Substance use disorders (SUDs) are complex, multifactorial conditions influenced both by genetics and environmental exposures. Like many heritable conditions, SUDs are often experienced by multiple generations within families. Being among the most highly stigmatized medical conditions, discussion around SUDs is often minimized, especially in the context of parenting and families.1 Compounding this reduced communication between family members, it is unclear whether discussing familial SUDs more openly, including parental SUD, could impact overall family wellness and/or impact rates of substance use or SUD in subsequent generations. No universal guidelines exist to help parents with, or in recovery from, SUDs decide whether or how to have these conversations. While further research is needed, based on our clinical experiences and principles of child development, this article is intended to support clinicians in helping children and families communicate about parental substance use.
There are many reasons parents may hesitate to speak to their children about their own substance use or their child’s experience or decisions regarding substance use. They may fear being hypocritical. They may feel unable to explain their experience or history of substance use in a developmentally appropriate way. Parents may be concerned that talking about their substance use will make their children more likely to try substances. Some parents feel intense shame and embarrassment about their substance use or the consequences of their use. Stigma often plays a large role in the hesitancy to discuss this topic and can compound the aforementioned parental experiences. Finally, parental decisions about SUD disclosure can be misinformed by incorrect assumptions about how much their children do or do not already know about parental substance use and its impact on the family.
There is ample evidence that improved parental communication with children about substance use in general can decrease the likelihood of adolescent substance use.2 Such communication is a recommended component of many successful substance use prevention programs. It is less clear, however, how effective these conversations are when parents themselves currently struggle or have struggled with substance use. In the absence of parental guidance or instruction to the contrary, some adolescents view parental substance use as evidence that their parents do not care whether the adolescent uses substances.3 Adolescent focus groups have highlighted attachment, parenting style, and the “hidden nature” of substance use as particularly impactful on adolescent wellness when a parent has struggled with substance use.4 Very little research exists regarding the impact of communication about parental substance use on adolescent substance use. One study found that the more alcohol-related problems a parent had, the more they communicated with their children about alcohol, which in turn correlated with fewer alcohol-related problems for their children.5 However, another study found that parental disclosure about their personal negative experiences with alcohol predicted a greater likelihood of adolescent alcohol initiation.6 This discrepancy could stem from many factors, including differences in the quality, timing, frequency, and specific content of communication, parent recovery status, child risk factors, or other factors not assessed.
Several programs and studies have sought to improve parent–child communication about parental illnesses such as cancer, depression, and PTSD. Benefits of these programs include improved illness comprehension, coping, and wellness in children as well as strengthened communication between parents and children through supported self-disclosure and facilitation of other parenting skills.7–9 Such communication-enhancing, family-based approaches may have universal applicability to other parental illnesses, including substance use.10
In the absence of universal guidelines, clinical experience and the following child development principles and family therapy practices can be utilized to support parents impacted by substance use as they make decisions about communication with their children.
Parental Choice
Honoring and recognizing parental autonomy and decision-making can prevent a clinician from pushing an unready parent into disclosure or communication. Helping parents recognize the difference between privacy (information primarily impacting an individual appropriately held in confidence) and secrecy (information that greatly impacts another not being disclosed to them) can support decisions about what information to share.
Developmental Principles
Generally, children are voicing readiness to discuss a challenging topic when they ask about it. When topics are persistently avoided, or children are told a topic can only be discussed “when you’re older,” children may receive the inadvertent message that the family does not and should not talk about hard things. Children are generally quite perceptive, even to nonverbal cues, and frequently already know more than parents think they know. Without added information or perspective, children may be left creating a much darker or scarier narrative than the actual circumstances. Alternatively, some children, particularly older children, may idealize or have a glorified perspective of parental substance use. Educating parents about age-appropriate communication and language can increase comfort and confidence in having these conversations.
Focus on Resilience
Parents can share the reasons they have made or are working to make a change rather than the reasons their challenges with substance use came to be. They can avoid glorifying or regaling language or stories about their substance use. Educating parents about the value of children hearing a balanced family narrative (“We are not all success, nor all failure”) can help alleviate shame and decrease worry that sharing challenges begets more challenges.
Many parents with SUDs seek guidance regarding whether or how they should discuss their substance use with their children. Child and adolescent psychiatrists and allied health professionals are well-positioned to support these parents. Providers can assess family preparedness to discuss parental substance use through a lens of parental autonomy and child developmental readiness. When indicated, providers can facilitate and support balanced family communication with an emphasis on resilience.
About the Authors
Maddy Powell, BS, is a fourth-year medical student at the University of Vermont Larner College of Medicine who is applying to psychiatry residency.
Oliva Harrison, MD, is a first-year child and adolescent psychiatry fellow at the University of Vermont Medical Center (UVMMC).
Brady Heward, MD, is an Assistant Professor at the University of Vermont Larner College of Medicine and the Psychiatry Clerkship Director.
Peter Jackson, MD, is an Assistant Professor at the University of Vermont Larner College of Medicine and Medical Director at the UVMMC Addiction Treatment Center.
Correspondence to:
Madeline Powell, BS, email: madeline.yvette.powell@gmail.com.
Funding
This article was not directly supported by a grant or other funding.
Disclosure
Madeline Powell and Dr. Harrison have reported no biomedical financial interests or potential conflicts of interest. Dr. Heward receives salary support from a Rural Communities Opioid Response Program, Rural Center of Excellence on Substance Use Disorders (RCORP-RCOE) grant (UD9RH33633) funded by the Health Resources & Services Administration (HRSA). He has also received travel support and honorarium for presenting at the “Taking Action: National Rural Substance Use Disorder Health Equity and Stigma Summit” held in Rochester, NY. Dr. Jackson receives salary support from a Rural Communities Opioid Response Program, Rural Center of Excellence on Substance Use Disorders (RCORP-RCOE) grant (UD9RH33633) funded by the Health Resources & Services Administration (HRSA). He also receives salary support from a Medication Assisted Treatment — Prescription Drug and Opioid Addiction (MAT-PDOA) grant (1H79TI085330) through the Substance Abuse and Mental Health Services administration (SAMHSA). He has received travel support for presenting at the “Taking Action: National Rural Substance Use Disorder Health Equity and Stigma Summit” held in Rochester, NY. He has received honoraria for presenting at AACAP Institutes. He has received travel support for participation in the US–China Comprehensive Drugs Dialogue funded by US-based non-profit INHR. He has received honorarium and travel support for education provided to the Center for Restorative Justice in St. Johnsbury, VT.
Author contributions
Writing – original draft: Madeline Powell (Lead). Writing – review & editing: Madeline Powell (Equal), Peter Jackson (Equal), Olivia Harrison (Supporting), Brady Heward (Supporting). Conceptualization: Madeline Powell (Equal), Peter Jackson (Equal).