Marital and Family Processes in the Context of Alcohol Use and Alcohol Disorders

Abstract

Alcohol use is often part of the fabric of marriage and family life, and although it is associated with certain positive effects, excessive drinking and alcohol disorders can exert a negative effect on the marital development and on the development of children in the context of the family. This review considers evidence that alcohol influences and is influenced by marital/family processes, including transitions into marriage and parenthood, marital satisfaction, marital violence, parenting, and child development. The review discusses the importance of antisocial behavior and the need to examine women's drinking, and the joint impact of men's and women's drinking on marital/family processes. The review highlights the lack of studies in certain key areas, including the link between discordant drinking and violence and marital satisfaction, the role of alcohol in child neglect, and the potential role of marital conflict as a mediator or moderator of the relationship between alcohol and child functioning.

Introduction

Alcohol presents two faces to the family. One face is that of a beneficial and healthful beverage that fosters warmth and intimacy. The other face is that of a potentially hazardous potion that jeopardizes one's family through conflict, violence, and deprivation. In a recent study of problem drinkers and their partners, we asked the partners what they liked and disliked about the drinking of the alcoholic partner. While some partners had nothing positive to say, others described positive relationship effects such as “opens up his feelings to me,” “he gets more sensitive and pays more attention to me,” and “he is also very giving and says nice things to me.” These same women also reported negative relationship effects like “more flirtatious with women,” “usually makes him moody or irritable,” and “bad mood/frightens me.” In understanding the interrelationship between alcohol and family functioning, we are confronted with this dual nature, and the impact of this is often a more heterogeneous picture than we imagine. In this review, we examine the interrelationships between drinking and alcoholism on one hand and marriage and family processes on the other hand, touching both on the positive and negative aspects, as well as on heterogeneity of alcohol effects.

Common Research Problems

Researchers addressing alcohol and family functioning face several methodological challenges. The first is the changing nature of the family. Several demographic trends have created a multiplicity of family structures that complicate the study of family processes (Bumpass 2004). Increasing proportions of individuals do not marry, but more than half of younger adults have cohabitated without marriage. The age of marriage and the likelihood of entering marriage with a child have increased. After a long period of increase, the likelihood of divorce has stabilized at about 50%. Fertility has decreased and the age of childbearing has generally increased. More than one-third of children are born to unmarried mothers, and more than half of all children will live in a single-parent household for some time. The consequence of these trends is the tremendous diversity of family structures and caregiving arrangements among families. In longitudinal studies, there are multiple transitions without a clear developmental sequence. The problem is further complicated by the fact that alcohol disorders are associated with family structures and the likelihood of transitioning to alternate family structures.

The second challenge is that excessive drinking and alcohol disorders are knotted together with other family disturbances. Alcoholics often have comorbid psychiatric disorders, and the interrelationship among these disorders is not always clearly understood (Kessler et al. 1997). These comorbid disorders may have independent impacts on family processes, but also may modify the expression of alcoholism within the family. Moreover, in the context of the family, the alcoholic's intimate partner may have psychiatric disorders, either independently or associated with the partner's alcoholism. Under these circumstances, disentangling the unique aspects of alcoholism on family processes is difficult.

The third challenge concerns the sampling of alcoholic or excessive-drinking families. Such families are often recruited from families in which one person has sought treatment. This often occurs at the insistence of an intimate partner (Cunningham et al. 1994) and may be less likely if the partner also is an excessive drinker (Kelly et al. 2004). It is possible that, relative to the population of alcoholic couples, couples recruited from clinical settings may have more marital commitment, but also may be less likely to have a partner who also has an alcohol disorder. Alternatively, alcohol-involved families may be recruited from the community, either through assessments of potential participants or through advertising specifically for such individuals. Given the prevalence of a current alcohol disorder and the potential recruitment biases, couples recruited in this manner may show less severe alcohol problems, fewer comorbid disorders, and perhaps less marital distress. Because we cannot assess the full population of alcoholic couples, some of these potential sample differences are speculative. Nonetheless, the primary issue is that the different sampling methods have the potential to identify alcoholic couples with quite different characteristics.

Intimate partner violence: behaviors that involve physical aggression from one person to a partner in an intimate relationship, including less severe items such as pushing, grabbing, and shoving as well as more severe items such as hitting with a fist and beating up

Alcohol problems: social, legal, or interpersonal consequences that occur while drinking (e.g., arrested for DWI, violent behavior) or are attributed to acute or chronic consumption (e.g., lost friends due to drinking, damaged health)

Transitions to Marriage and Parenthood

Does Alcohol Influence the Timing of Marriage?

Excessive drinking could influence the timing of marriage in two different ways. First, the acute impact of alcohol on decision-making and particularly sexual decision making, or the influence of more chronic heavy use on educational attainment, could necessitate the early assumption of adult roles. On the other hand, individuals involved in a pattern of excessive drinking may have an impaired ability to form an intimate relationship, be unwilling to commit to a marital relationship, or be viewed as an undesirable partner. From this perspective, excessive drinking could delay marriage. Studies have found that drinking patterns are associated with early marriages (Newcomb & Bentler 1985), delayed marriages (Fu & Goldman 1996), a decreased likelihood of an “on-time” marriage (Forthofer et al. 1996), and are unrelated to marriage (Bachman et al. 1997). Certain methodological factors could influence which of these effects would be identified. These include the age range of the participants at baseline, the severity of the alcohol variable for that age, and the age at follow-up. Leonard & Rothbard (1999) suggested that excessive drinking could be associated with early marriages for some individuals, possibly because of its co-morbidity with antisocial behavior, and with delayed marriage for others; however, the field still awaits more definitive research.

Do Transitions into Marriage/Parenthood Impact Drinking?

The transition to marriage

The literature regarding changes in excessive drinking over marriage and parenthood transitions is more consistent. Alcohol consumption, particularly excessive drinking, declines over the transition to marriage (Miller-Tutzauer et al. 1991), and this is not due to other transitions such as becoming a parent or completing one's education (Bachman et al. 1997). This “marriage effect” is also observed before marriage among men and women who report being engaged to marry and appears to stabilize within two years after marriage. The strongest findings are observed in large general population studies of young adults that assess drinking annually or biannually.

Excessive or heavy drinking: a pattern of alcohol consumption that exceeds normative levels and is considered to be hazardous, in terms of either the total amount of consumption over an extended time period (i.e., average drinks per day over the last month) or the frequent consumption of large amounts at one time

Alcohol diagnosis or disorder: a maladaptive pattern of physical, behavioral, and experiential symptoms that are indicative of impairments in functioning and/or physical or psychological dependence. This term encompasses both alcohol abuse and alcohol dependence (or alcoholism) and is usually assessed with specific criteria or is assumed because the individual has presented for treatment for alcoholism

Very little research has addressed why the transition to marriage leads to reduced excessive drinking. The most systematic work in this regard is by Bachman et al. (2002), in an expansion of their earlier work. Using data from Monitoring the Future, a large, longitudinal study of youth, these investigators examined changes in religiosity, social-recreational activities, friends' alcohol use, and normative views of alcohol use and found evidence that all of these were impacted by marriage. Structural equation models suggested that reductions in binge drinking were completely mediated by decreased “evenings out” and increased “disapproval of occasional heavy drinking” for both men and women. The model was examined for the total quantity of alcohol consumed in the last 30 days, and the results were largely comparable.

