Alcohol and the family

Summary

Alcohol can impact family life in a wide variety of ways. To understand, we must consider:

Children and parents:

• Parental drinking can impact children from birth, through childhood, and beyond. This can begin with the effects of Foetal Alcohol Spectrum Disorder, occurring when the foetus is exposed to alcohol as it passes across the placental barrier, through to lasting impacts for the children of dependent drinkers who may feel emotional effects throughout their lives.
• An alcohol-free childhood is recommended by the UK Chief Medical Officers. However, communication of this guidance is poor, and parents must compete for influence with an alcogenic environment – including the marketing from alcohol brands.

Relationships and partners:

• Alcohol use may affect intimate partner relationships – including contributing to conflict.
• Alcohol has been demonstrated to be a contributory factor to domestic violence. Further, those who experience this may use alcohol to cope with the violence experienced. This can place barriers between those who need support and services – evidence suggests many domestic violence services in the UK do not accept those with concurrent alcohol use disorders.

Families and carers:

• Family members of those experiencing alcohol problems are often overlooked in policy but are impacted in significant ways by these experiences; including financial hardships, the effects of bereavement, and impacts on their mental health.
• Carers looking after family members with alcohol use disorders, or their children, may be significantly financially and emotionally impacted, including through their significant experiences of stigma.

Introduction

Over recent years, as a substantial body of literature on alcohol’s harms to others has emerged, we have been given insight into the wide-ranging ways in which alcohol impacts upon family life.

However, despite a growing understanding of the effect alcohol use can have on parents, children, partners and other relatives – and the relationships between them – substantial policy action is still needed. Communication of the effects on family life has been lacking particularly.

Children and parents

Alcohol use has been found to impact children and parents in a variety of ways, throughout the course of pregnancy, childhood, and beyond.

Foetal Alcohol Spectrum Disorder

Foetal alcohol spectrum disorder, or FASD as it is commonly abbreviated, describes ‘all the various problems that can affect children if their mother drinks alcohol in pregnancy’ [1]. This includes:

• Foetal alcohol syndrome, and partial FAS

• Alcohol-related neurodevelopmental disorder
• Alcohol-related birth defects [2]

Foetal Alcohol Syndrome is a term commonly used to describe ‘the most involved end of the FASD spectrum’ [3].

In these conditions, the foetus is exposed to alcohol as it passes across the placental barrier. This can lead to effects including stunted growth or weight, distinctive facial stigmata, and damage to the structure of the central nervous system in development. This can result in psychological or behavioural problems at birth, physical symptoms such as an abnormally small head, abnormal facial features, hearing and sight problems, and heart and kidney defects, as well as psychological problems in childhood including memory and learning difficulties [4].

The risk to the foetus of FASD is raised with higher levels of maternal alcohol consumption, and ‘the severity and nature of this are linked to the amount drunk and the developmental stage of the foetus at the time’ [5]. Current Chief Medical Officer guidelines state that ‘the safest approach is not to drink alcohol at all’ [6]. They suggest they offer this guidance because the ‘research on the effects on a baby of low levels of drinking in pregnancy can be difficult to interpret’ and while ‘risks are probably low…we cannot be sure that [low levels of drinking are] completely safe’ [7].

However, evidence suggests that communication of these guidelines to pregnant women is limited. A mixed-methods study investigating awareness and communication of the guidelines by midwives in the UK found ‘that awareness specifically of the CMO guidelines was lacking amongst midwives’ with less than a third of the sample receiving four hours or more hours of training on the subject before qualifying [8]. This is further complicated by communications from alcohol industry sources – it has been demonstrated that:

Alcohol industry–funded organisations were statistically significantly less likely than public health websites to provide information on foetal alcohol spectrum disorder and less likely to advise that no amount of alcohol is safe during pregnancy. They were significantly more likely to emphasise uncertainties and less likely to use direct language (eg, ‘don’t drink’). Some alcohol industry–funded (and no public health) websites appear to use ‘alternate causation’ arguments, similar to those used by the tobacco industry, to argue for causes of alcohol harms in pregnancy other than alcohol [9].

There are difficulties in estimating the rates of these conditions in the UK, in part due to this lack of awareness. However, research suggests the rate may be as high as 2% [10].

Parental drinking

Estimates suggest that there are 189,119 children in England living with an adult who is alcohol dependent [11]. A much greater proportion live with a parent who drinks at a lower, non-dependent level. An estimated 30% of children (aged under 16 years) in the UK live with at least one binge drinking parent, while 22% live with a hazardous drinker [12].

