A pathway for families to cope with substance misuse in a Brazilian context

Stressful family life events and marginalized social environments may play important roles in child development. Family resources have become an essential point in intervention models based on prevention activities for children. The aims of this study were to investigate family resilience and its association with substance misuse in a Brazilian context. A case-control study of 305 children and adolescents (4 to 18 years old) who were exposed to addiction was undertaken. Sixty percent of the subjects were children of fathers with alcohol and drug problems and 40% were children of fathers without addiction problems. The type of substance use can have a significant influence on family resilience. The children of fathers with drug problems face more severe emotional and behavioral harms than children of fathers with alcohol problems. Families with a member who has an addiction problem are more likely to develop a higher threshold and are more resilient than are families whose members do not have an addiction problem. The data shows the importance of exploring family resilience as a way to expand coping resources for highly vulnerable groups. A pathway for families to cope with substance misuse in a Brazilian context


Introduction
In the addiction context, vulnerability related to drugs is defined as whether a specific group has increased susceptibility to drug abuse and related problems based on the family's socio-demographic profile and related risk factors [1,2].
Family environmental factors are well known to have a strong influence on the risk of substance use and other disorders in children [3]. In addition to substance use within the family, factors such as stressful life events and marginalized social environments [4] may play significant roles in child development and family dynamics. Investigating family resources has become an essential point in intervention models and in many preventive intervention strategies for children, based on family strength [5]. Knowledge about successful adaptation to stressful life conditions strengthens the conceptual base needed to frame treatment and preventive interventions for children at high risk [6,7,3] and for ethnic minority families at risk [8].
Despite the acknowledged importance of understanding resilience, the amount of current data about resilience in a family context is relatively limited [9,7]. Exploring family resilience as an important protective factor for the children of parents with problems with licit and illicit drug dependence can be a useful tool for potential intervention. Kimhi [8] speculated that resilience, following loss or potential trauma, is more common than is frequently believed. However, there are multiple and at times unexpected pathways to resilience. Resilience can be understood according to its relativity and should be regarded as a risk-exposing function. The severity and frequency of adversity should be considered in assessing resilience [10]. Evidence shows that individual components, such as children's resilience, are major protective factors [11,12]. A study investigating 482 adolescents reported that the risk factors related to parental addiction could decrease as individual resilience increases [13]. Thus, interest in investigating family resilience as a potential pathway for the reduction of such risks is mounting. The concept of family resilience was defined as the family's ability to rejuvenate and adapt to adversities related to alcohol and drug problems [9].
This study evaluated family resilience and its association with substance abuse problems in a Brazilian sample.

Methods
A case control study was undertaken at a selective prevention centre for children and adolescents from families with substance misuses (CUIDA) and a Pediatric outpatient clinic of the public health care facility, in partnership with Federal University of São Paulo, Brazil.
The sample comprised consecutive admissions of 305 outpatients treated at the services centres between April 2001 and June 2004. The sample was randomized by sex and age (4 to 18 years old) in two groups: (a) case group (CCG): 183 (60%) from a selective prevention service divided by Alcohol use and Drug use, (b) control group (CG) 122 (40%) children from a Pediatric Outpatient Clinic, according the eligible criteria:

Case selection
The case group was defined according the inclusion criteria: just one child representing your family (even with siblings) and one parents (only father) with a confirmed of alcohol abuse by Family CAGE test [14] and who were accompanied by a caregiver at the selective prevention service. The exclusion criteria were children of addicted mothers and children without the presence of parents or accompanied by a caregiver at the selective prevention service. According to this criteria, 31 participants were excluded, 14 (45.2%) had mothers who were addicted and, 17 (54.8%) had more than one child in the family.

Control selection
The control group was selected according to the inclusion criteria: one child per family without a history of family addiction. The exclusion criterion was children without the presence of parents or accompanied by a caregiver at the Pediatric Outpatient.

Questionnaires Brazilian economic classification criterion (BECC)
The socioeconomic rating system evaluates the purchasing power of urban families and individuals. The BECC is a system that classifies the population based on social classes as Class E (0 to 19 points) the least favored, Class D (20 to 34 points), Class C (35 to 58 points), Class B (59 to 88 points), and Class A (89 points or more) the most favored social stratum [15].