Some research has examined factors that might qualify the relationship between the transition to marriage and drinking reductions. However, much of this evidence is equivocal. For example, studies have found the marriage effect only for women, only for men, or for both men and women (Leonard & Rothbard 1999). Most of the research has focused on young adult participants, and few researchers have examined the marriage effect later in life. Bogart et al. (2005) found the marriage effect for marriages that occurred under 20 years old, and for marriages occurring in the 20s, which is developmentally normative. It is unclear whether marriage later in the 30s has the same protective effect. Some evidence suggests that the marriage effect may be stronger for European Americans in the United States than among African Americans (Curran et al. 1998, Mudar et al. 2002).

Several studies have shown that marriage serves as a protective factor even among those with serious alcohol problems. Chilcoat & Breslau (1996) assessed approximately 1000 young adult members of a health maintenance organization at age 21–30 and reinterviewed them three and a half years later. Among single subjects with no initial alcohol problems, those who married were less likely (8.6%) to experience an alcohol symptom at follow-up than single subjects who remained single (15.7%). Among subjects who had an alcohol diagnosis at baseline, the remission rate was higher among those who married (76.5%) than among those who remained single (46%). Dawson et al. (2006) reported on participants who had a lifetime diagnosis of alcohol dependence. Controlling for sociodemographic factors, alcoholism severity, and other disorders, entry into a first marriage increased the likelihood of nonabstinent recovery, but did not increase the likelihood of abstinent recovery.

The transition to parenthood

Only a handful of studies have examined women's drinking from conception to the postnatal period. These studies have documented marked decreases in women's drinking from prepregnancy to pregnancy, and a marked increase in drinking from pregnancy to the postnatal period. Others have reported significant declines during pregnancy and a marked increase to or above prepregnancy levels by 8 to 12 months postpregnancy (Fried et al. 1985, Homish 2004). Data from the Monitoring the Future project also indicate dramatic decreases in frequency of heavy drinking in the past two weeks, from baseline to pregnancy status for both men and women (Bachman et al. 1997). Other mediating factors, such as living arrangements, employment status, and marital status, did not account for this dramatic decrease in alcohol consumption from prepregnancy to pregnancy for women, but did explain the decrease in heavy drinking for men. Thus, although there was some reduction in heavy drinking among men that was associated with having a pregnant spouse, this reduction was explained primarily by the general condition of being married rather than the pregnancy status of the spouse.

These data also indicate an association between being a parent and reductions in frequency of drinking and frequency of heavy drinking from prepregnancy among both men and women. This association was not explained by marital status for frequency of drinking, but was explained by marital status for frequency of heavy drinking. There were reductions in both alcohol variables for single mothers, but not for single fathers (Bachman et al. 1997). Data from this study were obtained at two-year intervals over two decades. Thus, they describe general changes occurring over much longer periods, unlike the longitudinal data regarding increases in women's drinking after delivery described above.

Do Transitions Out of Marriage Impact Drinking?

Given that the transition into marriage is associated with reduced drinking, it is reasonable to hypothesize that the transition out of marriage would be associated with increased drinking. Cross-sectional studies indicate that divorced men and women are more likely to be excessive drinkers than are single men and women. However, as we discuss below, such an association could arise from excessive drinking playing a role in divorce. Consequently, longitudinal studies, particularly studies that can accurately place the temporal position of the divorce, are most informative. Two studies are particularly noteworthy. Bachman et al. (1997) found that the transition from marriage to divorce led to increases in the percentage of both men and women who were classified as heavy drinkers. Temple et al. (1991) conducted a meta-analysis of 12 longitudinal studies conducted in Europe, Canada, and the United States and reported that “for the younger age group, and for both sexes, not getting married and becoming unmarried are associated with increased typical quantity per occasion at follow-up” (p. 1279). These effects were homogeneous across all 12 studies. Moreover, it is not simply that individuals appear to drink more after divorce. They also appear to experience more alcohol-related problems (Chilcoat & Breslau 1996, Horwitz et al. 1996). As with the reduction in excessive drinking in the transition into marriage, there are various explanations concerning the increase in drinking over the transition out of marriage. It is important to recognize that entirely different explanations may account for these symmetrical effects. Several important changes occur with divorce, such as the diminution of family responsibilities (depending on the presence of children and the custody arrangements) and the restructuring of the social network and patterns of socializing that could be responsible for the increased drinking. Unfortunately, as with the transition into marriage, little empirical work exists that attempts to address the processes underlying the divorce transition.

Despite the strong support for increased drinking after divorce, there is one interesting and somewhat discordant finding. Wilsnack et al. (1991) found that married women who were problem drinkers at an earlier assessment were at a reduced risk for alcohol problems at follow-up if they had separated or divorced between assessments. This suggests that divorce among problem-drinking women may reduce the risk of alcohol problems, possibly by removing them from a heavy-drinking or stress-inducing partner.

Partner's Drinking and Alcoholism

Assortative Mating

Alcoholics are more likely to be married to other alcoholics than would be expected by random pairing of individuals (Jacob & Bremer 1986). Although this is labeled “assortative mating,” these studies do not differentiate between spousal influence, assortative mating, and differential divorce. In fact, although considerable research documents spousal similarity, even as early as immediately prior to marriage (Leonard & Eiden 1999), few studies directly address whether an individual's drinking pattern has a prospective influence on the selection of a spouse. Yamaguchi & Kandel (1993) found evidence of similarity between husbands and wives in terms of adolescent substance use, suggesting that the men and women had selected spouses whose drinking histories were similar. Labouvie (1996), in analyses of the two cohorts of the Rutgers Health and Human Development Study, reported that respondents' alcohol use at age 21–24 was predictive of spouses' alcohol use seven years later. These findings, although not definitive, are generally supportive of an assortative mating process. It is important not to overstate the extent of this process. A categorical examination (Mudar et al. 2001) found that among couples with a man who was not a heavy drinker, 7% of women were heavy drinkers. In contrast, among couples with a heavy-drinking man, 25% of the women were heavy drinkers. Moreover, 58% of heavy-drinking women were in a couple with a man who was not a heavy drinker. Hence, although there is strong evidence of similarity, it is clear that there are many couples in which husbands and wives have quite different drinking patterns.

Assortative mating: nonrandom selection of intimate partner, usually viewed in terms of similarity or concordance with respect to some specific characteristic

Spousal Influence

The clearest evidence of spousal influence is observed among treatment studies in which alcoholics are more likely to return to drinking if their spouse is a drinker (e.g., Moos et al. 1990). In a more recent example, McAweeney et al. (2005) followed alcoholic men and their wives recruited from the community for nine years. One of the predictors of husband recovery was whether the wife had an alcoholic disorder at baseline. In addition, there was evidence that husband recovery had a salutary effect on the alcohol problems of the wife, indicative of reciprocal effects of husband and wife drinking on each other's recovery.

