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British Journal of Addiction (1988) 83, 799-807

SYMPOSIUM PAPER
Predicting Alcoholism and Personality
Disorder in a 33-year Longitudinal Study of
Children of Alcoholics
ROBERT E. DRAKE,! j^l.D., Ph.D. & GEORGE E. VAILLANT,^ M.D.
Central Community Mental Health Services, ^Department of Psychiatry, Dartmouth
Medical School, Hanover, NH 03755, U.S.A.
Summary
The authors examine adolescent adjustments and the antecedents of DSM-III alcoholism and DSM-III
personality disorder in a 33-year longitudinal study of inner-city, non-delinquent sons of alcoholic men
(COA's). In early adolescence, the 174 COA's (38% of the sample) had more alcoholic relatives (in addition to
fathers), more non-Mediterranean ethnicity, more environmental stresses, and poorer adjustments than their
non-COA peers. Poor adolescent adjustment among COA's was associated with having a poor relationship
with one's mother. By midlife, 28% of the COA's had developed alcohol dependence, and 25% were diagnosed
with at least one personality disorder. Personality disorder but not alcoholism had strong continuities with
adolescent adjustment problems. Alcohol dependence was predicted by total number of alcoholic relatives, non-
Mediterranean ethnicity, low SES, and school behavior problems. Personality disorder was predicted by total
environmental weaknesses, poor maternal relationships, low IQ, and feelings of inadequacy.
Introduction Current research indicates that alcoholism is a
The children of alcoholics continue to gain atten- familial disorder strongly infiuenced by genetic
tion, both because they represent a common social factors (Schuckit, 1982). This is supported by
and clinical phenomenon that affects nearly 30 family studies (Cotton, 1979), twin studies (Kaij,
million people in the U.S. alone (Russell et al., 1960; Goodwin, 1976), and adoption studies
1984) and as an important target for high-risk (Goodwin et al., 1973; Goodwin, 1976). Psychoso-
research (Institute of Medicine, 1980; NIAAA, cial factors probably affect the genetic vulnerability
1983). Children of alcoholics (COA's) appear to to alcoholism and infiuence the development of
have increased rates of psychopathology in child- psychopathology among COA's, but little is known
hood and adolescence (Adler & Raphael, 1983). As about these factors (El-Quebaly & Offord, 1977).
adults, they have high rates of alcoholism (Cotton, There are few well controlled studies of the specific
1979), and they may also be vulnerable to a variety maladjustments characteristic of COA's and even
of other problems such as poor psychosocial func- fewer longitudinal studies of the continuities and
tioning, depression, poor self-esteem, and personal- discontinuities between their adjustment problems
ity disorders (El-Quebaly & Offord, 1977). in childhood and adult life. The few existing
longitudinal studies of COA's tend to be biased by
Reprint requests should be sent to: Dr Robert Drake, 2 Reservoir ^^^ Selection of highly delinquent, multiproblem
Road, Hanover, NH 03755 U.S.A. samples (Miller & Jang, 1977; Rydelius, 1981;
799
800 Robert E. Drake & George E. Vaillant
Werner, 1986). Poor outcomes in these samples
could be infiuenced by poverty, poor nutrition,
parental psychopathology, and other problems.
In this report, we will examine two chronic
disorders, alcoholism and personality disorder, in a
33-year longitudinal study of non-delinquent male
COA's in the community. Since delinquent boys are
prone to develop both alcoholism and antisocial
personality disorder (McCord & McCord, 1960;
Robins et al., 1962), our sample of non-delinquent
boys should be considered a relatively well adjusted
subset of inner-city COA's. Both paternal and
maternal alcohol abuse were approximately twice
as common among delinquent boys in the same
neighborhoods as our non-delinquent subjects
(Glueck & Glueck, 1950).
We believe that personality disorder constitutes
an important comparison outcome for alcoholism in
this sample for several reasons. First, personality
disorder, like alcoholism, is a chronic problem that
needs to be studied longitudinally (Frances &
Widiger, 1986; Drake & Vaillant, 1988). Second,
personality disorder, by definition, represents a
synthesis of maladaptive personality traits and poor
psychosocial functioning (APA, 1987)both of
which have been associated with adult COA's.
