Abstract
OBJECTIVES
To (1) Examine the prevalence and severity of alcohol’s harm to children in the U.S. and the relationship of the harmer to the child; 2) Examine caregivers’ sociodemographic characteristics, alcohol use, and exposure to harm due to a drinking spouse/partner or other family member as risk factors for alcohol’s harm to children.
STUDY DESIGN
We report data on 764 caregivers (those with parental responsibility for at least one child 17 years of age or younger) from the 2015 National Alcohol’s Harm to Others Survey (NAHTOS), a dual-frame national sample of U.S. adults.
RESULTS
7.4% of caregivers reported alcohol’s harm to children in the past year. Risk factors for alcohol’s harm to children included the caregiver’s own experience of alcohol’s harm from a spouse/partner or other family member. Caregivers with a heavy drinker in the household were significantly more likely to report harm to children. A caregiver’s own heavy drinking was not a significant risk factor for children in their care.
CONCLUSIONS
Alcohol places a substantial burden on children in the US. Although a caregiver’s own drinking can harm children, other drinkers also increase the risk of alcohol’s harm to children. Screening caregivers to determine whether there is a heavy drinker in the household may help reduce alcohol’s harm in the family without stigmatizing caregivers, who themselves may not be heavy drinkers.
INTRODUCTION
Parental substance use adversely affects children’s health.[1, 2] As with other drugs, adverse impacts of alcohol may extend beyond drinkers to the children in their care. A substantial body of research provides evidence for fetal alcohol spectrum disorders due to drinking during pregnancy [3–5] and for mental health issues in children of alcoholics.[6, 7] National data on alcohol’s harm to children are critical to document the adverse impacts of adult drinking on children’s health. Such data will help identify children at risk and can inform targeted interventions to prevent and reduce alcohol’s harm to families.[8, 9] Despite the documentation of alcohol’s harm to others as a significant global public health concern,[10–13] the extent to which drinking harms children has not been adequately studied in the U.S.
Currently available U.S. national data are limited in several ways. First, harm to children associated with parental drinking problems that do not reach clinical significance has been overlooked in research and clinical practice. National data on adult substance abuse indicate that alcohol’s harm to children may be substantial, as an estimated 7.5 million children younger than the age of 18 (10.5% of all children) live with a parent with an alcohol use disorder (AUD).[14] However, these data do not include other types of alcohol use. Research shows that the majority of alcohol problems in a population can be attributed to less heavy but more commonly occurring patterns of drinking, described as “the prevention paradox” in the literature on alcohol use.[15–17] Thus, examining only AUD in parents, provides an incomplete picture of alcohol’s harm to children. This problem can be overcome by considering a broader range of drinking that may harm children.
Second, national data on child abuse and neglect underestimate alcohol’s harm to children, because they only include reported cases of harm (thus excluding certain types of harm). Data from a national Australian study found the prevalence of alcohol’s harm to children was underestimated by child protective services data due to exclusion of harm, such as witnessing alcohol-involved violence and conflict, as well as a lack of systematic assessment of alcohol use among caregivers by child protective services and possible underreporting of alcohol involvement by caregivers to child protective services.[8]
Third, estimates of alcohol’s harm to children primarily focus on the parent or primary caregiver, and thus could be substantially higher if alcohol use by other drinkers in the child’s life, such as others in the household or family, also is considered. Finally, while drinking of a spouse, partner or other family member can negatively impact both caregivers and their children, alcohol’s harm to the caregiver are rarely systematically assessed in studies, and few studies have focused on the overlap between alcohol’s harm to adults and harm to children in their care.
To our knowledge, no U.S. studies have examined the relationship of alcohol’s harm to children with diverse measures of caregiver drinking, including other heavy drinkers in the child’s life, and caregivers’ own experiences of alcohol’s harm from others. To address the current gaps in the literature on children’s experiences of alcohol’s harm, the present study examined data from the 2015 U.S. National Alcohol’s Harm to Others Survey (NAHTOS) to: 1) estimate the prevalence of diverse types of alcohol’s harm to children in the U.S. (including abuse, neglect, and witnessing conflict caused by someone who had been drinking) due to any drinker in the child’s life, describe the relationship of the harmer to the child, and measure the subjective severity of such harm; and 2) examine caregivers’ sociodemographic characteristics, drinking behaviors, and exposure to harm due to a drinking spouse/partner or family member as risk factors for alcohol’s harm to children.
