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. Author manuscript; available in PMC: 2020 Aug 7.
Published in final edited form as: J HIV AIDS Soc Serv. 2019 Apr 21;18(2):111–128. doi: 10.1080/15381501.2019.1596185

Alcohol use, mental health, and parenting practices among HIV-positive mothers

Marya T Schulte 1,*, William Marelich 2, H Isabella Lanza 3, Nada M Goodrum 4, Lisa Armistead 4, Debra A Murphy 1
PMCID: PMC7413222  NIHMSID: NIHMS1032957  PMID: 32774181

Abstract

Mothers living with HIV (MLH) must balance childcare, their illness, and oftentimes other mental health problems/stressors. It is important to understand how a maladaptive coping strategy, (alcohol use) is linked to poorer parenting practices. We assessed the relationship between mental health/coping (anxiety, depression, alcohol use, social support) and parenting/family dimensions (communication, parenting style/stress, family routines/cohesion) among 152 MLH. Mothers reporting more psychiatric symptoms and less social support also reported poorer parenting practices and interactions. Further, MLH who used more alcohol reported less parenting involvement and fewer family interactions. Alcohol use, even at subclinical levels, can negatively impact the parent-child relationship.

Keywords: HIV/AIDS, parenting, children, alcohol, mental health

Introduction

Women comprise 24% of the estimated one million Americans living with HIV (Centers for Disease Control and Prevention [CDC], 2016). Of these, about 60% are estimated to have children (Shuster et al., 2000). Despite these numbers, research examining the psychological well-being of mothers living with HIV (MLH) and their offspring, particularly the coping strategies women use to manage the stressors related to being chronically ill parents, is underwhelming. Chronic parental illness is known to significantly impact children’s behaviors and psychosocial health due to the stress of managing an illness on top of child rearing and the effects of maternal psychosocial maladjustment on parenting practices (Pedersen & Revensen, 2005). Furthermore, MLH have the added burden of stigma attached to their illness (Chi, Li, Zhao, & Zhao, 2014). It is important to have a better understanding of whether and how maladaptive coping strategies, such as maternal alcohol use, are linked to poorer parenting practices.

MLH are significantly more likely to experience depression than the general population (Nanni, Caruso, Mitchell, Meggiolaro, & Grassi, 2015), and women with HIV have reported higher levels of psychiatric distress than men with HIV (Ashton et al., 2005). Many MLH are attempting to balance child caregiving and treatment of their illness with few resources and support; furthermore, HIV+ women are often battling histories of trauma and contextual stressors (Dyer, Stein, Rice, & Rotheram-Borus, 2012; McIntosh & Rosselli, 2012). The unique challenges MLH face explain the heightened risk of both psychiatric (most often depression and anxiety) and substance use disorders (Malee et al., 2014; Morrison et al., 2002). Stressors, anxiety, and depression among MLH can have detrimental effects on the parent-child relationship and are therefore important factors in understanding HIV affected families and possibly highlight places to intervene (Silver, Bauman, Camacho, & Hudis, 2003; Murphy, Steers, & Dello Stritto, 2001; Murphy, Marelich, Dello Stritto, Sweneman, & Witkin, 2002b).

Parenting and family constructs (e.g., family routines, cohesion, parental involvement, parenting stress) have long been identified as key determinants in predicting children’s mental and physical health. For instance, family routines, which refer to the level at which parents provide structure, consistency, and organization in the home environment (Voydanoff, Fine, & Donnelly, 1994), is seen as highly beneficial for promoting a predictable, secure home environment and facilitating the development of socially adaptive, rule-governed behavior in children (Koblinsky, Kuvalanka, & Randolph, 2006; Taylor, 1996; Taylor & Lopez, 2005). MLH experiencing fatigue and/or distress over the unpredictable course and management of their illness may find it more challenging to foster routines in their home environment. Additionally, stressors and psychosocial maladjustment linked to managing HIV is likely to negatively impact family cohesion and parental involvement (Murphy et al., 2002b). Family cohesion, defined by the strength of connectedness and bond between parents and children, has strong associations with children’s behavioral and emotional development (Soloski & Berryhill, 2016). Past studies have linked parenting stress to lower levels of family cohesion (Moreira Frontini, Bullinger, & Canavarro, 2014). Families with higher levels of cohesion tend to report fewer stressors and children are less likely to engage in risky behaviors (Foster et al., 2008). Given these findings, identifying the psychosocial maladjustment dimensions most associated with poorer parenting among MLH is warranted to inform future intervention efforts to enhance the developmental outcomes of children with MLH.