Research has historically focused on the children on alcohol dependent parents, and in recent years, a great deal has been learnt about the outcomes for and experiences of these children. A 2012 rapid evidence review into ‘the needs and experiences of children and young people where there is parental alcohol misuse’ [13] identified many adverse outcomes for these children, including experiences of violence and family conflict. Many other short- and long-term impacts have been identified, including affecting ‘a child’s attitudes and expectations around alcohol, their consumption habits as they grow up, and adverse consequences like educational delay, neglect, abuse or violence’ [14].

However, research suggests that harm may not be confined to the children of dependent drinkers [15]. A wide variety of harms to children have been found to be associated with non-dependent parental drinking; these include increased risk of hospitalisation due to alcohol-related conditions in adulthood [16], increased risk of beginning to drink, or escalating ‘through stages of drinking, from onset to experimentation to regular or heavy drinking’ [17], and increased risk of alcohol misuse during adolescence [18]. A systematic review of almost 100 studies found that:

In almost two of every three published associations, parental drinking was found to be statistically significantly associated with a child harm outcome measure [19].

Evidence from the UK supports this. A survey of almost 1,000 UK parents and their children aged 10-17, found that more than a third (35%) of children reported at least one adverse consequence as a result of their parents’ drinking – in a sample of predominately light and moderate drinkers. Children were presented with a range of negative outcomes that they could attribute to their parents’ drinking: 12% reported parents giving them less attention than usual, 11% reported being put to bed later than usual, and 8% reported thinking that parents argue more than normal. The work found that the more parents drink (beginning from only moderate levels) the more likely children were to report one of these negative outcomes, and that children who had witnessed their parents tipsy or drunk were more likely to report experiencing negative outcomes following their parent’s drinking – irrespective of how much their parent drank overall. Further, it was found that children of parents drinking for predominantly negative reasons were more likely to report experiencing at least one negative outcome [20].

Information for parents available from the UK Government is limited. The most recent guidelines discussing children and alcohol use were published in 2009 and ‘only advises how parental low-level drinking might influence children’s own alcohol use’ [21].

Children and alcohol

Drinking in childhood has been demonstrated to have a range of deleterious health and wellbeing consequences (for full detail, see the Alcohol through the life course – underage drinkers briefing). In line with this, the UK Chief Medical Officers recommend an alcohol-free childhood [22]. However, there are many barriers facing parents attempting to achieve this for their children. As more alcohol marketing moves online, it becomes increasingly difficult for parents to keep track of and respond to what their children are seeing through this. This is important as exposure to alcohol marketing has been shown to increase children’s likelihood to start drinking, to drink more, and to drink in riskier ways [23]. There are significant limitations to the regulation of alcohol marketing in the UK, leading a House of Commons Select Committee to suggest current codes failed to adequately protect children from such exposure [24] (see our Alcohol and marketing briefing for more detail). Further, while some parents believe that they can protect their children against future alcohol harm by introducing them to alcohol in the home, research has shown that parental supply of alcohol in fact increases the likelihood of future alcohol use problems for children [25].

Relationships and partners

Domestic violence

While it is important to remember that alcohol use cannot be considered an excuse for violence, it can be considered a contributory factor. Research to date has led many to conclude alcohol to be a ‘contributing cause of violence…[contributing] to violence in some people under some circumstances’ [26]. First, multiple studies suggest that a substantial portion of domestic violence perpetrators – estimates ranging from 25% to 73% [27] – have been drinking when committing their assault. Further though, cases of severe violence are twice as likely as others to involve alcohol [28]. Finally, it has also been shown that in relationships where one partner experiences drug or alcohol misuse, domestic abuse is more likely than not to occur [29]. For further details on this literature, please see our Violence and crime briefings.

Alcohol-related domestic violence disproportionately impacts the lowest socioeconomic groups. Analysis of Crime Survey for England and Wales data over a five-year period (2013/14 to 2017/18) has shown that alcohol-related violence victimisation overall ‘is disproportionately clustered in the lowest socioeconomic groups’ and that it is ‘higher rates of alcohol-related domestic and acquaintance violence for lower socioeconomic groups [which] are behind this pattern’ [30]. Indeed, this research found that the most disadvantaged groups experience prevalence rates (the proportion of victims in the population) up to five times as high as the most advantaged group, and incidence rates (the number of incidents of this violence per 1000 people in population) as much as 14 times as high [31].

Further, evidence suggests that some who experience domestic abuse may use alcohol as a coping mechanism – indeed, it has been found that following an instance of domestic violence, women who experienced this were twice as likely to drink as the perpetrator [32]. This has implications for victims’ ability to access support, as research from charities Against Violence and Abuse (AVA) and Solace Women’s Aid found that almost two-thirds (61%) of London boroughs only ‘sometimes accept’ women who use alcohol or drugs into their refuges – and two boroughs actively exclude them [33].