METHODS
Data Source
We report data from the National Alcohol’s Harm to Others Survey (NAHTOS), a dual-frame landline and mobile telephone survey that included oversamples of African American and Hispanic individuals. Survey fieldwork was conducted by ICF Macro, Inc., of Burlington, VT, between February and June 2015, achieving an overall cooperation rate of 60%, which is typical for national telephone surveys in the US.[18] The survey had a total of 2,830 respondents, including 1,400 landline and 1,430 mobile telephone respondents.
Case Selection Criteria
Cases for the present analysis include all respondents with at least one child in the household for whom they have caregiving responsibility. Of the 764 respondents meeting this criteria, 45.5% were men; 61.4% reported being non-Hispanic White/Caucasian, 12.9% non-Hispanic Black/African American (henceforth African American), 19.9% Hispanic/Latino, and 5.8% of “other” ethnicity (Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or “something else/other”). The large majority of the selected sample (94.2%; n = 720) completed the survey, and a smaller subgroup (5.8%; n = 44) completed all sections of the questionnaire used in the present analyses. As regards interview modality, 36.8% (n = 281) of the caregivers completed the survey via landline and 63.2% (n = 483) completed via mobile telephone.
Study Variables
Alcohol’s harm to children was measured using six items assessing whether any child that the respondent had caregiving responsibility for had been harmed due to someone’s drinking in the past year. Specific items assessed whether, because of someone’s drinking, a child had been a) physically harmed, b) yelled at, criticized or otherwise verbally abused, c) left unsupervised, d) there was not enough money for the child’s needs, e) the child witnessed violence, or f) child protection services (CPS) had been called.
The sources of harm (perpetrators) included various drinkers in the child’s life. These included (a) parents, (b) step-parents or the spouse/partner of a child’s parent, (c) a child’s guardian, (d) a sibling, (e) another relative, (4f) a family friend or (g) someone else (see Table 1).
Table 1.
Harms to Children by Maltreatment Type and Relation to Child (n =764).
| n | Weighted % | |
|---|---|---|
| Any alcohol-related harm to child | 61 | 7.4 |
| Child yelled at | 41 | 5.1 |
| Child witnessed violence | 21 | 2.2 |
| Family services called | 9 | 1.5 |
| Child left unsupervised | 12 | 1.2 |
| Child physically hurt | 7 | <1% |
| Not enough money for child’s needs | 6 | <1% |
| Relationship of drinker to harmed child (n=51)a | ||
| Parent | 25 | 49.1 |
| Another relative | 10 | 22.0 |
| Sibling | 5 | 4.7 |
| Step-parent or spouse/partner of parent | 2 | 3.5 |
| Family friend | 2 | 6.7 |
| Child’s guardian | 1 | 2.8 |
| Someone else | 6 | 11.1 |
| Severity of harm (range 1–10) | Mean | SD |
| Any type of harm, over all caregivers | 3.5 | 3.0 |
| By relationship of drinker to harmed child | ||
| Parent/Step parent/Guardian | 5.3 | 2.9 |
| Sibling/another relative/family friend/someone else | 3.0 | 2.7 |
| By type of harmb | ||
| Not enough money for child’s needs | 7.4 | 4.4 |
| Child left unsupervised | 5.6 | 3.1 |
| Family services called | 4.9 | 3.1 |
| Child witness violence | 4.8 | 3.6 |
| Child yelled at | 3.8 | 3.1 |
| Child physically hurt | 3.6 | 3.5 |
Relationship to drinker to harmed child missing for 10 cases
Weighted mean severity rating for the specific harm to child/children
Severity of alcohol’s harm to children was assessed using one question to obtain respondents’ ratings of the severity of harm to their child or children, which was reported on a subjective scale ranging from 1 to 10 (with 10 being the most severe).
