680802 research-article2016
SJP0010.1177/1403494816680802Werner and MalterudRecognising children with parental alcohol problems
Scandinavian Journal of Public Health, 2017; 45: 42–49
Original Article
How can professionals carry out recognition towards children of parents with alcohol problems? A qualitative interview study
ANNE WERNER1 & KIRSTI MALTERUD2,3,4 1Health
Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway, 2Research Unit for General Practice, Uni Research Health, Bergen, Norway, 3Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, and 4The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
Abstract Aim: The aim of this study was to explore informal adult support experienced by children with parental alcohol problems to understand how professionals can show recognition in a similar way. Methods: We conducted a qualitative interview study with retrospective accounts from nine adults growing up with problem-drinking parents. Data were analysed with systematic text condensation. Goffman’s concept “frame” offered a lens to study how supportive situations were defined and to understand opportunities and limitations for translation of recognition acts and attitudes to professional contexts. Results: Analysis demonstrated frames of commonplace interaction where children experienced that adults recognised and responded to their needs. However, the silent support from an adult who recognised the problems without responding was an ambiguous frame. The child sometimes felt betrayed. Concentrating on frames of recognition which could be passed over to professional interactions, we noticed that participants called for a safe harbour, providing a sense of normality. Being with friends and their families, escaping difficulties at home without having to tell, was emphasised as important. Recognition was experienced when an adult with respect and dignity offered an open opportunity to address the problems, without pushing towards further communication. Conclusions: Our study indicates some specific lessons to be learnt about recognition for professional service providers from everyday situations. Frames of recognition, communicating availability and normality, and also unconditional confidentiality and safety when sharing problems may also be offered by professionals in public healthcare within their current frames of competency and time. Key Words: Alcohol problems, childhood, social interaction, recognition, primary care, public health, qualitative interviews
Introduction Background Parental alcohol problems imply heavy strain on families, have potentially long-term negative health effects on the children and constitute a major public health challenge [1–5]. Children who grow up with such troubles at home often do not reveal the problems. Trying to maintain an idealised notion of the family, they avoid disclosing parental misuse problems [6,7].
They rarely approach public health services and are often described as invisible to professionals [6,8–11]. Practice dilemmas encountered by professionals working with domestic abuse are documented [12]. Taylor and Kroll [13] described the balancing acts required by professionals to develop a helping alliance. General practitioners (GPs) experience the
Correspondence: Anne Werner, Health Services Research Unit, Akershus University Hospital, PO Box 1000, N-1475 Lørenskog, Norway. E-mail:
[email protected] (Accepted 21 October 2016) © Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1403494816680802 sjp.sagepub.com
Recognising children with parental alcohol problems 43 challenges of addressing public health concerns in an area that many patients understand as normal and desirable behaviour [14]. The role of family support for children with parents with misuse problems has received much attention [15,16]. Several studies emphasise the informal support of relatives, friends and neighbours caring for children and families as a buffer in the face of stressful circumstances and reducing negative consequences of these parental problems [9,15–17]. Gorin argues that children who live with parental problems use informal support as their main means of accessing help, but this kind of help is often overlooked or undervalued [8]. Skatvedt and Schou [18] explored informal interaction situations between clients and therapeutic staff. They concluded that apparently trivial commonplace interactions were powerful situations that constituted emotionally moving and identity-constructing contexts with a significant impact on clients. Experiences from informal interactions with adults who recognised the needs of young persons affected by parental alcohol consumption may be helpful also in a professional context [10]. Talking with individuals who attended professional support as grown-ups due to their parents’ drinking problems during childhood and adolescence, we noticed that in spite of obvious needs, they had not received professional help during their upbringing [7,19]. They described feelings of having been betrayed by professionals and other adults who never asked about their situation or responded to their problems. However, they also told about some significant interactions