Few studies address the possibility of spousal-influenced drinking in community samples. In a sample of newlyweds, Leonard & Eiden (1999) found evidence in SEM analyses that husband drinking before marriage was longitudinally predictive of wife drinking in the first year of marriage, controlling for wife premarital drinking and husband drinking in the first year of marriage. In an independent sample of newlyweds, Leonard & Mudar (2004) replicated this association, but also found evidence that after the first year of marriage, wife's heavy drinking was longitudinally predictive of husband's heavy drinking. This study also examined factors that might promote spousal influence. We hypothesized that a husband's influence on his wife's drinking over the transition to marriage might reflect an interdependency process and a desire to maintain or consolidate their relationship. Our results suggested that husband-to-wife influence over the transition to marriage was stronger among women who were more highly dependent, reported fewer friends, and believed that alcohol had a positive impact on relationships. However, it is important to note that this effect was only observed over the marital transition, and was not observed from the first to the second year of marriage.

Drinking and Alcoholism as Influences on Marital Processes

Intimate Partner Violence

Distal drinking patterns and intimate partner violence

Excessive alcohol consumption and alcohol problems are robust correlates of men's violence toward women. The relationship has been observed in case-control studies of partner homicides and injured women seen in an emergency room. The relationship has been observed in other health care settings including primary health care, family practice clinics, prenatal clinics, and rural health clinics. It has also been found in large random samples of the general population and in random samples focused on specific minority populations (see Leonard 2002 for review). In a meta-analysis of this literature, Lipsey et al. (1997) reported an effect size of 0.22 for the association of chronic alcohol use and intimate partner violence (IPV), suggesting that the risk of violence among moderate to heavy drinkers is twice that of nondrinkers and light drinkers. However, the risk may be even higher among the very heavy drinkers. Recently, O'Leary & Schumacher (2003) utilized two nationally representative data sets to examine the full range of drinking and to determine whether the relationship represented a linear or threshold effect. Although they found weak evidence of linearity, they concluded, “the difference between high or binge drinking and more moderate levels of drinking appears to be an important threshold with regard to IPV” (p. 1582).

In contrast to men's drinking, the relationship between women's drinking and IPV is less well-established. Given the association between women and men's drinking, studies that control for men's drinking are the most pertinent. Across community samples, several studies have failed to find a relationship between women's drinking and IPV controlling for men's drinking (Kaufman Kantor & Asdigian 1997, Leonard & Senchak 1996), possibly because of the small number of very-heavy-drinking women, while other studies have found a relationship (Kaufman Kantor & Straus 1989, Schafer et al. 2004). In the Schafer et al. study, approximately 1600 European American, African American, and Hispanic couples were interviewed in 1995 and again in 2000. For both European American and African American couples, men's alcohol problems were associated with male-to-female violence, and female alcohol problems were associated with female-to-male violence. Studies of clinical samples of alcoholic or violent women are strongly supportive of a relationship. Similar to the findings of Schafer et al. (2004), Stuart et al. (2006) studied men and women arrested for IPV and found that perpetrators' alcohol problems were associated with their frequency of IPV, and the partners' alcohol problems were associated with the frequency of their IPV toward the identified perpetrator, for both male and female perpetrators.

IPV: intimate partner violence

Although research addressing women's drinking has usually controlled for the effects of partner's drinking, two recent studies suggest that the configuration of couple's drinking patterns are important predictors of IPV. Quigley & Leonard (2000) found that husband and wife excessive drinking in the first year of marriage interacted to prospectively predict violence over the next two years. The interaction indicated that IPV was more likely for excessive-drinking husbands with light-drinking wives. Leadley et al. (2000) found that discrepant drinking patterns were associated with IPV after controlling for heavy drinking. It may be that excessive drinking is not as contentious when both partners are heavy drinkers in contrast to couples with discordant drinking patterns. It is also plausible that drinking together serves a positive relationship function for concordant heavy drinkers, but not for discordant couples. This is an issue to which we return below.

Alcohol use and IPV following treatment

A growing number of longitudinal analyses suggest that changes in drinking behavior after treatment are predictive of changes in violence. O'Farrell and colleagues have conducted the majority of research in this area focused on alcohol. In a key study, O'Farrell and associates (2004) observed that alcoholic men involved in a combined alcoholism and behavioral couples therapy (ABCT) program reduced their IPV from the year before to the two years after treatment and that this effect was apparent primarily among alcoholics in remission. In addition, these changes were observed for both male aggression and female aggression, and for verbal aggression, overall physical violence, and severe violence. Finally, the extent of involvement in ABCT predicted subsequent partner violence, with some evidence that this effect was mediated by improved relationship functioning and reduced problem drinking. Because these studies used treatments that included ABCT, the reduced violence may be the effect of reduced alcohol consumption in the context of acquiring behavioral relationship skills. However, subsequent research has clarified this issue. O'Farrell et al. (2003) and Stuart et al. (2003) found reductions in husband-to-wife violence among male alcoholics receiving only treatment for alcoholism, and posttreatment violence was associated with fewer days of abstinence. Interestingly, one recent study focused on men who were court referred for treatment for IPV. Jones & Gondolf (2001) assessed the frequency of drunkenness among 308 male batterers for several times over a one-year period. Controlling for severe psychopathology and a previous arrest for non-domestic violence, the frequency of drunkenness was associated with IPV recidivism, with increases observed among men who reported being drunk 2–3 times per month in the time period that the recidivism occurred.

ABCT: alcoholic behavioral couples therapy

Proximal alcohol use and IPV

Although the relationship between men's drinking and IPV is well established, there is controversy as to whether the relationship reflects a direct causal relationship or whether it is spurious or indirect. This controversy stems primarily from the difficulties in establishing causality in psychological research rather than from conflicting data. Three sources of data provide support for a causal hypothesis. The first is experimental studies of alcohol and laboratory aggression, a topic beyond the scope of this chapter. The other two sources are studies of alcohol and marital interactions and event-based studies.

Experimental designs are often considered the strongest for inferring causality. In the context of alcohol and IPV, the primary difficulty with such an experiment is the development of a dependent variable that reflects aggression but that is also ethically acceptable. Marital interaction studies focus on negative verbal behavior in the context of a marital conversation. Although negative verbal behavior is not physical aggression, research has shown that, independent of marital distress, couples who have engaged in IPV display greater negativity in marital interactions than couples who have not engaged in such violence (e.g., Leonard & Roberts 1998a). Moreover, verbal aggression is longitudinally predictive of experiencing and perpetrating subsequent IPV (Schumacher & Leonard 2005). Several studies have examined the impact of alcohol on marital interactions. Leonard & Roberts (1998a) asked aggressive and nonaggressive husbands and their wives to discuss an important conflict, and then to discuss their most serious conflict after the husbands had received no alcohol, an active placebo, or an intoxicating dose of alcohol. Alcohol led to increased husband problem solving and increased husband and wife negativity relative to placebo and no alcohol. Aggressive and nonaggressive couples were equally influenced by alcohol. Similar studies have been conducted with alcoholics. Despite some inconsistent findings, these studies tend to support the hypothesis that alcohol increases negative interactions among alcoholics and their spouses, but not among control husbands and spouses (Jacob & Krahn 1988). It is of interest that this increase in negativity may occur only among alcoholics with antisocial features (Jacob et al. 2001). In an interesting extension of these studies, Haber & Jacob (1997) examined the influence of alcohol on the marital interactions of couples in which the husband, wife, or both were alcoholic. Alcohol was associated with lower negativity among couples in which only the wife was alcoholic, but higher negativity among couples in which both were alcoholic. In short, although there have been some discrepant findings, the administration of alcohol in the context of marital conflict appears to increase the expression of negative affect and behavior, even when both members of the couple are alcoholic.

