Alcohol Misuse in the Family? If Only My Doctor Had Asked

It was October 2012. I had been invited to give a lecture on secondhand drinking (the negative impacts of a person's drinking behaviors on others) to Stanford Medical School students enrolled in Dr. Stanley Fischman's Eating Disorders and Addiction Rotation.

Dr. Fischman asked me to speak with his rotation students on a regular basis given my decades experience with loved ones' alcohol misuse, my own eating disorders, and my relevant work experience. He wanted his students to understand the other side of a person’s alcohol misuse – secondhand drinking (SHD) – because it affects 90 million Americans. That’s five times the number of people whose drinking causes SHD, yet medical practices are primarily focused on the drinker and the health impacts the drinker experiences.

During my lecture, I explained drinking behaviors, which are at the root of SHD. Drinking behaviors occur when a person consumes more alcohol, thus more ethyl alcohol chemicals, than their liver can metabolize. When this happens, the ethyl alcohol chemicals interrupt the chemical portion of the brain's cell-to-cell communications. This suppresses normal neural network functioning responsible for judgment, memory, pleasure/reward, emotions, breathing.... In other words, it changes a person's thoughts, feelings, and behaviors.

Contrary to popular belief, it's not just the drinking pattern of alcoholism that causes these behavioral changes, although alcoholism is certainly one. Binge drinking, heavy social drinking, and alcohol abuse (terms now grouped together as alcohol misuse and/or alcohol use disorders) also cause drinking behaviors. Some of the drinking behaviors I referenced included:

  • crazy, convoluted accusations and illogical arguments
  • verbal, physical and/or emotional abuse
  • bullying; neglect
  • driving while impaired
  • domestic violence.

I went on to explain there is a direct impact – a second-hand effect – on people confronted and/or coping with those drinking behaviors. These include:

  • being on the receiving end of drinking-related verbal, physical or emotional abuse; neglect; bullying and believing it’s the “real” person coming out, not understanding the behaviors are the consequence of chemical changes in the brain
  • being seriously injured by an impaired driver
  • feelings of anxiousness, hopelessness, walking on egg shells because of the uncertainty, worry, fear, anger, concern triggered when in the sphere of an impaired person’s drinking behaviors
  • being on the receiving end of domestic violence or a sexual assault by a person whose brain functioning has changed under the influence of alcohol.

For the moms, dads, husbands, wives, brothers, sisters, children, grandchildren, grandparents, boyfriends, and girlfriends directly exposed to SHD, coping with these sorts of drinking behaviors activates their stress response. When this system is repeatedly activated, their stress becomes toxic, and they experience many of the following stress-related symptoms:

  • stomach ailments
  • insomnia 
  • anxiety, depression, frequent or wild mood swings
  • chronic neck and/or shoulder pain
  • frequent headaches, migraines
  • chest pain, palpitations, rapid pulse
  • increased anger, frustration, hostility
  • feeling overloaded, overwhelmed, helpless, hopeless


Screening for Alcohol Misuse in the Family is Screening for SHD and ACEs

During the lecture I referenced above, a student asked if I thought it was appropriate for a physician to ask a patient about drinking patterns of family members when the patient presents with stomach ailments, migraines, anxiety, depression, skin rashes, unexplained joint pain….

My unequivocal answer was "YES!"  I would have given anything if my doctor had asked me about alcohol misuse in my family when I went in to talk with her about feeling depressed. Not my drinking, but that of my family members. 

Instead, I was diagnosed with situational depression and put on Prozac for several months. When that didn't seem to work, I was put on Zoloft. That didn't work, either. I wasn't "depressed," but I wasn't "living" either.

Given 90 million Americans are affected by secondhand drinking, I continued, not screening for alcohol misuse in the family when presented with a patient exhibiting stress-related symptoms is to miss a powerful opportunity to help millions of Americans improve their lives and their life-long health.

Why? How? Because of the ACEs—SHD connection. 

Both ACEs and SHD cause toxic stress because of their chronic activation of the stress response system. Toxic stress results in the stress-related symptoms named above.