Harm to the caregiver were assessed using eight items asking about the adult caregiver’s experience of the following harms from a drinking family member or a spouse/partner in the past year: a) being harassed or insulted, b) threatened or made you feel afraid, c) physically harmed, d) traffic accident, e) damaged your property, f) pushed or assaulted, g) family problems, h) and financial trouble. The number of harms reported were coded as dichotomous measures (1 =one or more of the 8 harms; 0=no harm in the past year) for each possible source (that is, 1+ harm from a family member; 1+ harm from a spouse/partner).
Caregivers’ sociodemographic characteristics included: age (in categories, see Table 2, with age 60 and older as the reference category); gender; race/ethnicity (three indicators for African American, Hispanic/Latino, and “Other” with referent as non-Hispanic White); education (two indicators for high school or less and some post-high school education, with 4-year college or more as referent); employment (indicator for not currently working, which included those who were unemployed, in school, homemakers and disabled, with employed as referent); and an indicator for having an income below the 2015 poverty line (referent = not below the 2015 poverty line), using the income adjusted for household size.
Table 2.
Characteristics of Caregivers With and Without Alcohol’s Harm to Children (n=764)
| Caregivers not reporting harm n (%) | Caregivers reporting any harm n (%) | |
|---|---|---|
| Age | ||
| 18–29 | 120 (22.7) | 10 (17.2) |
| 30–39 | 186 (31.2) | 10 (20.6) |
| 40–49 | 209 (28.5) | 19 (32.9) |
| 50–59 | 123 (13.4) | 16 (25.3) |
| 60+ | 59 (4.2) | 6 (4.0) |
| Gender | ||
| Women | 414 (53.5) | 45 (68.1) |
| Men | 289 (46.5) | 16 (31.9) |
| Race/ethnicity | ||
| White | 369 (62.1) | 33 (52.4) |
| African American | 123 (12.7) | 9 (15.5) |
| Hispanic | 163 (19.5) | 11 (24.6) |
| Other | 48 (5.7) | 8 (7.5) |
| Education | ||
| High school diploma or less | 240 (37.7) | 22 (44.0) |
| Some post high-school education | 195 (31.9) | 18 (31.0) |
| 4-year college degree or more | 267 (30.4) | 21 (25.0) |
| Employment | ||
| Unemployed/Not currently working | 226 (27.1) | 18 (35.8) |
| Employed | 476 (72.9) | 43 (64.2) |
| Income | ||
| Below 2015 poverty line | 172 (23.4) | 18 (30.0) |
| Not below 2015 poverty line | 531 (76.6) | 43 (70.0) |
| Respondent caregiver’s drinking | ||
| Frequent heavy drinking (4+ drinks women per day/5+ drinks men per day at least monthly) | 37 (6.7) | 5 (8.7) |
| Not frequent heavy drinker | 666 (93.3) | 56 (91.3) |
| Respondent caregiver’s AUDa | ||
| At least mild AUD (2+ current symptoms) | 36 (6.7) | 7 (7.8) |
| No AUD (< 2 current symptoms) | 667 (93.3) | 54 (92.2) |
| Alcohol-related harm to caregiver | ||
| 1 or more harms from spouse *** | 19 (2.5) | 12 (15.2) |
| No harms from spouse | 680 (97.5) | 49 (84.8) |
| 1 or more harms from family member ** | 29 (4.9) | 15 (16.2) |
| No harms from family member | 670 (95.1) | 46 (83.8) |
| Heavy drinker in household other than respondent*** | ||
| One or more | 27 (4.0) | 18 (21.8) |
| None | 676 (96.0) | 43 (78.2) |
Differences assessed with design-based F-tests;
AUD = Alcohol Use Disorder.
p<.01,
p<.001.
Caregivers’ drinking included two measures of alcohol use by the respondent caregiver. Frequent heavy drinking was defined as drinking 4 drinks or more for women and 5 drinks or more for men at least monthly (versus less than monthly in the past year). Alcohol use disorder (AUD) was defined as meeting DSM-5 diagnostic criteria for mild AUD (reporting symptoms in 2 or more of 12 domains in the past year).[19]
We also included an indicator of having any heavy drinker in the household, not including the caregiving respondent themselves. Respondents were asked: “Thinking about the last 12 months, can you think of anyone among the people in your life – your family, friends, coworkers or others – who you would consider to be a fairly heavy drinker, or someone who drinks a lot sometimes?” If respondents answered affirmatively to this question, they were then asked to identify their relationship to the heavy drinker (possible responses included a current or past long-term spouse/partner, a parent, sibling, or other relative, friend, work colleague, or neighbor). Respondents were then asked if this person lived in the same household at any time in the last 12 months. Any heavy drinker living in the same household with the respondent was included in the indicator variable (referent = no heavy drinker in household).