Third, personality disordered individuals, like alco-
holics, manifest poor global mental health, experi-
ence subjective distress, and use immature mecha-
nisms of defense (Drake & Vaillant, 1985; Vaillant
& Drake, 1985). Finally, personality disorder is
presumed to have continuities with adolescent
adjustment problems (APA, 1987) that are charac-
teristic of COA's.
In this paper we will address the following
specific questions: (1) What adjustment problems
are manifested by nondelinquent adolescent COA's
compared with their peers? (2) How are these
adjustment problems related to specific environ-
mental disruptions? (3) What are the adult conse-
quences of COA status in terms of alcoholism and
personality disorder? (4) What are the predictors
from adolescence of DSM-III alcoholism among
COA's? (5) What are the predictors from adoles-
cence of DSM-III personality disorders among
COA's?
identified by the Gluecks between 1940 and 1963 as
a control group for their well-known studies of
juvenile delinquents (Glueck & Glueck, 1950;
1968). In more recent follow-ups (Vaillant &
Milofsky, 1982; Vaillant & Vaillant, 1981), the non-
delinquent group has been called the Core City
sample. In terms of age, IQ, ethnicity, and residence
in high-crime neighborhoods, this sample had been
carefully matched with 456 Boston youths who had
been remanded to reform school. At the time of
initial evaluation, the boys had a mean age of 14 2
years and a mean IQ of 95 12. Although there were
no blacks in the Core City sample, 61% of the boys
had at least one parent born in a foreign country.
At the time of the original study, the boys, their
parents, and their teachers were individually inter-
viewed. Public records were searched for evidence
of alcoholism, criminal behavior, and mental illness
in all first degree relatives. Multiple social agency
reports were available on most families. Over 90%
of surviving subjects were reinterviewed at ages 25
and 31 (Glueck & Glueck, 1968). At these inter-
views alcohol abuse (or its absence) was specifically
recorded. At age 47 years, a 2-hour semistructured
psychiatric interview with a detailed 23-item section
on problem drinking (Vaillant, 1983a) was used to
reinterview 87% of the surviving subjects. The time
frame used to assess alcoholism was the period from
age 21 years to age 47 years. In addition to the serial
interviews, recent psychiatric, medical, and arrest
records were also obtained on most subjects. These
records identified additional alcohol-related prob-
lems and helped to confirm that the subjects were
reliable informants.
On the basis of interviews and public records,
alcohol abuse was diagnosed in the biological fathers
of 174 (38%) subjects and in the biological mothers
of 32 (7%) subjects (Glueck & Glueck, 1950). We
treated paternal and maternal alcohol abuse sepa-
rately for several reasons. Maternal alcohol abuse
was relatively uncommon and usually overlapped
with paternal alcoholism. It may have been related
to fetal alcohol effects. It almost certainly infiu-
enced family dynamics. We therefore defined the
174 subjects with alcoholic fathers as COA's in our
sample and considered maternal alcohol abuse as a
possible modifying variable.
Methods
Sample
Our sample included 456 non-delinquent, inner-
city, adolescent boys. The sample was originally
Measures
Predictive variables included three types: familial
use of and attitudes toward alcohol, adolescent
environment, and adolescent adjustment. Outcome
33-Year Longitudinal Study of Children of Alcoholics 801
variables were DSM-III alcoholism and DSM-III
personality disorder. Interrater reliability on all
variables has been previously reported (Vaillant &
Vaillant, 1981; Vaillant & Milofsky, 1982; Drake et
al., 1988).
Familial Variables:
(1) Maternal Alcohol Abuse: On the basis of
family interviews and public records, the Gluecks
(1950) rated the subjects' biological mothers dicho-
tomously for alcoholism.
(2) Number of Alcoholic Relatives: This four-
point scale included all known first and second
degree relatives. Ratings were made when the men
were aged 47 years and were based on all available
data, including sibling alcohol use.
(3) Ethnicity: Parental cultural background was
rank-ordered to the extent that their country of
birth tended to condone responsible childhood
drinking and to proscribe adult drunkenness. This
four-point scale is described in detail elsewhere
(Vaillant & Milofsky, 1982).