One of the ACEs measured in the ACE study was living with a problem drinker or alcoholic. In other words, someone whose drinking causes drinking behaviors. Drinking behaviors cause negative impacts. Four examples of SHD – the negative impacts of a person’s drinking behaviors on others – listed in the left SHD column above are identical to three of the ACEs listed in the right ACEs column above.

Continuing with my response to the medical school student…

Had my physician screened for family alcohol misuse by asking the following screening question:

How many times in the past year has someone in your family or someone with whom you are in a close relationship had 4 or more standard drinks on any day (for women) or 5 or more standard drinks on any day (for men)?

the floodgates would have opened. 

I would have poured forth the pain and confusion and concerns and fear and repeated attempts to make the drinking stop and shared the insanity of what it was like to try to make sense out of the countless “somethings” that made no sense.

And my physician – if armed with the facts we know today about alcohol misuse, secondhand drinking (second-hand impacts of drinking) and adverse childhood experiences (ACEs) – would have calmed me down and explained, “It’s real. It’s a problem. You’re not to blame, but you can improve the quality of your life.”

She could have then given me a simple handout that unlocked the secrets to what had been consuming my life and my health for decades. It would have explained alcohol use disorders, ACEs, SHD, and the extreme physical and emotional toll that repeated exposure to secondhand drinking causes because of the chronically activated fight-or-flight stress response system. It would have listed anonymous alcohol use assessments; key resources for further information; and programs that could have helped me – the family member of the loved one who drank too much.

We Need an SHD—ACEs Study

I first learned of the Adverse Childhood Experiences (ACE) Study in 2009. This study measured the impact of adverse childhood experiences* (ACEs) on a person’s health across a lifetime.

*Adverse Childhood Experiences (ACEs) are divided into three categories, neglect; abuse; and household challenges. They include physical, verbal, sexual abuse; physical, emotional neglect; and growing up with a relative with a substance use or mental disorder, to name a few.

This study drew the clear connection between exposure to ACEs and a person’s physical and mental health across their lifetime. To say the ACE Study rocked my world is to put it mildly. Here was the something that explained to me the previously inexplicable.

I now understood that exposure to my loved one’s drinking behaviors (SHD) most likely had the biggest impact on my ACEs. Not only that, but my other alcohol misusing loved ones had experienced their own ACEs, most likely as a result of their exposure to SHD. In other words, untreated SHD became untreated ACEs because none of us understood that alcohol misuse didn’t just affect the drinker’s health. It affected the health of non-drinkers (non-alcohol misusers). I shared some of my realizations in my earlier articles, When ACEs are Rooted in Secondhand Drinking and When Recovering From ACEs is Recovering from Secondhand Drinking and Visa Versa.

The parallel between exposure to alcohol misuse (drinking behaviors) and secondhand drinking health consequences and exposure to a person’s cigarette smoke and secondhand smoking health consequences became obvious to me.

Until society understood that secondhand cigarette smoke was extremely harmful to the health of the non-smoker, we tolerated people’s smoking in our cars, homes, airplanes, restaurants, and other public places. Prior to secondhand smoking health implications research, many pediatricians didn’t ask a child presenting with asthma if there was a smoker in their house. Instead the child was treated for asthma but returned to a secondhand smoking environment that only exacerbated their symptoms.

Similarly, as shared in my story of my 2012 lecture and still true today, until society understands a person’s alcohol misuse is extremely harmful to the health of the non-drinker (non-alcohol misusers), we will continue to tolerate a person’s drinking behaviors. We will continue to treat the presenting health symptom(s) but not the root cause, namely secondhand drinking related stress. And just as the secondhand smoking prevention efforts were not about preventing a smoker's right to smoke, neither is a secondhand drinking prevention effort about preventing a drinker's right to drink. Both are about not tolerating the second-hand effects on others.

