Alcohol misuse and child maltreatment

For many, alcohol consumption is seen as part of the fabric of Australia's unique social culture, whether it is a beer at the local pub, a drink after work, a few glasses at the humble family barbeque, a bottle of red wine over dinner, or a few beers at a football game - all enjoyable and often harmless activities. The line, however, between enjoyment and problematic drinking behaviours, and how this may impact on an adult's ability to effectively parent his or her children, can be unclear.

Strong links between parental alcohol abuse and child maltreatment have been found across Australia, with child protection agencies reporting alcohol abuse as one of the top contributors in child protection cases (Leek, Seneque, & Ward, 2009; NSW Department of Community Services [NSW DOCS], 2007; Victorian Department of Human Services [VDHS], 2002). Although Australian child protection services do not regularly provide data on parental characteristics, available information shows excessive alcohol consumption is involved in child maltreatment in up to as many as 77% of cases (Dawe et al., 2007; Jeffreys, Hirte, Rogers, & Wilson, 2009; NSW DOCS, 2008; VDSH, 2002). While the multiple issues confronting parents of children in the child protection system confound these figures, experts agree that parental alcohol abuse represents a growing concern for many more Australian children than those currently identified through child protection agencies (Dawe et. al., 2007; Scott, 2009).

Child maltreatment associated with alcohol misuse is not confined to specific socio-economic or cultural groups. Research has shown that harmful drinking affects people at all levels of society and regardless of education, religion, gender or age (Australian Institute of Health and Welfare [AIHW], 2008). As Scott (2009) recently noted: "Children in the child protection system are the tip of the iceberg of a much larger number of 'at risk' children in the wider community" (p. 40).

Much of the recent research investigates alcohol misuse and its influence on parenting within the context of multiple and complex problems, including the misuse of other substances. While valuable, this research may fail to identify the unique impact that alcohol can have on parenting capacity, and may not capture all of the children at risk. This Resource Sheet attempts to illuminate the unique ways in which alcohol can affect parenting behaviours, and in some cases lead to child maltreatment.

What is an unsafe level of alcohol consumption for parents?

The National Health and Medical Research Council (NH&MRC, 2009) provided a set of guidelines for adults in relation to alcohol use and health risks (see Table 1). These guidelines consider both the risk of alcohol-related injury from binge drinking on a single occasion and the cumulative risk of harm from disease or injury over a lifetime. The guidelines may be helpful in considering a safe level of drinking for parents in relation to their own health and the possible effects on children. For example, if a parent is unable to protect or care for him or herself either during binge drinking sessions or as a result of cumulative harmful drinking behaviour, then their ability to protect, care or provide for children may also be diminished.

Source: NMHRC, 2009

More specific guidelines for what constitutes risky drinking patterns in relation to actively parenting children, however, are not currently available (Bromfield, Lamont, Parker, & Horsfall, 2010). It is important to remember that many parents drink alcohol, and this does not always lead to poor parenting behaviour. The extent to which alcohol use is problematic for parents is best thought of as a level of use that will impair a parent's judgment and/or alter mood that places a child at risk of harm by abuse or neglect (Dawe, 2008). The quantity of alcohol consumed is not by itself an indicator of the risk of child maltreatment, however, and any assessment for risks to children need to be considered alongside other risk factors, and within the context of individual circumstances (Dawe, 2008; Harbin & Murphy, 2006).

The absence of clear and practical guidelines for safe consumption of alcohol when parenting is significant when considered in the context of links between excessive alcohol use and parenting behaviour. Research findings that illustrate these links are explored in the following section.

What effect can excessive alcohol consumption have on parenting behaviour?

Research indicates that binge drinking and/or long-term alcohol abuse or dependence can produce psychological and behavioural changes, and as such, excessive alcohol use has the potential to affect the quality of parenting a child receives (AIHW, 2008; Dawe, 2008).

Intoxication from alcohol and the consequences of this can make it problematic for parents to manage the daily living skills required for parenting. Routine tasks such as cleaning, preparing meals, supervising children and ensuring a reasonable standard of hygiene is maintained, can become difficult when a parent is either intoxicated, experiencing a hangover or suffering the symptoms of withdrawal from alcohol use. Additionally, the ability of parents to help children maintain regular school attendance, provide assistance with homework, communicate with teachers and ensure appropriate bed times can also be impaired. Finally, parents' ability to meet their children's emotional needs by providing appropriately caring responses and engaging in play and other activities can be affected (Dawe, 2008; Dawe, Harnett, & Frye, 2008; Odyssey Institute of Studies, 2004).