One of the major advances in our understanding of acute alcohol consumption and IPV has been the use of event-based techniques. Two general approaches have been used. In a between-subjects approach, participants who have experienced an IPV event are compared with individuals who have experienced a less serious event (e.g., verbal aggression) controlling for stable dispositional variables (e.g., hostility) that differ between the participants and situational characteristics that differ between the events. In a within-subjects approach, an IPV event is compared with a less serious event collected from the same participant, with statistical controls for situational factors differing between the events. This approach can be extended to diary data that record the occurrence/nonoccurrence of IPV daily and link this to alcohol use on each day.

Event-based research has found that acute alcohol consumption is associated with both the occurrence and severity of IPV. The relationship has been found with between-subjects designs, within-subjects designs, and diary studies, and by men's reports, women's reports, and combined reports. It has been found in studies of community samples (Leonard & Quigley 1999), criminal justice surveys (Martin & Bachman 1997), and detailed studies of alcoholics and batterers in treatment (Fals-Stewart 2003). Studies that have examined both men's and women's drinking found largely uniform support for a relationship between men's drinking and IPV, but reported equivocal findings with respect to women's drinking. Several specific findings are worth highlighting. The amount of alcohol consumed prior to the violence is often quite substantial. Murphy et al. (2005) reported the husband consumed 13–14 drinks prior to IPV but 8–10 prior to verbal aggression events. In addition, Fals-Stewart (2003) found that the violence was most likely to occur within four hours after drinking. Finally, the event-based approach has been utilized to examine moderators of the proximal association of men's drinking and IPV. Fals-Stewart et al. (2005) tested antisocial personality disorder (ASPD) as a potential moderator in the context of a multiple-thresholds model of IPV. Among clinical samples of men who had previously engaged in IPV, alcohol consumption was associated with the occurrence of nonsevere violence for men who did not meet criteria for ASPD. For men with ASPD, proximal alcohol use did not increase the likelihood of nonsevere violence, but it did increase the likelihood of severe violence.

Marital Satisfaction and Stability

Heavy drinking and alcoholism are widely accepted as causes of marital problems and dissolution. In early studies, husband's alcohol use was one of the common reasons given for the breakup of the marriage (Levinger 1966). Similarly, among couples presenting for marital therapy, heavy drinking among the men is very common and is often a source of disagreements (Halford & Osgarby 1993). In an extensive review of the literature, Marshal (2003) found that studies with sufficient variability in measures of alcohol consumption and sample sizes reported significant negative correlations between alcohol consumption and marital satisfaction. He also found considerable evidence that alcoholics in treatment and their spouses have lower levels of marital satisfaction than appropriate groups, and that the marital interaction of alcoholics and their spouses were also indicative of poor marital functioning. One recent study (Floyd et al. 2006) found that hostile marital interactions were observed among couples with an antisocial alcoholic husband. Interestingly, positive interaction behaviors were highest among couples who were concordant for alcoholism (either both or neither had a diagnosis) and lowest among couples consisting of an alcoholic husband and a nonalcoholic wife.

It seems obvious that excessive drinking and alcoholism would have a detrimental impact on marital quality and, if unresolved, could result in marital separations and divorce. Although it seems implausible that there should be no causal influence, the nature and strength of that causal influence are not clear, nor is it clear whether there are any moderating factors. There are several key aspects to consider. First, as noted earlier, excessive drinking and alcohol disorders often co-occur with other disorders, such as antisocial personality and depression. For example, Whisman (1999) found that any mood, anxiety, or substance use disorder was associated with poor marital satisfaction for both women and men. However, after controlling for other disorders, neither alcohol nor drug use disorders were associated with marital satisfaction. Second, very few longitudinal studies have examined this issue, and the results are not entirely consistent. In a 1981 probability sample of women in which heavier drinkers were oversampled, wives' reports of husbands' drinking at baseline predicted wives' distrust and lack of support from husbands five years later (Wilsnack & Wilsnack 1990). In contrast, in a sample of newlyweds, Leonard & Roberts (1998b) observed that decreases in marital quality over the first year of marriage were predicted by husbands' average daily alcohol consumption, husbands' problem drinking, and wives' problem drinking at the time of marriage. However, only wives' problem drinking remained a significant predictor after controlling for sociodemographic factors, personality factors, and perceived conflict behaviors. Recently, Kearns-Bodkin & Leonard (2005) used longitudinal growth curve analyses to examine the relationship between frequent excessive drinking and marital satisfaction over a three-year period. Contrary to our expectations, we did not observe any longitudinal influence of husband or wife heavy drinking on declines in marital satisfaction or vice versa. However, there were significant correlations between one partner's change in alcohol involvement and the spouse's change in marital quality; steeper declines in drinking were associated with less steep declines in partner's marital quality.

A final key aspect is that, similar to studies of IPV, very few studies actually assess both husband and wife alcohol use and consider the possibility that the combination of husband and wife drinking may predict relationship quality. Specifically, research suggests that discrepant drinking patterns are related to marital functioning. In a community sample of married couples, McLeod (1993) found that couples who were concordant on lifetime alcohol dependence reported more positive marriages in comparison with discordant couples. Mudar et al. (2001) observed that newlywed couples with concordant heavy drinking had marital satisfaction scores that were comparable to couples with concordant nonheavy drinking, and that both of these groups had higher marital satisfaction than did couples with discordant drinking patterns. Homish & Leonard (2007) have found that the discrepancy between husband and wife heavy drinking is longitudinally predictive of lower scores on marital satisfaction. Finally, Ostermann et al. (2005) have found that discrepant drinking was prospectively predictive of the probability of divorce. It may be that excessive drinking is not as contentious among couples in which both partners are heavy drinkers, in contrast to couples in which one partner is not a heavy drinker. It is also plausible that drinking together serves as a positive relationship event for concordant heavy drinkers but not for discordant couples.

Marital Functioning as an Influence on Alcoholism

Marital Satisfaction as an Influence on Drinking

Marital problems create stress, and some individuals might increase their drinking in response. However, there are few empirical studies of this issue. In community samples, only two studies have examined this. Whisman et al. (2006) examined almost 1700 married men and women without a current alcohol disorder. Over 12 months, baseline marital dissatisfaction predicted the occurrence of an alcohol disorder after controlling for lifetime alcohol disorders, although separate analyses by gender could not be conducted. Testa & Leonard (2001) studied IPV as a predictor of drinking among women. After controlling for sociodemographic variables, initial relationship satisfaction, and verbal aggression, wives who experienced IPV during the first year of marriage reported a greater frequency of heavy drinking episodes.

