A study examining the experience of mental health professionals working with clients who have experienced problem alcohol use in the home during childhood was conducted in collaboration with University College Cork and the Silent Voices initiative of Alcohol Action Ireland.1

Background
Parental problem alcohol use (PPAU) refers to where a parent’s alcohol use impacts the welfare of the child or results in their maltreatment. It is not necessarily the quantity of alcohol consumed by the parent that can result in adversity, rather the pattern of use, the motivation for use, and its consequences. PPAU has been identified as one of the ‘toxic trio’ or the ‘trigger trio’ (along with parental mental health issues and/or learning disability, and domestic violence) that has a significant impact on child wellbeing.

Prevalence and impact of parental problem alcohol use
PPAU is estimated to impact 12.4% of the population of Ireland, both children and adults. In excess of 250,000 children currently live with adults who drink in a hazardous manner. Such alcohol use can have detrimental impacts on the children in those households and, as such, PPAU has been classified as an adverse childhood experience (ACE). Exposure to ACEs during childhood can affect health and development and can have a long-lasting negative impact. Living with PPAU can increase the risk for other ACEs, including neglect (both physical and emotional), abuse (emotional, physical, and/or sexual), parental mental health issues, and parental separation or divorce.

Children living with PPAU, or adult children of alcoholics, have described feeling embarrassed by their parents’ drinking behaviour, as well as feelings of guilt, frustration, and anger. They are also more likely to experience violence; adopt avoidant coping strategies; experience poor mental health, including being more likely to attempt suicide, in particular if maternal problem drinking is present in their lives; and living with PPAU can impact their relationships with others through to adulthood. Experience of PPAU has also been associated with earlier alcohol initiation, steeper escalation of alcohol use (compared with their peers without PPAU), and problem substance use in the child. However, as PPAU often co-occurs with other ACEs in the individual’s life, it is difficult to identify PPAU as the sole cause of such adverse outcomes.

‘Parentification’, where the child takes on parenting roles and responsibilities, has been described as a consequence for many children living with PPAU. It often results from the child’s need to regulate their own needs for attention, comfort and guidance, to provide a sense of control, to manage the stressors in their lives, but also to provide for their parents’ emotional needs. Such role-reversal has been found to have a significant impact on the mental health of the child, through to adulthood. Children exposed to PPAU have also been found to develop behaviours as a form of escapism from their situation; for example, participating in multiple extracurricular activities to avoid being at home.

Supports in Ireland
Despite PPAU being recognised as an ACE, there are no specific supports in Ireland equipped to deal with the complexities of children affected by PPAU. Many barriers exist to accessing available supports such as stigma, denial, secrecy, a lack of confidence, fear, and embarrassment, and often the focus is on treating the parent’s alcohol use but with little emphasis on the child’s needs. Also noted in the literature is the earlier intervention for children affected by problem drug use (illegal substances) compared with PPAU, resulting in the latter being exposed to adversity for longer. The Silent Voices initiative from Alcohol Action Ireland has urged the Government to fund services for those affected by PPAU and work to raise awareness of the issue among parents, educators, health professionals, the media, policymakers, and others who interact with children.2 Silent Voices is advocating for an initiative like that of Operation Encompass3 in the United Kingdom to be implemented in Ireland. Operation Encompass guarantees that where children are present at a police-attended domestic violence incident, the children’s school is notified, thus ensuring that services and supports are made available to the child.

Methods
In the survey, the responses of 132 mental health professionals were examined to determine their experience of working with clients who have experienced PPAU. The survey looked at their awareness, attitudes, knowledge, any training they received, and included open-ended questions which were analysed using thematic analysis.

Results
The majority of respondents were female (74%) and worked across the private and public sector, hospitals, charities, universities, and addiction clinics. Their experience in their role varied from less than 1 year to more than 25 years. Most had not received PPAU-specific training (70%), illustrating how mental health professionals have inadequate resources to meet the needs of their service users. Most respondents indicated that they would be in favour of training to enable them to identify children who have experienced PPAU (92%) and 97% supported anonymous data collection of PPAU prevalence through reporting to a central database, such as the Health Research Board (97%).

Less than one-quarter of mental health professionals who responded to the survey reported that they routinely ask their clients about PPAU (24%), with addiction counsellors and cognitive behavioural therapists most likely to ask (64% and 63%, respectively). Those who responded that they do not always ask their clients about PPAU were further prompted to expand on the scenarios when they would ask about PPAU. Four themes emerged:

1. A selective approach to enquiry (e.g. childhood difficulties, mental health difficulties, and financial and/or relationship difficulties)
2. Intergenerational problem substance use
3. Universal screening for PPAU
4. The exploration of PPAU only when disclosed.

Mental health professionals highlighted that their adult clients often reported how experiencing PPAU in childhood impacted their own parenting style and how they consciously strive to avoid repeating their parents’ behaviours. The most common protective factor identified was that of ‘one good adult’, a positive relationship with someone who shields the child from the potential distress of their PPAU experience. Certain traits and skills were also identified that act as protective factors, including extraversion, creativity, and intelligence along with education, extracurricular activities, having an awareness that their situation is not/was not within their control, and the value of talking to a mental health professional about their experiences.

Discussion
The study confirmed that many mental health professionals have not received adequate training to identify or deal with clients who have experienced PPAU but are amenable to such. The authors suggest conducting further research to identify why this lack of training exists and to identify potential barriers to accessing training. The risk and protective factors identified in the study correlated with those found in the literature and how co-occurring ACEs are prevalent among this population. The study also highlighted areas where interventions and programmes are most needed to reduce the impact of PPAU, specifically how supports outside the family home should be accessible and available to children.

1    Feeney M and Lambert S (2022) Understanding the views of professionals of the impact of parental problem alcohol use on clients. Dublin: Alcohol Action Ireland. https://www.drugsandalcohol.ie/37305/

2    For further information on the Silent Voices initiative, visit: http://alcoholireland.ie/campaigns/silent-voices/

3    For further information on Operation Encompass, visit: https://www.operationencompass.org/