Statistical Analysis and Ethical Statement
Descriptive statistics and logistic regression analyses used STATA version 14.1[20]. For all analyses, data were weighted to the U.S. population using the 2013 American Community Survey (ACS), adjusting for sampling and non-response. In the regression analysis, for Model 1 we entered caregivers’ sociodemographic variables. In Model 2, we added caregivers’ heavy drinking and AUD. In Model 3, harm from a spouse/partner, harm from a family member, and the presence of a heavy drinker in the household were added. The study was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) and approved by the Institutional Review Boards of the Public Health Institute, Oakland, CA, and ICF Macro, Burlington, VT.
Given the sensitive nature of the questions on harm to children, particular attention was paid to participant burden and possible discomfort with the items. If the respondent stated “don’t know” to more than one question, they were skipped out of this set of questions. Harm in the past 12 months was assessed without probing for current or ongoing occurrences and details about the specific child and perpetrator needed for reporting were not queried to increase disclosure by participants. Therefore, research staff was not required to make reports to child protection services. Interviewers provided referral information (toll-free number for counseling services for child abuse) to all respondents who endorsed any of the alcohol’s harm to children items.
RESULTS
As shown in Table 1, 7.4% of caregivers reported any harm to a child from someone’s drinking in the past year. The most prevalent types of harm reported were a child being yelled at and witnessing violence; calling family services was least prevalent. Not having enough money for a child’s needs was subjectively rated as the most severe harm, followed by a child being left unsupervised. Having called family services and a child witnessing violence were rated as moderately severe (see Table 1, lower section). Harm to children from a parent was most common, with those from another guardian the least commonly reported. Other relatives of the child accounted for almost a fifth of harm to children, and step-parents accounted for almost six percent of harm. Together, parents, step-parents and guardians comprised 55.5% of those reported as harming a child due to their alcohol use.
Table 2 shows sociodemographic and other characteristics of the caregivers who reported vs did not report harm/s to children. Differences in sociodemographic characteristics failed to reach statistical significance. Caregivers reporting harm from drinking spouses/partners and those reporting harm from drinking family members were significantly more likely to report alcohol’s harm to children than those caregivers who were not harmed themselves by someone’s drinking.
In regards to the caregiver’s own drinking, among those reporting alcohol’s harm to children, 8.7% reported frequent heavy drinking and 7.8% met criteria for AUD in the past year. These estimates are similar to those for caregivers not reporting harm to children (6.8% met criteria for an AUD, 6.7% reported frequent heavy drinking), and are similar to those for the U.S. general population.[21, 22] Notably, the percentage reporting one or more heavy drinker in the household other than themselves was much higher in caregivers reporting harm to children versus not (21.8% vs 4.0%, p <.001). Thus those reporting alcohol’s harm to children reported significantly higher combined rates of having either AUD or frequent heavy drinking or a heavy drinker living in the household (26.3% vs 13.8%, p <.03, results not shown).
Risk factors for alcohol’s harm to children
Table 3 summarizes logistic regression analyses examining sociodemographic variables, the caregiver’s own drinking and experience of alcohol’s harm from a spouse/partner and other family members, as well as the presence of a heavy drinker in the household as risk factors for reporting any (1+) types of harm to children. There were no significant associations of the demographic variables with reported harm to children (Model 1); additionally, when added to the analysis, the caregiver’s own frequent heavy drinking and AUD were also not significantly associated with harm to children (Model 2).
Table 3.
