Dr Sally Marlow
Alcohol, addiction and women
I returned to study after a career in the commercial sector, and following a psychology degree I embarked on an M.Sc. in Addiction at the Institute of Psychiatry, (as it was then known), King’s College London. I’ve always been interested in alcohol, addiction, and the relationships women have with these, and taking the masters seemed an ideal way to learn more. I also had a vague idea that I might do a Ph.D. in one or more of these areas, and the masters gave me the opportunity to develop my thoughts further. After a particularly good lecture by Professor Colin Drummond I acted on impulse and stayed behind to ask him if he would be interested in supervising me. He asked me to send him a proposal, which I duly did, and we worked together to refine it. Ten months later, by now with my M.Sc. in hand, I enrolled at King’s again as a student, but for a Ph.D. this time. Professor Drummond was my first supervisor, and my supervision team also included a parenting expert from King’s, Dr Matthew Woolgar, along with support from Professor Simon Coulton at the University of Kent.
PhD project aims
Alcohol, addiction and women are big topics. The key was to find research questions within these which were currently unknown; which it would be feasible to examine within the timeframes of a Ph.D.; and which had sufficient worth that they would be able to attract funding. As a mother myself, I was intrigued to find that mothers are one group of women where the literature on alcohol use and misuse is sparse, and I started to focus my efforts here. It became apparent very quickly that so little is known that I effectively had a blank slate. Starting from what I thought we most needed to know about these women, I identified four aims:
Background literature/previous work
There are more men who misuse alcohol than women, both worldwide (Rehm et al., 2003) and in England by a ratio of 2:1 (McManus et al., 2009). When it comes to alcohol misuse in families however, it is important to take into account that women are the primary care givers in the majority of families in the UK, and childcare responsibilities contribute to the fact that 71% of mothers in 2010 were either not in work or working part-time (Office of National Statistics, 2011). Several alcohol misuse researchers have pointed out the need to consider mothers separately (Leonard and Eiden, 2007, Girling et al., 2006), as fatherhood, motherhood and parenthood may share similarities, but they also have differences (Katz et al., 2007); and one of the groups where alcohol misuse has been least studied is in women with children (Leonard and Eiden, 2007). Further, alcohol misuse in families often co-exists with other family disturbances, such as social adversity, or mental health problems in either the person misusing alcohol or in their partner (which may or may not be related to their partner’s alcohol misuse). This makes disentangling the effects of alcohol difficult (Leonard and Eiden, 2007), and an additional problem for researchers is that maternal excessive drinking is particularly hard to identify (Adamson & Templeton 2012).
Research into mothers who misuse alcohol is important because their excessive drinking may impact not only themselves, but their children. In parents who misuse alcohol there is increased risk that they provide a “general lack of care, support and protection” for their children (Wales, 2009), which in extreme cases may result in serious injury or death. 29% of reviews of children’s deaths or serious injury at the hands of parents cited alcohol as a contributing factor (Brandon et al., 2012). Research on alcohol misuse in families is clustered mainly into the following areas:
There are other areas which can inform maternal alcohol misuse:
Crucially however, when I began my thesis, much remained unknown. The links between the parental substance misuse and alcohol misuse, parenting behaviours, and these outcomes, were not well researched or well understood. It was not known how many mothers misuse alcohol; how well these women were identified; or what other factors are present in these women’s lives.
With so much to investigate, my supervision team kept bringing me back to the central problems of how to measure and test my ideas. A clear definition of alcohol misuse was needed to do this, which involved examining another area of literature which became increasingly important: what alcohol misuse actually is, how it is defined, and how it is measured.
Work plan and timeline
I was fortunate enough to be fully funded for three years: my studentship from the Society for the Study of Addiction paid my academic fees, and Alcohol Research UK and King’s College London both provided me with a stipend. This funding determined my timeline – I was able to study full time as was my preference, but I would not have the luxury of any extensions.