Adolescent Environment:
On the basis of social service records and
interviews with the boys, their parents, and their
teachers, clinicians blind to all subsequently col-
lected information rated the boys' families on the
following variables:
(1) Socioeconomic Status (SES): Ratings were
assigned to the boys' families. This five-point
classification, devised by Hollingshead & Redlich
(1958), assigns weights to education, residence, and
occupation.
(2) Environmental Weaknesses: This was a 25-
item scale that rated the men by objective evidence
of what went wrong in their childhoods and was
based on concrete criteria that refiected the
Glueck's more clinically defined Delinquency Pre-
diction Scale (Glueck & Glueck, 1950). Representa-
tive items included: known to more than nine social
agencies, separated from both parents more than 6
months, father physically abusive.
(3) Relationship with Mother: Quality of mater-
nal parenting. This three-point scale ranged from
absent or hostile parenting to warm, supportive
parenting.
(4) Relationship with Father: Quality of paternal
parenting, defined by the same 3-point scale used
for the relationship with their mother.
(5) Parental Separation: Child separated from at
least one parent by age 14 for 6 months or longer.
This variable was rated for a subsample (N=127)
of personality disordered and non-personality disor-
dered subjects (Drake & Adler, 1987).
(6) Parental Death: At least one parent deceased
by age of initial evaluation. The variable was rated
for a subsample ( N= 127) of personality disordered
and non-personality disordered subjects (Drake &
Adler, 1987).
Adolescent Adjustment:
The following variables were measured in the
same manner as those referring to adolescent
environment:
(1) Hyperactivity: An estimate based on applying
Wender's Scale for minimal brain dysfunction
(Wood et al., 1976) to the man's boyhood records ex
post facto.
(2) IQ: Full-scale Wechsler-Bellevue Intelli-
gence Test score.
(3) Emotional Problems: This 3-point scale was
based on items formerly taken to represent 'neuro-
tic' problems of childhood such as excessive shyness,
tics, phobias, and enuresis (Drake, Adler & Vaillant,
1988).
(4) Boyhood Competence: This 8-point scale,
described in detail elsewhere (Vaillant & Vaillant,
1981), measures competence at age-appropriate
tasks such as school performance relative to IQ,
participation in clubs and sports, and peer relation-
ships.
(5) Physical Health: This 3-point scale assesses
childhood physical health in terms of severe or
prolonged illnesses, disabilities, and deformities.
(6) Peelings of Inadequacy: The boys were de-
scribed as feeling inadequate, inferior, or insecure
by at least two of the following sources: interviewer,
parents, teacher, or psychological testing. This
variable was rated for a subsample (_N=127) of
personality disordered and non-personality disor-
dered subjects (Drake & Adler, 1987).
(7) School Behavior Problems and Truancy:
Presence or absence of repeated truancy and/or
disciplinary complaints from teachers (Vaillant,
1983b).
Outcome Variables:
Clinicians blind to all information from childhood
evaluations rated the following adult outcome
variables:
(1) DSM-III Alcoholism Scale: On the basis of
adult interviews, mental health records, and arrest
records, clinicians rated prevalence of alcoholism
according to a 3-point scale (none, abuse, or
dependence) defined by the American Psychiatric
Association (APA, 1980).
(2) Personality Disorder: On the basis of midlife
(age 47 years) evaluations, two psychiatrists rated
personality disorders according to DSM-III criteria
802 Robert E. Drake & George E. Vaillant
Table 1. Familial and Adolescent Characteristics of COA's and Non-COA's
Characteristics
Family
Mother alcoholic
Many alcoholic relatives
Non-Mediterranean ethnicity
Adolescent Environment
Low SES
Many weaknesses
Poor relationship with Mother
Poor relationship with Father
Parental separation (")
Parental death (")
Adolescent Adjustment
Hyperactivity
Low IQ ( <90)
Emotional problems
Poor boyhood competence
Poor physical health
Feels inadequate (")
School problems
Paternal
Present
(JV=174)
10%
24%
54%
36%
71%
34%
58%
43%
26%
11%
30%
35%
83%
31%
47%
8%
alcoholism
Absent
(iV=282)
6%
13%
33%
29%
23%
24%
24%
20%
8%
8%
31%
27%
63%
19%
47%
3%
Kendall's
tau
0.09*
0.20***
0.19***
0.08*
0.47***
0.13**
0.35***
0.24**
0.25**
0.05
0.02
0.09*
0.11**
0.13**
0.00
0.10*
Note: Kendall's tau correlations refer to the full scale for all measures. Family
and adolescent variables are presented dichotomously in this table for ease of
description.