Adjusted Odds Ratios for Any Alcohol-Related Harm to Children from Three Logistic Regression Models
| Model 1 (n=756) | Model 2 (n=756) | Model 3 (n=752) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 95% C.I. | 95% C.I. | 95% C.I. | ||||||||||
| aOR | Lower | Upper | P-value | aOR | Lower | Upper | P-value | aOR | Lower | Upper | P-value | |
| Age of caregiver | ||||||||||||
| 18–29 | 0.69 | 0.17 | 2.74 | 0.60 | 0.65 | 0.17 | 2.54 | 0.54 | 0.56 | 0.14 | 2.35 | 0.43 |
| 30–39 | 0.66 | 0.15 | 2.91 | 0.58 | 0.63 | 0.14 | 2.86 | 0.55 | 0.72 | 0.14 | 3.75 | 0.70 |
| 40–49 | 1.27 | 0.33 | 4.86 | 0.73 | 1.24 | 0.32 | 4.77 | 0.75 | 1.49 | 0.35 | 6.33 | 0.59 |
| 50–59 | 2.10 | 0.53 | 8.35 | 0.29 | 2.08 | 0.52 | 8.29 | 0.30 | 2.34 | 0.52 | 10.44 | 0.27 |
| Male caregiver | 0.59 | 0.27 | 1.30 | 0.19 | 0.56 | 0.25 | 1.26 | 0.16 | 0.79 | 0.33 | 1.89 | 0.59 |
| Race/ethnicity of caregiver | ||||||||||||
| African American | 1.52 | 0.53 | 4.36 | 0.43 | 1.58 | 0.55 | 4.51 | 0.39 | 1.47 | 0.43 | 5.01 | 0.54 |
| Hispanic | 1.60 | 0.59 | 4.34 | 0.35 | 1.65 | 0.61 | 4.48 | 0.33 | 1.91 | 0.68 | 5.36 | 0.22 |
| Other | 1.49 | 0.53 | 4.16 | 0.45 | 1.55 | 0.55 | 4.37 | 0.41 | 1.51 | 0.57 | 4.05 | 0.41 |
| Education of caregiver | ||||||||||||
| High school or less | 1.21 | 0.50 | 2.90 | 0.67 | 1.17 | 0.49 | 2.80 | 0.72 | 1.33 | 0.59 | 3.01 | 0.49 |
| Post high school | 1.06 | 0.42 | 2.66 | 0.90 | 1.06 | 0.42 | 2.66 | 0.90 | 1.13 | 0.43 | 2.97 | 0.81 |
| Not currently employed | 1.19 | 0.52 | 2.73 | 0.68 | 1.19 | 0.51 | 2.76 | 0.68 | 1.37 | 0.55 | 3.38 | 0.50 |
| Income below poverty | 1.27 | 0.55 | 2.94 | 0.58 | 1.28 | 0.55 | 2.97 | 0.57 | 1.04 | 0.43 | 2.52 | 0.93 |
| Caregiver’s drinking | ||||||||||||
| Heavy drinking | -- | -- | -- | -- | 1.78 | 0.56 | 5.63 | 0.33 | 1.12 | 0.37 | 3.35 | 0.84 |
| 2+ DSM symptoms | -- | -- | -- | -- | 1.17 | 0.42 | 3.31 | 0.76 | 0.86 | 0.29 | 2.59 | 0.79 |
| Harm to caregiver | ||||||||||||
| Harm from spouse | -- | -- | -- | -- | -- | -- | -- | -- | 3.91 | 1.05 | 14.56 | 0.04 |
| Harm from family | -- | -- | -- | -- | -- | -- | -- | -- | 3.14 | 1.33 | 7.46 | 0.01 |
| Heavy drinker in HHa | -- | -- | -- | -- | -- | -- | -- | -- | 3.60 | 1.13 | 11.44 | 0.03 |
HH = household.
As shown in Table 3, when added (Model 3), the caregivers’ experiences of alcohol’s harm from a spouse/partner and from a family member each were significantly associated with alcohol’s harm to children. Caregivers who experienced alcohol’s harm from a spouse/partner were almost four times more likely to report harm to children, and caregivers reporting harm from a drinking family member were over three times more likely report that a child had been harmed due to someone’s drinking in the past year. Additionally, caregivers living with a heavy drinker in the household were almost four times more likely to report harm to children in the past year. Caregivers’ own drinking remained nonsignificant in association with harm to children.
