FACTORS IN CHILDHOOD AND YOUTH PREDICTING ALCOHOL DEPENDENCE AND ABUSE IN SWEDISH WOMEN: FINDINGS FROM A GENERAL POPULATION STUDY

Alcohol & Alcoholism Vol. 32,. 3, pp. 267-274, 17 FACTORS IN CHILDHOOD AND YOUTH PREDICTING ALCOHOL DEPENDENCE AND ABUSE IN SWEDISH WOMEN: FINDINGS FROM A GENERAL POPULATION STUDY LENA SPAK*, FREDRIK SPAK and PETER ALLEBECK Department of Social Medicine, GSteborg University, Vasa Hospital, S-433 Gflteborg, Sweden {Received September 16; in revised form 4 vember 16; accepted 26 vember 1%) Abstract The aim was to assess risk factors during childhood and youth for alcohol dependence/ abuse () in a population-based study of Swedish women. A total of 316 women were interviewed after stratified random sampling in the general population and a screening questionnaire. The interviews focused on social, psychological and behaviour characteristics as well as on early substance use patterns. Alcohol diagnoses were made according to DSM-IH-R and CTDI-SAM. Experiences of sexual abuse before the age of years, a history of psychological or psychiatric problems, early deviant behaviour and an episode of alcohol intoxication before the age of 15 years were significantly associated with in a logistic model. General indicators of low social class were not associated with increased risk of in a multivariate analysis. Sexual abuse in childhood was the strongest predictor of. This association has potential public health importance, and should be addressed in future studies on women and alcohol. INTRODUCTION The aetiology of alcoholism is multifactorial (Donovan, 186). In a general population survey of a national sample of US women, Wilsnack et al. () found that the most consistent predictors of onset of heavier drinking or adverse drinking consequences were younger age, cohabiting, lifetime use of drugs other than alcohol, and depressive episodes. Also, sexual dysfunction and depressive episodes predicted chronicity. Wilsnack et al. () also found that women with a history of childhood sexual abuse had significantly higher levels than non-abused women on different alcohol variables, e.g. alcohol dependence and problematic drinking (Wilsnack and Wilsnack, ; Wilsnack et al., 17). In Prague, Kubicka et al. (12) found that father's alcoholism, incomplete family of origin, conduct disorders in childhood and adolescence and a positive criminal record were supported as risk factors for alcoholism. Possible findings of different types of female alcoholism with different Author to whom correspondence should be addressed. patterns of risk factors were also reported (Kubicka et al., 12). Most research on predictors of female alcoholism has been done on clinical samples. For instance, Swett (14) found that physically and sexually abused psychiatric inpatients had a greater likelihood of reporting alcohol problems. Most of the women were abused for the first time before the age of 18 years. Turnbull (14) showed that reported family history of alcoholism was by far the strongest predictor, especially when the mother was an alcoholic. Perceived conflict with parents was another strong predictor (Turnbull, 14). Young adults with parents who were both substance abusers and had a psychiatric diagnosis were more likely to receive a substance abuse, depression or an antisocial personality diagnosis, compared with those whose parents only had a psychiatric diagnosis or no diagnosis at all (Weintraub, 10-1). Population-based studies of social and economic background factors have been performed mainly on men. In a longitudinal study of young Swedish men, Andrdasson et al. () found that contact with police or child care authorities, truancy, high socioeconomic status and many friends increased the risk of developing alcohol- 267 17 Medical Council on Alcoholism

