Journal of Addiction Research & Therapy
Open Access

The patients in our clinical practice, who were entering treatment for alcohol dependence for the first time in their older age, often mentioned two reasons why they did not come earlier: (1) Selfregulated drinking reduction during parenthood, when children were too young and/or (2) Fear to be separated from their children. We were interested if quantitative statistical data might be supporting this reasoning.

Biological and psychosocial factors both influence ("orchestrate") the development and course of alcohol-related problems including dependence. Alcohol use changes during late adolescence and early adulthood [1-4]. By far the most commonly offered explanation for young adult maturing out is that drinking-related reductions are driven by transitions into adult roles like marriage and parenthood [2,5-7]. Research indicates fewer problems with respect to drinking among married individuals compared with those who are single or divorced [8-10]. Lee et al. [3] presented results, that protective marriage effects on drinking quantity trajectories would be stronger among more severe pre-marriage problem drinkers. Matzger et al. [11] found that other factors were more important than marital status in predicting alcohol consumption. Little et al. [7] observed significant declines in alcohol consumption after adults have children. Parental duties and responsibility interfere with heavy alcohol consumption [2]. The claims regarding changes following fatherhood must be distinguished from those attributable to marriage [12]. Laborde et al. [13] found motherhood to be protective against drinking behaviors. Pregnant women appear to reduce their alcohol use for number of reasons, including the belief that alcohol is harmful to the developing foetus [14]. The transition to motherhood is associated with marked reductions in alcohol consumption [15,16]. Similar reductions were not observed for women who did not become mothers [15]. According to Bachman et al. [5] men less frequently used alcohol following fatherhood. Despite an overall trend toward maturing out, however, a substantial subset of individuals persists in risky drinking [17,18] and are therefore at increased risk for the escalation of drinking pathology [19]. Parental responsibilities might be motivation to limit drinking especially of heavy drinkers [3] when the children are young, but it can increase again later on [16], when children are less dependent. Another explanation might be that child rearing duties delay the decision to seek help for alcohol-related problems. The 2013 study by Grosso et al. [20] found that common internal motivators for women seeking treatment included concern about children affected by drinking. For example, some women may be motivated to seek treatment if they believe their substance use is negatively impacting their child, or because they fear losing custody of their child if they do not stop drinking [21]. Moreover, parenting and motivation for substance use treatment may be uniquely complex for women, since mothers may perceive the impact of their drinking on their child as both a facilitator and a barrier to seeking treatment [22,23]. According to Wilke et al. [24] popular beliefs hold that children serve as a primary source of a mother's treatment motivation; however, their study found the opposite was true. Children should not automatically be considered a primary source of motivation for participation in treatment. Among women at risk for problem drinking, treatment seeking can be hindered by a complex array of issues, and Small et al. [25] mentioned that fear of losing custody of children was one. The negative influence that children have on treatment motivation may reflect the practical or emotional difficulties of having to leave children behind or in some instances having children placed in foster care. Disruption, or threats of disruptions of family relationships (e.g. loosing custody of children), can prevent the women from entering treatment [26]. Our aim was to explore the association between parenthood and the age of treatment seeking for alcohol dependence in the retrospective naturalistic study. The assumption was that parents with more children will be seeking treatment for the first time in the older age, because of the treatment entry delay due to parenting.

The sample consisted of 1,316 patients who asked for treatment for alcohol use disorder for the first time in their life at Centre for Treatment of Drug Dependencies in Bratislava between the year 2011 and 2015. It was a retrospective, descriptive, clinical study. Included were only patients with ICD-10/WHO diagnosis of alcohol dependence (code F10.2), which was assessed by psychiatric examination. The exclusion criteria were any previous treatments for the diagnosis of alcohol dependence elsewhere in the past. Because of this finding in their histories 207 patients were excluded from the study. A total number of 1,109 patients were eligible for the analysis (71% males, 29% females) with a mean age of 43 (SD ± 12.6) years. Patients’ personal histories were reviewed with respect to their age and the number of children they had at time of treatment admission. Software SPSS 16.0 for one-way analysis of variance (ANOVA) was performed to analyze the association between these two variables for male and female patients. The study was approved by the Ethical Committee of the Centre for Treatment of Drug Dependencies.

Subjects were divided into the following groups: no children, 386 (35%); one child, 272 (25%); two children, 374 (31%); three and more children, 104 (9%). The mean ages at treatment admission of the whole group were 43.1 (SD ± 12.8) and 44.1 (SD ± 12.0) years for males and females, respectively. Patients of both sexes with no children had the lowest average age at their admission: males, 36 (SD ± 11.8) and females 35 (SD ± 10.0) years. The average ages for males and females with one child were 44 (SD ± 11.7) and 43 (SD ± 10.8) years, respectively. Males and females with two children entered treatment at the ages of 50 (SD ± 10.1) and 50 (SD ± 9.5) years. Males and females with three and more children entered treatment on average at ages 50 (SD ± 10.3) and 51 (SD ± 10.8) years, respectively. The association between number of children and age of the first treatment seeking due to diagnosis of alcohol dependence was statistically significant (p ≤ 0.001). There were no differences between males and females in this respect (Table 1).