' ' Subsample(N=127).
*/.<0.05; **p<0.01; ***p<O.OOl.
Table 2. Kendall's tau Correlations Between Adolescent Environment and Adjustment
Among COA's (N=174)
Adolescent
adjustment
Emotional
problems
Poor boyhood
competence
Poor health
School
problems
"Subsample ( N=47)
*/)<0.05; **/><0.01;
Environmental
weaknesses
0.06
0.14*
0.12*
0.16**
***p<0.001.
Adolescent environment
Poor
rel.
with
mother
0.16**
0.25***
0.14*
0.16**
Poor
rel.
with
father
0.02
0.08
0.12*
0.08
Parental
separation"
0.04
- 0. 16
0.20
0.13
Parental
death"
- 0. 11
- 0. 05
0.02
- 0. 12
33-Year Longitudinal Study of Children of Alcoholics 803
(APA, 1980). They diagnosed specific personality
disorders by consensus (Drake et al, 1988).
Table 3. Lifetime DSM-III Alcoholism Diagnoses
Paternal alcoholism
Present Absent
DSM-III Alcohol Diagnosis
None
Abuse
Dependent
58%
14%
28%
73%
16%
12%
Kendall's tau=0.17,/XO.OOl.
alcoholic relatives other than their fathers (Vaillant,
1983a).
Within the group of COA's, alcoholism was
predicted by number of alcoholic relatives, ethni-
city, SES, and, for a small number of subjects,
school truancy and behavior problems (Table 4).
Our measures of environmental disruption and
adolescent adjustment were remarkably unrelated to
subsequent alcoholic drinking. With the exception
of the few boys who presented school behavior
problems, correlations between adjustment prob-
lems in early adolescence and adult alcoholism were
not significant.
Result8
Adolescent Adjustment
As adolescents our children of alcoholics were
clearly different from their peers (Table 1). Their
families contained more alcoholic relatives in addi-
tion to their fathers and were more often of non-
Mediterranean cultural background. Their living
environments were strongly affected by disruptions
and poor relationships. The COA's were more
likely to have poor relationships with their mothers
as well as with their alcoholic fathers. COA's were
also less well adjusted than their peers. They had
emotional problems, poor competence in age-
appropriate skills, and poor physical health. De-
spite the non-delinquency selection criterion, a few
also demonstrated school truancy and behavior
problems.
Table 2 shows that the adjustment problems
characteristic of COA's were most strongly related
to one environmental variablepoor relationship
with one's mother. Only one other correlation, that
between total environmental weaknesses and school
problems, attained clear significance (p<0.01).
Given the number of correlations performed, rela-
tionships significant at the p=0. 05 level could be
due to chance.
Personality Disorder Outcomes
Table 5 shows that about one-fourth of our COA's
who received a full midlife evaluation appeared to
be personality disordered. This rate was no higher
than among non-COA's; nor were there any specific
personality disorders that were more common
among COA's than non-COA's.
Twelve (36%) of the COA's with personality
disorders were also alcohol dependent. Because
alcoholic men with personality disorders in this
sample were not impaired as children (Drake &
Vaillant, 1985), removing them from the sample
sharpens the focus on the continuities between
adolescent problems and adult personality disorders
(Drake et al, 1988). We therefore examined non-
alcoholic COA's to determine the predictors of
midlife personality disorders (Table 6). The signifi-
cant predictorsenvironmental weaknesses, poor
relationship with mother, low IQ, and feelings of
inadequacyare similar to the factors that pre-
dicted personality disorders in the complete sample
(Drake & Vaillant, 1985; Drake & Adler, 1987;
Drake, Adler & Vaillant, 1988). However, having a
poor relationship with one's mother, which showed
only a trend toward significance (p=0.07) in the
complete sample (Drake & Vaillant, 1985), emerges
as a strong predictor of personality disorders among
COA's.