Parental alcohol misuse has also been shown to negatively impact on parenting styles, with mood swings resulting in inconsistencies in parenting practices (Bromfield et al., 2010). Parents may become controlling, punitive and authoritarian on some occasions, and overly permissive and neglectful on others. They may yell more often, become irritable and inattentive, and engage children in inappropriate levels of responsibility such as allowing children to take on a parenting type role while the parent is intoxicated (Dawe et al., 2007; Odyssey Institute of Studies, 2004).

Alcohol also acts as a depressant on the central nervous system, which increases the risk of mental illness. Women are at considerably more risk than men for developing mental illness as a result of alcohol abuse, particularly depression, which is linked to problematic parenting through reduced responsiveness to children's needs (Dawe et al., 2008). Long-term cognitive impairment can occur as a result of alcohol dependence, a condition that is known to contribute to acts of self-harm, and in extreme cases death (AIHW, 2008). Children of parents who self-harm can be left fearful and anxious about the possibility of losing a parent and the potential impact this will have on their own lives, and when the death of a parent does occur, children may be left traumatised and displaced (Harbin & Murphy, 2006; Kroll, 2004; Odyssey Institute of Studies, 2004).

While the above parenting behaviours are not necessarily examples of child maltreatment, the immediate effects of intoxication can result in children being placed in harmful or dangerous situations (Dawe et al., 2008). In this next section we consider the research evidence for the relationship between parental alcohol abuse and the five major forms of child maltreatment.

Associations between alcohol abuse and child maltreatment

Child maltreatment refers to behaviour by parents, caregivers or others that is outside the norms of conduct and involves a substantial risk of causing physical or emotional harm to a child or young person, including the neglect of young person's basic needs (Price-Robertson & Bromfield, 2009). Strong associations have been found between the availability of alcohol and child abuse and neglect, suggesting that, alongside illicit drugs, alcohol plays a significant role in increasing risks of child maltreatment (Freisthler, Needell, & Gruenewald, 2005). Indeed, research has demonstrated that excessive alcohol consumption often plays a part in all of the major forms of child abuse and neglect (Laslett et al., 2010). What follows are brief definitions of the five commonly identified forms of child maltreatment accompanied by recent evidence of the relationship between these forms of child maltreatment and the misuse of alcohol.

Physical abuse refers to the non-accidental use of physical force against a child resulting in harm to the child. Physically abusive behaviours include shoving, hitting, slapping, shaking, throwing, punching, kicking, biting, burning, strangling and poisoning (Price-Robertson & Bromfield, 2009). Alcohol misuse is commonly linked with aggressive behaviour, a factor that features prominently in the physical abuse of children (Scott, 2009; Valleman & Templeton 2007). Children of drug and alcohol-abusing parents are twice as likely to be at risk of physical abuse as children whose parents are not misusing substances (Freisthler, Merritt, & LaScala, 2006). Parental alcohol misuse has also been found to be strongly associated with traumatic brain injuries in young children (Winqvist, Jokelainen, Luukinen, & Hillbom, 2008).

Emotional maltreatment (also sometimes called "emotional abuse" or "psychological abuse") refers to a parent or caregiver's inappropriate verbal or symbolic acts toward a child and/or a pattern of failure over time to provide a child with adequate non-physical nurture and emotional support. Emotional maltreatment can take five main behavioural forms: rejecting; isolating; terrorising; ignoring and corrupting (Price-Robertson & Bromfield, 2009). Parents who misuse alcohol may fail to provide the emotional support a child needs to feel safe and valued (Bromfield et al., 2010). Evidence also indicates that emotional abuse of children often co-occurs with incidents of reported domestic violence, which is also linked to excessive alcohol consumption and child physical abuse (Gibbs et al., 2008). In addition, children can be exposed to emotional maltreatment when parents force children to take on responsibility that is beyond the child's level of maturity. For example, a child may be required to look after the needs of siblings by providing care such as bathing, dressing or feeding. Children might also be used as a sounding board for parents who are, for example, in distress as a result of domestic violence or substance abuse (Dawe et al., 2007; Odyssey House, 2004).