In contrast to community samples, there is clear evidence that marital distress has an adverse impact on drinking among alcoholics in treatment. Couples who fail to complete conjoint alcoholism treatment have lower levels of commitment to the marriage (Epstein et al. 1994). Men in more satisfying marriages are more likely to have successful treatment outcomes (Maisto et al. 1998, Moos et al. 1990, Orford et al. 1975). Some data that suggest that verbal criticism may be a significant factor. O'Farrell et al. (1998b) examined expressed emotion (EE), which includes verbal criticism and overinvolvement. Alcoholics with high-EE spouses at the beginning of treatment had worse outcomes over the 12-month follow-up period than alcoholics with low-EE spouses.

Treating the Marriages of Alcoholics

If couples with better marriages do better after alcoholism treatment, it seems reasonable to hypothesize that the efficacy of alcohol treatment could be enhanced by coupling it with marital therapy. Seminal work, conducted by O'Farrell et al. (1985) and McCrady et al. (1986), reported promising effects for adding ABCT to alcoholism treatment, with respect to both marital functioning and drinking outcomes. This work and subsequent research by these two teams demonstrated that (a) the improvement was not simply due to including the spouse in the treatment context; (b) the improvement was observed primarily in ABCT and not other marital therapies; (c) the advantages of ABCT could be observed at two years after treatment, and (d) ABCT had an overall positive cost/benefit ratio (Epstein & McCrady 1998). Although less data are available for women's alcoholism, ABCT has been shown to be effective for both male and female alcoholics. More recently, this research has focused on two different issues: enhancing the long-term efficacy of ABCT for alcoholism and utilizing intimate relationships to foster and support treatment entry.

EE: expressed emotion

RP: relapse prevention

The efficacy of ABCT, like most therapies, dissipates with time. Moreover, couples with more severe marital problems, as well as more severe alcohol problems, are the most likely to relapse (O'Farrell et al. 1992). Two studies have assessed the value of additional relapse prevention (RP) sessions following standard ABCT for alcoholism. McCrady et al. (2004) found that four RP sessions did not lead to better marital or drinking outcomes in contrast to standard ABCT or ABCT with linkage to Alcoholics Anonymous. In contrast, O'Farrell et al. (1998a) found that 15 additional RP sessions led to better marital outcomes for 18 months after RP. For couples with very low pretreatment marital satisfaction, the RP sessions led to more days of abstinence than did ABCT alone. One potential explanation for the different findings is that O'Farrell et al. had 15 RP sessions over a one-year period, whereas McCrady et al. only had four, with three of the four occurring within six months post treatment.

Recent work has also focused on helping family members behave and cope more effectively when an alcoholic family member will not seek treatment. Sisson & Azrin (1986) developed a treatment for the family members of alcoholics that focused on avoiding violence, reinforcing sobriety, not reinforcing drinking, and strengthening the alcoholic's motivation for treatment. Miller et al. (1999) further developed this community reinforcement treatment (CRT) and conducted a clinical trial in which significant others (e.g., wives, parents) were randomly assigned to one of three conditions: (a) CRT; (b) an alternative approach designed to facilitate involvement with Al-Anon; or (c) the Johnson Institute Intervention, which was centered around a family/group confrontation of the alcoholic. All three approaches had a positive effect on the functioning of the significant others, but the CRT led more of the alcoholics to seek treatment than the other two approaches. Recently, Rychtarik & McGillicuddy (2005) evaluated two approaches for women with an alcoholic partner: a coping skills approach and an Al-Anon approach. This study found that involvement in either the Spouse Coping Intervention or the Al-Anon facilitation program led to improvements in spouse functioning and reductions in husband drinking. Of importance, a strong interaction was observed that suggested women who had experienced IPV had lower depression and had partners with fewer drinks per drinking day in the Spouse Coping Intervention relative to the Al-Anon facilitation program.

CRT: community reinforcement treatment

FAE: fetal alcohol effects

FASD: fetal alcohol spectrum disorders

Fetal alcohol syndrome (FAS): a developmental disability that includes central nervous system deficits, growth deficits, and a distinctive pattern of facial anomalies

Developmental Outcomes Among Children of Alcoholic Parents

Maternal Alcohol Use

The most significant consequence of chronic heavy maternal alcohol use during pregnancy is fetal alcohol syndrome (FAS). Children are diagnosed with FAS when they have central nervous system deficits (e.g., cognitive and/or behavioral problems), growth deficits, and a distinctive pattern of facial anomalies. Although many children with FAS have low IQ scores (below 70), a number of children with FAS perform in the low-average to average range. Compared to children with similar IQ or behavioral issues, FAS children exhibit consistent difficulties in arithmetic, executive function, and social-emotional development (Howell et al. 2006, Olson et al. 1998). A number of children exposed to heavy maternal alcohol use exhibit some but not all of the FAS features, and thus have fetal alcohol effects (FAE; Coles et al. 1997). These children tend to have higher IQ scores than those with FAS, although scores are still in the low-average to average range. They also have a broad spectrum of deficits ranging from facial anomalies and congenital abnormalities to neurodevelopmental and social-emotional problems. More recently, the term “fetal alcohol spectrum disorders” (FASD) has been used to collectively refer to children with FAS and FAE. In addition to chronic heavy alcohol use, some consistent, although small, effects on children's arithmetic abilities and school functioning have been reported as a consequence of maternal binge drinking during pregnancy, even before pregnancy recognition. Although the effects of chronic heavy alcohol exposure have been well documented, the effects of more moderate drinking during pregnancy have been the subject of more debate. Some studies have noted subtle effects on learning and behavior at relatively low levels of exposure (e.g., Jacobson & Jacobson 2002). Others have noted an interaction of alcohol exposure and maternal age on child outcomes, with children of older alcohol-exposed mothers at higher risk for negative outcomes (e.g., Streissguth et al. 1980). Children with developmental disabilities have significant effects on family functioning, including increased parental stress, lower support, higher parental depression, and higher parenting problems in response to difficult child behavior. These may be exacerbated among alcohol-exposed children raised by biological parents, who may continue to have problems with alcohol in the postnatal period.

Children of Alcoholics Literature

The relatively large literature on children of alcoholics focuses primarily on children of alcoholic fathers, and maternal alcohol problems, when present, are generally nested within fathers' alcohol problems. These studies range from infancy to adulthood and focus on a range of outcomes, including temperamental antecedents to alcohol problems, socialization experiences, behavior problems, substance use among peers, variables related to alcohol use such as expectancies, age of onset, smoking, and alcohol use, as well as problem drinking and transition to adulthood. Several models for increased vulnerability among children of alcoholics have been proposed, including the risk for substance abuse problems among children of alcoholics (see Sher 1991, Zucker 2006). Early research demonstrated associations between paternal alcoholism and externalizing and internalizing behavior problems (Sher 1991) and the subsequent development of substance use, alcohol problems, and alcoholism (e.g., Jacob & Windle 2000). Theoretical discussions on children of alcoholics have suggested that one pathway to greater substance use problems is via the association between fathers' alcoholism and difficult temperament in infancy, to poor behavioral undercontrol and greater externalizing problems in early childhood, to conduct disorder in middle childhood, to higher antisocial behavior and substance abuse in adolescence and adulthood (Tarter et al. 1999, Zucker 2006). These discussions have also emphasized the importance of gene × environment interactions or interactions of temperamental vulnerability and environmental risk in predicting child outcomes as a function of parental alcohol problems (Jacob et al. 2003, Tarter et al. 1999, Zucker 2006). In this view, temperamental predispositions may be activated only in the presence of environmental stress. As noted in a recent review (Zucker 2006), eight different longitudinal studies have provided consistent evidence that externalizing and internalizing problems are developmental precursors to substance use disorders in adolescence. However, longitudinal studies examining such pathways from conception or infancy have been few in number. Until recently, the majority of studies began in early adolescence with the goal of tracking substance use trajectories. The literature has also been plagued by treatment samples with generalizability issues, lack of consideration of comorbid risk factors, and lack of focus on process variables, although more recent longitudinal studies have used sophisticated methodologies to address these issues (see Zucker 2006).

