adults (Holder, 1998). Children of alcoholic parents may have behavioral and school difficulties, including negative self-concepts, fearfulness, loneliness, difficulties in concentrating, attendance, and work completion (Fisher & Harrison, 2000).

Some of these difficulties may be attributed to chaotic home environments where basic needs are erratically met (sleep, food, hygiene, supervision). The environments experienced by adolescent sons and daughters of alcoholic parents tend to be characterized by greater stress than those of other adolescents (Chassin et al., 1996).

Studies of the Children of Alcoholics Screening Test (CAST) indicate that the scores on this instrument are associated with greater degrees of family dysfunction and disruption, less family cohesion, less family support, inconsistent child care, increased family conflict, and less close/intimate parent-child relationships (Fisher & Harrison, 2000).

It is clear that tremendous heterogeneity exists among the population of children whose parent(s) have alcohol use disorders, although there is currently an incomplete understanding of this heterogeneity. It is not always clear how the developmental outcomes are affected by alcohol per se or by having experienced a stressful childhood environment (e.g., parental disability/mental illness, parents' divorce, parental death).

A long-term Danish study of the developmental outcomes for the cohort of children born in 1966 demonstrated that a parent's alcohol abuse during childhood and adolescent years may affect increased mortality, self-destructive behaviors (suicide attempts, drug abuse), experiences of violence requiring hospitalization, teen pregnancy rates, and unemployment among young people in the 15-27 year age range (Christoffersen & Soothill, 2003).

The pathway for influence appears to have been the ways in which a parent's alcohol abuse frames childhood experiences with parental violence, family separations, and foster care placements. Similar results were observed in a study of the impact of paternal alcohol abuse on child development outcomes conducted in Norway-the child adjustment difficulties result from an accumulation of risk factors, rather than being a direct effect of the parent's alcohol abuse itself (Haugland, 2003).

The relevant risk factors include parental psychological problems, family climate, family health, family conflicts, severity of the alcohol abuse, the child's level of exposure to the alcohol abuse, and distortions or changes in family routines associated with the drinking behavior. It is not clear how these results translate to United States systems.

While it is clear that some risks exist for children growing up exposed to a parent's alcohol abuse, it is also clear that considerable amounts of resiliency also exist. For example, no significant problems are demonstrated by as many as 44% of adult children of alcoholics (D'Andrea, Fisher, & Harrison, 1994).

Research suggests that there are multiple determinants of children's degree of vulnerability to adverse events: the nature of the event, the duration of the event, the dosage or intensity of the event, the presence of mitigating or compensatory factors in the environment, intrinsic and acquired resiliencies, interpretations of the events, and resources for coping with the events (Anthony & Cohler, 1987; Begun & Zweben, 1990; Berkowitz & Begun, 2003).

Some children who exist within environments that appear to be high in risk for the development of a host of pathological outcomes appear to develop relatively unscathed, while others are harmed-this includes the diversity of children's responses to living with an alcoholic parent (Begun & Zweben, 1990; Werner, 1986; Werner & Smith, 1982).

A child living with an alcoholic parent may also be living with a non-alcoholic parent who may provide many of compensatory parenting functions. A supportive non-alcoholic parent or other caregiving adult (i.e., grandparent, aunt/uncle, elder mentor, adult friend) provides nurturance, protection, and guidance which optimize the development of a child with an alcoholic parent (Werner & Johnson, 2000).

Resilient children of an alcoholic parent very often had a non-alcoholic mother/step-mother who served as the "mainstay" of the family-94% of daughters and 80% of sons leading successful adult lives, compared to only 60% and 33.3% respectively of daughters and sons who experienced coping problems. In short, if the child's home environment involved the presence of a functional, central, "buffering" parent, the negative developmental impact of a father's alcoholism was somewhat mitigated; children had more problems when their family lives did not include a person that could be described in this way.