The family index of regenerativity and adaptation-general (FIRA-G)
This index provide a set of evaluation of the Resiliency Model of Family Stress, Adjustment and Adaptation, it was developed by McCubbin [7]. The FIRA-G measures seven indices of family functioning: (a) Family Stressors -10 items on live stressor events and changes. (b) Family Strains -10 items regarding live stressful events and changes between family members. (c) Relative and Friend Support Index -eight items to evaluate the degree to which families call upon the support of friends or other relatives as a strategy that the family unit uses to manage its stressors and strains. (d) Social Support Index -17 items concerning the degree to which families integrated into the community and how much support they feel that they obtain from this network. (e) Family Coping-Coherence -four items toward families' skills in managing stressful events, strains, and changes. (f) Family Hardiness Index -20 items to measure the characteristic of hardiness as a stress resistance and adaptation resource in families. (g) Family Distress Index -five items to access the major difficulties that families experience that deteriorate the families' stability. The Brazilian version of the FIRA-G showed good values of reliability of 0.65 for the Resilience Family Index [16].

The child behavior checklist (CBC)
The checklist discriminate between normal and psychopathologically disordered individuals [17]. The CBC contains 20 items that assess social competence, and 118 items that evaluate behavioral problems in children and adolescents [18,19]. This checklist has been used in several studies, in more than 85 languages, and the Brazilian Portuguese version has reported an excellent level of sensitivity of 87%.

Psychosocial stress factors (PSF)
This tool examines the psychosocial stress situations. The selection of the items was based on the criteria of the International Criteria Diagnosis (ICD-10) [20]: psychiatric hospitalization of a family member, severe disease in the family, suicide of a family member, attempted suicide of a family member, problems with the police, death in the family, and physical aggression among family members.

The family cage (F-CAGE)
This test is a screening instrument consisting of four questions that identify family problems related to alcohol consumption [14]. The F-CAGE was adapted for the Portuguese Brazilian version. The cutoff corresponded to an affirmative answer [21].

Data collection
The interview was conducted with a female caregiver, that is, mothers, grandmothers, aunts and stepmothers in both services. The interview took about 90 minutes per child's caregiver at the respective services and a team of previously-trained psychologists administered the questionnaires.

Data analyses
Data were analysed using the Statistical Package for Social Sciences (SPSS) version 17.0. Statistical analyses include the Chi-square test or the Fisher's exact test for small samples, Student's t-test for independent samples, Duncan's test and logistic regression. For all the statistical tests, a significance level of 5% was considered.

Ethical considerations
This study was approved by the Ethics Committee at the Federal University of São Paulo (protocol number 917/99) and all the subjects signed an informed consent form. The patients did not receive any refunds or compensation for participating in this study.

Sociodemographic characteristics
Family: The sample comprised 305 families with children and adolescents (4 -18 years), 183 (60%) belonged to the case group, and 122 (40%) were in the control group. In the sample, 133 (43.6%) of the families had fathers with alcohol problems, 50 (16.3%) fathers with drug addiction, and 122 (40%) fathers were not users of alcohol or drugs. The following were found to be predominant: parents, fathers, adults (Mean=38, SD=11.6), with low educational level, poor (class D or E), Caucasian and having manual labor jobs. There was no statistically significant difference between the socioeconomic data in the sample.
Children: In comparing the mean age, there was a statistically significant differences between children with alcohol-dependent fathers (Mean=10.4, SD=4.2), children with fathers with drug addiction (Mean=8.4, SD=3.4) and children with fathers without the use of psychoactive substance (Mean=10.3, SD=4.2) (p=0. 007). Only 8% of the children were 17-18 years old, of these children, only 6 (24%) had completed high school. Further, of the 31% who should have completed 9 years of schooling, only 14% had completed. Regarding the number of siblings, 50 (16%) were the only 1 child in the family, 170 (56%) had one or two brothers and 85 (28%) had more than 3 brothers.
Of the 305 questionnaire, 8 (2.6%) were eliminated because of the supply of ambiguous answers using CBCL tools. According to the CBCL Resilience: Data of seven Index of family Functioning -Resilience are presented in Table 2. The differences were statistically significant in the mean Indices of Family Strains (p < .001), Total Resilience (p < .0001), Family Hardiness (p < .0001), and Family Distress (p <.000). For these indicators, except for the index of Family Hardiness, the means of the case group was higher when compared with the control group. Concerning Family Strains (p < .0001), the mean of the groups of children with parents who were alcohol dependence (Mean=14.3; SD=10.3) or with drug addiction (Mean=13.3; SD=7.9) were higher than the means of the control group. Family Hardiness (p < 0.000) presented the highest mean for the drug group (Mean=16.4; SD=8.7), followed by the alcohol group (Mean=15; SD=8.3). Concerning Family Coping-Coherence, a difference in the mean was observed (p < 0.000), in that the children of fathers who were alcohol-dependent (Mean=15.8; SD=1.7) and the group control (Mean=15.9; SD=1.5) were greater than the mean of the children with drug-addicted parents (Mean=15.2; SD=1.8). Regarding the Family Hardiness Index, the mean were highest in the control group (Mean=43.6; SD=7.8), when compared with the group with alcohol dependence (Mean=41; SD=8.7) and drug addiction group (Mean=35.7; SD=10.4). Differences in the Resilience Total Index were observed only between the control group (Mean=20.8; SD=11.8) and the alcohol group (Mean=29.6; SD=16). Although there was no statistically significant difference in the Social Support Index (p=.837), it was observed that children of fathers of the drug addiction group (Mean=63.2; SD=10.4) had less social support compared with the alcohol dependence group (Mean=64.2; SD=9.7) and control group (Mean=64.7; SD=8).