Although not all MLH are experiencing stress, anxiety, or depression at levels that would markedly decrease parenting capabilities, a subset of MLH are experiencing psychosocial maladjustment significant enough to negatively affect their parenting behaviors and relationships with their children. Moreover, this subset of mothers may be more vulnerable to engaging in maladaptive coping strategies to offset a heightened level of stress, potentially linked to their HIV status (e.g., managing their illness, the effects of not disclosing to their children, maneuvering the health care system). Seeking support is viewed as one of the most adaptive ways of coping (Herman-Stahl, Stemmler, & Petersen, 1995; Kort-Butler, 2009); however, past research has noted that social support among MLH is poorer than among other mothers with chronic illness (Hudson, Lee, Miramontes, & Portillo, 2001; Sanchez & Rice, 2010; Serovich, Kimberly, Mosack, & Lewis, 2001). Thus, MLH may resort to more maladaptive coping strategies, usually viewed as avoidance of the stressor through resources that may only temporarily mitigate its effects (Forns, Balluerka, Gomez-Benito, Kirchner, & Amador, 2010; Herman-Stahl et al., 1995; Seiffge-Krenke & Klessinger, 2000; Vuli-Prtorić & Macuka, 2006).

Alcohol use, a common avoidant coping strategy across populations, is potentially one maladaptive coping strategy utilized by MLH to decrease stress and negative mood (Cooper, Frone, Russell, & Mudar, 1995). Available studies suggest that the rates of problematic alcohol use among HIV+ women, versus those uninfected, are similar (Bing et al., 2001; Pence et al., 2008). Alcohol use can be viewed as a riskier coping strategy for HIV+ women due to possible interference with medication effectiveness, adherence, and disease progression (Howard et al. 2002; Miguez, Shor-Posner, Morales, Rodriguez, & Burbano, 2003; Samet, Horton, Meli, & Freedberg, 2006). Adding to this risk, using alcohol as an avoidant coping strategy is also linked to increased symptoms of anxiety and depression (Forns et al., 2010; Seiffge-Krenke & Klessinger, 2000; Vuli-Prtorić & Macuka, 2006). The link between problematic alcohol use and negative parenting behaviors and practices is well established (Arria, Mericle, Meyers, & Winters, 2012; Mares, van der Vorst, Engels, & Lichtwarch-Aschoff, 2011); however, less is known about how alcohol use influences the psychosocial adjustment and parenting of MLH.

The current study sought to assess the relationship between psychosocial (i.e., mental health and coping) and parenting/family dimensions among MLH, which may be different from other populations due to the unique and multiple stressors MLH are exposed to due to their illness. Furthermore, this study includes an examination of how one maladaptive coping strategy, alcohol use, may influence the parenting practices and behaviors of MLH, and how drinking relates to psychosocial maladjustment. It is important to evaluate whether alcohol use that does not necessarily meet diagnostic levels is still a significant contributor to mental health and family functioning among a community sample of HIV+ mothers. Understanding the interplay of psychiatric well-being, alcohol use, and parenting among HIV+ mothers is likely to inform not just mothers’ health behaviors, but also children’s mental health and long-term developmental outcomes.

Method

Participants

All procedures were approved by the Institutional Review Boards at the University of California, Los Angeles and Georgia State University. MLH and their children were recruited through HIV service organizations in Los Angeles, CA, and Atlanta, GA, for the Teaching, Raising, and Communicating with Kids (TRACK II) project. TRACK II is a randomized longitudinal controlled trial testing an intervention designed to assist MLH in disclosing their HIV status to their young children. Families were eligible for the study if the mother had a confirmed HIV diagnosis and was the primary caregiver of a well child (not HIV positive) between the ages of 6 and 14 who lived with her and was unaware of her HIV status at baseline. Families were excluded if mothers reported that the child had a developmental disorder or mental illness that would prevent participation. If more than one child was eligible, the target child was chosen using random selection. Interviews at the Atlanta site were conducted in English only, and those at the Los Angeles site were conducted in Spanish or English. All interested participants at the Atlanta site were English-speaking, and no potential participants were screened out based on language. Across both sites, 71% of families screened were eligible to participate. Baseline data from 152 mothers were utilized for the current paper.