with adults in everyday life when growing up. To our knowledge, there is not much research about specific lessons to be learnt for professional service providers from such everyday situations. Therefore, we wanted to explore potentials and limitations for professional encounters of lay social recognition of children who grew up with parents with alcohol problems. Frames of recognition – theoretical perspectives The frame concept was proposed by the sociologist Goffman as a way to understand patterns of takenfor-granted social structures that give meaning to a situation [20–22]. According to Goffman, social life contains available frames that individuals employ to organise and interpret their experiences into meaningful activities and a meaningful whole. Individuals fit their actions to their understanding of what is going on and ordinarily find that the environment supports this fitting [20]. Hence, frame analysis can be an approach to unpack the context of social interaction [22]. Goffman emphasised that he did not
address the structure of social life but the structure of experiences individuals have at any moment of their social lives [20]. Still, frames are parts of a larger structure; that is, the basis on which the definitions of the situation are built [20,22]. Jacobsen elaborates Goffman’s theories about the interaction order, in which rituals organise activities and create meaning for the participants in the same way as economic, technological or political orders [21]. Furthermore, he claims that interactive recognition, through rituals, courtesies and consideration, is a prerequisite for the idea of a micro-social interaction order. In the same line, Scheff [22] argues that mutual awareness is an important element of Goffman’s theories, although this term is not explicitly addressed. In this study, Goffman’s situational perspectives offered a lens to study how acts of recognition were framed or defined and to understand opportunities and limitations for passing such significant interactions over from lay encounters to professional contexts [20]. Aim We explored informal adult support experienced by children of parents with alcohol problems during childhood and adolescence to understand how professionals could show them recognition in a similar way. We emphasised frames of recognition with a special attention to interaction situations in commonplace contexts with a potential to be passed over to professional encounters. Method Design, participants and ethical issues We carried out a qualitative interview study with retrospective accounts from adults who grew up in families with problem-drinking parents. The Regional Committee for Medical and Health Research Ethics concluded that the study was not regulated by the Health Research Act (ref IRB 0000 1870). The study was approved by the local privacy protection advisors (Akershus University Hospital HF) (ref. 14-005). Informed consent was obtained. Our sample included nine individuals, three men and six women aged 25– 54 years (average 37 years). They were recruited by professionals at two alcohol and substance abuse clinics where they had attended treatment services for family members. We applied purposive sampling covering participants representing different backgrounds. Four participants had fathers with drinking problems, and five had mothers with drinking problems. None of these parents had attended treatment for alcohol misuse
44 Werner and Malterud Table I. Participants – demographic background data. Age 18–19 20–29 30–39 40–49 50–59 60–69 70+ Gender Women Men Children No Expecting a child Yes Education completed Primary/secondary school High school Bachelor level Master level
N 0 4 2 1 2 0 0 6 3 5 1 3 1 2 3 3
when the children grew up. One of the participants had struggled with substance misuse himself. Five grew up in intact families with both birth parents. All participants were Norwegian born and permanently or temporary employed, except one with disability pension. Five were living alone, while four were married or cohabitating. Socioeconomic status is presented in Table I. Data collection and analysis The first author conducted all interviews, duration 60–120 minutes. The interviews were semi-structured and dealt with participants’ experiences in everyday life when growing up, the impact of their parent’s alcohol problem on their everyday lives, and experiences of service needs and offers. Participants were specifically invited to recall events when s/he felt that somebody – healthcare professionals or other adults – should have noticed or intervened upon the problems. Several participants were initially ambiguous to tell about the troubles, although they emphasised the importance of research about the issue. Nevertheless, they concluded that it had been rewarding to share. In previous articles, we have dealt with experiences from everyday family life as the social context for service needs and offers [7] and experiences with professional services during childhood and adolescence [19]. For the present article, we focused on experiences of encounters with adults from the extended family and social network as recalled by the participants.