Which brings me back to my premise. We need a study that provides an understanding of the physical, emotional, and quality-of-life impacts across a person's lifetime caused by exposure to secondhand drinking. We need a study that will provide the data necessary for health care professionals and professionals in related fields to understand the importance of querying their patients (clients) about alcohol misuse in the family. The study could be something along the lines of:

  1. Does a family member or close friend in your life drink alcohol?
  2. If yes, do you see or experience any of the following behavioral changes when they drink (provide examples of behavioral changes, aka drinking behaviors, with a graded scale for each: 1 = never and 5 = very often)?
  3. Are you experiencing (or have you experienced) any of the following physical or emotional health or quality of life conditions? (list would consist of an expansion of the stress-outcomes shared above, with a graded scale for each: 1 = never and 5 = very often).

This study would document outcomes for exposure to SHD in a manner similar to the ACE Study’s documentation of outcomes for exposure to adverse childhood experiences.

Indeed, there are many causes of ACEs unrelated to alcohol misuse, but the population of people dealing with SHD—ACEs is likely the single largest. Addressing the consequences in this population with a study like that outlined above could:

  • Change the lives of the 90 million Americans affected by SHD, improving their physical and emotional health and quality of life by offering education and better prevention and treatment protocols
  • Help us prevent ACEs for the one in four children who live in families with a parent addicted to alcohol (National Association for Children of Alcoholics (NACoA))
  • Empower the medical and related professional communities’ screening for alcohol misuse in a patient/client’s sphere of influence, thereby screening for SHD | ACEs and, ultimately, helping their patients/clients treat the root cause of their health conditions and not just the symptoms
  • Empowers each of us to change the dialogue and free ourselves from tolerating drinking behaviors (secondhand drinking) the same way we changed the dialogue around smoking and no longer tolerate secondhand smoking
  • Educate society about alcohol misuse in general, which could do for those who misuse alcohol what the1964 Surgeon General’s Report on Smoking and Health did for those who smoked. The numbers of Americans who smoke cigarettes dropped to 15% in 2015 from 42% in 1964.

Related Studies: 

For greater detail and other perspectives on SHD, I’m sharing these relatively recent studies / reports on second-hand effects of drinking:

Parental Drinking and Adverse Outcomes in Children: A Scoping Review of Cohort Studies

Collateral Damage from Alcohol: Implications of 'Second-hand Effects of Drinking' for Populations and Health Priorities

Alcohol’s Collateral Damage: Childhood Exposure to Problem Drinking and Subsequent Adult Mortality Risk Abstract 

The Effects of Maternal Alcohol Use Disorders on Childhood Relationships and Mental Health

Global Research on Alcohol's Harm to Others

Facing Addiction in America, The Surgeon General’s Report on Alcohol, Drugs, and Health, 2016 







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Mary Beth Colliins posted:

Our organization is completely dedicated to this issue.  Rob Anda is on our Board of Scientific Advisors and prepared this whitepaper for us a number of years ago:  The Health and Social Impact of Growing Up With Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo (see attached).

Thank you so much for your comment and sharing the two attachments. I'd especially like to draw readers attention to Dr. Anda, Co-Principle Investigator for the original ACE Study's, white paper, The Health and Social Impact of Growing Up With Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo. As he concludes his paper, "Prevention and remediation of our nation’s leading health and social problems are likely to benefit from integrated approaches that incorporate information about their common origins in the enduring neurodevelopmental consequences of growing up with alcohol abuse and related adverse experiences during childhood."

Additionally, as a child of an alcoholic, I've been following your organization, NACoA's, work for some time. I urge readers who are in similar positions as mine; married to or the child of someone who is; or interested in these concepts to get involved and follow NACoA's work, as well.

Thanks again, Mary Beth...