Procedures

MLH and their children provided informed consent and assent, respectively. Interviewers were trained on recruitment and retention, informed consent, privacy and confidentiality, interviewing young children, emergency and safety procedures, and the computerized interviewing software. Interviews were conducted most often at the participants’ home, but could also be conducted at the recruitment site, or another convenient private location, using computer-assisted personal interviewing (CAPI) software. In CAPI, the interviewer reads each question aloud and enters the participants’ response into a computer. Mother interviews lasted approximately 75 minutes; child interviews lasted 45 minutes. Although the larger TRACK II intervention study assessed both mothers and children, the current study focuses solely on maternal report. Families were provided with monetary incentives for their participation ($60 cash for mothers; $30 gift card for children).

Measures

When available, Spanish versions of measures were administered. Otherwise, measures were translated by the Worldwide Translation Center in San Diego, CA. A translator and two editors completed the translations and evaluated the translated measures for accuracy, grammar, and style. The measures were then back-translated by a translator at UCLA (Marin & Marin, 1991).

Mental health and coping.

Anxiety.

MLH completed the Generalized Anxiety Disorder scale (GAD-7; Spitzer Kroenke, Williams, & Löwe, 2006), a seven-item measure assessing anxiety symptoms over the past two weeks. Participants are asked to report how often over the past two weeks they have been bothered by a range of anxiety-related problems (e.g., “feeling nervous, anxious, or on edge;” “feeling afraid as if something awful might happen”). Items were summed, with higher scores indicating more anxiety symptoms (mean value > 14). Current sample reliability based on Cronbach’s alpha is .91.

MLH also responded to four items assessing HIV-related anxiety -- the degree to which thinking about HIV/AIDS status and health affected functioning during the past week (i.e., sleep, appetite, desire to engage in social activities, and ability to concentrate at school or work). Higher scores indicated more health-related anxiety (Schulte et al., 2018). Current sample reliability is .89.

Mental health.

The Medical Outcomes Study (MOS 36) Health Self-report (Ware & Sherbourne, 1992) was used to assess psychological distress and well-being over the past four weeks. Higher scores are indicative of better overall mental health. The measure yielded a current sample reliability of .84.

Depression.

The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) is a 20-item measure assessing depression symptoms over the past week (e.g., poor appetite, depressed mood, crying spells, restless sleep, loneliness). Higher scores indicate more depressive symptoms. Current sample reliability is .81.

Alcohol use.

One item from the National Institute on Drug Abuse (NIDA, 1993) Risk Behavior Survey was used: “During the past 3 months, how often did you have at least one drink of alcohol?,” and responses were combined into a three-point scale; 0 (non-drinkers: no drinking at all), 1 (occasional drinkers: once a month or less, or more than once a month but less than once a week), and 3 (regular or heavy drinkers: one or more times a week but not every day, or every day). Because participants in the current study represented a non-clinical sample in terms of alcohol use (51.3% were non-drinkers, 38.8% were classified as occasional drinkers, and 9.9% as regular or heavy drinkers), mothers were asked more broadly about their drinking rather than detailed patterns of alcohol involvement.

Social support.

The Reliable Alliance and Attachment subscale items of the Social Provisions Scale (Cutrona & Russell, 1987) are rated on a 4-point scale, with higher scores indicating greater levels of social support. Current sample reliability is .63 for attachment, and .71 for reliance.

Parenting and family practices.

Parenting stress.

The Parenting Stress Index (PSI; Abidin, 1990) was developed for early identification of stressful parent-child systems. Higher scores are indicative of higher levels of stress. Current sample reliability is .93.

Family routines.

The Child Routines Inventory (Sytsma, Kelley, & Wymer, 2001) was administered, with mothers asked about the frequency of routines (e.g., regular chores, bedtime routines, special time talking each day). Higher scores indicate more regular routines. A reliability of .88 was obtained.

Three additional items were included to further assess family routines: “How regularly do you and [Child] do these family routines, like the ones we’ve just been talking about, in your household?;” “How much do you think your child feels [s/he] can rely on these family routines happening on a regular basis?”; and “How close do you feel to your child because of using family routines?” Participants were instructed to answer each item on a 100-point scale, ranging from 0 (not regularly at all; cannot rely on at all; not close at all) to 100 (very regularly; can rely on completely; very close).