Effects on inter-personal relationships

Alcohol use may affect intimate partner relationships – including contributing to conflict. Survey research conducted by Adfam, examining the experiences of those ‘whose couple relationships are, or have been, affected by drug/alcohol misuse’ either by a partner or another family member, found multiple impacts including arguments, negative effects on intimacy, and dissolution of relationships [34].

Figure 1  Findings from Adfam, survey with sample whose couple relationships were affected by partner or family member alcohol or drug misuse

Families and carers

Family members

Family members of those experiencing alcohol problems are often overlooked in policy but are impacted in significant ways by these experiences; as outlined in the ‘Families First’ report from the Alcohol Families Alliance [35], there are key concerns around the mental health and financial impacts this can have on family members, as well as the effects of bereavement:

• Financial: as well as the financial implications that caring for a family member with an alcohol use problem, or their dependents, can have on a family member (see section on Carers), having a family member with an alcohol use problem can also affect a person’s financial stability in other ways. The Life in Recovery survey, examining responses from 1,565 ‘individuals who had a family member in, or attempting, recovery from dependent drinking’ [36], found that ‘55.1% of respondents reported having debts… 27.7% of respondents reported that they couldn’t pay their bills…[and] 8.7% of respondents were fired or suspended from work while their family member was in active use,’ compared with 44%, 17.6%, and 4% respectively when the same family member was in recovery [37].

• Mental health: not only does alcohol use affect the mental health of the drinker (see The physical and mental health effects of alcohol briefing for further information), but family members’ mental health can also be affected. US research comparing health problems experienced by family members of those with alcohol or drug dependence to those of relatives of people with asthma and diabetes found that in the year before family members were diagnosed, ‘AODD family members were more likely to be diagnosed with substance use disorders, depression and trauma than diabetes or asthma family members’ [38].

• Bereavement: as the Alcohol and Families Alliance notes, the grief experienced by family members when loved ones die as a result of alcohol use is less ‘acknowledged or validated by society’ [39]. Further to this, a literature review of bereavement and addiction evidence suggests that parents of those with an alcohol use problem are ‘likely to experience a “double-death” in already having “lost” their child to drugs or alcohol prior to their biological death’ [40].

Carers

Those with alcohol use problems may require care; alcohol use problems can come with wide-ranging and significantly impactful physical and mental health problems (see The physical and mental health effects of alcohol briefing), but also with other challenges for which support is needed, such as financial difficulties [41]. This care is often provided by family members [42]; ‘nearly 1 in 3 adults are affected by a relative’s alcohol use’ [43].

This care provided by family members is highly valuable for two primary reasons. First, it builds what the Alcohol and Families Alliance term ‘recovery capital’, contributing to a person’s recovery [44]. Second though, it is cost-effective. Adfam suggests that for every £1 invested in supporting this family care ‘returns £4.70 in value for family members, people with substance use problems, and the state’ [45].

As the Alcohol and Families Alliance asserts, ‘carers of family members with alcohol problems should get the same support as other carers to help them carry out the

essential work that they do.’ Despite this, and the social value they provide, carers of those with alcohol use problems are routinely disadvantaged in two ways.

Firstly, there are barriers to these carers accessing support they are entitled to. Stigma surrounding alcohol use disorders may prevent carers coming forward to access support [46] or affect how they view themselves as carers – if they do not recognise themselves as carers, they may not be aware they are entitled to any support [47].

Secondly, when these carers do access support, what is available is limited. While caring for a family member can introduce additional financial responsibilities, the carer’s allowance is minimal – ’the lowest benefit of its kind, at £64.60 a week in 2018′ [48].

In some cases, a relative or friend may take on caring responsibilities for children when a parent experiences an alcohol use problem. These carers are known as kinship carers; ‘somebody who cares for the child of a relative or friend on a full-time basis’ [49]. This role is often taken on by grandparents; Grandparents Plus estimate that around 45% of kinship care arrangements with grandparents are due to drug or alcohol use. There are benefits for children in these settings – including consistency and maintained family relationships, such as with siblings.

They give love, stability and the support children need, and can mitigate some of the negative impacts of parental alcohol misuse [50].

However, as discussed, there can be significant financial and emotional impacts on carers [51]. Currently, these formal or informal arrangements do not entitle kinship carers to the same financial support which foster carers receive. This is particularly concerning when we consider this is a role often fulfilled by grandparents who may be more likely than others to be on a fixed income – indeed, the Family Rights Group suggests ‘3 out 4 of such carers experience severe financial hardship [and] 49% of kinship carers had to give up work permanently to raise the children’ [52].