The interviews were digitally recorded, verbatim transcribed and analysed with systematic text condensation, a method for thematic cross-case analysis [23]. We searched for significant situations with adults in childhood and adolescence, emphasising accounts about everyday frames with a capacity to explore potentials and limitations for recognition being passed over to professional encounters. Both authors negotiated the four steps of analysis: 1) reading the transcripts, obtaining an overall impression of experiences from significant interactions with adults, identifying preliminary themes; 2) developing code groups from preliminary themes, identify meaning units reflecting these particular interactions experienced as recognition and coding for these; 3) establishing subgroups within each code group exemplifying vital aspects of each code group, condensing the content of each of them, identify illustrative quotations; and 4) synthesising the condensates from each code group, presenting a reconceptualised description of each category. Analysis was supported by Goffman’s situational approach to frames of interactions and Skatvedt and Schou’s perspectives of informal commonplace interactions [18,20,21]. Results Analysis demonstrated frames of commonplace interaction where children had experienced that supportive adults had recognised their needs and in different ways responded to these. However, the silent support from an adult who recognised the problems without confirming or responding appeared to be an ambiguous frame with some limitations. The child sometimes felt betrayed, although the reasons for silence were perceived as understandable. Concentrating on frames of recognition which could be passed over to professional interactions, we noticed that participants called for a safe harbour providing a sense of normality. Being with friends and their families or a neighbour and escaping difficulties at home, without having to tell about the problems, was emphasised as important. Recognition could be experienced by the child when an adult with respect and dignity offered an open opportunity to address the problems, without pushing towards further communication. We elaborate on these findings in the following sections (for the quotations, participants are assigned pseudonyms). The ambiguous impact of silent support Some of the participants told about how their relations with adults incorporated a mutual understanding of the drinking problems at home, which could
Recognising children with parental alcohol problems 45 also include the fact that they did not have to discuss the matters. Several participants said that the problems at home were obvious and they thought everyone around them knew. Still, the adults seemed to “shut their eyes and ears and turn their backs to the problems”, as expressed by one. Looking back, many of them had felt betrayed by adults who never intervened or invited them to talk. A participant expressed disappointment towards the sister of her mother: Now I have mixed feelings for my aunt. She was fully aware of what was going on at home and pitied me and my sister. Still, she would never take action unless somebody asked. We would certainly not expose mother. (Betsy)
Several of the participants described significant commonplace situations with adults who, in various ways, showed they cared about the children and their parents, thereby embodying security. Participants remarked that some of these adults, often close family members, must have witnessed the magnitude of the problems. Still, they never commented, confirmed or acted upon the problems. One participant said that she did not expect the adult to solve the problems, but still had hoped for support by someone who said: “This is not good for you” or expressed empathy in other ways. Another said that the parents’ friends probably did what they felt they could do, suggesting they might not know how to talk about the problems with such a young person. Some said that the adults might want to avoid involvement in difficult relationships, others commented that the adults probably did not know how bad it was and, therefore, trivialised the problems. The dilemmas of close family members were also mentioned, such as grandparents who were squeezed between their own adult child and their grandchild, hence defending the adult person or avoided taking side. A participant described the reactions of her grandmother when she had tried to talk to her about the mother’s drinking problems: But you know, she is the mother of my mother. Therefore, the conversation becomes somehow unstable when we talk about it, because she very much wants to defend my mother. At the same time, she loves me and my sister. For her, the simplest way out is to blame my father. It is as if she never can see my mother as the responsible person. […] She does not fully understand it. (Catherin)
A safe harbour providing a sense of normality Some participants described how the presence of a family member, such as an aunt or a grandparent,