Internalizing behavior problems: feelings of depression, sadness, anxiety, and social withdrawal

Externalizing behavior problems: a combination of physical aggression, acting out behaviors, oppositional or defiant behaviors, and engagement with illegal activities

Trajectories: the shape or nature of change in a given variable or construct over time

The few studies focusing on early childhood trajectories indicate that children of alcoholics, especially those with two parents with an alcohol problem, deviate from more normative trajectories for externalizing behavior problems. For instance, Edwards et al. (2006) reported that children of nonalcoholics followed a developmental trajectory of increasing aggressive behavior from 18 months to 3 years, a peak at age 3, and a sharp decline from age 3 to 4. However, children of two parents with an alcohol problem did not exhibit the normative decline from 3 to 4 years of age. In addition, cumulative family risk (other parental psychopathology, family conflict, and negative parenting) was predictive of higher aggression at 18 months of age, and trajectories varied by child gender. Similarly, Loukas et al. (2003) examined trajectories of disruptive behavior from preschool to early adolescence among sons of alcoholic and nonalcoholic parents. Although disruptive behavior declined from preschool to age 12, sons of alcoholic fathers were consistently higher in disruptive behavior than were sons of nonalcoholics and this association remained after controlling for maternal alcohol problems, family conflict, and child temperament. Finally, Hussong et al. (2005) reported that girls of alcoholic fathers had lower social competence at age 6 than girls of nonalcoholic fathers on both self-reports and teacher reports, but did not differ at age 15, primarily due to decreases in social competence among girls of nonalcoholic fathers. Thus, although the association between parents' alcohol problems and early risk outcomes such as behavior problems is more consistent and suggests deviations from normative trajectories beginning between 3 and 4 years of age, results regarding positive aspects of social development such as social competence are not as clear.

Although few longitudinal studies have focused on early childhood antecedents of the pathways to risk among children of alcoholics, several have examined trajectories of substance use beginning in early adolescence, as well as predictors and consequences of these trajectories. These studies have used sophisticated analytic frameworks to examine longitudinal changes in alcohol-related outcomes in adolescence, from adolescence to adulthood, and within adulthood (see Chassin et al. 2004). Despite considerable variability in age of participants and the dependent measures, results indicate three to four specific trajectories including an early-onset/heavy-use group, a moderate/experimental/developmentally limited group, and a low-risk/low-use group. Across these studies, a family history of alcohol problems is consistently linked to the early-onset/heavy-use trajectory. Individual difference variables such as negative emotionality and low self-regulation have also been predictive of the early-onset/heavy-use trajectory (e.g., Chassin et al. 2004). One persistent question is the role of comorbid parental psychopathology such as depression and antisociality in predicting substance abuse trajectories among children of alcoholics. Using a prospective design, Chassin et al. (1991) reported that parents' alcohol problems were uniquely predictive of adolescent alcohol involvement and internalizing problems, parents' antisocial behavior was uniquely predictive of drug use and externalizing problems, and parents' affective disorder was uniquely predictive of internalizing problems. Thus, the results regarding the association between fathers' alcoholism and risky trajectory for alcohol involvement are quite consistent and remain even after including comorbid risk factors in model testing.

Many studies have assessed parental alcohol problems at a single point and have failed to consider that alcohol problems tend to fluctuate, with periods of remission and relapse. Studies of variations in child outcomes with fluctuations in parents' alcohol problems over time are few in number. Moss et al. (1997) reported that children with fathers who recovered from substance use during the first six years of the child's life were no different from controls by adolescence. Similarly, Moos & Billings (1982) found children of recovered alcoholics to be similar to controls on both family environment and child outcomes, with the exception of child depression, whereas children of relapsed alcoholics had poorer family environment and emotional functioning. DeLucia et al. (2001) specifically tested the hypothesis that parental recovery from alcohol problems may be associated with improvements in parenting, leading to better child outcomes. Contrary to expectations, parenting and child outcomes did not change over time as a function of fathers' alcohol trajectories over a three-year period, and this result was consistent across reporters (father or child) and for multiple-outcome variables. In summary, the temporal associations between fathers' alcohol problems or alcohol consumption and parenting or child outcomes have not been studied extensively and have produced mixed results, with more recent studies specifically testing variations over time producing largely null results. Large longitudinal data sets using more recent advances in statistical analyses of parallel processes may be better able to answer this question.

Parenting Behavior among Alcoholics

Few studies have examined dynamic associations between parenting behavior and parents' alcohol problems, and there are gaps in the literature during critical developmental periods such as transition to school and onset of puberty. Beginning in infancy, data from an ongoing longitudinal study indicated that parents' alcohol problems were significantly associated with lower positive involvement and sensitivity, and higher negative affect longitudinally, so that fathers who met diagnoses for alcohol problems at infant age of 12 months behaved more negatively with their children at 24 months, as did their partners (Eiden et al. 2004a). The toddler age (about 24 months) may be developmentally salient because of the increase in infant negative behavior at this age and the change in parenting requirements from nurturance to a combination of nurturance and limit setting. It is possible that the longitudinal associations between fathers' alcohol problems and fathers' parenting are particularly significant at 24 months, because of this change in child behavior, resulting in an increase in negativity among alcoholic fathers and their partners. Thus, the associations between fathers' alcoholism and parenting behavior may not be apparent until there are significant demands on parents to modulate their behavior in response to negative child behavior. Similarly, Whipple et al. (1995) reported that alcoholic fathers displayed lower dyadic synchrony and engagement during play interactions with their 3- to 5-year-old sons. Few studies have examined parent-child interactions among school-aged children as a function of parents' alcohol problems and nested risk factors. A number of studies have examined parenting among adolescent children of alcoholics, although only a handful (discussed below) have used observational methodologies. Jacob et al. (1991) compared families with alcoholic fathers, depressed fathers, and control fathers during dyadic and triadic conflict discussions both with and without alcohol. Nondistressed fathers displayed greater positive affect and problem-solving compared with the other two groups. Alcohol effects were apparent only in triadic interactions. Fathers were found to engage in more problem-solving behavior under the influence of alcohol compared with the no-alcohol condition. Jacob et al. (2000) examined dinnertime conversations of families with antisocial alcoholic fathers as well as those with nonalcoholic fathers. Families of antisocial alcoholics displayed lower positivity, but also lower disagreements and instrumentality. The authors interpreted these findings as perhaps reflecting higher disengagement among antisocial alcoholic fathers and their families in naturalistic settings. In addition to the association between parents' alcohol problems and parenting, a series of studies has used experimental paradigms to demonstrate child effects on parenting behavior. Parents who were exposed to a child confederate exhibiting deviant behaviors consumed more alcohol during interactions with this child confederate in comparison with parents exposed to normal child behavior (see Pelham & Lang 1999). This series of studies suggests that there may be a circular loop between parents' alcoholism, children's behavior problems, and parenting, with bidirectional influences between parents and children. Alcoholic parents are at higher risk for having children with behavior problems, and children's behavior problems may increase parental stress and lead to more drinking.