Alcoholism Outcomes
The COA's were much more likely than their peers
to receive a lifetime diagnosis of alcoholism, accord-
ing to DSM-III criteria. Table 3 shows that the rate
of alcohol dependence among COA's was more than
twice as high as among non-COA's. In addition,
many of the non-COA's who became alcoholic had
Discussion
Despite their non-delinquent status, the COA's
were less well adjusted during adolescence than
their age-mates from non-alcoholic families. They
had more emotional problems, more medical prob-
804 Robert E. Drake & George E. Vaillant
Table 4. Predicting Lifetime DSM-III Alcoholism Among COA's
Familial and Adolescent
Characteristics
Family
Mother alcoholic
Many alcoholic relatives
Non-Mediterranean ethnicity
Adolescent Environment
Low SES
Many weaknesses
Poor relationship with Mother
Poor relationship with Father
Parental separation (")
Parental death C)
Adolescent Adjustment
Hyperactivity
Low IQ ( <90)
Emotional problems
Poor boyhood competence
Poor physical health
Feels inadequate (")
School problems
Dependence
(JV=42)
7%
41%
79%
45%
69%
33%
62%
48%
27%
12%
31%
24%
81%
33%
53%
19%
Alcohohsm
Abuse
( N=21 )
9%
10%
43%
29%
76%
33%
57%
50%
63%
5%
29%
43%
81%
38%
50%
0%
None
(JV=86)
12%
22%
51%
29%
69%
30%
53%
38%
13%
12%
26%
38%
80%
31%
42%
3%
Kendall's
tau
- 0. 06
0.19**
0.13*
0.13*
- 0. 03
0.08
0.06
0.09
0.20
0.09
0.10
- 0, 05
0,04
0.01
0.10
0.22**
Note: Kendall's tau correlations refer to the full scale for all measures. Family and
adolescent variables are presented dichotomously in this table for ease of description.
"Subsample (iV=47),
*/><0.05; **p<O.Ol.
Table 5. DSM-III Personality Disorders Among COA's
and Non-COA's at age 47
Diagnoses
DSM-III Personality Disorder
Passive-aggressive
Dependent
Schizoid
Histrionic
Narcissistic
Mixed
Paranoid
Compulsive
Schizotypal
Paternal Alcoholism
Present Absent
(iV=167)(iV=288)
33 (25%) 53 (23%)
8 (5%) 30 (10%)
8 (5%) 20 (7%)
5 (3%) 10 (3%)
3 (2%) 11 (4%)
3 (2%) 10 (3%)
2 (1%) 1 (0%)
2 (1%) 2 (1%)
1 (1%) 1 (0%)
1 (1%) 8 (3%)
lems, more school behavior problems, and less task
competence. They clearly manifested signs of emo-
tional distress and were deflected from normal
developmental tasks. These findings are consistent
with those reported by Rolf et al. (1988) and others
Qacob & Leonard, 1986).
The COA's did not demonstrate poor results on
intelligence tests or hyperactivity. The absence of
significance could be due to the selection criterion of
non-delinquency. Because conduct disorder is
strongly linked with hyperactivity (Reich, 1988)
and only a few of our non-delinquent subjects were
conduct-disordered, we infer that COA's with
hyperactivity were largely excluded from our sam-
ple. In addition, the Gluecks evaluated subjects well
beyond the age of maximum vulnerability and did
not systematically gather data regarding hyperactiv-
ity (Vaillant, 1983a).
The COA's in our sample experienced a variety of
environmental stressors and disruptions. Poor ado-
lescent adjustment was, however, strongly associ-
ated with only one environmental variablehaving
an unsupportive relationship with one's mother.
This finding is consistent with the notion that the
non-alcoholic parent plays a key role in protecting
the child from parental alcoholism (Jackson, 1954;
Wilson & Orford, 1978). When this protection does
not occur and the child is more involved in the
alcoholic parent's disturbed world, this involvement
tends to produce maladjustment (Deutsch, 1982).