In year one I spent most of my time researching the literature, and trying to pin down the problem of definitions of, and measurements for, alcohol misuse. I settled for the phrase “alcohol misuse”, which although not a clinically diagnostic term, did capture a combined category of hazardous alcohol use, harmful alcohol use and alcohol dependence as defined in ICD-10 (World Health Organisation, WHO 1993), and the WHO lexicon (WHO 1994) . Next came measurement, and after consideration of various biomarkers and self-report screening tools, I decided on the Alcohol Use Disorders Identification Test (the AUDIT, Saunders et al 1993). The AUDIT is widely used in England, my chosen population, but NICE guidelines are ambiguous as to its use in women, plus several reviews suggested different cut-off points were necessary for men and for women, but with not much empirical evidence to back up those recommendations. I therefore conducted a systematic review and meta-analysis of studies validating the AUDIT in populations of women, which suggested the optimum AUDIT cut-off point to measure alcohol misuse in women is lower than the 8 recommended for men.
I applied what I’d found to examine prevalence using data from the Adult Psychiatric Morbidity Survey (APMS, McManus et al 2009). This has AUDIT scores for around 3,000 women, and also contains details of relationships with others in the same household, so I was able to extract the mothers, and there were over a thousand. More than a quarter of these were misusing alcohol. I then also used the APMS raw data to examine socio-economic, psychiatric and factors in these women, alongside selected life events. As expected, mothers who misuse alcohol look different to mothers who do not in a whole host of ways.
My final task was to examine the impact of alcohol on parenting behaviours, by developing a novel questionnaire: the Maternal Alcohol and Parenting Problems Index (the MAPPI). I used quantitative and qualitative data from a variety of sources to determine which parenting behaviours seemed to be most affected by alcohol in mothers. I tested the resulting 38 item questionnaire in an internet sample of mothers, and exploratory factor analysis revealed that seven domains of risk, pattern of drinking, emotional availability, children’s perceptions, help-seeking, mother’s mental state, and basic needs, all loaded on a single factor, termed “alcohol-related parenting problems”. There were significant differences in MAPPI scores in mothers when compared on the basis of their AUDIT status. The MAPPI also had good discriminant validity when compared with general parenting questionnaires such as the Alabama Parenting Questionnaire (Scott et al 2011) and the Brief Parental Efficacy Scale (Woolgar et al 2013). My studies complete, the only thing that remained was to write it all up into my thesis, and I spent the last six months with my head down working towards that final deadline.
Relevance of your work for the field
Being able to study this group of women for three years has been an absolute privilege. Not only have I been able to examine previously unstudied areas and contribute to knowledge about mothers who drink excessively, but I have also had the opportunity to develop my own skills as a researcher. I learnt more in the three years than I ever would have thought possible. I have published several papers, and have several more under development and consideration. Importantly, the Ph.D. has given me a strong understanding of the areas I want to focus on as a post doctoral researcher, and I have been able to apply for grant funding using my Ph.D. findings to support my applications.
My studentship from the SSA was an absolutely vital component of the funding package which made my research possible. My relationship with the SSA brought other benefits too: I was asked to present some of my findings in the 2013 SSA annual symposium, which gave me the opportunity not only to communicate some of my work, but also to practice defending it before my viva. Along with support from the SSA as a whole, members of the executive have offered support and advice individually, and I would particularly like to thank Jane Marshall, Jo Neale, John Strang and Ann McNeill, not forgetting Graham Hunt of course, who dealt with the nuts and bolts of my SSA studentship. I would also like to acknowledge here the enormous contribution of my supervisors, Professor Colin Drummond, Dr Matthew Woolgar, and Professor Simon Coulton. They supported me at every stage of the process, and were incredibly generous with their time and their brains.
Adamson, J. & Templeton, L. (2012) Silent voices: Supporting children and young people affected by parental alcohol misuse. London: The Office of the Children's Commissioner.
Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. & Megson, M. (2012 ) New Learning from serious case reviews: a two year report for 2009 – 2011. London: The Stationery Office.
Cleaver, H., Unell, I. & Aldgate, J. (2011) Children’s Needs – Parenting Capacity – Child abuse: Parental mental illness, learning disability, substance misuse, and domestic violence. 2nd edition. London: The Stationery Office.
Daniel, B., Gilligan, R. & Wassell, S. (2011) Child development for child care and protection workers. Jessica Kingsley Publishers.
Dawson, D.A., Goldstein, R.B., Moss, H.B., Li, T.K. & Grant, B.F. (2010) Gender differences in the relationship of internalizing and externalizing psychopathology to alcohol dependence: Likelihood, expression and course. Drug and Alcohol Dependence, 112 (1-2), 9-17.