Given the strength of the associations of harm from drinkers other than the caregiver with the reporting of alcohol’s harm to children (and the lack of association of the reporting caregiver’s own drinking with alcohol’s harm to children), we examined the overlap of caregivers’ own drinking with the caregivers’ own exposure to alcohol’s harm and with the presence of a heavy drinker in the household (detailed results available upon request). Regarding the former, of caregivers reporting frequent heavy drinking in the past year, 21.0% experienced harm from a spouse/partner and 9.9% experienced harm from a family member. Of those with AUD, 19.1% reported harm from a drinking spouse/partner and 17.5% reported harm from a drinking family member. Regarding the latter, 19.0% of caregivers who reported frequent heavy drinking and 22.5% with AUD reported having a heavy drinker in the household in the past year. Similar to the elevated rates of harm to children, 63.3% of the caregivers with a heavy drinker in the household reported an alcohol harm from a spouse/partner and 27.1% from a family member in the past year.
To assess whether family structure was related to alcohol’s harm to children, we conducted post-hoc analyses based on a subsample of married/partnered caregivers (n=481). The results from the multivariate regression models were very similar to the analyses of all caregivers reported in Table 3, the only exceptions being that having a heavy drinker in the household, and a caregiver’s experience of alcohol harm from a family member, were no longer significantly associated with harm to children for the married subgroup of caregivers. Harm from a spouse/partner (aOR = 29.42; p < 0.001) remained a risk factor for harm to children among the married subsample (results available upon request).
DISCUSSION
Our study provides recent population data on alcohol’s harm to children in the U.S. Because several of the harms to children assessed in our study include indicators of child abuse and neglect but go beyond the more severe child maltreatment harm, a review of U.S. national child maltreatment data is useful to contrast our findings with data on child maltreatment. Prior estimates of national rates of child victimization reported to Child Protective Services (CPS) are 9.1 per 1,000 children, where victimization included neglect, physical abuse, sexual abuse and “other” types of maltreatment.[23] The Fourth National Incidence of Child Abuse and Neglect Survey (NIS-4) conducted from 2005 to 2006 included children investigated by CPS, and also included other children recognized as maltreated by community professionals, whether or not they were reported to CPS or screened out by CPS without investigation.[24] The NIS-4 found that one child in every 58 in the U.S. (roughly 2%) experienced maltreatment.
Our survey data show that child maltreatment data might miss the broader range of alcohol harm to children (1% to 2% versus 7% found in our study). Notably, less than 2% of caregivers in our study reported calling family services, and this prevalence rate is similar to those reported in national child maltreatment data. However, even with an item that could be interpreted as not harmful by some respondents (“yelled at, criticized or otherwise verbally abused”) removed, our findings still suggest a higher prevalence of alcohol’s harms to children (any harm reported by 53 instead of 61) compared to that from the NIS-4 data. Thus, data from reported cases of child maltreatment may significantly underestimate certain types of alcohol’s harm to children where CPS is not involved.
Our study also provides unique data on a range of alcohol’s harm to children reported by caregivers from any drinker in the child’s life, as opposed to being limited to data on harm caused by a drinking parent or another caregiver. Data from the 2006–2009 National Survey on Drug Use and Health indicated that 10.5% of children lived with a parent who had an AUD including dependence or abuse based on DSV-IV guidelines.[14] Our 2015 data provide more recent estimates of problematic alcohol use among caregivers, with 14.7% of all caregivers reporting past-year AUD, frequent heavy drinking, or living with a heavy drinker.
Collecting data on heavy drinkers in the household is important, given our finding that the prevalence of harm to children is higher among those with caregivers experiencing harm from a drinking partner/spouse or other family member. The drinking of the caregivers themselves remained not significantly associated with harm to children in this national sample. This unexpected finding may be due to respondents being more willing to report other people’s drinking and harm experienced from others’ drinking more readily than attributing child harm to their own drinking, particularly when identified as a caregiver. Future studies should include measures of other’s drinking-related harm to children and not only rely on caregivers’ own drinking as the source of such harm to mitigate potential issues of under-reporting.