Family cohesion.

MLH were administered the cohesion subscale from the Family Functioning Scale (Bloom & Naar, 1994), with the three positively worded items used to create the scale. They rated the degree to which certain family characteristics, such as “a feeling of togetherness,” were descriptive of their family. Higher scores indicate a more cohesive family style. Current sample reliability is .79.

Mother/child communication.

The Parent-Child Relationship Inventory includes a Communication subscale (PCRI; Gerard, 1994), consisting of nine-items assessing the quality and frequency of communication between mother and child. Higher scores indicate better communication. The measure yielded a reliability of .87.

Positive parenting and involvement.

MLH were administered the Alabama Parenting Questionnaire, Involvement and Positive Parenting scales (APQ; Frick, 1991). These two scales consist of 16 statements rated on a 5-point scale assessing degree to which mothers report being involved in their child’s activities (e.g., helping with homework, attending PTA meetings) and using positive parenting techniques (e.g., offer praise for a job well done). Higher scores indicate greater involvement and more positive parenting techniques. Alpha’s for the measures were .72 for positive parenting, and .81 for involvement.

Analysis

Initial analyses were undertaken examining descriptive information (means, standard deviations, and correlations) across the sets of variables. Canonical correlation was then used to assess the overall association between the mental health and coping variables, and the parenting and family practices. Discriminant function analysis and multivariate regression were also applied to more closely evaluate alcohol use and its influence on parenting and family outcomes.

Results

Participants were 39.3 years old (SD = 7.8) and children were 9.6 years old (SD = 2.5) on average at time of baseline, with 51.3% of children identified as female. Approximately 38.2% of MLH self-identified as Latina, 52% as African-American, 4.6% as White, and 5.2% identified as multiracial or another race. Over half of the mothers were non-drinkers (51.3%), while 38.8% were classified as occasional drinkers and 9.9% as regular or heavy drinkers. Most MLH reported their marital status as being single/never married (40.8%); 24.3% reported being married, 13.8% separated, 13.2% divorced, and 7.9% were widowed. In terms of education, 21.7% of mothers reported completing at least high school or receiving a GED, 32.9% attended some college, vocational school, or completed a graduate and/or undergraduate degree. Only 28.3% of MLH reported past 30-day employment.

Table 1 contains descriptive information on the variables, including correlations, means, and standard deviations. Bivariate correlations show the majority of mental health and coping variables were at least moderately correlated with each other (r > +/− .30; see Cohen, 1992, for effect size cutoffs using r). The strongest correlations were between generalized anxiety and depression, alcohol use, and HIV-related anxiety; greater anxiety is associated with more depression, alcohol use, and more HIV-related anxiety. The parenting and family outcome variables show small-to-medium correlations with each other (r > +/− .20), with the strongest effects among the family routine variables. Across the variable sets, depression and alcohol use have small-to-moderate associations with many of the parenting and family outcome variables (e.g., greater depression and alcohol use are associated with poorer family outcomes). Regarding the mental health and coping variables, most have moderate associations with parenting stress (poorer mental health and coping are associated with greater parenting stress).

Table 1.

Correlations, means, and standard deviations for all study variables (N = 152).