268 L. SPAK et al. ism. Early symptoms of mental disorder and poor emotional control enhanced the risk for high consumers to become abusers or addicted (Andrdasson et al., ). Vaillant (183) concluded that heredity, ethnicity and antisocial behaviour are predictors of alcoholism in men, and suggested that poor conditions during childhood are due to parents' alcoholism and thus are not independent risk factors for alcoholism. In Sweden, the occurrence of alcohol dependence and abuse () among women has been measured in three previous population-based studies. These were all conducted in the period 168-172 (Hallstrom, 173; Ojesjo, 180; Halldin 184). As only 24 women with in total were identified in these studies, predictors were not ascertained. There is thus a need for populationbased studies on women using larger samples. The aim of the present study was therefore to analyse background factors for in women in a population-based sample. In particular we wanted to examine to what extent different social, psychological and behavioural factors during childhood and youth influenced the risk of lifetime. SUBJECTS AND METHODS Subjects The study was based on data from the Swedish multi-purpose population-based study on Women and Alcohol in Goteborg (SWAG) (Spak and Hallstrom, 15). The original study sample comprised all women (n = 30) born in 125, -35, 45, -55 or -65, who were registered in District West, a sector of Goteborg with 328 inhabitants (51 2 females), on 31 December 185. At the time of the interview, they were of ages 64-65, 54-55, 44-45, 34-35 and 24-25. exclusion criteria were used. Goteborg is an industrialized city with around 425 000 inhabitants (Statistical Yearbook, Goteborg, 186, Statistical Abstracts, Sweden, 18, Published by Statistics, Stockholm, Sweden, 188). Measurements The study was conducted in two phases and the study design has been presented in detail earlier (Spak and Hallstrom, 15). Phase 1 (questionnaire). A screening instrument for alcohol problems was developed. The questionnaire, called SWAG (Screening Women and Alcohol in Goteborg), was mailed to 30 women. Two written reminders were mailed, and, if necessary, the women were also telephoned. On the basis of the SWAG scores, we divided the subjects into three groups: 0 points (n = 177), 1-3 points (n = 47), and >4 points (n = ). Those who did not respond were put in a fourth group (n = 45). The response rate was 77.7% and another 6.5% (n = 202) refused to participate (Spak and HaUstrom, 16). Phase 2 (interview). Based on the scores obtained with the SWAG questionnaire, a stratified sample from phase 1 was invited for a structured interview (n = 47). Of these, 366 had responded to the screening questionnaire. From this group, we invited all women who scored at least 4 points on the screening questionnaire, a random 1/4 of those who scored 1-3 points and a random 1/15 of those with no points. We also invited 1/4 (n = 3) of those who did not respond in phase 1. The fractions were chosen so as to yield group sizes about equal to the size of the group that scored at least 4 points. We included all women from this group in order to include as many women with as possible. The response rate in the interview study was 88.3% for those who had answered in phase 1, and 67.3% for those who had not. The interviews were done by one male psychiatrist and two female clinical psychologists, all with several years of clinical practice experience. In this study, we only included the face-to-face interviews (n = 316). Of these, 48 had a lifetime diagnosis of alcohol dependence or abuse (Spak and Hallstrom, 15). The interviews focused on sociodemographic characteristics, psychological and behavioural parameters during youth and childhood, experiences of childhood sexual abuse, alcohol consumption and the use of licit and illicit drugs. Sexual abuse was defined as ever having experienced someone forcing or attempting to force them into a sexual activity. We also asked at what age such an experience occurred for the first and last time. The illicit drug use was defined as ever having used an illicit drug. We have defined abuse of licit drugs as the use of a drug either without prescription or using it more than prescribed, for the purpose of 'getting high' or to obtain other psychic effects. Clinical psychiatric diagnoses, including,