Neglect refers to the failure by a parent or caregiver to provide a child with the conditions that are culturally accepted as being essential for their physical and emotional development and wellbeing. Neglectful behaviours include failure to provide basic physical needs such as safe, clean and adequate housing, food and health care, warmth, nurturance and support, or failure to provide appropriate educational opportunities (Price-Robertson & Bromfield, 2009). Neglect is often the basis of repeated reports to child protection authorities, with alcohol as a contributing factor for chronic maltreatment of children who lack cognitive stimulation and emotional nurturing (Dawe, 2008; Fluke, Shustermen, Hollinshead, & Yuan, 2008; Scott, 2009; Yampolskaya & Banks, 2006). The chaotic lifestyles of many alcohol abusers can increase the risk of a child being neglected either physically or emotionally. Women whose partners abuse alcohol to the point of initiating high levels of family conflict may react to this extreme form of traumatic stress by neglecting their children's needs (Gibbs et. al., 2008; Valleman & Templeton, 2007). Parents in treatment who abuse alcohol admit to often leaving children unsupervised during bath and meal times, elevating the risk of injury or harm (Odyssey House, 2004). Other situations where children can be at risk of harm include: being placed in a motor vehicle operated by an intoxicated person (Laslett et al., 2010; NH&MRC, 2009); being left to fend for themselves if a parent loses consciousness; and being placed in positions where they are vulnerable of being abused by others (Dawe et al., 2008).

Sexual abuse can be broadly defined as the use of a child for sexual gratification by an adult or significantly older child/adolescent (Tomison, 1995). Sexually abusive behaviours can include the fondling of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, fondling of breasts, voyeurism, and exhibitionism and exposing the child to or involving the child in pornography, and can vary dependent on the relationship between victim and perpetrator (Price-Robertson & Bromfield, 2009). Although a limited amount of recent research has looked directly at the relationship between alcohol misuse and child sexual abuse, evidence does suggest that parents who drink alcohol excessively may fail to be aware of the predatory behaviour of others towards their children (Lown, Nayak, Korcha, & Greenfield, 2011; Walsh, MacMillian, & Jamieson, 2003).

Witnessing of family violence involves a child being present and able to hear or see a family member being subjected to abuse (physical, sexual or emotional) or witnessing damage that has been inflicted to a person or property by a family member's violent behaviour (Price-Robertson & Bromfield, 2009). A strong association has been found between alcohol misuse and domestic violence, most often perpetrated against women by men and occurring more often between couples with children (Scott, 2009). Additionally, experiences of domestic violence may result in women abusing alcohol in order to cope with violence, and where two adults are intoxicated the risk of conflict is increased. This in turn greatly increases the likelihood of children being traumatised by witnessing these disturbing events (Scott, 2009). In situations where domestic violence occurs, parents often report an inability to protect children from witnessing violence and experiencing verbal abuse (Bromfield et al., 2010; Harbin & Murphy, 2006; Odyssey Institute of Studies, 2004)

Additional forms of child maltreatment include fetal alcohol abuse and behaviours by pregnant and breastfeeding women that can endanger a fetus or the developing child (Price-Robertson & Bromfield, 2009). The use of alcohol during pregnancy increases the risk of harm to a fetus with a range of disorders possibly occurring including: facial anomalies, congenital abnormalities, and neurological developmental and social-emotional problems. Binge drinking, even in the early stages of pregnancy, has been found to have small effects on arithmetic abilities and moderate drinking can affect a child's behaviour and ability to learn (Leonard & Eidon, 2007). Babies born to women with alcohol misuse problems are found to be underweight, have lower AGPAR² scores and are more likely to require neonatal intensive care (Burns, Mattick, & Cooke, 2006). Hence, the NMHRC recommendations advocate abstinence when planning for pregnancy and during pregnancy as the safest option for mothers. Abstinence is also recommended as the safest option while mothers are breastfeeding. However, if breastfeeding mothers do consume alcohol the guidelines recommend: abstaining in the first month of a baby's life; consuming no more than two standard drinks in a day; not consuming alcohol directly prior to breastfeeding; and planning ahead by expressing breast milk prior to drinking. ³

How many children in Australia are at risk?

Estimating the number of children who are at risk of or have experienced alcohol related child maltreatment in Australia's population is not an easy task and is complicated by varying definitions of what constitutes child maltreatment as well as other methodological concerns (Lamont, 2011; Price-Robertson, Bromfield, & Vassallo, 2010). For example, respondents to drug and alcohol surveys are known to under-report usage patterns, and the use of the term "standard drink" rather than actual drink sizes and types can skew results. Additionally, not all cases of child maltreatment come to the attention of child protection agencies, and data drawn from national surveys do not currently provide reliable information from which estimates of at-risk children can be made with certainty (Dawe et al., 2007). However, within these limitations, recent data offers a broad picture of the prevalence of this problem in Australia.