Our organization is completely dedicated to this issue.  Rob Anda is on our Board of Scientific Advisors and prepared this whitepaper for us a number of years ago:  The Health and Social Impact of Growing Up With Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo (see attached). "In the case of persons who had grown up with household substance abuse, 81% reported at least one additional ACE and the majority had experienced 2 or more ACES. "  "Children experiencing alcohol abuse in the home should be screened for other types of maltreatment and traumatic stressors—and vice versa! This information, if routinely gathered will likely contribute to more meaningful diagnoses, earlier and improved treatment of exposed children and their caretakers, and better integration of prevention, social services, and legal venues. "  

I also thought I'd share the Pediatrics 1999 focus on core competencies created for medical professional to appropriately identify and address the issues facing children in these families. "It is suggested that all primary health professionals with responsibility for the care of children, whatever their area of training or discipline, have a minimal level of competence that includes a basic understanding of the medical, psychiatric, and behavioral symptoms of children and adolescents in families affected by substance abuse; be familiar with local resources; appropriately screen for family history/current use of AOD; determine whether family resource needs and services are appropriate; and be able to express an appropriate level of concern and offer support and follow-up."

If we appreciate the impact that SUD (and yes the additional who misuse) have on children, and respect that it is an indicator for additional ACEs, our communities are missing an acute opportunity to early identify and heal these children and families through optimum prevention.


Christine Cissy White posted:

My father was an alcoholic and violent but also absent before I was three. I always hesitated to refer to myself as an adult child of an alcoholic because I didn't grow up with an alcoholic even though I grew up without a parent because of alcoholism. But I didn't share a whole childhood of that type of toxic stress....Even doing the ACE test, I'd wonder if I should say "yes" to physical violence or alcoholism and divorce if they happened only happened during the first few years of life, but didn't continue for all 18 years.

First of all, I am so sorry to hear of your early life ACEs caused by your father and his alcoholism.  As for the potential toxic stress brain impacts of those experiences and your wondering whether they qualify as whole ACEs - they absolutely do. Quoting from ZeroToThree's website, "A child’s brain undergoes an amazing period of development from birth to three—producing 700 new neural connections every second. The development of the brain is influenced by many factors, including a child’s relationships, experiences and environment." 

Thus, during those first three years, the trauma (ACEs) we experience can significantly influence our brain architecture (wiring), yet we may have no identifiable memory to associate/verbalize those brain changes (those trauma-related events) because of where the brain is at developmentally at the time, and thus we may question whether they "really" happened or had a significant influence. For those of us who experience ACEs later in our childhood up to age 18, we will likely have the memory/ verbalization capabilities around the ACEs (though we may not have any idea of how to interpret or express them) because of the brain wiring processes the brain continues to undergo and the missing prefrontal cortex wiring. This post of mine may help explain what I'm trying to say here, "The Brain and Secondhand Drinking Connection."

BUT...something else that often influences those of us born into a family with an alcoholic (or alcohol misusing - doesn't necessarily have to be alcoholic) parent is the secondhand drinking impacts on our other parent. The trauma your mom may have experienced in her relationship with your father, for example, may have induced significant toxic stress-related behavioral changes (brain wiring) because we can wire new brain maps at any age, causing her to parent as a trauma survivor who has not received trauma treatment. Not only that, but she may have had her own SHD trauma as a child so she may also be parenting from ACEs and/or those experiences. Maybe this post of mine helps better explain this idea, "Mothers Who Love an Addict | Alcoholic." 

Whew - that was a long reply!

I REALLY do appreciate you taking the time to comment, Cissy, and share your thoughts and experiences. And I think your idea of a study on the impacts of SHR (Second-Hand Recovery) is excellent!

Take care,

Lisa: Thanks for bringing so much attention to this issue. I aways learn so much from you.

I'd love it if studies also looked at the impact of SHR (Second-Hand Recovery) as well, if and how things improve for child if a parent gets sober while a child is still a child. Does that help or minimize the impact?

My father was an alcoholic and violent but also absent before I was three. I always hesitated to refer to myself as an adult child of an alcoholic because I didn't grow up with an alcoholic even though I grew up without a parent because of alcoholism. But I didn't share a whole childhood of that type of toxic stress.

Even doing the ACE test, I'd wonder if I should say "yes" to physical violence or alcoholism and divorce if they happened only happened during the first few years of life, but didn't continue for all 18 years. Like maybe in some cases an ACE score could have a 1/2 point of a "yes" rather than a whole point because some types of adversity weren't daily or weekly, though present in childhood.  

Anyhow, thanks for ALL you do to educate others. Cissy 

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