might protect them, regulating the parent’s drinking pattern, without further intervention. Being observed, her mother would not take as much as usual, one of the participants said. Another said her mother “would never dare drinking” together with her own mother. Still, no participants described close family members who explicitly intervened in such situations. Other adults offered the children opportunities for getaway when conditions at home became unbearable. Some participants told about how their friends’ parents allowed them to stay with them, sometimes for several days, in periods of heavy drinking at home. One of them, who even had her own bed at the friend’s house, was relieved by the possibility to escape, although she was embarrassed by the situation. Another participant said there was no need to ask for permission to come or to explain further, it was just tacitly agreed upon. Knowing that they always could come when they needed was in these cases emphasised as more important than talking about the problems. One participant explained how adults could offer protection: [My mother] never made any efforts to find me somewhere to stay, but she would accept that I ran off. I packed my bag rapidly and slept over at my friend’s house. But mostly, I was in the house of a neighbouring couple with three children of my age. Sometimes I would hide in their closet when my father came after me to take me home. […] He stood by the door, yelling that I should come home. “No, she is not here.” I was sitting in the closet, listening to everything. (Fanny)
Mostly the situations were dealt with within frames of normalisations and not as crises or disruption where parents and children were in need of professional support. The primary connection was with the friend, while their parents provided a safe space without intervening. However, our data also exceptionally exemplified how the frame of interaction could shift during the situation or over times from visiting friends to emergency shelter. Only one participant told about a situation when the adults intervened by seeking professional help on behalf of the child, who was then 13 years old. She had stayed with the neighbours, refused to return home and insisted that they do something. This participant described the events which subsequently provoked them to take action on her behalf: After a while they made contact with the women’s refuge because it had been a period when problems culminated. […] with my grandmother’s cancer… and my father drank terribly much – he was unemployed and stayed at home a lot. It was booze all the time. That was when I ran away and took escape with my mother’s friend. (Fanny)
46 Werner and Malterud Demonstrating recognition in commonplace situations Several of the participants described recurrent situations where they felt safe and normal in the company of adults who never mentioned the parents’ drinking problems. Visiting a grandparent’s home was mentioned as a realm characterised by attention, practical support and normal activities, as compared to the challenges of the everyday drama experienced at home. Some of the participants mentioned their relations with a neighbour or the family of a friend, where they could come and stay for informal visits whenever they wanted. In this way, the problems were turned down and the situation normalised. Being around, having meals together, playing or working in the garden offered a feeling of normality, without any expectations to talk about the problems. A participant said: My grandmother and my older sister were sort of parents for me. I stayed with my grandmother during the summer holidays […] It felt so normal, staying with her the whole summer. We came there, we were served dinner and delicious breakfast, we did leisure activities – she made us feel normal. It was the same with my sister. (Catherin)
A few participants, however, described significant situations with adults who talked about alcohol misuse on a general basis or indicated that they knew about the drinking problem of their parents. One of the participants emphasised the impact for her when a judo coach during a training class said that one out of five persons is family of a person with alcohol problems. This made her realise that alcohol problems are common, although she could not imagine who else were affected. Another participant described his relief when a friend of his father said he understood the boy was in trouble and offered a talk about it. He never took the opportunity. Still, he maintained the importance of this episode, indicating that someone had recognised his situation as a teenager living alone with a problem drinking father. Participants mentioned especially that they would have appreciated small hints from the adults mediating the possibility to talk more about the situation, without pushing towards further communication. Some participants recalled situations during adolescence where adults had tried to push them to talk about their home situation. One said it was “just to satisfy curiosity rather than intending to help”. Another participant said she had to be absolutely sure that the person she talked to actually cared about her and wanted to know. Two participants referred to experiences from their own adolescence
when they described how they would approach young persons in their present jobs. One of them said he usually would let the other know he was aware of his struggles, leaving the initiative to the young person himself: But then he knows that somebody knows. Then it is much easier for him to come back after a week or two, asking: ‘Do you have two minutes for me?’ (Eric) Discussion Our analysis demonstrated frames of commonplace interaction where children had experienced adults to recognise their needs, such as a safe harbour, providing a sense of normality. Yet, the silent support from an adult who did not confirm or respond upon the difficulties could give the child a feeling of abandonment, contrary to the recognition mediated by an open invitation to address the problems. Frames of recognition are well suited for application in professional encounters in primary healthcare. Below, we discuss the strengths and limitations of the study design and the impact of these findings. Methodological reflections In this study, we interviewed adult participants, exploring their experiences of informal adult recognition during childhood and adolescence.We approached their retrospective versions, rather than interviewing youth situated in the middle of the problems. This was both an ethical and a strategic choice, since a core aspect of the problems we wanted to study was alcohol problems that might not be acknowledged and known to the services. Consequently, we are dealing with stories which have been modified over time [24], as the experiences have been elaborated in everyday life and in treatment groups. One might object that conditions have changed since these participants were young. However, comparable accounts are also reported in recent research [6,8,10]. Participants in our sample were recruited from treatment groups, and their experiences might exemplify the worse part of reality for children growing up with parents with alcohol problems. Still, the opposite argument may be equally valid – that those with the heaviest burden of suffering would not be sufficiently resourceful to seek treatment as adults. The findings deal with frames for recognition of unmet needs among children growing up with parents with alcohol problems. The existence and character of such unmet needs have been documented in our previous studies [7,19], and were not the focus for the present study. We did not interview the adults who played significant roles in these accounts, and
Recognising children with parental alcohol problems 47 we do not know whether they actually recognised the children’s need and problems. Still, the participants’ accounts indicated that they really valued the interaction, being recognised by these informal helpers. We interpreted the accounts of the situations within an interactional perspective, rather than as indications of psychopathology and dysfunctional families [17]. Such a position might blind us from observing inherent individual and emotional challenges related to frames of recognition. Appraisal of conditions for transfer of experiences from informal situations to professional encounters requires these opposite aspects to be balanced. Hence, we searched not only for potentials of recognition, but also specifically for constraints. The participants reported limitations related to silent support as not always being perceived as helpful. The protective and preventive impact of social support to vulnerable children We are not the first to demonstrate the significance of informal social support to children with parental alcohol problems [8,17]. Such support may include talk, but merely being with someone in an environment in which they feel safe is also appreciated by children [6,8,9]. Our findings confirm the impact of protection by caring adults keeping the children safe through hard times [15,16]. Moreover, protective frames may offer the children a feeling of having choices and being in charge of their lives [5]. Our study adds to existing knowledge by presenting frames not only perceived as beneficial by the children and adolescents, but also with a potential for transferral to service encounters. We have previously described how these children struggled to restore social order within the family and to act as normally as possible outside the family [7]. The present study reveals the impact of participation in everyday life activities together with adults who recognised the children’s needs and made them feel normal. Similar experiences are reported by children of parents with mental illness [25]. In prior studies, we have demonstrated that children with parental alcohol problems experienced limited support from professionals and other adults [7,19]. In the present study, we identified significant commonplace interactions with supportive adults within frames of recognition and normalisation. Analysis indicates that such experiences may reduce the children’s struggles and crises experiences and oppose loneliness. Hence, a GP or a school nurse can offer recognition towards a child in trouble by providing frames where a sense of normality is preserved. This can, for example, be carried out by allowing
temporary medical small-talk pending the trust needed to discuss more serious stuff, or appearing balanced instead of shocked when further details are exposed, confirming that this is a problem in many families. A subtle balance between frames of recognition and frames of abandonment Our analysis revealed that the normalisation frames also had some limitations. Some of the participants’ accounts dealt with situations that apparently functioned as emergency shelters, although the experiences were framed as informal visits. In such situations, when the adults neither explicitly nor implicitly expressed that they were aware of the difficulties of the children, the situation was not sufficiently resolved. Especially when the adult remained silent, recognition might turn into a feeling of abandonment. According to Goffman [20], the frames regulate standards for acceptable interaction and impose certain manners upon the individuals. Elaborating Goffman’s perspectives, Jacobsen [21] points to pitfalls of recognition rituals intended to maintain social order by avoiding offence of the other part. Our analysis demonstrates how children being with adults who seem to notice without responding, could become lost without a language to understand or confirm their experiences and definition of the situation. These observations support previous research suggesting that normalisation strategies apparently effective in childhood can be harmful in the longer run, and lead to problems of attachment and relationships later on [5,6]. It is, therefore, crucial that professionals find ways of sharing their hunches of family trouble with the child, without offending or pushing the issue. Our study emphasises the impact of professional support to adult family members and social network that are in the best position to protect the children [3,5]. However, the participants also called for direct support by recognition from professionals who noticed their troubles. From commonplace experiences to frames of recognition in professional encounters Only a small minority of young persons with psychological problems receive professional help [11]. Confirming previous research, none of the participants in our study had received adequate treatment during their upbringing [3,6–8,10,19]. Our study adds some lessons about recognition to be learnt from everyday situations for professional service