In a national survey looking at the range and magnitude of alcohol's harm to others, 17% of parent responders reported their children had been affected in someway by the drinking behaviour of another person (e.g., being criticised, witnessing domestic violence, or left in unsafe situations). A very small number of responders reported physical harm to children or calls being made to family services (Laslett et al., 2010). Other research conducted by The Odyssey Institute of Studies (2004), estimated that around 1.5% of Australian children (60,000) have parents seeking treatment for drug and/or alcohol abuse through treatment programs; a figure that they acknowledge fails to account for groups who seek treatment through primary health providers or for people who drink alcohol problematically and have not sought treatment. The largest Australian study on parental alcohol abuse suggests that 13.2% (451,621) of Australian children live in a household with at least one adult who binge drinks or drinks in a pattern consistent with chronic long-term use (Dawe et al., 2007). Finally, a recent analysis of the 2007 National Drug Strategy Household Survey suggested that this figure is between 17 - 34% (Maloney, Hutchinson, Burns, & Mattick, 2010).

Dawe et al. (2007) also found that high rates of binge drinking exist in the Australian community, with women in single parent households reporting higher levels when compared to women in couple households with children, a finding supported by Maloney et al. (2010). Additionaly, Dawe and colleagues found that in contrast to women, men are more likely to binge drink when they live in households with dependent children than in households where no dependent children are living, while Maloney and colleagues found that being male was a consistent predictor of risky drinking among parents. Although the rates for long-term chronic alcohol consumption are not found to be as high as those for binge drinking, there are still concerning levels for women in both single parent and couple parent households and a higher rate for men in coupled households with dependent children.

Overall estimations show that Aboriginal and Torres Strait Islander people are less likely to consume alcohol than the wider population (49% compared to 84%) (Dawe et al., 2007; Northern Territory Government, 2007). However, minority Indigenous populations are found to have the highest level of very risky alcohol consumption when compared to the general population (Dawe et al., 2007). Despite evidence that child protection applications in which alcohol is listed as a major concern show no difference between Indigenous and non-Indigenous populations, it has been estimated that up to 15% of Indigenous children in some states live in households where parents abuse alcohol (Dawe et al., 2007).

Complex factors associated with alcohol misuse

When parental alcohol misuse is combined with other risk factors, the negative effects can be cumulative and the potential for adverse outcomes for children is greatly increased (Bromfield et al., 2010). These risk factors include:

• relationship stress or breakdown;
• domestic violence;
• parental misuse of other substances such as illicit drugs;
• parental mental health problems (e.g., pre- and/or post-natal depression, bipolar disorder, post-traumatic stress disorder, schizophrenia);
• parental previous experiences of trauma and victimisation;
• poverty/unemployment;
• housing instability;
• low education;
• social isolation; and
• unavailability of familial and community support (Bromfield et al., 2010).

Much of the research into this issue investigates alcohol misuse within the context of these other risk factors and involves families from low socio-economic areas or those who have been in contact with child protection populations (Dawe, 2008). While such research is undoubtedly important, it seems clear that child maltreatment associated with alcohol misuse is a significant and under reported problem in Australia, and one that is not confined to specific sections of society. More research is needed to examine the unique impact that alcohol misuse has on the parenting capacity of people from all walks of life, and how best service providers and policy makers can respond to this problem.

Further reading

NCPC Resource Sheets

Child Abuse and Neglect Statistics <www.aifs.gov.au/nch/pubs/sheets/rs1/rs1.html>

What is Child Abuse and Neglect? <www.aifs.gov.au/nch/pubs/sheets/rs6/rs6.html>

The Prevalence of Child Abuse and Neglect <www.aifs.gov.au/nch/pubs/sheets/rs21/rs21.html>

Acknowledgements

The authors would like to acknowledge the valuable feedback and input of Professor Sharon Dawe, Dr Daryl Higgins, Elly Robinson, Pauline Kenny and Cathryn Hunter.

References

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Footnotes

1 In this paper, the terms "child maltreatment" and "child abuse and neglect" are used synonymously.

2 The AGPAR score is a quick form of assessment on a baby's health status following birth (Raising Children Network, 2010).

3 It is important to note that the alcohol consumption guidelines discussed here relate only to adults over 18 years of age. For parents and breastfeeding mums under the age of 18 different guidelines apply, with the NH&MRC (2009) strongly recommending abstinence as the safest option.