Table 1: Number of children and age at treatments admission.

The results show, that people who had more children were significantly older, when they were seeking treatment for their drinking problems diagnosed as alcohol dependence for the first time in their lives. Scientifically evidence-based data for this topic are scarce. There are several hypotheses for these findings, and they should be explored in future investigations supplemented by qualitative research. Still we can speculate on behavioural factors and possible motivation for the differences. Interestingly for us, there was no difference between men and women in the treatment seeking delays. Based on the literature, we expected that delay in treatment seeking will be more pronounced among women, because of their specific motivation to reduce drinking during pregnancy [14]. Later age for treatment entry due to alcohol dependence of parents could be complex, combination of time limited drinking reduction and effort to avoid treatment not to lose custody of their little children. Whether main factor, same for both, fathers and mothers, is the change in their social roles during parenthood, or is it combination of different motivations in men and women, but with the same result, should be further studied. The most commonly offered explanation for young adults is maturing out, that drinking-related reductions are driven by transition into adult roles like marriage, parenthood and employment [5,6]. The negative relation of social roles (e.g., marriage, parenthood) to specific patterns of behavior (e.g., problematic drinking) has been labeled role incompatibility by Yamaguchi and Kandel [27]. Role incompatibility theory is often referenced to explain how and why these roles influence maturing out. When state of conflict exists between behavior and demands of social role, this can initiate a process called role socialization whereby conflict is resolved through changes in the behavior [27]. It remains to be determined whether having children is protective factor against the development of heavy alcohol consumption and alcohol dependence, and/or, if it is also factor, which is ameliorating and delaying development of more severe alcohol use disorder among predisposed heavy drinkers. The findings of Lee et al. [28] suggest, that many high-risk drinkers merely reduce rather than eliminate their risky drinking. Practically, findings support the clinical relevance of "maturing out process” by suggesting that they often reflect natural recovery that occurs in young adulthood from clinically significant problem drinking (e.g. symptomatology and AUDs) [3,28]. Decline of clinically significant forms of alcohol involvement into remission does not necessarily mean they are no longer at any risk and in many cases there may be continuing reason for clinical concern [28]. When children are older and become less dependent some parents can continue with reduced drinking behavior, while the others my return to previous levels of drinking and fully develop the condition of more severe alcohol use disorder [16,28]. According to Borshmann et al. [16] for most women this protective effect diminished with drinking levels close to pre-parenthood levels after five years. Here, we can only speculate, that this is about the same time interval, which led parents to treatment seeking in our sample after their first and the second child became older. Much more information to support this assumption is necessary. Practical implication is that our finding might be supporting and supplementing past research of the clinical relevance of role incompatibility theory and hypothesis that it may have ameliorative effects on drinking reductions especially on heavy drinkers even beyond the time period of young adulthood. The integration of role-incompatibility themes into clinical practice would be consistent with the approaches like Motivational Interviewing that aims awareness of discrepancies between problem behaviors and client´s values, goals and priorities [26]. The lack of an explicit assessment of role incompatibility makes the interpretations of our results more speculative but may prove to be complex way for future research. Furthermore, previous research indicates that, some pregnant women and new mothers are afraid that their substance use will be discovered, and they will lose parental rights [25,22]. It is underscored how parenthood status should be addressed in attempting to decrease stigma and increase utilization of treatment. Though female focused interventions specifically focus on family and are usually the targets for interventions when parent status is considered, this analysis also demonstrates that fathers experience greater stigma as well [29]. Future research should examine the extent to which concerns over stigma affect the decision to attempt natural recovery. Because of lack of information we are not able to answer clinically important issue if delay of the first treatment entry was due to previous longer lasting moderate drinking or only due the effort to avoid treatment not to lose custody of their little children without significant reduction of heavy drinking. Design of our study does not allow inferring causality. The findings are preliminary and provide only limited information that cannot be thoroughly interpreted.

According to the results of our study it seems that the age of the first treatment seeking by the patients with alcohol use disorder is associated with parenthood. Parents of both sexes with more children tended to seek treatment for alcohol use problems diagnosed as dependence later, than those with one child or those who had no children.

The small number of observed variables did not provide enough data to examine more associations, which could explain the later age of admission of patients with more children who were seeking treatment for alcohol dependence. First, although there is broad theoretical justification for prediction that alcohol use should decrease following parenthood, this study was not designed to test specific theories why this occurred. Second, our study obtained no information on parent’s age at time of childbirth, neither of their co residence with biological children in the early childhood. Third, more precisely personal histories of patients seeking treatment should be reviewed in detail to confirm when they first sought treatment for alcohol dependence. It is possible that older subjects with more children in the study had more undetected previous treatment episodes for the same problem. Fourth, future prospective studies should provide deeper insight into the age differences revealed in this study. In this respect, the present results are preliminary. The descriptive, retrospective design of the study did not allow for precise data collection.