CHILDHOOD RISK FACTORS IN SWEDISH FEMALE ALCOHOLISM 26 Table 1. Factor analysis performed on variables from the social, psychological and behavioural domains Variable Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Frequent truancy during childhood or youth Shoplifted or participated in other criminality during childhood or youth Started to smoke before the age of or smoked regularly before the age of 15 Stayed away from home a whole night, without telling anybody, during childhood or youth Refused to eat during childhood or youth Difficulties in school, including special education Father's alcohol drinking Did not feel secure in the family Did not feel accepted and loved by father Rated more problems than normal during childhood or youth Mother's alcohol drinking Psychological or psychiatric problems, with or without treatment, during childhood or youth Somatic illness during childhood or youth Did not feel accepted and loved by mother Rated mother as strict Ever lived in a children's home or in a foster home Bedwetting during childhood or youth Father had psychiatric or psychological problems before the respondent was 18 years old Mother had psychiatric or psychological problems before the respondent was 18 years old 0.717 0.674 0.584 0.554 0.545 0.403 The first five factors with factor scores > 0.400 are included. were made according to DSM-III-R (American Psychiatric Association, 187). CIDI-SAM (Robins et al., 186) was also used for, as this instrument gives diagnoses according to several diagnostic systems, including ICD-10 (World Health Organization, 12) and DSM-III (American Psychiatric Association, 180). Analyses The variables were grouped into social, psychological, behaviour and substance abuse domains. We classified substance abuse in four different groups: illicit drugs, licit drugs, solvents 0.641 0.625 0.607 0.48 0.485 0.74 0.78 0.736 0.672 0.504 0.661 0.625 0.456 and alcohol intoxication. The illicit group includes ever having used cannabis, amphetamine, cocaine or crack, heroin or hallucinogenic drugs. For many of the variables, questions were asked about events during childhood (0-12 years) and youth (-17 years) separately, but were reported as ever occurring during age 0-17. Regarding smoking and alcohol intoxication, questions were asked about events occurring before or after age 15. The associations between risk factors and the dependent variable were expressed as odds ratios with 5% confidence intervals. We first assessed each risk factor separately in bivariate

270 L. SPAK et al. Table 2. Bivariate analyses of social variables during childhod or youth as predictors of lifetime alcohol dependence or abuse () Number Social variables Total OR 5% Q Socio-economic group of the father Number of sisters and brothers Reason for not living with both parents at the age of 18 years Ever lived in a children's home or in a foster home During childhood lost an important person, parent excluded Father's alcohol drinking Mother's alcohol drinking Father had psychiatric or psychological problems before the respondent was 18 years old Mother had psychiatric or psychological problems before the respondent was 18 years old High Middle Low 0-3 >4 Both parents dead Father dead Mother dead Parents divorced Moved from home Other Never or occasionally Often or problematic Never or occasionally Often or problematic Total number of subjects (n) = 316. OR: odds ratio; CI: 5% confidence interval. analyses. We then grouped the variables in the four different domains. Factor analysis was performed on the variables in the first three domains, in order to assess correlations between variables (Table 1). Based on this factor analysis, we identified a proxy variable 'early deviant behaviour' (factor 1), comprising the items smoking, truancy, criminality and 'stayed away a whole night from home'. As we wanted to analyse each substance variable separately, no factor analysis was performed on the substance abuse variables. Stepwise logistic regression analyses were performed within each of the domains. We entered those variables in the regression analyses that were significant (P<0.05) in the bivariate analyses. In a 78 70 148 265 51 165 1 41 2 276 38 27 30 4 0 284 2 278 23 258 53 67 57 126 228 40 148 17 16 33 70 7 240 27 237 25 188 6 244 236 20 223 41 22 37 17 4 3 8 22 2 36 42 5 26 40 8 3 35 12 0. 1.3 0. 1.7 2.0 1.6 2.1 2.8 2.5 2.7 1.1 2.2 2.4 0.8 1. 0.4-1.8 0.7-2.7 0.5-1.7 0.8-3.7 0.6-6.8 0.4-6.1 0.8-5.4 1.4-5.5 0.5 -.0 1.2-6.1 0.4-3.1 1.2-4.2-5. 0.2-2. 0.-3. final logistic regression model, we entered all significantly predictive variables regardless of domain. RESULTS In the bivariate analyses, we found that the risk of developing was more than double among women who had lived at a children's home or in a foster home. The risk was also increased for those with parents who drank alcohol often or had an alcohol problem according to the interviewee. The socio-economic group of the fathers had no effect (Table 2). Negative experiences from childhood and youth had a great influence on the risk for