Resilience (FIRA-G) and CBCL:
The findings showed that the FIRA-G scores were significantly associated with the CBCL subscales. Family Strains was the major risk factor concerning children's behavior and related with withdrawal, somatic complaints, anxiety/depression, social, thought and attention problems, delinquency and, aggressive behavior, and internalization, and externalization. Family strains and family distress were associated with all subscale of CBCL (Table 3).

Psychosocial stress family factors
Two of the seven psychosocial stress situations toward the children and adolescents were significantly associated with the vulnerability to the development of problems in family life (Table 4). Factors such as psychiatric hospitalization of any family member, suicide or attempted suicide of any family member, legal problems, and death in the family had no statistically significant difference in the groups. Physical aggression among family members was more common among the children of drug addicted parents, 23 (46%) when compared with alcohol-dependent parents, 38 (29%), whereas the presence of severe diseases were higher among the children of alcohol-dependent parents, 33 (24.8%) than among those of drug addicted parents, 10 (20%).

Discussion
In the present study, an association was identified between the socioeconomic status of a family and the development of maladaptive behavior in young adolescents. In particular, in this sample, 71% were considered as in the poverty range (economic class D or E), and 79% of the children were clinically scored, whereas 21% were nonclinically scored (p=.001). Socioeconomic status is not a determining factor in itself, as a family with a low income does not necessarily have dependence-related or violence-related problems [22,23]. In cases in which low socioeconomic status is accompanied by other risk factors, this factor can increase the risk of developmental problems in children and adolescents [24]. A study reported that having separated parents can be a risk factor when accompanied by other factors [25]. The majority of the parents investigated in this study were living as couples, and the proportion of separated parents was higher among the children of drug-dependent parents than among children in the other groups.
The group comprising children of drug-dependent parents was shown to have less social support as well. The findings of a national study [26] have shown that the mean age of drinking onset in Brazilian adolescents has decreased, to 13.9 years old. According to the World Health Organization [27], between the ages of 12 and 18 years, mental and behavioral disorders caused by the use of psychoactive substances can emerge. It is important to note that the mean age bracket for this sample was 8 to 10 years. Analyzing this evidence based on age, it is difficult to predict whether these children will develop a substance use pattern. In our findings, 98% of the subjects reported no substance use, and the 1.4% who had experimented with alcohol were children of fathers with alcohol dependence.
The seven indices of family functioning were designed to assess the dimensions of resiliency, which were understood to be risk or protective factors in this study. The effect of the diversity of each group of families is evident when comparing the resilience factors in the study groups with those in the control group. According to the FIRA-G indices, families with a member who is an addict are more likely to develop a higher threshold, and they are more resilient than are families who do not have a member with addiction problems. This phenomenon may be related to the fact that although it is clear that family hardiness and family strains represent important risk factors for the family system, it is important to consider that a healthy family is not one without problems, but rather one that has the potential to find alternatives to resolve conflicts, reduce destructive effects and increase gains [28]. Relying on this premise allows alternatives to be better developed and offered to the families living in this context of addiction and social vulnerability.
Another finding was that the drug group had less social support than the alcohol or control group. It is clear that addiction can interfere with a family's social life and networking [29,30], indicating   that the tendency to become isolated occurs not only in the drug user but also in the entire family system. Regarding their hardiness condition, the families with alcohol and illicit drug problems show a higher index for this resource according to Rutter [10]. Resilience has been shown to be relative and should be regarded as a risk-exposing function; consequently, the severity and frequency of adversity related to substance abuse should be considered when assessing resilience in these groups.