Measures 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Mental Health and Coping
1. Generalized Anxiety 1.00
2. Mental Health 0.08 1.00
3. Depression −0.75 −0.72 1.00
4. Alcohol Use 0.76 −0.06 0.12 1.00
5. HIV-Related Anxiety 0.63 −0.56 0.56 0.00 1.00
6. Reliable Alliance Social Support −0.28 0.32 −0.37 −0.04 0.24 1.00
7. Attachment Social Support −0.32 0.42 0.42 −0.06 −0.06 0.69 1.00
Parenting and Family Practices
8. Parenting Stress 0.48 −0.47 0.57 0.15 0.33 −0.32 −0.40 1.00
9. Family Routines −0.14 0.17 −0.22 −0.09 −0.04 0.16 0.09 −0.42 1.00
10. Regularity of Family Routines −0.19 0.19 −0.23 −0.17 −0.13 0.17 0.09 −0.30 0.55 1.00
11. Reliability of Family Routines −0.19 0.18 −0.25 −0.09 −0.16 0.22 0.22 −0.29 0.44 0.7 1.00
12. Closeness due to Family Routines 0.10 0.3 −0.21 −0.24 −0.15 0.15 0.21 −0.43 0.39 0.48 0.49 1.00
13. Family Cohesion −0.20 0.19 −0.24 −0.16 −0.16 0.29 0.29 −0.54 0.37 0.32 0.31 0.39 1.00
14. Mother-Child Communication 0.21 −0.24 0.24 0.33 0.08 −0.18 −0.09 0.39 −0.23 −0.23 −0.21 −0.34 −0.26 1.00
15. Parenting Involvement −0.13 0.21 −0.22 −0.18 −0.08 0.14 0.08 −0.41 0.49 0.43 0.37 0.41 0.30 −0.34 1.00
16. Positive Parenting −0.14 0.23 −0.21 −0.21 −0.08 0.16 0.14 −0.36 0.38 0.31 0.32 0.42 0.37 −0.25 0.65 1.00
Mean 14.07 21.34 39.18 0.59 7.29 13.12 12.47 80.11 62.48 70.49 74.51 86.25 9.89 15.80 39.00 26.86
SD 5.81 5.72 12.97 0.67 4.01 2.39 2.38 23.11 13.06 21.57 22.97 17.58 1.92 4.94 6.34 2.98
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p < .05 when r > +/− .159; p < .01 when r > +/−.208

Multivariate Associations Between Mental Health/Coping and Parenting/Family Practices

Beyond simple bivariate correlations, associations between mental health and coping predictors and the parenting and family outcomes were undertaken using canonical correlation, which was used to evaluate the number of dimensions along which the two sets of variables are related. Canonical variate pairs were derived, and the associations between the pairs form the canonical correlations.

Overall, the two sets of variables were interrelated along seven dimensions, yielding seven canonical correlations. Of these, only the first two canonical correlations were significant (0.63 and 0.49; see Table 2). The model with all seven canonical correlations included was significant, F(63, 772.07) = 2.42, p < .01. With the first canonical correlation removed, the remaining variate pairs remained significant, F(48, 678.16) = 1.54, p = .01. With the first and second canonical correlations removed, the model was no longer significant, F(35, 582.94) = 0.96, n.s. Thus, the first two pairs of canonical variates accounted for the significant relationship between our two sets of variables.

Table 2.

Correlations, standardized canonical coefficients, canonical correlations, percents of variance, and redundancies between mental health and coping predictors, and parenting and family outcomes, and their corresponding canonical variates (N = 152)

First Canonical Variate Second Canonical Variate
Variable Sets Correlation Coeff Correlation Coeff
Mental Health and Coping
Generalized Anxiety 0.82 0.34 0.15 0.78
Mental Health −0.74 0.01 0.27 1.08
Depression 0.93 0.56 0.05 0.14
Alcohol Use 0.27 0.17 −0.68 −0.71
HIV-Related Anxiety 0.55 −0.07 0.12 0.03
Reliable Alliance Social Support −0.54 −0.09 0.00 0.31
Attachment Social Support −0.64 −0.23 −0.18 −0.58
 Percent Variance 0.75 0.02 Total = 0.76
 Redundancy 0.30 0.00 Total = 0.30
Parenting and Family Outcomes
Parenting Stress 0.95 0.99 −0.03 0.50
Family Routines −0.34 0.17 0.22 0.00
Regularity of Family Routines −0.40 −0.12 0.29 0.29
Reliability of Family Routines −0.44 −0.23 0.03 −0.59
Closeness due to Family Routines −0.38 0.17 0.64 0.68
Family Cohesion −0.49 0.06 0.10 −0.09
Mother-Child Communication 0.46 0.13 −0.62 −0.54
Parenting Involvement −0.35 0.15 0.45 0.15
Positive Parenting −0.39 −0.14 0.46 0.26
 Percent Variance 0.35 0.09 Total = 0.45
 Redundancy 0.14 0.02 Total = 0.16
Canonical Correlation 0.63 0.49
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Results specific to the canonical variate pairs are noted in Table 2, which shows correlations between the variables and the canonical variates, standardized canonical variate coefficients, within-set variance accounted for by the canonical variates, redundancies, and canonical correlations. To best interpret these findings, correlations between the variables and the canonical variates are examined, with a minimum correlation of .33 indicative of good association (Tabachnick & Fidell, 2013). Based on information from Table 2, the variables in the mental health and coping set associated with the first canonical variate were anxiety (.82), mental health (−.74), depression (.93), HIV-related anxiety (.55), and social support (−.54 and −.64 for reliable alliance and attachment, respectively). From the parenting and family variable set, measures associated with the first canonical variate include parenting stress (.95), routines and related items (correlations ranging from −.34 to −.44), family cohesion (−.49), mother/child communication (.46), and parenting involvement (involvement and positive parenting, −.35 and −.39, respectively). Based on these correlations, the first pair of canonical variates indicate those who reported higher anxiety, worse mental health, more depression, and less social support, also reported more parenting stress, less regularity and related issues with family routines, less family cohesion, and poorer mother/child communication and less involvement.