A number of studies have examined the link between parents' alcohol problems and child maltreatment (see Leonard 2002) and noted clear associations between these constructs. However, studies examining the association between parents' alcohol problems and child maltreatment are fraught with methodological challenges that do not permit causal inferences. In an extensive review of the literature linking child abuse and neglect with parents' alcohol problems, Leonard (2002) noted that although a number of studies are methodologically sophisticated, involving large samples, clear definitions of alcohol problems and child abuse, and differentiation between different types of abuse, there remain a number of methodological and theoretical issues that need to be addressed. Primary among them is the need for theoretical models elucidating the processes underlying the relationship between parents' alcohol abuse and child maltreatment. Such models will need to examine potentially different processes underlying the association between alcohol abuse and child neglect versus other forms of maltreatment. Recent advances in the measurement of child neglect (e.g., Child Neglect Scale, Multidimensional Neglectful Behavior Scale) may lead to further developments in this area. A second problem is that the majority of data in this area are derived from agency reports. Previous studies have demonstrated that poor, minority families are more likely to be reported to Child Protective Services (CPS) and children are more likely to be placed out of home quickly, remain in the system longer, and receive more intensive and punitive services (e.g., Church et al. 2005). Thus, data derived from these sources are likely to be significantly biased. Another issue noted in the previous review was the need for a developmental orientation. Maltreatment of younger children may have a different etiology and consequence than maltreatment of older children. The gender of the parent with the alcohol problem was identified as also being important for advancing research in this area. There is some suggestion in the literature that maternal alcohol problems may be a more salient predictor of impaired protection of the child from negative external influences such as a predatory male, whereas paternal alcoholism may be a more salient predictor of physical or sexual abuse. Finally, a clearer understanding of temporal precedence of alcoholism before maltreatment occurs is important for understanding causal influences. This can only occur if alcoholism is viewed separately from other forms of parental psychopathology including other substance abuse, and if studies move away from lifetime measures of both maltreatment and alcoholism.

Marital and Parenting Processes as Mediators or Moderators of Outcomes

The adverse developmental outcomes observed among children of alcoholics may arise from a variety of different sources. As noted above, some of the cognitive and behavioral problems may occur because of prenatal alcohol use, as well as the use of other substances (e.g., tobacco, marijuana) common among women who drink heavily during pregnancy. In addition, some of the outcomes may reflect genetic influences associated with parental alcoholism and comorbid disorders. From a family process perspective, our major interest is in whether marital conflict or parenting behavior mediate, or possibly moderate, the outcomes observed in these families.

Considerable research has investigated whether marital conflict has an adverse impact on children, but only two studies have examined the role of marital conflict as a potential mediator of the associations between parents' alcohol problems and child outcomes. Using a community sample with primarily subclinical levels of alcohol problems, Keller et al. (2005) reported that parents' alcohol problems predicted higher marital conflict, higher marital conflict was associated with more ineffective parenting, and this in turn was associated with higher child behavior problems among kindergarten children. El-Sheikh & Flanagan (2001) reported that marital conflict mediated the association between maternal alcohol problems and children's externalizing symptoms among elementary school–aged children. However, when considered in the same model with maternal depression and parent-child conflict, parent-child conflict was the most significant mediator of the link between parents' alcohol problems and children's behavior problems. Both studies used cross-sectional designs. Studies using longitudinal data and incorporating measures of other parental risk factors, such as depression and antisocial behavior, in model testing may be better able to address this issue.

Several theorists note that the association between parents' alcohol problems and child outcomes are mediated or moderated by the quality of the environment, including both parent and peer influences (Windle 1994). Indeed, results from the Minnesota Twin Family Study indicated that parent-child relationships and peer deviance accounted for 77% of the variance in substances used by age 14 (Walden et al. 2004). In one longitudinal study beginning in infancy, parental warmth/sensitivity during play interactions in the infant/toddler period mediated the association between fathers' current alcohol problems and children's self-regulation at age 3 (effortful control and internalization of parental rules) (Eiden et al. 2004b, 2006). Data from the Michigan Longitudinal Study indicated that parents' negative affect expression mediated the association between child temperament at 3–5 years and externalizing behavior problems at 6–8 years among antisocial alcoholic families, but not among low-risk families (Wong et al. 1999). Studies with adolescent samples have reported that fathers' monitoring and family stress partially mediated the association between fathers' alcoholism and children's substance use trajectories in adolescence (Chassin et al. 1996). Although a consistent picture seems to be emerging regarding parenting as a mediator of outcomes, the literature is by no means unequivocal. Other studies have failed to find that the association between parent alcohol problems and child outcomes is even partially mediated by parenting (e.g., Barnow et al. 2002). This may be due to differences in sample characteristics, child age, measurement of substance use and parenting, and longitudinal versus cross-sectional designs. Shared method variance has been a problem in this literature because parent reports have often been used to measure parenting, parents' alcohol problems, and child outcomes. Studies with adolescents have partially mitigated this problem by including child reports of parenting and using multimethod assessments of child outcomes.

With regard to potential moderating effects, there is a general theme in the literature that the quality of the relationship with the nonalcoholic parent may buffer the impact of the alcoholic parent on child outcomes. Few studies have systematically examined this hypothesis, and fewer still have used prospective designs. Moreover, although this general idea has been investigated for some time, most studies have not used adequate statistical analyses to examine interaction effects, or true moderation. In one of the few studies using a prospective design and observational measures of the parent-child relationship, Edwards et al. (2006) reported that among 2- and 3-year-old children of alcoholic fathers, those with secure attachment relationships with their mothers had significantly lower externalizing behavior problems compared with children who had insecure attachment relationships with their mothers. A similar pattern was noted for internalizing behavior at 3 years of age. The results are similar to those reported by Moser & Jacob (1997). Results from this study, using an adolescent sample and observations of parent-child interactions, indicated that higher amounts of positivity expressed by the nonalcoholic mother with an alcoholic partner were associated with fewer child behavior problems. These results support the hypothesis that the modifying effect of a protective factor may only be apparent in the presence of adversity or risk (Rutter 1987, Werner 1986). In contrast, El-Sheikh & Buckhalt (2003) reported that children's perceived attachment to mother and father interacted with parents' problem drinking to predict 6- to 12-year-old children's social problems such that even among children with secure attachment to mother, parents' problem drinking was associated with higher social problems. However, the same study reported that family cohesion and adaptability has a buffering effect on the relationship between parents' alcohol problems and children's internalizing and externalizing problems among school-age children (El-Sheikh & Buckhalt 2003). Other longitudinal studies with adolescent samples have failed to find a buffering effect of parenting on the impact of parents' alcohol problems on child outcomes (Curran & Chassin 1996).