The adolescents living in alcoholic families that are less likely to begin using substances (including alcohol) are those who perceive that they have control over their environment, have good cognitive coping skills, and report that their families are highly organized (Hussong & Chassin, 1997).

Young adults from alcoholic families were less likely to report having drinking problems of their own if their families also managed to preserve rituals, structure, and daily routines (Hawkins, 1997). In short, the strength or disruption of the family appears to differentiate between children of alcoholics who experience greater or lesser degrees of well-being as adults, and drinking behavior and family functioning are strongly and reciprocally linked (Roberts & Linney, 2000).

Providing interventions, both preventive and treatment oriented, for children of alcoholics may be difficult and fraught with barriers (Morehouse, 2000). Some examples of barriers include: children (regardless of age) not wanting their parent to know that they are seeking help; children not having transportation or other access issues, including payment resources; fear, anxiety, lack of trust, embarrassment, and other emotional hurdles; parents minimizing the children's need or failing to provide consent; and, programs not being developmentally appropriate or appealing to this age group.

Fetal Alcohol Exposure

One significant source of risk associated with being the child of an alcoholic mother is the possibility of fetal exposure to alcohol or other substances. Fetal exposure to alcohol is associated with heightened probabilities for developmental delays, temperament difficulties, mental retardation, physical deformities, and neurological or other central nervous system vulnerabilities.

There is tremendous variability in the expression of these consequences of fetal exposure. The variability is poorly understood and only partially explicable in terms of amounts of alcohol consumed and timing in fetal development when exposure occurs.

Sibling Relationships

Alcohol research first used sibling studies to address the issue of heritability for alcohol problems. In addition to family pedigree and adoption studies, concordance in alcoholism patterns among monozygotic (identical) and dizygotic (fraternal) twin pairs were compared.

The results indicate greater concordance (similarity) in the patterns for monozygotic twins than among dizygotic twins and other non-twin sibling pairs, indicating the presence of a genetic influence on the development of alcoholism (Kendler, et al., 1992; McGue, Pickens, & Svikis, 1992). The outcome, however, has a strong environmental influence-otherwise, the concordance among monozygotic twins would be close to 100% (Kendler, 1995).

Brothers and sisters are important environmental influences on many aspects of individual development. They act as agents for socialization-through modeling, delivery of reinforcement/punishment contingencies, reminding one another of rules, and shaping one another's developmental environments.

In one study, it was observed that adopted children were significantly more likely to become drinkers if a sibling in their adoptive family consumed alcohol, and this influence was enhanced if the sibling was of the same gender and close in age to the adopted individual (McGue, Sharma, & Benson, 1996).

When an individual is a heavy drinker, that individual's family relationships often are distorted and dysfunctional-this includes relationships with brothers and sisters that may become distressed as a result of a complex of disruptive behaviors that may accompany heavy drinking (Stevenson & Lee, 2001). In some cases, siblings are role models for drug use and may be the ones providing access to substances (Epstein, Botvin, & Diaz, 1999; Epstein, Williams, & Botvin, 2002; Kaufman & Kaufman, 1992; Vakalahi, 2001).

Structured support for siblings of adolescent substance abusers may help reduce the risk that they, too, will develop substance problems, as well as reducing other family and social challenges that cause them distress (Boyle, et al., 2001; Gregg & Toumbourou, 2003). On the other hand, siblings, particularly older supportive siblings/step-siblings/foster siblings, are frequently present in the lives of individuals who made good adaptation despite being the son or daughter of an alcoholic parent (Werner & Johnson, 2000).

Families and Recovery

Family members and family process may play a direct role in relapse during recovery, as family conflict and/or strong negative affect (e.g., anger aroused during conflict) may precipitate renewed drinking by abstinent alcoholics (Maisto, O'Farrell, Connors, McKay, & Pelcovits, 1988; Marlatt, 2004, oral presentation). On the other hand, the family may play an important role in facilitating alcohol treatment and recovery processes (Connors, Donovan, & CiClemente, 2001; McCrady, 1986, 1989).