33-Year Longitudinal Study of Children of Alcoholics 805
Table 6. Predicting DSM-III Personality Disorder at Midlife Among Non-
Alcoholic COA's f2V=97)
Familial and adolescent
characteristics
Pamily
Mother alcoholic
Many alcoholic relatives
Non-Mediterranean ethnicity
Adolescent Environment
Low SES
Many weaknesses
Poor relationship with Mother
Poor relationship with Father
Parental separation"
Parental death
Adolescent Adjustment
Hyperactivity
Low IQ ( <90)
Emotional problems
Poor boyhood competence
Poor physical health
Feels inadequate"
School problems
Personality disorder
Present
(,N=2l)
5%
14%
38%
24%
76%
52%
62%
45%
25%
10%
38%
48%
95%
43%
60%
5%
Absent
(N=76)
11%
17%
49%
31%
66%
24%
51%
33%
25%
8%
24%
36%
75%
29%
17%
1%
Kendall's
tau
- 0. 08
- 0. 03
- 0. 07
- 0. 05
0.21**
0.22**
0.09
0.11
0.00
0.06
0.21**
0.13
0.12
0.15
0.42**
0.10
Note: Kendall's tau correlations refer to the full scale for all meaures. Family
and adolescent variables are presented dichotomously in this table for ease of
description.
Subsample (Ar=32),
**/><0.01.
Although the COA's were predictably stressed alcoholism themselves. Over the long-term, healthy
and poorly adjusted during adolescence, the adult adult development among the COA's appeared to be
consequences of poor adolescent adjustment were related to: (a) escaping from the alcoholic environ-
somewhat surprising. The primary negative conse- ment, (b) also leaving the non-alcoholic parent, (c)
quence of COA status was alcoholism, not personal- developing task competence, (d) experiencing and
ity disorder. Furthermore, neither alcoholism nor internalizing healthy relationships, and (e) the
personality disorder was related to most of the maturation of defense mechanisms,
measures ofmaladjustment observed in adolescence. The COA's who developed alcohol dependence
In other words, poor adolescent adjustment, which themselves had more alcoholism in their families
was common among COA's and was related to lack and were raised in low SES families and in ethnic
of maternal support, had little continuity with the subcultures that at that time failed to help adole-
chronic adult maladies of alcoholism and personality scents learn moderate drinking habits and failed to
disorder. Most of the boys with adjustment prob- proscribe adult drunkenness (Vaillant & Milofsky,
lems in early adolescence were remarkably resilient 1982). Since these behaviors were not measured
and had somehow overcome their difficulties by directly, we are assuming that cultural background
midlife. and SES were associated with familial attitudes
We have elsewhere considered the longitudinal toward drinking and intoxication. Passing on famil-
course and some of the factors involved in healthy ial attitudes toward alcohol may be one of the ways
adult development among COA's (Drake & Vail- in which psychosocial factors modify the genetically
lant, 1987). Many of the maladjusted adolescents infiuenced transmission of alcoholism,
continued to suffer during early adulthood but Alcoholism was also predicted in a small number
gradually recovered, provided they did not develop of COA's by the presence of school truancy and
806 Robert E. Drake &George E. Vaillant
behavior problems. Vaillant (1983a) has discussed
in detail the relationship between alcoholism and
sociopathy in this sample. Although most of the pre-
alcoholic subjects in this non-delinquent sample
appeared normal premorbidly, other studies show
that delinquent adolescents are strongly predisposed
to the development of antisocial personalities and
alcoholism (McCord & McCord, 1960; Robins et al.,
1962). Similarly, our subjects with school truancy
and behavior problems tended to develop both
sociopathy and alcoholism (Vaillant, 1983b). These
few boys might therefore be considered more
representative of delinquent rather than non-delin-
quent COA's.
Adult personality maladjustments, unlike alco-
holism, show strong continuities with adolescent
problems. Personality disorder in midlife was pre-
dicted by early weaknesses of constitution, environ-
ment, and ego strength. Surprisingly, the dimensions
of adolescent maladjustment that predicted to adult
personality disorders were non-overlapping with the
adjustment difficulties that characterized our
COA's. They were instead similar to the adolescent
problems that predicted personality disorders in the
full sample (Drake & Vaillant, 1985; Drake et al.,
1988; Drake & Adler, 1987; Vaillant, 1983b). This
finding suggests that many of the factors that
predispose to personality disorder have little to do
with parental alcoholism per se. One exception is the
extreme environmental stress of having an alcoholic
father and an unsupportive relationship with one's
mother. This situation represents a particularly
important vulnerability for COA's that does predict
personality disorder. It emphasizes the crucial role
that the non-alcoholic parent plays in insulating
children from the destructive effects of an alcoholic
parent.
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