Finally, the NAHTOS data provide rich information on harm related to a range of problematic drinking patterns, going beyond AUD by assessing associations of frequent heavy drinking among caregivers with reported harm to children. Parental or other family members’ heavy drinking typically is not assessed in pediatric practice settings, but our findings indicate that having a heavy drinker in the household may increase risk of alcohol’s harm to children. Further, experiencing harm due to another person’s drinking by a caregiver also may impair that caregiver’s ability to protect their children and thereby indirectly increase risk of alcohol’s harm to children. Finally, we note that child neglect or an inability to provide adequately for a child’s needs due to monetary shortages stemming from another person’s drinking is a harm that is rarely assessed in survey studies. We find that children are harmed by the drinking of many different types of others in their social environment. Therefore, it is critical to extend clinical inquiries about harmful drinking to others beyond the caregiver when screening for alcohol’s harm to children.
Limitations
Reporting biases can affect estimates of harm to children, particularly when data are provided by caregivers who are asked about their own and others’ drinking. Social desirability reduces likelihood of reporting of child abuse and neglect [25] and of alcohol and drug use in telephone interviews.[26] Further, although such reporting biases could have led to respondents to report alcohol’s harm to children caused by other adults more so than by their own drinking, reports of alcohol’s harm from other drinkers in the family or household also could be downwardly-biased. Under-reporting of abuse [25] and of drinking problems in adults in the child’s life are important to consider because they increase gaps in the identification of children at risk for alcohol’s harms. However, because the determination of heavy drinking by others involved a subjective assessment by respondents, caution should be exercised when interpreting the study findings.
Another limitation is that our assessment of child abuse did not include many types of physical harm assessed in child maltreatment studies, such as those using the Conflict Tactics Scale, and we excluded sexual abuse.[27] Up to a quarter of cases of child maltreatment in the NIS-4 were of child sexual abuse.[24] Therefore, including sexual abuse in the assessment of alcohol’s harm to children could result in even higher estimates of harm than those documented in our study.
Further, the response rate of 60% suggests that the generalizability of our findings to more ethnically and economically diverse population groups is limited. Cultural differences in what constitutes harm to children and the role of alcohol in such harms may affect reporting of alcohol’s harm to children. However, the small numbers of respondents in our study precluded a more nuanced examination of racial differences in alcohol’s harm to children. While we examined children being left unsupervised and lack of money to provide for a child due to someone’s drinking, we lacked the power to assess if specific harms differed by socioeconomic status. Future studies should examine the role of heavy drinking and other social contextual factors in child neglect between different socioeconomic groups. This will clarify whether scarce resources being spent on alcohol and/or the lack of other caregiving adults increase the risk of alcohol’s harm to children. These limitations notwithstanding, this is one of the first recent U.S. studies to gather data on a range of harm due to the different heavy drinkers in a child’s life.
Conclusions
Alcohol places a substantial burden on children in the U.S., with approximately seven and a half percent of caregivers in a national sample reporting alcohol’s harm to children in the past year. Although a caregiver’s own drinking can harm their children, other heavy drinkers also increase the risk of alcohol’s harm to children. Screening caregivers on whether there is a heavy drinker in the household might help to reduce alcohol’s harm to the family without stigmatizing caregivers, who themselves might not be drinking, or may not be problem drinkers.
Acknowledgments
Funding source: Funding provided by the U.S. National Institutes of Health’s National Institute on Alcohol Abuse and Alcoholism (NIAAA) grants R01AA022791 (T. Greenfield and K. Karriker-Jaffe, Multiple PIs) and T32AA007240 (S. Zemore and L. Kaskutas, Multiple PIs). Opinions expressed are those of the authors and do not necessarily reflect those of NIAAA or the National Institutes of Health (NIH) or sponsoring institutions, which had no role in the study design, collection, analysis or interpretation of the data, writing the paper, or the decision to submit the manuscript for publication.
Footnotes
Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.
Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.
Contributors’ Statement:
Drs. Kaplan, Greenfield and Karriker-Jaffe conceptualized and designed the focus of this study. Dr. Kaplan conducted analysis in consultation with Dr. Karriker-Jaffe. Drs. Kaplan and Nayak drafted the manuscript. Drs Nayak, Greenfield and Karriker-Jaffe provided feedback on analysis and assisted in editing the manuscript. Drs. Greenfield and Karriker-Jaffe obtained funding and oversaw data collection for the 2015 U.S. National Alcohol’s Harm to Others Survey. All authors approved the final manuscript as submitted.
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