Delargy, A., Shenker, D., Manning, J. & Rickard, A. (2010) Swept under the carpet: Children affected by parental alcohol misuse. London: Alcohol Concern.
Diehl, A., Croissant, B., Batra, A., Mundle, G., Nakovics, H. & Mann, K. (2007) Alcoholism in women: is it different in onset and outcome compared to men? European Archives of Psychiatry and Clinical Neuroscience, 257 (6), 344-351.
Girling, M., Huakau, J., Casswell, S. & Conway, K. (2006) Families and heavy drinking: Impacts on children's wellbeing. Wellington: Families Commission.
Heise, L.L. (2011) What Works to Prevent Partner Violence An Evidence Overview. London School of Hygiene and Tropical Medicine. STRIVE research [Online], Available from: http://r4d.dfid.gov.uk/Output/189039/Default.aspx [Accessed May 2013].
Katz, I., Corlyon, J., Placa, V.L. & Hunter, S. (2007) The relationship between parenting and poverty York York Publishing Services [Online]. http://www.jrf.org.uk/sites/files/jrf/parenting-poverty.pdf [Accessed January 2011].
Leonard, K.E. & Eiden, R.D. (2007) Marital and family processes in the context of alcohol use and alcohol disorders. Annual review of Clinical Psychology, 3, 285.
McManus, S., Meltzer, H., Brugha, T.S., Bebbington, P. & Jenkins, R. (2009) Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. The NHS Information Centre for Health and Social Care. Available from http://www.hscic.gov.uk/pubs/psychiatricmorbidity07 [Accessed November 2010]
National Institute for Health and Care Excellence (2011) Alcohol dependence and harmful alcohol use. Alcohol Use Disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. Guidleine CG115. [Online] Available from http://guidance.nice.org.uk/CG115/NICEGuidance/pdf/English. [Accessed Sep 2011]
Nolen-Hoeksema, S. (2004) Gender differences in risk factors and consequences for alcohol use and problems. Clinical Psychology Review, 24 (8), 981-1010.
Office of National Statistics (2011a) Mothers in the labour market. London: The Stationery Office.
Plant, M.L. & Plant, M.A. (1988) Maternal use of alcohol and other drugs during pregnancy and birth abnormalities: further results from a prospective study. Alcohol and Alcoholism, 23 (3), 229-233.
Rehm, J., Room, R., Monteiro, M., Gmel, G., Graham, K., Rehn, N., Sempos, C.T. & Jernigan, D. (2003) Alcohol as a risk factor for global burden of disease. European Addiction Research, 9 (4), 157-164.
Russell, P. (2006) A Matter of Substance? Alcohol or Drugs: Does it make a difference to the child? Stirling: Aberlour
Saunders, J.B., Aasland, O.G., Babor, T.F. & Grant, M. (1993b) Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction, 88 (6), 791-804
Scott, S., Briskman, J. & Dadds, M.R. (2011) Measuring Parenting in Community and Public Health Research Using Brief Child and Parent Reports. Journal of Child and Family Studies, 20 (3), 343-352.
Stacey, D., Clarke, T.-K. & Schumann, G. (2009) The genetics of alcoholism. Current Psychiatry Reports, 11 (5), 364-369.
Swadi, H. (1994) Parenting capacity and substance misuse: an assessment scheme. Association for Child Psychology and Psychiatry Review and Newsletter, 16 ( ), 237-244.
Turning Point (2006). Bottling it up: The effects of alcohol misuse on children, parents and families [Online]. Turning Point. Available from: www.turning-point.co.uk/inthenews/Documents/Bottlingitup06report.pdf.
Velleman, R. & Templeton, L. (2007) Understanding and modifying the impact of parents’ substance misuse on children. Advances in Psychiatric Treatment, 13 (2), 79-89.
Woolgar, M., Beckett, C., Falconer, S., Humayun, S., Marsden, A., Scott, S. & Dadds, M. (2013) A new, brief measure of parental efficacy for parenting practitioners. Available from http://www.parentingresearch.org.uk/Documents/Posters/Parenting%20Measures%20Agency%20Poster.pdf [Accessed January 2013].
World Health Organization (1993) The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization.n
World Health Organization (1994). Lexicon of alcohol and drug terms published by the World Health Organization [Online]. Geneva World Health Organization. Available from: http://www.who.int/substance_abuse/terminology/who_lexicon/en/ [Accessed May 2013].