CHILDHOOD RISK FACTORS IN SWEDISH FEMALE ALCOHOLISM 271 Table 3. Bivariate analyses of variables in the psychological domain during chudhood or youth as predictors of lifetime alcohol dependence or abuse () Number (/i) Psychological variables Total OR 5% Q Felt secure in the family Rated more problems than normal during childhood or youth Felt accepted and loved by father Felt accepted and loved by mother Rated father as strict Rated mother as strict Psychological or psychiatric problems, with or without treatment Sexual abuse first time < years first time > years Somatic illness during childhood or youth Never 278 37 242 74 267 35 22 20 222 66 254 57 258 58 257 27 26 256 60 244 24 7 51 230 26 252 53 7 46 230 38 226 16 224 44 34 25 23 37 40 7 31 37 28 20 31 5 32 16 3. 3. 2.2 3.4 1.5 1.4 4.3 5.0 1.7 2.6 1.8-8.5 2.1-7.5 0. - 5.0 1.3-.1 0.8-3.1 0.7-3.0 2.2-8.4 2.1 -.8 0.6-4. 1.3-5.1 Table 4. Bivariate analyses of variables in the behavioural domain during childhood or youth as predictors of lifetime alcohol dependence or abuse () Behavioural variables Restless Bed-wetting Difficulties in school, including special education Refused to eat Frequent truancy during childhood or youth Started to smoke before the age of years or smoked regularly before the the age of 15 years Stayed away from home a whole night, without telling anybody during childhood or youth Shoplifted or participated in other criminality during childhood or youth Total 281 35 27 1 284 32 202 24 274 42 253 63 22 24 25 Number 245 23 254 14 24 1 250 18 240 28 222 46 253 15 256 12 36 12 43 5 35 42 6 34 14 31 17 3 3 OR 3.6 2.1 4. 2.0 3.6 2. 3. 5.5 5% CI 1.6-7.8 0.7-6.2 2.2-10.7 0.8-5.4 1.7-7.7 1.4-5. 1.6-.6 2.1-14.7

272 L. SPAK el al. Table 5. Bivariate analyses of substance abuse as predictors of lifetime alcohol dependence or abuse () Total Ada OR 5% a Illicit drugs age at first time Licit drugs age at first time Solvents age at first time Alcohol intoxicated for the first time Never <18 years >18 yeajs Never <18 years >18 years Never <18 years Never or > 15 years <15 years alcohol problems later in life. Sexual abuse before the age of increased the risk of five times (Table 3). Most of the behavioural factors were associated with increased risk. Odds ratio was estimated as ~5 among those who reported shoplifting or had participated in other criminality during youth, as well as for those who had had difficulties in school (although the numbers were small) (Table 4). Early substance abuse also increased the risk for in adult life (Table 5). In the logistic regressions for each domain, we found that, among the social variables, 'ever lived at a children's home or in a foster home' and 'moved away from home before the age of 18 years' were significant predictors of. In the 245 23 47 83 63 162 2 15 261 50 7 12 3 75 54 2 256 10 22 34 28 10 8 30 43 5 32 16 7.4 2.2 1.5 2.2 3.1 2.8-1. 0. - 5.3 0.6-4.2 0. - 5.1 -.7 4.3 2.0 -.5 psychological domain, experiences of more problems than 'normal' during childhood or youth, psychiatric problems during childhood or youth and having been sexually abused before the age of years were associated with significantly increased risk of. In the behavioural domain, the variables 'felt worried during childhood or youth', 'difficulties in school including special education during childhood or youth' and 'early deviant behaviour' were significant, as were also 'use of illicit drugs before 18 years of age' and 'alcohol intoxication before the age of 15' in the substance abuse domain (Table 6). In the final logistic regression model, variables from the psychological, behavioural and substance Table 6. Stepwise logistic regression for each domain; childhood or youth Domain and variable OR 5% CI Social Moved from home <18 years of age Ever lived in a children's home or in a foster home Psychological Rated more problems than normal during childhood or youth Psychological or psychiatric problems, with or without treatment before the age of 18 Experienced sexual abuse first time < years of age Behavioural Early deviant behaviour Difficulties in school, including special education Restless Substance use Illicit drug use before the age of 18 Alcohol intoxication < 15 years of age 2.6 2.5 2.8 2.8 3.6 1.7 2.5 2.5 4.7 3.1 1.3-5.4 1.1-5.8 1.3-5.7 1.3-5.8 1.4-.0 1.2-2.5-6.3 1.1-5.8 1.6 -.6 1.3-7.3