The integration of relapse prevention with couples counseling has been shown to be effective (Connors, Donovan, & DiClemente, 2001). Furthermore, family-based therapeutic interventions with adolescent substance abusers are proving more effective than individual or group therapy treatment approaches (Waldron & Slesnick, 1998).

Treatment of a substance abuser appears to have a preventive effect on the mental health and substance abuse risks among their children (O'Farrell & Feehan, 1999).

Intervention goals with children of alcoholics are related to reducing their risk for developing alcohol problems of their own through identifying the dysfunctional behaviors that may be predisposing risks and assessing their risk (Fisher & Harrison, 2000). Social workers need to take into consideration the full gamut of vulnerability, risk, resilience, and protective factors expressed in a population in order to understand the heterogeneity in outcomes observed (Begun, 1993).

Family systems models hypothesize a series of homeostatic functions in families that have implications for the processes associated with an individual's recovery from alcohol problems. The underlying assumption is that an individual's maladaptive behavior (e.g., alcohol abuse) reflects dysfunction in the system as a whole (Van Wormer, 1995).

As such, the alcohol abuse serves an "adaptive" function for the family system as a whole. For example, the family is allowed to divert its attention away from and to avoid even more threatening issues (e.g., a source of conflict that threatens the system's integrity as a whole) by attending to a member's drinking behavior.

In this conceptualization, the drinking behavior transcends the individual and is relational, thus the relationships are a necessary focus of intervention (Waldron & Slesnick, (1998). These types of approaches are designed to address and restructure family interaction patterns that are associated with the alcohol abuse. As a result, the alcohol abuse is no longer "needed" by the family system for its survival.

In addition, some family systems authors have postulated that the family system adopts a host of "adaptive" responses to an individual's alcoholism-emotional repression, emotional walls and barriers, and other survival mechanisms. When the alcoholic family member stops drinking and attempts to re-engage with the family system, the system risks losing its hard-won sense of balance (equilibrium) that was established around the drinking and drinking individual (Brown & Lewis, 1999; Wegscheider, 1981).

It is argued that these "adaptive" behaviors may become functionally maladaptive, and that the family system may fight to regain its equilibrium by encouraging a return to drinking or by refusing acceptance of the changed individual who attempts to re-engage or redefine his or her old roles. Interventions based on this model emphasize interactional elements among family members and family structures-redefining roles, explicating rules that direct family behavior, and redefining boundaries (O'Farrell & Fals-Stewart, 1999).

Behavioral Family Models are founded on the principles of social learning theory. The underlying assumption is that alcohol use disorders are acquired and maintained through interactions with the social environment.

This includes observational learning (e.g., imitation of role models), operant learning (e.g., behaviors are enhanced or suppressed through reinforcing or punishing consequences), and the presence or absence of opportunities provided by the environment. In this framework, family is important in the development and maintenance of alcohol use disorders for several reasons (McCrady, 1989; Waldron & Slesnick, 1998):

• Their behaviors can act as stimulus cues that trigger drinking responses;
• Family members act as models for specific alcohol-related behaviors, as well as for more general coping strategies (e.g., observation of drinking to relieve stress);
• The family may influence an individual's emotional and physical reactions which are associated with vulnerability to alcohol abuse;
• Their responses can act to reinforce or punish efforts at sobriety, abstinence, or reduction of alcohol use
• Family members may interfere with the individual experiencing the negative consequences of drinking, and this shielding encourages perpetuation of the drinking.

Models of behavioral family treatment (including Behavioral Marital Therapy, BMT) encourage family members to address the ways in which they can facilitate recovery by providing positively reinforcing responses for behaviors that are incompatible with drinking, removing responses that might be encouraging drinking behavior, and attending to features in the environmental context that encourage drinking.

There may be additional components to specific approaches, such as behavioral family therapy to encourage the alcohol abusing family member to enter into treatment or to comply with treatment regimens (e.g., taking medication). BMT addresses the many ways in which an