48 Werner and Malterud providers. Our analysis indicates that it is the content of this support that may be crucial for the children, rather than the informal frames of the commonplace encounters as such. Professional action will, per definition, become formalised. Still, the primary care context may be suited for transferral of recognition from informal frames, since these services offer longitudinal contact and low thresholds for attendance. Reasons for primary care contact is allowed to be diverse and unclear but are still accepted as valid entrance tickets. School nurses, GPs and social workers are trained for family-oriented support. It is, therefore, vital that they notice and respond to discrete or ambiguous appeals for support by children who also work hard to perform to a normally functioning family [6,7]. Providers must be highly attentive upon hints about parental drinking or family problems, taking it as cues to probe about the nature and significance of the problems. Referral from other professionals who become aware of the problems (teachers, school nurses, police officers, outreach workers and hospital emergency departments) is crucial, although not always successful [26]. Participants in our study experienced that professionals engaging in individual family members’ problems seemed to avoid subsequent involvement regarding underlying parental drinking [19]. Other studies have revealed practice dilemmas faced by professionals working with families in need of support [12,13,27]. A study revealed school nurses’ professional dilemmas when immigrant teenage girls shared their experiences of violence explained by family honour, but prevented them from further action to protect the girls [28]. Hence, recognition must be enacted in a way which does not increase the burden of the children. Recognising and attending to the children’s needs It can be hard for young individuals to talk about parental problems. Research indicates that children may be very capable of making their needs and wants known, provided a climate with time for listening [9]. Mauerhofer et al. found that four out of five young people who did not consult for psychological problems visited their GP at least once during the previous year and suggest GPs to include questions conveying the message that discussing emotional and social issues is also part of the GP’s offer [11]. Our study emphasises the impact of a safe harbour with a sense of normality in spite of a difficult situation [6,7,11,19]. The office of a school nurse may also serve as a safe harbour, especially if a sense of normality is maintained.
Several studies have explored experiences among children and adolescents from counselling with primary care providers [11,28,29]. They want a patient, empathic and sensitive approach, based on trust, with someone who is helpful, caring, encouraging and recognises their circumstances [10,29,30]. Furthermore, they emphasise availability and confidentiality, listening and acknowledgement when talking to adults about family problems, as opposed to over-reacting, embarrassment, taking over, moralising or trivialising [8]. They want to remain involved in further decision-making with a supportive adult to “sort things out with”. Providers who take the time to get to know them, building partnership in the dialog and a trusting relationship, can make it easier for a young person to bring up sensitive themes [27–29]. Our analysis emphasises that silent support can also give the child a feeling of abandonment and contribute to even more uncertainty [8]. Having someone outside the family to confide in has been reported as helpful by children [9]. Previous studies have demonstrated the fragility, dilemmas and complexity of family support in relation to alcohol and substance misuse [3,6,15,16]. Lack of communication due to a desire to protect one another is a major barrier to show children and adolescents recognition [8]. Offering a safe and confident space where the young person can share worry or uncertainty about parental alcohol use, while at the same time be sufficiently in charge of the dialogue, is possible within primary care. Conclusion and implications Our analysis presents specific frames from commonplace interactions suitable for primary care providers to offer recognition towards children in need. Support may be put forward by communicating availability and unconditional confidentiality and safety when sharing secrets, worries or difficulties, thereby maintaining an atmosphere of normality. Furthermore, recognition seems to be enhanced by presenting an open opportunity to address the problems, without pushing, while being sensitive and attentive to the narratives and needs of the children or young person. Advancing such frames is obtainable for public health providers within their current frames of competency and time. Acknowledgements We wish to thank the participants and also the professionals at the two alcohol and substance abuse clinics in Oslo/Norway who facilitated recruitment.
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