Summary

Several important issues are apparent throughout the alcohol and family process literature, including the critical role of antisocial behavior patterns, the necessity of examining the configuration of both husband (father) and wife (mother) drinking patterns, and the clear necessity of utilizing designs that can examine bidirectional effects between drinking behavior and family processes.

It is clear that heavy drinking and alcohol problems are linked to antisocial behavior throughout the adolescent and adult years. Adolescents who are excessive drinkers appear to enter marriage early, primarily the result of the relationship of drinking and adolescent antisocial behaviors. The entry into marriage results in reduced drinking, in part through the adoption of social norms about excessive drinking and marriage. Although research has not addressed this issue specifically, it may be that individuals with antisocial characteristics would be less likely to adopt maritally congruent drinking roles and reduce their drinking. Studies of marital satisfaction and stability have not specifically examined alcohol and antisociality together. However, there is evidence that alcohol increases negative marital behaviors among alcoholics with antisocial characteristics, and studies of IPV suggest that antisociality and closely related factors moderate the association between alcohol and IPV. Together, these findings would suggest that alcohol and antisociality could have a strong impact on marital stability. In the area of parenting behavior, there is some evidence of differential behaviors between antisocial and nonantisocial alcoholics, as well as evidence that the developmental outcomes of children of antisocial alcoholics are worse in comparison with those of nonantisocial alcoholics, although whether this represents additive effect or moderation is unclear. These findings suggest an interleaving between heavy drinking and antisociality that together could have a very disruptive effect on the marriage and that could be involved in the intergenerational transmission of these two problems. These findings should create an impetus for studies of alcohol and family processes to actively investigate the role of subtypes of alcoholism in these processes, a call that was made by McCrady & Epstein (1995) more than 10 years ago and that is only slowly being heeded.

Although considerable research has examined family functioning among families in which the husband is alcoholic, much less research is focused on families in which the wife is an alcoholic or heavy drinker beyond the prenatal period. This is especially critical given evidence that although alcohol consumption decreases dramatically during pregnancy, there is a marked increase in drinking after delivery. There is also growing evidence that it is important to study husband and wife alcoholism jointly. Couples in which both are frequent heavy drinkers or have a lifetime diagnosis of alcohol disorder appear to have high levels of marital satisfaction, a phenomenon that prospectively may protect against marital dissatisfaction and divorce. In terms of IPV, the association is less clear. Leadley et al. (2000) suggests that heavy drinking is associated with increased IPV, but that discrepant drinking is independently associated with increased IPV. In terms of marital interactions, McAweeney found positive marital interactions among concordant alcoholics, but Haber & Jacob (1997) found that the most verbal negativity was displayed by concordant alcoholics. In terms of parenting, one study suggests the negative effects of parental alcoholism are more evident in couples in which both are alcoholic, and one study indicates that children from two alcoholic parents have a riskier developmental trajectory for aggressive behavior. These results suggest the possibility that concordant alcoholism may be associated with more stable marriages, and possibly less conflictual marriages, but have worse effects on the children. These findings lead us to argue for research that examines the configuration of couples in terms of drinking rather than research that simply examines the main effects of husband and wife drinking on family processes.

It is clear that studies must take a broader view of alcohol and family processes. We have reviewed studies that address marital violence, satisfaction, and stability, as well as parental dysfunction and the impact of alcoholism on the children. However, most research focuses on the impact of alcohol on one of these issues. Studies that address alcohol and the interrelationships among these marital/family domains are rare. Although marital satisfaction, IPV, and parenting behaviors are linked, studies focusing on alcohol have often treated these separately. Consequently, although a substantial literature indicates links between marital conflict, parenting, and child outcome, there are few such studies of these links in the alcohol field. In broadening our approach, other issues need to be examined. At several points, our review touched on potential bidirectional effects with respect to alcohol and marital/family processes. There is considerable evidence that heavy drinking leads to marital and family conflict. Moreover, negative emotions and interpersonal interactions often lead to relapses among alcoholics, and it seems likely that stress generated by marital/family conflict could motivate continued drinking. Few studies have specifically addressed this issue.

In our culture, and in many others, the consumption of alcohol is not an isolated event. It is woven into the fabric of marriage and family life. Through our shared experiences, we have developed expectations regarding whether and how drinking can have positive effects. We believe that alcohol enhances social situations and that it increases interpersonal warmth and intimacy. In family celebrations, alcohol is used symbolically to wish for health, long life, and prosperity. As a culture, we have also developed rules, both explicit and implicit, that serve to enhance the positive effects of drinking and to minimize the negative effects. Close interpersonal and family relationships serve important functions in communicating and monitoring these rules. As a young and extraordinarily dynamic society, these rules can sometimes be weak and contradictory, and the role of these relationships is all the more important. Given the vast changes in family development that we have seen in the past several decades, it is clear that research is vital in addressing the role of marital/family processes in heavy drinking and alcoholism and in developing approaches to strengthen these processes in the face of these cultural changes in the nature of the family.

Summary Points/Future Issues.

1. Marital and family transitions exert an influence both with respect to excessive drinking and the development of alcohol disorders, although the effect is strongest close to the transition.

2. Excessive drinking and alcohol disorders adversely affect marital satisfaction and stability, although this impact is observed primarily among couples with discordant patterns of consumption.

3. A strong association exists between excessive alcohol consumption and the occurrence of intimate partner violence, and although there continues to be controversy over the causal status, the evidence is supportive of a contributing role of acute heavy consumption in the occurrence of violence.

4. By treating the marriage in conjunction with alcoholism, Alcoholic Behavioral Couples Treatment appears to lead to improved drinking outcomes and greater marital satisfaction and has a salutary effect on intimate partner violence.

5. The association between parents' alcohol problems and child maltreatment has been well documented, but these studies have methodological problems that do not allow for causal inferences. In particular, although child neglect is the most common form of maltreatment, problems of definition and measurement have been rampant. Recent advances in measurement of child neglect should allow for more sophisticated study designs, including designs that allow causal inferences.

6. Alcoholic parents are at higher risk for having children with behavior problems, and children's behavior problems may increase parental stress and lead to more drinking, but more research is needed to firmly document the link between parental stress and drinking.

7. A large number of studies have documented the effects of marital conflict on child functioning. Given the effects of alcohol on marriage, future studies should use longitudinal designs to examine the potential role of marital processes as mediators or moderators of the association between parents' alcohol problems and child outcomes.

8. The early developmental trajectories of children of alcoholics leading to risk or resilience are still unclear. Although behavioral undercontrol is cited as an early milestone signifying a trajectory of increasing risk, this construct is not well defined and is not a developmentally salient indicator of risk until the preschool years. Better understanding of neonatal and infancy predictors of behavioral undercontrol and more cohesive definition of this construct would facilitate longitudinal research attempting to understand developmental pathways to risk and resilience among children of alcoholics.