Considering families with alcohol problems and families with drug abuse problems, both groups have shown high rates of family strain and stress. Studying these groups showed that the presence of substance misuse exposes the family system to high instability. The type of substance had different effects on the severity of the consequences among the three groups of children. The results showed that an increased vulnerability to emotional and behavioral problems in children whose fathers had drug problems was directly related to being in less resilient families, with a higher number of divorced parents, and with a lower score on the coping condition index compared with the families in the alcohol group (Table 3).
Substance misuse and the instability caused by an absence of family unity can affect family functioning, promoting more conflict among family members and generating a violent context [31]. There are evidences that the family setting is overwhelmed when substance abuse is accompanied by other factors, such as traumatic episodes, severe diseases and domestic violence [32]. As shown in Table 4, physical aggression among family members was one of the psychosocial stress factors observed in the present study, and this factor was shown to be significant in 24.3% of the 305 families evaluated. The proportion of physical aggression was higher in those groups with drug-dependent fathers than in the other groups. It is important to frame the association between domestic violence and addiction problems. As highlighted in another study, that children who have witnessed domestic violence are more vulnerable to developing substance abuse in adulthood as are children who have been physically abused [33].
This study has some limitations. The study population included families with low socioeconomic status who were living in an underprivileged and violent suburban area of São Paulo, Brazil, and the data should be evaluated with caution and cannot necessarily be extrapolated to others populations. It would be helpful to investigate family resilience as a protective factor and its correlation with other factors in families who present other contexts of vulnerability.
The construct of resilience is exceptionally difficult to measure, particularly in a family context. The roles of the protective and risk factors involved, the exchanges that occur between a family and its surroundings, and the mechanisms and outcomes that enable resilience and lifespan trajectories should be considered when assessing the factors that strengthen or weaken the resilience condition. This issue implies an understanding of the subjective degree of adversity. Experience of adversity related to addiction problems reflects the ambiguity that must be considered during family research [12,30]. It is relevant to consider that the questionnaire in the current study was administered to the caregivers of the evaluated children, which could have led to a biased perception regarding the family issues referred to in the questionnaires; that is matters relating to the children could have been denied or omitted by the caregivers who answered the questionnaire.
It is essential to emphasize a Brazilian context of vulnerability in which certain families are paralyzed and others are strengthened and more resourceful due to a persistent state of crisis or stress. This observation is related to a sample study group that is more resilient than one that does not experience addiction. Exploring the facets of resilience in families with high social vulnerability is a way to understand them as an entity that is not damaged, but rather able to  change and meet challenges, and this finding extends to the risk group of children of addicts. Resilience is a protective factor for children and families who shift their own view about family functioning.

Conclusion
This study suggests the importance of exploring family resilience as an important protective factor for children and family members who live in an addiction context and as a resource for preventive services. The seven indices of family functioning were designed to assess the dimensions of resilience, and in this study, these dimensions were understood as a measurement of risk or protective factors. These factors can be used as guidelines for action in preventive services and as a model for family services. The type of substance abuse affects the condition of resilient families and the severity of the consequences for children. The children of fathers with drug problems experience emotional and behavioral damage and exist in less resilient families in comparison with the children of fathers with alcohol problems. These data reflect the needs of families with members who are illicit drug users compared with the different needs of families in which alcohol dependence is present. The relevance of specific interventions underlines the importance of preventive intervention, including a family approach, involving children, that supports the family in the factors that are directly related to family functioning, such as the parents' relationship, economic issues, conditions of confrontation, and aggression among members.