CHILDHOOD RISK FACTORS IN SWEDISH FEMALE ALCOHOLISM 273 Table 7. Final stepwise logisitic regression analysis, regardless of domain Psychological/psychiatric problems < 18 years of age Sexual abuse first time < years of age Early deviant behaviour Alcohol intoxication < 15 years of age OR 3.0 3.5 1.6 2.6 5% CI 1.4-6.3 1.4 -.1 1.1-2.3-6.4 abuse domains remained significantly increased. The proxy variable 'early deviant behaviour' remained significant in the final model. The variables sexual abuse before the age of, psychological or psychiatric problems before 18 years of age and alcohol intoxication before the age of 15 were also significant in the final model. ne of the social variables remained significant (Table 7). DISCUSSION We identified a number of predictors for from the psychological, behavioural and substance abuse domains. An important predictor was sexual abuse before the age of, which remained significant in the final logistic regression model. The risk for lifetime was increased more than threefold among women with these experiences. This is in accordance with earlier findings (Wilsnack and Wilsnack, ; Swett, 14; Wilsnack et al., 17). Psychological or psychiatric problems in childhood or youth was another strong predictor that has also been identified in other studies of female alcoholism (Wilsnack et al., ; Kubicka et al., 12). The proxy variable 'early deviant behaviour' significantly predicted in the final logistic regression analysis, regardless of domain. This indicates that an important proxy variable of early behaviour problems, which indeed predicts future alcohol drinking problems in women, was identified in the factor analysis. However, since other risk factors had significantly increased odds ratios in the final model, the proxy variable was not a confounder in the sense that it removed the effects of other variables. Behaviour problems have earlier been reported as predictors of alcoholism in both men and women (Vaillant, 183; Kubicka et al., 12; Andre"asson et al., ). The risk of developing later in life was almost tripled for those who had been alcoholintoxicated before the age of 15. In Kubicka's study, regular drinking at or before the age of 15 predicted admission to a detoxification centre, but not a misuse leading to hospitalization on a ward for alcoholics (Kubicka et al., 12). We did not find that the use of illicit drugs before the age of 18 was a significant predictor in our final logistic regression model. This might be due to the small number of women who reported use of illicit drugs. It might also be due to the fact that use of illicit drugs co-occurs with psychiatric problems, a variable that was significant even in the final model. variable from the social domain remained significant as a predictor for female in the final multivariate analysis when variables from the different domains were included. Other studies have found that a family history of alcoholism increases the risk of the offspring receiving a lifetime alcohol diagnosis (Bohman et al., 181; Kubicka et al., 12; Turnbull, 14). In this study, fathers' frequent or problematic drinking increased the risk of their daughters developing only in the bivariate analysis. When we asked about their parents' alcoholic habits, the answers did not concern only biological fathers but also 'social' fathers. That only a small number of the women reported mothers' frequent or problematic drinking could perhaps explain why this variable was only of borderline significance in our bivariate analysis. The fact that the women subjectively reported parents' frequent or problematic drinking could also be a measurement bias. In conclusion, behavioural, psychological or psychiatric problems in youth and childhood, as well as alcohol intoxication before the age of 15, were found to be significant predictors of female in a Swedish general population sample. Social class in itself did not predict and no social items remained significant in the final