For the second set of canonical variate pairs, only alcohol use from the mental health and coping measures exhibited substantial association (−.68). From the parenting and family practices variable set, measures associated with the second canonical variate included the regularity of family routines (.64), mother/child communication (−.62), and parenting involvement (both parenting involvement and positive parenting, .45 and .46, respectively). Based on these correlations, the second pair of canonical variates show mothers who used more alcohol reported fewer regular family routines, had poorer mother/child communication, and reported less parenting involvement.

Aggregating the canonical correlation results across the pairs shows that mothers who exhibit greater anxiety and poorer mental health, and who report less social support and increased alcohol use, also report greater parenting stress, less family cohesion, less regularity with family routines, and a poorer mother/child communication.

Influence of Alcohol Use on Parenting and Family Practices

As a follow-up to the broader canonical correlation findings, the relationship between alcohol use and the set of parenting and family practices was further evaluated. Multivariate regression (Stevens, 1996) was applied as an aggregate measure of association, treating the set of parenting/family outcomes as a multivariate composite, with alcohol use as a sole covariate. Overall, alcohol use was found to be associated with the parenting and family outcomes multivariate composite, Pillais’ Trace = .155, F(9, 142) = 2.89, p < .01. In addition, with a single covariate in the model, Pillais’ Trace may also be interpreted as η2, suggesting overall that alcohol use and the set of parenting and family outcomes variables have a shared variance of more than 15%. In other words, 15% of the total variation in the set of parenting and family outcome variables could be accounted for by alcohol use.

To further clarify the relationship between alcohol use and parenting/family practices, discriminant function analysis was used to distinguish which of the parenting variables could best discriminate the three drinking categories: non-drinkers, occasional drinkers, and regular or heavy drinkers. Discriminant function analysis yielded two functions, Wilks’ Λ = .81, χ2 (18) = 31.08, p = .02. With the first function removed, Wilks’ Λ = .97, χ2 (8) = 5.20, n.s. Therefore, only one significant function was viable. Based on the group centroids, this function best discriminated those in the non-drinkers versus those consuming any alcohol (i.e., occasional drinkers and regular or heavy drinkers combined). Using information from the structure matrix (see Table 3), variables associated with the function include mother/child communication, regularity of family routines and closeness, parenting stress, and both parenting involvement measures. Based on these findings, mothers who report any alcohol use have poorer parent/child communication, report less regularity in family routines and closeness, have higher parenting stress, and exhibit less positive parenting and involvement.

Table 3.

Discriminant function analysis results discerning alcohol use groups (nondrinkers, occasional drinkers, and regular/heavy drinkers) based on parenting and family outcomes (N = 152)

Pooled Within-Group Correlations among Predictors
Predictor Variable Correlations of Predictors with the Discriminant Function Univariate F(2, 149) Family Routines Regularity of Family Routines Reliability of Family Routines Closeness due to Family Routines Family Cohesion Mother-Child Communication Parenting Involvement Positive Parenting
Parenting Stress 0.35 1.78 −0.42 −0.28 −0.28 −0.41 −0.53 0.37 −0.39 −0.35
Family Routines −0.18 0.61 0.55 0.44 0.39 0.36 −0.22 0.48 0.38
Regularity of Family Routines −0.41 2.46 0.70 0.45 0.30 −0.18 0.41 0.29
Reliability of Family Routines −0.21 0.66 0.48 0.30 −0.19 0.37 0.31
Closeness due to Family Routines −0.58 4.87 0.36 −0.29 0.39 0.40
Family Cohesion 0.38 2.12 −0.22 0.28 0.36
Mother-Child Communication 0.84 10.25 −0.31 −0.21
Parenting Involvement −0.37 2.98 0.63
Positive Parenting −0.42 4.57
Canonical R 0.40
Eigenvalue 0.20
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Discussion