274 L. SPAK et al. model. However, variables from the social domain will probably cause disturbances that are expressed in the other domains. Interesting questions are if and how the different predictors are associated with each other, and if they predict different kinds of alcohol problems. Childhood sexual abuse was the strongest predictor of. This association has potential public health importance, and should be addressed in future studies on women and alcohol. Acknowledgements We thank Stefan Granbom for statistical advice and computer programming. The study was supported by grants from the Swedish Council for Social Research, Stockholm, 4-O0:lC and the Bank of Sweden Tercentenary Foundation, Stockholm, 4-0:01. REFERENCES American Psychiatric Association (180) The Diagnostic and Statistical Manual, 3rd edn. American Psychiatric Association, Washington, DC. American Psychiatric Association (187) The Diagnostic and Statistical Manual, 3rd edn, revised. American Psychiatric Association, Washington, DC. Andrdasson, S., Allebeck, P. and Brandt, L. () Predictors of alcoholism in young Swedish men. American Journal of Public Health 83, 845-850. Bohman, M., Sigvardsson, S. and Cloninger, C. R. (181) Maternal inheritance of alcohol abuse: crossfostering analysis of adopted women. Archives of General Psychiatry 38, 65-56. Donovan, J. M. (186) An etiologic model of alcoholism. American Journal of Psychiatry 143, 1-. Halldin, J. (184) Prevalence of mental disorder in an urban population in central Sweden with a follow-up of mortality. Dissertation, Karolinska Institutet, Sundbyberg, Sweden. Hallstrfim, T. (173) Mental disorder and sexuality in the climacteric. Dissertation, Goteborg, Scandinavian University Books. Kubicka, L., Csemy, L. and Kozeny, J. A. (12) Case-control study of risk factors of alcohol misuse in Czech women: are there four types of female alcoholism? International Journal of The Addictions 27, 05-18. Ojesj6, L. (180) Prevalence of known and hidden alcoholism in the revisited Lundby population. Social Psychiatry 15, 81-0. Robins, L. N., Cottier, L. B. and Babor, T. F. (186) The WHOIMHA CIDI-SAM Interview, revised 187. Spak, F. and Hallstrdm, T. (15) Prevalence of female alcohol dependence and abuse in Sweden. Addiction 0, 1077-1088. Spak, F. and Hallstrdm, T. (16) Screening for alcohol dependence and abuse in women: description, validation, and psychometric properties of a new screening instrument, SWAG, in a population study. Alcoholism: Clinical and Experimental Research 20, 723-731. Statistical Abstracts, Sweden (18) Published by Statistics, Stockholm, Sweden. 188. Statistisk Arsbok (186) (Statistical yearbook) GOteborg. Swett, C. (14) High rates of alcohol problems and history of physical and sexual abuse among women inpatients. American Journal of Drug and Alcohol Abuse 20, 263-272. Tumbull, J. E. (14) Early background variables as predictors of adult alcohol problems in women. The International Journal of the Addictions 2, 707-728. Vaillant, G. E. (183) The natural history of alcoholism: causes, patterns and paths to recovery. Harvard University Press, Cambridge, MA. Weintraub, S. A. (10-1) Children and adolescents at risk for substance abuse and psychopathology. International Journal of the Addictions 25, 481-44. Wilsnack, S. C. and Wilsnack, R. W. () Epidemiology of women's drinking. Journal of Substance Abuse 3, 3-157. Wilsnack, S. C, Klassen, A. D., Schur, B. E. and Wilsnack, R. W. () Predicting onset and chronicity of women's problem drinking: a fiveyear longitudinal analysis. American Journal of Public Health 81, 305-318. Wilsnack, S. C, Vogeltanz, N. D., Klassen, A. D. and Harris, T. R. (17) Childhood sexual abuse and women's substance abuse: national survey finding. Journal of Studies on Alcohol, in press. World Health Organization (12) The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. WHO, Geneva.