Alcohol use and HIV have long been studied together. Historically, however, this research has largely focused on investigating ways in which drinking increases risk for engaging in sexual behaviors that increase risk of HIV infection (e.g., Hutton, McCaul, Santora, & Erbelding, 2008; Petry, 1999). Among those already infected, studies have examined factors that may interact with one another and help predict medical outcomes. For example, mental health status combined with alcohol use may place people living with HIV at increased risk for poor treatment adherence and compromised physical health (Cruess et al., 2005; Mellins, Brackis-Cott, Dolezal, & Abrams, 2004; Springer, Dushaj, & Azatr, 2012). Even minor levels of drinking have been associated with non-adherence among MLH (Murphy, Greenwell, & Hoffman, 2002a). Thus, any alcohol use is discouraged for those living with HIV. Less studied, however, has been how subclinical levels of drinking may affect the home environment through parenting practices and family interactions. The current study adds to the literature by examining how alcohol use, set within a constellation of other mental health/coping factors (anxiety, depression, and social support variables), relates to parenting/family practices (parenting style and stress, family routines and cohesion, and communication variables) among HIV+ mothers.

In our previous work, we have found that symptoms of anxiety and depression among MLH, particularly those who have not disclosed their HIV status, negatively affect the parent-child relationship (Murphy et al., 2001; Murphy et al., 2002b). Findings from the present study further support this. Our results showed that poorer mental health and reduced social support were related to increased stress in the parenting role and negatively impacted parenting practices and family interactions. More interestingly, we found that alcohol use was related to significantly fewer regular family routines, poorer mother/child communication, and less parenting involvement. In fact, 15% of the total variation in the set of parenting and family outcome variables was accounted for by alcohol use. Given that MLH in the current study were not a clinical sample in terms of alcohol use, this finding offers meaningful insight into how any drinking may be indicative of maladaptive coping that results in strained family dynamics. It has further implications in that physicians, nurses, and other case managers may obtain valuable information by querying MLH regarding their alcohol use, especially when there are signs of problematic family interactions, to determine when further referrals may be necessary.

While this study offers a unique look at the negative impact of even moderate use of alcohol on parenting and family practices among a geographically and ethnically diverse sample of MLH, it is not without limitations. First, the use of cross-sectional data limit interpretation of directionality in the relationship among variables. Longitudinal research is needed to better understand to what degree alcohol use influences parenting and family practices and vice versa. Second, we examined the parent-child dynamic among families in which the mother had not disclosed her HIV status; drinking, especially as a poor coping mechanism, may relate to parenting and family practices differently within families where maternal HIV status is not concealed. Third, the current study does not include child reports of the parent-child relationship and family environment: including the child perspective could help generate a more accurate picture of how alcohol use impacts HIV affected families. Fourth, the mothers’ own childhood experiences were not examined as a factor influencing the parent-child relationship. Future research would benefit from including a variable assessing maternal adverse childhood experiences. Lastly, this study relies on only a few questions assessing drinking behaviors among a sample of mothers with generally homogeneous alcohol use (a large portion were non-drinkers). A more in-depth assessment of alcohol use (e.g., physical and social or legal consequences of drinking, motives for drinking) that includes variable timeframes (e.g., past 30 days, lifetime) using a larger sample of mothers with more diverse drinking histories could yield more nuanced findings of why MLH drink and how reasons for use influence emotional and behavioral measures of the home environment.

Our findings offer support for the mental health/coping and parenting/family practices relationship among MLH. Even moderate alcohol use among a non-clinical population can negatively impact HIV affected families. As such, services targeting MLH should assess for alcohol use and provide harm reduction skills that promote alcohol use reduction and cessation. Due to the important role parents play in child development, these findings inform efforts that may not only improve maternal health behaviors, but also affect children’s mental health and long-term developmental outcomes.

Acknowledgments

Research reported in this manuscript was supported by the National Institute of Mental Health of the National Institutes of Health by Grant Numbers 5R01MH094148 (PI: Marya T. Schulte) and 5R01MH094233 (PI: Lisa P. Armistead).

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